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Chapter III

Contents

CHAPTER III

General Surgery

Robert M. Zollinger, M.D.

By the fall of 1943, Lt. Col. (later Col.) Robert M. Zollinger, MC, had been serving for approximately 15 months as chief of the surgical service in the 5th General Hospital, ETOUSA (European Theater of Operations, U.S. Army). This was a unit affiliated with Harvard University and was the first general hospital to be shipped overseas. The 5th General Hospital was established in Northern Ireland early in the spring of 1942.

The incumbent Senior Consultant in General Surgery became ill, necessitating his return to the Zone of Interior (fig. 126). The possibility of Colonel Zollinger's replacing him was first broached to the author by Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in Surgery in the European theater. At first, this new assignment seemed quite acceptable, since the author had worked with Colonel Cutler for many years during his surgical training and as a member of Dr. Cutler's immediate staff before the war. The author conferred with Col. Maxwell G. Keeler, MC, the commanding officer of the 5th General Hospital, concerning this proposed reassignment (fig. 127). He was then sent to Cheltenham, England, to meet with Col. James C. Kimbrough, MC, Director of Professional Services in the Office of the Chief Surgeon, ETOUSA, in order that the actual appointment might be submitted for formal consideration by the Chief Surgeon.

APPOINTMENT AS SENIOR CONSULTANT

There were both advantages and disadvantages inherent in an appointment as a senior consultant at the theater headquarters level at that particular time. These were graphically pointed out by Colonel Kimbrough, who was both a Regular Army officer and a urologist enjoying national reputation. He discussed the advantages of taking care of patients as compared to those of administering their professional care. He pointed out, however, that the consultant could be of utmost value in the long run by coordinating the utilization of personnel and standardizing therapy so as to provide optimum surgical care. He also warned that a "desk job" incorporating the difficulties of amalgamating the talents of various rugged individualists in the surgical world could be particularly harassing.

Although, according to the letter of the protocol, the author had the privilege of refusing the appointment, it became obvious that it was incumbent


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FIGURE 126.-Lt. Col. Ambrose H. Storck, MC, first Senior Consultant in General Surgery (third from left), at a reception given for Brig. Gen. Fred W. Rankin (left). Also in the group are Col. Lloyd J. Thompson, MC (between General Rankin and Colonel Storck), and Col. Rex L. Diveley, MC.

upon him to accept the appointment with good grace-much as he was disinclined to leave the Harvard unit. Members of the unit had been promised, when it was organized, that it would be left intact; however, this was not the case. In addition, although living conditions at a higher headquarters were usually exceptionally good, there was no particular sense of unit pride, and the junior officers were conscious of the presence of "brass." The most imposing deterrent was the knowledge that 50 percent of the senior consultants had developed poor health as a result of their service and had been sent back to the Zone of Interior. Several of these men were nationally known in their respective surgical fields. Any replacement, therefore, took a 50 percent chance on physical grounds alone.

One of the desirable features was that reportedly there was a good chance that senior consultants would be promoted from the rank of lieutenant colonel to that of colonel. The advantage of this became so striking that most medical officers, after a year or two overseas, would have led the Charge of the Light


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FIGURE 127.-Col. Maxwell G. Keeler, MC, extreme right, on the occasion of The Surgeon General's visit to the 5th General Hospital. Left to right, Brig. Gen. Paul R. Hawley, Col. Elliott C. Cutler, MC, Maj. Gen. Norman T. Kirk, and Colonel Diveley.

Brigade if the reward for survival had been promotion to a full colonel. A medical officer acting in an advisory capacity, rather than participating purely in the professional care of patients, would need to have this much rank, at least. Without it, he could not expect his recommendations for changes in procedure or personnel or his efforts to commandeer transportation to carry any weight, nor could he expect cooperation in other endeavors.

The author accepted and was appointed to the position of Senior Consultant in General Surgery in September 1943.

ORGANIZATION, FUNCTIONS, AND ACTIVITIES

The director of the group of consultants was the previously mentioned Colonel Kimbrough. The Chief Consultant in Medicine was Col. William S. Middleton, MC, of Madison, Wis., professor of medicine and dean of the University of Wisconsin Medical School. He headed the consultants who covered the various medical specialties. Colonel Cutler was the Chief Consultant in Surgery. The surgical group was larger than the medical group and included representatives of ophthalmology, otolaryngology, plastic surgery, neurosurgery, orthopedics, roentgenology, anesthesiology, maxillofacial surgery, and general surgery-the position to which this writer had been appointed.


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Colonel Kimbrough's office was one room about 12 feet square. The Chief Consultant in Surgery and the Chief Consultant in Medicine had desks side by side in an adjacent room of similar size. Opposite them was a room about 12 by 20 feet, which was used for a common meeting place. Activities of the week were reviewed, and policies were formulated at meetings held each Saturday morning in this room. Beyond this was a rather large room with desks around the periphery. These desks were placed back to back. In other words, there were groups of two consultants sitting face to face around the sides of the room. At one end of the room and in the middle were British civilian secretaries and several enlisted men who were used as messengers and file clerks. As one might expect, the main room was quite noisy and inefficient for ordinary working conditions. It was in many ways reminiscent of a boiler factory.

The amount of work done, therefore, depended a great deal upon how many of the consultants were present in the room at the time, how many were dictating, how many were holding conferences, how many were trying to make themselves heard over the telephone, how many were arguing with the personnel officer, the supply officer, or the motor pool or trying to interview new hospital personnel. These poor working conditions accounted in no small measure for the high mortality which had existed among consultants up to this time. In one room, gloom spreads rapidly. Certainly, these were working conditions quite dissimilar to any these surgeons had previously encountered. This does not imply that they needed more comfort than the surgeons in the field, but the nature of their work required a lot of planning and discussion, which was virtually impossible in the peculiar offices assigned to them.

Responsibilities of Senior Consultant in General Surgery

Although the specialty consultant ordinarily handled only those problems in his field, the Senior Consultant in General Surgery served more or less as a coordinator of the surgical group. This difference in responsibility was in some respects due to the fact that the Chief Consultant in Surgery was a general surgeon who had a wide experience in practically all fields of surgery and one who did not hesitate to make decisions upon professional or administrative matters in these particular fields. At times, however, the specialty consultants felt that this was an infringement upon their province; thus, perhaps, the situation was responsible for the creation of discord.

