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SECTION II.
CHAPTER XVIII.
DIVISION OF SURGERY OF THE HEAD.
Through the efforts of the General Medical Board of the Council of National Defense and of the various ophthalmological and otolaryngological societies, the surgeons of the country who were fitted to assume the obligations of ophthalmological, otolaryngological, brain, and oral and plastic surgery, or who were willing to fit themselves by special instruction to assume such duties, were enrolled and classified. The names of those willing to accept service in these departments were filed in the record room of the Surgeon General`s Office.
The Surgeon General, through conferences and correspondence with representatives of the various organizations concerned and of the committees and subcommittees of the Council of National Defense, kept in close touch with all the phases of the development of their work, and n July 9, 1917, and quarters in the Surgeon General`s Office were assigned and opened. 1 Eventually (Sept.29, 1917) the various committees and subcommittees of the Council of National Defense which had represented the surgical specialties ceased to exist, all of their work being merged into the Division of Surgery of the Head of the Surgeon General`s Office. This division, which eventually embraced the Sections of Ophthalmology, Otolaryngology, Brain Surgery, and Oral and Plastic Surgery, continued the work of the selection and classification of surgeons from civil life having special training in the branches concerned, and developed arrangements whereby intensive training could be given to other surgeons not yet fully qualified in these regards, the whole purpose being to make available Medical Reserve officers qualified for active duty in line with these specialties.
During the period between the time of the establishment of the Division of Surgery of the Head (July 9, 1917) and the cessation of the committees and subcommittees of the Council of National Defense much work in correlation was performed in relation to the needs of the Army in ophthalmology, otolaryngology, oral and plastic surgery, and brain surgery.
Along this line were the efforts in connection with the preparation of plans for a special hospital to be devoted to Surgery of the Head (head hospital) of 1,000-bed capacity, to be operated in France.2 On August 17, 1917, the committees of the council representing the head surgery specialties formed subcommittees (personnel, equipment, shop, hospital construction) to carry out the authorization by the Surgeon General of the head hospital. For many weeks the members of these subcommittees worked along these lines, were in constant consultation with supply departments of the Army, with the American Red Cross, with architects, laboratories, optical firms, manufacturers, directors of base hospitals already established,` and ultimately elaborated and compiled
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generous plans, which, with the cost involved, were presented to the Surgeon General, receiving his approval.
The Division of Head Surgery as originally organized (see Chart XIX)continued to function until November 30, 1918, when it was changed to the Section of Head Surgery of the Division of Surgery, the section including ophthalmology, otolaryngology, neurosurgery, and oral and plastic (maxillofacial) surgery. 3 The functions and activities of the division are summarized below:
(A) The classification of the surgeons available for service secured by sending out questionnaires and from the reports of confidential State advisers.
(B) The classification of officers in the service, following special instructions of the Sec ion of Surgery of the Head at cantonment base hospitals and the reports from commanding officers of hospitals and general inspectors.
(C) Equipment.-1. Standardization of instruments and material.
2. Selection of instruments for base hospitals and for the special hospital for surgery of the head (No. 115).
3. Selection of equipment for optical units.
4. Standardization of spectacle frames and size of lenses for military use.
5. Investigation of possibility of domestic production of glass for artificial eyes, and securing the manufacture of such glass as well as the manufacture from it of artificial eyes.
6. Standardization of an efficient goggle for aviators.
(D) Educational.-1. Outline of course of lectures to be given in cantonment base hospitals and at Medical Officers` Training Camps.
2. List of books for libraries at base hospitals.
3. Five books dealing with special surgery of the head compiled and the literature dealing with surgery of the head in all its branches abstracted. I
(E) Field organization.-1. A Section of Surgery of the Head in the Surgical Service was authorized for each base hospital in this country, and personnel assigned.
2. Assignments of specialists to post and general hospitals when requested.
3. Assignments to Medical Officers` Training Camps for military training. ???
4. Assignments to the Medical Service, Aviation Section, Signal Corps.
5. Inspections of Section of Surgery of the Head at camp base hospitals. ???
6. Inspection in France of the British, French, and American base and evacuation hospitals, and their facilities for surgery of the head.
(F) Assignments of officers to base and evacuation hospitals for overseas service.
(G) Special hospital for surgery of the head (No. 115) organized for service overseas. (H) Mobilization of one central optical unit and 14 auxiliary units. which were sent overseas on request of commander in chief.
(I) Supply of spectacles to soldiers.
(J) Statistics and other activities.-1. Enumeration of officers classified. (Details under section reports.)
2. Enumeration of officers given intensive surgical training in the various schools conducted through this division.
LIST OF SCHOOLS AND LABORATORIES.
1. Officers` School of Plastic and Oral Surgery, Northwestern University Dental School, Chicago, Ill.
2. Thomas W. Evans`s Museum and Oral School of Surgery, University of Pennsylvania. Philadelphia.
3. Neurosurgical Schools: Chicago, Dr. Dean Lewis, director; Philadelphia, Dr. Charles H. Frazier, director; New York, Dr. C. S. Elsberg, director.
4. Neurosurgical, Plastic and Oral Surgical School of St. Louis.
(K) Enumeration of officers assigned. (Details under section reports.)
(L) Enumeration of dental oral surgeons assigned duty with oral and plastic surgeons. (M) Schools at Fort Oglethorpe, Ga., ophthalmology, otolaryngology, neurosurgery, oral and plastic.
(N) Army neurosurgical laboratory, Johns Hopkins University, Baltimore, Md.. Capt. 1.. H. Weed, (lirector.
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Chart XIX.-Division of Head Surgery, Surgeon General’s Office, June 1918.
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The professional work which the Division of Surgery of the Head supervised in this country included also the eye and ear tests for the Aviation Section of the Signal Corps; the examination of all recruits whose visual qualifications were doubtful and the treatment of diseases and injuries of the eyes, including the prescribing of glasses for soldiers; the ear, nose, and throat examination of all recruits in whom there existed a question as to their physical qualifications, as well as the treatment of such diseases and injuries; passing on the teeth and jaw conditions of recruits and treating of diseases and injuries incident thereto; the care and treatment of brain and head injuries.
The number of officers assigned on recommendation of this division from .July 9, 1917, to November 30, 1918, was as follows: 5
Ophthalmology .................................................................................. 612
Otolaryngology .................................................................................. 491
Neurosurgery (including those given special instruction) ....................... 230
Oral and plastic (including dentists) ..................................................... 280
Total ............................................................................1,613
SPECIAL HOSPITALS.
In order to secure means for special surgical treatment for head cases, General hospital No. 11, Cape May, N. J., was organized and equipped for the purpose. This hospital had a capacity of 750 beds and was completely equipped and staffed to meet any emergency for the class of cases represented by the various sections of the Division of Head Surgery. 6
In addition to the special surgical treatment mentioned as afforded at this hospital, it was designated by the Reconstruction Division as a center for reeducation of the deaf.
A special base hospital (No. 115),7 authorized by the Surgeon General for the care of head cases abroad, was mobilized at Cape May, N. J., June 11, 1918, and was embarked for overseas on August 14, 1918. This hospital was specially staffed and equipped to care for the class of cases represented by the Division of Head Surgery. It was located at Vichy, France, where, as a matter of fact, it at first functioned as a general hospital, but was designated just before the time of the signing of the armistice for the special cases for which it had been organized.
SUPPLY OF SPECTACLES.
At the beginning of the war no provision existed for supplying soldiers with spectacles. The officer in charge of the Section of Ophthalmology arranged for the testing for glasses, together with the other treatment of the eye conditions to be done by the ophthalmologists in charge at the various camp base3 hospitals. An optician, obtained through the selective draft, was on duty in each hospital as a member of the Medical Department.
Arrangements were made with certain wholesale manufacturers to supply glasses through post exchanges at fixed prices. This plan, which was not wholly new, worked very satisfactorily, but was open to the criticism that the soldier had to purchase his own spectacles. Later the Government issued the glasses as part of the soldier`s equipment. 8
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THE SCHOOL AT FORT OGLETHORPE, GA.
In connection with general Medical Department instruction at Fort Oglethorpe and General Hospital No. 14, courses were organized for each of the sections in the Division of Head Surgery.
As the courses were organized, medical officers who elected were given opportunity to name the special course they wished to attend. They were then examined and only those who showed a well-founded knowledge of the subject selected were admitted to the special course concerned. At the completion of the course another examination was conducted to determine whether or not the student officers were to be retained on the register in the Surgeon General`s Office as qualified for a branch of head surgery. No further account of those who failed to pass the final examination was taken by this division.
DISTRIBUTION OF OVERSEAS PATIENTS.
