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Chapter IV

Contents

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SECTION I

GENERAL SURGERY

CHAPTER IV

SURGERY AT THE FRONT

GENERAL CONSIDERATIONS
            
 Medical Department plans for the surgical treatment of wounded at the front prior to our entrance into the World War, were essentially conservative.1   They were based almost purely upon a hypotherical war of movement; therefore, (dressing stations, field hospitals) and of evacuation hospitals, which were intermediate facilitis, was of paramount importance.  The evacuation of wounded, with notable exceptions which will be referred to later, was to be of rearward, to and including evacuation hospitals, were as follows:  With line organizations--regiments, trains, etc.; the sanitary train, comprising dressing stations, field hospitals; evacuations hospitals.2  
            
The Medical Department equipment, provided for a regiment or other line organization operating as part of a division, consisted of first-aid packets, equipment.3   In combat the duties that were to devolve on the sanitary personnel were to render first aid to the wounded; to esbablish and operate an aid station, and to collect wounded thereat;  to direct the trivially wounded to return to the line, and to direct others with slight wounds to the station for the slightly wounded; and in exceptional cases to transport the severely wounded to the dressing stations.  Since the regimental medical personnel was to keep in touch with the regiment, no elaborate or fixed arrangements for the care and treatment of wounded were to be undertaken. Such treatment was to be imited ordinarily to first-aid and to the readjustment of dressings which previously had been applied either by medical personnel in advance of the dressing station, or by the wounded themselves.
   
Activities at the dressing station (to be established by the ambulance company section of the sanitary train) were to be carried on under the following deparments: 5   Dispensary; kitchen; receiving and forwarding; slightly wounded; be immediately required to save life or to render the patients fit for further transportation.  Permanent occlusive dressings were to be applied, time permitting.  The rules generally to be followed were that no operative or other interference should be attempted under conditions unfavorable for asepsis or antisepsis, and that no wounded for whom transportation might be available should be delayed at the dressing staiton.
            
Since the function of the field hospital was to keep in tounch with the combatant organizations, and to provide care and treatment as far as practicable for the sick and wounded of the division until taken care of by the sanitary


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service of the line of communications, it could meet these conditions only when relieved promptly by medical units to its rear. Under ordinary battle conditions surgical operations were to be such only as might be needed to fit patients for transportation to the rear.6

In the evacuation hospitals, which were to relieve the field hospitals of their sick and wounded, the treatment of wounded was to be hardly more extensive than that at field hospitals, viz, emergency operations and better preparation for transport. Particularly was this true during battle when many wounded would be received. On the other hand, in the absence of many wounded and of the probability of an early move, complete surgical treatment was permissible.7
When we entered the World War its character had for long been static; it was possible, therefore, to partially immobilize the units mentioned above. Such being the case, evacuation of the wounded became less of an urgent necessity from a purely military standpoint and more or less subservient to the interests of the patients themselves. And whereas formerly no surgical intervention was to be practiced farther forward than base hospitals, except in times of quiet, it was found now that definitive treatment could not ordinarily be left until patients could reach hospitals in the rear; it had to be practiced in stages, and the preliminary stages must be accomplished as early and as near the front as possible. At this time, in contradistinction to former wars when rifle wounds were over 80 percent and shell wounds in the neighborhood of 13 or 14 percent,8 wounds caused by shell fragments were almost the rule (80 per cent); bullet wounds were rare.9 Since the wounds caused by the shell splinters were invariably infected with organisms whose period of incubation was extremely short, most severe complications, if not fatality, were to be expected unless surgical intervention could be practiced within a relatively few hours of the receipt of injury. Thus, though our earliest plans for surgery at the front had to conform to static warfare, this changed to open warfare at a time when our greatest numbers were involved, and though some general modifications in surgical treatment were possible, for example, delayed surgical treatment until patients in some instances could reach base hospitals located near the front, the treatment per se was essentially the same.

GENERAL TREATMENT OF WOUNDS

The subject of wound treatment at the front obviously must include all procedures from the application of the first-aid dressing on the battle field to the final dressing immediately preceding the evacuation of the patient from the zone of the advance to the base. The successive stages in which such treatment was given involved some or all of the following places or stations through which wounded men passed from the front line rearward: On the battle field, company aid stations, battalion aid stations, regimental aid stations, advanced dressing stations, dressing stations, field hospitals, mobile hospitals, evacuation hospitals.

While it is essential in the interests of completeness to consider the subject, in this chapter, from the viewpoint of the above enumerated places and stations, thus repeating some things which are given in greater detail in another


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volume of this history a it is not the purpose to discuss herein special surgical treatment, except in so far as is necessary. Such special treatment is made the subjects of separate subsequent chapters.

ON THE BATTLE FIELD

Each soldier was provided, as a part of his individual equipment, with either a Medical Department regulation first-aid packet or a front packet. In addition, Medical Department enlisted men, assigned to line organizations, carried a liberal quantity of these packets and iodine swabs. The first-aid packet, in a metal case 4 by 2¼ by 1 inch, comprised 2 gauze bandages, 4 by 8¼ inches, 2 gauze compresses, 3½ by 3½ inches, 2 safety pins, and directions for application.10

FRONT PACKETS

The following extract not only describes the kinds of front packets adopted for the American Expeditionary Forces, but contains as well directions as to the use of these packets: 11 The dressings here described are intended for use in the dressing stations of the units in combat, in the field hospitals, the mobile hospitals, the evacuation hospitals, and the base hospitals.

Surgical dressings should protect the wounded man from: (1) Trauma to his wounds; (2) loss of blood; (3) secondary infection, and should be so applied as to add to his comfort during treatment and transportation.

In the manufacture of these dressings it is not essential that absolute accuracy in measurements be observed.

Front packets
.-These packets are to be used by medical units in the area of combat. The outer covering is coated with paraffin to protect the contents of the packet against wet and vesicant gases.

1. PACKET NO. 1. RED LABEL

For small wounds.

This packet contains the following supplies, the outer wrapper of which is made of kraft paper dipped in paraffin. It is marked with two red bands.

On opening the outer covering there will be found: (1) 1 unbleached muslin bandage, 4 to 5 inches by 5 yards, cut on the bias; 2 safety pins, 1½ inches long, attached to the bandage. (2) A muslin bag, which opens at one end. This bag contains sterile dressings wrapped in a special paper. These dressings should be handled with as much care as possible to prevent contamination.

The sterile dressings comprise: (1) 4 gauze sponges or wipes, 4 inches by 4½ inches, for covering the wound; (2) 1 absorbent pad, 4 inches by 6 inches; (3) 1 gauze bandage,4 inches wide. With these supplies the wound should be covered and the absorbent pad held in place by the gauze bandage. Finally the muslin bandage should be applied and firmly fastened with the safety pins to make the dressing secure or to apply the proper splint.

II. PACKET NO. 2. WHITE LABEL

For medium-sized wounds.

This packet contains the following supplies, the outer wrapper of which is made of kraft paper dipped in paraffin. It is marked with two white bands.

On opening the outer covering there will be found: (1) 1 unbleached muslin bandage, 4 to 5 inches by 5 yards, cut on the bias; 2 safety pins, 1½ inches long, are attached to the bandage. (2) A muslin bag, which opens at one end. This bag contains sterile dressings
a Vol. VIII, Field Operations, American Expeditionary Forces.


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wrapped in a special paper. These dressings should be handled with as much care as possible to prevent contamination.

The sterile dressings comprise: (1) 4 gauze sponges or wipes, 4 inches by 4 ½ inches;(2) 1 absorbent pad, 6 inches by 8 inches; (3) 1 gauze bandage, 4 inches wide.

With these supplies, the wound should be covered and the absorbent pad held in place by the gauze bandage. Finally the muslin bandage should be applied and firmly fastened with the safety pins to make the dressing secure or to apply the proper splint.

FIG. 78.- Front-line packages Nos. 1, 2, and 3

FIG. 79.- First-aid outfit, complete

III. PACKET NO. 3. BLUE LABEL

 For large wounds.

 This packet contains the following supplies, the outer wrapper of which is made of kraft paper dipped in paraffin. It is marked with two blue bands.

 On opening the outer covering there will be found: (1) 2 unbleached muslin bandages, 4 to 5 inches by 5 yards, cut on the bias; 2 safety pins 1 ½ inches long are attached to each bandage. (2) A muslin bag which opens at one end. This bag contains sterile dressings


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wrapped in a special paper. These dressings should be handled with as much care as possible to prevent contamination.

 The sterile dressings comprise: (1) 6 gauze compresses, 4 inches by 8 inches; (2) 1 absorbent pad, 10 by 18 inches; (3) 1 gauze bandage, 6 inches wide.

 With these supplies, the wound should be covered and the absorbent pad held in place by the gauze bandage. Finally the muslin bandage should be applied and firmly fastened with the safety pins to make the dressing secure or to apply the proper splint.

 It was impressed upon the soldier that the first-aid dressing was for his individual use in the event of injury, and frequent inspections were made to insure the constant possession of these packets. Medical Department enlisted men assigned to battalions carried usually in a duffel bag or gunny sack a liberal quantity of these packets and iodine swabs. This was important because of the frequency of multiple wounds and of the frequent lack of a packet on the person of the wounded by reason of its having been either lost, or, contrary to instructions, applied to a wounded comrade. Directions for the use of these dressings were given each combatant as a routine, and all Medical Department personnel were fully instructed in their application. In the light of our experience particular attention in this instruction should be directed to: (a) The importance of applying the dressing directly to the wound without the interposition of either outer garments or underclothing. (b) The avoidance of the removal of clothing not neces- sary to uncover the wounds, thus lessening a tendency to shock. (c) The danger incident

FIG. 80.- First-aid bandage, with hooks and tape

to tightly packing a wound in the mistaken belief that complete cessation of hemorrhage is necessary. (d) Contraction of a dry dressing and bandage after their saturation with blood, water, or perspiration, with consequent circulatory interference, discomfort, and pain. Hemorrhage from fractured bone, lacerated muscles, or blood vessels of a limb inevitably results in swelling, and the earlier the application of a dressing and bandage to such a wound the greater should be the allowance for the consequent swelling. A dressing and bandage should be sufficiently snug to retain its position during transportation without causing constriction. (e) The desirability of immobilization of a wounded area, even in the absence of fracture. Rest of damaged tissue enables nature to marshal her defensive forces for the localization of infection, and the degree of immobilization of a wound area, even though only the soft tissues are involved, largely determines


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FIG. 81.- Immobilization of upper extremity against patient’s side

FIG. 82.- Thomas leg splint applied over clothing; traction made on shoe


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the chances of the wounds healing without infection or with only localized infection. Nothing tends to disseminate infective material, particularly sand, dirt, particles of clothing, and the like, more rapidly than muscle spasm in the vicinity of a wound, and the developmentn of gas gangrene after an apparently thorough de bridement of lacerated tissues is due, in all probability, to a dissemination of minute foreign particles beyond the zone of de bridgement. The immobilization of wound areas in regions having multiple layers of muscle with intervening planes of fascia, particularly the thigh and legs, should be presence and absence of fracture. (f) The imperativeness of making no attempt to cleanse a wound on the battle field, because of the insufficiently trained personnel, the time element, and the lack of essential facilities. A wound left alone rather than half cleansed is far more safe. Iodine, if available, was to be applied to the edges of the wound, but was not to be applied within a deep wound, since nothing could be accomplished in the way of antisepticizing, and the danger of setting up a new hemorrhage by dislodging a blood clot was to be in mind. (g) Immobilization, to begin on the battlefield when possible, by the use of simple straight or improvised splints. The use of the Thomas splint for either arm or leg on the battle field is rarely possible because of the time required for its proper adjustment and the impracticability of carrying on the person. Also, the Thomas splint is essentially a traction splint and does not afford complete immobilization unless reinforced with one or more straight splints. In the absence of any splinting material, for the purpose of transportation the upper extremity may be readily immobilized by bandaging or strapping it against the body, and the lower extremity by splinting against the opposite limb. Efficient splinting invariably includes the joints above and below the wound, whether or not fracture is present. Only by including these joints will muscle contraction cease

FIG. 83.– First aid in trench warfare


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and foreign particles remain in situ. Splints should never prevent free access to the wound and should be applied so as to permit changing the field dressing at the battalion aid station without removal of the splint. Adequate padding for all splints must be improvised on the battle field, and this is especially necessary over bony prominences, such as the elbow, wrist, iliac crest, great trochanters, femoral condyles, malleoli, and in the axilla. For this purpose articles of clothing, packing, leaves, grass, and the like can be utilized. The improper observance of this cardinal point predisposes to shock and the development of pressure necrosis of overlying tissues. The idea was to apply first aid immediately at the place where the wound was incurred, either by Medical Department personnel on duty with organizations in the front line or serving as litter bearers, or by litter bearers detailed from the line who were instructed in elementary first aid. Such application was usual in trench warfare, in which the casualties frequently occurred in the trench itself from desultory enemy fire, and special cover for dressing was not always essential. This applied also to a less extent to open warfare in periods of quiescence, but at times of great activity it was often impossible to apply dressings before transporting the patient to a company or battalion aid station, or even to reach the wounded for varying periods of time.

