APPENDIX
Pertinent Circular Letters
HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS
Office of the Surgeon
APO 512
15 MAY 1943
CIRCULAR LETTER NO. 13
MEMORANDA ON FORWARD SURGERY
1. Surgical Echelons.
a. The welfare of the patient and
the tactical necessity for rapid evacuation demand a clear understanding
of the function or mission of each unit of the Army Medical Corps. This is
best arrived at by dividing the treatment of a casualty into two stages--primary
and definitive. Separate groups of units provide each stage of treatment.
In general, the equipment of each group is designed for that purpose only.
b. Stations of the first and second
echelons--Aid Stations, Collecting Stations and Clearing Stations are
equipped and staffed for the primary phase of treatment. Arrest of hemorrhage,
splinting of the injury, resuscitation measures needed to make the patient
transportable and administration of sulfonamides are the urgent functions
of these stations. In addition, the treatment of minor injuries that allow
immediate return to duty is carried out without evacuation. A Clearing
Station is not designed to provide definitive treatment of battle casualties.
c. During combat, especially with
long distances in evacuation to the rear, Surgical Teams are attached
to certain Clearing Stations. It is their function to give emergency surgical
treatment to selected cases requiring immediate operation. This treatment
would not otherwise be available in this echelon. The lack of facilities
for pre-operative X-ray examination and for post-operative care of adequate
duration place a grave responsibility on the surgeon in the selection of
cases for surgery. These same limitations exist during quiet times. The
length of the evacuation line to the next echelon and changing tactical
conditions require frequent redefinition of the surgery undertaken in
the clearing station.
300
d. It must be remembered that the
lightly wounded soldier, or a casualty due to accident may regain full
combat status within the Theater if proper surgical treatment is carried
out, but the Theater may be deprived of his service by faulty surgical judgment.
Because a surgical procedure appears simple is not sufficient reason for
performing it in a Clearing Station unless the man can be returned to immediate
duty without evacuation to the rear.
e. Hospitals of the third echelon
(Evacuation Hospitals) are designed to initiate definitive surgical treatment
to battle casualties. The more delay there is before reaching this echelon
and the more hands the patient passes through in reaching it, the poorer
will be the final result. The evacuation line is not an assembly line
in which each surgeon does his bit to the patient. It is a conveyance
line along the course of which the progress of the patient may be halted
to save life or limb or render him transportable.
f. While Evacuation Hospitals are
adequately equipped and staffed to perform rehabilitation operations,
it is not the function for which they were designed. Even in quiet times
these patients are evacuated to the fourth echelon for operation unless
the Commanding Officer assumes full responsibility based on a knowledge
of the existing tactical situation as well as the surgical aspects of the
individual case.
2. Surgical Procedures.
a. Dressings: Ideally, the primary
phase of treatment is completed in the first unit reached that is equipped
to provide it. The dressing is then left undisturbed until the patient reaches
an Evacuation Hospital for operation. There are certain safeguards and
adjustments that must take place enroute, but these do not include inspection
of the wound by removal of the dressing unless definite indications
are present. A compound fracture is halted at the Clearing Station for more
adequate immobilization or resuscitation, but this need not involve redressing
the wound unless there is reason to arrest continuing hemorrhage. A wound
is not redressed solely for the purpose of reapplying local sulfonamide.
Oral administration is sufficient safeguard.
b. The same principles apply after
operation has been completed and the patient is being evacuated to the
rear.
c. Uninformed hands do unnecessary
dressings. The best safeguard for the patient is an adequate and legible
record that accompanies him. A receiving officer is then in a position
to refer to the record instead of looking at the wound. Many wounds after
debridement and arrival at the base can be closed by secondary suture. Infection
arising from contamination at the time dressings are changed makes this
impossible.
d. Wound Management: Common mistakes
in war surgery are: (1) Suture of wounds. (2) Tight Plugging
by Packs . Hemorrhage is controlled by a stitch ligature if from a large
vessel. Otherwise, by a temporary pack, elevation and firm pressure. If
a pack is left in a wound make a note that it should be removed at the first
opportunity. Vaseline gauze is laid loosely in a wound, not packed in.
(3) Failure to Immobilize Site of Injury. Large wounds
301
are immobilized even though fracture has not occurred. (4) Overexcision
of skin. Circular defects are slow to heal. Very little skin need
be excised, and in some instances none at all. (5) Failure to Open Deep
Spaces during definitive treatment by freely incising fascial planes.
* * * *
* * *
p. Compound Fractures: It is essential
to distinguish splinting applied for a limited time as a transportation
splint from apparatus or splinting designed for reduction and prolonged
or rigid immobilization. An adequate transportation splint prevents additional
soft part injury and further deformity. It cannot in itself cause nerve
injury, pressure sores, or jeopardize the circulation of the extremity.
It. provides adequate fixation for ambulance transport over rough roads,
but may not secure the fragments in rigid fixation or exert the traction
necessary for further reduction.
q. Plaster Casts: A more liberal
use of plaster of paris casting is urged. Plaster casings or slabs applied
as temporary transportation splints are padded and either bivalved or completely
split. Encircling bandages and cotton rolling under the cast are also split
as it soon becomes inflexible with dry blood or serum. Plaster casings
applied directly to the skin are rarely found advisable in forward areas.
If a skin plaster is applied for a definite indication, bony prominences
are padded and the cast is immediately split in its full length. No encircling
bandages or adhesive strips are placed under a plaster.
(1) All plaster casts applied
in forward areas should be split or bivalved as soon as sufficiently
dry.
r. Skeletal Traction: There is no indication
for the use of skeletal traction or skeletal fixation in conjunction
with transportation splinting in the forward area.
s. Internal Fixation: The use of
bone plates or screws is not recommended in stations forward of an Evacuation
Hospital.
t. Humerus: Skin traction, skeletal
traction and high abduction spica plasters or splinting are not only
uncomfortable but dangerous transportation methods. A hanging plaster
is unsuitable for transportation purposes. A simple U plaster slab running
from the affected shoulder over the anterior aspect of the forearm amid
upward to the axilla is usually sufficient. The wrist is supported by
a bandage sling. Following definitive surgery, the same type of splinting
may be used for further transport, or a carefully applied spica with limited
abduction (30° - 35°) may be used.
u. Femur: Traction applied by a
clove hitch, ankle bracelet or through the boot is not advisable for
longer than six hours. This type of traction should be changed to skin
traction at the Clearing Station.
v. Attention is drawn to the Tobruk
transportation splint highly recommended by the R. A. M. C. reports from
the Middle East. Medical Officers should familiar with the
design and methods of application of this splint and a more frequent use
is suggested.
302
w. If a plaster spica is used the
extremity is fixed in slight abduction and care taken to see that the
upper part of the cast does not impinge on the costal margin. If the other
leg is not tied into the spica, and it rarely need be, the plaster casing
is extended well above the costal margin with fenestration provided for
the abdomen.
x. Spica casting for either the
upper or lower extremity must be well applied with adequate padding to
avoid discomfort and pressure sores during transportation. These complications
as well as easier application have led to the development of the Tobruk
splint.
y. Amputation: In military
surgery an amputation is a two-stage operation--the first stage performed
in the overseas theater, the final stage, if necessary, in the Zone of
the Interior.
(1) The circular type Guillotine
is the amputation of choice. The indications for primary amputation are
control of hemorrhage, destruction of circulation, removal of irreparably
destroyed extremity and as a step in the debridement of a traumatic amputation.
The site of primary amputation is the lowest possible level of viable
tissues regardless of the eventual utility of the stump so formed.
(2) Delayed amputation
is performed for circulatory insufficiency, infection, gas gangrene in
which more conservative measures have been inadequate or in the judgment
of the surgeon will be inadequate, and uncontrollable secondary hemorrhage.
The site of secondary amputation is determined by the judgment of
the surgeon with respect to preservation of maximum bone length.
(3) Sulfanilamide is
dusted on the end of the stump and vaseline gauze dressing applied. Skin
traction is applied on the operating table and continued until
the stump is healed. All lower leg amputations are splinted with a
posterior slab to prevent flexion deformity of the knee. The splint extends
below the level of time stump. Transport in ½ ring Thomas splint with
support of the stump and continued skin traction.
(4) Adhesive plaster traction is
recommended in the forward areas where a bulky dressing may be desirable.
