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Orthopedic Surgery and Rehabilitation
Rex L. Diveley, M.D., and Mather Cleveland, M.D., Sc.D.
ORTHOPEDIC SURGERY, AUGUST 1942-MAY 1944
Maj. (later Col.) Rex L. Diveley, MC (fig. 158), was offered and accepted the position of Senior Consultant in Orthopedic Surgery, ETOUSA (European Theater of Operations, U.S. Army), on 4 July 1942. He reported to the Office of The Surgeon General, Washington, D.C., on 24 July 1942, where he was indoctrinated for the oversea mission. On 3 August, he was promoted to the rank of lieutenant colonel, and, on 12 August 1942, he received orders to proceed overseas. Colonel Diveley arrived at Headquarters, ETOUSA, on 26 August 1942, where he reported to Col. (later Maj. Gen.) Paul R. Hawley, MC, Chief Surgeon, ETOUSA.
Early Observations and Recommendations
The Professional Services Division in the Office of the Chief Surgeon was headed by a Director of Professional Services who supervised the professional activities of the Medical Department in the European theater and coordinated the work of consultants and specialists. There was a Chief Consultant in Surgery and a Chief Consultant in Medicine immediately subordinate to the Director of Professional Services. The senior consultant of each surgical specialty was, in turn, accountable to the Chief Consultant in Surgery.
As Senior Consultant in Orthopedic Surgery, the author's mission was to organize and supervise the conduct of orthopedic services and activities in the theater.
In September 1942, there were very few U.S. Army hospitals in the theater. Therefore, the first task was to ascertain the experiences of the British and Canadian Allies, as their organizations had been functioning many months. This consultant immediately contacted Brigadier Rowley W. Bristow, orthopedic consultant to the British Army; Mr. Reginald Watson-Jones, honorary orthopedic consultant to the RAF (Royal Air Force); Group Captain (later Air Commodore) Osmond Clark, orthopedic consultant to the RAF; Mr. H. A. T. Fairbank and Prof. Harry Platt, orthopedic consultants to EMS (Emergency Medical Service) hospitals; Mr. G. R. Girdlestone, orthopedic consultant to the Ministry of Pensions; and Prof. T. P. McMurray and Mr.
S. L. Higgs, regional orthopedic consultants to EMS hospitals. The EMS hospitals, while civilian institutions, were receiving and treating service cases in the various outlying sections of England.
The medical sections of the various headquarters of the Allied forces in the theater were visited, to include headquarters of the RAF, the British Army, and the Canadian Army. All of these offices were in London.
The principal British and Canadian hospitals and rehabilitation depots were visited, and several of the larger EMS hospitals which were receiving service cases were surveyed and studied. This consultant was very much impressed with the type of orthopedic work being accomplished in the British Army, Canadian, and RAF hospitals. These units had had several years of experience, and this study gave the Americans a basis for the organization of the U.S. Army orthopedic services.
At this time (October 1942), there were some 10 or 12 U.S. hospitals, and all of these units were inspected as to supplies, personnel, and type of work being accomplished. The medical and surgical supply situation was quite acute, and there was an alarming shortage of materials and surgical supplies available to the U.S. Forces. To investigate further the supply situation, the author visited the British medical supply depot at Ludgershall, the U.S. Army medical supply depot at Thatcham, and various medical and surgical supply houses in London.
As a result of the observations made and the information gained from these tours and a general survey of the theater, the author recommended to the Chief Surgeon that:
1. The medical and surgical supply situation in this theater being inadequate, the quantity of supplies should be increased, and a more efficient supply service should be rendered to the various hospital units.
2. Photographic records should be made and retained in each major hospital in the theater. A photographic department should be established in the Office of the Chief Surgeon for the making and filing of medical pictorial records and for the production of motion-picture training films.
3. If hospital records and/or X-ray films were to be retained as permanent records, they should be preserved and stored by mass photography (microfilming). This would give a permanent record and conserve storage space.
4. An intensive program of military orthopedic training should be instituted and given to surgeons in the European theater, especially to those in station hospitals. This training should stress the techniques of immobilization and transportation of fractures in the forward areas as well as the definitive treatment at the base areas.
5. A rehabilitation depot should be established in the theater to care for the convalescent patient and to recondition the underdeveloped soldier who had broken in training.
6. Certain specialized bone and joint injuries and conditions should only be operated upon by the orthopedic surgeon or the especially trained traumatic surgeon.
7. More study and care should be given the problem of foot and march injuries in combat troops undergoing training. This supervised care would save many man-days lost to divisions in training.
This consultant spent the remaining few months of 1942 attempting to implement the foregoing recommendations. First, he immediately contacted British military and private surgical supply sources and was able to obtain a limited quantity of instruments and supplies which would suffice the U.S. Army until standard U.S. Army types could be obtained from the United States or be manufactured in the United Kingdom. The author contacted the Signal Corps for the procurement of photographic supplies, but this branch was unable to furnish supplies or personnel to the Office of the Chief Surgeon or to the hospital units. Therefore, through Kodak, Ltd., Harrow on the Hill, this consultant was able to procure sufficient photographic materials to activate a central laboratory in the Office of the Chief Surgeon and to equip photographic laboratories in six general hospitals. To train personnel, Kodak, Ltd., established a medical photographic school in London. Medical Department personnel were trained at this school and then assigned to the central photographic laboratory or to the general hospitals.
No equipment was available in the United Kingdom suitable for photographing records. Conferences were held with Kodak, Ltd., and, through its research department, the company developed a photographic apparatus which would photograph transparencies (such as X-ray film), hospital records, and charts as large as 14 by 17 inches. Records were photographed on 35-mm. film and could be viewed on a Recordak film reader and be reproduced to any size by photographic enlargement. This machine, after perfection, was turned over to the Medical Records Division in the Office of the Chief Surgeon.
The author presented orthopedic lectures and demonstrations in the major hospitals and to medical personnel in the smaller units and the combat divisions.
In November 1942, approval was received to train personnel in rehabilitation. Negotiations were started to establish a rehabilitation depot. This rehabilitation program as planned was to (1) provide care for the convalescent,
FIGURE 159.-Left to right, Brigadier L. E. J. Whitby, RAMC, Brigadier Rowley W. Bristow, and Maj. Gen. D. C. Monro, Consulting Surgeon, RAMC, at a reception given by Maj. Gen. Paul R. Hawley and consultants, Cheltenham, England, 30 April 1943.
sick, or wounded personnel to reduce their period of hospitalization and return them to their units in a fit condition for regular duty and (2) redevelop personnel who had broken down in training, in order that they might be salvaged for full duty. (Further details concerning the rehabilitation program are presented later in this chapter.)
A study of march injuries and foot conditions was made in the 29th Infantry Division. It was found that 5 percent of a company would fall out when a forced march exceeded 15 miles. It was noted also that about 1 percent of the foot troops sent overseas would need reclassification, that 2 percent of the troops in the 29th Division needed special training to overcome abnormalities of the feet and legs, and that an additional 10 percent would definitely benefit by such treatment. After this study, certain troop-training regulations were altered which very materially cut down on the number of troops lost to the Division by training injuries. Also, several bulletins of instruction on the care of the feet were issued and distributed to line officers and troops.
Activities in 1943
In the early part of 1943, this consultant worked very closely with Brigadier Bristow (fig. 159), orthopedic consultant to the British Forces, and correlated U.S. and British teaching programs and the handling of the sick and
wounded in the two armies. This was accomplished both by conferences and by touring and inspecting line and hospital units in both the U.S. and the British Forces. In the latter part of January, Brigadier Bristow toured the United States, giving lectures on the operations of the Allied armies overseas with special reference to their orthopedic services.
Maj. (later Lt. Col.) William J. Stewart, MC (fig. 160), joined the Senior Consultant in Orthopedic Surgery as Associate Consultant in Orthopedic Surgery. Major Stewart spent most of his time giving lectures and demonstrations on orthopedic surgery to various active and staging hospitals. Four regional consultants in orthopedic surgery had also been appointed. These consultants handled orthopedic problems in their particular locality.
