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Chapter II

Contents

CHAPTER II

Orthopedic Surgery

Leonard T. Peterson, M.D.

ASSIGNMENT AND ORGANIZATION

Orthopedic Branch, Surgical Division. - Col. Leonard T. Peterson, MC, (fig. 4) was assigned as an orthopedic surgeon to the Surgical Division, Professional Service, Office of the Surgeon General, in September 1943. Upon reporting, he was given a friendly reception but no orientation or specific assignment of duties-probably because his was a newly created position. Almost immediately, a field trip was made with a group from the Office of the Quartermaster General to study the problem of rebuilt shoes. This trip proved to be very educational and a good introduction to the many duties which were to follow. Shortly thereafter, in December 1943, the Orthopedic Branch was officially established as a part of the Surgical Division. Colonel Peterson became chief of the Branch on 8 December 1943 and continued in this assignment and as consultant in orthopedic surgery to The Surgeon General until near the end of hostilities in 1945.

    Physical Therapy Branch. - Physical therapy activities in the Office of the Surgeon General were made a responsibility of the Orthopedic Branch in December 1943 upon formal establishment of that branch. The chief of physical therapy, Maj. Emma E. Vogel, had extensive professional and administrative experience in this field and provided immediate supervision and direction of personnel and training activities concerned therewith. The orthopedic consultant. assisted in matters of policy, directives, and publications. On all visits to hospitals, the orthopedic consultant inspected physical therapy activities and facilities. In February 1945, physical therapy activities in the Office of the Surgeon General were removed as a function of the Orthopedic Branch and made a separate Physical Therapy Branch under the Rehabilitation Division, Office of the Surgeon General.

    With reference to physical therapy treatment of orthopedic patients, it was always recommended that the type and limitation of various treatments be determined by the surgeon responsible for the treatment of any particular

1 This chapter, which covers the experiences and observations of the orthopedic consultant in the Office of the Surgeon General was written 10 years after the termination of World War II. The writing was based upon personal records, official reports, and a vivid recollection of many of the events of that period. Perhaps it was better that such events be recorded after a lapse of time, when the important issues were more likely to receive emphasis and the 1ess important problems seemed trivial by comparison.


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FIGURE 4. - Col. Leonard T. Peterson, MC, Chief, Orthopedic Branch, Surgical Division, Professional Service, Office of the Surgeon General, and Consultant in Orthopedic Surgery to The Surgeon General.

individual. Obviously, close liaison was necessary between physical therapists and the ward surgeon responsible for the definitive care and disposition of a patient.

FUNCTIONS AND DUTIES

Personnel

    Orthopedic surgeons. - An intimate knowledge was required of the qualifications, classification, and assignment of all orthopedic surgeons in the Zone of Interior. The orthopedic consultant recommended the initial assignment of orthopedic surgeons newly entering the service and, as necessary, recommended the transfer of key personnel. The recommendations were implemented through the Military Personnel Division. By reviewing the monthly rosters of general hospitals, replacement pools, and units leaving the United States for oversea duty, it was possible to keep informed as to the assignment of all orthopedic surgeons, who were classified A, B, or C according to their degree of skill and training. Almost without exception, it was found that


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medical officers with orthopedic training were properly assigned. There were, however, a few instances of trained surgeons serving in administrative positions overseas, and one certified orthopedist was assigned to selective service duties in his home State. Every recommendation or complaint on the placement of orthopedic personnel was promptly investigated and corrected.

    Enlisted orthopedic personnel. - Because of the shortage of trained enlisted personnel for brace and prosthetic shops, a survey was made of all qualified men in the Army, and their assignments were carefully scrutinized.

    Civilian consultants. - A number of civilian consultants were utilized in the nine service commands, and their initial appointment and travel orders were executed in the Office of the Surgeon General. A few specially qualified amputees were designated as consultants for the purpose of visiting amputation centers and instructing new amputees. These included Mr. Charles McGonegal, Mr. Donald Kerr, Mr. Harold Carlson, and Mr. Walter Bura.