THE COMPANY AID STATION

In some instances stations subsidiary to battalion aid stations were established in the front line for each company, conducted by two dressers assigned from the battalion medical personnel.12 At these company aid stations emergency treatment was given the wounded brought thereto usually by line litter bearers.

Such stations were more commonly used in trench warfare when it was possible to keep a small supply of surplus dressings and even splints, and sometimes a battalion medical officer took station there; but in open warfare the only available dressings usually were those carried on the person, and often the only shelter was that afforded by a shell hole, consequently the wounded habitually were borne to the battalion aid station.

THE BATTALION AID STATION

With the increased strength of our battalions, the battalion aid station closely approximated in size the regimental aid station as prescribed in the Manual for the Medical Department, the regimental aid station then not being generally employed.12

In trench warfare, battalion aid stations usually were located in dugouts in the support line, 250 to 1,000 yards in rear of the front line, on or near an evacuation trench.12 The equipment, in addition to that enumerated in supply tables for a battalion, included at least two Thomas splints, and a shock table for warming patients. Light was supplied by simple petroleum lamps, and in some electricity was present. Cooking was done below, when possible, coke or any available fuel being used and ventilators having dampers for excluding gas, led to the surface. Often the food was prepared in a separate adjacent


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dugout or improvised lean-to and in some sectors food was brought up in marmites at night time. The source of heat was small wood-burning stoves. The supplies were usually brought up by the battalion medical carts or other vehicles, and replacements were made through a system of exchange by ambulances, trucks, or litter bearers. The supplies habitually included stimulants and ample facilities and material for the preparation of hot liquid foods, and other articles of food were also stocked, as often in periods of intense bombardment patients could not be evacuated until after dark, and preparedness for the bestowal of all possible attention, short of surgical intervention, upon the wounded for a varying number of hours was necessary.12

FIG. 84.- Administering a hot drink to a shock case

    In open warfare these stations were of necessity simple and even rudimentary both as to shelter and equipment.12 Proximity to the front and alocation accessible to litter bearers both forward and rearward were absolute essentials, and frequently on account of the paucity of shelter and evacuation routes the stations of different regiments, even sometimes of those of different adjacent divisions in a narrow sector, consolidated. The distance from the front varied from 50 to 500 yards or more and was often in the support line. Advantage was taken of any possible shelter, such as a shell hole, quarry, culvert, cellar, or dugout, in locating the station. Supplies in addition to individual equipment consisted only of those that the personnel could carry up in gunny sacks and similar containers, and articles such as litters, splints, and


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blankets, accompanying, the evacuated patient were replaced by the bearers or ambulances by a system of exchange. The service simulated that of trench warfare in so far as possible. Immediate evacuation was the goal, but patients frequently had to he held until nightfall, and there were few or no facilities for treating shock. In attack the medical personnel with the front line usually applied first-aid dressings, and immobilized fractures when possible, leaving the wounded sheltered as far as practicable for collection, a few hours later, by the aid-station bearers, while they continued forward with the line. Similarly, if the movement was rapid the aid station, in moving forward to successive new locations, left the wounded, after administering to them as far as possible. at some centrally located " collecting point" for the facility of the following evacu-ation ambulance company. 12

With respect to surgical treatment, the procedures which obtained in the battalion aid stations may be summarized as follows: (1) Revision of the first-aid dressing. Pain, when present, was usually due to constriction of the wounded parts by gauze and bandage, which required changing or loosening.(2) Revision of splinting to insure proper immobilization for subsequent transportation. Application of the Thomas leg or arm splint when traction was indicated.

To arrest severe hemorrhage, whenever the element of time, available surgical facilities, and good surgical judgment permitted, the bleeding artery was sought in the wound and ligated above and below its laceration. If the primary search was unsuccessful and subsequent attempts necessitated material enlargement of the wound, it was often more desirable deliberately to seek and ligate the vessel beyond the wound margin, under conditions of strict surgical asepsis. Prolonged forcipressure---i. e., clamping artery forceps on the bleeding vessel or on the mass of lacerated tissue from which blood was oozing--sometimes succeeded in arresting the hemorrhage. It was possible thus for the forceps, properly padded with dressing, to be left in situ and the patient evacuated to the triage with this fact recorded on his field tag. Whenever, as a last resort, a tourniquet was used and left in situ, this fact was recorded and the ambulance driver or orderly instructed to loosen it for periods of five minutes at intervals of an hour. Only dire necessity justified the evacuation of a patient with tourniquet on arm or thigh. The duration of the journey from the ambulance head to the field hospital was so uncertain, and the prevention of intermittent loosening of the tourniquet because of inevitable traffic blockade, was so likely to occur, that every effort was to be made to ligate or apply forcipressure in all cases in which the rate of blood flow was sufficient to jeopardize the life of the patient. The maintenance of the body heat of the wounded by means of blankets, coats, hot-water bottles, canteens filled with hot water, and hot drinks (when not contraindicated by the nature of the wound) was vastly important. Any chilling of the body precipitates or aggravates shock, therefore every effort was made to have the wounded soldier leave the battalion aid station as thoroughly warmed as battle conditions permitted. Antitetanic serum was administered habitually, even incase of an apparently trivial wound, and the fact of administration recorded


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on the field tag, and indicated on the patient's forehead by a cross painted with iodine. If the wound or dressings involved the forehead, the cross was painted on the dorsum of one hand. The standard dose of morphine, one-fourth grain, was given immediately to all severely wounded, and to those slightly wounded in whom the single element of pain was considered to be a factor in the development of shock. Often it was advantageous to repeat the dose: Pain frequently did not become marked until during the transit to the field hospital and a comfortable journey was to be insured by the use of sufficient morphine.

OPERATIVE TECHNIQUE

In battalion aid stations, it was usually impossible for the surgeon to scrub his hands and change gloves for each wound treatment: Water and gloves were not always available, or the supply was very limited. However, instruments could be sterilized sufficiently by immersion in alcohol or ether, and by experience the surgeon could easily learn to dress all wounds without having his hands make contact with septic tissues or objects. With two pairs of dressing forceps, or with one pair each of artery and dressing forceps, he could accomplish any kind of dressing and continue with a series of cases without scrubbing his hands or changing his gloves after the completion of each. He usually had an enlisted assistant, previously trained to apply bandages and splints under his supervision.

THE REGIMENTAL AID STATION

As stated above, when we first entered the war the regimental aid station was the most forward unit aid station prescribed by field service regulations, but with the change of tables of organization increasing battalions to practically the former size of regiments, it was succeeded by the battalion aid station and became almost obsolete, though maintained in a few instances.12 The term persisted but usually signified merely the station and office of the regimental surgeon and the liaison point of regimental medical service, where service was rendered the regimental headquarters detachment, which was usually at or near regimental headquarters. The function of the regimental aid station when employed, was similar in both trench and open warfare to that of the battalion aid station and it sometimes served, especially in open warfare, as a collecting point for both the walking wounded and those for ambulance evacuation.12 In the confusion of attack, bearers conveyed the wounded to any point at which a medical officer was known to be, consequently the station of the regimental surgeon frequently became an additional temporary battalion aid station.

THE DRESSING STATION

The number and locations of divisional dressing stations were dependent upon the roads, available shelter and the width and activity of the divisional sector; generally from one to three to a division, located from 3,000 to 6,000yards from the front line.12

In trench warfare the dressing station, usually located in a dugout or in any available building, contained a greater amount and variety of equipment than was possible in open warfare, and had separate rooms for such purposes as


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FIG. 85.- Regimental aid station, 321st Infantry, October 3, 1918

FIG. 88.- Dressing station, Croix de Charemont, August 17, 1918


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FIG. 87- Ambulance company dressing station, open warfare

FIG. 88.- Dressing station, Labayville


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receiving, recording, and dressing the wounded, for shock treatment, the serving of hot foods, and for administration. Since more time was available for the care of men brought to the dressing station than was true under open-war-fare conditions, many who were merely exhausted were returned to duty after a few hours' rest during which they were given hot food; also, casualties depleted by hemorrhage or suffering from shock could be retained longer and consequently evacuated in better condition. The personnel usually worked in shifts.

In open warfare, buildings or other shelter were not always available and the dressing station was frequently under tentage, which sometimes was but a tent fly. Each dressing station was placed as near the front as conditions permitted; the location selected being generally with a view to its subsequent occupation by a field hospital as the action developed. Occasionally an advance dressing station, with reduced personnel, was established 1,500 to 2,000 yards from the front line, or nearer when possible, as a relay between battalion aid stations and the main dressing station.12 Commonly, the dressing station sections of two ambulance companies were utilized in the establishment of a main dressing station, one as an advance dressing station and the fourth held in reserve; often three were combined in one station and again each company operated its own station, the tactical situation being the decisive factor. Equipment was limited and in general consisted of dressings, splints, litters, blankets, antigas supplies, antitetanic serum, a few instruments, and drugs, including morphia, and kitchen equipment. The dressing station in a few instances was employed as a triage, in which event the division specialists were stationed here, but this was not habitual. 12 The function of the dressing station in general was to receive casualties, to administer indicated emergency treatment, and to group and evacuate to designated destinations when conditions permitted, but habitually to field hospitals. The emergency treatment comprised arresting hemorrhage, readjusting dressings, applying or readjusting splints, administration of morphia and of antitetanic serum when time permitted, stimulation by hot drinks and the retention and reviving of gassed and shocked cases as far as possible. Operations were limited practically to the closure of aspirating wounds of the chest, and to emergency ligations.

Since casualties usually came or were brought to the dressing station in groups the personnel could not always work in shifts, otherwise the service in general was similar to that of trench warfare. Because all Medical Department activities here were to subserve the prime function of evacuation, professional interference was reduced to the lowest possible minimum. Morphine was administered generally to the severely wounded; great importance was attached to the giving of hot food, for, as mentioned above, many with minor wounds required nothing more and after being fed voluntarily returned to the front line.