The specialty consultants were in close liaison with their counterparts in the British Army. In the field of general surgery, however, the entire group was represented by Colonel Cutler, who maintained living quarters in London. During the fall of 1943 and the winter of 1943-44, Colonel Cutler devoted considerable time to liaison work with the British and to the study of the care of wounded air force casualties who were being treated in the U.S. hospitals in East Anglia. The hospitals in East Anglia were, at that time, the only hospitals taking care of fresh casualties, since they were responsible for the reception and care of casualties from the U.S. Eighth Air Force.


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Evaluation of Surgical Service in New Hospitals

One of the chief assignments of every consultant was to visit the various hospitals as they came into the theater, in order to evaluate their professional personnel in his particular field. If at all possible, the incoming hospitals were visited in the staging area. In general surgery, each man on the surgical service was interviewed and a record of his professional background was maintained. Special attention was given to the evaluation of the chief and assistant chief of the surgical service, since the quality of professional care of any particular hospital was closely related to the training background of the chief of the surgical service.

The value of the intensive Halsted type of resident training was never so clearly demonstrated as in those surgeons working in oversea hospitals. Although they were far away from their ivory towers, they were never far away from the surgical principles they had been taught.

After each hospital service had been visited, the entire surgical complement was reviewed and annotations were made with regard to the qualifications of each surgeon. The probable efficiency and competency of the surgical service was discussed and assessed. In the fall of 1943, the quality of the surgical services in the theater's hospitals was quite good, and evaluation was not difficult. Eventually, however, as the theater began to be flooded with new hospitals, the quality of the surgical services became more of a problem. Also, at that time, many medical officers were transferred from the Army Air Forces to the Army Service Forces, and a number of officers of high rank but limited professional ability began to appear-distributed here and there-in the roster of almost all of the new hospitals in the European theater.

The visiting of hospitals by the consultant was important, since it gave each hospital's medical officers contact with men who were interested only in the professional care of patients. Frequently, the new medical officers felt that the Army was interested only in a type of surgical and medical care of which they disapproved. It was essential that the army directives and methods be explained to them by men who had been in the European theater for some time-men who had some idea of their possible future problems and of the reasons for differences between military and civilian practices. The medical officers in the hospitals did not hesitate to talk freely with the consultants on a "doctor to doctor" basis, and the consultants' visits were very beneficial in bolstering the morale of medical officers. On the other hand, the consultants occasionally might have been a little too sympathetic with a man desiring to make a change to further his own promotion.

Of greatest importance was the fact that at all times there were consultants who had on record and also personally knew the professional qualifications of all the medical officers of the hospitals in the European theater. In case illness incapacitated a key surgeon, or if a particular hospital experienced an increased professional load, the consultants knew whether or not the particular hospital


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involved was adequate and, if it was not adequate, where to find men who had the qualifications to assume this additional load. In order to make the most efficient use of this detailed knowledge of personnel, it was important that the senior consultants be appointed for a long period of time. This knowledge was invaluable, since the consultants could very readily supply the personnel officer with the names of additional, trained men to speed up the organization of new surgical services when the need arose among the many hospitals which eventually entered the theater without surgical personnel of the requisite high caliber.

The consultants, however, could only evaluate the professional personnel of the service as a whole and act as advisers to the personnel officer. Only the personnel officer at the appropriate headquarters could initiate orders for the transfer of a surgeon from one place to another. The consultant could recommend such a transfer, but this did not make it automatic. It was important, therefore, that the consultant be in close liaison with the personnel officer in the Office of the Chief Surgeon as well as with personnel officers in the base sections; and it was equally important that a spirit of complete confidence and cooperation exist between them.

Preparation of Manual of Therapy, ETOUSA

The Senior Consultant in General Surgery was also ultimately associated with the preparation of memorandums and directives. Information regarding the efficacy of treatment being given casualties in England, Ireland, and Wales was discussed as it was gained. Considerable time was taken to review previous directives and to prepare directives incorporating the new information. Every effort was made to promulgate directives that would be clearly understood by the surgeons and that would adhere to the best surgical standards yet be in accordance with the tradition of military directives and objectives.

This led to the realization of a need for developing a standard manual of therapy, including the medical and surgical aspects of care of the wounded soldier. Colonel Zollinger's predecessor had obviously encountered many obstacles in the preparation of such a manual, and practically no utilizable material had been compiled. After considerable discussion, it was decided that such a manual of therapy should (1) be small and compact so that it could be easily carried by the medical officer far into the forward area, (2) be up to date and consistent with the directives of The Surgeon General and the Chief Surgeon, ETOUSA, (3) contain the most recent information gained by experiences of the Medical Corps during the Italian campaigns as well as information from the British and French Allies, and (4) serve medical officers in the forward area as well as those carrying out definitive treatment in the base areas. It was finally decided, therefore, that each chapter should be divided into two parts-the first to deal with emergency treatment, and the second to be concerned with definitive treatment.

In order to restrict the manual to pocket size, each chapter had to be very concise and more or less in outline form. The medical consultants apparently


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had very little disagreement in the preparation of their chapters. The various surgical specialists, however, submitted long chapters and were loath to endorse the requirements of emergency therapy so vital in the most forward areas. It took considerable time and experience gained from their visits to the North African theater to persuade them that evacuation must take precedence over definitive treatment. It was extremely difficult to convince the medical officer, newly commissioned from civilian practice, that only the simplest things possible should be done in the forward areas; that is, cover the wound and then evacuate the patient to a place where definitive treatment could be carried out under more satisfactory conditions. The desire to do too much and therefore delay evacuation was a constant problem.

Since there was no consultant in thoracic surgery, this consultant was responsible for the chapters on the treatment of abdominal wounds and thoracic wounds. The directives issued from the Office of The Surgeon General were utilized, but, for the most part, the material was gleaned from experience gained in visits to various hospitals caring for Air Force casualties as well as for those casualties returning from Africa to the United Kingdom. Information was also gained from the North African theater and from talking with Colonel Cutler and others who had visited the North African theater and the eastern front of the Soviet Army.

There was little disagreement regarding the general care of the wound. Some of the major problems at that time were the use of chemotherapy and antibiotics-whether to use them locally or systemically, how much to use, and whether to use them simultaneously or separately. The use of gas gangrene sera and tetanus antitoxin and toxoid was also thoroughly discussed, and decisions were made as to their use.