Disposition Procedures

    Disposition from general hospitals. - Policies on the disposition and transfer of patients from and between hospitals in the Zone of Interior were established by The Surgeon General. The early discharge of patients to duty or placing them on leaves and furloughs meant a saving in hospital beds and hospital construction. Accordingly, one of the duties of the consultant in the Office of the Surgeon General was to uncover delays in disposition procedures and to expedite the discharge of patients. At the onset of the war, it was the practice to transfer patients no longer fit for military duty to the Veterans' Administration for treatment and discharge. It rapidly became evident, however, that the Veterans' Administration lacked the facilities and personnel to handle the large number of disabled. Furthermore, patients objected strenuously to discharge from the Army until they had reached maximum improvement. They felt that they received better care in the military hospital, and, in some instances, their incomes decreased upon separation from the service. This led to a change in procedures late in 1943 which called for the keeping of patients under military control until they reached maximum improvement. This plan necessitated extremely long hospitalization in many orthopedic cases. Delay in the disposition of patients was a common deficiency. The problem was not peculiar to the war period, for it has been observed in military and civilian hospitals before and since that time. Delays in disposition assume greater importance in times of emergency, however, and all personnel must be alert to the importance of keeping hospital time, per patient, down to a minimum.

    Interhospital transfers. - Another frequent observation was the unnecessary transfer of patients from station to general hospitals. In the wards of general hospitals, many patients were seen who did not require general hospital care--patients who should have been returned to duty from the sta-


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tion hospital. Additionally, convalescent hospitals were established to care for patients who did not need general hospital care and yet were not ready for discharge. But, with the increasing demand for hospital beds, many patients were sent to these convalescent hospitals only to be readmitted to a general hospital at a later date for additional definitive treatment. Qualified personnel were therefore required in convalescent hospitals properly to evaluate these cases before a decision was made as to their disposition--duty, discharge from the service, or readmittance to a general hospital. In many instances, time was lost in the disposition of patients when those who could have completed their definitive treatment at a general hospital and could have been discharged directly from the general hospital were needlessly transferred to convalescent hospitals.

Communications

    Preparation of policy directives. - Professional policies were largely determined at the hospital level in the Zone of Interior. In a few instances, directives on orthopedic policies and practices were published by The Surgeon General. One directive prepared by the consultant in orthopedic surgery for publication by The Surgeon General applied to the open treatment of compound fractures. Another applied to the principle of open amputation where amputation was required for infection or severe mutilating injury. The development of sulfonamides just before the war had led surgeons in civilian life to treat open fractures and emergency amputations by wound closure. The application of the same principles in war surgery, however, had led to disastrous results. Thus, it was necessary to promulgate these instructions directing that compound fractures and emergency amputations not be subjected to wound closure.

    Preparation of War Department Technical Bulletins (TB MED's). - . TB MED's were prepared from time to time as necessary in the Office of the Surgeon General. These bulletins were informative and advisory in nature. The consultant in orthopedic surgery prepared TB MED's on knee surgery, materials for open reduction, and the care of amputation stumps.

    Editorial review and professional assistance. - All professional papers submitted for publication which pertained to orthopedic subjects were reviewed by the orthopedic consultant. Assistance was given authors in preparing papers for submission to publishers. Disposition and retirement proceedings reviewed by the physical evaluation review board in the Office of the Surgeon General were often referred to the orthopedic consultant for opinion.

    Correspondence for The Surgeon General. - Of the many letters received by The Surgeon General, those pertaining to orthopedic problems were referred to the orthopedic consultant for review and reply. It was necessary to answer all these letters in a specific and courteous manner. Occasionally, very long and involved letters were received from obvious cranks. Such let-


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ters were disposed of in as simple a manner as possible in order to avoid involvement in an endless and useless correspondence.

Field Trips

    Approximately one-third of the patients in general hospitals in the Zone of Interior were charges of the orthopedic service. In many instances, the orthopedic census in a hospital exceeded 1,200 patients. Thus, nearly one-third of Colonel Peterson's time was spent on field trips visiting general and regional hospitals. Visits were made one or more times to all but 5 of the 65 general hospitals which were eventually established for the hospitalization of the U.S. Army. It was often apparent that the hospitals were burdened by the number of visiting consultants and inspectors in administrative and professional roles from various echelons. As a visitor from the Office of the Surgeon General, the author was always received with a spirit, of courtesy and cooperation. A few unpleasant experiences were encountered and these were probably due as much to the overzealousness of the consultant as to local conditions. As a rule, the commanding officer and his staff of an installation being visited made it possible for the visiting consultant to complete his mission in a pleasant and expeditious manner.

