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MEDICAL DE"PARMN

UNITED STATES ARMY

IN WORLD WAR II

DTIC

~APR 1 9 1995

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MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR II

ACTIVITIES OF SURGICAL CONSULTANTS

Volume I

Prepared and published uinder the direction of

Lieutenant General LEONARD D. HEATON

The Surgeon, General, United States Army

Editor in Chief

Colonel JOHN BlOYD COATES, Jr., MC

Editor for Activities of Surgical Consultants

B. NOLAND CARTER, M.D.

Associate Editor

ELIZABETH Ni. McFETRIDGL, M.A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

IWASHINGTON1, D.C., 1962
SURGERY IN WORLD WARl II

Advisory Editorial Board

MICHAEL 1E. DEBAKEY, M.D., Chairman

FRANK B. BERRuY, M.D. JoHNq B. FLiCK, M.D.

BRIAN BLADES, M.D. FRANK GLENN, M.D.

J. BARRETT~ BROWN, M.D. M. ELLIOTTr RANDOLPH, M.D.

STERIANo BUNNELL, M.D. (dec.) IsiDton S. RAvDiN, M.D.

NORTON CANFIELD, M.D. JOSEPH R. SHAEFF., M.D.

B. NOLAND CARTER, M.D. ALFRED U. $HANDS, Jr., M.D.

EDWARD D. CHURCHILL, M.D. HOWARD R. SNYDER, M.D.

MATHER CLEVELAND, M.D. R. GLEN SPURLINO, M.D.

DANIEL C. ELKIN, M.D. (dec.) BARNES WOODHALL, M.D.

ROBERT M. ZOLLINOER, M.D.

Brigadier General Douor.As B. KENDRICK, Jr., (ex officio)

Colonel JOuN BOYD COATES, Jr., MC (ex officio)

Colonel JAMES E. GRAA.r MC (ex officio)

The Hlistorical Unit, United States Army Medical Ser-vice

C0ooel JOuN BouD COATES, Jr., MC, Director

Colonel REx P. CLAYTON, MSC, Executive Officer

Colonel R. L. PARKER, MSO, Special Assistant to Director

Lieutenant Colonel R. J. BERNucCI, MC, Special Assistant to Director

Major WARREN W. D,%BoLL, M8C, Special Assistant to Director

Lieutenant Colonel MATTHIEW GINALICIC, MSC, Chief, Special Projects Branch

CHAREs It. WVImS, Ph. D., Litt. D., Cief , Historians Branch

ERNEST ELILIOTIT, Jr., Chief, Editorial Branch

Lieutenant Colonel LEONARD L. COLLIER, MSC, Chief, Information Activities Branch

Major ALBRERT C. RIGoS, Jr., Chief, General Reference and Research Branch,

TIAZEL G. HINE, Chief, Administrative Branich,

Library of Congress Catalog Card Number: 62-60004

Fo:~!cy te SPerin nt of D.,.-e ts. U.S. Goiernu;-nL Piit, 0 ce,
ACTIVITIES OF SURGICAL CONSULTANTS

Volume I

esAccesion For

'NTIS CRAMi

DTIC TAB

Unannounced 0 Aisification

............ . . . .

Availabiity Codes

Avail and /or

Spcial
MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the official history of the Medical Department of

the U.S. Army in World War II are prepared by The Historical Unit, U.S.

Army Medical Service, and published under the direction of The Surgeon

General, U.S. Army. These volumes are divided into two series: (1) The

administrative or operational series; and (2) the professional, or clinical and

technical, series. This is one of the volumes published in the latter series.

VOLUMES PUBLISHED

ADMINISTRATIVE SERIES

Hospitalization aml Evacuation, Zone of Interio),

CLINICAL SERIES

Internal .iedicine in World War II:

Vol. 1. Activities of Medical Consultants

Preventive Medicine in World War II:

Vol. II. Environmental Hy'4ene

Vol. III. Personal flealth Measures and Immunization

Vol. IV. Communicable Diseases Transmitted Chiefly Through lRespiratory and Alimentary Tracts

Vol. V. Communicable Diseases Transmitted Through Contact or

By Unknown Means

Surgery in World War I1:

General Surgery, vol. 1I

Hand Surgery

Neurourgery, vol. I

Neurosurger-y, vol. II

Ophthaknology and Otolaryngology

Orthopedic Surgery in the European Theater of Operations

Orthopedic Surgery in the Mediterranean Theater of OperationZs

The Physiologic Effects of Wounds

Vascular Surgery

v1i
ACTIVITIES OF SURGICAL CONSUtlTT

Miscbllaneous:

Cold Injuzry, Gr'ound Typ6

DentalSe,'vico in World1 Tar 11

Vetrinry ervce n.WorldllWzr 11

W~ound Ballistics8
Contributors

CLAUDF S. BECK, M.D.

Professor of Cardiovascular Surgery, Western Reserve University School of Medicine,

Cleveland, Ohio; Associate Surgeon, University Hospitals, Cleveland. Formerly

Colonel, MC, AUS.

FRANK B. BERRY, M.D.

Senior Medical Advisor to the Assil a.., Secretary of Defense (Manpower), Department of Defense; Professor of Clinical Surgery Emneritus, College of Physicians and

Surgeons, Columbia University, New York, N.Y. Formerly Colonel, MC, AUS.

JAMES J. CALLAUAN, M.D.

Professor and Chairman, Department of Bone and Joint Surgery, Stritch School of

Medicine, Loyola University, Chicago, Ill.; Professor of Bone and Joint Surgery, Cook

County Post Graduate School, Chicago. Formerly Lieutenant Colonel, MC, AUS.

B. NoLAN CARTER, M.D.

Professor of Surgery Emeritus, College of Medicine, University of Cincinnati, Cincinnati, Ohio. Formerly Colonel, MC, AUS.

HATIIER CLEVELAND, 'M.D., A.M., D. Sc., F.A.C.S.

Consulting Orthopedic Surgeon, St. Luke's Hospital and Presbyterian Hospital, New

York, N.Y., and Henry W. Putnam Memorial Hospital, Bennington, Vt.; Attending

Orthopedic Surgeon, New London Hospital, New London, N.H. Formerly Colonel, MC,

AUS.

BRADLEY L. COLEY, M.D.

Attending Surgeon Emeritus, Memorial Center for Cancer and Alli,!d Diseases, New

York, N.Y. Formerly Colonel, MC, AUS.

CONDICT W. CUTLER, Jr., M.D. (deceased)

Formerly Colonel, MC, AUS.

FRANK GLENN, M.D.

Chairman, Department of Surgery, and Lewls Atterbury Stinison Professor of Surgery,

Cornell University Medical College, New York, N.Y.; Surgeon in Chief, The New York

Hospital, New York, N.Y. Formerly Lieutenant Colonel, MC, AUS.

GEORoE R. GREENWOOD, M.D., M. Sc. (Surgery)

Associate in Surgery, St. Luke's Hospital, Bethlehem, Pa. Formerly Major, MC, AUS.

HENRY G. HOLLENHERG, M.D.

Associate Professor of Surgery. University of Arkansas School of Medicine, Little Rock,

Ark. Formerly Colonel, MC, AUS.

DouGLAs B. KENDRICK, Jr., Brigadier General, USA.

Director of the Staff, Office of the Deputy Assistant Secretary (Health and Medical),

Department of Defense.

ROBERT 1I. KEN-NEDY, M.D.

Formerly Professor of Clinical Surgery, New York University Post-Graduate Medical

School; Consulting Surgeon, Beekman-Downtown, Bellevue, and University Hospitals,

New York. N.Y. Formerly Colonel, MC, AUS.

JOHN J. LOUIZENHEISER. M.D.

Assistant Clinical Professor of Orthopedic Surgery, University of California School of

Medicine, San Francisco. Calif. ; Consultant in Orthopedic Surgery. Veterans' Administration HIospital. San Francisco; Chairman. Department of Orthopedic Surgery. St.

Mary's Hospital, San Francisco. Formerly Lieutenant Colonel, MC, AUS.

606222'-62-2 ix
X ACTIVITIES OF SURGICAL CONSULTANTS

FRANK J. McGowAN, M.D.

Senior Visiting Surgeon, St. Vincent's Hospital, New York, N.Y.; Clinical Professor of

Surgery, New York University Post-Graduate Medical Center, New York, N.Y.; Associate Attending Surgeon, The New York Hospital. Formerly Colonel, MC, AUS.

-LEsLIE E. MORRISSETT, M.D.

In private practice of otolaryngology, Greenwich, Conn. Formerly Lieutenant Colonel,

MC, AUS.

CHALES B. ODOM, M.D., F.AC.S.

Formerly Colonel, MC, AUS.

GROVER C PENBERTHY, M.D.

Professor of Clinical Surgery Emeritus, Wayne State University College of Medicine,

Detroit, Mich.; Senior Surgeon, Consultant Staff, Harper Hospital, Detroit, Mich.

Colonel, MC, Honorary Reserve, USA (Ret.).

LEONARD T. PETERSON, M.D.

Assistant Clinical Professor of Orthopaedic Surgery, George Washington University

School of Medicine, Washington, D.C. Colonel, MC, USA (Ret.).

M. ELLIOTT RANDOLPi, M.D.

Associate Professor of Ophthalmology, Johns Hopkins University School of Medicine,

Baltimore, Md. Formerly Lieutenant Colonel, MC, AUS.

HOWARD E. SNYDER, M.D.

Winfield, Kans. Formerly Colonel, MC, AUS.

TiHOMAS L. WARING, M.D.

Associate Professor of Orthopaedic Surgery, University of Tennessee College of

Medicine, Memphis, Tenn. Colonel, MC, USAR.

WALTER D. WIsE, M.D.

Professor of Surgery Emeritus, University of Maryland School of Medicine, Baltimore,

Md. Formerly Colonel, MC, AUi
Foreword

This volume, one of the total series that tells the story of the U.S. Army

Medical Departmne,.t in World War II, is the first of two books devoted to the

activities of the surgical consultants. It deals with their work in the Office of

The Surgeon General; the extension of the system to the Service Commands in

the Zone of Interior; and its operation in the U.S. field armies overseas. The

second volume, which will appear shortly, deals with activities of the surgical

consultants on the theater level in Europe and in the Asiatic-Pacific theaters of

war.

Although a skeleton consultant system had operated in the Medical Department in World War I, there was no formal provision for such a system before the

outbreak of World War II, and that lack was to plague the consultants throughout the war. It also plagued the comnmand surgeons under whom the consultants worked. Position vacancies were not always available. Lines of authority were not always clear. Questions of rank were often embarrassing.

Perhaps most trying of all, consultants overseas were hampered in their activities by the inconvenience and actual inefficiency caused by absence of direct

channels of communication between themselves and the consultants in the Office

of The Surgeon General. The great convenience of such unofficial channels as

were developed made the general deficiency even clearer. In the Zone of Interior, this difficulty did not long exist. Within a very short time, there was

close liaison between the consultants in the Office of The Surgeon General and

those in the various Service Commands, and standardization of medical care-a

wartime necessity-was accomplished more readily, and medical care was more

efficient, as a result.

The Professional Services Division that had existed before the war in the

Office of The Surgeon General can perhaps be regarded as the predecessor of

the World War II consultant system, but its scope was limited and its functions

were chiefly administrative. Among its seven subdivisions was the Subdivision

of Medicine and Surgery, a combination of specialties so obviously impractical

that it made further subdivision inevitable. The appointment of the late Col.

(later Brig. Gen.) Fred W. Rankin, MC, as Chief Surgical Consultant to The

Surgeon General on 1 March 1942 was shortly afterward followed by the establishment of a separate Surgery Branch, with subdivisions of its own. After

other reorganizations, this branch became the Surgical Consultants Division,

which operated under, and reported directly to, The Surgeon General.

When Colonel Rankin reported for duty, he found no definition of the functions of a surgical consultant, a deficiency that did not long handicap a person

of his dedication and tremendous energy. Nonetheless, many obstacles had to

be overcome in setting up necessary positions and otherwibe putting the consultant system into ol)eration.

Xl
XII ACTIVITIES OF SURGICAL CONSULTANTS

The tacit understanding early in the war was that the consultants were to

confine themselves to clinical problems. The understanding was soon abrogated. Before the war ended, the consultants everywhere had extended their

activities, with the full approval of those in authority, to a variety of administrative considerations, of which the assignment of professional personnel on the

basis of evaluation of their experience and ability was probably the most

important.

Early in the war, the assignment of newly commissioned medical officers by

the Office of The Surgeon General and other responsible headquarters was necessarily somewhat arbitrary. Those responsible for this function usually had

only paper qualifications to work with, and paper qualifieations, even when

there is every attempt to make the presentation honest and objective, can never

tell the full truth. The consultants, handpicked themselves, in turn hand picked

key personnel in their areas of jurisdiction. Fresh from peacetime practice,

they personally knmew the capacities of many of the physicians who were enter.

ing military service, and when they did not know the new officers personally,

they had ways of finding out about their abilities.

The consultants in the Office of The Surgeon Geneial recommended the

appointment of the consultants for Service Commands in the Zone of Interior

and for oversea theaters and field armies; for the surgical staffs of hospitals;

and for the newly organized auxiliary surgical groups, whose important role in

forward surgery they correctly predicted. IIow well the consultants performed

this particular mission is evident in the analysis made in 1945, by General

Rankin, of the assignment of 922 surgical specialists. Exclusive of the 37 who

were serving as consultants in the Office of The Surgeon General or in the Service Commands and elsewhere, 96 percent were engaged in practicing their own

specialties and were considered to be correctly assigned.

Among the other functions performed by the surgical consultants in the

Office of The Surgeon General in the initiation and extension of the consultant

system were the follo "ing:

They revised the equipment lists, eliminating outmoded instruments and

apparatus, providing new items, and equalizing distribution.

They pressed for the establishment of specialized surgical centers and implemented the concept. These centers utilized most efficiently the always

limited number of surgical specialists; utilized equipment with equal economy;

and constantly improved the treatment of casualties by concentrating those

with the same kinds of injuries in the same hospitals and thus providing continued, concentrated experience for the surgeons who treated them.

The consultants in the Office of The Surgeon General set up central supply

services in hospitals. They supervised programs of medical education. They

saw to it that libraries were provided with books and journals. They made

regtlar hospital staff conferences mandatory. They organized mieetings. on

greneral and special problems. They prepared circular lett rb. They commented on the ETMD's (Essential Technical Medical )ata reports) from the
FOREWORD XIII

theaters of combat, thus providing at least a tenuous link of communication

between themselves and the consultants overseas. They tried, unsuccessfully,

to set up a similar series of reports in the Zone of Interior.

The Surgical Consultants Division, Office of The Surgeon General, planned

various clinical studies, including those on penicillin and streptomycin. It an.

alyzed special problems such as hernia, varicose veins, and pilonidal sinuses.

The consultants in surgery in the First Service Command collected and analyzed 594 operations for pilonidal sinus; within a very short time, as a result,

the management of this condi.iion was completely altered.

The work of the surgical consultants in the Service Commands, tie oversea

theaters, and the field armies followed tie same patterns of endeavor as those

just described, adapted, as necessary, to the special conditions which each consultant had to meet. Their activities in these armies were of major importance.

It was in the forward areas that initial wound surgery was performed and, very

frequently, determined the end result of an injury in terms of survival, morbidity, or permanent deformity versus complete restoration to normal. The

chapters in this volume dealing with the work of Army consultants deserve the

most careful reading.

This volume tells, in summary, the dramatic story of the blood program in

World War II. (It is told in detail in another volume in this series.) This

story is a frank and forthright narrative, which makes clear that very few can

escape tle blaine for unthinking acce)tance of the original misleading concept

that plasma is a satisfactory substitute for whole blood. This volume also tells

other stories: The story of the aural rehabilitation program ard of the program

for the rehabilitation of blinded casualties (both told in detail iil another volume in this series) ; the story of the development of prosthetic devices for

amputees and of the rehabilitation of these men; and, finally, tie story of the

preparation for chemical warfare, which, mercifully, never came to pass.

This book describes frankly and realistically the difficulties encountered,

and the obstacles that had to be overcome, by the surgical consultants in all

areas as they set about their tasks. Some of their troubles arose, it must be

granted, because of their own inexperience in military matters. But more of

them stemmed from an initial failure to appreciate the potentials and implications of this new system. Most of the consultants, from their own 1)eacetime

clinical experience, correctly envisaged their own functions, and, because they

were imaginative, resourceful, and willing, they were soon able to translate

)eacetime concepts to wartime actualities. They sometimes had to school

themselves, at least at first, to working in headquarters and organizations that

were at best indifferent and that .sometimes were frankly hostile. It is a tribute

to the tact of the consultants as well as to their competence that the original

opposition to them promptly disappeared and that the con.sultant sytein spread

from a few commands in the Zone of Interior to overea theaters and to field

armies. It is an even greater tribute to their work that in the areas in which the

,'onsultant system did not operate. the desire for it wa, releatedly expres-,ed.
XIV ACTIVITIES OF SURGICAL CONSULTANTS

The consultants performed many functions, but they never lost sight of the

fact that their first duty was the provision of good medical care for wounded

casualties, The importance of this mission requires no elaboration. Its success is best estimated in terms of lives saved and in the decreased mortality and

generally normal status of those who survived their injuries-their often

incredibly severe injuries.

I am impressed, as I have been in all previous volumes of this historical

series, by the amount of factual material in this volume; by the frankness with

which the story is told; and by the interest which it holds for readers, even

readers who, of necessity, already know a great deal about it. The consultant

system was wonderfully successful, and we have reason to be thankful that it

is now an integral part of medical care in the Regular peacetime Army and an

important component of the professional training program of the Army Medical Service.

As the editor of this volume has stressed in his preface, there could not

have been a more felicitous choice for the post of Chief Surgical Consultant to

The Surgeon General than the late Brig. Gen. Fred W. Rankin. He came to his

milit ry duties with a fine background of personal surgical competence and

exl)erience and with the deep respect of his confreres. Widely informed on

the personnel to be assigned, he insisted that they be placed on the basis of their

ability and experience. lie recognized the major problems of surgical care

without ever becoming lost in their trivia. He slashed through administrative complications. His standards were undeviating. When his personal convictions were at stake, he was completely undeterred by rank. The remarkable

success of the surgical consultant system stemmed in large measure from his own

personal performance in the Office of The Surgeon General.

The contributors to this volume deserve thanks for taking on the task. As

its editor points out, they were willing to undertake it because they realized

that the consultant system was responsible to a major degree for the surgical

advances in the care of wounded casualties in World War II and therefore must

be recorded for practical clinical reasons as well as for historical reasons.

I express my gratitude to the consultants who wrote this story and who

helped to accomplish the achievements related in this volume and in the volume

to follow; to the editors, particularly the special editor for these two volumes,

the former Col. B. Noland Carter, MC; and to my associates who are helping

me to carry out one of the truly important missions of my own office, the preparation and publication of this history of the U.S. Army Medical Department in World War II.

LEONARD D. HE.A'rox,

Lieuteiant General,

The Surgeon General.
Preface

In 1953, The Surgeon General and his advisory committee on the Medical

History of World War II decided that such a history would not be complete

without a volume devoted to the surgical consultant system. A panel was

therefore appointed to implement and expedite the publication of such a

volume. Great credit is due the many men who served as surgical consultants

in World War II for their cheerful acceptance of the responsibility of contributing to this volume so many years after the completion of their military

duties. In order to refresh their memories, it was necessary for them to delve

into reports long since hidden in their own files or in those in the Office of the

Surgeon General. Their willingness to do so stemmed in large part from their

feeling, in which I concur most heartily, that the surgical consultant system

in World War II was effective and responsible in large measure for the remarkable surgical achievements in the care of the sick and wounded and therefore shoulh be recorded for historical as well as practical reasons. There is

every reasoi, for these men to feel proud of their accomplishments in World

War II. TI eir efforts constituted a real factor in the success of the surgical

results that were obtained and which were responsible for the maintenance

of the efficient and smoothly functioning surgical services supplied to the Army.

There is al obvious need for capable surgeons in the role of consultants

in times of war. When the civilian medical profeszion is called upon to furnish

surgeons to the Army, individuals of widely varying degree of competence

offer their services. It is difficult for the military authorities to evaluate the

true qualifications of the members of such a large and diverse group. They are

apt to feel that a doctor with the designation of surgeon can perform any

medical or surgical duty and therefore can be assigned with impunity to any

position which calls for a surgeon. In fact, this same feeling may be applied

to doctors in general, regardless of their specialized training, so that one might

find a well-qualified surgeon holding sick call while a general praditioner with

little or no surgical experience might be occupying a surgical position. The

handpicked surgical consultant, however, who is interested in building and

maintaining an efficient organization in the area under his jurisdiction can

ascertain what surgeons are available to him, can sort them according to their

qualification and experience, and can arrange for their proper asignment. The

classification and suitable assignment of surgical personnel is, I believe, the

most important function of the consultant. By placing the proper man ii, the

proper place, one is able to build an organization which will function in the

most efficient manner. Such a procedure promotes worale and, in utilizing

the individual talents of the surgeons under one's jurisdiction, affords the best

surgical care to the sick and wounded.

xv
XVI ACTIVITIES OF SURGICAL CONSULTANTS

It is not only imperative that the newer methods of treatment be made

available to the surgeons throughout the Army framework but also that strict

adherence to those surgical procedures which have been found most effective

be enforced. These objectives can best be accomplished by the consultant and,

next to his handling of personnel, constitute the most important part of his

duties. With his knowledge of what is happening in his area, the consultant

is well suited for the furtherance of public relations and for liaison within his

headquarters, with the Office of the Surgeon General, with civilian surgeons,

and with other consultants. He can and should be interested in the training

and education of the surgeons under his authority. Surgical meetings can be

organized at which discussions are held on the proper management of pertinent

cases, papers can be read, and the current literature reviewed. The consultant

has the duty also of reviewing manuscripts prepared in his area for publication

in surgical journals. Still another function of the consultant is to survey the

equipment and supplies of various installations and to insure that the facilities

with which to function in a proper manner are made available, These functions are merely a few of the more important ones which the surgical

consultants performed in World War II. Many others are revealed in the chapters of these volumes. The consultant system in World War II was begun on

a small scale and, owing to the excellent results which it )roduced, was steadily

expanded until it reached the furthermost parts of the Medical Department

within the Army. The surgical consultant system gained in stature as the war

progressed and emerged as an important cog in the machine which was manned

by the thousands of surgeons who gave of themselves so unselfishly in the war

effort.

It is said, and I believe rightly so, that medical histories of wars are rarely

read, even in wartime. It is to be hoped that such a fate will not befall this

volune, for it contains much of interest, particularly to those who may in the

future become a part of a surgical consultant system. The men who have contributed to it hope that the account of their efforts and their experiences will

not escape the attention of their successors and will prove of value to them.

An account of the activities of surgical consultants in World War II would

not be comiplete without special mention of the role which Brig. Gen. Fred W.

Tankin, Chief Consultant in Surgery to The Surgeon General, played in contributing to the success of the consultant system. HP was unusually well fitted

for his position in that he possessed certain attributes which enabled him to

accomlplish his mission in a most effective manner. His wide knowledge of the

personalities and capabilities of a large number of American surgeons made it

possible for him to assign accurately suitable individuals to key positions

within the structure of the surgical consultant system. His early recognition

of and his continued stress on the importance of the proper placemuent of personnel cannot be overemphasized. Ile repeatedly stated during the war that

his most effective means of providing the highest standardb of urgical care

for the sick and -wounded was to put the right mnan in the righit place. He had
PREFACE xvIir

an uncan y ability to recognize, important problems and to approach them,

directl Whiledisregarding the insignificant details. He had tremendous de!

termination. was never overawed by rank, and stood fast to those principles

which he considered to be just and right. He hated redtape and was unswerving ih his efforts to cut, through it to further the prosecution of the war. He

was an inspiring leader and one who constantly espoused the highest principles

of his profession.

B. NOLAND CARTER, M.D.
Acknowledgments

A great many individuals other than the authors themselves participated

in the preparation of this volume. Tile editor is happy to acknowledge the

valuable assistance ofThe members of the Advisory Editorial Board for their scholarly advice

and counsel.

Col. John Boyd Coates, Jr., MC, Director of The Historical Unit., U.S.

Army Medical Service, for his cooperation and never-failing interest in the

progress of this volume.

Miss Elizabeth M. McFetridge, who, as associate editor for the volune,

contributed materially by assisting several authors in the preparation of their

respective chapters; namely, chapters III, V, VI, XV, XVI, and XVIII.

Maj. James K. Arima, MSC, formerly of The Historical Unit, who was

designated acti,.n officer for this volume and assured that it was complete in all

detail before being forwarded for editorial processing.

The members of the General Reference and Research Branch, The Historical Unit, for providing the archival material and for corroborating data

obtained from other sources.

Mr. Melvin J. Hadden, medical illustrator, and the members of the Medical

Illustration Service, Armed Forces ht itute of Pathology, under the direction

of Mr. Herman Van Cott, chief of that service, who prepared the excellent

layouts for the illustrations and mounted them for printing.

Miss Elizabeth P. Mason, Cartographic Compilation Aid, of the Special

Projects Branch, The Historical Unit, for the preparation of maps which appear

in chapter XVI.

NEss C. Louise Brady, Editor, of the Editorial Branch, The Historical

Unit, for her skillful performance of the final editing of this volume and for

her preparation of tme index.

XVIII
Contents

Page,

FOREWORD - - - - - - - - -- - - - - - - - - - - - - - - - - -- xt

PREFACE------------------------------------------------------------ xv

ACXNOWhEDGMEP'' ~S------------------------------------------------ XVIII

Part I

SURGICAL CONSULTANTS IN THE ZONE OF INTERIOR

Surgical Consultants in the 0ffice of the Surgeon General

Chapter

IGeneral Surgery (B. Noland Carter, M9D.)-------------------------- 3

Functions ------------------------------------------------ 5

Personnel ------------------------------------------------ 6

Equipment and ' upplies----------------------------------- 17

Public Relations and Liaison --------------------------------- 21

Review of Manuscripts and Literature-------------------------- 24

Education and Training------------------------------------- 25

Consultation---------------------------------------------- 31

Summary ------------------------------------------------ 47

II Orthopedic Surgery (Leonard P'. Peterson, M.D.)--------------------- 49

Assignment and Organization--------------------------------- 49

Functions and Duties --------------------------------------- 50

Amputations. -- ------------------------------------ 56

Liaison and Cooperative Activities----------------------------- 61

Observations on Care of Orthopedic Injuries --------------------- 63

Summary and Recommendations ------------------------------ 64

III Chemical Warfare (George R. Greenwood, M.D.)---------------------- 67

Chemical Warfare Branch, Office of the Surgeon General------------- 67

Equipment for Protection Agninst Gas Warfare------------------- 71

Protection of Personnel Against Gas---------------------------- 76

Detection of Contaminated Food and Water --------------------- 77

Training Literature and Films -------------------------------- 79

Professional Policies in WVorld War 11--------------------------- 82

Classification of Chemical Agents------------------------------ 83

Chemical Burns ------------------------------------------- 92

Screening Smokes------------------------------------------904

IV Ophthalmology (M. Elliott Randolph, M.D.) ----------------------- 95

Ophthalmology Branch ------------------------------------- 95

Care of the Blind --------------------------------------- 9

Other Consultant Activities ------------------ --------------- 100

The Second Tour------------------------------------------ 102

Recommendations ----------------------------------------- 102

XIX
xk- ACTIVITIES OF SURGICAL CONSULTANTS

Cha pfer pagc

V Otolaryngology (Leslie E. Morrissett, M.D.) -------------------------- 105,-

Establishment of Otolaryngology Branch -------------------------- '105-

Clinical' Policies --------------------------------------------- 100,

Routine Admnistrative Procedures------ ------------------------ 149

Other Duties ---------------------- ----- ------------------- 110,

Aural-Rohabilitatian Program for tho Deitfened and Hard of Hearing. 112

Rccommendations ------------------------------------------- 120

VI The Blood Program (Brig. Gen. . 1glas B. Kendrick, Jr., USA) ---------- 121

Blood and Blood 'Substitutes at the Brginning of World War 1II--------122

Beginnings of the Blood and Blood Substitutes Program ..-----... 124

Immediate Problems in 1940----------------------------------- 128

Plasma Program ----------------- --------------------------... 130

Serum Program ----------.----------- ................ 137

Human Serum Albumin Program.----------------------- ----- 137

Whole Blood Program------------------------------------- .. 140

Evolution of the Oversea Blood P1-ogram --------- ---------------- 147

Oversca Transfusion Services-----------------------.... ------ 155

Provision of Blood From Zone ot Interior to Pacific Areas------------.157

Planning for the Invasion of Jar an --------------------- --------- 101

Surgical Consultants in thc; Service Commnands

VII First Service Command (C'ondict IV. Cutler, Jr., M.D.)------------------ 167

Medical Installations and Facilities ------------------------------ 170

Early Clinical Problems---------------------------------..- 174

Development of the General Hospitals-------- -------------------- 176

Debarkation Activitie ---------------------------------------- 179

Surgery na the Prison Camps----------------------------------- 181

Progress of Surgical Care-------------------------------------- 182

Convalescen~t Program---------------------------------------- 192

Mfedical Education Program ----------------------------------- 194

Conclusions ------------------------------------------------ 195

VIII Second Service Command (Robert 11. Kennedy, 3~f D.) ----------------- 197

Experience and Orientation------------------------------------ 197

Administrative Duties----------------------- ----------------- 197

Administrative Factors in Providing Patient Care-- ----- ----------- 198

Professional Activities------------- --------------------------- 200

Conferences ------------------------------------------------ 201

Surgery in General HIospitals------------------ --------- ------- 201

Surgery in Other Hospitals.....................................- 20

Streptonlycin------------------ ----------------------------- 207

Summary----------------------------- --------------------- 207

IX Third Service Command (W1alter D. Wise, M1.D.) ---------------------- 209

&signzncnt, Orientation, and Early Activities of Surgical Coiibultaiit -- 209

Observations Concerning IHospitais --------- --------------------- 210

Summary of Activities -------------------- ------------------- 213

Conmment------------------------------- ----------- -------- 213

X Fourth Service Command (Mather Cleveland, M.D., and Janies J. Callahan, M.D.) ------------------------------------------------- 215
'CO1'TS XI

*$ha~t~rPage

Section I. September 1943 to April 1944

Hospitals--------------------------------------------------- 215

Professional Problems and Activities of the Consultant --------------- 2'

Section 11. 1944 and 1945

General Duties of the Consultant ------------------------------- 218

Program of Specific Duties, 1944-------------------------------- 220

The Orthopedic Service and Some Aspects of Therapy ----------- ---- 220

XI 'Fifth Service Command (Claude S. Bceck, M.D.)-------------------... 2-7

Adjustment to the Army and Indoctrination----------------- .--- 2q7

The Consultant System--------------------------------------- 227'

Duties and Responsibilities of the Surgical Consultant--------------..2291

Early Problems-The Training Camps--------------------------...231

The Airbase Hospitals-------------------- ------------------- 232

The General Hospitals---------------------------------------- 232

General Impression------------------------------------------- 235

XII Seventh Service Command (Grover C. Penberthy, M.D.)------------------ 239

Scope of Activities of the Surgical Consultant ---------------------- 239

Professional Services------------------------------------------ 241

Surgical Problems of Interest ---------------------------------- 244

Comment -------------------------------------------------- 247

XIII Eighth Service Command (Bradley L. Coley, M.D., Henry G. llollenberg,

M.D., and Thomas L. W1aring, M.D.) ---------- ------------------- 249

Section 1. The First Consultant, 1942-44

Problems Dr:ring the Training Period, 1942-43--------------------- 249

Special Pr,blems--------------------------------------------- 251

Mfedical Education------------------------------------------- 255

Section II. The Second Consultant, 1945

The Consultant System --------------------------------------- 258

General Considerations --------------------------------------- 259

Professional MNatters------------------------------------------ 261

The Future of the Consultant System---------------------------- 264

Section III. Thle Orthopedic Consultant

Duties and Functions----------------------------------------- 264

Problems With Physically Unqualified Inductees-------------------- 266

Special Orthopedic Problems----------------------------------- 267

Special Centers and Rehabilitation------------------------------ 268

Mledical Education------------------------------------------- 269

Comment -------------------------------------------------- 269

XIV Ninth Service Command (John J. Lout zenheiser, M.D.)----------------- 271

Assignment and Orientation of Orthopedic Consultant---------------- 271

Area and M.Nedical Treatment Facilities --------------------------- 271

Orthopedists in the Conmmand---------------------------------- 272

Relationship of Consultant With Hospital Comanmders -------------- 274

Early Innovations and Improvements---------------------------- 275
XXII ACTIYITIES OF SURGICAL, CONSULTANTSVk~4teiPage,

X I Ninth.,Service Comnnid-Confiniued

Special& Cn ters ---------------------------------- -------- 279

Ortiop'dics In~ Generatafid Station Hospitals------------ -------- 281,

Comment---------------------- ----------------------- 2 6

Summary------------------------------------------------ 286,

Part 11

SURGICAL CONSULTANTS TO FIELD ARMIES IN THEATERSOF OPERATIONS

XV third U.S. Army (Charles B. Odomn, M.D.)----------------_-------- 29i

Section I. Administrative Considerations

The Consultant System--------------------------------...294

Planning in the United Kingdom Base ------------------------- 298

Evaluation and Assignment of Personnel ---------------------- 3 02

Medical Units -------------------------------------------- 304

Supplies and Equipment ..---------------------------------- 311

Professional Meetings--------------------------------------- 312

Records------------------------------- --------- ------ 313

Prisoners of War----------------------- ------------.... 313

Section 1I. Clinical Conisiderations

Dissemination of Clinical Policies ----------------------------- 314

General Considerations of Forward Surgery ------------- _-------- 315

Shock and Resuscitation ------------------------------------ 316

Administration of Morphine---------------------------------- 317

Antimicrobial Therapy-------------------------------------- 317

Wound Management--------------------------------------- 318

Regional Injuries ----------------------------------------- 319

Amputations --------------------------------------------- 324

Anaerobic Infections -------- ------------------------------- 326

Cold Injury---------------------------------------------- 327

Evaluation of Surgical Care---------------------------------- 329

Conclusions --------------------------------------------- 331

XVI Fifth U.S. Army (Howard E. Snyder, M.LD.)------------------------ 333

Section I. Administrative and Related Considerations

Appointment of the Surgical Consultant ----------- ------- ------ 333

Tactical Considerations------------------------- -------------- 338

Functions of an Army Consultant------------------------------- 351

Evaluation and Assignment of Personnel -------------------------- 353

Educational Activities---------------------------------------- 357

Meetings and Conferences ------------------------------------- 362

Visitors to the Army Area ------------------------------------- 368

Evaluation of Surgery ---------------------------------------- 369

Evacuation ------------------------------------------------- 374

Medical Installations in the Army Area ----------- 377
CO6NTENTS, xxIII

CkajilerPae

XVI- 'ith KU-. r -Continued

'Liii§,on With Medical Units of Other Allied Armies---------------- 388,,

Equipmnt,--;-------------- 7---------- r------------------ 3§1

Reass ignment of 'Medical Units for Operation ANVIL -------------- '3 96-

Records, Special Reports, and Publications-------------- -------- 3 97

Statistics ------------------------------------------------ 69

Visits to Army Medical Installations--------------------------- 400,5

Section II. Clinical Considerations

Evolution of Clinical Policies--------------------------------- 410:

Shock and'Hemorrhage ------------------------------------- 402

Development of the Blood Program----------------------------446,

Blood Replacement Therapy -------------------------------- 419

Chemotherapy and Antibiotic Therapy ------------------------- 421f

Special Types of Wounds and In juries----------------------- -- 423

Regional Injuries ----------------------------------------- 432

Complications-------------- ------------------------ -- --- 446

Section III, The German Medical Service in Italy

General Considerations ----------------------------------- .448

Echelons of Medical Care ----------------------------------- 452

Consultant System ------------------------ ---------------- 456

Inspections of German Hospitals------------------------ ------ 457

General Clinical Considerations ------------------------------- 458

Regional Injuries ------------------------------------------ 460

XVII Sixth U.S. Army (Frank Glenn, MI.D.) ---------------------------- 465

Duties and Functions of the Surgical Consultant------------------ 465

Triage, Treatment, and Evacuation---------------------------- 475

Philippine Islands Campaigns--------------------------------- 477

Supportive Therapy ------------------------------- -------- 481

Surgery of Regional Wounds and Injuries ----------------------- 485

Tropical Jungle Foot--------------------------------------- 492

Gas Gangrene -------------------------------------------- 494

Tetanus ------------------------------------------------- 495

Special Considerations -------------------------------------- 500

XVIII Seventh U.S. Army (Frank B. Berry, M.D.)------------------------ 505

The Landings in Southern France ----------------------------- 505

Preliminary Medical Planning-------------------------------- 506

Medical Aspects of the Invasion ------------------------------ 508

Critique of the 'Medical Aspects of the Landings------------------ 512

The Blood Program --------------------------------------- 525

Supply and Transportation---------------- ------------------ 531

The Optical Program...------------------------ ------------- 531

Education and Trraiiig-------------- ---------------------- 533

MNedical Units -------------------------------------------- 534

Statistical Data ------------------------------------------ 540

Clinical Policies ------------------------------------------- 547

Regional Injuries ----------------------------------------- 552

Anaerobic Infections---------------------------------------- 563

Burns--------------------------------------------------- 564
XXIV ACTIVITIES OF~ SURGICAL CONSULTANTS'

Cha piePaue

~I Eighth U.S. Armny (Frahkl J. McGowan, M.D.)----------- ---------

Surgical Manpower------------------------------------------ '565,,

Effects of Terrain, Climate, and Local Conditions---.-.------------- -:5 01

Evacuation of Casualties ----------------------------------- 572

Surgical Supplies and Whole Blood -------------------------- -573

Portable Surgical Hospitals---------------------------------- -573

Surgical Towins --------------------------------------------- 575

Medical Support In Amphibious Warfare ------------------------- 5675

Treatment of Particular Types of Wounds ------------------------ 577

Recommendations---------------------- -------- ------------ 57

APPENDIXES

A Civilian Consultants In Surgery to The Surgeon General --------------------- 581

B Circular Letter No. 2, Office of the Surgeon, Seventh U.S. Army, 18 July 1944..... 583

IN DHX ----------------------------------------------------------- 580

Illustrations

Num iber

1 Thle position of Surgical Consultants Division in the organization of thle Office of

the Surgeon General --------------------------------------------- 4

2 Lt. Col. B. Noland Carter, 'MC, Assistant Chief, Surgical Consultants Division,

Office of thle Surgeon General-------------------------------------- 5

3 Service Command surgical consultants at their meeting with Brig. Gen). Fred WV.

Rankin and his staff, 10-11 October 1944, in thle Surgeon General's office,

1818 II Street, NW., WVashington, D.C------------------------------- 13

4 Col. Leonard T. Peterson, Chief, Orthopedic Branch, Surgical Division, Professional Service, Office of thle Surgeon General, and consultant in: orthopedic

surgery to The Surgeon General-------------------------- --------- 50

5 Amputation of upper extremity --------------------------------------- 58

6 Army Prosthetics Research Laboratory ---------------------------------- 60

7 0Cineplasty surgery and prostheses, Sauerbruch type------------------------ 61

8 Suction-socket artificial imnb with two-way valve (J. A. Hanger) dleveloped from

German p~rototyp)es --------------------- ------------------------ 62

9 Army Medical Laboratory, Edgewood Arsenaal, Md ------------------------- 67

10 'Maj. George R. Greenwood, MNC, Chief, Chemical WaTlrfare Branch, Surgical

Consultants Division, Professional Service, Office of thle Surgeon General,

and consultant to Thle Surgeon General ------------------------------ 70

11 Gas casualty set, M-2 --------------------------------------- ------- 73

12 Demonstration of use of oxygen therapy outfit, 20 dual outlet, with hose line

assembly, at South Post, Fort Myer, Va., October 1944 ----------------- 75

13 Fitting gas mask inserts (optical lenses) in the field, 69th General Hospital,

Mediterranean Theater of Operations, 1945--------------------------- 77

14 M-4 water-testing kit-post-World War 11 Chemical Corps modlification of the

World War 11 water-testing kit------------------------------------ 78

15 Food testing and screening kit, a post-W~orld War 11 Chemical Corps mnodification

of the World War II Medical Department kit------------------------- so

16 Compicete first aid gas casualty kit, Medical Department item No. 9776400- 85

17 Maj. M. Elliott Randolph, MC, Chief, Ophithalmolog) Branch, Surgical Conbultants Division, Professional Service, Office of the Surgeon General ----------- 90

IS Final social rehabilitation of the blind at Old Farms Consalescent Hospital,

Avon, P'a----------------------------------------------------- 98
CONTENTS XXV

Number Page

19 Maj. Leslie E. Morrissett, MC, Chief, Otolaryngology Branch, Office of the

Surgeon General -------------------------------------------------- 106

20 Aural rehabilitation at Borden General Hospital, Chiekasha, Okla ------------- 113

21 Aural rehabilitation at Deshon General Hospital, Butler, Pa ---------------- 115

22 Prescription and fitting of hearing aids ---------------------------------- 118

23 Col. Douglas B. Kendrick, MC, Chief, Division of Surgical Physiology, Army

Medical School, Walter Reed General Hospital- ..-................... 126

24 Preparation for plasma transfusion -------------------------------------- 132

25 Serum albumin transiusion --------.------------------------------------ 139

26 Processing of blood in European theater before airlift from Zone of Interior was

instituted -------------------------------------------------------- 152

27 Blood, donated in Brooklyn 10 days previously, being stored in 48th Field

Hospital, ETO --------------------------------------------------- 154

28 Administration of blood in a forward area in France ---------------------- 156

29 Recreational and exercising facilities for amputees ------------------------ 199

30 Gymnastics in the reconditioning program at Thomas M. England General

Hospital, Atlantic City, N.J ------------------------------- ------- 203

31 Constructing and fitting artificial eyes at Halloran General Hospital, Staten

Island, N.Y ------------------------------------------------------ 205

32 McGuire General Hospital, Richmond, Va ------------------------------- 211

33 Dr. Rudolph Matas, visiting Ashford General Hospital, White Sulphur Springs,

W. Va., in 1944, points out the "Matas Compressor" used to stimulate

collateral circulation --------------------------------------- ------- 228

34 Sgt. Joco Montonio, medical illustrator at Ashford General Hospital, creating a

bust of Gen. Jonathan M. Wainwright that was later cast in bronze for

permanent retention as one of the Nation's treasures .....------------- 233

35 Ashford General Hospital, White Sulphur Springs, W. Va., formerly the Greenbraer Hotel ------------------------------------------------------- 235

36 Ashford General Hospital, being easily accessible from Washington, presented an

opportunity to show Army dignitaries the superior services being rendered

at Army general hospitals ------------------------------------------ 236

37 Result of self-mutilation of the hand ------------------------------------ 253

38 Dr. Dallas B. Phemistei of Chicago and Col. Bradley L. Coley making rounds at

the station hospital, Enid Air Force Station, Okla -------------------- 256

39 Dr. Sunner L. Koch discusses a case of hand injury with medical officers at

Camp Swift Station Hospital --------------------------------------- 257

40 Patient in rehabilitation program at Baxter General Hospital, Spokane, Wash.,

proudly displays completed boat ------------------------------------ 278

41 Northrup prostheses for the arm ---------------------------------------- 280

42 Lt. '-n. George S. Patton visits the 12th Evacuation Hospital to award decorat, ;to the wounded ..-------------------------------------------- 293

43 Col. Uharles B. Odom, MC, Consultant in Surgery to the Surgeon, Seventh

U.S. Army, and, liter, Consultant in Surgery to the Surgeon, Third U.S.

Army --------.------------------------------------------------ 294

44 Evacuation by light txsak for speed, protection, and negotiating muddy terrain_ 297

45 Intratracheal anesthesia in a field hospital platoon, with simultaneous administration of whole blood -------------------------------------------- 301

46 Team of mobile X-ray unit operating in an evacuation hospital iii France ----- 304

47 Itlitial stage of the establishment of a field hospital platoon ----------------- 305

48 An auxiliary surgical team operating with a field hospital platoon ------------ 309

49 Two members of the 101st Airborne Division drag badly needed medical

supplies which were airdrop, ,ed to the besieged at Bastogne, Belgium - 311
XXVI ACTIVITIES OF SURGICAL CONSULTANTS

Number Page

50 Nazi hospital unit surrenders in Germany -------------------------------- 313

51 Preparation of a mangled arm prior to amputation in a field hospital --------- 325

52 Medical troops of the 4th Division bring up equipment, using an assault boat

as a sled over wet snow -------------------------------------------- 328

53 A holding unit in the chain of air evacuation ----------------------------- 330

54 Maj. Howard E. Snyder, MC, Consultant in Surgery to the Surgeon, Fifth

U.S. Army ------------------------------------------------------- 334

55 Col. Richard T. Arnest, MC, Surgeon, II Corps, and Lt. Col. William H.

Amspacher, MC, Duputy Surgeon, II Corps ---- _-------------------- 336

56 Operating room, 77th Evacuation Hospital, North Africa ------------------ 337

57 Lt. Gen. Lucian K. Truscott, Jr., Commanding General, Fifth U.S. Army, congratulating Lt. Col. Howard E. Snyder, MC, Consultant in Surgery, Fifth

U.S. Army, after awarding him the Legion of Merit for exceptionally meritorious service in the performance of his duties ----------------------- 339

58 Evacuation of wounded from Sicily ------------------------------------- 340

59 Campaigns in Italy, 9 September 1943-8 May 1945 ----------------------- 342

60 Evacuation hospital in Italy during the wet season in the fall of 1944 --------- 343

61 Evacuation of wounded by aidmen of 10th Mountain Division during Monte

Belvedere offensive ------------------------------------------------- 344

62 Tents of 56th Evacuation Hospital being dug in on Anzio beachhead, April 1944. 348

63 Col. Edward D. Churchill, MC, Consultant in Surgery, NATOUSA; Col. Frank

B. Berry, MC, Consultant in Surgery, Seventh U.S. Army; Col. James H.

Forsee, MC, Commanding Officer, 2d Auxiliary Surgical Group; Lt. Col.

Howard E. Snyder, MC, Consultant in Surgery, Fifth U.S. Army ---------- 354

64 Nurses digging foxholes and loading sandbags around their tent, Anzio beachhead -------.--------------------------------------------------- 356

65 Brig. Gen. Joseph I. Martin, Surgeon, Fifth U.S. Army, addressing rehabilitation conference at Castel Fiorentino, Italy, 1945 --------------------- 364

66 The 48th Surgical Hospital, North Africa -------------------------------- 371

67 Air evacuation by converted C-47 transport plane, MTOUSA --------------- 376

68 Evacuation by L-5 plane from Firenzuola to Florence --------------------- 377

69 Collecting Station, 10th Mountain Division, Gothic Line ------------------- 378

70 Field hospital, North Africa -------------------------------------------- 380

71 Postoperative ward in 1st Platoon, 33d Field Hospital, Italy ---------------- 382

72 Lt. Gen. Mark W. Clark, Commanding General, Fifth U.S. Army, visiting 38th

Evacuation Hospital near Leghorn, August 1944 ---------------------- 389

73 Mpdicl installations in Italy, visited by Maj. Howard E. Snyder, MC, during

March 1944 --------.-------------------------------------------- 407

74 Hospitals near Anzio, Italy, visited by Major Snyder during March 1944 -------- 408

75 Medical installations in Italy, visited by Colonel Snyder during December 1941. 409

76 German prisoners of war in Po Valley, May 1945 ------------------------ 449

77 Care of enemy wounded ----------------------------------------------- 450

78 Captured German hospital and equipment ----------------------------- 453

79 Feldlazarett, German counterpart of U.S. evacuation hospital --------------- 455

80 Lt. Col. Frank Glenn, MC, Consultant in Surgery, Sixth U.S. Army --------- 467

81 The 58th Evacuation Hospital at Tacloban, Leyte, 25 October 1944 ---------- 470

82 Evacuation on Luzon was difficult after the Jaanese retreated high into

mountainous areas ------------------------------------------------ 472

83 Administration of plasma at an id station, Leyte Island, Philippine Islands -.. - 475

84 Litter evacuation through rain-swollen streams on Leyte ------------------- 477

85 Tent housing operating facilities of a portable surgical hospital, Consuegra,

Leyte Island ----------------------------------------------------- 478
CONTENTS XXVII

Number Page

86 Air evacuation on Luzon Island, Philippine Islands ------------------------ 480

87 Patient, a Chinese, had been wounded in the hand by shell fragments and had

active signs of tetanus upon admission to San Lazaro Hospital ---------- 408

88 Tandings of the 3d, 36th, and 45th Infantry Divisions, Seventh U.S. Army,

and their maneuvers from beaches to Blue Line, 15 August 1944 --------- 506

89 Operations in southern France, 15-28 August 1944 ------------------------ 509

90 Views of naval aid station on Red Beach, just east of the town of Cavalairesur-Mer, France, in 3d Infantry Division Zone, shortly after landings on

D-day, 15 August 1944 .------------------------------------------- 511

91 Col. Frank B. Berry, MC, Consultant in Surgery, Office of the Surgeon, Seventh

U.S. Army ------------------------------------------------------- 515

92 Evacuation of wounded from beach to landing craft for transfer to hospital

shil 3 on D-day, 15 August 1944 ------------------------------------ 516

93 The 27th Evacuation Hospital fully set up in France ---------------------- 522

94 Preparations for administration of blood to wounded soldier in evacuation

hospital near Dijon, France, September 1944 ------------------------- 553

95 The 2,000-bed 36th General Hospital at Dijon, France, one of CONAD general

hospitals in close support of the Seventh U.S. Army during the winter,

1944-45 --------------------------------------------------------- 554

96 Col. Frank J. McGowan, MC, Consultant in Surgery, Eighth U.S. Army ----- 566

97 The 30th Evacuation Hospital at Parang, Mindanao, Philippine Islands ------ 568

98 Maj. Margaret D. Craighill, MC, adviser to The Surgeon General on women's

health and welfare, arrives at Parang, Mindanao, with Col. George W.

Rice, MC, Surgeon, Eighth U.S. Army, to investigate the use of female

Army personnel in the X Corps ------------------------------------- 570

99 On the morning of Task Force V-5's landing on Green Beach, Parang, Mindanao, Colonel McGowan confers with Col. C. M. Downs, MC, Surgeon,

X Corps --------------------------------------------------------- 571

100 Evacuation by C-47 aircraft from Malabang airstrip, Mindanao ------------ 574

101 Administration of plasma to patient during litter carry, Mindanao ---------- 576

102 Operating scene, 23d Portable Surgical Hospital ----------------------- 577

103 Casualties debark from an LST hospital ship, Corregidor Island, March 1945-- 578

104 The 99th Evacuation Hospital, combat loaded on top deck of LST at Morotai

before the V-5 operations in the southern Philippines campaign --------- 579

Tables

1 General hospitals designated as specialized centers, December 1943 and August

1944 ------------------------------------------------------------- 46

2 Authorized patient capacity for surgical specialties, 1944 and 1945 ------------ 47

3 Admissions for and deaths due to wounds among casualties hospitalized in Third

U.S. Army hospitals, by wound classification, 1944-45 ---------------- 292

4 Analysis of 43,354 U.S. battle casualties treated in Third U.S. Army installations,

1944-45 ---------------------------------------------------------- 292

5 Operations performed in hospitals on Anzio beachhead during the final phase,

12-16 May 1944 ---------------------------------------------- 350

6 Presentations at Fifth U.S. Army M fedical Conferences ---------------------. 366

7 Periodic analyses of post mortem studies in ." -.a U.S. Army hospitals, 1944-45._ 400

8 Percentage distribution of wounds and deaths according to anatomic location of

injury in 71,000 casualties admitted to Fifth U.S. Army hospitals, 1943-45.. 401
XXVIII ACTIVITIES OF SURGICAL CONSULTANTS

Number Page

9 Percentage distribution of wounding agents, and deaths therefrom, in 71,000

casualties admitted to Fifth U.S. Army hospitals, 1943-45 --------------- 402

10 Comparative frequency of wounds according to anatomic location of injury in

22,246 casualties admitted to Fifth U.S. Army hospitals, 1944-45 --------- 403

11 Comparative case fatality rates according to anatomic location of injury in

22,246 casualties admitted to Fifth U.S. Army hospitals, 1944-45-- ------- 404

12 Distribution of 1,450 deaths from battle-incurred wounds in Fifth U.S. Army

hospitals, 1944-45, by location and type of wound --------------------- 405

13 Percentage distribution of principal causes of dea'lh in 1,450 battle casualties

admitted to Fifth U.S. Army hospitals, 1944-45 ----------------------- 406

14 Recorded receipts and distribution of blood and plasma in Seventh U.S. Army

hospitals, 1944-45 -------------------------------------------------- 529

15 Summary of casualties, by body area, treated in field hospitals in Seventh U.S.

Army, 1944-45 ---------------------------------------------------- 536

16 Summary of casualties, by body area, treated by teams of 1st and 2d Auxiliary

Surgical Groups in Seventh U.S. Army hospitals, 1944-45 ---------------- 539

17 Monthly distribution of hospital and clearing station admissions and deaths,

Seventh U.S. Army, 1944-45 ---------------------------------------- 541

18 Distribution by type of hospital and body area of 55,085 battle-incurred wounds

in Seventh U.S. Army hospitals -------------.------------------------ 541

19 Case fatality rates according to type of hospital and body area in 55,085 combatincurred wounds in Seventh U.S. Army hospitals --------------------- 542

20 Distribution, according to type of hospital and body area, of 1,360 deaths in

55,085 combat-incurred wounds in Seventh U.S. Army hospitals ---------- 542

21 Distribution, by body area, of 48,299 wounds in Seventh U.S. Army casualties,

according to division reports ---------------------------------------- 543

22 Percentage distributions of body area and of wounded- or injured-in-action

cases, by anatomic location, U.S. Army, in the Civil War and World Wars I

and II -----------.--------------------------.-------------------- 543

23 Hospital and clearing station admissions and dispositions, Seventh U.S. Army,

1944-45 ---------------------------------------------------------- 545

24 Returns to duty from clearing stations and hospitals, Seventh U.S. Army,

1944-45 ---------------------------------------------------------- 545

25 Returns to duty from 400- and 750-bed evacuation hospitals in Seventh U.S.

Army for a selected 3-month period - ..-------------------------------- 546

26 Distribution of anesthesia by type, and by type of hospital, Seventh U.S. Army,

1944-45 ---------------------------------------------------------- 549

27 Management and results in 717 penetrating wounds of the head in eight Seventh

U.S. Army evacuation hospitals for a selected 5-month period ------------ 559

28 Results in 616 surgically managed wounds of the head in relation to dural penetration in eight Seventh U.S. Army evacuation hospitals for a selected

5-nmonth period ----------------------------------------------- 559

29 Essential data in 182 spinal cord injuries in eight Seventh U.S. Army evacuation

hospitals for a selected 5-month period ----------------------------- 560

30 Essential data in 1,086 injuries to major arteries, Seventh U.S. Army, 1944-45-- 561

31 Anatomic location and origin of casualties in 1,211 amputations in Seventh

U.S. Army hospitals ------------------------------------------------ 562
Part I

SURGICAL CONSULTANTS IN THE

ZONE OF INTERIOR

Surgical Consultants in the Office of the

Surgeon General
CHAPTER I

General Surgery

B. Noland Carter, M.D.

At the onset of the war, the Professional Service Division of the Office of

the Surgeon General consisted of seven subdivisions among which was the

Medicine and Surgery Subdivision.

It was soon realized that, in order to carry on the medical and surgical

activities of the Office of the Surgeon General in an adequate fashion, it would

be necessary to create a separate organization for each. Therefore, in February

1942, a chief consultant in surgery, Col. (later Brig. Gen.) Fred W. Rankin,

MC, and his opposite in medicine, Col. (later Brig. Gen.) Hugh J. Morgan, MC,

were placed in charge of their respective and separate branches. In March

1942, the Surgery Branch of the Medicine and Surgery Subdivision became the

Surgery Division, functioning as an integral part of the Professional Service

and comprising subdivisions of general surgery, orthopedic surgery, regional

surgery, chemical warfare, and radiology. In August 1942, another reorganization within the Professional Service was effected whereby surgery became a

branch under a Medical Practice Division. This situation remained until

June 1943 when the Surgery Branch became the Surgical Division with its

functions divided among three branches, the Surgery, Radiology, and Physiotherapy Branches. This new plan also provided that nationally known specialists would be appointed as civilian consultants to The Surgeon General so that

their services would be available to the divisions having interest in and need

for expert consultation in the fields represented. By February 1944, the Surgery Division (formerly the Surgical Division and still a part of Professional

Service) consisted of branches in general surgery, orthopedic surgery, traisfusions, chemical warfare, and radiation-physiotherapy having been eliminated. In August 1944, the Surgery Division became the Surgical Consultants

Division,' was separated completely from the Professional Service, and was set

up as an advisory staff division on a separate level from the operating services

in the Office of the Surgeon General. From this time until the end of the war,

I The Surgical Consultants Division underwent a series of evolutional cl-ges in status during the

years 1942-45 On 26 -arch 1942, the Surgery Division N as created as a part if Professional Service,

Office of the Surgeon General. On 24 August 1942 the Surgery Division was changed to the Surgery

Branch, Medical Practice Division, Professional Service. On 15 June 1943 the unit became a division

again with the designation Surgical Division. and on 3 February 1944 it became the Surgery Division.

On 24 August 1944 the Surgery Division became the Surgical Consultants Division, responsible direetl)

to The Surgeon General. aud on 11 October 1945 the name was changed again to Surgical Consultants.

For ease of reference, the designation Surgical Consultants Dialion Is used for the unit throughout

this volume.

3
4 ACTIVITIES OF SURGICAL CONSULTANTS

the Surgical Consultants Division reported directly to The Surgeon General.

Thus, it may be seen, the surgical activities in the Office of the Surgeon General

began as a part of time Medicine and Surgery Subdivision, steadily widened in

scope, and ultimately became a large and independent division directly under

The Surgeon General (fig. 1).

I5 MAY 1941 I JANUARY 1945

THE SURGEON GENERAL7] THE SURGEON GENERAL

II DEPUTY SURGEON GENERAL

EXECUTIVE OFFICER ASSISTANT SURGEON GENERAL

H IF I EXECUTIVE OFFICER

PROFESSIOAL SERVICE

DIVISION

SURGICAL

SUBDIVISIONS CONSULTANTS DIVISION

MEDICINE

AND SURGERY

SERVICES

ETC.] FIELD INSTALLATIONS

FiounE l.-The position of Surgical Consultants Division in the organization of the Office of the Surgeon General.

At its inception in February 1942, the Surgical Consultants Division was

housed in two small rooms, and its personnel consisted of Colonel Rankin,

Chief Consultant; Lt. Col. (later Col.) B. Noland Carter, MC, Assistant Chief

(fig. 2) ; and Maj. (later Lt. Col.) Ambrose II. Storck, MC. As the war went

on and the demands on the Division increased, additional officers were added.

These were Col. Leonard T. Peterson, MC, Consultant in Orthopedics; Col.

Byrl R. Kirklin, MC, Consultant in Radiology; Lt. Col. M. Elliott Randolph,

MC, Consultant in Ophthalmology, ucceed(ed later by Col. Derrick T. Vail, MC;

Lt. Col. Leslie E. Morrissett, MC, Consultant in Otolaryngology, succeeded by

Col. Norton Canfield, MC, late in 1945; Lt. Col. Douglas B. Kendrick, Jr., MC,

and Lt. Col. Frederic N. Schwartz, MAC, Consultants in Transfusions; Maj.

Albert M. Johnston, MC, and, later, Maj. George R. Greenwood, MC, Consultants in Chemical Warfare; and Maj. R. Gordon Holcombe, MC, Consultant

in General Surgery. The following officers from Walter Reed General Hospital

were appointed on a part-time basis: Lt. Col. Brian B. Blades, MC, Consultant

in Tmoracic Surgery; Col. R. Glen Spurling, MC, Consultant in Neurosurgery,

replaced later by Lt. Col. Barnes Woodhall, MC; and Maj. Lloyd II. Mousel,

MC, Consultant in Anesthesia. Colonel Storck left the Division aftcr several
GENERAL -SURGERY 5

FiovUiE 2.-Lt. Col. (later Col.) B. Noland Carter,

MC, Assistant Chief, Surgical Consultants Division,

Office of The Surgeon General.

months and was replaced by Maj. (later Lt. Col.) Michael E. DeBakey, MC,

who, on the departure of General Rankin in September 1945, became the chief

of the Division.

The men who were appointed as civilian consultants to The .Surgeon

General to serve the Surgical Consultants Division are listed, with their area

of specialization, in appendix A.

FUNCTIONS

The functions of the Surgical Consultants Division of the Office of the

Surgeon General were defined in various terms in directives issued from time

to time during the war. The following are examples of these definitions:

"Promulgates policies concerning the practice of general specialized surgery

and radiology throughout the Army"; "The development of surgical policies

6062221-02---3
6 ACTIVIT.!'S OF SURGICAL CONSULTANTS

including newer methods of treatment and the initiation of recommendations

regarding same; renditions of professional opinions as to miscellaneous surgical

methods; approval by liaison with the Personnel Division of selection of personnel for key positions; formulation of policies concerning the purchase of

new drugs and items of equipment for the Medical Department, and consideration of ideas submitted by individuals, institutions and manufacturers"; and

"To exercise general supervision of surgical care throughout the Army, afford

consultation and advice to all departments of the Surgeon General's Office on

matters pertaining to surgery and to assist in the identification and proper

allocation and assignment of qualified commissioned surgical specialists." The

various functions of the Surgical Consultants Division can best be outlined

and presented under the headings of personnel, equipment and supplies, public

relations and liaison, review of manuscripts and literature, education and

training, and consultation.

PERSONNEL

The maintenance and elevation of high standards of surgery in the Army

were considered by the Surgical Consultants Division to be dependent upon a

number of factors, among the most important of which was the accurate placement of personnel, particularly of key personnel. The Division therefore took

an active and zealous interest in the selection and recommendation of personnel for the various surgical positions which it was necessary to fill throughout

the structure of the Medical Department. This was accomplished by various

means. Some selections were made through personal interviews or correspondence with civilian surgeons who had themselves manifested a desire for

an appointment in the Medical Corps, some N ere carried out through consultation with representatives of the specialty boards, and some were accomplished after consultation with the Military Personnel Division concerning professional qualifications and appropriate assignment of officers recently commissioned. It was believed that, if key positions could be filled with individuals

with proper professional qualifications and with proven ability for organization and supervision, the enormous problem of affording the best care of the

surgically sick and wounded would be solved in large part. This surmise

proved to be correct, as was evidenced by the superior manner iL which the

varied surgical activities were administered by those men who had been selectel

for positions of importance, such as consultants, chiefs of service, and members

of auxiliary surgical groups. At the very beginning of the war, it was somewhat difficult to 1)erformn this personmel function readily since the accepted

lines of authority as to personnel assignment were rather rigidly drawn. The

Military Personnel Division, however, with the understanding direction of

Col. (later Maj. Gen.) George F. Lull, MC, soon grasped the fact that the

Surgical Division possessed extremely accurate information concerning the

qualifications of many surgeons and therefore cooperated heartily and effectively. The importance of this personnel fwiction was realized by Maj. Gen.
GENERAL SURGERY 7

Norman T. Kirk, MC, soon after he became The Surgeon General in June 1943.

Genetal 'Kirk decreed that the identification and proper allocation of surgical

specialists was to be a function of the Surgical Consultants Division. Having,

-selected a man for a position of importance, the Surgical Consultants Division

purposed to support him in the performance of his duties in every way. This

was more readily accomplished in the Zone of Interior than in oversea theaters

of operations, which tended to function independently of the Office of the Surgeon General.

Consultants to Oversea Theaters

As requests for consultants in surgery and its allied specialties were received from the various theaters of operations, it was obvious that these consultants had to be highly qualified and unusually competent individuals with

special training and a broad background of experience as well as eminent reputations in their fields of endeavor. It was the important responsibility of tho

Surgical Consultants Division to select and to recommend these consultants,

all of wh61n were chosen according to these criteria. The first group of consultants was selected for the European Theater of Operations and consisted of

the following:

Chief Consultant in Surgery Lt. Col. (later Brig. Gen.) Elliott 0. Cutler, MC,

Moseley Professor of Surgery at Harvard

University.

Consultant in Orthopedics Lt. Col. (later Col.) Rex L. Diveley, 1MC, associate professor of orthopedic surgery, University

of Kansas, Lawrence, Kans., succeeded by Col.

Mather Cleveland, MC.

Consultant In Neurosurgery Lt. Col. (later Col.) Loyal Davis, MC, professor of

surgery, Northwestern University, Evanston, Ill.,

succeeded by Lt. Col. (later Col.) R. Glen Spurling, 1C, professor of neurosurgery, University

of Louisville.

Consultant in Ophthalmology Lt. Col. (later Col.) Derrick T. Vail, MC, professor

of ophthalmology, University of Cincinnati,

succeeded by Lt. Col. James N. Greear, Jr., MC.

Consultant in Anesthesia Lt. Col. (later Col.) Ralph 31. Tovell, MC, chairman of the Department of Anesthesiology, Hartford Hospital, Hartford, Connm.

Consultant in Otolaryngology Lt. Col. (later Col.) Norton Canfleld, .NIC, professor of otolaryngology, Yale University.

Consultant in General Surgery Lt. Col. Ambrose II. Storck, MC. succeeded by Lt.

Col. (later Col.) Robert M. Zollinger, 3MC, as- sociate professor of surgery, Harvard University.

Consultant in Plastic Surgery Lt. Col. (later Col.) James Barrett Brown, MC,

associate professor of clinical surgery, profes- sor of oral surgery, Washington University, St.

Louis. Mo., succeeded by Maj. (later Lt. Col.)

Eugene M. Bricker. MC, assistant professor of

surgery, Washington University.
8 ACTIVITIES OF SURGICAL CONSULTANTS

A short time after NATOUSA (North African Theater of Operations,

U.S. Army) was established, Col. Edward D. Churchill, MC, Homans Professor

of Surgery at Harvard University, was selected as chief consultant in surgery for

that command. The other surgical consultants in that theater were appointed

by the Surgeon, NATOUSA, on the advice of Colonel Churchill.

The situation in the Pacific cannot be so easily stated owing to the fact

that there was no single Pacific theater as such and also to the many reorganizations which took place among the various commands. Without reference from

the Office of the Surgeon General, Lt. Col. (later Col.) August W. Spittler,

MC, had been designated surgical consultant in the Hawaiian Department at

the beginning of the war. Col. W. Barclay Parsons, MC, associate professor of

surgery, Columbia University, was the first to be selected specifically for assignment to the Pacific as a surgical consultant. He served in the early years of

the war with USASOS, SWPA (U.S. Army Services of Supply, Southwest Pacific Area), until replaced by Lt. Col. (later Col.) I. Ridgeway Trimble, MC,

in August 1944. Serving with Colonel Trimble was Lt. Col. George 0. Eaton,

MC, Orthopedic Consultant, USASOS, SWPA. Both Colonel Trimble and

Colonel Eaton were later assigned to the staff of USAFPAC (U.S. Army

Forces, Pacific)-the eventual overall command for most of the Army in the

Pacific.

In the South, Central, and Western Pacific areas, which at one time or another operated under Headquarters, USAFMIDPAC (U.S. Army Forces in

the Middle Pacific), Headquarters, USAFPOA (U.S. Army Forces in the Pacific Ocean Areas), and Headquarters, USAFPAC, Lt. Col. (later Col.) Forester Raine, MC, was the surgical consultant for the Central Pacific with TA.

Col. (later Col.) Robert C. Robertson, MC, as his orthopedic consultant. Lt.

Col. (later Col.) Ashley W. Oughterson, MC, associate professor of surgery,

Yale University School of Medicine, had gone to Auckland, New Zealand, with

the 39th General Hospital and was appointed surgical consultant to the South

Pacific Area, in July 1943. Colonel Oughterson later served as surgical consultant at Headquarters, USAFPOA, Western Pacific Base Command, and at

Headquarters, USAFPAC. iHe went to Japan in September 1945 with advanced headquarters, General Headquarters, USAFPAC, and was immediately

made head of the General Headquarters, USAFPAC group of the Joint Coinmission for the Investigation of the Effects of the Atomic Bomb in Japan.

Maj. (later Col.) Howard A. Sofield, MC, replaced Colonel Oughterson as

surgical consultant in the South Pacific and was, himself, relieved by Lt. Col.

(later Col.) Willis J. Potts, MC. Lt. Col. (later Col.) Edward J. Ottenheimer,

MC, replaced Colonel Oughterson in the Western Pacific Base Command.

In the meanwhile, Col. John 13. Flick, MC, had been sent as surgical consultant to the U.S. Army Forces in the Middle Pacific when that command was

established as a ,uperior command over the South, Central, and Western Pacific
GENERAL SURGERY

base commands. There were others who, from time to time, were detached

from their organizations and served as consultants for particular studies or

specific operations. Still others were appointed as consultants in the various

subcommands of the sprawling Pacific areas following the surrender of Japan.

Col. Stephens Graham, MC, assistant professor of surgery, Medical College

of Virginia, was selected as chief consultant in surgery to the China-Burma and

India theaters in 1945.

All of these consultants shouldered their great responsibilities in a most

commendable manner. By their assiduous and unrelenting attention to their

many personnel problems and to their varied professional duties, they were

responsible in large measure for the type of surgical treatment which saved

more lives in this war than in any other conflict in the history of the world.

Constant vigilance for methods of implementing better and earlier surgery,

unfailing devotion to their diverse duties, and determined efforts to reduce

mortality and morbidity characterized the activities of these officers. The valuable role which they played in the maintenance of a high standard of surgery

cannot be overemphasized.

As the war progressed, it became evident that, under the existing circumstances, close liaison between these officers and the Office of the Surgeon General

was extremely difficult and at times impossible. In order that The Surgeon

General might be acquainted with, and therefore assist in solving in the most

expeditious and intelligent manner, the many problems arising in oversea

theaters, the reports known as Essential Technical Medical Data were instituted. The inclusion of a surgical section in this monthly communication from

the headquarters of all oversea theaters afforded a medium through which the

surgical consultants of these theaters were able to consider timely and pertinent subjects with the Surgical Consultants Division of the Office of the

Surgeon General. Replies to these reports were formulated each month, indicating the action which was taken by the Division, in an effort to aid in the

improvement of surgical care in the theaters of operations. These reports

constituted one of the most valuable sources of information concerning the

surgical experiences of oversea units. For this reason the Surgical Consultants Division took pardonable pride in its role in the development of this

medium for obtaining information on current mnedicomilitary problems in the

oversea theaters and in contributing to their solution.

In retrospect, one of the most serious defects in the maintenance of the

most effective lelations between the Office of the Surgeon General and the

theaters of operations was the lack of a closely knit liaison which can best be

had by an interchange of personnel. Considerably better teamwork could have

been effected had there been more frequent visits by members of the Surgical

Consultants Division to the various theaters, and vice versa. Many more problems could have been solved in a more effectual and expeditious manner had
10 ACTIVITIES OF SURGICAL CONSULTANTS

such a scheme been instituted. In retrospect, it seems unbelievable that dirihg

the entire war only two visits were made to foreign theaters of operations by

members- of the Division and that only a few more were made by surgical,

consultants from oversea theaters to the Office of the Surgeon General. It

should be noted that a considerable number of subordinate consultants in the

various specialties were appointed within the theaters by the chief surgeofis

with the advice of the surgical consultants.

Surgical Consultants to Service Commands

On 28 July 1942, the War Department authorized the appointment of

surgical consultants to be attached to the medical section of each service command headquarters in the Zone of Interior. These consultants were concerned

essentially with the maintenance of the highest standards of surgical practice.

Their function was to evaluate, promote, and improve the quality of surgical

care by every means and to interpret the professional policies of The Surgeon

General and aid in their implementation. The proper performance of these

functions involved an appraisal of the professional services in various medical

installations, the quality, distribution, and assignments of professional personnel, the availability and suitability of equipment and supplies, the nursing

care, recreational and reconditioning facilities, and other services which were

essential to the welfare and morale of the patients. The consultants exercised

their functions by assisting and advising the service command surgeons on all

matters pertaining to professional practice, providing advice on surgical subjects in general, stimulating interest in professional problems, aiding in the

investigation of professional problems, and encouraging educational programs.

The execution of these functions involved periodic visits to all medical installations and other units in the command which were concerned with the surgical

care of military personnel.

It became apparent from these considerations that the service command

consultants would need to be highly qualified and unusually accomplished individuals with special training and experience and eminent reputations in

their individual fields of endeavors. The selection and recommendation of

these consultants were made the responsibility of the Surgical Consultants Division, and all of them were chosen according to these criteria. Here, as in

many other situations which required the selection of an outstanding individual

for an important surgical position, a personal knowledge of and an acquaintance with the majority of the qualified American surgeons was essential. The

Surgical Consultants Division was thus equipped, and its choice of service

command consultants was more than justified by the manner in which they

performed their duties, the industry and zeal which they manifested, and the

high standards of surgery which were maintained in Army hospitalb under

their jurisdiction.
GENERAL SURGERY 11

A list of the service cc mand surgical consultants follows:

Service Cbmmand Geaeral Surgery Orthopedics

First Col. Condict W. Cutler, Jr., MC

Second Col. Stephens Graham, MC

Col. Robert H. Kennedy, MC

Third Col. Walter D. Wise, MC

Fourth Col. Rettig Arnold Griswold, MC Col. Mather Cleveland, MC

Col. I. Mims Gage, MC Lt. Col. James J. Callahan, MC

Fifth Col. Claude S. Beck, MC Lt. Col. Robert L. Preston, MC

Sixth Col. W. Barclay Parsons, MC Lt. Col. Ralph Soto-Hall, MC

Seventh Col. Grover C. Penberthy, MC

Eighth Col. Bradley L. Coley, MC Col, Thomas L. Waring, MC

Col. Henry G. Hollenberg, MC

Ninth Col. John B. Flick, MC Col, John J. Loutzenheiser, MC

Col. Meredith G. Beaver, MC

Liaison between the service command consultants and the Surgical Consultants Division of the Office of the Surgeon General was adequately maintained throughout the war. The advantage of the geographic factor in this

relationship is obvious. Frequent visits to the nine service commands were

easily and frequently made by the staff of the Surgical Consultants Division,

and on most of these visits the staff were accompanied by the service command

consultant. Telephone calls could be made without much difficulty, and correspondence could be exchanged without delay. The service command surgeons,

the commanding officers of hospitals, and the surgical consultants were in and

out of the Office of the Surgeon General constantly. Unquestionably, this ready

liaison was responsible for much of the efficiency with which both organizations

were able to function. Another even more important factor was that the service

commands were under the direct control of the Commanding General, Army

Service Forces, on whose staff was The Surgeon General. Therefore, the implementation of directives-both professional and administrative-was readily

effected, personnel changes could be quickly and accurately made, and a healthful, cooperative attitude engendered. In striking contrast to this satisfactory

liaison was that with the oversea theaters. As mentioned before, it was rare for

consultants overseas to visit the Office of the Surgeon General and vice versa,

correspondence had to be through command channels, and the theaters were

quite autonomous, with the result that interference, real or implied, was actually

resented.

As a means of effecting a closer liaison with the service command consultants, General Rankin, in October 1943, arranged a meeting of the service

command consultants in the Office of the Surgeon General. The meeting lasted

for 2 days, during which time many pertinent problems common to all service

commands were discussed informally, presented frankly, and solved realistically. Among these were questions dealing with limited service, operating on

defects existing before induction, operations on the knee joint, discharge, classification and assignment of personnel, anesthesia, types of cases to be admitted
12 ACTIVITIES OF SURGICAL CONSULTANTS

to station and general hospitals, hours of duty for medical officers, et cetera.

TIhe consultants thus had the Opportunity to present their achievements as. wellas thidir problems, and to discuss themn at first hand with members of the, Office

of the Surgeon General and with their fellow consultants. The meeting was

considered to be such a success that it was decided that similar ones would be

held at yearly intervals during the remainder of the war.

A second meeting wats hield on 10-11 October 1944, in the Office of the Surgeon General (fig. 3). At this time a more comprehensive program was presented, an outline of which follows.

10 October 1944:

Subject speaker

Demnobilization Plans as They Affect the Service Col. Arthur B. Welsh, MC

Commands

Transfer of Patients From Debarkation hlospitals It. Col. John C. Fitzpatrick, MC

Hospitalization Problems lDr. Hlit Ginzberg

Ciassilication andl Assignment of Personnel Maj. Robert Evans

Reconditioning Col. Augustus Timorndike, MC

Surgery in the Armny Air Forces Lt. Col. Alf red R. Shands, MC

Problemis in X-Ray Col. Ilyri It. Kirklin,.1MC

Photography in time Medical Department Capt. Ralph P. Creer, M1AC

Probleins of CDD (Certificate of Disability for Dis- Cal. Arden Freer, MC

chiarge) and Retirement

Cancer in the Army Col. It. Arnold Griswold, MC

History of Surgery In This War Lt. Col. Michael B. DeBakey, 310

Monthly Statement From the Surgical Service Iii Each Cal. Walter D. Wise, MC

Hlospitai of the Service Command to the Consultant

Anesthesia in the Service Commands Col. Johnl 11. Flick, MC

11 Oct ober 1944:

Subject Speaker

Injuries to Carpal, Navicular, and Lunate 3M0J. Ralph Sol-lali, MC

Management andl Disposition of Cases of Knee Injury Lt. Col. Robert Li. Preston, MC

Maj. Janies J. Callahan, MIC

Varicoccie and Undescended Testis Lt. Cal. Stephens Grahiam, MC

Phlebothromnbosis anil Pulmonary Elmbolisnm Cal. Bradley L. Coley, M1C

Closure of Colostomy Wond~s Cal. Claude S. Beck, 31C

Ophthalmology and the Blind 3M1J. M1. Elliott Randolpht 3C

The Deaf Maji. Leslie H. Mforrissett, 31C

Management and ilsposition of Cases oif Herniated Col. Grover C. Penberthy, MIC. and

NulusPlissMaj. Barnes Woodhall, MC

Use, of Penicillin in Reconstructive Surgery Lt. Col. Thomas Li. Waring, M1C

Infected Hands andl Hand Injuries Lt. Col. Condict W'. Cutler, Jr.,

MNC

The Management of Decubitus Ulcers Cal. I. Minis Gage, M1C

T1he service comnmanid consuiltants wore active in insurinr tile best care and a

rapid turnover of thme thousands of p~at ient as theN were eVaIcuated to the United

States from oversea t heaters. Thley maintainedf ani exceedinglA high level of

professional care iln time mnedical imstallatiomis withinl time Zonle of Interior. They

unified andl impllenmented the int M'Iret at ion of the jrofesiomial pal icieb stated
GENERAL SURGERY 13

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14 ACTIVITIES OF SURGICAL CONSULTANTS

by the Office of the Surgeon General. Their contribution to the care of surgical

patients was more than rewarding, and their devotion to their difficult and

diverse duties was inspiring.

Auxiliary Surgical Teams

In the early days of the war, the Surgical Consultants Division recognized

the potential of the auxiliary surgical groups as a means of bringing definitive

surgical care to the seriously wounded in the forward areas, especially when

the load of battle casualties was too great to be handled adequately by the

staffs of existing medical treatment facilities. Particular interest was tIrefore

taken in expediting the formation of these groups and in the seJection of personnel for the various specialized surgical teams N hich composed the groups.

These groups included teams of general surgeons, neurosurgeons, thoracic surgeons, plastic surgeons, orthopedic surgeons, and anesthesiologists. During the

fiscal year ending 30 June 1943, the Surgical Consultants Division selected and

recommended the personnel for the various teams of four complete auxiliary

surgical groups and for a portion of a tifth. An immense amount of time was

consumed in the selection of medical officers to fill these teams. It was considered of fundamental importance that they be staffed with well-trained

specialists since they were destined to afford the highest type of surgical care

to the wounded in the forward areas. How adequately this was aceomiplished

is indicated by the fact that each officer selected had had an average period of

surgical training of from 3 to 6 years.

These grou)s, though they were not accel)ted readily at first by the theaters

to which they m\ere assigned and not utilized to the best advantage until later,

proved to be of the greatest value. The concept of bringing well-trained surgeons to the seriously wounded, rather than the older one of evacuating the

casualties flr to the rear for definitive surgical care, was logical and sound.

There is little doubt that the adoption of this concept was a potent factor

in the reduction of mortality and morbidity among the wounded.

Surgical Consultants to Field Armies

Further evidence of the Surgical Consultants Division's conviction that the

ebtablishment of a consultant system was of the first importance iii the proper

handling of casualties throughout the Army \ as its interest ill reconimending

and ii implementing the appointlnent of suitably qualified individuals as surgical consultants to the %arious field armies. These positions called for welltrained surgeons i\ho combined a high degree of professional ability with

energy, enthusiaui, and the ability to handle difficult situations in a tactful

yet firm nmai,," When one conidlers that a field army has as its components

those iedical t ,iment facilities vhich give initial surmical care to the

mounded, one can appreciate the need for ,killful .,upervision of the manner

in llhich such t are ,hould be gi en. '[Ine theater cowiultanlc re,l)Omsibility
'GENERAL SURGERY 15

included the field armies within the theater, but those consultants could not

be familiar with the many problems which arose within each army, nor could

they have the time and opportunity to assist in solving them. On the other

hand, the army consultant lived closely withsuch problems, could give them individual attention, and, being a member of the medical section at army headquarters, was in the best position to provide a solution for them. In the majority

of instances the army consultants were selected by the Surgical Consultants

Division. They were as follows:

Army Consultant

In Europe

First Col. J. Augustus Crisler, Jr., MC

Third Col. Charles B. Odon, MC

Ninth Lt. Col. Gordon K. Smith, MC

Fifteenth Col, William F. MacFee, MC

In North Africa and the Mediterranean

Fifth Col. Howard E. Snyder, MC

In both Europe and the Mediterranean

Seventh Col. Frank B. Berry, MC

In the Pacific

Sixth Lt. Col. Frank Glenn, MC

Eighth Col. Frank J. McGowan, MC

Tenth Col. George G. Finney, MC

The importance of the mission which these men performed can best be

expressed in terms of lives saved and the decreased morbidity among the

wounded. They were vigilant as to the fundamental prin, iples of wound

management in the care of battle casualties, they were skillful in the assigninent and allocation of personnel under their control, and they contributed immensely to the promotion and maintenance of the high quality of surgical

care which was afforded throughout the armies.

Staffs for Various Army Hospitals

A personnel problem which was faced throughout the war was that of the

assignment of suitably qualified individuals to key positions in the various

Army hospitals in the Zone of Interior and in the conmunicitions zones of

theaters of operations. The surgical Consultants Division took an active and

zealous interest in the selection and recommendation of medical officers as the

hospitals were being organized. It was especially concerned with the assignment of specialists in the several fields of surgery. After numbered hospitals
ACTIVITIES OF SURGICAL CONSULTANTS

left the United States, the Surgical Consultants Division had no further

jurisdiction over their surgical personnel, but, in the case of Zone of Interior

hospitals, this did not obtain. The surgical staffs of the latter were frequently

being changed as a result of losses to oversea assignments and promotions to

positions of greater importance, and also for various unpredictable reasons.

Thus, it was constantly necessary for the Division to find suitable replacements

and to recommend their assignment. The service command consultants were

of inestimable assistance in this regard and were frequently consulted in an

effort to keep the key positions in Army hospitals filled with the best men

available. The Division was instrumental in defining what was meant by key

positions and in establishing the proper number of suitably trained officers to

be assigned to them. In this connection, a member of the Division sat on the

Kenner Board, a board to study many of the overall problems of medical

personnel staffing in the Army, and suggested revision of the surgical service

in existing tables of organization for all types of Zone of Interior and communications zones of theaters of operations hospitals. Likewise, it contributed

a large share to the formulation of new and revised manning tables for the

existing tables of organization. This task assumed greater importance as the

war went on with more hospitals being formed and with fewer surgical personnel being available with which to staff them. The manning tables became

much more realistic under these conditions and, as revised, eliminated any

criticism of overstaffing.

Extensive surveys were made from time to time concerning the qualifications of medical officers assigned to key positions in general, regional, and

station hospitals in the service commands. As a result, excesses and deficiencies

in -surgical specialists were discovered, and suitable adjustments were made. In

1945, a considerable number of medical officers were transferred from the

Army Air Forces to the Army Service Forces. The Surgical Consultants Division reviewed their professional qualifications, rated them for assignment in

keeping with their professional qualifications, rated them for assignment in

keeping with their abilities, and recommended them for proper assignment.

As a res.,lt of the intimate knowledge of the qualifications of the surgical

personnel in the hospitals in the Zone of Interior, the Surgical Consultants

Division was able to effect an equal distribution of surgical specialists throughout these installations, and such officers were assigned in positions where their

talents were utilized most effectively. In this connection the following facts,

taken from an editorial prepared by General Rankin, chief consultant in

surgery, and published in the April 1945 issue of Surgery, Gyilccology and

Obstetrics, are of interest. The assignments of 922 surgical specialists, quailfled by their respective boards, were reviewed. Ninety-bix percent of these

miien were found to be properly assigned. Of the 922, there were only ;37 who

were not actively emngaged iii performing burgical operations, but each of the

latter was serving as a consultait either ill the Office of The Surgeon Gemeral

or in the service commuamids.
GENERAL SURGERY 17

EQUIPMENT AND SUPPLIES

Among the functions of the Surgical Consultants Division, as outlined in

various directives, was that of consultation in the matter of equipment and

supplies designated for all the component parts of the Medical Department.

Immediately upon its creation as a part of the Professional Service, the Surgery Branch began in 1942 an intensive investigation and examination of those

surgical instruments, devices, sutures, and other materials which were currently

being furnished throughout the entire Medical Department with a view to

eliminating obsolete or unnecessary equipment, substituting and adding more

modern items, and conserving critical materials. This necessitated a detailed

review of ill surgical items on existing supply lists, numerous conferences with

the Procurement Advisory Division and the Supply Branch, and interviews

with many manufacturers and designers of surgical instruments and materials.

At the beginning of the war, surgical instruments were supplied to medical

installations as kits, each containing certain items of equipment. Thus, a general hospital, for example, would automatically be issued 12 number X kits; a

station hospital of a certain number of beds, 6 kits; and smaller installations,

3 kits. This procedure resulted in a tremendous waste of equipment, for in a

general hospital instrument case of 12 kits there would be 12 rib spreaders, 12

kidney pedicle clamps, and 12 of each of many other items of which only 1 or 2

were actually required. Also there would be too few of such essential instruments as hemostats, curved clamps, scissors, et cetera. In addition, there were

many instruments, considered to be essential by civilian surgeons, which were

not on the lists at all. By far the major portion of the task of resolving these

supply problems was completed during the first 9 months of the war, but during

the remainder of the conflict the continuous examination and reevaluation of

surgical items of equipment constituted an important portion of the work of

the Division. As new methods of treatment and hitherto unknown therapeutic

agents were developed, the responsibility for evaluating them and determining

how they were to be tested, used, and allocated to the various Army installations

was that of the Surgical Consultants Division.

Revision of Supply and Equipment Lists

In the attempt to revise the lists of basic specialty instruments, certain difficulties were encountered and were concerned primarily with manufacturing

details. This was due to the fact that a large number of these precision instruments had always been imported and, when this supply had terminated at the

onset of the war, it became necessary for the manufacturers in this country

to establish their own tooling process and to train personnel in this specialized

craft. Accordingly, in revising the lists of basic and specialty instruments, this

was kept in mind since it was necessary to conform to the ability of manufacturers to obtain requisite materials and to meet the supply requirements in an

expeditious fashion. Great credit is due the manufacturers for their ability
18 ACTIVITIES OF SURGICAL CONSULTANTS

to overcome these obstacles and to supply quickly equipment of standards equal

to, or even higher than, the standards of that formerly available.

It would be difficult to name all the results and advantages of these activities. Some of the more important of these included t complete revision of

lists of suture materials and needles. In suture materials alone, considerable

economy was effected by the deletion of large quantities of expensive cattgut and

the substitution of cotton and silk thread which was not only much less costly

but actually better suture material. Similarly, certain types of suture needles,

the use of which did not predispose to good surgery, were taken off the lists

entirely and proper ones substituted. In addition to such changes, recoinmendations were made for the deletion of numerous surgical instruments and

articles which were no longer in common use and for the addition of more

recent equipment necessary for the performance of the most modern surgical

procedures. Examples of the latter were the addition of needles suitable for

performing sympathetic block to relieve vasospasm associated with injuries of

the upper and lower extremities, physical therapy equipment for varioussized hospitals, X-ray equipment and foreign-body locators, and adequate apparatus for gastroduodenal suction. The contents of several types of medical

chests and first aid kits were revised.

Other results obtained which were worthy of special mention were recoimnendations for the complete surgical equipment for a surgical operating truck

and for the portable hospitals. Equipment lists of surgical items for the evacuation hospitals and the 500-bed general hospital were reevaluated and revised.

Suggestions for the addition of specialized instruments for the special surgical

centers were also made. Thus, for the neurosurgical and vascular centers,

special items, such as electrical cutaneous apparatus, oscillometers and thermnocouples, were provided. The entire list of anesthetics on the supply catalog

was reviewed with the purpose of determining their adaptability to an overall

Army policy concerning such agents based on simplicity, safety, and anesthetic

efficiency. On the basis of this review, the number of anesthetic agents was

reduced from 19 to 12, and War Department Technical Bulletin (TB MED)

43, Local Anesthetic Agent, was published on 18 May 1944. Recommendations

were made concerning the procurement and preparation of cotton waste and

1,etrolatuni-impregiated gauze for the care of burns, and thebe items were added

to the supply catalog. The Divison also aided in the preparation of tile list

of supplies for civilian aid iii occupied countries and for Americans who were

held prisoners of war by the enemy.

Central Supply Service in Hospitals

A" a nieanb of conserving certain medical supplies and of extending their

period of u.efuhiehb, the Surgical Consultantb Division in February 1943 propo-ed the establihmmenit of a central service s teire adaptable for utilization in

a'iou,s tation and gelneral hospitals. This -stem Cnslisted essentially of a
GENERAL SURGERY 19

centralized agency where equipment which was used for certain diagnostic and

therapeutic procedures, particularly in preoperative and postoperative care,

was to be prepared and dispensed. Among these items were those employed

in the performance of transfusions and intravenous medication, wound dressings, spinal puncture, thoracentesis, catheterization, gastric lavage, and oxygen

administration. These pieces of equipment were of the sort that might be used

for any patient but only as the occasion demanded. Their constant presence on

each ward was obviously unnecessary and, consequently, entailed expenditures

for unreasonably large quantities of supplies. It was apparent, therefore, that

the institution of a centralized agency responsible for the maintenance, proper

preparation, and dispensation of these supplies not only would permit greater

utilization from a smaller total quantity of supplies but also would mean greater

care, longer life, and a readier responsibility for many critical supplies. Likewise, a considerable saving could be made by the more effective utilization of

personnel. The proposal of this system was considered particularly important

in view of the tremendous burden imposed on the medical supply facilities by

the rapidly expanding Army. This burden was being increased steadily by the

fact that the availability and production of many articles were becoming

critically limited.

The recommendation by the Surgical Consultants Division that the centralized type of agency be established in both general and station hospitals met with

the instant and unanimous approval of all concerned in the Professional Service, but it took a great deal of time to convince the Supply Division that the

plan was a good one. A whole year elapsed before the plan was finally approved by all concerned, and War Department Memorandum No. W-40-44,

Central Service System in Army Hospitals, was published on 12 April 1944,

authorizing the establishment of this system which functioned with eminent

success throughout the remainder of the war.

Penicillin

Early in 1943, the new antibiotic, penicillin, was attracting attention on

account of its highly promising therapeutic possibilities as revealed by preliminary clinical and laboratory observations made both in England and in the

1 -ited States. The enormous potential value of this drug in military surgery

was quickly realized by the Surgical Consultants Division. There were many

conditions which, if they responded to this agent as accurately as seemed indicated, were of frequent occurrence among military personnel and constituted

serious problems from the standpoint of decrease in manpower, increase in hospitalization, and the imposition of added burdens on medical personnel and

medical facilities. It was evident that the therapeutic possibilities of penicillin

should be quickly and effectively explored. The limitedl productibility of penicillin at that time greatly restricted its clinical and experimental use. The

manufacture of the drug was a slow and laborious process as well as a very ex-
20 ACTIVITIES OF SURGICAL CONSULTANTS

pensive one, the drug was in great demand by the civilian population, and there

was very little to be had by anyone. It was obvious that, if the Army was to

evaluate properly this therapeutic agent, it needed the lion's share of the available material and had to proceed promptly with a thorough clinical trial of this

new drug.

It was for these reasons and in order to ascertain more exactly the usefulness of this agent, to determine its indications and contraindications, and to

standardize the therapeutic procedures associated with its use, that the Surgical

Consultants Division, with the cooperation of the Committee on Medical Research of the Office of Scientific Research and Development, established a prograin to conduct intensive investigative studies on wound infections and sepsis

in a limited number of general hospitals in this country. The first unit in this

program was Bushnell General Hospital at Brigham City, Utah, and it began

to function on I April 1943. A second unit was established at Hlalloran General

Hospital, Staten Island, N.Y., on 3 June 1943. For the first few months, these

institutions were centers for clinical and some experimental work with the drug.

Emphasis was placed on the type of case which was suitable for treatment, on

the most effective dosage, on the route of administration, on the length of treatment, etcetera. As soon as these liad been determined with reasonable accuracy,

the two centers were used as schools in penicillin therapy for medical officers

from other army hospitals which were later to be engaged in this program of

evaluating penicillin. As more and more such officers were trained and as

more and more of the drug became available, additional general and station

hospitals were placed in the program.

In order to assure a certain degree of standardization and homogeneity in

the overall study, each of the officers trained in penicillin therapy in each hospital was charged with the full responsibility of determining the cases to be

treated and the details and procedure in their treatment, of acquiring necessary

laboratory studies, and of maintaining and forwarding to the Surgical Consultants Division in the Office of the Surgeon General all of the case records.

The Division analyzed all such reports, tabulated them, and made an accurate

evaluation of them. In this way, an immense amount of quite accurate information was quickly obtained with the least waste of a scarce )roduct. This

information was rapidly disseminated to all medical officers throughout the

Army by the Office of the Surgeon General and to civilian physicians b) papers

published in the Journal of the .inu rican Medical .tsociution or by addresses

given before several medical and surgical societies. For example, an article

was published in the 18 December 1943 issue of the Jour'nal of the American

Medical Associatioti by Maj. Chamnp Lyons, MC, who was in charge of the

studies at Halloran General Hospital, dealing with 209 cases treated with

penicillin. Major DeBakey of the Surgical Consultants Division participated

in a panel discussion devoted to penicillin at a meeting of the American Medical

Association in June 1944 and reported on the use of penicillin in the treat-
GENERAL SURGERY 21

ment of over 1,500 cases of surgical infections of various kinds including 74

cases of septicemia, 169 cases of infection of the skin and subcutaneous tissue,

152 cases of wound infection, 62 cases of abscess, 78 cases of gas gangrene, 138

cases of septic compound fractures, and 265 cases of osteomyelitis. Colonel

Carter gave a similar presentation to the Kentucky State Medical Association

on 19 September 1944. Members of the Division prepared numerous articles

on penicillin for the Bulletin of the Army Medical Department, as well as

several circular letters and a technical bulletin on the subject. The Surgical

Consultants Division endeavored to maintain and advocate an open mind concerning the effectiveness of this drug and prevented the publication of many

papers by medical officers which would tend to indicate that penicillin was a

panacea in the treatment of all surgical diseases.

Until adequate amounts of penicillin were made available to all medical

installations throughout the entire Army by the remarkable ingenuity of the

manufacturers, it was necessary to allocate the drug to those installations, both

in the Zone of Interior and in the theaters of operations, in which it could be

utilized most effectively. For this purpose, a penicillin board was set up in

the Office of the Surgeon General. The board met at weekly intervals and did

much to insure the proper distribution of the drug. A member of the Surgical

Consultants Division sat on this board and, with the background of the information obtained as noted above, was able to contribute greatly to the effective functioning of his body. It can be safely said that both the investigative

study sponsored and controlled by the Surgical Consultants Division and the

Division's effort concerning the proper distribution of penicillin played a most

important part in furthering the proper and prompt usage of this very valuable

drug.

PUBLIC RELATIONS AND LIAISON

Throughout the war, the Surgical Consultants Division consistently endeavored to maintain close rapport and liaison with various institutions and

organizations including the National Research Council, medical schools, civilian

surgeons, and surgical and medical societies. It was believed that a closer

cooperation with and support to the Office of the Surgeon General would be

afforded by these important organizations if such a relationship was established. This purpose was greatly facilitated by the fact that the chief surgical

consultant, General Rankin, was president of the American Medical Association, vice chairman of the American Board of Surgery, and president of the

Interstate Post-Graduate Assembly. In additi 'n, other members of the staff

of the Division were active and well-known ra embers of various surgical organizations. Considerable effort was expended by the Division in this direction

from the beginning to the end of the war. Some of the more iml)ortant contributions of the Division toward the establishment of this important

relationship are given in the following paragraphs.
22 ACTIVITIES OF SURGICAL CONSULTANTS

During April, May, and June of 1942, the American College of Surgeons

conducted a series of war sessions in representative cities throughout the

country. These sessions were attended by thousands of surgeons, and in each

of them a member of the Division participated importantly. He outlinedthe

organization of the Medical Department which had been set up for the care

of battle casualties, discussed many of the surgical problems of military significance, and presented the current methods used by the Army in the

management of wounds, burns, shock, and fractures.

At the second series of war sessions held in 1943, a paper entitled "The Care

of the Injured in the Combat Zone" was prepared by members of the Division

and was presented by various medical officers. This paper received such favorable comment that it was published in the bulletin of the College. Again in

1944, another series of war sessions was held. At this series, a paper entitled

"War Wounds of the Extremities" was read by designated Medical Corps officers at the various meetings. The paper was prepared by members of the Division. At these sessions, a film was also shown which had been especially

prepared by medical officers in the Division. The film was entitled "Evacuation

and Care of Battle Casualties." This motion picture was so popular that it was

necessary to show it several times during each meeting, rather than only once

as had been originally )lanned. These sessions proved to be eminently successful in disseminating the existing knowledge which had been acquired in the

care of the sick and wounded. They stimulated the interest of the civilian surgeons in the Medical Department aid did a good deal to promote their seeking

commissions as Medical Corps officers.

At frequent intervals during the war years, the Division prepared papers

for presentation by its members, by The Surgeon General, and by various members of the Office of the Surgeon General at formal and informal gatherings,

surgical society meetings, and lay meetings. Such papers dealt with the current

and future activities and the personnel requirements of the Medical Department

of the Army, considerations of military surgical problems, detail of the care

of various types of war wounds, reviews of the accomplishments and contributions of the nedical profession during the war, rehabilitation of the wounded,

amputations, the use of plasma and whole blood, and similar subjects. Many

other papers were prepared for delivery at dedication ceremonies, manufacturing meetings, commencement exercises, and radio programs. Approximately

175 of these papers were prepared. Presentations of strictly surgical subjects

were made at meetings of the leading surgical societies such as the American

Surgical Association, the American College of Surgeons, the Southern Surgical

Association, the American Association for Tihoracic Surgery, the American

Medical Association, the American Academy of Orthopedic Surgeons, and the

American Orthopedic Association. Not only did these papers serve as a valuable public relations function but tlicy contributed importantly to the surgical

literature, and most of then can be found in the national surgical journals of

that period. Addresse were given by members of the Division. Still others
GENERAL SURGERY 23

were prepared for delivery by The Surgeon General at meetings of the Southem Medical Society. service command hospital gatherings, meetings of the

editors of State medical journals, the Council on Medical Education, the trustees of the American Medical Association and the House of Delegates of that

association, and several State medical societies. The Surgeon General also

spoke at dedication ceremonies of numerous military and civilian hospitals and

memorial buildings and at presentations of a considerable number of "E"

awards to industrial plants. These addresses did much to keep a wide segment

of the population informed concerning the accomplishments of the Army in

the surgical care of the sick and wounded.

Every effort was made to maintain a close liaison with the National Research Council. Members of the Division were in frequeat attendance at appropriate committee meetings of the Council including those of the Surgical Cominittee and the subcommittees on faciomaxillary injuries, blood substitutes,

orthopedic surgery, ophthalmology, burns, gas casualties, and surgical infections. Problems which confronted the Medical Department of the Army were

presented before these committees for investigation and solution, while, on the

other hand, recent developments, advance,,, and innovations which had resulted

from research activities and investigative studies of the National Research

Council were given to the Army for evaluation and for possible use. The assistance which the Council rendered the Armed Forces was invaluable, and great

credit is due it for its unfailing cooperation and devoted service. Without its

help, many problems would have remained unsolved, many lives would have

been lost, and much valuable information would have been long delayed in

reaching the military forces.

It would not be feasible in this volume to give a detailed account of the

many surgical problems which were considered at the Council meetings or of

their solution or rejection. Some of the more important ones were the evaluation of the use of the sulfonamides in surgical infections, the preparation and

preservation of plasma, the viability of the red blood cell, the use of serum albumin, the methods of prolonging the safe use of whole blood, the design for a

suitable container for oversea shipments of whole blood, the evaluation of the

usefulness of penicillin, the proper management of burns, the development of a

toxoid for gas gangrene, foreign body locators, tantalum wire and film, and

nerve suturing. A most kindly and cooperative relationship existed between

the Council and the Surgical Consultants Division. At times, however, when

the Army rejected a Council proposal as an impractical measure or as a plan

which could not be adapted to its complex organization and varied personnel,

the atmosphere would become a bit strained. But such incidents were rare, and

the meetings of the Council committees were enjoyable and most profitable.

Numerous advances and developments in many fields of surgery were evolved

and were promulgated in Army medical practice through this valuable reciprocal relationship between the Army and the Council.
24 ACTIVITIES OF SURGICAL CONSULTANTS

REVIEW OF MANUSCRIPTS AND LITERATURE

All articles written by officers of the Medical Department were required to

be submitted to the Office of the Surgeon General for approval before publication. This was in accordance with paragraph 8, section III, Circular Letter No.

1, Office of the Surgeon General, dated 1 January 1943, with Circular Letter No.

192, Office of the Surgeon General, dated 20 November 1943, and with Army

Regulations No. 310-10, dated 27 February 1943. It was required that all articles which dealt with surgical subjects be reviewed by the Surgical Consultants Division, that their suitability for publication be determined, and that, if

approved, further clearance be obtained from the Bureau of Public Relations,

War Department. One of the time-consuming functions of the Division was

the review of all these manuscripts on surgical subjects which were submitted

by medical officers as well as those by civilian newspaper and magazine correspondents reporting on the activities of the Medical Department. A conscientious effort was made to review such articles and to present constructive criticism to the authors. In general, the manuscripts were classified into three

groups; namely, those which were approved for publication elsewhere than in

the ldletin of the U.. Arimy Medical Department, those approved for publication in the Bulletin, and those disapproved. In the latter category, the Office

of Technical Information returned the paper to the author with a letter outlining the criticisms of the Office of the Surgeon General and the reasons for disapproval. The paper could be rewritten, if desired, in accordance with this

letter and resubmitted. Many such instances occurred.

These articles were reviewed according to certain criteria; that is, that the

contents did not reveal information of value to the enemy, did not break the

rules of medical ethics, did not show serious literary or scientific errors, did not

contain malicious, foolish or frivolous matter, did not purport, without the

proper authority, to represent the official attitude of the Army or the Medical

Department, and did not harmfully criticize an agency of the Government or

those of our Allies. The vast majority of these articles, if approved, were transmitted directly to that journal in which the author had requested its publication.

The importance of this review function was far greater than might at first be

realized. A certain number of the papers which were prepared by medical officers were poorly written and often filled with inconsistencies. It was therefore of considerable importance that they be reviewed for professional content

and that appropriate recommendation be made to the authors as to the suitabilit3

of the articles for publication. Since the approval of the Surgical Consultants

Division had to be obtained before publication could be considered, most medical officers were stimulated to prepare their manuscripts more carefully. In

addition, since the authors knew that any article published had to be approved

by the Division, it was considered that its publication was tantamount to endorsemnent by the Office of the Surgeon General of the therapeutic methodb described. In view of these facts, the Division was extremely cautious in the
GENERAL SURGERY 25

selection of material for approval. It was obviously impossible to approve

papers which were in conflict with stated policies of the Office of the Surgeon

General. In a few instances, papers contained observations which in civil

practice would deserve publication but which were disapproved by the Division

because of the interpretation in terms of Medical Department policy which other

medical officers would attach to publication.

An example of such a possibility was a paper received by the Division

regarding the successful control of ether convulsions by curare. This case

report was of interest and would have been approved for publication had it

not been for the fact that curare was known to be a dangerous drug and one

about which most medical officers knew very little. Furthermore, it was not

a standard item of supply. Had the paper been published, there was little

doubt that in the light of past experience, this office would have received

numerous requisitions for this agent for use in similar related conditions. It

is obvious that the widespread use of such a drug as curare by men incompletely

informed as to its pharmacological actions would have been highly undesirable.

Papers which appeared to be particularly suitable for publication in the

Bulletin of the U.S. Amny Medical Department were so recommended, and

the author usually agreed to that procedure. In the cas" of particularly important papers for which the authors requested publication in specific journals

(such as Surgery, Gynecology and Obstetrics; Annals of Surgery; or the

Journal of the American Medical Association), no insistence was made that

such material be published in the Bulletin. However, abstracts of such articles

were frequently prepared for that publication, and in some instances an entire

article was reprinted.

The number of articles submitted for review by the Division increased

steadily each year of the war. For example, in the month of January 1942

there were 39; in January 1943, 119; and in April 1943,163. The average number of articles received each year for review was approximately 850. The

usual percentage of rejection was about 23. In addition to these articles, the

Division was called upon to review innumerable surgical textbooks and similar

publications on surgical subjects to determine their suitability for use by the

Medical Department of the Army.

EDUCATION AND TRAINING

It quickly became apparent to the Surgical Consultants Division that it

should emphasize and be concerned importantly with education and with

training. In order to accomplish these functions, it was necessary to mork

closely with the. Plans and Training Division and m ith the Army Medical

Museum in an active initiating capacity as well as in an advisory one. Not only

was the preparation of instructional aids and literature on various surgical

sul jects an important function of the Surgical Consultants Division, but in

addition it was imperative that the Division )rovide the proper media through

which such material could be diseminated effectively throughout the Army.
26 ACTIVITIES OF SURGICAL CONSULTANTS

Publications

At the beginning of the war, the National Research Council undertook the

task of preparing various war manuals dealing with those medical and surgical

conditioii, which were important from a military viewpoint. The Surgical

Consultants Division, with the information it had acquired from reports from

surgical consultants in the United States and abroad, from personal contacts,

and from bulletins received from theaters of operations, was in a position to

offer considerable assistance and guidance in the preparation of those manuals

dealing with surgical subjects. For example, the war manul on abdominal

injuries was largely prepared by the Surgical Consultants Division and was

revised from time to time to include new material, such as compression injuries occurring in individuals who were partially submerged in water in the

region of depth charge or torpedo explosions. The manual on transfusion

therapy was critically reviewed, and suggestions were made for its revision.

The Division collaborated in the preparation and critical evaluation of all

other manuals concerned with surgical subjects. In an effort to make available

to medical officers the best current surgical opinion on war injuries, copies of

the war issues of the Bulletin of the .1 merhian College of Surgeons, which contained the most modern account of the management of war injuries, were

acquired, apportioned, and distributed to all general and station hospitals

both in the continental United States and abroad.

During the first year of the war, Technical Manual 8-210, Guides to

Therapy For Medical Officers, was critically reviewed, and recommendations

for changes and additions of new material were made., A new Field Manual

21-11, First Aid for Soldiers, was written by the Division during this same

period in cooperation with the Medical Consultants Division. A great deal

of time was spent in the preparation of tlhi manual. There were numerous

conferences with artists and photogralmers at Carlisle Barracks, Pa., and with

representatives of the Quartermaster Corps who had arctic experience concerning equipment, suplplies, and procedures as related to first aid for the sick

and wounded in extreme cold and snow.

In the early part of 1943, the preparation of a new book, "Surgical Anatomy for Medical Department Personnel," was begin, since the existing one had

become difficult to obtain and was in ineed of simplification and revision. Many

hours were spent in conference with Mr. Tom Jones, the medical artist w\ ho was

engaged in editing this volume, regarding the t3 pes of illustration, methods

of presentation of material, and the material to be included. Several months

later, the volume appeared and was most enthusiastically received. In addition to the large size for libraries, a pocket-size relume was published for

medical officers. The Surgical Consultants Division took a large share of the

credit for this book. which furnished to Medical Department personnel a

compact, simple, and beautifully illustrated surgical anatomy.
GENERAL SURGERY 27

Visual Aids

A C a liaison was maintained throughout the war with Col. James E.

Ash, M(, and his staff at the Army Medical Museum in an effort to make

available various types of material for the education and training of Army

personnel. Among the results of this cooperative association and effort were

the moulage models of war wounds, which depicted so graphically the anatomy and the pathology of these injuries; the collections of lantern slides

depicting a wide range of surgical conditions, operations, methods of evacuation, and other subjects; and a library of motion pictures portraying the many

phases of the surgical activities of the Medical Department. The collection

of lantern slides which was inaugurated by the Surgical Consultants Division

was unusually complete. This resulted from the fact that, at regular intervals,

a member of the Division reviewed the great volume of photographs which

poured into the Army Medical Museum and selected material which was suitable for inclusion in the collection. This collection proved invaluable as a

source of illustrations for lectures, training programs, and history.

Motion pictures were considered to afford the most effective medium for

training, orientation, and teaching. Accordingly, the Division took a special

interest in them. It was active in the selection of pertinent subjects - r portrayal by this means, in the collection of film from overseas and in this c, ,ntry,

in the integration of material into a complete motion picture, and finally in

the actual production of the finished product. Innumerable obstacles were

overcome in this field of endeavor, the chief of which was the difficulty in

getting the Signal Corps of the Army to process film, to splice it, and to furnish

sound tracks and titles. It was actually necessary in the beginning of the

motion picture program to have the work done in commercial studios or to

seek the aid of the U.S. Naval Photographic Science Laboratory in Washington. The hitter institution was extremely cooperative, and much credit is

due it for its prompt, willing, and excellent assistance. Various members of

the Division literally mured these motion pictures along and were solely

responsible for their production. After the value of these pictures was appreciated, their production through the Signal Corps became much easier. InI

order to insure the acquisition of well-prepared motion pictures on important

clinical problems relating to military surgical conditions, it wvas considered

desirable that the Office of the Surgeon General obtain the services of an experienced clinical photographer, who could be sent to various medical installations for the pl)eparation of such films. Mr. Milton Trauber of New York

City was appointed consultant in graphic surgical technique in March 1945.

Hi-, choice was an excellent one. and under his direction many thousand feet

of film were produced in the general hospitals in the United States. Such

films dealt with varied conditions among which were the convalescent care

and rehiabilitatitn of spinal cord injurie.-, the treatment of traumatic osteonm3 e-
28 ACTIVITIES OF SURGICAL CONSULTANTS

litis, repair of peripheral nerve injuries, and operative procedures in the care

of penetrating wounds of the chest.

In summary, it can be said that, by its active interest and perseverance,

the Surgical Consult, nts Division was responsible for the collection, the actual

preparation, and the filing of a library of still and motion pictures which was

of immense value in the orientation, training, and education of Medical Department personnel. The historical value of such a collection is immeasurable.

Medical Bulletin

The Surgical Consultants Division was intensely interested in the subject

of dissemination of professional information to medical officers and made

numerous attempts to provide suitable media for this purpose. This was considered an important function of the Office of the Surgeon General and essential

for the maintenance of the health of the Army. Statistical data, factual

knowledge, and various new developments about diseases, injuries, and surgical

equipment vere being obtained at frequent intervals by the Division from

numerous sources. This information was continuously being analyzed, interpreted, condensed, and translated into proper military form and, because

of its vital significance, had to be disseminated promptly and regularly and

made available to every medical officer. Accordingly, the Division repeatedly

urged, during the first years of the war, the adoption of a well-integrated

program for disseminating information and the establishment of a suitable

medium for such transmission. It was proposed that this medium be distinctive in content as well as in format and that it appear monthly with the period

elapsing between the preparation of the material and its publication, not to

exceed one month. Accordingly, it was first recommended in June 1943 that

the then existing Army Medical Bulletin which was published every three

months be reconstituted to answer this purpose. This and several similar

recommendations were disapproved, but finally such a program was approved,

and in October 1943 the first issue of the Bulletin of the U.S. Army Medical

Department, a monthly publication, appeared. The welcome reception the

latter publication received together with the fine comments concerning it fully

justified the efforts expended in producing it.

In order that the Bulletin might truly represent a valuable source of the

latest information on pertinent and timely problems relating to military

surgery, the Surgical Consultants Division contributed many articles for publication within its pages during the remainder of the war. It was the opinion

of the Division that succinct statements of important fundamentals of military

surgery repeatedly emplasized in the Bulletin would constitute a real and

effecdve means of maintaining a high level of surgical care throughout the

Army. This publication also afforded a medium through which medical

officers in forward echelons could be kept informed of the results which were

being obtained by the Medical Department as a whole. The Division contributed 90-odd articles to the Bulletbii during the war years. A complete list
GENERAL SURGERY 29

of these would be out of place here, but it might be stated that among the

varied subjects were penicillin, aneurysms, trenchfoot, immersion foot, cyclopropane anesthesia, pilonidal sinus, quadriceps deficiency, wounds of the rectum, blast injuries of the ears, tropical ulcers, morphine poisoning, tourniquets,

new gas casualty set, clinical significance of the Rh factor, acute infections of

the hand, and parachute surgical teams.

Directives

Other media for the dissemination of information consisted of circular

letters from the Office of the Surgeon General, War Department circulars, TB

MED's, and command letters of the Army Service Forces, These were distributed through command channels and for this reason did not necessarily

reach each medical officer. In fact, many officers stated that they did not

receive many of these directives which would have been most helpful to them.

The Surgical Consultants Division was active in contributing a great deal of

informative material for these directives throughout the war. In the earliest

days of the war, the circular letters of The Surgeon General were the most

frequently used medium. Again, it would not be feasible at this point to list

all such contributions, which were quite numerous and dealt with varied conditions and situations, Approximately 20 circular letters, 15 War Department circulars, 5 Army Service Forces letters, 10 directive letters to service

commands, and 20 TB MED's were prepared by the Division from 1942 to the

end of the war. The importance of these directives was emphasized by the

fact that one of the most urgent functions of the Surgical Consultants Division

was the definition of professional policies which governed many aspects of

surgical practice throughout the Army. The fact must be emphasized that

there was a wide variation in the professional abilities of medical officers. In

certain instances the application in the Army of certain surgical procedures,

therapeutic measures, or drugs used in civil practice had to be prohibited.

This was necessary in order to minimize undesirable results or untoward accidents known to occur when all medical officers were permitted to use the particular procedures, methods, or drugs in question. The directives noted above

constituted the means by which professional policies were defined.

Reference has already been made to the effectiveness of the report, Essential Technical Medical Data, as a means of obtaining accurate information

concerning the care of the sick and wounded in theaters of operations. This

information, when received, could then be transmitted to the other theaters as

well as to installations in the Zone of Interior. It became apparent that such

data should alro be obtained in the same fashion from medical installations in

the continental United States, and memorandums requesting this were sent to

the proper authorities in the Office of the Surgei'm General. These requests

were refused. The value of such reports with sections devoted to professional

problems encountered and results achieved in Zone of Interior facilities , ould

have been of great value not only to the Office of the Surgeon General but albo
30 ACTIVITIES OF SURGICAL CONSULTANTS

to theater surgeons and their consultant staffs. It was difficult to provide a

clear concept of therapeutic objectives, as visualized by specialists overseas, to

medical officers in the United States. Similarly, the problems confronting

specialists in the Zone of Interior and the results achieved in cases which received initial care overseas were unknown to medical officers in theaters of

operations. It is earnestly recommended that, in future conflicts, reports similar to the Essential Technical Medical Data report be required from both

theaters of operations and Zone of Interior commands.

On-the-Job Specialty Training

Owing to the sLortage of surgical specialists, including anesthesiologists,

training schools wer, instituted at certain designated medical schools throughout the country in the first year of the war. Tie courses given were for a 3-

month period. The selection of individuals to take these courses was the responsibility of the Training and Military Personnel Divisions in the Office of

the Surgeon General. The Surgical Consultants Division never endorsed these

courses and, in fact, was generally opposed to such a method of attempting to

train a surgical specialist at a medical school by lectiure and demonstrations

in so short a time. Many of these courses proved fruitless. As tle war went

on and the load of work increased in the general hospitals in the United States,

the Surgical Consultants Division suggested that medical officers with the

proper background be sent to these installations and assigned to specialist

services for on-the-job training. Since the nunber of such officers in any one

institution was small and since they could be supervised by certain of the

Army's outstanding specialists, the results were very satisfactory, and a considerable number of men were trained in this way. This was especially true in

the case of neurosurgery and in anesthesia. In the latter category, there was

an unusual shortage of trained personnel, so that nurses were trained in anesthesia in the Zone of Interior by the above method. This did much to release

physician anesthesiologists for oversea duty. In line with this policy of onthe-job training, the Division successfully recommended that, rather than give

refresher courses to those medical officers returning from extended tours of duty

in nonprofessional assignments or in assignments which had afforded limited

surgical practice, these officers be assigned as ward officerb or assistants in general or large station hospitals in the Zone of Interior in their specialty. Many

officers were thus assigned and were able once more to take up an active practice in the specialty in which they had been interested.

In cooperation with the Medical Advisory Board, the Surgical Consultants

Division established a program by which it would be possible to provide

medical officers who were candidates for certification by specialty boards to

obtain credits for training and experience in the respective specialties acquired

during military service. A Medical Officers Service Record was prepared

whiich, when properly completed, would proA ide authentic data for the variou6
GENERAL SURGERY 31

committees on eligibility of the American Specialty Boards for evaluation of

the experience which had been acquired by the medical officers.

CONSULTATION

It is evident from the preceding pages that the majority of the activities

of the Surgical Consultants Division were in reality of a consultative nature.

M,-qtion has been made of the efforts to procure and disseminate surgical

rmation to medical officers, to guard against certain surgical practices

.11ch were not considered proper, to supply adequate amounts of drugs and

equipment, to train and educate Medical Department personnel, and to assign

surgical personnel in the most effective manner. However, little has been

said thus far concerning the paramount function of the Division in strictly

professional consultation as related to the surgical management of the sick

and wounded. Since the staff of the Division was never engaged in the actual

surgical care of such individuals during the war, its consultative contributions

to clinical surgery in the Army stemmed of necessity from each staff member's

own background of surgical training and experience, from his knowledge of

sound surgical principles, and from his ability to evaluate the mass of surgical

data which was being received constantly by the Division. Thus, it was

necessary for the Division staff to analyze the multitude of reports which

were received from many sources throughout the Army, to evaluate their

contents in an effort to determine those surgical conditions which were assuming

importance as the war progressed, and to make certain that such conditions

were being managed in accordance with the most effective methods. Also,

it was the responsibility of the staff to ferret out and to prohibit surgical

practices which experience had shown to be dangerous or outmoded, as well

as to recognize and make mandatory by directives those practices which had

been proved to be most satisfactory. As has been stated previously, The

Surgeon General had complete authority in the Zone of Interior, and there the

enforcement of directives was readily accomplished. The service command

consultants were invaluable in disseminating the information gained by the

Division and in enforcing those policies recommended. The visits of members

of the Division to service commands were also very effective in this regard.

Reference has been made to the role which the Division played in the

early recognition of the military potentialities of penicillin and in its prompt

evaluation and proper use. Similar reference has been made to the use of

plasma and whole blood. In addition, there were a numbei of other instances

in which the Division was alert to the clinical application of laboratory investigations, the importance of certain surgical conditions from a military viewpoint, and the necessity of ad ocating measures for their proper management.

Several of these will be commented upon, but, since they have been dealt with

in detail in volumes of the history of the Medical Department, United States

Arm.v in World War II which are concerned with surgery, they will be described very briefly here.
32 ACTIVITIES OF SURGICAL CONSULTANTS

Trenchfoot

Perhaps the most unsatisfactory experience of the war was that concerned

with trenchfoot.2 The entire story of this condition was a ad one particularly

in view of the fact that the condition was preventable and in view of the fact

that the Surgical Consultants Division early in 1943, as a result of the experience on Attu, directed attention to the need for anticipating its widespread

occurrence. The complete story may be obtained from a section of the 1945

fiscal year report of the Division prepared by Colonel DeBakey. Colonel

DeBakey was intensely interested in this condition from the time of the

receipt of the first reports in 1943 concerning its occurrence. He warned

against the seriousness of this disease from a military point of view and

pointed out the measures by which it could be prevented or, if already contracted, how it should be treated. There was an impenetrable indifference to

his warnings and suggestions until the condition became one of major military

importance as a result of the terrific loss of manpower which it caused among

combat troops. Colonel DeBakey's account follows.

In the 1943-44 annual report of the Surgical Consultants Division, it was stated that

the high incidence of trench foot among troops in Italy during the winter of 1943-44 represented "perhaps the most unsatisfactory experience of the war." It was further stated

that "It is hoped that the measures now being instituted will prevent a recurrence of this

unsatisfactory experience." Unfortunately, this hope was not realized. During the

winter of 1944-45 in Western Europe the problem of trench foot assumed alarming proportions, exceeding by far in severity the situation In Italy during the previous winter. In

fact, no military force in the field with the possible exception of Napoleon's armies in the

War of 1812 has ever experienced such a devastatingly high incidence of cold injuries.

In vtk.w of these facts it is considered of Interest and in order for this year's annual

report to rcvlo,v the role which this division played in the trench foot problem. It is

neither the purpose nor intent of this report to )oint an accusing finger at any other

branch, division, service or corps as being responsible for this tragic experience. The

main objective is to record as faithfully and as accurately as possible the activities of

tills division for the considration of any voho in the future may be interested in them.

With this purpose in mind the following remarks are presented:

Between 11 May 1943 and 11 June 1943 there were 3,829 hospital admissions on Attu,

1,200 of which were listed as disease resulting from "exposure." Due significance was

attached to this obser'ation by a number of divisions in the Office of the Surgeon General,

among which was the Surgical Consultatits Division. The immediate implications of this

experience in terms of future operations in Europe were more acaitely appreciated by those

who were informed on the experiences with cold injuries among military forces of previous

wars. On 2J July 1943 a meeting was held in the Research Coordination Branch on the

Effects of Cold, and certain principles of first aid or emergency treatment were adopted

and preventive imeasures discussed. A memorandunt prepared by the Research Coordination Branch of the Operations Serxice for The Surgeon General and concurred in by the

reliresentatives of interested divisions presented a resume of the discussions and recommendations of this group. The Surgical Consultants Division began to devote considerable

attention to this problem which, although of negligible importance as far as the Arm3 's

experiences at that time viould indicate. im as appre i'ted as a condition N hici could become

2For t1w histr. of trenchfaot In World War IL ,o Nillcal levarp rint. t i 'United State- %rin3.

Cold Injury. Ground "l' o \\'a,shinglon 1' , (I" 'm lelllit Printing Office. 19 1,
GENERAL SURGERY 33

one of tremendous significance in the inevitable future large scale operations in Europe.

On 23 August 1943 this division prepared a memorandum on "Revision in accordance

with modern concepts of military publications on the subject of injuries resulting from

cold" for Brigadier General C. C. Hillman, who was Chief of the then existent Professional

Service of the OTSG. The last two paragraphs of this memorandum read as follows:

"3. No reference is made to the conditions of 'immersion foot,' 'trench foot' and 'shelter

feet' in any of the Field or Technical Manuals except FM 21-11, First Aid for Soldiers.

In view of the importance of these conditions and their disabling effects it would seem

desirable to disseminate, especially through the medium of manuals, information concerning their prevention and treatment.

"4. It is, therefore, recommended that these subjects be brought to the attention of

appropriate agencies of The Surgeon General's Office for correction. This Surgery Division

is prepared to cooperate in the publication of this material."

Besides conducting a review of the literature on the subject of cold injuries, which

included the relat-d conditions of trench foot, immersion foot, frostbite, and high altitude

frostbite, this division carried on extensive correspondence with Colonel Luther Moore of

the Alaska Defense Command regarding all phases of cold injuries in that command.

Likewise the Office of the Base Surgeon, Greenland, was contacted and information obtallied on the status of cold injuries as a problem In that region. Furthermore, conferences

on this subject were conducted by the National Research Council and attended by a

representative of this division.

Onl tile basis of the material which had been compiled by the Surgical Consultants

Division another memorandum dated 15 October 1943 was prepared for the Chief Professional Service the subject of which was "Frostbite, Immersion Foot, and Related Disorders." This memorandua recited tile activities of this office up to that time and

directed attention to two articles which ad been prepared for publication in the

BULLETIN OF THE U.S. ARM Y MEDIC.IL DEPARTMENT, one entitled "Immersion

Foot" and the other, "Frostbite." The first two paragraphs of this memorandum are quoted

here to reveal the statlis of the Army's experience at the early (late and tile attitude which

this division assumed in regard to the importance of training and proper equipment as

effective preventive measures:

"1. Because of the potential significance and jeopardous effect upon military olerations

in certain regions, injuries resulting from exposure to cold, such as frostbite, trench foot

and immersion foot have received serious consideration by this office. Accordingly, an

effort was made to determine the current incidence and morbidity of those hazards of

exposure to cold and to survey the present scope of tie problem as well as the recent authoritative knowledge on the subject with the view of ascertaining the need for further study

and preparing, coordinating, and disseminating tme best information on prophylaxis and

therapeutics of these conditions.

"2. In all effort to determine the incidence and morbidity of this subject, the reports

from the various regions where military operations are conducted at very low temperatures

were reviewed and a letter was forwarded to Colonel Moore requesUiig information oil the

frequenicy and seriousness of these conditions in Alaska. A copy of this letter is inclosed.

The results of this review resealed that the incidence of these conditions is relatively low.

A report from Northwest Service Command, Essential Technical Medical Data, for August

1943, states that "Frostbite of tie extremities in a mild form has been fairly conimon; however, serious cases requiring amputation have numbered less than six for this entire period

in the whole command which at one time included 22,000 troops. The best method of

prophylaxis lms been education, discipline and use of proper equipment for cold weather.'

Another report for August 1943, from the Office of the Base Surgeon, Greenland, states "the

incidence of frostbite has been practically nil due to the excellency of clothing and instructions by the Base Surgeon to all personnel oln how to early recognize anid preent frostbite.

A very few mihl cases of imllmer.ion foot have been seen. Palliative mieaures only w\ere
34 ACTIVITIES OF SURGICAL CONSULTANTS

used in treatments and the total .,umber of cases were too small for any statistical evaluation on methods of procedure." Another report for June 4, 1943, from Ft. Richardson,

Alaska, states that there were 43 cases of immersion foot among casualties evacuated from

Attu Island. These were all improving rapidly under a conservative treatment and required no additional measures. Another report from Hams, Alaska, on March 31, 1943,

concerning the number of casualties from frostbite incurred during a maneuver in which

535 men participated states that approximately 8% required hospitalization. More recently a survey of the cases evacuated from Attu Island to Zone of Interior with immersion

foot and frostbite, only about four or five per cent required hospitalization longer than

several weeks and only a very few of these required amputations of parts of the extremities.

A great majority of these recovered completely under conservative measures and were

returned to full duty status. It will also be observed in Colonel Moore's recent letter,

13 September 1943, a copy of which is attached, that the incidence of frostbite and immersion foot among personnel in Alaska has not been very high and the cases are so mild that

very few have had serious consequences. According to this review on the incidence and

morbidity of these conditions it would seem that the problem is not a serious one and that

the essential consideration is one of prevention which is really a problem of equipment and

training."

The articles on immersion foot and frostbite for the BULLETIN OF THE U.S. ARMY

MEDICAL DEPARTMENT were published in the November 1943 and December 1943 issues

of this journal which reaches every medical officer in the Corps.

During the winter months of 1943-44 trench foot made its appearance in appreciable

numbers among troops in Italy. In fact, during a period of 4 months the Fifth Army presented 1 case of trench foot for every 4 battle casualties, an exceedingly high ratio. The

tremendous military significance of this condition immediately became apparent to many

who before this time had not considered the subject a particularly grave one. Moreover,

the importance of preventive measures was quite evident when the experience among

Brtish troops fighting in the same regions was compared with that of the American troops.

There were very few cases of cold injuries among the British troops fighting in Italy at the

time when the Fifth Army suffered such heavy casualties from cold.

The trench foot problem in Italy was carefully followed by the Surgical Consultants

Division. All statistical data were studied and comparison struck with British experiences.

On 19 June 1944 the Surgical Consultants Division prepared a memorandum for the

Surgeon General in which paragraph 1 reviewed the unfortunate experiences in Italy of

the preceding winter. Paragraphs 2, 3, and 4, of this memorandum are quoted here for the

reader's consideration:

"2. It is apparent from these considerations that the trench foot problem is important.

that our recent experience has been far from satisfactory, and that steps should be taken

to prevent its repetition. The reasons for our unfortunate experience are quite apparent

and consist essentially in the inadequacy of our program of prophylaxis. Primarily, it

is due to inadequate instruction of personnel in methods of protection and the lack of

provision of suitable equipment, especially shoes and socks. It must be recog-ized, however, that even after these measures have been met they must be put into effect by unit

commanders, and personnel must apply them diligently if adequate protection is to be

achiexed. In the final analysis, this is a measure of discipline and responsibility of unit

commander,.

"3. It is. therefore, recommended that a vigorous program directed toward the

prevention of trench foot along lines which have proved to be effective be inaugurated

by this office. This should include:

"a. Time dissemination of information to troops on the hazards of exposure to uet and

cold and the careful instruction of personnel in proper methods of prevention.

"b. The provision of proper equipment and footgear for operations in wet, cold regions.

Efforts should be directed toward assuring the efficacy of this equipment.
GENERAL SURGERY 35

"c. The direction of attention to unit commanders of the importance of foot discipline

and of the diligent application of the protective measures.

"d. The dissemination of information to Medical Department personnel concerning the

most authoritative knowledge on first aid and definitive treatment.

"4. The potential significance of injuries resulting from exposure to wet and cold

such as frostbite, trench foot, and immersion foot were early realized by this office and have

been given serious consideration. In a memorandum prepared by this office dated

23 August 1943, Subject: 'Revision in accordance with modern concepts of military publications on the subject of injuries resulting from cold,' a review of the current military

publications on the subject was made and attention directed to their inadequacies. In a

subsequent memorandum prepared by this office dated 16 October 1943, Subject, 'Frostbite,

immersion foot and related conditions,' there was presented the results of a survey which

was made by this office to determine the scope of the problem as well as to obtain the most

recent authoritative knowledge on the subject, with the view of ascertaining the need for

further study and for preparing, coordinating, and disseminating the best information

on the prophylaxis and therapeusis of these conditions. The literature on the subject of

the effects of cold was reviewed and representatives of this office participated in conferences

of a special committee of the National Research Council for the purpose of evaluating the

problem, reviewing the most modern concepts of the pathologic physiology, and determining the best principles of prevention and treatment. On the basis of the review of the

literature and reports from authoritative and experienced individuals on this subject, and

on the basis of concepts formulated by this special committee of the National Research

Council, articles which incorporate the most authentic knowledge on frostbite, immersion

foot, trench foot, and related conditions, and the most rational principles of prophylaxis

and therapeusis were prepared by this office and published in the BULLETIN OF THE

U.S. ARMY MEDICAL DEPARTMENT. These articles also form the basis of revisions

which have been prepared for the various training manuals in cooperation with the

Training Division for this purpose. At the time of this survey, it was concluded in the

memorandum dated 16 October 1943, that while these conditions were not serious at the

time, they deserved serious consideration because of their potential significance. It was

also pointed out that 'the problem of adopting proper equipment for use in cold regions

and the education of personnel in protection against hazards of exposure to cold is one

that deserves greatest emphasis'."

Accordingly, The Surgeon General directed that a W.D. Circular (W.D. Circular 312

Sect. IV, dated 22 July 1944) be prepared by the training division on the basis of the

information furnished by the Surgical Consultants Division. Furthermore, a TB Med

(TB Med 81, 4 August 1944) presenting all phases of the subject was prepared by the

Surgical Consultants Division for immediate distribution to all medical officers. Moreover, an article was published in the June 1944 issue of Health which again called attention to the experience in Italy and its important implications. The concluding statement

read as follows: "A winter campaign in northwestern Europe could create a trench foot

problem of major importance if the lesson of Italy were not heeded."

It was felt that these publications would serve to impress on all military sources the

importance of the immediate need for rigorous action in the form of training soldiers and

line officers on the preventive methods to be employed if a repetition of the MTO experience was to be avoided in Europe during the coming winter.

Despite these efforts, November of 1944 saw time beginiig of another even more

extensive trench foot episode, only this time in France and Germany. On 9 December

1944 another memorandum A as prepared by this office for Time Surgeon General in which

the already alarming incidence of the condition in France wis cited. Time previous publications and correspondence of this division were once more reviewed and time recom-
36 ACTIVITIES OF SURGICAL CONSULTANTS

mendations to The Surgeon General made in the 19 June 1944 memorandum restated.

Paragraphs 3 and 4 of the 9 December 1944 memorandum continued as follows:

"3. In accordance with The Surgeon General's approval and direction, all of these

recommendations were carried out by this office to the extent possible within the limits

of its authority, as indicated by the following:

a. A War Department Circular (No. 312, Sec. IV, 22 July 1944) was prepared, setting

forth the essential principles of control and emphasizing the command responsibility

for their application.

b. Information to Medical Department rersonnel concerning the most authoritative

knowledge on the subject, including the most rational principles of prophylaxis and therapeusis was disseminated through articles published in TIE BULLETIN OF THE U.S.

ARMY MEDICAL DEPARTMENT (page 26, November 1943, and page 46, March 1944)

and a War Department Technical Bulletin (TB Med 81,4 August 1944).

c. Conferences were held with representatives of the Q.M.C. concerning provision of

suitable equipment for troops when fighting in cold, water-soaked terrain. Recoimendations were made to the Q.M.C. on the proper type of heavy woolen socks and water-proof

or water-resistant footgear.

"4. It is apparent from these considerations that this office has long recognized the

military significance of the trench foot problem. Citing the unfortunate experience with

this condition last winter, it was strongly urged in June 1944, that 'steps should be taken

to prevent its repetition.' Accordingly, all the elements essential to an adequate control

program were set forth by this office. However, the most important factor in assuring

the success of this program is enforcement of these elements and this lies within the

province of command rather than medical authority."

By the end of the winter some 45,000 soldiers had been incapacitated by trench foot.

The number of these men capable of ever resuming full combat duty was so small as to be

negligible. Thus the condition can be recorded as representing a most serious threat to

the success of ally military operation which requires men to remain in cold wet places

for extended uninterrupted periods of time unless a well coordinated llan of prevention

is enforced. Current statistical data were collected during the winter months from ETO

by means of regular recurring radiograms. The information contained in these was

carefully analysed by this division as well as others in the OTSG. Lt. Gilbert Beebe of the

Control Division deserves great credit for the energetic and superb mnanner in which

lie presented the important data each month iii the publication Health of which he is

editor.

In March 1945 an article was prepared by Lt. Beebe with the cooperation of the

Surgical Consultants Division entitled, "Cold Injury ill Future Pacific Operations." Attention was directed to the recorded experiences with cold injuries among the Japanese

troops during the Russo-Japanese War. The last paragraph of this article reads as

follows:

"Ii the event that large-scale operations in regions of the Northern Pacific become

necessary during the winter months, a repetition of the unfortunate experience with cold

injuries ill Europe call be prevented only by recognizing this danger and planning accordingly. The prompt provision of troops with suitable winter equilment, tile energetic enforcenent of individual foot discipline by line officers and the development ihenever

practicable of ways of providing rest periods during which combat troops can warm

themselves, dry their footgear and other clothing, and obtain warn food or drinks, represent the necessary mneasures in any N ell-conceived plan designed to prevent thi6 disastrous

and crippling condition."

Early in April the Surgical Consultants Di ision was visited by Colonel hluncilanl

of ASP Plans and Operations for the purpose of obtaining information on the subject

to be included in a letter from General Marshall to General MacArthur. This material

was prepared by thi division and coordinated i ith other interested divisionb of the OTSG.
GENERAL SURGERY 37

During the two winters when American forces were suffering heavy casualties, from

trench foot much was written, said, and done about this condition. In fact, an uncritical

observer might readily conclude that despite all that was done a high incidence of the

condition resulted and that trench foot, after all, is not preventable. Any historian or

student of the subject who in the future may be reviewing the trench foot experiences of

American Armies during this war in order to maintain a proper perspective must constantly ask himself two questions.

(1) What was the situation at the time this publication was printed or this action

taken?

(2) Was the information in this publication or this action felt by line officers and

soldiers in the field at a time when it would be effective?

Trench foot does not occur during summner months. It is a condition which occurs as a

result of prolonged uninterrupted exposure to cold and wetness. Il order for troops to

protect themselves, they must be thoroughly educated and informed on the subject before

those weather conditions are encountered. Training troops on a subject of this type after

they are engaged in intensive combat is less effective than training them during a period

prior to such action. The main concern of men engaged in combat is the preservation

of their lives. Attempts to teach men under such conditions measures for preventing

trench foot, which to them is seemingly unimportant at the moment, are not likely to

meet with any great degree of success.

Thus as the war in the Pacific progresses and our troops are ever approaching a

winter at geographic locations north of 320 latitude, the Surgical Consultants Division

cannot help but wonder what training programs are being conducted among troops in the

warm islands of the Pacific to inform timm on the great importance of cold injuries and

on tbe adequate measures for their prevention.

Anesthesia

There was a shortage of well-trained anestliesiologists throughout the

war, and as a consequence considerable effort was necessary on the part of the

Surgical Consultants Division to provide an adequate number of individuals

who were capable of administering anesthetic agents. Mention has already

been made of the schools of anesthesia which were conducted at civilian medical

centers and of the final successful attempts to solve the problem of a scarcity

of anesthesiologists by an oni-the-job training program for medical officers and

Army nurses at those Army hospitals having well-trained anesthesiologists on

their staffs. A direct consequence of the sometimes desperate shortage of

anesthesiologists was the danger to patients resulting from anesthetics given

by individuals with little experience or training. It therefore appeared imperative to the Division that it evaluate, with the assistance of civilian and Army

surgical consultants, the various anesthetic agents with particular view to

safety and permit the use of only those considered the least dangerous. This

was just as important in the field of local as in that of inhalation anesthetic

agents. Based upon reports of deaths, apparently due to certain local anesthetic agents, it was directed that only procaine hydrochloride be used for

infiltration anesthesia, and that agents for spinal anesthesia be restricted to

procaine hydrochloride (preferable), Pontocaine (tetracaine hydrochloride),

and Metycaine (piperocaine hydrochloride). At this time, a critical appraisal

606222,-02---5
38 ACTIVITIES OF SURGICAL CONSULTANTS

of inhalation anesthetics was also made, and it was directed that the use of

cyclopropane be discontinued.

The two most useful anesthetic agents under military conditions proved

to be ether and Pentothal sodium (thiopental sodium). In an analysis of

7,500 cases of anesthesia, it was found that the death rate attributable to Pentothal sodium was six times higher than the death rate from all other anesthetic

agents combined. This was regarded as an indication of the unwise use of Pentothal sodium rather than of its inadequacy for milita 'poses. The dangers

of this agent were being overlooked. Immediate effortF , -re, therefore, directed

toward better education concerning the use of Pentothal sodium by means of a

circular letter to the field and by the publication of several articles in the Bulletin of the U.S. Army Medical Department. The conditions in military surgery

in which Pentothal sodium had proved unusually valuable were emphasized, and

those in which the drug should be either avoided or used with great caution were

stressed. Attention was directed also to the importance of atropine in preoperative medication and to the administration of oxygen whenever feasible.

In matters concerned with anesthesia, Dr. Joseph Kreiselman of Washington, D.C., civilian consultant in anesthesia to The Surgeon General, and

Maj. Lloyd H. Mousel, MC, Chief Anesthetist, Walter Reed General Hospital,

were of inestimable value to the Medical Department. These two individuals

worked in close cooperation and with their backgrounds in anesthesia and

pharmacology provided excellent advice and consultation on many problems

of anesthesia. They advised personnel on supplies and recommended the

safest anesthetic policies and the most effective methods of resuscitation for

adoption by the Army.

Traumatic Shock

Shock was obviously destined to play a large part in the mortality resulting from war wounds, and the proper management of this condition immediately presented itself as one of the most important problems of military

surgery. The development of blood plasma was undoubtedly a great contribution to the treatment of shock, and by its use untold numbers of lives

were saved. Unfortunately, the early enthusiasm that accompanied this development was so forceful that it clouded sound clinical judgment and led to

the misconception, which persisted far too long, that plasma could be used as

an effective substitute for whole blood in the management of shock. This

misconception became so firmly entrenched in the minds of both administrative

and professional personnel that it definitelx handicapped the organization

and development of more effective measures for the control of shock.

The British had discovered the fallacy in this thinking by the time the

United States had entered the war, but, in spite of their experience, the U.S.

Army was painfully slow in recognizing its error. As a matter of fact, the

Surgical Consultants Division shared in this loose thinking for many months.

It was due in large part to the reports from the surgical consultant in
GENERAL SURGERY 39

NATOUSA that the Division was made to recognize its errors and to take

steps to correct them. Reports from this source, based on increased experience

and clinical and laboratory investigations, pointed out clearly that plasma

could not be used as a substitute for whole blood and that whole blood was

the agent of choice in the ultimate resuscitation of the majority of battle

casualties. It became apparent that whole blood was the only therapeutic

agent that could prepare seriously wounded patients to withstand the major

surgery which was essential for saving life and limb. The transfusion of

whole blood was more effective because not only did it restore blood volume

as plasma did, but it also replenished the oxygen-carrying capacity of the

blood by supplying red cells which plasma did not do. Plasma, however, was

invaluable, for it could be used in emergencies or in the far-forward areas where

it was not feasible to supply whole blood and it could tide a shocked patient

over the critical period required for evacuation to some installation where

whole blood was available. It became increasingly evident that both plasma

and whole blood were extremely valuable in the management of shock but that

both had their individual and specific purposes and, to be effectual, must be

used accordingly.

Early in 1943, the problem of supplying whole blood to theaters of operations was discussed on several occasions with other individuals in the Office

of the Surgeon General, and, though such a need was recognized in a vague sort

of a way, it was not considered to be of great importance. Furthermore, the

consensus was that it was impracticable to make whole blood available farther

forward than the general hospital. In an effort to assist the theaters in supplying their own whole blood transfusions, equipment was made available to them

and Circular Letter No. 108, Office of the Surgeon General, Transfusion of

Whole Blood in the Theaters of Operation, outlining the techniques to be followed, was distributed on 27 May 1943. The surgical consultants in the North

African and European theaters continued to stress the need for whole blood and

emphasized the facts that casualties who had bled severely were poor surgical

risks even though plasma had been administered in large quantities and that

whole blood had to be givc, to them before they could be operated upon safely.

As a result of these urgent requests, the Surgical Consultants Division

suggested strongly that transfusion sets, which had been developed at the Army

Medical Center, Washington, D.C., be made available to the theaters immediately. These sets were expandable, were conveniently packaged, were easily

usable and contained all the materials necessary for drawing and administering

blood. In addition, refrigerators for the storing of blood in the field had been

devised, and their procurement and issue were also recommended. This plan,

which had been worked out down to the smallest detail, was rejected as being

impractical and unnecessary. Finally, in May 1944, after several additional

attempts, this plan was approved. The equipment was standardized and made

available to the theaters.
40 ACTIVITIES OF SURGICAL CONSULTANTS

During the many months which elapsed between the time that the need

for whole blood became evident and the time at which the cited sets were made

available, the Surgical Consultants Divi.Aon had been interesting itself in the

possibility of supplying whole blood directly to oversea installations from the

Red Cross bleeding centers in the United States. After considerable experimentation and numerous conferences, the equipment necessary to such an effort

was devised and perfected. Also, a plan was worked out with the Red Cross

bleeding centers and with the Air Transport Command by which whole blood

could be thus supplied. Consequently, when it became evident in mid-August

1944 that the European theater blood bank could no longer furnish sufficient

amounts of whole blood, this plan, previously prepared, was approved by The

Surgeon General and the first shipment of whole blood overseas was dispatched

on 21 August 1944. Shipments were continued to the European theater until

10 May 1945, when further supplies were not needed. The shipments were then

diverted to the Pacific theaters in conjunction with the Navy-operated whole

blood program on the West coast. These were continued throughout the remainder of the war.

Another feature of shock which became apparent as experience increased

was that concerned with certain of its lethal sequelae. During peacetime,

shock is observed relatively infrequently, and experience with the condition

never approaches the massive scale that occurs in war. The lethal sequelae

are, therefore, less evident and tend to be less impressive. A number of battle

casualties suffering from severe shock were found to die with manifestations

of anuria or reduced urinary output. These lethal sequelae of shock were

considered to result from asphyxia of organs or tissues during the prolonged

period when the flow of blood was reduced in volume. Irreparable damage

was demonstrated in the tissues of the brain, kidney, and, possibly, the liver of

patients with delayed death resulting from shock. The Surgical Consultants

Division was extremely interested in instituting field studies and in stimulating

other studies in the United States concerned with the solution of this baffling

problem. Considerable light was shed on the physiology involved in this complicated condition, although the problem was never solved in its entirety.'

War Wounds

Before their entry into the Medical Corps, the majority of military surgeons had had little experience with, and only a slight knowledge of, the

management of the type of wounds which they were to encounter in the care

of battle casualties. Hence, it was essential that they be informed of sound

and proved methods of wound management and that these methods be emphasized repeatedly until they became thoroughly established. Two additional

factors contributed to the need for education along these lines and for the

strict enforcement of established rules and regulations.

Medical Department. United States Arm,%. Surgery In World War II. The Phiblolog c Effects of

Wounds. Washington, U.S Go~ernment Printing Oice, 1952.
GENERAL SURGERY 41

The first of these was the great variation in the training, experience, and

ability of the medical officers who were engaged in military surgery. The

second was the influence of Trueta's treatise which was concerned with the

management of war wounds in the Spanish civil war. This work appeared

shortly before World War II and created considerable interest. It was widely

discussed by surgeons, and the techniques of debridement, immobilization by

closed plaster casts, and wound packing with petrolatum-impregnated gauze

had made a definite impression on them. Some surgeons in this country went

a step further and, in certain extensive wounds seen in civilian life, practiced

wide wound excision and primary closure. Many techniques of debridement

appeared, and these varied from extensive excision of wounds to minimal removal of tags of devitalized or soiled tissue. Following these procedures, some

surgeons closed the wound tightly by primary suture, while others left it open

and either filled it loosely with gauze or packed it tightly.

Thus, it was evident that strong measures would have to be taken in the

Army to insure the proper application of those principles of wound management which the surgical consultants, both in the field and in the Office of the

Surgeon General, considered to be most suitable. It was necessary not only

to lay down these principles but also to enforce their application. These purposes were accomplished by means of directives, communications, published

articles, and addresses, but most importantly by the efforts of the surgical consultants throughout the Army. These principles of care of wounds are discussed in detail in many places ii the other volumes of this history which are

devoted to surgery. Their delineation, dissemination to medical officers

throughout the Army, and their enforcement constituted a major contribution

to the low mortality which occurred among the wounded and to the low incidence of serious infection, particularly of gas gangrene. It was the considered

opinion of the surgical consultants that nothing could take the place of proper

and adequate wound care in military surgery. Proper care was fundamental

in the management of the wounded, and other measures such as transfusions of

plasma or whole blood and the use of antibiotics and chemotherapeutic agents,

effective as they were, were considered to be merely adjuvants.

Peripheral vascular injuries.-The Surgical Consultants Division repeatedly emphasized the frequency of peripheral vascular injuries, especially

those involving major vessels, as an accompaniment of wounds of the extremity. The types of vascular injury and resulting sequelae were pointed out,

and proper methods of dealing with each were described. These injuries occurred much more frequently than was commonly realized. This was indicated

by the fact that vascular injuries were the cause for amputation of an extremity in approximately 20 percent of the cases in an extensive series which

was analyzed uy the Division in 1943 and 1944. Another indication of this

fact was the increasing number of traumatic aneurysims which were operated

upon at the vascular centers in the Zone of Interior. In connection with vascular injuries, the Division wab active ii, calling attention to the importance
42 ACTIVITIES OF SURGICAL CONSULTANTS

of vasospasin as a factor upon which the life of a limb may depend, particularly

if the viability of the tissues had been impaired by traumatisin. It also described methods for the detection of this condition and for its proper treatment.

Regional wounds.-As the war progressed and wider experience was had,

newer methods were developed for the management of regional wounds. These

were subjected to a critical evaluation based on the data received by the Division. Certain ones were considered to be of such value that they were described for the benefit of all medical officers and in many instances were made

the subject of directives. Among them were such subjects as the treatment of

injuries to peripheral nerves; the management of cranial-cerebral wounds;

proper timing of operations upon spinal cord injuries; the management of

wounds of the chest with special emphasis on the complications of hemothorax,

tension pueumothorax, open pneumothorax, retained foreign bodies, and

empyema; the treatment of combined wounds of the chest and abdomen; and

the care of penetrating wounds of the abdomen with special reference to those

:nvolving the colon or rectum.

Chemotherapeutic agents.-All war wounds were considered to be contaminated, although the degree of infection varied from minimal surface involvement to invasive infection with regional or generalized extension. Mention has been made of the importance of the application of sound surgical

principles in the prevention and trtatment of infections. The story of the

sulfonamides as a means of controlling infection in war wounds is all interesting

one. Early in the war, these chemotherapeutic agents were widely heralded

as "wonder drugs" and in the minds of many surgeons they were panaceas

in the management of surgical infections. Much of this enthusiasm resulted

from the glowing accounts of their use at Pearl Harbor, where they were

credited with performing miracles in the prevention of infection and in its

cure. The drugs were used both locally in the wounds and systemically. By

the time the Surgical Consultants Division was authorized and organized, the

Army had already purchased huge supplies of these drugs and had provided

that each soldier carry a supply for local use in the powdered form and for

systemic use in tablets. As soon after wounding as possible, the soldier was to

sprinkle his wounds with the powder and to ingest the pills. The press was

full of items indicating that this regime would afford remarkable protection

to our fighting men and that many lives would thus be saved.

In the sobering light of critical studies and observations, however, this

overenthusiastic concept regarding the value of these drugs began to be greatly

modified. Grave doubt was cast on their beneficial effects when applied locally, and limitations were found in their systemic use. Surgeons in our Army

and in that of the British began to veer sharply away from the introduction

of the drugs in wounds and commenced relying more and more on their systemic effects. The range of organisms affected by these drugs -'as found to be

restricted, and, from a military view point, the most important organisms affected were the streptococcub and the gonococcus. In spite of this, the drugs
GENERAL SURGERY 43

contributed greatly to the control of infections when used systemically and

were highly regarded. If the antibiotics had not been discovered, the extensive

use of the sulfonamides undoubtedly would have been continued throughout

the war. They were thus utilized until the supplies of penicillin became adequate. The local application of these agents, a practice which was once widespread in the clean as well as the contaminated wound and which was a definite

threat to the careful aseptic technique, fell into complete disrepute.

The Surgical Consultants Division played no part in contributing to the

original misconception of the remarkable curative properties of the sulfonamides or for their distribution throughout the Army. When all this was taking

place, the Division was not yet in existence. By the time the Division was

functioning, doubt was already being cast on the propriety of the use of the

drugs locally. Its role was to follow closely the clinical and experimental investigations, largely through the committees of the National Research Council,

and to ascertain the limitations of these chemotherapeutic agents. As soon as

these were defined, the Division was quick to take directive steps designed to

insure the proper use of these agents in the Army.

The contributions of the Division to the penicillin program have already

been enumerated. Streptomycin was discovered during the later phases of the

war but was used almost entirely on an experimental basis until sometime after

the war was over. A number of other agents for the control of infections

were suggested to the Army from time to time during the war, and at times

considerable pressure was exerted for their adoption and use. One of the

important functions of the Division was to survey these suggested drugs

critically, to evaluate them, and to recommend or discard them accordingly.

Gas gangrene.-Gas gangrene was recognized as one of the most serious

infections which might occur as a result of war wounds. The mortality and

morbidity from this infection at the outbreak of the war was therefore of the

gravest importance. The sulfonamides did not prove to be effective in either

the prevention or the cure of this condition, nor did penicillin, although for

a time it appeared possible that penicillin had some effect in prevention due

to its widespread effect on the accompanying pyogenic organisms. The most

important factor in the prevention of gas gangrene was the proper surgical

management of wounds in the early stages. This fact has been dealt with in

previous paragraphs. The Division was much interested in the possibility

of the successful production of a toxoid for the control of this infection and

made strenuous efforts to arouse interest in this field. No such toxoid was

developed during the war, but the efforts made at that time served as a stimulus

for the continuation of investigation in this direction during the postwar

period.

Pilonidal sinus.-While, strictly speaking, it may not, be considered in

the category of war wounds, the management of pilonidal sims developed into

one of the real problems of military burgery, particularly in Zone of Interior

hospitals. Due to a lack of a uniform policy in the burgical care of this con-
44 ACTIVITIES OF SURGICAL CONSULTANTS

dition, hundreds of thousands of man-hours were wasted in the first years of

the war. There was a surprisingly large number of these cases among military

personnel. Some cases showed no evidence of infection and were symptomless,

but many more became infected, probably as a result of repeated trauma during

the training period. The wards of Army hospitals contained many hundreds

of these patients, and the majority had been hospitalized for weeks or months.

The necessity for better defined methcls of treatment for this seemingly minor

surgical condition was completely overlooked and was appreciated only when

manpower became scarcer and enough time had elapsed to indicate that mandays were being lost as a result of it.

In September 1943, a directive was issued by the Office of the Surgeon

General indicating the type of operation which should be utilized. This was

done because it was recognized at that time that many different types of operation were being performed, ranging from complete excision and primary

closure to incision and drainage and packing with petrolatum-impregnated

gauze. By September 1944, it became evident that even with these recommended operations the existing methods of management of pilonidal sinus

were productive of extremely poor results. In support of this conclusion were

the results of statistical studies, made in Army hospitals, of the end results of

operative procedures. These indicated a loss of some 435,000 man-hours per

year. On the basis of these findings, the therapeutic policies relating to this

condition were revised extensively and expressed in War Department Technical

Bulletin (TB MED) 89, Pilonidal Cyst and Sinus, dated 2 September 1944.

This, in brief, directed that patients with uninfected pilonidal sinus were not

to be operated upon and that those having infected sinuses were to be treated

by simple incision and drainage. No excisions were permitted. Although

this policy did not permit a permanent cure, it did allow a much more rapid

return to duty and was preferable by far from a military viewpoint. Under

the new regime the hospital stay was rarely more than 2 weeks, whereas under

the older one many patients spent many weeks or even months in the hospital.

It was true that repeated hospitalization was more frequent under the new

regime, but, even so, many man-hours were saved. In retrospect, the importance

of this relatively minor surgical condition should have been appreciated much

earlier.

Thermal burns.--Thermal burns constituted a relatively small percentage

of all battle casualties but were not without importance in military surgery.

Accidental burns were more frequent among soldiers than among civilians of

the same age group for the reason that the former necessarily handled gasoline

and oil, grenades, and other types of ammunition. Airplane crashes, both in

and out of combat, contributed to the incidence. The serious nature of extensive burns and the prolonged reconstructive surgery required in many cases

f'irthe,' contributed to the importance of this problem. In 1943, for example,

25,609 patients were admitted to Army hospitals for the treatment of burns.

Only 751 of these were received in combat. and 203 of the latter group occurred
GENERAL SURGERY 45

as a result of airplane crashes. During the early part of the war, the tannic

acid method of treating burns was the most commonly accepted. In January

1943, the Surgical Consultants Division, by The Surgeon General's Circular

Letter No. 15, Treatment of Burns, recommended the pressure dressing technique as the most physiological procedure yet devised for the management of

burn cases. Tannic acid was still permitted to be used in cases of burns except

those of the face and hands. In September 1943, the tannic acid method was

abandoned and prohibited by Circular Letter No. 161, Office of the Surgeon

General. The pressure dressing technique, employing either boric acid or

petrolatum-impregnated gauze, thus became the only method which was endorsed by the Office of the Surgeon General. In March 1945, the Division

prepared TB MED 151 dealing with the surgical management of burns. This

technical bulletin presented the accepted method of the systemic management

of burns, plus an account describing the proper technique for applying an

adequate pressure dressing. The Army's extensive experience with this method

permitted the conclusion that it was highly effective in that it minimized plasma

loss, prevented infection, minimized skin loss, prevented scarring, and saved

lives.

Hospitalization

The policy of tranferring certain types of more difficult surgical cases from

station hospitals to general hospitals was made during the first few months

of the war, and it never ceased to be a cause of contention and irritation

to surgeons assigned to station hospitals. Likewise, it created a situation

which continually required firmness, combined with tact, on the part of the

service command consultants, one of whose numerous duties was to enforce

the policy. Many surgeons in station hospitals considered themselves entirely

competent to operate upon patients who were being transferred, and in some

cases this was true. On the other hand, there were many other surgeons in

station hospitals who were not considered capable, on the basis of their training and experience, of giving acceptable surgical care to the more difficult

cases. In the best interest of the greatest number of patients, the policy was

required. At the beginning of the war, when there were quite a iniber of

well-trained surgeons in station hospitals, comlaints were more frequent

and resistance stronger than later on, when many of these men were sent overseas. The Surgical Consultants Division was responsible for instituting the

policy and for the decisions as to which cases were to be treated only in general

hospitals. The Division was assiduous in carrying out the policy both through

its own staff when on inspection trips and through the surgical consultants

in the service commands. The policy was sound and was another evidence

that The Surgeon General was making every effort to insure the best surgical

care to Army patients.

This policy was further extended to inake certain general hospitals into

centers for the treatment of highly specialized cases. Specialized centers

60642221 -62- --- 6
46 ACTIVITIES OF SURGICAL CONSULTANTS

were established at first because of the fact that the hospitals thus designated

had unusually well qualified specialists on their staffs and in many cases

contained highly specialized and scarce equipment. In the beginning, there

were very few of these centers and they were for the benefit of patients in

general and station hospitals in this country. When the casualties from overseas began to be sent back to the United States in appreciable numbers, it began

to be apparent that there was not going to be a sufficient number of specialists

in many categories to care for them if they were sent indiscriminately to several

general hospitals having only one or two such specialists. The Division, quickly

realizing this fact, recommended that the centers be established in additional

categories and that they be staffed with specialists drawn from as many Zone

of Interior hospitals its necessary. Patients from overseas and from the Zone

of Interior requiring special surgical care were all to be concentrated in these

centers.

The plan was approved and put into operation. It was most successful

for it permitted the greatest utilization of scarce categories of surgeons, and

it made possible extremely productive investigative approaches to many important military problems such as those concerned with peripheral nerve injuries, deafness, vascular injuries, blindness, and amputations. The procedure

also permitted the concentration of expensive, highly specialized, and scarce

equipment into a few hospitals. With their specially selected staffs and their

superb equipment, these centers made an outstanding contribution both to the

care of )atients with conditions requiring special management and to investigations in various special fields. The growth of these centers and their importance is illustrated in tables 1 and 2.

It is important to keep in mind when examining table 1 that in certain

instances the beds allocated to the various specialties in hospitals previously

designated as centers were nmnnerically increased. Thus, the expanded activities

in these special fields of surgery cannot be fully appreciated in terms solely

of numbers of centers. Accordingly, the information on the total number

TABLE 1.-General hospitals designated as specialized centers, December 19,;3 and August 19.p

SI)ecialition December 1943 August 1914

Number Number

Neurosurgery-.------------- -13 19

Vascular-- 1 3

Thoracic ------ - 5 5

Am putations ... .. ... . ...... . ..- 4 6

Blind------- ..... - 1 2

Deaf. - 2 3

Plastic and ophthalologic 4 8

Deep X-ray therapy . 9

Radium therapy - 2 1 3
GENERAL SURGERY 47

TABLS 2.-Authorized patient capacity for surgical specialties, June 1944 and June 1945

Surgical specialty June 1944 Juno 1945

Neurosurgery ------------------------------------- 3, 044 18, 655

Thoracic surgery ------------------------------------- 630 2, 675

Plastic ---------------------------------------------- 868 6,849

Ophthalmologic -------------------------------------- 536 2, 325

Blind ---------------------------------------------- 50 425

Amputations --------------------------------------- 1, 470 7, 725

Deaf ----------------------------------------------- 727 1,120

Deep X-ray therapy ---------------------------------- 326 400

Radium therapy ------------------------------------ 30 30

Vascular ------------------------------------------- 334 1, 481

of Zone of Interior beds devoted as of June 1944 and June 1945 to each of

the specialties listed in table 1 is furnished in table 2 for comparison.

The creation of these specialized centers represented an effective solution

to the problem of care of particularly complex cases or ones requiring specialized care or study. The care of such cases was greatly improved by this

measure, and it represented a truly progressive innovation in the Medical

Department's program which fostered specialized care by specialists.

SUMMARY

The Surgical Consultants Division began as a branch of a subdivision in

the Office of the Surgeon General and emerged as an independent division

directly advisory to The Surgeon General. Throughout the war, its many

and varied functions were directed along the following two primary lines:

(1) To determine the most appropriate surgical methods of caring for the

sick and wounded and to see that therapy thus standardized was carried out

uniformly, effectively, and thoroughly; and (2) to initiate and participate

in administrative and logistic actions which would bring together the patient

and the proper surgeon at the right time and in facilities adequately equipped

and supplied to accomplish the task at hand.

A worldwide system of surgical consultants was established to realize

these goals. Consultants in general surgery were on the staffs of each service

comnmand headquarters, with an additional consultant in orthopedic surgery

where the caseload warranted his presence. Each theater of operations had

its surgical consultants at the theater headquarters, and many had consultants

in subordinate commands as well. There was a consultant in surgery in the

medical section of the headquarters of each field army engaged in operations

against the enemy. Additionally, eminent surgeons in the United States were

appointed as civilian consultants, particularly in the various specialized fields

of regional surgery where their knowledge and experience were indispensable.
48 ACTIVITIES OF SURGICAL CONSULTANTS

Relationships between consultants in the Office of the Surgeon General and

others in the Zone of Interior were close and direct, but, regrettably, relationships with consultants overseas were more indirect and distant.

The surgical consultants in the Office of the Surgeon General worked

with and through many agencies and offices-military, governmental, and

civilian. Of the nonmilitary organizations, there was an especially harmonious

association with the Division of Medical Sciences, National Research Council,

in the attempt to solve the many perplexing surgical problems of the war.

The remarkable surgical achievements of the war resulted in great measure

from the establishment of this effective system of surgical consultants and

the efforts of the men within this system.
CHAPTER II

Orthopedic Surgery

Leonard T. Peterson, M.D.

ASSIGNMENT AND ORGANIZATION

Orthopedic Branch, Surgical Division.-Col. Leonard T. Peterson, MC,

(fig. 4) was assigned as an orthopedic surgeon to the Surgical Division, Professional Service, Office of the Surgeon General, in September 1943. Upon

reporting, he was given a friendly reception but no orientation or specific

assignment of duties-probably because his was a newly created position.

Almost immediately, a field trip was made with a group from the Office of

the Quartermaster General to study the problem ot rebuilt shoes. This trip

proved to be very educational and a good introduction to the many duties

which were to follow. Shortly thereafter, in December 1943, the Orthopedic

Branch was officially established as a part of the Surgical Division. Colonel

Peterson became chief of the Branch on 8 December 1943 and continued in

this assignment and as consultant in orthopedic surgery to The Surgeon General until near the end of hostilities in 1945.

Physical Therapy Branch.-Physical therapy activities in the Office of

the Surgeon General were made a responsibility of the Orthopedic Branch

in December 1943 upon formal establishment of that branch. The chief of

physical therapy, Maj. Emma E. Vogel, had extensive professional and administrative experience in this field and provided immediate supervision and

direction of personnel and training activities concerned therewith. The orthopedic consultant assisted in matters of policy, directives, and publications.

On all visits to hospitals, the orthopedic consultant inspected physical therapy

activities and facilities. In February 1945, physical therapy activities in

the Office of the Surgeon General were removed as a function of the Orthopedic

Branch and made a separate Physical Therapy Branch under the Rehabilitation Division, Office of the Surgeon General.

With reference to physical therapy treatment of orthopedic patients, it

was always recommended that the type and limitation of various treatments

be determined by the surgeon responsible for the treatment of any particular

1 This chapte,, which covers the experiences and observations of the orthopedic consultant ill the

Office of the Surgeon General, was written 10 years after the termination of World War II. The writing

was based upon personal records, official reports. and a vivid recollection of many of the events of

that period. Perhaps it was better that such events be recorded after a lapse of time. ulen the

important Issue. uere more llkel3 to receive emphasis and the less important problems see med trivial

by comparlson.

49
50 ACTIVITIES OF SURGICAL CONSULTANTS

FIGURE 4.---Col. Leonard IV. Petersoni, NMC, Chief,

Orthopedic Branch, Surgical Division, Professional

S~ervice, Office of the Surgeon General, and Consultant

in Orthopedic Surgery to The Surgeon General.

individual. Obviously, close liaison was necessary between iliysicai therapists

and the warid surgeon responsible for the definitive care and disposition of a

p)atijent.

FUNCTIONS AND DUTIES

Personnel

Orthopedic surgeons.-Aii intimate knowledge was required of the qualifications, classification, and assignment of all orthopedic surgeons inl the Zonie

of Interior. The orthopedlic consultant recommended the initial assignnmient

of orthopedic surgeons newly entering time service and, as niecessary, recoinlmended the t ransfer of key p~ersonnmel. Tim reconmnendations were imniplemnted through the Military Personnel ])ivision. By reviewing the monthly

rosters of general hospitals, rep~lacemnent pools, and units leaving thme United

States for oversea dluty, it was possible to keep) informed as to the assignumment

of all ortliopedlic surgeoils, whio were classified A, B, or C according to their

dJegree, of 41kill :111d t rainimug. Almost without exception. it was found that
ORTHOPEDIC SURGERY 51

medical officers with orthopedic training were properly assigned. There were,

however, a few instances of trained surgeons serving in administrative positions overseas, and one certified orthopedist was assigned to selective service

duties in his home State. Every recommendation or complaint on the placement of orthopedic personnel was promptly investigated and corrected.

Enlisted orthopedic personnel.-Because of the shortage of trained enlisted personnel for brace and prosthetic shops, a survey was made of all qualified men in the Army, and their assignments were carefully scrutinized.

Civilian consultants.-A number of civilian consultants were utilized in

the nine service commands, and their initial appointment and travel orders

were executed in the Office of the Surgeon General. A few specially qualified

amputees were designated as consultants for the purpose of visiting amputation centers and instructing new amputees. These included Mr. Charles McGonegal, Mr. Donald Kerr, Mr. Harold Carlson, and Mr. Walter Bura.

Disposition Procedures

Disposition from general hospitals.--Policies on the disposition and

transfer of patients from and between hospitals in the Zone of Interior were

established by The Surgeon General. The early discharge of patients to duty

or placing them on leaves and furloughs meant a saving in hospital beds and

hospital construction. Accordingly, one of the duties of the consultant in the

Office of the Surgeon General was to uncover delays in disposition procedures

and to expedite the discharge of patients. At the onset of the war, it was the

practice to transfer patients no longer fit for military duty to the Veterans'

Administration for treatment and discharge. It rapidly became evident,

however, that the Veterans' Administration lacked the facilities and personnel

to handle the large number of disabled. Furthermore, patientz objected strenuously to discharge from the Army until they had reached maximum improvement. They felt that they received better care in the military hospital, and,

in some instances, their incomes decreased upon separation from the service.

This led to a change in procedures late in 1943 which called for the keeping

of patients under military control until they reached maximum improvement.

This plan necessitated extremely long hospitalization in many orthopedic cases.

Delay in the disposition of patients was a common deficiency. The problem was

not peculiar to the war period, for it has been observed in military and civilian hospitals before and since that time. Delays in disposition assume

greater importance in times of emergency, hoi ever, and all personnel must be

alert to the importance of keeping hospital time, per patient, down to a

minimum.

Interhospital transfers.-Another frequent observation was the unnecessary transfer of patients from station to general hospitals. In the wards

of general hospitals, mnany patients were Seen who did not require general

hospital care-patienh, who should have been returned to duty fromn the sta-
52 ACTIVITIES OF SURGICAL CONSULTANTS

tion hospital. Additionally, convalescent hospitals were established to care

for patients who did not need general hospital care and yet were not ready

for discharge. But, with the increasing demand for hospital beds, many

patients were sent to these convalescent hospitals only to be readmitted to a

general hospital at a later date for additional definitive treatment. Qualified

personnel were therefore required in convalescent hospitals properly to evaluate

these cases before a decision was made as to their disposition-duty, discharge

from the service, or readmittance to a general hospital. In many instances,

time was lost in the disposition of patients when those who could have completed their definitive treatment at a general hospital and could have been

discharged directly from the general hospital were needlessly transferred to

convalescent hospitals.

Communications

Preparation of policy directives.-Professional policies were largely determined at the hospital level in the Zone of Interior. In a few instances,

directives on orthopedic policies and practices were published by The Surgeon

General. One directive prepared by the consultant in orthopedic surgery for

publication by The Surgeon General applied to the open treatment of compound fractures. Another applied to the principle of open amputation where

amputation was required for infection or severe mutilating injury. The development of sulfonamides just before the war had led surgeons in civilian life

to treat open fractures and emergency amputations by wound closure. The

application of the same principles in war surgery, however, had led to disastrous results. Thus, it was necessary to promulgate these instructions directing that compound fractures and emergency amputations not be subjected to

wound closure.

Preparation of War Department Technical Bulletins (TB MED's).-

TB MED's were prepared from time to time as necessary in the Office of the

Surgeon General. These bulletins were informative and advisory in nature.

The consultant in orthopedic surgery prepared TB MED's on knee surgery,

materials for open reduction, and the care of amputation stumps.

Editorial review and professional assistance.-All professional papers

submitted for publicatior which pertained to orthopedic subjects were reviewed

by the orthopedic consultant. Assistance was given authors in preparing

papers for submission to publishers. Disposition and retirement proceedings

reviewed by the physical evaluation review board in the Office of the Surgeon

General were often referred to the orthopedic consultant for opinion.

Correspondence for The Surgeon GeneraL-Of the many letters received by The Surgeon General, those pertaining to orthopedic problems were

referred to the orthopedic consultant for review and reply. It was necessary

to answer all these letters in a specific and courteous manner. Occasionally,

very long and involved letters were received from obvious cranks. Such let-
ORTHOPEDIC SURGERY 53

ters were disposed of in as simple a manner as possible in order to avoid

involvement in an endless and useless correspondence.

Field Trips

Approximately one-third of the patients in general hospitals in the Zone

of Interior were charges of the orthopedic service. In many instances, the

orthopedic census in a hospital exceeded 1,200 patients. Thus, nearly onethird of Colonel Peterson's time was spent on field trips visiting general and

regional hospitals. Visits were made one or more times to all but 5 of the 65

general hospitals which were eventually established for the hospitalization of

the U.S. Army. It was often apparent that the hospitals were burdened by

the number of visiting consultants and inspectors in administrative and professional roles from various echelons. As a visitor from the Office of the Surgeon General, the author was always received with a spirit of courtesy and

cooperation. A few unpleasant experiences were encountered and these were

probably due as much to the overzealousness of the consultant as to local conditions. As a rule, the commanding officer and his staff of an installation being

visited made it possible for the visiting consultant to complete his mission in a

pleasant and expeditious manner.

These hospital visits of 1 to 3 days' duration were made to inspect the

orthopedic service, to review the professional work, and to determine the need

for personnel and equipment. Ward rounds were made, and each patient was

briefly examined with a review of his X-ray file. Details of previous treatment and proposed treatment and disposition of individual patients were made

a, matter of concern. General principles of treatment and policies pertaining

to the military-medical situation were frequently discussed.

It was interesting to m. )te the patient's response and his appreciation of the

individual attention which the visiting consultant might show in his case. All

the patients on the ward were obviously attentive and interested in any comment which might be overheard. It would, no doubt, have been interesting to

have heard the comments the patients made subsequently in their discussion of

the consultant's visit, but unfortunately-or fortunately-these are not a

matter of record. Great care was necessary during such a brief visit to insure

that comments and impressions did not reflect unfavorably on previous treatment of the patient. Every effort was made to reserve questionable details

for private conference where any errors or omissions could be reviewed in

detail.

Upon the orthopedic consultant's return, brief reports on the hospital

visits were made to The Surgeon General and forwarded through channels to

the hospital. In five instances, it was recommended that the chief of the orthopedic section in a general hospital be replaced. Although several objections

were raised to this change in personnel, the replacements were approved to the

ultimate satisfaction of the commanding officers involved.
54 ACTIVITIES OF SURGICAL CONSULTANTS

Supplies and Equipment

Scope of duties in connection with supplies and equipment.--Among

the important duties of the orthopedic consultant in the Office of the Surgeon

General were those concerned with supplies and equipment. For example, it

was necessary to catalog and standardize the entire list of equipment and

material necessary for orthopedic braceshops. In cooperation with the supply

division, this was accomplished, and a satisfactory system of supply for these

shops was established. Artificial limbshops presented a special problem with

the growing demand for prostheses and for research and improvement in prostheses. Seemingly minor items such as hinge joints and rubber bumpers proved

to be very important in the function and durability of an artificial limb. Surgical instruments, fracture tables, plaster bandages, and numerous other items

required constant, almost daily liaison with the supply division. Writing specifications and planning procurement of items related to orthopedic surgery

was a never-ending activity.

Innumerable items of equipment and suggestions for new items were referred to Colonel Peterson if they pertained to orthopedic treatment. The

enthusiasm of the inventor usually bore no direct relationship to the appropriateness of his device for use in the military service. Although many of the

devices, such as splints, arch supports, special shoes, and prostheses, were not

adaptable to military requirements, it was necessary to be constantly on the

alert in order not to disregard appliances or suggestions of definite merit. For

example, one manufacturer of arch supports maintained that every soldier

should be equipped with at least two pairs of his supports, since wars were

won or lust on the soldier's ability to march and surely this ability would be

greatly eaih.nced by his product. Another item was a special shoe constructed

with coil springs in the sole which would, according to the designer, relieve

fatigue and unpleasant impact when the wearer ran or jumped. Numerous

substitutes were proposed for Army splints and plaster of paris but were

usually without merit.

During the early years of the war, there was a lack of certain items of

operating-room equipment which, in many instances, was due to the individual

methods and requirements of the surgeon. Many instruments which had been

nonstandard before the war had to be rapidly standardized and rushed into

manufacture and procurement. It was necepssary to adopt the policy to obtain

instruments which would suffice for the greatest number, rather than to meet

individual demands. For example, in standardizing equipment for hip nailing, the cannulated three-flanged nail was adopted. An eminent authority on

this subject requested The Surgeon General to change from the cannulated to

the noncannulated hip nail. This was a case where the recommendation was

not consistent with military needs, and was not adopted. At another time,

some defective Steinmnn pins were supplied by one manufacturer, and many

of these pins broke. The situation required immediate correction.
ORTHOPEDIC SURGERY 55

Similarly, plaster of paris w.s initially supplied in bulk, and plaster

bandages were prepared locally in Zone of Interior hospitals. This procedure

required hospital space and personnel needed for other purposes. At the same

time, factory-rolled bandages were being shipped overseas. It became apparent that factory-prepared bandages were more economical and of better

quality, but, in spite of the efforts of the orthopedic consultantt, it was not until

near the end of the war that they became available for hospitals in the Zone of

Interior.

Special problems and projects.-An orthopedic equipment problem requiring special investigation and administrative effort by this author was that

of plates and screws for internal fixation. In 1943, it was discovered that plates

and screws for internal fixation were defective and that the existing specifications and standards were inadequate. With the cooperation of the National

Bureau of Standards, Department of Commerce, extensive testing was done on

plates and screws-testing which ultimately led to improved specifications and

the procurement of better products. This had a definite influence on the inanufacture of these items after the war and led to improved plates and screws for

bcth military and civilian use.

Another problem requiring similar action by the consuitant in orthopedic

surgery was the need for special shoes for foot deformities. The need for such

shoes became increasingly important with the return of battle casualties. The

manufacture of special shoes from ordinary measurements or plaster casts had

proved inadequate. With the cooperation of the Quartermaster General, a

system was designed to obtain casts and measurements from an impression of

the foot in magnetized steel balls which retained the weight-bearing imprint

until a cast was made. Next, personnel had to be trained in this technique to

staff six -ters which were designated for providing special shoes. With

rapid den ,uilization after the wai, this method was subsequently , scarded.

Prostheses were a definite problem throughout the war years. It was the

practice to obtain various types from manufacturers, and further fabricate

them in local limbshops. But specifications for artificial limbs and accessories

were very meager, and often items supplied were deficient in some respect.

There v..- s not sufficient inspection of the prostheses at the source to guarantee

the desired quality. The lack of quality, however, was often due to difficulty

in obtaining experienced personnel and necessary materials. These comments

are not intended to reflect upon the supply services or manfacturers but are

made in the it'Ierest of better procurement for any future energency. Without

adequate specifications, mass production, and careful inspection, it is not

,)o--;ble to supply adequately the needs of many thousands of new amputees

ii a -,)untry at war. Research and development on prostheses conducted during World War II and immediately thereafter are discussed in the paragraphs

on amputations, which follow.
56 ACTIVITIES OF SURGICAL CONSULTANTS

Facilities

As in the matter of equipment, there were also deficiencies in hospital

facilities for the care of orthopedic patients. Perhaps the lack of facilities was

more accentuated than that of equipment. Hospital plans had provided no

plaster room. Through some misconception, a small plaster dispenser of a

dental type was installed in the X-ray service for orthopedic use. It became

necessary to use at least half of a hospital ward to furnish adequate plaster- and

dressing-room facilities for orthopedic patients. Braceshop and X-ray facilities also were insufficient for the rapidly expanding number of orthopedic

casualties. These deficiencies were gradually corrected as new hospitals were

designed and built, and the consultant in orthopedic surgery shared in the

efforts to effect these improvements.

AMPUTATIONS

Amputation Centers

Establishment of amputation centers.-The orthopedic consultant's initial and, perhaps, foremost duty was the supervision and coordination of

activities pertaining to amputations and prostheses. Five amputation centers

were designated in March 1943 at the following Army general hospitals:

Walter Reed General Hospital, Washington, D.C., Lawson General Hospital,

Atlanta, Ga., McCloskey General Hospital, Temple, Tex., Percy Jones General

Hospital, Battle Creek, Mich., and Bushnell General Hospital, Brigham City,

Utah. The amputation center at Thomas I. England General Hospital,

Atlantic City, N.J., was established in August 1944. The seventh, and last,

center was designated at McGuire General Hospital, Richmond, Va., in January 1945.

