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SECTION II.
CHAPTER XVI.
DIVISION OF GENERAL SURGERY.
ORGANIZATION.
The expansion crisis created by the declaration of war necessitated unprecedented activity on the part of the Office of the Surgeon General. From the purely clinical side, these activities radiated very naturally along the lines mapped out by the Manual for the Medical Department, from the three centers of medicine, surgery, and laboratories.1 Early in the movement wise and insistent attention was centered on the r le of the medical specialties and of the necessity of specialization in the Medical Department of the Army as refined as that in civil life. With the sympathetic interest and support of the Council of National Defense, the Surgeon General developed, in the field of surgery, the formation of units or sections devoted to surgery of the brain; surgery of the eye; surgery of the ear, nose, and throat; orthopedic surgery; and oral and plastic surgery. In order to organize and correlate the facilities of general surgery, represented by the Division of General Surgery (see Chart XVII), the Surgeon General requested a civilian surgeon to act as adviser to him in regard to general surgery and all the surgical specialties, and to select such men as he deemed suitable to serve as associates.2
On July 9, 1917, the duties of this adviser were taken up in the Office of the Surgeon General. 3 After consultation with the Surgeon General and chiefs of divisions of the Surgeon General`s Office, a small group of surgeons was appointed for this work, the men being selected, as far as possible, from the South and West, as the States east of the Allegheny Mountains were already represented in the Surgeon General`s Office. It was decided to make the term in office only two weeks for the first rotation 3 This enabled the Surgeon General to choose the men who showed the greatest fitness for the work, and gave them an opportunity, during their first short term of office, to think over their problems so that their second term could be made longer and more efficient. It was not the intention that this advisory board should have distinct duties, but were to take up special problems as they presented themselves for investigation, and report to the Surgeon General.
It became daily more apparent that the painfully won experience of civil hospital organization must be reckoned with, and that the broadest and least hampered growth of the specialists rested upon their fundamental coordination of them with the mother subjects. As a result of the failure to appreciate this fact, the special branches of orthopedic and head surgery (including ophthalmology, otolaryngologv, brain surgery, and plastic and oral surgery), under enthusiastic and efficient guidance, developed along lines independent of general surgery and equal in standing, so that general surgery no longer repre-
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Chart XVII.–Division of General Surgery, Surgeon General’s Office, June, 1918.
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sented a team, with suitable players, in the various fields, but a league of teams essentially competitive.
This spirit of rivalry, while quite friendly, had a disorganizing tendency. It was quickly seen, from the standpoint of the injured soldier, that this would lead to inefficiency and disorder, twofold in significance. In the first place, it was mirrored in the almost total lack of organization in the office of the Division of General Surgery; and in the second place, it manifested itself for a time in the various base hospitals, where each of the eight constituted specialties worked under its own chief of service and without any chief or interdepartmental coordinating authority. 4
The necessary corrective forces were applied through the joint efforts of the Surgical Advisory Board and the Division of General Surgery. The changes instituted were based on the two fundamental considerations: (1) That the existing state of confusion necessitated the immediate institution of steps to reorganize the Division of General Surgery, so as to make it an efficient, directing center; (2) that caution should be practiced, lest, in reorganizing the division, efforts should be centered exclusively on the activities of general surgery, thus tending to create an added spirit of rivalry or competition instead of one of coordination and cooperation between general surgery and the surgical specialties.
On November 8, 1917, after numerous consultations with the surgical advisers, the Chief of the Division of General Surgery, the Chief of the Hospital Division, and the chiefs of the divisions representing the various specialties, the Surgeon General issued an order to the commanding officers of base and general hospitals providing for three services-medicine, surgery, and laboratories. 5 This order further provided that the surgical service should include the special sections of general surgery, urology, orthopedic surgery, head surgery, and roentgenology. In the Office of the Surgeon General, the contemplated organization of activities, along lines similar to those laid down in the above instructions, was not completed until a year later.
All the essentials for practical, efficient, and cooperative organization, however, were not settled, so that the surgical adviser and the Chief of the Division of Surgery were prepared to arrange and dispose of detailed problems.
CLASSIFICATION OF SURGICAL PERSONNEL.
Of these problems, the most serious and urgent was that of properly classifying the men available for surgical duty. Prior to this time surgical chiefs had been selected for the various cantonment hospitals by methods that were not only impractical, but also were sure to prove unsatisfactory and totally inadequate in securing proper personnel for the various military hospitals soon to be established.
In September, 1917, a medical officer was also placed in charge of the classification and assignment of surgical personnel of hospitals, and he immediately set about to cooperate in the classification and selection of personnel. The plan finally worked out was to group the men under one of four heads in accordance with the following scheme: 6
(A) Available for detail as clinical chief, field hospital, evacuation hospital, base hospital, special hospital, consultant.
Not available for detail because of (I) teaching, (2) civil hospital position, (3) dependents,
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(4) physical disqualifications, (5) assigned to active duty elsewhere, (6) on Red Cross base hospital unit.
(B) Available for detail as first assistant to clinical chief, field hospital, evacuation hospital, base hospital, special hospital.
Not available because of (same as under class A).
(C) Available for detail (1) on staff of hospital in class B, (2) as regimental surgeon after appropriate military training.
Not available because of (same as class A).
(D) Available for detail (1) on staff of hospitals in class B, (2) on duty in ally capacity or special duty with Medical Corps.
Not available because of (same as class A).
QUALIFICATIONS-FOUR CLASSES.
(A) Chief in large civilian hospital; known proficiency as an organizer and administrator and instructor.
(B) First assistant in large clinic, capable of assuming chief`s duties. Ability known to committee or ascertained to be satisfactory.
