Eugene M. Bricker, M.D.INTRODUCTION
In a description of the activities of a surgical specialtyconsultant in a theater of operations, the subject divides naturally into twomain headings: Administrative and professional. While, in fact, the functions ofadministration and professional care were inseparably related, they were socompletely different in nature that it appears justifiable to separatethem in this account for purposes of clarity. Two admissions are readily made:(1) The history will be biased in that the author is convinced of the importanceof plastic surgery in a theater of operations if the best care is to beavailable to all casualties; (2) any suggestions concerning the organization anduse of personnel are made with an operation such as that in the European theaterin mind, and with the realization that a future war may be entirely different.
At the beginning of World War II, plastic surgery could stillbe considered as a relatively new specialty. It was adolescent during World WarI, when it was practiced by few surgeons who approached it from various otherfields of primary interest, including dentistry, otorhinolaryngology, andgeneral surgery. Following World War I, plastic surgery grew to maturity, as awell-defined specialty, in very few clinics throughout the country. Its functionin a theater of operations was incompletely realized at the outbreak of WorldWar II, though the need for adequate coverage in plastic surgery was recognizedby Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA (European Theater ofOperations, U.S. Army), and a full-time consultant in this specialty was presentin the theater throughout the campaign. It could be said that the specialty, asapplicable to a theater of operations, approached full maturity during the warin Europe.
In the development of the Professional Services Division,Office of the Chief Surgeon, ETOUSA, a consultant in plastic surgery was one ofthe first to be named. The value of adequate organization of this specialty hadbeen impressed upon members of the U.S. Armed Forces in the British Isles by thegreat number of casualties resulting from the Battle of Britain that requiredreconstructive plastic surgery. Lt. Col. (later Col.) James B. Brown, MC(fig.182), arrived in England on 2 July 1942 in response to a specific requestfor a plastic surgery consultant. Colonel Brown was accompanied by Lt. Col.Eugene M. Bricker, MC (fig. 183), who succeeded him as Senior Consultant in
Plastic Surgery, ETOUSA, on 12 June 1943, after Colonel Brownhad returned to the Zone of Interior to organize and direct a plastic surgerycenter at Valley Forge General Hospital, Phoenixville, Pa. Throughout the entirecampaign until the dissolution of the Professional Services Division of theChief Surgeon's Office in July 1945, the author worked in close cooperationwith the consultants in the other surgical specialties. The work of the SeniorConsultant in Plastic Surgery was closely associated with that of Col. Roy A.Stout, DC, Senior Consultant in Maxillofacial Surgery of the Dental Corps (fig.184). This relationship was maintained on a completely cooperative basis, thefunction of the two specialties being determined by the fundamentalconsideration of surgical training and experience.
The administrative duties of all consultants were concerned with the provision of a high standard of professional care for casualties at all echelons. This responsibility became intimately involved with tables of organization, tables of supply, professional qualifications of personnel, evacuation of casualties, and the establishment of professional policies. At the time of this writing, and for the purpose at hand, it seems best to cover the subjects briefly and in a general way as they concern the specialty of plastic surgery. The consultant found himself continually traveling from hospital center to hospital center and from hospital to hospital out of headquarters based successively in London, Cheltenham, Normandy, and Paris. This was a remarkable experience for a consultant out of civilian life. The enormity of the buildup in England for the invasion of Normandy will probably never be equaled in the future. Indeed, if future wars are to occur, it is doubtful that such an enormous land
force poised for invasion will be necessary. The magnitude ofthe Channel crossing and the problems presented in caring for and evacuating thewounded were unique in the annals of military medicine.
Tables of Organization
At the termination of the conflict, it was believed that thetables of organization should be brought abreast of the recent advances in thedevelopment of surgical specialties, and that they should particularly allow forthe possible limitation of the number of qualifiedspecialists. There was a constant conflict throughout the campaign between thelocation of plastic surgeons according to the tables of organization and theactual location of plastic surgeons in line with logical developments based onneed. Thus, as a result of the size of this operation and the number of hospitalunits involved, it was never practical or possible to supply each 750-bed and400-bed evacuation hospital with a qualified plastic surgeon as required by thetables of organization. The placing of plastic surgeons on field army unittables of organization was founded on the principle that a very important periodfor surgery of maxillofacial wounds is early after injury. The progress of thecampaign proved this con-
cept to be correct, but the planning that called for animpossibly large number of plastic surgeons to be in army areas was inerror.
Plastic surgery in a theater of operations plays its majorrole at two levels: (1) At the evacuation hospital level in army areas wheredefinitive therapy is required for compound facial injuries, and (2) in thegeneral hospitals of the communications zone where later definitive therapy canbe given to massive soft-tissue wounds, burns, and definitive therapy can becontinued for maxillofacial wounds. The placement of plastic surgeons in thecommunications zone general hospitals was accomplished without table oforganization provision for them. This difficulty was not insurmountable, and itwas one of the responsibilities of the consultant to overcome it. However, theproblem seemed to be of some magnitude at the time, both to the consultant whowas trying to manipulate hospitals and personnel, and to the personnel beingmanipulated into tables of organization with no provision for them. The simplehuman characteristic of desiring earned advance in rank was frequently thwartedas a result of these administrative difficulties. It is recognized that some ofthese difficulties were unique to the specialty which was still developing andthe role of which in a theater of operations was still not clearly understood.
As the preceding discussion suggests, the problems of personnel were chiefly precipitated by the tables of organization. During the 2-year preparation for the invasion of France, the need for qualified plastic surgeons to care for the injuries occurring among thousands of staging and training troops was repeat-
edly demonstrated. During part of this period, there wereonly two plastic surgeons in England who could be designated as qualified forthe care of complicated cases. The situation was relieved in the latter part of1943 by the arrival of several plastic surgeons with incoming general hospitalsand by the return of army units from North Africa. During this long periodbefore D-day, active combat was being carried on by the Eighth Air Force in EastAnglia. The Eighth Air Force was served by a group of station hospitals, intocertain ones of which specialist personnel were placed. The whole experience ofproviding specialist care for tremendous numbers of staging troops, and for anactive air force based in the communications zone, demonstrated again and againthe urgent need for highly qualified surgeons in all the specialties. In thespecialties in which there was a shortage of qualified surgeons, it becameimperative that those who were qualified be placed in such a position that theycould cover a geographical area, and not have their activities confined entirelyto the unit in which they were assigned.
At the end of the war, there were present in thetheater 70 medical officers with the MOS (military occupational specialty)classification of Specialist in Plastic Surgery. As 9 of the 70 were inadministrative or other types of positions, it was impossible to use them inactive clinical work in plastic surgery. Of the remaining 61 surgeons, 24 had a"D" classification; the majority of the 24 were general surgeons orspecialists in some other branch of surgery. A much more accurate appreciationof the supply of plastic surgeons in the theater than is afforded by a survey ofthe 70 so listed can be obtained by realization of the fact that only 15 of the70 were classified as "B" or above, and only 8 of the 15 wereavailable for use in clinical plastic surgery. The total number of plasticsurgeons available for clinical use with classifications of "C" orabove was only 27. It seemed obvious that the place for the more experiencedplastic surgeons was in the hospitals located to the rear where a large numberof patients could be funneled to them, where theholding period was longer, and where they would have an opportunity to cover abroader field of surgery than was possible in the forward units. Accordingly,insofar as possible, the more capable surgeons were retained in the rear, andthe excessive demands of army unit tables of organization were met with thesurgeons in the lower classifications. Of the 24 surgeons in the "D"category, 13 were with evacuation hospitals. This consultant received wonderfulcooperation from these men along with the remarkable patience and courtesy withwhich they accepted his own limitations.
The training of additional plastic surgeons within thetheater proved to be a completely impractical task. The very nature of the workmade it mandatory that a relatively long period be devoted completely to thespecialty before any degree of proficiency could be attained. During the long,quiet period in England, there were not enough casualties accumulated in any onearea or location to offer training material of any value. The medical officerswho would benefit most from short periods of training were those who already hadan extensive background in surgery. Such officers in most instances were
loath to give up their chosen field of surgery which, in manyinstances, would have resulted in forfeiture of chance for advancement in rank.There were a multitude of officers who were anxious to get into plastic surgery,but almost invariably the meager surgical background of these men eliminatedthem from being anything other than assistants. Advantage was taken of thepresence of established British plastic surgery centers for training of U.S.Army surgeons during the long periods of relative inactivity. The surgeonsordered to these units were those with previous training in plastic surgery whowould be most benefited. The most extensively used British unit was that at theQueen Victoria Cottage Hospital, East Grinstead, Sussex East. Approximately 50officers were sent there for 10 days of lectures and demonstrations by Mr.Archibald McIndoe (later knighted). Other units at which American officers wereplaced on temporary duty were the Hill End Hospital at St. Albans under Mr.Rainsford Mowlem and the Emergency Medical Service Hospital at Park Prewett,Basingstoke, under Sir Harold Gillies. These British surgeons and many othersshowed a marked degree of cooperation and courtesy throughout the period ofclose association in England.
It would be impossible to pay individual tribute to thevarious surgeons who did so much in this specialty during this phrase of the warin Britain and Europe. To mention a few would be unfair to others. Much of theclinical work was quite outstanding, and many of the surgeons had an opportunityto demonstrate originality and imagination in their approach to the variouscomplicated clinical problems. Furthermore, the administrative ability that, ofnecessity, accompanied the clinical work of setting up a plastic surgery servicein a hospital and hospital center was enough to deserve special recognition.
Problems of supply were a rather minor but a constant source of concern for each consultant. The Supply Division of the Chief Surgeon's Office was always found to be very cooperative in the procurement and distribution of nonstandard items. Tables of equipment and basic allowances were found to be inadequate for the needs of the hospitals for special treatment that were developed as the campaign progressed. The items concerned pertained to the specialized types of surgery on large volumes of casualties. Detailed comments regarding deficiencies of supply were made in a report to The Surgeon General completed shortly after the war. It was believed that, since the use of hospitals for special treatment had reached such a degree of development and recognition in the European theater, in addition to the changes in organization aimed at facilitating the establishment of these hospitals, consideration should be given to the need for supplementary tables of equipment to furnish such units. The items concerned were such things as suction apparatus, needles and suture material, needle holders, tissue forceps, skin hooks, small hemostatic forceps, cotton-waste dressing material, dental arch bars, and dental elevators, all of which, it can be seen, are instruments of a specialty nature.
The complete absence of photographic equipment as an item ofmedical supply to both communications zone and combat zone hospitals was keenlyfelt as a handicap throughout the campaign. The need for such equipment waspartially relieved by procurement from the British. "Photographicunits" were placed with most of the hospital centers. In most instances,the equipment was placed in a hospital performing plastic surgery. It was foundthat reliance on the Signal Corps for clinical photography was completelyunsatisfactory. There always seemed to be plenty of photographs of Britishnobility visiting the hospitals, but, when an overworked operating surgeonwanted a photograph of some important clinical condition at an irregular hour oron an offday, it was often next to impossible to get it. Clinical photography inthe U.S. Army Medical Department was a sorely neglected field that cannotadequately be discussed here. A single detachment of artists and photographersfrom the Army Medical Museum, such as was supplied in the European theater, wasnot a satisfactory solution.