In 1945, amputees among Philippine soldiers came to the attention of

The Surgeon General. These amputees were entitled to the same benefits of

surgery and prosthetic fitting as others of the Armed Forces of the United

States. Accordingly, it was necessary to provide for their treatment in the

Philippine Islands 2 or to transfer them to amputation centers in the United

States. A plan was formulated in the Office of the Surgeon General ill

February 1946 to send a unit to the Pnilippines to establish an amputation

center. This unit, organized by Colonel Peterson, included 3 officers (1

of whom was an amputee), 2 occupational therapists, 1 physical therapist, and

16 enlisted men trained in limb fitting. This group sailed from San Francisco on 18 April 1946 with necessary shop equiplment and established an

2 3Parsons, W. Barciay, Trimble. I. Ridgemay. and Eaton. George 0.. Southwest Pacific Area. In

Medical Department, United States Army Surgery in World War II. Actiitie of Surgical Cousuitants. Volume I. Chapter XII. (In pleparation I
ORTHOPEDIC SURGERY 57

amputation center within 4 weeks of arrival in the Philippine Islands. A total

of 192 amputees were treated, and there were 94 operations and 118 prosthetic

fittings before the group departed in October 1946. A complete amputation

center with equipment and trained Philippine personnel was tranferred to

the local authorities to meet the needs of the military and civilian amputees

remaining.

Amputation statistics.-On the basis of information derived from reports

received from amputation centers, the Medical Statistics Division, Office of the

Surgeon General, has estimated that about 15,000 men in the U.S. Army (including Army Air Forces) suffered amputations during the period from 1

January 1942 to 31 March 1946. The maximum census reported by these

amputation centers for any one month was 9,246 in June 1945. The total

number of amputees included in these reports was 14,782, broken down as

follows:

Single amputation:

One leg -------------------------------------------- 10,620

One arm ------------------------------------------- 3,224

13,844

Double amputation:

Both legs ------------------------------------------- 870

Both arms --------------------------------------- 57

927

Triple amputation:

Both legs, one arm ---------------------------------- S

Both arms, one leg ---------------------------------- 1

9

Quadruple amputation ------------------------------------------- 2

Total ---------------------------------------------------- 14,782

It should be noted that these estimates do not include nondisabling amputationis

of fingers or toes of U.S. Army personnel who, after treatment, were continued in military service. Moreover, these estimates, based on reports received

from amputation centers in the Zone of Interior, exclude data on those

amputees who did not reach these centers; for example, amputees who died

overseas.

Operation of amputation sections at centers.-Few doctors had much

experience in amputations or prosthetic fitting before their military service.

They rapidly gained experience, however, and attained very high standards

of amputation surgery (fig. 5). With the aid of visiting medical consultants

and representative of the prosthetic industry, officers and enlli.ted men were

trained in details of prosthetic fitting. Medical ofiicers assigned to the amputa-
I~~~~~~~~~~ II vI I~ I andI 1l il1(1 I I I I I I I. l' iN8 L'F i ' th

I e 1 1 I P('Ic I \4I I Ifr I m 7 14 .\ii 0 i aII i t I lild i a e
ORTHOPEDIC SURGERY 59

procedures being carried out and the prosthetic fittings being used and included statistics on admissions, dispositions, and census. Each report was

obtained directly from the chief of the amputation section in spite of occasional

protests from various sources. It was believed that this method of direct

reporting was justified, since amputations constituted a special problem in

which close liaison wits necessary between the orthopedic consultant in the

Office of the Surgeon General and each officer in charge of an amputation

section at the centers. These reports supplied valuable information with the

least possible delay.

Conferences.-Several conferences were held during the war years oil

amputation centers and amputation activities. An international conference

met in Ottawa and Toronto in February 1944. Chiefs of the centers met

on three occasions during national orthopedic conventions in 1944 and 1945.

A conference was held in Washington, D.C., and at McGuire General Hospital

in June 1945 to consider amputation technique, prosthetic problems, the history

of amputations in World War II, and projected research and development.

Research in Artificial Limbs

Committee on Artificial Limbs.-Resparch in artificial limbs was almost

nonexistent before 1945. Prostheses had gradually evolved through tle efforts

of individual manufacturers. The available prostheses were quite satisfactory

for the lower extremity. From both the cosmetic and functional standpoint,

the devices for the upper extremity were still inadequate. At (he request

of The Surgeon General, the National Research Council established the Coinmittee on Prosthetic Devices (later called the Committee on Artificial Limbs)

in February 1945. It was hoped that this committee would help to improve

rapidly the specifications and manufacture of prostheses for the military

service. This, however, proved to be a long-range research program, and the

work of this committee did not actually benefit the anmputees in 1915 and 1946 or

for several years thereafter. Meanwhile, the U.S. Army established the Army

Prosthetics Research Laboratory at time Walter Reed Army Medical Center,

Washington, D.C., in August 1945, and the work of this laboratory has resulted

in greatly improved cosmetic and functional hands (fig. 6). The Committee

on Artificial Limbs continued to be supported by the Veteran' Admiiiist rat ion

and the U.S. Amy in the conduct of research by contract with unikersities

and manufacturers during the postwar years.

Commission on artificial limbs.--In March and April 1946, a commission

on artificial limibs directed by Colonmel Petersol, amd including Maj. Rufus If.

Alldrege. MC, and l)r. Paul Klopsteg, (chairntlm of tile Committe( oil Prosthetic Device., visited Eurol)e for the )Imrpose of Stud ing aimlUiptat ions amd

prostthese.s. The tour included Eligiamd, France, Cerially, Sw itzerlamd, and

Sweden where numerous amiputation celter., alld I imib.ihq)lop \ere observed.
'Ti I IT II :, FI -f I N I I . 1 IT Ni

NO ii ~ i~ii.i
Tw~o developmienit' rece aked special at iii by L tile comisiiIsioni duiring its

t oilt. Onle Nlas citlellt fol. tlie uipper ext tenit (fig. 7). and1 the otAIhet',

nct loll sockets~ for. tile lower x eii' (figr. ). S1tl),v(Jitelitllv bothI subjeets

ittiierlett ilitetllike re'.eali~ ilk lile Ui ted stale, and tile Principles were

LIAISON AN!) COOPERATIVE ACTIVITIES

Within the Office of the Surgeon Genera I.-TI ere, Nwas emcellent liaison

:111dl coopenit ionl Let wvet tile ol liopeii ioii,1n1t ant alltil le \arionl divislOils

of thle ( flice of tilie Sttz-eoui Genieral. R~ecordl ill ie Militarv Per.olilel

IDivi.,ion. IPer~oiiiel Service. ( flice of Ilie Suit-voti (eieral. 'N(eie avaiilble

at Atll ne, for review. lRecoliiiikeiilda ions, iie l)iv tile coti'utlailt t liek

M1ihltitar lPer~otitel DI vi~ioti. N\ it blut dela X Tile li'N icail staiiarih Briawlh.

Medical D] vi-iiiii. lPiolvioial Sk'n ice. freijuiit I, iooltllei lie Oitliopeii

lBtatic vit Ii treli'eii' to 'taiilaiiL oll 111 leiictilo'ehui al \ -lviii a, a~Phied

to eldi'teit and iil1iiiii--iolleul pei''l'u;tie. Frteuent iiiforoal conlelwetic'. et

helid \it il iepre-vtil ive,~ of t1lie Medhical Siippl \ i ) ~ilo. Suipp]l\ Sen lie.

Oflire of tile SicIi Getieral. ll jel~t ult~itiitNal prllIVIellt
62 ACIVIIES:~ OFi SURIGICAL. CO(NSULTANTS

P,'

FcaS. -Sliloll-si 'ket arIt ificia 1im 1)1)with t Wi)-NA;t UYilve (J. A. HangeriCi') devi'elpe frhII (iiidh lit it1 in.l A., L'ata %1-% (f Juutlei.B. Ali~puitve aiiid pros11olte If wee iiii ioplife l'ld qie. 10 ll The t Alil't v'j I i h liitell

i\j isjim, Operat iolli, Son' ire. TheM' relattei to I lie pn-paralit joti of' I raillitig

and field mtanuals, eleciallvy mi such Iluauterl, ii, fini aill. 1 lallol'tat joll of

sem endi molt iihii pict ttle'. sttch as -AMet MA( oiie-atV alnd -I )iail. ()f a

CM' ied tlit, teichiltical :i~pvcl, aill liltw at ioul '-Itt tl aitil thei care and I lailill±

With the service commands. TIlit' rt'Iat 1iwlip of I ll- volliiultalit ill tie
ORTHOPEDIC SURGERY 63

On several occasions, criticism was directed through channels to The Surgeon

General because of direct communication by telephone or letter, from the orthopedic consultant in the Office of the Surgeon General to the chief of orthopedic

service in a hospital. Nevertheless, many problems and questions arose which

could have been, and were, expedited through direct communication without

impairing the prestige or authority of commanding officers of hospitals or surgeons of service commands.

OBSERVATIONS ON CARE OF ORTHOPEDIC INJURIES

Errors and omissions were occasionally observed in the professional care

of patients with orthopedic injuries. In general, the standards of treatment

were exceptionally high and surgical technique was excellent. The residency

training prog:'am in civilian hospitals had furnished sufficient trained orthopedic surgeons so that several were available for each of the larger hospitals.

Their assistants, who had had 1 or 2 years of formal training, and others,

who were rapidly trained in the Army, became proficient in their assignments.

In spite of the heavy workload carried by the individual orthopedic surgeon

in a hospital-from 75 to 100 patients per medical officer-serious delay in

surgical treatment or disposition was rarely encountered. The following observations were notewtrthy:

Overtreatment.-Several aspects of overtreatment were common. In the

early months of the war, many upper-extremity injuries had extensive immobilization of the hand which prevented active use of the fingers, especially

at the metacarpal-phalangeal joints. This resulted in unnecessary stiffness

and prolonged incapacity. The consultant directed that prompt attention

be given to mobilization of the hand at the proximal palmar crease in order

to avoid fibrous ankylosis of the metacarpal-phalangeal joints. Some undisplaced fractures of the long bones which were not in danger of displacement

or nonunion were overtreated by prolonged immobilization. For example,

undisplaced fractures of the head and neck of the humerus, the head of the

radius, and the pelvis and march fractures of the foot required minimal

immobilization.

Internal fixation of compound fractures.-Compound fractures required emergency surgery and debridement. When it was necessary to delay

the emergency surgery, in some instances internal fixation was performed several days later after the optimun, time and yet before the danger of infection

had passed. When the debridement and fixation could not be performed immediately, it was not advisable to apply internal fixation until the wound had

completely healed. Failure to observe this principle resulted in osteomyelitis

and prolonged morbidity.

Fractures of the femur.-Fractures of the femoral shaft were immobilized in a plaster spica for transportation to the Zone of Interior, 1here the

cast was removed and the femur was )laced in traction arid balanced suspension
64 ACTIVITIES OF SURGICAL CONSULTANTS

until union was firm. If the cast was maintained too long, considerable stiffness and atrophy resulted. if traction was removed before union was firm,

deformity or nonunion followed. It was often demonstrated that both the

clinical and X-ray examinations were essential to establish the degree of

bone union. Occasionally, X-ray suggested union while clinical examination

revealed definite nonunion.

Delays in operation.-Delay in operation was noted in three types of

cases which deserve special mention. First, chronic osteomyelitis with sequestration was often treated conservatively after operation was indicated. Next,

chronic skin ulceration was allowed to continue after skin grafting was indicated to hasten recovery. On the other hand, this author observed that the

principle of early sequestration followed in a few days by skin grafting of the

saucerized wound was especially noteworthy on the service of Dr. Robert P.

Kelly, Jr., at Ashford General Hospital, White Sulphur Springs, W. Va.

Finally, many cases with definite meniscus injury were continued unnecessarily

long on conservative treatment when surgery was unquestionably required. The

delay in surgery for injured meniscus was a reaction to the frequent arthrotomy

which was noticeable in the early months of the war when cases had not been

carefully selected and no postoperative rehabilitation had followed. The

long-established principle of menisceetomy for internal derangement had

unjustly lost stature. Fracture or dislocation of a meniscus was a very common

injury among military personnel, and the need for surgical treatment was

usually obvious.

Rehabilitation.-The importance of rehabilitation was nowhere more

apparent than in the postoperative Ineniscectomy cases. In early hospital

visits, only a few places had an adequate rehabilitation program. While the

need for this rehabilitation had long been recognized in the military service

as an essential part of the postoperatih e care, repeated emphasis and education

were necessary before the principles of quadriceps exercise were generally

recognized and applied. An outstanding example of a good rehabilitation

program in postoperative knee cases was observed in 1943 on the service of

Maj. (later Lt. Col.) Robert L. Preston, MC, at Nichols General Hospital,

Louisville, Ky. The later development of a resistance exercise program is

attributed to the work of Capt. Thomas L. De Lorme, MC, and Maj. Francis E.

West, MC, at Gardiner General Hospital, Chicago, Ill.

SUMMARY AND RECOMMENDATIONS

Orientation to duties.-At the time of his assignment, a professional

consultant should be rapidly but thoroughly oriented in his duties and in the

limitations of his assignment.

Hospital visits and inspections.-Consultants must spend a great deal

of time in travel under hardship conditions that are not readily apparent.

Wartime traiel and accommodation. were fairly iugged even in the Zone of
ORTHOPEDIC SURGERY 65

Interior. A clean room with a comfortable bed, one easy chair, and a good

lamp were minimal accommodations which were not alvays available. The

hospitality to the visiting consultant contributed considerably to warm relations during his inspection. The reception given to the consultant in the "front

office" of a hospital being visited was often an indication of the spirit of the

command. The visitor had to be prepared for the occasional cool reception

by a hospital commander who was too harassed by other important problems.

Hospital inspections were very strenuous when they involved, as they

usually did, the examination of several hundred patients daily and the evaluation of professional personnel. Consequently, it was necessary to put hospital

personnel at ease as early as possible during the inspection. The sudden

descent on a hospital of a large number of consultants as in the wartime "Flying

Circus" trips must have left the hospital a little washed out after the visit

was completed. These massive inspections often lacked the atmosphere of

personal contact, and, in the opinion of the writer, the mission could have been

better accomplished by a less explosive type of inspection.

The amputee.-Among the various types of battle casualties, amputees

presented a unique problem. The emotional and physical disturbance resulting

from the loss of one or more limbs required a prolonged period of treatment

and readjustment. The congregation of a great many amputees, with their

multiple problems in prosthetic fitting and training, presented a public relations problem of considerable magnitude. An extensive file of headlines and

newspaper articles pertainimig to amputees was a constant reminder of the

necessity of meeting this problem with a planned programn in personal and

public relations. The writer is hopeful that continuing programs in prosthetic

research will furnish good prosthetic devices, and thus obviate some of the

difficulties of World War II. Nevel theless, comparable problems in prosthetic

fitting, rehabilitation, and social readjustment of the amputee are likely to

recur in a time of all-out war.
CHAPTER III

Chemical Warfare

George R. Greenwood, M.D.

Although active chemical warfare was never initiated in World War II,

preparation for it was begun early by various agencies of the Federal Government and was continued on an increasing scale until the end of the war with

Japan. This was only logical. It was well known that the enemy was equipped

to institute this kind of warfare. Furthermore, the argument was frequently

heard that the U.S. Army would be justified in instituting it in order to prevent

unnecessary casualties among its own troops. Had either of these contingencies

come to pass, it would have been the responsibility of the Medical Department

to care for the casualties of chemical warfare. Even before the United States

entered the war, therefore, planning along these lines had been undertaken.

CHEMICAL WARFARE BRANCH, OFFICE OF THE SURGEON

GENERAL

When the United States entered World War 11, the Army Medical Department owned and financed, but did not operate, the medical laboratory at Edgewood Arsenal, Md. (fig. 9). This laboratory, which conducted research studies

on the treatment of casualties caused by chemical agents, maintained liaison

FIoURE 9.-Army Medical Laboratory, Edgewood Arsena!, .1d.

67
68 ACTIVITIES OF SURGICAL CONSULTANTS

with the Chemical Warfare Service of the Army and kept The Surgeon General

informed on current developments. At that time, no medical officer was

assigned to his office.1

Appointment of Medical Liaison Officer

After 7 December 1941, when the possibility of chemical warfare became

an acute reality, the volume and pace of the work done at the medical laboratory

at Edgewood Arsenal increased, and a corresponding need arose for direct

representation of the Chemical Warfare Service in the Office of the Surgeon

General. To meet this need, Lt. Col. (later Col.) John R. Wood, MC, 2 chief

of the medical laboratory at Edgewood Arsenal, was appointed to the Surgery

Division, Office of the Surgeon General, on 21 May 1942, and was officially

designated as liaison officer representing The Surgeon General to the Chemical

Warfare Service.3 On 18 December 1942, however, Colonel Wood was transferred to Edgewood Arsenal, and, from then until August 1943, there was no

representative from the Office of the Surgeon General to the Chemical Warfare

Service.

In November 1942, when research in chemical warfare was being expanded

rapidly in response to the potentially urgent need of the Army, three groups

were engaged in the study of the medical aspects of this type of warfare, as

follows:

1. The Office of Scientific Research and Development had two committees

at work in this field. The National Defense Research Committee investigated

the effects of new chemical agents. Clinical studies were conducted when they

were practical, and the agents were studied experimentally, by observation of

the physiologic mechanismns involved and the possible inilnunochemical reactions. The Committee on Medical Research developed methods of treatment

for chemical injuries.

2. The Medical Research Laborator'y, Edgewood Arsenal, in addition to

carrying out a variety of peculiarly military scientific itanctions, made studies

similar to those made by both the committees of the Office of Scientific Research

and Development. In other words, the functions of the former duplicated

those carried out by the civilian agency.

3. The Medical Department of the Army had the responsibility of treating

injuries due to toxic and incendiary agents.

The development of chemical agents and the protection of troops against

then was the responsibility of the Army Chenical Warfare Service.

I Offce Order No. 87. Offlice of the Surgeon General, U.S Ar.in. 18 Apr. 1941

2 Office Order No. 175. Office of the Surgeon General, U S. Army. 1 June 1942.

Letter, Chief, Medical Research Dhision, to Commanding General. Edgewood Aisenal, 10 July

1942. subject : Medical Re-eatch Division. Edzewood Arsenal. Md.
CHEMICAL WARFARE 69

Permanent Organization

Chemical Warfare Service.-Reorganization was effected by the creation

of the Medical Division, Chemical Warfare Service, the director of the Division

being made directly responsible to the chief of that Service. 4 The research

laboratory at Edgewood Arsenal, which had been controlled and financed but

had not been operated previously by tle Medical Department of the Army, was

transferred to the Chemical Warfare Service and became an integral part of

the new Medical Division. The Division was nctivated on 3 July 1943,5 though

the transfer of the laboratory to it was not effected until 15 July 1943.G

The newly created Medical Division had several missions, as follows:

1. Its medical mission was to carry out such research work as was necessary

to develop adequate methods of treating injuries due to toxic and incendiary

agents likely to be used in war.

2. Its toxicologic mission was to study the biologic effects of these agents

and to develop adequate measures for the protection of troops against them.

3. Its liaison mission was twofold. First, it was to maintain such close

contact with civilian laboratories, particularly with laboratories receiving

financial support from the Office of Scientific Research and Development, as

would make possible the utmost practical applica ion of the work done in them

in the fields of chemical warfare. Second, it was to keep The Surgeon General

completely informed on all medical aspects of chemical warfare.

Office of the Surgeon General.-To permit the performance of the latter

mission more effectively, the Chemical Warfare Branch was established in the

Surgery Division, Professional Service, Office of the Surgeon General, on 12

August 1943, with Maj. (later Lt. Col.) Albert McG. Johnston as its bead.7

The functions of the Branch were (1) to maintain liaison with the Medical Division, Chemical Warfare Service, Army Service Forces, on matters pertaining to chemical warfare as related to the Medical Department of the Army, (2)

to prepare information concerning, and directive- for, the care of casualties

caused by chemical warefare agents, and (3) to assist iii the planning of field

equipment used in the prevention and treatment of chemical warfare casualties,

The new distribution of functions assigned to the Chemical Warfare

Branch, Office of the Surgeon General, certain responsibilities which had hereMemorandum for file 29 Apr. 1943, subject: Proposed Medical Divil,,n for the Chemical Warfare

Service Submitted by reiresentatives of the Chief. Chemical Warfare Sern lce, and The Surgeon

General.

3Office Order No 48. Office of the Chief. Chemical Warfare Se, ice, Arm Ser ice Forces, 3 July

1943

' Letter, D. C. Sapp. Adjhtant General. Office of the Adjutant. Army Serice Forces, to Commanding General, Chemical Wa fare ('enter. Edgcewood Arsenal. Md., The Surgeon General. and Chief,

Chemical Warfare Service, 5 Aug. 1944. subject. Transfer of Medical Department Research Laboratory,

Edgewood Arsenal, Md.

' (1) Office Order No. 572, Office of the Surgeon General. U S. Arml. 12 Aug. 1943. (2) Organization Chart. Office of the Surgeon General, U.S. Army. 3 Feb. 1944 S Manual of Organization and Standard Practices, Office of the Surgeon General, Arsu\ Service

Force,, 15 Mar. 1944.

606222'-62--7
70 ACTIVITIES OF SURGICAL CONSULTANTS

FiouRn 10.-MaJ. George I. Greenwood, MC, Chief,

Chemical Warfare Branch, Surgical Consultants Division, Professional Service, Office of the Surgeon General, and Consultant to The Surgeon General.

tofore belonged to the Chemical Warfare Service. One of the most important

was the preparation of literature on first aid for, and on treatment of, gas

casualties and on the detection of chemical agents in food and water. This

branch was also assigned the provision of equipment to implement the procedures described. The literature issued and the equipment specified were

based on recommendations made by the Medical Division, Chemical Warfare

Service.

Major Johnston, the first consultant for the newly established Chemical

Warfare Branch, was succeeded in March 1944 by Capt. (later Maj.) George

R. Greenwood, MC, (fig. 10) who served until 17 September 1945, when the

activities of this branch were suspended.

Policies.-The basic policy of the Chemical Warfare Branch was to keep

fully abreast of all developments in this field which might eventually have

some sort of . ipact on the Medical Department. In line with this policy,

Major Greenwo I usually paid three or four visits each week to the office of

Col. Cornelius P. Rhoads, MC, Chief, Medical Division, Chemical Warfare

Service, to discuss current problems relating to projects under way or to
secure inrmtion for.aritie tobe prepared by the Medica Department dealingy"Ith.,fii aid,or thier tretmenit for esualties of-,chemical warfare. The,

MediW;MRehearchLAboratory, Edgewod-Arsenal, was.As ,visited,at least,

'These direct contadts iti.d tlhe f miiay knowledge w.hich wias thuis secured,

graly d,teth solutionsof Man-edicail problems Which,- otherwise

migh hae tmpoariy founere in~idinitrairedtape after-they14 ha

reached'the Office of the Surgeon General. 'The cooperation recived from

0616n1I ods andfrolm Colonel Wo~od, chief of the 'edical Researoh Labo-

"rAbty, gwo Arsenail, and later fro Colonelr Ihoad'scesr a l

w.y coYrdiitl anduseful,.

In, thd, Offie of the Surgeon General, Major Greenwood's. chief coiitadts&

outsid6 "of 4h6 'Surgical Consultants, Division, weqre with-the'Teclhnical and

'Training ,D'hvisions, Operations 'Service, of that Office., The, personnel of, these,

divis6ions -were itiso most cooperatiye. They offered. tedlinicAl- help whenuever

li W49 ts meesary, and they Willingly accepted recommendations on medical niat-.

Majr renwodalsoxfiaintained -close contact -with- research, activities

of'cvlian itibortitories. 'He received- reports- from the National Research

Councifand~the Office of ScientificRsac an De e et$ . nh atne

th6ebg at the University of Chicago, at -Rockefeller Center, New York,

N.Y., and Ili Washingtoi iC Where the latest, research developmnents were

presented.

EQUIPMENT FOR PROTECTION AGAINST GAS WARFARE

Two important changes were made during World W11ar HI in equipment

used for thb protection and treatment of gas casualties. They had to do with

the gas citsualty set and the field oxygen equipment.

Gas Casualty Set

Reports from the Office of the Surgeon General, the Office of the Air Surgeon,9 and the Surgeon, Army Ground Forces, 10as well ais verbal discus~sions

w ithi numerous medical officers durirg the first months of United States participatioii in World War HI, indicated that the gas casualty set -%hich was

standard at the beginning of the war was undesirably heavy and unwieldy. A

report from NATOUSA (North African Theater of Operations, U.S. Army)

in 1943 stated that, because of their weighlt and bulk, these sets were not carried

forward of the most rearward division medical units. Revision of the equip9Letter, Headquarters, Army Air Forces, Washington, D.C., to The Surgeon General, Washington,

D.C., 26 Apr. 1943, subject: Gas Ct .uaity Set.

10 Letter, Maj. A. P. Thomn, 31C, Assistant Surgeon, Army Ground F'orces, to Lt. Col. John R. Wood,

MC, Director, M1edical Research Laboratory, Edgewood Arsenal, 29 Apr. 1943.
~72 4 '. IPIE OF -SURGICAL CONSULTANTS

;qent to- meet thiese objections Was therefore recomnei iepfs ~e,streamliiiedIilit-weiglit gas castalty set (fig,eed1 Inrposa. Miedil Researo bjhe Medidal'Re Iaborat, i, Egewood, At§eni.,a~d- was s§tandardized i3,y ffe AtinS,$rv.Ice Forces on ) -May, 1944. It was descrilbed'in th4 Jl19644:

the n~'set weighed only 45i pounds, in contrast to- the- 160 pounds of-,

the 'fdimer gas casi4ity chiest. It was made up of a gas caisualty, treatment-.

iiian ~ nsrts echof -which contained three ipqrerm elaprons and

three pairs of .imipermeable, glove Is. ThIle 'batsoui Kt Teaent, a

Casualty,, M~edichd Department 'Item , 0.97,76T), was an., expjendnble..itemf, re.

s ~iig a-rnall' suitcasa, and weighing, only 17 pounds. The contents of-the,

'kit were'suficientto caire for th6 chemical casuialties of one infantry 1atioii

,r- gh24 Skiours of active cbeinhical -warfatre.

The new kit had, other advantages in addition to it light *eight. Th

hubber -gskef -liing thie seain, between the lid, and bod'.- mAde-it -aterproof.,

Liside the 1kV was.- graphic-ibpresentatibms sowing the exact locationofeh

item of the contents, A booklet,, entitled "'Notes on Treatment of "Casualties

From Chem11ical Agents,"' was provided listing the symnptoms,, pati'ologric

*changes, and, diagnostic points useful in the management of thewe Inuis

Ai basic items were -provided for the treatinemit of all varieties of gases -

* likely to be encountered in modern chemical warfare,

The kit also included equipment for water testing with a book, 'of 'directions. Small units were thus supplie it smpedvefosceening,

but- sources of water~ so contaminate(-. with chemical agents that they could~not"

be made potable by the usuial methods of treatment in the field, s5uchi as,

* ~ chloination in the Lyster bag.

-Before the gras casualty treatment kit reached field units, however, a mna ,r

change had to be made, which caused considerable consternation in the Technical Division, Operations Service, and in the Supply Service. All of the work

on the kit, including its contents, had been carried out before March 1944,

When Major Greenwood became chief of the Chemical *Warfare Branch.

Shortly after his arrival in the Surgical Consultants Division, he was. summoned to the office of Col. (later Brig. Gen.) Fred W. Rlankin, MC, Chief

Surgical Consultant, to explain why a discrepancy existed between the policy

of treating burns caused by chemical agents and that of treating those caused

by more usual agents.

Trhe gas casualty kit included a number of tubes of 5 percent sulfathiazole

ointment, with instructions that the ointment be used in the treatment of

both incendiary and vesicant burns. This policy, however, although it was

in accordance with earlier instructions issued by the Office of the Surgeon

General, had been changed because of certain toxic effects caused by the abIt Report, Capt. Louis Venet, 3MC, and 2d Lt. Matt J. Oehlbcrg, Chemical Warfare Service, undated,

Report No. 14, Medical Iteseareb Laburatori. Edgewood Arsenal . A Gas Casualty Set for Medical Units.
FIU4'kI I I i*4iI il .1 2. A 
ACTIVITIES 'OF" SURGICAL 'qONSrJLTANT

sdrption Of sulfathiazoe When w it was used in burns involving large body

suffces., The current policy eliiniated the ointmentand, directed A6huse

of pTressure dressigs over ,petrolatuim-impregnated dressings. There .wa no,

reason,, as Colonel Rankl npointed out, why the samepolicy should not beused

Sthe rteatment of gas casualies. it beinga well-established fact ithatburns Sfi~stined by eVsicahtagents~did notdiffer from .other:burfs in any respect,

dii61W iighg tbrhpy.

a"'Jor Gre:en iiwood, who,,had just come to t1e hemical Warfare Braiich

hith6 Surgical Consultants Divisionfr6m. a field unit ,could-not explain -yy

the 4hiungesIn, iherapeutic policies hai not been, reflected in the components

ofthe gascasualty treatment kits. Fortunately, atlough thekits hadaalray

6enn uf'actured, they were'still in warehouses and ha'-d:not ben distrbutd

to i field uiits, so-petrolatum could be substituted for sulfa thiazole ointment.

On Colonel Rankints instructions, printing was also stopped on a revision

-of War Department Technical Manual (TM) 8-285, Treatment, of Casualties

From: Chemical Agents,, until the directions in the manual for the, treatment

.6f6esidant burns douifla1so be altered.

Field Oxygen Equipment

In an effort to place in the field sufficient equipment fog the treatimljnt by oxygen of the large number of injuries due to lung irritants which might

be expected in the event of gas warfare, the Army Service Forces, in March

1944, had standardized apparatus for the administration of oxygen (Oxygen

Therapy Outfit, 20 Dual Outlet, with Hose Line Assembly, complete, Medical

Department Item No. 9364200) (fig. 12). With this apparatus, a Single

source of oxygen could be used for the treatment of 20 gas casualties, each of

Whom would receive 8 liters of oxygen per minute, or for the treatment of 40

casualties, each of whom would receive 4 liters per minute.

Shortly after this item had been standardized, it became evident that the

apparatus was inadequate to furnish 100 percent oxygen to the number of

casualties it had been designed to treat.12 A study of accidents at various

chemical plants and of the casualties caused by the leakage of chlorine at

the widely publicized accident in Brooklyn on 1 June 1944 1 made this quite

clear. Reports from these sources showed that the average respiratory volume

of gassed subjects was 10 to 12 liters per minute and that in some instances

the volume ranged as high as 15 liters per minute.

12 (1) Letter, Director, Medical Research Laboratory, Edgewood Arsenal, to Chief, Medical Division,

Office of Chief, Chemical Warfare Service, 16 June 1944. subject: Report of Test on Oxygen Therapy Outfit Hose Line Assembly, 20 Dual Outlets. (2) Letter, Chief. Medical Research Laboratory, Edge.

wood Arsenal, to Capt. George R. Greenwood, 23 June 1944, subject: Oxygen Requirements of Indi.

viduals With Lung Damage.

"Brooklyn Chlorine Accident, a Technical and Medical Report. Prepared for the Medical Division, Chemical Warfare Service, under contract W-49-036-cws-1 with New York University College

of Medicine, 1 July 1944.
CHIM~ICAL WARFARE 75

ILI

ow !,Z.

41,j

}'zt, In,. 12. D),IoMt at ionl of u1,se ofX oxgull tjp utilt, 20 duial outlet, Nwith hose

as*110 ai l i P'ost, Forl .lyer, Va., O ctober 1941.

IIThe reco IuuIIet.] tt iou o f t I it, Mt'dicai I D)iN ijil I Ce iiicat I Warfa rv Sein ive,'

ithit the eqllipliilt be IlihfietI to proN ide foraI ;il1cre:1wei' tile floNN of 4)x. (peli.

N%117 COW11ui'u1l ill il,, Cli iicaii;l Warfare Brai,,hi, S1tiugical ( 'iltails

Dix isiou, IPiofe-'iOnalu :senlr and 11ial fon"141Watlefl to) tie Tvvhei~ical )i'iioli

Operatin iuSer 1 vice. for apprpr)iatC actio lol II11 . Ily ,Ivt9t1L,'

It ~asfllh -v lizd.1%lvil[le rcolilivlda iol I~tteltha tlie lili

ill the( raute of 114)XN jteriitvtl I1* the llv N appa)Itl t. to merveiolie the. dlivievilie-,

of the h)1IIwr app);ill Ii N~ollh do)tl)I&e Hit, lotgi.t o. auld siplh p~rolem~i of the

AruiV i itli rve pvt to o\. Nevi. The ;IkrioiilI ;iaer, of opvratiol' j1ihiv er 111ilied of thl~ w% kleel tliivitt atiul %NW fferledet ,ticietit ippiv-,~ of ' clitlei.

l o ie u. h I I) ) h e ' a ilee I . 4)il I e4 1i N ~ i t I a 'vit (J t l eic lv a ."t W I e l II re l i I xI i Iial f 

I .Ie hu M i d oal kij4 4,, ii lwmia \\iit I., , .Nr.I 4I ,tliu4 .It il.. fLa tll ,.

11 Ji Pll ,I.L
tO ACTIVI-TIES OP SURGICAL CO0Nl;LtAN

While .these de6velopments wNere. taking -place , the bossibility of the uSeof"

liquid-okyg6n, Wag also,-being investigtd tdenhewhether it wa,;PM7

n aparausdilit h-then Standardized.,ftoilb volt me, of 'bxygendould be provided in: a relatively Silspace ,Atnd the,,levy

cffmb~f§6ne oxygen cylinter& curr~ntly in use could be,.dispehsed'WitlI.

The, projed twas- dropped, for two- reasons. The first ~a ta,.~~ir

tthe oiriginal belief,-thle supply of -cylinders Pifoved' ay ilabbfdr a'upses4

Th6 second wasI that liquid oxygen- could. not 'b used, sat jsf actorilyi eq,,

rnent -then- on find which 'did not Provide -enough, prbsstire for the ,desired

4*atl 6f'low. An additional disadvantage was .that f-rom, W3toA 4 ppiceu't of thile

Vbwole of liquid oxygein was found, to'be, lost duringreach:24'hours of storitge"i

PROTECTION OF PERSONNEL, AGAINST'GAS'

In World War I,,the protection of ArM'y .p~rSolne against chiemical agents,

was.:the responsibility of the Medical'Depaitment until-the. organ Iizati I .o f,

,the,'ChiemicalWarfaf6 Service in July 1918. In -WorldWar I, this tsk _vas,

ailwaiys the riespons~ibilit-y-of the Chemical Warfare Service, The-?* dical,

'D~parmentf 'however, was concerned in ail aspects of, the matter -and 'r6-!

~u~y Participated in coniferences.

One of its deepest concerns Was theprovision of agas mask which, Would -' adequately -protect casualties wvho could not Wear the regu~lar Governmentis~ua mask because of ]lead injuries r'equiring bandages. After several-cpn,

frofices participated in by the6 Chemical, Warfare Branch, thle Development

Brianch (Technical Division, Office of the Surgeon General), and representatiV&~ of the Chemical Warfare Service, a model for this purpose was selected,

and Was standardized after proper testing.

Certain shortcomings of this model were recognized when it was adopted';

Sinice it covered the entire hlead and neck, heat and moisture tended to accumulate within it, Also, there was always is fairly large dead space within iti. no,

matter how carefully it was applied. To meet thiese objections, the Chemiceal

Warfare Service recommended onl 5 December 1944 '1 that a forced draft

blower, to be connected to six masks and to servo as a collective protector, should

be made part of the head -Wound gas mask equipment. The Chemical Warfar'e

B~ranch approved the equipment in theory but suggested service testing.",

When this had been carried out satisfactorily, the Office of the Surgeon General

recommended that the equipment be standardized.

"TReport, Medical Research Laborawry', VIdgewood Ar.senal, to Chief, NMedical Division. Chemical

Warfare Service. 31 Oct. 1944, subject: Test-, nt Liquid Oxygen Vaporizer.

Is Letter. Chief. Technical 1)ivision. Offic. Iof thle Chief, Chemical Warfare Service, to Office of the

Surgeon General, attention: Lt. Coi. John 13. !,inpp. 5 Dec. 1944, subject : Head Wound Gas .Mask.

isLetter, Chief, Technical DivisioL. Office, , the Ch~cf. Chemical Warfare Service, to Office of the

Surgeon General, attention : Lt. Col. John B Kiopp, 5 Dec. 1944. subject: Head Wound Gas Mask,

indorsemnent thereto. (iated 1.1 Dec. 1944.
Masking of helpless patients,- The CItiinical Waraiw e r~aili ma. av

I i vel viiletevted ill Oie appiiat loll (ii ga- li 1 4 lo ) uillhiv \\ho it 11( 14

ap I firl own. vit iier lawailM t hie \s ele iiwls iollt (IF lwcal(M lwe'\ 40111(1

not4 11M5 their 11:11idk. A tl4a llr l11)141111-4 I~l 116 l lrii)44M \\s oi tl\ ioii~l'v

hi-iki' hle~ilable, 'o t halt. ill ile, v~ eitl oI, (,a, Vs~hu.lllk, coliIlie vxieditiol141' happlied b.\s Ilo414it1l aniid ot hier toF'~i~e 1I li, --rolp (dl iali~s

'Ille prrdr vev elilal , \l' recoIliliiited NVs I'lii lbe 14) ille ve'vrall I' ,p

otIra ia~~k- ( Ii-,. 13) lienl i n il-v I Ilie ll -\\el!ii -el's ice lila~il, \\ ii I MA- :1

an A41 I haewe"s I lie cotlibl( K \iii iiil AI :1 I'aep ere.a id [h e oldet vn ice

mwII-1. \aitii 4l2\I or 4l2A2 h14(jlliece). 'le teciliiie \\a~, delcudi1l. \wit i

Hillii- liotm4t'. illXXII al 1)ejmrtl-liill leclii4Il Ihillet n ill ME)) 4!) IG9 -i(

Inll i le jIJ

I)F'lF :'rlO\ OF CONT' NXlIN ATFI FOOD ANI) \V VTF;H

Al thle lbe-go~ili (i l Uited l aw, palrtiipatiolt ill World14 War 1I. the

po4I-lblv 4tolitkilliliI1itt- Ill It. T\\04 kit~sl VW 's (\lli lls, d4k l0lIAIe I'01 (Ili,,

pulio, I).\ thev le(ical Rv~v-lhi Lal~tlorol's . V4i ill~ 'II 444ilillV \]ll Ilw

O; ' 2 412
78 ACTIVITIES OF SURJGICAL CONSULTANTS

Fuwt m, 14. MAl -1 ater-testitig ki-- post-Wor-ld WarII 11 Chem1ical Corps iiiotlilitcatioll Of

the World War 11 water-testing kit. 'lTe World War 11 AMedical D~epartmuent kit %%as

p~ackedt ill a %% (odenl box " iti fittIin~g, for all hu t les coat a li, iui td.

Natioinal IDefens e Researich (Com11mit tee. One kit (Kit, Water 'F~tirScreeniinlg, Medqical1eatma Itieat No. 91000()(). ,4t111dartdized ol 1) J1uly 194:3,

Served1 as a1 (pua it'lat we screenling kit. '['lle 01 her, kit KJit. Wa',ter- 'Festilag,

1Poi.,ons, Treatmiteat (Contriol. Medical D epatmaent Itemt No. 9.9307) contsnbted

of a lare sttitcase wich Cont a ined apparat u. , and chteiichtl ill ,.tfflicielit

qutant it ies to perform quait it at ike anal ' xse of contain iated A ater (figr. 14).

Instrttction., for the tt -e of t he* kit, Nere ltililied inl War D~epatmaent

Techniical Buillet in (TB'l MEl)) 37 onl 2S Apil 19441 and wvere rexi ked onl 30
HE CA ARP'ARE 7

St'ugut1044i- Copies bf-the originai instructions and tli:revision weretplaced,

ah" 6i kitA4th h m ean i6r d"contamination of food.hAd long, been -kfown ,nb

stnpdar d eqip ment Was aVailabtodetermine vWhether it was c~nitaminated

yth ag:ens iilly' ,to be used, i chemical warfare. It was therefore not

S ossible p to detrmine ~eir the degree of contamination or the efficiency Of

d:tht 6i.ta i loh~procdureSunt' softie ieans fOk-thinap urposehad been, d Mld. -,On/3l A st 44, tbe '.,,ctor-6f thi Meciical ,Researeli Laborato ,y

fbrwardedzto the Medhal Division,,Office ofthief, Chemical Warfare Service,.

satv,'proiimay'report on a.kit for-usb ini detecting chemical, contaminants in'

danigerous amouits-on food packages andn foods.

, The use of a k of this

kind i:th held, would prevent the indiscriminate disposal of supposedly contaminated 6od supplies and ,would keep losses at a minimum intheevent of

gas- warfa4re. The kit in question was ,approved by th:e Chemical WarfarTh'anch and was standardized by- tie Ariny Service Foices on 17 February,

19)4(fit. -15). Various manufacturing difficulties, however, delayed progress,

-anldho9tilities ceased about the time that two manufacturers were ready to

,embark oru fill-scale production.

TRAINING LITERATURE AND FILMS

Publications

Numerous publications, in addition to those dealing with professional.

pblicies,, setydd to disseminate training information concerning the medical

aspects of chemical warfare. TM 8-285, Treatment of Casualties From Clemical Agents, first issued on 10 July 1941, was successively revised on 14 February 1942,21 on 27 November i942, on 15 April 1944, and in April 1945. Each

revision brought up to date the changes in therapeutic policies developed in

the Office of the Surgeon General as new information became available. In

the last revision, two appendixes were added. One appendix, well illustrated

With photographs, dealt with the disposition of personnel with blister gas

burns. The other dealt with general principles in the handling of patients

contaminated by chemical agents.

The Bulletin of the U.S. Avmyj Medical Department was utilized to provide for medical officers short, concise reviews of the treatment of mustard

* War Department Technical Bulletin (T13 MED) 169, Changes 1, 30 Aug. 1944.

=Letter, Director Medical Research Laboratory to Chief, Medical Division, Office of Chief. Chemical Warfare Service, 30 Aug. 1944, subject: Kit for the Detection of Contaminating Chemical Warfare

Agents on Foods and Food Packaging Materials, with inclosure, dated 26 August 1944.

2War Department Technical Manual (TM) 8-285, Changes No. 1, 14 Feb. 1942.
so OF1' SIII4(IAMUIC(AL CONSU'LTANTiS

77"

*' IV

I111-7
h: i949; :1iiwihg" a number of changes iin policy concerning, first aid, .to

cheia Oai'f are c~ i ties th xsigtaining, 4Th on this subjectws

d"iA61546and wa elacedl by-!a ew film, TF'8:4186, Flist Aid ,'for

Chfi'F~la iiftbia esne.n is idplce were made the

'i loWIhgy~ar,-and in December 1944 , t w§brou ight atntd f~h_ ihb wasa toiheatensononth

cl f ifi i I~ ca ~ in Cheinical' Warfare& S vice. tha~t tlje 1943, fibmi

ti~e-of'the'Navy, informally approachedthe6 Triniine Division, 'Qffce ofl tq

§urgeal, eqjwith the~i ugstion-tiiat ajoint Arpy-Navy-film bpepad

th U-n subjectnd

Cetai difreences-ihupolic-y-bet ween ,the6-t~vo;Services hiad to brcoe

z~aionof iqud bste g~sontheskin,,diffefed from thieArmy proedurej aiid

the olitment ised' by thetwo Services were differeht. Aw asbelie~ed -that

th ese- diferences could, :rit~dily be overcome in the ~filmn, Whenth lectiIe,

uponx which, the Scenario, was, to bebased, was prepared, how~ever, it became,

clear that there woulld 'be considerable~difficulty ia-presenitig'bpth decontaiminatouprceure i ~hesame Em;ih

It as thn elive -hatths ostalecould be overcome by filriug two

Sepai ate versions .of' the prlocedoir an# issuing the appropri-ate, v ersion of the

film t each b~an~i of the ServicoS.21 Army Service Forces headquai'ters howpveri, *lin this idea -was peented, ruled tbh nder the eircumstanices the film,

-could,,noidlonger6 be cliassified4 as a joint Army-Navy proje. o

The, original plan, therefore, wvas amendedto, provide'the Navy with acopy

of tiie Arm ii,:into wbic~h at sequence, presenting the Navy decontamination

Ptocedtire And Shot sepiiately, could be Spliced.

The letuire conining the technical information was then sent to the

Signal Corps. Their writers, stationed in the Eastern Division stucjlos othe

Army Pictprial Service at Astoria, Long Islund, N.Y., prepared thle scenario.

When the fiifst effort of these writers was reviewed by the chief of the Chemical

Wiliare Mullc, who had been selected to serve as technical adviser for the

flbn, it was found thiat they had overemphasized the hiorrors of chemical, warfare. This 'Was anl important item contrary to present policy, and the scenario

theref ore'liad to be rewritten.

283Memorandum for the record, Medical Division, Chemical Warfare Service, 27 Feb. 1945, subject:

Training Film on First Aid for Gas Casualties Due to Chemical Agents. 294emorafidum, Chief, Chemical Warfare Branch, Surgical Consultants Division, for Director.

Training Division, attention: Colonel Ainlay, 2 May 1045, subject: Training Film on First Aid for

Gas Casualties.

w (1) Mkemorandum. Brig. Gen. R. W. Miss, Chief, Operations Service, for The Commanding

Generai, Army Service Forces, attention : Director, Training Requirements Division, 27 Mar. 1945,

subject: Request for Training Film, second indorsement thereto, dated 8 May 1945. (2) Letter, Director, 'Military Trraining, Army Service Forces, to Chief, Bureau 'Medicine and Surgery, Iwavy Department. 23 'May 1945, subject: Training Film on "First Aid for Gas Casualties."
82 ~ACTIVIT~IES- OFSURGICAL CONSULAT

'After several more consultations, With th4, writerS at both Astoria aiid, - ~Wasiiipg~f, anaccptable sca aidwas prepared.' - :

The Signal Corps decided that their Western Division studio in Holly-:

wood, Calif.wouldbe the scene of the filming. Productipn was about to egin

when hostilities ended on 14 August 1945, and the who'le prop ject-wa anceled. I iew'of the changes in policy concernifig treatment Of gasdasuaito,h.

Chemical Warfare Branch recommendd to the TraijigDivisi~n,0Of

thd Surgeon Generali:in April i945, tlat the Filmstrip FS-80, TheFirst Ad

Kit for "Gas Casualties'"be declared obsolete. It was decided thatthis striPllduldb 'replaced by a strip dealing with first aid, asth individual-s0!dier.

wastaught to practicie it. Yrame descriptions h ben ead Submitted "o 'to iS9

!airricks for sketching wheL hostilities ended.

PROFESSIONAL POLICIES IN WORLD WARII

Although toxic gases were never employed against U.S. troops in World.

War [I, it was necessary to be as fully prepared against tlhem fromtle medlciti

standPoint as from the military standpoint. To teach the soldier prot

1imself against them, and to teach him first aid in the event of their useit Was,

heessary to demonstrate the action of certain gases.

Tear gas, a favorite chemical agent for training purposes, made the soldier

proficient in the use of the gas mask, Otlier gaseg, such as phosgene, lewisite,

and mustard, were also used-in dilute quantities to acquaint the soldier With, the

odors of various toxic agents. In the medical officers' courses at the Chemical

Warfare School, Chemical Warfare Center, Edgewood Arsenal, Md., trainees

saw the effect of mustard on their own skin When it was applied in a small

quantity. Furthermore, they saw the effects of many of the gases on experimental animals.

The most massive exposure of Allied troops to gas occurred at Bari, Italy3

when enemy bombing resulted in the release of a large quantity of mustard gas

which was in one f the Allied ships in the harbor. Many casualties resulted.

informative reports on the pathologic processes in these casualties were forwarded to the Medical Division, Chemical Warfare Service, by the Chief

Medical Gas Officer, NATOUSA.

In anticipation of possible gas warfare on some of the jungle islands of the

S3uthwest Pacific, the Chemical Warfare Service had established an experimental station on a previously uninhabitable tropical island in the Archipi6lago

de las Perlas in the Gulf of Panama. The aims were to determine the feasibility of carrying on offensive gas warfare in a jungle climate and to learn if

Army protective equipment would be efficient in its primary purpose while it

* Memorandum, Chief, Chemical Warfare Branch, Surgical Consultants Division, for Director,

Training Division, attention : Lt. Col. R. J. Moorehead, 23 July 1945, subject: Comments on Training

Film, First Aid or Self Aid in Chemical Warfare.

w Report, Lt. Col. Stewart F. Alexander, MC, C'nsultant, Chemical Warfare Medicine, Office of the

Surgeon, NATOUSA, to Director, Medical Service, Allied Force Headquarters, and to the Surgeon,

NATOUSA, 27 Dee. 1943, subject: Toxic Gas Burns Sustained In the Bari flarbor Catastrophe.
CHEMICAL WARFARE 83

still permitted troops to carry on their normal, every day and night living and

duties.

One of the largest of the field tests was conducted on this island in August

1945. Two companies of volunteer troops from the Canal Zone maneuvered

for 24 hours in an area on the island which had previously been bombed with

mustard from B-24 bombers. The troops were fully protected with standard

protection equipment. The area was bombed in a concentration of 180 tons per

square mile, far greater than any field of battle concentration experienced in

World War I. The chief of the Chemical Warfare Branch and several other

medical officers from the Army and Navy, whose primary military interests lay

in the field of chemical warfare, were invited to attend this test as observers.

At the end of the 24-hour period, the troops engaged in the test were all

thoroughly examined by medical officers. There was not one casualty. There

was no opportunity to see any first aid executed, but it was comforting to know

that Army protective equipment was so efficient.

First aid.-The teaching of first aid in chemical warfare was extremely

difficult. Most chemical agents required separate rituals, and it was necessary

for the soldier to be able to distinguish between different gases at a time when

circumstances would make the differentiation difficult if not impossible. Instruction on these matters during the war was gradually made as simple as

possible, with the idea that if the soldier did not bear in mind all the details he

had been taught at least he would remember certain essential points.

CLASSIFICATION OF CHEMICAL AGENTS

For medical purposes, the most useful classification proposed for agents

of chemical warfare segregated them according to their primary physiologic action. On the other hand, such a classification, while satisfactory from

this standpoint, made no allowance for the secondary effects of which many

of these agents were capable, nor did it include either the incendiaries (white

phosphorus, magnesium and its alloys, thermites, and oils) or the screening

smokes (HC (hexachloroethane) mixture, titanium tetrachloride, and sulfurtrioxide-chlorosulfonic acid solution).

On the basis of their physiologic action, toxic chemical agents used in

w'trfare were classified as follows:

1. Vesicants (blister gases), which included mustard, nitrogen mustard,

lewisite, ethyldichlorarsine, and phenyldichlorarsine.

2. Lung irritants (choking gases), which included phosgene, chloropicrin,

and chlorine.

3. Sternutators (vomiting ghses), which included diphenylamninechlorarsine, diphenylchlorarsine, and diphenylcyanarsine.

4. Systemic poisons (blood and nerve poisons), which included hydrocyanic acid, cyanogen chloride, and arsine.
'77/

84 ACTIVITIES OF SURGICAL CONSULTANTS

5. Lacrimators (tear gases), which included chloracetophenone, chilora-!

:cotophenone solutions, and brombenzylcyanide.

Two of the gases in this list, the nitrogen mustards and cyanogen chloride,

were first described in the course of World War II. Information concerning

the nitrogen mustards was released in War Department Training Circular.

No. 86 on 13 November 1942, and information concerning cyanogen chloride

was released in April 1944.

Vesicants

EvOlution of policies

The treatment of mustard burns varied considerably in the course of the

war, as the various editions of TM 8-285 show. In the July 1941 version,-

tannio acid and silver nitrate were recommended for local use. In the November 1942 version, amyl salicylate and sulfadiazine ointment were recommended

for the same purpose. In the April 1944 version, the use of these agents was

prohibited, only mild ointments were advised, and the use of local pressure

dressings with petrolatum jelly was the treatment of choice.

One of the most notable advances made during World War II in the field

of chemical warfare was the discovery of the compound known as BAL

(British Antilewisite). Its value as a specific in first aid and in the later

treatment of casualties caused by lewisite and other arsenical vesicants was

first recognized in 1941,11 but it was not until 1943 that the Medical Division,

Chemical Warfare Service, recommended that BAL eye ointment be standardized. 4 This was accomplished on 8 July 1943, and 3-gm. ophthalmic tubes

were prepared for individual issue.

The value of BAL ointment in decontamination of the skin after lewisite

contamination was not questioned. It was considered to be more judicious,

however, rather than to encumber the soldier with another tube of ointment

for the skin and thus complicate first aid measures further, to continue the

use of M-5 protective ointment (which was used primarily for mustard contamination) for the arsenical vesicants also, since it was fairly effective against

the latter chemical agents. In September 1943, BAL ointment, in %-ounce

tubes, was approved for issue in Kit, First Aid, Gas Casualty, (fig. 16) and

Kit, Treatment, Gas Casualty.

By the close of the war, in an effort to standardize first aid procedures

when the eyes were contaminated by any liquid gas, the application of BAL

eye ointment, followed by massage and irrigation, was recommended for all

contamination of the eyes by liquid vesicants25 In 1941, irrigation alone had

Medical Department (Edgewood Arenal) Memorandum Report 39. C. B. Marquand. 0. E.

McElroy, and T. W. Kethley, 15 Dec. 1941, subject: The Use of Beta-Gamma-DImercapto-PropylAlcohol (DTIT) In the First-Aid Treatment of Liquid Lewisite Burns.

3 2Medical Department (Edgewood Arsenal) Memorandum Report 88, F. Dickson Brown and B. 11.

Mc., amara, 1 May 1943, subject: The Effectiveness of Self Eye Medication During Pain and Blepharospasm. 3 (1) War Department Technical Bulletin (TB MED) 153. First Aid for Liquid Blister Gas Contamination of the Eye, March 1945. (2) Liquid Vesicant Contamination of the Eyes. Bull. U.S.

Army M. Dept. SG: 30-31. March 1945.
CHEMICAL WARFARE 85

.... .

U§!

U4 L~ ~ ~ ~ is ~~~~~7E i iS( tUI~kt I&v Si:1i(O~~It vi t~tItitr o )74O

.X, OP 'ona 13QP it. B. I~itki i~ 1 (03 t(li'. LC aIII 30 sO 1L li f i Va t iiiiat id Of4:

iiei jii~ ~i0~QIt ~i~Iuii~ i ~C i~ifWt~3& iii~tIV ~iiliit ll1)1tni4vf
86 ACTIVITIES OF SURGICAL CONSULTANTS

been recommended for mustard contamination. Lewisite contamination was

not mentioned in the first edition of War Department Technical Manual

8-285, which was published in that year. In 1942, the application of eye ointment M-1 was recommended for lewisite. In 1944, BAL eye solution M-1

was recommended for lewisite contamination, and in 1945 this preparation was

recommended for mustard contamination also.

For many years, it had been believed that the fluid in blisters caused by

lewisite was both vesicant and toxic, and, on this basis, aspiration of the blisters

was advised, to prevent the possibility of arsenic poisoning. A thorough investigation of the subject during the war permitted the statement in 1914 that,

although the fluid does contain a trace of arsenic, it is neither vesicant nor

toxic and aspiration is therefore not necessary.36

With the discovery of the effectiveness of BAL in decontamination of

the eye and skin after contamination with lewisite and other arsenical blister

gases, much effort was expended in an endeavor to determine its effectiveness

in the treatment of systemic poisoning caused by these agents. Because of

BAL's ready absorption by the skin, it was recommended in 1944 that this

compound be used as an inunction under these circumstances. BAL in oil,

which had been studied for a considerable time for possible systemic use, was

standardized by the Army Service Forces on 22 May 1944, and information

concerning it was disseminated in War Department Technical Bulletin (TB

MED) 101, Use of BAL in Oil and BAL Ointment in Treatment of Systemic

Poisoning Caused by Lewisite and Other Arsenical Blister Gases, dated 4

October 1944, and also in the November 1944 issue of the Bulletin of the

U.S. Am'my Medical Department.

Final policies and practices

At the close of the war, the following data and instructions concerning

poisoning by vesicants, as detailed in TM 8-285, April 1945, represented the

current therapeutic practices in the U.S. Army Medical Department:

Vesicants as a group act primarily on the eyes and skin. When inhaled,

they cause injury to the respiratory tract. When absorbed, they cause systemic

poisoning.

Mustard. -The eyes are more vulnerable to mustard than is any other part

of the body. Symptoms do not immediately follow exposure, and the latent

period varies from 1 or 2 hours to 12 hours, depending upon the degree of

exposure. Resulting lesions vary from mild conjunctivitis to severe injuries

of the cornea with opacification, ulceration, and vascularization.

If the eyes have been exposed to mustard vapor only, no decontamination

procedure is of any value. When contamination involves liquid gas, however,

first aid procedures employed within 2 minutes will be of value. BAL ointment should be squeezed directly into the lower conjunctival sac, after which

the eye should be massaged for 1 minute and then irrigated for from 30 seconds

War Department Technical Manual (TM) S--285. 15 Apr. 1944.
CHEMICAL WARFARE 87

to 2 minutes. The application of ointment, even if previous symptoms are

lacking, is followed by pain and blepharospasm, but the pain will be relieved

or entirely controlled by irrigations.

Mild conjunctivitis is treated symptomatically. Sulfacetimide (Sulainyd)

sodium solution (2 drops) in 3 percent solution is instilled every 4 to 8 hours

to prevent infection. In more severe cases, with edema of the lids, photophobia,

blopharospasm, and other obstruction of vision, pain is likely to be persistent

and morphine or other systemic sedation must be used to control it. Mydriasis

should be effected by the use of atropine in 1 percent solution.

Infection can be prevented by the instillation of it few drops of Sulamyd

sodium in 3 to 10 percent solution every 4 hours, or by the use of penicillin

(1,000 units per 100 cc.) or of sulfathiazole ophthalmic ointment. Secretions

can be removed by gentle irrigations with isotonic saline solution. Established infections should be treated by the instillation of Suhunyd sodium in

10 percent solution every 2 hours, or by the local use of penicillin or of sulfathiazole ophthalmic ointment. every 4 hours.

No immediate symptoms follow the exposure of the skin to mustard vapor

or liquid, but at the end of a latent period lasting from 1 to 19 hours erythlma

devolors, with itching and some burning, followed by vesication in all but

mild exposures. Liquid mustard on the skin requires prompt decontamination. The excess liquid should be blotted off, M-5 protective ointment applied

freely, the excess wiped off, and additional ointment applied and allowed to

remain until it can be washed off with soap and water. Erythemna should be

treated symptomatically. Blistered and denuded areas should be treated by the

application of sterile petrolatum and covered by sterile pressure dressings.

A sterile technique is essential, and frequent changes of dressing should be

avoided.

Specific antibacterial therapy should be employed according to the indications. Penicillin, which is the drug of choice, should be givwn intramuscularly

in doses of 25,000 units every 3 hours as long as indicated.

Symptoms following the inhalation of mustard vapor come on slowly.

They begin with hoarseness and possibly aphonia and progress to cough,

fever, and dyspnea. Lesions rango from mild hyperemia of the laryngeal

and tracheobronchial mucosa to congestion of the pulmonary parenchyma,

with mild patchy edema, emphysema, and focal atelectasis. Bronchopleumonia is a frequent complication.

Cough and irritation should be treated symptomatically. Bronchitis should

be treated with steam i halations. When clinical evidence of severe respiratory

tract injury exists, penicillin should be given prophylactically, in the hope of

preven.ting bronchopneumonia. Should pneumonia develop, the usual treatment for it should be enployed.

Absorption of mustard through the skin or the ingestion of mustardconltaminated food or water may cause severe gastrointestinal (listurbances

associated with pain, ntusea and vomiting, diarrhea, -ind sometimes feve" and
88 ACTIVITIES OF SURGICAL CONSULTANTS

prostration. When the quan ity absorbed approaches the lethal dose, the hematopoietic tissue may bec damaged, as evidenced by leukopenia and thrombocytopenia in the peripheral blood.

Treatment consists of infusions as indicated to maintain the fluid and

electrolyte balance; barbiturates to control restlessness and discomfort; and

morphine, if necessary, to reduce gastrointestinal activity.

Nitrogen mustards.-The eyes are affected more quickly by nitrogen

mustards than by mustard, though not as quickly as by lewisite. The lesions

are, in general, similar to those caused by mustard, but the symptoms may be

more severe, and local necrosis of the cornea may terminate in rupture of the

globe. Decontamination and treatment are carried out as described under the

heading of mustard. The same holds for the management of skin lesions and

lesions of the respiratory tract.

The most pronounced effects of the absorption of nitrogen mustards

through the skin or the respiratory or gastrointestinal tracts are on hematopoietic t, sue and lymphoid tissue. Degenerative changes in bone marrow

may be followed by involution of the thymus, spleen, and lymph nodes, with resulting lymphopenia, granulocytopenia, thrombocytopenia, and anemia. If

vomiting and diarrhea occur, as they frequently do, they should be treated by

transfusions of whole blood and the use of other parenteral fluids as indicated.

Lewisite.--Liquid lewisite is extremely damaging to the eyes. Pain and

blepharospasm occur immediately following exposure, and there is immediate

searing of the cornea, with edema and closure of the eye within an hour. The

degree of corneal injury depends upon the degree of exposure. Healing may

occur without permanent defects, but the more severe exposures are likely to

terminate in pannus formation or massive necrosis.

Decontamination and therapy should be carried out as for mustard. In

ontrast to its effect in mustard poisoning, however, BAL ointment immnediately relieves pain and blepharospasm caused by lewisite. If it is used within

1 minute of exposure, healing usually occurs without permanent damage. If

it is used within 10 minutes, healing will occur, but there will be some residual

eff-cts. Used after 30 minutes, the ointment is of no value.

Contact of liquid lewisite with the skin produces, within a few seconds,

a stinging pain, which quickly increases in severity. The pain is followed

within about 30 minutes by erythenia and within about 12 hours by vesication.

Tissue damage is in general more severe than that caused by mustard.

Ideally, lewisite can be decontaminated by BAL ointment, which is spread

on the skin in a thin film, rubbed in, and allowed to remain for a minimumn of

5 minutes. By this method of application, any lewisite which has been absorbed is neutralized, as is the lewisite on the skill. The reasons for not using

it, however, have already been set forth (p. 84). Treatment of lewisite poisoning is similar to that for poisoning by mustard.

Inhaled lewisite vapor is extremely irritating to the respiratory tract and

causes lesions similar to those caused by mustard. Therapy ih a combination
CHEMICAL WARFARE 89

of the treatment recommended for mustard injuries of the respiratory tract and

the treatment recommended for systemic arsenical poisoning.

Systemic poisoning with lewisite may result from i absorption from skin

contamination or from absorption of vapor from the respira -rv tract. Loss

of fluid from damaged capillaries may be severe enough to cause hemoconcentration, shock, and death. Focal necrosis of the liver may be the result of

oxidized products and lewisite, and pulmonary edema may follow direct inhalation of ie vapor as well as absorption from the skin.

Therapy directed toward systemic lewisite poisoning is indicated in the

presence of any of the following manifestations:

1. Any evidence of pulmonary edema, such as a cough with dyspnea and

frothy sputum.

2. Any skin burn the size of the hand, or larger, if decontamination has

not been effected within 15 minutes of exposure; skin contamination of 5 percent of the body surface if evidence of skin damage has appeared within 30

minutes of exposure; and blisters the size of the hand or larger.

When lewisite has been absorbed through the skin, BAL ointment should

be rubbed into the affec!ed areas and permitted to remain. BAI., in oil (10

percent solution) should be given intramuscularly into the buttocks, the dosage

being adjusted to the estimated body weight (2.5 cc, for 125 pounds, 3.0 cc. for

150 pounds, 3.5 cc. for 175 pounds, 4.0 cc. for 200 pounds). Four doses are

given at 4-hour intervals, though in severe cases the interval between the first

and second dose is shortened tt, 2 hours. A single daily dose in half the

original amount is then given for 3 or 4 days.

A wide variety of syn,ptonis and signs may occur from 15 to 30 minutes

after the injection of BAL in oil. The most serious of these is a transient rise

in blood pressure. Reactions may last 30 minutes, but, unless they ore prolonged or unduly severe, the full course of treatment should not be interrupted.

Ethyldichlorarsine and phenyldichlorarsine.-'rhe lesions and symptoms caused by these agents are similar to those described for lewisite, and the

same treatment is required.

Lung Irritants

Evolution of policies

The treatment and dispositioni of persomel exposed to lung irritant gases,

as prescribed in succeeding issues of TIM 8-285, Treatment of Casualties From

Cliemic I Agents, underwent three definite modifications during the course of

the war.

In the 1941 edition of the manual, prompt, absolute rest was advocated,

even in the latent stage. The administration of morphine was forbidden, even

though the patient aight be restless and apprehensive. Venesection was advocated as probably the best available therapy for phosgene poisoning during

the cyanotic stage.
90 ACTIVITITIS OF SURGICAL CONSULTANTS

In the 1942 revision, it was left to the discretion of the commanding Officer

of the battalion, with the advice of the surge on, to determine whether or not a

soldier who had been subjected to lung-irritant gas should continue in combat,

due account, being taken of the possible risk of pulmonary edema.

In the 1944 revision, the definite policy was adopted that men might continue at their duties pending the appeaitance of clear-cut symptoms. In the

sme year, it was recommended that morphine be given whenever the administration of oxygen failed to iuiet tb patient. Venesection was no longer

advocated, on the ground that it und,ubtedly did harm during the shocklike

stage and was of doubtful value at any time.

Final policies and practices

At the close of the war, the foll ,wing data concerning th effects and treatment of lung irritants, as prescri'ed in TM 8-285, April 1945, represented

current U.S. Army medical policy.

Of the important lung irritatts, phosgene produces its primary effects on

the pulmonary parenchyma, while chloropicrin and chlorine are more likely to

injure the trachea and bronchi.

Phosgene.-Initial damage to the capillaries of the pulmonary parenchyma after the inhalation of phosgene is followed by loss of fluid from the

capillaries and by early, massive, pulmonary edema. Loss of plasma into the

alveoli results in hemoconcentration. Pulmonary edema reaches its maximum

12 to 14 hours after exposure, and gaseous exchange in the lung is inhibited.

Death from anoxemia may occur within from 24 to 48 hours. In cases which

go on to recovery, edema begins to subside at the end of 48 hours. To prevent

secondary bronchopneumonia, which may develop from 3 to 5 days after exposure, specific antibacterial therapy, preferably penicillin, may be given

prophylactically when edema begins to subside.

The early symptoms of phosgene poisoning, which include coughing,

choking, or vomiting, are not a prognostic y.,rdstick. In some cases, a latent

period of from 2 to 24 hours is followed by signs of pulmonary edema, of which

cyanosis is the most ominous. The condition may become steadily progressive,

and the patient eventually passes into a shocklike state. If signs and symptoms

of respiratory distress appear in a person who has been exposed to phosgene

and has continued with his duties, he must be put at complete rest immediately,

kept comfortably warm, and given oxygen in as high concentration as possible.

If distress continues, morphine may be given cautiously, in small doses.

Codeine is useful if cough is the most prominent symnptom.

Drugs tested and proved useless or even harmful in the treatment of plio,-

gene poisoning include atrol)ine and cardiac and rebpiratory stimulants such

as epinephrine (Adrenalin), epliedrine, amnplhetaminle (Benzedrine) sulfate,

nikethamnide (Coramine), pentylenetetrazol (Metrazol), and alcol,,il. Plasma

anl parenteral fluids are not useful. Venesection is also not useful and is

definitely harmful if pract iced (luring the shocklike stage.
CHEMICAL WARFARE 91

Choropicrin.-The effects of this agent are essentially the same as those

of phosgne, except that chloropicrin is quite irritating to the eyes and more.

destructive to the bronchiolar epithelium. Symptomatic treatment is sufficient if the ocular injury is mild. Otherwise, therapy is the same as for phosgene.

Chlorine.-The immediate symptoms of chlorine poisoning, which include

burning in the throat, coughing, and a sense of suffocation, are the result of

injury to the upper respiratory tract. The gas is extremely irritating to the

entire respiratory tract. Therapy is the same as for phosgene poisoning.

Sternutators

Measures against sternutators, the effect of which, while temporarily incapacitating, is transient, underwent only one change during the course of the

war. The original treatment was to inhale the vapors from a bottle containing

bleach powder. Later, chloroform vapor was substituted.

Sternutators are dispersed by heat in the form of smoke. The medical

effect of all three gases in the group is similar. They irritate the nose, sinuses,

throat, and eyes. Symptoms include pain and a sense of fulness in the nose,

headache, a sensation of burning in the throat, a sense of tightness in the chest,

very severe coughing and sneezing, lacrimation, frequently nausea and vomiting, and sometimes mental depression.

Except during the act of vomiting, the gas mask should be worn during

exposure to these agents. The inhalation of chloroform may give considerable

relief, but, whether it is used or not, prompt recovery is the rule in all cases.

Systemic Poisons

Evolution of policies

The treatment of cyanide poisoning by arnyl nitrite was considerably modified in the course of the war. In the July 1941 edition of TM 8-285, it was

recommended that amyl nitrite fumes be inhaled for 15 to 30 seconds every

3 minutes until sodium thiosulfate could be given intravenously. In the November 1942 revision, it was recommended that the number of ampules used in

a given case be reduced to four, and, in the April 1944 revision, the number

was reduced to two. However, since the purpose of the medication is to form

methemoglobin and since a greater concentration than could be produced by

these dosages was desirable, the April 1945 revision of the manual recommended

that a total of eight ampules be given in four doses of two ampules each. This

amount is adequate to combat the effects of the cyanide gases, and the vasodepression which follows its use is not dangerous.

With this exception, no serious modifications in the therapy of systemic

poisons were made during the course of the war.
92 ACTIVITIES OF SURGICAL CONSULTANTS

Final policies and practices

Hydrocyanie acid.-This agent produces its effects by combination witli

an enzyne essential for oxidation within the tissues. The respiratory center

is particularly susceptible. Exposure to high concentrations of the gas results,

within a few seconds, in an increased depth of respiration, followed within 20

to 80 seconds by convulsions and within 60 seconds by cessation of respiration.

The heart continues to beat for several minutes longer.

As soon as the gas mask is applied, two ampules of amyl nitrite are

crushed and placed beneath the facepiece. The procedure is repeated every

3 or 4 minutes until eight ampules have been given. The nitrite immediately

forms methemoglobin, which competes with the enzyme in taking up the cyanide. When it is available (it was an item in short supply during World

War II), sodium nitrite (10 cc. of 1 percent solution) should be injected intravenously over a period of 1 minute at 10-minute intervals until a total of 50

cc. has been given. Each injection of sodium nitrite is alternated with the

injection by vein of 10 cc. of 10-percent sodium thiosulfate solution. Artificial

respiration should be attempted if respiration ceases.

Cyanogen chloride.-The immediate action of this agent is similar to

that of hydrocyanic acid, but it also acts on the respiratory tract as phosgene

does. Treatment is similar to that prescribed for hydrocyanic acid and phosgene.

Arsine.--After arsine is absorbed from the respiratory tract, its first effect

is to produce hemolysis, evidenced by anemia, hemnoglobinemnia, inethemoglobinemia, and henloglobinuria. It also affects the liver and kidneys by way of

its presence in the circulating blood. Death results from anemia or from

hepatic or renal failure.

Treatment consists of intravenous fluids, blood transfusions as indicated,

and injections of BAL in oil as in the treatment of systemic lewisite poisoning.

Lacrimators

No change was made in the treatment of contact with lacriinators in the

course of the war. All gases in this group cause immediate pain, blepharo- spasm, and lacrimation, and they also irritate the skin and nose.

The most effective first aid measure is immediate masking. The eyes

must not be rubbed; if they contain liquid contaminant, they should be washed

out with water. Superficial skin burns should be treated symptomatically.

A 0.25-percent solution of sodium sulfite neutralizes these agents.

CHEMICAL BURNS

White phosphorus ignites spontaneously when it is exposed to air, and if

the flaming particles hit the skin they are always dificult to remove. Copper

sulfate in l)ercent solution was recommended as a first aid measure. The
CHEMICAL WARFARE 93

flame could be extinguished and the particles could be kept from reigniting

by repeated applications of water until the copper solution could be applied.

The usefulness of copper sulfate is twofold. It coats phosphorus particles

with copper phosphide, so that they do not reignite on exposure to air, and

it makes them visible in the burned areas of the skin, with the result that they

are more readily removed. 7

Early in 1944, reports from ETOUSA (European Theater of Operations,

U.S. Army)"8 suggested that gauze or double-napped cotton flannel impregnated with copper sulfate would be useful in the equipment of the individual

soldier, since wetting the pad with water from his canteen would immediately

provide copper sulfate solution. On requisition from this theater, an issue of

nonstandard double-napped flannel pads, 3 by 3 inches, impregnated with

copper sulfate and packed three to an envelope, was approved. After thorough

investigation, standardization of the item was accomplished on 5 February

1945.3 The pad was described in the July 1945 issue of the Bulletin of the U.S.

A rimy Medical Department.

Reports from the Southwest Pacific in 1945 were to the effect that casualties

caused by white phosphorus were steadily increasing in number and that some

patients had developed what was believed to be systemic phosphorus poisoning.

Medical officers in the field reported difficulty in securing information on the

subject, which was not surprising in view of the paucity of material in the

literature. Because of this lack, and because of the apparent increase in

casualties from phosphorus, the Medical Division, Chemical Warfare Service,

was requested to compile all available information on the subject to be forwarded to the theaters in the form of a technical bulletin and to be published

in the Bulletin of the U.S. Army Medical Department. Hostilities ended

before these plans could be carried out.

Thermite, magnesium, and magnesium alloys.-The only medical problems associated with these agents were the removal of metal particles from the

tissues and the treatment of the resulting burns, in which approved methods

were always employed.

Oil incendiaries.-Oil incendiary bombs and flamethrowers introduced

the usual problem of burns. In addition, they caused pullonarT damage

and laryngeal and glottic edema if used in enclosed spaces. They also reduced

the oxygen content of the air. Treatment consisted of the introduction of fresh

-r Informal Monthly Progress; Report, Medical Research Laborator., Medical Division, Office of

the Chief, Chemical Warfare Service. 15 Sept. 1944.

(1) Sanitary Report. Sth Infantry Division, XV Corps, ITY'OUSA. March 1944. (2) Report. 1st

Lt iugo H. Vivadell and 2d Lt Alex Scilezinger, 44th Chemical Laborator.%. ETOUSA. 7 June 1944,

subject" Study of the Preparation and Use of Copper Sulfate-Inpregnated Pads as First Aid Against

Burning White l iosphoruA on the Skin.

v (1) Memorandum. Capt George It Greenwood. Surcical Consultant, Division. for Chief. Medical

Division. Chemical Warfare Service, 16 Aug. 1944. subject. Project Spcifications for Copper Sulphate

Pad. (2) Letter, Medical Research Laboratory. to Chief. Medical Di ision. Office of the Surgeon

General, 11 Dec 1944. subject : Copper Sulfate Pads. with first Indorsement thereto. 13 Dec. 1944.

10 Letter Chief Consultant in Surger.\. Surgical Consultants Division. Office of the Surgeon General. to ('hief. Medical Di-'ision. Chenilcal Warfare Service. Armjn Service Forces. 19 June 1945. mubject:

Systemic Phosphorus l'oisi'ning.
94 ACTIVITIES OF SURGICAL CONSULTANTS

air and, when possible, the use of oxygen in high concentrations. Burns were

treated as if they were ordinary thermal burns. Artificial respiration was

sometimes necessary.

SCREENING SMOKES

HC (hexachloroethane) mixture.-Serious or even fatal consequences

may follow exposure to this smoke in enclosed spaces or near its point of production in the open. The zinc chloride it contains has a damaging effect on the

respiratory tract and may produce coughing, choking, and asthmalike symptoms at once, as well as pulmonary edema later. Immediate symptoms are relieved by the intramuscular injection of 0.5 cc. of Adrenalin (1:1,000).

Pulmonary edema is treated as if it were caused by phosgene. If exposure has

been particularly heavy, BAL in oil is given in appropriate doses, as in lewisite

poisoning.

FM (titanium tetrachloride).-This liquid produces acid burns of the

skin and eyes, which are relieved by washing with water.

FS (sulfur-trioxide-chlorosulfonic acid solution).-This liquid causes

acid burns, and in heavy concentrations it may seriously affect the eyes, skin,

and respiratory tract. Minor lesions are treated symptomatically after they

have been washed with water. The treatment of burns of the skin, eyes, or

respiratory tract depends upon the severity of the damage.
CHAPTER IV

Ophthalmology'

M. Elliott Randolph, M.D.

OPHTHALMOLOGY BRANCH

Activation and functions.--The Ophthalmology Branch, Surgical Consultants Division, Professional Service, Office of the Surgeon General, was

activated on 15 April 1044. Maj. (later Lt. Col.) M. Elliott Randolph, MC,

(fig. 17) who previously had been on duty with the Army Air Forces, became

its first chief. The functions of the newly created Ophthalmology Branch were

as follows: To establish policies and procedures in general ophthalmology and

care of the blind in the Army; to advise on assignments of qualified specialists

in these fields; to correlate information and afford consultation and advice pertaining to ophthalmology and care and management of the blind; and to

maintain liaison with the Navy, the Veterans' Administration, the Federal

Security Agency, and civilian ophthalmologic groups.

Office space was provided for Major Randolph in the office of Lt. Col.

Walte H. Potter, SnC, the director of the spectacle program and chief of the

Optical Branch in the Medical Supply Division. A cordial and smooth-functioning relationship existed between these two branches.

Shortly after assuming his new duties, Major Randolph was informed by

The Surgeon General that he was to be responsible for the program to rehabilitate the blind and deaf. This came as a considerable shock, and, while it seemed

somewhat logical that the blind should be his responsibility, rehabilitation of

the deaf seemed somewhat out of the question. Fortunately, Major Randolph's

superiors in the Surgical Consultants Division shared his sympathies and were

able to convince Maj. Gen. Norman T. Kirk, The Surgeon General, that someone elso should be brought into the Division to be responsible for the program

for tit, ,habilitation of the deaf. This was later accomplished (p. 105).

CARE OF THE BLIND

Apparently, no provision had been made for the reception and care of

blinded casualties until they began to arrive from overseas. These patients

filtered into various receiving hospitals and then were turned over to the

Veterans' Administration for rehabilitation. Following a Presidential direcI See also the "Medical Department, United States Army, Surgery In World War I Ophthalmology

and Otolaryngology. Washington: U.S Government Printing Office, 1957."

95
96 kc'ril'ITIE:S OF SURGICAL CONSULTANTS

IFicumu I 7.-MaIj. .11. Elliott Randolph, .1C, C'hief,

Professjinal Serv ice, Oltive of the Surgeon Genieral.

tive, Valley Forge General Hlosp~ital, I1lloellixxie, Pa., andt I)ibbie General

Ilospittil, 'Menlo Park, Calif., xA ere dosiiznated as centers xx here each blinded

casualty was to be sent. lit either center, hie was to receive certain phases of

preiiiuinarx social relvtiil hat ion while undergoing defiuit ive medical care.

Wh lk this had been accoiltlisIhed. lie W as to be t ranisferred to Old Farmns Con-

,%alescent I [ospital (Special), Ax on, Pa., for a cottr.,e of 12 ixevk * finial Social

IAmabiiitat ion. Thel( Presidential direct ive also stated that every blinded

1-uat oiginating inl ille Arnn~ Navy or Mlarines would be sent to an Army

faiiy. 'Llie Nax lioxx cx er, xx as Hot iii accord N% ih tlu k programt and asked

that their caulisand also Adi-iue. camualties be t ratisferried to thle Navy hosp~ital inl Philadelphia.

Old Farms Convalescent Hospital (Special) -Plani s for the acttiaon

of Old Farms Coluvaie.,vet I [ta-pit al (.Special) -couuIouil11x referred to a., Old

Farins or Ax on ( )h Fa tiii -xx eie heiul i'Nrstalliized uponl Major Raldol ph'se

an lival inl tile Office of the suigeon G eneral. The t'acilit x %%x as to lbe unider' lite

ov-erall direct ion of Col. Fu-edevik, IF[. Th'orne. M ( ' also fonilel ' X of (lhe Army

Air F~orces, and inore recenithl comnmandinig olhicei- of lite regrional hospital
OPHTHALMOLOGY 974

at Keesler Field, Miss. As the opening of Old Farms drew near, there was

curiosity concerning the type of rehabilitation program for the blind that

would be established there and who would direct it. Colonel Thorne, it was

""vealed later, had already asked for the transfer to Old Farms of key

personnel from the rehabilitation facilities at Valley Forge General Hospital.

Naturally enough, any program for the rehabilitation of the blind would have

been successful with such men in control as the director of the program for the

blind at Valley Forge, Sgt. (later Capt., MAC) Alan R. Blackburn, Jr., and

his two associates, Sgt. (later 1st Lt., MAC) Richard E. Hoover and Sgt.

(later 2d Lt., MAC) Paul Conlon. The personnel problem was finally solved

by the transfer of Sergeant Blackburn to Ol Farms Convalescent Hospital

to direct its new program. Sergeants Hoover and Conlon remained at Valley

Forge to direct the program there. On 21 July 1944, the first blinded casualties

from Valley Forge General Hospital arrived at Old Farms for their final

period of social-adjustment training before discharge from the Army.

During the fall of 1944, Major Randolph continued to make trips almost

every week to Old Farms. The main purpose of these trips was to permit

Lieutenant Blackburn to pour out his tales of woe. The former used every

means at his disposal to bolster the morale of the latter. In spite of his unhappiness, Lieutenant Blackburn was doing a magnificent job. Additional

personnel were becoming available, and, as the year drew to a close, it appeared that morale was ever improving (fig. 18). At the same time, considerable difficulty was being experienced with the Veterans' Administration

because it was believed that this organization was not prepared to assume the

responsibility of looking after the blind after the Army had completed its

mission of social-readjustment training. At about this stage in the program,

Major Randolph was relieved from his assignment in the Office of the Surgeon

General (p. 102). A full account of subsequent developments at the Old Farms

Convalescent Hospital (Special) is given in another volume of the history

of the Medical Department, United States Army.2

Valley Forge General Hospital.-Ieanwhile, the programn for the blind

was functioning most efficiently at Valley Forge General "lospital under the

overall direction of Lt. Col. James N. Greear, Jr., MC. The program benefited

immeasurably by Colonel Greear's foresight and organizational ability. Every

available soldier who had had any experience with rehabilitation of the blind

was transferred to Valley Forge General Hospital. The specific rehabilitation a.4pects of the program were under the direction of Sergeant Blackburn

until his transfer to Old Farms. Ile was ably assisted by a number of Army

and civilian workers.

Dibble General Hospital.-Inasmnuch as it was found necessary to establish an additional rehabilitation ceiter for the blind at Dibble General Hiospital, Lt. Col. Norman Cutler, MC, w- placed in charge of the eve ser,'ice

and made responsible for initiating a relabilitationi progra for the blind

SSee footnote 1. p). 9..
9Skc(ivriTi-, OF" RSI GICAI. CONSULTANTS

m 1'. i il, ll-izie
OPHTH'IA LMOLOGY 9

k iw luL I", (1k1 illiiiv. C. 'WV' lilt., a Iiubballq aiIlos'i, future ' ucati (11
i00 ACTIVITIES OF SURGICAL CONSULTANTS

similar to that at Valley Forge General Hospital. He started from nothing,

and since all key personnel were at Valley Forge the going was pretty difficult

at -fist. Soon, however, some civilian personnel qualified in rehabilitation

of the blind were obtained on the west coast and orienters a were trained by

the staff at Dibble. Equipment was gradually assembled, and, by October

1944, a training program was running most efficiently. A separate building

was erected for projects of the rehabilitation program.

OTHER CONSULTANT ACTIVITIES

Ophthalmologic personnel.-One of the first things the chief of the

Ophthalmology Branch did after his arrival in the Office of the Surgeon

General was to review the ophthalmologic personnel in each of the eye and

plastic surgery centers. Fortunately, this author knew personally the chief

of the eye section at most of the centers and kept in contact with their problems

tl,rough personal telephone calls. The equipment situation was fairly satisfactory, but all the centers were in critical need of additional ophthalmologists.

As the patient census at each hospital became greater after D-day, the need for

additional trained ophthalmologists became more apparent. The Army Air

Forces released about 10 qualified ophthalmologists who were eagerly pressed

into service and distributed to the various eye centers. The ideal of 1 ophthalmologist to 50 patients was never realized. At Valley Forge General Hospital,

the largest of the eye centers, the average was about 1 to 190.

Field trips.-During this time, the consultant in ophthalmology made

numerous trips to Valley Forge General Hospital because of its proximity.

There, he learned firsthand some of the problems concerning the rehabilitation of blinded casualties and also the needs and problems of the clinical

side of Army ophthalmology. About the last of May 1944, the consultant in

ophthalmology visited the eye services at Woodrow Wilson General Hospital,

Staunton, Va., Nichols General Hospital, Louisville, Ky., and Lawson General

Hospital, Atlanta, Ga. Each service was staffed with a particularly outstanding ophthalmologist, and the services were excellently run. Major Randolph

visited Dibble for the first time during the summer of 1944. The eye cases

were beginning to overflow, and there was a great need for more space and

more trained ophthalmologists, a situation which was not alleviated.

Civilian consultants in ophthalmology.--On 2 September 1944, Major

Randolph wrote a personal letter to each surgical consultant in each service

command designating the types of eye cases which should be sent to various

hospitals and, in adlition, recommending that a civilian consultant in ophthalmology be appointed in each service command. Certainly, each plastic and

eye center was located conveniently near a large medical center so that the

use of civilian consultants could have beei very practical and helpful. Nothing,

3 Ortenters N\as an appellation given ,isted personnel Aho wiere a..igned to a newb blinded

person to match over Min and to orient him in t~er* re.,pect a Ith reftrence to hi. person and his

environment.
OPHTHALMOLOGY 101

however, came of the recommendation except in the Ninth Service Command,

where Dr. Frederick Cordes of San Francisco kept in close touch with Dibble

General Hospital and w,:s tremendously helpful.

Acrylic artificial eyes.-In March 1944, General Kirk returned from his

visit to the European theater where he was impressed with the achievements

of the new plastic artificial eye which had been devised by Capt. (later Maj.)

Stanley F. Erpf, DC, at the 30th General Hospital, England. He conceived

the idea of recalling Captain Erpf to this country to work on standardizing

production techniques with two other dental officers who had been experimenting along similar lines in the Zc.ie of Interior, Maj. Milton S. Wirtz, DC,

and Maj. Victor H. Dietz, DC. Inasmuch as the stock of artificial eyes in

this country was being rapidly depleted, it was extremely fortunate that the

process of fabricating such eyes from dental acrylic was discovered at that

time, This project was the responsibility jointly of the Optical Branch under

Colonel Potter, his associate Mr. Stanley W. Rybak, and the Ophthalmology

Branch.

It was decided that a training center for the fabrication of plastic

artificial eyes would be set up at Valley Forge General Hospital, and each

service command was instructed to send one or two dental surgeons for a period

of 4 to 6 weeks' training under the tutelage of the aforementioned officers.

Although those in charge of the project were assured in emphatic terms that

there was not an inch of room available at Valley Forge, adequate space was,

nonetheless, quickly found and the program became an outstanding success.

These dental officers were then distributed, after a training period, to the eye

centers throughout the country and they, in turn, set up laboratories for training enlisted personnel. The program kept functioning in each hospital until

the closing of each center.

Liaison with consultants in ophthalmology overseas.-Major Randolph, during his first term in the Office of the Surgeon General, kept in contact with Col. Derrick T. Vail, MC, the senior consultant in ophthalmology

in the European theater. Colonel Vail's needs were mostly those of ophthalmic

supplies, and the filling of his demands was speeded up in this country whenever it was possible. Maj. (later Lt. Col.) Trygve Gundersen, MC, was a

part-time consultant in the Mediterranean theater. Major Randolph kept

in fairly close contact with him. The author, however, knew nothing whatsoever about ophthalmologic consultants in the Pacific areas. His personal

friends among the ophthalmologic personnel who had been so unfortunate as

to be sent to the Pacific all wanted but one thing-to be sent home as quickly

as possible.

First tour ends.-About Christmas 1944, Colonel Vail arrived in the

United States from Europe. Strangely enough, the thought immediately

occurred to Colonel Greear that he had had enough of Valley Forge General

Hospital and was most anxious to get into administrative work again. le

calculated, also, that Major Randolph was more than anxious to get into

60222 62-9
102 ACTIVITIES OF SURGICAL CONSULTANTS

clinical work and away from administrative work. Thus, it seemed to him

that Colonel Vail might be the solution to each problem. Major Randolph ,

never knew quite how the details were worked out, but on,22 Februa 1945

he was transferred to Valley Forge General-Hospital, Colonel Greear was

transferred to Europe, and Colonel Vail took over as chief of the OPliithamology Branch. This seemed to satisfy everybody but Colonel Vail. As

usual, however, Colonel Vail did the job in his customary, superb way. Meanwhile, Major Randolph was promoted to lieutenant colonel in January, shortly

before his reassignment to Valley Forge General Hospital.

THE SECOND TOUR

Colonel Vail remained as tle consultant in ophthalmology and chief of

the Oplthalmology Branch until 28 July 1945. He was succeeded by Major

Gundersen, who requested and received his release from the Army about the

end of November 1945. Again, Colonel Randolph was notified by Lt. Col.

Michael E. DeBakey, MC, that his former position was open and that there was

not enough time to train another man to take over. Colonel Randolph resumed

his former position on 8 December 1945.

A bright spot of these early days i Washington during December 1945

was the consultant's relationship with Brigadier Sir Stewart and Lady DukeElder who had been invited to this country by General Kirk. Sir Stewart

had been the consulting ophthalmologist to the Royal Army throughout

World War II. Colonel Randolph accompanied them on a tour of several

hospitals in the East, and it was a great experience. Colonel Randolph spent

the remaining months in the Office of the Surgeon General working on the

history of ophthalmology in World War II. In April 1946, when he finally

convinced Colonel DeBakey that this history had been completed, he was

released from the Army.

RECOMMENDATIONS

One cannot be associated in an administrative medical position in the

Army without realizing that certain recommendations should be given serious

consideration. The following recommendations in the event of another national emergency are prompted by the author's experiences as the consultant

in ophthalmology to The Surgeon General during World War II:

1. A consultant in ophthalmology should be placed on active duty at

once in tie Office of the Surgeon General. If a man of high qualification is

present in the Army, let him be considered as consultant. If such a man is

not available, the executive committee of the American Oplthalhological Society might be asked for its opinion as to a desirable civilian ophthalnologist.

2. Upon the activation of each oversea thefater, a consultant in ophthalmology should be placed on duty at once and be made responsible for the

ophthalmologic program within the theater. Whether he should serve part
OPHTHALMOLOGY 103

time or full time in this capacity would depend upon the size and burden of

the theater.

3. On the assumption that there will be an eye center in each service command, or similar command in the Zone of Interior. the chief of the center

(presumably an ophthalmologist of outstanding qualifications and competence) should serve part time as consultant in ophthalmology within the command. In particular, he should advise the servica command surgeon on the

qualifications and assignment of ophthalmologists. The policy of having

the surgical consultant or the surgeon of the command evaluate the qualifications and make the assignment of such highly specialized physicians as ophthalmologists is open to question.

4. A consultant in charge of the care of blinded casualties should be appointed immediately. He should be chosen after consultation with leading

authorities in the field, and should have had a long and outstanding experience

in work with the blind. He should work closely with the consultant in ophthalmology, but he would probably serve as well in a civilian capacity as in

a military capacity. In World War II, the delayed appointment of a consultant in charge of the care being given blinded casualties seriously delayed the

program.

5. An optical section should be activated at once in the Office of the

Surgeon General and should be given responsibility for all supplies and for

the administrative details of the artificial-eye program. It should work in

close cooperation with the consultant in ophthalmology. An officer, thoroughly

experienced in the problems of optical and medical supplies and possessing

special familiarity with the spectacle program, should be assigned to the office

of the consultant in ophthalmology in each oversea theater.

6. The ophthalmologic and otolaryngologic services should be separated

administratively in large installations, such as regional and general hospitals.

A competent man should head each service, and he should be independently

responsible to the chief of surgery. A single chief of section in the ophthalmologic service cannot possibly provide competent administrative and professional supervision of a patient load of 200 per officer, as was frequently

required in World War II.

7. Monthly reports should be submitted by oversea consultants to the

consultant in ophthalmology in the Office of the Surgeon General. Abstracts

of these reports could then be incorporated in a monthly newsletter for distribution to oversea and Zone of Interior installations.

8. During basic training, all medical officers should receive a certain

number of lectures on traumatic ophthalmology. More advanced work could

be made available in elective courses.

9. Articles dealing with military ophthalmology should be microfilmed

for general oversea distribution. This activity should be one of the responsibilities of the consultant in ophthalmology in the Office of the Surgeon

General.
104 ACTIVITIES OF SURGICAL CONSULTANTS

10. During World War II, the Army Air Forces convinced many doctors

of the desirability of joining this branch with the result that an unnecessarily

-large number of outstanding ophthalmologists joined the Army Air Forces

aid spent the rest of their Army days performing the most trivial types of

ophthalmology in regional and station hospitals. A large number of this

country's then leading ophthalmologists were responsible for large clinics in

Florida and the Southwest. The need for such men in the huge Army eye

centers was glaringly apparent. The hospitals in which these men were

serving could have been handled adequately by an ophthalmologist who had

recently received certification by the American Board of Ophthalmology

eligible for such certification.
CHAPTER V

Otoiaryngology

Leslie E. Morrissett, M.D.

ESTABLISHMENT OF OTOLARYNGOLOGY BRANCH

Until the middle of 1944, the specialty of otolaryngology had no official

representation in the Office of the Surgeon General. Individual chiefs had

the responsibility for the conduct of their otolaryngologic sections, which were

usually organized under the surgical services, in hospitals throughout the Zone

of Interior. If problems in this field reached the Professional Service, Office

of the Surgeon General, the usual policy was to refer them to the chief of the

ear, nose, and throat service at Walter Reed General Hospital. Three civilian

consultants in otolaryngology had been appointed early in the war and were

available for consultation. They were Dr. Albert C. Furstenberg, Ann Arbor,

Mich., Dr. Dean McAllister Lierle, Iowa City, Iowa, and Dr. John Mackenzie

Brown, Los Angeles, Calif.

The program for aural rehabilitation of the deafened and hard of hearing,

which eventually became the most important consideration of otolaryngology in

World War II, was set up under the direction of the Reconditioning Division,

Professional Service, Office of the Surgeon General. The impetus for the

creation on 15 June 1944 of the Otolaryngology Branch, Surgical Consultants

Division, Office of the Surgeon General, was the need for a reorganization of

this program. As a matter of fact, when the consultant in otolaryngology was

finally appointed, the magnitude of the rehabilitation program made it necessary for him to give almost his entire time to it and left him little time for other

duties in the specialty of otolaryngology.

Although there had been a realization of the potential importance of the

problem of the deafened soldier as early as May 1943 (p. 112) and the realization had been implemented by the establishment of three specialized centers for

the treatment of defective hearing, the initial program was under the direction

not of an otologist but of a psychiatrist. In June 1944, Brig. Gen. Fred W.

Rankin, Chief Consultant in Surgery to The Surgeon General, following a

visit of inspection to two of the three hearing centers, reported to The Surgeon

General that the chief defect of the current program was the total lack of uniformity in the operation of these centers. He recommended that, to overcome

this defect and to improve the program in other ways, an otologist be placed on

duty in the Office of the Surgeon General to devote his full time to the program

for the deaf. This recommendation had been discussed informally by per105
106 ACTIVITIES OF SURGICAL CONSULTANTS

Fiauma 19.-Maj. Lcshie E~. Morrissett, MC, Chief,

Otolaryngology Branch, Office of tile Surgeon General.

sonnel concerned with the program since it had first been instituted and had

been a matter of particular concern to the late Dr. Wailter Ilughson, Otological

Research Laboratory, Abington Memorial Hlospital, A~bington, Pa., then

serving as a civilian consultant inl otologry.

General Rankin's recommendation was implemented onl 13 July 1944 with

theacivaio ofth Otlayngology Branch and the appointment of Maj.

(later Lt. Col.) Leslie E. Morrissett, MC, as Branch chief (1!'g. 19). Major

AMorri~sett bad been chief of the eye, ear, nloze, and throat service at Borden

General H~ospital, Chicka~ha, Okla., where his dutties had included the direction

of the Rehiabilitation Center for the lDeafened and Hard of hfearingt.

CLINICAL POLICIES

Clinical policies (lid not require a great deal of Major Morrissett's attenlI ion. These p)olicies were fairly well e-,tablished by the time of his appointment andI. inl general, followed thle policiez, then inl effec inl cil jan pract ice.
OTOLARYNGOLOGY 10?

Elective surgery of the nose, throat, and ears was prohibited except on very

clear-cut indications. Since, however, nasal and pharyngeal defects were not

usually iegarded as causes for rejection, many men inducted into the Army

required otolaryngologic treatment, and the volume of this work was sometimes

quite large.

Tonsillitis was the most frequent otolaryngologic diagnosis in Zone of

Interior hospitals, but tonsillectomy was permitted only when it was regarded

as absolutely essential for the maintenance of the health and military effectiveness of the individual soldier. Rigorous enforcement of this rule produced no

deleterious results. Acute tonsillitis was treated by routine measures, including the use of penicillin after it had become available.

Pharyngitis and nasopharyngitis occurred in much the same frequency as

in civilian life except for the epidemics which often followed the arrival of

increments of new troops in camps. Treatment was by the methods ordinarily

used in civilian life. Surgery was not permitted for deviations of the nasal

septum except when the deflection was marked and was attended with obstructive symptoms, headaches, and complaints referable to the ears.

Elective surgery on the larynx was limited to the removal of polyps and

papillomas. The incidence of carcinoma of the larynx was surprisingly high,

in view of the youth of the Army group. Laryngectomy was usually performed, but an occasional patient was treated by the irradiation technique of

Cutler.

Otitis externa, while chiefly a problem in the Pacific, was sometimes observed in Zone of Interior hospitals, particularly in the South. A variety of

antiseptic and chemotherapeutic methods were employed in its management, but

there was no doubt that the essential phase of treatment was strict cleanliness

of the external auditory canal.

Otitis media furnished the same constant problems that it does in civilian

life. Although the chronic condition was not regarded as a cause of rejection

for service, it was often necessary to arrange for certificate of disability discharges for men suffering from it. Management of both acute and chronic otitis

media was by the practices then prevalent in civilian life. The sulfonamide

drugs were used until penicillin became available and was added to the armamnentarium. The fact that there were only a few cases of mastoiditis was

considered by some observers to be attributable to the use of these agents.

However, the general impression was that, while these agents might have been

helpful in some cases of acute otitis media, they were of doubtful value in

acute exacerbations of the chronic disease and were of no value at all in

chronic cases. Insufflations of sulfanilamide powder, which at one time were

very popular, later were universally believed to be both ineffective and harmful. It was unfortunate that the masking effects of chemotherapy and antibiotic therapy were not more generally realized. Inexperienced physicians did
108 ACTIVITIES OF SURGICAL CONSULTANTS

not always ap. -ciate the fact that relief of symptoms was not necessai'ily

synchronous wi ,. 6he resolution of infection.

The volume of cases of chronic sinusitis was very large. Like otitis media,

this disease was not regarded as a cause for rejection of draftees, and a considerable number of men later had to be given certificate of disability discharges

for this reason. Sinusitis was sometimes a complication of the epidemics of

nasopharyngitis which followed the arrival at camps of increments of troops

fresh from civilian life. Therapy followed the usual civilian practices, and

elective surgery was discouraged. The systemic use of the sulfonamides and

penicillin was sometimes valtable in acute cases in which the micro-organisms

were sensitive to these agents, but, as in otitis media, they were of no value in

chronic cases and their masking effects were often harmful.

Bronchoscopy and laryngoscopy were used for both diagnostic and therapeutic purposes upon the proper indications. The fenestration operation was

not permitted. Rhinoplastic surgery for cosmetic or other reasons was permitted in a few special cases, but for other reasons-for example, physiological

reasons-it was permitted in indicated cases. In these instances, it was done

by otolaryngologists with special training and with the express permission of

the hospital commanding officer.

Anesthesia was a matter of the individual surgeon's preference. Endotracheal anesthesia gradually became popular for radical operations on the antrum

and mastoid, which, as just indicated, were not numerous. Tonsillectomy was

performed under some form of general or local anesthesia.

After the activation of the Otolaryngology Branch in the Office of the

Surgeon General, special cases which formally would have been referred to the

chief of the ear, nose, and throat service at Walter Reed General Hospital

now reached the consultant in otolaryngology through channcls. Most of the

cases which reached the consultant through the physical evaluation review

board in the Office of the Surgeon General concerned the disposition of patients.

Cases which concerned West Point cadets had to do with whether otolaryngologic conditions such as perforated eardrums would warrant continuation at the

Academy or would require dismissal on the basis of physical disability. Army

regulations governed decisions on these cases.

The recommendations made by the consultant in otolaryngology in the

Office of the Surgeon General were, of course, not directive in force. In one

particular case, which had occupied much time and thought and for which

the recommendations were made jointly by several consultants, the commanding officer of the hospital declined to accept the recomnnendations and continued to refuse to accept them even after active intervention by General

Rankin. This was not a usual situation, of course, but one which did occasionally occur and for which no immediate remedy was obvious.
OTOLARYNGOLOGY 109

ROUTINE ADMINISTRATIVE PROCEDURES

Hospital Organization and Personnel

Policies on hospital organization were already well established when the

Otolaryngology Branch was activated in the Surgical Consultants Division,

Office of the Surgeon General, in July 1944. As a rule, sections of otolaryngology were a part of the surgical service. In a few hospitals, otolaryngology was a separate service. In most, sections on otolaryngology and

ophthalmology were conducted conjointly by a single officer trained in one

branch or the other or, very occasionally, in both. This was obviously an

undesirable state of affairs. In small station hospitals, where there was,

perhaps, no other solution to the problem, patients who needed specialized care

in the field in which the section chief was not trained were transferred to

general hospitals. In larger hospitals, the policy of combined services was

unfortunate. There were shortages of specialized personnel, it was true, but

the popular explanation of the situation was that the tables of organization

which provided for the joint management of two widely dissimilar specialties

were the result either of the operation of the Office of the Surgeon General

under the Army Service Forces or of the failure to provide for a consultant

in otolaryngology on the proper level to advise upon such matters.

By July 1944, most hospitals, both those in the Zone of Interior and those

designated for oversea service, were fully manned, but otolaryngologic personnel were now in short supply. Later, in a number of instances, recommendations for changes in assignment were made and were based on personal observation of competence or were regarded as valid for other reasons. However, for

one reason or another, none of these recommendations was implemented.

The Army Air Forces, which were then part of the Army, had a surplus

of well-trained otolaryngologic personnel who were not very busy. Recommendations for transfer of some of these officers to make up for shortages in

Army hospitals in the Zone of Interior and overseas were made informally but

were not acted upon.

Equipment and Supplies

Consultations with the proper authorities concerning cquipment and supplies for otolaryngology were, as a rule, very disappointing, probably because,

again, the Otolaryngology Branch, Office of the Surgeon General, was activated

at such a late date. The errors were those which might have been expected in

lists of equipment made up, as a rule, by medical officers with no special training in otolaryngology.

.ks a rule, however, serious deficiencies were not numerous. Improvisations were sometimes necessary, but no patients really suffered because of lack

of equipment. There were numerous complaints, but most of them could be

explained by the rather general desire of surgeons in all fields to want more

606222-2-- 10
110 ACTIVITIES OF SURGICAL CONSULTANTS

than they have. On the ether hand, much of the equipment was far too

elaborate. It was a good r'eal more than most otolaryngologists were used

to in civilian practice and was entirely unnecessary in view of the limited

amount of surgery permitted in many installations. Hospitals which needed

more equipment either improvifed it or secured it on loan from general surgery

services.

There were, however, a number of deficiencies in the equipment for the

hearing centers. Audiometers were in limited supply for a long time. These

were delicate instruments frequently in need of checking and repair, and

their maintenance was slow and difficult. In many instances, insufficient space

had been provided for proper testing (20-foot lanes), and the areas were

not sound conditioned or correctly located. In at least one hospital, the room

for audiometric testing was adjacent to the motor pool. These deficiencies

were partly due to failure to appoint a consultant in otolaryngology until late

in the war and were partly a reflection of the status of audiology before the war.

OTHER DUTIES

Hospital construction.--The professional duties of the consultant included the making of recommendations concerning construction and equipment in new hospitals and alterations in existing hospitals. These duties required consultation with appropriate sections of the Office of the Surgeon

General and were chiefly concerned with the hearing centers. Professional

'idvice in regard to these centers was usually readily accepted.

Special centers.-In addition to the centers for the treatment of hearing

impairments, special centers were established for the treatment of laryngeal

and esophageal cases and for speech defects. The speech defects were principally from head injuries, and the centers, which were never very active, were

opeeated in conjunction with neurosurgical and ,neurologic personnel. The

principal ce-.ter for the treatment of laryngeal injuries, which injuries proved

far more numerous than had been expected, was at Walter Reed General

Hospital.

Field trips.-Each of the hearing centers was visited several times when

necessary, but travel by the consultant in otolaryngology was otherwise strictly

limited. He was not included in any of the so-called "Flying Circus" trips,

in which groups of officers in the Office of the Surgeon General traveled by air

to various hospitals in the Zone of Interior to study the administrative organization, the functioning of the various services, and the care of patients. Other

consultants, however, were included in these "Flying Circus" trips from time

to time.

The personal observation, which would have been possible had the policy

on travel been less restrictive, would have obviated the difficulties which arose

from corre 'ondence regarding personnel. In numerous instances, letters

were receive(t from otolaryngologists concerning assignments, equipment,
OTOLARYNGOLOGY u1

therapeutic methods, and other matters which were not always easy to evaluate

at long distance. Some of these letters could, of course, be discounted upon

the first reading. In other instances, however, though the complaints seemed

justified, it was almost impossible to recommend action without personal observation. In only one instance was such personal observation permitted.

On that occasion, it was recommended that the officer in question be transfer'ed

to another installation in which his duties would not provide the opportunities

for the surgery he was attempting.

Liberal use of the long distance telephone compensated to some degree for

the restraints upon travel by the consultant in otolaiyngology.

Liaison.-Liaison with various otolaryngologic organizations and with lay

and other organizations concerned with this field was one of the duties of the

consultant in otolaryngology.

After his appointment to this position, this consultant served on the Subcommittee on Otolaryngology, Division of Medical Sciences, National Research

Council, and replaced the medical and administrative officers who had served

previously on the Subcommittee. He was also appointed alternate liaison

officer and, later, liaison officer on the Committee on Sensory Devices, Office of

Scientific Research and Development.

Liaison officers were invited to all section meetings of Office of Scientific

Research and Development committees, at which their special projects were

discussed. Direct and official contact was permitted with National Defense

Rearcl Committee contractors without, violation of rules concerning communication through official channels. No substantial change in research projects was permitted without the approval of the responsible supervising division of the Office of Scientific Research and Development, but this arrangement provided frequent and helpful contacts with persons concerned in these

projects. Many of the practical results of the research carried out by the

special committees of that office were applied at the hearing centers as preliminary data became available, but the war ended before these projects were

completed.

Other groups with which liaison was maintained included the American

Academy of Ophlialmology and Oto-Laryngology; the American Otological

Society; the American Laryngological Society; the Section on Laryngology,

Otology and Rhinology of the American Medical Association; the American

Broncho-Esophagological Association; the Triological Society (the American

Larynological, Rhinological and Otological Society) ; the American College

of Surgeons; and the American Board of Otolaryngology. For the most part,

liaison was effected informally, frequently by telephone or by personal contact.

These contacts, ho~vever, were extremely profitable in that specialists in the

field could be 1 ' informed of Army problems and progress and that the

consultant in ot6iaryngology, in his turn, could keep abreast of therapeutic

and other advances.
112 ACTIVITIES OF SURGICAL CONSULTANTS

Close liaison was maintained also with the American Hearing Society

through its central office in Washington; the Volta Bureau of the Alexander

Graham Bell Association for the Deaf; and other lay organizations. These

contacts frequently brought to the attention of the consultant in otolaryngology

both general problems and special cases.

The consultant in otolaryngology served as a member of the Subcommittee

on Audiometers and Hearing Aids of the American Standards Association and

attended several meetings. At a conference on underwater sound at the U.S.

Submarine Base, New London, Conn., a paper was presented as part of a

symposium on this subject.

The consultant attended meetings of specialized societies and presented

talks on the occasion of special meetings, such as the silver anniversary meeting of the New York League for the Hard of Hearing when it met with the

Otolaryngology Section of the New York Academy of Medicine, New York,

N.Y., in 1944.

Close liaison was maintained with the Veterans' Administration, chiefly

through informal conferences. The relationship was invariably cordial and

cooperative, and it was believed that a good groundwork had been laid for

the assumption by the Veterans' Administration of the care of deafened

veterans after the war.

Public relations.-A large part of the consultant's duties had to do with

a field that might be termed public relations. This included correspondence

on special cases with members of Congress who forwarded letters from their

constituents. These letters usually dealt with physical disabilities which, it

was believed by the soldiers' parents, would be jeopardized by continuation

of service, by continued service in the present assignment, or, in particular, by

oversea service. The most usual reasons listed were sinus trouble, hearing defects, headaches, and a former history of mastoid disease. Each of the cases

was, of course, investigated, but only very occasionally was the request regarded as justified from the standpoint of the soldier', well-being.

AURAL-REHABILITATION PROGRAM FOR THE DEAFENED AND

HARD OF HEARING

Background and General Considerations

The impetus to the appointment of a consultant in otolaryngology in the

Office of the Surgeon General in July 1944 was, as already mentioned, the

need for changes in the Army aural-rehabilitation program. The description

of this consultant's functions, in fact, began with a stbt)ment of his responsibility for the establishment of policies and procedures in the care of the deaf

in the Army.

Specialized centers for the treatment of Army personnel with defective

hearing sufficient to preclude their return to duty had been set up in May

1943 at Borden General Hospital (fig. 20); Hoff General Hospital, Santa
OTO]LAYNGOLOGY11

FIGURE 20.-Aural rehabilitation at Borden General Hospital, Chickasha,

Oklahoma. A. Audiometric assessment of hearing loss. B. A group learnIng lipreading with the aid of motion pictures. C. Practice class In

lipreading.
114 ACTIVITIES OF SURGICAL CONSULTANTS

Barbara, Calif.; and Walter Reed General Hospital, Washington, D.C. The

center at Walter Reed General Hospital was transferred to Deshon General

Hospital, Butler, Pa., in September 1943 (fig. 21). The first phase of the program was under the direction of a trained psychiatrist, Maj. (later Lt. Col.)

Walter E. Barton, MC, Assistant Director, Reconditioning Division, Oflice

of the Surgeon General.

By January 1944, the increase in the patient load at the specialized centers

had resulted in so many problems that a conference on the whole subject of

rehabilitation of the deafened was authorized by The Surgeon General and

was held at Hoff General Hospital, 2-4 February 1944. The mere perusal of

the recommendations made by this conference made it evident that the three

specialized centers for rehabilitation of the deafened were operating, for all

practical purposes, as individual units, and this lack of coordination was one

of the chief reasons for the establishment of an Otolaryngology Branch.

The reorganized program is described in detail in the volume in this series

concerned with otolaryngology, but certain of the essential facts require

repeating here.

The problem with which the Army found itself confronted in the rehabilitation of the deafened and hard-of-hearing soldier had no parallel in civil

life, either in the mnmber of patients to be dealt with or, in some cases, in the

circumstances of tbeir deafness. At the beginning of the aural-relabilitation

program, the following three special difliculties had presented themselves:

1. Tie material used in the teaching of the hard of hearing in civilian

life was almost entirely directed toward children.

2. The Army at this time had neither the trained )ersonnel to conduct

such a program nor tie technical personnel to build, install, and maintain

the essential electroacoustic equipment.

3. Highly specialized and difficult-to-obtain equipment was required.

Development of the Program

The first duty of the newly a)pointed chief of the Otolaryltngology Branch

was to survey the situation at the three hearing centers. An analysis of the

data secured made it clear that deafened and hard-of-hearing )atients had,

on the whole, received excellent care and that the chief deficiencies of the prograin at this time had to (1o with lack of equipment, shortages of personnel,

and lack of uniformity and procedure. True, corrective action was being

taken to overcome these deficiencies, but the added impetus provided by the

appointment of the consultant in otolaryngology to coordinate and integrate

activities undoubtedly accelerated developmentc 9 f the full-fledged programn

which eventually evolved. The followiing developments were particularly

noteworthy:

Equipment.-A list, of basic equipment was drawn up with the assistance

of Dr. Richard K. Silverman, director of tile Central Institute for the Deaf,

atiliated with Washington Uliversit y. St. l'ouis, Mo., and Mr. C. E. Hlarri-
OTOLARYNGOLOGY15

Fi ,t-R 21.-Aura I re'Im iIit at ioti at D v~Iioi GeneiralI lI&, pita I. I at hr. P a. A. Speechi

intel % iewv and evaluationi. 11 Ada inistratiuii of the* I.areii discriminaation tv!t. C. Plyhulugical viallaa t jun uf mlviii a abil it me and alit i adv fur rehabiilita tio um aivl g.
116 ACTIVITIES OF SURGICAL CONSULTANTS

son, who had had many years of experience in electronics at this institution.

In July 1944, all three centers were still without sound-level meters, magnetictape recorders, some units of electroacoustic equipment, and other equally basic

items. However, by 1 November 1944, most of the essential equipment had

been procured and installed in all three centers. At the same time, utilization

and disposition of the equipment, which previously had varied widely, were

standardized and made uniform.

Personnel.-The staffs aiready at work in the hearing centers in July

1944 were augmented as rapidly as possible to meet expected patient loads.

Qualified personnel already in service were identified from a search of personnel records in The Adjutant General's Office and assigned to the centers.

All organizations working in the field, both lay and professional, governmental

and private, were solicited for assistance. Eventually, an adequate number of

both military and civilian personnel were secured for the positions open in the

hearingcenters.

When, on early visits to the centers, it was found that otologists specially

trained for the program were being assigned to other duties and that their

specialized skills were not being fully utilized, the importance of retaining

intact the organization which had been set up was explained to responsible

officers in the service commands, and the time, effort, and monies expended in

the training of personnel were emphasized. Later, a War Department memorandum stressed the importance of retaining in their specialized capacities

critically needed specialists, among whom were listed psychiatric social workers, lipreading specialists, speech correctionists, and acoustic technicians.

Organization.--Under the plan of reorganization put into effect by the

consultant in otolaryngology, an otologist directed the aural-rehabilitation

program at each center. Medical officers became responsible to the otologist

for the diagnostic and therapeutic management of the patients, whereas,

formerly, the program had operated as a group of separate services. Although

compliance with the basic plan of organization was insisted upon, each center

was given latitude for the expression of individual initiative in its program.

Facilities for the transmission of information from center to center insured the

rapid utilization for all patients of any policy or procedure which had proved

of value in a single center.

Selection of patients.-The standards of hearing acuity under which men

were inducted into service obviously permitted the entrance of many with

markedly defective hearing. Moreover, the tests by which acuity was determined were admittedly inaccurate. Originally, a hearing loss of 60 decibels

was required for admission to the centers. Later, thc hearing loss requirement

was reduwed to 30 decibels, which experienced otologists regarded as much

fairer, even though it would materially increase the load oil the special centers.

Expansion.-The original plan was that each aural-rehabilitation center

should maintain a maximum load of 250 patients. As the patient load increased, problems of a(hitional expansion continued to arise. Early in 1944,
OTOLARYNGOLOGY 117

various estimates brought the maximum number of casualties who might require treatment for deafness within the year to more than 13,000. Available

facilities would not permit the handling of more than 4,000 per year, even if

the turnover continued as expected. Additional facilities were therefore

planned for between 4,500 and 9,000 patients per year, which would require, on

the basis of a 10-week hospital residence, an additional bed capacity of between

900 and 1,750 beds.

Later, it was found more practical to manage patients admitted to the

centers for aural rehabilitation as convalescents, and, under this plan of management, the proposed additional hospital facilities were considered unnecessary. The plan of transferring patients in the hearing centers to convalescent

barracks was originally undertaken experimentally, but it proved both feasible

and practical. In addition to releasing hospital beds for other, more urgent

purposes, it removed the patient from a hospital atmosphere, improved his

morale during the period of rehabilitation, and permitted a desirable program

of activities outside of actual aural rehabilitation which could better be carried

out away from the regimentation and discipline necessary in hospital wards.

Hearing aids.-War Department Circular No. 81, issued on 23 February

1944, limited the prescription and fitting of hearing aids to the special hearing

centers, except for patients in general hospitals under treatment for conditions

which precluded their transfer to special centers (fig. 22). The original policy

was to supply aids only to men whose impairment had been suffered in line of

duty. Later, on 23 February 1944, this policy was altered and aids were

furnished to all deafened men in service, regardless of when or how the

impairment had originated.

The situation in respect to hearing aids was altered in the reorganized program in several ways. Scientific tests were devised to determine the special

aid suited to the needs of the individual patient. Patients themselves were

completely separated from commercial contacts. Savings in both time an,'

money were effected by having the individual Lucite tips for the patients made

by trained technicians in Army dental laboratories and by letting indefinite

quantity contracts for the purchase of aids most frequently used, as determined

by survey.

Narcosynthesis.-One of the outstanding developments of the auralrehabilitation program was the management of cases of psychogenic deafness

by narcosynthesis. The results in the first cases in which this method was

applied were so good that its use was extended, and, in all, 102 patients were

thus treat,, d at the Hoff Center, with the cooperation of the otologist, the

psychiatrist, and the psychologist. Although this technique was highly

successful in military circumstances, it was doubted that it would be as

effective in civilian life.

Civilian consultants.-Valuable suggestions concerning the aural-rehabilitation program were made by the late Dr. Walter Hughson, before the
22 rilljj~.. I iI.IIII.
OTOLARYNGOLOGY 119

establishment of the Otolaryngology Branch in the Surgeon General's Office.

Mention has already been made of the assistance rendered by Dr. Richard K.

Silverman and Mr. C. E. Harrison in the planning and procurement of special

equipment. The latter two individuals made a number of trips to the centers

in connection with the designing and installation of this equipment, and

Dr. Silverman made valuable suggestions for the lipreading and speech-correction programs. Dr. Gordon Berry, then President of the American Otological

Society, gave generously of his time and supplied valuable advice when the

program was in its earliest stages as well as after the Otolaryngology Branch

had been established. Dr. Hallowell Davis and others of the psychoacoustic

laboratory of Harvard University gave valuable help in various aspects of the

program for the treatment of the deafened soldier.

Early in the program, Dr. Douglas Ross was assigned to Deshon General

Hospital in connection with the otologic studies of the National Defense Research Committee. His association with the staff there proved of so much

benefit that at the suggestion of the consultant in otolaryngology he also visited

the other centers, where lie held numerous conferences with the staffs and was

able to iron out many difficulties on the basis of his experience in similar situations at the Deshon Center.

Maj. Victor 0. Skyberg, SnC, who had had a wide experience in civilian

life as both teacher and administrator at the New York School for the Deaf,

W'hite Plains, N.Y., at Gallaudet College, Washington, D.C., and at the Minnesota School for the Deaf, Faribault, Minn., visited Borden and Hoff Centers

late in 1944 and would have visited the Deshon Center except for his untimely

death just as his tour of duty at the Hoff Center was concluded. Major Skyberg's constructive criticisms resulted in further standardization of methods at

all centers and in other improvements.

Followup.-Unfortunately, no adequate followup studies were made

within the Army on patients discharged from the hearing centers. The Deshon

center, however, investigated, by means of questionnaires, 468 of its patients

who had been discharged with hearing aids. The personal impressions of

workers in the program were that a large proportion of the patients returned

to civil life had made highly satisfactory adjustments. In many instances,

it was stated that the standards of living, as the direct result of aural rehabilitation, were actually higher than they had been previously. This was especially

true of those whose hearing had been impaired before their induction.

Conclusions

Although nothing new was revealed during the war about the problems

of patients who were deafened or who had suffered severe damage to their

acoustic mechanism, the mass of military casualties permitted a study of the

whole field of deafness which would have been impossible in civilian life. Much

of the accumulated data merely confirmed previous impressions, and much of

it was inconclusive. Nonetheless, it would be fair to say that, as a result of
120 ACTIVITIES OF SURGICAL CONSULTANTS

the wartime experience, the treatment of deafness was advanced by at least two

decades.

The integration of the aural-rehabilitation program was perhaps its most

significant aspect. For the first time, there were placed under a single roof,

it large-scale collaboration, the otolaryngologist who specializes in otology, the

acoustic engineer, the psychologist, the social worker, and the teacher of the

hard of hearing. Each specialized center was provided with the best possible

equipment. Every member of the staff was a specialist in his field. Some

teachers were themselves as handicapped as their pupils and were vital illustrations of what handicapped persons can accomplish. Every phase of the

program was carefully planned, with the objective of making it as intensive

and, at the same time, as streamlined as possible. Eventually, as would have

been desirable from the beginning, an otologist was put in overall charge of

the program, since auditory impairment, regardless of its social and emotional

complications, was primarily a medical problem.

In all, some 9,500 deafened and hard-of-hearing soldiers were treated in

the three aural-rehabilitation centers.

RECOMMENDATIONS

In retrospect, the prime achievement of the Otolaryngology Branch Surgical Consultants Division, Office of the Surgeon General, was the operation

of the specialized centers for the treatment of deafened and hard-of-hearing

soldiers. It was unfortunate that the uniform program finally put into operation at all of the centers was not instituted as soon as the centers were established. It was equally unfortunate that the program did not develop originally

under otologists, the specialists primarily responsible for the management of

hearing impairments.

For these and other reasons, it is indicated that in the event of another

w'-r an otolaryngology branch should be created at once as one of the specialty

branches in the Office of the Surgeon General, if such a branch should not exist

at the time, and regardless of the form the organization of this office may take

in the future. It would be fair to say, without unduly magnifying the importance of the specialty, that many of the problems which arose during the early

years of the war concerning personnel, equipment, therapy, and other considerations would not have arisen had an otolaryngologic consultant been ai ailable

for advice and guidance.

It should be pointed out also that the rank of the consultant in these fields

should at least approximate the ranks of other consultants in the various specialties. An officer in the rank of major was handicapped in his dealings with

officers of rank higher , han his own, even though their duties were comparable.

Finally, the record wouh suggest that the restrictions on travel for the

consultant in otolaryngology which prevailed in World War II should not

prevail in the event of another war.
CHAPTER VI

The Blood Program

Brigadier General Douglas B. Kendrick, Jr., USA

How many thousands of lives were saved in World War II by the use of

whole blood and plasma in the management of battle casualties will never be

accurately known. The almost blind dependence originally placed on plasma

proved erroneous, but this blood component never lost its value as a means of

keeping casualties alive until they could be brought to Army medical installations in which whole blood was available. The use of whole blood was, however, the keystone of the arch of resuscitation, and resuscitation was, in turn,

the keystone of all surgery.

In World War I, men died without surgery because the means of resuscitation were not available. In World War II, men survived because they were

operated on, but the fundamental reason for their survival was that they lived

or, more correctly, were kept alive until they were fit to be operated on. They

were kept alive by plasma ultil they could be given whole blood. They were

resuscitated-which means, literally, brought back to life-by whole blood,

which made operation possible. Very often they were kept alive during operation by the continued use of whole blood. Finally, many times, their recovery

after operation was expedited by the use of whole blood, even if it was not

again necessary to keep them alive.

There is no exaggeration in any of these statements, sweeping though they

may be. They are generalizations, it is true, but they present the correct

picture of how surgery was made possible in World War II and how it saved

the lives of thousands of soldiers who otherwise would have died.

Since the importance of whole blood in resuscitation was realized almost

from the beginning by all the personnel and agencies connected with the program, it is difficult to understand why its procurement, distribution, and employment got off to such a slow start in World War II. Any explanation must

be a mixture of opinion and fact. It seems fair to say that the chief reason

was that overenthusiasm for the potentialities of plasma as an almost complete

blood substitute tended to minimize the consideration which might otherwise

have been given to the development of methods for making the use of whole

blood practical.

Before World War II began, as will be pointed out later (p. 141), there

had been only one practical demonstration, by DeGowin and his associates' at

I DeGowin, E. L., and Hardin, R. C.: A Plan for Collection, Transportation, and Administration of

Whole Blood and of Plasma in Warfare. War Med. 1 : 32G-341, May 1941.

121
122 ACTIVITIES OF SURGICAL CONSULTANTS

the State University of Iowa College of Medicine, Iowa City, of the possibility

of storing whole blood for any extended periods of time and shipping it over

considerable distances. More important, as the discussion at the first meeting

of the Committee on Shock and Transfusions, Division of Medical Sciences,

National Research Council, 2 clearly shows, the feasibility of such a project had

to be developed and accepted as a concept. This consideration was much more

important than the existing lack of means to store blood and to transport it

safely over long distances. It was even more important, for that matter, than

the fact that an oversea air transportation system had not yet been developed

when World War II began.

Finally, those in charge of the blood program, while they clearly understood that large amounts of whole blood would be required in the management

of battle casualties, did not begin to make their voices heard until 1943. It

was not until the end of that year that strong, constructive, concrete recommendations began to be made, and it was not until the following year, 2 months

after D-day in the European theater, that these recommendations were finally

accepted and implemented in the Office of the Surgeon General.

The whole program for the provision of blood and blood substitutes in

World War II was a superb national effort. Both Federal and civilian agencies participated in it, but its lifeline was provided by the millions of volunteer

donors who gave their blood to supply blood, plasma, and other blood substitutes for the Army, including the Army Air Forces, and the Navy. Over the

period of the conflict, total bleedings of these volunteer donors numbered

13,326,242.' This gigantic pool of what was truly a lifegiving fluid contributed

immeasurably, intangibly as well as tangibly, to the successful outcome of the

war. It was a visible manifestation of the loyalty to their country of the

individual donors who gave their blood and who thus demonstrated their belief

in the way of life for which the United States of America stands.

BLOOD AND BLOOD SUBSTITUTES AT THE BEGINNING OF WORLD

WAR II

Historical Note

The need for transfusions of whole blood in casualties with battle- incurred

wounds had been recognized in World War I, and the effectiveness of this

method of combating shock had been demonstrated by Robertson 4 and others,

as early as 1916. Blood transfusion increased in popularity as the war progressed, but for practicatl reasons it was never used routinely, and it was

attended with a number of disadvantages and risks.

2 Minutes, meeting of Comluittee on Shock and Transfusions. DIh Ison of Medical Sciences, National

Research Council. 31 Ma.% 1040.

Robinson, G. Canby, American Ited Cross Blood Donor Service During World War 11 Its

Organization and Operation. Washington: The American National Red Crobs, I July 1946.

' Robert.son. L. Bruce ' The Transfusion of Whole Blood. A Sugge.stion for Its More Frequent

Employment lit War Surgery. Brit. M J. 2 3S-40. S July 1916
THE BLOOD PROGRAM1 1,23

The use of blood plasma as a substitute for whole blood was also proposed

in World War I. In March 1918, Ward 5 pointed out that the administration of citrated plasma, which could be preserved easily and injected safely,

would meet the need of casualties in shock from hemorrhage, who, in his

opinion, required replacement of depleted fluid more than replacement of

lost hemoglobin. He also noted that the risk of hemolysis of the donor's

corpuscles by the recipient's plasma would thus be eliminated. Earlier that

year, Rous and Wilson 0 had advanced the same theory and had reported the

experimental use of plasma for resuscitation of animals after massive blood

loss.

Later in 1918, Mann 7 proposed that blood serum be used for the treatment of surgical shock, on the basis of the good results which fie had obtained

with it in experimental shock. He also suggested that homologous serum

might be of value in circumstances in which serum could be stored and whole

blood could not be obtained.

Interval Between the World Wars

It required the experience of World War II to establish the efficacy of

large volumes of blood, administered rapidly, in the resuscitation of exsanguinated casualties and their conversion to acceptable candidates for surgery.

The interval between this experience and the tentative experience of World

War I was characterized by a number of developments, which may be briefly

summarized as follows:

1. Outstanding contributions to the literature of shock were made during this period by Cannon,8 Parsons and Phemister, 9 Moon,' 0 and Blalock,"

among others. As time passed, Cannon's original theory, that shock is produced by the absorption of toxic materials from the site of injury, was supplanted by the work of Parsons and Phemister, and later by the work of

Blalock. These observers demonstrated that shock is the result of loss of

fluid locally, at the site of injury, and that the local loss causes, in turn, a significant decrease in the circulating blood volume. By 1940, the concept had

been generally accepted that the basis of shock is a decrease in the circulating

blood volume, as just stated, or a discrepancy between the blood volume and

the volume capacity of the vascular system, or a combination of these two

alterations in the normal physiologic processes, with resulting tissue anoxia,

5 Ward, G. R. :, Transfusion of Plasma. Correspondence. Brit. MJ. 1 : 301, 9 Mar. 1918.

6 Rous, P., and Wilson, G. W. :, Fluid Substitutes for Transfusion After Hemorrhage. First Com.

munication. J.A.M.A. 70: 219-222, 26 Jan. 1918.

7 Mann, F C. *, Further Experimental Study of Surgical Shock. J.A.M.A. 71 : 1184-1188, 12 Oct.

1918.

$Cannon, Walter B. : Traumatic Shock. New York and London: D. Appleton and Company, 1923.

9 Parsons, E., and Phemister, D. B.: Hemorrhage and "Shock" ;.. Traumatized Limbs. An Experimental Study. Surg., Gynec. & Obst. 51 : 190-207. August 1930.

11 Moon, Virgil 11 ! Shock and Related Capillary Phenomena. New York: Oxford University Press,

1938.

11 Blalock. Alfred Principles of Surgical Care Shock and Other Problems. St. Louis :, The C. V.

Mosby Compan3, 1940.
124 ACTIVITIES OF SURGICAL CONSULTANTS

which, if not reversed, leads to death. It is upon these concepts that the

molern use of whole blood in the management of shock is based. Strumia

a his associates,12 whose first work was done with intravenous serum in the

treatment of severe infections, later substituted plasma for serum because

of its greater simplicity of preparation and the greater yield from the same

amount of whole blood. In 1935 Filatov and Kartasevskij 13 reported the use of

intravenous plasma as a hemostatic agent, and in the same year Heinatz and

Sokolow 14 used plasma in the treatment of hemolytic shock. The following

year, Elliott 5 suggested that untyped serum and plasma be used when transfusion was indicated in the management of surgical, traumatic, and obstetric

shock. His reasoning was that the maintenance of osmotic pressure is a

fun-tion of the plasma proteins and that the need for replacing lost blood volume is more important than the need for replacing red blood cells. During

the next 2 or 3 years, a number of other observers also published reports on

the use of plasma in the management of shock and described techniqaes for

its preparation in the liquid, frozen, and dried states.

2. The considerable amount of work on the fractionation of plasma done

by Cohn 16 and his associates led to the use of serum albumin for the treatment of shock.

BEGINNINGS OF THE BLOOD AND BLOOD SUBSTITUTES PROGRAM

When it became increasingly evident, early in 1940, that the United

States might eventually become involved in the hostilities in Europe and that

the Medical Department of the Army might be called upon to care for mass

casualties resulting from enemy action, the major problem which confronted

the Department was the development of an improved method of treating traumatic shock.

At this time (the spring of 1940), the situation with respect to the use

of blood and blood substitutes in the management of shock may be summarized as follows:

1. The use of type-specific whole blood had become a practical procedure

in civilian hospitals, but it was still given in only small amounts and, as a

rule, heroically; that is, transfusion was still being resorted to chiefly in

critically, or at least gravely, ill patients, whose status was truly desperate.

12 (1) Strumla. M. M., Wagner, J. A., and Monaghan, J. F.: The Intravenous Use of Serum and

Plasma, Fresh and Preserved. Ann. Surg. 111: 623-629, April 1940. (21 Struiia, M. M., and

McGraw, J. J. : The Development of Plasma Preparations for Transfusions. Ann. Int. Med. 1.5. 80-88,

July 1941.

13F!iatov, A., and Kartasevskij, N. G.: Die Transfusion von mensehlichem Blutplasma als blutstillendes Mittel. Zentralbl. f. Chir. 62: 441-445, 23 Feb. 1935.

14t elnatz, S W., and Sokolow, N. I. : Plabmatransfuslon als Methode der Wahl in der Behandlung

des hiiinolytlschen Schocks. Zentralbl. f. Chir. 62 : 1753-1755. ?7 July 1935.

'5 Elliott. J. : A Preliminazi Report of a NeN% Method of Blood Transfusion. South. Med. & Surg.

98: 643-645, December 1936.

" Cohn, E. J.. Properties and Functions of the Plasma Proteins, With a Con'ideration of the

Methods foi Their Separation and Purification. Chem. Rev. 28: 395-417. April 1941.
THE BLOOD PROGRAM 125

The concept that blood should be used liberally to prevent the development of

situations of desperation was still very far off.

2. Direct techniques of transfusion were still in frequent use, though a

gradual shift to indirect techniques was occurring. The changeover, however, was slow for two reasons; namely, lack of satisfactory equipment and

the reactions credited to the use of citrate as a preservative fluid.

3. Reaction rates from blood transfusions were still sufficiently high to

alarm even the most enthusiastic proponents of the liberal use of whole blood

There was almost complete ignorance concerning pyrogenic reactions, which

were the most frequent variety and which occurred most insidiously.

4. The use of blood plasma was still chiefly experimental.

5. The use of blood serum (the liquid portion of the blood separated

from the solid elements after clotting) was also almost entirely experimental,

its administration at this time being advocated by only a few pioneers.

6. The use of serum albumin had not yet been developed.

Program at the Army Medical School

The first steps in the solution of the problem were taken by Col. (later

Brig. Gen.) Charles C. Hillnan, MC, Chief, Professional Service Division,

Office of the Surgeon General. Colonel Hillman's first action was to request

Co]. (later Brig. Gen.) George R. Callender, MC, Commandant, Army Medical School, to organize a blood research branch in the Department of Surgical Physiology at the school.

This department had been set up in 1936 by Capt. (later Col.) Sam F.

Seeley, MC, but, in 1938, when Captain Seeley had been transferred elsewhere,

it had ceased to function, after 2 years of very active operation. Capt. (later

Col.) Douglas B. Kendrick, MC, (fig. 23) was selected to head the reactivated

department because of his earlier training17 The original personnel consisted of himself and an enlisted man who served as his technical assistant.

Program of the National Research Council

At the time that Colonel Hillman requested Colonel Callender to set up

a blood research program at the Army Medical School, lie also, acting for The

27 During a civilian urgical resldee. at Grad. Iloqpltal. in Atlanta. under Dr. Daniel C. Elkin,

Captain Kendrick had had a considerable experience in the large amount of traumatic surgery handled

at that institution, with its attendant piobleo, including shock. Ile had also served under Dr. Fred

Rudder, who was greatly interested in the use of ihole blood in shock and who had devised an

ingenious apparatus for direct transfusion.

After his service at Grady Hospital, Captain Kendrick entered the Army Medical Corps and,

because of his previous experience, was sent for a year to the Intitute of Experimental Medicine at

the Mayo Clinic. Roehester, Min.. whe-e he worked on shock, icplacement fluids, gas gangrene, and

special uses of the sulfonamides. He also did work In anesthesia under Dr. John S. Lund). The plan

had been that on Captain Kendrick's return to the Armn Medical School he should continue Captain

Seele.\'s work Funds for research, however, proved so inadequate that this plan could not be carried

out, and lie was therefore assigned to the orthopedic ser ice, Walter Reed General Hospital, and was

on this servlc,' when, at Colonel Hillman's request. the Department of Surgical Physiology at the Army

Medical School wae reactihatd. with research in blood and blood substitutes as its chief objective.-

J. B. C., Jr.
126 ACTIVITIES 01F SURGICAL cONSULTANTS

Fiumn 23.-Cu1. Douglas 13. Kenidrick, AMC, Chief, Di~ ision Of S1uigical1 Ph*,-i01O*-

Army M1edical School, Walter Reed General 110sjpital.

Surgeonl (ellvra~l, requiested t he 1)ixi.,ion of Aledical Sciehlce ', National Research Council, to w.,winble a ci% il imi commnitte i% hicli could act in formally,

in anl advisoivN calnltit.N. to thle 'Sui-"eonl" ( ciiral of liek AiiiivY anid tile xax.

'rhe Commiittecc onl Shock an d 'L'iaii.fui~Oi1S, AN hicli N" app~oinlt ed ill rce.poii~e

to t 1i.i, requie't. I ici its fiit. mneet nig onl :1I May 19-0.'' Dr. Walter B3. Cannon.

Protc.,.or of 1Phivsiolol(v. I[art aid Mtedical School, Blol n M\a'.., Z'erl ed as

Cia611M ina Of t11 l uiet I ii, 101id thle S ubcommiiit tee iii Blood Sii~t itie-" was ap)-

p)oited ilh D r. ('~ ru' C. Stugi. onfve'- of Initernial iAlt'diciic. 1Uiii'eiity

of Mtichig--an Medical School, Ann Arbor, Michi.. a., cliait'niaii. Ill April 19 tI.

D)r. Sti ur1i-,A', Ilk t~ vueedd b.\ - Dr. Roei't 1F. L oeb. Li eo of Mevdic lie at

thle samle SChooI1. 1 9

Other nilellil ier- of tlie Sulwcoiiniuee wevre). El Iiici 14L. 1 )Go\ inl, \\ho

SerVed as -ecrvtr Dv r. ( oiiliefil, '. Rlioatl, Dr). 0 . It. Robert oli. Dr. '10o111

Scudder'. Dr). Max Ar. St ri ja. ai iD1)r. ( )w en I1. Walinevi e. The inlitial

mleet ini~r held oil 19 A pril 19 II. \\a' a! o ank-etided bI Dri. Lew i, 11. 'Weed.

- S..I. i,. p122
THE BLOOD PROGRAM 127

Chairman, Executive Committee, Division of Medical Sciences, National Research Council; Dr. Milton V. Veldee, Chief, Biologics Control Laboratory,

National Institute of Health; Lt. Comdr. Lloyd R. Newhouser, MC, USN;

and Captain Kendrick. All the members of the Subcommittee had previously

done outstanding work in the field of blood and blood substitutes.

Program in the Office of the Surgeon General

Until 1942, the primary responsibility for the program on blood and blood

substitutes rested with the Blood Research Division., Army Medical School.

In that year, the responsibility for the program in the Office of the Surgeon

General was assigned to the Surgical Consultants Division. At the same time,

Lt. Col. B. Noland Carter, MC, assistant chief of the division, was made responsible for all matters concerning fluid replacement in shocked patients.

On 24 November 1943, the Transfusion Branch was created in the Surgical

Consultants Division, with Colonel Carter as chief and Maj. (later Lt. Col.)

Frederic N. Schwartz, MAC, as operations officer. 0 The Transfusion Branch

was eventually given the entire responsibility for the blood procurement prograin up to the point at which the blood was placed on aircraft for oversea

shipment.

For a 3-month period in 1943, Col. Charles F. Shook, MC, had served

as special representative to The Surgeon General on blood and plasma transfusions. When the Transfusion Branch was created, Colonel Kendrick assumed these duties. In November 1944, when Colonel Kendrick was transferred to the Pacific, he was succeeded by Maj. John J. McGraw, Jr., MC. The

duties of the special representative to The Surgeon General on blood and

plasma transfusions were to formulate policy, to estimate blood requirements,

and to evaluate the efficiency and suitability of apparatus, equipment, and

technical procedures. Major Schwartz handled administration, supply, and

personnel. Recommendations were channeled through Colonel Carter.

In all his connection with the blood program, Colonel Kendrick served

as chief of the blood research program at the Army Medical School. When

he was assigned to the Office of the Surgeon General in 1943, as special representative on blood and plasma transfusions, it seemed more advisable for him

to continue to operate under the table of allowances at the Army Medical

School, in order to provide free access to the research facilities still needed

in the program. During the entire war, there was always the closest possible

cooperation between the school and the Office of the Surgeon General. Both

General Callender at the school and General Hillman in the Office of the

Surgeon General gave unlimited support in all Colonel Kendrick's activities,

and all matters dealing with blood, shock, or resuscitation were automatically

referred to Colonel Kendrick.

- Annual Report, Surgery Division. Surgeon Generals Office, Fiscal Year 1944.
128 ACTIVITIES OF SURGICAL CONSULTANTS

Cooperation With the Navy Program

In April 1940, shortly after Captain Kendrick had been assigned to the

Division of Surgical Physiology at the Army Medical School, Lt. Comdr.

Lloyd R. Newhouser, MC, USN, was assigned to the National Naval Medical

Center, Bethesda, Md., with duties very similar to Captain Kendrick's. The

two officers encountered each other in the course of their work, and, since they

were trying to accomplish the same results, it seemed only sensible to pool

their efforts, which they did until late 1944, when both were transferred to

oversea duty. The collaboration, while entirely unofficial, was approved and

encouraged by the superior officers in both services and proved extremely

fruitful.

Commander Newhouser and Colonel Kendrick kept themselves closely

informed of each other's plans and progress. As a result, many items were

standardized by both the Army and the Navy and most orders were placed

with a consideration of joint needs. The intimate liaison between the Army

and the Navy was an important factor in the maintenance of a smoothly running program for the procurement of plasma, albumin, and, later, whole blood.

It wias out of this informal arrangement that formal plans were eventually

consummated for the Navy to assume the responsibility of flying blood to the

Pacific.

IMMEDIATE PROBLEMS IN 1940

Among the major problems to be solved when the blood and blood substitutes program was set up at the Army Medical School in the spring of 1940

were the following:

1. I-low could blood for transfusion be provided in sufficient quantities for

the large numbers of casualties to be expected in modern warfare?

2. How could blood be safely stored?

. ow could the current high incidence of transfusion reactions be

reduced?

4. What type of equi)ment could be developed to provide steri'e, pyrogenfree, easily dispensable transfusion fluids?

5. What types of blood substitutes could be provided? How could they

be stored safely? How could they be used in the field?

6. How could the medical profession, which was still, for the most part,

highly skeptical on these various points, be convinced of the safety and desirability of employing whole blood and blood substitutes in the management of

trauma?

The first step in the solution of these problems was to collect as much

information as possible on the following points:

1. The clinical use of whole blood.

2. The availability of blood plasma and its clinical use.
THE BLOOD PROGRAM 129

3. The processing of fluids for intravenous use.

4. The development, manufacture, and testing of equipment for the administration of fluids intravenously.

The literature was surveyed and analyzed, and a large collection of reprints was built up. At this time, the literature on shock was voluminous,

but the literature on plasma and other blood substitutes was rather scanty,

and contributions on liquid plasma were just beginning to appear.

Information on these subjects was also collected, by personal visits, from

the following sources:

Dr. (later Capt., MC) John Elliott, pathologist at the Cabarrus Hospital,

Salisbury, N.C., who had developed a method of processing sterile, pyrogenfree plasma in liquid form. When Dr, Elliott later entered the U.S. Army,

he was assigned to the Army Medical School, where he instructed personnel in

the processing of the liquid plasma used in Zone of Interior hospitals. He

also contributed to the development of the vacuum bottle manufactured by the

Baxter Company and used, with certain modifications, for both plasma and

whole blood during the war.

Dr. Max M. Strumia, pathologist at the Bryn Mawr Hospital, whose work

on dried plasma has already been mentioned.

Dr. John Reichel, of the Reichel Laboratories, Kimberton, Pa., who had

worked with Dr. Strumia on the development of equipment for drying plasma.

Dr. Stuart Mudd, Professor of Bacteriology, School of Medicine, University of Pennsylvania, Philadelphia, Pa., and Dr. Earl W. Flosdorf, an

experienced refrigeration engineer who had worked with Doctor Mudd as his

research uas.istant on the preparation of serum and on freezing and drying

plasma.

Information was also secured from Sharp & Dohme, a firm which had

long been interested in the preparation of antisera and other immunizing

agents. This company had done considerable work with typhoid anti other

vaccines, and, with the help of Dr. John Reichiel, had pioneered in the development of vacuum-drying equipment.

Many of the manufacturers of intravenous solutions and blood transfusion

apparatus both at this time and later worked in close cooperation with the

Blood Research Division, Army Medical School, in the development of a

closed system for the collection of blood to insure sterile, pyrogen-free storage.

When the blood program was more fully developed, all the laboratories

of the commercial pharmaceutical houses also worked in close cooperation with

each other, exchanging information and reporting problems and their solutions.

Sharp & Dohme, which held many patents on various drying processes, offered

the use of these patents without charge to the other laboratories working on

plasma for use in the Armed Forces during the war emergency.
130 ACTIVITIES OF SURGICAL CONSULTANTS

PLASMA PROGRAM

Dried Plasma

Development of the plasma program began with the distribution, for testing purposes, of dried plasma prepared in Dr. Strumia's laboratory at the Bryn

Mawr Hospital to the Army and Navy Medical Schools and to members of the

Subcommittee on Blood Substitutes, National Research Council. Blood for

this program was collected by the Southwestern Pennsylvania Chapter, American Red Cross (p. 135). The dried plasma proved both safe and effective, and

on 19 April 1941 the Subcommittee recommended that either frozen or dried

plasma be employed as a blood substitute in the treatment of shock.

This recommendation was accepted by the Armed Forces for the following reasons:

1. Supplying whole blood to the Armed Forces in the quantities likely to

be needed, together with the safe storage and transportation of the blood,

presented logistic problems of enormous proportions which could not be solved

in the light of either the knowledge possessed or the facilities available in

1940-41. Preservative solutions which would permit long storage periods were

just being developed. Investigations on thoroughly dependable, avid grouping

sera were in their early stages. The development of adequate equipment for

the collection, storage, and dispensing of whole blood was in its infancy.

Refrigeration equipment for use in the field under varying conditions of heat,

cold, and humidity had not yet been manufactured. Finally, an airlift capable

of delivering blood to the far reaches of the battlefront was still almost 3 years

away.

2. Plasma is a homologous protein fluid with the osmotic equivalent of

blood. Separated from its cellular components, it can be frozen and dried

to less than 1-percent moisture content. In this state, it can be packaged under

vacuum and preserved for years, without refrigeration and without being

affected by extremes of heat and cold.

3. Plasma can be administered without typing or cross-matching.

4. The use of plasma is attended with a very low incidence of reactions.

When it first began to be distributed commercially, each package contained a

questionnaire to be filled out and returned to the Army Medical School after

the plasma had been administered. The reports on 9,161 plasma transfusions

given in ove'sea hospitals showed only 249 pyrogenic reactions (2.7 percent)

and only 106 allergic reactions (1.2 percent). These rates corresponded with

those reported from hospitals in the Zone of Interior. All the reported reactions were mild.

5. The equipment necessary for the reconstitution and intravenous administration of dried plasma could be incorporated in a small kit, which could be

made available under almost all conditions of war.
THE BLOOD PROGRAM 131

6. The yield of plasma was greater-from 15 to 20 cc. more per pint of

blood-than the yield of serum.

7. Most important of all, in the light of the immediate needs, plasma could

be easily and safely produced commercially in large quantities.

These inherent organic characteristics of plasma, particularly the ease

with which it could be manufactured, stored, and transported, obviously made

it a practical and desirable agent. The reasons for its selection in 1941, while

not fully explaining the failure to supply whole blood to field units at this

time, did take cognizance of obstacles which went far toward discouraging

even the most ardent advocates of whole blood as a feasible replacement fluid

in Zone of Interior hospitals. These reasons were considerably more valid

in the recommendation of plasnma as a feasible and practical agent for blood

replacement in oversea hospitals.

Packaging.-As soon as the decision was made to employ dried plasma

as a blood substitute, it became necessary to standardize a method of packaging it. The Blood Research Division of the Army Medical School cooperated

with the Subcommittee on Blood Substitutes, National Research Council, and

with the National Institute of Health to devise a standard package, which

could be used by both the Army and the Navy.

The package which was eventually developed (fig. 24) contained a waterproof fiberboard box; a rubber-stoppered bottle of dried plasma, evacuated to

28 inches of vacuum, with the sterile, pyrogen-free equipment to administer it,

contained in a sealed tin can evacuated to 26 inches of vacuum; and a rubberstoppered bottle of distilled water, with the equipment necessary to combine

it with the plasmit, contained in a tin can.

After some changes in the initial specifications, this package, which was

first produced by commercial laboratories in 1941, was used with satisfaction

throughout the war.

The first packages which were put up contained 250 cc. of dried plasma,

together with the appropriate amount of diluent fluid. Late in 1943, the

amount of plasma in each package was increased to 500 cc. The change was

made for the following reasons: (1) The realizationi, gained with increasing

experience, that the average wounded man required at least 500 cc. of plasma

for resuscitation and (2) the increasing necessity for conserving scarce materials, such as rubber tubing and needles, and for utilizing scarce shipping

space to the fullest extent.

The new program created one major problem. For physical reasous,

since the speed of drying was partly a function of the surface area of plasma

exposed and the thickness of the plasma shell, it was found difficult to dry

500 cc. of plasma in a bottle not much larger than the bottle designed to contan half that amount. Within a short time, however, this problem was solved

in commercial productioil as it had been solved in the laboratory.

By the time the change in packaging was made, medical officers had fully

realized the need for larger quantities of plasma and were delighted to have
44

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THE BLOOD PROGRAM 133

Production.-In all, 10,299,470 pints of the 13,326,242 pints of blood

collected by the American Red Cross in its blood procurement program were

processed into dried plasma.21 More than 3,000,000 packages were put up

containing 250 cc. of dried plasma and more than 3,000,000 packages containing 500 cc.

Homologous serum jaundice.-In the light of the postwar incidence of

homologous serum jaundice attributable to plasma transfusions, it is important to emphasize certain facts abouc Liro wartime use of plasma. Although

plasma was used in enormous quantities for battle casualties, it was not until

late in 1945 that pooled plasma was indicted as the vehicle for the causative

agent of this disease. Numerous cases of jaundice had occurred previously in

military personnel after plasma transfusions, but the causative connection

between the jaundice and the transfusion was not immediately realized. In

retrospect, what happened is clear. A single transfusion of blood is likely to

cause jaundice in only a small percentage of the recipients. When, however,

blood is pooled, as it is when plasma is processed, the chances of contracting

jaundice are correspondingly increased. Furthermore, whereas only 8 pints

of blood were pooled in the preparation of the liquid plasma used in Zone of

Interior hospitals, amounts as large as 50 pints were pooled in the early stages

of the dried plasma program for overseas, and later, in 1944-45, even larger

amounts were frequently pooled. The relation of these various facts to the

development of jaundice is now perfectly evident, but the causal sequence was

not appreciated until the war had ended.

Liquid Plasma

One of the first projects of the Blood Research Division at the Army

Mfedical School was an investigation of the possibility of supplying liquid

plasma to hospitals in the Zone of Interior. Experience in a number of civilian hospitals had indicated that the plan could be operated successfully,

though, because of the high rate of contamination, the collection and processing of plasma in this form in the United States for the British had not

proved practical. The explanation was the unsatisfactory equipment used.

The Blood-for-Britain experience demonstrated that a completely closed, sterile system was necessary for the collection and processing of plasma, and, unfortunate though it was, it undoubtedly saved the Army program from mistakes

which otherwise certainly would have been made.

The first liquid plasma for Army use was prepared in December 1940 in

the small blood-donor center set up at the Army Medical School. An average

of 6 donors a day were secured by phoning persons whose names were provided,

in groups of 10, by the American Red Cross. The calls were made at night, and

the donors were asked to report the following day.

21 See footnote 3. p. 122.

60222v-62-11
134 ACTIVITIES OF SURGICAL CONSULTANTS

On 1 June 1941, a bleeding center was opened in Washington, D.C., as an

Army-Navy project. The American Red Cross procured the donors and operated the center with technical help furnished by the Army Medical School

and the Navy. The blood secured was divided between the Army and the

Navy, and the Army share was processed into liquid plasma at the Army Medical School. In January 1942, regular shipments of liquid plasma to a number

of Zone of Interior hospitals were begun.

The experimental program proved so successful from the outset that plans

were made to supply all Zone of Interior hospitals with liquid plasma. Several

medical officers and a number of enlisted technicians were attached to the Division of Surgical Physiology, Army Medical School, for training, and were then

sent out to establish five other centers in various parts of the country. These

centers supplied the requirements of the hospitals in adjacent service commands. In 1943, four of the six centers were converted to bleeding centers for

dried plasma and albumin, leaving the other two centers (in Washington, D.C.,

and Denver, Colo.) to collect blood and process it into liquid plasma for all

Zone of Interior hospitals.

There were no confirmed reports of the distribution of contaminated

plasma to any hospital, and the incidence of transfusion reactions was small.

Of the 310,135 blood donations delivered from bleeding centers to military

medical hospitals, 295,200 were converted to liquid plasma for utilization in the

military services in the Zone of Interior. The remainder were used for whole

blood transfusions at hospitals near the conters and for dried plasma prepared

at the Army Medical School for use by Army Air Force units in th Zone of

Interior.

Participating Agents in the Plasma Program

Commercial laboratories.--The processing of whole blood into dried

plasma for the Armed Forces was a function of the large biologic and pharmaceutical laboratories. The first contract, for 15,000 packages, was made with

Sharp & Dohme, because of the previous experience of this firm in allied fields.

The first plasma was processed commercially in February 1941, and, before the

declaration of war on 8 December 1941, three other laboratories had received

contracts. Eventually, nine laboratories were processing plasma for the Armed

Forces, as follows:

Sharp & Dohme, beginning 4 February 1941.

Eli Lilly & Co., beginning 1 October 1941.

Lederle Laboratories (Division of American Cyanamid Co.), beginning 14

October 1941.

Reichel Laboratory (later, Reichel Division of Wyeth, Inc.), beginning 18

November 1941.

Ben Venue Laboratories, beginning 10 January 1942.
THE BLOOD PROGRAM 135

Cutter Laboratories, beginning 12 January 1942.

Hyland Laboratories, beginning 13 May 1942.

Parke, Davis & Co., beginning 29 June 1942.

National Institute of Health.-The National Institute of Health exercised no control over the preparation of blood substitutes until Cohn's 2

2 fractionation of plasma proteins and the preparation of dried plasma. Up to that

time, no question of interstate commerce was involved. With these accomplishments, however, the products became biologics, over manufacture, storage, and utilization this agency had to exercise contro. Lo produce and sell

biologics, including serum, albumin, and dried plasma, a license from the National Institute of Health was required.

Close liaison was maintained by the Army and Navy throughout the war

with Dr. Milton V. Veldee, Chief, Biologics Control Laboratory, National Institute of Health. Minimum specifications were prepared for the processing

and pack.ging of plasma and the products of plasma fractionation. All modifications in both apparatus and techniques for the dried plasma program were

made only after consultation with, an I approval by, Dr. Veldee, Commander

Newhouser, and Colonel Kendrick. Representatives of the National Institute

of Health frequently visited the commercial laboratories, aiding them in the setting up of routine techniques for the preparation of dried plasma and assisting

them in the solution of special problems.

American Red Cross.-When the decision was made to use commercially

dried plasma as a blood substitute in the war emergency, the American Red

Cross was selected as the collecting agency. Several of this agency's chapters

had had some previous experience in the procurement of blood donors in cooperation with several civilian hospitals. Further experience had been gained

in the Blood-for-Britain Program conducted in New York City from August

1940 to January 1941.

The first phase of the national program to secure blood for dried plasma

was inaugurated by the Southeastern Pennsylvania Chapter in Philadelphia,

in September 1940. This chapter, as has been mentioned, procured the donors

for the study of the preparation and use of dried plasma then being conducted

by Dr. Strumia, under the auspices of the Subcommittee on Blood Substitutes,

Division of Medical Sciences, National Research Council.

The formal request that the American Red Cross undertake the responsibility of collecting blood for the dried plasma program was made on 8 January 1941 by the Surgeons General of the Army and the Navy, after extended

discussions. The program was formally inaugurated on 4 v-1,ruary 1941, in

New York City, and was continued until 15 September 1945. In all, 35 chapters participated.

The initial phases of the program were directed and supervised by Dr.

William DeKleine, Medical Director, American Red Cross. In July 1941, Dr.

2 See footnote 16, p. 124.
136 ACTIVITIES OF SURGICAL CONSULTANTS

G. Canby Robinson was appointed National Director for the American Red

Cross Blood Donor Service, and Dr. (later Major, MC) Earl S. Taylor was

appointed technical director. Major Taylor had worked in the blood bank at

Presbyterian Hospital, New York, N.Y., and therefore came to these duties

with a wide experience in the blood bank field.

The processing of donors and the collection of blood under the rigid tech.

nical controls imposed by the National Institute of Health was an operation

of real magnitude. The Red Cross accepted the responsibility of establishing

donor centers, recruiting donors, providing administrative personnel, and also

providing part of the professional personnel. Because of the immensity of

the undert4uking, however, and the military need for physicians, it eventually

became necessary for the Red Cross to ask help from tle Army and the Navy

for the operation of their 35 blood centers and their associated mobile units.

At one period of the program, the services of 127 physicians were necessary.

The 60 medical officers supplied by the Army were assigned to the Army

Medical Purchasing Office and were placed under the operational control of

the Office of the Surgeon General. They were directly supervised by Major

Taylor; for practical reasons, after he had been commissioned in the Medical

Corps, he retained his )osition in the Red Cross, so that medical officers working in the blood collection centers would be under th, supervision of a medical

officer. Essential as was the work of these centers, it was neither an interesting

nor a desirable assignment. Attempts were made to rotate the officers assigned

to the centers, but they were not particularly successful, and many of the officers remained in an assignment for 2 or more years.

During 1940 and 1941, before the entry of the United States into the war,

the response of the public to appeals for donations of blood was not encouraging. After the attack on Pearl Harbor, on 7 December 1941, the number of

donors increased sharply, and it became necessary to scledule appointments

and control the donations with due regard for the facilities available for drying

plasma; these facilities were developed as rapidly as the necessary equipment

could be provided for them.

As the wnr progressed and the numbers of casualties increased, calls for

blood donors increased correspondingly. In 1944, more than 5,000,000 pints

of blood were collected, and donations averaged 100,000 pints per week. After

blood began to be flown to the Pacific areas, in November 1944 (p. 158), appeals for donors were regulated according to the needs reported by the officer

on Guam who was in charge of the program.

National Research Counil.-On 7 January 1941, at the same time that

Maj. Gen. James C. Magee, The Surgeon General of the Army, requested the

American Red Cross to initiate a blood donor program for supplying plasma

for the Armed Forces, le addressed a letter to Dr. Lewis 11. Weed, Chairman,

Executive Committee, Division of Medical Sciences, National Research Council,

in which he requested that the Division of Medical Sciences undertake general

supervision of the professional services involved in this project. Dr. Weed
THE BLOOD PROGRAM 137

replied on 9 January 1941 that the Division of Medical Sciences would gladly

undertake the responsibility and would do everything possible to make the

cooperation effective. The Division's personnel rendered invaluable services

throughout the period of the emergency.

SERUM PROGRAM

In the early days of the Army blood program, there was considerable

discussion concerning the possible advantages of human serum over plasma.

Serum has a number of advantages, the chief advantage being that it does not

contain fibrinogen, which is easily precipitated from liquid plasma. On the

other hand, plasma, from the technical standpoint, is somewhat easier to prepare, and the yield from a given portion of blood is somewhat larger than

the yield of serum. Reports that human serum had given adverse reactions

in some instances, particularly when it was very fresh, were not confirmed in

a series of 24 cases in which it was tested clinically. The number of cases was

too small to warrant conclusions, but the satisfactory results cast considerable

doubt on the risk of reactions after its use.

As a matter of fact, the advantages of plasma and serum were admittedly

about equal, but the National Research Council chose to recommend the use of

plasma for the Armed Forces, and the Army and the Navy chose to accept the

recommendation for the practical reasons already listed (p. 130), chiefly the

geater yield 'of plasma per pint of blood and the fact that it could be produced safely and readily, in the large quantities necessary, by commercial

houses. In addition, the widest previous experience had been with plasma,

and the urgency of the situation did not permit delay for further testing before the initiation of mass production.

The results achieved by the use of plasma fully justified its selection,

though the Canadian Army, in which serum was used, had equally good

results with that blood substitute.

HUMAN SERUM ALBUMIN PROGRAM

Early discussions of the Committee on Shock and Transfusions, Division

of Medical Sciences, National Research Council, had dealt with the possible

use of both bovine and human albumin in shock. It had been hoped that

bovine albumin, which could be procured in almost unlimited quantities from

abattoirs all over the country, might prove an effective blood substitute. The

first studies were encouraging, but later investigations showed that this substance was not entirely safe for intravenous use, and its employment did not

progress beyond the experimental stage.

For a number of years before the war, Dr. Edwin J. Cohn, Professor of

Physical Chemistry at Harvard University, and his associates had been working on methods for the fractionation of plasma proteins. Early in 1911,
138 ACTIVITIES OF SURGICAL CONSULTANTS

both Cohn 2' and Janeway 2 suggested the possibility of using human serum

albumin in the treatment of shock and hypoproteinemia. After adequate testing, this substance, in contrast to the bovine product, was found to be a safe

and effective blood substitute. On 5 January 1942, the Conference on Albumin

of the National Research Council recommended to the Surgeons General of

the Army and the Navy that it be adopted for clinical use and that the Red

Cross be requested to add to its program the procurement of donors for the

processing of blood into albumin.2

The first successful use of human albumin was reported by Major Kendrick."

6 The patient, who had multiple compound fractures, was in serious

shock, with a blood pressure of 76/30, when he was admitted to Walter Reed

General Hospital in May 1941. The response to therapy was prompt, and

within a few hours reduction of all his fractures was possible. In all, albumin

was used with excellent results in 87 cases at this hospital. Other tests were

carried out at Peter Bent Brigham Hospital, Boston, Mass.; the University

of Minnesota Hospital, Minneapolis, Minn.; the Presbyterian Hospital, New

York City, N.Y.; and the U.S. Naval Medical Center, Bethesda, Md.

Albumin was dispensed in 25-percent solution in 100 cc. of distilled water.

At first, the intrinsic sodium chloride content was allowed to remain in situ.

Later, albumin wa3 dispensed salt-free. It was packaged in a glass vial, with

a rubber stopper at each end to facilitate its administration (fig. 25).

The small size of tho package in which albumin was dispensed led to its

selection by the Navy as the preferred blood substitute because of space limitations on destroyers and other small craft. Albumin was also utilized, for

the same reason, by the Marines in their isiand operations in the Pacific. The

Army continued to use the standard Army-Navy package of plasma both

because of the good results obtained with plasma and because of one of the

disadvaitages of albumin, the necessity of administering isotonic fluids with

it to dehydrated casualties.

The high concentration of albumin in the standard package made its

physiologic effect dependent upon the rapidity with which it mobilized interstitial fluid. in a well-hydrated patient, this was not problem; the circulating

blood volume was promptly increased, and the intravascular discrepancy

characteristic of shock was promptly overcome. In the dehydrated casualty,

the problem was different, and, since the majority of wounded soldiers, under

the rigorous conditions of combat, were dehydrated, the administration of

isotonic fluids along with the albumin was necessary in most cases, even though

it was not always practical.

23 See footnote 16, p. 124.

SJaueway, C. A.: NVar Medicine. with Special Emph:sis on the Use of Blood Substitutes. New

England J. Med. 225: 371- 'Sl, 4 Sept. 1941.

233Minutes, meeting of Conference on Albumin, Divi3ion of Medical Sciences, National Research

Council, 5 Jan. 1942.

3Mudd, Stuart, and Thalhimer, William. Blood Substitutes and Blood TranAfu.don. Springfield:

Charles C. Thomas, 1942, p. 200.
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140 ACTIVITIES OF SURGICAL CONSULTANTS

Another disadvantage of albumin was that its yield per pint of blood

was less than the yield of plasma; 3.2 to 4.0 pints of blood were required for

each 100 cc. of albumin, against only 2.4 pints of blood for a 500-ce. unit of

plasma.

Albumin, nonetheless, had a number of advantages, as follows:

1. It was stable in solution for protracted periods and over a wide temperature range.

2. It was therefore suitable for use in almost any part of the world in

which the Armed Forces might be called upon to operate.

3. It was ready for immediate use, without reconstitution.

4. It occupied little more than a tenth of the space occupied by the standard Army-Navy package of plasma.

5. Later, albumin was proved to be nonicterogenic. It remains stable

after heating to 600 C. (140 0F.) for 10 hours.

WHOLE BLOOD PROGRAM

Initial Obstacles

As has already been pointed out, the use of plasma as a replacement fluid

in shocked casualties was never regarded by knowledgeable authorities as

anything more than a compromise which was required by the exigencies of

the first months of the emergency. At the first meeting of the Committee on

Shock and Transfusions, National Research Council, in May 1940, the question

of the possibility or likelihood of improving present methods of preservation

of whole blood was raised, as well as the possibility of increasing the safe

period Dr. Plass stated that he had already used blood more than 30 days old

without any serious reactions, and that lie believed that it would be possible,

by varying the preservative fluid, to extend the safe period even longer.2

In the beginning, however, not a great many observers believed that the

extensive use of whole blood would be feasible in forward hospitals in wartime. Very few members of the medical profession, whether military or civilian, foresaw that a situation would arise in which the quantities of whole

blood required for the adequate treatment of battle casualties in theaters of

operations would necessitate the shipment of blood from the Zone of Interior.

Such a contingency seemed particularly unlikely after large amounts of plasma

began to be shipped to oversea forces. Experienced physicians, both civilian

and military, thought that the brevity of its useful life would make it impractical to ship blood over long distances. Finally, as has already been

mentioned, dependable air transport service, a sine qua non of a blood program

for oversea troops, was not available in 1940, when the emergency began to

develop.

- See footnote 2. p. 122.
THE BLOOD PROGRAM 141

An additional reason for skepticism about the practicality of a whole

blood program was the lack at this time of a satisfactory preservative solution

which would permit the storage of blood for more than a few days. Many

believed, in fact, that it would never be practical to store blood in any solution

for much longer periods.

Not all authorities accepted this reasoning. Even before the outbreak of

the war in 1939, as already mentioned, DeGowin and his associates had transported blood, chilled and kept cold by wet ice, in a solution of their own devising. It had been moved great distances both by land and by air, then returned

to the laboratory, checked, and finally used for clinical transfusions without

complications.

Although shipment of blood overseas was not seriously considered when

the emergency first became evident, investigations were nonetheless continued

to develop dependable typing sera, preservative solutions, blood-collecting

equipment, and refrigerated shipping containers. The result was that when

logistic support for an oversea blood program, in the form of a dependable

airlift, did become available, the procurement, safe storage, and safe transportation of blood were no longer impractical.

Early Experience in North Africa

The British, with the outbreak of war in 1939, immediately organized a

blood transfusion service, under the full-time direction of Brigadier Lionel

E. H. Whitby, RAMC. Experiences in the North African fighting demonstrated the necessity for large quantities of whole blood in the management of

wounded casualties, and a blood transfusion unit was promptly organized to

supply the British Eighth Army. Several thousand pints of blood were provided to forward hospitals from this unit in Cairo, and when the Eighth Army

moved into Italy, its hospitals continued to receive blood from North AfLica

until the transfusion unit moved to Bari, Italy.

Peports of the British experience in North Africa were made available

to the Office of the Surgeon General, U.S. Army, through Col. Frank S.

Gillespie, RAMC, British medical liaison officer, who was stationed at the

Medical Field Service School, Carlisle Barracks, Pa., during the early months

of the war. Colonel Gillespie made every effort, as the British experience

progressed, to keep The Surgeon General informed of changing concepts in

the care of battle casualties. Colonel Kendrick, The Surgeon General's special

representative for blood and transfusion, was exceptionally fortunate in having

his complete cooperation and support at a time when medical intelligence was

relatively limited.

The whole British experience in North Africa proved that plasma was

not enouh, although extremely valuable, in the provision of temporary circulatory support for patients who had suffered multiple ,xtensive wounds,

accompanied by massive hemorrhage, from mortars, high explisives, and land606222v-62-12
142 ACTIVITIES OF SURGICAL CONSULTANTS

mines. Whole blood, which had the oxygen-carrying property lacking in

plasma, was essential for the support of casualties during the period of anesthesia and initial wound surgery.

Because he had been kept so well informed on these matters by Colonel

Gillespie, Colonel Kendrick had had extended discussions on the subject of

whole blood versus plasma with personnel of the Surgical Consultants Division,

Office of the Surgeon General. He considered it essential that Col. Edward

D. Churchill, MC, who was ordered to North Africa in January 1943 to serve

as consultant in surgery, North African Theater of Operations, U.S. Army,

should have the same information before the landings which were to take

place in Italy later in 1943. The opportunity to inform him arose during his

predeparture briefing in the Office of the Surgeon General, while he was reviewing the filmstrips which had been prepared by Colonel Kendrick on first

aid in the field and on resuscitation, including the use of whole blood as well

as plasma. Colonel Churchill was also informed that one of the main functions

of the Department of Surgical Physiology, Army Medical School, was to

investigate and evaluate equipment by which blood could be collected and

shipped long distances with expedition and safety. It was suggested to him

that, upon his arrival in North Africa, he undertake a study of the whole

problem, with the twofold objective of determining (1) whether, with plasma

readily available, blood was really needed and (2) if blood was needed, how

it could best be provided.

Almost as soon as Colonel Churchill arrived in North Africa and reviewed

the situation, he concluded that there was no doubt of the need for large

quantities of blood in combat areas to treat casualties with severe wounds.

During the next several months, he wrote of this need to The Surgeon General;

Brig. Gen. Fred W. Rankin, MC, Chief Consultant in Surgery, Surgical Consultants Division; Colonel Carter; and Maj. (later Lt. Col.) Michael E. DeBakey, MC, Chief, General Surgery Branch, Surgical Consultants Division.

Establishment of transfusion unit.-Shortly after U.S. forces landed

in Italy, in September 1943, Col. (later Maj. Gen.) Joseph 1. Martin, MC,

Surgeon, Fifth U.S. Army, urged the theater Surgeon, then Brig. Gen. Frederick A. Bless6, MC, to form a transfusion unit to support Fifth U.S. Army

field and evacuation hospitals. In December 1943, Colonel Churchill delegated

Maj. (later Lt. Col.) Eugene R. Sullivan, MC, to survey blood transfusion

needs and facilities in the Army area.

Meanwhile, General Martin rtuested British assistance for the landings

planned for January 1944 in the Anzio-Nettuno area by British and United

States components of the Fifth U.S. Army. In resl)onse to this request, the

British supplied a blood transfusion unit, which was located with the field

and evacuation hospitals near Anzio. Blood was received by this unit from the

British blood transfusion unit at Foggia: a large part of the supply was collected from U.S. Army Air Forces l)ersonnel in tie Foggia area, but the work

of collecting and processing was done by British pernomnel, -ith British
THE BLOOD PROGRAM 143

equipment. U.S. hospitals in the Anzio-Nettuno area received approximately

4,000 pints of blood from this source.

In January 1944, the blood situation was reviewed in all its aspects by

General Martin; Col. Richard T. Arnest, MC, Surgeon, Peninsular Base Section; Col. Virgil H. Cornell, MC, Commanding Officer, 15th Medical General

Laboratory; and Major Sullivan, representing General Bless6. The need for

whole blood was evident, and, as a result of the meeting, plans were made for

the establishment of a blood transfusion unit to be located at the 15th Medical

General Laboratory, near Naples, Italy.8- The first blood was collected by

this unit on 23 February 1944, and between that date and 9 May 1944 approximately 4,000 pints were collected, most of which was sent to the Anzio beachhead. Even before operation of the unit had begun, it was obvious that the

original estimates for collection of an average of 100 pints of blood daily for

the use of field and evacuation hospitals were unrealistically low, and the plan

was modified to provide for the collection of 200 pints daily.

Development of Equipment and Containers

From the time of the reactivation of the Division of Surgical Physiology,

Army Medical School, in 1940, the personnel of the Division had been keenly

aware of the following facts:

1. Wounded men who had lost large quantities of blood in combat were

poor surgical risks, even though they had received plasma in large quantities.

2. They must receive whole blood in large quantities before they could

become safe risks for anesthesia and surgery.

3. A whole blood program would become practical only when an acceptable

type of transfusion equipment and satisfactory containers for transportation

had been developed.

Long before the reports of the British and U.S. experience in the North

African Theater of Operations had begun to be received in the Office of the

Surgeon General, the Division of Surgical Physiology, Army Medical School,

had been investigating the development, for use in the field, of efficient

transfusion equipment which would meet the following requirements:

1. Whole blood could be collected and stored safely only if donors were

bled by the utilization of a closed sterile system.

2. The blood must be collected in a preservative solution in which it could

be stored safely for 2 or 3 weeks.

3. The chief cause of transfusion reactions is the presence of pyrogens

in the recipient sets, usually as the result of improper cleaning. Therefore,

the only practical solution of the problem of administering blood in the field

would be the employment of an expendable transfusion set, to be used once

and then discarded. Under field conditions, the difficulties of cleaning and

" Organizational History, 1944, 6703d Blood Transfusion Unit (Overhead).
144 ACTIVITIES OF SURGICAL CONSULTANTS

preparing collecting and recipient sets would make the use of standard

equipment both impractical and unsafe.

The equipment eventually developed at the Army Medical School for the

storage of whole blood consisted of a 1-liter vacuum bottle for the preservative

solution (Alsever's solution) and an expendable recipient set consisting of

Monel-metal filters, rubber tubing, and an intravenous needle. Each package

also contained typing serum.

All equipment was packaged under sterile conditions and hermetically

sealed in an easily opened aluminum cartridge. The cartridges were packed

six to a box for export,

Deve±pment of Refrigeration

The pregram for providing whole blood for oversea use could not become

a reality until, in addition to the development of equipment for collecting and

administering the blood, means of refrigeration had been developed for its

storage and for its preservation during transportation. Work was begun as

early as 1942 on a light-weight transportable aluminum refrigerator. The

model which was eventually developed held 50 bottles of blood and could be

operated either from the usual power outlets or from the 24-volt battery

ordinarily used in transport planes.

When the need for whole blood in ETOUSA (European Theater of

Operations, U.S. Army) became urgent in August 1944, no refrigerated container for the transportation of whole blood had yet been developed, though

other organizations had been working with the Division of Surgical Physiology, Army Medical School, on a fiberboard container for this purpose. Even

had this container been ready for use when the emergency arose, it is doubtful

that it would have been used; the urgent need at that time was for transporting

as much blood as possible and utilizing all shipping space in planes for this

objective. Refrigeration was then a secondary consideration.

The first blood which was sent to Europe, in August 1944, was therefore

shipped without refrigeration. By November 1944, when the shipment of

blood to the Pacific was begun, the Navy had developed an excellent refrigerated shipping case. It was a double-walled cardboard box, insulated with 2

inches of cotton waste and with an inner and outer lining of aluminum foil.

It held 1C bottles (of 000 cc- content) in a. wire rack, in the center of which

was a large tin can which held 19 pounds of wet ice. By this device, which was

used in all shipments to the Pacific, blood could be kept at a constant

temperaturo for about 24 hours.

Work on the Army refrigerated container was completed shortly after the

Navy container became available, but it was not put into use by the Army until

April 1945. In the meantime, other expedients were employed, as necessary,

in transporting blood to Europe.
THE BLOOD PROGRAM 145

Development of Preservative Solutions

Another essential requirement for the shipping of whole blood overseas

was the development of a satisfactory preservative solution. Early in 1943,

the Army Medical School began comparative studies of various solutions and

soon arrived at the conclusion that Alsever's solution was superior to the other

solutions then available. This solution, which contains 2.05 gin. of dextrose,

0.42 gin. of sodium chloride, and 0.8 gin. of sodium citrate per 100 cc. solution,

has one great disadvantage, that it must be used in 500-cc. amounts for each

500 cc. of blood. This was a serious consideration, particularly in wounds of

the head and chest, in which overloading the circulation with excessive fluids

could be dangerous.

Otherwise, Alsever's solution had a number of advantages, which were

evident in the more than 2,000 transfusions in which it was employed at Walter

Reed General Hospital. Criteria of evaluation were (1) the amount of

supernatant hemolysis and (2) evidences of clinical improvement after transfusion. Blood collected in this solution had been shipped, unrefrigerated,

from Washington, D.C., to the west coast and back and also to Prestwick,

Scotland, and back and had been suitable for use at the end of the journeys.

It withstood the shaking, as well as the changes of temperature, incident to

transportation and storage over long periods of time under adverse conditions.

Blood collected in this solution also appeared to store well from 21 to 30

days tit 40 C. (approximately 40' F.). It could also be exposed to average room

temperature (200 C., 680 F.) for a period of hours without undergoing changes

which would make it no longer safe or useful in the treatment of hemorrhagic shock. Finally, Alsever's solution was more easily administered

through standard Army filters than was blood preserved in other solutions,

which tended to clog these filters, particularly after the blood had been stored

for more than 7 days. The explanation probably was the greater dilution

of the blood in Alsever's solution; the dilution minimized the precipitation of

fibrinogen which occurs when blood is stored in a cold environment. This

factor was of special importance in forward hospitals, in which ease of administration was essential.

On 24 September 1943, at the request of the Army and the Navy, the

Subcommittee on Blood Substitutes had recommended the use of Alsever's

solution for the preservation of blood to be stored more than 5 days. -

" This

solution was therefore employed in August 1944, when it became necessary to

fly blood to Europe, because it was the only solution immediately available

which had been tested in large numbers of cases and which had been approved

by the Subcommittee on Blood Substitutes.

Progress had been made, however, in the development of other suitable

preservative solutions, and the Loutit-Mollison, A.C.D. (acid-citrate-dextrose)

29 Minutes. meeting of the Subcommittee on Blood Substitutes, Division of Medical Sciences,

National Research Council, 24 Sept. 1943.
146 ACTIVITIES OF SURGICAL CONSULTANTS

solution seemed particularly promising. On 30 August 1944, the Subcommittee

ol Blood Substitutes recommended that Alsever's solution be replaced by the

Loutit-Mollison solution.'0 This solution, 25 cc. of which is used for each

100 cc. of blood, consists of 1.33 percent trisodium citrate, 0.47 percent citric

acid, and 3 percent dextrose; the pH is in the neighborhood of 5.0.

The recommendation of the Subcommittee was not immediately accepted

by the Army, on the ground that the A.C.D. solution had not yet been tested

in a suflicient number of cases. Moreover, some concern was felt over the

increased precipitation of fibrinogen which occurred when it was used and

which tended to plug the filters in the recipient sets. Additional studies, however, indicated that this solution preserves red blood cells somewhat better than

Alsever's solution, and, in addition, the Navy, which had used it in all the blood

flown to the Pacific, had an unbroken record of success with it. These facts,

combined with the undeniable advantage of its smaller bulk, were responsible

for the Army's changeover to this solution on 1 April 1945.

Development of Blood-Grouping Sera

Studies were also made on blood-grouping sera in the Division of Surgical

Physiology, Army Medical School, in collaboration with the Division of Chemistry. Eventually, a highly satisfactory, extremely avid serum was developed,

each lot of which, when it was manufactured commercially, was tested at the

Army Medical School before it was used.