(C) Experience that of chief of out-patient department; second assistant in clinic: general practitioner doing surgery.
(D) Experience that of hospital interne, minor dispensary position, etc.
(1) Men assigned to classes (A) and (B) only when their qualifications are known to this office.
(2) Men in all classes will have their special ties noted on card.
(3) Special summary card will be made for each man, being a confidential expression of committee`s findings from his record or from personal knowledge of committee members or data from this office.
The perfection of the plan necessitated inquiry into the records of hundreds of men in the various base, general, and post hospitals, followed by certain reassignments in order to reorganize the personnel with properly qualified men, where this was necessary. In selecting this type of personnel, only those men were picked for service overseas who were less than 45 years of age, and therefore most likely to be able to meet the severe test of long hours of work.
Hand in hand with the classification and selection of men for the base, general, and post hospitals, the personnel was selected for a number of evacuation hospitals in process of organization.
INSTRUCTION.
Late in July, 1917, arrangements were completed whereby medical officers were enabled to receive intensive surgical instruction. At the Rockefeller Institute, beginning August 1, 1917, the principles of wound healing and the treatment of wounds were demonstrated to classes of approximately 15 men over a period of two weeks for each class. These classes of intensive instruction were made up of officers of the Medical Reserve Corps assigned to active duty who had had surgical training and were destined for future general surgical activity. In addition to the course at Rockefeller Institute, other courses covering traumatic surgery and fractures were given at the following places: Bellevue Hospital, New York; Boston City Hospital, Massachusetts General Hospital, Boston; University of Pennsylvania, Philadelphia; Charity Hospital, New Orleans, La.; Pittsburgh, Pa.; Roosevelt Hospital, New York; Lakeside Hospital, Cleveland, Ohio; Presbyterian Hospital, Chicago; Mayo Clinic, Rochester, Minn. These courses, which were started early in November, 1917,averaged about 10 men, except the one at Rochester, Minn., where an average
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of 30 men attended, and each course lasted approximately a month. By the 1st of December the officer organization was running smoothly and by the end of December the classification of surgeons was practically complete.
PLAN OF ORGANIZATION AND ACTIVITIES OF THE DIVISION OF GENERAL SURGERY.
The beginning of the year 1918 saw the Division of General Surgery running along plans so well matured that it was possible, in answer to a formal request from the General Staff on February 8 to submit the following plan of organization and activities:8
1. FUNCTION.
The Division of General Surgery classifies surgeons of the Medical Reserve Corps according to professional capacity and trains those who are not fully qualified to a state of higher medical efficiency. The fully qualified men as well as those mentioned above are intensively trained in standardized military operative surgery. Surgical instruments and equipment are likewise standardized on the basis of simple efficiency. The properly graded and trained men are appropriately assigned, and the distribution of the instruments and supplies is recommended by this division.
2. ORGANIZATION.
(A) IN WASHINGTON.
1. Chief, lieutenant colonel, Medical Corps.
2. Rotating advisory staff composed of eight surgeons of outstanding reputation; all majors, M. R. C. (one on duty all the time).
3. Assistant to chief and advisers. To act for either in case of absence (Department of Personnel), major, M. R. C.
4. Department of surgical instruments and equipment. Function: Standardization and recommendation concerning purchase of all surgical appliances and supplies; major, M. R. C., lieutenant, Sanitary Corps, N. A.; sergeant, first class, Medical Department, U. S Army.
5. Department of Personnel. Functions:
(a) Classification of all officers of Medical Reserve Corps on basis of surgical ability. Accomplished by:
(1) Study of application papers.
(2) Confidential information from outside sources.
(3) Monthly reports from commanding officer of each base, general and cantonment base hospital.
(4) Efficiency report on each officer attending various classes of intensive instruction.
(5) Personal inspection by chief or an assistant major, M. R. C.; lieutenant, S. C., N. A.
(6) Department of educational, editorial, and literary supervision; functions:
(a) Standardization of curriculum of various classes of instruction.
(b) Compilation of abstracts of all important surgical publications from August, 1914, to the present. These have been bound and forwarded to the directors of classes in war surgery, to all important military hospitals in the United States and Europe, and will be kept up to date by a similar monthly publication.
(c) Selection and manufacture of suitable moving-picture films and lantern slides for instruments of medical officers in cantonments and training camps; two majors, M,1. R. S.
(B) OUTSIDE OF WASHINGTON.
1. School for wound healing and modern antiseptic treatment of wounds (Rockefeller Institute).
2. Schools for intensive training in war surgery and fractures, held in large clinical centers, one or more, in New York, Boston, Pittsburgh, Cleveland, New Orleans, and Rochester, Minn. (Mayo clinic).
3. Continuation of clinical instruction in cantonment, base hospitals under direction of chief of surgical service and qualified assistants.
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4. Selection, assignment, and maintenance of an efficient surgical service in United States Army base, general, cantonment base hospitals in this country. Accomplished by monthly reports of qualifications of personnel and of surgical operations performed. Inspection of equipment and surgical activities by chief of this division or an assistant when indicated.
5. Selection and assignment of surgical personnel for evacuation and base hospitals for duty overseas.
6. Under the direction of the Division of General Surgery, Base hospital No. 116 has been organized and is now ready for overseas service.
7. A mobile operating unit intended to furnish the best operative facilities for service cases near the front is now being organized by this division.
(C) OVERSEAS.
1. Two directors of general surgical activities in France.
3. STATISTICAL DATA.
More than 6,000 Medical Reserve officers have been classified as doing 10 per cent or more surgery in civil life. The Division of General Surgery has given courses of intensive training to 594 medical officers. The Division of General Surgery has at present:
466 surgeons on duty at base and general hospitals in United States Army.
