Orthopedic Surgery and Rehabilitation
Rex L. Diveley, M.D., and Mather Cleveland, M.D., Sc.D.
ORTHOPEDIC SURGERY, AUGUST 1942-MAY 1944
Maj. (later Col.) Rex L. Diveley, MC (fig. 158), was offered and acceptedthe position of Senior Consultant in Orthopedic Surgery, ETOUSA (EuropeanTheater of Operations, U.S. Army), on 4 July 1942. He reported to the Office ofThe Surgeon General, Washington, D.C., on 24 July 1942, where he wasindoctrinated for the oversea mission. On3 August, he was promoted to the rank of lieutenant colonel, and, on 12 August 1942,he received orders to proceed overseas. Colonel Diveley arrived atHeadquarters, ETOUSA, on 26 August 1942, where he reported to Col. (laterMaj. Gen.) Paul R. Hawley, MC, Chief Surgeon, ETOUSA.
Early Observations and Recommendations
The Professional Services Division in the Office of the Chief Surgeon washeaded by a Director of Professional Services who supervised the professionalactivities of the Medical Department in the European theater and coordinatedthe work of consultants and specialists. There was a Chief Consultant in Surgeryand a Chief Consultant in Medicine immediately subordinate to the Director ofProfessional Services. The senior consultant of each surgical specialty was, inturn, accountable to the Chief Consultant in Surgery.
As Senior Consultant in Orthopedic Surgery, the author's mission was toorganize and supervise the conduct of orthopedic services and activities in thetheater.
In September 1942, there were very few U.S.Army hospitals in the theater.Therefore, the first task was to ascertain the experiences of the British andCanadian Allies, as their organizations had been functioning many months. Thisconsultant immediately contacted Brigadier Rowley W. Bristow, orthopedicconsultant to the British Army; Mr. Reginald Watson-Jones, honorary orthopedicconsultant to the RAF (Royal Air Force); Group Captain (later Air Commodore)Osmond Clark, orthopedic consultant to the RAF; Mr. H. A. T. Fairbank and Prof. Harry Platt, orthopedic consultants to EMS(Emergency Medical Service) hospitals; Mr. G. R. Girdlestone, orthopedicconsultant to the Ministry of Pensions; and Prof. T. P. McMurray and Mr.
1For detailed discussions of the administrative andclinical policies and practices in orthopedic surgery in the European theaterduring World War II, see: Medical Department, United States Army. Surgery inWorld War II. Orthopedic Surgery in the European Theater of Operations.Washington: U.S. Government Printing Office, 1956.
S. L. Higgs, regional orthopedic consultants to EMShospitals. The EMS hospitals, while civilian institutions, were receiving andtreating service cases in the various outlying sections of England.
The medical sections of the various headquarters of theAllied forces in the theater were visited, to include headquarters of the RAF,the British Army, and the Canadian Army. All of these offices were in London.
The principal British and Canadian hospitals andrehabilitation depots were visited, and several of the larger EMS hospitalswhich were receiving service cases were surveyed and studied. This consultantwas very much impressed with the type of orthopedic work being accomplished inthe British Army, Canadian, and RAF hospitals. These units had had several yearsof experience, and this study gave the Americans a basis for theorganization of the U.S. Army orthopedic services.
At this time (October 1942), there were some 10 or 12 U.S.hospitals, and all of these units were inspected as to supplies, personnel, andtype of work being accomplished. The medical and surgical supply situation wasquite acute, and there was an alarming shortage of materials and surgicalsupplies available to the U.S. Forces. To investigate further the supplysituation, the author visited the British medical supply depot at Ludgershall,the U.S. Army medical supply depot at Thatcham, and various medical and surgicalsupply houses in London.
As a result of the observations made and the informationgained from these tours and a general survey of the theater, the authorrecommended to the Chief Surgeon that:
1. The medical and surgical supply situation in this theaterbeing inadequate, the quantity of supplies should be increased, and a moreefficient supply service should be rendered to the various hospital units.
2. Photographic records should be made and retained in eachmajor hospital in the theater. A photographic department should be establishedin the Office of the Chief Surgeon for the making and filing of medicalpictorial records and for the production of motion-picture training films.
3. If hospital records and/or X-ray films were to be retainedas permanent records, they should be preserved and stored by mass photography(microfilming). This would give a permanent record and conserve storage space.
4. An intensive program of military orthopedic trainingshould be instituted and given to surgeons in the European theater, especiallyto those in station hospitals. This training should stress the techniques ofimmobilization and transportation of fractures in the forward areas as well asthe definitive treatment at the base areas.
5. A rehabilitation depot should be established in thetheater to care for the convalescent patient and to recondition theunderdeveloped soldier who had broken in training.
6. Certain specialized bone and joint injuries and conditionsshould only be operated upon by the orthopedic surgeon or the especially trainedtraumatic surgeon.
7. More study and care should be given the problem of footand march injuries in combat troops undergoing training. This supervised carewould save many man-days lost to divisions in training.
This consultant spent the remaining few months of 1942attempting to implement the foregoing recommendations. First, he immediatelycontacted British military and private surgical supply sources and was able toobtain a limited quantity of instruments and supplies which would suffice theU.S. Army until standard U.S. Army types could be obtained from the UnitedStates or be manufactured in the United Kingdom. The author contacted the SignalCorps for the procurement of photographic supplies, but this branch was unableto furnish supplies or personnel to the Office of the Chief Surgeon or to thehospital units. Therefore, through Kodak, Ltd., Harrow on the Hill, thisconsultant was able to procure sufficient photographic materials to activate acentral laboratory in the Office of the Chief Surgeon and to equip photographiclaboratories in six general hospitals. To train personnel, Kodak, Ltd.,established a medical photographic school in London. Medical Departmentpersonnel were trained at this school and then assigned to the centralphotographic laboratory or to the general hospitals.
No equipment was available in the United Kingdom suitable forphotographing records. Conferences were held with Kodak, Ltd., and, through itsresearch department, the company developed a photographic apparatus which wouldphotograph transparencies (such as X-ray film), hospital records, and charts aslarge as 14 by 17 inches. Records were photographed on 35-mm. film and could beviewed on a Recordak film reader and be reproduced to any size by photographicenlargement. This machine, after perfection, was turned over to the MedicalRecords Division in the Office of the Chief Surgeon.
The author presented orthopedic lectures and demonstrationsin the major hospitals and to medical personnel in the smaller units and thecombat divisions.
In November 1942, approval was received to train personnel inrehabilitation. Negotiations were started to establish a rehabilitation depot.This rehabilitation program as planned was to (1) provide care for theconvalescent,
FIGURE 159.-Left to right, Brigadier L. E. J. Whitby, RAMC, Brigadier Rowley W. Bristow, and Maj. Gen. D. C. Monro, Consulting Surgeon, RAMC, at a reception given by Maj. Gen. Paul R. Hawley and consultants, Cheltenham, England, 30 April 1943.
sick, or wounded personnel to reduce their period of hospitalization and return them to their units in afit condition for regular duty and (2) redevelop personnel who had broken down in training, in order that they mightbe salvaged for full duty. (Furtherdetails concerning the rehabilitation program are presented later in thischapter.)
A study of march injuries and foot conditions was made inthe 29th Infantry Division. It was found that 5 percent of a company would fallout when a forced march exceeded 15 miles. It was noted also that about 1percent of the foot troops sent overseas would need reclassification, that 2percent of the troops in the 29th Division needed special training to overcomeabnormalities of the feet and legs, and that an additional 10 percent woulddefinitely benefit by such treatment. After this study, certain troop-trainingregulations were altered which very materially cut downon the number of troops lost to theDivision by training injuries. Also, several bulletins of instruction on thecare of the feet were issued and distributed to line officers and troops.
Activities in 1943
In the early part of 1943, this consultant worked veryclosely with Brigadier Bristow (fig. 159), orthopedic consultant to the BritishForces, and correlated U.S. and British teaching programs and the handling of the sick and
wounded in the two armies. This was accomplished both byconferences and by touring and inspecting line and hospital units in both theU.S. and the British Forces. In the latter part of January, Brigadier Bristowtoured the United States, giving lectures on the operations of the Alliedarmies overseas with special reference to their orthopedic services.
Maj. (later Lt. Col.) William J. Stewart, MC (fig. 160),joined the Senior Consultant in Orthopedic Surgery as Associate Consultant inOrthopedic Surgery. Major Stewartspent most of his time giving lectures and demonstrations on orthopedic surgery tovarious activeand staging hospitals. Four regional consultants in orthopedic surgery had alsobeen appointed. These consultants handledorthopedic problems in their particular locality.