In order to demonstrate and teach plaster of paris technique to the medical officers of the command and especially to those in combat units, schools were established in key positions throughout the theater. Medical officers and their corpsmen were ordered to these schools for a 3-day course in the handling and application of plaster of paris, splints, and casts for the immobilization of fractures and extensive wounds prior to transportation.
In the latter part of February 1943, the author was ordered on temporary duty to the North African theater to inspect hospitals and line units there and to study methods being used in the transportation and treatment of orthopedic casualties (fig. 161). This consultant returned to the European theater in the latter part of March 1943. During this trip, he obtained much information for the Chief Surgeon, ETOUSA, relative to medical supplies, field medical service, casualties, and various aspects of professional services. For orthopedic surgery, the author obtained considerable information of value relative to the training and instruction of European theater medical personnel in the transportation of fractures, plaster of paris technique in forward units, first aid treatment in the forward areas-especially in the handling of fractures, and initial orthopedic surgery in the forward areas.
FIGURE 161.-Surgery in the North African theater approximately at the time of Colonel Diveley's visit. A. An orthopedic ward in the 38th General Hospital, Heliopolis, Egypt. B. A mobile surgical truck and tentage permitting the simultaneous operation of three surgical teams.
As this consultant toured the entire North African theater, a photographic unit from the Signal Corps traveled with him and was most helpful in obtaining thousands of feet of motion picture films. The footage was assembled into a tour report which was shown to the Chief Surgeon's staff and to various units in the European theater upon the author's return.
Much time was spent at the Queen Elizabeth Hospital and the British Amputation Center at Roehampton, England, in correlating the fitting of artificial prostheses to U.S. personnel and in making motion pictures for training films on amputation technique. Eventually, the following training films were produced in color and with sound track:
"Rehabilitation," which provided a complete description of the program of rehabilitation and reconditioning in the theater;
"Forward Plaster Technique," which was made and used in collaboration with the British and Canadian orthopedic services and demonstrated the transportation plaster of paris technique then in use in the forward areas;
"Medical Service in the Air Force," which showed medical activities in the Eighth Air Force;
"Amputation Technique," which demonstrated the technique of the emergency amputation and the manufacture and fitting of a prosthesis for a below-knee amputation; and
"Medical Service in the North African Theater," which depicted the medical services in the various echelons of the Medical Department in the North African theater.
The Eighth Air Force was especially active with its daily bombing runs, and most of the American casualties in the European theater during 1943 originated as a result of air combat. Therefore, this author spent increased amounts of time with the Eighth Air Force units. Practical demonstrations and lectures were given in the handling of fractures, gunshot, and fragment wounds, and especially in the transportation of casualties from aircraft to the airfield first aid station and thence to the hospital for definitive treatment.
The Senior Consultant in Orthopedic Surgery and his associates spent considerable time in the investigation of the possible use of resins and plastics in the treatment of fractures. After considerable research, it was believed that there were neither time nor facilities in the European theater even for carrying out a preliminary investigation. It was considered, however, that the use of plastic splints for external as well as internal fixation was a most important subject and should be studied at some future time.
The European theater Medical Field Service School at Shrivenham was activated and the Senior Consultant in Orthopedic Surgery was responsible for several lectures and demonstrations each week, especially in the use of splints and dressings in the field.
This consultant was appointed a member of the EMS consultant group on orthopedic surgery of the British Ministry of Health. Since the EMS hospitals cared for service personnel locally, this gave the author an excellent opportunity to work out a close liaison for the handling and exchange of U.S. sick-and-wounded personnel. Monthly meetings of the consultant group were held in London.
There was some difference of opinion between general and orthopedic surgeons as to who should handle certain bone and joint conditions and fractures. General Hawley issued orders that these bone and joint conditions and all fractures would be handled by the orthopedic surgeon when available.
The orthopedic surgeons in U.S. Army hospitals had been organized, and plans were made for monthly meetings. The first meeting of the command's orthopedic surgeons was held at the 2d General Hospital near Oxford on 27 April 1943. Brigadier Bristow and Mr. Girdlestone were the guest lecturers on orthopedic subjects. The Inter-Allied Conferences on War Medicine, held monthly under the auspices of the Royal Society of Medicine, gave an opportunity for the interchange of ideas among the medical members of the Allied forces in the United Kingdom.
The author worked closely with Col. Lloyd J. Thompson, MC, Senior Consultant in Neuropsychiatry, to correlate the rehabilitation program which had been activated for convalescent neuropsychiatric patients.
General Hawley appointed a committee of three theater consultants to inspect each new hospital unit as it arrived in the theater. After a thorough study, this committee was to report to the Chief Surgeon any deficiencies in supplies or personnel and to outline a course of indoctrination for the unit in the theater.
On 23 and 24 July 1943, a combined conference of orthopedic specialists of the British Military Forces, the British Ministry of Health, and the U.S. Forces was held in London. Two of the previously mentioned motion picture training films, "Medical Service in the North African Theater" and "Forward Plaster Technique," were shown. These films were then made available to the British Forces for showing and instruction.
The American Medical Society, ETOUSA, held its first meeting on 23 June. The majority of papers and addresses were given by the orthopedic personnel of the theater.
The author returned to the Zone of Interior for a period of temporary duty extending from 20 September 1943 to 1 January 1944. Major Stewart assumed the duties of Senior Consultant in Orthopedic Surgery during the author's absence. During this temporary duty, this consultant presented many lectures and the European theater motion picture training films throughout most of the United States. He visited a majority of the rehabilitation centers in the Zone of Interior. At the request of The Surgeon General, the author helped to activate and equip a model rehabilitation center at England General Hospital, Atlantic City, N.J.
In October, during this consultant's sojourn in the United States, an orthopedic shoe repair program was instituted at the Disciplinary Training Center No. 2912, Shepton Mallet, Somersetshire. At this institution, corrective shoe repairing services could be provided. This program not only gave service to the Medical Department but was very valuable in the rehabilitation of the inmates of the disciplinary training center.
Activities Early in 1944
In 1944, after he returned to the European theater, the author placed great stress on the rehabilitation program and devoted much time to future planning for expansion of the program.
In February, this consultant was appointed Director of Rehabilitation in addition to his other duties. Therefore, a request was made for Lt. Col. (later Col.) Mather Cleveland, MC, to come to the European theater and assume the duties of Senior Consultant in Orthopedic Surgery.
Much pressure was being exerted on General Hawley by Lt. Gen. John C. H. Lee, Commanding General, SOS in The British Isles, to use osteopaths in the Medical Department. General Lee asked that they be commissioned in the Sanitary or Medical Administrative Corps and be used in the Medical Department, especially in rehabilitation activities. General Lee held the opinion that the osteopath could treat the back case better and more efficiently than could the orthopedic surgeons. General Hawley suggested a plan of assigning a group of osteopaths to the rehabilitation center at Stoneleigh where an osteopathic manipulative department was activated. As the cases were admitted to this unit complaining of low-back pain and disability, they were assigned for treatment alternately, one to the manipulative department and one to the orthopedic section. General Lee also required the assignment
of orthopedic surgeons who were staying in the theater and were not busy to observe this test of talent in the treatment of low-back pain and disability. After several months of competitive treatment, the osteopathic department was discontinued in complete vindication of the Medical Department's treatment.
During the spring months of 1944, the author continued with his routine duties as Senior Consultant in Orthopedic Surgery (fig. 162). Finally, in May 1944, Colonel Cleveland arrived to relieve Colonel Diveley as orthopedic consultant. Thence, Colonel Diveley's entire time could be devoted to rehabilitation activities (pp. 477-501).
REX L. DIVELEY, M.D.
ORTHOPEDIC SURGERY, MAY 1944-JULY 1945Chronology
As Senior Consultant in Orthopedic Surgery for the European theater, Col. Mather Cleveland, MC (fig. 163), arrived 20 days before D-day and was completely unfamiliar with the hospitals and orthopedic personnel of the theater. During a period of initiation from 20 May to 6 June 1944, he visited 42 of the hospitals in the United Kingdom in the company of Lt. Col. William J. Stewart, MC. Colonel Stewart was thoroughly familiar with all hospitals and orthopedic surgeons assigned to the theater, having served under Col. Rex L. Diveley, MC, for considerably over a year. His evaluation of the orthopedic officers and orthopedic sections of hospitals was accurate and stood up well. During this pre-D-day period, everybody was tensely awaiting the invasion of the Continent. Most of the orthopedic sections of the hospitals visited had a very low patient census in anticipation of battle casualties due to arrive.
