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Chapter VII

Contents

CHAPTER VII

First Service Command

Condict W. Cutler, Jr., M.D.

    Consultation service in surgery began in the First Service Command upon appointment of Lt.. Col. (later Col.) Condict W. Cutler, Jr., MC, as consultant in general surgery in December 1943. Colonel Cutler reached his station, Boston, Mass., on 12 December. A few days earlier Maj. (later Lt. Col.) Wilfred Bloomberg, MC, had been assigned as neuropsychiatry consultant, and shortly afterward Lt. Col. (later Col.) George P. Denny, MC, arrived to become the service command medical consultant. It was immediately necessary to establish a plan of procedure with the service command surgeon and the headquarters staff as to the consultants' duties and the methods of carrying them out. It was decided first to begin an evaluation of professional personnel.

    This function of professional evaluation continued throughout to be a major activity of the surgical consultant. Repeated visits, questioning, and observation served to correct impressions of the qualifications of professional personnel. The classification of medical officers became a formal process on a national standard in June 1944. 1 It remained the function of the consultant to verify the correctness of the military occupational specialty numbers assigned to individual officers.

    In initiating visits to installations, the service command surgeon proposed that visits by the consultants be made in a group. The consultants felt that separate visits would not impose inconvenience on the staffs of the hospitals, since their activities would involve different services. It was recognized also that the needs of hospitals for visits by the consultants would differ considerably and that the arrangement of team visits would result in unnecessary visits by certain consultants. They were agreed that visits by consultants should be arranged individually and that each, with the approval of the service command surgeon, should work out his own schedule according to his best judgment.

    Subsequent events proved the correctness of this attitude. When visits were undertaken as a team, virtually all work at a hospital was temporarily interrupted. The length of time required by the three consultants for the completion of their work differed considerably. After several team visits had been made, the plan of combined visits was abandoned.

    The surgical consultant prepared an outline on the purpose of consultant visits which included the following points:

    1. Observing (1) the care and handling of patients, (2) the adequacy, maintenance, and condition of medical facilities and equipment., (3) the pro-

1 War Department Circular No. 232, 10 June 1944.


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fessional abilities of medical officers, (4) the extent of employment of medical officers to the best advantage, (5) the maintenance of standards, ethics, therapy, and educational activities, (6) the status of cooperation, leadership, and morale, (7) the degree of efficiency in records maintenance, and (8) the degree of efficiency in the movement of patients to final disposition.

    2. Making recommendations at the installation for the improvement of any condition which might require only local action.
    3. Determining personal problems, aspirations, and attitudes of medical officers.
    4. Consulting with the professional staff on technical problems.
    5. Promoting educational activities by (1) bedside discussion of cases, (2) arranging staff meetings, conferences, et cetera, (3) arranging graduate medical meetings and programs, (4) encouraging medical officers to pursue candidacy for specialty board certification and professional societies, (5) giving talks, lectures, or demonstrations, and (6) encouraging clinical research.
    6. Rendering reports on the above matters.

    There was a tendency at first on the part of hospital commanders to refer to consultant visits as inspections and to expect investigation, criticism, and a formal report. Every method was employed to have it understood that the purpose of the consultant's visit was purely professional and that it was intended to be constructive and profitable. Very shortly, the feeling of apprehension was overcome and the visits were thereafter welcomed.

    In addition to the regular visits, hospital officials were given to understand that the surgical consultant would at all times be at the call of hospitals for aid in clinical problems. It was agreed that the chiefs of service in hospitals should have free access by phone or letter to the surgical consultant for personal discussion of professional problems. This arrangement contributed greatly to the effectiveness of the consultant's services.

    It was believed desirable to effect a close cooperation with the personnel officer in the office of the service command surgeon. It was necessary that the consultants be consistently informed of changes and transfers of personnel and that serious consideration be given to their recommendations. All effective working agreement was established with the personnel officer. The necessity for this arrangement was shown by the need for numerous adjustments of the staffs of various hospitals to accommodate for shortages created by transfer of officers for oversea assignments. It was necessary also that the personnel officer be aware of the identity of key medical officers and that he request replacements should they be reassigned. He was guided largely by the consultant as to the professional acceptability of replacements and as to their placement.

    There was at first a tendency on the part of hospital commanders to assume that the assignment of professional personnel to positions of relative importance of the surgical staffs should correspond with their relative ranks. This policy would not have led to maximum efficiency since there were instances in which the degree of professional competency was not consistent with mili-


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tary rank. Eventually, the principle was established that assignments as chiefs of service or chiefs of section would be governed by professional capacity. This permitted the placement of the most able men in positions of professional control with men of less competence, even though of higher rank, under their supervision.

    As the exigencies of the military situation required the withdrawal of surgeons for oversea service, it was the practice of the Office of the Surgeon General to offer replacements. The policy of permitting the Zone of Interior establishments to absorb the timelag involved frequently produced troublesome shortages of personnel. This lag was not infrequently as long as from 60 to 90 days and required local adjustments of personnel. When general shortages existed, as was the case with orthopedists and eye, nose, and throat specialists, such adjustments were not readily effected.

    To aid in the work of Lovell General Hospital, Fort Devens, Mass., when medical officer shortages existed, it was customary to utilize officers of the Medical Department Replacement Pool at Lovell. This aid would have been of great assistance at other hospitals could these officers have been assignable on temporary duty to them. Authority thus to utilize their services was lacking. Recently commissioned officers assigned on an intern basis, however, proved very helpful as ward officers.

    Another personnel difficulty arose from the transfer of trained enlisted technicians for oversea assignments. The necessity for constantly retraining replacements to take the places of well-trained orderlies, operating-room assistants, and other technicians imposed a serious handicap on surgical activities at hospitals.

    The surgical consultant visited all hospitals as frequently as possible. In 1944, the consultant made 42 regular visits to 18 hospitals and numerous special visits in response to calls. Numerous special visits were also made in company with The Surgeon General, specialist military consultants, and civilian consultants.

    On regular visits, special inquiries were made, as directed by Brig. Gen. Fred W. Rankin, Director, Surgical Consultants Division, Office of the Surgeon General, on the treatment of hernia, pilonidal disease, skin-grafting, and varicose veins, and also on the furnishing of eyeglasses, surplus instruments, anesthesia and anesthetics, the use of tourniquets, and other matters.

    On 12 June 1944, as a check on the surgical services, Colonel Cutler sent a letter to all chiefs of services through their hospital commanders. This letter began: "In expectation of increasing activity in the Hospitals of this Command, it is desirable that the following matters concerning each Surgical Service should be examined at the present time and corrective measures taken wherever appropriate." The letter detailed requirements and standards with respect to : (1) Personnel, including officers, nurses, physiotherapists, corpsmen, and technicians; (2) equipment and supplies, such as instruments, sterilizers, and central supply; (3) operating room, including physical equipment,


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management, aseptic and operative technique, anesthesia, and postoperative care of patients; (4) ward services, comprising arrangement, supplies, instruments and dressings, and dressing and treatment technique; and (5) laboratory service. The letter also concerned X-ray, physiotherapy, reconditioning, and staff activities, including ward rounds, conferences, reviews of current literature, investigation and preparation of original material, and the progress of individual staff members toward licensure by the American College of Surgeons and the various boards.

    During July 1944, the consultant surveyed activities in anesthesia throughout the command and reported the results to General Rankin.

    Other activities of the surgical consultant consisted of giving talks and demonstrations, participating in clinics and conferences, assisting in the program of the Committee for War-Time Graduate Medical Meetings, and acting as consultant in reconditioning activities. Reports on his activities were regularly rendered to the service command surgeon, to General Rankin, and, more formally as indicated, to The Surgeon General. These reports provided the material from which much of the narrative to follow was obtained.

MEDICAL INSTALLATIONS AND FACILITIES

    During the latter part of December 1943 and the first part of January 1944, Colonel Cutler made. a complete round of visits to hospitals of the command. At this time, the medical treatment. facilities of the First Service Command were dispensaries; station hospitals of the harbor defenses, ports of embarkation, training camps and centers, and airfields; and general hospitals.

    Dispensaries were located. at service command headquarters and Fort Banks for the Boston area, at Watertown Arsenal, Mass., at Springfield Armory, Mass., at various institutions of learning where there were training cadres and military students, and in certain separate battalions. At each of the dispensaries, there were officers capable of administering minor surgical treatments and of determining cases requiring hospitalization. Until the close of war, changing conditions affected these facilities very little. They continued to serve the outpatient needs of their areas.

    The station hospitals of the various harbor defense posts of the Eastern Defense Command were important factors at the beginning of 1944. The harbor defenses were maintained at nearly full authorized strength and required full manning of their station hospitals. In addition to their normal duties, these hospitals made examinations for induction, cared for certain dependents, and treated casuals taken ill or injured in the neighboring areas. Most of these station hospitals were housed in permanent brick buildings on the old posts, and many of them maintained subsidiary hospitals, as well as dispensaries, at outlying posts.


