MEDITERRANEAN THEATER OF OPERATIONS

UNITED STATES ARMY

Office of the Surgeon

APO 512

10 March 1945

CIRCULAR LETTER NO. 8

SUBJECT:  Notes on Care of Battle Casualties.

The contents of several previous circular letters pertaining to the surgical management of the wounded are consolidated and in certain instances extended or modified in the following recommendations.

1.  The care of the wounded must always be shaped by conditions and  circumstances that govern the tactical situation at the moment. It has been shown by this Theater that the surgery of war need not be molded by concessions to the need for haste and the confusion of caring for overwhelming numbers of patients. Military surgery is not a crude departure from accepted surgical standards, but a development of the science of surgery to carry out a specialized and highly significant mission. Modern surgical treatment employs many adjuvants to operative techniques, such as chemotherapy, fluid replacement therapy, the transfusion of whole blood and fractions of blood employed as substitutes, potent anesthetic agents and narcotics. These tools are as important to the military surgeon as his scalpel, but are equally dangerous to the patient if used without expert precision. One of the major responsibilities of the military surgeon is to make full use of these and similar measures and at the same time to avoid the dangers that may attend their usage.

The ever-present necessity for evacuation of the wounded to the rear is in fundamental conflict within ideal surgical management of the individual patient. To minimize this conflict, close coordination between the functions of administration and professional services is required. It is the responsibility of the medical officer charged with the surgical management of the patient to place technical procedures properly, both in time and in space, with due regard to the tactical situation on the one hand and to the welfare of the patient on the other. Unless the surgeon visualizes his position and the function of his hospital in relation to other surgeons and other hospitals, he may become confused in the mission he is to perform. Although some needed operation may be performed correctly, the military effort may be impeded and unforeseen harm done to the patient if the operation is done at the wrong time or in the wrong place.

It is the responsibility of administrative officers charged within the establishment of evacuation and hospitalization policies to adapt the schedules of movement of patients to the maintenance of highest standards of surgical treatment. Priority of movement must be accorded to patients with certain types of injuries just as the duration of hospitalization in a given zone must be differentially adjusted to the urgent surgical needs of the patients. The term “nontrans-

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portable” as relating to the unfitness of battle casualties for interhospital transfer must, when military necessity permits, be extended beyond actual danger to life by a consideration of the likelihood of deformity, ultimate disability, and delay of recovery when these hazards exist.

Just as the placement of various types of hospitals and consequently the provision of the facilities for surgery are determined by the geographic deployment of a military force, phases of surgical management exist that in general will conform with military echelons. These phases of surgical management are:  first aid measures, initial wound surgery, reparative wound surgery, reconstructive surgery, and rehabilitation measures.

First Aid Measures. Within the divisional area surgical management is limited to first aid measures and emergency resuscitation. Hemorrhage is controlled, splints and dressings applied, morphine administered for pain, plasma infused for resuscitation, a booster dose of tetanus toxoid is given, and chemotherapy initiated.

Initial Surgery. Actual conditions of warfare will determine both the facilities provided for emergency wound surgery and their location with reference to the combat area. In general, initial surgery is concerned with complete resuscitation so that surgery may be performed, and within surgical procedures designed to prevent or eradicate wound infection. Many of the seriously wounded casualties can be resuscitated only by a surgical operation in conjunction with transfusion and plasma therapy. For this reason, it is important that delays for the purpose of resuscitation ahead of an installation equipped for major surgery be kept at a minimum. Placement of the advance surgical hospital in physical proximity to the divisional clearing station accomplishes this end.

Reparative Surgery. The general hospitals of the communications zone receive casualties from the hospitals of the forward area for further surgical management. As the initial wound operation is by definition a limited procedure, nearly every case requires further treatment. Soft part wounds, purposely left unsutured at the initial operation, are closed by suture, usually at the time of the first dressing on or after the fourth day. Fractures are accurately reduced and immobilized until bony union takes place.

