Contents

SECTION II

ORTHOPEDIC SURGERY

CHAPTER I

ORGANIZATION

DIVISION OF MILITARY ORTHOPEDIC SURGERY

At a meeting of the American Orthopedic Association held in Washington in May, 1916, it was voted that, in consideration of the possible contingencies which might arise in this country from war in Europe, there should be appointed a preparedness committee, whose duty it would be to consider the needs and equipment of orthopedic hospitals should such be required in any future emergency. The president of the association appointed this committee, which formulated a standardization of special hospital supplies and equipment, and reported to the association at its meeting in Pittsburgh, in May, 1917. Atthis meeting it was voted that the association should offer the services of its members to the Government in any way most acceptable, and suggested that aid in orthopedic methods of examination, treatment, and instruction of conditions affecting the soldier in training, would be a practicable activity.

On July 2, 1917, the resolutions passed by the association were presented to the Surgeon General by a committee, and the suggestions embodied therein were accepted by him. He requested that the committee prepare a brief of directions for distribution to surgeons in camps to serve as a basis of instruction and examination in matters of orthopedic interest. This brief ' comprised instruction in regard to the foot and footwear, and to the affections of joints, spine, etc., and was intended to serve as a guide for the standardization of orthopedic work in military usage.

In accordance with the plan of organization which provided for representation of the different branches of medicine and surgery in the Surgeon General's Office,² on July 25, 1917, a reserve officer was detailed to take charge of the part of the work that included orthopedic surgery and physical reconstruction.³

It was evident at once that a large amount of work would be necessary at the time of the incoming drafts in camps, and as reports from abroad were showing the rapid development of the need of orthopedic surgery among the disabled soldiers, and as it was also evident that there would be need of preparation on a large scale for the care of our soldiers when they should be returned to this country, plans were at once formulated to provide for the work in the Surgeon General's Office. An orthopedic advisory council was formed, composed mainly of ex-presidents of the American Orthopedic Association and of

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those representing the orthopedic section of the American Medical Association, and these representatives were invited to serve in an advisory capacity.⁴

The first meeting was held on August 2, 1917. It was decided at this meeting that a letter should be sent to all orthopedic surgeons, stating that this council had been formed, and requesting that all questions of an orthopedic nature be submitted to and go through the chairman of the council, and that a circular letter be sent to all of the men who were practicing orthopedic surgery, for the purpose of obtaining data on their qualifications and their availability for service. In view of the large number who would be called upon for orthopedic service during this war, it was the opinion that instruction should be instituted in the universities and hospitals to give additional training to those who should take up the work. It was suggested, also, that a circular bulletin be sent at intervals to all who were interested in orthopedic surgery, to give information in reference to the activities of this division. Accordingly, a bulletin announcing the formation and purposes of the council was sent to all the surgeons in the country who were known to be interested in orthopedic surgery. ⁵

The Surgeon General decided, after several conferences with the officer then in charge of orthopedic surgery, to create a division of orthopedic surgery; to plan for the proper personnel both in France and in the United States; to arrange for the necessary hospital equipment overseas, which would provide for the special care of the soldier as soon after his injury as possible; for the development of the orthopedic reconstruction in the United States, and for the work of orthopedic surgery in the Army.^a He directed that a report be prepared which would serve as a basis for the development of such a division, and which would embody the outlines of its work.⁶

It was evident at this period that the immediate needs, in addition to the work already outlined for the cantonments, were: To provide for the care of future orthopedic cases in France by the establishment of hospitals especially equipped and supplied with the special personnel; to provide for the demand for a large increase of available surgeons who could aid in carrying on this increased work, both in France and in the United States; to provide hospital facilities for the orthopedic reconstruction of disabled soldiers returning to the United States: and at the same time to provide the means for the industrial reeducation of these same men, to fit them for return to civil life, and arrange for their installation; to provide a large corps of specially trained masseurs to treat the joint and muscle conditions and deformities such as were being met with in the other countries, and to organize these workers into some official position.

The Surgeon General directed the division of orthopedic surgery to provide the proper personnel, both for France and for the United States, to arrange for the necessary hospital equipment overseas, and to develop plans for orthopedic reconstruction in the United States, including the orthopedic work in the cantonments.
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^a For details of the organization and work of the division of military orthopedic surgery, see Vol. I, Chap. XVII. p. 424.

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After the original personnel of the division of military orthopedic surgery was more or less automatically supplied and determined by the enrolling of the available trained orthopedic surgeons, it was quite apparent that this force must be considerably augmented as the demands upon its numbers increased. It was clear that the source of this supply must be found among the younger general surgeons and a number of the many young practitioners who had already obtained acceptable training along surgical lines.

The policy of the orthopedic division was to depend entirely upon recommendations or personal applications for the first contact with the candidate. When such recommendation or application was received, the person recommended or submitting the application was immediately reserved to orthopedic service if not commissioned, or if commissioned and not reserved for other service. A personal questionnaire was then sent to him.

Upon the return of the questionnaire properly filled, an effort was made to verify the contained statement of the experience and qualifications of the applicant and to decide as to his desirability and his availability. Applicants who appeared desirable and available were then either transferred to the orthopedic service, if already commissioned, or were advised as to seeking a commission before assignment. As soon as possible these officers were assigned to classes in the various courses in order to receive special instruction in both the military and surgical aspects of their future work before assuming their camp duties.

In these early days it was evident that the number of available orthopedic surgeons would prove inadequate and that it would be necessary to give special instruction to some of the younger surgeons who desired to enter the division of orthopedic surgery, in order to train them as assistants to orthopedic surgeons.

Early in September, 1917, arrangements were made with the postgraduate department of Harvard University⁷ and with the New York Post Graduate Medical School and Hospital ⁸ to establish a course of instruction, and a definite syllabus of this instruction was prepared with the advice of the orthopedic advisory council. On October 15, arrangement was made to extend the course of instruction to include Philadelphia.⁷

Early in November, 1917, with the experience gained in the university courses, a meeting of the council and teachers was held in Washington and a standardized course of instruction determined upon, this schedule was used in all courses of instruction.

Through the cooperation of orthopedic surgeons of New York, another course was arranged for that city, instruction to begin November 1.⁹ As many of the men from the far South and Southwest were applying for the opportunity of entering this division and for instruction, it was decided that in order to avoid the expense of long transportation, similar courses should be established in different parts of the country. Accordingly, arrangement was made to organize a course in Oklahoma City, to begin December 1.¹⁰ The facilities at the Army Medical School, Washington, were utilized for special orthopedic instruction.¹¹

In the fall of 1917, an orthopedic service was established at the Walter Reed General Hospital, Washington, and the use of the wards and clinical

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material was offered in connection with the proposed course established officially through the approval of the Surgeon General.¹¹ The first class under this arrangement entered upon the course on November 12, 1917, and the establishment of the course as a part of the Army Medical School was announced.¹²

A medical officer who had had unusual technical training was detailed for service in the Army Medical School as teacher of applied mechanics, apparatus, and plaster, and was also given charge of the establishment of the school. Experts connected with the Surgeon General's Office gave instruction in their special branches. Later, other schools were established, following the same plan and schedule of instruction, and in the summer of 1918, courses were being given in Boston, New York, Philadelphia, Washington, Camp Greenleaf, Chicago, Oklahoma City, and Los Angeles. In all 691 officers passed through the different schools.¹³

By an arrangement with the Bureau of Medicine and Surgery, Navy Department, the courses of instruction in orthopedic surgery were made available for naval medical officers.¹⁴

TRAINING WITH THE BRITISH

The return of the British wounded to England had made it evident that over 50 percent of the serious battle casualties represented chronic conditions of the extremities--bones, joints, muscles, and nerves--and special centers had been prepared for their reception. By the spring of 1917, it was impossible to man these special surgical centers with British surgeons who had had orthopedic training because of the demand on the English medical profession for service on the various battle fronts. It was for this reason that Maj. Gen. Sir Robert Jones, through the British Medical Department, asked for American orthopedic.^{15 a}
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^a The following statement made by Maj. Gen. Sir Robert Jones, R.A.M.C., portrays the othopedic situation in England and, in addition, expresses an appreciation of the activities of the American orthopedic surgeons who were supplied by our Government for duty in British orthopedic hospitals:

"The Great War made so extensive and sudden a demand upon medical overseas service that we were faced with a serious shortage of young medical men at home. This shortage became more and more acute as time passed, and was experienced in every department of surgery. Were it not for the great ability and vision of our Director General (Sir Alfred Keogh) events would have proved much more tragic than they did. As it was, fractures and wounds which had been carefully treated abroad lacked an adequate continuity in their treatment on arrival here--for, owing to the character of our struggle and the sudden and ever growing demand for beds, a fear naturally arose that a stasis would seriously dislocate military operations. Under such conditions a choice of evils favored the rapid emptying of our beds. In the same spirit that the soldiers sacrificed their lives, a further sacrifice was demanded of our wounded.