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    Typical of these hospitals was the station hospital at Fort Banks. This hospital received patients from the Harbor Defenses of Boston and also served as the admitting hospital for all military personnel in the area of metropolitan Boston. In 1943, it treated 5,570 patients. In January of 1944, its rated capacity was 205 beds. There was considerable crowding, and it was necessary to use auxiliary wards. The staff of Fort Banks Station Hospital controlled medical treatment facilities at Fort Strong, where the facility was then being operated on dispensary basis; Fort Warren, which had a 25-bed station hospital; and Fort Ruckman, Fort Dawes, Fort Revere, Fort Heath, Fort Duvall, and Fort Standish, all six of which had facilities operated on a dispensary basis. Fort Andrews had a 75-bed permanent hospital building. The forts were subposts of Fort Banks.

    The other harbor defense station hospitals were the station hospital at Fort H. G. Wright, located on Fisher's Island, N.Y., and serving the Harbor Defenses of Long Island Sound; the one at Fort Adams, Newport, R.I., serving the Harbor Defenses of Narragansett Bay; the one at Fort Rodman, serving the Harbor Defenses of New Bedford, Mass.; the station hospital at Camp Langdon near Portsmouth, N.H.; and that at Fort Williams, serving the Harbor Defenses of Portland, Maine.

    At the time of the earlier visits, these installations were quite active and, because of the number of troops in the harbor defenses, it was necessary to maintain all adequate and competent surgical staff in each. During the succeeding year, however, there was a steady withdrawal of personnel from these stations. This permitted a considerable reduction of the surgical staffs and the release of officers for assignments overseas. The policy was then adopted of reducing to dispensary status the number of outlying station hospitals in the various harbor defense posts and concentrating the resulting excess medical officers in major station hospitals. With the opening of Waltham Regional Hospital, Waltham, Mass., on 1 February 1944, the hospital at Fort Banks was reduced to a dispensary status. At each of the retained station hospitals, it was necessary to keep a surgical staff competent in diagnosis and prepared to perform emergency operations and elective procedures of a nonformidable nature. The surgical staffs of the harbor defense hospitals maintained all excellent, record of efficiency.

    At Camp Myles Standish, Mass., there was maintained an active station hospital under the authority of the Boston Port of Embarkation. This hospital served a staging camp during a period of troop movements overseas. The census at the camp varied greatly between 5,000 and 30,000 troops. Patients from among these personnel in transit were, for the most part, suffering from training injuries and emergency ailments. During the early part of 1944 there were many patients suffering from chronic disabilities which made them unfit for oversea service. To remedy this situation, efforts were made to have the responsibility for the discovery of such conditions fixed definitely at the stations of origin. In the latter months of 1944, patients taken from shipments


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because of hernia, pilonidal disease, internal derangements of the knee, and other chronic conditions appreciably lessened.

    As the shipment of soldiers overseas diminished, there was a consistent decrease in the activity of this hospital. Accordingly, on 25 January 1945, the hospital at Camp Myles Standish was designated a debarkation hospital to replace the hospital at Camp Edwards, Mass. It continued to serve for the reception, temporary hospitalization, sorting, and redeployment of patients returned from oversea hospitals.

    At the inception of the consultation service, large station hospitals were maintained at Camp Edwards and Fort Devens. Although both of these camps had passed the peak of their training activity, the hospitals were still fairly active and maintained full surgical staffs. The station hospital at Fort Devens had a 1,550-bed capacity, and on the occasion of the surgical consultant's first visit there were 589 patients. The hospital at Camp Edwards had 724 patients at this time, of whom 394 were surgical. The latter also hospitalized patients of the East Coast Processing Center, Camp Edwards.

    The census at Edwards and Devens fluctuated considerably with a general trend downward. This permitted a reduction in the surgical staffs and the release of personnel for oversea service. On 15 July 1944, the station hospital at Fort Devens was assimilated as a part of Lovell General Hospital.2 Some of the surgical staff of this station hospital joined Lovell, and others were used to augment the staff of the recently opened Waltham Regional Hospital.

    On 24 July 1944, the station hospital at Camp Edwards was designated as a debarkation hospital. The hospital continued to serve in this capacity until 25 January 1945 when the debarkation function was taken over by the hospital at Camp Myles Standish. Camp Edwards Station Hospital was then redesignated as the U.S. Army General Hospital, Camp Edwards. Later, a hospital center was activated at Camp Edwards to administer the general hospital and the Camp Edwards Convalescent Hospital.

    It was part of Colonel Cutler's earlier duties to visit hospitals at Army airfields. At the beginning of 1944, there were four airfields of the Air Transport Command three of which were located at Presque Isle, Houlton, and Bangor, Maine. The fourth was Grenier Field, Manchester, N.H. Hospitals of the First Air Force were at Bradley Field, Conn., and Westover Field, Mass. The functions of these hospitals were similar to those of the station hospitals of the ASF (Army Service Forces). They were prepared to deal quickly with severe casualties in considerable numbers resulting from a plane crash. There was set up in each an emergency room equipped with all needed instruments, dressings, splints, medication, laboratory apparatus, and plasma. Considerable ingenuity was employed in perfecting these arrangements and in the preparation of "crash bags" for use in the field.

    A station hospital was also maintained at the Army Air Forces Technical School, New Haven, Conn. Most of the patients were students in training

2 General Orders No. 124, Headquarters, First Service Command, 11 July 1944.


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courses at Yale University and casuals in the New Haven area. In January 1945, the hospital was closed.

    Consultation service was provided to these Air Force installations until the First Air Force called for its discontinuance. In May 1945, this service was resumed on an invitational basis. In all respects, except reporting, the service rendered to these hospitals was of precisely the same character as that accorded to hospitals of the Army Service Forces. Invitations to the consultants to visit these installations and requests for emergency consultation were frequent after May 1945 and were promptly responded to. The closest liaison was maintained with the Westover Regional Hospital at Westover Field, Chicopee Falls, Mass. This hospital maintained an efficient staff and functioned effectively.

    On 27 June 1944, Waltham Regional Hospital was opened. It was designed to accept patients from all the outlying station hospitals. As the receiving hospital for the Boston metropolitan area, it took over the functions of the station hospital at Fort Banks. In addition, it hospitalized casuals in the area and dependents. The staff, strengthened by personnel transferred from the former Fort Banks and Fort Devens Station hospitals, was organized as for a general hospital and dealt with all types of emergency and elective surgery.

    Until the opening of Waltham Regional Hospital, Lovell General Hospital received all cases of major surgery occurring in the command, together with a few casualties from overseas. In February 1944, Lovell General Hospital--of wooden barracks construction-had 400 patients on the surgical services. Its staff, under Maj. (later Lt. Col.) Clifford H. Keene, MC, was of a high order of competence. There were sections of general surgery, orthopedic Surgery, neurosurgery, urological surgery, and an active ear, nose. and throat service. Subsequently, neurosurgical and plastic work, as well as ophthalmologic surgery cases, were transferred to Cushing General Hospital, Framingham, Mass. Lovell continued throughout the war as a general hospital and received increasing numbers of oversea casualties. On 15 July 1944, Lovell General Hospital absorbed the Fort Devens Station hospital. This additional capacity was quickly utilized, and at the close of the war Lovell General Hospital was operating with full wards.

    Cushing General Hospital had not opened at the time of Colonel Cutler's arrival. Its staff, however, had been gathered and was being trained. On 25 January 1944, this hospital opened formally with Maj. (later Lt. Col.) Robert L. Mason, MC, as chief of surgery. At first, it received mostly cases originating within the Service Command. When oversea casualties began to be received in increasing numbers in the summer of 1944, the Zone of Interior patients were diverted to Waltham Regional Hospital. The accession of patients at Cushing General Hospital became more rapid with the designation of this hospital as a neurosurgical center and, subsequently, as a center for plastic surgery and ophthalmology.3 Its bed capacity was

3 War Department Circular No. 347, 25 Aug. 1944.


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eventually expanded to 2,168, and it was rapidly filled and remained so at the chose of hostilities.

EARLY CLINICAL PROBLEMS

    Before the arrival of the consultant in surgery, each hospital commander determined the type of surgery which his staff was capable of performing. Occasionally, there were being undertaken at station hospitals formidable and elective operations on the intestinal tract and kidneys and orthopedic procedures such as bone grafting of fractures and the surgical care of internal derangements of the knee.

    On 10 January 1944, War Department Circular No. 12 defined the policy of the War Department as to the transfer of patients to general hospitals. The circular stated that elective surgery of a formidable type is normally a function of general hospitals and that patients requiring such operations would be transferred to the nearest general hospital as soon as transportable. This changed the surgical services of the station hospitals considerably. There was at first some resentment on the part of the station hospital personnel at being deprived of valuable clinical material, but it soon came to be understood that the policy worked to the best interest of the patients.