360 surgeons on duty at medical officers` training camps for military training.
138 surgeons on duty in classes of intensive instruction.
145 surgeons on duty in evacuation and base hospitals now mobilized for overseas.
Later in the course of the year, 1918, after the division had been working in accordance with the plan outlined above, it was possible to catalogue the organization and activities in greater detail. This detail was furnished in a report to the Surgeon General by the chief of division in part, as follows: 8
DIVISION OF SURGERY.
Function.-The Division of Surgery is a professional division (charged with the consideration of all matters relating to surgery.
1. Personnel.-Recommendations to the Personnel Division of properly qualified members of the Medical Reserve Corps for the assignment to the surgical services of base, evacuation, and general hospitals, other hospitals, units, and independent posts and commands, to meet the requirements thereof.
2. Surgical equipment board.-Recommendations to the Supply Division for surgical equipment of suitable character and adequate quantity.
3. Maintenance of surgical efficiency.-(a) The inauguration and supervision of classes of intensive instruction for selected officers of the Medical Reserve Corps.
(b) Supervision in a broad general way of the character and efficiency of surgical work done throughout the Army. The organization of surgical teams and the investigation of special surgical problems as they arise.
(c) The preparation of outlines for classes of intensive instruction at clinical centers and for use of instructors in all the large hospitals.
(d) The supervision of surgical literature with the object of furnishing promptly to medical officers the latest approved information with regard to the development of war surgery and other surgical problems which are presented to the camps and cantonments.
Collaboration with the Division of Medical History with regard to surgical statistics, literature, etc., with relation to history of war.
The selection, grading, and providing for special instructions; and the recommendation for assignment of women physicians under contract for duty as anesthetists.
THE ORGANIZATION OF SPECIAL SURGICAL UNITS.
Chief of division.-All activities of the various officers are coordinated and controlled by the chief. All memoranda and reports are vised by him.
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PERSONNEL.
Officer charged with:
1. Assistant to and understudy for chief of division. Also assists and advises with surgical adviser to the Surgeon General (Major Mayo).
2. Selection of officers for detail to intensive courses for further training.
3. Classification of surgeons according to professional capacity and, previous training.
4. Based on this classification, the selection of officers for surgical work in all organizations ,e. g., base, evacuation, general hospitals, other hospital units and independent posts and commands, to meet the requirements thereof. Providing the adequate number of officers with proper qualifications for duties as chiefs of service, assistants, operating surgeons, and ward surgeons, etc. Assembling surgical teams in groups for service overseas.
Assisted by officer charged with office detail of:
1. Requests to Personnel Division for all orders for assignment of officers held by Surgical Division to active duty, to medical officers` training camps, to base and other hospitals, and else-where, when required.
2. Request for orders of officers to classes of intensive instruction at New York, Chicago, Phila-delphia, New Orleans, San Francisco, and Rochester, Minn.
3. Correspondence for division chief.-(a) With the commanding officers of base and general hospitals regarding nominations for availability of officers for classes of intensive instruction and transfer to other stations to meet the need thereof.
(b) Notification of commanding officers of hospitals with regard to professional qualifications of officers assigned or to be assigned.
4. Classification.-(a) Assisting Major Sullivan in properly classifying officers; retaining them for the Division of Surgery, including the following up of each case awaiting commission; and requesting orders for assignment to active duty when and where needed.
5. Efficiency reports.-(a) Reviewing and recording efficiency reports of all medical officer sin the surgical service, rendered monthly by the commanding officers of the different hospitals, noting their qualifications and adaptability, and requesting orders for transfer of officers reported as unfit for base hospital duty.
(b) Reviewing and recording the efficiency reports from (classes of intensive instruction on the student medical officers in attendance.
6. Records.-(a) "Master index" of all officers assigned to the Division of Surgery, showing name, home address, age, rank, classification, changes of status, professional efficiency, adaptability, etc.
(b) "Training camp file": Cards for all officers undergoing training at medical officers` training camps, noting reports of efficiency and availability for other assignment upon completion of military training; cross-checking with records at training camp and correspondence relating thereto.
(c) "Suspense file" of cards for officers in process of being commissioned, candidates and applicants for commission who are qualified as surgeons, and are desired for assignment by the Division of Surgery.
(d) "Special file" for cards showing name records, orders of all officers assigned to surgical service in all cantonments, general and post hospitals, also hospital organizations for overseas service.
(e) "Special instruction file" of cards for officers who have been and are being ordered to classes of intensive instruction.
7. Miscellaneous.-Following up of special cases and conditions that arise in the administration of the division which pertain to the personnel of the Division of Surgery.
SURGICAL EQUIPMENT BOARD.
Officer charged with:
1. Investigation and examination of surgical equipment, and standardization of instruments and appliances, based on the practical efficiency and needs of the service; the consideration and modification of equipment with regard to type, quality, and quantity, to meet needs of surgical service; and the preparation of proper recommendations to the Supply Division.
2. Inspection of surgical equipment at hospitals when required. Assistant charged with:
l. Care of surgical instruments, appliances, etc., submitted for examination.
2. Records of reports of surgical equipment submitted to hospitals for trial.
3. Proper distribution of surgical bulletins, pamphlets, reviews, and reports.
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MAINTENANCE OF SURGICAL EFFICIENCY.
Officer charged with:
1. The inauguration and supervision of classes of intensive instruction in war surgery and fractures, the treatment of infected wounds by the Carrel-Dakin method, and the instruction in the administration of anesthetics.