Designed to prevent or cut short wound infection either before it is established or at the time of its inception, this phase in the surgical care of the wounded is concerned with shortening the period of wound healing and seeks as its objectives the early restoration of function and the return of a soldier to duty with a minimum number of days lost. In addition, it affords the return of patients to the United States at an earlier date and in better condition and minimizes the ultimate disability and deformity in the seriously wounded.

The success of this important phase of surgery depends on the provision of an adequate period of hospitalization in addition to competent surgical care, particularly in specialized fields. It is not to be confused with the reconstructive phase of surgery, which may be postponed until return to the Zone of the

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Interior. The ideal time for the procedures of reparative surgery will be found between the fourth and tenth days after wounding. The patient then becomes “non-transportable” for a period of time which, in the case of fractures, may extend to eight or ten weeks. Transfer of patients between fixed hospitals within the zone of communications must be regulated with these considerations in mind, otherwise the objectives of this phase of surgical management may be sacrificed. The establishment of special centers within general hospitals for certain types of surgery during this phase is highly desirable, as the procedures are oftentimes of considerable magnitude and call for mature and experienced professional judgment. Advancement of general hospitals in close support of Army or utilization of air evacuation from Army to more remote fixed installations are two measures that further the establishment of a program of reparative surgery.

Reconstructive Surgery. Early evacuation to the United States is desirable for patients whose return to duty cannot be anticipated within the limits of the hospitalization policy of an overseas theater. The phases of reconstructive surgery and rehabilitation may then be integrated.

2.  Wound Management.
  a.  Initial Wound Surgery.
(1)  X-ray. In the preoperative examination of a battle casualty X-ray examination is essential.
(2)  Adequate assistance and instruments, a good light, and access to the wound that is unhampered by faulty position of the patient are basic requirements. Ample preparation of a wide field by shaving the skin will allow for extension of the incision or counterincision.
(3)  Bold incision is the first essential step in an operation on a wound. Adequate exposure is necessary to carry out excision of devitalized tissues. On the extremity the line of the incision is placed parallel within the long axis of the limb; elsewhere it follows the natural lines of skin structure. Only the devitalized skin of the margins of the wound is excised in a strip rarely wider than 2 to 3 mm. The creation of circular skin defects is avoided.
(4)  Incision and excision of the fascial layers is performed in the same manner to give free access to devitalized muscle. Unrestricted exposure of successive anatomic layers permits the complete excision of devitalized muscle and the removal of foreign bodies.
(5)  The surgeon must be familiar within the blood supply of muscles, particularly large groups like the gastrocnemius-soleus muscles of the calf and respect these vessels in his dissection. Deep recesses of the wound containing foreign bodies may be approached by counterincisions planned anatomically rather than by sacrificing normal muscle structures.
(6)  Use fine hemostats. Use the finest ligature compatible with the procedure. Include the smallest possible amount of tissue in ligating a bleeding point. Do not repeatedly bite the wound with tissue forceps. Sponge gently with pressure instead of wiping. Remaining devitalized tissue produced by

