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Chapter XI

Contents

CHAPTER XI

Fifth Service Command

Claude S. Beck, M.D.

ADJUSTMENT TO THE ARMY AND INDOCTRINATION

    Realizing that the war was for a great cause, Lt. Col. (later Col.) Claude S. Beck, MC, was one of the many who felt that this country had obligations to help preserve democracy. Colonel Beck was eager to give up his work, important as he thought it was, and join the service. The uniform gave him a sense of satisfaction, but as an Army officer Colonel Beck was green as grass. A pool for medical officers was a new expression for him. A number of old friends and acquaintances were in it, and their common cause brought them all closer together.

    The famous Walter Reed Army Hospital, where Colonel Beck first reported, emanated respectability: she was the queen bee of the Army and nothing less than the Office of the Surgeon General decided upon her medical personnel. The best of the Army Medical Corps were there. Colonel Beck listened to many unimportant lectures in his indoctrination and was given time to unwind from civilian life. He had a sense of guilt because he was not busy; then he wrote two medical papers. Soon afterward, he was assigned.

    On the first day of his new assignment, Colonel Beck invited the service command (then corps area) surgeon to have dinner with him. He was anxious to find out about his duties without wasting time. Colonel Beck was informed that the surgeon would wait to see how they were going to get along before he accepted the invitation. Colonel Beck was still green and did not know how his own transplantation into the Army was going to turn out. Many others felt the same way, and these adjustments created problems which had to be met and solved. They were problems of uprooting and adjustment to a new environment. Every soldier had problems, and many of them Colonel Beck was to see in the Army camps later on. It took time and adjustment to become a soldier. This was a lesson everyone had to learn.

THE CONSULTANT SYSTEM

It appeared to Colonel Beck that the consultant system was new in the Army, although there had been consultants in World War I. At the begin-

1 This account was written 10 years after the termination of the war. It was written by request. and I believed there was little I could add to the reports and recommendations made during the period of my assignment. It was also written from memory, because I did not have ready access to these reports. I assumed that my general impressions were desired rather than the intricate details of everyday life in the hospitals - C. S. B.


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FIGURE 33. Dr. Rudolph Matas, visiting Ashford General Hospital, White Sulphur Springs, W.Va., in 1944, points out the "Matas Compressor" used to stimulate collateral circulation.

ning of World War II, the consultant system was not well established. Col. (later Brig. Gen.) Fred W. Rankin, MC, had much to do with the establishment of this system. He had charge of the Surgery Branch in the Office of the Surgeon General, but he had much to do with the extension of the system to the various sections of surgery. In the early period of the war, each service command surgeon had the power to say whether he wanted a surgical consultant. If the answer was "no," Colonel Rankin became persuasive to extend the system. No one who had known Colonel Rankin in civilian life would have recognized that he could be persuasive, but when it was for a purpose he could be persuasive.

    In the course of time, there were consultants in surgery, medicine, orthopedics, psychiatry, and other specialized fields. Civilian consultants also were used (fig. 33). The latter did not wear the uniform, but they gave important service. Outstanding among the civilian consultants was Dr. Sterling Bunnell who not only originated many of the operations on the hand but gave lectures, conducted clinics, and performed or supervised many operations on the hand in Army hospitals. Dr. Bunnell made one of the important contributions to the surgery of the war. This type of contribution was a "natural" because the developmental period of these specialized operations occurred in the


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quiet of civilian life, and then widespread application came with the thousands of hands wounded in the war.

    The Society for Medical Consultants came into existence after the war. This group holds regular meetings for discussion of problems, and, at frequent intervals, consultants are sent to medical facilities in Europe and the East where the work in their own fields, give lectures, and make reports which are widely distributed. In this way, the quality of the medicine is brought to light, the morale of the Medical Corps is given a boost, and the service is improved. The consultant system was weak in the early period of the war, but it became well established later in the war and exists today as a necessary part of the U.S. Army Medical Service.

DUTIES AND RESPONSIBILITIES OF THE SURGICAL CONSULTANT

    The duties of the surgical consultant were not defined when Colonel Beck was assigned to the Fifth Service Command. When Colonel Beck arrived in his assignment, it was obvious that he was not needed, and he also felt that he was not, wanted. The first favorable reaction from the surgeon came when Colonel Beck told him that he wanted to be assigned overseas with the Army.

    The office to which Colonel Beck was assigned used the mail and telephone for communication with the various medical installations. There were few, if any, personal visits to these installations. Commanding officers were called in to service command headquarters for occasional meetings, but the process was not reversed. Colonel Beck attended these meetings and the discussions pertained to matters of organization and explanation of directives from Washington. The service command surgeon did the talking. The meetings were formal and served little purpose. There was no freedom of discussion, and it appeared that the care of the sick or wounded soldier was not the chief concern. Colonel Beck was never introduced at these meetings, and he was never invited to make comment or to discuss a subject. The Regular Army officers from the field were hesitant to speak out and ask questions. and the surgeon's office in turn seemed hesitant to speak freely with the Office of the Surgeon General.