With the invasion on 6 June, the author was assigned to consult at the 38th and 110th Station Hospitals and the 48th and 95th General Hospitals in the Southampton area. These hospitals were serving on a so-called transit basis-really as near-shore evacuation hospitals whose function was to perform essential emergency surgery and then evacuate the casualties by hospital train to the general hospitals to the north. For the most part, these hospitals received their first casualties on 8 or 9 June, gradually and in small numbers. The 110th Station Hospital, however, did an excellent job in receiving and sorting 1,000 battle casualties in 20 hours. By 12 June, the transit hospitals were busy and the chain of evacuation was filled with casualties. There were many blast injuries due to explosion of mines at sea. These casualties had profound vascular damage, with fractures or dislocations of the knee, and the like, and amputation was usually necessary.
The author's duties next led him to the Normandy beachhead in July at the time of the Saint-Lô breakout. At the time of this visit, the necessity for
increased supplies of whole blood was obvious. Plasma was not an effective substitute. Soon thereafter, at the urgent request of the Chief Surgeon, whole blood began to arrive from the Zone of Interior.
This consultant then devoted much of his time to a continuous round of visits to the various medical activities of the theater, 232 altogether in the 6 months following D-day. General, station, evacuation, and field hospitals and three army headquarters were visited, consultations were held, and reports on the visits were rendered to the Chief Surgeon. In the following 5 months, the author made 107 hospital visits and visited three army headquarters as well. During the 11 months that active hostilities lasted on the Continent, approximately 340 visits were made to various medical activities by the Senior Consultant in Orthopedic Surgery.
Professional Care of Wounded
During the 6-month period after the invasion, the chief preoccupation was on setting and maintaining an optimum standard of professional care for the constant and heavy stream of battle casualties that flowed from the main line
of resistance back through the field and evacuation hospitals to the general hospitals (fig. 164). While the Manual of Therapy for the European theater, published on 5 May 1944, dealt with the treatment of bone and joint casualties in general terms along fundamental lines, it soon became apparent that more specific instructions were necessary. These instructions, based on experience gained by consultants and surgeons who were caring for the wounded, were formulated in Circular Letters No. 101 (dated 30 July 1944) and No. 131 (dated 8 November 1944) issued by the Chief Surgeon, ETOUSA. These instructions dealt with circular amputation, debridement of the wound, immobilization of fractures for transportation, treatment of wounds over bones and joints in general hospitals, delayed primary closure of wounds over compound fractures (then called secondary closure), and injuries of the hands. The instructions in the circular letters were very specific and, in general, were strictly adhered to. By this means, the function of each hospital in the chain of evacuation was defined and thereby each medical echelon knew what treatment it was expected to perform, what had been done forward, and what would be done in the rear.2
The hand wounds were under the care of orthopedic and plastic surgeons. Hand centers were established both on the Continent and in the United Kingdom Base. Outstanding salvage work was performed in many of these centers.
Problems arising from combined neurosurgical and bone and joint injuries were resolved by the Senior Consultant in Neurosurgery and the Senior Consultant in Orthopedic Surgery. Such casualties were treated at neurosurgical centers. These two activities have been described elsewhere in this history.3
Delayed closure of wounds over compound fractures - Delayed closure of wounds over compound fractures was the most important single accomplishment in the care of bone and joint casualties. Some of the older surgeons were at first reluctant to try delayed closure, but younger surgeons readily acquiesced in the attempt. Successful delayed primary closure ingeneral hospitals depended on complete or adequate debridement performed in evacuation hospitals. The failures, with breakdown of the wounds and resulting bone infection, could be traced to early technical failure or delay, sometimes unavoidable, in the debridement. This delayed primary or immediate primary closure of wounds over fractures was not new. It had been done in World War I, in small numbers to be sure, but it had been forgotten or ignored. The effort to reestablish the idea of closure of wounds over compound fractures reemphasized the saying: "They who forget the past are condemned to repeat it."
Orthopedic Surgeons in the European Theater
The European theater, at the close of hostilities, had a total of 281 hospitals of which 146 were general hospitals. Among these general hospitals, only slightly over 10 percent were affiliated units. These affiliated hospitals arrived very adequately staffed with actually an overabundance of trained personnel. The orthopedic sections of these affiliated hospitals which arrived in 1942 and 1943 were plundered to obtain chiefs of orthopedic sections for other hospitals arriving later with no trained orthopedic personnel.
By the end of 1944 and early 1945, general hospitals were reaching the theater "staffed with bodies," as the saying was, but with little or no trained personnel. The problem of finding chiefs for orthopedic sections (and other chiefs also) became almost impossible to solve (fig. 165).
Of the 16,000 civilian doctors of medicine who served in uniform in the European theater, there were only 63 diplomates of the American Board of Orthopaedic Surgery. In addition to these, there were 95 partially trained orthopedic surgeons and 85 young general surgeons with training in the handling of fractures. This hard core of about 240 medical officers was responsible for the professional care of approximately 250,000 bone-and-joint casualties and injuries among U.S. Army troops and, in addition, of many thousands of prisoners of war.
The tables of organization of the various hospitals in the theater called for a total of almost 450 trained orthopedic specialists, Military Occupational Specialty 3153, B or C rating or better. There were only 217 medical officers who could possibly be considered as possessing these skills. The proper utilization of available orthopedic surgeons was, and in the future will be, a matter of great moment, since at least 40 or 45 percent of battle casualties and injuries will invariably involve bones and joints.
It was the author's considered opinion that each field army should have had as consultant a highly trained orthopedic surgeon with the rank of colonel. Such a consultant could have supervised and trained younger surgeons in evacuation or other army hospitals where the bone and joint casualties were received for debridement and applications of proper splints for evacuation to hospitals in the communications zone. The general hospitals needed one or, if available, two orthopedic surgeons to treat compound or simple fractures and amputations and to handle other bone and joint problems that were received. Large station hospitals, if serving large bodies of troops in training or if acting as general hospitals, also needed a trained orthopedic surgeon.
There will never be an oversupply of these officers in the event of another great national emergency, and therefore careful planning will be required to see that all are effectively used.
Proper Utilization of Experienced General Hospitals
The utilization and proper location of experienced, affiliated hospitals was of the utmost importance. At the time of the invasion, most of the affiliated general hospitals in the European theater during World War II (12 to 14 in number) had been in the theater for from a year to 18 months. They were given priority for movement to the Continent. This was a reward for service, but unfortunately it meant that during the first 6 or 8 weeks after D-day, the "first team" was sitting on the bench. That is, they were staging, crossing the Channel, and in the process of being set up. A good many of the personnel of these hospitals were used on temporary duty to augment other hospitals, to be sure, but the smooth operation of well-established hospitals was missing. At the beginning, most of these hospitals were first set up on the beachland and later moved to other parts of France or Belgium (fig. 166). In planning their second moves, it would have been ideal if they could have been dispersed in such a way as to serve as parent hospitals for the hospital centers and base sections later established on the Continent. At times, two or more of these affiliated general hospitals were assigned to a single center and, at the close of hostilities, there were two hospital centers at Reims with some 17 new and inexperienced general hospitals and with no older experienced hospital within call. These older affiliated general hospitals furnished the junior consultants in all branches of medicine and surgery.
It was impossible for a single senior orthopedic consultant, in spite of his making more than 30 visits a month to various medical installations and traveling thousands of miles, to cover the theater adequately. The young surgeons needed professional advice and supervision, in many instances, at frequent intervals.
In late November or December 1944, seven junior (regional) consultants in orthopedic surgery were appointed in the United Kingdom Base-each to cover one of the seven hospital centers in addition to their duties as chiefs of orthopedic sections at their own general hospitals. Most of these junior consultants performed very valuable service in helping their colleagues to maintain a high standard of professional care for the wounded and injured soldiers. At that time, and in fact during most of the campaign on the Continent, those with fractures of the long bones were all evacuated to the United Kingdom, where the holding period before evacuation to the Zone of Interior was 120 days.