Careful supervision of the policies regarding evacuation and constant observation of the flow of casualties to insure that those which were an exception to the general rule were promptly and adequately provided for proved to be among the most important duties and responsibilities of a consultant. The general picture of evacuation varied from day to day and was influenced by the tactical situation, the number of casualties, and the weather. Maxillofacial injuries were considered to travel well. Their early evacuation from army areas was urged, and provisions had to be made in the communications zone to insure against their being lost and not being transferred promptly into the hospitals for special treatment. Burn casualties were also evacuated into specialty hospitals as soon as possible. No special provision was made for the large number of extremity wounds which would require plastic surgery. These cases were picked out of the hospitals in the communications zone and transferred to hospitals providing plastic surgery service as soon as the need for this type of surgery was recognized. Transit and holding hospitals played a very important part of the evacuation of specialty type casualties. The following paragraphs from the Semi-Annual Report, Plastic and Maxillofacial Sections, Professional Services Division, Office of the Chief Surgeon, U.S. Forces European Theater, for the period 1 January-30 June 1945, indicate the main features of the evacuation problem presented by casualties with severe facial injuries:
The care of maxillofacial casualties isdirectly related to the efficiency and speed of evacuation, since continuity oftreatment must be maintained. Throughout the campaign, one of the chief dutiesof the Senior Consultants in Plastic and Maxillofacial Surgery has been toenforce priority of evacuation for maxillofacial casualties, to brief airholding units in the preparation of casualties for air evacuation, and to seethat patients were properly dispersed from landing areas in which a highconcentration of cases accumulated. Train and boat evacuation also presented theproblem of making Hospital Train crews and Hospital Ship Platoons aware of thespecial problems involved in caring for and feeding
the severe maxillofacial casualties. Arrangements werefinally made with Evacuation Divisions of the various Commands to have thosemaxillofacial casualties going to the Zone of Interior by water to go only onHospital Ships, where care by properly instructed medical personnel could bedepended upon.
1. Air Evacuation: a. Front to Paris: Maxillofacialcasualties were given a high priority of evacuation directly from the front toParis, where they were accumulated in the 108th and the 1st General Hospitals.This relieved the load on the forward transit general hospitals and placed thecasualties early in the hands of specialists, where they could remain untilready for evacuation to the Zone of Interior.
b. Front to England: Any available air lift to England wastaken advantage of by priority maxillofacial casualties. There were periods whencasualties were admitted to the special hospitals in England within 36 to 48hours of the time of injury. This proved to be a tremendous advantage in securingthe quality of specialist care desired at an early date and making itunnecessary for the case to go through repeated stages of evacuation.
c. Li?ge to England: The 15th General Hospital at Li?ge,Belgium, functioned as a special maxillofacial hospital for the 820th HospitalCenter and as a holding transit unit for air evacuation to England. Thisarrangement functioned very well during the heavy Ardennes fighting and servedto decrease the load arriving in the Paris area, as well as to keep thecasualties in the hands of specialists. Major Carroll Stuart, MC, and Major LeoLa Dage's team of the 5th Auxiliary Surgical Group did a very commendable jobat this unit while the casualties were heavy and Li?ge was being bombed. InEngland the air evacuated casualties were passed through the 154th GeneralHospital near Swindon. Personnel were added to this unit to care for the load ofcasualties. From the 154th General Hospital, the cases were dispersed to the117th, the 91st, the 192nd, and the 158th General Hospitals by ambulance, and toother hospitals by train or hospital car.
d. Paris to Zone of Interior: Maxillofacial casualties weregiven first priority for air evacuation to the Zone of the Interior. Paris wasthe departure point from the Continent. The 1st General Hospital functioned asair holding unit where the adequacy of preparation for air evacuation waschecked.
e. England to Zone of Interior: From all special hospitals inEngland cases were evacuated to the Zone of the Interior by air as air lift wasavailable.
2. Train and Boat: Insofar as possible, allmaxillofacial casualties were evacuated by air. Evacuation to the Zone of theInterior by boat was confined to Hospital Ships during the latter part of thecampaign.
3. Function of Transit Hospitals at Li?ge and Swindon: Thedesignation of such specialty transit hospitals was found to be a very necessarystep to control the direction of evacuation and to insure patients falling tothe hands of surgeons and dentists with special training and interest.Approximately 3,000 maxillofacial casualties passed through the 154th GeneralHospital at Swindon from D-day to V-E Day.
Plastic or Maxillofacial Surgery Centers
The establishment of hospitals for special treatment, or "plastic and maxillofacial surgery centers" presented problems that were inseparable from those described in preceding paragraphs on tables of organization and personnel. As a matter of fact, the establishment of these specialty hospitals was the solution to the tables of organization and personnel problems. On 30 March 1943, in a letter on the subject of patients requiring plastic surgery, the Office of the Chief Surgeon, ETOUSA, designated the 298th General Hospital, at Bristol, and the 30th General Hospital, at Mansfield, as centers for plastic surgery. During the following year eight more specialty hospitals for plastic surgery were developed in England. On 10 June 1944, Circular Letter No. 81,
concerning hospitals with facilities for specializedtreatment, was issued by the Office of the Chief Surgeon, ETOUSA, and designatedhospitals for special treatment and plastic surgery, neurosurgery, thoracicsurgery, and urological surgery. Thus 10 hospitals, scattered geographically tocover all areas of hospitalization in England, were designated as plastic andmaxillofacial surgery centers. Subsequently, one more general hospital was sodesignated in England. This arrangement provided one plastic surgeon toapproximately 10,000 hospital beds. If specialist care was to be made availableto all casualties arriving in England, it would be necessary to scatter theavailable surgeons geographically rather than to place them in a smaller numberof hospitals and thus allow each hospital a larger staff. Previous experiencewarned, and it was later vividly demonstrated, that during the heavy flow ofcasualties long ambulance hauls of patients to specialized hospitals would notbe possible. Plastic surgery could not have served the mass of casualties inEngland through two or three ideally setup and ideally staffed plastic surgeryservices.
Preparation for the designation of a hospital as a so-calledspecialty center usually consisted of moving a qualified specialist into thehospital chosen. This move was preceded in eight of the centers by theinstallation of additional facilities in the hospital plant for the latetreatment of burns by saline baths. From here on, development of the specialtysection became largely the responsibility of the specialist himself. In the caseof plastic surgery in 1,000-bed communications zone general hospitals, thedifficulties encountered resulted directly from the tables of organization. Anew surgical section requiring nurses, ward officers, trained technicians, andsome items of special equipment had to be fitted into a hospital which wasconsidered to be already organizationally complete. In some instances, weeks ormonths transpired before a section could be sufficiently developed to beconsidered possibly to be running efficiently. The plastic surgeon became allintegral part of the hospital to which he was assigned. This was an advantage sofar as cooperation from other members of the hospital was concerned, but itproved to be a great disadvantage when movement of the surgeons becamenecessary. Replacements were always necessary or wanted when a surgeon was to bemoved. The finding of a replacement and the prolonged administrative details ofchanging the surgeon's assignment from one hospital to another resulted, insome instances, in defeating the object of getting the surgeon quicklytransferred to a place in which he was more urgently needed.
In England, the plastic surgery centers had the mostfavorable opportunities to develop and to work efficiently. The administrativedecentralization that started very early after the influx of large numbers oftroops favored the efficient function of specialty hospitals. The breaking up ofEngland into base sections made it possible for certain hospitals to bedesignated for the coverage of a base section. The desires and recommendationsof the Chief Surgeon's senior consultants were enforced through a base sectiondirective, and the base section consultants were of inestimable value in seeingthat such directives were followed. Later, when England became designated as theUnited Kingdom
Base Section, the division of the hospitals into hospitalgroups again facilitated the use of special hospitals. The most efficientorganization prevailed at the end of the campaign when all hospitals in Englandwere included administratively under seven hospital center headquarters. Theareas covered by the hospital centers were smaller, the hospitals were usuallyfairly well concentrated, and the contact between the surgeon of the hospitalcenter and the commanding officers of various hospitals was direct. By the timethis administrative organization had developed, the plastic surgery centers wereestablished and their functions understood. Transfer of patients from otherhospitals to the plastic surgery centers was carried out with a satisfactorydegree of efficiency. The plastic surgeons in the designated hospitals acted asconsultants for the hospital centers, thereby furthering the good relationshipbetween the various hospitals and the specialty surgical services.
The situation as it existed in England during the terminalmonths of the campaign could be considered as being almost ideal, with oneexception: The plastic surgery services in the individual chosen hospitals stillhad to be developed on an entirely improvised basis. The additional help thatwas necessary was not provided in the hospital organization. It was necessary tobeg, borrow, or steal it. The same often was true of adequate ward, dressingroom, and operation room space. In addition, with the shortage of qualifiedplastic surgeons, it eventually seemed advisable to close a service in one ofthe hospitals and to depend for coverage of the area on transfer of patients toa hospital in an adjoining hospital center. Withdrawal of the specialist from ahospital nearly always met with opposition from the commanding officer of thehospital as well as from the commanding officer of the hospital center involved.This opposition was understandable, since it was the duty of the hospital centercommanding officer to insure adequate professional coverage for his command.Nevertheless, it was often difficult to fit the supply of plastic surgeons tothe obvious needs and at the same time supply the supposed needs of individualadministrative subdivisions that were not acquainted with the overall picture ofsupply and demand in surgical specialists. These difficulties are enumerated notbecause they were insurmountable administrative obstacles but because theyappeared to be unnecessary; that is, they could have been avoided by betterplanning for the distribution of specialist personnel.
Professional policies for the theater emanated from the consultants in the Professional Services Division of the Office of the Chief Surgeon. The formulation of professional policies was influenced by many factors that required serious consideration in planning for the care of casualties falling into a surgical specialty. The factors of greatest significance were (1) the expected numerical flow of casualties, (2) the average professional ability of the personnel that were to handle the casualties, (3) the specific needs of the particular types of injuries, and (4) the hospitalization policy for the theater (which was
gradually shortened as the reserve of hospital bedsdecreased). Policies were made known from the Office of the Chief Surgeon bycircular letters, administrative memorandum, subject letters, and contact of theChief Surgeon's consultants with the medical personnel in the varioushospitals. The Manual of Therapy, ETOUSA, compiled by the consultants andpublished in May 1944, served as a guide to the general medical and surgicalofficers and to the various specialists. With the reception of large numbers ofcasualties, certain policies were changed and the changes made known insubsequent circular letters on professional care.
The very close contact it was possible for the SeniorConsultant in Plastic Surgery to maintain with the plastic surgeons throughoutthe various centers in England and France proved to be of enormous value.Current professional problems could be discussed in this way and ideas of thevarious surgeons interchanged. In addition, frequent visits between the surgeonsof the different plastic surgery centers were encouraged. It was thus possibleto define the limits of plastic surgery to be carried out in the theater and tosee that these policies were uniformly adhered to. It was always the aim to doonly what was urgently indicated and to prepare the patients for evacuation tothe Zone of Interior as soon as possible. The Medical Bulletin, ETOUSA, publishedmonthly, served as a very valuable unofficial means of getting information tomedical officers throughout the theater. This publication was used to advertisethe specialty centers, to explain their function, and to encourage the transferof patients to these hospitals. The administrative professional policiespertaining to the various types of casualties falling to plastic surgery arediscussed in subsequent paragraphs devoted to professional care.
