CHAPTER II
Administrative Considerations
During the approximately 2,500-mile advance by United States Army troops from Casablanca in North Africa, where landings were made in November 1942, to Como on the Swiss border of Italy, which was reached early in May 1945, a continuous flow of casualties were treated in United States Army hospitals. This was the largest continuous combat experience for United States troops since the War of the Rebellion.
Many of these casualties had suffered bone and joint injuries. All of them were treated under conditions without parallel in any previous war. They were treated initially by concepts and methods prevailing in civilian practice, many of which were soon found wanting in the circumstances of militarysurgery. Similarly, some of the techniques which had been employed by surgeonsof Allied armies already in the field and which were adopted by United StatesArmy surgeons were also found wanting. Increasing experience and repeatedcritical evaluation of results frequently led to the modification of conceptsoriginally accepted and methods originally used and sometimes led to theirreplacement by entirely new measures. Modification and replacement of thetechniques originally used were, however, a matter of evolution; they werenot accomplished by directives.
The regimen for the management of bone and joint injuries which was in effect at the end of the war was based upon a program of staged management which was applicable to all wounds and which had evolved from continuing experience. Neither of its component parts, initial surgery and reparative surgery, was new, nor was the combination of the two components new. Such a program had been recommended by some surgeons and employed in some cases in World War I. It was not until the spring of 1944, however, that the scope and timing of the program were fully developed in World War II and thatit was universally applied. This program was applicable to most wounds ofthe soft tissues and was of major importance in the management of bone andjoint injuries, the end results of which depended, as much as upon any othersingle factor, upon the initial management and later reparative managementof the compounding soft-tissue wound.
EVOLUTION OF THE CONSULTANT SYSTEM
Officers and enlisted men of the Army Medical Department assigned orattached to combat elements furnished the only medical support for the NorthAfrican landings 8 November 1942, but mobile and fixed hospitals, staffedwith
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their intrinsic professional personnel, were established soon afterward. It was not until March 1943, however, that the consultant system began to function in the theater, with the arrival of Col. Edward D. Churchill, MC, consultant in surgery to the theater surgeon. There was a lapse of another 6 months before, on the recommendation of Colonel Churchill, a consultant in orthopedic surgery was appointed.
By the time the consultant in this specialty was appointed, it had become apparent that orthopedic surgery was sufficiently important in its own right in this active theater of operations to require more direct attention than a consultant in surgery could spare for it from his other duties. This was because (1) a large proportion of all combat-incurred injuries involve the bones and joints and (2) a large proportion of these wounds present major problems of management.
The landing at Salerno on the Italian mainland by the Fifth U. S. Army in September 1943 had resulted in a considerable increase in all casualties and in a corresponding increase in the number of bone and joint injuries. At the same time, certain personnel problems became apparent. Shortly after the landings in Italy, 11 general hospitals and several large station hospitals designated to operate in Bizerte, Oran, and Naples, arrived from the Zone of Interior. Previous experience had already revealed the need for supervision of the management of casualties with bone and joint injuries. In particular, it had showed that orthopedic surgeons without previous military experience, however wide their experience in civilian orthopedic practice might have been, required orientation in the principles and techniques of military surgery.
Maj. (later Col.) Oscar P. Hampton, Jr., MC, chief, orthopedic section, 21st General Hospital, was therefore placed on duty in the Office of the Surgeon, North African Theater of Operations, as acting consultant in orthopedic surgery. His mission was (1) to visit the newly arrived general hospitals; (2) to appraise the professional qualifications of their orthopedic staffs; (3) to acquaint their staffs with previous experiences in the theater in the management of combat-incurred bone and joint injuries; and (4) to record observations which might lead to improvement in the management of these injuries.
When this mission was concluded, in December 1943, Major Hampton was dispatched to time Fifth Army, then fighting near Cassino, to communicate to forward surgeons the observations he had made in the base area, with particular reference to the quality of initial wound surgery and transportation splinting. Throughout the war, the exchange of experiences between hospitals of forward and rear areas was to prove one of the most profitable functions performed by all consultants.
After February 1944, when the position of consultant in orthopedic surgery to the theater surgeon was made permanent, Lieutenant Colonel Hampton continued to function in that capacity under the consultant in surgery until the consultant staff of the theater was deactivated in September 1945.
Neither the II Corps, which operated in Africa, Sicily, and Italy, nor the Seventh U. S. Army, which operated in Sicily, Italy, and southern France,
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ever had an officer assigned as consultant in orthopedic surgery. When Capt. (later Maj.) Floyd H. Jergesen, MC, of the 2d Auxiliary Surgical Group, was placed on temporary duty in the office of this surgeon, Fifth U. S. Army, late in 1943, to make a special study of gas gangrene within Maj. (later Lt. Col.) F. A. Simeone, MC, he was also appointed acting consultant in orthopedic surgery to the Fifth Army and served in this capacity until after the Cassino-Rome campaign in May and June 1944. Thereafter, as in the Seventh Army, the surgical consultant to the Fifth Army supervised the management of bone and joint injuries.