Because of a natural limitation of personnel in head surgery, it was necessary to congregate the returned injured soldiers in a limited number of hospitals or "centers." The final distribution of the cases as this applied to head surgery was published by the Hospital Division and was as follows: 9
Eye:
U. S. Army General Hospital No. 1, Williamsbridge, N. Y.
U. S. Army General Hospital No. 2, Fort McHenry, Md.
U. S. Army General Hospital No. 6, Fort McPherson, Ga.
U. S. Army General Hospital No. 11, Cape May, N. S.
Walter Reed General Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
Blind:
U. S. Army General Hospital No. 7, Roland Park, Md.
Ear, nose, and throat:
U. S. Army General Hospital No. 2, Fort McHenry, Md.
U. S. Army General Hospital No. 6, Fort McPherson, Ga.
U. S. Army General Hospital No. 11, Cape May, N. J.
Walter Reed General Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
Deafness and speech defects:
U. S. Army General Hospital No. 11, Cape May, N. J.
U. S. Army General Hospital No. 41, Fox Hills, Staten Island.
Maxillofacial:
U. S. Army General Hospital No. 2, Fort McHenry, Md.
U. S. Army General Hospital No. 11, Cape May, N. J.
U. S. Army General Hospital No. 40, St. Louis, Mo.
Walter Reed General Hospital, Takoma Park, D. C.
Organic diseases of the nervous system:
U. S. Army General Hospital No. 11, Cape May, N. J.
Walter Reed General Hospital, Takoma Park, D. C.
Peripheral nerves:
U. S. Army General Hospital No. 1. Williamsbridge, N. Y.
U. S. Army General Hospital No. 2, Fort McHenry, Md.
U. S. Army General Hospital No. 3, Colonia, N. J.
U. S. Army General Hospital No. 6, Fort McPherson, Ga.
U. S. Army General Hospital No. 11, Cape May, N. J.
U. S. Army General Hospital No. 26, Fort Des Moines, Iowa.
U. S. Army General Hospital No. 28, Fort Sheridan, Ill.
U. S. Army General Hospital No. 29, Fort Snelling, Minn.
Walter Reed General Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
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Wounds or injuries of the skull or brain or spinal cord:
U. S. Army General Hospital No. 2, Fort McHenry, Md.
U. S. Army General Hospital No. 3. Colonia, N. J.
U. S. Army General Hospital No. 6, Fort McPherson, Ga.
U. S. Army General Hospital No. 26, Fort Des Moines, Iowa.
U. S. Army General Hospital No. 28, Fort Sheridan, Ill.
U. S. Army General Hospital No. 29, Fort Snelling, Minn.
Walter Reed Hospital, Takoma Park, D. C.
Letterman General Hospital, San Francisco, Calif.
A staff of specially qualified surgeons was assigned to each of these hospitals. The equipment of each, together with the general equipment (physiotherapy and reconstruction), was adequate to meet immediate surgical conditions; it also provided means for the care of convalescents, and shops, schools, and other facilities for education and reconstruction.
As the proper treatment of peripheral nerve cases embraced professional care involving more than one section, it was determined to put this under the supervision of a commission made up of representatives from general surgery, orthopedic surgery, neurosurgery, and neurology. On January 31, 1919, the Peripheral Nerve Commission 10 was appointed.
The function of this committee was to study all peripheral nerve cases and to prepare a report on their treatment for the action of the Surgeon General.
SECTION OF OPHTHALMOLOGY.
The Section of Ophthalmology was originally organized, as to personnel, in the Subcommittee of Ophthalmology of the Division of Surgical Specialties of the General Medical Board, Council of National Defense, and was transferred to the Division of Head Surgery after the organization of that division in the Surgeon General`s Office. It continued so to function until the reorganization of the office, November 30, 1918, when the Division of Head Surgery, as stated above, with its constituted sections, became the Section of Head Surgery of the Division of Surgery.
OPHTHALMIC PERSONNEL RECORDS.
Very early the first set of indexed cards of all ophthalmologists assigned to duty in various general and base hospitals, or available for such assignment, was prepared from data collected by the Subcommittee of Ophthalmology (Council of National Defense) and was filed in the Surgeon General`s Office. These cards were systematically corrected from time to time, the ratings being added or altered according to the reports received from hospital commanding officers, chiefs of sections, and inspectors, and information thus obtained was placed on file with the officer`s papers in the Record Room of the Surgeon General`s Office. In August, 1918, an entirely new set of cards was prepared, the ratings being checked to date, according to reports as noted above. In addition, there were then available the reports of the results of the examinations in the School of Ophthalmology, Camp Greenleaf, Fort Oglethorpe, Ga., furnished weekly by its director. Still later, corrections were made as the results of reports from the consultant in ophthalmology in the Surgeon General`s Office, obtained by him on his various visits to those hospitals designated as eye centers. The officers assigned to overseas duty
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in evacuation and base hospitals were listed, with their ratings, and these ratings were forwarded in a special courier letter sent weekly to the senior consultant in ophthalmology, American Expeditionary Forces. Officers found to be unsuited to the special duties of ophthalmic practice who had been "held in ophthalmology" were released as soon as possible to the Personnel Division for other duty.
From the carefully kept records reasonably accurate information was constantly available, whereby the various requests for ophthalmologists could be complied with according to the duties required. For example, an officer competent in refraction work, but inexperienced in operative technique or clinical observation, was assigned, as far as possible, to the duty for which be showed proficiency. Should a request be made for a medical officer who com- bined with ophthalmology, otolaryngologic experience-and this was not infrequently the case-the assignment was made only after consultation with the officer of the Section of Otolaryngology.
TRACHOMA CAMPS.
The possibility of an outbreak of trachoma in the Army was taken into account and various recommendations were made on the subject by the Subcommittee of Ophthalmology, Council of National Defense.a At the request of the Committee of Publication of the council, a special chapter on this disease, its prevention and treatment, was incorporated in War Manual No. 34 Later this problem was investigated and reported upon. 4-b
At this date, February 14, 1918, the new Manual of Instructions for Medical Advisory Boards, 12 contained a regulation to the effect that registrants with chronic conjunctivitis in districts where trachoma was common be most carefully studied. If the diagnosis of trachoma could not be excluded,, the registrant was to be accepted for general military service in the deferred remedial group (Group B). Registrants with trachoma otherwise physically and mentally fit, with vision up to the standard for military service, would be accepted for service in the deferred remedial group. To expedite action, an additional memorandum 13 recommended that the methods of the Public Health Service be investigated, that a trachoma concentration camp be considered, that measures to prevent the return of trachoma subjects to the civilian population be devised, and that opportunities for establishing a differential diagnosis between true trachoma and other conjunctival lesions resembling the disease should be facilitated. A further memorandum suggested 14 Grayson Springs, Ky., Cerulean Springs, Ky., or Olympian Springs, Ky., as a suitable location for a trachoma concentration camp. No action being taken on this recommendation, a further memorandum requested authority for the utilization of the buildings and grounds at Fort Thomas, Ky., as a trachoma concentration camp. 15 This was approved by the Hospital Division on April 4, 1918. All these recommendations were disapproved by the War Department as inconsistent with plans already completed for other uses of the buildings at Fort Thomas. On April 15, 1918, a further memorandum was addressed to the Hospital Division, the object being to obtain `authority for the location of a
* For an account of the prevention of trachoma in the Army camps, see the article by Col. Nelson M. Black, M. R. C., IS the Wisconsin Medical Journal, Milwaukee, 1920, xix, 5-15.
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trachoma camp at Olympian Springs, Ky., and a memorandum to the Surgeon General of April 17, 1918, restated the recommendations already made.16 These memoranda were again approved by the Surgeon General. After careful inspection and investigation of Olympian Springs, a report was submitted on April 22, 1918, in which it was urged that immediate action be taken to obtain this property for the purpose stated.17 As frequent inquiries from the various camps and cantonments as to the disposition of trachoma cases continued to reach the Surgeon General, a memorandum was issued from that office, dated July 18, 1918, 18 directing that, until otherwise notified, men in the service with advanced trachoma, with pannus, scar tissue, induration of tarsus, and trachoma granules on the bulbar conjunctiva, be discharged on surgeon`s certificate of disability, while cases of doubtful trachoma, showing rapid im-provement, be retained for treatment, every precaution being taken to prevent the communication of the disease. In a final revision of the standards of physical examinations governing entrance into the Army, trachoma subjects were clarified among those "who shall be unconditionally rejected for all military service." 19 The Section of Ophthalmology was then directed to write an opinion as to the disposition of trachoma cases found in various camps or reported from base and general hospitals. In a report rendered July 12, 1918, the following recommendations were submitted: 20
A few Cases of trachoma have appeared at the various concentration centers of the United States military service, while in one camp only have the cases recorded as trachoma assumed proportions that would constitute a numerical menace; every case of trachoma must be so regarded until it ran be placed in control and under treatment. Hence:
1. All men with undoubted chronic trachoma, pannus, scar tissue, induration of tarsus, and trachoma granules on the bulbar conjunctiva, as well as on the tarsal conjunctiva, should be S. C. D’d, and it should be recommended that such trachoma subjects report immediately on return to their homes to the nearest health authorities or to the officers of the Public Health Service for disposition and treatment.