PROFESSIONAL RESPONSIBILITIES AND PROBLEMS
It was the responsibility of a surgical consultant to see that, so far as possible, each casualty was directed to the hands of a physician qualified to provide the necessary care as rapidly as this could be accomplished after injury. As indicated in the foregoing discussion of administration, this responsibility concerned the consultant with all phases of the tactical situation, but chiefly with the evacuation of casualties and the placement of professional personnel. Since plastic surgery was coming of age and was represented by a consultant in the Office of the Chief Surgeon, it seemed advisable to establish a definition of what plastic surgery should entail. Accordingly, plastic surgery was defined, in Circular Letter No. 5, Office of the Chief Surgeon, Headquarters, ETOUSA, by the Chief Surgeon on 12 January 1943, while Colonel Brown was still in the theater, as follows:
1. Definition: Plastic surgery includesmaxillofacial surgery and is defined as the care and treatment, in all stagesof:
a. Injuries of the face and jaws that may alter the shape of the bony structure or leave disfiguring scars.
b. Injuries of any part of the body whichrequire skin grafts or flaps, scar adjustments or surface tissue readjustment.
c. Serious burns which may not be regarded initially as falling within the classes in subparagraphs a and b above.
2. Technical Supervision: The SeniorConsultant in Plastic Surgery is the adviser of the Chief Surgeon and will,under the direction of the latter, exercise technical supervision of all plasticsurgery in ETOUSA, regardless of echelon.
The definition was a good one and served a very useful purposein clarifying responsibility in matters of professional policy. The inclusion ofmaxillofacial surgery under plastic surgery is difficult to justify completelysince the fundamental sources of training are quite different for each, and thetwo fields, though closely associated in many ways, are quite divergent inothers. Except in the case of a few surgeons, qualified in both surgery anddentistry, it was always necessary for the two specialists to work as a team ifthe highest standard of care was to be maintained. Patients were admitted tohospitals on the surgical service under the responsibility of the chief ofsurgical service. The dental officers were used to the fullest extent andfurnished constant and invaluable assistance in caring for all cases offractures and injuries about the mouth. Without the dental officers to help withsuch cases, the surgical services would have been crippled. Subsequent commentson the treatment of maxillofacial casualties in this chapter step considerablyunto the field of the dental officer with maxillofacial training. Colonel Stout,Senior Consultant in Maxillofacial Surgery, worked side by side with the SeniorConsultant in Plastic Surgery in the care and supervision of maxillofacialinjuries, and many of the views expressed on this subject stem directly fromhim.
This author, having been drafted into the position of SeniorConsultant in Plastic Surgery, has long had mixed feelings about theadvisability of a man who is basically a general surgeon acting as consultant insuch a specialty. However, the professional policies and decisions that wererequired in this theater of operations were of such basic commonsense andgeneral surgical nature that the situation was not as incongruous as it mighthave been. It was found that, in addition to bedside consultation, theconsultant could provide an important professional service by the rapidword-of-mouth dissemination of information during his travels. He was inexcellent position to observe and to utilize the knowledge and experience ofmany first-class surgeons and thus crystallize ideas and policies that weregenerally beneficial. It was most important that the natural process of learningby experience be speeded up as much as possible in order that the good inprofessional policies be separated from the bad and promptly put into generalpractice. The consultant was in a key position to facilitate this process and toappreciate the necessity for altering professional policies in accordance withthe dictates of the tactical situation.
Before World War II, the only definite knowledge available concerning treatment of the severe facial wounds of war was that which resulted from World War I. The basic principle of treatment of severe facial wounds ema-
nating from World War I was that such wounds should beclosed, or partially closed, and that massive displacements of tissue were to bereplaced as soon as possible, with primary healing as the aim. The basicprinciple had been supplemented because of two very important factors by thetime the active phase of World War II approached: (1) Twenty years of civilianexperience had been acquired in handling the severe injuries resulting from thespeedup and increase in motor transportation; (2) chemotherapy had establishedan important place as a method of prophylaxis and treatment of infections. Itwas believed that these two factors would allow aggressive extension of thebasic principles emanating from World War I. Thus, it was concluded thatthe time for complete definitive surgery was immediately in the hands of thefirst qualified specialist who received the patient, providing that theprocedure was feasible and not complicated by such loss of tissue as to make itimpossible. Even the latter cases should be treated definitively as far aspossible, leaving only replacement and reconstructive procedures to be done at alater date. The object was to produce definitive treatment that would make itnecessary, in many cases, for later surgery to consist only of superficial woundrevision or excision. The proper treatment of fractures was an integral part ofthe procedure. In order to approach as nearly as possible the theoretical ideal,definitive surgery at the evacuation hospital level was urged to the limit ofthe professional talent available there. So far as possible, the most highlyqualified plastic surgeons were retained in the rear medical installations wherethey could handle a greater volume of casualties through triage and where theirtalents could be used on a broader scope of surgery than at the front. Thesystem produced results that were quite gratifying, considering the tremendousgeographical area covered and the mass of casualties handled.
A section of the Manual of Therapy, ETOUSA (app. F, p. 989),indicates the policies pertaining to the treatment of maxillofacial injuriesthat were in effect at the time of the Normandy invasion.
The sources of severe facial injuries were multiple.Civilian-type injuries resulting from vehicle accidents and fist fights werealways common, and, during the period before the invasion of France, providedthe majority of maxillofacial injuries. Casualties from the Air Forces presentedno notably characteristic features. Landing and takeoff accidents resulted in anumber of blunt-force facial injuries, many of them complicated by associatedburns. Flak wounds varied from massive shearing injuries caused by large shellfragments to small perforating ones resulting from small missiles. Some of thesmall missiles from flak were of exceedingly high velocity and producedconsiderable comminution and "blowing out" of the face. During thehedgerow fighting in Normandy, there was an unusually high incidence ofmaxillofacial injuries resulting from the close type of combat and the necessityfor the men to expose their heads to see the enemy. These wounds werepredominantly caused by small arms fire and were characterized by beingexceedingly severe and not
FIGURE 185.-Anterior and lateral views of very extensive injury, associated with extensive loss of tissue. Note the tracheostomy which was absolutely essential for the survival of this patient. Such casualties also presented extremely difficult feeding problems, and a gastrostomy was occasionally justified. Little of a truly restorative or a reconstructive nature can be done for such an injury during the early phase of care. The problem is one of keeping the patient alive and getting him ready for evacuation to the Zone of Interior.
being associated with wounds elsewhere in the body (fig. 185).This is the type of injury that lends itself to extensive early definitivetreatment since associated wounds do not influence the patient's condition orhave to be considered.
Also, during certain periods of the Normandy campaign, therewas a high incidence of a virulent type of wound from "tree bursts" ofmortar fire and high-explosive shellfire. In wooded sections, the shells wouldexplode in the air upon striking a tree. This not only decreased the time inwhich a soldier could drop to the ground for protection but changed thedispersion of the smell fragments so that dropping to the ground gave no addedprotection. These wounds were very often associated with other wounds of thetrunk or extremity which complicated treatment of the maxillofacial injury.Landmines produced a characteristic injury that often was extremely severe.During the fighting around Aachen and the crossing of the Siegfried Line,landmine casualties were especially numerous. They were usually accompanied byshattered feet or legs which made the patient's general condition so criticalthat little could be done for the face. The facial injury consisted of"tattooing" with multiple
FIGURE 186.-Powder "tattooing" as illustrated by this casualty was almost invariably associated with blindness in one or both eyes. The aftereffects of this "tattooing" could be greatly lessened by vigorous early treatment. It was possible in some instances for the anesthesiologist to scrub and debride the powder marks of the face while the surgical team was taking care of other injuries. It was unfortunate that the insignificance of this particular phase of the patient's injury understandably led to its early neglect in so many instances.
small perforating wounds which usually involved both eyes (figs. 186 and 187).
Evacuation hospital - Planning for the management offacial injuries was based on the belief that the time for the most effectivedefinitive treatment was at the evacuation hospital level. This concept wasproved to be correct, particularly for those casualties without massivesoft-tissue loss. Maxillofacial surgical teams of the auxiliary surgical unitswere effectively used by being placed in evacuation hospitals. At this level,the casualty was treated for shock, all bleeding was controlled, the airway wasinsured, the extent of the injury was surveyed, and the patient was rested andprepared for operation. If the condition of the patient permitted and thetactical situation allowed, a complete definitive operation was then done (fig.188). The bony skeleton
FIGURE 187.-A blast injury, resulting from a mine explosion, somewhat different from the usual in that the foreign particles were larger and were easily removed. Blast "tattooing" as illustrated by this case could be greatly benefited by prolonged and fastidious curettage and soap and water cleaning of the thousands of small punctate wounds. (Case of Maj. Byron C. Smith, MC, 1st General Hospital.)
was reduced and the initial fixation applied. The wound was debrided and, ifadvisable, closed in layers. The patient was continued on penicillin, which wasstarted upon arrival at the hospital, and held until he had passed the criticalperiod before being evacuated. Tracheotomized patients were held for a minimumof 4 days to become accustomed to the tracheotomy and to develop some degree ofself-reliance in case of emergency. Feeding problems were held at least untilthe more acute problem of maintaining fluid intake had subsided. The object wasto get these casualties back as quickly as possible to a specialty center in thecommunications zone as soon as they could be transported safely (fig. 189).
General hospital - In the United Kingdom Base Section,there were 10 general hospitals, staffed and equipped as treatment centers forpatients with maxillofacial injuries as well as for burn casualties andcasualties with massive soft-tissue loss of the trunk or extremities. Thesespecialty hospitals were geographically dispersed over England, one suchhospital being designated in each hospital center. From the evacuation hospitalwhere the initial definitive treatment had been given, the casualty wastransferred to the communications zone and, if it was severe enough to warrantit, directly into one of the specialty hospitals. The severe facial injurieswere continued on a logical regimen aimed at anatomical replacement of tissues,the promotion of healing as rapidly as possible, the reduction and fixation ofskeletal derangements and through it all, the maintenance of morale and thenutritional state.
It is obvious that this effort involved many more people thanthose primarily concerned with plastic surgery or the treatment of maxillofacialinjuries. Consultation with the general surgeons, the ophthalmologist, and theotorhinolaryngologist was an integral part of the conduct of such a service.Dental officers of the hospital staff became a part of the plastic andmaxillofacial team. The Senior Consultant in Plastic Surgery was almostinvariably accompanied by Colonel Stout of the Dental Corps during hisinspection of these centers. The suggestions of Colonel Stout concerning themanagement of complicated jaw and facial fractures furnished an invaluable andindispensible supplement to the author's own inadequate experience in thisfield. However, it was found that the application of basic surgical principlesand commonsense would usually point the way to a solution for most of thecomplicated injuries.