"In 1916 we were ordered to start an orthopedic hospital for military cases in Liverpool, but at that time so short of hospitals were we all over the country that only 250 beds could be afforded to the so-called chronic or orthopedic cases. At that time it was not fully realized that an ideal orthopedic hospital was primarily intended to prevent the occurrence of disability and deformity, which in so large a proportion of cases were the results of hurried evacuation and inefficient treatment. The wards were immediately filled with a ghastly array of derelicts. In spite of the fact that we were seriously handicapped for want of staff, the experiment proved so successful that I was practically given a free hand to increase oar beds in Liverpool and start similar establishments in other centers. In a few months we had increased our bed acommodation from 250 to nearly 20,000. By degrees the orthopedic hospital was found in London, Leeds, Edinburgh, Aberdeen, Glasgow, Newcastle, Manchester, Bristol, Newport, Cardiff, Dublin, Belfast, and other towns. Instead of deal in merely with cases which resulted from want of continuity in treatment, and which were hopelessly crippled, we received many directly from abroad. This was the opportunity which was needed in order to stem the tide of deformity. Our aim in forming an orthopedic center was to procure:

"(I) A staff of surgeons who had had previous experience of the principles and practice of orthopedic surgery, operative, manipulative, and educational.
"(2) Men who though not specializing in orthopedic surgery were interested in it, and only needed experience to At them to take charge of wards as new centers were formed.
"(3) Still younger men, who were ultimately to go abroad where a training in the elements of orthopedic work would be to their great advantage.

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The first group sent over consisted of 20 selected men.¹⁶ They were surgeons who had had a considerable amount of experience in civil orthopedic surgery and some experience in industrial surgery. On their arrival in England they were shown the work being done in the British war hospitals. A few weeks were spent in learning the types of disabilities that were met as the sequel of war wounds and the methods of treatment that had proven efficacious. Then one or two senior medical officers and several junior officers were assigned to the various hospitals in Great Britain, the principal centers being Shepard's Bush, Oxford, Manchester, Edinburgh, Glasgow, Aberdeen, and Cardiff.  

The Americans were at once put in charge of wards or of services and were made responsible to the British surgeons in charge.¹⁶ The increased staff made possible more intensive study of the cases and closer supervision of the treatment. It also made possible better coordination of the various measures used in restoration of function. One man made or helped make the diagnosis, performed or assisted at the operation if one were required, and had charge of the subsequent treatment, which usually consisted of massage, hydrotherapy, electrotherapy, exercises, and work in some curative vocation. The vocations found useful were fish-net making, basket work, wood turning, jig-saw work, cabinet making, and carpentry. Forestry and farming also were employed.

The types of cases referred to this section were those requiring restoration of function to muscles, tendons, and joints; and as the muscle, joint, and tendon changes formed an important part of the results of nerve injuries, nerve lesions were included, as were also malunited and ununited fractures. As the work developed one surgeon not only took part in, but was made responsible for the ordering of the entire treatment of a given patient, so that there was as perfect coordination of the treatment as possible from the time the patient was received up to the time of his discharge.¹⁶
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 "(4) The center would further consist of a series of auxiliary departments, each under an expert in the particularmethods of treatment under his direction, such as departments for electricity massage, muscle-reeducation, hydrology, and gymnastic drill.

"Every center contained on its staff, in addition to specialists, a well-known surgeon, a neurologist, and a physician and consultations were of weekly occurrence in which every member participated.

"A great feature of these centers was the curative workshops. They acted directly and indirectly on the welfare and recovery of the patient-directly as a curative agent when the work done gave exercise to the disabled limb, the work being employed as an agent in restoring coordinate movements; indirectly in the psychological effect produced by the stimulus of work. King Manuel, representing the British Red Cross and St. John of Jerusalem, was our tower of strength in this department.

" Before the development of these hospitals was in any way complete we were hard pressed to the point of despair for the want of young orthopedic surgeons. It was anathema to keep any young surgeon in the country. The authorities on this point were adamant. Their views were, that as it had become necessary for surgeons with families to go abroad, no excuse could hold good for the retention in this country of young men, no matter how expert. ‘Could not the older men he trained to do orthopedic work,' we were asked. At last permission was given that we could retain 12 young surgeons, and we were promised that under no circumstances would they be sent abroad. This was a great gain; but 12 men could not do justice to so vast a problem as that which confronted us, and the work was sorely handicapped. It was at this moment that your great nation came to our assistance. Sir John Goodwin placed before the American authorities a statement of our difficulties, and they promised us help. I shall never forget the thrillof joy I experienced when there arrived in Liver-pool five young orthopedic surgeons placed at our disposal by the American Government for the period of the war. They were an extraordinarily fine body of men, keen, enthusiastic, and well trained. These units were distributed amongst the various centers and were given charge of wards. It is impossible to speak too highly of their loyalty, discipline, and devotion to duty. There sprang up immediately a bond of fraternity between them and their English colleagues, and the relationship was maintained throughout. The American Government wisely decided that their young surgeons on their way to the war area should spend a few weeks in the English orthopedic centers in order to gain experience. This arrangement was of distinct benefit to both nations. We often had over a hundred American surgeons working in this country at one time.

"I should like to pay a tribute of gratitude to America for the splendid service rendered by these young men. They came to us in our extremity; they filled a gap which seriously threatened to sterilize our reconstructive efforts, and they filled it with distinction and success."

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Into such organizations new groups of young medical men were taken on their arrival from America, trained for three months or more, and then sent to the American hospitals in France.¹⁶ It was a graduate school of the most thorough and practical type and made possible the training of men in a short time to do efficient work not only for the British Army but also for the American Army when they were transferred.

The special points learned were the best means for restoring function to stiffened joints, or, if joints were destroyed, the positions of choice for ankylosis of the various joints as shoulders, elbows, wrists, hips, knees, and ankles. Vocation plays a part in the choice and at first this was not considered. The value and methods of tendon transplanation were carefully worked out. The diagnosis of nerve lesions was studied and the treatment of nerve lesions greatly advanced. Methods of treatment of simple and compound fractures were well learned in the orthopedic centers because the patients were kept there until late results were determined.

Another smaller group of American orthopedic surgeons went overseas with the first American base hospital unit which had been organized under the American Red Cross and hastily commissioned in the United States.¹⁶ They were sent at the request of the British Medical Department to take over, in connection with other American base hospitals, certain British general hospitals in France receiving wounded direct from casualty clearing stations on the Flanders front.

These men were endeavoring to show that orthopedic surgery had its contribution to make to acute general surgery; deformity, if it was to be prevented, must be recognized as potential deformity in the early stages of wound healing. The contribution was not a conspicuous one but nevertheless a real and a considerable one. They learned the wonderful toleration and resistanceof the synovial membrane; how to overcome infection; danger of marking time in war wounds; new methods of immobilization. They did not forget their plaster technique but they appreciated its limitations. They were able to work out a system of splinting which, taking the best that the British experience had demonstrated and adding certain American types which measured up to this standard, has stood the hard test of the war and enormously simplified our treatment of fractures and joint injuries.

STANDARDIZATION OF SPLINTS

In the supply of proper splints to our armies and hospitals overseas throughout the military activities the development of the idea of proper splinting for the wounded did not come suddenly as a completed system but rather gradually, being built up by experience. Early in August, 1917, a number of the senior medical officers of the American Expeditionary Forces saw the advisability of fixing some standards for splints and appliances and surgical dressings for the American Expeditionary Forces. It was realized that the great majority of American surgeons coming to France would have had little or no experience with the treatment of battle casualties and that, unless

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something was done to put the best kind of a system in force at the beginning, our Army would have to start, at the cost of both life and limb to our men, and gradually build up, through recognition of mistakes, to the point attained by the British and French after three years of war experience. A board of selected medical officers was appointed to study the question and make suitable recommendations thereon. This board was commonly known as the splint board. There were two such boards, the first of which was called into existence by a special order issued August 20, 1917, an extract of which follows: ¹⁷

A board of medical officers is hereby appointed to meet at these headquarters, at the call of the president thereof, for the purpose of investigating and reporting upon the advisability of standardizing certain appliances to be used by the Medical Department, and upon completion of this duty will return to their proper stations. The board will be guided by instructions from the chief surgeon.