Most general hospitals on the Continent were serving on a transit basis, with a holding period of only 30 days. During a good part of the winter of
1944-45, many of the continental general hospitals were moving from a first to a second location (fig. 167); consequently, junior consultants in orthopedic surgery on the Continent were not appointed until the spring of 1945, when nine such appointments were made. The cessation of hostilities supervened so shortly thereafter that only a little over half of these appointees actually served effectively. If these continental junior consultants could have been appointed earlier, they would have helped materially in enhancing and standardizing the care of the wounded with bone and joint problems.
The reports of the junior consultants had to travel a long road through channels before a few of them eventually reached Colonel Cleveland. Some of these reports never arrived. The junior and senior consultants should have ready access to each other.
The Senior Consultant in Orthopedic Surgery held two meetings in London with the United Kingdom junior consultants in December of 1944 and June of 1945. The continental junior consultants met with him in Paris in June 1945. Out of these conferences came the revision of the orthopedic portion of the Manual of Therapy.4
Rank for Orthopedic Surgeons
For the responsibility which the orthopedic surgeon carried, there was no provision made for commensurate rank. There was actually no provision in the tables of organization for theater consultants, and any promotion to the grade of colonel had to be borrowed from some new hospital or hospital center that entered the theater with vacancies in these higher grades.
There were approximately 12 outstanding orthopedic surgeons who had served as many as 3 years in the grade of major in various general hospitals of the theater. It was the firm conviction of the Senior Consultant in Orthopedic Surgery that each of these officers should have been promoted to the grade of lieutenant colonel, and such recommendations were made. Of the 12 orthopedic surgeons recommended for such promotion, only one reached that grade while in the European theater.
It was difficult to explain to an orthopedic surgeon why the dental officer, the roentgenologist, the psychiatrist, the chief of laboratory, the chief nurse, and so on, in a 1,000-bed general hospital should, by table of organization, be advanced to the grade of lieutenant colonel, while the orthopedic surgeon, who was responsible for the professional care of 40 or 45 percent of the wounded, could not advance beyond a majority. Such discrepancies should be remedied so that responsible and outstanding officers can be given rank commensurate with services rendered.
Meetings of Senior Consultants
The position of senior consultant in the European theater carried great responsibility and afforded endless possibilities for improving the professional care of the sick and wounded and maintaining a high level of such care.
When possible, the senior consultants met weekly at headquarters in Cheltenham, London, Valognes, and Paris as the Office of the Chief Surgeon moved forward, and once a month the Chief Surgeon met with his consultants. The most inspiring meetings to this consultant were the informal weekly gatherings presided over by Col. (later Brig. Gen.) Elliott C. Cutler, MC. These were high level discussions of all prevailing problems, in which suggestions were freely offered and were usually well received by all 12 or 13 surgical specialists present.
During active hostilities, two meetings were held with British and Canadian consultants and one with all the Allied consultants. With the exception of the polylingual meeting with translations into and out of French and Russian, which instantaneous translation would have helped, these meetings were extremely helpful.
The Chief Surgeon supported the consultants to the hilt if he thought they were correct and did not hesitate to correct or reprimand them if they were wrong. The writer will always consider it a great privilege to have served with the senior consultants in the European theater during World War II.
MATHER CLEVELAND, M.D.
Activities Centered in the United Kingdom, 1942-44
Soon after arriving in England in August 1942, Lt. Col. (later Col.) Rex. L. Diveley surveyed all U.S. Army Hospitals that were then functioning. During this survey, he observed that a significant percentage of military personnel was being readmitted to hospitals because the men were unable to carry on the physical rigors of their former duties. An examination of a sampling of these patients revealed that their prolonged stay in hospitals had definitely deteriorated them mentally as well as physically. No attempt was being made to bring these hospitalized personnel to their former physical capacity before discharge from the hospital. The result was a great loss of man-days to the Army.
Colonel Diveley immediately undertook to ascertain how the British services had solved this problem. It was found that the RAF, the British Army, and the Royal Navy had established special convalescent depots to which convalescent, sick-and-wounded personnel, after hospitalization, were being sent for rehabilitation or reconditioning. In these depots, a complete and comprehensive program of exercises was given to restore these men to their former physical capacity.
In the fall of 1942, Colonel Diveley outlined for the Chief Surgeon a plan for the establishment of a convalescent rehabilitation center in the European theater. He proposed the establishment of a center where sick or wounded military personnel could be sent as soon as they became convalescent and no longer needed active surgical and medical attention in a hospital. At these centers, he suggested a complete and supervised physical, educational, military, and recreational program which could be given to restore patients to their former physical and mental capacity.
This plan, in general, was approved by the Chief Surgeon. He issued orders to select a site, to prepare a provisional T/O&E (table of organization and equipment), and to train personnel who would be required to operate such a convalescent center.
Rehabilitation and reconditioning facilities
Rehabilitation Center No. l - After the author had inspected several available sites, the All-Saints Hospital, Bromsgrove, Worcestershire, was selected and procured. A provisional T/O&E was prepared by the Operations Division, Office of the Chief Surgeon, based upon the personnel and equipment of a 150-bed station hospital. Five officers and six enlisted men with proper qualifications were trained at the British 102d Convalescent Depot at Kingston and the British Army School of Physical Training at Aldershot. On 7 April 1943, the l6th Station Hospital, augmented by specially trained personnel, opened Rehabilitation Center No. 1 in the All-Saints Hospital. The essential staff consisted of Maj. (later Lt. Col.) Clayton H. Hixson, MC, Commanding
Officer; Captain Gullingrud, Executive Officer; Maj. (later Col.) Frank E. Stinchfield, MC (fig. 168), Chief of Professional Services; Capt. (later Lt. Col.) Marcus J. Stewart, MC (fig. 169), orthopedic service; 2d Lt. (later Capt.) Gerald F. Seeders, Inf., Director of Physical Training; and 2d Lt. Paul E. Hall, MAC, Director of Military Training. Under the efficient professional guidance of Major Stinchfield, a well-balanced physical and military program was developed (fig. 170). Patients were admitted from station and general hospitals as soon as they became convalescent, were able to be up and around, and could care for their own toilet. Although the hospital load of the theater was very light, the census of the center had rapidly increased to 431 by 1 September 1943.
It soon became evident that the facilities at Bromsgrove and the staff of the 150-bed station hospital were insufficient to handle the anticipated convalescent patient load of the theater. Consequently, a general hospital site at Stoneleigh Park, near Kenilworth, Warwickshire, was secured, and the 8th Convalescent Hospital replaced the 16th Station Hospital as the operating unit of Rehabilitation Center No. 1. Key personnel of the 16th Station Hospital were transferred to and retained in the 8th Convalescent Hospital, which opened the center at Stoneleigh on 5 October 1943. Major Stinchfield assumed command of the center at the new location.
By December 1943, the census of trainees at the rehabilitation center had reached 1,300 (fig. 171). At this time, it was necessary to release the 8th Convalescent Hospital for assignment to a field army. This unit was replaced by the 307th Station Hospital (750 beds). Key personnel of the 8th Convalescent Hospital were retained for assignment to the 307th Station Hospital, and Major Stinchfield continued in command. This exchange of units was con-
summated on 5 December 1943. In January 1944, the census at Rehabilitation Center No. 1 showed over 1,700 officers and enlisted trainees.
By the time D-day, 6 June 1944, arrived, the patient load at Rehabilitation Center No. 1 had increased tremendously and, with the assault on the Continent, further expansion of its facilities became extremely necessary. After many unsuccessful attempts to obtain the Irish Labor Camp (Ministry of Works), adjoining the center, the Camp was made available on 19 June 1944. This allowed for an expansion of 700 patients and increased the overall capacity at Rehabilitation Center No. 1 to approximately 3,700 (fig. 172).