    The provisions of this circular necessitated some readjustment of surgical personnel. It became possible to strengthen considerably tile surgical staffs of general hospitals by the transfer of competent surgeons from station hospitals as more and more of the general hospital surgeons were withdrawn by the requirements of oversea service. Besides, the policy assured the patients of more skillful management. of their formidable surgical conditions, while it by no means deprived the station hospitals of a considerable number of problems with which their surgeons were qualified to deal.

    The performance of operations for hernia in station hospitals was by no means uniform. One of the early activities of the surgical consultant was an effort to standardize the performance of this operation as outlined by the Office of the Surgeon General.4

    The provisions of Circular Letter No. 72, Office of the Surgeon General, dated 17 March 1943, in regard to the treatment of varicose veins were also emphasized. A more judicious use of the methods of diagnosis and of treatment by ligation and injection was undertaken.

    The provisions of Circular Letter No. 169, that patients with uninfected pilonidal cysts and sinuses should be operated upon, whenever possible, before infection occurred, had resulted in a considerable number of these operations. Almost universally, operation resulted in late healing and considerable loss of time and manpower.5 Colonel Cutler surveyed this situation and analyzed 594 operations. The average length of hospitalization was 53 days. Primary

4 Circular Letter No. 121, Office of the Surgeon General, U.S. Army. 13 July 1943.
5
Circular Letter No. 169, Office of the Surgeon General. U.S. Army, 25 Sept. 1943


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union had failed in 23 percent of cases in which complete closure was done. The following statement was made by Colonel Cutler in a letter to General Rankin, dated 21 February 1944:

    I have been greatly surprised to observe the large incidence of this condition among our troops. I believe that the fundamental congenital defect is a common one, but only in rare instances is it the source of sufficient inconvenience to the civi1ian patient to make him seek surgical relief. Infection of the sinus with abscess formation requires drainage. Repeated episodes of this sort lead to an extirpation of the source of trouble Hence, in civil life, the surgeon sees only those cases which are complicated and troublesome.

    Although the less cleanly life of combat troops may lead to a larger incidence of infected eases, I have no doubt that a great majority would go through a military experience with little more trouble than is encountered in civil life.

    The extirpation of all discoverable pilonidal sinuses in the Army represents a policy of perfection, beneficial results of which are outweighed by loss of manpower. Minor variations in technique make relatively little difference in the time required for healing, which, in most instances, is inordinately long--often thirty to ninety days. I advise against the tight-closure procedure. I feel sure that we shall see a good many recurrences. Even at this relatively early date, a number have been seen.

    I believe that pilonidal sinus which does not produce active symptoms should be left alone. Infection should be dealt with by incision and drainage. One or more repetitions of infection should require the excision of the sinus with, at most, suture of the skin to the presacral fascia without attempt at side-to-side closure. I believe such a policy would certainly save a vast number of days of hospitalization.

    On 2 September 1944, War Department Technical Bulletin (TB MED) 89 appeared, rescinding The Surgeon General's Circular Letter No. 169 and stating, '"* * * true pilonidal cyst and sinus without purulent discharge, infection or history of acute abscess or inflammation will not be considered disqualifying for continued general military service, provided the condition does not interfere with the performance of the individual's duties in his military occupation specialty. Operation will not be performed in these cases, except as indicated in cases of infected cysts and sinuses."

    Among the early clinical problems was that of persistent urethritis, both specific and nonspecific. There were many cases of gonorrheal urethritis which had proven resistant to sulfonamide therapy. Penicillin had not as yet come into general use for this condition. Some sulfa-resistant cases were being treated with fever therapy. While it appeared in some instances to be beneficial, fever therapy was decidedly unpopular with the victims and led to many problems of discipline. The procedure was also attended by some danger. The greater efficacy, speed, and safety of penicillin therapy proved a valuable change.

    In the handling of nonspecific urethritis, penicillin proved less successful. There was a different method of treatment in almost every hospital visited. All of these measures seemed to be equally ineffective.

    Three common types of injury occurred as a result of training activities or sports. They were sprained ankles, fractures of the carpal navicular bone, and internal derangements of the knee.


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    Sprained ankles were the most common injury. The orthopedists were about equally divided as to the relative efficacy of (1) rest with immobilization for a short time followed by walking with supporting strapping or (2) treatment by procaine hydrochloride (Novocain) injection and full unsupported use at once. The popularity of the latter treatment waned in favor of treatment by rest and support which came to be generally readopted.

    Carpal navicular fractures were more common than Colles' fractures. No doubt a good many of these were missed and masqueraded as sprains of the wrist. A number were picked up when, on direction of the consultant, it became the rule to make four X-ray exposures of every injured wrist--anteroposition, lateral, and two oblique. Prolonged immobilization in the position of function produced almost uniformly excellent results.

    Traumatic internal derangements of the knee, especially injuries of the semilunar fibrocartilages, were also encountered with some frequency. The policy of placing these cases in general hospitals was productive of better results. A factor in earlier recoveries was preoperative quadriceps exercise and its early resumption after operation.

    One training hazard was a directed exercise in which a soldier, seated on the shoulders of a companion, wrestled with another, similarly mounted. This maneuver resulted in three fractured femurs within a 2-week period, and its discontinuance was recommended by the consultant. At about this time, injuries from supervised athletics and physical training exceeded 14 percent of all injuries from military accidents. 6

    As combat casualties began to appear at Lovell General hospital, very satisfactory work had already been begun in the treatment of injuries of the soft parts and of the intestinal tract. There was still an inclination to treat compound fractures of long bones by the closed-plaster method or with dressings through windowed casts. The importance of knee mobilization and of the quadriceps exercises was not yet fully understood. Progress in the institution of skeletal traction was rapidly made, and special attention was given to the program for the activation of joints.

DEVELOPMENT OF THE GENERAL HOSPITALS

Lovell General Hospital

    The gradually increasing influx of surgical patients from oversea theaters required the gradual expansion of Lovell General Hospital and its eventual absorption of Fort Devens Station Hospital. In February 1944 there were only 400 surgical beds occupied by patients at Lovell General Hospital, and by the end of August 1945 there were over 2,600 surgical patients. In August 1944, a reconditioning center at Fort Devens became a function of Lovell General Hospital and was designated Lovell East.

6 Monthly Progress Report, Army Service Forces, War Department, 31 Jan. 1945, Section 16: Safety.


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    Additional medical officers were required for the expanded institution, and it was necessary to procure replacements for many of the staff transferred overseas. The chief of surgery, Colonel Keene, was transferred and Lt. Col. Ralph F. Bowers, MC, replaced him. The chief of orthopedics, the chief of urology, and the chief of eye service were also lost and replaced, as well as numerous assistant chiefs of sections and junior members of the staff. In spite of these changes, the professional efficiency was maintained at a high level.

    At the suggestion of the surgical consultant, a surgical clinical conference was held at Lovell General Hospital on 30 March 1944. To this were invited the personnel of Army and Navy hospitals and a number of civilian doctors. Over 400 officers and doctors attended, as did the service command surgeon and the commanding general. The staff conducted rounds and demonstrations. There was an exhibit of clinical material which included bone grafting, a demonstration of penicillin therapy, the use of tantalum, and the production of prosthetic dental appliances. Papers and cases were presented. This conference was of great value in establishing a pleasant liaison among neighboring hospitals, with the Navy, and with the civilian profession. It served to unite the members of the surgical services in a common effort.

    Lovell General Hospital joined Cushing General Hospital and the medical service of the First Naval District in presenting an exhibit on military surgery at the meeting of the Massachusetts Medical Society on 23 and 24 May of the same year.

Cushing General Hospital

    At Cushing General Hospital, growth of the surgical service developed particularly in the sections in neurosurgery, plastic surgery, and ophthalmology, for which specialties it was designated by the War Department as a special treatment facility.7 The reception of patients within these special fields required the maintenance of a general surgical service of modest proportions and an orthopedic section of considerable magnitude, since most of the patients presented concurrent orthopedic problems. Fractures and osteomyelitis were common in the neurosurgical patients. Many patients presented problems of plastic, orthopedic, and neurological surgery combined.

    Since these patients required the attention of more than one section, the surgical consultant suggested the arrangement of a system of regular intersectional conferences. By this means, a complete therapeutic program was laid out for each patient. Progress of patients was noted and transfers were arranged as necessary between the sections. This system was put into effect while there were still but few patients in the hospital. Its value became apparent as the hospital filled, and it proved an effective means of managing the interrelated problems of the various sections.