THE FIELD HOSPITAL

The field hospital was the last and largest divisional unit of the Medical Department in the chain of evacuation, the function of which in general was to receive casualties from the dressing station, and to institute all measures possible under varying conditions to best fit them for continued evacuation,


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FIG. 89.- Unloading severely wounded at Field Hospital No. 28, Varennes Meuse, October 2, 1918

FIG. 90.- Slightly wounded awaiting readjustment of dressings, Field Hospital No. 28, October 2, 1918


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usually to evacuation hospitals. Field hospitals were located from three to eight miles from the front line, depending upon such factors as the enemy range of fire, roads, fuel, water, availability of buildings, and the locations of evacuation hospitals.12 Whenever possible they were grouped, preferably in a village or at the confluence of roads from the sector served, for convenience both in the interchange of patients and for the ambulances.

In trench warfare and in some quiet sectors the field hospital was of a semi-permanent character and was often elaborately installed with modern equipment and conveniences in well adapted commodious buildings or well arranged dugouts.12 The equipment in addition to all surgical essentials included electric lights, portable radiographic and laboratory units, steam sterilizer, and other similar conveniences. In a few instances they, complete with equipment, were taken over from the French.12 Usually, under these conditions, one field hospital functioned as triage and cared for the wounded and gassed, one cared for the sick, one for skin and venereal cases, and the fourth was held in reserve frequently conducting a convalescent camp for transportable patients and supplementing the other three as required. All cases likely to become fit for duty in from 10 to 14 days were held. While no definitive measures were undertaken, greater latitude and freedom of action within the discretion of the staff was customary than usually proved possible in open warfare.

In open warfare the situation presented all phases, from conditions obtaining in quiet sectors during periods of quiescence, simulating trench warfare, to the intense activity of attack and advance in which improvisation and individual resourcefulness were the prime factors. When equipment was sparse and of the simplest, often no patients could be held, operations and professional work were reduced to a minimum and the work resolved into a problem of evacuation. On the other hand, in a few instances, as in the cases of the 2d Division at Chateau-Thierry,13 and the 3d Division at Chierry (August, 1918) and also at Verdelot,14 conditions obtained whereby the field hospitals were located in commodious buildings with clean, well-lighted operating rooms in which modern aseptic surgical work was done by attached special surgical teams, which included nurses.

The normal personnel of the field hospitals usually was augmented by the division specialists of the various branches and at times also by special operating and shock teams. In a few instances, their facilities for the care of nontransportable wounded were increased by the attaching of mobile surgical units.12 Also, additional enlisted men were attached, as occasion demanded, who were usually trained for and assigned to special semipermanent team duties. The equipment necessarily varied with conditions and ranged from that which was complete and even elaborate, including a portable X-ray outfit, which also supplied electric lights in trench warfare and in quiet sectors, to that which was scant and often in part improvised in periods of great activity and rapid movement.

The following description of the surgical work of field hospitals extracted from a report of the 3d Division, in general terms, is fairly typical of that of other divisions, though there were so many differences in details, both in this


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division at various times and between this and other divisions, that it is illustrative rather than of universal application: 14

In operating the hospitals, officers and enlisted men were divided into two shifts, as far as possible, working from 7 a. m. until 7 p. m., although at times all were on duty for longer periods. Division specialists made regular visits to the field hospitals for purposes of consultation and supervision of eases in their own special branches.

The receiving ward of the triage hospital of the 3d Division in the second battle of the Marne was located in an Adrian barrack; the surgical dressing room was in a smaller building at the rear, and the shock and operating rooms were in a smaller building across the street. Near it were the ward tents. When patients were taken from ambulances at the receiving ward, litter cases were carried as far forward as possible, and litters set on the floor on one side of the building, while sitting patients occupied benches along the other side. The record desk at the far side of the building was passed by all patients as they left this room. The receiving officer examined litter cases, sorting out the nontransportable, those to be re-dressed, and those who were to be evacuated immediately. He designated proper wards for all others and designated those who could have liquid or other food. He checked diagnosis tags and especially the records regarding antitetanic serum. Those having no record or proper mark indicating that they had received serum were given the prophylactic dose here. When possible, the record of the case was taken at this time. This first examination was quite thorough, for diagnosis tags were often written under shell fire and frequently failed to record all the wounds the patient had received. When additional wound were found they were noted on the tag. The tags were also checked to verify nontransportable cases, especially those with active hemorrhage, which were given first consideration. Their records were taken at once, and they were sent to the dressing room or the shock ward. Many shocked cases were warmed in the receiving ward, given morphine, hot liquids, and other foods, and reacted so well that they were transportable. Morphine in large doses from a stock mixture was given in the receiving ward to many cases marked for evacuation, such as patients with joint lesions which were well splinted, fracture cases, etc. Injury to the hands and feet caused more pain in proportion to the amount of tissue destruction than any other classes of cases. Cases for re-dressing, not in a state of shock, were sent to the well-heated dressing ward, where care was exercised to reduce to a minimum the exposure of patients while being dressed and to perform accurate work. Many first-aid packet dressings applied on the field had slipped out of place; but this was seldom the case when two or three pieces of adhesive plaster were used to secure the bandage to the skin. Very few tourniquets were found tight enough to impede circulation. They had generally been loosened at some forward dressing station and bleeding controlled by adequate packing and well-applied bandages. Many of the tourniquets that had not been loosened cut off the venous flow only.

In the rush of work, fracture cases with a good splint that looked comfortable, showed no evidence of shock or hemorrhage, and did not complain of much pain or tight bandages were considered transportable. When but few cases were being received, nearly all fractures were sent to the re-dressing ward for a careful examination. The most common defect in dressings was that bandages were too tight, especially on the forearm, the upper third of the leg, or about the ankle. Many patients complained of pain at the site of fracture or wound, which was relieved when a tight bandage at some distant point on the limb was loosened. Fracture cases were prepared for evacuation by the use of salvaged clothing packed loosely about the limb, and masks were used for pillows. Care was taken in case of fracture of the extremities that the Thomas splint was properly applied and that excessive bleeding was not taking place. When found necessary to hold fracture cases, they were sent to the appropriate ward, kept warm and free from pain. There were very few that required active shock treatment after being prepared and classed as transportable.

Sick patients whose condition was not serious were sent to the medical wards. Usually a separate hospital received these cases. Those with trivial conditions who were able tore turn to duty within a few days, were retained; the others were evacuated. Transportable surgical cases awaiting evacuation and the slightly wounded who might be returned to duty


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in a day or so were sent from the receiving or dressing wards to the surgical wards for slightly wounded, and they also were retained.

Hot drinks, food, and water were available in the receiving wards an were given to practically all cases except those with penetrating wounds of the abdonmen. Soup, coffee, and chocolate were the three hot drinks used, and when Imore than one was available patients usually preferred the first mentioned. Food of all kinds was served, including delicacies furnished by the Red Cross and articles taken from the regular ration. To keep hot liquids or other food, a two-burner kerosene stove was set on a block in the receiving ward, but dhring rush periods liquid nourishment was served direct from kitchen containers.

 On the whole it can be said that the condition of the patients received on the Marne was not as good as those received in the Meuse-Argonne offensive, where we operated close behind the lines. The trip of 17 kms. by ambulance from Chateau-Thierry to Verdelot was attended by considerable jolting and there was a longer interval between the time of injury and hospital treatment. This was offset by the fact that better hospital facilities were afforded by good buildings, operating rooms, skillful nursing by trained female nurses, anl freedom from the dangers of shell fire.

The shock ward received all shock eases, whether the condition was present on admission, developed in other wards, or was subsequent to some surgical operation. All wet clothing was removed from the patient and he was wrapped in warm blankets, arranged on a litter in such a manner as to permit the heat from two primus stoves, or solidified alcohol cans, placed underneath, to circulate within the folds of the blankets and about the body of the patient. The blood pressure and pulse were taken frequently; and, in a case where collapse was threatened, intravenous injections of saline solution or 5 percent acacia were given until the patient rallied. Some surgeons preferred the gum acacia to the saline solution, hut from the small clinical experience obtained in field hospitals it was impossible to derive any conclusions of value. Blood transfusion was resorted to on a number of occasions. The technique of this procedure was fully explained and supervised several times daily by surgical consultants experienced in the method. The donors were classified and were usually obtained from among very slightly gassed patients.

 Most of the shock cases were caused by gunshot wounds of the abdomen, head, thigh, or knee, and in many of the last-mentioned wounds the shock seemed out of proportion to the character of the wound. When cases were admitted that required surgical treatment they were first revived by the above method and then sent to the operating room. On the Marne all cases from the operating room were sent to the shock ward for examination, and treatment if necessary, before they were sent to the surgical ward. The shock ward retained the majority of its cases about four hours and had a mortality rate of about 10 percent.

 Re-dressing was done mainly in the surgical ward for slightly wounded. A medical officer was on duty here constantly to apply dressings, to detect developing shock and hemmor- rhage, and to supervise generally the work of the ward. Feeding was of great importance in this ward. Many face cases required the use of a rubber tube. Morphine and codeine were practically the only drugs used. Hypodermic injections of sterile water were found efficient in many cases. As the use of Dakin's solution exercised a mental effect, it was used in most of the cases and was applied every two hours. In gunshot wounds of the extremities the elevation of the limb afforded great relief in many cases. Active hemorrhage was very infrequent in cases that were re-dressed; usually wnen found it complicated injuries about the hands and face. Tight packing with large shell-wound dressings and properly applied bandages left few cases requiring ligation.

In the operating room most of the work consisted in controlling hemorrhage, removal of foreign bodies, ddbridement of wounds, adjusting fractures, and otherwise preparing the patients for evacuation. In the Marne battle, after July 15, most of the surgical work was performed by special surgical teams attached to the division for that purpose. From July 15 to 20 three operating teams operated continuously on head, chest, abdominal, and thigh cases, which had been classed as nontransportable. Beginning the first week of August, three teams were in constant operation at Chierry on the Marne, in Field Hospital No. 27, on this same class of patients. They rendered great service to the severely wounded, and brought to within a short distance from the firing line the skill of experienced surgeons and


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nurses. Both at Chierry and at Verdelot the surgical operating rooms were located in excellent buildings, with good light and clean surroundings, making thoroughly aseptic work possible. Before and after operations the shock teams with their surgeons and nurses, worked over many apparently hopelessly wounded men. The radiographic unit, operating in close proximity to the surgical room, proved invaluable. But few plates were made, as the fluoroscopic method, being rapid and accurate, was used almost exclusively. After fractures were reduced the work was checked up under the fluoroscope.

The following discussion of the surgical service in the field hospitals of the 42d Division is also quoted,15 for it illustrates in many respects the methods employed and the conclusions reached. The methods differ in some respects from those of the 3d Division, which are quoted above. The descriptions of the work of these two divisions are the most explicit that can be found:

 It was the universal policy to evacuate at once to the rear all cases capable of bearing the trip, so that operative surgery in the field hospital resolved itself into treatment of the seriously wounded; that is, of those whose condition was such that further transportation was both inadvisable and dangerous to life. Very early in the campaign it was realized that for the most part field hospitals must rely on their own resources in the care of such cases, for in an active fighting unit, moving rapidly from one sector to another, it was impossible to depend upon the arrival of specially trained operating teams from the rear. The hospitals had to be as mobile as the division and able at a moment's notice to care for the wounded. In spite of surroundings and regardless of whether units were working in well- equipped hospitals or in barns or tents, provision always had to be made for prompt action in those cases requiring immediate surgical intervention. At an early date, in order to be prepared for any contingency, six operating teams and four shock teams were organized from the personnel of the section. Operating room assistants, anesthetists, orderlies, and litter bearers were selected and given special training. Operating and shock teams worked in relays, thus allowing periods for rest. The mobile X-ray equipment was a valuable adjunct to operative work, making possible the location of foreign bodies and the demonstration of the extent and nature of fractures. On several occasions it furnished light for the operating room. At times the drain on sterile dressing was so great that it was necessary for hospitals to do their own sterilizing. This was accomplished by a fairly large portable sterilizer of French design, which served the purpose admirably. Operating routine was essentially the same in all cases.