Stockinette applied with skin glue may be substituted at the base. Adhesive
plaster traction strips must extend to the edge of the incised skin
and be anchored by two circular strips. They should not extend upward beyond
the base of the limb.
(5) Secondary closure of amputation
stumps is not recommended.
z. Peripheral Vascular Insufficiency : Following wounds that jeopardize the blood supply of an extremity
transport beyond an Evacuation Hospital is delayed until
the collateral circulation has been demonstrated adequate or until amputation
has been performed. Immobilization for transport, or the additional trauma
and shock incident to transport may be a determining factor in producing
gangrene.
303
(1) Principles guiding
treatment of a limb with defective circulation are as follows: (1) Immediate
restoration of blood volume with plasma supplemented by whole blood transfusion
to establish normal oxygen carrying capacity of the blood. (2) Prevention
of loss of body heat by dry woolen coverings for body and limbs. (3) Do
not ligate a major artery in continuity. Divide the vessel between ligatures.
(4) Ligate and divide the companion vein. (5) The extremity supplied by
the divided vessel should not be elevated but slightly depressed. Wrap
in wool or cotton. Do not directly heat.
(2) To stimulate the development
of collateral circulation the following measures are recommended: (1)
Heat the body (not the limb) under a cradle. (2) Novocain block of sympathetic
chain repeated daily if necessary. (3) Under special circumstances, sympathectomy.
(4) Vasodilating drugs are of questionable efficacy. (5) Passive vascular
exercises. (6) Incision of deep fascia planes if a tense hematoma is present.
(3) Arterial spasm may
be encountered when a missile passes close to an artery or there is an
adjacent fracture. There is no external bleeding or hematoma. The limb is
cold, numb and muscle action lost. Peripheral pulses are absent. There is
no pain in contrast to occlusion of the artery by an embolus.
(4) Peripheral pulses
return in a few days as color amid warmth reappear in the limb. Treatment
is directed toward warming the body, and the use of sympathetic novocain
block. If the vessel is exposed during debridement direct application
of procaine may be tried.
(5) All casualties with
defective circulation in an extremity, particularly of the leg should
be under close observation for the development of gas gangrene.
* * *
* * * *
(S) F. A. BLESSE
F. A.. BLESSE, Brig. General,
AUS, Surgeon.
DISTRIBUTION:
CG, Fifth Army 500
CG, II Corps
450
CG, NAAF 300
CG, ABS
500
CO, MBS
800
CO, EBS
CO, Hq. Comd., AF 50
SURGEON, NATOUSA 100
304
HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS
Office of the Surgeon
APO 534
9 JUNE 1943
CIRCULAR LETTER NO. 16
SUBJECT: MEMORANDA ON FORWARD SURGERY
ESPECIALLY APPLICABLE TO AMPHIBIOUS OPERATIONS
1. General Principles of Wound Management:
a. Surgical operation performed under
unfavorable conditions without facilities for proper after care is often
more hazardous than prompt evacuation if the patient is transportable
or can be made so.
b. Wounded evacuated by water should,
particularly during early phases of combat, be so bandaged and splinted
that they can swim or at least remain afloat should emergency require
it.
c. Overdosage with morphia produces
dangerous coma and respiratory depression that may delay the administration
of an anesthetic or render evacuation transport hazardous.
d. All wounds are left open after
debridement, frosted with sulfonamide and loosely filled with vaseline
gauze. There are no exceptions. (See below for specialized regional
situations).
e. Only bruised and devitalized skin
need be excised, and this with narrow margin. Avoid circumcision of wounds
leaving circular defects by using linear extensions to gain exposure.
f. During debridement open all deep
pockets and transversely divide fascial planes.
g. Do not pack wounds with gauze or sulfonamide.
h. Immobilize site of extensive injury even
if fracture is not present.
i. Continue oral administration of sulfonamide.
j. Make notations on casts and on Field
tags and records, (casts are frequently changed) particularly of what
was done at operation. These notes are not merely for statistical purposes
although essential as such. They are required for the subsequent care
of the patient.
2. Plaster Casts.
a. Split or bivalve all casts as soon
as dry. There are no exceptions.
b. Pad all casts and split padding
as well as cast. Non-padded plaster is not suitable for transportation
splinting.
c. Apply no circular adhesive or bandage
under cast.
305
d. Maintain foot in neutral position
with correction of tendency toward equinus, valgus or varus.
3. Compound Fractures.
a. Objects to be achieved in initial surgery
are control of infection and safe, comfortable transportation. Reduction
and rigid fixation of fracture can be accomplished at The Base.
b. Careful debridement as priority
case. No internal fixation forward of Field or Evacuation Hospitals. Do
not pack wound--loosely fill with vase-line gauze. Splint for
transportation. Skeletal fixation or traction not recommended for transportation
splinting.
c. Femur: Evacuate in
Tobruk splint (See Appendix) as early as circumstances permit to reach
Base for correction of deformity. A fractured femur should reach a General
Hospital in the rear within 10 days. Do not. evacuate with clove hitch
or boot traction--use skin adhesive.
d. Knee-joint: In debridement minimize
incisions that compound joint. Remove accessible foreign bodies. Irrigate
joint with saline. Close synovial membrane. Loosely fill debrided wound
with vaseline gauze. Evacuate early, immobilized in plaster or preferably
Tobruk splint.
e. Leg: Careful debridement all wounds
in multiple injuries, as circulation frequently impaired and gas gangrene
likely. Penetrating wounds of calf may require incision for hemostasis
as deep hematoma impedes circulation. Bivalve rather than split casts
so inspection dressings may be possible without losing position in compounded
fractures. Hold patient if circulation is questionable, otherwise evacuate
as early priority.
f. Humerus: Use modified Velpeau
plaster bandage to hold arm to trunk, or ‘‘U” plaster. Skin traction,
skeletal fixation, high abduction spica and hanging cast unsuitable for
transportation splinting.
* * *
* * * *
10. Amputations:
a. Circular type guillotine is amputation
of choice. In forward surgery performed for control of hemorrhage, destruction
of circulation, removal of an irreparably destroyed extremity, and as a
step in the debridement of a traumatic amputation. The site is the lowest
possible level of viable tissues regardless of the eventual utility of
the stump.
b. Gas gangrene infection occurs in
certain cases with 24 hours delay in evacuation from the field. Amputate
only if more conservative surgery and full dosage (80,000 to 100,000 units
of polyvalent anti-toxin) are judged inadequate.
c. Apply skin traction on the operating
table and maintain during evacuation.
306
d. No sutures. There are no exceptions.
(S) F. A. BLESSE
F. A. BLESSE, Brig.
General, AUS, Surgeon.
Incl: Appendix
DISTRIBUTION:
To all Medical Officers
CG-Fifth Army 900
CG-NAAF
450
CG-ABS
500
CG-MBS
800
CG-EBS
700
CO, Hq. Command AF 50
Surgeon, NATOUSA 250
APPENDIX
Tobruk Transportation Plaster. – Recommended for fractures
of the femur, wounds involving the knee joint and fractures of the leg
near the knee.
1. Dress wound and retain dressing with strips of adhesive
plaster. No circular dressing or bandages should ever be put on under
a plaster case.
2. Support patient with a pelvic rest, or bowl under sacrum. One
assistant holds the foot by the heel and toes and exerts traction. The
foot is kept at right angles. A second assistant supports the fracture
and keeps the knee bent at 10 degrees flexion with the palms of the hands
not the fingers.
3. Apply traction strapping as close up to the wound as possible.
Fold distal ends of straps into cords.
4. Pad the heel and malleoli with wool. Turn back the traction straps
from the region of the malleoli while winding the wool round. Pad the
knee prominences similarly. There have been some cases of foot drop from
pressure on the external popliteal nerve. Pad the upper part of the thigh
close to the ring of the splint with a layer of wool. Pad the entire
extremity with sheet wadding or stockinette.
5. Lay a strip of tin (obtainable from ration boxes etc.) wrapped
in paper over time anterior surface of the length of the limb to beyond
the toes.
6. Prepare a plaster slab (6 thicknesses)--apply posteriorly
as high as possible and distally over heel and sole of foot to
project 3-4” above the toes.
7. Complete plaster cast with circular bandages round the
slab enclosing the whole of the leg and foot except the dorsum of the
toes and mould. Do not cover over traction straps further than just above
time malleoli.