    After Colonel Beck had acquired some experience, he understood that this was the Army. There was no doubt in the mind of anyone running the office to which Colonel Beck was assigned that it was adequate in all its various functions. A big and important job of organization was being done, and it was not necessary to have a surgical consultant who might have access to Washington. Colonel Beck started from scratch.

    One experience, which the author remembers, might be worth notation. It was his first visit, to Camp Campbell, Ky. This was one of the large camps


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and was situated between Kentucky and Tennessee, miles away from the railroad station. The new consultant arrived at the railroad station at 2 o'clock in the morning. He had difficulty in getting in touch with the camp to get transportation. After he arrived at the camp, the driver suggested that Colonel Beck get in touch with the officer of the day for a room for the rest of the night. Then Colonel Beck introduced himself to the commanding officers of the camp and hospital and began with his work. These preliminary problems are cited as examples of unnecessary difficulties that existed and of the lack of planning at that time.

    The duties of the surgical consultant covered considerable territory, but they were restricted entirely to making a report. In other words, the report terminated the consultant's responsibility. If an undesirable condition continued to exist at the time of the next visit, it could be reported again. Never was there any attempt to change the consultant's report or to interfere with the writing of it in any way. If the condition was not corrected, the consultant never attempted to use other methods, and there were a few instances when correction was not made. In some instances, remedial action was slow, but almost always something was done about every important recommendation.

The Consultant's Report

    The consultant's report was composed of six parts, as follows:

    1. General considerations, including comment on the hospital as a plant--the wards, operating rooms, cleanliness, and so forth.
    2. Surgical personnel, including a sketch of the training and competence of everyone on the surgical service and his surgical specialties with his rating, background in surgery, and so forth.
    3. Census of patients.
    4. Detailed discussion of professional work, general surgery, and surgical specialties, including the quality of the work, types of surgical conditions, the number of patients, the backlog of patients to be treated, personnel needs, problem cases, and so forth. Individual patients were examined. Suggestions were made for the correction of any professional, personnel, or hospital problems that existed. X-ray, anesthesia, and pathology were included in this survey. The autopsy examinations and also reference to surgical deaths were included. In one of the reports, the backlog in general surgery was 92, that in orthopedic service 27, and that in neurosurgery 400. This lopsided situation called for the shifting of personnel from one service to another.
    5. Medical meetings, library, and medical journals.
    6. Summary and conclusions, presenting every possibility for improvement. This required judgment to separate the important items from the unimportant items.


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EARLY PROBLEMS - THE TRAINING CAMPS

    As Colonel Beck looked back over his experiences, he could see readily that the activities of the Medical Department were those that pertained to (1) the care of soldiers in training, (2) the care of those wounded in war, and (3) rehabilitation and care after the war was terminated. The problems in each of these categories were related to the stage of the war. There was some overlapping, but essentially they were different.

    The early problems in the training camps were without number. Things happened very fast; medical officers were in short supply; often they were available for only brief periods of time. Later on, the census of an entire camp might fall, in a period of months, from a very large number to almost none.

    The most important problems in the training camp hospitals were related to drafted soldiers who did not want to be soldiers. Many devices were used such as feigning backache, developing enuresis, resorting to self-inflicted wounds, and so on. The backache and bed-wetting problems were important because these individuals occupied several hundred beds in the large station hospitals. It was necessary to differentiate those who had a pathological lesion producing the symptoms from those who did not, and this involved much work and expense. It took some time for medical personnel to learn how to make this differentiation without too much delay. After the differentiation was made, the problem of disposition remained for the Army, and this was also a serious problem.

    In one of the station hospitals, the chief of surgery performed appendectomies without pathological changes in the appendix, and about 100 beds were occupied by such patients. This officer had to learn that appendectomy was not a prophylactic operation. In another hospital, there was an epidemic of mumps and orchitis, and an enterprising medical officer thought it would be scientific and educational to do biopsies on the testicle. This officer learned that the taxpayer could not afford unnecessary operations with their pension aspects later on.

    A great variety of problems were encountered involving individual cases. The following incidents can be recalled. A soldier developed acute appendicitis. On the way to the hospital, he received a hypodermic injection of morphine. The correct diagnosis was not made, and the patient died. One death was due to a small stab wound of the heart, and there was no operation. Several cases of subdural hematoma were not recognized. Another patient died from hemorrhage after a spinal fluid tap through the foramen magnum. It serves no purpose to recount these occurrences; suffice it to say that they were brought to light and did not remain hidden and that the consultant system was largely responsible for bringing these mistakes into the open. At times, there were no medical personnel adequate for the responsibilities imposed; the personnel were changing rapidly and the best effort


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consisted in using what was available. But the consultant had discussion of the problem, and on some occasions an officer was sent in from a nearby general hospital to take care of an urgent condition in a station hospital.