On arrival at the field hospital cases were sorted and classified according to the nature of the wounds and also with regard to the condition for further transportation. Cases presenting symptoms of shock were taken at once to the shock room for special and immediate treatment.

In the preoperative ward patients were again closely examined with a view to determining which needed prompt attention. All such were picked up on the following special chart:


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PREOPERATIVE WARD

Name....................................Date and hour received.......................................

Condition:
    Good
    Fair
    Shock
        Traumatic
         Hemorrhagic
Nature of injuries:                             Tourniquet:
Physical Examination:                        Paralysis:
Concious.                                           Location
Unconcious                                        Sensory
Semiconcious                                     Motor

Chest wound:                                   Abdominal wound:
Open.                                                Location.
Closed.                                             Physical symptoms
Hemo-or pneumothorax

Urine:                                        Stools:
Amount                                      Normal
Blood or clots.                            Blood

Vomiting:                                   Fractures
Frequency                                 Location and description
Amount.
Character.

Hematoma:                         Disposition:
Location.                             X-ray
Pulsating.                            Operating Room.
Bruit                                     Died

(Signed).........................................................................

This chart was found to be invaluable from many standpoints, especially from the fact that it necessitated careful examination of all patients. Crowded and insufficiently lighted advance aid stations, rapid evacuation from these stations under shell fire, and divided responsibility at times resulted in failure to record the use of tourniquets or the detection of hemorrhage. In the same connection, one case of morphine poisoning was observed, but, fortunately, was discovered in time to prevent a fatality. * * * The case is cited to show the danger of failure to record the use of morphine, for as the patient was badly shocked as well as poisoned, it would have been pardonable for the entire syndrome to have been attributed to shock alone.

Of equal importance was the advisability of recording all obtainable data concerning the nature of the wounding agent as well as the manner in which the wound was sustained. It was a well-recognized fact that shell fragments or bullets entering the body might travel in any direction, leaving no external clue to their subsequent course, the final destination of a missile being determined by its nature, velocity, and angle of entrance. Given a chest wound, a bloody vomitus would be strong evidence that the missile had passed through the diaphragm and penetrated the stomach, and to omit this evidence from the records was a serious mistake, for, although a perfect operation might be performed on the chest wound, the complicating abdominal injury untreated would surely have been fatal. On the other hand, when a patient came to the operating room a carefully taken description of his wound saved valuable time for the surgeon and for the patients who were painfully, though patiently, waiting their turn.


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Every shock case upon reaching a field hospital was sent at once to the shock ward and( the patient's record kept oin the following report chart:

                                     SHOCK WARD
Name:                           Individual Report
Natue of Injury:            Organization
Blood pressure:            Date and time of injury:
                                    Date and time received:
                                    Condition of patient:
                                    Moderate or severe shocki

Treatment:                 Tourniquet:
Infusion, c.c.               Location:
Transfusion, c.c.         Duration.............Hours
External         
Morphine.
Stimulants.
Specify any other         Effect of treatment
                                    Improved
                                    Unimproved
                                    No response
Disposition:
Time.
Operating room.
Evacution,
Died.

Was patient returned from operating room, and final disposition?

This chart was adopted in order to permit a close study of the cases treated for the purpose of determining the relative value of the various forms of treatment. Upon arrival of a case in the shock ward the litter was placed on a pair of low trestles, one for each end. The officer in charge made a hurried examination for open or concealed hemorrhage. If none was found the patient was covered with warm blankets and heat applied beneath the litter. Solid alcohol was used for heating purposes, usually four cans to a single patient, these being protected by metal boxes open at one end only. Blankets were then dropped over the sides of the litter to the ground. Warm drinks were given in small quantities if the patient had no abdominal wound or was not slated for early operation. The only cardiac stimulants used were caffeine citrate and camphorated oil, used subcutaneously. Morphine Was given, both for the relief of pain and for its general beneficial effect. Gum acacia salt solution was used extensively, with unsatisfactory results, and blood transfusion was not always feasible.

    The length of a patient's stay in the shock ward depended upon his condition. If reaction was prompt anud there was no special need of an immediate operation he was evacuated. If operation was indicated it was performed as quickly as circumstances would permit.

Anesthetics used were ether and ethyl chloride, preferably the latter, owing to the fact that it induced rapid anesthesia and was well borne. No untoward effects of any kind were observed from its administration. At the close of an operation the patient was returned to the shock ward for further treatment until full reaction had occurred.

A study of shock cases treated by the field-hospital section of the 42d Division led to the following conclusions concerning the etiology of shock: During the early days of the division's participation in active campaign, when the weather was warm and the men were in splendid condition both physically and mentally, the number of shock cases was relativelv small. It was observed during this period that even cases in severe shock responded readily to treatment. * * * In striking contrast was the clinical picture presented by the wounded during the closing weeks of the war. Not only was there a greater number of shock cases, running up to 17 to 20 percent of the severely wounded, but they were far


107

graver in character, reacting very slowly to the most energetic treatment. Worn out by long fighting, with little chance for rest, exposed to cold, with insufficient protection, constantly wet and insufficiently fed, with (cold food-a condition necessitated by the risk which fires close to the line would have entailed-the troops were at a low-water mark of fitness, mentally and physically. * * * The mortality in shock cases was, consequently, extremely high in spite of every possible form of treatment, and the experience of all was that, no matter what the type of treatment, results were most unsatisfactory and discouraging, for the patients were not only wounded but exhausted. This experience coincided with that of other divisions.

It was found that war surgery, like all traumatic surgery, constantly presented three great problems, viz, shock, hemorrhage, and infection. Shock has already been discussed but it must be emphasized that this avas materially lessened by the careful attention given the wounded at regimental and advance aid stations and by the rapid evacuation by ambulance companies of all wounded to the field hospitals. Hemorrhage was controlled by the tourniquet or by direct ligature, which insured the delivery of patients to their destination without serious loss of blood. With regard to infection, it was noted in the early days of the war that the number of wounded men dying from tetanus was very large. Accordingly, a thorough system of immunization was carried out and every wound, no matter how trivial, was considered justifiable cause for the administration of antitetanic serum. So religiously was this plan followed that a wounded soldier rarely appeared at a field hospital without first having received his prophylactic dose of serum. Experience with infection caused by gas-forming bacilli was limited in the field hospitals, owing to the fact that in most instances cases were received promptly after injury and were evacuated before the development of this grave condition. This was true also of the pyogenic wound infections, but an effort was made to prevent all infection by the adoption of well-recognized preventive measures.

In the 42d Division operations in field hospitals were limited to the following classes of cases: Thoracic aspirating wounds, abdomical cases where hemorrhage might be rapidly fatal or a peritonitis imminent, cases requiring amputation, joint injuries, and all hemorrhagic cases.

It was not intended that definitive surgery should be performed in field hospitals except upon certain nontransportable patients, as evacuation hospitals were provided for this purpose. The scope of professional activities in field hospitals varied greatly according to the intensity of the action, but during an offensive it was customary to evacuate all patients as soon as they could endure transportation. After the formation of the First Army its orders required that operations in field hospitals be reduced to a minimum. and similar orders were published in several corps.

Though evacuation hospitals habitually were located well up toward field hospitals, an exception occurred when the 1st and 2d Divisions attacked toward Soissons. During this attack evacuation hospitals were not moved up because no advance information had been given the medical authorities concerned 16, Also they were at considerable distances from much of the front in the later stages of the Meuse-Argonne operation, on account of lack of railroads in the immediate rear of the divisions.

Because of the accessibility of evacuation hospitals during the first part of the Meuse-Argonne operation, only two types of patients were operated upon in field hospitals, in the 5th Division, viz, those with aspirating chest wounds and hemorrhage.17 Later, on account of the considerable length of time elasping from receipt of wounds until arrival at hospital, al] types of cases were operated upon if they could not be transported to the evacuation hospital within 15 hours after being wounded, except that patients with aspirating


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chest wounds and uncontrollable hemorrhage continued to be operated upon irrespective of this time limit. In the 5th Division, wounds operated upon under these circumstances were, relatively, as follows :17 Abdomen, 20 percent; chest, 27 percent: head, face, andl neck, 9 per cent; upper extremities,18 percent; lower extremities, 26 percent. No patients were operated upon who could possibly have been transported within the time limit--15 hours--except those whose wounds were so severe that operation was imperative.17

The operations performed most frequently in the 5th Division were trans-fusions and arrest of hemorrhage. In about 19 per cent of the patients admitted to triage, antitetanic serum had to be administered, there being no record of its having been given farther forward. 17

The following records pertaining to the 32d Division, A. E. F., indicate the plans which were promulgated in that division for the care of its wounded, more particularly in the field hospitals, and in addition show with what success they were carried out under battle conditions:

[Memorandum]

HEADQUARTERS, 32D DIVISION,
OFFICE OF DIVISION SURGEON,
August 31, 1918.

To All Medical Officers, this Division:

INSTRUCTIONS FOR OPERATION OF TRIAGE, THIRTY-SECOND DIVISION

It is essential that all casualties from the front pass through the triage.

The following plan of operation, with minor modifications, has been successfully followed by a field hospital of this division. No radical departure therefrom will be made, except by order of the division surgeon:  

1. Functions.- The function of a triage is, in general: First, the grouping of casualties as to degree, which determines whether they are (a) transportable; (b) nontransportable. Second, their classification as to type of casualty, i. e., (a) G. S. W.-S, (b) G. S. W.-O, (c) psychoneurosis, (d) gassed, (e) injured, (J) sick. Other functions of a triage are: 1. The rendering of minor surgical aid and medical treatment in emergencies, to make transportable, if possible, cases that would otherwise be nontransportable. 2. The readjustment, or renewal of dressings and of splints where necessary. 3. The administration of antitetanic serum for immunizing purposes where it has not already been administered. (Accept no evidence that it has been administered other than a statement to that effect on the diagnosis tag or the presence of the characteristic sign on the patient's forehead. A statement by the patient that he has had a hypodermic injection must not be accepted as proof.) 4. The preparation of hot drinks and food, to be given when indicated. 5. The triage is not a collecting station, but a means of separating and evacuating with all possible speed, through proper channels to designated hospitals
2. Operations, Records and Reports.- I. A medical officer shall examine each case as admitted, marking the disposition of case on the back of the diagnosis tag with colored pencil. A clerk will then follow to collect the necessary data; the completion of which he will indicate on tag by a fixed symbol or otherwise. (Cross in circle is suggested.) The noncommissioned officer in charge of litter detail will assure himself that each tag bears this symbol before evacuating such case from triage. II. Accurate and complete record of all patients will be made, listing casualties separately by, first, 32d Division; second, other United States units; third, allied troops; fourth, enemy. And giving in each instance name and Army serial number, rank, company and organization, nature of casualty, disposition. This information will be recorded on Form 4, A. G. O. S. D., A. E. F.; two copies to be forwarded to the division surgeon's office by courier. The period of record thus compiled will be six


