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Appendix B



15 MAY 1944


SUBJECT: Principles of Surgical Management in the Care of Battle Casualties

1. Surgical Echelons
2. Morphine
3. Blood Transfusions
4. "Transportable" and "Non-transportable"
5. Surgical Procedures
6. Sulfonamide Therapy
7. Penicillin Therapy
8. Secondary Closure
9. General Principles to be followed in the Use of Plaster Casts
10. Treatment of Anaerobic Infections
11. Radiology in Forward Area
12. Identification of Gases in Cylinders

1. Surgical Echelons

This first paragraph has been extracted, with only minor changes, from a circular letter, Office of the Surgeon, North African Theater of Operations. The policies expressed herein are sound, are based upon experiences in combat and will in general govern the activities of Medical Department personnel in this Theater.

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 or functionally similar medical installation, is not designed to provide definitive treatment for battle casualties.

c. 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.

d. Hospitals of the third echelon, Evacuation Hospitals and Field Hospitals with attached Surgical Teams, 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 results. The evacuation line is not an assembly line in which each surgeon does his bit to the patient. It is a


conveyer line, along the course of which the progress of the patient may be halted to save life or limb, or to render him transportable.

e. Although Field and Evacuation Hospitals with attached Surgical Teams are adequately equipped and staffed to perform rehabilitation operations, they are not designed for this function. Even in quiet times, patients requiring rehabilitation operations will be evacuated to a fourth echelon hospital except when the Commanding Officer decides otherwise, based on knowledge of the tactical situation as well as the surgical aspects of an individual case.

2. Morphine

This note appears because, although morphine is one of humanity's greatest aids in warfare, it is also often misused and frequently given in unnecessarily large and dangerous quantities.

a. Dosage. Morphine sulfate gr. (15 mgm.) is usually adequate; gr. (30 mgm.) may be required and is safe unless repeated. Always record amount and time of injection.

b. Administration. Subcutaneous or intramuscular injection is employed when a gradual prolonged effect is desired. Massage at the site of injection will hasten absorption. Intravenous injection (gr. 1/8, 8 mgm.) is employed when a rapid effect is desired.

c. Contra-indications. The doses of morphine given as preoperative medication for seriously wounded patients should be small (gr. 1/6, 10 mgm. or less). Morphine must be administered with caution to the walking wounded, to patients to be evacuated by air; or in the presence of jaundice, cranio-cerebral injury, pneumothorax, hemothorax or pleural effusions. Morphine will never be used as a sedative for manic or hysterical states.

d. Poisoning. Overdosage with morphine is characterized by pinpoint pupils and slow respirations. The outstanding serious effect is anoxia, caused by respiratory depression.

e. Delayed Morphine Poisoning in Battle Casualties. Subcutaneous injections of morphine are poorly absorbed in patients who are cold, or who have a low blood pressure and are in shock, under which circumstances pain may not be relieved. As a result, repeated doses given in an attempt to relieve pain may be followed by morphine poisoning when the peripheral circulation is re-established and the unabsorbed deposits of morphine are absorbed rapidly. The intravenous administration of morphine in patients who are cold, or who have low blood pressure and are in shock, will eliminate this problem. Always check for previous administration of morphine and always record the amount and time given.

f. Treatment of Morphine Poisoning. Provide a clear airway. Administer oxygen, under intermittent pressure if necessary. A maximal dose of ephedrine, gr. (30 mgm.) administered intravenously, using rise in blood pressure as a guide to dosage, may be employed. Caffein sodium benzoate, gr. 7 (0.5 gm.) intravenously, may be useful. Empty the stomach prior to development of coma. Stimulate diuresis by means of intravenous glucose. Change position of patient frequently.

3. Blood Transfusion

a. Blood used in the treatment of casualties in shock will ordinarily be administered in the ratio of one part blood to two parts of plasma (one pint of blood to four units of plasma).

b. Procurement of blood within unit: Units equipped with the Field Transfusion Kit will follow the instructions contained therein for bleeding lightly wounded and noncombatant personnel and for care of the apparatus.

c. Procurement of blood from ETO Blood Bank: Evacuation Hospitals, Field Hospitals, LST's, Holding Units and Transit Hospitals will be supplied with blood from the ETO Blood Bank. All blood from this source is Type O and will not be cross-matched. On the bottle label is an expiration date, beyond which the blood will not be used. The following rules will be strictly followed in the use of Bank blood:-

(1) Blood will be refrigerated constantly between two (2) and four (4) degrees above zero centigrade (+35 to +42 F.) and kept in the dark.