2. All men with follicular trachoma, not advanced into the stage of chronic trachoma with lesions above summarized, and therefore amenable to comparatively rapid cure, should be sent to the base hospital for treatment, where every precaution to avoid the possibility of communicating the disease should be exercised.
The treatment of these men should be undertaken by the Chief of the Subsection of Ophthalmalogy of the base hospital and submitted to the well-recognized mechanical(surgical) operative measures, followed by medicamental application until a cure results, when they may be returned to their units.
Should, in any instance, the treatment prove ineffective at the end of a reasonable time, or the lions of advancing chronic trachoma develop in spite of treatment, the subject should be S. C. D’d as before described.
3. All men with chronic conjunctivitis and secondary folliculosis, the so-called border-line cases, should be admitted to the base hospital, and be sent for treatment as before described. To summarize: The present regulations shall remain in force, with the addition that the S. C.D’d men shall carry with them a recommendation that they shall report, or be reported, to the health authorities, or the Public Health Service, and that cases admitted for treatment shall be submitted at once to approved methods of dealing with this disease, mechanical as well as medicamental.
These recommendations were approved by the Surgeon General and the Hospital Division, and adopted as the regulations governing the management of the trachoma cases in the United States Army. 21
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SPECTACLE GLASSES.
The standardization of spectacle lenses for use in the military service of the United States was begun by the Subcommittee of Ophthalmology, Council of National Defense. In September, 1917, these plans were matured and received the approval of the Surgeon General, the standard lens to be flat, round, and 40 mm. in size, and the frames of white metal of the best stiff construction. Requests for bids to supply such standard spectacle glasses to the camp base hospitals and general hospitals were mailed to seven optical manufacturing companies.
In November, 1917, the chiefs of the ophthalmic services in all the base hospitals were informed on the subject of the standard spectacle frames and lenses, with the specifications which had been decided upon, and where they could be obtained until the post exchanges, through which they were later furnished, were able to take their supply in hand.
On November 14, 1917, the bid of one of the competing optical firms was accepted by the Surgeon General, and this firm was so informed on November 27, 1917. On the same date a letter of instructions on the furnishing of soldiers with spectacle lenses 22 was transmitted to all division surgeons at the National Army and National Guard camps. This letter directed that arrangements be made through the base hospital post exchange, or a suitable camp post exchange, to furnish spectacles according to prescription by the Subsection of Ophthalmology, Section of Surgery of the Head of the Base Hospitals. The price at which they would be furnished by the optical company whose bid had been accepted was also stated as well as the price at which they were to be sold to officers and soldiers. The standard size of the frames and lenses was specified. To provide for the proper adjustment of the spectacle frames it was directed that an optician be selected from among the drafted men and assigned to duty in the Subsection of Ophthalmology of each base hospital.
This method of supplying glasses through the post exchanges at a fixed price remained in operation until March 13, 1918, when the Section of Ophthalmology took up the question of furnishing enlisted men with spectacles free of cost, and outlined the plan in a memorandum to the Surgeon General, which was approved on March 20, 1918. As the result of this recommendation, the following order was promulgated: 8
VII. During the present emergency lenses for the correction of visual defects, and suitable frames therefor, will, when prescribed by medical officers (or by civilian physicians employed under proper authority), be issued without charge by the Medical Department to all enlisted men who have been definitely accepted for the military service. They will not be issued to recruits who for any reason are about to be discharged from the service.
The soldier`s receipt for the lenses and frames will be taken by the issuing officer in each instance, and will be the medical officer`s voucher for dropping them from his return of medical property.
Should the lenses or frames be subsequently damaged, lost, or destroyed while in the soldier`s possession and without fault on his part, they will be repaired or replaced without charge by the Medical Department. Should they be damaged, lost, or destroyed through fault on the part of the soldier, they will be repaired or replaced by the Medical Department, and the cost, repair, or replacement will be collected by stoppage against the soldier`s pay.
The plans for supplying spectacle lenses to soldiers as part of their equip-ment were not completed until June 6,1918, when a memorandum to the Supply
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Division was forwarded by the Section of Ophthalmology, suggesting that a form letter of instructions be sent, through channels, to officers whose duty it was to prescribe glasses for enlisted men at the various posts, base, and general hospitals. This form letter was also to contain a list of the camps and cantonments, with notation in each case of the wholesale optical manufacturing companies best suited to furnish glasses under the provisions of the order named. In accordance with this recommendation, on June 7, 1918, by direction of the Surgeon General, a letter of instructions was sent to every medical and supply officer concerned. This letter also specified that glasses at 10 per cent increase above the wholesale price would be furnished to officers and their families and to nurses. 23
On June 13, 1918, a complete classified list of all the camps and cantonments, together with the wholesale optical manufacturing companies best suited to supply glasses according to the regulations, was prepared. The Supply Division of the Surgeon General`s Office sent this 24 to all officers concerned with the ordering of spectacle lenses in the Army, and informed the various optical manufacturing firms selected as to the exact territory each must be prepared to cover with the supply of glasses as prescribed and ordered.
While no spectacles other than those which conformed to the published specifications were issued, should an enlisted man desire to procure through the post exchange other types of frames, he was authorized to do so at such price as was in force at the time of the purchase. The supply of glasses to those in the military service other than enlisted men was governed by a letter dated July 1, 1918. This was issued by the Chief of the Division of Surgery of the Head under the direction of the Surgeon General. It provided for the purchase of glasses for officers and others. 25
As in the city of Washington there was no post exchange, and none nearer than Walter Reed Hospital, Takoma Park, D. C., Fort Myer, Va., or Camp Meigs, D. C., the following suggestion was made:
In order that officers and their dependents, nurses, enlisted men and their dependents, and civil-service employees of the Government may be enabled to purchase glasses at 10 per cent above the wholesale price, as provided for through the medium of the post exchange in Form Letter No. 39, S. G. O., where such post exchange exists, it is recommended that the secretary of the Y.M. C. A. be requested that this organization shall act as the medium through which the purchase of glasses shall be made from the wholesale firm manufacturing the " issue glasses " purchased by the supply officer of the attending surgeon`s office, in Washington.
This plan was approved and the Young Men`s Christian Association gave ready cooperation. The necessary letters of instruction and orders were issued, and the equipment, with a practical optician on duty, was housed in the Young Men`s Christian Association hut at Ninth Street and Pennsylvania Avenue. This proved to be an excellent arrangement. The plan continued in operation until February 4, 1919.
The arrangements which have been described for the supply of glasses gave universal satisfaction.
OPTICIANS AND OPTICAL UNITS.
Plans for the utilization of practical opticians and optical units in the Medical Department of the Army were begun by the ophthalmic members of the Joint Committee (Committee on Surgery of the Head) of the General Med-
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ical Board, Council of National Defense, as soon as the Surgeon General authorized (August 15, 1917) the establishment of a special hospital of 1,000-bed capacity for surgery of the head in the American Expeditionary Forces. 7 The material and data collected and catalogued at this time were of great use later to the Section of Ophthalmology of the Surgeon General`s Office.
Among the men drafted, or subject to draft, were many practical opticians. Letters from these men were received in large numbers, offering their services as opticians; other letters came from the manufacturing firms containing offers of men in their employ for the same duty. Although the regulations did not permit the induction of these men into the service as opticians, their names and requests were catalogued by the Section of Ophthalmology, and from this classified list it was possible later in many instances to supply the opticians required in the Subsection of Ophthalmology of the various base hospitals, and also in the organization of optical units.7 A form letter was prepared and mailed to each optician who had offered his service as such, explaining that it would be accepted, if possible, whenever required.
An effort was made by optometrists individually and by optometrical organizations as such for recognition by the Medical Department. The offers were all carefully considered, but no change in the regulations, which contained no provision authorizing this, was made.
During the winter of 1917 and 1918 the chief of this section, while on duty on a tour of inspection in France, was ordered by the chief surgeon of the American Expeditionary Forces to make investigations as to the best methods of spectacle-lens supply for the American Expeditionary Forces. In his report it was pointed out that plans for such supply were already in the Surgeon General`s Office, and that on order the necessary opticians and optical equipment could be furnished. On February 25, 1918, a base optical unit and eight auxiliary units (Units 1-8) were requested by cable. 27 They were mobilized at Camp Crane, Allentown, Pa., in March, 1918, and left the United States April 26,1918, arriving in France May 4, 1918.
On September 4, 1918, a cablegram from the Headquarters of the American Expeditionary Forces reached the Surgeon General`s Office, requesting that six additional optical auxiliary units, in personnel and equipment to correspond with those which had sailed April 26, 1918, should be sent to France. 27 Their organization was immediately begun. They, like those which had preceded them, were mobilized at Camp Crane, Allentown, Pa., in October, 1918, and sailed on November 12, 1918.
ARTIFICIAL EYES AND GLASS FOR ARTIFICIAL EYES.