An effective technique was also devised at the Armny Medical School for the

rapid identification of group 0 donors." This was an urgent and important

consideration, since only group 0 blood was sent overseas.

Training of Personnel

Even though blood wis not shipped overseas until the summer of 1944, all

personnel attending courses given by the staff of the Blood Research Division,

Army Medical School, had, since 1943, been trained in the collection of blood,

the preparation of equipment, and the typing and cross-matching of blood.

Related programs at the Army Medical School, such as the programs for

liquid plasma and dried plasma, afforded some training for a small number of

medical officers and enlisted technicians, who were capable of operating blood

donor centers. Similar training i as given to the oflicers assigned to the Red

Cross blood donor centers. This training included the theory and practice of

blood grouping, details of transfusion therap.), and similar matters. All

courses conducted at the school for medical oflicer , also included 10 hours'

instruction on shock and fluid-replacement therapy.

3* Report, Third Conference on Blood Storage, I)ivlsion of Medical Sciences, National Research

Council, acting for the Committee on Medical Research, Office of Scientific ItReearch and levelopment,

30 Aug. 194 .

31 Kendrick, D. B., Jr. Elliott, J., Relehel, J., Jr., and Vaubel, E. K. : Supply of Preserved Blood

to European Theater of Operations. A Preliminary Report. Boll. U.S. Army M. Dept. 84 . 6G-73,

January 1915.
THE BLOOD PROGRAM 147

All through 1943 and 1944, the Committee on Shock and Transfusions and

the Subcommittee on Blood Substitutes, National Research Council, emphasized

the need of placing trained personnel in charge of the blood program in all

phases and at all stages. After the Mediterranean and European theaters had

formed their own blood transfusion units, the Transfusion Branch, Surgical

Consultants Division, Office of the Surgeon General, and the Division of Surgical Physiology, Army Medical School, collaborated in drawing up tables of

organization and equipment for blood transfusion teams. These tables were

submitted for approval to Headquarters, Army Service Forces, late in 1944 and

were approved early in 1945.12

EVOLUTION OF THE OVERSEA BLOOD PROGRAM

Blood Banks in Oversea Theaters

The completion of the various projects just outlined made it practical in

the fall of 1943 to draw up a plan for the establishment of blood banks and

the development of transfusion services in oversea theaters. There were now

available, as the result of the joint activities of the Division of Surgical Physiology, Army Medical School, and the Subcommittee on Blood Substitutes,

National Research Council, the following items: (1) An expendable transfusion

set, (2) a satisfactory preservative solution, (3) a refrigerator for the storage

of blood for as long as 21 days, and (4) satisfactory grouping sera. The safety

and efficiency of all of these items had been thoroughly tested, which made it

feasible to propose that this equipment be sent to oversea theaters and that

the theaters be authorized to train their own personnel in the collection and

distribution of blood to all forward and fixed hospitals. The proposed system,

on the most ex cting analysis, seemed almost foolproof. In particular, it disposed of the chief cause of anxiety in transfusion, the rei.se of equipment, a

practice which inevitably increases the incidence of pyrogenic reactions under

circumstances of warfare.

On 5 October 1943, Colonel Kendrick addressed a memorandum to Colonel

Carter on the subject of transfusions in theaters of operations. The plan proposed in this memorandum, which provided for the use of whole blood in

general, evacuation, and field hospitals in theaters of operations, was based on

the fundamental concept that the handling and use of whole blood and other

replacement fluids is a specialized branch of medicine and that to collect blood,

to group it correctly, and to transport and preserve it safely requires the services of specially trained personnel. These functions cannot be delegated to

untrained personnel because any slip, however trivial, in the collection, processing, and use of whole blood may result in severe and even fatal reactions, in

addition to unnecessary and sometimes excessive losses of a scarce and valuable

substance.

32 War Department Table of Organization and Equipment No. 8-500, 18 Jan. 1945.
148 ACTIVITIES OF SURGICAL CONSULTANTS

A memorandum for The Surgeon General, incorporating the essentials

of this plan, was prepared the following month by General R~ankin 1

3 and was

hand carried to The Surgeon General by Colonel Carter and Colonel Kendrick.

The plan was rejected on the following grounds:

1. Plasma was regarded as adequate for the resuscitation of wounded

men.

2. It was considered impractical, from a logistic standpoint, to make locally

collected blood available farther forward than general hospitals in the communications zone.

3. Shipping space was too scarce to warrant using it to send disposable

transfusion equipment overseas.

In the light of these facts, it was The Surgeon General's decision that the

provision and use of blood in oversea theaters should be limited to the instructions set forth in Circular Letter No. 108.1 This letter outlined the techniques

to be followed in the transfusion of fresh whole blood in general hospitals

in oversea theaters within 4 hours after it had been collected. It also provided for the transfusion of stored blood, to be collected by a closed system

and to be used within 7 hours after its collection.

The plan which had been proposed to The Surgeon General and had been

rejected was presented to the Subcommittee on Blood Substitutes by Colonel

Kendrick at the meeting on 17 November 1943.15 After the matter had been

thoroughly discussed from the standpoint of its practical implications, the

following motion was moved and passed:

RESOLVED: That the Subcommittee on Blood Substitutes recommend through channels that the Surgeon General of the Army give consideration to the transportation of

whole blood by airplane to certain theaters of operations. '

Although a satisfactory airlift was available when this plan was presented

to The Surgeon General, the proposal was rejected, principally, again, on the

grounds that (1) plasma was adequate for resuscitation of battle casualties and

(2) flying blood overseas was not practical.

Although personnel in charge of the blood program were not in agreement with The Surgeon General's decision, they had no choice but to accept

it. The basic reason for The Surgeon General's refusal to consider the proposed program was undoubtedly that he shared the still rather general opinion

33 Memorandum, Brig. Gen. F. W. Rankin for The Surgeon General, 6 Nov. 1943, subject: Trans.

fusion of Whole Blood In the Theaters of Operations.

" Circular Letter No. 108, Office of the Surgeon General, U.S. Army, 27 May 1943, subject: Transfusion of Whole Blood in the Theaters of Operations.

33 At the meeting of the Subcommittee on Blood Substitutes on 24 September 1943. everyone who

had been present at the meeting of the Committee on Shock and Transfusion held on 3 November 1941

agreed that it had been the consensus of the group that the Armed Forces should use whole blood in

the treatment of shock whenever possible. The discussion had been omitted, unfortunately, from the

minutes of the meeting, and it wvas suggested that the minutes be corrected to conform with the facts.

3 Minuteg, meeting of the Subcommittee on Blood Substitutes, Division of Medical Sciences, National Research Council, acting for the Committee on Medical Research, Office of Scientific Research

and Development, 17 Nov. 1943.
THE BLOOD PROGRAM 149

that plasma was a satisfactory agent of resuscitation and that the use of whole

blood in large amounts in battle casualties was not necessary. Undoubtedly

also, he had been directed by higher authority to limit the amount of medical

supplies shipped overseas. It therefore seems reasonable to assume that, since

he shared the general belief that plasma was adequate for resuscitation, he

did not consider that supplying transfusion equipment in order to liberalize

the use of whole blood was sufficiently important either to substitute the equipment for other supplies and thus keep within the allowable tonnage, or to

point out to the Commanding General, Army Service Forces, under whom

his office operated, the urgency of making an exception in order to supply whole

blood for wounded men.

Provision of Blood From Zone of Interior for European Theater

Early in 1943, Brig. Gen. ..-ter Maj. Gen.) Paul R. Hawley, MC, Chief

Surgeon, ETOUSA, had directed that provision be made for supplying whole

blood to combat casualties. Plans for obtaining the blood and flying it from

the United Kingdom Base after D-day had been completed by 31 May 1944.31

The operation was conducted with great efficiency by Maj. (later Lt. Col.)

Robert C. Hardin, MC, Senior Consultant in Shock and Transfusion, and Lt.

Col. (later Col.) James B. Mason, MC, Chief, Operations Division, Office of

the Chief Surgeon, ETOUSA.'8

As early as April 1944, those responsible for the provision of blood for

the European theater had given urgent thought to the acquisition of type 0

whole blood from the Zone of Interior. Even before D-day, it had become evident that a sufficient supply of blood for the estimated combat casualties could

not otherwise be provided, and urgent requests had been made for blood to be

sent from the Zone of Interior to the European theater. After D-day, these

requests increased in urgency as it became more and more evident that using

troops in the United Kingdom Base, as donors was completely impractical to

supply the amount of blood needed for the adequate treatment of thousands

of casualties with multiple wounds.

Blood from the United Kingdom Base was in reasonably adequate supply

from D-day until just before the operations in the Saint-L5 area which culminated in the breakthroug0h on 18-19 July 1944. Then it became a critical item

of supply. It actually had to be rationed and allotted to the areas in which

the greatest number of casualties were anticipated. The daily demand for

blood had risen steadily and by the first of August was between 1,000 and

1,500 pints.

On 3 August 1944, a radio request was received by The Surgeon General

from General Hawley asking for one thousand 500-cc. units of whole blood

per day for the European theater. On 13 August 1944, with General Hawley's

37Mason, J. B Planning for the ETO Blood Bank. MU. Surgeon 102:460-468. June 1948.

3s Mason, J B The Role of the ADSEC in the Suppli of Whole Blood to the Twelfth Army Group.

MB. Surgeon 103: 9-14. July 1948.
150 ACTIVITIES OF SURGICAL CONSULTANTS

approval, Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in

Surgery, Office of the Chief Surgeon, ETOUSA, flew to the United States,

accompanied by Major Hardin, to request The Surgeon General to supply

generous quantities of whole blood to the troops in Europe by an airlift from

the Zone of Interior. In their presentation, these officers made it perfectly

clear that, unless blood could be made available in quantities far beyond the

amounts which could possibly be provided overseas, wounded men with multiple wounds would receive less than optimum treatment and some of them

would certainly die.

The plan for an airlift of blood to Europe which had originally been

proposed in November 1943 and which had not then been found acceptable

was modified in certain details, to meet the exigencies of the present situation,39 and was again presented to The Surgeon General. It was approved

at once.

Colonel Cutler and Major Hardin made their request for an airlift of blood

to Europe on 17 August 1944. Four days later, on 21 August, the first shipment was flown from the Zone of Interior to Prestwick, Scotland. It was transshipped to Salisbury, England, the base of the ETOUSA Blood Bank, and

thence was flown to France. On 28 August, Colonel Kendrick left the Zone

of Interior with a large shipment of blood. His request for orders for oversea travel had been justified by the reasoning that it was simply not possible

to put a system, however good it might be, on paper and expect it to work of

itself. When blood was the substance to be transported, it was considered

essential to follow it up, to see that it was properly handled at every point

along the way, and also to see that it was properly used.

Critique of Results

From 6 June to 20 August 1944, all the blood used in all ETOUSA hospitals on the Continent was collected in England and flown across the Channel

(fig. 26). Of the 385,231 pints of whole blood handled by the ETOUSA

Blood Bank between 22 May 1944 and 24 May 1945, 197,712 pints (51.3 percent) were flown from the United States. 0

The ability to provide blood in such quantities so promptly when the need

in the European theater became imperative was the end result of the previous

activities of many persons and organizations, as follows:

1. By this time (August 1944), the American Red Cross had 35 bleeding centers in operation throughout the country. The Red Cross program was

well controlled by the appropriate committees of the .National Research Coun-

" Memorandum, Brig. Gen. F. W. Rankin for The Surgeon General, 3 Aug. 1944, subject: Provisions for Supplying Whole Blood to ETO From U.S.A.

,o See footnote 38, p. 149.
THE BLOOD PROGRAM 151

cil, and cooperation between the Council and Army and Navy personnel

working on the blood program was invariably excellent.

2. All the equipment needed was ready, and ready in sufficient quantities.

The Army and Navy personnel working on the blood program had for many

years worked closely with the manufacturers of transfusion equipment, and,

when the urgency of the situation was made known to these firms, they provided promptly all the help and cooperation required.

3. A satisfactory preservative was available (p. 145). Alsever's solution

had the disadvantage of bulk, and it is regrettable that the Loutit-Mollison

(A.C.D.) solution, which had the advantage of less bulk and which was found

later to be just as efficient, was not sanctioned earlier by the Subcommittee on

Blood Substitutes, Division of Medical Sciences, National Research Council,

and was not accepted earlier by the Army when it was later recommended by

the Subcommittee. Alsever's solution, however, filled the initial needs of the

situation admirably.

4. Although a satisfactory refrigerated shipping case was not available

when blood was first flown overseas to Europe, Alsever's solution permitted a

15-day storage period, and there was no spoilage because of this lack. The

shipment of 500 bottles which Colonel Kendrick took over on his flight was

checked at intervals, and the temperature in the pasteboard containers did not

vary more than 60 F. (3.30 C.) in the approximately 12 hours which it took

to cross the ocean from New York to Prestwick, Scotland. The aircraft flew at

an altitude of from 8,000 to 10,000 feet, and it was cool all the way. Fortunately, fall was near when the demand for blood became urgent, and, before the

need ceased, in May 1945, a refrigerated case was in use and the change had been

made from Alsever's to the Loutit-Mollison solution.

5. Although the training of personnel in the Zone of Interior had never

been formalized, informal training had been provided, as far as this was

possible, by those in charge of the blood program. It had always been recognized that blood would eventually be flown overseas and that it must be handled

all along the way by specially trained personnel and not in routine medical

supply channels.

In addition to the personnel trained for direction of the centers in which

blood was collected for liquid plasma (p. 134), the officers in the courses at the

Army Medical School since 1943 had been instructed in resuscitation in all of

its aspects and had also been taught to realize the importance of special

handling of blood even though they did not, themselves, know the precise

details. Trained personnel were already available in the European theater, and

in the Mediterranean theater, although the latter theater never received blood

from the Zone of Interior.

6. Finally, an efficient airlift was available. From the geographic standpoint, the Red Cross bleeding center in New York was most suitable for the
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THE BLOOD PROGRAM 155

OVERSEA TRANSFUSION SERVICES

The European Theater of Operations

After he had arrived in the European theater late in August 1944, Colonel

Kendrick spent the next 2 months in England and on the Continent including

Italy.,"

Information on developments in the use of whole blood had been sent to

the Office of the Chief Surgeon, ETOUSA, by means of copies of the monthly

Essential Technical Medical Data reports from other theaters and through

other sources. In addition, Colonel Sullivan and Major McGraw, from the

Mediterranean theater, had visited the European theater before D-day and

had reported on the operation of the blood bank in the Mediterranean theater,

which had been an active theater of operations for 21/2 years before D-day

in Europe.

It is important to realize that the military situation in the two theaters was

entirely different and that the medical situation differed accordingly. In the

Mediterranean theater, a single army was operating on a single land mass,

within a relatively limited area. Although serious transportation problems

existed in the Mediterranean theater, blood did not have to be flown across

water. Blood was necessarily flown from England to the Continent, which

meant that, in bad weathe tilood could be transported to the European

theater. This was an extre, -ous matter in the European theater, for the

always limited supply of blood did not permit storage in any significant

amounts.

There were also other differences. In Italy, medical control could be

uniform; there was one army and one army surgeon. In the European theater,

several armies were operating, and each army surgeon, like each army commander, had his own concepts of how to care for patients. The use of blood

was only one of many therapeutic methods in which medical personnel, inexperienced in the treatment of combat casualties, required careful indoctrination and instruction. The First and Third U.S. Armies had been in combat

only a relatively short time when blood began to be supplied to them in

liberal quantities. The Third U.S. Army, in fact, had been operational for

less than 3 weeks. In either Army, there had been no chance to set up research teams and little time for operating surgeons to grasp the urgent need

for the use of whole blood in liberal amounts.

The transfusion service in operation when Colonel Kendrick arrived

in the European theater showed how excellent such a service could be,

even without support from the Zone of Interior, when it was under the

control of a competent medical officer who used all the resources available to

41 Report, Lt. Col. Douglas B. Kendrick, I'rofeosional Service Di% ision, Office of the Chief Surgeon,

to Chief Surgeon, ETOUSA, 26 Sept. 1944, subject: Report of Trip to Firbt and Third Army Medical

Installations.
lii'i ~ ~ i*II~ ~ ~ he A01111. i i 1 i 11i111 e r fi i oi sii li It e iilfiil 10s11 lit i e' eli.,. ghit

I~~~~~~ e ,ii.e ikI* i ee Ieei I Iie it I It lia i. ie I ~I r f ).:11 i 1 I e Ie-' u ii'

whi' es ~ (f1,1V ~ ~ .jeer* 11:11 ite i. I I~ m I Ie II Ituil. I;e'~ I'k' i ite h er il l ii Iuleieuet1

K r~e'I I r i i I a 4iI I hIeI i I 1(,;i'l I C'w: -'eII 1,(1111 I de 1 i Ii .l.-1'a'e hI 1411 1 WIIt I

it of I'I I iI I % a f1 4 e, 1'*- huat~ ,' jI IiI I - iit 1 ie. % ivit'u. ;t l or ' iet. i ' i I,, li

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14, 1I Ai Ii I, ier II i 1 :1 11111i e ,eri ii' hI_'ae' 

ee~iel. i lei t : I Ii sI 1i:es 111i I :1eest - it- lie i If;I l'i'.g I 1i,11ItI 0 ti.

e'lififL- :ssI i':I e it-h lI's, Iiiil hiIil i .(rt I 9.f F/.~, I 111 1s .1 i t 10-4

Bet Tvalabl Copf
THE BLOOD PROGRAM 157

A highly efficient blood bank had been developed. 4- Blood was obtained

from volunteer donors who, it was certain, would not go into combat within a

specified period of time. By the expedient of paying each donor $10 per pint,

all the blood needed could be secured. A C-47 plane, which had been made

available to the 15th Medical General Laboratory, flew the blood to designated

centers, whence it was delivered to forward areas by truck and ambulance.

Delivery was often an achievement of considerable magnitude, in view of the

frequently unfavorable flying weather and the bad roads constantly crowded

with military transport. The blood, however, always got through.

This theater, in 1943, had set up a board for the study of the physiologic

effects of wounds,"' and the interest of the board members and others in the

whole question of shock and resuscitation, including posttransfusion anuria,

had created a great interest in replacement fluids in all field and evacuation

hospitals and had served as a real stimulus to the effective use of whole blood.

In the Mediterranean theater, therefore, Colonel Kendrick's function was

chiefly to listen and learn. He frequently regretted that circumstances had

not permitted him to visit this theater before he visited the European theater.

He brought back many valuable ideas to the Zone of Interior not only about the

use of whole blood but also about the cardinal principles of resuscitation, including such details as the maintenance of an adequate airway and aspiration

of pneumothoraxes to restore normal respiratory physiology and improve

respiratory exchange by injections of procaine hydrochloride to control pain

in patients with fractured ribs.

PROVISION OF BLOOD FROM ZONE OF INTERIOR TO PACIFIC

AREAS

Because of the close liaison maintained between Commander Newhouser

of the U.S. Navy and Colonel Kendrick, it was logical that when the former

was sent to the Far East in June 1944 to survey the situation in respect to

the distribution and correct use of albumin, Colonel Kendrick should have

been given orders to accompany him, to study the distribution and use of

plasma, as well as the provisions for whole blood.

The Situation in June 1944

Supplies of plasma in the Pacific had been adequate for a long time. Albumin, which was just beginning to arrive in June 19-44, was never widely

used in Army medical installations.

In SWPA (Southwest Pacific Area), blood had been provided up to this

time from three sources as follows:

1. It was collected locally in each installation, as the need for it arose.

'2 See footnote 28. p. 143

(' Medical Department, United States Arin,. Surgery in World War II. '1 he Phbiologic Effects

of Wound,. Waslington : U.S. Go% ernment Printing Office. 1952,
160 c~liiei - ACTIVITE FSRIA OSLAI

of4,tChie Surgeon, USASOS, SWPA; and a number of others whohad a

specialmiterestimtheuse of whole blood. By apresentation of allthe deills

of the ,prgraim, ,olonel Kendrick Was able t show theseofficers tat 4ey,

coud hve lltheblod teyneeded, sterile, safely refrigerted, and delivered

according to their requests, ifthey merely made the requests,

. .the month Colonel Kendrick spent with-the Sixth U.S. Army,

was st4gng for the Luzon- operation, he worked out a whole-blood.progrm

forthisinvasion and arranged for the delivery of:blood from Ouam acco!rding,

te timatedneeds from D.day onward. From the standpoint ofthe ,ue of

whole bloq, the Lyte operation could have been more efficiently hadled.

The~oration: on Xuzon was well handled. -from, this standpoint oneofho

-chiq reaons being that Colonel Kendrickhad been ableto locate on it . .. iti . pathologist-and fine medicalofficer, Capt; Henning H. Thor -, MC,

'ho,- Vith -totaly'inadequate souirc6si,4ad ,done his, bstto supply the; Sixkh,, U.S. ,Army need frwoebodWhen-Cap tain Thorpe cae into thePro.

'graffii-most' of the operational difficulties had bien cleared away,

TheLuion_ campaign was Athefst -in, the Pacific ,in which whole-:bbA

W' w-gisbien to nearly all casualties with moderate andWsevere wounds, regardso whether, or nt they wvere n shook when they wee received4 il

anevacuation ... hospitals, After this operation, itto k little Weffort to.convince

Sixth :U.S. Army medical officers, both at headquarters, and in the ,field,, 'f i:"'" • " .vtlue of~the o °d prograim. : : :

The Okinawa Operation

When Colonel Kendrick returned to Hawaii after his tour- in the' Suflir

west Picific, which had included several days of conferences with Lieutnant.

Bownh on Guam, he was relieved of his responsibilities for the blood progc-am in the Pacific and was never replaced. He was assigned to command

aTenth U.S. Army field hospital, which was designated to land on Okinawa,

on.D60. Before Colonel Kendrick could report to this hospital, Col..Frederic B. Westervelt, MC, Surgeon, Tenth U.S. Army, assigned him to .his

headquarters as consultant on blood and shock for the Okinawa operation,

for Which this army was then staging. In this capacity, Colonel Kendrick

was able to see that the ships which went to Okinawa from Saipan were loaded

With all the blood likely to be needed for the first days of the operation.

On the first days after the landings, Colonel Kendrick, accompanied by

Col. George G. Finney, MC, Consultant in Surgery, Office of the Surgeon,

Tenth U.S. Army, Lt. Col. (later Col.) Harold A. Sofield, MC, and Col. Walter B. Martin, MC, made daily trips ashore for indoctrination purposes.

During this period, and for the first few days after the Tenth U.S. Army went

ashore, the circumstances were peculiarly propitious for this purpose. The

Japanese had retreated south as the landings had been made, and it was a

week before real resistance was encountered. During this interval, it was
'TIM BLOOD:'PROGRA

A..... tag along,,the way was, the blood ever touched by any but trained, ' specahie& rsonneli, whose assignments were, peranent. In the Pacific,f

- fact, loowas consistentlv handled by what, amounted to special w dehvery

service, 0ich is the only sale and proper way to handleit. It isjimportat

;tEO' mp siUe, h6weverthat the,'highly efkcien t blood _service in the.Pacfir.

haditie'rts.-in, the ,experience~gained in th~ ZoeofItriheM ier r- + er 'theater,-and the :European theater afterj4 yearsof warfare.

: The t blood for fle Pacific areas left the Zone: of Interior on, 2

em rnbe -944and was-sent to Leyte via Guam. Colonel Kendrick reached . Hawai ofu25 November and wei to Leyte, also ViaGuam, tiseuss the who i .

V rblof the use and supply + of blood ' with Lieutenant Brown and With

oikrs -edi in te oc , Gn, d, Guy et , f rg

USAOS(U.. rmySevies of Supy)SWA

The Leyte and' Luzon Oetins

Thefirst blood shipped from Le tpGuamo te p .vie aperfect illustra-..

tion of what can happen to thisprecious commodity when once it leavesth 6

care of pe 'onnel specially trained to -handle it. When this blood which hd

6ii. so carefully protected all, the way from the.Zone, of Interior, reached,

eyte it--iteft the hands of trained personnel. It was at once takenout of the+

figerate containers in which it ha been received, thrown into trucks a d'

transp1rted over a 4- or 5-hour period, to the medical installations which had

reqeStedit, At this season, I.eyte was a placein which bit was possible tohave,

mud oiithe shoes and dust in the eyes atthe same time, The temperature was

0 -. , i the shade, and the humidity was extieme, The casual treatment of

the ,uader mblod these circumstances rendered it entirely unusable, and- the

carefully Worked out program was in a fair way to being wrecked.

'In November 1944, there were no personnel in the Pacific theaters with

the respnsibility of receiving and supervising the handling and distributioin

ofbl6d, or with the authority to undertake these tasks. More important.

there was no general recognition of the importance of the liberal use of blood

in 'battle casualties. Colonel Kendrick's task of indoctrination was not,

particularly, easy. He had to convince the medical officers of an army which

had been fighting effectively for se'veral years that the blood program had a

great deal to offer them. He also had to convince the medical officers of an

army which had never had enough of anything that they could have all the

blood they needed and wanted merely by asking for it. It was fortunate that

he had visited the Mediterranean and European theaters before he went to the

Pacific, for he was able to bear eyewitness testimony to the feasibility and usefulness of the plan he was advocating.

Through the wholehearted and efficient cooperation of Maj. (later Lt.

Col.) Frank Glenn, MC, Consultant in Surgery, Office of the Surgeon, Sixth

U.S. Army, a meeting was arranged with the senior medical officer of the Navy

in the area; reprisentatives of the Surgeon, Sixth U.S. Army; representatives
160 ACTIVITIES OF SURGICAL CONSULTANTS

of the Chief Surgeon, USASOS, SWPA; and a number of others who had a

spcial interest in the use of whole blood. By a presentation of all the details

0f the program, Colonel Kendrick was able to show these officers that they

could haVe all the blood they needed, sterile, safely refrigerated, and delivered

according to their requests, if they merely made the requests.

In the month Colonel Kendrick spent with the Sixth U.S. Army, which

was staging for the Luzon operation, he worked out a whole-blood program

for this invasion and arranged for the delivery of blood from Guam according

to estimated needs from D-day onward. From the standpoint of the use of

whole blood, the Leyte operation could have been more efficiently handled;

The operation on Luzon was well handled from this standpoint, one of the

chief reasons being that Colonel Kendrick had been able to locate, on Leyte,

a trained pathologist and fine medical officer, Capt. Henning H. Thorpe, MC,

who, with totally inadequate sources, had done his best to supply the Sixth

U.S. Army needs for whole blood. When Captain Thorpe came into the program, most of the operational difficulties had been cleared away.

The Luzon campaign was the first in the Pacific in which whole blood

was given to nearly all casualties with moderate and severe wounds, regardless of whether or not they were in shock when they were received in field

and evacuation hospitals. After this operation, it took little effort to convince

Sixth U.S. Army medical officers, both at headquarters and in the field, of

the value of the blood program.

The Okinawa Operation

When Colonel Kendrick returned to Hawaii after his tour in the Southwest Pacific, which had included several days of conferences with Lieutenant

Brown on Guam, he was relieved of his responsibilities for the blood program in the Pacific and was never replaced. He was assigned to command

a Tenth U.S. Army field hospital, which was designated to land on Okinawa

on D+60. Before Colonel Kendrick could report to this hospital, Col. Frederic B. Westervelt, MC, Surgeon, Tenth U.S. Army, assigned him to his

headquarters as consultant on blood and shock for the Okinawa operation,

for which this army was then staging. In this capacity, Colonel Kendrick

was able to see that the ships which went to Okinawa from Saipan were loaded

with all the blood likely to be needed for the first days of the operation.

On the first days after the landings, Colonel Kendrick, accompanied by

Col. George G. Finney, MC, Consultant in Surgery, Office of the Surgeon,

Tenth U.S. Army, Lt. Col. (later Col.) Harold A. Sofield, MC, and Col. Walter B. Martin, MC, made daily trips ashore for indoctrination purposes.

During this period, and for the first few days after the Tenth U.S. Army went

ashore, the circumstances were peculiarly propitious for this purpose. The

Japanese had retreated south as the landings had been made, and it was a

week before real resistance was encountered. During this interval, it was
T4HE9BLOOD' PROGRAM 161

therefoe -possible for these 6fficers to visit every field and evacuation hospi lt ashb6, Whether Army or Navy, and to pass on to the-hospital stars

all6the indrmantion in their possession, includingthe information Colonel

Kenidrick had secured in the Mediterranean and; European theaters, aboti

the coireet use of whole blood for battle casualties. When the hard fighting

started, the medical officers responsible for the care of battle casualties were

well trained, and the ratio of blood units used to casualties was 1 : 1 (40,000

casualties, 40,000 pints of blood used). At this time, in Europe, the ratio

was 0.9 ! 1.

After the development of the blood program and indoctrination in resuscitation on Okinawa, Colonel Kendrick assumed command of the 31st Field

Hospital, where observation of the approximately 10,000 casualties who

passed through it gave him an excellent opportunity to study in detail the

use of blood at this level.

Critique of Results

The experience in the Pacific demonstrated the following facts:

1. It is perfectly practical to collect blood in the Zone of Interior and

deliver it to a theater far removed from the mainland, It was not unusual

for blood to be collected in the United States, sometimes in cities as far inland

as Chicago, and to be used in places as remote from the point of collection as

Okinawa within 6 days after it had been collected.

2. A theater transfusion officer with his staff, attached to the office of

the theater surgeon and given the proper authority and resources, can keep

a combat force adequately supplied with blood.

3. The resources made available to this officer must, however, include

all the staff, personnel, and equipment necessary to collect, process, and deliver

whole blood to any medical installation in the theater.

4. In dealing with a commodity such as blood, which has only a brief

life and which is easily contaminated and rendered not only useless but harmful, handling and distribution must be the responsibility of medical officers

and other personnel trained in this particular specialty. Blood cannot be

handled either efficiently or safely through conventional supply channels.

PLANNING FOR THE INVASION OF JAPAN

Just before the end of the campaign on Okinawa, at the suggestion of

Col. I. Ridgeway Trimble, MC, Consultant in Surgery, Office of the Chief

Surgeon, SWPA, General Denit invited Colonel Kendrick to Manila to

develop the planning for the blood program for the invasion of Japan

(Operation OLYMPIC). There was sufficient time to send the plans to the

Office of the Surgeon General, so that Major McGraw, then serving as representative on blood and transfusion, could comment on them in the light

of his experiences in the Mediterranean theater. It was interesting that
162 ACTIVITIES OF SURGICAL -CONSULTANTS

even at this late date, while Sixth U.S. Army medical personnel attached to

the'Chief Surgeon's office fully recognized the urgent need for whOle bld,

they were still doubtful that all thatwas regarded as necessary for the invasion

of Japan could be supplied,

After the program to supply blood from the mainland had once been

instituted, there was never a shortage of blood in the Pacific Ocean areas.

At times, when the weather was bad and supplies for only 24 hours were on

hand, some concern was felt, but, as in the European theater, the blood never

failed to arrive when and where it was needed. Had Operation OLYMPIC

*come to pass and had the estimated five or six hundred thousand casualties

occurred, there seems little doubt that sufficient supplies of blood could again

have been provided for all their needs.

Bibliography

Kendrick, D. B.: Prevention and Treatment of Shock in the Combat Zone. Mil. Surgeon 88: 97-113, February 1941, and Army M. Bull. 58: 88-60, October 1941.

_: Procurement and Use of Blood Substitutes in the Army. Ann. Surg. 115: 1152-

1159, June 1942.

-- : The Prevention and Treatment of Shock During Surgical Procedures. Mil. Surgeon 92: 247-253, March 1943.

-- : Refrigeration Applications for Blood Plasma and Biologicals. Refrigeration

Engineering 47: 33-39, January 1944.

-- : The Use of Plasma, Whole Blood and Human Serum Albumin by the Armed

Forces. J. Internat. Coll. Surgeons 7: 289-295, July-August 1944.

, and Newhouser, L. R.: Human Plasma and Serum. Army M. Bull. 58: 61-71,

October 1941.

-, and -: Blood and Plasma Transfusions in the Armed Services. Army M.

Bull. 60: 41-62, January 1942.

, and -: Blood Substitutes in the Military Service. Ml. Surgeon 90: 306-315,

March 1942.

, and -: The Problems Confronting the Armed Services Concerning the Use

of Blood Substitutes. In Mudd, Stuart, and Thalhimer, William: Blood Substitutes

and Blood Transfusion. Springfield: Charles C Thomas, 1942, p. 200.

-. , and -: Blood Substitutes in the Military Service, War Medicine, a Symposium. New York: Philosophical Library, 1942.

, and Relchel, J., Jr.: Practical Approach to Treatment of Shock. Anesthesiology 4: 497-507, September 1943.

-, -, and McGraw, J. J.: Human Serum Albumin Concentrated; Clinical Indications and Dosage. Army M. Bull. 68: 107-112, July 1943.

, and Uihleln, A.: Shock in Controlled and Splenectomized Animals Under Ether

and Pentobarbital Sodium Anesthesia. Surgery 12: 76-80, July 1942.

McGraw, J. J., Jr., Vaubel, E. K., Relchel, J., Jr., and Elliott, J.: Complications of Blood

Transfusion. S. Clin. North America 25: 1042-1056, October 1945.

Miller, E. B., and Tsdall, L. H.: Reactions to 10,000 Pooled Liquid Human Plasma

Transfusions. J.A.M.A. 128: 863-867, July 1945.

Moloney, W. C.: The Rh Factor and Blood Transfusion; Observations on a Group of

Rh-Negative Individuals Transfused With Rh-Positive Blood. Brit. M.J. 2: 916-918,

29 Dec. 1945.

-, Lonnergan, L. R., and McClintock, J. K.: Syncope in Blood Donors. New England J. Med. 234: 114-118,24 Jan. 1946.
TH BL6OD 4RGA 6

NeWhoser; Lt "I., anidKeudick, P. B.: Huffiani Plasma. and, Serum: Developmeit, ad,*

and : Us .NM.Bl. 69656-4i4 October19.41

-, Bl~d ubsituesTher Dveopmenit and- Use in the Armed Service U a.MBul 0I-8Jtiary, I~4

and -- :the Use'of. Blood Substitutes by the Armed Forces, M. Ann. Disticqt

ofClWbA 11: 12-15i Januhary 1942.

iliemer, L.: 'The Separation and Concentration of the Isohemagglutinins From Humanv

Seru0s. JSIleice 9k: 7-,15'Jan., 1943

-- Oncley, IJ L., Melln, M., Elliott, J., and Hutchinson,-M. C.:,The Separation and

dofceniiw ofUoemagj~tlnnsFrom Group-Specific Human Plasma. J. Ciin.,

Striuia Newouer, L, R., Kendrick, D. B., and McGraw, J. J.: Development of

'Eqfilpmebnt 'for Administration of Dried Plasma in the Armed Forces, War Med.,

2:410-418, January 1942.
SurgicealConsulat in the Service Co-tmands

006222-2--13
CHAPTER VII

First Service Command

Condict W. Cutler, Jr., M.D.

Consultation service in surgery began in the First Service Command

upon appointment of Lt. Col, (later Col.) Condict W. Cutler, Jr., MC, as consultantif general surgery in December 1943. Colonel Cutler reached his staPior., Bost6nh, Mass., on 12 December. A few days earlier Maj. (later Lt. Col.)

Wilfred Bloomberg, MC, had been assigned as neuropsychiatry consultant, and

shortly afterward Lt. Col. (later Col.) George P. 'Denny, MC, arrived to become the service command medical consultant. It was immediately necessary

to establish a plan of procedure with the service command surgeon and the

headquarters staff as to the consultants' duties and the methods of carrying

them out. It was decided first to begin an evaluation of professional personnel.

This function of professional evaluation continued throughout to be a

major activity of the surgical consultant. Repeated visits, questioning, and

observation served to correct impressions of the qualifications of professional

personnel. The classification of medical officers became a formal process on

a national standard in June 1944.1 It remained the function of the consultant

to verify the correctness of the military occupational specialty numbers assigned to individual officers.

In initiating visits to installations, the service command surgeon proposed

that visits by the consultants be made in a group. The consultants felt that

separate visits would not impose inconvenience on the staffs of the hospitals,

since their activities would involve different services. It was recognized also

that the needs of hospitals for visits by the consultants would differ considerably and that the arrangement of team visits would result in unnecessary visits

by certain consultants. They were agreed that visits by consultants should be

arranged individually and that each, with the approval of the service command

surgeon, should work out his own schedule according to his best judgment.

Subsequent events proved the correctness of this attitude. When visits

were undertak,-n as a team, virtually all work at a hospital was temporarily

interrupted. The length of time required by the three consultants for the

completion of their work differed considerably. After several team visits

had been made, the plan of combined visits was abandoned.

The surgical consultant pr-pared an outline on the purpose of consultant

visits which included the following points:

1. Observing (1) the care and handling of patients, (2) the adequacy,

maintenance, and condition of medical facilities and equipment, (3) the proWar Department Circular No. 232. 10 June 1944.

167
'168 ACTIVITIES OF SURGICAL. CoNsuTAitS

f :sonal abilities of medical officers, (4) the extent of employment of medlcai -6ifi e to the. best advantage, (5) the maintenance of standards, ethics, 4erapyl, and educational activities, (6) the, status of ,cooperation, leadership, end.

irale, (7) the, degree of efficiency in records maintenance,,and (8), the dgree

o ef idiency in the movemeht of patients to final disposition.

-2. Makifig recommendations at the installation for the improvement -o

any, condition which might require only local action.

3. Determining personal problems, aspirations, and attitudes of medical '

4. Consulting with the professional staff on. technical problems,

5. Promoting educational activities by (1) bedside discussion of cases,

(2) arranging staff meetings, conferences, et cetera, (3) arranging graduate

imedical meetings and programs, (4) encouraging medical officers to ,prsue

candidacy for specialty board certification and professional societies, (5) 'giying talks, lectures, or demonstrations, and (6) encouraging clinical research,

6 Rendering reports on the above matters.

There was a tendency at first on the part of hospital commanders to rfer'.

to consultant visits as inspections and to expect investigation, criticism, and

a formal report. Every method was employed to have it understood thatthe

purpose of the consultant's visit was purely professional and that it was intended to be constructive and profitable. Very shortly, the feeling of apprehension was overcome and the visits were thereafter welcomed.

in addition to the regular visits, hospital officials were given to understand

that the surgical consultant would at all times be at the call of hospitals for

aid in clinical problems. It was agreed that the chiefs of service in hospitals

should have free access by phone or letter to the surgical consultant for personal

discussion of professional problems. This arrangement contributed greatly to

the effectiveness of the consultant's services.

It was believed desirable to cffect a close cooperation with the personnel

officer in the office of the service command surgeon. It was necessary that

the consultants be consistently informed of changes and transfers of personnel

and that serious consideration be given to their recommendations. An effective

working agreement was established with the personnel officer. The necessity

for this arrangement was shown by the need for numerous adjustments of the

staffs of various hospitals to accommodate for shortages created by transfer

of officers for ovemea assignments. It was necessary also that the personnel

officer be aware of the identity of key medical officers and that he reruest replacements should they be reassigned. He was guided largely by the consultant

as to the professional acceptability of replacements and as to their placement.

There was at first a tendency on the part of hospital commanders to assume

that the assi, nment of professional personnel to positions of relati, importance on the s cgical staffs should correspond with their relative ranks. This

policy would not have led to maximum efficiency since there were instances

in which the degree of professional competency was not consistent with 'mili-
triyr&ak. Eventually, theprinciple Was establishedthat assignients as chiefs

of s~' ~&r2 chiefs',ofsectioi 'would be governed by prof6sional capadity. -Tlfidperiititted the plaicement ofthbemost able meninpositions-of.professional-

-contrlwith men of ess COmpetence,.even though of higher rank, under their

sp visioit

AS,4 exigencies of the military situation required the withdrawal of

s r~ge o ioversea service, it was the practice of the 0fce of, the Surgeon

Gineiilt..ffi replacements. The policy of permitting the Zone of Interior

est bliShiridnt's to absorb the timelag involved frequently produced trouble;

§som6 shortages of personnel. This lag was not infrequently as 1ong as from;

60 6 90 days and required local adjustments of personnel. When general shortages xisted, as was the case with orthopedists and eye, nose, and throat

specialists, tich adjustments were not readily effected.

Toaid:'in the work of Lovell General Hospital, Fort Devens, Mass., when

medicalfficer shortages existed, it was customary to utilize officers of the

Medical'Department Replacement Pool1 0 iovell. This aid would have been

of gea4t assistance at other hospitals could these officers have been, assignable

on, temporary duty to them. Authority thus to utilize their services was

lacking. Recently commissioned officers assigned on an intern basis, howlever, proved very helpful as ward officers.

Another personnel difficulty arose from the transfer of trained enlisted

teclnicians for oversea assignments. The necessity for constantly retraining

replacements to take the places of well-trained orderlies, operating-room assistants, and other technicians imposed a serious handicap on surgical activities

at hospitals.

The surgical consultant visited all hospitals as frequently as possible. In

1944, the consultant made 42 regular visits to 18 hospitals and numerous spedial visits in response to calls. Numerous special visits were also made in

company with The Surgeon General, specialist military consultants, and civilian consultants.

On regular visits, special inquiries were made, as directed by Brig. Gen.

Fred W. Rankin, Director, Surgical Consultants Division, Office of the Surgeon General, on the treatment of hernia, pilonidal disease, skin-grafting,

and varicose veins, and also on the furnishing of eyeglasses, surplu instruments, anesthesia and anesthetics, the use of tourniquets, and other matters.

On 12 June 1944, as a check on the surgical services, Colonel Cutler sent

a letter to all chiefs of services through their hospital commanders. This

letter began: "In expectation of increasing activity in the Hospitals of this

Command, it is desirable that the following matters concerning each Surgical

Service should be examined at the present time and corrective measures taken

wherever appropriate." The letter detailed requirements and standards with

resi)ect to: (1) Personnel, including officers, nurses, physiotherapists, corpsmen, and technicians; (S) equipment and supplies, such as instruments, sterilizers, and central supply; (3) operating room, including physical equipment,
170 ,-: ACTIVitIES OF SURGICAi CONSULTAnTS

manargement, aeptic and operative technique, anesthesia, and pos tbperaive

,cae 0of.patients; '(4) ward, services, comprising arrangement, supp!iidi, instr,-

omentsanhd-dressings, aid dressiiig anidtreatment technique ;4and (5) :4apuat ry

service., The letteralso concerned X-ray, physiotterapy, .. conditining,. and

staffactivities, including ward rounds, conferences, reviews of curren li ta

ture, Investigation and -reparation of original material, and the ppogres of 

individual staff 'members toward licensured by the American College bfitStir

4gi0sndthe variousbfards.

During July 1944,,the consultant surveyed activities in anesthesia tlrdugh,

out-the copmmand and reported the results to General Rankin.

Other activities of the surgical consultant consisted of giving -talks id'

demonstrations, participating in clinics and conferences, assisting in the P1igram-of the Committee for War-Time Graduate Medical:Meetifgs, and acting

,asonsultant in reconditioning activities. Reports on his activities we r"egularly rendered to the service command' surgeon, to General Rankin, and,

inore formally as indicated, to The Surgeon General. These reports .riovidedthe material from which much of the narrative to follow was obtaiied,

MEDICAL INSTALLATIONS AND FACILITIES

During the latter part of December 1943 and the first part of January

1944, Colonel Cutler made a complete round of visits to hospitals of the 'coin-

-mand. At this time, the medical treatment facilities of the First SeiVice

Command were dispensaries; stat-rin hospitals of the harbor defenses, ports

of embarkation, training camps and cunters, and airfields; and general

hospitals.

Dispensaries were located at service command headquarters and Fort

Banks for the Boston area, at Watertown Arsenal, Mass., at Springfield Armory, Mass., at various institutions of learning where there were training cadres

and military students, and in certain separate battalions. At each of the

dispensaries, there were officers capable of administering minor surgical treat.

ments and of determining cases requiring hospitalization. Until the close

of war, changing conditions affected these facilities very little. They continued to serve the outpatient needs of their areas.

The station hospitals of the various harbor defense posts of the Eastern

Defense Command were important factors at the beginning of 1944. The

harbor defenses were maintained at nearly full authorized strength and required full manning of their station hospitals. In addition to their normal

duties, these hospitals made examinations for induction, cared for certain

dependents, and treated casuals taken ill or injured in the neighboring areas.

Most of these station hospitals were housed in permanent brick buildings on

the old posts, and many of them maintained subsidiary hospitals, as well as

dispensaries, at outlying posts.
'FIRST :SERVICE COMMAND .171: "

Typical of thesehospitals wasthe station, hospltai at Fort Bank&, This

hospit"alire66ived patient from the Harbor tDefenses of Boston andialso seived

as the adnfittini hospital for all military personnel'in the area'of:metropolitan.

Boston; In, 14, it -treated 570 Opatients, 'In January., of 194 'Its rated,

:Capacity was 205 beds. There was considerable crowdiiig, and it was necessaxy

to use.uxiiiary wards. The staff of Fort Banks Station, Hospital controlled

medicalfreatment fadilitier ot Fort.Stiong, where the facility, was then being

operated ox dispensary basis; Fort Warren, which had a 25-bed station hospital; and ,Fort Ruckman, Fort Dawes, Fort Revere, Fort Heath, Fort Duvall,

and Fort Standish, all six of which had facilities operated on a dispensary

basis. Fort Andrews had a 75-bed permanent hospital building. The forts

weresubposts 0fFort Banks.

The oother harbor defense station hospitals were the station hospital at

Fort H. G. Wright, located on Fisher's Island, N.Y., and serving the Harbor

Defenses of Long Island Sound; the one at Fort Adams, Newport, R.I., serving the Harbor Defenses of N arragansett Bay; the one at Fort Rodman, serving the Harbor Defenses of New Bedford, Mass.; the station hospital at Camp

Langdon near Portsmouth, N.H.; and that at Fort Williams, serving the

Harbor Defenses of Portland, Maine.

At the time of the earlier visits, these installations were quite active and,

because of the number of troops in the harbor defenses, it was necessary to

maintain an adequate and competent surgical staff in each. During the succeeding year, however, there was a steady withdrawal of personnel from these

stations. This permitted a considerable reduction of the surgical staffs and

the release of officers for assigmnents overseas. The policy was then adopted

of reducing to dispensary status the number of outlying station hospitals in

the various harbor defense posts and concentrating the resulting excess medical officers in major station hospitals. With the opening of Waltham Regional

Hospital, Waltham, Iass., on 1 February 1944, the hospital at Fort Banks was

reduced to a dispensary status. At each of the retained station hospitals, it

was necessary to keep a surgical staff competent in diagnosis and lrepared to

perform emergency operations and elective procedures of a nonformidable

nature. The surgical staffs of the harbor defense hospitals maintained an

excellent record of efficiency.

At Camp Myles Standish, Mass., the P wxas maintained an active station

hospital under the authority of the Bosb.,a Port of Embarkation. This hospital served a staging camp during a period of troop movements overseas. The

census at the camp varied greatly between 5,000 and 30,000 troops. Patients

from among these personnel in transit were, for the most part, suffering from

training injuries and emergency ailments. During the early part of 1944, there

were many patients suffering from chronic disabilities which made them unfit

for oversea service. To remedy this situation, efforts were made to have the

responsibility for the discovery of such conditions fixed definitely at the stations of origin. In the latter months of 1944, patients taken from shipments
4, ACTIViTIES OF SURIOi, CoNSWL0TA S

because of hernia pilonidal iease, internal- derangements of the knee, and'

otherchronccondtipprc k f h -i yesse ed.

As the shipeni of s61dii F overseas diminished, there -was a c6nsistoiit

dcrease li the activity 6f this hoital. Accordingly, on,25 ,tanuar i 4,te;

hospital at Camp Myles Standish was designateda .debarkation hospta to

r'pla cethe hospital at Camp Edwards, Mass. It contihued to serve for tihe

reception, temporay hospitalization, sorting and redeployment of -patients:

r ttfrnedfromo versea hospitals.

At the inception of the consultation service, 1arge station hospitals vwere

ihaintained at C411p Edwards an&FortDevens., Although both of these amps

bed passed the peak of their training, activity, the hospitals, were still fairly

active and maintained full surgical staffs. The station hospital at Fort Devens

aind a i;550- bd, capacity, and on the occasion of the surgical consultnnt'

4firs visit there were 589 patients. The hospital at Camp Edwards .d; 4

patients at this time, ofwhom 394 were surgical. The latter also hospitalized

patients of the East Coast Processing Centeri Camp Edwards,

The census at Edwards and Devens, fluctuated considerably with a general

trend, downward, This permitted a reduction in the surgical staffs-and the

release of personnel for oversea service. On 15 July 1944, the station hospital

at 'Fort Deves was assimilated a a part of Lovell General Hospital., Some

of the surgical staff of this station hospital joined Lovell, and others were used

to augment the staff of the recently opened Waltham Regional Hospital.

On 24 July 1944, the station hospital at Camp Edwards was designated

as a debarkation hospital. The hospital continued to serve in this capacity

until 25 January 1945 when the debarkation function was taken over by the

hospital at Camp Myles Standish. Camp Edwards Station Hospital wasthen

redesignated as the U.S. Army General Hospital, Camp Edwards. Later, a

hospital center was activated at Camp Edwards to administer the general hospital and the Camp Edwards Convalescent Hospital.

It was part of Colonel Cutler's earlier duties to visit hospitals at Army

airfields. At the beginning of 1944, there were four airfields of the Air Transport Command three of which were located at Presque Isle, Houlton, and

Bangor, Maine. The fourth was Grenier Field, Manchester, N.H. Hospitals

of the First Air Force were at Bradley Field, Conn., and Westover Field, Mass.

The functions of these hospitals were similar to those of the station hospitals

of the ASF (Army Service Forces). They were prepared to deal quickly with

severe casualties in considerable numbers resulting from a plane crash. There

was set up in each an emergency room equipped with all needed instruments,

dressings, splints, medication, laboratory apparatus, and plasma. Considerable

ingenuity was employed in perfecting these arrangements and in the preparation of "crash bags" for use in the field.

A station hospital was also maintained at the Army Air Forces Technical

School, New Haven, Conn. Most of the patients were students in training

- General Orders No. 124, fleadqaarter., First Service Command, 11 July 1944.
FIRST SERVICI OMM~f AND 1783<

courses-at' Ya6 UniVei.ity and casuals in the New, Haven area. In January194, the h6pia W 1td, ( 

C,onsult~ti~fiecite was 'pibVidedto hese Air, Force iistallations ufil

the Fin.iW :Fordd called for itsdiscontinuance. In, May 1945, this servic&: wasresumed on .an invitational basi§. In afl-respects, except reporting, the

servicedended to,.these hospitals was of precisely the bame character as that

accdidedto hospitals of the Army Service-Forces. Tntitations to the consult: antsht, ,isit.the installa4tions ind requests foremergency consultation were

'freque ti ntsfr 6 ay 1945 and were promptly responded to. The closest liaison,

'Vfs mainiained with the Westover Regional Hospital at Westover Fieldi.

hiicope6 7alls, Mass. This hospital maintained an efficient staff and fun,-

On,.2T Jun6 1944, Waltham Regional Hospital was opened. It was de'!

signed toacept patients from all the outlying station hospitals. As tiereceiviiig hosp al~f6r the Boston metropolitan area, it took over. the functions of the

statidn.hbspital at Fort Banks. In addition, it hospitalized casuals-in the area

and'depen4dnts, The staff, strengthened by personnel transferred from the

former Fort banks and Fort Devens Station Hospitals, was organized as for a

general hospital and dealt with all types of emergency and elective surgery.

Until the opening of Waltham Regional Hospital, Lovell General Hospital received all cases of major surgery occurring in the command, together

W itli a few casualties from overseas. In February 1944, Lovell General Hospital-of wooden barracks construction-had 400 patients on the surgical

services. Its staff, under Maj. (later Lt. Col.) Clifford H. Keene, MC, was of

a high order of competence. There were sections of general surgery, orthopedic

surgery, neurosurgery, urological surgery, and an active ear, nose, and throat

service. Subsequently, neurosurgical and plastic work, as well as ophthalmologic surgery cases, were transferred to Cushing General Hospital, Framingham, Mass. Lovell continued throughout the war as a general hospital and

received increasing numbers of oversea casualties. Oin 15 July 1944, Lovell

General Hospital absorbed the Fort Devens Station Hospital. This additional

capacity was quickly utilized, and at the close of the war Lovell General Hospital was operating with full wards.

Cushing General Hospital had not opened at the time of Colonel Cutler's

arrival. Its staff, however, had bec:i gathered and was being trained. On

25 January 1944, this hospital opened formally with Maj. (later Lt. Col.)

Robert L. Mason, MCA, as chief of surgery. At first, it received mostly cases

originating within the Service Command. When oversea casualties began

to be received in increasing numbers in the summer of 1944, the Zone of

Interior patients were diverted to Waltham Regional Hospital. The accession of patients at Cushing General Hospital became more rapid with the

designation of this hospital as a neurosurgical center and, subsequently, as

a center for plastic surgery and ophthalmology.' Its bed capacity was

2 War Department Circular No. 347, 25 Aug. 1944.

600222- 02-14
'1IC ACTIVIiEOFSRIACNUTAT

eyentually, expanded to ;i168, And it was -iapily filled and remaiedS tis a

EARLY CLINICAL PROBLEMS

Before the arrival of the consultant in surgery, each hospital, commander'

determined the type of surgery whi ch his staff was capable of perf6fhiiig.

'Qcsoi nally, there were 'being undertaken at station hospitals formidabl6

and, 'elective operations on the intestinal tract and kidneys and orthope-dic"

proedui'es such as-bone grafting of fractures and the surgical care of int6onal

deanige6ments of thoqknee

.On 10 January 1944, War Department Circular No. 12 defined the ~po9T,

of the War Department as to the transfer of patients to general hospiti.

The circular stated that elective surgery of a formidable typeig normIlly A

function of geperal hospitals and that patients requiring such operations

o-ldbe transferred to the nearest general hospital as soon astrans0rtaible.

This changed the surgical services of the station hospitals considerably, There

was. at first some resentment on the part of'fle station hospital personnel at

being deprived of valuable clinical material, but it soon came to be understood, that the policy worked to the best ifiterest of the patients.

The provisions of this circular necessitated some fead jistment of surgical

personnel. It became possible to strengthen considerably the surgical' staffS

of general hospitals by the transfer of competent surgeons from station

hospitals as more and more of the general hospital surgeons were withdrawn

by the requirements of oversea service. Besides, the policy assured the patients

of more skillful management of their formidable surgical conditions, while

it by no means deprived the station hospitals of a considerable numbei' of

problems with which their surgeons were qualified to deal.

The performance of operations for hernia in station hospitals was by no

means uniform. One of the early activities of the surgical consultant was

an effort to standardize the perfornance of this operatioi. as outlined by the

Office of the Surgeon General.'

The provisions of Circular Letter No. 72, Omnce of the Surgeon General,

dated 17 March 1943, in regard to the treatment of varicose veins were also

emphasized. A more judicious use of the methods of diagnosis and of treatment by ligation and injection was undertaken.

The provisions of Circular Letter No. 169, that patients with uninfected

pilonidal cysts and sinuses .bhoull be operated upon, whenever possible, before

infection occurred, lind resulted in a considerable number of these operations.

Almost universally, operatio., rc ulted in late healing and considerable loss

of time and manpower3 Colone' Cutler surveyed this situation and analyzed

594 operations. The average len th of hospitalization was 53 days. Primary

4 Circular Letter No. 121. Office of the Surgeon General. U.S. Army. 13 July 1943.

ZCircular Letter No. 109. Office of the Surgeon General. U.S. Arrmy, 2. Sept. 1943.
Jnion'hitd faild- in '23 **rent of cases in Which complete closuire' wias done,

The ~f~loingstaefien m~ made, b&~ onef Cutlor-in a Ie' to ene a]1

Rkn daed'2ilteb itay1944

Thave,,bn- greatly, aurprised, o observe the 'lage incidence of this, condition, amlong:

our. iorogps. L-beiev that-the fufidimeiiti Congenital defect Is a commuon one, but, ~onW'In ~ir insancs is t te sou'rce-of oufficient 'inconvenience to the civlianpatit

to bu-sek Ik 8rgial elif. infction of the sins. with' abscess, formation requires drafnan*ge. tepeated episodei 6f this sort lea& to an extirpation of the source of troub.

Hene~1 cvillie, hesurgeon, sees only those cases which Are conmlcte'~ trouble.

'some.,

Alkthough. theb less cleanly life of combat tioopA may lead to -a.-lArger -incidec -of, infe6ted' cases;, 1 hae 'no' doubt -that a great majority. Would gothroiih -A militarj

experience with little more tiouble Than is enooutiuered-in. civl life.

The extirpationl of all' 'discoverable plonldal sinuses In' -the, Army represents, a.

policY of 'perfectioni pbeeilcial results of which are outweighed by ' loss of manpower. ihbf. yvlitions in tecbniu I m ake relatively little- differetie Inin hetln euliedfor'hel ~, WhchInmost instances, is' nordinately long-often, thirty to ninety days. I ;advlm Aalit the tigbt-closure procedure. I feel sure ttwe shall see a, good many.

recurrences.. Even at this relatively early date,. a number have been seen.

i'kbeieve that pilonidal Aifius which, does not produce active symptoms should, be0

ketaloh. 'Infection should be dealt with by incision and, drainage. One or, more repet- tin fInfecti6n should requ ire the excision of th siiiiis witl,at most, uueo h

ikin: to he presAcral'fascia without attempt at side-to-side closuire. I believe6 such 'a

jIocy Would c~rtAIniy save a vast number of days of hospitaliation.

On 2"Se6pfember 1944, Wall epartment Technicall Bulletin (TB MED)

89 appeatred,, rescinding The Surgeon General's Circular Letter No. 169 ahd

,statin&, * true pilonidal cyst and sinus without purulent discharge,

infection or history of acute abscess or inifainmatioii will not be considered'

disqualifying for continued general military service, provided the condition

does hot interfere with the performance of the individual's duties in his

military occupation specialty. Operation will not be performed in these cases,

except as indicated in cases of infected cysts and sinuses."

Among the early clinical problems was that of persistent urethritis, both

specific and nonspecific. There were many cases of gonorrheal urethritis

which had proven resistant to sulfonamide therapy. Penicillin had not as yet

come into general use for this condition. Some sulfa-resistant Cases were being

treated with fever therapy. While it appeared in some instances to be6

beneficial, fever therapy was decidedly unpopular with the victims and led

to many problems of discipline. The procedure was also attended by some

danger. The greater efficacy, speed, and safety of penicillin therapy proved

a valuable change.

In the handling of nonspecific urethritis, penicillin proved less successful.

There was a different method of treatment in almost every hospital visited.

All of these measures seemed to be equally ineffective.

Three common types of injury occurred as a result of training activities or

sports. They were sprained ankles, fractures of the carpal navicular bone, and

internal derangements of the knee.
476O ACTIVITIES OF'SURGICA mzONAN

S -prainedankles were the, most common ivjury The orthopedists *erel about equally divided as to the relative efici~cy of (1)' rest withimiiza~i$ti m

for .a -shor time followed "by walking with 'supporting strapping, or (2).

kati ent by procainie hydrochloride (Novocain) injection and Tl .u

ported use at once. The popularity of the, latter treatmeit .aned in iavor

of -treatment by rest and support which came to be generally aeadopted

Carpal navicular fractures Were more-common than Colles' fi'actures; No doubt a good mait of these were missed and masqueraded as sprainsg:f the

wrist. A number were picked up when,.on direction of the consultantit becAju tho-rule to make -four, X-ray, exposures of, every injured -wrist -antebdposition, lateral aniid tw oblique. Prolonged immobilization in tie position of,

Jiunc tion produced almost-uniformly excellent results.,

Traumatic internal derangements of the knee, especially injuries oftthe

seinilunar fibrocartilages, were also encountered with some frequency. Thi6

pojioy of placing these cases in general hospitals was productive of better ie.

sults. A factor in earlier recoveries was preoperative quadriceps exercise and

its early resumptioil after operation.

One training hazard was a directed exercise in which a soldier, seatedon

the shoulders of a companion, wrestled with another, sinilarly mounted. This

maneuver resulted in three fractured femurs within a 2-week period, and its

discontinuance was recommended by the consultant. At about this time, injuries from supervised athletics and physical training exceeded 14 percent of

all injuries from military accidents.,

As combat casualties began to appear at Lovell General Hospital, very

satisfactory work had already been begun in the treatment of injuries of the

soft parts and of the intestinal tract. There was still an inclination to treat

compound fractures of long bones by the closed-plaster method or with dressings through windowed casts. The importance of knee mobilization and of

the quadriceps exercises was not yet fully understood. Progress in the institution of skeletal traction was rapidly made, and special attention was given to

the piogram for the activation of joints.

DEVELOPMENT OF THE GENERAL HOSPITALS

Lovell General Hospital

The gradually increasing influx of surgical patients from oversea theaters

required the gradual expansion of Lovell General Hospital and its eventual

absorption of Fort Devens Station Hospital. In February 1944 there were

only 400 surgical beds occupied by patients at Lovell General Hospital, and by

the end of August 1945 there were over 2,600 surgical patients. In August

1944, a reconditioning center at Fort Devens becine a function of Lovell General Hospital and was designated Lovell East.

6 Monthly Progress Report. Army Service Forces, War Department, 31 Jan. 1945, Section 16.

Safety.
I!RST SER ICEOCOMMANDAdditi lal medical ,oficers werbrequired for the expanded istitution,and,

it was necessy Tro to e repliteements ior, many of the staff transf erred over,

sdegs The ch1ief of surgery, Cokeim& ,.~~~nferdn~,.o.Rap

Y F oviersMC ieplaced him. The chief of orth.pedics, the chief, of urology,

andi tecief o,6 f eye service were also lost and, replacea; gs welt fis. numerous

assistant chiefs of Sections and junior members of the:staft; In. spite of 4hese

changes, the piofessional efiiency ,'l-i maintained-at albigh level.

At!hsiiggestioi of the surge ,1 coinsultnt, asurgical olinicalconference

-was held at, Lvell General/Hospitalon 30March 1944. To this wereinvited..

She personne6lf Army an dNavy hospitals and a niimber of civilian-,doctors

6vef 400 oii4is and doctors attended, as didthe serVice command surgeon and

t comiandihg general. The staff conducted fiounds and demionstrations,.

There was afn exhibit, of clinical material which included bone grafting, a.

de-m6ntrtff!Gnof penicillin therapy,,the use of tantalum, and the prductionof

i ithetib dental appliankes, Pipers.and cases were presented. This confersence wasbf gieat value in establishing a pleasant liaison among neighboring

hospitals, Vitl the Navy, and' with the civilian p'ofession. If-served to. unite

the meim isof ti surgical services in a cominoh effort.

Lovell' Gehieral Hospital joined Cushing General Hospital and the medical,

sefvic of t First NavalDistrict in presenting an exhibit on military surgery

at the meeting. of the Massachusetts Medical Society-on 23 and,24 May of the

samey year.

Cushing General Hospital

At Cushing General Hospital, growth of the surgical service developed particularly in the sections in neurosurgery, plastic surgery, and ophthalmology, foi which specialties it was designated by the War Department as a

specihl treatment facility.' The reception of patients within these special fields

r qiiired the maintenance of a general surgical service of modest proportions

and an orthopedic section of considerable magnitude, since most of the patients

presented concurrent orthopedic problems. Fractures and osteomyelitis were

common in the neurosurgical patients. Many patients presented problems of

plastic, orthopedic, and neurological surgery combined.

Since these patients required the attention of more than one section, the

surgical consultant suggested the arrangement of a system of regular intersectional conferences. By this means, a complete therapeutic program was laid

out for each patient. Progress of patients was noted and transfers were arranged as necessary between the sections. This system was put into effect while

there were still but few patients in the hospital. Its value became apparent

as the hospital filled, and it proved an effective means of managing the interrelated problems of the various sections.

There tended to be an overlapping of the activities of the section of neurosurgery and the neurological section of the medical service. A plan was proWar Department circular No. 347, 25 Aug. 1944.
a8, ACT IVITIES OF SURGICAL, CONSULTANTSV,

posed .an, adopted on 18 August 1944 which provided that the neurological sect ion of tliemed catls rivice and the neurosurgical sedtionof the surgialservice

oWQrk it€oncert. Free consultations were; arraiiged:betw en nthe zedicalneuroblgiSt and the neurosurgeon for the evaluation, treatment, and distributionof,

cases. The .neurosurgical patients were thenceforward admitted to theiieuro;

logical section of thenmedical service, wlere diagnosisw as accomplished. SurgicAlpatients were then transferred to the neurosurgical section for operation

And:iminediate aftercare and were transferred once more. to, theneurologicla

section for further treatment. This plan permitted! the medical neurolo ical'

sectionii to perform its functions of investigation, appraisal, and treatment,:

meanwhile. relieving the neurosurgical section of this burden. This,system

workedto the satisfaction of all concerned. This plan, successfully instituted,

at Cushing General Hospital and communicated to General Rankin by:Coloel:

Cutler, became one of three plans authorized for the management of neurosu'- r

gical cases as set forth in a letter from Brig. Gen. Raymond W. Bliss on:25

J'aiuary 1945 to the Surgeon, First Service Command.

Provision was made for the specific care of spinal cord injuries. A special

ward had been set up for their accommodation, with a special program of

restoration of nutrition, care of infected bladders and bedsores, and for thle

beginning of rehabilitation. By November of 1944, this ward was in full operation with 26 patients, and by September 1945 there were 88 paraplegic , cases.

Messing facilities, gymnasium, physiotherapy room, recreation room, and wards

sufficient to accommodate ;l of the paraplegic patients were established in a

separate group of buildings.

The plastic section was opened on 23 September 1944 by the transfer of

personnel and some equipment from Bushnell General Hospital, Brigham City,

Utah. Before this arrival, there had appeared on the neurosurgical section an

increasing number of injuries and deformities of the hand. Because of the

special nature of these injuries, and because of the need of many of them for

plastic procedures, the surgical consultant recommended that such cases be

cared for as a special group with ward space allotted to them specifically under

the plastic section. In early October 1944, the hand cases were placed in charge

of a special officer- orking in this section. He received consultation advice and

assistance in operating, as required, from the chief of neurosurgery, the chief

of orthopedics, the chief of plastic surgery, aid the surgical consultant. At the

close of hostilities, there were 150 patients in the subsection for hand surgery.

In early December 1944, Dr. Sterling Bunnell, Civilian Consultant to The

Surgeon General for Hand Surgery, spent 5 days at the hospital evaluating

patients, operating, and instructing officers in charge of the hand section.

The author suggested to The Surgeon General that all hand cases requiring formidable surgical reparative procedures be congregated in special hospitals. On 21 December 1944, a letter was received from The Surgeon General

informing Colonel Cutler that all reconstruction hand cases would in the
FIRST SEUIOE COMMAND' 0 179

qfrtrb6,sebt t0 plastic centers. Tlis ,proVision undoubtedly orked to the

'greatbehefit of patienit suffer ing. fi'm if~nd injuries.

,Cusling, Generaliospital w as alsp designaie&as a- center r ophthail-m

ogybyAwa iDopartment Circulari o.,817, 25August 1944; necesstating ssignment :f .traine& Iophthalmologists. Its activities at first were confined to

'ophthalmio procedu es, in association 'the plaSti Sectiof In Novembe Ii

1944, there were but 24 patients in-the opbthalmology section. Eight moniths

iater, its patients numbered i0', and the program for the production of acrylic

eyes waswell underway. By the end of the warthe ophthalmology section

had 140patients. Colonel.Mason continued as chief of surgery until May 1945, being replaced &by : ot Horatio Rogers, MC. While anumber of the junior officers were.

released'for oversea assignment, the chiefs of sections remained. This perlpittedth6 maintenance of a closely integrated service such as is reqpired-by A,

multiple s§ecialty center.

Camp Edwards -General Hospital

The hospital at Camp Edwards served as a station hospital until 24 July

1944. On that date it became a debarkation hospital and, until its designation

as a general ospital, its staff was busied with the reception, evaluation, treatment, sorting, and reshipment of all patients arriving at the port of Boston;

Th'I's change of function from a station hospital to a debarkation hospital required readjustment of the staff, rearrangement of the surgical' service for its

new duties, and certain changes in personnel. Doctors to travel on hospital

trains to various parts of the country were furnished from the staff of the Camp

Edwards Debarkation Hospital. During its active period, the debarkation

'hospital at Edwards was handling between three and five thousand patients

per month.

When the debarkation activities were taken over by the hospital at Camp

Myles Standish, it was necessary rather rapidly to readjust Edwards to fulfill

the functions of a general hospital. Major changes of plan and personnel were

required. During the period of change, there were three changes in the chief

of surgical service, Lt. Col. William A. Mahoney, MC, was succeeded by

Maj. Joy K. Donaldson, MC, who was succeeded in turn by Col. Edwin F.

Cave, MC. The chiefs of orthopedic section and of general surgery were also

changed twice during this period. By early September 1945, the hospital, at

3,200-bed capacity, was caring for 1,158 patients on its surgical services.

DEBARKATION ACTIVITIES

At Camp Edwards, the large station hospital designated on 24 July 1944

as a debarkation hospital was eminently suited to the purpose by reason of its

accessibility to the port or Boston. To it were brought frequent shipments of

oversea casualties, numbering from 200 to 500 at a time. Hospital trains
180: ACTIY&IES OF SURGICAL, CONSULTANTS"

*bo'ghtpatients fromiiship to ward in about,4'hours. When hospital carsiwere

uedi.th6&Phcie t of patients on the train coiuld' be quite rap iand "com-,

-ioft-ib1J ,ffeded' 'Whe iInn leeper madeup te tra t snesay

tio'remove windoWs t permitthlie loadiigofthe stretchers. This slowed dowm

:tti 16ading: considertbly and pisented great difficulty-in the handlingof

Patints-ii-; body casts aiid spicas. The personnelof the ,port-of! deba kation:

ieq i red considerable skill and effidiencyin the-inov~ment'of patients inispiteI.

Aftthe Camp dwards end, unloading platforms Were provided and:the.

- de Wad arehouses, now-empty ,were u, d for the reception of patents Prls-.

oiier'of war fronthe stokade at Camp Edwards were-effectively empoyed:

The first shipment of wounded arrived on 27 July, 1944, These consisted"

of wounded German prisoners recently evacuated from the battles of NorMandy. 'There were 297, of whom 168 were litter patients., Many ha'd- had no

Changes of dressing since the initial debridement. Most of them had 'been.

wounded about 2 weeks before their shipment, The procedure followed was

typial of that followed in subsequent shipments.

RoUnds had been made by surgeons on the train en route from the port,,

and the patients had received food. They were taken by ambulances to the

hospital, about a mile distant, and Were moved to their beds. Each ward was

occupied half by litter patients and half by ambulant patients. The ambulant

patients aided with the care and feeding of those confined to bed. The

patients were bathed and furnished fresh bedwear, and temperatures were

taken. Ward officers inspected each patient, and the chief of surgery then visited those who required attention.

After a night's rest for the patients, complete rounds were made. Wounds

were inspected and cleansed. Fresh dressings were applied. Casts were inspected and removed from patients with elevation of temperature. Casts were

also removed whpi they were constricting, were broken, loosened or softened

by discharges, showed evidence of bleeding, or were painful. Determination

was made as to which patients could be safely and comfortably transported to

their ultimate destination. The hospital decided to retain but 6 of the first

168 litter cases.

In spite of the fact that no other care had been administered than that

received in the first evacuation hospital, the wounds in general were in excellent condition, although the dressings were much soiled. About 25 percent

of the casts required removal and replacement. Many were saturated with

pus, and all were malodorous. Pressure sores were notably lacking. Among

the six patients to be retained were two with active cellulitis following compound fractures. In one there was an abscess in the fascial planes of the foreaim, and the other had a wound of the thigh in which tight packing had impounded pus.
FIRSTw I ERVI1iHJ COMMAi4l181

Thegeperafly satisfactory condition of the:patients,,:the healthy aspT

tf fieStf.the wdunds, and the infreqiiency,6f complicationsthrough ajourney

of'2 Weeks'1duration were noteworthy. Even the. major, injuries of co mpoundcomminuted fractures of thelohgbohes, had carried very well in-plaster.

Pitieits whowere iot transportable were treated further at the hospital at

amp Edwards 6or ,Wre transferred'to one ofthe, nearby general -hospitals.

Following the period- oftreatment and'sorting at the debarkation hospital,

the Ptie#infwefe shipped to the hospitals of eventual destination.

"During debarkition-activities, but three deaths occurred; Two German prisonerN'of wir, suffering from empyema 'were transferred to Lovell Gener at

'ospita t 04d'died there. One ambblant medical patient died suddenly fromA6mb6lism while intrafisit to a h6spital in the interior.

F61!&wing the designation of the Camp-Edwards debarkation hospital as

a genikial'hspital debarkation activities were transferred to Camp Myles

Stfndish. Tihre, the procedure Was essentially the same. At the close of

the war this hospital Was still functioning 4s a debarkation hospital. The

total number of patients passing through Camp Edwards debarkation hospital was 17,437 The hospital at Camp Myles Standish handled 22,016 evacuees 8

SURGERY IN THE PRISON CAMPS

The ships which brought in prisoner-of-war wounded also brought considerable iiumbers of healthy German prisoners. They were distributed to

prisoner-of-war camps in northern New England and itilized in the logging,

industry and the cultivation of potatoes. Prison camps were established in

New Hampshire at Camp Stark and in Maine at floulton, Princeton, Seboofilook, and Spencer Lake.9 In addition, there were stockades at the Army

airfield at Presque Isle, at Camp Edwards, and at Fort Devens.

Where hospitals were nearby, as at Camp Edwards and Fort Devensi

stockade dispensaries filled the need for medical care. Patients requiring

hospitalization were transferred to the adjacent hospitals. In the more remote

areas, injuries were found to be more frequent and often severe. These injuries consisted usually of ax and saw wounds of the legs, arms, and hands

and closed fractures. There were a number of surgical emergencies, notably

acute otitis media and mastoiditis, perforated peptic ulcer, intestinal obstruction, and appendicitis.

For these emergencies in the remote lumber camps, airangeients were

made with local civil hospitals to which the patients could be transported.

The towns nearest to Seboomook Lake and Spencer Lake were between 50 and

65 miles away. It was therefore recommended that surgeons be supplied to

these remote camps who were competent tc deal with such emergencies. DursReport, Hospitalization Section, Office of the Surgeon, First Service Command, 15 Sept. 1945.

Annual Report, First Service Command Medical Activities. 1944.
,12ACIITE OF ,SURGICAL :CONSULTA NTSo ,

:ing the: subsequent winter, several patients with acute appendicitis and" on,

Sviw~th pepticulcer ~erforatiou wyer successfully operated upon'at thee caps.

Ii was: found that many of-the prisoners at remote camps were . sufferjng

frmunele steomlvelitis cronic otitis, pepti6 ulcersi an herniasm ivhic

thieatened strangulation. It was recommended that more careful nedi6al

'screenipgn b done at thie port. lefore assignnenlt of 'prisoners,, and, hnds

abilitie threatened- the development of surgical. emergencies, the prisoners,

w6eb tob assigned,to stockadescl0se to general hospitals This suggeitiob

avs- carried out, and allprisoners suffering fromnthreatening disabilites: wer'e.

-iemoved froiwthe prison camps in the remote districts.

PROGRESS OF SURGICAL CARE

Surgical emergencies were, encountered and, dealt with at all hospitals.-

Tlere was no fatal ,case of appendicitis or of perforated peptic lcer withn

the service command during the author's tenure as the ,surgical consultafti.

Nonformidable surgical procedures of an elective character were carried out

in. station hospitals as permitted by directive. In the Waltham Regional

HospitalI as in the regional hospital at Westover Field, cholecystitis, goiteri,

malignancies of the stomach and large intestine, ulcerative colitis, and -ecurrentlhernia were encountered. Lt. Col. Benjamlin S. Custer, MC, at Westover

Field, Lt. Col. George A. Marks, MC, at Waltham, and their staffs dealt with,

these surgical conditions with sound judgment and skill and with satisfactory

resilts,

Abdominal Surgery

In the general hospitals, problems peculiar to the injuries of war were

met, and progress and improvement were made in their treatment. Among

these problems were intestinal injuries which sometimes presented simple

colostomies or enterostomies; were sometimes complicated by injuries of the,

pelvic bones, the chest, the bladder, the perineum and rectum; or were associlated with remote fecal fistulas to the skin and the urinary tract. Colonel

Keene, chief of surgery at Lovell General Hospital, developed a considerable

interest in the care of these patients with abdominal injuries. The procedures

that he developed in caring for an initial group of 40 cases were observed by

the consultant.' ° Assured of the soundness of Colonel Keene's procedures,

Colonel Cutler advised their adoption in the other two general hospitals.

In patients in which spurred colostomies had been made at the initial

operation there were found reversal of the spurs, interposition of omentun

or mesentery, and the involvement of loops of small intestines in adhesions

about the spurs. Operative investigation by completely freeing the extruded

bowel from the wound and its dissection within the abdomen clearly demonstrated the hazard of spur clamping by reason of unsuspected complications.

V Keene, C. 1. : Reconstruction of Wounds of the Colon. Surg., Gynee. & Obst. 79: 544-551.

November 1944.
FIRST' SERVICE, COMMAND 18

'It became the practice to separate the limbs of thespur and to close, the boyel,

Ooning by vappropriate- suture drto resect the involved portion of the gutd~lby p'erfirminn:an end-toend anastomosis of the'largebowe; 'Such'repairs wee

then,,droppd backiwithiirthe adomen. Simp!e loop colostomies were similarly

delt, With.

One hundred and four such operations were done in the three general.

hospitals according to this plan. Eighty-eight healed and remained cl0sed

Thire-was ona.death fromperitonitis.

When cmplicating. injuries of bone- or urinary tract fecal fistulas from

the distal portion of the laige.intestine, or injuries-of the rectum or perineuhi

Were, encountered, transverse colostomies of an obstructing type were done.

Deviie 6olostomies first employed appeared to have no advantage over the

simple divided colostomy. Once the fecal stieam was completely divertedand

appropriate incision and drainage or sequestrectomy or repair of the urinary

tract done,,healing was relatively rapid. Closure of the initial colostomy was

thee' done, followed by closure of the secondary obstructing colostomy.

Orthopedic Surgery

In thegeneral hospitals, treatment of bony injuries was pursued according

to directive. In the suspension traction treatment of fractures of the femur,

it was interesting to Colonel Cutler to note an increasing tendency to place

the Kirschner wire through the tibial tubercle .ather than through the condyles

of the femur. The orthopedic surgeons agreed that, when the traction was

so employed, the knee joint was less jeopardized and the quadriceps exercises

were better performed. Movement of the knee joint with the Pierson extension

was apparently little interfered with by the tibial placement of the wire.

The treatment of osteomyelitis underwent considerable changd. In the

earlier days, there was a tendency toward closed-plaster treatment. Later,

the wounds were treated by open method and appropriate traction was applied

for the underlying fracture. At Cushing General Hospital osteomyelitis was

treated by a complete sequestrectomy followed by daily open dressing of the

wounds. After trying a number of materials, the orthopedic section settled

upon penicillin solution on gauze as being the best dressing. The vounds

granulated rapidly, but slow epithelization often delayed needed nerve repair.

Early in 1945, Colonel Cutler recommended the trial of early skin grafting

of these granulating osteomyelitis wounds following sequestrectomy. The

results demonstrated at Newton D. Baker General Hospital on 11 and 12 May

1945 fully confirmed the validity of this proposal."1 Following careful sequestrectomy, dermatome skin grafts were applied between 1 and 2 weeks after

operation. This procedure was made standard in all of the hospitals of the

service command.

It Urological Conference and Symposiun on the Paralyzed Patient at Newton D. Baker General

Hospital (Martlnsbuig, W. Va.), 11-12 May 1945, pp. 05-79.
1,84 ACTIVITIES OF SURGICAL CONMSULTANT

'ifU deeI-lying-osteoml!yeitis following-early sequestrectomyj wounids ),er ,

1oftlopen. First at Lovell Ge:neral Hopital. as earlycasJune1944, and, sibseqhently, at Cushing, an attempt -at closure of these wounds at the -time, of

seqiestiectomy Was begun. Penicillin, the use of which-had formally been

appioVedin February 1944,12 was used systemically before and after operation.

Peiicillin solution (1500 units per cc.) Was also used to irrigate the depthls of

the, Wounds through catheters inserted at the time of operation. That ,helocal use of this drug contributed-to the success of the treatment was doubtfil.

On 22 January 1945, Dr. Marius N. Smith-Petersen, Civilian Consultat

-in Orthopedic Surgery to The Surgeon General, visited Cushing Genxeral

Hospital ie proposed that metallic cannulas instead of catheters be inserted'

at the time of sequestrectomy. Through these cannulas, penicillin solution

was to be injected at intervals of 2 or 3 hours until the discharge had lost its

puritlnt character. The cannulas were then to be withdrawn from the wound,

the-scar was to be excised, and complete resuture of the wound was to -be

done. By the middle of September 1945, 53 cases had been treated by this

method. Of the 41 completed cases, 35 had been closed and remained closed.

The average duration of treatment, from sequestrectomy to complete closure

of the skin, was 31 days.

Dr. Smith-Petersen believed that it was possible, with the aid of systemic

and local penicillin, to obliterate major bone defects by collapsing osteotomies

at the time of sequestrectomy or subsequently in the presence of granulating

wounds. He suggested that, even in the process of osteomyelitis or granulating

wounds, it was possible and safe to perform arthrodesis. In six such operations

performed, there were no untoward results.

As a result of his teaching, the performance of operations of bonG reconstruction was undertaken at an earlier date following the healing of osteomnyelitis than had hitherto been thought safe. This policy materially shortened

hospitalization and permitted the earlier repair of injured peripheral nerves.

Lovell General Hospital, which received the earlier casualties, admitted

eight patients who had been treated by the application of metal plates to

fractures of the long bones in the oversea theaters from which they had )een

evacuated. Six of these had nonunion and loosened plates with distraction

or absorption at the bone ends. The plates had to be removed and traction

suspension instituted. Six cases were seen with fractures splinted by external

skeletal fixation. With but one exception, these cases showed absorption at the

pinholes, and they had open draining sinuses. During these early months,

a number of patients were received whose condition of depletion from prolonged

sepsis required the postponement of any operative procedure for several weeks.

It was believed that some of these might have benefited by longer hospitalization

abroad with more attention to supportive treatment. Among the depleted cases

were four American wounded who had been held prisoners. Their open fractures of the femur had been treated by German surgeons with intramedullary

12 War Department Technical Bulletin (TB Med) 9, 12 Feb. 1944.
FIRST 'SERVICECOMMAND

pin ihg (Kfintschernails). All were suppurating, and the, nails, whichwer .

the r"40 b seen -by" the10s ita~tfs a ob ihrw.

-Co mbiied Bone and Nerve, In"juries

t Cushing General' Hospital, as a result of intersectional conferences,

'it was o ften pssible- to combine the procedures -of orthopedists id -neuio-, surge4s. Thus, when 'bone grafts were required in °patients with divide,4

peripheril nerVes,,exposure of the site was carried out by the orthopedist whi,,.

Wvhile -rkair of the 'ierve was being done by the neurosurgeqn, made ready

the be n graft and subsequently applied it to the fracture. When the nerVe

efids could not readily bq united, the orthopedic surgeon performed appro4

priate' shortening 'of bone.

Neurosurgery

Restoring peripheral nerves following injury furnished the bulk of the.

work of the neurosurgery section. At first, tantalum wire sutures and pro,

tecting tantalum foil cuffs were used in the uniting of nerves. In the early

months, of 1945, however, a number of cases were observed in which the tantalum cuff had fragmented with considerable scar tissue in and around the

fragments. The use of tantalum foil was therefore discontinued.

By 27 June 1944, frozen nerve grafts had been arranged for with Dr.

Frank Ingraham of Harvard University. This work was encouraged by Dr.

Jason Mixter, Civilian Consultant in Neurosurgery to The Surgeon General.

By September 1945, Lt. Col. William P. Van Wagenen, MC, Chief, Neurosurgery, Surgical Service, was able to report no satisfactory results from donor

grafts.

"When the satisfactory restitution of peripheral nerves failed, the orthopedic section was called to perform the appropriate tendon transplantations,

In some of the cases of footdrop, a wedge of tibia was formed and placed in

the posterior talus to prevent plantar flexion of the foot beyond right angles.

Inskull and brain injury, removal of the irregular edges of the damaged

skull, careful excision of the scarred and adherent dura, and freeing of the

underlying brain cortex were done. Repair of the dural defects, originally

performed with fascia lata, was later done with fibrin film. The defects in

the skull were repaired with shaped tantalum plates.

Also treated were a number of cases of brain and spinal cord tumor. Operations on the spine for herniated nucleus pulposus were rarely applicable to

Army personnel with any prospect of return to active duty, and few of these

operations were periormed.

Care of Paraplegic Patients

At the close of hostilities, 88 paraplegic patients were under treatement.

At the time of their reception, they were emaciated, anemic, and incontinent;

evidenced profound avitaminosis and suprapubic cys cstomies; were afflicted
186 .... ACtiV1T1ES OF 'SURGICAL CONSULT :

with 'iarge decubitus ,ulcers; and =a'ere-in a low state of moraleT. hey were

"p lac(:din .one ,,

ward , ,with :spcially trained, attendantsand.nures.

*t, lrst, t was thoughtf nece6ssar-y-to keep Ihes6 patients i e ui

Ueatment of their bladder ,infectin and to' maintain the--suprapubiC -cystos,

tommies for long periods of -tim becm ppairent t that these pa ents, ooud tb of Later, itbecame coul of b bed-earlier ou and that the suprapubic rainage could be replaeby utretliral catheter at an early date. This revised program began iii, June

gatMions of the -bladder at 2-hour intervals were continued, until cyst,

metric examinati n ivealed, diminutioa of :spasticity, At this timettidaft

drainage was instituted andwas continued until the suprapubic - opeIng, was

close1a~nd audtomatic bladder function had-beehi established, This beeainepart,

of-k detailed.standard plan of management.

Qperative treatment of the decubitus ulcers was undertaken. At qperation, the utlcer was excised with complete undercutting of the skin and' subcutaneous tissue, Closure of the defect wasperformed in two layers, thee eep

fascia and the skin. The stitches were left in -place for 21 days. Ulcers aS

lai'ge as l cm. in diameter were successfully healed. Over 50 such operations

wei'e done, and 60 percent of the bedsores closed by suture remained healed

on the first attempt.

As decubitus ulcers were closed, the nutrition and morale of the patients

improved with greater rapidity. Regular exercising of the unparalyzed

muscles of the upper body was carried on assiduously from the start and-pa-

-tients were permitted to be in wheelchairs and were given instruction in walking. In July of 1945, an instructor was secured from the Institute for the

Ciippled iand Disabled in New York to direct this training.

Urological Surgery

The work of the urological surgeons, in addition to the treatment of

blaider complications of spinal cord injuries, consisted in the care of, congenital and acquired anomalies and infections of the urinary tract. There

ujm.e also cases of kidney lacerations by gunshot wounds and fistulas of the

ureter or of the bladder to the surface or to the abdominal viscera. Such

injuries were often associated with osteomyelitis of the pelvic bones or hip,

injuries of the penis, and perineal urethra.

Typical of the cases of injury of the ureter was one at Lovell General

Hospital in which the left ureter had been damaged 2 cm. from the bladder

by a bullet which had entered the coccygeal region and had passed through

the rectumn and bladder. Urine drained through the coccygeal sinus together

with fecal material. There was a chronic abscess and pyonephrosis. Nephrostomy was followed by resection of the damaged portion of ureter and ureteral

anastomosis. The result was satisfactory. Injuries with fistulas and osteomyelitis of the pelvic bones were successfully treated by diverting colostomy
"FIRST* SERVICE COMAND -18

and subsequent local surgical attenion; ,ne caseof obliterative scarring-o,

themembanous.,portion of theurethra reqi d Perinea reconstuetiom of -th

:urethra,_, .. Mostofthe-Urologicawork of a formidable nature wascrL tried owateither

1,vell or Cusihg General, Hos itals. The surgical:ponsultan :recommendedn

that in, each of, the hospitals the, urologist institute an ative. program for the .etecion ,Of stones forming in, the urinary traet.' especially in patients long,

bdddn 'ytaking, sulfoiiainide, digs;

Plstic +and Hand Surgery "Cushiig General Hospal l was designated, as, a, center for plastic surger

in-Augus 0944. Before this,, it had been, the practice at Lovell4General Hoe

pita d to cPer bone-finjuriesinprepaiation f~r'bone-grafting. It was apparent,

to the surgical consultant that the required-policy of sending such cpaes tp

the sPeci'l plastic center as Cushing General Hospital would interrupt the

course of t1reatment, involve longer hospitalization, and unduly Uurden, the

.pIasfi0,sectioh at Gushing. This point of view-was communicated to General'

+Rankin~ who approved the practice of performing these simpler plastic procedurs ati general hospitals. Thus,, the covering of bone. injuries ,by sokimi

grafis was .carried on. at Lovell and subsequently at Camp Edwards General

Hosp ital It proved- to be o satisfactory method of handling these cases.

BY the middle of September 1945, the plaistic section at Cushing Genera1

Hospital was caring for 306 paients. Very, successful work was done in the

resurfacing required by severe scars. the transfer of tube grafts in preparation,

for further orthopedic surgery, the repair, of severe burn contractures, and

reconstructive work about the hands, neck, and face, This work was carried

onin close cooperation with the sections of ophthalmology, otolaryngol"ogy, and

deitistry. One case in particular, lacking the entire mandible bjow the

angles, was brought far on the road to presentable restitution. This section

Profited by the visits of Dr. Jerome'P. Webster and Dr. Robert H. Ivy on 23

and:24 MaY 1945.

The subsection on surgery of the hand instituted under the plastic section,

Cushing General Hospital, in October 1944 had its own officer in charge, Capt.

James W. Littler, MC. He received instruction and assistance from the neurosurgeon, the orthopedic surgeon, the plastic surgeon, and the surgical consultant as required. On 1 December 1944, Dr. Sterling Bunnell, Consultant

in Hand Surgery to The Surgeon General, came to Cushing General Hospital

for a 5-day visit, his first official visit to an army hospital. He held clinics

and demonstrations, operated with the officers in care of these hand cases, and

instructed them in operating technique.

The hand surgeons held regular consultation conferences weekly with

neurosurgeons, plastic surgeons, and orthopedists. The officers in the hand

surgery subsection rapidly developed the ability to carry on this work on a

specialty basis with less and less assistance from the other specialists. Success-
tur, ~eacivaionof joints by co rrective spiliting- and capsotmski

-rs~ir Aqipgi orcie etme, tifazipdatations -of ryadcreto

grft ~e kilfll ue&I to restore 16ingtlrAnd, sblty, to,,damaged- ongk,

bos uccessful atrpate mlyn.~utlm cp of'-tlie metaabphalangeal Joints, were dpne 'The' reinjlts of thse operatns weregaiy -14g. "By 12' Spteinber-1945,teewr 200 pints ,und~er .tidep.inth.,is,

Eye, Ear, -Nos, Throat- Sui'gcrY_

'Since, the work of the plastic secitin ivolved-reparative and reconsttuctiva,-,

sPrgery'of~h uppe eprt pas.sages,0 o orhnlaryngologists having plastic tigery ekpbrience were placed i-nh section. At the,,other hiospitals,.

qopIiiiolai'yngologists were requirt ii for the carryg onof routie treatmebnt

of .ifftions and abuiorillities of~ile ears, iioseanidthtroait. There were found;'

a gdo aniysoldierissufferinig wvithchroic otti;sz.nedia resistantto treatnent.,

It was ,found that imderlying mflitokt involvernent was often responsible, andinastoidetoinies weropriormed in thie genieral ospitls anld' i thieregipil'

liospktdI At Waltham.

At, thdIe general "hospitals, eye specialists were also mnaintained for, tlie 'care

of-injuries and infections of theeye. At the stAtioni-and regiul hiospitals,

oph1thalmologic speciailists performed riefraitions qnd the fitting of gif mes,

as well as routine eye exainrations.

After the opening, of the ophthalmology section at Cushing General',HospitAl-in Augist 1944, the ophithialomologists were busied with work about-the

66i~ iVolved in plastic procedures. Theo imjor activity of this sectiohnecnn;

sisted.,in. enucleation or revision of enucleAtion for the fitting of acrylic eyes.

The- ophithalmnologists ejcpressed the opinion that an earlier revision Shortly

following injury would be productive of better ultimate results. The productioni of acrylic eyes was successfully carried on.

Amnong the conditions treated by the ophithalinologist were foreign bodies

emnbedded in the eye, chioroiditis, traumatic cataract, and retinal separation1.

Amiong the interesting ear, nose, and throat cases seen at Cushing General

Hospital were two of gunshot injuries of the trachea and the esophagus, both

of which mnade a satisfactoryf recovery. At Lovell General Hospital, several

cases of advanced suppurative sinusitis were treated, two with osteomnyelitis of

the frontal bonie. Sequestrectomy and subsequent replacement of skull defects

with tantalum plates brought about satisfactory recovery.

Gynecology and Obstetrics

F or the care of the WAC's (Women's Armny Corps), nurses, and femiale

civilian dependents, gynecology w"as done on an outpatient basis at station hospitals, operative cases being transferred to Lovell General Hospital or W althami
,FIRS 'SERVICE COM MAND 8

RbjioptI4sp!Wa. QObstetkida prcewsas are na h t wo

hospials;

praing 0 om

mont,, Prcedures, and tehiu. Equipment. was usu4Ily found to be satis;

fa~~~~tory.~~~~~ AtWlhmad uh'g oopaelgt ere, unisatisfactory

T~dnjcl~ roc~urs ~ere~orectd a ocasin requiired. There was,

a ptc~suerfuou ~endi~y' q frhihin~ ~i per~ig-rooms.; Theseoyere;

i~~t~6ii'~comeiiatin. he preenc ~fsurlus and- unauthoried,

'Instririns wa hecked on the request of tile Director, Suige8 Divisn,

O1c Ifl' Surgeon General,

'It ;wasn ie-cessary toinblke-sure that operating-roomft facilities were being.,

uieetoiiil~ capacity. it was, the, duty of-thd -anesthesiologsts to maintain a,

satifa~ti~yoperating-robm program... At Lovell 'Genebral I ospit.d o per ting,

facilities becainw very, much crowded, but this-was reolieyed -by the openig of

'L6VOJMspital North; At-Cushing Geneifal Hospital, there developed a. back-,

log of surkical cases,and4 it 'as recommended that the operatiug-rooi~ faclities

'be icreameby newconstruction.

Aniesthesia,

1t, was pbssib]6 to maintain officers competent in. anesthesia. at all hospitals.

'RO'p Offs~- a6nsthesia, were made to the Director, Surgical Consultants Dii

sinM of the Surgeon General; on 1 August 1944ad2 Oct~e 94

These '1'ep~rts showed anesthesia practices in -the command- to be satisfactory,

an&d the, equipmeiit, adequate. it was the practice to utilize spinial' and local

anestheia' Very largely in the station hospitals, At Watham, Regional Hospitdl and-,At the general hospitals, folly qualified anesthesiologists were maintainied. Sdhbols for nurse anesthetist,, were also esta Iblished at these hospitals

The use of spinal anesthesia became less common in formidable surgical

cases. A gas-oxygen-ether sequence for these cases was generally preferred.

Occasiohally, Penthotlial sodium (thiopental sodium) was used and gave complete satisfaction. Continuous spinal anesthesia proved satisfactory. There

were no anesthetic accidents.

Among the functions of the chiefs of anesthesia was the management of

the recovery wards. These wards were maintained in all the general hospitals

and proved completely satisfactory. Air-conditioning of the operating rooms

at Cushing General Hospital contributed greatly to the comfort of the surgeons

and the welfare of the patients.

Central Supply Service

A central supply service was -.,lso under control of the anesthesiologists

and chiefs of operating rooms. The program for their installation was recommended by the consultant in June 1944. The establishment of this type of
10AC TIVIIES 8OF SURGICAL, CONSULTANTS1

servild was confirmed and outlined in April 1944.11 Difficulty and delay ii

establishment of these services, was due tolack of adequate space. At Gushing General Hospital,a room ,vhiclhiadbeen provided was too'small, At Lovdl

General Hosiitali at Waltham Regional Hospital, annldat the Camp Edwards

hospital, no such provision was originally made. At Lovell, authorii tpjo

for necessary construction Was requested on 24 April 1944, and the system was

put into effective operation in May i945., The activities of the cetral-supply

servicesystem in this hospital were complicated by the system's division hnto

two active units, Lovell North and LovellSouth. At Waltham Regional i:ospital, additionaf opstkuction was not completed until July 1945. UTitiiiiat

timeithe operatingroom furnished the necessary supplies. At Camp Edwards,

request for construction was made on 27 April 1944,5but at the closo oflostilities construction was still underway, Where the central supply service

wvas put into operation, its great value was recognized.

Orthopedic Braceshops

Orthopedic braceshops were part of the original equipment of Cushing

and.Lovell General Hospitals. These facilities made splints and braces for all installations of the command. As the workload increasd, delays resulted

in August 1944, it was recommended that a braceshop be installed at Waltliam

Regional Hospital for its own use and that of the neighboring station hospitals. The construction was authorized, and the shop started effective operation in January 1945, At Camp Edwards, a braceshop, authorized in February

1945, was not put into operation until July 1945.

At Lovell and Cushing General Hospitals, civilian bracemakers were

employed and assisted by technicians whom they trained. It was necessary

to arrange with the Personnel Division, Headquarters, First Service Command,

to protect this scarce category of trained enlisted men from loss by transfer.

At Cushing, because of the need for supporting apparatus for paraplegics

and neurosurgical cases and for the corrective splinting of hand injuries, the

work was extensive. Many of the splints used were especially designed for

particular problems and could not be produced in bulk.

In the orthopedic clinics, one of the most frequent problems was that of

flat feet. The ARCH-O-GRAPH equipment proved unsatisfactory. The

arches would not stand up under conditions of active use. Consequently, a

program for fitted metallic arches was developed.

Major deformities of the feet required the production of special shoes

beyond the capacity of the orthopedic shops. The laboratories of the United

Shoo Machinery Company had perfected a device for securing impressions of

such deformed feet and a process for producing shoes to fit them. The Surgeon General authorized the trial establishment of the process in the First

1 War Department Menmoraduin No. W 40-44. 12 Apr. 1944.
-fIUST SERV1Ot-0MANb 9

S.. rVice-,Commahd, under the Boston Quartermaster Pepot."4 Tlsugicai' ,

cofnsultant was cdharged with the arranging of the program, which was-put

i.to.. efec 6'f-.at once. An. orthopedic: surgeon, Capt. Saul Stinberg, MC0,- wa

assig"nh d to the Boston Quartermastr Depot for instruction hnd ,research in

" iml baiit shoes, Catain/Steinberg was. aso to Wrk with the Lawrence

Cl: Ohiiiati1seai~ihLaboriatory inothr shoe in estigations.

Physical Therapy

Phy~icail therapy finctioned, in cooperation, with- ailsectionis in the-hos.

Spitalgpaiticularly idt-the ,sections Of,,orthopedics, ,underthe. superVision.0of,

Whi6hit, operated. There Were a sufficet number of Whirlpool bathselectric

heat apparatuses, infrared and, ultraviolet1amps, and treatment tables., Physi-.

cal therapy aides, enlisted technicians,, and WAC personinelcparried onl most of'

'the treatme . Medical ocr2physiotherapists were available atLovell and at

Cushing. Ward buildings lent themselVes poorly to the needsof a physio;

ther apy departmenlt Removal of partitions and elimination of- sinall rooms,,

proh~ng lrgeopn sac, ere effected zat -ivefi and Cushing, much to,

the :advantage of the service. At Cushing, authorization, was requestd for

the enlargement of-the building. At Lovell General Hospital, it Was necessary;

t establiQs a second physical therapy department-in Lovell North. feetwe~ii 400 and 500 treatments were given daily at LovelGenera!.KHos,

pital. AtCushing, more.than 600-treatments.were provided -per day. There

vasa conbined totalof 1T13 73 treatments during the month of-August 1945

At aniip-MEdwards :Convalescent Hospital, where during the summer of 1945

bt~~en 400 and 5,000 patients -were accommodated, a building was. provided,

and staffed for the treatment of between 200 and 300patients daily.

The policy Of the surgical consultant was to emphasize the importanceof

employilig manipulative physical therapy judiciously, intelligently, and spar- ifngly Emphasis was consistently placed on remedia and corrective exercises

raier than on baking, massage, and manipulation. There was a tendency to

refer patients for physical therapy for the patient's satisfaction and the relief

of the6siirfen without due regard to the specific needs of the individual. It

was insisted that a specific prescription for treatment should be worked out

for each patient and that periodic evaluation of the case should be made.

Exercises were instituted even for patients in bed. Attached to each of

the physiotherapy departments was a gymnasium equipped with apparatus for

remedial exercising. Directed exercises for the paraplegic cases at Cushing

General Hospital were undertaken while the patients were still in bed and

were carried on later in a special physiotherapy department attached to their

own wards.

24 Letter, The Surgeon General to Commanding General, Headquarters. First Service Command,

Boston, Mass., attentloo: Surgeon, 24 Jan. 1945, subject: Study of Special Shoes at The Boston

Quartermaster Depot.
'192! ACVITJt8S OF SUHI0AL C0NULAT

Occupational theray

Occuptional ,therapy was; esigued to, restore tlie-strenigth. and" usefulness

!,psignqd to It ~his-needs. At the general 'hospitl, anasoa ap dad

~on'als~et Hspial ~hps yer se ~p, for, this. At Lovell, under Capt.,

Sidney Licht, tools, with.,gradedl lhndles,, loomis, pinting presses, leg - obr

footopeatedbansawsandJigsalws, all with adjustale fixtures, 0.vie

graduated.rAfige of "motion. Hlere,,also, wereemploye plning, liAndsawihg, ppipig, -weavin g, and sandpapering. se ofiti and instruction proved,

valutale,for patients suffering fromn upper extr-emuity, disabi lities.

SUMimary

S~urgical care, in all its phases, resulted in 11,063- battle casualties' -(surgia)bing,1a41itted-to First Service Command. hospitals between 14Janutary

and- I July 1945 for definitive treatment. Deaths numbered nine, or 0.08

percent, somewhat, less than one per thousand.

CONVALESCENT PROGRAM'

The reconditioning program Was established and, its policies were outlined

iy, Circular Letter No. 168, Office of theSurgeouGendra), dated 21 September

1948, A reconditioninig officer was ap~pointed at First Service Commandied

quarters, and the surgical consultant wits ordered to act ats consuitmint in ie6-

coniditioning. '1ho surgical consultant visited the recon'lztioning center of the

Second Service Command at Atlantic City, N.J., onl 31 Javiiary 1944. Onl 24

and 25 April 1944, hie attended a reconditioning conferec at lalloat Genera

HTospital, Staten Island, N.Y., and at Thomnas,). England General Hospita~l,, Atlantic City, N.J. Some, of the recommnioded procedures were adopted In the

First Service Commnand.

thle reconditioning program was carried oil in hospitals until April 1944

when a reconditioning center was set up in barracks at Fort Devens for Classes

I and 11 patients."3 T1his activity continued ats a part of Lovell General and

Convalescent Hospital until 25 January 1945, at which time the convalescent

hospital was opened at the U.S. Army Mfedical Center, Camp Edwards.

Before its opening, a principle was proposed by the surgical consultant

which was adopted. T1his policy provided that beyond at certain point of

recovery Chi~s I and II patieits bioold be sepairatedl into two groups, as

follows: (1) Those who would return to duty as soldiers and (2) those who

were to be separated fromn the service by certificate of disability for discharge.

The two groups thence forward were to pursuel1 separate programs predicated on

their unlike purpos)0es. T1hese dlifferences, it was pointed out, made thle two

13 Letter. Commiandiug General. First Service Commnand, to Commanding Officers. All Posts and

Camps. First Ser% Ice Command, 10 Ap1r. 1944. subject. Rieconditioning In General and Station Hospitals.
FIRSTSERIEM D 1930

gbpii~ tib , and, attempts to,- combine, the. reconditioning., of,'the t~o.

bda§§-4ould. isk failure _ahd l6We- 8inom~fai6e jf.ith. Separate grouping

Anothbei'pincdiple wasthhttth6e convalescent soldlip should continue toi40e

a, patieht, tb receive continuig medidal cake,-And an adjustment of his pfogranm

b~ktot e iithis physical needs. This principle, too,,Was con We ~lymhi tainid;,

Wadofcr n h owlset ho§Oital- were, imbued With asenseA4

'their responsibiity to -thir -patients. Consultations were .arrangted. with spe-,

diahsts. when niecessary. egul.r eica rond wer mde and thpail

progress notd Oi-tliis basis, physiotherapy, remedial, exercises, gymnastis,

andoccupationil therapy Were individ Ally- prescribed.

The 'initituion of the cOin'alescenlt hospital at.Camp. Edwards permnitted

greate :kcOpeIWnhe reconditioning prog'ram.

'Thesi§irgicalconsultant believed ,thiat it wouyld ,be desirable to develop-a

blos6 lihi§oh, on tieoh6 hand, bet~een medical'officers of- hospitals and reconditioning'lunits, aiid,,on the oth~er, between thles6 niedicaloffider~s and thoseofficers

e 'jWeb~d to make classification and assignment of the sick -and wuie

soldier foll m'recovery. He believed thiatsuch assigiimoit should lake iiito Ia~diin t ifIormAtion gainied by medical o fficers and thatfaili~e to'dO this would-

-est aniiiiy iipropei s§ignments. Thus, more satisfactory classifying aidi

assgiiing could-be, done, and the rehlospitilization of mnany patients be avoided.

'This matter of r eclassification and assignment Nyas- nad6 the subj"ect of a

m 'emoindumx to General Rankin. In it, ColonelCutler stated that thie collecting of dlata, pertinent to subsequent classification should begin during hospitaiiiation, -and that iliformatioil acquired concerning the soldier at the hospital

wher'b definitive treatment, was given, should accompany the soldier to the reconlditionling-unit. At the reconditioning unit, further data concerning his ptogrs, physical status, response to training, and acquired abilities might be

added; 'Th6se data should be fully utilized, Colonel Cutler recommended, in

effecting intlelligent disposition, and specific recommendations as to the type

of duty at soldier may be able effectively to perform should be furnished by his

physicians to the authority performing classification and assignment. It was

pr~oposed that an officer authorized specifically to recommend such assignment

to at,~ rities at the personnel distribution center be placed in each of thle genieral and convalescent hospitals. At the reconditioning conference held at

Thomas M. England General Hospital on 25 and 26 April 1944, it was proposed

that reclassification officers be actually placed in various hospitals. Such

reclassification officers were assigned in June 1945 to general hiospitals.G

The surgical consultant also believed that adequate and accurate information should be furnished to the soldier concerning his physical status and

the nature of serious disability hie had suffered. It was represented that

patients required such diagnoses and records for health guidance and for the

14 War Department Circular No. 170, 13 June 1945.
, 194 ACTIVITIE S OF SURGICAL CONSULTANTS

ihformationodftheir civilian-physiciahs in-the event, ofillness or of compiica- ti~ ingfroiib 6 rviwe ilness orinjury, Several nstances were brought,

t te attetition of the surgicalconsuitant in which the lack of thisinformation

had- Woked to the disadvantag.of discharged: soldiers. The securing, ofstuci

iiAtio0itn by the veteran's civilian physician ,through channels might be

attbnde by suchdelay, as would render the information useless. Uponrecoim,

miendation of the surgical consultant and under authority of ArmyjRegulations

N, 4O-890, dated 29 August 1944i a command letter was issuedon 9 April 94,i

by iHeadquarters, First Service Command, calling the attention of commanding,

Officers of posts, camps, and stations to the provisions of that- regulation.,

'The letter stated: "It is desired that every soldier separated fromthAe.

service in this Command be informed of his right to request a transcript of the

medical record of any illness for which le may have been hospitalize:dwhile

in military service. The importance of this record for his future protection and

Welfar4 e should be explained to him. It is further desired that he be informed.

'that tle proper method of making this request is through channels to the Cominanding Officer of the latest Regional, General, or Convalescent Hospital in

Which-hospitalization occurred." The letter further directed that the furnish,

ing of requested records be facilitated by the commanding officer of the hospital

concerned and that commanding officers of personnel centers and hospitals provide for the inclusion of this information in orientation lectures given by separation counseling officers.

MEDICAL EDUCATION PROGRAM

One of Colonel Cutler's duties was to further education activities of the

staffs of the various hospitals. He always inquired whether proper library

facilities were available and attempted to determine whether there was an effective program of meetings and staff conferences. Such meetings and conferences were arranged and maintained in all hospitals during the consultant's

tour of duty. It was the consultant's practice frequently to attend such meetings and to join in the discussion, occasionally presenting clinical material himself. In most of tho hospitals of the command, he presented illustrated

talks and demonstrations on the early care of hand injuries and other topics.

It was his practice, also, to distribute and explain information gained at meetings of surgical societies and conferences held at the Office of the Surgeon General and in other commands. At all conferences attended outside the command,

the consultant reported on results and procedures developed within the First

Service Command. From time to time, selected officers were sent to visit hospitals in other commands in order to learn metl,ods and procedures successfully

developed there. By this means the First Service Command hospitals benefited by the experience of other facilities in such matters as the employment of

penicillin and streptomycin, special methods in the care of paraplegics, and

reconditioning.
A lprogrran which assigned4a number of recently,.commissioned officers to

hospitalsf6fr periods of about 6 weeks'duiration.provided another ieducational

d av ge& , in ,'the hospitals, programs ,of instruction for ,these mnen were '" :onductid by the staff. " . .. " ","

The "onsultahts at First Service Command. headquarters aided in the

deyV'fopienet and prosecution of the-program of the New England 'Committee

for fWar-Time Gaduatde Medical Meetiigs. Schedules were arranged for the,

visits,6f-instructors furnishedlby the committee to allhospitals.

Clihicalmeetings at Lovell and Cushing General Hospitals were attended,

by nedica officers oi the First Service Command, Navy medical officers, and

einbors of the ci~ilian ,profession . At on6e meeting at Cushing on 16 April

1945, he Boston Orthopedic Society was the guest of the Cushing staff. The,

attendance exceeded two-hundred. A combined medical exhibit, was presented by Lo veil and Cushing General Hospitals in conjunction with the Navy at

the meeting of the Massachusetts Medical Society in Boston on 23 and 24

May -1944i

The visits of The Surgeon General and of his special consultants were

of great value in maintaining high professional standards and in the interpret ation of directives. The visits of the civilian consultants proved valuable.

Among these visits were those of Dr. Smith-Petersen, Dr. Jason Mixter, Dr.

Webster, Dr. Ivy, Dr. Frank R. Ober, Dr. Bunnell, and other distinguished

members of the profession. Specialists in the New England area responded

readily to many requests by the surgical consultant for assistance in the solution of specific clinical problems.

It was the consultant's policy to rotate officers from the smaller station

hospitals and from the prison camps into the general hospitals for periods of

duty, and many such transfers were made.

An effort was made to encourage the members of the surgical staffs to

qualify for licensure by their specialty boards, and several officers received

approval during this period. Papers and reports of clinical investigations

prepared by the surgical consultant and by members of hospital staffs ap- peared in medical publications. In all matters pertaipr )g to his duties, the

surgical consultant was accorded the fullest assistance and cooperation by

the service command surgeon, by all officers of the headquarters staff, and

by the commanding officers of hospitals. The effort, interest, cooperation, and

loyalty of the hospital surgical staffs left nothing to be desired.

CONCLUSIONS

The experiences of this author as the surgical consultant of the First

Service Command have led to the following personal observations:

1. The value of the consultant system depends on an understanding by

command authority of its proper P '.ction as an agency for attaining and

maintaining the highest level of professional performance in the Armed

Forces.
'196AcTVIE OFn SUoGi O CONSULTAN TS

S. As far as is, consistent with military action,. consultants: Should be kaccorde-the fullest freedom of movement withintheir respective areas. Orders.

othei# movement shudb eemdin large measure by. their. own esti

ait6of'where thiir services will be most efftive at: any moment.

3., Free, direct communicaton. should, bepermitted consultants withth6.

.prdofsionalpers~onel undertheir supervisibn, through technical.ratherltnh.

• mmaind chin61s.

4. Gradingand, placement of officers'in' their specialties should'Ie done,. ,hdi.e practiiable, with the consultants' knowledge and, as. far'as posibIe

according to their adice.,

Ai. Degree of responsibility to 'be given an individual in. the ca r of

patients should bdetermined by professional coipetence iather than"by nihtary rank. As far as possible, rank among professional: medical officers should

be mide consistent with competence anddetermined primarily, on, that 'bass.

6. ?nder the: cnsultant's advice, utilization of pooled or casual medical

officers should be facilitated by their temporary assignment to install4iofi~s

in areaswhere shortages of professionalpersonnel-exist.

,. *'henever practicable, medical officers stationed in small instailations, especialy in remote and isolated areas, should be rotated,into the larger, genefl hospitals for periods of duty, The consultants should assume responsi- bility for recommending such specific transfers to the command authority.

8. In future planning for fiXed medical installations, adequate provision should be made for (1) central supply facilities, (2) braceshops, (3) recovery wards, (4) adequate operating rooms for accommodation of peakloads, and

(5) air-conditioning of operating rooms.

9 Separate programs of reconditioning should be provided for convalescent soldiers who are to be returned to duty and for those who are to be

separated from service.

10, Proper classification and assignment of soldiers returned to duty from

hospitals requires close cooperation between the classification and assignment officers and the medical officers last concerned in the soldier's recovery from

injury or illness.

11. For health guidance and for the information of any subsequently at,

tending physician, a soldier discharged from a service hospital should be

furnished a record of the diagnosis of his injury or illness and all pertinent

data concerning it.
CHAPTERYI .... , 0,d C miiiitid,

Robet.H. Knnedy, M.D.

EXPERIENCE AND, ORIENTATION

ol, jRobkrt H Kennedy, MC, was Chief of Surgica['S ryicgs sit Percy

foies !Geilibial Hospital, Btle, Creek, Mich., from September 19402,to August,

19 44ahd- t' Mayo General' Hospital, Gdlesburg, fIll, from August 1944 to,

Jainuay 1945. Bith hospitals were in the Sixth Service Command, Dur-.!

'ig 'ths':peiod:he also served , oi a nhmber of occasions asacting' surgical

cdnsultah t6 ,the iSi:th Service Command, headnarters, 'which had-no don sultants'assigned toits medical division. This arrangement of combined duties

as, chi6If;of'urgical service and acting surgical consultant was uisatisfactoryj

yet it did give'some oientation-as to the possible problems and opportunities

of'a surgi6ail-6nsultant.

Colonel-Kennedy was given no guidance as to his duties from tile Office

of thle Surgeon General or the local command at the time of his assignment

as surgical consultant, Second Service Command, on 18 January 1945, Neither

was there any period of orientation. The value of his work, therefore, depended oi the attitude of the service command surgeon toward administrative

and professional problems. It was necessary that mutual confidence be developed first, and that, once mutual confidence had been established, a continuous effort be made to keep the new consultant's Work mainly on the professional rather than the administrative level. Colonel Kennedy was accorded

full cooperation from the Office of the Surgeon General and the service coinmahd surgeon throughout his tour of duty, which ended 31 January 1946.

ADMINISTRATIVE DUTIES

There was a border zone between administrative and professional decisions and details in which a consultant was of much assistance to the service

command surgeon, but as a rule the consultant employed his time to the greatest

advantage in supervising patient care--indeed it was his primary responsibility to see that such supervision took precedence over his other duties. For

example, each commanding officer in the Second Service Command submitted

a monthly request for promotion. Also, each division in the service command

headquarters was asked to rate monthly, in order, all officers on the roster

with regard to priority for promotion. This entailed Colonel Kennedy's

going over several hundred names in which scores of changes occurred each

197 606222-..-2-15
198ACTIVITIES- OF SURGICAL CONSUL *T&T

ifirth.' It as iaturalthat few, :if any, promotional vacancies shoul

f& alstaff each month. The fimespnt on tr ing-to appris:th1ise

wien _SP94sienfiously in, order to preserve moraile, was largely w ast and

W, "il av een e, spent morewisely oncinical problems,

ADMINISTRATIVE FACTORS-IN PROVIDING PATIENT CARE

'ri itat C6nstructidn, The type:of-hospital construefionmade a great difference.in theeti nc

6f, adinistrAtion. and,6f rofessioiial care. 'There, were fivo erlid 1 8 'in S"cSo ut rvice Command, "ne, whch was of the cantonment type , ilt

afte_ the war :began, could be operated efficiently., Another, a, cbnsi alie

portion of Which had been built before the war, consisted of two cantomentm

type units a mile and a half apart and could never be properly integrated. Two

nowState hospitals Were taken over and ultimately fiunctioned well' but only

after numerous structural changes and adaptations. The changes were so

extensive that the State could barely recognize these institutions when thely Were returned. The fifth general hospital was made up of severalresort hotels

ih an:area in which all hotels were not released to the Army. This setup was

never satisfactory for effective administration and resulted in much wasted

effort. Good patient care was rendered in all, but the consultant's time required

at each institution was definitely proportional to the effectiveness of hospital'

construction.

Loeation of Hospital

The site of a hospital played a vital part in its efficiency. A hospital

Within New York City was over an hour's travel from the traditional centers

of recreation in Manhattan. Patients could go to Manhattan rarely, but were

always restless because of its proximity. Well-meaning lay persons came in

hordes to try to help, and interfered considerably with orderly care. A hospital

at a shore resort had good individual morale among patients, difficulties in

maintaining discipline, and constant spoiling of troops from exposure to tourist

crowds (fig. 29). A general hospital within a training post was unsatisfactory

from a morale and recreation standpoint. The cantonment type of hospital

6 or 8 miles from a small inland city seemed to keep its patients uniformly

satisfied and adjusted.

Personnel

The nonavailability of competent professional personnel throughout 1945

was a great problem. Bed occupancy in Zone of Interior installations was

constantly increasing. The amount of required operating and rehabilitation

was stepped up markedly. In each of the surgical services, there was a scarcity

of experienced personnel except among a few top key men. By the fall of

1945, a steady stream of medical officers were returning through New York
SECOND SERVICE COMMAND 199

FIGURE 29.-Recreational and exercising facilities for anipute,. A. Amputees swimmning.

B. Quadruple amputee riding exercising bicycle. Note tourists on open beach.
206- ACTIVITIES OF SURGICAL CONSULTANTS

City from abroad an hadlto be assigned to posts according to their experence.

Thmiajor interest of many~of thiese officers Was discharge. It was remarkable,

that the greatly inceasd volume of work was caoriedon so efficiently. y9I

4t thathlate period in the war, the greatest lack was still in trained orthopedic

'The most efficient organization to head a surgical service proved to betliat

conitingof a-chief, an assistant chief, and an administrative assistant -tolthe

chief. There was much paperwork to be done, and the chief should have keen

OliOvd of this as far as possible. The assistant chief, preferably, should'have

been a mature key man in one of the specialties, an officer who could h a dassihed the responsibilities of the chief in his absence but who otherwise hadno

offide duties, The executive assistant to the chief should have been a young

Medical officer with an orderly mind, who probably was unavailable for. oversea-service, and who could have acted as a buffer for the chief. In the future,

Medical Service Corps officers may be effective in this position, but not many

members of the wartime Medical Administrative Corps were customarily

ready for such a position.

The general hospitals varied so greatly in their construction, location, and

special missions that a table of organization had little practical value. For

example, officers at Halloran General Hospital, Willowbrook, Staten Island,

N.Y., had to become debarkation officers about twice a week; those at Tilton

General Hospital, Fort Dix, Wrightstown, N.J., were flooded with problems

from the separation center after September 1945; and Thomas M. England

General Hospital, Atlantic City, N.J., as an amputation and neurosurgical

center, and Halloran General Hospital, as a neurosurgical center, required

many more operating surgeons if the load was to be kept moving. The consultant had to jockey assignments constantly among hospitals according to the

particular load and the available medical manpower.

PROFESSIONAL ACTIVITIES

Patient Service

In spite of all administrative problems, the basic job of the consultant was

ward rounds. He learned how the chief of each section handled his patients

and his professional personnel; who was happy and who, disgruntled; who was

being used in a most effective spot, and who was not hospital mterial. Were

patients being kept too long? Did they belong to a convalescent hospital? Had

they reached maximal improvement? Would they be unfit for further military

service, and should they be ready for their civilian life immediately without

further rehabilitation? Were the men who constituted the disposition board

taking all these factors into account? Clinical lectures might have been of

value in slack times, but with the normal overload of duties during the author's

service as a consultant, personal contact with the ward officer in examAes of
his iiiin~diate problems oi eimport. Dvas Drs. WIlliam Darrach and

W*iliamii -'Pluimme, wevla consultants in orthopedic sugry, visited al, e nlur gioCo duringConel 6Iihalhospits Kennedy's tenure nd ere.. •

a c0isti isouice, of stimition to officers in group conferences. Thi left

S C~6eleinedy free.at tihesaei time to delveinto other hospitaldetails.

-CONFERENCES'

71 "" 'Sedond Service Command anesthesia conference was held on t June194at eadquarters, Second Service. Command, GoVernors Island, N.Y. It

was attendd -by 74 perspns, and it spread much valuable infoFmation, Ac6hiiWhcW6 n spinal cord injuries washeld& at talloran General Hospital 6n

1:0 Q er ahd at Thomas M. England Geneial Hospital on 0 October 1945

and, Vs 'iattdod by 95 people. These sessions reviewed, the most recent

gsnin 1i t.h8'tredaieht fparaplegics.

Interhospital Visits

On several occasions there was sufficient lull in theload of work to permit,

fho-6 seding ,of the chief of surgical service at a general hospital-to another

gdnetii hPital in the command for from 2 to.4 days' observation. Similarly,

th 6hiefb at the general and regional hospitals spent one day together at Camp,

Vpt6*,,Cnvalescent Hospital, New York, N.Y. Several chiefs of sectionsw*ere,

placed' on temporary duty for short periods at hospitals outside the command

for observation of particular types of treatment. All of these-visits were vitalt

in improving the care and lessening the morbidity of the individual soldier.

The consultant had an opportunity to visit a number of installations and

facilities outside of the command. This was usually at the time of some

special conference. In all instances, new valuable ideas were obtained from

observing the manner in which problems were being met in other commands;

SURGERY IN GENERAL HOSPITALS

Amputation Center

The amputation center at Thomas M. England General Hospital was

authorized to have 1,200 beds for amputees. In only 3 months was its census

as low as 1,200; the maximum number of patients tho hospital registered at

one time was 1,625. Maj. Rufus H. Alldrege, MC, was Chief, Amputation

Section, and did an outstanding piece of work. His results in Syme's amputations were particularly noteworthy.

In compression bandaging of the stumps, 2,000 to 2,200 Ace bandages

had to be washed daily. Washing was being done in the hospital laundry, but

the bandages were dried in open corridors in the basement, creating a most

untidy appearance. What had been the hotel bakery adjoined the area and
202 ACTIVITIES OF SURGlIL CON'SULTA4NTS

Wa ,not in ue -at, this- time. It wvas found that~tlie-,baiidages ,cbid ,be pta

S ut over the:traysiisedlfor baking rlisand Ithat each of the 8tiays of'a'single

unit' voiild-accommodateb en0ad.4tndg.TwQ motor. driers with.

heatifig units were devel ped, and the entire loiad of 'bandages could!b iedied,

hv 'Wttal 01, problemswee more dificult for solution. .

The limbhop clreated many probleinssince as, ,i y as 292 prosteses

.erecobmpleted in one month. Persoieihad to-be changed too rapidly. Stu-'

dents always were in training. The limb shop ,pesoinel strength -reaehi a.

highofi82, Individuals worked on day and night shifts. Research welnton

conkomitantly with production, so that changes in material andtypes wer

too frequent. It would have been more efficient if research couldAav¢e bee

carried on 'in a smaller unit and not where 1,500 amputees were Waiting for

-thbi prosthese so that they could be discharged,

The work of the physical therapy personnel for the amputP,, was out-;

standing. Remedial gymnasiums with pulleys, steps, walking ramps, a*d

mirrors were set up in two hotels. A new training program was set Up late,

in 1945according to which no soldier wasallowed to wear his prosthesis until

he 'had developed proper muscle balance of all parts of his body (fig.,0).

Striking work was done at Halloran General Hospital by combined neurositrgical and orthopedic operators in cases with healed wounds which

required both a bone graft and peripheral nerve suture. The neurosurgeon

exposed the involved nerves. With the aid of the neuropathologist doing

frozen sections, the amount of necessary nerve was removed until there was

no longer scar involvement. The orthopedist then entered the picture and was

told by the neurosurgeon in upper arm cases how much shortening of bone

was needed, if any, in order to bring tie nerve ends together without tension.

The orthopedist then prepared the bone ends and did his bone graft, and the

neurosurgeon returned to the case and did the nerve suture and closed the

wound, In some instances these procedures required as much as 12 or 14 hours,

but in no instance was there severe shock. This shortening of bone, of course,

was done only in upper extremity cases.

Neurosurgical Centers

In cases of herniated nucleus pulposus, if operation was indicated, the

question of whether a fusion was to be done was decided by agreement of the

neurosurgeon and the orthopedic surgeon.

The load of paraplegic patients at Thomas M. England General Hospital

reached 110 and that at Halloran General Hospital, 108. Much thought and

effort was exerted to obtain the best care for paraplegic patients. All fields

of medicine concerned cooperated in the effort with a neurosurgeon in charge

at Thomas M. England, and a urologist, at Hlalloran. At the latter hospital,

large decubitus ulcers over the sacrumn were closed after March 1945 by full
• Frouis 30.--ymniastlcs in -th, reconditionilng progriunh

at Thomais 5. hinglaiid General ,UospItali Atlantic CIty,

NJ.

thickness flaps mobilized by under'cutting out over the buttocks, even ap,

pioaching the grieat trochanters. Itwvas often a 4- or 5-hour plastic procedure,

but the results were excellent. The writer believes that Thomas M. England

General 1-lospital was the first Army hospital to perform this operation. At

this same hospital, a dining room was set up on the ward floor with tables

so arafiged that wheelchairs could be wheeled to the table with the patients'

extended legs under the table. The dietitian was particularly valuable in

the recovery of paraplegics. A printing press was obtained and a newspaper

started. The paraplegics served as reporters, editors, typesetters, pressmen,

and newsboys. One physical therapist was assigned full time to this ward,

with a number of WAC personnel trained in physical therapy to assist her.

At Italloran General Hospital, a large ward was set up as a gymnasium with

mats, parallel bars, overhead ladders, wall ladders, and other similar equipment. An open-air swimming pool was completed in midsummer 1945 and

was available to the paraplegics. The progress made in the professional and

psychological care of these patients at both institutions was outstanding.
2o* ACTIVITIES OF SURGICAL-CONSULTANTS

Orithopedic Sections

Thoroughly competent chiefs ofthe orthopedic section yerepresent in all h6bpitils~ b t, pi k eymen, n t ,, large q

load 'was underthe direct care

ofMi wifhJo little expertience,or interes., T echnge in offcei's was,, o

i~api~that, in- spite of biuh effort, the use ofsuspiension-tactionivasnever. too

satisfktoiy. Too many patients were kept in plaster encasement, Them amiteaniice of proper length and axis while an open fracture was healing was,

a6c6omplishefd particularly well at Halloran General Hospital- as was also th

condiiioningof the quadriceps and the maintenance of proper power 0fthe

Achiiles tendon. This was due to an exceptional section chief, M aj. George

Caitponter, MO. At Thomas M. England Hospital, the amputation center

made&considerable fresh homologous bone available. Maj. Rafe N. Hatt, MC,

chief of the orthopedic section, used this in many instances to replace loss of

major bone length with excellent results. This Was before the idea of a

bone hank had been conceived.

In all but one hospital, the chief of orthopedic section was in charge of

physical therapy. The least valuable physical therapy department was the

one in which a full-time officer in physical therapy was in charge. In..Hailoran, the major portion of physical therapy treatment was performed on bed

cases. This was as it should have been, rather than waiting for bed cases to

become ambulatory. Massage should not have a major use in Army physical

therapy.

The value of occupational therapy depended entirely on the imagination

of the personnel. At that time, too few technicians were trained to give functional occupational therapy, and the stress was chiefly on recreational therapy.

This was little needed outside of neuropsychiatric sections.

Miscellaneous Patient Care

The plastic, artificial-eye center at Halloran General Hospital, under Maj.

Victor H. Dietz, DC, did beautiful work (fig. 31). Maj. Dietz was one of

the originators of this process.

Anesthesia schools for nurses were conducted at four hospitals. Twentyfour nurses were graduated during 1945. The nurse anesthetists were of great

assistance.

Cantonment type buildings lent themselves readily to the installation of

a recovery ward adjacent to the operating suite. This was done at Rhoads

General Hospital, Utica, N.Y., and at Tilton General Hospital. With a recovery ward, for which the anesthesia section was responsible, much better

attention could be given to postoperative treatment as regards fluids, sedation,

atelectasis, et cetera.

A central supply proved valuable in all hospitals. Because of the prevalence of hepatitis, a system was introduced at Rhoads General Hospital in

the summer of 1945 by which all syringes and needles were carefully cleaned,

then separately wrapped and autoclaved.
SECOND SERVICE COMMAND 205

FIGURE 31.-Coiistructizig and fitting artificial eyes at Halloran G~eneral HIosp~ital.

Staten Island. N.Y. A. Plainting- the iris. At far left is miold for preparation of the

cornea, and the basic artificial globe is in the center. B. Affixing primary veins to the cornea. C. Patient wvearing colnpletedl left eye.

600222'-62--16
-206' ACbTIVITIES OF' SURICAL CON4SUTANmTSg

SURGRY I OTH R QSPITAL

Stationand, Convalescent Ho spials

T ehty.eight visitsweieinad to regional or station hospit!s., Thes- .

pitls h-ad many problems. Inappo1{iing his tinme among these h ospitals,

h9 consultant ' took into consideration thei greatest good. for thegreate t

:Th~eCamp Uptop. Convalescent Uo~spital~reqtiiiedmuchl time. Its~cehisus,

iched 4;100. Many patients wei're admitted directly from debarkatiomports

With no moke than it 1field i ,dicl' record. Many patients Were sent Irom

general' hspitals tb the ipeconditioniigi ceiterg in braces and, splints, at ,atime

~i~iX- diPitives were issued to, clear general hospitals as much as possible.

Qrhopedic and neurosirgical consultants from Halloran General Hospital ,

Visiled Camp Upton Convalescent Hospital weekly to advise as to care-andI

dispoSition. Two fine remedil gymnasiums were, qpened in the fall of 1045

whfere patients were taken by companies for therapeutic exercise. It was a:long

hard pil for those concerned to succeed in their desires at thispost. By Janu

*ry 1946, Colonel Kennedy believed that this hospital offered- a tremendous

olprtunity for pretechnical and educational, as well as physical, reconditioning of the soldier under conditions in which his needed medical care was

propeily supervised and continued, and his disposition was determined after

Proper survey by competent officers.

Hospitals Not Under Jurisdiction of Second Service Command

There were within the Second Service Command area three AAF (Army

Air Forces) hospitals and three port of embarkation hospitals, the latter being

directly under the Chief of Transportation, Washington. The surgical consultant could visit the embarkation hospitals, according to regulations, only by

the following chain qf events: The request for consultation had to be initiated

by the chief of surgery tothe hospital commander, who, in turn, endorsed it to

the commanding officer 6i the port of embarkation; the port commander then

endorsed it to the Chief of Transportation; the request then went to The Surgeon General of the Army, to the Second Service Command Surgeon, and

finally, to the consultant. Naturally, this process took several days and the

soldier concerned was likely to be beyond the need of consultation. A similar

chain of events was required in AAF hospitals. The situation was particularly

unhappy because Camp Kilmer Station Hospital, Stelton, N.J., had a complement of 1,524, and the hospital at Camp Shanks, Orangeburg, N.Y., provided

1,259 beds. After the first visit of the consultant to each of these hospitals, the

situation was corrected so that the chief of surgery telephoned his request

directly to the consultant, who then made a visit to the hospital sub rosa. In

the future, such situations should be corrected at a high level.
STREPTOMY-IN .

Much of the early cliical wyork with streptomycinwas carried out. in tihe

Se phrevicq, Command. In May 1. sinmLinta..of llis was

obtkine &from Merk c o fo se inbladder infections in,,p~fP1g*cs4 Halloran. General HospitIn, June, approvas was obtained. for a streptogmyciin

p.61 iii-'tlhe'Second.-Seyvice Command, and,Q.00,00) units were maintained at

t .joS~cdiid Seryice&ommnand .Iaboratory, New, York,, NY,, and 10,000,00

uhits, each 'inre, r tined:at Thoma M,. England, Halloran, Rhoads, and:

ilt h ii Ual Hospitals. T he'fug Was to b issued only on authorization ..

tl service coimmand consultants after the case 'had been discussed: with hospital

In svoifal instances, °streptomycin was used in acute abdominal emergen6i sshuli .ageneral peritonitisfollowing ruptured appendix. Somietimes it

vas injected within a few iour§of operation before cultures were obtained,

Tih its, use-in infected bladdeis, it was found' at Halloran that the 'Proteus bacflus codAid be promptly eliminated within 48 to 72 'iours with a-dosagae

of 1 ,0100' units, but that the bacillus usually recurred within 5 -or 7 days;.

Whei thi administration was repeated, it Was found that the bacteria were

much more resistant to streptomycin. It was therefore determined that an

initiul dosage of from 2,500,000 to 3,000,000 units was necessary in these cases.

In AUgust, the entire output of streptomycin was taken over by the Army

and a ceitain amount of the drug was made available to Thomas M. England,

Halloran, and Rhoads General Hospitals, which acted as pools for the rest of

the command. During the last 3 months of 1945, streptomycin was used as

little as posible because, due to the changeover of method of manufacture, little

could be made available in comparison with the demands. In September i945,

under t he direction of Capt. Edwin J. Pulaski, MC, a research project concerning the effect of streptomycin in war wounds was begun at Halloran. Certain

ward beds were assigned to Captain Pulaski, and a special laboratory was

set up.

SUMMARY

In the Zone of Interior, a consultant system was necessary in surgery. The

consultant was able to diffuse knowledge at the various installations for the

benefit of the soldier. He was able to assign surgical personnel so that they

would be used at their greatest value. He was able to support professional

personnel in positions involving responsibility often greater than that to which

they had been accustomed. He was also the eyes and ears of the service command surgeon in the handling of the professional problems of the command.

Close mutual understanding and cooperation between the surgeon and the

surgical consultant were required, and when they were lacking a change in

incumbents was indicated.
CHAPTER IX

" lhird Service %iommandl

'Water D Wise, M.D.,

ASSIGNMENT, ORIENTATION, AND EARLY ACTIVITIES OF

SURGICAL CONSULTANT

St;, Col. (later Col.) Walter D. Wise, MC, was ordered,tb duty as surgicat

consultant to the Third Service Command and the Military District of Washing-tw August 1943. Previous tothis time, le had been -serving as medicl

director of Se1ective Service for the State of Maryland with the rank of lieutenant colonel. Rumor had had it that assignment as a surgical consultant

carried with-it the rank of colonel and that Colonel Wise would not be assigned to the area in which he lived. As noted, however, he was assigne4

to! the mid-Atlantic area of the eastern seaboard, and his rank of lieutenant

colonel .remained unchanged until July 1944 when a promotion to the rank

of colonel was received. Following this promotion, Colonel Wise was able

to carry out his duties much more efficiently, to act with more authority, and

to command the respect due a surgical consultant.

Since Colonel Wise was the fifth or sixth service command surgical consultant to b appointed, he profited considerably by the experiences of earlier

appointees. For example, Col. Bradley L. Coley, MC, who was serving as

surgical consultant to the Eighth Service Command, had presented before

the American Surgical Association a paper dealing with the duties of a surgical zonsultant which proved to be a great help. Additional assistance was

available, through connunication with many of the other consultants who

were porsonal friends.

Owing to the fact that the commanding general of the Third Service

Command did not know what functions the position of a surgical consultant

entailed and had not been informed of Colonel Wise's appointment, the situation was at first embarrassing; and this consultant's duties were rather vague

for the first few weeks. He visited the nearby smaller hospitals and made

reports in an effort to learn the routine, to improve the surgical services in

the various hospitals, and to become familiar with methods of preparing and

submitting reports. Soon, orders were received to report to a general hospital in another service command for a month's indoctrination. In retrospect,

it seemed that a trip of a few weeks or a month with one of the established

surgical consultants would have been a better aid in the training of a newly

209
210 ACTIVITIES OF SURGICAL CONSULT.NTS

appoifited consultant. Something was learhed, howeverjAbout the paperwqr9k

iii-Ageneral hospital, dispositionboards, and, perhaps more importaiti,about

the -weIknesess-f someof the services in. this -particu lar jiospital. Aft rt e

month' oftraining, Colonel Wise's routine work began with Visits throughout

the, Third Service Command and the Military District of Washington. Which

*ere-cbntinued until after V-J Day.

At the time of Colonel Wise's appointment there was as yet no medical'

or neuropsychiatric consultant in the Third Service Command, and no orthoped&econsultant was ever assigned. The vast number of fractures and.other

orthopedic conditions were seen by Colonel Wise, who, fortunately, had had

a large experience in fractures. The services of the late Dr. Guy Leadbetter

of WaShington, a civilian orthopedist and consultant to The Surgeon Genera],

were available. Dr. Leadbetter visited a number of the general hospitals and

some of the regional hospitals with the surgical consultant with great benifit

to the patients, the orthopedists, and the surgical consultant. Eventually, the

medical and neuropsychiatric consultants were appointed. The three consultants-surgical, medical, and neuropsychiatric-visited all of the medical installations in Pennsylvania, Maryland, Virginia, and the District of Columbia.

They also met most of the ships coming in to Newport News, Va., with sick

and wounded and accompanied the patients on the train to McGuire General

Hospital, Richmond, Va., where they were sorted for distribution to appropriate centers (fig. 32). Before McGuire General Hospital was opened, some

shipments of wounded went to Woodrow Wilson General Hospital, Staunton, Va.

OBSERVATIONS CONCERNING HOSPITALS

Personnel and Interpersonal Relations

By August 1943, the general hospitals in the Third Service Command

were, with few exceptions, manned by well-selected, capable medical officers.

The station hospitals, though the staffs were not permitted to do major-grade

surgery except in emergencies, needed much more supervision and more frequent visits. The regional hospitals occupied an intermediate position in the

type of sLgely which was permitted and in the talents of the staffs. In

correcting any inadequacies in the regional and station hospitals, Colonel

Wise always had the full cooperation of the Office of the Surgeon General.

With one or two exceptions, there was little or no evidence of use of

)olitical influence in the hospitals of the Third Service Command. Friendships of long standing, however, or ties newly made among the medical officers

of the Army of the United States and the U.S. Army created some ten)seness

and at times inefficiency. In one important hospital, there was a staff that

contained ;everal friends of civilian days, and there was a group from one

large cit. ho had worked together at home. Some of these had received

assigmnents by the commanding officer of the hospital which were not strictly

based on merit, with some bad results. The consultant was slowly learning
TID SEICE COMMANID 211

e
212* ACTIVITIES OF -SURGICAL, CONSULTANTS,

about-this situation wlhen tie Office of the Surgeon General obtained-accirate

ifsid6, information and sent representatives fromiboth the Surgical and Xed

l 1isultants Divisionsandtthe situatn wasremedibd,

A situation that, seemed, to-i he-surgicul consultant ,to need -impr6veinent

.as,,tlho.6ccasion~al lack of ability on-the part of-the bRegular'Army medica:

ofer" to, give proper value to the professional qualifications of an outstanding

temporary medical officer commissioned in the AIS (Army of the VUned

States), Thisresulted in some inequities not conducive to good service. Like.

wise,, some of the highly trained surgeons of the AUS would not or coulqtnt

assume administrative responsibilities demanded by the Army. It was:ii such

situations that the consultant could be of great value. He, too, was of the

AUShowever, and sometimes went down to defeat at the hands of an occasional hospital commander who had been trained to adhere to rigid require;

ments of the Regular Army.

Outstanding Performance of Personnel

Upon assuming duties as surgical consultant, Colonel Wise found that, as

previously mentioned, there was already much surgical talent in the command, particularly in some regional hospitals and in the general hospitals.

Some of this talent was, of course, ordered overseas; some remained for the

duration; and some had already returned from overseas. Other talented

surgeons came later. Not all who deserved commendation can be mentioned,

and it may be wrong to name any for fear of unjust omissions. It would seem

lacking in appreciation, however, not to mention the high type of work done

by such men as James Barrett Brown and Bradford Cannon in plastic surgery;

Rettig Arnold Griswold, John C. Lyons, John Owen, and Leslie E. Bovik

in general surgery; T. Campbell Thompson, Henry F. Ullrich, George 0.

Eaton, Leonard B. Barnard, and Sims Norman in orthopedics; Brian B. Blades

in chest surgery; and M. Elliott Randolph in ophthalmology. Each of these

surgeons had associates of ability. Outstanding help was given the regional

hospital fit Fort George G. Meade, Md., by Lt. Col. John H. Mulholland,

MC, of the 1st (Bellevue Affiliated Unit) General Hospital.

Equipment

The hospitals were superbly equipped with instruments, traction apparatus on the wards, X-ray machines, and physiotherapy equipment. When

Germany was defeated and the end of the war seemed in sight, many temporary wartime medical officers gave consideration to this plethora of Army

hospital equipment and the dearth of it in civilian hospitals. Remembering

that this valuable material had already been paid for by the public, they

wondered if it could not be made available at reasonable rates to the civilian

hospitals at the close of the war. Suggestions along these lines were made
THR, EVIECOMM AND 1213~

461i ii advance of V"J Day, and:hopes were high, but realization fell far

)vl~ 'opes.

Effictso,6f ,Rapid Dm6obilizAtidn

After V-J Day, rapid demobilization so damaged medical organizations

tp, rrke it difficult to keep the Zone of Interior hospitals manned with

c apabl t§,urgeons. The consultant had little or no time for supervision of, the

deteriorating surgical work because he was kept at service command headquartrs trying to find replacements for officers being let out. Unfortunately,

the di~charge of patients from hospitals could not keep pace with the discharge or medical officers. The signing of the armistice stopped surgical

admissiois to a tremendous degree, but it did not speed up the healing of the

cases of osteomyelitis of the femur nor did it provide the needed plastic.

surgery, in those previously wounded or burned.

SUMMARY OF ACTIVITIES

There were many incidents outside of the routine duties of the consultant

which served to keep up his interest and to be stimulating. Among these was

the recognition of the dangers of Pentothal sodium (thiopental sodium) as

an anesthetic agent and a report of these findings to the Office of the Surgeon

General, with the resulting directive from that Office as to the proper use of

the drug. Another was attendance at a very secret conference dealing with

Japanese balloons which were being sent on the stratospheric air currents and

which had landed in considerable numbers in the Northwest and also in the

north-central region of the United States. There were many other experiences

which were more of personal than of historical interest.

The duties of the service command consulting surgeon in essence were to

obtain the best treatment for ill or injured members of the Armed Forces and

any others treated in service command facilities. To this end, he evaluated

surgical personnel and equipment of all kinds; consulted about individual

patients, classes of patients, new and old measures and procedures; and attempted to be an activator of hospital staffs. He stimulated staff meetings,

grand ward rounds, conferences, and journal clubs; helped arrange for speakers; and tried to see that new procedures of merit were not neglected, while

trying to discourage procedures that had been tried and found wanting or did

not justify further trial. In this he was aided a great deal by formal meetings

and discussions at installations within his service command and by many meetings arranged by the Office of the Surgeon General and held in Washington or

commands within reasonable distances.

COMMENT

The sudden expansion of the Army Medical Corps and the rapid establishment of the many oversea and Zone of Interior hospitals and other medical

units was necessarily a great drain on medical and surgical talent. As a re-
214- ACTIVITIES: ,QF S9URGICL CONS9ULTANTS'

sit, all -demands could not' be net in ,the way desired, This naturally led to

much effort in, the attempt to ,get the mtost.advantageous disposition of avilable nen. Thsfforts, in turnh, wereacmaiab iapitet hr

and- ritisn thr.Toghdal -could'not ber~acQ,. 6~ve rtheiess Ah

~gi~.l~erieerecIvab the pqtients was, -all lhings con, iderdf a igh'

0
CHAPT.ER'X

Fourth !Service Command

itM~hr Cleveland, M.D.,, and James 1. Calahan,. M.D.

Secti0ni. September 1943 to April 1944

The Fourth Service Command, comprising the south6astern tier of

'States-4orth. and Soutli Carolina, Georgia, Florida, Tennessee, Mississippi,

and AlAbama-during 1943 and 1944 had approximately 2 miiiion troops in

training. To serve" the medical needs of these troops, there were 130 station

andJ geherfi'hospitals.

The Fourth Sei'vice Command surgeon, Col. Sanford W, French, MC,

VHl headquarters in Atlanta, Ga., had the services of consultants in medicine,

surgery -ad psychiatry, and in September of 1943 a consultant in orthopedic

surgery, Lt. Col. (later Col.) Mather Cleveland, MC, Was added. At the time,

only one other service command (the Fifth) had an orthopedic consultant.

The training of troops, ground or air, entailed strenuous physical exercise

with many fractures. The sports program probably contributed as many

fractures asj if not more than, the obstacle courses. Accidents due to vehicles

on and off the post added to this list of injuries to bones and joints. A large

percentage of the surgical cases in all hospitals were injuries of this type and

were under the care of the orthopedist. Even before casualties began to arrive

from overseas, it was obvious that an orthopedic consultant was required for

the large service commands.

Colonel Cleveland's tour of duty in the Fourth Service Command as

orthopedic consultant extended from September 1943 to mid-April 1944. During this period, the general hospitals were being increased in number and the

large station hospital staffs were being depleted to supply medical personnel

for oversea units. In many instances, adequately trained orthopedic surgeons

were no longer available in station hospitals. Elective surgical procedures

and major fractures, by directive, were supposed to be evacuated to general

hospitals, and orthopedic surgery in station hospitals was confined to first

aid, minor fractures, and an enormous outpatient service.

HOSPITALS

Many of the station hospitals in the Fourth Service Command were very

small, especially those serving a great majority of the smaller airfields. For

instance, within a radius of 50 miles about Finney General Hospital, Thomas215
.1" ACTIVITIES OF SURGICAL CONSULTANTS,

Ville, Ga,, there were- 5 oi' 6-sinall Air Force station hospitals, each completely

6quiiped.andstaffed With an average iumber, ofnrse? and medicalofcers

fdr th e iatient load' There werealSo largeAir Force station h"spitals ,scil

as" s6,atKee~er Field, Bil6xiMiss., at-Gulfport Army Air Field. ,Guilfport,%

i§- -aid at Maxwell Field, MontgOmery, Ala, These were very wdl iprovided with nurses and competent professional personnel and. ktndered .ahigli otfi~iy6,profdissiobal care;

Ti6 station hospialS Of the Army Service Forces serving large numbers

of,, troops-of Army Ground Forces at the larger training centers, such as Fort

Bragg, N.C., Fort Jackson, S.C., Fort Beinfnig, Ga., Camp Blanding,YFia.,

Qamp Van Dorn, Miss., and Camp Shelby, Miss., were enormous and, int hlip

ligit of experience, were vastly overbuilt and, in time, professionally ifiderminned. Four of these hospitals had 4,000 or more beds, and the maximum,

census, the writer believes, was never over 50 percent of the bed capacity.

The general hospitals in the service command were almost invariably well

equipped and had a competent professional staff in each instance.

Although the semiautonomous Army Air Forces were actually under

Army command, it became increasingly evident, during the consultant's tour

of duty, that the service command consultants were less and less welcome at

the Air Force hospitals, It was impossible not to call attention to the evident

fact that the small Air Force station hospitals were too numerous and too overstaffed with nurses and physicians, while many of the hospitals serving the

Army Ground Forces were lacking sufficient nurses and physicians for the

patient load. These personnel discrepancies constantly called to one's attention became distasteful, and the service command consultants finally visited

Air Force hospitals only on invitation. It is to be hoped that in any future

emergency, there will be better distribution of physicians and nurses.

PROFESSIONAL PROBLEMS AND ACTIVITIES OF THE

CONSULTANT

The problems confronting a service command consultant in orthopedic

surgery were mainly (1) personnel and (2) professional care of soldiers with

injuries involving bones and joints. The field of military orthopedic surgery

was well defined and well recognized in most instances. An occasional chief

of surgical service considered himself competent to handle the entire field of

surgery and overrode the judgment and neglected to use the operative skill

of his orthopedic chief. This resulted, in one instance at least, in ill-advised

elective knee joint surgery.

The problem of having skilled personnel in the proper places was fairly

constant. There were increasing inroads on the orthopedic services of the

various large station hospitals as personnel were withdrawn to staff new hospitals intended for oversea service. Withdrawn also were orthopedic surgeons

belonging to affiliated hospital units, which had completed their parallel train-
FOiiT SER(VICE COMM ND 21

ing witl the stationhospitals and movedto ports of embarkation. It became

evidiii-that mostf iftlie station:hospitals woul4d:no longer/have trained orth-

' By tl spring of 1943',directives had been.issued' to transferall. -a or

ortlioledi& problems, inejuding elective surgery, to -tle general hospitals lot hilicommaii. The 2 original gencrlhospitals in the command were incr6hased, during late 1948. and early 1944, ,to 11, and, an adequate brthopedid

seton oWas :provided for each of these hospitals. In some instances, well-

'trained,' rti6pedic surgeons were left in some of the larger station lispitils,

but t6 scope of tleir professional work was curtailed. For the most part

tliirectives were complied with, and major orthopedic problems were iandi~~ i~ii ti general hospitals.

Dbiriig the author's 7 months as orthopedic consultant for the Fourth

SbrvicCbihmand, he visited the 11 general hospitals, all of the large Army

station hospitals, and many of the smaller ones, approximately 60 hospitals in

a lb

A, separate report was rendered on each hospital. Reports on class I

hospitals ut posts, camps, and stations were submitted to the Commanding

General, Fourth Service Command, through the commanding general or officer

of tlo installation. If the hospital was located on an installation of the Army

Air Forces, the report was submitted to the commanding general or officer

of tle airbase, Reports on general hospitals surveyed were submitted to the

Commanding General, Fourth Service Command, attention Chief, Medical

Branch.

These reports were thorough. All orthopedic patients were seen and

problems were discussed fully with the chief of section. The X-ray department, physical therapy, rehabilitation; and disposition of patients were reviewed. The operating rooms were inspected, and anesthesia, nursing, and

personnel were commented upon. A hospital with a large orthopedic service

or section might take 2 or 3 days to survey. At the end of such a survey, very

complete data were available on which to evaluate the orthopedic care afforded

in that particular hospital or medical installation.

Colonel Cleveland considered his chief function to be teaching and the

interpretation of the various directives related to medical care. The term

"inspection" seemed to connote a snooping and, perhaps, an effort to find fault.

A consultant had to be fair and kindly, but lie could not escape occasionally

finding conditions which required warning or even reprimand through proper

channels. The consultant needed to "walk softly but carry a big stick." IIe

could only advise; the command surgeon ;.uld implement the advice if lie saw

fit. A consultant who hoped to be invariubly popular was, above all, foolish.

Personnel allotments for a service command headquarters carried no specified position or rank for medical consultants. It was Colonel Cleveland's

considered opinion that, since the Armed Forces are constructed on a basis

of rank and are thoroughly rank conscious, consultants should ha% e had rank
21i8 ACTIVITIES, OF SURGICAL LONSULTANT

-4il t6 or h;het than that of the commanding bfficers o fall medical fadiities

Oi the consultants ofally, o0the Fourth Service ,Command were ent

0 iif@ a team to survey a, trouble spot for the, service command, surg~o. ,I. . oie mii 6tjice, one of this service command's newly opened general-hospitas!.

eceived'undue and unwarranted publicity:by a radio commenta torbecause- oftlhe c ofusion that attends any new staff which is overwhelmed by the arrival

"of a arge number of patients. A complete survey of the hospital, was -made,

air patients were seen, and some semblance of order was instituted. aditinal orth6pedic personnel were provided. Many of the patients admitted,

tolis hospital could have been disposed of at the station hospitals, a majority

bret in to duty.

Oi another occasi6n, all the consultants were sent together to Stark Gei-,

rHospital, Charleston, S.C., to see the first casualties returned from Norfth

Africa. The wounds-of the extremities with long-bone fractures had at this

time all been treated by the closed-plaster technique-a method later abandoned; Many of the amputees had protruding bone ends visible in the stump

du6 to failure to utilize skin traction on the stump. Stark General Hospitalwas transformed into a debarkation hospital and the casualties were shipped

from this point to the general hospitals nearest the homes of the returnees.

The relationship between the four consultants-medical, surgical, orthopedic, and psychiatric-in the command surgeon's office was cordial and helpful. Mutual problems were freely and fully discussed. The surgical

consultant and orthopedic consultant frequently, on separate tours or consultations, noted and brought to each other's attention problems affecting the

surgical service or the orthopedic section of various hospitals.

It was a pleasure to serve under Colonel French and on his staff with

Col. I. Mims Gage, MC, Col. F. Dennette Adams, MC, and Col. (later Brig.

Gen.) William C. Menninger, MC. The staff made a constant effort to see

that the sick and wounded of the Fourth Service Command received superior

care. It was believed that, on the whole, they did receive such care.

MATHER CLEVELAND, M.D.

Section II. 1944 and 1945

GENERAL DUTIES OF THE CONSULTANT

The consultant's general duties were twofold as follows: (1) To supervise

the overall professional care of the sick in hospitals of the Army Service Forces

in the service commandl, and (2) to evaluate professional personnel and make

recommendations for their assignment. In further detail, the orthopedic consultant, Lt. Col. James J. Callahan, MC, provided overall direction and supervision of the orthopedic services in each medical treatment facility, conducted

regular rounds of orthopedic wards, maintained liaison with the Professional
FOU R TH-SERVICE COMMAND ,19.

Sr&Vi'- ifi theffice of tl3e Sugeon Generall and the other members of the service command medical- section, evaluated professional per snneI assignedt 16

ofithopedi-services within the service conmand,, and made recomqmendations

regarding a signment and transfer, of ,personnel'. P6fessional papers were,

subimittedi o tohe consultant for his approval for pUblication by the TedichI

Department, Afterreviewing these papers, he forwardedthem to the Office

ofth6Surgeon General. It was the consultant's purpose to encourage by pre- ept thelughest level of professional care of patients and the general imprveiii~t, With kdspect to professional information and skill, of the officers assigned

to .the orthopedic services. He had to be available for professional consultatioh concedting orthopedic cases. It was expected of fli orthopedic consultant ,

'thathe make suggestions for the correction of deficiencies in service.

It may go into the record that, in Colonel Callahan's personal experience

'as an.orthopedic consultant, he always received the fullest cooperation of the

service command surgeon, who was, first, Col. Sanford W. French, MC, and,

later, Br'ig, Gen. Robert C. McDonald. Both officers always gave a sympathetic

ear to suggestions. Most observations were discussed with the commanding

officer and chief of services at each hospital, and corrections or suggestions

were made at the time of discussion. The commanding officer and the several

chiefs of services in every instance gave the most constructive cooperation.

Area Served

The orthopedic consultant served as adviser to the service command surgeon and, through him, advised the appropriate branch in the Office of the

Surgeon General. The services of the orthopedic consultant of the Fourth

Service Command were available to the 40 hospitals in operation at the close

of 1944 in that command. Ten were general hospitals, of which three-Kennedy, at Memphis, Tenn., Lawson, at Atlanta, Ga., and Northington, at Tuscaloosa, Ala.-were designated as special centers for neurosurgery as well as

orthopedic surgery. Lawson General Hospital was, in addition, an amputation center; and Northington General Hospital was also a plastic center where

specialists performed plastic surgery. A creditable achievement may be recorded here because of the many corrections of deformities and disfigurements

which enabled restored patients to be returned to society and even to duty.

The Fourth Service Command did not have its own vascular center; thus,

all vascular surgery cases had to be transferred out of that command.

The remaining seven general hospitals were Battey, at Rome, Ga.; Finney;

Foster, at Jackson, Miss.; Moore, at Swannanoa, N.C.; Oliver, at Augusta, Ga.;

Stark; and Thayer, at Nashville, Tenn. All the general hospitals had qualified orthopedic surgeons who were certified by the American Board of Orthopedic Surgery.

Stark General Hospital was the receiving hospital for the Fourth Service

Command. There, patients were received from overseas; casts were changed

or removed; wounds, dressed; new casts, applied; and the patients were made
220ACTIVITIES O0F -SURGICAL CONSULTANTS

generally comfortable beforethey ,were- transferred, for, definitive.,treatinto

hb§Pittiliclose ,to their .homes. The staff at Stark.-General Hospitail id a

.. ..j.§ servfic under .pressing, eircumstances of great numbersof patients

phgliroug i in-,rapid urnover.

PROGRAM OF SPECIFIC DUTIES, 1944

During 194, the orthopedic consultant visited each medical -treatment,

fabiiy ii the Purtlh Service Command at least once and in most instnc"es', twie. Dur ig these visits, ward rounds were made with the chiefs of the

various, services. The work of the several sections was reviewed, the quality

O ciiiical records was assessed, and patients presenting special problemswe

examined on. a consultative basis. The consultant was also called on to disuss.

current. medical problems with the officers. Those consultations and-geberal,

epen-forums contributed importantly to professional progress, for each oft1

officemr had an opportunity to voice his opinion and to acquire knowledge from

the bther officers or the visiting consultants. This approach helped to unify

the system of treatment, so that medical care to the patient was inevitably

improved.

A further duty of the consultant was to attend meetings of the different

medical disposition boards in order to facilitate the disposition of cases andat

the same time to insure that disposition was made in accordance with existing

instructions of the War Department.

It was required of the consultant that he supervise decisions to operate so

as to eliminate unnecessary operations in cases in which disability existed before induction. It was in this regard, for instance, that recurrent dislocations

of the shoulder and recurrent injuries or dislocations of semilunar cartilages-"

particularly in those cases in which there was a severe atrophy revealing a long

history of injury-were accurately screened before surgery was permitted.

It was evident in this type of condition that the patient would not return to

active duty. Limitations were never imposed on any type of reconstructive

surgery that might yield the best possible functional result. Treatment, however, liad to be planned with a view to the patient's ability to return to duty

whenever this was at all a possibility.

THE ORTHOPEDIC SERVICE AND SOME ASPECTS OF THERAPY

Back wards.--Some of the general hospitals had organized back wards

(wards for back disorders) collectively controlled by the orthopedic surgeon,

the neurosurgeon, the physiotherapist, and the roentgenologist. When the

many cases in these wards had been reviewed, it was decided to have a consultation with all the ward personnel. Each case was again reviewed and

examined individually. At the conclusion of the examination of all the patients, it was decided that a back ward was not a wise method of grouping back

cases. The patients discussed their symptoms with one another and found them
TOURTMSERVIOECOMMAND- 2

,smilri;althouiih tlefiidings were often different; thus, subjective symptoms

-incrasoed Theb4ck wards were as a consequence disbanded. Pisbandi1ig

t iee ard§ did not eliminAte the problem, hjowever, becuse so nmany casesiu

b diagnosed as di§ksynd'oms or.as-positive forn disk'finhing. The di .-ha&beine a-too p pulhr diagnosis. Certainly, disk cases occurred, but n6bt

so.0 comnilly- as the diagnoses 'had been nade;- moreover, it was believed that

w'!b- th6y, did exist, treatment should be conservative. Patients were therefter~placed intraction. Many were placed in plaster of paris casts. Mapy

dthemvere manipulated either with or without a cast application, The numbei

of opepative disks was.substantially reduced. On the other hand, when theie

:Were o&efinite indications for surgery--that is, when the patient did not re9spoiidt6 conservative care--the orthopediu surgeon assisted the neurosurgeon;

'If cofigenital deformities existed in the vertebras or if there were beginning

artiritic changes, then stabilization, either with cortical and cancellous bone

or corticallbone alone, enabled the patient to have restored to him a stable back;

Those patients who had fusions performed were in a large measure relieved

of pain; but those who did not have a fusion done frequently complained of

the.same pain postoperatively. Even though the patients thus operated on

would usually have to be discharged because of disability, an effoit was made

to restor6 them so that they could return to gainful employment.

PhySical therapy under orthopedic service.-The Surgeon General

placed physical therapy under the orthopedic service, which was an excellent

idea inasmuch as the orthopedic service furnished most of the patients for the

physical therapy unit. The close cooperation between the chief of physical

therapy and the chief of orthopedics in a hospital meant better and quicker

rehabilitation of the patient. More than half of the patients in most of the

hospitals were under orthopedic care. For that reason, it was suggested that

the chief of physical therapy make rounds with the orthopedic ward surgeon

to permit frank discussions in evaluation and choice of treatment.

Complete rounds innovation.--In point of fact, a logical suggestion was

adopted pertaining to complete rounds. Each time the consultant visited a

hospital, he saw every patient in the ward. This encouraged the younger officers, improved the morale of the patient who then felt that lie was given the

benefit of consultation, as lie was, and confirmed each chief of service in his

judgments or helped him to resolve his doubts in difficult cases.

Amputations and rehabilitation.-Lt. Col. Edward C. Hol~sher, MC, who

was in charge of the orthopedic and amputation service at Lawson General

Hospital, guided commendably the program instituted at the hospital in

which, for example, every effort was made to preserve the involved joint,

which was usually the knee joint. Conservative treatment, to be sure, as

always, depended on careful evaluation so that the patient's life would not

Fe endangered. Efficient traction, careful plastic repair, early physical

therapy, and rehabilitation in all its facets all constituted care of such superior

quality that many of the amputees could be reclassified and returned to duty.
S 222"ACTIVITiES 0' SURGIAL CONSLTANT'S

The, formation of a large rehabilitation: center at Daytona Beach, Fa

calld J4 WelcirConvalescent Center, significantly relievedthat phase64f the

workload',at ,thetgeneral, hospitals., As soon as-a patient-iva- ainbtotg, he

was'4ransferred to ,that large installation where care Was geared exclusively

to tie :pr6blems of rehabilitation, There, the will to get well wis An Active '

force. Under the direction, of Maj. Newton C. McCo1lough, MO, the" setion

on 6rthopedics provided superior care. As the service command consultant

on ian inspection visit, Colonel Callahan had the opportunity to examine 6V 0'

patient. Major McCollough and the consultant discussed individual pr6bldi

cases, to determine appropriate disposition regarding ti'ansfer to a geiinal:

hospital or a specialty center for definitive care or for further surgery.

Prevention of. fractures by proper fitting of boots and soeks.-Agram was developed at Fort Benning to correct avoidable deficiencies-in the6

wear.Ing of boots and socks. First to be considered were the shoes and socks

of the parachutists of the airborne divisions. Each soldier was measured for

correct size of socks and boots. Many had been wearing socks that Were t66

short and boots that were inadequate. This malpractice was evidenced by

the number of needless injuries to feet and the number of fractures of the

leg and ankle. The boots were designed with double straps which would not

remain in the slot intended for them; frequently the straps would catch in the

shroud of the parachute, throwing the foot. As a result, typical fractures of

parachute jumpers were observed-fractures of, the ankle and of the head of

the fibula, as well as knee joint injuries. That defect in the boots was

corrected.

It was Maj. Roy Ciccone, MC, who classified the fractures incurred and

collaborated in bringing about the needed corrections in apparel.

Multiple operations of the knee.-At the beginning of the war, many

operations of the knee were performed without enabling the soldier to return to

duty. Instead, certificates of disability for discharge had to be issued. Later,

a program was instituted whereby the men were better screened in the first

place. Those operated on were given appropriate preoperative and postoperative exercise and rehabilitation opportunities; thus, the numbers that

had to be discharged were greatly reduced. This curtailment of surgery did

not apply to those who had received injury in line of duty, although the new

exercise and rehabilitation measures, under complete supervision, benefited

them as well.

Many of the cases of internal derangement of operative knees had been

the result of insufficient care in evaluation before operation. There were,

for example, two cases of arthrotonies in which no pathologic condition had

been observed. An occasional soldier had been operated on for an internal

derangement of the knee, although the condition had existed before induction.

Inasmuch as half the orthopedic surgery at Fort Benning at one point concerned internal derangement of the knee, the opinion was submitted that each

case be more carefully considered and evaluated. It had been true, moreover,
FOURTH SERVIC COMMAND 223

that soldiers who were operated on for internal derangements of the knee

were ilowed out of bed in less than a week after the operation. Rehabilitaton.

wa. tarded and not hastened by such early weight bearing. Many distended,

swo.en, painful knees were observed as a result of too early weight bearing

andearly ambulation.

Recurrent dislocations of the shoulder.-Again, many cases of recurrent dislocations of the shoulder had existed before entrance or induction into

the service. With the rigors of military training, dislocations were bound to

recur. Early operations to correct these conditions had not been successful,

so that the soldiers had to be reclassified for limited service or discharged. As

time and experience progressed, it was realized that it took at least 6 to 12

mont s before such patients could be returned to useful service. The number

of operations thereafter authorized was greatly reduced. Surgical correction

was attempted only when the prognosis gave reasonable justification.

Fusion operations on the splne.-Fusion operations on the spine were

authorized only when there was an unequivocal indication for the procedure.

Backaches from conditions that had existed before induction into the service

were rarely considered an adequate indication for surgery.

March fractures.-Another change that was instituted concerned fractures incurred during marches, designated march fractures. It w: - concluded

that it was better not to transfer patients with march fractures to , aeral hospitals because, by the time the diagnosis was made, the fracture was well on

its way to healing. Two or three weeks of rehabilitation or of limited duty

would enable the soldier to resume active duty.

Traction for simple fractures of the femur.-In the treatment of fractures of the femur, an order had been issued to place the extremity with simple

small fractures of the femur in traction. That was wise, for the alternative

ine.sure of placing the leg in plaster-although it afforded good immobilization-did not give an opportunity to examine the limb for the presence of

thrombophlebitis or phlebothrombosis. Neither did the plaster-encased leg permit early active physical therapy, including massage, muscle contraction, and

movement of the knee and ankle-an essential motion. These difficulties, for

example, were characteristically observed in fractured femurs evacuated from

overseas in plaster spicas.

Many orthopedic surgeons were under the impression that casts represented

the optimum in treatment, so that it was nzcessary in making rounds or visits

to the hospitals to explain the advantages of the traction and to insist that the

order be executed. Deformities had frequently been lound in those cases in

which the fracture had been immobilized in a body cast. Traction, either skin

or skeletal, resulted in fewer deformities and fewer cases of shortening; moreover, it facilitated the dressimig and care of wounds.

Open fractures and skin grafts.--There were many cases of open fractures of the shaft of the femur or of the tibia with a loss of bone substance in

which skin arafts had been performed, a skin dressing had been applied, and
294 ACTIVITIES OF SURGICAL CONSULTANTS

the leg had healed. Exercise had been ordered to keep the adjoining joits

actiye soas to increase circulation and restore muscle tone. Later reconstuc,

tiresUrgery reinforced the shallow or narrow bone and resulted in excellent

weightbearing surfaces. This treatment certainly obviated the need fdr many

amputations and prevented permanent disabilities in the weight-bearing extremity. The policy of saving what tissues remained so that something could

be added to the preserved member was worthwhile as it gave a well-functioning

limb as an end result.

Osteomyelitis and skin grafts.--Chronic osteomyelitis following open

wounds was observed often, because of the program of treatment of open or

compound wounds. At first the cases were protracted, but later, after the

wound had healed or at least had begun to granulate, either early grafting was

done or a skin dressing was applied. Because of the early skin dressing, the

wound remained clean. Operation was performed early in such cases with a

full thickness graft or pediele graft. The entire program was well worth the

time and effort as it reduced the morbidity and saved many an arm or leg that

might otherwise have been lost.

To be sure, it was discovered early that the antibiotics were helpful, but

they were not wholly responsible for the improved results. Antibiotics could

not substitute for good debridement, skin coverage, or dressing in cases of

chronic osteomyelitis or cases of large open wounds.

Massive bone grafts.--If the skin graft had fulfilled its purpose of a

closed clean wound, then the consideration for definitive treatment was in order. Thus it was that large defects were soon closed with bone grafts. Many

were successfully accomplished because of the clean wound and bed furnished

by the skin graft; otherwise, in cases of large defects, it would have been necessary to amputate. In many instances, this important procedure prevented regrafting and the unnecessary loss of precious bone. Dr. John Flanagan at Kennedy General Hospital was responsible for some of the excellent surgery of

these massive bone grafts which saved many arms and legs.

Regrettably, a bone bank was not available at that time. Bone from such

a bank could have bridged the defect without sacrificing the patient's own bone

and would have permitted the patient to be ambulatory early, without the risk

of fracturing the good member at the donor site.

Hand surgery.--Hand surgery centers were established with the initial

instruction given by Dr. Sterling Bunnell to all the officers from the general

and regional hospitals. The benefits of this experience in how to salvage as

many hands and fingers as possible and in making tendon and nerve grafts

carried over into civilian life. Many hands which would otherwise have been

useless were saved and rehabilitated. That effort represented the first time that

emphasis was placed on the specialty of hand surgery.

The braceshop.-An important facet of the orthopedic organization was

the braceshop. Most of the braceshops were in charge of civilian bracemakers

who worked commiiendably for long hours in the performance of their duties and
FouRTh :SERVICE COMMiND 225'

in instructing Army personnel. Their trainees were able to produce professioiiai'braces and calipers. Many of the military trainees have carried the skill

of iiriemifaing over into ciVilian° life from the Army where they had perf6reado6 ssefntially in an auxiliary service vital to successful orthopedics.

Miscllianeous observations.-It, was interesting to observe in the orthopedic clinics how many soldiers had objective symptoms, how many subjective, and how many had symptoms entirely without foundation. Of all symptoms rec 'rded in the clinics, foot disorders represented about 70 percent; knee

disabilities, about 15 percent; and backaches, from 15 to 20 percent. These proportions varied, to be sure, particularly in regional hospitals with large numbers of trainees. At Moore General Hospital, at one time, there were 40 cases

of Self-ifiicted gunshot wounds.

It was-interesting that there were so few cases of thrombophlebitis or phle;

bothrombosis among the vast number of injuries treated in the Fourth Service

Command.

At Lawson General Hospital, there were four cases of temporary paralysis

as the result of using the pneumatic tourniquet-three in the lower extremity

and one in the upper. All patients recovered.

The large prisoner-of-war camp at Camp Forrest, Tenn., presented many

serious orthopedic problems. Lt. Col. Clarence W. Hullinger, MC, was in

charge, with the assistance of Maj. Ernest Dehne, MC, and other surgeons.

Their program was notably efficient. Col. Mims Gage, the service command

surgical consultant, and the orthopedic consultant frequently visited Camp

Forrest for review purposes and, on occasion, participated in surgical procedures to rehabilitate patients. Colonel Gage's advice and constant vigilance

for complications were noteworthy. The close cooperation between the surgical

service and the orthopedic service was largely due to his interest.

All the commanding officers and personnel of the hospitals in the Fourth

Service Command performed excellently during the writer's term as consultant. It was the exercised aim of all to give each injured serviceman the

best possible result in the shortest possible time. To further that end, the

best available professional personnel were invariably assigned to the positions

of chiefs of services. As a consequence, during his tenure Colonel Callahan

enjoyed the fullest cooperation of certain chiefs of orthopedic surgery who

have not been credited in previous reports, such as Lt. Col. T. Campbell

Thompson, MC, Lt. Col. Frank G. Murphy, Lt Col. Everett I. Bugg, Jr., MC,

Dr. I. William Macklis, Lt. Col. Saul Ritchie, MC, Lt. Col. Edward Parnall,

MC, Lt. Col. Harold C. McDowell, MC, and Maj. F. Bert Brown, MC.

JA3[Es J. CALLAHAN, M.D.
CHAPTER XI

Fifth Service CommandClaude S. Beck, MD. 1

ADJUSTMENT TO THE ARMY AND INDOCTRINATION

Realizifigthat the war was for~a great cause, Lt. Col. (later Col.)- Claude

S. Blek, M9, was ore of-the many who felt that this country had obligations tohel6p , e democracy. Colonel Beck was eager to give up his work,

Importantias he thought it was, and join the service, The uniform gave him

a sense of satisfaction, but as an Army officer Colonel Beck was green as grass.

A pol -fonimedicd1 officers was a new expression for him. A number of old

friends aid acquaintances were in it, and their common cause brought them

all closeri together.

The famous Walter Reed Army Hospital, where Colonel Beck first

reported, emanated respectability; she was the queen bee o the Army and

nothingless than the Office of the Surgeon General decided npon her medical

personiel. The best of the Army Medical Corps were there. Colonel Beck

listened to many unimportant lectures in his indoctrination and was given

time to unwind from civilian life. He had a sense of guilt because he was not

busy; then he wrote two medical papers. Soon afterward, he was assigned.

On the first day of his new assignment, Colonel Beck invited the service

command (then corps area) surgeon to have dinner with him. He was anxious

to find out about his duties without wasting time. Colonel Beck was informed

that the surgeon would wait to see how they were going to get along before he

accepted the invitation. Colonel Beck was still green and did not know how

his own transplantation into the Army was going to turn out. Many others

felt the same way, and these adjustments created problems which had to be

met and solved. They were problems of uprooting and adjustment to a new

environment. Every soldier had problems, and many of them Colonel Beck

was to see in the Army camps later on. It took time and adjustment to

become a soldier. This was a lesson everyone had to learn.

THE CONSULTANT SYSTEM

It appeared to Colonel Beck that the consultant system was new in the

Army, although there had been consultants in World War I. At the beginz This account was written 10 years after the termination of the war. It was written by request.

and I believed there was little I could add to the reports and recommendations made during the period

of my assignment, It was also written from memory, because I did not have ready access to these

reports. I assumed that my general impressions were desired rather than the intricate details of

everyday life in the hospitals.-C. S. B.

227
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FTH~EVC~OM 229

quiet of ciilian life, aid then widespread application came with the thousands

The:Society for Medical Consultants came into existdnce-aftet the war.

Tfiis. g hiiildsregulAriineetings for discussion of prbblems,oand, at frequent

intervals, consultants are sent to medical facilities in Europe and. the East

whi ethey work in their own fields, give lectures, and make reports which are

widely distributed, In this way, the quality of the medicine is brought to light,

the')i'aleof the MedicalCorps is given a boost, and the service is improved.

The consultant system was weak in the early period of the war, but it became

well established later in the war and exists today as a necessary part of the,

US. Aiym Medical Service.

DUTIES AND RESPONSIBILITIES OF THE SURGICAL

CONSULTANT

The duties of the surgical consultant were not defined when Colonel Beck

was assigned to the Fifth Service Command. When Colonel Beck arrived in his

assignment, it was obvious that he was not needed, and he also felt that lie

was not wanted, The first favorable reaction from the surgeon came when

Colonel Beck told him that he wanted to be assigned overseas with the Army.

The office to which Colonel Beck was assigned used the mail and telephone

for communication with the various medical installations. There were few,

if any, personal visits to these installations. Commanding officers were called

in to service command headquarters for occasional meetings, but the process

was not reversed. Colonel Beck attended these meetings and the discussions

pertained tv matters of organization and explanation of directives from Washington. The service command surgeon did the talking. The meetings were

formal and served little purpose. There was no freedom of discussion, and

it appeared that the care of the sick or wounded soldier was not the chief concern. Colonel Beck was never introduced at these meetings, and lie was niever

invited to make comment or to discuss any subject. The Regular Army officers

from the field were hesitant to speak out and ask questions, and the surgeon's

office in turn seemed hesitant to speak freely with the Office of the Surgeon

General.

After Colonel Beck had acquired sonie experience, lie understood that

this was the Army. There was no doubt in the mind of anyone runfing the

office to which Colonel Beck was assigned that it was adequate in all its various

functions. A big and important job of organization was being done, and it was

not necessary to have a burgical consultant who might have access to Washington. Colonel Beck started from scratch.

One experience, which the author remembers, might be worth notation.

It was his first visit to Camp Campbell, Ky. This was one of the large camps

606222Y-62-17
2380 ACTIVITIES OF SURGICAL CONSULTANTS'

and Was situated between Kentucky and Tennessee, miles away from the

railroad station. The new consultant arrived at the railroad station at2

0,jo0 in the morning. He had difficulty in getting in touch with the camp

to gei transportation. After he arrived at the camp, the driver suggested

that- Colonel Beck get in touch with the officer of the day for a room for the

rest of the night. Then Colonel Beck introduced himself to the commanding

officers of the camp and hospital and began with his work. These preliminarY

problems are cited as examples of unnecessary difficulties that existed and of the

lack of planning at that time.

The duties of the surgical consultant covered considerable territory, but

they were restricted entirely to making a report. In other words, the report

terminated the consultant's responsibility. If an undesirable condition continued to exist at the time of the next visit, it could be reported again. Never

was there any attempt to change the consultant's report or to interfere with the

writing of it in any way. If the condition was not corrected, the consultant

never attempted to use other methods, and there were a few instances when

correction was not made. In some instances, remedial action was slow, but

almost always something was done about every important recommendation.

The Consultant's Report

The consultant's report was composed of six parts, as follows:

1. General considerations, including comment on the hospital as a plantthe ward's, operating rooms, cleanliness, and so forth.

2. Surgical personnel, including a sketch of the training and competence

of everyone on the surgical service and his surgical specialties with his ratihg,

background in surgery, and so forth.

3. Census of patients.

4. Detailed discussion of professional work, general surgery, and surgical

specialties, including the quality of the work, types of surgical conditions, the

number of patients, the backlog of patients to be treated, personnel needs,

problem cases, and so forth. Individual patients were examined. Suggestions

were made for the correction of any professional, personnel, or hospital problems that existed. X-ray, anesthesia, and pathology were included in this

survey. The autopsy examinations and also reference to surgical deaths were

included. In one of the reports, the backlog in general surgery was 92, that in

orthopedic service 27, and that in neurosurgery 400. This lopsided situation

called for the shifting of personnel from one service to another.

5. Medical meetings, library, and medical journals.

6. Summary and conclusions, presenting every possibility for improvement.

This required judgment to separate the important items from the unimportant

items.
'FIFTH SERVICE CoMMAND 231

EARLY PROBLEMS-THE TRAINING CAMPS

As!:C0l6iel Beck looked back over his experiences, he could see readil

ithat- ie"iciivities, of the' Medical Department were those that pertained to

(1),th6 care of soldiers in training, (2)the care of those.wounded in war, ani

(3) rhaiali ation and care after the war was terminated. The problems in

'.ch f these' categories were related to the stage of the war. There was some

0 erpi~ping, but essentially they were different.

The eaily problems in the training camps were without number. Things happened 'ery fast; medical officers were in short supply; often they were

available for only brief periods of time. Later on, the census of an entire

camp might fall, in a period of months, from a very large number to almost

none.

The most important problems in the training camp hospitals were related

to drafted soldiers who did not want to be soldiers. Many devices were used

such as feigning backache, developing enuresis, resorting to self-inflicted

wounds, and so on. The backache and bed-wetting problems were important

because these individuals occupied several hundred beds in the large station

hospitals. It was necessary to differentiate those who had a pathological

lesion producing the symptoms from those who did not, and this involved much

work and expense. It took some time for medical personnel to learn how to

make this differentiation without too much delay. After the differentiation

wis made, the problem of disposition remained for the Army, and this was also

a serious problem.