(2) Blood will be removed from the refrigerator and administered cold. It will under no circumstances be pre-heated.

(3) Blood which is allowed to rise above six (6) degrees centigrade will be used within four (4) hours and will not be re-cooled.

(4) All used equipment will be exchanged at time of delivery of blood.

d. Non-transportable Casualties

The proper sorting of casualties into transportable and non-transportable classes is of prime importance in evacuation. The following listed types of casualties are usually non-transportable and should be submitted to surgery early. This classification can only serve as a guide, and each individual case deserves separate appraisal.

4. Non-transportable Casualties

a. Wounds of the abdomen

b. Wounds of the chest which are serious, either because of-

(1) a large sucking wound, or

(2) such massive intra-thoracic hemorrhage that the patient's condition is unsuitable for transportation.

c. Trans-thoracic or abdomino-thoracic wounds. These are often difficult to diagnose and are frequently missed-note that in wounds of the buttock the missile may lodge in the thorax or, similarly, with wounds of the shoulder the missile may lie within the abdominal cavity. If X-rays are available, final lodgement of the missile will make diagnosis easy, but if not, the medical officer must always examine the opposite cavity from wounding to rule this out.

d. Casualties who remain in "shock" after therapy, and whose condition cannot be made suitable for transport. In this group are included multiple fractures, casualties with injury to major vessels, and avascular extremities in which gas infection is likely to occur, and those with concealed hemorrhage.

e. Certain casualties with maxillofacial wounds, where mechanical difficulty in breathing endangers life during transport.

5. Surgical Procedures

a. Dressings. Ideally, the primary phase of treatment will be completed in the first unit reached that is equipped to provide it. The dressing is to then be left undisturbed until the patient reaches a third echelon unit for operation. There are certain safeguards and adjustments that must take place en route, but these do not include inspection of the wound by removal of the dressing unless definite indications for so doing are present. A compound fracture case may be halted at the Clearing Station for more adequate immobilization or resuscitation, but the wound should not be re-dressed unless necessary to arrest continuing hemorrhage. A wound will not be re-dressed solely for the purpose of re-applying local sulfonamide. Oral administration is sufficient safeguard.

The same principles apply after operation has been completed and the patient is being evacuated to the rear. Uninformed hands do unnecessary dressings. The best safeguard for a patient is an adequate and legible record that accompanies him, which makes it possible for a receiving officer to refer to the record rather than looking at the wound. Infection arising from contamination incurred at the time dressings are changed may make impossible secondary suture of wounds after debridement and arrival at a third echelon unit.

b. Debridement of wounds. This is the basis of the proper treatment of all battle casualties. It is definitely more important than chemotherapy, and reliance on the latter must not diminish devotion to the proper surgical treatment of wounds. Use ample incisions, practice minimal removal of skin and bone, and maximum removal of all dead or devitalized muscle. Never close primarily wounds debrided under field conditions. Pack wounds open lightly, never plug tightly.

Under favorable circumstances, it is desirable that severed nerves and tendons should be approximated, preferably with metallic or non-absorbable sutures (see Manual of Therapy, European Theater of Operations).


c. Amputations. Amputations for trauma will be a circular open (guillotine) amputation at the lowest possible level, followed by the application of skin traction. Skin traction will be applied immediately and must be maintained during all stages of evacuation, including evacuation to the Zone of Interior, and until the stump is completely healed. Skin grafting will not be used as a substitute for skin traction.

6. Sulfonamide Therapy

a. A soldier wounded in action is instructed to take by mouth, as soon as possible, 4 gms. (8 tablets) of sulfadiazine, from his own First Aid packet, except when wounded in the abdomen.

b. The medical officer first dressing the wound should frost it lightly with sulfanilamide powder. Not more than 5 gms. (contents of one packet) should be placed in the wounds of any individual, irrespective of the number and size of the wounds.

c. Continue sulfadiazine orally until definitive surgery is instituted. The maintenance dosage is 1 gm. orally every 4 to 6 hours, or 2 gms. parenterally every 8 to 12 hours. Chemotherapy should be given cautiously in the presence of dehydration (for dangers, see Manual of Therapy, European Theater of Operations).

d. Sulfonamide and penicillin therapy will be carried out concurrently.

e. Both penicillin and a sulfonamide should be placed in wounds after definitive surgical treatment (see par. 7h).

f. Sulfonamide therapy will be continued after surgical treatment by oral or parenteral routes, as instructed in the Manual of Therapy, European Theater of Operations.

g. Sulfonamide therapy for burns shall consist only of parenteral therapy or local application, never both.

