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First United States Army, Report of Operations, 1 August 1944 - 22 February 1945

Books and Documents

FIRST UNITED STATES ARMY

Report of Operations
1 August 1944 - 22 February 1945

ANNEXES
9 - 10 - 11 - 12 - 13 - 14

ANNEX NO.11

MEDICAL SECTION REPORT


Annex 11

Table of Contents

I.      INTRODUCTION    

II.    HOSPITALIZATION AND EVACUATION        
        A.    Pursuit across France and Belgium    
        B.    The Siegfried Line    
        C.    The German Counterattack    
        D.    The Allied Counterattack 
 
III.   TRANSPORTATION 
 
IV.   MEDICAL SUPPLY SECTION        
        A.    Exploitation of the St. Lo Break-through (1 Aug.-12 Sept. 44)    
        B.    The Battle of Germany (13 Sep.-15 Dec. 44)    
        C.    The German Counteroffensive and the Drive to the Roer River (16 Dec. 44-22 Feb 45)
  
V.    SURGICAL        
        A.    Pursuit Phase    
        B.    The Siegfried Line    
        C.    Phase of Enemy Counterattack    
        D.    The Allied Counterattack    
        E.    Notes on Professional Care Applicable to all Phases of Warfare    
        F.    Clinical Notes  
 
VI.    MEDICAL ACTIVITIES        
         A.    Operation of the Medical Service    
         B.    General Remarks    
         C.    Incidence of Reportable Diseases    
         D.    Respiratory Diseases    
         E.    Malaria    
         F.    Diphtheria    
         G.    Meningococcus Meningitis    
         H.    Mumps, Measles, German Measles, and Chicken Pox    
         I.     Scarlet Fever    
         J.     Diarrheal Diseases    
         K.    Infectious Hepatitis    
         L.    Summary

VII.  NEUROPSYCHIATRY ACTIVITIES
        A.    Neuropsychiatry Casualties    
        B.    Discussion 
 
VIII.  DENTAL SERVICE

IX.   VENEREAL DISEASE CONTROL AND TREATMENT ACTIVITIES    
        A.    Venereal Disease Control    
        B.    Treatment of Venereal Diseases  
 
X.    VETERINARY SERVICE    
        A.    Exploitation of the St. Lo Break-through (1 Aug.-12 Sep.)
        B.    The Battle of Germany    
        C.    German Counteroffensive and Drive to the Roer River (16 Dec.-22 Feb.)
        D.    Remarks

XI.    NURSING SERVICE

XII.   PERSONNEL 
 
XIII. MEDICAL STATISTICS    
         A.    General    
         B.    Operations    

List of Appendices

APPENDIX
        1.     DISEASE RATE SUMMARY    
        2.     WOUNDED ADMITTED AND DISPOSED OF    
        3.     CLASSIFICATION OF WOUNDED BY CAUSATIVE AGENT    
        4.     CLASSIFICATION OF WOUNDED BY ANATOMICAL LOCATION
        5.     CLASSIFICATION OF WOUNDED BY CAUSATIVE AGENT AND ANATOMICAL LOCATION
        6.     CHRONOLOGIC SUMMARY OF ADMISSIONS BY ACTION, BY TYPE
        7.     CHRONOLOGIC PERCENTAGE ANALYSIS OF COMBAT MEDICAL STATISTICS    
        8.     PERCENTAGE ANALYSIS OF COMBAT MEDICAL STATISTICS
        9.     COMBAT MEDICAL STATISTICS—EXPLOITATION OF ST. LO BREAK-THROUGH
       10.    COMBAT MEDICAL STATISTICS—THE BATTLE OF GERMANY
       11.    COMBAT MEDICAL STATISTICS—THE GERMAN COUNTER-OFFENSIVE AND DRIVE TO THE   ROER RIVER    
       12.    COMBAT MEDICAL STATISTICS—D+56 THROUGH D+261
       13.    COMBAT MEDICAL STATISTICS—D-DAY THROUGH D+261   
       14.    NUMBER OF ADMISSIONS FOR COMMUNICABLE DISEASES (Aug.-Sept. 44)    
       15.    NUMBER OF ADMISSIONS FOR COMMUNICABLE DISEASES (Oct. 44-23 Feb. 45)    
       16.    GRAPHIC RATE SUMMARY OF TYPES OF ADMISSIONS, 1944
       17.    MEDICAL STATISTICS SUMMARY (for the four-week period ending 25 Aug. 44)    
       18.    MEDICAL STATISTICS SUMMARY (for the five-week period ending 29 Sept. 44)    
       19.    MEDICAL STATISTICS SUMMARY (for the four-week period ending 27 Oct. 44)    
       20.    MEDICAL STATISTICS SUMMARY (for the four-week period ending 24 Nov. 44)    
       21.    MEDICAL STATISTICS SUMMARY (for the five-week period ending 29 Dec. 44)    
       22.    MEDICAL STATISTICS SUMMARY (for the four-week period ending 26 Jan. 45)    
       23.    MEDICAL STATISTICS SUMMARY (for the four-week period ending  23 Feb. 45)


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ANNEX  11

I.    Introduction

    Between 26 July and 4 August 1944, the entire complexion of the tactical situation on the front of First U. S. Army was altered. Medical units of First U. S. Army were deployed to support troops engaged in a slow advance, receiving high casualties from an enemy defense planned and executed to exact maximum costs for every foot of ground yielded. In the nine days mentioned above, the tremendous pressure exerted by the United States Armies resulted in an almost complete dissolution of these defenses.

II.    Hospitalization and Evacuation

A.    PURSUIT ACROSS FRANCE AND BELGIUM

    Contingent on this collapse, a new problem presented itself to the surgeon of First U. S. Army. Heretofore, field hospitals had operated at division clearing station level, functioning solely for the purpose of providing definitive surgery for badly wounded cases whose ability to stand transportation was limited. All other sick and wounded had gone to evacuation hospitals located at distances varying from four to fifteen miles behind the front lines. When the German defenses crumbled, the combat troops raced ahead, extending the lines at tremendous speed. As the tactical situation finally developed, First U. S. Army formed the southern jaw of a long pincer, and the area from which casualties could be expected extended over one hundred and fifty miles in length. It was at once apparent that large installations such as evacuation hospitals could not be expected to keep up with such a rapid advance. Furthermore, since the retreating enemy found it almost impossible to regroup, save in one instance when he counterattacked in the direction of Mortain, striking a rather severe blow at the 30th Infantry Division, casualties fell away to minimal numbers. This abrupt change in the medical situation made it necessary for the army surgeon to change his policies in order that adequate medical service might be provided by the means at hand. The solution achieved was based on the following changes:

1.    Employment of Field Hospitals

    As explained in the. report of the early stages of the campaign, one hospitalization unit of a field hospital was established adjacent to each division clearing station. This policy provided means for early treatment of those patients (triaged) as nontransportable.

    During the later phases, as the lines of evacuation were greatly lengthened, it was necessary to move hospitals forward with


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greater speed than had been called for previously. It was decided that, due to their greater mobility and because of the fewer casualties being encountered, the hospitalization units of field hospitals could be employed as small evacuation hospitals. This decision proved of great value.

2.    Employment of Evacuation Hospitals

    Throughout the period, these hospitals were utilized as far forward as the tactical situation would permit. This was accomplished by the closing of a hospital and clearing it of patients in order to move forward. Sufficient hospitals were kept mobile so that one was always available to leapfrog a unit that had either been taxed to capacity or, because of its great distance from the advancing front, was no longer of great value to the forward troops.

    When, due to the relative immobility of evacuation hospitals, it was no longer feasible to attempt to keep pace with the combat troops and the field hospitals were being utilized as small evacuation hospitals, the evacuation hospitals were employed as transfer points. Serving in this capacity, they materially lessened the distance over which casualties had to be transported in one continuous move. After the patients were rested, wounds cared for, and dressings applied, the casualties were turned over to the control of Advance Section, Communications Zone, for further evacuation to general hospitals in the rear, or to air strips for evacuation.

    Following the break-through at St. Lo, many of our hospitals had large surgical backlogs due, in great measure, to the large numbers of lightly wounded casualties being treated. This condition hampered their mobility and thus their usefulness to the medical service. At a conference attended by Chief Medical Officer, Supreme Headquarters, Allied Expeditionary Forces; Surgeon, Advance Section, Communications Zone; Surgeon, First U. S. Army; Executive Officer, Office of the Surgeon, First U. S. Army; and Operations Officer, Office of the Surgeon, First U. S. Army, it was decided to establish the 77th Evacuation Hospital, an Advance Section, Communications Zone organization in the rear of First U. S. Army to receive these lightly wounded, unoperated cases, thus relieving the backlog in army hospitals.

3.    Handling of Special Type Cases

    The 91st Medical Gas Treatment Battalion, which was designed for the treatment of gas casualties, was utilized as a hospital for the care of special types of cases. These cases interfere with the primary mission of an evacuation hospital. After having been augmented with the necessary equipment, it was given the mission of handling the following:

    a.     Contagious diseases; measles, German measles, mumps, chicken pox, scarlet fever, and dysentery.

    b.     Malaria: It was found upon investigation that all cases were recurrent in nature and had been contracted during the campaigns in North Africa, Sicily, and Italy, or during maneuvers in the southern section of the United States. The these cases had not been complying with recent directives for the taking of atabrine for suppressive therapy. This was due to various reasons: not available, did not like it, and did not agree with them.

    c.     Return to duty cases: Arrangements were made with G-1, First Army, and the replacement system, whereby all cases returning to duty would be handled by the 91st Gas Treatment Battalion, 4th Convalescent Hospital, and the 618th and 622d Clearing Companies. This arrangement worked well during the earlier stages of the period, but as the movements of combat units became increasingly faster, it fell into a stage of disorganization. At times, medical units were not relieved of their duty cases by the replacement system.

    d.     Self-inflicted wounds: Patients suspected of having inflicted a wound upon themselves for the purpose of escaping hazardous duty were transferred to this unit as soon as transportable. These cases were held pending investigation by a representative of the Inspector General.


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4.    Employment of 4th Convalescent Hospital

        a.     Return of duty cases: See paragraph 3 above.
        b.     Ambulant, ten-day cases.
        c.     Venereal disease cases.

5.    Employment of 618th and 622d Medical Clearing Companies

        a.     Return to duty cases: See paragraph 3 above.
        b.     Combat exhaustion cases.
        c.     Neuropsychiatric cases.

6.    Employment of Clearing Companies as Holding Units

    The speed at which our combat forces moved forward not only caused the above changes in the policy of employment of hospitals, but also in the utilization of the medical clearing companies. Many hospitals were needed in the forward zones while they were still immobilized with a small number of nontransportable abdominal and chest cases. Hospitals were in need of a method to relieve them of such cases so that their efficiency would not be impaired by leaving their own personnel behind to care for such nontransportables when moved to a new location.

    In view of this situation, the army surgeon employed clearing companies to take over these cases, thus relieving the hospitals of their responsibility. The clearing companies cared for these patients until they were transportable and then evacuated them to Communications Zone hospitals in the rear.

    Until mid-September, the pursuit of the fleeing German armies continued. Two changes taking place during this period are noteworthy. One, all field hospitals were placed under centralized command, accomplished by assigning them to the Headquarters and Headquarters Detachment, 177th Medical Battalion. The first mission assigned the battalion was to reassemble the field hospitals. Hospitalization units were scattered over an area of one hundred by two hundred miles at fourteen different locations. At the completion of assembly, the army surgeon ordered that field hospitals would provide evacuation hospital service to the army on a basis of one field hospital per corps. The basic plan used to carry out this assignment was to place a hospital headquarters and two hospitalization units forward in support of each corps at all times. One of these two units was designated as the unit of record, set up completely, and augmented as necessary by the personnel and materiel of the accompanying unit. The third unit remained in reserve until progress made the advance of the hospital necessary. Then it moved up, became the forward unit, and was supplemented by addition of the hospital headquarters and one of the units which it had passed in moving forward. Because of the relatively few casualties sustained during the drive through France and Belgium, the system outlined above remained in effect until the army ran into stubborn resistance at the German border.

    The second change involved the organization of the army surgeon's office itself. Because of the great distances over which medical service had to be rendered, the army surgeon inaugurated the plan of detaching a section of his office from the headquarters of First U. S.. Army and sending the detachment out as an advanced section of the office of the surgeon. The executive officer, operations officer, medical supply officer, and four enlisted men accordingly left the headquarters at Versailles and proceeded to La Capelle, France, where a medical service area was established. Later, this detachment, preceding the movement of the headquarters by many miles, moved to Ouffet, Belgium, and finally to Eupen, when the headquarters of First U. S. Army reached such position that the army surgeon decided that adequate control could be supplied from the main command post. By means of this device, immediate knowledge and on-the-spot control was secured. On many occasions, possible stumbling blocks in evacuation were foreseen and dealt with, prior to their reaching a point where serious consequences resulted. This device, by shortening the lengthy and difficult communication lines, permitted immediate opera-


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tional control which would have been, in a large measure, denied the surgeon, had not the advanced command post been maintained.

    The policy of grouping the majority of evacuation hospitals in a centrally located army medical service area, leaving one or at most two, out in support of the right and left flank corps was instituted. The application of these arrangements to a situation where communications were poor and over-all operating distances great accomplished two vital needs. First, control of army medical units was simplified; second, the bulk of casualties were concentrated, simplifying evacuation to Communications Zone establishments.

    The solution to the problem of handling special types of cases, a group made up of contagious diseases, malaria, and ambulatory convalescents remained the same. Such cases came under the control of the 91st Medical Gas Treatment Battalion and the 4th Convalescent Hospital, relieving the evacuation hospitals of the necessity of filling beds needed for surgical cases with such patients. During. the last half of the month of September, the 4th Convalescent Hospital, because of lack of sufficient transportation, was left behind. The 91st Medical Gas Treatment Battalion took over the cases normally handled by the 4th Convalescent Hospital, in addition to its usual duties. The organization of this unit permitted the setting up of three entirely separate hospital establishments, allowing control over a lengthy axis. Thus, the battalion was able to maintain a hospitalization unit in contact with the troops and open for admissions at all times.

    Combat exhaustion and neuropsychiatric cases were, as heretofore, evacuated to the 618th and 622d Clearing Companies.

B.    THE SIEGFRIED LINE

    As the combat troops approached the fortifications of the Siegfried Line, enemy resistance stiffened and the tactical situation settled into one of a relatively static front. Opportunity was taken to regroup the medical units of First Army so that this new phase of the campaign might be more adequately covered. An area was secured midway between the army's north and south boundaries, and the bulk of army medical units, evacuation hospitals, NP hospitals, 91st Medical Gas Treatment Battalion, the 1st Medical Depot Company, and the headquarters of the medical groups were concentrated in this area with all possible speed. The army surgeon rearranged the army medical units to provide three identical groups. One group operated in each corps zone and was charged with the responsibility for control of army medical service. The composition of the three groups was as follows:

31st Medical Group

178th Medical Battalion
426th Medical Battalion
621st Medical Clearing Company
564th Ambulance Company
565th Ambulance Company
566th Ambulance Company
574th Ambulance Company
463d Medical Collecting Company
501st Medical Collecting Company
502d Medical Collecting Company
47th Field Hospital


68th Medical Group

175th Medical Battalion
176th Medical Battalion
662d Medical Clearing Company
449th Medical Collecting Company
45 1st Medical Collecting Company
454th Medical Collecting Company
576th Ambulance Company
577th Ambulance Company
578th Ambulance Company
594th Ambulance Company
13th Field Hospital
51st Field Hospital


134th Medical Group

179th Medical Battalion
180th Medical Battalion
450th Medical Collecting Company


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452d Medical Collecting Company
464th Medical Collecting Company
617th Medical Clearing Company
479th Ambulance Company
546th Ambulance Company
575th Ambulance Company
583d Ambulance Company
42nd Field Hospital
45th Field Hospital


    The Headquarters and Headquarters Detachments of the 57th and 177th Medical Battalions were placed directly under control of the army surgeon's office, and were given the task of providing evacuation, reinforcement, and, by means of the Provisional Truck Company, transportation to the army medical units which had been concentrated in the vicinity of Eupen. These battalions had the following composition:

57th Medical Battalion

384th Ambulance Company
591st Ambulance Company
Provisional Truck Company

177th Medical Battalion

427t Medical Collecting Company
493d Medical Collecting Company
618th Medical Clearing Company
622d Medical Clearing Company
633d Medical Clearing Company

    To increase coordination of the movements and disposition of medical troops, it was decided that group commanders would be given the authority to control all medical transportation within their zone of action. Group commanders were informed that they would be responsible for augmenting and reinforcing, from the units attached to their groups, army, corps, and divisional medical installations in their corps zone. The purpose of this reorganization was to mobilize army medical service as highly as possible. Actual operations throughout the remainder of the month gave proof that the desired ends could be obtained under the above outlined organization.

    During the last week in September, heavy rain changed fields and country roads into veritable quagmires. Routine hospitalization and evacuation procedures were greatly retarded and, in some cases, made hazardous for both patients and Medical Department personnel. A decision was made by the army surgeon that while such conditions of climate and terrain prevailed, all First Army hospitals, and as many supporting medical units as possible would be established in buildings.

    While engaging in pursuit of the enemy, the army sustained relatively few casualties. The major problem of evacuation was to conquer the distances involved in all routes. At one time during this period, approximately one thousand German wounded, at one division cleaning station, jammed evacuation channels in that area completely. The situation was remedied by augmenting ambulance with truck evacuation for lightly wounded prisoners, distributing the more seriously wounded to field and evacuation hospitals with the very lightly wounded to Advance Section, Communications Zone hospitals. Since the possibility of recurrence of a like situation remained, the army surgeon decided that, henceforth, lightly wounded prisoners should be processed through normal Prisoner of War channels, where provisions had previously been made to treat them, while seriously wounded prisoners would follow normal routes of evacuation. The resultant elimination of large numbers of lightly wounded removed an unnecessary burden from the receiving and evacuating sections of the hospitals and preserved bed space necessary for the seriously wounded.

    Lack of bed space provided by the Advance Section, Communications Zone, at reasonable distances from army installations, made it necessary to continue establishment of army evacuation hospitals as transfer points. Without these transfer points, ambulance routes would have at times exceeded  one thousand miles in length.

    Efforts were made by Communications Zone to alleviate the pinch of evacuation demands.

    On 11 September it was learned that airstrip A-85 E at Cerfontaine would become available to First Army on 13 September. Advance Section, Communications Zone, placed a holding unit at that location. This was the first time since July that First Army had been afforded the opportunity to evacuate a signifi-


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cant number of casualties by air. A temporary reduction in the number of army hospital beds necessarily given over to the task of holding casualties was effected by this means. However, because of weather conditions, variations in the number of planes available, and the increase in casualties as German resistance stiffened, the evacuation problem began. again to assume critical proportions. At times, evacuation from the army area was closed down for periods ranging from twenty-four to forty-eight hours. Army hospitals formerly held as reserves had to be pressed into service to provide holding capacity. A further temporary easing of this situation was effected by the arrival of hospital trains in Liege. However, an average of three trains daily would have been necessary to maintain complete evacuation of army hospitals and such numbers were not available. The 618th Clearing Company, heretofore utilized for the hospitalization of combat exhaustion cases, was opened as a holding unit in the vicinity of Ouffet. It was necessary to use this unit in addition to those beds already set aside at army evacuation hospitals to hold cases awaiting evacuation. On the 26th of September, a new airstrip, A-92, was opened in the vicinity of St. Trond, and evacuation from it was instituted. The establishment of the 15th General Hospital in Liege came as a further aid to evacuation. However, a complete solution was not reached until mid-October. Many factors combined to bring about unsatisfactory conditions. The. lack of an administrative air field, inability to secure sufficient transport aircraft when a field was available, inadequate numbers of general hospital beds at reasonable distances from the army area, scarcity and irregularity in arrival of hospital trains, all combined to produce this situation. However, Advance Section, Communications Zone, continued to make strenuous efforts to improve this situation, and by mid-October amelioration, of all conditions mentioned above had been effected. At no time, despite this pressure, did any casualties suffer for lack of medical care.

    The month of October was a period given over, in large measure, to the build-up of resources in preparation for launching a major offensive designed to carry First Army to the Rhine River. A regrouping of armies, carried out in the latter part of, the month, saw the newly arrived Ninth U. S. Army shifted from the south to the north flank of First U. S. Army. XIX Corps passed from control of First Army to Ninth Army, VIII Corps from Ninth Army to First Army as part of this shift. First Army medical units in XIX Corps sector were turned over intact, with the exception of the 47th Field Hospital and the 4th Convalescent Hospital, to control of Ninth Army. Reciprocally, Ninth Army medical units in VIII Corps sector passed to control of First Army. A list follows of the medical units involved in the exchange:

Units lost

41st Evacuation Hospital
91st Evacuation Hospital
111th Evacuation Hospital
31st Medical Group
178th Medical Battalion
426th Medical Battalion

Units assigned or attached

102d Evacuation Hospital asgd from 9th Army
107th Evacuation Hospital asgd from 9th Army
110th Evacuation Hospital asgd from 3rd Army
64th Medical Group
170th Medical Battalion
240th Medical Battalion
442d Medical Collecting Company
463d Medical Collecting Company
501st Medical Collecting Company
502d Medical Collecting Company
621st Medical Clearing Company
564th Ambulance Company
565th Ambulance Company
566th Ambulance Company
574th Ambulance Company
419th Medical Collecting Company
423d Medical Collecting Company
439th Medical Collecting company
623d Medical Clearing Company
580th Ambulance Company
581st Ambulance Company
590th Ambulance Company
595th Ambulance Company


    One additional 400-bed evacuation hospital, the 110th, passed to control of First Army from Third Army in the exchange.

    Admissions to First Army hospitals occurred on a decreasing scale after the end of


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the first week in October, and it was realized that due to the tactical situation, this period of relative quiesence would last some time. V Corps and VIII Corps sectors were the scene of patrol activity only. VII and XIX Corps collaborated during the month in the encirclement and siege of Aachen, the town finally being taken by troops of the 1st Infantry Division. The majority of battle casualties sustained by the army for the period originated from this operation.