In retrospect, delay in the appointment of a consultant in orthopedic surgery for the Mediterranean theater appears to have been wise. At the time of the North African landings, as has already been pointed out, few if any of the medical officers in time United States Army had had any experience within battle-incurred bone and joint injuries. Furthermore, none of the orthopedic surgeons who participated in the landings had served as observers within the Allied armies before the entrance of the United States into the war. Sound policymaking was obviously impossible until some experience in military injuries had been achieved. During the first months of combat, therefore, the surgeons in charge of the orthopedic sections in the various fixed hospitals worked out their special problems, observed the results of different methods of management, and in many instances recorded the data upon which sound future recommendations could be based. When a consultant in orthopedic surgery was finally appointed, comprehensive plans for the management of combat-incurred injuries were being evolved, and the experience in the theater, as far as it had gone, could be transmitted in an organized fashion to newly arrived personnel.
Whether this decision not to appoint consultants in orthopedic surgery to the armies was equally wise is more open to question. A basis for the decision was that even serious wounds of the extremities were usually, from the standpoint of initial wound surgery, second-priority cases, and that orthopedic surgeons were usually assigned to the evacuation hospitals in which the forward surgery of bone and joint wounds was chiefly performed. The policy of assigning orthopedic surgeons to evacuation hospitals may have been wasteful of trained personnel, as will be pointed out shortly (p. 13). The appointment of a consultant in orthopedic surgery to each army would have eliminated the need for a trained orthopedic surgeon in each evacuation hospital and would have meant a considerable saving in specialized personnel, who were always in short supply. There would have been other advantages in the appointment of an orthopedic surgeon to each of the armies. Such a consultant, moving continuously from hospital to hospital, could have done much, in his supervisory role, to improve the initial surgery of wounds of the extremities. He could also have played an important role in the education of medical officers who had had no previous experience in military surgery and who, in many instances, had had no previous experience in bone and joint injuries.
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Functions of the Consultant
Both as acting consultant in orthopedic surgery and in his permanent capacity, the consultant in orthopedic surgery routinely advised the theater surgeon, through the consultant in surgery, on a variety of matters, such as the following: (1) The personnel assignments to orthopedic-surgery sections, including not only those of trained orthopedic surgeons but those of other surgeons and other medical officers who had to assume the management of bone and joint injuries; (2) the organization and functioning of orthopedic sections; (3) the quality of the management of bone and joint injuries; (4) changes in concepts and techniques of orthopedic surgery, both as the consultant in orthopedic surgery personally observed these changes and as they were reported to him in his official capacity; (5) the results being obtained; and (6) future planning.
Some of the consultant`s time was necessarily spent at headquarters in administrative work, but most of his time was spent in the field. With the approval of army surgeons, frequent visits were made to hospitals in the combat zone, particularly during offensives, when the flow of casualties was heavy. Methods of management were observed, and suggestions for improvement were made to the consultant in surgery for each field army. These suggestions chiefly concerned the principles of debridement and the application of transportation splinting as a preliminary to the further treatment of casualties in the communications zone.
One of the chief problems in forward areas was the training of surgeons who had to care for casualties with bone and joint injuries but who had had no previous experience to qualify them for this duty. As a continuing effort, this was the responsibility of the chiefs of surgery in the various hospitals, but it was also a major responsibility of the consultants in surgery for the theater and the armies, and of the theater consultant in orthopedic surgery.
The consultant in orthopedic surgery utilized his time chiefly in the hospitals of the communications zone, where fractures and other conditions of the bones and joints could be segregated and where more definitive management of these injuries was accomplished. This was in contrast to the situation in the hospitals of the army area, where bone and joint injuries were, for the most part, a part of the general surgical problem. The major portion of the consultant`s time was spent in hospitals close to the rear boundary of the army. These were the installations in which casualties were received from forward hospitals at the time when precise definitive surgery was necessary and could be most effectively carried out.
The general plan was to visit each fixed hospital for several days at a time, actually living with the orthopedic staff, observing their work in the operating room, following them on ward rounds, discussing general and special problems in both formal and informal sessions, suggesting and implementing such changes in policies and practices as special circumstances might require, and rendering whatever other aid was requested. These were tours of inspection, it is true,
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but the major emphasis was upon their instructional aspects. The most practical way to achieve this objective was to study, within the medical officers assigned to the orthopedic section, the cases under treatment at the time of the visit.
These studies were comprehensive. They included the history of wounding, details of previous treatment, roentgenologic examinations, progress to date, plans for future care, anticipated disposition, and possibilities for later reconstructive surgery. It was always emphasized that, while the management of orthopedic problems was necessarily conducted by inclusive rules in time of war, the objective in each case was individual--to obtain the best result that could be obtained for the particular patient under consideration.
Improved techniques observed in one hospital were communicated to other hospitals as the consultant visited them in their turn. When new regimens were in process of introduction, when the volume of work was excessive, or when specific clinical observations had to be made for future planning, the consultant in orthopedic surgery frequently remained in one hospital for a week or more, integrating himself, for all practical purposes, into the hospital staff for this period of time, in order to accomplish results more quickly.