In order to demonstrate and teach plasterof paris technique to the medical officersof the command and especiallyto those in combat units, schools were established in keypositions throughout the theater. Medical officers and their corpsmen wereordered to these schools for a 3-day coursein the handling and application of plaster of paris,splints, and casts for the immobilization of fractures and extensive woundsprior to transportation.
In the latter part of February1943, the author was ordered on temporary dutyto the North African theater toinspect hospitals and line units there and to studymethods being used in the transportation and treatment of orthopedic casualties(fig. 161). This consultant returned to the European theater in thelatter part of March 1943. During this trip, he obtained much informationfor the Chief Surgeon, ETOUSA,relative to medical supplies, field medical service, casualties, and variousaspects of professional services. For orthopedic surgery, theauthor obtained considerable information of value relative to the trainingand instruction of European theatermedical personnel in the transportation of fractures,plaster of paris technique in forward units, first aid treatment in the forwardareas-especially in the handling offractures, and initial orthopedic surgery in theforward areas.
FIGURE 161.-Surgery in the North African theater approximately at the time of Colonel Diveley's visit. A. An orthopedic ward in the 38th General Hospital, Heliopolis, Egypt. B. A mobile surgical truck and tentage permitting the simultaneous operation of three surgical teams.
As this consultant toured the entire North African theater, aphotographic unit from the Signal Corps traveled with him and was most helpfulin obtaining thousands of feet of motion picture films. The footage wasassembled into a tour report which was shown to the Chief Surgeon's staff andto various units in the European theater upon the author's return.
Much time was spent at theQueen Elizabeth Hospital and the British Amputation Center at Roehampton,England, in correlating the fitting of artificial prostheses to U.S. personneland in making motion pictures for training films on amputation technique.Eventually, the following training films were produced in colorand with sound track:
"Rehabilitation," which provided a completedescription of the program of rehabilitation and reconditioning in the theater;
"Forward Plaster Technique," which was made and usedin collaboration with the British and Canadian orthopedic services anddemonstrated the transportation plaster of paris technique then in use in theforward areas;
"Medical Service in the Air Force," which showedmedical activities in the Eighth Air Force;
"Amputation Technique," which demonstrated thetechnique of the emergency amputation and the manufacture and fitting of aprosthesis for a below-knee amputation;and
"Medical Service in the North African Theater,"which depicted the medical services in the various echelons of the MedicalDepartment in the North African theater.
The Eighth Air Force was especially active with its daily bombing runs, andmost of the American casualties inthe European theater during 1943 originated asa result of air combat.Therefore, this author spent increased amounts of time with the Eighth Air Force units.Practical demonstrations and lectures were given inthe handling of fractures, gunshot, and fragment wounds, and especially in the transportation of casualtiesfrom aircraft to the airfield first aid station andthence to the hospital for definitive treatment.
The Senior Consultant in OrthopedicSurgery and his associates spent considerable time in the investigation of thepossible use of resins and plastics in thetreatment of fractures. After considerable research, it was believed that therewere neither time nor facilities in theEuropean theater even for carrying outa preliminary investigation. It was considered, however, that the use of plasticsplints for external as well as internal fixation was a most important subjectand should be studied at somefuture time.
The European theater Medical Field Service School atShrivenham was activated and the Senior Consultant in OrthopedicSurgery was responsible for several lectures and demonstrations each week, especiallyinthe use of splints and dressings in thefield.
This consultant was appointed amember of the EMS consultant group on orthopedicsurgery of the British Ministry of Health. Since the EMS hospitals cared forservice personnel locally, this gave the author an excellent opportunity to workout a close liaison for the handling and exchange of U.S. sick-and-woundedpersonnel. Monthly meetings of the consultant group were held in London.
There was some difference of opinion between general and orthopedic surgeons as towho should handlecertain bone and joint conditions and fractures.General Hawley issued orders that these bone and joint conditions and allfractures would be handled by the orthopedic surgeon when available.
The orthopedic surgeons in U.S. Army hospitals had been organized, and plans were made formonthly meetings. The first meeting of the command's orthopedic surgeons was held at the 2d General Hospitalnear Oxford on 27 April 1943. Brigadier Bristow and Mr.Girdlestone were the guest lecturers on orthopedic subjects. The Inter-AlliedConferences on War Medicine, held monthly under theauspices of the Royal Society of Medicine, gave an opportunityfor the interchange of ideasamong the medical members of the Allied forces in theUnited Kingdom.
The author worked closely with Col. Lloyd J. Thompson, MC, Senior Consultant inNeuropsychiatry, tocorrelate the rehabilitation program which had been activated for convalescentneuropsychiatric patients.
General Hawley appointed a committee of threetheater consultants to inspect each new hospitalunit as it arrived in the theater.After a thorough study, this committee was to report to the Chief Surgeon anydeficiencies in supplies or personnel and to outline a course of indoctrinationfor the unit in the theater.
On 23 and 24 July 1943, a combined conference of orthopedic specialists ofthe British Military Forces, theBritish Ministry of Health, and the U.S. Forces was heldin London. Two of the previously mentioned motion picture training films,"Medical Service in the North African Theater" and "ForwardPlaster Technique," were shown. These films were then made available to theBritish Forces for showing andinstruction.
The American Medical Society, ETOUSA, held its first meeting on 23 June. Themajority of papers and addresses were given by the orthopedic personnelof thetheater.
The author returned to the Zone of Interior for a period of temporary dutyextending from 20 September 1943 to 1 January 1944. Major Stewart assumed theduties of Senior Consultant in Orthopedic Surgery duringthe author's absence. Duringthis temporary duty, this consultant presentedmany lectures and the European theater motion picturetraining films throughout most of the United States. Hevisited a majority of the rehabilitation centers in theZone of Interior. At the request of The Surgeon General, the author helped toactivate and equip a model rehabilitation center at England General Hospital, Atlantic City, N.J.
In October, during this consultant's sojourn in the United States, anorthopedic shoe repair program was instituted at the DisciplinaryTraining Center No. 2912, SheptonMallet, Somersetshire. At this institution, correctiveshoe repairing services could be provided. This program notonly gave service to the Medical Department but was very valuable in therehabilitation of the inmates of the disciplinary trainingcenter.
Activities Early in 1944
In 1944, after he returned to the European theater, the author placed greatstress on the rehabilitation program and devotedmuch time to future planning forexpansion of the program.
In February, this consultant wasappointed Director of Rehabilitation in addition to his other duties.Therefore, a request was made for Lt. Col. (later Col.) Mather Cleveland, MC, tocome to the European theater and assume the duties of Senior Consultant in Orthopedic Surgery.
Much pressure was being exerted on General Hawley by Lt. Gen. JohnC. H. Lee, Commanding General, SOS in The British Isles,to use osteopaths in the MedicalDepartment. General Lee asked that they be commissioned in the Sanitary or MedicalAdministrative Corps and be usedin the Medical Department,especially in rehabilitation activities. General Lee heldthe opinion that the osteopath could treat the back case better and moreefficiently than could the orthopedic surgeons. General Hawley suggested aplan of assigning a group ofosteopaths to the rehabilitation center at Stoneleighwhere an osteopathic manipulative department wasactivated. As the cases wereadmitted to this unitcomplaining of low-back pain and disability, theywere assigned for treatmentalternately, one to the manipulative department andone to the orthopedic section. General Lee also required the assignment
of orthopedic surgeons who were staying in the theaterand were not busy to observe this test of talent in the treatment of low-backpain and disability. After several months of competitive treatment, theosteopathic department was discontinued in complete vindication of the MedicalDepartment's treatment.
During the spring months of 1944, the author continued with his routineduties as Senior Consultant in Orthopedic Surgery (fig. 162). Finally, in May1944, Colonel Cleveland arrived to relieve Colonel Diveley as orthopedicconsultant. Thence, Colonel Diveley's entire time could be devoted torehabilitation activities (pp. 477-501).
REX L. DIVELEY, M.D.
ORTHOPEDIC SURGERY, MAY 1944-JULY 1945Chronology
As Senior Consultant in Orthopedic Surgery for the European theater, Col.Mather Cleveland, MC (fig. 163), arrived 20 days before D-day and was completelyunfamiliar with the hospitals and orthopedic personnel of the theater. During aperiod of initiation from 20 May to 6 June 1944, he visited 42 of the hospitalsin the United Kingdom in the company of Lt. Col. William J. Stewart, MC. ColonelStewart was thoroughly familiar with all hospitals and orthopedic surgeonsassigned to the theater, having served under Col. Rex L. Diveley,MC, for considerably over a year. His evaluation of the orthopedic officers andorthopedic sections of hospitals was accurate and stood up well. During thispre-D-day period, everybody was tenselyawaiting the invasion of the Continent. Most of the orthopedic sections of thehospitals visited had a very low patient census in anticipation of battlecasualties due to arrive.