    As a corollary to the decrease in the number of hospital beds necessarily held for battle casualties, increased capacity was provided for the care of diseases with a convalescent period of relatively short duration, such as the respiratory diseases usually occurring during late fall and early winter months. These and other relatively less important factors combined to present to the surgeon the opportunity to retain, within the administrative boundaries of the army, numbers of personnel which would have passed in the normal chain of evacuation to Communications Zone hospitals. The mechanisms by which such advantage was secured were as follows:

    a.    Corps and division clearing stations were given the mission of holding minor cases of disease for treatment to expedite return of such personnel to duty.

    b.     The medical group operating in the zone of each corps was directed to establish an army clearing station. This clearing station admitted the overflow of minor cases from corps and division clearing stations, operated a dental prosthetic laboratory in addition, and provided dispensary service to troops operating in the immediate vicinity.

    c.     On the 20th of October, First Army hospitals put into effect the policy of holding for return to duty all patients whose period of illness would last twenty days or less. This was a temporary change in policy, to remain in  effect only during such time as casualties were light.

    One minor problem occurring during this period was the hospitalization in Belgian territory of German civilians. Due to the friction existing, it became necessary to set aside a 200-bed civilian hospital to prevent incidents such as would certainly have arisen had Germans been placed haphazardly in Belgian hospitals.

    Because of the distances involved, evacuees from the 110th Evacuation Hospital in VIII Corps sector did not go through the usual channels to the rear of First Army, but were sent to the Communications Zone installations to which Third Army was being evacuated. This mild disturbance of routine evacuation was a result of the shift of Ninth and First Armies.

    Because of the same dislocation of the axis of First Army, plus the broadening of the First Army front, it became necessary to relocate certain units.  The 4th Convalescent Hospital moved to Spa; the 91st Medical Gas Treatment Battalion established a company in the northern corps zone (VII) and made plans to direct the remaining companies to the areas of the central (V) and southernmost (VIII) corps.

    Difficulties in evacuation experienced during the preceding month were eliminated gradually. Increase in Advance Section, Communications Zone holding capacity and the advancement of Communications Zone general hospitals provided adequate bed space. Material aid was provided by assignment of a greater number of hospital trains, twelve in all, in the rear of First Army.

    November found the tactical situation of First Army little altered from the preceding month. Although major hospitalization policies in effect during the month of October remained unchanged, several minor innovations are noteworthy.

    Formerly, patients with self-inflicted wounds were held in the 4th Convalescent Hospital pending investigation by the Inspector General, when suspicion existed that the occurrence involved intent to escape hazardous duty. The plan reduced the number of hospital beds available for convalescent patients. To remove this condition it was decided that the patient would return to his organization prior to investigation, at such time as his physical condition permitted. The hospital was to inform the patient’s unit that his status was undetermined. On completion of the investigation required, the unit was to return the data necessary for completion of records to the hospital. Here, final entries


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were to be made on the patient’s record, or the army medical and surgical consultants and the information forwarded to The Surgeon General, should the record no longer be in possession of the hospital. Such procedure met with approval of the army inspector general and was adopted.

    In an attempt to gain an over-all picture of the results of treatment in army hospitals, First Army medical officers were stationed for short periods in the Advance Section, Communications Zone hospitals in rear of First Army. It was the duty of these officers to check the condition of patients brought into Advance Section, Communications Zone installations and through this estimate, ascertain wherein our treatment could be improved.

    On 8 November, the army surgeon held a conference at the 4th Convalescent Hospital of all hospital, group, and separate medical unit commanders. During this conference, both administrative and professional aspects of army medical service were discussed. Topics considered under the administrative heading were discipline, with particular emphasis on gasoline and tire conservation improvement of unit messes, passes, rotation of personnel between army and Communications Zone units, arming of Medical Department personnel, and the inception of a system of routine inspections by officers from the office of the army surgeon. The handling of duty cases was reexamined to emphasize the basic idea behind the army surgeon’s plan for their disposition. This idea was that there lay within the power of the Medical Department the opportunity to render an appreciable service to the army, through salvaging and return to duty by means of the convalescent agencies at its disposal, key personnel who otherwise would pass out of the control of army. Furthermore, this plan freed the replacement systems of both army and Communications Zone from much administrative procedure. A final administrative note emphasized the importance of continual maintenance of dispensary facilities by all medical units. The army surgeon directed the consideration of all present to the fact that the Medical Department is a service, and must function as such at all times and under any conditions. The professional portion of the program was handled by the venereal disease control officer, who discussed matters of current importance. The army medical statistician pointed out common errors in reporting. The meeting was concluded by the army medical supply officer who introduced a questionnaire on the status of excess T/E matériel.

    During the month, preparations were made, by means of conferences with G-1 and G-4 agencies, to furnish medical care to large numbers of recovered Prisoners of War, in the event that  such groups were turned over to army on short notice. A basic detachment was set up, consisting of two medical officers and fifteen enlisted men, plus the equipment necessary to establish dispensary and minor hospitalization facilities in the event of overrunning one of these, German installations. This plan included the utilization of medical personnel and supplies present at such installations. After incorporation in the general service plan for care of recovered Prisoners of War, copies of the plan were distributed to those Medical Department units selected for its execution.

    Undoubtedly, the most serious problem to confront the army medical service during the month was that posed by the tremendous increase in trench foot cases. The first case of this condition appeared as early as the 27th of August, and was found in the records of a hospital unit then attached to Third Army. Admissions for this condition remained low during the months of September and October, rising during the first weeks of November, and reaching an all-time high on the 14th of that month, on which date 335 cases were admitted. Following this peak, a mean strength of approximately 100 admissions per day was sustained during the month. The greatest possible number of factors which could aid in the production of the condition were present at this time. The cold, damp weather, combined with the relatively static type of fox hole. warfare, produced the wet feet and immobility which are the etiological agents of trench foot.

    The following preventive measures were used to combat the disease:

        a.     On 1 October, Professional Memoran-


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dum #5, was published. This memorandum outlined the conditions under which trench foot could best exist and the necessary measures for its prevention. Its main theme was directed at instilling in the individual soldier the knowledge which would enable him to reduce materially his opportunities for becoming a casualty from trench foot.

        b.     Circular Letter No. 3, Office of the Chief Surgeon, European Theater of Operations, was distributed to all medical units, to include regimental medical detachments. This circular set forth detailed instructions on prevention, diagnosis, and treatment of trench foot.

        c.     On 17 November, a letter was prepared by the army surgeon, again emphasizing the importance of the disease, and recalling much information already disseminated. It added some new points gathered during the experience of the past weeks. This letter was distributed as an attachment to a letter from the army commander to his corps commanders.

    On the 27th Of November, representatives of the army surgeon held conferences with all corps and division surgeons at which the following points were emphasized:

        a.     That sufficient supplies of dry socks were provided for all men.

        b.     The necessity for wearing overshoes. If only small size overshoes were available, the men should be directed to wear the overshoes over two pairs of socks.

    General discussion at these meetings brought forth the fact that frequent rotation of units from the front lines to an area where drying facilities were available, was probably the most important prophylactic measure in the prevention of trench foot. Throughout the period, this office continued to lay stress on foot care by the individual soldier, through daily change of footgear, especially socks, and exercise of the feet, meanwhile reiterating the importance of unit rotation as the most efficacious method for reduction of manpower loss from the disease.

    To prevent loss of overshoes from division stocks, all army medical units were ordered not to evacuate overshoes with the men taken from division clearing stations.

    To check on the incidence of recurrence, persons admitted a second time with a diagnosis of trench foot were reported by name, rank, and Army serial number.

    Moderately severe to mild cases of the disease were sent to the 91st Medical Gas Treatment Battalion where a thorough study of the conditions and its response to various types of treatment was conducted. Its importance in the production of a high noneffective rate, plus the sometime permanent disability incurred, indicated the necessity for maintenance of continued effort towards its suppression during the remaining winter months.

    Toward the end of November, increasing difficulty was experienced in the securing of buildings large enough to house army medical units. Two factors were responsible: first, the sparse settlement of the central and southern part of First Army zone of action; second, the general rush for covered accommodations.

    For the first two weeks and two days of November, fighting was limited to patrol activities and artillery duels. As a result, casualty admission rates for the first half of the month were light. However, on the 16th of the month, VII Corps launched an attack employing three infantry divisions, one regimental combat team of a fourth infantry division, one armored division, and one combat command of another armored division. On the 18th of the month, admissions rose to an over-all figure of 1,879 for one twenty-four hour period. The terrain fought over, principally the forests around Hurtgen, was impassable to ¾-ton field ambulances and the litter-carrying 1/4-ton truck. Inability to use either of these important vehicles in the dense woodlands which were practically devoid of a road net, placed the all-important task of evacuation in forward areas upon the litter bearer. Army medical units were drained of all personnel available for the task. A shortage of Medical Department personnel existed in the replacement system at this time. Thus, when request was made to the army G-1 for additional litter bearers, it was necessary to process 190 line troops in accordance with the dictates of the Geneva Convention, give them a period of training as litter bearers, and use them for 20 days in this role. An indication of the magnitude of the task involved in first echelon evacuation may be gathered from the


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knowledge that in one corps zone, 415 litter bearers were employed in addition to those normally present in divisional medical units. Valuable assistance in solving this problem was rendered by Advance Section, Communications Zone. From staging general hospitals, litter bearers were supplied to First Army by the Advance Section, Communications Zone surgeon. Using these litter bearers in evacuation hospitals, the army surgeon was able to free litter bearers of First Army medical units to reinforce the hard pressed divisional medical units. In other respects, evacuation within the army proceeded without incident.

    On one occasion, several evacuation hospitals became so jammed with casualties due to the failure of evacuation in rear of the army that it became necessary to shift patients to other evacuation hospitals in a relatively quiet sector. Too few hospital trains, the necessity to evacuate the patients of a general hospital struck by a robot aircraft, damage to the rail-heads in the city of Liege by the same type of missile, culminated in a lack of sufficient bed space to receive First Army evacuees.

    The first fifteen days of the month of December saw few changes. The bulk of the troops of First Army were concentrated on the northern flank of the army area. No major shift of either policies or units occurred. All resources were being utilized to retain, with First Army medical installations, as many cases for return to duty as hospital bed space would allow.

C.    THE GERMAN COUNTERATTACK

    On the 16th of December, report was received by this office that the town of Malmedy was being shelled. This report came from the 44th and 67th Evacuation Hospitals functioning in that town. Report was also received that the city of Eupen was being shelled. Two hospitals, the 67th and 5th Evacuation Hospitals located in Malmedy and Eupen respectively, suffered a slight amount of damage to their buildings. The commanding officer and one noncommissioned officer of the 454th [sic, 464th] Medical Collecting Company were killed during the shelling of Malmedy while rendering first aid to civilian wounded.

    At 1900 hours, word was received that the enemy had made some penetration on the VIII Corps front and along the boundary between VII and V Corps. Based on this information, the decision was made to move the 1st Hospitalization Unit of the 42d Field Hospital from Wiltz, and the 107th Evacuation Hospital from vicinity of Clerveaux [Clervaux] to St. Hubert as fast as it could be entrucked; the 102d Evacuation Hospital was closed to admissions in preparation for movement. Withdrawal of the evacuation hospitals was completed successfully but a portion of the field hospital was overrun by the German advance. Lost with the officers and men of the field hospital was one surgical team of the 3d Auxiliary Surgical Group.

    At 0100 hours, 17 December, an officer from the 134th Medical Group was sent to Headquarters, 99th Infantry Division, to determine the tactical situation along the boundary between V and VIII Corps.  Although the information with which this officer returned indicated that the Headquarters of the 99th Infantry Division did not think the situation serious, decision was made to withdraw the 1st Hospitalization Unit of the 47th Field Hospital, then located at Waimes, and the 3d Hospitalization Unit located at Butgenbach [Dom Bütgenbach] later in the morning. However, the German advances were in excess of all estimates and so rapid that completion of these moves was impossible. The 1st Hospitalization Unit was actually overrun, but before any damage was done American troops reentered the area, and all personnel of the unit as well as the patients were able to reach our forces. However, it was necessary to abandon the equipment of both hospitalization units.

    At 1530 hours, 17 December, it was neces-


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sary to order the 44th and 67th Evacuation Hospitals in Malmedy to evacuate their installations of all transportable patients and the bulk of their personnel. Later that night and during early hours of the following morning it became possible to complete the total evacuation of these two hospitals. In addition to the hospitals in Malmedy, the 618th Medical Clearing Company operated a combat exhaustion center in the town. On the 18th of December, such patients and personnel as could be moved were evacuated from this installation and a detachment consisting of two officers and eighteen enlisted men remained behind to take care of patients left in the station. On the 20th of December, 247 patients and the remaining personnel of the 618th Medical Clearing Company were evacuated from Malmedy. During this period, constant check of the tactical situation was maintained in order to ascertain when it would be safe to attempt recovery of the equipment of the two evacuation hospitals abandoned in Malmedy and of Company C of the 91st Medical Gas Treatment Battalion similarly left behind in Grand Halleaux. On the 19th and 20th of December, when it appeared that the northern advance of the German army had been checked south of Malmedy, the equipment of these organizations was recovered.

    On the 18th of December, orders were received from the Chief of Staff, First U. S. Army, to evacuate all medical units then located in the town of Spa. Original plans called for evacuation to Remouchamps, but they were amended later and a new destination, the city of Huy, was indicated. On that day 1,000 patients were evacuated by army ambulance and trucks from the 4th Convalescent Hospital, 900 going to the 3d Replacement Depot and 100 to the 130th General Hospital in Ciney. The 102d Evacuation Hospital was entrucked and evacuated to Huy, closing there the evening of the 18th.

    Later that night report was received that the 107th Evacuation Hospital in operation at St. Hubert and the 110th Evacuation Hospital at Esch were filled because evacuation was not keeping up with their admissions. The ADSEC Surgeon’s Office was contacted and immediate relief of the situation was effected.

    On the 19th of December, because of the necessity for moving the 4th Convalescent Hospital, the bed capacity of Company C of the 91st Medical Gas Treatment Battalion was reduced to such levels that a ten-day evacuation policy could not be supported. Accordingly, on this date the army surgeon instituted a total evacuation policy.

    The same day, notification was received from G-4 that the VIII Corps would look to Third U. S. Army for supply and evacuation.

    On the 20th of December a Letter of Instructions was received from G-4, First U. S. Army, informing this office that First U. S. Army was to be placed under operational control of 21 Army Group. This office was requested to submit a list of medical units which it wished to retain to provide medical service for the army. The list follows:

2d Evacuation Hospital
5th Evacuation Hospital
44th Evacuation Hospital
45th Evacuation Hospital
67th Evacuation Hospital
96th Evacuation Hospital
97th Evacuation Hospital
102d Evacuation Hospital
112th Evacuation Hospital
128th Evacuation Hospital
Hq and Hq Det 68th Medical Group
Hq and Hq Det 134th Medical Group
Hq and Hq Det 50th Med Bn
Hq and Hq Det 53d Med Bn
Hq and Hq Det 57th Med Bn
Hq and Hq Det 175th Med Bn
Hq and Hq Det 176th Med Bn
Hq and Hq Det 177th Med Bn
Hq and Hq Det 179th Med Bn
Hq and Hq Det 180th Med Bn
Hq and Hq Det 187th Med Bn
382d Med Coll Co Sep
383d Med Coll Co Sep
442d Med Coll Co Sep
423d Med Coll Co Sep
427th Med Coll Co Sep
439th Med Coll Co Sep
445th Med Coll Co Sep
449th Med Coll Co Sep
450th Med Coll Co Sep
451st Med Coll Co Sep
452d Med Coll Co Sep
454th Med Coll Co Sep
457th Med Coll Co Sep
458th Med Coll Co Sep
459th Med Coll Co Sep


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464th Med Coll Co Sep
468th Med Coll Co Sep
469th Med Coll Co Sep
470th Med Coll Co Sep
482d Med Coll Co Sep
484th Med Coll Co Sep
491st Med Coll Co Sep
492d Med Coll Co Sep
493d Med Coll Co Sep
479th Med Amb Co
489th Med Amb Co
546th Med Amb Co
565th Med Amb Co
575th Med Amb Co
576th Med Amb Co
577th Med Amb Co
578th Med Amb Co
583d Med Amb Co
584th Med Amb Co
956th Med Amb Co
617th Med Clr Co Sep
618th Med Clr Co Sep
622d Med Clr Co Sep
628th Med Clr Co Sep
629th Med Clr Co Sep
633d Med Clr Co Sep
649th Med Clr Co Sep
660th Med Clr Co Sep
662d Med Clr Co Sep
684th Med Clr Co Sep
1st Medical Depot Co
Det “A” 152d Sta Hosp, atchd
13th Field Hospital
45th Field Hospital
47th Field Hospital
51st Field Hospital
66th Field Hospital
10th Medical Laboratory
3d Auxiliary Surgical Group with present achmts
4th Convalescent Hospital
91st Med Gas Tr Bn

Due to the XIX Corps taking over the VII Corps sector, it was necessary to move First U. S. Army hospitals out of Brand immediately. Accordingly sites were secured at Verviers and the 128th and 97th Evacuation Hospitals were directed to establish in that location. On the request of the surgeon, Ninth U. S. Army, the 96th Evacuation Hospital was instructed to remain open for receipt of Ninth Army casualties. During this period when closure and moving of so many First
U. S. Army. hospitals became necessary, the ADSEC Surgeon’s Office granted permission to the army to hospitalize patients directly in the 77th Evacuation Hospital, which unit was acting as a holding unit to the rear of First U. S. Army.

    On the 25th of December, G-4, First U. S. Army, instructed the army surgeon to move all medical units, other than those absolutely essential for operations, to a position west of the Meuse River. It was further directed that any installation east of the Meuse be held in readiness for movement on twenty-four hours notice. Accordingly, the 96th, 5th, and 45th Evacuation Hospitals, the 4th Convalescent Hospital, plus combat exhaustion hospitals and all hospitalization units of field hospitals not in use at the time, were directed to reconnoiter in the specified area. Two of the evacuation hospitals were ordered to find sites where it would be possible to receive patients. Many difficulties were encountered in finding suitable locations as the area contained few large towns. By the 31st of December, movement of medical units was completed. At this time First Army, working under a total evacuation policy, had the following evacuation hospitals open; the 2d in Eupen, the 128th and 97th in Verviers, the 102d Evacuation Hospital, and all three hospitalization units of the 51st Field Hospital in Huy. Plans were under way to replace the 51st Field Hospital with the 67th Evacuation Hospital at such time as its equipment was checked and ready. The 618th Combat Exhaustion Center was open west of the Meuse at Avesnes.

    The problem of trench foot continued to receive a good share of attention by the army surgeon. In addition to the measures outlined previously, other points of attack were sought out in order that no detail which could lead to improvement would be slighted.

    This office secured the services of three Sanitary Corps officers. They were sent, one to each of the three corps, with the mission of investigating all factors which could possibly have a bearing on the incidence of trench foot. These officers were instructed to seek opinion and facts not only from officers, both line and medical, but also from the individual soldier himself. As a summary of the more important facts presented in their reports, the following list is included:


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    a.     Overshoes were lacking in the larger sizes (from size 10 up). One corps was short 11,000 pairs of these larger sizes.

    b.     Rigid disciplinary measures were an aid in prevention of trench foot. In one unit this was carried as far as having squad leaders sign a daily certificate which stated that each man in his squad had that day carried out approved preventive measures.

    c.     Rotation of units from the actual front line to an area where drying facilities were available was mandatory.

    d.     Reinforcements lacked knowledge of foot care.
    Suggestion was offered to the army quartermaster that an experiment be conducted to determine the relative merits of the shoes and galoshes presently issued, as compared to shoepacs, by equipping a battalion with the last type of footgear.

    This office approved the issue of reconditioned shoes as another aid in the fight against trench foot. These shoes were to be thoroughly cleaned, reconditioned, and issued to the soldier by quartermaster bath units, thus insuring him a clean, dry pair of shoes following his visit to such an organization.

    The 12th Army Group directed that an educational film on trench foot be prepared in First U. S. Army. The technical work was done by a photographic section from Supreme Headquarters, Allied Expeditionary Forces. Clinical material was obtained at First U. S. Army medical installations and medical supervision supplied by a medical officer of First U. S. Army.

    In the months prior to the German counterattack, evacuation was effected by employing one medical group in each corps zone. Two separate medical battalions with their component collecting, ambulance, and clearing elements supported army service area installations and coordinated the activities of the army combat exhaustion centers. A ten-day evacuation policy was in effect.

    The main difficulty experienced as a result of the German counteroffensive was that of maintaining contact with rapidly moving or partially encircled clearing units. The problem of evacuating entire hospital installations on short notice placed further strain on the system. Although movement of hospitals was effected as necessary, suitable buildings for their establishment were found only in a few cases. The reduction of bed capacity brought about by this circumstance plus the necessity of keeping available beds open for receipt of fresh casualties made the establishment of a total evacuation policy mandatory.

    During the early days of the enemy attack, 16 through 19 December, the army received one medical battalion headquarters, three collecting companies and one ambulance company from Ninth U. S. Army. These additional resources enabled the Surgeon, First U. S. Army, to augment the ambulances of the 134th Medical Group, evacuating the V Corps, and to send a total of thirty ambulances from First U. S. Army reserves, to the 64th Medical Group, evacuating VIII Corps. Further augmentation of VIII Corps ambulances was effected by means of one platoon from an ADSEC ambulance company which was given the mission of evacuating the 107th Evacuation Hospital.

    When VIII Corps passed to Third Army control, the 64th Medical Group, composed of two battalion headquarters and one collecting company, four ambulance companies and one clearing company, were relieved from assignment to First U. S. Army. In addition, the 169th Medical Battalion, attached to VIII Corps and serving as the corps medical battalion, plus one field and three evacuation hospitals, were detached from First U. S. Army in the shift.

    XVIII Airborne Corps came to First U. S. Army unequipped with a corps medical battalion. This deficit was made up by using the battalion headquarters and one collecting company, obtained from Ninth Army, plus one platoon of a First Army clearing company. Further, no medical group was available to take over regulation of third echelon evacuation in this corps zone. Thus the end of the month found the 68th Medical Group servicing the entire VII Corps, which had been returned to the line on the right flank of First U. S. Army and, in addition, the majority of the divisions of XVIII Airborne Corps. The 134th Medical Group evacuated the V Corps and the left flank division of XVIII Corps.


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Plans were under way to secure a third group headquarters, to return army medical service to the former set-up wherein one group serviced one corps only, since experience had taught that such a system provided optimum conditions for control.