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the missile or by the surgeon must slough before the wound can be closed by secondary suture.
(7)  Large wounds in regions of heavy muscles, particularly when complicated by comminuted fracture, require especial care. The depths of these wounds must be opened by a long incision with counterincision if necessary to allow free dependent drainage.
(8)  Only enough dry, fine, mesh gauze is used to separate the surfaces of the wound. It should be smoothly laid in the wound--not “packed”.
(9)  Ether, white soap, and benzene, have slight but definite necrotizing effects on living muscles. Green soap and various other substances used as detergents have greater necrotizing effects. Physiological saline solution is relatively innocuous. In general, progress in wound management points away from the introduction of any agent unto a wound, either for its supposed mechanical or antiseptic effect.
(10)  Old wounds (48 hours or longer) are managed in accord within the same principles, except that in selected cases of established pyogenic infection and anaerobic cellulitis within toxicity the general condition of the patient to withstand radical surgery may be improved by immobilization, penicillin and repeated blood transfusions until an optimum time is selected for intervention. In postponement of surgery the advantage that accrues from the immediate drainage of septic hematomas, large masses of dead muscle, and fascial plane abscesses is not to be forgotten. Postponement of surgery is not justified if clostridial myositis (gas gangrene) may be present.
(11)  Proper transportation splinting is provided for skeletal and joint injuries. Soft part wounds are supported by firm pressure dressings and may, if extensive, be advantageously enclosed in a light plaster. Care is taken to avoid any constricting action of a pressure dressing placed on an extremity. Plaster casts must always be padded and split or bivalved before the patient is returned to the ward.
  b.  Reparative Wound Surgery.
(1)  0n arrival at a hospital where bed care can be assured for a period of at least fifteen days (soft part wounds) the original dressing is removed in the operating room under aseptic precautions. X-ray films should be at hand.  If the primary wound operation has been complete and has been properly done, all superficial wounds and many deep wounds may be closed by secondary suture at this time (4 to 10 days). Foreign bodies in soft parts adjacent to the wound are removed. Following suture, the part is immobilized, preferably by a light plaster, or if this is impractical, by bed rest.
(2)  The presence of residual dead tissue or established infection manifested by profuse discharge of pus, reddening and edema of the wound margins, persistent fever or toxicity is an indication for delay in secondary suture. When these manifestations are present but minimal, the wound is allowed to “clean up”. This process can be hastened by moist dressings or by additional surgical excision of devitalized fragments. Secondary suture

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can then be performed in a few days. If established infection is severe, or if the patient is toxic and anemic from deep seated sepsis, a course of penicillin therapy and blood transfusions is instituted and followed by radical wound revision, and staged closure.
(3)  Wounds that have been laid open properly at the initial operation tend to gape widely and give the impression of extensive skin loss. This appearance is actually due to loss of support of the deep fascia. Skin defects are more apparent than real in the majority of cases and closure of a defect is made from local tissue within suture in a straight line when possible. Undermining with advancement or rotation of flaps provides sufficient skin in nearly all instances and is preferable to grafting.
(4)  Technical considerations that are important to the success of secondary wound closures are:
  (a)  Atraumatic handling of tissue.
  (b)  Avoidance of tension sutures.
  (c)  Accurate approximation of skin margins. The epithelial bridge is the main support of the wound for a considerable period of time.
  (d)  Obliteration of dead spaces by pressure dressings and immobilization. Stab wound drainage may be instituted when desired and is preferable to drainage through the suture line.
  (e)  Leaving sutures in place for twelve days if stitch infection does not develop.
  (f)  Suture in straight lines rather than the creation of sharp angles.
(5)  Preliminary bacteriologic analysis of the flora of a wound does not provide information pertinent to making the decision to perform secondary suture or allow the prediction of the result. If the suture is not successful because of infection, appropriate studies and corrective therapy is instituted before resuture is attempted.
(6)  The conditions that most often jeopardize results are:
  (a)  Suture of a wound that is discharging pus. This usually means dead tissue in the depths.
  (b)  Too early motion. (Wounds breaking down for this reason should be immediately resutured.)
  (c)  Unrecognized foreign bodies adjacent to the wound.
  c.  Closed Plaster Treatment.
(1)  The regimen of closed plaster management of war wounds is not considered as satisfactory as the method described above when field conditions permit the use of the latter.
(2)  While the necessity for the rapid turnover of large numbers of casualties might justify an adoption of the closed plaster method of management of compound fractures, a high penalty in the form of skeletal deformity would be the inevitable result. Results obtained by secondary suture do not justify the use of closed plaster for soft part wounds.
(3)  When it is desired to allow granulations to cover exposed bone in deep irregular wounds, the wound may be encased in plaster subject to in-

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frequent changes. This is also an accepted method of management for established infection of bone, particularly when the wound has caused an extensive loss of overlying soft parts or there is a large bone defect. Before application of the plaster, all devitalized tissue and loose bone fragments are excised. There should be no pocketing or pooling of pus in the fracture site or adjacent fascial compartments. Small surfaces of bare cortical bone may be removed surgically when this permits closure of the defect by suture or skin graft.

