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Chapter I

Contents

SURGICAL CONSULTANTS IN THE ZONE OF INTERIOR

Surgical Consultants in the Office of the Surgeon General

CHAPTER I

General Surgery

B. Noland Carter, M.D.

    At the onset of the war, the Professional Service Division of the Office of the Surgeon General consisted of seven subdivisions among which was the Medicine and Surgery Subdivision.

    It was soon realized that, in order to carry on the medical and surgical activities of the Office of the Surgeon General in an adequate fashion, it would be necessary to create a separate organization for each. Therefore, in February 1942, a chief consultant in surgery, Col. (later Brig. Gen.) Fred W. Rankin, MC, and his opposite in medicine, Col. (later Brig. Gen.) Hugh J. Morgan, MC, were placed in charge of their respective and separate branches. In March 1942, the Surgery Branch of the Medicine and Surgery Subdivision became the Surgery Division, functioning as an integral part of the Professional Service and comprising subdivisions of general surgery, orthopedic surgery, regional surgery, chemical warfare, and radiology. In August 1942, another reorganization within the Professional Service was effected whereby surgery became a branch under a Medical Practice Division. This situation remained until June 1943 when the Surgery Branch became the Surgical Division with its functions divided among three branches, the Surgery, Radiology, and Physiotherapy Branches. This new plan also provided that nationally known specialists would be appointed as civilian consultants to The Surgeon General so that their services would be available to the divisions having interest in and need for expert consultation in the fields represented. By February 1944, the Surgery Division (formerly the Surgical Division and still a part of Professional Service) consisted of branches in general surgery, orthopedic surgery, transfusions, chemical warfare, and radiation--physiotherapy having been eliminated. In August 1944, the Surgery Division became the Surgical Consultants Division,1 was separated completely from the Professional Service, and was set up as an advisory staff division on a separate level from the operating services in the Office of the Surgeon General. From this time until the end of the war, 

1 The Surgical Consultants Division underwent a series of evolutional changes in status during the years 1942-45.  On 25 March 1942, the Surgery Division was created as part of a Professional Service Office of the Surgeon General.  On 24 August 1942 the Surgery Division was changed to the Surgery Branch, Medical Practice Division, Professional Service.  On 15 June 1943 the unit became a division again with the designation Surgical Division, and on 3 February 1944 it became the Surgery Division.  On 24 August 1944 the Surgery  Division became the Surgical Consultants Division, responsible directly to The Surgeon General, and on 11 October 1945 the name was changed again to Surgical Consultants.  For ease of reference, the designation Surgical Consultants Division is used for the unit throughout this volume.


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the Surgical Consultants Division reported directly to the Surgeon General. Thus, it may be seen, the surgical activities in the Office of the Surgeon General began as a part of the Medicine and Surgery Subdivision, steadily widened in scope, and ultimately became a large and independent division directly under The Surgeon General (fig. 1)

FIGURE 1 - The position of Surgical Consultants Division in the organization of the Office of the Surgeon General.

    At its inception in February 1942, the Surgical Consultants Division was housed in two small rooms, and its personnel consisted of Colonel Rankin, Chief Consultant; Lt. Col. (later Col.) B. Noland Carter, MC, Assistant Chief (fig. 2); and Maj. (later Lt. Col.) Ambrose II. Storck, MC. As the war went on and the demands on the Division increased, additional officers were added. These were Col. Leonard T Peterson, MC, Consultant in Orthopedics; Col. Byrl R. Kirklin, MC, Consultant in Radiology; Lt. Col. M. Elliott Randolph, MC, Consultant in Ophthalmology, succeeded later by Col. Derrick T. Vail, MC; Lt. Col. Leslie F. Morrissett, MC, Consultant in Otolaryngology, succeeded b Col. Norton Canfield, MC, late in 1945; Lt. Col. Douglas B. Kendrick, Jr., MC, and Lt. Col. Frederic N. Schwartz, MAC, Consultants in Transfusions; Maj. Albert M. Johnston, MC, and, later, Maj. George R. Greenwood, MC, Consultants in Chemical Warfare; and Maj. R. Gordon Holcombe, MC, Consultant in General Surgery. The following officers from Walter Reed General Hospital were appointed on a part-time basis: Lt. Col. Brian B. Blades, MC, Consultant in Thoracic Surgery; Col. R. Glen Spurling, MC, Consultant in Neurosurgery, replaced later by Lt. Col. Barnes Woodhall, MC; and Maj. Lloyd H. Mousel, MC, Consultant in Anesthesia. Colonel Storck left the Division after several


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FIGURE 2 - Lt. Col. (Later Col.) B. Noland Carter, MC, Assistant Chief, Surgical Consultants Division, Office of The Surgeon General.

months and was replaced by Maj. (later Lt. Col.) Michael E. DeBakey, MC, who, on the departure of General Rankin in September 1945, became the chief of the Division.

    The men who were appointed as civilian consultants to The Surgeon General to serve the Surgical Consultants Division are listed, with their area of specialization, in appendix A.

FUNCTIONS

    The functions of the Surgical Consultants Division of the Office of the Surgeon General were defined in various terms in directives issued from time to time during the war. The following are examples of these definitions:  "Promulgates policies concerning time practice of general specialized surgery and radiology throughout the Army"; "The development of surgical policies


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including newer methods of treatment and the initiation of recommendations regarding same; renditions of professional opinions as to miscellaneous surgical methods; approval by liaison with the Personnel Division of selection of personnel for key positions; formulation of policies concerning the purchase of new drugs and items of equipment for the Medical Department, and consideration of ideas submitted by individuals, institutions and manufacturers"; and "To exercise general supervision of surgical care throughout the Army, afford consultation and advice to all departments of the Surgeon General's Office on matters pertaining to surgery and to assist in the identification and proper allocation and assignment of qualified commissioned surgical specialists." The various functions of the Surgical Consultants Division can best be outlined and presented under the headings of personnel, equipment and supplies, public relations and liaison, review of manuscripts and literature, education and training, and consultation.

PERSONNEL

    The maintenance and elevation of high standards of surgery in the Army were considered by the Surgical Consultants Division to be dependent upon a number of factors, among the most important of which was the accurate placement of personnel, particularly of key personnel. The Division therefore took an active and zealous interest in the selection and recommendation of personnel for the various surgical positions which it was necessary to fill throughout the structure of time Medical Department. This was accomplished by various means. Some selections were made through personal interviews or correspondence with civilian surgeons who had themselves manifested a desire for an appointment in the Medical Corps, some were carried out through consultation with representatives of the specialty boards, and some were accomplished after consultation with the Military Personnel Division concerning professional qualifications and appropriate assignment of officers recently commissioned. It was believed that, if key positions could be filled with individuals with proper professional qualifications and with proven ability for organization and supervision, the enormous problem of affording the best care of the surgically sick and wounded would be solved in large part. This surmise proved to be correct, as was evidenced by the superior manner in which the varied surgical activities were administered by those men who had been selected for positions of importance, such as consultants, chiefs of service, and members of auxiliary surgical groups. At the very beginning of the war, it was somewhat difficult to perform this personnel function readily since the accepted lines of authority as to personnel assignment were rather rigidly drawn. The Military Personnel Division, however, with the understanding direction of Col. (later Maj. Gen.) George F. Lull, MC, soon grasped the fact that the Surgical Division possessed extremely accurate information concerning the qualifications of many surgeons and therefore cooperated heartily and effectively. The importance of this personnel function was realized by Maj. Gen.


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Norman T. Kirk, MC, soon after he became The Surgeon General in June 1943. General Kirk decreed that the identification and proper allocation of surgical specialists was to be a function of the Surgical Consultants Division. Having selected a man for a position of importance, the Surgical Consultants Division purposed to support him in the performance of his duties in every way. This was more readily accomplished in the Zone of Interior than in oversea theaters of operations, which tended to function independently of the Office of the Surgeon General.

Consultants to Oversea Theaters

    As requests for consultants in surgery and its allied specialties were received from the various theaters of operations, it was obvious that these consultants had to be highly qualified and unusually competent individuals with special training and a broad background of experience as well as eminent reputations in their fields of endeavor. It was the important responsibility of the Surgical Consultants Division to select and to recommend these consultants, all of whom were chosen according to these criteria. The first group of consultants was selected for the European Theater of Operations and consisted of the following. 

Chief Consultant in Surgery  -  Lt. Col. (later Brig. Gen.) Elliott C. Cutler, MC, Moseley Professor of Surgery at Harvard University.
Consultant in Orthopedics  -  Lt. Col. (later Col.) Rex L. Diveley, MC, associate professor of orthopedic surgery, University of Kansas, Lawrence, Kans., succeeded by Col. Mather Cleveland, MC.
Consultant in Neurosurgery  -  Lt. Col. (later Col.) Loyal Davis, MC, professor of surgery, Northwestern University, Evanston, Ill., succeeded by Lt. Col. (later Col.) R. Glen Spurling, MC, professor of neurosurgery, University of Louisville.
Consultant in Ophthalmology  -  Lt. Col. (later Col.) Derrick T. Vail, MC, professor of ophthalmology, University of Cincinnati, succeeded by Lt. Col. James N. Greear, Jr., MC.
Consultant in Anesthesia  -  Lt. Col. (later Col.) Ralph M. Tovell, MC, chairman of the Department of Anesthesiology, Hartford Hospital, Hartford, Conn.
Consultant in Otolaryngology  -  Lt. Col. (later Col.) Norton Canfield, MC, professor of otolaryngology, Yale University.
Consultant in General Surgery  -  Lt. Col. Ambrose H. Storck, MC, succeeded by Lt. Col. (later Col.) Robert M. Zollinger, MC, associate professor of surgery, Harvard University.
Consultant in Plastic Surgery  -  Lt. Col. (inter Col.) James Barrett Brown, MC, associate professor of clinical surgery, professor of oral surgery, Washington University, St. Louis, Mo., succeeded by Maj. (later Lt. Col.) Eugene M. Bricker, MC, assistant professor of surgery, Washington University.


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    A short time after NATOUSA (North African Theater of Operations, U.S. Army) was established, Col. Edward D. Churchill, MC, Homans Professor of Surgery at Harvard University, was selected as chief consultant in surgery for that command. The other surgical consultants in that theater were appointed by time Surgeon, NATOUSA, on the advice of Colonel Churchill.

    The situation in the Pacific cannot be so easily stated owing to the fact that there was no single Pacific theater as such and also to the many reorganizations which took place among the various commands. Without reference from the Office of the Surgeon General, Lt. Col. (later Col.) August W. Spittler, MC, had been designated surgical consultant in the Hawaiian Department at the beginning of the war. Col. W. Barclay Parsons, MC, associate professor of surgery, Columbia University, was time first to be selected specifically for assignment to the Pacific as a surgical consultant. He served in the early years of the war with USASOS, SWPA (U.S. Army Services of Supply, Southwest Pacific Area), until replaced by Lt. Col. (later Col.) I. Ridgeway Trimble, MC, in August 1944. Serving with Colonel Trimble was Lt. Col. George O. Eaton, MC, Orthopedic Consultant, USASOS, SWPA. Both Colonel Trimble and Colonel Eaton were later assigned to the staff of USAFPAC (U.S. Army Forces, Pacific)--the eventual overall command for most of the Army in the Pacific.

    In the South, Central, and Western Pacific areas, which at one time or another operated under Headquarters, USAFMIDPAC (U.S. Army Forces in the Middle Pacific), Headquarters, USAFPOA (U.S. Army Forces in the Pacific Ocean Areas), and Headquarters, USAFPAC, Lt. Col. (later Col.) Forester Raine, MC, was the surgical consultant for the Central Pacific with Lt. Col. (later Col.) Robert C. Robertson, MC, as his orthopedic consultant. Lt. Col. (later Col.) Ashley W. Oughterson, MC, associate professor of surgery, Yale University School of Medicine, had gone to Auckland, New Zealand, with the 39th General Hospital and was appointed surgical consultant to the South Pacific Area, in July 1943. Colonel Oughterson later served as surgical consultant at Headquarters, USAFPOA, Western Pacific Base Command, and at Headquarters, USAFPAC. He went to Japan in September 1945 with advanced headquarters, General Headquarters, USAFPAC, and was immediately made head of the General Headquarters, USAFPAC group of the Joint Commission for the Investigation of the Effects of the Atomic Bomb in Japan. Maj. (later Col.) Howard A. Sofield, MC, replaced Colonel Oughterson as surgical consultant in the South Pacific and was, himself, relieved by Lt. Col. (later Col.) Willis J. Potts, MC. Lt. Col. (later Col.) Edward J. Ottenheimer, MC, replaced Colonel Oughterson in the Western Pacific Base Command.

    In the meanwhile, Col. John B. Flick, MC, had been sent as surgical consultant to the U.S. Army Forces in the Middle Pacific when that command was established as a superior command over the South, Central, and Western Pacific


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base commands. There were others who, from time to time, were detached from their organizations and served as consultants for particular studies or specific operations. Still others were appointed as consultants in the various subcommands of the sprawling Pacific areas following the surrender of Japan.