Although in all of these tours some attention was given to elective surgery, its performance was generally discouraged (p. 271). Emphasis was placed upon the necessity, in all military surgery, for the prompt return of the soldier to duty and upon the lack of justification for the use of hospital-bed space by any man whose future combat usefulness could not be assured.
Special educational efforts had to be undertaken when such radical changes were in the making as (1) the application of reparative surgery to compound fractures, in the spring of 1944 (p. 58); and (2) the extension of the program to wounds of the hip joint some months later (p. 242).
VISITS TO MEDICAL INSTALLATIONS
The activities of the consultant in orthopedic surgery in the Mediterranean theater can best be illustrated by his (summarized) reports to the theater surgeon of two typical visits of instruction, one in September and the other in October and November 1944.
September 1944
This tour, which began 8 September and ended 26 September 1944, covered the following hospitals:
Army hospitals.- Army hospitals visited included the 8th, 38th, and 94th Evacuation Hospitals and platoons of the 33d Field Hospital. The matters examined, which were later discussed with Lt. Col. (later Col.) Howard E. Snyder, MC, consultant in surgery, Fifth U. S. Army, were as follows:
1. Amputations were discussed in the light of Circular Letter No. 46, 29 August 1944, Office of the Surgeon, North African Theater of Operations,
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United States Army.1 Emphasis was placed upon the importance of good skin traction and the use of the elastic cord which had become available for this purpose.
2. The results of the methods then in use for handling wounds of the knee joints were reported. Emphasis was placed upon the importance of good immobilization in the forward area by the use of single hip spica casts, or, at least, Tobruk splints. Emphasis was also placed upon the instillation of penicillin after the joint had been closed at operation and upon aspiration, with reinstillation of penicillin, through a window in the cast 24 to 48 hours after operation.
3. It was recommended that injured hands be immobilized in the position of function and that a good occlusive dressing be applied. It was also recommended that a trial be given to the so-called boxing-glove type of plaster cast over mechanics waste and sheet cotton. This method was then being tested in a number of hospitals, and its more extensive use was suggested.
4. It was pointed out that immobilization and. the use of an occlusive dressing in wounds of the soft parts treated in forward areas were essential for successful reparative surgery in rear hospitals.
64th General Hospital. - This hospital, which was visited 11-15 September, was the only general hospital at Leghorn, Italy. It was very busy with battle casualties. Some few were admitted for initial wound surgery. Others were received from evacuation hospitals. Many patients were admitted from station hospitals with large outpatient clinics. The casualties included both United States and British naval personnel. Although relatively few seriously wounded men were being admitted at this time, the treatment of many of the injuries was very time consuming. Arrangements for handling fresh battle casualties were excellent, and the work was well integrated with the reparative phase of the hospital work.
Surgery on fracture cases was observed in the operating room, and ward rounds were made. In general, reparative surgery was satisfactory. There had been some modifications in the program, the evaluation of which could be made only at a later date. A few fractures had been managed by internal fixation. Results in the few wounds which had been closed at initial wound surgery were not considered satisfactory, and staged procedures were advised.
The sections of Circular Letter No. 46 which applied to orthopedic surgery were discussed.
It was noted at this hospital that several soldiers of the 92d Infantry Division had received tetanus antitoxin instead of tetanus toxoid. A wound adjacent to the knee had been sutured in the battalion aid station with the foreign body still in situ. These and related observations were reported to Colonel Snyder.
Hospitals in the Rome area. -The 33d General Hospital was not receiving patients at the time of this visit, and all remaining patients were already pre-
1 See appendix, pp. 326-331.
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pared for transfer to other hospitals. The more serious fracture cases were examined on the wards. Under the stress of choosing the hospital, a number of patients with fractures of the femur had been boarded for the Zone of Interior. Their transportability seemed doubtful, and it was suggested that notes be made on their records to warm the next receiving hospital that further definitive care might be needed before evacuation.
The reparative-surgery program had been carried out well in this hospital with strong (perhaps excessive) emphasis on internal fixation.
The 12th General Hospital had an excellent program of reparative surgery in accordance with theater recommendations. The orthopedic section had an extremely conservative attitude toward the internal fixation of compound fractures.
The 12th General Hospital made a number of suggestions, including the following:
1. That dry fine-mesh gauze be substituted for vaseline gauze in all echelons.
2. That hand injuries observed in forward areas he put up with mechanics waste between the fingers as well as over the entire hand in the application of pressure dressings. There was skepticism about the value of the boxing glove plaster cast, but it was regarded as worthy of a trial.
3. That simple interrupted sutures be used for delayed primary closures, instead of vertical mattress sutures.
The 6th General Hospital was visited for only half a day, and the number of cases observed was necessarily limited. The reparative-surgery program was in full use, with satisfactory results. At a meeting of the surgical staff, Circular Letter No. 46 was freely discussed. Objection was raised to the "no deviation" clause under amputations, and a case was described in which each dressing produced hemorrhage until a skin graft was applied; then healing was prompt. The staff concurred in the principles laid down in this circular but felt that occasional exceptions should be permitted. It was suggested that, if and when good surgical judgment seemed to call for a deviation from the stated policies, the deviation should be permitted but full explanatory notes should be added to the record.