    There were several instances of inadequacy on the part of the commanding officer of the smaller facilities. There were also instances of an inadequate officer having been assigned as chief of the surgical service. Such mistakes produced results that were often obvious, and, as a rule, correction was readily made. An inadequate commanding officer or chief of surgical service could do considerable harm to the proper conduct of the hospital. The one and only way to find out about a medical officer was to watch him in action and see what he did. There were occasions when former friendships and a pleasant personality were the factors on which assignment in a hospital was made. Three of these assignments produced considerable turmoil, but in the course of time they were corrected. With respect to conduct of hospitals and medical schools, the Army acted much more expeditiously and with much more wisdom than did the trustees of our civilian medical institutions. Indeed there was no comparison in the conduct of military and civilian institutions. It would be good for society as a whole if our medical institutions, including the medical schools, were subjected to the same critical analysis by competent consultants as were the military medical institutions during the war.

THE AIRBASE HOSPITALS

    Colonel Beck visited a number of station hospitals located at airbases. He understood that the Army Air Forces expected to have their own general hospitals, and this seemed to be the program in the early part of the war. Assigned to these hospitals were large numbers of highly trained medical personnel. For the most part they had little work to do, and later some of these officers were made available to the Army Service Forces where they were needed. It was a serious mistake in Army organization to try to separate these services. These medical personnel were needed by the Army Ground and Service Forces.

THE GENERAL HOSPITALS

    The general hospitals were organized primarily for the care of those wounded in war. These hospitals were usually large installations with a bed capacity of about 3,000. Location was based upon civilian population so that the wounded soldier could be hospitalized near his home. Several large station hospitals were converted into general hospitals after the camps were vacated. These hospitals were organized to give definitive treatment to those who needed it. The chiefs of services and other professional personnel were the best obtainable. In many instances, they were the outstanding surgeons of America. The organization was done with great care. The quality of the work in these hospitals was excellent. When specialized help was needed, such as for the hand, it was obtained. Consultants in surgery, orthopedics, psy-


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FIGURE 34. - Sgt. Joco Montonio, medical illustrator at Ashford General Hospital, creating a bust of Gen. Jonathan M. Wainwright that was later cast in bronze for permanent retention as one of the Nation's treasures.

chiatry, and medicine supervised the work and disseminated knowledge from one hospital to another. Ancillary personnel at the general hospitals were highly skilled in their areas of specialization, and their talents were available in many fields (fig. 34).

    There were, of course, many problems, but the most important problem was to keep abreast of the work. The most common type of injury was an open wound with bone infection. A patient with this type of injury arrived at the hospital with the extremity in a cast. The cast was immediately removed after arrival. The wound was cleansed, dead bone was removed, and a split-thickness skin graft was applied over the bone. The sulfonamides and penicillin were available and were used. These drugs helped to make this treatment successful. In some cases, part of the skin graft sloughed away, but it was usually possible to convert the wound from an open one to a closed one. A cast was applied, after which the patient was sent home for a period of weeks or months.

    The patient was then brought back to the hospital, as time permitted, and definitive surgery was done. Defects in the bone were filled with bone chips. This technique was developed by Maj. (later Lt. Col.) Marvin P. Knight, MC, at Crile General Hospital, Cleveland, Ohio. A full-thickness or a sliding skin graft was applied to cover the bone. This early cover of the wound was not en-


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tirely new, but Colonel Beck's first contact with it was at Ashford General Hospital, White Sulphur Springs, W. Va., where it was employed by Maj. (later Lt. Col.) Robert P. Kelly, Jr., MC, and at Billings General Hospital, Fort Benjamin Harrison, Ind., where it was used by 1st Lt. (later Capt.) Ernest M. Burgess, MC. When its value was recognized, Colonel Beck extended this method throughout the command by sending officers to these hospitals for temporary duty. The method was presented at a medical meeting for the medical officers of the Fifth Service Command which was held at Newton D. Baker General Hospital, Martinsburg, W. Va., in May of 1945, and from there its use was extended to the other service commands by Col. I. Mims Gage, MC, Col. W. Barclay Parsons, MC, Lt. Col. (later Col.) Condict W. Cutler, Jr., MC, Col. Waiter D. Wise, MC, and Col. Leonard T. Peterson, MC.