2. The supervision of the character and efficiency of surgical work done throughout. the Army by the inauguration of monthly reports covering detail of surgical operations, and supplemental reports as to death, infection of clean wounds following operation, of patent errors in surgical services, and the checking up of the surgical technique of teams. (Assisted by Captain Davison. 1
3. Inspection of surgical staffs at hospitals; supervision of organization of surgical teams and investigations and consultation with regard to special surgical problems as they arise.
Officer charged with:
1. The preparation of outlines for (classes of intensive instruction for clinical centers and for use of instruction in all the large hospitals.
2. The supervision of surgical literature with the object of furnishing promptly to the medical officers the latest approved information with regard to the development of war surgery and other surgical problems which are presented in the camps and cantonments.
3. Cooperation with the Division of Medical History.
4. Review of original articles in surgery submitted for publication by officers of the Medical Department with the rendition of necessary recommendation to the Publication Board.
Officer charged with:
1. Assistant to chief of division as advisor to the Medical Reserve officers on duty in division in military procedure, correspondence, Army regulations, and orders.
2. Assistant to Surgical Equipment Board in consideration of changes of and addition to standard Army equipment.
3. Checking, reviewing, and tabulating reports of surgical operations of all hospitals. including report of deaths on surgical service, infection in clean wounds, etc.; comparing records of surgical staffs, standardizing the form and manner of surgical reports; formulation of instruction to chiefs of surgical staffs (through the commanding officers in hospitals) relative thereto.
SPECIAL SURGICAL UNITS.
Special surgical units organized by specific authority: Base Hospital No. 116, special fracture hospital, mobilized for duty with the A. E. F. on December 20, 1917.
By a system of card cataloguing, it was made possible properly to select officers for their professional training in war surgery, to classify them according to their professional capacity, and to place them in the various surgical positions established in all of the hospitals of the country. In addition, surgical teams were recommended to the Personnel Division for overseas duty.
SURGICAL EQUIPMENT.
The Surgical Equipment Board on June 1, 1918, submitted a report in part as follows:
1. As soon as practicable after the organization of the Division of (General Surgery, the Surgical Equipment Board was organized, the express purpose of which was to "investigate and examine surgical equipment, standardize instruments and appliances, based on the practical efficiency and needs of the service, the consideration and modification of equipment with regard to type, quality, and quantity, to meet the needs of the surgical service.
* * * * * * *
4. Because of our considerable dependence on other countries for high-grade surgical instruments, the attempt to provide them from our own manufacturing resources to meet the urgent and immediate demands was extremely difficult.
5. Through the activities of the committee on standardization appointed by the Council of National Defense in May, 1917, a "List of staple medical and surgical supplies" was issued. Several vital requirements governed the selection of this list of instruments. Types that were sufficiently simple to insure quick production and early availability in great quantities were designated. In
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many instances these were not the most desirable types, but, being obtainable in minimum time, were accepted to bridge the period of emergency. During the early part of this year the production had increased to such a degree that the process of eliminating undesirable types and substituting more acceptable ones of the standard type has received attention. Standardization of surgical instruments and equipment when practicable or designation of selected types that are available and acceptable has contributed markedly toward rapid production and efficient service.
6. Numerous inspections of base hospitals have unearthed several instances of inferior material and workmanship in parts of the surgical equipment, due, no doubt, to a certain degree, to an attempt to "force" the production as well as to failure on the part of some makers to fulfill the specified requirements. The rate of production at present is making it possible to require a higher standard in all surgical equipment without retarding the activity or efficiency of the hospital services. All suggestions as to improvement and modifications of surgical equipment have been given careful consideration, and whenever practicable have been recommended for adoption. It has not been the policy of this board to recommend instruments or apparatus of untried value or to ignore recommendations or improvements possessing any promise of merit, but by careful investigation, practicable demonstration, and consultation with experts to promote the efficiency of each division of the surgical service, without "clogging" by unnecessary or complicated equipment. This method of investigation and selection has, until recently, been conducted by this office.
7. During April General Order, W. D., April, 1918, was issued, organizing "The Invention Section, General Staff, Army War College," to whom all ideas and inventions of a mechanical, electrical, or chemical nature are to be referred for investigation and action, the Surgeon General`s Office being represented on both the Examiner`s and Advisory Board.
8. Early in the year the gauze situation became rather acute. In an effort to forestall any serious shortage in our surgical dressings the re-usable knitted gauze was developed. In company with Mr. Henry Pope, a manufacturer of knitted goods, a member of this board entered the knitting mills, and by trying out many types of yarn and fabric succeeded in developing a knitted gauze that can advantageously be substituted for woven gauze, the reclamation of which is difficult.
9. It is tubular in form, lightly woven, knitted cotton, selvaged, of appropriate sizes and shapes, and can be rapidly produced. Careful experiments and practical use justify the assumption that these dressings can be reclaimed several hundred times, making a supply of 100 pounds equal to 10,000 pounds in actual service after the initial supply, thus very materially reducing the cost and releasing transportation space for other things. It has been estimated by a questionnaire that the average amount of woven gauze used and not reclaimed averages 2 miles per week in each base hospital in this country. Re-used knitted gauze is now being supplied to all hospitals in this country of 100 beds or over in the following sizes and types:
(a) Gauze packing, approximately 1 by 18 inches.
(b) Sponge, approximately 2 by 2 inches.
(c) Compress, approximately 4 by 4 inches.
(d) Dressing pad, approximately 6 by 8 inches.
(e) Absorbent pad, approximately 8 by 12 inches.
(f) Absorbent pad, approximately 12 by 24 inches.
(g) Abdominal roll, approximately 4 inches by 5 yards.
(h) Head net for scalp and mastoid dressings.
(i) Head and face mask for operating-room service.
(j) Ward mask.