In August, 1917, the Subsection of Ophthalmology, Council of National Defense, interested itself in the supply and manufacture of artificial eyes. It was learned that the glass used in the manufacture of artificial eyes had been obtainable chiefly from one source in Germany, and that the manufacture of this glass in the United States had not been attempted on account of the limited demand for it. As the result of considerable effort, samples of this glass were obtained. On September 6, 1917, the question of its analysis was taken up with the Bureau of Standards, Department of Commerce, and the matter referred to the glass specialist at the Pittsburgh laboratory of the
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bureau. At the request of this laboratory, samples of the glass were then sent it. For a number of months there followed a series of conferences, chiefly concerning the chemical problems involved, through letters and personal interviews between the Section of Ophthalmology and the Bureau of Standards, the Geo-Physical Laboratory, a selected number of firms dealing in artificial eyes, and a manufacturing glass company.
Ultimately, samples of the glass needed for the manufacture of artificial eyes were procured, as well as the finished product. While these eyes were by no means the equal in quality of the foreign article, they gave promise that had it become necessary to depend upon domestic production of artificial eyes additional experiments would have succeeded in developing a more suitable glass and one free from some of the objections which pertained to that which was first produced. As the Government was not obliged to depend upon glass manufactured in this country for this purpose, and as it was found that the supply of artificial eyes carried in stock by various dealers in the United States would suffice to meet the demand, further experiments along this line were discontinued.
A survey, made in part by the Council of National Defense, and in part by the Division of Finance and Supply of the Surgeon General`s Office, revealed the sources from which these artificial eyes could be obtained. A large number were purchased and stored in the New York supply depot. A portion of this supply formed part of the equipment of the first optical unit which sailed on April 26, 1918. 28 After the establishment of the eye centers in this country-that is, when, in the late summer and fall of 1918, wounded were returning from overseas-on request of the Section of Ophthalmology, the Division of Supply and Finance of the Surgeon General`s Office divided the remaining stock of artificial eyes among the hospitals designated as eye cen-ters, namely, Walter Reed, Takoma Park, D. C.; United States General Hospital No. 2, Fort McHenry, Md.; United States General Hospital No. 11, Cape May, N. J.; United States General Hospital No. 6, Fort McPherson, Atlanta, Ga.; United States General Hospital No. 26, Fort Des Moines, Iowa; and Letterman General Hospital, Presidio of San Francisco, Calif. In so far as possible, soldiers returning from overseas who required artificial eyes, or operations on the sockets in order that the artificial eyes might be adjusted, were sent to one of the hospitals named. If this were not expedient, the Division of Finance and Supply, on request from the Section of Ophthalmology, authorized, through channels, the officer in charge of the Ophthalmic Service of the hospital to which a soldier had been assigned to purchase the needed artificial eyes, at a fixed price, from the nearest civilian shop having such eyes in stock. In this manner an adequate supply was always at the disposal of the various ophthalmic services of the base and general hospitals of the country.
INSPECTIONS.
According to the plan of organization of the base hospitals of this country, there was authorized and established in each one of them a section of Surgery of the Head in the Surgical Service, including a Subsection of Ophthalmology. These sections and their component subsections were systematically inspected by officers detailed for that purpose from the Division of Surgery of the Head.
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Practically all of these subsections were visited once, and many of them twice, during a period beginning in September, 1917, and ending in July, 1918.
The needs of the service as to equipment and personnel were thus ascertained and were then provided for on recommendation from the inspecting officer. This systematic inspection proved to be one of the most effective measures for correcting to date the record cards on file in the Surgeon General`s Office of those officers who were "exempt to ophthalmology." The inspections also included one in France and England, which began early in November, 1918, and ended February 13, 1918. 29 Its purpose was to observe the methods employed by the English and French Medical Corps, with special reference to ophthalmology, otolaryngology, maxillo-facial surgery, neurological surgery, and the medical care of the aviator. During this inspection in France all the base hospitals except three at that time in our own service, four British base hospital areas, and one French hospital sector from its base to the front, were inspected. In England, several general hospitals, one special hospital devoted to plastic surgery, and St. Dunstan`s Hotel were visited.
A complete report of the work and the conclusions arrived at, with recommendations, was submitted to the chief surgeon, American Expeditionary Forces, and to the Surgeon General. From the eye standpoint the chief recommendations were: A standard eye equipment for all hospitals in the American Expeditionary Forces, as already planned in the Surgeon General`s Office, and separate wards for the care of eye patients, one chief eye center, in the sense of a hospital devoted to surgery of the head; the establishment of eye centers to care for the major eye cases of given hospital areas; the assignment of competent ophthalmic surgeons to hospitals to be erected in the advanced areas; the organization of optical units in various zones, one central optical shop for the supply of spectacle lenses; and the appointment of a director or consultant in ophthalmology in the American Expeditionary Forces. 29
EDUCATIONAL AND LITERARY ACTIVITIES.
Soon after the establishment of the Section of Ophthalmology, a course of lectures on ophthalmic practice, to be given in camp base hospitals and at medical officers` training camps, was outlined. The detailed account of this type of instruction will appear in the volume on education and training. Although in general this plan did not result in any notable special achievement in ophthalmic teaching, in several base hospitals, notably at Camp Custer and Camp Lewis, much attention was devoted to this subject, and the courses put at the disposal of the officers on duty in the Subsection of Ophthalmology were productive of good results.
The chief advance in training ophthalmologists for service in the Medical Corps of the Army was coincident with the establishment of the School of Ophthalmology, Medical Officers` Training Group, Camp Greenleaf, Fort Oglethorpe, Ga. Prior to its organization a school of this character had been in contemplation for a considerable period of time, and was the subject of many conferences between the Section of Ophthalmology and the officer in charge of medical instruction at Camp Greenleaf. From June 15 to June 30, 1918, a preliminary survey was made of the available buildings and clinical material,
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the possible courses of instruction in ophthalmic work and in cooperation with other schools already established or in process of establishment, the laboratory facilities, the staff required, and the standards for admission. The recommendations, as a result of this survey, incorporated in a report which was submitted to the Surgeon General and to the commandant of the camp, were approved.
On July 23, 1918, the Surgeon General ordered the organization of the ophthalmic instruction, with the collection of the necessary equipment and oversight of the alterations required in the building assigned for the purpose at the school. This building was officially known as Ward 30, Division A, of United States General Hospital No. 14.30 On August 7, 1918, preliminary lectures and demonstrations were begun, and on August 12, 1918, the formal opening of the ophthalmic school took place.
This School of Ophthalmology was organized and put into operation for the purpose of training ophthalmologists who had entered the service as such and had been assigned to the Medical Officers` Training Camp for instruction. It afforded student officers, even though they had in civilian life devoted long periods of time to eye work, an opportunity for postgraduate ophthalmic instruction which proved to be of the utmost service. It also permitted all those who were engaged in this work, either as instructors or as student officers, to approach their duties from the military standpoint. In so far as possible, emphasis was placed on instruction which would fit the student officers for ophthalmic services abroad. The school continued in operation until December 31, 1918.
The literary and educational activities of the Section of Ophthalmology other than those already described consisted in the preparation of (a) camp and war manuals;4 (b) the delivery by order or authorization of various addresses and lectures;31 and (c) the presentation before scientific societies, or in medical schools, of various papers pertaining to ophthalmic war surgery and practice. 31
CONFERENCES.
In addition to the daily routine, conferences were held, as occasion required, between the Chief of the Division of Surgery of the Head and other divisions of the Surgeon General`s Office and the Section of Ophthalmology. 32 Conferences in relation to the trachoma problem have already been mentioned. Special reference may be made to the following: (1) With the Division of Aeronautics on the visual requirements of aviators at reexaminations (Oct. 11, 1918); (2) with the Sanitary Division on ocular conditions to be recorded in the examinations of soldiers at the time of demobilization, on the revision of the ophthalmic diagnosis for the code book, on the classification of ophthalmic operations, on the ocular examination of registrants, on forms for taking ophthalmic histories; (3) with the Statistical Division on the ophthalmic diseases on which statistical data were desirable; (4) with the Medical Section of the Bureau of Railway Administration on the practical methods of testing color blindness; l5) with the Finance and Supply Division on the distribution and purchase of artificial eves, on the equipment for eye centers, and on the instruments and
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drugs for overseas hospitals, as well its for newly established hospital centers in this country; (6) with the Hospital and Personnel Division on the assignment of contract ophthalmic surgeons and the distribution of eye cases from overseas; (7) with the Legal Department on the percentage of disability to be allowed for the loss of one eye, the other remaining perfect; (8) with the Library Division of the Surgeon General`s Office on the history of ophthalmology in the war. The Chief of the Division of Surgery of the Head participated innumerous conferences, in many of which ophthalmic questions of importance were discussed and decided; for example, in reconstruction, on the standardization of the professional reports for base hospitals, on instruction on general hospitals, and on the regulations for selective-service registrants.
SPECIAL HOSPITALS FOR EYE CENTERS.
As described in the History of the Division of Surgery of the Head, General Hospital No. 11, Cape May, N. J., was organized and equipped for the special surgical and other treatment of "head cases," and therefore included an eye service, with a carefully selected personnel, and later became one of the eye centers.