It was this consultant's impression that the European theater had very little in the way of directives or information from the Zone of Interior regarding the treatment of casualties. However, it was frequently reemphasized through channels from the Office of The Surgeon General that all wounds were to be left open. Before the proofs for the Manual of Therapy, European Theater of Operations, were sent away, Colonel Kimbrough again called the author's attention to a recent cablegram stating that all amputations were to be left open. These instructions were, of course, contrary to everyday experience in civilian life, when wounds had been seen early and under ideal conditions. Furthermore, Col. William F. MacFee, MC, had carried out primary debridement and closure in a number of casualties in East Anglia which had occurred in the Army Forces, and he had apparently obtained excellent results. Men in the Army Air Forces, however, returned to their bases every day and had baths and clean clothing. The surroundings of an aircraft were not apt to be so contaminated as were those of the foot soldier who might be wounded on soil which had been tilled over a period of centuries.

A great deal of space was taken to describe the debridement of a wound. In order to demonstrate debridement with a simple sketch, a sergeant who had been interested in drawing was transferred from the author's old unit, the 5th


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General Hospital, to Cheltenham. He made some very helpful pen-and-ink sketches illustrating various principles of first aid treatment.

This consultant's experience in preparing the Manual of Therapy convinced him that the most recent well-substantiated methods and principles of treatment of war casualties should be taught to all medical students and become a part of the indoctrination of each medical officer. It seemed a great waste of time and energy for surgeons to indoctrinate thousands of medical officers scattered throughout the hospitals and bases in principles which could have been given better during medical school or at least during their basic training.

In May 1944, Maj. Gen. Paul R. Hawley, the Chief Surgeon, and Colonel Cutler presented the Manual of Therapy at a conference with Lt. Gen. John C. H. Lee, Commanding General, SOS (Services of Supply), in the British Isles. They were very proud of this booklet which could be carried in the medical officer's pocket. General Lee noted that it had not been dated and asked for which war the booklet had been prepared. This omission was remedied by handstamping the date on the front of each booklet. It was the first U.S. Army manual printed without having been officially dated.

Lectures at Medical Field Service School

One of the responsibilities of the consultants was to lecture at the Medical Field Service School. Each man was assigned to lecture in his particular field to a group of medical officers brought there from time to time for indoctrination (fig. 128). The Medical Field Service School was under the direction of Capt. (later Lt. Col.) Bernard J. Pisani, MC, an excellent director who cooperated extremely well with the consultants, making the trip a most enjoyable one.

This was one of the functions of the consultant group which was always pleasant, since it involved teaching younger men. Perhaps the teachers would not have been so enthusiastic had they realized that many of their students had been sent there for disciplinary indoctrination rather than for purely professional instruction. This consultant suspected that the mediocre medical officers from many of the units were given a better medical education thereby than the men who adhered to the line. This was not altogether true, however, since many of the superior officers were originally sent to this school (fig. 129).

PREPARATIONS FOR NORMANDY INVASION

Planning LST Operations

In the latter part of February 1944, Maj. Gen. Albert W. Kenner, Chief Medical Officer in General Eisenhower's Headquarters, SHAEF, held a meeting with General Hawley, Col. David E. Liston, MC (Deputy Chief Surgeon), and representatives of the First U.S. Army, the British Army, the British Navy, and the U.S. Navy concerning the professional care to be provided on an LST (landing ship, tank). The Chief Surgeon's Office had made recommendations concerning the policies to be carried out on these ships.


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FIGURE 128.-Lt. Col. William A. Howard, MC, Chief, Intelligence Section, Operations Division, Office of the Chief Surgeon, ETOUSA, lecturing to a class of medical officers at the Medical Field Service School, ETOUSA, upon its reopening at the Chateau Du Marais, near Paris, France.

Planning for the treatment of casualties to be evacuated on LST's during the initial invasion of Normandy became one of Colonel Zollinger's responsibilities. He thus became a liaison officer to the U.S. Navy for this preinvasion planning. The number of LST's available, which was then, of course, secret information, was 110.

Preparing these plans involved the following problems. First, what treatment could be carried out on the LST after it was loaded with casualties on the far shore and directed back to the three unloading points in southern England? Second, what medical personnel would be needed in addition to the personnel of the LST? Third, what medical and surgical supplies would be needed?

LST's converted to provide an operating-room platform were discussed. Other proposed minor changes were to be made to assist the moving of casualties about the ship through the narrow passageways. It was planned that the casualties would be loaded on stretchers and placed on the floor of the inside deck after the tanks and trucks transported to France had been landed. This would provide a huge, readymade, one-room hospital ward.

The type and amount of surgery to be performed would depend upon how soon functioning hospitals could be set up on the far shore. It was apparent that, in the initial stages of the invasion, many fresh casualties would have


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FIGURE 129.-One of the first classes to graduate from the Medical Field Service School, ETOUSA, at Shrivenham Barracks, England. Capt. Bernard J. Pisani, MC, commandant of the school, kneeling in the center of the front row.

to be loaded on LST's and treated by the personnel aboard. It was then agreed and promulgated in a directive that conservatism would be the policy with respect to major surgery in the treatment of casualties being returned to England in the LST's.

Since the Navy had the primary responsibility, planning for supplies and personnel to be placed aboard LST's involved close coordination with the Navy. The author, acting as liaison officer to the Navy, required frequent conferences to find out details concerning medical supplies already available on LST's and what was needed from the Army to complement them. A pharmacist's mate in naval headquarters in London seemed to be the most thoroughly informed concerning the medical complement of every class of ship in the U.S. Navy. These supply lists had to be reviewed, and, so far as possible, necessary additions had to be furnished by the Navy. Any further supplies would have to be provided by the U.S. Army. A means of accomplishing this was the cause of considerable concern.

A problem which seemed almost insurmountable was how to provide sterile dry goods for the performance of any surgery on the LST. There was no room to store a large supply. Furthermore, since the LST was to return to the far shore immediately upon delivering the casualties to England, how were sterile dry goods to  be laundered and replaced promptly at the end of each trip? Although there was some sterilizing equipment aboard an LST, the amount of dry goods was almost insignificant.