    There tended to be an overlapping of the activities of the section of neurosurgery and the neurological section of the medical service. A plan was pro-

7 War Department Circular No. 347, 25 Aug. 1944.


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posed and adopted on 18 August 1944 which provided that the neurological section of the medical service and the neurosurgical section of the surgical service work in concert. Free consultations were arranged between the medical neurologist and the neurosurgeon for the evaluation, treatment, and distribution of cases. The neurosurgical patients were thenceforward admitted to the neurological section of the medical service, where diagnosis was accomplished. Surgical patients were then transferred to the neurosurgical section for operation and immediate aftercare and were transferred once more to the neurological section for further treatment. This plan permitted the medical neurological section to perform its functions of investigation, appraisal, and treatment, meanwhile relieving the neurosurgical section of this burden. This system worked to the satisfaction of all concerned. This plan, successfully instituted at Cushing General Hospital and communicated to General Rankin by Colonel Cutler, became one of three plans authorized for the management of neurosurgical cases as set forth in a letter from Brig. Gen. Raymond W. Bliss on 25 January 1945 to the Surgeon, First Service Command.

    Provision was made for the specific care of spinal cord injuries. A special ward had been set up for their accommodation, with a special program of restoration of nutrition, care of infected bladders and bedsores, and for the beginning of rehabilitation. By November of 1944, this ward was in full operation with 26 patients, and by September 1945 there were 88 paraplegic cases. Messing facilities, gymnasium, physiotherapy room, recreation room, and wards sufficient to accommodate all of the paraplegic patients were established in a separate group of buildings.

    The plastic section was opened on 23 September 1944 by the transfer of personnel and some equipment from Bushnell General Hospital, Brigham City, Utah. Before this arrival, there had appeared on the neurosurgical section an increasing number of injuries and deformities of the hand. Because of the special nature of these injuries, and because of the need of many of them for plastic procedures, the surgical consultant recommended that such cases be cared for as a special group with ward space allotted to them specifically under the plastic section. In early October 1944, the hand cases were placed in charge of a special officer working in this section. He received consultation advice and assistance in operating, as required, from the chief of neurosurgery, the chief of orthopedics, the chief of plastic surgery, and the surgical consultant. At the close of hostilities, there were 150 patients in the subsection for hand surgery. In early December 1944, Dr. Sterling Bunnell, Civilian Consultant to The Surgeon General for Hand Surgery, spent 5 days at the hospital evaluating patients, operating, and instructing officers in charge of the hand section.

    The author suggested to The Surgeon General that all hand cases requiring formidable surgical reparative procedures be congregated in special hospitals. On 21 December 1944, a letter was received from The Surgeon General informing Colonel Cutler that all reconstruct ion hand cases would in the


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future be sent to plastic centers. This provision undoubtedly worked to the great benefit of patients suffering from hand injuries.

    Cushing General Hospital was also designated as a center for ophthalmology by War Department. Circular No. 347, 25 August 1944, necessitating assignment of trained ophthalmologists. Its activities at first were confirmed to ophthalmic procedures in association with the plastic section. In November 1944, there were but 24 patients in the ophthalmology section. Eight months later, its patients numbered 103, and the program for the production of acrylic eyes was well underway. By the end of the war, the ophthalmology section had 140 patients.

    Colonel Mason continued as chief of surgery until May 1945, being replaced by Col. Horatio Rogers, MC. While a number of the junior officers were released for oversea assignment, the chiefs of sections remained. This permitted the maintenance of a closely integrated service such as is required by a multiple specialty center.

Camp Edwards General Hospital

    The hospital at Camp Edwards served as a station hospital until 24 July 1944. On that date it became a debarkation hospital and, until its designation as a general hospital, its staff was busied with the reception, evaluation, treatment, sorting, and reshipment of all patients arriving at the port of Boston. This change of function from a station hospital to a debarkation hospital required readjustment of the staff, rearrangement of the surgical service for its new duties, and certain changes in personnel. Doctors to travel on hospital trains to various parts of the country were furnished from the staff of the Camp Edwards Debarkation Hospital. During its active period, the debarkation hospital at Edward was handling between three and five thousand patients per month.

    When the debarkation activities were taken over by the hospital at Camp Myles Standish, it was necessary rather rapidly to readjust Edwards to fulfill the functions of a general hospital. Major changes of plan and personnel were required. During the period of change, there were three changes in the chief of surgical service. Lt. Col. William A. Mahoney, MC, was succeeded by Maj. Joy K. Donaldson, MC, who was succeeded in turn by Col. Edwin F. Cave, MC. The chiefs of orthopedic section and of general surgery were also changed twice during thus period. By early September 1945, the hospital, at 3,200-bed capacity, was caring for 1,158 patients on its surgical services.

DEBARKATION ACTIVITIES

    At Camp Edwards, the large station hospital designated on 24 July 1944 as a debarkation hospital was eminently suited to the purpose by reason of its accessibility to the port of Boston. To it were brought frequent shipments of oversea casualties, numbering from 200 to 500 at a time. Hospital trains


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brought patients from ship to ward in about 4 hours. When hospital cars were used, the placement of patients on the train could be quite rapidly and comfortably effected. When Pullman sleepers made up the train, it was necessary to remove windows to permit the loading of the stretchers. This slowed down the loading considerably and presented great difficulty in the handling of patients in body casts and spicas. The personnel of the port of debarkation acquired considerable skill and efficiency in the movement of patients in spite of these handicaps.

    At the Camp Edwards end, unloading platforms were provided and the adjacent warehouses, now empty, were used for the reception of patients. Prisoners of war from the stockade at Camp Edwards were effectively employed as litter bearers.

    The first shipment of wounded arrived on 27 July 1944. These consisted of wounded German prisoners recently evacuated from the battles of Normandy. There were 297, of whom 168 were litter patients. Many had had no changes of dressing since the initial debridement. Most of them had been wounded about 2 weeks before their shipment. The procedure followed was typical of that followed in subsequent shipments.

    Rounds had been made by surgeons on the train en route from the port, and the patients had received food. They were taken by ambulances to the hospital, about a mile distant, and were moved to their beds. Each ward was occupied half by litter patients and half by ambulant patients. The ambulant patients aided with the care and feeding of those confined to bed. The patients were bathed and furnished fresh bedwear, and temperatures were taken. Ward officers inspected each patient, and the chief of surgery then visited those who required attention.

    After a night's rest for the patients, complete rounds were made. Wounds were inspected and cleansed. Fresh dressings were applied. Casts were inspected and removed from patients with elevation of temperature. Casts were also removed when they were constricting, were broken, loosened or softened by discharges, showed evidence of bleeding, or were painful. Determination was made as to which patients could be safely and comfortably transported to their ultimate destination. The hospital decided to retain but 6 of the first 168 litter cases.

    In spite of the fact that no other care had been administered than that received in the first evacuation hospital, the wounds in general were in excellent condition, although the dressings were much soiled. About 25 percent of the casts required removal and replacement. Many were saturated with pus, and all were malodorous. Pressure sores were notably lacking. Among the six patients to be retained were two with active cellulitis following compound fractures. In one there was an abscess in the fascial planes of the forearm, and the other had a wound of the thigh in which tight packing had impounded pus.


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    The generally satisfactory condition of the patients, the healthy aspect of most of the wounds, and the infrequency of complications through a journey of 2 weeks' duration were noteworthy. Even the major injuries of compound comminuted fractures of the bong bones had carried very well in plaster. Patients who were not transportable were treated further at the hospital at Camp Edwards or were transferred to one of the nearby general hospitals.

    Following the period of treatment and sorting at the debarkation hospital, the patients were shipped to the hospitals of eventual destination.

    During debarkation activities, but three deaths occurred. Two German prisoners of war suffering from empyema were transferred to Lovell General Hospital and died there. One ambulant medical patient died suddenly from embolism while in transit to a hospital in the interior.

    Following the designation of the Camp Edwards debarkation hospital as a general hospital, debarkation activities were transferred to Camp Myles Standish. There, the procedure was essentially the same. At the close of the war, this hospital was still functioning as a debarkation hospital. The total number of patients passing through Camp Edwards debarkation hospital was 17,437. The hospital at Camp Myles Standish handled 22,016 evacuees.8

SURGERY IN THE PRISON CAMPS

    The ships which brought in prisoner-of-war wounded also brought considerable numbers of healthy German prisoners. They were distributed to prisoner-of-war camps in northern New England and utilized in the logging industry and the cultivation of potatoes. Prison camps were established in New Hampshire at Camp Stark and in Maine at Houlton, Princeton, Seboomook, and Spencer Lake.9 In addition, there were stockades at the Army airfield at Presque Isle, at Camp Edwards, and at Fort Devens.