This board was made up of six surgeons who were especially fitted by their past experience and insight into the requirements of the situation to undertake this work. One of its first acts was to recommend to the chief surgeon, A. E. F.,that it be empowered to choose not only splints but also the surgical dressings and accessories necessary to a complete but limited equipment for the medical units of the American Expeditionary Forces. Further, that it be instructed to produce a small book, suitably bound, that would contain all the information on the character of these supplies for the Medical Department, as well as a simple, definite outline as to how to use them-a manual, in fact, for the use of all medical officers.¹⁸ The chief surgeon approved these recommendations and the board instituted a definite plan of action.

MANUAL OF SPLINTS AND APPLIANCES, FIRST EDITION

Meanwhile the manuscript and drawings for the "splint manual" ¹⁹ were accepted finally and the board adjourned, making the following recommendations: (a) That the manuscript of the manual be submitted to the chief surgeon for his approval and adoption; (b) that the American Red Cross be requested to have 25,000 copies printed for distribution to all medical officers of the United States Army; (c) that the American Red Cross take immediate steps to start the manufacture of splints, so that when our troops became engaged and suffered casualties there would be the necessary appliances on hand to take care of the fractures according to the rules laid down in the manual; (d) that all questions relative to changes in this equipment, or in the methods advised for its use, be referred to the board for its action in order to prevent useless duplication or impractical ideas gaining a foothold.

By way of comment on the celerity with which the labors of the board were accomplished: The order calling the board into existence was issued on August20, 1917; ¹⁷ the date of the commanding general's signed approval of the manuscript of the manual was September 9, 1917; ¹⁸ the first copies of the first edition were delivered to the supply depots of the American Expeditionary Forces six weeks later. The board had also chosen a set of surgical dressings, and had made an agreement with the American Red Cross for the manufacture of the standard splint accessories.

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The following extracts from the introduction to the Manual of Splints and Appliances illustrates the attitude of the board toward their problems:

The board was unanimous in its opinion that the splints and appliances officially adopted by the American Army should possess the following qualifications: (1) Efficiency and correct mechanical principles. (2) Simplicity of design and low cost of construction, so that sufficient quantities may be always available. (3) Transportability, in order that an efficient splint may be applied at the front and remain in situ until the patient reaches the more or less permanent base hospital, and, if occasion demands or the surgeon elects, may even be expected to make possible an entirely satisfactory end result without change of the type of splint.

The Medical Department has no desire to dictate the exact line of treatment which shall be employed in the base hospitals. It is the desire, on the contrary, to encourage ingenuity in devising better methods for the treatment of these bone and joint injuries, which comprise so large a proportion of the battle casualties. The board is convinced, however, after a careful review of existing methods in the armies of the Allies and enemies, and a personal experience in the active treatment of these lesions in the present war, that the simple apparatus recommended may be employed with entire satisfaction as to the end results, and without any great degree of previous training.

The board believes that with the three types of wire-ring traction and counter-pressure fixation splints embodying the Thomas principle, the Jones "cock-up," "crab" wrist splint, the long interrupted Liston splint, with adjustable foot piece, an anterior thigh and leg splint, Hodgen type, the Cabot posterior wire splint, the wire-ladder splint material, light splint wood, and plaster of Paris bandages and Bradford frames, treatment of all bone and joint battle casualties may be efficiently carried out at the front and, if necessary, in base hospitals.

Holding this belief they have been influenced in thus restricting their recommendations to the above types of splints and splint material, by a consideration of the following advantages which their universal use would secure: (1) Possibility of quick manufacture and ease of distribution, thereby making available large numbers of splints of unit construction. (2) The combination of traction and fixation in the same apparatus, thereby favoring the comfort of the patient and avoiding the necessity of accessory adjustment. (3) Universality of type and simplicity of mechanical principle, thereby insuring quick familiarity with their uses and efficient application by the surgeon.
 
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It will at once be obvious that this manual does not aim to be a complete treatise on the treatment of this class of lesions. Its purpose is to put into the hands of the military surgeon a practical, time-saving guide, in which the text has been made completely subservient to graphic illustration.

MANUFACTURE OF THE STANDARD SPLINTS AND ACCESSORIES

The American Red Cross undertook the manufacture of the various surgical supplies that the splint board had adopted as standard for the American Army,¹⁹ until such time as the Army could take over the work and carry it out without assistance from outside agencies, because at that time there was no organization in the American Expeditionary Forces that had either the time or the personnel to undertake such a venture, while the Red Cross had at its disposal both of these commodities.

A bureau was established in the building occupied by the American Red Cross where the samples which were submitted were examined and compared with the models. It proved that unless definite standards absolutely were insisted upon, remarkable variations would appear in the output. Contracts were given to eight shops situated about Paris; however, owing to the difficulty

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FIG. 1.- The Poliquen hitch. This and Figures 2 and 3 illustrate three practical methods of applying traction to a fractured lower extremity over the shoe. These methods are simple and can be executed after sufficient practice in the dark. The adjustable traction strap is a special device for this purpose. The Poliquen hitch and the Collins hitch are made with muslin bandages

FIG. 2.- The Collins hitch

FIG. 3- Special adjustable traction strap for saddle-girth hitch

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FIG. 4.- Adhesive plaster traction. Method of cutting and folding traction, adhesive strips; anterior view of application to leg; lateral view of application to leg; the lateral band 1 ½ inches wide, the spiral strap ½ inch wide.

FIG. 5.- Stocking traction. Light-weight sock cut off at toes glued to lower leg, ankle, and dorsum of foot; piece of splint wood or ladder splint material passed between sock and sole of foot; traction by means of cords tied through sock and splint material.

FIG. 6.- Sinclair skate. A board cut as pictured and attached to the foot by adhesive plaster or glued strips. These strips may be extended up the leg as far as the position of the wounds permits. The position of the foot as to flexion or extension, or as to rotation inward or outward, is obtained by adjusting the screw which slides up and down in slot. The inversion or eversion of the foot is obtained by adjusting the length of the cords as they run to the extension cord

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FIG. 7.- Mechanical drawing of Thomas traction arm splint. For bed treatment chiefly. Uses: Injuries to the shoulder joint; to the shaft of the humerus; to the elbow joint; to the forearm

FIG. 8.- Thomas traction arm splint; applied for bed treatment. Rods are in horizontal plane and arm is resting on slings which are held with clips. By tightening or loosening these slings the position of the fragments of the bone may be modified. Traction is obtained by tightening the extension strips, which are attached to the end of the splint. Note the position of the hand with two-thirds full supination

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FIG. 9.- Thomas traction arm splint applied with rods in vertical place and arm slung from upper rod as is sometimes necessary because of position and magnitude of wound. Traction should be applied by attaching straps to end of splint. Light additional traction may be attached directly tn the splint

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FIG. 10.- Thomas traction arm splint applied to obtain traction on the lower fragment and at the same time to allow flexion of elbow. This position is sometimes necessary with fracture of the lower third of the bone. Traction by adhesive plaster to the skin is preferred, but because of the nature of the wounds this may not be possible

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FIG. 11.– Treatment without splints, due to extensive wounds. The extension should be obtained by adhesive plaster to the skin wherever possible, but if not feasible the sling as pictured in Figure 10 may be used

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FIG. 12 - Mechanical drawing of hinged traction arm splint. Uses: Injuries to shoulder joint; to shaft of humerus; to the elbow joint; to the forearm. Should always be used as splint for transportation

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FIG.13.- Hinged traction arm splint. For application the rods should be Opposite the anterior and posterior surfaces of the arm. The hand should be two-thirds fully supinated. The slings should be applied so as to best support the fragments and to interfere the least with the wound This type of splint may be used for all the purposes of the Thomas traction arm splint. The Thomas traction arm splint, however, should not be used for a transport splint unless the rods are bent at a point 2 inches away from the ring so that the plane of the ring will make an angle of 30 ^° with the rods instead of 90 ^°, the normal position

FIG. 14.- Mechanical drawing of Jones humerus traction splint. Uses: Injuries to the shaft of the humerus, in which traction on the humerus and flexion of the elbow joint are desired; to the elbow joint in which flexion is desired; to the forearm

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FIG. 15.- Jones humerus traction splint. This type of splint is to be used for fractures of the humerus at or below the middle of the shaft in which flexion of the elbow is desired. The splint is to be used largely for ambulatory treatment. The hand should be two-thirds fully supinated. The traction should be obtained wherever possible by adhesive plaster to the skin. The strap across the opposite shoulder to support the splint should always be used and adds much to the comfort of the patient

FIG. 16.- .Jones "cock-up" or "crab" wrist splint and application. Uses: To retain the position of dorsal flexion of the hand in cases of injury to the wrist and in nerve and muscle injuries which produce wrist-drop; to obtain full extension of fingers add piece of ladder splint material, or use ladder splint material alone

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FIG. 17.– Hinged half-ring thigh and leg splint, for transportation use in injuries to the shaft of the femur; injuries to the knee joint; injuries to the leg.