With the invasion on 6 June, the author was assigned to consult at the 38thand 110th Station Hospitals and the 48th and 95th General Hospitals in theSouthampton area. These hospitals were serving on a so-called transit basis-really as near-shore evacuation hospitals whose function was to performessentialemergency surgery and then evacuate the casualties byhospital train to the general hospitals to the north. For the most part, thesehospitals received their first casualties on 8 or 9 June, gradually and insmall numbers. The 110th Station Hospital, however, did an excellent job inreceiving and sorting 1,000battle casualties in 20 hours. By 12 June, the transit hospitals were busy andthe chain of evacuation was filled withcasualties. There were many blast injuries due to explosion of mines at sea.These casualties had profound vascular damage, with fractures or dislocations ofthe knee, and the like, and amputation was usually necessary.
The author's duties next led him to the Normandy beachhead in July at thetime of the Saint-L? breakout. At the time of this visit, the necessity for
increased supplies of whole blood was obvious. Plasma wasnot an effective substitute. Soon thereafter, at the urgent request of theChief Surgeon, whole blood began to arrive from the Zone of Interior.
This consultant then devoted much of his time to acontinuous round of visits to the various medical activities of the theater,232 altogether in the 6 months following D-day. General, station, evacuation,and field hospitals and three army headquarters were visited, consultationswere held, and reports on the visits were rendered to the Chief Surgeon. Inthe following 5 months, the author made 107 hospital visits and visitedthree army headquarters as well. During the 11 months that active hostilities lasted on the Continent, approximately 340visits were made to various medical activities by the Senior Consultant inOrthopedic Surgery.
Professional Care of Wounded
During the 6-month period after the invasion, the chief preoccupation was on setting and maintaining an optimum standard of professional care for the constant and heavy stream of battle casualties that flowed from the main line
of resistance back through the field and evacuation hospitals to the general hospitals (fig. 164). While the Manual ofTherapy for the European theater, published on 5 May 1944, dealt with the treatment of bone and joint casualties ingeneral terms along fundamental lines, it soon became apparent that more specific instructions were necessary. These instructions, based on experience gained by consultants and surgeons who were caring for the wounded, were formulated in Circular Letters No. 101 (dated 30 July 1944) and No. 131 (dated 8 November 1944) issued by the Chief Surgeon, ETOUSA. Theseinstructions dealt with circular amputation, debridement of the wound, immobilization of fractures for transportation, treatment ofwounds over bones and joints in general hospitals, delayed primary closure ofwounds over compound fractures (then called secondary closure), and injuries ofthe hands. The instructions in the circular letters were very specific and, in general, were strictly adhered to. By this means, the function of eachhospital in the chain of evacuation was defined and thereby each medical echelon knew whattreatment it was expected to perform, what had been done forward, and whatwould be done in the rear.2
The hand wounds were under the care of orthopedic and plastic surgeons. Hand centers wereestablished both on the Continent and in the United Kingdom Base. Outstanding salvage work wasperformed in many of these centers.
2See footnote 1, p. 459.
Problems arising from combined neurosurgical and bone and joint injuries were resolved by theSenior Consultant in Neurosurgery and the Senior Consultant in Orthopedic Surgery.Such casualties were treatedat neurosurgical centers. These two activities have been described elsewherein this history.3
Delayed closure of wounds over compound fractures - Delayedclosureof wounds over compound fractures was the most important single accomplishmentin the care of bone and joint casualties. Some of the older surgeons were atfirst reluctant to try delayed closure, but younger surgeons readily acquiescedin the attempt. Successful delayed primary closure ingeneral hospitals depended on complete or adequate debridement performed inevacuation hospitals. The failures, with breakdownof the wounds and resulting bone infection, couldbe traced to early technical failure or delay, sometimes unavoidable, in the debridement. This delayed primary or immediateprimary closure of wounds over fractures wasnot new. It had been done in World War I, in small numbers to be sure,but it had been forgotten or ignored. The effort to reestablish the idea ofclosure of wounds over compound fractures reemphasized the saying: "Theywho forget the past are condemned to repeat it."
3See footnote 1, p. 459.
Orthopedic Surgeons in the European Theater
The European theater, at the close of hostilities, had atotal of 281 hospitals of which 146 were general hospitals. Among these generalhospitals, only slightly over 10 percent were affiliated units. These affiliatedhospitals arrived very adequately staffed with actually an overabundance oftrained personnel. The orthopedic sections of these affiliated hospitals whicharrived in 1942 and 1943 were plundered to obtain chiefs of orthopedic sectionsfor other hospitals arriving later with no trained orthopedic personnel.
By the end of 1944 and early 1945, general hospitals werereaching the theater "staffed with bodies," as the saying was, butwith little or no trained personnel. The problem of finding chiefs fororthopedic sections (and other chiefs also) became almost impossible to solve(fig. 165).
Of the 16,000 civilian doctors of medicine who served inuniform in the European theater, there were only 63 diplomates of the AmericanBoard of Orthopaedic Surgery. In addition to these, there were 95 partiallytrained orthopedic surgeons and 85 young general surgeons with training in thehandling of fractures. This hard core of about 240 medical officers was responsible for the professional care of approximately250,000 bone-and-joint casualties and injuries among U.S. Army troops and, inaddition, of many thousands of prisoners of war.
The tables of organization of the various hospitals in the theater calledfor a total of almost 450 trained orthopedic specialists, Military OccupationalSpecialty 3153, B or C rating or better. There were only 217 medical officerswho could possibly be considered as possessing these skills. The properutilization of available orthopedic surgeons was, and in the future will be, amatter of great moment, since at least 40 or 45 percent of battle casualties andinjuries will invariably involve bones and joints.
It was the author's considered opinion that each field army should havehad as consultant a highly trained orthopedic surgeon with the rank ofcolonel. Such a consultant could have supervised and trained younger surgeonsin evacuation or other army hospitals where the bone and joint casualties werereceived for debridement and applications of proper splints for evacuation tohospitals in the communications zone. The general hospitals needed oneor, if available, two orthopedic surgeons to treat compound or simple fracturesand amputations and to handle other bone and joint problems that were received.Large station hospitals, if serving large bodies of troops in training or ifacting as general hospitals, alsoneeded a trained orthopedic surgeon.
There will never be an oversupply of these officers in theevent of another great national emergency, and thereforecareful planning will be required to see that all are effectively used.
Proper Utilization of Experienced General Hospitals
The utilization and proper location of experienced, affiliated hospitals was of theutmostimportance. At the time of the invasion, most of the affiliated generalhospitals in the European theater during World War II (12 to 14 in number) hadbeen in the theater for from a year to 18 months. They were given priority formovement to the Continent. This was a reward for service, but unfortunately it meant that during the first 6 or 8 weeks after D-day,the "first team" was sittingon the bench. That is, they were staging, crossing the Channel, and in theprocess of being set up. A good many of the personnel of these hospitals wereused on temporary duty to augment other hospitals, to be sure, but the smoothoperation of well-established hospitals was missing. Atthe beginning, most of these hospitals were first set up on the beachland and later moved to other parts ofFrance or Belgium (fig. 166). In planning their secondmoves, it would have been ideal if they could have been dispersed in such a way as to serve as parent hospitals for the hospital centers and base sections laterestablished on the Continent. At times, two ormore of these affiliated general hospitals were assigned to a single center and,at the close of hostilities, there were two hospital centers at Reims withsome 17 new and inexperienced general hospitalsand with no older experienced hospital within call. These older affiliatedgeneral hospitals furnished the junior consultants in all branches of medicine and surgery.
It was impossible for a single senior orthopedic consultant, in spite of his making more than 30 visits a month to various medical installations and traveling thousands of miles, to cover the theater adequately. The young surgeons needed professional advice and supervision, in many instances, at frequent intervals.
In late November or December 1944, seven junior (regional)consultants in orthopedic surgery were appointed in the United Kingdom Base-eachto cover one of the seven hospital centers in addition to their duties as chiefs of orthopedic sections attheir own general hospitals. Most of thesejunior consultants performed very valuable service in helping their colleaguesto maintain a high standard of professional care for the wounded and injuredsoldiers. At that time, and in fact during mostof the campaign on the Continent, those with fractures of the long boneswere all evacuated to the United Kingdom, where the holding period beforeevacuation to the Zone of Interior was 120 days.