In the light of time 60-day holding policy, the section on duration of traction for fractures of the femur was also questioned. It was agreed that Circular Letter No. 46 gave time hospital staff authority to maintain traction as long as a patients condition required it.
At the 73d Station Hospital, a planeload of battle casualties had been received from France the night before. Many of the injuries were serious, including fractures of the femur and wounds of the knee joint. Arrangements had been made to transfer the most seriously wounded patients to a general hospital. Several fractures of the femur were in traction on the wards. It was suggested that in the future, if such patients were transportable, they be sent to a general hospital as soon as possible after admission. Some excellent results were seen in this station hospital, but a tendency was noted to hold, as
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possible category B (limited duty) dispositions, patients who would almost certainly require category C dispositions. The whole question of dispositions was discussed with the chief of the surgical section.
It was noted in all the general hospitals visited that many patients who had received penicillin in the evacuation hospitals were being received without the proper notification ("On Penicillin") in the appropriate place on the jacket of the Medical Field Record, as prescribed in Circular Letter No. 36, 1 July 1944, Office of the Surgeon, North African Theater of Operations, United States Army.2 This omission was reported to Colonel Snyder.
October-November 1944
These visits of inspection, which began 15 October and ended 19 November, covered the Continental Advance and Delta Base Sections.
Continental Advance Base Section. - The 46th General Hospital was visited 16-24 October and again 17 November. The surgical service, on the first visit, was heavily loaded with both United States and French battle casualties. French casualties were reaching the hospital without initial wound surgery. Efforts to perform initial surgery on the French casualties and reparative surgery on both French and United States casualties had taxed the surgeons to the limit, and reparative surgery had been possible to only a limited degree. Formal and informal conferences were held with the surgical service, laboratory service, and commanding officer, and the North African Theater of Operations, United States Army plan of reparative surgery, which consisted of surgery, blood replacement, and penicillin therapy, was described in detail. The reception of the plan was enthusiastic. At the request of the orthopedic surgeons, a number of patients were operated on to demonstrate the principles of the program. Many case histories were obtained, and serial photographs were arranged for. On the return visit to this hospital, 17 November, the new program was found to be functioning adequately.
The 36th General Hospital was visited 25-28 October, 30 October-1 November, and 16 November. At the time of the first visit, time surgical service was functioning with incomplete physical facilities, and the orthopedic section was particularly handicapped. Improvement was noted on the return visits, which were made at the request of the recently installed chief of the orthopedic service, for consultation on a number of cases of various types. This officer was doing an excellent job.
The 21st General Hospital was visited 29 October. The surgical service was not yet ready for admissions, but the facilities planned for the orthopedic section were the best yet seen in the theater. The orthopedic staff, as the result of an extensive experience, was already competent in reparative surgery.
The 180th Station Hospital was visited 1 November. At a staff meeting, the entire program of reparative surgery was presented and was followed by a prolonged question-and-answer session.
2 See appendix, pp. 321-326.
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The 35th Station Hospital was visited 2 November, when the weather prevented travel to the Delta Base Section, as planned. Reparative surgery was discussed at length with the chiefs of surgery and orthopedic surgery. The hospital was busy with minor battle casualties and had received some severely wounded patients from two plane crashes and a number of roadside accidents. Many patients were seen on the wards in consultation. The professional work was good.
Delta Base Section. - The 43d General Hospital was visited 3-6 November, 10-11 November, and 13-15 November. The surgical service was overloaded with United States Army casualties and German prisoners of war. Reparative surgery was in progress on the wounds of the soft parts. The chief of the orthopedic section was then hospitalized; later, he had to be evacuated to the United States, and a new chief of section was subsequently appointed by the hospital commander. Formal and informal conferences were held, and many patients were seen in consultation. Some were operated on, by request, to demonstrate the principles of the reparative-surgery program. Considerable progress was being made on orthopedic work in this hospital.
The 3d General Hospital was visited 7 November. Orthopedic surgery was being conducted along the same principles as had been previously employed at this hospital. Some cases were well handled, but the management of others did not measure up to the theater standards. This situation was reported to the Delta Base surgeon.
The 78th Station Hospital was visited 5 November. This hospital had received casualties from the Airborne Task Force, the most severely wounded of whom had received initial surgery at the 514th Clearing Company. Ward rounds were made and problems discussed. Transfers to general hospitals were being made correctly.
The 70th Station Hospital was visited 12 November. Surgery on the usual good station-hospital level was being performed.
The 80th Station Hospital was visited 12 November. The chief of surgery appeared to he doing an excellent job. All phases of reparative surgery were discussed with him. Several special problems, among them fractured femurs, were observed and discussed on the wards.