A special base hospital for the care of patients overseas who would require expert care from the standpoint of opthalmology, otolaryngology, neurological surgery, and maxillofacialsurgery, authorized by the Surgeon General August 15, 1917, was mobilized at Cape May, N. J., on June 11, 1918. Collecting the equipment and organizing the medical and nursing personnel of this hospital became a particular duty of members of the Section of Ophthalmology. This hospital, listed as Special Base Hospital No. 115, was embarked for overseas on August 14,1918; its work is described in the report of the senior consultant in ophthalmology for the American Expeditionary Forces. 33
Soon after wounded from abroad began to arrive in this country, it became necessary, in order adequately to furnish the means of supplying special types of treatment, to select a number of hospitals or centers for this purpose. As the result of consultations between the Section of Ophthalmology, through the Chief of the Division of Surgery of the Head, and the Hospital Division, six hospitals, namely, United States Army General Hospital No. 1, Williamsbridge, N. Y., United States Army General Hospital No. 2, Fort McHenry, Md.; United States Army General Hospital No. 6, Fort McPherson, Ga.; United States Army General Hospital No. 11, Cape May, N. J.; the Walter Reed Hospital, Takoma Park, D. C.; and Letterman General Hospital, San Francisco, Calif., were designated as eye centers, and to them, as far as possible, soldiers with wounded or diseased eyes, and especially those requiring blepharoplastic surgery, were assigned. 9 Lists of the wounded as they reached this country, with the overseas diagnosis of each soldier, were submitted to the various divisions and sections of the Surgeon General`s Office and for each a hospital was designated according to his medical and surgical requirements. In accordance with this plan, the majority of soldiers with eye injuries or diseases were sent to one or other of the eye centers. Whenever, for geographical or other reasons, such assignment was not deemed advisable, the wounded soldier was transferred to a base or general hospital not specifically designated as an eye
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center, but with ophthalmic surgeons on duty capable of giving the necessary attention. Further, to meet conditions better, several hospitals were selected as auxiliary eye centers; for example, that at Camp Lewis; United States Army General Hospital No. 26, Fort Des Moines, Iowa; and United States Army General Hospital No. 28, Fort Sheridan, III.
The ophthalmic staffs of the eye centers and the auxiliary eye centers were selected so that they should include medical officers skilled in ophthalmic surgery, and particularly in blepharoplastic work.
CONSULTANTS.
The question of the appointment of consultants for the various general and special medical and surgical divisions and sections of the Surgeon General`s Office was the subject of frequent conferences with the Surgeon General. The plan of designating consultants, similar to the one in operation in the Medical Service of the British Expeditionary Forces, as it had been observed by the officers sent on an inspection tour in France and England, to which references have been made, was recommended in their report, especially for the sections of the Division of Surgery of the Head. It was particularly urged after the organization of a staff of consultants by the chief surgeon, American Expeditionary Forces, and the receipt of reports indicating the value of such assignments. Naturally, the need for consultants in the hospital service of this country was not so insistent as it was overseas, especially after the active participation of American soldiers in the combat areas, although, in point of fact, officers inspecting camp hospitals on this side were not infrequently requested to assume the functions of consultants by the chiefs of various services and by the hospital commanding officers. The need of consultants became more evident as the wounded from overseas began to arrive in this country and to be distributed, as before described, to groups of selected hospitals. Accordingly, all of the eye centers, with the exception of Letterman General Hospital and the auxiliary centers, were systematically visited as occasion required, and the work of a consultant was carried out, as requested, by the hospital commanding officers, chiefs of sections, and subsections.
After the appointment of a senior consultant in ophthalmology in the American Expeditionary Forces, the Section of Ophthalmology, Surgeon General`s Office, and the office of the ophthalmic consultants of the American Expeditionary Forces kept in communication by means of correspondence and a weekly courier letter. 34 In this manner, requisite additions to the overseas ophthalmic personnel and to the ophthalmic equipment were ascertained, and an endeavor was made to supply them. Moreover, the ratings of ophthalmic surgeons designated for overseas hospitals were forwarded as soon as their assignments had been made, thus putting the senior consultant in ophthalmology, American Expeditionary Forces, in possession of information by which he might be guided in their selection for special duties. In brief, as far as possible, an effort was made to correlate the work of the Section of Ophthalmology of the Surgeon General`s Office and that of the office of the ophthalmic consultants of the American Expeditionary Forces.
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ASSIGNMENTS.
The, various assignments, transfers, and releases from the beginning of the work of the Section of Ophthalmology until January, 1919, may be classified as follows:
To Medical Officers` Training Camps........................................ 368
To base, port, post, and general hospitals in this country..... 493
To overseas hospitals and unite ................................................ 276
Transferred to other services ...................................................... 360
Naturally there is a certain amount of duplication in these figures. Thus, officers assigned to training camps may be included among those assigned to hospitals or to overseas units. The total number of ophthalmologists assigned to duty during the war was 612. Of this number, 150 were on duty in France on December 31, 1918. 5
SECTION OF OTOLARYNGOLOGY.
The Section of Otolaryngology was organized on August 7, 1917. 5 The first activity of the section was to continue the work already started by the Subcommittee of Otolaryngology of the Council of National Defense and to apply the results of this committee`s labors. The chief activity of this committee had consisted in sending out questionnaires to specialists in otolaryn- gology, filing and indexing them when they were returned, distributing the application blanks for the Medical Reserve Corps of the Army to its specialists, and advising on the classification of the applicants on the receipt of their papers in the Surgeon General`s Office. By means of the questionnaires, a list was mule of the otolaryngologists of the country who were ready for immediate or deferred service. In most cases, the questionnaires gave sufficient data for classifying and rating the applicants. Where there was doubt, application was made to members of the profession who had been selected to act as State consultants.
The personnel in otolaryngology of the various camp hospitals was selected from the physicians who answered the questionnaires. During the war period, securing adequate personnel and placing it in a manner satisfactory to the service and to the individuals concerned was the main function of the Section of Otolaryngology. In order to bring this about, much correspondence was carried on with otolaryngologists seeking information regarding the military service, and many consultations were held in the Surgeon General`s Office with physicians whose desire to do their part brought them to Washington for advice.
In May, 1918, a circular letter was sent to 100 otolaryngologists who, a year before, had expressed their willingness to enter the Medical Corps at a later date, should their services become necessary.
Coincident with the enrolling and assigning of otolaryngologists to the base hospitals in this country, a tentative list of assignments for base hospitals abroad was drawn up. On August30, 1917, a medical officer was appointed consultant in otolaryngology to the line of communications; on April 1, 1918, he was appointed senior consultant and director of ear, nose, and throat surgery in the American Expeditionary Forces.
A special building for the Section of Surgery of the Head, for use in base hospitals in this country, was designed jointly by the Section of Otolaryngology
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and the Section of Ophthalmology. (For description, see Vol. V, Military Hospitals, United States.)
A working set of instruments for the Section of Otolaryngology was pre-pared and instruments were supplied to the base hospitals. Later this list was modified, extended, and standardized. An instrument list for a special head hospital abroad was drawn up also; the Section of Otolarylngology took its proportionate part in planning the special hospital building for the head hospital abroad.
In October, 1917, the chief of the section made an inspection trip to Camp Devens, Camp Upton, Camp Mills, and Camp Dix, and in late October,1917, he made one of a party of four for a two months` tour of observation overseas. This party went in the interests of the surgical specialties of the head and the medical care of the flier. They were given ample opportunities to study the manner in which the specialties were managed in the English and French Armies. In addition, they visited the majority of the American base hospitals in France. An extensive report of their observations was rendered to the Surgeon General, with recommendations. 36
In June and July, 1918, the chief of this section made an inspection of the Section of Surgery of the Head at Camps Lee, Jackson, Hancock, Wheeler, Sheridan, Beauregard, and Shelby.
In connection with the examination of the registrants of the draft, the standard of hearing for admission to the Army was revised, and the tests for malingerers were amplified. Later on, the regulations for medical advisory boards, as far as they concerned otolaryngology, were also revised and rearranged.
A committee was appointed to investigate ear protectors. The results of this investigation were submitted to the Surgeon General in March, 1918. 37 A brief account of the work on reeducation of the deaf is given in Chapter XIX, Division of Physical Reconstruction. A full account will appear in the volume on Physical Reconstruction.
A manual of abstracts of the literature bearing on otolaryngology in the war was compiled in this section and published as War Manual No. 8. 4 In addition, a monthly journal was prepared and issued by the section.38
The School of Otolaryngology of the Medical Officers` Training Camp at Camp Greenleaf, Fort Oglethorpe, Ga., began its work on May 8, 1918, with 19 pupil officers, and closed in January, 1919, 90 student officers having taken instruction in the school, 57 of whom were rated as qualified otolaryngologists. "A collection of anatomical specimens (supplied by individual officers representing this -specialty) and an abundant supply of instruments and other teaching paraphernalia constituted the equipment of the school, which filled an important place in rating men in the specialty of otolaryngology and in acquainting them with the modern methods of diagnosis and treatment.