    Where hospitals were nearby, as at Camp Edwards and Fort Devens, stockade dispensaries filled the need for medical care, Patients requiring hospitalization were transferred to the adjacent hospitals. In the more remote areas, injuries were found to be more frequent and often severe. These injuries consisted usually of ax and saw wounds of the legs, arms, and hands and closed fractures. There were a number of surgical emergencies, notably acute otitis media and mastoiditis, perforated peptic ulcer, intestinal obstruction, and appendicitis.

    For these emergencies in the remote lumber camps, arrangements were made with local civil hospitals to which the patients could be transported. The towns nearest to Seboomook Lake and Spencer Lake were between 50 and 65 miles away. It was therefore recommended that surgeons be supplied to these remote camps who were competent to deal with such emergencies. Dur-

8 Report, Hospitalization Section, Office of the Surgeon, First Service Command, 15 Sept. 1945.
9
Annual Report, First Service Command Medical Activities, 1944.


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ing the subsequent winter, several patients with acute appendicitis and one with peptic ulcer perforation were successfully operated upon at these camps.

    It was found that many of the prisoners at remote camps were suffering from unhealed osteomyelitis, chronic otitis, peptic ulcers, and hernias which threatened strangulation. It was recommended that more careful medical screening be done at the port before assignment of prisoners, and, when disabilities threatened the development of surgical emergencies, the prisoners were to be assigned to stockades close to general hospitals. This suggestion was carried out, and all prisoners suffering from threatening disabilities were removed from the prison camps in the remote districts.

PROGRESS OF SURGICAL CARE

    Surgical emergencies were encountered and dealt with at all hospitals. There was no fatal case of appendicitis or of perforated peptic ulcer within the service command during the author's tenure as the surgical consultant. Nonformidable surgical procedures of an elective character were carried out in station hospitals as permitted by directive. In the Waltham Regional Hospital, as in the regional hospital at Westover Field, cholecystitis, goiter, malignancies of the stomach and large intestine, ulcerative colitis, and recurrent hernia were encountered. Lt. Col. Benjamin S. Custer, MC, at Westover Field, Lt. Col. George A. Marks, MC, at Waltham, and their staffs dealt with these surgical conditions with sound judgment and skill and with satisfactory results.

Abdominal Surgery

    In the general hospitals, problems peculiar to the injuries of war were met, and progress and improvement were made in their treatment. Among these problems were intestinal injuries which sometimes presented simple colostomies or enterostomies; were sometimes complicated by injuries of the pelvic bones, the chest, the bladder, the perineum and rectum; or were associated with remote fecal fistulas to time skin and the urinary tract. Colonel Keene, chief of surgery at Lovell General Hospital, developed a considerable interest in the care of these patients with abdominal injuries. The procedures that he developed in caring for an initial group of 40 cases were observed by the consultant.10 Assured of the soundness of Colonel Keene's procedures, Colonel Cutler advised their adoption in the other two general hospitals.

    In patients in which spurred colostomies had been made at the initial operation there were found reversal of the spurs, interposition of omentum or mesentery, and the involvement of loops of small intestines in adhesions about the spurs. Operative investigation by completely freeing the extruded bowel from the wound and its dissection within the abdomen clearly demonstrated the hazard of spur clamping by reason of unsuspected complications.

10 Keene, C. H.: Reconstruction of Wounds of the Colon. Surg., Gynec. & Obst. 79: 544-551. November 1944.


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 It became the practice to separate the limbs of the spur and to close the bowel opening by appropriate suture or to resect the involved portion of the gut by performing an end-to-end anastomosis of the large bowel. Such repairs were then dropped back within the abdomen. Simple loop colostomies were similarly dealt with.

    One hundred and four such operations were done in the three general hospitals according to this plan. Eighty-eight healed and remained closed. There was one death from peritonitis.

    When complicating injuries of bone or urinary tract, fecal fistulas from the distal portion of the large intestine, or injuries of the rectum or perineum were encountered, transverse colostomies of an obstructing type were done. Devine colostomies first employed appeared to have no advantage over the simple divided colostomy. Once the fecal stream was completely diverted and appropriate incision and drainage or sequestrectomy or repair of the urinary tract done, healing was relatively rapid. Closure of the initial colostomy was then done, followed by closure of the secondary obstructing colostomy.

Orthopedic Surgery

    In the general hospitals, treatment of bony injuries was pursued according to directive. In the suspension traction treatment of fractures of the femur, it was interesting to Colonel Cutler to note an increasing tendency to place the Kirschner wire through the tibial tubercle rather than through the condyles of the femur. The orthopedic surgeons agreed that, when the traction was so employed, the knee joint was less jeopardized and the quadriceps exercises were better performed. Movement of the knee joint with the Pierson extension was apparently little interfered with by the tibial placement of the wire.

    The treatment of osteomyelitis underwent considerable change. In the earlier days, there was a tendency toward closed-plaster treatment. Later, the wounds were treated by open method and appropriate traction was applied for the underlying fracture. At Cushing General Hospital osteomyelitis was treated by a complete sequestrectomy followed by daily open dressing of the wounds. After trying a number of materials, the orthopedic section settled upon penicillin solution on gauze as being the best dressing. The wounds granulated rapidly, but slow epithelization often delayed needed nerve repair.

    Early in 1945, Colonel Cutler recommended the trial of early skin grafting of these granulating osteomyelitis wounds following sequestrectomy. The results demonstrated at Newton D. Baker General Hospital on 11 and 12 May 1945 fully confirmed the validity of this proposal.11 Following careful sequestrectomy, dermatome skin grafts were applied between 1 and 2 weeks after operation. This procedure was made standard in all of the hospitals of the service command.

11 Urological Conference and Symposium on the Paralyzed Patient at Newton D. Baker General Hospital (Martinsburg, W. Va.). 11-12 May 1945. pp. 65-79.


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    In deep-lying osteomyelitis following early sequestrectomy, wounds were left open. First at Lovell General Hospital as early as June 1944, and subsequently at Cushing, an attempt at closure of these wounds at the time of sequestrectomy was begun. Penicillin, the use of which had formally been approved in February 1944, 12 was used systemically before and after operation. Penicillin solution (1500 units per cc.) was also used to irrigate the depths of the wounds through catheters inserted at the time of operation. That the local use of this drug contributed to the success of the treatment was doubtful.

    On 22 January 1945, Dr. Marius N. Smith-Petersen, Civilian Consultant in Orthopedic Surgery to The Surgeon General, visited Cushing General Hospital. He proposed that metallic cannulas instead of catheters be inserted at the time of sequestrectomy. Through these cannulas, penicillin solution was to be injected at intervals of 2 or 3 hours until the discharge had lost its purulent character. The cannulas were then to be withdrawn from the wound, the scar was to be excised, and complete resuture of the wound was to be done. By the middle of September 1945, 53 cases had been treated by this method. Of the 41 completed cases, 35 had been closed and remained closed. The average duration of treatment, from sequestrectomy to complete closure of the skin, was 31 days.

    Dr. Smith-Petersen believed that it was possible, with the aid of systemic and local penicillin, to obliterate major bone defects by collapsing osteotomies at the time of sequestrectomy or subsequently in the presence of granulating wounds. He suggested that, even in the process of osteomyelitis or granulating wounds, it was possible and safe to perform arthrodesis. In six such operations performed, there were no untoward results.

    As a result of his teaching, the performance of operations of bone reconstruction was undertaken at an earlier date following the healing of osteomyelitis than had hitherto been thought safe. This policy materially shortened hospitalization and permitted the earlier repair of injured peripheral nerves.

    Lovell General Hospital, which received the earlier casualties, admitted eight patients who had been treated by the application of metal plates to fractures of the long bones in the oversea theaters from which they had been evacuated. Six of these had nonunion and loosened plates with distraction or absorption at the bone ends. The plates had to be removed and traction suspension instituted. Six cases were seen with fractures splinted by external skeletal fixation. With but one exception, these cases showed absorption at the pinholes, and they had open draining sinuses. During these early months, a number of patients were received whose condition of depletion from prolonged sepsis required the postponement of any operative procedure for several weeks, It was believed that some of these might have benefited by longer hospitalization abroad with more attention to supportive treatment. Among the depleted cases were four American wounded who had been held prisoners. Their open fractures of the femur had been treated by German surgeons with intramedullary

12 War Department Technical Bulletin (TB Med) 9, 12 Feb. 1944.


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pinning (Küntscher nails). All were suppurating, and the nails, which were the first to be seen by the hospital staffs, had to be withdrawn.

Combined Bone and Nerve Injuries

    At Cushing General Hospital, as a result of intersectional conferences, it was often possible to combine the procedures of orthopedists and neurosurgeons. Thus, when bone grafts were required in patients with divided peripheral nerves, exposure of the site was carried out by the orthopedist who, while repair of the nerve was being done by the neurosurgeon, made ready the bone graft and subsequently applied it to the fracture. When the nerve ends could not readily be united, the orthopedic surgeon performed appropriate shortening of bone.