7. Penicillin Therapy

a. Penicillin therapy (parenteral) will begin at Clearing Stations, and will be continued at Field and Evacuation Hospitals. Its local use in wounds will begin in Field and Evacuation Hospitals where definitive surgery is carried out.

b. The phrase "Penicillin Treated" will be entered on the EMT or Field Medical Record after the diagnosis in every case so treated. Additional data, including dosage in units, method of administration (parenteral or local) and time and date of administration will be entered on the back of the [EMT] or on Clinical Record form in cases where a Field Medical Record has been initiated.

c. Penicillin is unstable and is best preserved at 4 centigrade. Where refrigerators are not available, keep in coolest spot possible and away from sunlight. Use as soon as possible after removal from hermetically sealed vial, whether in normal saline or sulfanilamide powder. Vials which are out-dated will not be discarded.

d. Do not use in small superficial wounds of gutter type, or where missile lies close to skin and no fracture.

e. Parenteral Therapy

(1) For parenteral use penicillin is dissolved in normal saline. Add 10 cc. cold normal saline to 100,000 unit vial of penicillin and inject intramuscularly 2 cc. per casualty. Needles and syringes must not be sterilized by use of antiseptic solutions and must be cold because both chemicals and heat inactivate penicillin.

(2) Penetrating and perforating wounds of soft parts: give 20,000 units intramuscularly every 4 hours from Clearing Station through period of definitive surgery and for 48 hours thereafter.

(3) Wounds with compound fractures: give 20,000 units intramuscularly every 4 hours from Clearing Station through period of definitive surgery and for 72 hours thereafter.

f. Double above doses, paras. e (2) and (3), where wounds are in region of buttock, perineum, upper thighs and popliteal space.

g. Penicillin therapy may be extended beyond the 48 and 72 hour specified post-operative time, paras. e (1) and (2), if sepsis becomes a major problem.

h. Local use in wounds (both soft part wounds and compound fractures) at time of definitive surgery; Dust 20,000 units of penicillin mixed with 3 grams (1 teaspoonful)


of sulfanilamide into the wound at the close of the debridement. This is best accomplished by mixing the contents of a 100,000 unit vial with 15 grams (5 teaspoonfuls) of sulfanilamide, and using 1 teaspoonful per wound. All containers must be absolutely dry and cool before mixing. Where wounds are multiple, use up to 40,000 units of penicillin in 6 grams of sulfanilamide, distributing proportionately according to severity of wounds. The use of penicillin in wounds is not mandatory but is advisable in all wounds where there is severe destruction of tissue. Should the supply of penicillin be limited, omit local application.

i. Penicillin therapy does not contradict or interfere with sulfonamide therapy.

8. Secondary Closure

a. Although the first principle for the military surgeon to bear in mind is not to close the wound he has freshly debrided, it is essential that he close this wound at the earliest possible moment that is safe. Early closure means limitation of infection and fibrosis, and an earlier restoration to duty. If the primary debridement has been thorough, small wounds may be closed as early as the third day, though the average wound not until the fifth day. Observation of the signs of inflammation, such as discharge, reddening, pain and swelling, will determine whether or not a wound can be closed. It is wiser not to dress the originally debrided wound until the day when secondary closure might be practical, since each dressing invites contamination of the wound. If closure is considered safe, it should be done loosely without undermining the edges or using sharp instruments, and by using retention sutures of silk, or silkworm gut, spaced widely apart and loosely tied. Should mild infection appear, hot, moist dressings may save breaking down of the wound and hasten the healing process. Any signs of severe infection require immediate removal of the sutures.

b. Closure of wounds with fractures should only be undertaken when full penicillin therapy is being practiced and when all the signs of infection are absent.

c. Wounds closed early, before the establishment of granulation tissue or scar tissue, are easier to close than those closed after one or two weeks. In wounds that have been open for a long time, skin grafting is often better than closure by suture. If the original debridement has been practiced with the minimal of skin removal, as suggested above, closure by sutures will be simple.

d. Removal of sutures from such secondary closures should not take place before 10 days unless stitch infection develops. After removal of the sutures it may be wise to maintain approximation of the wound edges with adhesive plaster.