By arrangement with the commanding officer of the medical officers` training camp, all students in the school who had completed six weeks` military training were allowed to give their entire time to professional work. The course of instruction was arranged on a four-weeks basis. August 15, 1918, a form for the monthly report of otolaryngological operations was distributed to the various general, base, and post hospitals. By this means, operations were checked and tabulated. The forms became a
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part of the permanent records of the Surgeon General`s Office. From these reports the following table is constructed.
Table of operations from returns available March 1, 1919.
On September 12, 1918, six otolaryngologists were sent overseas as a unit. The members were unattached, in order to be available for quick assignment. November 21, 1918, a second otolaryngological unit was selected and was awaiting orders.
Beginning with October, 1918, a duplicate of the record of each otolaryngologist assigned to duty overseas or to an organization destined for such service was sent by weekly courier to the senior consultant in otolaryngology, American Expeditionary Forces, for his information and guidance.
For some time after the armistice, the activities of the Section of Otolaryngology were concerned mainly with the release, retention, or reassignment of its personnel, and the collection and tabulation of historical data. In order to obtain the latter, circular letters were sent to all the general, base, and post hospitals. Besides maintaining a minimum personnel at the various hospitals, the staff of the special hospitals designated to receive head cases was increased and strengthened. 40
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Tabulation of personnel (continued)
SECTION OF BRAIN SURGERY.
As noted in the beginning of this chapter, a subcommittee on brain surgery was organized within the General Medical Board of the Council of National Defense, and, along with other subcommittees involved in surgery of the head, was transferred to the Surgeon General`s Office with the organization therein of the Division of Head Surgery. 1
At the inception of the idea in the Council of National Defense circular letters were addressed to all the principal hospitals and universities of the country, requesting them to submit the names of all surgeons available for duty as brain surgeons or capable of becoming such after intensive training. Questionnaires as to training and qualifications were then submitted to the men named. There were also organized throughout the country advisory committees, consisting of prominent neurologists, as referees in relation to the names of candidates submitted from their neighborhoods. In addition, there was organized a central advisory committee, made up of the leading brain surgeons of the country.
As the number of qualified brain surgeons was limited, neurosurgical schools of instruction were established in Philadelphia, New York, Chicago, St. Louis, and later at Fort Oglethorpe, Ga. 41 The course of instruction consisted of lectures and demonstrations in the anatomy, physiology, and pathology of the central nervous system, with surgical and neurological clinics. The course lasted 10 weeks, and the number of students at each course numbered about 30. The medical schools and hospitals of the cities in which the instruction was given were most generous of their facilities in the furtherance of this enterprise. At Philadelphia and New York, three courses of instruction were given; at Chicago and St. Louis, one; while the Oglethorpe school had only begun to function when the need ceased. From the questionnaires submitted, and after selection through the advisory committee, about 250 officers were retained for the Brain Surgery Section out of about 1,000 names submitted from the hospitals
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and medical schools. A manual,4-c compiled in the Surgeon General`s Office from the leading authorities and from the recent abstracts of foreign and domestic literature on war surgery of the nervous system, was subsequently used as a textbook at the neurosurgical schools. A second neurosurgical manual, 42 more elaborate and comprehensive than the first, was published and distributed in the spring of 1919.
At the suggestion of the central advisory committee, a neurosurgical laboratory was established at Baltimore, Md. At this laboratory an exhaustive research into the infective processes of the central nervous system was conductod. A thorough test of the action of the chlorine antiseptics upon nerve tissues and also an investigation into drainage of the subarachnoid space were made.
Each Red Cross hospital still in this country was requested to assign two members of its surgical staff for special instruction in the neurosurgical schools. At this time it was hoped that a practical school might be established in France, to which the members of hospital units already overseas could be assigned, but this was not possible. By October, 1917, the first class from the first school at Philadelphia had graduated 32 officers.
In addition to the selection, training, and assigning of personnel, the Section of Brain Surgery, in conjunction with the Section of Maxillofacial Surgery, selected and arranged for manufacture of 200 sets of major operating-room equipment for brain, plastic, and oral surgery. These sets were made up of the instruments that had been found available through the Council of National Defense and were destined to be supplied to every base, evacuation, and mobile hospital.
Following a trip of inspection made by the Chief of the Section of Brain Surgery to the war hospitals of Canada, in December, 1917, authority was requested to establish another research laboratory at the University of Michigan for the study of peripheral nerve injuries.43 At this laboratory a large number of experiments were performed on animals. The various methods of surgical nerve repair were tried out and regeneration through various grafts was studied. It was at this laboratory also that the advantage of alcohol injections for the prevention of neuromata was brought out.
As the various classes were graduated from the neurosurgical schools, the members were assigned to duty in the base hospitals, but were available for any neurosurgical work that might develop.
The base hospitals and evacuation hospitals organized in the Surgeon General`s Office included in their personnel two officers assigned from this section. There were also sent to France in the summer of 1918, 10 officers who constituted Neurosurgical Team No. 1.44 When the armistice was signed, about 190 officers from this section were on duty with the American Expeditionary Forces.
With the beginning of the influx of wounded soldiers from France, certain hospitals throughout the country were designated for special care for neuro surgical cases. 45 These were: U. S. Army General Hospital No. 11, Cape May, N. J.; Walter Reed General Hospital, Takoma Park, D. C.; U. S. Army General Hospital No. 1, Williamsbridge, N. Y.; U. S. Army General Hospital No. 2, Fort McHenry, Md.; U. S. Army General Hospital No. 3, Colonia, N. J.; U. S. Army General Hospital No. 6, Fort McPherson, Ga.; U. S. Army General Hospital
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No. 26, Des Moines, Iowa; U. S. Army General Hospital No. 28, Fort Sheridan, Ill.; U. S. Army General Hospital No. 29, Fort Snelling, Minn.; Letterman General Hospital, San Francisco, Calif.
To each hospital was assigned an officer from the Section of Brain Surgery, who was made Chief of the Neurosurgical Service. In addition, an orthopedic surgeon and a neurologist were assigned to each hospital on the staff of the Surgical Service.
The majority of neurosurgical cases among returned soldiers were peripheral nerve cases. On January 29, 1919, the Surgeon General appointed a Peripheral Nerve Commission" to correlate and study these cases.
Under the advice of the Peripheral Nerve Commission, the Section of Brain Surgery printed and distributed the Peripheral Nerve Register. 46 Every peripheral nerve case was examined and studied according to this register and duplicate copies thereof were furnished to this section in the Surgeon General`s Office. Thus, it was hoped that from the uniform data of a large number of cases a real contribution might be made to the study of peripheral nerve injuries. The final study of these cases being in the hands of the Peripheral Nerve Commission, the Section of Brain Surgery was abolished during the summer of 1919. 47
SECTION OF PLASTIC AND ORAL SURGERY.
The preparations made by the Surgeon General for the care of injuries of the face and jaws during the late war were based upon observations regarding these injuries in the armies of the Allies and upon the best experience in civil practice of our own workers in this field.
Wounds of the face and jaws attracted particular attention from the beginning of the World War, not only on account of the disfigurement which they cause, but even more from the difficulty that was at first encountered in dealing with them. The special difficulties met with in their treatment, which differentiated them somewhat from other war injuries, arose from the attitude which regarded dentistry and surgery as two distinct and separate professions. The surgeon is not technically trained to splint fractures of the jawbones, yet early proper fixation is one of the most important points of the treatment. The dentist as such is not trained to care for the wounded tissue beyond fixation of the bones, yet repair of the soft tissues and proper drainage may be equally important. The earlier literature of these injuries in the recent war shows the great ingenuity manifested in devising fixative and corrective appliances for overcoming deformities that were largely due to lack of early treatment. As the means for handling these cases became better organized, attention was directed more to the surgical side of this special problem, until at the time of entry of the United States into the war the trend of thought of practically all authorities led to the conclusion that a definite plan of treatment for face and jaw injuries should be initiated at the earliest possible moment after receipt of the wound.
The two fundamental principles, therefore, upon which was based the preparation for the work of plastic and oral surgery by the Surgeon General of the Army were: (1) That the work could be carried out to its highest efficiency only by close cooperation of the surgeons and dental surgeons, and (2) that proper treatment should be instituted early and be continuously carried
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out on systematic lines. To carry out the designs of the Surgeon General it was necessary to have a large personnel, both surgeons and dental surgeons, who had received some special instruction in the general plan proposed, so that teams would be available in every advanced, intermediate, and base hospital to which the wounded would be brought. An efficient standard equipment was hardly of secondary importance.
Failure of realization of these plans to the fullest extent was not due to want of cooperation of the medical and dental professions, either in civilian life or in the Army, but to the exigencies of war. Where the plans actually fell short, disaster was averted by the splendid spirit of the personnel, who at any time and anywhere made ingenuity and enthusiasm compensate for material and conveniences when either or both of the latter were lacking.