    Col. Stephens Graham, MC, assistant professor of surgery, Medical College of Virginia, was selected as chief consultant in surgery to the China-Burma and India theaters in 1945.

    All of these consultants shouldered their great responsibilities in a most commendable manner. By their assiduous and unrelenting attention to their many personnel problems and to their varied professional duties, they were responsible in large measure for the type of surgical treatment which saved more lives in this war than in any other conflict in the history of the world. Constant vigilance for methods of implementing better anti earlier surgery, unfailing devotion to their diverse duties, and determined efforts to reduce mortality and morbidity characterized the activities of these officers. The valuable role which they played in the maintenance of a high standard of surgery cannot be overemphasized.

    As the war progressed, it became evident that, under the existing circumstances, close liaison between these officers and the Office of the Surgeon General was extremely difficult and at times impossible. In order that the Surgeon General might be acquainted with, and therefore assist in solving in the most expeditious and intelligent manner, the many problems arising in oversea theaters, the reports known as Essential Technical Medical Data were instituted. The inclusion of a surgical section in this monthly communication from the headquarters of all oversea theaters afforded a medium through which the surgical consultants of these theaters were able to consider timely anti pertinent subjects with the Surgical Consultants Division of the Office of the Surgeon General. Replies to these reports were formulated each month, inch-eating time action which was taken by the Division, in an effort to aid in the improvement of surgical care in the theaters of operations. These reports constituted one of the most valuable sources of information concerning the surgical experiences of oversea units. For this reason tire Surgical Consultants Division took pardonable pride in its role in the development of this medium for obtaining information on current medicomilitary problems in the oversea theaters and in contributing to their solution.

    In retrospect, one of the most serious defects in the maintenance of the most effective relations between the Office of the Surgeon General and the theaters of operations was the lack of a closely knit liaison which can best be had by an interchange of personnel. Considerably better teamwork could have been effected had there been more frequent visits by members of the Surgical Consultants Division to the various theaters, and vice versa. Many more problems could have been solved in a more effectual and expeditious manner had


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such a scheme been instituted. In retrospect, it seems unbelievable that during the entire war only two visits were made to foreign theaters of operations by members of the Division and that only a few more were made by surgical consultants from oversea theaters to the. Office of the Surgeon General. It should be noted that a considerable number of subordinate consultants in the various specialties were appointed within the theaters by the chief surgeons with the advice of the surgical consultants.

Surgical Consultants to Service Commands

    On 28 July 1942, the War Department authorized the appointment of surgical consultants to be attached to the medical section of each service command headquarters in the Zone of Interior. These consultants were concerned essentially with the maintenance of the highest standards of surgical practice. Their function was to evaluate, promote, and improve the quality of surgical care by every means and to interpret time professional policies of The Surgeon General and aid in their implementation. The proper performance of these functions involved air appraisal of the professional services in various medical installations, the quality, distribution, and assignments of professional personnel, the availability and suitability of equipment and supplies, the nursing care, recreational and reconditioning facilities, and other services which were essential to the welfare and morale of the patients. The consultants exercised their functions by assisting and advising the service command surgeons on all matters pertaining to professional practice, providing advice on surgical subjects in general, stimulating interest in professional problems, aiding in the investigation of professional problems, and encouraging educational programs. The execution of these functions involved periodic visits to all medical installations and other units in the command which were concerned with the surgical care of military personnel.

    It became apparent from these considerations that the service command consultants would need to be highly qualified and unusually accomplished individuals with special training and experience and eminent reputations in their individual fields of endeavors. The selection and recommendation of these consultants were made the responsibility of the Surgical Consultants Division, and all of them were chosen according to these criteria. Here, as in many other situations which required the selection of an outstanding individual for an important surgical position, a personal knowledge of and an acquaintance with the majority of the qualified American surgeons was essential. The Surgical Consultants Division was thus equipped, and its choice of service command consultants was more than justified by the manner in which they performed their duties, the industry and zeal which they manifested, and the high standards of surgery which were maintained in Army hospitals under their jurisdiction.


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A list of the service command surgical consultants follows:

Service Command - General Surgery                  Orthopedic

First   -      Col. Condict W. Cutler, Jr., MC
Second  -  Col. Stephens Graham, MC
                 Col. Robert H. Kennedy, MC
Third  -      Col. Walter D. Wise, MC
Fourth  -    Col. Rettig Arnold Griswold, MC            Col. Mather Cleveland, MC
                 Col. I. Mims Gage, MC Lt.                      Col. James J. Callahan, MC
Fifth  -       Col. Claude S. Beck, MC Lt.                  Col. Robert L. Preston, MC
Sixth  -      Col. W. Barclay Parsons, MC                  Lt. Col. Ralph Soto-Hall, MC
Seventh  -  Col. Grover C. Penberthy, MC
Eighth  -     Col. Bradley L. Coley, MC                     Col. Thomas L. Waring, MC
                 Col. Henry G. Hollenberg, MC
Ninth  -     Col. John B. Flick, MC                            Col. John J. Loutzenheiser, MC
                 Col. Meredith G. Beaver, MC

    Liaison between the service command consultants and the Surgical Consultants Division of the Office of the Surgeon General was adequately maintained throughout the war. The advantage of the geographic factor in this relationship is obvious. Frequent visits to the nine service commands were easily and frequently made by the staff of the Surgical Consultants Division, and on most of these visits the staff were accompanied by the service command consultant. Telephone calls could be made without much difficulty, and correspondence could be exchanged without delay. The service command surgeons, the commanding officers of hospitals, and the surgical consultants were in and out of the Office of the Surgeon General constantly. Unquestionably, this ready liaison was responsible for much of the efficiency with which both organizations were able to function. Another even more important factor was that the service commands were under the direct control of the Commanding General, Army Service Forces, on whose staff was The Surgeon General. Therefore, the implementation of directives--both professional and administrative--was readily effected, personnel changes could be quickly and accurately made, and a healthful, cooperative attitude engendered. In striking contrast, to this satisfactory liaison was that with the oversea theaters. As mentioned before, it was rare for consultants overseas to visit the Office of the Surgeon General and vice versa, correspondence had to be through command channels, and the theaters were quite autonomous, with the result that interference, real or implied, was actually resented.

    As a means of effecting a closer liaison with the service command consultants, General Rankin, in October 1943, arranged a meeting of the service command consultants in the Office of the Surgeon General. The meeting lasted for 2 days, during which time many pertinent problems common to all service commands were discussed informally, presented frankly, and solved realistically. Among these were questions dealing with limited service, operating on defects existing before induction, operations on the knee joint, discharge, classification and assignment of personnel, anesthesia, types of cases to be admitted


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to station and general hospitals, hours of duty for medical officers, et cetera. The consultants thus had the opportunity to present their achievements as well as their problems, and to discuss them at first. Hand with members of the Office of the Surgeon General and with their fellow consultants. The meeting was considered to be such a success that it was decided that similar ones would be held at yearly intervals during the remainder of the war.

A second meeting was held on 10-11 October 1944, in the Office of the Surgeon General (fig. 3). At this time a more comprehensive program was presented, an outline of which follows.

10 October 1944:

Subject - Speaker

Demobilization Plans as They Affect the Service Commands - Col. Arthur B. Welsh, MC
Transfer of Patients From Debarkation Hospitals - Lt. Col. John C. Fitzpatrick, MC
Hospitalization Problems - Dr. Eli Ginzberg
Classification and Assignment of Personnel - Maj. Robert Evans
Reconditioning - Col. Augustus Thorndike, MC
Surgery in the Army Air Forces - Lt. Co1. Alfred R. Shands, MC
Problems in X-Ray - Col. Byrl R. Kirklin, MC
Photography in the Medical Department - Capt. Ralph P. Creer, MAC
Problems of CDD (Certificate of Disability for Discharge) and Retirement - Co1. Arden Freer, MC
Cancer in the Army - Col. R. Arnold Griswold, MC
History of Surgery in This War - Lt. Col. Michael E. DeBakey, MC
Monthly Statement From the Surgical Service in Each Hospital of the Service Command to the Consultant - Col. Walter D. Wise, MC
Anesthesia in the Service Commands - Col. John B. Flick, MC

11 October 1944

Subject - Speaker

Injuries to Carpal, Navicular, and Lunate - Maj. Ralph Soto-Hall, MC
Management and Disposition of Cases of Knee Injury - Lt. Col. Robert L. Preston, MC, Maj. James J. Callahan, MC
Varicocele and Undescended Testis - Lt. Col. Stephens Graham, MC
Phlebothrombosis and Pulmonary Embolism - Col. Bradley L. Coley, MC
Closure of Colostomy Wounds - Col. Claude S. Beck, MC
Ophthalmology and the Blind - Maj. M. Elliott Randolph, MC
The Deaf - Maj. Leslie B. Morrissett, MC
Management and Disposition of Cases of Herniated Nucleus Pulposes- Col. Grover C. Penberthy, MC, and Maj. Barnes Woodhall, MC
Use of Penicillin in Reconstructive Surgery - Lt. Col. Thomas L. Waring, MC
Infected Hands and Hand Injuries - Lt. Col. Condict W. Cutler, Jr., MC
The Management of Decubitus Ulcers - Col. I. Mims Gage, MC

    The service command consultants were active in insuring the best care and a rapid turnover of the thousands of patients as they were evacuated to the United States from oversea theaters. They maintained an exceedingly high level of professional care in the medical installations within the Zone of Interior. They unified and implemented the interpretation of the professional policies stated


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FIGURE 3 - Service Command surgical consultants at their meeting with General Rankin and his staff, 10-11 October 1944, in The Surgeon General's office, 1815 H Street NW., Washington, D.C. Front row- (left to right): Col. John B. Flick, Col. B. Noland Carter, Col. I. Mims Gage, Brig. Gen. Fred W. Rankin, Col. W. Barclay Parsons, Col. Bradley L. Coley, Col. Grover C. Penberthy. Back row (left to right) : Maj. R. Gordon Holcombe, Lt. Col. James J. Callahan, Col. Thomas L. Waring, Col. Claude S. Beck, Col. Walter D. Wise, Lt. Col. Condict W. Cutler, Jr., Lt. Col. Robert L. Preston, Lt. Col. Ralph Soto-Hall, Lt. Col. Stephens Graham, Col. John J. Loutzenheiser, Lt. Col. Michael B. DeBakey, Lt. Col. A. H. Shands, Col. Byrl H. Kirklin.

 


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by the Office of the Surgeon General. Their contribution to the care of surgical patients was more than rewarding, and their devotion to their difficult and diverse duties was inspiring.

Auxiliary Surgical Teams

    In the early days of the war, the Surgical Consultants Division recognized the potential of the auxiliary surgical groups as a means of bringing definitive surgical care to the seriously wounded in the forward areas, especially when the load of battle casualties was too great to be handled adequately by the staffs of existing medical treatment facilities. Particular interest was therefore taken in expediting the formation of these groups and in the selection of personnel for the various specialized surgical teams which composed the groups. These groups included teams of general surgeons, neurosurgeons, thoracic surgeons, plastic surgeons, orthopedic surgeons, and anesthesiologists. During the fiscal year ending 30 June 1943, the Surgical Consultants Division selected and recommended the personnel for the various teams of four complete auxiliary surgical groups and for a portion of a fifth. An immense amount of time was consumed in the selection of medical officers to fill these teams. It was considered of fundamental importance that they be staffed with well-trained specialists since they were destined to afford the highest type of surgical care to the wounded in the forward areas. How adequately this was accomplished is indicated by the fact that each officer selected had had an average period of surgical training of from 3 to 6 years.

    These groups, though they were not accepted readily at first by the theaters to which they were assigned and not utilized to the best advantage until later, proved to be of the greatest value. The concept of bringing well-trained surgeons to the seriously wounded, rather than the older one of evacuating the casualties far to the rear for definitive surgical care, was logical and sound. There is little doubt that the adoption of this concept was a potent factor in the reduction of mortality and morbidity among the wounded.