In one of the station hospitals, the chief of surgery performed appendectomies without pathological changes in the appendix, and about 100 beds were

occupied by such patients. This officer had to learn that appendectomy was

not a prophylactic operation. In another hospital, there was an epidemic of

mumps and orchitis, and an enterprising medical officer thought it would be

scientific and educational to do biopsies on the testicle. This officer learned

that the taxpayer could not afford unnecessary operations with their pension

aspects later on.

A great variety of problems were encountered involving individual cases.

The following incidents can be recalled. A soldier developed acute appendicitis. On the way to the hospital, he received a hypodermic injection of

morphine. The correct diagnosis was not made, and the patient died. One

death was due to a small stab wound of the heart, and there was no operation. Several cases of subdural hematoma were not recognized. Another

patient died from hemorrhage after a spinal fluid tap through the foramen

magnum. It serves no purpose to recount these occurrences; suffice it to say

that they were brought to light and did not remain hidden and that the consultant system was largely responsible for bringing these mistakes into the

open. At times, there were no medical personnel adequate for the responsibilities imposed; the personnel were changing rapidly and the best effort
232 ACTIVITIES OF SURGICAL CONSULTANTS

consisted in using what was available. But the consultant had discussion of

thep0blem, and on some occasions an officer was sent in from,a nearby, gen,

eral.hospital to take care of, an urgent condition in a station: hospital.

There were several instances of inadequacy on the part of the com mand-,

ing officer of the smaller facilities. There were also instances of an madequate officer having been assigned as chief of the surgical service. Such mis

takes produced results that were often obvious, and, as a rule, correction was

readily made. An inadequate commanding officer or chief of surgical service

could do considerable harm to the proper conduct of the hospital. The one

and only way to find out about a medical officer was to watch him in action

and see what le did. There were occasions when former friendships and a

pleasant personality were the factors on which assignment in a hospital was

made. Three of these assignments produced considerable turmoil, but in the

course of time they were corrected. With respect to conduct of hospitals and

medical schools, the Army acted much more expeditiously and with much

more wisdom than did the trustees of our civilian medical institutions. Indeed there was no comparison in the conduct of military and civilian institutions. It would be good for society as a whole if our medical institutions,

including the medical schools, were subjected to the same critical analysis

by competent consultants as were the military medical institutions during the

war.

THE AIRBASE HOSPITALS

Colonel Beck visited a number of station hospitals located at airbases.

He understood that the Army Air Forces expected to have their own general

hospitals, and this seemed to be the program in the early part of the war.

Assigned to these hospitals were large numbers of highly trained medical personnel. For the most part they had little work to do, and later some of these

officers were made available to the Army Service Forces where they were

needed. It was a serious mistake in Army organization to try to separate

these services. These medical personnel were needed by the Army Ground

and Service Forces.

THE GENERAL HOSPITALS

The general hospitals were organized primarily for the care of those

wounded in war. These hospitals were usually large installations with a bed

capacity of about 3,000. Location was based upon civilian population so that

the wounded soldier could be hospitalized near his home. Several large station hospitals were converted into general hospitals after the camps were

vacated. These hospitals were organized to give definitive treatment to those

who needed it. The chiefs of services and other professional personnel were

the best obtainable. In many instances, they were the outstanding surgeons

of America. The organization was done with great care. The quality of the

work in these hospitals was excellent. When specialized help was needed, such

as for the hand, it was obtained. Consultants in surgery, orthopedics, psy-
FIFTH SERVICE COMMAND 233

440,

FicuiF 34.-Sgt. Joco 'Montolo, Medical illustrator tit Ashford General Hlosp~itaIl, creating a, bust of Gent. Jonathani M1. Wainwright that was latter cast in

bronze for permntent ret ention as one of the Nat ion'sItreasures.

citiat ry, and mnedicine supervised the w~ork and disseminated knowledge from

one hlosp~ital to another. Ancillary personnel at thle g~eneral 1toz:pitails were

highly skilled ini their areas of spci alizat ion, and their talent s were a ailable

in many fields (fig. ' -U)

There were, of course, many problems, but the most importatnt problem

was to keep abreast of the work. The most common type of injury wvas an

open woutnd with bone infection. A patijent withI this typ~e of injury arrivedl

at the hospital wN itli the extremity ill a cast. T1'le cast was immitediately remioved

after arrival. T1'Ie wound mas cleansed, dead )oite was removed, and a sp)litthiclies,skinigraft NN asapplied oN er the bone. The sulfonamides and penicillin

were available anid were used. These drugs helped to make this t reamemit successful. In s'ollie (ases, part of tile skill graftt sloliled a" aY. but it mas usually

possible to convert the wound from n t openU one to a, closed onie. A cast was

apl))ied, after which the patient w assenit home for a period of weeks or Imoniths.

The p~atienlt was thien brought back to the hospital, as time p)ermitted, and

definitive surgery was done. D~efects in thme hone were filled with bone chips.

This technique was developed by Maj. (later Lt. Col.) Mlarvin 1'. Knighit, MC,

tit Crile General h1ospital, Cleveland. Ohio. A full-tiickmess or a slidingc skin

graft was applied to cover, the bone. This early cov er of thme A oumind w sot enl-
234 ACTIVITIES OF SURGICAL CONSULTANTStirely new, but Colonel Beck's first contact with it was at Ashford General

H sital, White Sulphur Springs, W. Va., where it was employed by ~mj..

(latei:Lt. Col.) Robert P. Kelly, Jr., MC, and at Billings General Hospitil,

Fort Benjamin Harrison, Ind., where it was used by 1st Lt. (later Capt.) Ernest

M. Burgess, MC. When its value was recognized, Colonel Beck extended:this

method throughout the command by sending officers to these hospitals for temporary duty. The method was presented at a medical meeting for the-medical

officers of the Fifth Service Command which was held at Newton D. Baker

General Hospital, Martinsburg, W. Va., in May of 1945, and from there its use

was extended to the other service commands by Col. I. Mims Gage, MC, Coh W.

Barclay Parsons, MC, Lt. Col. (later Col.) Condict W. Cutler, Jr., MC, Col.

Walter D. Wise, MC, and Col. Leonard T. Peterson, MC.

This method of'treatment increased the bed capacity of each general hospital by as many as several hundred beds by making it possible for the patients

to leave the hospital and return later when operation could be done as a routine

procedure without exceeding the facilities of each hospital. This program saved

the Fifth Service Command the equivalent of one general hospital. The consultant was pleased to have been instrumental in this development.

Colonel Beck had difficulty in arranging the aforementioned meeting. The

treatment of osteomyelitis was not sufficient reason to persuade the service command surgeon to give permission for such a meeting. Later on, the consultant

did succeed in arranging a urological conference and symposium on the paralyzed patient. The treatment of osteomyelitis was put on the program as a

subject of secondary importance, but it was presented at this conference. This

was the first meeting for discussion of professional problems with which

Colonel Beck had any contact in the Army. There were several meetings of the

surgical consultants in the Office of the Surgeon General, but these concerned

matters of policy rather than the surgical care of patients. The need for such

a meeting was great, and this meeting yielded more than small results.

Some of the most difficult problems were the injuries that involved the

urological system. A competent urologist was not available for every general

hospital, but it did become possible to place a competent urologist on temporary

duty at other hospitals as necessary. This was a good idea, and it worked out

very satisfactorily.

Great effort was made for the care of the paralyzed patient. All kinds

of services were brought to bear upon these patients. These included the

services of the neurosurgeon, urologist, orthopedist, general surgeon, psychiatrist, nutritionist, and rehabilitation personnel.

Specialization

Some of the hospitals were designated for special services. Thus, Ashford

General Hospital (fig. 35) was a vascular center, several hospitals were designated as neurosurgical centers, and several, as plastic surgical centers. For

various reasons, this was a necessary development. Highly qualified personnel
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236 ACTIVITIES OF SURGICAL CONSULTANTS
PIPT'II SERVICE COMM13AN.D 237

ia. iu 36,. - Ashfor d General H ospi tal, livinog easily accessible froii Wash inigton,

presented anl opplortiunity to slwiN Army dligniitaries thme superior services being rendered

at Armiy general hospitalsA. Col. D~aniel C. Elkin, 31C, chief of surgical service, explains

to Maj. Geni. Anthony C. McAuliffe, hero of the siege of Bastogne, sonme of the outstanding

work (lone at Ashford. It. Colonel Elkin amid the hosiilal commnander, Col. Clyde McK.

Beck, MC, show thle incomng Army Chief of Stuff, (teneral of the Army I)M~ ght 1).

E"iseuhloN~r i'.le facilit ies a a ilabtle at thle hospital. C. Colonels Beck and Elkin orienit tile

incoin g direct or oif t he Veteranus' Ad imiist rat ion, Gun. Omna r N. Bradley, onl tile services

priov ided ini Army general hmospit als.

ance that these hospitals easily sulrpassed tite best civilian hospitals of that

p~eriod. The members of the Medical Corps who served in these hospitals took

pridle iii their accompllishments (figr. :36). They knew that it was the care of

the patient that camne first. These medical officers also knew that organization

was nieces,,ary so that the work couild be done, and this organization of which

they wvere a part was as good as could he achieved.

Personally, this consultant had satisfaction in his assi gnment. Trhe Ariny

organizat ion made it possible for hii to be effective. Ile knew that his work

was wvell regarded by General Rankin. General Rankin and Col. (later

.Maj. Gen.) Edwvard A. Noyes, in the Fifth Service Command, deserved

a large part of tite credlit f-r Colonel Beck's services. An important source of

satisfaction NNas tlte contacts wvith the medical officers ini the places iN here they

wvorked. Colonel B~eck was someone who could be talkied to ini private as an

individual without relationshipj to Armny rank. Many a problem, small to the

606222-62-- 15S
238 ACTIVITIES OF SURGICAL CONSULTANTS

ospital -but -important to the officer, was solved on the basis f 'such me.etings.

SE~ronie needs a friend, anda young doctor who had-been ,up r ted.from;4his

environment was in special need of someone:who could understand him. , Some

of the prolems brought to light by these private conversations were,,ifndeed,

imfpor(4nt to the hospital.

The author's final advice isto let the light of understanding be, cast,.upon

the problem. Then it can be solved, As long as the problem is hidden itdefies

solution and often remains as a torment working against the best of effort and

the highest fulfillment of duty.
CHAPTER XII

Seventh Service Command

Grover C. Penberthy, M.D.

As a Reserve officer, Col. Grover C. Penberthy, MC, was informed early

in June 1942 of the establishment of a consultant service which was to be a

part of. the Medical Department. He was requested to accept a duty assignment as a consultant to one of the nine corps areas, later designated as service

commands, of the ASF (Army Service Forces). His orders to active duty in

the Seventh Corps Area were contained in War Department Special Orders

No. 175, dated 2 July 1942. Colonel Penberthy reported for active duty at

Fort Wayne, Detroit, Mich., on 25 July and joined Headquarters, Seventh

Corps Area, Omaha, Nebr., on 29 July 1942.

Colonel Penberthy remained in this assignment throughout the war. It

was a pleasant experience marked by cooperation of the personnel, both military and civilian, at Seventh Service Command headquarters and in installations and facilities visited withip the command. Appreciation is expressed

for the cooperation and support given by Maj. Gen. C. H. Danielson and Maj.

Gen. Louis A. Craig who were, in turn, commanding generals, and by Col.

(later Brig. Gen.) Sidney Erickson and Brig. Gen. Paul X. English who were,

in turn, chiefs of staff of the Seventh Service Command. Appreciation is

also expressed for the cooperation and support given by Col. Herbert C. Gibner,

MC, Col. Harvard C. Moore, MC, and Col. Charles R. Mueller, MC, who were,

in turn, service command surgeons; by Col. Neill J. Everitt, MC, assistant to

the surgeon; and by the officers in the surgeon's office.

Inasmuch as there was no set pattern for the consultant's activity as

applied to hospital surgical services, except that of a well-run civilian hospital, the continued spirit of cordiality and cooperation shown by the Office

of the Surgeon General and the associated officers at Headquarters, Seventh

Service Command, helped materially to carry through the concepts of this

additional Medical Department service which the assignment of the consultant

represented. It also afforded an opportunity to evaluate the results of the

superior educational programs carried on in the medical schools, combined

with the advanced intern and resident training in the hospitals.

SCOPE OF ACTIVITIES OF THE SURGICAL CONSULTANT

Colonel Penberthy's activities were carried out principally in the field

of visiting both the ASF and the AAF (Army Air Forces) installations and

activities. These included 4 general and 58 station hospitals, with the break239
240 ACTIVITIES OF SURGICAL CONSULTANTS

down of the latter as follows: 16 ASF station hospitals, 32 AAF station hospitils, and 10 station hospitals at prisoner-of-war camps. The station hospital

at Camp Carson, Colo., was designated as a general hospital early in 1945, and

eight of the station hospitals (four ASF and four AAF) were subsequently

classifiedi as regional hospitals. In December 1944, the key officer personnel

assigned to these regional hospitals, through the joint action of the ASF, the

AAF, the AGF (Army Ground Forces), and the ATC (Air Transport Coinmand), were named as subconsultants to visit their respective satellite station

hospitals. This arrangement made possible more frequent professional visits

to the satellite hospitals and relieved the surgical consultant at a time when

general hospitals were receiving more battle casualties and when much of the

major surgery originating in the Zone of Interior was being concentrated in

the regional hospitals. The number of Colonel Penberthy's hospital visits each

year varied from 88 to 100.

Visits were also made at times to most of the seven induction stations,

which were subsequently reduced in number to meet the reduced inductee input.

Dispensaries, such as the Kansas City General Dispensary, were visited from

time to time.

The principal public relations activity consisted of participation in nonmilitary medical programs, including the War-Time Graduate Medical Meetings; lending support to local, State, and national meetings; and representing

the commanding general or service conuand surgeon at specific functions.

The principal contribution of the surgical consultant was made in the

field. His field trips entailed considerable travel-chiefly by rail or automobile,

and later by military airplane-over an area including nine States, extending

east and west from the Mississippi to the Rocky Mountains and north and

south from the Canadian boundary to the Arkansas State line. Because he

spent so much time away from the service command surgeon's office, the extent

of administrative duties assigned the consultant was minimal. le served in

an advisory capacity relative to medical policies, classification of Medical

Corps officers, and assignment of Medical Corps officers to ASF installations

and hospital units being assembled for oversea duty.

Reports of Inspection

The consultant submitted a written, detailed report of each inspection lie

made in the field. His report oil an ASF facility was submitted to the station

surgeon, the service command surgeon, and The Surgeon General; that on an

AAF installation was submitted to the station surgeon for such disposition as

was indicated by AAF authority. Usually, the report was sent to the commanding general of the Army Air Forces, for the attention of the Air Surgeon.

The inspections were reported under the following headings:

1. Authority for inspection.
SEVENTH 'SERVICE COMMAND 241

2. Hospital plant (consideration of the general setup, bed capacity (normal and possible expansion), census, alterations or new construction, problems,

'phh~eiitiia so forth).

3. Prsonnel (numerical and professional adequacy of officers assignied

tothe surgical service).

4. Training (professional and technical programs and conferences).

5. Surgical service (a description of the overall setup, patient load of the

respective sections, cases presented atd discussed on ward rounds in each

section, and consideration of problems pertaining to the service).

6. X-ray (type and adequacy of the equipment, workload, and personnel,

including trainees).

7. Operating room (adequacy of equipment, which was limited and inadequate in the early period of the war but more or less complete near the end;

types of anesthetics administered, complications if any, the workload per

month, personnel assigned, and the training program for enlisted men).

8. Physiotherapy (equipment installed, personnel assigned, workload, and

training program in force).

9. Professional care (discussion of care being given in the wards and

special cases requiring consultation).

10. Disposition boards (meetings held, number of cases reviewed, and

promptness of disposition).

11. Records (universally found to be complete).

12. Library (a good variety of bound textbooks and medical journals

representing the specialties was available).

13. Nurses.

14. Enlisted personnel (number assigned, specific training programs conducted for technicians, orientation lectures and demonstrations, and rotation

among the various sections).

15. WAC (Women's Army Corps) personnel assigned.

16. Summary and evaluation of professional service.

PROFESSIONAL SERVICES

Service command surgical consultant.-The military consultants, when

ordered to active duty, were charged with carrying out the following which

had been proposed as a definition of their functions and responsibilities: "Act

in an inspectorial and consultative capacity; the duties shall include the evaluation of the professional qualifications of medical personnel, appraisal of

therapeutic and diagnostic procedures and agents, and the coordination of

professional practice by local discussion with hospital staffs of such special

problems as may present themselves." The chief function of the surgical

consultant was, therefore, the evaluation and supervision of professional services. To this end, when the consultant visited hospitals, most of the patients
242 ACTIVITIES OF SURGICAL CONSULTANTS

on the surgical services were presented to him on ward rounds in the respective' sections.

Informal discussions often developed with special or selected cases relative not only to the diagnosis and treatment but to the disposition of such cases

as well. Reference has already been made to the opportunity afforded the

consultant to evaluate the results of the prevailing high standard of resident

training. With few exceptions this training was apparent at most hospitals

and was manifested in the approach made by the officers in arriving at a diagnosis--particularly in problem cases, their overall understanding of the particular surgical problem, and the subsequent surgical management. The

writer can say with certainty that le has benefited professionally many times

as a result of his wartime experiences as a consultant.

In addition to the ward activity and conferences, an informal meeting

was usually held with the medical officers at which time Colonel Penberthy

presented some subject or participated in the program by entering into the

discussion of some subject presented by a duty officer of the hospital being

visited.

Colonel Penberthy participated in the AAF orthopedic conferences in

the fall of 1943 at Buckley Field, Denver, Colo., Lincoln Army Air Field,

Lincoln, Nebr., and Jefferson Barracks, Mo., presenting the subject of burn

therapy. At the AAF surgical conference in September 1944 at Lincoln Army

Air Field, he presented the subject of wound healing.

Civilian consultants.-This additional consultation service was inaugurated by The Surgeon General late in 1943. It was Colonel Penberthy's

privilege to accompany the civilian surgeons in their visits to medical activities in the Seventh Service Command. Dr. Robert D. Schrock, orthopedic

surgeon of Omaha, Nebr., in December 1943, visited station hospitals at Lincoln Army Air Field, Camp Carson, Colo., and Camp Hale, Colo., and Fitzsimons General Hospital, Denver, Colo. Dr. Frank D. Dickson, orthopedic

surgeon of Kansas City, Mo., in January 1944, visited Winter General Hospital, Topeka, Kans., and O'Reilly General Hospital, Springfield, Mo., and

the station hospitals at Fort Riley, Kans., Camp Phillips, Kans., Fort Leonard Wood, Mo., and Camp Crowder, Mo. Dr. William Jason Mixter, neurosurgeon from Boston, Mass., inspected the neurosurgical see'vice at O'Reilly

General Hospital on 3 July 1944. In September 1945, Dr. Schrock again visited the orthopedic services at Schick General Hospital, Clinton, Iowa, and at

O'Reilly and Winter General Hospitals. The contributions made by these

surgeons were constructive and most important. Each submitted a report on

his visits. The officers at all installations gave unanimous, favorable expression to this additional consultation service. In turn, the civilian consultants

no doubt benefited and couldn't help but be impressed with the superior quality of the surgical service being rendered by the officers in these two major

branches of surgery.
SEVENTH SERVICE COM IMAND 243

The temporary service of Dr. Sterling Bunnell in the Seventh Serv-

-ice Command to conduct conferences on surgery of the hand was another outstanding contribution. Two such conferences, with an intensive program

extending through 4 days, were held at O'Reilly General Hospital in February and August of 1945. The course consisted of didactic lectures illustrated

by lantern slides depicting the anatomy and physiology of the hand, diagnostic

and clinical conferences, and operative clinics. The officers in attendance

were from installations of both the ASF and AAF and numbered 27 for the

February refresher course. For the course in August, 37 medical officers from

ASF facilities and 11 from the AAF attended. The officer personnel on duty

at O'Reilly General Hospital were also in attendance, which gave an overall

enrollment for each course of approximately 70. The available clinical material, of great variety, was inexhaustible. There were 200 to 300 crippled

hands in the wards, not including a large group of brachial plexus and other

neurological injuries. At the clinical conferences, free discussion was encouraged after Dr. Bunnell's presentation of the cases and their evaluation relative

to possible surgical procedures to restore at least partial function of the injured

member. The benefits derived by the officers in attendance would be difficult

to evaluate, except that it was observed that many returned to their respective surgical services with a new interest, a new enthusiasm, and a better concept of the surgical management of the crippled hand. In a few of the hospitals, hand clinics were set up for discussion and evaluation of new cases

and postoperative results.

War-Time Graduate Medical Meetings.--Colonel Penberthy participated in two programs in Denver of the War-Time Graduate Medical Meetings. Dr. Charles G. Johnston, Professor of Surgery at Wayne State University College of Medicine, Detroit, Mich., accompanied Colonel Penberthy

in June 1946 and met with medical officers at the regional hospitals at Camp

Crowder and Fort Leonard Wood and at O'Reilly General Hospital. In

addition to ward conferences with discussion of cases, Doctor Johnston presented the subject of intestinal obstruction at a general meeting. This presentation was supplemented by a motion picture depicting the use of the

Miller-Abbott tube, which emphasized statistically the disadvantages and

advantages to be gained by its use in selected cases.

Promotions and morale.-The surgical consultant shared in sponsoring

recommendations for promotion of worthy officers in consultation with the

service command surgeon, with Colonel Everitt, assistant to the surgeon and

in charge of officer personnel, and with the medical consultant. In many

instances, opportunities for promotion were inadequate, due perhaps to the

fact that too little attention, apparently, had been given to this deserving

activity by those responsible. Many medical officers with long periods of

preparation for their duties had entered active military duty equipped and

trained to render competent professional service, but ii many cases these facts,

unfortunately, were not given proper recognition.
24A ACTIVITIES OF SURGICAL CONSULTANTS

The need for the maintenance of morale became apparent early and -was

more noticeable in the later months. Colonel Penberthy made every attempt.

tomaiitain a high level of morale by encouraging presentation of personalt

pi'obims to him, by commendation for work well done, by a change of station,

or assignment to an oversea unit in individual cases insofar as this was:possible and advisable, and by encouraging officers to submit experiences and

observations for publication. Also, support was given to officers interested

in securing places on national medical programs.

Manuscripts.-Many manuscripts prepared by officers on surgical subjects were reviewed and efther returned with comment or forwarded to the

Office of the Surgeon General for consideration. Encouragement was given

to the officers to submit thei- experiences for publication.

Relation of the surgical consultant to the commanding officers of hos.

pitals and chiefs of surgical service.-Colonel Penberthy's association with

commanding officers and chiefs of surgical services in the various hospitals

was a friendly one. Problems, both professional and pertaining to personnel,

were discussed informally. Tile position taken by the consultant was to lend

support to the respective installations being visited, rather than to be critical.

Mutual understanding between those in authority at the hospitals and the

consultant was productive of beneficial results and the establishment of a sound

relationship with the service command surgeon's office. Informal correspondence between hospital commanders and chiefs of surgical services and the consultant was encouraged, except where official matters discussed would require

the information to be forwarded through channels. The understanding and

leadership of both the commanding officers and the chiefs of surgical service

were reflected in the general setup and in the contribution made by the various

hospitals.

SURGICAL PROBLEMS OF INTEREST

The surgical services, with perhaps a few exceptions, throughout the conmand in both the ASF and AAF hospitals were considered superior. This

superiority was reflected in the high standard of surgical practice which was

maintained and in the comparatively low incidence of serious complications.

Surgical mortality was reported to be minimal.

The more common conditions requiring surgical operation during the

period when troo)s were in training were for hernia and appendicitis. The

incidence of both was apparently high in the larger camps.

Hernia.-The frequency of hernia operations and the low incidence of

recurrences following operation was shown in statistics for the year 1943.

Sixty-seven hospitals, which included station and general hospitals, replied

to a questionnaire and reported 3,996 operations performed for the correction

of inguinal hernia (some bilateral). There were 11 recurrences reported from

10 hospitals. Four cases had previously been operated on, and of this numi-
SEVENTH SERVICE COMMAND 245

bet two had been operated upon previously on two occasions. Some of the

recurrences had been operated on elsewhere in Army hospitals. The low

incidence of recurrences reported-none at all in some instances-was explained

by the -fact that many of the postoperative cases were in time moved to other

stations, a consequence of which was that the followup was limited.

Appeudicitis.-The incidence of this surgical lesion was perhaps no higher

than would be seen in a comparable civilian population, but the number of

operations performed did appear to be relatively high. This may be explained

by the fact that the soldier who reported to sick call was hospitalized early

in this illness in most instances and encouragement was given to operation

when the clinical and physical findings warranted a diagnosis of appendicitis.

This did not mean that unnecessary operations were performed, but following

this program of management no doubt contributed to a minimum of complications and also to the low mortality. In many instances, patients with

complications had not been seen until late in their illness. They had been

transferred from another station where they had not reported ill for fear of

not being included with their associates in changes of station.

Pilonidal cyst disease.-The incidence of infected pilonidal cyst with

draining sinus tracts was comparatively high during the training period of

the Army, especially at the larger stations. There were many instances of

long periods of morbidity and a resultant loss of duty time in the early months

of the war. The lesion had seldom been seen in the surgical clinics during

World War I, and, because of the high incidence in World War II, many

theories were advanced as to possible contributing factors, such as riding in

jeeps, trucks, airplanes, and other vehicles. These conclusions, however, were

not always valid, as many patients admitted for surgical care gave no history

of exposure to possible trauma from such causes.

Experiences with this lesion as reported from a general and a station

hospital may be considered representative of those of other clinics. The general hospital reported the following:

A complete comprehensive study was made of 102 patients. The pilonidal cyst, although

considered a congenital anomaly consisting essentially of embryonic inclusion of skin

structure in the subcutaneous tissues of the sacrococcygeal area, appeared primarily in the

age group 20 to 30 years. The loss of duty time and manpower were evaluated in this

study, which showed that 90 lost on an average of 5 months, 75 men lost five-and-a-half

months and 6 lost more than 1 year; the longest reported time lost was seventeen-and-aquarter and seventeen-and-a-half months.

At the time of this particular visit in April 1943, it was reported that 40 of

the 45 in the service in September 1942 had been before the disposition board

and had been discharged to a duty statuc.

The following experience was reported at the AAF station hospital:

132 cases were operated upon from the time of the opening of the hospital August 6,

1042 to September 1944. Before the present form of treatment was instituted following

the SGO Circular Letter No. 169, September 25, 1943, subject Pilonidal Cyst and Sinus, 33

cases were reviewed and it was found that the average hospital stay was 57.5 days, 18
246 ACTIVITIES OF SURGICAL CONSULTANTS

having been hospitalized 99 days, the longest, 158 and the shortest, 12 days. The acute

cases are only incised and drained. Excision was practiced subsequently In 71 cases~with

4 reported as failures. The average hospital stay for the first operation has been 9,1,days

afid for the second, 18.4 or 27.5 days In all. The excised cases were closed using cotton

sutuies without retention sutures, and the patient was kept in bed 12 days.

Th postoperative cases presented on ward rounds at the time of this visit

showed the wounds to be clean and healed. The skin at the site of the scar

was freely movable. The conservative management, as outlined and observed

throughout the command, materially shortened the period of morbidity, and

the loss of duty time was kept to a minimum. Improvement in the surgical

management of this group of patients was further noticeable following the

circulation of War Department Technical Bulletin (TB MED) 89, Pilonidal

Cyst and Sinus, dated 2 September 1944.

Fractures.-Training activities developed a variety of fractures which

were handled in much the same way as in civilian practice. Skeletal traction

was emphasized in the management of selected fractures of the long bones,

although plaster immobilization was no doubt more commonly used. Early

ambulation was universally practiced where it was practicable, with various

types of walking supports, such as the walking iron, a rocker arrangement,

a rubber heel, or a piece of an old rubber fire casing. There was nothing unusual observed in the treatment of fractures except for the problem of delayed

union, which attracted attention simultaneously at two stations; namely, Station Hospital (changed on 18 June 1944 to Army Air Forces Regional Hospital), Buckley Field, Denver, Colo., where the altitude was about 5,000 feet,

and Camp Hale, where the altitude was reported to be over 9,000 feet. No

satisfactory explanation was arrived at, although it was observed that some

patients who had come originally from a lower altitude manifested X-ray evidence of delayed union. The majority of the fractures treated at Camp Hale

were of the lower extremities close to or above the ankle joint and were the

result of skiing accidents.

Knee injuries.--This group of injuries, particularly meniscal tears and

ligamentous rupture, comprised a very considerable portion of the operative

material during the training period at several of the camps. It became apparent

early that meniscal removal as a rule was seldom followed by return to full

duty status in less than 3 or 4 months. For this reason, more conservative

therapy was instituted, and surgical treatment was resorted to only when the

patient had a history of recurrent disability. It was further found that operative ligamentous reconstruction in the absence of arthritic changes could restore

otherwise permanently disabled knees to a limited duty status.

Other problems.-There were many other interesting surgical problems

and nunerous instances of outstanding achievement in the Seventh Service

Command. Fractures of the femur, trenchfoot, and hand surgery deserve

mention in this connection, but these subjects have been covered in detail in

other volumes of the clinical series of the history of the Medical )epartment,

United States Army, World War II.
'SEVENTH. SERVICE COMM11AND 247

COMMENT

C ionel:,Penberthy's assignment to duty in the Seventh Corps Area, later

design4ated as the Seventh Service Command, in July 1942 as the surgical con,

sultant was .enjqyable and, in many respects, profitable. The reception, givenl

him: at the many stations and hospitals visited from time to time was friendly.

The exceptions were few and came early in his experience when it was possible

that there was a misunderstanding of the responsibility and position of such an

officer. The resistance was minimal, and in most instances good cooperation

was given the consultant by both the commanding officers and those engaged

in the professional and administrative work.

The purpose of the consultant service was intended to be constructive, and

every attempt was made to fulfill the desired purpose. The overall professional

surgical service was maintained at a high standard. Weaknesses, where noticeable, were easily corrected. The high type of surgery performed and the clear

judgment shown by medical officers clearly demonstrated the results of higher

education and the good intern and resident training.

In looking back with the idea of forming some constructive suggestions

from his experience, the writer has little to offer as an improvement over the

teamwork (group practice) developed by officers in various hospitals, especially

where key personnel were kept intact.

The changes in personnel made to meet the needs and exigencies of war

often temporarily disrupted a service, but generally the change was made with

no appreciable lowering of the high standard of surgical care given the patients.

The program of professional training as directed by The Surgeon General

and carried out by the hospital commanding officers and chiefs of services provided an excellent opportunity for the continuance of one's education. The

program gave officers the privilege of participation, thereby edding, no doubt,

to their own security. Although there was the need for assigning medical

officers to combat units, it often occurred to Colonel Penberthy that sufficient

consideration was not given to a selected group of already partially trained

young officers in the various surgical specialties to continue in their respective

fields to meet postwar professional needs and to replace trained surgeons deserving of consideration for early return to civilian practice.

The morale of medical officers throughout most of the active period of

war was good, with a few exceptions where promotions on the basis of age and

contribution were not given proper and full consideration. With the end of

active warfare, the morale problem stemming from the small number of promotions was intensified; although there was no noticeable letdown in professional care given the sick soldier, one sensed an apparent feeling, on the part

of the officers, of indifference to their responsibilities. This lack of interest

on the part of some of those who were responsible for giving recognition

by promotion for services rendered was in part corrected. However, for the
248' ACTI*ITIES OF SURGAICAL CONSULTANT

oelibenefistimptlatig ,interest, it is ).b1lieved tha~t the change .of -viewpot me to ltTe iedi br good haorale, Was mnderstood byi ll.in ~e

ffiiiS, i he event :jitbecomes, necessary to enljstthhep Lasmahgil

tinied anid pAtrlotlo group df civilian, physicians, more. recognition in, the ww

ofpromnotioii will- ho doub6t) 'egiven, ~yt9Dprntfte -ryto~intP~itiu n of the Amn
- CAPTER ,'XIII1

Eighth Serviee Comad

1Bdey L. Coley,, M.D., .Henry ,G. Hollenberg, M.D., and

Thomas L. Wdrihg, M.D&h

Section I. The First Consultant, 1942-44 A

% PROBLEMS DURING THE TRAINING PERIOD, 1942-43

During, the latter half of . and the entire year of 1943, the problems,

'whicli faced Co. Bradley L. Coley, MC, as Consultant in Surgery, Eighth Service Commandi were related largely to the surgical care of more than one million

troopshwiliwere undergoing training in the service command.

Onhe. of these problems Was to evaluate the skill and competence of medical

officers assigned to the surgical services of the various station and general

hospitals under jurisdiction of both the Eighth Service Command and the

Army Air Force. Due to the frequent changes in personnel, the survey of

hospital surgical services became a more or less continuous process, When

deficiencies were found, a shifting of medical officers was often required ,

During the first half of the war, many operations were performed for the

correction of defects that had existed before induction. Sufficient care in the

selection of cases for operation was not always taken by surgeons who had had

no previous Army experience. Soldiers were often operated upon in these early

days without regard for the necessity of their return to a combat unit. In

many instances, an operation which, judged by civilian standards, was successful left the soldier incapable of continuing a rigorous training program. As a

result, the final disposition was reclassification for limited service or even a certificate of disability for discharge. This experience taught medical officers that,

in the Army, operations frequently should be withheld and that the personality

and psychiatric background of the individual should be very carefully evaluated before proceeding -,vith the correction of conditions existing prior to induction. Illustrative of conditions in this category were internal derangements of the knee, herniated disks, recurrent dislocations of the shoulder,

varicose veins, and certain congenital defects, such as lnaldescent of the testis

and pilonidal sinus. The last-named condition was responsible for great loss

1 Col. Bradley L. Coley, MC, served as surgical consultant in the 'Aghth Service Command from

the latter part of July 1942 to mid-March 1945, at which time he was succeeded by Col. Henry 0.

Hollenberg, MC. Colonel Cole3's remarks pertain more to situations characteristic of the early and

middle years of the war, while the comments of Colonel Hollenberg which follow were based on

observations during the last year of the war.-B. N. C.

249
250 ACTIVITIES OF SURGICAL CONSULTANTS

of manpower due to prolonged hospitalization following operation and frequent recurrences necessitating further operation.

The experience with pilonidal sinus in the Eighth Service Command wa,

no doubt, duplicated by observations of consultants in other service commands.

At first, the general practice was excision with open packing of the wound,

which was then supposed to heal by granulation. This technique was used

on soldiers with symptomless sinuses that had never given the slightest trouble.

Such prolonged delay in healing followed this method that partial closures,

following the technique advocated by MacFee and by DePrisio, were popular

for a time, Later on, exeision and primary suture was employed with various

modifications, such as the use of fascial flaps as attempted by Shute, Burch,

and others. Many of these cases, that is, complete closure by suture, appeared

to heal satisfactorily and remained so for considerable periods, only to reopen

and drain again. The writer holds no brief for a particular technique,

although experience has prejudiced him against wide excision and packing

and against extensive fascial plastics. He is, however, convinced that patients

with symptomless sinuses should never be operated upon and that incision and

drainage, where necessary for infection, is all the surgery that is necessary.

In the first 9 months of 1942, there was an estimated loss of nearly thirty

thousand man-days due to prolonged hospitalization for pilonidal sinus in 20

of the larger hospitals in the Eighth Service Command. At that time, the

consultant proposed that no cases be operated upon unless their condition prevented participation in the active training program, and that simple measures

be taken for inflamed cases. It was indicated that pilonidal sinus cases ought

not have been accepted for full duty or that some better method of treatment

than excision should have been devised. The wide variation in treatment

employed for this condition was, in itself, testimony to the failure of any one

method.

From the viewpoint of the consultant, the methods for screening inductees

were seriously deficient. Too many soldiers were being admitted to hospitals

for defects which were disqualifying beyond any question. Too large a daily

load of examinations was being carried out by too small a group of civilian

doctors at the induction stations. This manner of screening left little doubt

that serious errors would be relatively common. If the national emergency

had been less acute, it would have been better to have had a group of medical

officers who had been especially trained to recognize disqualifying defects perform all selective physical examinations. More care at this level would have

resulted in an enormous saving of man-days and public funds. It would have

spared the expense of future care in Veterans' Administration facilities of men

whose disabilities marked them as incapable for military service.

In this earlier period, most station hospitals had competent surgeons; but,

as the number of units activated for oversea movement increased, the caliber

of surgeons in station hospitals decreased steadily. The directives limiting

the type of operations for elective conditions permitted in station hospitals
EIGHTH SERVICE COMMAND 251'

Ws~a dause for considerable complaint on the part of the surgeons. At first,

manyo tese surgeons were as competent as were the surgeons in general h0se

ita As h result of this policy, however, the, wholesale transfer of su,

cases of elective surgery from station to general hospitals soon began-to overta t atter. It wa therefore found necessary to designate a few station

hospitals aS regional hospitals where certain types of surgical cases originating

in the Zone of Interior were treated. By strengthening the staffs of these

regional -hospitals, adequate surgical care was assured. This modification

W6rked.well and seemed sound.

The 10 general hospitals of the Eighth Service Command were for the

mdst part supplied with excellent specialists in the surgical fields and rendered

service of high order. The establishment of centers for special types of surgery, for example, amputation centers, was a factor in obtaining the highest

possible standards of surgical care.

With regard to Air Force hospitals, Colonel Coley acted merely in an

advisory capacity, and his recommendations were not necessarily followed.

At times, perhaps, his recommendations were not welcomed by higher medical

echelons of the Army Air Forces. Nevertheless, relations between individual

surgeons in the Air Force hospitals and the sarvice command surgical consultant were uniformly cordial.

SPECIAL PROBLEMS

During the course of Colonel Coley's tenure as the surgical consultant,

many special problems arose. A discussion of some of these problems follows.

Early ambulation.-At the outset, several large general hospitals were

successfully practicing the policy of early ambulation. Interest in this method

of postoperative management spread rapidly, despite the fact that the Office of

the Surgeon General was opposed to it in hernia cases and was rather unfavorable toward it after other abdominal operations. As a result, several of these

hospitals were unable to continue using the method, although their experience

with it indicated that it was a definite advance.

Psychosomatic disrders.-It became progressively more evident that

surgeons were often quite unfamiliar with the complexities of psychosomatic

complaints. Often when individuals had been operated upon, the outcome

was disappointing and resulted in a certificate of disability for discharge or a

reclassification for limited service. Having learned by experience, some surgeons refused, except in cases of emergency, to operate on any patient in which

there was question of a psychosomatic element until the patient had been seen

by a neuropsychiatrist and a clearance for operation had been given.

Acute appendicitis.-In view of the large number of operations performed for this condition, the mortality rate in the Eighth Service Command

seemed surprisingly low. There were, however, a sufficient number of deaths

to stimulate the consultant to make a study of all cases coming to autopsy

from hospitals in the service command. Although this investigation had not
252 ACTIVITIES OF SURGICAL CONSULTANTS

been completed by the time Colonel Coley left for oversea service, the following

impressions had been gained:

i. The most significant factor appeared to be delay in admission of cases

to station hospitals. This was due to the reluctance or indifference on the part

of the individual in seeking medical attention promptly. Less excusable were

the occasional cases in which the dispensary doctor prescribed for the patient's

complaints without examining the abdomen.

2. Reliance on local instillations of the sulfonaniides and the systemic

administration of penicillin to combat peritonitis led to the late recognition

of secondary pelvic and subphrenic or subhepatic abscess. A number of cases

survived for several weeks only to die of sepsis; autopsy revealed the presence

of these undrained collections of pus. More strict compliance with the precept that a patient with abdominal distress or pain should never receive medication until the abdomen has been examined would have resulted in earlier

operative interference. Perhaps posters could have been utilized warning the

soldier of the necessity of reporting abdominal pain to the dispensary immediately.

Refusal of the soldier to undergo operation.-It was noticeable how

frequently men undergoing basic training refused to have a hernia operation

and how seldom disciplinary action was attemptud to enforce the operation.

This reluctance on the part of authorities to force the issue became common

knowledge through the "grapevine," and the percentage of refusals increased

sharply. It always seemed patently unfair to Colonel Coley to permit an

otherwise healthy individual to escape the risk of foreign service because he

feared the infinitely smaller risks of an operation for inguinal hernia and

refused to submit to surgery.

Hand infections.-Hand and finger infections caused concern. Usually,

Ay were seen routinely in the dispensary, and, too ofter, they were treated

.Lre on an ambulatory basis. Incisions totally inadequate were made without anesthesia, and the resulting drainage was insufficieit. As a result, the

service command surgeon, on the advice of the surgical consultant, issued a

directive to all installations that cases of hand infections, regardless of their

trivia' ity, be sent directly to the station hospital for observation, hospitalization, and appropriate treatment.

As a result of the consultant's experience with cases of hand infections,

he offered the following suggestions:

1. All hand infections should be admitted to the hospital without delay,

and none should be treated on an ambuatory basis in the dispensary.

2. It should be made a rule that all operations for hand infections be

performed under a general anesthesia and with a tourniquet (preferably a

blood pressure cuff pumped up to 280 mg. Hg).

3. Penicillin should be used at the earliest stage of even the most apparently trivial case of hand - fection. (A few cases had been seen in which such
EIGTH'I SERVICE COMMANND 253

1"i(,vitr 37.-Ietoit of seiti-l iatioi of I lie htandi.

treittiiieit 'veiiieil. to) :n)ort an infect ion i hich at thle outsevt appeared to be

of a serious niature.)

L. Tle just ituion1(1 of couirses for ut itwig t 'urlgow,- abLllft handi ilifectlolls and hanld illjuries has prov)edI at Nery Naluale 11vaIeasue. Dr. Sterling

Buiiilels coit rilitio(1 ill tis respuct %%as oiitt aidiiig. Ill tile tuture, luch

VOIii*sCs 5 hould be 'el 111) earls' ill thle traininig periodi ill order that, traincees

might recei~ e instiuct ion ill flie intelligent hiandliing of these aesfrom tilie

out set, 1t m ould him! beenl nil iorliolls hlp if D~r. Buiniehl's" vouseM cold

have b~een gi vein in 19412 inist ed of 19415.

5. Conlsiderat iol lIkoll be g ixen Ilike ques.t ion whet her hnd infetedions,

and1( especially hnd iiiiiies, mould in tile future lie lunidleul. better b%~ general

,It igCOils t han by orithop~ i edhic C 1i ge( Ii s.

Self-inflicted wounds,~ -Thle consulhtaut %%as iuiipress ed Niili tile ijunuh1er.

of Cases of Nvoiubl thlit appeareu I to hau e been self- intlio-ted. TIhe innjoi it x of

luese \ ere Ilinsile Nvoiiinl oftenl Jitni . according to the 1lust .i\, Ii le: lie,

indi vidual Nwas cleniui, il M- 1 iflte or carbinle. A nluinhel. N ere attributled

to accideiuts iii connect ion witIlI mpjiil0 'bo(ot ing duriuur fiuu-otullil. ( hie Case

ill particutlar. how %ever. ilN ol ed aI Mold ier- N Ito ued 11 li1t diet to seVNV e coniph tely nil1 fouri finlgers of hi, left liial equlir-ing 11 ,tr-okes to () oiiiplet e tile

job (fig. 37). Oil lhe Vu ole, it \\'I extireinely difficlit to pros t that ninny

of lliese N ouiids]- N eie se] f-il ict eu. It N oitld eiui. t herefore. that th lecx penidiees of othieis shloulld be correlated anld th lca ire, matter shold reccike

exi elinle s tdy'.
254 ACTIVITIES OF SURGICAL CONSULTANTS

Reconditioning.-A well-coordinated plan for reconditioning patients in

all ofthe Eighth Service Command hospitals was developed. This was due

largely to the caliber of those in charge, to the provision of an adequate physical

setting in nearly every instance, to close cooperation on the part of the surgeons, and to a general acceptance of the whole idea of the plan on the part

of the patients. The following eight points concerning reconditioning appear

worthy of special comment:

1. Too often there was a feeling on the part of medical officers that higher

authorities were going to measure the success of their reconditioning unit by

the actual number of patients who were admitted and retained; that is, by

the size of the unit. Unquestionably, this, in some instances, resulted in an

unnecessarily prolonged stay.

2. A misconception arose as to whether every patient, regardless of his

condition or of the nature of his illness or accident, was to be sent through

a formal reconditioning process rather than be discharged directly to duty.

3. Probably too much emphasis was placed upon the physical side of

reconditioning at the expense of the mental and, especially, the spiritual side.

4. Directing a large reconditioning annex was one of the more important

jobs in a hospital, and the position should have been made more attractive

by setting it up on a par with the other major services and giving it commensurate rank.

5. Close proximity of the hospital proper to the reconditioning annex

was a distinct drawback.

6. Standardized periods for rehabilitation were to be deprecated; instead,

more individualization by ward officers was desirable.

7. For those convalescents who did well and who cooperated fully in the

program, ir centives, such as weekend passes, could have been furnished to

advantage.

8. A healthful competitive attitude, properly supervised, was considered

desirable.

To summarize, it was believed that the idea should have been constantly

borne in mind that reconditioning was only a means to an end; that is, the

return of the soldier to duty as soon, and in as good general condition, as

was possible with safety to himself.

Rehabilitation.-It was felt that reconditioning as carried out in station

and regional hospitals was more effective than was rehabilitation in general

hospitals. The former hospitals were concerned with patients who, for the

most part, were eventually going to return to duty, whereas the same was not

true in the case of many of the oversea casualties which comprised the general

hospitals' rehabilitation sections.

It was also felt that the proximity of the rehabilitation annex to the rest

of the hospital-apparently unavoidable in the case of the general hospitalswas a distinct disadvantage.
EIGHTH SERVICE COMMAND 2-5

There -was a marked variation in interest in occupational therapy. Efforts

to niak this activity more practical and less diversional might have enhanced

its Vaile.

The same program of rehabilitation and reconditioning could not have

been expected to function effectively under such basically different conditions

as existed with respect to individuals returning to duty and those who were

not. More attention should have been paid to providing for a well-organized

program to bridge the gap between early convalescence and true vocational

training.

Prisoners of war.-The care of patients in the prisoner-of-war hospitals

was generally satisfactory and was noticeably so in Glennan General Hospital,

Okmulgee, Okla., during the period that this installation served in that capacity. On the other hand, some of the smaller hospitals were handicapped by

language difficulties and by an insufficient number of trained medical officers.

In these, the surgical patient was not cared for so satisfactorily. It was necessary to make cHanges in the personnel in order to correct some of the situations that arose in the hospitals attached to some of the prisoner-of-war camps.

MEDICAL EDUCATION

The consultants ii! ighth Service Command and especially the

surgeon, Col. (later Brig. ... ) W. Lee Hart, believed that the program for

medical education was a most important phase of the consultant's work. Teaching, round table conferences, grand rounds, and informal presentations of

special topics were among the measures adopted in connection with this program of medical education. In addition, through the generosity of the Rockefeller Foundation, and as a result of the efforts of the service command medical consultant, Col. Walter Bauer, MC, a fund was provided which enabled

the service command to make three further contributions to the improvement

of medical education. The first of these entailed visits of from 10 to 14 days'

duration by outstanding civilian practitioners, many of whom were highly

experienced in teaching. These visits embraced a group of station, regional,

and general hospitals. The visitors and the consultant made rounds, examined

patients, conducted round table conferences, and gave talks usually illustrated

by lantern slides; they were available for informal conferences with the various members of the surgical staff. Among the surgeons who participated in

this program were Dr. Philip D. Wilson, Dr. Robert L. Payne, Dr. Dallas B.

Phemister (fig. 38), Dr. Sumner L. Koch (fig. 39), Dr. Frederick W. Bancroft,

Dr. Warfield M. Firor, Dr. Peter Heinbecker, and Dr. Harold L. Foss. In

addition, a distinguished pathologist, Dr. Fred W. Stewart, visited a number

of the general hospitals where special emphasis was laid on the pathology of

cancer and its histologic diagnosis.
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258 ACTIVITIES OF SURGICAL CONSULTANTS

In the first area were those impressions obtained while he was not a member

of the consultant team but observed it from the outside, so to speak, as chief

of service in a general hospital. This was a period during which the Army

was being built to its maximum size and effectiveness, and the general morale

was high. The second period was the final year when Colonel Hollenberg

was, himself, a consultant. During this time it was obvious that the general

conduct of the war was coming to a successful conclusion. The buildup was

entirely over, and enthusiasm for the Army was decreasing and, finally, was

extremely low. The period of demobilization occurred at the end of this year.

While it cannot be said that morale was low, certainly interest in the Army

was almost nonexistent and everyone was anxious to return to civilian life.

The third period is that since the war when this writer has observed in a general way the utilization of consultants during peacetime and in the oversea

armies of occupation.

THE CONSULTANT SYSTEM

Until World War II, the Medical Department of the U.S. Army did not

recognize or encourage much specialization among its medical officers. The

fields of ophthalmology, otolaryngology, and certain forms of surgery constituted exceptions to this general situation. A doctor was a doctor and could

be put to work doing surgery or medicine or whatnot. This was the attitude

also in civilian medicine to a large degree. But at the outset of World

War II and with the great mobilization which was under way, it was recognized that the advantages of specialized work, so clearly apparent and prevailing in civilian medicine, should also be utilized in the Army. The decision to utilize specialization was obviously made at high levels of authority.

Many changes were made to accomplish this end and to improve the effectiveness of the Medical Department in general.

Among certain innovations was a widespread system of censultants. The

men so assigned were physicians recruited almost exclusively from civilian

ranks. An attempt was made to procure men a little older and more experienced than the average and, ideally, men with some national standing. From

the beginning, they were made to understand the overall plans and pitfalls

involved in the program and were assigned to headquarters of service coinmands, field armies, and so forth. It was the duty of these consultants to make

periodic visits throughout the command or theater to see that professio.all

work was actually set up and operated according to a well-thought-out plan,

to see that men were properly assigied and utilized, and to insure that

proper procedures were being carried out in accordance with good general

medical practices and in accordance with every changing Armjii order. It

was their further duty to work closely with higher authority and to act as

liaison and coordinating officers between the headquarters of the command

to which they were assigned and the various hospitals.
EIGHTH SERVICE COMMAND 259

GENERAL CONSIDERATIONS

Relations between medical officers of the USA and those of the AUS.--

One needs to recall that at the very beginning of mobilization in World War

If there was a small group of regular medical officers well trained in the

operations of the Army Medical Department. Practically all of the vast

number of new medical officers were completely unfamiliar with the manner

in which the Army and the Medical Department operated. A small number of the older men called to service in World War II had seen service in

World War I. This situation may not obtain to a similar degree henceforth

when many young physicians will have served previously. These regulars

were, in all cases, men familiar with Army regulations, accustomed to command and to obey, and, in many but not all cases, quite proficient in the care

of sick and wounded. The new medical officers were all recruited and commissioned as temporary wartime officers in the AUS. Many were commissioned in field grades and were mainly without one day of training as soldiers.

They brought to the Army a vast amount of patriotic enthusiasm, a high grade

of professional ability and attainment, and fine fellowship; but they had no

awe of rank and, occasionally, even showed disrespect for some phases of

Army manners and customs.

The author has on the whole great respect for the understanding and

tolerance on the part of most of the Regular Army officers in this situation.

But there were those among them who took a harsher position toward these

new men because of their clumsiness with strictly Army matters, on account

of the rapid attainment of their rank, and for other reasons. This situation

furnished fertile ground for unhappiness and stubborn resentment all around.

Likewise, nearly all the newly recruited personnel realized that there were

reasons for Army regulations and forced themselves to adapt promptly. In

fact, some attempted this so completely as to make themselves almost comical.

But there were others who took the unjustifiable attitude that soldiering was

a Boy Scout affair to be resisted.

Another point of tension existed between officers of the Regular Army

and those of the AUS pertaining strictly to professional matters. There was

no question but that the new officers brought to the Army a higher overall

professional skill than had existed before. Due consideration immediately

needs to be given to certain regular officers who had high peacetime reputations and ability in the field of amputations, tuberculosis, certain infections,

and so forth. But, on the whole, the proposition stated above would have to

be accepted. As a result of this condition, awkward situations arose. The

most serious was that a regular officer of high rank in administrative or command authority could dictate by his influence or order professional treatment

which the AUS officer knew to be outmoded or less effective than some other

form of treatment. This not only resulted immediately in less effective treatment but completely undermined confidence in these commanders. Most often,

such orders were circumvented or disobeyed causing the responsible officer to
260 ACTIVITIES OF SURGICAL CONSULTANTS

feel frustrated and resentful toward his subordinates. This is not to say by

any means that the professional thoughts and suggestions of such regular

officers should not have been made or should not have been considered or were

not in many cases quite helpful. Quite the reverse was true. In the matter

of early ambulation, for instance, it was largely the members of the Regular

Army who put forth this idea which was finally generally accepted. But, on

the whole, it was eventually necessary to create a situation wherein the regular

officers had their province of complete administrative and command authority

(where certainly they only were thoroughly capable) and wherein the AUS

officers had more or less complete domain over the care of the sick and wounded.

This happy solution came about in no small part through the activities and

influence of the consultants and, of course, by the spirit of cooperation and

the good will of all concerned.

Relations between the Medical Department and other branches of the

Army.-Another area of tension existed occasionally between certain line officers and the Medical Department personnel associated with them. Actually,

officArs of the line and all Army personnel, including post and army commanders, had respect, great friendliness, and even affection for the Medical

Department, which was so useful to them in time of need. But, during any

rugged period, the Medical Department could be visualized as a softer berth.

Commande's might have felt that unreasonable demands were made by the

Medical Department as regards supplies, personnel, and so forth. As a result,

line commanders of high rank might have seriously interfered with the program of the Medical Department. Their action usually did not concern the

medical officers of the AUS but involved a dispute between brother officers

of the Regular Army. III all these encounters the Medical Department, without outside help, frequently caine off second best because of their lesser rank

and because they exercised no command outside the Medical Department.

This resulted, again, in a feeling of resentment on the part of hospital coinmanders, for instance. To do justice, however, it needs to be pointed out

at once that, here again, a post commander, for example, might often have been

right and have been acting with information not generally held. The consultant frequently and suddenly found himself in the middle of a problem of

this sort on the occasion of a routine visit. It might be pointed out that the

consultant at the time of each visit to a post first visited tile post headquarters

and made himself available for a conversation with the post commander. And

this occurred likewise at the time of his departing from the post. In all cases

in the author's experience consultants were warmly receih ed and cordially regarded. They were recogniztd as individuals visiting various camps and in

touch with high authority. Problemus of all sorts could be brought up and

freely discussed. In many of these instances, the consultant, using a good

deal of tact and diplomacy, could intercede very successfully and bring about

a solution to local problems by his own efforts. In other instances, the matter
EIGHTH SERVICE COMMAND 261

could be properly taken to a higher authority much more quickly and informally than through other Army channels.

Persoinnel problems.--The problems which could arise concerning personnel were legion. This might have been more pronounced among medical

officers than among any others. There were personality conflicts between individual officers of the AUS, great unhappiness as to assignment, violent conflicts as to professional ideas between officers of the same grade or of different

grades (officers of the AUS really had little awe of rank, though they all

earnestly sought higher rank), and strongly felt differences between chiefs of

services and hospital commanders. In all of the problems, and possibly here

best of all, the consultant was helpful. Everyone concerned could talk to the

consultant with confidence in the fact that he was having an interested and

unbiased hearing which was entirely off the record, if necessary. The consultant had a better overall picture as a rule than anyone at an individual post and,

in almost all instances, could offer helpful advice or a downright solution

to local problems. The acceptance of his opinions was amazing. Yet, in

this connection, it might be brought out that in the last analysis he had no

direct authority. His influence was more like that of one physician among

others in civilian practice. The only real authority could be obtained by

requesting specific action through the service command surgeon, and service

command personnel officer, and so forth.

PROFESSIONAL MATTERS

Stimulation provided by consultants.-In strictly professional matters,

every honest physician needs and desires consultation frequently. Groups

working within a hospital or any medical organization soon became familiar

with each individual's thinking and need for stimulation of new ideas and new

personalities. The consultants furnished this stimulation admirably and in

direct proportion to their individual personality and professional attainment.

In the Eighth Service Command during World War II, a rather successful

and unique plan of utilizing civilian consultants was in effect. With funds

generously donated by the Rockefeller Foundation it was possible to invite

an older and usually distinguished civilian physician to accompany a military

consultant of like specialty during his rounds of a number of hospitals and

usually over a period of a week or two. The funds were sufficient to pay the

expenses of this civilian and to furnish a small honorarium. The professional

stimulation furnished by this additional consultant was profound. Their visits

were of interest to nonmedical personnel. And these civilian physicians themselves greatly appreciated the chance to be of service and the opportunity to

see so intimately the workings of the Army. They were unanimous in expressing their appreciation after each visit. The favorable effects of this sort

of plan were obtained, the author would imagine, through the system of utilizing different civilian consultants from month to month in the oversea armies

of occupation after the war. It was certainly a good plan as far as strictly

606222-62-19
262 ACTIVITIES OF SURGICAL CONSULTANTS

professional matters were concerned; the usefulness of such civilian consultants-was limited in certain respects inasmuch as they were not members of the

Military Establishment.

Policing of hospitals and services.-As regards policing of hospitals and

services, the consultants fulfilled a highly useful, though to them disagreeable,

service. The different sizes and types of hospitals were nicely organized and

equipped with the personnel to do varying degrees of professional work. Furthermore, certain general hospitals are set up as centers for such interesting

disorders as arteriovenous aneurysms and other vascular conditions, plastic

procedures, and so forth. And, for very good reasons, it was highly desirable

that specialized work of certain exceptional sorts be done in a special place

by highly qualified specialists. But, physicians are a queer lot in such matters. Confidence or overconfidence, boredom or great professional pride and

interest influenced medical officers in many cases to overlook orders which

limited their work to certain types of cases and caused them not to refer proper

cases to the specialized centers. Under the worst circumstances, the hospital

commander himself might have been unsympathetic with any referral plans;

lie might have had such pride in his hospital and such confidence in his medical

officers that lie did not require them to follow orders to refer particular cases,

He might not have permitted them to do so.

Although it must be admitted that some major and specialty work was

well done in smaller hospitals and smaller groups, the reverse was too frequently true. This writer has seen common duct injuries in simple cases where the

patient should have been referred according to orders to another hospital where

thoroughly capable surgeons were in waiting. In their routine rounds, consultants were alert to this situation of medical officers wanting to do more than

they were permitted to do. Monthly checkups at headquarters on all deaths

furnished clues in these unfortunate cases not properly referred. In fact, the

system of consultants was a deterrent to these errors' happening at all because,

in the first place, the consultant could make the regulations clear and, in the

second place, it was known that there was some system of check. In practice,

however, the search in hospitals for such cases, which were usually well hidden

away, constituted something of a game. The stakes were high, the rules were

changed too often, and the penalties were ill-defined for the offender. For the

innocent victim, the penalty was often clear cut.

Relations with the Army Air Forces.-This writer, while a consultant,

also visited hospitals of the Army Air Forces, as was customary in the Eighth

Service Command. Certain well-recognized difficulties between the medical

service of the Army Air Forces and the rest of the Army were never apparent

on any such visit. Tile cordiality and cooperation even exceeded that at the

hospitals with which this consultant was more directly connected. For instance, on one occasion the service command surgical consultant, accompanied

by a civilian consultant, found insurmountable difficulties for convenient travel

by air or otherwise between Santa Fe, N. Mex., and Amarillo, Tex. The result
EIGHTH SERVICE COMMAND 263

Wasa bus-ride. Whenthe general commanding the Air Force base at Amarillo

heard'of, this, his assumed air of wiath was considerable and his directions to

telone on-ithe next occasion for a plane were quite explicit. Fromhis viewpoint, h 'd hundreds of aircraft flying about on mock assignments for trainiig. It would have been a proper mission for one of his officers to fetch a consultant on orders to visit the base. Certainly his offer was accepted on the

next occasion, but, to have asked for such a service without such an invitation

might well have been considered presumptuous.

On all visits made by this consultant to these Air Force hospitals, suggestions and criticism, while given more guardedly, were ,vell received and acted

upon. Oi a professional basis, visits seemed to be received with even more

eithusiasm. Everyone apparently recognized that there were some differences

at higher levels and beyond the control of those concerned at the local level.

Relations with other consultants of the Air Forces were, of course, cordial in the

extreme for the reason that they were in many cases good friends and all

civilians in uniform trying to do a good job with the armed services. It

would seem that in later years and with changing conditions there will still

need to be different groups of consultants for various branches of the service

for the reason that some of the overall problems differ widely in the various

branches. At the same time, much of the work could be unified.

The life of a consultant.-The life of a consultant is usually active and

interesting, though, in some respects, rather trying and out of keeping with that

of a doctor in the usual sense. A consultant's duties are perhaps 25 percent of

a clinical sort regarding patients, and that rather strictly in the true sense of a

consultant. A surgical consultant, for instance, rarely operates. This is a situation which may cause a strange void in his heart. There is a vast amount of

tiring travel, in hot or cold weather, and a great amount of small chatter and

social amenity. Although the latter duties may at times be pleasant and at

times boring, they are always important and it is in such conversations that

goodwill between various factions may be brought about. The making of

routine reports is troublesome but not arduous. Decisions as to personnel problems may be difficult or heart-rending. The individual consultant works out

his own most effective way of going about his business. Some utilize an austere

and firm manner. As a rule, the kindly, gloved approach-always fair and

thorough-is most appreciated and effective. For these various reasons, consultants in specialized fields of medicine need, of course, to be true specialists

in that category. But the work so largely concerns overall problems that the

men need to be broad. Orders as to their conduct and duties can be givei only

in general terms as the situations are always different. Judgment and freedom of action are required and must be exercised properly. For these reasons,

a man in any specialty can act as a consultant in many respects. For the same

reason that general surgeons are usually the directors of surgical departments

in schools and that general internists are directors of medical departments, it

is usual that these two categories head up the two main groups of consultants.
264 ACTIVITIES OF SURGICAL CONSULTANTS

The .Army has such a vast volume of work in the fields of psychiatry arid

orthopedics that the men in these departments are in some respects more helpful in a clinical way than any others.

The ideal consultant.-An ideal consultant needs to be a bit olderman,

thoroughly trained and capable in his specialty. He needs to be articulate,

tactful, and socially agreeable. Certainly he needs good judgment in routine

and in unexpected situations. He should be either forceful or persuasive. He

should be interested, to some degree, in teaching and should be sympathetic

with personnel problems ip various categories of personnel. A degree of

modesty after considerable unaccustomed attention is a great asset. He should

not be downcast when overruled. One with a strong stomach and good bowels

will go far.

THE FUTURE OF THE CONSULTANT SYSTEM

It would be useless in many respects for this writer to attempt to predict

the need for this system in the future. Yet, many of the problems discussed

are present in an army of any size and under any conditions. In the event of

any large mobilization again, the same problems will recur. Fairminded men

with a broad vision and with a wide acquaintance with men in American

medicine can again head up such a consultant system and, with proper

modifications, again put it into good use,

HENRY G. HOLLENBE-G, M.D.

Section III. The Orthopedic Consultant

During the latter half of 1940 and the entire year of 1941, the physicians,

both civilian and military, in the induction stations were, for the most part, not

sufficiently acquainted with or oriented in the military standards of physical

fitness and allowed many men with musculoskeletal disabilities to be taken into

the Army. The endeavor which was made to qualify these inductees for general

military service was not too successful and wi ' be explained in detail later.

In 1942 and thereafter, training and combat injuries added greatly to the caseload of orthopedic conditions which, with a corresponding increase of other

surgical conditions, made it impossible for the service command consultant

in general surgery to supervise the entire surgical part of the medical situation.

Hence, there came into being the orthopedic consultant, Col. Thomas L. Waring, MC.

DUTIES AND FUNCTIONS

Tle administrative and professional duties of the orthopedic consultant

paralleled those of the surgical consultant. Among the many duties of the

orthopedic consultant was the evaluation of the competence of the medical personel assigned to the orthopedic service. When deficiencies were found, their

correction usually required a shift of personnel. This often could be accom-
266 ACTIVITIES OF SURGICAL CONSULTANTS

have been affected. When this rule was observed, the value of the consultan's

Visit was enhanced.

PROBLEMS WITH PHYSICALLY UNQUALIFIED INDUCTEES

It was frequently noted in the evaluation of an orthopedic service that the

orthopedic surgeon did not exercise sufficient care in the selection of cases for

operation; for example, a patient was operated upon without sufficient regard

for the probable outcome insofar as returning him to combat duty was concerned. This error in operative indication was no doubt due to the fact that

the orthopedic surgeon in question was not fully indoctrinated into military

medicine. The most glaring examples that could be cited were in those conditions that had been incurred prior to induction. By civilian standards, these

operations were justified; however, by military standards, the reverse was true.

Most frequently, these operations were for the following orthopedic conditions:

Internal derangement of the knee, recurrent dislocation of the shoulder, congenital deformities, fracture deformities, ruptured disk, and bunions. Rarely

was a patient returned to general duty after an operation for such a condition

incurred before induction; a few were assigned to limited duty; but the

majority of the patients received a certificate of disability discharge. The

orthopedic surgeons in the command soon learned that, even when the aforementioned conditions were incurred in line of duty, great care in evaluating

the personality and psychogenic background of the patient was necessary before

giving an absolutely valid indication for operation. This experience taught

all that great care should be exercised in evaluating the patient, and that,

frequently, operation should be withheld.

Many of the directives limiting the type of operation for elective conditions

permitted in a station hospital did not concern the orthopedic surgeon, for in the

majority of the station hospitals no trained orthopedic surgeon was assigned.

The surgical service was habitually covered by a general surgeon who usually

did not have much interest in orthopedic surgery and was glad to be relieved

of it.

It became quite evident that better methods and more careful orthopedic

examinations were necessary in order to weed out inductees with disabling

orthopedic conditions. The large number of men inducted with such disabilities

certainly attested to the deficiencies in the method of screening inductees. The

mistakes were due to (1) inexperience of the civilian physician or of the examining medical officer in military medicine, with failure to realize the significance

of the danger of minimizing or overlooking defects, (2) too few medical personnel to handle the number of inductees examined, and (3) too little attention

given to the inductee's statement on his disability.

It was well known that certain orthopedic conditions could only be diagnosed by an adequate history in a period of quiescence; for example, a knee

with a torn semilunar cartilage might have shown no physical evidence of this

condition when the torn portion of the cartilage had been temporarily replaced.
266ACTIVIIES-OF SURGICALCONSUTANTSl~

havj6been affected. W hen tlis rule-was obseivedthe value ofthe consultant's&

'visit~wa ehhanced.

YPROBLEMS WITH PHYSICALLY UNQUALIFIED INDUCTEES'

it was frequently noted-in the evaluation of an orthopedic service, th1 theorthopedic surgeon did not exercise sufficient care in the.selection of cases for

6peration; for example, a patient was operated upon without sufficient regard

for -the probable outcome insofar as returning him to combat duty Wascon,

cerned, This error in operative indication was no doubt due to the faet 4hat

the brithopedic surgeon in question was not fully indoctrinated into military

iiedicine. The most glaring examples that could be cited were in those condi:

"tibns that had been incurred- prior to induction. ,By civilian standards,tllese,

operations were justified; however, by military standards, the reverse was true:

Most frequently, these operations were for the following orthopedic conditions:

Interna, derangement of the knee, recurrent dislocation of the shoulder,, congenital deformities, fracture deformities, ruptured disk, and bunions. Rarely

was a patient returned to general duty after an operation for such a condition

incurred before induction; a few were assigned to limited duty; but the

majority of the patients received a certificate of disability discharge, The

orthopedic surgeons in the command soon learned that, even when the afore -

mentioned conditions were incurred in line of duty, great care in evaluating

the personality and psychogenic background of the patient was necessary before

giving an absolutely valid indication for operation. This experience taught

all that great care should be exercised in evaluating the patient, and that,

frequently, operation should be withheld.

Many of the directives limiting the type of operation for elective conditions

permitted in a station hospital did not concern the orthopedic surgeon, for in the

majority of the station hospitals no trained orthopedic surgeon was assigned.

The surgical service was habitually covered by a general surgeon who usually

did not have much interest in orthopedic surgery and was glad to be relieved

of it.

It became quite evident that better methods and more careful orthopedic

examinations were necessary in order to weed out inductees with disabling

orthopedic conditions. The large number of men inducted with such disabilities

certainly attested to the deficiencies in the method of screening inductees. The

mistakes were due to (1) inexperience of the civilian physician or of the examining medical officer in military medicine, with failure to realize the significa),ce

of the danger of minimizing or overlooking defects, (2) too few medical personnel to handle the number of inductees examined, and (3) too little attention

given to the inductee's statement on his disability.

It was well l, ,wn that certain orthopedic conditions could only be diagnosed by an adequa i history in a period of quiescence; for example, a knee

with a torn semilunar cartilage might have shown no physical evidence of this

condition when the torn portion of the cartilage had been temporarily replaced.
Simifarly, arecurrent dislocation of thie sioulder-would iaVe shown nq physica "

finding.except vhen itwas-dis1cated. Too often, an, attitude wt*Asake by the

examiiiihg, ifi edical offieet that the ,inductee Was trying to keep out of the miliu ei ,iceless tii ,ile resuit thathle was inducted.witlh adisability which-made

himivuseless,t0 the military, anid his ultimate fate was a ce':tificate of disability,

discharge indu curse of time; with much inconvenience to. the Government

and needless expenditure, of :public funds. These deficiencies were overco e

by sta g ,ginduction stations with adequate medical petsonnel specially tr ined'

t ro cogniz6 these conditions and by-taking-A more-ealistieattitudetoWard-tl~e

me'dioal,[i~tements ofthe examinee,

'SPECIAL ORTHOPEDI PROBLEMS

Many musculoskeletl, problems were enicountered Whichriequired special:

consideration, A discussion of some of these problems considered worthy of

Como'und fractures.-In the early days of the war, it was most difficult

'to convince orthopedicand other surgeons treating-compound fractures that

in military, surgery the use of internal fixation and primary closure was a dangerous procedure and should not be followed. Later, a directive from the

Officeof-tle Surgeon General prohibited the practice of internal fixation and

closure.

March fractures (fatigue fracture, insufficiency fracture).-March fractures, especially of the metatarsals, presented a major problem in infantry

training centers. The disability resulting from this condition interfered with

the continuation of basic training. In the beginning, trainees with this condition were hospitalized and the extremity was placed in a short leg plaster cast

with a walking bar. The average period of disability was from 6 to 12 weeks.

It was soon realized that, although this was a painful condition, it was not

serious. A method of treatment devised at Camp Wolters, Tex., and used

successfully in the Eighth Service Command, did not require hospitalization

and allowed continuation of training, excepting only forced marches. Treatment consisted simply of a rigid steel shank in the shoe which prevented flexion

of the foot at the metatarsophalangeal joints. March fractures of the inetatarsals were the only type of fracture in this classification that could be treated on

an ambulatory basis. Fatigue fractures of the major bones of the extremities

and pelvis required hospitalization.

So-called sprained wrist.-Undoubtedly, the majority of injuries to the

wrist from falls resulted in simple sprains, but, from bitter experience, it was

found that a certain percentage of the so-called sprained wrists actually were

fractures of the carpal navicular bone. When this condition was allowed to

prevail for a long period of time, severe disability resulted. In order to detect

the fracture, it was determnaed that all injuries to the wrist should be X-rayed

in four planes-anterior-posterior, lateral, right and left oblique. Initially,
268 ACTIVITIES 'OF SURGICALCONSULTANTS,

these 'viWs may have shown no fracture; howevei, the injury had to beltreated

as factreuil iIproved otherwise by a similar sto -as2wesltr

Ankle ftactiuires.-May poor results were noted folloW ing bimaleo a1

aind'itrimallieoiar fracture of the ankle when the fractures were not redyuced, - aifiatomicliy. Minor fractures could usually be satisfactorily reduced by

manipulation with anatomic replacement of all elements, especially thoseinvolving only the medial malleolus, but all other types ofankle fractures should.

haVe ben reduced by open Operation.

"The painful l0w back.-This condition was very common in all Service,

conimiahi and th, only the experienced surgeon could differentiate betwe6n the

'legitimate and the feigned. Consequently, it was common knowledge that.(this.

condition was difficult to evaluate, and outpatient physical therapy clinicswere

overburdened With these patients. However, as a more thorough understand,

ing of this condition was gained, and as consultation with the neuropsychiatrist

became more frequent, complaints of low back pain decreased appreciably.

Self-inflicted wounds.-The majority of self-inflicted wounds, especially

those of the feet and hands, were incurred while the soldier was on furlough,

In a significant number of cases, the opposite lower or upper extremity from

the handedness of the soldier was injured. These cases always presented a very

delict,,e situation as to line of duty.

Hand injuries and infections.-In the early stages of the war, treatment of hand injuries and infections was so haphazard that headquarters of

the Eighth Service Command sent out corrective directives to all medical treatment facilities. One of these bulletins 3irected that all hand injuries and infections should be handled by the section 'vith the most experienced surgeon in

this field, regardless of whether he was a general surgeon or an orthopedic

surgeon.

SPECIAL CENTERS AND REHABILITATION

The establishment of special treatment centers was a definite step forward

in providing better care for the soldier. This was especially true with regard

to the hand, neurosurgical, and paraplegic centers, which required highly

specialized personnel in scarce categories.

The hand centers, with Dr. Sterling Bunnell as the chief consultant, contributed much to the knowledge of hand injuries. Information and indication

of treatment of these injuries were disseminated widely and a decided improvement was reflected in the care of hand cases. Many outstanding surgeons of

postwar days have received their training in these centers and have continued

to contribute to the knowledge of hand surgery.

The rehabilitation program as established in the hospitals, rehabilitation

centers, and annexes to the various treatment centers did much to lessen the

convalescence period. It was the consensus that the rehabilitation centers located at a distance from the hospital were more effective because, at times,

patients were retained in the center longer than was necessary, especially in

those rehabilitation activities connected with the named general hospitals. It
EIGHTH SERVICE COMMAND 2A

*0, reail , however, that thepr9gram in connection with, a generalhospital

i d ain certain respects from that in a regional hospital. In the latter, a

greatt~imip~er of patiet,..were expected.t return toduty; Therec6ndition-

,g, programwas a very important part of the treatment.

MEDICAL EDUCATION

It is the impression of this author that every physician is better off professibnily r having spent some time in the military service. There may be excptionS to this statement, but they should be relatively few. The~medical ofder ha&d ai opportunity to associate with other medical officers, ranging from

gener al piractitioners to the highly specialized, from all parts of the country.

In most h6§sitals, the educational program was excellent and-waskeyed to the

dissemination of medical knowledge useful to all concerned. The specialist

with practice and association narrowed to a very limited field found out what

was going on in fields other than his own. The consultant system contributed

much-to-the dissemination of medical knowledge.

Libraries in most fixed establishments were equipped fairly adequately,

with the exception of reference files. This defect was overcome to a certain

extent by the excellent photostatic reproductions obtainable from the library

of The' Surgeon General.

In the Eighth Service Command, through the efforts of Colonel Bauer,

additional educational advantages were obtained through the Rockefelle'

Foundation; for example, the purchase of medical books, periodicals, and clinical pathological material and visits of outstanding physicians and surgeons.

Arrangements were made with these specialists to spend a prescribed period of

time in the service command, visiting the various medical facilities with the

service command consultant. It was impossible for such a specialist to visit all

facilities. Consequently, in order that full advantage could be taken of his

teaching, the institution so favored would invite interested medical officers of

neighboring institutions to be present. Full cooperation was obtained in this

by service command headquarters and other facilities involved. The visiting

specialist and the consultant made rounds, examined patients, conducted roundtable conferences, gave formal talks, and. generally, were available to all concerned literally 24 hours of the day.

The orthopedic surgeons l'articipatin ',at his program were Dr. Arthur

Steindler, Dr. Marius N. Smith-Petersen, Dr. Ralph K. Ghormley, Dr. J. Albert Key, Dr. J. Spencer Speed, Dr. William W. Plummer, and others.

COMMENT

The writer wishes to comment, not through a sense of duty but because of

the very sincere belief, that the primary concern of the Eighth Service Command surgeon, Colonel Hart, was to see that every soldier received the best

6062221-62-20
2QACTIVITIES ,Oy ' SURG.iCl it:CONSPLTANS4

~z <7~-~ ~1 ard~e- possible. Nio shohitut were to1eratod;,rank a not enter into- the-, j~ijze.Th mst ineadal ffer a were assge to poiisf re4

"pilty, regardlssof raink. T1iat -this policy created veryJ ,lttle animoisit

wa~f.realy surprising ad,4i th opiion'of he wifterwsdetoheot

hegarty, cooperagtion of -all, echelons of the miedical service of the Eighh~v

-:C bn~ a~ii'dTHOMAS M.D
CHAPTER, XIV

Nih Service Command

John . outzenheiser, M.D.

ASSGNMENT ANDOPIENTATION OF ORTHOPEDIC CONSULTANT

It wag not -until December 1943 -that an, orthopedic, consultant wasaps

pointed in ithe Ninth Service Command. This- consultant was Col. John j

-Loiitzenhei er;,MC,, who had entered-inilitary service more thanfa year earlier.

His pii.'ise.rvice as chief of orthopedics in a general hospital- proved tobe

use i ad haid allowedhiwto obtain full knowledge of many of the problems,

that cpic6rnhed an orthopedic section in a general hospital. With such a

backgrufd, a consultant had more sympathy with the multiple difficulties

which ,existd on the home ground of the various hospitals in his command.

qn ,ip6rtipg to the Ninth Service Command headquarters at Fort Dougr

l s, Utahthe new orthopedic consultant was briefed on his duties by Col.

John B. Flick, MC, Consultant in Surgery, before reporting to Brig. Gen.

46i M. Willis, who was surgeon of the command. Colonel Loutzenheiser's

introduction to the consultant group with which he was to work was an

important moment in his military service. As he recalls it, General Willis

said "Wehave a gi'eat medical team here, and we will insist that you be a

teni player." It did not take long for Colonel Loutzenheiser to realize that

this commahnd had taken a group of brilliant individualistic doctors and had

w6lded them into an efficient consultant team for military medical purposes.

Col. Verne R. Mason, MC, Col. Lauren H. Smith, MC, and Colonel Flick were

the medical, psychiatric, and surgical consultants. These consultants gave

Colonel Loutzenheiser a few words of advice which should be noted here

becatie undoubtedly this advice helped him in his relationship with hospital

commanders as well as with his fellow orthopedic surgeons in service. They

stated: "We make an effort to work harder than anyone else in the hospital we

are inspecting and you must do likewise if you expect to gain the respect of

your cbnfreres, be helpful before , ou are critical, study the commander's

personality as well as his personnel, and report only accurate, factual, existing

circumstances."

AREA AND MEDICAL TREATMENT FACILITIES

The geographic area of the Ninth Service Command was comprised of

the eight Western States of Montana, Idaho, Washington, Oregon, Nevada,

Utah, California, and Arizona. This area contained 12 general hospitals, 11

of which were located in the coastal States of California, Oregon, and Wash271
272ACV Es O CONSULTANTS

ihgtoh, and the-other in the State ofUtah. There were in CaiforniaA~wo

_goulhospi'tali at Oakland, and Pasadena And. large -sttioA hospit. s.t

rort Od, Camp Ro0bei's, Camp inan, and mp p Stoneman. In addition,

there worelarge station hospitals at- Fort Lewis, Wash.,,and' at'FortHuadluca,,

Ariz. There were-other hospitals to be visited,, suchlas those of the port oft

eI barkatidn at Seattle anid San Francisco and the ,prison camp hospitaL at

hi*iiqBii, Ariz. Air Force hospitals were occasionally visited when the need

was, indicated. When one considers the great distances which had to -be

covefd' in the Ninth Service Command and the number of hospitals to ,be iipc ted its evideit that the consultant spent alnost as mucht time traveling

:asli6did in actual work.

In order to design a ,practical plan for inspecting this command, the area

wasdivided into four sections: Northwest (Washington and Oregon); north0rn6Cai1fornia and Nevada; southern California and Arizona; intermountain--7

-Idaho and Montana, where there were no general hospitals; and Utah, Where,

the service command headquarters and amputation center were located.

Ideal~ly, one needed a 3,day stay in a large general hospital to accomplish the,

optimum good, but, often, no more than 1 or 2 days could be spent because

of the time required to cover the service command. A consultant should not

have been absent from his headquarters for more than 2 weeks. Tlhat length

of time allowed one to visit from four to six hospitals on each inspection trip

in an area as large as the Ninth Service Command, it might have been better

if a regional consultant system had been set up which would have allowed all

the station hospitals within a given area to come under the consultatioh of a

top orthopedic surgeon from a nearby general hospital. Such a plan should

have worked well and improved the care of patients in the smaller hospitals.

Uifortimately, it was difficult to divide responsibility or delegate authority

when oie was personally responsible to the surgeon of a command. As it was,

the mission of the orthopedic consultant would never have been accomplished,

and the job could never have been done, hr.d it not been for the extraordinary

efficiency and cooperation of the Surgical Consultants Division in the Office

of the Surgeon General, the service command surgeon, and fellow service

command consultants. It can be stated also that ute chiefs of orthopedic

surgery in the general hospitals of the Ninth Service Command were highly

competent surgeons who made the work of the orthopedic consultant much

more a pleasure than an irksome duty.

ORTHOPEDISTS IN THE COMMAND

Outstanding Orthopedic Surgeons

A list of the orthopedic surgeons ,ho did fine work in the Ninth Service

Command would necessarily be long, ',ut they must be named. Many of them

not only carried in their regular dutL.,s, but also assisted the orthopedic consultant in establishing teaching centers for the training of surgeons in certain
NINTHM SERVICE-TCOMMAND 273"

liiiited;pl esQ f orthopedic surgery. These officers are not idehtified with -a

pticulii 'hospital becAusethey often served, in- more than one. Wherd possble; the,6hiefs of orthppedic surgery are listed With their assistants, as they

w0k dd as a joint team. In all instances, however, the chief of service was.

responsibl for the high character of he work, loyalty, and enthusiasm of his

assistints,:Lt. Col. Ernest E. Myers, MC, and Maj. HaroldW. Woughter, MO,

Lt. Col. Richard B. McGovney, MC, and Capt. Mario F. Tagliagambe, MCI

MaJ. Carroll 0. Adams, MC, and Capt. A. Luckey, Lt. Col. Edward K. Prigge,

MC, and Capt. Frederic W. Rhinelander, MC, Maj. Thomas H. G. Aitken, SnO,

ad, Capt. Alvin J. Ingram, NC, Maj. Robert F. Warren, MC, and Capt. Robert

B. Ports,tM, Maj. George E. Waters, MC, Maj. Norman R. Brown, MC, Capt.

HaroldhUnger, MC, Maj, Robert H. Denham, MC, and Capt. Walter Carpenter,

MC, Maj4 (later Lt. Col.) Maurice M. Pike, MC, and Capt. Donald R. Pratt,

MC, Maj. -Donald B. Slocum, MC, and Capt. (later Maj.) Donald H. Moore,.

MC and .Robert King, and Capt. Joel Hartley, MC. These were the men

who made a great contribution to orthopedic surgery in the Ninth Service Command. There were others who played an almost equal part in this command

but did more important things elsewhere. Undoubtedly, the latter will be

listed for their accomplishments in the reports of other consultants.

Relationship of Consultant With Orthopedists

The relationship of the consultant with the orthopedists in the various

hospitals was one of mutual respect. Open criticism of procedures was never

made except in private. Ward rounds were a procedure for observation, information, and note taking for later critical survey. Criticism of care in the

presence of patients was prohibited, but useful discussion was allowed. Orders

from higher authority were enforced by the consultant, but he never tried to

force a confrere to his opinion. There were times when criticism was better

accomplished by asking for a written review of patient care when some particular procedure was in question. This procedure may have been a favorite

of the orthopedist on duty, and one that was not in full accord with overall

surgical policy. After he had made a review of his patient care he often

came to the proper decision without any comment from the consultant. Another approach to the problem of getting an orthopedist to change his ways

was to discuss the success that some other hospital was having with an approved

procedure. If these methods failed, one gained cooperation either by bringing

an important orthopedic civilian consultant on hospital rounds to criticize,

while making valuable suggestions, or by bringing another capable orthopedic

officer in to work alongside the recalcitrant chief of section. Soon the competitive effort of fine work would improve the entire orthopedic service. It

was necessary to have a personnel officer in the headquarters of the service

command who was willing to work with the consultant in order to accomplish

these ends. Forcing a chief of section to agree with the consultant, going over

his head to the hospital commander, or undermining him with his chief of
274: ACTIViTIES' OF SUItR!CAL CONSULTANTS,

surgery Were not~prbper or effective methods. If the surgeon- was colipetent

but stubbdnn :thiere were better-'ays of hanidiig, the situation; -Onthe otlier.' haiid oif ie refused tobe coopera tie, it WasadVisible to movb him immedi t y.

Rarely w-as-there a surgeoJn who did not -have some real value. AiqanwL

"ivas considbred, to- be .in~ompetdnt in onie job might prove, to. be ,competeit in

'aflthei'. Theconsultant was obligated to find a. pr:oper place .for each man,

RELATIONSHIP OF CONSULTANT WITH, HOSPITAL COMMANDERS'

it took the consultant a little time to realize that others had problems,

48 Wall as he. it took time for- a hospital commander to develop 'an, ade~uftte,

orgahization, and, once it was obtained, any commander was -nderstandably '

Wiwilling to have the organization disrupted. Ii tle movement of personnel',

it Was ii' ecessary to replace able officers with officers equally able,, thus naintaining harmony with efficiency. To attain this harmony and efficienqyi tl'e

consultant was advised to make an effort to establish understanding with tie

command officers of the hospitals. Wlere this was possible, it always ledto

Uitiil benefit. Occasionally, when the commanding officer of a hospital was

desirous of having some change made in his orthopedic service, the consultant

was able to meet his desires and better his service. At the same time, such

changes made it possible to improve orthopedic service elsewhere which could

make better use of the medical officer subject to transfer. Colonel Loutzenheiser did not desire to be considered overly politic during his inspection, trips.

Notwithstanding, he considered it a duty as welt as a privitge to know commanding officers well. There were a few commanding officers who considered

the consultant system a nuisance, but most of them appreciated its usefulness.

It was recognized that few of the general hospitals had adequate orthopedic facilities. Most hospitals were built on a 1918 plan, With a plaster room

not much larger than a clothes closet and without adequate X-ray equipment

nearby. There were no braceshops of any importance. Orthopedic departments were overloaded with inpatient and outpatient consultations. Patients

waited for the operating schedules to provide time and space sufficient for their

care. Consequently, the first reports sent in by the new consultant were

extremely critical-not of the hospitals themselves, but of the facilities which

they offered. Many hospital commanders were offended by such surveys and

considered the consultant's report incorrect and unjust.

On arriving back at headquarters, the consultant soon sensed that he was

just about as unpopular there as he was in the field. It was presumed that some

of the indorsements on his reports suggested that the orthopedic consultant was

attempting to force the hospitals commanders to request improvements and

additional facilities which they did not believe necessary, on the basis that

a good commander gets along with what he has and does the best he can with

it. Fortunately, at about that time, The Surgeon General established a

precedent for adequate orthopedic facilities, and clarification through his office

allowed all improvements to be made which did not require new construction.
N1NTW8SERV10E:.COM1AAND27

The 'Ninth Service Command immediately provided adequate orthopedic'

Suggestions, resulting froh 'this conflict in opinion as to the adequacy of

rthiopddic 'ilities inclded the f6llowing: (1) That a consultant in, the

Me.dica"Department shou}d hav rank com'mensuratewith his position, (2)

that planning for improved facilities in all, hospitals for specialized care was

needed, (3 that the sick and injuro'l ihould bive the'best facilities available

and a h liem When neededm not -onths later, and (4)- that the orthopedic

constiltants' should, be briefed in the Office of the Surgeon General before reportng to :their assignments and twice a year thereafter, if possible.

t sho Ud be stated that this consultant rarely found it satisfactory to

-deal entirely witl the executive officer, of a hospital. The commanding officer

who considered it more efficient to have his executive officer deal entirely with

a, consultant never reached the degree of rapport necessary for the proper

coordination of his hospital activities with the service command or with the

'Office of1othe'Surgeon General.

EARLY INNOVATIONS AND IMPROVEMENTS

Orthopedic Consultation in Hospitals

In the ,face of heavy workloads, it became necessary to solve the problem

of providing inpatient and outpatient orthopedic consultation for the other

hospital services. It was noted that patients were being referred for consultation from all sections of a hospital for trivial reasons; that is, nondisabling

back ailments and shoulder, knee, and hip complaints for which orthopedic

consultation was believed to be necessary. With the consent of the commanding officers of the hospitals, courses were established for training medical

officers on other services in basic orthopedic examination. The routine examination of the feet, back, and other joints was not outside the province

of any medical officer. After the development of these teaching courses, the

consultation load dropped off markedly, and the valuable time of the orthopedic

surgeons was released for longer periods in surgery. Concurrently, the

younger medical officers were grateful for the more adequate knowledge they

had gained.

Screening and Grading Patients for Surgery

As the consultant becanie familiar with his job, he soon realized that the

remote wards of the hospital often contained large munbers of patients awaiting surgery. As capacity loads appeared, he found th most needed surgery

being well done, but patients with chronic surgical conditions were waiting

too long for their operations. As a result of this finding, the consultant

reversed his ward rounds and from then on started with the convalescent wards

and worked up through the hospital to the acute wards. This resulted in a

different system of orthopedic care. With more exacting criteria for screening
S27 ACTIVITIES OF :SURGICAL CONSuLTAINTSA

Ad grading patients, the chronic bone and' joint infections-were- movednto,

wa vards and took: their ,place on the daily sugical schedule. In, order to,

accompiish this with' ohly a few orthopedic surgeons, it was neessary to train

jui r :medical officers With surgical backgrotind in limited surgicalprocedures.

The technique of careful cleanup of chronic bone infections, seconxdh

closres, andsplit-skin gifting allowed a better production inein the surgi al

Some oif the-hospitals were staffed With medical officers who were much.

mdre cpable of -teaching than officersin other hospitals and consequently, wre,

selected a teaching, centers, As young surgeons were assigned to the-Ninth

Srvice C"ommand,,thiey, were further assigned to these teaching centers, for

later, distribution overseas or into the hospitals of greatest needs. Subih

nianeuvering demanded complete cooperation between the personnel: officer

andcthe surgical consultant.

'Under the new gystem of ward arrangement with regard to the. patieht's

conditi6n, the numbei of wards designated as convalescent decreased. When

a patient reached a convalescent ward in the new system, he knew that: h

Wal on his way to recovery. The descriptive terms "acute, "subacute," and.

"chironxi with respect to wards were discontinued, and the terms "active

Sirgicai,"1 "continuing surgical," and "convalescent" were used in their place,

Qn acceptance of this classification, the number of patients available for,

transfer to special surgical-reconstructioA centers increased, and the number

of convalescent bedpatients d&reased. Purther benefit was derived by getting these patients to the special center- with their chronic bone infections cleaned

up and the skin closed, thereby reducing the workload in the special centers and.

allowing them to move ahead with their particular type of reconstructive

surgery. Before the establishment of this system of care, when the patient

was recognized to have a combined bone, nerve, and skin lesion, lie might have

been wrapped up in plaster and shipped out with his chronic infection only

to sit in the special center and await care first by the orthopedic section, then

by tlo) plastic section, and finally by the neurosurgical section. This led to

the overloading of special centers, with consequent delay in elective surgery,

and with the production of surgical backlogs. Acceptance by orthopedic

sections of their full responsibility in the care of chronically infected bone and

joint lesions before transfer to special centers overcame this problem.

Diagnostic Screening in Unit Dispensaries

In the Ninth Service Command, the orthopedic consultant had infrequent

contact with line officers. Problems did arise in the command's large military

catmps, but, with few exceptions, they were efficiently cared for by the medical

officers assigned to those stations. The line officers at Camp Roberts, however,

never could be convinced that their training program created more casualties
tI ixiecessary. Mardhing dOuble time onpaved areas when, fatigued would.

keep4'.War r, toB64with maciond tg~ fractures.

n0:oiie Fort LeWis dedlppd a sudden pa alysis of,'its-medical

dispe~a. .system whei -the trop concentration there became high. This

'failum of'thbdi.

pensary ystem ledto -a breakdown of the station andgeneral

hospial eryices. In order to get patients out of the dispensary, they were

sbft :f "laboratory and X-ray investigation. Consequentlyi,they -stood, in

line Waiting to got in dispe'nusaries, laboratories, and :Xray stations, thereby

reating a traffic jam in medical service. In the absence of other consultants,

fh-rieicommafd surgeon was forced to send thde orthoPedic consultant

ior-in,6§sti'_& on of ,the niedical- situation at Fort LeWis. Thisismentioned

oy cse itgave the consultant an o pportunity to provide a diagnostic

idreenmgin. s'vice for the dispensary medical officers, thereby protecting both

the gtation and general, hospital inpatient and outpatient* services from being

ovefloaded., An internist, surgeon, psychiatrist, and orthopedist were put incharge of this scieening. and diagnostic service These medicalofficers organ,

ized a course of instruction for the dispensary officers and trained them in

echiiques of examination so that only problem cases would come from the

disp6#sary to the screening and diagnostic service. The dispensary officers

were allowed to attend consultations when possible. Such ( .. tnization greatly

improved the morale of the dispensary Qffiers who had previously felt as

theugh-they were being left out of things. It also gave the service command

an opportunity to use several medical officers of high rank whose ability had

not beon fully utilized in their former assignments. These officers made a real

contribution and gained a sense of personal accomplishment which up until

that time they had not enjoyed. The process of finding the right man for the

right job and having him dedicate himself to it and consequently feel that he

had served'his country fully, gave this author a gratification probably as great

as any other that he had while in the service.

Integrated Physical Rehabilitation

After another tour of inspection of the general hospitals, Colonel Loutzenheiser found that little was required of him for the proper functioning of

their orthopedic sections. Unanimously, the chiefs of orthopedic surgery had

suggested that an improvement in the coordination of physical and occupational therapy was indicated. As the census increased in the hospitals, the

physical therapy departments became overloaded and it was difficult for the

physical and occupational therapists to get their work done with the limited

number of personnel assigned to these tasks. Inasmuch as these therapists

were most important to the care of orthopedic patients, recommendation was

made that they be coordinated and work as one therapy team.

The orthopedic consultant, with his interest in establishing effective rehabilitation, soon found that lie was involved with the reconditioning program.
27s ACTIVIIES O 4 1 11IC(AI ('4 N81 L.'ANTS

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NINTH SERVICE COMMAND 279

SPECIAL CENTERS

Integrated Reconstructive Surgery

Xii the course of time, the Office of the Surgeon General established a nuiinUbi' Of 'pecial centers in selected hospitals. On visiting hospitals so designated, tie oi'thopedic consultant realized that the activities of the special center

were taking precedence over all others in the hospital, with consequent loss of

a sense of:proportion for combining the interests of the special center with the

iest of the hospital's activities. It took a good dealof doing on the part of all

the consultants to make some of these centers realize their full obligation. In

ohe 4istance, it was necessary to make a factual survey of the existing conditions within a certain hospital before full cooperation of the various sections

could be gained for the development of a complete reconstruction surgical team,

Recommendation was made for establishing a therapy conference of orthopedic and plastic surgeons and neurosurgeons who were to decide in each problem case the mode of procedure and the timing of the various and subsequent

procedures that would be necessary to restore the patient. A followup report

of these patients was made every week. Experience with such an integrated

special therapy program proved that this was an advantage over methods used

formerly. The recommendation was then made that special centers be combined into special reconstructive surgical centers. This was not accomplished

by 1946, but this consultant felt that it would have been a better method than

the one in use. Thoracic surgery might have remained as a single special center, but the other surgeries would have functioned more efficiently if they had

been combined. Amputation centers might have been another exception to the

idea of combined centers, as the need for group therapy, for amputation surgeons to work with limbfitters, and for special shops for prosthetic manufacture presented a problem best handled in a single special center.

Amputations

Prosthetics research.-'rhe amputation center in the Ninth Service Coinmand was located at Bushnell General Hospital, Brigham City, Utah. This

hospital was located within 60 miles of service command headquarters, and the

orthopedic consultant was ordered as his first duty to make a comparative study

of the Army and Navy amputation prostheses. As a result of this duty, an

amputation prosthesis research center was established and financed at the start

by Mr. John Northrop of the Northrop Aircraft Company. This consultant

was responsible for Mr. Northrop's interest in this field and worked with him

and his engineers during the last 2 years of the war. Improvements were made

in upper extremity prostheses with the use of lightweight metals and plastics

and with the application of latest engineering principles (fig. 41). On the

artificial legs, plastic sockets were developed to replace those made of leather.

The Committee on Prosthetics Services, National Research Council, reported

these research activities in considerable detail with due credit to this consultant
280) ACI N111111->1 OF' SURI~CAL. COSI'ILI'A.\I

u B ~I \ te vid oft 191, the aloipta iuul celivit I a i I'Clate 'I'litr llopitt al 

prIl~ Ile'li, 'llop \\ a,' Cild lCtI it) ualke can, bi l oadIu~. atilt([ l ui t lloduk X\ CEC

im~ il tiouIaulim Ow ato al in of uuhiauia 1:0 poihitial al0 : miati tth titlt I

Olu , \\vi mt m Ii ld a t It Iil ift t I he u tI l 111 al t liai 1C: ke l ul halt. CIv I Iwu

tiatitiandi \a el haal. I fut I TI pilaiut -CO1, vi vha odle tal Nt er betia hiah

\\allu a 1te ilil tIn alui -lre of iih liii a vMIuuhh I\ 11-litiujit iand it a

ilrly;Ill[ 1 'Iric and X al irii It ' I IITi nv-iilc I l i li .N ih v il
NINT. SEVIC COMAND281

, pqkM, Th.le rigid artificial hand, could not do this. At that time, the grote.que

OTOEICS, IN GNERA ANI) STATION HOSP!ITALS

After tu*dy of the amputation centers andinitiation ofprosthetic researi

'eproblefs of-th general and station, hospitals occupied, the major. prtion, of" theorthopedic consultant's time. :Inspection of the ozthopedioservicesat

... 2igen lhospitals and twice that numberof statidnhospitals demanded too

S'was a neces a bak ground for learning, the4polm fec

hositlasthe wreal disiilr.The major ,problems to 4be_ solved' Were

placezni 4( of personnel best fitted for their job, (2) development of ade - -quate'lailiies within, thehospitai to allow, the w ork to'be done efficientlyani .. rapdly '() rragemnt orproper miovemnent, of patients with, particula,

regrd toth6e.pathological siati, (4) coordinationofpyiaadocpti6n'itherapies into one-therapy program, and(5) organiization.of effective, ' :,habil r ii.~nprog rams for the conivaileent patient. : ',

OtoeicPesne

Th esnnel problem was alas diffiut 'but not insurmhountable. There

was neverafi4,dequate personnel. The'problem wassolved in part by utilizing th wel irned to thebst advantage and havig diem train additional personneltodo limited:surgery (the same-Procedures again and-again until, the

junfior surgeons had-reached a high degree of prof1iency). This allowedthe

rai ort hopedic surgens to complete the major definitive surgery, The

0 ortho ihiefsof surgery were selected for surgical ability ahd ,qality of

jeadeship.' Their -personial accomplishments, devotion to -duty,,and kindness,

to theiatients were more thannoteworthy. It was their outstandingchiracteri -at -inspired so, many youngsurgeo ns to-become orthopdic surgeon s.

The roblm ofpersonnel pla,,cemen divided itself into-several componentsas

'foiws: (1) Selection of department-heads (chiefs of sections)-, (2) evaluation

aiid, assay _ personnel to work with 6t6 -chiefs of sections, (3) training of

medical"6ffleti for lihitOd special surgery, and (4) movement of inyorthopedic 6&fc6r fo bettermentof service..

SSOe~~in.-The methodused for selectiOn of chiefs of section was satisa

factor. -The Office of the Surgeon General assigned an orthopedic surgeon to

the service command with arecommendation that he b made chief of Section.

The service command knew the needs and usually made proper placement of

the qualified officer. In the Ninth Service Command, the service command surw

f:derd the consultants to work with the personnel officers in all problem s

fplacement and transfer within the service command. This order resulted in

many benefits as the consultants knew the personnel intimately as to person-
82: ACTIVITIES OF'SURGIAL, CONSULtANS

S aitd, ablity, afid-leadership; and the personnel officer khnew ohly their naie,.

graaesi and classifiedt-0ns.-

Evaluation.-- T e ,evaluation or assay of 4orthopedic offices wasaccomrplished soon aiher theirassignment. Three montls f- on-the-job-service was

usuall an adequate period for evaluation, althouglthere were times whenone

month proved to be adequate. Only a few of the officers who had been certifled as orthopedists by the American Board of Orthopedic Surgery were-incapable of acting as chiefs of sections. These few had acquired little train11g

in the surgery of trauma and were of necessity trained within the sei--vice

command, Occasionally, the transfer of such an officer would lead tomisunderstanding between the Office of the Surgeon General and the service

command. The opportunity to evaluate orthopedic officers for particular assignments occurred in the Ninth Service Command by the end of the year 1943.

Training.-As early as 1942, the problem of training officers for particular

assignments was answered by the assignment of medical officers to permanent

general hospitals, such as Letterman General Hospital, San Francisco,. Calif.

In this hospital, the surgical services were well organized, and teaching services

were easily established with superior personnel working in a city wheretwo.

medical schools were located and were willing to assist in any teaching problem. Later, other hospitals had to be used for teaching and training cnters

since Letterman General Hospital became more and more concerned with the

receipt and disposition of casualties from oversea theaters. Well-staffed and

well-organized orthopedic, plastic, amputation, and neurosurgical sections

were used to train and evaluate medical officers with surgical training assigned

to the command. In this manner, particular surgical talents in the young

surgeons were developed and they became more useful for oversea or general

hospital assignments.

Transfers.-The need for moving medical personnel from one hospital to

another has been mentioned earlier in this discussion. One had to be certain

that the transfer of a valuable medical officer was demanded by need for improvement of the service. All the reasons for the transfer of an officer had to

be fully justified, or the consultant would have been considered fanciful and

untrustworthy. When transfer was justified and allowed, there was considerable inconvenience and Government expense occasioned. Consequently,

transfers or changes of station within the service command of married officers

had to be infrequent. During war, there is no situation which can be considered completely static or stationary. The personnel one has today may be

gone tomorrow, and the consultant's recommendations of last week may appear

stupid and ridiculous next week because of a change in events over which he

has no ontrol. The safest course was to postpone the action believed advisable and save this move on one's mental checkerboard for the (lay he might

be forced to make it. The following phrase is used by tacticians for this

method of procedure: Never do today what you can do better tomorrow.
NTH S'ERVICE COMMAND28

FaI iies

The' §dciid majOr problem-trat cdncerningadequate working~coiiditionsith~intbe hbspit al fooptimal care qf-patients-was a real and serious problem1

Geiieri<hospitals were built on plans which were, outmoded,-for the, existing

neleds. he 'jeVilopment of: fadiilities f0r efficient orthopedip care culdi have,:

b~eii planed ifi, advance, but such facilities were totally inadequate, in the

iieWly c6nstiucted general hospitals, of 1942. Recommendations should hae

been pfehted to hospital, commanders for the -best utilization of existihg

•aconiodations to p'ovide, adequate orthopedic space. As, it was ihospi a

dofinifihdrs opened their hospitals with these fixed plans and gave one the,

impressioi that they would be criticized by higher authority if they deviated

'fi6m them. Also, the surgical consultants who were burdened with all 'the

arly' problems had to many troubles to worry about orthopedic facilities.

:Sh9id theie ever be a "next-time," orthopedic consultants should be appointed

at the start along with other consultants in ,the major branches, of military

medicine and surgery. Although this consultant had the privilege of serving

with a hllpful, cooperative group of consultants under efficient and loyal

commands, it remained his opinion that orthopedic surgery should have been,

given a place equally important as so-called general surgery. There was a

need for a specially trained liaison officer to coordinate the surgical specialties

for the hospital. Such an officer could have served on the same level with the

executive officer under the hospital commander and eliminated considerable

interse'vice and section friction. The presumed and actual higher authority of

a chief of surgical service was too often a roadblock to the rapid improvement

of facility for, and service to, patients.'

Proper Movement of Patients

The third of the listed major problems pertained to the need for proper

movement of patients with particular regard to the pathological situation.

This problem could be further divided into three areas where improvement was

needed: (1) Selection of patients to be held for continuing care upon their

arrival at a general hospital, (2) transfer of appropriate patients to special

centers where their care could be better accomplished, and (3) movement of

patients within a hospital to give them a proper psychological attitude toward

their own individual problems.

Experience in the Ninth Service Command noted the difficulties and dangers of mass movement o ' patients in their evacuation from one hospital to another, both within the command and from overseas into it. Fractures of long

bones were subject to multiple changes of immobilization apparatus during a

period of repair which resulted in displacement of fragments, delay in healing,

2 The organization plan for a general hosoltal now includes the position of a chief of professional

services to coordinate all professional activities, but a chief of surgical ser'i e still retains the direct

responsibility for supervising all surgery in the hospital.-J. B. C., Jr.
284 ACTIVITIES-OF SURGICAL CONSULTANfTS

and ldss of' joit, function. Delay in early wound cleanup (after wounding)-

d't'eious surgial disaster. The Arm Air Forces pefforined.a magnfhen

jbbi, air evacuation, but failure-by medical officers to think in termsof pat

1ogical tiine caused irreparable damage to occur in a wounded extrenmity

wich should have been surgically cleaned up or debrided within the socall1ed,

gn hours before bacterial fixation in avascular tissue. Air tra p rt

Zight, have.allowedemergency surgery to be performed at considerable 'distanCe 'from the place of wounding, but it had to be performed, within the-time

lihits decreed by the pathological situation, Simple bullet wounding occurring

iere gas bacillus contamination existed resulted in extremity amputation

when the patient was transported by air for too many hours before stopping

f6r surgical cleanup. Granting that there may have been overriding military

situations, many patients who would have benefited from air evacuation spent

excessive periods in oversea hospitals in the Pacific awaiting ship transport to

centers for definitive care. In a number of instances, the care could have-been

provided where they were, Mass evacuation and "thou shalt not" orders from

higher authotity presented greater dangers than the evils they were designed

to prevent when careful screening of pathological conditions and selection of

patients for evacuation did not occur. Every medical officer should have

recognized that clire of the patient was a personal responsibility and the orders

designed for overall inprovement in care did not lessen his personal obligation

to the patient.

Effective Rehabilitation and Convalescent Programs

Long-term planning.-Efforts to coordinate a complete rehabilitation

plan for the sick and wounded were made in the Ninth Service Command

before the inception of formal reconditioning programs. Ideas prevailing in

the Ninth Service Command differed considerably from those presented in

some portions of the reconditioning program. Rehabilitation, in the Ninth

Service Command concept, began prior to definitive care. Orthopedic surgeons were requested to plan the entire surgical reconstruction before performing '.e first definitive operation. Surgery was considered an important part

of rehabilitation and often the most important part. Envisioning the entire

course of rehabilitative care often eliminated procedures which promised little

benefit in the total care. The important question that arose in such planning

conferences was the following one: What will be the optimal end result if

all goes well? The next important question, which had to be answered in

the monthly followup review of such problem cases, was the following: Should

our original opinion regarding optimal end result be changed? An optimal end

result was considered the best that one could obtain in a given pathological

condition. Once this type of thinking governed decision as to surgical procedure and followup care, a satisfactory base was established for a sensible

productive system of reconstructive surgery and patient rehabilitation. After
bi1 e'a r's experience in a-general, U i

spital with sUch a plail, the consultant

ethed 6h spitai. todesign a system of ortopedic care baed on

rqig terift'hinfkitigafier than on sh6it-ter'i thikik ig.

BY1945,t ths consultant 'as-conin~iced' that the plastic. surgeons, and the

neurosurgeons should participate with th6orthopedie :surgeons in a ,planned,

st*tm, of surgical recoistruction. Thereafter, the procedure was adopted

heeffi a4 we'Ay group meeting of these, specialists determined the future,

s§kiicai: e0use of patients whose pathological problem involve4 the thrie'

spIialities* The benefits in patient care aceruing from these methods suggested

7 Wthat hspitals with these three surgical specialties should act as centers for

:cs6tiiictive surgery and shouldbeso designated.

Convalescent' hospltalS.-In 1945, the Ninth Service Command was or,

d6red:'t establish convalescent hospitals which actually were to function as

rhabilitAtion centers, should the war continue into 194647. Comiplete

fac ities- forthese centers were set up at Fort Iewis and at Camp Mitchell,

Calif. These camps had some accommodations already available which made

the early establishment of such centers possible. Unfortunately, neither conValescent center was climatically suited for its purpose. The handicapped and

disabled soldier in actual need of rehabilitation should have had a comfortable

climati environment. Although there was an excellent group of officers in

charge of the convalescent centers and an efficient rehabilitation plan was in

action, it soon became obvious that the patients were not happy in their sur,

roundings. The following two conclusions were drawn from observation of

the two -convalescent centers of the Ninth Service Command: (1) The truly

disabled and handicapped more anxious to receive adequate medical care in

addition to retraining for a new occupation which they could carry out with

their known handicap and (2) many patients who had no real need for convalescent care were sent to a convalescent center. It was further concluded that

careful study of the rehabilitative needs of various types of patients was

necessarT before designing a convalescent hospital. A common fault in

hospitals seeking to rid themselves of the ambulant chronic complainer was to

send him to a convalescent hospital. This was the type of patient who did

not belong in a rehabilitative facility which dealt with the truly handicapped

and disabled.

R~sum6 of Hospital Orthopedic Care

During the last year of the war, orthopedic sections geared to care for 400

orthopedic patients found themselves with a census of 800 to 1,000 patients.

The total census increased until in late 1945 a peak load of 13,000 orthopedic

patients, excluding those in station hospitals, were being cared for in the Ninth

Service Command. By that time, the hospitals were well equipped to handle

their surgical load.. A few hospitals which never should have been anything

more than medical centers were obliged to carry on with large censuses of

surgical patients with only three available operating rooms. The staffs of
i286: !0AdTIViiIE0F SURGICAL CONSULTANTS

tlise 'hospitals deseve special commendation for -.takingeXceptioniall' god

6f theirpatients . Thetraining systems devised o year 'beforewer , iw paying, iidends, and" there -were now many yqung surgeons able. to assistie

*liiited numiber of orthiopedistsin doing .tleir'work ... " _

' xpeiience duringtliperiod'of 1944-15 Occasioned tvo reconimendationis.

bn6 f these was that smaller station -host itals should not have an orthppedic

section inasmuch as directives from the Office, of the- Surgeon. General .prohibied tle performance.of an major orthopedic surgery in that type, of

h0§pitil, The-other recommendation was that reconstrudtion, centers be created wich woul allow ,neurosurgery, .plastic skin repair of the extremitiesi 'and

orthopedic surgery to be performed ii the same hospital. It was.foundthat.

orthopedic care in convalescent -hospi tals was best accomplished, when 9fficers

-tri6nd 'in disability evaluation wer,) placed in charge of the convalescent

physical restoration of these patien. It was further recommende dthat each

of these medical officeis be trained n a center for, surgical restoration, supervising'both physical and occupational therapy and the physical reconditioniig

of hispatients.

COMMENT

The Ninth Service Command owed a debt of gratitude to Dr. Leroy Abbott,

professor of orthopedic surgery at the University of California School of.

Medicine, who on several occasions toured the service command general hospitals offering advice and stimulating the orthopedic medical officers on duty;

This consultant has already praised the work of the orthopedic surgeons who

served in the n/inth Service Command, but he would be remiss if he failed to

emphasize the dedicated work of Colonel Myers at Bushnell General Hospital.

This great gentleman and accomplished surgeon worked 16 hours every day

caring for his patients, and his tremendous workload brought him well past

the point of physical exhaustion from which he never fully recovered.

SUMMARY

In summary of Colonel Loutzenheiser's experiences as consultant in orthopedic surgery for the Ninth Service Command in the years 1944 and 1945, the

following final suggestions are offered, for further consideration:

1. The orlhopedic consultant to a service command should be carefully

indoctrinated before reporting to his assignment.

2. The War Department should design a military hospital planned foi

needs of the future rather than for those of the past.

3. Orthopedic surgery should be recognized as a major branch of surgery

in relation to the care of war wounded.

4. A combination of orthopedic surgery, plastic surgery, and neurosurgery

into reconstructive surgical centers is most important.
7NNH SEVC'COMA14ND' ~8

. oftaWise, separate centers ior orthopedic surgery plastic surgery

a~fd'nejrosurgery Are disadvantageous andlead to mutpe rnfesad ea

6 nisfructive surtgical centers :should -be locatedl near larefeters,

of ~pdpu ation -and their medical'schools.' Convalescent hospitals -should, bp

placed inoptimal climatic areasfor final rbh~bilitative,6ere.

7. 'h cns itant sho~u d- have6 a&equate rankh in order to .meet commnand--

mgo iers on ap ppr hit~rykYvel'.and-it-should'he establishedthat th con-,

ilt'~p~nt~te~fic~of the -Surgeon Generalinlsofak, a"his, duti&s'reouir

ii P ~it~tion f clnic l oicies anid practce§ promuilgated by.that-office
SARMIiES 'SURGICAL CONSULTANTS IN THEATERS TO FIELD

OFOPERATIONS
CHPTR V

Thid US.i Army.

CGhardes B. Odom, M.D

Secti L Admfinistrative Conrsidebraflonas

Thlel Third-U,,.S. Army created a number of: records. It traveled-bfather 2

an atr on thie grouind than-a-ny arlzyii in, history. In the, 281 days'between

1 A~u~ -1944, -wheni- this -Army ibecalme operational -and $ May 1945, .when

Ahe ifiitiument, of -German -sur render. was- signed, "it moved fom the -ivasioiv

beahesof FYranc e to .the~ Austrian Alps.- During -this period, 4li6 Th ird US

Army captured 1,280,688 prisoners,, killed 144,500 enemy troops,and-itoufided

T1"he med4ical servce- of the Third US. Army also set records." During~the

perid reaed cted it toal o 31~68persnsincudig,-5,2,25 civilians and.

2356 -~y prsonnel.

-Betweefi 1 August 1944-.and-80 April 1945, th@ 'followinig sullties -were

'4ospitalized in-Thiid U.S. Army hospitals:

Diseat ifon (hawlfc

------------------------.. ---------------. ------....... 1',454 'british Arny tioo6ps------r------------ ------------------- 50

Fre-cl A.rmiy tros ;- ------------------------------ ------- 2. 0M

V.5;..NAvy and Marine Corps personnel----------- ----------- =5

British Navy anid French Navy personnel ----- --------- ----------- 6

ife~nm ftorc~s Personnel-- ---------------------------------- 16,989,

---; ------------------------------------------------- 2, 31

Otheis, §pecifically French Forces of the Interior------- ----------- 188

For the 91,454 U.S. Army battle casualties admitted during, this ,period, the

case fatality rate was 2.73 percent. Wounds in these casualties were dividedt

into 23,283 serious and 56,676 slight, excluding the 11,495 wounds incurred in

De-cember for which no breakdown is available. the 91,454 wounds are classified as to anatomic location in table 3. The case fatality rate for the first

5 months during which the Army was operational, 2.9 percent (table 4), was

reduced to 2.6 percent during the remaining months of combat. The highest

case fatality rates were in wounds of the abdr-nen, wounds of the head and

spine, and wounds of the chest (tables 3 and 4).

1 (1) Semiannual Report, Surgeon, Third U.S. Army, ETOUSA, I Jan.-30 June 1940. (2) Annual

Report, Surgeon, Third U.S. Army, ETOUSA, 1945.

291
~~ACTIVIIES, OF SURGICAL CONSULTA±TS

TABILi;. &-Adznissiohg jar antd-deathe due-to woundk.amiong casualties ho pitalized- in Ths'rd

U.S. Army hospitals, by, wound' dlaseificalion, I August "1944-30O Apri '149*

Wound classification Admissions Deiaihi

-IWtundi other than burns:

do al------------------------------------4, ..... 20367

Thbold---------------------------------------- 8, 020 ~ 23.

'Neurolog-ib 1~---------------------------------------------- -71387 -651

-Upper extreity -------- ------------------------- 22, 99I"

Lb6w~r. extremity--------------------------------... 33, 057 304

k tt .......................................... -4, 363 98,

Other----------------....----------------------- 4, 795 79

total ----------- ----------------------------- 90, 441 2 529

Burns, all locations----------------------------------.... 1, 013 27

Grand total ----------------------------------- 91, 454 2,0556

5 Of the 7,38 admissions for neurologic wounds, 5,776 were for wounds of the head, with 562 deaths; 521 were for wounds,

of the spine with 82 deaths; and 90 were for wounds of the nerves with?7 deaths,

TABLEA.-Analyais of 48,354 U.S. battle casualties treated in Third U.S. Army installations,

I August 1944-1 January 1945

Trotal cases Anatomio location of wound or Injtury - _____.To.'al deaths Case fatality

rate (percent) Number Percent

Wounds or injuries other than burns:

Read------------------------------ 3, 008 6. 22 336 11. 17

Face and neck ---------------------- 3, 007 6. 22 28 . 93

Chest ----------------------------- 4, 401 9. 10 348 7. 90

Spine ------------------------------ 778 1. 61 28 3. 59

Abdomen -------------------------- 2, 162 4. 48 349 16. 14

Buttocks--------------------------- 2,348 4. 85 53 2. 25

Upper extremity..-- ----------------- 12,646 26.15 42 .33

Lower extremity -------------------- 16, 812 34 77 180 1. 07

Other ----------------------------- 2, 533 5.2 50 1. 97

Total --------------------------- 47, 695 98. 64 1, 414 2. 96

Burns, all locations----------------------- 659 1. 36 18 2. 73

Grand total---------------------- 48, 354 100. 00 1, 432 2. 96

IPercentage of grand total.
IR,~~ &~.U -ARMY'',3

Fuau.A42.--Ltt den, Gdorge S. Paon vi~its he 12th Evacuation Hiospita

to award decorations to the wounded,

it ioutd.be inposible to report on the work of the surgical consultant to

the Surgeop, Third U.S. Army, without making mention of Lt. Gen. (later

Gen,) Ge6rge S. Patton, Jr., USA, the Commanding General. Contrary to

the impresgi6n held by many who did not know him, he was an ektremely

kind and-very humane individual. this was reflected in his interest in those

under hi oommand, He had the greatest concern for the welfare of all his

troops, 'e ?articularly those who had been injured in battle (fig. 42). He

was not satisfied with mere statistical reports of casualties. He wanted to see

for himself that the wounded were properly cared for, and, while this plan

was not generally practical for an officer in his position of command, he made

many unschieduled and unheralded visits to hospitals to see the sick and

wounded. When he could not see them himself, he wanted direct reports from

medical and other officers who had seen them. From the campaign in Sicily

when General Patton was the Seventh U.S. Army commander, to the end of

the war, preparing these reports was one of the chief duties of the surgical

consultant.

6062221-62-21
294 ACTIVITIES OF SURGICAL CONSULTANTS

Fwouia., 43.-Col. Charles It. Odon, MC, Consultant In

Surgery to the Surgeon, Seventh U.S. Armny, and,

later, Consultant hi Surgery to the Surgeon, Third

U.S. Army.

General Pattoni had the faculty of ispirinr truly mnagnificenit loyalty

in those who were associate([ with himi. As it result, although his demands

frequently verged1 on the impossible, somehow or other the impossible tasks

that hie asked his staff and his troops to perform were usuially accomplished

with skill and dlisp~atch.

THE CONSULTANT SYSTEM

E~volution of the System

When the Unitedl States entered W~orldl War 11, there was no consultant

,33stem, andl no provision for one, in the Army Medical D)epartmnent, although

17orld 'War I hadl seen the dlevelopmnit of a very complete consultant system

in the AEF (American Expedlitionary Forces). T1he system was again developed ini World War 11 because it was found to b)e necessary.

It was of gradual evolution. It was first empiloyed in ground combat in

the Southwest Pacific aiid Central Pacific Areas. In the North African (later

M~editerranean) Theater of Operations, Col. Edward 1). Churchill, M1C, served

as Consultant in Surgery to the theater Surgeon, and Maj. (later Col.) HowardI

E. Snyder, MC, who was later Consultant ini Surgery to thle Surgeon, Fifth

U.S. Armyv (p. 3:33), served as Consultant in Surgery to the Surgeon, 11 Corps,
THID U.. ARMY,"

Th~e 'iciia ca jainWhich wsishort n br iatddnopouc a

great mnme f ~ casiualties., Shortly after lt begant, Lt. Col, (aeilC CoL)

!~ares'B. 'doi, :O '(4~g. 43) w 0as apointdcnulatt heSre

S~i01%h,,U-.S. Armhy, but,because -of the brevity of01 acin h O Ih f

conultnt id ot ometothe full' realization.which iit- was to assume later-in.

the Cili gn iItaly aid n the carnpna ns ,inthe European tete. No -

tbelsstheSiclh~ capain frnisheod a backgroi'ndof experience which lter

'Pr9Y'e-d,,'4N4,le.

Functions of te Suirgical ConsuftanThe rJitical- oonsultant Jn, a field armny served first of all, tobrdgei the,

gap ~ ~ aWpeiosyeitdbtWeeui-Reguloir ~ O -he Amny, medical officers, ,who,

8Colonei dtien MaJor), OPdon began, his, military- service witht thie d4thG,(eneral Hiospitali, the,

LUni niiit''eitive61ity, Schol of Medicine Unit, whc assentito Fort Jackson, S.C.. in 1942 for

trlaining , Sh'orifiafterw ard, Coloniel '- Odoni was ,tronsferred to -Fort Knox, Ky., -wheire, in 'ordler -to

eviiesddiiial hospitals, persobnnel from -a nuiabe& of generail hospital units ~were being assemibleil,

The stif -oi-the'ist Fvacuatiofn 114 iiilfal. in -which le wasi ap'pointed chief of the suigical siection. *as

otiii'led 'with otcerg tranifeied fromji th affiliated units from nthe Louisian'a State University- School.

ot. Medii n t ew Orleans and the medical schools of, the University of Orejonu, the University of

Il~ocheist-r,Yale,-Vni~ersity, gail'TAiiard University. The ist",iv~Akusiion 'Hospital was sent to North Africa In November 1942, as a component'of the

it. A'rinored"6' Cs '(Wiiterht TitskForce), under tile command of General, Patton. The mission of

thmetoops wao to secure-beaclih-ads and bases on the coast of-Morocco.

Folimwiik the Tuniila campllaiu, the 91st Tivaciiation Hoiliftal wai ordered to Algeria, where it

began, friiig for the invasion of'Sicily. Just before the invasion, Colonel Odoin was piaed at the

I k(ad of -sirgical team which was assigned to the B.S. Monrovifa, General Vittion's command ship.,

0h the'jaoring Of the in1vasi 6n, Colonel Odoni went ashore with time assault troops ait Gelao and in

July 1943,.lu'riit, the course of the Sicilian campaign, he was appointed surgical consultant to the

Surgeou, Sev'mith U.S. Army.

- in D'cmbler 1Q43, after sitting out the storm of publicity precipitated by time so-called slapping

lincident, G'eneral Patton departed from Palermo alone by plane. The officers left behind in his head.

* qua'rt; hbad no idea whether lie would receive a new assignment or would be retired. The answer camte '2 wee'k's Iiter, wh'en Brig. Gen. (later Maj. Gen.) Hobart It. Gay, USA, his chief of staff, and 'a

number of dthe'r officers from various sections, of the Seventh U.S. Army were ordered to England. Colonel Odom, who had remained with the Seventi, U.S. Army Headquarters after the Sicilian cantpaign, 'was the medical officer selected to accompany him.

Upon their arrival lit England, by way of Algiers, Algeria, Casablanca, Morocco, and Prestwick,

Scotland; these officers joined General Patton, who, meantime, had been appointed Commanding

General, Third U.S. Army, at Peover, a small village near Knutsford in the Midlam.ns. Here, prepa- rations were In progress for 'receiving the Third U.S. Army headquarters from Fort -amu Houston, T1ex.

When the headquarters arrived, General Patton assumed command, and the officers who had been

orderd tip fron North Africa were Integrated into the headquarters staff.

Coloniel Odom became surgical consultant to the Surgeon, Third U.S. Army, remaining In this

position Whrouihout the fighting in Europe. In June 1945 he was appointed chief of Surgery at

Brooke General Hospital, Fort Sain Houston, and remained in this position until he was separated

from service in December 1945.

It would be Impossible to report on the work of tile burgleal consultant to the Surgeon, Third

U.S. Army, without making mention of General Patton's relation to him. Colonel Odonm's first contact

with General Patton was fit the hospital unit set up in -Mostaganeml, Aigeria, whmich was receiving casualties in May atJ June 1943. lie went ashore on the same landing craft xith him in tile Sicilian

* Invasion and was billeted at the same place with him on tile first night ashore.

Colonel Odom's position thereafter was not only thmat of surgical consultant but, In a sense, timat

of plersonal physician to General Patton throughout tile war in Europe. This relation undoubtedly

pllayed a part in the role of the surgical consultanlt to the Third U.S. Army surgeon. One of its first

results was that during tile plianning in England for D-dw Colonel Odom lived with General Patton's

Immediate staff and had full access to nil planning, iL..uuding tile toil secret plans developed In tile war room. Unlike consultan~ts of some other armies, he therefore had the advantage of knowing all

tilat was necessary to know for tile preparation of mledical facilities for the invasion and could thus

fulfill his own duties and responsulitics as efficiently as posslble.-J. B. C., Jr.
296' ACTiVITIES'OF SURGICAL 'C0NSULT TS

had been trained in Army discipline, line of command,. and othermdcomiitar matters, and th6-medicar officers fresh ifroin the civilian prctic of. m6dicine, who were. indiVidualists, who were, concerned only witl. -medici~, ad-who had to lea that the Sickand Wounded must be treated with regard

,to nedicomilitary considerations as well as by the' techniques of civlian,

practice.

The surgical, consultant to the Surgeon, Third US. ArmY, had the Same

duties as surgical consultants in other fild armies. He advised the Surgeon oh -a variety of matter such as (1) evaluation and assignment of persoinel,.,

(2) 2-qrganization and functioning of surgical sections-of hospitals iiwthe forW'ihrdarea (3) the quality of medical service rendered, with suggestqns .or

-its improvement, (4) changes in concepts and techniques of surgical manager

ment of combat injuries, (5) indoctrination of new medical personnel, (6),,

tfe results being obtained in the care of battle casualties, and (7) future% plafining.

'Colonel Odom, as already noted, was closely associated with all medical

Planning for invasion of the Continent. Although the Third U.S. Army did

not become operational until 1 August 1944, Colonel Odom arrived in France

With the Third U.S. Army surgeon on 6 July, and from the onset of the campaign he worked from that portion of the office of the army surgeon, which

was located at the forward echelon of Third Army headquarters.

Colonel Odom's location in the forward echelon gave him the best possible opportunity to keep in close touch with the tactical situation 'id.to be

fully informed concerning casualties. Each morning, he was privileged to

attend the war room conference of key members of the headquarters' staiff, an

experience which was extremely interesting in itself and which made it possible to anticipate where the heaviest action would occur and where the greatest

number of casualties must be cared for. The Operations and Training Subsection, Medical Section, Third U.S. Army, at the forward echelon maintained

a map on a day-by-day basis which showed the distribution of all medical units

and all surgical teams. This information made it possible to provide prompt

and efficient medical support for all units in action.

Colonel Odoin worked out of the office in the forward echelon, sometimes

being absent from it for several days at a time. In such circumstances, days

sometimes elapsed between his reports to the Army surgeon's office, but on his

return an informal report, at least, was always made on the conditions observed.

Movement from one medical unit to another permitted on-the-spot observation. In the Third U.S. Army, under General Patton's dynamic leadership,

advances were frequently so rapid that keeping up with medical units was

something of a problem in itself (fig. 44). Full provision, however, was made

for Colonel Odomn's transportation. A driver and jeep were regularly assigned

to him, and, if hospital units were too widely separated for ground transportation to be practical, he was assigned a cub observation plane and a pilot. A
7- -

Fiovim 44.-R vactlation by light tank for speedl, protection, andi negotiating imuddy

terrain.

plane of this size could be landled in the field next to a. hospital, and its use

Savedl muich time in moving around the armny area.

C'ol. (later Brig. Geni.) Tfhomnas 1). Ilurey, MC, Surgeon, Third U.S.

Army, and Col. .John Boyd Coates, Ji*., 1MC, Executive Officer, had the task of

supporting the adlvancing Armly by leapfroggig mnedical uniits which were leatpfrogg ed across each other. Since the surgical consultant mnovedl with the comnnmand post of the armny, it was often possible for himi to recommend adlvanltageous hlosp~ital locations to the Operations, and TIrainingr Subsection. Also

being thoroughly familia- with the abilities and~ capacities of the various

medlical unlits, hie wats often able to recommend the use of one unit, insteadl of

anot-o- ats better suited to the inmnediate jot) to be (lone.

Finally, because of his close observation of their work, the surgical contsuiltant wats able to recommend that one or another unit, be given at few dlays'

rest. Th'Iese recomnmendlations were almiost invariably follow-ed by the Operationis and ITra,~iig Subsection. Th is pol icy held for the larger unit h as well as

the sniller units and even for inldividluals. When surgical teanis had beent
298 ACtIVSITIESoF SURGICAL CONSULtNT i

4hough a, padticuiarly busy period,. it wais customary lttransfer :themteenv

S:por.arilynt6onssbusyiositals inrear a11as. 1

Colonel doidid a certain tinount of, surgica Nork himself, party for

demonstration purposes iind partly to, help :out hard-pressed surgical, teams

W ieuii the number of casualties was particularly heavy,

He also performed a number of operations in, evacuation hospitals,,some

-f wlic;li except for the, desire to keep, key personnel in headquarters, would

liave been handled in general hospitals in the communications zone, or even in.

Zon6 of Interibr hospitals,

B16twedu the Sicilian eampaign and the invasion of Normandyfor i

staice, Colonel Odom performed a bilateral inguinal hernioplasty on the0ief,

of Staff, SeVeinth U.S. Army. The resulit was excelleit, and the latter oker

was able to remain active throughout tie campaign on the Continelnt and;

later, made an outstanding record as Commanding General, 1st Cavahy biviL

sionj in tlheKorean War. Also, General Patton's ordnance officer wasoperated

on for intestinal obstruction; a segment of bowel was resected, and lie was

returned to duty in Third Army headquarters within 2 weeks.

A unit commander who had sustained a serious abdominal wound was

brought out of a German Army prison camp while the battle for the towniin

which it was located was still in progress. Two cub plan'es were flown into

the camp, with Colonel Odon in one of them. After blood transfusion and

sedation, the patient was flown out of the camp in the other plane and Wits soon

on the operating table in an evacuation hospital a few miles behind the frontline. This officer is still in service.

Still another officer in headquarters was operated on for acute appendicitis;

he was back on duty within a week, without ever leaving the army area. The

assistant G-2 lost an arm in a German hospital when lie was taken prisoner

in a skirmish late in the European fighting. When lie was located and recaptured by U.S. Army patrols, revision of the stum) was carried out in an

evacuation hospital, and he remained oii duty until the end of the war.

These and other operations were performed by the surgical consultant

with the full knowledge and approval of General Patton, who believed most

strongly in the doctrine of keeping all personnel, )articularly key personnel,

in the army area, so that they would not lose contact with their units. It was

a tremendous boost in morale for a wounded soldier to return to his own unit,

and an equal boost for the morale of the unit to which the nman was returned.

It also improved the prestige of the Medical Department, for it furnished

concrete evidence to the troops that when they were J! or injured they wouli

be cared for promptly and competently.

PLANNING IN THE UNITED KINGDOM BASE

During the first 2 months after medical planning began in the United

Kingdon for the invasion of the Continent, the weather was typically rainy,

foggy, and cold, but physical circumstances were otherwise propitious for
Aw:effict operations.. Field' grade, officers werO billeted in,,,private Efiglishi

homesnotmore than a mile or two fomheadquarters, and otier-offlers.were

.Certainmajo problems faced the.'medical service of the TPid Us,,Army

before, the invasiof the Continent .(Operation OVERLRD), as follows:

I! P.rpar tion and intensive study of"the medicaLplan for this operation.,

2 Therecepti0n, -cqu!isitioih preparation, training, ajd briefing pfxmdicalhunits asigiled Nth'Tlird:Ari,

3The .preparation of a medical supply plan and t!e ,procurement of,

suppliesand, equipment,, including the improvisation of substitutes for W hat

was ot ,available in sufficieti quantities for distribution to all units before

thein asion:

Indoctrination

Probably the major problem that confronted the professional ,service of

the Third'U;S. Army during the early months of 1944 was the dual necessity

of orienting, medical units for combat duty and of rounding out and balancing

the specialty staffs of the hospital units.

-Among all the hospital units assigned'to the Third Army, only the 16th

Field Hospital had had any combat experience before it went into action in

ETOUSA (European Theater of Operations, U.S. Army). Most units had

had some maneuver experience, but a few had had little service or none at all

in the field. The 91st Evacuation Hospital, which had had experience in the

Mediterranean theater, went onto the Continent with the First U.S. Army, as

did some of the other medical units originally assigned to the Third Army.

These units, which landed in Normandy late in June and during July, functioned under the Surgeon, First U.S. Army, during this period, as did the

surgical consultant to the Surgeon, Third U.S. Army. When the Third Army

became operational on the Continent on 1 August 1944, these units reverted

to it.

To compensate for these deficiencies in training, which were immediately

obvious when the planning for the Normandy invasion was begun, a formal

orientation course was planied and carried out.

Course of instruction.-Infornal indoctrination and briefing were, of

course, a continuous process, but a forminl 7-day course was conducted at Peover

Hall, Knutsford, Cheshire, England, in order to provide maximum background

to personnel who would perform professional duties in the surgical and medical

specialties in Army hospitals. The conference was attended by officers of the

Medical Corps, Dental Corps, and Army Nurse Corps from the various hospital units assigned to the Third Army. The lecturers and other instructors

included the chief and senior consultant for the theater in each specialty, as well

as other medical officers with combat experience in the particular subjects under

discussion. A wide variety of subjects were covered, with emphasis on the

special procedures in each field which had been standardized in the light of the

exi)eriences in North Africa, Sicily, and Italy. Demonstrations were also pro-
'30,ACTIVITIESOF SURGIO C ~ LAlNtS

vieSuch as lthe arrangemnt of surgical~ qipet udertnae.p.1)

'This Ay qoiurS'eprpved extreeply, benefoial. A~ilgotlir," ad-,tgp,,

was the prol isio~~n' !prqperb baegrounhd on~whicli inieic]onison p

somniel-could base- further studyqf, the -,roble~n wi -they were to .faco _in.

bpe rtions onl Ohe Continent. The plannied, itensive instruction mande t

jiossiblo (or mniuy hiospital-tunits, evenl though they had no combat expeience

itniid imany of their personnel'had hiad little xnilitary-ekpieriencei to adjust thin

S01ve's tapIldly ', to comlbat conditions, and to tireat and evacuate large number

of casualties *hen the Third Army lbegame operational on 1 August 104Lan&

thlinedical units were committed. Theaeaemeclofcrvnwihu

Previdus experience, soon learned to follow directions and coinprehiend',why a

certain routine was necessary, while at the same-time lie did not subordinate

Ijisown goodl judgment aiic individual initiative to it,

Later' in the' war, policies and practices devised t.t one unit and found

efficient in it were conveyed to other units by the surgical consultant as hie moved

~ibiotthe iArmiy areai, and they were soonin igoeeral use. All such items~weo

i ncluded in the siummar'y of events which the consultant Submitted to tlie Istorical Section, Third 'U.S. Army, at the end of each imonth and in the final

suminary submitted at the end of the campaign. It is devoutly to be hloped

that these and other lessons learned in conflict, will iiot again be forgotten,

ats so Much was forgotten between World War I andl World War 11.

T1'Ie orientation course just described priovidled anl excellent opportunity

for the hosp~ital staffs to become acquainted with the army consultants, as well

as with the theater consultants in the Office of the Chief Surgeon, ETOUSA.

It is believed that this p~relimninary acquaintance had much to (10 with the

cordial relations always maintained between army and theater personniel

during the fighting in Europe. Col. (later Brig. Gemi.) Elliott C. Cutler,31MC,

frequently made roundls in Third U.S. Army units with Colonel Odomn, and

munch of the credit for the low mortality rate in battle casualties in the European theater is (lue to his efforts. Like aill personnel in the theater chief Surgeon's office, hie was always most hielpful wvhen lie was called upon01 for advice

or other assistance.

Other courses.-I addition to the formal course just describedl, all existing facilities in the United Kingdom w~ere used for the training of personnel in various specialities, particularly anesthesia and orthopedic surgery.

Instruction in shiock and transfusion ait the Britishi Army Blood Supply Depot,

Southumlead Hospital, Bristol. was nmade available for a small niumber of miedlical

officers. A course for nurses, dlesigrned1 esp~ecially for thie training of Chief

niurses and other key nurses, was conducted at the American School Center,

shrivienhlai, and prov1edl extremely useful. A 1-(lay course in plaster techniqlues was couductedIat tile 10thi Station Hosp1 ital in the Manchiester area. All

of these courses were planiled to p~recede 30-day periods of temporary dulty- in

these Specialties in stat ion and general hospitals.
THIRD U.S. ARMY 301

FIGuRE 45.-Intratracheal anesthesia hit'a field hiospitall platoon, wit

simiultaneouis admnistration of whole blood.

Perhlaps the most useful of these special courses was lhe one in anesthesia,

in which field one of the most serious shiortages was discovered in thle medical

planning for D-day. This problem was solve~l lby utilizing the experience of

Maj. (later Lt. Col.) John R. Abajian, Jr., MC, who had taught anesthesia

before entering the Army. He prepared a series of lectures andl spent 2 or 3

weeks at a tine in each fieIld and evacuiation hospital, demnonstratinug the administration of the various types of anesthesia and otherwise instructing the

p~ersonnel assigned to anesthetic duty. By this means, it, was p)ossible to set upl

in each hospital a staff of three or four medical ollicers aiid the saine number

of nurses who had sonmc fundamental knoNNledge of aiest hesia. Anesthesiologists were trained in the same manner in auxiliary surgrical teamls.

By the time Major Abaj ian left, a unit, hie had succeeded in giving valuable instruct ion in both thle theory and pract ice of the adiniisrat ion of anesthetics and had also given Valuable assistance ink the liatlIidli of casualties

in the operating room. I [is work elevated the standardsb of both anesthesia

and surgery in thle Third F.S. Army (fig. 45).

4106222'-62 -- 22
30i AC 'IVIES OF SURGICAL CONSUL.TA S

i spite of adminijstrlti eand otier difficulties whicliicreased as the date

'for operations ontmhe Continent approached; it was possible, during:a 3-menitl

p i1'id to trid'n approxkimately 10 tedical officersand aboutK300 nurses in ="::: ~ aiu hber, o fp rofessioinal and inilita!ty s ulijects.

EVALUATION AND ASSIGNMENT OF PERSONNEL

While the orientation courses just described were in progress, specific actioi wis taken to evaluate the qualificatiqns. and experience of all nedical:

oicers in the Th ird V.S. Army. Each officer filled out a questionnaire on his

professional qualifications, and -on the basis of a careful study of these records

it considerable number of changes in hospital staffs were instituted. Q Wuified

surgeons in the various specialties were transferred from posts in whicl their

talents were likely to be wasted to posts in which their talents could best-be

utilized. In particular, a number of officers were transferred, for this reason,

from other field units into hospital units or auxiliary surgical teams. In all,

78 Medical Corps officers were transferred to other posts between 30 March and

1 July 1944.

Most shifts in personnel were made on the basis of the recorded training

and experience which the various medical officers had had before they entered

upon 'their military service. After the Third U.S. Army became operational,

evaluation was on a more practical basis, by direct observation of work in tie

field. It was then necessary to make a number of additional changes. Deficiencies in training became evident, and lack of leadership ability and personality diliculties often became apparent only after units had begunto function.

When the ability of a surgeon came into question, as it sometimes did, the

surgical consultant always checked on the complaint by direct observation before recommending any action.

The best method of adjustment, when these various difficulties arose, was

usually to change the assignment. Medical officers who had been unhappy

misfits in one organization were often happy and successful in another. In

fact, the surgical consultant often served almost as a chaplain for medical

officers who found it difficult to adjust to a military routine.

When there was a great deal of activity, as there was throughout operations on the Continent, changes in assignment were fairly easy to accomplish

without-delay or red tal)e.

When the Third U.S. Army embarked for the Continent, it was short

about -25 Medical Corps office-,s, chiefly in the units which had been phased

in late. The shortages were particularly serious in radiology, neurosurgery,

and anesthesia.

It had been expected that these shortages would be overcome by a wider

use of Medical Administrative Corps officers, but by the middle of November,

whein the last of these officers had been furnished to the Third Army, casualties

among Medical Corps officers about equaled the paper surplus, and shortages

in the Medical Corps continued to the end of the war.
THIRD ,U,8*,,ARAIY :

Op '0 hthaimo -I the.entire Third' U.S, Army, .there were-originally.

onytree, ocers trainejt :as 0pltlalmologists. Two, of tiem Were in- tli

same uit, :it'ituatiohvlihf vad pfomp'tly c6rrected,'by the transfer of one of

them to anothliiiiit,

'Th ,mdt experienced andbest trained, of these officers, in addition tdohis, . duties at h!iis b h unit, serkVed'as in ai$ijiary consultant, moving fromone unit

to anothi as'iis',

servikescould best be Utilized. He was usually stationed:in

a forwAYd evAcuation hospital, where he could examine casualties with eye in-. juries iidd~i~ect their tre~tmnent. His advice was veryhelpful in the prepa,

,ration of diie tivesc'-ncerning-eye injuries.

...dl0igy.-k well-trained roentgenologist in one of the evacuation bos-

,pitatls, Lt. -61 Frank Huber, MC, served as an auxiliary consultant to th,

surgical consultant, in addition to his work at his own,unit. He visited- other.

hospitais'upon request and clecked the work of the personnel and the adequacy

of e qiipnieht 'in the X-ray departments. His advice was ofgreat assistance

inwobtainibg the best possible utilization of the X-ray equipment supplied for

use in -the field. One of his important duties was to check on the health of

personnel engaged in X-ray work. le made sure that proper precautions were

taken for their protection and directed routine blood studies, to be certain that

they were hoc being deleteriously affected by radiation.

Colonel lIuber also checked on the work of the three mobile X-ray units

assigned, to the Third U.S. Army. These units, which were part of the 4th

Auxiliary Suirgical Group, filled t dual deficiency. The table of organization

for an evacuation hospital provided for only one roentgenologist, who obviously

could not work day and night over the long periods of time the hospital was

in active operation. The mobile units made it possible to reduce the waiting

period in evacuation hospitals receiving a rush of battle casualties by providing

qualified roentgenologic coverage over a 24-hour period (fig. 46). These teams

were also useful in training inexperienced radiologic personnel in new units

which joined the Third U.S. Army just before D-day and during active operations on the Continent.

The amount of X-ray work required in a field hospital did not justify the

assignment of trained roentgenologists to these units. On occasion, however,

when evacuation was not practical because of the tactical situation, as in river

crossings, a mobile X-ray unit was attached to the field hospital platoon and

served a very useful purpogc.

Nursing service.-Nurses were always in short supply in both evacuation and field hospitals during rush periods, and the illness or incapacity of a

single nurse could result in a serious situation. Too much credit cannot be given

to the inembers of the Army Nurse Corps who worked side by side with surgical

teams in units close behind the frontlines, often under shellfire, as well as in

other forward installations. Their mere presence did a great deal for the

morale of the troops.
Siiar crediti 'Ilat i a-1) 11 "(I' lit t iali.ial Int'lI %\ ho \ foriked% aliaitlo, anda

I ,tk-I I t ) vaitt il ca~l ~lah ike, fti t hit bill t l-lit \\ vitl a. illi o riii., I'la It i I

\lIC(AL t NIlTS

1 11eld I Ito-Iital,~

Earl ilt I lk- l h.A\tiai a lalpal-, it \\a, lI'muld that na otl) (Ilk-IIia ti ef

ltailli t i hi a- tilil 'ira jtttjle (1) 3 :70). \itia iliv ttiaaia ii ill \\icl I i.

t), arl v. 'kiltl hli a tut.

ha aI aw itA itk, r ti ov latlt ''ti ilat ittibl a-lial' ijtli 1a laaii edt
TIRDlh U.S. ARMY 0

P14u11ii -47. Iitila stage of tile etiabihmeniit of a field ho sial hlatoon. I alai i

Shock NN lichl did 11 ot responiid ploiilt I 'v to appr~opriate thierap) 'x or witeit for any

oither rvw~oii theN requtiredl promlpt sur-gical care and ler tiiiktik to m illistattdl ik)oleieilt (o)theivitailoit lt fil- hter (I eriotiat ion.

No fieldI hitwpitaI ill the Tird U .S. AriiiiN N~as eiploved as a 11iit withI a

hitngle e11el1t iousm' -whie) ntwa i onl ilie Ia.,t tho of 1914. 1In.tvrad.

field llo. pita1l or port ioii. thereof ~teaahdtociI Ichill tit lattachied

act le phttooii. of thie~e lioo.jntal' to dkoi'ioii ' forlill:e ill proxiittit% to dk~i.ioii

clearintg stat ions. a. ju.,l de~crihed (lig. .7).

Theoreticau liv. iew 1( ho~I)iuals " ere "tatl'ed atd equiipped to "o to %%ork jutIlietliatel 'v after their arilal ill lhe theater. Acttiall,% per.,olikeI -iie to

thtemt were -elioin t rainled to (do ilia jor. :.1i1(111% Mild littalk had had little or.

I to experience i ut I Ii, area. The I ield( lo' pit a I. a -i ,n ed t o the iv lIird I .1 1.xt

had -tial lbeeui t rajiteo ftiolea IT~il 1 .tai ioul hio-Itil h 1%1 lillil and wereV

tillprepa redI for operat ioni ill t lit, field. It %%&' the leitllll that,1 :-l lto'pilal,

ill tile ftttuie lholild he t rained und1(er tactical or. Arnn. ( ioiitd F'orce, tpr

vi~ion., not utidei thle ntipeiioit of Aiiti1Y Sen~ice Fotrce'. it) itilire t heir

receTiving proper field and ittaiteliver Ia t*Itiitl)i.

%;ince it \\a- at It he el of t Ilie ield hlpita! t hat ( lie to 0 ru~ilcial aind evict -

illo, sui-rt ry . \otld he peiformted. t lie ilio't practical soltion of t lie priobleml

preselited hY lie lack of t railiiig ofl lie-v hiopitak \\a' to tevcouiAjl-k itit ilti.
~306ACtIVITIES. OF SURGICAL CONSULTANTS%

Partiy traine&or trained surgeonswere detached fromthem and transferred,

toe:acuationo ljucals or ,urgical teams,' in, -whlich iey would-work -iindr

suieision. They were replaced: in the fieldhospital by trained' surgicai

teams,. made-up fromthe staffs of genheral hospitals or, from auxiliary surgical

gibups.(p. 308). This meant that, in effect, the field hospitals were firsp~uU~d

dowi and thenbuilt ip again. The result was.a surgical hospital in whlichlihe

best surgical talent in the army was utilized to the fullest advantage.,

In the field hospital, shock teams prepared thecasualties for surgery, and

surgical teams (p. 308). performed the necessary surgical, procedures, The

greatest efficiency was usually attained-by employing Pne shock team and' one

shrgibal team on each 12-hour jhift. Organic personnel of the fieldhbspitAl1 platoon assisted in preoperative and postoperative care and were respqpsihle

for administrative duties. The qualities of leadership possessed by the platoon;

commander were extremely important in maintaining harmony and promoting,

efficiency.

Soon after the Third U.S. Army became operational, it became evident

that field hospital platoons set up adjacent to division clearing stations~would

not be able to move forward with clearing companies because of the nontransportable patients occupying the beds after surgery. This dilemma was solved

by attaching the personnel and equipment of an army collecting company to

each field hospital platoon. These companies were designated as holding units.

When it became necessary for the field hospital platoon to move forward, all

nontransportable patients were left in charge of the holding unit. The patients were evacuated as soon as they became transportable, after which the

holding unit rejoined the field hospital platoon.

This proved a very efficient plan. Few or no organic field hospital personnel had to be left behind with the holding unit, and very little equipment

was necessary. The efficiency of the holding unit )ersonnel was naturally

greatly increased if the unit had worked previously with the field hospital and

had an understanding of the care required by patients with various types of

wounds.

Evacuation Hospitals

While field hospitals accomplished the saving of an incalculable n)umber of

seriously wounded battle casualties who required immediate surgery, evacuation hospitals also handled their share of heavy surgery, especially when they

were located close to thv frontlines and the flow of casualties was heavy. In

addition, these hospitals cared for an enormous volume of less seriously

wounded battle casualties, many of whom were returned to duty.

The rapid treatment of battle casualties and the return of soldiers to duty

within the army area required a well-balanced staff in the evacuation hospital,

headed by a chief of surgery who had both sound surgical judgment and adiinistrative ability; the latter was quite as important as the former in the care

of wounded men at this echelon.
_THfIDpbU.S. ARMYIt 30

.Evciiation llospitals iilji I ird-U.S, Army were fouid to operAtembst,.

effienfly when.they. wver-eorgiuiiz&l'to staff.8 'or i0 Operating tabl6s around

the glock, day- i d dy ou iTe organiic persdinelto~f the hospital, was not

suffeiit,hlioever,to provide tlietwo 1 ,houi' siifts, require, .tomiaiwinisul,

a schedule any §f siained l6 peribd:oflime, It had, 'en demonstrated early.

in thapin, n uope that thi~eeieny obf asurgeoli- in.Ani evacuationl

-hospital, was definitely 1 educed-if hie worked longer' thatn 12 hiours, at a time.,

Iis,_ atigue manifested itseif in a lower standard- o work as-wellas in his :

total tciivement. A i4-hdur period of relief provided sufficient, rest.for him,

to d6Oifitifit6owrk hardfolohgpetiods.

Th' solion of thils problem was the use of auxiliary surgical teas during th e 4eiods of peakloads, which werte usually -immediately fkter the hospital

iads:beti . et up in a forward sector, The, m nimum requirement was two,

:general surgial and two shock teams. The addition oftlese teamsto the o - ganic persoinel of -the hospital: permitted efficient functioning and prevented sm'ia ilkacklogs fromn pyramid ing.

The Medical Sectiof , Third Army headquarters, had a very tightly integrated, system of communication coicerning,,and control of, the casualty flO0v

iiitova cuation hospitals. The system did not attain its full efficiency until

the- end of the first week of Third US, Ariny operations, and there were, of

course, .occasions on which it was more efficient than others, Such subordinate

niP as flie medical group with its very specialized facilities and with the

exellent- signal communication which was almost constantly available, played

a major role. Organization and constant supervision were necessary to achieve

control of the flow of casualties into evacuation hospitals, but the results were

so satisfactory that few persons outside of those intimately concerned with

them realized how well the measures which were adopted to achieve these

results were working.

The surgical consultant was kept fully informed of the casualty situation;

his office in the forward echelon received daily reports of the number of casualties admitted to each evacuation hospital, together with information on the

surgical backlog and on the distribution of surgical teams. There were many

instances in which this liaison proved extremely valuable.

The organic transportation of evacuation and field hospitals was not sufficient to move evacuation hospitals completely from one location to another,

though moves were frequent. Durnlg August 1944, for instance, these hospitals averaged about four moves each, the distances ranging from as little as

10 miles to as much as 100 miles. Before the campaigns in Europe started,

the Medical Section, Headquarters, Third U.S. Army, had been advised that

additional transportation could be obtained as necessary from quartermaster

truck companies. As soon as operations got under way, it was evident that

this source of transportation would not be available; General Patton cornmrtndeered all trucks and other available extra transportation to move petroleuni products and ammunition.
308 ACTIVITIES OF SURGICAL CONSULTATS

-The Operations and Training Subsection of the Medical Section splved

this difficulty by setting up a provisional truck unit consisting, of all available

tkucks -frofh the medical unI s under Third U.S. Army control A char was. maiiitadned, and enough trucks were dispatched to meet the particular neds

of evacuation and field hospitals whenever they were obliged to move.

Estimates ilidicate that about 43 percent of all-casualties handled in Third

U.S. Army evacuation hospitals were eivurned to duty in the army area. They

were practically always sent back to duty in their original units, Getting

persohnel back to their own units, as mentioned elsewhere, was as much armust

in General Patton's command as was neatness in dress. He recognized the tremendous morale factor for both officers and enlisted men inherent in this plan.

No dif~ctive was writtei on the subject, but seeing that this particular policy

was adhered to accounted for one important segment of the duties of the surgical consultant.

Auxiliary Surgical Groups and Surgical Teams

The teams of th 4th Auxiliary Surgical Group, which functioned under

the Third U.S. Army during the whole period of combat on the Continent,

contributed greatly to the high standard of surgical care achieved in this

army. For the most part, the chiefs of the various teams were well trained in

their specialties before they entered service. Although they lacked actual experience in the handling of battle casualties, their previous training permitted

them to adapt their talents rapidly to the exigencies of wartime situations, and

their surgical techniques left little to be desired.

A single auxiliary surgical group, even though it consisted of 64 teams,

was not sufficient to care for the casualties of an army which often had from

12 to 15 divisions in action. When the teams of the 4th Auxiliary Surgical

Group proved insufficient for the necessities of special situations, additional

teams were requested. They were provided either froi the 1st and 5th

Auxiliary Surgical Groups or by temporarily attached teams made up of

qualified personnel from general hospitals not active at the time.

The field hospital platoons attached to each division clearing station (p.

306) had to be staffed according to the immediate combat necessities. The number of surgical teams functioning in any one unit thus varied with the number

of casualties who had to be cared for at the particular time. Surgical teams and

shock teams were most usefully employed in field hospitals (fig. 48). As a rule,

two general surgical teams and two shock teams were attached to each field

hospital platoon in operation. W1"hen casualties were very heavy, they were

supplemented by additional teams, which remained ouily long enough to reduce

the existing surgical backlog.

The organic personnel of an evacuation hospital, as just pointed out, no

matter how well qualified they might have been, could not cover the needs of

such an organ, "ation over a 24-hour period in which bactle casualties were often

admitted at the rate of from 100 to 150 per day. For most efficient operation,
IIIR i U.S. ARMY 

309

]?io iom 4.- A iuxiliry suirgicalI tellink op eratn l wit a fie optl p)111101.

an evacuation hospiitali re(IliiredI tile aSSist iice of t \ o erqal -,I ll-iel tnns

0110 orthlopedlic surgical teaml, onle nielrosurg-oical teazun, and onle liiaxillofacial

teamn. Thle specialty t eamis usually com-eed tilie 12-hourl period %\ hichI would

have reuiniled unicovered if t here had been amlnilabile only tile single quialified

repreSentatives of these specialtiesoni tile oIralic h05)it alSn t,

specialty teamls funct ioned1 be-t at this level. Thiswis because tile great

i'.ajority of Casualties With ext reimity %i uinls head injuries, and iiiaxillotacial

injuries were readily t ransportable and could be uIioied 15 or 3t) iniles. or farther. b~ehinid thle flli , () the area ill Which elaacuat loll lhospit als ii ee set up1.

Surical tealls were also) of g-reat lahie inl bridgehleads across nI ers. Ill

these Ci rcumistances. tihe %iiuded could not readily be e aculaled. Elen Iilieu

troops Were onl thle olvlisi ye, it iias found that Ibtiliit iie surgeryl could be acco~ll ishIl I liv diese teallis iiiu1cl fart her foriiad than had pi miolusly been

realized.

The bes't miedlical sup)port for ariored di~ isiols \\a., prl mided In thle line

of a unit 'tafled bYIo slurgical team., and t%"0 shock teanis. Thlencesr

tentage, surgical ecuiilleilt. an1d otlher sulpplies could bi. inlo\i e ilk tiio tuck.

A unit of this kinl mid mlove along ii ithi. and~ be set up1 nlext to, a comnipaImy

of tile medical battalion of anl armiored divisionl. A field hlospital plaltooni

followed this liiiit. taking. oi er the casualties, N\ho had beeii operated oil and
310 ACTIVITIES OF SURoIAL CONSULTANTS, '

leav iig the surgical teams free to move forward again with the arn0ored

Atvisi n.

Assignments of surgical teams were al vays so, arranged that a few teams

w erhel din reserve, to throw into areas in -which unexpecied needs might rpse. This systm, also permitted periods of rest for teams which had been working

underkpressur6 for long periods of time.

One of the chief points which had been stressed to teams of auxiliary-surgi

cal groups when they first began to function in North Africa was that they

must operate in harmony with the organic personnel of the hospital units fo

which they were assigned. In the first days of combat in-France, there was some

friction between the teams and the hospital staffs, but it promptly disappieared

as the help which could be provided by the teams became evident. In the few

cases in which personality difficulties developed or persisted, it was a simple

matter to switch the team assignments.

The constitution of field and evacuation hospitals and their supplementation by aux-1 :-ry surgical group teams illustrate the cooperation which existed

Within the Third U.S. Army. The executive officer, Col. John Boyd Coates, Jr.,

MC, was responsible for the location and setup of these hospitals, but, with his

full cooperation, all shifting of surgical teams was carried out through the

surgical consultant, who made his decisions from his knowledge of the status

of the hospital (that is, the number of casualties admitted and the surgical backlog) and of the capabilities of the available teams. The office of the army

surgeons was kept informed of all movement of the teams, and assigmnents

were accomplished without friction or other difficulties because of the cooperation of the army surgeon and his executive officer. The information which the

surgical consultant obtained, usually by on-the-spot observation at points at

which heavy casualties were expected, was acted upon immediately, and the

need for additional help, of the precise quantity and quality needed, was often

met within a matter of hours. As a result, the highly specialized personnel of

auxiliary surgical group teams was used in the most etiective manner possible.

During the Battle of the Bulge, in December 1944, information was received at Third Army headquarters that many casualties were piling up in

Bastogne, Belgium, and that help was needed to care for them becau, e the

medical units attached to the 101st Airborne Division were completel exhausted (fig. 49). A volunteer surgical team, consisting of five medical officers

and five Medical Department enlisted men, was formed from the personnel of

the 12th Evacuation Hospital, which was then located in Nancy, France. This

team, with sufficient medical supplies, was transported to Thionville and then

was flown into Bastogne by glider. This was about 36 hours before the Allied

breakthrough and the relief of the besieged forces by the advanced element of

the 4th Armored Division. The surgical consultant, who entered Bastogne

with these troops, was able to assess the casualties at firsthand and to direct

their treatment and evacuation.
TIJHID i.S. ARMY 311

Fuili-F: 4'J.-T%%o ii iwnr uof t i. le 0. s Airborne I )isil drag Willy3 lieded

mietlivall st~titplieN Mlc tijvti r~e ajiitioppIed lo dive usieged II I~it~i* I110011mi.

SU PPIES AND) EQUI PM ENT

ill adequaite (Pjltitii es, "0 that .1illie ulls M ilch hilaned ill IF'aliee a fiet I)-ta

Nvere 1 1lly eqluippIedl. %lIUb " V IRttl-Iil . tue IV Olit01igl tile IN1hle I)etwid of

Ig itIg'. I it addit ion. atl ittn 16l. 1.S. A11% equt~ipmetiI~tiu " ;1: sitpplemttet b%

VCIl)t ttte( eqluipmttet I )titl"Allaltt 1911, for iti.statte, Itiore t hian 2001 totis

of (jetnian1 mtedical supplic.s were ('ap( IIted. Abhout t a lijid of t li, miaterial

coliid be ll et 1) v U.S. Arttti% uIledial untilt. anld %%a., oAtittIIeled acoilind N.

DI-irit tle ittittlis lbefote the Thirtd I.S. A1ti11 1% comimiitted ott tile

leC.ittie W1(jt~ielihI %it hi it,, I[M. [ile coopietat ion i oh~. Elliott C Ie. MC.

C htief ( oiluhtantt itlltugt to thle C hilef Sutrgeotn. ETOUSA. miade it o -

Wie to augttuetttl Ilte eolttliptoetit Nthplieol b% tahles ofl equiipmieuit N% tl vetilt

olier. itemtn %Nhich hadl lett tfoil itl the Mehttajaihettto lbe tfill

ottl ieti to b le -iit for tit(- prpe futittil iliu (ofl %atiolht ulit'. Thtem.

iteuti- itlttulded ad t li otnal d t iiaItiachiie' _(toet'atot for elect ik-lia.rl

iuhitt-: andio tioti-lanardtizeul 'iu1quhie, lot iot aiti te"ilijal lptoiiedIIt1tt. 511411I It

\itallin~ tithe- fori blood ea l -c tito Itiilad filill ftoamt andu iliet itetti

III-oritil e otietiltition ioul-e ill Eti111latiu before. I -da~ tjot iipti i-a.-

t ittl- and( alterat tin ittll t omtine II-ve clihttiittict %%c dlliotu-ttlt d lwaitc
2 12ACTIVITIES 6i, SUAGICAL CON ginTANTS"

,theY,%ad,'been foun tobeofalenAfiaSiiyad.tl.Qxefthe

daemonsttons coiene h etn po etg othat the ce1 sirlupl unitmwereallycentril, The supply tet as set~l up, th &at etrf or

etg-401n, which branched of f:rom it i, cruifor fashion, The orijiu,

pla 'li~d frte ben dspesio ofallsUch facilities. the Substit :-aj"

'WIlpli -jetnrdcdthe _number of personnel neerdc~ ~e~ne nPecessary to seuesu iS, iud made, it, necessary fo1esnnlt t4 ud i~~~~ain,~el~o re o e'hmanto-n 

Becus of tk'1e peure ofieve ,n eia oete eeognzd

i6 Thrd; lJ Am; n no,4 reulrl scheduled erei~vs o p

tineshowver duiglulisin military operationsreeentattivef of

he ugia st8ff of fedand'evacutation hospitadswere sulmnqnedto mee at

some cqotra! point, for the discussio oprblm of gnrlcnen hs

coiifei~uce were' of great benefit, Mdclofcrfo.tebgn~n, ~d

of'Ui~~~~rnc prsne atteece~eecs Ier 

'C6nfetrences arranged bythe hae o-utnswr loo rt au.

They keeveryoneposted on routine, and'specil practices, especially adyanoesin hetretmnt f asultesan prvied ueflforum for the exchtagof, Ideas. cOfficers W~ho, had becone- interested. in, special9 hlikal, problems 'were-,

the conclusions arvda'ee'asdaogt themirgialtfeaunis AndhospitA

Colonel: Odoni also attend'ed several meetings of the medical staffs ofAL

A4l1ied.Aruies. 6ne6f these meetings 1ield in. 'Paris -w.mu'fte

Atle

giisocf the, Continent, was Iarticlaly,'helpful cause, of tlie oppobrtuniity

A4ffoided' ,-fortI the evaluation-of the, work of forward, units. it was "gratifying

to hear- only ininor criticisms- fromn the hospitals in the comncainzone.

Wheui Qolonel Odaom returned fromn anoqther of thiese general',meetijigs, wich~l '~sheld in Btruises in- D"ecember 1944, he receJlor .S ryhtu

qfi~iaeby passing through the area in which thie 3att'leof thie:Buige ,wasto

eiuptonly 24-houf§ later.

Time and events did not permnit formnal publications from the Third' 0.S.

Ambut Colonel Odomn made a personal study of amp~utations and Vascular

inju'ries§ in-the Third U.S. Armly anid reported the aiialysis at one of theInterAllied) Conferences on War Medicine convened by the Royal Society of 3,M edicine inlfMay 1945 3 (p. 324). A Supplementary report on the samne subject was

published in Surgery in 1946.4

3 Odom, Charies B.: Vascular Injuries In Battle Casualties. In Inter-Alied Conferences on War

Medicine, 1942-1945. London: Stapies Press Limited, 1947, 107-171.

4Odom, C. B.: Causes of Amputations in Battle Casualties With Emphasis on Vascular Injuries. Surgery 19: 502--569, April 1940
313

Pak

PI(a 1:1, .10. Nazi hojoilal 111111 '111-I'vilder, III (;vrillally.

RECORDS

The record., kepi ill all 11opilal, of the Third U.'S. Arm 11,41111arl N

evilililled 10\ the cmi'lillmll ill frollivill "j)(11 clawl". and their impol.-

:11 Ick, \\ a, 111, Wd \\ livi Im or a llopiul I k i"llvd. The, aill v I I I I

upoll I I lec I I I a I t er, re'l I I I v( I n I I I 1.\ I( I v( -A ) I v \ v I I \x I I .I I I v I I I

N\ (I re vx I re I I le v I I I , v .

A 1 1, v )I I livil. record., ill ( I I I I I, I -a I v. 'I I v 4 ) r i I I : I I v I I I

I I le I )a I v I I I I lel I I iv I , v I I 11: 11 ('11 . a I it I I I I v I ': I I -I I I I I lV( I i I Io I T his

'Ivlkl had I he ;1(1\ alit age ()I* illa lilt a ill ill-,, :I cow i 1111oll, of all pal ivilt.,

handIvIl ill vach lm pil a 1. and it A-() perillit led Illvdic:1 I officer, lied I o I he

Imil to rm iv\\ I liv ca.(" \\ hich I Ile.\ had handled peroliall.\

PH ISONERS ( ) F W \ I

I i li-4r t 11v varl I] 11 )11111, of I he (I:tllll miu'll, ill Europe. \\ hcll mll wrillall

field IIIA'd i"al 1111 it cre k,:kl It lived. \\ ollilded owill.\ ca,11,111 iv,, \\ k.l.k. o aclialod

I Ill-mi-,di liollil:k I I A I In \ challilel, of v\ aclull ioll. A, I he Third I *.S. A I'll).\

,III% a 11, v cmil 11111k.d. I.\ el lll(,l (I:ki ll-, , of ( ivi'lliall Hid it a r \ 114"pil al, \\ viv

1111CM (11141 ( fi A I I i ro-I I \ I, \\ a , 1-11ol mt I I April 1,11:1 dvIinill--, 111v

4d, dic lilvdical -vl\iv Ill lk.-om-d I() dw-v ill-lalh-
tios'Gemln rionrsofwar .uncovere on the field, of lbttle, And. r~n

qpuiring,,prompt car e, were, to be treated-adeaiaetru~ mn4ca

chainel. Those unicovered in German ~lt~~riiiwop~l e o~

* managed b1y a "sayut poiy htciast ionwpermit~g, B~fltjefteld

liospit~.'hn h iia~ate teredy, ifr, di hge- from, the.id ioptaf,,:

the 4,0 feid!en wdgiie eeW

coiiselida o of erman patfienlts in Imilitary, or., civil'a optl a

accominplished, wtieiieer the erlsanepentdndmaximum usq M as

mnad of erian m iedical department supple an-qimnt fdcJsup1)l , ss far 'as psil, were- ivolemishd fri captured- dern: sfocks

Wheueveir poible, ,Gernian medical -officersi ere lJeft in ofhrge of t1ie~ejn thdt;

liospital~~~~~~~~~~~~~,o easwr bu didtaiv roie yUS.Aii ndc4 units.

'It 'tht "tha treatment instituted was..cqmnsuat e 1itl U S, stand'rd :of

Oin oiii, siortly after thie, Ge~~ins riirfler, Qo9...uel Q4oii wyAs

instucte by eneral _Patton1 to examine ildMrnl.Kl.onRiset;

he h1a been capturedan w~hieinamalror.tn itih.psnt

Geran h3 icinwho' c .itended. that i~o was too ill~,nti oyv. olnel , Odomfnd 1 hm1 iiiiexcellent physical condition exept orvi d'mlhyperte# ipi

Sfewiihours after this repott had been~givehu to General VITtton,iedasl

0ii.XRundsiedt was onr his way to at risouer-of-war canpin 4Englandj.

Section II, ClinjicalConsiderationis

DISSEMINATION OF CLINICAL, POLICIES

In- iddition to the Abinual of Therapy, E uropean Theater of 'Operlitions,-

ii'i Mfay 1944, surgical p~olicies in th ThrUS ry were chieflY do'-

terbinied by the second (surgical) part of the mnedical plan which formned'Aiiniek 16, to the Third U.S. Army Plan for Operation OVE.'RLOIRD, dated.1 11

M4ay 1944. These T iird Army surgical policies were revised by at direIctive

publih on 13 October 1944.6

The surgical consultant prepared the directives pertaining to surgery which

emanated from Third U.S. Army headquarters, insuring that they conformed,

with the appropriate directives f roin the Office of the Surgeoni General and the

Office of the Chief Surgeon, ETOLTSA. After at directive badl been issued,

the consultant ascertained, on his next visits to army units, that it was fully un1-

derstood and was being followed.

As a inatter of convenience, as well ats to point, uip the chaniges in p~olicies,

the surgical policies set uip in M1iay 1944 and revisedl in October 1944, after 3

mtonths of combat, aire (described together.

See footnote 1(2). p). 291.

Annex No. XIV. After Action iteport. 0111ce of the Surgeon. Third U.S. Army. 15 Mny 1945.
"TIRD ,S.18 ARMY ~1

'GENERALr COSIDERATIONS OF IQR R SURE)

Un th"Third .S. Army muedica plan, for'Operationi OVEIRLORJ , date

11,y J44, 19 itWas, ppint out that epa'ly,, skilled, Asirgical care .,of battlb:

castie~is 'hepricial uncio ofmeicaintallain s uppotn il

ary; 'hicae~asBeote fqo ingpiciples!

1. 'Fii d pimfary care iJnclude onlydessig.of, woundsotrlo

iiiorrhage, spInting of fractures,.andtreatment of ihock. These measures"

are ~iii~i~ ottatbatlionai aions a~ t colcingand ~clearingstio.

1.eld 1)urgii ey ts'q to-be undertaken in inistAqltions.1 fowar of-4

-Jhot iii iportat' conieration ,iiitie early care of the wounded is thie,

pr~ei sotig f casualties. This-,sortiIng ,(triage) perit lgtywinddd.

tobretrnd qicl o'duty, while Seriously, won ded -casualties are, eva~u

a~dq~ild r e~iuatoiihositasthe echelonAat-wli lithey aretrateA-.

pedin -,pon their trA anprtbility; his medica picaulties.*ere diVided' int -two groups,4 Js olloWs;.

(1) rhlnsportable'g~p consisting, of those, who could withstand movem~ht to the reair Without deterioration; and(4antrnptbegou, c~i~isiigofcasaltes wwould'do poorly when ~vd and whose dui~

(ithe s-_atus resltn!g from,1 Whose wounds) requrdiiueit ramn~

There -Wer'e a ~numNbr, of categories ii the nontiransportable group, as

i-Casualties, usually those with multiple wounds, who ,reinled 'in shock,

in spit o6f itetisive r~ssiitative tbekaPy,

6. Caisualties withiabdom'ifial wounds, particularly those with possible con,

cealed hemorrhage. In evaluating these patients, it was emphasized that

another fact had to be, taken into (consideration, that all previo ,us experience

'had show~n that paiet woaduerne laparotomy coulld not be safely

moved for at least 7 or 10 days. Iii other Words, the triage of this-group req uned the 1ev aluation of both the postoperative circumstances and the casualty's

prese6it status.

3. 'Casualties with large sucking chest wounds or massive intrathoracid,

he6morrhage.i

4. Casualties with transthoracic or thoracoabdoininal wounds. It was

pointed out that these wounds are difficult to diagnose and are likely to be

missed -because the path of the missile is frequently unexpected. In wounds

of the buttocks, for instance, the missile may come to rest in the thorax, while in

wounds of the shoulder, it might lodge within the peritoneal cavity. If X-ray

facilities were available, it was recommended that they be used to settle the

matter.

5. Casualties with wvounds about the face and neck causing mechanical

interference with respiration. Patients in this category would usually require

tracheotomy before evacuation.
16ACTIVITIES, OF SURGICAL, CONSULTANTS,

SHOCK AND PRESUSCITATION

:8ck--wa 11einost, important -cause of death In. cAsualties wNlid Zido!6t

'die 4iiimiateWy' of, tlier - ounds. Wfit wvas ~not treated ,promiptly ,anid igor-

'6ugyiitwas likely to ecome, irversible. Its, prqlongtin,,even if the patet,

di' iibt die immediately, often led-to at subsequenit f'Attlify from anuria, Anopgbk

~ii~~c~stnt factor; tr nq:fnsi reactions ddno seem-,of great im Ttaude,

lfi cigonection, d Alkalini'katio anidother -methods were found to b jfkn

-V'aueifi 6itliet the prevenition, or the treatment of this compcation. The

A'ifip 'tnconisideration wast6 bring. the'casualty promptly outcof shock.-

Adequate shock therapy based on the, use, ofpam.ad strewhe

bp wa pobbly th most important single method of lowering the mortality.

anhd', 6rbidity from combat -Wo~hnds. Operation WVas pei'formed as -so as,

pfossible after' resuscitation and vas regarded as pArt of the' resuiscitative ri fin"'

th adiistrtio wr f~l'frwr'~ptl fo~r the treatment of 'shock ,and. nof bood.The chiifs of laboratory services wvere responsib'le,

fot he upevision of the hospitalblood program.

Plhshiq was available,'to -all medical units: as far forw iAr da as battalion aid,

ktations. It was, ue in .lbrlqatte in teq prevention, of shock adi

resuscitation, until a, field hIiospital could be reachied.. It Wqs of'value, however,,

as 8I~ a poi'ary expedient. No casualty coulId-be--properypeae o

surery'viholt te se f woleblod.Plasma and, whole blood weeorig-;

'ilally used in thie lroportion ~of 2,pints o lsat 1pn fbod ua h

cainpifi progressed, more and more blood was used;

Before-fl-day, tlid policy was formulated that the Third.U.S. Army-would

haye Attached to z-'livery it a blood bank detachment for the redeipt, storage, and deI..' 

ofwihole blood, The bloo wuas to be delivered daily to all hospitals on .a

so~calod "m~ilk run." Plans were also made, and hospitals wvere equipped,'to

o6btfifivwlhole blood from hospital personnel.

TIhese plans were based on the provisioni of blood by the theater blood baink

in the ,,United Kingdom Base. During initial operations, 190 pints were* de:

livered daily for the use of the whole Third U.S. Army. This supply was entirely inadequate, even with supplementary provision of whole blood secured

by bleeding hospital personnel. Late in August, supplies from the Zone of

interior became available, and from 500 to 7100 pints of blood were received

daily. This was an entirely adequate provision. There was only one occasion

thereafter on which whole blood was badly needed and was not available in

sufficient quantities. Colonel Odom wva- dispatched by the armny surgeon to

theater headquarters, then in Paris, andi a conference with Maj. Gen. Paul R.

Hlawley, Chief Surgeon, ETOUSA, and General Cutler, his consultant in surgery, insured an adlequate supply for all immediate needs and future necessities.

The blood was delivered in refrigerated trucks and stored at a temperature

of 350 to 400 F. (approximately 20 to 40 C.). All blood which had passed the
exjDration date ma~rked onthebQttle or'whc hd be loe obcm af

waisdiscarded;- iarming ufiitlved,,te risk, of 'hernolysisi-and all-transfusiois,.

were ade "thc-ldiblood

Yinail,1gftsttc for the 6I'hird uS. Arm bl1opd-plasma pirogram show~tlha 4,8260 transfusions werp acpqi~plie frs -9~t whlP lo,959wt

'stoe wh1 lo4 n 695 ihdied plasmak, O0ther, blood substitutes wr

ADMJISTATO Qf MORSINE

Because, of 'the early experiences .in the Mediterraneani theater, mnorph'ine,, Ia sedmrecuiou inthe-European theater.. In Italyi al be on tha th reQtjionof doe omophine, even" whewthe oiia os i o

seem ei~~~e a xrml agru n 'couldlead to 'morpiiepsIig

Thie, expljaion, W'As, tli .absorptionofAthe riginal amount, wqa aV'first, in- hi1bited by, cold" and da~np,,as wejlas by- hi-altit4ds bu w aciiae when,

"the,patient was broughit ito awarm environmhent,, or-a-lower level. If the

oiiaul: dose had- ben: repete, -both ,4o~es- wee absorbed with afnge'ou

Whe~~~~n morph~~ine was indicafed, a, dosage o - qure f ri (5m

vqsnsuAlly adeqpato, although occasionally .one-hailf .grin l(30, mgi) wa

qred for he controtbf paih. YArger doses Wprej~iever repeated. Thq Li! Oe

and of moun l~e njeciow ,,eaWays reord.

'Morphine was administered subcutaneously or intramuscularly if a gradual,, polongedl effect was dqesiredi_ and ,intravenously if ia rapid effect was desired,

Intaveou inectonwas in the. amount, of on6 sixth-of a grain.(t mg40.) Massageat the gite of intramuscular or subcutaneous~ inection lastenied, absorpANTIMICROBIAL THERAPY

ChemothrAoY.-in the, Third'U;S. Armny medical plan for, Operation

OVERORDsoldiers Wounded in actio 11were directed to- take, by. Mouil 4

grms of s§ulfadiazine in tablet form from their first aid packag assona s

'ib-unless the Wounds invblved the abdomen. At least half a canteen of Water

*agtobe dimikwithin he next 5 or 10 minutes,

The niedical offcer who, first dressed the wound was-instructed to frost it

lihl wI suilfanilamide powder. The powder was available in 5-gm.

packets, and, under no circumstances, regardless of the size and number of his

wound, wer more thnw packets (10 gmn.) to be used for a single casualty-.,

Sulfadiazine by mouth was to be continued until definitive surgery had

been accomplished. The maintenance dose was 1 gin. orally every 4 to 6 hours

or 2 gin. parenterally every 8 to 12 hours. After debridement, or after definitive surgery, all wvounds were again lightly dusted with sulfanilamide powder,

and sulfonamide therapy was also eontinued by the oral or parenteral route.

Medical officers were instructed to be constantly on the alert for a possible

reaction to the sulfonamide drugs If a reaction occurred, the medication was
tl&- ACTIVITIES OF'SUJRGICAL COSUL TANT

t~ i'scotinued efitirely or. continued in decreased doags nd dekrirt,

,oberv'atiom

i yth time, the Mafy 194medical plani was issued, the extperience ,in ,,the

actirranean theater had sliown tluW the sulfonamid pearations in a woun

trefor e contin entfifly. within a few motsafter the: ivasion of the, Cotnet Thywr ,

founl to be of no0"therapeuti c -value, and: wound, heal ing wavts actuatlly d-elayed

whencryt~l wee u~ed Loal eaciswer6 -not unconmo, and after the.",

wounded, man hiad resumed his activities the wound,,sometimes hroke -down.,

n-tll~i *h~p.Vncli as..available for. general ,use.in m~iita#ry

080.~l when0 the Thfd V.. Army- !*came operational. It was admn' iisto,.L

pIArenteridly -in -clearing stat ions, and .the, same -regimen IVA SL ntiued~i lfl1& ai evacuiation hopitals. The, admnIinistraion of penicillin by tearet41

tbuite, ,coibined, with early, adequate debridement, was-regarded*as, the iqt

mprant sinigle cnrb tot ihelow incidence of -woufidifection repbrte4..