10. A separate laundry unit, providing adequate washing, drying, and forming facilities, has been arranged for at each base hospital, the installation of which and instructions relative to the reclamation of the gauze are under the supervision of a sanitary officer designated by the Supply Division for that purpose.
11. It is believed that in the near future light, portable laundry units can be installed in many overseas and evacuation hospitals, and that, if necessary, front packages can be equipped with this gauze to be reclaimed at the first hospital reached by the wounded.
INSTRUMENTS.
1. In so far as was feasible the cases of instruments, M. M. D., were systematically revised and modernized by additions from the standard list, Blue Book No. 1. By this method surgical instruments and cases already on hand and contracted for were utilized.
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2. Specialization of the Division of General Surgery into general, orthopedic, and head surgery necessitated the provision of special instruments, apparatus, and cases for each special section. Among these are the brain, plastic, and oral case, auxiliary eye case, and many special instruments not in cases.
3. Base hospitals, this country, base hospitals and evacuation hospitals, overseas, are equipped according to revised lists to which "Additional articles" have been added. As new instruments, supplies, and equipment are needed, they are regularly authorized and added to this list of initial equipment of base hospitals and evacuation hospitals, respectively.
4. The instrument shortage, at one time a somewhat alarming feature, has continually improved, and at present the Supply Division has the situation in hand.
ANESTHESIA APPARATUS.
1. After careful inspection and practical trial of many types of gas oxygen apparatus, keeping in mind the value of portability and adaptability to conditions likely to be encountered overseas, the following portable improved apparatus were recommended and adopted as acceptable types: Connell, McKesson, Heidbrink, Safety, and Teter. Provision has been made for their issue as rapidly as possible.
2. Through the experiments of the Rockefeller Institute for Medical Research at New York and the surgical and medical staffs of our base hospitals, the value of Dakin`s solution in certain infections has been established.
3. In the beginning of the war such a demand for the Carrel-Dakin apparatus for use in this country was not anticipated, but the widespread streptococcic invasion made it imperative to supply a large number of these outfits to base hospitals here. This has been done, and ample provision made for an adequate supply for overseas service as well. All questions as to the proper type of apparatus for administering or manufacturing Dakin`s solution have been referred to the Rockefeller Institute for recommendation, and the methods employed at this time are satisfactory.
4. Following the policy of standardizing all apparatus where possible, and conserving transportation space without sacrificing efficiency, a wheeled stretcher carrier, equipped with a metal litter, designed to fit any type of standard field litter, available for either hospital or field service and as an emergency operating table, was devised and developed by Colonel Moncrief, Major Fishleigh, and others in the Office of the Surgeon General. This appears to meet every requirement and will soon be ready for issue.
5. The sterilizing facilities at base hospitals have not proven adequate. Provision has been made to increase them when needed. Where operating pavilions are to be enlarged, an additional sterilizing unit will be installed that pus and clean services may be effectively separated. The Chief of the Laboratory Service in each base hospital has actively cooperated with the Surgical Service in all questions pertaining to sterilization. Imperfections have developed in operating tables at various hospitals. A more durable type that will withstand the severe usage to which they are necessarily subjected has been recommended for immediate issue.
6. The scarcity of suitable drugs for local anesthesia caused some little concern during the recent epidemic of empyema, but novocaine is now available and is supplied where needed. A suitable intratracheal anesthesia apparatus for the head section and general use when indicated has been provided. In answer to a cabled request from the Surgeon General, Ambrine is now being manufactured in this country by an agent of the inventor, and is obtainable in suitable quantities.
7. Orthopedic apparatus and appliances are provided for and their adaptability being -gradually enhanced by minor improvements in the efforts to standardize.
8. A more efficient lighting unit for operating rooms is being installed where required.
9. An increased supply of Moncrief dressing sets is being provided to facilitate ward work. The large number of empyema and other primarily infected cases makes it essential to facilitate this daily labor. A reserve supply of all base hospital surgical instrument equipment has been recommended.
10. Where experience has proven the inadequacy of any particular instrument for the type of work that develops in any service, suitable substitutions have been made.
11. Some few shipments of foreign-made instruments, especially hemostats, have been round on inspection to be below the standard. This deficiency is in process of correction.
12. Needles are now available in abundance, and for spinal anesthesia, a flexible, nickeloid type has been substituted. Through the Supply Department provision is being made for a reserve stock of standard instruments, cases, etc., to bridge over any emergency that may arise.
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13. The mobile operating unit, now virtually completed and ready for service, has been fully equipped with specially constructed motorized sterilizers, X-ray outfits, and surgical instruments, with a suitable reserve supply for all emergencies.
14. Many other changes, additions, and substitutions of varying importance have been recommended, and it is believed that in so far as is practical the foundation for standardization and adequate provision for a supply of surgical instruments and equipment to meet the needs of the service has been successfully established by the Supply Division.
EMPYEMA COMMISSION.
During the months of December, 1917, and January and February, 1918,many cases of pneumonia were reported from all of the camps in the South. Accompanying this epidemic of pneumonia, so-called, a large number of cases of empyema began to be reported. During an inspection trip through the different camps made by the Chief of the Division of General Surgery, Surgeon General`s Office, it was recognized that this epidemic of pneumonia with empyema accompanying constituted a type of general septicemia with tendency to localization in the lungs and pleura; that the invaded organism frequently was in the greater proportion of cases a streptococcus, generally of the hemolytic type. At all of the camps much work had been done in attempting to determine the nature of the infection. The mortality varied from 40 to 60 per cent in those cases in which a large amount of fluid had been in the pleural cavity. The method of treatment in the early stage of the epidemic had been, universally, drainage by the removal of one of the ribs, generally in the mid-axillary line, but in some of the camps repeated aspiration had been attempted. In some of the camps the number of cases showing empyema, so-called, had been considerably over 100.