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hours, 6 a. m. to 12 noon, 12 noon to 6 p. m., etc. III. The nontransportable wounded will be admitted to advanced operative field hospital immediately and directly from the triage receiving tent. IV. A daily summary for the 24-hour period ending 6 a. m. and known as triage report will be prepared andi sent by courier to the division surgeon's office as soon after the closing of the period as possible. V. Only cases admitted to field hospitals will be carded on field medical card and reported oln Form 22, A. G. O. S. D., A. E. F. Cases dying in triage or enroute to triage will be forwarded and admitted to a hospital, where the necessary records will be made and proper provision made for burial.
3. Personnel.- I. The personnel shall consist of two teams; each on a 12-hour tour of duty and composed of (as a minimum) 1 medical officer, 1 noncommissioned officer, 2 clerks, I stenographer, 12 litter bearers, 2 men for kitchen detail, 1 ward attendant for each tent in which patients are held, and 2 men for dispensary and dressing room.
4. Equipment.- The following equipment has been found adequate: I. One ward tent or other shelter as a receiving ward, with a capacity for at least 12 litter and 40 sitting cases. When feasible it should be well lighted. II. A second ward tent or other shelter for the temporary care and segregation of the seriously wounded transportables while awaiting evacuation. III. A third ward tent or shelter for the temporary care and segregation of slightly wounded sitting cases. IV. A fourth shelter for those cases classified as sick or as psychoneurotic; which are ordinarily sent to one of the division field hospitals. V. A small cover, such as is afforded by a 14 by 14 tent fly, for (a) storage of litters, necessary medical supplies, blankets, etc.; (b) office. VI. Equipment necessary for the preparation and serving of food.

Enlisted personnel must be especially trained in their respective duties and instructed as to the function and purpose of a triage, namely, grouping of casualties, correct record, speedy evacuation.

G. E. SEAMAN,
Lieutenant Colonel, Medical Corps,
Division Surgeon.

HEADQUARTERS 32D DIVISION,
September 3, 1918.

From: J. W. Vaughan, major, Medical Corps, United States Army.
To: The Chief Surgeon, A. E. F.
Subject: Surgical care of the wounded from the 32d Division during the drive from August 27 to September 2, 1918.

1. Since the report last made upon the surgical care of wounded from the 32d Division several changes have been made in the organization. These changes have been instituted as a result of the experience gained in the Fismes drive, and it is the opinion of those who have had to do the work that they have facilitated in the proper handling of the wounded. 
2. The chief change was one put into effect by the commanding officer of Field Hospital No. 127. This consisted in the placing of a triage, in compliance with an order of the division surgeon, a short distance in advance of the operating hospital for seriously wounded, thus separating it entirely from our advanced operative hospital, to which it was attached in our former drive. All wounded were brought to this triage by the division ambulances. These ambulances were unloaded and immediately returned to the front stations for more wounded. In that way no serious blocking ever occurred at the advanced dressing stations.
3. At the triage the patients were sorted out as to the degree of severity of their wounds. Accurate records were also kept of the wounded so that a report of the number, rank, organization, and severity of the wounds could be made every six hours. (It is imperative that the best and most decisive medical men available should direct this work.) The severely wounded were sent to our advanced operative station, which was 12 kms. behind the front line at the beginning of operations. Inasmuch as the distance between the two stations was only about 200 yards, the mule-drawn ambulances were used for this purpose. The less seriously wounded were evacuated by truck and attached motor ambulance company to Evacuation Hospital No. 5, which was stationed 19 kms. farther in the rear. From here evacuation was carried out by train to Paris.


110

4. One train of wounded was also evacuated by train direct from La Vache Noire to Paris, the latter place being just about 1 km. from the triage, at a tine when sufficient motor transportation to Evacuation Hospital No. 5 was not obtainable.
5.The placing of the triage entirely separate from and slightly in advance of the operating station for seriously wounded enabled the officer in charge of the same to send only non-transportable cases to that station. Abdomens, sucking chests, serious heads, cases in shock or apparently standing transl)ortatiott poorly, and those showiing evidence of hemorrhage were the only ones sent.
6. the total number of wounded was 1,758 up to the time of writing this report. Of these, 256 were sent to the hospital for seriously wounded. Of these 256, 41 were so seriously wounded that they died within a few hours after admittance. Blood transfusion, intravenous injections of gum, and other methods used to combat shock failed to be of benefit in these cases. In addition, seven deaths were charged to the hospital, the deaths occurring en route to the triage, the bodies being brought so that our burial squad could attend to them.
7. Operative treatment was given to the 215 cases remaining. Amongst these cases there were 34 deaths. The separate wounds encountered in the 215 cases were 419 in number, and were divitled as shown in the following table. The wounds encountered in the cases that proved fatal are also tabulated.

CHART

Cases showing evidence of fulminating gas gangrene totaled 8; of these, 2 died. Figures were furnished by the adjutant of Evacuation Hospital No. 5 upon September 1, which showed that tip to that time 1,635 casualties from the 32d Division had passed through their hands. Of these, 367 were gas cases and 122 medical, leaving 1,146 surgical cases.
8. Of the latter, 676 were operated upon at No. 5, and amongst these there had been but 6 deaths, which showed that the sorting at the triage had been exceedingly well done These showed wounds of chest, abdomen, right and left femur, gas gangrene of right and left feet, and a case of hemorrhage from a neck wound. These cases had been sent on from the triage at a time when the advanced hospital was filled and it was thought that they might receive attention sooner if sent on. This probably should not have been done and was an error in judgment on mvy part, as possibly some would have been saved if attended to at the advanced station.
9. A good proportion of the cases which so far have survived operation at the advanced institution were in shock, or showed evidence of having suffered from considerable hemorrhage, upon arrival. In fact, the percentage of these cases was so large that a rule was adopted that every case entering the hospital should first be seen by the head of the shock team, and that the order in which surgical attention was given was under the direction of the shock team entirely, inasmuch as through their constant observation they were able


111

to estimate when a case should 1be operated ujion much better than could the operating surgeon who was busy with many other things.
10. The shock team furnished was No. 116, and their work was of inestimable value. I would request that in the future two teams be assigned to this division, when in all active sector, so that it will be possible for one to relieve the other. It was found necessary to divide the last team and add one more officer from our own dlivisional personnel in order that this team could functionate in 12-hour shifts.
11. I would again request that two X-ray teams be furnished our advanced operating hospital, so that it will be possible to work 12-hour shifts there also. The team attached to us worked constantly without rest for over 48 hours and carried on with but little sleep for the full six days.
12. One operative team was furnished us by the surgical department for our advanced unit. This was Navy Operating Team No. 1. The work done by this team was excellent, and I would again suggest the necessity of more equipped teams for advanced hospitals during active times.
13. As in our former drive, it was found necessary to make up teams from the officers and enlisted personnel of the division. These were practically the same as those detailed dill the report upon activities in the Fismes sector. Six such teams were used, and without such resources it would have been impossible to give the seriously wounded the attention required.
14. An attempt was made to follow up the cases operated upon in our advanced institution in order to ascertain what the ultimate outcome was. A total of 88 cases were seen in the base hospitals in Paris. Of these, 14 had been operated upon at Field Hospital No.127, and amongst these there had been one death from gas gangrene.
15. Some system Of follow-up should be devised whereby a record of these cases can be kept and thus the ultimate value of advanced operative institutions for seriously wounded can be ascertained. It would appear, however, that there is a decided place for small mobile advanced institutions, which should i e attached to each division, especially if our evacuation hospitals are to be stationed so far in the rear. Such institutions are absolutelv essential in case of all advance of 10 kms. or more if our seriously wounded are to receive proper attention.

(Signed)
J. W. VAUGHAN,
Major, Medical Corps, United States Army,
Consulting Surgeon.

THE EVACUATION HOSPITAL

In both trench and open warfare the evacuation hospital is usually the first surgical formation reached by the wounded that is completely equipped and prepared for the treatment of all cases. At the evacuation hospital, which operated either alone or in conjunction with one or more mobile hospitals, primary operations were performed, emergency operations performed at the more forward stations were revised, the severely wounded were hospitalized until they either succumbed or became transportable to the base, and all transportable wounded, after receiving appropriate treatment, were evacuated immediately in order to make room for other convoys of wounded.

FUNCTIONS

Evacuation hospitals which reached the zone of the armies were operated directly under the jurisdiction of the army surgeon and not under the chief surgeon of the line of communications, as our regulations had stipulated previous to our entry into the war.18 The army surgeon, cooperating with the


112

deputy of the chief surgeon, A. E. F., at G. H. Q., supervised their distribution, location, and expansion, coordinated their activities with the service of the front, and, through a medical officer assigned to the regulating station, effected their clearing by hospital trains. In the few instances, when evacuation hospitals were not located on a railway line, the army surgeon effected their evacuation to a railway by ambulance companies under his command.18 These evacuation hospitals, too, were supplemented by mobile hospitals, which performed similar functions but were smaller and more mobile.

While in certain respects our field hospital continued to be an emergency hospital for the battlefield, it became more nearly a magnified and improved dressing station than a hospital. This made the evacuation hospital the actual theater of our surgical effort there, especially during very active periods. The evacuation hospital, plus the mobile hospital and the mobile surgical unit, thus constituted the hospital for early surgery; upon it, to a very great extent, the patient's life and limb depended. It proved a necessary to apply in this hos- pital with great rapidity, to the most urgent cases, the best treatment known to modern surgery, in order to secure satisfactory professional results, and at the same time, in order to secure the best administrative service, it was likewise necessary to evacuate its patients as quickly as possible to provide beds for incoming wounded. To a certain degree these needs conflicted, and it was only by the utmost diligence and perspicacity that they could be reconciled in periods of stress, or, that, if this proved impossible, their conflict could be reduced to a minimum.19

It should be explained here that our medical service did not accept the tenet of our Allies that the more lightly wounded should receive preferential attention in the zone of the armies because of the greater probability of their return to active service, and also because a greater number could thus be cared for in a given period.20 Increased knowledge of surgery proved that removal of devitalized tissue and foreign bodies from slight wounds could be accomplished successfully back of the zone of the armies, and that surgical interven-

FIG.91.– Sorting wounded


113

tion within 12 hours was not essential in the slighter cases in order to prevent infection by the gas-forming bacilli.21 The earlier belief that early operation was essential in all cases had an important influence, however, in causing the British and the French to locate so many large, relatively immobile hospitals so close to the front. Their entire evacuation hospital service was also profoundly influenced by the fact that shell wounds, so common in this war, were practically always infected by gas-forming organisms, and that, in order to get the best results, operation was advisable within 12 hours after injury.21 At such operations foreign bodies were removed, the wound débrided and left open until bacteriological examination showed that its closure was warrantable. This last procedure, in uncomplicated flesh wounds, was usually possible in four to five days and recovery was complete in from three to five weeks. No one questions the necessity for very prompt action in serious wounds, but it had also been believed that return to the colors would be expedited if the slightly wounded as well as the seriously wounded could be operated on within 12-hour limit of time. Later observations showed that practically the same results were obtained in the slightly wounded, without retained foreign bodies, if operation were delayed 24 hours or even longer. Upon this knowledge was based the American policy of sending such cases farther to the rear for operation if pressure was such that their numbers would overtax an evacuation hospital of approximately 1,000-bed capacity at the front.21
          
Our evacuation hospitals then sought especially to give surgical treatment to severely wounded patients whom it was not advisable to send, unoperated upon, farther to the rear, and then to hospitalize such patients until they were fit to be moved, so far as might be necessary, but only, as circumstances permitted, to hospitalize here also the less seriously injured. As a rule, the treatment given the latter was temporary, though sometimes it was definitive, but

FIG.92.– Wounded awaiting admission to hospital


114

this was only if the demand for beds was not pressing. In times of great stress there were never enough evacuation hospitals at the front to give full surgical attention to all the wounded: nor was it proposed that there should be, for such provision would have required tn excessively large hospitalization in the zone of the armies. Except for the small percentage of very seriously wounded Who had to be hospitalized in evacuation hospitals because they could not endure transportation to the rear, our evacuation hospitals were merely relay or clearing stations in the hospitalization and evacuation chain.