8. The traction straps are now emerging from the plaster just
above time malleoli. Turn them back and cut the plaster away from where
they emerge,
307
sufficiently to free the straps from the plaster. This allows the
traction to be on the leg and not on the cast. Trim the plaster over
the dorsum of the toes. See that the little toe is free.
9. Apply Thomas Splint preferably half-ring and fit lower
part of ring against Tuber Ischii and adductor muscles. Hold up ring so
as to obtain correct position and insert pads of wool anteriorly and laterally
between the ring and the thigh to maintain the position. Tie traction
straps to notch in splint and insert spreader and Spanish Windlass.
10. Wind plaster bandages round the side bars of the splint,
and round the limb to anchor the splint to the limb.
11. Support distal end of splint with splint bracket.
12. When plaster is moderately firm cut down on thin strip
over whole length plaster and withdraw strip and split the
plaster . Cut the underlying padding within scissors or knife. It
is not unnecessary to cut stockinette.
13. With indelible pencil draw diagram of fracture and write
simple details, (late of wounding, treatment, date of application of plaster,
unit, etc.
NOTE: This splint is only intended as a transportation splint
for the journey to the base. There is no need to aim at accurate apposition
in the Forward Area. On arrival at the Base Hospital X-ray examination
should be made, position corrected if necessary and routine treatment employed.
This form of fixation will do quite well even for fractures of the
upper third of the femur for transport.
HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS
Office of the Surgeon
APO 534
26 JUNE 1943
CIRCULAR LETTER NO. 19
* * * *
* * *
Operations on the Knee Joints........... IV
* * * *
* * *
IV – OPERATIONS ON THE KNEE JOINTS.
1. Careful surgical judgment is to be exercised in the selection
of cases for excision of semilunar cartilages. A history of locking is
essential. Instability of the knee joint is a contraindication. Post operative
care in the form of early weight bearing without crutches and exercise
of time quadriceps muscle groups instituted early under supervision is
essential to recovery.
308
2. Operations for major knee disabilities such as repair of
collateral or cruciate ligaments, or removal of both cartilages are to
be undertaken only on recommendation of a Disposition Board of a General
Hospital.
For the SURGEON:
(S) E. STANDLEE
E. STANDLEE, Colonel,
M. C., Deputy Surgeon.
DISTRIBUTION:
CG, Fifth Army 600
CO, ABS 500
CG, MBS
600
CO, MBS Center District
200
CG, EBS 600
CG, NAAF
450
CG, Force 141 300
CO, HQ Comds.., AF 50
Surgeon, NATOUSA 150
HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS
Office of the Surgeon
APO 534
22 JUNE 1943
CIRCULAR LETTER NO. 20
SUBJECT: Tunisian Campaign--Comments by Hospitals of the Zone
of Communications on the Treatment of Battle Casualties in Forward Areas.
NOTE: At the end of the final phase of the Battle of Tunisia, several
hospitals of the Zone of Communications were asked to submit comments
on the surgical treatment of battle casualties received during the campaign.
Although quotation marks have been eliminated, the following paragraphs
are direct transcriptions of these comments and suggestions. Specific
case histories have been assembled in the Appendix with designations as
footnotes. Many of the principles emphasized in these comments have been
incorporated in Circular Letters, and they should be carefully observed
by all Surgeons in the Theater.
Figures in parentheses refer to case histories in the Appendix.
Comments in parentheses were not received from the hospitals.
309
1. General Consideration.
a. In general, the great majority
(90%) of patients received from the combat zone have been well and adequately
treated, and good judgment has been exercised in selection of cases suitable
for evacuation to this general hospital.
b. In several instances time severity
of the injury has not seemed to warrant evacuation to this point, where,
with a large proportion of the cases prospectively to be evacuated to
the Zone of the Interior, it is inevitable that the patients should acquire
an exaggerated idea of the severity of their injury, and a reluctance
toward return to duty. (1)
c. There are rare instances of patients
who were so critically ill on admission that their evacuation has appeared
unwise and unduly hazardous.
d. Many patients might have been returned
to full or limited service if they had not been told that they were to
be sent to the Zone of the Interior, or that they would not regain full
function of an injured part.
e. Almost all of our patients have spoken
will appreciation of the skilled and kindly treatment they have received
in the most forward areas--litter bearers, battalion surgeons, and on
back. Most of the patients have had excellent treatment and in particular
the work of the Surgical Teams has been outstanding.
f. A number of our patients have received
wounds due to shell fragments. The vast majority of these wounds have
been satisfactorily treated by excision and left open. Most of them have
healed kindly and have required only secondary closure or skin grafting
for complete healing.
g. Judging from the comparatively small number
of war casualties treated in this hospital it seems evident that delayed
primary suture of wounds, particularly in patients who are to be evacuated
is an ill-advised procedure (This does not apply to secondary suture in
a Base Hospital where the patient can be held until healing is complete.)
The suture of wounds using a gauze pack as a drain should be avoided. The
pack dries and acts as a plug rather than a drain.
2. Initial Treatment of Wounds.
a. Adequate debridement of wounds
in combination with a filling of vaseline gauze and the use of sulfa
drugs and plaster immobilization has produced clean wounds in most instances.
The patients have arrived in good condition, relatively comfortable, and
have only rarely shown even slight temperature elevation.
b. The extent of some wounds suggests that
skin removal has been too extensive in many cases.
c. Large numbers of foreign bodies are still
present in the wounds in many cases. The metallic foreign bodies only
occasionally are responsible for persistent draining sinuses. In one case
fragments of cloth were found just beneath the skin, where even casual debridement
might have discovered them.
d. Conservation of digits. Numerous fingers with
compound injuries and lacerated tendons have been treated conservatively,
often with tendon
310
suture and splinting. An over heroic attempt has been made in the
presence of sepsis to preserve digits devoid of function. The protracted
splinting in these cases results in diffuse stiffness of the hand unrelieved
by late amputation of the useless digits, and necessitating evacuation
to the Zone of the Interior. From the standpoint of military usefulness
the results of early amputation in badly damaged fingers have been more
satisfactory.
e. There have been several instances
of attempted primary tendon repair in severe crushing or gunshot wounds
of the hand. None of these has been successful.
f. Packing. The commonest criticism
of the packing of wounds is that excessive amounts of gauze have been
used, frequently acting as a plug, and often introduced through a small
wound of entrance. In several cases through and through gauze strips have
been used to pack perforating wounds of the extremities. Coarse meshed
dry gauze has been used for packing in many cases, the removal of which
is difficult and unnecessarily traumatizing. When it is necessary to use
dry gauze packs to control bleeding, early removal is urgent and a notation
that such packing has been employed would ensure an early change of cast.
g. On many occasions when time casts were
removed and the wounds dressed, tight vaseline packs were found in place
and when these were removed there was a gush of dammed back discharge.
It seems desirable that the vaseline gauze strips be laid from the bottom
of the debrided wound out over the skin in an axis at right angles to
the wound. Having lain such strips all about the circumference of the
wound the remaining central cavity can be filled with vaseline gauze folded
back and forth. It is worth repeating that the debridement should be complete,
the sulfanilamide sprinkled into all crevices of the wound and the vaseline
packing inserted loosely.