The large number of cases of empyema which accompanied or followed pneumonia led to the organization of the Empyema Commission." A study of the subject was begun by a commission located at Camp Lee, Va. In addition, local teams were raised by other base hospitals from the attached personnel, consisting of a surgeon, an internist, and a bacteriologist to study local conditions, all information being collected in the Surgeon General`s Office and disseminated to the various camps.
As the spring advanced the epidemic spread to the North, and Camps Dodge, Taylor, and Custer became invaded. At Camp Dodge a study of the pathology of the condition was made, and as a result of the investigation the pathological nature of the disease was established.
The commission at Camp Lee soon established the wiser procedure and in streptococcus infection insisted on conservative treatment until the acute pneumnonic process had subsided. During this period aspiration was under-taken if the respirations were seriously embarrassed. As soon as the resistance of the patient had been somewhat lowered and the acute pneumonic process had subsided, drainage between the ribs was instituted by means of a flutter valve tube. This being soon withdrawn, it was found that these cases could be healed within three weeks after drainage was instituted. At the Rockefeller Institute, early operation, with the use of Dakin`s solution, was followed by considerable primary mortalities owing to the early operative procedure; but the important fact was soon established that in 80 per cent of the cases in from a week to ten days the pleural cavity could be rendered sterile and
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the wound sutured without subsequent drainage. The general nature of the treatment as instituted at Camp Lee had already been arrived at in a great many of the camps, notably Taylor, Pike, and Lee, so that the principle of conservative treatment in the early stages became firmly established.
At this time the study of the treatment of chronic cases was begun by the Empyema Commission and others, and the Surgeon General`s Office began to accumulate these cases in separate centers for intensive study.a
SURGICAL SERVICE.
With the beginning of June, 1918, the Division of Surgery was functioning fairly well. The many problems of inherent perplexity gradually found solution, and the spirit of cooperation in the Office of the Surgeon General manifested itself in part in the smoother running of the division. There was a noticeable disjunction between general surgery and the surgical specialties, but later in the year even this was overcome by an office order which made the chief of the Division of General Surgery the administrative officer for all surgery. 10 Not only did this order effect closer coordination but it did this without destroying the initiative of the surgical specialties or in any way making them subsidiary to the mother specialty in a scientific or purely clinical sense.
Early in July, 1918, the main energies of the division were directed toward making a complete detailed survey of the character of surgical work done in all the camps. A system of reports was developed by means of which it was possible to secure very early information regarding unnecessary surgical operations, avoidable wound infections, and unwarrantable deaths. It was possible, as a result of these reports, to institute corrective measures covering these three topics. It was the policy of the division at all times to allow the widest latitude of judgment to all surgical chiefs on all purely surgical matters, but it was necessary, of course, at all times to have a thorough knowledge of the professional and temperamental qualifications of the various chiefs.
A carefully considered and well-worked-out plan for running a standard surgical service was devised, but was never forwarded as an official document, in order to avoid conflict with the normal initiative of the various chiefs. This plan, however, was fully expounded to the various commanding officers and surgical chiefs, who, for one reason or another, came to Washington. Further-more, the plan of a standardized scheme was always discussed with the various commanding officers and surgical chiefs by the surgical consultants who went from Washington to the camps.
One important element in the scheme of standardization was that of the conservation of supplies. In the early days of haste and primitive organization there was little time or inclination to conserve, but as organization proceeded it was possible to emphasize the idea of rational economy to the point that some of the camps showed a cost per operation of 20 to 30 cents as contrasted with an earlier cost of $2 to $3.11 The use of knitted reusable gauze, the reclamation of cotton, alcohol and iodine, the economic use of catgut and adhesive plaster, were all elements in a most pronounced cost reduction.
a See, Empyema, Vol. XI, Part Two. Section 1.
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CONSULTANTS.
By August, 1918, a comprehensive system of consultation tours was inaugurated. This system was planned after mature consideration and after a formal and extended conference held at Washington with three enthusiastic surgical chiefs, who had been called in from the field, and who presented their views before the Acting Surgeon General and the Division of Surgery. The consultants were assigned groups of camps in geographic relations and were instructed to cover all possible topics pertaining to every phase of surgery. Each consultant on his return to his station submitted a report covering his consultation and always appended a special estimate of the professional qualifications of the surgical personnel of the various camps visited. 12 On the basis of these reports measures were instituted to strengthen the service where-ever necessary.
SURGICAL LITERATURE.
Another important factor in the maintenance af surgical efficiency during the last year of the war was the distribution of surgical literature. The activity of the Division of Surgery along this line took on a very definite form, and adhered throughout to the policy of avoiding the academic and practicing only the most utilitarian methods. It was realized that the exigencies of the situation left little time for extensive or intensive reading. Therefore a carefully prepared digest of all important American, English, French, Italian, and German (when procurable) contributions to surgery was published in a 50 to 60 page monthly Review of War Surgery and Medicine 13 and sent to the camps in this country and overseas. In addition to this, there was prepared for distribution a Manual of Surgical Anatomy, 14 which was a volume made up of 400 anatomical plates without text, but with clear legends and a full explanatory index. The drawings were selected solely from the point of view of their use in war surgery. In September, 1918, after correspondence with the British war office, the Surgeon General published 20,000 copies of the British Official Manual of the Injuries and Diseases of War,"5 and arranged for a wide distri- bution of this almost invaluable treatise. At about this same time their was delivered from the press, Abstracts of War Surgery,"` a book of four hundred and odd pages, furnishing abstracts, topically arranged, of all the important surgical articles published by the Allies from the declaration of war up to the time of American participation. During September, 1918, arrangements were completed for publishing, in pamphlet form, the conclusions adopted by the four interallied conferences on war surgery. These pamphlets, unfortunately, were not ready for distribution until after the armistice.