FIG. 18.- This and Figure 19 show method of applying traction to fractured lower extremity in the field. Note the stretcher bar suspending the traction splint and the wire foot support holding the foot at right angle to the leg; also note the method by which the splint is secured to the stretcher bar by the use of bandages. The shoe should never be removed in the field

FIG. 19

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FIG. 20.- Mechanical drawing of long Liston splint with interrupting bridge of iron wire

FIG. 21.- This and Figure 22 show the long Liston splint with interrupting bridge. Applied for stretcher transport only. Uses: Injuries of the pelvis requiring fixation in transport; of hip joint requiring fixation and abducted position in transport. The upper thigh and hip should be supported in transport by a sandbag or pillow or spica bandage. Note the thoracic and leg bandages and bandage passing from thoracic bar over shoulder. Additional slings for support of leg or thigh may be added as desired, and if the bones are much comminuted a piece of wire ladder splint material applied to the back of the leg and thigh under the slings furnishes more complete support

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FIG. 22

FIG. 23.- Mechanical drawing of Thomas traction leg splint. Uses: Injuries to the shaft of the femur; to the knee-joint; to the leg

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FIG. 24.- Thomas traction leg splint with traction attached to end of splint and splint slung from cradle. The position of the foot at the right angle is held by sole band, also attached to the cradle. The supporting slings upon the splint should be of sufficient number to give thorough support to the leg and by the adjustment of these the position of the fragments may be modified as is desired

FIG. 25.- Thomas traction leg splint applied with suspension to the Balkan frame. Additional traction is attached to end of splint and suspended over pulley. The chief traction should always be obtained by attaching the traction straps directly to the end of the splint and this adjusted with the Spanish windlass. Additional traction may be added by direct pull on the splint. The position here shown is that which is desired for fractures above the junction of the middle and lower thirds and below the neck. The same position here shown is desirable for fractures of the femur below this level. By adjusting the position and tightness of the slings the position of the fragments may be modified. For fractures of the middle of the thigh the sling under the middle of the thigh should he tight, since the fragments usually sag downward. For fractures at or below the junction of the lower and the middle thirds the sling under this region should be tight, because of the same usual backward sag of the fragments. The traction hands should extend was near the seat of the fracture as the condition of the wounds will permit

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FIG. 26.- Showing the use of Ransohoff "ice tongs" in conjunction with the Thomas traction leg splint, to secure skeletal traction. At times, because of difficulty in replacing the fragments especially with fracture of the lower third of the femur, skeletal traction is desired until the healing is sufficiently advanced to make the more routine treatment possible. If such skeletal traction is needed the "ice tongs" are preferable to other methods, and if used the points should be inserted just above the widest part of the femoral condyles, as far forward as possible, avoiding the knee joint. This method of treatment is not compatible with transportation, and should be reserved for special cases. Subsequently if transportation becomes necessary before union has taken place the usual methods of treatment should be employed

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FIG. 27.– Position for fracture of neck of femur or fracture into the trochanter. Only such traction as is required to steady the leg should be used, since the crowding of the bones together in this position is desired. Because of the extensive character and location of the wounds the use of the Thomas splint is often not possible, and under such conditions the Hodgen splint straightened at the knee should be used

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FIG. 28.- Mechanical drawing of anterior thigh and leg splint, Hodgen type. Uses: For suspension of the limb from overhead support in injuries to the thigh and leg. NOTE.-At places marked N the rods should be notched or roughened to prevent the supporting straps from slipping out of place

FIG. 29.- Wooden bed frame, for traction by weight, and pulley and overhead counterweight suspension. Application for lower limb injuries, limb in anterior thigh and leg splint, Hodgen type. Uses: For suspension of limb from overhead support in injuries of thigh and leg. This splint is used simply for a frame to sling the leg in case the nature of the wounds makes the Thomas splint impossible. The traction straps should be attached directly to the weight and pulley, and should not be attached to the splint. By careful adjustment of the slings the position of the bone fragments can be controlled

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FIG. 30.– Mechanical drawing of Cabot posterior wire leg splint. To be used with or without side splints. Uses: Injuries to the soft parts of the lower limb requiring fixation in transport; slight injuries to the knee or piece will be inclined and ankle requiring fixation in transport; fractures of the fibula; wounds of the ankle joint; injuries to the foot. The rods of the splint should be thoroughly padded, and they may be bent to allow flexion at the knee if desired. Side splint of wood or wire ladder may be used in connection with the splint if desired

FIG. 31.– Cabot posterior wire splint applied with supination of the foot. When used for injuries of the ankle and tarsus the entire splint should be twisted so that the foot piece will be inclined and hold he foot in the position of varus. The object of this position is to overcome the natural tendency toward the valgus deformity with the subsequent development of flat foot.

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FIG. 32.- Mechanical drawing of ladder splint material. Uses: For shoulder, upper arm, elbow, forearm, wrist, hand, lower leg, ankle, and foot splints; side splints in combination with Cabot posterior wire leg splint; coaptation splints; where malleable light splint material is to be desired

FIG. 33.- Mechanical drawing of snowshoe litter. The snowshoe litter is not only useful in the evacuation of the wounded from the field, but is also useful for transporting cases of spinal or pelvic injuries to the hospitals in the rear

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FIG. 34.- Maddox unit clamps, iron pipe and bed frame clamp. Applied for simple leg traction by weight and pulley

FIG. 35.- Special use of Thomas traction leg splint. Applied over uninjured shoulder, for shoulder and arm injuries. NOTE.-Shoulder straps for supporting splint; thoracic swathe for counterpressure; supporting slings clipped to rods; traction bands; nail twister for maintaining and regulating traction

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FIG 36.-  Hand and wrist splint. This splint should be used for the lacerated wounds of the hand or wrist, being applied over the usual large dressing. While the splint is intended largely for use in the early stages of such injuries, it may be continued into the later stages provided the padding is so applied that the position of the hand and fingers with reference to ultimate function is maintained. When this later stage of the treatment has been reached, a molded plaster-of-Paris splint, or a carefully molded piece of wire ladder splint material, is usually more satisfactory

FIG. 37.- Mechanical drawing of abduction arm splint. For injuries of the shoulder or of the humerus in the upper third it is desirable to maintain the abducted position after the patient is allowed to be up and about. For this purpose a well fitting plaster-of-Paris dressing may be applied. If wounds are present or if less rigid fixation is required, the splint pictured should be used. This is adjustable as to the amount of abduction by use of the shoulder chain, and can be applied with the arm fully extended, in which position light traction is possible, or the arm may be flexed to the right angle or the half this position by the adjustment at the elbow. The arm should be held with the humerus in two-thirds outward rotation. The splint is reversible, so that it can be used upon either the right or left side

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in obtaining raw material, manufacture presented many problems. A large warehouse was established ¹⁹ for the accumulation, sorting, and packing of splints as they came from the factories.

During the months of October and November, 1917, there was much to do in the way of inspection of the output of the splint factories, the board felt keenly its responsibility in establishing a definite standard to which manufacturers of splints should be held. The method followed was to look over the finished product of a factory, comparing it with the working model in the presence of the foreman. After an appreciable number had been collected, the chief surgeon, A. E. F., directed that a certain supply be kept always in that warehouse and that the remainder be shipped weekly to the two medical supply depots,¹⁹ one at Cosne and the other at Is-sur-Tille.

The entire proposition was put on a good business basis. In this connection an effort was made to look ahead in the purchase of supplies so as not only to prevent idleness in the factories for want of material to work with, but also to speed up constantly their output, much assistance being given in this direction by the purchasing department of the American Red Cross. An accurate set of mechanical drawings of the standard splints was made. Early plans were made to have a shop where new ideas in appliances could be worked out; ultimately, this idea was of great value, as several new and valuable appliances were developed in the shops.

Early necessity also was foreseen for having a splint repair shop, where broken and soiled splints could be renovated. At the beginning, however, this seemed very remote, and no definite steps were taken to get this very necessary adjunct to the splint supply of the Army started until well along in the spring of 1918. Then it was started at Dijon, where it served not only as a repair shop, but also as a factory for new splints, and it delivered, in the days of greatest stress, a goodly number of splints each day to the nearby medical supply depot at Is-sur-Tille. ¹⁹

To determine approximately the number of various kinds of splints that would be needed by the American Expeditionary Forces, percentages of the various fractures, from statistics of the casualties that had occurred in the British and French Armies were figured. Upon this basis the splint board, early in October, 1917, placed with the American Red Cross an order for28,100 splints.¹⁹ When about 50 percent complete, the order was increased to 100,000 splints of all types, in the hope that this number would be adequate for the American Expeditionary Forces for a considerable part of the first phase of the military effort.