While the more seriously wounded properly required two weeks' hospitalization after operating before being transferred, sometimes the demand for beds was so great that the more seriously wounded had to be removed in less than half the time. Brain injuries, if operated upon here, were kept, if possible, at least 10 days. Knee-joint, abdominal, and chest wounds were retained from10 days to two weeks when ]possible, but patients with these wounds sometimes were evacuated after five days, or, very rarely, in even less time. Patients with compound fractures of the femur were kept as long as possible.21 It was estimated that about 10 percent of the beds in evacuation hospitals would ordinarily be used for the, severely wounded and the remainder for patients to be evacuated immediately. It was recognized, however, that this proportion, like many others pertaining to evacuation hospitals, was subject to radical modification in order to meet the constantly shifting military situation and its hospital requirements. 21 Elasticity of this hospital proved essential in both size and service.16

The capacity and organization of individual evacuation hospitals were based, to at certain extent, on an estimate of what the maximum daily admissions would be. With some exceptions these did not exceed 1,000, but on some occasions there were more than 1,400; for example, in Evacuation Hospital No. 9, on October 10, 1918, during the Meuse-Argonne operation.22 Excessive pressure, due to the intake of more patients than an evacuation hospital could care for, was controlled sending patients out on reoperative trains," though


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some hospitals objected to this practice on the ground that it indicated inability of the institution to handle patients properly. It was contended also that the time which must elapse before these patients could be delivered by train to hospitals in the rear would exceed the length of time they would have to await operation in the evacuation hospital concerned and that their chances of infection would thereby be increased. In any event, these patients were transferred from the evacuation hospital only after very careful examination an redressing. The transferable were held to include those with such injuries as fractures caused by rifle and machine-gun bullets, but without much bony destruction; gutter wounds; and flesh wounds with retained bullets. But local demands and the resources available at the time really determined what classes of patients should be transferred. An important factor influencing the use of preoperative trains was the number and rapidity of operating teams available at the evacuation hospitals. The number of operating teams was increased in the evacuation hospitals; then work was speeded up. The number of unoperated patients it was necessary to evacuate from the evacuation hospitals during the Meuse-Argonne operation fell from above 1,370 in the first phase of that engagement to 293 in the second.23

When the 24-hour intake of patients at an evacuation hospital exceeded 1,000 the routine plan of work ordinarily had to be changed if all patients were to be cared for locally. The necessary speeding up of operating teams under such circumstances depended or their good organization. Shifts at the eleventh hour generally proved unsatisfactory, and it was found that sometimes, due essentially to inadequacy in number, experience, and speed of operation teams, preoperative trains had to be used How severe the pressure was at times is indicated by the tact that in the six weeks subsequent to June 13, 1918. Evacuation Hospital No. 7, at Coulommiers, near Chateu-Thierry, received and evacuated 27,000 eases. Between June 14 and November 11, 1918, it admitted more than 50,000 patients,24 while Evacuation Hospital No. 9 admitted more than 32,000 during the Meuse-Argonne operation, September 26 to November 11, 1918.22

Generally speaking, more than half the patients admitted to evacuation hospitals in the zone of the armies were surgical cases, and of these about half were operated upon. Data on this subject, however, are incomplete, and these figures apply only to those hospitals which reported on this subject.

The quota of personnel on duty in the receiving ward also differed somewhat in the several hospitals, but usually it consisted of 2 officers, 1 sergeant, 8 clerks, 2 guards, and 8 or 10 litter bearers. Officers on dluty here gave emergency treatment in case of hemorrhage, supervised litter bearers' activities, the preparation of records, and the care of valuables, made appropriate note on the admission and of a patient if antitetanic serum had not been administered and distributed patients to wards for gassed and medical patients, to the dressing tent for walking wounded, to the preoperative ward or to the shock ward, as the case might be. Records were made here giving each patient's name, his military designation, diagnosis, and any other necessary data obtained from personal interrogation and from an examination of his field card and diagnosis tag.20 If the patient was unconscious these facts were obtained


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from other patients accompanying him and from his identification tag, as well as from the other sources mentioned.25 In some hospitals a nominal list was usually made on the admission of patients, and two copies of Form 52 were made out for each patient in the wards. One of these was sent to the sick and wounded office at once, and this furnished the data for reports called for from the hospital. The other copy was turned into the sick and wounded office when the patient was evacuated. In other units complete records were made, so far as this was possible, in the receiving ward, and these records were supplemented later by data from the operating room and wards. Walking wounded who were seriously injured were sent to the preoperative ward, tagged for immediate attention. Similar tags were placed on shock patients and on those with tourniquets.

The dressing room for the slightly wounded was locate(l near the receiving tent. Its equipment was simple, consisting of one or two operating tables, benches, a table for instruments, and dressings and utensils which had been sterilized in the main sterilizing room.25 One or sometimes two officers, assisted by one or two nurses and by two or three enlisted men, were on duty here. At this point al second sorting was effected. The officer on duty examined, dressed, and recorded patients admitted to this department, giving antitetanic serum to such patients as had not already received it. Patients requiring immediate operation or who might be evacuated at once (on litters, if the pressure was great) were properly tagged and sent to the preoperative ward. Patients whose conditions were not critical, requiring X-ray examination, were sent to the X-ray department. Since patients with very serious injuries for example, injuries of the large blood vessels and even compound fractures of the skull-were sometimes ambulatory, careful attention was given every wound, however slight it might appear to be. At this point, too, careful search was made for injuries of nerves and blood vessels. Provisional diagnosis and administration of antitetanic serum or morphine were noted on the patient's field medical card.25

Other patients than those already mentioned were sent to the wards for slightly wounded, or to the evacuation ward, after their wounds had been dressed and they had received hot food or drinks if, as in some hospitals, these had not already been given in the receiving ward. Slightly wounded patients who had developed intercurrent diseases, such as pneumonia, dysentery, or the like, were sent habitually to the appropriate medical wards. 25

Decision as to whether slight wounds should be operated upon was based on the rate of admissions, the number of surgical teams and their speed. It was found that an experienced team operating two tables often handled 35 or40 minor patients during its shift; later this number was notably increased because of better organization and improved skill, until many teams operated upon more than 60, some more than 80 patients, and one team more than 90 patients, during the daily shift.23 In periods of comparative quiet at first practically all surgical patients admitted were operated on, and toward the end of the war this was the case even during periods of great military activity. The chief of the surgical service kept his teams fully occupied, the number of preoperative patients transferred being limited only by the surgical facilities locally available.25


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The third major sorting of patients was effected in the preoperative or classification wards, which received the wounded admitted on litters and certain ambulatory patients sent from the dressing tent. Patients received here required So percent of the professional skill available in an evacuation hospital. At this point, on alternating day and night shifts, were stationed the most experienced men on the professional staff, selected with regard to accuracy and rapidity of decision and adjustability to the constantly shifting standards which controlled the disposition of patients. The quota of nurses and orderlies in this department was large; usually there were 1 officer, 1 nurse, and 4 enlisted men to each ward. Day and night shifts were provided. Patients were undressed, bathed, if possible, and their wounds were examined and dressed. When possible they were undressed in one tent and their wounds were dressed in another. 20

In some hospitals a sketch and description of the wound were made when patients were being bathed, and this record accompanied the patient to the operating room. If the patient's condition was critical, his clothing was not removed until he had been anesthetized, or, if he was badly shocked, not until rising blood pressure warranted it.20

In the preoperative ward waiting patients received morphine, if this was needed, and hot drinks and food if these had not already been administered or if desired.25

The success of an evacuation hospital's service was commensurate in very large degree to its methodical and successive distributions of patients. At the three points mentioned above-receiving ward, dressing room, and preoperative ward-it was essential that there be prompt, accurate diagnosis and immediate distribution in conformity with very changeable demands for evacuations. Distribution from the preoperative ward was determined primarily by the number of patients to be cared for and by the facilities for operating, and not entirely by the patient's condition. When operating teams were limited in number, or were inexperienced, a rapid influx of patients would change the standard of selection of patients for operation from all-litter and the more serious walking cases into, for example, a very much more restricted class composed chiefly of patients with abdominal wounds, aspirating chest wounds, and fractures of the femur by shell fragments. Under such circumstances patients had to be sent out on preoperative trains until operating teams were furnished in sufficient number and had acquired sufficient speed to care for them.20

Only in exceptional cases were patients sent from the preoperative ward direct to the operating room. These included patients with active hemorrhage, or patients received with tourniquets in place, and with certain fractures without splinting.20

The preoperative ward, X-ray section, operating rooms, and wards for the severely wounded were grouped as near together as possible, for it was essential to reduce carriage by litter to a minimum. If this was not done, it was found that litter squads were exhausted after a week's offensive.20

Patients were distributed from the preoperative ward, according to rate of admission and available operating facilities, into (a) special wards for head,


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chest, and abdominal patients; (b) shock ward: (c) X-ray ward: (d) operating rooms; and (e) evacuation ward.20

In some hospitals, to facilitate their care, patients with head, chest, or abdominal wounds were segregated in a special ward which accommodated both preoperative and postoperative patients. Such a ward was best located next the shock wards, but was not attended by the same personnel, the shock teams being fully occupied in their own department. When this arrangement was followed, this special ward received, among others, patients who were too badly shocked to undergo immediate operation.20

The special ward for head, chest, and abdominal patients, containing those both operated and unoperated upon, was in charge of one of the most competent officers available. If patients with head injuries were to be operated upon before evacuation, the operation was performed as soon as possible. Patients with abdominal wounds were operated upon as soon as their condition warranted. In injuries of the chest immediate operation was indicated in only a small group of cases: (1) Aspirating chest wounds; (2) large retained foreign bodies; (3) severe injury of bones; (4) complicated lesions of the diaphragm.20 Other chest wounds were sent to this ward for observation and were there placed in the sitting position, given morphine, splinted by adhesive plaster when this was called for, and administered other necessary treatment. A combined infection by B. welchii and streptococcus usually required operation, but a large majority of the chest wounds did not require surgical intervention.

FIG.94.- Recovery ward of an evacuation hospital.