The previous year, while the author was assigned to the 5th General Hospital, he had been instrumental in developing a mobile surgical unit. At


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FIGURE 130.-Rubberized sheets replacing cloth drapes in a mobile surgical unit.

that time, it was learned that rubberized material supplied by the British could be made available in place of the dry goods. The material came in bolts, and given lengths could be cut with a hole in the middle to be used as laparotomy sheets. Similar sizes could be utilized for towels and drapes for tables and sterile instruments. The material, weighted down with clamps, could be boiled at the same time as the instruments. It could be boiled repeatedly without deterioration. It was decided that 25 yards of this material would be made available to each LST (fig. 130).

Each surgeon to serve aboard an LST was given a copy of the Manual of Therapy, a dozen pairs of rubber gloves, and the 25 yards of rubberized material to prepare for operating drapes and gowns. The army kit of surgical instruments was also given to each surgeon. Chemotherapy was made available to each LST in a larger supply than its usual complement. All these supplies were delivered to the three collecting points where the personnel selected for LST duty were to be gathered for instructions.

The Navy was ready to supply, for each LST, one medical officer who had been brought into the Armed Forces immediately upon finishing a 9-month internship. One surgeon and two surgical technicians were to be supplied by the Army for each LST.


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Discussions were held with the medical officer of the 1st Medical General Laboratory, who was in charge of meeting the demand for whole blood on each LST, and adequate plans were made.

Toward the middle of May 1944, recommendations were made for the actual selection and assignment of surgeons and surgical technicians for the LST's. One-third of the group was to come from theater SOS units, one-third from the Third U.S. Army which was staging at that time, and one-third from the Army Air Forces. These men were ordered to various places in southern England for indoctrination preliminary to being ordered to a particular LST.

It was part of this consultant's responsibility to coordinate the indoctrination of these groups of men. They had not been aware, up to this time, that they were to comprise the medical complement of the LST's. When the medical personnel assigned to these LST's were apprised of their mission, they were quite shocked. Most of them regarded it as being more or less a suicide assignment. They believed that the shores of France were loaded with heavy artillery, mines, and multiple German divisions, and that poison gas would probably be used. They had no way of knowing how poorly the coastline of France was defended, compared to their expectations. Most of the line officers had already been reassured.

Discussions as to procedure were started about 16 May 1944. On that day, this writer visited the 28th General Hospital, at Trowbridge, and reemphasized conservatism in the care of the wounded aboard LST's. At this late date, only 16 of the 34 men ordered to report to this collecting point had arrived, and some of these were without proper clothing. It was essential to supply the physicians and their technicians with additional clothing, especially underwear.

The group at the 316th Station Hospital at Newton Abbot was also interviewed and briefed, and the men seemed well qualified and confident of their capabilities to do major abdominal surgery, if necessary.

On 17 May 1944, a discussion was held with the group assembled at the 115th Station Hospital, near Plymouth. The majority of these men had been taken from the Army Air Forces. One officer disclaimed his ability to perform general surgery because he was a proctologist. Arrangements were made for his replacement.

In discussions with the physicians assigned to these LST's, it was amazing to find that they invariably expressed concern over the qualifications of their so-called surgical technicians. Since the true nature of the technicians' assignments was not known, many of them were, in reality, anything or everything but surgical technicians. The officers evidenced real panic and attempted in every way possible to contact their parent units to effect a return of the untrained enlisted men and to have them replaced with well-trained technicians. Necessary steps were taken to facilitate these transfers.

Considering the operation with the aid of hindsight, it would seem that the commanding officer of a hospital dispatching a medical officer to serve on an LST should have known the importance of the assignment. On the other


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hand, his consideration of the possible hazards involved might have made his decision more difficult.

Planning Special Studies

Lt. Col. (later Col.) Joseph A. Crisler, Jr., MC, surgical consultant to the First U.S. Army, visited Cheltenham rather regularly at the time of the surgical consultant's Saturday morning meetings. In addition, other conferences were held concerning his estimated requirements for penicillin, medical supplies, specially trained personnel, and so forth. Plans were also made for gathering data on abdominal wounds, thoracic wounds, and cases of gas gangrene, as they were treated on the far shore by the First U.S. Army.

Several forms were proposed in an attempt to gain some statistical information regarding the treatment and outcome of these wounds. It was hoped that these reporting requirements could be printed and distributed to surgical teams and that each unit in the hospital could be made responsible for collecting such information. Actually, each form required too much information to be practical, and, although such information would have been invaluable, there was no way that it could be secured easily. Certainly, it was regrettable that there was no table of organization to provide for study groups which could have developed special studies for the cases carrying a high mortality.

Distinguished scientists were present and available in the European theater, who could have constituted a research study group, had an appropriate table of organization been available. Such a group should have been assigned not only to theater headquarters but also to each base section and each hospital center.

It probably would have been most desirable to have had an officer in every hospital, regardless of its size, designated as the responsible individual for collecting such professional data or for the maintenance of an appropriate and official diary concerning the treatment of patients-a diary which could have been submitted to the Office of the Chief Surgeon at regular intervals for study and appropriate action.

Provision of Whole Blood

Several months before the invasion, there was considerable discussion concerning the use of proportions of plasma and whole blood in the treatment of casualties. This aspect of planning has been thoroughly covered elsewhere. It should be mentioned, however, that Maj. (later Lt. Col.) Charles P. Emerson, MC, and Maj. (later Lt. Col.) Richard V. Ebert, MC, of the 5th General Hospital, devoted a great deal of time to the development of a mobile field transfusion kit. Their kit could be stored in a wooden box used in the shipment of 50-caliber ammunition. It consisted of material for typing and cross-matching and all other material necessary for collecting and giving blood. These very thoughtful, sincere individuals proved to their own satisfaction that it was possible to wash out transfusion bottles with distilled water and sterilize them with alcohol. Actually, they took blood from each other under these circumstances and readministered it to themselves without ill effects. This was, to be


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sure, a very crude arrangement, but it would have made available whole blood transfusions in any area, should it have become necessary as a lifesaving measure.

At that time, it was not clearly understood how sufficient amounts of whole blood could be delivered to the far shore, especially to forward areas. The Signal Corps, in cooperation with these two officers of the 5th General Hospital, developed a teaching film on the use of the field transfusion kit. It eventually became apparent that blood would be flown from the United States, and these kits would not be necessary; but it did show that, despite great handicaps of equipment and supply shortages, the ingenuity of the U.S. Army officer could provide the best possible care for the American soldier.