Rehabilitation Center No. 2 (Officers) - Early during the operation of Rehabilitation Center No. 1, it became evident that officers and enlisted men should be segregated when undergoing a program of convalescent rehabilitation. Accordingly, a rehabilitation center for officers, Rehabilitation Center No. 2, was activated at All-Saints Hospital, the original site of Rehabilitation Center No. 1. A detachment of trained personnel from the 307th Station Hospital was assigned to operate this facility by working with members of the 1st Auxiliary Surgical Group, which was now temporarily quartered at Bromsgrove. Later, when the 77th Station Hospital had been made available for the rehabilitation program, Detachment B of this hospital relieved the detachment of personnel from the 307th Station Hospital in the operation of Rehabilitation Center No. 2. This change took place on 23 February 1944. Still later, the 123d Station Hospital was assigned the mission of operating the rehabilitation center for officers.
Reconditioning Center No. 1.-As the patient load of the theater continued to increase, and additional centers became necessary, experiences indicated that certain convalescent patients needed only general exercises or body hardening to bring them to their former physical capacity (reconditioning), as contrasted to others who required certain specific remedial exercises in addi-
tion to general body hardening (rehabilitation). Accordingly, an additional unit was requisitioned to establish a reconditioning center. A general hospital site was secured at Erlestoke Park, near Devizes, Wiltshire. This site had accommodations for about 1,500 convalescent patient-trainees. The 77th Station Hospital (750 beds) was designated the operating unit for this new center. The staff of the 77th Station Hospital was ordered to Rehabilitation Center No. 1 (307th Station Hospital) for indoctrination and orientation. Since the entire unit would not be required to operate Reconditioning Center No. 1, a detachment of the 77th Station Hospital, as mentioned earlier, was ordered to operate Rehabilitation Center No. 2 for officers. The remaining unit personnel of the 77th Station Hospital, having completed their training and indoctrination at Rehabilitation Center No. 1, moved to Erlestoke Park, and during March 1944 began to operate Reconditioning Center No. 1.
The facilities of Reconditioning Center No. 1 at Erlestoke Park, however, were limited, and this plant was needed for a general hospital. It was necessary to procure an additional site. A military campsite was secured at Packington Park, near Coventry. The advance party of the 77th Station Hospital moved into this site on 5 July.
At the request of the British War Office, arrangements were made for an interchange of convalescent soldiers undergoing rehabilitation. The purpose of this exchange was to further Anglo-American relationships. The interchange was started during the first week in June 1944, and a party of British convalescent patients was continually maintained at Reconditioning Center No. 1 throughout the year, except during the change in location of the center.
Rehabilitation Center No. 3 - With the increase of the patient census following D-day, it became apparent that an additional number of rehabilitation beds would be needed. The 313th Station Hospital was selected for conversion into a 3,000-bed rehabilitation center. This unit was operating a station hospital at Fremington, Devonshire. The site was not suitable for a 3,000-bed center as its capacity was limited to about 2,000 patients. It was decided, however, to use this plant temporarily. The staff was indoctrinated at Rehabilitation Center No. 1, and, on 20 July 1944, this unit started to receive patients for rehabilitation. Physical training instructors, as well as military and physical training officers, were assigned to augment the regular staff.
Not long after activation of Rehabilitation Center No. 3, a suitable site was obtained at Warminster Barracks, Warminster, Wiltshire. After appropriate adaptation of the site, Rehabilitation Center No. 3 was moved to Warminster and began operations there on 21 December 1944.
Rehabilitation Center No. 4 - By the latter part of August 1944, the facilities of the three rehabilitation centers and the Reconditioning Center were about filled, and a unit and a site for an additional center were requested. The 314th Station Hospital was committed to the mission. The staff, then operating a tented hospital at Truro, Devonshire, was ordered to Rehabilitation Center No. 1 for indoctrination. A site was selected at Honiton-Heathfield which would accommodate some 2,300 trainees and which, with tented expansion, could handle a total of 3,000 patients. On 13 September 1944, the unit was activated as Rehabilitation Center No. 4 and began to receive convalescent patients.
Conversion to convalescent centers - As the first rehabilitation and reconditioning centers began operations, it was very apparent that the standard T/O&E for a 750-bed station hospital did not provide for sufficient personnel with appropriate qualifications to operate a large rehabilitation center. General Hawley, when the difficulty was brought to his attention, directed that the Operations Division of his office make a study of the conversion of the T/O&E of a 750-bed station hospital to that appropriate for a 3,000-bed rehabilitation center and the conversion of a 250-bed station hospital to a 1,000-bed reconditioning center. Colonel Diveley and Colonel Stinchfield collaborated in this study. With concurrences from the ETOUSA G-1 (personnel and administration) and G-3 (operations and training), special tables of distribution and allowances were created for 1,000-bed reconditioning centers and 3,000-bed rehabilitation centers. These tables were sent to the War Department, which, the author learned on 23 June 1944, had approved them for publication as T/O&E's for 1,000-bed and 3,000-bed convalescent centers. Early in December 1944, the War Department ordered conversion of five hospitals on the theater troop list to convalescent centers in accordance with the new T/O&E's. This was accomplished by converting four station hospitals (750 beds) to 3,000-bed convalescent centers and one station hospital to a convalescent center of 1,000 beds. The convalescent centers thus activated were designated as follows:
Convalescent hospitals on the Continent - Upon the request of the Chief Surgeon, the author proceeded to the Continent in August 1944 to survey the requirements for reconditioning and rehabilitation and to examine the conduct of the convalescent training program within such station and general hospitals as were operating. This consultant recommended that, because of the short evacuation policy in effect on the Continent, it would be impracticable to conduct a full rehabilitation program there at this time.
On 12 September 1944, upon request of the Chief Surgeon, the writer made a second trip to the Continent. He inspected the 7th and 8th Convalescent Hospitals, which were operating under the communications zone. After this visit, he recommended that additional physical- and military-training personnel be assigned for the more efficient operation of these units, if they were to continue functioning as communications zone units. This recommendation was concurred in by the Chief Surgeon. Cadres were selected from among trainees at the training school at Rehabilitation Center No. 1 and were sent to these units. This consultant followed up these actions with frequent visits to the Continent to survey and maintain contact with the 7th and 8th Convalescent Hospitals.
The 7th Convalescent Hospital was established at Étampes and had facilities for handling approximately 1,700 convalescent patients. With the addition of military- and physical-training personnel, it established a commendable convalescent training program. The unit was handicapped by the added function of operating as a station hospital to care for personnel of the 19th Reinforcement Depot, which was adjacent.
The 8th Convalescent Hospital had its initial location at Barneville, on the Channel, later moving to Valognes, near Cherbourg. The Valognes site was not ideal and was capable of housing only some 2,000 convalescent patients. But, with the addition of a cadre of military- and physical-training personnel, this unit operated a fair convalescent training program.
Organization for supervision
Rehabilitation activities in the Office of the Chief Surgeon were begun on the initiative of Colonel Diveley and incidental to his primary duties as Senior Consultant in Orthopedic Surgery. On 25 February 1944, Colonel Diveley was appointed Director of Rehabilitation in addition to his other duties as Senior Consultant in Orthopedic Surgery, and Major Stewart, who had just reported to the Office of the Chief Surgeon, was named as his assistant. As a result of a special conference attended by General Hawley, Colonel Eyster of the G-3 Section, ETOUSA, and Colonel Diveley, it was deemed advisable to have a representative of the Chief Surgeon on the G-3 staff section in order to correlate the rehabilitation program. This was accomplished by the appointment of Maj. (later Lt. Col.) Milton S. Thompson, MC, to this duty on 15 February 1944.
As the rehabilitation work in the office increased, Capt. (later Maj.) Julian A. Sterling, MC, from Rehabilitation Center No. 1, was assigned to duty as an assistant. Several clerks, artists, secretaries, and a physical training instructor were also added to the staff. Capt. (later Maj.) Blaise P. Salatich, MC, Medical Liaison Officer from Headquarters, U.S. Strategic Air Forces, ETOUSA, to the Rehabilitation Division, Office of the Chief Surgeon, reported for duty on 18 April 1944.