    This method of treatment increased the bed capacity of each general hospital by as many as several hundred beds by making it possible for the patients to leave the hospital and return later when operation could be done as a routine procedure without exceeding the facilities of each hospital. This program saved the Fifth Service Command the equivalent of one general hospital. The consultant was pleased to have been instrumental in this development.

    Colonel Beck had difficulty in arranging the aforementioned meeting. The treatment of osteomyelitis was not sufficient reason to persuade the service command surgeon to give permission for such a meeting. Later on, the consultant did succeed in arranging a urological conference and symposium on the paralyzed patient. The treatment of osteomyelitis was put on the program as a subject of secondary importance, but it was presented at this conference. This was the first meeting for discussion of professional problems with which Colonel Beck had any contact in the Army. There were several meetings of the surgical consultants in the Office of the Surgeon General, but these concerned matters of policy rather than the surgical care of patients. The need for such a meeting was great, and this meeting yielded more than small results.

    Some of the most difficult problems were the injuries that involved the urological system. A competent urologist was not available for every general hospital, but it did become possible to place a competent urologist on temporary duty at other hospitals as necessary. This was a good idea, and it worked out very satisfactorily.

    Great effort was made for the care of the paralyzed patient. All kinds of services were brought to bear upon these patients. These included the services of the neurosurgeon, urologist, orthopedist, general surgeon, psychiatrist, nutritionist, and rehabilitation personnel.

Specialization

    Some of the hospitals were designated for special services. Thus, Ashford General Hospital (fig. 35) was a vascular center, several hospitals were designated as neurosurgical centers, and several, as plastic surgical centers. For various reasons, this was a necessary development. Highly qualified personnel


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FIGURE 35. - Ashford General Hospital, White Sulphur Springs, W.Va., formerly the Greenbrier Hotel.

were assigned to these special services. The other general hospitals transferred patients to these centers. This became a requirement, and it was closely observed by this consultant.

GENERAL IMPRESSION

    In writing this history, it has been necessary to recall as many experiences as possible. Time has added both highlights and shadows to these experiences. The important timings still stand out in memory, while the relatively unimportant things are gone.

    No man placed in an important assignment does a perfect job, and, likewise, no big organization can ever do a job that is completely perfect. It could always be done better. Regardless of how perfect the record can be made to read, the work actually is never perfect.

    The record for the Fifth Service Command was not perfect. It was very imperfect in the early part of the war. The imperfections due to bad judgment were susceptible to correction, and they were corrected. The others inherent in the rapid building of an Army had been scarcely correctible in years gone by and probably will not be correctible in the future. Many factors were responsible for the early inadequacy, and these need not be enumerated here.

    The general hospitals, however, were something that this country can point to with pride and satisfaction. The amount of work done and the quality of the work done in the general hospitals stand as a great monument to medicine in wartime. If comparison is possible, it can be stated with considerable assur-


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FIGURE 36. (See opposite page for legends.)


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FIGURE 36 - Ashford General Hospital, being easily accessible front Washington, presented an opportunity to show Army dignitaries the superior services being rendered at Army general hospitals. A. Col. Daniel C. Elkin, MC, chief of surgical service, explains to Maj. Gen. Anthony C. McAuliffe. hero of the siege of Bastogne, some of the outstanding work done at Ashford. B. Colonel Elkin and the hospital commander, Col. Clyde McK. Beck, MC, show the incoming Army Chief of Staff, General of the Army Dwight D. Eisenhower, the facilities available at the hospital. C. Colonels Beck and Elkin orient the incoming director of the Veterans' Administration, Gen. Omar N. Bradley, on the services provided in Army general hospitals.

ance that these hospitals easily surpassed the best civilian hospitals of that period. The members of the Medical Corps who served in these hospitals took pride in their accomplishments (fig. 36). They knew that it was the care of the patient that came first. These medical officers also knew that organization was necessary so that the work could be clone, and this organization of which they were a part was as good as could be achieved.

    Personally, this consultant had satisfaction in his assignment. The Army organization made it possible for him to be effective. He knew that his work was well regarded by General Rankin. General Rankin and Col. (later Maj. Gen.) Edward A. Noyes, in the Fifth Service Command, deserved a large part of the credit for Colonel Beck's services. An important source of satisfaction was the contacts with the medical officers in the places where they worked. Colonel Beck was someone who could be talked to in private as an individual without relationship to Army rank. Many a problem, small to the


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hospital but important to the officer, was solved on the basis of such meetings. Everyone needs a friend, and a young doctor who had been uprooted from his environment was in special need of someone who could understand him. Some of the problems brought to light by these private conversations were, indeed, important to the hospital.

    The author's final advice is to let the light of understanding be cast upon the problem. Then it can be solved. As long as the problem is hidden it defies solution and often remains as a torment working against the best of effort and the highest fulfillment of duty.