Preparing for Reception of Casualties

In addition to attending conferences with the First U.S. Army consultants, this consultant took part in several meetings in the Southern Base Section, at which time the surgical chiefs of the various hospitals were gathered together. At these meetings, emphasis was placed on the rehabilitation of patients and their early return to duty. It took constant surveillance by the consultants to make certain that patients were not held for definitive surgery which would prevent their being returned to duty within a period of 60 days. This became increasingly important, for, as the time of the Normandy invasion drew near, the necessity for providing empty beds in the transient hospitals, especially in the southern part of England, became more acute.

The surgical consultants visited hospitals in the Southern Base Section rather frequently during May 1944, urging clearance of all possible beds in preparation for the reception of casualties. In addition, plans were drawn up to provide surgical teams to the hospitals that were concentrated around the reception zones for casualties returning from the LST's. Detailed plans were made for the reception of these casualties and for the triaging of these cases in order that specialty care would be made available as soon as possible, depending upon the type of wound.

Last-Minute Activities, May 1944

Late in May 1944, there were constant changes in the maxima of demands upon the consultants. The First U.S. Army had raised the requirements for whole blood, and new transfusion sets had arrived which were being made available for the Third U.S. Army. This occasioned changes in the supplies to be provided LST's.

There was also considerable discussion regarding the proper use of sulfanilamide, as well as penicillin. The feasibility of providing the First U.S. Army alone with sulfanilamide, to be taken by mouth as well as dusted on wounds, and providing the Third U.S. Army only with penicillin was considered, in that it would afford a well-controlled experiment to determine which was the more effective in the control of infections in war wounds. It was the consensus, however, that the American public would not approve such a study and that the U.S. soldier was entitled to everything that was available for his care. The


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FIGURE 131.-Ample stores of sterile goods being prepared at the 50th Field Hospital for the Normandy invasion.

U.S. soldier seemed to feel psychologically secure when he had sulfanilamide available for his own protection. The uniformed soldier or technician had more confidence in these drugs as far as their ability to save life was concerned than had the experienced medical personnel responsible for the details of administration of the drugs.

Some time was spent visiting the various hospital centers, which had now become organized for the mass reception of casualties. A consultant in surgery was to be assigned in each of these hospital centers, or the best qualified chief of surgical service in one of the center's hospitals was to be nominated as a senior consultant for the center. Everywhere the hospitals were well organized for the reception of casualties. They had improved their central supply, and ample stores of sterile dressings and so forth had been prepared in anticipation of a great inflow of casualties (fig. 131).

This consultant was not apprised of the date of the invasion, nor did he meet anyone who appeared to want to know the date. All were afraid that they might violate security in an accidental way. As far as could be ascertained, the hospitals were empty, the supplies were adequate, the staffs were well balanced, and the hospitals were supplemented by members of the 1st Auxiliary Surgical Group until such time as they were needed on the far shore.


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ACTIVITIES DURING NORMANDY INVASION

A conference was held with LST surgeons at Southampton on 8 June 1944 concerning observations on the unloading of casualties. This procedure was carried out quite smoothly, but the triaging officer was unable to carry out the plan to sort the patients at that point because of insufficient time. The LST's had to be reloaded quickly with fighting equipment.

Several LST surgeons were interviewed. One of these men stated that he had brought back 46 casualties on his LST. He had been able to debride some wounds and utilize his rubber sheeting, had given blood transfusions, and had carried out penicillin therapy. He seemed quite convinced that his supplies were adequate and that he would be able to do the necessary surgery in a satisfactory manner. When the casualties were received, those who needed it were given a large amount of plasma and some were given whole blood and prepared for early evacuation.

The surgeons who served on the LST's were required to submit a report of their experiences, One of these reports may be found in appendix E (p. 985).

Observations on Treatment of Casualties

One of the functions of the consultants was to observe and report on the treatment of casualties from the time they were received from the LST's to the time they were admitted to the various hospitals, including observations on the methods of transportation used (fig. 132). The consultants were the only ones who could provide any followup information and then report back to the surgeon responsible for the initial treatment regarding his successes or failures. The lack of adequate followup observations was one of the most disappointing experiences of the military surgeon.

Treatment by these physicians was quite good, and the few cases of gas gangrene seen during the everyday reception of casualties were usually in prisoners of war. Scanty records, failure to continue penicillin therapy, inadequate immobilization, improperly made colostomies, and failure to evacuate patients when the patient load became excessive were some of the mistakes most commonly made.

Directives were quickly prepared by the consultant group in the Office of the Chief Surgeon to point out the common and more serious mistakes. These directives were disseminated to all hospitals and surgical tams. For example, some of the transient hospitals noted that abdominal cases were given fruit juices quite early, and this, combined with early evacuation, resulted in considerable distention of the abdomen.

Study of Gas Gangrene and Wound Closure

There was hope that an extensive study of gas gangrene could be carried out and that facilities available at the 1st Medical General Laboratory could be used to develop a training film in gas gangrene. For example, it was ob-


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served that many patients with so-called cases of gas gangrene had received the customary 18 ampules of gas gangrene serum but actually had never had this dreaded infection. Some of these diagnoses were based on the smear taken of the wound, while others were based on inexperience-failure to appreciate the fact that most gunshot wounds contained air in the tissues and that crepitus was a common finding. Several illustrative cases were found, and motion pictures were made of these particular patients, including their treatment.

Another function of the surgical consultant in the early days following the invasion was to urge the principle of early secondary closure of wounds. By 18 June, some hospitals were already taking cultures of wounds, with the idea of making intensive studies in the proper method of treating such wounds. Information gained regarding the proper debridement of wounds and proper principles to be followed in secondary closure was taken to each hospital by frequent consultant visits. This was the only way that such information could be rapidly disseminated. Any directive issued would have lagged far behind in the promotion of better care for thousands of patients.

Practically every hospital center began its own study, trying to determine the best principle of carrying out secondary closures. Some of the questions in the minds of the surgeon follow:

1. How extensively should the wound be debrided before secondary closure?

2. Could the wound including the skin be closed?

3. How soon after injury should the secondary closure be carried out?

4. Should local chemotherapy or antibiotics have any place in the management of the secondary closure?

5. Did the administration of these drugs systemically before and following the procedure enhance the chance of success of the closures?