The 5l4th Clearing Company was visited 9 November. This station now had roentgenologic facilities, and its equipment was considered satisfactory. Two surgical teams, one from the 36th General Hospital and one from the 43d General Hospital, were attached to this Company. Operations had numbered 32 in September, 58 in October, and 16 to date in November. The work did not justify the attachment of two surgical teams, and the Delta Base Section surgeon was so informed. He planned to return the team from the 36th General Hospital to its proper station. The teams were advised to split all plaster casts(unsplit casts having been observed at the 78th Station Hospital) and to utilize elastic cord, a supply of which was on hand, for skin traction on amputation stumps.
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Additional activities. - The consultant in surgery, Seventh U. S. Army, was informed of time observations made in rear hospitals on the surgery performed in forward hospitals. Case reports were furnished to him, and ward rounds were made with him at the 36th and 46th General Hospitals. At his request, information was supplied to the surgeon, Sixth Army Group, concerning the observations which had been made on casualties being evacuated by train and air from Army holding stations to Continental Advance and Delta Base Sections, and from Continental Advance to Delta Base Section.
ASSIGNMENT OF PERSONNEL
When the landings were made in North Africa, in the fall of 1942, time exact role to be played by qualified orthopedic surgeons in an overseas theater was still to be determined. This was chiefly because the exact surgical missions of the various echelons of medical care in the staged management of the wounded had not yet been clearly defined.
Only a few of the evacuation hospitals which arrived early in North Africa had orthopedic surgeons on their staffs, though many had general surgeons experienced in the management of fractures. The initial experiences led to the decision that each such hospital should have an orthopedic surgeon on the staff. This was not because it was expected that all wounds of the extremities would affect bones and joints or because it was considered essential that an orthopedic surgeon should perform all initial surgery in bone and joint injuries, which was an obvious impossibility. The chief reason for the decision was that a qualified orthopedic surgeon should be available in each evacuation hospital for consultation on such special problems as wounds of the joints, complicated fractures of the femur, injuries which might require amputation. and similar serious problems. It was felt that the orthopedic surgeon, with his specialized knowledge and wider experience in plaster techniques, would be extremely useful to the general surgeons who would necessarily perform most of the initial surgery in evacuation hospitals. It was also intended, of course, that, as time permitted, the orthopedic surgeon should himself handle injuries of extreme severity, such as compound comminuted fractures of the femur and penetrating wounds of the knee and hip joint.
Another reason orthopedic surgeons were assigned to forward hospitals had to do with the management and disposition of soldiers with non-battle-connected complaints, such as internal derangements of time knee, painful backs, and foot disabilities. Manpower, especially combat manpower, was always in short supply, and it was essential that as many of these soldiers as possible should be returned to duty as promptly as possible, without the loss of time and effort which would be expended in their transfer to general hospitals. On the other hand, it was equally important that men who really needed treatment and who could not be promptly returned to duty should be evacuated to
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hospitals in the rear without delay. These decisions were often delicate and could best be made against a background of orthopedic training and experience.
For these reasons, many of the younger, well-trained and capable orthopedic surgeons, who had had previous experience in civilian traumatic surgery, were transferred to evacuation hospitals as soon as they arrived in the theater on the staffs of general hospitals. This proved to be a wise plan as long as policies concerning the management of bone and joint injuries were still in a state of flux. The anticipated effectiveness of these trained orthopedic surgeons was fully realized, and they made important contributions to the increasing efficiency of initial wound surgery. They themselves, however, were seldom content with these assignments, and requests for transfers to general hospitals were frequent, on the ground that as trained orthopedic surgeons they would be more useful in the performance of reparative surgery and definitive reduction of fractures than they were in evacuation hospitals, where initial surgery was limited to debridement, gross alinement of fractures, and transportation splinting.
Although the weight of these arguments was fully realized, the policy of assigning orthopedic surgeons to evacuation hospitals continued the same in the Mediterranean theater throughout the war. In retrospect, this inflexibility does not seem to have been altogether wise. As policies of surgical management in forward areas became standardized and as surgeons in these areas became experienced in the management of wounds of the extremities, the original need for orthopedic surgeons in evacuation hospitals became much less pressing. At this time, in view of the shortage of trained orthopedic personnel in rear hospitals and the demands of the regimen of reparative surgery for trained men, it would probably have been wiser to utilize in general hospitals many of the surgeons assigned to evacuation hospitals. The assignment of a consultant in orthopedic surgery to each army (p.5) would further have reduced the need for experienced orthopedic surgeons in hospitals in the army areas.
Orthopedic surgeons who were heads of orthopedic teams were occasionally attached to field hospitals in the division area in Sicily and in the early days of the fighting in Italy, but this practice was a misuse of qualified personnel and was soon discontinued. Injuries of the bones and joints were seldom, in themselves, of sufficient urgency to require treatment in field hospitals, and the few which were could be cared for by the well-trained general surgeons attached to these installations. Orthopedic surgeons, on the other hand, were seldom equipped to treat the serious wounds of the chest and abdomen which constituted the chief work in a field hospital, and they could not, therefore, handle a proportionate share of casualties with these injuries or of casualties with multiple injuries involving the chest and abdomen as well as the extremities. For these reasons, orthopedic teams were used only in evacuation hospitals after early 1944.