Iin he fil revacujitioh-hospta iwhc flie sugrwsperfoiine.,

IThe dosage of',peidciiin, ell-§ asthe time of administration and-1the

-foute (aetrlo oa) Was recorded iunits 6,the ,emergency4 medical,

tag an1d 'the field: medicalrecord, .n piteof repeated spot che~cks anidcoilstait

emppipi upon the imnportalnce Of these nOtationsr these instructions, unforIWOUND MANAGEMENT

in all, instruction of Third U.S. Army medical personnel, as well as in)h

iiedical plan issued in May 1944, it was emphasized that all battle injuries

must 'be debrided and that debridement was the most important single ,phiase,

of cokiet surgical care. The operation was to include removal of minimal

amounts of skini but of maximal amounts of devitalized tissue, as well as

thorouigh mechanical cleansing to remove all dirt, debris, and readily accessibl

fomreigni bodies; foreign bodies at a distance from the wound we're to be left i

situ. After debridemient had been performed in a forward hospital, the wound

was to be left unsutured, with the edges kept separated by strips of petrolatumimpregnated gauze. Tight packing of the wound was to be avoided, since a

pack acts as a plug and invites infection.

It was often extremely difficult to make medical officers fresh from civilian

life realize the importance of radical debridement in battle-incurred injuries.

In the directive issued in October 1944, emphasis was again placed on the necessity for the wide excision of all damaged muscle, the thorough mechanical

cleansing of wounds, and the removal of minimal amounts of skin. Particular

stress was put on adequate incisions. The circular excision of skini around

small wounds was specifically forbidden; this technique resulted in prolongation

of the convalescenceeand made delayed primary wound closure veryv difficult.
THI,,RD . 4, S,., ARM 9319, ., , :i/ .

A-lthoughth6first principle ,ofniilitary-srgery as, to debride the wouiid

and'eavetopeni t was equally essential thatclosure be effected as promptly

' a~s sibii',,to limit infection-the incidence of which, was remarkably low. -

and fibrsi I an4 Aci ite tec atsrturn to. duty.

f p." imary debridement. had been adequate, wounds could usually, 1 be!: ,,;

qlosdAearly as the t6,ird day after operation, though it was ,preferale to'I

ieae'he opn oranothe24r48hus Whether a wound co uld besafely

csea, or should beleft open for av lon~ger peridwas a, cliniical dcs n hc

w as not 'made until th~e debrided wounld was uncovered in th~eoperating rodm.

lPrelimiary 'ispection and- repeated dressings were avoided, on the ground

tha~e.prcedutresinyited .... contamnation.

as Closure was considered, safein the absene of such signs of inflanimation,

ischarge, reddening, painvand swellng, The wound edges were brought

together'16oselyi withouit underniningof the edges. Sharp: instruments were

Maoded R ention sutures, wlhicliwereof silk or silkwoqrmgut, were spae e'

*, . uwdely, and~h' t loosely. ",

If.mild infection was apparent- inthe debrided wound, hot moist dressings

were-appliedr befroe closure. Was undertaken. Healingwas usually pro0npt.

-If eidefnces e of ,infection became apparent in-a wound 'after delayed primary

closureiimmediate removal of the sutures was indicated.

REGIONAL INJURIES:

Bone and Joint Injuries

JWounds of the extremities (table 3).accounted-for more than 61 percent

of the battle-incurred 'injuries treated in Third U.S. Army hospitals between

1. August 1944 and 30 April 1945. The majority of these injuries involved

bone , joints, or both.

Fraicuris-In the initial surgical plan, directions were given that all

compound- fractures be debrided and left open and that the injured limbs be

immobiiized,.in splints or plaster casts before the casualty was transported to

a hospiali the communications zone.

No external or internal plating or other fixation was permitted in field

or evacuation hospitals of the Third U.S. Army. Definitive reduction of fractures Was not regarded as the mission of forward hospitals. In the October

i944 directive, it was again emphasized that field and evacuation hospitals

were responsible for the debridement of compound fractures, transportation

splinting, and preparation of the patient for early evacuation in comfort and

safety but for nothing else in bone and joint injuries.

When plaster of paris casts were used, circular bandages or other circular

dressings were not used under them. All casts were padded. All circular casts

were split through all layers, including the layer of wadding, down to the skin.

Casts on the lower extremity were split from the tips of the toes to well above

the knee. Casts on the upper extremity were split from the tips of the fingers
A2 ACIVITIES OjF SURGICAL CO6NSUlT. "NTSk

tAbove, theb elbow. Thispecauition, wias taken in the operatingro ,a n

1hoints' ulfl-r'ng or'half-ring splints-were permitted 'only in emerqgence fz 0i'Ai" adiic.isilatis They were rep]ae asqsoox'as possibl;b'y'

dir~dtiVew W oe s ei thni h a 94pln naera ih

the (icthbe direteteprcde aasolo:

1.-Wiadures- of the hiumerus were immobilized by plaster of "payis spical banidae~s." T he arm was hel owr-n ro1e6eijys htIh fore'

-9zi -a in ftont of, the; body, The elbow its fxd" At least, 00b, A,:plater - o prs elea' banddge wses atsatr than-atspica,,Audugj'Ing'

2. Frichires of th~eforoarn, wrist ,.Anihd; iii were bonmobilizekd'-by circular

platsterbf .pari's-casts-extenidinigto thie _midbrachjia'l, rei .A asapledt

th -fokeafm and 'hand wwscut backi to heproximal ,palmiar sulcus,:to'perrit -6 'ln(uuimpeded4 Motion-of the fingers, excejpHi injuri "' of the ecaal

of bigs Thntecast was e6xtenddto -he. tip- of. thepfigers. Fraurs o tQ qjffmur were .im~bilized iim adobecruaplse

gtth fid fth on legto he pneslvi. hepcwa eimoedbapsepamo stu ,athej legs, nhtekeesihifeked,. A were spread apart, the14 a~

ration, beiggae tote i t te littr The uweof 'the _Tobruk'sp10i1

was permitted in selected fractures of-the femur.

.4PtFactures of the tibia anid~fibuliawerieinmnobihized-ini circular Plaster of

'Paxis b~andages exte~iiig ,fromn toes to groin~. The footw*As placed in neutral

-Joit' finuries. Wounds of the joints, were treated, as soft tissue -woud

Were treated,_by -debridement, with removal- of all foreign bodies and devftal-"

izedtissue6 within the joint. Closure of the joint was essentia, thko~lgli- the s ,oft tie Wound was left open, as in the usual debridemnent. Penlicillin solution

was iistilled into the join i eitly after closure.

Hand Injuries

By the time the October 1944 directive was issued, the dangers ofptpolonged' immobilization in hand injuries had become fully evident, and. much10

emnphasis was therefore placed upon them. The objective in all hand injuries

wa 's early, active motion, which wats militated against by prolonged immobilization.

The policy was to treat all injuries of the hand as soft tissue injuries. Special efforts were mnade t: close the wound promptly by suiture or skin graft. When tendon and bone fragments were exposed, the patient was transferred as promptly as p)ossible to the nearest plastic surgery center.
"THIRDUAM ~

-Amiyiptatio~n was- ,performhed -only in, tie ,most extremne, cases,aid then at"

the mstdstal poitpssible. hr a n exception to this gerali h t)pn

as oi in, copon fcures of tedistal. .portion of a R,fngeracon

Danle~d by destrucion, of tjwe ,flexor and extensor, tendons, the digit lwas ampu tate piipladeltym~o fte remneinng, fingersan, hee

tirehand kiasipractcd -7

In seleted ~cases, when. seletal raion -was- necessar to euerdcin

and imobilization of -metacal Iracturesi was, appliedtrglth prox umal phalanges. Again,, there wastepin oerlactimemotion;,iinno

me"carophlangeal joinits were left free. Pul trAction wvas-ni'le'prmitte~

'xiofci WounS'

m1isdieMay 1944meica plnftwsepaied thiat wounds of the face

treated, 2M With. sP6cial care a debridemient. Excisioni shouild be as

cosraieas 'ppssible,,an~das mucl as~posgible of h, skin, muscle,, bone, and,

The.% iiittctions'-wereexpaiided in the6 directive issued, in, October 4944

Iti as, hoiugh~t'thati lie, missile hiad peihetra'the nasal. muo acmplete

preliinfary, ekamination was c'oiduicted,tq determine possible interniAnae.

if heh, nasalhuo was injured, the cavity, was-packed v rnal~ sin.

pregijated with a sulfonamnide duo'iimentt hnuelingon;botli surfaces, ofthemucosaan4 to peyeit closure of the aiirwvay -by adhiesions. TIegue

which i otruded from 'the nostriLw~is replaced every 5 or 10 days.

BPefore a patient with a nasal injury was evacuate4,,a thorough examinat6ion was,,inade,- to insure that the nasal airway was open. If adhiesions were

founid, they were severed, and the nostril was again packed, to prevent their

-re-forming.

Abdominal Injuries

The importance of colostomy in -wounds of the colon and rectum was a

lessoni which had been learned in the Mediterranean theater by painful experience and wvhich was emphasized throughout the campaigns in Europe.

Whienever possible, when the double-barreled type of colostomy was employed, the large intestine was mobilized to permit approx imation of 2.5 or 3

inches of bowel within the peritoneal cavity. When loop colostomy was employed, the initial opening seldom exceeded an inch in length. The incision

wvas made in the region of the presenting t aenia, parallel to the long axis of

the bowel. It was emphasized that in injuries of the rectum or the siginoid

the bowel must be severed in order to secure complete interruption of the fecal

stream below the site of the colostomy.
32 ACTiVITIES OF'tSURGICA: WN8LTA NV

Nerosurick I njuries.

S;lnal injurles.,Compression fractures of the spe were reducedbyi hyp. xtensmni,~ a aplasterof parm jacket was apphed wle the patint was

Ssillti is~p-ition. Infratures of the:lMmbar or lower dorsal vertebrue,,the

:, jak tended from the symphysis pub-s'to the sternal notch. in, cervical

and'4pper doisal fractures, the head was included in an extension 0fthe jacket

G6nshot wouhds-causing fractures of the spine and dAmage to the spinal

cordwere treated in evacuation hospitals, where the extent of the:injury could

be dtertihined-by the combined efforts of the orthopedic surgeon and the.neuroirgdon, If surgery was required and operation would be possible within 36,

hi9i4s:bf ihjury, the patient was immediately evacuated'to the nearest general

hospital in the communications zone. If this was not practical, exploratory

laminectomy was carried out by the nlurosurgeon in the evacuation hospital;,

the exploration was undertaken whenever there was any doubt that the cord

was completely severed. Transportation of patients with spinal cord injuries

in plaster was prohibited.

If the patient with a spinal cord injury could not void, he was catheterized, and the catheter was left in situ. Tidal drainage was instituted as soon

as possible and was continued until complete neurologic evaluation was possi'ble.

Special care was taken to insure that the bladder was emptying impletely.

After 'this evaluation, tidal drainage was continued if there was evidence of

early bladder recovery.

Early high suprapubic cystostomy was recommended if bladder recovery

was not promptly evident in cord bladder secondary to permanent cord damage.

A large mushroom or Malecot catheter was used and was changed frequent!y,

to prevent infection and incrustation. Daily bladder irrigations were also

practiced.

Peripheral nerve injuries.-Nerve damage was sought for in all injuries

of the extremities, even if the lacerations were slight. The objective in all

peripheral nerve injuries was early repair at a specialized neurosurgical center.

Primary repair was not undertaken in hospitals of the Third U.S. Army; the

established technique was delayed repair, within 21 to 90 days after wounding

and after complete healing of the soft tissue wound.

Exposed nerves were, however, never left exposed in a forward hospital.

Whether or not they were found to be injured at debridement, they were

covered by fascia, muscle, or both. The severed ends of a damaged nerve were

frequently loosely approximated by one or two nonabsorbable sutures, to prevent retraction. If the defect was so extensive that this was not possible, the

severed ends were marked by single nonabsorbable sutures.

Vascular Injuries

All surgeons of the Third U.S. Army were thoroughly indoctrinated with

the importance of attempting repair of vascular injuries, since in their repair

lay the great9st possible chances of salvage of limbs.
THRDU..ARMY32

Th Vitaliumh tubes, an~lheparin, necessary for a, l~arg-se aplct ion o

the nonsuture technique of vasculr -anastomosis Were not-available, in large

tiaities&,,but, s4cient supplies v ere available to permit ,a, fair trial- ofthe, eto.Glass' or.plastic' tubes w4ere usedh in a ew casesin, whc Bkeoe

tii.i s ei'pt avilable. Reports- by Blkemoreand 9ther-vasculrsurgen~s

6n, the nonsuture,repAir of blovd vessels were repro duce, and copies were ... cdlui . thhnds of every chi4 of surgery and every ch~ief of a, sugical team.

Was i~h6 consenisus-tht 4-iese procedures. were, usual ly im~ractical, for.

~gnrfl:W6-ti tAhheld, foi' he folloWing rea96hs:

ieognition.of ji injury to a hood vessel was essential for successful,

ap1p atibuq6f repair. techniques. Diagnosis could notlb expeted o0thecrpsman Wlio &A'Stcared for the casualty on .the battlefield, and even if he shouli:

recgnze the injury 'e could not institute therapy. Civilian surgeons WI o,

repeatedlyrecommended the repair of vascular injuries during the war failed

totakento considerationthe lmitations of first aid men and the conditions.

under ,vhlichAhiey vorked. 2A major part of the discrepancy between the results in vascular injurtes.

encoufitered in civilian life andthose encountered in military practice could be

explained 'by, ifferences in the timelag. The lapse of time between wounding

andsurgery is seldom excessive in civilian practice. In World War II, the,

timelag averaged, at the best, between 6 and 12 hours.

3. There were other differences between civilian and military practice,

The battle casualty, in contrast to the civilian patient, who usually was in good

condition,,was often exsanguinpted and in shock. The battle casualty's blood

pressure was low. His tissues were anoxic. There was often hemorrhage into

the fascial planes of the injured extremity, with resulting hematoma formation

and pressure on the collateral circulation, which itself was often injured. The

disappointing results of sympathetic block, which was used routinely before

and after vascular surgery, could frequently be accounted for by these conditions ratherthan by badly performed blocks.

4. The preparation of fresh vein grafts was too time consuming to be generally undertaken in military practice. Had frozen grafts been available, another objection to the repair of combat-damaged blood vessels might have been

removed.

5. Heparin must be used to prevent clotting at the site of repair in all nonsuture techniques of vascular anastomosis. This measure, however, would have

been attended with considerable risk, for a third or more of all casualties with

vascular injuries had multiple wounds. Fatal hemorrhage occurred for this

reason in a number of patients who had been heparinized.

6. The institution of surgical procedures in the battalion aid station, where

only resuscitation and first aid measures were employed, would have required

the revision of the entire system of management of casualties in forward areas.

This might have been justified if there had been large numbers of casualties

with vascular injuries susceptible of salvage. The lives of other casualties
324 ACTIVITIES OF SURGICjA CO ULA S

could" it justifiably be imperiled, however, for a group of casualties whoqconSAhalls~ of ce.-A single lacation or a single punctuieound, ofa

maj~ ~terywas uncommon. Mo~ often, the vascular-injury wasz asociite4,

w!_h oher injurie%..

In 9,030 battle casualties treatedjn' the Tfrd U.S. Army duringits, entire-

:eraona1 i lpe iiod, on!ly 837, or 0.9. percent, hadwounds classi ed as .

This wVas a much smaller pioportion than civilian surgeons might suppose., iC

i~1evdtht~thi igure is -accurate; because alI surgeons were o n' tIe lr t [( , f~r~vidbar ihjur~ies, excellent records were kept.

QOf these 837 njuries to major arteries, 423 came to amputation. Inno cas,

ihvhich removal of the limb was necessary was the operation performed.with

0t :chsultation, in. retrospect, it almost seems that conservatism was, overemphasized; it is believed that an occasional life waslost in tile laudable attenipit save a limb.

On6lY 70 blood vessels are known to have been repaired in Third U.S.Armty

hospitals. When these cases are compared with the 592 comparable injuries

in',Which ligation was done, it is seen that gangrene dt, eloped in 57 percent

of theligated cases against 38 percent of the ases in which 'epair was under,

taken. The comparison, however, is scarcely valid. One reason is that the

repair series is disproportionately small. The second and principal reason is

that. only the most'favorable cases were selected for an attempt at repairi and

the comparison of the series is -therefore not a comparison of parallel cases.

On the other hand, the distinct advantage in vascular repair is evident in this

small series and is an indication that the technique should be employed whenever it is practical.

Repair of damaged vessels by suture was always the method of choice,

even when it involved reduction of the caliber of the damaged vessel by as much

as 50 percent. Only the larger arteries, including the subclavian, axillary,

brachial, iliac, femoral, and popliteal vessels, lent themselves to this technique

of repair.

Arteriovenous aneurysms and false aneurysms were treated conservatively

in forward hospitals. Definitive treatment was usually undertaken in hospitals

in the communications zone 6 weeks or more after wounding. In the interval,

because of the development of an adequate collateral circulation, gangrene of

the extremity seldom resulted.

AMPUTATIONS

There were more amputees in World War II than in World War I, partly

because there were more casualties and partly because more men who had lost

an arm or a leg lived to return home. The use of more destructive missiles

explained the higher amputation rate, particularly the extensive use of land-

'See footnote 3, p. 312.
TIR tmU.S. ARMY 325

l(i I ll. 51. 1 I I ~n I Iili oII(f i n v a IIii~VI Ii'i a11 IiIIi tut4 I4 Iik ~i : 1 ld h Mita1

.

I I IIIe."NNI hi ch% v e I ) ra -t I (i'a I I-NI II 11io N% I I ill Woilto r N Wa Ir I . T le I i re -t, rvIm.ItlI

of iiijlirtve 110111 taiadiiiie", i., slioNN ilk (i he NIld ,v of i.S33 ampuilttion i0Ii~4Idticted by' Cioloniel (hloiii, ill N hiuh there Nwere li:7eS ampuI~tat ionli o1 the lower

ext leinit comnparvid NithI 1.)s'amlthiti(i.0t I e uiIwr)et\tIVI i I Y.

I 1Y far Ithev 1arge-t Iitiiil I I v 4 I.ofaI d IdIteI ev tl4.i e)-vrvd ill t Ile TIu rd 1-.S. A I-iiv.

as ill other~i arili&'., hadil o,~t Ithe iiii'IilkbeL imimiedhiat4'1 lipo4Ji N oliiIii& .ntillliiiib had uteel 'o hadIN iiiaii"1etha OlaR l b~ld otal tNI j iii n oiliipletioli oftthe aitihlitat iiik WANZ the olx practia cLI lilvihod of1 I Real ilviit 1.1)

%%vrI' fori Rilit itllu ill jLttie". w hich otteli ilikohlbed l444Ri4. blood&'iI~ lC'.C

ati lt itt i Ri'e Meic41al (4hhcl.R'% V.o I ivateti I hie l''tivilt, ilk ft-t'.ait

hhidtilCv of a Iht\v ci eil t' hitiehe-I N IlialI-dt41) %, all t'xpihtili " Get iilai Illliek

tha, (t 64 1111 jit 1,i\th 441 tl 11 i1,iail l til l- 144 o )f4 1 1vi'.4'lltt'4 I 4~ c.X iIItt Ivri
326 ACTIVITIES OF -SURGICAL, CONSUL TANT

Ml6 k or, sympathectomy or :that ,bipodvessel anastomosis would effect.a.50i

ent reduction in h e ii ce of amputations for -vascul arinuries, .iiai-ion to primary trauma vcular injuries and clostridial i~nytositpS

ard' ieion indica rchief wprovthey: e t cha if endiations-for amputation in World WarIL, ItsnOtwort t Atthechief cause of amputation in World.War I, secondarytnfection,

wa4sipractically unkn6wn-inWorld War II, inwhich it was eliminated byearly,,

adeat6 debridement, supplementedby chemotherapeutic and antib iotic agents.,

Syipatletic biock was performed routinely whenever the bloo -supplyWaiasiterfered with, but it was not of great value,.as a rule, because the &ol- 'late~al -circulation was likely to have been damaged algo.

Amputation was performed by the open cifrcular technique des c idinCirculiarI.otter No. 101, Office of the Chief Surgeon, Headquarters, ETOUSA, :

3.0 July 1644. Skin traction was applied to effect closure of the stump,

ANAEROBIC INFECTIONS

Clostridial Myositis

During the operational period of the Third U.S. Army, 445 casualties

wvith clostridial myositis were encountered, of whom 258 came to ampUtation.

Characteristically, wounds which produced destruction of muscle, either di,

rectly or by interruption of the blood supply, were particularly susceptibleto,

this type of infection. It was most frequent in wounds of the buttock, upper.

thigh (in compound fractures of the femur), anterior tibial muscles, shoulder

girdle, and short flexors and extensors of the forearm.

In order to prevent unnecessary amputations on the mistaken diagnosis of

clostridal myositis, particular attention was paid to the classification of clostridial infections, as follows:

1. Diffuse clostridial myositis. In this condition, amputation was performed immediately, as far as possible above the visible evidence of infection.

This type of infection accounted for 14 percent of the total recorded infections,

and 15 percent of the amputations, in the Third U.S. Army. The rat. of amputation was four times as high in German prisoners of war treated in U.S. Army

hospitals. The most reasonable explanation of the difference was the greater

delay from the time of injury to surgical care, which was almost inevitable in

prisoners and which was sometimes a matter of days. Once the prisoners were

received, they had the same treatment as U.S. Army casualties.

2. Clostridial cellulitis involving only a muscle or a group of muscles. In

this condition, wide excision of the devitalized local tissue was all that was

necessary. Amputation was never indicated.

3. Localized clostridial abscess. Incision and drainage were sufficient.

Amputation was never indicated.

W'hen casualties were received early, that is, within 24 hours after wounding, clostridial myositis was seldom a problem. It was preventable, in almost
all eases',4e byodqut debridemenit of- all wounds, onie, of t, lie onts 4hichi thel

~5U~ca cnsltntneerf~edto tsi alys to all hospitals.

Onc c6otkil n yositis" ha developed,, there *as, not -i grea et to -be

d&6 0t,:ij ij Iavailable measures -we ei don aouhi, AAMri' thugre emploed, ixicudingifsiot- olniyad teamnstration,. of, penicillin n a agen niot

Te general impresion Wasithat gas gangrene aintitokinwas of littlexvalu,

tlhdughit* ugs ied regulal il he prqscrib64dpoes.' The libpral'use, of pen'l-.

cillin, in doqsages nuch above the ordNPAry, was ilso-routine,ioligh'it'Wa., thoughtthatilhe-whole value of this mneasure was to control'seconda~y' infection

an ieattheatibibti~d'ite efetupoh& Welch' sbacilliik,

Amphittiqnwfs.useflil if it could bepqrorme d disA11 1f theinfection,

was lnte tlh ,*49 waSlmost, never "lifesaving.

Tetanius calli occur in any wound),"rgardless, of-its size anid locAtioii, and4 it

was qute reqentinprisoners of war. It Was practically nonexistent bo-

~ever,, intvU;S., Armny casualties and in thle 'an adianf casualties handled i U.

Afiny'hdspitdls.,sice the Armed, Forces of'both nations had been rnmunized

updu Qiiteinig Service.,

Th&Ariny and,-Canadian casualties received 1 cc, of tetanus toxid sub.

*tanleously as -soon As -possible after wounding., If its administration had not

beeii rqe~rded',bon the emergency Medical tag or the field medical record and the,

Wounded man could not be entirely definite about it, the injection was repeated. An injection ii h aeaon a iven ,b efore manipu~lation or exploration of old anw u t esma o n w s

Wounded A' E'ed soldiers who had not previously been immunized, as well

as all wounded civilians, and prisoners of war, were given 3,000 units of tetanus

anitoxin intramuscularly. Eveni though appropriate tests for sensitivity had

always been conducted before the injection, a syringe containing 1 cc. of adrenaline (epinephrine) in 1: 1000 solution was kept at hand, to be prepared for unexpected reactions.

COLD INJURY

True Third U.S. Army had the unhappy distinction of having in it the

first case of trenchfoot to be reported in the European theater. It appeared on

27 August 1944, in a First U.S. Army hospital unit then attached to the Third

Army.' By 12 October, 25 or 30 cases of trenchifoot had been reported in the

35th Division; some of them, wvhich were attributed to lack of overshoes, had

occurred as early as 6 October.

These cases heralded the beginning of a widespread epidemic of trenchfoot

in early November and a second epidemic, this time in the form of frostbite,

the following month, during the Battle of the Bulge. In each of these epidem9Annual Report, First U.S. Army, 1944.
3028 A1.I ESO'SIGCLcomiuLTATS ~ sj.i'I'I u 

- , '~A

F'ua-w: 52 -AitlicaI lrtoouj if the 4th 1 i~ is.in brilug III eililIiift, Uiiliig li

ic, nip riiii-dr~l.s. kimiid t11i lie large.'t ilil)1T of vases inl hie theater. A

tliil-l epidvelic, ill FehritI;I Id. iooklhe torinlo (iftrenchfoot.

'The "tory of (-)ldl inil- inl the Eittopetii TIheater of O)perat ion,, is told1 inl

de~tail ill another lolumie inl tilis serie".1 ' It lived not he repealted here, though

it Should( be 'aid t hat tile Third U.S. Armoy, which aloi" N itli thle Fir-A, U.S.

A 1.11n had the laig'e~t numiber of cae. of cold injurY inl thle theater, also had

Ihe Ilea vie"'t and uII o4 d i flic Il t coil at li"'i ,iiI IIII III . Bloth artiies ak.o Niff1ered

fioiii *.hoit'tae" anid act tl llick. ot prioper 1)1otect ie clot Iii itd Iootgear dtiiin"). tilie Nvor-t of tilie Winter Weather. Thle N ititer of 19-14--45 %%ls tile ino ,t.

severe ill "~es en Euirope inl many yeas, (fig. l'2).

fin addition to tlie elierget ic pre~ cut ve act iol takll bhle Chlief Sitrgeon.

1101 SA. several irect ive., onl tile Ithjvvt of tile pI e,(eI it ioI of c-old iinjutry

werle i uIled frot th le ol ice of tilie Zii rgeot i of thle Th ird 1'.S. A-IN i v.(etie T ta

Il:ittot I ,pp)ort tl and1( par It IcipatiOli I. etcl~ CI aractIerkit ica -~ g o I oItI". Ilk. recogiuized ait once, that this~ '%lu ll coiiiiaiid re-ponl~ibililtx ad 'tated 1Iinequi~ ocallyN

t hat (lte excelive dev-elopmiient of c-old injIur- *iii III. organi/at ion iii tile 'Ihird

AHIiv \\otIld he IT-ll-ided 1.a iildiClit iOn Of j1iMnleipuite -ilper mli and conitrol.
-THIRD TS ARMY 39

' Q 21" Nd r 4in-resonse to. a command directive issued by Lt. Gen.

Om" r O . :~radley, Commanding, General, 12t Army Group, General Patton

made he bunt ta~mnt that tecurrent menace w~s not -the German, A'm,

.hichthe U;. Arm had practically destroyed, butthe weater, General . Pittn htatd .further that, if they.did not exert thehs1ves, the weather might

*flt ddtroy. them ithrough' the ,-incidence of tkenchf69 t is-not~surprising,

th& *inthe first ePidemic of' cold injury began to lessen inintensity, the most,

.precipit~oukdlinie ii iiicidence was in the Third- _$S.Army.,

The questmn of .whether or not the Purple Hearit should be given for trench, 166t- did-h6t. arise, in the Third U, Army, General Patton smply directed,

D iurmig the fall and winter:of1944-45, admissions for coldiniury requir d.

W ghrge qeqocupAnqy in forward hospital And an 6nprmo6us amount of m~edical

&ttention nd nursing care, io satisfactory treatment Was ever devised, and

th~ medical,,pi6blemswere almost-as serious as theoloss jn manpower. When

the oerlrmiiig.o Ievacuatiqn hspitls with this typeof ca suaty becameeviSdentan Army clearing company was instfuqtedto.set up a cod injury facility,. to whichtiny patients inthe army area were evacuated. This installation, 4at

-'le st to some degree, removedthe pressure from Third U.S. Army evacuation

Inaddition, a company of the 94th Medical Gas Treatment Battalion was

designated to receive from other Third U. Army medical -installations certain

casiualties 'Whose cold injuries were mild. These patients Were held for from

10 to 20 days to determine whether they could be returned directly to duty within

the army, area. In a significant number of cases, this proved possible.

EVALUATION OF SURGICAL CARE

One of the chief responsibilities of the surgical consultant had to do with

ways and means of improving surgical care in all forward medical treatment

facilities. When he visited a hospital, after he had talked with the commanding Officer and the chief of the surgical service, it was this consultant's practice

to make rounds with the latter. On these rounds, questions of clinical policy

were thrashed out, and the care which individual patients had received was

evaluated and corrected as necessary.

Constant vigilance was required to insure that surgical directives were being

fully complied with. The adequacy of debridement and the splitting of plaster

casts, for instance, could never be taken for granted. Even during the last

month of operations on the Continent, when every medical unit in the Third

U.S. Army had had several months of experience in the field, it was necessary to

continue to emphasize basic surgical policies, in order to avoid occasional slipups during rush periods.

One of the best ways to evaluate the care which casualties were receiving

in army hospitals was to check the condition of patients ready for evacuation

in holding units, as well as at airstrips and at train terminals (fig. 53). From
330 ACTIVITIES OF SURGICAL CONSULTANTS

FIGURIE 53.-A hoIdin,,, unit inl tile chiain~ of anr ev anuation. As a rule, the.,e units

Nvere op)eratedl by ineiical gas treatment battalions.

them, it was possible to get all overall idea of the type of surgery performied inl

the hosp1 ital units feeding casualties into these points, iu well as to spot errors

made by particular hospitals or by indlividual :,urgeoiis. When error's were

discovered, thle hospital respoitnible w~as prompl 1 tly ntotified, or thle iitdii idual

case was traced back to tlie surgeon responsible, not to reprimand him1 but, to

prevent a recurrence of the err-or. Errors were remnarkably infrequent, and

care was generally onl a very high level.

Observation at evacuiation points also inale, it po.ssible for tile surgical

consu'tltanit to keep t e armyi sttrgeoil ilforitiedq of tile condition of pat jents about

to be evacuated to g4,eneral lhospit als inl thle commliunjications~ zone. It iva. soon

learned, incidentally, that it was essential to stat ion a sltn(1Lonl with sound

slulriical judgment and cons~iderable experience at all holding iiunits and ei actiatioji points i t lie best interests of the paitients were to lie sevrved.

A r-elort to thle siur-aical. consultant by 'Maj. IDudley ,WI. Smith, MIC, based

onl 500 case , collected at the 94th General H~ospital front thle Fir~t, 'I'lliird, and

Ninth U.S. Armies is anl excellent 61unnnlarv of tile errors " hich had to be

avoided in forward ho.spitab, inl the nianagetlenit Of w Ound-, of the ext remities.

'['le essenitial error,. all of withich attvested the paramiounlt imlportanlce of adequate

inil surery ill tile combat Zone. wvere as follows:

1. *Wounds sometimes could not he closed either becalize thle\- Contained

dead muscle and dania-ed fascia which had niot been renio ed at initilal, debrideument or because they had been blocked by heavy ptotu-ipeiatdgauze

wicks or improper drims.
R ......

,,: :, 2., Casts were sometimes not completely split, and' sheet~wadding was occasoay-not.sp it'l.

3,Eft efiti~g 'i which: vascular, ijuries were associated with, bone, andl joifinjuri t e hr d sometimes not been correctly immobilized during

transportaion;,..

1 4. mnafew-instances, all foreignbodes i oits had not been removed . S5., Somie~patints subjeeted to amputation were grossly anemicandneeded. ,

he 6 The e4xitence of ,nervelesions and skinlosses-was not always note&on.

The.. 4ie, a 6f'tliis sort of specific report by a competent forward-surgeon:

f ajor(MaoSlmith was assigned to 'the 4th Auxiliary SurgicaliG roup and was- on .

detadhdd'rvi e with the 94th;GeneralHosptal)is toobvious to need helbor.- . 'ation. It'was certainly one of the bet possible.waysof identifyig errors and

hav: them orr te• -CONCLUSIONS

The mostnimportant lessons 'in thecare of casualties learnedin ThirdA uS.. Army hospita s duringthe campaign in Europe may be summarized as follows:

-E, lslled i care of the Wounded, asnear the front as possible, con

i lusiely proved its worth. Such care can best b, provided by proper triagel'

with div-ersin of nontransportable casualties to the platoon of a fieldhospital

s taffedby ,tained surgical teams and located in close proximity to the clearing

2. The staffs of evacuation hospitals should also be supplemented by surgical' teams to accomplish the rapid treatment of battle casualties and the return

ofso!idr t, duty in the Army area.

3. Suigical teams were of great value in providing medical support for

armored divisions and in bridgeheads across rivers, when prompt evacuation

o f the woinded was often impossible.

4. By the use of these methods, it was found that definitive, lifesaving surgery could be accomplished much farther forward than had previously been

realized.

5. Adequate shock therapy is founded upon the use of stored whole blood,

with plasma used only as a temporary expedient until blood is available.

0. If resuscitation is not accomplished promptly and adequately, shock

becomes irreversible. Profound shock was apparently the single constant

factor in the fatal anuria observed in battle casualties.

7. Infection can be prevented by early, adequate debridement, supplemented

by routine parenteral penicillin therapy. The local use of sulfonamides proved

ineffective and often retarded wound healing.

8. Extreme conservatism should be the rule in respect to amputation,

though injuries were often so mutilating that this policy was completely impractical.
32AtiYJTIES Ors 8UOCLC6 SULTANTSt

9.The repair of damaged blood xvemeis *as no feasible as a routin6.policy

'in forw ad hoptasin World War II. 'It should,,be, practiced' howr, i

AtM th9et, gangrene is lilkely to develop in, about half of all yascui irnj uries,

though h rprini saler in the small grou~pAo casesi hc eari

consdere fea ini psi

10. The siolutiionot the prolem ~of c-old, injury -is ~proepetio~n by the pr

vi1ofpoe thing and footgr and, by effec tive commndicpne

Oncecoldinjury had -develope, no method'of treatmnent was found reall

The mxoraile of troops is greatly-enhanced- bthe feturn of wound.dinnto,

dyinter own unit.Ti aritepoiynth ThrdUSAryan

onewhih aid largb diVidends.
CHAPTER'.XVI

Rq~~)'~ . Sydr, MAD

Secdin i. Administratve and, Related Cnsiderations

APPOINTMENT OF THE SURGICAL CONSULTANT

The- appointment 0f Maj. (later Col.), Howard:MSnyder, MC, as Con,

-sutant,-mSuygery to the Surgeon, I Corps, and later to the Surgeqon,Fifth... . S US. Army (fig. 54), nitiated 0he consulatit dystein field armies in World,

I W~ar : 'Hksappintment sI , came about, howeverby a sriesof almost fortut ciicfrounstances.

Obs rvations in the United- Kingdom

MajorSnyder was assigned -to the thoragio Surgery section of tfe 7MW

EvacuatiiZospital, the.affiliated'University of Kansas Medical Sdhol unit ,

which,, after cpompletion_ of -its basic -traning at Fort Leonard Wood,VMo,,

Was sentoE'ngland, where it arived early inAugust.1942, At the suggestion of i Iarold Gilies, then -head of the plastic surgery services of the EMSo

(Emrgency Medical Service) in, England, he requested permission to~ggoto

Londonto obsrve the work of Mr. A. Tudor Edwards, who was head of 'th4

thoracic surgical services Of the EMS. Similar permission wasrequested for

the other members of the thoracic surgery team of the 77th Evacuation Hos-

%'.lInless otherwlse indicated, data in this chapter were derived from the following sources in

addition to,,the official diary of the consultant in surgery, Fifth U.S. Army: (1) Fifth Army Medical

Service :History, 1944, (2) Fifth Army Medical Service History, 1945. (3) Starr, Chester 0. (ed.):

From Salerno tthe Alps. A History of the Fifth Army, 1943-1945. Washington: Infantry Journal

Press, 1948,..and (4) Medicine Under Canvas. A War Journal of the 77th Evacuation Hospital.

Kansas C1ity: T-e Sosland Press, Inc., 1949.

'Dr. Snyder, a graduate of Jefferson Medical College of Philadelphia, served a rotating internship

at the Pennsylvania Hospital and received his surgical training under Dr. John H. Gibbon, Sr., at the same hospital. His training was unusually comprehensive because Dr. Gibbon believed that thoracic

surgeryi urologic surgery, gynecologic surgery, and traumatic surgery are all part of general surgery.

Dr. Snyder's surgical training was completed under his father, an expert general surgeon, who could use a cystoscope as dexterously as a bronchoscope and who, like Dr. Gibbon, believed that general

surgery covers a wide range.

The 17th Evacuation Hospital, the affiliated Reserve hospital unit of the .. _,al School of the

University of Kansas, was organized in the summer of 1940 but was not activated until 10 May 1942.

Dr. Snyder was commissioned in the rank of major and was assigned to the thoracic surgery section.

He was promoted to lieutenant colonel in July 1944 and to colonel a year later.

Colonel Snyder is another of the many medical officers whose excellent civilian training and com- prehensive experience could be immediately adapted to the responsible duties they were called upon

to assume in World War I. In his service, his broad general training peculiarly fitted him for the

duties of consultant to the surgeon of a field army.-J. B. C., Jr.

333
334 ACTIV;TIES -0' SURGICAL ,CONSUILTANTS-'--'

pt1One of the. membe rs, Capt.(ae a Wendell. A.. Grcean,- MC,Jws,

a geeral surgeon, ad the ot her,Cat(ler1a)HrwnJBon C

1k was Mr. Tuor E-dwards idea th-at this team should spenid 10l day 1wt

pinL Lodon, 4 ek t h oto M 'hpt~tEpsom,~n addi

Suyderi, dO Consutant 'In-,, Sr.,

ger- to the ureo,)ttUS

th nainof North Africa -wasimietwe thyiooialyubcuo

I~itedthreor, f heapproximately 10weeks ofobservation and, training

brigially proposed, only dascould be devoted to this purpose

-While arrAnrcillents- for this tour Of dut& were under way, Major, Snyder's

~inio-was spent very profitably. He came to know Mr. Ronala, Belsey, _ the

liead'df the thoracic sIurgery-service a~t Clhe Kewstoke EMS Hospital at Westonsuper-Mare, near Frenchay Park, where the 77~th Evacuation Hospital- was

located. Mr. Belsey had completed his traininmg in thoracic surgery under-Dr.

(later Col.) Edward D. Churchill, at the Masachusetts General Hospital, B3ostonl, Mass., as well as elsewhere in the United States.

The British at this time -were quite short of medical personnel. Anesthesia

at the Kewstoke Hospital was in charge of a pediatrician, and Mr. Belsey had.

no surgical assistants. He was therefore delighted to have a surgeon to help

him, and Major Snyder took advantage of every opportunity to work with him.

M ost of the chest surgery at this hospital was secondary surgery, on old wounds,

but a certain amount of fresh work came in irregularly.
FIFTHUS. RMY 335",

,T hetur of chet sirgery centds and' clinics began with 3 days' observation

of fM. "wrdrs,' worki Partof the timewas spent at the Brompton MhspitaI.

in iLonidoiiand part ,at the King Edward VII anatoriuin i Mihurst. It was

S ,reveleationta thorae sureon, who was used to the elaborate-setup and

tea mw r~,f.Jackson Cler,' and Tucer -to observe- the performance o., , bichsoipes jn an operatng room which had- ieen setup correctly but in,,,

... *hich~ r ok n q:. ther .. pxA ,ewor . .e.. nosrgcl . assistants ,no nurses,' an noatnanso0n . .

kind.itnans fny'

! jpr Sinyder and his associates next visitied the Horton EMS Hospital,

S wh0ee theyJserved~the-work of Mr. N. R. Barrett and Mr W, , P.Cleland,

r.... Bai,, a t, jnl dn q4 fO his work at this opia, 1 frequently served asicn- n

lsult an<in!thrcio atyariius.hospitals hsurgery in Wales. The US. surgeons watfc~dtfri ad~ther~associates in the operating 'surgeons room, made rounds

iiti them ,studied, their -preoperative and postoperativ!e care,, and nattnded

thi ideences. These conferences, at which cases were discussed,,roentgdno-!

gram~s showijn '41pl sigery co0vered, were pAitiirl y~ 6$'if bindag"hse"ofeorcc u

All, o ftheBritishsuygeons were uniformly courteous, hospitable, and-gen- oftheir experience yincluded,:in addition to those

already mntioned, Dr. Clifford Hlyi6, gr. C. P. (later Sir Clement) Thomasp,

Mr. .-(lit r SirRussell) Brock, and Mr, A. R. Hunter, The anesthesiol0;

'gst at the'hospitals visited, Pr, M. D. Nosworthey andDr. S. W.-Magil,,were

~lhl~yC ouis and hielpful,

'The information obtained from all of the hospitals visited proved of great

value when, combat-incurred injuries of the chest were encountered in North

Africa a few weeks later. Perhaps the most important lesson learned was the

value of early and repeated aspiration of hemothoraxes without air

replacements.

Experiences in North Africa

Two weeks before the 77th Evacuation Hospital sailed for North Africa

on 1 November 1942, it was assigned to the II Corps, Central Task Force. Col.

Richard T. Arnest, MC, was corps surgeon, and Maj. (later Col.) William H.

Amspacher, MC, was his deputy (fig. 55).

The hospital debarked at Mers-el-Kebir on 11 November 1942 (D+3) and

immediately took over the civilian and military hospitals at Oran, 12 miles

away. As no transportation was available, Oran was necessarily reached by

hiking. Chaotic conditions were found at both the civilian and the military

hospitals. The patients, including the military casualties, who had been in

charge of French interns, had received little medical or other care. It was a

rather terrifying introduction to combat surgery.

On 24 November, the 77th Evacuation Hospital was relieved of its duties

in the Oran hospitals and moved into tents (fig. 56) in a red clay vineyard

about 31/ miles south of the city. Here, patients from the immediate area
36( ACTIVITIES 01F SURGICAL CONSULTANTS

I

F.1' 55,11~ Cor-!I 'ips mledical olhicei s. A. Col. Richard T1. Arnest, MC, Surgeon. It. Lt.

Col. WillIiii 11. Alnsiaclier, M.NC, D eput y Surgeon.

Were treated inl ward tenIt s, and boat load(s of casialIt ies, c Iiiel lBritnili mounded,

wvere occasionally receiv'ed fromu A lgiers.

Sincve thle li ent load1 was 1n0t enough to keep the hio,it al A~ta ffoccupied,

Major snlyder (Oil the vaulsugg-est ion of all Air Force inedical officer who

had (delivered patient s to I le iosI)ital ) reqiieted periio1 to observe lite N ork

of thle teain" of the -)d Auxiliar-Y Surgiceal Group which had been attached to

hie Briti Easterii Task Force and wvere, thlen working inl the( British Cottagre

hospital at Alirs 'erI-lissioii a at onlce gratted, wvith thle understandingi thlat M1ajor Snyder's ob:-ervat ions m~ould be reported Onl his ret urn. ThiWas (done (p). ()

Onl 20 J anuarY 1943, thle 77th IEvacuiatioii I [o.pital was moved to all area

south of T1ebe -sai Algeria. Onl 1t Februar-y, it Nwas alerted to receive ca.,lualties, fromn the breakthrough at Kw~seriiie Paus, and w it lii S hour., it had

rented 1)o. The tactic-al situnationl thlen requiired t(lie renioval of tie hios'pital

to thle ievai. The mlove w~as eonlilletedI !in :.11o" altid freezing t jelliper~at iii dii--

ing thle ight, and by dawnvi 4SO aiddit ionial p~atiet, had beenl received.

Appointment as Surgical Consultant, II C'orps

Onl 1.) March 1943. Mahjor SnN dler reported Onl teiil)orY dulty to I I C orp.'

hieadqujart er, limear Lebe .a. w ith Iiiiit ctioii. to exvdlilate t like ul:e of siliirricil

teamls inl cearing -t at ioll. For lhi, i lipOwC. lie traveled with Ci(olonel
FIFTH U.S. ARMY 337

FIGURE 56.-Operating room, 77th Evacuation Hospital, North Africa.

Ainspacher to various corps and other istallations and also spent 6 days at a

clearing station stalled by the 1st Platoon, Company D, 51st Medical Battalion,

whose intrinsic personnel was augmented by two general surgical teams and

one shock team f rom thle 2d Aux ilIiary Surgical Group. Various reconimendations were made as a result of this tour of duty (p. 369).

Shortly afterward. Col. Edwarid D. Churchill, M1C, ConsuIt anit in Surgery

in the Office of the Surgeon, ,NATOUSA (North African Theater of Operations, U.S. Arnmy), suggested to Colonmel Arnest, the Corps surgeon, that Major

Snyder be retained at Corps headquarter., in time cap~acity of surgical consultant.
:"''•• -' 838 ACTIVITIES OF SURGICA L CONSUL TANTS:

Colonele Arnest at first hesitated to act ,on tie suggestion. because the headquarters table of organizatoin had no provisin for such a ,positio v entul)Y, hoeeoplonel, Arnest appne arSyershi'p fnl,

servce ffier;thogh is uties- were ponfinedto suIrgery.-

Major Snyd r remained withoIl Corps'lieadquarters,though he was not,

formali assigned toit until just before the,inyasion of Sicily on 10 Juiy 1943.

He.went ashore with the invading troops on D-day, at H + 8.

Appointment, as Surgical Consultant, Fifth U.S. Army

The Sicilian campaign ended on 17 August 1943. On 26 September, Major

' nyder -received orders for temporary duty in the Qffice of -the Surgeon,. NATOUSA, in Algieis. On his arrival, he was informed that Brig. -Gen

Frederick A. Bless6, Surgeon, NATOUSA, was then in Italy with Col. (later

Maj Gen.) Joseph I. Martin, MC, Surgeon, Fifth U;S. Army, and that i was

Gener:ai Bless6's intention, on Colonel Churchill's suggestion, to ask Colonel

M artin whether he would like to have Major Snyder as surgical consultant !or,

thsFifth U.S, Army;

On his return to Algiers on 5 October 1943, General Bless6 reported that

Colonel Martin had willingly acceded to Colonel Churchill's suggestion.

Major Snyder was ordered to return to Sicily and join II Corps headquarters,

which was then preparing to move to Italy. After overcoming a variety of

transportation and other difficulties, he finally reached Fifth U.S. Army headquarters in Naples on 11 October 1943. Until 19 November, while still assigned

to II Corps headquarters, he acted as consultant in surgery to the Fifth'U.S.

Army. On this date, his permanent orders were received. He continued to

serve in this position until 1 October 1945, when Fifth U.S. Army headquarters

disembarked at Boston (fig. 57).

As this account indicates, Major Snyder's appointment as consultant in

surgery, Fifth U.S. Army, developed by a series of chance circumstances. His

appointment was the prototype of the consultant system in all U.S. armies in

World War II.

TACTICAL CONSIDERATIONS

Sicily

Major Snyder, who had been assigned to the II Corps as surgical consultant (p. 337) shortly before the invasion of Sicily, landed in Sicily on D-day (10

July 1943) at H+3, with the 261st Amphibious Medical Battalion. He was

in the first group to go ashore from the U.S.S. Samuel Chase, on which this

unit, with its headquarters, had been transported. For some reason, never

clear, the headquarters of the unit was landed 4 hours ahead of any of its three

companies.

The first casualties on D-day were handled by the Navy, in beach stations

set up in each of the six landing areas. The stations were set up promptly, and
Ftum Ei- 57 D .. G3en. L~ucian K. 1'riis-tt .J .. Coininniidiiig (,viivi'a1, Fifth U.S. Aril3',

vo~Itiiat ill, Ll. ('4t I1uvm .in E. siil itt, .11C Cuiislilitnii ill slirgvr' . Fif1th I .S. Aiiii ,

after iiw a rd lug him n the Lvjoln of Aferi for exceita lly ilierit uriou. ,enic~ e ill the

pierformnce of his (lot ics.

t ei a pe iiolthe (i~ilt exidlnt N o ll i ti l" i 't a d ila it" 11 h i

('onpanY C of' tile 2(;1IN Aiiiplliioil Medical Bat talioni landed, as

p~lainned l. O l-tlaY at If-, 7, but withlotut it., equiiliit. It set., tip a 'tti olt

N\ itli the veulapiiaett of'( Compll B. Il mlio~ pvi~oiiiieI \\vrv not landed linti iile

aiteiiuooii of Ilie niext (1:1\ A Ilumbiler of, othler 1iiiit., exptrieticed -iulili dili-

(-tIt ies ill t it, I tidiiiofUl tI eqipIIvIi i \\iI to I lIItI peis o I I IIev or ite eI Ia. bIt t v\ ac nIat ion of Casualties (Iig. o5) to tile lbeaclie. and t lietice to t[lie boat ' pio'ed

with Iinaiitlkabtl\l. littIV (oiifiltzioit.

01n D-, 2. the APA', (t Iali1)ort-. attack) and XA PA", (ex peiiieiitll

A\ )A.\f) mu-lied 11iiloadiio, anld leitl the bhini. llieiea tter. all cnltillii

this, area lece iked initial care eit lieu In flt, clvaiiio stat ion oftl( the Al dical

Blattalion w itk Ill-ical teaii- attacliei or iii ( omipiiii A of tile 21.14 -kiiipilioi., A'ledlical Baittalioii. bh)tl of w liich were corps lltnitN.

)n l 3)- ', two platooii, of tile 11thi Field I lo'pit al iegihli to receive anld

hold va-lult ie-. moi tie '):)i Evacutatiotn Ilo~Jpital lbegtii ito function i l I) ', G

Th'le IEhiIcuiuittioti Ilo-pittil bad lieen laulded i I) - 1. lint1 it- eqniiliin (iltd

not liegili to arIrive ttnt il -2 dttv- later. and it \\as 1) -, 1 before all of' it N a-,

reei ved.
AA teftr Iledcal 1 - . -v ic prblem\\a toprmidesup ortfortrop.-

N\Il(.I p r'lin'a %\~v I~lvaill. vlvi .Th * i o f h rbvn\ ,th

11e lo f ll- l f fi ld ll' it l, -(t11" 11 ,I Ip o to (i II -. l la il

Suaiicl (ll MIti IP. 10 )\ \ P 1 lilb i l lm ,1r m Ii d A IiiI.
Wounded. Sturgi.cal care in theplatoons oftlefield hospitals was prompt:a .. '

excefit .'. 'Wen4e diision clearing station moved forwardi thfield'hspit a1

p !at~onJede • it was closedto admissions andserved asa holCding-hospital fr , os-p"ri.a i h -another platoon came forward a dset up glongsJde

o the divi~ion clearing station As a: result of these arrangements, the medical''

caresuppliedwas up to that time, the -besiin the theater. The nontransport.-

a I 'casulies of the I1 Corps received initial- wound surgery within ' to, 2,

Excellent surg!ia cdar9 was: al§oprovided for transportable casualties at

evacuation hqspitals The400-bedsemimobile evacuation hospital pro6ved-to,

'be a satisfactory and practical unit. One reason was lat hospitals of tbii

size couldbe moved rapidly into new-locationus, a policy which proved necessary

at Ifreubnt intervals during the fighting in Sicily.

Italy

TIhe Sicilian campaign ended with tle fall of Messina, Sicily, on 17 August

1943. On'3 -September, the British Eighth Army landed on the toe of&the

Italian Peninsula, and 6 days later, on 9 September, the Fifth U.S. Army

landed. at Salerno, south of Naples (fig. 59). Italy surrendered the same day.

Naples -fel to the Allied armies on 1 October, and 12 days later, on 13 October,

Italy declared war oni Germany. The Germans were slowly pushed up the

Peninsula until 3 February 1944, when they forced the Allies to a standstill at.

Cassino, on the Gustav Line.

Meantime, on 22 January 1943, elements of the Fifth U.S. Army and other

Allied troops had made a landing at Anzio, south of Rome, with the expectation

that union with the other Allied forces in the south would occur in about a week.

It did not occur until 25 May, more than 4 months after the invasion (p. 410).

Rome fell on 4 June 1944, 2 days before the invasion of Normandy.

All through the early summer of 1944, the Fifth U.S. Army pursued the

fleeing German troops. The medical problems of the first months in Italy,

which had been the care of casualties while new hospitals were being acquired

and inexperienced medical officers were being trained, were now exchanged for

the problem of keeping hospitals near enough to the front to receive and care

for the wounded.

Concentration on the events in the European theater often clouded the

realization that fighting was also extremely heavy in Italy. German resistance became increasingly strong as the summer of 1944 adN anced. As an illustration, Rosignano, a small town on the road to Leghorn, was reached on 4 July.

The southern third of the town was occupied on that date, but the northern

edge was not reached until the evening of 7 July. Even then, the enemy held

houses on the outskirts of the town and in the country immediately behind it.

Leghorn fell to the Allies 18 July. The last 20 miles of the advance to the

Arno were extremely difficult, and there were numerous hard-fought engage-
3 42 ACTIVITIES OF SURGICAL, CONSULTNT

~ ~ NAPLSF~ 21~4004,

'N d ~~AN712 0 14

lei

FiE 59.-Camp~aigns in Italy, 9 September 1943-8 MAy 1945.

ments because the Germans were trying to delay the Allied advance until their

fixed defenses on the Gothic Line were completed. This line was to prove even

harder to breach than the Gustav Line, which had held the Fifth U.S. Army

below Cassino so many weeks during the first winter of the fighting in Italy.

After Fifth U.S. Army troops and their supporting medical installations

had been withdrawn for the invasion of southern France (p. 396), the army in

Italy underwent considerable regrouping before the North Apennines Campaign was launched on 10 September 1944. The drive to the north came to a

halt with the heavy rains in late October (fig. 60). Enemy resistance increased,
6"lrin10.- 1>" acuttioIi hospital ilk Italy duing (he \ svt stalu ill the fall of 111,

antd supp] -lv route, mer II.,o cloggi.'tl x1\ iti moild t hat t he.% NN vrv altiio'li iliiipik-,al.

Th'le adA alice A as not imattijed tititil th il idd~le oii A pril t he fIll)N iin x at

W le I it Nv. Is ,I1o p] l, t Ie fo r\\ a 1 d I rok ,' c I IlItI "Ve I Ilkv Il ob ject ii I~ o Io' tI I

Nwas lbatl v 1) air' liiilve aw\tN ill thle ceter. aiid tihe Po ValleN \\a., oil].\ I 1iiiles

a1wav oil t he righlt flank.

11i1uteriziti'y of hiosital ill"ialtioii, N a" dehua ,ed bvcatil. oil a tutuohetr

of occa,,ioll., afihet ilit, tiii to tlit, tio-tli calki to a halt, it \\&, thol(Itlt that allother attack Nwas to be. haunched. Oil at llaIt ((tie occaioti. ( lt-t lina EK~c,

hIc~pla] liit" 1,ere iiihitiiied dhat the (htixe Aw lud ta that iliilit. butt a te\\

1ioti, later N otd m a, rele i'v eli ~ourier that it had a±-aiti bveen postipmted.

plot idew mooden floor,~ for the' l1o 1 jta illit ill llolll1 pll)lilied Amlie, to kevep

\ ithe 1elhoiielllb 'A al alit1 dlerltake 'mu 011 illl w literltittij. 1t, \%a

pol'.il e.

eitboug l iel Na~ , oact xe, offeiix due ltt -I t kv illel \ of 1911 1..

tile 'it Itatioti W a~ l, (et ettiei 111 tt C 'al-I. ill l'ehtiax al.. for inlalne.

ti (tll nd tte -xeia dllilatiin" Ill]!-. A\t allowt t11e .atie titme, dwi 11bt

ITe- e atnd other alt ion-. evenl ill thle ab-euket oIf a latge--cale ollewix . protitetI temipot-atilYv ti aNt altall lot for ."fIti IS. Arnmy h ospital'. ill
344 A~~~wivansIE OF~ S4URGICAL CONSULTANTS

II~tH.(I AJ~II (1 L~4)1llcihy aite t tI uii-Y i iIn dirn

i~oite ~QI t ui~i cd'ie e~Auaan o isd1 fIlanlI suvIIl'i-

~vIs.~ 7et i c ujr riaIi~ce l luli
-dd ti6ii to thenisual flow of casualtieswhch was small but continuous; The

t" .. : dac~tion H~pital, wikc had been set up at Pitramala-and' hadbeen,

lP*~ghy wnteizd, ~ecive th lrges , numbers durig-the first*3 months

of 1945.

lDfigthe win ermbnths.of 1944-45,it was the policy to move casualities

w ith ijuries directly roin the installations at which they had received

Witi *'Wund .surgery, whether field or evacuation hospiials, to either the 24t

0664ifabspital inFlorence or the 70th General Hospital in Pistbia. Casual-!

6 hwitless serious injuries were evacuated to base hospitals in Leghorn and

The-LcAmpaign for the Po Valley, the last campaign of the war in Italy,

abgan i 4 April 1945. Bologna was captured on 21 April, and on 2 May Ger.

nin troosin Italy, with those in southern Austria, surrendered uncondition-

'Medical planning.--Medical planning was progressively better in each

campaign-in Italy, and the planning for the terminal campaign resulted in

bettor ifiddical support for the troops than they had ever before received. This

excellent-record was achieved in spite of two difficulties, as follows:

1 . Thd casualty load was greatly increased. The medical service, though

it had never received adequate increments to replace the trained personnel which

it had been obliged to surrender for the invasion of southern France (p. 396),

had to care for Brazilian and Italian troops as well as troops of the Fifth U.S.,

Army.

2. Frequent moves were necessary during the last weeks of the fighting, to

keep up with the advancing Allied forces. All units, including medical units,

were ordered to reduce their equipment to the barest essentials and to employ

any improvisation which might increase their mobility.

Colonel Snyder's participation in the planning for the final campaign was

more intimate than in any previous campaign. He had access to all tactical

plans, he was consulted on all points which involved medical planning, and his

advice was accepted concerning the placing of field hospital platoons and other

administrative matters, as well as concerning the staffing of the medical units

to be committed.

The Anzio Beachhead

For a variety of reasons, the most serious medical problems encountered in

Italy were met on the Anzio beachhead (Operation SHINGLE).a The operation was planned to weaken the German Gustav Line, which was holding the

Fifth U.S. Army forces in check at Cassino. It developed into a holding operation against a numerically superior enemy, the outcome of which, on at least

half a dozen occasions, was decidedly in doubt.

Special medical planning was necessary for the Anzio invasion because

shore-to-ship evacuation of casualties would require closer and longer coopera3 Bauehspies, R. L.: The Courageous Medics of Anzio. Mil. Maed. 122: 53-05, 119-128, 197-207,

267-272, 338-359, and 429-448, January-June 1958.
':'° " ,346- .ACTIVITIESOk SUAGICAL-CONSU

ion pbetween the Army and theNavy than had previously been necessary The

o~isf~t ho plaiiingywhich. was,.well reheatrsedctin adance -'the oyrlyrj

retuirn ofcasualties tlie:beaches and their transfer thence .to'shps, Itwas

dieto General Mairtif's foresighlt and carefuil plaihing that the medical op~ra,

tWon,,i Spiteof all the difficulties which attended .iticontinued to be.efient ii

.Ligndng&'-The initial stages of the landings went off remarkably well.,

The landing, which was apparently a complete surprise to the efiemy. was

effeWd without resistqnce, and by noon of D-day the VI Corps had reaced Its

prliminary objectives ashore. Medical units were put ashore many hlours ahead

bftlihe estimated times, With- ample supplies (p, 3914)., The 2d, platoon of. the

33d Fild Hospital, was landed at R+ 6, withi attached surgicai and slhockl eams

from the 2d Auxiliary Surgical Group. The Ist and 3d Platoons of tlis0,liop ital were in the bay but were not landed until D+ I because they wore 'not

needed earlier. Casualties were less than 1 percent of the troops committedin

the landings, instead of th6 estimated 12 percent.

The campaign.-These satisfactory conditions continued for only a.bput

48 hours. Then the tactical situation worsened, and the medical situation along

with it, The light bombing raids on D-day increased in intensity and thereafter were a permanent part of the picture. Hospital ships were bombed in the

bay, and one of them, with 75 patients on board, was sunk. By 1 February,

no area was safe from enemy planes. Practically continuous bombing 'and

strafing of the beachhead area were punctuated by heavy attacks at intervals.

The original locations of the hospitals which had landed on the beachhead

promptly became untenable. They were relocated in open terrain, as far as

possible from military objectives, but the best this could be was not very .far,

for the beachhead was only about 7 miles in depth. There were no functional

distinctions between field and evacuation hospitals. Both were practically on

the frontline. There was no protection in depth from enemy fire. Antiaircraft

batteries, ammunition dumps, an airfield, and other military installations were

of necessity located on the edge of the medical areas.

Since enemy fire could reach every part of the beachhead, casualties were

heavy. The 95th Evacuation Hospital was practically destroyed by bombing

early in February, and the 33d Field Hospital was also heavily shelled. There

were heavy casualties after both incidents. In addition to the wounded, 4

nurses, including the chief nurse and her assistant, 2 medical officers, and 16

enlisted men of the hospital complement were killed at the evacuation hospital,

and 2 nurses and an enlisted technician were killed at the field hospital. It is

doubtful that the medical installations on the beachhead were deliberately

bombed. They were clearly marked, as prescribed by the Geneva Convention,

but it was practically impossible to separate them from legitimate military

targets. The bombing of the 95th Evacuation Hospital was definitely accidental. The pilot of the German plane jettisoned his bombs when he was try-
ng- to escape British Spitfires. The plane was shot down, but the pilot, escapd

466661-eniel ,ina lived world of unpredctable vilence, in wh',-med-a persondl shared. Most of the damage and casualties -were ,

ki~9db artillery fre, but on-one oco, iqni February "German,

tank:,lii6st boke :through to the hospital aiea. It was not unusua afr. ..

piatient-to',hiae to be ecuated :from ong hospitalto another, sometimes with.

attndants "ntinuingtrans'fusions 6nroiteone holding the bottle while -anotheristeadle the-needle.

Had It not been for the -0-,yeqr-;old wine ceaves on -thd'eachhead, Ahc

served,1i Wbi'ets, headquarters,,and qther purpOses, casualties oould undoubtedly ah ve en much: heavier, In March, after the soil hadbegun to dry- out

frofm the ncessant rains of the winter, the medical services went underground

(fig.62)Excavations were pr 84 to a depth of 1/2 feet, with revetmenitsarhind them, andsandbag baffles were placed around double ward tents. Sheet

meta wa placed over pyramidal tents and-covered with sandbags. Patients,,

nurses,-and: medical personnel on the wardswere thus fairly well protected.

Operating rooms Were similarly constructed and protected. This was most

important. Previously, when an air raid warning had sounded while an operation was in progress, the personnel engaged in it had had no choice but to continue with what they were doing. With the protective measures now taken,

only direct hits need be feared.

Evacuation-From the beginning of the Anzio operation, an attempt was

made. to care for all casualties before they were evacuated by LCT's (landing

craft, tanks) and boat ambulances to hospital ships. If recovery was expected

within 14 days or less, the wounded were kept in evacuation hospitals on the

beachhead. If it was believed that it would take longer, both soldiers and any

of the remaining civilians who had been wounded or who were ill were evacuated

to the Naples area as soon as they could be moved. As many effectives as possible had to be retained, and experienced combat soldiers were never evacuated

unless there was no other course. Slightly wounded and sick were evacuated

because the bed space had to be saved for the wounded who needed it more.

Eventually, a 200-bed hospital was set up on the beachhead for the diagnosis and

treatment of venereal disease, and a 400-bed holding hospital was also set up to

take the pressure off the field and evacuation hospitals. These two plans made

it possible to retain on the beachhead many thousands who otherwise would

have had to be evacuated.

In the opinion of surgeons on the beachhead, casualties were often evacuated to the base earlier than was desirable. On the other hand, when Colonel

Churchill visited the hospitals of the beachhead on 2 June 1944, in the course

of the breakout, he expressed the opinion that casualties were being held too

long. Air transportation had begun only a week before, on 26 May.
q1'1t(1lCAT, CI N S I LTA NT S

A.-

aw=

.14 W4 1 it"

I;Fo

PI(.I w G2 Tclll, III' llvlli 4 4111- 111 4,11 Aliml loo'.4thilead. ApIR

H ill A I 11(i [-III -. 1 1(14, %\all, I'll it-III 1. I'l 1.4 1 Ion .. I* W ill,
FI~HU.SARMY349

O~asonalyWhen, tlie dasuay load, was unusully heavy on 'th~beach- e'dimen,n who were transportable were evacuated to bse hospitals

'N Aple ~ fok' jnititil wound-surgety, which thy thus received e arler tha-n,

,he+k+i'f+ +h~ ha'd ben kttAzi, I'd as

+ '+ Rioitd.- W The routine t the~ 33d Field liospitail was typical of thie

demandson afrontline installation- at, the Anzio-beachhead. your operating,

t ablisfunioined almost continuously. Thesix surgical teams attached to.the

lospital froimthe d Auxiliary, Surgical' Groupwere divided into three groups ,,

of'ivo tanis each. Each group was on firstcall for -12 hours,,on secdond, all for.

anotdher,12 ours, and off duJy for a third1.2-hur period.,

Wheh casualties once reachod a; hospital, the timelag Was seldom more . than tha ecessary d for resuscitation, 'thanks to careful planningan super-,

vision. At one time, for instance, the 56th Evacuation Hospital had a-back-. log.of 1650cases, which was heavier than the workload of any other hospital,.

though 411, were busy. As soon as the other hospitals had dleared up their

smaler a kl ogs, 75 patients were transferred from the 56th Evacuation,

Hospitafiid distributed among them, thus equalizing the timelag. Later,,it

*as ftufid; necessary to enlarge this hospital, so that it had eight operating

tables and three tents for preoperative preparation.

Wounds were not the only medical problem on the beachhead. There was

a high incidence of trenchfoot (p. 431). Casualties from malaria were also

high. Milaria was endemic in the Anzio-Nettuno area, which was part o

the Pontine Marshes, and it was estimated that at least one in every 20of

the civilians (most of whom had been evacuated to Naples by Allied Military 2

GOvernment) had chronic malaria, Malaria was also present in U.S. Army

troops who had been in North Africa and Sicily and in Italy below Rome,

An aggressive antimalarial program, including the administration of quinacrine hydrochloride (Atabrine) and an all-out sanitation attack, helped to

bring this disease under control.

Random statistics from the Anzio beachhead indicate the amount of surgery required there. Between 30 January and 22 February 1944, the 56th

Evacuation Hospital admitted 5,345 patients and operated on 3,663. The 93d

Evacuation Hospital, which was heavily bombed during the same period,

averaged just over 44 operations per day, the number ranging from 4 on one

day to 111 on another. During the final offensive, hospitals on the beachhead

received 1,400 casualties during the first 24 hours and 800 during the second.

Figures for the period 12-16 May (table 5) are typical of the number of

operations performed in hospitals during this final phase.

Between 22 January and 22 May 1944, U.S. Army hospitals on the

Anzio beachhead handled 33,128 casualties from all causes, and between 23

May and 5 June they handled 15,200. The figures for British hospitals for

the same period are, respectively, 14,700 and 2,196. In all, 47,193 persons

were evacuated from Anzio during the course of the operation. Capt. Eugene

F. Haverty, MC, evacuation officer from the Office of the Surgeon, Fifth
''" " a' L '- . a 

. . " " • ' ' ° .

&mei ACTIVITIES OF SU TRGICAL C6ONqSUtTANTSI

7AU5-Operalions 0 )eiats.6n Ansio beacheduig e

eprmpd'i1 -______ duig,(q

Evacuaton............. 127' 5'

thEvauaton.. ........... 71 4 9

, ' ' l l t F e i d 10t 

. . F~ld40 21 7464 . . . . . . . . . . . . . .. '3 7 3 5 ' 2 1 ! . .

a t---d-----------3-5 ~ ~ ~ ~~ ----- --- -1181

U.,. Army, was killed by a shell while supervising the loading of casua t ies

on anLST (landing, ship, tank). Otherwise, there was no loss of life.among

casualties or medical personnel' in the course of the evacuation,

Weather

The weather in Italy added materially to the difficulties of medical care

in-a-c0mbat area. During thesummer-molnths, it was extremely hot. Durig

thelfali and winter of i943-44, there was almost unbroken cold, rainy weather,

which complicated the evacuation of casualties in mountain warfare and also

resulted in a serious outbreak of trenchfoot. During the succeeding winter,

the weather was much the same, but fighting was generally less intensive.

The 8th and 94th Evacuation Hospitals, however, as well as several field

hospital units, operated in the mountains in snow for several months. The

tmipi 'ure went below freezing in November, and thawing did not begin

until after the middle of February.

Some hospitals also suffered catastrophic damage as the result of weather.

Early in November 1944, th Arno River broke over its retaining wall and

inundated the area of the 38th Evacuation Hospital, then set up near Pisa.

Almost 500 patients and the attendant medical personnel had to be moved

to u. building 300 yards away, which housed the advance platoon of the 12th

Medical Depot. The water, which ultimately reached a height of 6 feet in some

areas, was almost 4 feet high before the last patient had been moved. A great

deal of equipment was lost, including part of the surgical consultant's personal

instruments for chest surgery.

In December 1944, after most of the hospitals had completed their winterizing, which had been delayed in the belitf that an offensive would be launched, heavy rains and high winds from the central Apennines nullified mu--h nf the work already done. At the 8th Evacuation Hospital, then set

up near Pitramala, 8 ward tents were blown down, and 40 patients recently

operated on had to be transfeired to the 15th Evacuation Hospital. Later
S the da, *hen additional tentage was-uprooted, all the other patients iithe

hospita ~iiie'a rcuinary ke .measuire.

UImltAly, tents were- frequenitly s§et up, in the form of a cross or side b

§ide,,to simplify ghting and heating and reduce exposure~of personnel. This plan the hnces of the tents' being uprooted and blown over.

FUNCTIONS OF AN ARMY CONSULTANT

T6ie ,dties and responsibilties of the consultant in surgery, Fifth ,U;.

Ariy -were, in, general, those of all army consultants. His basic function

was to aist the army surgeonin providing care of the highestquality fok

wounded men and for all others who for any reason required surgical-care in

te co bat onoe. His functions were peculiar to this army only in the sense that thpy were evolutionary.

Although Major Snyder's duties varied according to the special phase of

comnbat; they were, in general, as follows:

1. Ile evaluated for the army surgeon and his executive officer the professional capabilities of all surgical personnel (p. 353). This frequently required

the recommendation of tiansfers of personnel from unit to unit, to channel

off excesses of surgical talent in some organizations and to improve the level

of perforifiance in other, weaker organizations.

2. In cooperation with the theater consultant in surgery, he directed the

educational programs by which medical officers, fresh from civilian life, became acquainted with the requirements of military surgery. He also occupied

himself with modifications of planning and techniques by which errors could

be corrected and the level of surgical performance elevated.

3. He served, in effect, as a channel of surgical information between the

various installations in the army area. This made possible the rapid transmission of suggestions, techniques, improvisations, and other useful ideas which

otherwise would have been disseminated slowly or perhaps might have been

lost entirely.

4. He worked in close liaison with the corps surgeons who directed the

movement and operations of field hospital units set up adjacent to division clearing stations. In particular, lie recommended the assignment of teams from

auxiliary surgical groups to these units.

5. He endeavored to improve the per-,rmance of individual evacuation

hospitals in special aspects of surgery by attaching to them, according to their

needs, highly trained surgical teams to assist and train organic personnel.

6. le assisted in the planning of the surgical component in the support of

combat operations, working in close cooperation with the chief of the operations

section in the army surgeon's office. This cooperation was fullest, and therefore most fruitful, in the later phases of the fighting in Italy.

7. He advised the army surgeon on such matters as triage, evacuation, the

nature and limitations of the surgery to be performed in the various echelons
352 ACTIVITIES OF' SURGICAL CONSULfTANT

6f iedical care, and the holding:period- after operation in field and evacuation

8 8. Heb made regular tours of inspection of medical installations in-the;army,

araeiadvising and assisting the staff as necessary. On his return from"these

turs, he reported his observations to the army surgeon and to the consultantin

surgery to the theater surgeon, evaluating the qualifications of each hospital

staff Aid the total-hospital performance.

9. On these tours, he saw seriously ill patients in consultation or examined

other-Oatients in the hospital on request. Also, in compliance with a number of

suggestions made to him to this effect, he demonstrated the techniques of orWard surgery in newly arrived hospitals. In other hospitals, when the patient

load was heavy during rush periods, as frequently happened on the Anzio beachhead, for instance, he took his turn at the operating table with the hospital staff.

10. He advised the army surgeon and his medical supply officer op alt matters of surgical equipment (p. 391) and also advised the installations he visited

on the most efficient use of their equipment.

1I. He analyzed clinical records and post mortem reports on all battle

casualties who died in army hospitals (p. 399), in order to weigh the relative

merits of various surgical procedures and to evaluate the correctness of the

therapy employed in the individual fatalities. These observations led to recommendations for changes in policies and techniques as well as to other recommendations.

Major Snyder also performed a number of other duties not particularly

related to his position as consultant in surgery, Fifth U.S. Army, but arising in

the course of the war. One of these duties was to serve on a general courtmartial. Another, the most painful task he had to perform during his entire

military service, wes to serve as medical officer at the hanging of four rapists

in Sicily and to pronounce these men dead.

It was most important, in the performance of his numerous duties, that

Major Snyder immediately establish frank, correct relations with the staffs of

the Fifth U.S. Army hospitals. Early in his experience, he encountered a considerable amount of suspicion of both his functions and his motives; some of

it was covert, but some of it was quite openly expressed. This attitude was

almost inevitable; as already pointed out, this was an entirely new assignment,

and there was no past experience to serve as a point of reference. Once the

proper relations were established, however, and the potential usefulness of the

consultant system was realized, Major Snyder was always received with great

cordiality, and his visits were utilized to the fullest.

From the beginning of his assignment, Major Snyder spent most of his

time in the field, sleeping at Headquarters, Fifth U.S. Army, no oftener than

once or twice a week. Periods spent in individual hospitals varied from a few

hours to several days, depending upon their location, their special needs, and the

tactical situation. Both the number and the duration of his visits were chiefly

determined by the workload. His repeated visits to Anzio, for instance, were
suired by the cnin seriousness of the tactical situation, which kept all.

urid h motiung seoes_

6h ,ospitalsin thdeareataked far beyond their normki capacity.

In'-aigh-1944, whenMajor Snyder was provided with his own transportation4 ad a driver, he was able to increase the number of hospitals visited because

hew as nblonger dependent on others for his movements.

EVALUATION AND ASSIGNMENT OF PERSONNEL

Th6questionnaires, which all medical officers completed, provided a reasonably a-.deqUQ t record of the officers' medical training and civilia., experience. These records were kept up to date in the army surgeon's office. The

information which they contained was available to the commanding officers of

hospitals, and assignments could be made in the light of recorded professional

qualifications.

It wits a fairly common experience that paper qualifications, however

fairly they might be recorded, were not always matched by performance in

the field and under stress. It was not. possible to judge the potential of any

medical officer until he had met such tests. Evaluation of the capacity of individual surgeons, as distinguished from their training and experience, required observation of their work. Their correct assignment was based upon

these observations, and this f',e"on therefore came to be one of the most im-,

portant duties which the sum ensultant for the Army had to perform.

Major Snyder spent consi. . _e time at this task, but, because of the large

number of hospitals in the FifLh U.S. Army area, he could not always undertake it himself and had to rely upon the estimates of the chiefs of surgery in

the hospitals. To accept their evaluations, however, it was necessary that they

first be evaluated themselves. Their judgment of others depended upon their

own training, experience, ability, and potentialities.

It was extremely important that the chief of surgery in any forward hospital be an officer of special competence in surgery; that he be levelheaded

under stress; and that he possess the administrative ability to organize and

direct the work of the surgical section. Previous experience with forward

surgery in North Africa and Sicily was a most valuable qualification for officers

who served in these positions in the Fifth U.S. Army. Most of them were

extremely capable men, who rendered outstanding service both professionally

and administratively. A small number were not competent and had to be

replaced.

The evaluation of the surgeons in the surgical and shock teams of the

auxiliary surgical groups was another function of great importance. These

teams served in field hospitals (p. 885), which took care of urgent, first priority

surgery, and it was essential that highly competent surgeons be assigned to

them. Here, also, paper qualifications did not always prove an infallible index of ability, though these teams had an unusually high proportion of surgeons with special ability and training.
354 ACTIVITIIES OF SURGICAL CONSI:ITANTS

FI.ucl 63 ( Col IIJIrd 1). Chuhilil, A~IC, C'onltanti:4 ill sui'4' to thei Surlgeon4l, NATOUS1 A, C'ol. Frank It. Berry, MC, Con~isultantillII S'lruvr to Owi sllrgvi'l4

Sevellili V.S Arimy, Col. ,James 11. Itirste. MC, Comma31:44nn Officer, 2d! Aux~iliariy

Suirgical G~roup, and Lt. Cl Ihm~ard 1". Sn13der. A(l. ('on'ililluill Surigel'rt theiii

surgeon, lifth U.I S A 314k.

Whllavei jpno5Ibi11t'. al 1a'v O [ i d '1i1i-4'44iI %%re 44h't irI ill el' aLtliaI loll

Ios I) ita Is, %% It4'rI I leir %%ni 4A)11hII1I I bk' -111)v'I n jst' I a I ItI va Iia ItI I4)1'4. I le :

were a's'i~fli4d t4o the4 hons 1 itak ,I ill fit her tr, flaid. ill %x hi4 i 'pvvial qii1alilicatin l all ini il ive j~'wei4 riredil'4.

Onice i lle silgoi4al I)4'niesl~l of, aII'4 tu!i hadt 1

4)'4'i v% :iiiaitvd ,) o 'rence's

0il 1'T'C01Il))4'ld:4i loll-, I'm41I ra14r \\~s'i tc4I hld \\t ti (1 Colonel ( 'bonr41n11l I lhg. I,):),

of i114' 1mn'I~il:1I i I 1 ectio In. NNit 11 pil i4)Iiai ret'vren44' to4 de114Iei)4ies %"l

'liiVeir e No \\w ax of, 441 4)il4'4 1 i1112 I I)'(4 lefic it'll i4. ANllik iit , po4"ilI4',

Nweak perQl'4lilkI NWell' replaced1 I4N prol4)I N 4I1ified44 pero'ilk414. W 13)143 lilt, lt's

4j1ialified o4dicer, were trl'.4vuIrto 14 lill 1. i)Ih lilt )', col 4)11 ork ulinder u-

~i'4)il)itid li -liw ((4I' (411nn ioeitui444Ial relihitl'r~u 4 4' 4Iia. If 1114'dtt caloes

pal elitiein lit or--llc )31'111 N\10)1 tir-li nI 1144' lw *'11 o ali ". i 44 111 14 )4

correctedI b.\ thi 'ii)1i iloaa-li' "-li)Iilt t44 the4 I4Ispnal (4 tho4)I':4i.. 441144)ic441.
FIFTH-'KU.& ARMY '$

" tDem * r 1944,. Arrangements Were made in the Officeof the Surgeon,_

Peninfiilar-BasoSectiont, fo §nd teams frm, evacuation hospitals to0baSe, .hos.

Tjti ~6 of6 weeks' temporary duy-hlesmlrteams from ~base ho6spital

9tved, lor t he -same length o7f -time ,in, forward units. -This policy, which,

P-oVd rprofitable, # vas continued until the heavy fighting during the , bealmtjit the"PoValley in April 1945 made it impractical,.

"Nurse' and enlisted, personnel.-"In August 1944, before the invasion ,of

southern France, there were 14 medical units in the Fifth U.S. Army areato:

-Which ,3irsds were assigdied. Of the ,14 units, 4 were field hospitals, WithA,,.

-nursesiuibh; 5 were 400;bed evacuation,hospitals, with 40 nurses each; 4 were

7 ().bedt ' euatibn hospitals, with 53 nurses each; and 1 was the 2d Auxiliary

Surgical 'Group, with 65 nurses.

Nur ses were always in short supply, and the nursing care of first priorit y.

casualtiesafter surgery was a continuing problem. When. the patient census

in a field hospital platoon exceeded 20, as it frequently did, the 6 nurses provided for by the table of organization could not handle the load. The deficiency was usually met by sending forward nurses from evacuation or base

section hospitals to augment field hospital personnel during the rush periods.

The nurses of the Fifth U.S. Army rendered superb service and contributed incalculably to the morale of the troops. This was particularly true at

the Anzio beachhead (fig. 64), where six nurses were killed and a number of

others were wounded.

Enlisted men who helped to care for the wounded in all capacities, from the

battlefield to the rear of the Fifth U.S. Army area, are deserving of the same

high praise. There were many casualties among them and many instances of

almost incredible bravery and devotion to duty. Pfc. Lloyd C. Hawks, Medical Detachment, 30th Infantry Regiment, was awarded the Congressional

Medal of Honor for devotion beyond the call of duty at Anzio.

Rank.-The numerous contacts necessary between medical officers of the

Fifth U.S. Army and the British medical officers serving in the same command

were often complicated by embarrassing discrepancies in rank. Throughout

the war, at medical conferences as well as at conferences between officers in all

other branches, the British were usually represented by officers who outranked

U.S. Army officers by at least one rank and often more. The counterpart of

Col. (later Maj. Gen.) Joseph I. Martin, MC, Surgeon, Fifth U.S. Army, for

instance, was the Surgeon of the British Eighth Army, who was a major

general.

These discrepancies often made for embarrassment if not actual difficulties.

The explanation of the higher British rank was frequently inherent in their

system. In the British Army, an officer, on being assigned to a task which

called for a certain rank, was given that rank temporarily if he did not already
35~ ACTIVITIES OF SURGICAL CONSULTANTS

NU

~ 4/

" ,'

F'IGURE 61.-Nurbeb on Anzio be achheaid. A. Nuw diggini; foxholes. 11. Nurwes loading

sandbags around their tent.
''possess i4 'When the task was finlshed, he revertead-to his originai and

EDUCATIJONAL- ACTIVITIES

Manyof the surgical techniques of previous warshave become obsolete

at the outbrieakof ,another war. More important, the lessons of .past wars are

rea ily forgotten, if indeed they are ever fully learned. Finally, while there

always a progressive evolutionary improvement in surgical techniques between w arsi :some of these techniques are not applicable'to combat surgery,,

afnid'thebeiareapplicable only after they have been modified,

MWakeS, therefore, are almost inevitable in the management of the

w unded i first days of any war. New methods of merit develop rapidly,

it ie true, but they are learned and applied only if deliberate efforts are~made

to educate newly inducted medical officers into the principles of wartime surgery; to, teach them the modifications of peacetime methods which wartime

requires;, and also to teach them that the techniques of peacetime, however

admirable they may be, usually cannot be applied wholesale to military

urgery,

There were two reasons for the confusion in the management of combatincurred injuries which occurred in the early days of the North African

fighting, The first was that the lessons of World War I, explicitly set forth in

the official history of the Medical Department, had to be relearned. Only a few

medical officers in the North African theater even knew of the existence of these

very useful volumes, and even fewer knew what they contained,

The second reason was that there were almost no medical officers in the

North African theater who were familiar with the lessons the British had

learned during the 3 years in which they had been in the war and in which they

had had an extensive experience in Africa. It might be sound policy between

wars to send consultants and other medical observers to foreign countries, to

study their medicomilitary techniques. Certainly, it should be the practice,

whenever friendly countries permit it, to send observers to conflicts in which

the United States is not participating. Finally, once the United States enters

a war, every effort should be made to capitalize on the previous experience of

her allies.

These principles were not put into practice in World War II. It has already been pointed out that when Major Snyder's hospital was in England in

1942, before it was ordered to North Africa, his endeavors to capitalize on the

British wartime experiences in chest surgery were successful only after a long

delay, and in the end the time thus spent was only a fraction of what originally

had been planned (p. 334).

The experience in other theaters was the same as in the North African

theater, and for these reasons the educational activities of a consultant in

surgery to a field army were always extremely important.

606222v-62-25
Methods,

Theedcaio~lprogra o ugr in, the Fifth 'U.S.Arywsinbt

itsformal and' inforial- aspects, primarily the, responisibility of, e army

igikIl consultant. was-the consultant's duty, so to plan and-implement-this.

proramas b isure the accomiplishmient of thiree objectives, as follow-

.iapid, dissemination ofknowledge of. medicomilitary methbd6 oI g

med. alipersonnel already w'thin the FifthU.S., Army area.

2., Rapid educatidn of newly arrived units-in the principles andtechniqus,

.. . Transnission of reports of accumulating mediconiilitary experience

throbugh channels (the Surgeon, Fifth U.S. Army, to the theater sirgni,. sothe surgeons in general hospitals in the base 'section might knoW 'th probl •

lerns eincountered in the army area.

'These objectives were accomplished in the following ways:

1. Both informal and formal meetings were held (p. 362). Tliepfesenta6-

tiori of special problems and new techniques at these meetings and, evenmore,,

the ree and uninhibited discussions which followed these presentations prove4'&

an invaluable as well as extremely interesting means of instruction.

2. The surgical consultant visited all installations in the army area as.

often as po,:ible. Personal contacts with individual surgeons infield and

eVAcuation hospitals as well as in battalion aid stations, clearing stations,,an4

collecting stations materially reduced What might be termed the educational

timelag. Conferences with small groups and sometimes with the entire surgicai

stAff permitted the exchange of ideas, the suggestion of changes, and the tactful

correction of errors.

If all the surgeons on the staff could not be seen personally, conferences with

the chief of surgery and ward rounds with him and his associates provided

opportunities for the evaluation of the work being done and the care the patients

were receiving. These rounds also furnished opportunities for informal con.

sultation on difficult and obscure cases. Observation of work in operating tents

could be followed by appropriate suggestions to the chiefs of service or to individual surgeons, as the opportunity presented.

All of these plans permitted effective teaching which was, perhaps, the

more valuable because it was both practical and unobtrusive.

3. Conferences with individual surgeons in divisional medical services

served to keep the consultant informed of the problems which arose in the

division area and promoted better management in all echelons because of the

ensuing discussions and the decisions reached at them. These decisions were

rapidly conveyed to all the medical installations in the Fifth U.S. Army area.

Medical officers of line divisions were encouraged to visit hospitals and other

medical installations in the rear, on the ground that an understanding of the

needs and problems of all echelons by all echelons made for better care of the

wounded in every echelon.
4, Thep licy ofbkeeping surgeons in forward installations informed. of

theconditio : 9 ! r6f g#dunxccdy theiir patients as they were received in installations farther, ,us§eful from the teaching' stahd-Pbit-and -also 6

;Pf'd id d'*d bpetitive stimulus. Asnoted elsewhere (p.373), this policy ws

fi6nd6V devte4nly to the repot and correction of ,errors., Quite as inuh- attention was devq ed to outstandingly good results achieved by special techniques of

daagmet.,

5, Magjo.Snyder frequently demonstrated the techniques of combat surgery

:t i6wl. arrived units Vithout previous medicomilitary experience. Early in,

th&*at,_thi§,proveda rapid and usefutmethod of teaching and one whichwas

;frcjutiftly requested, particularly in thoracic and thoracoabdominal injuries.

As the war progressed, this s~rt of teaching became unnecessary, because there

had coife ite existence a sound nucleus of qualified surgeons capable of doing

surgery on every kind of combat-incurred wound and doing it well. Major

Snyder contihued, however, to assist during rush periods, as on his numerous

visits to the Anzio beachhead (p. 410).

6. Bdf0be any division was sent into combat, a meeting was held with all

its medical Officers. The discussions particularly concerned the special medical

necessities of the offensive about to be undertaken, any new methods to be employed, and the errors to be avoided. During rest periods, meetings with the

same personnel permitted critiques of the medical performance in the offensive

justconcluded.

7. When a hospital was found to be weak in a particular department, such

as thoracic surgery or orthopedic surgery, standards could be elevated and

care of the wounded improved by placing a qualified team from an auxiliary

surgical group in the hospital for a sufficient period of time to permit training

of the assigned personnel in that specialty.

8. Contacts between forward and base surgeons proved to be highly educational. Arrangements were therefore made, as circumstances permitted, for

officers in base hospitals to go forward to observe special types of surgery, such

as chest surgery, at first hand in more forward hospitals.

9. Special visits of instruction by medical officers particularly qualified

in certain subjects provided another highly practical means of indoctrinating

medical officers in correct use of established techniques and in new techniques.

Among these visits were the following:

Lt. Col. Harvey S. Allen, MC, spent several weeks in army hospitals in 1944

lecturing on hand surgery and the correct splinting of wounds of the hand.

Lt. Col. Oscar P. 1 ampton, Jr., MC, lectured on, and demonstrated, the

correct techniques of surgery and splinting in wounds of the extremity.

This was in February 1944. Later in the year, Colonel Hampton and Maj.

Champ Lyons, MC, worked in one hospital for 6 weeks, demonstrating surgery

of the extremities, with special emphasis on adequate debridement, correct

splinting, the liberal use of whole blood, and the correct use of penicillin.
8:i~i 360),: "" ACTIVITIES OF SURGICAL CONSULTANTS

'T1isg.Agent Was just becominig available for general use,, and its limitations,

d§, 'ell as its potentialities were stressed. lAter,-these ofllcerslcondcted seiinarson .the same subjects in all the other evacuation hospitals in letheater

InTfe fl'of- 1944, a n extende d tour of' Fifth, U.S. Arm*.nmedicanstalla_ " ion by Col. Eldridge H. Campbell, Jr., MC, was of great valu , t he

development of the neurosurgical program. Colonel: Campbell, who, wasthen

seryvingas acting consultant in neurosurgery, devoted muchof his time to the.

Management of peripheral nerve injuries; casualties with iftracranial, mwonudlp

with particular reference to their transportability; and spinal cord injuries.

On 28 October 1948, Capt. (later Maj,) Floyd H. Jergesen,.MC, beigAnto-

-Work in the evacuation hospitals on the Garigliano Front and at Anzio. for,

periods of from 5 to 14 days in each hospital. Captain Jergesen, who, was

serving as consultant in orthopedic surgery to the Surgeon, Fifth U.S.,Army,,

defonstrated surgery of the extremities, with particular emphasis on t.horough

eXcisional surgery, fasciotomy, and dependent drainage. His activities grew

out of the high incidence of clostridial myositis in Italy at the time. All

hospitals were instructed at this time to notify him of all cases of actual

or suspected gas gangrene. For the next several months, Captain Jergesen

saw every case which developed in Fifth U.S. Army hospitals, as well as many

cases which developed in base hospitals.

By July 1944, the Mediterranean theater had ceased to receive new hospitals and new divisions, and there was therefore no further need to train

inexperienced organizations and personnel. Most of the lessons of wartime

surgery that had been learned in Africa, Sicily, and the early fighting in Italy

had by this time been very well learned indeed.

Major improvements in the surgical care of casualties were not confined

to any single echelon in the medical service. Educational activities had extended from battalion aid stations through evacuation and convalescent hospitals, and improvements were equally widespread. The improvements were,

in part, the consequence of the increased experience of individual medical

officers and other personnel in combat surgery, but they were also, to a large

degree, the result of the intensive and carefully planned educational program,

which had extended through the whole medical service of the Army. In this

program, the role of each echelon of medical care was clearly defined, and

their relations with each other were indicated with equal clarity.

Circulars and Circular Letters

Circular letters in one sense proved the most useful method of all of

disseminating information, for they specified official policy, leaving no excuse

for misunderstanding.

Some of these letters were prepared almost as emergencies, in response to

needs which were evident and highly urgent. Thus, the first circular letter

from the Office of the Surgeon, Headquarters, II Corps, which dealt with the
treatmeit, ofcasualtie, was prepared by Major.Snyder-after his-first inspec-,

tio ~§ of wrk f urgical teams in clearinig stationis inNrhArica, early

.he.6i . hod circular letter from this headquarters, which dealt with gas

gangrene afididih as pubAished in Augus, 1943,1 was precipitatedby the,

aarm ng iicience of cosoridial myositis in the Sicilian campaign. Medical

cifrcuars on this same, subject were necessary from the Office of the Surgeon,

Headquarters, Fifth U.S. Army, in October 1943,0 shortly after the -landings

at'SilernO, and in MAy194V7

Anoth rdircular letter from the Office of the Surgeon, Headquarters, 11

Corps, published early in August 1948, was devoted to the care of the wounded,

in Siciil. It was prepared at the conclusion of the tour of medical installations on ,that'island made by Colonel Churchill, Lt. Col. (later Col,) Perrin H,

Long, MC, and Major Snyder. The necessity for it was explained in the introduction, as f6lows:

1. Inrouo .

'A. -Surgical procedures In the present campaign indicate that many of the lessons,

learned In Tunisia are not being universally applied in Sicily. Rules and recommendations

are not expected to replace the exercise of Individual judgment by the surgeon or provide

for exceptional circumstances. Deviation from certain basic principles, however, is not

acceptable when based on inexperience or unfamiliarity with those principles.

this letter dealt with basic principles of management of the wounded

which remained substantially unchanged throughout the war.

Medical circulars from the Office of the Surgeon, Headquarters, Fifth

U.S. Army, dealt with trenchfoot; 1 sulfonamide therapy; 10 the disposition

of battle casualties in forward echelons, based on careful triage at the clearing

station; 1 blood transfusions; 12 and the correct use of Pentothal sodium (thiopental sodium) anesthesia, 13 from which a regrettable number of deaths were

occurring. Several of these circulars were prepared by the surgical consultant,

with the assistance of appropriate officers qualified in the particular field in

question, and the consultant assisted in the preparation of those which he

did not prepare himself.

'Circular Letter No. 1, Office of the Surgeon. Headquarters, II Corps, 12 May 1943, subject:

Treatment of Casualties.

5 Circular Letter No. 2, Office of the Surgeon, Headquarters, II Corps, 5 Aug. 1943.

Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army, 20 Oct. 1943,

subject: Gas Gangrene.

I Medical Circular No. 9, Office of the Surgeon, Headquarters, Fifth U.S. Army, 5 May 1944,

subject: Anaerobic Infections.

Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, 7 Aug. 1943.

Medical Circular No. 6, Office of the Surgeon, Headquarters, Fifth U.S. Army, 24 Nov. 1943. X* Medical Circular No. 1, Office of the Surgeon, Headquarters, Fifth U.S. Army, 21 Jan. 1944.

1Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army, 7 Apr. 1944,

subject: The Disposition of Battle Casualties in Forward Echelons.

i Medical Circular No. 10, Office of the Surgeon, Headquarters, Fifth U.S. Army, 6 May 1944.

1 Medical Circular No. 7, Office of the Surgeon, Headquarters, Fifth U.S. Army, 22 Apr. 1944,

subject: Pentothal Sodium Anesthesia; Blood Transfusions; Post Mortem Examinations.
t6-5 ACTIVITIES-OF SURGICAL OSLAT

MEETINGS AND , CONFERENCES'

Meetings and conferences in theFifth U.S. ArmY were of variou-kRdih, in addition to the staff Meetings, already described, in the hospitals §hih,

'ajorSnyder visited on his tours (p. 358). These conferences were 1usuaIy

AeldK at the end of his visit. Meetings were also held,whenever he visited a h6s

pital. accompanied-by any of the distinguishedvisitors to the theater (p. 36J'.

Some hospitals held weekly staff conferences for their own personxel,. Ax

excellent series of this sort was conducted at the 16th Evacuation Hospital,

Where Lt. Col. (later Col.) Manuel E. Lichtenstein, MC, Chief of Surgery,,held

wedkly conferences, almost without exception throughout the war.

Frequent informal meetings and group discussions were held with. the

visitors to the theater and with others. They ranged in size and formality-from

discussions in pyramidal tents late at night (with half a dozen officers huddled

around a potbellied stove) through surgical clinics and ward rounds (which

could be set up at any time) to the Fifth U.S. Army Medical Conferences, at

which more thhn 306 medical officers were often in attendance.

Informal Meetings

The following meetings are typical of the informal, unscheduled meetings

held at irregular intervals, in various medical installations in the army area, as

the place and the person came together.

In November 1943, Col. L. Holmes Ginn, Jr., MC, Captain Jergesen, and

Major Snyder talked to the medical staff of the 3d Division at the clearing

station near Riardo. Their presentation and the discussion which followed

ranged widely, covering emergency and transportation splinting; the management of shock; the arrest of hemorrhage, with special reference to the use of

tourniquets; the correct use of morphine; and sucking chest wounds and

abdominal wounds.

On 2 December 1943, Major Snyder talked to the surgical section, 8th

Evacuation Hospital, on wounds in general, wou. ds of the chest and abdomen,

and shock and hemorrhage. On 11 December, at an all-day session at the 15th

Medical General Laboratory, presided over by Col. Virgil H. Cornell, MC, its

commanding officer, Colonel Churchill spoke on the prophylaxis of wound

infection and the principles of wound management. Captain Jergesen, Maj.

(later Lt. Col.) Fiorindo A. Simeone, MC, and Major Snyder spoke on gas

gangrene. On 15 December, Major Snyder talked to the 3d Platoon, 35d Field

Hospital, on wound excision, vascular injuries, amputations, and shock. On 28

December, at a meeting held at the 1st Platoon of the 33d Field Hospital near

Venafro, Maj. (later Lt. Col.) Samuel A. Hanser, MC, discussed the duties of

a chief of surgery in a field hospital. Major Snyder compared them to the

responsibilities of a senior resident on a surgical service, who must make rounds

on all patients and be responsible to the chief of surgery (here Major Snyder)

for the quality of the surgery done by all assistant residents; that is, the sur-
'Oft U 'RY363"

igcal' teams,-attached to the hospital. Thismeeting was held, to, the sound of

' 9gus; the U;S, Long Tonis were 500 yards behind the field, hospital,, which

ffibidt-s-, hahappened 91 one of Major Snyder's previ0U.S visits--that if an

S eneniy shotatour artillery fell short, the hospital would hit.

On ft Vebruary i944, a meeting at the 38th Evacuation Hospital was devotedi to chest injuries, with special reference to the mange ent ofwet lung,

hiiSe ,atropine and morphine,,.nd intercostal andi paravertebralprocaine

-hydrochllrice(Novocain) - block. The speakers included Lt. Col. Paul W.

S Sger, MC ;Maj. Thomas H. Burford, MC; Maj, Benjamin Burbank, MC;

On .20 arch, anaerobic infection, with particular reference to-gas gangrene, was discussed at a meeting at' the 21st General Hospital. Participants,

in addition toColonel Churchill and Major Snyder, included Colonel Hampton,

Maj. (later Lt. Col.) Tracy B. Mallory, MC; Capt. Louis DeS. Smith, SnC;

Major-Lyons, Major Simeone, and Captain Jergesen. On 22 March, at the 23d

eralospitaIA. Col. (later Col.) Michael L. Mason, MC, spoke on injuries

6f the iand.

.0. 25,March, at the 401st Evacuation Hospital (French), the meeting wtis

presided over by General Hugenot, Chief Surgeon, French Medical Corps,

and Maj. Etienne Curtillet was one of the participants in the animated discussion devoted to Pentothal sodium. The French regarded this agent as contraindicated in shock, hemorrhage, and chest and max'ilofacial wounds. They

used it in head injuries but not in abdominal injuries.

On 30 March, at Marcianise, Major Snyder talked to the 2d Auxiliary Surgical Group on triage at the division clearing station, surgery in field hospitals,

and chest surgery in field and evacuation hospitals. On 31 March, at the 52d

Station Hospital, the discussion concerned surgery in forward hospitals and

wounds of the chest. On the same day, a special meeting was held with the

thoracic surgeons of the 2d Auxiliary Surgical Group on the indications for

chest surgery in forward hospitals.

On 7 May, Major Snyder addressed the entire staff of the 33d Field Hospital on a number of subjects, including blood transfusions and the management

of anuria. Many surgeons expressed themselves as afraid to use potassium

chloride, as advocated by Lt. Col. (later Col.) Marion H. Barker, MC, Chief of

Medicine, 12th General Hospital, because of its possible toxic effect on the

heart.

Fifth U.S. Army Medical Conferences

The Fifth U.S. Army Medical Conferences were the only formal medical

conferences held in the Fifth U.S. Army area. They were instituted by General Martin in November 1943, when the army headquarters was located in the

palace at Caserta; here, the meetings were held in the Royal Opera House.

When headquarters moved forward, the conferences were held in one or another

of the evacuation hospitals.
304 ACTIVITIES 01P SURIGICAL CONSULTANTS

FIGUiur 65.-Brig. Gen. Joseph 1. Martlin, Surgeon, Fifth U.S. Army, addr essing i'eliabilli

tatlon con~feren~ce at Castel Fiorentino, Italy, in 1945. Lt. Col. IJolvard H. Supder is seated

Oil the genieral's right.

T1hese meetings pr1ov'ed ani extremely valuable mieans of disseinating information onl surgical Subjects. , particularly during the first winter iin Italy,

when the educational needs Were greatest. At this time, the front was genierally stable, and army medical installations were not too widely scattered.

T1'le conferences couldl therefore be attended by medical officers of all echelons

in the army area, as well as byimany from stat ion and general Iboslpitals supporting the army. At the 17 February 1944 nmeeting, when p~eiipheral vascular

lesions were discussed, the audience overflowed the tent and attendances of 250

or 300 were niot uniusual.

The Fifth U.S. Armyv surgical consultant planned all surgical programs.

The speakers were selected because of their grasp of implortant current problemns or their proficiency in special fields. General 'Martin, Surgeon, Fifth

U.S. Army, pr1esided at almost all of the conferences, which lie ranl with efliciency andl (lizatch (fig. 6,)). At, his request, Major Snyder always closed the

discussions on surgical subjects. mnaking certain that accep)ted principles, as

they' were laid k Min officially, were clearly delineated. TIhe only formn of censorship exercised t these meetings, in fact, was 'Major Snyder's insistence

that no p~olicies and pra~ctices lbe adlvo&.atedl which did not, conform wvith thlose

applrovedl by the tetradam ugos
FIFTH U.S. ARMY 365

Discussions from the floor were always animated and were frequently very

useful. At the 4 November 1943 meeting, for instance, when the subject was

gas gangrene, Maj. (later Lt. Col.) Henry K. Beecher, MC, discussed anesthesia in this condition. During the discussion at the 25 November meeting,

the general subject of which was anesthesia, it was brought out that Pentothal

sodium had been employed too freely, and its use in head injuries was condemned.

With occasional exceptions, these Fifth U.S. Army conferences were held

weekly from their institution in November 1943 until shortly before the fall

of Rome in June 1944. Most of them were on surgical subjects, but a few were

devoted to other subjects, including neuropsychiatric casualties, typhus fever,

pneumonia, infectious hepatitis, and malaria.

Table 6 gives some idea of the range of the material covered at these conferences and the outstanding caliber of those who made the presentations.

There was general regret when tactical circumstances made it impossible

to continue these conferences, and there was universal agreement that they

had served their purpose well.

Other Meetings

On 11 February 1944, at a meeting of the Peninsular Base Section Medical

Society in Naples, Captain Jergesen and Major Snyder spoke on clostridial

myositis, and Maj. (later Lt. Col.) Benjamin W. Rawles, Jr., MC, and Maj.

Harvey S. Allen, MC, spoke on burns. Brig. Gen. Leon A. Fox, MC, spoke on

typhus. By the time this meeting was held, the Naples epidemic, which had

reached its peak in the middle of January, had been conquered. More than

1,500,000 men had been dusted with delousing powder in the course of the

campaign. The mildness of the single case of the disease which occurred in an

American soldier was attributed to his vaccination.

Major Snyder attended the Congress of the Central Mediterranean Force

Army Surgeons, held in Rome from 12 to 19 February 1945, together with

other medical officers from the Fifth U.S. Army and the theater. The whole

field of war surgery was covered, and special sessions were devoted to wounds

of the chest and wounds of the abdomen. The closing address was male by

Maj. Gen. Morrison C. Stayer, Surgeon, MTOUSA (Mediterranean Theater

of Operations, U.S. Army). Ie emphasized, as did his opposite number,

Maj. Gen. William C. Hartgill, C.B., O.B.E., M.C., K.H.S., that war surgery

in the Mediterranean theater had been a pooled experience, with British and

American medical personnel part of one team and with patients from all the

Allied armies treated in forward hospitals as if they too belonged to one team.

General Hartgill particularly stressed the fact that in this war the wounded

man was not brought back to the surgeon; rather, the surgeon was brought up

to the wounded man, and his chances of life were thus increased manyfold.

606222-62----26
3(;(; ACTIVITIcil 01?, -SURGWICAL CONSULTANTS

TA IIu.: 6. !Pr(cnrlftiofs at Fifth, U.S. A rini, iedical Conference8

Subhject Sptnikpr

.1 November P)4-- Gas ganigrene. - (apt. Floyd H. .Jergemen, MC, 2d

Au'xiiary Surgical Group.

(npt. ilobert W. Augustine, MIC, 38th

E~vacumationm Hospiital.

1A. Col. Kenneth F. Ernst, MC.

I I Novemiber 19-131- Ch~est wound..s. Maj. Hlenry K. Beecher, M C,

NATOUSA.

'Mj. Lawrence NI. Shefts, MIC, 2d

Au~iliary Surgical Group.

Caipt. Lyman Brewer, MIC, 94th

E vacuation Hompital.

Maj. Daniel A. Mfulvihill, MCQ, 15th

E vacuation Hospital.

-18 November 19413 - .Xdomninal wou ids----- aLj. Howard A. Patterson, MIC, 95t

Ev~acuation Hospital.

Maj. James IM. Mason III, MIC, 2d

Auxiliary Surgical Group.

2:3 November 19-13 ---- Anesthesia ------------ Capt. John '4. Beffel, Jr., MC, 15th

Evacuation Hospital.

Xjaj. Henry K. Beecher, NMIC, N ATOUSA.

Major Howell, RAMIC, 14th Casualty

Clearing Station.

2 December 19-13 - Fractuzres ----------- Maj. Howard E. Snyder, MC, Fifth

U.S. Army.

Capt. Floyd HT. Jergeseri, MIC, 2d

Auxiliary Surgical Group.

2:3 December 19-13 Iea'l imjuiesL- - M:j. William It. Pitts, MC, 38th

Evacuation Hospital.

Maj. Laurence N1. Weinberger, TMC,

16th Evacuation Hospital.

30o December 1!943 - -IMaxillofacial injuries. - I Maj. Samuel G. Balkin, MIC, 94th

Evacuation Hospital.

Captain Rehifield, MC, 36th General

* Hoqpital. 1gbcrt W. VanD. Cowa, MC,

Fifth U.S. Army.

( January 19-4.-1 -- --- Trenclifeit ---------- -- Maj. John Parke, MC, 109th Medical

Buattalion.

(apt; Sidney Gait, MC, 56th Evacuat ion Hospital.

Ca.t. William F. Hickey, Jr. MC,

* 3d Convalescent Hospital.

13 .Jaimarv 19-1-1 ------- Shock arnd hemnorrhage.. Maj. Charles .8. Rtife, MC, 94th

Evacuation Ilospital.

'Mnj. James M. Sullivan. MIC, 2(d

Auxiliary Surgical Grouap.
FIFTH U.S. ARMY 367

TAnLs, 6.-Presentations at Fifth U.S. Army Medical Conferences-Continued

Date, Subject Speaker

20 January 1944 ------ The prevention of infec- Lt. Col. Michael L. Mason, MC, 12th

tion in war wounds. General Hospital,

Lt. Col. Sigurd C. Sandzen, MC, 94th

Evacuation Hospital.

3 February 1944 ------ Treatment of battle Maj. Oscar P. Hampton, Jr., MC,

fractures in base 21st General Hospital.

hospitals. Maj. Howard E. Snyder, MC, Fifth

U.S. Army.

10 February 1944 ---- Secondary wound closure- Maj. Harvey S. Allen, MC, 12th General Hospital.

Maj. John Burke, MC, 23d General

Hospital.

Lt. Col. Langdon Parsons, MC, 52d

Station Hospital.

17 February 1944 ---- Vascular injuries ------- Capt. Byron H. Evans, MC, 94th

Evacuation Hospital.

Lt. Col. Manuel Lichtenstein, MC,

16th Evacuation Hospital.

Maj. Fiorindo A. Simeone, MC,

NATOUSA.

24 February 1944 ---- Chest injuries --------- Lt. Col. Paul W. Sanger, MC, 38th

Evacuation Hospital.

Maj. Thomas H. Burford, MC, 2d

Auxiliary Surgical Group.

Maj. Benjamin Burbank, MC, 2d

Auxiliary Surgical Group.

Capt. Arthur J. Adams, MC.

2 March 1944 -------- Occurrence of heart fail- Capt. Byrd S. Leavell, Jr., MC, 8th

ure in blast injury. Evacuation Hospital.

9 March 1944 -------- Spinal cord injuries ---- Capt. Wolfgang W. Klemperer, MC,

2d Auxiliary Surgical Group.

Maj. John E. Webster, MC, 36th

General Hospital.

Maj. Henry G. Schwartz, MC, 21st

General Hospital.

6 April 1944 ---------- Hemoglobinuria Maj. Tracy B. Mallory, MC, 15th

nephroses. Medical General Laboratory.

Transfusion reactions .. John J. McGraw, MC, 15th

il Mdical General Laboratory.

Blood banking for a field Maj. Eugene R. Sullivan, MC,

army. NATOUSA.

20 April 1944 -------- Injuries of the hand --- Lt. Col. Michael L. Mason, MC, 12th

General Hospital.

4 May 1944 --------- Gas gangrene ---------- Capt. Floyd H. Jergesen, MC, 2d

Auxiliary Surgical Group.

11 May 1944 --------- Wounds of the extrem- Lt. Col. Oscar P. Hampton, Jr., MC,

ities. N ATOUSA.

Penicillin -------------- Maj. Champ Lyons, MC, NATOUSA.
368 ACTIVITIES OF SURGICAL CONSULTAN7

VISITORS TO THE ARMY AREA

The visits to the Fifth U.S. Army area of Col. Edward D. Churchill, M(

consultant in surgery to the theater surgeon, were always welcome and helpfu

Earlier, in July 1943, in the course of the Sicilian campaign, Colonel Churchil

Lt. Col. Perrin H. Long, MC, Consultant in Medicine to the Surgeo

NATOUSA, and Major Snyder, Consultant in Surgery, II Corps, made a toi:

of all II Corps medical installations and all Seventh U.S. Army medical il

stallations as far to the rear as Palermo. The divisions of the Corps, und

the command of Lt. Gen. (later Gen.) Omar N. Bradley, were making suc

rapid progress across the island that medical evacuation and supply were soi

times rather difficult. The installations visited included battalion aid sti

tions, collecting and clearing stations, field hospital platoons, and 400-bed an

750.bed evacuation hospitals. The circular letter prepared at the conclusic

of this tour has already been described (p. 361).

On this visit, as in all others, Colonel Churchill's high standards were rl

flected in improvement in the work of the installations visited and in the w

cellent quality of all the surgery finally done in this theater. The repor

which he published for the information of theater and army surgeons an

which he submitted to the Office of the Surgeon General were equal]

helpful. 4

In the spring of 1943, Dr. Allen 0. Whipple, professor of surgery at tl

Cornell Medical School, spent some time in Tunisia, on his return from t1

Middle East, where he had been observing the work done in British hospital

His clinical observations on delayed primary wound closure and penicillin ai

discussed elsewhere (p. 425). In company with Major Snyder, he visited map

of the installations at the Bizerte medical center, and both of them addresse

members of the 2d Auxiliary Surgical Group, which was then stationed ther

Col. Johan M. Holst, Surgeon-General of the Norwegian Army and pr,

fessor of medicine and director of the surgical clinic at the University of Os!

made an extended stay in the Fifth U.S. Army area in the winter of 1944. F

visited many of the hospitals in the army area, including those on the Anz

beachhead. His talks, which were all informal, were of great value.

Visitors from the European theater before D-day in that theater includ

Col. (later Brig. Gen.) Elliott C. Cutler. MC, Chief Consultant in Surgery ]

the Office of the Chief Surgeon, ETOUSA, i ho had recently returned fro:

Russia and who had much interesting and useful information about medic

practice there; Lt. Col. (later Col.) Ralph M. Tovell, MC, Consultant j

Anesthesia; Col. Kenneth D. A. Allen, MC, Consultant in Radiology; ar

Col. James Snyder, MC, Executive Officer, First U.S. Army. Brig. Gen. Fr(

14 Before Colonel Churchill assumed his duties as consultant in surgery to the Surgeon, NATOUS

in March 1943, much useful advice and a-sistance were received from Lt. Col. Frank B. Berry, M

chief of the surgical service of the 9th Evacuation Hospital, the affiliated Roosevelt Hospital un As long as Colonel Berry remained in the theater (until August 1944, when he participated in t

invasion of southern France as chief surgical consultant for the Seventh U.S. Army), Colonel Snyd

found his associations with him very helpful in his own work.
FIFTH U.S. ARMY 369

W. lRankin, Director, Surgical Consultants Division, Office of the Surgeon

General, visited the Mediterranean theater in 1944, and in the spring of 1945

Lt. Col. Michael E. DeBakey, MC, Chief, Surgical Branch, Surgical Consultants Divisin, Office of the Surgeon General, was another visitor.

During the first winter of the war in Italy, the 36th General Hospital

was stationed at Caserta, immediately adjacent to Fifth Army headquarters.

Its close proximity made it possible to utilize the advice of the many competent

surgeons on the staff, including Lt. Col. James M. Winfield, MC, Chief cf

Surgery, and Maj. (later Lt. Col.) William M. Tuttle, MC, thoracic surgeon.

At this time, medical officers from the 12th General Hospital were attached

to the 36th General Hospital, and their services were also utilized. Among

them were Lt. Col. Michael L. Mason, MC, Chief of Surgery, and Maj. (later

Lt. Col.) Harvey S. Allen, MC, hand surgeon. These officers made major

contributions to the evolution of policies of medical management in the

Mediterranean theater.

During the second winter of the war in Italy, the 24th General Hospital

was stationed in Florence, and, again, it was possible to make use of the

advice of the many excellent surgeons on the staff, among them Lt. Col. (later

Col.) Francis J. Cox, MC, Chief of Surgery, who was an experienced orthopedic surgeon, and Maj. (later Lt. Col.) Bently P. Colcock, MC, a general

surgeon.

While the 24th General Hospital was stationed in Florence, seriously

wounded casualties were evacuated to this general hospital when they left

field and evacuation hospitals. At one time during the winter of 1944-45,

this hospital had 60 patients with colostomies on one ward. The proximity

of the general hospital to the army hospitals often made it possible for the

surgeons in the general hospital to confer with the surgeons who had performed

the initial wound surgery in the cases they were then treatipg.

The visits of all of these medical officers and professional men to the Fifth

U.S. Army area and the contacts possible with officers in the base hospitals

contributed materially to the studious and scientific approach to the problems

of war surgery which characterized all medical organizations in that army.

EVALUATION OF SURGERY

North Africa

Major Snyder's first evaluation of oversea surgery was in the North

African theater, when he was placed on temporary duty in II Corps headquarters for this particular purpose. His report to the Surgeon, IT Corps,

on 3 April 1943 was based on his observations in the following installations:

1. The French Hospital in Gafsa, in a II Corps clearing station, set up and

staffed by the 1st Platoon, Company D, 51st Medical Battalion. The organic

personnel of the platoon was supplemented by two general surgical teams

and one shock team from the 2d Auxiliary Surgical Group.
370 ACTIVITIES OF SURGICAL CONSULTANTS

2. The 2d Platoon of the Clearing Company, 1st Medical Battalion, also

atGafsa.

3. The treatment stations of Company A and Company C, 47th Medical

Battalion (1st Armored Division), at Maknassy Road.

4. The treatment station of Company B, 2d Battalion, 16th Medical Regiment, Maknassy Road. One general surgical team from the 2d Auxiliary

Surgical Group was attached to this installation.

Casualties from the 1st Division evacuated on the El-Guettar-Gafsa Road

were sorted at the clearing station of the 1st Medical Battalion, at which they

arrived between 1 and 5 hours after wounding. Nontransportable casualties

and severely wounded casualties were transferred immediately to the cleaing

station of the 51st Medical Battalion. Other casualties were sent on to tb

48th Surgical Hospital (fig. 66), 50 miles to the rear.

Casualties from the Maknassy area passed first through the treatment stations of the 47th Medical Battalion, 1st Armored Division, then through the

clearing station of the 51st Medical Battalion, at which they arrived from 5 to

24 hours after wounding. Here they were sorted, the nontransportable being

held for surgery there and the remainder being sent back to the 48th Surgical

Hospital.

Sorting was generally well done, and as a result surgical personnel in the

clearing stations could utilize their time in the care of only the seriously

wounded. For the most part, excellent judgment was also used in the selection

of cases for surgery by the teams of the 2d Auxiliary Surgical Group, and the

surgery performed was generally commendable.

The 48th Surgical Hospital, as just mentioned, received the presumably

less seriously wounded casualties who were regarded as fit for evacuation before

undrgoing surgery and also received casualties evacuated after having undergone surgery in the clearing stations.

The 21 deaths which occurred at t his installation revealed some grounds

for criticism, as follows:

1. Among the 32 patients operated on at the 51st Medical Battalion, 4

deaths occurred from 5 to 27 hours after operation k2 other patients died before

evacnation). It was concluded that less speedy evacuation of patients who had

undergone surgery might have saved some lives. A number of thebe men had

been evacuated before they had reacted from anesthesia.

2. At the other extreme, 10 deaths occurred in patients who had passed

through the clearing stdtions forward but had not received surgery in them. It

was concluded that a few of these lives might have been saved if primary

surgery had been performed eailier at the forward installations.

3. Of the seven remaining dea, '!. live occurred in patients who had passed

through other clearing stations wil iout surgery and two in patients who had

reached the hospital from a battalon aid station and a collecting company,

respectively.
FIFTH U.S. ARMY 371

E-4

0A

coz
872 ACTIVITIES OF SURGICAL CONSULTANTS

The following recommendations with respect to other subjects were made:

1. A more convenient method of blood transfusion should be made

available.

2. A source of blood other than clearing station personnel should 06

provided.

3. Provision should be made for oxygen therapy.

4. A shock team from the auxiliary surgical group should be assigned to

every clearing statior , et up to act as a forward surgical hospital.

5. An orthopedic surgery team, or at least an orthopedic surgeon, would

add greatly to the efficiency of each forward surgical installation.

6. Caution should be used in the administration of morphine. An analysis

of the records suggested that overlarge doses of morphine might have played

a part in some of the fatalities, while other records seemed to point to the same

conclusion, though they bore no notation concerning administration of the

drug. It was suggested that a directive be issued warning against any but

small doses of morphine in chest injuries, prohibiting its use entirely in intracranial injuries, and ontlining other precautions in its administration.

Excessive morphine dosage was a well-recognized clinical problem from

the beginning of the war. Whenever Major Snyder talked to medicai oflicers

and corpsmen and to division medical services, he alvays advised that a half

Syrette be administered rather than the full (grain 1/2) Syrette dose. Necessary instructions concerning the judicious use of morphine were contained in

Circular Letter No. 1, Office rf the Surgeon, Headquarters, II Corps, dated 12

May 1943, concerning the treatment of casualties, and specific instruoi 'ons concerning the dangers of overdosage were given before the invasion of Italy.

The importance of this problem was particularly evident in the 100th Infantry Battalion (Separate), made up of American-born Japanese from

IIawaii and the Philippine Islands as well as a small number of native-born

Japanese. The same problem was encountered in the 442d Infantry Regiment

(Separate). Japanese are so small that even the reduced amount of morphine

received from half a Syrette affected them much more than it did U.S. troops,

who were taller and heavier.

7. More explicit instructions should be issued concerning the emergeney

treatment of head and chest wounds, as well as the disposition of these casual.

ties. Casualties observed in the clearing stations and the 48th Surgical Hospital, as well as the records studied, indicated that specialty teams for the treatment of head and chest injuries should be located nearer to the front than

evacuation hospitals, at least as these hospitals were then located. The 48th

Surgical Hospital was between 50 and 85 miles from the main battlefront at

various times, and the 9th and 77th Evacuation hospitals were between 60 and

145 miles behind it.

Recommendations concerning anesthesia and equipment (p. 392) were also

included in this report, in which it was noted that the recommendations concerning clearing stations were intended to apply only to those set up to act as
FIFTH U.S. ARMY 373

forward surgical hospitals. With this report, Major Snyder submitted a short

ti'eatise on the emergency care of wounded in forward installations. One of the

points repeatedly emphasized was that provisions must be made in whatever

installation major surgery was performed to hold the patient for a safe period

of time afterward.

Sicily

Major Snyder's initial observwti- s in Sicily showed that surgery was, on

the whole, good, and some of it was extraordinarily good. On the other hand,

surgeons without previous experience in combat-incurred wounds were doing

inadequate initial wound surgery (debridement) and thus were responsible for

at least some of the clostridial myositis which was then causing a great deal

of concern (p. 445). Here, as all through the Italian campaign, it seemed inevitable that when new hospital units came into the theater they must acquire

experience by making mistakes before uniformly good surgery could be expected from them. Many surgeons required time to learn the importance, for

instance, of a bold approach to a wound and the necessity for an incision of

sufficient length to permit adequate exposure of the wound depths.

Tie circular letter issued from the Office of the Surgeon, Headquarters,

II Corps, on 7 August 1943, was designed to correct these and other errors, some

of which could be traced to an earlier circular letter issued from the Office of the

Surgeon, Headquarters, NATOUSA.'1 The most important of these errors

was the direction that all wounds, without exception, be left open.

Italy

As the war progressed, it was found that one of the most useful means of

evaluating the quality of the surgery done in forward installations was by

examination of casualties after they had reached base hospitals. After this

plan was adopted, Major Snyder made it his practice to make notes on special

cases, attempting to select those in which results had been outstandingly good

as well as those in which errors had been made or complications had developed

or the subsequent course indicated that the procedure at initial wound surgery

was not too well advised or had been inadequate.

By this means, it was possible to determine the quality of surgery done in

forward hospitals and to identify the units, and even the individual surgeons,

whose technique and judgment either required correction or had been unusually

good. These data were given to the surgeon concerned or to his surgical chief.

From the beginning, medical officers in the Fifth U.S. Army manifested an

unusual interest in following up their patients in order to evaiuate the procedures carried out on them in forward echelons. This was as true of the battalion

surgeons and surgeons in clearing and collecting stations as of those in field

is Circular Letter No. 16, Office of the Surgeon. Headquarters, NATOUSA, 9 June 1943, subject:

Memoranda on Forward Surgery Especially Applicable to Amphibious Operations.
374 ACTIVITIES OF SURGICAL CONSULTANTS

and evacuation hospitals. Opportunities were provided, as far as possible, to

capitalize on this interest by permitting surgeons from forward installations to

visit fixed hospitals in the base.

During certain phases of the Italian campaign, there were unusually good

opportunities to follow up patients operated on in the combat zone. On the

Cassino front, for instance, field and evacuation hospitals were located near

each other, and base hospitals were established in nearby Caserta and at Naples.

The close physical proximity of army and base installations provided exceptional opportunities for informal exchanges of visits and for the weekly army

conferences. It was thus possible to study the management of wounds, assess

the work performed in each organization, correct errors, and promulgate for

early adoption whatever new surgical techniques had been developed.

Similarly, during the offensive against the Gothic Line in the spring of

1944, the 24th General Hospital was located in Florence, within the army area,

and another excellent opportunity was provided for chiefs of surgery in field

and evacuation hospitals, as well as other medical officers, to follow up their

cases.

EVACUATION

The successful utilization of field and evacuation hospitals in the army area

depended upon successful triage (the selection of patients for surgery on the

basis of priorities). Triage, which was carried out at the division clearing

station, was based upon th following considerations: (1) Care of nontransportable casualties in field hl-pital platoons placed adjacent to division clearing stations and with their intrinsic personnel augmented by auxiliary surgical

group teams and (2) evacuation of transportable casualties from clearing stations to evacuation hospitals farther to the rear.

Evacuation hospitals were set up in depth along the main axis of advance

in the zone which they were supporting. Early in 1944, it became the duty of

tie corps surgeon and the medical units unler him, chiefly the corps medical

battalions which handled evacuation from division areas to army hospitals, to

execute triage of transportables. Efforts were made to keep the hospitals

nearest to the front free for the care of the more urgent cases, while casualties

with less urgent wounds were sent to the rearmnost hospitals. It was also the

policy to send the mainstream of casualties who could withstand prolongation

of transportation to the rear during daylight hours and to use the more forward hospitals at night, to reduce the hazards of driving in tle blackout.

It had been repeatedly demonstrated in North Africa and Sicily, as it was

evident until the end of the war, that the placing of field hospital platoons

immediately adjacent to clearing stations not only simplified transportation of

seriously wounded casualties from one installation to the other but actually

saved many lives. Corps headquarters therefore always made every effort to

place these units as close together as the terrain and the tactical situation

permitted.
FIFTH U.S. ARMY 375

Facilities for Evacuation

As in all previous wars, litter carries and ambulances furnished the principal means of evacuation from the frontline to the battalion aid station and

thence to clearing stations. On flat terrain, this presented only the usual difficulties, In muntain warfare, the situation was often extremely difficult.

Some casualties were moved by mule pack, others by cables strung between

mountain peaks. Nothing, however, took the place of litter bearers in mountain

fighting. Those from a battalion aid station often had to evacuate casualties

to the rear to ambulance collecting points, and litter bearers from collecting

companies had to work forward and assist in collecting casualties from the

battlefield. Even with Italian soldiers to assist, it was necessary to ask Allied

Forces headquarters to allot 100 litter bearers above the number allotted by the

table of organization for each division engaged in mountain warfare.

Evacuation from the Anzio beachhead, which also furnished special difliculties, is described elsewhere (p. 347). The decision concerning where the

casualty should be delivered from tile battalion aid station rested with the division surgeons. Most of theni directed that patients be taken to the collecting

station.

From the standpoint of conservation of drivers, this was a desirable arrang'~ement. The approach from the aid station to the collecting station was

generally hazardous, and limitation of the number of drivers meant the limitation of tile number exposed to enemy observation and fire. If all drivers had

made tie run from the aid station to the clearing station, all of them would

have been subjected to major risks, and more drivers and more ambulances

would have been necessary.

Air evacuation began in Sicily about D + 5 and proved a safe and expeditious way of removing casualties to the hospitals in North Africa (fig. 67).

During the fall and winter of 1944-45, most patients N% ho went to base hospitals

were evacuated froya Rome or Naples by means of C-47 (civilian DC-3) planes,

as a responsibility of the base section.

Air evacuation of individual patients by L-5 l)lanes (fig. 68) was begun

experimentally in Italy early in March 1945. Patients had to be selected carefully for this mode )f transportation since no medical care NN as possible during

the flight. On the other hand, practically all of those thus transported had had

initial wound surgery and were in good condition.

Since ample ambulance facilities were available, theze planes were not

used widely in the Po Valle3 campaign, though they mere extremely useful in

flying blood for\ ard from the blood bank in Florence. They were very useful,

however, during the mountain lighting later, as well as still later, when the

army broke out into tire alley and the medical berN ice had to be bpread over

hundreds of miles.

Theoretically, the plau was that the babe ectioi w ould evacuate casualties

bv collectitig themi at ,pecified holding points ill tie army area. During m obt
876 ACTIVITIES OF SURGICAL CONSULTANTS

F 1GUR: 0.-Air evacuation by converted C-47 transport plane, MTOUSA.

of 1944, the base lacked facilities to implement this plan and the army evacuated

casualties either to transfer points designated by the base or directly to base

hospitals. During the first 3 months of 1945, it became the policy to hold in

army hospitals all patients except those whose conditions demanded treatment

which could be secured only in base hospitals. During this period, several

general hospitals were located in the army area, and if the patients who had

to be evacuated to them could be returned to duty they were channeled back

to the army area eit -r through the ordinary agency of replacement companies

or through the 3d Convalescent Hospital, Montecatini, Italy.

The holding period in Italy varied from 60 to 120 days, the longer period

being permitted when, as at this time (early 1945), the fighting was less active.

Hospital trains were first employed in Italy in November 1943. A typical

traill was staffed with 4 medical offlicers, 6 nurses, and 33 enlisted men and could

accommodate about 135 litter patients, placed in three tiers in compartments

or along the sides, in addition to 215 ambulatory patients.

The railroad equipment first used was defectihe and the service erratic.

Later, when a loading point was established at Caserta and the trains began

to be handled by railroad operating personnel with experience in the United

States, this became a very satisfactory method of evacuation. The trip from

Caseita to Naples, when this method of evacuation had become A ell developed,

took 1 hours.
PFIl U.S. ARMY 377

Fi~ int: 6S.--E vacuiat ion by L -5 lii Il'ifrom Fil mi'iitIl to FlorenceP. A seuioul or

Ille~ Side of (i I Ie ltlns, pl-Iitiiihg a stre(tchier Ito lo iI1ii1ced oil Olhe deck ill Owe

rea r, wherit is se~(ciuely hi shed.

IMEDICAL INSTALLATIONS IN THE ARIMY AREA

Battalion Aid Station

At the battalion aid Stattioni, to wIt lik thle caSa~lty WIS l-0oiu"llt flout1 the

battlefield, mirgival unleasure" m cre limti ted to tlio.e, "luich %%oulld render himn

tranusportable. T1hey inicliuded (1) inIpectio1 of the die.,iigr, an s1)liltagO

aplplied1 onl the battlefield, N% ithk :,ich rein forcemenut or alt eral I.-ia iiiigit, be

ncar- (2) control of hemorrhage by kcoul~pr-e ,soIi mj ii~ ligatureL o1-

tourniquet as niecessary; (3) attention to the airx ay wvith, oceasiouially, the

performiance of t rachteotomy ; ( 1) proter at tent ion to sucking~ i ouuid.- of the

cl'est and relijef of I eiil'ii)I PuIeliulot hioiax ; anid 5.-) adminkt rat ion of pla16una

(i). 416).

Minor Noluuids ill ca.'iialt iev N~ Io could lbv prolipt l. ret urnued to ditN %%ere

also car-ed for at thle bat lal ioui : aid Stationi.

Collecting Station

'Ihe cllct iig ~ a io (Ii~ 0). A hio. e function i , imuplicit ill it., naime, xias

r'e~rauded bY nc )-tI utedival oHIhier 't aut Mi.importantt p~oint ill thle dil i.'ioui tiledical

ser-vice. DIuirinug 194 1. it'- elintilatiol N a-' aid% ocaltet ill -ouite qiiaitcr '. bilt there
3 78 ACTIVITIES OF SURGICAL CONSULTANTS

tP.

-A .- : A" -X0

Fwtho 1--co .i. I It tins, Stit lot 100 Moluntia in I )visioii. U oi hic Line.

Were ii1111V Oood reason.'i for its Cont inuiation, 11tid hkothliii calie of t hese

sn "rest ons.

Most casualties mere 1101(1 at the collect ing st ation only long enlough to

clieck their condition and tendler any further first aid necessary. r1ourniquets,

(lI'ebsiiigs, aiid 51)1111kt m~ere examned, and it wvas ascert ainied that thle airmy

was patent. Additional lplasiia Was adiihtered if itecessarv. Th'Ie general

1011ey wats to (to n11othiing active iiiiless there A~as a1 real iiidicat ion for

interference.

'['le castialty'b name and~ orgaiaion aont ot her dat a required for official

r~ecords, wIilil had beeti re-or~ded ait like baitht lion alid Miat ion, Aeve chiecked at

the C0o1Vec11 ilig6tati. A1011 reg4iiieit al coiinaiiders, reqtiired that reginiient al

mt1VeIui set t hiz, iifotriiat ionl froim t hie~e ii~t allat ioiis- and leuider Complete

reportsof baittle ca.sutalties frontl the reg..imient . l)et ails 6ecitired er coIcernjinI'r

themnber of ca.tialt ie.,. t Ike locationk of t lie engagt1Viuenlt itll ichi'l t hie had beenl

Wounded, Ihe tI pe of %I eapoins , ,d siniilar dat a %%ere. lnsuall- lit, first

'"1fiait iii totiiat ion to reaich t(lie, re-Iimniit al coiti;nier. ''is a ee

of cotirse. im altiable to hlii inl itle tsei ~uu~ of Ilie' bttle ill Xikichi Ihib

Feginelt ~ a~ ngaed.I ne.s all1 castia It ies passeud thliotuli~ collecting ztations.,

I his iilhI et-et- al iniformiat ion could not hiate been settired mtili the patienits

had reached thle leajili t Aat ions fart her to thle rear. xx Iiicl i "as often 1ii1ii'

hiours later.

Whien all otflsive wa., otil or. whien earlx eN actiat iol "a" not essevlt ial.

ca'.tualt ie" %xi ere ttttal livlid ili 1 lie collecting-i s-tatl ion tt i ant amutlanice load

had heeli acctulilittated. Illose %%ith I int ptiorit~ x motiids. 'licl a.,x motiilds of
the iest :/ 'bdomen, and those in severe shock were often sent back singly W"thiidividua attendantsto supervise their care en routfe when ;ersonnelI

... ld:be spared. This- po lcyn rucdthe avere, timelag betweenwounnghit S nd init~iealunsurgery, but because triage wa -carenfl, noevdlence Vas accuuad ti o set, that the r'kwsicease& for thep iaut ie el unl

.i j ambe n661 owasecued. *Asce 

Occasionally, if theclearing station wais cl os at ha dtle ollectig sta - tdIo m , bysed and' heulief tasoken directly fromthe bital ai4'

tat.o tothe arie sanuot tis wasp nar ofaid,

16e6'ai ow'the it atione

Clearing 'Statin

s obletxienlbacel of the Tuntsian cam had persugap ter - foruhe tptlanningof medial care in tSh Sicilian campaignAhatefaculits

for surgern r dequat sne thpoo e r f asualties submitted to suIig suai bstablished-asterfrit rhastan. the division ing ,n

pi ih i report on the-use of teams fr mnteauiliary surgical gro04

p69), Ma1'or Sniyderhad ipportedtrigstpolion)ftforw aid su rgi ine- He

reci omended, her, hatwenth ntrinscstt of clear.ng platoons o

cork mic4 battalions wreasugmnted by auilinary urgicalgroup tams,,

thise fiefintof theplatons also be inreaed. Their origial, tables of eauip'i , ; 'erie t ade uatefortheir newe missionl

e furter recomendedis inc 8dthe performane6c surgery At division,

clrifng stiein wol eaintre w itht roperifunctioningof thes ntAbllA tions, at platoons of e aring cpan ignated-to spl sria are

Ashoul deetup adjcent- to the clearingstations athe r than w!i them.

Ths;arrange ent woudAmake it possfile for the seriously Wolinded to be, op- erate' on promptly, budt would, at-the sam time, leave the clearing stationis

reto pier1form their bai fucin oftrage. From this su gestion, it was only a step, to the ialarne ntnmly

eusefafinld thospital patoo, rather tfan the clearing plaoon ofsemedical

thee pntcip imrovement ectedin second echelon medical sevicesurger

th US Fft Am in194had to do with "the 'fuinctioning of cleariig st 'Ationts. Afe an analysis- of the 80. deaths which h. ad, occurred_-inI 'Fifth US.

-Arm evaciitibon hospitals in Janluary 1944, MajorShyder concluded'thiat r

* cAi~fdUlfiage in the clearing stations might have-ditected~a largerh ubr of

casuAlties -f6 the field hospital platooni immediately 44jqcent to, them andwould' probably have led to a-reduction in the mortality rate. Of 44' patients

'in, deep §h6ck-or with first priority Wounds whose case iiistories he studied, 8Q

were sent directly to evacuation hospitals from the clearing stations, while the

'remaining"$., although they were sent to field hospitals, were merely ob served'

there and then were sent, to evacuation hospitals for initial wound surgery.
380' ACTIVITIFMS 01? SURGICAL CONSULTANTS

Fic~u111 7O.-F41cld hospit alI, NorthI Africat

These observations led to the institution of an educational progrvam in the

clearinga stations, based onl a medical circular dealing 'tmith the disposition of

battle casualties in forward echelons.'" The p~romplt impIrovemnent which occurred in thle triage of casualties ait clearing stations was minntained until thle

enid of the wa r.

Field Hospital

When platoons of fieldl hosp)itals wvere designated for theo performance of

for%% ard suirgical care in Sicily, they ustsumed functions quite different from

the station hospital typ~e of care whichl they had provided inl North Africa (fig.

70). In Sicily, they were set upl immediately adjacent to dlivision clearing

Stations, the location often beig within range of enemy artillery, and they

were p)rovidled with more surgical equipmient than had beeni gi% en thle clearing

platoonis of mted ical bat talionlb which had per-formed form~ard burgery inl North

Africa.

The concept of for %ar-d surlgioal care inl tie-ld lloslpitalk was bw~ed on two

coulsiderat ionls, as follows:

1. Certain calsitalt ie- , .suchl as tlio.,e " ithI abdominal or severe chtest wounds

anid those inl deep Shock, ilitist reveix e sittigieal vare at the Ic' el of the clearing

station if they are to survive.

-2. Patients, who have been ,ubmit ted to major miurglry inust niot be mlo~ ed

earlier than Sor 12 dav a fter operation.

11 See footnlote 11, p. 301.
The. careof first piliritpients at the level of' the clearingstation had

many 4ti~atages, Proongedevacuation ~of seribuslywounded patients, whidh

S wasdeleterious, was avoided, When the intrinsic, staff -was aug ite& 'byr teai;s froman auxiliary surgical gr6up, the number ofsur eons aidnuirses

S was"iop6itibnately.larger in fieldhospitals .than in evacuation hospitals,,

hichi- ant that seriously wounded casualties could bcaredfor with les

delay, An, could: receive better po rative care. Segregatio Aof ,patints with-sri6u4 woindsi prmitte closer observation and, generaly bettecareFiual,the establishment of field liospitals at~the level of .the clearing, station,'

prv gh'hly advan tageous fromn the standp~oint of tr-,op mo vory a

Ialvic ,*iiwhich was-thus supported knew that A hospitalstaffed with compete'nt surgeons and xiursegs i ts otd so far forward.tat ifh ere seriously Wo.inded he;wouldreeive sUperior careowith a minimum of delay.

Uder exceptionalocircunstances, when a 'heay casualty ,load had -re

1ulted~ in., a backlbg ofpatients in-a, field hospital, some:paients in the igrup 'werselected for treatnient by resuscitative measures and then were transferred,

to" tenearst ev acuatibn hospital. The objective was to reduce the timeiag b

tween ouing and surgery,but the practice was ecognized -s an undesirabemgenc yeasure afid was actively discouraged as aregular prcedur o

As. z4 Jmatter of coveieneadto avoid- repetiin th s faxlary

surg ig rOup teams ifield hospitals'is disusdlksewhere (p, ,85 .. " use of 'field .hosital platoons augmented by teams from auxiliary,

surgiiial~jiwoups sa ved- the lives of many severely, wounded. Beause the field

hopital"Was only a short, ltter carry from theclearing, stationImany cas- 6

ties cold beoperated on who would never have withstood operatiOn after pro6- ,1ondeVicuation tothe rear. Mortality rates in field hospitals wereigh, 'but tby wouldhave been much higherif this forward~surgical miit lad not existd,4 an the ,number6f patientswith:sekious abdominal andchest wounds

wo could-be returned to duty after surgery in them and convalescence in bae .- spitasli" realh surprising.. Pospea ti v" emanagement.-one of the important surgical lessonsof the

1fihting in North Africa Was that patients who had undergne major surgery, particulrly abdominilsurgery, did hot wihstand evacuation until 8or,1 days aindp'eife bly ilonger, aftr. operation. Thebpostoperative care of these casualties was thus 6ne of the responsibilities of field hospitals'(fig. .1 . . Holding the pitients after 6peration was, a siinpie ma ter when the hospital Ws ituated'behind a stable front or a slowly advanciiig front. In these

tactical circuimstances, ( ne fildd hospital could serve two divisions in the line by using twoof its three platoons at the two division clearing stations while the

third piatdbn held patients at a fixed location until they could be evacuated

and it could leapfrog over one platoon or the other when the division clearing

stations moved.

With a rapidly moving front, the problem was somewhat more compli- cated. Then, every division usually required the suppoit of an entire field
382 ACTIVITIES oF SURGCAL CONsurTAN~tS

I i um 71 1Postoperat lye ward in Ist Platoon, 33d Field Hospital, Italy.

hospital, thle p~latoons of which were set up) ini dlepthI behuind the fronit. Only

the forward platoon, set up beside the divisioni clearing station, received casualties. T1he othler two platoons held postoperative patients in various stages of

convalescence until the3 could be evacuated and these platoons, in turn, could

mnove forwardl.

When the forw~ardi platoonl of thle field hospital, mwich %%as adjacent to the

cleai-'-,g station, was closed to admuissionis, the rearmlont platoon was moved

forward to establish treatmuent facilities beside the clearing station in the latter's new forn~ard, position. The p~latoon AN hicli was no longer receiN ing new

patients cont intued to care for its postoperative lpatients unt il they weore ready

for evacuat ion. Experieuce had !tooiu slw'oii that the slieletouuized plan origiiially devised was not adequate. A surgical teamu bad to remain NN itli lie holding unit, to care for patients who iiiight reqtuire surgery for ,secondar% hemnorrhage, woun11d dehiscei ice, bubdiaphagunat ic abs cess. clost rid iil m vositib, and

other Compullicationis. It NN as also neces-sary' to leai e an operating roomt 'set lip,

as well as facilities for radiography and 1lutorosc-opy.

It was sonietimtes possible to pro% ide postopeiat i' e care by ino% iuna evactiation hospitals to sites occupied by field hospitals, leaving thle platoonsb of the

field hospital free to umove forward. This was perfectly ,atisfactory. Tbe
impor tntconsdertio wa-h rvso fpsoeaiecarein, the instaa

tiont ti Which~h patient had reced urgica care. I au~~swr oe

enpy h4betorgard mos ,t patients asrApidly tiansportable, the emphai U~n pnte~oeaiea t, 'icd I was, not long'before it was realized,

that copeep~ope atve car wa quallyimporat

vaUatio Hspita

-Th evacution hospital ,proved the ideal uni nwiht provide defini~

t sugr Ui MX or te-majort ofwude nWorld WriI.

Ad9is0ins to, evacuhation hospitals weqre mixd k both. medical and sugiod

cases. beingreceved, thoUgh the mieical load wAs lightened when-seil-hs

pitlsweese u tr the -treatenit of .venereald dies an the. caefneu&o-

-ychitri casual1 11ties. With-first pio ritycasualties diverte d to fleldIhospitl, thsevacatio 'hsia- were capbeoprvdgeclen surgerytog ther acomlisunetsdepended, ultimately, upon the, extent an dcare with,

whih nntrnsprtale asultis hd ben iltred out in clearing,stations and fiel hopitas. hen histask, had been well1 done, a vcainhsia a

~to 100 refr peods ofdy ntiefsrss

An attmpt wa ala s a o bilance the numhber of lghtly and s1-

riouly n ouned teilyadmssins.The, Ofcein, corps head,'qatrs

chage f hsptalzatonand evcilaton 1"ow the number, of patientwh

to hopitls hic o dver casualties whn the, first1hopital had, reace t

Wheni serious backlogs- developed itwas spoetimes found wiserlto rans- port aauaty who *ould 'not be harmed.by further evacu'ationt n~r

hospital in which the workload -was, lighter and 1 he col, d.receive, immediate

sugry., D1urilg th pusi nrt of, Rome, .sane-casualties, who woudh

beeihsld ii ariiyhospitals unider more stati ',conditions,* weevacuated for

surgery to baUse hospitals earlier than ordinarily desirable. This *as anothe

opeatinalnecssiy ichwas regarde6d as expedient' but not 4" e , .b The400-bed evacuiation ,,hospital, reinforcedb w rmr surgical tams

proveIaN leo.adln h same number of ceasualties per, da asa evacto h *pta ithI its intrinsic staff. The larger, capacity o h ZOb~

evauatbn-os~tal. wasa tn -adVantage buta ~hospitaL.oftis size was cumesomei to mbive. Whna 400be hospital was provided with extra be c~pAcit in hefor o a4qutel euiped claring ,platoons k- po Vrcmt' ' e isnt -i a' fluid tiaical ituatio than' th6 lagr~pptl harrangeinienit had- another desi ~b6-9ec-h~linigpatoonis Nwhichfurnished& the addWina could rable 'f 11pc-heea ti Af 9 b6 left aso ing-ui i yl~ e theipareht'eVacuation hospial mvefrwad These hospitals fi~equently had pati. ints -who haqtd. had,
.384 ' ACTIJ~VITIS o SU CACNSULTANTS

,thoracic or abdominal or other major surgery shortly, before, and it was justas

impoftant-to. old thesepatients intlhse units for the proper length of time , -

afteroperation asit was.to .hold the ,seriously wounded i-the:field hosptal platoons for a certaiirieridof time after sur

The rapidmovement of evacuationhospi tals was quite-impor tant,Durng

the :adVane. north of ome, for instance, n then summer of 194, gains of'i miles, aday ormore byithe Fifth U.S, Army were not uncommon. 'One

Ocasjnheiit Evacuation, H vital was 15,milesbehind the frontline on.

one da#yand, 30 milesbehind-it onthe next day. The:8th IEvacuatio Hospital, one8a day in June 1944, wasplaced -nly 6 miles behind tho frotline and, witin

afeww hurs, found its forward location fully justified by the sped of the.

rn spite.of carefultriage at the clearing station, it, was ine vitabloethat as

the load-on field hosp0tals:increased, he number of; seriously.,wounded casual-.

ties in eaeuaionhospitals ilso inre, the most forardhospitals natuialli

recivngth mstseriousl woundeLp.38) At the beginning of the-9!Yensive.whicheculminated in the breakthrough into the Po Valleyin April :1945ono .. evacuation hospitaireceived so many casualties ith extensive and often nil-;

alth o.Ugh its surgeons- were .experne and : ompetent-.and , were ai 4'eby reeauxiliary surgical group teams. The rearmost ofthe evacuation lsospitas

supporting this offensiveon the other hand, alhough it -was augmentedby"

onlyonesurica tea, credfor140 essserousy wunded caslualties ,over

the same 24-ho--peio with, no--difficulty- at all.

Dtring 1944, several- significant changes and, impoe nt ocure in

FifthU.S. Army evacuation hopitals, as follows:

I1 The standard of thoracic surgery ina, number-of hospitals Wasgre'atly

'improved by the attachment to them ,of eperienced.thoracic, surgidal,' teamsfor periodsoffrom 1 to,3 months. Drming'this time, sustained efforts:were

made, toteach the intrinsie surgical staff refinements in:, themahnagemeit of

wounds of -the chest. Thiswas .a matter of considerable importance, since allchestsurgery., except in-nontransportablecasualties, was donein evacuation

-hospitals. In addition, casualties with thoracoabdominal woUids often,

reac.hedevacuation, hospitals-from forward,-areas in Which there were no.interVening i1d hospitals. Surgeons in evacuation hospitals who had the responsibi it y for these patients were kept busy, and it was essential tlt th ekyb

coin tent;

2. Most neurosurgery was also done in evacuation hospitals, aid, seve ra

hospitals, which had no neurosurgeons on their staffs were strengthened by, the

temporary attachment of neurosurgical teams, which were withdrawn when

the special need had passed.

3. The same plan was also followed with maxillofacial teams.

4. All evacuation hospitals adopted the policy of holding casualties in

shock Or preoperative wards before surgery. The assignment of cases to in-
d!iial rgica1.teaAms and the4deion as-to.the 6 optimum timefor surgery

wrsIfete the responsib ilothe chief of 'surgery or his representative

Ah iid~sometfisthat of the-medi l oicerin charge of, the shock ward. Post

operatvecarewas usually supervised by the operatng surgeon. 8 . o e/lectivesurgery was performed in evacuation hospitasdurig p. node~f sustained combat a etivity.r In quiet'priodsbtiwnaoffensiyes,;, mnor

elective vsurgery3, icluding delayed primary wound, closure, was sometimesr

permitted f itseeme likelythat the :

patient could be rturned to duty fro,

t' 'evcuation hospital or fr0m the convalescent'hospital. in the army area, o .n0ajo relective surgery was ever permitted in an. evacuationhospital.

6, ~ Jecae paciceforthesurica etabishd stffsofmost evacuation

hositas~t met ncea wekorof tenoer-for the preentation'anid discussion ,of., -- c tliniicail mater~ial , .. ." . .. :, ,- • ''

Auxijary- Srgici a Groups

Major Snyder's first ass ignment,beforehe was formallyappoited-pro , fessioaI servicesofficer to the ,Surgeon, ICorps, was to eval- uat e th 'e work~ot ( th!e teams from the-.2d Auxiliary Surgical Group whiich. were working in a

Bitish ihospiital in, Algiers. Hisg firs orders when ,he reported, to, H Corp s

heaqurtes n Mrc 193 o eporary duty were toevalate ' the, use, of,

simirsurgical teamis in, clearing stations. Mietherree beaeaquane pro[tly iththe excellent work, ofwhich thesetams were capable as ell

as-with the pontialitiesfor i usfulness ina combat zone.

Assinmet hspltlu.Suricalteas tofied fom axilarysurgickl

0grOups ere used infield:hospitals for the first time, in theSicilian campaign ,.

Bfore the invasion,,Colonel Amspacher and Major, Snyder sente.considerable

timeith theprofessional staff of the 11th FieldHospital. and With members ,o'

thd tehis.if the 2d and 3dAuxiliary Su rgicalGroups which were to augm6e , its taff. _rgajc, Much of thistimewas devotedI the discussion of, functios hfledosPital platoons witch were to sere as forward surgical'units. DurIng th.lttorpart of. the Sicilian campaign, tho 0thField Hospital -alsdcame,

SOriginhly, fied hspitals had functioned as little more'than station -hose ital~, :inhg the Sicilian, campaign, When platoons from the 10th Fi Id

HospitaWhad been sent forwar'd.t0 install the !selves"beside clearing stations.

id provid6 §ufgicil care'for nontrhsportable casualties, it had become evident,

that, for this type of organization to function efficiently, its, organic persionne

-must b gmiinted byteaisfrom an- auxiliarysurgical group. Such te ams

Were-thbeefore attahed to the 1h Fieid 'HoRpital, just as they had, been at-;

:tachad t'the 1th Field Hospital before the invasion. This plan was- used: thereafter.-

The piofessional personnel 6f auxiliary surgical group teams sent to field

hoispital '.platoons had to be selected with special care. Young, healthy general surg4eon, capable of performing major surgery of the abdomen,, chest, and

extremities, proved most desirable. The specialist who was not also a good
;386 ACTIVIT.IES- OFSURGICA CON SULtANTS

goneiat surge0n did not belong in a field hospital. Chest and abdominial

Wounds fornied the mapr potioniof the workload. The, team on duityAt a Jy

giyen time, however, had,to be able to handle all ,the patients admitted while

it was on duty,;:0therwise, extrhaloads had to be carried by ther, teams, Tis

mpeanht s specialty teams asb orhopedic surgery. teams,, neuro~urical

teams, andmaxiilofacial teams ver, not ideally suitedfor workin field hospitail

and were betterattached to evacufition hospit'als, in whih-these special W as

w 6e'chiflhaidled.i

'Thoracic surgery teams capable of doing goodeeral.surgery, were, extremely'valuable in fieldiospit'als, ,though, there were net-enough 9f, them- to

haiigndle the thoracic surgery which- hadto be done, in them. The prolpemn

Was, best solved" by a ttaching one thoracic surgeon to a field .hospital platon

to perform some operations.himself, to~superiseopreoperative andp p0st.eatvo tareiaid toteach generalsurgeons the indications for, ,and the finer techniques of, thofacic- sufgical pioceures. Mdany young general surgeons thus

Jparned to do good'thoracic surgery ofi the sort necessary in a fieid hospitai.

Anesthesiologists 'With surgical teams also improved the efficiency'Pf 'less

well trainedanesthesiologists in field hospitals by teachingthem the-technique' ofendotrachea" anesthesia, the use of the bronchosco for aspjration of kle

trachea and larger bronchi, and other techniques. Inthis connection, surgeons

with, experience, in thoracic surgery did much to elevate the standards of anesthesia for this kind of surgery in both field and evacuation hospitals,

A"signment to evacuatlonhospital-Auxiliary surgical group teams

also functioned in evacuation hospitals. As already mentioned, a 400-bed

evacuation hospital, if augmented by two or three surgical teams, could do

essentially the Same volume of surgery as a 750-bed hospital with its orgamic

personnel. In times of great activity, as many as six surgical teams were often

a ssigned to an evacuation hospital.

Administrative considerations-Originally, the auxiliary surgical group

teams were not used to their full capacity. The teams which were attached to

field and evacuation hospitals had to stay with these hospitals, even after their

usefulness was ended. The II Corps surgeon in Africa and Sicily and the

Fifth U.S. Army surgeon in Italy moved them only when they were needed

elsewhere.

When the group headquarters was established in Italy in 1944, close coordination was effected between the Office of the Surgeon, Fifth U.S. Army,

and the group headquarters, under the command of Col. James H. Forsee, MC.

For example, when a team had finished work at a field or evacuation hospital,

it was recalled to group headquarters, to rest up and get ready for the next job.

All teams had to be kept on the alert, to be prepared to move on very short

notice to field hospital platoons which were receiving more casualties than the

teams already assigned to them could handle. The fact that it was possible to

shift teams rapidly to the units in which they were needed did much to improve

the caliber of surgery in the Fifth U.S. Army. In fact, the Sicilian experience
386 ACTIVITIE O77RICLON$LAT

g4,ier6i surgeon did not. belong, in, a field, hospital. Chest -and abdomifnal

woung ds Iformedthe-major portion- of the -workload. The;team on,:uty.at an

,givent.me, however, had to be.able t handle all , the patients admjitted while

ilt. ason duty; otherwise, extraloads had to, b carried by othe ,teams,. hThi meant that such specialty teamsas orthopedic surgery teams, neurosurgicA

teamsand .maxillofacial teams were not ideally suited for work in field-hospitas

andwere better attached to evacuation ,hospitals, in which these special wound§

'Thoracid, surgery Aeaiscapable of doing good- general surgery wereextremely-valuable, in. field' hospitals,.though.ithere Were-not- enough of therA ..

hlandle :allthle thoraceic surgery wv~hich had -to, be -done in ~them. The prob lem,

wasbest solved by attachingone thoracic surgeon to-a field hospital, pltoorn 4iperfo9rm some operations himself, to-supervis preoperative afidpostopeta tiye cari, andto techgene~ral eurgeons the indications-for, ,andthe finer techniqUes- of, thoracic -surgical procedures;- Many young. genera surge .n thus

gr to do good tloraoic surge~y f.the ,ort nec6ssary-in a field hospital,.

.Anesthessiologists-withsurgical teams also imprgved' theefficiencyof less

well trained aesthesiologists in field hospitals by teachgthemn the techiiiq,•

o0f endotracheal-anesthesia theus6 of the-bronchoscope for aspiratio 6aofthe

trachea and larger:bronchi, and other te hniques. In this connection,-surgeos with,ekperienc; in thoracic surgery di.d much to, elevat the standards of

nesthesia for this kind of surgery in boh fieddand evacuation hospitals; ,

As-iguinent to evicuation hapitals.-Auxihiary -surgicaljgroup jteams, ,

also functioned in evacuation hospitals,. As -already mentioied, a 40 d

evacuation hospital if augmented ,by two or -three surgical teams, coid do

essent illythe same volume of surgery as a-750.bedhospital with its organic,

personnel, Tn times of great activity, as many as six surgical teams were f ten

Administraiive conideations.-Originaly, the auxiliary surgicalgroup

teams were not use~d to their flll capacity.; The teams§ which wereattachiedIto

field ,and evacuation-hospitals had-to stay. With these hlbpitals, even-After their

usefuness wasended Tlie, Ii Corps surgeon in Africa and S c fidthe

Fifth U.S. Army surgeon in Italy moved them only when they wereneeded"

When the group' headquarters, wast esabhished in Italy in i944, closecoobrdihation was effected between-the Oice:of theSurgeon, Fifth US. Army,

and the group headquarters, under the command of Col. James H. Forse MC.

,For example, when ateam had finished work at a field'or evacuation hospital,

it was:recalled to groupheadquarters, to iest up and get ready, for thenext-job.

A teams had to be kept on the, alert, to be propared to move onerysort

notice to field hospital platoons whi~ch were receiving more casualties than- the

;teams already assigned to them could handle. The fact that it was possible to

shift teams rapidly to theunits in which they weke needed did much to impove

the caliber of surgery in the Fifth U.S. Army. In fact, the Sicilian expeiience
:4, 

,. ~~~~~ . .t ...', , :" ~~~ ..... ... 

provedtit1he attachment of surgical and other teamis from auxliary, surgical

groups 4 ' fieldhospitals provided far better surgical care than had 'ben wpf

, , d~arher, , whenmsurgery wasdone in cl ring,stations, On 12 May, 41q . .

f6r, in§tance,, -Major Syder foun a backlog- of surgical cases at.the 11th' .

'ieldf ik, Ih , was supporting- the 85th Divisioni. the breachingof , ,

theGustaLine. CooneiForsee was notifiedandaditionalsurgical teams

were at 6ioe sent forward' to supplement the-three teams already-assighed to th-e

hospital, T days later, the56th Evacuation Hospital- also- ad a ar ge-

. ilog oioperations. Severalconplete sUrgical-teamswere.immediately seht

orwif to, elitRapidmovemnent, of this kna woldhaebenmosibe

wihot h poprad ministrative setup.

The hmberb of tams attachedto- a fieldhpspitalhad to be flexible, first,

t,'cdMPensAt6 for the increasei*nsurgery -which r sultedfrom a broadening of6 the c61cept of the nontransportable casualty, and, secondo to meet the increii6d

workload iipeakperiods., 'Two tams could readily handle all-the work Aduing~statiopiods, but4at leastsixsurgicaltams andtwo, shoqk teams were required du.ing an, offensive, whilethe" Useof eight surgical teams wasnot at

:{-" ':" 'Whev the mission otf fiel hositals ,was extended totthe surgical .care;of:,....

nontianisbitabl eiasualties, it was found,.as4 already nbted, thatthe organic

staff~was not;, sufcient.to handle lthe new responsibilities. Late in,1943 , as^

ar-tial r odtioi n of this problem, it became, the practice, to appoint- thechief "

surgeonof some one of theauxiliary surgical group teams-attached-to the field

hopiali s'hif 'of -the surgical ser'vieinit. The appointment,*wa made by

thOconwaiing officer of the -field hospital, with the advice of ColonelrFqrse

anfd Major Snyder.,

This plan did Ilotpr ove paiticlarlysatisfacthry. One teasoh was that,

ocasio-ally, early inthe, war,.the ranking officervwas not- the officer best qualified ofessionaly t° serve as cif of the suical s rvice. ninohe rer ason was

,that thprofessional work of this officer withhis. own team left, him:iittle time

t pervise t 9 woesria evc sqaey

Ttid.,difficulties were grdually overcome. In December 1943, Majr

Snydli' was -given permission by Lt. Col, (later-Col.), Clement F.,St.John,,

MC, hief fPlans and Operatidns, Ofce of theSurgeon, 'Fifth, US.ArMY,

b t tiaf FbQrsee about the placement of auxiliary surgicalgroup

em$I fleIA'hospitals and the use of Oi the surgeons as hief of su rge

Additional discussions Were held with Lt. Col. Samuel A. Hanse: MO Coin

mafdifig Offcer, 33d Field Hospital, and with Maj. James M. Mason III, MC.

Atti. time, there was considerable feeling between field hospital per-

§6nne6Ya nd adxilia ry surgical group personnel; fi~id hospitalpe ronfiel, rather

iatbfallY, resented the alterations in their functions required by the addition

of suiges to take care of surgery which they had been led to believe, they

woud iperform themselves. Mafjor Hanser took a broadminded ond highly

intelligept view of the new arrangements and was most cooperative and under-
88ACPTIVITIE.S OF SAURGICAL-CONSULTANTS

standng. Mjor Mson aacompetent- surgeon, 'who understood the profes-, ,sional and administrafive'problems of forwa*i surge ry and could advise Major

Snyder-concerning the new problemslikely to ars with the- appointmentin

4& -"fi ospital-of a ,sutrgicalchief wh was not ,part of its, orai per'-nl.I

Tepro[em, was evenhtually solved b4y th4ppoinitment ftems xe

rIence dofficeramong the- teamsa'signed toa fied hosp ita-platoon toperform

thedutes f~srgial hief fodr the platooni. It *w soon found that thems

heoul .d devotehimsel.f entirely tthe supervision of the work in-tehospital.,

Hisdutes ncldedtrige;A suevsion ofpoperAtiIV eA rain ~u -tion,4 ana postoperative.- care- .and consultation, -as.necesry, on wou s, o .

~pari~uar eveityor dffiult. Hs*6rk,'in.the operating room was- limite

.toastancein casesof thls kind.and to the, demonstration of new ;techiques

andof modifieations ofeatablishedtehniques tOthe hospital staff. "'" Not the leas important of the functions of. thechief of surgery was~coopeation with the commanding officer of the hospital in, the correlatio0n of

.administr.ative andprofessional functions, In the'last .6 months.of, the .-wart

th .chief.of surgery ina, field hospitalcame to be kownl.very proerly, asthe

coordinator. The title was first employed, i the 2dPlatoon ofthe"83dYie.d

-Hospital, in Which Lt. Col. Sigurd C, Sandzen, WM , of the 94thEvacuatio, .

spiptti, .was- serving-as-chief oflsurery, Colonel Saidzen had requested

A similar requestwas made by Col. Eldridge.H; Campbell, Jr. Mto, of the. .~33d Gen~eral Hospital, who-served. as surgical coordinator .at the 1st Platoon,

qf the 33d Field Hospital during the Po Valley offensive, ir Aprili945_6oiiel

Campbell, earlier, had brought, a complet team of anesthesiolngist nurses,, and,

enlisted meni to erve with hifmfor several weeks in a field hospital.

Duringthe sprig of 1944, it-wasproposed that aforward surgical unit

bemade-up from the staff of.the-38th Evacuation Hospital (1g.,T2), t handle

fst priority.cases. Thettables of organization and equipment for-thisunit

weroeprepar(edbut, the hospital f6und'itself with so much to dothat the pro,

LIAISON WITH MEDiCAL UNITS OF OTHER- ALLIEbD ARMIES

P.art 0f Major Sny der's dutiesas ,sconsultant in -surgery to the Surgeon,

Fifth U.S. Army,included liaison with, and assistane.to, Allid medical'units

'Both General Martin and-his executiye officer, Col. Charles o, Bruce, Mq, thought that the

dilIulties which had arisen in the operation of field hospitals in tht Mediterranean theater might be

eliminated by the formation of a mobile arm' surgical, hospital in which the commanding officg, A

competent general surgeon, Would serve as chief of surgeiy. Thir unit would have the propet nii nbef

of qualified surg"ns as part of its integral personnel, or its personnel could be supplemented, as necssary,by teams from an auxiliary surgical group. The tables of organization and eqiuipment for.

such a unit were drawn up in the Office of the Surgeon, Army Ground'Forces, to which Colonel Bruce

Was assigned after the war. It was a disappointment to Colonel Snyder that mobile army surgilal

hospitals were not used in Korea as field hospital platoons augmented by surgical teams had been used

in iily.
IFTHi 1U.8. ARIMY :1S9

Sle 1vl Al i r
"390' ACtIVITIES -65 SUR1GfIA CONSULTAN 1,

servig With theU.S.-Army. The following activities are tyepicalof thj phase

On26 November i943, he-visited a French- fieldI spital near Mbn6e'Cas

'sino. Theunit was ,sulposed to-have- thre-surgical ,tieams,. eachi Workln a

8-hour shiftand an. attached mobile surgicalunit Eachteam, whichcfisisted

handle .16 surgical cases iheach g-hour operating Period. Siice, 0ny, tW

teams were:presently attaehed: to the-unit, the staff was workibg 1'2,-hoil

shifts. Two perafing tabies were in continuous use. The third: table w#a§

supplied with fluoroscopic facilities. Tentage was limited, andsterihz

inshort supplyi but otherwise ,th6 teams had all the equipment they needed.

The §urgical work at this hospital was excellent.

On 9 January 1944, U.S. station and general hospitals at the Fair Grounds

.at Naples, which were receiving French wounded, were visited, to deteminewhether the complaint that surgery performed in French forward 'hbspitais

was too radical was justified. No instance of overzealous cebridement *ais

found in the patients examined, all of whom seemed in excellent condit!0h.

On 4 February 1944, Major Snyder, acqompanied by Maj; Oscar P.

Hampton, Jr., MC, then serving as acting consultant in orthopedic sfigery for

the theater, visited the 401st Evacuation Hospital (French), then 'located

between Alife and Pratella. They came away with only admiration 'fr the

work'being done. A suggestion made by Maj. Etienne Curtillet wasopionptly

adopted in U.S. Army hospitals; namely, that plain fine-mesh gauze rather

thanipetrolatum-impregnated gauze be used in wounds. Major Hampton was

particularly impressed by this suggestion and did much to disseminate it.

When a Brazilian Expeditionary Force joined the Fifth U.S. Army in the

summer of 1944, U.S. Army medical officers were designated to supervise their

training in first aid measures and field sanitation. Professional Brazilian

personnel were at first assigned to the 38th Evacuation Hospital, which was

supporting U.S. troops holding down the left flank of the Fifth U.S. Army

sector; Brazilian troops had been integrated with these troops. When the 16th

Evacuation Hospital moved to Pistoia in November 1944, Brazilian medical

personnel were attached to it, and it was designated to care for Brazilian casualties. Lt. Col. Manuel E. Lichtenstein, MC, chief of surgery at this hospital,

organized the Brazilian personnel into teams, with definite assignments, and

they rapidly became an excellent working organization.

Brazilian casualties who required evacuation from the Fifth U.S. Army

area were sent to the 7th Station Hospital, which was then serving as a general

hospital in Leghorn, and those who required evacuation from the theater were

sent to the 45th General Hospital in Naples.

On 5 December 1944, Major Snyder visited a platoon of the 32d Field

Hospital beyond Pistoia, in which a Brazilian surgical team was working.

The team was headed by the professor of surgery at the University of Silo

Paulo, a well-qualified surgeon, whose team was doing excellent work.
W1i the 7fth, h'achation H~sPi~t al arrived- in -Engiand, the only equipmentwhic itliad for tioracie surgery was a Pair of rib shears, a right and left

rib raspatoryand a Nq. 14 French ascites trocar. Other general and special

pgas also lackig, The explanation of soie of these defieni es came to light in North Africa, when it was discoveied, from the i918

'inwspapers in WVhich the instrmnents-Were packed,'that'the table of equipment

by Wiiil th y had been p-ovidc ,was a World WarI table.

s0i'atiobs in British chest centers (p. 333) showed that the British

Were well equipped for thoracic surgery at this time Their sets had been,

statndrdizedfind more than 50 had been. distributed to Army, Navy, and Air

F~ee unhits, 'They included long-handled instrumentsfor working within the

tl ,ih endoscopie equipment; adequate anesthesia apparatus; and various

anesthetic agents for chest surgery, including cyclopropane. The equipment

also'included tables or cabinets equipped to convert electrical current into high

frequency current for cutting and coagulation, as well as for converting the curieiitinto low tension current for use with endoscopic and other lighted instrument, This type of table also had a suction machine attached. It thus took

the place of (1) the Bovie apparatus used for cutting and coagulation, (2) the

suction machine, and (3) the battery case or rheostat which provided low tension

current for lighted instruments. The British regarded this particular piece of

equipment ac indispensable for chest surgery, Mobile thoracic surgery teams

functioning in the United Kingdom were also supplied with all the equipment

just listed, as well as with portable X-ray apparatus.

The proper steps were at once taken to report the inadequacy of the 77th

Evacuation Hospital equipment. Meantime, the medical officers on the staff

each donated a small amount of money, which proved sufficient for the purchase

of a suction machine and a Bovie electrosurgical unit for neurosurgery. Members of the thoracic surgery team personally purchased a brcaehoscope and a

number of instruments for thoracic surgery. The equipment was secured at

the Genito-Urinary Manufacturing Company Limited in London, an old and

well-established firm which had originally supplied only cystoscopes and other

instruments for genitourinary surgery but which now handled equally excellent

surgical equipment of all kinds.

Even with the equipment supplied personally by members of the thoracic

surgery team in the 77th Evacuation Hospital, its equipment, like that of other

U.S. evacuation hospitals, did not begin to equal the British equipment for even

their mobile surgical units. When the 77th Evacuation Hospital was assigned

to the II Corps, Colonel Arnest and Majn-" i.spacher did all in their power to

bring the equipment up to standard requirements, but in the 10 days before the

unit sailed for North Africa this was an impossible task. The deficiencies were
ACTIVITIES OF'SURGICALCONSUTANT'S'

u"uortnuhate for competent thoracic surgery is imposble without ,poper

Whienthe 77th Evaduation :Hospital reached Orai an4 hadh to as.sumethe

care:of casualties. immediately (p. 335), it found some ofthe eqUimenpe f" tie

38th Evacuation Ho6spital, which had landed at Arzew a little eavier, 4 : the

hospitals it was taking over. This waS fortunate, for the 77th Evacuation

Hospital did not.receive any of its own, limited equipment until several:: days.

afterit h ad landed. The situation of this hospitalin rsp¢t to deflciencie of

equipment andd delayed receipt of such equipment as'had been, provided- wag

unfortunately characteristic of the situation of many other hospitals diiring the

beakly.fightingin North Africa,

Reommendations.-When Major Snyder was'placed on tempor ary duty

inTI-Corps headquarters in March 1943 to evaluate the use of surgicaliteans in

clearing stations (p. 336), he made a number of recommendations to the Surgeon, II Corps, concerning the equipment of these teams, as follows:

1., Portable anesthetic equipment is essential for the care of patients with

certain types of wounds and must be provided if surgery is to be provided: in

clearing stations.

2. A larger autoclave for sterilizing linens and dressings is a basic need,

as is a field range burner unit for heating the sterilizer.

3. A satisfactory portable operating table is also a basic need in each clearing station.

4. A pelvic rest or a portable Hawley fracture table must be available for

all general surgery teams as well as for all orthopedic surgery teams of auxiliary

surgical groups.

5. A portable suction machine would be of great value in the surgery of

perforating wounds of the abdomen.

6. Teams of auxiliary surgical groups should have their own transportation.

These recommendations were all eventually carried out, though the question of transportation for teams from the auxiliary surgical groups was never

entirely settled. In southern Tunisia, teams attached to the II Corps were

provided with their own transportation by Colonel Arnest. When they returned to their headquarters, this transportation was turned in. The arrangements in Sicily were similar. After the headquarters of the 2d Auxiliary

Surgical Group was moved to Italy, the group was authorized a certain amount

of transportation, and Colonel Forsee maintained it in a motor pool, sending it

forward as necessary when the teams had to be moved.

Sicily

Before the invasion of Sicily, the field hospitals, which replaced clearing

stations of medical battalions as the most forward installations in which surgery

was to be performed, were provided with much more in the way of surgical

equipment than the clearing platoons had possessed. There were, however,

still a numler of shortages.
FIFTH ~US RMY33

; '~~Oe e.of, .lio. most conspicuous- shortages was in anesthetic app~aratus. "In. ::,.:.

gicily, ,evac!ation iospitalS lad anesthetic machines, though At-inuinbe rYas

somwlat-limited. Auxiliary surgical:group. teains .working. hin field hospiti' pllaons woe stiliill-equippedctin.tisrespet, Maj.:(later Lt.Col- )Lawrence

M. Shefts,,MO, did, most of his itrathoracic work, asa matter of n cessity.,

'inder Pentothalsddium and oxygen, the oxygen being suppliedthroug;lva 1i3B

('toodtby, Lovelace, Bul bulia) mask. His results were extremely satisfactori,. In fact,h1e performed so many operations with this sortof anesthesiha

without untoward' consequences that he almost convinced himself and his:

:associates thRtAis Was the ideal anesthesia for intrathoracic woik, in which :it m~gneraly:gardeid ts contraindiatedi

1n1 ,SIi fieldhospitals had only .a single X-ray mahine for each hospital. Itwis promptly evident that'if a field hospitil's three platoons were to.

function satisf.actorily.as 3ndividuial platoons, each mnst' have its own X-ray

equipnient. X-ray equipment was also necessary ir Al holding units if adequate postoperative carewas to be supplied.

In 1943, when X-ray films were in short supply, limitations had to be

placed upon the number used. In 1944, when supplies became more abundant,

theselimitations wereremoved, Then, almost without exception, roentgenograms were. made before operation unless the surgeon was absolutely eertain

that there were no fractures and no retained foreign bodies. Some hospitals

improvised large dryers, so that the dry processed films were ready when the

patients went to the operating room.

Transportation difficulties explained some shortages of equipment in Sicily.

In one collecting station, for instance, three patients with compound fractures

of the femur were brought in by litter between 12 and 18 hours after wounding,

all of them nsplinted because the battalion surgeon, who was receiving his

supplies by pack mule, had run out of splints and his fresh supplies had not

arrived. It is a tribute to the atraumatic fashion in which these patients had

been handled that none of them was in shock.

Italy

After the first 6 months of the campaign in Italy, except for such special

circumstances as have just been described, surgeons in the Fifth U.S. Army

usually had the best equipment available for field surgery and had it in ample

amounts. Some annoying and wasteful shortages, however, still persisted. A

small electrical unit, equipped to resharpen operating knife blades, for instance, would have relieved the frequent shortages of these blades and would

have prevented the discarding of instruments which otherwise might have been

used for many more months.

Some equipment, such as audiometers, was always in limited supply, and

patients who required a study of possible hearing loss were sent to the special

centers which possessed them. This was not an unreasonable arrangement.

Similarly, casualties who required elect rocardiogranis had to be evacuated to
39QATIITIES, OF SURGICAL: CONSULTNTS,

tlie bitu intil the 8thi Evacuiatiow Hospital, was established asothe army enter

'lotila~suchf iestigatibns.

Transpoitatiol of isupplies was a. considerable problem in Italy ,ntApril

194,duringthe iace eross the Po. tle, when supply ep os adn, dumnp

weie still back in Flo'rence. Medical. supplies then often had. togive way to

more, crucial needs, such.,as gasoline, imuntion, bridging. materials,.? nd,,

Ationis.,

Nonstandard Equipmht

Ohe ofihe-duies of the surgical consultant to the Surgeon, Ffth ThS.

Army, was to advise him and his medical supply officer concerning the surgical

equpment needed for all army inedical-installatins. In line with this duty,

•re usts foi' items-in excess of tables of equipment were submittedto Major

Sn-'yder for commnent and advice, His advice was alwaysfollowed. Some of

tlhe additional equipment was really needed, but a great deal was not. It often,

t'ok newly nductedoffi cers some tine to-lean that they were not operating

ihder conditions of civilian life and-must make do withwhat they wer given.

As zaf matter of fact, a directive from the threater commander permitted ,the

army surgeon to make additions to the equipment lists of hospitals in the area

as he considered it necessary. This permission was a great aid to efficient-functi0oning when demands on a hospital were abnormally high or when special

equipment Was really needed.

Anzio

Supplies at Anzio furnished a number of critical problems, though the

original landings were without incident, The first section of the Advance

Platoon, 12th Medical Depot Company, arrived with the second wave of assault

troops on D-day. After the first landings, however, no other medical supplies

could be landed for the next 5 days. Fortunately, enough had been brought

ashore to cover this period. So many supplies were destroyed by shelling when

they were concentrated in the usual dumps that it was necessary to distribute

'them widely, in order to protect them.

Acute shortages of blankets, litters, and similar items developed because,

when patients were loaded on LST's for evacuation to Naples, there was no

time, and it was not the place, for exchanges and bookkeeping. Eventually, a

plan was set up of placing an empty 34-ton truck on every boat which took

casualties to Naples. When the ship arrived at the base, the truck was loaded

with litters and blankets which were provided by the hospitals receiving the

patients. The truck was returned to the beachhead on, the LST.

Improvisations

The development of improvised equipment to overcome shortages and of

special devices to improve techniques was heartily encouraged in all hospitals,

and information concerning these items was promptly disseminated. The improvisations ranged from the simple bending of the rod in an ammunition box
-"" FIFTH ,US,: RMiYo -35 !! -

.to-lt.it.for Use ,as-va pLsma stand to the constructionof Oa -i'efrigerator -for the

li 4Th-. Armored Medical, Battalion, when a shadowless ligit -fo the

operatg roomwasrequired , constructed- one by reclaiming theheadlights:of

seral v

i' iioes destroyed by enemy .action. and inserting tie fiosted, ero.sribbedglass in front of a light bulb. When the light was attached-toa swing. ing afrfi it couldbe focused on, thewound without casting a shadow. When

lmedicalofficers of the same unit were called upon to explore eardrums without

an otoscope, a yeryefficienit one -was constructedfrom a flaslight, an aluminum,

--cone aly~ged rom a crashed enem:- aircraft, and-amagnifying glass.

At-the.398th .Evacuation Hospital, an excellent vacuum bottle was devised

from n old Baxter saliie bottle. A tire patch was used to cover the two holes

in' the i'ubber stopper. A small amount of citrate solution was then placed in

tebott~e' which was autoclaved With the rubber stopper inserted loosely. As

soonas the hautoclave was opened, the stopper was jammed into the neck of the

bottle. Enough suction could be developed with this improvised vacuum bottle

to withdraw a liter of blood. The same bottles were used in donor sets as well

as for aspiration of the chest. They worked very well for all of these purposes.

One- improvisation, the use of Baxter bottles in which saline solution had been

* put up to collect urine, proved of great clinical usefulness. It was essential

th at accurate urinary output records be kept on all patients in field hospitals,

but there was very little time and very limited personnel for this purpose. The

problem solved itself when a Baxter bottle was kept by the cot of every patient

in t field hospital unit and the contents were measured each time (usually twice

daily) the bottle was emptied. This proved a very practical method of recognizing oliguria and impending anuria.

Suction for intra-abdominal surgery was provided by an ingenious plan in

the clearing station at Gafsa and in the 48th Surgical Hospital at Fdriana. A

jeep or command car was moved close to the operating tent, and a long rubber

tube was connected to the suction apparatus which ran the windshield wiper of

tle car. The tubing was brought into the tent and connected to a suction bottle, after which the windshield wiper was turned on. This meant the sacrifice

of a needed vehicle, but commanding officers were more than willing to give up

a car to provide this very essential aid to abdominal surgery.

The Relation of Equipment to Results

After the Peninsular Base Section was established, all Fifth U.S. Army

medical supplies were secured from it, as were supplies for the French and

Brazilian units, and sometimes for the Italian and British units, which served

with this army. During the Italian fighting, 2,524 tons of medical supplies

were received by the 12th Medical Depot in the Peninsular Base Section, and

2,402 tons were issued.