    Medical Department reinforcements continued to prove a source of anxiety to the army surgeon. Litter-bearers, more than ever essential to evacuation in the terrain facing First U. S. Army, were the focal point of this difficulty. As mentioned previously 190 line troops were serving in this capacity. On 3 December, a ten-day extension of their services was granted and they remained on duty until 13 December, on which day 173 were returned to reinforcement pools. Seventeen of the original 190 were killed in action, missing in action, wounded or AWOL.

    The 8th Infantry Division drew sixteen litter bearers from the 134th Medical Group to supplement division litter bearers. On the 20th of December, a request was received from the 2d Division for 150 Medical Department reinforcements of all types. As reinforcement sources were still unable to aid, six medical officers and ninety-seven enlisted men were supplied from army medical units to meet these requests. A call for medical officers from the 75th Division was met by again drawing these men from army medical units. This constant depletion of third echelon medical units to supplement or fill gaps in first and second echelon units forced the army surgeon to ask for assistance from Communications Zone medical sources. At one period during this month, over three hundred Medical Department personnel from Communications Zone units were on duty in First U. S. Army medical installations. The above figures will serve to show the severe strain placed on the Medical Department by performance of this task in addition to its normal functions.

    During the period, evacuation was maintained satisfactorily within the army. At no time were army installations unable to accept further admissions. Evacuation to the rear of First U. S. Army kept pace with all demands placed upon it.

D.    THE ALLIED COUNTERATTACK

    The beginning of January found the 2d Evacuation Hospital located in Eupen, the 97th and 128th Evacuation Hospitals in Verviers, the 102d Evacuation Hospital and the 51st Field Hospital in Huy. In the army service area west of the Meuse, the remainder of First Army's evacuation hospitals were located as directed by the Army G-4.

    At this time, the Medical Service of the First U. S. Army was operating under a total evacuation policy. Building space for establishment of hospitals was extremely scarce, and climatic conditions prevented setting up in fields as vehicle turn-arounds became impassable in a matter of hours despite all efforts at maintenance. Fortunately, casualties were light at this particular time and their handling imposed no strain on the First Army medical units under conditions of total evacuation.

    However, it was the desire of the army surgeon to return as quickly as possible to a system whose facilities permitted holding, in army control, the maximum number of cases whose hospitalization expectancy was of short duration. Accordingly, the 2d and 5th Evacuation Hospitals were ordered to receive cases of respiratory disease and cases with a hospitalization expectancy of ten days or less. The 2d and 5th Evacuation Hospitals returned convalescent cases to duty through the 91st Medical Gas Treatment Battalion. In addition, the 91st Medical Gas Treatment Battalion still received cases of disease as before. Inability to open the 4th Convalescent Hospital necessitated this solution, which, though makeshift, served the desired ends. The system went into effect on the 12th of January and provided the basis for return to a 10-day evacuation policy.  


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    In addition to the above installations, the 618th Medical Clearing Company operated a combat exhaustion center at Antheit in the vicinity of Huy. Later in the month, the 622d Medical Clearing Company was established at Eupen and functioned there as a combat exhaustion center.

    Venereal disease cases were treated by a detachment from the 4th Convalescent Hospital operating at Company B, 91st Medical Gas Treatment Battalion. Thus, all functions formerly carried out by the 4th Convalescent Hospital were performed by other medical units, assisted in some cases by personnel .from that organization.

    For the remainder of the month, all efforts were directed toward reestablishment of sufficient army hospitals to allow a resumption of the normal handling of casualties. On the 17th of January, the 45th Evacuation Hospital was ordered to leave Jodoigne and proceed to Spa. At Jodoigne, it secured a hospital site and was held in readiness against its possible need in the event of further progress to the west by the German armies. At the same time, the 96th Evacuation Hospital was ordered to proceed from Velm to the same site at Spa, where the two hospitals were set up together. On the 19th of January, they were opened to receive patients. January 24th saw the return of the 5th Evacuation Hospital to Eupen with the 128th Evacuation Hospital taking over its assignment at Hannut. On 31 January, the 5th Evacuation Hospital was opened to receive patients. The move of the 128th Evacuation Hospital was necessitated by a command decision to return the buildings occupied by the 128th and 97th Evacuation Hospitals to VII Corps for use as a rest center. The 97th Evacuation Hospital was forced to leave the buildings in Verviers at the same time. It was sent to Malmedy, where a hospital was established and opened on the 30th of the month. On the 29th of January, the 128th Evacuation Hospital moved from Hannut to Banneaux, Belgium and established a hospital for the handling of respiratory diseases, thus relieving other evacuation hospitals, which were in better position to provide short ambulance hauls for battle casualties, of the necessity of handling such cases. On the thirty-first of the month, the 44th Evacuation Hospital moved to Vielsalm and opened to admissions.

    On the 24th of the month, the 4th Convalescent Hospital opened in the city of Dinant. Though far to the rear of the left flank hospitals of First Army, this location was on the best road net and included the only suitable buildings available under the conditions in force at the time. With its reopening, the handling of convalescent cases returned to the normal set up, easing the load carried by the 91st Medical Gas Treatment Battalion.

    During the month, the 622d Medical Clearing Company had established a combat exhaustion hospital in the city of Eupen at the former site of the 45th Evacuation Hospital. Combat exhaustion casualties were at a low level during the entire period and at no time were either of the installations, the 618th or the 622d Medical Clearing Companies, overburdened.

    On the third of January, the army surgeon called a conference of the commanding officers of the 4th Convalescent Hospital, 91st Medical Gas Treatment Battalion, and the 177th Medical Battalion, the latter agency being the administrative echelon governing the two combat exhaustion hospitals. The purpose was to discuss the high rate of AWOL’s charged to these units. It was discovered that a fallacy existed in placing the blame on these medical units, since the individuals concerned most frequently committed the violation after discharge from the unit.  An individual could rejoin his unit and be physically present there while charged against the hospital as AWOL. Such charge remained until information filtered through channels and corrected the error. The Adjutant General charged those going AWOL after being marked duty, or while en route to their parent organizations, to the parent organization, thus eliminating the condition which led to the incorrect figures of AWOL’s from medical units. At the same time, the army surgeon directed the institution of measures to reduce opportunities for such dereliction, and to impress on the men being returned to duty that they were actually being returned to their parent organization and not to a reinforcement depot.


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    Advance Section, Communications Zone, again materially assisted First U. S. Army medical units by the loan on a temporary duty status of over three hundred medical personnel from staging general hospitals.

    Because of the few buildings available to house evacuation hospitals, it was often necessary to erect tentage to supplement the covered accommodations used. Particularly, in the case of sections requiring space to permit expansion and freedom of movement such as the receiving section, was this true. It was necessary to provide such tented adjuncts with heat, and in exposed positions, with side-wall bracing to shut out gusts of wind. To meet this need, the First U. S. Army engineer and the surgeon agreed upon the construction of sectionalized flooring for tentage. Floor sections measuring 4 by 8 feet were constructed and side walls to fit both lengthwise and at the ends of hospital ward tents. Twenty-four such 4 by 8 foot sections completely floor, a ward tent.

    At the beginning of January, control of evacuation was implemented by two Medical Groups, the 68th and 134th. These groups coordinated third echelon evacuation in three corps zones, each having one corps and a part of another to service. In response to a request submitted in December, a third medical group, the 64th, with two battalion headquarters, the 170th and 240th, was assigned to First U. S. Army, rejoining 10 January 1945. On the 18th of January, using five collecting and two ambulance companies and one field hospital, it became operational in support of the XVIII Airborne Corps. Evacuation presented no insurmountable obstacles. Low temperature, ice, and snow made road conditions difficult in the extreme. The lengthening of evacuation routes coupled with the necessity of supplying XVIII Airborne Corps with a medical battalion from army medical units, depleted ambulance reserves below a desirable minimum. Nevertheless, no breakdown occurred at any time. Evacuation to the rear of First U. S. Army met all demands placed upon it in a highly satisfactory manner.

    The opening days of February found eight evacuation hospitals open in support of First U. S. Army. These included the 2d and 5th Evacuation Hospitals at Eupen, the 97th at Malmedy, the 45th and 96th at Spa, the 67th at Huy, and the 44th at Vielsalm. The 128th Evacuation Hospital opened on the 2d of February at Banneaux for the hospitalization of respiratory diseases, relieving the other evacuation hospitals of the necessity of handling such cases.

    On the 5th of February, the VII Corps swung into line on the north flank of First U. S. Army. To support the operations of this corps, the army surgeon arranged to take over the Koerner Caserne at Brand, occupied at that time by Ninth U. S. Army medical troops. These buildings formerly had housed First Army medical units, and were well adapted to use as hospitals. On the 6th of February, the 102d Evacuation Hospital opened in this location, followed on the 11th of the month by the 44th Evacuation Hospital.

    Because of the extremely long ambulance haul required to transfer patients to the 4th Convalescent Hospital, it was decided to remove the two evacuation hospitals from the Caserne at Spa and establish the 4th Convalescent Hospital there. Accordingly, the 45th Evacuation Hospital was moved into bivouac in the vicinity of Spa, and Detachment A of the 4th Convalescent Hospital was moved to Spa where it opened on the 12th of February. On the 14th of February, the 96th Evacuation Hospital was also closed and moved to Dolhain, being replaced by the remainder of the 4th Convalescent Hospital.

    To make room for a rest center, the 67th Evacuation Hospital was moved from the town of Huy to the Caserne at Brand where it went into bivouac.

    During this period, from the middle to the end of February because of flooding of the Roer Valley and the necessity for reorganization following the campaign which brought First Army up to the banks of the Roer and saw the capture of the Urfalsperre and Schwammeneuel dams, casualties declined appreciably in number. Thus the end of the month saw five of the First Army evacuation hospitals, the 2d, 45th, 67th, 96th and 128th, closed. A rather remarkable item may be


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noted here. The 2d Evacuation Hospital had been in continuous operation in the town of Eupen for a period of one hundred and forty-two days except for four days during which it had been closed to admissions.

    No major changes occurred in the hospitalization policy of First Army during this period. It remained on a ten-day holding basis and at no time were the hospitals without a substantial reserve of bed space.

    During the month of February, evacuation routes were shortened considerably as the front of First Army decreased in length. The return of the 4th Convalescent Hospital to Spa from Dinant also aided materially in this respect. When the airborne troops employed in the XVIII Airborne Corps were relieved from First Army and replaced by infantry divisions, ambulances assigned from army to cover these units returned to their normal duties in third echelon evacuation. These factors aided in relieving the strain which the Medical Service of First U. S. Army had felt since the break-through and its contingent dislocations.

    The thaw occurring during the month removed the menace of icy roads, but, combined with heavy vehicular traffic, soon reduced roadways to rubble. Road after road in the army zone had to be withdrawn from the traffic circulation plan and in some cases abandoned permanently. A direct route for ambulance evacuation became a rarity. Seeking to circumvent the additional misery and actual damage which could be incurred by the patient forced into long trips by ambulance over such roads, the army surgeon gave directions that experiments be made with light aircraft to determine their usefulness, particularly in the field of moving the seriously wounded litter casualty from field hospitals or division clearing stations to evacuation hospitals. On the 17th of February, using an L-5B liaison plane equipped with racks for one litter, a simulated casualty was carried from the 8th Infantry Division clearing station to the 102d Evacuation Hospital at Brand. The test was successful and on the 20th of February, the first battle casualty was flown from this clearing station to Brand. The trip occupied ten minutes of actual flying time as compared to ninety minutes of travel by ambulance over miserable roads. During the remainder of the month of February, using the same equipment, twenty-three patients were flown from field hospitals and division clearing stations to army evacuation hospitals. Because of the success of earlier missions, the assignment of planes, pilots, and ground crews to the medical section of First U. S. Army was requested. Four L-1 planes were received and two pilots. These were attached to the liaison squadron serving Headquarters First Army and the pilots, secured from a squadron of P-47 pilots, received training from the liaison squadron in the handling of light aircraft. On the 27th of the month, the first patients were carried in these aircraft. Further plans were laid for the formation of a self-sufficient squadron of these light evacuation aircraft, complete with the necessary ground crews. The aircraft were marked with the Geneva Convention symbol to identify them. Although poor weather made scheduled runs for the aircraft a matter of chance, the advent of spring led to the planning for regular use of air evacuation.

    The period covered by this report found the surgeon of First U. S. Army confronted with three tactical situations which were totally dissimilar in all aspects. At the beginning of the month of August, the rout of the German forces made necessary the establishment of a highly mobile medical service, capable of keeping up with rapidly moving troops. Low casualty rates allowed maintenance of adequate treatment facilities by employment of a smaller medical unit than that normally used as the purveyor of definitive treatment, specifically, the field hospital. To their rear, the evacuation hospitals were used as holding units to break long ambulance trips between army and Communications Zone medical installations. A change of the tactical situation, brought about by stiffening resistance, increased casualty rates and made necessary the provision of more hospital capacity for definitive treatment, and thus brought the field and evacuation hospitals back to the roles for which they had been specifically selected. The attack of Von Rundstedt’s armies dislocated army medical units and, because crowded ac-


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commodations prevented establishment of sufficient hospital beds, caused temporary abandonment of the ten-day evacuation policy. However, a rapid return to this policy was made after the progress of the German armies had been stopped and it was maintained without an interruption since that time. That the constitution and utilization of the Army Medical Service and the supporting Communications Zone services was basically sound may be deduced from the absence of two elements. There was no serious breakdown in evacuation. Nor was there any complaint indicating that any soldier did not receive all the medical care which the limitations of field service did not exclude.


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III.   Transportation

During the initial stages and up to and through, the time when the German forces in France collapsed, the system of coordinating the loan of vehicles between units was effected through the office of the army surgeon and accomplished its purpose. But when the distance involved in each trip ran up to 100 miles, communications and turn-around time made control by a unit capable of following up the vehicles imperative. Accordingly, a provisional Medical Department truck company was set up, finally coming under command of the 57th Medical Battalion, Headquarters and Headquarters Detachment. Trucks and drivers were pooled under the direction of this organization. In periods of rapid movement, one hundred and fifty trucks were out on missions, coordinated by the personnel of the battalion. On other occasions, when the situation was static, the number of vehicles pooled on temporary duty with the Provisional Truck Company was reduced to fifty.

    Maintenance equipment was secured and mechanics from various units, placed on temporary duty with the organization with this task being rotated at intervals between units. By this means, the all-important bogey of break-down and loss of service was defeated.

    After the German collapse at St. Lo, a new problem presented itself to the medical service. This was to provide hospital care over a front which, as the situation developed, extended for a distance of approximately 150 miles. It was thought best to concentrate all Medical Department transportation, save those few vehicles necessarily left behind in each installation for housekeeping purposes. Using the vehicles of all the evacuation hospitals plus thirty from the 91st Medical Gas Treatment Battalion, three truck fleets of about sixty vehicles were set up, and the hospitals were moved entirely by these fleets, one fleet of sixty vehicles serving to move one evacuation hospital. Due to the shortage of quartermaster transportation, the medical depot which, at that time, was carrying approximately 1,200 tons of medical supplies, was also moved with these same vehicles, as well as two sections of the advance depot platoon, each of which carried approximately sixty tons of supplies. Between the 21st and 31st of August, ten evacuation hospitals of 400 beds, one evacuation hospital of 750 beds, the 1st Medical Depot Company, the 91st Medical Gas Treatment Battalion, the 10th Medical Laboratory and a 500-bed section of the 4th Convalescent Hospital, were moved distances averaging 165 miles.

    Numerous difficulties arose. In the early part of the movement, the supply of gasoline at the forward end in the vicinity of Senonches, was somewhat uncertain. Tactical troops movements necessitated a lengthening of the route and on occasion made it impossible for supply units to move for periods of time varying from two to twelve, hours. Control of the truck fleets was made extremely difficult by all the foregoing factors plus the distances covered. An added element that made for difficulty was the lack of maps in the possession of the drivers of the vehicles. This was overcome by having strip maps, or simpler still, typewritten routes containing the numbers of highways involved, plus the main towns through which the routes passed, given to the drivers. At the completion of these series of movements, it was thought wise to form, in anticipation of such moves in the future, a Provisional Truck Company containing one hundred vehicles, under the control of the 68th Medical Group. The Provisional Truck Company was set up, using ten vehicles from each of the ten 400-bed evacuation hospitals. In addition, it became necessary to mobilize all the field hospitals to such an extent that they could keep up with the rapid movement of the divisions. Accordingly, thirty-nine vehicles were allotted to the 177th Medical Battalion under whose control the field hospitals came, with the object of having one field hospital platoon always ready to move in each


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of the three corps zones. The gasoline situation was even more critical at the forward end of the route but this was partly solved by arranging that each outgoing convoy would carry with it sufficient gasoline to return to its starting point. Further, large quantities of lightly wounded German prisoners caused a drain on the number of vehicles available for these movements, since it was necessary to press trucks into service for their evacuation.

    With the speed of tactical troop movements constantly pulling medical units toward the front, the first two weeks of September were similar to the last two weeks of August so far as transportation was concerned. The Provisional Truck Company, formerly under the 68th Medical Group, provided the main source of Medical Department transportation during this period. Increased operational flexibility, improved maintenance, and greater control of a useful number of  2½ -ton trucks were the benefits resulting from the formation of this organization. Due to the fact that a multiplicity of tasks must be carried out by a group headquarters with a limited number of personnel, an administrative shift was made which placed the truck company under the control of the 57th Medical Battalion, since this unit would be able to spare more time to an organization which had become extremely important to the Medical Department.

    Because of the distances involved, it was necessary to move several units by train. The 2d and 96th Evacuation Hospitals, and a 500-bed section of the 4th Convalescent Hospital were moved in this way. The extreme rapidity of movement had left these units so far to the rear that truck transportation would have been uneconomical and was discarded in favor of rail. The end of September found army medical units in good position with regard to the combat troops. Negotiations were being carried out for the rail movement of the remainder of the 4th Convalescent Hospital, which during the entire month of September had remained at Gathemo. Completion of this movement would complete the regrouping of all First Army medical units

    The abrupt slowing of progress as the Siegfried Line was reached lessened the need for trucks. Therefore, much unit transportation was returned to parent organizations, leaving only sufficient trucks with the Provisional Truck Company to carry out the mission of supplementing Medical Department unit transportation.

    The arrival of the detachment of the 4th Convalescent Hospital at Maastricht completed the regrouping of Medical Department units begun during the month of October.

    A minimum amount of movement of large army medical installations occurred during the month of November. Because of this, the number of trucks kept with the Medical Department Provisional Truck Company was reduced to 50.

    Further, because of the static situation still extant, pooled transportation had been cut to fifty 2½-ton, 6 x 6 trucks at the beginning of the month of December. Until the enemy attack was launched, only one movement of any size was accomplished. The 128th Evacuation Hospital was moved from Dolhain to Brand. Beginning on the 16th of the month, nine evacuation hospitals, one convalescent hospital, and three field hospitals, one advance section of the 1st Medical Depot Company, and one company of the 91st Medical Gas Treatment Battalion were moved during the remaining fifteen days of December. 1,726 patients were transferred from the 4th Convalescent Hospital to reinforcement depots by truck. On seventy-three missions, Medical Department trucks of the Provisional Truck Company covered 44,838 miles. The close of the period found one hundred trucks pooled under the direction of the Provisional Truck Company.

    The month of January again saw much movement of Medical Department units. A total of 32,419 miles was covered by the 2½-ton trucks of the Medical Department Provisional Truck Company on 235 truck trips. It must be realized that in addition to the mileage ‘recorded by these trucks each unit moved supplies in vehicles of its own, although the bulk was made up of trucks from the Provisional Truck Company. Thus, the above mileage figure is an index to movement and is in no way a total recording. As before,  the centralized control of a large number of


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trucks proved of great assistance in the moving of large numbers of medical units.

    Only a moderate amount of movement of First Army medical units took place during the month of February. The provisional truck company, under the Headquarters and Headquarters Detachment of the 57th Medical Battalion remained close to Headquarters, First U. S. Army. Rotation of maintenance vehicles and mechanics attached to this organization was effected during the month.

    The pooling of 2½-ton, 6 x 6 trucks was found to be of great advantage in the maintenance of centralized control of the movement of army medical units. Had these trucks been dispersed with the units to which they belong, difficulties of communication would have slowed the movement of units appreciably and in some cases defeated entirely the purpose for which the move was planned. Further, by concentration of repair facilities and maintenance equipment at the headquarters of the provisional truck company, these vehicles received more efficient maintenance than they could have received had they relied on the units serviced. Though flaws existed in the system, it proved a swift, reliable source of transportation.


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IV.    Medical Supply Section

A.    EXPLOITATION OF THE ST. LO BREAK-THROUGH

l Aug.-12 Sep. 44

    Up until the collapse of enemy resistance at St. Lo and the subsequent break-through, Medical Supply was in an excellent position to accomplish its mission. The 1st Medical Depot Company was situated about ten miles to the rear and in the approximate center of the army area. In this location, it was accessible to forward units and at the same time close to its source of supply. Though issues were heavy, there was no serious shortage of supplies, and the supplies on hand were adequate to meet demands. However, with the break-through, the picture changed from one of a fairly stable warfare to one of rapid movement. This change brought with it many new problems; chiefly, the ability of keeping up with a fast moving tactical situation. In order to do this, the two advance sections of the medical depot company were utilized to the maximum and in the month of August moved twice, in order to support forward units. The advance sections were semi-mobile and transportation was not as critical with them as it was with the Base Section. During the first week in August 1944, it was necessary to move the base section to St. Lo, France, and using one hundred and eighty trucks it took three days to move 1,300 tons of medical supplies. It was now apparent that the transportation was not present in sufficient quantity to move the base section any great distance, carrying the tonnage that was currently on hand. The army medical supply officer realizing this, directed a physical inventory of depot stock, and items that were considered not essential for current operations or that were bulky and slow moving, such as Balkan frames, ward tents, and refrigerators, were weeded out and turned over to ADSEC. In order to lighten the load further, forced issues of certain items were made to evacuation and field hospitals. Typewriters and 55-gallon drums of white gasoline were among these. In addition, all units were called upon to bring themselves up to T/E strength on Medical Department items. As a result, depot tonnage was cut from 1,300 tons to 1,100 tons. This streamlining process was offset somewhat, however, by a period of light issues due to relatively few casualties.