 *   *   * * * *
 
  h.  Amputations.
(1)  The most important phase in the management of amputations is the functional rehabilitation of the patient by the fitting of a prosthesis. Amputation centers have been established in the Zone of the Interior for this purpose. It is the expressed desire of The Surgeon General that the early management of amputations in overseas theaters conform within policies that have been set forth in numerous Bulletins and Circular Letters and which are summarized below.
(2)  In the forward area., amputations will be performed at the lowest possible level except that a proximal amputation will be done in preference to a disarticulation. The technique for the performance of amputations is as follows: A circular incision is made through the skin at the lowest level compatible within viable tissue and the skin allowed to retract; the fascia is then incised at the level to which the skin has retracted. The superficial layer of muscle is then cut at the end of the fascia and permitted to retract. At its point of retraction, the deep layers of muscle are cut through to the bone. After the deep muscles have retracted, the periosteum of the bone is cleanly incised and the bone sawed through flush with the muscles. No cuff of periosteum is removed as in a closed amputation. Bone denuded of periosteum will sequestrate if infection is present and a ring sequestrum often results when the periosteum has been removed. It is important also that no periosteum be elevated or torn from the bone in the stump by rough handling. The properly performed Hapless guillotine stump exhibits a slightly concave open cross section of the extremity.
(3)  The proper dressing of the stump is important. The end of the stump is dressed with  fine mesh gauze in such a manner that it does not overlap the skin edges. Skin traction is applied immediately. This may either be by a stockinette cuff attached within ace adherent or by adhesive tape. Traction is obtained preferably by a light plaster cast within a wire ladder banjo. The cast always incorporates the joint above the amputation, e. g., a spica for an amputated thigh. The Army Hinged Half-Ring splint may be utilized as an alternative. Medical Supply Item No. 36614, Cord, Elastic, for Traction. is available and is preferable to plasma tubing for the elastic traction. Before evacuation, the traction is examined and if doubt exists as to its effectiveness it is reapplied.
(4)  At the base areas, secondary closure of a circular guillotine amputation stump is not indicated, as it is impossible to suture the inelastic fascia

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without wasteful shortening of the bone. Bone length can be saved by continuing the skin traction for an additional period of time 4 to 6 weeks. Closure of stumps by sliding flaps, plastic resection within sacrifice of bone length, or formal reamputation are procedures to be carried out in the Zone of the Interior rather than in an overseas theater. Skin grafting is not indicated. Vertical incisions in the stump made for control of infection or as part of the initial debridement should be closed by secondary suture while skin traction is being maintained to cover the defect at the end.
(5)  In the Communications Zone continuous skin traction is maintained in all cases. After removal of the cast or splint, maintenance of 4 to 6 pounds in below-knee and 6 to 8 pounds in thigh stumps of traction over a pulley at the foot of the bed is indicated. Traction is continued until the wound is healed. Priority air evacuation to the Zone of Interior should be available for amputation cases as soon as they are able to be transported. Traction during evacuation is provided for by stockinette and a banjo plaster.
  i.  Fractures.
(1)  The management of a compound fracture is divided into the following phases: first aid splinting in the field; debridement and the application of transportation splinting in a mobile hospital; final correction of the deformity and attainment of wound healing and bony union at a fixed hospital (reparative phase); reconstructive or corrective surgery (bone grafting, osteotomy, sequestrectomy, etc.) in the Zone of the Interior. In every phase attention is directed to the ultimate function of the extremity which is dependent on muscles, nerves, blood vessels and joints as well as on skeletal integrity.
(2)  Transportation Splinting applied subsequent to initial wound surgery for evacuation from mobile to fixed hospitals is not designed to provide anatomic reduction or prolonged fixation in suitable reduction. Except in rare instances it is by plaster of Paris. Plaster bandages are adequately padded and bivalved or split through all layers to the skin. Skeletal fixation by the incorporation of pins or wires into the plaster is not recommended. The only indication for the use of internal fixation in the forward area is to preserve the vascular integrity of the extremity.

