Bunnell fostered the development of hand surgery

A specialty was born from his World War II effort of organizing hand surgery centers.

Issue: Issue 5 2003

Few would disagree that Sterling Bunnell, MD, was one of the fathers of the specialty of hand surgery. His creation of a nationwide network of military hand centers, combined with a textbook that was for years regarded as the standard resource on hand surgery and his coordination of some of the first hand fellowships for young surgeons, changed the way the world manages hand and upper extremity injuries.

Sterling Bunnell , MD --- Sterling Bunnell, MD, was the first president of the American Society for Surgery of the Hand, Bunnell created a nationwide network of military hand centers. His influence also spread beyond America’s borders, particularly to Europe and Asia.

Prior to World War I, physicians performed upper extremity and hand surgery in a fragmented manner, usually by surgeons with no specialized training in the area. General surgeons, orthopaedists, neurosurgeons and the early plastic surgeons would be called in one by one to treat the upper extremity injury — orthopaedists for bone, neurosurgeons for nerve tissue and general or plastic surgeons for tendon and soft tissues. This division among the duties of hand surgery led to longer treatment times and care that was not directed toward reconstruction but stabilization.

The period between World War I and World War II saw the creation of a few publications on hand injuries and infections, but surgical duties for upper extremity injuries remained divided among surgeons.

Genesis of hand surgery

“World War II was the genesis of hand surgery,” said David P. Green, MD, of the Hand Center in San Antonio, U.S.A. “It was because of Sterling Bunnell’s influence that the specialty was established.”

Leading up to World War II, Bunnell was a general surgeon with a strong interest in hand surgery who practiced in his hometown of San Francisco. During World War I, he published his first scientific article, “Repair of tendons in the fingers and description of two new instruments.” Just prior to America’s involvement in World War II, Bunnell finished his seminal work, Surgery of the Hand, which would become the gospel for the upcoming generation of hand surgeons worldwide. At the onset of the United States’ involvement in the war, Bunnell was appointed a special civilian consultant to the U.S. Secretary of War.

According to George E. Omer Jr., MD, U.S. medical officials predicted that upper extremity injuries among U.S. soldiers would number more than 88,000 during the course of World War II, of which 22,000 would be hand injuries in soldiers who would not return to action.

In anticipation of the flood of expected hand injuries back to the United States, Norman Kirk, MD, then the U.S. Army Surgeon General, assigned Bunnell to “guide, integrate and develop the special field of hand surgery.” To do this, Bunnell undertook the task of developing and managing nine regional hand centers across the country, all the while retaining his hand consultant role at Letterman General Hospital in San Francisco.

Claiming there was not enough room for three surgeons to practice at U.S. Army Letterman, Bunnell united colleagues and acquaintances that he knew had an interest in hand surgery coupled with a background of general, orthopaedic and neurosurgery to become the first hand specialists. He trained and placed close to 40 of these selected surgeons as chiefs and staff in the nine hand centers. He also periodically toured the facilities to teach intensive training courses, conduct round table discussions and perform some of the more difficult surgeries.

Profound influence

“The organization of hand surgery care with the military patients during World War II by Dr. Bunnell set up a system that stayed in the U.S. military through [the Vietnam War],” said Omer, professor and chairman in the department of orthopaedics and rehabilitation and chief of the division of hand surgery at the University of New Mexico School of Medicine. “He made it so that one surgeon took care of all hand injuries at the same time. That was a major idea at that time — develop a guy who is skillful enough so he doesn’t have to adhere to the old specialty units.”

James Strickland, MD, of Indianapolis, U.S.A., past president of the American Academy of Orthopaedic Surgeons, said, “Bunnell found surgeons who were competent in the management of all tissues and brought them together in settings where the management of their upper extremity wounds — mostly gunshot and explosive wounds — could be managed in a much more streamlined, effective and beneficial manner.

“His influence on the men that were there was profound, and the sequence of individuals who came after him became the powerhouses of American hand surgery,” he said.

“He was the catalyst,” Green added. “He was the guy that got it all going. Eventually someone would have discovered that these upper extremity injuries were more than orthopaedic, were more than plastic, vascular and neurological, so we need someone who could do it all. However, it was Dr. Bunnell who put it all together.”

Close to home

Although he traveled the world and extensively toured the nation during the war, Bunnell always returned to his home base, San Francisco. He was born there in 1882 and received his undergraduate degree in 1904 from the University of California at San Francisco. From there, he went on to earn a medical degree from the university in 1908.

His skill as a surgeon, coupled with his interest in the anatomy and physiology of the hand, made him well-known and respected prior to his World War II experiences. He published many articles and pioneered surgical protocols, such as the techniques for tendon transfer in the upper extremities.

His dedication was always to education and furthering the understanding of the hand. He served as a mentor to many orthopaedic surgeons, and physicians from around the world flocked to San Francisco to observe and learn from him.

Bunnell saw to it that the advances he introduced during the war continued afterward. Immediately after the war, the surgeons he brought together to lead and staff the U.S. Army hand centers became the core of the American Society for Surgery of the Hand (ASSH), one of the first major medical subspecialty organizations in the West. He became the society’s first president in 1946.

“The founding members [of ASSH] were drawn almost exclusively from the U.S. Army wartime hand centers,” Strickland said. “It was kind of a gathering of the men who served in the centers and a few others that they knew who formed the nucleus of ASSH in 1946. They were dedicated to the practice of hand and upper extremity surgery.

Bunnell’s textbook also served as “a bible” to orthopaedic surgeons with an interest in hand surgery in post-war Japan, said Yasuo Yamauchi, MD, professor emeritus at Juntendo University and immediate past president of the International Federation of Societies for Surgery of the Hand (IFSSH).

Introduced to surgeons after the war, the book helped to foster development of the field of hand surgery in Japan, he said.

Joseph Boyes, MD, who later practiced with Bunnell and edited later editions of his textbook, is credited with establishing the first formal hand resident program; however, many acknowledge Bunnell’s informal training courses in the hand as the unofficial beginning of residency training.

Prior to the war and just after, a rivalry ensued between the Chicago hand specialists, led by Michael L. Mason, Harry S. Allen, Sumner L. Koch and Allen B. Kanavel, and the San Francisco school led by Bunnell, L.D. Howard and Donald R. Pratt. “Between the two groups, they were the leaders in the academics of hand surgery,” said Strickland, a past president of ASSH. “If you wanted to learn hand surgery during that time, you went to either one.”

Bunnell died in 1957.