The degree to which early facial reconstruction and repaircould be accomplished was a continual source of amazement and stemmed directlyfrom the availability of antibiotics coupled with good surgical care. An effortwas made to take full advantage of the opportunity afforded to obtain earlytissue replacement and healing. Much of this was definitive plastic surgery atits best. However, the majority of the surgery in the European theater was aimedat preparing the facial casualty for evacuation to the Zone of Interior in thevery best condition for travel with the wound in the very best condition for acontinuation of whatever subsequent reconstruction might be necessary (fig.190). Many things were learned, only a few of the most important and obvious of
FIGURE 188.-The treatment of a compound facial wound at the evacuation hospital level. The wound illustrated is associated with fracture of the maxilla and loss of tissue about the nose. The maxilla was supported by an arch bar to which wires were attached and brought out through the wound for superior traction. The wound was then closed as much as possible after conservative debridement. No attempt was made to reconstruct features associated with loss of tissue. These areas were left open for later reconstructive surgery. (Case of Maj. Vilray P. Blair, Jr., MC, 45th Evacuation Hospital.)
FIGURE 189.-A casualty with a severe wound of the chin and mandible as he arrived in the communications zone. Note the nasal feeding tube which had been of vital importance. In this case, superior traction and support was supplied to the mandible and tongue through elastic bands and a circumferential head bandage. The circumferential head bandage was found to be just about as reliable during evacuation as was the plastic head cap.
which can be mentioned in the following paragraphs. To discussthe treatment of maxillofacial injuries of war in detail would require aseparate volume.
Hemorrhage - When active intervention for the control ofhemorrhage became necessary, it was found preferable, and in the majority ofcases possible, to expose the bleeding point and ligate the vessel. Remarkablyfew cases were seen in which trunk vessels had been ligated for uncontrollablehemorrhage. The majority of these cases were secondary hemorrhage associatedwith infection, and the results of trunk vessel ligation was not the mostsatisfactory.
Airway -By the end of the war, it was realized thattracheotomy was a much more vitally important procedure than had beenanticipated. It was found to have a place for the critical patient who was nearsuffocation. In addition, it was found useful for the patient who had anadequate airway, but whose wounds made breathing difficult, messy, and a causeof continued anxiety
FIGURE 190.-A major facial wound with loss of nose, maxilla, and mandible, representing a composite of the problems presented by these casualties. The problem at first seems to be almost an insurmountable one of maintaining the patient's airway, nutritional state, and morale. A. The patient during his critical stage in an evacuation hospital. B. The man ready for evacuation to the Zone of Interior. The posterior mandibular fragments are stabilized by metal cap splints and a connecting bar. (Case of Maj. Leo H. La Dage, MC, 5th Auxiliary Surgical Group.)
on the part of the patient and his attendants (fig. 185). In such cases, tracheotomy relieved the anxiety, put both the patient and the wound at rest, and simplified nursing care, subsequent anesthesia, and operative procedures.
Debridement - In the preparation of facial wounds forclosure, the procedure of debridement was found to be as important as it was forwounds elsewhere in the body. However, it was completely different becauseit was necessary that it be conservative and at the same time thorough.Debridement and closure had to be judiciously associated with adequate dependentdrainage for wounds involving the buccal mucosa, the floor of mouth, and theparanasal sinuses. Debridement and closure could not be practiced on facialwounds with massive soft-tissue loss. In such cases, the procedure was alteredto provide for as early healing as possible without gross displacement offeatures (fig. 188). The suture of skin to buccal mucosa was a procedurefrequently practiced (fig. 191).
Primary closure - The success of primary closure offacial wounds was directly dependent upon the skill with which the debridementand closure were done and upon the extent and location of the wound. Asurprising percentage
FIGURE 191.-This compound injury is associated with fracture and loss of bone and loss of overlying soft tissue. The skin to buccal mucosa suture provides early healing and at the same time simplifies the care of the fracture and floor of the mouth by making these areas more accessible. Any attempt at early closure and reconstruction of this facial defect would have been a serious error. Notice the multiple wire loops for control of the bone fragments by elastic traction. (Case of Lt. Col. B. Eugene Boyer, MC, 53d General Hospital.)
of them were successful (fig. 192). Those that were unsuccessful were subjected to secondary closure in the communications zone hospitals after the wounds had been cleaned up and the associated skeletal derangements stabilized.
Infection.-Routine antibiotic therapy had a definiterole in the low incidence of spreading infections. It is of great interest that,in his travels, the Senior Consultant in Plastic Surgery did not see one case ofLudwig's angina. Spreading cellulitis and erysipeloid infections werepractically nonexistent. The infections observed were localized and, for themost part, due to poor debridement or lack of provision for adequate drainage ofwounds in which drainage was indicated (fig. 193).
Reduction and fixation of fractures - Before a compoundfacial wound was closed, the initial reduction and fixation of fractures wasaccomplished with the following ends in mind: (1) Restoration of normalanatomical position and contour, (2) restoration of normal occlusal relationshipbetween the maxilla and mandible, (3) maintenance of the dental arch andprevention of collapse
FIGURE 192.-This case admirably illustrates the results of the early definitive treatment of compound facial injuries. Most closures of this nature were done in evacuation hospitals. However, the case illustrated here was closed at the 1st General Hospital in Paris, having been evacuated by air. Primary closure was most effectively applied to soft-tissue wounds without associated skeletal injury and without soft-tissue loss. The case illustrated shows the result of minute tissue replacement followed by primary healing. The transverse maxillary fracture was supported through a plastic head cap attached to an arched bar. (Case of Maj. Byron C. Smith, MC, 1st General Hospital.)
(figs. 191 and 194). The multiplicity of means of fixation of facial and jaw fractures cannot be discussed in detail here. Suffice it to say that the problem was chiefly a mechanical one and was influenced by many factors. If the patient was seen early enough and if the anesthesia was adequate, reduction could usually be accomplished manually. If impaction or swelling and fixation prevented manual reduction, a plan for traction reduction had to be formulated.
FIGURE 193.-This case illustrates a penetrating wound of the antrum with infection. Most infections observed were due to inadequate debridement or lack of provision for adequate drainage. Infection in the above case could have been prevented by debridement of the maxillary antrum and the provision of adequate drainage through the buccal fornix.
The mechanical means were multiple and those used would vary with the individual surgeon and the individual case. Certain principles, however, were considered in the application of these mechanical means. These principles were: (1) To strive for simplicity; (2) to take advantage of every favorable factor offered by the peculiarities of the case (that is, the presence of key teeth for application of apparatus, the holding of one fragment in place by impacting it against another, or the holding of a posterior mandibular fragment in position by a retained molar); and (3) to avoid external applications and plaster head caps when possible. It was in this phase of care that the "multiple loop" wiring method of Colonel Stout was used most extensively (fig. 191). Intermaxillary rubberband fixation, applied to multiple loop wires, served a great purpose in the European theater both for the early care of maxillofacial casualties and for the later definitive support of mandibular and maxillary fractures during the final healing phase.
FIGURE 194.-Compound facial wound associated with loss of the maxillary alveolus and overlying soft tissue and a fracture of the mandible. Good early care with an acrylic resin splint to mandible and stabilization of the remaining maxillary fragments.
Drainage.-At the time of closure, the indications for establishing adequate drainage had always to be kept in mind. This was a principle that was well understood during World War I when infection after closure was much more likely to be a critical complication than at the time of the present conflict when spreading infection could, to a great extent, be controlled by sulfonamide or penicillin therapy. Failure to provide adequate drainage was a not uncommon error in the treatment of the first casualties following the invasion of Normandy. It was believed that drainage should be instituted routinely for the following types of wounds:
1. Wounds involving the floor of the mouth. The floor of the mouth should beclosed, and dependent external drainage provided. This could usually be donethrough an external portion of the wound.
2. Severe wounds associated with the comminuted fracture of the mandible. Thedrained area should include the fracture site.
3. Deep wounds of the upper neck. Such wounds were subject to accumulation ofblood and serum because of the unavoidable motion following swallowing andbreathing.
4. Wounds involving the maxillary sinus were drained into the nose or buccalfornix.
5. Wounds which resulted in the turning of a large flap. Accumulation ofserum and blood was guarded against by the insertion of a small drain afterreplacing the flap.
6. Compound wounds of the frontal sinus were drainedexternally (provided the wound did not involve the posterior wall and dura).
7. Extensive comminuted fractures of the mandible, compoundedinto the mouth, but not associated with external wounds through which drainagecould easily occur. Such wounds were treated by a properly placed incision andthe insertion of a drain.
Delayed primary and secondary closure - Primary closureof facial wounds at the evacuation hospital was the general practice whenpossible. However, there were cases that for various reasons were foundinadvisable to close in the evacuation hospitals. For instance, an evacuationhospital group swamped with casualties might be in a position to bypassmaxillofacial injuries that were considered transportable through an airevacuation unit directly to hospital centers in England where they would arrivein only a few hours (fig. 192). Many facial injuries were then subjected todebridement and closure with successful results from a few hours to as long as72 hours following injury. Without question, penicillin therapy had an importantbearing on the fact that comparatively late, radical, definitive procedures werepossible. The absence of invasive infection was the clinical finding supportingthe rationale of late closure. Technically, delayed primary closure did notdiffer from early closure.
The cases requiring secondary closure might be classified intwo categories, as follows: (1) Those that had previously been closed withunsuccessful results; (2) those that were not closed previously and in whichdelayed primary closure had been advisable. Both of these types becamecharacterized by surface infection, sloughing of devitalized tissue, and abscessformation if drainage was inadequate. The problem resolved itself into one ofnursing care, care of the wound, maintenance of the nutritional state, andcontrol of infection in preparation for secondary closure. Reduction andfixation of skeletal parts proceeded concomitantly, and in these cases theprocedure frequently became one of gradual traction reduction.
Secondary closure was done judiciously, with the realizationthat the results could not be accepted as final and with the understanding thatthe procedure was never strongly indicated unless it would increase the comfortof the patient or result in producing a healed wound that would terminatepathological processes detrimental if allowed to proceed (fig. 195). An effortwas made not to lose sight of the fact that the normal healing process of anopen wound produces results that are frequently difficult to surpass by surgicalintervention. If the wound was not resulting in loss of bone or important lossof function, it was realized that closure or revision by experienced hands manyweeks later, after the tissues had healed and softened, might be expected tooffer the best results (figs. 196 and 197).
FIGURE 195.-This case illustrates the secondary closure of a compound facial wound. Some casualties were so severely injured and the circumstances of their treatment so complicated that early definitive care could not be accomplished before evacuation became necessary. The case illustrated here shows the condition of a casualty upon arriving at a general hospital 5 or 6 days following injury. There is an extensive defect of the maxilla. In such cases in which there was no extensive loss of tissue, the soft-tissue parts could be replaced as soon as possible. This case illustrates the results of such an early secondary closure. (Case of Maj. Douglas W. Macomber, MC, 91st General Hospital.)