9. General Principles to be followed in the Use of Plaster Casts

a. No circular bandages, dressings, or strips of adhesive shall be used under a plaster cast, as these constrict the extremity and may cause extensive damage if swelling of the part occurs.

b. Adequately padded plasters are probably safer in average hands. Padding should be applied to all bony prominences such as malleoli and heels, knees, particularly over the head of the fibula, wrists and elbows. In addition, sufficient padding should be used over the soft parts to permit some swelling within the cast.

c. All layers of plaster, sheet wadding or dressings must be cut through down to the skin immediately after the application of a cast following an operation or manipulation. Swelling of the part will occur and, unless all layers of the plaster padding and dressings are cut through, it will be impossible to spread the cast to prevent extensive damage when swelling occurs.

d. Attention should be paid to the position of the extremity encased in plaster. The foot should be at a right angle to the leg, the knee should be in 10-15 of flexion, the hip should be in neutral position or slight flexion. The wrist should be supported in neutral position to prevent wrist drop, and the elbow ordinarily is best supported at a right angle. In these positions the patient will transport comfortably, will not take up undue space, and the tendency to develop troublesome fixed deformities will be minimized.


e. A line diagram in indelible pencil should be inscribed on the cast, indicating the approximate location of fracture and position of fragments. The number of the unit, date of injury, date of operation and type of operation should likewise be written on the cast so that if the Field Medical Record is lost, a reasonably satisfactory substitute record will be readily available.

f. Either a platform or a loop or wicket of plaster should be applied to the foot of the cast in order to protect the toes from pressure of blankets, bed clothes, et cetera. Plaster applied to the hand should be trimmed back to the proximal palmer crease to permit full flexion of the fingers and metacarpal phalangeal joints.

10. Treatment of Anaerobic Infections

a. Gas Gangrene

(1) Types of Wound. Wounds destroying muscle, either directly or by interruption of the blood supply, are particularly susceptible to anaerobic infections. Such infections are more frequent at the following sites of wounds:-(i) buttock; (ii) upper thigh (compound fracture of femur); (iii) anterior tibial group; (iv) shoulder girdle; (v) short flexors and extensors of forearm.

(2) Types of Infection. The following types of infection must be recognized, since they require different therapy:-

a. Gas gangrene (clostridial)

(1) Diffuse myositis
(2) Localized myositis
(3) Cellulitis, "gas abscess"

b. Gas gangrene (streptococcal), rare

(1) Myositis

(3) Diagnosis

a. Clinical. The differential diagnosis among the various types of clostridial gas gangrene and streptococcal myositis must be made to avoid unnecessary radical surgical treatment.

(1) Clostridial myositis, diffuse: This may develop within 6 hours from the time of wounding, usually within 3 days. The onset is acute with a severe systemic reaction. Locally there is pain, marked swelling, frequently profuse serous exudate, slight gas formation, variable odor of decay and pale or blue-gray appearance of involved muscle. The skin is tense and often white, but may be mottled with a livid appearance if the process is widespread.

(2) Clostridial myositis, localized: In 5-10 percent of the cases, localization of the process to a single muscle or group of muscles occurs. Symptoms and signs are the same as for the diffuse type.

(3) Clostridial cellulitis: This process is limited to the immediate area of the wound. The onset is gradual, usually after 3 days, with slight systemic reaction. Locally, there is abundant gas formation with a foul odor, slight swelling, and little local change of the muscle and overlying skin.

(4) Streptococcal myositis: The onset is delayed for 3-4 days, and severe systemic reactions do not appear until the late stages of the infection. Locally, there is marked swelling with profuse purulent discharge, slight gas formation, and slight odor. The involved muscle is slightly edematous and the overlying skin is tense, often with a coppery tinge. Streptococcal myositis comprises only a few of the cases of gas gangrene.

b. Laboratory Recognition of infections with anaerobic bacteria is made on clinical findings, which should be checked, where possible, with a smear made from the material in the depth of the wound. A small piece of involved muscle, rubbed on a glass slide and stained by the Gram method, is examined under the microscope. In the presence of clostridial gas gangrene, such smears usually show a predominance of large gram-positive rods. Pus cells are scanty and degenerate. In streptococcal myositis, gram-positive bacilli are absent and in their place large numbers of small-sized streptococci are


found among masses of pus cells. Whenever facilities are available, anaerobic wound and blood cultures should be carried out.