Surgical Consultants to Field Armies

    Further evidence of the Surgical Consultants Division's conviction that the establishment of a consultant system was of the first importance in the propel-handling of casualties throughout the Army was its interest in recommending and in implementing the appointment of suitably qualified individuals as surgical consultants to the various field armies. These positions called for well-trained surgeons who combined a high degree of professional ability with energy, enthusiasm, and the ability to handle difficult situations in a tactful yet firm manner. When one considers that a field army has as its components those medical treatment facilities which give initial surgical care to the wounded, one can appreciate the need for skillful supervision of the manner in which such care should be given. The theater consultant's responsibility


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included the field armies within the theater, but those consultants could not be familiar with the many problems which arose within each army, nor could they have the time and opportunity to assist in solving them. On the other hand, the army consultant lived closely with such problems, could give them individual attention, and, being a member of the medical section at army headquarters, was in the best position to provide a solution for them. In the majority of instances the army consultants were selected by the Surgical Consultants Division. They were as follows:

Army - Consultant

In Europe
   
First - Col. J. Augustus Crisler, Jr., MC
    Third - Col. Charles B. Odom, MC
    Ninth - Lt. Col. Gordon K. Smith. MC
    Fifteenth - Col. William F. MacFee, MC

In North Africa and the Mediterranean
   
Fifth - Col. Howard E. Snyder, MC

In both Europe and the Mediterranean
   
Seventh - Col. Frank B. Berry, MC

In the Pacific
   
Sixth - Lt. Col. Frank Glenn, MC
    Eighth - Col. Frank J. McGowan. MC
    Tenth - Col. George G. Finney, MC

    The importance of the mission which these men performed can best be expressed in terms of lives saved and the decreased morbidity among the wounded. They were vigilant as to the fundamental principles of wound management in the care of battle casualties, they were skillful in the assignment and allocation of personnel under their control, and they contributed immensely to the promotion and maintenance of the high quality of surgical care which was afforded throughout the armies.

Staffs for Various Army Hospitals

    A personnel problem which was faced throughout the war was that of the assignment of suitably qualified individuals to key positions in the various Army hospitals in the Zone of Interior and in the communications zones of theaters of operations. The surgical Consultants Division took an active and zealous interest in the selection and recommendation of medical officers as the hospitals were being organized. It was especially concerned with the assignment of specialists in the several fields of surgery. After numbered hospitals


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left the United States, the Surgical Consultants Division had no further jurisdiction over their surgical personnel, but, in the case of Zone of Interior hospitals, this did not obtain. The surgical staffs of the latter were frequently being changed as a result of losses to oversea assignments and promotions to positions of greater importance, and also for various unpredictable reasons. Thus, it was constantly necessary for the Division to find suitable replacements and to recommend their assignment. The service command consultants were of inestimable assistance in this regard and were frequently consulted in an effort to keep the key positions in Army hospitals filled with the best men available. The Division was instrumental in defining what was meant by key positions and in establishing the proper number of suitably trained officers to be assigned to them. In this connection, a member of the Division sat on the Kenner Board, a board to study many of the overall problems of medical personnel staffing in the Army, and suggested revision of the surgical service in existing tables of organization for all types of Zone of Interior and communications zones of theaters of operations hospitals. Likewise, it contributed a large share to the formulation of new and revised manning tables for the existing tables of organization. This task assumed greater importance as the war went on with more hospitals being formed and with fewer surgical personnel being available with which to staff them. The manning tables became much more realistic under these conditions and, as revised, eliminated army criticism of overstaffing.

    Extensive surveys were made from time to time concerning the qualifications of medical officers assigned to key positions in general, regional, and station hospitals in the service commands. As a result, excesses and deficiencies in surgical specialists were discovered, and suitable adjustments were made. In 1945, a considerable number of medical officers were transferred from the Army Air Forces to the Army Service Forces. The Surgical Consultants Division reviewed their professional qualifications, rated them for assignment in keeping with their professional qualifications, rated them for assignment in keeping with their abilities, and recommended them for proper assignment.

    As a result of the intimate knowledge of the qualifications of the surgical personnel in the hospitals in the Zone of Interior, the Surgical Consultants Division was able to effect an equal distribution of surgical specialists throughout these installations, and such officers were assigned in positions where their talents were utilized most effectively. In this connection the following facts, taken from an editorial prepared by General Rankin, chief consultant in surgery, and published in the April 1945 issue of Surgery, Gynecology and Obstetrics, are of interest. The assignments of 922 surgical specialists, qualified by their respective boards, were reviewed. Ninety-six percent of these men were found to be properly assigned. Of the 922, there were only 37 who were not actively engaged in performing surgical operations, but each of the latter was serving as a consultant either in the Office of The Surgeon General or in the service commands.


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EQUIPMENT AND SUPPLIES

    Among the functions of the Surgical Consultants Division, as outlined in various directives, was that of consultation in the matter of equipment and supplies designated for all the component parts of the Medical Department.. Immediately upon its creation as a part of the Professional Service, the Surgery Branch began in 1942 an intensive investigation and examination of those surgical instruments, devices, sutures, and other materials which were currently being furnished throughout the entire Medical Department with a view to eliminating obsolete or unnecessary equipment, substituting and adding more modern items, and conserving critical materials. This necessitated a detailed review of all surgical items on existing supply lists, numerous conferences with the Procurement Advisory Division and the Supply Branch, and interviews with many manufacturers and designers of surgical instruments and materials.

    At the beginning of the war, surgical instruments were supplied to medical installations as kits, each containing certain items of equipment. Thus, a general hospital, for example, would automatically be issued 12 number X kits; a station hospital of a certain number of beds, 6 kits; and smaller installations, 3 kits. This procedure resulted in a tremendous waste of equipment, for in a general hospital instrument case of 12 kits there would be 12 rib spreaders, 12 kidney pedicle clamps, and 12 of each of many other items of which only 1 or 2 were actually required. Also there would be too few of such essential instruments as hemostats, curved clamps, scissors, et cetera. In addition, there were many instruments, considered to be essential by civilian surgeons, which were not on the lists at all. By far the major portion of the task of resolving these supply problems was completed during the first 9 months of the war, but during the remainder of the conflict the continuous examination and reevaluation of surgical items of equipment constituted an important portion of the work of the Division. As new methods of treatment and hitherto unknown therapeutic agents were developed, the responsibility for evaluating them and determining how they were to be tested, used, and allocated to the various Army installations was that of the Surgical Consultants Division.

Revision of Supply and Equipment Lists

    In the attempt to revise the lists of basic specialty instruments, certain difficulties were encountered and were concerned primarily with manufacturing details. This was due to the fact that a large number of these precision instruments had always been imported and, when this supply had terminated at the onset of the war, it became necessary for the manufacturers in this country to establish their own tooling process and to train personnel in this specialized craft. Accordingly, in revising the lists of basic and specialty instruments, this was kept in mind since it. was necessary to conform to the ability of manufacturers to obtain requisite materials and to meet the supply requirements in an expeditious fashion. Great credit is due the manufacturers for their ability


18

to overcome these obstacles and to supply quickly equipment of standards equal to, or even higher than, the standards of that formerly available.

    It would be difficult to name all the results and advantages of these activities. Some of the more important of these included a complete revision of lists of suture materials and needles. In suture materials alone, considerable economy was effected by the deletion of large quantities of expensive catgut and the substitution of cotton and silk thread which was not only much less costly but actually better suture material. Similarly, certain types of suture needles, the use of which did not predispose to good surgery, were taken off the lists entirely and proper ones substituted. In addition to such changes, recommendations were made for the deletion of numerous surgical instruments and articles which were no longer in common use and for the addition of more recent equipment necessary for the performance of the most modern surgical procedures. Examples of the latter were the addition of needles suitable for performing sympathetic block to relieve vasospasm associated with injuries of the upper and lower extremities, physical therapy equipment for various-sized hospitals, X-ray equipment, and foreign-body locators, and adequate apparatus for gastroduodenal suction. The contents of several types of medical chests and first aid kits were revised.

    Other results obtained which were worthy of special mention were recommendations for the complete surgical equipment for a surgical operating truck and for the portable hospitals. Equipment lists of surgical items for the evacuation hospitals and the 500-bed general hospital were reevaluated and revised. Suggestions for the addition of specialized instruments for the special surgical centers were also made. Thus, for the neurosurgical and vascular centers, special items, such as electrical cutaneous apparatus, oscillometers and thermocouples, were provided. The entire list of anesthetics on the supply catalog was reviewed with the purpose of determining their adaptability to an overall Army policy concerning such agents based on simplicity, safety, and anesthetic efficiency. On the basis of this review, the number of anesthetic agents was reduced from 19 to 12, and War Department Technical Bulletin (TB MED) 43, Local Anesthetic Agent, was published on 18 May 1944. Recommendations were made concerning the procurement and preparation of cotton waste and petrolatum-impregnated gauze for the care of burns, and these items were added to the supply catalog. The Division also aided in the preparation of the list of supplies for civilian aid in occupied countries and for Americans who were held prisoners of war by the enemy.

Central Supply Service in Hospitals

    As a means of conserving certain medical supplies and of extending their period of usefulness, the Surgical Consultants Division in February 1943 proposed the establishment of a central service system adaptable for utilization in various station and general hospitals. This system consisted essentially of a


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centralized agency with equipment which was used for certain diagnostic and therapeutic procedures, particularly in preoperative and postoperative care, was to be prepared and dispensed. Among these items were those employed in the performance of transfusions and intravenous medication, wound dressings, spinal puncture, thoracentesis, catheterization, gastric lavage, and oxygen administration. These pieces of equipment were of the sort that might be used for any patient but only as the occasion demanded. Their constant presence on each ward was obviously unnecessary and, consequently, entailed expenditures for unreasonably large quantities of supplies. It was apparent, therefore, that the institution of a centralized agency responsible for the maintenance, proper preparation, and dispensation of these supplies not only would permit greater utilization from a smaller total quantity of supplies but also would mean greater care, longer life, and a readier responsibility for many critical supplies. Likewise, a considerable saving could be made by the more effective utilization of personnel. The proposal of this system was considered particularly important in view of the tremendous burden imposed on the medical supply facilities by the rapidly expanding Army. This burden was being increased steadily by the fact that the availability and production of many articles were becoming critically limited.

    The recommendation by the Surgical Consultants Division that the centralized type of agency be established in both general and station hospitals met with the instant and unanimous approval of all concerned in the Professional Service, but it took a great deal of time to convince the Supply Division that the plan was a good one. A whole year elapsed before the plan was finally approved by all concerned, and War Department Memorandum No. W-40-44, Central Service System in Army Hospitals, was published on 12 April 1944, authorizing the establishment of this system which functioned with eminent success throughout the remainder of the war.

Penicillin

    Early in 1943, the new antibiotic, penicillin, was attracting attention on account of its highly promising therapeutic possibilities as revealed by preliminary chemical and laboratory observations made both in England and in the United States. The enormous potential value of this drug in military surgery was quickly realized by the Surgical Consultants Division. There were many conditions which, if they responded to this agent as accurately as seemed indicated, were of frequent occurrence among military personnel and constituted serious problems from the standpoint of decrease in manpower, increase in hospitalization, and the imposition of added burdens on medical personnel and medical facilities. It was evident that the therapeutic possibilities of penicillin should be quickly and effectively explored. The limited productibility of penicillin at that time greatly restricted its clinical and experimental use. The manufacture of time drug was a slow and laborious process as well as a very ex-


20

pensive one, the drug was in great demand by the civilian population, and there was very little to be mad by anyone. It was obvious that, if the Army was to evaluate properly this therapeutic agent, it needed the lion's share of the available material and had to proceed promptly with a thorough clinical trial of this new drug.

    It was for these reasons and in order to ascertain more exactly the usefulness of this agent, to determine its indications and contraindications, and to standardize the therapeutic procedures associated with its use, that the Surgical Consultants Division, with the cooperation of the Committee on Medical Research of the Office of Scientific Research and Development, established a program to conduct intensive investigative studies on wound infections and sepsis in a limited number of general hospitals in this country. The first unit in this program was Bushnell General Hospital at Brigham City, Utah, and it began to function on 1 April 1943. A second unit was established at Halloran General Hospital, Staten Island, N.Y., on 3 June 1943. For the first few months, these institutions were centers for clinical and some experimental work with the drug. Emphasis was placed on the type of case which was suitable for treatment, on the most effective dosage, on the route of administration, on the length of treatment, et cetera. As soon as these had been determined with reasonable accuracy, the two centers were used as schools in penicillin therapy for medical officers from other army hospitals which were later to be engaged in this program of evaluating penicillin. As more and more such officers were trained and as more and more of the drug became available, additional general and station hospitals were placed in the program.

    In order to assure a certain degree of standardization and homogeneity in the overall study, each of the officers trained in penicillin therapy in each hospital was charged with the full responsibility of determining the cases to be treated and the details and procedure in their treatment, of acquiring necessary laboratory studies, and of maintaining and forwarding to the Surgical Consultants Division in the Office of the Surgeon General all of the case records. The Division analyzed all such reports, tabulated them, and made an accurate evaluation of them. In this way, an immense amount of quite accurate information was quickly obtained with the least waste of a scarce product. This information was rapidly disseminated to all medical officers throughout the Army by the Office of the Surgeon General and to civilian physicians by papers published in the Journal of the American Medical Association or by addresses given before several medical and surgical societies. For example, an article was published in the 18 December 1943 issue of the Journal of the American Medical Association by Maj. Champ Lyons, MC, who was in charge of the studies at Halloran General Hospital, dealing with 209 cases treated with penicillin. Major DeBakey of the Surgical Consultants Division participated in a panel discussion devoted to penicillin at a meeting of the American Medical Association in June 1944 and reported on the use of penicillin in the treat-


21

ment of over 1,500 cases of surgical infections of various kinds including 74 cases of septicemia, 169 cases of infection of the skin and subcutaneous tissue, 152 cases of wound infection, 62 cases of abscess, 78 cases of gas gangrene, 138 cases of septic compound fractures, and 265 cases of osteomyelitis. Colonel Carter gave a similar presentation to the Kentucky State Medical Association on 19 September 1944. Members of tine Division prepared numerous articles on penicillin for the Bulletin of the Army Medical Department, as well as several circular letter's and a technical bulletin on time subject. The Surgical Consultants Division endeavored to maintain and advocate an open mind concerning the effectiveness of this drug and prevented the publication of many papers by medical officers which would tend to indicate that penicillin was a panacea in the treatment of all surgical diseases.