The varieties and numbers of splints in this first order were based on the theory that we would have about the same proportion of fractured arms and legs among our casualties as the British and French. On the whole, it was nota bad method of apportioning the numbers of the different types of splints, as subsequent orders proved. The full list of splints, splint accessories, and appliances at the disposal of the Medical Department when the 1st Division began to enter the line in the Ansauville sector north of Toul, January 14-15, 1918,was the following: Splints: Thomas traction arm; hinged traction arm; Jones humerus traction: Jones "cock up" wrist; Thomas traction leg; hinged half-ring

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(Blake-Keller) thigh and leg; long Liston interrupted; anterior thigh and leg, Hogden; Cabot posterior wire leg; wire-ladder splint material. Splint accessories: Balkan frame; Maddox pipe frames; galvanized net wire gauze, in rolls; clamps, rope, pulleys, weights, etc.

It is worthy of note that this was the entire splint equipment chosen by the splint board and held by it to be adequate for the Army's need. The number of splints having thus been reduced to 10, it remained to be seen whether this number was sufficient, or perhaps would be susceptible of further reduction, in the practical test soon to be given it.

As events soon proved, however, it became necessary on several occasions to order an extra supply of a certain splint, and indeed, to place large orders for additional supplies of the whole list. Thus in the latter part of June, 1918,when for over a month there had been the severest kind of fighting north of Paris, in which three divisions of the American Expeditionary Forces had suffered heavy casualties, an absolute shortage of splints occurred. On the first of July it was found that the quantity of splints and associated supplies was running very low in the advance area. It was also found that, due to the slow delivery of raw material, the shops were not able to produce up to their full capacity. Every effort had been made to secure delivery of this raw material which consisted of various sizes of iron wire rod used in making the splints. All forms of business in Paris were feeling the strain of the suspense caused by the approach of the German Army. On this account, most of the reserve stock in the Red Cross warehouses in Paris had been distributed. Feeling the necessity for some immediate decisive action, arrangements were made with the French for the immediate release of a considerable tonnage of the raw material needed.

The "third Army order," which called for 54,000 splints, was then formulated. To complete it there was needed 45 tons of steel wire rods, and, as above stated, this was in large part obtained from the purchasing department of the Army.¹⁹

On October 26, 1918, the status of the splint question was as follows:"The Army had ordered a total of 462,350 splints; of these 229,927 had been made up to that date. The total number supplied to the American Expeditionary Forces was 177,468.

At this time the entire order was about 50 percent complete, but since the raw material to complete the entire order was on hand in the storehouse in Paris, the remainder could have been executed by the early months of 1919.¹⁹

During the winter 1917-18 a weekly conference was held with the orthopedic surgeons from the different divisions in order that the details might be worked out and made standard. In order that the system would work uniformly and successfully, it was necessary to settle points like the following: The number of splints which should make up the equipment of a division in the field; how these splints should be divided among the various units of the division; what should be the standard equipment of a battalion aid post; what should be the standard splint and dressing equipment of a field hospital, a mobile hospital, an evacuation hospital, and a base hospital. These and numerous other questions had to be agreed upon, with the realization that the

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men had had but little experience and that changing conditions would change a good many of the rules laid down.

Certain minor pieces of apparatus had to be supplied to make splint application efficient, notably a stretcher bar. It was found while demonstrating the splints to the medical officers of the 26th Division that it was necessary to elevate the end of the Thomas thigh splint to a considerable angle when the stretcher was placed in the small Ford ambulance in order to close the tail gate of the car. An appliance to suspend the splint had to be devised immediately as it was expected then that the troops would be in the line in about two weeks time. A competent stretcher bar was worked out and adopted by the splint board, and 500 of them were ordered made. They were supplied in time to be distributed to the ambulance companies of the 1st Division before that division entered the trenches.

On the night of January 15-16, 1918, the 1st Division moved into the trench positions in the Ansauville sector.²⁰ This portion of the line had long been quiet, being dominated by Mont See, a high hill which the Germans at that time held. In consequence, the trenches were in a poor state and the entire problem of the evacuation of the wounded was one of great difficulty, as it involved long carries by stretcher. It was here that the first actual experience came. Soon there was a daily and nightly run of casualties arising from the increase of artillery activity and from raids. These wounded men had to be carried usually over a mile through a winding trench before they reached the battalion aid post. At night, it was frequently possible to carry the wounded out over the top of the trench, thus immensely lessening the burden of the long carry; in the daytime this was not practical, as a rule, because the country was very flat.

In the town of Mandres an aid station was functioning as a "sorting station," the first post of this kind established in the American Expeditionary Forces. The surgeon in charge was much interested in the problems of the orthopedic department, and he devised a "trench litter" on which, like the Stokes litter used by the Navy, a wounded man could be carried on his side, face down, or head up or down, without slipping off. This was found to be valuable, was approved by the Surgeon General and by the splint board, and was adopted as part of the standard equipment. It proved especially valuable to Artillery troops who as a rule had their aid posts in deep dugouts with narrow entries.

During the last two weeks of August and up to September 12, 1918, efforts were directed toward getting a sufficient supply of splints and accessories forward to equip the First Army, in preparation for the St. Mihiel operation. Supply depots were organized at the Justice group of hospitals and at Souilly-the first to take care of the main effort which was to proceed from the old trench positions north of Toul; the second was to take care of the troops and hospitals on the left flank of the St. Mihiel salient. A system was planned for the return to the front of all splints that had been taken out, by having an order issued that made it imperative for ambulance drivers to exchange with hospitals where they had unloaded wounded, one for one, in blankets, splints, and

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apparatus, so that there would be a return flow of these appliances to the divisions.

Orders similar to the following were issued in army, corps, and divisions, which defined the use that was to be made of the splints:

HEADQUARTERS FIRST ARMY, AMERICAN EXPEDITIONARY FORCES, OFFICE OF CHIEF SURGEON.

Memorandum:

For the purpose of securing ulniforlmity of splinting and the best results in fracture cases, the following instructions are issued:
1. All fractures are to splinted at the earliest possible moment; this means, where the man falls. If this is impossible, the splint should be applied at the battalion aid post. No fracture should pass through the advanced dressing station, "triage," unsplinted.
2. The Thomas full or half ring traction splint will be used for all fractures of the lower extremities from the pelvis to just above the ankle.
3. The Cabot posterior wire splint or wire ladder splint is to be used for all wounds of the calf, ankle, and foot.
4. All wounds of knee, no matter how slight, are to be splinted.
5. The hinged traction arm splint will be used in fractures of the humerus, elbow, and upper forearm.
6. Ladder and wood splints will he used in fractures of the long bones only where traction splints can not be efficiently applied and to supplement such splints.
7. The fact that traction is the immobilizing factor in all traction splints should never be lost sight of and the utmost care should be taken to apply the proper degree of traction to obtain fixation.
 
*     *     *     *     *      *     *    *     *     *

MANUAL OF SPLINTS AND APPLIANCES, SECOND EDITION

In October, 1918, a second board of medical officers was organized to go over the work of the first splint board.²¹ In this way, it was desired to continue this work, adding to it where necessary, and also eliminating anything that might be found to be superfluous.

The new board went over the samples of splints and appliances then in use. The board used the first edition of the splint manual as a model to write another booklet, similar in every respect but containing the changes that the board had seen fit to adopt.18 In a few days the manuscript was ready; it was given to the American Red Cross to have 35,000 copies printed. By the first of February, 1919, its distribution began. In this second edition of the manual it was possible to set down the exact figures for the requirements of field medical units, and various types of hospitals, as to splints and splint accessories.

ORTHOPEDIC DEPARTMENT, A. E. F.