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FACILITIES
In World War II, before a casualty with a bone and joint injury reached a general hospital in the communications zone, he had passed, successively, through a battalion aid station, a collecting station, a clearing station, and an evacuation or field hospital. The care he received in tine division area was limited to emergency measures designed to supplement the first aid he had received on the battlefield and to make him transportable to the evacuation hospital. Classification as to transportability was a major responsibility of the clearing station. No special orthopedic equipment other than splints was therefore usually required in these echelons of medical care (figs. 1, 2, 3, 4, and 5).
Soldiers with wounds of the extremities, as already noted, were usually second-priority casualties. They were therefore not transferred to the field hospital adjacent to time clearing station unless shock, the presence of a tourniquet, a traumatic amputation, an abdominal wound, a severe chest wound, or an impaired airway required immediate attention.
Definitive initial surgery in the evacuation or field hospital was directed toward the management of the soft-tissue injury, not the bone injury, except for gross alinement of fractures and immobilization for transportation. Plaster of paris and auxiliary supplies and splints were therefore the only special equipment required for bone and joint injuries in the evacuation hospital (figs. 6, 7, and 8). A fracture table was essential equipment, and the portable fracture table provided by Medical Supply (Item No. 7099300) proved entirely satisfactory.
Materials for internal fixation of fractures, overhead fracture frames, and material for the management of fractures in balanced-suspension skeletal traction were authorized items of supply in evacuation hospitals. They were all superfluous items at this level. They are used in the definitive management of fractures, which is the mission of hospitals in the communications zone, though not of installations in the army area.
In the general hospital in the communications zone (fig. 9), where fractures were reduced and other definitive care provided, desirable special facilities included, at a minimum-
1. An operating room, at least 20 by 25 feet, to accommodate two operating tables and a large table for sterile supplies. It was also desirable to have an adjoining room in which patients could be anesthetized and in which the transportation casts applied in the evacuation hospital could be removed.
2. A ward of 75 to 100 beds, to be used as a femur (traction) ward. It was essential that this ward be equipped for the taking of roentgenograms with portable apparatus and desirable that it be near the X-ray department.
3. Other wards of 75 to 100 beds. When it was practical, it was best to admit patients to these wards according to the nature of their injuries, but anatomic subdivision was not always possible because of multiplicity of wounds and the variations in the bed status. The principle of segregation of special
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FIGURE 1. - First aid in field, Fifth U.S. Army, Italy, December 1943.
injuries, however, was sound and preferably was adhered to as circumstances permitted.
4. A plaster room, about 20 by 30 feet, equipped with three plaster tables; a fully equipped table for dressings; and storage cabinets for splints, accessory materials, and sterile supplies. This plaster room was preferably located adjacent to the principal orthopedic ward. It was used for tine changing of plaster casts as well as for minor surgical procedures, usually without anesthesia.
Essential items of supply in a general hospital included an adequate number of overhead fracture frames, Army half-ring leg splints, and materials for balanced-suspension skeletal traction and for internal fixation of fractures, as well as materials for the application of plaster-of-paris casts.
5. Facilities for the examination of ambulatory patients from other wards and of outpatients. The plaster room could be used for this purpose, if necessary, but this was less desirable than provision for a special consultation and examining room.
Brace shops. - Although tables of organization included a qualified brace maker in the personnel of all numbered general hospitals, tables of equipment provided little equipment for braces hops when these hospitals first came into the North African theater. It soon became evident, however, that there was a definite need for a few braces, special splints, belts, and similar items in an overseas theater which functioned on a 90- to 120-day molding policy.
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FIGURE 2 - Continued. C. Administration of first aid to infantryman in Fifth U.S. Army battalion aid station in Italy. This man, like the casualties in B, had been dug out of a wrecked building which had collapsed after being hit by a shell. D. Administration of plasma to wounded German prisoner outside of Fifth U.S. Army battalion aid station in Italy, April 1945.
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The first brace shop to function in North Africa was set up at the 21st General Hospital, late in 1942, soon after the hospital was established at Bou Hanifia, the site of a former spa, some 65 miles south of Oran. Many of the tools were secured from the well-equipped machine shop that had been part of the former bathhouse and motel facilities. Other tools, as well as supplies of steel, leather, and salvaged canvas, were obtained from the engineering and quartermaster departments in the base section.
As this shop was the only equipped brace shop functioning at this time in the Mediterranean Base Section, requisitions were forwarded to it, through the office of the base surgeon, from other hospitals in the area. Eventually, the volume of requisitions became so large that this shop was formally designated as brace shop for the entire base section. This proved an efficient and economical plan. As might have been expected, the orthopedic staff at the 21st General Hospital made the fullest use of the brace shop, but orthopedic surgeons in other hospitals in the base section were also assured of the braces and belts which they needed without the expenditure of a large overhead in their own hospitals. There was no waste of personnel. Requisitions from other hospitals in addition to his own kept the brace maker at the 21st General Hospital busy at all times and justified the maintenance of a fully equipped and staffed shop. The requisition and provision of material were also simplified and expedited by the operation of a single shop rather than multiple shops.