    These hospital visits of 1 to 3 days' duration were made to inspect the orthopedic service, to review the professiona1 work, and to determine the need for personnel and equipment. Ward rounds were made, and each patient was briefly examined with a review of his X-ray file. Details of previous treatment and proposed treatment and disposition of individual patients were made a matter of concern. General principles of treatment and policies pertaining to the military-medical situation were frequently discussed.

    It was interesting to note the patient's response and his appreciation of the individual attention which the visiting consultant might show in his case. All the patients on the ward were obviously attentive and interested in any comment which might. be overheard. It would, no doubt, have been interesting to have heard the comments the patients made subsequently in their discussion of the consultant's visit, but unfortunately--or fortunately--these are not a matter of record. Great care was necessary during such a brief visit to insure that comments and impressions did not reflect unfavorably on previous treatment of the patient. Every effort was made to reserve questionable details for private conference where any errors or omissions could be reviewed in detail.

    Upon the orthopedic consultant's return, brief reports on the hospital visits were made to The Surgeon General and forwarded through channels to the hospital. In five instances, it was recommended that the chief of the orthopedic section in a general hospital be replaced. Although several objections were raised to this change in personnel, the replacements were approved to the ultimate satisfaction of the commanding officers involved.


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Supplies and Equipment

    Scope of duties in connection with supplies and equipment. - Among the important duties of the orthopedic consultant in the Office of the Surgeon General were those concerned with supplies and equipment. For example, it was necessary to catalog and standardize the entire list of equipment and material necessary for orthopedic braceshops. In cooperation with the supply division, this was accomplished, and a satisfactory system of supply for these shops was established. Artificial limbshops presented a special problem with the growing demand for prostheses and for research and improvement in prostheses. Seemingly minor items such as hinge joints and rubber bumpers proved to be very important in the function and durability of an artificial limb. Surgical instruments, fracture tables, plaster bandages, and numerous other items required constant, almost daily liaison with the supply division. Writing specifications and planning procurement of items related to orthopedic surgery was a never-ending activity.

    Innumerable items of equipment and suggestions for new items were referred to Colonel Peterson if they pertained to orthopedic treatment. The enthusiasm of the inventor usually bore no direct relationship to the appropriateness of his device for use in the military service. Although many of the devices, such as splints, arch supports, special shoes, and prostheses, were not adaptable to military requirements, it was necessary to be constantly on the alert in order not to disregard appliances or suggestions of definite merit. For example, one manufacturer of arch supports maintained that every soldier should be equipped with at least two pairs of his supports, since wars were won or lost on the soldier's ability to march and surely this ability would be greatly enhanced by his product. Another item was a special shoe constructed with coil springs in the sole which would, according to the designer, relieve fatigue and unpleasant impact when the wearer ran or jumped. Numerous substitutes were proposed for Army splints and plaster of paris but were usually without merit.

    During the early years of the war, there was a lack of certain items of operating-room equipment which, in many instances, was due to the individual methods and requirements of the surgeon. Many instruments which had been nonstandard before the war had to be rapidly standardized and rushed into manufacture and procurement. It was necessary to adopt the policy to obtain instruments which would suffice for the greatest number, rather than to meet individual demands. For example, in standardizing equipment for hip nailing, the cannulated three-flanged nail was adopted. An eminent authority on this subject requested The Surgeon General to change from the cannulated to the noncannulated hip nail. This was a case where the recommendation was not consistent with military needs, and was not adopted. At another time, some defective Steinmann pins were supplied by one manufacturer, and many of these pins broke. The situation required immediate correction.


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    Similarly, plaster of paris was initially supplied in bulk, and plaster bandages were prepared locally in Zone of Interior hospitals. This procedure required hospital space and personnel needed for other purposes. At the same time, factory-rolled bandages were being shipped overseas. It became apparent that factory-prepared bandages were more economical and of better quality, but, in spite of the efforts of the orthopedic consultant, it was not until near the end of the war that they became available for hospitals in the Zone of Interior.

    Special problems and projects. - An orthopedic equipment problem requiring special investigation and administrative effort by this author was that of plates and screws for internal fixation. In 1943, it was discovered that plates and screws for internal fixation were defective and that the existing specifications and standards were inadequate. With the cooperation of the National Bureau of Standards, Department of Commerce, extensive testing was done on plates and screws - testing which ultimately led to improved specifications and the procurement of better products. This had a definite influence on the manufacture of these items after the war and led to improved plates and screws for both military and civilian use.