Early in November, 1917, when relatively few American troops were in France, a meeting of the senior orthopedic surgeons of the American Expeditionary Forces was held to go over the situation and plan the course of action which the orthopedic service, A. E. F., should follow. It was decided that it was not the time for the institution of elaborate plans of organization, but one in which the best service could be given by undertaking in a small way the evident problems that faced the American troops and hospitals, and by using the nucleus of well trained medical officers who had been sent to England to serve as orthopedic surgeons with the British, a few at a time, in places where they

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could accomplish something. In that way, an organization could be built up that would fit accurately into the military machine that was developing at the same time. Headquarters, professional services, were established at Neufchateau, the center of the divisional training area.²²

By the first of January, the organization of the orthopedic department had been worked out and another group of officers was ordered to the American Expeditionary Forces from England.²³ It was realized that the fracture case needed what the French had termed a system of "radial control"; that is to say, a wounded man passing from front to rear must always be under the care of surgeons who understand what has happened before they treat the man and what is going to happen after he is sent on. This system should be under the direction of one man, this man to be responsible. It was decided that the department of orthopedic surgery should be held responsible for the "radial control" of fractures, and bone and joint injuries.²⁴ Under this system, one orthopedic surgeon was made responsible for the splinting in the area of the divisions, corps, and army; another was responsible for the splinting and treatment given to the wounded in the mobile and evacuation hospitals. A third man was to have the responsibility for the fracture treatment in the base hospitals in the intermediate and base areas. Over this system, the chief of the department was to exercise supervision, maintaining the necessary personnel, inspecting the entire "radius" from front to rear to discover and prevent any deterioration in the character of treatment at any of the stages. In short, here was the organization necessary to see that the standard of splinting was first taught and afterwards carried out.

In the reorganization of the professional services, American Expeditionary Forces, in June, 1918, the director of orthopedic surgery, A. E. F., became known as senior consultant, orthopedic surgery; his assistants, with supervisory duties over hospital centers and other formations were designated consultants.²⁵

After some weeks of experience with actual combat conditions, the director of general surgery, A. E. F., arranged for division orthopedic surgeons to takeover the responsibility of all the surgery that arose from the time a soldier was hit until he reached a hospital. The following circular concerns not only this subject, but also outlines the general assignment of responsibility to the orthopedic service, in so far as the share of that service in case of the wounded was concerned:

OFFICE OF THE CHIEF SURGEON,
AMERICAN EXPEDITIONARY FORCES,
France, 16 August, 1918.

Circular No. 46:

1. Upon the recommendation of the chief consultant in surgery, and with the approval of the director of professional services, the following instructions are published for the information and guidance of all concerned.

INSTRUCTIONS CONCERNING THE TREATMENT IN ORTHOPEDIC CONDITIONS INCLUDING FRACTURES AND JOINT INJURIES

2. The work of the division of orthopedic surgery in the medical organization of the army divides itself quite clearly into two parts, one having to do with the preparation of the men for the expected colnmat, and the other assisting in their recovery if wounded. The first has to do with saving men  for service who would otherwise be discharged as physically

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unfit and also as the result of careful training, increasing the number of days that should be expected of the men for active duty. The second has to do with the saving for service of men who but for such work might not have lived, or been so crippled as to be of no use to the army.
3. Without such methods of treatment available for those needing such care in the precombat or training period, large numbers of men will be lost for active duty as the ordinary medical measures can only give temporary relief.
4. Without such methods in cases of combat or other injury there will be much unnecessary loss of function and much of the acute surgical treatment will be purposeless.
5. In each of the large hospital centers, a base hospital with special personnel and equipment for caring for such cases will he installed, while in the detached base hospital special services will be established so that there wvill be the least possible transferring of cases from one hospital to another.
6. Consultants in orthopedic surgery will be assigned to groups of hospitals whose function it will be to keep in touch with the othopedic work of the given group. These con- sultants should be freely used by the staff of the respective hospital and can be reached through the commanding officers of the hospital centers.
7. To best accomplish the purpose of the division and to make the services of its members available, the following instructions will govern.

AMPUTATIONS

8. Cases of amputation of either extremity will be assigned as soon as possible to the orthopedic service for the needed special treatment. A guillotine amputation for instance without other injuries, can usually be moved without risk in one week and with suitable measures rapid closure of the wound is usually possible so that an artificial leg can be fitted and the man get about without crutches many times in from four to five weeks from the time of the injury. It is desirable that transfer to the orthopedic service take place as early as possible before contractures have taken place so that the temporary artificial limb, in case that is desirable, can be most favorably fitted on and the most muscles used to the best advantage.

TENDON INJURIES OR INFLAMMATION

9. The cases of injury to the tendons or inflammation in or about the tendons should be assigned, as soon as the primary wound healing is well established or as soon as the acute inflammatory reaction has subsided, to the orthopedic service. Early transfer to the special services is important in order that the treatment having to do with full restoration of function in the part that has been injured or inflamed may be established at the earliest possible moment and before adhesions have formed or have become organized.
10. Cases of flat, weak, or pronated feet associated with pain, swelling, or inflammation when admitted to a hospital should be transferred to the nearest convalescent camp. From here, in keeping with the degree of difficulty, the cases should be transferred for full duty or to the orthopedic training camp depot division for training to fully overcome the weakness, or for noncombat duty tinder "C" classification.
11. No cases of uncomplicated flat-foot should be exempt from service or recommended for transfer to the United States as all can be made useful for military service.

SPINAL STRAINS AND WEAK BACKS, CHRONIC BACKACHES

12. Cases of weak, painful or lame backs, or of sprain of the spinal or sacroiliac joints, should be transferred either for full duty, or for noncombat duty under class " C " classification.

GENERAL BAD POSTURE

13. Cases of general bad posture, which is commonly associated with lack of vitality or general endurance as well as being part of the condition leading to weak feet and weak backs, should be sent for training to the orthopedic training camp, depot division.

FRACTURES

14. For all cases of fracture of bones other than the head and face, or of extensive muscle injuries, it is of the utmost importance that proper splints be applied at the earliest

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possible moment so that the transfer of the patient to the hospital in which treatment is to he given is associated with the least possible damage to the tissues adjacent to the injured bone. The Thomas leg splint, the hinged half-ring splint, the Thomas hinged arm splint (Murray modification), the Cabot posterior splint and the ladder splinting are appliances most needed for such work.
15. In case the fracture is compound, the wound treatment at the evacuation or other hospitals should follow the principles outlined by the chief consultant of surgical services.
16. After the primary wound treatment has been given these cases should be transferred to the orthopedic service in which the most approved methods for the early restoration of function to the injured part will be available. An effort should be made to transfer the cases to such services, wherever possible, within a week or 10 days of the time of injury, this being the most favorable time as regards bone repair. All fracture cases which, for any reason, can not or should not be transferred to one of the services as indicated above should be reported to the senior consultant in orthopedic surgery, or the orthopedic consultant of the area.
17. Simple fractures should not be converted into open fractures except under very exceptional conditions or after consultation with one of the orthopedic consultants. A result which may not be as perfect anatomically as might have been produced by open operation, may nevertheless be functionally good. This is so commonly the case that the risk of infection which is greater under the war conditions than in civil life should be avoided whenever possible.

JOINT INJURIES

18. All injuries of the joints should be protected with the same care for transport to the hospital in which the treatment is to be given that has been indicated for fractures. Suitable splints should be applied immediately and the standardized list of splints of the army provides types that will meet all the needs.
19. In case the injury is associated with open wounds, the principles of the wound treatment are those which have been laid down by the chief consultant of general surgery.
20. Since in all such injuries ultimate function is the chief requisite treatment having for its purpose the restoration of function should be instituted as soon as possible, and for this purpose, it is desirable that cases of such injury be transferred, as soon as the primary wound treatment has been given to the orthopedic service. It is important that such transfer be made before unnecessary adhesions have formed so that the restoration of function can be obtained in the least possible time. In all such functional restoration it should be clearly understood that while motion is to be encouraged at the earliest possible moment, it should consist entirely of active motions performed by the patient in which case the reflex muscular contraction will protect the joint from undue injury. All passive motion should be avoided.
21. Operations upon the joints that are not emergency in character should not be performed until after consultation with one of the consultants in orthopedic surgery.

TRANSFER TO THE UNITED STATES

22. It will be the policy to send to the United States as soon as transportable, all cases that are of class "D" type, or cases in which prolonged treatment will be required for restoration to duty.

This fixed the responsibility and also saved the situation from the confusion that would have arisen from having two sets of men doing practically the same thing, and perhaps not conforming to any standard system of instruction. Thus it came about that each division surgeon depended upon his division orthopedic surgeon to carry out a definite course of instruction for the medical department of the division.

The problem became that associated with evacuation of wounded and surgically shocked men, in addition to the treatment in the advanced area of fractures and joint injuries. During trench warfare, the evacuation problem was not so diflicult; ambulance routes could be marked out on the map, and

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posts could be located in definite places, and be well protected; most important of all, the hospitals where surgery could properly be done could be located within easy hauling distance of the zone of combat. Careful plans for the evacuation of sick and wounded and for furnishing a constant flow of supplies from rear to front lines by a system of exchange were worked out. It was found that the work done in the instruction of the medical department was bearing fruit, and that it was a rare occurrence for a man with a fracture to reach an aid post without a splint, usually applied very creditably.