On 3 June 1944, by Office Order No. 32, Office of the Chief Surgeon, the Rehabilitation Division was formally established as an independent division
within the Office of the Chief Surgeon. Colonel Diveley was appointed chief of the division. The functions of the division were listed as follows:
1. To direct and conduct research in rehabilitation procedures.
On 16 June 1944, a conference was held with members of the ETOUSA G-1 and G-3 staffs and the Field Force Replacement System at which Col. David E. Liston, MC, Deputy Chief Surgeon, ETOUSA, clarified the obligations of the Chief Surgeon in carrying out the program of rehabilitation in the theater, as follows:
1. The Chief Surgeon would expand the convalescent training program as the need arose and insofar as such expansion would not jeopardize availability of beds for hospitalization. Hospital personnel would in each instance be supplemented by branch immaterial personnel to supervise military training coincident with physical reconditioning. Such personnel would not be charged to the Medical Department.
2. The Chief Surgeon would discharge patients to the Field Force Replacement System when conditioning had proceeded to that point where the individual would not be physically harmed by normal physical exertion and would be capable of returning to his former or new occupation after 2 or 3 weeks further hardening in the Field Force Replacement System.
By the latter part of June, base section surgeons had appointed rehabilitation officers to their staffs. Maj. William N. Brewer, MC, was appointed in the Western Base Section, and 2d Lt. (later 1st Lt.) Robert S. Rice, MAC, was appointed in the Southern Base Section.
On 12 July 1944, the forward echelon of the Office of the Chief Surgeon moved from the United Kingdom to the far shore. By decision of the Chief Surgeon, the Rehabilitation Division remained in the United Kingdom and was attached to the Office of the Surgeon, United Kingdom Base.
In August 1944, a request was made that a rehabilitation division be established in the Office of the Surgeon, United Kingdom Base. Major Brewer, who had previously been the rehabilitation officer for Western Base Section, was appointed chief of this subdivision of rehabilitation in the Office of the Surgeon, United Kingdom Base. He selected a staff of officers and enlisted assistants.
Later in 1944, Maj. (later Lt. Col.) Richard F. Kelsey, MC, a staff member of Rehabilitation Center No. 2, was added to the staff of the Rehabilitation Division, Office of the Chief Surgeon. Maj. H. Heim, Ord, was assigned to duty with the Rehabilitation Division, Office of the Chief Surgeon, to coordi-
nate the information and education work within the convalescent training program.
In the latter part of December, word was received from the Office of the Chief Surgeon, then at Paris, that the Rehabilitation Division would move from its location with the Office of the Surgeon, United Kingdom Base, to Paris. At that time, the Rehabilitation Division, Office of the Chief Surgeon, in addition to an artist-statistician and clerks, consisted of the following officers: Colonel Diveley, chief of the Division; Colonel Thompson, Rehabilitation Liaison Officer from the Office of the Chief Surgeon to the G-3 Section, Headquarters, ETOUSA; Major Sterling, assistant chief of the Division; Major Kelsey, Consultant in Rehabilitation and Hospital and Convalescent Center Inspector; Major Salatich, Rehabilitation Liaison Officer from Headquarters, U.S. Strategic Air Forces, ETOUSA; and Major Heim, Coordinator for Information and Education Activities.
Similarly, in the Office of the Surgeon, United Kingdom Base, Major Brewer, was Chief, Division of Rehabilitation; Capt. Herzl M. Daskal, MC, was Hospital Inspector and Consultant in Rehabilitation; and 1st Lt. Andrew M. Gould, MAC, was Administrative Assistant.
Convalescent training program in hospitals.-With the guidance of experience in the European theater and instructions from the Office of The Surgeon General in Washington, a general program of convalescent training and education was initiated for each station and general hospital in the theater (fig. 173). Much opposition was evidenced by hospital staffs to the introduction of such a program. This was due for the most part to a lack of understanding on the part of professional men in the concepts of convalescent rehabilitation. The program at the rehabilitation centers progressed most satisfactorily, but the program within the station and general hospitals was very sluggish, and little interest was evidenced. It became necessary to undertake special indoctrination and training activities to encourage more active convalescent training programs in hospitals (pp. 492-494).
A constant check was maintained on the convalescent program in hospital units. Two or three representatives of the Rehabilitation Division continuously inspected the programs and gave indoctrination lectures. Ward surgeons were made aware of their responsibilities in the conservation of manpower through an adequate convalescent program and through the proper reclassification of sick-and-wounded military personnel to duty.
Reclassification.-Considerable difficulty was evidenced in both rehabilitation centers and hospitals in the proper reclassification of personnel being returned to duty. Through the efforts of the Rehabilitation Division and the Ground Force Replacement System (formerly the Field Force Replacement System), classification teams were selected and trained. These teams were placed in special hospitals, hospital centers, and rehabilitation centers to orient personnel in the proper reclassification of sick-and-wounded personnel.
Rehabilitation in station hospitals acting as general hospitals - By 1 August 1944, the general hospitals were filled to capacity. Many convalescent patients in the general hospitals still needed surgical dressings or followup medical care. These patients could not be sent to rehabilitation centers but should have been evacuated from general hospitals to make bed space for casualties who required definitive medical or surgical care and treatment. The situation was alleviated by the designation of certain station hospitals to act as general hospitals in the care of the slightly wounded and those convalescent patients still requiring some active medical or surgical care. The Rehabilitation Division, appreciating the fact that over half of the patients in these station hospitals would be in the convalescent training program, took steps to upgrade their rehabilitation programs. Special supplies and training aids were furnished, and special training personnel were attached to each hospital.
Army Air Forces participation - Initially, about 10 or 15 percent of the trainees in the rehabilitation centers were patients from the Army Air Forces. It was believed that more specialized training should be given to these trainees. Brig. Gen. (later Maj. Gen.) Malcolm C. Grow, Surgeon, Eighth Air Force, was contacted through Col. Herbert B. Wright, MC, in regard to obtaining specialized personnel to carry on this mission. However, cooperation of the Air Forces at this time was very meager.
FIGURE 174.-Maj. Gen. Norman T. Kirk inspecting the 307th Station Hospital. Others pictured are, left to right, Colonel Stinchfield, Brig. Gen. Malcolm C. Grow (partially obstructed by Colonel Stinchfield), and Colonel Diveley.
In February 1944, following a special visit and inspection of hospitals and rehabilitation centers by Maj. Gen. Norman T. Kirk, The Surgeon General, Maj. Gen. David N. W. Grant, the Air Surgeon, General Hawley, and General Grow (fig. 174), a coordinated program of rehabilitation training for Air Force personnel was outlined, and the Office of the Chief Surgeon, ETOUSA, was assured the cooperation of the Army Air Forces in the theater. An Air Force liaison officer to the Rehabilitation Division, Office of the Chief Surgeon, was requested and obtained. Special surveys were made to determine needs of the program, and training aids and equipment were supplied as required, not only to all convalescent centers but also to the program in each station and general hospital.
General Grow, now Surgeon, U.S. Strategic Air Forces, assigned flight surgeons to duty with the six general hospitals that were caring for most of the Air Forces personnel. These flight surgeons supervised the convalescent care and rehabilitation of Air Forces personnel in accordance with directives of the Chief Surgeon. The Air Forces provided excellent cooperation in supplying personnel and training equipment for the rehabilitation program. Rehabilita-
tion Center No. 1 was designated as the center for Air Force enlisted men, while officers were sent to Rehabilitation Center No. 2 (fig. 175).
Amputee morale team - At the request of the Chief Surgeon, an "amputee morale team" was organized in the early part of November 1944 to visit all hospitals. The team demonstrated the use of prostheses and showed a motion picture film on what could be accomplished by a man who had lost his arms. This aided greatly in lifting the morale of those personnel who had lost a limb.
Personnel and training
Special rehabilitation and reconditioning personnel - With the steady growth of the rehabilitation and reconditioning programs, it was found neccessary to train a large number of officers and enlisted men to be used in the activation of other centers and to be assigned to hospitals for the convalescent training program (fig. 176). An initial allotment of 50 officers and 100 enlisted men was made available for this training and subsequent assignment to specialized positions. With the continued growth of the rehabilitation program and as requirements for trained personnel became greater, the Ground Force Replacement System, ETOUSA, G-1, was asked to provide additional officers and enlisted men of either general- or limited-assignment status for training as physical education instructors and directors of other
duties pertinent to the rehabilitation (convalescent training) program. On 6 July 1944, an additional 100 officers and 300 enlisted men were allotted to the rehabilitation program for training purposes. This made a total of 150 officers and 400 men available for use in the rehabilitation program.