    During the period, Medical Supply was called upon to furnish support to units that were cut off or surrounded. When the enemy counterattacks developed at Mortain, an infantry battalion was separated from its parent unit and badly in need of medical supplies. The army surgeon in the preinvasion planning had forseen [sic] such a possibility and prepared lists of items essential for one day’s operations for type units; companies, battalions, regiments. These included splints, folding litters, blankets, plasma, morphine, dressings, and drugs, and were prepackaged for air drop. Many of these prepackaged supplies were dropped to isolated groups during the counterattacks near Mortain and no doubt saved many lives.

    With the difficulty encountered by the lack of transportation for forward movement, replenishment of depot stocks from the rear became a problem. Consequently many items appeared in short supply, such as sutures, needles, catheters, oxygen, sheet wadding, and penicillin. Many of these items were available at rear installations, but transportation was not available to move them forward. This necessitated the depot dispatching trucks in emergencies to bring supplies forward. It was fortunate again that issues were light and casualties few. In the majority of items, stocks on hand in the depot, though low, were sufficient to satisfy demands.


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    As the pursuit of the enemy continued after the failure of the counterattack at Mortain, lack of transportation continued to be a growing source of concern. The advance sections which were easier to move because of the lighter load they carried, were not such a problem; however, the base section was a constant source of trouble. From its location at St. Lo, France, it moved to Gathemo, France, a position that was useless almost as soon as established. Issues were light due to continuing light casualties and therefore depot stocks were adequate. Toward the latter part of August, a move of 175 miles was made to Mesnil-Thomas, France, and 75 trucks from the Provisional Medical Department Trucking Company were used.

    With the rapid forward movement still continuing, communication, as well as transportation, became a source of difficulty. At times supplies that were needed by units were not on hand in the advance sections, and due to lack of communication, the information could not be transmitted back to the base section. If it had been possible to communicate readily with the base section, these needs could have been met more expeditiously. In order to be closer to the actual situation, the medical supply officer joined the executive officer and the chief of operations at an advanced CP.

    During the first week in September, the advance sections continued to carry the bulk of the issues, as they were well forward and supporting divisional units. The base section remained at Mesnil-Thomas, France. Due to the unusual tactical situation, this area became obsolete prematurely and a movement was required to place the base section in position again.

B.    THE BATTLE OF GERMANY

13 Sep.-15 Dec. 44

    Medical supply difficulties and problems of the previous period remained acute on into September. Primarily they were varied transportation difficulties, and the problem of maintaining consistent and adequate support to a fast-moving front. During this period, actual demands for supplies represented but a few tons per day, issues being in direct proportion to casualty rates.

    Typical of the army services’ problem of keeping in contact with tactical units was the case of the base medical depot. The number of trucks available to move any or all sections of the depot was limited to army Medical Department organic vehicles. These trucks were already overtaxed, being used to move all army medical units, many of which had priorities over supply installations. To help relieve the situation, stock levels were again reduced to make the depot more mobile. In this inventory and stock reduction, 300 long tons of slow moving or excess items were returned to ADSEC depots. Transportation for the moving of the depot was not readily available even with the reduced tonnage. At one location, the stock had just arrived and without filling one requisition, the depot was again moved to Soheit-Tinlot, Belgium. Upon arriving at this, location, the stock was again moved, this time to Eupen, Belgium. The stock reaching this location represented the most active stock and considerable tonnage remained in the old army service area until more transportation became available. During this period, the two advance sections were used to the maximum.

    It was found that the transportation handicap was felt not only by First Army but was just as acute with installations to the rear. This proved to further increase forward supply problems. With supply from the rear falling behind, property exchange supporting ADSEC operated air evacuation failed to function and evacuated items were stripped from the army


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area. For a period of 72 hours, the only blankets and litters obtainable were 10,000 captured German blankets and 500 captured German litters. This supplement kept the chain of evacuation functioning. At this time, shipments from the rear on army requisitions dropped to practically nothing. Because of this, 5,000 units of penicillin had to be flown in by artillery liaison planes. All requisitions and back orders on Communications Zone were canceled due to the confused condition of due-in records. Four requisitions were immediately submitted through channels to replenish fast diminishing depot stocks. Deliveries on these requisitions continued to be slow and incomplete and First Army Medical Department trucks had to be dispatched to the rear to bring supplies forward.

    When all sections of the depot were forward, they were situated so as to afford maximum support to the army. The base was established in the center of the army zone and was easily accessible to the many hospitals concentrated in the Eupen area. The two advance sections were operating on the two flanks at Malmedy, Belgium and Valkenburg, Netherlands.

    Up until the time of the Aachen offensive, casualties were light. Depot operations were normal, issues were slow, and the drain on depot stocks was not heavy. This was fortunate as transportation difficulties continued to reduce depot stocks. Certain items remained in short supply as a result of faulty transportation facilities. Requisitions on army allocated tonnage were placed on Communications Zone but shipments as received were sketchy, incomplete, and delayed. To maintain proper due-in records and to keep requisitioning on a 14-day level basis became increasingly difficult with the extended time lag between requisitioning and date of receipt.

    Every effort was made to relieve the situation of so many items remaining in short supply. Army Medical Department transportation was dispatched to draw supplies directly from Communications Zone depots. In spite of this, certain items remained in short supply since they were either in craft lying off shore or were in rear Communications Zone depots beyond the reach of army transportation. Misdirected rail and truck convoy shipments remained a problem. Often, rail cars as well as truck convoys consigned to another command were received in this sector and had to be rerouted. One shipment on a First Army requisition was directed to Ninth Army then misrouted a second time, arriving at some forward installation in the Netherlands. The depot commander as well as representatives of the 25th Regulating Station personally followed the routing of these cars until it was finally received some months after the initial shipment. In addition, many supplies were received that had not been requisitioned and could not be used in army installations. It was during this period that the demand for supplies increased, the Aachen offensive being under way.

    To ascertain the basis for the difficulty experienced in receiving supplies in forward areas, representatives of the surgeon’s office, 12th Army Group, conferred with this office and attempted to follow an army requisition through its complete processing. These representatives accompanied the requisition from army G-4 to the 25th Regulating Station, to Advance Section, Communications Zone, to Communications Zone, to the depot and its processing there, and started back with five trucks loaded with a portion of the requisition. These officers found that many days passed before the shipment was finally accounted for. En route the trucks had been unloaded, repacked on rail cars, and again forwarded and lost. The conclusion of the investigation as reported by these officers was that stocks available in Communications Zone depots often became delayed or lost in transit and that the Transportation Corps had no facilities to follow through or regulate these shipments.

    Another problem arose as the result of shifting of army boundaries and the accompanying transfer of corps and supporting army units. First Army lost XIX Corps which was supported by one advance section of the depot company and the 102d and 107th Evacuation Hospitals. It was felt that the most expeditious way of handling the transfer of supplies was to leave physical stocks in the respective areas; transferring depot personnel to assume


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control of the stock formerly operated by the other command. This was accomplished and operations were resumed with the 2d Section supporting VIII Corps at Bastogne. The few necessary stock adjustments were quickly made.

    Transferring complete hospital assemblies was more difficult. A sharp discrepancy in the operational equipment between hospitals of the two commands was noted. The army surgeon decided that the standards of First Army Hospitals would not be reduced and the equipment furnished the two transferring hospitals in excess of Tables of Equipment as First Army special projects was directed to be retained within the army. The units leaving objected on the grounds that this equipment was necessary for continued efficient operation. A conference of army surgeons was suggested to consider the possibilities of establishing a standard list of equipment for all commands. The army surgeon and his medical supply officer represented First Army at the conference held at Communications Zone headquarters in Paris and detailed recommendations for changes in present Tables of Equipment and Equipment Lists for evacuation and field Hospitals. As a result of this meeting, new allowances based on First Army levels were adopted to be authorized within the theater.

    Late in October the base depot at Eupen operated under a severe handicap using open storage for warehousing. Heavy traffic plus constant rains eventually made operations in the mud impossible. After considerable search, buildings were located at Dolhain, Belgium, which could house the base depot completely with its optical and repair sections, bin stock section, and warehouse section. The depot was moved, and the change afforded greater protection for supplies in addition to increasing the operational efficiency of the depot.

    Army hospitals setting up in buildings for the first time found requirements for many supplies and repair services not available through normal supply channels. For such items, local procurement was employed extensively and centrally administrated from the army surgeon’s office through the purchasing and contracting officer. To relieve the increased labor burden, civilians were also employed.

    In November, the transportation problem in the rear remained acute and shipments of replenishment stock were far below requirements. Against a minimum daily maintenance requirement of 12 tons or 360 tons for a 30-day period only 5 tons of supplies were brought forward. Such irregularities in replenishment stock made operations most difficult and the general supply situation in respect to stock levels progressively deteriorated to an unsatisfactory condition. Many items requisitioned but not received were attributed to the persistent Communications Zone problems of, first, being unable to get the necessary priority to unload craft laying offshore, and secondly, the inability to obtain sufficient transportation to move supplies, from rear (beach and port) depots to advanced depots in support of First Army. In addition, many shipments leaving Communications Zone depots were never received within the army. This condition existing for approximately two months resulted in the accumulation of over 400 zero stock balances.

    To relieve this situation, direct communication was established with the office of the chief surgeon. The commanding officer of the army medical depot company personally visited Paris to adjust army due-in records in coordination with Communications Zone shipping records and thereby accounted for shipments long over due and presumed lost. Army organic transportation was utilized to insure the prompt receipt of supplies shipped from the rear since the situation did not permit complete reliance on rail transportation. Shipments of critical items were expedited by Communications Zone using hospital trains and air transport. Generally, shortages lists were reduced and with a steady stream of replenishment stock being received, the general supply situation improved. Advance Section, Communications Zone M409 became operational in Liege at this time and greatly alleviated the over-all supply situation. Continued improvement was noted during the latter part of November and through the 1st part of December until the supply picture was normal and healthy.


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C.    THE GERMAN COUNTEROFFENSIVE AND THE DRIVE TO THE ROER RIVER

16 Dec. 44-22 Feb. 45

    As the German counteroffensive developed during the second and third weeks of December, Medical Supply was presented with two problems. The first was to insure complete support to the army’s defensive actions, that is, to replace the equipment losses and to meet the increased demand for expendable supplies. The second was to remove depot stock from areas that were threatened by possible enemy advances.

    Due to the rapid advance of the enemy, divisional and other units were forced to abandon much of their medical equipment and required 100 per cent replacements in several cases and lesser degrees of replacement in others.

    Various army units including two evacuation hospitals and units of two field hospitals required the complete replacement of equipment for two field hospital hospitalization units and many major items of equipment.

    Every effort was made to determine quickly the extent of losses in medical equipment and supplies. Divisions and hospitals were personally visited by representatives of this office and arrangements were made to insure immediate replacement of needed items. For a short period of time, units were permitted to draw directly upon depot M409 located at Liege to relieve the burden on army supply installations.

    Concurrent with the problem of reequipping medical units, the movement of army dumps away from zones of possible enemy action had to be accomplished. When the enemy offensive began the base depot was located at Dolhain, Belgium, the First Advance Section was at Bastogne, Belgium, and the Second Advance Section at Malmedy, Belgium. As the advance sections were in the area immediately threatened by the enemy, movement of them was imperative. By infiltrating trucks into Malmedy, the entire stock of the Second Advanced Section was removed to the base section. The First Advance Section at Bastogne, Belgium, encountered more difficulty in moving. When it was learned that Bastogne was threatened, empty ambulances returning to the rear were commandeered and items in critical supply were loaded. As much as possible was evacuated to Lebin, Belgium, by this method However, even this position was threatened and the section was again forced to withdraw, going to Carlsburg, Belgium. One small contingent of this section in Bastogne was surrounded, with a few tons of supplies, but continued to supply troops fighting within the city until it was relieved. This section was soon moved from Carlsburg, Belgium, and joined the base section at Dolhain. In compliance with orders from First Army G-4 that all major supply installations withdraw to the rear of the army area, the base depot was moved to Basse Warve, Belgium. The entire move was accomplished by rail.

    Depot stocks up to this time had been drained heavily. The cooperation and proximity of forward Communications Zone depots helped immeasurably in meeting the enlarged demand for supplies.

    The First Advance Section assumed Issue responsibility at Dolhain, Belgium, with stock heavily augmented to meet the expected increased load. A level of approximately 100 long tons was carried during the period. A large percentage of this was represented by T/E items. The base section, moving into army reserve, was accompanied by the optical and repair section. The blood bank detachment remained at Dolhain to supply those hospitals operating well forward.

    Every effort was made to restore all units to 100 percent T/E strength in medical items. In spite of abnormal issues, stock levels remained satisfactory. Units were instructed


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to inventory their equipment and to requisition shortages through the army surgeon’s office. In this way losses could be replenished from available depot stocks or shipments expedited from Communications Zone.

    Once established at Basse Warve, the base depot began a general stock replenishment program, calling heavily on depots M409 and M413T. With the tactical situation once again fully under control, the base depot prepared to return to Dolhain. Some difficulty was experienced in obtaining sufficient goods wagons to effect the transfer in one move. However, obstacles were removed and representatives of the 25th Regulating Station accompanied the trains to insure their safe and prompt arrival. Once the depot was established, normal depot functions were resumed.

    The First Advance Section, being relieved of issue responsibility at Dolhain, moved to Brand, Germany, in support of the army left flank. The Second Advance Section remained at Huy, Belgium, for approximately two weeks and then returned to its former location at Malmedy, Belgium.

    The month of February was devoted to army build-up. Generally speaking, issues were light with depot stocks adequate to meet the demand. Stocks carried by the advance sections each averaged 50 long tons. This level was maintained by daily requisitioning on the base dump.


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V.    Surgical

A.    PURSUIT PHASE

    In this phase, the hospitals and professional personnel were entering the third month of combat experience. The surgical service had available well-staffed, experienced hospitals and an adequate number of qualified surgical teams. As a result of this experience, the following observations are noteworthy:

    a.    The requirements of a good army medical service are not alone the possession of experienced hospitals staffed with qualified surgeons.

    b.     The capacity of a hospital to care for a heavy flow of casualties should not be determined by the number of vacant beds that can be made available through evacuation or by increasing the bed capacity. The number of available personnel is of equal importance and must be augmented throughout. More administrative personnel, more nurses, ward officers, surgeons, and even litter bearers have to be provided.

    c.     Under the pressure of. a large and sustained flow of casualties, clerical mistakes increase, errors of judgment occur, and medical care is less efficient throughout.

    d.    When the number of cases awaiting operation in a hospital exceeds the 24-hour capacity of the operating room and its potential capacity when augmented by surgical teams, the indication exists for sending back without definitive treatment, patients who would ordinarily be held in the hospital.

    e.    The quality of medical care and surgical treatment as well as mortality statistics should be judged in the light of the current tactical situation, and the number and type of casualties being received.

    f.    A qualified surgical team and good operating room facilities should be maintained, at holding units and transfer points to care for the wounded that have developed complications or have been improperly selected.

    g.     Sorting of the minor wounded admitted to evacuation hospitals cannot be established on a sound basis when evacuation is sporadic.

B.    THE SIEGFRIED LINE

    This phase of the campaign afforded the first opportunities for forward surgeons to visit Communications Zone hospitals. As a result of their observations, improvements were made in tile methods of recording important professional data.

    Policies were changed in favor of holding certain types of patients for a longer period. Among these were patients with chest injuries, vascular injuries, badly contaminated compound fractures, and fever (temperatures over 100˚

F.)

    With the onset of winter, cold injury to the extremities made its appearance. The professional care of trench foot was organized according to the following plan.

    a.    All cases of trench foot showing marked objective signs such as gangrene, discoloration, blisters, marked edema or infection, were evacuated to general hospitals.

    b.    All other cases were transferred to the 91st Medical Gas Treatment Battalion which was designated as the center for the study of trench foot.

    c.    After completing an 8- to 10-day treatment at the center, ambulatory patients were sent to the convalescent hospital where they were refitted with larger shoes and galoshes,


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given exercises, prescribed walks and, finally, close order drill before return to duty.

    d.     All cases of suspected trench foot were held in corps and division clearing stations until objective manifestations of the condition were sufficiently obvious to justify the diagnosis of trench foot. Experience had already established the fact that even with very gradual warming of the feet by exposure to temperature of 65˚ to 70˚, the condition would become obvious within the first 24 to 48 hours. This method of management was of definite value in that approximately 7.5 per cent of the cases could be returned to duty as having had a mistaken diagnosis, that is, cold feet. As a result of observation and experience with trench foot, the following conclusions were reached:

    a.    That the prevention of trench foot and the execution of preventive measures is a command function which can be stimulated and checked as to its effectiveness by medical officers.

    b.     That the system of holding these cases at the division level is the most efficient way of assuring the early return to duty of cases with cold feet; at the same time, the treatment of the established cases is not seriously delayed or impaired.

    c.     That the return to duty of the minor cases which were the only ones held in army area was, on the basis of 1,000 cases, approximately as follows:

Diagnosed cold feet and returned to duty     75
Returned to duty from convalescent hospital     140
     Total returned to duty     215

Evacuated from center     40
Evacuated from convalescent hospital    20
Evacuated from evacuation hospital    725
     Total     785

That only the minor cases should be held in army area. Of these, approximately 20 percent can be returned to duty.

    Up to 1 January, 42 cases of recurrent trench foot had been reported. Only 8 of the 42 cases occurred among patients who had been treated at the center and returned to duty through the 4th Convalescent Hospital.

C.     PHASE OF ENEMY COUNTERATTACK

    Professional care of patients during the phase was confined to preparation for evacuation of all transportable patients and the definitive treatment of all nontransportable cases. It has not been possible to evaluate all the effects of this phase upon the professional care of battle casualties.

D.    THE ALLIED COUNTERATTACK

    1.     At first, when field hospitals were forced to return to tentage, winterized tents were not available for all units but the patients suffered few ill effects. Upper respiratory infections among surgical patients were no greater than the increased rate of respiratory disease among all personnel. Pulmonary complications were attributable to the natural exposure of casualties before they reached hospitals. The necessity for hospitals to utilize tents instead of buildings was short lived.

    2.    The chief complication during this period was the high incidence of trench foot and frostbite. All battle casualties had to be care-


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fully examined for evidence of cold injury to the feet. Plaster casts applied for extremity wounds were trimmed so as to permit observation of the feet whenever trench foot or frostbite was suspected.

    3.     The differential diagnosis between trench foot and frostbite involved the problem of the award of the Purple Heart. Clinically the differentiation could seldom be made. Accurate diagnosis hinged upon the degree of chilling. Patients exposed to temperature below freezing were by directive diagnosed as frostbite.

    4.     On 23 January a meeting for discussion of the trench foot problem was called at the office of the chief surgeon and was attended by the surgical consultant. Here it was learned that the management of trench foot as set forth by First Army and as previously described in this report had been adopted by the other armies of this theater.

    5.     New professional policies and activities during this period comprised the following:

    a.    Vascular surgery.  In an effort to improve the results of treatment of patients with main artery damage to the extremities a vascular clinic was set up in the 45th Evacuation Hospital. One surgical team from the 3d Auxiliary Surgical Group was attached to this hospital to treat these cases. Special record forms were stenciled for local use and for distribution to other hospitals. Additional equipment in the form of plastic tubing and oscillometers was obtained in sufficient quantity to begin the same study in the 2d Evacuation Hospital. The results were encouraging but too meager to form the basis for conclusions.

    b.    Cellulose acetate gauze.  Another addition to the surgeons' armamentarium was obtained in very limited, quantity; namely, absorbable gauze (cellulose acetate) which was used as a hemostatic agent to control hemorrhage from sources uncontrollable by suture, such as lacerations of kidney or liver. In addition to having hemostatic properties, this gauze is absorbable and can be sutured in place or left as a light pack which does not require subsequent removal. The value of this gauze is fairly well established but it is not yet in mass production.

    c.    Management of patients with self-inflicted wounds.  A new directive which required that SIW patients be held in army medical installations pending the determination of their line of duty status by the forward medical units called for some revision in the plan of management for these cases. To meet the situation, an orthopedic surgeon from the 3d Auxiliary Surgical Group was attached to the 91st Medical Gas Treatment Battalion to supervise the care of these cases, especially the eases that had to be held for more than a week after definitive treatment. Certain categories of cases that could not be held without jeopardizing life or prejudicing recovery were defined. Individual patients who might develop complications which would bring them into this category were to be seen by this officer before evacuation. In addition, delayed primary closures were accomplished under his supervision. A program for active motion of joints and general physical exercises was carried out.

    d.    Physiotherapy unit.  Upon direction of the army surgeon a small physiotherapy unit was staffed and equipped to provide ultraviolet, infrared and Swedish massage treatments.


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E.    NOTES ON PROFESSIONAL CARE APPLICABLE TO ALL PHASES OF WARFARE

1.    Sorting of Wounded for Treatment and Evacuation in the Army Zone

    a.    Sorting is an essential function of forward surgery. It facilitates treatment and evacuation. On the accuracy with which sorting is accomplished will depend the lives of the seriously wounded, the combat status of the lightly wounded, and the efficient employment of the hospitals in each surgical echelon.

    b.     There are two kinds of sorting:

            (1)     The grouping of cases for transport to the proper hospitals.

            (2)     The sorting of patients within the hospitals for treatment and for evacuation.

    c.    To accomplish the first type of grouping, the responsible officer should have a clear understanding of the function of each medical installation, a grasp of the current evacuation policy and an average degree of clinical judgment and common sense.

    d.     To accomplish the second type of sorting, the sorting officer should possess a high quality of surgical judgment based on experience. In addition, he should know the capacity of his operating theater and the qualifications of the surgical teams and individual surgeons so as to arrange the distribution of the more serious cases to the more experienced teams. He must be capable of rapid work and judgment and appreciate the constantly shifting standards by which to judge the distribution of cases. In short, he should be the most experienced officer on the staff.

    e.     There is a difference of opinion as to where the first sorting of casualties should be done. In the First U. S. Army, the focal point for sorting was at the apex of the division in the division clearing station where casualties were divided into four groups destined for different units:

            (1)    Lightly wounded. Those whose injuries were so minor as to allow immediate return to duty were held there for treatment.

            (2)    Special center cases.

            (3)    Nontransportables. The primary purpose of sorting of wounded at this point was to divert the nontransportables to the field hospital which was the furthest point forward at which definitive surgery was done.

            (4)    Transportable battle casualties destined for evacuation hospitals.

    f.     The nontransportable cases were those with—

            (1)    Continuing hemorrhage uncontrolled by first-aid measures.

            (2)    Wounds of the abdomen.