(It is recommended that the term “pack” be dropped from common usage
and reserved specifically for a temporary procedure used to control hemorrhage.)
h. Immobilization. Many casts are
excessively thick and heavy. Insufficient padding, or padding carelessly
applied, has resulted in pressure sores in several cases. The use of circular
bandages inside casts, or of slings, may result in constriction or pressure
sores. Simple linear incision of a circular cast is not sufficient safeguard
against swelling and circulatory embarrassment. In one instance of simple
uncomplicated fracture of both bones of the leg, amputation was barely
averted because of circulatory damage which could have been avoided by
proper padding or bivalving of the cast.
i. We particularly condemn the use
of the skin tight plaster on the acute injury, even those split up the
front. We have had about 20 cases of fracture of the leg and a few of the
arm come to us in plasters applied directly to the skin at the time of debridement
in forward hospitals. With very few exceptions the skin has been blistered
when these casts were removed. Sheet cotton, stockinette, cloth of any
kind or even newspaper should be used to protect the skin.
j. Insufficient splinting and immobilization
has been applied. (2) (3) Contractures have developed which have been
very troublesome and in some
311
cases have necessitated evacuation to the Zone of the Interior for
this reason alone. Cock-up splints for radial nerve injuries are generally
too short. Patients with peroneal palsy are not protected against foot
drop.
k. Hip spicas in the majority of cases
are carried unduly high and cause a considerable amount of unnecessary
discomfort. In shoulder spicas a common error is to place the
arm in too great abduction, and in or behind the frontal plane of the body
rather than forward of it. Patients transported in “hanging casts” for
fracture of the humerus do not travel well. (4)
l. Of the 272 patients treated, 111
were compound fractures, all but four of whom entered this hospital by
air ambulance in excellent condition. The great majority of these patients
had been treated by early debridement, local application of a sulfonamide
packing with vaseline gauze and application of a padded plaster cast.
m. Fractures have been well immobilized
and the plaster work has been excellent. In only a few instances has
it been necessary to remove plaster because of constriction.
n. In badly comminuted fractures where good
position has been obtained at operation loss of position is to be feared
with change of cast. These cases are problems. While we favor the 10th
to 12th day change of plaster we have allowed them to go several weeks
pending soft tissue fixation of the fragments. It would be helpful if plasters
in such cases could be bivalved rather than split down the center, so the
dressing might be done and a new cast applied over the remaining half.
(Bivalving plasters prior to transportation means strengthening
the halves by slabs and secure approximation before evacuation.)
o. Penetrating or perforating injuries
of the knee have frequently been opened surgically in forward hospitals,
foreign bodies or bone and cartilage chips removed, the joint irrigated
thoroughly, sulfanilamide inserted into the joint, the synovial membrane
closed and the wound then packed open. All so treated have done well with
a minimum of synovial reaction. After the operative procedure all cases
should be immobilized in a long leg plaster to the groin and the use of
a cross stick at time ankle to prevent rotation.
3. Amputations.
a. The small number of amputations
seen would have benefited had they been transported in Thomas splints
with skin traction applied to the skin flaps. The open wounds were clean
but the skin had retracted to the point that reamputation will probably
be necessary to accomplish a serviceable stump.
b. In two instances a final amputation
was done at too high a level to permit use of an artificial limb. Several
cases of amputation have arrived within severe flexion contracture of
the knee for lack of a posterior splint. Several cases of severe hip flexion
contracture have been received as a result of omitting posterior splints
following thigh amputations.
c. Out of twelve cases of anaerobic
gas bacillus infection in one hospital, 2 were in sutured amputation stumps.
312
d. In the following case, (5), a
conservation type of amputation was performed through a level far below
the site of vascular occlusion in an infected leg. I think the lesson here
is that the line of demarcation in infected extremities with vascular occlusion
does not mark the level at which an amputation stump will be sustained.
Circulation just enough to maintain viability of tissues will not withstand
an amputation or cope with an infection. Amputation in such cases must be
high, if possible above the level of vascular occlusion.
* * *
* * * *
(S) F. A. BLESSE
F. A. BLESSE, Brig. General,
AUS, Surgeon.
Incl: Appendix
DISTIBUTION
CG, Fifth Army 600
CO, ABS
500
CG, MBS
600
CO, NIBS Center District 200
CG, EBS 600
CG, NAAF
450
CG, Force 141
300
CO, HQ. Comd., AF 50
Surgeon, NATOUSA 150
HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS
Office of the Surgeon
APO 534
18 NOVEMBER 1943
CIRCULAR LETTER NO. 48
PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED -- .I
PARAGRAPH III, CIRCULAR LETTER NO. 191S AMENDED -- .II
USE OF EXTERNAL SKELETAL FIXATION APPARATUS (ROGER ANDERSON) IN
TREATMENT OF FRACTURES OF THE EXTREMITIES -- III
DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF COMPOUND FRACTURES
WITH OR WITHOUT SECONDARY SUTURE OF WOUND -- IV
FRACTURES OF CARPUS -- V
HERNIATED NUCLEUS PULPOSUS -- VI
“PARRY”OR MONTEGGIA FRACTURE -- VII
THE TOBRUK SPLINT AND HIP SPICAS -- VIII
TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA -- IX
I – PARAGRAPH IV, CIRCULAR LETTER NO. 19 IS AMENDED AS FOLLOWS:
Operation of the Knee Joint
Follow-up studies on over 200 operations performed in this theater
for removal of dislocated or ruptured semilunar cartilages and other derangements
of the knee joint have been compiled. Appraisal of these results lead
to the following recommendations:
1. Operations for the repair or reconstruction of the collateral
or cruciate ligaments of the knee, or for recurrent dislocation of the
patella, are not to be performed in this theater.
2. Careful study and mature surgical judgment will be exercised
in the selection of cases for excision of a semilunary cartilage or joint
mouse.
a. Elective arthrotomy of the knee will
be performed only on the Orthopedic Service of a General Hospital.
b. Initial injuries of the semilunar cartilage
without locking and those that unlock by gentle manipulation, or after
5 to 6 days of skin traction, will not be subjected to operation. Pressure
support, rest, graduated to protected, then full weight bearing and carefully
supervised quadriceps exercise for 2 to 10 weeks, are suggested as a method
of management. Following symptomatic relief these soldiers may be returned
to duty.
c. Arthrotomy will be limited to:
(1) The persistent locked
knee.
(2) The unlocked knee
in a soldier who cannot perform noncombat duty because of his disability.
This will be only the exceptional case.
d. Contraindications to be
considered are age, arthritic changes, instability of the joint and, in
particular, any but the most favorable mental attitude of the soldier.
e. Recurrent cases, not locked, and those
recurrent cases that unlock within non-operative therapy, are to be returned
to duty unless the total period of disability in any calendar year exceeds
90 days. Under such circumstances, they will be transferred to the Zone
of the Interior.
f. Operation for the removal of both
cartilages from one knee or for one cartilage from each knee is to be
performed only on written recommendation of a Disposition Board of a General
Hospital.
3. A General Hospital in which arthrotomy of the knee is performed
will be expected to hold the patient for a minimal period of six weeks,
so that the operating surgeon may supervise the regimen of post-operative
exercises and motion essential to a good result. Proper post-operative supervision
is as essential to recovery as the operation. If prevailing evacuation
policies indicate that the patient cannot be lucid for at least 6 weeks
post-operatively, he should be transferred farther to the rear for operation.
314
4. After 6 weeks in a General Hospital, the patient may be
transferred to a Convalescent Hospital for further care with full instructions
relative to continuation of corrective exercises.
II – PARAGRAPH III, CIRCULAR LETTER NO. 19 IS
AMENDED AS FOLLOWS:
Operations for Recurrent Dislocation of the Shoulder Joint or Chronic
Dislocation of the Acromio-clavicular Joint
1. The history of a patient relative to previous dislocation
of the shoulder is notoriously unreliable. Before making a diagnosis of
recurrent dislocation, one or more episodes should be confirmed on Army
Medical Records, preferably with supporting X-Ray evidence.
2. Operations of this type will be performed only with written approval
of the Disposition Board of a General Hospital following demonstration
that the disability is of a nature that the soldier cannot perform non-combat
duty and when his age and mental attitude give a reasonable prospect of
military rehabilitation.
III – USE OF EXTERNAL SKELETAL FIXATION APPARATUS
(ROGER ANDERSON) IN TREATMENT OF FRACTURES OF THE EXTREMITIES.
1. This is a highly specialized method for the treatment of
carefully selected cases, chosen on the basis of special indications.
2. The use of external skeletal fixation is to be limited to surgeons
with training and experience in the method. If a special indication for
use of the method is found in a hospital without such a surgeon, the patient
will be transferred to a hospital with this trained personnel.
3. A patient within the apparatus in place is not to be transferred
from one hospital to another within the theater except under emergency
conditions. When a transfer is essential, he is to be routed to a hospital
where there is a surgeon experienced in the method. Patients are not to
be evacuated to the Zone of the Interior with the apparatus in place, but
will be held for a sufficient time to permit the removal of pins and the
substitution, if indicated, of conventional means of splinting.
4. Clinical records of each patient, on whom the method is utilized,
will be forwarded through channels to the Surgeon, NATOUSA, after the
treatment is completed. This record will contain essential data for identification
of the case, date of injury, fracture diagnosis, original treatment, character
of the wound if compound, problem involved and indication for use of
the method, length of time required to apply the apparatus and reduce
the fracture, number of X-Ray films required, date and extent of any observed
distraction, incidence of pin infection and other complications, date
of removal of the apparatus and subsequent treatment, result. and disposition.