Training and indoctrination of personnel engaged in the hospital convalescent training program - To overcome initial resistance to the hospital convalescent training program and to orient the staffs of the various hospital units involved, indoctrination lectures were given, and a motion picture film on rehabilitation was shown. There was also a lack of trained personnel to implement the convalescent training program in hospitals. To obviate this, a special school was established at the rehabilitation center where wardmasters from various station and general hospitals were sent for a course of training in the conduct of a convalescent training program (fig. 177). Upon returning to their units, these trained men were able to indoctrinate the hospital staff as well as other wardmasters and enlisted personnel in the proper principles of the convalescent training program.
Later, in order to encourage a more active hospital program several conferences were held with the hospital personnel. In May 1944, the commanding officer, rehabilitation officer, and orthopedic surgeon of each station and general hospital were ordered to Rehabilitation Center No. 1 for an orienta-
tion conference. This meeting was addressed by General Hawley. Following his address, indoctrination papers on representative activities and results of rehabilitation were given. A model program was inspected during the afternoon. In addition to this meeting, two regional conferences were held later in the month with rehabilitation officers from hospitals in the various base sections.
To assist in the conduct of the hospital convalescent program, several additional publications were issued by the Rehabilitation Division. One, titled "Bed Exercises for the Convalescent Patient," described and illustrated many essential and valuable exercises and was used as a guide by patients and wardmasters. A second publication, in the form of a mimeographed pamphlet, described and illustrated various types of remedial apparatus that could be improvised for use by the convalescent patients. A third publication, in mimeographed form, listed, by subjects, the training films and filmstrips available for use in the convalescent training program.
On 31 August 1944, a regional conference on the conduct of the convalescent training program was held at the 55th General Hospital and was attended by all rehabilitation officers of the 12th Hospital Center. On 1 September 1944, a similar meeting and demonstration was held at the l60th General Hospital for rehabilitation officers of the 15th Hospital Center. On 11 October 1944, a regional conference was held at the 160th Station Hospital for all rehabilitation officers from hospitals in the Southern Base Section. On
12 October 1944, a conference was held at the 160th General Hospital for all rehabilitation officers from hospitals in the Western and Eastern Base Sections. The meetings were attended also by representatives from staging hospitals. These conferences provided an excellent medium for interchange of ideas, indoctrination, and the demonstration of a model convalescent training program.
Training films - During the summer of 1943, a documentary motion picture film was produced in sound and color depicting the program and activities of a rehabilitation center. The author took this documentary film to the Zone of Interior, and, after a showing to The Surgeon General, and following his request, the film was screened for various hospital units throughout the country with accompanying indoctrination lectures. This tour covered a 3-month period, which gave ample time for all to study the reconditioning program that had been activated at Bromsgrove. A model convalescent rehabilitation unit, based on experiences in the European theater, was set up by this consultant at England General Hospital in Atlantic City, N.J.
By the end of August 1944, two additional motion picture films on activities of the program had been completed and distribution had been started. One, an orientation film, titled "The Convalescent Training Program," was shown to the staffs of all hospitals. The other, titled "Physical Training Instructors," was used in the Physical Training Instructors' School at Rehabilitation Center No. 1, for indoctrination and training.
On 24 August 1944, a group of visual aid coordinators arrived and were immediately oriented in the conduct of the rehabilitation program. Their mission was to establish film libraries, to screen films, to repair projection apparatus, and to give other assistance to the conduct of the convalescent training program throughout the theater.
Supplies and equipment
In anticipation of an expanded program in the theater, sufficient gymnastic supplies, remedial apparatus, training films, and other training aids were requisitioned and secured early in the program. Supplies, special equipment, and training aids for use in the convalescent training program in hospitals were secured for each hospital and distributed. Also, in May 1944, through arrangements with Special Services, additional stocks of athletic, recreational, and educational equipment were set aside for requisition and use within the convalescent training program. Through special arrangements with the Army Pictorial Service, 16 mm. motion picture and 35 mm. filmstrip projectors were obtained for the rehabilitation program. The Rehabilitation Division placed and distributed the projectors. The limited supply of remedial apparatus and gymnastic equipment that had been obtained was exhausted. Requirements were computed for the ensuing 12 months, and sufficient apparatus was secured through the General Procurement Authority
from Spencer, Heath and George, Ltd., Enfield, England, to meet immediate needs. Close liaison was maintained with the American Red Cross, which was responsible for many of the recreational and diversional activities. The latter organization was most cooperative at all times and provided personnel and supplies to the centers and hospitals unstintingly.
Maximum use was made of improvised aids to physical rehabilitation in which both construction (or fabrication) and use provided a means for augmented physical reconditioning. Such apparatus included shoulder wheels, knee pulleys, finger grips, and steps.
December 1943 - At the end of the year 1943, Rehabilitation Center No. 1 had been in operation for 9 months, since April, at its two locations, Bromsgrove and Stoneleigh. During this period, there were 3,089 admissions and 1,808 dispositions. Of the dispositions, 83 percent were discharged back to duty and 17 percent were sent back to hospitals for further treatment. The caseload was divided approximately into: Orthopedic, 80 percent; general surgery, 10 percent; and medicine, 10 percent.
On 31 December 1944, approximately 31,500 beds were available for convalescent patients in the European theater. In addition to the 12,400 beds in the convalescent facilities in the United Kingdom, general and station hospitals had set aside areas for the use of 11,500 convalescent patients. Nine station hospitals had been completely set aside to handle approximately 3,600 convalescent patients. The 7th Convalescent Hospital at Étampes, Seine Base Section, France, and the 8th Convalescent Hospital at Valognes, Normandy Base Section, France, were each rated at 2,000 beds for a combined total of 4,000 beds on the Continent.
Convalescent trainees actually in the five centers in the United Kingdom and two convalescent hospitals on the Continent totaled 13,600 at the end of 1944. The total number of convalescent patients discharged from all rehabilitation and reconditioning centers in the United Kingdom from 7 April 1943 through 31 December 1944 was 34,761. Of these, 88.0 percent had been returned to duty in the European theater (chart 3). Among the aforementioned 34,761 patients discharged in the United Kingdom during this period, there were 14,247 battle casualties, 82.7 percent of whom were returned to duty in the theater (chart 4). Overall dispositions from all convalescent facilities (five in the United Kingdom and two on the Continent) during the period from April 1943 through December 1944 totaled 40,440, of whom 86.5 percent had been returned to duty in the European theater. A greater number of days was required for rehabilitation than for reconditioning; rehabilitation required an average of 49 days per patient, and reconditioning, an average of 39 days. A total of 1,637 officer patients had been discharged from the 833d Convalescent Center during the period, of which 78.7 percent were returned to duty in the European theater (chart 5).
496CHART 4.-Disposition of 14,247 battle casualties discharged from all rehabilitation and reconditioning centers in the United Kingdom during the period 7 April 1943-31 December 1944 CHART 5.-Disposition of 1,637 officer patients (classified as disease, battle, and nonbattle injuries), discharged from the 833d Convalescent Camp (Officers) during the period 7 April 1943-31 December 1944
Activities Centered on the Continent, 1945
During final operations
On 8 January 1945, the Rehabilitation Division, Office of the Chief Surgeon, moved from London to Paris, leaving an adequate and competent staff with the Office of the Surgeon, United Kingdom Base, London, and established its officers at 127 Champs Élysées. On 9 January, two veterans of World War II who had suffered limb amputations and who had been fitted with prosthetic appliances at Walter Reed General Hospital reported for duty with the Rehabilitation Division. These veterans visited hospitals in the theater to meet personnel who had lost limbs and to indoctrinate them as to their expected normalcy in future activities. The two veterans were great morale builders to these unfortunate patients.