            (3)    Wounds of the chest which were serious and produced respiratory distress:

      (a)    Large sucking wounds.

      (b)    Stove-in chest.
        
      (c)    Massive intrathoracic hemorrhage.

            (4)    Transthoracic or abdomino-thoracic wounds. These were often difficult to diagnose without X-ray and occasionally were missed.

            (5)    Extremity wounds with—
           
      (a)    Serious impairment of blood supply or with tourniquet in place.

      (b)    Traumatic amputations.

      (c)    Suspected gas gangrene.

            (6)    Patients with compound fractures of the femur and patients with multiple wounds who remained in shock and whose condition could not be made suitable for transport.

    g.     Sorting of patients within the hospital:

            (1)    In the receiving tent of the evacuation hospital, all patients were admitted and further sorted by the receiving officer for assignment to the following wards:

      (a)    Shock ward. All patients who needed resuscitation or were urgently in need of surgery. In this ward, all means for combating shock were assembled.

      (b)    Preoperative ward. Those who needed surgery but not urgently. This class of pa-


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tients constituted the bulk of the ward in an evacuation hospital.

      (c)    Evacuation wards. Those who could travel back to receive definitive treatment in the next surgical echelon. It must be realized that all walking wounded are not slightly wounded cases.

     (d)    Medical wards.

            (2)    Sorting for operation was the most difficult of all sorting.

      (a)    The order in which patients were sent to the operating room was determined by the condition of the patient upon admission, the extent of the wound, and its potential complications. The selection was made by an experienced surgeon with mature judgment; in a field hospital by the leader of the surgical team, in the evacuating hospital by the chief of the surgical service.

      (b)    In the selection of patients for operation, the importance of preoperative study and preparation must not be lost sight of. Each individual case received separate appraisal with reference to the surgical urgency of the wound, the degree of shock, and the response to resuscitation measures. The high priority cases were those with—

     1.    Uncontrolled hemorrhage, which must be stopped by surgery.

     2.    An occasional maxillo-facial injury with severe obstruction to the airway which required tracheotomy for relief.

     3.    Extremity wounds with major artery damage or massive muscle damage of the thigh or buttocks.

     4.    Thoraco-abdominal wounds.

     5.    Abdominal wounds must be attempted as soon as their condition warrants intervention. Hemorrhage and peritonitis were the urgent considerations.

     6.    Chest wounds. Profound physiologic disturbances could usually be controlled by such measures as needle aspiration of air and blood, insertion of a flutter valve for pressure pneumothorax, aspiration of tracheo-bronchial tree temporary closure of sucking wounds, novacain injection of intercostal spaces and oxygen therapy. Chest cases proved of most interest as to when to intervene.

     7.    Major or multiple compound fractures were early priority cases as were wounds of major joints.

        (3)    It must be realized that the above listing of high priority cases is not intended to convey the impression that all cases in one category were sent to the operating room before any cases were selected from the next group. The listing is only a guide to priority. The time of the operation was determined by the condition of the individual case. Many patients had a combination of wounds. Priorities will change with changes in the patient’s condition, but the less seriously wounded can not continue to lose their priority at the threshold of. the operating room.

        (4)    In the shock ward, as elsewhere, the gravity of each patient’s condition was assessed on clinical signs. Measurements of blood volume and determination of values for plasma protein, hemoglobin, red cell count and volume and hematocrit readings give valuable information, but in the First Army, such laboratory data had not been compiled and correlated on a sufficiently large number of patients to serve as a basis for determining the quantity of blood or the speed of transfusion required for a given case. The first attempt to conduct such studies was made during a very busy period when casualties were so heavy that the investigation officers found themselves giving blood and plasma rather than making detached observations. A second attempt during a lull was more successful.

   (a)    From a practical point of view, when a patient in shock fails to respond to energetic resuscitation measures, it was recommended that the patient be reexamined on the assumption that a continuing process existed which might be remediable only by surgery. Search was made for evidence of concealed hemorrhage, mechanical disturbances of the cardiorespiratory mechanism, increasing intracranial pressure, spreading peritonitis, or gas gangrene.


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   (b)    On the other hand, when a patient responded to resuscitation measures, it was important to time the operation so that the patient did not pass the peak of improvement. Once past this peak, it was difficult and often impossible to attain the same degree of response. During pressure periods, delay may mean a lost opportunity for selecting the optimum time for surgery.

  (c)    From the clinical viewpoint, it was recognized that repeated observations of the blood pressure and pulse should be made and recorded. A single reading may be very misleading. Pulse volume may be more important than pulse rate. Collapsed veins and fluctuations of blood pressure sounds .with respiration suggest inadequate restoration of blood volume. Turning and changing the position of a patient in shock may be followed by a sudden change for the worse. Conversely, rest is beneficial and warmth, not externally applied heat, but simply getting a patient into a warm room or tent after exposure to cold was definitely worthwhile.

        (5)    At the other end of the scale of urgency were the less seriously wounded. The actual disposal of these cases will depend upon factors of a logistical rather than purely professional nature. At times of pressure, there never were enough front line hospitals to give immediate and full medical attention to all wounded. Consequently, hospitals were evacuated of such patients as a careful examination indicated as transportable under the conditions imposed. When the number of cases awaiting operation approached 24-hour capacity of the operating theater or its potential when augmented by the addition of surgical teams, the indication existed to bypass, that is, to send on without definitive treatment, all cases that could safely travel, provided these cases received surgical treatment earlier at the next hospital to the rear.
        
  (a)   Before sending on such cases, they were fed, hydrated, and given the indicated penicillin therapy. We did not find it feasible to give penicillin, plasma, or blood transfusions while patients were being transported in ambulances.

        (6)    The extent to which bypassing was used is reflected in the following statistics:

Hospital and Period (incl.)

Battle Casualties admitted

Total surgical procedures

Bypassed cases

Percent bypassed

 

2d Evac     16-19 Nov '44

499

296

203

40.8%

 

5th Evac  16-19 Nov '44

431

185

246

57.2%

45th Evac         16-19 Nov '44

602

264

338

56.0%

128th Evac       17-19 Nov '44

916

434

482

52.8%

Total (4 hospitals)

2,448

1,179

1,269

52.1%

Total (2d, 5th, and 45th E.H.)

1,532

745

787

51.3%


Note.
  The 2d, 5th, and 45th Evacuation Hospitals received only litter patients after 1500, 17 November. The 128th Evacuation Hospital received only walking patients after 1500, 17 November. 2,271 cases were admitted to these four hospitals from 1500, 17 November to 2400, 19 November, of which 1,167 (51.6 percent) were walking.

    h.     Sorting of post-operative cases for evacuation was the final sorting in the army zone.

(1)    Since rapid evacuation was a tactical necessity, the sorting of post-operative cases for evacuation to general hospitals in the rear or to the UK went on continuously. Obviously the evacuating officer must evaluate the condition of the individual patient in terms of the ordeal which he faces. The means of transport and time-distance to the next hospital were factors which influenced his decision. In all cases, the opinion of the operating surgeon was respected and no patient was evacuated without his sanction unless evacuation was by command decision. Surgeons were kept posted as to the pressure being exerted by the number of cases, otherwise the hospitals, in some situations, would soon have been filled with eases marked not to be evacuated. Surgeons were also reminded that evacuation and optimum post-operative care of a single case might conflict.

(2)    The decision for evacuation of postoperative cases was as far as possible left to clinical judgment, but experience demonstrated the need for establishing policies which regulated the length of time certain types of cases were held after operation. The necessity for an arbitrary policy of this type first became apparent on the basis of reports


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emanating from the general hospitals in the UK concerning the abdominal cases. Many of these cases were being transported too early and arrived in poor condition. As a result of these reports, the policy was put into effect that all abdominal cases would be held for a minimum of ten days regardless of clinical factors.

(3)    Other policies of a more general nature served as guides to the selection of patients for evacuation, for example:

      (a)    Chest cases having undergone thoracotomy or debridement with closure of sucking wounds were held until the cardio-respiratory function was stabilized and there was no rapid reaccumulation of blood or fluid.

      (b)    Extremity cases with main artery damage or impairment of circulation were detained for observation until a definite decision was reached as to the viability of the limb and the necessity for amputation.

      (c)    Evacuation of neurosurgical cases that still required parenteral or tube feeding was avoided.
 
      (d)    Tracheotomized patients were detained for instruction in the care of the tube. Otherwise they were to be accompanied by an attendant.

      (e)    One of the most difficult decisions to make concerns the lightly wounded. It is axiomatic in military surgery that the lightly wounded who can return to duty within the time limit set by the current evacuation policy must be held in a combat zone. When the evacuation policy is restricted to ten days, the tendency is to hold patients who actually require a much longer convalescence before they can be returned to duty; for example, patients with penetrating wounds of the muscle of an extremity were ready for duty within ten days. So-called ten-day duty cases were sent to a convalescent hospital after receiving definitive treatment in an evacuation hospital.

      (f)    When patients were being evacuated to a holding unit on a beach or near an air strip rather than directly to a general hospital, it was necessary to maintain adequate operating room facilities and a qualified surgical team at the holding unit to care for the wounded who developed surgical complications.

(4)    Mistakes in the selection of cases for evacuation were quite apparent when viewed from the rear. General hospitals can furnish information as to how well the forward units were working, but unfortunately, the opportunity for forward surgeons to visit the general hospitals for personal observation of their cases came late in the campaign. In the early stages, they learned from reports that were sent forward. Later, during quiet times, visits to the general hospitals in the next surgical echelon were arranged.

2.    Plasma and Blood Transfusions

       a.    Early in the campaign, the question was raised as to whether blood transfusions were being given to patients who might be resuscitated equally well with plasma: To answer this question, a study of the treatment of shock in field and evacuation hospitals was planned with a representative of the chief surgeon's office. Shock teams from general hospital personnel were sent to army hospitals where they collected data on the ratio of plasma to whole blood given in the shock wards of forward hospitals. A summary of the information contained in the report showed that the ratio of plasma to whole blood given in evacuation hospitals was 1.34 to 1, and field hospitals 1 to 1.63.

        b.     The administration of plasma began at the battalion aid station. The transfusion of blood usually was initiated at the field or evacuation hospitals, but a few patients received blood transfusions in the clearing stations. The principle followed was to carry resuscitation only to the point which would permit safe transportation of the patient to a hospital installation. It was believed that the peak of resuscitation should be attained for the first time at the hospital where surgery was available.

        c.     It is difficult to give an arbitrary figure as to the amount of plasma and blood that should be given to an individual patient. Estimates of the total quantity required were based on a consideration of such factors as the amount of blood lost, the presence of continuing hemorrhage and the presence of blast injury to the lungs. In general, thoracic cases should receive blood in preference to plasma


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and in such cases, hydration should not be pushed to the fullest extent.


        d.     Reactions. (1) Reactions to the transfusions of plasma occurred. On one occasion, it was necessary to discontinue the use of all plasma of a certain manufacture.

    (2)    Reactions from blood transfusions in the form of a slight shiver or mild rigor followed by a rise of temperature were fairly frequent. Reactions in the form of a severe rigor and a temperature over 105˚, and even fatal reactions occurred in waves and the cause was difficult to trace. There is some evidence to support the following factors: errors in typing, hemolysis due to the use of blood that is approaching the expiration date, physical changes in the blood resulting from freezing or possibly from not keeping the blood at optimum temperatures during delivery from the base depots in the States or UK, contamination as shown by cultural studies and the presence of pyrogens.

    (3)    A certain incidence of hemoglobinuria and anuria occurred. Anuria was probably a result of several factors among which may be mentioned multiple blood transfusions, chemotherapy and the damaging effect upon the kidney of certain unknown products of tissue destruction or a prolonged state of shock and low blood pressure.

    (4)    Alkalinization of patients who exhibit hemaglobinuria or anuria was indicated according to directives.

    The drug recommended was sodium citrate which was not always available and which the majority of patients received in large quantities along with multiple blood transfusions. Sodium lactate was never available. As a substitute, a solution of sodium bicarbonate was used intravenously in a few cases with good results.

    (5)    Jaundice was not uncommon. If additional transfusions were necessary for  jaundiced patients, the use of fresh blood was safer.

    e.     Mechanical difficulties in the transfusion of blood at times constituted serious problems. This difficulty was most prevalent on the beach but was manifested later in the transfusion of UK blood. The difficulty was attributed to the filter and to the small bore of the needle in the recipient set. The Paris blood which was received in small quantities to tide over a critical period clotted and would not flow. The surgical consultant of the theater expressed the opinion that this blood did not contain a sufficient quantity of citrate solution. The U. S. blood (Alsever’s) flowed freely but had the objectionable feature of being 50 percent dilutent and 50 percent blood.

3.    Anaerobic Infections

        a.     Tetanus toxoid afforded complete protection of U. S. soldiers against the development of tetanus.

        b.    Gas gangrene was diagnosed in 0.5 per cent of all battle casualties admitted to First Army hospitals. Prisoners of War were included in this figure and showed a higher incidence than American casualties. From 6 June to 1 January 1945, there were 552 cases of gas gangrene, 362 of which occurred in U. S. troops. During the summer months of June, July, and August, the incidence was 0.51 per cent among 54,991 battle casualties. During cooler weather in September, October, November, and December, the incidence was 0.66 per cent among 41,070 battle casualties. The mortality rate for all cases of gas gangrene occurring from August to December was 12.2 percent.

        c.    The diagnosis of gas gangrene was entirely on clinical findings as it was not feasible for the laboratory to make satisfactory anaerobic cultures or examinations of involved muscle. It is fair to assume that some cases reported as gas gangrene were mistakes in diagnosis. If the diagnosis of gas gangrene is reserved for true clostridal myositis, the number of cases would be considerably smaller and the mortality rate higher.

        d.    A study of gas gangrene to be of value required the full time of a specially equipped mobile laboratory unit. The limited number of qualified personnel available did not justify their utilization on a research problem which involved approximately 3 per 1,000 U. S. casualties.

        e.    Serum therapy was not used as a prophylactic measure except in a few isolated cases.


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In spite of the routine tests for sensitivity, serious and at times fatal reactions followed the injection of antisera in the treatment of gas gangrene.

4.    Penicillin

        a.    After seven month's use of penicillin in the treatment of battle casualties, it was not yet possible to assay its value in terms more specific than clinical impressions nor attribute to penicillin beneficial results, the credit for which was not in part due to other factors. For example, was reduced mortality attributable to time, technique, better surgery, blood transfusions, sulfonamides, or penicillin?  Penicillin was a new factor but not the only new factor introduced.

        b.     It was obvious that comparative results could not be obtained by denying penicillin to a large group of battle casualties as long as an adequate supply was available.

        c.    Penicillin undoubtedly contributed to minimizing wound infection. It did not eradicate gas gangrene although it may have contributed much toward the prevention and control of clostridial infections. There was presumptive evidence that it was beneficial in abdominal wounds in preventing infection of retroperitoneal and mesenteric hematomas. It was injected routinely into the pleural sac where it persisted for at least 48 hours and was probably effective for 96 hours. In the prevention and control of infection in all types of wounds, penicillin was of great value so long as it was not regarded as a substitute for good surgery.

        d.    Methods of Administration. (1) Parenternal. The current method of intramuscular injection every four hours was practicable but did not maintain an optimum blood level. The British advocate the continuous intramuscular drip method as more efficient and less painful than the intermittent injection.

     (2)    Local.  At present, penicillin is mixed with a sulfonamide powder for local use. A better dilutent may be developed. The Australians have used powdered plasma successfully.

5.    Primary Aid

    a.     In the Medical News No. 5, Office of the Surgeon, First U. S. Army, 29 April 1944, the function of the medical installations in the divisional area was defined as primary aid and this was outlined in specific points. A review of these points in the light of the experience of seven months of combat is given.
    
    b.    (1)  Measures for control of hemorrhage and pain. The most important of these were the tourniquet and the morphine syrette.

    (a)    Tourniquets have saved many lives and doomed an occasional limb. The danger comes from tourniquets that may be covered over by clothing or blankets and remain undetected from the time the patient leaves the aid station until he arrives at the field hospital. The fact of the tourniquet should always be noted on the emergency medical tag. There were a few cases in which this was neglected and a viable limb was lost.

    (b)    The morphine syrette contained 1/2 grain of morphine tartrate. This amount was given partly because it was thought that the tartrate salt of morphine was less potent than the sulphate. Experience did not bear this out. Moreover, in cold weather when circulation was slow, patients were very apt to have delayed absorption. When subsequently warmed and transfused, the cumulative effects suddenly asserted themselves and the patients passed into morphine poisoning. It is well to keep this fact in mind and to handle the morphine syrette with discretion.

           (2)    Resuscitation measures (plasma and blood).  (a) Plasma was used at the battalion aid station but was not given to the point of delaying the patient on his journey to the rear. Plasma given at this level means time lost. While it was a temptation to give a patient who had not quite responded to his first three bottles, another three bottles, benefits slowly gained are very apt to be dissipated again under the unavoidable result of further transportation and once the patient relapsed, his condition was much more likely to be irreversible. Occasionally, it was necessary to hold a patient at the aid station but the rule was to sacrifice full resuscitation for early evacuation.


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        (b)    Blood was not used at the aid stations but it was used by some clearing stations when they were adjacent to field hospitals so that the blood could be taken over very quickly. No blood banks were maintained at clearing stations.

            (3)    Protection of the wound from further contamination. The large Carlisle dressing was sometimes too small and when two or three of them are superimposed, they become bulky and hard to handle. It was recommended that a larger dressing be made available, patterned after the British “shell” dressing.

            (4)    Initiation of chemotherapy. The instructions for the local and systemic administration of sulpha drugs were well followed, but it was recommended that the local application be discontinued for the following reasons:

    The main danger was overdose. The patients were already taking sulpha drugs by mouth and they were not very well hydrated. Absorption from a large raw surface is rapid. Cases of urinary blockage were seen. Secondly, the sulpha cannot be evenly distributed when it is only sprinkled and not rubbed in. Some parts of the wound became caked with a heavy layer and others got none at all. Thirdly, the sulfonamide cannot reach the depths of the wound when it is sprinkled in, and it is in the depths that it is most needed. Finally, at debridement, the sulpha was seen to be inseparably mixed with dirt and clotted blood, it had to be removed, together with all the tissues upon which it could have had any effect. It seemed more effective to postpone the local application of sulfonamides until the time of debridement.

            (5)    Administration of tetanus toxoid. The “booster” dose remained routine with all American casualties. Prisoners of War were given the antitoxin. No case of tetanus was reported among American casualties in the army area.
    
            (6)    Splinting of injured part for transportation. On the whole, splints were well applied in the forward area. In some instances, splints were carelessly applied ,and occasionally no splints were applied to extremities with fractures or extensive wounds. During the assault phase, the outstanding deficiency in the preparation of casualties occurred in connection with dressing the litter, especially the failure to put blankets beneath the patient. Ring splints continued to be a problem in the upper extremity. They were safe only when the patient could be watched continuously and this was difficult during evacuation. A well-applied Velpeau bandage was probably better for the majority of fractures of the upper arm. In the lower extremity, the ankle hitch led to pressure necrosis when it was left on more than six hours. After this length of time, it  should be loosened if there is any question in the mind of the examiner.

            (7)    Accurate recording of the significant data on the emergency medical tags was commensurate with the conditions under which the recording was accomplished.

            (8)    In the evacuation from forward stations, the ¼-ton truck converted into a litter ambulance was indispensable. It was inconspicuous, roadworthy, and could go where a regular ambulance cannot go. Aid stations would be at a loss without their “jeep ambulance.”

            (9)    The medical officers of the forward echelon acquitted themselves painstakingly and courageously of an exacting and often dangerous task. They treated the casualties during the first critical hours, carried out the primary triage, and solved many a bottleneck. Successful evacuation depended largely on their judgment and devotion. They earned high praise.

6.    Definitive Surgery

        a.    Surgical personnel.  (1) Recommendations for changes and additions in the T/O of medical units were submitted by these units and discussed by the various sections of the Army Surgeon’s Office.

    (2)    It was recognized that the chief difficulty in obtaining well qualified surgeons and surgical specialists to staff all the hospitals was the limited number available, but it was also obvious that the chief obstacle to the proper assignment, prompt interchange or adequate replacement of available personnel was in the final analysis contingent upon rank.


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    (3)     Experience answered the question of whether the most skilled surgical specialists should be placed forward in army hospitals or in general hospitals to the rear. The requirements for forward surgery were as follows:

           (a)    Anesthetists. Surgical teams need tile best trained anesthetists. Evacuation hospitals need at least two fully qualified anesthetists to supervise the work of the other less qualified individuals.

           (b)    Neurosurgeons. The best neurosurgeons should be forward. One in each evacuation hospital and three to lead surgical teams meet the requirements.

           (c)    Orthopedic surgeons. The most skilled orthopedists should be placed in general hospitals in the Communications Zone or the Zone of Interior. There is little need for an orthopedic surgeon, in the civilian sense of the word, on surgical teams. Evacuation hospitals each need one trained orthopedist.

           (d)    Thoracic surgeons. The minimum requirements were one for each evacuation hospitals and one per four surgical teams.

           (e)    General surgeons especially qualified in abdominal surgery and trained in the application of the four major types of plaster casts were essential on surgical teams and in evacuation hospitals; four per evacuation hospital was recommended.

           (f)    Maxillo-facial surgeons. The cosmetic type of plastic surgeon was not needed in forward surgery. One oral surgeon (dental) and one maxillo-facial surgeon was required in each evacuation hospital, and on each of three surgical teams.

           (g)    E. E. N. T.  Qualified ophthalmologists were too few. One was needed in each evacuation hospital. One ENT surgeon per evacuation hospital was a necessity. To find one surgeon qualified in both was rare.

           (h)    Surgical teams.

       1.     The model surgical team for First Army was as follows:

   (a)    A mature general surgeon whose primary interest was abdominal work.

   (b)    A thoracic surgeon.

   (c)     A younger surgeon who had had hospital training in orthopedics and was skilled in the    application of plaster.

   (d)    A highly qualified anesthetist with additional training in bronchoscopy.
    
   (e)    A surgical nurse either on the team or provided by the hospital.

   (f)    Surgical technicians. Two to four trained enlisted men depending upon whether the team was working in a field or an evacuation hospital.

      2.    Specialist teams. With properly staffed evacuation hospitals, the only specialty teams needed were three neurosurgical and three maxillo-facial teams.

        b.    The policy of employing personnel from inactive medical installations (general hospitals and evacuation hospitals) for temporary duty with active hospitals assured the effective utilization of all available medical personnel in times of stress.