    Another problem requiring similar action by the consultant in orthopedic surgery was the need for special shoes for foot deformities. The need for such shoes became increasingly important with the return of battle casualties. The manufacture of special shoes from ordinary measurements or plaster casts had proved inadequate. With the cooperation of the Quartermaster General, a system was designed to obtain casts and measurements from an impression of the foot in magnetized steel balls which retained the weight-bearing imprint until a cast was made. Next, personnel had to be trained in this technique to staff six centers which were designated for providing special shoes. With rapid demobilization after the war, this method was subsequently discarded.

    Prostheses were a definite problem throughout the war years. It was the practice to obtain various types from manufacturers, and further fabricate them in local limbshops. But specifications for artificial limbs and accessories were very meager, and often items supplied were deficient in sonic respect. There was not sufficient inspection of the prostheses at the source to guarantee the desired quality. The lack of quality, however, was often due to difficulty in obtaining experienced personnel and necessary materials. These comments are not intended to reflect upon the supply services or manufacturers but are made in the interest of better procurement for any future emergency. Without adequate specifications, mass production, and careful inspection, it is not possible to supply adequately the needs of many thousands of new amputees in a country at war. Research and development on prostheses conducted during World War II and immediately thereafter are discussed in the paragraphs on amputations, which follow.


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Facilities

    As in the matter of equipment, there were also deficiencies in hospital facilities for the care of orthopedic patients. Perhaps the lack of facilities was more accentuated than that of equipment. Hospital plans had provided no plaster room. Through some misconception, a small plaster dispenser of a dental type was installed in time X-ray service for orthopedic use. It became necessary to use at least half of a hospital ward to furnish adequate plaster- and dressing-room facilities for orthopedic patients. Braceshop and X-ray facilities also were insufficient for the rapidly expanding number of orthopedic casualties. These deficiencies were gradually corrected as new hospitals were designed and built, and the consultant in orthopedic surgery shared in the efforts to effect these improvements.

AMPUTATIONS

Amputation Centers

    Establishment of amputation centers. - The orthopedic consultant's initial and, perhaps, foremost duty was the supervision and coordination of activities pertaining to amputations and prostheses. Five amputation centers were designated in March 1943 at the following Army general hospitals: Walter Reed General Hospital, Washington, D.C., Lawson General Hospital, Atlanta, Ga., McCloskey General Hospital, Temple, Tex., Percy Jones General Hospital, Battle Creek, Mich., and Bushnell General Hospital, Brigham City, Utah. The amputation center at Thomas M. England General Hospital, Atlantic City, N.J., was established in August 1944. The seventh, and last, center was designated at McGuire General Hospital, Richmond, Va., in January 1945.

    In 1945, amputees among Philippine soldiers came to the attention of The Surgeon General. These amputees were entitled to the same benefits of surgery and prosthetic fitting as others of the Armed Forces of the United States. Accordingly, it was necessary to provide for their treatment in the Philippine Islands2 or to transfer them to amputation centers in the United States. A plan was formulated in the Office of the Surgeon General in February 1946 to send a unit to the Philippines to establish an amputation center. This unit, organized by Colonel Peterson, included 3 officers (1 of whom was an amputee), 2 occupational therapists, 1 physical therapist, and 16 enlisted men trained in limb fitting. This group sailed from San Francisco on 18 April 1946 with necessary shop equipment and established an

2 Parsons, W. Barclay, Trimble, I. Ridgeway, and Eaton, George O.: Southwest Pacific Area. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume II. Chapter XII. [In preparation.]


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amputation center within 4 weeks of arrival in the Philippine Islands. A total of 192 amputees were treated, and there were 94 operations and 118 prosthetic fittings before the group departed in October 1940. A complete amputation center with equipment and trained Philippine personnel was transferred to the local authorities to meet the needs of the military and civilian amputees remaining.