Most general hospitals on theContinent were serving on a transit basis, with a holdingperiod of only 30 days. During a good part of the winterof
1944-45, many of the continental general hospitals were moving from a first to a second location(fig. 167); consequently, junior consultants in orthopedic surgeryon the Continent were not appointed until the spring of1945, when nine such appointments were made. The cessation of hostilities supervened soshortly thereafter that only a littleover half of these appointees actually served effectively. If thesecontinental junior consultants could have been appointed earlier,they would have helped materially in enhancing and standardizing the careof the wounded with bone and joint problems.
The reports of the junior consultants had to travel a longroad through channels before a few of them eventually reached ColonelCleveland. Some of these reports never arrived. The junior and seniorconsultants should have ready access to each other.
The Senior Consultant in Orthopedic Surgery held twomeetings in London with the United Kingdom junior consultants in December of1944 and June of 1945. The continentaljunior consultants met with him in Paris in June 1945. Outof these conferences came the revision of theorthopedic portion of the Manual of Therapy.4
4See footnote 1, p. 459.
Rank for Orthopedic Surgeons
For the responsibility which the orthopedic surgeon carried, there was no provision made for commensurate rank. There was actually no provision in thetables of organization for theater consultants, and any promotion to the gradeof colonel had to be borrowed from some new hospital or hospital center thatentered the theater with vacancies in these higher grades.
There were approximately 12 outstanding orthopedic surgeons who had servedas many as 3 years in the grade ofmajor in various general hospitals of the theater. It was the firm conviction of the Senior Consultant inOrthopedic Surgery that eachof these officers should have been promoted to the grade of lieutenant colonel,and such recommendations were made. Of the 12 orthopedic surgeons recommendedfor such promotion, only one reached that grade while in the Europeantheater.
It was difficult to explain to an orthopedicsurgeon why the dental officer, the roentgenologist, the psychiatrist, the chief of laboratory,the chief nurse, and so on, in a1,000-bed general hospital should, by table of organization, be advanced to the grade of lieutenant colonel,while the orthopedic surgeon, who was responsible for the professional care of 40or 45 percent of the wounded, could not advance beyond amajority. Such discrepancies should be remedied so that responsible andoutstanding officers can be givenrank commensurate with services rendered.
Meetings of Senior Consultants
The position of senior consultant in the European theater carried great responsibility and afforded endless possibilities for improving the professional care of the sick and wounded and maintaining a high level of such care.
When possible, the senior consultants met weekly at headquarters inCheltenham, London, Valognes, and Paris as the Office of the Chief Surgeon moved forward, and once a month the Chief Surgeon met with his consultants. The most inspiring meetings to this consultant were the informal weeklygatherings presided over by Col. (later Brig. Gen.) Elliott C. Cutler, MC. These were high level discussions of all prevailing problems, in which suggestions were freely offered and were usually well received by all 12 or 13 surgical specialists present.
During active hostilities, two meetings were held with British and Canadian consultants and one with all the Allied consultants. With the exception of the polylingual meeting with translations into and out of French and Russian, which instantaneous translation would have helped, these meetings were extremely helpful.
The Chief Surgeon supported the consultants to the hilt if he thought they were correct and did not hesitate to correct or reprimand them if they were wrong. The writer will always consider it a great privilege to have served with the senior consultants in the European theater during World War II.
MATHER CLEVELAND, M.D.
Activities Centered in the United Kingdom, 1942-44
Soon after arriving in England in August 1942, Lt. Col. (later Col.) Rex. L. Diveley surveyed all U.S. Army Hospitals that were then functioning. During this survey, he observed that a significant percentage of military personnel was being readmitted to hospitals because the men were unable to carry on the physical rigors of their former duties. An examination of a sampling of these patients revealed that their prolonged stay in hospitals had definitely deteriorated them mentally as well as physically. No attempt was being made to bring these hospitalized personnel to their former physical capacity before discharge from the hospital. The result was a great loss of man-days to the Army.
Colonel Diveley immediately undertook to ascertain how theBritish services had solved this problem. It was found that the RAF, theBritish Army, and the Royal Navy had established special convalescent depots towhich convalescent, sick-and-wounded personnel, after hospitalization, werebeing sent for rehabilitation or reconditioning. In these depots, a completeand comprehensive program of exercises wasgiven to restore these men to their former physical capacity.
In the fall of 1942, Colonel Diveley outlined for the Chief Surgeon a plan for theestablishment of a convalescent rehabilitation center in the European theater. He proposed the establishmentof a center where sick or wounded military personnel could be sent as soon asthey became convalescent and no longer needed activesurgical and medical attention in a hospital. At these centers, he suggested a complete and supervisedphysical, educational, military, and recreational program which could be given to restorepatients to theirformer physical and mental capacity.
This plan, in general, was approved by the Chief Surgeon.He issued orders to select a site, to prepare a provisional T/O&E (tableof organization and equipment), and to train personnel who would be required to operatesuch a convalescent center.
Rehabilitation and reconditioning facilities
Rehabilitation Center No. l - After the author hadinspected several available sites, the All-SaintsHospital, Bromsgrove, Worcestershire, was selected and procured. A provisionalT/O&E was prepared by the Operations Division, Office of the ChiefSurgeon, based upon the personnel and equipment of a 150-bed station hospital.Five officers and six enlisted men with proper qualifications were trained atthe British 102d Convalescent Depot at Kingston and the British Army Schoolof Physical Training at Aldershot. On 7 April 1943, the l6th StationHospital, augmented by specially trained personnel, opened Rehabilitation CenterNo. 1 in the All-Saints Hospital. The essential staff consisted of Maj. (laterLt. Col.) Clayton H. Hixson, MC, Commanding
Officer; Captain Gullingrud, Executive Officer; Maj. (laterCol.) Frank E. Stinchfield, MC (fig. 168), Chief ofProfessional Services; Capt. (later Lt. Col.) Marcus J. Stewart, MC (fig.169), orthopedic service; 2d Lt. (later Capt.) Gerald F. Seeders, Inf.,Director of Physical Training; and 2d Lt. Paul E. Hall, MAC, Director ofMilitary Training. Under the efficient professional guidance of MajorStinchfield, a well-balanced physical and military program was developed (fig.170). Patients were admitted from station and general hospitals as soon as theybecame convalescent, were able to be up and around, and could care for their owntoilet. Although the hospital load of the theater was very light, the census ofthe center had rapidly increased to 431 by 1 September 1943.
It soon became evident that the facilities at Bromsgrove and the staff of the 150-bed station hospital were insufficient to handle the anticipated convalescent patient load of the theater. Consequently, a general hospital site at Stoneleigh Park, near Kenilworth, Warwickshire, was secured, and the 8th Convalescent Hospital replaced the 16th Station Hospital as the operating unit of Rehabilitation Center No. 1. Key personnel of the 16th Station Hospital were transferred to and retained in the 8th Convalescent Hospital, which opened the center at Stoneleigh on 5 October 1943. Major Stinchfield assumed command of the center at the new location.
By December 1943, the census of trainees at the rehabilitation center had reached 1,300 (fig. 171). At this time, it was necessary to release the 8th Convalescent Hospital for assignment to a field army. This unit was replaced by the 307th Station Hospital (750 beds). Key personnel of the 8th Convalescent Hospital were retained for assignment to the 307th Station Hospital, and Major Stinchfield continued in command. This exchange of units was con-
summated on 5 December 1943. In January 1944, thecensus at Rehabilitation CenterNo. 1 showed over 1,700 officers and enlisted trainees.
By the time D-day, 6 June 1944, arrived, the patient loadat Rehabilitation Center No. 1 had increased tremendously and, with theassault on the Continent, further expansion of its facilities became extremelynecessary. After many unsuccessful attempts to obtain the Irish LaborCamp (Ministry of Works), adjoining the center, the Camp was made available on19 June 1944. This allowed for an expansion of 700 patients and increasedthe overall capacity at Rehabilitation Center No. 1 to approximately 3,700 (fig.172).
Rehabilitation Center No. 2 (Officers) - Early duringthe operation of Rehabilitation Center No. 1, it became evident thatofficers and enlisted men should be segregated when undergoing a program ofconvalescent rehabilitation. Accordingly, a rehabilitation center for officers,Rehabilitation Center No. 2, was activated at All-Saints Hospital, the originalsite of Rehabilitation Center No. 1. A detachment of trained personnel fromthe 307th Station Hospital was assigned to operate this facility by working withmembers of the 1st Auxiliary Surgical Group, which was now temporarilyquartered at Bromsgrove. Later, when the 77th Station Hospital had been madeavailable for the rehabilitation program, Detachment B of this hospitalrelieved the detachment of personnel from the 307th Station Hospital in theoperation of Rehabilitation Center No. 2. This change took place on 23February 1944. Still later, the 123d Station Hospital was assigned the missionof operating the rehabilitation center for officers.