    Until adequate amounts of penicillin were made available to all medical installations throughout the entire Army by the remarkable ingenuity of the manufacturers, it was necessary to allocate the drug to those installations, both in the Zone of Interior and in the theaters of operations, in which it could be utilized most effectively. For this purpose, a penicillin board was set up in the Office of the Surgeon General. The board met at weekly intervals and did much to insure the proper distribution of the drug. A member of the Surgical Consultants Division sat on this board and, with the background of the information obtained as noted above, was able to contribute greatly to the effective functioning of his body. It can be safely said that both the investigative study sponsored amid controlled by the Surgical Consultants Division and the Division's effort concerning the proper distribution of penicillin played a most important part in furthering the proper and prompt usage of this very valuable drug.

PUBLIC RELATIONS AND LIAISON

    Throughout the war, the Surgical Consultants Division consistently endeavored to maintain close rapport and liaison with various institutions and organizations including the National Research Council, medical schools, civilian surgeons, and surgical and medical societies. It was believed that a closer cooperation with and support to the Office of the Surgeon General would be afforded by these important organizations if such a relationship was established. This purpose was greatly facilitated by the fact that the chief surgical consultant, General Rankin, was president of the American Medical Association, vice chairman of the American Board of Surgery, and president of the Interstate Post-Graduate Assembly. In addition, other members of the staff of the Division were active and well-known members of various surgical organizations. Considerable effort was expended by the Division in this direction from the beginning to the end of the war. Some of the more important contributions of the Division toward the establishment of this important relationship are given in the following paragraphs.


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    During April, May, and June of 1942, tine American College of Surgeons conducted a series of war sessions in representative cities throughout the country. These sessions were attended by thousands of surgeons, and in each of them a member of the Division participated importantly. He outlined the organization of the Medical Department which had been set up for the care of battle casualties, discussed many of the surgical problems of military significance, and presented the current methods used by the Army in the management of wounds, burns, shock, and fractures.

At the second series of war sessions held in 1943, a paper entitled "The Care of the Injured in the Combat Zone" was prepared by members of the Division and was presented by various medical officers. This paper received such favorable comment that it was published in the bulletin of the College. Again in 1944, another series of war sessions was held. At this series, a paper entitled "War Wounds of the Extremities" was read by designated Medical Corps officers at the various meetings. The paper was prepared by members of the Division. At these sessions, a film was also shown which had been especially prepared by medical officers in the Division. The film was entitled "Evacuation and Care of Battle Casualties." This motion Picture was so popular that it was necessary to show it several times during each meeting, rather than only once as had been originally planned. These sessions proved to be eminently successful in disseminating the existing knowledge which had been acquired in the care of the sick and wounded. They stimulated the interest of the civilian surgeons in the Medical Department and did a good deal to promote their seeking commissions as Medical Corps officers.

    At frequent intervals during the war years, the Division prepared papers for presentation by its members, by The Surgeon General, and by various members of the Office of the Surgeon General at formal and informal gatherings, surgical society meetings, and lay meetings. Such papers dealt with the current and future activities and the personnel requirements of the Medical Department of the Army, considerations of military surgical problems, detail of the care of various types of war wounds, reviews of the accomplishments and contributions of the medical profession during the war, rehabilitation of the wounded, amputations, the use of plasma and whole blood, and similar subjects. Many other papers were prepared for delivery at dedication ceremonies, manufacturing meetings, commencement exercises, and radio programs. Approximately 175 of these papers were prepared. Presentations of strictly surgical subjects were made at meetings of the leading surgical societies such as the American Surgical Association, the American College of Surgeons, the Southern Surgical Association, the American Association for Thoracic Surgery, the American Medical Association, the American Academy of Orthopedic Surgeons, and the American Orthopedic Association. Not only did these papers serve as a valuable public relations function but they contributed importantly to the surgical literature, and most of them can be found in the national surgical journals of that period. Addresses were given by members of the Division. Still others


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were prepared for delivery by The Surgeon General at meetings of the Southern Medical Society, service command hospital gatherings, meetings of the editors of State medical journals, the Council on Medical Education, the trustees of the American Medical Association and the House of Delegates of that association, and several State medical societies. The Surgeon General also spoke at dedication ceremonies of numerous military and civilian hospitals and memorial buildings and at presentations of a considerable number of "E" awards to industrial plants. These addresses did much to keep a wide segment of the population informed concerning the accomplishments of the Army in the surgical care of the sick and wounded.

    Every effort was made to maintain a close liaison with the National Research Council. Members of the Division were in frequent attendance at appropriate committee meetings of the Council including those of the Surgical Committee and the subcommittees on faciomaxillary injuries, blood substitutes, orthopedic surgery, ophthalmology, burns, gas casualties, and surgical infections. Problems which confronted the Medical Department of the Army were presented before these committees for investigation and solution, while, on the other hand, recent developments, advances, and innovations which had resulted from research activities and investigative studies of the National Research Council were given to the Army for evaluation and for possible use. The assistance which the Council rendered the Armed Forces was invaluable, and great credit is due it for its unfailing cooperation and devoted service. Without its help, many problems would have remained unresolved, many lives would have been lost, and much valuable information would have been long delayed in reaching the military forces.

    It would not be feasible in this volume to give a detailed account of the many surgical problems which were considered at the Council meetings or of their solution or rejection. Some of the more important ones were the evaluation of the use of the sulfonamides on surgical infections, the preparation and preservation of plasma, the viability of the red blood cell, the use of serum albumin, the methods of prolonging the safe use of whole blood, the design for a suitable container for oversea shipments of whole blood, the evaluation of the usefulness of penicillin, the proper management of burns, the development of a toxoid for gas gangrene, foreign body locators, tantalum wire and film, and nerve suturing. A most kindly and cooperative relationship existed between the Council and the Surgical Consultants Division. At times, however, when the Army rejected a Council proposal as an impractical measure or as a plan which could not be adapted to its complex organization and varied personnel, the atmosphere would become a bit strained. But such incidents were rare, and the meetings of the Council committees were enjoyable and most profitable. Numerous advances and developments in many fields of surgery were evolved and were promulgated in Army medical practice through this valuable reciprocal relationship between the Army and the Council.


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REVIEW OF MANUSCRIPTS AND LITERATURE

    All articles written by officer's of the Medical Department were required to be submitted to the Office of the Surgeon General for approval before publication. This was in accordance with paragraph 8, section III, Circular Letter No. 1, Office of the Surgeon General, dated 1 January 1943, with Circular Letter No. 192, Office of the Surgeon General, dated 20 November 1943, and with Army Regulations No. 310-10, dated 27 February 1943. It was required that all articles which dealt with surgical subjects be reviewed by the Surgical Consultants Division, that their suitability for publication be determined, and that, if approved, further clearance be obtained from the Bureau of Public Relations, War Department. One of the time-consuming functions of the Division was the review of all these manuscripts on surgical subjects which were submitted by medical officers as well as those by civilian newspaper and magazine correspondents reporting on the activities of the Medical Department. A conscientious effort was made to review such articles and to present constructive criticism to the authors. In general, the manuscripts were classified into three groups; namely, those which were approved for publication elsewhere than in the Bulletin of the U.S. Army Medical Department, those approved for publication in the Bulletin, and those disapproved. In the latter category, the Office of Technical Information returned the paper to the author with a letter outlining the criticisms of the Office of the Surgeon General and the reasons for disapproval. The paper could be rewritten, if desired, in accordance with this letter and resubmitted. Many such instances occurred.

    These articles were reviewed according to certain criteria; that is, that the contents did not reveal information of value to the enemy, did not break the rules of medical ethics, did not show serious literary or scientific errors, did not contain malicious, foolish or frivolous matter, did not purport, without the proper authority, to represent the official attitude of the Army or the Medical Department, and did not harmfully criticize an agency of the Government or those of our Allies. The vast majority of these articles, if approved, were transmitted directly to that journal in which the author had requested its publication. The importance of this review function was far greater than might at first be realized. A certain number of the papers which were prepared by medical officers were poorly written and often filled with inconsistencies. It was therefore of considerable importance that they be reviewed for professional content and that appropriate recommendation be made to the authors as to the suitability of the articles for publication. Since the approval of the Surgical Consultants Division had to be obtained before publication could be considered, most medical officers were stimulated to prepare their manuscripts more carefully. In addition, since the authors knew that any article published had to be approved by the Division, it was considered that its publication was tantamount to endorsement by the Office of the Surgeon General of the therapeutic methods described. In view of these facts, the Division was extremely cautious in the


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selection of material for approval. It was obviously impossible to approve papers which were in conflict with stated policies of the Office of the Surgeon General. In a few instances, papers contained observations which in civil practice would deserve publication but which were disapproved by the Division because of the interpretation in terms of Medical Department policy which other medical officers would attach to publication.

    An example of such a possibility was a paper received by the Division regarding the successful control of ether convulsions by curare. This case report was of interest and would have been approved for publication had it not been for the fact that curare was known to be a dangerous drug and one about which most medical officers knew very little. Furthermore, it was not a standard item of supply. Had the paper been published, there was little doubt that in the light of past experience, this office would have received numerous requisitions for this agent for use in similar related conditions. It is obvious that the widespread use of such a drug as curare by men incompletely informed as to its pharmacological actions would have been highly undesirable.

    Papers which appeared to be particularly suitable for publication in the Bulletin of the U.S. Army Medical Department were so recommended, and the author usually agreed to that procedure. In the case of particularly important papers for which the authors requested publication in specific journals (such as Surgery, Gynecology and Obstetrics; Annals of Surgery; or the Journal of the American Medical Association), no insistence was made that such material be published in the Bulletin. However, abstracts of such articles were frequently prepared for that publication, and in some instances an entire article was reprinted.

    The number of articles submitted for review by the Division increased steadily each year of the war. For example, in the month of January 1942 there were 39; in January 1943, 119; and in April 1943, 163. The average number of articles received each year for review was approximately 850. The usual percentage of rejection was about 23. In addition to these articles, the Division was called upon to review innumerable surgical textbooks and similar publications on surgical subjects to determine their suitability for use by the Medical Department of the Army.

EDUCATION AND TRAINING

    It quickly became apparent to the Surgical Consultants Division that it should emphasize and be concerned importantly with education and with training. In order to accomplish these functions, it was necessary to work closely with the Plans and Training Division and with the Army Medical Museum in an active initiating capacity as well as in an advisory one. Not only was the preparation of instructional aids and literature on various surgical subjects an important function of the Surgical Consultants Division, but in addition it was imperative that the Division provide the proper media through which such immaterial could be disseminated effectively throughout the Army.


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Publications

    At the beginning of the war, the National Research Council undertook the task of preparing various war manuals dealing with those medical and surgical conditions which were important from a military viewpoint. The Surgical Consultants Division, with the, information it had acquired from reports from surgical consultants in the United States and abroad, from personal contacts, and from bulletins received from theaters of operations, was in a position to offer considerable assistance and guidance in the preparation of those manuals dealing with surgical subjects. For example, the war manual on abdominal injuries was largely prepared by the Surgical Consultants Division and was revised from time to time to include, new material, such as compressor injuries occurring in individuals who were partially submerged in water in the region of depth charge or torpedo explosions. The manual on transfusion therapy was critically reviewed, and suggestions were made for its revision. The Division collaborated in the preparation and critical evaluation of all other mammals concerned with surgical subjects. In an effort to make available to medical officers the best current. surgical opinion on war injuries, copies of the war issues of the Bulletin of the American College of Surgeons, which contained the most. modern account of the management of war injuries, were acquired, apportioned, and distributed to all general and station hospitals both in the continental United States and abroad.

    During the first year of the war, Technical Manual 8-210, Guides to Therapy For Medical Officers, was critically reviewed, and recommendations for changes and additions of new material were made. A new Field Manual 21-11, First Aid for Soldiers, was written by the Division during this same period in cooperation with the Medical Consultants Division. A great deal of time was spent in the preparation of this manual. There were numerous conferences with artists and photographers at Carlisle Barracks, Pa., and with representatives of the Quartermaster Corps who had arctic experience concerning equipment, supplies, and procedures as related to first aid for the sick and wounded in extreme cold and snow.