The finding of anaerobic bacteria in a wound is not uncommon, and such finding should not influence the surgical treatment, unless there are local clinical signs of anaerobic infection.

(4) Prophylaxis. Early, adequate debridement of wounds is the best prophylaxis for anaerobic infections. Debridement where there has been massive destruction of tissues, more particularly in the region of the buttocks, perineum and upper thighs, and where major vessels are injured, must be radical and thorough, using long incisions. If hematoma is present, deep fascial planes must be incised, especially in the popliteal area. Bilateral incisions in the popliteal space just inside the hamstring tendons should be made. The fascia over both heads of the gastrocnemius should be incised-all clots should be evacuated and any continued bleeding controlled by ligature or suture. Gas gangrene antitoxin, sulfonamides and penicillin are not to be considered substitutes for early, adequate debridement. However, where circumstances delay debridement of the wounds mentioned in para. 10. a. (1), for 24 hours or longer, one (1) ampule of gas gangrene antitoxin may be given intramuscularly. Penicillin and sulfonamides are to be used as directed in paras. 6 and 7.

(5) Therapy.

a. Surgical - This depends upon the extent of the disease and the type of anaerobic infection. Diffuse clostridial cellulitis is encountered in approximately 80 percent of cases in these categories.

(1) Clostridial myositis, diffuse: Amputation as far above visible evidence of involvement as possible must be carried out immediately, using the guillotine method, and leaving the wound open.

(2) Clostridial myositis, localized: Extirpation of the involved muscle, or group of muscles, should be practiced through long incision.

(3) Clostridial cellulitis: Incise the localized process and remove the devitalized tissue. Radical surgery is not indicated.

(4) Streptococcal myositis: Extensively incise and drain the involved muscles. Radical extirpation or immediate amputation are not indicated.

b. Serum therapy.

(1) Clostridial infections: Three (3) ampules of gas gangrene antitoxin should be given intravenously and repeated hourly for 6 doses (see Manual of Therapy, European Theater of Operations, page 35, para. 27). This may be modified according to the condition of the individual case. Test patient for allergy to horse serum before administration of antitoxin. Adrenalin in a syringe should be at hand.

(2) Streptococcal infections: No serotherapy is indicated.

c. Chemotherapy.

(1) Penicillin: Give initial dose of 20,000 units, intravenously and 20,000 units intramuscularly, followed by 20,000 units intramuscularly every 2 hours for a period of 3 days. Period of therapy may be modified as seems necessary. Place in the wound 50,000 units mixed in 4 gms. (1 teaspoonful) of sulfanilamide, and repeat at dressings.

(2) Sulfonamides: Give 5 gms. of sulfadiazine by mouth initially and 1 gm. every 4 hours.

d. Supportive treatment: Since there is rapid destruction of erythrocytes, frequent whole-blood transfusions will be necessary.

e. All instruments used in anaerobic infections should be sterilized by autoclaving, when available, and the instruments must not be covered with oil, since bacteria surrounded by oil cannot be wetted and therefore are not killed at the usual temperatures.

f. If gas gangrene antitoxin is used, record number of ampules used and name of manufacturer.

b. Tetanus

(1) Types of Wound. Any wound, regardless of size or location, is a potential source of tetanus, particularly small puncture wounds.


(2) Prophylaxis

a. Every wounded man will receive 1 cc. of tetanus toxoid, subcutaneously, as soon as possible. This will be recorded on the Emergency Medical Tag, or on the Field Medical Record. If there is no record of the administration of toxoid, or any doubt as to its previous administration, 1 cc. of tetanus toxoid will be given and so recorded.

b. Early, adequate debridement.

c. 1 cc. of tetanus toxoid will be given prior to the manipulation or exploration of an old wound.

d. After appropriate tests for sensitivity, members of Allied Forces (except Canadian), civilians and others will receive 3,000 units of tetanus antitoxin intramuscularly. The Canadian Forces will receive 1 cc. of tetanus toxoid. A syringe containing 1 cc. of 1:1,000 of epinephrine (adrenalin) should always be at hand when tetanus antitoxin is given.