    Amputation statistics. - On the basis of information derived from reports received from amputation centers, the Medical Statistics Division, Office of the Surgeon General, has estimated that about 15,000 men in the U.S. Army (including Army Air Forces) suffered amputations during the period from 1 January 1942 to 31 March 1946. The maximum census reported by these amputation centers for any one month was 9,240 in June 1945. The total number of amputees included in these reports was 14,782, broken down as follows:

Single amputation:
One leg -     10,620
One arm -    3,224
                                      13,844

Double amputation
Both legs - 870
Both arms - 57
                                           927

Triple amputation:
Both legs, one arm - 8
Both arms, one leg - 1
                                               9

Quadruple amputation -           2

Total -                           14,782

it should be noted that these estimates do not include nondisabling amputations of fingers or toes of U.S. Army personnel who, after treatment, were continued in military service. Moreover, these estimates, based on reports received from amputation centers in the Zone of Interior, exclude data on those amputees who did not reach these centers; for example, amputees who died overseas.

    Operation of amputation sections at centers. - Few doctors had much experience in amputations or prosthetic fitting before their military service. They rapidly gained experience, however, and attained very high standards of amputation surgery (fig. 5). With the aid of visiting medical consultants and representatives of the prosthetic industry, officers and enlisted men were trained in details of prosthetic fitting. Medical officers assigned to the amputa-


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FIGURE 5. - Amputation of upper extremity.  A. Amputation site.  B. Fitted prosthesis.  C. Limb fabrication for double amputation.

tion sections were responsible for the surgery, postoperative care, prosthetic fitting, and rehabilitation of the amputees. Each medical officer on the amputation sections at the centers had from 75 to 100 patients under his care, which was more than an average workload.

    Informal monthly reports were sent to the consultant in orthopedic surgery in the Office of the Surgeon General from each amputation center. These one-page reports designated the various types of amputations and surgical


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procedures being carried out and the prosthetic fittings being used and included statistics on admissions, dispositions, and census. Each report was obtained directly from the chief of the amputation section in spite of occasional protests from various sources. It was believed that this method of direct reporting was justified, since amputations constituted a special problem in which close liaison was necessary between time orthopedic consultant in the Office of the Surgeon General and each officer in charge of an amputation section at the centers. These reports supplied valuable information with the least possible delay.

    Conferences. - Several conferences were held during the war years on amputation centers and amputation activities. An international conference met in Ottawa and Toronto in February 1944. Chiefs of the centers met on three occasions during national orthopedic conventions in 1944 and 1945. A conference was held in Washington, D.C., and at McGuire General Hospital in June 1945 to consider amputation technique, prosthetic problems, the history of amputations in World War II, and projected research and development.

Research in Artificial Limbs

    Committee on Artificial Limbs. - Research in artificial limbs was almost nonexistent before 1945. Prostheses had gradually evolved through the efforts of individual manufacturers. The available prostheses were quite satisfactory for the lower extremity. From both the cosmetic and functional standpoint, the devices for the upper extremity were still inadequate. At the request of The Surgeon General, the National Research Council established the Committee on Prosthetic Devices (later called the Committee on Artificial Limbs) in February 1945. It was hoped that this committee would help to improve rapidly the specifications and manufacture of prostheses for the military service. This, however, proved to be a long-range research program, and the work of this committee did not actually benefit the amputees in 1945 and 1946 or for several years thereafter. Meanwhile, the U.S. Army established the Army Prosthetics Research Laboratory at the Walter Reed Army Medical Center, Washington, D.C., in August 1945, and the work of this laboratory has resulted in greatly improved cosmetic and functional hands (fig. 6). The Committee on Artificial Limbs continued to be supported by the Veterans' Administration and the U.S. Army in the conduct of research by contract with universities and manufacturers during the postwar years.

    Commission on artificial limbs. - In March and April 1946, a commission on artificial limbs directed by Colonel Peterson and including Maj. Rufus H. Alldrege, MC, and Dr. Paid Klopsteg, chairman of the Committee on Prosthetic Devices, visited Europe for the purpose of studying amputations and prostheses. The tour included England, France, Germany, Switzerland, and Sweden where numerous amputation centers and limb shops were observed.


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FIGURE 6. - Army Prosthetics Research Laboratory. A. Machine shop. B. Electroforming mold for cosmetic glove. C. Finishing cosmetic gloves in the processing laboratory.


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FIGURE 7. - Cineplasty surgery and prostheses, Sauerbruch type. A. Cineplasty, proximal third of forearm, end view. B. Prostheses with Hüfner hands, flexed.