Rotation flaps, pedicle grafts, free skin grafts.-With the exception of the free skin graft, none of the procedures listed in the title of this paragraph were considered to have a role in the early treatment of maxillofacial wounds. If there was massive loss of tissue requiring replacement, it was believed that this was better done at a later stage in the Zone of Interior. An occasional wound lent itself to free skin graft as a means of promoting a healed surface, though it was rather surprising how infrequently such wounds were encountered.
Feeding and maintenance of nutritional state - In anyhospital in which maxillofacial casualties were accumulated, the problem oftheir feeding soon became an acute one. In the specialty hospital in theEuropean theater, it became the habit, as soon as the load of patients warrantedit, of setting up special feeding facilities for these casualties. The Americansoldier, almost regardless of the handicap, will get enough to eat if he isgiven the opportunity. A few of the casualties were definitely reticent aboutfeeding themselves before
FIGURE 196.-This case illustrates a poorly advised secondary closure of a soft-tissue wound of the face. This wound obviously needed skin replacement rather than secondary closure since the wound was not causing disability and nothing was to be gained by closing it. If free skin-grafting was inadvisable at the time, such wounds were much better left for secondary healing and subsequent plastic revision.
others when this procedure involved the messy use of fingers or feeding tubes. If they were segregated with other patients suffering from the same handicap, this embarrassment disappeared, and a spirit of rivalry could be stimulated to see which could get the most food down and gain the most weight. Feeding of severe maxillofacial casualties in the late stage became a matter of simply supplying the soldier with suitable food in the right environment. Feeding in the earlier stages of care of such casualties provided a much more serious problem and frequently had to be solved by the insertion of a nasogastric tube for this purpose (fig. 190). Gastrostomy was not infrequently indicated in those severe types of casualties which could be expected to experience great difficulty in the ingestion of food over a long period of time and in whom a nasal tube could not be expected to be tolerated sufficiently long.
Blast injuries.-Blast injuries from landminespresented a most distressing problem. It was seldom the case that these patientswere in good condition and without other associated severe injuries. Had thisnot been the case, it would have been possible to have given more of the blastinjuries complete definitive treatment at an early hour. When it could be done,this treatment consisted of very careful, complete, meticulous cleansing of theface with removal of all embedded particles (fig. 187). Obviously, if thoroughlydone, the procedure could be expected to require hours of operating time, andfor this
FIGURE 197.-This case illustrates a major facial defect at the time the patient arrived at a general hospital in England. Buccal mucosa to skin suture often is not possible in the extensive cheek defects. All efforts should be bent toward promoting bony replacement and union, in controlling sepsis, and in maintaining the patient's nutritional state. This type of patient is one requiring extensive nursing care and oral hygiene. Reparative or reconstructive surgery is not feasible at an early date. It is possible that an occasional wound of this nature might be speeded in healing by an early free skin graft, although occasions when this procedure could be used are not frequent.
reason it was frequently impractical because of other priority casualties or because of other associated more severe injuries. The condition resulted in very disfiguring scarring and "tattooing," and, when possible, complete early care was administered.
Summary - The concept that certain types of injuries could best be managed by triage and evacuation to specialty centers in the communications zone was amply verified during World War II. The time and effort expended in establishing plastic and maxillofacial centers certainly proved to be justified. The same could be said for the specialties of neurosurgery and thoracic surgery. So far as facial reconstruction was concerned, it was of the greatest importance that proper judgment be exercised in determining just what and how much should be done in a communications zone. The policy of providing skeletal replacement and stabilization plus soft-tissue healing in as good an anatomical position as possible was a sound one. Such a policy made it possible to evacuate the casualties to the plastic surgery centers in the Zone of Interior in the best possible condition for final definitive surgical correction. The advent of the chemotherapeutic drugs and antibiotics had a profound impact upon the successful management of maxillofacial casualties as well as of all others.
By direction of the Chief Surgeon, ETOUSA, the treatment of burns that might require skin-grafting was made the responsibility of the Senior Consultant in Plastic Surgery. In view of the fact that so many burn casualties were expected to fall into this category, the Chief Surgeon and Col. Elliott C. Cutler, MC, Chief Consultant in Surgery, ETOUSA, asked the Senior Consultant in Plastic Surgery to formulate the policies for the treatment and evacuation of all burn casualties. At the time Colonel Brown, the first Senior Consultant in Plastic Surgery, ETOUSA, and this author arrived overseas in July 1942, there was still considerable debate within the National Research Council and the Surgeon General's Office over the problem of "closed" and "open" treatment of burns. At this time, "closed" and "open" methods referred to treatment by eschar-forming protein precipitants such as tannic acid, and non-eschar-forming dressings such as bland ointment or plain gauze.
Since Colonel Brown had always been an advocate of open methods oftreatment, there was never any question in the European theater about whichwould be used. At the outbreak of the war, the use of tannic acid for thesurface treatment of burns was still the official policy of the Army. By late1942, this policy was changed by directives from the Surgeon General'sOffice, and 5 percent sulfadiazine in a water soluble cream base was advised.Tannic acid was taken off the tables of supply, and 5-percent-sulfadiazinecream was inserted. Early in 1943, the Cocoanut Grove disaster occurred inBoston and the voluminous writing following the treatment and study ofthese burn casualties, along with further studies by the National ResearchCouncil, led to the withdrawal of sulfadiazine for local treatment of burns bythe Office of The Surgeon General because of the danger of toxic absorption ofthe drug from the burn surface. These various occurrences ledto complete confusion in the minds of the individual medical officers who were to havethe responsibility of treating burn casualties under combat conditions. Studiesemanating from treatment of the Cocoanut Grove firecasualties led to the widespread belief that not only should treatment of theburn surface be restricted to the application of a bland ointment but anypreliminary cleansing and debridement of the burn could be dispensed with.
The Senior Consultant in Plastic Surgery disagreed with both of theseconcepts in the treatment of war burns. A program was then instituted in theEuropean theater to brief all incoming medical units concerning a standardizedmethod of treating burns and to insure that each hospital unithad a well-defined plan of admitting, sorting, and treating thesecasualties if they should arrive in large numbers. In all planning at thattime, thought had to be given to the possibility of mass civilian as well asmilitary casualties. It was believed to be possible that many civiliancasualties might result from enemy bombing, as in the Battle ofBritain. It was believed mandatory that some semblance of standardization oftreatment of burn casualties be established. This was not accomplishedwithout some difficulty. Many first
aid kits, particularly those kits supplied to the armored divisions, werestill arriving in the theater containing tannic acid jelly. It was also ofinterest that, during the height of this educational program, a prominentvisiting surgeon from the United States gave several very important lecturesin which he not only deprecated the use of local antibacterial agentsand of local cleansing and debridement but also created doubt and confusionconcerning the efficacy of plasma replacement therapy in resuscitation. Withthe endorsement of Colonel Cutler, Senior Consultant in Surgery, and GeneralHawley, the Chief Surgeon, the policy was established in the European theaterthat burns would be treated by gentle and careful debridement and cleansing when possible,and the burn surface would be covered with a thin layer offine-mesh gauze impregnated with 5-percent-sulfadiazine cream over which wouldbe placed a pressure dressing. The policies concerning the treatmentof burns, as crystallized in the Manual of Therapy, ETOUSA, appear inappendix G (p. 993) of this volume.
An interesting facet of this story was precipitated by the withdrawal fromthe tables of supply of the 5-percent-sulfadiazine cream by direction of theOffice of The Surgeon General and upon the advice of the NationalResearch Council. Again, with the backing of the senior medical officers ofthe European theater, it remained the policy that sulfadiazine cream wouldbe used, and an attempt was made to procure the drug from localBritish sources. Unfortunately, the British could not produce sulfadiazine in adequatequantities at that time. A substantial quantity of sulfadiazinepowder was therefore ordered from the United States, and arrangements weremade for its incorporation in a cream base by British drug firms. However, whenthe sulfadiazine powder arrived (almost 2 years later) itwas well past D-day, and the matter of local chemotherapy in the treatmentof burns had faded into insignificance with the advent of unexpectedlyadequate supplies of penicillin. It was suggested by the SeniorConsultant in Plastic Surgery that the sulfadiazine powder residing in awarehouse in London be turned over to the British on reverse lend-lease. Twoweeks after this was accomplished, the Eighth Air Force had traced this supplyof the drug and requested it for use on their bomber crew personnel as aprophylactic to reduce the incidence of upper respiratory infections andotitis media which were exacting such a toll from the crew members. Whatbecame of the ton of sulfadiazine powder is not known, but this consultant wasimmensely relieved to have heard no more about it.
In retrospect, the advocacy of 5-percent-sulfadiazine cream in fine-mesh gauze for the treatment of all burns was probably poorly advised. It was used extensively during the early part of the war and, so far as this author is aware, there were no deaths directly attributable to overdosage from absorption of the drug from the burned surface. However, it was recognized that this danger did exist. There is no doubt in this author's mind that this was an effective way of controlling infection of the burned surface in the early postburn period. However, when penicillin became available in adequate amounts, it was quite logical to dispense with local chemotherapy and whatever hazard it may have
entailed. It was this consultant's strong clinicalimpression that sulfadiazine cream was most effectively used in the treatmentof hand burns. Here, there was no danger of overabsorption, and surfaceinfection seemed to be better controlled than by other methods. It isunfortunate that there were no reliable controlled studies made on thissubject.
Etiology.-Accidents accounted for a large portion oftheburn casualties, and, as might be expected, they occurred most frequently in thewintertime. Command directives were issued forbidding the use of gasoline and other flammablematerials for starting fires, for cleaning clothes, and for cleaning garage floors.In spite of theseefforts, high octane gasoline continued to be used for such purposes, and some ofthe most severe burns occurred as a result. Because of the experiences of the British duringthe Battle of Britain, a high incidenceof burns from the Eighth Air Force was expected. However, burn casualties fromthis source were never received in the numbers anticipated. It wasbelieved that the low incidence of Air Force burns in the earlydays resulted from the fact that active air combat was carried out onlyacross the Channel. Fighter pilots fell in France or Germany; and bombercrews most likely to have been subjected to burns did not get back to thebases in England. Burns from the Air Force as a result of active combat werelimited almost completely to those received during takeoff and landing accidentsin England. After the liberation of prisoners at the end of the war,a large number of the Air Force casualties were found to havesuffered from burns and had been treated in enemy prisoner-of-war hospitals.
The landing on the shores of Normandy did not produce thelarge number of burns that might have been expected from closelypacked troops in flammable vessels landing on a hostile shore. The incidenceof burn casualties increased after the breakthrough at Saint-L? when troopspractically lived in traveling tanks and armored vehicles. These vehiclesalmost invariably burned upon being hit, and, in the case of the tanks which werehard to get out of, the resulting burns among the crew werevery severe. Flash burns from bazooka fire were occasionally seen but were notcommon. Burns from white phosphorus and chemicals were comparatively rare.An unexpected and not infrequent type of burn was that occurring inparatroopers when they struck high tension wires during descent, withresulting limited but deep electrical burns.