Neurosurgery

    Restoring peripheral nerves following injury furnished the bulk of the work of the neurosurgery section. At first, tantalum wire sutures and protecting tantalum foil cuffs were used in the uniting of nerves. In the early months of 1945, however, a number of cases were observed in which the tantalum cuff had fragmented with considerable scar tissue in and around the fragments. The use of tantalum foil was therefore discontinued.

    By 27 June 1944, frozen nerve grafts had been arranged for with Dr. Frank Ingraham of Harvard University. This work was encouraged by Dr. Jason Mixter, Civilian Consultant in Neurosurgery to The Surgeon General. By September 1945, Lt. Col. William P. Van Wagenen, MC, Chief, Neurosurgery, Surgical Service, was able to report no satisfactory results from donor grafts.

    When the satisfactory restitution of peripheral nerves failed, the orthopedic section was called to perform the appropriate tendon transplantations. In some of the cases of footdrop, a wedge of tibia was formed and placed in the posterior talus to prevent plantar flexion of the foot beyond right angles.

    In skull and brain injury, removal of the irregular edges of the damaged skull, careful excision of the scarred and adherent dura, and freeing of the underlying brain cortex were done. Repair of the dural defects, originally performed with fascia lata, was later done with fibrin film. The defects in the skull were repaired with shaped tantalum plates.

    Also treated were a number of cases of brain and spinal cord tumor. Operations on the spine for herniated nucleus pulposus were rarely applicable to Army personnel with any prospect of return to active duty, and few of these operations were performed.

Care of Paraplegic Patients

    At the close of hostilities, 88 paraplegic patients were under treatment. At the time of their reception, they were emaciated, anemic, and incontinent; evidenced profound avitaminosis and suprapubic cystostomies; were afflicted


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with large decubitus ulcers; and were in a low state of morale. They were placed in one ward with specially trained attendants and nurses.

    At first, it was thought necessary to keep these patients in bed during the treatment of their bladder infection and to maintain the suprapubic cystostomies for long periods of time. Later, it became apparent that these patients could be out of bed earlier and that the suprapubic drainage could be replaced by urethral catheter at an early date. This revised program began in June1945.

    Irrigations of the bladder at 2-hour intervals were continued until cystometric examination revealed diminution of spasticity. At this time, tidal drainage was instituted and was continued until the suprapubic opening was closed and automatic bladder function had been established. This became part of a detailed standard plan of management..

    Operative treatment of the decubitus ulcers was undertaken. At operation, the ulcer was excised with complete undercutting of the skim and subcutaneous tissue. Closure of the defect was performed in two layers, the deep fascia and the skin. The stitches were left in place for 21 days. Ulcers as large as 12 cm. in diameter were successfully healed. Over 50 such operations were done, and 60 percent of the bedsores closed by suture remained healed on the first attempt.

    As decubitus ulcers were closed, the nutrition and morale of the patients improved with greater rapidity. Regular exercising of the unparalyzed muscles of the upper body was carried on assiduously from the start and patients were permitted to be in wheelchairs and were given instruction in walking. In July of 1945, an instructor was secured from the Institute for the Crippled and Disabled in New York to direct this training.

Urological Surgery

    The work of the urological surgeons, in addition to the treatment of bladder complications of spinal cord injuries, consisted in the care of congenital and acquired anomalies and infections of the urinary tract. There were also cases of kidney lacerations by gunshot wounds and fistulas of the ureter or of the bladder to the surface or to the abdominal viscera.. Such injuries were often associated with osteomyelitis of the pelvic bones or hip, injuries of the penis, and perineal urethra.

    Typical of the cases of injury of the ureter was one at Lovell General Hospital in which the left ureter had been damaged 2 cm. from the bladder by a bullet which had entered the coccygeal region and had passed through the rectum and bladder. Urine drained through the coccygeal sinus together with fecal material. There was a chronic abscess and pyonephrosis. Nephrostomy was followed by resection of the damaged portion of ureter and ureteral anastomosis. The result was satisfactory. Injuries with fistulas and osteomyelitis of the pelvic bones were successfully treated by diverting colostomy


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and subsequent local surgical attention. One case of obliterative scarring of the membranous portion of the urethra required perineal reconstruction of the urethra.

    Most of the urological work of a formidable nature was carried on at either Lovell or Cushing General Hospitals. The surgical consultant recommended that in each of the hospitals the urologist institute an active program for the detection of stones forming in the urinary tract, especially in patients long bedridden or taking sulfonamide drugs.

Plastic and Hand Surgery

    Cushing General Hospital was designated as a center for plastic surgery in August 1944. Before this, it had been the practice at Lovell General Hospital to cover bone injuries in preparation for bone grafting. It was apparent to the surgical consultant that the required policy of sending such cases to the special plastic center as Cushing General Hospital would interrupt the course of treatment, involve longer hospitalization, and unduly burden the plastic section at Cushing. This point of view was communicated to General Rankin, who approved the practice of performing these simpler plastic procedures at general hospitals. Thus, the covering of bone injuries by skin grafts was carried on at Lovell and subsequently at Camp Edwards General Hospital. It proved to be a satisfactory method of handling these cases.

    By the middle of September 1945, the plastic section at Cushing General Hospital was caring for 306 patients. Very successful work was done in the resurfacing required by severe scars, the transfer of tube grafts in preparation for further orthopedic surgery, the repair of severe burn contractures, and reconstructive work about the hands, neck, and face. This work was carried on in close cooperation with the sections of ophthalmology, otolaryngology, and dentistry. One case in particular, lacking the entire mandible below the angles, was brought far on the road to presentable restitution. This section profited by the visits of Dr. Jerome P. Webster and Dr. Robert H. Ivy on 23 and 24 May 1945.

    The subsection on surgery of the hand instituted under the plastic section, Cushing General Hospital, in October 1944 had its own officer in charge, Capt. James W. Littler, MC. He received instruction and assistance from the neurosurgeon, the orthopedic surgeon, the plastic surgeon, and the surgical consultant as required. On 1 December 1944, Dr. Sterling Bunnell, Consultant in Hand Surgery to The Surgeon General, came to Cushing General Hospital for a 5-day visit, his first official visit to an army hospital. He held clinics and demonstrations, operated with the officers in care of these hand cases, and instructed them in operating technique.

    The hand surgeons held regular consultation conferences weekly with neurosurgeons, plastic surgeons, and orthopedists. The officers in the hand surgery subsection rapidly developed the ability to carry on this work on a specialty basis with less and less assistance from the other specialists.  Success-


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fully accomplished were tendon transplants and grafts, peripheral nerve sutures, reactivation of joints by corrective splinting and capsulotomy, skin resurfacing, corrective osteotomies, transplantations of rays, and correction of nonunion and malunion of the metacarpals and phalanges. Doweled tibial grafts were skillfully used to restore length and stability to damaged long bones. Successful arthroplasties employing tantalum cups of the metacarpophalangeal joints were done. The results of these operations were gratifying. By 12 September 1945, there were 200 patients under treatment in this subsection.

Eye, Ear, Nose, Throat Surgery

    Since the work of the plastic section involved reparative and reconstructive surgery of the upper respiratory passages, otorhinolaryngologists having plastic surgery experience were placed in the section. At the other hospitals, otorhinolaryngologists were required for the carrying on of routine treatment of infections and abnormalities of the ear's, nose, and throat. There were found a good many soldier's suffering with chronic otitis media resistant to treatment. It was found that underlying mastoid involvement was often responsible, and mastoidectomies were performed in the general hospitals and in the regional hospital at Waltham.

    At the general hospitals, eye specialists were also maintained for the care of injuries and infections of the eye. At the station and regional hospitals, ophthalmologic specialists performed refractions and the fitting of glasses, as well as routine eye examinations.

    After the opening of the ophthalmology section at Cushing General Hospital in August 1944, the ophthalomologists were busied with work about the orbit involved in plastic procedures. The major activity of this section consisted in enucleation or revision of enucleation for the fitting of acrylic eyes. The ophthalmologists expressed the opinion that an earlier revision shortly following injury would be productive of better ultimate results. The production of acrylic eyes was successfully carried on.

    Among the conditions treated by the ophthalmologist were foreign bodies embedded in the eye, choroiditis, traumatic cataract, and retinal separation.

    Among the interesting ear, nose, and throat cases seen at Cushing General Hospital were two of gunshot injuries of the trachea and the esophagus, both of which made a satisfactory recovery. At Lovell General Hospital, several cases of advanced suppurative sinusitis were treated, two with osteomyelitis of the frontal bone. Sequestrectomy and subsequent replacement of skull defects with tantalum plates brought about satisfactory recovery.

Gynecology and Obstetrics

    For the care of the WAC's (Women's Army Corps), nurses, and female civilian dependents, gynecology was done on an outpatient basis at station hospitals, operative cases being transferred to Lovell General Hospital or Waltham


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Regional Hospital. Obstetrical practice was also carried on at the latter two hospitals.