6. How long should the wounds closed secondarily be immobilized?

7. How soon could rehabilitation exercises be started without danger of disruption of the secondary closure?

It soon became apparent that it was the thoroughness and care of the surgeon carrying out the debridement in secondary closure more than the type of chemotherapy or antibiotic which was used that determined the result. If the surgical service of a hospital was in the charge of a very well-trained surgeon-especially one who believed in attention to the fine details in technique in care of patients-then the results in the hospital were good.

Regional Wounds

Eventually, thoracic wounds began to be concentrated in the various hospital centers, and the principles of early closed drainage and early decortication were followed. The principles had been developed in Italy, and it was the duty of all surgical consultants to impart this information wherever thoracic surgery was being performed.


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FIGURE 132.-The reception and transportation of casualties from the Normandy invasion. A. Ambulatory patients walking off an LCT. B. Transportation by cargo truck to a train loading point.


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FIGURE 132.-Continued. C. Transportation inland by a hospital train. D. Patients arriving finally at the 305th Station Hospital on 15 June 1944.


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Although the treatment of abdominal wounds was good and the majority of these cases were kept on the far shore within a few days after the onset of the invasion, the problem of the management of high intestinal fistulae was not satisfactorily solved. Small bowel fistulae were noted for their poor response to transportation. The surgeons were urged to avoid ileostomies or jejunostomies either by tube or exteriorization, if at all possible. They were further urged to administer sufficient fluids to bring these patients into fluid and electrolyte balance and to make every attempt at early surgical closure of the fistulae.

The management of vascular injuries of the extremities was also a problem. There was a tendency at times to incorporate the extremity in a lot of padding and a plaster case, which resulted in overheating as well as in covering the tissues and making it impossible to appraise the viability of the tissues during the hours of evacuation. The closeness of the cast to the heel enhanced the possibility of necrosis and infection. It was urged that these extremities be covered with sterile towels and that the patients be evacuated from the transit hospital in traction.

Before the end of June, many casualties were being received by air, and the majority were in good condition.

ACTIVITIES ON THE CONTINENT

As Senior Consultant in General Surgery, the author was informed that he would be assigned to the advance section of the communications zone, under the overall command of Col. (later Brig. Gen.) Charles B. Spruit, MC, as soon as this headquarters was established on the far shore. After spending some time in the staging area, this consultant finally arrived on the far shore on 16 July 1944. Reporting to the surgeon of the communications zone, he was advised to report to Col. Charles H. Beasley, MC, surgeon of the advance section headquarters, to work in the Professional Services Division of that headquarters and on 19 July, he first contacted Colonel Crisler, surgical consultant to the First U.S. Army.

Surgical and Shock Teams From Base Hospitals

After 19 July, the author met almost daily with the consultants of the First and Third U.S. Armies. During these evening meetings, the needs for surgical teams and other needs were discussed.

As soon as general hospitals had been set up in the staging area in France, Colonel Zollinger contacted them and asked them to organize their professional personnel into surgical teams. These teams were to consist of two surgeons, one anesthesiologist, one surgical nurse, and two surgical technicians. Each team was given the designation "A," and each was to be ordered out by number.

The First U.S. Army was to keep by number and name the chief of each team. It was planned that, insofar as possible, these teams would be assigned


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to evacuation hospitals to facilitate their relocation and eventual return to their parent units. In many instances, these men in general hospitals had been in the staging area in England for a considerable time and were more than eager to get into active work as members of a surgical team. They were instructed to report to a particular hospital, as designated by the army surgical consultant. No official orders were ever issued for these teams, and probably no official record was ever made of the fact that between 60 and 70 of these teams were used to supplement the surgical care of patients within the First U.S. Army during the middle of July 1944.

When the flow of casualties was quite heavy, it was obvious that mortality, especially in field hospital platoons receiving nontransportable wounded, could be lowered if sufficient personnel were available to administer whole blood to casualties awaiting operation. Accordingly, shock teams from the medical service of these same general hospitals in staging were formed to consist of one officer, one nurse, and one enlisted mail. Two such shock teams were to be attached to each of the three platoons of a field hospital. These teams were to take along with them a form to record the amount of whole blood and plasma given in a clearing station both preoperatively and postoperatively. It was believed that in this way valuable information could be obtained as to the actual needs for whole blood and plasma in the forward areas. These data were to be gathered and correlated each week.

It was necessary for the author to visit the various field hospitals and explain the setup and function of the shock teams, since the newly formed teams were very much overworked. It was estimated that one surgical team could do about 7 or 8 abdominal operations or 12 chest cases within 12 hours (fig. 133). There were not enough personnel with the surgical teams to provide preoperative and postoperative care, and for that reason the shock team performed a valuable service. After these shock teams were assigned, they were so busy and engrossed in their work that records were inadequately kept. It was necessary, therefore, for this consultant to suggest that the nurse be made responsible for keeping these records. A report of the activities of these teams was submitted to communications zone headquarters for transmission to the Chief Surgeon.

Approximately 104 surgical and shock teams were drawn from the various general hospitals in the staging areas. These teams were returned to their own units within a relatively short time after the breakthrough at Saint-Lo, France. The experience demonstrated that each hospital, regardless of its size, should be subdivided and organized into surgical teams as well as shock teams. In this way, all professional personnel, including both surgeons and medical officers, could be assigned a useful function. Certainly, a shock team should be available to support each surgical team during the time of reception of heavy casualties. These shock teams, previously organized and set up, probably served as great a function in saving lives as did the surgical teams.


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FIGURE 133.-Field hospitals functioning. A. Surgical teams operating on nontransportable, seriously wounded patients at the 45th Field Hospital. B. A shock ward at the 34th Field Hospital.