    Two developments received special attention by the commission during its tour. One was cineplasty for the upper extremity (fig. 7), and the other, suction sockets for the lower extremity (fig. 8). Subsequently, both subjects underwent intensive research in the United States and the principles were applied with increasing popularity after World War II.

LIAISON AND COOPERATIVE ACTIVITIES

    Within the Office of the Surgeon General. - There was excellent liaison and cooperation between the orthopedic consultant and the various divisions of the Office of the Surgeon General. Records in the Military Personnel Division, Personnel Service, Office of the Surgeon General, were available at all times for review. Recommendations made by the consultant for the assignment and transfer of orthopedic personnel were implemented by the Military Personnel Division, without delay. The Physical Standards Branch, Medical Division, Professional service, frequently consulted the Orthopedic Branch with reference to standards on the musculoskeletal system as applied to enlisted and commissioned personnel. Frequent informal conferences were held with representatives of the Medical Supply Division, Supply Service, Office of the Surgeon General, on specifications, requirements, and procurement


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FIGURE 8. - Suction-socket artificial limb with two-way valve (J. A. Hanger) developed from German prototypes. A. Lateral view of prosthesis. B. Amputee and prosthesis. C. Fitted prosthesis.

of all orthopedic supplies and equipment. The Medical Supply Division endeavored to meet every need for the proper professional care of orthopedic patients.

    There were many conferences and cooperative projects with the Training Division, Operations Service. These related to the preparation of training and field manuals, especially on such matters as first aid, transportation of the wounded, and other technical training subjects. A number of motion pictures were made, in conjunction with the Training Division, on orthopedic topics. There was a documentary film for amputees, "Swinging into Step." Several motion pictures, such as "Meet McGonegal" and "Diary of a Sergeant," pertained to upper-extremity amputees. Other motion pictures and filmstrips covered the technical aspects of amputation surgery and the care and training of amputees. A film, "Plaster Casts," was made for the training of plaster-room technicians and other personnel.

    With the service commands. - The relationship of the consultant in the Office of the Surgeon General with the various service commands was of considerable importance. The service command surgeon was naturally desirous of maintaining his authority and integrity and, on occasion, objected to direct communication between the orthopedic consultant in the Office of the Surgeon General and consultants or hospital personnel within his service command.


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    On several occasions, criticism was directed through channels to The Surgeon General because of direct communication by telephone or letter, from the orthopedic consultant in the Office of the Surgeon General to the chief of orthopedic service in a hospital. Nevertheless, many problems and questions arose which could have been, and were, expedited through direct communication without impairing the prestige or authority of commanding officers of hospitals or surgeons of service commands.

OBSERVATIONS ON CARE OF ORTHOPEDIC INJURIES

    Errors and omissions were occasionally observed in the professional care of patients with orthopedic injuries. In general, the standards of treatment were exceptionally high and surgical technique was excellent. The residency training program in civilian hospitals had furnished sufficient trained orthopedic surgeons so that several were available for each of the larger hospitals. Their assistants, who had had 1 or 2 years of formal training, and others, who were rapidly trained in the Army, became proficient in their assignments. In spite of the heavy workload carried by the individual orthopedic surgeon in a hospital--from 75 to 100 patients per medical officer--serious delay in surgical treatment or disposition was rarely encountered. The following observations were noteworthy:

    Overtreatment. - Several aspects of overtreatment were common. In the early months of the war, many upper-extremity injuries had extensive immobilization of the hand which prevented active use of the fingers, especially at the metacarpal-phalangeal joints. This resulted in unnecessary stiffness and prolonged incapacity. The consultant directed that prompt attention be given to mobilization of the hand at the proximal palmar crease in order to avoid fibrous ankylosis of the metacarpal-phalangeal joints. Some undisplaced fractures of the long bones which were not in danger of displacement or nonunion were overtreated by prolonged immobilization. For example, undisplaced fractures of the head and neck of the humerus, the head of the radius, and the pelvis and march fractures of time foot required minimal immobilization.

    Internal fixation of compound fractures. - Compound fractures required emergency surgery and debridement. When it was necessary to delay the emergency surgery, in some instances internal fixation was performed several days later after the optimum time and yet before the danger of infection had passed. When the debridement and fixation could not be performed immediately, it was not advisable to apply internal fixation until the wound had completely healed. Failure to observe this principle resulted in osteomyelitis and prolonged morbidity.