Reconditioning Center No. 1.-As the patient load of thetheater continued to increase, and additional centers became necessary,experiences indicated that certain convalescent patients needed only generalexercises or body hardening to bring them to their former physical capacity(reconditioning), as contrasted to others who required certain specificremedial exercises in addi-
tion to general body hardening (rehabilitation).Accordingly, an additional unit was requisitioned to establish areconditioning center. A general hospital site was secured at Erlestoke Park,near Devizes, Wiltshire. This site had accommodations for about 1,500convalescent patient-trainees. The 77th Station Hospital (750 beds) wasdesignated the operating unit for this new center. The staff of the 77thStation Hospital was ordered to Rehabilitation Center No. 1 (307th StationHospital) for indoctrination and orientation. Since the entire unit would notbe required to operate Reconditioning Center No. 1, a detachment of the 77thStation Hospital, as mentioned earlier, was ordered to operate RehabilitationCenter No. 2 for officers. The remaining unit personnel of the 77th StationHospital, having completed their training and indoctrination at RehabilitationCenter No. 1, moved to Erlestoke Park, and during March 1944 began to operateReconditioning Center No. 1.
The facilities of Reconditioning Center No. 1 at ErlestokePark, however, were limited, and this plant was needed for a general hospital.It was necessary to procure an additional site. A military campsite was securedat Packington Park, near Coventry. The advance party of the 77th StationHospital moved into this site on 5 July.
At the request of the British War Office, arrangements weremade for an interchange of convalescent soldiers undergoing rehabilitation. The purpose of thisexchange was to further Anglo-American relationships. The interchange was startedduring the first week in June 1944, and a partyof British convalescent patients was continuallymaintained at Reconditioning Center No. 1 throughout the year, except duringthe change in location of the center.
Rehabilitation Center No. 3 - With the increase of thepatient census following D-day, it became apparent that an additional numberof rehabilitation beds would be needed. The 313th Station Hospital wasselected for conversion into a 3,000-bed rehabilitation center. This unit wasoperating a station hospital at Fremington, Devonshire. The site was notsuitable for a 3,000-bed center as its capacity was limited to about 2,000patients. It was decided, however, to use this plant temporarily. The staffwas indoctrinated at Rehabilitation Center No. 1, and, on 20 July 1944, thisunit started to receive patients for rehabilitation. Physical traininginstructors, as well as military and physical training officers, were assignedto augment the regular staff.
Not long after activation of Rehabilitation Center No. 3, asuitable site was obtained at Warminster Barracks, Warminster, Wiltshire. Afterappropriate adaptation of the site, Rehabilitation Center No. 3 was moved toWarminster and began operations there on 21 December 1944.
Rehabilitation Center No. 4 - By the latter part of August 1944,the facilities of the three rehabilitation centers and the Reconditioning Center were aboutfilled, and a unit and a site for an additional center were requested. The 314th Station Hospital was committed tothe mission. The staff, then operating a tented hospital at Truro, Devonshire, was ordered toRehabilitation Center No. 1 for indoctrination. A site was selectedat Honiton-Heathfield which would accommodate some 2,300 trainees and which, withtented expansion, could handle a total of 3,000patients. On 13 September 1944, the unit was activated asRehabilitation Center No. 4 and began to receive convalescentpatients.
Conversion to convalescent centers - As thefirst rehabilitation and reconditioning centers began operations, it was veryapparent that the standard T/O&E for a 750-bed station hospital did notprovide for sufficient personnel with appropriate qualifications to operate alarge rehabilitation center. General Hawley, when the difficulty was brought to hisattention, directed that the Operations Division of hisoffice make a study of the conversion of the T/O&E of a 750-bed stationhospital to that appropriate for a 3,000-bed rehabilitation center and theconversion of a 250-bed station hospital to a 1,000-bed reconditioningcenter. Colonel Diveley and Colonel Stinchfield collaborated in this study. With concurrences from theETOUSA G-1 (personnel and administration) andG-3 (operations and training), special tables of distribution and allowanceswere created for 1,000-bed reconditioning centers and 3,000-bedrehabilitation centers. These tables were sent to the War Department, which,the author learned on 23 June 1944, had approved them for publication asT/O&E's for 1,000-bed and 3,000-bed convalescent centers. Early inDecember 1944, the War Department ordered conversion of five hospitals on thetheater troop list to convalescent centers in accordance with the new T/O&E's.This was accomplished by converting four station hospitals (750 beds) to3,000-bed convalescent centers and one station hospital to a convalescent centerof 1,000 beds. The convalescent centers thus activated weredesignated as follows:
825th Convalescent Center
77th Station Hospital (Reconditioning Center No. 1)
826th Convalescent Center
307th Station Hospital (Rehabilitation Center No. 1)
827th Convalescent Center
313th Station Hospital (Rehabilitation Center No. 3)
828th Convalescent Center
314th Station Hospital (Rehabilitation Center No. 4)
833d Convalescent Camp
123d Station Hospital (Rehabilitation Center No. 2)
Convalescent hospitals on the Continent - Upon the request of the Chief Surgeon, the author proceeded to the Continent in August 1944 to survey the requirements for reconditioning and rehabilitation and to examine the conduct of the convalescent training program within such station and general hospitals as were operating. This consultant recommended that, because of the short evacuation policy in effect on the Continent, it would be impracticable to conduct a full rehabilitation program there at this time.
On 12 September 1944, upon request of the Chief Surgeon, the writer made a second trip to the Continent. He inspected the 7th and 8th Convalescent Hospitals, which were operating under the communications zone. After this visit, he recommended that additional physical- and military-training personnel be assigned for the more efficient operation of these units, if they were to continue functioning as communications zone units. This recommendation was concurred in by the Chief Surgeon. Cadres were selected from among trainees at the training school at Rehabilitation Center No. 1 and were sent to these units. This consultant followed up these actions with frequent visits to the Continent to survey and maintain contact with the 7th and 8th Convalescent Hospitals.
The 7th Convalescent Hospital was established at ?tampes and had facilitiesfor handling approximately 1,700 convalescentpatients. With the addition of military- and physical-training personnel, itestablished a commendable convalescent training program. The unit washandicapped by the added function of operating as a station hospital to carefor personnel of the 19th Reinforcement Depot, which was adjacent.
The 8th Convalescent Hospital had its initial location at Barneville, on theChannel, later moving to Valognes, near Cherbourg. The Valognes site was notideal and was capable of housing onlysome 2,000 convalescent patients. But, with the addition of a cadre of military-and physical-training personnel, this unit operated a fair convalescent training program.
Organization for supervision
Rehabilitation activities in the Office of the Chief Surgeon were begun onthe initiative of Colonel Diveley and incidental to his primary duties asSenior Consultant in Orthopedic Surgery. On 25 February 1944, Colonel Diveleywas appointed Director of Rehabilitation in addition to his other duties asSenior Consultant in Orthopedic Surgery, and MajorStewart, who had just reported to the Office of the ChiefSurgeon, was named as his assistant. As a result of aspecial conference attended by General Hawley, Colonel Eyster of the G-3Section, ETOUSA, and Colonel Diveley, it was deemed advisable to have arepresentative of the Chief Surgeon on the G-3 staff section in order tocorrelate the rehabilitation program. This was accomplished by theappointment of Maj. (later Lt. Col.) Milton S. Thompson, MC, to this duty on 15February 1944.
As the rehabilitation work in the office increased, Capt. (later Maj.) JulianA. Sterling, MC, from Rehabilitation Center No. 1, was assigned to duty as anassistant. Several clerks, artists, secretaries, and a physical traininginstructor were also added to the staff. Capt. (later Maj.) Blaise P. Salatich,MC, Medical Liaison Officer from Headquarters, U.S. Strategic Air Forces,ETOUSA, to the Rehabilitation Division, Office of the Chief Surgeon, reportedfor duty on 18 April 1944.