An estimated 90 percent of all burns involved only thehands and face. A majority of the hand and face burns were superficial andcould have been completely eliminated by the slightest degree of protection. In spite of continued efforts, it was impossible to get air force personnel towear gloves as a precautionary measure against burns. The attitude of theyoung flier was that, while flying in combat, protection against burns was theleast of his worries. He would not hamper himself by wearing gloves, nor wouldhe consider any face protection that would restrict motion or limit the field ofvision. Essentially the same philosophy was characteristic of the tankcrewmen. Ordinary clothing was adequate protection against flash burns elsewhereon the body.
Evacuation hospital - During combat, the evacuation hospitalprovided the first opportunity for the effective treatment of burn casualties.For resuscitation, reliance was placed on plasma and on saline and glucosesolutions in adequate amounts. After resuscitation, the burn casualty was takento the operating room and the burn surface was cleansed of dirt, clothing, andhanging devitalized skin. The dirt and filth that covered many of these woundsmade it seem inadvisable to apply dressings without some effort at cleansingand debridement. Frequently, a mild soap or detergent was used gently on theburn if the condition of the patient permitted it. A good many burns were oflimited surface extent and were not associated with other injuries. Underthese circumstances, a meticulous debridement and cleansing seemed advisable.Burn surfaces were covered with 5-percent-sulfadiazine cream,petrolatum-impregnated gauze, or boric acid ointment gauze, and a pressuredressing was applied. Often, plaster splints would be added for immobilization.The casualty was then held, and resuscitation therapy was continued until his condition was considered satisfactory for evacuation. Patients with severeburns traveled poorly and often had to be held for several days before theycould be safely moved. Evacuation was through regular channels by hospital trainor air.
General hospital - Upon reaching the communicationszone, the bad burns were transported to hospitals designated for their carewithin a hospital center. In the United Kingdom Base Section, there were alwayshospitals that had been designated for plastic and maxillofacial surgery andhad been prepared with adequate physical facilities for the management ofcomplicated burn casualties. The plastic surgeon and his team in these hospitalsworked with members of the general surgical service and medical service inpreparing the burn casualties for the necessary skin-grafting operations. The10 specialty hospitals in England treated the great majority of burncasualties occurring in the European theater, and the standard ofprofessional management was uniformly high. The casualties were caredfor by nurses, orderlies, and medical officers with a special and detailedappreciation of their needs. Saline bath units had been provided in eightof the specialty hospitals in England, and they were used extensively to makethe changes of dressing as painless as possible and to promote hygiene of thewound (fig. 198). During the period of preparation of the wound for grafting,the general care of the patient was of utmost importance. His feedingand his state of morale were factors demanding constant attention. Corpsmenplaced in charge of these patients were often combat soldiers on limited dutyafter having been burned in combat and having gone through treatmentsimilar to that which they were now overseeing. The morale factor provided bythese corpsmen as well as the enormous physical effort they expended in caring forthe casualties in these burn centers was tremendous andcannot be acknowledged adequately. During the heaviest phase of the war, theburn centers were uniformly filled to capacity, and several
FIGURE 198.-There were 10 burn centers in England, scattered from the south coast to Liverpool and Nottingham. These centers proved invaluable for the accumulation of severe burn casualties requiring prolonged dressings and grafting. Large porcelain tubs for saline baths were provided in these centers and were used practically around the clock for the changing of dressings, debridement, exercise of extremities, and so on. The personnel of these centers, in addition to the doctors and nurses, consisted of corpsmen, many of whom were combat soldiers who themselves had suffered from burns. These men were trained to handle the patients in the baths and to do the debridement and dressings, and they proved to be ideal for the job.
of them worked on a 24-hour basis in keeping up with theresuscitation, dressing, debridement, saline tubing, and skin-grafting of thesebadly injured soldiers.
The saline bath units consisted of from one to four largetubs placed in rooms provided with adequate heat in the hospital selected anddesignated for the handling of burn cases. Some of these hospitals wereselected before and during construction, and the burn units were incorporated inthe hospital plan. In other completed hospital plants, or in those takenover from the British, an existing ward was modified and the saline bath unitswere added. The tubs were obtained from a firm in Scotland and were large and ofcast iron with a thick, high-grade porcelain that would permit satisfactorycleansing and sterilization. The units were used during the late stages oftreatment of burns and were considered particularly necessary for those burnsinvolving the trunk, buttocks, and lower extremities. The first burn dressing inthe general hospital was usually done in the operating room under light generalanesthesia. This first dressing was usually from 2 to 6 days, or longer, afterthe initial application of the dressing in an evacuation hospital. Subsequentdressings were usually done in the saline bath units, at which time debridementof sloughing, devitalized tissue could be done most advantageously. Thisprocedure greatly decreased the pain of dressings and facilitated the rapidhealing of the wound surface and its preparation for grafting if this wasgoing to be necessary. The bathrooms were supervised by medical officers andnurses.
Much of the actual work was done by corpsmen who weretrained to do the dressing, cleansing, and debridement of wounds and thefilling, emptying, and cleaning of the tubs. These were the enlisted men, a goodmany of whom had suffered severe burns themselves and had been throughone of the treatment centers. The possibility of cross infection receivedcareful study and consideration. Casualties with active hemolytic streptococcalinfections were either not subjected to saline baths or were submitted to theprocedure in a bath reserved for their use. Other organisms presented nodifficulty from cross infection if the tubs were properly cleansed.Cleansing of the tubs was done with hot water and soap, followed by anantiseptic detergent. Cetyltrimethylammonium bromide, a British preparation, wasthe detergent most frequently used. This detergent was also found to be verygood for the primary cleansing of the burned surfaces and for thesubsequent cleansing of the wound and the surrounding skin. Submission ofpatients to saline baths had to be done with some caution. Reactions werenot uncommon, and occasionally a sick patient had to have the bathsdiscontinued. An effort was made to keep the temperature constant at about 105?F. and to keep the degree of salinity at normal by manual manipulation of theinflow of water and the addition of salt. It was not believed to be of greatimportance that these factors be absolutely controlled so long as the patientwas comfortable and the solution was not allowed to become hypertonic. The bathsoffered an excellent opportunity for exercise of muscles and joints, and, with theminimum of effort,
it was possible to prevent the marked deformities that sooften have a tendency to occur before skin-grafting can be done. The baths werea very great factor in maintaining the morale of the patient, particularly ifthe patient had been unfortunate enough to have undergone a series of changes of dressingswithout baths before admission to the specialty hospital.
With the professional talent available and the physicalfacilities provided, it seemed advisable to establish the policy that all burns would beheld until they were healed or grafted. These same intensiveefforts that were aimed at getting the burn wound ready for grafting wereequally effective in promoting healing. Care had to be exercised not to graftunnecessarily. It was to the credit of the medical officers takingcare of these patients that hundreds of them were successfully grafted at anearly date with resultant restriction in disability and loss of function.Immediate burn excision and grafting was not practiced except in an occasionalcase of electrical burn. The general practice was that of repeated debridementand dressings until the wound was clean enough for graft. If,by that time, the remaining third-degree loss was great enough and appearedto warrant it, a split graft was applied. The advent of penicillin to helpcontrol infection contributed greatly to the success of early grafting. Themanually operated Padgett dermatome was available in the theater but wasnot an unmixed blessing. Good blades were available for those surgeons capable of cutting freehand grafts. So-called stamp grafts and pinchgrafts were used occasionally in special situations.
Burns of various parts of the body presented differentproblems, but two areas in particular warrant special comment.Eyelid burns were very frequently observed. If these were severe enough, the problem ofmanagement in a communications zone hospital inpreparation for evacuation to the Zone of Interior was a very trying one. The concernwas primarily one of protection of the globe and preservation of sight.Almost invariably, patients with severe eyelid burns would have severe burns of thehands and could not be depended upon to takecare of themselves during evacuation. In those cases in which lid eversion made itevident that the cornea was endangered, it seemed advisable to make some effort todecrease the danger by promoting lid adhesions or by grafting the lids (fig. 199). Adecisionas to just what to do for an individual casualty was frequently very difficult. It isbeyond the scope of this presentation to go into this matter in detail. Suffice itto say, grafting of lids should not be done in a theater of operations if it can be avoided withoutendangering the cornea (fig. 200). It can be said also that the promotionof lid adhesions is not an entirely effective method of protecting thecornea since, in the severely burned lid, the contracting force isgreat enough to cause the adhesions to stretch and reexpose the cornea toulceration (fig. 201). The situation is one demanding the most stringentnursing care and the closest collaboration between ophthalmologist and plastic surgeon.
FIGURE 199.-This case illustrates ectropion from burns and is the type of case which, it is believed, urgently required correction by grafting before evacuation from the theater of operations. The danger of resulting corneal ulceration was considered to be too great to allow such patients to go through the chain of evacuation without being able to close their eyes. This case illustrates an extreme situation in which an early graft was done with very acceptable results. (Case of Maj. Dean W. Tanner, MC, 158th General Hospital.)
FIGURE 200.-This case is an excellent example of a needlessly applied eyelid graft. Obviously, there would have been no ectropion if the lids had been left to heal spontaneously. It was sometimes extremely difficult to determine whether grafting was indicated or not. Usually, if there was any question about it, it was better to postpone the procedure until it could be done by competent plastic surgeons in the Zone of Interior.
FIGURE 201.-Illustration of the futility of controlling lid contraction after burns by formation of interpalpebral adhesions. If adhesions appeared effective they were not necessary. Where protection was most needed because of contraction, the adhesions usually stretched and required protection did not result. This patient probably required grafting before evacuation. A satisfactory result was obtained. A and B. Views of eyelids, with eyes open and closed, before grafting.
Burns of hands were obviously of very great importance fromboth the numerical and functional standpoint. It was with hand burns that theprevention of edema and early control of infection were found to be of suchgreat practical value, since the ultimate loss of full thickness of skin wasas dependent on these factors as on the initial thermal injury. A burnedhand allowed to develop uncontrolled edema not only resulted inembarrassing the circulation of the tightly stretched skin of the dorsum butmade this skin more susceptible to infection. In this way, large areas of skin that were not destroyed by the initial thermal injury could be convertedinto third-degree burns. Therefore, it was the aim to make hands surgicallyclean as early as possible and to control edema by effective pressuredressings and elevation. The position of the hand and fingers during this periodof immobilization was, of course, considered to be of great importance. Theinitial hand dressing was left on for from 6 to 8 days, following whichexercise of the hand in saline baths and careful daily debridement was started. From thistime on, supervised active exercise was emphasizedin maintaining flexibility of the joint capsules. The burn was made clean anddebrided of eschar as rapidly as possible. When the hand was clean enoughfor graft, it was carefully evaluated to determine whether the overall functionof the hand could be more benefited by grafting with its attendant period ofimmobilization, or by continued exercises while spontaneous healingprogressed (figs. 202 and 203). A decision was made upon themerit of each individual case, with the realization that preservation offunction depended upon early grafting when it was really necessary but thatfunction could be lost by unnecessary grafting and its associated period ofimmobilization.