The organization of the Section of Plastic and Oral Surgery began early in July, 1917, by the Joint Committee on Head Surgery, Council of National Defense, with the approval of the Surgeon General. 1
The province of the plastic and oral surgeon was then defined as the care of injuries and surgical diseases of the mouth and its essential structures, including the bony framework and soft tissues of the face, and also of the neck when the major part of the injury is situated above the clavicle, with the exception of certain injuries and surgical diseases coming within the province of the ophthalmologist, the otolaryngologist, and the brain surgeon.
It was at once recognized that comparatively few men working in general surgery were familiar with the use of the various mechanical means which had been developed by the dental profession for the retention of jaw fractures. On the other hand, the training of the ordinary dental surgeon did not fit him for doing major surgical operations. To meet this situation, the following plan was formulated: To secure the services of the general surgeons of large experience, accustomed to doing plastic and bone surgery, and to correlate each with a dental oral surgeon. In this way, the individual maxillofacial case would be given the benefit of the skill and the knowledge of both professions.
As a beginning in the securing of personnel, letters were sent out to over 200 of the more prominent surgeons, asking for suggestions as to individual men whose training and practice were such as to make them especially fitted for the Section of Plastic and Oral Surgery. At the same time, inquiries were started as to available dental oral surgeons. From replies to these letters and from other sources, the names of surgeons and dental surgeons who could possibly qualify for the work were obtained. To these surgeons and dental surgeons letters were sent outlining the proposed plans and urging cooperation, together with questionnaires to be filled out and returned. The dental personnel for this work was selected, of course, with the cooperation of the Dental Section, and frequent consultations were held by the chiefs of the two sections concerned on all matters affecting both. In this manner, by the end of 1917,147 surgeons and 117 dental oral surgeons had been selected and classified for this work.
Insetting out to the prospective surgeons the field covered under the head of plastic and oral surgery, it was emphasized that the commanding officer or director of each hospital might delegate such other work to the surgeon in charge of oral surgery as he might see fit, so that a man taking up this work would not necessarily be limited to the particular field.
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An important feature of the preparation of surgeons and dental oral surgeons for handling war injuries was to make available to them the literature pertaining to the subject. A complete survey of the current American and foreign literature was therefore made in the Surgeon General`s library; abstracts of the principal articles were made, published from time to time in The Military Surgeon, and distributed in the form of reprints to the men interested. Time did not permit a full exposition of the subject in a special manual, and it was therefore decided to incorporate much of this material in a new Surgery and Diseases of the Mouth and Jaws, 4-d which was designated as the official textbook of the section and placed in every hospital at home and overseas. New articles from the literature were abstracted as they appeared, and published in the Review of War Surgery and Medicine 42 and the Survey of Head Surgery, issued monthly by the Surgeon General`s Office and distributed to the personnel. 38
In order to correlate the functions of the surgeon and the dental oral surgeon in this work, to afford a review of the anatomy, of the operative surgery, of the literature, and, for the dental surgeon, the various methods of splinting, it was decided to conduct, under the supervision of the Surgeon General, short, intensive courses of instruction in certain civilian medical and dental schools for officers assigned to the section.48 These courses were conducted by the staffs of the schools chosen, supplemented by teachers from the neighboring schools. All of the teaching in these courses was under the direct supervision of the section, and the general plan, with the allotment of time to each subject, was designated by the Surgeon General`s Office. In each school an outline of the lectures and laboratory demonstrations was taken, transcribed, and forwarded to the Surgeon General. Complete reports as to proficiency and aptitude of individual officers were sent in at the completion of each course. In this way a very fair idea was obtained of individual ability, and men who did not prove suitable for the work were dropped from the section. The courses varied in length from three to six weeks, and covered a period from October 15, 1917, to March 30, 1918. The following schools were selected for these courses: Washington University, St. Louis; University of Pennsylvania, Philadelphia; and Northwestern University, Chicago. 49
The number of officers who attended the courses follows:
St. Louis, 92 medical officers; 41 dental officers.
Philadelphia, 43 medical officers; 48 dental officers.
Chicago, 29 medical officers; 34 dental officers.
About 14 per cent of these men were lost by the Section of Plastic and Oral Surgery for various reasons, among them being lack of adaptability for this special work, transfer to other divisions of the medical service through military exigencies, and physical disability.
In August, 1918, plans were formulated for four weeks` courses of instruction in plastic and oral surgery to be given as part of the instruction at the Medical Officers` Training Camp, Camp Greenleaf, Ga. Two courses were given, the first ending November 16, 1918, and the second, December 14, 1918. The signing of the armistice rendered unnecessary any further plans along these lines.
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While awaiting final detail to units for overseas service, the officers retained by the Section of Plastic and Oral Surgery, after completing their special courses of instruction, were assigned either to medical officers` training camps or to temporary duty in camp base hospitals. It was quickly realized that in this country there was little of the special maxillo-facial surgery to be done, and these officers for the most part were given such other work as the commanding officer deemed advisable. The dental officers, of course, were kept busy in the camps with the regular dental work.
With the organization in the Surgeon General`s Office of the various base and evacuation hospitals and other units for overseas service, the call came for personnel in plastic and oral surgery, and to each unit were assigned one surgeon and one dental oral surgeon who had received the special training to fit them for this work. In addition to the regular base and evacuation hospitals, 10 special oral units were organized, each consisting of two surgeons and two dental oral surgeons, and sent overseas on March 31, 1918. 50
Base Hospital No. 115, organized as a special head hospital, and including in its personnel four surgeons with special training in plastic and oral surgery, and two dental oral surgeons, together with special equipment for caring for face and jaw injuries, was mobilized for overseas service on June 30, 1918.
This section worked continuously upon the selection, simplification, and standardization of instruments and equipment to be used by the officers assigned to overseas hospitals. Both on general surgical principles and upon facts gleaned from the war experiences of others, it was recognized that if the jaw cases could receive early, effective treatment, much suffering, much convalescent time, and not a few lives could be saved, and every effort was made to place properly trained personnel in the most advanced operating stations, provided with proper equipment for instituting early care of the cases, including apparatus for temporary fixation of fractures.
In anticipation of the return of overseas wounded to the United States in April, 1918, plans were formulated whereby certain hospitals in this country were prepared with the proper special staffs and equipment to receive the various classes of cases. Arrangements were made for the prompt classification and evacuation of cases from ports to these hospitals. It was provided that all cases of disease and injury of the face, jaws, and neck should be sent to General Hospital No. 11, Cape May, N. J. During the last three months of 1918, cases of maxillofacial injury began to arrive from overseas and were sent to this hospital. It soon became evident that one hospital for the care of these cases would be inadequate, and by February, 1919, the following hospitals were designated as maxillofacial centers:" Walter Reed General Hospital, Takoma Park, D. C.; General Hospital No. 2, Fort McHenry, Md.; General Hospital No. 11, Camp May, N. J. April 1, 1919, General Hospital No. 40, St. Louis, Mo., was added to the list, and in June, 1919, the service at General Hospital No. 40 was transferred to the post hospital, Jefferson Barracks, Mo. At each of these hospitals the service consisted of a chief of maxillo-facial service, a number of ward surgeons and surgical assistants, and several dental surgeons and prosthetists. Of slightly over 800 cases of maxillo-facial injury received in these and other hospitals from overseas, 374 were still
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under treatment on June 30, 1919, at Walter Reed General Hospital, General Hospital No. 2, and Jefferson Barracks. Shortly afterwards the remaining cases at General Hospital No. 2 were transferred to Walter Reed General Hospital and to the post hospital, Columbus Barracks, Ohio. By June 30, 1920. the number of cases under treatment was reduced to 94. 54
An important feature in connection with the care of maxillofacial injuries was the preparation of special records in the form of drawings, photographs, plaster and wax models, which, when completed and assembled, were sent to the Army Medical Museum. At the special hospitals mentioned a complete staff of artists, photographers, and wax modelers were assigned by the Surgeon General to carry on this work.
With the organization of the staffs and equipment in the general hospitals designated to care for maxillofacial injuries from overseas, the administrative functions of the Section of Plastic and Oral Surgery in the Surgeon General`s Office practically ended. One officer was retained in a consultive capacity.
PERSONNEL.a
(April, 1917, to December, 1918.)
Lyster, T. C., Brig. Gen., M. D., chief.
Parker, Walter P., Col., M. C., chief.
de Schweinitz, G. E., Col., M. C.
Black, Nelson M., Lieut. Col., M. C.
Blair, V. P., Lieut. Col., M. C.
Frazier, C. H., Lieut. Col., M. C.
Greenwood, Allen, Lieut. Col., M. C.
Kerr, H. H., Lieut. Col., M. C.
Mosher, Harris P., Lieut. Col., M. C.
Naffzigger, Howard, Lieut. Col., M. C.
Richardson, Charles W., Lieut. Col., M. C.
Bagley, Charles, jr., Maj., M. C.
Brown, G. U. I., Maj., M. C.
Bruner, W. E., Maj., M. C.