315
IV – DELAYED OPEN REDUCTION AND INTERNAL FIXATION
OF COMPOUND FRACTURES WITH OR WITHOUT SECONDARY SUTURE OF WOUND.
1. This procedure is still under trial within reference to
indications, hazards, and incidence of serious complications. Its use
is restricted to special groups authorized to assume the responsibility
as a special study.
V – FRACTURES OF CARPUS.
1. Greater care is to be exerted in making a precise and early
diagnosis of carpal fractures and dislocations. Early reduction is essential
if a satisfactory result is to be obtained.
2. Operative treatment for old unrecognized fractures of the scaphoid
will fail to rehabilitate a soldier in this theater. If complete disability
is present, he should be transferred to the Zone of the Interior.
VI – HERNIATED NUCLEUS PULPOSUS.
1. Recommendation Par. II, Circular Letter No. 19, 26 June
1943, is interpreted to apply to all patients, Army, Navy or Allied Force
under treatment for this condition in U. S. hospitals.
VII – ”PARRY” OR MONTEGGIA FRACTURE.
1. Attention is directed to fracture of the shaft of the ulna
within dislocation of the head of the radius. Uncommon in civilian practice,
this fracture due to direct violence to the forearm (blow with rifle
butt or other blunt weapon), is not infrequent in military experience.
It is essential that the dislocation of the radius be recognized and proper
treatment instituted at the time of initial treatment.
VIII – THE TOBRUK SPLINT AND HIP SPICAS.
1. Experience has shown that the use of Tobruk splint is best
limited to fractures of the lower one-third of the femur, supra-condylar
fractures, and wound damaging the knee joint. Even in these injuries
it has no advantages over a well applied hip spica.
2. The most comfortable and efficient hip spica for immobilization
of a fracture of the femur for transportation, following initial surgical
treatment, is a short waisted, double spica extending only to the knee
on the well leg and maintaining 20 to 30 degrees of abduction within the
knee slightly flexed. The plaster on the injured leg is carried beyond
the toes by a plaster slab, leaving the toes fully exposed anteriorly. Care
is taken to avoid equinus and to hold the foot in a neutral position between
valgus and varus.
3. High waisted plasters that extend to or above the costal margin
cause discomfort. It is better to tie in the well leg and stop the plaster
just above the iliac crest.
316
4. The chief responsibility of the surgeons of the forward
area in the management of all compound fractures is the prevention of infection,
rather than the anatomic correction of deformity. Early evacuation to
the Base (a fractured femur should reach a General Hospital within 10
days) will allow for definitive reduction of the deformity.
IX – TRANSPORTATION OF CASUALTIES WITH PARAPLEGIA.
1. Meticulous nursing care is essential for the prevention
of bed sores. This care is interrupted by rapid evacuation through a chain
of hospitals. While it is important to transfer these cases to the Base,
when they are transportable, they should not be subjected to long ambulance
lifts. On arrival at, an intermediate station, careful nursing care should
be provided immediately. If there are signs of pressure sores, the patient
should be held for corrective measures before further transfer. These patients
do not complain of pain and quite different criteria are required in an estimation
of whether they are to be classified as “transportable” than are found applicable
in the management of other casualties.
For the SURGEON:
(S) E. STANDLEE
E. STANDLEE,
Colonel, M. C. Deputy Surgeon.
DISTRIBUTION:
Surgeon, NAAF 400
Surgeon, NAASC 300
Surgeon, EBS
400
Surgeon, MBS 300
Surgeon, ABS 150
Surgeon, IBS
100
Surgeon, PBS 500
Surgeon, AMGOT 25
Surgeon, CD MBS 50
Surgeon, Seventh Army
350
Surgeon, Fifth Army 600
Surgeon, Hq. Command, AF50
Surgeon, NATOUSA 200
317
HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS
Office of the Surgeon
APO 534
19 APRIL 1944
CIRCULAR LETTER NO. 26
SUBJECT: Wound Management.
1. The keystone of successful wound management is the initial
surgical operation. When this is performed correctly the complications
of infection are absent or minimal and secondary suture may be carried
out promptly and successfully. To coordinate the initial surgery in the
forward area within the definitive surgery at the base observance of the
following principles is essential.
2. Initial Wound Surgery.
a. 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 counter
incision..
b. 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 with 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. Circular
defects are to he avoided.
c. Incision and excision of the fascial layers
is carried out 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. The
operation on a wound is an anatomic dissection and should never be made
to resemble a digital pelvic examination.
d. 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.
e. Use fine hemostats. Use the finest ligatures
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 the missile or by the surgeon
must slough before the wound can be closed by secondary suture.
f. Large wounds in regions of heavy muscles
particularly when complicated by comminuted fracture require especial care.
The depths of these
318
wounds must be opened by a long incision with counterincision if
necessary to allow free drainage of blood and tissue that may not be identified
as dead at the time of debridement.
g. Only enough vaseline gauze is used to separate
the surfaces of the wound. It should be smoothly laid in the wound--not
“packed”.
h. Local application of sulfanilamide is a
minor adjunct to surgery and is used as a fine frosting of the surfaces.
It is not to be “rubbed in”.
i. Ether, white soap, and benzene have slight
but definite necrotizing effects on living muscles. Green soap, hydrogen
peroxide and various other substances used as detergents have greater
necrotizing effects. Physiological saline solution, petrolatum and boric
acid ointment are innocuous. If a detergent is needed, white soap is the
least objectionable.
j. Old wounds (48 hours or longer) are
managed in accord with the same principles except that in selected cases
of established pyogenic infection and anaerobic cellulitis with 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.
3. Secondary Wound Surgery.
a. On arrival at a hospital where bed care
can be assured for a period of 15 days the first dressing is removed in
the operating room under aseptic precautions. X-ray films should be at hand.
If the primary wound operation has been a complete one, 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.
b. The presence of residual dead tissue or
established infection indicated by profuse discharge of pus, reddening
and edema of the wound margins, persistent fever or toxicity are the common
indications for delay in secondary suture. When these indications are present
but minimal, the wound is allowed to “clean up”. Moist dressings, heat
and azochloramine are generally considered to hasten this process. Additional
surgical excision of devitalized fragments may speed the process. Secondary
suture 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.
c. Closure of wounds that compound fractures
or joints is only to be undertaken when the surgeon is completely familiar
with the use of penicillin as an adjunct to surgical wound revision. Penicillin
will not “sterilize” a wound that contains devitalized bone, fascia,
tendons or foreign bodies. Immediate success may be obtained, but delayed
abscess formation, joint infections
319
and osteoperiostitis are likely to appear as sequelae. The wound
revision that is an essential part of “cleaning up” wounds that complicate
fractures or joints for closure, either at the time or subsequently, is
not to be taken lightly. Preparation of the patient by transfusions, diet
and accessory surgical procedures is essential.
d. Wounds that have been properly laid open
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 with suture
in a straight line which possible. Undermining with advancement or rotation
of flaps provides sufficient skin in nearly all instances and is preferable
to grafting.
e. Technical considerations that are important
to the success of secondary wound closure are:
(1) Atraumatic handling
of tissue (see par 2, e).
(2) Avoidance of tension
sutures.
(3) Accurate approximation
of skin margins. The epithelial bridge is the main support of the wound
for a considerable period of time.
(4) Obliteration of dead
spaces by pressure dressings and immobilization.
(5) Leaving sutures in
place for 12 days if stitch infection does not develop.
(6) Suture in straight
lines rather than creation of sharp angles.
(7) Closure by adhesive
plaster strips is not as satisfactory as suture.
f. The conditions that most often jeopardize
results are:
(1) Suture of wound that
is discharging a large amount of pus. This usually means dead tissue in
the depths.
(2) Hemolytic streptococcus
infection.
(3) Diphtheria wound
infection.
(4) Too early motion.
(Wounds breaking down for this reason should be immediately resutured.)
(5) Unrecognized foreign
bodies adjacent to the wound.
g. 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.
Infection may be considered indicative of the susceptibility of the individual
to the predominate wound organisms.
4. Specialized Problems.
* * * * * *
*
c. Amputations.