When the 21st General Hospital was moved from North Africa to Italy, the brace shop at the 46th General Hospital served the hospitals in the medical center at Oran by the same general plan. The brac emaker in charge had had
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FIGURE 5. - Ambulance transportation of wounded, Fifth U.S. Army, Italy, April 1945
an extensive experience in civilian life, and brace makers from other hospitals in the area at times worked under his direction. In Italy, the brace shop at the 21st General Hospital served the 3 general and 2 station hospitals in the medical center at Bagnoli, just outside of Naples, as well as the orthopedic section of its own hospital.
A shop planned for the 24th General Hospital and intended to serve the medical center at Bizerte did not become operational, as this hospital and the other hospitals the brace shop was intended to supply moved to Italy shortly after the equipment for the shop had been issued. Hospitals not served by area brace shops continued to operate their own small shops, to meet their special needs. In these isolated hospitals, the brace makers usually served as orthopedic technicians, with brace making an incidental assignment.
The output of the theater brace shops consisted chiefly of canvas belts for support of the back, metal braces for personnel returning to limited duty, and individual splints and appliances. Standard splints were repaired and altered, and shoes were also altered. Since patients with fractures which would not permit return to duty within the period of the theater holding policy were evacuated to the Zone of Interior while they were still in plaster, there were few calls for the type of brace which would be needed during reconstructive surgery and rehabilitation.
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FIGURE 7. - Scenes in 8th Evacuation Hospital, Fifth U.S. Army, Italy, January 1944. A. Wounded soldiers lying in receiving room of hospital. B. Winterized wards of hospital. Winterizing was accomplished by building up wooden sides inside the side walls of the ward tent to the height of the caves and placing wooden frames, with doors, at the ends of the tent. Wooden floors were also provided. C. Operation of initial surgery for wounds of the extremity in progress.
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FIGURE 9. - 24th General Hospital, Florence, Italy. A. Exterior view of headquarters and surgical buildings. B. Operating room. C. Large surgical ward, serving especially for patients in traction.
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HOSPITAL ADMINISTRATION
Assignment of cases. - When the North African Theater of Operations was established, the assignment of responsibility for compound fractures was somewhat confused. Some chiefs of surgery felt that, as in World War I, these injuries should be the responsibility of general as well as orthopedic surgeons and should be treated in general surgical as well as orthopedic sections. In several hospitals, the chiefs of surgical sections elected to assign casualties with bone and joint injuries alternately to general surgical and orthopedic sections.
These policies proved unwise and unsound. The general surgeon and the orthopedic surgeon frequently had wise counsel and skilled assistance to offer each other in the management of combat wounds, but only a brief experience was necessary to demonstrate that the best results were obtained when bone and joint injuries were managed exclusively in orthopedic wards. Almost without exception, this was the policy in effect in all general hospitals in the theater by the spring of 1944.
Segregation of bone and joint injuries, as already noted, was neither necessary nor practical in evacuation hospitals, where initial surgery was limited to management of the compounding wound. In properly operated fixed hospitals, however, it was found best for orthopedic sections to receive all casualties with fractures and joint injuries except, for obvious reasons, those with associated fractures of the ribs, skull, and maxillofacial bones. Fractures of the bones of the hand were also exceptions to this policy in hospitals in which general surgeons experienced in the management of hand injuries were attached to the staff. Otherwise, these injuries were managed on orthopedic wards.
Patients with concurrent wounds which relegated fractures to a place of secondary importance were admitted to the general surgical or other appropriate wards, but personnel from the orthopedic section assumed responsibility for the bone and joint injuries. Failure to provide permissible treatment of the fracture would have resulted in needless deformity and might even have caused a spreading, life-endangering infection.
Orthopedic surgeons also had the responsibility for all acute, recurrent, and chronic conditions affecting the function of the bones and joints of the extremities and of the back and shoulders.
Consultations were answered on request from the remainder of the surgical service and from other services in the hospital. Examinations were carried out on the ward or in the outpatient department, according to the status of the patient.
Caseload. - The proportion of the hospital census represented by the orthopedic caseload varied according to the total hospital census, which might be unusually high because of medical conditions or for other reasons. As a rule, during an active campaign, the orthopedic section accounted for about 25 percent of the hospital population and for about 35 to 40 percent of the
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surgical census. After the campaign ended, these proportions usually increased because of the long periods of hospitalization required by casualties with fractures.
To take care of this load ideally in a 1,000- or 2,000-bed general hospital, the following personnel was necessary:
1. A chief of the orthopedic section, who was responsible to and worked under the administrative control of the chief of the surgical service. Technically, a classification of B-3153 was desirable, though, when their training, initiative, and industry warranted it, these assignments were often given to officers with classification of C-3153. Many of these officers rapidly attained the higher rating, particularly if they had had some previous civilian experience in acute trauma of the extremities. Many of them did outstanding orthopedic surgery in North Africa, Sicily, and Italy.
If the chief of the orthopedic service were to perform his duties competently, he had to exercise his supervisory and executive functions to the fullest extent. They were not so exercised when he dissipated his time and effort by assuming the duties of a ward officer on any special ward. It was essential, instead, that he keep his time free for ward rounds, supervision of junior officers, emergency consultations, observation of seriously ill soldiers, and operating-room duties. At times, he had to spend the entire day in the operating room. The best section chiefs were those who utilized their time in this fashion.