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F.    CLINICAL NOTES

1.    Introduction
    
    The following comments, observations, and statistical data are intended to reflect the experience of the First Army in the application of the surgical principles incorporated in the Manual of Therapy. No attempt has been made in the discussions to deal completely with each subject.

2.    X-ray

        a.    Field hospitals had complete X-ray equipment in each hospitalization unit but only one trained radiologist per hospital. There was no problem of volume.

        b.    Evacuation hospitals needed additional equipment as well as more personnel for 24-hour duty. The X-ray department of evacuation hospitals could not keep pace with surgery and evacuation when there was a large number of admissions shortly after the hospital opened nor when the hospital continued to receive a peak load of casualties day after day. Mobile X-ray units were used to avoid or relieve this situation. Without this assistance, the X-ray department resorted to fluoroscopic examinations and diagnoses to overcome the bottle-neck.

        c.    In the First Army, the three companies of the 91st Medical Gas Treatment Battalion were used as a center for certain types of medical cases and for the care of SIW’s. This. battalion had no X-ray equipment nor personnel. Two mobile X-ray units were necessary to provide three companies with minimum radiologic facilities which left only one mobile unit to service all evacuation hospitals. Three mobile units were needed for an army. Requisitions for X-ray equipment and personnel for this unit were submitted.

        d.    The supply of X-ray films was critical. To prevent loss of films and retakes the flash-box method of marking radiographs was instituted.

3.    Anesthesia
    
        a.    Mention has been made of the necessity for skilled anesthetists in forward surgery–skilled not only in the administration of inhalation, intravenous, and block anesthesia, but especially qualified in the endotracheal method. Training in bronchoscopy was very desirable.

        b.    The responsibility of the anesthetists was great. Often they had to administer an anesthetic to a patient who needed extensive surgery but was at best a poor risk. Not infrequently, they were called upon to give anesthesia to two patients at the same time. During the operation, they supervised the administration of blood, plasma, or other intra venous fluids.

        c.    The relative frequency with which different methods of anesthesia were used varied in field and evacuation hospitals.

   (1)    As representative of methods of anesthesia used in field hospital surgery, the following percentages derived from an analysis of 4,111 anesthetics given by anesthetists of 3rd Auxiliary Surgical Group Teams are cited:

    Inhalation (70% by endotracheal tube)     62%
    Intravenous        35%
    Block and local     3%
    Spinal          Less than 1%

   (2)    In evacuation hospitals, a much lower percentage of inhalation anesthesia was used. The statistics on anesthesia below are from an evacuation hospital where 9,712 patients were operated upon from 24 June to 24 December 1944:

    Pentothal          60.06%
    Local    27.94%
    G. O. E  7.43%
    Open ether        1.23%
    Combined pentothal         2.43%
    Spinal    .79%
    Gas oxygen       .12%


170

   (3)    Spinal anesthesia found little place in forward surgery. Its use was largely restricted to operations or acute abdominal conditions such as appendicitis.

   (4)    Local anesthesia was extensively used in neurosurgery.

   (5)    A large number of sympathetic blocks were done for impaired circulation of the extremities.

        d.    Bronchoscopy was done on 6 per cent of the patients operated upon by auxiliary surgical teams.

4.    Neurosurgery

        a.    Available neurosurgeons.  At the time of the invasion, the First Army had one neurosurgeon with each evacuation hospital and three neurosurgeons in the 3d Auxiliary Surgical Group. Two of the latter were on general surgical teams and the third was appointed as an advisor in neurosurgery. Subsequent appraisal of specialists in the evacuation hospitals revealed that three evacuation hospitals did not have well qualified surgeons in this specialty. To remedy this situation, two of the younger neurosurgeons from the auxiliary surgical group were transferred to two of these evacuation hospitals and the third hospital was provided with a neurosurgical team under the leadership of the Advisor in Neurosurgery. A second neurosurgical team was obtained from the 4th Auxiliary Surgical Group and employed until August when it was possible to secure the services of a neurosurgeon from a general hospital to lead a second neurosurgical team.

    The following statistical report of neurosurgery in the First Army by hospital and surgical team does not include the cases for the month of December. It is noteworthy that the combined mortality of penetrating wounds of the brain was 14 per cent and of compound fractures of the skull was only 1.9 per cent. Permanent transfer of this neurosurgeon subsequently was effected.

        b.    Neurosurgical teams. The number of neurosurgeons required for an army depends upon the length of the front more than upon the number of divisions. Three neurosurgical teams would be adequate provided each evacuation hospital had a competent neurosurgeon. With only two neurosurgical teams, the work at times taxed the capacity of both teams.

        c.    Plan of management.  Before the invasion, it was recognized that certain types of brain injuries could undergo definitive surgery as late as 48 to 72 hours after injury. On this basis, a policy for bypassing neurosurgical cases was worked out with the Neurosurgical Consultant from the Chief Surgeon’s Office.

        d.    Spinal cord injuries.  Confusion existed with reference to the indications for laminectomy in cases of spinal cord injury. The current policy allowed a liberal exercise of surgical judgment and the tendency toward the end of the campaign was to operate upon a greater percentage of these cases than was the practice in the early days. A conference for clarification of this issue was delayed by the change in the tactical situation. Reports received toward the end of this period indicated a high incidence of decubitus in patients with spinal cord injury. An air mattress to protect the bony prominences was needed and an improvised type made from life preservers had been suggested.

        e.    Statistics.   Neurosurgical cases admitted to First Army hospitals (6 June 1944 to 31 December 1944):

[Neurosurgical Cases]

(See attached table.) In the last war 1917-18) Cushing, the master neurosurgeon, reported 133 penetrating wounds of the brain with 43 deaths, a mortality of 31 per cent.

    Electro-coagulation, suction machines and illuminated retractors were new tools since the last war. Penicillin and sulfonamides


171
        
NEUROSURGICAL STATISTICAL REPORT

were new drugs. These factors enabled better surgery to be performed.

5.     Wounds of the Eye

    Qualified ophthalmologists were scarce. Each evacuation hospital had one, but none were available for surgical teams of the auxiliary surgical group. At one time, consideration was given to the organization of “head teams” by adding an eye surgeon to the neurosurgical or maxillo-facial teams. A primary obstacle was the lack of a sufficient number of ophthalmologists to justify employment on cases such a “part time” basis.

    The utmost conservation in the enucleation of eyes in the forward area was advisable. When enucleation was done as part of the surgical procedure for a wound of the orbit, the disorganization of the eyeball was such as to preclude the possibility that the apparently shattered eye might be saved. General surgeons did not operate on eye cases.

    The following statistics from the 97th Evacuation Hospital reflect a conservative attitude toward enucleations:        

Removal of foreign bodies     16        
Wounds requiring suture of cornea      7
Wounds requiring suture of sclera        9
Wounds requiring suture of conjunctiva           7
Wounds with intraocular foreign bodies.          2
    (Patients evacuated at one for removal of  f. b.)
Wounds with intraorbital foreign bodies not removed     5
    (Patients evacuated for removal of f.b.)
Patients evacuated for enucleation       12
Enucleation of remains of severely lacerated eyes           6
Chalazion operations    2

    Total          66

    The policy of leaving damaged eyes for enucleation in general hospitals overlooked  the fact that eye casualties are rarely just eye cases. They usually had multiple wounds of the head or other parts of the body.

6.     Maxillo-Facial Surgery

        a.     For the care of maxillo facial injuries, each evacuation hospital had a maxillo-facial surgeon and an oral surgeon. In addition, the  auxiliary surgical group had two maxillo-surgical teams, whose primary duty was the treatment of  maxillo-facial injuries in field hospitals when associated injuries rendered the patients nontransportable. Since relatively few maxillo-facial cases were operated in field hospitals, the team worked in evacuation hospitals and went forward only on call


172

from the field hospitals To cover a wide front, three rather than two maxillo-facial teams were needed.

        b.    The principles of treatment of these mutilating injuries in forward hospitals was outlined in the Manual of Therapy. Application of these principles in the field deserves comment:

    (1)    In the primary aid phase of treatment, the correct litter posture (face down) during evacuation to evacuation hospitals had not always been followed.

    (2)    Tracheotomized patients were accompanied by an attendant or held for four days for instruction in the care of the tube.

    (3)    Intramaxillary multiple loop wires with intermaxillary elastic traction proved adequate to bring about centric occlusion in the majority of mandibular and maxillary fractures.

    (4)    Edentulous mandibles offered a greater problem, especially when dentures were also destroyed or lost. The use of Roger Anderson type of pins and bars had been restricted.

    (5)    Circumferential wiring of the mandible had at times been necessary. Fractures at the angle of the mandible with the upward riding posterior mandibular fragment were left for correction in general hospitals or handled by elastic traction to plaster head cap by means of a stainless steel wire passed through a drill hole in the bone.

    (6)    Maxillary fractures were supported by a plaster head cap attached to a labial arch bar, an acrylic or Kingsley type splint, or stainless steel wires passed through the cheeks on either side. Some reports from the general hospitals raised considerable objection to the plaster head cap as a very uncomfortable appliance.

    (7)    A study of statistics showed that 5.8 per cent of the wounded admitted to First Army hospitals had maxillo-facial injuries. From 6 June 1944 to 1 January 1945, 5535 maxillo-facial injuries occurred. The case fatality rate was 1.4 per cent. (0.5 per cent of these deaths were pre-operative.) Breakdown of these statistics for tabulation is difficult but the separate reports of three evacuation hospitals and of one maxillo-facial team are included as representative:

44th Evacuation Hospital

2d Evacuation Hospital

97th Evacuation Hospital


173

[97th Evacuation Hospital, continued]

Maxillo-Facial Team No. 1, 3d Auxiliary Surgical Group

7.     Burns

    Burns did not constitute a major problem numerically. The total number of burns (all locations) admitted to hospitals from 6 June 1944 to 1 January 1945 was 1143, with a mortality of 2 per cent.

    The principles of treatment were as described in the Manual of Therapy, which permitted the surgeon a choice between sulfadiazine cream 5 per cent, petrolatum, boric acid ointment with or without sulfanilamide powder on fine meshed gauze to cover the burned surface.

    All these methods were used but the preference was for the sulfadiazine cream.

    A few surgeons objected to the pressure dressing on the face on the basis that the secretions from the eye, nose and mouth collected beneath the dressing.

8.    Surgery of the Extremities

        a.    Debridement of Wounds. The practice of minimal removal of skin and bone and maximum removal of devitalized muscle, the use of ample incisions, the relief of tension by fascial incisions and the avoidance of plugging wounds with vaseline gauze are essentials which were well known but not always well executed.

        b.     Plaster Casts. To insure that the general principles in the application of casts were followed, it was required that the surgeon write his name on the cast.

    The Tobruk splint was seldom employed as a transportation splint.

    Records of the 3d Auxiliary Surgical Group show that members of surgical teams utilized four major types of extremity casts as follows:

    Hip spica   433
    Full leg       609
    Shoulder spica        178
    Velpeau     340

    Experience established the advisability of postponing the application of a plaster hip spica following debridement for compound fractures of the femur on patients whose condition was poor at the completion of the debridement operation. Instead of a hip spica, an Army leg splint was applied with skin traction. One or two days later when the patient’s condition had improved, the splint was replaced by a plaster spica. In the hands of the general surgeon, this method was less time-consuming and required less moving and changing of the patient’s position.

        c.    Comparative statistics on compound fractures. The following table shows the total
number of compound fractures admitted by two evacuation hospitals selected at random. The operative mortality is almost identical:
          45th Evac.        5th Evac.

Total cases            2341            2584

Total deaths          0.26%          0.23%


    Compound fractures of the femur when, studied alone show a somewhat higher mortality:

           45th Evac        5th Evac

Total cases            212            225
Total deaths 5  7
Mortality  2.3%          3.1%


174

    A certain percentage of compound fractures was associated with a severe degree of shock which made the casualties nontransportable. As nontransportables, they were admitted to field hospitals. The figures of one of the more active field hospitals (51st Field Hospital) show a much higher mortality rate than evacuation hospital figures:      

 

Operations

Post-op. Deaths

Post-op. Morality

 

Femur and pelvis

73

12

16.43%

 

Tibia, fibula and foot

66

12

18.18%

 

Scapula and humerus

54

2

3.7%

 

Radius, tibia and hand

16

0

---

 

Total

209

26

12.44%


When a field hospital functioned as a modified evacuation hospital, the mortality rate was altered by the fact that both “transportable” and “nontransportable” casualties were admitted.     

 

Operations

Post-op. Deaths

Post-op. Morality

 

Femur and pelvis

119

7

5.88%

 

Tibia, fibula and foot

194

4

2.06%

 

Scapula and humerus

96

1

1.04%

 

Radius, tibia and hand

138

1

.72%

 

Total

547

13

2.37%


        d.    Hand and foot injuries. (1) Reports from general hospitals indicated that hand and foot injuries were the most poorly managed of all wounds. The four deadly sins were:

            (a)    Insufficient cleansing by gentle scrubbing with soap and water.

            (b)    Tendency to over-debridement of these wounds.

            (c)    Use of nail and pulp traction.

            (d)    Prolonged or over-fixation of the hands and feet in the treatment of injuries of metacarpals, metatarsals, or phalanges.

            (2)    A large percentage of injuries of the hands and feet belong in the category of self-inflicted wounds (SIW’s). Special provision was made for the care of these cases. At one time the difficulties involved were primarily administrative and secondarily professional in that SIW’s had to be held until cleared by the Inspector General. The delay in evacuation of these patients thus occasioned subsequently was overcome.

           (3)    The principles of treatment of these wounds incorporated in Circular Letter No. 131, Office of the Chief Surgeon, ETO, 8 November 1944, were an improvement based on experience over the methods previously recommended and employed.

        e.    Vascular surgery.  (1) The handling of extremities with main artery damage was disappointing. Blakemore’s nonsuture method of blood vessel anastomosis was employed a few times without convincing results. It is doubtful if this Blakemore method had much application. Heparin was not available for use except on two or three patients.

            (2)     Paravertebral sympathetic nerve block did not prevent a high incidence of gangrene but apparently permitted amputation to be accomplished at a lower level. Improvement in the circulation was observed with sufficient frequency to justify the continuation of the policy of employing sympathetic nerve block routinely and as early as possible.

            (3)    Periarterial sympathectomies were not advocated.

            (4)    Lateralsutures and a few anastomoses of main arteries were done successfully but it was seldom possible to attribute the result to the repair when viable limbs also followed ligation at similar levels.

            (5)    The results of treatment for main arterial damage to extremities were most discouraging. When heparin and papaverine became available, it was planned to establish a vascular clinic to afford a better opportunity for study of these cases and for a more controlled test of the various methods of restoring the circulation including the use of glass tubes, a method developed by the Canadians.

            (6)    The following are vascular surgery statistics of operations performed at the 45th Evacuation Hospital:


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[Vascular Surgery Statistics]

(7)    The following are vascular surgery statistics of operations performed by members of the surgical teams of the 3d Auxiliary Surgical Group:

    Number of Patients  191
        Suture or anastomosis        15
        Major ligations     178
        Number of patients with
            sympathetic blocks         98

        f.    Amputations. (1) A conservative attitude was maintained toward amputations. Consultation was required. Devascularized limbs were given a chance, and not amputated as a primary operation. Inadequate circulation following damage of the main artery, certain types of gas gangrene and the completion of a traumatic amputation were the usual indications.

            (2)    Physiologic amputation with a tourniquet in patients who did not respond to resuscitation had a limited application but bad to be advocated with caution.

            (3)    Amputation under refrigeration anesthesia was satisfactorily accomplished a few times.

(4)    The number of amputations of the lower extremity was almost twice that of the upper extremity. The following table shows the number of extremity amputations of all types:   

Month

Upper

Lower

 

June

99

154

 

July

263

470

 

August

135

216

 

September

49

88

 

October

43

127

 

November

84

217

 

December

109

76

 

Total

782

1,348

 

Percentage

36.7%

63.3%

 

Grand Total

2,130

 
9.    Thoracic Wounds

    Early in the assault phase it became apparent that the management of chest cases was attended by a certain amount of confusion.


176

    Gradually a more conservative trend developed with reference to removal of foreign bodies. Measures for control of the urgent physiologic disturbances were more effectively employed pre-operatively and operations were better timed.

    Approximately 60 per cent of sucking wounds were treated by debridement, aspiration of blood and closure in layers. When thoracotomy was indicated, adequate access could usually be gained by extension of the wound. Separate thoracotomy incision was made when the nature and location of the missile tract was unsuitable for extension.

    Bronchoscopy as a pre- and post-operative measure was done frequently to clear the tracheo-bronchial tree of mucus and blood.

    Experience supported the opinion that chest cases must be resuscitated more carefully than other severe casualties, that the too liberal use of intravenous fluids invites pulmonary edema, and that brood is safer in this respect than plasma. The over transfusion of chest cases must be avoided.

    A study of evacuation revealed that too many chest cases arrived at general hospitals with a large amount of bloody fluid in the chest. Special attention was directed to this finding in an attempt to correct the fault, but it was not considered feasible to require a routine X-ray or aspiration of the chest before evacuation of each patient.

    The number of patients with thoracic wounds admitted to First Army hospitals from 6 June to 31 December 1944 was 8,770 which was 9.1 per cent of the total admissions. The case fatality rate was 8 per cent (preoperative 3.4 per cent, post-operative 4.6 per cent).

10.    Thoraco-abdominal Wounds

        a.     The fundamental problem in the management of thoraco-abdominal wounds was the question of surgical approach. A combined chest and abdominal operation is difficult to withstand, and was less often employed than a single approach. The choice between a thoracic and abdominal incision is contingent upon many factors and must be made for the individual case.

        b.    Thoraco-abdominal wounds are serious injuries which might be expected to have a higher mortality rate than abdominal wounds without associated thoracic injury. In small groups of cases, this was usually true but in a large series, the mortality was actually lower. There were 1,238 patients admitted to army hospitals with thoraco-abdominal wounds (1.3 per cent of the total admissions). The mortality by case was, pre-operative 6.9 per cent, post-operative 12.4 per cent, total 19.3 per cent. The mortality for abdominal wounds was 22.4 per cent. This was difficult to understand. Probable explanations, are:

            (1)    The most serious thoraco-abdominal wounds may not have reached a hospital alive.

            (2)    Surgical procedures carried out through a thoracic approach were less severe on the patient, and the majority of cases were approached from above.

            (3)    Chest wounds have a lower mortality rate than abdominal wounds and in some instances the abdominal operations were only exploratory in extent.

        c.    The statistics given below represent an analysis of thoraco-abdominal operations performed by members of surgical teams:  

 

Number of patients    

413

 

Through thoracotomy approach    

238

       

Suture of diaphragm

226

       

Splenectomy

57

       

Closure of GI perforations

34

 

Through laparotomy approach

193

       

Exploration only

42

       

Suture of diaphragm

99

       

Operations of abdominal organs

168


11.    Abdominal Wounds

        a.    Incidence.  The incidence of abdominal wounds among battle casualties admitted to army hospitals was 4.1 per cent. The mortality rate (case fatality) for 3,925 patients was 2.4 percent which does not take into account the deaths which occurred in patients after they had been evacuated from the army zone. This represents a striking improvement when compared with the mortality of abdominal wounds in 1917-18 (AEF) which was 66.8 per cent. It is recognized that a number of variables arise in calculating the mortality rate of abdominal wounds, but the large number of


177

cases handled offsets many of these factors and establishes this figure as an accurate calculation during all types of warfare on the continent.

        b.    Reasons for reduced mortality.  Reduced mortality may be attributed to several factors among which penicillin and sulfonamides must be given due credit. The time element, the technique and the quality of surgery and post-operative, care each contributed to the successful management of these cases. Selection of patients for operation could obviously result in a low post-operative mortality but the figure 22.4 per cent includes both pre- and post-operative deaths. The post-operative mortality was only 16.2 per cent. Furthermore, the policy of accepting the risk, and not adjudging bad-risk patient inoperable was followed. Some of the pre-operative deaths occurred shortly after the arrival of the patient in the hospital. Evaluation of the patient before operation is an important principle which depends upon the experience and judgment of the surgeon. The recognition of continuing or concealed hemorrhage was a deciding factor in undertaking a poor risk operation rather than persisting in repeated blood transfusions and futile resuscitative measures. The time factor stressed so graphically by Sir Cuthbert Wallace in the statistics of the last war is still important but to a less extent. Blood transfusions, Levine and Miller Abbott tubes and other methods of treatment represent advances in surgery since 1917-18. The availability of blood for transfusion was an outstanding factor in this campaign. The policy of holding all post-operative cases for ten days or longer decreased but did not eliminate the complications incident to travel, such as evisceration.

        c.    Comments on technical procedures.  (1) Drainage of the peritoneal cavity for infection is not indicated. In the presence of liver laceration, drainage below diaphragm was done. Drainage of the retroperitoneal spaces for perforation of retroperitoneal portions of the colon and drainage of the space of Retzius following perforation of the bladder were necessary.

    (2)    Experience demonstrated the necessity for supporting the incision with an adequate number of well placed retention sutures to prevent evisceration. The sutures should incorporate all layers at least down to the peritoneum and should be tied loosely over the skin, not over gauze or through rubber tubing. Removal of retention sutures before the patient was evacuated was avoided.

    (3)    Small bowel injuries were treated by suture of perforations, or when necessary, by resection and anastomosis by an adequate method. Exteriorization of small bowel and enterostomies were avoided.

    (4)     Large bowel perforations. There is a difference in the management of injuries of the right and the left side of the colon.

           (a)    For lesions of the rectum and pelvic colon, the indication for complete diversion of feces is met by an ample spur colostomy with complete transverse division of the bowel and covering the distal stoma with vaseline gauze. Wounds of the rectum demand free drainage by incision of the fascia propria in addition to spur colostomy. Protoscopic examinations were often of diagnostic value in determining the presence of injuries of the rectum.

           (b)    In dealing with injuries of the right colon, the indication is for decompression of the colon. The dangers of leakage and the known insecurity of sutures makes simple closure of a wound of the colon a hazardous procedure. Large bowel perforations were exteriorized. Some of the distal perforations in an exteriorized segment were closed provided the proximal perforation afforded sufficient decompression. Otherwise, exteriorized perforations were left open. Sigmoid colostomies were opened when they were made.