(3) Signs and Symptoms. The rarity of this disease must not prevent its recognition. The earlier tetanus is recognized, the more effective treatment will be. The earliest sign is trismus. The patient may complain of pain and stiffness in the neck, back and abdomen. Dysphagia may be present. Localized tetanic contractions are not uncommon.

(4) Treatment

a. General. At the appearance of the earliest signs of tetanus, immediate therapy is indicated. All cases must be treated vigorously. The patient should be isolated in a quiet, darkened room.

b. Control of spasms. Trismus may be controlled by administration of barbiturates, e.g. Nembutal, which are essentially anti-spasmodic in action. Nembutal, grs. 3 (0.2 gms.) may be given rectally in a well-lubricated capsule that has been perforated several times with a pin. More rapid absorption will be effected if the contents of a capsule are dissolved in water and the solution injected rectally through a catheter of small caliber. The dose may be repeated as required, care being taken to guard against cumulative action and the production of anesthesia. Sodium Amytal, grs. 6 (0.4 gms.) represents an equivalent dose and for treatment over a period of days this drug is to be preferred. Overdosage will be indicated by evidence of hyperpyexia and incipient atelectasis or pulmonary edema. For spasm involving many muscular groups where anoxia is a feature, administration of Pentothal sodium in 2.5 percent solution intravenously is indicated. The objective is to give just sufficient to control the seizure and to permit effective artificial respiration. From 2 to 4 cc. may be required. Longer acting barbiturates are preferable for prolonged control of spasms, but supplementary administration of Pentothal may be necessary to control acute episodes producing anoxin. For the same purpose, 0.5 gm. of Sodium Amytal, dissolved in 10 cc. of sterile distilled water, may be injected intravenously at the rate of 1 cc. per minute. Avoid use of long acting barbiturates such as Veronal or Luminal because of its cumulative action.

Supportive treatment, administration of saline, glucose and/or plasma, is essential. The prime requisite is to maintain oxygenation, producing muscular relaxation to permit effective respiratory action. All efforts will be defeated if obstruction of the upper respiratory tract is permitted.

Tracheotomy should be performed if laryngeal spasm is causing suffocation.

c. Antitoxin.

(1) Locally: After appropriate tests for sensitization, 10,000 units of tetanus antitoxin should be used for infiltration about the wound.

(2) Intramuscularly: Therapeutic administration of tetanus antitoxin should be early and adequate. After appropriate tests of sensitization, an initial dose of 40,000 units of antitoxin should be given intramuscularly.

(3) Intravenously: 20,000 units may be administered intravenously 6 hours after the intramuscular injection. This dosage may be repented on the second and third


days if conditions require. Extremely large doses of antitoxin are no longer considered helpful.

(4) Intraspinal: Antitoxin should not be given intrathecally.

d. Surgical

(1) Local debridement: This is based on the fact that the bacterial anaerobes are the sole source of the toxin. The wound must be widely opened and kept open. Amputation must be considered if other reasoning is suggestive of such a radical procedure. Such debridement should be preceded by the local injection of antitoxin as described in para. c. (1) above.

11. Radiology in Forward Area

Attention to the following general principles will improve the efficiency of a forward area X-ray service, especially when casualties are received in large numbers.

a. Housing. Evacuation hospitals should be arranged to do radiography, fluoroscopy and processing simultaneously. One way to accomplish this is to use a ward tent plus two darkroom tents, one for radiography and one for fluoroscopy, at least the processing tent inside the ward tent. Most hospitals place both within the ward tent. A second inside tent can be improvised from a latrine screen if a second darkroom tent is not available. Improvised duckboards in the darkroom are advantageous. Waiting room for walking cases can be made with empty X-ray chests for seats between the darkroom and fluoroscopic tents, and one low side of the ward tent. Field hospital units have only one X-ray machine, therefore will not require two darkroom tents.

b. Power. The utmost skill should be exercised in the care and operation of electric generators. The instructions issued with each generator should be meticulously studied and followed by the radiologist and technicians.

c. Radiography

(1) The field unit X-ray machine on a mobile base can be used beside a table more efficiently if a board or other type of track is improvised to guide the movement of the machine up and down the length of the table.