On 3 June 1944, by Office Order No. 32, Office of the Chief Surgeon, theRehabilitation Division was formally established as an independent division
within the Office of the Chief Surgeon. Colonel Diveley was appointed chiefof the division. The functions of the division were listed as follows:
1. To direct and conduct research in rehabilitation procedures.
2. To control rehabilitation technical operations.
3. To direct the training of personnel for implementation of therehabilitation program.
4. To formulate policies on rehabilitation.
5. To consult on matters relating to the conservation of manpower. All thesefunctions had been inaugurated during the previous 6 months by Colonel Diveley,the Director of Rehabilitation.
On 16 June 1944, a conference was held with members of the ETOUSA G-1 and G-3staffs and the Field Force Replacement System at which Col. David E. Liston, MC,Deputy Chief Surgeon, ETOUSA, clarified the obligations of the Chief Surgeon incarrying out the program of rehabilitation in the theater, as follows:
1. The Chief Surgeon would expand the convalescent training program as theneed arose and insofar as such expansion would not jeopardize availability ofbeds for hospitalization. Hospital personnel would in each instance besupplemented by branch immaterial personnel to supervise military trainingcoincident with physical reconditioning. Such personnel would not be charged tothe Medical Department.
2. The Chief Surgeon would discharge patients to the Field ForceReplacement System when conditioning had proceeded to that point where theindividual would not be physically harmed by normal physical exertion and wouldbe capable of returning to his former or new occupation after 2 or 3 weeksfurther hardening in the Field Force Replacement System.
By the latter part of June, base section surgeons had appointedrehabilitation officers to their staffs. Maj. William N. Brewer, MC, wasappointed in the Western Base Section, and 2d Lt. (later 1st Lt.) Robert S.Rice, MAC, was appointed in the Southern Base Section.
On 12 July 1944, the forward echelon of the Office of the Chief Surgeonmoved from the United Kingdom to the far shore. By decision of the ChiefSurgeon, the Rehabilitation Division remained in the United Kingdom and wasattached to the Office of the Surgeon, United Kingdom Base.
In August 1944, a request was made that a rehabilitation division be established in the Office of the Surgeon, United Kingdom Base. Major Brewer, who had previously been the rehabilitation officer for Western Base Section, was appointed chief of this subdivision of rehabilitation in the Office of the Surgeon, United Kingdom Base. He selected a staff of officers and enlisted assistants.
Later in 1944, Maj. (later Lt. Col.) Richard F. Kelsey, MC, a staff member of Rehabilitation Center No. 2, was added to the staff of the Rehabilitation Division, Office of the Chief Surgeon. Maj. H. Heim, Ord, was assigned to duty with the Rehabilitation Division, Office of the Chief Surgeon, to coordi-
nate the information and education work within theconvalescent training program.
In the latter part of December, word was received from theOffice of the Chief Surgeon, then at Paris, that the Rehabilitation Divisionwould move from its location with the Office of the Surgeon, United Kingdom Base, to Paris. Atthat time, the Rehabilitation Division, Office of the Chief Surgeon, in addition to an artist-statisticianand clerks, consisted of the following officers: Colonel Diveley, chief of theDivision; Colonel Thompson, Rehabilitation Liaison Officer from the Office ofthe Chief Surgeon to the G-3 Section, Headquarters, ETOUSA; Major Sterling,assistant chief of the Division; Major Kelsey, Consultant in Rehabilitation andHospital and Convalescent Center Inspector; Major Salatich, RehabilitationLiaison Officer from Headquarters, U.S. Strategic Air Forces, ETOUSA; and MajorHeim, Coordinator for Information and Education Activities.
Similarly, in the Office of the Surgeon, United KingdomBase, Major Brewer, was Chief, Division of Rehabilitation; Capt. Herzl M.Daskal, MC, was Hospital Inspector and Consultant in Rehabilitation; and 1st Lt.Andrew M. Gould, MAC, was Administrative Assistant.
Convalescent training program in hospitals.-With theguidanceof experience in the European theater and instructions fromthe Office of The Surgeon General in Washington, a general program ofconvalescent training and education was initiatedfor each station and general hospital in the theater (fig. 173). Much opposition was evidenced by hospital staffs tothe introduction of such aprogram. This was due for the most part to a lack of understanding on the partof professional men in the concepts of convalescent rehabilitation. The program atthe rehabilitation centers progressed mostsatisfactorily, but the program within the station and general hospitals wasvery sluggish, and little interest was evidenced. It became necessary toundertake special indoctrination and training activities to encourage moreactive convalescent training programs in hospitals (pp. 492-494).
A constant check was maintained on the convalescent programin hospital units. Two or three representatives of the Rehabilitation Divisioncontinuously inspected the programs and gave indoctrination lectures. Wardsurgeons were made aware of their responsibilities in the conservation ofmanpower through an adequate convalescent program and through the properreclassification of sick-and-wounded military personnel to duty.
Reclassification.-Considerable difficulty was evidenced inboth rehabilitation centers and hospitals in the proper reclassification ofpersonnel being returned to duty. Through the efforts of the RehabilitationDivision and the Ground Force Replacement System (formerly the Field ForceReplacement System), classification teams were selected and trained. Theseteams were placed in special hospitals, hospital centers, and rehabilitationcenters to orient personnel in the proper reclassification of sick-and-woundedpersonnel.
Rehabilitation in station hospitals acting as generalhospitals - By 1 August 1944, the general hospitalswere filled to capacity. Manyconvalescent patients in the general hospitals still needed surgical dressingsor followup medical care. These patients could not be sent to rehabilitation centers but should have beenevacuated from general hospitals to make bed space for casualtieswho required definitive medical or surgicalcare and treatment. The situationwas alleviated by the designation of certain station hospitals to act as generalhospitals in the care of the slightly wounded and those convalescent patientsstill requiring some active medical or surgical care. The RehabilitationDivision, appreciating the fact that over half of the patients inthese station hospitals would be in the convalescenttraining program, took steps to upgrade their rehabilitation programs. Specialsupplies and training aids were furnished, and special training personnel wereattached to each hospital.
Army Air Forces participation - Initially, about 10 or 15percent of the trainees in therehabilitation centers were patients from the Army Air Forces. It wasbelieved that more specialized training should be given to these trainees. Brig.Gen. (later Maj. Gen.) Malcolm C. Grow, Surgeon, Eighth Air Force, was contacted throughCol. Herbert B. Wright, MC,in regard to obtaining specialized personnel to carry on this mission. However,cooperation ofthe Air Forces at this time was very meager.
FIGURE 174.-Maj. Gen. Norman T. Kirk inspecting the 307th Station Hospital. Others pictured are, left to right, Colonel Stinchfield, Brig. Gen. Malcolm C. Grow (partially obstructed by Colonel Stinchfield), and Colonel Diveley.
In February 1944, following a special visit and inspection ofhospitals and rehabilitation centers by Maj. Gen. Norman T. Kirk, The SurgeonGeneral, Maj. Gen. David N. W. Grant, the Air Surgeon, General Hawley, andGeneral Grow (fig. 174), a coordinated program of rehabilitation training forAir Force personnel was outlined, and the Office of the Chief Surgeon, ETOUSA,was assured the cooperation of the Army Air Forces in the theater. An AirForce liaison officer to the Rehabilitation Division, Office of the ChiefSurgeon, was requested and obtained.Special surveys were made to determine needs of the program, and training aidsand equipment were supplied as required, not only to all convalescent centersbut also to the program in each station and general hospital.
General Grow, now Surgeon, U.S. Strategic Air Forces,assigned flight surgeons to duty with the six general hospitals that werecaring for most of the Air Forces personnel. These flight surgeons supervisedthe convalescent care and rehabilitation of Air Forces personnel in accordancewith directives of the Chief Surgeon. The Air Forces provided excellentcooperation in supplying personnel and training equipment for the rehabilitationprogram. Rehabilita-
tion Center No. 1 was designated as the center for Air Force enlisted men,while officers were sent to Rehabilitation Center No. 2 (fig. 175).
Amputee morale team - At the request of the Chief Surgeon, an "amputeemorale team" was organizedin the early part of November 1944 to visit allhospitals. The team demonstrated the use of prostheses and showed a motionpicture film on what could beaccomplished by a man who had lost his arms. This aided greatly in lifting themorale of those personnel who had lost a limb.
Personnel and training
Special rehabilitation and reconditioning personnel - With thesteady growth of the rehabilitation and reconditioningprograms, it was found neccessary to train a large number of officers andenlisted men to be used in the activation of other centers and to be assigned tohospitals for the convalescent training program (fig. 176). An initialallotment of 50 officers and 100 enlisted men was made available for thistraining and subsequent assignment to specialized positions. With thecontinued growth of the rehabilitation program and as requirements for trainedpersonnel became greater, the Ground Force Replacement System, ETOUSA, G-1,was asked to provide additional officers and enlisted men of either general- orlimited-assignment status for training as physical education instructors anddirectors of other
duties pertinent to the rehabilitation (convalescenttraining) program. On 6 July 1944, an additional 100 officers and 300 enlistedmen were allotted to the rehabilitation program for training purposes. Thismade a total of 150 officers and 400men available for use in the rehabilitation program.