All the above-detailed literary activity of the Division of Surgery had a dual purpose. In the first place, the aim was to maintain a high degree of professional efficiency in the active medical corps, and, in the second place, it was the purpose of the division to see that the various publications should serve as fundamental texts in surgery for the Students` Army Training Corps Medical Section). The signing of the armistice nullified the latter purpose.
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LIAISON WITH OVERSEAS SURGICAL SERVICE.
During August, 1918, the chief consultant, surgery, American Expeditionary Forces, returned from France for conference with the Surgeon General and the Chief of the Division of General Surgery. These conferences represented the first real liaison between the American home and overseas divisions and were productive of much real benefit. For example, it was learned that properly qualified anesthetists were in urgent demand. Within eight weeks the Surgeon General had established 15 or 20 special schools for anesthesia in the various camps. 17 By hearty cooperation with the Interstate and the American Associations of Anesthetists it was found possible to place several of the leading anesthetists of civil life as directors of these schools, and in very short order the Surgeon General was prepared to send overseas monthly from 15 to 30 specially trained anesthetists (officers, nurses, and enlisted men). The training received by. these pupils was confined to the drop ether, gas-oxygen, gas-oxygen-ether methods.
With the completion of this program of anesthesia the Division of Surgery felt that it was in full command and had adequate control of all the fundamental factors necessary in the training of medical officers. Intensive thought and direction had been given to the Medical Officers` Training School, Camp Green-leaf, Fort Oglethorpe, Ga., and the various other schools established at an earlier date were kept under careful survey. The surgical activities in the various camps, although varying markedly from real war surgery, nevertheless furnished adequate material for the comprehensive training of surgeons along many important lines.
STATISTICS.
The following statistical report, compiled by the Division of Surgery, gives an idea of the volume of surgical work of 32 base hospitals. 18 From this report it may be seen that it was possible for the various officers connected with the Surgical Service to receive intensive training in the fundamental principles of surgery, as well as in their application:
The following report, compiled from the records of the division, embodies in brief form the activities of the Personnel Branch of the Division of Surgery (general surgery) up to November 11, 1918.
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The application papers of every officer carried in the files of this division were reviewed by an officer capable of passing on the qualifications of the applicant; duplicate cards were made on which were entered a brief personal history of the man, together with his classification, based on the attached classification chart; and his name was listed in the files of the Personnel Division as being "Retained for general surgery," in order that his movements might be controlled by recommendation of this division. All orders were placed on both cards, and reports, either from classes of instruction or from the commanding officers of the different hospitals, were entered from time to time as they were received. In this way it was possible to compare division`s rating of the individual with that of his instructors and his commanding officers. In only a very small percentage of cases was the division`s original rating wrong.
In keeping track of the surgical personnel the simplest system possible was followed. As stated above, duplicate cards were made for each officer, one card being carried in an alphabetical master file, the other in a station file.
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The station file contained till base, general, and post hospitals in this country. as well as the numbered hospitals for overseas duty. Whenever a man was moved from one station to another his card was moved with him, proper entry of the order being made on both cards. A set of cards containing the names of all officers assigned to overseas organizations was forwarded to the Chief of Surgical Service, in care of the chief surgeon, American Expeditionary Forces, in order that they might know just what was thought of each man and what his training and instruction had been prior to his sailing for overseas duty.
AFTER THE ARMISTICE.
With the declaration of the armistice there was a natural let down in all the activities; this went hand in hand, however, with a keen appreciation of the newly developing needs that had to be met. As far as these altered conditions and circumstances concerned the Division of Surgery, they emphasized the lessened significance of training officers for overseas duties and the tremen-dously heightened significance of providing highly specialized surgical skill for the returning overseas wounded.
The arrival of overseas wounded necessitated that all the energies of the division be bent toward providing adequate surgical care. This particular problem was bound up with several essential fundamentals. The port hospitals at best could serve only as clearance hospitals,. where a sort of triage had to be worked out, and where, above everything else, an adequate number of beds had always to be available for the reception of patients. From these port hospitals, patients had to be distributed with a due regard for the sentiment which prompted the citizenry of the United States to desire that their own wounded be housed near home. The equally important consideration had to be met of distributing special cases (neurosurgical, fractures, maxillofacial, amputations, etc.) to special centers equipped to afford the best type of specialized treatment. The Surgeon General succeeded in working out a plan that met both of these considerations, and the Division of General Surgery provided adequate personnel of proper professional character and maintained efficiency by frequent conferences (through consultants) as well as by letters of instruction.
A special Peripheral Nerve Commission 19 was created to devise, visé, and control methods for handling all neurosurgical cases; the Empyema Commission continued along its field of special activity; 9 special instructions were drawn up and circulated covering the fundamental principles underlying the treatment of osteomyelitis; 20 special consultation visits were made to check up on the question of preventable deformities; detailed survey was maintained over the various artificial-leg fitting centers; a special officer devoted his whole time to a survey of the treatment of fractures; and a new center for instruction in the Carrel-Dakin technique was established at Walter Reed Hospital.
Along such lines of intensive correlation, control, and supervision the division was working at the end of July, 1919.
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PERSONNEL.b
(April, 1917, to Decembe, 1919.)
Finney, J. M. T., Brig. Gen., M. D., chief.
Moncrief, William H., Col., M. C., chief.
Sullivan, Raymond P., Col., M. C., chief.
Hanner, John W., Col., M. C.
Kanavel, Allan B., Col., M. C.