(2) Positioning should be standardized according to the guide for forward areas furnished each X-ray department by the Office of the Chief Surgeon.

(3) Film drying will be hastened if it can be accomplished outside the darkroom, unless a free current of air can be forced through the darkroom by an improvised lightproof trap. The ventilator alone is inadequate. Item 60120, clips, photographic, will amplify hangers and permit easy stringing of roentgenograms on wires or rope.

(4) Water inlets and drain outlets from the processing units, by improvised hose or pipe "plumbing," will increase the darkroom efficiency.

(5) Roentgenograms should be identified accurately as per existing directives.

d. All patients transferred to other hospitals will be accompanied by their roentgenograms. A filing system should allow easy availability of roentgenograms to those who want to see them and, at the same time, make it possible for them to be accumulated and leave with all patients of a convoy on short notice.

e. There should be a uniform and well-defined policy between the receiving or triage officers and the radiologists as to what type of case will require X-ray examination, and the priority and volume in which they will be sent to the X-ray department. The use of litter bearers to and from the X-ray department should be mutually pre-arranged.

f. Requests for X-rays should be brief and exact throughout the hospital, so that the specific purpose of each request is evident, assuring that the proper technique and positioning can be immediately selected by the radiologist. This will obviate retakes.

g. X-ray examination should only be requested when the findings will affect treatment or, more rarely, the disposal of the patient.

h. Patients in shock, or threatened shock, should not have X-ray examinations except in rare emergencies.


i. Missile Wounds

(1) Upper thighs and buttocks-should have additional A.P. or P.A. radiographs of the pelvis and lower abdomen, because complicating involvement is frequently found here.

(2) Thorax-should have additional A.P. and lateral radiographs of the upper abdomen, because of frequency of transdiaphragmatic involvement.

(3) Upper arms, shoulder and neck-should be considered for additional A.P. (or P.A.) radiographs of the thorax to exclude upper lung involvement.

j. All soft tissue wounds of the extremities should have an A.P. and lateral X-ray examination of the injured part, including the nearest joint, prior to surgical treatment.

k. Transportable cases with wounds of the face and skull should generally not have X-ray examination until special treatment is available.

l. Localization of foreign bodies in extremities is generally best accomplished by A.P. and lateral radiographs. Fluoroscopic orientation by the table device is generally not as practical in extremities as A.P. and lateral radiographs because bandages and wounds prevent marking the skin, and because the surgical approach to the foreign body may not be determined until after the X-ray study, and thus skin marking, even when possible, may not be placed on the proper aspect of the extremity. Lateral radiographs of extremities can, and should be made with the patient supine, when turning the patient causes pain.

m. Fluoroscopy is seldom as satisfactory as radiography. It is most useful in thoracic cases as an adjunct to radiography, and in localization of foreign bodies in the pelvis where lateral views are impractical and stereoscopy is not available. It is used for other types of cases mainly when facilities for radiography are not adequate to keep abreast of the volume of patients. Fluoroscopy, when not expertly supervised, can be a menace to patients and operators. It should never be attempted until the eyes have been accommodated at least 15 minutes.

12. Identification of Gases in Cylinders

a. Identification of gases in cylinders may be difficult. In order to avoid serious accidents, great caution must be exercised in properly identifying contents of any particular tank.

b. Identification of a gas in a cylinder may be made by the following methods:

(1) By reading the chemical symbol of the gas imprinted in the metal of the valve of British cylinders.

(2) By reading the chemical symbol or name of the gas imprinted in the metal at the shoulder of the cylinder (symbol on British cylinders, full name on American cylinders).

(3) By reading the paper label or tag on British or American cylinders.

(4) By reading the symbol or name of the gas stencilled on or near the shoulder of a British or American cylinder. Arrangements for employing this means of identification have recently been made with the British Oxygen Co. and may not be found on all cylinders for some months to come. Cylinders are also being stencilled in U.S. medical depots.

(5) By interpreting the color or combinations of colors with which British or American cylinders are painted. Color markings on a cylinder must be considered only to corroborate labels and are never to be used as a single means of identification. In no instance will the color of valve caps be considered significant.

(6) To identify gases in cylinders, check for all these means of identification. Unless all means in evidence agree, the gas should not be used.

For the Chief Surgeon:

J. H. McNinch
Colonel, Medical Corps, 
Executive Officer.