Training and indoctrination of personnel engaged in thehospital convalescent training program - To overcome initialresistance to the hospital convalescent training program and to orient thestaffs of the various hospital units involved, indoctrination lectures weregiven, and a motion picture film on rehabilitation was shown.There was also a lack of trained personnel to implement the convalescenttraining program in hospitals. To obviate this, a special school was established at the rehabilitation center where wardmasters from variousstation and general hospitals were sent for a course of training in theconduct of a convalescent training program (fig. 177). Upon returning to their units, these trained men were able to indoctrinate the hospital staffas well as other wardmasters and enlisted personnel in the proper principlesof the convalescent training program.
Later, in order to encourage a more active hospital programseveral conferences were held with the hospital personnel. In May 1944, thecommanding officer, rehabilitation officer, and orthopedic surgeon of eachstation and general hospital were ordered to Rehabilitation Center No. 1 for an orienta-
tion conference. This meeting was addressed by GeneralHawley. Following his address,indoctrination papers on representative activities and results of rehabilitation weregiven. A model program was inspected during the afternoon.In addition to this meeting, two regional conferences were held later in themonth with rehabilitation officers from hospitals in the various base sections.
To assist in the conduct of the hospital convalescentprogram, several additional publications were issued by the RehabilitationDivision. One, titled "Bed Exercises for the Convalescent Patient,"described and illustrated many essential and valuable exercises and was used asa guide by patients and wardmasters.A second publication, in the form of a mimeographed pamphlet, described andillustrated various types of remedial apparatus that could be improvised for use bytheconvalescent patients. A third publication, in mimeographedform, listed, by subjects, the training films and filmstrips available foruse in the convalescent training program.
On 31 August 1944, a regional conference on the conduct ofthe convalescent training program was held at the 55th General Hospital and wasattendedby all rehabilitation officers of the 12th Hospital Center. On 1 September 1944, a similarmeeting and demonstration was held at the l60th General Hospitalfor rehabilitation officers of the 15th Hospital Center. On 11 October 1944, a regionalconference was held at the 160th Station Hospital forall rehabilitation officers from hospitals in theSouthern Base Section. On
12 October 1944, a conference was held at the 160th General Hospital for allrehabilitation officers from hospitals in the Western and Eastern Base Sections. The meetingswere attended also by representatives from staging hospitals. These conferencesprovided an excellent medium for interchange of ideas, indoctrination, and thedemonstration of a model convalescent training program.
Training films - During the summer of 1943, a documentary motionpicture film was produced in sound and color depicting the program andactivities of a rehabilitation center. The author took this documentary film tothe Zone of Interior, and, after a showing to The Surgeon General, and followinghis request, the film was screened for various hospital units throughout thecountry with accompanying indoctrination lectures. This tour covered a 3-monthperiod, which gave ample time for all to study the reconditioning program thathad been activated at Bromsgrove. A model convalescent rehabilitation unit,based on experiences in the European theater, was set up by this consultant atEngland General Hospital in Atlantic City, N.J.
By the end of August 1944, two additional motion picture films on activitiesof the program had been completed and distribution had been started. One, anorientation film, titled "The Convalescent Training Program," wasshown to the staffs of all hospitals. The other, titled "Physical TrainingInstructors," was used in the Physical Training Instructors' School atRehabilitation Center No. 1,for indoctrination and training.
On 24 August 1944, a group of visual aid coordinators arrived and wereimmediately oriented in the conduct of the rehabilitation program. Their missionwas to establish film libraries, to screen films, torepair projection apparatus, and to give other assistanceto the conduct of the convalescent training program throughout the theater.
Supplies and equipment
In anticipation of an expanded program in the theater, sufficient gymnasticsupplies, remedial apparatus, training films, and other training aids wererequisitioned and secured early in the program. Supplies, special equipment, andtraining aids for use in the convalescent training program in hospitals weresecured for each hospital and distributed. Also, in May 1944, througharrangements with Special Services, additional stocks of athletic, recreational,and educational equipment were set aside for requisition and use within theconvalescent training program. Through special arrangements with the ArmyPictorial Service, 16 mm. motion picture and 35 mm. filmstrip projectors wereobtained for the rehabilitation program. The Rehabilitation Division placed anddistributed the projectors. The limited supply of remedial apparatus andgymnastic equipment that had been obtained was exhausted. Requirements werecomputed for the ensuing 12 months, and sufficient apparatus was secured throughthe General Procurement Authority
from Spencer, Heath and George, Ltd., Enfield, England, to meet immediateneeds. Close liaison was maintained with the American Red Cross, which wasresponsible for many of the recreational and diversional activities. The latterorganization was most cooperative at all times and provided personnel andsupplies to the centers and hospitals unstintingly.
Maximum use was made of improvised aids to physical rehabilitation in whichboth construction (or fabrication) and use provided a means for augmentedphysical reconditioning. Such apparatus included shoulder wheels, knee pulleys,finger grips, and steps.
December 1943 - At the end of the year 1943, Rehabilitation Center No.1 had been in operation for 9 months, since April, at its two locations,Bromsgrove and Stoneleigh. During this period, there were 3,089 admissionsand 1,808 dispositions. Of the dispositions, 83 percent were discharged back toduty and 17 percent were sent back to hospitals for further treatment. Thecaseload was divided approximatelyinto: Orthopedic, 80 percent; general surgery, 10 percent; and medicine, 10percent.
On 31 December 1944, approximately 31,500 beds were available forconvalescent patients in the European theater. In addition to the 12,400 beds in theconvalescent facilities in the United Kingdom, general and stationhospitals had set aside areas for the use of 11,500 convalescent patients. Ninestation hospitals had been completely set aside to handle approximately 3,600convalescent patients. The 7th Convalescent Hospital at ?tampes, Seine BaseSection, France, and the 8th Convalescent Hospital at Valognes, Normandy BaseSection, France, were each rated at 2,000 beds for a combined total of 4,000beds on the Continent.
Convalescent trainees actually in the five centers in the United Kingdom andtwo convalescent hospitals on the Continent totaled 13,600 at the end of 1944.The total number of convalescent patients discharged from all rehabilitation andreconditioning centers in the United Kingdom from 7 April 1943 through 31December 1944 was 34,761. Of these, 88.0 percent had been returned to duty inthe European theater (chart 3). Among the aforementioned 34,761 patientsdischarged in the United Kingdom during this period, there were 14,247 battlecasualties, 82.7 percent of whom were returned to duty in the theater (chart4). Overall dispositions from all convalescent facilities (five in the UnitedKingdom and two on the Continent) during the period from April 1943 throughDecember 1944 totaled 40,440, of whom 86.5 percent had been returned to duty inthe European theater. A greater number of days was required for rehabilitationthan for reconditioning; rehabilitation required an average of 49 days perpatient, and reconditioning, an average of 39 days. A total of 1,637 officerpatients had been discharged from the 833d Convalescent Center during theperiod, of which 78.7 percent were returned to duty in the European theater(chart 5).
496CHART 4.-Disposition of 14,247 battle casualties discharged from all rehabilitation and reconditioning centers in the United Kingdom during the period 7 April 1943-31 December 1944 CHART 5.-Disposition of 1,637 officer patients (classified as disease, battle, and nonbattle injuries), discharged from the 833d Convalescent Camp (Officers) during the period 7 April 1943-31 December 1944
Activities Centered on the Continent, 1945
During final operations
On 8 January 1945, the Rehabilitation Division, Office ofthe Chief Surgeon, moved from London to Paris, leaving an adequate andcompetent staff with the Office of the Surgeon, United Kingdom Base, London, andestablished its officers at 127 Champs ?lys?es. On 9 January, twoveterans of World War II who had suffered limb amputations and who had beenfitted with prosthetic appliances at Walter Reed General Hospital reported forduty with the Rehabilitation Division. These veterans visited hospitals inthe theater to meet personnel who had lost limbs and to indoctrinate them asto their expected normalcy in future activities. The two veterans were greatmorale builders to these unfortunate patients.