Surgery in the Fifth U.S. Army showed steady improvement and increasingly good results after the landings in Salerno. While there is no doubt that
S, 396 .': ACTIVITIES OF SRGICAL CONSULTANTS

par of he considerably less good results originally scured can beekpl ned

byine-xperie'nce of surgeons untrained in military surgery, equipmepthort,-

ages also had something , to do with them. Later, when experience ha4dheeni

6accumulated and' supply, shortages had ceased; the surgical results finthe Nedi-,

eoquipment undoubtedly ,played -some :part in. them.,

'REASSIGNMENT OF MEDICAL UNITS FOR .OPER

(l a July 1944, i preparation-fr-the invasion of souther Francer(Opra-

: oNVIL): by the Seventh US, Army'on6 15 August 1944, the foll owihg

inee dal-uppptt was vithdri4wn from thbeFifth U.8. Army:

I. The 52d and 6th -Medical ,Battalions.

Th i. ,0hand, 11th fid Hos pitas

3 . The -i1i, 93d, and 95th Evacuation Ispitals, each of which.:had a

4. Half the teams of the 2dAuxiliary Surgical Group.

The surgical burden thus thrown,.up6 the remammg medical sup port-,of,

the Fifth U.S. Army, while enormous, was not felt immediately becase t ie

fightingl had' slowed down considerably when these units were withdrawM

When,'however, the character of combat changed-from-the battle of pUrsuit

which had occurred during July and August to the'bitter fighting- duiring the

North Apnnines campaign in the fall and wiiIter of 1944-4, thechangeid

tactical situation produced the heaviest sustained combat load'in the listry of

the:Fifth U.S. Army.

The medical service of the Army was called upon to handle this load-with

seriously impoverished resources; at first only one new unit (the 15th Field

HOspital) was assigned to it to replace the two field hospitals and the thred

eVacuation hospitals which had been withdrawn to support the Seventh U.S.

Army. Medical personnel worked at top speed to try to keep abreast, of the

constant flow of admissions, but there was a limit to the physical endurance of

the surgeons, and it was necessary to acquire surgical teams from base hospitals

to augment their depleted numbers.

The use of these teams, for a number of reasons, was not the solution of the

problem, and the difficulties of the medical service were brought to the attention

of the Commanding General, Fifth U.S. Army, in a letter from the Surgeon,

Fifth U.S. Army, and were in turn brought by him to the attention of the Commanding General, NATOUSA, on 15 December 1944, as follows:

Based on the assumption that Fifth Army would consist only of one U.S. Corps (with

not more than three divisions actively engaged) with a very narrow front, an unusually

large number of Fifth Army service units were assigned to Seventh Army to support adequately French and U.S. Operations. Since 15 July 1944, the 92nd Infantry Division, a

Brazilian Infantry Division, the * * * Infantry Regiment and the * * * Tank Battalion

have been added to the Fifth Army troop list without addition of any service units other

than those being activated. * * * Not only has there been an increase of combat troops,
but Fifth 'Army hasbeen required 'to commit two corps on-a' wide front ** with the

r tuit ti, veryl ritical-,shortageof service units iras developedand isseverely handLl

i pih 'th Fifth Army operations at one of the most critical tines of the LItalian Campaign.

'Fifth fniyJ i has sevenEvacuAtion- ospltalsto support six'U.S divisions, one Brazilian

'Division, and-one separate infantry regiment * • *. One complete surgical group is- nee

essarPto prIde adequate surger,' for'Fifth Army * "* Fifth-Army has operated sevamonths with, anI n insu ieetnumb6er of surgical teams andIt haibeen ncessaylo

provide. tas'from Evacuation Hopitalsfor Field-Hospitals injtorwardarasand this

hasseriouislyreduced the surgical service of~theEvacuation, Hospitals * * *. A few teams

ae b ee ided from base units, at various times * I*f it was necessary to attach.

these teams (luring the time Fifth Armywas regrouping, additional teams will be necessary

hen active operatioihs begin * * *, Duration of attachment ofBase Section Hospital

teins to:Evcticition fHospitals has been limited &und the -teams are often recalled during,

the time whentheir need is critical. The solution most desirable to Fifth Army is theoetufrn to 1fth Army of that part of the Second Auxiliary Surgical Group which was assigned

to:Sevent 'Army * *

'The solution most desirable to Fifth Army" did not come to pass, and

themedicalserVide problems were resolved as follows:

L Th6.29th Station Hospital was converted to the 170th Evacuation Hospital. Th6 responsibility for its conversion, the training of unit personnel, and

the assembling of appropriate equipment for the operation of an evacuation

'hospital'was assigned to the Surgeon, Fifth U.S. Army.

2. At, the same time, the 15th Field Hospital was assigned to die Fifth

U.S. Army. The headquarters and two platoons were withdrawn from Corsica.

and 'the remaining platoon was withdrawn from Seventh U.S. Army control

in southern France.

Medical service in the Fifth U.S. Army was not further augmented through

the remainder of the war in Italy.

RECORDS, SPECIAL REPORTS, AND PUBLICATIONS

Records.--In all tours of hospitals, Major Snyder made it a practice to

discuss clinical records, examine them at random, and insist that they be kept

complete and up to date. He made detailed notes of special cases in his official

diary, especially those from which lessons could be learned concerning good

management as well as poor management and frank errors. These case histories, as already noted, proved very useful in the educational program.

Essential Technical Medical Data reports were carefully read before they

were transmitted to the Surgeon, Fifth U.S. Army. Major Snyder added such

comments as seemed indicated, but the reports were neither condensed nor

-dited. He also submitted with them any material of value which lie had collected himself.

Full records were always kept by the teams of the 2d Auxiliary Surgical

Group, first by the members themselves. In the course of the fighting in southern Tunisia, Major Amspacher directed that the teams send copies of their

clinical records on all 11 Corps casualties to the corps surgeon's office. Colonel

Forsee continued this policy, and during 1944 and 1945 team records of surgical

6062221-62-2S
*~ ... - ,'r. X_3 7 . 1 

~398 ACTiTiiES OF SURGICAL CONSULAN tS"

ji: #94adi duplicate; 'The hiialysis, oqthejpaterialz

or r~pres~ts tho most complete,, nd mos carefu 1st ud 'a

serkies odf combat-inceurred abdomrinal.-iijuries ever, 'to be recorded. Itform h

ui~orton f one of the Surgical tolumes of "the history of, the U.S. Arm

S8pecial, repo'rts&-A number of spcial-suirgical'iiivestigations we~riq in - inthb Fiftih U..Arm n were, formally reported to the ar -my, surgeona

T. Shock, thejaprfrec toeatoradplsapoei aus

3Transfuso teaY -in battle casuaties, with, evidences* of Arellatr

fa ife by ,Capttin ~adichi.

4. The Surgery 6fabdominal-Wounds, by MAfj,:Fred J. Jarvis,M.

II'. Iitkapleuril, and 'intrthaclic wi, Nounds,. by Capt. (later Ma.) Leo tM

6.iToracoabdomina1 battle -casualties, byCpIHnyL Hfmn MO,

'.Trenchfoot, by Maj;, Fiorindo A.,Simeone, 4C (p. 428).

8,Arterial ihijuries by- Major Simeone. (p. .431);

9Gas gangrene, by Maj. Floyd H., Jergesen, MfC, and M ajor_.Simeone

10. The physiology of the severely wouinded, by a special- board, from tbie

theater surgeon's office, which partly elucidated, but did not solve, tlie.s ~pcia1

problems of oliguria and anuria in wounded men. This report forms anothier.

ofthe volumes of the surgical series in the history of the U.S. Army Medical'

Department-in World War 11.19

Publications.-Major Snyder consistently encouraged individual medical

officers who were accumulating a wide experience in war surgery and in the,

management of shock and other related conditions to keep their own detailed

records and, later, when their data were sufficiently comprehensive, to prep'are

it for publication in scientific journals. He read all of the articles to be submitted for publication and returned them to the authors for necessary alterationis before they were cleared for the journals of choice.

In all, some 50 articles were submitted for publication from the Fifth

U.S. Army, covering a wide range of subjects, as follows: Administrative

considerations, including the use of surgical teams from auxiliary surgical

groups; shock and resuscitation, including the use of whole blood; anesthesia;

gas gangrene; trenchifoot; chemotherapy and antibiotic (penicillin) therapy;

causes of death in battle casualties; craniocerebral wounds; maxillofacial

' Medical Department, United States Army, Surgery in World War 11. Volume Il. General

Surgery. Washington: U.S. Government Printing Office, 1956.

IP.NMedical D~epartmient, United States Army. Surgery in World War 11. The Physiologic Effects

of Wounds Washington: U.S. Government Printing Office, 1952.
wounds, ciihest'injuries,'incildingcolntiibutionson wetlung, nerve block decOr , ticati6i in ernpyema and&.hemoth'ora ,andwounds ofthea,at; thoracab-

,omi'nainjluries; wounds of th abdiomen,, with specialreference to-wounds

S 6f thedolon and' rectum; ugoeniital , wounds;and vascular surgery, including

A16e use0of thetourniqiet

-STATISTICS

,ornom the beginning of combat in North Africa in November 1942, mucl • mp~isis " as pA~cuption- tli -ipracof performhng-post mo tem exami;,

i6ti9 oiall patients ,ho died inarmy hospitals. ThieoreticalIy,,tiis slhuld

haiv, ,been ,i routine 'matter; ,the -understanding, was -that -autopsy would be

pedrformed in, all, such, deaths. Actually, for a variety of reasons-niot all of

theii based upon-the prssure of work-autopsy wasomitted in manY cases,

This wasthe situation in the North African theater late in 1943 wIen

'fi jor Snyder initiated a special project concerned with the detailed analysis

of deaths 'im cimbat-neurred wounds in Fifth tS. Arny hospitals.

AOn 31, December 1943, Colonel Martin, the army surgeon, sent a letter to all hospitals in the Fifth U.S, Army area directing that complete records

of alldeatls in these hospitals, inclding the autopsy protocols, be submited

to his officr. Reports began to come in promptly, but some iospitals were

negligent or careless about the details required, and on 22 April 1944 the attention of commanding officers of hospitals was called to Colonel Martin's orig- i niil letter.

Theire was a progressive increase in the percentage of post mortem examinations reported as time passed (table 7), the proportion rising from less

than a third-of the deaths reported in the January-March 1944 period to more

than 80 percent in the January-May 1945 period, There was also a corresponding rise in the number of histologic examinations in autopsied cases.

Fromthe time the project was initiated, the analysis of these reports occupied the attention of the surgical consultant for tit least part of his time

several days a week. Each case history was carefully studied, and an unexpectedly large amount of information was secured from them. For one thing,

it was possible to evalate the results of various methods of treatment as well

as the overall care the casualties were receiving in army hospitals. For another, the analysis proved extremely useful in the educational program which

was still underway because inxperienced units were still coming into the theater. If errors were disclosed which needed correction, they were discussed

immediately with the responsible personnel. This proved a rapid and practical way of instructing inexperienced surgeons in the principles and practices

of military surgery.

The medical circular issued from the Office of the Surgeon, Headquarters,

Fifth U.S. Army, on 7 April 1944,-0 is an illustration of the practical applica-

'*See footnote 11, p. 301.
400ACTIVITIES OF SUj]RqICL P60$ULTAITS

'TXL~7-Peiodc' nal yee of ppstmorlem- sludiia in. Ffth U..Army 46spias aur

Gross autopsy reoports- Histoioi o reports' Nmber - -

rmdof deaths i 4ehtawf, Peehg

sued Number, odeth. Number odets of reported- studied, Atudled, atpl

Jftiniary-m arch-_ 529 171' 9 38' '37 7. '0 J'2.

.AU'Jd- ------------ 4 26 R2. 1'19 2 4. 7T 46 9;

n)gis-eeme 284, 180 83;4 1 9. 34.,*9 550

_946

Janiutiay-M4y15 128 82, 6" 94_ a0 3

"Total--------- 1, 450- 733. 50.'6' 349- 24A0 47 -'A

SDurligtis period, 1,582 U.S.battle casualty deaths Were reported from Fifth V.8.-Army hosiale, butthe histories

4ouinLy,450 wiero recedved in time to be included in this analysis.

-tin'of aalses hee I 'wtspreard -iV the surgical:consultan t-assoia

cerfimnerrorS -in -triwge became, evident inthe survey of.,thqeepostm orem,

-tlep-&ig Paragraph, four of this circular follows:

4.. lnitfa-abd4oinlnal wounds have been overlooked particularly, when the woufid -of,

entrance was not In the abdominal, wall. Patients who have- received-plasma fo ihock

ai,,b~fiallon, Aid Statioim, Col lecting Stations, Clearing Stations, o r ield Hosiplial]s, h'ave',

b",n-set onW tIvacuatlow H1ospitals, when their, blood pres~sure, readings -returlied- to

norl. this group of patients 1s isarticularly prone to develoo severe shock with turther

'eviation and- should receive6 surgical care IIn the miosiIt forward' i'eld Hospital; unit.

ilfureto recogniz e f irst piority cases in other categories has Ibeen cost ly. ICareful trige

or, sorting in the cl eari ,ng stationwill save -lives.

Ahalyses concerned with various periods of the Italian campaignshowod,

, progressive improvement in the results of surgery on -combat casualties.I

w Ias thought that this stud*. which was based upon insistence on good clinical

records, played no small part in the continued improvement in results in army

hospitals and in the high level of achievement finally attained.

In March 1945, Capt. (later Maj.) James W. Culbertson, MC, 8th Evacuation Hospital, was placed on temporary duty in the office of the army surgeon

to work with Colonel Snyder in the preparation of a formal report on these

studies.2l Captain Culbertson devoted his entire time to this project until it

was completed early in September 1945.

21 Snyder, Howard E., and Culbertson, James W.: Study of Fifth U.S. Army Hospital Battle Casualty Deaths. In Medical Department, United States Army. Wound Ballistics. Washington: U.S.

Government Printing Office, 19062, pp. 473-530.
FFTWh Z.SARMY 40

, "- " ",-.. ' Analysis of Hospital .Deathis, :

twe6 1 January 104 and 2,May i945, the ,dateof ithe German -sur--

rener in Italy, 1,562 deaths from battle4ncurred injuries in Fifth U.S. Army

1,hoiptals i Italy wer reported to Major Snyder. Sufficiently detailed recbds, on'1, 50 of -these reached, him in time t6 be- filwked in, his analysis,

Whebithese records were examined in detail, it was found that 39ofthe cases "inludein them didnot ent61y -fit. the, terms, of reference of the stu4y,,as:

these phpti.ents 'Were dead on arrival. The number of the complete-analyses,

th kd :idi-W s necessarilylimitedato 1 41i cases,

Thie data, analyzed by Colonel Snyder and Captain Culbertson (tables 8

thfigii i6) 'included, the distribution of Wounds and- deaths. by p6riods adordinfig t e anatOmic.location of the injury, the wounding agent, -and the

place of death (field or evacuation hospital) -and theprincipalcauses of death.

'The tables, reproduced herewith, represent only a small proportion of the

,endi dius amount of data secured in the analysis,

It is ,difficult to- make precise statements about 'battle casualty deaths

because of 'the large number-of variables concerned, some of, which, are'beyond

contr l. Misleading conclusions, furthermore, are readily arrived at unless

statisticsaie interpreted in the light of circumstances.

It is generally agreed that, in all wars, the proportion of casualties who

die n the-battlefield of their wounds is about 20 percent, or one in every five.

This was-true in Italy, in which the percentage for the January 1944-May 1945

period Was 19.86. The proportion was highest (20.7 percent) in the JanuaryMarch 1944 period and lowest (18.84 percent) in the August-December 1944 period.

A valid method of analyzing the efficiency of a medical service is on the

basis of the number of wounded who reach hospitals alive. Hospital case

fatality rates, however, are dependent not only upon the efficiency of the

TABLE 8.-Percentage distribution of wounds and deaths according to anatomic location of

injury in 71,000 casualties admitted to Fifth U.S. Army hospitals,

9 September 1948-81 May 1945

Wounds Deaths

Location of wound (percentage) (percentage)

Head -------------------------------------------------- 6.75 19.90

Maxillofacial -------------------------------------------- 6. 11 1. 61

Chest- ----------------------------------------------- 8. 92 21. 80

Abdomen ---------------------------------------------- 4. 11 28. 70

Lower extremity ----------------------------------------- 39. 20 16. 17

Upper extremity ---------------------------------------- 26. 20 5. 08

Other ------------------------------------------------- 8.71 6.74

Total -------------------------------------------- 100. 00 100. 00
402 ACIITE O URGICAL CONSULTANTS

,A~ 9.-Perceniagi 'itribution of wvunditgagent,,and deaths therefrraii,1,OQO ca8ua1f'ea

adittedl to. U.S, Ar~my, hoe pitas ,91 Sike be1943.41 M "zui946'

W94pi kiit

............ .. . .. ... .. .. .. .. 27.. 

tAl bu-- ------- ------------------ 17 23..........

Mie----------------------------5.8 .6

'D~ftfi e------- ------------------------------ 315,1

Gdrand Total.4--------------------------------100. 0 100. 0

A' Ined Wig 2,M~ self-infllcted*646i

medical service -that the hospital provides but also, upon thie effciency. of, tl ,

evacuation service which brinigs casualties to it. At Anzio,, where hois

weie lo cate, ey close to the frontline, casualties reached the hospitals rapidly,.

kid, the hospital case rate was as high as 517 percent. At other times _and'in.

other areas,' when hospitals were further rem *oved from the front,, hospital'

cA e.fatality rates were much lower. Generally speaking, however, the Overall

mortality is improved by rapid evacuation, which brings the patient to surgery

more promptly.

Iii Italy, between January 1944 and May 1945, inclusive, a number ofsurveys produced the following data:

1. In the January-March 1944 period, 35.3 percent of all casualties who

died in army hospitals died before the induction of anesthesia. The percentage fell during successive surveys and reached 21.6 percent during the

January-May 1945 period.

2. In the January-March. 1944 period, 7.3 percent of all battle casualties

who were killed in action or died of wounds died in hospitals after the induction of anesthesia. The percentage also fell during successive surveys and

reached 5.3 percent during the January-March 1945 period. 3. In the January-March 1944 period, 1.515 percent of all battle casualties

(including those killed in action and those injured or wounded in action)

died in hospitals after the induction of anesthesia. The percentage also fell
TI~'lI - -403' S. RMY 

TALa '0oprd1iv6, frequency of wdunds ,according- to ,anid4omic locaion of- injury in4

£D,46 ~aial~s amited o F~fAUS.Arnyhospital8, 1, Auguitf1944-31 May.1"45,

ate Fe~thousand

-Y fin p of W vautln'Fed-.

n~a ....... ---- --.-- - A 70: .20.,60,- 10 0

Sca.p........8O 41".,00 37; 75 -

Bn -------------------------- --. 0 20' 10

Softtisse.~------------------------ 15-8 53 P- 4680 --

Eyeadea-- ------------------- ------. 6 i-. 00

............. .... : 21....00. 120,,70"-

----- ---- _ .. . . . .. . . .50 , 10.:20. 'A."40

i......................----- ........... -27.' 20- '38.18 37,30.

bc---------------- ...... ------- 210.006 31. 55, 46, 40',

AbdonhaH

u 'd '~lah; .. .. .. .... : 1....3 . 10 6.,.93 7.40 -

o' n~Ii~lal-------------------18500 -14. 30- 28,40,

'TAPrfab 0 Wiall .------------------------. 'A 00, - 3;2 'A l 00-

o 'bined..-------------------------31. ft~ 3, 24, 58

Ciiati-racture------------ ---- --.... 32,'M 57, 00' -54,,00,

-- Ti-ufrm Tianputatiou---------------------- 8 80 8, 44 8.0

- u~~lia---------------- ----------- 15. 80 04. 001 87. 80

........ 8&. 00 251;' 00 237.'00

do m pounA fracture---------------- ------ 57. 00 74.00Q 712!,50

-tfiiidtio amputation ----------- -- -------- 107.'00 13.30 21.46,

Othr~;--------------------------- 1 A0 25.00 230

IRprfi ithese two categories was considered Inaccurate. Possibly some thoracoabdominal injuries were re- p tqunde~r coiisblned Intra-abdorninal and Intrathoracie injuries.

durn -g successive surveys and reached 1.05 percent in the January-March 1945

peiod;

Other Data

Certain other statistical data might also be listed, as follows:

1. _During 1944, 17 percent of all casualties in the Fifth U.S. Army were

killed in action, and 72 percent were wounded iii action. The remainder were

missing in action or were taken prisoner.

2. Of the 72 percent -wounded in action, 2.5 percent were returned to duty

from division clearing stations after treatment, and 9 percent were given

surgical care in field hospitals. The remainder received initial wound surgery

at evacuation hospitals.
TA *Z 1 i.-Coniparative, Caie Y044,t~ rases acordin4. to ahatomi ,kcazii ofinjrIi-fl'

Loeaton tie owolm ~id bospital ky ii~tidn oie

_; --- --- -- , .... ... ..

---------. . .. . . .. .1 .. 1 

Ne..k.... ---------- go-23. -. 87

Chest

........... .. . . . . ...... . 13.2

ra-rai----------------- -- ---------- ----- 00- 5. 4--- 7, 80--

'Intra-Abdominal -------------------------- 22.,80 17. 10 P2,i0

Tradoibcdminal----_1------------------- 26.00' 13.0 2260)

Combind--------------------- ------- 24.600 8. 96 18, '6

De0 piugcie ---------------------------- ----------- .03, ,03

C6&iP-und'fracture------------------------ 1, 68 . 08 1

Traumiatic amiputation-------------------5, 90 . 5 1 0

Lower bextre'M'ty:

Deep auscle ----------------------------- 1.90 . 29 .3

Cnpudfracture------------------------a 390 . 80 0

Traumatic amputation--------------------~ , 10 2. 97 4.30

Oerq ------------------------------------- .5.9.5

Total--------------------------------- 11.80 1.35 2.20

I awd on principal wound.

3. Of the wounded in action who reached medical installations, 2.9 percent died of wounds. Of these, 'T percent died in division clearing stations, 83

percent in field hospital -s, and the remainder in evacuation hospitals.

4. The case fatality rate in wounded casualties who received emergency

surgery in field hospitals was 10.9 percent, against 1.9 percent in casualties

evacuated to evacuation hospitals for treatment.

5. Of the 97.1 percent of wounded casualties who were treated in army

hospitals and survived, about 17 percent were returned to duty from the army

area. Tli, -3mainder were evacuated to base hospitals.
TALU12-~~Dsfib~iP f .460 death from. batile-incurred ,wounds ir, Fifth U.S. Armg,

'6;psal,. iqiuary4944-E *Mai945;-Py ?o toiadtypieofu'ound1I

March I94 Aprll-.3ul I)cMber lanuary- 1944WMay "1944' 1944' May 1945' 41457

Locaton and type of wound, - - -- - -

r...a... ... 97' 18. 3 81 10, 8 57 20. 1 46 29. 7 281 19.,4+

1 .2 3 .6 1 .4 1 .6 6 _A

' 8r------... 1.5 10 2,1 2 .7 0 3.9 , 26 i~

Sia ......-----. 7 1.3 4 .8 8 2.8 6 3. 9 25 1:T

tlio ol 6.. . ...........-- 44 8.3 49 10.2 30 10,5 It 7.1 134 2

Thi6rA~o64bdomiia1.--------0 2 11. 7 74 15. 3 43 15. 1 23 14. 8 '202139

do Wn14..;------------18 3.4 17 3.6 10 3.5 8 5.2 53 3.7

4bonnpli----------124 23. 5 131 27, 2 80 28. 2 33 21. 3 368 25.A

Etetei..............-83 15. 7 58 12. 0 28 9. 9 9 5.8 17A 12, 3

U601aasl16dimitlple-------8 3 15. 7 55 11, 4 25 8. 8 12 7. 7 175 12. 1

Undeterined ...- _----------2 .4 0 .0 0 .0 0 10 2 .1

Total;.------------ 529 100. 0 482 100.0 284 100. 0 155 100. 0 1,450 100, 0

I During this period, 1,662 U.S, battle casualty deaths were reported from Fifth U.S. Army hospitals, but the his

tories of only 1,4150 ivere received in time to be Included In this analysis.

VISITS TO ARMY MEDICAL INSTALLATIONS

As already mentioned, Major Snyder spent most of his time in the field,

particularly in the period immediately after his appointment as consultant in

surgery to the Surgeon, Fifth U.S. Army. At this time, there were numerous

newly arrived hospitals in Italy, without previous combat experience, and it

was essential that they be indoctrinated promptly in the principles and techniques of military surgery.

When this immediate emergency bad passed, there were numerous other

problems to solve, and, until the end of the war, Major Snyder continued the

practice of visiting hospitals. As figures 73, 74, and 75 indicate, these visits

were far too numerous to be recorded in detail within the limits of this chapter.

The following summarized accounts, however, are representative of Major

Snydei 3 activities during these visits.

95th Evacuation HospitaL.-Major Snyder's first tour of Fifth U.S.

Army medical installations after his appointment as surgical consultant to the

army began with a visit to the 95th Evacuation Hospital in Naples on 13 and

14 October 1943 The method he employed there was substantially the same

as that used in ft' his subsequent tours.
4061 ACTIVI[TIES, OF SURGICAL CbiNSULTsT" BLE'll3--Percentage di8tr& utonof rincipal cMuses of deatlin 1,450 batle casualties adiniited

to Fipifti .. ArnL'hoepitale,. 1 Januar 19 44-*R~~ 95

January. April-Jl augitary 3anar

March 1944 '1944 Waycmbe M4,~r

,Caises ofdeath

ghboo---------------_-183 34.6 194 40.3 91, 3 ,2.0 S' 5' 5 3.

Traraiiial-------------..65 12. 3 66 13.7 45 15.8 30 23.2 22 4

Nejihropa thy;-------------. 9 1'.7 25 5. 2 -20 9. 2 8' 8 471

Ptoit..------------ -13 2.5 2 5.4 1'9 0.7 4.5 4657 4J5,

C044alta1nyositis -------- 35 6. 5 11 2.3 4 1. 4 1 .6- 11 I'A'

Thieumofis--------------20. 2.6 6 1. 2 17 0.0 6 3.69 4 49 3 4

..............------- 5 .9 9 1.9 0 3.2 4 -2i 6 27 1';9

thrombotio-embolism -------- 5 .9 12 25 1 .4 2 1.3 2 ,

SOP4,qaI rd ..awna---------. 6 1.1 1 .2 6 2,1 3 1.9 16 1 .1

'.L'haoheobronohiai, obstrlict~bzi; aspiration of vomitus. 3 . 0 1 . 2 3 1. 1 4 2.0 11, .8

Traeheobroncehial obstruotion, aspiration of blood

and miuus--------------- 1 .2 4 .8 3 1. 1 3 1.9 11 . 8

Cerebral isoemin ---------- 2 .4 1 .2 2 .7 3 1.9 8 .6

Other -------------------- 28 5.3 25 5.2 24 8.5 9 5.8 86 k.9

Undetermined------------ 154 29. 1 101 21. 0 34 12. 0 14 9. 0 303, 20.,9,

Total ------------- 529 98. 71 4821 100. 1, 2841 100. 2 155 99. 9 1,40, 100.

I During this period, 2,02 U.S. battle casualty deaths were repotted from Fifth U.S. Armsylhospitals, buttiehlstlories

of only 1,410 were received lit time to be Included In this analysis.

His first conference, which was with the chief of surgery, consisted of

an evaluation of the qualifications of the surgical personnel of the hospi tal and

their assignments. He then made rounds with the chief of surgery and the

other surgeons on the staff, discussing with thew techniques of management of

the various wounds encountered. He also observed operations. He lost no

opportunity of talking informally to the memnbers of the staff, doink, a great

deal of indirect teaching in this way.

At the conclusion of the visit, hie met with the, entire staff. The subjects

discussed included the management of injuries of the extremities, with special

emphasis on time importance of adequate debridement in those in which gas

gangrene was a possibility; the routine in abdominal wvounds and in chest

surgery; the use of the sulfonamides (penicillin was niu& yet generally available) ; the importance of holding patients after surgery until they were safely

transportable; and the importance of careful recordkeeping, his suggestions

being based upon his random examination of the patients' charts.

36th Division,-Medical units of the 36th Division were visited during the

period 25-27 October; a day was spent in each of the infantry regiments.
IFTH' U.SARMY40

. N Vnofro k IA

A6f.\'~)~ '",~AbLRAD

R~ .. )Poeu Eeeto4 f

Mugnano ~ ~ ~ Pr IQ...4IvoFl~t5

tl.A ,

SSv( (Mar 2,6,7,9) v.

T eto ,ldo P

39E ae(oD6*72 (M)

(MarMarch 1914.

HraJornyde tketoedcal ofcru n is i e nteueo

Thomas th split; techiquesof cotrolifthrhae withspeialempasi

on~~ dagrGonceihteapiaino( th6 toriquets; thepeauin

necessary~~~~~~~U1JL60 inteueo'mrhn3n0tednesofo) dsg; n h m

portance complee of and accuratereodng f tedt rqie n mr

reprte tohe o th suger heha wtne ihositalintehaer

reimenta surg-eoa nsallthen compay, commader of the. mewadia battalionM, aurnd
408- ACTiVITIES OF SURrOAL CONSULkTTS

Ciileino

Campornorto

SL Ferriere

H6SPITAL. nok

. .. . ..........

ROAD

RAILROAD

0 5

MILES

FIuRE 74.-Hospitals near Anzio, Italy, visited by Major Snyder during March 1944.

other medical officers for a general discussion of surgical problems in the

division. The discussion covered gas gangrene; the use of tourniquets; the

danger of circular bandages; the contraindications to packing of wounds; and

the management of abdominal injuries in forward installations. It was

arranged that battalion surgeons be equipped with 30-cc. syringes and ampules of serum albumin and with sulfadiazine crystals for intravenous use.

33d Field HospitaL-On 2 and 3 November 1943, Major Snyder with

Captain Jergesen, visited the 2d Platoon of the 33d Field Hospital, which was

located beyond Dragoni and west of Alife. The outstanding impression of this

visit was the observation of an extremely severe case of clostridial myositis involving the right upper extremity and the chest wall.

On 6 November, the 3d Platoon of this same hospital was visited, with Maj.

Henry K. Beecher, MC; this platoon was supporting the clearing station of the

45th Division south of Venafro. Although the hospital had not been very

busy previously, Italian casualties from a mine explosion had been brought in

just before these observers arrived, and there were so many serious chest and

abdominal wounds associated with deep shock that an auxiliary surgical group

team from the 94th Evacuation Hospital had to be brought up to help with the

necessary surgery. Some of the surgery was excellent, some not so good. On
_ROAD, Ji*

L P4Evoc(Doc 4;l3,fl

5_nROA II2'6 -44 

(Elevflon 1/n 0e~ ,"'@

0 iO . 0. - r'' ~ - 34~t,2T,,7

14________________( ogadr " Y

<"V~w '~f.4Z5 .I N' ~ , 

Ad od r -0*S.6

15 iac(c (006 1.7,111) 'T f)P.A

Tlodnc

F~d I~Evo(Dee,9) C~f~giLo~"r~,

~ -' i'~" xzx

wihgsgnrn a bevda hspaoon.rzz

On4 7an8 ovmte2Pltoofte3dFedHsil, hic

wa now-eial P tallatis ielvisited byraio Cooneianyradin eemernd44 l 

the followivgd, aneeewt the surgeon mlcaehst ins this platoe wabpr

tiiated Sndr byt Major Beecher apting Jegee n andca Majonydteri.Th

iAotc ohi blood rpaofteenstas parcuterlyomsed Onete aita

thgsnrenopo~e, was 8oevedbeat ti plton.d h ii t dPaono

On 71ad0 November, the Platoon d of the 33d Field Hospital, whviichI

was nosear adaeta wathst evisid Operisation, ahraobdnal a wbound4

wals fobsredm the srge onearcompliatedchsos was performded bytr

Brtis At time, muand the hositas errqit.evoeratogeten ito was

theefopredsi on 8er oevembe, tllobvcold thed isi atlheod Ploon ofbra
410 ACTIVITIES OF SURGICAL .CONSULTANTS'

use, of which a as recommended. Several cases of gas-gangrene were alo pbseroa. 'Captain jergesen talked to the staff on, anaerobic:inft tonsiand:g or

A " brief visit to the 94th Geieral Hospital on tle afternoon,bf-10 9ovem- 'bet ended, tis particular tour of army hospitals. Onmany othertours,,quite

Te. Anzio beatchhead.-,The first of the nine trips which Major Snyder

madeto.the Anzio -

beachhead after the landings there on 22 Januar 1941

lasted :(including the travel time from Naples to the beachhead and return),,

ffrom,0 'February to 10 February, inclusive. Two other trips were ma&de in

February, one in March, one in April, three in May, and the last in June. ./All

f-these trips were for periods of several days, and between 23 May and 6 June

Majir: Snyder was continuously on the beachhead.

The-first trip from Naples to Anzio was complicated by a German air raid

just as the LST docked at Nettuno. The Germans were shelling the docks at

rather frequent intervals, and bombing continued off and on during Major

Siyder's inspection of the 33d Field Hospital and the 56th, 93d, aid 95th

Evacuation Hospitals, which were grouped together a few miles from .the

beach. The casualties from these raids have already been described (p. 346).

On his second trip tq the beachhead, from 13 through 17 February 1944,

Major Snyder began to take his turn at the operating table, as he did on subsequent Visits.

The final offensive on the Anzio beachhead was launched on 23 May 1944.

As soon as word of it was received, Major Snyder went up by the first available

transportation (LST). Casualties were heavy, and immediately on his arrival,

after he had made rounds at the 33d Field Hospital and the 11th, 15th, 38th,

and 94th Evacuation Hospitals, he began to assist with the heavy backlog of

operations at the 38th Evacuation Hospital. For the first 48 hours, he and

Captain Jergesen operated together. Then each of them acquired an assistant

and worked separately. During this period, Major Snyder made daily morning and evening rounds in all the hospitals in the area.

Shortly after the fall of Rome, on 4 June 1944, the 38th Evacuation Hospital was set up in Rome, and Fifth U.S. Army headquarters were moved to

Anzio. Thus, one phase of the medical responsibility in Italy ended.

Section II. Clinical Considerations

EVOLUTION OF CLINICAL POLICIES

Principles of Surgical Care

In the first weeks of the fighting in North Africa, there were few specified

clinical policies. Surgeons chiefly employed the techniques which they had

found satisfactory in clinical practice. The results, however, were often not

as good as they should have been because (1) combat-incurred wounds differ
FIFTPHS:l AMY 41

in extent, and severity,froin mostpeacetiine wounds and (2) thecircumstances

of !trsurger difJ materially fromi those.-f civiliani surgery.

The chief diderence between military and civilian surgery is iatin civilian

su:rgeryA singje,"surgeon usually, inakesall the decisiois, for a single casualty

i~ii litie:in, ry sirger.tie decisions are made by a, number of surgeons.

From the time a wounded solIier was tagged on thebatlefieid or in abattalion

aid station of ,the -Fifth U.S. Army intil-the completion of the cycle of treat,

mpnt, evacuation, and disposition, he was cared for by a series of sirgeops,

hn seriesof installations. The judgment and decisions of many medical officers,, wer interwoven in the threads of his recovery. Every surgeon who

treated, him was called upon not only to evaluate the patient's status but also

to ,etinate his own surgical capabilities and limitations and the facilities at

:hand,to perform the necessary surgery. All decisions had to be made in the

light- of ircuimstances peculiar toa field army in combat.

The whole system of medicomilitary care was based on the premises that

medical care is accomplished in echelons; that the mission of each echelon is

both specified and limited; and that all medical officers must not only perform

the duties specified for them but must also limit themselves to the duties specifiedfor that particular echelon,

Fifth U.S. Army surgeons were allowed and expected to exercise resourcefulness and ingenuity. They had ample freedom to act in emergencies in the

light of their professional experience and judgment. The system was flexible,

but it remained a system, based upon general principles which surgeons were

expected to apply to particular cases unless there was some very good reason

indeed for not doing so. Furthermore, it was always essential that surgeons

who had deviated from what was considered standard practice to make clear the

extent of the deviation and the reason for it.

Establishment of Priorities

On the basis of triage at the clearing station, casualties were divided into

nontransportable patients, who made up about 10 percent of all casualties, and

transportable patients. Categories could not always be defined with exactitude,

but they served as useful guides. Once they had been established during the

fighting in Sicily, as set forth in Circular Letter No. 3, Office of the Surgeon,

Headquarters, II Corps, dated 7 August 1943,22 they remained substantially

unaltered during the course of the war.

First priority cases.-In this letter, first priority cases were specified as

follows:

1. Severe shock or continuing hemorrhage after temporary resuscitation

in a clearing station.

2. Compound fractures of long bones complicated by shock or hemorrhage,

or fractures which had not been completely and comfortably immobilized.

" See footnote 8, p. 361.
412 ~ACTVITIES I OF SURGICAL'CONSULTANTS

3: Wo1. ' r~unds " "- of-the extremities in which theblodsupply was im~aire4:r

similar' wounds in which it *vould be necessry to, evcat0 c as'a yVith~

a, toriqe in situ. ecauat

4. Wud§ characterized by extensive-muscle damagepcalwodsf

.the ho~ilder girdle, thighs, or calves, in all of which, clstidial yositiSgw!a4

a sePrious pos~ibility", 4. Tiaumticoamputations.

6. Hetdiijuries ass6iathdwitl deep coma or, wythsigns of increased ,in

I raca iapresur%.

" aillofacial wounds or wounds of the neck of special severity "oras

sociated with respiratory difficultie. .

8. Silking cbest wounds, andany other chet wounds associated ,ithl

9, Th loracoiibdomnalwounds.

1!0. Abdominal wounds and wounds of the buttocks which mightAave

penetrated the abdomen or the rectum.

Setond priority caesa-Casualties with the following types of ,wounds

were transferred directly from clearing stations to evacuation hospitals without

pasing through the field hospitals:

1. Simple fractures and compound fractures of long bones in which' the

patients were transportable (that is, they were not in shock,and had-no other

injuries which made them nontransportable) and in which satisfactory :im-.

mobilization had been accomplished or could be accomplished in the clearing

station.

2., Peripheral nerve injuries, if not complicated by compound fractures or

extensive muscle damage.

3. Oraniocerebral injuries which were not associated with coma or signs of

intracranial pressure.

4. Chest wounds which were not sucking and were not associated with

respiratory difficulties,

It is characteristic of the ubiquity of the disease even in wartime that it was

specified that patients with early acute appendicitis or with possible appendicitis

should be transferred to evacuation hospitals for surgery.

SHOCK AND HEMORRHAGE

Special Studies in Shock

The steady decrease in the number o battle casualties who died in Fifth

U.S. Army hospitals before they could ' operated on or even anesthetized is a

reflection of the steadily increased effeciveness of the management of shock

during the fighting in Italy. A number of medical officers played a special part

in this improvement. A discussion of their achievements follows.

The first scientific appraisal of shock in the Fifth U.S. Army was begun

by Captain Lalich on the Cassino front in December 1943. In March 1944, on
hS. AFIRH MRMY 4i3

thebAnib, ichhead, he wasirovided with sufficient laboratory equipment by'

n 'ifeb Comrnanding* Offcer, l5th : e i enerai Labo atory, to,

mii~e the ~ailed studies necessary to support his thesis that blood Iloss .is the

chief faict6oith shock, Hisab6ratory investigations inluded deterniinations Sf theiie tdrit; the plasma protein, ,the nonprotein nitrogen ofthe blood.and,

blo chi'd"es,, ' and the carbon dioxide combining power of the- blood., Othe On "basis of clinical observations -alone, Captain Lalich had already

t.4vtted that battle casualties who were in shock be divided into three cate6.

or!es:acbordiig to the followingcriteria:

T patient has a normal blood pressure, with noii gnificant abnormalities'in pulsevolume or pulse rate, but his wounds are sufficiently numerous, and

of suffSientgravity, to make expectation of circulatory failure reasonable.,

Replacement , therapy in the amount of 500 cc. of plasma and 500 cc. of blood,

should therefore be institutedbefore surgery..

2.Thd blood pressure ranges from 90 mm, Hg down to the lowest level at

which it can be demonstrated, Resuscitation requires 1,000 to 2,000 cc. of

blood.

3. The blood pressure cannot be determined by auscultation. The patient

should receive, immediately and rapidly, 500 to 1,500 cc. of blood, the precise

amount- depending upon how much is needed to raise the systolic pressue to

about 100 mm. Hg. After this level has been reached, an additional 500 to

1,000 cc. of blood should be given before the patient is put on the operating

table. If the systolic pressure fails to rise to at least 50 mm. Hg after 1,500 cc.

of blood has been given over a period of 15 to 30 minutes, operation should be

resorted to without further delay, for continuing hemorrhage or factors other

than blood loss are probably contributing to the continuing shock, Among

these factors are gross contamination and infection of the pleural or peritoneal

cavities and toxemia from clostridial myositis. Even when these conditions

are chiefly responsible, blood loss may also play some part in the patient's state

of shock.

The second study on shock was conducted by Lt. Col. John D. Stewart,

MC, and Lt. (later Capt.) Frank B. Warner, Jr., MC. It was begun in January 1944, when Mobile Unit No. 3, 2d Medical Laboratory, was set up at

Cassino, beside the 3d Platoon of the 11th Field Hospital. This hospital was

doing first priority surgery, and the objective of the investigation was to study

the response of seriously wounded men from the standpoint of shock, hemorrhage, and dehydration.

In the preliminary report of this study to the Surgeon, NATOUSA,

through the Surgeon, Fifth U.S. Army, dated 17 March 1944, the following

findings were listed as characteristic of shock:

1. Absence of hemoconcentration.

2. Reduction in the blood volume.
4i4' ACTIVITIES OF SURGICAL CONSU T91

.. A greater redudtion of red ,cell -conentration, than, of plasma- Protein

edepitration inmdiatel-v'afterwounidinig.

.. Alater Iowering of both red ,ceif andplasmaprotein oncentration.

r uht delayed'dehydain

Ai.niion was called jn this report -to the variability,of ,both vasoiforo.

and esiovascular - responses to woundiig and to the fact that the :reactonqs

tosoho k and hemorrhage vere-much less stereotyped than had usually .be1n.

sup~d.

The original observations of Major Stewart and Lieutenant Warner.we re

based on a study of. 35 desperately vWounded casualties Operated on attlie 11th

Fid.Hospital as well as of several patients with f-is gangrene. Studies had also .beenmade on blood specimens provided by other hospitals nearby. Thie

tsurgical staff was kept informed of all laboratory findings and was able tollSe

thi'information in the management of its cases.

In their final report on 2 January 1945, Colonel. Stewart and Cloptiin

Warner discussed observations on 100 patients, of whom 48 had penetrating

abdominal wounds, 32 had penetrating thoracic wounds, and 55 had compound

fractures (the figures are overlapping) ; 17 had died during the period, of the

investigation. In addition to the studies already listed, special studies on th

urine were included in this report.

Conclusions from the total study were as follows:

1. The syndrome of wound shock was notable for its variability.

2. Reduction in blood volume was characteristic of untreated shock,

3. Hemoconcentration was not encountered, but decreases in plasma protein concentration and hematocrit readings were evident from the outset.

4. Dehydration and azotemia were common in the early recovery period.

5, The urinary reactions were indicative of a rather mild base deficiency.

6. No evidence of excessive use of plasma or whole blood was detected.

A third study of shock was made at Cassino and on the Anzio beachhead

by Maj. Henry K. Beecher, MC, Consultant in Resuscitation and Anesthesia,

NATOUSA, and Capt. (later Maj.) Charles H. Burnett, MC. Most medical

officers who had studied shock believed that it was wiser to resuscitate the

patient as completely as possible before placing him on the operating table

unless there was evidence that continuing blood loss or some one of the other

factors just listed was responsible for his condition. As a result of this study,

Major Beecher and Captain Burnett took the contrary position. Their concept was that surgery be considered a phase of the program of resuscitation

and given an earlier place in it. This meant that, when the systolic blood pressure had reached 80 inni. IIg and the patient was warm and had a good color,

he should be placed on the operating table without further delay. Whatever

additional blood replacement might be necessary could be accomplished during

the operation. Some medical officers agreed with this concept and put it into

practice, but it did not win general acceptance.
FI~H U.S.~.RM 415

TheBoard for the!Study of th.Severely Wounded jnade grea, contribu

tions to the study f shock, crush injuries, andnephrbpathies..3

%Captaih Waich's inyestigatipns-conistituted ,the first ,scientiflc Study oqf shockin battle casualties in Wrd War fI. is studie4together'Withotlse,

conducted by~ rSewr an Cati Wair,s shwed that blodloss,.

with aresutant decrease:in the circulating blood volume, is the most inporcause of shock in battle casualties. These observations wereonfirmed:

b~th *rkofMjor , echer, and- Captain Burnett and by the Board for

the :StUdy of the Severly Wounded, The practical application of their

obS-vatis§ placed "the mahagement of shock upon a rational basis and was

responsible for the saing of many lives.

Principles of Resuscitation

Rapid, complete examination of the casualty in shock was an immediate

necessity,to determine the conditions present which might be contributing to

his status so that immediate steps could be taken to correct or control them.

Among the shock-producing conditions likely to be found were the following:

T. Cardiorespiratory embarrassment from painful wounds of the chest

wll; sucking wounds; hemothorax; pneumothorax and tension pneumothoiax; cardiac tamponade; paradoxical respiration; accumulation of blood,

mucus, or both in the tracheobronchial tree; and anoxia from- any of these

causes,

2V Continuing hemorrhage.

8. Large soft-tissue wounds and inadequately immobilized fractures,

4. Wound sepsis, including clostridial myositis,

5. Gross contamination of the peritoneal cavity in abdominal wounds.

The measures to control and correct these conditions included maintenance of a patent airway; postural or suction drainage of tracheobronchial

secretions; closure of sucking chest wounds; relief of hemothorax or tension

pneumothorax; oxygen therapy; and conservation of body heat.

Whatever the contributory cause, however, the underlying cause of shock

in most cases was blood loss, either alone or associated with one or more

of the factors just listed. The regimen of resuscitation was a complex affair,

but the keystone of the arch was the administration of whole blood.

Resuscitation was not an end in itself. It was a means to an end. The

end was the operation, which was imperative in the control of hemorrhage,

peritoneal contamination, and numerous other conditions and which was an

essential part of the management of all cases. Timing was important. When

the patient had reached an optimum stage of recovery, it was essential to

take advantage of the moment and operate at once, for the status of a wounded

casualty was never static, and deterioration was the rule if surgery was too

long deferred. Once the patient had slipped back into shock, secondary

=See footnote 1S, p. 39S.
7 416, ACTIVITIES OF SUR GICAL CONSULTANTS, '

.es.. ctaion was more difficult tha'n primayi esuscitation, and many exper-P •

,eib&spsggeted tha itws-ee ssatisfactory,

DEVELOPMENT OF THE BLOOD PROGRAM

North. Africa

U.S. medical officers found, as soon as they began to care for casualties

in North Africa, how essential whole blood Was both for freshly wounded

casualties and for those whose wounds were older. When U.S.

pitals landed and began to operate the hospitals in Oran, plasma was availiible to theim in large quantities, but most of them had come overseAs with.

limitedequipment for transfusion or none at al. In the 77th Evacuation

Hospital, in which Major Snyder was in charge of chest surgery, the only

equipment available for transfusion-was that which Captain Lalich, Who headedthe Shock team, had secured from the British blood bank in England' The

hospital had neither citrate nor distilled water and had no facilities .to

make the latter. Sodium citrate was obtained from a French pharmacy, a

still Was borrowed from the French, blood was obtained from the hospital

detachment, and the casualties cared for in this hospital received more whole

blood than plasma.

The need for whole blood transfusions in the management of combat casualties and the extreme inadequacy of the equipment for transfusions were

reported to the Surgeon, II Corps, early in December by the chief of surgery

of the 77th Evacuation Hospital through channels. Major Snyder also emphasized the importance of whole blood in his critique of surgery in clearing stations in North Africa for the Surgeon, II Corps, in March 1943 (p.

372). In his report, he stated that (1) a shock team should be part of the

personnel assigned from an auxiliary surgical group to a clearing station,

(2) a more convenient method of blood transfusion should be made available,

and (3) a source of blood other than clearing station personnel should be

provided.

Sicily

When Circular Letter No. 3, Office of the Surgeon, Headquarters, II

Corps, was published on 7 August 1943 (p. 361), plasma was still considered

to be the most effective weapon for combating shock, though it was noted

that, when hemorrhage was a major factor in the patient's status, whole blood

should be used as soon as crossmatching could be completed. It was also

directed that both blood and plasma be used without delay and in sufficient

quantities to accomplish resuscitation, even if this took large amounts. Finally,

it was emphasized that, once the patient had been satisfactorily resuscitated,

he must not be allowed to slip back into shock, since secondary resuscitation

was less effective and miore difficult than primary resuscitation.
?FIFTH"U.S A Y41

"Durfig the fighting in Sicily, lbood donorsi.,as inNorth.Africa had to be

ketiredfiim the personnel of hospital units or from neighboring service.

units.T; iuso es as si North Africa, had th be-prepared, coleaned,, and'itrilz~d~byhosita -roiel The frequiencyb ofmilaiax educed'the,

Iiipf'availabledor, but volunteers, oni thke whole,. repnded genrul aiid' ti hospital dhaplainsorendered effective aid in keeping donors. continu-a,

FiftliVS. Army

By: theid:of 1944,.m6s hospitals in, the Fifth US. Armyhad established

their own small', blood banks, in which type-specific bloodwas, held for 24

hbVirs, pr, 6ccasionally, a little longer. In a few hospitals, th; administra

: tiion of Wo ht this tiieeave 'ag4&0.5 to-0.8 pint per c4sualty, but asa rule;

th6 1 ratewasfar below this. As Major Snyder went from hospital to hospitalt"

it was e4sy fir him to tell from the appearance of the patients after operation:

-whether they had received sufficient blood; if they had not, they looked white,

n&eld out. In almost all hospitals in the winter of 1943-44, it was necessary

to urge medical officers to use blood more liberally.

In, February 1944, a central blood bank, designed to supply whole blobd.

to the Fifth U.S. Army, was organized to supply whole blood for Fifth U.S.

Army installations, chiefly through the work of Maj. (later Lt. Col.) Eugene

R. Sullivanl MC, Field and evacuation hospitals were thus relieved of the,

diffidlt task of drawing their own blood in the quantities then being used in

forward surgery, and the always undesirable practice of bleeding line and

service troops in forward areas was also ended. This organization, officially

designated as the 6713th Blood Transfusion Unit (Provisional), was attached to the 15th Medical General Laboratory in Naples, under the command

of Colonel Cornell.

In April 1944, a program was set up by which a medical officer from each

army hospital and a technician from each hospital laboratory were sent to

Naples for 3 days of intensive instruction at the blood bank. Handling of the

banked blood at the individual hospitals was much improved as a result of

these courses.

Anzio beachhead,-The first blood provided by the blood bank at Naples

went to the Anzio beachhead, on 25 February 1944. Up to this time, whole

blood had been provided to both British and U.S. Army hospital units by

the British 12th Field Transfusion Unit. The initial 200 pints of blood

brought in on the day of the landing, 22 January, had been used up by 27

January. Thereafter, an average of 100 pints a day was brought in, usually

by LST's, occasionally by small planes which could land on the airstrip without drawing German fire. It was the responsibility of the two enlisted men

who checked all incoming supplies to watch for the siipments and to arrange

for their immediate dispatch by truck to the medical dump. The blood was

held there until it was called for by the British transfusion unit, which con-
418 ACTIVITIES OF SURGICAL CONSULTANTS

tinued to store the blood and distribute it to the hospitals. The performance

of this unit was highly efficient.

Before the breakout at Anzio, it had become evident that the 6713th Blood

'le'ansfusion Unit would not be able to supply as much blood as would be

needed for the casualties expected. With General Martin's approval, Major

Snyder discussed the problem with Lt. Col. (later Col.) Kenneth F. Ernst,

MC, Commanding Officer, 2d Medical Laboratory (a Fifth U.S. Army unit).

He agreed to supply an additional 100 pints of blood daily. He was able to

secure the necessary equipment and supplies, and on 26 May 1944, to the surprise and gratification of the surgeons on the beachhead, lie delivered the first

100 pints. The same supplement was received daily until the need for it no

loi.ger existed. This laboratory could have supplied more blood if it had had

more donor sets. As it was, it had to stop in the middle of the day to resterilize

its equipment.

Between 22 January and 4 June 1944, 10,624 pints of blood were used in

U.S. Army hospitals on the beachhead, an average of 1 pint for each 2.01

battle casualties, and 3,685 pints were used in British hospitals, an average of

1 pint for each 2.95 casualties.

Use of Blood

From the time the Naples blood bank began to operate, field hospitals were

always supplied with all the blood they required. Evacuation hospitals, for

a time, continued to operate their own blood banks when the casualty load was

not heavy. When it was, their supplies were augmented with blood from the

base bank. Later, these hospitals were also supplied with all the blod they

needed from the blood bank. In July 1944, when the advance up the 'peninsula

was rapid, forward hospitals sometimes ran out of blood; when they did, a

supply was promptly flown in by cub plane.

As a rule, clearing stations were not supplied with blood. On a few

occasions, however, as when the advance was particularly rapid after the

breakout from Anzio, blood was used in some of the clearing stations which

were well ahead of field hospitals. There were no untoward results, but when

field hospitals were abreast of clearing stations there was no real need for

this practice.

Blood was used with more and more liberality as the months passed, and

its value was increasingly appreciated. This was true in all echelons of medical care. In the last 4 months of 1944, 9,903 pints of blood were given to 15,553

casualties admitted to Fifth U.S. Army hospitals-0.63 pint per casualty. In

1945, before the fighting in Italy ended, the ratio was 1 pint per casualty.

Blood was used with equal liberality in general hospitals. Colonel Hampton and Major Lyons, for instance, in their demonstration of correct surgery

of the extremities at the 21st General Hospital in the fall of 1944, reported

the daily use of 1,000 cc. or more in septic patients, in order to bring the hematocrit and plasma protein to normal levels.
IFTH "U.s. ARMY 419

Colonel Snyder and Captain Culbertson, in their study of combat fatal.

ities in Fifth U.S. Army hospitals, provided the following data on the use

1. f all wounded patients treated in field hospitals, about 70 percent

reqUired blb'd transfusions and about 63 percent required plasma. An average of'S pihts of blood was given to each patient who required blood and an

average of 2.5 units of plasma to each patient who required plasma.

2. In evacuation hospitals, about 20 percent of the patients required blood

transfusions. Each of them received an average of 2 pints. About 15 percent

of the patients required plasma., and each of them received an average of 2.5

units.

The superior management of the blood bank established at Naples and

the unlimited quantities of blood which it supplied contributed greatly to the

improved results of combat surgery in the Mediterranean theater in the last

year of fighting. The medical officers who headed shock teams and supervised

resuscitation of shocked patients developed great skill and judgment in the

preparation of battle casualties for surgery, and the saving of many lives can

be attributed to their fine work.

BLOOD REPLACEMENT THERAPY

Techniques

Once it was realized that shock was chiefly due to loss of blood, restitution

of the depleted blood volume was recognized as the principal component of

resuscitation. Plasma was used from the battlefield through the clearing station, in sufficient quantities to render the patients transportable to hospital

installations. Thereafter, whole blood was chiefly used except in burns, in

which, logically, plasma was employed in large quantities, particularly immediately after injury.

When the patient was in severe shock, 1,000 cc. of whole blood was given

rapidly into two veins, under positive pressure. In extremely urgent cases,

when the blood pressure could not be obtained at all, the first 1,000 cc. of blood

was administered without crossmatching; since all blood used was low titer

group 0 blood (p. 420), this expedient was regarded as safe, at least under the

circumstances. After the systolic blood pressure had reached 80 mm. Hg, the

rate of the transfusion was reduced. When the pressure approximated normal

(100 mm. Hg or higher), an additional 500 cc. of blood was administered unless there was some urgent reason for operating immediately. The rationale

of this practice was that a systolic blood pressure in the neighborhood of

normal was often attained before the depleted blood volume had reached a

satisfactory level.

Blood replacement was frequently continued during operation unless exploration of an abdominal wound revealed that peritoneal contamination was
420 ACTIVITIES OF SURGICAL CONSULTANTS

the principal factor responsible for shock; in these-circuinstances,, if ther -had,

not been a considerable los of blood, plasma could be used.

Lokng before the end-of the war, copper sulfate solutions were, in universal

use, for the determnination of hemoglobin, hematocrit,, and plasma ,protein

values in battle casualties. The procedure was standard in both fieldh'spitals

afid evacuation hospitals and proved extremely valuable- in estimating :the

nutritional- state of patients after operation. This useful development grew

out of the work of Captain Lalich on the Anzio beachhead (p. 412).

Reactions

The blood sent from the Naples blood bank to the Anzio beachhead was

Oll type 0. One set of recipient tubing was furnished with each two bottles of

blood, There were no serious reactions, but a few patients had mild attacks

of shivering or slight chills. When this happened, the transfusion was continued from another bottle of blood, the partially used bottle being employed

for another casualty.

In April 1944, anuria was reported in a number of casualties who had

been transfused with untitered group 0 blood. Shoruly afterward, a serious

reaction was reported in a group A recipient who had received 2,500 cc. of

group 0 blood. Major Snyder at once initiated discussions with Major

Beecher, Captain Burnett, Captain Lalich, and others who had made special

studies of shock and resuscitation. Captain Lalich reported the development

of urinary difficulties in a number of individuals with cases of shock which he

had investigated. They were by no means universal, but they had occurred,

and some of them had been serious. He did not think, however, that sufficient

evidence had yet been accumulated to inculpate group 0 blood or to ask that

the blood bank furnish type specific blood. Others in the group thought that

this request should be made immediately. These reactions were also discussed

with officers at the 15th Medical General Laboratory.

It was agreed, as the result of the conferences, that low titer group 0

blood should be given a further trial before any change in the present policies

was instituted. As a precaution, all blood with an anti-A or anti-B titer over

1: 250 was to be marked "For group 0 recipients only."

On 1 May 19414, when Major Snyder visited the 33d Field Hospital on

the Anzio beachhead, he received reports of two deaths in group A recipients

who had received group 0 blood. Most medical officers were now convinced

that the use of group 0 blood in group A recipients was unsafe and should

not be continued. Major Beecher returned to Naples, to discuss the matter

further with officers in the blood bank there, and it was agreed that sufficient

evidence was now at hand to warrant a change in policy and the supplying of

group A blood for A recipients. It was aFh agreed that a circular letter should

be prepared to accompany the shipments of group A blood.

Before these arrangements could be consummated, the decision was reversed; and the Surgeon, Fifth U.S. Army, was informed by radiogram from
FIFTH U. ARMY 421'

the Commanding General, NATOUSA, that hereafter the base collecting sectioii of Blood Transfusion Unit 6713 would furnish the Fifth US. Army

installations with only one type of blood, group 0, with an agglutinin below

1: 64. It Was indicated that this radiogram was for action by the Command-

,ing-Oflier,;iSth Medical General Laboratory

There were two reasons for this decision. One was the fear that more

deaths might be caused by errors in crossmatching if both group A and group

B bloods were supplied than would occur if group 0 blood titered for anti-A

and anti-B agglutinogens continued to be used. The second was the possibility

that group A blood might be administered through tubing through which

plasma was running, with resultant serious reactions.

In a return radiogram, the commanding officer of the 15th Medical General Laboratory made the following points:

1. Rigid compliance with the order received might necessitate discarding

half the 0 blood drawn. In the past, 0 blood with an anti-A titer of 1: 250 or

over had been marked "For group 0 recipients only." These bloods had comprised only about 15 percent of all bloods drawn. The order in the wire from

NATOUSA precluded the use of 0 blood with a titer of over 1: 64 for anyone.

Immediate authority was requested to use group 0 blood for 0 recipients,

regardless of titer.

2. Four histologically proved cases of fatal hemoglobinuric nephropathy

were known to have followed the use of group 0 blood for A recipients. In

two of these fatalities, only low titer blood had been used. Major Beecher had

information of other clinical cases in which the circumstances were similar,

and he had ceased to use group 0 blood for group A recipients.

An immediate investigation by Colonel Churchill was requested, with

authority to modify or revoke the order of 13 May from theater headquarters.

The matter was finally resolved by continuing, as in the past, to use group 0

blood of any titer for 0 recipients and to mark all blood with an anti-A or

anti-B agglutinogen titer of 1: 250 or more "For group 0 recipients only."

CHEMOTHERAPY AND ANTIBIOTIC THERAPY

The Sulfonamides

Because penicillin was not available during the fighting in North Africa

and was available only in limited quantities and for strictly limited use in

Sicily and in the first months of the fighting in Italy, sulfonamide therapy

was used both locally and systemically during this period.

The studies of Major Stewart and his associates on shock (p. 413) included

determinations of the sulfonamide levels in the blood. In both the preliminary

and the final reports, these observers called attention to the erratic and uncertain

blood sulfonamide levels. They warned that this unpredictability should be

kept in mind in any appraisal of the presumed benefits of routine sulfonamide

606222r--62-29
22ACTiVITIES OF SUGOL.OSLATS,

thekapy in severely wounded men. it both overdosage -and ineffectiveleyels

wp 6't be avoided',sulf6namide therapy must be controlled by blood determia-.

The local use of the, sulfonamides became more infrequent as the .war,

ro rssed. Opinions p9,oncrn m g .tle value of this route 'had differed widely.

A few surgeons consideredlocal sulfonamile therapy ofgreat value, a: nui4r

considered it harmful, and the majority :believed that it made no differnce,

whether or not it was used.

The possible implication of sulfonamide therapy in lower nephon nephrosis

isdiscissed under "Complications, Anuria and Nephropathy."

Penicillin

When penicillin first became available in Sicily in the summer of 193,

itsuse was limited to the treatment of clostridial myositis. It was also used

only on this indication in the first months in Italy. The routine of securing it

was quite complicated. It was distributed by the 15th Medical General'Labo.

ratory in Naples, which served as a depository for it, and it had to be secured

by requisition from certain designated hospitals in the army area. When it

Was needed at the 15th Evacuation Hospital on the Anzio beachhead, for instance, it was necessary forthe chief of surgery there to call Lt. Col. (later Col.)

Phillip W. Mallory, MC, Executive Officer, the 56th Evacuation Hospital,

each time he needed a supply.

By the spring of 1944, penicillin had become available in sufficient quantities to be used in all wounds in which it was indicated. Meantime, at the 21st

General Hospital, Major Lyons, consultant in penicillin therapy, and Major

Hampton had set up a septic ward in which they were demonstrating a threefold program in the surgery of the extremities, consisting of adequate debridement, liberal blood transfusion, and penicillin therapy (p. 359). Penicillin was

given in dosages of 200,000 Florey units daily (25,000 units every 3 hours)

by the intramuscular route. At the suggestion of these observers, this regimen

was instituted in all field and evacuation hospitals as soon as the casualty was

admitted. The operating surgeon decided whether to continue the use of

penicillin after operation.

Penicillin was sometimes used intraperitoneally in abdominal injuries,

occasionally in combination with the local implantation of sulfanilamide powder

or crystals. Opinions concerning its value by this route differed as widely

as opinions concerning the local use of sulfanilamide. There was general

agreement, however, that penicillin was of great value when used locally in

the pleura and the joints.

Penicillin was introduced at about the time forward surgery was greatly

improved, particularly in respect to more adequate debridement, with greater

emphasis upon the removal of all devitalized tissue. This was also the period

in which blood began to be used in generous quantities and in which delayed
FIE: , H S. AR MY 42

prmary Wounid closure wa generally employed in base hospitals. The p olicy

ofwound closurewhich was highlysuccessful,, was posil bcuemsofte

wouii 66oi "and: wer healthy and, clostridiai nmyositis ,had ceased to be

S the6 thiit' had'be earii&ii. Penicillin Was given,and deserved,; a c n

isideiiblishare of the credit, f6r these achievements. Knowlbdgeable surgeons

citfinued to insist, howevd, that good surgery was the basic theRreasonefor 

impovqm enin results, and there is no doubt that their emphasis upon it was

hetirl sIf6 ed

SPECIAL TYPES OF WOUNDS, AND INJURIES

Soft.Tissue Injuries and Fractures

Iiffial wound surgeiry.-The principles of initial wound surgery, particularly t iportance of adequate debridement, had been thoroughly taught bfore the war and were fully apprecited from the beginning of the fighting in North Africa. Certain practices were introduced, and others were

modifiedjbut the fundamental principles remained unchanged. As the war

prg ed however, these principles were more generally and more correctly

applied.

Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps,

dated 7 August 1943, gave the following directions for the management of

wounds produced by high explosive shell fragments:

1. All foreign bodies should be localized by fluoroscopy before operation.

2. Devitalized and contaminated skin should be excised, but healthy

skin should not be sacrificed.

3. The ski,, wound should be enlarged by appropriate incision to permit exposure and excision of all underlying devitalized and contaminated

tissue and to provide adequate drainage to the depths of the wound. This

required similar incision of the fascial plane.

4. Foreign bodies, which frequently carried in bits of clothing, dirt, and

other foreign material, should be removed.

5. When debridement had been completed, raw surfaces should be dusted

with sulfanilamide powder, and fine-mesh petrolatum-impregnated gauze

should be placed loosely in the wound.

6. The wound should never be sutured primarily.

Changes in this technique were as follows:

1. Fasciotomy proved a very useful method in hematomas of the leg

and in wounds associated with swelling and with impairment of the blood

supply. It was performed at initial wound surgery or later according to

the indications of the special case.

2. The type of incision based on the Z-plasty incision employed in plastic

surgery proved very useful in extensive injuries in areas in which there was

24 See footnote 8, p. 361.
424- ACTIVITIES OF SURGICAL CONSULTANTS,

little excess of skin. Each limb of the incision was begun at the opposite

corner of the traumatic incision. Delayed- primary wound closure was greatly

facilitated when this incision was employed in the types of wounds mentioned.

3. After January 1944, fine-mesh dry gauze began to be used in Wounds

instead of petrolatum-impregnated gauze.

The circular letter published in August 1943 stated that little of no

debridement was necessary in through-and-through wounds produced by highvelocity bullets. This did not prove a satisfactory policy. Later, it became

the practice to make a sufficiently long incision through the skin and fascia

in this type of wound to permit a search for possible muscle damage. If

no damage was found, nothing further was done. If damage was found,

debridement was proceeded with according to the usual technique.

The principles of adequate debridement of high explosive wounds of the

extremity were, as already mentioned, known before the war, and they were

emphasized throughout the war. They never changed. The problem was

not the management of these wounds. It was teaching inexperienced surgeons and staffs of newly arrived hospitals to follow these principles and

practices. That these principles and practices be followed was essential, for the

whole program of reparative surgery (delayed primary wound closure) was

based upon the adequacy of initial wound surgery.

Fracture management.-The management of compound fractures at initial wound surgery was limited to the correction of gross malposition. Definitive reduction was not the function of an army hospital. Roentgenologic

controls were not feasible in a forward hospital, and, even if precise reduction

could have been maintained during the application of transportation splinting,

it would probably have been lost when the cast was split or bivalved, as was

the fixed rule in forward areas, to guard against circulatory impairment during

transportation. Definitive reduction, by whatever method was indicated, was

the function of the general hospital, at reparative surgery.

Removal of totally detached bone fragments was part of initial wound

surgery. All large fragments whose removal would have created a segmental

bony defect were left in situ, as were all small fragments which had any

attachment at all.

Delayed primary wound closure.-Closure of the wound was the function of general hospitals in the base but was occasionally completed on minor

wounds in convalescent hospitals in the army area. The wound was inspected

in the operating room, and if it looked clean and healthy it was closed by interrupted sutures. Contraindications to closure included infection; the presence

of necrotic tissue in more than minimum amounts (small fragments of necrotic

tissue were excised) ; and inability to secure closure without tension unless a

skin graft was employed. Wound healing was usually prompt and satisfactory

if initial wound surgery had been adequate.
FIFTHi U.s. 'ARMY 425

Most Surgeons preferred to perform delayed primary wound closure within

4 to 10days after wounding. As experience was accumulated, the earlier tim,

ing came tobe considered more desirable.

When Dr. Allen Whipple visited North Africa in the fall of 1943 (p. 368)',

he h6djust 6turned from observing British surgery in the Far East. British

surgeons asribed their success in delayed primary wound, closure to the local

use of penicilin. Under Colonel Churchill's direction, a number of U.S. Army

surgeons at the Bizerte medical center had been trying out this technique, but

without using local antibiotic or other therapy. After Dr. Whipple had observed the Outcome of these cases, he concluded that penicillin had nothing

whatever to do with the results he had observed in British hospitals and agreed

with U.S. Army surgeons that their good results were due to good surgery

alone.

Splinting and casting.-The primary splinting applied in fractures of

the extremities was, like the first dressings, intended to serve until the patient

reached a hospital in which surgery could be performed. This was not always

practical; improvised splinting frequently had to be employed to remove the

patient from the battlefield to the battalion aid station. In any event, whatever splinting had been applied on the battlefield was inspected in the battalion

aid station and in subsequent division installations, but it was not disturbed if

it was adequate.

The hinged full-ring arm splint was found unsatisfactory in southern

Tunisia, and its use was discouraged in Sicily.2

" It was entirely abandoned

during 1944. This splint was poorly adapted to fractures of the elbow, and

patients were seldom comfortable in it. A few cases of gangrene were reported

as the result of pressure of the ring on the blood supply in the axilla.

Fractures of the shoulder, arm, and elbow were best immobilized by placing

the arm in a sling and then binding it to the chest, with the elbow in 900 flexion,

with another triangular bandage. An axillary pad was always used. Some

surgeons preferred to use padded wire splints for these injuries.

The Army half-ring hinged splint remained the most satisfactory transportation splint available during the war in the first echelon of medical care

for fractures of the thigh, knee, and upper and middle leg. As time passed,

surgeons learned to apply it more competently. For one thing, they learned

to use it merely to immobilize the limb, without attempting to reduce the fracture. They also learned to avoid excessive and harmful traction.

In fractures involving the knee and the lower and upper thirds of the

femur, the half-ring splint was so bent as to provide for from 200 to 300 knee

flexion. At least five muslin slings were used to support the thigh and leg

and additional slings were employed for the foot. The litter bar used to secure

the splint to the litter added to its effectiveness.

= See footnote 8, p. 361.
426 ACTIVITIES OF SURGICAL CONSULTANTS'

Fractures of the lower third of the leg and of the ankle and foot were

usually- immobilized in Wire ladder splints. One splint was applied to, the

postrior surface Of the legand the:plantar surface of the, foot, and a sec0nd

was usd as a U or stirrup splint to support the sides of-the leg and the foot.

piec of the first splint. The splints were well padded and Were held in place

by baidages.

'Transportation splinting after surgery was accomplished with well-paddedplaster casts. Circular casts were split or bivalved down to the skin while

the patient was still on the operating table. There were no exceptions to this

regulation.

The plaster Velpeau was preferred for transportation splinting in fractures

of the shoulder, arm, and elbow. The most satisfactory immobilization of

compound fractures of the femur was secured by a plaster spica, applied to

include the intact thigh, with the upper part of the cast extending to just above

the iliac crest.

The Tobruk splint required less plaster and less water than other plaster

casts, and it was sometimes, of necessity, used when these commodities were

in short supply, as not infrequently happened in desert fighting in North

Africa, It was occasionally used in extensive soft-tissue wounds of the lower

extremity. Otherwise, this splint, which British surgeons favored highly,

never won popularity with U.S. surgeons. They used the plaster spica, as

just deseribed, except in occasional cases in which there was a concomitant

wound of the abdomen, Then the Tobruk splint was useful. This splint

was sometimes used in fractures of the knee joint and, less often, in fractures

of the leg. More often, a long-leg plaster cast was used for injuries of the

leg and a single plaster spica for injuries of the knee joint.

Joint Injuries

The evolution of the management of joint injuries followed the same

general pattern as for soft-tissue wounds and fractures. Early in 1944, it was

directed that arthrotomy be performed in all joint wounds, to permit wide

excision of devitalized cartilage and removal of all foreign bodies. After irrigations with physiologic salt solution, the synovia or capsule was closed, and

penicillin solution was instilled. Aspiration of the joint and reinstillation

of penicillin were carried out at 24-hour intervals after operation for as long

as seemed necessary.

The application of these princil)les to injuries of the knee joint led to a

greatly reduced incidence of infection and much better functional results. A

similarly bold approach was recommended in injuries of the hip joint, but

it could be applied much less universally. This is an inaccessible joint, and

the number of orthopedic surgeons in the theater who had sufficient knowledge

of surgery in this area to perform the radical surgery required was always

limited.
TFI7H U.S. ARMY 427

Resection was practiced in injuries of the knee joint but-was not employed

1h injurieso6fother joints.

Vascular Injuries

Considerable improvement was effected in the management of wounds

of- the major vessels of the extremities as the war progressed, but these wounds

remained &serious problem throughout.

The use of tourniquets.-Originally, the use of tourniquets was both confused and unsatisfactory. Early in the war, they were used far too frequently

and removed far too often. After a tourniquet had been applied by a corpsman on the battlefield, it was examined by the first medical officer who saw

the casualty and frequently was removed by this medical officer. If the tourniquet was not removed, it was the policy to loosen it routinely every 30 minutes.

In some cases, death occurred from the cumulative effects of the bleeding which

ensued each time the tourniquet was loosened. These fatalities usually took

place during evacuation by ambulance, on trips lasting several hours, when

the medical corpsman loosened the tourniquet every 30 minutes as he had been

instructed to do. Many deaths which could have been avoided were thus precipitated because no facilities were at hand to control the hemorrhage which

frequently followed the removal of the tourniquet.

Later, the policy was reversed, and, once a tourniquet had been applied, it

was not loosened or removed, particularly if the casualty was in shock, until

facilities were at hand for the immediate control of hemorrhage and the replacement of blood loss. It was found to be safe, when a large vessel had been

damaged, to leave the tourniquet in place for periods of from 4 to 6 hours during cold weather and for somewhat shorter periods in warm weather. Rubber

tubing proved more satisfactory than the Army-issue webbing tourniquet.

The study of the use of tourniquets, with particular reference to patients in

shock, which was carried out by Maj. Luther H. Wolff, MC, and Capt. Troglier

F. Adkins, MC, of the 2d Auxiliary Surgical Group, was the basis of the following regimen, which was in general use when the war ended:

1. Patients with tourniquets in situ should have the highest priority for

transportation to the nearest hospital. The emergency medical tag should

indicate that a tourniquet is in place. Marking the forehead with a red T was

an additional precaution.

2. An effective tourniquet should be placed on an actively bleeding extremity at the earliest possible moment.

3. At the end of about 2 hours, if the patient was not in shock and if all

circumstances were favorable, the medical officer might cautiously loosen the

tourniquet if facilities were available for immediate control of hemorrhage.

If bleeding was negligible or did not recur, the tourniquet might be removed,

but the patient was kept under continuous observation, and the tourniquet was

left in place for immediate reapplication.
428 ACTIVITIES OF SURGICAL CONSULtANTS'-

4. On no account should a tourniquet on a patient in shock be removed

within 4 to 6 hours of its application unless the'blood volume had-been-at least

phtly replaced by phsma or whole blood. After this time, the removal; or

loseifing of the tourniquet was a matter of individual judgment. Im.many

iistances, sufficient clotting and spasm had occurred by this time to prevent,

further bleeding.

t5. When a tourniquet was in place, the temperature of the affected limb

was lowered as much as possible short of actual freezing,

Maiageent.-The first group of vascular injuries managed by lumbar

sympathectomy was reported by Maj. James M. Mason III, MC, and Capt.

W. Phillip Giddings, MC, from the 2d Auxiliary Surgical Group. Although

their results were inconclusive, they thought the procedure had promise.

Later, Major Simeone used sympathectomy in a number of vascular injuries

of the lower extremity and advocated its prompt performance whenever the

patient's condition permitted it. Probably the best results obtained in vascular

injuries followed the use of this technique.

Major Simeone also used the Lord-Blakemore Vitallium cuff in a few

anastomoses of the popliteal and femoral arteries, but the results were not encouraging. " In four cases thus treated at the 33d Field Hospital in December

1943, there were three failures. Other observers had the same experience. As

time passed, it became evident that, if the wounds were extensive, vascular

repair was likely to be successful only when surgery could he undertaken within

4 to 6 hours of wounding. This criterion could seldom be met.

Vascular injuries were the subject of a special study and a number of

formal and informal meetings in Fifth U.S. Army hospitals. All speakers

emphasized that any major vascular injury should have priority of care.

At one of these meetings, a patient was presented who had been treated by

a French surgeon, for a bleeding popliteal artery, by means of ligation and

division of the common femoral artery at the level of the inguinal ligament.

The wound in the popliteal area was packed, but the artery was not directly

attacked. The result was apparently excellent; in fact, the foot on the injured

side was warmer than the normal foot. Major Snyder, nonetheless, felt constrained to warn against this technique until a sufficiently large series of cases

had been collected to prove both its safety and its value. No such series was

ever reported.

Neurosurgical Injuries

Head injuries.-Some patients with head injuries were sent to field hospitals for resuscitation or evaluation, but surgery was done in this echelon of

medical care only if the injury was associated with hypertension; a slow pulse;

fixed, dilated pupils; respiratory depression; and deep coma. This group of

casualties were to be treated by emergency decompression in field hospitals. All

Meulleal Department, United States Army. Surgery In World War II. Vascular Surger.%,

Washington: U.S. Government Printing Office. 1955.
'FIFTH,:U.S. ARMY 429

other patients with head injuries only were to be transported to evacuation

Iffapatient with injuries in other parts of the body had tO be cared for in

-a fiel ho, tl because of those wounds, the-chief of surgery in the field -hospital, at his-discretion, might call a neurosurgeon forward from an evacuation

hospital, usually 5 to 15 miles to the rear, to evaluate the head injury and to

operate forit if he thought it was necessary. This system worked very well iII

the'few ases in which it was necessary to invoke it.

In the evacuation hospital, foreign bodies were rem, t initial wound

surgery if they were accessible; that is, if they were on the same side as the

injury. If they were on the other side, they were left in situ. Most surgery

was performed under local analgesia unless the patient was uncontrollable.

Then Pentothai sodium was used,

On one of Colonel Snyder's trips to Anzio, he found, in one hospital, that

general surgeons were doing neurosurgery and neurosurgeons were doing chest

and abdominal surgery. This was stopped immediately. When neurosurgeons

were limited to their specialty, there were enough in the theater to handle all

cases. A neurosurgeon was assigned to almost every evacuation hospital, and,

if the caseload proved too heavy, a neurosurgical team from the 2d Auxiliary

Surgical Group could be attached to the hospital temporarily. Later in the

war, when it was found desirable to have two neurosurgeons in each forward

evacuation hospital so that there could be round-the-clock neurosurgical care,

the neurosurgeon in the rearmost evacuation hospital was moved to the hospital

nearest the front.

During 1944, techniques in neurosurgery improved greatly, and Fifth U.S.

Army neurosurgeons operated on large series of head injuries with mortality

rates far below those reported in World War I. The rates were still high, however, and 19.4 percent of the battle casualty deaths studied in Fifth U.S. Army

hospitals in 1944 and 1945 occurred in patients with intracranial injuries

(table 12).

Spinal cord injuries.--Injuries of the spine in which the cord was involved also remained a serious problem throughout the campaign in Italy.

The percentage of deaths in which spinal or spinal cord injuries were the responsible factor increased from 1.3 percent in the first 3 months of 1944 to

3.9 percent in the January-May period of 1945 (table 12), but the increase was

only relative; it was accounted for by the fact that casualties with associated

chest and abdominal injuries who had died in the earlier period were now surviving long enough to be hospitalized.

Whenever possible, patients with spinal cord injuries were placed under

the care of neurosurgeons, for evaluation and for laminectomy if it was indicated. Since spinal cord injuries were often associated with wounds which

rendered the casualties nontransportable, they had to be evacuated to field hospitals, which were not staffed with neurosurgeons.

606222V62-30
4ACTIVITIES OF SURGICAL, CO

It was ,eventually concluded that it was in the best interests of patients

With multiple wounds to perform the necessary surgery on the spinal qqrd

injury in field hospitals ratherthan prolong the timelag and subject themAt

the frther trauma incidental to transportation to an evacuation hospital se*-

eial hours or several days after surgery for, the other wounds. The necessary

surgery for intrathoracic and intra-abdominal wounds was completed before.

the necessary surgery on the spinal wound was performed. Whenever pss ible,

all of the wounds were cared for at the same sitting, though occasionallylaminectoiny was deferred for a few hours or for a day or two. The 7o'ri k of

general surgeons in evaluating these cases and in performing the indicated

neurosurgery, including laminectomy, was w, 11 done.

Thorough debridement or complete wound excision was just as necessary

in ifitravertebral wounds as in any other wounds. Removal of bone fragments

and foreign bodies and excision of devitalized and contaminated tissue were

performed as in the usual debridement. The dura was closed.

If there was loss of bladder function in spinal injuries, suprapubic cystostomy was performed routinely before the patient was evacuated from the army

area to a base hospital.

Peripheral nerve injurles.-There was general agreement that primary

nerve suture was contraindicated in the army area. This was completely

reasonable. Most of the wounds had been incurred hours before the patients

were first seen, and primary closure of a potentially dirty wound would

have been extremely hazardous. For primary nerve suture to be accomplished, a wide, extremely careful wound excision would have been necessary,

and even in these circumstances primary wound closure would have greatly

increased the hazard of infection, particularly anaerobic infection.

A few surgeons believed that the separated nerve ends should be identified

with wire or black silk or should be approximated with a single suture, but

the majority believed that nothing at all should be done to the damaged

nerve ends at initial wound surgery.

Major Snyder recommended that no surgery for peripheral nerve injuries

be done in forward hospitals. This was partly because the results were

likely to be pu-.' and partly for other reasons. He had observed one fatal

case in which clostridial myositis developed in an extremity when initial wound

surgery was deferred until a neurosurgeon was free to suture the nerve primarily. He had also observed a death in Tunisia which could be attributed,

at least partly, to the added time consumed in the primary suture of a radial

nerve at surgery for a compound comminuted fracture of the humerus. He

felt very strongly, in view of these observations, that surgery on peripheral

nerve injuries should not be performed in army hospitals.

Thermal Injuries

Burns.--It was consistently held in the North African theater that the

correct treatment for burns was the removal of gross debris and the immediate
applicaion of fine-mesh, petroiatum-impregnated gauze overlaid with dry

gauze-and c6ttoU waste. An occlusive bandage was then used, to achieve

A'sightinprssion.

.Thei ... commenidations were set forth in the circular letter issued aft

etiiin9ai of Sicily . In the Italian campaign, the instructions for limited

debrlrement were, changed to include gentle cleansing with cotton,. soap, and

VaWter, tind the excision of gross debris and loose skin. The use of tannic

acid1 had ]ien banned in Africa, and, after the invasion of Sicily, the use of

all ceagilats Was forbidden,

Aiieithdsia for debridement was discouraged after a patient with only

a moderate burn died an anesthetic death during Pentothal sodium anesthesia.

Plasma, penicillin, and blood transfusions were used routinely in serious

biirns.

Cold mjury.-The first casualties with cold injury (trenchfoot) observed

in Italy passdd through a clearing station south of Cassino the first week in

November 1943, though not all of them received a correct diagnosis.

After cold injury once appeared, the incidence increased rapidly and over

the 6-month period ending 30 April 1944, there were more than 5,700 casualties from this cause in the Fifth U.S. Army. For all practical purposes, these

losses were quite as serious as combat losses, for, almost without exception,

they occurred in frontline troops, who were always in extremely short supply

during the fighting in italy. During this winter, losses from cold injury

amounted to about 7 percent of division strength, and hospital admissions

from this cause constituted 9 percent of all admissions for disease."

The lessons of the first winter in Italy were well learned, and, during the

second winter, in the 6-month period ending 31 March 1945, there were only

1,572 cases of cold injury. Many of these injuries represented recurrences

in men who had suffered from cold trauma during the previous winter. No

satisfactory form of treatment was ever developed, and medical officers learned

from these recurrences that return to full duty is possible in only a limited

number of casualties who have once suffered trauma from cold.

The control of trenchfoot is a command responsibility, and much of the

decrease in incidence during the second winter of the war in Italy can be

traced to the assumption of this responsibility by commanding officers at all

levels. Medical officers, however, participated in the preparation of circular

letters on the subject, in general educational efforts, and in other phases of

control.

An intensive study of cold injury in Italy was made by Major Simeone.

The story of trenclifoot in tihe Mediterranean theater in the volume on cold

injury in this series of histories is based largely on his reports.

a7 See footnote 8, p. 361.

23 Medical Department. United States Army. Cold Injury, Ground Type. Washington , U.S.

Government Printing Office, 1958.
432 ACTIVITIES OF SURGICAL CONSULTANTS

REGIONAL INJURIES

Maxillofacial Injuries

Maxillofacial wounds were managed by the same general principles

throughout the war. The routine included debridement, with the sacrifice

of as little tissue as possible; early fixation of the jaw fragments, by elastic

traction; provision of an adequate airway, by tracheotomy if necessary; and

primary closure of the soft-tissue wound with horsehair or fine silk. Healing

without infection was the rule, and no instance of gas bacillus infection was

reported in this group of wounds.

The 'riginal plan that these wounds should be handled in evacuation

hospitals proved sound. The reasoning was that if a good plastic or maxillofacial surgeon did the work there, or supervised the surgery, the results would

be better than could be accomplished by a general surgeon without special

training in plastic surgery.

In October 1943, Fifth U.S. Army surgeons began to see many maxillofacial injuries caused by a new type of personnel mine, which was weak and

exploded underground. The lower extremities and trunk therefore often

escaped injury, but the face and hands were burned, and gravel, rubber, leather,

and dirt were blasted into the tissues and caused numerous and often severe

lacerating and penetrating wounds.

The mortality rate in maxillofacial wounds was low. There were only

6 deaths from this cause in 1,450 battle casualty deaths studied in Fifth U.S.

Army hospitals (table 12).

Wounds of the Neck

The cardinal points in the management of wounds of the neck were as

f'llows:

1. Debridement of all involved structures. Multiple involvement was

the rule because of the anatomy of the area.

2. Prompt identification of wounds of the carotid artery, with early, adequate blood replacement combined with oxygen therapy to combat cerebral

ischemia.

3. Identification and attempted repair of wounds of the cervical esophagus.

Primary closure was frequently impossible. These wounds were comparatively

uncommon.

4. Removal of foreign bodies from, and drainage of, the retropharyngeal

and retroesophageal spaces.

5. Resuscitative and supportive therapy according to the indications.

C~rvical wound- were the chief cause of death in 26 of the 1,450 battle

casualty deaths studied from Fifth U.S. Army hospitals (table 12). Of the

11 patients in this group who died of shock, 4 had lacerations of the carotid

artery, and 6 had lacerations of tb- jugular or the subclavian vein. Four other
FIFTH U.S. ARMY 433

patients in the 1,450 fatal cases also had lacerations of the carotid artery with

cerebral ischemia, but the vascular injury was not the immediate cause of

death.

Wounds of the Chest

Major Snyder's contacts with combat-incurred wounds of the chest followed immediately upon his observations of these injuries in England (p. 335).

When the 77th Evacuation Hospital landed in North Africa and took over the

hospitals in Oran, many of the casualties had received little or no care. In

particular, wounds of the chest had not been debrided, sucking wounds had

not been closed, and hemothoraxes had not been aspirated. Although some

of these hemothoraxes became infected, none of the patients developed empyema

because daily Pspirations of the chest were instituted and sulfonamide therapy

was employed systemically.

In Tunisia and Sicily, the correct management of chest wounds was often

difficult because of the lack of proper anesthetic and other equipment. Maj.

Philip F. Partington, MC, prepared needles with flutter valve attachments

made from condoms or Penrose drains, and the improvised equipment proved

very satisfactory in the management of tension pneumothorax in casualties

who had to be evacuated. It was learned early in the war that water seal

bottles were not only unsatisfactory but were also dangerous to use during

evacuation, whether they were connected to needles or catheters, for the drainage of air or blood from the pleura.

It was a strict rule that no patient be evacuated with an intercostal

catheter in place. If he had to be moved, water seal drainage was replaced

by flutter valve equipment. A number of surgeons abandoned catheter drainage after thoracotomy except when oozing was unusually profuse or there

was a continuing air leak from the lung, because of the difficulty in maintaining the correct use of water seal bottles. Most of the time, the casualty

was on a cot only a few inches above the floor, and, whenever an uninformed

person picked up the water seal bottle to see how much drainage had occurred,

the fluid ran back into the chest. It was found that fewer aspirations of the

chest were necessary when closure was accomplished without intercostal drainage than were necessary after removal of the intercostal catheter in cases

which had been drained.

The circular letter, published after die invasion of Sicily,21 gave the following directions for the management of wounds of the chest:

1. Shock, continuing hemorrhage from the chest wall, tension pneumothorax, and open sucking wounds should be treated by the necessary emergency

measures at the battalion aid station or the collecting or clearing stations.

2. Casualties suffering from dyspnea and those in continued shock or verging on shock should be transferred to a field hospital. Casualties with sucking

See footnote S, p. 361.
434 ACTIVITIES OF SURGICAL CONSULTAN'Ti

chest wounds and persistent hemorrhage from the chest wall should al6. be

treated:in ,-6feld hospittils.

, Transporitble casualties should be treated in, evacuation hospitals. As,

it wo*kdd out, the majority of casualties with wounds of the chest were treated

'in evacuation hospitals because tley were safely transportable to them.

This circular letter set forth the management of the wound at initial -wound

surgery as follows:

1, Sucking chest wounds should be debrided.

2, Loose bone fragments, bits of clothing, and accessible foreign bodies

should be removed.

3. Wound closure should be accomplished.

Tlioracotomy.-If retained foreign bodies were present which might re4

quire removal by formal thoracotomy, and initial wound surgery had been

confined to the chest wall, the patient was transferred to an evacuation hospital as soon as respiratory equilibrium had been accomplished.

In January 1944, it was directed that thoracotomy, through the wound

or through an elective incision, might be done in field hospitals on the indication of sucking chest wounds; continued intrathoracic hemorrhage; tho.

racoabdominal wounds; and large bronchopleural fistulas not controlled by

conservative measures. If the wound had to be enlarged after debridement

to permit satisfactory examination of the depths, removal of readily accessible

foreign bodies was permitted. It was also directed at this time that, if possible,

large foreign bodies be removed from the lung at initial wound surgery in

evacuation hospitals if the patient was unlikely to reach a base hospital within

10 days.

Hemothorax.-During their preliminary observations in England, Major

Snyder and his associates had been warned by Mr. Tudor Edwards that the

management of hemothoraxes would be one of their major tasks as thoracic

surgeons. British surgeons taught that aspiration of a hemothorax should be

performed at least once a day, or, in the early stages, even oftener. Massive

clotted hemothoraxes might occasionally be encountered in which thoracotomy

would be necessary in a forward hospital.

Air replacement, which was recommended after aspiration in War Department Technical Manual 8-210, published in 1942,30 had been entirely abandoned

by British surgeons. Their reasoning was (1) the lung reexpanded rapidly

and therefore hemorrhage was unlikely to occur, (2) bleeding was less likely

to recur if the lung was fully expanded, and (3) if air were injected after

aspiration of blood and empyema should subsequently develop, it would be

total empyeina and most difficult to manage.

The large number of casualties with hemothorax encountered in the hospitals at Oran had received little or no treatment, as has already been noted,

and some of the wounds were already infected. The British teachings were

promptly put into effect, with remarkably good results, and thereafter were

0 War Department Technical Manual 8-210, Guides to Therapy for Medical Officers, 20 Mar. 1942.
FIFTH U.S. ARMY 435

employed regularly. Even late in the war, however, it was sometimes necessary to warn competent chest surgeons that air replacement must not be

employed after aspiration of the chest.

Major Snyder, after his observations in England, came to believe quite

strongly that if a massive clotted hemothorax was encountered in a forward

hospital it should be evacuated by thoracotomy. The surgeon, in such cases,

had to be prepared to stop bleeding from a l]rge pulmonary vessel. The development of large clotted hemothoraxes which were not aspirated early was

usually to be explained by bleeding which had occurred so rapidly that the

respiratory movements of the lung and chest wall could not defibrinate the

blood rapidly enough to prevent clotting. This frequently happened when

large pulmonary vessels were injured. When the hemothorax filled with

blood, the lung collapsed, and bleeding from the damaged pulmonary vessel

ceased. When the clotted blood was evacuated, hemorrhage might again ensue

and the surgeon must be prepared for the contingency.

Evacuation of the hemothorax by merely opening the chest and scooping

out the clotted blood with the hand differed from the decortication necessary in

base hospitals when a clotted hemothorax had persisted for from 3 to 6 weeks

after injury. Even then, the entire mass of clotted blood often peeled readily

from both the visceral and the parietal surface, thus permitting immediate

reexpansion of the lung.

Wet lung.--The condition which came to be known as wet lung was frequently encountered. It was a collection of mucus and blood in the tracheobronchial tree which the patient could not or did not cough up because of

painful wounds of the chest wall, hemothorax, pneumothorax, or inhibition

of the cough reflex because of coma. Wet lung was associated with bronchospasm, and bronchorrhea was often extreme.

It was found that this condition could be readily controlled by procaine

hydrochloride block of the affected intercostal muscles or by paravertebral

block of the two segments above and the two below the wound. The patient

receive(! a small dose of morphine and atropine before the procedure, and the

atropine was repeated at 4-hour intervals afterward if necessary. The nerve

block frequently had to be supplemented by endotracheal catheter suction and

occasionally by bronchoscopic aspiration.

This treatment often transformed a severely ill patient, with bronchospasm, dyspnea, and cyanosis, into a person who was quite comfortable and

who could easily expectorate the mucus and other material blocking the tracheobronchial tree. If the patient had been in shock, the change was particularly

striking. It was seldom necessary to repeat the procaine block.

Some surgeons regarded wet lung as potentially so dangerous that they

advocated the performance of procaine block in all patients with chest injuries

before they were evacuated from the clearing station to an evacuation hospital.

Most surgeons did not regard the procedure as practical in the clearing station

or as necessary in all chest wounds.
48k ACTIVITIES OF SURGICAL CONSULTANTS'

Final principles of management.-It was the consensus in the Mediterraniean theater at theend of the war that wounds of the chest should be managed

according to the following principles:

1 Of the casualties with wounds of the chest who do not die onthebattefield, very few will'die later if fully trained surgeons can care for them in prop,

erly equipped hospitals. A surgeon experienced in both thoracic and

abdominal surgery is best qualified to treat the severe wounds of the chest

encountered in forward hospitals.

2. Severe wounds of the chest require first priority management. This

means that they must have surgical care promptly, in the farthest forward

hospital.

3. Prompt, well-directed resuscitative measures are essential, especially

if there are complicating abdominal wounds.

4. Anesthesiologists well trained in endotracheal anesthesia are essential in the correct management of wounds of the chest. Endotracheal anesthesia administered through a closed apparatus capable of positive pressure gives

the best results in perforating and penetrating wounds.

5. Open chest wounds should be occluded with gauze and adhesive strapping before the patient is evacuated to a hospital equipped and staffed for definitive chest surgery.

6. Patients with continuing intrathoracic hemorrhage and large bronchial

fistulas require immediate thoracotomy.

7. Hemothorax should be managed by prompt, repeated aspiration, without air replacement. This technique is not associated with any risk of

hemorrhage.

8. The only treatment required in most uncomplicated wounds of the

chest is debridement of the wound of the chest wall.

9. Large pneumothoraxes are managed by early aspiration, followed by

continuous aspiration by a catheter connected with a water seal if the pneumothorax recurs because of a continuing leak of air from the lung or a bronchus.

10. There are clear-cut indications for thoracotomy by way of the chest

wound. Indications for performing it by way of a separate incision are as

follows: (1) Intrathoracic hemorrhage; (2) large bronchial fistulas; (3) foreign bodies in the pleural cavity; (4) large sucking wounds which could be explored with little or no extension of the traumatic wound; (5) massive clotted

hemothorax; (6) cardiac tamponade; (7) wounds of the esophagus, diagnosed

or merely suspected; (8) thoracoabdominal wounds, diagnosed or merely

suspected.

11. At the end of the operation, it is wise to carry out certain supplementary procedures. The pleura should be well irrigated, to evacuate all

blood, foreign bodies, and air. The lung should be completely expanded by

inflating it out to the chest wall whenever the pleura has been opened traumatically or surgically. Bronchoscopic aspiration of blood and mucus from the

trachea, main stem bronchus, and lower bronchi should be employed at the end
FIFT~H U.S ARMY 437

of the operation, as well as during it, if less radical procedures fail to clear the

tracheobronchial tree. This measure is not necessary if tracheal suction by

cateter has been successful.

12. Intercostal nerve block is an important phase of adjunct therapy. It

relieves piin, and thus promotes deeper breathing and facilitates expulsion, by

cough, of blood and mucus in the tracheobronchial tree.

13. Replacement therapy is most important. Whole blood is preferred

to other fluids, and autotransfusion of intrapleural blood should be used whenever this is practical. The blood should be given slowly after the systolic

pressure has reached 80 mm. Hg, and no more should be used than is necessary to achieve adequate resuscitation.

14. Sulfonamide or pencillin therapy should be instituted as soon as possible and continued until the pleura is free of air and fluid and any pulmonary

consolidation present has resolved.

15. When the casualty has sustained multiple wounds, surgery of the

chest wounds is usually done first. Most thoracoabdominal wounds are best

handled by the thoracic approach (p. 438). If the wounds must be managed

separately, the chest wound is cared for first.

Mortality rates.--During 1944, there was general improvement in the

management of chest injuries. There were still unwise thoracotomies. There

was still a reluctance to perform aspiration often enough in hemothorax, and

there were occasional instances in which either more surgery or less surgery

should have been done in the field hospital. Many surgeons, however, had acquired a knowledge of, or had improved their previous knowledge of, preoperative and postoperative management as well as operative techniques. The most

striking improvements occurred in anesthesia; preoperative management; the

selection of cases for thoracotomy; the use of the thoracic approach in thoracoabdominal wounds; evacuation and cleansing of the pleura; and complete reexpansion of the lung.

Nonetheless, in spite of these improvements, thoracic, thoracoabdominal,

and abdominal trauma contributed most heavily to deaths in the Fifth U.S.

Army. In the 1,450 battle casualty deaths studied from Army hospitals, these

categories (table 12) accounted for more than half of the fatalities (thoracic,

9.2 percent; thoracoabdominal, 13.9 percent; combined thoracic and abdominal,

3.7 percent; and abdominopelvic, 25.4 percent).

Case histories.-Major Snyder's official diary was filled with illustrations

of chest injuries well and ingeniously handled or of interest for other reasons,

as the following histories indicate.

1. A casualty who was observed in an evacuation hospital in Sicily, when the caseload was unusually heavy, taught an extremely valuable lesson. The history was unknown; he had been found on a mountainside and brought in in a semicomatose state. He

was in the shock ward, propped up on a litter, gasping for breath, and practically comatose.

His respiration had a peculiar, grunting sound. Roentgenograms of the skull had shown

an apparent small fissure fracture, though there was no contusion or abrasion of the scalp.

When Colonel Churchill and Major Snyder examined him, there were three significant
438 ACTIVITIES OF SURGICAL CONSULTANTS

findings. There was dullness over the entire left hemithorax, the cardiac dullness was on

the right, and the trachea was displaced to the right. The man died almost as soon as

aspiration of the chest had been started. At post mortem, the left pleural cavity was

found filled with 4,500 cc. of blood, caused by a partial laceration of an intercostal artery

which was caused, in turn, by a broken rib. In short, this man had died of Intrathoracc

hemorrhage from a simple, undiagnosed, overlooked rib fracture.

2. Another patient observed in an evacuation hospital had a sucking chest wound

which had been treated in the field hospital by debridement, sucking out of the pleura,

and pleural closure. The wound was packed, without intercostal drainage. A roentgenograin taken before this operation had shown partial collapse of the lung and hemopneumothorax. When the patient was observed 7 days later, he still had a partial collapse of

the lung, and the hemothorax had become massive and clotted. Decortication was necessary later. In this case, it would have been better to have evacuated the pleura com.

pletely at the first operation and inp"tuted intercostal drainage or to have let the patient

alone until he could be treated definitely In an evacuation hospital.

3. In a case observed at the 50th Evacuation Hospital, 475 cc. of blood had been

removed from the pericardium by aspiration. It continued to reaccumulate, and exploration revealed that it was oozing from a tiny leak caused by a tangential wound of the right

ventricle. Repair was performed 12 hours after injury. The patient's postoperative

condition was excellent, but he had an associated division of the cervical spinal cord from

a bullet which had proceeded upward and posteriorly.

4. A patient observed at the 38th Evacuation Hospital had compound fractures of

both legs caused by a mine explosion. Although he arrived in reasonably good condition,

he became dyspneic shortly afterward and died within 24 hours. At autopsy, tile wounds

of the legs were found in satisfactory condition, and all other findings were negative

except for the lungs. They floated in formalin solution; but, on section, diffuse hemorrhages

were found throughout the pulmonary tissue, as pronounced near the hilum as at the

periphery. There was considerable fluid. Ecchymosis was diffuse, and there were no

large hematomas, but the hemorrhage appeared to be interstitial. The lungs were dark

bluish red throughout.

No case of this kind had been observed previously by the surgical consultunt, but a number were seen later. A number were also studied by Lt. Col.

Tracy B. Mallory, who regarded the condition as a possible combination of

fat embolism and blast injury.

Thoracoabdominal Injuries

Major Snyder's convictions about the management of thoracoabdominal

wounds came from his early observation and care of a number of these injuries. In particular, he believed very strongly that the best approach to them

was through the chest wall.

The first of these patients, a Ranger, was operated on in Tunisia, in March

1943. Using the transthoracic approach, Major Snyder was able to remove

the spleen, suture several lacerations of the jejunum and colon, and then suture

the diaphragm and chest wall. The operation was performed with considerable

difficulty because neither oxygen nor positive pressure anesthesia was available.

The anesthesiologist, however, overcame these difficulties with considerable

ingenuity. lie had some endotracheal tubes and a rebreathing bag. He took

a Y-tube from a stethoscope and hooked the lower limb to an endotracheal
FIFTH U.S. ARMY 439

'tube. One of the upper limbs was hooked to a tube leading to a Flagg can

of ether arid the other to the rebreathing bag. The bag was inflated by blowig it, up by mouth. When it was necessary to expand the lung, once in the

nliddle "of the operation and again as the chest was closed, the tube to the

et er can was clamped, and manual pressure was made on the bag.

The patient withstood surgery well in spite of these unpropitious circun.stances, and he was evacuated the following day, as a matter of necessity,

for distance of 50 miles. Five days later, he was sitting up in bed and on

a geieral diet. His recovery seemed assured, but postoperative care was poor,

becauie of the rush of casualties, and he died of profound anemia. He had

had n blood at all and very little care of any kind. With average attention,

he vould undoubtedly have lived.

Another equally instructive case was observed at autopsy in Italy, at the

38th ENtacuation Hospital. This patient had a sucking wound of the chest

and a laeration of the diaphragm, through which the omentum had herniated.

The lacei tion of the diaphragm had been repaired in a field hospital 3 days

before. he intention was to perform laparotomy as soon as the patient had

reacted from shock. The plan could not be carried out because the hospital

was heavil( shelled and all the patients had to be evacuated at once to the

38th Evacuation Hospital. When laparotomy was performed there, 24 hours

after the first operation, some blood was found in the peritoneum, but no

other injury was evident. The next day, 900 cc. of blood was aspirated from

the left chest; the chest wound seemed clean. Twenty-four hours later, a

large swelling was found extending from the chest wound up the left chest

posteriorly and into the axillary area. The pulse was very rapid, and the

temperature was 1080 F. (42.20 C.). Death occurred before the sutures closing

the chest wound could be removed.

At autopsy, the latissimus dorsi above and below the wound was three

times the normal thickness, dark red, and full of gas bubbles. No infection

was evident in the subcutaneous tissues. Fecs were escaping through the

chest wound from a laceration of the splenic flexure of the colon on the

retroperitoneal aspect.

Further investigation showed that the chest wound had been excised and

the skin wound left open, according to standard practice. The surgical incision made over the rib above the skin wound had been tightly closed.

In this case, just as was done in the first case, all the necessary surgery

could have been accomplished through the diaphragm, and exploration through

it would have revealed the wound of the colon.

The management of a thoracoabdominal wound was governed by the

position of the wound as follows: -1

Principles of management of left-sided wourds.-Failure to recognize

left-sided thoracoabdominal wounds resulted in a number of fatalities. The

1 Snyder, H. E. : The Management of Intrathoracic and Thoracoabdominal Wounds in the Combat Zone. Ann. Surg. 122: 333-357, September 1945.
440 ~~~~A( 1'!V'I IE I* F SIMI( AL CO NS~ULT'IANTS1

poss.ib~ility tliat~ (he 11155 ile badtrl erel ih.d:plragin had, to be considered

Mi CVe'1v chiest an1d( abd(omlinal wound. Expj-rt-v thracotomy wits oftenl

inidicated as at diagnostic. measure. Often, !:Ii" it enlargement of the debrided

%%olund permitte el X)orat ion sufficient, to determine the p)resenice or absence

of a wound of the diaphragni.

WN'hien a thoracotoimny thirough a large inlcision wits necessary, it was best

to mnake it separate front the wound. Sometimes, however, the wound wits

-it the site of the elective incision. and thoracotomy through the wound was

thien n~ecessary.

Most surgeons familiar with thoracic surgery preferred the thoracic

:ippLroacli to all, thoracoabdominal wounds, even if laparotomy had to be. done:

-also. The diaphragmatic wound was enlarged through the open chest, the

enlarg-eient being sufficient for exploration and repair of all accessible abdominail structures. In the great majority of cases,, all necessary abdonminal

proeduescould be carried out through the thloracotomy incision.Slnc

toniy, repair of woumds-of the stomach, and mobilization of the splenic. flexure

are much more easily accomplished through this approach than by celiotomy.

Almost the entire small intestine, the transverse and descending colon, and

the kidney are usually accessible. Wounds of the retroperitoneal portion of

the splenic flexure, the spleen, and the posterior gastric surface were seldom

mnissed by at thoracic approach but were frequently overlooked at celiotomy.

Objection was .5ometimes raised to dealing with wounds of the colon and

small intestine through the chest, on the ground that infection of the pleural

cavity igh-t result. This was not a valid objection. Whenever a wound of

the (liaphragin existed, contents of perforated hollow organs beneath the

diaphragm were sucked into the pleural cavity before operation. Thoracotomy

made possible the thorough evacuation of gastric and intestinal contents which

mnight be present in the pleural cavity. It was believed that in left thor-mcoabdominal wvounds it was well to accomplish all surgery in the left upper quad-

*r-ant of the abdomen through the thoracic approach ieven when it was known

* that laparotoiny would also have to be done.

Tf1e site of elective thoracotomy in tljoracoaldominal. wounds was utsually

the 9th oi- 10th~ rib bed or interspace. 3Many of these wounds involved the

8th, 9t]), 10th, or 11th rib or interspaces. Ai ncis o in the 9th to 11th costal

heds or. interspaces might be extended forwardLthrougli the abdominal wall to

facilitate necessary procedures within the abdomen. It was, desirable to extend

* the incision for 1 or 2 inches into the abdonminal wall if this procedure would

eliminate the necessity for a separate large abdominal incision. Small musclesplitting inicisions were indicated for subdiaphragmatic drainage or exterioriZation of mnobi lized loops of the colon.

Wounds and incisions of the diaphragm were repaired with interrupted

suitures of fine cotton or silk. The diaphragmatic edges were imbricated, or

the first row of stitches was inverted toward the abdlomen with the second

Best Available Copy
FISH Ti:t. RMY 441

row. Catgut was not satisfactory for this purpose; a number of wound dis.

ruptinse*Or reported when it was used.

'It -Was not the custom to crush the phrenic nerve as a routine measure in

diaiphragifidic wounds, though it might be indicated if the defect to be repaired

Was verylarge.

Other steps of the procedure included removal of foreign bodies from the

pleura or lung; suture of the pleura over lacerations of the lung; irrigation of

the pleura with physiologic salt solution; and complete reexpansion of the

lung as the wound in the chest wall was closed.

Thoracotomy incisions were closed with cotton or silk, except occasionally

when the time factor justified the use of catgut. As a rule, the time factor had

to be considered because of a backlog of other seriously wounded patients; it

seldom had to be considered because of the necessity for rapid, termination of

the operation due to the patient's condition.

Penicillin therapy, both local and systemic, was always indicated in thoracoabdominal wounds. Some surgeons preferred to use sulfanilamide locally

in the peritoneum.

Principles of management of right-sided wounds.-Thoracotomy was

indicated in almost every wound of the right diaphragm, regardless of the

size of the missile or the possible size of the wound in the liver. Hemorrhage

or escape of bile was often profuse.

Thoracotomy was done, and the wound in the diaphragm was enlarged

to permit institution of subdiaphragmatic drainage of the hepatic wound.

Drainage was accomplished by large Penrose drains; the gauze protruding

from the inner end was packed loosely into the liver wound. Fatal hemorrhage was reported in wounds of the liver which had not been packed or sutured.

The drains were invariably brought out subdiaphragmatically, through a separate subeostal incisin or an incision in the loin, never across the pleural space.

Right thoracotomy incisions from the 9th to the 11th interspace could be

extended into the anterior abdominal wall, to permit examination of the liver

and hepatic flexure, the right half of the transverse colon, the duodenum, and

the head of the pancreas. The need for a separate celiotomy incision was often

thus eliminated. Wounds of the posterior diaphragm could also be enlarged

to permit nephrectomy, suture of the kidney, or establishment of drainage of

the perinephric area through a stab incision in the loin.

Suture of the right diaphragm, as of the left, had to be done with the

greatest care. The use of interrupted sutures of fine silk or cotton was mandatory. Biliary-pleural fistulas were repeatedly observed when catgut was used.

Suture of the diaphragm to the chest wall was avoided, as was drainage of the

liver through the diaphragm and the chest wall.

As in wounds of the left side of the diaphragm, it was always best to

complete the chest surgery before making a laparotomy incision.

Combined thoracic and abdominal wounds.-When chest and abdominal

wounds were present in the same patient without a communication through
pFtI U.S :ARMY 441

row. Catgut was not satisfactory for this purpose; a number of wound dis.

ruptions were reported whenit was used.

It wis not the custom to crush the phrenic nerve as a routine measure in

diaphragmatic wounds, though it might be indicated if the defect to be repaired

was very, large.

Other steps of the procedure included removal of foreign bodies from the

pleura or lung; suture of the pleura over lacerations of the lung; irrigation of

the pleura with physiologic salt solution; and complete reexpansion of the

lung as the wound in the chest wall was closed.

Thoracotomy incisions were closed with cotton or silk, except occasionally

when the time factor justified the use of catgut. As a rule, the time factor had

to be considered because of a backlog of other seriously wounded patients; it

seldom had to be considered because of the necessity for rapid, termination of

the operation due to the patient's condition.

Penicillin therapy, both local and systemic, was always indicated in thoracoabdominal wounds. Some surgeons preferred to use sulfanilamide locally

in the peritoneum.

Principles of management of right-sided wounds.--Thoracotomy was

indicated in almost every wound of the right diaphragm, regardless of the

size of the missile or the possible size of the wound in the liver. Hemorrhage

or escape of bile was often profuse.

Thoracotomy was done, and the wound in the diaphragm was enlarged

to permit institution of subdiaphragmatic drainage of the hepatic wound.

Drainage was accomplished by large Penrose drains; the gauze protruding

from the inner end was packed loosely into the liver wound. Fatal hemorrhage was reported in wounds of the liver which had not been packed or sutured.

The drains were invariably brought out subdiaphragmatically, through a separate subcostal incision or an incision in the loin, never across the pleural space.

Right thoracotomy incisions from the 9th to the 11th interspace could be

extended into the anterior abdominal wall, to permit examination of the liver

and hepatic flexure, the right half of the transverse colon, the duodenum, and

the head of the pancreas. The need for a separate celiotomy incision was often

thus eliminated.. Wounds of the posterior diaphragm could also be enlarged

to permit nephrectomy, suture of the kidney, or establishment of drainage of

the perinephric area through a stab incision in the loin.

Suture of the right diaphragm, as of the left, had to be done with the

greatest care. The use of interrupted sutures of fine silk or cotton was mandatory. Biliary-pleural fistulas were repeatedly observed when catgut was used.

Suture of the diaphragm to the chest wall was avoided, as was drainage of the

liver through the diaphragm and the chest wall.

As in wounds of the left side of the diaphragm, it was always best to

complete the chest surgery before making a laparotomy incision.

Combined thoracic and abdominal wounds.-When chest and abdominal

wounds were present in the same patient without a communication through
442. ACTIVITIES OF SURGICAL CONSULTANTS

a wound in the diaphragm, transdiaphragmatic surgery was not recommended.

It4ould have violated surgical principles because it would have subjected the

i itact -pleura to contamination. Contamination is always present. when the

daphgigm is perforated together with perforation of a hollow viscusi.

When chest-and abdominal wounds occurred-inthe same casualty, primary

care of the intrathoracic wound was the more important unless profuse, intra.

abdominal hemorrhage or massive evisceration made laparotomy an urgent

primary procedure.

Abdominal Injuries

By 1944, certain fundamental principles for the management of abdominal

injuries had been established in the Mediterranean theater and were being

followed routinely in Fifth U.S. Army hospitals. The importance of rapid

resuscitation and early operation was generally appreciated, Almost every

patient with an abdominal wound was given the chance which surgery offered;

only casualties who were moribund on admission to the hospital did not reach

the operating table. The number of surgeons who did excellent abdominal

surgery was also steadily increasing,

When the United States entered World War II, the concept was that

resuscitation from shock must be accomplished before surgery was undertaken.

Generally speaking, this was correct. But it was promptly learned in North

Africa and Sicily that this rule had its exceptions and that if some casualties

were to survive they must be operated on before the blood pressure reached a

satisfactory level. Major Snyder was particularly impressed with a fatal case

observed on one of his first hospital tours in Italy; the patient was repeatedly

scheduled for surgery, and surgery was repeatedly deferred because his blood

pressure could not be elevated above 50 mm. Hg even with large amounts of

blood. The surgeons in field and evacuation hospitals were always advised

that these patients, without more delay, should be taketi to the operating room

and explored. The explanation in such cases was very frequently that massive

hemorrhage was continuing or that massive contamination of the peritoneal

cavity had occurred.

Captain Lalich, even before lie had the laboratory proof of the essential

role of blood loss in shock, had formulated this rule; if a patient did not respond

to 1,000 cc. of blood given over a period of approximately 10 minutes, preparations should be made for exploration. While these preparations were being

made, there would be time for another 500 cc. of blood to be given, and the transfusion should be kept running during surgery. In effect, surgery was thus

made a part of the resuscitative procedure, and many lives were saved as a

result.

Not the least important of the reasons for the improvement in the results

in abdominal injuries was the provision, instituted soon after the landings in

Sicily, for holding patients who had undergone laparotomy for from 10 to 14

days afterward. There was no surer way of increasing the mortality of
kIFTtr -U.S. ARMY 443

ab4ominal injuries than by evacuating patients immediately after surgery, as

had-ben the original practice. After the 24th General Hospital was set up in

Fldrefnce abdomial in, wounds the fall of 1044, it became the practice to hold all patients with in the field hospitals in which they had been operated on

until they could be evacuated directly to base hospitals. This practice not

only eliminated the usual stopover at an evacuation hospital but also made it

possibl to procee4 more promptly with closure of the colostomy.

Management.--Wounds of the stomach and small intestine were treated

by repair whenever this was possible; otherwise, resection was done, with

primary anastomosis. In these wounds, as in all other perforating wounds

of hollow viscera, the subfascial space wis drained with a Penrose drain or

rubber tubing, and the skin was not sutured except for the closure effected by

retention sutures. The practice of exteriorizing wounds of the small bowel

was discouraged. Small wounds --I *he cecum and ascending colon were also

treatedby primary suture and we.. -. ot exteriorized.

A few surgeons thought that, if circumferential damage was minimal,

small wounds of the left colon could be treated by primary suture; cecostomy

was always performed in such cases.

All sizable wounds of the colon and all wounds in which there was segmental interruption of the blood supply were treated by exteriorization of the

affected part at initial wound surgery. If the wound was in the rectum or the

rectosigmoid, proximal colostomy was performed. Wounds in the antimesenteric border of the colon were u3ually exteriorized as tangential loop colostomies.

Wounds in the mesenteric border were managed by complete division of the

lumen of the bowel and exteriorization of both limbs as a spur colostomy. The

limbs of the colostomy were so placed that they tended to fall together, but they

were not usually sutured. In some cases, the divided ends of the bowel were

separated by an intervening bridge of skin. The importance of adequate

mobilization of the segment of the colon to be exteriorized was increasingly

appreciated, and retracted colostomy stumps were seldom observed.

Some wounds of the colon had to be managed by right colectomy, with an

ileotransverse colostomy of the spur type. Surgeons were instructed to bring

the terminal ileum and transverse colon out together through a separate surgical

incision and suture them together to form a long spur. The spur was usually

crushed early in the postoperative period, preferably by the fourth postoperative

day.

Exteriorization was always accomplished through an incision separate from

the main surgical incision. At the 15th Evacuation Hospital, on one of his

visits, Colonel Snyder observed a number of patients with wounds of the colon

whom he had seen earlier, at the 33d Field Hospital. In all of these cases, exteriorization of the colon had been performed through the laparotomy incision,

and all the wounds were breaking down. It was not long before all forward

surgeons had been instructed to bring the colon out through a separate stab

wound.
444 ACTIVITIES OF SURGICAL CONSULTANTS

Originally, petrolatum-impregnated gauze had been used to hold the skin

edges open. It did not prove very satisfactory; the subcutaneous fat waswidely

separated, and the gauze was very diflicult to remove. It was suggested that

rubber tissue drainage of the fatty layer be substituted for this type of gauze

drainage. The practice soon became standard and made it possible to close the

skin completely without danger.

Postoperative measures.-The daily administration of from 500 to 750

cc, of plasma was standard practice in the immediate postoperative period. The

Levin tube or Wangensteen suction was used for from 3 to 7 days after operation. Otherwise, the postoperative regimen followed the usual plan.

Wound dehiscence.-The incidence of wound dehiscence was always distressingly high in abdominal wounds. The best results were secured in closure

of the laparotomy incision by the use of fine catgut for the peritoneum and

interrupted sutures of fine silk or cotton for the fascia. Retention sutures of

heavy silk or wire, tied loosely, were always used. They were so placed as to

include the fascia, or the fascia and muscle, or all layers of the abdominal wall.

Mortality rates.-Intra-abdominal wounds accounted for more deaths in

the Mediterranean theater than any other group of wounds. They (abdominopelvic wounds) were responsible for 368 (25.4 percent) of the 1,450 battle

casualty deaths studied in Fifth U.S. Army hospitals (table 12). The principal

wound in 40 other deaths was also intra-abdominal, but this injury was not the

principal cause of fatality in these cases.

Hand Injuries

The management of hand injuries in the forward area early in the war was

generally poor, and improvement was slower in coming than it was in most

other injuries3 2 In fact, little was done to standardize the management of these

injuries until the second winter of the war, when the troops were halted on the

Gothic Line. At this time, the 24th General Hospital was located in Florence,

and the Army evacuation hospitals were chiefly located north of this city, with

a few to the west. With the lull in combat, it was possible for Maj. Harvey S.

Allen to make a tour of all of these hospitals, lecturing on and demonstrating

the correct care of hand injuries.

The basis of management was adequate debridement, with, at the same time,

sacrifice of as little tissue as possible. Primary nerve suture, as already mentioned, was not permitted in army hospitals, and both primary and secondary

tendon suture was also forbidden. When excisional surgery had been concluded,

the exposed structures were covered, contrary to the usual rule that wounds

should be left open.

The hand was put up in the position of function, splintage being accomplished by any of several methods. One splint, the so-called boxing glove splint,

Medical Department. United States Arm)l. Surgery in World War II. Hand Surgery. Washington: U.S. Government Printing Office, 1955.
FIFTH U.S. ARMY 445

was d!,velped' by Colonel Cox, Chief of Surgery, 24th General Hospital.

Aiothdf spliht-was devOeloped'by Lt. Col.,Michael L. Mason andMajor Allen.

These s6phlitwee constructed by Ordnance personnel and were supplied on

redqUt to siiigons in fbrward areas. Wire ladder or plywood splints were

probablyinor generally used than any other kind.

Wheh the boxing glove splint was used, the hand was put up in the position

of.function, in a huge compression dressing which was held in place by a thin

layer of plaster-of-paris bandage extending to the upper forearm. The fingertips and the tip of the thumb were usually left exposed.

The Mason-Allen splints were constructed of aluminum. Their distinctive

feature was a half sphere or half ball over which the palm was placed. These

splints could be used on either hand and proved quite satisfactory. Since the

war, they have been available from commercial sources.

COMPLICATIONS

The incidence of clostridial myositis (gas gangrene) was high in the Sicilian campaign, and its disastrous potentialities were promptly recognized.

Captain Jergesen, of the 2d Auxiliary Surgical Group, was particularly

aroused by the problem, and many of the valuable suggestions in Circular

Letter No. 2, Office of the Surgeon, Headquarters, II Corps," were made by

him.

The incidence of this complication continued high in the early fighting in

Italy, and when Major Snyder assumed his duties as consultant for the Fifth

U.S. Army in September 1943 he found Colonel Martin, Surgeon, Fifth U.S.

Army, seriously alarmed about it. Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army, 4 was immediately prepared. It described in detail the etiologic factors and prophylactic and therapeutic methods

of management. In all visits to hospitals, Major Snyder presented this subject,

and it was also the subject of one of the first of the Fifth U.S. Army Medical

Conferences (p. 366).

By the end of October 1943, Colonel Churchill had taken steps to initiate

an intensive study of clostridial myositis and of vascular injuries in general

in Fifth U.S. Army hospitals (p. 428). The work was in charge of Captain

Jergesen and Major Simeone. In December, arrangements were made with

Colonel Cornell, head of the 15th Medical General Laboratory, to furnish a

mobile laboratory with a clinical pathologist and two bacteriologists to assist in

the investigation.

This investigation and the intensive educational efforts made throughout

the Fifth U.S. Army hospitals resulted in a prompt reduction in the incidence

of clostridial myositis. Good surgery, based on more liberal debridement of

wounds in which this complication was a possibility, accounted for much of

the improvement. Established infection was also better managed, by the liberal

1 See footnote 5, p. 361.

34 See footnote 6, p. 361.
446 ACTIVITIES OF SURGICAL CONSULTANTS

use of blood, serotherapy, and the administration of penicillin. Before the use

of penicillin became routine in all severely wounded battle casualties, the incidence of clostridial myositis had been reduced to five or six cases per thousand,

After its use became routine, there were only nine instances of gas gangrene in.

the last 4 months of 1944, during which 15,553 battle casualties were admitted

to Fifth U.S. Army hospitals.

Clinical considerations.-The British had had an extensive experience

with clostridial myositis before the United States entered the war, and Major

Snyder was able to discuss it in detail with Maj. J. D. MeacLennan, RAMC,

whose special assignment was investigation of anaerobic infections in the British

Eighth Army. His studies included both the laboratory and the clinical aspects.

Major MacLennan emphasized the following clinical features of infection

with 0tostr'idiulm welehii perfrlingen8 :

1. The onset is rapid. He had observed the infection in one casualty only 5

hours after wounding.

2. Pain is the first complaint.

3. Early in the course of the infection, the casualty is bright, alert, but

extremely apprehensive.

4. The fever is high and the patient seems very ill.

5. The skin is pale and marbled, and there is some edema. Gas is comparatively scanty.

6. The muscle is at first pink, then pale and mushy, then reddish purple,

and finally slate blue.

7. When the infection is pure, the odor is sweetish and only mildly foul.

In Clo8tridium no vyi oedeinatiens infections, the following clinical features

are notable:

1. The onset is slower, the infection seldom being seen earlier than 8 hours

f -wounding.

2. There is little or no pain, the first complaint usu.-lly being a sense of

heaviness in the affected part.

3. The patient is apat'.etic.

4. The fever is not high.

5. The skin is discolored. Edema is pronounced, and as a result little gas is

-vident.

6. The mu;cle changes rapidly from pale pink to dark brown and then to

bl'. k. The wound drips fluid, and the tissues seem full of fluid.

7. The odor may be sweetish and foul but is seldom pronounced.

Major MacL-nnan also discussed oti~er anaerobic infections as follows:

1. In anaerobic streptococcic cellulitis, ti'e muscles are brick red, moderately

swollen, and edematous. The oder is foul. A smear from the muscle shows

manly leukocytes and small, shortchain streptococci, with only a few clostridia,

in cuntrast to C7. welchii infections, in which there are few pus cells and

many clostridia.
FIFTH U.S. ARMY 447

Treatment consists of liberal incision into the muscle and local sulfanilamide therapy.

2. In anaerobic cellulitis, the patient is not very ill. Pain is not marked.

The .odor is foul. Gas is profuse, but the infection is limited to the fascial

planes and muscle devitalized by the wounding agent.

Treatment consists of excision of dead tissue, adequate drainage of

fascial planes, and systemic and local sulfonamide therapy.

All of this iiformation was incorporated in the extensive discussion of

anaerobic infections contained in Medical Circular No. 9, Office of the Surgeon,

Headquarters, Fifth U.S. Army." Early in the war, two deaths from pulmonary embolism occurred in the

94th Evacuation Hospital after amputation for gas gangrene. The technique

employed thereafter in this hospital, that the femoral vein be ligated distal

to the profunda in all amputations on this indication, later became routine

in all army hospitals.

Special precautions in the evacuation of patients with vascular injuries also

became routine, as it soon became evident that anaerobic infection frequently

developed in these patients.

Thrombosis and Embolism

In November 1943, following several deaths from pulmonary embolism, all

confirmed at post mortem, it became the policy to watch patients closely for

the development of phlebothrombosis. The wisdom of this policy was soon

evident in three cases in which thrombosis of the femoral vein was suspected.

All were studied by venography. One venogram showed only a saphenous

thrombosis. The others showed thrombi in the femoral vein, probably ascending into the iliac vein. Phlebotomy and thrombectomy were done in both

cases, with immediate symptomatic relief and ultimate recovery, though fever

did not, subside for several days and swelling persisted even longer.

The following spring, Major Lyons performed numerous venous ligations

for phlebothrombosis, which in some instances was associated with thrombophlebitis. In his experience, there was successively less edema with the

performance of common iliac ligation, external iliac ligation, superficial

femoral ligation, and common femoral ligafign. It was his opinion that the

tremendous edema observed in some fractures of the femur could be explained

by thrombophlebitis.

Anuria and Nephropathy

Anuria and oliguria were frequently encountered in severely wounded men.

Part of it could be explained as a physiologic response to wounding, but by

January 1944 the incidence had increased to a considerable degree, and some

other explanation was necessary.

see footnote 7, p. 361.
448 ACTIVITIES OF SURGICAL CONSULTANTS

One theory was that sulfonamide therapy might be responsible, and special

precautions for its use were detailed in a medical circular from the office of the

Fifth U.S. Army surgeon in January 1944.G After attention had been called

to the fact that most cases of anuria to date had occurred in patients who had

received sulfadiazine intravenously in 5-gm. doses, the following precautions

were laid down:

1. Not more than 10 gin. of sulfanilamide powder should be used intraperitoneally and in associated wounds at the time of operation; at least half of

this amount should be dusted into the peritoneum.

2. Intravenous sodium sulfadiazine therapy should not be started until 24

hours after operation, after the patient had reacted from anesthesia and

shock. The dosage then was not to exceed 2.5 gmn. every 12 hours,

3. Sulfonamide therapy was to be promptly discontinued if the 24-hour

urinary output was less than 1,000 cc. or if gross or microscopic hematuria

developed. Fluid intake should be adequate to insure a minimum urinary output of 1,500 cc.

Special instructions were also given for the use of sulfonamide therapy in

wounds in which clostridial myositis was likely to be encountered.

Anuria continued to occur in spite of these precautions, and the role of mismatched blood was then advanced as the causative factor. It undoubtedly explained some cases, but it did not provide a universal explanation. This type of

nephropathy was also frequently observed in patients with crushing injuries

and in those with very severe wounds who had been in shock for long periods of

time.

In the fall of 1944, the board set up to study physiologic pathology in the

severely wounded (p. 415) had the special objective of investigating lower

nephron neplhrosis. All patients who developed this condition or in whom it

seemed impending were reported to the board at once, and prophylaxis and

therapy were carried out according to their recommendations. The board's final

conclusion was that no single factor was responsible for lower nephron

nephrosis.31

Major MacLennan recommended alkalinization therapy, but no satisfactory

treatment for lower nephron nephrosis was ever developed, except that it was

learned that, contrary to the original practice, fluids should be limited when

the condition appeared or seemed impending.

Section III. The German Medical Service in Italy

GENERAL CONSIDERATIONS

Practically all of the prisoners whom Allied medical services were called

upon to treat in Italy were Germans. Since the Italians surrendered to the

Allied forces as the invasion of Italy was in progress in 1943, very few became

See footnote 10. p. 361.

See footnote 19. p. :98.
I'IFt'I Id \HM-lI 76- I'H o\' l 1 y 5 1491011sof% 

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Pot ValleY (fig. 76) after tile breaktouigh tre ill April 1) f urjnied a

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depo"itoie' for tile sick anid wotiilet Iellilmiltsof li eimilt.On :3 May

191. all Alliedi force. hieadquarter, lireck tnatde m captuoredi (elliiniii pri. ollens

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450 ACTIVIT'IES~ OF SURGICAL CONSULTANTS

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J..I,..,II S HMY451

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452 ACTIVITIES OF SURGICAL CONSULTANTS

tions, supplemented by interviews with German medical officers in hospitals

and hospital groups and with others who held staff positions in German armies

and army groups, 8 yielded much information of-interest.

While it is impossible to judge the standards of German military practice

by the conditions found in hospitals operated by a beaten enemy after 6 years

of war, there is no doubt that, since 1933, both the quantity and quality of

German physicians had steadily deteriorated. By U.S. standards, observations

in German hospitals showed their food and their medical and surgical supplies

to be inferior and their medical and surgical practices no more than mediocre.

ECHELONS OF MEDICAL CARE

The chain of evacuation of German wounded was basically similar to that

employed in the U.S. Army, although triage differed in a number of respects.

The system was as follows:

1. First aid was rendered by a noncommissioned officer in an installation

(Verwundetenest) located very far forward. The measures employed were

limited to dressing the wound; the application of transportation splinting,

traction splinting, or pressure bandages; and the application of tourniquets.

Care at this level corresponded to the care given U.S. Army casualties on the

battlefield by company aidmen.

2. The wounded were then evacuated to an installation (Truppenverbandplatz) which corresponded to the U.S. battalion aid station. All care at this

level, as in the similar U.S. battalion aid station, was directed to preparing the

casualty for evacuation farther to the rear.

A medical officer who corresponded to the U.S. Army battalion surgeon

carried out much the same functions as his U.S. counterpart. The dressing

over the wound was checked, but it was not disturbed unless there was some

indication for the interference. An occlusive dressing was applied to an open

chest wound. Tracheotomy was performed if necessary. Hemorrhage was

arrested by pressure bandages, the application of a tourniquet, or, less often,

by hemostat or ligature. If lie required it, the patient was catheterized. Pain

was relieved by standard methods. Shock therapy (physiologic salt solution,

external heat by electric heaters, Periston, or Nikethamide (Coramine)) was

instituted.

3. The wounded were next evacuated to an installation (Hauptverbandplatz) set up by the sanitiits company of the division about 4 miles behind the

frontline. It was staffed to perform functions similar to those of a U.S. Army

clearing station, but it also was equipped to hospitalize patients (fig. 78). It

could care for 200 routinely, and in times of stress the bed capacity could be

expanded to care for from 300 to 400 casualties. The table of organization

"'Brig. Gen. Prof. 11. Burkle de la Camp, M.D. Advisory Surgeon to the Officer in Charge of the

Medical Service of the Army of the Southwest. Subject : Report of experience gained during the

entire work of the Medical Servlke from 1939 to 1945. Reference: Oral order issued by the Officer in

Charge of the Medical Service of the Army of the Southwest to prepare a report on the experience

acquired, for submission to the Americai Occupation Authorities. 3Merano. June 1945.
FIL'li' US$. ARIMY 45i3

~JSL:'

'ji~ -.1 ".a' itl~li l kvjujIuu lulii1il pi Fu u s u ljt

ii i uiuuti ~l l8lit lulutalinth Iluuuu ;ni. lhPlV1

t~uu222 Al
454 ACTIVITIES OF SURGICAL CONSULTANTS

provided for two operating surgeons, but, when a push was on, six or eight

additional surgeons might be attached.

Primary surgery was performed on minor wounds at this installation.

When the flow of casualties was light, those with abdominal wounds and other

injuries which made them nontransportable also received initial wound surgery

here. Casualties with craniocerebral injuries, chest wounds, and major compound fractures were evacuated farther to the rear. According to the German

medical field manual, the functions of the Hauptverbandplatz included tracheotomy; closure of open chest wounds; aspiration of the pericardium in cardiac

tamponade; emergency amputations; definitive arrest of hemorrhage; suprapubic eystostomy; surgery on nontransportable casualties; and administration

of blood and blood substitutes.

At the beginning of the war, all army divisions had two sanitiits companies. At the end, only armored divisions and mountain divisions had two

companies, though each corps surgeon had one under his control to use at his

discretion. When two sanitlits companies were available to each division, two

Hauptverbandplatzen were often set up.

At the beginning of an offensive, a horsedrawn sanitlits company was

placed 3 or 4 kilometers behind the line, ready to receive casualties. The other

company, which was motorized, was held in reserve, to be used after substantial

gains had bb:n made. If the gains were extensive and the Hauptverbandplatz

was required farther forward, the motorized company moved forward, leaving

its patients to be taken over by the horsedrawn unit, which left its patients, in

turn, to be taken over by a Feldlazarett.

4. Next in the chain of evacuation was a unit (Feldlazarett), corresponding, in general, to a U.S. Army evacuation hospital (fig. 79). It was designed

to care for 200 patients, and its table of organization provided for only 2

operating surgeons. In times of stress, however, the intrinsic staff was augmented by surgeons from other units.

Ordinarily, the Feldlazarett provided primary surgery for head wounds,

transportable chest wounds, severe muscle wounds, wounds of the buttocks,

and major compound fractures. When the Hauptverbandplatz was rushed,

patients with abdominal injuries were evacuated for care here, though the

preference was to care for them farther forward.

As this description has indicated, there were often two divisional units

performing surgery ahead of the most forward field hospital. When, however, a

major offensive had been launched, division, army, and army group hospitals

might all perform primary surgery only on the less seriously wounded, casualties with intra-abdominal and intracranial wounds being put aside in favor ,f

those more likely to survive and to bo returned to full duty. Generally speaking, the German Army system of medical care was extremely flexible, but its

flexibility tended to favor the lightly wounded at the expense of the seriously

wounded, the group which U.S. Army medical oflicers considered first priority

patients.
J~_J

Foum 79.-Feldlazarett. In the German medical service, this

installation corresponded to a U.S. evacuation hospital.

5. General hospitals (Kriegslazaretten) were usually assigned to an army

group. In Italy, most of these installations were grouped at Merano and

Cortina d'Ampezzo.

The major function of these hospitals was to care for patients who had

been operated on at more forward units and who could not be returned to

duty. In addition, certain casualties received primary surgery here, including

those with penetrating head wounds complicated by involvement of the eyes

or ears and those with maxillofacial wounds. In very busy times, such as

occurred during the frequent offensives launched by both sides, all patients

requiring major surgery might be evacuated to these general hospitals for it,

the units farther for yard being engaged in caring for men who could return to

their units *ithin a reasonable time after operation. It was not at all unusual

at such times for patients with abdominal injuries, head injuries, and other

serious wounds to receive no surgery at all.

6. In addition to these units, other medical installations cared for casualties

with slight wounds and illnesses and for convalescents, as follows:

In each German division was an ersatz company which served as a replacement depot and reconditioning unit for lightly wounded casualties who had
456 ACTIVITIES OF SURGICAL CONSULTANTS

received primary surgery in the Hauptverbandplatz. Patients were ordinarily

held here for a week. During this time, a medical officer directed their reconditioning, which was chiefly accomplished by exercises. There were usually

between 50 and 100 of these patients in an ersatz company at a single time.

The staff usually consisted of medical officers who had been injured or Who were

oi, limited service for some other reason.

Hospitals for patients with slight injuries and mild illnesses were established in army areas and general hospital centers by elements of transport

units (Krankentransportabteilungen). These units received their patients

from the Feldlazaretten in the army area or from the Kriegslazaretten in the

army group area or hospital centers. Most patients remained 2 or 3 weeks.

7. The German Army medical service had no auxiliary surgical groups.

The army surgeon used personnel from reserve units or less active units to

augment the staff of busy units.

Administration.-For control purposes, medical units of 100 beds were

incorporated into larger units, and these units into still larger units. Hospitals

found better staffed and equipped than others were invariably those designated

to treat elite casualties, such as Luftwaffe and SS troops.

CONSULTANT SYSTEM

Each army gronp had two consulting surgeons and one consulting physician. Each army had the same number. The army group also had consultants in ophthalmology, otology, and psychiatry. Their surgical assistants

were physicians who had had 3 or 4 years of surgical training after graduation

from medical school.

Consultants were selected from medical schools or civilian clinics. If

they had served 6 weeks in the army before the outbreak of the war, they had

the rank of major; otherwise, they entered as lieutenants. Promotions were

granted to officers with the civilian rank of professor, regardless of their

primary grade, after they had served half the usual time requirement. A

major thus became a lieutenant colonel after 18 months and a lieutenant colonel

a full colonel after 3 years.

The duties of the German consultants were in general much the same as

those of consultants in surgery in the U.S. Army. There was, however, one

exception. When a consultant visited a hospital, lie took along his assistant

and a noncommissioned officer, together with a full set of instruments, because

he was frequently ca'fled upon to operate, or decided for himself to operate, in

special cases. The relative paucity of skilled -urgeons in tbe German Army

made the operating function of the consultant extremely important; many

hospitals had no surgeons on their staffs capable of performing difficult major

surgery.
FIFTH 'U.S. ARMY 457

INSPECTIONS OF GERMAN HOSPITALS

During the first week of May 1945, Colonel Snyder visited a number of

Germaii h6pitals in all echelons of medical care, making notes on the administrative aspects of these installations and examining numerous casualties.

Some of these patients had had primary surgery within the past 48 hours to

21 days, but others had been wounded a year or more earlier.

All along the roads traversed in reaching these hospitals, rail lines, railroad bridges, and other rail installations were largely demolished because of

the excellent work of the U.S. Army Air Forces on the Brenner Pass and its

approaches. Bombing damage was practically always confined to the areas

near these targets, and transportation along the roads had therefore not

been interfered with. Numerous groups of German soldiers were observed

marching along the highway to the rear, without guards, although they were

still armed. Convoys of troops, also without guards, were also proceeding

to the rear. They were all orderly and well-behaved, and the absence of guards

apparently did not move them to attempt to escape.

The following notes on special hospitals are representative of the conditions found in all of the hospitals inspected:

A Luftwaffe hospital, set up at Villa d'Este at Cernobbio on Lake Como,

was operated chiefly as an orthopedic surgery center. The Germans had added

a magnificent operating room to this luxury hotel, and the equipment was

excellent. A small prosthetic shop was operated by three mechanics, and the

patients for whom prostheses were being prepared were serving as their assistants. All parts, including metal joints, were made from raw materials in

the shop. Some prostheses were constructed of wood and others of a plastic

material which could be softened with acetone for molding and fitting.

The surgical standards in this hospital seemed much higher than in many

others inspected. Even so, the U.S. medical officer who had been attached to

it to check on the professional work done by the German staff reported that

the aseptic technique here, as in most other hospitals, was far from optimum.

Surgeons did not wear masks, even when performing elective major abdominal

surgery or orthopedic surgery, and the incidence of wound infection was high.

At Feltre, the hospital staff consisted of 11 medical officers, 2 medical

administrative officers, 1 dentist, and 5 chaplains. When this hospital was

inspected on 5 May 1944, it had only 295 patients; 84 had been evacuated

within the previous 24 hours.

At Feldlazarett No. 200, at Primeiro, there were 3 medical officers and

80 patients. At this hospital, as at the hospital at Feltre, the surgery was of

poor quality.

At a group of three other hospitals visited the same day, the bed capacity

was 1,200, and there were 860 patients. Each hospital occupied three or four

hotels; one of the installations was entirely for paratroopers and another for

Luftwaffe patients. The surgery in these hospitals, all of which housed high-
458, ACTIVITIES OF SURGICAL CONSULTANTS

ranking officers and 6ther special patients, seemed of a higher quality than in

soni of the hospitals which had been inspected earlier, but wound infection and

gas bacillus infections were widely prevalent.

At this installation, Colonel Snyder was told of a new drug, still secrdet,

which was being used by injection for clostridial myositis. It did not impress

him as being as good as penicillin, and, since nothing more has been heard of

it, his impression was probably correct.

The hospital center at Merano consisted of 14 hospitals, each occupying

several hotels or other buildings. Near it, on the outskirts of Bolzano, was a

hospital for the lightly wounded, with its bed capacity of 3,000 little more than

half occupied. It was said that this was an unusually large number of patients

for this installation. The staff consisted of 12 medical officers, 3 administrative officers, 200 enlisted men, 44 German nurses, 7 Italian nurses, and 3 Russian and 3 Italian Red Cross Sisters. The commanding officer had plans to

discharge 500 of his approximately 1,600 patients within 2 weeks, 600 within

4 weeks, 300 within 2 months, 100 within 3 months, and the remainder within

6 months.

At the center at Merano, 42 Allied wounded were in process of evacuation

under the supervision of Maj. (later Lt. Col.) Claude E. Welch, MC, who had

been detailed from temporary duty with the 8th Evacuation Hospital for this

purpose. According to the Germans, four of these patients were nontransportable.

One of this group was a U.S. Thunderbolt pilot, who had been shot down

in February 1945 and badly burned. He was still very ill, little more than skin

and bones, and the Germans had allowed him to become very anemic. One eye

had been enucleated 2 days before Colonel Snyder's visit, because of sepsis,

and the cornea of the other was white. The German plan was to give him 200

to 250 cc. of blood by direct transfusion every second day. He was given 4 pints

of blood and large doses of penicillin at once and was moved to a U.S. Army

hospital 48 hours later.

The ranking officer among Allied wounded in this center was a British

major who had been captured in December 1944 an, had undergone a mid thigh

amputation. le reported that the food he had received was as good as was

available and that his treatment had been generally good, though the Germans

were very domineering, particularly to the Italian staff of the hospital. An

Italian physician had worked in the hospital along with German medical

officers, in preference to being sent to a concentration camp, and this patient

reported that he had been extremely kind to all the Allied prisoners.

GENERAL CLINICAL CONSIDERATIONS

The outstanding impression gained from a survey of these and other

Germnm hospitals in Italy was that infection was many times more frequent

than in U.S. Army hospitals. The generally pale and anemic appearance of

the patients was in contrast to the healthy appearance of most patients in
FITH U.S. ARMY45

U.S Army hospitals. Clinical practices in the German Army medical service

explained these observations. Blood was used in little-more than homeopathic

a mounts, and an almost complete lack of aseptic technique accounted for the

prevalence of wound infection, the extent of which was almost incomprehensible in the year 1945, regardless of military circumstances.

Colonel Lichtenstein, who subtitled his report to the Fifth U.S. Army

surgeon "The Story of a Finger," described the ward rounds and other activities

of a German surgeon substantially as follows:

He examined clinical records, X-ray films, and soiled bandages. He determined the patient's state of hydration by running his finger across his tongue.

He then readjusted several mechanical supports, lie shook hands with the

superintendent of the hospital and other visitors on the ward. With his assistants, he examined draining extremity wounds without gloves or a mask, using

the same instruments throughout and proceeding from one case to another

without washing his hands. In fact, he did not wash his hands during the entire

morning. Conversation over open wounds was completely uninhibited. The

American observer noted that he himself did not offer to shake hands with

him when the so-called rounds were over.

Under these conditions, which were of the same order though perhaps

somewhat less extreme in most of the hospitals inspected, infection was practically inevitable, and interviews with many German surgeons indicated that

they had come to regard it as such. A German consultant who had seen service

in World War I, as well as on the Russian front in World War II, stated that

infection was just as much a problem in World War II as in World War I.

Shock and hemorrhage.-German wounded received in shock were

treated by external heat, stimulants, Periston when it was available, and direct

blood transfusions.

The Germans regarded Periston as an excellent substitute for plasma and

of such high osmotic properties that it was retained in the blood stream for

12 or 14 hours. It was furnished in 500-cc. units, and the dosage did not exceed

2 units. 9 Supplies, however, were limited, and it was not available in all

German medical installations, even in units in the division area, which had

prior claims on it.

All blood transfusions were done by the direct technique, in amounts of

200, 300, 500, or 800 cc. Occasionally, a casualty was given 1,000 cc., but larger

amounts were never used, and most of the German surgeons questioned were

opposed to giving more than 200 to 300 cc. of blood at any one time. As already noted, the extreme pallor of many patients seen in German hospitals,

and the moderate pallor of most of them, supported the surgeon's statement

that blood was used only in small quantities and in selected patients.

wPeriston has never been popular in the United States and was regarded in 1958 as a poor plasma

substitute. It has been determined that it is not all excreted, a certain amount being deposited in

some of the organs of the bodA. U.S. medical officers were in agreement Nith German medical officers

that a maximum dosage of 1.000 cc. ,hould never be exceeded.
46O~ACTIVITIES OF SURGICAL CONSULTANTS,

At the best, it seenled that a German casualty, no matter how serious his

Wouid Or how deep his shock, would:not everrejceive-more than-1,QO c. ofl

Peristhn and 1,000cc. of blood. If the pulse did not retutn-in a patientyith

an abdominal or otherserious wound iii espoise to this type of resuscitati0n,,

be Was simply not operated on. The impression was, gained that satisfactory.

restoration of the pulse volume was the criterion of successful resuscitation and

that surgery was seldom performed if this was not achieved.

This method of treating shock and loss of blood was in sharp contrast-t

U.S. Army methods. In the U.S. Army, plasma was availablein all forward,

medical units in the division and was used in large enough quantities to make-

-casualies tranportable to field hospitals, in which banked blood was available.

By the end of the war, U.S. battle casualties in the Mediterranean theater were

receiving an average of 1 pint of blood each. Furthermore, casualties who did

nbt respond promptly to vigorous shock therapy were operated on immediately

and thus given their chance of life. This bold policy saved many lives.

REGIONAL INJURIES

Head injuries.-Most of the German casualties with intracranial wounds

who were observed at the hospitals visited in May 1945 needed additional

surgery. At the hospital center at Gardone Riviera, which Colonel Campbell

surveyed on 6 May 1945, there were 40 patients with head injuries, 30 of whom

needed further surgery. About a dozen patients with wounds of the spinal

cord were examined, about the same proportion of whom needed operation. At

this hospital, a general surgeon was in charge of neurosurgery. Maj. (later

Lt. Col.) Henry L. Hoffman, MC, was assigned to it as professional supervisor.

Chest wounds.-Most of the patients with chest wounds observed in German hospitals had been wounded weeks and months earlier. About 60 percent

of them had empyema. Colonel Snyder was informed that empyema could be

expected to develop in about this proportion of shell-fragment wounds and that

it could also be expected in about 30 percent of all bullet wounds. In the U.S.

Army in World War II, empyema came to be a very uncommon complication.

Opinions expressed by German surgeons concerning the management of

chest injuries varied widely in details but were fairly unanimous in respect to

most principles. It was agreed that shock of some degree was present in most

chest wounds and that its management must take precedence over management

of the wound unless there was a wide open pneumothorax or a severe and menacing hemorrhage. When there was serious internal bleeding, or an increasing

hemothorax, the patient needed constant attention; otherwise, shock might

pass on to collapse, and the patient would bleed to death. When a large number of wounded me- were received at the same time and the surgeons were busy

in the operating roo , a junior officer or intern or whoever else was available

was employed to mak so-called collapse examinations, to make certain that a

failing circulation and serious bleeding would be reported before they became

irreversible.
FIFH ,.S.=4IMY 461:,

No sirgry Was done in, perforating chest wounds unless :there vefe,

indiit6vn ib fragments. The policy -of early, repeated aspiration in h emqthbra*, which was routine in US. Army hospitals, .was not employed in German

ipsp it1,iind there seemed no general ,pqlicy for the management of this- Sniplckti6n; Some surgeons stated that aspiration was never employed

unl it became necessary to relieve dyspnea associated with a large hemothorak

or hemopneumothorax. Others said that aspiration was performed within the

first 5 dys after wounding. One consulting surgeon said that this had-been

the-practice early in the war unless respiratory difficulties required interference

eailier"'but that it had recently become the practice to perform aspiration as

soon asthe casualty had reacted from shock, usually within 48 hours after wounding.

The treatment of empyema seemed rather more uniform. Closed inter.

ostal (Biilau) drainage was instituted as soon as infection or pus was evident.

The catheter was attached to a water-seal bottle, which was usually converted

into a Wangensteen-like suction apparatus by the use of two additional bottles.

Drainage was continued until the cavity was obliterated. If this had not

occurred at the end of 6 months, the empyema was considered to have become

chronic, and thoracoplasty and decortication were employed by the modified

Sclede's technique. Rib resection was seldom employed.

'No facilities were provided for gas anesthesia or for positive pressure

delivered by an anesthetic machine. A good machine was available for oxygen

therapy, but it was apparently seldom or never used for expanding the lungs

during intrathoracic surgery. Endotracheal tubes were not observed in any

hospital, and no chest surgeon or anesthesiologist mentioned this technique.

Most chest surgery was performed under open-drop ether anesthesia or local

analgesia supplemented by Pentothal sodium given intravenously.

Thoracoabdominal wounds.-Only a small number of patients were observed with thoracoabdominal wounds. None was extensive, and, in all instances, surgery had consisted of laparotomy and simple closure of the wound

in the chest wall. No patients were seen who had been treated by the transdiaphragmatic surgery which was regarded so favorably by U.S. Army chest

surgeons. When inquiries were made about this technique, the replies were

rather vague. One surgeon stated that the thoracic approach might be used if

the chest wound was large and the intra-abdominal wound small.

In the absence of facilities for positive pressure at operation, and without

well-trained anesthesiologists experienced in anesthesia for chest surgery, it

was concluded that the German wounded could not have had the advantages of

modern intrathoracic and transdiaphragmnatic techniques.

Abdominal wounds.-Only a small number of patients with abdominal

injuries were found in the German hospitals which were captured and in those

which fell into U.S. Army hands when the mass surrender occurred. This is

not surprising if one conside s the tactical situation during the preceding weeks

and the German policy of care of casualties, which favored the less seriously

606222-62--:32
462 AOTIVITIES OF SURGICAL CONSULTANTS

*6i ded. It seems doubtful, in the confusion of the final weeks of- fightingand

theh&vy casualties associatecd with the crushing German defeat iw the6l .. -Push ;thit txanycasual ies with abdomnih4 injuries § were ortinate enpugh .

niidergo any surgery at all. In the combined hospitals at Me'rano, in hich

:6ig7"'sualties had been collected by 6 June 1945, there were only 261 pati ts

with abdominal, thoracoabdominal, or combined thoracic and abdominal-.

6unds§, and il) of these were listed as superficial wounds.

O(ily two patients who had undergone abdominal surgery were observed -

by Colonel Snyder, both of them in the same installation. One of themnhadhad

4,eg&ive exploration and had developed a huge incisional hernia. Ti other

was making a satisfactory recovery after surgery on the small intestine,

It was evident, in spite of these observations, that the Germans were,

iiipressod with the advantages of early surgery in forward installations for

intiraabdbminal wounds, The army manual of surgery recommended it,. and

German surgeons stressed it in interviews held with them.

One surgeon described a Hauptverbandplatz on the Russian front in .which.

37 operations for abdominal injuries had been performed over a 2-month

period. There were eight deaths. The timelag was usually 2 hours; when it

rose to 6 or 8 hours, results were less good. This hospital was located close to.

the frc tline, which was well stabilized, and the Germans were well dug in.

Also, the casualty load was not heavy, Surgery could therefore be performed

in the division area on almost all patients; not more than six or seven were

evacuated, for various reasons, to the Feldlazarett farther to the rear.

Even when conditions were fcvorabl,. however, it was clear that patients

with abdominal injuries who did not resp.,nd to shock therapy did not have

emergency surgery unless there was reason t, believe that shock was produced

by intra-abdominal hemorrhage. It was not clear, from the replies to questions,

how the distinction was made between shock due to intra-abdominal hemorrhage

and shock due to massive peritoneal contamination.

Techniques of abdominal surgery, when it was employed, seemed much the

same as those used in U.S. Army hospitals. Wounds of the liver were drained.

Wounds of the stomach and small intestine were repaired unless the wound

was so extensive that resection was necessary. Small wounds of the colon were

usually repaired, after which proximal cecostomy was usually done. Large

wounds of the colon were exteriorized.

It is doubtful that the Germans, without whole blood in adequate amounts

and using only the direct technique of transfusion, could have improved their

results in wounds of the abdomen even if they had attempted surgery on these

desperately wounded casualties. What U.S. Army surgeons accomplished in

this group was due not only to their own skill but also to the skill and superior

equipment of their anesthesiologists, the judicious use of banked whole blood,

and the use of oxygen and all the other facilities and equipment which the

U.S. Army provided to insure the best possible care for every wounded man.
;FT~'T~'A~~fV46V

Wounds of the extremiities.--iostwounds of the extremities were treated

prima, rily in tlie HauptVdrbanidplatz or the Feldlazarett. Tli careful, wound

excisioni -practiced Jy US Army surgeons was practically unknown. One. Gmi6 i hgeon statedthatle had done only five or six suehoperatiolis during

the entiN', eWar; li had performed primary wound closure in all of them.

Many of the patients seen in German hospitals had had little or no exCisioinal siiigery. Treatnent seemed to have been limited to incision of the skin

hind fascial planes, excision of devitalized edges of skin wounds, and removal

of gross debris and devitalized tissue. Whether the devitalized tissue present

:in mafiny f the wounds examined had been left in situ or had developed after

idadequatpdebridement it was not possible to say. Unless the wound was large,

perf6 ating wounds associated with fractures were often treated without surgery, as WbVre all bullet wounds. As a result of these practicesi infection was

frequent and extensive, and there w-as a great deal of gas edema and actual gas

gangrene,

One surgeon described the management of badly damaged heels by excision

of the talus, calcaneus, and half the scaphoid and the cuboid. HIe then put the

foot in the drop position, in which it was anchored with Steinmann's extension

pin. Tl patients were then fitted with below-the-knee prostheses, which they

wore most of the time. He reported good functional results in a quarter or a

third of the patients treated by this method; amputation was necessary in the

remaining cases.

Wounds of the joints.-Perforating joint wounds from small arms or

high explosive shell fragments were frequently treated without surgery unless

there was a large wound of exit. When infection developed in knee joints in

which fractures had occurred into the joint, drainage was sometimes tried

tentatively, but more often resection was resorted to at once. Resection of the

elbow, wrist, and shoulder joints was also sometimes done to control infection.

Most patients observed in German hospitals after joint resections were still

septic. Infected wounds and resected joints were often treated with irrigations

of Dakin's solution.

Splinting and traction.-Compound fractures of the femur were put up

in skeletal traction, with Kirschner wires, whether they were treated in field or

general hospitals. When infection developed. the limb was incorporated in

plaster, but some traction was us'tally contir'' in fractures of the head of

the fenmur caused by shell fragments, the fenorai neck and head were usually

resected at initial wound surgery.

Techniques of splinting varied. In some simple fractures of the femur,

unpadded walking plaster spicas were used after the method of 1hhler. Similar

spicas were used in some compound fractures after the soft-tissue wounds had

healed. These walking spicas were not used in the early management of fresh

com)ound fractures from bullet or shell fragments as Trueta had used them in

the Spanish Civil war.
A.6" ASCIVITIES OF SURGiCAL IONSULTANTS

-Sife slugeoiis favored the use-of wooden-or wire ladder splints fqr several'

t-s .fte.r operation; then plaster, casts, which Were always.4padd6d,. Were,

la~!id. Othiersurgeons.used-plaster immediately tfter operation. W-indowS

wr6 cut: into te cast to provide for dressing, the wouid and for the man4gpme nt f infection, the anticipation of which seemed-to be routine.

A iingenious apparatus made of perforated metal pipes served as an excellent substitute for the Balkan frame. It was capableof many combinations,

sluitl.he pulley wheels could be adjusted to the desired position for any sortof

tiAcMtion. Sometimes a complete Balkan frame was constructed from these

p~ipe ,'but more often a single pipe clamped to the metal hospital or hotel led

was-used to support sidearms which provided the necessary numberof pulley

w heelsin the desired position.

In the hospital at Cernobbio, Colonel Snyder encountered two German

surgeons who had been using the nail devised by Kiintscher for the management of fractures of the femur and other long bones. One of them, the chief

of Surgery at the hospital, had participated in the original work at the University of Kiel in 1937. lHe had the iecords of 550 clinical cases in which.thiS

method had been used and in many of which he had done the operation. There

were no fatalities in this group, but there were some instances of fat embolism.

The original experimental work on animals carried out at various periods after

nailing showed that about a third of the bone marrov" is destroyed when the

nail is inserted and that small fat emboli are nearly always dislodged.

The German Army had prepared a booklet describing in detail the technique and the indications for this method of fixation. In fractures of the

femur, a straight, rigid nail was used; it was driven down through the

trochanter and into the distal fragment under fluoroscopic control. The nails

used for the other bones were flexible and slightly curved.

The surgeons interviewed at Cernobbio stated that for a time many surgeons had attempted to use the Kiintscher nail, with disastrous results.

Osteomyelitis had developed, and there were some deaths from shock. After

the original wave of enthusiasm had thus been quenched, a few qualified surgeons were designated to use the technique when they considered it indicated.

In the opinion of the surgeon who had worked with Kiintscher, the intram2dullary nail should be used only on strictly limited indications, chiefly in

closed fractures of the middle third of the femur, in which the fracture line

was transverse or almost transverse. These patients could walk without additional splinting in from 8 to 10 days after nailing. Kiintscher's former associate did not consider the nail indicated in fractures of the tibia, humerus,

radius, or ulna, though he did use it in compound fractures of the femoral shaft

after wound healing or when healing was occurring without infection.

The other surgeon at Cernobbio had used the technique in a few infected

compound fractures of the femur and the humerus when the desirability of

fixation seemed to outweigh the risks of introducing a nail in the presence of

infection.
Fraink Glennj M.D.

Them4itary actin in .the Southwest Pacific Area was complex.and unique

in comparisonwith!that in other theaters during-:World ,,War-II It was complex:11ecause it involved amphibious landings, carrierbalsed and land'-bae Ai" supportiand' infantry warfare, 7ithartilery support aided bytanks .an4d',

flimethiowers in tropical jungle, well- defdnded-by the enemy. It was uniqu e

in, thahe're were numerous combat action§sin various. phases going on simultanously 6ver a *ido geographic area. Thus, while one action was- at. it hihothers Were being initiated or completed, Planning was continuou

and ,smetimes difficult to fulfill, because of great distances between point of'

staging,,embarkation, and. invasion These circumstances established the desirability for providing adequate surgical care that was not infrequently definitiv in-the most forward areas for the severely wounded.

DUTIES AND FUNGTIONS OF SURGICAL CONSULTANT

Early in 1944, Maj (later Lt. Col.) Frank Glenn, MC, was an assistant

to Col. William B. Parsons, MC, Consultant in Surgery, SOS (Services oi

Supply), SWPA (Southwest Pacific Area). Concurrently, Major Glenn was

in charge of special projects at the direction of Brig. Gen. (later Maj. Gen)

guy B. Ddnit, Chief Surgeon, USAFFE (U.S. Army Forces in the Far East).

In these dapacities, Mfajor Glenn visited the Sixth U.S. Army surgeon, Col.

(later Brig. Gen.) William A. Hagins, MC. Although the specific purpose of

this visit was to instruct forward medical units in the use of penicillin which

had just been made available in limited quantities to the SWPA at the request

of Colonel Hagins, two additional objectives were undertaken. The first of

these was to evaluate the type of surgery performed in forward combat-area

hospitals and the second was to brki and instruct personnel of hospitals

assigned for the first time to the Sixth U.S. Army-hospitals that had had no

experience under combat conditions.

During the following months, until October 1944, in carrying out the

duties of a surgical consultant, Major Glenn was able to visit both SOS and

Sixth U.S. Army units. It therefore evolved that, after making a tour of the

medical units in the forward area, the consultant would return to those in rear

bases. Thus, an opportunity was presented to observe how the casualties of

one campaign were cared for in the most forward combat areas and to follow

465
466: AC TivTES OFSURGIOAL CONSTA

theiii hroug the chain of medical evacuationi to the fixed. hospitals in erar.

"It wistleresult of ftlisoverall picture that enabled a surgical pcnsultAnt.to

make -suggestions to-the, surgeon in the 1frward area.. Furthermore such,

-iaisoii ,.lfYed information to. -ear units thatgave them a better understanding,

ofthlpfoblemis encountered-by tle forwai'i medical units.

There were certain differences between the problems of the theater ,cone

sultait and an army cohsltant. Particularly was this true where the-actiohs§

werek6elatively small and took place at intervals of great distance. Throughout the SWPA after the Buna operations, assault landings were of an din,

phibious nature, and the number of troops employed varied from a small task

fdrce 6ofa few hundred men to a force of several divisions, Each. militar

objective preseted different problems. The medical units accompanying such

dcmbat forces functioned for various periods and then were comparatively

idle. The army. consultant was confronted with the problem of having varying

numbers of new medical units for only a short time before action and then fer

relativeoy brief intervals during the active phase of a campaign. He then

moved onto a somewhat similar episode in the next step. It was difficult for

him to know the exact capacity and ability of the surgical personnel of these

uilts. It was because of these circumstances that the army consultant, if he was

to assist in giving the wounded the best care, required that surgical personnel

assigned to forward medical units where surgery was to be performed-evacuation, field and portable surgical hospitals--be of the very best. In the type of

*arfai'e carried on in the SWPA, well-trained and mature surgeons were of

greater critical and immediate importance in the forward medical units than

in the rear bases. Surgical skill and judgment were urgent in the care of the

wounded. If this service was available in the forward area, human life as well

as limb could be conserved. The forward area was where the seriously wounded

3ither died or lived, and the period required to determine this was relatively

sh6rt. On the other hand, if a wounded soldier reached a fixed medical installation in a rear base, whether he returned to duty or was evacuated to the Zone of

Interior was largely a matter of the type of wound. Skill and mature judgment

on the part of the surgeon in the base incrmased or decreased the time period

required for the proper disposition of these woundc but rarely determined

the life or death of the patient.

The affiliated general hospital units in the SWPA had an abundance of

surgical talent. The 400-bed evacuation hospital units frequently had only one

well-trained surgeon, and in some field hospitals the best trained surgeon was

of mediocre ability. The portable surgical hospitals, when they ii ere first

organized in the SWPA, had officer personnel of a superior type. Their surgeons were for the most part selected from affiliated units. It was the quality

of the medical officer and his training, ability, and maturity that established

the portable surgical hospitals in the ey. ; o! the SWPA. More attention should

have been paid to the allocation of professional personnel. There was reluctance on the part of SOS, SWPA, to release surgeons for duty in the forward
SIXTH USARMY46

Fiouna 80 -- Lt. Col. Frank Glenn, M, Conhiitnt, in

Surgery, Sixth U.S. Army.

area because they -wished to keep them in the bases. This attitude-led to the

delay in sending surgical teams to the forward area,

Majort Glenn was assigned as surgical consultant to the Sixth U. S. Army

on 1 October 1944 (fig. 80). He was familiar with the organization of this

army as a result of numerous visits to organizations assigned to it during his

period of service with the Surgeon, SOS, SWPA.

The Philippine campaigns then about to begin were the largest military

operations yet to be undertaken in the SWPA, Throughout the Leyte campaign, which was a difficult one because of the weather and tactical situation,

the surgical consultant was unable to cover each surgical service as frequently

as he would have liked. Later, in the Luzon campaign, at the request of the

Sixth U.S. Army surgeon, Lt. Col. George 0. Eaton, MC, Consultant in Orthopedic Surgery, SOS, was placed on temporary duty with the Sixth U.S. Army.

He and the surgical consultant together were able to maintain a closer relationship with a larger number of surgical services.

The supervision of the surgical activities of an army was dependent upon

many factors, one of the most important of which was an accurate knowledge

of the personnel of the various surgical units. Insofar as it was feasible,

surgical units were visited by the surgical consultant prior to their embarking

upon a mission. It was customary for the surgical consultant to visit the hospital and inform the commanding officer of the purpose of his visit. Thereafter,
468 ACTIVITIES- OF SURGICAL COXSULTANTS

hie would talk to the chief,6f the surgical seryice pxplaining the duties of the

consultant and how these could best be accomplished for the benefit of ~tle

wounded. Tim~e permitting,2 or 3 days would be taken to gain an insightinto

* Th bacground, t raiing, and personality, of the individuals on the surgc.,.

service. During this period, meetings were also held to outline the geiieral.

principles to be followed in the care of the-wounded and to discuss any prblems that might appear to be peculiar to the oncoming mission. In many

instances where the unit had not formerly been in action under combat conditions, one encountered considerable enthusiasm and an equal amount of ignorance of forward area surgery. The surgical consultant found it difficuilt to

undeiitand how surgeons Who had been in the military service for 1- or 2 years

or longer and who presumably were trained for duty with combat troops could

appear to have so little factual information concerning the task before tlem.

The commanding officers of many of these hospitals had little information as

to how-their men performed in action.

Some commanding officers had joined the units some time after their

organization, even as late as the day of embarkation, and had had no opportunity to see their personnel work together in a hospital. Information available to these hospital commanders was frequently limited to such data as

appeared on the personnel record-Officer's and Warrant Officer's Qualification

Card (WD AGO Form 66-1). By direct association, however, with the

professional staff during the period of travel and staging, these hospital commanders were usually able to evaluate fairly well the adaptability of individuals. The information obtained by the surgical consultant from these initial

visits concerned generally the training and qualifications of the professional

members of the surgical staff. The outstanding surgeons were readily recognized, and likewise those who had very little in the way of training or

experience. Many of the surgeons, however, could not be accurately evaluated

from the contact of this one visit. It was true that gross misfits were sometimes found, and, when they were, their disposition was discussed with both

the chief of the surgical service and the commanding officer and proper

recommendations were made for a shift within the organization to resolve the

problem. If, however, the transfer of the misfit to another organization was

required, then, following discussion with the hospital commanding officer and

his chief of surgical service, recommendations were made to the army surgeon

to correct the inalassiglment. Generally speaking, commanding officers were

cooperative; the chief ci the surgical service was more directly concerned and

was usually more aggressive in correcting an unfavorable situation. Failure

to secure cooperation was encountered where there was a close personal relationship between the officer in command and a staff member. Under such circumstances, commanding officers were reluctant to accept the consultant's recommendations and offered excuses of various types for the individual.

Li an effort to secure uniformity of policy in handling cases, discussions

of a common pattern were presented before all units, and at the same time
ARMY469 .SIXTH-USdirectivestIat' had been issued by the army surgeon on the recommendation,

df the surgiclf consultant were given to each medical officer. During these:

discussions' ofcers were given an, opportunity to ask questions in order, to

claify various types of treatment. Although these meetings were well attenided an ei thusiasmv- and: attention were excellent, later experience showed

th4t many medical officers disregarded or forgot .policib§ that had been clearly

defined. Thisresulted in recurrence of i.stakes that were common to many

unit operating in the forward area. Pr dowing these visits, the surgical consultant reported to the army surgeon his evaluation of a unit as a whole and'

made recommendations for strengthening the unit, and, if an excess of unusual

talent wAs found, names of such Officers were listed for use inother units. It was

ndt"pOssible to see ll units before their arrival in the combat area because some

of -them came from other areas and, in some instances, although they were

within the area, they were inaccessible. The Sixth U.S. Army surgeon was

most interested and concerned in the evaluation of .the personnel of the surgical services of the various medical units. Cooperation was complete and at

no time were recommendations by the consultant regarding the change of personnel not accepted. It should be emphasized, however, that all. deficiencies

were-not corrected because replacements were often not available.

In evaluating the ability of operating surgeons assigned to medical units

destined to function in combat areas it was evident that certain fundamental

prerequisites were overlooked by those evaluating surgeons within the Zone

of Interior. Surgeons for forward area units had to be particularly well

balanced and mature if they were to carry out the duties of a chief of service

or a section chief. Highly developed specialists with backgrounds suggesting

unusual accomplishments were sometimes found ineffective in these units. In

the selection of personnel for a field or evacuation hospital, it was necessary to

take into consideration not only the type of surgery that was to be performed

but also the conditions under which it would be accomplished. Highly emotional, easily excitable, and impatient individuals were a detriment to this

type of medical installation.

As an army moved forward into a combat area, the surgical consultant

followed the medical units entrusted with the care of the wounded. Definitive

surgery in the Sixth U.S. Army was done in portable surgical, field, and

evacuation hospitals for the most part. After amphibious assault landings,

the wounded were cared for by the Navy until one of the above organizations,

or part of it, could be established ashore and set up for operation. As these

installations were established and expanded, the surgical consultant attempted

to maintain an overall picture of their actions. This was facilitated by the

Medical Section, Headquarters, Sixth U.S. Army, for here information on the

location and the patient load of each medical unit was at all times available.

The general plan was to keep in close touch with those units that were carrying

the heaviest patient loads. In Leyte, for instance, the evacuation hospitals

did most of the definitive surgery during the early days of the fighting (fig. 81).
470 ACTIV ITIES OF SURGICAL CONSULTANTS

Piavar 81 The 58th Hwviluatioli HIospital at Tactobaul, Leyte,

25 October 1944.

Somietimes tile surgical conlsuL .it: would, make one, of these ho!,pitals his headquart ers, giigpait -itilar1 at teta .onl to tile condit ion of the( patients 111ho

arrived, wa It lungw ill the olperatilt c~lii, corriecti plug ,iict iceb hatll wer~e to ho

dli scotnIraged, and, not infrequently, taking at hand ill ant operat ion to demionsi iate how the procedure miight he iluipro~ ed. 11o1mu1(h Were. miade 1ith. biurgical othcesp rIlgilig froml N aIId officer's to thle Chiuf Of Ser-Vices. 'Ihere waNs not

quest ion ink the mlindl of the suIrgical consutli ant, that. this was whiere a trule

evaluation of ,Il- rical personnlel w as ito he made-by direct ohservat ion of tho

SilrOlls Ill act ion. The p~reop~erat ive preparat ion of tile l otiiideil, a decisionl

ato 1, ]l ia operat ion hold be pl-folIied, tile j iltid-iiit andt dIext elit v exercised[ at tilie operat jugl~ table. like postoperat ike car, ad the inkter-est, accorded

the patient miade up1 the MOst ilill)Or'talt itenis that det ermnjed a surgeol's

ellicienlev.

The well -t rained Surgeon with N ears of cliniical experience hack of himl,

likitlre ill jiudglIkellt. 111d reasonalible inl react ion to adherse. ci idulist ali1ces WS

thle onle individual ink t Ii. is ar %%1 mi cont rihted lkios-t to t lie bliilit record

of lie Medical Corps, au far' a1s thle etssoi l ae Of ile NNotuided] inl thlie

forward area wa oierid t w as, not aisto point out that it wst here

hal~t thle capa),ble me1dicall Officers, put forth Ii sperinniiall effort . sleeping Only a

few hkoursN a daN, w oI-~rk icotn ul, anid doiug mnore than one imidi' idual

was1 r 1,1.0 I'llnb]N eXl)eCt~d 0 to Ccolill46isl. TIi, ellhu't "as rquired nkot becaus-e

there wAN't a shlort age of iiuedical officer,, :o far- ast ttaide of oI-rIkIzatIjU ion t ellt Ii
n ., . ,

SXTIH T .. I 471

was concerned, buit'because the abilities of all those who held authoried-posi-

;tions ii the ifiidicl uits~wde not- c~mparible,

'"he -sdrkial- consultant iiiWeK 'his tks, as 'being ,oncerned- with, main1aingiigas idgh a ,tandard as possible for the surgical care of all the wounded.,

ini he':army., In this, the army, surgeon, General Iagins; cohicurred and-pro- vided al possible cooperation and support. Inorder to-accomplish this, itwas

necndsaiy for the consultant t see firsthand as many of the wounded as possible along ,the chain of medical evacuation from battalion aid stations to the.

rearmost' hospitals. In the early phase of an action while the advancing,

-periieter was relatively small, this was eiasily done, but as the area increased

ctineft Athere time when the consttltant was able to see only a few of the medical

un its functioning each day. Their numbers increased as the days passed and

the tbtal: area over which they were scattered became larger. For example, in

lkyte, until the front extended int0 tl ieyte Valley,,operations were confined

to within a few miles of the bkyte Gulf and all casualties Were funneled into a

relatively small area. Evacuation Was from one airstrip and by water back to

the-rear bases. If the consultant was familiar with the units and kept their

locations in mind, and if he knew the surgeons, he was able to be of invaluable

aid to the army surgeon when new and unexpected problems arose. As a

perimeter moved rapidly and extended its fingerlike projections several miles,

as in the Leyte Valley, and medical units were for periods inaccessible, support

was sent forward to bolster deficiencies that might have been anticipated.

Evacuation points were excellent places to gain quickly an overall picture of

What was being done in the surgical care of the wounded. Furthermore, other

factors that had a bearing on the care of the wounded were much more apparent

at evacuation points than in the individual units. Such factors included the

tactical situation, its bearing on transportation, and the availability of beds,

which in turn determined the evacuation policy to rear bases.

The weather, roads, and transportation in turn influenced the number of

beds that were available just as the same factors played a role in the transportation of patients from medical installations to evacuation points (fig. 82). The

patients, as seen at these points, gave a fair cross section of what the hospitals

from which they came were doing, for the quality and style of craftsmanship

followed the pattern of the talent that produces it. One of the most effective

methods for correcting improper practices was to list patients and what had

been done and then to visit the hospitals involved and, through their commanding officers and chiefs of surgical service, present the findings to the responsible

medical officer. When areas to be covered were small, the consultant could keep

in direct contact with chiefs of surgical services by frequent visits.

The surgical consultant going from one surgical service to another and

with an overall view of the wounded was always able to indicate something of

what the immediate future might hold. Preparation for a heavy casualty load

always facilitated the actual caring for it. Innovations in one unit were

suggested in others; likewise poor procedures in surgery were avoided.
472 A(1'1V ITI> ES1O SURGICL(' CONSULTANT1S

F161-Mt~ It) , ELjtidi~'~likit i I ii l %.1 diiuu.Ic tr iu 4 ULicT W t .14 t 'IWIV 1- 1C'1(4 IIIJ 1100ti
SIXTH U.S. ARMY 473

FiGuRE 82.-Continued. C. A team of 15 native Filipinos was required to evacuate one

casualty down steep mountain slopes. Six were litter bearers; the others formed a human

chain to prevent litter bearers from sliding or falling from cliffs bordering the trail.

Failures to follow policies previously set down by the surgeon in the surgical

care of the wounded were best corrected on the spot. Direct explanation

usually corrected the improper practices in the recalcitrant, but actual demonstration was the best means of telling another surgeon how a procedure should

be done. No surgical consultant should have been inhibited in operating to

demonstrate what he wanted done. lie likewise should have been willing to

assist any of the surgeons in his area when asked.

When, as in the Lingayen Valley, long and irregular lines were formed

and extended until a large number of medical units were distributed over

several hundred miles, it became impractical to see all surgical services at frequent intervals. The general practice was to bypass those thtt were selfsufficient and to concentrate on those that required help. If indicated, such

units were quickly reinforced by surgical teams with superior talent.

Although the Luzon campaign extended over a larger area, transportation

was seldom a problemn because tle weather was dry, there were hard-surfaced

roads, and I--5 Cub planes were available. Thus, patients could for the first

time in the SWPA be transported considerable distances quickly to field and

evacuation hospitals. By and large, the portable surgical lio,pitals were no

longer called upon to do bo large a proportion of the pri:ary" definitive surgery.

Because of overall circum.tances referred to el.sewhere, portable surgical hospitals, prior to the Luzon campaigp, had to do more than it wat ever intended

they should. Working undvi" tr intg c.tonbat condition.s, Oe siurgeon. of thewe
474 AOTIVITIES OF SURGICAL, CNSULTAiTS'

* small units had for the most part functioned in a-mahnei that: stoodout. ai

tibifteto American surgery. It thus became a matter of pride andtradition

for, portable surgical-hospitals to do more and greater surgery. Unforunately,,

fiy of the oldest of theseunits by this time had lost their most capabie stir,

bins by rotation, ahd replacements Were too often surgeons of limited e xperi, ence. The same was true'for many of the new portable surgical hospitals. It

i'uird emphatic instructions to persuade thm to doonly what was indicated:

raffher than what thfey were willing to attempt. It was fortunate that at-this

phase, of the war the field and evacuation hospitals reinforced with surgical

teaunscould be-utilized as intended.

The surgical consultant attempted to make himself available at all times

for 'problems that were constantly occurring. Little time was spent in the

arrmy sqrgeon's office during active periods of combat, but the office kept in toucI

'vith hith. Availability had to be stressed; critically ill wounded soldie rs did

not wait. If help was to be effectual, it was not to be postponed, If a surgeon in a forward unit asked for help or advice, the consultant could rest

assured that his services would be appreciated.

The consultant also concerned himself with seeking out hidden talent, No

army the size of the Sixth U.S. Army in World War II could have been expected to have all persons, including medical officers, in the positions for.which

they were best fitted. Medical officers well trained in surgery were found in

positions where no surgery could be done. Anesthesiologists, too, were found

in line organizations doing a minimal amount of medical work. It should also

be mentioned, however, that all medical officers who claimed to be misplaced

and who desired a change could have readily misled a consultant who had a

sympathetic ear.

The problem of promotions became an item of great concern in the forward

area after units and/or officers had been on foreign duty for a year or more.

Many well-trained medical officers, some of whom were eligible for classification as specialists and some of whom had passed their respective boards, accepted lower rank than they should have on entrance into the service. In

particular, this s!emed to have been true for those doctors without previous

military experience. At the same time, doctors in reserve military organizations too often were given rank that was not justified on a basis of professional

qualifications. Many medical officers thus found themselves overseas with

organizations under circumstances that fixed their rank or at least made l)romotion unlikely so long as they remained in the assignment they occupied at the

time they arrived in the oversea theater. It was true that the policy of prometing lieutenants to captains enabled the lowest grades to be properly dealt

with. But other medical officers in the SWPA who had worked efficiently and

well for 2 years in the New Guinea jungle but who remained captains and

majors-the grades they were rivel when they entered military service-had

just cause for complaint.
_1715

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476, ACTIVITIES OF SURGICAL, CONSULTA NTS,

If transportation was a, simple matter,,then: the most important phise-uftiage

occurr6& in fi7olld and evacuatibn hospitals. Thus, in the Southwest Pacifi9,

tlie portable -field, and evacuation hospitals wvere ,ith important statfinos for

th0srply~wounded. It was in thee thai the very important-third 4ep, 'd6fin!iie surgeryi ow as ~a cconi pl ish e d ,

Itwas li66 then that mature judgment, straight thinking, and soundconolusionsprovided for the greatest good for the greatest, number. Once the

patient's status Was established, preoperative treatment was begun and follow edby the indicated -surgical procedures. The procedures followed, wee

based.on the overall policy that provided first, for the saving of life; second,

for thepreservation of a part; and third, for the maintenance and restoration

of function. Definitive surgery that failed to contribute to these was contraindicated. For the majority of wounds,°the indicated procedures were simple, Therewere a limited number of injuries that required heroic procedures

involving considerable technical detail. Head, intrathoracic, and intra-abdominal woundswere examples and required that the simplest procedure that

accomplished the desired end was the one of choice. For instance, it was more

important to deflect the fecal stream in injuries of the pelvis involving the

rectum rather than to do extensive procedures that aimed at an end result such

as might be undertaken in civilian practice under the most ideal surroundings.