Secondary closure of a circular guillotine amputation stump is not
commonly indicated, as it is impossible to suture the inelastic fascia
without wasteful shortening of the bone. Bone length can be saved by continuing
the skin
320
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 of defects
may be performed for temporary resurfacing of stumps that will later
require plastic procedures or reamputation. It should not be employed
when further use of skin traction will promote healing or covering of
the bone end with normal skin. Vertical incisions in the stump made for
infection or as part of time initial debridement should be closed by secondary
suture while skin traction is being maintained to cover the defect at the
end.
* * * * * * *
e. Closed Plaster Treatment (Truetta).
The regimen of closed plaster management of war wounds has not been
judged applicable to the field conditions of this theater. It is advisable
to remove the initial dressing for inspection of the wound in all cases
at least by the 15th day. Incorporation of pins or other fixation devices
in the initial plaster to maintain the reduction of fractures obtained
at the initial operation has been found impractical as a means of transportation
splinting.
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.
Infrequent change of plaster as practiced in the theater has many
advantages, particularly when it is desired to allow granulations to
cover exposed bone in deep irregular wounds (Orr). It is also an accepted
method of management for established infection of bone particularly when
the wound has caused all extensive loss of overlying soft parts or there
is a boric defect. Small surfaces of bare cortical bone may be removed
surgically when this permits closure of the defect by suture. When resurfacing
by skin graft is possible in a shallow wound the bare cortical bone may
be left for spontaneous sequestration.
f. Military Aspects. Secondary wound surgery
in an Overseas Theater must be measured against the objectives that are
sought. In general, these are:
(1) To return a soldier
to duty with a minimum number of days lost.
(2) To return patients
to the Zone of Interior at an earlier date and in better condition.
(3) To reduce ultimate
disability and deformity by preventing or cutting short a phase of late
wound infection with fibrosis and other harmful sequelae.
An aggressive attitude is desired in the case of any soldier who
may be returned to duty in this theater. On the other hand, to suture a
small clean wound that is compounding a fracture of the femur is merely
a stunt, as the soft parts will be healed before the bone unites.
321
It is not desirable to embark on elaborate plastic procedures such
as crossed extremity skin flap grafts or operations undertaken for cosmetic
purposes.
For the SURGEON:
(S) E. STANDLEE
E. STANDLEE Colonel,
M. C., Executive Officer.
DISTRIBUTION:
All Medical Installations
Surgeon, SOS NATOUSA
800
Surgeon, Fifth Army
500
Surgeon, Seventh Army
100
Surgeon, AAFSC/MTO 800
Surgeon, NATOUSA 200
HEADQUARTERS
NORTH AFRICAN THEATER OF OPERATIONS
Office of the Surgeon
APO 534
1 July 1944
CIRCULAR LETTER NO. 36
SUBJECT: Penicillin Therapy in Wound Management, Surgical
Disease, Burns, and Anaerobic Infections
1. General.
a. In World War II, two quite different policies
have governed the use of chemotherapeutic agents in the management of
wounds. Chemotherapy has been recommended: (1) as a substitute
for adequate wound surgery, seeking to delay and minimize operative procedures;
(2) as an adjunct to established and progressive surgical measures designed
to achieve better results within an increased margin of safety. The latter
has been and will continue to be the policy governing the management of
the wounded in this theater.
b. The use of penicillin as an adjunct
to surgery outlined in this circular is defined as therapy rather
than prophylaxis. Routine immunization of troops with tetanus
toxoid is a prophylactic measure. Administration of penicillin
for contaminated wounds and established infection is a therapeutic measure.
As with all therapy, if the desired goal is to be achieved, intelligent
and precise professional supervision of every detail is essential.
2. Scope of Penicillin Therapy.
a. Penicillin is accepted as the best available
antibacterial agent for gram-positive bacteria and gram-negative diplococci.
It is ineffective for gram-negative bacilli.
322
b. Penicillin does not sterilize dead, devitalized
or avascular tissue, nor does it prevent the septic decomposition of
contaminated blood clot. There is no evidence that it can neutralize preformed
bacterial exotoxins or inhibit the locally necrotizing bacterial enzymes
in undrained pus. These limitations demand that surgical wound management
retain the principles of excision of devitalized tissue, dependent drainage
of residual dead space, evacuation of pus and delayed or staged closure
of contaminated wounds (see Circular Letter No. 26, Office of the Surgeon,
Hq. NATOUSA).
c. The use of penicillin in an individual
patient is based upon the decision that infection is probable or present.
d. It is recommended that parenteral administration
be the basis of penicillin therapy. The local or topical use of penicillin
is a supplement to systemic therapy only in lesions of the central nervous
system, serous cavities and joints. The diffusion of the drug into these
areas appears slow and limited.
3. Penicillin Therapy in Relation to Sulfonamide Therapy
.
a. Topical and oral administration of sulfonamides
as first aid measures will be continued.
b. Intravenous sulfonamide prior to initial
surgery will be replaced by parenteral administration of penicillin (par.
6, a).
c. At the conclusion of the initial wound
operation, the decision will be made either to institute a postoperative
course of penicillin therapy or to maintain chemotherapy with sulfonamides.
It is recommended that the agents be used individually and not concomitantly.
If a course of penicillin is elected, topical frosting of the wound with
sulfonamide is omitted. The following observations will serve as a guide
in this decision:
(1) Clinical experience
with penicillin has been greatest with wounds of the extremities and
the thorax. The drug is recommended for these injuries.
(2) The value of penicillin
in craniocerebral wounds is well established, but an extensive experience
has not been accumulated.
(3) Cleanly debrided
soft part wounds uncomplicated by fracture, extensive tissue destruction,
or retained missiles are adequately handled by sulfonamide therapy.
(4) Preliminary evaluation
of penicillin therapy for fecal contamination of the peritoneal cavity
is encouraging but at the present time is inadequate for comparison with
sulfonamide therapy. In view of the difficulties in maintaining a fluid
intake adequate to safeguard sulfonamide therapy in this group of cases,
substitution of penicillin may be made at the discretion of time surgeon.
Forcing of fluids is not necessary solely because of penicillin therapy
and in fact, reduces the effective concentration of the drug by rapid
urinary excretion.
4. Routes of Penicillin Administration.
a. Intramuscular. This is the standard route
for administration. The deltoid, gluteus and thigh muscles are recommended
as the sites for injection. The same area may be used repeatedly. Subcutaneous
administration is to be avoided.
323
b. Intravenous. The intravenous route is reserved
for patients with shock or immediately life endangering infection. A
single intravenous injection provides a therapeutic concentration of
the drug that lasts for two hours. If intravenous therapy is indicated
to span a longer period, the injection is repeated or constant drip administration
instituted.
5. Dosage.
a. Systemic therapy. Current practice dictates
a dosage of 200,000 units in 24 hours, given as 25,000 units every three
hours by the intramuscular route. Larger initial dosage or greater 24
hourly dosage have no demonstrable merit. Maintenance of full dosage schedules
throughout the course of therapy is better than a graded terminal decrease
in dosage.
b. Local therapy. The powdered sodium salt
of penicillin is slightly acid and provokes a burning pain and serous
discharge if applied to an open wound. A solution containing 10,000 units
per c. c. is well tolerated as an intramuscular injection but may produce
headache, meningismus and pleocytosis of the spinal fluid after intrathecal
injection. The maximal effective local concentration is 250 to 500
units per c.c. The usual concentration employed chemically varies between
500 and 5,000 units per c.c. with predominate usage of a solution containing
1,000 units per c.c. The following dosage schedules are recommended for
local instillation:
(1) Intrathecal space 7,500 units
(2) Pleural cavity 25,000 units
(3) Peritoneal cavity 50,000 units
(4) Knee joint 10,000 units
Local instillation of penicillin may be repeated at intervals of
12 to 48 hours in accordance within clinical indications. Needle aspiration
and injection is preferable to inlying tubes.
6. Use of Penicillin in Mobile Hospitals. The following
recommendations are made on the basis of procedures that have been found
practical in Evacuation Hospitals:
a. Upon arrival in the shock or preoperative
ward, the wounded will receive 25,000 units of penicillin intramuscularly,
unless the wound is certainly of a trivial nature. If shock is present,
an additional 25,000 units will be given intravenously.
b. Preoperative dosage is continued at 3 hourly
intervals. It is more practical to give penicillin to every patient in
a preoperative ward at the same time, than to keep each patient on a dosage
schedule based on the time of arrival. There is no objection to a time
interval of less than 3 hours between the first two injections.
c. The decision to continue penicillin
or to substitute sulfonamide in the postoperative period is made when
the operation is concluded and the nature and extent of the injury evaluated
(see par. 3 c).