During January, the hospitals of the European theater wereoperating at fullest capacity due to the large numbers of battle casualties.This naturally curtailed rehabilitation activities in hospitals but made formore efficient early transfer of patients to the rehabilitation andconvalescent centers. Particularly efficient convalescent reconditioning wasbeing accomplished at the 7th and 8th Convalescent Hospitals operating in the communicationszone on the Continent. The economy of centralized convalescent care was nevermore strikingly emphasized than during this critical phase of militaryoperations in the European theater.
Two officers were assigned to the Rehabilitation Divisionfrom the Special Services and Information Services of the theater to coordinatethe procurement of supplies and to advise in educational reconditioning.Arrangements were made with the cinema branch of Special Services for thedistribution of recreational movies to hospitals and within the library sectionof Special Services for the acquisition of additional books and magazines forthe use of the convalescent patients.
Additional rehabilitation personnel were being trained atthe school conducted by the 826th Convalescent Center in the United Kingdom.These personnel were greatly needed in the hospital programs. In earlyFebruary, an allotment of 150 officers and 400 enlisted men was made availablefor training in the rehabilitation program and for subsequent assignment tohospitals and convalescent centers.
During this period, a 30-day evacuation policy was operatingon the Continent; therefore, the conduct of a convalescent program was not universally required.With the 60-day evacuationpolicy, beginning late in February, the program of convalescent training wasreinstituted within the hospitals in France and Belgium. On 21 February 1945,at a special conference of hospital center commanders and base surgeons, plansfor convalescent rehabilitation on the Continent were outlined. Tentatively, aconvalescent facility was to be established within each hospital center. Itwas also announced at this
conference that trained rehabilitation personnel would beassigned to each hospital. Later, conferences were held with surgeons of basesections and with the commanding officers of hospital centers to assist in thereorganization of the convalescent training program on the Continent. A seriesof lectures was given by members of the Rehabilitation Division to thepersonnel of all the hospitals.
Frequent indoctrination visits were being made to theconvalescent hospitals within the field armies. The purpose of these trips wasto recommend methods of improving the program of convalescent activities forpatients retained in the army area. It was difficult,however, to activate definite programs due to the rapid advances being made. Itwas noted, however, that patients in army convalescent hospitals had little orno problem of physical or morale reconditioning and that patients were anxiousto return to their units as soon as possible.
On 25 February, Colonel Stinchfield was appointed supervisorof convalescent rehabilitation in the United Kingdom, in addition to his otherduties. He retained command of the 826th Convalescent Center.
In March, Colonel Thompson was relieved of his liaison dutieswith the G-3 Section, Headquarters, ETOUSA, and assigned to the RehabilitationDivision, Office of the Chief Surgeon.
A continuing search was being made throughout this periodfor suitable sites for convalescent rehabilitation facilities in France andBelgium. The Rehabilitation Division, in coordination with the Supply,Operations, Hospitalization, and Personnel Divisions, Office of the ChiefSurgeon, completed plans for the activation of six convalescent centers on theContinent. Selected locations and bed capacities were as follows:
Number of beds
Plans were also made to move the 828th Convalescent Centerand several selected station hospital units from the United Kingdom to theContinent. Selected personnel from various rehabilitation units in the UnitedKingdom were ordered to the Continent for use in the activation of new units.
Since there were no true rehabilitation centers functioningon the Continent, and since, after 1 April 1945, patients were transferred tothe Zone of Interior when they required more than 60 days of hospitalization,the burden for convalescent management was placed on each hospital (fig. 178). Medicalofficers in busy hospitals were not too favorablydisposed toward their part in the program unless they had a clear concept of therelationship of rehabilitation and reconditioning to the principles and practiceof scientific medicine.
Therefore, complete and thorough indoctrination of the medical officerswas constantly being carried out.
During the latter part of April, many conferences were held with the ChiefSurgeon and his officers in regard to the redeployment of convalescent centersand personnel to the Zone of Interior.
V-E Day and phasing out
On 8 May, V-E Day was announced, and immediate plans were made for the redeployment of the 826th ConvalescentCenter to the Zone of Interior.
On 15 May 1945, Colonel Diveley proceeded to the Zone of Interior in order tocoordinate the redeployment of the convalescent center and the rehabilitationpersonnel. Colonel Thompson was appointed acting chief of the RehabilitationDivision.
The major emphasis in the hospital convalescent training program was shiftedto the augmentation of educational reconditioning.
Toward the end of May, arrangements were made to return all air forcespecialized-training equipment and all other surplus supplies. Manyrehabilitation personnel were made available to the Zone of Interior.
Sites in Germany for use as convalescent centers were surveyed, but theselection of these was dependent upon the policy of occupation.
As of the end of June 1945, the Rehabilitation Division consisted of 10 officers, 2stenographers, and 2clerks. During the period from December 1944 through June 1945, 138 officersand 585 enlisted men had beentrained as rehabilitation training personnel. The convalescent centers had discontinued operations andhaddisposed of all patients as of 6 June 1945. In the United Kingdom, convalescent centers were instaging areas preparatory to movementto the Zone of Interior. Supplies and personnel were being prepared to maintain a convalescent facility in occupied Europe (U.S. MilitaryZone) whenrequired. The 7th and 8th Convalescent Hospitals had been recalled to thearmies. A convalescent training program was being conducted in all operatinggeneral and station hospitals. The activities for the convalescent patientwere adapted to the local situation and the patient's requirements.
Dispositions for the period from January through June 1945 indicate that 35,597 patients were discharged from the convalescent centers inthe United Kingdom. Of the 28,846 patients returned to duty, 55percent were returned to general assignment and 27 percent to limitedassignment. During the total period of operations of convalescent centersfrom April 1943 through June 1945, there were 70,358 dispositions reported,of whom 84.5 percent were returned to duty after an average total period ofhospitalization and convalescence of 95.7 days (table 2).
Category of trainee
Average number of days in hospital
Average number of days in convalescent center
Average number of days of hospitalization and convalescence
Disease and nonbattle injuries
The general and station hospitals in the United Kingdom, for the first 4months of 1945, reported that 259,834 patients were discharged, of whom197,846 were ultimate dispositions. Of the latter, 29 percent were returned togeneral duty, 17.5 percent were sent to limited assignments, and 53.5 percent were transferred tothe Zone ofInterior. During the first 4 months of 1945, these hospitals transferred foradvanced rehabilitation in their convalescent sections 63,269 patients, of which49,949 were ultimate dispositions. Of these, 53.8 percent were returned to general duty,39.2 percent were given limited assignments, and 7percent were transferred to the Zone of Interior. The average duration of stayfor a convalescent patient admitted to the convalescent section in thesegeneral and station hospitals was 46.1 days in the hospital and 18.5 days in the convalescent section for a total of 64.6 days.
The convalescent activities program in the European theater was conducted most successfully during World War II with adherence to the following principles which were developed early in the program.
1. Each convalescent patient was gradedperiodically by his medical officer upon the basis of objective as well assubjective findings. The patient's activities were prescribed in accordancewith his rate of recovery and his military occupational specialty. Theactivities program was adapted to local requirementsand was generally proportioned among physical and military reconditioning and recreational diversion.
2. The entire program was based on the fact that the mission ofthe Medical Departmentwas the conservation of manpower and the preservation of the fightingstrength of the military forces. This was accomplished by furnishing those who had becomedisabled with such hospitalization facilities as wouldspeedily restore them to health and finally to fighting efficiency. It wasnot enough that the patient be cured of his disease, or that his wounds behealed, but it was necessary that treatment cover the entire period from thetime he became a casualty until he was physicallyand mentally normal and couldreturn to take his former place in his unit. Specifically, the rehabilitationprogram covered that phase from the time he became a convalescent patient and could leavethe hospital until he had completely recovered and could return to his unit.
3. The rehabilitation center was a military unit thatprepared convalescent military personnel for further military service or fordischarge to useful civil life. The scope of a rehabilitation center includedthe acceptance of the patient from the hospital as soon as possible after he had reached the convalescent stage.He was then treated with specific physical therapy or remedial exercises, aswell as general reconditioning and hardening exercises, which cut the period ofconvalescent days to a minimumand prepared the soldier to return to duty in a strong, able physical condition.The rehabilitation center had as its aimmental as well as physical rehabilitation. With these goals achieved, thesoldier, when discharged to duty, had not only the physical ability to carryon his task, but also the proper mental attitude to carry the task tocompletion.
The reconditioning center had none of the hospital atmosphere. Mentaland physical deteriorationoccurred while the soldier was in the hospital, and the longer he was hospitalized,the more permanent thisdeterioration became. He was, therefore, removed as soon as possible from thehospital to an atmosphere of appropriate military and physical training.
REX L. DIVELEY, M.D.