(c)    Combined injuries of the ileum and the right side of the colon presented the greatest problem. Exteriorization of the ileum and end of the divided colon as a double-barrelled ileo-colostomy was not a satisfactory procedure. End to side anastomosis of the ileum to the transverse colon with exteriorization of the damaged segment of ileum and colon was advocated. The patient’s condition would not often permit an additional resection which is the ideal. procedure.

           (d)    The hazards of crushing the spur and the small risk of producing a peritonitis in


178

patients with colostomies led the surgeons responsible for reconstructive procedures on the bowel to prefer the procedure of taking down the colostomy and completely restoring the continuity of the colon. For these reasons, a loop colostomy was preferred. Spur colostomies are indicated when resections of a segment are necessitated by perforations of the mesenteric border, injuries to the mesentery resulting in non-viable segments or extensive lacerations of a segment. Accurate descriptions of operative procedures were of utmost importance to the surgeon responsible for reestablishing intestinal continuity.

    (5)    The management of injuries of the liver, spleen, and kidney are described in the Manual of Therapy. The importance of drainage of liver injuries below the diaphragm was demonstrated repeatedly by the subsequent development of thoraco-biliary fistulae or bile peritonitis in cases not drained.

    (6)    Injuries of the ureter were surprisingly few and not always detected until their presence was revealed by the drainage of urine from a posterior wound.

    Patients who have a suprapubic cystostomy can be kept dry by the attachment of a suction apparatus to air indwelling urethral catheter.

    (7)    Surgical procedures. An analysis of 1,834 abdominal operations by auxiliary surgical teams shows the relative frequency with which various surgical procedures were employed:

    42     percent had closure of gastrointestinal perforations.
    34    percent had colostomies and various exteriorizations.
    19    percent were negative or not amenable to surgery.
    17    percent had intestinal resections.
    14    percent had operations on the liver.
    13    percent had operations on the urinary bladder.
    5    percent had acute inflammatory conditions.
    4    percent had splenectomy.
    2     percent had operations on the biliary tract.
    2    percent had transperitoneal nephrectomy.

These percentages add up to more than 100 because many patients had more than one procedure.


179

VI.    Medical Activities

A.    OPERATION OF THE MEDICAL SERVICE

    During the early part of this period and during the pursuit across Northern France the evacuation hospitals and the convalescent hospital were not employed at all times. At these times the field hospitals took over the functions of the evacuation hospitals. Similarly during the early part of the breakthrough the evacuation hospitals and convalescent hospital were not used in the usual manner and the evacuation policy was changed so that patients were sent to ADSEC hospitals as soon as transportable.

    When the situation became more stable and the battle of Germany began and again after the battle of the bulge, the evacuation and convalescent hospitals and the 91st Medical Gas Treatment Battalion functioned is they did prior to these periods.

B.    GENERAL REMARKS

    From a study of the casualty figures from other theaters and Medical Intelligence publications it was estimated that approximately 30 to 40 per cent of admissions to army hospitals would be for medical causes, exclusive of N.P. cases. Fortunately, experience indicated this estimate to be too high. The table below gives, for army hospitals, the total admissions, medical admissions, and percent that were medical admissions by weeks for the period concerned:

[Medical Admissions vs. Total Admissions by Week, Part 1]

[Medical Admissions vs. Total Admissions by Week, Part 2]

    From a study of the above figures it will be seen that the number and percent of medically sick was less than might well have been expected.  There was a gradual rise in the number of patients with disease treated in army hospitals.  The increase in percent of medical cases in most instances is a false one since at those times battle casualties fell off while disease casualties remained more constant.


180

C.    INCIDENCE OF REPORTABLE DISEASES

    The following table presents the total number of reportable diseases admitted to First Army Hospitals for the period. (Source: ETOUSA MD Form 310).  

 

Total admissions 

 

175,310

 

Total Disease

50,718

 

Percent disease

28.8

 

Common respiratory disease

7,387

 

Diphtheria

30

 

Influenza

112

 

Measles

31

 

Measles, German

26

 

Meningococcal meningitis

34

 

Mumps 

113

 

Chicken pox

5

 

Pneumonia, primary

191

 

Pneumonia, secondary

33

 

Pneumonia, atypical

596

 

Scarlet fever

44

 

Septic sore throat

1

 

Tuberculosis (all forms)

22

 

Vincent’s angina

47

 

Common diarrhea

1,973

 

Dysentery, bacillary

27

 

Dysentery, amebic

25

 

Dysentery, unclassified

51

 

Malaria

2,201

 

Hepatitis, infectious

150

 

Kerato-conjunctivitis

1

 

Poliomyelitis  

2

 

Pneumatic fever

13

 

Scabies

344

 

F.U.O.

525

 

Gonorrhea

1,018

 

Syphilis

575

 

Other V. D.

18

 
D.    RESPIRATORY DISEASES

    This group of diseases occupied first place as the cause for medical admissions to army hospitals. At no time, however, did they constitute a real problem. The incidence of these diseases was low at the beginning of the period, but with the advent of colder weather and more stabilized warfare there was a steady increase. However, the actual numbers were less than might reasonably have been expected.

    There were about three times as many cases of atypical pneumonia as of bacterial lobar pneumonia. Patients with pneumonia were, considered as nontransportable beyond the evacuation hospital. Bacterial pneumonias were treated with sulfadiazine and with penicillin when the clinical situation indicated, with uniformly good results.

E.     MALARIA

    During the previous period malaria was responsible for the largest number of cases of disease admitted to army hospitals At the beginning of the period being reported on the incidence of malaria was high also but the number of cases steadily decreased so that at the close of  the period it constituted no problem The table below shows the weekly ad missions to army hospitals of cases of malaria:

Week ending            Cases of malaria

4 August              239
11 August            246
18 August            251
25 August            104
1 September        102
8 September        119
15 September      132
22 September      137
29 September        85


181

Week ending            Cases of malaria

6 October            89
13 October  79
20 October  65
27 October  46
3 November 49
10 November          46
17 November       56
24 November       55
 1 December        34
8 December         31
15 December       19
22 December       36
29 December       35
  5 January           16
12 January 25
19 January 18
26 January  14
2 February 25
9 February 21    
16 February            17
23 February          10
    
    Total              2,201

    The vast majority of the cases were truly recurrent. A few “new” cases were reported but these also proved to be individuals who had been in malarious regions previously and on atabrine suppressive therapy while in such regions. It is believed that they became parasitized but did not develop the clinical disease because of the atabrine. The incidence of so much malaria is believed due to the fact that personnel did not take atabrine as directed. Many patients were interviewed and none were found who developed the disease while taking atabrine. The only way that men can be induced to take the drug regularly is by thoroughly educating them as to the necessity for so doing.

    During this period patients with malaria were hospitalized and treated with quinine for two weeks. Those who did not respond well or had complications were evacuated out of the army area.

F.      Diphtheria

    Every patient with a membrane in the respiratory passages was considered as diphtheria and treated as such without waiting for cultures or studies of smears. Initially patients were treated with antitoxin alone in large doses. Later, however, penicillin was used in conjunction with antitoxin. The importance of early treatment and adequate treatment was stressed. Diphtheria, patients were considered nontransportable. They were kept in the evacuation hospital until clinically and bacteriologically well and were then evacuated as litter patients to the Communications Zone. Two deaths occurred from diphtheria, both the result of faulty diagnosis. The first patient was diagnosed as having a peritonsillar abscess and was evacuated to the U.K. where he subsequently died of diphtheria. The second patient was diagnosed as having a Vincent’s Throat and was treated, with Mapharsen and peroxide gargles. As the result of these two deaths a further directive was issued to make medical officers more “diphtheria conscious.”

G.    MENINGOCOCCUS MENINGITIS

    Patients suspected of having meningococcal infections were treated with intravenous sodium sulfadiazine by the first medical officer suspecting the diagnosis. Subsequent study and treatment was carried .out in the evacuation hospital and such patients were regarded as nontransportable. Penicillin was used both intramuscularly and intrathecally where indicated. The results were uniformly good. Only one death occurred. This patient was diagnosed late and, though adequately treated when the diagnosis was made, he died. The autopsy showed a considerable area of encephalitis as well as meningitis.


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H.     MUMPS, MEASLES, GERMAN MEASLES AND CHICKEN POX

    Mumps, measles, German measles, and chicken pox were not a problem. They were treated in army medical installations and returned to duty therefrom unless complicated.    

I.    SCARLET FEVER

    Only forty-four cases occurred. These were treated with sulfadiazine and, in a few in stances, with penicillin. No deaths and no complications or sequaelae were noted.

J.    DIARRHEAL DISEASES

    The common diarrheas were constantly present but in small numbers. There was never an epidemic of these diseases. There was some increase during the summer months and again in December associated with an increase in respiratory disease. A few cases of bacillary dysentery occurred but these were all of the mild types. A few cases of amebic dysentery were reported; all of these were recurrences of infections acquired elsewhere. The common diarrheas were treated expectantly; the bacillary dysenteries with sulfadiazine and/or sulfaguanidine with good
results.

K.    INFECTIOUS HEPATITIS

    It was reasonable to expect that there would be many cases of this disease but there were only one hundred and fifty and they presented no special problem. They were treated in the accepted manner and evacuated to rear when transportable. There were deaths and all cases were mild.

L.    SUMMARY

    In conclusion it can be stated that the incidence of disease was less than might reasonably have been expected; the health of the command was good, and, except for malaria, there were no epidemics or special medical problems.


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VII.   Neuropsychiatry Activities

A.    NEUROPSYCHIATRY CASUALTIES

    During the period 1 August 1944 to 22 February 1945, 20,585 or 9.84 percent of the total number of patients admitted to First Army medical installations were neuropsychiatric patients; of this number 9,596 or 46.62 percent of the neuropsychiatric casualties admitted were returned to full field duty.  A tabulation of the incidence of neuropsychiatric casualties by month follows:

[Table]

B. DISCUSSION

1.     August    
    
    The tremendous push required to breakthrough at St. Lo, Vire, and La Haye Du Puits during the last few days of July and the first ten days of August was responsible for the high incidence of NP casualties during the period (80 percent of the NP casualties for August occurred during the first two weeks).

    The sharp increase in the rate of return to duty of NP patients was the result of experience gained by the line and medical officers as well as the psychiatrists during the pre ceding weeks.

2.    September

    The race across France into Belgium up to the Siegfried line from 15 August to 15 September produced a low, incidence of NP casualties for obvious reasons. During September, the percentage of NP cases returned to duty dropped to about one-half of the previous month. This was because lines of evacuation were severely stretched, the division clearing stations were moving so rapidly that very little treatment of combat exhaustion cases could be accomplished there; and the exhaustion centers were often out of touch with the front or were in the process of moving so that NP patients from the divisions reached these installations too late to be satisfactorily treated and many such patients by-passed the exhaustion centers entirely. Furthermore, during ten days of this month a total evacuation policy was in force.

3.     October and November

    The tactical situation during these two months, except for the localized severe fighting in the Hurtgen forest 20 November to 1 December 1944, was largely static hence the low rate of incidence of neuropsychiatric conditions.

During this period the ratio of NP patients


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returned to duty was influenced by two factors. First many of the casualties showed a very low tolerance for emotional stress and therefore did not make good risks for return to duty (a large percentage of this group were replacements). Also in this category was found a number of previously wounded soldiers who discovered, upon return to combat duty that they were “not able to take it anymore.” Second, incident to the long continued action (4 to 5 months) with proportionally few breaks, an increased number of excellent veteran soldiers appeared to be emotionally “burned out” and offered poor prognosis for duty without prolonged rehabilitation which is not available within a field army.

4.    December

    The Ardennes break-through by the German Army was responsible for a much lower incidence of neuropsychiatric casualties, than were previous military reverses experienced by the American Forces, for instance in the Kasserine Pass action in. North Africa where over 40 per cent of admissions were neuropsychiatric. During the December breakthrough only 1,752 neuropsychiatric casualties were reported out of a total of 19,403 admissions, or an incidence of 9.02 percent. Several reasons for the discrepancy between the expected and the actual incidence of neuropsychiatric conditions during this period are apparent.

        a.    An undetermined number of individuals who underwent neuropsychiatric break-downs in this action probably became battle losses, K.I.A., W.I.A., or M.I.A. directly as a result of the break-down, thereby somewhat lowering number of cases reported.

        b.    Probably more important was the reaction on the part of the individual, based upon a personal hatred of the enemy which developed suddenly as a result of the German tactics and practices in this action. To many soldiers, for the first time, war became personal and not just a maneuver In reinforcement of the above-mentioned motivation must be included that of “chagrin” and “surprise,” that the heretofore victorious American Armies could be “pushed” around in this way.

        c.    During this period 35.6 percent of neuropsychiatric admissions were returned to duty; this figure undoubtedly would have been higher had it not been necessary to evacuate all casualties to the rear of the army area for seven of the fifteen days involved.

5.    January and February

    The successful comeback from the battle of the bulge during January was reflected in the relatively low incidence of neuropsychiatric disabilities, as well as in the increased rate of return to duty of such casualties, and the continued gains achieved during February produced the lowest incidence of “combat exhaustion” for any period during the entire campaign.

6.    Passes and Furloughs

    Greater emphasis upon recognition and treatment of so called “combat exhaustion” in forward areas (battalion aid stations) coupled with the expansion and elaboration of division and corps “rest areas” and the introduction of the policy providing for thirty day furloughs in the United States materially contributed toward reducing the incidence of disorders of this type among combat troops.

7.     Survey

    A survey was conducted to determine the ultimate fate of individuals who had been returned to duty from army exhaustion centers. As of 1 February completed reports had been received on 708 men, many of whom were returned to duty during July and August. The report is submitted below:

    1.    Total cases reported    708
             a.    On duty with units            217
             b.    Killed in action     21
             c.    Wounded in action             84
            d.     Evacuated for neuropsychiatric disabilities     278

    2.    Decorations (exclusive of Purple Heart)       30
            a.    Promoted              11
            b.     Commissioned        2


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    3.    Average time on duty since release from exhaustion center       4 weeks

    4.    The majority of those who had a recurrence of “combat exhaustion” were evacuated within the first 48 to 72 hours after their return to duty.

8.    Operations
    
    First Army operated two “exhaustion centers” at army level during August, September and part of November; for the rest of the period covered in this report one exhaustion center was found to be adequate to carry the load of the treatment of neuropsychiatric casualties evacuated by divisions.

    As a rule these exhaustion centers were in operation alternately thereby permitting the one which was in the process of moving to do so unencumbered by  patients.

    Each “exhaustion center” was basically an army clearing company augmented by equipment to provide facilities for 500 beds. Psychiatrists were added to the professional staffs of the company from the evacuation hospitals. One of the exhaustion centers (the 622d Clearing Company) had six weeks training in neuropsychiatric procedures prior to the invasion; the other did not. Both companies functioned in an outstanding manner and turned in superior performances throughout the campaign. During the first two weeks of August each of these 500-bed installations were caring  for over 1,000 patients, however after that time the patient load was in proportion to the 500-bed capacity.    

VIII.    Dental Service

The report of dental operations between 011200 August to 222400 February 1945 may be divided into three phases, namely the period of movement across France and Belgium, the more static period from 12 September 1944 to 15 December 1944 when movement was of units rather than of the entire Army, and the movements of retirement and of advance during the battle of Germany.

    During the period of exploitation and pursuit, Chests No. 60 were used whenever an outfit remained in one location for a few days and the field kits for emergency treatment at other times. Divisions continued to operate efficiently Chests No. 60 and even while in combat did prosthetic repairs by using their Chests No. 61 and No. 62. During the third phase the use of chests was greatly restricted due to the tactical situation.

    The streamlined dental laboratory, made up of three mobile dental laboratory trucks, continued to operate at capacity with the 4th Convalescent Hospital and continued to do so through the second and third phases as a part of the 3d Auxiliary Surgical Group.

    In the second and third phases two mobile dental laboratory trucks, on loan from ADSEC, operated in conjunction with corps units helping greatly the prosthetic situation. Five impression chests were rotated among small units, the necessary fabrication of prosthesis being done by the Central Dental Laboratory, Paris, or the 3d Auxiliary Surgical Group laboratory. The greatest weakness of the prosthetic service is the lack of a T/O for prosthetic teams to operate the mobile dental laboratory trucks on hand and the inadequate number of such trucks. All such personnel have to be drawn from the units being surveyed and changes constantly.

    Activation of five dental prosthetic detachments was authorized on 11 February 1945, but no personnel was made available.

    The operative dental work of the army, divisions, and hospitals was adequate and satisfactory except in some instances where the unit commanders continued to use dental personnel for duties other than dentistry.


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IX.    Venereal Disease Control and Treatment Activities

A.    VENEREAL. DISEASE CONTROL

    The following rates per thousand per annum are for white and colored troops during the period covered by this report:

August:
    White   1.6
    Colored           19.5
    Aggregate         1.9

September:
    White          14.6
    Colored     150.4
    Aggregate    18.1

October:
    White          18.8
    Colored     181.3
    Aggregate    26.6

November:
    White          18.5
    Colored     162.9
    Aggregate    23.2

December:
    White          16.5
    Colored     175.9
    Aggregate    23.2

January (1945):
    White          19.3
    Colored     243.6
    Aggregate    28.0

February (1945):
    White          19.3
    Colored     153.2
    Aggregate    24.3

    In September and October many soldiers had opportunities to go through large cities, where brothels were operating and there were many street walkers. During the month of October, 254 new cases of venereal disease were contracted in Paris. The November rate was somewhat lower than that for October, with the majority of cases being contracted in Liege or Verviers. In January 1945, the majority of new cases of. venereal disease were contracted in Liege, Verviers, and Paris, with Liege being the source of 129 cases in February, the majority of new cases were contracted in Paris. There was a considerable drop in the number of cases contracted in Liege and Verviers. Houses of prostitution were not a great problem from the standpoints of serving as sources of infection because all known houses were placed off limits as soon as discovered. However, there remained the problem of some soldiers who entered these off-limit areas despite off-limit signs and daily periodical checks by military police.

    The greatest sources of infection were from street walkers and café bars operating as clandestine brothels. Whenever evidence was obtained to prove that the latter was true, steps were taken by the military police to put the place off limits. One of the favorable factors in the attempt to establish a successful control program was the utmost cooperation given by the army provost marshal and G-5.

    Vice surveys of all army territory were conducted in collaboration with the army provost marshal’s office. All civil affairs detachments were contacted in order to ascertain the status of registered or clandestine brothels, the number of prostitutes in the area, and the procedure used in the treatment of civilians with venereal disease. Whenever brothels were found to be in operation, a recommendation was made to the army provost marshal to place these houses off limits.

    Regular visits were made to corps surgeons to discuss pertinent venereal disease control problems. Some of the divisions were visited, although their problems continued to be mi-


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nor in character because of the tactical situation.

    Periodic visits were made to surgeons of various army troops, especially those organizations in which there was a high venereal disease rate. Pertinent problems were discussed with the commanding officer and his surgeon. Some of the various suggestions offered were as follows:

    Increase in educational program, particularly to small groups of men.

    Use of sulfathiazole prophylaxis.

    Special emphasis was placed on obtaining epidemiological data of value and follow up on this information by unit venereal disease control officer in so far as was practicable.

    Recommending the immediate placing of all suspicious “houses and cafes” off limits if it were thought that they served as sources of venereal infection.

    At first, information gathered from ETOUSA Form 302 Md were turned over to respective civil affairs detachments in order that the individual might be apprehended and examined for venereal disease. Later an SOP was suggested by the surgeon’s office to the Public Health Division, G-5, Army. This was concurred in by the latter section and distributed to all Civil Affairs Detachments. The contents of the letter are as follows:

      18 November 1944

726.1 (E)

SUBJECT:    Standing Operating Procedure for Coordination of Venereal Disease Control Procedures with the Office of the Army Surgeon.

To:        Corps, Division, and Detachment Military Government Officers, and Detachment Civil Affairs Officers.

    1.    To facilitate execution of established policies for Venereal Disease Control, increased coordination of Civil Affairs public health procedures is desirable with those control procedures utilized by the Army Surgeon. This will be accomplished as follows:
    
        a.    Reporting of Cases. The Army Surgeon’s V.D. Control Officer will submit to the CO of the detachment the name, and address of every prostitute who has been reported as a source of V.D. infection, acquired by soldiers in the area of the detachment’s jurisdiction. The Detachment Civil Affairs Officer for public health will then present this information to the local health officer, or Burgomeister. He will request that the named prostitutes, or suspected source of infection, be placed in custody, and examined for the presence of venereal infection, as authorized under Belgian laws.

        b.    Medical Examination of Venereally Infected Persons is authorized, and is required by Belgian law, for all persons named as probable or suspected sources of venereal disease. Under present laws prostitutes or others may be released after one examination, if the findings show no infection. It is the desire of the Army Surgeon that those individuals reported as V. D. “Suspects” should be given a total of three examinations on each of three consecutive days before release, and that release from custody be given only if all three examinations are negative. Civil Affairs Officers will therefore endeavor to enlist the cooperation of the civilian authorities to accomplish this procedure.

        c.    Results of Clinical Examination, whether negative or positive, will be requested from the local health officer after the third successive examination. The health officer will be requested to submit the findings of the examination of the reported suspect, and the action taken, with regard to compulsory treatment, or release from custody. Such information will be requested within five days after prostitutes, or other suspected individuals, are reported to the civilian authorities. This information will be forwarded as a separate report to the Army V. D. Control Officer through the Public Health Department, G-5, First United States Army.

    2.    A specialist for assisting detachment Civil Affairs Officers, and for coordinating civilian venereal disease control with the Army control program, will be provided by the Public Health Department, G-5, this headquarters. He will work closely with the Army Venereal Disease Control Officer, and will assist detachment Civil Affairs Officers in accomplishing the foregoing instructions.

    Seventeen prophylactic stations were established by the army surgeon’s office. Personnel of these stations gave approximately 3,100 prophylactics during the period covered by this report.


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   A list of all prophylactic stations in army, corps, and Communications Zone territory was distributed to corps, division, and separate unit commanders.

    Several issues of the Medical News, First Army, contained notes on venereal disease. Particular emphasis was placed on the obtaining of pertinent data for the ETOUSA Form 302 MD. Unit Surgeons were also requested to give information on the monthly sanitary report in regard to the following items:

    (1)    Whether or not there were brothels in the vicinity or any form of activity in prostitution.