324
d. No patient will be held in a mobile
hospital solely for the purpose of continuing penicillin therapy. The
usual criteria based on the condition of the patient will determine the
suitability for evacuation. In general, the drug is continued for 2 to
3 days beyond the period of clinical recovery from the hazard or subsidence
of infection. A course of therapy may be associated with slight fever
which disappears after the drug is stopped. Suitable periods of therapy
are:
(1) Soft part wounds 5 to 7 days
(2) Compound fractures 10 to 12 days
(3) Thoracic wounds 8 to 10 days
(4) Abdominal wounds
8 to 10 days
(5) Craniocerebral wounds
8 to 10 days
(6) Joint wounds
7 to 14 days
e. Patients evacuated prior to completion
of a course of therapy will carry a notation “On Penicillin” in the space
provided under the designation “Special attention needed in transit, or
other remarks” on the jacket of the Field Medical Record (Form 52d). This
will indicate the need for continuation of therapy in holding stations, hospital
ships and fixed hospitals.
7. Use of penicillin in Holding Stations or Hospital Ships
.
a. Form 52d will be examined in each case
upon admission to identify those patients receiving penicillin therapy
(par. 5 e).
b. 25,000 units of penicillin will be administered
intramuscularly every 3 hours to all such designated patients.
8. Use of Penicillin in Fixed Hospitals.
a. Patients designated as “On Penicillin”
(par. 5 e) will have time course continued on admission to time hospital.
Discontinuance of therapy will be time responsibility of a medical officer
after lie has reviewed the status of time patient.
b. Secondary suture of cleanly debrided
soft part wounds does not require penicillin therapy. Soft part wounds
requiring delayed debridement or secondary debridement or within established
infection may properly receive penicillin.
c. Reparative surgical procedures on wounds
complicated by skeletal, joint, nerve, tendon or vascular injury require
penicillin therapy.
d. Established wound infection is an indication
for penicillin therapy.
e. Early secondary reparative operations
through recently healed wounds require penicillin therapy.
9. Surgical Disease.
a. Acute or chronic infections such as
furuncles, carbuncles, felons, desert sores, tenosynovitis, etc. should
be treated with penicillin whenever it is judged that loss of time from
duty can be shortened.
325
10. Burns.
a. The local application of sulfonamide crystals
or ointments containing sulfonamides is not recommended. Fine mesh (bandage
cloth) vaseline or boric acid gauze is preferable. Under no circumstances
are tannic acid preparations or other escharotic agents to be used in this
theater.
b. Extensive burns or burns that may include
areas of full thickness skin loss will be treated systemically with penicillin
or if preferred sulfadiazine.
c. See Circular Letter No. 26 regarding
policy of early skin replacement.
11. Anaerobic Infections.
a. Clostridial myositis (gas gangrene).
Early and adequate wound surgery remains the most effective preventive
measure. Early diagnosis of this complication when it occurs, is essential
to adequate treatment. Treatment utilizes surgery, penicillin, antitoxin
and whole blood transfusion. It is recommended that penicillin be given in
the following manner: Initial dosage of 100,000 units intravenously, within
25,000 units intramuscularly at the same time. A course of 25,000 units
intramuscularly every 3 hours day and night is instituted. Larger dosages
and other regimens have not afforded any more satisfactory results. Sulfonamides
are discontinued during penicillin administration.
b. Anaerobic cellulitis and other anaerobic
infections. Penicillin therapy is used as with clostridial myositis (par.10
a).
c. Amputation for anaerobic infection.
(1) It is of prime importance
to differentiate between clostridial myositis and other anaerobic wound
infections to prevent the needless sacrifice of limbs on the basis of clinical
findings of gas and putrid wound exudate.
(2) In the management of
clostridial myositis a limb need not be amputated solely as a measure
designed to arrest the infection. If trauma vascular occlusion and
advancing infection, acting singly or together, have so damaged the extremity
that functional restitution is unlikely, amputation is performed as a ready
and effective adjunct to the arrest of infection.
(3) The early diagnosis
of clostridial myositis and the employment of penicillin and other adjuncts
to therapy, permit the management the infection to be confined
to the excision of involved muscles. If the excision of muscles judged necessary
to eradicate the infection must be so extensive that functional restitution
of the extremity is unlikely, amputation should be performed.
(4) When amputation is performed
as a part of the surgical treatment of clostridial myositis, the use of
penicillin and other adjuncts to therapy allow other considerations than
the eradication of infection to play a part in selecting the level for
amputation. Provided all muscles invaded by the infection and
326
remaining in the stump are carefully excised, a more distal level of
amputation may be selected if the ultimate function of the extremity is
thereby conserved.
For the SURGEON:
(S) E. STANDLEE
E. STANDLEE,
Colonel, MC., Deputy Surgeon.
.
DISTRIBUTION:
Surgeon, Fifth Army
600
Surgeon, Seventh Army 300
Surgeon, SOS NATOUSA
800
Surgeon, AAFSC/MTO
600
Surgeon, NATOUSA
300
HEADQUARTERS
NORTH AFRICAN THEATER
OF OPERATIONS
Office of the Surgeon
APO 534
29 AUGUST 1944
CIRCULAR LETTER
NO. 46
* * *
*
* *
SURGICAL MANAGEMENT OF THE WOUNDED........III
* * *
* * * *
III—SURGICAL MANAGEMENT OF THE WOUNDED.
Note: The contents of this circular letter as well as Circular
Letter Nos. 26 and 36 are to be brought to the attention of every Medical
Officer in the Theater who is assigned responsibility for the management
of the wounded.
* * *
* * * *
7. Reparative Surgery of the Lightly Wounded.
a. It is an eloquent tribute to the high standards
that have been attained in forward surgery that the suture of wounds at
the time of the first dressing at the base is established as a routine
procedure. To maintain this standard requires constant vigilance in techniques
as described in Circular Letter No. 26. The lightly wounded combat soldier
is the most valued military asset entrusted to the care of the Medical
Corps. His treatment must be carried out or closely supervised by surgeons
within mature judgment and experience. There are no “minor” wounds.
b. Forward surgeons will indicate on the record
or on the cast the extent of actual skin loss. At the time secondary suture
is performed it is difficult
327
to distinguish between the gaping of a long incision that can be closed
by approximation and the existence of a sizeable defect that will require
skin graft.
c. An increased use of splinting of soft part
wounds following debridement is advisable. Circular plaster encasement
if placed proximally on an extremity must be immediately bivalved to avoid
constriction.
d. In the closure of wounds, particularly those
of the extremities, further refinements are desirable in techniques that
have a direct effect on restoration of function and early return to duty.
(1) Transversely divided
muscle bundles may be closed by suture, staging the closure of the skin
to a later date.
(2) Very accurate approximation
of the skin as in a plastic procedure is desirable. When drainage is required,
this should be through a counter incision.
(3) More use should be made
of the principles of plastic surgery, viz., the advancement and rotation
of skin flaps, zig-zag plastics and other tricks of closure that, minimize
scar contracture and limitation of motion.
(4) Trauma to skin margins
by rat tooth forceps and rough handling is productive of necrosis and
imperfect healing.
(5) Prolonged hospital neglect
of unhealed wounds and skin defects must be stopped. It is recommended
that the chief of surgical service personally review cases of unhealed soft
part wounds that remain in hospital longer than four weeks so that proper
treatment can be expedited.
8. Amputations.
a. 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 time early management of amputations in overseas theaters
conform within policies that have been set forth in numerous Bulletins and
Circular Letters. There will be no deviation from these policies in this
theater.
(1) Forward Area.
(a) Level.
Amputations will be performed at the lowest possible level except that
a proximal amputation will be done in preference to a disarticulation.
(b) Technique.
The properly performed flapless guillotine stump exhibits slightly concave
open cross section of the extremity. A circular incision is made through
the skin at the lowest level compatible with 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 within the muscles. No cuff of periosteum is removed
as in a closed amputation. Bone denuded of periosteum will sequestrate
if
328
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.