    Fractures of the femur. - Fractures of the femoral shaft were immobilized in a plaster spica for transportation to the Zone of Interior, where the cast was removed and the femur was placed in traction and balanced suspension


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until union was firm. If the cast was maintained too long, considerable stiffness and atrophy resulted. If traction was removed before union was firm, deformity or nonunion followed. It was often demonstrated that both the clinical and X-ray examinations were essential to establish the degree of bone union. Occasionally, X-ray suggested union while clinical examination revealed definite nonunion.

    Delays in operation. - Delay in operation was noted in three types of cases which deserve special mention. First, chronic osteomyelitis with sequestration was often treated conservatively after operation was indicated. Next, chronic skin ulceration was allowed to continue after skin grafting was indicated to hasten recovery. On the other hand, this author observed that the principle of early sequestration followed in a few days by skin grafting of the saucerized wound was especially noteworthy on the service of Dr. Robert P. Kelly, Jr., at Ashford General Hospital, White Sulphur Springs, W. Va. Finally, many cases with definite meniscus injury were continued unnecessarily long on conservative treatment when surgery was unquestionably required. The delay in surgery for injured meniscus was a reaction to the frequent arthrotomy which was noticeable in the early months of the war when cases had not been carefully selected and no postoperative rehabilitation had followed. The long-established principle of meniscectomy for internal derangement had unjustly lost stature. Fracture or dislocation of a meniscus was a very common injury among military personnel, and the need for surgical treatment was usually obvious.

    Rehabilitation. - The importance of rehabilitation was nowhere more apparent than in the postoperative meniscectomy cases. In early hospital visits, only a few places and an adequate rehabilitation program. While the need for this rehabilitation had long been recognized in the military service as an essential part of the postoperative care, repeated emphasis and education were necessary before the principles of quadriceps exercise were generally recognized and applied. An outstanding example of a good rehabilitation program in postoperative knee cases was observed in 1943 on the service of Maj. (later Lt. Col.) Robert L. Preston, MC, at Nichols General Hospital, Louisville, Ky. The later development of a resistance exercise program is attributed to the work of Capt. Thomas L. De Lorme, MC, and Maj. Francis E. West, MC, at Gardiner General Hospital, Chicago, Ill.

SUMMARY AND RECOMMENDATIONS

    Orientation to duties. - At the time of his assignment, a professional consultant should be rapidly but thoroughly oriented in his duties and in the limitations of his assignment.

    Hospital visits and inspections. - Consultants must spend a great deal of time in travel under hardship conditions that are not readily apparent. Wartime travel and accommodations were fairly rugged even in time Zone of


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Interior. A clean room with a comfortable bed, one easy chair, and a good lamp were minimal accommodations which were not always available. The hospitality to the visiting consultant contributed considerably to warm relations during his inspection. The reception given to the consultant in the "front office" of a hospital being visited was often an indication of the spirit of the command. The visitor had to be prepared for the occasional cool reception by a hospital commander who was too harassed by other important problems.

    Hospital inspections were very strenuous when they involved, as they usually did, the examination of several hundred patients daily and the evaluation of professional personnel. Consequently, it was necessary to put hospital personnel at ease as early as possible during the inspection. The sudden descent on a hospital of a large number of consultants as in the wartime "Flying Circus" trips must have left the hospital a little washed out after the visit was completed. These massive inspections often lacked the atmosphere of personal contact, and, in the opinion of the writer, the mission could have been better accomplished by a less explosive type of inspection.

    The amputee. - Among the various types of battle casualties, amputees presented a unique problem. The emotional and physical disturbance resulting from the loss of one or more limbs required a prolonged period of treatment and readjustment. The congregation of a great many amputees, with their multiple problems in prosthetic fitting and training, presented a public relations problem of considerable magnitude. An extensive file of headlines and newspaper articles pertaining to amputees was a constant reminder of the necessity of meeting this problem with a planned program in personal and public relations. The writer is hopeful that continuing programs in prosthetic research will furnish good prosthetic devices, and thus obviate some of the difficulties of World War II. Nevertheless, comparable problems in prosthetic fitting, rehabilitation, and social readjustment of the amputee are likely to recur in a time of all-out war.