During January, the hospitals of the European theater were operating at fullest capacity due to the large numbers of battle casualties. This naturally curtailed rehabilitation activities in hospitals but made for more efficient early transfer of patients to the rehabilitation and convalescent centers. Particularly efficient convalescent reconditioning was being accomplished at the 7th and 8th Convalescent Hospitals operating in the communications zone on the Continent. The economy of centralized convalescent care was never more strikingly emphasized than during this critical phase of military operations in the European theater.
Two officers were assigned to the Rehabilitation Division from the Special Services and Information Services of the theater to coordinate the procurement of supplies and to advise in educational reconditioning. Arrangements were made with the cinema branch of Special Services for the distribution of recreational movies to hospitals and within the library section of Special Services for the acquisition of additional books and magazines for the use of the convalescent patients.
Additional rehabilitation personnel were being trained at the school conducted by the 826th Convalescent Center in the United Kingdom. These personnel were greatly needed in the hospital programs. In early February, an allotment of 150 officers and 400 enlisted men was made available for training in the rehabilitation program and for subsequent assignment to hospitals and convalescent centers.
During this period, a 30-day evacuation policy was operating on the Continent; therefore, the conduct of a convalescent program was not universally required. With the 60-day evacuation policy, beginning late in February, the program of convalescent training was reinstituted within the hospitals in France and Belgium. On 21 February 1945, at a special conference of hospital center commanders and base surgeons, plans for convalescent rehabilitation on the Continent were outlined. Tentatively, a convalescent facility was to be established within each hospital center. It was also announced at this
conference that trained rehabilitation personnel would be assigned to each hospital. Later, conferences were held with surgeons of base sections and with the commanding officers of hospital centers to assist in the reorganization of the convalescent training program on the Continent. A series of lectures was given by members of the Rehabilitation Division to the personnel of all the hospitals.
Frequent indoctrination visits were being made to the convalescent hospitals within the field armies. The purpose of these trips was to recommend methods of improving the program of convalescent activities for patients retained in the army area. It was difficult, however, to activate definite programs due to the rapid advances being made. It was noted, however, that patients in army convalescent hospitals had little or no problem of physical or morale reconditioning and that patients were anxious to return to their units as soon as possible.
On 25 February, Colonel Stinchfield was appointed supervisor of convalescent rehabilitation in the United Kingdom, in addition to his other duties. He retained command of the 826th Convalescent Center.
In March, Colonel Thompson was relieved of his liaison duties with the G-3 Section, Headquarters, ETOUSA, and assigned to the Rehabilitation Division, Office of the Chief Surgeon.
A continuing search was being made throughout this period for suitable sites for convalescent rehabilitation facilities in France and Belgium. The Rehabilitation Division, in coordination with the Supply, Operations, Hospitalization, and Personnel Divisions, Office of the Chief Surgeon, completed plans for the activation of six convalescent centers on the Continent. Selected locations and bed capacities were as follows:
Plans were also made to move the 828th Convalescent Center and several selected station hospital units from the United Kingdom to the Continent. Selected personnel from various rehabilitation units in the United Kingdom were ordered to the Continent for use in the activation of new units.
Since there were no true rehabilitation centers functioning on the Continent, and since, after 1 April 1945, patients were transferred to the Zone of Interior when they required more than 60 days of hospitalization, the burden for convalescent management was placed on each hospital (fig. 178). Medical officers in busy hospitals were not too favorably disposed toward their part in the program unless they had a clear concept of the relationship of rehabilitation and reconditioning to the principles and practice of scientific medicine.
Therefore, complete and thorough indoctrination of the medical officers was constantly being carried out.
During the latter part of April, many conferences were held with the Chief Surgeon and his officers in regard to the redeployment of convalescent centers and personnel to the Zone of Interior.
V-E Day and phasing out
On 8 May, V-E Day was announced, and immediate plans were made for the redeployment of the 826th Convalescent Center to the Zone of Interior.
On 15 May 1945, Colonel Diveley proceeded to the Zone of Interior in order to coordinate the redeployment of the convalescent center and the rehabilitation personnel. Colonel Thompson was appointed acting chief of the Rehabilitation Division.
The major emphasis in the hospital convalescent training program was shifted to the augmentation of educational reconditioning.
Toward the end of May, arrangements were made to return all air force specialized-training equipment and all other surplus supplies. Many rehabilitation personnel were made available to the Zone of Interior.
Sites in Germany for use as convalescent centers were surveyed, but the selection of these was dependent upon the policy of occupation.
As of the end of June 1945, the Rehabilitation Division consisted of 10 officers, 2 stenographers, and 2 clerks. During the period from December 1944 through June 1945, 138 officers and 585 enlisted men had been trained as rehabilitation training personnel. The convalescent centers had discontinued operations and had disposed of all patients as of 6 June 1945. In the United Kingdom, convalescent centers were in staging areas preparatory to movement to the Zone of Interior. Supplies and personnel were being prepared to maintain a convalescent facility in occupied Europe (U.S. Military Zone) when required. The 7th and 8th Convalescent Hospitals had been recalled to the armies. A convalescent training program was being conducted in all operating general and station hospitals. The activities for the convalescent patient were adapted to the local situation and the patient's requirements.
Dispositions for the period from January through June 1945 indicate that 35,597 patients were discharged from the convalescent centers in the United Kingdom. Of the 28,846 patients returned to duty, 55 percent were returned to general assignment and 27 percent to limited assignment. During the total period of operations of convalescent centers from April 1943 through June 1945, there were 70,358 dispositions reported, of whom 84.5 percent were returned to duty after an average total period of hospitalization and convalescence of 95.7 days (table 2).
The general and station hospitals in the United Kingdom, for the first 4 months of 1945, reported that 259,834 patients were discharged, of whom 197,846 were ultimate dispositions. Of the latter, 29 percent were returned to general duty, 17.5 percent were sent to limited assignments, and 53.5 percent were transferred to the Zone of Interior. During the first 4 months of 1945, these hospitals transferred for advanced rehabilitation in their convalescent sections 63,269 patients, of which 49,949 were ultimate dispositions. Of these, 53.8 percent were returned to general duty, 39.2 percent were given limited assignments, and 7 percent were transferred to the Zone of Interior. The average duration of stay for a convalescent patient admitted to the convalescent section in these general and station hospitals was 46.1 days in the hospital and 18.5 days in the convalescent section for a total of 64.6 days.
The convalescent activities program in the European theater was conducted most successfully during World War II with adherence to the following principles which were developed early in the program.
1. Each convalescent patient was graded periodically by his medical officer upon the basis of objective as well as subjective findings. The patient's activities were prescribed in accordance with his rate of recovery and his military occupational specialty. The activities program was adapted to local requirements and was generally proportioned among physical and military reconditioning and recreational diversion.
2. The entire program was based on the fact that the mission of the Medical Department was the conservation of manpower and the preservation of the fighting strength of the military forces. This was accomplished by furnishing those who had become disabled with such hospitalization facilities as would speedily restore them to health and finally to fighting efficiency. It was not enough that the patient be cured of his disease, or that his wounds be healed, but it was necessary that treatment cover the entire period from the time he became a casualty until he was physically and mentally normal and could return to take his former place in his unit. Specifically, the rehabilitation program covered that phase from the time he became a convalescent patient and could leave the hospital until he had completely recovered and could return to his unit.
3. The rehabilitation center was a military unit that prepared convalescent military personnel for further military service or for discharge to useful civil life. The scope of a rehabilitation center included the acceptance of the patient from the hospital as soon as possible after he had reached the convalescent stage. He was then treated with specific physical therapy or remedial exercises, as well as general reconditioning and hardening exercises, which cut the period of convalescent days to a minimum and prepared the soldier to return to duty in a strong, able physical condition. The rehabilitation center had as its aim mental as well as physical rehabilitation. With these goals achieved, the soldier, when discharged to duty, had not only the physical ability to carry on his task, but also the proper mental attitude to carry the task to completion.
The reconditioning center had none of the hospital atmosphere. Mental and physical deterioration occurred while the soldier was in the hospital, and the longer he was hospitalized, the more permanent this deterioration became. He was, therefore, removed as soon as possible from the hospital to an atmosphere of appropriate military and physical training.
REX L. DIVELEY, M.D.