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Evacuation and Sorting

This consultant visited various evacuation hospitals largely to maintain contact with the surgical and shock teams on temporary duty from the general hospitals and to make an effort to obtain data concerning the most efficient use of whole blood and plasma (fig. 134). On occasion, the consultants were also directed to visit holding units to assist in the triage of patients. For example, as many as 600 casualties awaiting air evacuation might be held by a medical battalion. Patients with large wounds, casts, or wounds of the abdomen and chest and those with complications were carefully checked before air evacuation. Chemotherapy was not attempted unless these casualties were to be held overnight. Surgical teams from the 1st Auxiliary Surgical Group were assigned to these units. Occasionally, surgery was necessary, especially when bad weather prevented evacuation by either air or sea. Hospitals did not find it difficult to supply auxiliary mobile surgical teams that had their own equipment. The parent hospitals were all in need of additional help, and a great spirit of cooperation existed among them.

The problem of triaging patients from holding units to advance section hospitals consumed increasing amounts of time. At first, those cases were selected that had a reasonable chance of returning to duty within 10 days after admission to hospitals in the advance section area. Allegedly, the first time abdominal cases were kept 10 days instead of 7, the patient load in the field hospitals was increased. The rapid forward advance of friendly armies after 1 August, however, resulted in a marked decrease in the number of casualties.

On 4 August, members of the Advance Section, Communications Zone, visited the holding unit at Omaha Beach. There were 1,100 patients in the particular unit, and 300 were selected for transportation on the first ambulance train from Lison Junction to Cherbourg. The visitors attempted to select cases that might have a reasonable chance of getting back to duty within 10 days or 2 weeks. Therefore, soft-tissue wounds, acute sprains, medical complaints, and similar cases, for the most part, were chosen. No fractures, nerve, tendon, or major blood vessel injuries, or wounds of the palm of the hand, the sole of the feet, the scrotum, the peritoneum, or the buttock were selected unless they were quite small.

Officers were instructed as a group and as individuals in triaging these cases. Two hundred and twenty-one were sent by the first train. The author accompanied this group to observe how well patients could tolerate transportation in the 40 hommes et 8 chevaux boxcars, which had been converted into an ambulance train (fig. 135).

There were three tiers of litters, with the wounds of the patients positioned toward the aisle in order that they could be inspected frequently by the medical officer. Several No. 2 medical chests were on the train, as were plasma and tourniquets. Fruit juice, K-rations, urinals, water, and so forth, were available in each car. The train ride was extremely slow, the train fairly crept to Cherbourg, and the entire trip took about 5 hours. The patients, however, withstood it quite well and were delivered to the 298th General Hospital.


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FIGURE 134.-The 9th Evacuation Hospital. A. A general view (both buildings and tentage were utilized). B. Operating room.


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FIGURE 135.-The first hospital train movement on the Continent. A. Chevaux boxcars at Lison Junction. B. The interior of a boxcar fitted with brackets to hold litters.


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Evaluation of patients with hernias, varicose veins, and similar disorders determined whether they should be operated upon at that time or should be transferred to another type of unit. The entire policy of necessity changed rather rapidly, depending upon the bed space available in the advance section hospitals.

On 5 August, the author visited the 5th General Hospital, which was functioning in Carenton, France, at the base of the peninsula. The hospital staff estimated that no more than 10 or 20 percent of its cases could be returned to duty within 10 days. The period of rehabilitation then had to be extended, and it was suggested that triage be more rigid in order to make more beds available for minor casualties that had a good chance of returning to duty within 2 weeks. These types of cases usually included soft-tissue wounds under 3 inches in length without associated damage to nerves, tendons, and major blood vessels.

From time to time, the consultants returned to England or other parts of the United Kingdom to visit the various hospitals and hospital centers. On these visits, they made rounds with the chiefs of surgery in order to discover any mistakes made on the far shore. It was worthwhile to point out to these men the difficulties under which the surgeons on the far shore labored. It was also necessary to check upon how well the patients were withstanding transportation by air, because there was some question as to how well thoracic and abdominal patients would tolerate the airlift. When the consultants returned again to France, they could report to the surgeons in the forward area concerning the good work that they had done as well as note errors which might be rectified with benefit to the patients.

In addition to visiting hospitals, consultants reviewed articles for inclusion in the monthly medical bulletin which was prepared for the information of all officers. Several meetings were held with the various thoracic surgeons in order to develop general principles of thoracic surgery to be included in the medical bulletin. Similar notations were made concerning the treatment of arterio-venous aneurysms.

The consultants shuttled back and forth between the United Kingdom and France as the occasion demanded. Toward the latter part of August 1944, a fair amount of the consultants' time was concerned with changes in policy. More and more patients were being held in the general hospitals, which became more completely established in France as the army moved eastward.

As patients were evacuated, it became necessary to mark on the outside jacket or record whether or not they were to go to communications zone facilities on the Continent or to the United Kingdom. As a general policy, it was suggested that all patients with fractures of the long bones and those with hernias be sent to the United Kingdom. On the other hand, patients with soft-tissue wounds were to be held for as long as 30 days and then be sent to convalescent hospitals located in areas near the general hospitals in Normandy. It was also planned that any patient whose condition would permit transfer


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to the Zone of the Interior at the end of 1 month would be treated in a general hospital on the Continent. The same rule was to apply to prisoners of war.

It was necessary to arrange for the indoctrination of triaging officers at the various field hospitals near airstrips. These triaging officers were selected from general hospital personnel because they played a very important role in the conservation of manpower and in keeping patients in France who might be quickly rehabilitated and returned to duty.

Miscellaneous Activities and Observations

During the latter part of August, a circular instructed all general hospitals to compile lists of various types of surgical shock teams, according to the new table of organization that had been sent over from the Zone of Interior, for assignment to the 12th Army Group, which in turn would determine their distribution.

Arrangements were made to assign Major Ebert and Major Emerson of the 5th General Hospital to a forward field hospital to study shock. They carried their own laboratory equipment. These men ultimately gathered very significant data which were later published in Annals of Surgery. One of their most significant findings was the fact that, by actual measurement, many of the compound fractures of the femur had lost as much as 40 percent of their total blood volume. These medical officers were impressed by the great need for whole blood replacement and emphasized that plasma was not an adequate substitute for whole blood in a severely wounded soldier.

As the armies began to move forward farther and farther into Europe, distances became so great that the role of the consultant became less effective. Furthermore, the consultants in the United Kingdom had been well organized and were quite capable of functioning independently. More and more attention could be devoted to the development of principles regarding definitive treatment of casualties. For example, some hospitals began to segregate all their hand cases into a separate ward.