Methods of transportation splinting that have proved safe and comfortable are:

Femur:  A low waisted “one and one half” plaster spica within the knee slightly flexed and minimal abduction.
The Tobruk plaster and the Army leg splint within skin traction do not provide as adequate immobilization and should only be used as emergency measures when large numbers of casualties or multiple wounds in a single casualty demand concessions to operating time or for special indications such as the presence of a colostomy or suprapubic cystostomy. When restricted to lower third femoral fractures and knee joint injuries the Tobruk splint provides adequate immobilization.

Humerus: A thoracobrachial plaster with the arm forward in internal rotation.

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A plaster Velpeau bandage binding the arm to the trunk within the forearm flexed at a right angle and placed across the chest.
The Army humerus splint designed for field (first aid) use is not suitable for postoperative transportation splinting.
A hanging cast is both uncomfortable and ineffective as a method of transportation splinting.

Forearm:
A circular plaster bandage that extends to the midbrachial region within flexion of the elbow and extending only to the proximal palmar crease.
Plaster slabs in the form of “sugar-tongs.”

Tibia and Fibula:
A circular plaster bandage from toes to groin. The knee is slightly (15 degrees) flexed and the foot held in neutral position at 90 degrees to the axis of the limb. A plantar slab may extend beyond the toes to afford protection, but hyperextension is to be avoided.
(3)  Reparative Surgery of Compound Fractures. (See Wound Management, par. 2 c on Closed Plaster Treatment.)
Reparative surgery in compound fractures is made necessary by leaving unsutured the large incisions made for debridement and the recognized fact that splinting suitable for transportation is inadequate for complete reduction and fixation of the fracture. The goal is functional restoration of the extremity and demands treatment of muscle and nerve injury as well as skeletal damage. Observance of certain basic principles are important to the success of this phase of management.

Preoperative correction of anemia by whole blood transfusion. Despite whole blood transfusion for resuscitation in the forward area, a high percentage of compound fracture cases will arrive at a fixed hospital in the Communications Zone with low red cell volume (hematocrit) and hemoglobin. An approximate estimate of the quantity of whole blood needed to restore red cell volume may be deduced from the rough rule of 500 cc blood for each 3 points of the hematocrit or 0.9 grams of hemoglobin. In the use of whole blood transfusion for correction of secondary anemia or hypoproteinemia the total volume administered in a 24 hour period should not exceed 1000 cc except to replace blood lost at operative procedures. Thus is in contrast within the larger volumes that are administered for resuscitation when the total circulating blood volume may be greatly reduced. No correlation exists between the hematocrit or hemoglobin levels and circulating blood volume and care must be taken not to precipitate pulmonary edema by overtransfusion of a patient in whom the blood volume has been restored by dilution but who still shows a greatly reduced cell volume (hematocrit) and hemoglobin.

The surgical elimination of residual necrotic tissue. No available chemotherapeutic agent can “sterilize” an open wound containing devitalized tissue or blood clot. A properly managed clean wound requires no local antiseptic.

The control of invasive infection by systemic chemotherapy. Systemic penicillin therapy in a dosage of 25,000 units every three hours is recommended

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as a routine adjuvant for secondary operations on compound fractures. Treatment is continued postoperatively until the likelihood of invasive infection is passed.