Summary.-During the buildup phase before the invasionof Normandy, this author had rather grandiose plans for detailed study of burncasualties. He was even successful in having the Chief Surgeon's Officeapprove certain directives and statistical forms and charts which he hoped toaccumulate by the thousands and from which it was anticipated valuableinformation might be secured. Needless to say, from D-day until theend of the war, this type of research was out of the question and allefforts were simply bent toward adequate care of the injured and themaintenance of lines of medical evacuation. The author had a feeling of guiltthat more positive information did not result from this tremendous experience. Atthe same time, he had a feeling of admiration and respect for the medical officers who performed the terrific task oftaking care of theburn casualties in the various centers. In retrospect, it can be statedwithout equivocation that the establishment of the burn centers was goodplanningand paid off tremendously in the results which were achieved. Regardless oflater concepts of burn treatment and cross infection, the saline baths,as used, were effective in the handling of mass casualties during
World War II, and the writer would still want such facilities.The European theater was well supplied with highlyqualified personnel and, after combat began, they were utilized to thevery highest degree possible. Some perfectly superb work was done by variousmedical officers in the management of burn casualties, particularly in themanagement of the severely burned hands, and it is to be regretted that thepatients involved were not subsequently followed and the results ofthis experience properly recorded. For those readers who may wish to becritical, the foregoing account is admitted to be an extremely superficialexposition of the management of this important type of casualty during World WarII in the European theater.
Wounds Other Than Head Wounds
If one examines the medical history of World WarI, it will be found that the possibility of delayed primary and secondaryclosure of wounds was recognized and practiced to a limited extent near thetermination of that conflict. However, the chief impression left by the FirstWorld War was that wounds should be debrided and left openfor secondary healing. This impression was strengthened by the interveningexperience of the Spanish Civil War and the widely publicized plasterimmobilization of wounds after debridement. The wounds treated by this manner werethose of the extremities, and afteradequate debridement the wound was dressed open, usually withpetrolatum-impregnatedgauze pack, and a plaster encasement dressing was applied. The plaster was notchanged for many days. The wounds did well and, if debridement had beenadequate, usually at the time of first inspectionof the wound the base was found to be covered by healthy granulations and there was no evidenceof invasive infection. Thetransportation of casualties was simplified by this procedure as was the nursing care.The disabling effects of prolonged immobilization and healingby secondary intention were minimized.
World War II was entered not only with thebackground of knowledge from World War I and the Spanish Civil War, but alsowith more of an appreciation of the methods whereby function of anextremity could be preserved after a severe wound. Furthermore, the day of the wonder drugshad arrived and the sulfonamides and antibiotics were readyfor exploitation. Another factor of very great importance was that surgeonsinterested in reconstructive and plastic surgery had been demonstrating for the pastseveral years what could be accomplished with various types ofgrafts in the healing of wounds, and the importance of healing extensive burn wounds by early grafts was generallyrecognized. It was natural that these background factors led immediately to a more aggressivemethod of war wound management as soon as the medical officers had an opportunity tostart taking care of casualties.
FIGURE 202.-This case ideally illustrates the principle of active motion and early grafting for the burned hand. Active motion can only be accomplished with all dressings removed. It was found to be most easily accomplished with the patient reclining in a saline bath so that the hands could be held in elevation and submerged at intervals as the exercise progressed. Smaller arm saline baths proved to be more practical when the burn was limited to the hand and arm.
FIGURE 202.-Continued. The left hand, in the case illustrated, shows extensive persistent deep epithelial islands surrounding small areas of third-degree skin loss. This type of hand should not be grafted; instead, motion should be maintained and spontaneous healing encouraged. If grafting is indicated, eventually it may be done as a late, clean definitive operation. The right hand in this case obviously presents a deep third-degree burn with sloughing tissue and is the type of burn that should be grafted at the earliest possible date. The result of early grafting of the right hand in this patient was excellent. Some of the grafts were placed over small areas of exposed tendon. This type of work had to be done in the theater of operations. If the patient had been returned to the Zone of Interior, in spite of air evacuation, 1 or 2 weeks' time would have been lost before graft could be applied. (Case of Maj. Dean W. Tanner, MC, 158th General Hospital.)
Early in 1943, this consultant was attached to the 298th GeneralHospital from the University of Michigan MedicalSchool which was stationed just outside Bristol, England. Shortly after hejoined the hospital, it was filled with a boatload of casualties from the NorthAfrican invasion. These patients had received what amounted to evacuationhospital care and arrived in England 2 or 3 weeks after having been injured. A remarkableopportunity was provided to study war woundsof varied extent and to crystallize opinions
FIGURE 203.-This case illustrates the result that can be obtained by early radical graft to the dorsum of severely burned hands. The entire dorsum of each hand has been covered by an early graft. The flexibility and motion of the fingers are a direct result of the early application of skin covering. (Case of Maj. Byron C. Smith, MC, 1st General Hospital.)
regarding their treatment. It was perfectly obvious that the provision of early healing by secondary closure would limit scarring,fibrosis, edema, and disability. It was also perfectly obvious that the sameresults could be achieved with much larger and more extensive wounds,not amenable to secondary closure, by healing the wound with split graft. Manysuch wounds were grafted very soon after the patients arrived in the hospital.The results of these procedures were most gratifying. The plasticsurgery service at the 298th General Hospital pushed theprinciples of early closure and grafting. This principle was extendedsubsequently to include pedicle grafting for compound injuries with exposedjoints, tendon, and bone. At the first ETOUSA Medical Society meeting held atthe 298th General Hospital in June 1943, theresults of an extensive grafting and secondary closure of war wounds weredemonstrated, and it was predicted that such surgical procedures wouldplay a very great role in the treatment of war casualties to be expected whenthe Continent was invaded. The conception of excluding infection from thebody by making the body surface intact was promulgated. Just exactly whenand on what type of casualties this conception could be successfullypracticed was not completely realized at that time. Early in 1943, a soldierwas admitted to the 298th General Hospital after receiving an accidentalexplosive wound of the hand with exposure of bone and tendon. This man wassuccessfully treated with an immediate undelayed pedicle graft 24 hoursfollowing his injury. In the light of this success and of the experience gainedin treating casualties from North Africa, it was believed that secondary closureand free and pedicle grafting would be possible ofapplication to war casualties on a large scale during the approaching invasion.The plastic surgery centers throughout England were set up with this as one of the important functions in mind. It later proved to be a verymajor portion of the work done in these hospitals.
The wounds under discussion were almost all confined tothe extremities. A few of them were wounds of the shoulders and buttocks(fig. 204). They were the result of small arms fire or shell fragments which had been treated bydebridement at the evacuation hospital level. Thecondition which had to be treated at the general hospital could be considered as due tothe primary missile wound and its resultant necessary debridement. When receivedin the general hospital, these wounds varied in age from 3 days to 2 weeks. Many ofthem were associated with compound fractures. Since secondary closure of suchwounds can be considered as a general surgical procedure, the subject is not discussed indetail in this presentation. However, the role played by the plastic surgerycenters in the treatment of the complicated soft tissue and extremity woundsis briefly outlined.
FIGURE 204.-This case illustrates the possibility of secondary closure of large, soft-tissue defects by extensive undermining and direct wound approximation. It was important that a proper balance be maintained between the possibility of closure by this method and the need for tissue surface replacement in the form of a free graft. (Case of Lt. Col. Thomas O. Otto, MC, 305th Station Hospital.)
Free skin grafts.-The type of wounds most frequentlysuitable for healing by the use of free grafts was those which presentedextensive loss of skin with exposed muscle or fascia which could be expectedto take a graft. If bone or tendon presented themselves within the depth of thewound, free graft was usually unsuitable, a pediclegraft being indicated if simple secondary closure was impossible. Woundssuitable for free graft were usually confined to the massive fleshy part ofthe extremities or of the trunk (fig. 205). Extensive wounds of the feet,ankles, lower leg, knee, and corresponding areas in the upper extremityusually required covering by use of the pedicle graft.
The wound was prepared for free skin graft in essentially thesame manner that it was prepared for secondary closure. It was necessary that it be free of sloughing tissue and free of localizedcollections of pus. It was not necessary to wait until a granulation tissue bedhad developed. It was found that a free graft could be applied satisfactorilyat any time interval after debridement, provided the wound fulfilled thequalifications of being free of sloughing tissue and growth of surfaceorganism. Repeated debridement and wet dressings played an important rolein the preparation of the "dirty" wound. Dakin's solution wasvery prominent by its almost complete absence from the surgical armamentarium.
FIGURE 205.-The extensive disability that would have resulted from secondary healing of this wound is obvious. The postoperative illustration shows the admirable result obtained by closure of the large defect by mobilizing the skin edges and by free skin-grafting that portion of the wound which could not be closed. (Case of Maj. Douglas W. Macomber, MC, 91st General Hospital.)
The free grafts were applied in a fairly standardized manner which usuallyinvolved immobilization of the extremity and some type ofpressure dressing. It was of some importance that proper judgment beexercised and that insignificant wounds not be grafted. Many woundswhich appeared almost certainly to need a graft were found to be not worthy of agraft by the time they were clean enough for this procedure. Needless tosay, a few instances were seen in which a small wound had been successfullygrafted but the soldier remained disabled as a result of an unhealed donorarea. It has been mentioned previously that the dermatome was not an unmixed blessing.
Pedicle grafts - The wounds suitable for covering by useof a pedicle graft were those of the extremities in which importantstructures (bone, tendon, and nerve) are normally covered by a relatively thin layer of superficial tissue andskin. This situation exists in thefeet, ankles, anterior portion of the lower legs, knees, hands, wrists,forearms, and elbows. These are all vitally important functional areas. Agood many wounds involving these parts were of the avulsed type which, following adequatedebridement, presented exposed bone and tendon andoften open joints, impossible of closure by any other means than the use of apedicle graft. If these important exposed structures were to be preserved, the pedicle graft must be applied at an early date.This was considered to beone condition in which a definitive plastic surgery procedure in a theaterof operations was urgently indicated. If the procedure was postponeduntil the casualty arrived in the Zone of Interior, important function andstructures would be lost. The recognition of the need for the procedure ofpedicle grafting and its effective application in a theater of operations was a new development in war surgery. By effective application it ismeant that the conditions requiring pedicle grafts were widely recognized andthe casualties were accumulated into plastic surgery centers where theprocedure could be properly controlled and well done. There were recorded 700pedicle grafts of this nature, done in the plastic surgery centers in Englandalone. During the tour of the Senior Consultant in Plastic Surgery through the plastic surgery centers in the Zone of Interior in March of 1945,theevaluation of the procedure of pedicle graft by the Zone of Interior'ssurgeons was carefully sought. It was found to be held in very highregard and to be considered in many cases to have greatly simplified laterreconstructive procedures.
The preparation of the wound for pedicle graft differed slightly from the preparation of a wound for secondary closure, or forcovering by skin graft, in that it did not have to be nearly so complete. All gross sloughing tissue obviously needed to be removed. However, thecovering of a wound by tissue
which was viable, and which did not have to rely forcontinued viability on nourishment from the wound itself, offeredpossibilities which had never been exploited to the fullest. Not only was this coveringself-sustaining in that it carried nourishing bloodsupply, but it served as a viable vascular dressing for the surface of the woundwhere it could actually contribute to the natural processes of overcominginfection and healing. It wasfelt that pedicle grafting to accomplish secondary covering of the woundwas even more physiologically sound than was secondary closure in that there wasno embarrassment of the circulation of the wound margin by tension or deep sutures,and the wound, always a contaminated one, was not closed in the true sense ofthe word, since completedrainage was afforded the entire wound through the wide margin to which the graft wasnot sutured.