A number of surgical principles seemed to be violated from time to time. Such errors as the inadequate exteriorization of the colon for a temporary colostomy were studied, and corrective measures were then written up as an editorial in the European theater Medical Bulletin. Some difficulty was encountered in the evaluation of casualties in holding units before they were finally sent back to the Zone of Interior. The holding units apparently were too busy and did not assume the responsibility of continued treatment before the patients were evacuated. It was obvious that more experienced surgeons were needed to evaluate these cases and screen them before the patients were evacuated, whether by sea or air.

Toward the end of August, this consultant visited various army areas and continued a close relationship with the very cooperative consultants in the armies. Toward the end of September, the consultants were directed to visit the 16th Field Hospital which had received a number of wounded French


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from the 2d Armored Division. The question arose why this hospital should encounter such a high mortality. Upon visiting it, the consultants learned that these patients were severely wounded because, like many brave Frenchmen, they had left their tanks and walked directly into the line of enemy fire. Their distaste for taking cover, as practiced by other types of troops, accounted for the very extensive wounds.

As a matter of fact, a platoon of this hospital received 60 severely wounded during this specific period, 34 of whom came from the 2d Armored Division. Four of the thirty-four patients had been operated upon in the clearing station of the French division. All four died within 2 days.

FIGURE 136.-Lt. Col. Robert M. Zollinger, MC, Commanding Officer, 5th General Hospital, Carentan, France.

The average delay from admission to operation was 10 or 12 hours. This was due to the fact that, during the first 24 hours, the platoon had but one surgical team. This time interval was consistent with the delay observed in many other field hospitals during the study on shock. Actually, when receiving casualties, the field hospitals needed both surgical and shock teams.

About the first of October 1944, it became a policy that affiliated units which had been overseas for a long time should be commanded by members of their own units. Accordingly, Lt. Col. (later Col.) Louis M. Rousselot, MC, of Columbia University, was assigned as commanding officer of the 2d General Hospital, and, on 9 October 1944, the author replaced Col. Maxwell G. Keeler, MC, as commanding officer of the 5th General Hospital (figs. 136 and 137). Such a change was welcome, since the great distances involved made the role of the consultant increasingly difficult. Furthermore, the various armies were well organized with their own consultant staffs, and the principles of treatment were by then well understood by all. Professional care in the army areas was excellent, and the theater was filled with highly skilled men. Base sections had been set up in France as well as in the United Kingdom. At this time, it would have been invaluable had research teams been


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FIGURE 137.-The entrance to the 5th General Hospital.

organized to gather and record data regarding the professional care of these patients, returning such data to the Zone of Interior.

The author was in command of the 5th General Hospital until it returned to the United States in October 1945. The unit was disbanded at Fort Dix, N.J., that same month.

CONCLUSIONS

The position of a consultant in a theater of operations is hard to define, since there was no tangible table of organization and no precedent as to authority and responsibility. It might be said that the consultant had the same relationship to the regular medical officers as the regular medical officers had to the line officers. In other words, under ordinary circumstances they were a necessary nuisance, especially when they justifiably sought promotion to the rank of colonel; but they were absolutely essential when casualties were high, when morale of the soldier was low, and when morbidity and mortality were unsatisfactory.

Provision should be made to insure sufficient rank up to and including brigadier general for nationally known men who serve in oversea theaters as consultants. High rank is most essential in order to command the same authority as consultants of similar capacity in Allied armies and to add weight to the consultant's recommendations to hospital commanders.

Since the professional care of patients is not limited to any particular army or base section, and since casualties must invariably be evacuated from


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the field army back through the communications zone and finally to the Zone of Interior, the nomad consultant should be welcome in any area. He is, after all, concerned with the professional care of patients and functions primarily as a doctor.

There was too great a barrier between the consultants in the headquarters of the Office of the Chief Surgeon and those in the various field armies. There was no friction between the consultants themselves, but limitations did exist, since each army was independently responsible for its own internal administration and resented any outside interference.

The consultants in the European theater were concerned especially with their inability to requisition transportation. Perhaps it would have been better, however, had they moved more as a group. When several consultants, each in a special car, arrived simultaneously at a hospital, it was disturbing to the officers of the hospital and tended to create a friction which persisted throughout the war.

Because the duty of the consultant was to "observe and recommend," he often lacked the authority to achieve his goal. It may have been due partially to the fact that he was not thoroughly informed as to the overall program of the theater. Consultants should have been better briefed by administrative officers concerning their problems of supplies, men, and equipment.

Both the regular and the reserve medical officers who served as consultants point to the fact that the morbidity and mortality rates were lower than those of any previous war, despite the great mass of casualties. These low rates are attributed to many factors, among which are planning, training, evacuation, and indoctrination in the professional care of patients. Each group, therefore, played a vital role and should have made every attempt to understand the goals and problems of the other group. By the end of the war, a much clearer understanding had developed among them.

RECOMMENDATIONS

Under the system which prevailed in the European theater during World War II, consultants could only recommend the transfer of individual medical officers. The rapport attained with the personnel officer, therefore, became a matter of utmost importance. It should have been incumbent upon the personnel officer to accept without reservation the consultant's recommendations for the transfer of professional personnel.

The tables of organization of headquarters of all levels should include authorized positions for the entire group of consultants and provide for their ranks. Sufficient authority should be given consultants to carry out their recommendations. This, of necessity, includes the granting of sufficiently high rank, commensurate with the authority desired. Furthermore, promotion or appointment of one of the consultants in a table of organization headquarters should not preclude the promotion of another because there is only one vacancy


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in that particular rank. This situation could be alleviated by the creation of a separate table that provides for the positions and ranks of consultants.

In order to assure the most efficient application of their time and energies, consultants should have permanently assigned transportation on call, as does a physician in civil practice. To enable consultants to visit various facilities at will and coordinate professional activities by personal conferences would greatly aid the standardization of procedures, bolster the morale of surgeons, and improve the professional care of patients. The consultant should not have to waste time trying to wrangle transportation from the motor pool.

The theater surgeon, the army surgeon, the base section surgeon, and even the commanding officer of a hospital center should have a table of organization and manpower allocations for research and observation teams. Such teams should be accepted, in principle, as being just as essential for good surgical care as are logistics, evacuation, and the like. These teams could then observe and record the type of professional care casualties receive as they pass from first echelon medical services all the way to the installations for definitive treatment and rehabilitation.

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