Coleman, Claude C., Maj., M. C.
Covington, L. C., Maj., M. C.
Ivy, Robert H.. Maj., M. C.
Loeb, H. W., Maj., M. C.
Penberthy, G. C., Maj., M. C.
Barnes, Harry A., Capt., M. C.
a 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) Organization and report of the activities of the Section of Surgery of the Head. On file, Record Room, S. G. O., Weekly Report. File. Correspondence. Subject: Committee on Head Surgery. On file, Record Room, S. G. O., 156772 and 199804 (Old Files); 021.4 (Council National Defense).
(2) Correspondence. On file, Record Room, S. G. O., 172158 (Old Files).
(3) Office order, No. 97, S. G. O., November 30, 1918.
(4) (a) Manual of Ophthalmology. Prepared by the Subsection of Ophthalmology, Section of Surgery of the Head, Division of Surgery, Office of the Surgeon General, War Department. Government Printing Office, Washington, D. C., 1917.
(b) Medical War Manual No. 3, authorized by the Secretary of War and under the super- vision of the Surgeon General and the Council of National Defense. Second edition, thoroughly revised. Illustrated. Lea & Febiger, Philadelphia and New York, 1918.
(c) War Surgery of the Nervous System. A digest of the important medical journals and books published during the European war. Compiled by the Division of Brain Surgery, Section of Surgery of the head. Office of the Surgeon General, Washington, D. C., 1917. Government Printing Office, Washington, D. C., 1917.
(d) Surgery and Diseases of the Mouth and Jaws. A Practical Treatise on the Surgery and Diseases of the Mouth and Allied Structures, by Vilray Papin Blair, A. M., M. D)., F. A. C. S., professor of oral surgery in the Washington University Dental School, and associate in surgery in the Washington University Medical School. Third edition. Revised so as to incorporate the latest war data concerning gunshot injuries of the face and jaw. Compiled by the Section of Surgery of the Head, Subsection of Plastic and Oral Surgery, Office of the Surgeon General of the Army, Washington, D. C., with 460 illustrations. C. M. Mosby Co., St. Louis, 1917.
(e) Medical War Manual No. 8, authorized by the Secretary of War and under the super- vision of the Surgeon General and the Council of National Defense. Lea& Febiger, Phila- delphia and New York, 1918.
(5) Weekly reports from the Chief of the Division of Head Surgery to the Surgeon General, United States Army. On file, Record Room, S. G. O., Weekly Report File.
(6) Records of General Hospital No. 11, Cape May, N. J. On file, Record Room, S. G. O., 730 (Head Surgery, Cape May, N. J.) (K).
(7) Correspondence. On file, Record Room, S. G. O., 322.3 (Base Hospital 115). Annual Report of the Surgeon General, United States Army, 1918, 364; 1919, Vol. II, 1103.
(8) G. O. No. 35, W. D., April 15, 1918.
(9) Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1095.
(10) Letter from the Surgeon General to Maj. George Muller, January 31, 1919. Subject: Peripheral Nerve Commission. On file, Record Room, S. G. O., 024.14 (Surgery of Head).
(11) Report by Lieut. Col. Nelson M. Black, M. C. On file, Record Room, S. G. O., 710 (Trachoma).
(12) Manual of Instructions for Medical Advisory Boards, office of the Provost Marshal General. On file, Record Room, S. G. O., Document file. Prescribed by the President under au- thority vested in him by the terms of the selective service law (act of Congress approved May 18, 1917). Office of the Provost Marshal General, Form 64. Washington, Government Printing Office, 1918.
(13) Memo. for the Surgeon General of the Army from Maj. Nelson M. Black, in charge of ophthalmology, February 28, 1918. Subject: Concentration Camp for Registrants afflicted with Trachoma. On file, Record Room, S. G. O., 710 (Trachoma).
(14) Memo. (undated). Supplementing that of February 28, 1918. Attached thereto (supra).
(15) Memo. for the Surgeon General, United States Army, from Maj. Nelson M. Black, in charge of ophthalmology, March 14, 1918. Subject: Trachoma. On file, Record Room, S. G. O., 710 (Trachoma).
(16) Memo. from Maj. Nelson M. Black to the Hospital Division, April 15 and 17, 1918. Subject: Olympian Springs. On file, Record Room, S. G. O., 601 (Olympian Springs) (S).
(17) Report by Lieut. Col. Nelson M. Black, M. C. On file, Record Room, S. G. O., 710 (Trachoma).
(18) Memo. from Col. W. H. Parker, M. C., for the Surgeon General, United States Army, for the information of division surgeons. Subject: Trachoma. On file, Record Room, S. G. O., 726.3.
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(19) Form 75, June 5, 1918. Standard of physical examination for the use of local boards, district boards, and medical advisory boards under the Selective-Service Regulations 160, section 184. Issued through the office of the Provost Marshal General of Washington, Government Printing Office, 1918.
(20) Report by Lieut. Col. G. E. de Schweinitz, July 12, 1918. On file, Record Room, S. G. O., 726.3 (General).
(21) Correspondence. On file, Record Room, S. G. O., 726.3 (General).
(22) Letter from the Surgeon General, United States Army, to the division surgeons, November 27, 1917. Subject: Furnishing Soldiers with Spectacles. On file, Record Room, S. G. O., 413.75 (Spectacles).
(23 ) Letter from the Surgeon General, United States Army, to medical and supply officer, June 7, 1918. Subject: Spectacles. On file, Record Room, S. G. O., 413.7 (Spectacles).
(24) Letter from the Surgeon General, July 11, 1918. Subject: Spectacles. On file, Record Room, S. G. O., 413.7 (Spectacles).
(25) Letter from the Surgeon General to medical and supply officers, July 1,1918. Subject: Spectacles for Officers: On file, Record Room, S. G. O., 413.7 (Spectacles).
(26) Letter from Lieut. Col. Nelson M. Black to secretary, Young Men`s Christian Association, July 2,1918. Subject: Spectacles. On file, Record Room, S. G. O., 413.7 (Glasses).
(27) Cablegrams from headquarters, A. E. F., February 25, and September 12, 1918. Subject: Optical units. On file, Record Room, S. G. O., Cablegram File.
(28) Annual Report of the Surgeon General, United States Army, 1918, 364.
(29) Ibid., 363.
(30) Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1103.
(31) Papers. On file, Board of Publications, S. G. O.
(32) Report of activities of the Section of Ophthalmology from July 1, 1918, to April, 1919. On file, Record Room, S. G. O., Weekly Report File.
(33) Report of activities of the Ophthalmic Service, A. E. F., by Lieut. Col. Allen Greenwood. On file, Historical Division, S. G. O.
(34) Correspondence. On file, Record Room, S. G. O., 730 (Ophthalmology, A. E. F) (Y).
(35) Annual Report of the Surgeon General, United States Army, 1918, 364.
(36) Reports. On file, Record Room, S. G. O., 319.124 (Ophthalmology, A. E. F.) (Y).
(37) Correspondence. On file, Record Room, S. G. O., 400.11 (Ear Protectors).
(38) Survey of Head Surgery. Prepared by the Division of Surgery of the Head in the Office of the Surgeon General, August, 1918, to January, 1919. Copies on file, Finance and Supply Division, S. G. O.
(39) Correspondence and reports. On file, Record Room, S. G. O., 353 (Otolaryngology); and 353 (Camp Greenleaf) (c).
(40) Weekly reports, activities of Section of Otolaryngology, Division of Head Surgery. On file Record Room, S. G. O., Weekly Report File.
(41) Correspondence. On file, Record Room, S. G. O., Correspondence File 353. (Neurosurgery, Philadelphia, New York, Chicago, and St. Louis) (F).
(42) Manual of Neuro-Surgery. Authorized by the Secretary of War under the supervision of the Surgeon General. Prepared under the direction of the Neurosurgical Section of the Division of Surgery, in collaboration with the Section of Head Surgery, General Surgery, Orthopedic Surgery and Neuropsychiatry, the Army neurosurgical laboratories, and the instruction laboratories of the Army Medical Museum, Washington, D. C., Government Printing Office, 1919.
(43) S. O., No. 238, W. D., October 10, 1918, par. 364, assigning Contract Surg. G. Carl Huber to duty at University of Michigan, Ann Arbor, Mich.
(44) Correspondence. On file, Record Room, S. G. O., 320.2 (Personnel, Base hospital) General; 322.3 (Medical Units, Neurosurgical).
(45) Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1096.
(46) Clinical records, entitled "Peripheral Nerve Register." On file, Record Room, S. G. O., 700.6-1.
(47 Office order No. 496, S. G. O., August 14, 1919.
(48) Annual Report of the Surgeon General, United States Army, 1819, Vol. II, 1100.
(49) Reports of schools. Subject: Instruction in Maxillofacial Surgery. On file, Hospital Division, S. G. O.
(50) Correspondence. Subject: Oral Units. On file, Record Room, S. G. O., 322.3 (Plastic and Oral Surgery Units) (V).
(51 ) Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1100.