Operating Rooms

    It was the duty of the surgical consultant to note operating-room equipment, procedures, and technique. Equipment was usually found to be satisfactory. At Waltham and Cushing, holophane lights were unsatisfactory and were replaced by Castle or multibeam lights.

    Technical procedures were corrected as occasion required. There was a tendency to place superfluous furnishings in operating rooms. These were removed on recommendation. The presence of surplus and unauthorized instruments was checked on the request of the Director, Surgery Division, Office of the Surgeon General.

    It was necessary to make sure that operating-room facilities were being used to full capacity. It was the duty of the anesthesiologists to maintain a satisfactory operating-room program. At Lovell General Hospital, operating facilities became very much crowded, but this was relieved by the opening of Lovell Hospital North. At Cushing General Hospital, there developed a backlog of surgical cases, and it was recommended that the operating-room facilities be increased by new construction.

Anesthesia

    It was possible to maintain officers competent in anesthesia at all hospitals. Reports on anesthesia were made to the Director, Surgical Consultants Division, Office of the Surgeon General, on 1 August 1944 and 20 October 1944. These reports showed anesthesia practices in the command to be satisfactory and the equipment, adequate. It was the practice to utilize spinal and local anesthesia very largely in the station hospitals. At Waltham Regional Hospital and at the general hospitals, fully qualified anesthesiologists were maintained. Schools for nurse anesthetists were also established at these hospitals.

    The use of spinal anesthesia became less common in formidable surgical cases. A gas-oxygen-ether sequence for these cases was generally preferred. Occasionally, Penthothal sodium (thiopental sodium) was used and gave complete satisfaction. Continuous spinal anesthesia proved satisfactory. There were no anesthetic accidents.

    Among the functions of the chiefs of anesthesia was the management of the recovery wards. These wards were maintained in all the general hospitals and proved completely satisfactory. Air-conditioning of the operating rooms at Cushing General Hospital contributed greatly to the comfort of the surgeons and the welfare of the patients.

Central Supply Service

    A central supply service was also under control of the anesthesiologists and chiefs of operating rooms. The program for their installation was recommended by the consultant in June 1944. The establishment of this type of


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service was confirmed and outlined in April 1944.13 Difficulty and delay in establishment of these services was due to lack of adequate space. At Cushing General Hospital, a room which had been provided was too small. At Lovell General Hospital, at Waltham Regional Hospital, and at the Camp Edwards Hospital, no such provision was originally made. At Lovell, authorization for necessary construction was requested on 24 April 1944, and the system was put into effective operation in May 1945. The activities of the central supply service system in this hospital were complicated by the system's division into two active units, Lovell North and Lovell South. At Waltham Regional Hospital, additional construction was not completed until July 1945. Until that time, the operating room furnished the necessary supplies. At Camp Edwards, request for construction was made on 27 April 1944, but at the close of hostilities construction was still underway. Where the central supply service was put into operation, its great value was recognized.

Orthopedic Braceshops

    Orthopedic braceshops were part of the original equipment of Cushing and Lovell General Hospitals. These facilities made splints and braces for all installations of the command. As the workload increased, delays resulted. In August 1944, it was recommended that a braceshop be installed at Waltham Regional Hospital for its own use and that of the neighboring station hospitals. The construction was authorized, and the shop started effective operation in January 1945. At Camp Edwards, a braceshop, authorized in February 1945, was not put into operation until July 1945.

    At Lovell and Cushing General Hospitals, civilian bracemakers were employed and assisted by technicians whom they trained. It was necessary to arrange with the Personnel Division, Headquarters, First Service Command, to protect this scarce category of trained enlisted men from loss by transfer. At Cushing, because of the need for supporting apparatus for paraplegics and neurosurgical cases and for the corrective splinting of hand injuries, the work was extensive. Many of the splints used were especially designed for particular problems and could not be produced in bulk.

    In the orthopedic clinics, one of the most frequent problems was that of flat feet. The ARCH-O-GRAPH equipment proved unsatisfactory. The arches would not stand up under conditions of active use. Consequently, a program for fitted metallic arches was developed.

    Major deformities of the feet required the production of special shoes beyond the capacity of the orthopedic shops. The laboratories of the United Shoe Machinery Company had perfected a device for securing impressions of such deformed feet and a process for producing shoes to fit them. The Surgeon General authorized the trial establishment of the process in the First

13 War Department Memorandum No. W 40-44, 12 Apr. 1944.


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Service Command under the Boston Quartermaster Depot. 14  The surgical consultant was charged with the arranging of the program, which was put into effect at once. An orthopedic surgeon, Capt. Saul Steinberg, MC, was assigned to the Boston Quartermaster Depot for instruction and research in specially built shoes. Captain Steinberg was also to work with the Lawrence Climatic Research Laboratory in other shoe investigations.

Physical Therapy

    Physical therapy functioned in cooperation with all sections in the hospitals particularly with the sections of orthopedics, under the supervision of which it operated. There were a sufficient number of whirlpool baths, electric heat apparatuses, infrared and ultraviolet lamps, and treatment tables. Physical therapy aides, enlisted technicians, and WTAC personnel carried on most of the treatments. Medical officer physiotherapists were available at Lovell and at Cushing. Ward buildings lent themselves poorly to the needs of a physiotherapy department, Removal of partitions and elimination of small rooms, providing a large open space, were effected at Lovell and Cushing, much to the advantage of the service. At Cushing, authorization was requested for the enlargement of the building. At Lovell General Hospital, it was necessary to establish a second physical therapy department in Lovell North.

    Between 400 and 500 treatments were given daily at Lovell General Hospital. At Cushing, more than 600 treatments were provided per day. There was a combined total of 17,373 treatments during the month of August 1945. At Camp Edwards Convalescent Hospital, where during the summer of 1945 between 4,000 and 5,000 patients were accommodated, a building was provided and staffed for the treatment of between 200 and 300 patients daily.

    The policy of the surgical consultant was to emphasize the importance of employing manipulative physical therapy judiciously, intelligently, and sparingly. Emphasis was consistently placed on remedial and corrective exercises rather than on baking, massage, and manipulation. There was a tendency to refer patients for physical therapy for the patient's satisfaction and the relief of the surgeon without due regard to the specific needs of the individual. It was insisted that a specific prescription for treatment should be worked out for each patient and that periodic evaluation of the case should be made.

    Exercises were instituted even for patients in bed. Attached to each of the physiotherapy departments was a gymnasium equipped with apparatus for remedial exercising. Directed exercises for the paraplegic cases at Cushing General Hospital were undertaken while the patients were still in bed and were carried on later in a special physiotherapy department attached to their own ward.

14 Letter. The Surgeon General to Commanding General, Headquarters. First Service Command, Boston, Mass., attention : Surgeon, 24 Jan. 1945, subject : Study of Special Shoes at The Boston Quartermaster Depot.


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Occupational Therapy

    Occupational therapy was designed to restore the strength and usefulness of injured extremities by the performance of useful tasks which might have training or recreational value. The work prescribed for the individual was designed to fit his needs. At the general hospitals, and also at Camp Edwards Convalescent Hospital, shops were set up for this. At Lovell, under Capt. Sidney Licht, tools with graded handles, looms, printing presses, leg- or foot-operated bandsaws and jigsaws, all with adjustable fixtures, provided graduated range of motion. Here, also, were employed planing, handsawing, painting, weaving, and sandpapering. Use of the piano and instruction proved valuable for patients suffering from upper extremity disabilities.

Summary

    Surgical care, in all its phases, resulted in 11,063 battle casualties' (surgical) being admitted to First Service Command hospitals between 1 January and 1 July 1945 for definitive treatment. Deaths numbered nine, or 0.08 percent, somewhat less than one per thousand.

CONVALESCENT PROGRAM

    The reconditioning program was established and its policies were outlined by Circular Letter No. 168, Office of the Surgeon General, dated 21 September 1943. A reconditioning officer was appointed at First Service Command headquarters, and the surgical consultant was ordered to act as consultant in reconditioning. The surgical consultant visited the reconditioning center of the Second Service Command at Atlantic City, N.J., on 31 January 1944, On 24 and 25 April 1944, he attended a reconditioning conference at Halloran General Hospital, Staten Island, N.Y., and at Thomas M. England General Hospital, Atlantic City, N.J. Some of the recommended procedures were adopted in the First Service Command.

    The reconditioning program was carried on in hospitals until April 1944 when a reconditioning center was set up in barracks at Fort Devens for Classes I and II patients.15 This activity continued as a part of Lovell General and Convalescent Hospital until 25 January 1945, at which time the convalescent hospital was opened at the U.S. Army Medical Center, Camp Edwards.