If procedures were not lifesaving or if they increased the hazard of treatment even though reconstructive, they were not considered justifiable. These

procedures could be taken care of later when life would be more secure, either

in rear area hospitals or in hospitals designated for reconstruction work in

the United States.

The forward area hospitals concerned with triage in the SWPA attempted

to direct the care of the wounded so that, first, life and limb would be preserved; second, the lightly wounded would be returned to duty as early as

possible; and third, as a link in the chain of medical evacuation, their facilities would be kept available for new casualties. It followed that in order to accomplish this pattern, patients who could withstand transportation better before definitive surgery than after had to be operated upon, when possible,

where the necessity for moving them after operation was reduced to a

minimum.

In the process of triage, treatment, and evacuation, all the exigencies of

war were involved. So varied were these from operation to operation, from

campaign to campaign, and from day to day in the Southwest Pacific forward

areas that no rules could have been set that would have covered the various

questions that arose. Only general policies could be set forth and the employment of these left to those who at the time and place were responsible. Only

they could and did have the accurate picture of the various problems. The care

of the wounded, triage, treatment, and evacuation in tropical jungle, on the

one hand, and on the plains of Luzon, on the other, were different in detail but
SIXTH U.S. ARIMY 477

JFiGulti: 81I. -ILi tl I cileICIIIt 1(O1 thIirough riiiii-sw(li treams oCii il LeteI.

not inl objective. All thlings coinsidlered, they Alerie accomipl ished equal ly %% ell

inl both tyvpes of t erra il.

PHILIPPINE ISLANDS CAMPAIGNS

Leyte

T1hie iui' ;sion of thle Plhilippinles at Leyte, thle largent operation ' Net toa take

place inl thle Southwest Pacific at that tiiee, involved an centire field armIy. It

begran onl 17 October' 19141 and wvas declareLd enided onl I July 194.). Sixth U.S.

Army part icipat ion inl thle canipaigan iwas from 20 Oct ober 19-1- to tle enld of

thle Year1. D)IIuII thle 1mo~4 active coiiihbat operat ion..'t a1t il tilie end of 1)eceinber 191 1). a lmost 9,000 Niolinded wevre ca red for ill armiy miedical installations. From the out set. actelerat ian of tilie a.'antlt date treated a dillicult

mledic'al 'it uat ioli.

Adequa me sila cCare ot p~atienits vi a" rendteredl dhifficult by tilie voliiariative isolat ion at ct'itainl for%% ard unmit. ill tile field, by tile freqiitd. ]on.,i litter

earri(e from11 late of wVoundIing' to tie imitallat ion 1)1o% idiiig emier-'euitv 'Ilrerandh by thle ifficult A' cai her and terra in (figr. 81). Lon- and uncertain

line,; of evcviuationi. .1-apanez-V~ ioa'llilock.. anid (othler' factors at t illivs cintiiiied

to farce in't allat ion-, to pert'aiii smrgeiv hexo~l htheir' ilawuitd sitipe. ii) hold
4 78 ACTYI VITIIES OF SU'RG ICAL COXqUINTANTS

CIn(l)II'tIl~. L eyte~ I la

palt iUt", \NlI) '4ltll 1ia~e I)('10 te titiCilIl 1110 promtpt] and u~ to e~ dCitttte

of te it, sile gt N\1. petlottiiel ill polltable "11.iilta1lt 1) 1 attil'edk 1 di\ i

siotl lea tiillg uity ljale (fig. 8,)'1). e~ vl~ia 1aueu tta I. .wIti

per.,outtu'l alti equipnttttll anti hey lackedtlt he avilit iv, to gi e lM1.l olletatk

Cue 'l. 'The vail * pefrneti~~It~ of' ojuerola. , liputI Patienit. Wit Itbldotttital

sotne tlittle a ftetn~ itt. I fere. foi- example~. it \\. illot adl"' ' N. pouiilt to mtlltiQ

Altt . mae Vutit ip-.it hen\ AN h tot oeratt oi cril titt' v, N itil ihe G

t I Il Ii Ih ite itd I a ~it 1)11 tt 1. A t IuuII-t )I lti I -I -r I I - I jt I tt IIIl l I t \v l'I I vI Itie

titc!t jil t n IIit IjotII. it, .am.remt \\ i. Ilote 41it Iptolvet ill l a x t.t haill lit iIIIN
"gave eiellenit" sirgical -care to the wounded because of adequate personnel,

eqtuipment, afidproximityto the source of the patients. Asthe forces moved inlandcth:pictuire eiangd. A sigle n road ithe Leyte Yatley *thitslanes

-into fh thills 6veri Arici~n troops could~,advanice, soon bam ira -

passablb withohtiiiuous rain and truck traffic. It was not unusuailfor troops,,

't:be.i 6, ted ozi ikg'h rourid by h igh water, Japanese roadblocks, or impass.

Able iads. Ther wa's no continuous advancing line. U hlike the portable

surgicalhp~pihs and clearing stations, the evacuation and other 'larger .ho9spitals Whichi were first set up could'not be moved forward under these crm-

'inistandes. Sniall forward hospital units were on, occasion shelled out of:

.pQSiiofi afid the perimeters of some were penetrated by the~enemy.

Luzon

The invasion of Luzon by Sixth U.S. Army forces began on 9 January

0,45. There had been ample time for planning With the result thatprovision

for adequate medical support was accompanied by a policy of selecting highly

qualified'surgeons for field and evacuation hospitals. Furthermore, these units

Wbre supplemented with surgical teams. From January until the latter part

of April;' there occurred approximately 27,000 wounded. In contrast to the

Leyte campaign, the overall tactical situation was ever favorable; there was

a minimal display of hostile airpower so far as the ground troops were concerned. The weather was dry and ileasant. There were numerous hard,

surfaced roads, and transportation for the wounded was adequate. Cub planes

(L-5 type) were also available in fair nuabers for the first time (fig. 86),

Each division had alloavewe to it one evacuation, one field, and two portable

surgical hospitals. To each evacuation hospital one surgical team was attached,

and, to each' field hospital two surgical teams were attached. The teams h'd

been selected from hospitals in the rear bases by the theater surgeon on the

recommendation of his surgical consultant and for the most part were well

known to the surgical consultant of the Sixth U.S. Army. It followed, therefore, that in the forward area the strongest teams were assigned to those hospitals that had the lesser amount of superior surgical talent or that promised

to have the heaviest casualty loads.

The surgical care accorded the wounded on Luzon was of a high degree

of excellence and superior to that in any forward area in previous campaigns

in the Southwest Pacific. Evacuation of the wounded was accomplished much

more quickly and with greater ease. The proportion of patients that had to

be operated upon in the portable surgical hospitals was greatly reduced. Not

only were a greater proportion of the wounded operated upon in the field and

evacuation hospitals, but certain of these hospitals were designated to care

for special types of wounded for which they were particularly qualified. Head

injuries, maxillofacial wounds, and others were thus given definitive treatment by specialty groups. These hospitals were located in permanent build-
SI~l'8. ( SCC 0~j) S? IC I'il!/(' f(W h 1P? ld-v.
hgs, -b-t as schoolhouses and-churches, and could be expanded easily. Thus,.

-thn~d: forevacuation tothie rear b~ases Was renderedilesstacute than it had ibiin obiL:yte 'Where tehtage was~ a :a prezniumh.

Thereditibn6 of the time lapse between Wounding and: definitive, surgery

dimiiished the indideeh I of severe, wound "infection. For example, gas galigfehe'was infrtquent on Luzon as compared witlh the Leyte campaign in which

fioiost ,l0(Pcases develped among approximately 9,000 casualties, whereas

there "6r6'l6s than half that number in some 27,000 casualties, on Luzon (p.

494). 'That patients with abdominal wounds did not have to be evacuated to

far.irmved",bhses. a and could be left unmolested for from 10 days to 2 weekS

afteroperation undoubtedly decreased the mortalityfor that.,group,

The value of adequate whole blood from the United States in the treatmentof the seriously wounded could not be overemphasized. In the seriously

wounded -and partially exsanguinated, to be able to replace large blood loss without stit and to be able to follow resuscitation with early superior surgery

was gratifying. The daily distribution of blood to field and evacuation hospitals'prbvided a source- of whole blood for the more forward units even to

the battalion-aid stations where it could and should have been used. Approxima ly 20,00 units of blood were used on Luzon during the first quarter of

1946 by the Sixth U.S. Army.

SUPPORTIVE THERAPY

Plasma and Whole Blood

During the first half of 1944, as one made rounds on surgical wards in the

most forward medical units as well as in those of the hospitals in the rear bases,

it was quite evident that more blood was needed for the wounded. Hemoglobin

values and red blood cell counts were too low. In the forward areas, plasma

was used in great quantities in the resuscitation of the wounded. It gave volume

to the circulating medium, but it did not inerease oxygen-carrying capacity.

Blood was used too infrequently and in too sma13 amounts. The source of fresh

whole blood was limited to medical unit personnel and whatever troops might

be nearby. Many of the men had had malaria so that this hazard was ever

present. Facilities and equipment for processing blood for transfusions in the

New Guinea jungle were more limited than in civilian hospitals back home,

and the incidence of transfusion reactions was consequently higher. There were

units whose professional personnel were limited in their experience with transfusions, and as a result they were easily discouraged and instead of seeking out

the cause of the reactions took refuge in the erroneous conclusion that transfusion reactions were unavoidable in the tropics.

FIoua 86.--Air evacuation on Luzon Island, Philippine Islands. A and B. Evacuation

by L-5 aircraft. C. Catalina flying boat standing by for wounded. D. Casualty on

Stokes litter being loaded into Catalina flying boat for evacuation to Manila.
482 AoTIVITIES OF SuRGICALCoNSuLTANTS :

The paltieht evaduated from -the, forward, area to the-rear hospitalso tob

oft6ilhid a lowserum protein level as well as reduced hemoglobin: and red cell

oiiit. It Was the ,repeated experience of the constiltant after xmaking, ward

irounIds iiithese liospitidil to insist tiat more triansfusins be given-,andthen to

lMear the various rea sons why they Were not given. The, answer, rested4 in .the

fact, that ant. adequate supply of satisfactory, preserved whole blood was .not

avaiiable, This Was the state of affairs despite the fact that a highly efficient.

scd s6ientifically controlled Australian blood bank in Sydney, a combined Australian-Arny Medical Corps and Australian -Red Cross Society organization,

furiished blood for American units in New Guinea. Citrated wholet blood.

piicked in insulated and iced boxes were sent from Sydney to New Guinea.where

it, Was-r6;iced or kept in refrigerators until used. This was not satisfactory

because there were many instances of excessive hemolysis, fibrin clots, and reactidiis. These all contributed to a general lack of confidence in preserved wlole

blood and the tendency to further popularize plasma.

When the SWpA was extended into Netherlands New Guinea and Hollaiidih-became the main base, because of both the distance and unsatisfactory

experience with the citrated refrigerated blood from Australia, it was decided

to establish a blood bank. The U.S. Navy had had in operation for some time

a blood bank on the LST (landing ship, tank) 464, and, in cooperation with

Army units, blood was taken from troops, processed, and sent forward. With

the same processing, a blood bank was established at the 27th General Hospital

in Hollandia. Working in conjunction with the LST 464, this blood bank provided the greatest amount of citrated blood ever to accompany a task force up

to that time in the SWPA; namely, the invasion of the Philippines at Leyte.

This was a step forward to correct the inadequate supply and use of whole

blood, in particular, in the care of the freshly wounded, but left considerable to

be desired. There were still too many reactions. There was some breakage

and also excessive hemolysis. Fibrin clots caused difficulty in administration.

On 23 November 1944, the first citrated blood provided by the American

Red Cross was flown by C-54 to Leyte from the United States by way of

Hawaii and Guam. Lieutenant Lake and Lieutenant Hendrick of the U.S.

Navy, representing the Red Cross, accompanied the shipment of blood consisting of 64 bottles contained in 4 regular containers. These were used in medical

units under control of the Sixth U.S. Army. This well-processed blood in

containers equipped with adequate filters and individual sterile sets for administration immediately answered the common objections to giving transfusions. No longer was it necessary to call on troops staging for missions to

give blood, processing setups were no longer needed, and the preparation of

equipment for administration was obviated. Furthermore, the container for

transporting the blood was well constructed and efficient. The unit containing

16 bottles was ideal for sending to the smallest units doing definitive surgery.

The blood arrived on Leyte from San Francisco in from 5 to 7 days. This adequate supply of whole blood that was made available for the wounded soldier
SIXTH U.S. ARMY 8

was accomplishments in the war. In due course a distribution

systdm was establish~d that provided a daily supply to field and evacuation ispital'. The ambulances andsnaliplanes evacuating patients ,frm clearing

conipanies audportabl6 surgical hospitals transported bloodforward. The use

f- r6 u ntities of wholeiblood where, severe hemorrhage had occurred did,

withbiht doiibt contribute to the saving 0f lives in the forward area that would'

other is4!h0e been lost, As much as 4,000 cc. per wounded soldier were used

withinthefisAt 24 hours of wounding. When such quantities were indicated,

onetransfuisio alone Was of little avail. With adequate blood available, exsanguinating'hemorrhage and shock Were much better treated immediately, and:

the genbral' ppearance of the more seriously wounded greatly improved. The

proof"that the product and equipment supplied was excellent was demonstrated'

by the results. One evacuation hospital gave 720 units of blood in one month

Withoutasiiigle serious reaction.

Throughout the Luzon campaign, the blood supply from the States was

well maintained and it was possible to set 4,000,000 RBC as a minimal level for

all patiehts.

Chemotherapeutic Agents

The use of sulfonamides locally as a first aid procedure in the treatment

of the wounded was described in basic War Department Field Manual (FM)

21-11, First Aid for Soldiers.

It was the observation of the surgical consultant that no other one procedure was followed so uniformly as the local application of sulfonamide powder to wounds in fresh battle casualties. It was applied by the aidman, and

the soldier was well aware of the possible benefits of such chemotherapy. To

that extent, it was a valuable moral therapeutic adjunct in his care. The use

of sulfonamides locally during and following definitive treatment of wuunds

was likewise uniformly employed in the various surgical units of the forward

area as late as the early part of 1943. Inadequate debridement was followed

by the application of sulfonamide powder locally, and in many instances it

was accompanied by the sense of false security on the part of the surgeon. On

surgical rounds, one would occasionally see wounds that had been incised to

various degrees and filled with sulfonamide powder that acted as a foreign

body. It was common practice, following a well-done debridement, for the

surgeon to sprinkle various amounts of sulfonamide powder into the depths

of the wound. In exploration of the abdomen where no perforation of the

viscera was encountered it was not unusual to see a surgeon sprinkle sulfonamide powder in a clean wound. On direct questioning as to what was being

accomplished by such use of sulfonamides, there we'c many replies indicating

that they believed it was of great chemotherapeutic value, that it prevented

infection if it was not already present, that its use in clean wounds was justified in the tropics on the basis of preventing infection, and that it acccierated

wound healing.
-84 ACTIVITIES OF SURGICAL CONSULTa.NTS .

Although there was considerable literature before 1942 which demon

stratedthe limited, effectiveuse of sulfonamides in.infction, demonstrated tlat

thie,as considerable foreign body reaction wliere sulfonamidewas , placed in

the wound locally,, and explained that the local use-of sulfoniamides inhibited' wound hlealing and certAinly did not, accelerate it, thete facts Were not wel

kno . Repotsin publications by the Army and Navy, recording in glowing.,

trinstlie prophylactic use of sulfonamides at the Pearl harbor disaster, also

gave a great number of medical officers a sense of false security. Medical offers

not well trained in basic principles of surgery Were inclined to do miniiimal

surge y and then apply sulfonamide powder in or on, the wound.

When penicillin was made available to medical units in the forward area

in Match 1944, the assistant surgical consultant of the SWPA had an opportunity to discuss with a large number of medical officers their conception of

wound infection and the mechanism of wound prophylaxis by means of chemo).

therapeutic agents. Too frequently, there was a lack of understanding that in

theb pevention of wound infection one of the most important requirements was

the removal of devitalized tissue and the prevention of the extension of infection

by providing adequate drainage. The impression did exist that sulfonamide

placed on a wound superficially penetrated into its depths. That the pouring

out of exudate from traumatized tissue mechanically moved the sulfonamide

from where it would have been efficacious in inhibiting growth seemed to have

been forgotten. The complications of the systemic use of the sulfonamides

were not well appreciated, and serious complication occurred as a result of

sulfonamide therapy plus dehydration. Directives were published by the army

surgeon's office cautioning the use of these drugs systemic'ly and outlining a

course that provided for adequate fluid intake and alkalinizaL'n.

An attempt was made to discourage the use of the sulfonamides locally

fhllowing definitive surgery in the hope that there would be more attention

given to complete and adequate surgery including the removal of devitalized

tissue and providing for complete and free drainage.

If, in the opinion of the surgeon, sulfonamide therapy was indicated, then

it was recommended that surgeons watch the patient's fluid intake and check at

frequent intervals the blood and urine in an effort to discover early any untoward complications of these groups of drugs. It was pointed out early in 1944

in a directive from the army surgeon's office that the use of sulfonamide was

not obligatory. A few months liter, it was recommended that the existing

liberal local use of sulfonamide therapy be curtailed. Late in 1944, the surgical consultant of the Sixth U.S. Army recommended that local sufonamide

therapy be discontinued and that only systemic therapy be used on cases in

which it was clearly indicated. In spite of the efforts of educational measures

taken, a large number of medical officers continued to use sulfonamides locally

in wounds. Those most convinced of its worth and most insistent on its merit

were those who had recently arrived from the Zone of Interior. The publicatin of War Department Technical Bulletin (TB Mcd) 147, in March 1945,
SIXTHU.S.ARMY485"

s ~h0Ud hadvsettleditheproblem which had been controversial- since the',reports,

'in JanuaryandFebruary '4942 of the ?eark Harbor. disaster.

SURGERY 'OF REGIONAL wouNDs AND INJURIES

Neurological Injuries

C asualhties having head wounds with brain injury were evacuated i

, when

posib!le, to designated fleid and- evacuation hospitals for definitiVe treatment'

'Puringothe, various actions. in New Guinea, there were-many instances when

this was imprctical and definitive surgicalftreatment'ha d to be done in portable surgical liogpitals. For the-most part, tlese-patients Withstood transportation

well.-, Extensive, time-consu"ming procedures were sometimes required-in ras,

siveinjur es, and thus, a-small number of patients would keep a neurosurgeon busy. T96 fdw trained neurosurgeons were in the forward area and there were times, when neurosurgiel teams could have been well used. Large defects of

the durawere closed With fascia and sliding scalpflaps. 'De.magpd brain tissue

and foreign bodies when accessible were-removed. Fibrin foam was first available in early 1945 and proved to be of great value in the control of bleeding. The postoperative care of these patients during the early phases of an

action and before Army Nurse Corps members arrived presented a real problem.

Nurses trained in the care of postoperative neurosurgical patients were invaluable and second in importance only to the surgeon in the most seriously injured

head cases. Both in New Guinea and on Leyte, lack of neurosurgeons and

facilities for special nursing care limited the attention accorded these patients.

On the other hand, on Luzon, both were available, and care given there was

superior in every way.

Spinal cord injuries due to intact missiles and shell fragments were

occasionally subjected to laminectomy and exploration during the fighting in

New Guinea. The results led to almost complete abandonment of this proce.

dure. Following preliminary treatment including careful suprapubic drainage established by placing a well-fitting mushroom catheter in the dome of the

bladder, these patients were given a high priority for evacuation to rear bases.

They were transported in complete body spicas, Limited nursing facilities,

cots, plaste ?iceas, and long distances from the rear area were factors that

contributed to the large decubitus ulcers so common to those with cord injury. Peripheral nerve injuries were rarely repaired. The ends of divided

nerves were frequently mswked by placing a suture of black silk or a silver clip

in the divided ends.

Thoracic Injuries

The closure of open chest wounds in battalion aid stations and clearing stations was well done by strapping with adhesive tape and massive dressings.

Large wounds and those associated with severe hemorrhage did poorly; lesser

wounds did well. These patients likewise tolerated transportation if hemor606222'-62---33
486 ACTIVITIES -OF'SUR GICALXCONSUTANTS

rh was not great. Where circumstances required that these patients be

,caid for in afortable -su'gical, hospital-without inattracheal closed, system',

106ethesia, operative procedures were limited, I~cal anesthesia ando.major

chest, sugeiy wer6 not ompatiblbe; open anesthesia could.,e dangerous hide'ed

Whui possible,-all1iiiajor chest-injiries-wer cared foiin designated 6vuation,

§P ts .'where those with :both experience, and equipment were available.

Hemorkhaging -vounds had to be controlled by the simplest procedure in.the.

forward area, Sometimes, there was a tendency to do too much following the

sii~ess of the contro1ofblood loss. Perhaps in no Other group was fresh whole blood more important than in

inasie hest wounds where there had been large blood loss. This with oxygen

therapy was found to be lifesaving and was followed by successful resuseitatipn..

It *As found that preserved whole blood, such as that received from thieStates

or rear blood banks, had a reduced- oxygen-carrying capacity and, although,

better than plasma , could readily overload the circulation.

the closed treatment of pneumothorax and hemothorax by early aspiration

was in general followed. This practice, together with penicillin therapy,

proved very satisfactory. While the later incidence of empyema in patients

thus treated was not known, by far the great majority of these patients ran an

afebrile course prior to evacuation or discharge.

Abdominal Injuries

During the Leyte campaign, approximately one-half of those with abdominal wounds were operated upon in portable surgical hospitals, and the

remainder were operated upon in surgical units of larger size, such as field and

evacuation hospitals. Those operations that were done in the portable surgical

hospitals were sometimes delayed for as long as 18 hours after wounding because these hospitals were most forward and isolated. During the first part

of the campaign, plasma was used to bolster these patients on their way from

the battalion aid stations to the hospital where definitive surgery was to be

done. After the inauguration of the delivery of blood from the United States,

it was possible to use more whole blood during this critical phase for those who

were partially exsanguinated.

Here again, whole blood was of great benefit to resuscitation. The period

required for retrieving a patient from shock and reestablishing his vital

proc.esses so that he could withstand the added burden of operation was

reduced. Experienced surgeons appreciated the importance of this preoperative phase, and for the most part the wounded were well prepared for operation.

Anesthesia employed on abdominal cases in the portable surgical hospitals

was usually open-mask ether. Because the simple abdominal injury was

associated frequently with injuries to the diaphragm or chest, one of the

shortcomings of the portable surgical hospital was inadequate anesthesia.

For abdominal injuries, open-mask ether was adequate, but it was not suitable

for open chest operations. In field and evacuation hospitals, machines were
IV .SIXTH'U.S. 'ARMY 48T

aVilWab ,nd- ifitratracheal tubes were placed before operation was begun.'

Local iind spinal anesthesia, was discouraged and little used. The evacuation

6f gastki con tents befofrebeginning an anesthesia was-routine practice.

a d al woundsrequired h, definite pattern or-preoperative examination,

and4preParation. The following procedure was followed: Complete physical

exaniainion in an atfempt to determine site of entrance and exit of the

missile, ,X4y examination to determine the presence or absence of shell fragmont or intra-abdominal air, neurological examination of the lower extremi.

ties-te reVeal absence of nerve or cord injury, and catheterization to establish

integrity of thebladder wall. Crrying out these procedures preoperatively

rediiced the time consumed in determining them later during the operation.

The expluration of the abdomen of the battle casualty required ingenuity.,

Large abdominal defects sometimes dictated the type of incision. The smaller

wounds, a ndthese might be associated with the most extensive abdominal injuries, were best explored by an adequate incision-midline, midrectus, or

transverse, Observation of the difficulties that operating surgeons encountered

showed that inadequate exposure accounted for many, as did also lack of a

routine for exploring the abdominal contents. Occasional injuries of the

large bowel, in particular in the distal portion, were overlooked. Then too,

wounds of the pelvis involving the rectum required continual vigilance. The

treatment of defects of the large bowel and rectum by those new to forward

area surgery often demanded close supervision.

The objective of saving life with the minimal risk and not attempting

to determine what might be survived or tolerated had to be kept foremost in the

surgeon's perspective. Post mortem examinations were all important for this

purpose. Many surgeons found it extremely difficult to follow the instructions

of exteriorization of the large bowel or complete deflection of the fecal stream

by an adequate colostomy. Nevertheless, after a period of experience, surgeons

accepted the policies which had been laid down in an attempt to guide them

from these common pitfalls. In the reconstruction of the continuity of the

intestinal tract, many surgeons insisted on using a side-to-side ouastomosis,

whereas an end-to-end, had they been familiar with it, could hay. been accomplished more quickly and would have given a better physiological result.

Liver injuries combined with large bowel injuries had the highest mortality

rate. Liver injuries alone likewise were dangerous. Drainage of these wounds

to the exterior was accomplished with a more favorable result. Injuries of

the stomach and small intestines unassociated with large bowel injuries had

an incidence of recovery of upwards of 85 percent. The use of the Wangensteen

tube or the Miller-Abbott tube postoperatively did a great deal to prevent

abdominal distention and vomiting. The placing of these tubes postoperatively

in all abdominal cases was routine.

Wound disruption was a complication th- could have been greatly diminished. Abdominal closures ordinarily were made with catgut, silk, or cotton.

Catgut layer closure was probably most frequently used. Grossly contain-
'488' AOIVITIES OF SURGIOAL COINSUTTi S

Siiteld abdominal wounds were very prone to- infection and ,dehiscence.

Through-and-through suture material:siVaw wire, gage 12-, without closure

f t kl .skin-proved most satisfactory, Whereas though-aid4hrough, silk

(number 14 or braided) and plastic suture material (such as Dermalon) or

silk-ormwgut" were very inefcient. Abdominal wounds inwtwich -tle skin was.

left open with petrolatum-impregnated gauze placed in the subcutaneous

tissue had'-an opportunity to drain if infected and, were undoubtedly a means

of reducing the incidence of wound disruption. It would be highly desirable

-to firnish all forward units in the future with adequate amounts.' of "Soft

silver wire, 12 gage, with atraumatic needles to place these sutures.

The greatest surgical heartbreak in World War II was the result of

moVing patients with intra-abdominal injuries-too soon after operation. The

experience of World War i had recorded this fact well. The various directives

and instruction sheets dwelt upon it. Nevertheless, because of the nature of

the fighting in New Guinea and on Leyte and, to a lesser extent, on Luzon,

patients were brought into forward units where they could not be evacuated,

Sometimes for from 12 to 18 hours. The surgeons there viewing the situation

as they saw it, and not without some justification, operated upon these patients

whose postoperative course would be satisfactory. Then, for one of a number

of reasons, the patient would be moved. The tactical situation might be the

reason, or more space might be required. The reason was immaterial to the

end result; the fact remained that abdominal patients moved within the first

10 (lays of operation developed a high incidence of complications and that many

of them were fatal. This fact was more evident to the consultant than to

anyone else, and at his insistence the Surgeon, Sixth U.S. Army, brought into

action in the Luzon campaign ways and means that reduced to a minimum

the moving of abdominal patients so soon after operation,

Injuries of the Extremities

Approximately two-thirds of all injuries occurred in the extremities.

For the purpose nf discussing the experience of treating these injuries in the

forward area, they may be divided into two groups, those involving soft

tissue only and those involving soft tissue and bone. The goal in the care

of these cases was to save life, save limb, and preserve function insofar as

possible.

All wounds occurring in the forward area, whether from the intact missiles

or shell fragments, required adequate exposure of the missile track in order

that devitalized tissue could be observed and that it might be ascertained

that blood vessels supplying the structures in that area were intact. If adequate exposure was accomplished by long linear incisions, muscle groups separated to expose injured tissue, and injured tissue removed, and, at the same

time, if the blood vessels were examined and, if injured, ligated, there were

few later complications due to infection and hemorrhage. The term "debridement" was grossly misconstrued. The wounds of a bullet, entrance and exit,
sIxTH TflSx RMY 489

-*,6 r oinetifies said -to be debrided when only a circular blit of skin was:.

f"~move'd-:fr the skii-niargin.: The one procedure that, in the consultanits

- - ees~l eiiej a surgeon .a being, inadequate was to practice tl.e circular inciio j .

~ ~~i aoutth -ulet oud ndsprinkle sulfoham ide, pwer about'

St j6n sderihg ti hadi suigicaily treaed the wound. . i.-glineai daeomPressant incisions that exposed the'missile track, foi.

lowed-by the removal of damaged tissue and the placing of a single sheet of

.petro itum-inpregnated gauze, established conditions that made anaerobic,

gro th impr6bable and ordinary infection rare. The period of disability

obseved ini the forward area from bold incisions was minimum. Wounds,

were" appk0ached from the wound of entrance or exit down to the depths. The

exploration of ,blood vessels- within a wound was continually stressed. Hematoim in th6 region of the blood vessel invariably meant hemorrhage from one

-of the main vessels or a- tributary. Patients in shock with lowered blood pressure would cease to hemorrhage,-a clot would formar , later, with a reestab-

:l1shed normal blood pressure or manipulation an., sometimes, infection,

renewed hemorrhage would take place. Repair of blood vessels either by

suture of a defect or by an anastomosis was unsatisfactory and not employed;

rather, the blood vessel was ligated. Ligation of large vessels, such as the

fembral or popliteal, which jeopardized the distal circulation were given the

benefit-of sympathetic block,

The immobilization of soft-tissue wounds was insisted upon. Throughand-through bullet wounds that had been explored through adequate incision

were immobilized in plaster just as routinely as were the massive soft-tissue

wounds, in some of the evacuation and station hospitals that served as general

hospitals in the forward area, early delayed closure was practiced as well as

early skin graft. Both procedures were to be recommended and were not

utilized as fully as they might have been. Soft-tissue wounds exhibiting considerable tissue damage were placed on penicillin therapy for from 8 to 10

days. Where the wounds were received late and the likelihood of anaerobic as

well as aerobic bacterial growth was evident, sulfonamides were used systemically. Soft-tissue wounds of the thigh and buttocks, associated with injury to

the pelvis and its contents, the bladder, the bowel, and the rectum, necessitated

radical incision in an effort to prevent extension of infection, or to combat it,

if already existing. Wounds of the upper thigh have been given inadequate

attention chiefly because of the failure to recognize that many of these wounds

involved intraperitoneal damage. Wounds involving all joints and, in particular, wounds of the elbow and knee required incision with decompression of

fascia overlying adjacent muscle groups as well as exposure of blood vessels

that may be the source of expanding heinatoma. The optimum position of any

soft-tissue wound is one that provides for the least restriction of circulation.

In the battalion aid station, hemorrhage was controlled, dressings and

splints were applied, sedation for the control of pain was administered, prophylactic chemotherapy was instituted, and patients were resuscitated from
4 90. ACTIVITIESOF ,SURGICAL CONSULTANTS

i6ck if tme prnitfed. Definitive surgery for injuries involving bone bega

sith:A the pit t lda ll tsort i'

Wi h--he-in tht could accomplish sat katoy- tilen of ,th sof tissue

Woilhd and compleely imm ilize bone gments. The only satisfactoy

method of'immobilizationih forward aitea-instllations was the application,6f

plaster cast. Immobilization-,rather than reduction of displaced, fragents

was adhered to w hen lhe-patient was treatedin -portable,, field, or 6vacuation

'lib pftais. The transportation of compound fractures in plaster casts was associated with an extremely low incidence of complications. If a wouiid had

-been Well decompressed, and. in the majority of compound fractures the Jnury

liad already established this, immobilization in plaster rarely if ever interfered

With the circulation. In the field and evacuation hospitals where X-rays were

vailable, alinement of fragments was satisfactorily done. There were times,

it wits true, when the ideal position was not obtained; however, it was expected

that Within 2 or 8 weeks from the time of wounding the patient could be transported to installations where additional procedures could be undertaken to

ahccomplish this. Internal fixation and traction were not employed in forward

area installations. Only occasionally was open reduction of a fracture done to

replace a fragment that jeopardized the circulation or nerve supply of an

extremity. Too few surgeons arriving in the forward area had had adequate

training in the use of plaster. The best quality of plaster of paris, adequate

training in its use, and continual stimulation to develop better methods of

securing strength with less bulk is to be encouraged in the future. The use

of plaster was not the restricted domain of the orthopedic surgeon, and general

surgeons should have been masters in its use. The supply of plaster frequently

ran low during the early days of an action. Units accompanying combat

groups should have carried large supplies of plaster and the necessary cotton

batting to go with it.

The principle of guillotine amputation at the lowest level of viable tissue

was closely followed, but only by insistence and repeated admonition was skin

traction maintained. The use of skin traction by stockinet and skin adherent

was very effective in reducing the healing time of the stump, provided that

elastic traction was maivtained with proper adjustment.

In the immobilization of fractures for transportation, there were certain

tendencies that were common in all groups. The first was the hesitancy to use

the plaster spica of insufficient extent to completely immobilize the part involved. In the transportation of patients by plane, in particular in plaster

spica, exaggerated abduction made handling of the patient extremely difficult.

Although ideal position could not be obtained always, tLe degree of abduction

should be maintained at a minimum. Immobilization of a knee joint necessitates the immobilization of the joint above and below. This required

repeated emphasis. The shoulder spica was of great importance in the evacuation of patients over long distances. Such casts required care in application

in order that they fit well and that they be strong enough not to give way. A
SIXTft-'U;. AIMY' 491:

rokeiiplaster shoulder spica was dangerous. Only rarely were'hanging casts

used:6iiatients in the fokward area Who were:to be evacuated;

Burns

Wid,1the:'invasion of Leyte,. suicide bombings began to produce a larg6

number of:'burnedpatients. Many ships were hit in the harbor, and, if a large

number of personnel were aboard,, the resulting casualties Were likewise great.

The majority of these men suffered burns with or without other injuries. In

some, instances, the total number of wounded removed from a single libei'y

ship was 80. These patients Were treated on LST's fitted out as hospital ships

and., operated by the Nvy, and by shore medical units of the Army. The

treatmet of large numbers of burned patients became rather standardizedduring, the 8 weeks that the Sixth U.S. Army was on Leyte. Patients were

given m6rphine before they were removed from the ship and then transferred

by-litter to wherever they were to receive further treatment. Here, all clothing

was cut away. Those with burns only were separated from those who had

complicating injuries or other injuries or both, Debris and detached skin

were removed, and the burned surfaces were covered with 12-inch squares of

petrolatum-impregnated gauze. Over this was placed gauze waste or Dakin's

padding reinforced with bandage. Over this was placed stockinet. This did

not constitute a pressure dressing; rather, it was a petrolatum dressing on the

burn surface so reinforced as to hold it in place. Patients received plasma

While dressings were being applied. Patients with massive burns were followed closely with heinatocrit, and the reading was used as the criteria for the

amount of plasma to be given. When protein (serum) determinations could

be made with the copper sulfate method, this was used. The local treatment

of the burns consisted of using petrolatum-impregnated gauze and preventing,

insofar as possible, further injury and contamination. Initial drug therapy

for preventing infection was limited to penicillin-120,000 units per 24 hours.

Original dressings, if expertly applied, could well be left unmolested for

several days. The control of infection varied, and later sulfonamides were

sometimes employed, in particular sulfadiazine, adequate attention being gi-Ven

to alkalization and water balance.

The treatment of patients with severe burns and injuries from bomb

fragments presented complicated problems that required every ingenuity. The

mortality rate was high. For example, after a suicide plane hit one ship, 21

of the ship's personnel were killed, 26 were both wounded and burned, 12

were wounded only, and 8 died within 24 hours.

Patients with wounds and extensive burns were difficult problems. The

general plan was to treat shock with morphine, plasma, and transfusions.

Thereafter the surgical procedure, as indicated, was followed. Burns were

treated as early as possible, but there was of necessity considerable variation in

therapy.
492AOT VITIES OF SUiiGICA1L CONSUTiANTS,

!:"- TROPICAL JUNGLE FOOT

Approximately 120 patients wvere, admIttedto two evacuation nlspaIs n

t ilfiiid of 1eyt6 oi23 NoVember 19W because of sWoilen, painfultfeethe

i f which showed various degrees of ulceration. These. soldiers ,iad'al

been drotigh a similar experience. They had- ben under combat donditionis,

nthe frontline. Typhoons and. rain - had been almost continuous. Th yh4d

ben in foxholes and crawling through the jungle for a period, of from9 to,

ii 7days, -During this time, thoy ha& rately removed their shi. Ther were

io socks sy or footwear to clange to. A majority of the patients saiithat

afterbeing under this condition for from 4 -to 7 days they began to, hai'e"

burni g sensations, first on the dorsum of the feet and then on the toes~and - s is w0 s onls,

At first, moving about gave them some relief. This was soon lost, however,

ai& Walling ecame increasingly painful. When they removed their shoes,

their foot appeared swollen and quite pale. If the shoes were left off, thefeet

became flushed and warm, burned, and developed a tingling sensation that was

luite painful. Elevating the feet gave some relief. If, the shoes were left

Off for a half an hour or more the feet became so swollen that shoes could

scarcely be replaced. In this early phase, the feet showed no areas of loss ofskin

or ulceration. A§ time went on under these conditions, the feet became more

swollen and painful with ulcerations appearing first on the dorsum, then

about the toes, and rarely on the sles, although cracks in the skin of the soles

did appear. Because of pain, walking became impossible. Many of these

patients had been in an isolated group. When relief came, they were carried

by litter through swamp and over difficult terrain that they could not have

traversed themselves. It was estimated by these troops that almost 50 percent of their group suffered similar foot disabilities. Two soldiers volunteered tie information that their feet did fairly well as long as they could

take their shoes off at night but that, when this was not possible, disabling

symptoms developed rapidly.

The findings on examination of these patients were remarkably similar

and varied only in degree. They had been in the hospital less than 12 hours

when examined by the army surgical consultant. All were fatigued, but only

rarely did they seem to be resting. They assumed different positions; some

lay with their feet elevated, others sat with their feet on the cots, still others

clasped their ankles and lower legs, and some let their feet dangle. They

tended to shift from one position to another. The most common complaint

was a burning sensation of the dorsum and soles with a "deep ache." An

attempt to stand on the feet was accompanied by a look of helplessness and

distress as well as pain. On walking, they moved with htsitant deliberation,

slowly increasing the body weight on the foot after putting it down. They

reminded one of i cat walking on fly paper. Washing with cool water and a
little Oap gayve momentafy -elief and then as, the skin,, dried the -discomfort

reiiiid~ :6cks.and. dirssjs - -intolerable.-- ... wThF 'a is'considerable', variation in the appearance of 'the feet, of these,

'Paiints; wi r~are-,exception, there was a. marked, to - in itens6 erythemna, whijl swelling madethe s6es-.buige. -ahd the ,skin, of the dorsuni -tense. and , shiig, There-were frequentiy blebS-and ulcerations with weeping serum

at the asa. of and between the toes. The distal portions of the toes were,

S som~time~ biw, white, mdttled, and- cold-' In many, -there wa a Swollen- -

ekthtinatous appearance of the remainder of the "foot. After'the feet had

be4 washed with soap and water and the: skin had been allowed-to dry, the,

invdlved skin could be seen--to be well demarcated at the shoe 'tops. There,

was edema below this level-'but rarely above it. There were scattered areas

of eccltiym6siS in the patients showing greatest involvement, Pulses were

nOt 6bliterated in any of the feet examined and-the variation was within thenormal range. Blushing on pressure was slow, likewise the return flush,

The ulcerations -of the skin likewise varied a, great deali being most

numerous over the dorsum and toes. These were almost blotchy in appearance, giving the impression that they had been produced by abrasion and

pressure, except for the fact that in some the superficial layers of skin had

been lest and in others the destruction extended down to and through the

true skin. Some of the ulcerations were well demarcated with a small zone

of necrotic skin along the margin, giving the appearance of decubitus ulcer

or gangrene. The skin between the ulcers, especially over the dorsum, was

pale, cold, and inert. The erythematous areas did not readily blanch on pressure which caused pain.

Systemic reactions were lacking, except fatigue from inability to sleep.

Temperature, like pulse rates, was within normal range. There was a striking

lack of secondary infection in the ulcerated areas. Only a few patients

who had had previous troubles, such as epidermophytosis, exhibited any evidence of tubular lymphangitis. Approximately 15 percent admitted some

discomfort in the groins on direct question; all of these had enlarged and

sensitive lymph glands. There did not appear to be any parallelism between

the swelling and pain of the feet and the lymphadenopathy.

Sensory changes were indistinct. Areas of numbness and tingling could

be demonstrated by light touch and pinprick, and yet pressure was painful.

Elevation of the feet seemed to increase the areas of diminished sensation.

L. general, attempts to outline the areas of paresthesia and anesthesia were

unsatisfactory because of the discomfort and fatigue of the patients.

The treatment of these patients consisted first in general supportive measures. Shoes were removed, socks cut off, and the feet bathed in cool water

with white soap. This gave considerable immediate relief but was of short

duration. If the feet remained in the water longer than 10 or 15 minutes,

606222'-62-34
491 ACTIVITES OF r URGICAL CNULAT

the burning and:ingling, increased, as it did- when they wvre emoved irom ,

the, AWte aind allwed'to r.. The ,Absence of a dressing, or ,th6.applicati'dfi. of* a light dry, diessi'ng, seeme togv 'ie kesigt ineral oi'wa

not~i tleatdand laholin was not. usd9aiu sedativeser e &e

1to:ive est, Th iqpatiehts were kept off their feet'insof as this wasfpopibl " In::mi crsivded forwiard hiospital. The majority of~the patients Wore evacuated'i

.6ntrary 4to.the course of patieits suffering: with the usual trenoiifoqotor

4ierion foot,. hese patients recovered relatively rapidly from the local

swellingi :ecoriati6ni. AndThnfectiohandS-6s0 from the vasomotor manifesta;

-t-iofisof discoloration afid pain. They were greatly improved withii 4 or S d: :/ : days 'aitehosp'ham, ,.' '

A"folowuii ;studyof tliese cases.was madei Sympathetic block,,was done

oi a1eW Othe patidiits with some- improvement-of, symptoms, but few or ino

obje'tivecianges were observed. It was reported from a rear, base,,-W 6re

.thee patients arrived some 10 days latr, that they were almost symptom

ftee aid ha4 evidently 'ecovered' rapidly.

GAS GANGRENE

'Before the Leyte camnpaign, reports made by medical units in the forward

SixtliU.S. Army area showed 24 cases of gas gangrene during 1944. FortYseven cases of clinically diagnosed gas gangrene occurred during the 65,day

period that the Sixth U.S. Army was oil Leyte. The 47 cases developedfroin

8,893 battle casualties and were of a fulminating type. Whereas the mortality

rate for the group of 24 was less than 10 percent, in the 47 it was over 30

percent. The onsets of symptoms and signs were sudden and dramatic, the

virulent infection sometimes appearing within 24 hours of wounding. A very

probable explanation of the sudden increase was in the fact that most of- the

fighting on Leyte took place in the ricetields that were fertilized by the "night

soil" in thickly populated areas, an ideal source of the clostridia. In addition, 45 cases developed in patients evacuated to rear bases. The total number

of deaths following gas gangrene in the 92 patients was 29, a mortality rate

of 31.4 percent.

In contrast was the experience in the Luzon campaign where, in over

twice the number of wounded, there were only 30 patients who developed gas

gangrene during the months of January, February, March, and April. The

mortality rate was 16.6 percent. The difference in these last two groups was

caused by many factors, which can best be summed up as follows: On Luzon,

conditions permitted the earlier and more satisfactory treatment of the wounded,

and the weather and bacterial flora of the land where the fighting took place

did not result in such a high degree of contamination of the wounds with

Clo8tridium ivelchii or other anaerobes.
SIXTH, .S.' ARM*Y 4951

op~rfiniyt~osevemay f ETANUS 1 ln a

Ai 0s6hntiiitant in Surgery, SiAhthU.S, Army, Qlonei Glenn hadia

i .t srv oftle civilianwounded in Manila, 'Theimedical

Sitnp't n 6 the igh 'incidence and' severity o tetanus len, appearing wfas

e ident,e af -a d the cojlction of information and -data about such. patients

was ib n . The civlian.-hospitals,operating under combat.and sieg- conditiofis'fhii'h prevented' the preparation and accumulationof detailed records,

were Aided by army rsonnel, and one civilian hospital-,he San, Lazaro Hos,

(4!--s operated directly by representatives of the SurgeOn, SiXth US.

Army for afew weeks~after American troops enteredManila. The account

of :4he 6bservations concerning the careof civilian battle casualties who deveioped tetanus represents inormation collected from allpossible sources.

In order that the unusual background that provided such optimum conditioibs for the development of tetanus may be kept in mind,, it is necessary: to

ieVie* gorhe of the circumstances then existing. I city that is held and defended by one military force and attacked by another from the air and groundas well asby a not far off naval force soon becomes a place where the care of

the wounded and sick is difficult indeed, Manila was such a place in February

and March cf 1945. The inhabitants could not flee the city; they were subjected to the action of Japanese military force as well as to the fire from the

American elements besieging the city. The civilian population long had been

on a limited diet, and this was markedly curtailed with the onset of active

fighting. The wounded-victims of air bombing, artillery fire and small arms,

hand gienades, and bayonets and swords of the Japanese--steadily accumulated. The casualties were taken by relatives, friends, or bystanders to the

hospitals. These institutions were also casualties-some had sustained direct

hits; personnel had been depleted in some instances by enemy action, in other

instances by urgent demands to administer to those outside the hospitals; some

in attempting to protect their families had been cut off from returning, others

had been commandeered by the Japanese. The result was that only a token

number of the hospital personnel were in these hospitals and, under the prevailing confusion, organization did not exist. The water supply was cut off

early, the sewage systems became blocked, and the food supply was further

limited, as it had been for some time before, and very quickly became almost

negligible. The civilian hospitals were overfilled with the wounded, the dying,

and the dead.

In the San Lazaro Hospital a few days after the beginning of the battle

for Manila, there were approximately 1,300 civilian patients, and over 1,100 of

these had been wounded. From this group, 156 cases of tetanus developed.

The picture of this hospital was a most unhappy one--it was overcrowded, all

beds and all floor space were filled with the wounded, many lying, many dead.

' Glenn, Frank: Tetanus--A Preventable Disease. Ann. Surg. 6: 124, December 1946.
~4 ATVItIES -OF SURGICAT CONSUTAT

y... a largethe dead had'the most zVsere wounds of thehead, thqrax,iand

abdomen. However, anong th eliving there-were wounds- of evefy partyap- ,

piiiaOel Y'70 percent involin flormore of' the ,extremities.. Anocsiohif ound had been closed,,but the majorioy had had no'surgiealcare. Some

Wound7s were covred wit- dresi&ngs of sorts consisting of iparts of clothing.

Bandages were few and. fliessivarmed over the partially- exposed wounds.

Fractures o6f Ahe xtremities.,were splinted.forthe, most part only by the .ain, Stat 'revented: patient from' moving. The patients, children aid adulls,

Seliited all plhases of injury, exsaniguination, sho ck, infection, and;mal;-

:Th6 ocation of wounds in the 150 patients who, developed, tetanus :was-as,,

: - ', follo~s:'

zbcation~ of 1Oifi(Z o

Head'andl~f _--------------------------------------- ---------- 0U

Ne---------- --------------------------------------- 1

------------------------------------------- T--------------1

Abdoinen and back --------------------------------------------- 17

litck----- ------------------------------------------

------------------------------ --------- ----------------- 4

Upper extreinities---------------------------- ------------------ 34

Lower extremtities---------------------------------------------- 70

4in'rns and iiellaneous ---------------------------------------- 2t

Thiere were miany instances of mnultip~le wounds. The number of patients with

Wounds of the head and neck who developed tetanus was small in comnparisonto those with wounids in other regions of the body. Compound comminuted

fractures of the long bones associated with massive soft-tissue damage_ and,

extensive infection, on the other hand, seemed to be the type of wound most

frequ~ently associated with tetanu s. Dependable and accurate data were seldom

aivailable as to the exact time of wounding and the onset of the symptoms of

tetanlus. It call be said with certainty that there were instances of tetanusbeing-evident as early as 3 days and as late as 20 days from the date of injury.

It mnty, be estiniated that 60 percent of the patients who developed unmistakable

evidence of tetanus did so within 7 days.

The onset of symptoms was difficult to evaluate because of the general poor

condition of these patients as described above. The vital processes were so

depressed in the group and the clinical pictures so complicated by coexisting

abnormal states and infections that they masked the classical early manifestations of the disease, such as the complaint of headache, stiffness of the neck

muscles, and difficulty in chewing. Locked jaws were all too evident when fully

dleveloped(, as wvere tetanic seizures andl opisthotonos, and yet often these were

the first manifestations of the disease to be observed. It should be stressed

that the complaint of headache, stiffness of muscles, and p~ain in the region of

the wounds could be elicited from the majority of the wounded.

Local tetanus was observed in the region of wounds and also in muscle

groups proximial to the wound as wvell as ini the muscle of the entire extremity.
tXTU.ARMY49

Severe loal ;etanusasso'ciated with mild ,generaltetanus Was not-uncommon,

and muscle spasm,. both, tonic- and: clbnic was maked,'intie extremity where,

tlwo"u-nd waslocateod, sually,theWound-was loca4ed-in the distal pprtion,

as ontie forearm or hand of the upper extremity or onthe leg or foot -of te

lowerextremity. Local tetanus, ni01ing an, extremity Independent of flte

wound was not seen. Howiveer,- oi:e patint developed Ieal tetanus in th6

stump of amid-thigh amputationfollowi'ng remval of a gangrenous, legi.t1he

result of a compound fracture of the distal portion of -the femur.. Tetanus

was not observed' beforethe opertion,.andl al tetanus Was present oh, the

following day. it persisted'f or almost 2: weeks and subsided. During this

period, ihere was a sligh:trismus and almost no stiffness of. the neck muscles.

The most frequently observed clinical picture was as follows: A patient with, a wound of considerabW!extent in an extremity would be unable to open

his moutlby 5 or 7 days after injury. There would be marked trismus and:

stiffness of the neck muscles. Associated:with, these two findings there would

exist, or soon follow, mild spasms which fixed the head, body, and extremities

in a straight line- -orthotonos. Within amatter of hours as the seizures became

more pronounced and more frequent, opisthotonos developed with greater involvement of the back muscles, so that during a spasm the back became arched'

and thoebody was truly supported by the head and heels. Concomitantly, there

wouldappear the classical risus sardonicus with elevation of the eyebrows and

retraction of the corners of the mouth, producing a grimace that exposed the

locked jaws (fig, 87). Orthotonos was observed to be followed not only by

opisthotonos but emprosthotonos. Spasm and rigidity of the abdominal muscles was. an early and common finding that preceded generalized seizures and

persisted during and between them. As spasms became more intense over a

period of hours or days, they rendered breathing difficult. With the muscles

of the neck and diaphragm and the intercostals in spasm, the air exchange was

so reduced that the lips and nail beds became very cyanotic. During the

severe spasms, there was profuse perspiration, and pain was excruciating and

unbearable. As the disease progressed and the spasms increased in severity

and frequency, the patient became physically exhausted but remained mentally

clear and terrified. An occasional patient died during a spasm, but the majority, following complete exhaustion, became listless, and the diminishing

convulsive seizures were followed by death.

Dysphagia was common and present in about 75 percent of all patients

with tetanus, whereas trismus was more constant. A few (four) patients with

a rapidly fulminating type of the disease did not exhibit trismus. The forearms and hands in the majority of tetanus patients were, in general, spared

to a remarkable degree, so much so that even those with the most severe spasm

could grasp the sides of the bed or cot during seizures.

The deep reflexes were early exaggerated, and the Babinski reflex was

positive in approximately 20 percent of new cases. Ptosis of the eyelids was

observed in seven instances in the 156 patients. Facial paralysis was seen only
498 AOTiVtliES'OF SRGICAL- IOSLAT

PiuaEs 87i--PAtieni, a'Chlhese, had'beeni wounided In the hand by sheWl tragients ah4 id a'active sis, o~ tetanfis upon admission

to San Lazaro Hospital. Note thd rstfs saidouicus.

once and no history could be obtined as to whlether or not this Was~present

before the onset of the disease, True cephialic tetanus as described in.41the

literature was not observed. Extensor responses of the foot and leg onl

stimulation or during a convulsive seizure were common,

'Those patients with generalized tetanus exhibited various degrees of

uiay retention and, without- exception, had difficulty in urinating, During

a spasm, urin -e would be expelled in small amounts. Although a spastic vesical

sphincter has been the cause commonly ascribed to this, no difficulty was encountered in catheterizing men or women. Spasm of the rectal sphincter was

readily demonstrated early in generalized tetanus. Fecal impactions were

rarely seen because the food intake of most of the patients had for some time

been negligible.

The great variation of extent and severity of the wounds in such a group

of civilian battle casualties with little or no previous primary surgical treatment offered some opportunity to evaluate late operative therapy. Those patients with well-established tetanus who could withstand operation, although

improved by such therapy so far is sepsis and general condition were concerned,

seemed to follow the common pattern of the disease and, with or without specific therapy, died. The incision and drainage of grossly infected wounds, the

removal of foreign bodies and the accompanying manipulation, oW the other

hand, did not appear to increase the progress or severity of the disease.

Furthermore, guillotine amputation for extensive injuries of the extremities
!SIXTHTS RM 9

6metirnes sociated with gangrene and Cl. welchii infection did not appear

toaltefe'r t course. However, it was significant that, i th group ofalmost

40 patieits in the San Lazaro Hospital upon whom amputations, were per- fbrmed and whohad no ;eidence of tetanus-at the timeof operatinand no

othei 4ounds only 3 developed tetanus; 2. of these died-and1l ran a courseof

(weeks l eventuai1y, recovered..As previously stated; ,extensive wounds of

th-exti' 6 ities involving deep strcturies accounted- for -the greater number

of patients with tetanus,, although there were also.many examples of thbs6-

who li.d& superficial wounds, Burns in .particilari With or without additional,

in jufis,:I.d to tetanus, although somewhat later. In a group of 37 patients,

with, severe bukns, 10 developed tetanus 10 days or longer after injury. The

coiirse of the disease in these patients was apparently just as fulminating as

in those A61developed the disease with a shorter incubation period, and all

Sten' died

Penidillin was used-in six patients with tetanus. Daily amounts of 200,000

units Were given to five of these in 25,000-unit doses intramuscularly every 3

hours. There was no apparent effect upon the tetanus infection. The period

of treatment was as follows: Two patients received penicillin for 6 days; one,

for 5 days; one, for 2 days, and another for 36 hours. All of the six died. One

child received a total of 1,200,000 units over a period of 48 hours, the initial

dose being 25,000 units given intravenously and 50,000 units intramuscularlythis was repeated every 3 hours. Again, the terminal course was un'altered.

Penicillin was used locally in two patients who developed tetanus following

burns. The wounds were grossly infected, and penicillin was applied in

strengths of 500 units per cc. without evident improvement.

In the last 3 weeks of February at the San Lazaro Hospital, 140 patients

in the group of 156 with tetanus died, a mortality rate of almost 90 percent.

That death was due to tetanus alone cannot be said because of coexisting conditions and other infections. There was little tetanus antitoxin for specific treatment. The facilities for general supportive treatment were also limited, and

sometimes even the most simple patient care was lacking. Many patients died

within a few hours after the appearance of the symptoms of tetanus, but many

more lived for from 3 to 10 days.

The single most important item available was morphine. This drug in

.008-gram doses reduced the duration and the severity of the spasms. It gave

the patient rest and enabled those with dysphagia to swallow liquids that

otherwise could not have been administered. Morphine given as indicated,

sometimes as often as every 2 hours, did repress respirations, but it was the

most useful of the drugs available and it is doubtful that pulmonary complications were increased by its use. Atropine, .0005 gram, given with morphine

definitely improved respirations in severe spasms with marked opisthotonos.

Paraldehyde and chloral hydrate by rectum were well tolerated and effectual in a limited degree. The various barbiturates available were of minimal

value. Severe and devastating generalized seizures were sometimes controlled
0Q,0 AOTIV!TIES OF SURGICAL CONSULTANTS:

b using chloroform or ether or, both as a general anesthesia for shortperiods

in order to give the patientso.ne respite. Ether in oil, administered rectally,

liko*ise reduced convuilsivc seizures and was perhaps the best drug, for the,

puIrpose under the prevailing conditions. Very little tribomoethanoi (Avertin)

-as vilable, but, in the few patients who were fortunate enough to receive:

it, th relief was gratifying. The Filipino physicians were unanimous,.in

advocating the use of a 25-percent solution of magnesium sulfate, injecting it

intramusdularly in 2-cc. doses, and employed it almost routinely. It depresses

respiration to an alarming degree. Sedatives of all kinds were of some value,

in controlling seizures and spasms, and, by conserving the patient's strength,

life was frequently prolonged.

During February, March, and April of 1945, almost 500 patients were

ieported to have had tetanus in various civilian hospitals in Manila. It was

estimated that there were, during this period, approximately 12,000 civilians

Wounded, and an incidence of almost 40 per thousand developed tetanus. The

mortality rate for the 473 reported cases was 82.1 percent. These patients for

the most part had little or no primary or early surgical care. As far as is

known, none had had tetanus toxoid before being injured.

The incidence of tetanus in Manila under peacetime conditions would

indicate that it would be high in combat. The American soldier was fighting

under conditions quite similar as to climate and soil, His physical condition

was, of 'course, superior to that of the average citizen of Manila. Furthermore,

when wounded, he received early and adequate surgical care and, in addition,

he had been immunized with tetanus toxoid. That this immunization was

completely successful is borne out by the complete absence of tetanus among

the U.S. Army forces on Luzon.

SPECIAL CONSIDERATIONS

Portable Surgical Hospitals

The portable surgical hospital consisting of 4 medical officers and 25 enlisted men became popular soon after it was introduced in 1942. It was a small

compact mobile unit and could be attached to some elements of a combat team.

In comparison to any other existing unit providing definitive surgical treatment of the wounded, it was easy to move and easy to supply. The deserved

popularity of this unit and its accomplishments were, however, due to the

personnel. The officers who volunteered for this type of service were exceptionally well trained. They in turn selected the best in the way of noncommissioned officers and enlisted men they could find. During the early days

of the New Guinea campaign, the demand for this type of unit was great, and,

had it not been available, many wounded would not have received the excellent

care that they did. The portable surgical hospitals were used throughout

the New Guir. ,' campaign, through Leyte, and to a lesser degree in Luzon.
M501

Sometimes, the same general conditions existed as prevailed in the early part

of 'IN New Guinea -campaign, but, as the campaign progressed and greater

numNers,6ftroops Were employed, the portable surgical 'hospital Was stili sed,

It , 'ha& at best certain shortcomings, First, equipment-paiticularly for,

anesthesi-.Waslimited; second, facilities for postoperative care were limited;

a ndtidi, these units:might result in agreat waste of surgicalpersonnel. Yet,

if they did not contain excellent surgical talent, they were worse than useless-,

they were, dhngerous..

For small task forces fighting in the jungle, the portable surgical hospital, well staffed with a minimal amount of equipment, functioned to an unusual

depree of efficieney. When this unit, however, was used where larger combat

units wer employed and where transportation was available, it was not the.

unit of choice in which to do definitive surgery. Because replacements in.

some of the earlier formed portable surgical hospitals were not of the same caliber -as the -personnel of the original groups and because in the formation of

newer hospitals superior personnel was not placed in them, the quality of work

under cbmparable circumstances became distinctly inferior. Small groups

not well trained, out on their own, and confronted with problems far beyond

them were apt to repeat unnecessary mistakes. The combination of portable

surgical hospitals and clearing companies was permissible when other organizations welre not available, but they did not constitute the proper unit for definitive war surgery. Portable surgical hospital units were too small for doing

definitive surgery and they lacked personnel and equipment. Most importantly, they were unable to provide proper postoperative care and from a practical standpoint tended to evacuate postoperative patients too early. This was

particularly applicable to patients operated upon for abdominal injuries. Far

better were the 400-bed evacuation hospitals.

Surgical Teams

Surgical teams consisting of 2 officers and 4 enlisted men equipped with

b..sic operating instruments were requested by the surgeon of the Sixth U.S.

Army and provided by the Surgeon, SOS, SWPA. Orders provided for their

assignment to the Six ii U.S. Army on temporary duty and their return to their

original station when the duty was completed. In the army, these teams were

assigned to those medical units where they could be employed most profitably.

On Leyte 4 teams were used, and on Luzon 23 teams.

In th Sixth U.S. Army, it was the general policy to have one team attached to an evacuation hospital and two to each field hospital. Without exception these teams were well received by the forward units, and, from the time

of their arrival, cooperation was excellent. The teams worked under the direction of the chief of dhe surgical service of the hospital to which they were attached. They werc ',,en the same responsibility as the regular staff members.

One team functioned as a unit in the operating room when feasible. Teams
502 AOTIVITIES OF SURGICAL CONSULTANTS

participated in the care of patients from shock ward to evacuation, caring for

their on postoperative patients. When hospitals were carrying peakloads,

the teams would often be split, and each surgeon was paired with a lessex- pereiiced medical officer of the hospital staff, to make up a team. Thus, very

early, the teams were absorbed by the surgical service so that they functioned as

anifitegral part of it. The great volume of work that the forward units were

called upon to do taxed them all. The commanding officers and surgical chiefs

of these hospitals stated that they could not have rendered the treatment that

they were able to give the wounded had their staffs not been supplemented by

these teams, For the most part, the hospitals that sent these teams deserved

commendation for the careful selection of both the professional and technical

personnel. The officers and men of the teams were well pleased with their experience, and their value was well demonstrated. Some of the teams were

shifted from their original assignments when work became slack and help was

needed elsewhere.

Two par,,i hute surgical teams commanded by Capt. Robert S. McCleary,

MC, under Lt. Col. Francis W. Regnier, MC, Surgeon, 11th Airborne Division, were first used near Ormoc on Leyte. Each team was composed of 2

medical officers and 12 enlisted men and was equipped with materials and

instruments to enable them to do major surgery in the field. The first team

to embark on a mission jumped in southern Leyte and in the ensuing 20 days

cared for 160 patients, 42 being litter cases. There were 3 head, 4 chest, and

2 abdominal wounds; 18 compound fractures; and 1 appendectomy. Two

patients died before operation could be undertaken. This experience demonstrated that this type of unit had a place with airborne troops who may for

some time be isolated. The teams were used in other missions on Leyte and on

southern Luzon.

Nurses in the Forward Area

In spite of the provision for nurses in field and evacuation hospitals,

members of the Army Nurse Corps were not in the forward areas early when

the patient loads were at their peak in these medical units. This was observed

in the Admiralty Islands, in Netherlands New Guinea, Leyte, and Luzon.

The immediate postoperative care of the wounded was without exceptiol superior when nurses with years of training were in charge, in comparison to

the Medical Department enlisted men-willing and enthusiastic as these enlisted men were. The care of the wounded would have been improved by placing nurses in all field and evacuation hospitals as soon as they were secure.

Indeed, the small risk to which the nurses would have been subjected would

have been greatly overshadowed by the service they could have performed.

That this was not realized was attested to by the attitude of commanding officers, task force surgeons, and some members of the professional staff of various hospitals who held that "female" nurses were an added burden and required

additional quarters and facilities, and that additional personnel for guards was
ARMY 503

requireid. They frankly stated that they did not want them because they were

to .much tiouble and yetthey:liadnever-had them forward in the earlyphases of iati6hi. Some medical officers wefr naive enough to believe that the corpsmien were just as experi in P9stoperative care as the nurse. The, standards

fr pOstpepative, cafe were ,low among surgeons who,prfessed to this belief..

Another objodtion offered was that to bring nurses in after the men had :put

uplth6hie'o§ital and place them in charge in the care of the patients would be

ailoW: to~th6,66rpsmens morale.

There were many reasons, arguments, and opinions as to why nurses should

have beeni ini the forward areas much earlier than they were. No one could

doubt, that~ieibers of the Army Nurse Corps were capable of rendering nursing care far superior to that provided by the less well trained corpsmen. Furtheoffibrei it would have been the rare experienced surgeon who did not con,

siderthat good nursing was of major importance in, and an inseparable part of,

postoperative care. The contrast was evident when, in the later phases of the

action, nurses arrived and assumed their role.

Clinical Research and Investigation

The need for an organization for the correlation and encouragement of

clinical and laboratory research had prompted Col. Maurice C. Pincoffs, MC,

Chief Consultant in Medicine, USAFFE, and Col. Henry M. Thomas, Senior

Consultant in Medicine, SOS, SWPA, to request through the theater chief surgeon and the Office of the Surgeon General a medical general laboratory. From

a surgeon's standpoint, it was highly desirable that hospital facilities and laboratory be combined. After considerable discussion among the consultants, it

was decided to combine a 250-bed station hospital with the general medical laboratory to form a research unit. Because there were several medical officers in

the theater who were interested in and capable of investigative work, as evidenced by previous accomplishments, it was requested that the general medical

laboratory be sent to the theater with certain of its positions vacant. In March

of 1944, requisitions having passed proper channels, word was received from

the chief surgeon's office that a general medical laboratory with certain specified

vacancies would arrive in the theater. Inability to secure proper priorities and

other delays resulted, and the 19th Medical General Laboratory at Hollandia,

New Guinea, did not disembark from the United States until August 1944, to

arrive in September.

In the meantime, steps were taken to locate personnel within the theater

who would contribute to such an organization. The 12th Station Hospital was

selected to be combined with the medical general laboratory, and it was transferred from Australia to Hollandia. Plans were drawn up with the assistance

of SOS, SWPA, engineers to house together the two organizations. Likewise,

plans were made for such changes and additions required to render the Australian portable buildings suitable for scientific investigation in tropical New

Guinea. The amount of material and extra equipment required was great.
504 ACTIVITIES, OF SURGICAL CONSULTANT S

However, with a high priority obtained in higher headquarters, the ,materi~a

was 9ecured from quartermastr sturces,,then lcated in, Sydney, Australia , and'

W6§-plhcedaboakd- a liberty ship destined for Hollandia. Not long, after-the arriv&I :ftle 12th Station, Hospital, the 19t, Medical dneralLabrato ,ad

the eitra equiphient in Hollandia, the-tactical program was stepped upfor tbe,

inVas fi of the PhilippineIslands and the project Wascurtailed, althugh 6th

Jabrtory was.later completed.

Clinical and laboratory investigation should have been. considered an integral part and function of the Medical Department during service inao freign

theater.' Knowledge of tropical surgery as well as tropical medicine could

liave teen increased with profit much earlier, had the proper organizatioi been

available. Because there was no official organization of this type provided, for,,

the construction and securing of one was met by a great deal of resistance. One

ranking medical officer in the theater chief surgeon's office bitterly opposed

"research in the jungle." A base surgeon of equal rank was insistent that such

an organization would deprive the wounded of proper care. Such attitudes

were relics of the dark ages, and they delayed progress.

A table of organization and equipment for a combined laboratory and hospital capable of doing clinical and laboratory investigation and including the

facilities of a medical general laboratory should be set up for use in any future

war.
rnk B.Be rry, M ..

T"HE LANDINGs IN SOUTHERN iRANCE

FraTe aSion, troops of the ,S6venth- U.S, Armyiwhich landed -in, southerfi

1nsAugusti 444, & onssted of thei3d, 80th, and, 45th- infantt'y Division4. 88)g i

. Al hadjhad lingcombat service, either with the.II Corps i the

fipraifis in Nbrth Afiricaduring the campaigns in i 423, or withe Fifth

WS. Army in Italy. The e troops were therefore baWlewis andwere also,

Sthoughily familiar ,withthe functioning of their own first and second echelonmedical w e vices in combat, as well aswith the functioning of supporting corps

ith, a single exception, the 51st Evacuatilon Hospital, all the hospital' units briginallyassigned to the Seventh U.S. Army bfr the invasion had seen,

service in the North African, Sicilian, and Italian campaigns, and all. were

wi staffed. W!n tlie 51st Evacuation Hospital landed in southern Franceit

had.not-even unpacked its equipment since loading at the port of embarkation

in the United States. It wastlierefore an unknown quantity-at the time of the

landing. It had, however, a- well-balanced and well-trained staff of surgeons

who had been carefully selected for this particular mission, and it had functioned' as- a unit on extensive desert maneuvers in the Zone of Interior. As a

result, itwas soon able to carry heavy loads for sustained periods.

The teams of the 2d Auxiliary Surgical Group which landed on D-day in

southern -France had also seen service in all previous campaigns in the North

African theater.

As a result of their previous experiences, these organizations were all

familiar with the professional policies developed by Col. Edward D. Churchill,

MC, Consultant in Surgery to the Surgeon, MTOUSA (Mediterranean (formerly North African) Theater of Operations, U.S. Army), and had profited

by his instructions. They were also familiar with the professional aspects of

medical care of military casualties as these policies were promulgated in the

technical circular letters issued from the office of the theater surgeon. The

surgical care of all patients in Seventh U.S. Army installations was originally

based upon the principles developed in previous campaigns and set forth in

these letters. Later, it was also based upon the principles set forth in publications from the Office of the Chief Surgeon, Headquarters, ETOUSA (European Theater of Operations, U.S. Army).

505
,506kcTivITIES OF S~URGICA~L CONS4ULTANTS

Oraguignon 5 -~

3 gnolre-,

Traesr

4, Le',M~yr($ Le r

Collobr res Cglh -J~ ~ 6 INFANTRt 0 VII

Romatuelle.

La ndeles-Moure

FildiU SS. Lainu-ii. of the~ 3d1. 36111, miid 1:111 i tfil ly I oiio. S'v eol I I .'S. Army,

aldIheir 111:11W11% N*r from I bce. lo IfIlue L.ine. 15 AuiglilN 1.

PIIELIMI NARY MEI)ICAL P~LANN ING

P1l111,; for the provliioll of lpr)Ie.sional mtedhi(ctl.elu ice. for I lie imai~soll

of '-oultlierti F'rance fell int d11 e followintg foul. ('.tl0or1lte.

I. lefelitk e mrl"Icatl lolicie, \we eslabllis..led i 1cillartit Lef let No. 2.

( )live of thle .St111geoll, I le~ad(jualte1., Se eath Vii.S. Ar .daled IS .1111y 19-14

( append ix BI ).l*

2. Aditi ioiiml pl)(i'ollltl weve 1)1o\ lesl torth le field lio'spital, atnd 400-bed

,eitittiioliilv evatsiitt 1(11 lto'plails l e vilipllo , \esi duing I lie lauditig pha1-e. 'u,

well a,~ forithe hiospilatl shlipi.lSs(ltIli' . hptti I ltlisl)0ts. and tile

Iirsl S-peial Seinice Foce. 'Hie lzt tei ol.-ailzal ion \\I. It m1lixedl ('aiadiati
ASEVENTH US RM 0

and Aericangroup, whichlike rangers and commandos,.had a-specil combat'.

-mission.

~SAn ad"'quate supply of 'fresh bloao ad dquatesupple fpncli

Wee prqv06iddto ;be landed with the, Assatult -fforcs on D-,day.,, Provisionwas, also made, for h6,daily delivery thereafter, beinnPnD 1 fbod

and~pgm t6 pencili g I)+v~p& lnce 4 A ssistafice was offered to the FirstFrench.Army, Which Was to accom.

p ahy the SbVenath .U.S. Army, particulqrly in -respect~tQ supplementalttrailing

ofidicalpbficets, hoial plies,and:the delivery of blood.

Surgical Policies for the Invasioh

Standardsurgica1 policies for the care of the woundedin the Seventh U.S.

AMIriy wripet up under the supervision of'Cdl. Myron P. Rudolph, C, army

suronAn i oi isultaton-withColonei. Churchill.

'The TOUSA -(North African Theater of 0perations, U.S. Army),, Circlar'lefttersfor 1943 and,1944, as Well as Circular Letter No, 71, -Office of

the. CiefSiirgeon, ETOUSA,' were freely utilized in the preparation of afore-

-M0itiohedOrcular Letter No, 2 which set forth the principles of professional

miinige6Vefor the invasion and thereafter.

Planswere also made for a continuing flow of medical information to the

consultant .in surgery from army-hospitals during the ,ntire campaign, in

Order to assure the best standards of profesional care by continuing analysis

of the iicidence of special types of wounds, the performance of special opeFa;

tioins, the incidence of special complications, the use of whole blood, and similar

miatters. These data Were requested in Circular No. i5 in August 1944 and

are discussed later in this chapter under appropriate headings.

Hospitals and Medical Personnel

Planning for the invasion provided for the landing of hospitals and medical personnel by the following schedule. No nurses were put ashore with any

unit until D+4.

1. Provision was made for the landing on D-day, with the first assault

troops, of beach clearing companies, which were to be under Navy control

until the landing forces had secured the beachhead. In the 3d and 45th Division sectors, the surgical teams attached to the field hospitals landed with the

clearing companies and remained with them until the beachhead had been

secured.

Two field hospitals were also to be landed with the next wave of assault

troops. Two platoons of the 10th Field Hospital were to support the 3d Division, and two platoons of the 11th Field Hospital were to support the 36th

I Circular Letter No. 71, Office of the Chief Surgeon, ETOUSA, 15 May 1944, subject: Principles

of Surgical Management in the Care of Battle Casualties.

: Circular No. 15, Seventh U.S. Army, 31 Aug. 1944.
508, ACTfVITiES OF SURGICAL CONSULTANTS

Division. The third platoons of these hospitals were to land with the-45,tli

Dvision., .J. 'o to be landed with the invading, troops was adetachment ofthoe2dj

Au-filiiy Surgiai Group, coniposed' o 14 generail surgical teams, 3 ishoc ," teani3 8or thop~edic teams, 2 thoracic-surgical lteams, and 1' neurosurgical. teaxm,..

Thes t nswere to bedivided among thefield hospitals.

.Tlhe field hospitals which landed with the invading troops were also aug

mente byteams : drawn from the 750-bed evacuation hospitals and the:general

hospitals designated for later landings. These teams, which were also intended,

th reinforce the 400-bed evacuation hospitals to be landed late on D-day and

on D+ 1, included (1) general surgical teams, consisting of a surgeon,, an

assistant surgeon, an anesthesiologist, and two technicians, and (2) shock teafns,

consisting of one medical officer and three technicians. Skilled technicians

were also drawn from the same pool and attached to field hospitals, to perform

nursing functions until the nurses assigned to these hospitals were landedi on

D+4. All reinforcing personnel were to be automatically returned to their

ownunits as soon as their units had been landed.

The forward distributing section of 6703d Blood Transfusion Unit (Overhead) also landed with the invading troops on D-day.

2. Plans were made for the landing on D-day and D + 1 of three semimobile

(400-bed) evacuation hospitals. Two maxillofacial teams, two dental-prosthetic teams, and one neurosurgical team, all from the 2d Auxiliary Surgical

Group, were attached to these hospitals.

3. The nurses assigned to the field and 400-bed evacuation hospitals were

to be landed on D+4, as were the nurses assigned to the teams of the 2d Auxiliary Surgical Group, which had been landed earlier.

4. Four 750-bed evacuation hospitals were to be landed between D+10

and D+15.

In addition to the personnel attached and assigned to the organizations

just mentioned, other personnel had to be provided, as follows:

The First Special Service Force required six additional medical officers

and one additional enlisted technician.

Forty medical officers were needed on transports and LST's, to care for

the troops on them and for such wounded as might be evacuated by sea.

One or two additional surgeons were required for each of the hospital ships

to arrive on the far shore on D + 1 and D + 2.

These special needs, as will be pointed out elsewhere, were underestimated

in the initial planning.

MEDICAL ASPECTS OF THE INVASION

The landings in southern France were conducted as planned in almost all

respects (fig. 89). The 3d Division landed on a beach to the west of Saint-
'9E'ftN-;TH,'U,8. ARMY

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FIGURE 89.-Operations in soutbern France, 15- .)S August 1944.
~10 ACTIVITIES OF SURGICAL'CONSULTANTS

Tr pd and the 45th Division'landed:on a beach to the east. The 36th Division,

whibh landed at Saint-Rapha '

l, encountered considerable enemy resistance and

wasia ble, until 48 "hours after the first landings, to use, one of, thb hes:

*hfdh, aodingto npans, it wasto occupy. 'The 1three areas on which troops

Were landed weie about50 miles from eachotler. Ieadquarters, Seventli,,"T, :$

Army, was located at Saint-Tropez.

Beach detachments (fig. 90) were set up almost immediately after the

trops began to land, and, by the night of D-day, two field hospital platoons

*ei-ih full operation. Shortly after the landings, the division surgeon of the

36th Division reattached two of the general surgical teams, which had landed

with the 11th Field Hospital, to the beach clearitg -tation of the 56th Medical,

Battalion, to permit more work to be done in it.

Each division had been made responsible for its own loading. The ETMD

(Essential Technical Medical Data) reports for the 36th and 45th Divisions

and for the 56th Medical Battalion reported too great dispersion in the loading

of both personnel and equipment, with resulting delay and confusion in unloading and in the establishment of beach clearing stations and field hospitals.

The personnel and medical supplies of the 3d Division had been so loaded

that both attached platoons of the 10th Field Hospital could be unloaded

promptly on D-day. One platoon had been set up and was receiving patients

late in the evening, and the other began to operate the following day. One

of these platoons was located in the same urea as the beach clearing station

of the 52d Medical Battalion.

The personnel of some of the 400-bed evacuation hospitals landed on D-day.

Their equipment began to be unloaded on D + 1. The 93d Evacuation Hospital,

supporting the 45th Division, began to operate on D + 2, and the 11th and 95th

Evacuation Hospitals on D+3. These three hospitals were reinforced by

surgical teams and other teams from the 9th, 27thl, and 59th Evacuation Hospitals (750-bed hospitals), which were to be landed between D+10 and D+15

as well as by teams from the 21st, 36th, and 43d General Hospitals. There

was thus an abundant supply of medical officers and enlisted medical personnel on shore at all times. As later convoys arrived, some of the medical

officers who had been withdrawn from general hospitals for temporary assignment to troopships were attached to evacuation hospitals then in operation

while awaiting the arrival of their parent organizations.

Medical facilities to care for lightly wounded casualties who could be

returned to duty, as well as for neuropsychiatric patients and patients with

venereal disease, were set up and in operation by D-4.

The 6703d Blood Transfusion Unit (Overhead) landed as scheduled on

D-day and was immediately attached to the 52d Medical Battalion. Later,

it was attached to the platoon of the 10th Field Hospital supporting the 45th
"MAIN11111 V.S. ARMY

-iL

'qw

WAMW
512 AOTIVITIES OF-SURGICAL C0NSUiTANTS

Divifi6i. Stilllater, thisunit was attached to the O3d Evacuation Hospital 

'Thei w;asan ampi6supply of blood at all times, The plane and boat service,

fist ~riployed, like the plane service which ,assumed' t I it4sponsibility' later, oprted smoo-0tly f!rom the Yrery beginig an -iecouier oil tile plaluiaas.

rlquently used by other staff sections of the Seventh '.S; Army fO.the,

.dliery of 'esgs

Distributini of penicillin for the landings was made the responsibility, of

bloodbank p isonnel. The field hospitals also brought in a smallinitiai supply

ivith them, and 2,000 ampules accompanied: the blood shipment which aiifed

on D+1. Additional amounts continued to be brought in by the planes transp6ting blood until all the penicillin required could be supplied and distributed

thio ugh normal medical supply channels.

Two medical officers became casualties during the landings, when ahalftrack in which they were riding struck a mine. They were evacuated iminedi

ately by ship. The enlisted technician who had landed with the surgical

consultant and who was trained in both anesthesia and operating-room, techniquetook over the duties of the injured anesthesiologist (p. 515). The plastic

surgical team to which the other injured officer was assigned was reconstituted

as it general surgical team (p. 562).

CRITIQUE OF THE MEDICAL ASPECTS OF THE LANDINGS

Qualifications of an Army Surgical Consultant

The surgical consultant to a field army, who always works under the

overall direction of the army surgeon, has the following important functions:

1. He establishes surgical policies for the army. While they are necessarily more detailed, these policies must be consistent with the policies established by the theater consultant in surgery, with whom the army consultant

must be in frequent and close contact. The army consultant, however, provides specific as well as general direction and must meet given situations on

his own authority as the needs arise.

2. He must be familiar with all the organizations assigned or attached

to the army and must know their approximate troop strength and their tactical

use. He must know which organizations are to make the initial landings and

which are to be phased in at later dates. If an amphibious or oversea movement is planned, he must know tho loading order.

3. le must know intimately all the details of medical support available

for assignment and must be aware of the training and experience of the staff
SEVNTHXJU.§. ARMY51

of eachii~dida unit, as wel l.sdf its compositeexperienee, so that all assign- mets '~be 1144,d inh6lightOf this knoiwjedge. 4. He -i§ responsible,,. a' all tin e for th e appraisalothe quality and,

.... He 'i responhsibl ialso forassuring thadequacy-pf supplies- of Iteh

blodand', antibiticsb.or army medial tratment facilities.

6'. ;femust -e knoW the medical facilities of the country in which -the, army

rigthe n campaign itself, the duties of an army consultant-in surgery,

IAn Addift0nt'thiose just listed; in6lude th -following:

1. Pkision of the best possible surgical care for battle casualties from

tfhe mob#tf ward medical units in division areas through convalescent hospitals in the ieii rY area, in, order to insure- the recovery, within the army area

and w*thin theshortest possible period,-of the largest posible number of men

whib c ifb returned tocombat. Provided that the tactical. and other circumstances permit, it is highly desirable to hold within the army area, those

-casualties whose physical condition will allow their return to duty within

the established evacuation policy.

2. Cooperation and coordination with the operations section of the army

sirgeon's dflice, in order to insure that all hospitals are well placed and-that

their movements are timely.,

3. Cooperation and coordination with the personnel section of the army

surgeon's office, to insure that personnel for various installations are correctly

selected and placed, so that they can do the best possible work in the light of

their own abilities and the needs of the situation.

4'. Collection of certain surgical statistics and the institution of special

studies.

The outline of these duties of the consultant to a field army before, during,

and after an invasion carries certain implications concerning his own qualifications and his place in the general military scheme.

It is almost essential that the consultant be a surgeon with academic

standing in civilian life, who has held positions on the staff of a civilian hospital, who has had experience in the training and education of younger men,

and who belongs to leading surgical societies.

These specifications obviously imply that the consultant will be a surgeon

with the required training and experience, that he will know how to teach,

and that he will have contacts with a wide circle of friends and acquaintances

on a level of experience and training similar to his own. These are important

considerations. An important phase of the consultant's duties will be the teaching of inexperienced surgeons, and another important phase will be the evaluation of personnel attached to units coming into the army area.
514' ACTIVITIES OF SURGICAL CONSULTANTS

in short, the previous military experiences ,of the consultant in surgery

to a f ld army, in addition to his surgical competence, in large measure

dete. ,ne his capacities for his work.,

MedicOmilitary Experiences of the Surgical Consultant, Seventh U.S. Army

Headquarters, Seventh U.S. Army, was in Algiers at the time of the,

assignment of Lt. Col. (later Col.) Frank B. Berry, MC, (fig. 91), and the

initial planning for the invasion, described elsewhere, took place there. Early

in July, the headquarters was transferred to Naples, where the remaining plans

for the invasion were made,

Crlonel Berry sailed with the invasion troops from Naples on 14 August

1944. Twenty-four hours later, the target area was reached, and his ship lay off

Saint-Tropez, waiting for the opening naval bombardment. H-hour was 0630

on 15 August. He went ashore later in the day, between 1600 and 1'0O hocurs.

The 36th Division, which had landed at Saint-Raphabil, about 25 miles overland from Saint-Tropez, where he went ashore, had run into trouble, The roads

between the two towns were held by Germans, and it was D+2 before he got

through to the medical units of this division. The area in which he was

put ashore was heavily mined, and for the next several hours, while "'e thumbed

rides from army vehicles for transportation from one medical .cility to

another, one of his important duties was to avoid mines.

His immediate duties as army consultant in surgery were clear. Certain

urgent questions hod to be settled immediately. How were the beach clearing

3 In World War I, Col. Frank B. Berry, MC, surgical consultant to the Seventh U.S. Army, had

served as a medical officer In the Department of Supply (the World War I counterpart of the con.

munications zone of World War II) in France.

In World War II, he left the Zone of Interior in September 1942, as chief of the surgical service,

9th Evacuation Hospital (the Roosevelt Hospital unit). After staging in England for about 5 weeks,

this hospital landed In North Africa In November 1942, 8 days after the first landings. The hospital

was assigned to the II Corps, which was the main lighting element of U.S. Army troops, from the

landings until the end of the Tunisian campaign, and it served in direct support of the combat units

of the corps from the end of January 1943 until the enemy surrender in Africa in May 1943.

The 9th Evacuation Hospital was assigned to the Seventh U.S. Army just before the Invasion of

Sicily. Early in September 1943, after the island had been taken, the hospital moved to Sicily, where

it assumed the emergency and routine care of the troops staging to invade Italy.

Early in January 1944, when the French needed medical help, the 9th Evacuation Hospital was

moved to Naples and was attached to the Peninsular Base Section. From this time, until July 1944,

the hospital acted as a general hospital, caring for all French patients received from the First French

Army, which was operating with the Fifth U.S. Army. This was a unique experience for an evacuation

hospital, which does not ordinarily see the end results of its own surgery.

In May 1944, In response to a telegram from the War Department, Colonel Berry was declared

available by the theater chief surgeon, Maj. Gen. Morrison C. Stayer, and was ordered to report to the

Surgeon, Army Ground Forces, Washington, D.C. The assumption was that the Army Ground Forces

was at last to have a much-needed consultant in surgery (p. 523). When he reached Algiers, Colonel

Berry learned that Colonel Charchill had Informed General Stayer that in the planning for the contemplated future operations of the Seventh U.S. Army, which had been designated for the invasion of

southern Europe, he had been earmarked for assignment as consultant In surgery to that headquarters.

General Stayer had not previously been Informed of this contemplated assignment. Colonel Berry

was given his choice--to report to Headquarters, Army Ground Forces, in Washington, or to be assigned to the Office of the Surgeon, Seventh U.S. Army,, as consultant in surgery. He chose the latter

assignment.-J. B. C., Jr.
'ARMY

Fiouav 91.-Col, Frank B, Berry, MC, Consultant In Surgery, Office

of the Surgeon, Seventh U.S. Army.

stations operating? What was the status of the platoons of the field hospitals?

Did they need extra help? Had the supplies of blood been landed? These

and other matters occupied his time for the next several days.

Almost as soon as Colonel Berry had landed, he found work for the

technical sergeant with training in anesthesia who had landed with him. They

met a vehicle coming back from a field hospital and were told that the hospital

anesthesiologist had been wounded by a mine. Colonel Berry instructed the

technician accompanying him to go with the personnel on the vehicle to the

field hospital, where he was put to work immediately.

All clearing stations on the beaches were operating smoothly. The platoons

of the field hospitals attached to the 3d and the 45th Divisions were beginning to establish themselves a couple of miles back from the beach, and Colonel

Berry spent the first night ashore with a platoon of the 10th Field Hospital

which was attached to the 45th Division. Both platoons of this hospital were

caring for patients by nightfall on D-day.

Until the field hospitals could receive patients, casualties from the beaches

were being evacuated to hospital ships (fig. 92). Only surgery of the most
ill _' il -ltIt I l\1 li-4d o i i and (-I 'l4,4 1 4 ' IN t1')] l lin ' "

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SEVBNTH,,UXS ARMY 5~

Special Details of Planning and Execution

The: olcinvasiow of southern France was an efclefitly planned operation, from bh the military and the medical standpoint, and,* on the whole,.

it wert according to plan, Hospitals were movedi, without special difficulties,

with ie divisions Which they were supporting. Field hospital platoons were

oft.right up with the arfillery , within a few miles of the front. On one

occasion, near Crest, France, a platoon was caught in -the line of fire, between

German and U.S. Army artillery; they could hear shells going over in both

diredtions but fortunately suffered no hits.

The following points deserve comment:

In order to fulfill his duties with the greatest possible efficiency, an army

consultant in surgery mitst be included in all the planning of the army staff

which involves medical support. This means that he must be cleared for

the receipt and handling of top secret information. There must be frequent free contact, as well as mutual understanding and trust, between the

consultant and the army surgeon, and plans and strategy must be discussed

frankly between them. To provide him with the proper stature, the army

consultant in surgery, like other key officers, should be known by the chief

of staff and by the army commander also. On the other hand, che consultant must clearly realize the differentiation between his own functions and

authority and the functions and authority of the army surgeon. He must

acknowledge the authority of the army surgeon and make every effort to

support him at all times and to improve his position with the entire army

staff, When basic relations are on this plane, responsible duties can be carried out in an atmosphere of mutual trust and confidence.

Most of these requirements were fulfilled in the Seventh U.S. Army,

but there were some deficiencies whose existence made for less competent

planning than might otherwise have been possible. For one thing, the surgical consultant did not meet either the commanding general or the chief of

staff until the troops were actually on the way to the invasion beaches. The

initial contact, which was entirely accidental, opened the way to a cooperative

future relationship.

More important, full knowledge of the initial phase of the oversea movement and the landings came to him piecemeal, much of it by indirection, and

then only because he kept his eyes and ears open. The place of landing, the total

number of medical units assigned to the Seventh U.S. Army, and the phasing

of the landings of the others which were to come in later for support, also

came to him piecemeal.

This was a basic fault. A consultant in surgery to a field army has heavy

responsibilities, and, like other staff officers, lie cannot fulfill them efficiently

unless lie has full information on all medical phases of an invasion or campaign. As it was, the surgical consultant to the Seventh U.S. Army had no

broad, overall picture of the invasion beforehand, though in the planning of

606222'-62-35
518 ACTIVITIES OF SURGICAL CONSULTANTSl

any medicomilitary operation the total needs must be known in order to assure

its success. This generalization applies to professional care and personnel

as well as to needs of materiel. Under exigencies of war, of course,many

last-minute changes may have to be effected, but, ideally, the consultant should,

have the picture in its entirety rather than piecemeal, so that the problem may

be evaluated as a whole and action not be taken as a succession of afterthoughts.

If the total problem could have been visualized from the surgical stand-

.ooint well in advance of the landings in southern France, the total available

medical personnel could have been utilized with much greater efficiency. The

surgical consultant learned, for instance, only 5 or 6 days before the troops

sailed, that a group of special Canadian and American ranger troops were to

land on the Hybres Islands at H-6. The intrinsic medical leadership of this

unit was good, but the medical staff required considerable strengthening. By

the time the information concerning their needs had reached the surgical consultant, however, most of the additional personnel available from supporting

units (p. 506) had been attached to the larger invasion commands. The mission of the rangers was important, but to supply additional personnel for

them made it necessary to "scrape the bottom of the barrel." The results might

have been expected. Three of the first group of supplemental medical officers attached to this force during their last days of training 125 miles south

of Naples promptly developed the well-known military complaint of "severe

lame backs." When, under appropriate authority, the consultant was seeking for replacements for them, the commanding officer of the general hospital

from which lie was seeking the replacements, himself a Regular Army officer,

inquired whether he thought any of his men might get hurt. The consultant

could have handled the rangers' medical problems better if he had known

of their needs earlier.

Similarly, lie had no advance information about any hospital or other

ships designated to care for casualties which were to arrive in the target area

during the first 3 days of the invasion. Had he known of these needs earlier,

the ships would have been better supplied with surgical and shock teams and

would also have had more liberal supplies of blood. As it was, the ships were

somewhat understaffed, and blood was in somewhat short supply.

Functions of Medical Units

As noted elsewhere, the medical organizations designated to accompany

the invasion troops which landed in southern France were well trained and,

with a single exception, had had experience in previous combat. When the

time for the invasion arrived, competent personnel were, as a rule, distributed to the best possible advantage in the light of the surgical consultant's

somewhat incomplete knowledge of the invasion plans. With the arrival

of new hospitals in the late fall, a number of additional changes were made.

In some instances, poorly staffed evacuation hospitals were strengthened by
520 AOTIVITIES OF SURGICAL CoNSULTANTS ,

with surgical facilities and adequately staffed, to LST's, and to hospital shps.

Theseships should be equipped for major and minor surgery on large Aumb*s

of chsualties. Their use keeps the beaches clear for other military and-medical:

necessifies.

The assignment of surgical and shock teams to beach medical battalions,

field hospitals, and hospital ships further provides optimum initial care , of'

the wounided during the first days of the invasion. It also assures a triple

reserye against untoward eventualities.

The experiences during the invasion of southern France demonstrated

that tie personnel of evacuation hospitals should not be landed on D-day. Since

their equipment cannot land with them, their presence on the beaches merely

increases the problems of food supply, tentage for bivouac areas, and other

logistic support, with no return for the effort. Evacuation hospitals are best

landed between D+1 and D+4. The whole emphasis in the initial phases.of

a landing should be on (1) the beach clearing stations, (2) small, mobile units,

such as field hospital platoons, and (3) augmentation of these units by surgical

and shock teams.

In order to provide for the early return to duty of lightly wounded and

ill personnel in the combat area, a medical unit equipped to handle convalescenttype patients must be set up within the first few days of a landing. Without

provisions of this sort for lightly wounded casualties and for men with minor

medical conditions and neuropsychiatric and venereal diseases, many soldiers

who could return to duty within a few days will be evacuated out of the army

area. It is obviously highly desirable to retain this type of patient in the

army area; many of them, otherwise, will be lost to combat service.

Provision of Blood and Penicillin

The utilization of a blood plane and the distribution section of the 6703d

Blood Transfusion Unit (Overhead) proved, as already stated, a highly

efficient operation. The use of the same setup for the distribution of penicillin

was adapted from a plan which had proved extremely successful in Italy.

It proved equally successful in southern France. It not only provided a complete and elastic coverage for hospitals in the army area but also relieved the

normal medical supply system, with its rapidly shifting depots, of what

might otherwise have been a troublesome storage problem in the days inmediately after the invasion.

Promulgation of Policy

In the initial planning phase of an invasion, it is important that as much

basic information as possible concerning army policy be issued as command

directives. That this plan was used in the circular issued about the optical

repair units was regarded as one of the reasons for their efficient operation

4 Circular No. 16, Seventh U.S. Army, 4 Sept. 1944.
520 AOTIVITIES OF SURGICAL CONSULTANTS

with- surgical facilities and adequately staffed, to LST's, and to hospital ships.

These ships should be equipped for major and minor surgery on large nuinbrS

ofachualties. Their use keeps the beaches clear for other military and medical

necessities..

The assignment of surgical, and shock teams to beach medical battalions,

field hospitals, and hospital ships further provides optimum initial care of

the wounded during the first days of the invasion. It also assuies a triple

reserve against untoward eventualities.

The experiences during the invasion of southern France demonstrated

that the personnel of evacuation hospitals should not be landed on D-day. Since

tleir equipment cannot land with them, their presence on the beaches merely

increases the problems of food supply, tentage for bivouac areas, and other

logistic support, with no return for the effort. Evacuation hospitals -are bet

landed between D+1 and D+4. The whole emphasis in the initial phases of

a landing should be on (1) the beach clearing stations, (2) small, mobile units,

such as field hospital platoons, and (3) augmentation of these units by surgical

and shock teams,

In order to provide for the early return to duty of lightly wounded and

ill personnel in the combat area, a medical unit equipped to handle convalescenttype patients must be set up within the first few days of a landing. Without

provisions of this sort for lightly wounded casualties and for men with minor

medical conditions and neuropsychiatric and venereal diseases, many soldiers

who could return to duty within a few days will be evacuated out of the army

area. It is obviously highly desirable to retain this type of patient in the

army area; many of them, otherwise, will be lost to combat service.

Provision of Blood and Penicillin

The utilization of a blood plane and the distribution section of the 6703d

Blood Transfusion Unit (Overhead) proved, as already stated, a highly

efficient operation. The use of the same setup for the distribution of penicillin

was adapted from a plan which had proved extremely successful in Italy.

It proved equally successful in southern France. It not only provided a complete and elastic coverage for hospitals in the army area but also relieved the

normal medical supply system, with its rapidly shifting depots, of what

might otherwise have been a troublesome storage problem in the (lays immediately after the invasion.

Promulgation of Policy

In the initial planning phase of an invasion, it is important that as much

basic information as possible concerning army policy be issued as command

directives. That this plan was used in the circular issued about the optical

repair units 4 was regarded as one of the reasons for their efficient operation

I Circular No. 10, Seventh U.S. Army, 4 Sept. 1944.
SVENTH-U.S. ARMY 521

(p. 532). A similar plan had been followed in the circular about trenchfoot5

Consiutants in the Surgical Subspecialties

In the actual landing operation, it is important that the consultant in

surgery 'beaccompanied by one -or more specialists and one or more enlisted

technicians. The ophthalmologist and the technician trained in anesthesia

who made the landing with Colonel Berry on D-day were both employed by night (pp. 515, 531).

Itdbes not seem necessary to have consultants in the surgical subspecialties in the office of the surgeon of a field army. It was the policy in the

Seventh U.S. Army to use medical officers trained in orthopedic surgery,

ophthalmology, and neurosurgery, but assigned to hospitals, as informal

cons ultants, and the plan proved far more satisfactory than the overstaffing

and the top-heavy structure which would have resulted from the formal

appointment of a number of consultants in these specialties in the army

surgeon's office. The success of this plan, of course, depends upon the availability of trained and competent personnel in the medical units of the specific

army concerned. It also is contingent upon the authority given to the consultant in surgery to a field army to select and handle his own personnel. This

he should have. The consultant to the theater chief surgeon should select

for the consultant in surgery to the army a medical officer who is experienced

and reliable and who is acceptable to the army surgeon. Then, he should

permit the consultant to select the medical officers whom he wishes to assist

him and should allow the consultant to use these officers in the manner which

seems best to him.

Whether or not the consultant has a formal staff of consultants is immaterial. What matters is that he should have ready access to medical advice

in problems arising in specialties outside of his immediate field.

Coordination Within the Office of the Army Surgeon

During the Seventh U.S. Army's campaign in the European theater, there

was, perhaps, less close liaison between the consultant in surgery and the chiefs

of the operations and the personnel branches of the army surgeon's office than

might have been desirable. This lack manifested itself in two ways. The

first was in occasional staffing difficulties, although all personnel questions were

coordinated with the personnel section of the army surgeon's office. The consultant in surgery should know the personnel in the medical units in the army

area, both those already assigned and those coming in, so that he can place

the best qualified medical officers in the places in which they can be most useful

rLetter, Lt. Col. W. G. Caldwell, AGD, Adjutant General, to All Units, Seventh Army, 31 Dec.

1943, subject: 'Trench Foot.
522 kc'ImvrmIs OF SURIGICAL CONSULTANTS

I'i;Iil 3. - -Th 271 ±It E%1~ a('ilit ionl I Ilosii 1:11if 1111Y3 Sit 111) ill France.

lnot alwa* N. the 'itmioll illill th e lith Vi1.8. ArilI v liii'iitik

T1hie Cl0Iinl emoiee of occaionali~l lack( of 1w i.,il NitIil 111vi i arI\lm i

"(e011,1 Olbee iiiiceiied thle iolieIat ioiii bl~lch. A, a r'1iilt of tlli- h(ick, thle

select ionl of lio'piitik I o be,~ IloN ci ad fIhe t iiii of the Ioom vilivilt~. olill imies

ll0.jpitltl ahivi it had1 lieli hilly , it l1 ip .93 jirvI-vlted a ,i,,ailit, problemi.

sihlii ii illioli ill (;II bot 111v Iieili:1 :1uid Ilw ti l ical nit jalon, to iiiake

1'&i~liiiiliitiiiicollcolllii i hut Ii l lijial- to lbe liiwedP at 'i cii lime, hlld

the hio~itiks to lie diIa.±iivd fori pviahl iiii-il'-. iline' jiei.,oiiil a, %\ell a.,~

'1 it ion il elpd ill t ive So\ ilIt I '.'S .Aill beiiiiiit aii iiie\pieiiueu e~ iiiail hlu-pito l. hew\ k Liiu \i anlot (lii efl i i *1titei. al~ N\ ai ia-i-ii tI o i \ en~

-iii i\pleiiltel JlioopIi al. cwtehhlitl* I a11eil it \\ a, left (il I Ilie lia -iule of tie lline

a-, a1 hioli i it . lThe con-i1 il X\ wolil nut 1i1\ v iaurved ( ii *livi. a--iliiiiit,
SEVENTH U.S. ARMY 523.

Assignment of Personnel

In retrospect, perhaps the matter of chief concern to a consultant in surgery

in afield army, both during the invasion and later, has to do with personnel.

The assignment of personnel during the invasion has already been discussed.

4atei the Major problems of personnel had to do with the Staffing of evacuation

hospitals coming into the army area from the Zone of Interior.

Evacuation hospitals carry a very responsible load, for the brunt of the

initial surgery of the wounded falls upon them. Eyes, limbs, and lives will be

sacrificed unnecessarily unless surgery of the highest quality is performed in

them. In a field army, the consultant does not have sufficient leeway, or sufficient reserves of personnel, to correct staffing errors. An army in combat, in

faQN never has a reserve of medical officers. On the contrary, it always has a

deficit. Deficiencies in field hospitals can be covered by auxiliary surgical

teams, but evacuation hospitals must, as a rule, take care of their own personnel

problems. They must, therefore, be staffed with the greatest care in the Zone

of Interior. This was not true of all hospitals which were assigned to the

Seventh U.S. Army, and original errors in staffing were not always easy to

correct overseas.

It is easy to explain why these mistakes were made. During the period of

mobilization and training in the Zone of Interior in World War II, medical

units other than those directly supporting the Army Air Forces were trained

under the general supervision and control of two headquarters; namely, Headquarters, Army Ground Forces, and Headquarters, Army Service Forces. The

training of evacuation hospitals was generally the responsibility of Army

Ground Forces.

Early in the war, the Surgeon, Army Ground Forces, did not have detailed

personnel records or other information to guide him in the assignment of professional officers of the Medical Corps. Such records as did exist were incomplete. They did not indicate the professional background of the individual

officer or his stature in the civilian profession. Unless he was personally known

to the Surgeon, Army Ground Forces, or to his immediate staff, he had to be

assigned without the benefit of detailed knowledge concerning his professional

and other capabilities.

Surgeons of the various armies in the Zone of Interior during the mobiliza.

tion and training period of special units and before their departure for overseas were similarly handicapped in the assignment of medical officers for specific duties. An army surgeon, of course, had delegated to him by the army

commander the authority to reassign medical officers within the army, the

assignments being handled by normal staff procedures. An army surgeon,

however, often had little or no more information about the various medical

officers than did the Surgeon, Army Ground Forces, or, indeed, the Personnel

Division, Office of the Surgeon General. Adequate, complete records were

simply not available. The evaluation and classification of medical officers
524 ACTIVITIES OF SURGICAL CONSULTANTSaccorAding to specialties and their proficiency ratipgs within their specialties

were a later development. This information, in fact, became available only

aftetthe planning for the European campaigns was over and could, in actuality,

be pqto use only after much of the fighting was over.

These facts explain why, during the period of training and mobilization

in the Zone of Interior, medical officers were sometimes assigned to key spots

in hospitals which they were not qualified to occupy, while other officers, junior

in rank in the particular organizations, were sometimes better qualified to hold

the more important posts.

The surgical consultant was fully cognizant of these difficulties and. was

quite aware that, under the circumstances, one of his principal duties was to

visit newly arrived medical units and to develop, by all means at his disposal,

full information concerning the professional as well as the military training

and background of the various members of the hospital staff. The point to

bear in mind is that, while theoretically the solution of the problem is simplemerely the movement of personnel from one post to another-practically this

is never a simple matter because of demands for personnel in an army area

overseas.

The problem in the Zone of Interior might have been at least partly resolved

earlier, and with ultimate economy in medical personnel, if the surgeon of

each army had had on his staff consultants in surgery, medicine, and neuropsychiatry. These consultants, however, were likely to be assigned just before

the army departed for overseas. In the meantime, the personnel officer in the

army surgeon's office, and, for that matter, thi personnel officer in the Office of

the Surgeon, Headquarters, Army Ground Forces, were most often medical

administrative officers whose training and background in no way qualified them

to evaluate the training and capabilities of professional medical officers.

Assistance to the First French Army

The First French Army had its own medical officers, but it was shorthanded, and assistance was rendered to them when it was requested. By a semiofficial arrangement, the Seventh U.S. Army consultant in surgery acted as an

assistant consultant iii surgery to them in cooperation with Col. Etienne Curtillet, who was organically assigned to this army as consultant in surgery.

Colonel Curtillet was a member of the faculty of the University of Algiers, in

which the level of surgical work was excellent.

During the staging period, the Seventh U.S. Army consultant frequently

visited the French field and evacuation hospitals based in Naples, to maintain

contact with them and to help them as much as possible with their organization

and supply problems. Some of these hospitals were newly created. Others had

served with the French forces in the Fifth U.S. Army during the winter and

spring of 1943-44.

Colonel Curtillet landed in France, a few days after D-day. He and the

Seventh U.S. Army consultant sometimes traveled together visiting U.S. Army
S§EVENTH U.S. ARMY

and Frehch units as they were encountered. The Seventh U.S. Army did not

furnish the French Army with medical-officers but accepted two or three of their

ic~ist a time for trainihg in Seventh U.S. Army field hospitals. Thus, thes

hlospitals would be jointly staffed by French and U.S. medical officers. The

Frech ,appteciated the training, and they provided, in turn, much useful

assistafice' Some French casualties were also cared for in Seventh U.S. Army

fieldhospitals.

-Particular attention was paid to the French trar ",n service, whose

laboratories and main drawing unit Were in Algiers. A!. zany conferences

with the Surgeon, First French Army, and with officers of the transfusionservice, itwas planned that blood would be flown daily from Algiers to Naples, in

refrigerated boxes, and would be delivered to the French Army hospitals

through the- Seventh U.S. Army blood bank service. From Naples, the

French supply of blood was delivered with the U.S. Army blood by courier

on the beaches or to the advanced airfields, according to the stage of the campaign. The responsibility for maintaining liaison with the forward distributing section of the 6703d Blood Transfusion Unit (Overhead) as well as with

the planes that transported the blood rested with the French. Minor difficulties were experienced in the implementation of this plan. The French

liaison service frequently failed to maintain prompt contact with the airfields

to which the blood was delivered, and some confusion in the supply of blood

resulted, while at times there was a considerable accumulation of stocks of their

full and empty blood containers at the airfields.

THE BLOOD PROGRAM

The story of the blood program in the Seventh U.S. Army falls into three

phases as follows: (1) The provision for supplies of blood before the invasion,

(2) the provision of blood during the landings and immediately thereafter, and

(3) the routine provision of blood during the remainder of the campaign.

Preinvasion Planning

In February 1944, a central blood bank, designed to supply whole blood

to the Fifth U.S. Army, was organized by Colonel Churchill with the full support of the Surgeon, NATOUSA, Brig. Gen. Frederick A. Bless6, who was

succeeded on 1 March by Maj. Gen. Morrison C. Stayer. The project also had

the full cooperation and support of Brig. Gen. (later Maj. Gen.) Joseph I.

Martin, MC, Surgeon, Fifth U.S. Army. The blood bank, which -,as attached

to the 15th Medical General Laboratory in Naples, under the command of Col.

Virgil H. Cornell, MC, was officially designated as the 6713th Blood Transfusion Unit (Provisional) in April 1944.

The work of this transfusion unit was so satisfactory in supplying blood

for the Fifth U.S. Army that a second, similar unit was activated for the purpose of drawing whole blood from base troops for the Seventh U.S. Army.

606222v-62-36
526 AOTIVITIES OF SURGICAL CONSULTANTS

Field and evacuation hospitals would thus be relieved of the almost imposible

burden of drawing their own blood in the large quantities needed in forward

installations, while the undesirable practice of bleeding line and servicetroops

in forward areas would also be eliminated.

The second unit, designated the 6703d Blood Transfusion Unit '(overhead, was made up of personnel withdrawn between February and April

1941 from (1) an inactivated station hospital, (2) the 1st Mobile Medical

Laboratory, and (3) the original blood transfusion unit set up in February

1944. The second unit, like the first, was attached to the 15th Medical General

Ioaboratory for instruction and training. Eventually, two other bleeding stations for this unit were set up, one near Case.-ta, Italy, and the other, after

the invasion, in Marseilles (p. 527).

The organization, training, and operation of both of these units wore

greatly facilitated by the hearty cooperation and interest of Colonel Arnest,

Surgeon, Peninsular Base Section, and Colonel Cornell. As a result of their

efforts, the 6703d Blood Transfusion Unit (Overhead) was a trained and

smoothly functioning blood bank when it was assigned to the Seventh U.S.

Army for invasion. All of its members deserve very great praise and credit

for the superb backing which they gave to Army medical units throughout the

campaign in southern France.

Before the invasion, the unit was divided into two functional sections. One

was assigned to the 1st Mobile Medical Laboratory for the invasion. The personnel of the forward distributing section of the 6703d Unit which landed

with the assault troops on D-day was attached to field hospitals for the landings. The base collecting section remained with the 15th Medical General

Laboratory in Naples until adequate facilities could be set up in France

(p. 527).

The Invasion

Personnel of the 6703d Blood Transfusion Unit (Overhead) were distributed as follows for the invasion:

An officer and an enlisted man were attached to a platoon of the 11th Field

Hospital, which w.s attached to the 45th Division. They were supplied with

seven box containers, containing a total of 188 bottles of blood. They also had

with them the main refrigeration unit on a vehicle.

Two enlisted men were attached to a platoon of the 10th Field Hospital,

which was attached to the 3d Division. They were supplied with four insulated

box containers containing a total of 144 bottles of blood and with a refrigeration unit on a vehicle.

Two enlisted men were attached to a platoon of the 11th Field Hospital,

which was attached to the 36th Division. They were supplied with seven

box containers, containing 168 bottles of blood, and with a refrigeration unit

on a vehicle.
StVTH U.S. ARMY 527

The Special Service Force (p. 518) was given 100 bottles of blood in box

coiitainers, and additional amounts of blood were placed on some of the hosp sital . is supporting the invasion. More would have been supplied if the

details ofth6e use of these ships had been known earlier (p. 518).

All of the blood to be used on D-day was loaded just before departure, and

a supply of whole blood not over 7 or 8 days old was thus assured for the

immiidi~ite needs of the invasion. In planning for supplies of blood for the

landings, fhe sound principles of combat loading were carefully observed; the

blo1d was loaded late, so that it could be taken off the vessels early, and the

supplies wvere distributed among several ships. To accomplish this required

cons iderable persuasion of both corps and division surgeons and line officers.

Through the cooperation of the Navy and the Army Air Forces, arrangements were made to deliver whole blood to the target area, beginning on D+1

and eontinuing until an airstrip could be established. The plan involved flying

blood from Naples to Corsica and then carrying it to the landing beaches by

patrol vessels, motor torpedo boats. In all of this planning, the consultant

in surgery received invaluable help from Colonel Cornell, who personally

arranged for all contacts along the route of delivery of the blood, so that delays

would be avoided. As a result, more blood than was necessary was always

available during the landings, as well as later in the campaign. Contact with

the collecting unit in Naples was maintained by daily cables and through

the couriers who accompanied all shipments of blood.

Battle casualties for the first 3 days of the landings had been estimated at

1,881. Previous experience had indicated that about 0.6 pint of whole blood

per battle casualty would be required. In addition to the small amounts provided for hospital ships, a total of 1,400 bottles of blood was provided for this

period, which was an excess of 271 bottles over the calculated need of 1,129

bottles. The surplus was regarded as essential insurance against possible loss.

Actually, battle casualties numbered 989, and nonbattle casualties, whose requirements for whole blood are generally less than those of battle casualties,

numbered 205.

Postinvasion Experiences

The Seventh U.S. Army was fortunate in landing in territory occupied

by friendly civilians. This made it possible, in October, to bring the collecting

section of the blood transfusion unit from Naples into the rear of the army

area and establish it at Marseilles, where it was located on the principal street,

and where it was shortly handling about 200 donors a day, though it had been

originally set up to draw only 100 bottles per day. A local supply of blood

was thus available to suppleme.nt what came from Naples, and, later, when

control of the Seventh U.S. Army passed from the Mediterranean theater to

the European theater, to supplement what came from Paris.

When the collecting section of the blood transfusion unit was moved to

France, this section and the 1st Medical Laboratory established a collecting
528 AMYIVITIES OF SURGICAL CONSULTANTS

unit in the 59th Evacuation Hospital at pinal. This unit, which operated for

only 3 weeks, drew and processed during this time more than 2,400 bottles of

blood. In order to use donors more efficiently during this period, group A as

well as group 0 blood was supplied to hospitals. The 375 bottles processed

were plainly labeled, and there were no untoward incidents.

Blood from the European theater reached Seventh U.S. Army hospitals

for the first time in November 1944, when the logistic support of the army

passed to that theater. The first shipment consisted of 350 bottles of blood

drawn and processed in the European theater. Still later, blood was supplied

to Seventh U.S. Army hospitals from the Zone of Interior through the European theater blood distribution organization; most of the blood used in these

hospitals eventually came from that source.

The forward distributing section of the blood transfusion unit encountered

increasing logistic difficulties in southern France from the time of the landings

until March 1945. The distances were always long. The roads, through

mountains, often were poor and frequently were snowbound and icebound.

During December 1944 and January 1945, because of the Colmar Pocket, the

front was divided into two rugged sectors. For this reason, in addition to the

run of 130 miles to the rear, to pick up the blood from CONAD (Continental

Advance Section, Communications Zone, ETOUSA) at Dijon, it was also necessary to make daily runs of 100 miles to each sector. Communications with the

base were always difficult, often uncertain, tortuous at best, and, occasionally,

impossible. After the air service had to be temporarily abandoned because of

very bad flying conditions in October 1944, it often took 2 to 4 days for the

two sections of the blood bank to communicate with each other, or to communicate with Paris through the Southern Line of Communications. It is remarkable that, in spite of these handicaps, there was never a lack of available blood.

It is equally remarkable that this result was accomplished by a forward section

that never consisted of more than one officer and five or six enlisted men and

that operated entirely with its own three trucks and two borrowed weapons

carriers.

On the other hand, poor liaison, bad roads, long hauls, and lack of adequate

refrigeration resulted in a regrettable waste of blood both by hemolysis and by

outdating. During January and February 1945, the loss by hemolysis alone

(from shaking of the containers) amounted to about 30 percent of the blood

supplied.

Early in March 1945, the supply of blood was greatly simplified when

the services of two blood distributing sections were obtained from the 127th

Station Hospital. These sections were attached to CONAD, and by CONAD

to one of the air holding units, to act as a rear blood station. By this time, an

effective means of daily communication had beeil set up with the blood bank

in Paris. The rear blooA station received all incoming blood from Paris, stored

it, and shipped the containers back to Paris. This station was now able to

care for the needs of most of the army hospitals and also the needs of the for-
SEVENTH ,U.S. ARMY 529

ward distribution section of Blood Transfusion Company 6825, which Was

attached t6 the-132d Evacuation Hospital and which provided for the needs:of

the #4pitals in the southern sector until the end of hostilities. After this

dmpiy anid the units from the 127th Station Hospital had returned to-their

parent organization s latein May 1945, the hospitals inthe Seventh U.S. Army

'became responsible for the operation of their own blood banks.

Table 14 shows the supply and distribution of blood and plasma in Seventh

U.S. Army hospitals from D-day (15 August 1944) to 30 April 1945. A total

TAnLr, 14.--Recorded receipts and distribution of blood and plasma in ,Seventh U.S. Army

hospitals, 15 August 1944-80 April 1945 1

Dlsposition of blood and plasma August 1944 September 1944- Total

April 1945

Units of blood:

Landed on D-day ............................ 800 ------------ 800

.Cotal received ............................... 2, 080 84, 640 86, 720

Distributed to--

Field hospitals ------------------------- 1,008 24, 175 25,183

Evacuation hospitals ..................... 887 32, 313 33, 200

Total ------------------------------- 1,895 56, 488 58, 383

Distributed to base -------------------------------- - 8, 558 8, 558

Used inClearing stations ------------------------ .102 89 191

Field hospitals ------.------------------ 662 17, 415 18, 077

Evacuation hospitals --------------------- 638 25, 277 25, 915

Total ------------------------------- 1, 402 42, 781 44, 183

Known to have been discarded ------------------------- 7, 958 7, 958

Patients transfused inField hospitals ----------------------------------- 4, 459 4, 459

Evacuation hospitals---------------------------- 13, 461 13, 461

Total ---------------------------------------- 17, 920 17, 920

Units of plasma used inField hospitals ---------------------------- 358 14, 081 14, 439

Evacuation hospitals ------------------------ 1,392 23,390 24, 782

Total ---------------------------------- 1,750 37, 471 39,221

tIn addition to the obvious discrepancies In this table, which are explained in the text and which are chiefly due to

inaccurate records, the amount of blood distributed in October, because of a change in the method of records and the loss

of certain records, is only estimated. It is believed that the records for the amount of blood used are reasonably accurate,

and 500 unltb were added to this amount to estimate the total amount received during this month.
530 ACTIVITIES OF SURGICAL CONSULTANTS -

of 2,080 units were received during August, including 800 units landed on

D-day, and a total of 84,640 units were received during the period September

1944 to April 1945. Of this amount, 8,558 bottles were distributed to the base,

and, according to the records, 191 bottles were used in clearing stations, 18,077

bottles in field hospitals, and 25,915 in evacuation hospitals. The records show

that 7,958 units were discarded. There is obviously a very wide discrepancy

between the amount of blood received and the amount of blood used and otherwise accounted for. This can be explained in the following two ways: (1) The

keeping of poor records, particularly the failure to record the amount of blood

used for the large number of casualties who were resuscitated in field hospitals

and then sent to evacuation hospitals for necessary surgery; and (2) the hoarding of blood which was later discarded without record, a practice which played

a particularly large part in the wastage of blood during the winter months.

Transfusion Reactions

At the request of Lt. Col. (later Col.) Ralph M. Tovell, MC, Consultant

in Anesthesia, Office of the Chief Surgeon, ETOUSA, an analysis was made

of the reactions following 7,780 transfusions on which data were available in

that office. The number of reactions recorded, 69 (0.9 percent), is regarded

as much too low. The obvious explanation, again, lies in inadequate records;

in field and evacuation hospitals, because of the heavy load of severely wounded

casualties, only the serious reactions were recorded, and minor reactions were

either missed or went unrecorded.

Blood secured in the European theater was preserved with acid citrate

dextrose solution. Blood received from the United States was preserved with

Alsever's solution which requires an excess of fluid and which is particularly

undesirable when transfusion is necessary in head and chest cases. The age

of the blood received from the United States and the early lack of refrigeration also accounted for some of the reactions which occurred. Another practical consideration was that the 1,000-cc. bottles which had to be used for blood

preserved with Alsever's solution required almost twice the amount of space

required for blood preserved with acid citrate dextrose solution.

Of the four deaths which occurred after blood transfusions, three followed

the use of blood preserved with Alsever's solution. In two of the three cases,

positive cultures were obtained from the blood which had been used; in one

of these cases, the same micro-organisms were grown in a culture of the

patient's blood. In the third case, no cultural studies were made, but the blood

had a foul odor, and hemolysis was evident when it was examined later. All

three of these patients went into profound shock after transfusion of 100 to

300 cc. of blood, and none of them responded to intensive resuscitative measures. All three, unfortunately, had had smooth and uncomplicated postoperative courses and were transfused merely to elevate the blood level before

evacuation.
SEVENTH U.S. ARMY 531

The fourth fatality occurred 3 days after the transfusion of 1,500 cc. of

blood. Other causes perhaps played some part in the fatality, but the severe

henolytijdreaction was unquestionably a contributory cause.

Medical officers from certain field and evacuation hospitals, especially the

9th and 61st Evacuation Hospitals, were particularly interested in transfusion

reactions, the problem of anuria, and the use of type-specific blood in patients

who required repeated transfusions. Their comments and suggestions were

most helpful, and the records in these hospitals were particularly accurate.

SUPPLY AND TRANSPORTATION

Lt. Col. Augustus J. D. Guenther, MAC, Chief, Medical Supply Branch,

Office of the Surgeon, Seventh U.S. Army, and the 7th Medical Depot Company deserve the highest praise for their efficient cooperation in the procurement of supplies for army hospitals. Many items in excess of basic allowances,

such as suction apparatus, portable orthopedic tables, anesthesia apparatus, and

laboratory equipment, were approved for issue by Colonel Rudolph, Surgeon,

Seventh U.S. Army, and were supplied because their use would enhance the

professional care of patients.

One service performed by the Medical Depot deserves special mention,

the maintenance of surgical equipment, including sharpening and repair of

instruments and repair of suction apparatus, sterilizers, and other essential

equipment. Their repair had been a difficult problem in North Africa. Instruments and apparatus turned in for repair or salvage lay about on shelves or

floors for weeks and sometimes were never returned. Sometimes, unacceptable

substitutes were received in place of the original equipment. At that time,

it was often simpler for hospitals to invoke the services of the Ordnance Corps

for repairs than to try to have the work done by Medical Supply, whose rightful function it was. Problems of this kind did not arise in Seventh U.S. Army

hospitals.

Trapsportation for semimobile (400-bed) evacuation hospitals was basically adequate. The 750-bed evacuation hospital was not intended to be semimobile but could have been made so if sufficient trucks had been provided. It

is only fair to add, however, that all shortages of transportation were not

attributablq to shortages in the basic allotment but were due to the number of

extras, captured accessories, and other excess items being moved by the hospital

unit.

THE OPTICAL PROGRAM

Capt. (later Maj.) David B. Solouff, MC, ophthalmologist with the 9th

Evacuation Hospital and a diplomnate of the American Board of Ophthalmology, laaded with the Seventh U.S. Army consultant in surgery on D-day and

served throughout the campaigl as an unofficial consultant in 'Ahthalmology.
532 ACTIVITIES OF SURGICAL CONSULTANTS

He visited all evacuation hospitals in the army area twice, discussing with the

ophthalmologists on their staffs the problems of outpatient work, special surgical problems, and the efficient use of the optical repair unit. As new hospitals came into the army area, he evaluated the ophthalmologists on their

staffs and advised concerning their training and capabilities. His work was

of great value and was of great assistance to the surgical consultant.

The optical program for the repair or replacement of broken or lost

spectacles is an excellent illustration of the detailed medical planning necessary for an invasion. From conversations with Brigadier Sir Stewart DukeElder, Consultant in Ophthalmology to the British Army, the surgical consultant had become fully aware of the importance of the prompt repair or replacement of spectacles. On one occasion, early in the campaign in North

Africa, a replacement pool of 3,000 British troops had been held outside of

Cairo solely because their broken or lost spectacles had not been repaired or

replaced. For the same reasons, it was later necessary to evacuate a large

number of men from the Anzio beachhead.

In the planning of the medical program for the invasion of southern

France, arrangements were th refore made for the early landing of a mobile

optical repair unit, which was in operation, with complete services on D+4.

Many persons are completely incapacitated or seriously handicapped without

their glasses, and it is natural that soldiers should desire to escape danger and

avoid hazardous duties. For these practical reasons, the provision for the

mobile optical unit so soon after the landings conserved a considerable amount

of military manpower.

Circular No. 16, Seventh U.S. Army, dated 4 September 1944, directed

that prescriptions for glasses and Government-issue glasses for repair should

be sent to the 7th Medical Depot Company. The circular also provided that

soldiers who were completely incapacitated without glasses (those with vision

less than 20/200 O.U.) should remain in the hospital and that their glasses

should be repaired on a first priority list. Later, one of the evacuation hospitals was designated as an alternate official collecting and distributing center

for broken and lost spectacles, the glasses being sent to this hospital or to the

medical supply depot, whichever was most convenient.

Colonel Guenther displayed a constant interest in the optical repair unit

and made many helpful suggestions concerning it. The unit, which was

under his operational control, deserves great credit for the promptness and

efficiency of its work. From 15 August 1944 until the end of May 1945, 12,921

pieces of work were completed, and a daily average was maintained of 24

new pairs of spectacles and 6 repair jobs.

All evacuation hospitals were equipped with a trial lens case, in excess of

tables of equipment. The load of refractions was at no time excessive, though

some hospitals occasionally questioned the necessity for them.
SEVENTH U.S. ARMY 533

EDUCATION AND TRAINING

It was routine practice in the Seventh U.S. Army, whenever a new unit

designatdl for the care of combat casualties came into the army area, for it to

udrgq a period of training before it became operational. First of all, the

consultant in surgery for the army visited it while it was staging and discussed

miajor problems of personnel and procedure with the appropriate medical

officers. Then, one of the following two plans was carried out:

1. The new unit was reinforced by experienced surgical teams, the senior

member of one of the teams being designated as temporary chief of the surgical service of the hospital.

2. A key geoup of surgeons, nurses, and enlisted personnel from the new

hospital was exchanged, for periods of 2 or 3 weeks, with a similar group from

one of the older and more experienced hospitals. By this plan, a double type

of teaching was provided, first by the older group attached to the new hospital,

and second by the members of the more experienced hospital to which personnel from the new hospital were temporarily attached.

In addition to these formal plans of training, arrangements were made

with nearby general hospitals for members of the staffs of newly arrived evacuation hospitals to visit them frequently, observe the wounded as they were received from the forward area, and witness the initial wound dressings and

certain reparative procedures.

Experienced teams from auxiliary surgical groups were attached to new

field hospitals, to instruct their staffs in procedures in the field. Lt. Col.

James M. Sullivan, MC, 2d Auxiliary Surgical Group, who commanded the

detachments of auxiliary surgical groups attached to the Seventh U.S. Army

for the duration of the campaign in Europe, frequently visited the new hospitals, to instruct and assist their personnel.

The training supplies for medical officers of the First French Army has

already been described (p. 524).

As far as was practical in an army area, all hospitals were encouraged

to hold staff meetings. Three meetings of the Vosges Medical Society, Seventh

U.S. Army, were arranged by the army surgeon. The subjects discussed at

these meetings were, respectively, penetrating wounds of the knee joint,

neuropsychiatric problems, and resuscitation and traumatic shock. The meetings were all well attended, and discussions were free and fruitful.

Medical officers in the Seventh U.S. Army were encouraged to produce

reports for publication. The response was good. The 93d Evacuation Hospital submitted a report on intra-abdominal wounds. The 9th Evacuation

Hospital prepared reports on neurosurgical problems and injuries of the knee

joint and was preparing reports on intra-abdominal wounds when the medical

meeting for which the papers were intended had to be canceled for reasons

of combat. The 117th Evacuation Hospital presented an excellently worked up

symposium on severe burns; the studies included detailed data on blood volume
534 ACTIVITIES OF SURGICAL CONSULTANTS

hematocrit, hemoglobin, red and white blood cell counts, plasma proteins, and

blood chlorides. Members of the 2d Auxiliary Surgical Group prepared

pipepr on the differential diagnosis of abdominal injuries, the application of

the principles of war surgery to thoracic injuries in civilian life, the early

closure of soft-part defects by skin grafts, and wounds of the heart.

The surgical consultant to the Seventh U.S. Army presented a paper on

wounds of the knee joint at a MTOUSA medical meeting in Naples in January

1945 and another on wounds of the chest at the 819th Hospital Center in

Verdun in April 1945. At the request of the editor of the ETO USA Medical

Journal, he prepared a paper on surgery in the field for wounds of the abdomen.

The consultant in surgery also attended three meetings of the U.S. and British

Army consultants, two in Paris a..4 one in Brussels.

MEDICAL UNITS

As has already been pointed out, all of the hospital units assigned to the

Seventh U.S. Army for the invasion of southern France, with the single

exception of the 51st Evacuation Hospital, had seen service in previous campaigns in the Mediterranean theater. The 51st Evacuation Hospital compensated for its lack of experience by an excellent and carefully selected staff.

Five of the other six evacuation hospitals had participated in the North African,

Sicilian, and Italian campaigns, and the 27th Evacuation Hospital had had

some experience in Italy, while acting as a general hospital for the care of

French troops. All of the field hospitals were experienced, and all were augmented by experienced teams from the 2d Auxiliary Surgical Group.

During the fall and winter of 1944-45, several new field and evacuation

hospitals were assigned to the Seventh U.S. Army. The field hospitals included the 54th, and 66th, and the 81st Field Hospitals. The evacuation hospitals included the 112th, the 116th, and 117th, the 127th, and the 132d Evacuation Hospitals. The 57th and 64th Field Hospitals and the 103d Evacuation

Hospital were also assigned to the Seventh U.S. Army for varying periods

of time.

These hospitals varied in their experience and professional competence.

The 54th Field Hospital and the 103d Evacuation Hospital had served with

the Third U.S. Army. The 57th Field Hospital had functioned as a station

hospital. The other hospitals were fresh from the Zone of Interior and had

had little training as integrated units. Moreover, their professional staffs had

been provided hurriedly just before the hospitals were sent overseas, and, as

a result, inadequately trained and inexperienced medical officers were serving

as chiefs of services and as senior surgeons.

The 81st Field Hospital and the 127th Evacuation Hospital, which arrived

in the theater in March 1945, designated at first to care for prisoners of war

and displaced persons, were assigned later to German concentration camps.

They therefore did not require as numerous personnel changes or as close

supervision as hospitals assigned to the care of combat casualties.
S~3ENT U,. ARtMY55

SMe4sure,s were at once taken to train the new'hospitals and instruct them

ini thengeerkal principles of miiitary surgery. This was ehiefiy done~by ef,- fectihg exonanges of personnelbtweenthemand the more experienced evacuatidr ho pita s. Even these changes did not bring the inexperienced ,units up

to the ileve of more experienced organizations. This was respecially true of

the organizaftions that arrived in 1945. The theater could not supply the,

deficienies in personnel, for just at this time, to complicate matters, the Chief

Surgefii ETOUSA, was calling on the hospitals in the army area for experienced surgeons to take charge of surgical services in newly arrived general

hospitals in the Communications Zone.

Field Hospitals

The employment of field hospitals in southern France, both in the landings

and later, followed the plan by which they had been employed with such great

success in the Fifth U.S. Army. Difficulties of relationship were encountered

in only one division, whose medical officers took, or seemed to take, the position

that the field hospital was encroaching upon the rights and duties of the clearing

station. This particular division sometimes left the field hospital to fend for

itself, and it did not always choose sites for it which would place the hospital

and the clearing station in the close proximity to each other required for each

organization to perform the most efficient possible work. As a matter of fact,

there is never any quarrel between these two types of organizations; their duties

are clearly defined and sharply differentiated.

Although field hospital platoons were permitted to operate with as many

as 50 beds each, it was found in the Seventh U.S. Army that the more nearly

the census could be kept to 30 beds the better the hospitals functioned and

the more mobile they were.

The work of field hospitals was limited to the care of nontransportable

casualties. About half of these casualties could be sent back to evacuation

hospitals after examination and resuscitation, though to maintain this proportion required careful evaluation and triage. The casualties who were retained and cared for in the field hospital were chiefly those with wounds of

the abdomen and chest and major traumatic amputations (table 15). These

casualties received prompt and expert care. Field hospitals in the Seventh

U.S. Army were never employed as forward evacuation hospitals. Instead,

they were used as a useful screen for the evacuation hospitals, increasing the

ability of these hospitals to handle the main surgical load.

Evacuation Hospitals

The chief function of evacuation hospitals was the performance of initial

wound surgery. All the evacuation hospitals in the Seventh U.S. Army rendered daily reports, as of midnight, concerning their surgical status; that is,

the number of patients awaiting surgery and the number of hours estimated
'53 ACI~VITIES OF SURGICAL CONTSULTNTS'

tmmt -it.-Summary of casualies, by, body area, *reated in field hospital in Seventh U.S.

Army, December 1944-April 19461

Preoperative deaths Postoperative Total deathsAdmis. Olera; deaths 

Body area sonsons

Number Percent Number Percent Numbei Pereent

Abdomen ---------- 1,164 33 2.8 965 221 22. 9 254 21. 8

Thorax ------------ 1, 459 37 2. 5 502 79 14. 1 116 8.0

Thoracoabdominal-.-. 306 8 2. 6 272 82 30. 1 90 29. 4

Head ................ 183 30 16.4 21 3 14.3 33 18 0

Spine ................ 42 3 7. 1 14 7 50.0 10 23. 8

Upper extremity ------ 200 -------------- 90 1 1. 1 1 .5

Lower extremity ------ 699 13 1.9 347 37 10.7 50 7.2

Other ---- _-------- 110 1 .9 11- .......------ 1 .

I The figures in this table present a fair sampling of the type of work done In field hospitals and of the results achieved.

The lower ease fatality rates in table 16 can be explained by the fact that the work presented In it was done In both field

and evacuation hospitals, the work in evacuation hospitals having the diluting factor of having been done upon transportablo casualties who were less seriously wounded than those operated on in field hospitals.

as necessary to clear up the backlog (surgical lag). A continuing effort was

made to equalize the loads of the evacuation hospitals and to prevent tle surgical lag from exceeding 8 hours, though this objective was naturally impossible

of attainment in periods of sustained offensives, when casualties were heavy

and hospitals moving rapidly.

Control of the surgical lag was, for all practical purposes, a matter of

traffic regulation. A liaison officer, or a representative of the ambulance company who was either a commissioned or a noncommissioned officer, was stationed at each evacuation hospital, to control the flow of patients. When he

saw the surgical lag becoming excessive, he took action to remedy it upon

the advice and at the request of the chief of surgery. Several expedients

would be employed. Priority II patients who could not return to their duties

within the holding period of the army would be sent to general hospitals if

they were transportable, particularly if, by the transfer, they would receive

surgery earlier than in the evacuation hospital. A second possibility was a

request to the Commanding Officer, Detachment 2d Auxiliary Surgical Group,

to send whatever teams might be available to the evacuation hospital to help

clear up the backlog.

Still another possibility was the diversion of casualties to hospitals in

another army corps area. In times of stress, the representative of the ambulance company was not too closely confined by corps boundaries. Hospitals

supporting different corps were often located close to each other, and it was

only reasonable, if one hospital was overloaded, to divert patients to another

whose work was lighter. Elasticity of services, resourcefulness of chiefs of

surgery, evatmation officers, and liaison personnel, and coordination of administrative functions and professional services did much, in these circumstances,

to decrease the surgical lag and insure earlier surgery for the wounded.
SEVENTH, U.S. ARMY 537

This whole concept was admirably stated in War Department Technical

Bulletin (TB MED) 147, Notes on Care of Battle Casualties, dated March 1945:

a. Tli i'e present necessity for evacuation of the wounded to the rear is in fundamental conflict with ideal surgical management of the individual patient. To minimize

this conflict, 'close coordination between the functions of administration and professional

eervcea. required. It Is the responsibility of the medical officer charged with the surgical

man agenient of the patient to place technical procedures properly, both in time and in

space, with due regard to the tactical situation on the one hand and to the welfare of

the patient on the other. Unless the surgeon visualizes his position and the function

of his hospital in relation to other surgeons and other hospitals, he may become confused

in the mission he is to perform. Although some needed operation may be performed

correctly, the military effort may be impeded and unforeseen harm done to the patient

if the operation is done at the wrong time or in the wrong place.

b. It is the responsibility of administrative officers charged with the establishment

of evacuation and hospitalization policies to adapt the schedules of movement of patients

to the maintenance of highest standards of surgical treatment. Priority of movement must

be accorded to patients with certain types of injuries just as the duration of hospitalization

in a given zone must be differentially adjusted to the urgent surgical needs of the patients.

Auxiliary Surgical Groups

The teams which participated in the landings in southern France in

August 1944 were all from the 2d Auxiliary Surgical Group (p. 505). In

November 1944, additional teams, all from the 1st Auxiliary Surgical Group,

were assigned to the Seventh U.S. Army. This component consisted of eight

surgical teams, two shock teams, two orthopedic teams, one thoracic-surgical

team, one neurological team, one maxillofacial team, one dental-prosthetic

team, and one X-ray team. These newly arrived teams were immediately

attached, for operations and administration, to the detachment of the 2d Auxiliary Surgical Group already in the theater. Later, four surgical teams,

two thoracic-surgical teams, one orthopedic team, one neurosurg'cal team, and

one X-ray team, also from the 1st Auxiliary Surgical Group, were also assigned

to the Seventh U.S. Army.

In order to facilitate their assimilation, new teams from the 1st Auxiliary

Surgical Group worked, at first, with experienced teams of the 2d Auxiliary

Surgical Group. Some of the new teams required considerable instruction. It

was provided by this plan, as well as by the tireless efforts of Colonel Sullivan,

Commanding Officer, 2d Auxiliary Surgical Group Detachment. The temporary union of components of two different auxiliary surgical groups proved

a very wise plan. The groups served as a stimulus to each other. Some of

the new teams had never before worked in field hospitals, and some teams

which had had this experience were accustomed to being shifted about much

more frequently than was the practice in Seventh U.S. Army hospitals.

Originally, some thought had been given to assigning an experienced

surgeon from each team as commanding officer of each field hospital unit.

The idea was abandoned, chiefly because it would have reduced the number

of available teams, all of which were needed. Much the same end was
538 ACTIVITIES OF SURGICAL CONSULTIANTS

attained, and attained in a more effective fashion, by leaving the teams with

the same field hospitals as long as possible rather than shifting them from

hospital to hospital. In this way, a spirit of cooperation, and of semipermanenice at least, was created.

An excellent source of instruction for both new and experienced teams

was provided by the monthly autopsy reports. After the surgical consultant

had studied these reports in his own office, they were forwarded to the

teams which had handled the particular cases, with his own comments and

with whatever additional details could be obtained.

In Seventh U.S. Army hospitals, all auxiliary surgical group teams were

used as they were constituted, the nurses assigned to the various teams remaining with them permanently. In the First U.S. Army, nurse assistants assigned

to the teams were apportioned among field hospitals and allowed to remain

with them. The teams were then reconstituted, so that each consisted of four

officers, including an anesthesiologist, and four enlisted technicians. The Surgeon, First U.S. Army, considered that the rearrangement increased the capacities for work of the whole group, which was essential with the heavy load

of casualties cared for in hospitals in this army. The plan obviously has much

to commend it, including the advantage of making life somewhat easier for the

nurses.

Neurosurgical and maxillofacial teams were of maximum usefulness in

evacuation hospitals and were usually attached to these installations. Other

teams from auxiliary surgical groups, or their counterparts, served with field

hospitals. If evacuation hospitals required assistance during rush periods

or for other reasons, the necessary teams from these groups were temporarily

attached to them. A surgical or thoracic-surgical team and an orthopedic

team were usually attached to newly arrived evacuation hospitals for a week

or two after they became operational.

Surgeons from the teams of the auxiliary surgical groups, as well as the

teams themselves, were frequently given special assignments. Thus, one senior

surgeon acted as chief of surgery in a Seventh U.S. Army evacuation hospital

for 2 months. Another surgeon from a thoracic-surgical team spent 4 months

on an exchange basis in an evacuation hospital, both to furnish instruction in

thoracic surgery to the hospital staff and to permit two surgeons from the staff

to see service in a field hospital. A maxillofacial and a thoracic-surgical team

spent 3 months building up these special services in a busy general hospital.

An X-ray team was permanently attached to an evacuation hospital that had

lost its radiologist. Members of a surgical team were flown into Crailsheim,

Germany, when the 10th Armored Division was temporarily surrounded. One

team supported the 13th Artillery Brigade, First French Army. Another

team was dispatched with a task force which had bottled up pockets of the

enemy in Bordeaux and western France in April and May 1945.

In retrospect, it appears to this consultant that a number of changes

might have improved the functioning of the teams of the auxiliary surgical
41, ARMY

TA LU 6.-u-inunag ofcasualtis, by. body area, trea'td by tedmt of let and d Auxiliary.

Sircal:.Giro5 in ,Seventh U., Army hospitals, ! A4ugust 1944-9 May 1946

Jiody atea. Operations Deaths- cae fatality ,

rto'

Abdomen------------------------------ - 1, 343 266 1.8'

T ibrd Thrx--------------------------------- na ....................... ----- 655, 43, 6 5,4Od

Thorcoabdonnal- ------------------------ 520 92 17.7, : e~ ................................... 362' 30 9A

M-lad------ii----------------------------- 316 360 S pi MxlocIa------------------------------ .a.e. ..... .... .... .... .... ... 14 126 0 2 1A0 14. 3

Up~ . ................. 501 9 1. 8

LW,....------------------------------------ 1,023, 34 3.3

Oither.--............................ 465 15 3,2

T t.----------------------------- 5,009 497 O.9

groups, Personnel of the teams might have been better balanced. There

should' havebeen, for example, a larger number of shock teams, at least two

forevery field hospital of three separate platoons committed to action, or at

least two shock teams per division, based on a concept of one field hospital

per division.

Orthopedic teams would have been more useful at the evacuation or general

hospital level than in field hospitals. Definitive surgery on the extremities is

not performed in field hospitals to any great extent, and orthopedic surgeons

are not usually experienced in the type of surgery performed in them, Field

hospitals need, above all else, surgical, thoracic-surgical, and shock teams.

X-ray teams did excellent work in augmenting the organic radiologic

personnel in the hospitals, but it is questionable whether X-ray equipment is

necessary for every team. Frequently, when the load of casualties is heavy,

extra hands are needed, not extra equipment.

Statistics showing the work performed by the teams of the 1st and 2d

Auxiliary Surgical Groups iuring their service with the Seventh U.S. Army

are presented in table 16.

Convalescent-Type Facilities

The primary mission of the Army medical services in forward areas, as

set forth in aforementioned TB MED 147, is twofold, as follows:

1. They must care for battle injuries and must care for, as well as prevent

and minimize, nonbattle injuries and illness. All casualties must be given

the best possible care, and, at the same time, hospital bed space must be conserved and the maximum number of casualties must be restored to duty.
540 ACTIVITIES OF SURGICAL CONSULTANTS

2. In order to maintain mobility and keep hospital beds free for future

casualties, prompt evacuation of the long-term sick and wounded from the combat areas is essential.

Convalescent-type hospitals, set up in the army area, lighten the strain

on army hospitals and at the same time facilitate the return of sick and lightly

wounded men to duty. Convalescent-type hospitals, as already mentioned, also

care for neuropsychiatric patients and for patients with venereal disease.

In the Seventh U.S. Army, a clearing station was utilized for these purposes

after the landings until authorized convalescent hospitals arrived. The experience in southern France proved that the prompt provision of a facility of

this type was essential. The utilization of army medical collecting and clearing

platoons (collecto-clearing platoons) solved the problem very satisfactorily. If

these facilities had not been provided at once, lines of evacuation would have

been further strained, and many men who were returned to duty within a few

days would have been evacuated from the army area and would, perhaps, have

been permanently lost to combat duty.

STATISTICAL DATA

Admissions, Deaths, Distribution of Wounds

During the course of the campaign in Europe, this consultant in surgery

personally collected data on a total of 55,085 battle-incurred casualties treated

in Seventh U.S. Army hospitals. These data were secured by providing, before

the invasion, for their submission to the consultant at specified intervals (p.

507). They are not, of course, entirely accurate, and they differ, as personally

collected statistics always differ, from official data. It is believed, however, that

they are sufficiently reliable to permit certain conclusions to be drawn from

them. They also show the volume of work handled in the various medical

units of the Seventh U.S. Army. Most of them need little comment.

Table 17 shows the monthly distribution of admissions and deaths in the

army hospitals and clearing stations for the whole period of the campaigns in

France and Germany.

Tables 18, 19, and 20 show the distribution of admissions and deaths according to body area in Seventh Army field and evacuation hospitals. Table

21 shows the distribution of wounds according to body area based on division

reports. Although the opportunities for careful examination of casualties in

division medical facilities are less good than in other hospitals, the agreement

between table 21 and table 18 is surprisingly close.

Table 22 shows the percentage distribution of wounds according to body

area in the Mediterranean and European theaters in World War II in comnpari.

son with the distribution in other wars in United States history. The only

notable discrepancy, that in the percentage of chest wounds in World War I,

can probably be explained by the onmission from this group of cases of injuries

of the shoulder girdle.
A SEEtkHVTh. ARMY54

hi,* 17.-MAfthly dislribulioh of hospital and, clearing station -admissions and dah, .. Seventh U:'S. Army, ,15 August 1944-7 May 1945

k dmissions Deaths

'" " ' M6hth .... __ _ _ __ _ _- ~ -__ _ _ _ - -

- - Casualties, Noncombat Disease Hospital Clearing Total, injuries station

14944:

3, 1i26 1,179 4,948 68

Sel*tein' ...... 3;'948 1,398 7, 221 93 9 102

............- 7,203 1,861 10, 208 189 24 21T

m Lr ....... 7, 217 2, 779 11, 564 192 14 20

Decembbr- .......... 7, 847 3, 857 11, 939 179 31 210

... anuary............--, 566, 5, 444 13, 890 176 35 211

Febrd ar....... 5,100 3, 283 13,583 126 24 150

Mafbh ............... 8,046 3,383 14, 375 208 30 238

0pi1- ----------- 8, 834 3, 796 12, 656 291 79 370

Total ......... 60, 887 26, 980 100, 384 1, 454 246 1, 768.

I Note that this total exceeds the sum of the deaths for hospitals and clearing stations because there is no breakdown

for August 1944;.

Source,, Reports of Casualties (WD MD Form No. 861) and Combat Statistical Reports (ETO USA MD Form-No,

323).

TAsLE 18.-Ditribution by type of hospital and body area of 65,085 battle-incurred wounds in

Seventh U.S. Army hospitals

Battle-Incurred wounds

Body area _

Field hospitals Evacuation hospitals Total

Number Percent Number Percent Number Percent

Abdomen -------------------- 1, 299 26. 0 906 1.8 2, 205 4. 0

Thorax ---------------------- 1, 675 33. 6 2, 645 5. 3 4, 320 7. 8

Thoracoabdominal ------------- 264 5. 3 187 .4 451 .8

Head ------------------------ 188 3.8 3,163 6.3 3,351 6.1

Maxillofacial ------------------ 111 2. 2 3, 211 6. 4 3, 322 6. 0

Spine -------------- _------- 49 1.0 371 .7 420 .8

Upper extremity --------------- 285 5. 7 14, 174 2& 3 14, 459 26. 3

Lower extremity --------------- 860 17. 2 21,044 42. 0 21, 904 39. 8

Other ------------------------ 260 5.2 4,393 & 8 4,653 & 4

Total ------------------ 4, 991 100. 0 50, 094 100. 0 55, 085 100. 0
542ACUTIVITIES'OF SURGICAL CONSULTANfTS'

TApLic 19.w-Caae fatality rates accurding to type-of hospital and bodyi area in 665 bti.

incurred wounds in'Seventh U.S. Armyhospitali

Case fatality rae

Blody area- ____- Field Evacuation Total hospitals, hospitals

Abdomen ----------------- --- 24. 6 11. 5 16.2

Thork;_x------------------------------------8 &7 31.3 :&,4

Thoiacoabdominal----------------------------- 26.5 15. 0 21.17

d-----------------------------------18.6 ... 8.8 9. 1

Maxillofacial --------------------------------- 2. 7 . 7 'A8

Spine -------------------------------------- 20.4 81 935

Extremities---------------------------------.... 5.0 .3 .1

Other -------------------------------------- 8. 5 .7 1,1

TAIILx 20,-Distribution, according to type of hospital and body area, of 1,860 deaths in 55,085

combat-incurred wounds in Seventh U.S. Army hospitals

Deaths

Body area________-____ ___ - __ ____

Field hospitals IEvacuationt hospitals Total

Number Perea Number Perccnt Number Perests

Abdomen-------_----------- 310 48. 3 104 14. 9 423 31. 1

Thorax ---------------------- 14A6 22. 1 88 12. 6 234 17. 2

Thoracoabdominal ------------- 70 10. 6 28 4. 0 98 7. 2

Read ------------------------ 34 5. 1 272 38& 9 306 22. 5

Maxiliofacial------------------ 3 . 5 24 3. 4 27 2. 0

Spine---------- -------------- 10 1.5 30 4.3 40 2.9

Extr-mities-------------------- 57 8. 6 122 17. 5 179, 13. 2

OW s------------------------ 22 3.3 31 4.4 53 3.9

Total ------------------ 661 100. 0 699 10-0. U 1, 360 100. 0

The most striking point in these tables is the extraordinarily low case

fatality sate, 2.5 percent, in a war characterized by the use of enormously dest.active weapons. The good results can be attributed to a combination of

factors, beginning with the alertness, intelligence, and resourcefulnes of the

enlisted aidinen. of the Medical Departmlent, on the battlefield and ending with

expert and devoted nursing care on the part of the Army Nurse Corps, supplement'ed by the work of wvardinasters ar (I other nonprofessional ward personnel. From the surgical standpoint, a variety of factors must be taken into

account, including an excellent regimen of resuscitation and postoperative management, with special emphasis on whole blood transfusions; excellent anesthesia; and the administration of penicillin and the sillfonamides as adjunct

measuies. None of these cor-iderations, however, equaled in importai~ce the

perlormnance of good surgery by well-trained and experienced surgeons.
SEET .. ARMY, 548,

TkDLU'21e-Dietribuion, by body aria, of 48,099 wounds in Seventh U.S. Army casualties,,

-according io divsion reports I

,, " Body *. .Wounds ares,,

Number Percent

Abdi6mn -----------.................................... 1, 607 3. 3

Th- - .- . - .- . -'- . - . - .3, - - 281 6. 8

Thorialoabdominnal....................................... 373 .

ead ........-. .......................................... 3, 350 6 9

xlfal-........................................... 3, 045 0. 3

SPne----------.----------------------------------- 293 .

Upper extremty ........................................ 12, 765 26. 4

Lower extremity ......................................... 18, 427 38 2

Other .................................................. 5,158 10. 7

Total ............................................. 48, 299 100.0

I This table should be compared with table 18. These data were reported by divisions In which opportunities for

careful examination were less good than In hospitals, yet the agreement between the distribution of wounds In the two

tables Is surprisingly close,

TAILE 22.-Percentage di8tributions of body area and of wounded- or injured-in-action ca8es,

by anatomic location, U.S. Army, in the Civil War and World Wars I and II

World War 11

Anatomic location Body World Civil area l European Mediter. War I I War'

Total S theater 3 ranean

theater '

Head, face, or neck ------------- 12.0 14.7 13.6 14. 0 11.4 10.7

Chest ---------------------...- 16.0 10.4 10.7 10.2 3.6 11.7

Abdomen -------------........ 11.0 5.6 5.3 4.7 3.4 6.7

Upper extremity -------------- 22. 0 27. 9 27. 4 29. 2 30. 2 35. 7

Lower extremity -------------- 39. 0 41. 4 43. 0 41. 9 45. 4 35. 2

Total ------------------- 1 00.0 100.0 100.0 100.0 100.0 100.0

I Based on a study by Burns and Zuckerman of the surface area o' *he human male body. The percentages sloan

represent proportions of total body area. Based on consolidations of various Army and theater reports and spedal studies encompassing some 460,000 wounded

or injured In action.

3 Based on consolidations of data from the First, Third, Seventh, and Ninth U.S. Field Armies.

, Based on experience of the Fifth U.S. Army during 1944.

Distributions based on number of mounds, not wounded men.

Source: Medical Statistics )ivision, Office of the Surgeon General, Department of the Army.
544 ACTIVITIES OF SURGICAL CONSULTANTS

Ballistics

It is curious, in view of the interest always evinced in the causative agents

of combat-incurred wounds in all wars, that the figures for all recorded wars.

should be so grossly unreliable on this point. In an endeavor to improve this

situation, it was requested that pertinent data be submitted each month by division clearing stations, from which, it was believed, the most accurate information could be secured because casualties are first observed in them and are most

likely then to give a correct account of their injuries.

Of the more than 50,000 casualties whose wounds were analyzed from this

standpoint, about one-quarter had sustained their wounds from small arms fire,

and about three-quarters from high explosives. Wounding agents in 50,204

battle-incurred wounds were recorded by Seventh U.S. Army division clearing

stations, as follows:

Woundit g agent

Bullets: Wounds

Unspecified -------------------------.---------------------- 4, 790

Rifle --------------------------------------------------------- 5, 882

Machinegun --------------------------------------------------- 1,774

Total ------------------------------------------------------- 12, 446

High explosives:

Shell (artillery) --------------------------------------- 5,389

Mine --------------------------------------------------------- 1,868

Blast concussion ----------------------------------------------- 1, 711

Bomb -------------------------------------------------------- 557

Boobytrap ---------------------------------------------------- 81

Grenade ------------------------------------------------------ 22

Unspecified --------------------------------------------------- 28,130

Total ------------------------------------------------------- 37,758

Grand total ------------------------------------------------- 50,204

In Fifth U.S. Army hospitals, the relative proportions were 18 percent and

78 percent; no information was available on this point in the other armies.

Forty-three wounds caused by bayonets and other cutting weapons are not

included in Seventh U.S. Army data.

Of the 251 deaths which were reported among the 50,204 battle-incurred

injuries analyzed, 72 (28.7 percent) were caused by small arms fire and 179

(71.3 percent) by high explosives. These percentages correspond rather

closely with the percentages of wounds caused by each type of weapon. The

case fatality rate for small arms fire injuries was 0.57 percent and for high

explosive injuries 0.47 percent.

Changes in the distribution of causative agents as the war progressed

reflected the changing type of combat. In December 1944, 21 percent of the

casualties were caused by small arms fire and 79 percent by high explosives.
S§EVENTH U.S. ARMY 545

As the bi'eakthrough in the late winter and spring of 1945 became more and,

moecomplete and as the Germnan Army progressively disintegrated, sniping,

kesistance, by localized groups, -and, guerrilla, tactics took the place of organizdwarfare. As a result, there was an increase in the proportion of wounds

caused by small arms fire. In April 1945, in contrast to the December 1944

figures, 40-percent of the casualties were caused by small arms fire and 60

percent by high explosives.

Returns to Duty

The proportion of patients returned to duty from forward installations

is shown in tables 23, 24, and 25. The total number returned to duty was 40

percent, the proportions for disease, non-combat-incurred injuries, and combat-incurred'injuries being, respectively, 50 percent, 36 percent, and 16 percent.

TABLm 23,-Hospital and clearing station admissions and dispositions, Seventh U.S. Army,

15 August 1944-7 Mlay 1945

Vause for admission Direct admis. Returned to duty Evacuated

sions

Number Number Percent Number Percent

Disease-------------------------.. 103, 797 58, 350 56 39, 401 38

Nonbattle injury ----------- _-------29,09 10, 707 36 19, 303 64

Battle Injuries or wounds.----- 63, 245 10. 017 16 49, 040 78

Total ----------------------. 197, 011 79, 074 40 107, 744 55

Source: Reports of Casualties (WD SID Form No. 86f) and Combat Statistical Reports (ETOUSA AID Form No.

323).

TABLE 24.-Returns to duty from clearing stations and hospitals, Sevfnth U.S. Army,

1 September 1.944-30 April 1945

Month Clearing sta- Hospital Total tion

1944

September-------------------------------------- 1, 28i 5, 266 6, 547

October---------------------------------------- 1,830 5,954 7,784

November----------------------------------------- 2, 801 5, 739 8, 540

December ------------------------------------------ 4,627 6, 104 10, 791

1945

January------------------------------------------- 4,354 6,090 10,444

February ----------------------------- ---------- 5,709 6,369 12,078

March---------------------------------------I 1 ,3 5,274 9,813

April ------------------------------------------ 3,144 5,330 8,474

Total----- ---------- --------------------- 28, 285 46, 186 74, 471

Source Reports of Casualties (WDI) MD Form No. 861) and Combat Statistical Reports (ETOUSA 'MD Form

No. 323).
546. ACTIVITIES OF SURGICAL CONSULTANTS

T-Abi 25.-Returns to duty from 400- and 750-bed evacuation hospital8 in Seventh U.S. .Army

for a Belected 8-month period

Hospital Admisions Returns to duty *

400-bed hospitals: Number Number Pen*€

11th Evacuation ----------------------- 4, 343 691 "15. 9

93d Evacuation ---------- _------------ 4, 750 831 17.'5

95th Evacuation -- _----_---------------- 4, 728 754 15. 9

Total ...................................... 13, 821 2, 276 16.0

750-bed hospitals:

Oth Evacuation ................................ 4, 573 084 21. 5

51st Evacuation ............................... 5, 310 1, 053 19. 8

59th Evacuation --------------------------..... 8, 918 2, 040 22. 9

Total ------------------------------------- 18, 801 4, 077 21. 7

A number of suggestions were made concerning the alteration of medical

facilities within the army area, or the increase of the facilities then provided, so

that the percentage of returns to duty could be increased, with, at the same time,

the conservation of medical manpower. These suggestions included special

medical evacuation hospitals; special neuropsychiatric hospitals; the assignment of small surgical hospitals to each division; the provision of evacuation

hospitals of uniform size (400 to 600 beds); a greater use of 750-bed evacuation

hospitals; reorganization of the intrinsic staffs of evacuation hospitals by a

reduction in personnel, to be compensated for by a wider use of auxiliary surgical teams; the use of an army field type of general hospital; and the conversion

of convalescent hospitals into smaller, more mobile units or companies.

There is no doubt that, under certain tactical conditions, an increased utilization of smaller and more mobile hospitals of the convalescent type would increase the percentage of returns to duty within the army area. If evacuation

hospitals were of two sizes, one should be kept relatively small and the other,

which would be larger, would fill the needs then filled by existing evacuation

hospitals. In both types of evacuation hospitals, the intrinsic staff would be

augmented, as necessary, by the full employment of teams from auxiliary

surgical groups.

Compared with smaller hospitals, a 750-bed evacuation hospital has the

following two major disadvantages: (1) It is more difficult to displace the

larger hospital, particularly if a withdrawal must be made and (2) when a

750-bed hospital is moving, it clogs the road,, to a much greater degree than a

400-bed hospital.

On the other hand, experiences in the Seventh U.S. Army in World War

II indicated that, from the standpoint of returns to duty, the 750-bed hospital

is somewhat more efficient (table 25). The 400-bed and 750-bed hospitals listed
SEVENT- U.S. ARMY 547

in table 25 Were all similarly located over the 3-month. period surveyed, all

were empl6yed during the same active offensive, and all had the same missions.

The givatr eficiency of the 750-bed hospitals may be attributed to their, greater

hoigin capacity, their ability to expand more rapidly than smaller hospitals,

and theii ~ire diversified medical and surgical staffs.

CLINICAL POLICIES

The information on which the clinical portion of this chapter is based was

secured, in part, from the information requested in Circular No. 15, Seventh

'U.S. Army, dated 31 August 1944 (p. 507). The data requested included the

following

1. Deaths by name, rank, Army service number, and organization, with a

brief analysis of each case and pertinent comments.

2. The same information for all enucleations or eviscerations of the eye.

3. A breakdown of all major amputations (thigh, leg, arm, and forearm).

Details of the case were to be supplied whenever it was thought that amputation could have been prevented.

4. Information on all injuries to major vessels and their management, with

special attention to amputations.

5. Information on all cases of anaerobic myositis (name, rank, Army

service number, and organization, with details of the management of the case

and the results).

6. The same information on all wounds of major joints in which suppuration had occurred.

7. Information on all major infections of special interest or significance.

8. Data on transfusions, including the number given, the number of patients transfused, the total amount of blood used, the details of reactions, and

any other information that might be useful concerning the use of whole blood.

The data secured by this command circular were recognized as not inclusive

and, in some instances, as not altogether accurate; but they were ample to show

clinical trends and to permit conclusions concerning special methods of treatment and other matters.

Resuscitation

One error never made in Seventh U.S. Army hospitals was to conceive of

resuscitation as being limited to the administration of plasma or blood transfusions. On the contrary, resuscitation was regarded as a routine which required, in addition to the use of plasma, blood, or both, according to the indications of the special case, the following measures, also according to the indications of the special case: Control of hemorrhage; splinting of the wound; application of dressings; administration of morphine, if required for the control

of pain, on the field or in the battalion aid station; administration of oxygen;

aspiration of blood and air from the chest; injection of the intercostal nerves

with procaine hydrochloride (Novocain); emptying of the stomach, the blad-
548 ACTIVITIES OF SURGICAL CONSULTANTS

der, or both; maintenance of a free, dry airway; and a multitude of other

procedures designed to make the patient a suitable candidate for surgery. Resuscitation, in short, ranged from protection of the casualty from unnecessary

exposure immediately after injury to the final performance of initial wound

surgery; even inexperienced surgeons soon came to realize that the act of operation was frequently an integral and essential phase of the routine of resuscitation.

Emphasis was constantly placed upon adequate blood replacement and the

proper timing of surgery in relation to the administration of blood and the

response to it. Excess administration of blood, however, particularly in wounds

of the head and chest, was discouraged as both unnecessary and, occasionally,

dangerous. The collected statistics show that administration of blood was at

the rate of 0.14 pint per patient when both combat-incurred and noncombat

injuries were considered and at the rate of 0.72 pint when only battle injuries

were considered. The minimum monthly average was 0.54 pint per battle

casualty in August 1944 and the maximum, 0.91 pint per battle casualty in

April 1945. The increase is an index of the increasing experience gained by

surgeons in army hospitals and clearing stations as the war progressed. The

average amount of blood used in field hospitals, 3.9 pints per persons transfused, was, for obvious reasons, higher than the amount used in evacuation

hospitals, which was 1.8 pints per person transfused.

The shock teams of the auxiliary surgical groups rendered invaluable assistance in all field hospitals, and all evacuation hospitals maintained an aggressive attitude toward this condition. Shock wards were well organized and

were always under the direct supervision of experienced medical officers. A

shock ward was no assignment for a medical officer who did not appreciate all of

the problems and risks of shock in casualties with combat-incurred wounds,

however competent he might be in civilian practice.

Anesthesia

Well-trained anesthesiologists were attached to all army hospitals and

served on all auxiliary surgical teams. Anesthesia in forward hospitals was

therefore always competently administered. Capt. (later Maj.) Daniel

Massey, MC, 9th Evacuation Hospital, a diplomnate of the American Board of

Anesthesiology, was utilized informally as a consultant, just as Captain Solouff

was used as an informal consultant in ophthalmology.

All new hospitals arrived with two officer anesthesiologists on their staffs.

While their organizations were staging, these officers were placed on temporary

duty in experienced field and evacuation hospitals, so that, when their own

units went into action, they had already had some experience with combat-incurred injuries and had come to appreciate the difference between surgery for

them and elective surgery, or even emergency surgery, in civilian practice.

At the request of Colonel Tovell, statistics on anesthesia were collected for

a 6-month period in Seventh U.S. Army hospitals (table 26). The difference
SVENTH-R ARMY 549

T'ifoM 6.-DIstribution of aneshesia-by type, and by type of hospital, Seventh U.S. Army,

I November 1944-80 April 1945

T Type of anesthesia eEvacuation hospitals Field hospitals

Cases Percent Cases Porcent

IntrAvenous (pentothal sodium) ----------------- 22,363 53. 1 71 2. 8

Inhalation ---------------------------------- 9,762 23.2 2,148 86.2

Combined intravehous and inhalation ------------ 3, 849 9. 1 56 2. 2

Field blocks - ......-------- --------------------- 4, 904 11. 6 45 1.8

Rigiofial (miscellaneous) ------------------------ 558 1. 3 117 4. 7

Spinal ------- -------------------------------- ; 383 .9 11 .5

Smpatheio block -------------------------- 319 .8 44 1. 8

Total ----------------------------------- 42,138 100. 0 2, 492 100. 0

I Endotracheal anesthesia was used 3,042 times in evacuation hospitals and 1,782 times In field hospitals, this being

31,2 percent and 83.0 percent, respectively, of the Inhalation anesthetics given in those installations.

between the methods used in field hospitals and those used in evacuation hospitals reflects the differences in the surgical problems encountered in the two

types of installations. The much smaller percentage of endotracheal anesthesias given in evacuation hospitals (81.2 percent, versus 83.0 percent in field

hospitals) is a further reflection of this fact.

Early in the experience in North Africa, the advantages as well as the

added safety of a combination of intravenous anesthesia (thiopental sodium)

and nitrous oxide anesthesia were not recognized. Had the war lasted longer,

there is no doubt, considering the trend already evident, that this combination

would have been employed even more frequently in evacuation hospitals,

chiefly at the expense of some of the other techniques.

The inhalation agents most often used were ether and nitrous oxide, with

induction by ethyl chloride. Chloroform was rather frequently used for

induction in the 9th Evacuation Hospital, always under the direct supervision

of Captain Massey. There were no reactions and no deaths.

Anesthesiologists in various army hospitals provided well-planned instruction in anesthesia for both nurses and carefully selected enlisted personnel on

their staffs. As a result, most hospitals had 8 or 10 additional anesthetists who

had had some special training, and bottlenecks because of anesthesia therefore

seldom existed. The 9th Evacuation Hospital began to train enlisted personnel as anesthetists early in the Tunisian campaign. Instruction was given

over a 2-year period by practical demonstrations, personal supervision, study

groups, group discussions, and, eventually, clinical practice. This plan had

several advantages. It assured the surgical section of a permanent group

of trained anesthetists. It did not deplete the nursing section, which was

always shorthanded. It provided an excellent stimulus for the enlisted personnel of the hospital. It was one of the trained technicians of this unit who

went ashore with the surgical consultant on D-day and who was immediately

003222-62--37
550 AOTIVITIES OF SURGICAL CONSULTANTS

attached to the 10th Field Hospital, to replace the anesthesiologist who had

been wounded during the landings. He served in this hospital until D!12,

thus solving a problem which otherwise might have seriously delayed' the care

of the wounded.

The 11 deaths in Seventh U.S. Army hospitals which apparently must be

attributed, wholly or in part, to anesthetic agents or to the accidents and com-

'A plications of anesthesia were distributed as follows:

Three deaths were due to Pentothal sodium (thiopental sodium)

anesthesia alone. The collected statistics show that this is a ratio of 1 to 7,511

anesthetics when Pentothal sodium was the sole agent and 1 to 8,799 anesthetics

when it was combined with other agents. These ratios compared very favorably

with those of civilian hospitals.

One death was due to combined Pentothal and spinal anesthesia.

One death was due to procaine poisoning following sympathetic block.

The assumption was that the injection was probably too deep; the anesthetic

agent was found in the spinal fluid.

One death occurred after ether anesthesia. In this case, open ether was

administered through a mask held over an endotracheal tube and too high a

concentration was undoubtedly given directly into the trachea. Death occurred

on the second postoperative day, and autopsy revealed an extremely diffuse

purulent capili, ry bronchitis.

One death followed the preanestletic administration of morphine and

atropine. The patient, who had acute appendicitis, went into collapse after the

subcutaneous administration of 0.010 gin. of morphine and 0.0045 gin. of

atropine. He did not respond to intensive efforts at resuscitation and died

within an hour, without anesthesia or surgery. Although these are standard

doses of the drugs, which are used routinely in preoperative preparation, the

death must be charged to the medication.

One death was due to unrecognized obstruction of a bronchus by the

endotracheal tube.

Three deaths were due to aspiration of vomitus with bronchial occlusion.

Chemotherapy and Antibiotic Therapy

The NATOUSA policy of administering penicillin to all casualties except

the most lightly wounded immediately upon their arrival in forward army hospitals was followed in the Seventh U.S. Army. Later, when this army caine

under ETOUSA operational control, the first dose of penicillin was administered in clearing stations.

The protection afforded by penicillin permitted broadening of the scope

of all surgery and, particularly, it permittcd thorough debridement of wounds,

regardless of the timelag between wounding and initial wound surgery. Penicillin proved to have many advantages over the sulfonamides previously used

routinely. It was more potent. It had none of the untoward complications of

the sulfonamides, particularly the renal complications. It did not depress
SEVENTH U.S. ARMY 551

the'bone marrow. On the other hand, while its use greatly improved the results

ofthe opeiatibns performed in Seventh U.S. Army hospitals, penicillin was

neer-i~arerded'as a substitute for good surgery.

:Penicillin was used locally as well as systemically, but only in delayed

debridementg, wounds of the chest and abdomen, and wounds involving the

cerebrospinal system. Its topical use was discouraged under all other

circumstances.

As a general rule, the administration of the sulfonamides was left to the

discretion of the individual surgeon until the publication of Circular Letter

No. 7, Office of the Surgeon, Seventh U.S. Army, dated 13 April 1945, which

discouraged their local use as an adjunct to initial wound surgery. By this

time, the concept had developed that their use within wounds was not only not

beneficial but might be harmful.

There was no proof, one way or the other, that the employment of sulfonamide powder on first aid dressings had any real effects. There is, however,

an inherent urge in man to put something on a fresh wound beyond a simple,

dry, sterile dressing. It was thought wiser, therefore, not to interfere with

this first-echelon practice, on the ground that it was not harmful and might be

beneficial and that, in any event, it was superior to the application of iodine

or a mercurial.

General Surgical Policies

General policies of surgical care of casualties in Seventh U.S. Army hospitals were stated in Circular Letter No. 2, Office of the Surgeon, Seventh U.S.

Army, dated 18 July 1944. They were reiterated in Circular Letter No. 17,

Office of the Surgeon, Seventh U.S. Army, dated 30 December 1944. The

latter letter stated again the fundamental principles of initial wound surgery

and dealt with specific types of wounds, particularly wounds of the right

colon (p. 556). Both these letters, like the letters issued later dealing with

special types of wounds, simply contained formal instructions for policies

which had already been in effect and which experience had shown to be useful

or necessary modifications of, or additions to, the policies officially established

before the invasion of southern France.

The chief difficulty in new units was failure of their surgeons to realize

the extreme importance of performing debridement according to fundamental

principles. They fully appreciated the necessity for it in theory, but in practice

they failed to consummate the theory. They were inclined to excise skin and

superficial tissue while failing to incise fascial planes widely and to debride

deeper tissues adequately. The resulting wound was relatively small and

bulging, packed with gauze under tension, often infected, and seldom ready for

closure at the first dressing.

As medical units in the Seventh U.S. Army gained in experience, their

techniques of debridement improved. They came to realize that correct debridement is not a rough hacking away of tissues in hit-or-miss fashion but is,
552 AOTIVITIES OF SURGICAL CONSULTANTS

instead, a precise operative procedure which demands good light, adequate

assistance, wide incision of fascial planes, exposure of all recesses of the wound,

careful hemostasis, anatomic dissection of tissues, complete removal of all

damaged tissues, and a consistently atraumatic technique throughout all steps

of the procedure.

Inexperienced medical officers also made other errors. They administered

excessive doses of morphine. They sent patients to the rear inadequately protected with blankets, particularly blankets underneath the body. They were

inclined to change dressings more often than was necessary in collecting and

clearing stations. They evacuated patients from hospitals with intact or inadequately divided casts, tight dressings, poorly immobilized parts, unaspirated

chests, retracting colostomies, and insufficient blood replacement.

These errors, which were all fairly common, were partly attributable to

inexperience in military surgery and partly to failure to comprehend the entire

medicomilitary situation. They were soon rectified by visits to, and comments

from, more experienced general hospitals and older field and evacuation hospitals. When these errors were called to the attention of corps and division surgeons, these officers were always most cooperative and took immediate steps to

correct them. As new medical officers gained in experience, they themselves

came to appreciate the value of sound initial surgery and to realize that it protects the patient from infection and other complications, makes early reparative

surgery possible, and achieves the greatest possible conservation of manpower.

REGIONAL INJURIES

Wounds of the Extremities

Wounds of the extremities accounted for about two-thirds of all admissions

for battle-incurred wounds to Seventh U.S. Army hospitals. Wounds in the

lower extremities were considerably more frequent than in the upper. In

evacuation hospitals, these wounds made up about 70 percent of the workload.

In field hospitals, they accounted for only about 30 or 35 percent, the rest of

the load being made up of thoracic, abdominal, and thoracoabdominal wounds.

First echelon care was generally good. Tourniquets were used with

discretion and efficiency, and their use seldom gave rise to complications. Occasionally, particularly in newly arrived medical units, morphine was administered in excess. At times, patients wvere received inadequately protected

from exposure and with fractures unsplinted. It was sometimes difficult to

impress upon inexperienced personnel that a properly dressed litter required

blankets under the p'xtient as well as over him.

The initial surgery of compound fractures in army facilities consisted of

adequate resuscitation, proper debridement, careful appraisal and repair or

other nmanagemnent of major vascular injuries, and the application of transportation casts. Patients with vascular injuries had to be held until viability

of the limb was assured or amputation was obviously necessary. The principle
SEVENTH U.S. ARMY 553

Z

FIGUREl 0.-Prvintrat ioiis for admliist rat ion of blood to "o uiided soldlier ill

evacula tioll hospital Inear Dijon, France, Septlember 1944. Note thle (1iagrami of the

fraN iile oii thle calxt. Note als~o that thie Cast has lien split, inl acco rdanie Mill

regulaionis.

of compiIlete (lebridenlent, is p~aramnount inl miodernt military surgery anid is

nlowhere Iore importanlt thili inl comnitldnd trsamid m ounids of the joints.

Som dlhiuly was elncounlteredl inl imi ~ssing tupon bilgli l ]iWiiits

file ill) orta lce of slch matters as firm butt nonconstrict ili dIressinigs and1( the

Corriect posit ion a Id supp)ort of tile inijur~ed 111111), ats A~eli as thle v ital necessity

of completely Splitting all Casts and all lavers of Circular bandages and dressings (fig. 94I). Unless casts were sp)lit before evacuat ion, preferably while

they were still wet, patients were likely to be received inl genieral hospitals

with p)ainfuil, swollen linmbs, wvitit the risk of Serious inifection inlcreased, and

with conlvalescenlce g'reat iy prtolongedl.

Thle definit iie t reatnment of mnajor fractutres was not tile re-'pomisibilit 'v of

fieldl army hospitals. TPhis ftinlctioli liertaiuied to lai~pitals ill coniinitiuicationls

Zonel(S anid thle Zonle of Interior. Patients %Nith 11seiolts fractutres were. givenl,

as fait- as possible, early 1)riol-it ill t lalilbortatioml to grellelal llo."pit"1 aLfig. 9 5),

sthat they would arri ve NN ithlili or. 6 davs after xNounlding'. v ithinl tile optimluml

p~eriodl for iii it ial m wound drves-i hg. delayed clo.tire or, redebridemtellt. and iii itiat ion of treatmIent of thle tractin.

Ill the rus~h of Nvork. .iugeui sII(it ilnie totgot that th e i it itat ion and

mta inteniance of trtact ion wvere impilortanlt plvules (if the rott te of reslttsCitatioli

in patients withI. fralctures of thle feutr or tib~ia and that the practices also
ACTINTIA 1:11, "p, SCRICIN Al, ONS1 1,111ANTS

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SEVENTH U.S. ARMY 555

employed in the 9th Evacuation Hospital in Italy, while it was serving French

casualties. They included formal arthrotomy in all wounds of the joints;

complete debridement, with the removal of all foreign bodies, free bone fragments, and damaged and devitalized cartilage; thorough lavage; closure of the

joint capsule; instillation of penicillin; and immobilization of the limb in a

plaster spica or Tobruk splint.

Patients with wounds of the knee joint treated by this technique were

followed up in general hospitals, and, as far as could be ascertained on informal

surveys, the only infections which were present occurred in joints which were

already grossly infected at the time of initial wound surgery and those in which

the instructions concerning formal arthrotomy and complete debridement had

not been followed. In the 9th and 51st Evacuation Hospitals, which conducted

a special study of arthrotomies of the knee joint, only 2 infections were observed in 227 cases. One patient had undergone initial wound surgery 10 days

after wounding and the other, 14 days after. Gross infection was present at

the time in both cases. None of the other wounds showed any signs of infection

when the patients were evacuated to the rear.

Compound fractures of the hip joint were, fortunately, not frequent. in

previous wars, the subsequent course of these cesualties had often been tragic,

with long-drawn-out sepsis and, eventually, destruction of the joint to such an

extent that major problems of reconstructive surgery were posed. In March

1945, two of the more experienced surgeons in the Seventh U.S. Army were

requested to apply to wounds of the hip joint the bold policy which had met

with such great success in wounds of the knee joint in both British and U.S.

Armies. Before this policy was instituted, it was discussed informally with

Brigadier Sir W. Rowley Bristow, Consultant in Orthopedic Surgery, RAMC,

at a chance meeting. The procedure is much more formidable in the hip joint,

but the urgent necessities of these wounds warranted its trial.

Colonel McNeil, of the 51st Evacuation Hospital, whose remarks on the

preoperative use of traction have already been mentioned, had good results with

it. Lt. Col. James E. Thompson, MC, reported in detail the nine formal

arthrotomies of the hip joint which lie had performed in the 9th Evacuation

Hospital. In several of these cases, damage to the deep layers of the gluteus

medius muscles and destruction of the gluteus minimus had been so extensive

that no concept of the true situation could have been gained through the usual

type of incision. The destroyed muscle tissue and the dirt and bits of clothing

embedded in the wound could not have been completely visualized or completely

removed unless a formal arthrotomy had been performed.

I Colonel Thompson and Colonel Berry reported the folloA% up on seven of thee nine cases at the

meeting of the American Surgical Association in 1948. (Thompson, J. E.. and Berry, F. B.: Penetrating Wounds of Major Joints. Tr. Am. S.A. 65: 567-584. 1947.) The late results were a convincing demonstration of the ialue of a bold approach to \%ounds of the hip joint.
ACTIVITIES OF SURGICAL CONSULTANTS

Wounds of the Abdomen

In Seventh U.S. Army hospitals, contrary to the usual experience, approximately 40 percent of casualties with abdominal injuries received their initial

treatment in evacuation hospitals instead of field hospitals. This was necessary

because of the tactical situation. During one period of the fighting, an evacuation hospital was only about a quarter of a mile from the field hospital, which

made it possible to distribute casualties to both according to their workloads.

During three other periods of fighting, the same situation prevailed in respect

to several field and evacuation hospitals. As a result, when field hospitals were

under pressure, evacuation hospitals received casualties which would ordinarily

have been cared for in hospitals farther forward. Finally, when field hospitals

were moving, it was frequently the practice to take casualties directly to evacuation hospitals, in which, even though the ambulance haul was slightly longer,

they could be cared for more promptly.

Patients with abdominal injuries were treated according to the sound

policies already established in the Mediterranean and European theaters. The

objective was to perform operation as soon as possible. With this idea, resuscitation was expedited, and in most cases was accomplished within 3 hours or less,

the assumption being that, if a response was not observed within this period,

either hemorrhage was continuing or massive peritoneal contamination was

responsible for the continued state of shock. In both circumstances, surgery

was regarded as a part of resuscitation and was proceeded with promptly.

In order to avoid ileocolostomy, which had given somewhat inferior results

in hospitals in Italy, the following technique was employed in wounds of the

right colon: I

1. If the wound of the ascending colon was small and clean cut, it was

either exteriorized or repaired in two layers; in either case, a large cecostomy

was provided.

2. If the damage was irreparable, resection of the involved area of the bowel

was carried out, either in a single stage or in two stages, depending upon the

extent of the lesion, the degree of peritonitis present, and the condition of the

patient.