    (2)    Note on control measures taken if there were isolated instances of activity in prostitution.

    (3)    Availability of mechanical and chemical prophylactics in addition to the regular dispensary prophylactic station.

    (4)    Note on control measures taken by unit venereal disease control officers in collaboration with the Provost Marshal or Civil Affairs Officer in the locality. The hitter office was consulted in regard to prostitutes who were known or suspected as sources of contact.

    Intensive control campaigns were carried out in Liege, Verviers, and Charleroi with the military police and civil affairs detachments. All houses of prostitution and “suspicious cafes” were posted off limits. In Liege, during the two month period that this city was under army jurisdiction, over 100 brothels and cafes were posted off limits and checked day and night by military police of the vice squad. In Verviers and Charleroi the same procedure was carried out.

    Local civil officials were contacted periodically in order to ascertain the various problems that were confronting them relative to civilian venereal disease control. All discussions of this type were coordinated through G-5.

B.    TREATMENT OF VENEREAL DISEASES

    The venereal disease treatment center of the 4th Convalescent Hospital continued to be the reception unit for all cases of venereal disease not treated on a duty status. This arrangement proved very satisfactory, as patients received diagnostic study and treatment in the army area, thus obviating the transfer of patients out of the army area.

    Sulfonamide-resistant and new cases of gonorrhea not treated on a duty status were given 100,000 units of penicillin intramuscularly. Patients not cured by this procedure were given a second course of penicillin, total dosage: 200,000 to 500,000 units.

    Darkfield examinations were performed on three successive days on all penile lesions when indicated.

    Cases of primary and secondary syphilis were treated by the intramuscular injection of 2,400,000 units of penicillin, over a period of seven and one half days.

    Reactions from penicillin were noted in a very small percentage of the patients and were of a mild Herxheimer type.

    Results from penicillin therapy were excellent. The cure rate for gonorrhea cases was 95 to 98 per cent. A quick disappearance of spirochoetes from lesions was noted following penicillin therapy given to cases of early syphilis. Darkfields that were per formed on positive lesions 9 to 12 hours after initial darkfield examination were negative. Lesions epithelialized in from 5 to 7 days.

    In September, due to the tactical situation, the personnel and equipment of the venereal disease center were transferred ta the 91st Medical Gas Treatment Battalion, which acted as the treatment installation. This was for a period of approximately four weeks. This arrangement proved to be satisfactory, considering the numerous problems involved.

    The army venereal disease control officer made several visits weekly to the treatment center for the purpose of seeing patients in consultation and checking records.

    Patients needing further study and treatment were evacuated to general hospitals.


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    At the close of the period, arrangements were being made to begin the six-month follow-up of penicillin treated luetic cases, which consists of complete blood and spinal fluid study.

    In August 1944, individual medical installations were given permission to administer penicillin for gonorrhea (Circular Letter 107, OCS, 25 August 1944). The instituting of this procedure reduced the burden on the venereal disease treatment center and at the same time enabled the patient to remain with his organization. In the event of relapse or therapeutic failure patients were admitted to the venereal disease treatment center for further study and treatment.

X.    Veterinary Service

A.    EXPLOITATION OF THE ST. LO BREAKTHROUGH

1 Aug-12 Sep.

1.    Inspection of Food Supplies

        During this phase it was very difficult to maintain contact with veterinary officers of the various units and to cover inspection of all food supplies because of frequent changes of locations of units and installations. Field rations were used by most of the combat troops. Rations were issued from temporary railheads, from QM class I depots and front truckheads. Arrangements were made for the veterinary officers from the 10th Medical Laboratory and the 282d Signal Pigeon Company to inspect food supplies at depots and truckheads. Each officer had an enlisted assistant. Tests were made on questionable supplies at the laboratory. At the request of the army quartermaster food supplies of both animal and nonanimal origin were inspected by the Veterinary Service. Veterinary officers with divisions checked food supplies at their respective break-down points. Enemy food dumps were found in numerous towns, but many of them contained canned and dehydrated items which could not be readily incorporated into the army ration. Such supplies were released. to local populations through civil affairs channels. Inspection of supplies released for civilian use was usually performed by civilian health authorities. Standard operating procedure for handling captured food supplies required reports through channels to army G-4, who notified the army quartermaster and surgeon. Numerous instances came to the attention of the army veterinarian where this procedure was not followed and such supplies were issued by capturing units without being inspected by the Veterinary Service. A large store of frozen carcass beef was found at Namur, Belgium. It had been imported from Denmark by the Germans. Quality of carcasses varied from canner grade to good grade. A total of 738,200 pounds was issued to army troops. This plant was then used for storage of class I perishables.

2.    Care of Animals

    Guard dog teams were inspected at least once each month and arrangements were made with each unit to contact the Army Veterinarian in case emergency service was required. Service was then provided from closest organization having a veterinary officer assigned. Since all guard dogs were obtained from the British, arrangements were made with the veterinarian, 21 Army Group, to


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evacuate dogs requiring lengthy treatment to British veterinary hospitals. Dogs remained in good health during this phase. Care and treatment of pigeons was supervised by the veterinarian of the unit. Paratyphoid infections, coryza and conjunctivitis were the prevailing diseases among the, birds. Very few enemy horses were captured during this phase and there were not many requests for treatment of wounded civilian livestock.

3.    Personnel

    Due to the changes made in Tables of Organization during 1943, which eliminated the veterinary officers from, corps, infantry and armored divisions, the problem of providing adequate veterinary service was complicated. On 1 August 1944 there was a total of eight veterinary officers with units of this command. Two were with armored divisions, which had been authorized to continue to operate under former Tables of Organization. Two were with infantry divisions and had been reported as being in excess of Tables of Organization. There being no position vacancies within this command or in other commands under ETOUSA Headquarters, they were authorized to remain with their divisions. Two officers were with airborne divisions. One officer was assigned to a Pigeon Company and one to the Army Medical Laboratory. Of the eight veterinary officers assigned to units of this command at the time of the assault only six arrived on the continent. Two officers with the airborne divisions did not accompany their units.

4.    Equipment

    Although not authorized by Tables of Equipment, it was requested that veterinary officer and NCO kits be made available in the army medical depot for all veterinary personnel. It was also requested that three each of veterinary Chests 80 and 81 be made available for issue as authorized by the army veterinarian. During this phase the only veterinary equipment available was that which was brought along by individual officers. Most of them had meat and dairy inspection cases and veterinary officer’s kits. No additional equipment was received through supply channels and no veterinary equipment was captured. Equipment was adequate for duties being performed.

B.    THE BATTLE OF GERMANY

13 Sep.-15 Dec.

1.    Inspection of Food Supplies

    Food supplies consisted of various types of Quartermaster rations supplemented by fresh fruits and vegetables. No captured supplies were inspected during this phase. A large class I army railhead was established for receipt of all food supplies except perishables. A class I depot was also established. Operational rations were retained at the rail-head and issued to truckheads directly from this installation. Type “B” rations were stored and issued at the depot. Perishables were stored at the large refrigeration plant at Namur, Belgium and hauled directly to truckheads in refrigerated trailers  There were usually six army truckheads in operations. A recuperage section was set up at the army railhead where all damaged supplies and those suspected of being deteriorated were inspected by veterinary personnel to determine proper disposition. Army truckheads were inspected by a veterinary officer once each week. Inspection of supplies in division and separate unit break-down points was covered by veterinary personnel where available. In units having no veterinary personnel, this responsibility was assumed by


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other officers of the Medical Department.

    Heavy rainfall during this period made protection of supplies a serious problem. No closed warehouses were available for storage. Dunnage, tents, and tarpaulins were difficult to obtain. There was some loss of food supplies caused by contamination and deterioration due to exposure to weather. Damage due to freezing was slight.

2.    Care of Animals

    Dogs were inspected at least once each month. Each unit was notified where emergency Veterinary Service could be obtained. Health of dogs continued to be good. One quartermaster war dog platoon of twenty-four dogs was received from the United States during this period. One sergeant, MD (VS), is attached to this team for supervision of care and treatment of minor conditions. The unit was informed of location of nearest veterinary officers who could be contacted in case of emergency. Sixty horses, draft type, were obtained by the 9th Infantry Division during this period for the purpose of packing in supplies and bringing casualties out. Thirty of these animals were obtained by local requisition and thirty were horses which were captured. The captured horses were badly infested with ringworm. Some of these animals were used for a short period but with improved weather they were disposed of. The 4th Infantry Division requested riding horses for their command. Sixteen were obtained by local requisition and sixteen were procured through the army quartermaster, who obtained them by purchase on reverse lend lease. These animals were used only for a short period and were then turned in to army quartermaster, where they were held for reconditioning and disposition. Nine were returned to owners before the end of the year. Forage was obtained from captured supplies and by requisition. Veterinary service was provided by the division veterinarian, 9th Infantry Division, and the army veterinarian. Three outbreaks of hoof and mouth disease were investigated during the period. Two outbreaks were confirmed in southern Belgium and Luxembourg. Outbreaks affected both cattle and hogs. The infection did not seem to be very virulent and mortality was reported to be low. Control measures were taken over by local health authorities. Disinfectants were requested and furnished from civil affairs medical supply depot. Hoof and mouth disease serum, which was requested by local veterinarians, could not be obtained. It was reported that serum had been used during the German occupation with good results in checking the spread of this disease. Destruction of infected animals and contacts was not practised. Quarantine of infected premises and disinfection were the only control measures used. Infected animals were given symptomatic treatment. An outbreak of Rotlauf disease (swine erysipelas) was reported in Luxembourg, 540 hogs being affected. This outbreak was controlled by use of serum, which was obtained from a laboratory in Brussels, Belgium. All control work was performed by civilian veterinarians It was reported that all livestock disease control work during the German occupation was supervised by German army officials. No requests were received for treatment of wounded civilian livestock during this period.

3.    Personnel

    The veterinary officer from the 282d Signal Pigeon Company was assigned to the Army Veterinarian as assistant and placed on detached service at the army railhead and depot. His enlisted assistant from the Pigeon Company was also placed on detached service at these installations. The veterinary officer from the 10th Medical Laboratory was detailed as Army truckhead inspector. Two division veterinarians were lost by transfer during this period. One sergeant, MD (VS), arrived with the War Dog Platoon which was assigned.

4.    Equipment

    Two Veterinary Chests No. 80 and one Chest No. 81 were received by the Army Medical Supply Depot during this phase and were available for use by units which were using horses. Other equipment was adequate for duties being performed.


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C.    GERMAN COUNTEROFFENSIVE AND DRIVE TO THE ROER RIVER

16 Dec.-22 Feb.

1.    Inspection of Food Supplies

    Continued as during previous phase. Sanitary inspection of army QM bakeries was also taken over by the Veterinary Service at the request of the army quartermaster.

2.    Care of Animals

    Units with guard dogs and war dogs were visited in new locations and notified where Veterinary Service could be obtained. Two units abandoned kennels and had to kennel dogs in buildings until new houses could be built. The health of the dogs continued to be good. Horses from the 4th Infantry Division, which were being cared for at a quartermaster salvage depot, were left temporarily under civilian care. These animals remained in good condition during the period.

D.    REMARKS

3.    Personnel

    The veterinary officer assigned as assistant to the army veterinarian was transferred back to the Pigeon Company, but continued to, carry on the inspection of food supplies at the army class I railhead and depot. In addition to this duty he assisted the officer from the medical laboratory in inspection of army truckheads. Inspection of quartermaster bakery units was handled by these same officers. Two veterinary officers were gained during this period by transfer.

4.    Equipment

    No equipment was lost or acquired during this period. There was adequate equipment for duties being performed.

    Present Tables of Organization do not provide adequate veterinary officers to perform all duties normally required of this service. It is impossible to extend the inspection service for food supplies beyond army truckheads except where veterinary officers are assigned to receiving units. Care of animals presented a problem at times due to lack of veterinary personnel and would have become a serious matter if horses suddenly had been put into use by army units on any large scale.


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XI.    Nursing Service

    During August and September many First Army hospitals were not operational. This gave the nurses their first real rest since arriving on the Continent.

    In September many First Army hospitals were in the vicinity of Eupen. For the first time since the invasion First Army nurses were living in buildings instead of tents. A well stocked nurses sales store was provided in this area, and a beauty shop was placed “on limits” in the town proper.

    On the 15th of October a letter from this office was sent to hospital commanders recommending 50 per cent of the T/O for second lieutenants be given battlefield promotions.

    One hundred and sixty ETO type woolen battledress came into the army area on 20 October. This three-piece suit comprising jacket, skirt -and slacks was placed on sale with priority for field hospitals and auxiliary surgical group nurses. This was the first uniform made available which was warm, smart, and practical. A three-piece ATS British battle dress uniform was later issued to all First Army nurses.

    Early in November a list was compiled of all First Army nurses thirty-eight years of age or over, together with all data pertaining thereto. This list was submitted to the office of the chief surgeon, European theater of operations, for the purpose of rotating these nurses to Communications Zone units.

    On 15 November the fourth conference of First Army Chief Nurses was held at the 45th Evacuation Hospital in Eupen. All principal chief nurses, assistant chief nurses, and platoon leaders were present. The purpose of this conference was to ascertain the status of clothing and post exchange supplies for nurses, to reemphasize the importance of bedside care for patients, and to encourage greater efforts toward standardization within units.

    On the 17th and 18th of December approximately one hundred First Army nurses lost all their clothing and equipment, due to a hurried exit from their hospitals. Ten of these nurses in the First Hospital Unit of the 47th Field Hospital set up in a school house in Waimes, Belgium, were almost taken prisoners. Through the intercession of the platoon commander and a German civilian in whose small hotel these nurses lived, the German officer permitted them to remain with the patients. The ambulance in which these nurses were eventually evacuated was strafed and bombed by enemy planes. They finally reached the 298th General Hospital in Liege where they were cared for until they rejoined their unit on 23 December.

    The fifth conference of First Army chief nurses was held at the 96th Evacuation Hospital on 27 January 1945. Agenda of the assistant directors conference in Paris early in December was discussed. Statistics relative to First Army nurses were given to the group. The new efficiency report was discussed in detail along with reemphasizing the importance of adequate and superior nursing care.

    There were no major problems concerning First Army nurses or the Nursing Service during this period. Adequate recreational facilities were made available and were fully utilized. The nurse reinforcements coming into First Army continued to be nurses who had requested duty in a field unit and in many instances had requested a First Army unit.

    Nurses Statistics:

    1.     Forty-two nurses were evacuated as patients.

    2.     Thirty-five nurse reinforcements came to First Army hospitals.

    3.     Two hundred and thirty nurses were promoted to 1st Lieutenant.

    4.     Fifty-four nurses received the Bronze Star Award.

    5.     Five nurses were awarded the Purple Heart.

    6.     Five nurses were awarded the Certificate of Merit.


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XII.     Personnel

    The usual procedures for the transfer of medical personnel both into and out of First U. S. Army units were effected. The provisions of WD Circular 99 1944 were placed in effect so far as Medical Administrative Corps officers were available. In addition to the twenty-nine Medical Administrative Corps officers received in July, another shipment of twenty was received early in August and were immediately assigned to corps br reassignment to divisions.    

    In order to release as many Medical Corps officers for reassignment as quickly as possible, the policy of battlefield appointments of Medical Administrative Corps officers was cleared through the G-1 Section, this headquarters, and units were instructed to submit recommendations for appointment on enlisted men who were considered eligible. This move facilitated the filling of vacancies created by the reassignment of Medical Corps officers. At that time Medical Administrative Corps replacements were not available, except in small numbers.   

    Informal arrangements were discussed and made with the Office of the Chief Surgeon, European Theater of Operations to establish a policy for rotation of Medical Corps officers who, either because of age or prolonged periods of field and combat duty with forward units, were considered not qualified for duty with forward units.  These officers were to be rotated to hospitals in the Communications Zone and replacements were to be furnished in company grade and not to exceed thirty-five years of age.

    With the concurrence of the Deputy Chief of Staff, Administration, this headquarters. The reassignment of one Medical Corps officer was made from each Antiaircraft Artillery Battalion as called for under provisions of WD Circular 99, 1944. The necessary Medical Administrative Corps replacements were not available but it was agreed that the urgency for Medical Corps replacements was great enough to warrant this reassignment with the understanding that Medical Administrative Corps replacements would he furnished as soon as they became available. This was accomplished shortly thereafter.

    Throughout the period, tile policy of rotating Medical Corps officers from combat units to evacuation hospitals was effected so far as the limited Table of Organization of army hospital units would permit.

    On numerous occasions it was found necessary to supply divisions by detailing Medical Corps personnel to forward units on a temporary duty status.

    In cases where acute shortages arose, informal arrangements were made for obtaining necessary personnel by telephonic communication with the Office of the Chief Surgeon, European Theater of Operations. The personnel thus obtained were assigned to Headquarters. First Army and upon arrival reassigned to lower units. In order to expedite the obtaining of necessary Medical Department personnel reinforcements, arrangements were made with the corps surgeons to communicate frequently with this office and to forward verbal reports of Personnel shortages in units under their command. This proved helpful in determining status of Medical Department personnel throughout First Army.

    Permission was obtained for substitution of Medical Administrative officers for Medical Corps officers in separate army medical collecting companies. Due to the nature of the mission of these units it was thought that services of Medical Corps officers were not required and that these officers could be better utilized in a professional capacity elsewhere. Further arrangements were made with European Theater of Operations for immediate appointment of Medical Administrative Corps officers from First Army medical field units. The Medical Corps officers thus released were used in professional assignments.


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XIII.    Medical Statistics

A.    GENERAL

    This portion of the report of the medical section provides a summary of salient facts pertaining to the medical phase of operations of First Army from the beginning of the exploitation of the St. Lo break-through to the close of the period. So far as possible the tabular and graphic data included have been arranged to coincide in date with the various actions which comprise the operation. These tables and charts provide information as to the numbers and rates of battle casualties,  the incidence of disease and nonbattle injuries, the numbers and proportions of combat exhaustion cases, evacuation from the army area, anatomical distributions of wounds, distribution of wounds by causative agent, and so forth.

B.    OPERATIONS

    The previous report, for the period from to 6 June through 31 July 1944, planning in England of the procedures for  the combat medical statistics reporting system and its institution effective with arrival on the continent, and also covered the first seven weeks of operations. During that period most of the purely mechanical flaws in the system, such as are inherent in any new and extensive process, were found and corrected. When it became evident that if the Combat Medical Statistical Report were to serve the purpose for which it was designed its submission  would have to be expedited to such an extent that the consolidated report for the entire army could be completed sometime during the day following that covered by the report it was decided that the medical groups would be given the responsibility of establishing a special courier service, for the transmission of the reports from units within their respective areas to the office of the army surgeon. The medical groups further delegated this responsibility in part, at least, to the battalions under their command until it evolved into a supplemental function of the evacuating agencies in the lower echelons, In this way it was, in most instances, possible to obtain these essential reports within the outlined the  time limits imposed without violating the letter or the spirit of the policy. In certain instances it was difficult to impress those not directly concerned with the consolidation or use of these data of the imperative need for meeting the deadlines established. Eventually, however, the prompt, efficient handling of this report became a matter of habit and  the entire situation was more satisfactory to all concerned. There were times, however, especially during the rapid advance across France, when, due to the great distances involved, or the tactical situation, some slight delays were encountered. In general, the reporting system functioned, as it should, in an almost automatic manner. This made it possible for the major effort to be made in giving maximum distribution of the information gathered to the offices or agencies where it would be of most value for immediate operational use or for planning purposes. Distribution of these data was made to the interested staff sections and to higher medical authorities in the form of extractions and analyses as  well as complete consolidations. In addition to the latter which are required by regulations or directives, informal arrangements  


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were made to furnish the following items of information regularly to the persons or offices indicated:

    1.     Daily consolidated Combat Medical Statistical Report to the Chief of Staff, First Army.
    
    2.     Number of civilians remaining in hospitals daily to G-5.

    3.     Disease tabulations to the army medical consultant.

    4.     Classification of wounded tabulations to the army surgical consultant.

    5.     Data on admissions and dispositions of prisoners of war to the provost marshal.

    6.     Location of hospitalized personnel to interested agencies upon inquiry.

    7.     Name, rank, and unit of prisoners of war admitted to G-2, order of battle.

    8.     Name, rank, ASN and unit of SIW cases to the Inspector General.

    9.     Weekly cumulative totals of combat statistics to 12th Army Group, 21st Army Group, SHAEF and the Office of the Chief Surgeon.

    In September a part of the Medical Records Division, Office of the, Chief Surgeon, ETOUSA, was established in Paris to process the weekly reports (86ab and 310) and to, receive and transmit the other Medical Department reports to that portion of the Medical Records Division still remaining in the U.K.

    Some difficulties were encountered in the Office of the Chief Surgeon because of the differences in methods of preparing and, consolidating the Weekly Statistical Report (Form 86ab) and the Combat Medical Statistical Report (Form 323) and because of other variations in procedure which existed among the armies. A meeting of medical records personnel from all the army and base section headquarters was called the latter part of October. Representatives from First, Third, and Ninth Armies and from all the Base Sections on the continent attended. The informal preliminary conferences and a major portion of the principal meetings were devoted to analysis of the reporting procedures and the problems of the field armies. The methods of report preparation and consolidation within each army were explained, major variations were studied and compromises were agreed upon which would aid in the approach to uniformity of methods.

    The first week of December 1944 a second meeting of the medical records personnel of the armies was called. The prime purpose of this conference was to consider the possibilities of revamping the medical reporting system as it applies to field armies to eliminate overlapping and duplications of reports and to decrease to the greatest extent possible the reporting burden on units in the field. A draft outlining in general terms First Army’s suggested plan for the attainment of these objectives was presented to the representatives of the Third, Seventh, and Ninth Armies for consideration and discussion. This plan which met with general approval in, principle suggested the discontinuance of the present Weekly Statistical Report (Form 86ab) and Hospital Statistical Report (Form 310). A modification of the Combat Medical Statistical Report form would be used for both the daily and weekly information desired. The weekly reports from clearing stations and from hospitals would be prepared by a simple summation of the entries on the daily reports for the period covered. Aid stations and dispensaries would submit a report weekly on this standard form covering only those cases of which they make final disposition. It was decided that the medical statistics group in each army would prepare a draft of a proposed revised Combat Medical Statistical Report and submit it to the office of the chief surgeon for correlation of the ideas contained and for preparation of the final form and issuance of the directive putting the new reporting system into effect.