    In the early part of 1943, the preparation of a new book, "Surgical Anatomy for Medical Department Personnel," was begun, since the existing one had become difficult to obtain and was in need of simplification and revision. Many hours were spent in conference with Mr. Tom Jones, the medical artist who was engaged in editing this volume, regarding the types of illustration, methods of presentation of material, and the material to be included. Several months later, the volume appeared and was most enthusiastically received. In addition to the large size for libraries, a pocket-size volume was published for medical officers. The Surgical Consultants Division took a large share of the credit for this book, which furnished to Medical Department personnel a compact, simple, and beautifully illustrated surgical anatomy.


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Visual Aids

    A close liaison was maintained throughout the war with Col. James E. Ash, MC, and his staff at the Army Medical Museum in an effort to make available various types of material for the education and training of Army personnel. Among the results of this cooperative association and effort were the moulage models of war wounds, which depicted so graphically the anatomy and the pathology of these injuries; the collections of lantern slides depicting a wide range of surgical conditions, operations, methods of evacuation, and other subjects: and a library of motion pictures portraying the many phases of the surgical activities of the Medical Department. The collection of lantern slides which was inaugurated by the Surgical Consultants Division was unusually complete. This resulted from the fact that, at regular intervals, a member of the Division reviewed the great volume of photographs which poured into the Army Medical Museum and selected material which was suitable for inclusion in the collection. This collection proved invaluable as a source of illustrations for lectures, training programs, and history.

    Motion pictures were considered to afford the most effective medium for training, orientation, and teaching. Accordingly, the Division took a special interest in them. It was active in the selection of pertinent subjects for portrayal by this means, in the collection of film from overseas and in this country, in the integration of material into a complete motion picture, and finally in the actual production of the finished product. Innumerable obstacles were overcome in this field of endeavor, the chief of which was the difficulty in getting the Signal Corps of the Army to process film, to splice it, and to furnish sound tracks and titles. It was actually necessary in the beginning of the motion picture program to have the work done in commercial studios or to seek the aid of the U.S. Naval Photographic Science Laboratory in Washington. The latter institution was extremely cooperative, and much credit is due it for its prompt, willing, and excellent assistance. Various members of the Division literally nursed these motion pictures along and were solely responsible for their production. After the value of these pictures was appreciated, their production through the Signal Corps became much easier. In order to insure the acquisition of well-prepared motion pictures on important. clinical problems relating to military surgical conditions, it was considered desirable that the Office of the Surgeon General obtain the services of an experienced clinical photographer, who could be sent to various medical installations for the preparation of such films. Mr. Milton Trauber of New York City was appointed consultant in graphic surgical technique in March 1945. His choice was an excellent one, and under his direction many thousand feet of film were produced in the general hospitals in the United States. Such films dealt with varied conditions among which were the convalescent care and rehabilitation of spinal cord injuries, the treatment of traumatic osteomye-


28

litis, repair of peripheral nerve injuries, and operative procedures in the care of penetrating wounds of the chest.

    In summary, it can be said that, by its active interest and perseverance, the Surgical Consultants Division was responsible for the collection, the actual preparation, and the filing of a library of still and motion pictures which was of immense value in the orientation, training, and education of Medical Department personnel. The historical value of such a collection is immeasurable.

Medical Bulletin

    The Surgical Consultants Division was intensely interested in the subject of dissemination of professional information to medical officers and made numerous attempts to provide suitable media for this purpose. This was considered an important function of the Office of the Surgeon General and essential for the maintenance of the health of the Army. Statistical data, factual knowledge, and various new developments about diseases, injuries, and surgical equipment were being obtained at frequent intervals by the Division from numerous sources. This information was continuously being analyzed, interpreted, condensed, and translated into proper military form and, because of its vital significance, had to be disseminated promptly and regularly and made available to every medical officer. Accordingly, the Division repeatedly urged, during the first years of the war, the adoption of a well-integrated program for disseminating information and the establishment of a suitable medium for such transmission. It was proposed that this medium be distinctive in content as well as in format and that it appear monthly with the period elapsing between the preparation of the material and its publication, not to exceed one month. Accordingly, it was first recommended in June 1943 that the then existing Army Medical Bulletin which was published every three months be reconstituted to answer this purpose. This and several similar recommendations were disapproved, but finally such a program was approved, and in October 1943 the first issue of the Bulletin of the U.S. Army Medical Department, a monthly publication, appeared. The welcome reception the latter publication received together with the fine comments concerning it fully justified the efforts expended in producing it.

    In order that the Bulletin might truly represent a valuable source of the latest information on pertinent and timely problems relating to military surgery, the Surgical Consultants Division contributed many articles for publication within its pages during the remainder of the war. It was the opinion of the Division that succinct statements of important fundamentals of military surgery repeatedly emphasized in the Bulletin would constitute a real and effective means of maintaining a high level of surgical care throughout the Army. This publication also afforded a medium through which medical officers in forward echelons could be kept informed of the results which were being obtained by the Medical Department as a whole. The Division contributed 90-odd articles to the Bulletin during the war years. A complete list


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of these would be out of place here, but it might be stated that among the varied subjects were penicillin, aneurysms, trenchfoot, immersion foot, cyclopropane anesthesia, pilonidal sinus, quadriceps deficiency, wounds of the rectum, blast injuries of the ears, tropical ulcers, morphine poisoning, tourniquets, new gas casualty set, clinical significance of the Rh factor, acute infections of the hand, and parachute surgical teams.

Directives

    Other media for the dissemination of information consisted of circular letters from the Office of the Surgeon General, War Department circulars, TB MED's, and command letters of the Army Service Forces. These were distributed through command channels and for this reason did not necessarily reach each medical officer. In fact, many officers stated that they did not receive many of these directives which would have been most helpful to them. The Surgical Consultants Division was active in contributing a great deal of informative material for these directives throughout the war. In the earliest days of the war, the circular letters of The Surgeon General were the most frequently used medium. Again, it would not be feasible at this point to list all such contributions, which were quite numerous and dealt with varied conditions and situations. Approximately 20 circular letters, 15 War Department circulars, 5 Army Service Forces letters, 10 directive letters to service commands, and 20 TB MED's were prepared by the Division from 1949 to the end of the war. The importance of these directives was emphasized by the fact that one of the most urgent functions of the Surgical Consultants Division was the definition of professional policies which governed many aspects of surgical practice throughout the Army. The fact must be emphasized that there was a wide variation in the professional abilities of medical officers. In certain instances the application in the Army of certain surgical procedures, therapeutic measures, or drugs used in civil practice had to be prohibited. This was necessary in order to minimize undesirable results or untoward accidents known to occur when all medical officers were permitted to use the particular procedures, methods, or drugs in question. The directives noted above constituted the means by which professional policies were defined.

    Reference has already been made to the effectiveness of the report, Essential Technical Medical Data, as a means of obtaining accurate information concerning the care of the sick and wounded in theater's of operations. This information, when received, could then be transmitted to the other theaters as well as to installations in the Zone of Interior. It became apparent that such data should also be obtained in the same fashion from medical installations in the continental United States, and memorandums requesting this were sent to the proper authorities in the Office of the Surgeon General. These requests were refused. The value of such reports with sections devoted to professional problems encountered and results achieved in Zone of Interior facilities would have been of great value not only to the Office of the Surgeon General but, also


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to theater surgeons and their consultant staffs. It was difficult to provide a clear concept of therapeutic objectives, as visualized by specialists overseas, to medical officers in the United States. Similarly, the problems confronting specialists in the Zone of Interior and the results achieved in cases which received initial care overseas were unknown to medical officers in theaters of operations. It is earnestly recommended that, in future conflicts, reports similar to the Essential Technical Medical Data report be required from both theater's of operations and Zone of Interior commands.

On-the-Job Specialty Training

    Owing to the shortage of surgical specialists, including anesthesiologists, training schools were instituted at certain designated medical schools throughout the country in the first year of the war. The courses given were for a 3-month period. The selection of individuals to take these courses was the responsibility of the Training and Military Personnel Divisions in the Office of the Surgeon General. The Surgical Consultants Division never endorsed these courses and, in fact, was generally opposed to such a method of attempting to train a surgical specialist at a medical school by lectures and demonstrations in so short a time. Many of these courses proved fruitless. As the war went on and the load of work increased in the general hospitals in the United States, the Surgical Consultants Division suggested that medical officers with the proper background be sent to these installations and assigned to specialist services for on-the-job training. Since the number of such officers in any one institution was small and since they could be supervised by certain of the Army's outstanding specialists, the results were very satisfactory, and a considerable number of men were trained in this way. This was especially true in the case of neurosurgery and in anesthesia. In the latter category, there was an unusual shortage of trained personnel, so that nurses were trained in anesthesia in the Zone of Interior by the above method. This did much to release physician anesthesiologists for oversea duty. In line with this policy of on-the-job training, the Division successfully recommended that, rather than give refresher courses to those medical officers returning from extended tours of duty in nonprofessional assignments or in assignments which had afforded limited surgical practice, these officers be assigned as ward officers or assistants in general or large station hospitals in the Zone of Interior in their specialty. Many officers were thus assigned and were able once more to take up aim active practice in the specialty in which they had been interested.

    In cooperation with the Medical Advisory Board, the Surgical Consultants Division established a program by which it would be possible to provide medical officers who were candidates for certification by specialty boards to obtain credits for training and experience in the respective specialties acquired during military service. A Medical Officer's Service Record was prepared which, when properly completed, would provide authentic data for the various


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committees on eligibility of the American Specialty Boards for evaluation of the experience which had been acquired by the medical officers.

CONSULTATION

    It is evident from the preceding pages that the majority of the activities of the Surgical Consultants Division were in reality of a consultative nature. Mention has been made of the efforts to procure and disseminate surgical information to medical officers, to guard against certain surgical practices which were not considered proper, to supply adequate amounts of drugs and equipment, to train and educate Medical Department personnel, and to assign surgical personnel in the most effective manner. However, little has been said thus far concerning the paramount function of the Division in strictly professional consultation as related to the surgical management of the sick and wounded. Since the staff of the Division was never engaged in the actual surgical care of such individuals during the war, its consultative contributions to clinical surgery in the Army stemmed of necessity from each staff members own background of surgical training and experience, from his knowledge of sound surgical principles, and from his ability to evaluate the mass of surgical data which was being received constantly by the Division. Thus, it was necessary for the Division staff to analyze the multitude of reports which were received from many sources throughout the Army, to evaluate their contents in an effort to determine those surgical conditions which were assuming importance as the war progressed, and to make certain that such conditions were being managed in accordance with the most effective methods. Also, it was the responsibility of the staff to ferret out and to prohibit surgical practices which experience had shown to be dangerous or outmoded, as well as to recognize and make mandatory by directives those practices which had been proved to be most satisfactory. As has been stated previously, The Surgeon General had complete authority in the Zone of Interior, and there the enforcement of directives was readily accomplished. The service command consultants were invaluable in disseminating the information gained by the Division and in enforcing those policies recommended. The visits of members of the Division to service commands were also very effective in this regard.

    Reference has been made to the role which the Division played in the early recognition of the military potentialities of penicillin and in its prompt evaluation and proper use. Similar reference has been made to the use of plasma and whole blood. In addition, there were a number of other instances in which the Division was alert to the clinical application of laboratory investigations, the importance of certain surgical conditions from a military viewpoint, and the necessity of advocating measures for their proper management. Several of these will be commented upon, but, since they have been dealt with in detail in volumes of the history of the Medical Department, United States Army, in World War II which are concerned with surgery. they will be described very briefly here.


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Trenchfoot

    Perhaps the most unsatisfactory experience of the war was that concerned with trenchfoot.2  The entire story of this condition was a sad one particularly in view of the fact that the condition was preventable and in view of the fact that the Surgical Consultant's Division early in 1943, as a result of the experience on Attu, directed attention to the need for anticipating its widespread occurrence. The complete story may be obtained from a section of the 1945 fiscal year report of the Division prepared by Colonel DeBakey. Colonel DeBakey was intensely interested in this condition from the time of the receipt of the first reports in 1943 concerning its occurrence. He warned against the seriousness of this disease from a military point of view and pointed out the measures by which it could be prevented or, if already contracted, how it should be treated. There was an impenetrable indifference to his warnings and suggestions until the condition became one of major military importance as a result of the terrific loss of manpower which it caused among combat troops. Colonel DeBakey's account follows.

    In the 1943-44 annual report of the Surgical Consultants Division, it was stated that the high incidence of trench foot among troops in Italy during the winter of 1943-44 represented "perhaps the most unsatisfactory experience of the war. It was further stated that "it is hoped that the measures now being instituted will prevent a recurrence of this unsatisfactory experience." Unfortunately, this hope was not realized. During the winter of 1944-45 in Western Europe the problem of trench foot assumed alarming proportions, exceeding by far in severity the situation in Italy during the previous winter. In fact, no military force in the field with the possible exception of Napoleon's armies in the War of 1812 has ever experienced such a devastatingly high incidence of cold injuries.