2. A senior ward officer, to serve in a twofold capacity, as assistant chief of the orthopedic section and as ward officer on the traction ward. As the reparative program for compound fractures developed (p.53), it became extremely important to have on each service an experienced orthopedic surgeon, or a general surgeon with special experience in traumatic surgery, who was qualified to make quick decisions when the pressure of work was too heavy for the chief of the section to make them all. These decisions frequently had to be made in the operating room.
The assistant chief of section was usually either a C-3153 or a C-3150 (general surgeon), though officers with D classifications, who were interested in traumatic surgery, frequently advanced, sometimes rapidly, to the higher rating. In the Mediterranean theater, it proved perfectly satisfactory for general surgeons to assume the management of fractures and joint injuries, provided that they functioned as members of the orthopedic staff, under the supervision of the chief of the orthopedic section. It was, however, neither desirable nor practical for a general surgeon to have the responsibility of fracture management if at the same time he had the responsibility for abdominal and chest injuries and for other unrelated injuries.
3. Junior ward officers. These officers had classifications of D-3153 or D-3150, but, as in other categories, it was possible for officers with general-duty classifications to advance to specialty categories if they were interested in traumatic surgery. Each junior ward officer usually carried a patient load of 75
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to 100 patients, the number varying with the size of the hospital and the number of admissions after a campaign.
When convalescent sections were set up in general hospitals, it was found to be highly desirable for each ward officer to continue to supervise his own patients as they were transferred to these sections. This duty increased the officers caseload, but, as convalescent casualties required only a minimum of care, the burden seldom proved excessive, and the continuity of care thus secured was well worth the extra effort.
4. Technicians. A qualified, industrious group of enlisted technicians was indispensable for the smooth functioning of an orthopedic section. Their training in plaster and splinting techniques was the responsibility of the chief of the orthopedic section in each hospital. An orthopedic section caring for 400 to 500 patients required at least 5 technicians and also required the services of a brace maker (p.15). Properly taught technicians readily mastered all the principles and details of plaster, splinting, and skeletal-traction techniques. With experience and under minimal supervision, they could apply plaster casts, including spicas; erect Balkan frames (see fig. 9C); arrange pulleys for skeletal traction; and perform numerous similar duties, thus leaving medical officers free for strictly medical tasks. Technicians also made plaster bandages, if stock supplies were not available.
It was the usual practice for the best qualified man in tine group to serve as the chief technician. Among his other duties were the storage, maintenance, and supply of splints, accessories, and plaster.
Outpatient dispensaries. - After a short experience with the operation of outpatient dispensaries in general hospitals, it became clear that these dispensaries should be kept to an absolute minimum and should be chiefly used for seeing ambulatory patients in consultation and for periodic observation of convalescing patients. Any other plan handicapped the smooth functioning of the orthopedic section because it required the withdrawal from it of much-needed personnel. Outpatient clinics attached to station hospitals were better prepared to take care of the type of work ordinarily seen in a civilian orthopedic clinic, and it was particularly desirable and convenient for them to exercise this function in base sections.
GRAPHIC RECORDS
Early in 1944, the Army Pictorial Service provided, informally, photographers to assist the consultant in orthopedic surgery in recording methods of splinting and other orthopedic procedures and in securing illustrations of the results of wound and fracture management. These illustrations proved very useful for instructional and demonstration purposes.
Later, the 3d and 6th Medical Composite Detachments, Museum and Medical Arts Service, supplied both photographers and artists as the need arose. Photographs and drawings were thus accumulated to show variations
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in traction and splinting methods, serial wound management, the technique of special operations, and various other items. In many instances, it was possible to make complete case studies from the first observation of the casualty in a forward hospital, before initial surgery, to the end results of management in base hospitals, before disposition. Motion pictures were also made, some of them in color.
ACCUMULATION OF DATA
Throughout the period of active fighting, as well as after the war ended, several different plans were followed to accumulate data on casualties with bone and joint injuries. The following methods were used:
1. Throughout the period of active fighting, efforts were made to stimulate the interest of the various chiefs of orthopedic sections in accumulating factual information on small groups of cases according to their special interests.
2. In relatively quiescent periods, arrangements were made through the theater surgeon for several chiefs of orthopedic sections in general hospitals to travel about the theater to visit other general hospitals and to gather data on subjects of special interest to them and to the theater consultant in orthopedic surgery. These trips also served to acquaint the surgeons making the surveys with techniques and methods employed in other hospitals.
3. After the war ended, arrangements were made through the theater surgeon to have additional surveys made by other orthopedic surgeons, who visited most of the hospitals and studied their records on special orthopedic problems.
4. Still other medical officers were placed on temporary duty in the Office of the Surgeon, to study disposition-board proceedings and other records available in that office, in an effort to gather as much data as was possible on several special orthopedic problems and on the results of the treatment employed for them.
The data thus collected furnish some of the supporting information in various chapters of this history.