In June, 1918, when several of our divisions were actively engaged with the enemy, our plan of evacuation had to be changed entirely because of the relatively large numbers of wounded. Hospitals had to be hastily set up at the front and there were not enough of them to meet the demand for beds; the wounded had to be carried long distances in any available vehicle of transportation. It was at this time that the supply of splints began to run low in the front area, and the system of shops and distribution was so severely taxed.

Just prior to the Meuse-Argonne operation one of the orthopedic surgeons conceived an idea that was to work out in a most fortunate manner. It was realized that a loss of time occurred in the army hospitals where much operating was going on due to the care and precision necessary to the proper application of splints to fractures after operation. This was often due to the fact that the operating surgeon usually entrusted splint apllication to one of his assistants. At all events, it was a well-known fact that fracture cases usually reached the hospitals much better splinted than when they left the hospitals for the journey farther to the rear. It was suggested that in each mobile and evacuation hospital, there should be one or more "splint teams," each to be composed of one officer and two enlisted men. To this end a number of junior officers and enlisted men were collected at the hospital center, Bazoilles, and were given practical instruction in the application of splints and the treatment of fractures ²⁰ (these officers were of the orthopedic department and had had considerable training beforehand). Thereafter splint teams were assigned to each hospital in the army area where their function was to take hold of the fractures as they were admitted to hospital and to follow them through. It was a most useful addition to the chain of good fracture treatment which had had a weak link at this point; it made it possible for the surgical teams to turnout from 30 to 40 percent more work; it also encouraged the division orthopedic surgeons in the knouwledge that the work they were doing would be carried on, and not terminate at the first stopping point.

INSTRUCTION OF DIVISIONAL MEDICAL PERSONNEL

It was recognized early that something must soon be done to acquaint the officers and men of the Medical Department serving in these divisions with the standard splints and how to apply them; accordingly, at the request of the director of the division of orthopedic surgery, several medical officers who had had six months' orthopedic experience in England were assigned to the American Expeditionary Forces to help in the establishment of the work.¹³ These medical officers were all men of experience as specialists in civil life, and had become familiar with the use of the traction splints. They were distributed

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among the combat divisions then in training and to each of them the American Red Cross assigned a small automobile, thus making it possible for them to cover the territory occupied by their respective division. They arranged schedules for instruction of the various units of the division in the application of the standard splints.

About March 1, 1918, in the four original combat divisions of the American Expeditionary Forces, the instruction as to splinting and the supervision of the distribution of splints and supplies had reached a satisfactory stage. The medical officers who served in the four first divisions to engage in combat gained an experience as division orthopedic surgeons that made them experts on much of the knowledge that is necessary to a divisional medical officer; this practical knowledge was gained none too soon for the pressure that was to be put on all departments by the arrival of the bulk of the American Expeditionary Forces. After a few weeks of actual experience in the evacuation of the wounded, it became very evident that the instruction of the enlisted men of the Medical Department was of the greatest importance. In consequence, a large part of the effort of the division orthopedic surgeon was spent in giving lectures and demonstrations to the personnel of the various divisions; stretcher bearer units were created and these men had to be instructed in the application of splints and first aid.

These stretcher bearers felt a keen pride in learning to apply a splint quickly and perfectly and this too, when blindfolded or wearing a gas nask. The men of the Medical Department who went with the companies into action and who worked under the direction of the battalion surgeons became. as a rule, very proficient in all details of splinting.

In addition to the instruction given within the divisions, there was given at the sanitary school at Langres to each class of medical officers a set of lectures that put before them the salient points of the system then in vogue for caring for the wounded in the area of combat.

SPECIAL TRAINING BATTALION

In December, 1917, a camp was established for training men phviscally unfit for marching and combat duty, men in whom physical defects had developed or had been accentuated since entering the Army.²⁷ Many of them were able to conduct their work in civil life without much or any annoyance, but they could not perform as soldiers. In some instances, the cause of the man's breakdown was not definite; in others, it was a combination of different elements such as mechanical strain, accident, change of living conditions, fatigue, and mental depression. Each man was a problem. Shirkers were among those sent to the camp, but a large number of them represented men of insufficient muscular development.

Headquarters of the special training battalion was established at Harche-champ, a town about seven miles northeast of Neufchateau.³⁷ There the men could be treated in large numbers, grouped as far as possible, and their ailments treated in such groups. Having determined the physical defects or habits of each individual entering the camp, treatment was established to correct the defect or defects and to develop a proper habit of carriage and life.

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WORK FOR RESTORATION OF PROPER FUNCTION

The work at the camp was planned (1) to remove the cause or causes of the defects, if the causes still existed; (2) to correct the deformity which had been produced by the cause or causes; (3) to teach the men proper use of the joints and muscles of the body; (4) to increase the muscular strength of the men so that they could not only get themselves around the camp and through the day's work, but would be able also to carry the additional weight of the soldier's equipment. The treatment was planned in the above sequence. All the training at the camp had to be carefully planned and thoroughly carried out. Accuracy and precision had to be practiced by both the officers and the men.

The men, as they arrived at the camp, were very imperfect specimens, but it was found that approximately 80 percent could be made into useful material and returned to their organizations as fit combat men.

A card the size and shape of the Army service record was filled out in duplicate; it contained the name and number, rank, organization, age, and the date and source of admission to the battalion, and the date of entrance into the Army. Silhouettes were taken of the body trunk in profile. This was a very quick and simple method of recording posture. The personal history was recorded in brief, and, in the physical examination, especial note was made of the teeth, ears, back, feet, defects in posture, and method of using the feet. Treatment was prescribed.

The feet were measured carefully, and then the shoes fitted over two pairs of heavy socks, always giving ample room over the foot and the toe. These shoes had the heels raised on the front inside corner to throw the weight on the outside of the foot. All the men were shod in this way unless there was definite reason for not doing so. No graphic records of the feet were made.

While in receiving Company "A" the men were graded as to their aptitude and capabilities. They were given light police duty, easy calisthenics and games, with talks on the general principles of the training, and demonstrations on the care of their shoes and other equipment. Each man was issued two pairs of field shoes of proper size, adjusted as prescribed to correct his balance and whatever other defects existed. Straps and simple cleats only were em-ployed. When this had been done and their other equipment completed, if their physical condition had sufficiently improved, they were entered on the roll of Company "A", and began their active training.

GENERAL PRINCIPLES OF THE TRAINING

For the feet.- The men were taught that the foot and leg are muscular members of the body, to be used in locomotion. The triple exercise was taught to strengthen the leg and foot muscles after correction by the stretching of any existing deformity. In all marching and walking, the men were instructed to toe straight ahead and bend the knee out, carrying the weight over the small toes, the weight to be kept on the outer side of the foot at all times in marching and standing, either at attention or at ease.

For the back.- The system comprised stretching of shoulders over a roll. The exercise of straight leg raising and trunk raising to strengthen the anterior

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abdominal walls; the men stood with a nearly flat back, hips very slightly back, abdomen held up, chin in. The position of attention is an easy, alert posture, with knees straight, not in hyperextension, the weight equally distributed on the front and heel of the foot. The posture is somewhat like that taken by a man when he prepares to jump. He is ready for the command.

The whole camp had a general program, and each company had a special program of its day's routine, the work in each succeeding company being made progressively harder and more continuous, with shorter periods of rest.

A complete military organization was found to be necessary in order to establish and maintain discipline, without which nothing could have been accomplished in the training of these men.

Once each week the chief orthopedic surgeon selected the men who seemed fit for promotion. These men were inspected in standing and marching, and their records for persistent work during the week considered. Silhouettes were again taken to record improvement in posture. A list of men thus selected for promotion was turned in to the company commander, and those considered eligible were transferred to their original organization.

MEDICAL ORGANIZATION

The duties of each orthopedic surgeon comprised the following: At company sick call, 7.30 a. m., all light ailments were treated; all men with a temperature or any severe symptoms were immediately sent, accompanied by a sergeant, to the camp surgeon. By this method, the number of men attending the morning sick call was reduced immediately; prompt treatment and return to duty were facilitated.

No men were confined to their billets. If suffering from slight surgical or medical maladies which really prevented their taking part in the active training, they were given a day of kitchen police or other light duty. Everyone worked unless really sick, and if sick, was sent immediately to the hospital. If the diagnosis was not clear, no man was sent to the hospital without a thorough physical examination and a consultation with the orthopedic chief. In this way it was possible to detect men suffering from visceral ptosis, not discoverable without a thorough physical search into the relations of posture to digestive and general symptoms.