(c) Dressing
and skin traction. The end of the stump is dressed within 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. A
Thomas splint may be utilized as an alternative. When this is done in lower
leg amputations, a posterior splint from midthigh to beyond the stump is
provided to prevent flexion contracture of the knee. 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.
(2) Base.
(a) All
thigh amputations and those of the leg at or near the site of election
will be treated by continuous skin traction. Secondary suture or skin grafting
of the terminal defect within or without revision will not be done. Removal
of the cast or splint and maintenance of 6 to 10 pounds of traction over
a pulley at the foot of the bed is recommended. Traction is continued for
several weeks (at least 6) until all layers of soft tissue have been firmly
fixed by scar formation. Priority air evacuation to the Zone of Interior
is 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.
(b) Amputations
in the lower third of the leg and of the upper extremity may be closed
by secondary suture provided the wound is clean and a course of penicillin
is instituted. If closure is not feasible, skin traction is maintained.
(c) Amputations
of the thigh or leg performed in fixed hospitals for trauma, vascular
insufficiency or infection will be carried out in conformity within the
above principles. In the upper extremity, modifications to scenic primary
or early secondary closure are permissible in individual cases.
(d) Patients
received with injuries that require amputation will benefit by an explanation
of why the amputation is necessary prior to the operative procedure. About
one in five patients will exhibit psychic reactions, often depressive
in type, a few days after the operation. As soon as the patient is surgically
comfortable and mentally receptive, an interview within a psychiatrist
may be extremely helpful. Particular attention should be paid to what the
patient may reasonably expect in the way of aid. The establishment of
amputation treatment centers in the ZI may be explained, and assurance
given relative to prosthetic appliances, and his potential economic and
social status. Fortification of this type, before a patient becomes the
target of a sympathetic family and friends, may tip the scales in favor
of rehabilitation in contrast to life long disability and resentment.
329
9. Fractures of the Femur.
The program of reparative surgery in fixed hospitals, improvements
in skeletal traction techniques, and penicillin therapy are expected to result
in unproved apposition and alignment of the fractures and improved knee
and muscle function, after the fracture has united. Therefore the following
recommendations and made:
a. Fractures treated by skeletal traction.
(1) Knee flexion produces
quadriceps stretch and predisposes to patellar fixation. As flexion increases
quadriceps exercises become more difficult. While some knee flexion is
necessary for comfort and to aid in reduction of the fracture it should
be held to a minimum. For lower third fractures two-wire skeletal traction
is recommended. By this method traction is made by a wire (or pin) in the
tibial tubercle while a second wire through the lower femoral fragment permits
vertical “lift”. Extreme knee flexion is avoided.
(2) Quadriceps setting exercises
and knee motion should be carried out several times daily as soon as
wound management permits. Knee motion begun early produces less strain
on the fracture site than that begun late after joint "stiffness"
has set in.
(3) Duration of traction.
Traction in the great majority of cases must be continued until there is bony fixation clinically and roentgenologically. This will average
about 10 to 12 weeks. Prolonged traction permits an increasing range of
knee motion and will prevent angulation in a cast during evacuation to
the Z of I.
(4) A low spica extending
to the knee on the well side is the recommended splinting for transportation
to the Z of I. Uncertainty of evacuation and because a spica is preferably
applied at least 48 hours prior to transporting, have resulted in many
fractures of the femur remaining in plaster for several weeks or months awaiting
and during evacuation, thereby predisposing to restricted knee motion.
Collaboration between the surgeon and the disposition officer permits the
application of the spica 48 hours prior to evacuation. Fractured femurs immobilized
after traction are excellent priority 4 cases for air evacuation.
b. Fractures Treated by Internal Fixation.
(1) Wire loop fixation. Alinement
should be protected by prolonged skeletal traction followed by a spica
(see 9 a (3) (4)).
(2) Plating or Multiple Screw
Fixation. Postoperative immobilization in a Thomas splint with Pierson
attachment permits early knee motion. Following wound healing and a period
of knee motion and quadriceps exercises, a spica (see 9 a (3) (4)) is used
for evacuation to the ZI.
IV - DISASTER MANAGEMENT IN FIXED HOSPITALS.
Any hospital in the theater, no matter how far removed from the
Combat Zone suddenly may be called upon at any hour of the day or night
to receive and care for large numbers of wounded or injured. It is essential,
therefore,
330
that plans for such an emergency be made in advance and be clearly understood
by both administrative and professional staffs. The following principles
are important:
1. Early recognition of what may be termed the “pattern of trauma”
so that appropriate treatment may be instituted without delay. This is
established by a careful examination of a representative sample of time
injured and supplemented by inquiry regarding the source and nature of
injury, the time elapsed since injury and the possible number of casualties
to be admitted. Serious secondary effects may be masked by obvious primary
manifestations: thus, the lethal effects of underwater blast may
be masked by the effects of immersion; the inhalation of noxious fumes
may pass unrecognized while superficial flash burns are treated. With explosions
of ammunition ships or dumps in a theater of war, consideration must always
be given to the possibility that agents of chemical warfare may have been
released.
2. Establishment of wards adjacent to the admitting ward for reception
of patients is essential rather than distribution of the new patients throughout
the hospital.
3. Triage is established at the time of admission to sort three groups
of patients:
a. Those in immediate need of resuscitation,
close preoperative supervision and emergency operative procedures.
b. Those that require surgery but will
be transportable if and when it is necessary to reduce the backlog of
cases awaiting operation by transfer to other hospitals for treatment.
c. Lightly injured that will be discharged to
duty after a short period.
Patients in group a. will be sent to a “shock” ward where treatment is
carried out under close supervision. They receive first priority X-ray
and laboratory service.
Group b. require ordinary ward supervision and second priority X-ray
and laboratory service. Clinical records should be maintained and a tentative
evacuation list prepared.
Group c. should be fed and made comfortable, but professional attention
postponed during the emergency period unless special indications arise.
4. Surgical Management.
Patients in group a. are assigned to operative teams who direct
the preoperative care, request necessary laboratory examinations and
schedule the operation. One or more officers are assigned to the Shock
Ward and remain on the ward. It is their duty to be familiar with the progress
of each patient; what treatment has been ordered, and what examinations
are in progress or have been completed. In addition they carry out resuscitation
measures under surgical direction.
After operation, if the patient is in precarious condition he should
be returned to the Shock Ward or to an adjacent Postoperative War-- but
under no circumstances sent to some remote ward of the hospital.
331
5. Whole Blood Transfusion
Plans must include a well thought method of supplying whole blood
in considerable quantity. Circular Letter No. 30 should be studied. Reliance
cannot be based on securing blood from theater transfusion units, as
the function of these installations is to supply blood to armies in combat.
A supply of vacuum bottles, transfusion sets, refrigerator space and a
donor list from the detachment will enable the laboratory to start a banked
reserve. Immediate steps may be taken to supplement the donor list from
organizations in the immediate vicinity. Type specific blood should be
used as most economical of donors.
6. Reserve Surgical Supplies.
Sufficient supplies must be kept on hand at all times to meet the
demands of an emergency. Vaseline gauze, fine mesh gauze and other sterile
supplies may be stored in sealed containers and resterilized as often
as necessary.
7. X-ray Service.
Request for X-ray examinations should be based on the priority of
the case, and the X-ray Department must not be flooded with examinations
that can be postponed. Patients that may be transferred to another hospital
for surgical operation need not be X-rayed unless necessary to the determination
of transport ability or disposition.
A system for viewing wet films should be planned, and facilities
made available for the films to accompany the patient to the operating
theater.
8. If doubt exists regarding the nature, source of circumstances
surrounding the incident, examination of casualties dead on arrival or
dying in hospital may be of importance not only for official record but
for treatment of the survivors.
For the SURGEON:
(S) E. STANDLEE
E. STANDLEE,
Colonel, M. C., Deputy Surgeon.
DISTRIBUTION:
Surgeon, Fifth Army
600
Surgeon, Seventh Army
300
Surgeon, SOS NATOUSA
800
Surgeon, AAFSC/MTO
750
Surgeon, Replacement Command 50
Surgeon, NATOUSA
300
332
HEADQUARTERS
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-
333
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
334
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
335
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
336
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-
337
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
338
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.
339
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
340
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-
341
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
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