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Those requiring it were X-raved, and in many cases it was found that if the missile had originally been embedded in the lungs it had dropped down and could be removed from the bottom of the chest cavity. A thorough examination of the wound was made and drainage established if needed. Preoperative treatment of head, chest. and abdominal wounds, and decision concerning operation, required special care, skill, and judgment. Head wounds, no matter how severe, usually did better if treated at once, but such interference delayed the evacuation of the patients concerned by some two weeks. Whether operations should be performed here or deferred until the patient reached a base hospital where he could remain indefinitely was a highly controversial subject.20 From a professional standpoint, operation on head wounds at an evacuation hospital was indicated; from a military standpoint that is, the necessity for evacuation it usually was not. This was one of the instances where individual and general interest conflicted. 20

For the shock ward a Bessonneau tent usually was employed, equipped with all means for treating shock, including heat, posture, morphine, fluids. and gum acacia solution, or citrated blood. It was adjacent to the preoperative ward, and in addition to being kept at a high temperature--90 F.--was equipped with hooded tables which further secured warmth to patients in a state of shock. In general, this ward received patients with blood pressure below 100, and other patients as condition indicated. 20 A large proportion of patients admitted here had fractures of the femur, and most of its other patients had severe and multiple injuries. Patients were usually sent to this ward direct

FIG. 95.– Heating chamber for shock cases


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from the receiving department, but occasionally those who had developed shock more slowly also reached it from the dressing room, from the preoperative ward, or from the operating room. When a shock patient had improved and his blood pressure was rising, the chief of the surgical service determined when operation should be performed. As delay now meant increased infection or lost opportunity, such patients had precedence over all others except those with active hemorrhage. Patients who developed shock while under operation were sent to the shock ward, or, if necessary, were transfused by the shock team while on the operating table.20

It proved convenient to place the X-ray department at one side of the operating room and the sterilizing room at the other side. If a Bessonneau tent was used for the X-ray department there was room for dental and laboratory departments in the same tent.20

The X-ray ward was also close to the preoperative ward and sometimes connected with it. Its interior was darkened by black cloth or paper. Selection of patients to receive fluoroscopic or screen examination was made by the chief of the surgical service. Most patients so examined were those with fractures or foreign bodies. Clean, uncomplicated, perforating bullet wounds were not examined radiologically, as a rule, unless the missile had passed close to a bone or a joint.25 Shell wounds, on the contrary, required X-ray examination in every case, as otherwise it was impossible to determine the presence or location of shell fragments in the deeper tissues. Injuries to the cranium were photographed both to facilitate immediate care and to furnish a record for the use of other surgeons who would attend the patient in future.25 However, plates were used only for conditions of peculiar interest and where accurate localization of foreign bodies was desired. Whatever the method of examination employed, the radiographer made a record of his findings in a brief note or sketch on a slip which was affixed to the patient's field medical card or entered it on the card itself. As a matter of fact, the majority of patients operated upon were examined radiologically before they were sent to the operating room, though certain types were operated on without this; for example, those with active hemorrhage or those received with a tourniquet in place, and fractures that had not been splinted before admission.20

From the radiological department the patient was sent to the operating room; or, if no fracture or foreign body was found, and (before team service was fully developed) if early operation was not possible, to the evacuation ward. 20

Though operating-room facilities differed considerably in the several hospitals, when possible to avoid it, not more than 10 patients were allowed to accumulate, awaiting operation. A Bessonneau tent, floored with wooden sections (transportable) and provided with a sectional table and one sectional shelf under it running the length of the tent, proved very satisfactory, but two such tents were advisable to meet emergency needs. One of these was sometimes used for minor injuries only.20 The top of the table mentioned was used for scrubbing basins and sterile instruments, while the shelf below contained packets of gauze, towels, sheets, bandages, and similar articles, and below this, on the floor, was space for splints. The operating tent was made light-


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proof by black linings with hinged window flaps. From 6 to 10 operating tables--usually 8--were spaced on the side of the tent next the long table holding instruments, leaving a 4-foot passage at their other end for litters, which were made to pass in one direction only. One or, if possible, two electric lights-one on a long cord, and each provided with a cone shade to prevent dispersion of light rays, especially upward-were placed over each operating table. Tables were provided also with slings, rigged up on wires. Each operating team used two tables, a method which speeded up work considerably, especially on minor wounds requiring local anesthesia and head wounds which required shaving of the entire scalp. Patients with abdominal, head, and chest wounds were assigned to special teams.20 Local regulations concerning such matters as suture or nonsuture of wounds, hours of assignment, and conservation of supplies were posted, especially for the information of surgical teams temporarily assigned.20

Two surgically clean nurses, with all the available instruments boiled and divided equally between them, could supply any number of teams that could operate in a Bessonneau-tent ward. When each shift went off duty, and, as happened much more frequently, when a break in asepsis or other condition required, an entirely fresh layout was made.20

An orderly served each shift, noting on each patient's field medical card a statement of the surgeon's findings, the operation performed, and the word "evacuate" or "detain." Patients held included especially those with wounds of the head, chest, and abdomen, with fractured femur, and with shock. A copy of the note made was entered in the operating-room book, supplemented by an entry of the patient's name, his official designation, the interval between injury and operation, the diagnosis, and the X-ray report. The operator's name followed both entries. Decision as to whether patients were to be evacuated was influenced by admissions, concerning which the chief of the service kept the operating teams informed. The field medical cards of patients who died on the operating tables were completed and turned in to the record office.20

The operating room was usually in charge of an officer under whom were the recorder, a noncommissioned officer in charge of the enlisted personnel then on duty, a nurse in charge of sterile instruments, an enlisted man who received them from her for each operation, three general utility men to move patients and to hold a leg or an arm to facilitate operation, six litter bearers, one messenger, and one man in charge of sterilizing dressings. The nurse in charge of sterile instruments had a great quantity of these at hand on a table provided for the purpose, and issued them as called for.25

When a patient was carried from the operating room he passed the assignment sergeant, who designated the ward to which he should be taken. This was determined from notes on the patient's card-evacuate or detain- and from the record kept here of the location of vacant beds. Sterilization apparatus was installed in a hut or tent near the operating room, but separate from it, as a rule, because of the danger of fire. This equipment approximated the following articles: Autoclaves of 24-inch diameter, numerous drums for dressings, instrument boilers, and three vessels each


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FIG. 96.- Fracture ward of an evacuation hospital

FIG. 97.- The splint room of an evacuation hospital


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provided with a faucet and having a capacity of 25 gallons. The last named were supported on an iron foot base and all were heated by gasoline burners. There was some variation in this equipment, the personnel of a unit sometimes showing considerable resourcefulness in extemporizing apparatus.25

The work of sterilization was conducted as a rule bv two nurses assisted by two or three enlisted men.25

The wards of the hospital other than those mentioned above were for postoperative patients, for other surgical patients awaiting evacuation, for certain medical cases, and for gassed patients. In postoperative wards alternate shifts of one officer, one nurse, and six enlisted men usually were provided. In some units the operating surgeons spent eight hours a day in ward service. These postoperative wards, like others, were assigned to different ward surgeons who might or might not be members of operating teams. As a rule, ward surgeons dressed postoperative cases except when these were difficult and the admissions few. All surgeons in charge of wards carried out the usual administrative record routine, making needed notations on field cards, daily reports of transportable and detention patients, classifying transportable patients as "walking" or "litter," "medical" or "surgical'" "officers," and so on.20 This classification was made daily: in some hospitals twice a day. In certain hospitals patients were tagged for removal with distinctly colored cards.

GENERAL SURGICAL RULES

The following general rules concerning operative treatment in evacuation hospitals are based on the collective experiences of medical officers in the American Expeditionary Forces:

PREOPERATIVE PREPARATION

One should put in operation all methods which can be applied in advance in order to increase the margin of operative safety. The patient's temperature must have been brought back to normal, and it must not be allowed to fall as the result of exposure, wetting, or rough manipulations incident to surgical preparation of the operative field or to transportation from the receiving tent or ward to the operating table. Bring the life of the cell into the best state possible before the operation; blood transfusion may have to be supplemented by the free administration of water, per os, per rectum, or intravenously. Water must be given in advance of the operation: one can not water a cell in a moment; it takes time to do it. It takes more time to water cells when they are sick than when they are well; therefore one must give hours of time to watering the cell. The greater the degree of shock the less absorption will there be through the lymph channels; therefore subcutaneous injections of water are frequently useless and may permanently damage the tissues they compress.

The exhaustion of starvation must always be considered and relieved. Regardless of the severity of their wounds, nine out of ten wounded soldiers clamor for food before they are discharged from the ambulance. There is no logical reason why soft, easily digested warm foods should be withheld.


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Soldiers with intra-abdominal lesions should, of course, be excluded from the buffet which forms so important a part of the admitting tent; practically they are the very ones who manifest no desire for food. While admitting the fact that the giving of nourishment to a patient who will shortly afterwards be anesthetized presents certain esthetic disadvantages, no harm can be caused by this custom. When one has seen hundreds of wounded men eating their fill at the buffet and then, deloused, washed up, and clothed in clean pajamas, fall into their beds and into profound slumber, from which they awaken a few hours later strengthened and refreshed for their operative ordeal, there can be no further doubt as to the best procedure to follow.

Preoperative purging should be omitted. Up to the present time no definite proof of the actual existence of intestinal auto-intoxication has ever been demonstrated. That purging induces gas formation, harmful peristalsis, dehydration, and disturbed sleep is beyond question.

The preparation of the field of operation should be intrusted entirely to a properly trained orderly, usually forming part of an operating team. Having bared the wounded area with a minimum amount of exposure of the patient's body, the dressings should be removed and the wound protected from contamination by means of a gauze sponge or wad of sterile cotton. Shaving should be gently done and the remaining lather removed with pledges of gauze or cotton. Violent use of a brush for scrubbing is undesirable, as it uselessly traumatizes the skin; a gauze sponge saturated with soap and water is preferable. Large amounts of water or antiseptic solution poured over the operative field do no good and tend to lower body temperature through vetting of skin and drapings. The placing of rolled sterile towels or wads of cotton around the dependent portion of the field of operation will prevent or minimize the wetting of the body. Whatever solution is used should be wiped or mopped up as the cleansing progresses. Having completed the mechanical cleansing of the operative field, the gauze plug in the wound should be removed and the area swabbed with ether and painted with tincture of iodine. A dry piece of gauze or sterile towel should protect the wound until the surgeon is ready to operate.

Immobilization of compound fractures must be maintained throughout the preparation of the operative field. This is always possible when a Thomas arm or leg splint has been previously applied and slings arc available over each operating table for elevation of extremities.

A hypodermic injection of morphine, grains ¼, and atropine, grains 1/150 , should be given by a nurse one hour before the operation, unless there has been a previous administration of the same. The operative field can be prepared without disturbing the patient's sensorium if he is narcotized; in cases associated with extreme pain the dose of morphine can be repeated.

STERILIZATION AND SURGICAL SUPPLIES

The sterilization room must be adjacent to the operating tent or barrack and should include storage of splints and sterile goods. Two teams on 12-hour shifts should be constantly on duty. Two orderlies clean and scrub the instruments; one orderly repairs the gloves and sharpens scalpels; and a nurse superintends the storing of the instruments into standard sets and their subsequent


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sterilization. The size of these teams may have to be much increased if additional teams are operating. The preparing of standard debridement sets and standard dressings in anticipation of the arrival of a convoy of wounded is of extreme importance and the sterilizing room must at all times keep ahead of the demand. During the World War, a debridement set usually comprised the following instruments: Tate's straight clamps, 4; Tate's curved clamps, 8;Kocher's clamps, 4; French (terrier) clamps, 5; mouse-tooth forceps, 2; scissors, curved, 1; scissors, Mayo, 1; Allis's forceps, 3; towel clips, 4; needle carrier, 1;retractors, small, 1; grooved director, 1; scalpel, 1; needles (two of a size), 6.