Peck, Charles H., Col., M. C.
Walker, John B., Col., M. C.
Dye, John S., Lieut. Col., M. C.
Martin, Edward, Lieut. Col., M. C.
Moschowitz, Alexis Y., Lieut. Col., M. C.
Seelig, M. G., Lieut. Col., M. C.
Snyder, H. McC., Lieut. Col., M. C.
Weiser, Walter R., Lieut. Col., M. C.
Cody, Claude C., Maj., M. C.
Holmes, Claude D., Maj., M. C.
Kahlke, Charles E., Maj., M. C.
Keene, Floyd E., Maj., M. C.
Muller, G. P., Maj., M. C.
Turnure, Percy R., Maj., M. C.
Wyer, Henry G., Maj., M. C.
Davison, Thomas P., Capt., S. C.
Fisher, Albert G., Capt., S. C.
Holmes, Benj. H., Capt., M. C.
Mann, H. L., Capt., M. C.
Mooradian, A. P., Capt., S. C.
Wilson, Harry I., Capt., S. C.
CONSULTANTS.
Mayo, Charles H., Col., M. C., chief.
Mayo, William J., Col., M. C., chief.
de Schweinitz, George E., Col., M. C. (ophthalmology).
Mosher, Harris P., Col., M. C. (otolaryngology).
Blair, V. P., Lieut. Col., M. C. (plastic and oral surgery).
Frazier, Charles H., Lieut. Col., M. C. (neurosurgery).
ROTARY SURGICAL BOARD.
Mayo, Charles H., Col., M. C.
Mayo, William J., Col., M. C.
Binnie, J. F., Lieut. Col., M. C.
Haggard, W. D., Lieut. Col., M. C.
McGuire, Stewart, Lieut. Col., M. C.
Bevan, A. D., Maj., M. C.
Freeman, Leonard, Maj., M. C.
Mixter, Samuel, Maj., M. C.
Ochsner, A. J., Maj., M. C.
MacKenzie, K. A. J., Capt., M. C.
b In this list have been Included the names of those who at one time or another were assigned to the division, during the period, April 6, 1917, to December 31, 1919.
There are two primary groups: The chiefs of the division, and the assistants. In each group names have been arranged alphabetically, by grades, irrespective of chronological sequence of service.
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REFERENCES.
(1) Regulations for the Government of United States Army general hospitals, 1914, 23. Manual for the Medical Department, United States Army, 1916, par. 290.
(2) Letter from Surgeon General to Dr. William J. Mayo, June 27, 1917. On file, Record Room, S. G. O., 143365 (Old Files).
(3) Memo. for the Division of General Surgery from Col. William J. Mayo, M. C. On file, Record Room, S. G. O., 024.14 (Division of General Surgery).
(4) Circular Letter from the Surgeon General to commanding officers, base and general hospitals, October, 1917. On file, Record Room, S. G. O., 024.2 (Administrative Division), 1917.
(5) Correspondence. On file, Record Room, S. G. O., 321.6 (Medical Department): circular letter from the Surgeon General to commanding officers, base and general hospitals. On file, Historical Division, S. G. O.
(6) Special report of personnel, Section of General Surgery, October 12, 1917. On file, Record Room, S. G. O., Weekly Report File.
(7) Correspondence. Subject: Instruction in Surgery. On file, Record Room, S. G. O., 151418 (Old Files).
(8) Correspondence. On file, Record Room, S. G. O., 024.14 (General Surgery).
(9) Correspondence. Memo., outline of study of empyema, and reports to the Surgeon General from the Empyema Commission. On file, Record Room, S. G. O., 710 (Empyema), 1918. Memo. for the Division of Surgery from Maj. Allen B. Kanavel, M. C. (member of Empyema Commission). Subject: Inspection of Surgical Department, Camp Lee. On file, Inspection File, Surgical Section, Hospital Division, S. G. O.
(10) Office order, No. 97, S. G. O., November 30, 1918. On file, Record Room, S. G. O., 024 (Division of Surgery), 1917.
(11) Report of Division of Surgery. On file, Record Room, S. G. O., Weekly Report File.
(12) Reports of surgical consultants. On file Record Room, S. G. O., Correspondence File 730 (Surgery).
(13) Review of War Surgery and Medicine, Vol. I, Nos. 1 to 10 (March to December), 1918; Vol. II, Nos. 1 to 6 (January to June), 1919. Government Printing Office, Washington, D. C.
(14) Manual of Surgical Anatomy, authorized by the Secretary of War and under the supervision of the Surgeon General and Council of National Defense. Prepared under the direction of the Division of General Surgery, in collaboration with the Division of Orthopedic Surgery, Surgery of the Head, Genitourinary Surgery, and the Advisory Staff in Surgery in the Office of the Surgeon General, United States Army, 1918.
(15) Injuries and Diseases of War. A manual based on experience of the present campaign in France, January, 1918. Reprint of the official British manual. By permission of the British war office. Government Printing Office, Washington, D. C., 1918.
(16) Abstracts of War Surgery. Prepared by the Division of Surgery, Surgeon General`s Office, 1918. C. V. Mosby, St. Louis, Mo., 1918.
(17) Weekly Reports, S. G. O. (General Surgery), October 3, 1918. On file, Weekly Report File S. G. O.
(18) Partial statistical report of surgical work in 32 base hospitals, November 7, 1918. On file, Record Room, S. G. O., 730 (Surgery).
(19) Correspondence. On file, Record Room, S. G. O., Correspondence File, 730 (Surgery).
(20) Letter from Surgeon General to commanding officers, base and general hospitals. Subject, Osteomyelitis. On file, Record Room, S. G. O., 710 (name of camp)