Reduction or closure of soft tissue defects. Exposed cortex of bone, nerves and tendons are vulnerable to the necrotizing effect. of wound suppuration and are protected by the apposition of adjacent soft parts.  Transversely divided important muscle groups are united by suture. Fascial compartments are restored to minimize scarring and improve muscle function. Certain of these procedures may be staged operations. Emphasis should not be placed on early or complete skin closure, as in most cases any remaining cutaneous defect will heal before bony union occurs.

Provision of drainage for residual exudate. Severely comminuted fractures may require dependent drainage in association with the apposition of soft parts over exposed bone. Exteriorizing fascial plane incisions have proven superior to stab wounds or rubber drains. Upper extremity fractures rarely present a drainage problem. The thigh may be drained by a posterolateral incision between the vastus lateralis and the biceps. An adequate posterior drainage route for the shaft of the tibia does not exist and such an injury may necessitate a period of "on the face" nursing.

Internal fixation of battle fractures is not feasible commonly because of extensive comminution. Further, the method demands further periosteal stripping and surgical trauma to the wound. Limitation of the use of this method to cases carefully selected by specialists fully experienced in the techniques and  hazards of its usage is strongly advised. An example of sound usage is the employment of screws for restoration of the anticular surface of a major joint. Reduction of the fracture is the goal of reparative surgery--not the use of internal fixation.

Use of suspension traction. The application of suspension traction in the treatment of fractures, particularly those of the femur, is the safest and most satisfactory method of management.  In fixed hospitals fractures of the femur should be treated by skeletal traction for ten to twelve weeks until enough union has been obtained to permit safe transportation to the Zone of the Interior in a plaster spica. The use of suspension traction promotes the maintenance of joint and muscle function and prevents angulation or over-riding deformity.

Overpull and resulting distraction must be avoided at all times, particularly in cases associated with injury or division of the thigh muscles. Certain cases of this type require very expert attention and delay in the application of traction until firm fibrous union of muscles has been attained by suture.

  j.  Joints.
Early complete debridement is the keystone of success in the management of wounds that compound a joint. The wound of the soft part is excised and the bone and cartilage damage assessed through incisions that provide complete exposure. Comminuted fragments of bone and cartilage are removed from the joint and a careful search made for foreign material. Badly comminuted frac-

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tures of the patella are excised completely as a step in the debridement of a knee joint wound.

Every effort is made, after cleansing the joint cavity, to close the capsule. The skin is left unsutured. Closure of the joint is especially  difficult the face of extensive loss of soft parts. When it is impossible to close a joint by suture of synovia or capsule, an occlusive dressing is applied. On arrival at a fixed hospital, effort is directed toward closing the defect by advancement of a skin flap or other plastic procedure.

Adequate exposure of the hip joint is a specialized procedure that requires precise anatomical orientation. The same principle of management must be applied to improve the results of this particular lesion.

Penicillin is inserted into a joint at the end of the operation. In joints that are accessible to needle aspiration, accumulating exudate may be withdrawn and penicillin injected during the postoperative period.

Wounds of the ankle joint within comminution of the os calcis or astragalus are peculiarly liable to sepsis. Initial debridement of comminuted bone fragments must be minimal if function is to be preserved and early efforts are made in the reparative surgical phase to reduce or close the skin defect with split thickness graft when necessary. When sepsis is established, subperiosteal excision of necrotic bone fragments followed by wound closure by graft or suture should not be delayed.

For the SURGEON:
  (S)  E. STANDLEE
E. STANDLEE, Colonel, M. C., Deputy Surgeon.

DISTRIBUTION:
 Surgeon, PENBASE  300
 Surgeon, NORBS 20
 Hq. A/G of S 10
 Surgeon, Adriatic Base Command  100
 Surgeon, Fifth Army 600
 Surgeon, AAFSC/MTO 700
 Surgeon, Replacement Command 50
 Surgeon, Rome Area Command 25
 Surgeon, Hq. Command, AF 30
 Surgeon, MTOUSA 300