    In view of these facts it is considered of interest and in order for this year's annual report to review the role which this division played in the trench foot problem. It is neither the purpose nor intent of this report to point an accusing finger at any other branch, division, service or corps as being responsible for this tragic experience. The main objective is to record as faithfully and as accurately as possible the activities of this division for the consideration of any who in the future may be interested in them. With this purpose in mind the following remarks are presented:

    Between 11 May 1943 and 11 June 1943 there were 3,829 hospital admissions on Attu, 1,200 of which were listed as disease resulting from "exposure." Due significance was attached to this observation by a number of divisions in the Office of the Surgeon General, among which was the Surgical Consultants Division. The immediate implications of this experience in terms of future operations in Europe were more acutely appreciated by those who were informed on the experiences with cold injuries among military forces of previous wars. On 29 July 1943 a meeting was held in the Research Coordination Branch on the Effects of Cold, and certain principles of first aid or emergency treatment were adopted and preventive measures discussed. A memorandum prepared by the Research Coordination Branch of the Operations Service for The Surgeon General and concurred in by the representatives of interested divisions presented a resume of the discussions and recommendations of this group. The Surgical Consultants Division began to devote considerable attention to this problem which, although of negligible importance as far as the Army's experiences at that time would indicate, was appreciated as a condition which could become

2 For the history of trenchfoot in World War II, see "Medical Department, United States Army, Cold Injury, Ground Type. Washington U.S. Government Printing Office, 1958''


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one of tremendous significance in the inevitable future large scale operations in Europe. On 23 August 1943 this division prepared a memorandum on "Revision in accordance with modern concepts of military publications on the subject of injuries resulting from cold" for Brigadier General C. C. Hillman, who was Chief of the then existent Professional Service of the OTSG. The last two paragraphs of this memorandum read as follows:

    "3. No reference is made to the conditions of 'immersion foot,' 'trench foot' and 'shelter feet' in any of the Field or Technical Manuals except FM 21-11, First Aid for Soldiers, In view of the importance of these conditions and their disabling effects it would seem desirable to disseminate, especially through the medium of manuals, information concerning their prevention and treatment.

    "4. It is, therefore, recommended that these subjects be brought to the attention of appropriate agencies of The Surgeon General's Office for correction. This Surgery Division is prepared to cooperate in the publication of this material."

    Besides conducting a review of the literature on the subject of cold injuries, which included the related conditions of trench foot, immersion foot, frostbite, and high altitude frostbite, this division carried on extensive correspondence with Colonel Luther Moore of the Alaska Defense Command regarding all phases of cold injuries in that command. Likewise the Office of the Base Surgeon, Greenland, was contacted and information obtained on the status of cold injuries as a problem in that region. Furthermore, conferences on this subject were conducted by the National Research Council and attended by a representative of this division.

    On the basis of the material which had been compiled by the Surgical Consultants Division another memorandum dated 15 October 1943 was prepared for the Chief Professional Service the subject of which was "Frostbite, Immersion Foot, and Related Disorders." This memorandum recited the activities of this office up to that time and directed attention to two articles which had been prepared for publication in the BULLETIN OF THE U.S. ARMY MEDICAL DEPARTMENT, one entitled "Immersion Foot" and the other, "Frostbite." The first two paragraphs of this memorandum are quoted here to reveal the status of the Army's experience at the early date and the attitude which this division assumed in regard to the importance of training and proper equipment as effective preventive measures:

    "1. Because of the potential significance and jeopardous effect upon military operations in certain regions, injuries resulting from exposure to cold, such as frostbite, trench foot and immersion foot have received serious consideration by this office. Accordingly, an effort has made to determine the current incidence and morbidity of those hazards of exposure to cold and to survey the present scope of the problem as well as the recent authoritative knowledge on the subject with the view of ascertaining the need for further study and preparing, coordinating, and disseminating the best information on prophylaxis and therapeutics of these conditions.

    "2. In an effort to determine the incidence and morbidity of this subject, the reports from the various regions where military operations are conducted at very low temperatures were reviewed and a letter was forwarded to Colonel Moore requesting information on the frequency and seriousness of these conditions in Alaska. A copy of this letter is enclosed. The results of this review revealed that the incidence of these conditions is relatively low. A report from Northwest Service Command, Essential Technical Medical Data, for August 1943, states that "Frostbite of the extremities in a mild forum has been fairly common; however, serious cases requiring amputation have numbered less than six for this entire period in the whole command which at one time included 22,000 troops. The best method of prophylaxis has been education, discipline and use of proper equipment for cold weather." Another report for August 1943, from the Office of the Base Surgeon, Greenland, states "the incidence of frostbite has been practically nil due to the excellency of clothing and instructions by the Base Surgeon to all personnel on how to early recognize and prevent frostbite. A. very few mild cases of immersion foot have been seen. Palliative measures only were


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used in treatments and the total number of cases were too small for any statistical evaluation on methods of procedure." Another report for June 4, 1943, from Ft. Richardson, Alaska, states that there were 43 cases of immersion foot among casualties evacuated from Attu Island. These were all improving rapidly under a conservative treatment and required no additional measures. Another report from Hams, Alaska, on March 31, 1943, concerning the number of casualties from frostbite incurred during a maneuver in which 535 men participated states that approximately 8% required hospitalization. More recently a survey of the cases evacuated from Attu Island to Zone of Interior with immersion foot and frostbite, only about four or five percent required hospitalization longer than several weeks and only a very few of these required amputations of parts of the extremities. A great majority of these recovered completely under conservative measures and were returned to full duty status. It will also be observed in Colonel Moore's recent letter, 13 September 1943, a copy of which is attached, that the incidence of frostbite and immersion foot among personnel in Alaska has not been very high and the cases are so mild that very few have had serious consequences. According to this review on the incidence and morbidity of these conditions it would seem that the problem is not a serious one and that the essential consideration is one of prevention which is really a problem of equipment and training."

    The articles on immersion foot amid frostbite for the BULLETIN OF THE U.S. ARMY MEDICAL DEPARTMENT were published in the November 1943 and December 1943 issues of this journal which reaches every medical officer in the Corps.

    During the winter months of 1943-44 trench foot made its appearance in appreciable numbers among troops in Italy. In fact, during a period of 4 months the Fifth Army presented 1 case of trench foot for every 4 battle casualties, an exceedingly high ratio. The tremendous military significance of this condition immediately became apparent to many who before this time had not considered the subject a particularly grave one. Moreover, the importance of preventive measures was quite evident when the experience among British troops fighting in the same regions was compared with that of the American troops. There were very few cases of cold injuries among the British troops fighting in Italy at the time when the Fifth Army suffered such heavy casualties from cold.

    The trench foot problem in Italy was carefully followed by the Surgical Consultants Division. All statistical data were studied and comparison struck with British experiences. On 19 June 1944 the Surgical Consultants Division prepared a memorandum for the Surgeon General in which paragraph 1 reviewed the unfortunate experiences in Italy of the preceding winter. Paragraphs 2, 3, and 4, of this memorandum are quoted here for the reader's consideration:

    "2. It is apparent from these considerations that the trench foot problem is important. that our recent experience has been far from satisfactory, and that steps should be taken to prevent its repetition. The reasons for our unfortunate experience are quite apparent and consist essentially in the inadequacy of our program of prophylaxis. Primarily, it is due to inadequate instruction of personnel in methods of protection and the lack of provision of suitable equipment, especially shoes and socks. It must be recognized, however, that even after these measures have been met they must be put into effect by unit commanders, and personnel must apply them diligently if adequate protection is to be achieved. In the final analysis, this is a measure of discipline and responsibility of unit commanders.

    "3. It is, therefore, recommended that a vigorous program directed toward the prevention of trench foot along lines which have proved to be effective be inaugurated by this office. This should include:

    "a. The dissemination of information to troops on the hazards of exposure to wet and cold and the careful instruction of personnel in proper methods of prevention.
    "b. The provision of proper equipment and footgear for operations in wet, cold regions. Efforts should be directed toward assuring the efficacy of this equipment.


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   "c. The direction of attention to unit commanders of the importance of foot discipline and of the diligent application of the protective measures.
   "d. The dissemination of information to Medical Department personnel concerning the most authoritative knowledge on first aid and definitive treatment.

    "4. The potential significance of injuries resulting from exposure to wet and cold such as frostbite, trench foot, and immersion foot were early realized by this office and have been given serious consideration. In a memorandum prepared by this office dated 23 August 1943, Subject: 'Revision in accordance with modern concepts of military publications on the subject of injuries resulting from cold,' a review of the current military publications on the subject was made and attention directed to their inadequacies. In n subsequent memorandum prepared by this office dated 16 October 1943, Subject, 'Frostbite, immersion foot and related conditions,' there was presented the results of a survey which was made by this office to determine the scope of the problem as well as to obtain the most recent authoritative knowledge on the subject, with the view of ascertaining the need for further study and for preparing, coordinating, and disseminating the best information on the prophylaxis and therapeusis of these conditions. The literature on the subject of the effects of cold was reviewed and representatives of this office participated in conferences of a special committee of the National Research Council for the purpose of evaluating the problem, reviewing the most modern concepts of the pathologic physiology, and determining the best principles of prevention and treatment. On the basis of the review of the literature and reports from authoritative and experienced individuals on this subject, and on the basis of concepts formulated by this special committee of the National Research Council, articles which incorporate the most authentic knowledge on frostbite, immersion foot, trench foot, and related conditions, and the most rational principles of prophylaxis and therapeusis were prepared by this office and published in the BULLETIN OF THE U.S. ARMY MEDICAL DEPARTMENT. These articles also form the basis of revisions which have been prepared for tine various training manuals in cooperation with the Training Division for this purpose. At the time of this survey, it was concluded in the memorandum dated 16 October 1943, that while these conditions were not serious at the time, they deserved serious consideration because of their potential significance. It was also pointed out that 'the problem of adopting proper equipment for use in cold regions and the education of personnel in protection against hazards of exposure to cold is one that deserves greatest emphasis'."

    Accordingly, The Surgeon General directed that a W.D. Circular (W.D. Circular 312 Sect. IV, dated 22 July 1944) be prepared by the training division on the basis of the information furnished by the Surgical Consultants Division. Furthermore, a TB Med (TB Med 81, 4 August 1944) presenting all phases of the subject was prepared by the Surgical Consultants Division for immediate distribution to all medical officers. Moreover, an article was published in the June 1944 issue of Health which again called attention to the experience in Italy and its important implications. The concluding statement read as follows: "A winter campaign in northwestern Europe could create a trench foot problem of major importance if the lesson of Italy were not heeded."

    It was felt that these publications would serve to impress on all military sources the importance of the immediate need for rigorous action in the form of training soldiers and line officers on the preventive methods to be employed if a repetition of the MTO experience was to be avoided in Europe during the coming winter.

    Despite these efforts, November of 1944 saw the beginning of another even more extensive trench foot episode, only this time in France and Germany. On 9 December 1944 another memorandum was prepared by this office for The Surgeon General in which the already alarming incidence of the condition in France was cited. The previous publications and correspondence of this division were once more reviewed and the recom-


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mendations to The Surgeon General made in the 19 June 1944 memorandum restated. Paragraphs 3 and 4 of the 9 December 1944 memorandum continued as follows:

    "3. In accordance with The Surgeon General's approval and direction, all of these recommendations were carried out by this office to the extent possible within the limits of its authority, as indicated by the following:

    a. A War Department Circular (No. 312, Sec. IV, 22 July 1944) was prepared, setting forth the essential principles of control and emphasizing the command responsibility for their application.
    b. Information to Medical Department personnel concerning the most authoritative knowledge on the subject, including the most rational principles of prophylaxis and therapeusis was disseminated through articles published in THE BULLETIN OF THE U.S. ARMY MEDICAL DEPARTMENT (page 26, November 1943, and page 46, March 1944) and a War Department Technical Bulletin (TB Med 81, 4 August 1944).
    c. Conferences were held with representatives of the Q.M.C. concerning provision of suitable equipment for troops when fighting in cold, water-soaked terrain. Recommendations were made to the Q.M.C. on the proper type of heavy woolen socks and water-proof or water-resistant footgear.

    "4. It is apparent from these considerations that this office has long recognized the military significance of the trench foot problem. Citing the unfortunate experience with this condition last winter, it was strongly urged in June 1944, that 'steps should be taken to prevent its repetition.' Accordingly, all the elements essential to an adequate control program were set forth by this office. However, the most important factor in assuring the success of this program is enforcement of these elements and this lies within the province of command rather than medical authority."

    By the end of the winter some 45,000 soldiers had been incapacitated by trench foot. The number of these men capable of ever resuming full combat duty was so small as to be negligible. Thus the condition can be recorded as representing a most serious threat to the success of any military operation which requires men to remain in cold wet places for extended uninterrupted periods of time unless a well coordinated plan of prevention is enforced. Current statistical data were collected during the winter months from ETO by means of regular recurring radiograms. The information contained in these was carefully analyzed by this division as well as others in the OTSG. Lt. Gilbert Beebe of the Control Division deserves great credit for the energetic and superb manner in which he presented the important data each month in the publication Health of which he is editor.