Since the only reason for holding a casualty long enough in a theater ofoperations for the application of a pediclegraft was the early performance of the procedure to preserve function, thetechnique had to be developed for this purpose. If the peculiaritiesof the case were such that the graft could not be applied to the woundfor 2 or 3 weeks or longer, there was no point in holding the patient in theEuropean theater for the procedure. It waspresumed that the medical organization in the Zone of Interior would be able toaccomplish the procedure within that period of time.If the case was such that important structures and function would not be lost if atemporary free skin graft was applied, it was better that the free graft be doneand the patient be evacuated to the Zone of Interior. The procedure was, therefore, reserved forthose cases in which the graft could be applied without delay and in which earlyapplication was mandatory. The technique of application of the pediclegraft was consequently modified in order that it might be extended toas large a number of cases falling into this category as possible.
The great majority of pedicle grafts were done as directundelayed flap grafts, elevated and attached to the recipient area at one sitting.The direct abdominal wall (fig. 206) and thoracic(figs. 207 and 208) flap grafts were the simplest to use. In the beginning, direct graftsfrom the lower leg were done with some trepidation. As experience and ingenuityincreased, it was discovered that there were few wounds from the knee down that couldnot be coveredwith a direct graft from the other leg. It can be stated that the direct crossed leg pedicle grafts proved to bemuch better than attempts toclose lower leg defects by the use of local rotation flaps. When the defectrequired coverage by skin and subcutaneous tissue, the results of pediclegrafts early in the war surpassed those of local methods of closure and the latter were discarded.
FIGURE 206.-This case is an ideal illustration of the type of injury in which pedicle grafting should be done without delay. All flexor tendons were exposed. The soldier was wounded on 6 September 1944. Eight days later, the wound was completely covered by an abdominal pedicle graft. The last photograph shows the arm 6 weeks following injury. The value of an early pedicle graft in an injury such as this cannot be exaggerated.
FIGURE 206.-Continued. It was estimated at the time of discharge of this soldier that he would get about 85 percent return of function of the hand. Without the pedicle graft, there would have been complete loss of function. (Case of Capt. William W. L. Glenn, MC, and Lt. Col. Eugene M. Bricker, MC, 22d General Hospital.)
FIGURE 207.-This case illustrates the end result of replacement of a large soft-tissue loss of the upper arm by use of an undelayed pedicle graft from the chest wall. In planning all undelayed flat grafts, the size and position of the base is obviously of very great importance. The size of the base in this case demonstrates the extreme which sometimes may be necessary if a graft is to be successful. (Case of Maj. Clifford LaV. Kiehn, MC, 117th General Hospital.)
One factor that accounted for the use of the lower leg so frequently as a means of accomplishing crossed leg pedicle grafts was that many of these wounds were complicated by associated fractures (fig. 209). It was a frequent occurrence that a pedicle graft might be urgently needed, but its application was almost impossible because of an accompanying fracture. A great deal of ingenuity was exercised in solving these problems. In some cases, it was justifiable to consider applications ofthe graft as being more important than primary consideration of the fracture. Properly applied plaster splints could sometimes be made to hold the fracture in position during application of the graft. The use of Anderson splints was resurrected to help solve these problems, and they were found to be of distinct value in some cases for maintenance of position during the period of preparation of the wound and application of the graft
(fig. 210). The splint was left in place only until thegraft was completed, a matter of 3 or 4 weeks, after which it was removed andthe generally accepted methods of treating fractures were institutedfrom this point on.
Very few delayed flap grafts were done. Obviously, if delaywas necessary, the job might just as well be done in the Zone of Interior. However,there were a few instances in which the procedure could besimplified and the certainty of a satisfactory outcome increased by delaying the pediclegraft. This would often be done while the wound was being prepared toreceive the graft.
Tubed pedicle grafts were found to have very littleapplication in solving the needs of early grafting in a theater of operations. Evenwhen the time element was of no importance, tubing of the graft was considered to be asuperfluous procedure.
Pedicle grafting was not used for facial reconstruction inthe communications zone. It was felt that this was a procedure better done inthe plastic surgery centers in the Zone of Interior.
Summary.-The opportunity of using pedicle grafts inthe treatment of complicated war wounds on such a scale as was done in theEuropean theater was a unique experience. There is no doubt that itserved a great purpose in the preservation of function in manyextremities.
Treatment of Hand Injuries
Plastic surgeons had long been interested in the problemspresented by the injured hand. Long before the invasion of Normandy, burnedhands and the severe wounds of hands received accidentally in combat training wererecognized as acute problems.After the Normandy invasion, it was discovered early that hands were going to forman unexpectedly high percentage of casualties andthat the principles involved in treating hand injuries were not generallyrecognized. The plastic surgeons were then interested primarily in replacing thesoft-tissue loss in the avulsed type of injury (figs. 211 and 212). This hadbeen practiced as an early procedurepreviously at the 298th General Hospital in England. This problem having beenrecognized, cases were searched for throughout the hospital centers in Englandand those requiring pedicle grafts were transferred to the hospitals designated forplastic surgery. This accumulation of the severely injured hands in the plasticsurgery hospitals led to the logical conclusion that the best method forhandling all hand injuries was to place them in special services underinterested, qualified personnel.
On 4 September 1944, a memorandum on the subject ofdevelopment of hand centers (app. H, p. 999) was submitted to the ChiefConsultant in Surgery and referred to handcenters in both the communications zone and the Zone of
FIGURE 208.-A complicated compound fracture with extensive loss of overlying tissue is converted into a simple fracture by the use of an undelayed pedicle graft. It was found that these grafts could be applied to wounds that far from fulfilled our original concept of how a wound should appear before a graft could be applied.
FIGURE 208.-Continued. A vascular type of graft cannot be compared with a free graft that depends on the wound for its own sustenance. A well-planned pedicle graft is a viable vascular dressing that can be considered as carrying sustenance to a wound. (Case of Maj. Clifford LaV. Kiehn, MC, 117th General Hospital.)
FIGURE 209.-This soldier was wounded by machinegun fire on 5 August 1944 in France. He was evacuated to a hospital center in England where a split graft was attempted on 8 October. It was not until 21 October that the patient was transferred to a plastic surgery center and the pedicle graft applied.
FIGURE 210.-This case illustrates the technique of immediate undelayed cross leg pedicle graft covering a compound defect of the tibia. The Anderson splint was occasionally used in these complicated cases. The splint was dispensed with as soon as a graft was applied. Large, undelayed flap grafts such as that illustrated were possible. The fact that the leg grafts were done with such a low incidence of failures was undoubtedly due, in large part, to the youth of the patients. (Case of Lt. Col. Malvin F. White, MC, 129th General Hospital.)
Interior. Following this, hand centers were developed both inEngland and on the Continent. It was the aim to have each center under thesupervision of both a qualified orthopedic surgeon and a plastic surgeon. Withthe cooperation of Col. Mather Cleveland, MC,1Senior Consultant in Orthopedic Surgery, most of the hand centers were locatedin the hospitals designated for plastic surgery. Although this was a verydefinite step forward, it by no means solved the problem of adequate care forhand injuries.
With the start that was made, it is believed that, had the warprogressed, the organization would have resulted in a standard of care for handinjuries never before equaled. Unfortunately, this state of affairs was far frombeing reached by the end of the war. The difficulty resided in the fact that theplastic and orthopedic surgeons themselves had much to learn, and the respectiveconsultants were slow in recognizing the need for fundamental changes in overallpolicies. The surgeons in the hand centers believed at an early stage that theyhad reached an impasse because they were not receiving the casualties earlyenough after the injury. This led to the idea that possibly more definitivesurgery should be done at the evacuation hospital level. The standard of care atthe evacuation hospital level previously had not been high. Although it may beunderstandable that the surgeons at the evacuation hospitals were more concernedwith injuries of a more serious nature, it hardly justifies the delegation ofinjured hands to surgeons of the least experience, as was frequently done. InMarch 1945, a directive was issued stating that hand injuries should be closedafter they were debrided in the evacuation hospitals. The results of this policycould never be determined with certainty because the war ended soon after it wasput into effect. It is, indeed, doubtful that much would have been accomplishedby this change in policy.
Hand wounds with such loss of soft tissue that importantunderlying structures were exposed fell into the category of those amenable topedicle grafting. The procedure of pedicle grafting of such wounds had certainshortcomings and limitations, the most notable of which was the unavoidablelimitation of motion and poor position often necessary during application of thepedicle graft. With proper care, these objectionable features could, to a largeextent, be avoided. It was possible to have good position and active motionmaintained during the time the graft was being applied in most, but not all,cases. It took fine judgment to weigh the disadvantages afforded by theseobjectionable features against the need for pedicle graft and to decide whetherthe procedure should or should not be done. This author's views at the time onthe treatment of hand injuries were set forth in a memorandum, dated 5 March1945, to Colonel Cleveland, Senior Consultant in Orthopedic Surgery, ETOUSA,(app. I, p. 1001).
1Cleveland, Mather: Chapter IV, Hand Injuries in the European Theater of Operations. In Medical Department, United States Army. Surgery in World War II. Hand Surgery. Washington: U.S. Government Printing Office, 1955.
FIGURE 211.-The illustration of a large, soft-tissue loss from the dorsum of the hand, associated with underlying bone injury. Such a wound might conceivably be covered by a split graft. However, the possibilities of return of function and subsequent reconstructive surgery are greatly increased if a pedicle graft is used.
Summary -When one considers all the thought andplanning devoted to the preparation for treatment of maxillofacial injuries,burns, and massive soft-tissue injuries, it is surprising that more definitiveplans for the treatment of injured hands were not formulated earlier in thecourse of the war. It was never anticipated that severe hand injuries would formsuch an important segment of the casualty list. It is perfectly obvious that ananatomical structure as delicate and complicated as the hand requires the mostdetailed and skilled care if function is to be maintained. Although the latephase of care of injured hands has been developed to a very fine degree, thereis no doubt that the very early care could be of equal importance in thepreservation of function. Until very late in the war, our overall efficiency inthe early care of hand injuries might be compared to that of a plumber trying toservice a Swiss watch. This should not obscure that fact that there were two orthree surgeons in the European theater who were extremely expert at hand careand who were, to a large extent, responsible for stimulating more interest inthis type of injury.
FIGURE 212.-The provision of surface covering through and beneath which subsequent reconstructive surgery would be possible was of primary importance in the rehabilitation of the injured hand. However, it had to be applied with a proper perspective and with consideration of total hand function. In the case illustrated here, the urgent demand for palm covering in relation to subsequent function is perfectly obvious. (Case of Lt. Col. B. Eugene Boyer, MC, 53d General Hospital.)