    Before its opening, a principle was proposed by the surgical consultant which was adopted. This policy provided that beyond a certain point of recovery Class I and II patients should be separated into two groups, as follows: (1) Those who would return to duty as soldiers and (2) those who were to be separated from the service by certificate of disability for discharge. The two groups thence forward were to pursue separate programs predicated on their unlike purposes. These differences, it was pointed out, made the two

15 Letter, Commanding General, First Service Command, to Commanding Officers, All Posts and Camps, First Service Command, 10 Apr. 1944, subject: Reconditioning in General and Station Hospitals.


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groups incompatible, and attempts to combine the reconditioning of the two classes would risk failure and lower the morale of both. Separate grouping and separate programs were indicated for the two classes.

    Another principle was that the convalescent soldier should continue to be a patient, to receive continuing medical care, and an adjustment of his program best to meet his physical needs. This principle, too, was consistently maintained.

    Ward officers in the convalescent hospital were imbued with a sense of their responsibility to their patients. Consultations were arranged with specialists when necessary. Regular medical rounds were made and the patient's progress noted. On this basis, physiotherapy, remedial exercises, gymnastics, and occupational therapy were individually prescribed.

    The institution of the convalescent hospital at Camp Edwards permitted greater scope in the reconditioning program.

    The surgical consultant believed that it would be desirable to develop a close liaison, on the one hand, between medical officers of hospitals and reconditioning units, and, on the other, between these medical officers and those officer's empowered to make classification and assignment of the sick and wounded soldier following recovery. He believed that such assignment should take into account information gained by medical officers and that failure to do this would result in many improper assignments. Thus more satisfactory classifying and assigning could be done, and the rehospitalization of many patients be avoided.

    This matter of reclassification and assignment was made the subject of a memorandum to General Rankin. In it, Colonel Cutler stated that the collecting of data pertinent to subsequent classification should begin during hospitalization, and that information acquired concerning the soldier at the hospital where definitive treatment was given should accompany the soldier to the reconditioning unit. At the reconditioning unit, further data concerning his progress, physical status, response to training, and acquired abilities might be added. These data should be fully utilized, Colonel Cutler recommended, in effecting intelligent disposition, and specific recommendations as to the type of duty a soldier may be able effectively to perform should be furnished by his physicians to the authority performing classification and assignment. It was proposed that an officer authorized specifically to recommend such assignment to authorities at the personnel distribution center be placed in each of the general and convalescent hospitals. At the reconditioning conference held at Thomas M. England General Hospital on 25 and 26 April 1944, it was proposed that reclassification officers be actually placed in various hospitals. Such reclassification officers were assigned in June 1945 to general hospitals.16

    The surgical consultant also believed that adequate and accurate information should be furnished to the soldier concerning his physical status and the nature of serious disability he had suffered. It was represented that patients required such diagnoses and records for health guidance and for the

16 War Department Circular No. 176, 13 June 1945.


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information of their civilian physicians in the event of illness or of complications arising from the service illness or injury. Several instances were brought to the attention of the surgical consultant in which the lack of this information had worked to the disadvantage of discharged soldiers. The securing of such information by the veteran's civilian physician through channels might be attended by such delay as would render the information useless. Upon recommendation of the surgical consultant and under authority of Army Regulations No. 40-590, dated 29 August 1944, a command letter was issued on 9 April 1945 by Headquarters, First Service Command, calling the attention of commanding officers of posts, camps, and stations to the provisions of that regulation.

    The letter stated: "It is desired that every soldier separated from the service in this Command be informed of his right to request a transcript of the medical record of any illness for which he may have been hospitalized while in military service. The importance of this record for his future protection and welfare should be explained to him. It is further desired that he be informed that the proper method of making this request is through channels to the Commanding Officer of the latest Regional, General, or Convalescent Hospital in which hospitalization occurred." The letter further directed that the furnishing of requested records be facilitated by the commanding officer of the hospital concerned and that commanding officers of personnel centers and hospitals provide for the inclusion of this information in orientation lectures given by separation counseling officers.

MEDICAL EDUCATION PROGRAM

    One of Colonel Cutler's duties was to further education activities of the staffs of the various hospitals. He always inquired whether proper library facilities were available and attempted to determine whether there was an effective program of meetings and staff conferences. Such meetings and conferences were arranged and maintained in all hospitals during the consultant's tour of duty. It was the consultant's practice frequently to attend such meetings and to join in the discussion, occasionally presenting clinical material himself. In most of the hospitals of the command, he presented illustrated talks and demonstrations on the early care of hand injuries and other topics. It was his practice, also, to distribute and explain information gained at meetings of surgical societies and conferences held at the Office of the Surgeon General and in other commands. At all conferences attended outside the command, the consultant reported on results and procedures developed within the First Service Command. From time to time, selected officers were sent to visit hospitals in other commands in order to learn methods and procedures successfully developed there. By this means the First Service Command hospitals benefited by the experience of other facilities in such matters as the employment of penicillin and streptomycin, special methods in the care of paraplegics, and reconditioning.


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    A program which assigned a number of recently commissioned officers to hospitals for periods of about 6 weeks' duration provided another educational advantage. In the hospitals, programs of instruction for these men were conducted by the staff.

    The consultants at First Service Command headquarters aided in the development and prosecution of the program of the New England Committee for War-Time Graduate Medical Meetings. Schedules were arranged for the visits of instructors furnished by the committee to all hospitals.

    Clinical meetings at Lovell and Cushing General Hospitals were attended by medical officers of the First Service Command, Navy medical officers, and members of the civilian profession. At one meeting at Cushing on 16 April 1945, the Boston Orthopedic Society was the guest of the Cushing staff. The attendance exceeded two hundred. A combined medical exhibit was presented by Lovell and Cushing General Hospitals in conjunction with the Navy at the meeting of the Massachusetts Medical Society in Boston on 23 and 24 May 1944.

    The visits of The Surgeon General and of his special consultants were of great value in maintaining high professional standards and in the interpretation of directives. The visits of the civilian consultants proved valuable. Among these visits were those of Dr. Smith-Petersen, Dr. Jason Mixter, Dr. Webster, Dr. Ivy, Dr. Frank R.. Ober, Dr. Bunnell, and other distinguished members of the profession. Specialists in the New England area responded readily to many requests by the surgical consultant for assistance in the solution of specific chemical problems.

    It was the consultant's policy to rotate officers from the smaller station hospitals and from the prison camps into the general hospitals for periods of duty, and many such transfers were made.

    An effort was made to encourage the members of the surgical staffs to qualify for licensure by their specialty boards, and several officers received approval during this period. Papers and reports of clinical investigations prepared by the surgical consultant and by members of hospital staffs appeared in medical publications. In all matters pertaining to his duties, the surgical consultant was accorded the fullest, assistance and cooperation by the service command surgeon, by all officers of time headquarters staff, and by the commanding officers of hospitals. The effort, interest, cooperation, and loyalty of the hospital surgical staffs left nothing to be desired.

CONCLUSIONS

    The experiences of this author as the surgical consultant of the First Service Command have led to the following personal observations:

    1. The value of the consultant system depends on an understanding by command authority of its proper function as an agency for attaining and maintaining the highest level of professional performance in the Armed Forces.


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    2. As far as is consistent with military action, consultants should be accorded the fullest freedom of movement within their respective areas. Orders for their movement should be determined in large measure by their own estimate of where their services will be most effective at any moment.
    3. Free, direct communication should be permitted consultants with the professional personnel under their supervision through technical rather than command channels.
    4. Grading and placement of officers in their specialties should be done, where practicable, with the consultants' knowledge and, as far as possible, according to their advice.
    5. Degree of responsibility to be given an individual in the care of patients should be determined by professional competence rather than by military rank. As far as possible, rank among professional medical officers should be made consistent with competence and determined primarily on that basis.
    6. Under the consultant's advice, utilization of pooled or casual medical officers should be facilitated by their temporary assignment to installations in areas where shortages of professional personnel exist.
    7. Whenever practicable, medical officers stationed in small installations, especially in remote and isolated areas, should be rotated into the larger general hospitals for periods of duty. The consultants should assume responsibility for recommending such specific transfers to the command authority.
    8. In future planning for fixed medical installations, adequate provision should be made for (1) central supply facilities, (2) braceshops, (3) recovery wards, (4) adequate operating rooms for accommodation of peakloads, and (5) air-conditioning of operating rooms.
    9. Separate programs of reconditioning should be provided for convalescent soldiers who are to be returned to duty and for those who are to be separated from service.
    10. Proper classification and assignment of soldier's returned to duty from hospitals requires close cooperation between the classification and assignment officer's and the medical officer's last concerned in the soldier's recovery from injury or illness.
    11. For health guidance and for the information of any subsequently attending physician, a soldier discharged from a service hospital should be furnished a record of the diagnosis of his injury or illness and all pertinent data concerning it.