The two-stage operation was regarded as safer than single-stage surgery

and was performed, whenever it was feasible, by the following technique:

After ileotrnsverse colostomy had been performed, the distal stump of the

resected ileum was exteriorized, as a mucous fistula, well out in the right lower

quadrant. A loop of transverse colon or the hepatic flexure just proximal to

the ana3tomosis was then delivered through a subcostal incision. This loop was

divided, and the ends were left open. The wounded portion of the colon was

exteriorizL ' either through the lower incision, with the ileum, or through the

upper incisi. i, along with the colon, whichever was simpler.

Circular Letter No. 17, Office of Surgeon. Seventh U.S. Army, 30 Dec. 1944.
SEVENTH U.S. ARMY 557

Although this technique was employed in only a limited number of cases,

surgeons in both army and general hospitals reported good results with it. It

caused less excoriation of the abdominal wall than the standard operation,

nursing care was simpler, and patients seemed to recover more promptly.

In the collected series of 55,085 admissions for battle-incurred wounds, the

case fatality rate for abdominal injuries was 19.2 percent. The rate in field

hospitals was 24.6 percent and in evacuation hospitals 11.5 percent.

Wounds of the Thorax

Almost all casualties with wounds of the thorax were sent first to field

hospitals for examination, evaluation of their wounds, and such resuscitation

as might be necessary. About 40 percent were held in field hospitals for treatment; the remainder were regarded as safely transportable to evacuation hospitals for definitive treatment.

Early in the Seventh U.S. Army experience, some surgeons believed that

formal thoracotomy should be performed rather frequently at the time of initial

debridement and that the official policy of conservatism would produce less

satisfactory results. As the campaign progressed, it became clear that results

were better and fatalities fewer when the official policy was strictly followed.

When these patients were evacuated to general hospitals, they were usually

well on their way toward regaining normal lung expansion and function. Reports by general hospitals and observations in visits to these hospitals ihdicated that these results were permanent and not ephemeral.

Indications for primary thoracotomy, either by extension of the wound or

by a separate incision at a site of election, were based on the policies which had

been promulgated and practiced in the Mediterranean theater. They were

as follows:

1. Continuing intrapleural hemorrhage not controlled by hemostasis in

the course of debridement of the chest wall.

2. Anatomic or clinical evidence of penetration of the diaphragm.

3. Suspected visceral damage, the suspicion being based on the fact that

a missile had traversed the mediastinum or lodged in it.

4. The presence of large intrapleural foreign bodies or debris readily accessible by extension of the traumatic wound.

5. Wounds of large bronchi or of the intrathoracic portion of the trachea.

The following conditions were not regarded, in themselves, as indications

for initial formal primary thoracotomy:

1. The presence of foreign bodies (metallic fragments or bits of rib) in

the lungs or of small fragments in the pleural space.

2. Hemothorax. (The evacuation of blood from the pleural cavity by suction at the time of debridement of the chest wall was not regarded as thoracotomy.)

3. Laceration contusion of the lung in the absence of definite evidence

of continuing hemorrhage.

606222-62-38
558 ACTIVITIES OF SURGICAL CONSULTA.NTkS

Emphasis in all wounds of the thorax was placed on such details of effec-,

tive resuscitation 'as complete aspiration of blood and air from the pleural

cavity, aspiration of the tracheobronchial tree, and the administralien of whole

blood and oxygen as required. Warnings were issued against the use of excessive amounts of blood and other intravenous fluids in patients with wounds

of the chest.

In the 55,085 hospital admissions for battle-incurred wounds analyzed,

the case fatality rate for thoracic injuries was 5.4 percent. The case fatality

rate in field hospitals was 8.7 percent, and that in evacuation hospitals, 3.3

percent.

Thoracoabdominal Wounds

Thoracoabdominal wounds accounted for about 5 percent of all admissions

for battle-incurred wounds in Seventh U.S. Army hospitals. As surgeons

gained more and more experience with them, it became the general practice to

approach them first through the chest. This policy favored prompt restoration to normal of deranged cardiorespiratory physiology, and it permitted abdominal exploration and the necessary intra-abdominal surgery under the

most favorable possible circumstances.

In the 55,085 hospital admissions for battle-incurred wounds analyzed, the

case fatality rate for thoracoabdominal injuries was 21.7 percent. The case

fatality rate in field hospitals was 26.5 percent, and that in evacuation hospitals,

15.0 percent.

Wounds of the Head and Spine

The Seventh U.S. Army N.s particularly fortunate in its complement

of nine experienced neurosurgeons, tnd neurosurgery, as a result, was extremely

well covered. Five of these highly trained neurosurgeons were assigned to

hospitals, and four to neurosurgical teams. One of these teams was attached

to a field hospital for the landings, but it was soon realized that the services

of a neurosurgeon could be better utilized in an evacuation hospital, and the

appropriate transfer was made. Full use was also made of three other sirgeons who had some previous experience in neurosurgery.

At the suggestion of Col. R. Glen Spurling, MC, Senior Consultant in

Neurosurgery, ETOUSA, four of the neurosurgeons attached to Seventh U.S.

Army hospitals and neurosurgical teams were given 60-day temporary duty

transfers to neurosurgical centers in the United Kingdom Base, and four of

the surgeons from those centers served in the Seventh U.S. Army hospitals

for the same period. This plan proved highly beneficial, not only in the variety

of experience which it permitted but also because of the opportunities it gave

to each group to comprehend the problems of the other group.

At Colonel Spurling's request, data for injuries of the head (tables 27

and 28) and injuries of the spine (table 29) in Seventh U.S. Army evacuation hospitals were analyzed for a 5-month period.
SEVENTH U.S. ARMY55

TABLE 27.-Management and results in 717 penetrating wounds of the head in eight Seventh

U.S. Army evacuation hos pitals for a selected 5-mionth period

EvcainTotal Nonsurgical deaths Surgical cases

hoialto ____ ____ _____-__________

Cases Duaths Percent Number Percent -lme Depths Percent

9th------------113 17 15,0 11 9.7 102 6 5.9

11h.....126 28 22.2 15 11.9 111 13 11.7

27th------------87 14 16. 1 6 6.9 81 8 9.9

51st------------44 19 43.2 8 18.2 36 11 30.6

59th------------89 34 38.2 22 24.7 67 12 17.9

93d------------81 15 18.5 i1 13.6 70 4 5.7

95th------------96 22 22.9 12 13.5 84 10 11.9

116th-----------81 20 24.7 10 19.8 65 4 6.2

Total_... 717 1lOP 236 11 14. 1 616 68 11.0

TABLE 28.-LPesults in 616.surgically managed wounds of the head in relation to dural penetration in eight Seventh U.S. Armny ev'acuation hospitals for a selected 5-mionth period

Fv1)io opia ural penetration No dural penetration Total

Evacatin hopitl-- ____________ I = -. - - -- ______- 

Cases Deatha Percent Cases D~eaths Percent Cases Deaths Percent

9th ------ _------ ------ 98 5 5. 1 4 1 25.0 102 6 5.9

11Ith------------------- 81 12 14.8 30 1 3.3 111 13 11.7

27th ----- ------------- 66 7 10.6 15 1 6.7 81 8 9.9

51st------------------- 31 11 35.5 5 0 .0 36 11 30.6G

59th------------------- 52 12 23. 1 15 0 .0 67 12 17.9

03d ------------------- 54 3 5.5 16 1 6.3 70 4 5.7

95th------------------- 72 9 12.5 12 1 8.3 84 10 11.9

1160th----------------- 51 4 7.8 14 0 .0 65 4 6.2

Tt-------505 63 12.5 111 5 1 4.5 616 68 11.0

Wounds of th, t-i!-od Vessels

Many of the amputations performed ini Seventh U.S. Ariny hospitals were

necessitated by wounds of the major arteries. Amiputation was necessary in

nearly 30 percent of 1,086 vascular injuries onl which dlata were personally

collected (table 30). Onl the basis of this analysis, Circular Letter No. 9, dated

18 May 1945,9 was preparedJ, but its distribution was accomplished too late

for it to be useful during hostilities. The policies which it stated, however, had

already been in effect for a considerable time.

11Circular Letter No. 9, Office of the Surgeon, Seventh U.S. Army. IS May 194-1.
560 AOTIVITIES OF SURGICAL CONSULTANTS

T.IILE 2.-Essential data in 182 spinal cord injuries in eight Seventh U.S. Army evacuation

hospitals for a selected 5-month period

Location ofinjury Paralysis Laminctorny Case fatality

rate

Evacuation hospital

9th--------------------- 37 6 12 19 14 23 22 24 12 12 6.613.6

11th ------ _--------------- 37 6 24 7 21 16 23 13 10 12 50.0 8.7

27th ------------------- 33 7 12 14 8 25 20 58 6 23 .0 5.0

51st ---------------------- 6 0 3 3 3 3 6 8 2 1 .0 .0

59th -------------------.. 20 5 12 3 15 5 11 14 1 12 33.027.3

93d --_------------------- 19 4 13 2 12 7 9 ---- 2 8 60.033.0

95th -------------------- 24 5 12 7 19 5 21 26 4 0 66.624.0

l6th--------------------- 6 1 4 1 5 1 12 0 1 .0 .0

Total -------------- 182 34 92 56 97 85 113 37 69

Tile first principle of management of vascular injuries was that it should

be conservative, with amputation the last resort. Repair of the damaged artery

was to be effected whenever possible. Sympathetic lumbar blocks were done

routinely with procaine, and lumbar sympathectomy was performed in a few

instances.

Suture was always employed when the technique was feasible. Evaluation of the techniques in which prostheses were employed is difficult because no

single procedure was carried out in a large series of cases. Survival of the

limb followed the use of vein transplants in two of four cases. One limb

survived after the use of a polyethylene tube transplant and another after

the use of a glass tube. It is impossible even to comment on such small numbers of cases, though, of the artificial grafts and prostheses employed, polyethylene tubing was thought preferable to Blakemore metallic cuffs and vein

grafts because the technique was simpler.

In March and April 1945, heparin became available in limited quantities

and seemed to be of some vlue, though it is known that in at least one instance

serious delayed oozing followed its use. It was thought that a more extended

trial might have demonstrated it to be of real usefulness if it were used with

the proper precautions.

Actually, the outcome of every arterial wound depended in large measure

upon the nature of the injury: Whether the wound was small and clean, or

large, contaminated, and infected, with widespread destruction of tissue;

whether the vessel was completely or only partly divided; whether the injury
562 ACTIVITIES OF SURGICAL CONSULTANTS

TAuLE 31.-Anatomic location and origin of casualties in 1,211 amputations in Seventh U.S.

Army hospitals

Origin of casualty

Location of amputation

U,S. Army Non-U.S. Army Not differen. personnel personnel tiated'

Arm ----------------.------------------ 101 33 41

Forearm ........ .......................... 98 20 13

Thigh ..................................... 316 83 49

Leg ....................................... 689 105 82

Not stated -------------------------------- 7 11 92

Total -------------------- - 1,211 252 277

Maxillofacial Wounds

Three Seventh U.S. Army hospitals, the 9th, the 27th, and the 117th

Evacuation Hospitals, had strong maxillofacial sections, and the policy, as

far as it was practical, was to send most maxillofacial injuries to them. The

other hospitals showed varying degrees of interest in this special problem.

One of the two maxillofacial surgery teams which landed on D-day lost

its senior surgeon, by wounding, ahnost immediately (p. 512). It was reconstituted as a general surgical team, the need for which was then greater; this

team thus had the added advantage of having, as one of its members, a surgeon with some experience in maxillofacial surgery. For the same reasonthat the need for general surgical teams was greater-a third maxillofacial

surgery team which arrived in southern France, in December 1944 was reconstituted as a surgical team.

As the experience in the Seventh U.S. Army area showed, serious maxillofacial injuries are best handled in evacuation hospitals, in which trained

oral and maxillofacial surgeons are available to treat them. Maxillofacial

teams are also more usefully employed at this level rather than in field hospitals. If hemorrhage is arrested and a proper airway is established and

maintained, casualties with this type of injury tolerate transportation very

well, prone or sitting for' -ard, though they may require the attention of special attendants while they are in transit. If, for any reason, a casualty with

a maxillofacial injury had to be held in a field hospital, a maxillofacial team

could go forward to treat him, exactly as was the practice when other specialized injuries required treatment in a more forward hospital.

Wounds of the Eye

Only the simplest and most urgent ophlthalmologic surgery was performed in army facilities. Every effort was made to conserve the eyes.

There is no doubt that some wounds required additional surgery in the com-
SEE TH .S. ARMY 561

TABLE 30.-Essential data in 1,086 injuries to major arteries, Seventh U.S. Army, 15 August

1944-80 April 1945

Artery InJuries Amputations Deaths

Carotid - - - - - - - - - - - - - - - - - - _ -- 10 5 4

External carotid; ------------------------------- 2 ----------

Stibciavian- --------------------------------------- 10 2 2

Axillary --------------------------------------- 19 6 1

Brachial------------------------------------- 198 31........--

Radial---------------------------------------- 67 3 .........

lnar----------------------------------------- 30----

Radial and ulniar ..........---------------------- 17 8 .....

Common iliac----------------------------------- 3................---

Internal iliac.......-------------------- 1--------------------

External Iliac----------------------------------... 18 5 1

Femoral-------------------------------------.... 155 70 1

Superficial femoral------------------------------- 34 19 -----

Profunda femonis-------------------------------- 22-----------

Superficial femoral and profunda femois --------- I----------

Popliteal-------------------------------------- 179 125_----

Anterior tibial ---------------------------------- 94 3........--

Posterior tibial -------- ------------------------ 153 7 ----- Anterior and posterior tibial ------------------------ 46 30 .....

Posterior tibial and peroneal ------------------------ 5 2 -----

Anterior and posterior tibial and peroneal --------------- 1-1........

Peroncal --------------------------------------- 7 1 -----

Renal ----------------------------------------- 2 ------ 2

Aorta.-------------------------------------------- 3 ------ 2

Total ------------------------------------- 1,086 319 13

was situated at, or near, an important vascular anastomosis; whether circulation was still active in the limb wihen the, patient was first seen; and whether

thrombi had already formed.

Amputations

Exclusive of immediate traumatic amputations, the collected figures show

that, in Seventh U.S. Army hospitals, 1,211 major amputations were performed on Army personnel, in addition to 252 amputations on non-Army personnel, and 277 ampatations in which the origin of the casualties was not

stated (table 31). If the first and third of these groups are con~sidered as

though they were composed entirely of U.S. Army personnel, the ratio of

amputations to battle casualties would be 1: 40.9 in the 55,058 hospital admissions for battle-incurred injurks oai which data were personally collected.

If nonbattle casualties are include(' the ratio would be 1 : 53.6. These high

ratios are explained by the numbers 4f Iandmines encountered during offensive

operations, pardcularly in the fight' ig in November and December 1944 and

March 1945.
SEVENTH U.S. ARMY 563

munications zone, but there were only four known instances in the army area

in which both eyes were lost, which is remarkably low, in view of the nature

of modern combat. It is possible that some eyes had to be removed in hospitals in the communications zone.

The collected figures show that 193 enucleations or eviscerations of injured

eyes were performed in 189 patients, which is 0.32 percent of the approximately 60,000 admissions for battle-incurred injuries officially reported in the

Seventh U.S. Army. An additional 136 enucleations or eviscerations were

performed in prisoners of war and non-U.S. Army personnel. Whenever

it was feasible, a glass sphere was implanted in Tenon's capsule after the eye

had been removed.

ANAEROBIC INFECTIONS

In World War I, excluding wounds due to chemical warfare, there were-

* * * 128,265 wounds of the soft parts with 9,719 deaths; of the wounded II this group,

1,389 developed gas gangrene, which amounts to only a little more than 1 percent (1.08).

The death rate amaong those who received Wounids of the soft parts which became comllplicated with gas gangrene was 48,52 percent, the actual munber of deaths being 074.

Among the 25,272 whose wounds included bone fracture there were 2,751 deaths.

The invidence of gas gangrene aniong the bone fracture cases was mich higher than

among those who sustained wounds of the soft parts only, the total being 1,329 with

593 deaths. The incidence li this group of the wounded was therefore 6.26 percent and the

ease mortality rate 44.66 percent.0

Tie combined incidence of gas gangrene in these two groups of World

War I casualties (153,537) was thus 1.8 )ercent.

In World War II, the situation was very different, though, unfortunately,

the records do not differentiate between anaerobic cellulitis and anaerobic

myositis. By 1 November 1944, 24 anaerobic infections had occurred in U.S.

Army personnel, with 2 amputations and 10 deaths, and 47 such infections

had occurred in undifferentiated personnel, who may have included U.S.

Army personnel, with 15 amlputations and 2 deaths.

From the end of November 1944 until the end of April 1945, there were

152 anaerobic infections in U.S. Army personnel, with 90 amputations and 38

deaths; over the same period, there were 46,630 U.S. Army battle casualties.

The incidence of anaerobic infections during this period is thus 0.3 percent,

and the case fatality rate for this type of infection, 25 percent.

Between November 1944 and April 1945, there were also 93 instances of

anaerobic infection in personnel other than Army personnel, with 40 amputations and 15 deaths.

Tile very considerable improvement in respect to the incidence and results

of gas gangrene in World War II can be explained in several ways. Anti10 Coupal, Jamnes F.: Pathllog. of Gas Gangrene Follouo ing War Wounds. i The Medical Departmient of the United States Armi. in the World War. Patholog.% of the Acute tespirator3 Diseases,

Gas Gangrene Fullouing War Wounds. Washington: U.S. Go~eranent Printing Oaice. 1929, iul. XII,

P. 412.
564 ACTIVITIES OF SURGICAL CONSULTANTS

toxin was used in some cases, but the results were not convincing. Earlier

surgery, routine complete debridement, transfusions of whole blood, and the

use of 'penicillin undoubtedly played a part in the improved results. The

chief credit, however, is attributable to the performance of good surgery by

well-trained surgeons, who were available in far greater numbers in World

War II than in World War I.

The cases of clostridial infection known to have occurred in non-U.S.

Army personDAi were attended with a much higher case fatality rate than

those which occurred in U.S. Army personnel, as might have been expected,

since the great majority of casualties in this group were prisoners of war who

had been wounded and had been without treatment for many hours before

they arrived in Seventh U.S. Army hospitals.

BURNS

The 1,284 burns which were included in the statistics collected in forward

hospitals in the Seventh U.S. Army were chiefly produced by field ranges and

similar equipment. A few phosphorus burns were encountered in the winter

and spring. Routine treatment consisted of the application of petrolatumimpregnated gauze and pressure dressings.
CHAPTER XIX

Eighth U.S. Army

FranA 1. McGowan, M.P.

SURGICAL MANPOWER

The surgical treatment in the Eighth U.S. Army area of soldiers wounded

in combat was carried out in portable surgical hospitals, evacuation hospitals,

and field hospitals. The surgical training of men in the evacuation hospitals

was, in general, good. There were, however, marked differences in individual

abilities among these surgeons. The surgical abilities of the staff of the field

hospital were, on the other hand, of a definitely lower quality, and, in the

author's experience, the field hospital did not function at all well. It is a

matter of record that the actual frontline surgery was, for the most part, performed by clearing companies reinforced by portable surgical hospitals with

accompanying surgical teams. This was certainly the case in the Battle of

Leyte, the Battle of Zig Zag Pass on Luzon, the operations on Bataan, the

retaking of Corregidor, and the lower Visayan operations, which were conducted wholly by the Eighth U.S. Army and involved 51 amphibious landings

on two dozen islands.

The Eighth U.S. Army took over the battle for Leyte (p. 477) on 26 December 1944 at a time when the Leyte campaign was declared strategically

closed. The subsequent mopping-up operation, which was handled by the

Eighth U.S. Army, accounted for 26,000 dead Japanese.

At the time when the Battle of Leyte was being fought in the region of

Carigara and the Ormoc Corridor, the forward care of the wounded was done

entirely by portable s3urgical hospitals and clearing companies. The 58th and

the 36th Evacuation Hospitals were some 15 to 20 miles in the rear. Evacuation to these hospitals was extremely difficult because of the condition of what

were called roads, the constant rains, one-way bridges, and the movement of

supplies in the opposite direction.

In the XI Corps landing in the region of Subic Bay, which was quickly

followed by the Battle of Zig Zag Pass, the situation was again practically the

same. There were two portable surgical hospitals up forward some 2 or 3 miles

behind the lines. After 5 to 7 days, the 36th Evacuation Hospital was established some 15 miles to the rear. There was, of course, no transportation after

darkness, so here again the brunt of the primary surgical treatment of all types

of war wounds was carried on by the portable surgical hospitals and a separate

clearing company reinforced by surgical teams.

565
566 ACTI VITIES OF SURGICAL CONSULTANTIS

F'i( ti, 96. A-('ii. Frd ill ,i Mc o% all, Aft C Cunsiltaut ill Surgery, E-Ai t 1U.S. Ariluy.

Whenl Corregidor m a- ret akeni lie medical sMil)1ort furilied duing the

first week consii cii of thle oigau ic reginlieni til niedical det achmuientw hliil had

j ulped 1 itlk thle pa raclilit i pl ,, one por1table nirical hiosp~ital which miade

thle subsequent anip I ibious landing oil t lie beach. Tedyatrii~lidig

the coimandtl~illnz oflic-er of tIlie porltable "u rgical hwil~iiat w a, evactitied Ijvcatuzc

of epidiemic ihelat itis. nLle~e two mtedical iiis Nwere coii.,ol idni ed oil the "Top

of tile Rock" and, ill tie( da N to follow, were si reni hetied bY thle addiition of

sm'eral sil-eow'. Th'ii -aiiiv pioceduie N a, rat her t~ Iical of I lie. actual sitllationl inl regard to thlit iiicliin of hiandliing the N ounided during the remiainider

of thle ViaVai operations. whlich plided wilh the fall of lDa~ao ('ily inl

Mlindaulao.

te,-esmall unit-,. hiere fore, in tilie experienice of Col. Frank .J . McGowan,

11C. Constultant inl Siiigcr-N. Fig hi Ii U.S. Ann11Y. t fig. 96) bore thle lbrili t of

the ,ut-ical treatmeinit of thle wouinded -soldier. nhey wereI nanu01ed by- ,% otlmg

ieli Wvith little .um'ical experiencke, kand th le-IICte of aI w l(raneJI-I'Von

ill t hie - Iilit w a ilie except ion rat her thian thle rule. The majority of wvellqualified imcmi. and by that is mieanit iinei w~ho had attaiiied or mere qualified for

tle raitinga of tlie Alliericanl B oa rd of S;urci v. w trito be found iii thle ,eneral

hospitals and in tlie evactiat ion hiospit als.
EIGHTH U.S. ARMY 567

Evi.nation hospitals were designed to function early. However, in many

instances, due to difficulties in terrain, overwhelming difficulties in transportation, and the rapid movement of tactical units, they were never ill a position to

receive cases until late in an operation (fig. 97). This was especially true

during tho Battle of Zig Zag Pass.

Many incidents contributed to failure in otherwise well-laid plans. For

exam)le, on Cebu Island, Japanese mines on the beachhead delayed the early

establishment of an evacuation hospital, although its personnel were used.

Casualties were high, and hospitalization facilities, consisting of a division

clearing company plus personnel from the 58th Evacuation Hospital, were

swamped with patients. Again, within a very short time after the landing on

Mindanao at Polloc Harbor, the combat troops advanced so far over difficult

terrain that they outstripped the two evacuation hospitals by some 75 to 100

miles. In the southern Philippines campaign for Mindanao, one portable sur

gical hospital en route to the Davao area was ambushed by the enemy, its equipment was destroyed, and the commanding officer was seriously bayoneted.

The lives of wounded soldiers were saved in forward medical units and

not in the rear hospitals. Wounded soldiers rarely arrived in rear hospitals

until from 7 to 10 days after the time of injury, a demonstration of their ability

to survive and travel. Proper treatment, if afforded early, saved many lives,

minimized complications, and shortened future care. These remarks are made

with particular reference to the SWP X (Southwest Pacific Area) with its

isolated islands, its great difficulties in transportation, and an average inedical

strength which was always below authorized strengths. This deficiency in

personnel was further complicated by the theater policy of separating nurses

from their units before moving into combat zones. In the European theater,

nurses accompanied their units on the Normandy invasion. The policy of separating the nurses seriously affected those units which had trained with their

complement of nurses, especially as the enlisted personnel replacements, supposedly on a basis of two enlisted men to one nurse, were never supplied in that

ratio and were, in most instances, badly lacking in training. The consultant

could heve. urderstand why army nurses were not allowed to join their units

on D+3 or D+4 or just as quickly as there was local security. The casualty

load was heavy, and the nurses would have contributed greatly to the increased

efficiency of all surgical units. As it worked out, they were shuttled about in

the rear areas, and those complements of nurses that finally caught up with

their units did so at a time when the casualty load was low and the unit was

on the verge of becoming inactive (fig. 98).

The Eighth U.S. Army conducted the Visayan operations which Gen.

Douglas MacArthur called "a model of what a light but aggressive command

can accomplish in rapid exploitation." This campaign called for task force,

up to the size of an army corps (X Corps,, Miiidanao), each of which had to
5 76 AC'TIVITIES OF SURGICAL CONSULTANTS

alcted1 as aln evacilat ioul lio-liital sh1ip ( hg. Ili; ) llv~v LS' ruce i'ed paitienits

duigdao light htours, pulledi tttl,litte ait andsh hu 1 eutiinil at sea tluuiuiigy

tile nigilt. 'l'lev ]Ilud V.8. Na\ uu altelw.. TI'liee leamii colisi.led ra ueiv

of 1\eli-triiiued sullrgeoli. (olotiel I N-o\\,tli v \otltl adN i ealgilt u tile

stall's of I liese 11S1 loits~ \ iltk \\ell-t lrilletl "Illgeoil. frlut the Armyt (4) do

the sluerv oil Ilie~v hlils. All ojtli lillllbgi.N and a llellrunivllg il Nwere required lit tile Stilgial leant. ( )ii ILzoll. ii fliXl Corap, act ion (Zig Zag lPass,

hiat'an. orre'gitot.), ltere mas liot) ailieti tp)itltluiiit ll( Ipoli. F'ort unnalelv

Colonel M tanlocatedl a I .S. Na'ix jIldial t tlie I taitiet ilk ophil lialittology

Nvlit) seiveti as aolt-llltilit. fl in~ tih 111 l opillioli. tio:M ttapvlat joll bet N~eelt

tile AMetical Cortps of I lie A u'1Nt anlit, Na\ ,v inl aulilthiilioll Vt ifare NN a., N itll.

Only thloroi'"ltl' trained eI "JI11111't l ltilih Je Ilk t Iti-tjetl Vt itli tile Fet'eii

()lit tali N lanitlig,. tite Isl NXere 't olage placvnto[ t0ill ilt. of \N hole blood.

FTe ".tored. refigratedl hlttitt -iould h It VteIli pacheti 1), plaui. \\ith a mtedicali

ofliter ies1)oll ible for it, tcale. andeiil~ Uli tistlliolt, loto ofteli. blood

Awas tli.tribrttel ihphlia/alth titiow-iorit a ttoi\ t antd %Xla-.illitialt to locate

(filz 10)1). Th'le lalidililig of w itolu blootd \\a IS c mttl tore eflitiilt \Itlil lt vSpotl-iltle l)(TlS0)l Was ill tcta-ge.
()F SUGCL 'ULAT

le

-4k i l i l , I I' !-11 111 1 ,11 t

*:114,11' n flvi'l
570 ACTI V IT I E,; oF SIAMICAL CONSIA"VANTS

v I A

I., \1 j M a n-a I I I I I I I N I I T lit, s I 11,

mit'll " I I ( .: I I I I I 11il \\ el fa re, ll a I 'a I I , '. \x 11 11

I t i 4 , ( . \1 ( '. slln n-t Ill. I :IL.,Ill 11 1 S A rlll . I Ill \ c-I I -'a I v I lit, il't. ill I ullia It, A rlli per

'4111110 Ilk I Ito X 4 "wip, At 11.11 1, Colillivi M4 (;ll\\ all

F F F E( "' I , s OF TERIX, A I N. CIA NI ATE. \ N I ) LO , ki, CON DITIONS

, H it, I e I. r; I i I I , k ) I. I I it, I I I ) - I I ill 11 . wlk , 1, re I I I k I (I I Ilic I I I I. Thi, \\:k, pa rt ic tilli rl N 4 ) i I i t I le I )a t t It, ( I f v \ I v le rk, k )I it I I I 14 )1 1 v Iv r;I I 11, I.\ I I I Iv,, -I I I 'll I de.

( olit ri I ;111 )1,.\ 1 4 ) I I li, el e I Ilk, litoOl, vill i a I'll i I I I iv- \\ ll \ I k", :111

so fol.. ! !

v I I ; I I v. i I I I I ul I I I , t I i I )I . lt I i I I )v I'll I I \ v A I ) I I I

( I I I I k I I I . \\ a v I. 1k. d it-Ili 14-:1 1 real v, )I I w It I v, ilk FI 14 111 a rI it \\

impo"ilolt, to carl, wil :111.\ I'mil h wile a it it it 14r it: I I k I I',-, I I I I ke

illoulit :1 i it I )a"t."

( ) i 1 2 1 N 4 )\ el i i I w r m w c( m a I i a \\ :1 11,( I\ I I I ilk I k, -,t -A,- f

inill ler'li )l 1 1*( 1( )l a I I I le :i',i I I V % a i I la 1( )l I I I i ),I ) I 1 .1 I'l iv-v lilvil I :I t Itle t I I I I

I I wi r f4 )\I i( d v,, I'm- 2 (it- 3 \\ eck- and v I A - ill 1 (.1.1 v\11mi'lvd. )11 1 he -:mlv

da.\ , he a\\ in't \\ccll oll and I'll, cli-e- lil I lit, :'6( It 1.:\ aclull 14)11 bi-plial.

lideed. I[ \\ a- v\ t'll Al l1lik-1111 I I I I I hvc ci '111lial I I ( to q I I I I I , i I I i ) I I , a I I k V\ lCtilll kill ill 1110 Clot I\ (1,11, - Of I 11V I X\ I k- Clilli 1:11-11 \\ ll,

allull till it oil. I k

fright I'll I pi-40,1vill. Mc( ;(m all 01t 4011v t, I killp id, :A) \\Ajillided t ( )1 111(w

( 'orrldor X\ Ito luld hevil :,, (I;k.\ - In I rall-it \\ if It 11(o
-Ploiia: I~i) il1i I llorii if t Ta , P* liVt ce -Vs ailling (pi (.1el tteacdi,

~igeoi X Corps,.

The itiauthor landed onl Cut t egitor onl I's March (tle initial lan1ding had,

]ieli oill tle th'II) XViI I abut IU00 1ilit.s of blood -ollie fresli blood fromileh

.36th l+aellat ioul I lpitail auid :.onltll olltod firomj a liwq)51 lld ~ip iluic

Ray.. I fe found tie( 1,"t Port able SkIrigitaI I lo!pit al onl thle beach. antd t hat

A I efi oouu1 whI he tiicIop of Il iie I hick " s i rt rea ci ct I lie foun aiit corvs o1

ftact U rs. Ole mnajority of %i i i lcre Uiq t au it 1. 'Ii Ic( )51( P~ aic litle I 14cgb

fretit -bad1 jtlinlled 2,1010 men of %Nltoln 152 hiad been iimii'd. The t hiird %%avo

bf jumnpers had I c ie l ii eti e IN lt-iii .Ja I a Ilese. TIIv:Mv %X eric e lotgig

fi-iire8 givenl at ile re-rillielita*l comml~andl ji0.,t t t hat Iii.Tl rcue

folund had I itilte ei itofli t ho jtinip.

('olonel;Alt-Go% an or-aiiieda sltrivaI smtup) cooftj tit, I lt Portable

Surgical I lospital and tlte'03 UPl~eikieiirs lil k tletaldili(11ii Mni bV",1ii to

ateil~. At. 2~ l %b, ater ian out anti late couild iint Ile iti-et.

Duriiig that 1iiit . Ow lie lrs of tiet Imind explosions totil-'ed %Nitli lilly

ca~taJ~is. There %%a, liticli fireili1 ilig allow thle btiillm. I Ivre. (pill of t lie

(lililties (Itle to tetra iii X~a, thle lac-k of %\mai a., t lie- Rod, %\as to be s upplied

1w akuer boat M lijci had 11o1 culivi ill. Aiililantic veacatit 11,1 ttil i to lte

* beach wvas utndier snilall arlii, fire. anit olie t.oio% \I~ - toritietl bac~k.

* ~It 1%,as ilitere't ill. to note that liolit. of tile cc-ot ctmpililld ractl ihe of

tile Memr. tint t'eateti for 1 ll hitiurs. \ vllt ilitti slick \X li del ited andh ioiiiiuo-
~~~72 ~~~AOTIVITIES OF SRIA OSLAT

bilize. ad, that no.bad effects were, notedfrom the use of. the outdatd'bio'd

The line.of evacuation from Corregidor was as follows:, From tie stop

of, t, amulnc oi to , hebea ch; f rorn the beach, by LOM (IadingIi '

craft,,yiechaied) a ind LST'landing ship takfoiud a;by~klne

from.h.bay "to" th~e 36th.Evacuation.Uospital. There were ventuaily. on

'Cor egor one large- operating ,room With three tables, a plaster .roolp,1 a. Srcovey ward, and'agood surgical team.

EVACUATION OF cASUALTIES •

The methods of evacuation ranged all the way-fron natvelltter bearers,

to Ducks (single.engine, general-purpose- amphibian ,airplanes),:ambulances,

Watecraft, and air evacuation planes--L-SB's wlhich, could 'accommodate one

litter or one sitting patient and 0-47's. There Were all manners and combina-

'rauatioiv of casualties by 0-47's implied the necessity for a condition,

Sof security for the most part. Evacuationby J-5B's, wh ile tedious becaus of

the limited carrying capacity and range of the planes, was of extreme, value

in Colonel McGowan's experience because it could be carried out when. the4e

was no security and-was lifesaving in many situations where evacuationi byroad was impossible. For instance, during the Battle of Zig Zag: Ptss,

the 64th Portable Surgical Hospital found itself entirely cut off in the Dhnalupihan area. The staff had been operating for days on all types of war injuries,

had about run out of supplies, was crowded with postoperative cases, and was

running short of food. Colonel McGowan took a surgeon from the 36th

Evacuation Hospital and three L-B's from the airstrip at San Marcelino,,

Luzon, landed near the hospital, and set up an evacuation scheme whereby, in

48 hours, it was possible to remove all of the wounded.

The maintenance of close contact between the hospitalization and evacuation sections in the army surgeon's office was necessary in order to avoid the

dangerous piling up of wounded soldiers in forward areas. Evacuation of the

wouided from the frontlines by light aircraft was frequently resorted to by

the Eighth U.S. Army during the Visayan operations and was responsible for

the saving of many lives. Evacuation by C-47 or C-46 hospital plane of

postoperative patients from small islands with limited medical facilities to

larger bases on neighboring islands kept the forward zone in a fluid state and

prevented the accumulation of postoperative cases where their care would

seriously hamper the already overtaxed personnel (fig. 100). Considerable

credit must be given to the sergeant pilots who flew the light aircraft. Had

more planes been availaule at the time, mauch more effective work could have

been accomplished in the care of the wounded.

From the experience with these and other situations where aircraft were

used in the evacuation of battle casualties, the author was strongly of the
;-, ':< IGHTHfUhS. :ARMY . 578 L<

opinion.thht air evactuation ,of the -wounded- slould be under the controlof the.,

" ,inyisurge h or,,his,,ipyresentative,,and'nota ,,funcitionof, G (oistics(sup..

n, 'several sitiations, where aircraft 0 'both typ es were, se up for

evacua ion ,othe Wounded by G4' there-was 4he temptation: to use the!sair .. erfi f6 the fransot~ nhoiedical.:freight, a practc' hc ineferwt h

he dule 'et. fip for evacuating Waent&~

S9URGICAL .SUPPLIES AND AOL- BLooD

In i eneral, the mdical; and surgical supply situation was.:adequate, At.

tfines, whenthere w're.temporary failures of supply, -thos iailures .were .du

ThUtIior would-like particularl~y to, compliment the Army and the Navy , authoriti~en their wholblood prqgram. The bood-began to arriv6.oiLytp

:inNO~6vbe6r 1944. It Was well packaged with 16 units of Whole blood to a

co ntainer ;in which were 17 pounds ofei'acked,,ice, The accompanying tubing

was reaction proof, With the-advent of these units, transfusion of whole blood

ecame as simple to a~ndinister as plasma had been, and 'more and more whole

blodwasu6sed. Up to thiis time, the surgeons had'been prone to use plasma

'father than whole blood because plasma had been.much easier to administer

and its valuo had been too enthusiastically stressed (fig. 101). Toa large

extent, they were using a makeshift type of tubing and methods -which led to

frequent.clotting, reactions, and other unfavorable results. Throughout the

entire iete campfaign and subsequent to it, Lt. Col. Frank-Glenn, MC, Consultant-in ,Surgery, Sixth U.S. Army, and Colonel McGowan insisted upon the

use of whole blood whenever possible.

PORTABLE SURGICAL HOSPITALS

Portable surgical hospitals were originally set up for jungle warfare, where

larger units could not operate (fig. 102). Their chief weaknesses, which were

obvious toward the close of the campaign in the SWPA, were:

1. The mediocre abilities of the professional personnel-to which generalization there were some outstanding exceptions-and the many replacements

resulting from rotation.

2. The lack of equipment which seemed adequate on paper but was woefully lacking when it is realized that these small units practically bore the

brunt of frontline definitive surgery. They had no generator, no electrical

illumination, no refrigeration, no suction apparatuses, and no resuscitation

equipment.

3. In the press of work, they were not set up to function independently.

Consequently, as often as Colonel McGowan could, lie insured that they were

attached to separate clearing companies and reinforced with surgical teams.
ACTiVITIES M" Sl RGICA1, C()\sl LTANTS

MW k kv

0 WINN
EI1' 11dt 1111 ARMY U~I 575i

I'4~ itiat of pat ivllts to be v~ ucmi tet ftoiii Thatatig attlie 0iltlit litesidoilt t 21s Aprtil I1915.

It. Vie%% of littler paltien't living tatded ino C'-47. C . Intlerior (of lmntd( C-17.

SURiICAL TEAMS

lit tihe SAi'A. thieit' welt' lioliv of thet aitxiiiattN Irgicill gttollp'; Nilieltk

MC(. ttt-gali/t't a1 -t'ta'- of, lll.icai tealins lit, takenl froti teal. vecelon ttunit."

Meidt att ix t'liled i men. A flee Coontei P'ir oti, he4t tileo :WiAVA Col. 1.

InI~.S. P)lI INiAli viiO. l Sui BiAR .FA re gdr

Beachtl Wal eithe thu Ntil callat iolotptI t e-' ailt iliterel. i~t vll ofT tNo
570 ACTIVITIES OF SURGICAL CONSULTANTS

PIa titl 101. AdiliisI tat of poisino t,) pai lent duri ig l itt er catri3 , Min datnao.

acted as anl evaciat ion hiospit al lt ip ( g.y 103). Th'ese I L~received patienits

t1-li i daylIight hiI ours, pu11lled 01151o I :it t dtk.alid retmaited at seat duttring

the night. They had U.S. Naa , N silr-gical It eani. These evatisl Consisted ra rely

of well-trained surgeons. Colonel NMc( lo%%,ii would aa iagutent lugr the

stall's of these LSTr liosIita.. with well-t rainled surlgeons fronlt ile Armly to dto

thle surgery oil thtemships11. Ail opdit ha liiiologist and a I tell rostligeol k were Ilequired inl thle surgical teanii. ()It Luizoit, il ttle XI Corp" actijolt (Zig- Zag Patss,

B~ataan, Corregidor) , t here i ah no t ta ited tiplithIalntic sillgeol i. Fortuittately,

Colonel McGowanl located a1 U .S. N ava imedical olhicer trinied ill opl it Ita1lology

who served as a couisnlt ant. Inl tilie alit Ior'z opit ion, ciosev coolpetat it bet a enl

thle Medical C'orps of tile Artiy aind thle Naa y ill a1it 1 dtibioul. NNarlfare aa as I itll.

Only tltorouglN Iraitteil penstliitel shlitih be eti"Iitet %itlk the receivling

and (disposititon o;f casulaltijes.

Oil Ilia ty 1,lndings. I I a eI' e storage .t lacevs for illi it. of aa hole blood.

'rTe storedl, refrigerated blood ,htouIld It tae been packed 1) plan.~ NN it Ita ittedical

officer re~spouts'ible for itz care. :xrveltj utgt. anud di~t ibiti olt. Tloo ofteut, blood

was (list ribuited Itaphtazarddl thtroughiout a .olt o% attd %a s dilitilt to locate

(fig. 104). The handling of w hol blod Na amuitchi more elhcietit a htei a --eSIpollille pl)&-soli Nats inl clia rge.
EIGHTH U.S. ARMY57

FIGURE 102.-Opera t lg scene, 23d Portable Surgical H ospitIal.

TREATMENT OF P~ARTICULAR TYPES OF WOUNDS

The t icatinent of Nvtr wvounds has beeni well covered elhew1here as a result.

of the extensive data which caine out of thle war thieater . The auithor, however, Av'otlld flie to stre's somle of the following observations with respect to the

treatment of regional injinrie,,-observations ba:,ed on his experience as the

surg-ical consultant, Eight h U.S. Arny.

Abdominal injuries.-There must be rouitine use of grastric drainage with

adleqtato suipportive therapy t hrouigh the liberal uise of blood and plasina.

*Wire stit imre' d-ould be emlployed to clo~e the abdonudiiia %aI ill n eriolus caes.

There should be more f requlent nse, of t rans% er- e and obliquie iinciionts.

Chest injuries.-The earlier (liagno~si6 of umassi~ e helotliorax niust be

Ur',e d. Open totacotoniv shouild be resorted to a.- ,ooii as it is indicated and,

nigneal soonler thanl it wvas (lne. More intelligent, use of lnlorphilte i ' requiiredl. The stirgeon has to distinlu it bet weemi thle rest le' mmew due to tile

lack of oxygen and real pain.

Wounds and injuries of the femur.-Thorough bWt. not too radical

(lebridlent itutst be practicedi and must be followed bY the application of

a1 doulble-leg spica plaster. Medical officer, smoldd appreciat e the fact that
578 ACTIVITIES OF SURHGICAL CONSULTANTS

in March 1915

a linml-sa\'in', (ebl'idlenent is a cliallei±~e ti tle wood :st1lgeohl and Illoic di i-It'II.

to perform t hanl a il Iillot iit mnpultat ion.

H E"COIMNENDATIONS

Ill tile event of any ftulre war,~ it will be l" toces iflace w ii 1-qima Ii ied

surgeon, inl forwvard medlical units ill orde~r to imlprove I lle carev of va.,imalties.

We~tll-iiilifietl 'Ilrgeolls IiiaY be tell~moamil?\ at taclled to he liitak act ivel.% enl2naMe(I ill t h~e Sulpport of Comibat (ipelat ion.ll.' ataihtei ol b lide

as it wats ill tile EtioiieaithIeater' I N, the emlipjlo~Ieilt (it alxiliaI " t'i.ta

grot(Ill)s. Vi 'Oll, specialist, Asi m l iev as. igri e to the fonm~'a mt are'e. and tilt-,

ten( t'aI lt11"lge , ill t hese areas should be capablt, id pel'tormuinaZ wajol' 'tii'gical

olpetat loll.

)Nevl v arrli vedl Inedica I officers5 sltold be allt ched for ra in i im, and

orienitat ion to active gemie'al I llo-litals, at all eall da(]te. 'I'lle ](Ne" v arr'ived

should also lie at tachied to imore forwar'd 1ilit for pro'per orlientat ion amnd

expierienlce inl actutal colbat, b)itt tilie Coimblat zonle is Ihut tile pilace to traimi sIlrt'

a ons mini thIe futndamental priniples of' 'vat tr. e
Iii~iltigt efo i re IalpIh % .5 (Ilr iiit lhol i 11v pal l ipi Itu- t~iindl h' ilg'y

ar.i andi oil oll'ial iall' zoi t't'ai'l " jili jl i I~dihi ot al IATotl it thoold

bt' ith' chhtl*A aill a ink of, liii. -ihltl okIIIIialiil oa ohottt ant ol at i o lit' v, nr a

ctioj1:10t' i l l01 ( b id al %% tt. o i. :1 Al a ll"pa (ei1- i 'i led it i o m .m (WO Si' .
und6jgone -long, trainingin the Zone of iteror a nd,.many inspcin as to,, ehuiient, ability to set up in, the, field,.et cetera, Hoever to the ,best, of.

the iuthotr's noWledge, no~ne of t hese-units had had an evalulation 'of'their

'The aut would strongly recommhend, that,, in the-future,under~circumstances -si'milar ,to those which ,existed in tiem EithVU.S. Army-during Worl&i

War I, si~gcal coinsultants beregularly assigned to each ,armiy orps, ? ad, a fqenyasbecomes ,necessary,, a consultan6 be assgned: o eachA diiii

combt
APPENDIX A,

Anestheiolo' ir"'Sidito SurgeCop tinued

ANra Relalilitathian i

, &EidA14 rii lykank r R. Obef

General9urgpry,.~rW WPune

br S~ne Harjfl Dr Ro4bort D. Sc'lrock,

Wlon

Neuromurgerr,:, ,llD Wlo

Dr, ,Wilaion Mxter, Dr. Jobn~macKensie:Browhn

;Ophthlmoloy Dr.Alhit'C.-FUirtenbiurg

Dr. . PhnisyCalhun r. Walter.flughsoi

-Dr 066 bliler

Dr C~iE B~dleyDr.lefoert .Meblv r

rr. sru Oere iec

Dr HroldR~ConrkicaV Phitography,

Dr U.Earl Conell r~ Mlton TAubier,

DrWilli Drch6wThf

-Dr Albert Key- 'D.,.....Alpua

Dr. Guy adbetier Dr.* Etraha M

606222-62--39
APPENDIX B

HiEADQUARTE RS% .SEVENTH4 ARMY

ASBJECtvSuiery,

M nihi ........ ...............----- ------ .... ... . 2

Tea~s~~-----------------------------------------4

St~cMicci~---------------------------------------..........

.......... --- I ......... ------- ------ -----

Plsm ndBlo----------------------------...... ----------- 7

Sulfonamides........ 6--&P..........-----------------------------

Burns ......--- _------_-----------------------------------1

1,The64uricaI policy that ivil- be followed, is. a deyeloliment of- those principles and

odsoTeaythAt-have been developed- ad, esta blished-b y NATQU SA4throughout-te

past eighteen mnts Fl use will be, made of 'a v~igorousttansfusion~reauucitation pro.;

gram by theestablishment oft blobd-banks within each, hospital'6 1' with theasitneo

theArm ank(Se. Bl~d Vi) nd he obie lbortoresControlof infection will-be

stenthened by' te use of penicillin, 1hc w)l4b availbl in sufcetqatte ota

treat~mentmay. ,be continuous from the Field -Hospital! to the Base. Treatment-of thepatient" m ust", be considered 1as a --continuous' u iie d effort with 'utniost copration -and,

clarli ofiteatment aud records -by-.each- echelon conicerned. A combianatio 6 the avn

of ifean lib wthearly restoratloa of -functiont and rturn to duty 'should be the aimof al installations.

* 2 Brpfi. Ei~chelons. Extract from NAtOUSA Circular on~orward Ourgery:.

a Th wefar ofthe patient and the tactical necessity for rapi,-e safe,

eiacuation, demand, a clear understanding of the function-,or mission of ,each, unitof the,

Army-Medical Department. This -is best arrived at by dividing the treatment of-a casualty

Into, two stages-"prmar and definitive. Separate groups of -units provide each stage o!

i reatm ent. ]ih general, the e'juiprnent of each group is designed for Its particular purpose

IF Y. ib. Aid Stations, Collecting Stations, and Clearing Stations (First and Second

Echelons) -are equipped and staffed to render the primary phase of treatment. Arrest of

khemorrhage, splinting, resuscitation measures needed to make the patient transportable,

ind adinistration of sulf Ionamides, are the prime functions of thes sttions. In addition, the 'treatment of minor Injuries is 'carried out without evacuation. A ClearingStation is not designed to provide definitive treatment of battle casualties."

c. A proportion of admissions will be flontransportablea. A nontransportable is a

patient that cannot be evacuated farther without real danger to life and limb. (FM 8-10,

par. 65c.) These patients will be transferred immedif tely to the attached Field Hospital

Unit in support of the Clearing Station. No surgery will be performed forward of the

Field Hospital.

d. Third Echelon units, Field and Evacuation Hospitals, with attached Surgical

Teams, are designed to Initiate surgical treatment of battle casualties. Every effort

583
584AOTIVITIES OF ,SURGICAL ,CONSULTAiNTS'

:shoud, be made to.delivercasualties, requiring hospitalization to the.ge units as qulckly~As>

sibl6s that 'lives miay be saved, proper surgical care, instittedi and convaiiescenc4

'k6~enedi

'(i) The Field Hospital Units supporting Division Clearingi Statloug ar&, bequ6iped to care for non-transportable casualties, These 'conslst :of two'groups r

hsthe sufeing, from,, grave life edngering' physiological. disturbances, suchAs -hem6-

6hagd, severeshoclk, caidloresplratory !inbilance from wotfiids.ot',the.perieardium or ,large

suckieig wounds of the chest intra-cranial presure, and certain m'axillo-facl. orneck

ionids 'in which there is obstruction to respiration. Second, there is the groupoiof Am- "

peOing fulnifiating infections; this includes all, thoracoabdominal and abdominal wounds

oro w6tuds in other areas thatmhy 'have penetrated the abdomen, such aswoundsof the

buttocks and iighs; 'extremity wounds with severe vascular injuries or evidencewof gas

infedt on, major 'traumatic amputations, and compound fractures of the long bones with

extensive'softparA damage,

.. (2) Th6vacuatlon Hospitals, are of two types: The semi-mobile 400-bed,

750-bed Installations. To these are transported all cases not requiring the flrst'

Priority urgent surgery of the Field Hospital units, and also medical and venereal pti'enti, !

At times certain of these units may be used for specialized triage purposes.

3, 'Morphie. An initial dosage of morphine sulfate, gr. 1

A (0.015 gins.) is sufcient,

Poses' of gr. (0.030 gins.) are too large: such dosage causes too great respiratory

depression, is definitely bad for intra.cranial and maxlllo-facial lesions, and accomplishes

no more than the smaller dose In abdominal and chest casualties. Whenever morphine Is

administered, the amount and time will be clearly recorded. Morphine, when given subcutaneously, is poorly and slowly absorbed in patients who are in shock; therefore,

repeated administration in such cases is fraught with real hazard, for, as recovery from

shock ensues, absorption of the accumulated amounts may be rapid and morphine poisoning result. This danger may be avoided in such patients in shock by a single dose of gr.

1, (0.010 gins.) to gr. 3/4 (0.015 gins.) given intravenously, never more.

4. TPetanus. A stimulating dose, 1 cc., of tetanus toxold will be given to all casualties

in first or second echelon units. This dose will be recorded in the EMT Tag, To date

there has been only one (1) case of tetanus in the U.S. Army in this Theatre.

5. Surgical Procedures.

a. Dressings. After initial application, dressings will not be disturbed until the

Field or Evacuation hospital is reached, except for hemorrhage. They are inspected at

each stop along the line of evacuation, however, and splints readjusted or dressings rearranged when necessary. Frequent and unnecessary change of dressings increases the

risk of hemorrhage and infection and also increases time-lag from wounding to initial

surgery. "Innumerable sufferers in every war have beer bandaged into their graves at

the hands of over-enthusiastic dressers." (Jolly)

b. Tourniquets. Tourniquets are seldom necessary and frequently misused. When

applied properly for otherwise uncontrollable hemorrhage, a tourniquet may be a lifesaving measure. When improperly applied, however, bleeding is increased and complete

exsanguination may occur. The sole indication for their use is active spurting hemorrhage

from a major artery. For hemorrhage from veins and lesser arteries a small pack and

bulky pad bandaged snugly over the bleeding point will almost always suffice. To date

the tourniquet has been used with guod judgment by Aid Men and Battalion Surgeons. In

applying the tourniquet, if rubber tube or bandage is employed, 2 or 3 turns are made

about the limb stretching the rubber between each application. The knot or ends are

then to be made fast so as to prevent any slipping. The limb is observed for a few

moments to be sure that hemorrhave has ceased. If not, the tourniquet must be readjusted and tightened. Unless the uoarniquet is so applied as to accomplish its purpose of

stopping hemorrhage, it is not only useless, but harmful, and may well cost a life rather

than save one. When non-elastic material and Spanish windlass mechanism is used, a firm
A. PPENDIX.:B 13 -,585 '

'pad. 'rmrSiobandage'is placed over: the, course :of theartery, one ,turnr oi',the tourniquet

miadle about the~liib, and,'the tourniquet-tightened nti ailbleeding stops. Thewindlass

igsediird -4oAhatrno relaiationocurs.and the-limb observed~for:afew minutes. Do not

ap4 y' a tourniquetdirecty *over, the skin, Jfrpossible. Leaze a layer of: cIothing-or 'towrel.

aiIce; VWhenever atunqe -has been applied, this will beso noted'in-CAPITALS',

on t.e kM.'T Tg ad t reason therefor stated as a guide to alstations tobthe Fieldc. -Amputa . ons, 'The policy on amputations ts oneof conservatism. Every effort wil.he: made:to save land give the limb a-cksnce. Tbe prompt administration of peniilin,

:metIculous.d1bridement, and possibleparavei,.,bral sympathetic block will help. Aiv. puttions wi'i.always beperformed at the iowest possible They Willbe 'eel.circular, the

incision :passing through each tissue-layer at,, the level- of retraction of the next most,

uperficial layer; Le., sin,,deep fascia,: muscles, bone, no primary suture, A loose covering:

of fonemesh diry or [ atmimpregtd,-gauze wll-be: placed over the surface and,

skintraction-down-to the skin edge applied immediately. 610 pounds. are used. When

ipplife evenly- this has the-beneficial effectof an, even-pressure, dressing. Packing will

Nt,-be-.iiged. in lower leg amputations- some type of posterior, splint from midthigh to

eyofidt e'.stump is provided to prevent cotracturdiat theoknee, A Thomas-splint or

plaser cuff wfth wire cage may be used for attachmeii of traction. No skin graftlngoor

scondary suture will beperformed in army installations. The object of amputation for

traumais the saving of life and as much limb length a possible. Every inch saved is of

great value in forming the final useful stumps, This, however, must be left to Base and,

ZI Units.

d, Debridement of Wounds, Careful attention will be given to Circular Letter,

No. 26, Office of the Surgeon, NATOUSA, 19 April i944, Subject: Wound ManagemenL

"The keystone of successful wound management is the initial surgical operation. WL;.sn

this is performed correctly the complications of infection are absent or minimal and seeondary -suture may be carried out promptly and successfully." Chemothera.,y is an ad.

junct-and can never be substituted for meticulous, complete, proper initial surgery. Good

light and wide incision to provide amplo exposure are necessary to permit adequate removal of damaged underlying tissues. A team of two is far superior to the single operator.

All foreign matter, loose and unattached bone fragments, damaged muscles, and fascia

must be removed at the initial procedure. An absolute minimum of skin is removed and

wounds are never circumcised. No primary suture, except of cranial wounds and somue

wounds of the lace.

(1) Head wounds are to be transferred promptly to an Evacuation Hospital

unless there are signs of intracranial pressure or uncontrollable hemorrhage, when they

will go direct to a Field Hospital.

(2) Eyes. One (1) percent atropine is to be instilled, an anesthetic bland

ointment, such as butyn metaphen smeared liberally in the eye, and across the lids, and

a pressure dressing held snugly in place with overlapping strips of adhesive applied. The

patient is then sent to an Evacuation Hospital. Here a conservative policy will be pursued

and every effort made to preserve the eye. There is no danger of sympathetic ophthalmia

within the first 3 weeks after injury. Therefore, unless there is danger from infection or

hemorrhage, great conservatism will be practiced.

(3) Maxillo-facial. Ensure an adequate airway and transfer sitting or semiprone to an Evacuation Hospital. Occasionally it may be necessary to send such a casualty

directly to a Field Hospital.

(4) Chest. These patients are to be sent as No. 1 priority to a Field Hospital

when there is continuing hemorrhage, signs of cardiorespiratory failure, or suspicion of

abdominal involvement. Otherwise, transfer to an Evacuation Hospital.

(5) Abdomen, and Thoracoabdominal cases are all sent direct to the hospital

nearest the Clearing Station, usually a Field Hospital. Wounds of the rectum are in-
ZW8 ACTIVITIES OF SUl1GCArt CONSULTANTS"

clid d li, this -group. Wounds of the buttocks and upper thighs~are frequently, In thIs9,:

gioi. A irecta exatuination-will be done oh all' ca'es; 11l6od-6n .tbe exam~iqgpge

hi| llisr~tal nolovement. ~A colostomy is performed for , all Wounds oftii m,..

prferabi y of te simple lop type. In all.wounds of the colon, the damaged, part Is :ex-2

irioltsed, or if th wound is in a Axed portion of the-colon, a proximal eoioy is

perforiied. Theabdo inenis aiways closed with through andthrough sutures;,-the pjiltoneum and, posterior and: anterior sheaths may be closed in addition.

'(6) Joiat will be widelyopened, meticulously debrided'of all foreighijatte .

dead tissue, loose and ragged, fragments of bone and cartilage, andblood clot, and, t en

Stbhrughly irrigated with aliine. The synovia is then closed, a'flapof fascia orskin]beifig

utili'ed to close defects when necessary,, and 10,000 units of penicillin (250,units per cc, !in

salifie) are injected Into the joint. The skin Is not to besuturedand no, drains are to be

used n to the Joint. The limb is then Immobilized in plaster, For the knee, the most com

inoi and important J6int affected, a hip spica is applied, Under periods of great stress

a-ehcliar upper thigh to lower leg cast may be substituted. For Immobilization of;the.

knee this is not as good as the hip spica, but Is far superior to the usual lower leg. midthigh-cast, Which permits rocking of the joint. The cast will be split.

(7) Comtipound Fractures. Mau . casualties with compound, fractures-of, the

long bones or traumatic amputations are in severe shock or have lost much blood so that

prompt resuscitation Is necessary. These are transferred direct to the Field Hospitals.

The purpose of the forward hospital is not to treat the fracture but to make such casial.

ties transportable to the rear as rapidly as possible where treatment of the fracture will be

undertaken. For this reason, only thorough debridenment and plaster immobilization of

these cases will be carried out in forward hospitals, and parenteral administration of

penicillin begun (See. VIII). Internal fixation will be used only when it is evident that the

circulation will be jeopardized by inpliugement of the bone ends. Pins incorporated into

casts will not be used, They do not transport well. The transportation cast is the safest

and most practical and comfortable means for transporting such patients to the rear.

These casualties will be given first priority evacuations. Such casts will also be used for

extensive soft part injuries without bone or joint damage.

(8) Nerve Injaric8. Nerves will not e sutured in hospitals of the first three

echelons. There are no exceptions.

(9) Blood Vessels. Rarely it may be possible to repair wounds of major

arteries, If not, they are to be doubly ligated and the damaged portion excised. Never

ligate In continuity. The accompanying vein is ligated and divided, adjacent nerve trunks

are injected with 1 percent procaine and paravertebral block of the sympathetic chain

with 1 percent procaine Is performed. This may be repeated at 12-24 hour intervals or

sympathectomy decided upon. Cases of major vascular Injury will be sent to the nearest

unit, generally a Field Hospital.

(10) Evacuationt. As far as possible, no abdominal, thoracoabdominal, head,

or major vascular casualties will be evacnlated before the 10th or 12th post-operative day.

The same applies to the more serious chest cases. Such patients do not tolerate transportation. Fractures will have first priority.

(11) Records. The need for careful, accurate, legible, records is emphasized.

A concise, clear description of what is done in each installation is essential for the best

uninterrupted and continued care of the patient. The "how, when, and where" of a wound

or injury are the first Items to be noted. The "when" includes the hour as well as the date

of occurrence, and the same applies to the time of arrival in different installations. The

type of missile is also noted. It is particularly important to note on the record, and also

on the cast, the presence and size of skin defect, the type of fracture, nerve and vessel

lesions, and the type of colostomy formed and length of spur when present. Sulfonamide

and penicillin therapy as to amount given and whether or not continuance is desired will

be stated.
APPND1X I, -5

8 , Plaster Casts. When- plaster of paris is, used, no.circularadliesive, or bandage will,

betapplied underneath the cast, Allcasts areto-be-padded, and:all are to lbe split throgliout their',entire length immediately. This splitting must include ailllayersiofercaitr .

• padding or dressings down to the skin. Unpaddedor unsplitcasts ha:e*i0 place in f0rward ins i'a6ns, 'T foot is a the leg, the-knee-and-hip flexed very

lihladte toes'free. The piantar surfaceof t66 cast will extend beyond tbetoes ora loop beyond the toes made so as to wlthstand.the wbight of the bed.clothes, 'In arm

e~sithe arm is in neutrhi position, ,slightly forward, with the wrist and hAnd supported'

i neutral position, or in cock.up. Flexion at thewrist Is iot -to be used. Casts-withthe

.armin full abduction orhanging-casts, Will not be usedi as-these are very p0r-for trans,

,prtation. in thirdechelon instaliations, casts-are ied for transportation, purposes as

wejlas for theunderlying iajury-soit part, or fracture; bence, transportability becomes

an. imporitnt, conslderatloh ,

, and the castapplied accordiaigly. -Diagrams, dates of Wound,

aid'cast!ing, mi~d notes wir1be written on casts With anindelible pencil,

7- Plania'and Blood. Plasma is, used in alplaces from the battlefield'itself to the ZI.-

As a. measure of resuscitation, its value rests chiefly in supporting the hemorrhage or shock

,casualty until-he arrives at a station where whole blood.is available. It Is in no way,a

subtte for Whole, blood. Up to '50 ccs, may-be given rapidly, After that there is the,

danger of further diluting an already grave hemodilution. Careful perusal of Circular

,eter No. 30,, Office ofthe Surgeon, NATOUSA, 12 May 1944,,Subject: Blood Transfusions,,

!is recommended, and its instructions will be followed, An Army Blood Bank Unit Will

furiis h low titro "0" blood to the Field Hospitals. Depending on the demand here, some

,may be, available for the Evacuation Hospitals. This blood may be'used for all patients,

inamounts up to 1,000 or 1,500 cecs. After this, specific type blood should be used. High

titre "O"'blood will also be available but the use of this must be restricted to "0" recipients. All recipients and donors will be erossmatched. This may be rapidly performed

(3-5 min,) by the centrifuge method and doubtful cases checked by the longer slide

technic.

a, It 1 essential that the Evacuation and rear units maintain their own blood

banks as outlined in Circular Letter No. 30. Only in this way can adequate supplies of

whole blood be assured. Blood will be used judiciously and not wasted. Only the amount

needed to bring about adequate resuscitation and carry the patient through his surgery

and post-operative period is to be given, for the risk of fatal anuria is not negligible. There

will be adequate blood available at first, but the various units will organize their own

blood banks as rapidly as possible.

8. Sulfonanides and Penicillin. Sulfonamides will be used both locally and orally at

the original dressing of the wounded casualty. No further local application will be made

until the patient reaches the Field or Evacuation Hospital, though oral administration will

be continued. When admitted to these installations all except the certainly trivially

wounded will receive an initial injection of 25,000 units of penicillin intramuscularly,

which is to be continued on a 3-hour schedule until stopped by the Surgeon. At the first

dressing or operation he will decide whether to continue penicillin or sulfonamide. Both

will not be used. Instructions given in Circular Letter, NATOUSA, Subject: Penicillin,

will be carefully followed.

9. Infections. The Clostridial infections comprise the important group that is encountered in forward surgery. Early, careful, thorough surgery, combined with adequate

blood replacement and penicillin is the best preventive. Sulfonamide Therapy is of no

demonstrable value, either as a preventive or therapeutic measure. Certain facts relating

to the incidence should be borne in mind. About three-quarters of the cases are in wounds

of the lower extremities. One-half are complicated by fractures, and one-third by vascular

injuries. Yet the mortality is lower in these two groups than when only soft parts are

injured. Apparently less concern is felt over the possibility of "gas" in this type of wound
.:.- 88 ,- , ACTIVITIES oF sURGICAL CONSUTT S

fiand these cdses are-not recognized earl.*. Jergesen-hasdescribed the early symptomstas,: " " I, pain, L2 mental dhanges ,either hyperactiveoor drowysy and, apathetic, 3. 'rapid pulse Out,

of proporilon to temperature, 4. 'temperature. To gese.may- be added loss of'apptie.,

The most important and, common of these, is, pain, often with strikingly, sudden, onset.

;h isusould call for immediatore;dxaminationof the woundand notljust a,"dose of inorphine:afid, drop around later policy. Inspdtion,,of the weoindwillishoiw swellingi4sometime ski disoloatio, muclechanes, ossbly the ~presepce of gas,,pd pssbl

puttefactveodor. Early diagnosis may be greatly facilitatedby proper training~of the,

niising. and ward personnel, andisuiprvision, of this-problem by one or two office is~ir a -ifnt. in this wiAy Any -cfange in -a'patient's condition will'cbe -noted early, and brought

to the atientiouno1f the surgeon, and many valuable'hours saved. True clostrildial, myositis

-ou'd bedifferefitiated from anaerobic celiulitis. In the former, the-infectiqn, is ihnthe

mus ls or muscle groups, in the latter, it, is in the fascial planes, and the niuscles aro

uninvolved. Anaerobic cellulitis responds readily to wide incision, excision of, daiaged -

issiiegs, a nl penicillin. ,Vith the' use of penicillin, blood, and perhaps antlgas serum, -th

urger ' of true clostrldial iuyositls may be more conservativethan formerly. If- the,in

fetioi is litmilted to one or only a few muscle groups, these alone may be completely excised

and: awide fascltomy performed. No amputation will be performed merely for the control

of-the infection. If the limb is so badly impaired that it will be of no functional use, oi-If

after excision of the involved muscles the limb would be useless, then amputation is Andlcated. It should be performed at the lowest level consistent with a healthy useful limb.

It need not be completely above the limit of the infection for such infected muscle as may

be left can be excised and an extended fasclotomy performed. The patient may then ,be,

cafrled along on penicillin therapy and other adjuncts.

10, Burns. Burns will be treated by application of boric ointment gauze and pressure

dressings. The use of a snug fitting stockinet over the dressings is recommended, This

provides even pressure. Unless the burn is grossly dirty no initial cleansing will be done.

Blisters are left undisturbed or aspirated with sterile precautions. When cleansing, is

necessary, simple non.irritating detergents such as white soap are employed. Loose tags

and shreds of tissue are snipped off, No further debridement is carried out. Full aseptic

technic in caring for burns, with all personnel masked, is employed. Tannic acid or other

escharotics will not be used, In severe burns a secondary anaemia develops, hence, whole

blood, as well as plasma will be necessary. The employment of these will be governed

by the plasma protein, hematocrit, and hemoglobin levels, as well as by the clinical condition of the patient. Adequate plasma, blood, and fluid replacement is essential, but one

must be careful not to drown the patient with an over-enthusiastlc program.

11. The Patient. From start to finish, from the Aid Man until the final completion, one

way or the other, of the case, all those having care of and contact with the wounded, injured, or iII, must constantly bear in mind that he is one of themselvs---a human being.

Carelessness, neglect, and rough or harsh treatment will never be tolerated. The patient

must always be cared for as one would like himself to be treated. Thus, kindness and

consideration go hand in hand with therapy.

M. P. RUDOLPH

Colonel, MC

Surgeon
INDIf

A4LixNLt C6L.J.-R,, Jik,, 301 Arnericar.,Bohrd of guifgeryi 21,6M'

Abscessi closildlil, loalzed, 326 tlion,,111;

bscess peicillin therapy li , 21 Ame~rican College of Surgeons,22, 111, 170,

A C souti3. eiAcdcitr te-dextrose American Cyantimid'Co., 184'

solution ~~~Aimerican ieiinr oc~

Acdhyroyaie'83,092 Am~rican Mheihg kSciety, 112;

tn ie,'i treatmeto hsa A erican Iarnglogical, .RhInological ,and

burs, 4; tological Socilty,, Ill

Acid~citrW-~dextrose solution, 145-146, 161 Ameilcan Lary I gologica Socety

-AnM~~t A J, 63 American Medical Asgociation, 20-22,111,

An?~sMj.C.i),278 American Ophthalmoiical Society, 02

kA'A H, Col ',., 21 Amierican Orthopedic Associa'tionj,42

Adjuialitbeneral, The, 116' American OtologilcalSociety, 111, 119,

* Aaits, Capit. T. F., 427 American Red Cross, 180, 133, 135-18184 40,

Admhiralty Islands, 502 150-151, 482

Adrnaln, 27assistance of, In Army Blood Program,

Afi 31,3860, n 386 135-136

Ageat.s of chemical warfare, classification, participation of, in Plasma Program, 135-

of,' 83-92 136

* Air Surgeon,The, 240 American Red Cross Blood Donor Service,

Ali'Trahsport Command, 172,240 136

AZT" EN, kaj.t ft.H G., 273 American School Center, Shrivenham, 300

Albumin, -157 American Specialty Boards, 6, 31

Albumini, Wvie, 137 American Standards Association, 112

Algeria,'265n, 336 American Surgical Association, 22, 20D

Aigiers,-295n; 336, 338, 385, 514, 514n, 525 Amputation:

Alife, 300,408 causes of, 41-42, 324-326

ALLuoBE, Maj. R. MI., 59, 201 centers, 56-59, 201-202, 219, 221, 279-281

ALLEN~, Lt., Col. H. S., 359,365, 444, 445 conferences, 59

ALLEN, Col. K. D. A., 368 open circular technique of:

Allied forces, 375, 448-449 directive on:

Allied M.VI litary Government, 349 Circular Letter, No. 101, Office of the

Alloys, Imaghesium, 83, 93 Chief Surgeon, HTOUSA, 19)44, 326

Alsever's solution, 144-146, 151, 530 research center, 279

Ambulation, early, 246, 251 sections at amputation centers, 57

* American Academy of Ophthalmology and statistics, 57

Oto-Laryngology, Il1 vascular inJuries as cause of, 41-42

American Academy of Othopedic Surgeons, Amiputations, 56-6, 324-326, 331, 561

22 ratio of, to battle casualties, 561

American Association for Thoracic Surgery, reporting:

22 directive on:

American Board of Anesthesiology, 548 Circular No. 15, Seventh U.S. Army,

American Board of Ophthalmology, 532 1945-547

American Board of Orthopedic Surgery, 219, Amputees:

282 motion picture on:

American Board of Otolaryngology, i11 "Swinging into Step," 62

589

606222-62-40
590 .V;r.IVITiE8, OF SURIIAL CONSULT'ANS

"Ampufiee's, uppet~extreiuity:Ares-Citnd

mjotlowipictures on: USAry,1, 29 9ii28

,'4Diar , df a Seieaut,"1-62 308, 30, 97, 505-5ol04

We~tMGonei;6 Sixth U..A y 159-160, 102, 6A0

AMS~, /J~ W IL,335-37~ 85, 391, Tenth' U.S.Amy W

4j, ,.SArmj ,1 .482

Amy iftrte,7treatment of cyanide poisoning Army Air Forces,,10, 57, 95-90, 100, 141 109,

Al~'h'i~ 1n' 122,4134,4142, 173,22. 3-4,~4~23

Aioi, icylatejp 84' 202-203, 205;284, 830,31,471653,

'Anstonioosi, 489 '52T

omoisgsclarFirst, 172-473,

04cmim of~32 Army Air Forces Base, Amarillo, 202'

A4464heaW89 548-550 Army Air Forces Regiooal Hospttal, iucey

iiatiniini 10; 36' 'Field, Denver, 240-

Apegti:Y681, Onddtracheal, 380- Armly Air Forces, Otation flospital: Afiesthesia,, inflltratiou use -of procaine Buckley Field, Denver, Colo., 24Q0

lijaricfiioride'foi, 37 duitport.Army Field,, Miss., 216

*Aiieshestglocal:Keesler FilMiss., 216

'dirctiv on:Maxwell Field, AMa., 216'

WarD9o0artment Techlumcal 'Bulletin 43, Army Air Forces Techinical School,'172

Loc al Anesthetic Agent, 1914-18 Army Dental Corps, 299

Anesthesia, spinal, agents for, 37 Army Grounid'Forces, 71, 210, 232, 240, 205,

Akimlotics, 1,ihalationi, appraisalof, 37-38 514n, 523 2

Aiibrysius, 29 Army Medical Bulot in, 2

arteriovenous, 262, 324 Army Medical Center, 39

false, 824 Army Medical Corps, 218, 227, 229

Annali of Surgery, 25 Army Medical Museum, 2.5, 27

Aittitokin,-gas gangrene, 32 .7 Army Medical Purchasing Office, 130

Amiria, 447-448' blood research program, 125

Anuria, fatal, p~rofoundl shock as a factor in, Army Nurse Corps, 290, 303, 485, 5024503,

331 542

Anzio, 142, 143, 341, 345, 349, 852, 855, 402, Army of the United States, 210,212,257

410, 41$, 429 Army Pictorial Service at Astoria, 81, 82

Anzio beachhead, 345-35, 352, 35, 359, 308, Army Prosthetics Research Laboratory, 59

375, 410, 414, 417-118, 420, 422, 532 Army Regulationscampaign, 340-347 40-596,29 Aug. 1944-194

evacuation from, 347-349 310-10, 27 Feb. 1943-24

landings on, 340 Army Service Forces, 10, 29, 07-09, 72,.74,

workload on, 349-350 79, 81, 80, 109, 147, 149, 172-173, 216, 218,

APA's. See Transports, attack. 232, 239, 240, 243, 205, 5-2

Apennmines, 342, 350, 396 ARNEsT, Col. It. T., 143, 335, 337-838, 391-

Appendicitis, 244,245 392, 519, 520

acute, deaths due to, 251-252 Arno River, 341, 350

Archiphiago de las Perlas, 82 Arsinie, 83, 92

Armies: Arthrotomices, of the knee Joint, study of, 555

Eighth British Army, 141, 355,440 Artificial limbs:

Eighth U.S. Army, 565-580 comnmission onl, 59, 61

Fifth U.S. Army, 142, 156, 333-404, 505, research in, 59

514nm, 524-520, 535, 544 Artificial-eye p~rogram, 103

First French Army, 507, 514mu, 510, 524, Asmii, Col. J. E., 27

525, 533, 538 Ashford General Hospital, 04, 234

First U.S. Army, 155, 299, 327-328, 330 Astoria, 81, 82

Ninth U.S. Armny, 3:30 Atabrine, 349
Ateectsi~ fca,fllwin lte, inhalation' Biattalions, Medical-Conitinuiedof musa: , ap, 87 5Ist"-7i M69;370!,

Atroine~n propertivemedcation, 38 d-9, 1

Auckland, 8 ot-f g40t 4410 396,x 

DeafnedandHar of earng,112120 Battey- General Hoopitai, 21p backg~~und an genral cnideratlins Battle oftei ge 31,32,2

deeomnto,14119' BaifercZ.,129:

Austalia 158482,504Back', CoV.'8, 27-232, 234, 237'

Austrla Ary eilCorps, 482 .B3anxi 1. Ci~oi. H.,K., 365i,408,-40, 410, Ausotralia looIid D.isibui~tion Chapter, M,5 414, 415;,420, 421I

Ausraia 1ed CrssSoiey 482' Blu,81

Auxlirysugialgr -pteams, 14, B334 R0831, 

Auiliariy srical groups, '06)8410,_385L-688; Tha, Brig. Gen.-F. B., 1114, 511in, 515, 510,

it,-93 537ki 546.

24-36-37,84, 39, 55,30, 3$-30, BIB maisk, 30

385,_302, 396- 39, 427-4, 445,1 505 Billingg General Hlospital, 234

508, 59, 36-53,~539Biologies 53-534, .Confr;ol'. Laboratory,.aina i

34-3s tttut6 f -Realth, 127,135,

o5th-30&8 Br s aiait A.,' Jr.j ) Ailoh;l' Fs.SOld ld 'ar C Con .BAs, Lt. Col.EB, B., 4,'212 "aecn opitl(pca) Blakemore tubes, 323,

BIAy-oCk, A.,4123. Back vAids,, 220 Brxsafi, Brig..Gkn F. A., 142-143, 38, 25; BA ( 3dinercaptopiropanol), 84,,86-89, Blind, care ofi 9-7, 1063

92,94: Presidential directive onl, '95-96, HBAL-4i oi and BAL ointmnt, use -of, in BLl8Ss,'Brlg., Gen.'R. W., 178

treaitmnentof sy'stemic poisoning caused Blister gases. See Gases, blister.

by eWisfte anid' other arsenical blister Blood, * Ole, 481-483,573

gasesestablishment of airlift of, 158-109

directive on: in managlement of shock, 38,122-124, 331

Njr ar Deopartment Technical Bulletin provision of, to Leyte, 159-00, 481

TBM ),101, 1944-86 provision of, to Luzon, 159-160,481 BAXCOT, . V,25provision of, to Okinawa, 160-161

Bai~-lftlMie 172 provision of, to Pacific, 157-161

-pail, 82,141 ciltique of results of, 161

BARkEM, Col.'M. H., 363 transfusion of, directive on: BABXNARD, is. B., 212 Circular Letter 108, Office of The Surr

BAIUStT, N. R.-, 335 geon General, 1943-39

BAHTOx, Lt. Col. W. U., 114 use of, 418-419

Bastogne, 310 value of, 331, 481

Bataan, 56, 575-576 Blood and blood substitutes, at beginning Of

Battalion, Infantry: World War 11--122-124

1O0th-372 Blood bank (s) :

Battalions, Medical: Australian, 482

1st-370 ETOUSA, 150

47th- 170, 395 Ilollandia, 482
-192ATIVITrIES OF SURGI C COSULTANTSg

in",thver sads ewinea, -:482Bso u6rnatre ,

coleton centers. See Ceanters, Biowss E.Vl . . 7

Blood 419, lasnia 81483Brachialp plxu,24

Aed ni' of,'38 :DD.nY, (en;,. O:N., 329,368

~Bki~dProgrm, 12-162 radle~ieidConn,12

Amerciit Cossassstace 1d n, 35- ,h~kllan P*xpeditionay Force, 30

Aripy-Natonal Ifistitute of H1ealth coop

Amy-.avy cooperation in, 128,4134, 16T- BRIsT , Brigadier Si .Roxr 5m5

izP'ifth U.S. Army, 417-421. British Army Woiod Snpplj~epot,80

;ii0No~th Africa, 410- 1rts-atr~s~re 3 136'

i~iVeuthku.s Army, 525-53 rihlgt Aimy, 141, 355,440,

Iciely, 4164171 iis oti4ii

'pi~~ims in 1001810BIoci , Sir MUsURlL, 3

respoilsibility for, 127,147 Brombenwyicyanide, 84

Blood replkacemeit therapy, 419-421 Brolupio4wesital, M35

te~chniques of, j19-420, llrpchopnieltadnia, following nintlatiooff

-Blood' Research-iiim Ank eia as, gus 87 'Sch ~ ~ ~ eicl ~ 127,ra Bol, mutr Hospital. 205n 12,129, 131, 133, 1,0 1 ~ ok 1eea ospa n

Blood -research program, Army Medical lkbiq , MaJ.F. B., 225

'School, 125- LtWN 'A .,1 -158-100

Blood transfusion Company 0&15-529 B~owN , Maj.4H. J., 334

'Bloodl transfusion units: If tWN, 3, B., 2i2

Iiih' Briish Field, 41'7 BaowN , 3. M., 105

603&d verhead)-508, 510,520o.52;1s-506 IiowNr, Maj. N. R., 273

671,3th (Provisional)-417, 418, 421, 52 Brussels, 312,534

lood transfusions: Bryn 'Mawr Hospital, 129, 130

directive on: Buckley Field, Col.,242

Medical Circular No. 10, Office of Sur- Buoo, L~t. Col. E. 1., 225

gon, Fifth U.S. Army, 11944--901 Bulletin of the Amnerican~ 0ollege of SurBlood v'essels: geo?4, 0

litigation of, 324, 489 Bu~lletin4 of the U.S, Artmy Medical- bepdrtrepair of, 322-324, 332 ment, 21, 24, 25,38, 72,79, 93

nousuture technique of, 323-324 establishment of, 28-20

suture lin, 324 July-1045--93

Blood-for-Britain Program, 135 November 1944-86

Blood-grouping serai, 146 Buns, 466

Bwoomnao, Lt. Col. W., 107 BUNNELI, S., 178, 187, 195, 2214, 228, 243,

Board for the Study of the Severely 253,268

Wounded, 415 BURA, W., 51

Boards, American Specialty, 0, 31 Bluutuxi, M1aj. B., 363

Bologna, 343 Bureau of Public Relations, War DepartBolzano, 458 meat, 24

Bone bank, 224 BUIWORD, Maj. T. 1I., 363

Bone grafts, nmssive, 224 BURUEss, Capt. E. 'i., 234

Boothby, Lovelace. Bulbuliaii Mask. 393 BuMNrnT,3Maj. 0. 11., 414, 415,420
1INDEX "593 " 

Bzfis410,4"L-31491,564 CapMyles StandishDebarkation, Hospital,- prsqrdressing- tlni 6,ftmfie i

jenti of; directive on C Myles :9tandish Station: Hospital,,

Circ i~~ete No. _15,-.Office-of The Mas,1-72

ueonii Geeral, 1903-45 Camp'Phillipsaio HpilKans,242,

prohiiti~lof'sof tanic add in ,treat. apRbra ai. 7

mnfii 6f4-,iei- ,ve~on r Camp Roberts Station Hospltal,'272

Circlar- LterNo. 16Ofce of The, Camp Shanks StatinHsial .. 0

SurgeowdGeneral,.IW48-45 Cm hlySainHsiaMs. 1

surgicaliiietgemint of, diretIve on: Cam Stofiemav Staio hoptlaIf. 7

War D)epartmeiit Technical Biietin ,Camp U pton, Convalescent 'Hospital, N.Y.,

(TB'ED)~151 194-4w201,206

sysemi maageentof, ,directive on: Camp Van Dorn Station-Hospital, Miss,, 216,

War epartme TehiclBulletin -Camp Wolters,' e, 267

01BME) 151,, 1646- -46; Capins

treatffent of, directives on Anzio beachhead, 348-47

Cdie'uaf tetter No, 41, -Office of The In Europe 295, 307, 313, 540

Suge &hGeeral,, 1943-45 Iin Pshce,540-

dCicu,iirLetter No.- 161, Office, of The in Germiany#,,540

Stig~oT~e~ra, ~43.-45in souther"n-,rance, 526

Burns, chiemial 92-04 In Southwest Pacific, 573

Burns, mustard, treatmnent of, 80, 84 Italian, 29N, 374, 400,429,431,505,531

Blurns, of the e ye, So Leyte, 467, 477-419, 481, 486, 404, 500-

Burns,- ther'mal, 44-45,94 502,565, 570,573,575

B ushneil Genieral Hospital, 20, 56, 178, 257, Luzon, 407, 478, 479, 481, 488, 488, 494,

270-20,286500,501-402

New Guinea, 500

CabariisHosptal,129North African, 304, 60, 534

Cairo, 141 North Apennines, 342

dALLAwAN, Lt. Col. J. J., 218-210 PhilI ppine Is lands, 467,567

CALLNDSR,.Brig. Gen. G. Rt., 125,127 Sicilian, 205, 2098, 338, 361, 368, 38, 445,

Camp BlAnding'Station Hospital, 216 505,531

Camp Campbell, Ky., 229-230 Tunisian, 295n, 549

Camp Carson Station Hospital, Colo., 240, CAMPBELL, Col. H. H., Jr., 360,388,460

242 Canadian Army, 137, 500-507

Camp Crowder Regional Hospital, 243 Canal Zone, 83

Camp Crowder Station Hospital, Mo., 242 CANFrIELD, Col. N., 4

CANN;ONx, Maj. B., 212 Camp Edwards, Mass., 172, 179-181,192 CAN NON, I. B., 123,120

CapEd9 dsCnvlscn Hsitl312 Care, surgical, evaluation of, 249, 329-331,

191-193369-374

Camp Edwards Debarkation Hospital, 172, Care of:

179-181 battle casualties:

Camp Edwards General Hospital, 179, 181, directive on:

187, 190 War Department Technical Bulletin

Camp Edwards Station Hospital, 172-173, 147,1945-537, 539

179 orthopedic InJuries:

Camp Forrest, Tenn., 225 observations on, 03-04

Camp Haan Station Hospital, Calif., 272 p~araplegic patients, 185-180

wounded:

Camp Hale Station Hospital, Colo., 242,240 directive on:

Camp Kilmer Station Hospital, N.J., 206 Circular Letter No. 3, Office of the

Camp Langdon Station Hospital, N.H., 171 Surgeon, 11 Corps, 1943-411-412,

Camp Mitchell, Calif, 285 410,423
54AOTIVITItS OF SURGICAL, CONSULTNTS'

carigra, ~Centero, neurostirgical-Contine

'Carlil arrak a, 614 eney Geea~sia,

HKe1. 4)0,,141 ~ L edy.Geiira'Uospitali219,

iutP T0^11a Mj :G., 204 Nrhntne~a~s~a,21

C~ aps V. 23Thonuis 11. England General 4iospltaflij

C~iTa, Cl Bx, 4,21, 127,, 142, 147,448, 264&03

1~8-Ceittersiorihopedic surgery, 287-

CagafihlncA,295n Keiefidy Genrl 'osptal, 219

Cai fatality rates, 542, 557 Lawson General Hospital, 219

for abdominal Injuries, 557 Nortilngion General.Hospital, 219

tb* anaerobic Infections, 60 Centers, pitrapiegic; 268

'for thoiaeoabdouiinal wounds, 558 Centers, plastic surgery, 234,287,320

forwounds of the thorax, 5M8 Northington General Hospital, 219

Casbitai'36, 374,376,526 CenterN, retonstructive surger, 266285,-)81,

Cas~ino, 3414342, 341 1, 374, 413, 414, 431 Centers, rehabilitation, 285,287

Clisting, 4125-420 Daytona Beach, 222

Casitaities froin chemical agents, treatment Welch Convalescent Center, 222

of: Centers surgical reconstruction, 276, 25-287'

directives on: Center", vascular, 234

War Department Technical Manual Central Institute for the D)eaf, 114

(TIM) 8-25, 1941-74, 79, 84, 91 Central Pacific, 8, 294

War Department Technical 'Manual 8- Central Pacific Base Command, 8-9

2&5, 1942-79, 84, 01 Central Service System lin Army Hospitals,

War Department Technical Manual 8- establishment of:

1285.1944-70, 84, 91 directive on:

War Department Technical Manual 8- War Department Memorandumt Na.

28,1045--79,86,,91 Wm-4(-14, 1944-19

Cora, Col. B. F., 179 Central sup~ply service, 189-190, 196

Cebu island, 567 Central Trask Force, 335

Cellulitis: Cernobblo, 457, 464

Anaerobic, 447, 563 Chemical warfare, 67-94

anaerobic streptococcic, 446-447 Chemical Warfare Branch, Surgery Diviciostridlial, 326 slon, Professional Service, Office of The

Center, amputation research, 279 Surgeon General, 67-71, 72), 74, 76, 77,

Cenetr, hospital, 819th-534 79, 81, 83

Center, prosthesis research, 279 establishment of, 69

Centers, amputation, 56-59, 279-281 transfer of responsIbilities to, fromn ChemiHalloran General Hospital, 202 tcal Warfare Service, 69

Lawson General Hospital, 219, 221 Chemical Warfare Center, Edgewood ArThomas M. England General Hospital, senal, 82

201-2102 Chemical Warfare School, Chemical WarCenters, aural-reliabilitation, 110, 112,) 114- fare Center, Edgewood Arsenal, 82

119 Chemical Warfare Service, Army Service

Borden General Hospital, 112 Forces, 67-69. 76, 79, 82, 83

Deshon General Hospital, 112, 119 Chemnot herapeu tic agents, 42-43

h1off General Hospital, 112, 114, 117 Chemotherapy, 42-43, 317-318, 550-551

Waiter Reed General HiospitaIl, 114 Cheshire, 299

Centers, bleeding, 134, 136 Chief Consuitant in Surgery, HTOUSA, 150,

Red Cross, 151 300. 311, 316, 368

Centers, convaleseent. 285, 286 Chief Medical Gas Officer, NATOUSA, 82

Centers, hand, 268 Chief of Staff, Seventh U.S. Army, 298

Centers. neurosurgieal, 234,268, 287 Chief Surgeon, ETOUSA, 149. 300, 311, 316,

Hialloran G enerai Hospital, 202-203 328, 535
.Chief-,Sugeon,'US!- imy-' 46 303 fSup Ciclar '6 LetteCof tinec Gn I

~ChW~i~gen, ,;;.ry Srvies f SP- No. 416, dfice,'of 'The gurgeon Gener3l

-Ch6V' Coniultant, In -Surgery to The, 'Sur- Noe6,Ofceo h ugenGnr geon'Geher3l72 2'St, 9 l92'

C iinarih .t ter! 'No, 16,ffc of ,The ;Surqeon Genebral,

Chloacetphenne; 4. 2 Sep. i4-174

Chiioral liydrate, in, treatment ;of .tetanus, No, 192, Obffceof The6 Surgeon- General,

49920:NoV. 'i94--24

Chlrin, 8~91civil Ian C onsultants, in. Surgery, See Conil

injry tirchea, and bronbht-by,, 90, 91 sult~nt(g) -In Surgery,Q Cii Iliah.

Chloro1picrin, 8A3,90" 91civilian surgical consultants.' See -CoiP,

inuytoiahea-an d broiwhi b ',90, 91 sultant(s), iw-Sirgery, Civiltan.

Choin gse,.See Gases, choking. Clearance of artilede for publication:

CI{UROHILLCol.', '§,,8,142 , 294, 334,,337- dir~ectives on:

338,4, 354' 361-363, 8681- 421, 425, 455, Army Regulations 310-10, 1043-27"

50,507;514h, 525, Circular Letter No, 1, Offce of The gur-,

Czccoiq Mj.-3,x-2 geon General,,1943--24

Ciriiar-.Circular Lette'r No. 192, Office, of The

No15,Seventh U.S. Army, 31 Aug. 1944- Surgeon General, 1043-24

50T,,547 CuumAi), W. P.,. 35

No.1i6,"SV vnth - U.S. Army, 4 Sept. 1944- CLEI'ELA'ND, Col; MX, 215, 217

526,532 loatfrt~ w"vo oedemat6e8, 446

See 414oMedical Circular, (1loatridiu~m weckU, 494, 499

CircularLete- Perfriagfena, 446

No,. -1, 'Office of the Surgeon,, 1I Corps, CoATrs, Col, J. B.,, Jr,, 297, 310

12 May 1943-360,372 COuiN, R. J., 124, 135, 137

No. 1j Office of The Surgeon General, 1 CoLcoox, Lt, Col. B1, P., 369

Jan. 1943-24 Cold injury, 327-329, 431

No. 2, Office of The Surgeon, ft Corps, importance of prevention of, 332

5 Aug. 1943--361, 445 in tropics, 492-494

No, 2, Office of the Surgeon, Seventh U.S. CoLEY, Col. B. L., 209,249,251-252

Army, 18 July 1944-506, 507, 551, 583- Colles' fractures, 176

588 Colmar Pocket, 528

No. 3, Office of the Surgeon, 1I Corps, Colostomy:

7 Aug. 1943-411-412, 416, 423 double-barreled type of, 321

No. 7, Office of the Surgeon, Seventh U.S. loop, 182-183,321

Army, 13 April 1945--551, 554 spurred, 182-183

No. 9, Office of the Surgeon, Seventh U.S. Columbia University, 8

Army, 18 May 1945--559 Commanding General:

No. 15, Office of The Surgeon General, Army Service Forces, 11

January 1943-A5 Fifth U.S. Army, 390

No. 17, Office of the Surgeon, Seventh U.S. 1st Cavalry Division, 298

Army, 1944-551 Fourth Service Command, 217

No. 71, Office of the Chief Surgeon; NATOUSA, 421

ETOUSA, 15 May 1044-507 Third U.S. Army, 293, 295n

No. 72, Office of The Surgeon General, 12th Army Group, 329

17 Mar. 1L943-174 Commanding Officer, 33d Field Hospital, 387

No. 101, Office of the Chief Surgeon, Commission on artificial limbs, 59, 61

ETOUSA, 30 July 1944-326 Committee for War-Time Graduate MediNo. 108, Office of The Surgeon General, cal Mfeetings, 170

27 May 1943-39, 148 Committee on Artificial Limbs, 59
'596" ACTIVITIES OF SURGICAL CONSU~TANTS

Commitee on kfcl ltesearch, OfIce of Consultant(s) JiiOphithahnology-Con.. .'eeiin eearchand Development;- 20, Offic fTeSrenGnrlCx

Cdoiiiifiiite on Prostfijl Devices,' 50 recommendation of,104

C&i ffte6 on- ProsthMies Sgeiices, National reiew-of 6phthalmologic,,personfielbby,

-Rsarch Council,279 -1001

Cbmimiitiee on S ens6ry Devices, Office of, Cons ultant(s) in Orthopedic Surgery~28

JScitfl-Research and -Deelopmenmt, -111 232-283

dozmmnittee onh Shiock and Transfusions, Di. CvIVIIan,, to the Surgeon General, 184,

olid f Med 1cM -Seien~eg, Nailonal Re duties and functions of, 204-266*

li0&h- Couiii '122-- 13,L-A 0 147- Elihth-SeiV6c Commffand,, 204-270

CQNA D.Se on~'tinental Adlvance Section, Fifth Service Command, 215, 228, 232

-Communinications Zone, ETOUSA. Fourth Service Comman d, 215-246

Coi~efenes,302~365duties of, 218-220-

Am~mn-AirFores orthopedice, 242 professional ae'tivities of, 210-220

-Afpiy-Air Forces surgical, 242 professional problems of, 216-218 -ciinicpathologic, 256 Ninth Service Command, 271:4T7 -- Fifiith US. Army Medichi, Conferences, recommendations of, 280-287

3024865, 445 relations of, with hospital commanders,

-on ahnestheshIA,201 074475

-6 n hanmd surgery, 243 relations of, with orthopedists, 278-72t4

on spinal. cord injuries, 21.o 11AMC; 555

orthopedic, Army Air Forces, 242 Ser vices of Supply, 467

round table, 255 Surgical Consultants Division, Office of

Congenital defects, 249 The Surgeon General:

ConesI, of the pulimonary parenchymat, activities of, In communications,. 52-53

floig inhalation of mulstard vapor, 87 correction by, of deficiencies In hospitalCongress of the Central Mediterranean Force facilities, 56

Arm~y Surgeons, 865 duties of, in supplies and equipment,

Congress of the United States, 112545

Congressional Medal of Honor, 855 editorial review and assistance by, 52

Conjuinctivitis, 87 field trips by, 53

CONLAN, 1st Lt. P., 97 fuctions andi duties of, 111"o

Consultant in Anesthesia, Office of the handling of correspondence by, for The

*Chief Surgeon, ETOUSA, 530 Surgeon General, 52-53

Consultant(s) in General Surgery, First liaison and cooperative activities, 61-03

Service Command, 167-108, 194-190 with the service commands, 02-03

Consultant in Hand Surgery to The Surgeon within the Office of The Surgeon Gen.

General, Civilian, 178, 187, 224, 228, 243, eral, 01-02

2M3,268 personnel management by, 50

Consultant(s) In Medicine, 215, 228, 232- preparation of policy directives by, 52

233 recommendations of, 04-05

Consultant In Neurosurgery, ETOUSA, 558 to The Surgeon General, Civilian, 184

Consultant in Neurosurgery to The Surgeon Consultant In Otolaryngology, Office of The

General, Civilian, 185 Surgeon General:

Consultant(s) in Ophthalmology: duties of, 106-119

British Army, 532 field trips by, 110-111

Civilian, Ninth Service Command, 100-101 liaison activities of, 111-112

in oversea theaters, 101-102 recommendations of, 120

Office of The Surgeon General: Consultant(s) in Psychiatry, 228, 232-233

activities of, in rehabilitation of blind, Fourth Service Command, 218

95 Consultant in Resuscitation and Anesthesia,

field trips by, 100 NATOUSA, 414
C6osltanit-s) in-lSurey CStiftant (s), In Surgery. Contifned

'amputee asprob e~o,6 eet USAm ot~~

261~ 2243 ~ 2 e1princs2o,8145,

contributios ,of, tod auril-fehbiliWa Sit TmSAzy, ;50

teclig' by,1~53;25i 6 6ttnuition'piovided by, 261-22

to 4be i~gou General, 178, 184-185, teaching by, 253, 255-264 6

Tenth U.S., Army, 160,

Eighth S -iice mand, 249-270 Third Service Comadnd, earlytactivit ms

ciiia,25,255-256' of, 209-21

Eiht. .S rmy, 566, 9,577, 579 Third'U.S. Ar my, functions of, 295-208

recommendations of,, 578-480, to field'armi'es in thters-of operations, -evtluidli"y,otb suricalcare, -329-8.31 14;1, 474, 291480

Fift §Srvice, Commind, .228' importance of, 15

-dtitsaiid~responsibilttli~of, 229-280 qu alificatiops of, 512-514

~~roportr off3ils~ sibiiities of, 526-524

Fifth -U,Army, 333, 338, 851-352, 360 to overses theaters, 7-10, 4 7-48

edtcatioaLabtivities 6f, 3P1,1357-361 selection and recommendation of, b"

functions of, 3-11-352 Surgical ConsultAntw Diision, 10

lson of, with other allied armies, to service commninds, Zone of interior,

888-390 10-14,831, 47-48, 167-207, 209225, 227"

recommendations of, 392 236,239-247, 2497

visits of, to Army medical Installations, care of -patients from oversea theaters

40"-10 by, 14

O'rst"Serice ,Command, 167-168, 194-196 liaison between, and Surgical Consult.

recommendations of, 195-196 ants Division, 11

Fourth Pervice Command, 215, 218 to the Chief Surgeon, UTOUSA, 7, 150, functions of, 351-M52 311, 316, 388

hospital visits and inspections of, 64-65 See also CUTLEit, Brig. Gen. E. C.

ideal, 264 to the Surgeon, MTOUSA, 5

importanee of, in maintenance of high to the Surgeon, NATOUSA, 38-89, 142,337 standard of surgery, 9 See aloo (Hu5ouiLL, Col. E. D.

liaison -activities ?t. 9 8-390 Zone of Interior, 3-05, 67-162, 167-207, life of, 263-M6 209-225, 227-247, 249-287

medical education by, 255-256 See also Consultant(s) in General SurOffice of The Surgeon General, 3-45, 67- gery; Consultant In Hand Surgery; Con162 sultant(s) In Neurosurgery; Consultorientation of, to duties, 64 ant(s) In Opthalomology; Consult11 Corps, 333, 336-337 ats nOtoei ugr;Cn Second Service Command, 197-207 sant(s) In Otlroope ugy; Ofco- administrative duties of, 197-201 TSurgeo) n GeterarylogO.ieo professional activities of, 197, 200-207Th ugonGnrl

Services of Supply, Southwest Pacific Consultant service, 239,247

Area, 4(35 Consultant system, 227-229, 258, 294-298,

Seventh Service Command: 333

inspection reports of, 240-241, 247 educational advantages of. 269

professional services of, 241-244 evolution of, 204-295

scope of activities of, 239-241 future of, 264

Seventh U S. Army: Consultant system, German Army, 450

assistan,., of, to First French Army, Continent, the, 296-300, 302-303, 308, 311-

524-525 312
;598AUi'VITIE'S-OF 'SURGdICA CONSUtLTANTS

Continental, Adv~ance Secton, Commnunicai Deaths, analysis of:

tioi~Zoe, ETOUA, 528directive oh:

Convjlecenc, '84~266Crculai No. 15 ~ -enhU.8. Aimq;

Scare and--rehibilitation of 1945-547' -pnacordinjurle, inmot oinpitetIure oini27 IDeaths, hospital; analyatis of, 401.-4M'

:Cosnas, F., 101 Deaths d uie.to -

doxiLki, Col. X. H;, 143,'362,418, 417, :445, abdominal Wajris '444, 557

525 427 chiest wounds, 437

Cornell ,,Medical, School, 368 Intrawabdominal wounds, 444

Cop:severe burns and Injuries from bomb,

11 Armored Corps, 205n fragments, 491

U Corps, 294, 335, 336, 838, 369,1391, 392, DEBAkxEy Lt. Col, M.B,5,-20, 32,102, 141

19T,.410 369

.11 Corps, Central Task Force, 835,341 Debarkation activities, 170-181

VI C6r!K, 346 Debridenlent, 41,319; 321

N Poips,~ Midanao, 567 early, adequate, 318-319,326, 329,'j4:l,,373, XI Co~,56423,424,430,444,571-572

Corregidor, 566, 571, 572,575,570 limb-saving, 577-578

Corsica, 397, 527 radical, In battle-Incurred Injuries, 818

DicGowiN, R, L,, 122,126 Cox, Col. F. J., 369,445Da xMj.B,422

CPRAIG, Ilia). Gen, L. A., 239 DK3s ~ 3

Crest, 517 Delay in early wound cleanup, 284

Crile General Hospital, 233 Delay in operation in orthopedic Wlnjes,

COLuaaTSOzr, Maj. J. W., 400-401, 419 64

CusTiLLET, Col. E., 303,390,524,525 Dm Loamic, Capt. T. L., 64

Cushing General Hospital, 173, 177-179, 1&3- Demobllmition, rapid, effects of, 213

184, 195DENixAm, 87-19, Maj, RI. H., 273

C1s4iR 1.7C-1915,1 82 DENIT, Maj. Gen. 0, B., 159,161,405

Cu'umCol C.W.,Jr. 16, 19-10, 72 DrriNy, Col, G. P., 167

175~, 178, C.82-183 , 119, 234 10 12 Department of Commerce, 55 175,78,12-13,19-194234Department of Surgical Physiology, Array CUUmRs, Brig. Glen. R. C., 150, 300, 311, 310, Medical School, 125,134, 142

308 Deshon General Hospital, 112, 119

CUTLER, Lt. Col. N., 97 Detachment 2d Auxiliary Surgical Group,

Cutter Laboratories, 135 536

Cyanogen chloride, 83,84, 92 Detection of contaminated food and water,

Cyclopropane, discontinuance of use of, 38 7T-79

Cystostoniv early high suprapubic, 322 Development Branch, Technical Division,

Operations Service, Office of The Surgeon

Dakin's padding, 491 Generai, 76

Dakin's solution, 403 Dibble General Hospital, 90-97, 101

DANIELSOx, M1aj. Glen. C. H., 239 DxcxsoN, F. D., 242

DAIUA0I, W., 9.01 DisTrz, Maj. V. UI., 101, 204

Davao City, 500, 567,509 Dijon, 528

DWvis, H., 119 Diphlenyvlamninechilorarsinie, 83

D-day, 100, 122, 149, 155, 295n, 301, 303, 311, DIp~henylchlorarsine, 83

316, k38-339, 346, 308, 394, 505, 507-510, Dlphenylcyanarsine, 83

515, ' 21, 524, 520-527, 529-531, 549, Disorders, psychosomatic, 251

502,54, Disposition procedures, 51-52

Deaths, according to body area of wounds, Division of Medical Sciences, National Re540 search Council, 48, 111, 122, 136, 151
-JNDEX 59

Diiso o~uriaiPysoogArmy Mked. Emphysema, followIng the, inhalato -of.

eal School? ,148 144, 146-447 uardpr,8

lprogram,4 128, 184, .5915 4604,

11h 02nglis &Channel 1 50

:101st-3 10, ~la 2

Amored: -Epinephrine, 3827

4th-310:" E uipen,for protkctUW against Waifare

,Cavalry i7 7

1st 28~ Eqipment, surgical, 811-812,531

"Infanitry onultation' on,. 6,, 17-21

526 at Anslio, 394

Mth-2 erly. decehoies i,'9- 36t-46-47,50, PT-58 10514,626 mrviain in,. 3-395

450l -40& 49, 505,507,'510-512, 515, 526 nIay 9-9

85 h-387 in; Sicily, 392-493'

92d 343nonstandard, 394

Mountin rlatin of, to results, 395-396.

10th-348 forotaynooy10-0 iDoAifisiiMaj, J.- X, 179 ERIdxSON,ABrig.- Gen, 8,239 Douor centers. See Centers; bleeding. ERNS14T,,C01, K. F.; 418

Diiion I,. 408 MUFF, Maj. $I . 10i

164ctinjuries, -common, 262 'Ersatz company, 045545

DbUXkS.Ekk, 1Brigadier Sir STEWART, 102, Erythema, treatment of, 87

532 Essenitil Tecbnie~aal Medical Data, 9 - fDunn-EDER, Lady, 102 155' 397

Institution of, 9

Ear, Noe and Throat Service, Walter Reed Ether, as- anesthetic agent 38

General Hospital, 108 Ether, open-mask, 486

East Coast Processing Center, Camp Ed- Ethdchoasn,8,8

wards, 172 ETOUSA. See European theater.

Eastern Defense Command, 170 ETUo i*, dc 328j9ur124, 

EATONi Lt. Col. G. 0., 8, 212, 467 European theater, 39-40, 93, 101, 122, 144-

Edema, following Inhalation of mustard 145, 149-153, 159-160, 16.'* 205, 295n, vapor, 87

Edgewood Arsenal, 67-69, 72, 82 290, 300, 314, 327, 328, 341, A 18 50W, 521, Eduction 533534527, meical 528, 530, 540, 550, 556, 1147, 575, 578

Eductio, 53534Blood meica, Bank 150 methods, in Eighth Service Command, 255 surgical consultants for, selection of, 7

EDWA~s, T. 333 434transfusion . services in, 147, 151, 155-156 Eighth British Army, 141, 355, 446 Evacuation, 374-376, 475-477, 572-573

Eighth Service Command, 249-270 facilities for, 3" .3-376

Eighth U.S. Army, 56-8 rapid, in reduction of mortality, 402

El Guettar, 370 Evacuatioii Detachment, 36th-571

Eli Lilly & Co., 134 Evaluation of surgical care, 249, 329-331,

ELLIOTT, Capt. J., 124, 129 369-374

Embolism, 447 EVERIT, Col. N. J., 2, 239, 243

Emergency Medical Service, 333-335 Eye and plastic surgery centers, 100-101
*000AQ'IVITliES OF SURGiCAL CONSUt1AXTS(-

Eyglsses, repair of:- First Fkrench Army, 507,,514i, 56 2,55

dire~tv& on:533 538

1CiruarNo 16, Sevehth U.S. Army, 'First Naval District, i7

14--20, 532 FrtSrieComn;179

Ee li rtfia O lIa problenis- o6 7-7

debraio d ti,0 aviesi,7.41

Faiite, opta,-283 edic l istallations -ad,1f' i

convalescenit-type, 530-540 4 7 - adaclte

-Far Wst,&157, 425 First Specilk'Sefvice.Force, 506, 508

derAl Security Agency, 95 First U.S. Army, 155;,299, 327428, 830:

Feiii Wiirett, 4564, 463 Fisher's island,i17

F]Mid imxrettNo. 26-45ft titiiimons General Hospital, 242

Feltr, ~57FLAd ANr'J4 224,

Femur:-Fraox, 0o1. J. -B., 8,_271

compound fractures of, 320 -Floieuice, 345,,369, 374,394, 443, 444

'fractuirs ot,,063-64, 176, 184-185, 228, 246, FXuomw, H. Wi 129

O320 326, 425-42%, 469-404,'571-572 '1,FlyingCircus" field trips, 110

irles of, 577-578 Fgi,4

pen fractures of shaft of, 223, Vousna, Cl, J.-H., 380,387, 392,397

Aimpie fractures of, traction for, 223, Fort Adams Station Ho spitAl, R.I., 171

F~rina,895Fort Andrews, Mass ,, 171, F1ieoxgen equipment 74-76 Fort Blanks, Mass.,170-171

Fifth Srice Command; 215, 0.27-238 Fort Banks Station Hospital, Massq 171,17

activties of Medical Departmentin, 231- Fort Benning station Hospital, Ga.,'26

23$ 222-223

Fifflu U.S. Army, 142, 150,333-464, 505, 514n, Fort Bragg Station Hospital, N.C., 216

624, 525, 535,544 Fort Dawes, Mass., 171

administration in, 833-401 Fort Devens, Mass,, 169, 181, 192

Bl ood IProgram in, 417-418 Fort Devens StatilonHospital, 172-173,176

chemotherapy In, 421-423 Fort Dix, N.J., 200

clinical considerations in, 410-448 Fort Douglas, Utah, 271

clinical policies of, evolution of, 410-412 Fort Duvall, Mass., 171

establishment of priorities In, 411-412 Fort George G. Meade Regional Hospital, publications of, 398-390 Md., 212

records In, 397-398 Fort H. G. Wright Station Hospital, 171

*special reports in, 398 Fort Heath, Mass., 171

statistics In, 399-405 Fort Huachuca Station Hospital, Ariz., 272

surgical care In, p~rinciples of, 410-411 Fort Jackson, S.C., 291

FxLgrov, A., 124 Fort Jackson Station Hospital, 216

FiNNEY, Col. G. G., 160 Fort Knox, Ky., 291

Finney General Hospital, 215, 219 Fort Leonard Wood, Mo, 3

Finos, W. M., 255 Fort Leonard Wood Station Hospital, 242-

First aid, 83 243

directive on: Fort Lewis Station Hospital, Wash., 272,

WVar Department Field Manual (FBI) 277, 285

21-11, First Aid for Soldiers-20, 483 Fort Ord Station Hospital, Calif., 272

First aid for chemical casualties: Fort Revere, Mass., 171

motion picture on: Fort Riley Station Hospital, Kans., 242

TF 8-1180-81 Fort Rodman Station Hospital, Mass., 171

First aid kit for gas casualties: Fort Ruckman, Mass., 171

filmistrip on: Fort Sam Houston, Tex., 295n

FS 8480-82 Fort Standish, Mass., 171

First Air Force, 172-173 Fort Strong, Mass., 171
For Wrrn SatonHositl,171 kFrance,,69i 150, 158,291, 296,3131,42

FTort'Wayne,. Mich, 239 36 9,54,S 4 2

zFogs, H, L,55FizHCi..W,21,189

_outh, SrieCma,25-225 eahMdc op,86

:Fracture,1924242 Froite ~dmco,372

a ralaVlcu, 17, FURTERNI~ ,A 0

cerviaVn upper dora1,322,

Colles 176 afa '895, b'mo ii1-267TAS,01;I M.,, 218,,,22, 234

debidement of, 819 Gilldudt'.Colegi,I 19

3ner ixatioo, 63 Gangrene, ,gas. SecGias, gangrene Moi

of emu,'36 aidifierGetifral HotalR,4

fatigu, 2872Gas, potecton of persone tagainst, 17

Aaor uefntiVe treatment of,"h 55 i e i o:

management of, 21 i6-8, 17,184-185, _Circular L *tter No. 2, Office of Suti.,

228224, 26,267268 28-24, 316:-2, gebb, -II'Corps, 194-361I, 445

82,~i32, 5,571-572 Medil Cifrcular No. .4, Office- of tfiie

nia'rci 22,27Sugen Fifth -U.S. Army, 1943-,

of metatarsals, 267 '361; 445

'of anikle," 22,28,426 Medical Cicular- No. 9, Office 'of, the

of 'arm, 425,42.6 Surgeon, Fifth 'U.S. Army, 104"6~-81

of elbow, 425, 426 447

2 o"'tmu, 6-64 16, 184-185, 246, 320. pencillia therapy in, 20-21, 43

326, .425, 426, 463, 464, 571-572 prevention of, 43

trAction'-for, 223 See also Myositis, clostridial.

of, fibula,, 320 Gas-casualty set, 29, 1 74

otft46 Gases:

of forearm, 320 blister, 83-89

of hand, 320,821 choking, 83, 89-91

of head of the fibula, 222 lung irritant, treatment of personnel exof humfierui, 320,430 posed to, 89

of knee, 425, 426 tear, 84, 92

of long bones, 246,2 83-284 vomiting, 83, 91

of lower extremities, 246GAMjGe.H ,2n

of l~e ileg,420Gela, 295n

of lwerleg,426General surgery. See Surgery, general.

of owe lmba doral or erterae 3~ General Surgery Branch, Surgical Consultof middle leg, 42 ants Division, Office of The Surgeon Genof shoulder, 425,426 eral, 142

of spine, 322 Geneva Convention, 346

of thigh, 425 Genito-Urinary Manufacturing Co. Ltd., 391

of tibia, 320 German Army, 298, 329, 341, 345, 459, 545

of upper leg, 425 German management of:

of wrist, 320 abdominal wounds, 461-462

open, 2234224 chest wounds, 460-461

p~revention of, 222 head injuries, 460
GermnA management, of-Continued, H nbq Lt. Col. 1R. C., 121,1, %150'

trAcoabdomial woimds,A01 HApai SON,,C. E +414,41b9

,oundsof jonts 463 HG':LMj Gei., W. 0,36

Gema miedi cal s ervice, In Italy, 448-464 Cp.3, -IRL 273

Germn spintig aidirctioA03464 Harvard Med"IlSoo12

GnORMLY, h,269 B A*-, Maj. RW., 204,

GINR, 01H 29 au randplatxz, 4521,454, 450,4 462 463

Giianir-Wi;Capt IV P., 428 A .~v pt . . 349

G~L SP ol ,A i5 141,4 ' Hjawyaii,153-100,372, 482

GiL0gs i AwOOL 333'HA sfcIiC,35

G:NNif1ol,_, L H., 302 HAWLi-, Maj. Gen. P. R,, 149, 316,

rGx iqIN'1't. Col, F., 159, 465, 4607, 49C5 573 HCmi1xture 83, 94

Glenini GenralHoe~t3)25~Hearing hills:

GothicLineu, 242, 374',444 directive oil:

G'dng ofpatients for gurgery,25-7 War Department Circular No 81;.

Grnft, bohi, mags lye,, 224, 1044-117

,Graftg,, veln, 323HSNTS W 1.

G 01A, o.1., 9 H!5CKPq425Z

GICA, '1t. 1o. J. N., Jr., 97, 101-102. IHeiorrlisje,412-410

GssNwon Mj.0. IL, 4# 70, 71, 72, 74 German treatment for, 450-460

Gre3)ie' Field, Manchester, N.,11., 172 Hemodtho rax, 43 4435

Gsmoowi Col. It. A., 212 Heparin, use. of, in ijonsuture-techalotisf of

GhienA, a). * A., 334 vasculdi~anastomoois, 323

Gu1am, 1, 36, 158-100, 4 L0 IHernia, 244-246

6G TurnnR, Lt. Col, A, J. b.,Z31, 532 Herniated'disks, 249

*Guides to Therapy for Medical Officers, 434 H1exachloroethane (HO), mixture, 83,94

Gulf of Panama, $82 HILLMAN, Blrig,-Gen. 0.0C,'125-127

Gulf of alerno, 510 HZMMUCST?.IN; Capt. A.,8398

GmxiEN, Lt. Col. T., 101, 102 Historical Section, Third U.S. Army, 300.

* Gustav Line, 341-342, 345,387 Hoff General Hospital, 112,114, 117

Gynecology and obstetrics, 188-189 IHOFrMAN, Lt. Gol. H. L., 398, 40

JIoLCOMwR Maj. R. G., 4

H.4omzs, Brig. Gen. WV. A., 465, 471 Hollandia, 158,482, 503-5N4

Hlalloran General Hospital, 20, 192, 200-204, HOLLENBERG, Col. H. 0., 257

200-207 Howsna, Col. E. C., 221

HJAMPTON, Lt. Col. 0. P., Jr., 359, 363, 390, IHois, Col. J. M., 368

418, 422, 5N Hlonans Professor of Surgery at Harvard

Hand Infections, 268 University, 8

recommendations for management of, 252- cy,1tL.B.E,9

253

Hand Injuries, 224, 268, 320-321, .444-.445 Hro mrec eia evc ls

management of, directive on: ipitai, 334, 335

Circular Letter No. 7, Office of the Sur- Hospital:

geon, Seventh U.S. Army, 194.5--554 construction, 110, 198

See also Hand surgery; Injuries of ex- equipment, 212-213

tremities; Wounds of extremities. location, 198

H1and surgery, 224, 268, 320-32-1, 444-445 organization, 100

IIA~xsER, Lt. Col. S. A., 362, 387 orthopedic care, Ninth Service Conmnand,

Harbor Defenses of Boston, 171 287j-287

Harbor Defenses of Long Island Sound, 171 personnel, 109

Harbor Defenses of Narragausett Bay. 171 Hospital center, S19th--534
'flosp iddas *-H6Oltnleacuto Cotnud

rec~mm6&iibn s 5 th"349,387?.410,,422

15-16Z . th-510,52& in on ofInerir,51-3,7,15, 1010, 7t-fi -33 372*81-392,410 *1 0,;129;,131,13 1 41 4 2 81553 -9W1st- 30 _*295n, seletio andrecmmendation ,1 'i5 2,6 of.% staffs 93-9,4,960,401052,3

,ffo,' by ' Sur gieacaCofiau ,lits.Di. 1.sion , 94th-850 ,,, 408,,410,447

performanc oprsohnii, 21. 12h-Z % Hospitals, irbs, 3

24 -2151-269, 272 ii 17tb- 53f

jospitals, H nyjjh rvIce korces," 44 1132-6 9 M84

Bion~tn HspialLonon,835401st-.(~reich)-3 90' Horton Emergency. MedicaZ 'Sertc Ho- Hsptl i,4 -300*, 380-383, 53552

Kewaoke mergncyMedical Service l-3, 385,-887, 396, 4i3-44,1507, 510, Hospital, Ep46om, 33"'~35% )526

.Ie khe . ierency -~ ia Service, 150l-3906-Wv7

~Io~P~l, 'estdnsuperare, 334,lt-9

Ki Eard-T I- Sa trim M hurat, 8s-~ 85' 32d-390

Soutbead, 00 33-340,,349, -362, 303, 387-388, 40 -10, - - cnvaescnt~ osptal,' 85,287420

S6tli-.534

Canip dwards,172, l91-193 5t-3

Ca0plitqn, 201, 206 6t-3

Loveli-General and Convalescent, 192 Oofh-534

bid, armis Convalescent- (Special),, 0- 8lsk-534

974 Hospitals, Fifth U.S. Army, 343, 300, 399, numbred:428, 429, 432; 442, 444, 644, 554 37 ... Hospitals, French, 390

Hospitals, debarkation: at Gafsa, 309.

Camp Edwards, 172, 17M-181 Hospitals, general, 16, 18-19, 27, 170, 181, Camp Myles Standish, 172,179 192-193, 21, 232-235, 245, 251, 271, 390

Hospitals, embarkation, 206, 272 development of, 170-179

Hosp oias, eVacuati on, 18, 300-308, 322, 383- namedi:

385,53t3,552,558,507 Ashford, 04,234 8th-3 45, 350, 302, 384, 294, 400, 458, 510 Battey, 219

9th-372, 510, 514n, 531, 533, 548, 549, 551, Billings, 234

562 Borden, 106, 112

llth-384, 390, 410,510 Brooke, 295n

l~th310Bushnell, 20, 56, 178, 257, 279-280, 280 I2th-33 0, 0,1,2,4 Camp Edwards, 179, 181, 187, 190

16th-362, 390 Cushing, 173, 177-179, 183-184, 187-191, 27th-50, 534, 562 195

36th-565, 570,572 Deshon, 112, 119 38thi-350, 363,388,390,392, 395, 410, 439 Dibble, 96-97, 101
604L A ~IV ts 'OF, SURGiCAL CONQSULAb

Hosjtii~ geera-con~ine ~ -Hospitals,, generil--ContinuMd

'Finey 2i, 'orthopedics66l .- 1 28 l 1 242 -F.t11-mons, 

F oste ,42 of .6'rle~ "rofifel ih;'232

"Fprogram f or on tbeJbtanigh,3

56"" itransfer 219;2 opatent, o: ilr o 2

Loof, 12-73 60 16-77 14,16- Hospitals, ema,29,31,449, 458,A6

~5Ay inspectons of, 457-458

'66661re 569, 210

4 ii,"il.,125ospitals, regioaft, 16, 104,1272t

Nih~a,4,10 Bubkley, Fheld,'Denver, 246 oithngton, 2190a' ~wer 4

Oi~e,29Fort-George, G :Meade,:212 O'Relly,'242248Fort leonaid Wood,, 242-243 Percy Jon8 61Wlhm,i171-, ik82 18-90 ,Rbqods, 204, 207 WesO Ver, 131 Schick, 242 Hospitals, Seventh'U US.i Army, 507, 508, 52, 3tari, 214L216 3,54M,51 5

Thomasi M. England, 56,192, 193,200- 250, 3i90 20, 207 nmd T!lon, 20, 204,' 207 Army Ali orces, Buckley Field, D~an. U.S. Array General Hospital, Camp Ed. ver, 246 wards, Mass., 172 Army Ali Forces, Gulfport Army Air Valley, Forge, 9697,100-102 Field, 216 Walter RIeed, 4, 38, 56, 105, 110, 114, 138, AryArFreKslrFed 1

145, 227Army Air Forces, Maxwell Field, 216,

Winte, 242Camp Blanding, 216 Woodrow Wilson, 100, 210 Camp Carson, 4,240,242 numbered: Camp Crowder, 242 Ist-212 Camp Edwards, 172-173, 179 I2th-363, 369 Camp Haan, 272 2lst-363l, 418,422,510 Camp Hale, 242, 24C! 23d-36= Camp Kilmer, 206 ..4th-345, 309,374, 44344 Camp Langdon, 171 27th-482 Camp MYles Standish, 171-172 30th-l0t Camp Phillips, 242 33d-388 Camp Roberts, 272 3th-309, 510 Camp Shanks, 206 43d-510 Camp Shelby, 216 45th-390 Camp Stoneman, 272 Olth-295n Camp Van Dorn, 210 7th--345 Fort Adams, 171

94th--330, 410 Fort ]Banks, 171, 173
Hspitals, station Cotne4yperemia, of the laryngeal. and. rce

named-eountinued -bronchial mucosa, followi4g thS Aubila

For 10,29-23tilon' Benin, of tnustard Napor,87

FVort Bragg,.216

Fort Devensi,172 173, 176, ImmersIon-fot,29j,570

FotH0Wight 17 fooleali 492A4

Fo'Huachuca, 7 !m6bi ainb~~id patrcsseh

Fort' Jackso, 210 iief iiTim'stetsI

Fo"Itewii, 242-243Ini hW,9-

-F.i~d 72-Idatitr9 Y6~Bu,242IndO itriato'29'9-02,

Xocon eoflnstructiun, 299-00

YbrtW ~Infection, of- skli 'afi&d4bcutanedus- tisine,

FortA~il!~n, ~ThInfectlon,,lpreVenti of,861

numbredInfection, secondary, 326;

l~th-0InTfections,, anaerobic, -32"-27, '563-564, 1oth4-80, irecti1oi

'2Ot44W9 Medical'Clicular No. 09-OfflicO ofthe ir127h-59 gonFifthU.S, Army, 1944--361,,447,

ortho6pedics in, 281 Infections, gas bacillus, 458

Hospialssurgcal:Infections, hand, 29, 252, 268-

48th.-37, 37,895Infections, surgical, penicillin therapy in, 21

portable;,P 501, 565,506,567, 573 Infections, wound, penicillin -therapy, in, 21-

64th;,-572 INGRAMu, Capt. A, J., 273

HRosiitasthird U.S. Army: Injuries:

lessgonfr learned in, &31-432 abdominal, 321, 442-444, 486488, 534, 556-

Woun~d infection In, 318 557,577

'Hospitals,, various: mortality from, 444, 487, 557

B rom ptoii Hospital, 335 postoperative measures in, 444

Brinkawr Hospital, 129-130 wound dehiscence In, 444

Cabarinis Hospital, 129 battie~incurred:

Massachusetts General Hospital, 256 case-fatality rate in, 542

N4avi Medical Center, 128,138 radical debridement in, 318

Peter Bent Brigham Hospital, 138 blast, 29

-Presbyterian Hospital, 136, 138 combined thoracic and abdominal, 441-442

Sin Laiaro, 495-500 duct, common, 262

U.S. Nlavy Hospital, Philadelphia, 96 large bowel, mortality from, 487

University of Minnesota Hospital, 138 liver, mortality from, 487

Houlton airfield, Maine, 172 maxillofacial, 482, 562

House of Delegates, American Medical As- mutilating, 325

sociation, 23 nasal, 321

HoYLE, 0., 335 neck, 432-433

HUBER, Lt. Col. P., 303 neurological, 243, 485

HUOIISON, W., 105, 117 neurosurgical, 322,428430

HULLINGEa, Lt. Col. C. W., 225 of blood vessels, 559-561

Human Serum Albumin Program, 137-140 of bone and nerve, combined, 185

HUNTER, A. R., 335 of chest, 436-437, 584, 577

HURLEY, Brig. Gen. T. D., 297 of ears, 29

Hybres Islands, 518 of extremities, 319,488491, 552-554

Hyland Laboratories, 135 See also Injuries of hand
606 ~~AOTi VITIES. OF':$URGIC,, CNUTN

tinjurles-'-Confifiued Inaino suhr rance.7-d 'tin

of eyks582530sricloice or 0

enucleittlohs,*-elsceratons~ In, W8 promulgation of, 520.

of femiw,6-841818-8,2-2,4, Italy, 82, 141-14, 155;, 5,95, 299,4304,312;,

a ~'12,425, 42;43,4,515257- 37:38 4-4,4931,6034,8,

578 72,'375, 3761;t386,'392 397, 401402,'405,

man agementpof, directIVe on:. Z14n, 520, 521, 56 3,5458

,Citdu ar Letter No. 7, Offiee of -the valuation of su'rgery in, 37347,4

Aurgeon,S evnth U.S. Araty, 15-- medical plani in, q4&.

of Ii iiW;A2*87,539

tor-rectum, 321 aaeeArmy, 49-5

of Mgni ol, 321 Jaudice, homoliogous serum,13

6pa'- cord,,3 2242"9-43 Jefferson Barracks, 242-

0o Spine, 322,5W8 JIKPMa F , 6 328330,408,

~erplerl ere,322, 430,485 400, 410,'.45

repair of, motion plett re on, 27-28 , 6JU1TKL A, McG., 4, 89, 70-,

&eiipheralvascular, 41A42 0;~sN ,, 243

, 3e1on 39-324, 432-445, 485-491, 552- J I nt, Commission for -the Ifivestigatin, of.,

593 the Effeeta of ilie Atomic Boinb in Japan;~

softtlise, 423-420 JOmfEs, T.i 286

special types of,423"43 Journai1 of the Aincricais medical Aseociotermal, 4&30 Hion, 18 December, 1I43-,20, 25,

-thoracic, 485 -48%657-w5 Junglefoot,1trplcal, 492494

thoracoebdominial, 438-442, 558

* case fatality rateg for, 558 Kansas City General Dispnsary, 2040

Ref t-sided, 4t9-441 kARTA5fi1VgKZJ, N4. G., 124

* rght-sided, 441-442 Kasserlne Plass, 368

vascular, 32"926,427-428, 445,559-561 KE*, Lt. Col.0C. U.,,173,177,1821

amputation In, 41-42,559 Keesler Field, 97

dir~ective on: KELLY, Lt. Col. R. P., 04,234

Circular Letter No. 9, 1945--559 KENDRICK, Col. D. B., Jr., 4, 125, 12 -128

incidence of, In Third U.S. Army, 324 135, 138, 141, 142, 147-148,150, 161, i55-16i

Soo also Fractures; Wounds. KENNEDY, 0o1.1R. H., 197, 201, 206

Installations, medical, in army area, 377,488 Kennedy General Hospital, 219

institute for the Crippled and Disabled In Kenner Board, 16

New York, 188 Kentucky State Medical Association, 21

Inter-Allied Conferences on War Medicine, KERR, D., 51

312 KEY, 3. A., 280

Interstate Post-Graduate Assembly, 21 KING, Maj. Rt., 273

Invasion of Normandy, 567 King Edward VII Sanatorium, 335

Invasion of southern France, 50W, 517-518 KIRK, Maj. Gen. N. T., 6-7, 95, 101-10-0

consultants in surgical subspecialties KIRELIN, Col. B. Rt., 4

for-521 Kirschner wire, 183

functions of medical units In, 518-520 Kit, First Aid, Gas Casualty, 84

medical aspects of, 508-525 Kit, Treatment, Gas Casualty, 72, 84

medical lalnninlg for, 500-45OS0, 517--51S Kit, Water Testing, Poisons, Treatment

prov~ision of blood and penicillin for, 520 Control, 78
KitWatr~etin, Sreeing 18Leyte, 4067, 469, 47 4749 8-483 45

Kis siil instruzn&ts7 486, 488, 491-492, 494i,500-52, 65,570,

iti 'i Wink.7, 7 k 7

.,direcav1e ow:, provii of.whole blood to,7159-160 War~D~partent Teci llulletlfiV3, le3~eG

:, 447 - itL"o if,A'ik '

Knee,-, Lr~? Mc. 05, Inidre f;1;2 2, 246,534,555 Ligation of blood v esgels;24, 489,

An erat i&deagepnieut of , 223,249 Ltbinoln' Airrid;4

K tic*l, ti -. 33' bzh;A. F.24;426 "ku4 f ;i.;2k5n, 29 London, i , 2O,,,334, 891-

Kranlcentraiportabteil en, 456 Loss- of' manpower due tio ~pilondal: sinus,,.

* ~ ~~~~~ Kegaarte,444, 249,.250. Loisan ate iUniversity Schlool 'of:Medi., Ki fiee ail',-64' cne, 2956-

Lonit.oison luin146-5

Labratries,, commercial, priptng n Louswazaj o.3,3, 7,77 8

4,z-135 LOel q eneral. and, Convalescent Hospital,. rh e~era ei 1al:

lsth-143, ~ 36241-47 ~ ~ ~ 157 ~ 1,, -2-2245 fopltal, I.h Ieea 169, 172--173, 176P- - , 177,184t 186,192, 196

* -1~h-50-504Lovell opial North, 18-190, 191

Laotiles, medical: Loiell10opital South,190-

41At-52T- LST. See Landing Whp, ank.

4494 -1tMbie L-vokmir Capt. A., 273

2d.=4118 Luftwaffe, 45"-57

Lacinators, 84,92 LuiL, MaJ. Gen. G.TF., 6

LakeComo 457Lung tiritanis, 83,89-91 - 11 To)- - Lung irritations, 79-80 L-ALTR, Capt. J. T., 398, 412, 415-410, 420 Luzon, 467, 473, 479, 481, 483, 485, 488, 404, 442-

ha igcraft, mechanized, 572 500, 501, 5W2, 56, 572, 576

Landingprovision of whole blood to, 159-160

Landingj craft tank, 817 Lross, Maj. C., 20, 359, 363, 418, 422

Landiii ship, tank, 349, 482, 491, 506, 516, Lyoxs, J. C., 8, 212

572, 56756 Lyster bag, 72

'hospital'ship, 491

Lawience-Climatic Research Laboratory, 191 MAcARYHtUR, Gen. D., 567

Lawson Gene~ral Hospital, 56, 160, 219, 221, MAOKLIS, I. W., 255

225 MACLENNAN, Maj. J. D., 446,448

LCM. See Landing craft, mechanized. MAGEE, Maj. Gen. 3. C., 136

LOT.See andig crft tnk.MAOIL4. S. W., 335 LCT.SeeLaningcrat tnk.Magnesium, 60, 83,93 LPADBETTEB, G., 210 MAHONEY, Lt. Col. W. A., 179

Lederle Laboratories, 134 MALLORY, Col. P. WV., 422

Leghorn, 341, 345,390 MALLOuY, Lt. Col. T. B., 303, 438

Letterman General Hospital, 282 Management:

Lewisite, 83,88-89 of abdominal Injuries, 443-444, 577

systemic poisoning with, 89 of chest wounds, 436-37, 577
408' ACTiVITIES OF SRICA CONSULTANTS

ManagmentContnuedMODOWELii Lt Col. H. C,. 225

of, frActurei, 21,63-, 10184-1&5, 2 23- McGoNEG, C., 51

~24 20,26-28,28-284, 3191322, '826, Mcdbvaair, Lt. ,Col. Rit.., 2713

42342,43, 08,40, 58,571-572 MCGOWAN, Col. -F.,1,, 560, 570-,470A79, odf~a ~ ' les,224 ' 2,320-821 44 cRAMj 1., r-12,5,6

di~ieon: Meur Gee-optl 0, 50, 20"

Ctrli '.Ietter No. 7, Office of- the csrUlD,5455

Sulikeon, Seventh U.. rmy, Medical:Adl~ninistratfive Corps, 200, 302

of~r vphifoundswith bone.infection, 233- M~edicai Circular.;

1234, No. 1,' 'Office, otf he Suirgeon, Fifth'.Joi&pllonil sin~s, 43-44,,N2420 Armny, 21 Jan. 1044-301

of i~chgenic deafness, 117 No, 4, Offlce -of the SurgeonFifthl 'US,

of iopi'iined ankles, 175-170 Arzny,-20 Oct. 1943--361, 445

ofva scular injuries, 428 No.. 4, Office -of the Surgeon, Fifth, Uj..

of~ybunds and injuries of the femur, 577- Army, 7 Apr. 1044-301

578, No, 6, Office of the Surgeon,, Fifth:uX.S.

~of wounds involvling joints, 480 Army, 24 Nov. 1943--361 itojeratve38-3 No; 9, Office 'of the Surg, F UAh 

surgical, principles of: Armiy, 5.May 1044-801, 447

drcilV6 on: No, 10, Office of the Surgeon, Fifth U.S..

Circular Letter No, 71, Office of the Armny, 0 May 1944-361

Chief Surgeon, ETOUSA, 1044--07 Medical College of Virginia 9

SOQ also Treatment. 'medical Consultant:

.1auchester, 300 Fourth Service Command, 215

Mantia, 101, 495-M0 Services of Supply, SWPA, 503

MA4mx, F. C., 123 U.S. Army Forces In the Far East, 503

MianpOwer, surgical, 5W -50 Medical Consultants Division, Office of The

Manual of Therapy, European Theater of Surgeon General, 20, 212

Operations, 314 Medical Department Replacement P~ool,

March fractures, 223, 207T Lovell General Hospital, 109

Marcianise, 303 'Medical depots:

MAHKs, Lt. Col. G. A., 182 7th-531, 582

Marseilles, 527 12th-350, 304

MARTI, Mal. Gen. J, 1L, 142-143, 338, 340, M1edical Division, Chemical Warfare Serv355, 30.3-304, 399, 418, 445, 525 ice, Army Service Forces, 09, 70, 79), 81, 820,

MARTIN, Col. W. B., 100 84

M1asking of helpless patients: Medical Field Service School, 141

directive on: Medical Officers Service Record, 30

War Department Technical Bulletin 169, Medical Research Laboratory, Edgewood,

1045--77 Arsenal, (18. 71, 72, 77, 70

MASON, Col. J. B., 149 Medical Section, Headquarters, Third U.S.

MASON, Maj. J. M., 111, 387, 428 Army, 307

MASON, Col. M. L., 803,809, 445 Miedical Service Corps, 200

M.%AsoN, Lt. Col. R. L., 173, 179 M3edical Statistics Division, Office of The

MAsOV, Col. V. It., 271 Surgeon General, 57

Massachusetts General Hospital, 250 'Medical Supply Division, Supply Service,

Massachusetts Medlical Society, 177, 195 Office of The Surgeon General, 01, 95

MASSEY, Maj. D., 54S-549 Medical units, Third U.S. Army, 304-310

Mayo General Hospital, 197 Mledicine and Surgery Subdivision, ProfesMcCloskey General Hospital. 50 sionai Service Division, Office of The SurMCDOSAI1, Brig. Gen. It. C.. 219 geon General, 3
Meierranean theater, 101 15-56, 16 Mortality-Continued,

161 81,817 29, 80, 89,896, 419, 431, 16Woi severe burnis and Injuries from botb

;,460,527,540, 556,;557'Trgeis.9

157,b &uiinkiay surgical groups, 14-15, Meetinigs,professional, 312 'b ug cobtnts~ofedame,

Inter-Auied1onferencesonwar Medicine, '15y

812 Mostaanem 295fi

Merano,'. 8, 462,frapte

Meral 88'fr0ann2 r frt'i pbr 

Meto, dtioa,5-0 casualtis Sk o ceia

'Metycalne,. In snianteia37for 'triing -of plaster room -technicja

Middle HW, 868 ,se at!6

'Midlads, 9n, -- for~*0 - iamtes: 'i~~ete 

'M , _,iltay Dstiet ofWsigo,29'iro e~t'o

Miltar P~sone Diison, Personnel '4MeitMcegalii, 862

SN oice PK f~e Surgeon ,General,6, Moussr. kiaj,: .H. 4,38,

30,50,61Mdoment of patlits, 23-24. Miller-bbott ube, 24, 48t TOUSA. iqqoMeiterranea hetr M -da k Ml566,567,589 eaIth8ater.

1M9osN 2 -J',1 Munry,

iioneiinial'iteiij 144 Msad 3 68

.'Monrovia,"295nMustard, lqi,8 ~MoBli~ed'r'e,343 ustad burns, teatment of, 79-80

Monte Cassino; 390 Mustard vapor, 87

Moat ea'tinl,786 Musiards0, nitrogen:

MooNV 123directive U on:

Mooa, aj .,273 War Departmenit Training Cicla1 o

o ,39 2on, 86,1942--84

Mior deea optl 1,2 MYERa, Lt.-Col. R2 H., 273, 286

Morale, tro,32Myositis, anaerobic, 563

Morbiity, redluction of: reporting of:

by uxlirysurgical groups, 14 directive on:

by surgical consultants to field armies, 15CiclrN.5,evnhUSAmy

M9SON, 3, 31945-547 BigGen.H. 

Ito oc, 295i yositis, clostridial, 326-327, 360-361, 373,

*administration of, 317 40 4-4,48 5

Ii reatm~nt of tetanus, 499 directives on:

poisoning, .0 Circular Letter No. 2, Office of the SurMonnxsss'r, Lt. Col. L. E2., 4, 106 geon, 11 Corpi, 43-361, 445

Mortality, 401-403,542 Medical Circular No. 4, Office of the

from abdominal Injuries, 441,487,557 Surgeon, Fifth U.S. Army, 1943-

from acute appendicitis, 251-252 361, 445

from chest wounds, 437 Medical Circular No. 9, Office of the

from intia-abdominal wounds, 444 Surgeon, Fifth U.S. Army, 1944-361,

from large bowel injuries, 487 447

from liver in juries, 487 incidence of, 360, 445
610 A U~~~lY 1T XE & O Sr I AI C O N SU T T

'IAnC, 79, 310 NrhArc,28 9n 9,30 3436'

ale, 4, 38 4, 34,39 05 7,35, 39 5 , 4 391, 425, 43 1,51 4

7 39,34, 4051, 410; 417-418; 420, 507, rtAfcathte,8391243737,

NarosytheesInthed nangelninto psy- 423, 426,,430,44250,075450'

chogenic 41 deafness, 7~evaluation of suigr n -7 National(and Buea ofS drs, Department - hl bodprogrnI, 4-3

'Nationai~fes ReerhCommittee, Of.; 4.4uorL 279

f',ScIefitlfe ,Research And- Develqo Northrop AircrAft,Co, 279,

Niiionai Iilstitute of-Health, 127, 13i, 136 "Notes on Treatment of Casualties, Vrm

:Paticpatoa fiv inl aProkifim,4~35 Chemical,Agent8,72

National Research Councl;,21,,23;,26, 48, 59, Noumba, 158,

11; 16-12, n 1010-11, 18-1~7; Novocain, -76

140,A147, 150151, 29Noyis, Maj., Gen RA,, . 237

'blodandblodsubstitutes-jprogrtim of,, 'Nursing seki~vce, 303-M0, 355

120-127, A1387

* Coiierence on Albun, 138 on a, , it, 195

paticipation of, InPlastm Progratm, 130- Olom,.Col 'C,'B.,295, 29n 29-208,30012, '8brca Comittee of-3314, 316, 32

NATOUSA. See North African~ theater. Office-of Scientific Rtesearch and Devop.i*

'NkalMedlcal Center, 128, 138 ment,- 20, 968, 69,71, 78, ill

Na4 Blood Donoi, Service, 158 Office of Tlechnical Informastioni, 2)4

Nephfropathy, 447-448 Cfflce of. the ir. Suige~n,71 Niephrosi, lower nephron, 448- Office of the Chief Surgeon, ETOUSA, '149-.

Ner~e-iijuries, peripheral, Seo Injurles. 150, 155, 314, 505

Netherlands New Guinea, 482, 502 Office of the Quartermaster General, 49

Nettuijo, i42-143,,349 OMeie of tile Surgeon: Veliosurgery, 185, 384 Fifth, U.S. Army, 349-35, 361, 387, 445,

*Civilian Consultant Ii, to The Surgeon NATOUSA, 373

General, 185 11 Corps, 361, 373

New CaIedonia, 158 Seventh U.S. Army, 514ni, 521-522, 531

New Engla nd Committee for War-Time Office of Thle Surgeon General, 3, 0, 8, 9-12, Graduate Medical Meetings, 195 1,6,2-25, 27-30, 39, 41, 44, 47,48949, New Guinea, 158, 474, 481-482, 485, 488, 503 51-54, 5W-59, 62, 68-72, 76, 79, 96-9T,

New York Academy of Medicine, 112 100-103, 15, 108-11, 112, 114, 12;2, 125, New York League for the Hard of Hearing, 127, 130, 141-143, 161, 169, 189, 194, i97, 112 210-213, 219, 227-229, 234, 239, 251i 256, New York School for the Deaf, 119 2, 275,279, 281-22 3,27 1,38

New Zealand, 8

NawuousEa, Capt. L. R., 127, 128, 135, 157, 369, 503

158 blood program in, 127

Newton D. Baker General Hospital, 1K23 liaison with surgical consultants in- over.

Nichols General Hospital, 64, 100 sea theaters, 9-11, 48

Ninth Service Command, 101, 271-287 liaison wvith surgical consultants In seryhospital orthopedic care Ini, 285-287 Ice commands, Zone of Interior, 11, 47-

Ninth U.S. Army, 330 48

Nitrogen mustard, 83, 88 See also Surgeon General, The.

Nitrous oxide, 549 Oil Incendiaries, 93-94

Nonsuture repair of blood vessels, 323-324 Oils, 83, 93

NORMAN, S., 212 Okinawa, p~rovision of whole blood to, 160-

.Normandy, 180, 2.98, 299, 341, 567 101
INDEX 61

Old Faiiis. ' See Old, Faims- Convalescent Osteomyeits, chronic, following open.

Hosptal Specal),wounds, 224

i FarmsConvalescent Hospital (Special), OsteomyellItis, penicillin therapy In, 21 ,90 ;T;° ' 0te0"myeiils,' tfaum ti tiatnent of,

Oiguriaj , 44'i " xnotion' piure ofii'T7-28

'Olier~eneAI~Hspial,219Otitis extei'a, 107

Operation6 ANVIL, reassignment of medical Otitis niedia,:107-108,

-unit for,896-897 Otplaryngology, 105-420

QperatiwonOLYMPIC, 161 Otolaryngology Branch, Surgical, Consul. opertion E'. LORD, 299 tants Division, Office of The Surgeon

Third U.S. Army medical plan for, 315, General:

clinical policies of, 106-108

Operation SHINGLE, 345 establishment of, 105-106, 108-109, 114,

Orerations, multiple, of the knee, 222-223 119

Operatlons'and Training Subsection, Medl- Otolaryngology Section, New York Academy.

cl ,Setioh, Third U.S. Army, 29W-298, of Medicine, 112

Otological Research Laboratory, Abington

Operations Service, Office of The Surgeon Memorial Hospital, 106

General, t1 Ottawa, 59

Ophthalmology, 95-104, 303 OTTNHETAMIs, Col. E. J., 8

directive on: OU01TEnSON, Col. A. W., 8

War Department Circular No. 347, Oversea Blood Program:

1944-179 blood banks in oversea theater.: for, 147-

Ophthalmology, traumatic, 103 149

Ophthalmology Branch, Surgical Consult- evolution of, 147-154

ants Division, Professional Service, Of- plans for invasion of Japan, 161-162

lice of The Surgeon General, 95, 101-102 Overtreatment, 63

activation of, 95 OWEN, J., 212

functions of, 95 Oxygen, administration of, 38

Optical Branch, Medical Supply Division, 95, Oxygen Therapy Outfit, 20 Dual Outlet,

101 with Hose Line Assembly, criplete, 74

Optical Program, 531-532

Optical repair units, 532 Pacific, 8, 101,127,138,144,157-162,284

directive on: otitis externa in, 107

Circular No. 16, Seventh U.S. Army, provision of whole blood to, 157-161

1944-520, 532 Pacific theaters, 40

Oran, 335,392, 433-434 Pain, of low back, 268

Ordnance Corps, 531 Palawan, 569

O'Reilly General Hospital, 242-243 Palermo, 295n, 368

Ornoc, 502 Paraldehyde, in treatment of tetanus, 499

Ormoc Corridor, 565,570 Paris, 312, 527, 534

Orthopedic Branch, Surgical Division, Pro- Parke, Davis & Co., 135

fessional Service, Office of The Surgeon PASNALL, Lt. Col. H., 225

General, 49,61 PARSONS, E., 123

establishment of, 49 PAR30NS, Col. W. B., 8, 234, 465, 575

organization of, 49 PARTIN GTON, Maj. P. F., 433

Orthopedic Consultant. See Consultant(s) Patient care, 197, 200-207

in Orthopedic Surgery. PATTON, Gen. G. S., Jr., 293-294, 295n, 296,

Orthopedic service, Fourth Service Corn- 298, 307-308, 314,328,329

mand, physical therapy in, 221 PAYNE, I. L., 255

Orthopedic surgery. See Surgery, ortho- Pearl Harbor, 42, 136, 484-485

pedic. PENBERTHY, Col. G. C., 239-244,247
12 A0TIVITIES OF SURGICAL CONSCLtNT !f ' S

Penicllin~, 29,318,327,422-423, 55"-51 Phbysical Therapy Branch, Rehabilitationestablishment of program for studiles of, 20 Division, Office of The Surgeon GenerAia,

• theraP34n-.t establishment of, 49

abcis4,21 Pierson extension, 183

eXposure of skin to mustard vapor or PiKE, Lt, Col; M. M,, 273

liquid, 87 Pllonldial cyst:

hand ifectlons,o252 directives on:,

sirgical infections, 21 Circular Letter No, 109, Office oi'Tfie

tetanus, 499 Surgeon General, 1943-174

Peninsular Base Section, 395, 514n, 519 War Department Technical Bulletin

Peninsular Base Section Medical Society, (TB MED) 89, 1944-44, i75, 240

365 Pllonidal cyst disease, 245-248

Pentothal sodium, 38, 189, 213, 301, 363, 365, Plionldal sinus, 29, 44

393; 429, 431,401, 550 directives on:

directive on: Circular Letter No. 169, Office of The

Medical Circular No. 7, Office of Sur- Surgeon General, 1943-174

geon, Fifth U.S. Army, 1944--01, War Department Technical Bulletin

use of, education on, 38 (TB MED) 89, 1944-44, 175, 246

Peover, 295 loss of manpower due to, 43-44, 249, 250

Peover flail, 299 problem of management of, 87-88, 43-44,

Pery Jones General Hospital, 50, 197 249-250

Peripheral nerve injuries. Sco Injuries, PlNcOVrys, Col, M. C,, 503

peripheral nerve. Plperocalne hydrochloride, In spinal anesPerlston, 459,400 thesla, 37

Personnel, evaluation and assignment of, Pisa, 350

6-10, 198, 200, .07, 281, 302-304, 353-357, Pistola, 345, 390

4609 Pitranala, 345, 350

Personnel, medical, Seventh U.S. Army, 507- Plans and Training Division, 25

508 Plasma, blood:

Personnel, orthopedic, 281,322 dried, 130-1,33, 135-130

evaluation of, 282 in treatment of shock, 130-131

selection of, 281-282 frozen, in treatment of shock, 130

training of, 282 In World War 1, 123

transfers of, 282 liquid, 133-134

Personnel, problems concerning, 261 preparation and preservation of, 23

Personnel Division: Plasma program, 130-137

Headquarters, First Service Command, in Pacific, 157

190 participating agents t, 134-137

Office of The Surgeon General, 523 Plasma proteins, fract4onation of, 135, 137

Peter Bent Brigham Hospital, 138 Plas teIno fcioation o1 3

Pl m:SOx, Col. L. 'r., 4, 49, '53-51, 614, 234 Plseimoliaon24 Petou Cel.L, 4, 49Plaster P etrolatum room technicians, training of: jelly, 84m o i n p c u e o :

PmIIUSTEm, D. B., 123, 255 motion pictures on:

, henyldlchlorarsine, 83, 89 "Plaster Casts," 02

Philippine Islands, 50-57, 373, 467, 469, 471, Plastic procedures, 262

473-474, 477-482 li.uMMI:rt, W. W., 201, 269

Philippine medical personnel, 57 Po Valley, 343, 345, 355,375, 384, 388, 394

Phlebothrombosis, 447 l'olsons. blood, 83

Phosgene poisoning, 83, 89-91 Poisons, blood and nerve, 83, 91-92

effects of, on pulmonary parenchyma, 90 Poisons, nerve. 83

Phosphorus, white, 83. 92, 93 Poisons, systemic, 83, 91-92

Physical Standards Branch, Medical Divi. Policies. clinical, 547-552

sion, Professional Service, 61 dissemilnatlon of, 314
Ptolicies, su.iieal, directives on: Progranm, convalescent, 192 -194

Crcurtlar Le.!r.ttrNo. 2, Offce of the Sur- Program, medical educattion, 194 :195

ieon., g g[Venth 'U.S. Arajy, 1944--506- Program, reconiditioning:,

, ,Circularng etter 'No. 17, Offce o)f the Sur- Circular Letter No. 168, Office of The

. geon,:Seiith US; Army, 1044-551 Suirgeon General, 1943-192

Polloc Harbor, 507 Program for the Aural-Rehabilitation of the

:o P~ntine Mar~shes, 849 Deafened and Hard of Hearing, i12-120)

P'ontocaine,' in spinal anesthesia, 37 Prosthesis research center, 279

P oL, , H,, 554- Protection of personnel against gas,, 71-77

Port Moresby, 158 Proteus, 207

Po0ns,Capt.R. B., 273 Psychosoniatic disorders, 251

PovTns, Lt. Col, W. H., 05-101 Publications, training, 26, 28-2, 70-80

PdrtS, Col. J., 8 PuLASxr, Capt. E. J., 207

pratella, 390,409 Pulmonary damage fromPRATT, MaJ. D, R., 273 chlorine, 91

Presbyterian Hospital, 136, 188 chloropicrin, 91

' Presque Isle Airfield, Maine, 172, 181 cyanogen chloride, 92

Pressure dressing technique for manage- hexachlc. ethane mixture, 94

iment of burns: hydrocyanic acid, 02

directive on: lewisite vapor, 88, 89

:.Circular Letter No. 15, Office of The lung-irritant gas, 90-91

Surgeon General, 1943-45 mustard vapor, 87

PSsTON, Lt. Col. R. L., 64 oil incendiaries, 93-94

Prestwick, 145. 150-151, 295n phosgene, 90

Paxoos, Lt. Col. FE. K., 278 screening smokes, 94

Primeiro, 457 sulfur trioxide-chlorosulfonic acid soluPriority cases of battle casualties: tion, 94

directive on: Purple Heart, 329

Circular Letter No. 3, Office of the Stir.

geon, II Corps, 1948--411--412, 416,

S423 Quadriceps deficiency, 29

Prso cmp:Quartermaster Corps, 26

Camp Stark, N.H., 181 Quartermaster General, The, 49, 55

Houlton, Maine, 181

Princeton, Maine, 181 Radiology, 303

Seboomook, Maine, 181 RAIN, Col. F., 8

Spencer Lake, Maine, 181 RANDOLPH, Lt. Col. M. E., 4, 95, 97, 100-102,

surgery In, 181-18221

Prisoners of wvar, 225, 255, 313-31421

German, 448-449 RANKIN, Brig. Gen. F. W., 3, 5, 16, 21, 72, Probems:74, 105, 106, 108, 142, 148, 169-170, 175,

of physically unqualified inductees, 266- 178, 187, 189, 193, 228, 237, 368-369

267 RAWL S, Lt. Col. B. W., Jr., 365

orthopedic, 267-268 Recommendations of orthopedic consultant,

I-personnel, surgical, 261 Surgical Consultants Division, 64-O5

Procaine hydrochloride, 176 Reconditioning, 254, 277-278, 286

in spinal anesthesia, 37 Reconditioning Division, Professional ServProcurement Advisory Division, 17 ice, Office of The Surgeon General, 105,

Professional Service, Office of The Surgeon 114

General, 3, 17, 19, 69, 105, 218-219 Records, 313

606222-62-----41
f614 OIIISO URIA OSLAT

Riefrigerator for storing of blood, distribu. Rupture, ligamentous, 246

tibof of, heaters; 3 Russia, 368'

'Regbients:R:K SW4

- -~30hAT;- S t u, Col, CQ 1., 387'

'442d Separate--372 SitL,1

l~th-370 *Si4rope'r' 5'10,j 514

aPrachute 'apii'0

503d571Saleno,301,,395

RKGXE, t.CF.1 IV;, 602 Salisbury; 1W0

e1bitao 0,212322,245, Sar. LTazaro Hospital, 495-M00

28"0 81, 284-285, 287 San Malrcelino6, 572

6euters, 10V, 222 SANDEEN,,Lp Cl 5 . 8

iqte gted,, 27 TT278 SANo~u,'Lt. Col,P. I,83

'of apee,2-22Sanitlits company, 452-454

ofblind nd deaf,,prograiii for, 95 Schede's technique, 401

Riehitbilttation Center for the Deafened and Schick General Hospital, 242

Htard of Hearing, 106 School of Medicine, -University of Pensyl.

Ratoitrii ., ,120 vania, 129

ReIiel Division, Wyeth, Inc., 134 Schools, anesthesia, 204

Rieichel Laboratories, 120,134 ftuiaoo., 14., D)., 242

Relations,, between Medical Department and ScJitwAtE, Lt. Co1. F. N., 4, 127

other branches of Army, 200-2001 Scotland, 145,.150, 151, 295n

Relations, between medical officers of U.S. Screeniing:

Army and Army of the United States, 259- diagnostic, in unit dispensaries, 270-27T

200 of Inductees, 250

Resus~citation, 310-317, 547-548 of patients for surgery, 275-276

principles of, 41&-410 SOUDDER, J., 120

Returns to duty, statistical data on, 545-547 Sebooinook Lake, 181

Rnzr1ELANnaEt, Capt. F. W., 273 Second Service Command, 192, 197-207

RHrOADS, Co1. 0. P,, 70, 71, 120 Second Service Command Laboratory, 2007

Rhoads General Hospital, 204,207 Section on Laryngology, Otology and RhinolRiardo, 302 ogy of the American Medical Association,

RicE, Brig. Gezi. G. W., 579 ill

RITOnE, Lt. Col. S., 225 Sections, orthopedic, 204, 270

ROBERTSON*, L. B., 122 SEELEY, Col. S. F., 125

ROBERTSON, 0. H.,.11.0 Selective Service for the State of Maryland,

ROBERTSON, Col. R. 0., 820

ROBinsoN, G. 0., 135 Senior Consultant in Medicine, Services of

Rockefeller Center, 71 Suppjly, SWPA, 503

Rockefeller Foundation, 2&5-256, 281, 20-5 Septicemia, penicillin therapy in, 21

educational advantages provided by, 09 Serum albumin, use of, 23

RooERs, Co1. H., 179 Sertum, blood, 123, 135

Rome, 341, 345,349, 365, 375,384,410 Sce also Human Serum Albumin ProRooms, operating, 189, 196 gram; Serum albumin; Serum Program.

Rosignano, 341 Serum albumin, use of, in treatment of

Rloss, D., 119 shock, 124

Rous, P., 123 Serum Program, 137

Royal Army, 102 Service, orthopedic, Fourth Service ComnRoyal Society of Medicine, :312 suand, 220-221

Ru noLlii, Col. M. P., 507, 5 31 Service comnnand surgical consultants, 11
SericeComans:SOL6VFF, Maj; Di B., 531,,548,

lighth, 49-270 50 ec Servic'es of Supply,_

kFifth, 21,227--238 SuhPaii,,~5

First 107~196~uthPacii aeCommand, 8-9,

Fourth, 21P225, $otheastern Pennsylai ChpeAer

NIBt,11 7.27 ican 'Red Cross, 130X13

~ ~ Soutern Mdical Society, 23,

~Svn~239-248 Southern Surgical Association, 22

R~th,4Southmbd Z spitAl, 800

!Third 0-1 Southwest Pacific, 82, 93, 158, 160,,294, 475;

~S~vceofSupl~ 46-401,50 477-479

'96ventl Cor, Areaf, 239r,~ 4 Southwest Pacific Area, 157-:158, 405-40,

Seventh ivice~ommand, 239-248, 478, 474, 484,,567, 578, 575, 579-

)roimot6 ioiad morasle in, 243-244,-247 Southwestern Pennsylvania Chapter, Amereveth,,U. S. Army, 158, 293,- 295b, 298, 308, 4can Red Cross, 130

398,30T 505504Spanish civil war, 41

Jakkaiment of personnel of, 523-524 Spectacle program, 95

medical units, 534-54 SPEED, J. S., 269

Sharp &JDohme, 129, 131 Spinal cord:

"drrLt o. L. x., 393 fra ctures of, 32

81h60k, 300, 310-17 4210Injuries of, 322, 429-3

German treatment for, 459-400 convalescent care and rehabilitation In,

stfidies in, 412-415 27

ste f lethal sequelae of, 40 Spine:

whole blood In management of, 38, 122- fusion operations on, 223

124, 331- Injuries of, 822, 558

Suoox,'Col; C. F., 127 SPLIT=LER Col. A. W., S

Shoulder, recurrent dislocations of, 223, 249 Splinting, 425-420

Shrlvenham, 300 regional, 320

Sicily, 293, 296n, 299, 304, 312, 338-341, 349, transportation, 310

352-35, 300, 374-376, 380, 380, 411, 421- splints:

422, 425, 431, 483, 442, 514n half-ring hinged, 425

evaluation of surgery In, 373 Mason-Allen, 445

Signal Corps, 27, 81, 82 Sprains, ankle, treatment of, 175, 170

Silver nitrate, 84 Springfield Armory, 170

StLvERMAN, R. KX, 114, 119 SPUaRiNO, Col. R. G., 4,558

SimEoNE, Lt. Col. F. A., 302, 303, 398, 428, Stark General Hospital, 218, 219

431, 445 State University of Iowa College of MediSixth Service Command, 197 cine, 122

Sixth U.S. Army, 159-100, 162,405-504 Stations:

Skeletal traction, 240 battalion aid, 377

Skin grafts, 223-224, 233-234 clearing, 379-380

SICYBEBO, Maj. V. 0., 119 collecting, 377-379

SLOCUM, Maj. D. B., 273 Statistics, amputation, 57

Surxr, Maj. D. W., 330, 331 STAYER, Maj. Gen. M. C., 305, 514n, 525

SMITH, Capt. L. DES., 363 STEINBERG, Capt. S., 191

SmriH, Col. L. H., 271 SENLR . 6

SMiTn-PETERsEN, M. N., 184, 193, 269 Steinmann', A.,nio 209 4,4

Smokes, screening, 83,94 Steinmtannetnsionpi,4,40

SNYDER, Col. H. E., 294, 33464Stnuars839

SNYDER, Col. J., 368 STEWART, F. WV., 255

Society for Medical Consultants, 229 STEWART, Lt. Col. J. D., 398, 413, 414, 415,

SOFIELD, Col. H. A., 8, 160 421

SolcoLow, N. 1., 124 STORCK, Lt. Col. A. H., 4
616' ACTIVITIES OF SURGICAL CONSULTANTg'S

Strept6mycin, 43, 207 Surgeon-Continued

'STi~u A, M. M., 124, 126,129-130, 135 Fifth U.S. Army, 143, 294, 343, 358, 364,

STiu Is; 0.0. 126 386, 388, 394, 36, 397, 399, 405,4142

Sub niittee on Audiometers and, Hear- 445,525

ling, ;Aids, American Standards Assocla- First French Army, 525

oiii,112 First ServiceCommind, 178

Subcommittee on Blood Substitutes, Corn- First U.S. Army, 299,538

niitteb on Shock and Transfusions, Dlvi- MTOUSA, 365

sion of Medical Sciences, National NATOUSA, 8, 142, 143, 368,413, 525

Research Council, 126, 130-131, 135, 145- Peninsula Base Section, 143, 355, 519, 526

148,151 II Corps, 294,392,397,416

Subcommittee on Otolaryngology, Division Second Service Command, 197

of Medical Sciences, National Research Services of Supply, SWPA, 501

Council, 111 Seventh U.S. Army, 295, 507, 531

Subic Bay, 565, 571-572,575 Sixth U.S. Army, 159, 405,467, 469, 501

Sularnyd sodium, in treatment of mild con- Tenth U.S. Army, 160

junctivitis, 87 Third U.S. Army, 203, 295n, 296-297, 29

Sulfacetimide sodium, in treatment of mild Surgeon General, The, 7, 0, 10, 11, 22-23, 31,

conjunctivitis, 87 38, 40, 49, 51, 52, 53, 54, 56, 50 63, 68,

Sulfadiazine ointment, 84 09, 95, 102, 105, 114, 125-127, 135, 136,

Sulfonamide therapy, 331, 421-42, 483-484, 138, 141-142, 147-150, 169-170, 178, 184,

551 190, 195, 206, 210, 221, 24), 242, 247, 269,,

directives on: 274

Circular Letter No. 7, Office of the See also Office of The Surgeon General

Surgeon, Seventh U.S. Army, 1945-- Surgeon General of the Navy, 126, 135, 138

551, 554 Surgeon General of the Norwegian Army,

Medical Circular No. 1, Office of Sur- 368

geon, Fifth U.S. Army, 1944-361 Surgeon4, orthopedic, Ninth Service CoinWar Department Technical Bulletin mand, 273

(TB Med) 147, 1945-484 Surgery, 312

n sirgical infections, 23 Surgery:

Sulfonamides, 42 abdominal, 182-183

definition of limitations of, 43 elective, 385

effect of, on streptococcus and gonococcus, eye, ear, nose, and throat, 188

42 general, 3-48

local application of, 43 consultant in, functluns of, 167-168

Sulfur-trioxide-chlorosulfonic acid solution, hand, 187-188,224, 227,246, 268

80,83,94 in prison camps, 181-182

SULLIVAN, Lt. Col. H. R., 142-143, 155,417 orthopedic, 49-65, 183-185

SULLIVAN, Lt. Col. J. M., 533,537 training in, 300

Supplies and equipment, surgical, 311-312, plastic, 187-188

531, 573 reconstructive, 276, 283-287

for otolaryngologp,, 109-110 integrated, 279-281

Supply and equipment lists, revision of, by thoracic, 279, 384

Surgical Consultants Division, 17-18 urological, 186-187

Supply Branch, 17 Surgery, Gynecology and Obstetrics, 16, 25

Supply Service, 72 Surgery BranchSupport, medical, in amphibious warfare, Medical Practice Division, Professional

575-576 Service, Office of The Surgeon General,

Surgeon: 3, 17, 228

Army Ground Forcs, Washington, 514n, Medicine and Surgery Subdivision, Pro523 fessional Service Division, Office of The

Eighth U.S. Army, 579 Surgeon General, 3
INDEX61

Surgeryivision, Professional Service, Of- Surgical, Consultants Divlsioni Office of The

liceof Te Oe~r~li3,69, Srgeo 89 urgeo4,Genera1-otine

SriaAnfoMcaalDpr n 'orthopedic consultant In,49-W

Personnel, ,26 preliain bi stil dmto p Sirgical 'Committee, NationaL ;Research .tures;.27-28

Council, 23 professlibnai consultatlofi seivices oft.31.-

" Suil onsuitafits ee,'C6nItit (s)in 47

Gneral tSurgery, .Consultant in Hand proposal-of, for establishment of central Surgery.,onslt n iNeurosurgery; service system, 18-19

!C 6 lt(t)i~ pthaoiogy; "Consult- public relations of, 2123 an t(0:!' i n rtiaolSkl Surgery; dahsalt- review by,,'of manuscripts and literature,

i • t~ih labryngkology; Cnsultant(s) in 6,24-25 .revision of, supply-and equipnent lists by,

-Sr -clConsultants Division,, Office, of The 1748 rueo role of, in development of Essentiai Tech.-

1096,442;4169, '189, 212, 272, 369 nical Medical Data, 9

advanceiieiit by, of education and train- selection and recommendation by, of staffs

• iig, 25-8 for variou's Army hospitals, 15-16

issistaince by, in preparation of surgery suggestion by, for revision of surgical:

manuals, 6 service, 16

BliodlProgram in, 127-128 Surgical Division, Professional Service Of;

onsultation of- flee of The Surgeon General, 3, 6

with Mllitary Personnel Division, 6 Suture, in repair of blood vessels,, 824

with iilty boards, 6 Sweden, 59

consultation services of, on- Switzerland, 59

anesthesia, 37-38- SWPA. See Southwest Pacific Area.

equilpaent and supplies, 17-21 Sydney, 158,482, 504

hosit lizatlon, 45-47 Syme's amputation, 201

trauniatic shock, 38-40 Sympathectomy, 326

trenchfoot, 32 lumbar, 560

use of plasma and whole blood, 31, 38-40 Sympathetic block, 325-326,489, 560

war wounds, 5-, 31,40-45

definition of professional policies by, 29 TAGLIAGAMBE, Capt. M. F., 273

development by, of visual training aids, Tannic acid in treatment of burns, prohi27-28 bition of use of:

establishment by, of Bulletin of the U.S. directive on:

Army Medical Department, 28-29 Circular Letter No. 161, Office of The

establishment by, of Medical Officers Surgeon General, 1943-45

Service Record, 30 Tantalum wire and film, 23

establishment by, of on-the-job training in TAYLOa, Maj. E. S., 136

general hospitals, 30 Teams, surgical, 308-310, 501-502, 546, 575

establishment by, of program for study of Importance of, 331

penicillin, 20-21 parachute, 29, 502

evaluation of drugs by, 43 thoracic, 386, 391

evlutional changes in, 3-6 Tears, meniscal, 240

functions of, 5-47 Tebessa, 336

Identification and allocation of surgical Technical Division, Operations Service, Ofspecialists by, 6-16 ice of The Surgeon General, 71, 72, 76

liaison of, 6, 9, 10, 11, 21-23, 27, 48 Tenth U.S. Army, 160

with American College of Surgeons, 22 Terrain, effect of, in battle of Leyte, 570,

with National Research Council, 23 571

with oversea theaters, 9-11, 48 Testis, maldescent of, 249

with professional associations, 29,-23 Tetanus, 327, 495-500

with service command consultants, 11 antitoxin for, 327
018i ACTIVITIES OF SURGICAL, CONSULTANTS

Tetracifie hydrochloride. Sec Pontocaine Training, surgical, 25-31, 103,204,,2O4 269, .

ThayrGnerl Hspial,219507,538-534,5Z80

Therapy on the job speciaity 30-31, 209, 525,,533,

antibiotic, 318, 5o0-551 538,578-579

-anhinicrbilal, 317-818 Tann is

blood replacement, 419-421 publcations, 26i,28-29, 79-80'

itwounasoche8- visual aidsa, 27-8,, 8i42;255

'Waipr tmn ehia aul8 Training Division, Operations S&vIce'

21,1942-- 434 Office of The Surgeon General, -30, 62,141i

Occupational, 192 81

penUfiilin, 550-551 Transfers, interhospital, 51

physical, 191, 221 Transfusion, blood:

sul!fonamide, 23, 331,361, 421-422, 483-485, in European theater, 147,151,155-156

561,554 In Mediterranean theater, 147, 151, 13,:

Tirifilt,, 83, 93 156-157, 416-421

Thionvilie, 310 instruction in, 300

Thliopental sodium, 549 oversea, 155-157, 417-421

86c 44Eo Pentothal sodium, reactions to, 420-421, 530

Thiid'Service Command, 209-214 Transfusion Branch, Surgical Consultants

h6pitals in, 210-213 Division, Office of The Surgeon Geheral,

performance of hospital personnel in, 212 127,147

Third U.S. Army, 155,291-332 Transfusion of whole blood, in the theaters

administrative considerations of, 291-314 of operation:

casualties hospitalized in, 291 directive or,:

clinical considerations of, 314-332 Circular Letter No. 108, 1943-39, 148

dissemination of clinical policies in, 314 Transfusion sets, distribution of, 89

persons treated in, 291 Transportation, 531

Third U.S. Army Plan for Operation OVER- Transports, attack, 339

LORD, 314, 315, 317 Txperm., 7

Tuom~, SirCLEMNT, 35 TRUBER, M., 27

THOMAS, Sir CLEMEN, 335 Trauma, primary, 326

THOMAS, Col. H. M., Jr., 50 Treatment ofThomas M. England General Hospital, 56, abdominal injuries, 443-444,577

192,193,200-204,207 burns, 242

THOMPsON, Lt. Col. J. E., 555 casualties:

THOMPSON, Lt. Col. T. C., 212,225 directive on:

Thoracotomy, 434,557-558 Circular Letter No. 1, Office of SurTHORNE, Col. F. H., 96 geon, II Corps, 1943-360, 372

THORPE, Capt. H. H., 160 casualties from chemical agents:

Thrombosis, 447 directives on:

Tilton General Hospital, 200,204,207 War Department Technical Manual

Titanium tetrachloride, 83, 94 8-285,1941--74,79, 84,91 Titnum telita 4 e War Department Technical Manual

Tobruk splint, 426 8-285,1942-79,84,91

Toronto, 59 War Department Technical M1anual

Tourniquets, use of, 29, 427-428 8-285,1944-79,84, 91

TovELL, CO1. R. M., 368, 530, 548 War Department Technical Manual

Traction: 8-285,1945--79,86, 91

pulp, 321 chest injuries, 436-437, 577

skeletal, 321 fractures, 21, 63-64, 176, 184-185, 223-224,

skin, 326 246, 267-268, 283-284, 319-322, 326, 423-

Training, medical, 533-534 426,430,463, 464, 553,571-572
-INDEX' 1

TreWent tn -Continid' U.S. Army Medical Center, Oamp.Edward,

hld-ndiJuries,,224, :68, 320-321, 444-445, 192 -554 U.S. Army MedicalSer'ice, 229 i232

open wo uns with bone infection, 238-234 U.S. Army Services of Suply, Southwest ,

p~l~ida snu;4344,'249250Pacific Area; 8,

apra~pedl iiies,7'5;,176, U.S. Marines, 96, 138

traimatic osteomyeliis: U.S. 'Naval Photographic Science Laborai

.motioii picture on, 27-28 tory in Washington, 27

vhAco edelns: U.S. Navy, 81, 95; 96, 122, 131,134,136, 14-

difective on: 146, 151, 158-161, 195, 338i840, 391,469,

'Circular Letter No. 72, Office of The 482, 484, 491, 527, 573, 576

Surgeon General, 1943-174 blood program of, 128, 151

vascuiar iiJuries, 427-428 U.S. Navy Hospital, Philadelphia, 96

wouindedlln SouthwestPacific, 475-477 U.S. Navy Medical Corps, 576

woundls and injuries of the femur, 577- US.S. Samuel Qhaeo, 338

578- U.S. Submarine Base, New London, 112

Trenchfoot, 29, 246, 327-329, 431 University of Algiers, 524

directives on: University of California School of Medicine;

L ttei,_.Lt. Col. W. G., Caldwell, Adju- 286

tant General, to All Units, Seventh University of Chicago, 71

Army, 31 Dec. 1943-521 University of Kansas Medical School, 333

Medical, Circular No. 6, Office of Sur- University of Kiel, 464

geon, Fifth UAS. Army, 1943-361 University of Michigan Medical School, 126

epidemics of, 327-328 University of Minnesota Hospital, 138

See also Cold injury. University of Oregon School of Medicine,

Triage, 340, 374, 475-477 295n

directive on: University of Oslo, 368

Medical Circular No, 4, Office of Sur- University of Pennsylvania School of Medi.

geon, Fifth U.S. Army, 1944-361 cine, 129

importance of, 331 University of Rochester School of Medicine,

in German Army, 452 295n

TaIMBLE, Col. I. R., 8, 161, 575 University of SAo Paulo, 390

Triological Society, 111 Urethritis, specific and nospecific, 175

Trueta's treatise, 41

Truppenverbandplatz, 452 VAIL, Col. D. T., 4, 101-102

Tunisia, 295n, 368, 392, 397, 425, 433, 438, Valley Forge General Hospital, 96-97, 100-

514n 102

TUTTLE, Lt. Col., W. McC., 369 VAN WAOENEN, Lt. Col. W. P., 185

Varicose veins, 174, 249

Ulcers, tropical, 29 Vascular conditions, 262, 428

ULLnICI, Lt. Col., H. F., 212 Vasospasm, 41-42

UNOER, Maj. H., 273 VELDEE, M. V., 127, 135

United Kingdom, 300, 333-335, 391 Venafro, 362, 408, 409

United Kingdom Base, 149, 558 Verdun, 534

planning in, 298-302 Verwundetennest, 452

theater blood bank in, 316 Vesicants, 83, 84-89

United Shoe Machinery Company, 190 Veterans' Administration, 51, 59, 95, 97, 112,

United States. See Zone of Interior. 250

USAFFE. See U.S. Army Forces in the Far Visayan Islands, 505-567, 572

East. Visits, interhospital, 201

U.S. Army Forces in the Far East, 465, 503 Visual aids in training, 27-28, 62, 81-82, 255

U.S. Army General Hospital, Camp Ed- Vitallium tubes, 323

wards, Mass., 172 V-J Day, 210, 213
620 ACTIVITIES OF SURGICAL CbONSULAT

_4os. M3EE4 Warfare chemical, 67-94-

'V~AvB46Auofth Axander Graham Bell WA~ilNG,CoT , 24

:Aiociaftii'orThe'Deaf, 12' i Cst, .,..,, 41A4,415

VoN.Tm meetingsng

"Y o~iclYcety,33 243

1WGNXR,4 -A.,, 124 Wms ijGE 7

Wales, 335: aetw-rea~"

Waltei Reed Army'Medcal Center, 59 Wayne State 'University Coll ege 6 Md

W~l~ edGbrl'~jia,4 38, q6, cine, 243

Wthm egonal Hospal1743 182, WEED, L.:H,126, liQ6

W~~am;0. H., 126 Wehrac, Lt E, 458.

Wangena'teen tfube, 487 Welch's bacilluis, _327

'War, Dejidtent, 10, 220 WEsT, Maj. F.R 6. 4

Wa.ea 'eC-irculiar- West Pacifti, 8

';NAZ'0Ja. 1944-174, WVesteifiPacific-base Command,89

No,'i4i, 25MAug 1944-7 Westover Fleld,472-178

VWar.Deartmnent Field Man -ual (FM) 21-11, Westover Regional Hospital, 178, 182

Fitdfo Slder,26, A83 Wet lung, 435

War Depiartment Memorandum No. W*AO- W~i#PPLE, A. 0., 368,425

44,42 April 1044-19 WHIMn, BrkiadlirL. H ., 141

War Deparitment Special Orders No, 175, White I ubrSprings, 84

~J~u~194-239Whole Blood Proirarni 140.447

War Dep#Ament Technical Bulletin (TB development' of blood-groupIng sera for, "MED)"- 146,

37, 28Apill 1944-78 equipment and containers for, 143-144

4318May 1944-18 In North Africa,141-143

89,,2 Sept. 1944-44,175, 246 Initial obstacles In, 140-141

101, 4 Oct. 1944-80 preservative solutions for, 145-146

-1417, March 194"-84,537, 539 refrigeration for, 144

151, March 194"-5 training of personnel for, 146-147

419June 1945--77 WiLLIs, Brig. Gen. J. M., 158, 271

War Department Technical Bulletins (TB WILSON, G. W., 123

MED's), preparation of, by surgical con- WIL8ON, P. D., 25

sultant. 52 WINFIELD, Col. J. MACF., 389

War Department Technical Manual (TM) - Winter General Hospital, 242

8-210, Guides to Therapy for Medical Of- IzrT, Maj. M. S., 101

ficers, 26 WisE, Col. W. DI., 209-210,212-214,234 8-210, 20 Mar. 1942-434 ~or' a.L . 2

8-2 85, 10 July 1941-74, 79,84,91 Women's Army Corps, 188, 191, 241,278

8r-285, 27 Nov. 1942-79,84,91 WOOD, Coi. J. R., 88,71

8-285,15 April 1944-79,84, 91 WOODHALL, Lt. Col. B., 4

8-285, April 1945--79, 86,91 WOODROW Wilson General Hospital, 100,

War Department Training Circular No. 86, 210

13 Nov. 1942--84 World War 1-36, 83, 121-123, 227, 259, 294,

War wounds, consultative services of Surgi- 300, 324-326, 357, 891, 429, 459, 488,

cal Consultants Division on management 514n, 5.54,563, 564

of, 5-8, 31, 40-45 triage In, 475

WARD, G. R., 123 IWOUGHTRn, Maj. H. WV., 273
.Wounifd, open,':with fiondjn&cilonj 233-234 Woiifiis-C~fidtiud,'

Woiii'b*llisics" 5,445W5 io hortlkieori,4 320

after debrideppiit3hi, 326w of

~~rjdeia~d,2445 opn, itlioneizifctln,23-234

wiif&- clee i boinal wounds, regional,42, 485491, 577-578

:444, sef fiictdi2M3 6

WOtind healig, 242' spec al types of,,423-43

"'om ife'f e icilntheia&~ In, 21 Seeai0'486. ies

QAM,28 fractfres of, 820, ~aidoiin~32, 4244, 34 565U,-577, lnJriles to, 267

J aliominoelvira444 of, socalled, 267-268

conulatveserics n,5, 1,4044 23- XAPA. fte Transport , attk, kxprhiie

fiemur, 5774,78

ntaetba,430 Zilg Zag Pasns, W6, 672,1716 maillfiIacil, 821, 482 Zoneo ofuterior, 7, 16,12, 15, io, 21, 29 j'""-81 '

t4oracoabdominal, 438-44 68, 11 0,15 0,~0-1,1941

Woun6d surery, initial 428242 183-134, ,140, 149-151, p58,,155159, 161,

dIsjtr~butio ra,", 325, 469 478 8,55 514u,5354

540'~5 58534,558,58W

of anterior tibi Al muscles, W ~ hopitals, 51-53, 55, 57,105, 107, 109-n0,

of buttock, 326 12%,18i,18A38, 164, 213,298, 5M8'

of cbhisCt,orality In, 437 manageinent of 'pilouidalsinius -In,,43 of extensors of forearm, .326 provision of whole blo~d ro'm, for Euro*

oU, extremities, 319 pan theater, 14915

of rectum', 29 to the Pacific, 15t-161