Special instruments and special dressings can be added when called for according to the nature of the wounds presented by any particular case. These complementary sets should all be made up and sterilized in advance. Abdominal, amputation, craniotomy, bone and lung sets were all standardized, as follows: Abdominal complementary set: Ribau retractors, 2; self-retaining retractor, 1;deep abdominal retractor, 2; sponge sticks, 2; intestinal clamps, straight, 2;intestinal clamps, curved, 2; Tate's curved clamps, 6; needle holder, Mayo, 1;tissue forceps, 1; Blake suction tip, 1; needle, cutting, Martin, 1; needles, Mayo,2; needles, Ferguson, 2. Amputation complementary set: Amputation knife,medium, 1; amputation knife, Catlin, 1; saw, 1; Gigli saws with handles, 2;lion-jaw forceps, 1; retractor, 1; metacarpal saw, 1; rongeur forceps, 1. Crani-otomy complementary set: De-Vilbiss with blade, 1; drill with burrs, 1; bone punch, 1; chisels, 2; trephine, 1; Doyen blunt needle, 1; grooved director, 1;alligator forceps, 1; Gigli saws with handles, 2; Luer syringe, 30 c. c., 1; dura elevator, 1; brain spatula, 1; pad of French needles, 1. Bone complementary set: Periosteal elevators, 2; spoon curettes, 3; mallet, 1; lion-jaw forceps,1; bone-cutting forceps, 1; gouge, 1; chisels, 2; sequestrum forceps, 1. Lung complementary set: Costotome, 1; lung retractor self-retaining, 1; lung forceps, large, 1; lung forceps, small, 2; lion-jaw forceps, small, 1. With each set of instruments the following standard dressings should be issued:

CHART

In addition to the above, the following dressings are called for in special cases: Dakin pads, one-half yard gauze; gauze rolls, five yards.

The above issue of instruments and dressings will prove adequate except in a few cases of multiple wounds or very large wounds. Additional supplies should always be available.

QUALIFICATIONS OF EVACUATION HOSPITAL SURGEONS

War surgery is similar to civil traumatic surgery, except that many of the wounds encountered are more severe and especially more lacerating than usually obtains in industrial surgery. A civilian surgeon thoroughly familiar with his routine work merely has to adapt himself to military conditions and necessities.


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The frontline surgeon is no longer able to choose his own surroundings; he has to make the best of those in which his lot is cast. Of the wounded in detail he can see little; he sees them only en masse. The sine qua non of a good military surgeon is to submerge in a large degree his individuality as promptly and as thoroughly as possible. To succeed in surgery at the front a man must possess adaptability, good powers of observation, mental alertness, and judgment. He must not be carried away by a desire for elaborate and time-consuming technique, which will cause him to prolong an operation anf complete all the surgery in one sitting when only the most necessary work should be done, the rest being left for the surgeons at the base. To get the patient off the operating table in as good a condition as possible and to remove any cause for further complications are the primary desiderata in surgery at the front. It goes without saying that it good physique is necessary to withstand the privations and tremendous pressure of work that one is liable to be subjected to in the zone of the advance, and here the youthful surgeon, other things being equal, is to be desired. Above all, perhaps, the surgeon at the front must not have forgotten his gross anatomy for lie can not safely explore a region for a foreign body or attempt the preparatory treatment of a lacerated wound associated with a compound fracture without its aid. Next in order of importance is a good practical acquaintance with infections; not the bacteriology of the laboratory and the microscope, but the clinical signs, the appearance of the tissues and their behavior when invaded by infectious material. He should know the danger areas for gas infection and be able to distinguish between localized gas infection and the progressive type which rapidly becomes deep and malignant and demands bold and radical surgery. Each surgeon must yield his personal idiosyncracies and desires in the common interest, and use standard sets of instruments and standard sets of dressings, which permit a marked reduction in the general service. He must possess, or be capable of evolving, a rapid though safe technique in order to keep pace with the stream of wounded. Finally, each surgeon must train himself to operate as much as possible by the "'hands-off ' method, i. e., to operate without needlessly contaminating gloves or sterile gown. .As a rule, in active evacuation hospitals only two pairs of gloves and one gown will be issued to each surgeon per period of duty; hence the necessity of rapidly acquiring the above technique. Gloves are easily sterilized, without removal, by scrubbing with soap and water and by immersion in 1 percent of lysol solution, but the gown must be kept free of the operating table and the undraped 1portion of the patient throughout the surgeon's period of duty

GENERAL PLAN OF OPERATING SCHEDULE

Regardless of the terrain, the general arrangement of admitting tent, shock room, sterilizing room, X-ray room, and operating room should be such-is to avoid any retracting of steps from the time of admission to final disposal of the case in shock room, ward, or evacuation tent. This essential system has been aptly termed the "one-way system."

Each operating team, composed of one operator, an assistant, an anesthetist, a "sterile" nurse, and an orderly, will have to work in day or night shifts which vary between 6 and 12 hours each. The orderly prepares the patient for


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operation and assists his team as directed. Another orderly for every two teams should also be on duty to record data concerning the operations and to maintain the operating room blotter, so that a record may be kept of all operations performed in the hospital. In each operating room there should also be one enlisted man, scrubbed up and wearing a sterile gown and gloves, who obtains from the nurse in charge of all the sterile supplies the necessary instruments and dressings for each operation. One utility runner for every two teams will assist in holding legs or arms (where pulleys are not utilized), in changing the positions of patients, or in any other such duties as may arise in the course of or prior to an operation. Whenever possible, an orthopedist should be given supervision of all splintings.

Each team should have at least two and preferably three operating tables at its disposal. Thus the surgeon finishing the important part of one operation may leave the remainder to his assistants while he cleanses his gloves and proceeds to the next table to find the next patient whom he finds anesthetized, his wound area surgically prepared, and protected, and the necessary instruments ready. The third table is used for splinting and will be found to be a great time saver. As one operation nears its end, the anesthetist is replaced by the orderly or nurse who, under the supervision of one member of the team, holds the patient's jaw forward and adds a few more drops of ether, if indicated. Unless this system is strictly adhered to, much time will be needlessly wasted in the operating room. A properly organized system will easily quadruple the operative output of a surgical team--an all important item during a heavy battle.

Six or more litter bearers should be on duty in 12-hour shifts to carry patients from the X-ray room to the operating room and thence to the ward or recovery room for critical cases.

The constant flow of patients should be under the direct supervision of the admitting officer-now become director of surgical material. As soon as a convoy has been disposed of he should take position near the entrance to the X-ray and operating rooms, to prevent undue congestion at any point.

RULES OF GUIDANCE FOR OPERATING TEAMS

For the general guidance of operating teams the following rules were posted in some operating rooms:

General surgical rules for the information of operating teams:
           
Débridement
.- Débridement should be thoroughly carried out in preparation for delayed primary closure. Excise a minimum amount of skin. Whenever possible avoid transverse incisions of skin and muscle. Double funnel débridement in deep penetrating wounds of extremities is preferable to one way operation. Leave no tabs of fat, muscle, or fascia. All high explosive and shell fragment wounds and those due to explosive projectiles must be freely opened and conservative debridement carried out; they should not be sutured. Dakin tubes should be established, if necessary, and gauze lightly inserted. Vaseline gauze on skin for protection. Exceptional cases of exposed blood vessels, head, face, chest and joint wounds may alter the above rules.


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Wound suturing.- Al1 wounds of soft parts to be left open, except: Scalp and face: chest; abdomen--counterdrain when necessary; joints--close capsule. Do not suture skin.
Wound dressing.- Final dressing should preferably be a gauze fluff soaked in Dakin's solution and placed so as to keep the wound open. Some surgeons swabbed the wound out with ether, followed by tincture iodi; others used tincture iodi alone. Conservation of gauze in wound dressings.
Drainage.- Penrose rubber tubing for through-and-through drainage. Mosquito netting soaked in ambrine to avoid plugging wound.
Amputations.- Consultation before all amputations. No guillotine amputations. Conserve all skin possible and as much of the limb as possible, i. e., as safety will permit. This is of especial importance in amputation of the forearm. Large vessels should be carefully dissected free before ligation. Nerve trunks should be severed high.
Compound fractures.- All compound fractures should be approached through free incisions which are to be left open. Loose pieces of bone without periosteal covering should be removed. No wire or bone plates should be used for fixation. Drains must not be placed against bone fragments.
Joints.- Gentle manipulation at all times. Preservation of joint except in the presence of extensive comminution.
Nerves.- Surgeons must examine carefully before operation all wounded extremities for loss of nerve function. Nerves should be sutured with fine silk and then covered with fascia or muscle.
Perforating bullet wounds.- Perforating bullet wounds without extensive bone comminution or injury to important blood vessels or nerves do well with-out operation. If they are to be evacuated, however, they must be débrided to omit the 5 to 10 percent of infection that occurs.
Responsibility of the surgeon.- The surgeon is responsible for everything that happens to the patient from the time he is placed on the table until he is evacuated from the hospital. If the patient is in poor condition after the X-ray examination, the surgeon is not expected to operate contrary to his own judgment. If doubt exists, a decision may be arrived at in consultation.
Records.- Operations must be recorded upon the completion of each case. Always state in the record that the foreign body has or has not been removed.

REFERENCES

(1) Manual for the Medical Department, U. S. Army, 1916, par. 628.
(2) Ibid., Article XIII.
(3) Ibid., par. 633.
(4) Ibid., par. 642.
(5) Ibid., par 681.
(6) Ibid., par. 705.
(7) Ibid., par. 800.
(8) La Garde, L. A.: Gunshot Injuries. William Wood and Company, New York, 1916, 411.
(9) Letter from Dr. J. S. Dauriac, formerly consulting surgeon, French Seventh Army, to Maj. H. H. Young, M. R. C., July 18, 1917. Subject: Medical Department organization at the front. On file, S. G. O., World War Division, Medical Records Section, 726.1 M.
(10) Manual for the Medical Department, U. S. Army, 1916, par. 944.
(11) Manual of Splints and Appliances for the Medical Department. Printed by the American Red Cross, 2d ed., Masson et Cie, Paris, 1918, 46-50.
(12) Report of the Medical Department activities of the combat divisions, by Col. B. K. Ashford, M. C., undated. On file, Historical Division, S. G. O.
(13) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. O.
(14) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. O.
(15) Report of the Medical Department activities, 42d Division, A. E. F., prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. O.
(16) Report of activities, G-4-B, medical group, fourth section, general staff, G. B. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918. On file, Historical Division, S. G. O.
(17) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated. On file, Historical Division, S. G. O.
(18) Evacuation system for a Field Army, by Col. C. R. Reynolds, M. C., undated. On file, Historical Division, S. G. O.
(19) Report on evacuation hospitals, by Maj. Geo.W. Crile, M. C., undated. On file, Historical Division, S. G. O.
(20) Cutler, E. C., Major, M. C.: The Organization, Function and Operation of an Evacuation Hospital. Military Surgeon, Washington, 1920, xlvi, No. 1, 9.
(21) The evacuation hospital, Lecture No. 146, Army Sanitary School, Langres, France, by Col. B. K. Ashford, M. C., undated. On file, Historical Division, S. G. O.
(22) Report of Medical Department activities, Evacuation Hospital No. 9, A. E. F., prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(23) Report on the evacuation of the wounded in the Meuse-Argonne operation, by Col. H. H. Lyle, M. C., undated. On file, Historical Division, S. G. O.
(24) Report on Medical Department activities, Evacuation Hospital No. 7, A. E. F., prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(25) Report of Medical Department Board, C. H. Q., A. E. F., 1919, undated. On file. Historical Division, S. G. O.