The orthopedic surgeon accompanied the men at drill each morning and afternoon, correcting the errors in marching and statics. He had to be constantly on the alert, encouraging, explaining, demonstrating to the men what was expected of them. He carried duplicate record cards and made frequent notes tbereon of each man in the field.

During periods of rest between drill, the orthopedic surgeon gave talks to the men on such subjects as the care of the shoes and feet, the proper position of the body in marching, proper use of the feet, hygiene in the trenches, the fundamental purposes of the training camp. In the afternoon the men were given the only special curative exercises included in the curriculum. These exercises were reduced to the simplest. The triple exercises, i. e.: (1) Planter flexion of the toes, foot extended. (2) Hold this; twist foot in. (3) Hold (1) and (2); pull foot into dorsal flexion to strengthen the leg muscles; straight

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leg raising for trunk and abdominal muscles. These exercises, coupled with certain very simple stretching maneuvers, taken bv the man himself either with his hands or by standing on the edge of his bunk, were all the special treatment given. All other training was given in large groups.

Any alterations in the shoe adjustments were ordered by the orthopedic surgeon. Once each week, he rigidly inspected every man in his charge, as to the condition of his feet and shoes, noting improvement, seeing that the heels were tilted enough and in good condition, making sure the shoes were properly fitted.

The same officer coached the men in their play, attempting, with the sanitary officer, to find games in which all the men would take an active part. Among other things, the men were trained to run and jump in good form.

Three evenings each week the chief orthopedic officer gave the junior orthopedic officers instruction upon orthopedic conditions occurring among the troops, special emphasis being laid upon the methods of treatment to be followed in the Army.

The men advanced from Company "A" to Company "B," which demanded greater endurance with longer periods of drill and games, and shorter and fewer periods of rest. The transfer was made to clearly mark an advancement. In this sort of training, it was considered necessary not only carefully to grade the training, but also to encourage the men by a clearly defined progress from grade to grade, separating the grades from one another as definitely as possible.

In Company "A" the men drilled without the rifle, though they were taught the care and nomenclature of the piece, how to aim and fire, and had no long marches, while in Company " B " they carried their rifles during the morning but had no rifles or any other equipment on the march which they took during the afternoon.

From Company " B " the men who had proved their fitness to perform the drill required, who showed good form at the Saturday inspection, and who could go through the exercises required of them at tlhe examination, i. e., a demonstration of their foot exercises, were transferred to Company "L." For this company, the program was made still more exacting. The men therein began to be more like soldiers of the line, but, thev were given two 10-minute rest periods in the morning's program and one half-hour lecture period. Three afternoons weekly they took a long march, and on two days a short one, followed by some active games.

In Company " M," into which they next progressed, after a similar examination, the work became still more constant and strenuous. Each morning they were given calisthenics, followed by Butts' Manual, lasting an hour, during which only short breathing spaces were permitted. The orthopedic surgeon constantly watched their position. Then followed a bayonet drill of the most active sort, lasting an hour. After another 10-minute rest period, the morning program was brought to an end by an hour of company and squad drill, and the school of the soldier. In the afternoon foot exercises were given and then the men fell in with full pack and equipment for a march of two hours, with one 10-minute rest at the end of the first hour. In this march the men were accompanied

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by their officers and the orthopedic surgeon. Silhouettes, taken of a man as he entered and as he progressed from company to company, showed in a very graphic way how he learned the proper standing posture and improved carriage, and how the round shoulders and hollow backs were made to disappear.

Between January 1 and March 20, 1918, the special training battalion received about 680 noncommissioned officers and men. From this number most of the camp personnel was recruited. One hundred and fifty men passed through the complete course of training, and were returned to their organization. They were fit when they left this camp.

It was found necessary to investigate every man who stayed longer than four weeks in any one company. In this way were culled out those who could best be used for other work. One hundred men who did not advance rapidly, or were otherwise unfit, were sent to Versailles to start the spring gardens for the Army. Twenty men unable to qualify as soldiers, but who had had experience in driving motors, were transferred to the Motor Transport Service.

In the last of March, the 350 men still in training were returned to their commands, and the special training battalion, with a small permanent personnel, was transferred to the 1st Depot Division at St. Aignan and there continued its activities until the cessation of hostilities. During the St. Mihiel and the Meuse-Argonne operations, the need of men at the front was so great that many of the men under training, who could have been made of combat fitness had there been time enough for the training, were detached from the training battalion and sent to the front for noncombat duty. At one time 1,000 men were sent to the First Army area to assist in staffing the hospitals; 1,200 men were sent at another time for the same duty; 1,000 men were sent to act as prison guards. In this way, the size of the training battalion was reduced materially and the work from then on consisted very largely in the reclassification of the men rather than the training which would have been possible had there been sufficient time.

REFERENCES

(1) Circular No. 23, W. D., S. G. O., August 13, 1917.
(2) Memorandum, Surgeon General's Office, August 20, 1917.
(3) S. O. No. 171, W. D., July 25, 1917, par. 130.
(4) Announcement made by the Surgeon General of organization of Department of Military Orthopedics, August 20, 1917. On file, Record Room, S. G. O., 167136 (Old Files).
(5) Letter from the Surgeon General to surgeons, August 20, 1917. On file, Record Room, S. G. O., 730 (Orthopedics).
(6) Plan for organization and development of Orthopedic Department, submitted by Major E. G. Brackett, M. R. C., and Major J. E. Goldthwait, M. R. C., approved August 17, 1917. On file, Record Room, S. G. O., 210122 (Old Files).
(7) Article on Division of Military Orthopedic Surgery, No. 11, 1917. On file, Record Room, S. G. O., 739 (Orthopedics). Reports and Correspondence. On file, Record Room, S. G. O., 353 (Orthopedics).
(8) Correspondence on instruction orthopedics. On file, Record Room, S. G. O., 353 (New York City) (F); 353 (Orthopedics, General); 730 (Orthopedics).
(9) Schedule of orthopedics instructions. On file, Record Room, S. G. O., 730 (Orthopedics).
(10) Correspondence. Subject: Instruction Orthopedics. On file, Record Room, S. G. O., 353 (Oklahoma City, Oklahoma) (F); 353 (Orthopedics, General); 730 (Orthopedics).
(11) Correspondence. On file, Record Room, S. G. O., 353 (Walter Reed General Hospital) (K); 353 (Orthopedics, General); 730 (Orthopedics).
(12) Letter from Brigadier General William H. Arthur, Commandant, Army Medical School, to the Surgeon General, outlining course for twenty-second session, November 3, 1917, par. 4. On file, Record Room, S. G. O., 730 (Orthopedics).
(13) Abstract of reports, Orthopedic Division, S. G. O. On file, Record Room, S. G. O., 024.14 (Orthopedic Section).
(14) Annual Report of the Surgeon General, U. S. Army, 1919, page 1104.
(15) Report of the activities of the division, Military Orthopedics, S. G. O., 1919. On file, Record Room, Surgeon General's Office, 024.2.
(16) Report of the Orthopedic Activities of the Medical Reserve Corps in England (Exhibit " B" attached to Weekly Report of the Division of Orthopedic Surgery to the Surgeon General, August 10, 1918). On file, Record Room, S. G. O., 024.2.
(17) S. O. No. 73., G. H. Q., A. E. F., August 20, 1917, par. 17.
(18) Manual of Splints and Appliances for the Use of the Medical Department of the United States Army, 1918. Second Edition, Printed by the American Red Cross, Paris,1918.
(19) The Military History of the American Red Cross in France by Lieut. Col. C. C. Burlingame, M. C. Copy on file, Historical Division, S. G. O., 124.
(20) Brief Histories of Divisions, U. S. Army, 1917-18. Prepared in the Historical Branch,War Plans Division, General Staff, June, 1921.
(21) S. O. No. 284, A. E. F., October 11, 1918, par. 169.
(22) Circular Letter No. 45, S. G. O., A. E. F., August 13, 1918.
(23) S. O. No. 181, December 8, 1917, par. 18; No. 8, January 8, 1918, par. 12; No. 12, January 12, 1918, par. 26, and No. 14, January 14, 1918, par. 47, Headquarters, A. E. F.
(24) Circular Letter No. 29, Office of the Chief Surgeon, A. E. F., May 21, 1918.
(25) G. O. No. 88, G. H. Q., A. E. F., June 6, 1918.
(26) Letter from Chief Surgeon, A. E. F., to Commanding Officer, Base Hospital No. 116, October 18, 1918. Subject: Orthopedic Training. On file, A. E. F. Records.