    In March 1945 an article was prepared by Lt. Beebe with the cooperation of the Surgical Consultants Division entitled, "Cold Injury in Future Pacific Operations." Attention was directed to the recorded experiences with cold injuries among the Japanese troops during the Russo-Japanese War. The last paragraph of this article reads as follows:

    "In the event that large-scale operations in regions of the Northern Pacific become necessary during the winter months, a repetition of the unfortunate experience with cold injuries in Europe can be prevented only by recognizing this danger and planning accordingly. The prompt provision of troops with suitable winter equipment, the energetic enforcement of individual foot discipline by line officers and the development whenever practicable of ways of providing rest periods during which combat troops can warm themselves, dry their footgear and other clothing, and obtain warm food or drinks, represent the necessary measures in any well-conceived plan designed to prevent this disastrous and crippling condition."

    Early in April the Surgical Consultants Division was visited by Colonel Huncilman of ASP Plans and Operations for the purpose of obtaining information on the subject to be included in a letter from General Marshall to General MacArthur. This material was prepared by this division and coordinated with other interested divisions of the OTSG.


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    During the two winters when American forces were suffering heavy casualties from trench foot much was written, said, and done about this condition. In fact, an uncritical observer might readily conclude that despite all that was done a high incidence of the condition resulted and that trench foot, after all, is not preventable. Any historian or student of the subject who in the future may be reviewing the trench foot experiences of American Armies during this war in order to maintain a proper perspective must constantly ask himself two questions.

  1. What was the situation at the time this publication was printed or this action taken?
  2. Was the information in this publication of this action felt by line officers and soldiers in the field at a time when it would be effective?

    Trench foot does not occur during summer months. It is a condition which occurs as a result of prolonged uninterrupted exposure to cold and wetness. In order for troops to protect themselves, they must be thoroughly educated and informed on the subject before those weather conditions are encountered. Training troops on a subject of this type after they are engaged in intensive combat is less effective than training them during a period prior to such action. The main concern of men engaged in combat is the preservation of their lives. Attempts to teach men under such conditions measures for preventing trench foot, which to them is seemingly unimportant at the moment, are not likely to meet with any great degree of success.

    Thus as the war in the Pacific progresses and our troops are ever approaching a winter at geographic locations north of 32o latitude, the Surgical Consultants Division cannot help but wonder what training programs are being conducted among troops in the warm islands of the Pacific to inform them on the great importance of cold injuries and on the adequate measures for their prevention.

Anesthesia

    There was a shortage of well-trained anesthesiologists throughout the war, and as a consequence considerable effort was necessary on the part of the Surgical Consultants Division to provide an adequate number of individuals who were capable of administering anesthetic agents. Mention has already been made of the schools of anesthesia which were conducted at civilian medical centers and of the final successful attempts to solve the problem of a scarcity of anesthesiologists by an on-the-job training program for medical officers and Army nurses at those Army hospitals having well-trained anesthesiologists on their staffs. A direct consequence of the sometimes desperate shortage of anesthesiologists was the danger to patients resulting from anesthetics given by individuals with little experience or training. It therefore appeared imperative to the Division that it evaluate, with the assistance of civilian and Army surgical consultants, the various anesthetic agents with particular view to safety and permit the use of only those considered the least dangerous. This was just as important in the field of local as in that of inhalation anesthetic agents. Based upon reports of deaths, apparently due to certain local anesthetic agents, it was directed that only procaine hydrochloride be used for infiltration anesthesia, and that agents for spinal anesthesia be restricted to procaine hydrochloride (preferable), Pontocaine (tetracaine hydrochloride), and Metycaine (piperocaine hydrochloride). At this time, a critical appraisal


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of inhalation anesthetics was also made, and it was directed that the use of cyclopropane be discontinued.

    The two most useful anesthetic agents under military conditions proved to be ether and Pentothal sodium (thiopental sodium). In an analysis of 7,500 cases of anesthesia, it was found that the death rate attributable to Pentothal sodium was six times higher than the death rate from all other anesthetic agents combined. This was regarded as an indication of the unwise use of Pentothal sodium rather than of its inadequacy for military purposes. The dangers of this agent were being overlooked. Immediate efforts were, therefore, directed toward better education concerning the use of Pentothal sodium by means of a circular letter to the field and by the publication of several articles in the Bulletin of the U.S. Army Medical Department. The conditions in military surgery in which Pentothal sodium had proved unusually valuable were emphasized, and those in which the drug should be either avoided or used with great caution were stressed. Attention was directed also to the importance of atropine in preoperative medication and to the administration of oxygen whenever feasible.

    In matters concerned with anesthesia, Dr. Joseph Kreiselman of Washington, D.C., civilian consultant in anesthesia to The Surgeon General, and Maj. Lloyd H. Mousel, MC, Chief Anesthetist, Walter Reed General Hospital, were of inestimable value to the Medical Department. These two individuals worked in close cooperation and with their backgrounds in anesthesia and pharmacology provided excellent advice and consultation on many problems of anesthesia. They advised personnel on supplies and recommended the safest anesthetic policies and the most effective methods of resuscitation for adoption by the Army.

Traumatic Shock

    Shock was obviously destined to play a large part in the mortality resulting from war wounds, and the proper management of this condition immediately presented itself as one of the most important problems of military surgery. The development of blood plasma was undoubtedly a great contribution to the treatment of shock, and by its use untold numbers of lives were saved. Unfortunately, the early enthusiasm that accompanied this development was so forceful that it clouded sound clinical judgment and led to the misconception, which persisted far too long, that plasma could be used as an effective substitute for whole blood in the management of shock. This misconception became so firmly entrenched in the minds of both administrative and professional personnel that it definitely handicapped the organization and development of more effective measures for the control of shock.

    The British had discovered the fallacy in this thinking by the time the United States had entered the war, but, in spite of their experience, the U.S. Army was painfully slow in recognizing its error. As a matter of fact, the Surgical Consultants Division shared in this loose thinking for many months. It was due in large part to the reports from the surgical consultant in


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NATOUSA that the Division was made to recognize its errors and to take steps to correct them. Reports from this source, based on increased experience and clinical and laboratory investigations, pointed out clearly that plasma could not be used as a substitute for whole blood and that whole blood was the agent of choice in the ultimate resuscitation of the majority of battle casualties. It became apparent that whole blood was the only therapeutic agent that could prepare seriously wounded patients to withstand the major surgery which was essential for saving life and limb. The transfusion of whole blood was more effective because not only did it restore blood volume. as plasma did, but it also replenished the oxygen-carrying capacity of the blood by supplying red cells which plasma did not do. Plasma, however, was invaluable, for it could be used in emergencies or in the far-forward areas where it was not feasible to supply whole blood and it could tide a shocked patient over the critical period required for evacuation to some installation where whole blood was available. It became increasingly evident that both plasma and whole blood were extremely valuable in the management of shock but that both had their individual and specific purposes and, to be effectual, must be used accordingly.

    Early in 1943, the problem of supplying whole blood to theaters of operations was discussed on several occasions with other individuals in the Office of the Surgeon General, and, though such a need was recognized in a vague sort of a way, it was not considered to be of great importance. Furthermore, the consensus was that it was impracticable to make whole blood available farther forward than the general hospital. In an effort to assist the theaters in supplying their own whole blood transfusions, equipment was made available to them and Circular Letter No. 108, Office of the Surgeon General, Transfusion of Whole Blood in the Theaters of Operation, outlining the techniques to be followed, was distributed on 27 May 1943. The surgical consultants in the North African and European theaters continued to stress the need for whole blood and emphasized the facts that casualties who had bled severely were poor surgical risks even though plasma had been administered in large quantities and that whole blood had to be given to them before they could be operated upon safely.

    As a result of these urgent requests, the Surgical Consultants Division suggested strongly that transfusion sets, which had been developed at the Army Medical Center, Washington, D.C., be made available to the theaters immediately. These sets were expandable, were conveniently packaged, were easily usable and contained all the materials necessary for drawing and administering blood. In addition, refrigerators for the storing of blood in the field had been devised, and their procurement and issue were also recommended. This plan, which had been worked out down to the smallest detail, was rejected as being impractical and unnecessary. Finally, in May 1944, after several additional attempts, this plan was approved. The equipment was standardized and made available to the theaters.


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    During the many months which elapsed between the time that the need for whole blood became evident and the time at which the cited sets were made available, the Surgical Consultants Division had been interesting itself in the possibility of supplying whole blood directly to oversea installations from the Red Cross bleeding centers in the United States. After considerable experimentation and numerous conferences, the equipment necessary to such an effort was devised and perfected. Also, a plan was worked out with the Red Cross bleeding centers and with the Air Transport Command by which whole blood could be thus supplied. Consequently, when it became evident in mid-August 1944 that the European theater blood bank could no longer furnish sufficient amounts of whole blood, this plan, previously prepared, was approved by The Surgeon General and the first shipment of whole blood overseas was dispatched on 21 August 1944. Shipments were continued to the European theater until 10 May 1945, when further supplies were not needed. The shipments were then diverted to the Pacific theaters in conjunction with the Navy-operated whole blood program on the west coast. These were continued throughout the remainder of the war.

    Another feature of shock which became apparent as experience increased was that concerned with certain of its lethal sequelae. During peacetime, shock is observed relatively infrequently, and experience with the condition never approaches the massive scale that occurs in war. The lethal sequelae are, therefore, less evident and tend to be less impressive. A number of battle casualties suffering from severe shock were found to die with manifestations of anuria or reduced urinary output. These lethal sequelae of shock were considered to result from asphyxia of organs or tissues during the prolonged period when the flow- of blood was reduced in volume. Irreparable damage was demonstrated in the tissues of the brain, kidney, and, possibly, the liver of patients with delayed death resulting from shock. The Surgical Consultants Division was extremely interested in instituting field studies and in stimulating other studies in the United States concerned with the solution of this baffling problem. Considerable light was shed on the physiology involved in this complicated condition, although the problem was never solved in its entirety. 3

War Wounds

    Before their entry into the Medical Corps, the majority of military surgeons had had little experience with, and only a slight knowledge of, the management of the type of wounds which they were to encounter in the care of battle casualties. Hence, it was essential that they be informed of sound and proved methods of wound management and that these methods be emphasized repeatedly until they became thoroughly established. Two additional factors contributed to the need for education along these lines and for the strict enforcement of established rules and regulations.

3 Medical Department, United States Army. Surgery in World War II. The Physiologic Effects of Wounds. Washington: U.S. Government Printing Office, 1952.


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    The first of these was the great variation in the training, experience, and ability of the medical officers who were engaged in military surgery. The second was the influence of Trueta's treatise which was concerned with the management of war wounds in the Spanish civil war. This work appeared shortly before World War II and created considerable interest. It was widely discussed by surgeons, and the techniques of debridement, immobilization by closed plaster casts, and wound packing with petrolatum-impregnated gauze had made a definite impression on them. Some surgeons in this country went a step further and in certain extensive wounds seen in civilian life, practiced wide wound excision amid primary closure. Many techniques of debridement appeared. and these varied from extensive excision of wounds to minimal removal of tags of devitalized or soiled tissue. Following these procedures, some surgeons closed the wound tightly by primary suture, while others left it open and either filled it loosely with gauze or packed it tightly.

    Thus, it was evident that strong measures would have to be taken in the Army to insure the proper application of those principles of wound management which the surgical consultants, both in the field and in the Office of the Surgeon General, considered to be most suitable. It was necessary not only to lay down these principles but also to enforce their application. These purposes were accomplished by means of directives, communications, published articles, and addresses, but most importantly by the efforts of the surgical consultants throughout the Army. These principles of care of wounds are discussed in detail in many places in the other volumes of this history which are devoted to surgery. Their delineation, dissemination to medical officers throughout the Army, and their enforcement constituted a major contribution to the low mortality which occurred among the wounded and to the low incidence of serious infection, particularly of gas gangrene. It was the considered opinion of the surgical consultants that nothing could take the place of proper and adequate wound care in military surgery. Proper care was fundamental in the management of the wounded, and other measures such as transfusions of plasma or whole blood and the use of antibiotics and chemotherapeutic agents, effective as they were, were considered to be merely adjuvants.

    Peripheral vascular injuries. - The Surgical Consultants Division repeatedly emphasized the frequency of peripheral vascular injuries, especially those involving major vessels, as an accompaniment of wounds of the extremity. The types of vascular injury and resulting sequelae were pointed out, and proper methods of dealing with each were described. These injuries occurred much more frequently than was commonly realized. Thus was indicated by the fact that vascular injuries were the cause for amputation of an extremity in approximately 20 percent of the cases in an extensive series which was analyzed by the Division in 1943 and 1944. Another indication of this fact was the increasing number of traumatic aneurysms which were operated upon at the vascular centers in time Zone of Interior. In connection with vascular injuries, the Division was active in calling attention to the importance


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of vasospasm as a factor upon which the life of a limb may depend, particularly if the viability of the tissues had been impaired by traumatism. It also described  methods for the detection of this condition and for its proper treatment.

    Regional wounds. - As the war progressed and wider experience was had, newer methods were developed for the management of regional wounds. These were subjected to a critical evaluation based on the data received by the Division. Certain ones were considered to be of such value that they were described for the benefit of all medical officers and in many instances were made the subject of directives. Among them were such subjects as the treatment of injuries to peripheral nerves; the management of cranial-cerebral wounds; proper timing of operations upon spinal cord injuries; the management of wounds of the chest with special emphasis on the complications of hemothorax, tension pneumothorax, open pneumothorax, retained foreign bodies, and empyema; the treatment of combined wounds of the chest and abdomen; and the care of penetrating wounds of the abdomen with special reference to those involving the colon or rectum.

    Chemotherapeutic agents. - All war wounds were considered to he contaminated, although the degree of infection varied from minimal surface involvement to invasive infection with regional or generalized extension. Mention has been made of the importance of the application of sound surgical principles in the prevention and treatment of infections. The story of the sulfonamides as a means of controlling infection in war wounds is an interesting one. Early in the war, these chemotherapeutic agents were widely heralded as "wonder drugs" and in the minds of many surgeons they were panaceas in the management of surgical infections. Much of this enthusiasm resulted from the glowing accounts of their use at Pearl Harbor, where they were credited with performing miracles in the prevention of infection and in its cure. The drugs were used both locally in the wounds and systemically. By the time the Surgical Consultants Division was authorized and organized, the Army had already purchased huge supplies of these drugs and had provided that each soldier carry a supply for local use in the powdered form and for systemic use in tablets. As soon after wounding as possible, the soldier was to sprinkle his wounds with the powder and to ingest the pills. The press was full of items indicating that this regime would afford remarkable protection to our fighting men and that many lives would thus be saved.

    In the sobering light of critical studies and observations, however, this overenthusiastic concept regarding the value of these drugs began to be greatly modified. Grave doubt was cast on their beneficial effects when applied locally, and limitations were found in their systemic use. Surgeons in our Army and in that of the British began to veer sharply away from the introduction of the drugs in wounds and commenced relying more and more on their systemic effects. The range of organisms affected by these drugs was found to be restricted, and, from a military viewpoint, the most important organisms affected were the streptococcus and the gonococcus. In spite of this, the drugs


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contributed greatly to the control of infections when used systemically and were highly regarded. If the antibiotics had not been discovered, the extensive use of the sulfonamides undoubtedly would have been continued throughout the war. They were thus utilized until the supplies of penicillin became adequate. Thus local application of these agents, a practice which was once widespread in the clean as well as the contaminated wound and which was a definite threat to the careful aseptic technique, fell into complete disrepute.

    The Surgical Consultants Division played no part in contributing to the original misconception of the remarkable curative properties of the sulfonamides for their distribution throughout the Army. When all this was taking place, the Division was not yet in existence. By the time the Division was functioning, doubt was already being cast on the propriety of the use of the drugs locally. Its role was to follow closely the clinical and experimental investigations, largely through the committees of the National Research Council, and to ascertain the limitations of these chemotherapeutic agents. As soon as these were defined, the Division was quick to take directive steps designed to insure the proper use of these agents in the Army.

    The contributions of the Division to the penicillin program have already been enumerated. Streptomycin was discovered during the later phases of the war but was used almost entirely on an experimental basis until sometime after the war was over. A number of other agents for the control of infections were suggested to the Army from time to time during the war, and at times considerable pressure was exerted for their adoption and use. One of the important functions of the Division was to survey these suggested drugs critically, to evaluate them, and to recommend or discard them accordingly.

    Gas gangrene. - Gas gangrene was recognized as one of the most serious infections which might occur as a result of war wounds. The mortality and morbidity from this infection at the outbreak of the war was therefore of the gravest importance. The sulfonamides did not prove to be effective in either the prevention or the cure of this condition, nor did penicillin, although for a time it appeared possible that penicillin had some effect in prevention due to its widespread effect on the accompanying pyogenic organisms. The most important factor in the prevention of gas gangrene was the proper surgical management of wounds in the early stages. This fact has been dealt with in previous paragraphs. The Division was much interested in the possibility of the successful production of a toxoid for the control of this infection and made strenuous efforts to arouse interest in this field. No such toxoid was developed during the war, but the efforts made at that time served as a stimulus for the continuation of investigation in this direction during the postwar period.

    Pilonidal sinus - While, strictly speaking, it may not be considered in the category of war wounds, the management of pilonidal sinus developed into one of the real problems of military surgery, particularly in Zone of Interior hospitals. Due to a lack of a uniform policy in the surgical care of this con-


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dition, hundreds of thousands of man-hours were wasted in the first years of the war. There was a surprisingly large number of these cases among military personnel. Some cases showed no evidence of infection and were symptomless, but many more became infected, probably as a result of repeated trauma during the training period. The wards of Army hospitals contained many hundreds of these patients, and the majority had been hospitalized for weeks or months. The necessity for better defined methods of treatment for this seemingly minor surgical condition was completely overlooked and was appreciated only when manpower became scarcer and enough time had elapsed to indicate that man-days were being lost as a result of it.

    In September 1943, a directive was issued by the Office of the Surgeon General indicating the type of operation which should be utilized. This was done because it was recognized at that time that many different types of operation were being performed, ranging from complete excision and primary closure to incision and drainage and packing with petrolatum-impregnated gauze. By September 1944, it became evident that even with these recommended operations the existing methods of management of pilonidal sinus were productive of extremely poor results. In support of this conclusion were the results of statistical studies, made in Army hospitals, of the end results of operative procedures. These indicated a loss of some 435,000 man-hours per year. On the basis of these findings, the therapeutic policies relating to this condition were revised extensively and expressed in War Department Technical Bulletin (TB MED) 89, Pilonidal Cyst and Sinus, dated 2 September 1944. This, in brief, directed that patients with uninfected pilonidal sinus were not to be operated upon and that those having infected sinuses were to be treated by simple incision and drainage. No excisions were permitted. Although this policy did not permit a permanent cure, it did allow a much more rapid return to duty and was preferable by far from a military viewpoint. Under the new regime time hospital stay was rarely more than 2 weeks, whereas under the older one many patients spent many weeks or even months in the hospital. It was true that repeated hospitalization was more frequent under time new regime, but, even so, many man-hours were saved. In retrospect, the importance of this relatively minor surgical condition should have been appreciated much earlier.

    Thermal burns. - Thermal burns constituted a relatively small percentage of all battle casualties but were not without importance in military surgery. Accidental burns were more frequent among soldiers than among civilians of the same age group for the reason that the former necessarily handled gasoline and oil, grenades, and other types of ammunition. Airplane crashes, both in and out of combat, contributed to the incidence. The serious nature of extensive burns and the prolonged reconstructive surgery required in many cases further contributed to the importance of this problem. In 1943, for example, 25,609 patients were admitted to Army hospitals for the treatment of burns. Only 751 of these were received in combat, and 203 of the latter group occurred


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as a result of airplane crashes. During the early part of the war, the tannic acid method of treating burns was the most commonly accepted. In January 1943, the Surgical Consultants Division, by The Surgeon General's Circular Letter No. 15, Treatment of Burns, recommended the pressure dressing technique as the most physiological procedure yet devised for the management of burn cases. Tannic acid was still permitted to be used in cases of burns except those of the face and hands. In September 1943, time tannic acid method was abandoned and prohibited by Circular Letter No. 161, Office of the Surgeon General. The pressure dressing technique, employing either boric acid or petrolatum-impregnated gauze, thus became the only method which was endorsed by the Office of the Surgeon General. In March 1945, the Division prepared TB MED 151 dealing with the surgical management of burns. This technical bulletin presented the accepted method of the systemic management of burns, Plus aim account describing the proper technique for applying an adequate pressure dressing. The Army's extensive experience with this method permitted the conclusion that it was highly effective in that it minimized plasma loss, prevented infection, minimized skin loss, prevented scarring, and saved lives.

Hospitalization

    The policy of transferring certain types of more difficult surgical cases from station hospitals to general hospitals was made during the first few months of the war, and it never ceased to be a cause of contention and irritation to surgeons assigned to station hospitals. Likewise, it created a situation which continually required firmness, combined with tact, on the part of the service command consultants, one of whose numerous duties was to enforce the policy. Many surgeons in station hospitals considered themselves entirely competent to operate upon patients who were being transferred, and in some cases this was true. On the other hand, there were many other surgeons in station hospitals who were not considered capable, on the basis of their training and experience, of giving acceptable surgical care to the more difficult cases. In the best interest of the greatest number of patients, the policy was required. At the beginning of the war, when there were quite a number of well-trained surgeons in station hospitals, complaints were more frequent and resistance stronger than later on, when many of these men were sent overseas. The Surgical Consultants Division was responsible for instituting the policy and for the decisions as to which cases were to be treated only in general hospitals. The Division was assiduous in carrying out the policy both through its own staff when on inspection trips and through the surgical consultants in the service commands. The policy was sound and was another evidence that The Surgeon General was making every effort to insure the best surgical care to Army patients.

    This policy was further extended to make certain general hospitals into centers for the treatment of highly specialized cases. Specialized centers


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were established at first because of the fact that the hospitals thus designated had unusually well qualified specialists on their staffs and in many cases contained highly specialized and scarce equipment. In the beginning, there were very few of these centers and they were for the benefit of patients in general and station hospitals in this country. When the casualties from overseas began to be sent back to the United States in appreciable numbers, it began to be apparent that there was not going to be a sufficient number of specialists in many categories to care for them if they were sent indiscriminately to several general hospitals having only one or two such specialists. The Division, quickly realizing this fact, recommended that the centers be established in additional categories and that they be staffed with specialists drawn from as many Zone of Interior hospitals as necessary. Patients from overseas and from the Zone of Interior requiring special surgical care were all to be concentrated in these centers.

    The plan was approved and put into operation. It was most successful for it permitted the greatest utilization of scarce categories of surgeons, and it made possible extremely productive investigative approaches to many important military problems such as those concerned with peripheral nerve injuries, deafness, vascular injuries, blindness, and amputations. The procedure also permitted the concentration of expensive, highly specialized, and scarce equipment into a few hospitals. With their specially selected staffs and their superb equipment, these centers made an outstanding contribution both to the care of patients with conditions requiring special management and to investigations in various special fields. The growth of these centers and their importance is illustrated in tables 1 and 2.

    It is important to keep in mind when examining table 1 that in certain instances the beds allocated to the various specialties in hospitals previously designated as centers were numerically increased. Thus, the expanded activities in these special fields of surgery cannot be fully appreciated in terms solely of numbers of centers. Accordingly, the information on the total number

TABLE 1. - General hospitals designated as specialized centers, December 1943 and August 1944


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TABLE 2. - Authorized patient capacity for surgical specialties, June 1944 and June 1945

of Zone of Interior beds devoted as of June 1944 and June 1945 to each of the specialties listed in table 1 is furnished in table 2 for comparison.

    The creation of these specialized centers represented an effective solution to the problem of care of particularly complex cases or ones requiring specialized care or study. The care of such cases was greatly improved by this measure, and it represented a truly progressive innovation in the Medical Department's program which fostered specialized care by specialists.

SUMMARY

    The Surgical Consultants Division began as a branch of a subdivision in the Office of the Surgeon General and emerged as an independent division directly advisory to The Surgeon General. Throughout the war, its many and varied functions were directed along the following two primary lines: (1) To determine the most appropriate surgical methods of caring for the sick and wounded and to see that therapy thus standardized was carried out uniformly, effectively, and thoroughly; and (2) to initiate and participate in administrative and logistic actions which would bring together the patient and the proper surgeon at time right time and in facilities adequately equipped and supplied to accomplish the task at hand.

    A worldwide system of surgical consultants was established to realize these goals. Consultants in general surgery were on the staffs of each service command headquarters, with an additional consultant in orthopedic surgery where the caseload warranted his presence. Each theater of operations had its surgical consultants at the theater headquarters, and many had consultants in subordinate commands as well. There was a consultant in surgery in the medical section of the headquarters of each field army engaged in operations against the enemy. Additionally, eminent surgeons in the United States were appointed as civilian consultants, particularly in the various specialized fields of regional surgery where their knowledge and experience were indispensable.


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    Relationships between consultants in the Office of the Surgeon General and others in the Zone of Interior were close and direct, but, regrettably, relationships with consultants overseas were more indirect and distant.

    The surgical consultants in the Office of the Surgeon General worked with and through many agencies and offices-military, governmental, and civilian. Of the nonmilitary organizations, there was an especially harmonious association with the Division of Medical Sciences, National Research Council, in the attempt to solve the many perplexing surgical problems of the war.

    The remarkable surgical achievements of the war resulted in great measure from the establishment of this effective system of surgical consultants and the efforts of the men within this system.