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Chapter XII

Contents

CHAPTER XII

Seventh Service Command

Grover C. Penberthy, M.D.

    As a Reserve officer, Col. Grover C. Penberthy, MC, was informed early in June 1942 of the establishment of a consultant service which was to be a part of the Medical Department. He was requested to accept a duty assignment as a consultant to one of the nine corps areas, later designated as service commands, of the ASF (Army Service Forces). His orders to active duty in the Seventh Corps Area were contained in War Department Special Orders No. 175, dated 2 July 1942. Colonel Penberthy reported for active duty at Fort Wayne, Detroit, Mich., on 25 July and joined Headquarters, Seventh Corps Area, Omaha, Nebr., on 29 July 1942.

    Colonel Penberthy remained in this assignment throughout the war. It was a pleasant experience marked by cooperation of the personnel, both military and civilian, at Seventh Service Command headquarters and in installations and facilities visited within the command. Appreciation is expressed for the cooperation and support given by Maj. Gen. C. H. Danielson and Maj. Gen. Louis A. Craig who were, in turn, commanding generals, and by Col. (later Brig. Gen) Sidney Erickson and Brig. Gen. Paul X. English who were, in turn, chiefs of staff of the Seventh Service Command. Appreciation is also expressed for the cooperation and support given by Col. Herbert C. Gibner, MC, Col. Harvard C. Moore, MC, and Col. Charles R. Mueller, MC, who were, in turn, service command surgeons; by Col. Neill J. Everitt, MC, assistant to the surgeon; and by the officers in the surgeon's office.

    Inasmuch as there was no set pattern for the consultant's activity as applied to hospital surgical services, except that of a well-run civilian hospital, the continued spirit of cordiality and cooperation shown by the Office of the Surgeon General and the associated officers at Headquarters, Seventh Service Command, helped materially to carry through the concepts of this additional Medical Department service which the assignment of the consultant represented. It also afforded an opportunity to evaluate the results of the superior educational programs carried on in the medical schools, combined with the advanced intern and resident training in the hospitals.

SCOPE OF ACTIVITIES OF THE SURGICAL CONSULTANT

    Colonel Penberthy's activities were carried out principally in the field of visiting both the ASF and the AAF (Army Air Forces) installations and activities. These included 4 general and 58 station hospitals, with the break-


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down of the latter as follows: 16 ASF station hospitals, 32 AAF station hospitals, and 10 station hospitals at prisoner-of-war camps. The station hospital at Camp Carson, Colo., was designated as a general hospital early in 1945, and eight of the station hospitals (four ASF and four AAF) were subsequently classified as regional hospitals. In December 1944, the key officer personnel assigned to these regional hospitals, through the joint action of the ASF, the AAF, the AGF (Army Ground Forces), and the ATC (Air Transport Command), were named as subconsultants to visit their respective satellite station hospitals. This arrangement made possible more frequent professional visits to the satellite hospitals and relieved the surgical consultant at a the when general hospitals were receiving more battle casualties and when much of the major surgery originating in the Zone of Interior was being concentrated in the regional hospitals. The number of Colonel Penberthy's hospital visits each year varied from 88 to 100.

    Visits were also made at times to most of the seven induction stations, which were subsequently reduced in number to meet the reduced inductee input. Dispensaries, such as the Kansas City General Dispensary, were visited from time to time.

    The principal public relations activity consisted of participation in non-military medical programs, including the War-Time Graduate Medical Meetings; lending support to local, State, and national meetings; and representing the commanding general or service command surgeon at specific functions.

    The principal contribution of the surgical consultant was made in the field. His field trips entailed considerable travel--chiefly by rail or automobile, and later by military airplane--over an area including nine States, extending east and west from the Mississippi to the Rocky Mountains and north and south from the Canadian boundary to the Arkansas State line. Because he spent so much time away from the service command surgeon's office, the extent of administrative duties assigned the consultant was minimal. He served in an advisory capacity relative to medical policies, classification of Medical Corps officers, and assignment of Medical Corps officers to ASF installations and hospital units being assembled for oversea duty.

Reports of Inspection

    The consultant submitted a written, detailed report of each inspection he made in the field. His report on an ASF facility was submitted to the station surgeon, the service command surgeon, and the Surgeon General; that on an AAF installation was submitted to the station surgeon for such disposition as was indicated by AAF authority. Usually, the report was sent to the commanding general of the Army Air Forces, for the attention of the Air Surgeon. The inspections were reported under the following headings:

1. Authority for inspection.


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    2. Hospital plant (consideration of the general setup, bed capacity (normal and possible expansion), census, alterations or new construction, problems, policies, and so forth).
    3. Personnel (numerical and professional adequacy of officers assigned to the surgical service).
    4. Training (professional and technical programs and conferences).
    5. Surgical service (a description of the overall setup, patient load of the respective sections, cases presented and discussed on ward rounds in each section, and consideration of problems pertaining to the service).
    6. X-ray (type and adequacy of the equipment, workload, and personnel, including trainees).
    7. Operating room (adequacy of equipment, which was limited and inadequate in the early period of the war but more or less complete near the end; types of anesthetics administered, complications if any, the workload per month, personnel assigned, and the training program for enlisted men)
    8. Physiotherapy (equipment installed, personnel assigned, workload, and training program in force).
    9. Professional care (discussion of care being given in the wards and special cases requiring consultation).
    10. Disposition boards (meetings held, number of cases reviewed, and promptness of disposition).
    11. Records (universally found to be complete).
    12. Library (a good variety of bound textbooks and medical journals representing the specialties was available).
    13. Nurses.
    14. Enlisted personnel (number assigned, specific training programs conducted for technicians, orientation lectures and demonstrations, and rotation among the various sections).
    15. WAC (Women's Army Corps) personnel assigned.
    16. Summary and evaluation of professional service.

PROFESSIONAL SERVICES

    Service command surgical consultant. - The military consultants, when ordered to active duty, were charged with carrying out the following which had been proposed as a definition of their functions and responsibilities: "Act in an inspectorial and consultative capacity; the duties shall include the evaluation of the professional qualifications of medical personnel, appraisal of therapeutic and diagnostic procedures and agents, and the coordination of professional practice by local discussion with hospital staffs of such special problems as may present themselves." The chief function of the surgical consultant was, therefore, the evaluation and supervision of professional services. To this end, when the consultant visited hospitals, most of the patients


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on the surgical services were presented to him on ward rounds in the respective sections.

    Informal discussions often developed with special or selected cases relative not only to the diagnosis and treatment but to the disposition of such cases as well. Reference has already been made to the opportunity afforded the consultant to evaluate the results of the prevailing high standard of resident training. With few exceptions this training was apparent at most hospitals and was manifested in the approach made by the officers in arriving at a diagnosis--particularly in problem cases, their overall understanding of the particular surgical problem, and the subsequent surgical management. The writer can say with certainty that he has benefited professionally many times as a result of his wartime experiences as a consultant.

    In addition to the ward activity and conferences, an informal meeting was usually held with the medical officers at which time Colonel Penberthy presented some subject or participated in the program by entering into the discussion of some subject presented by a duty officer of the hospital being visited.

    Colonel Penberthy participated in the AAF orthopedic conferences in the fall of 1943 at Buckley Field, Denver, Col., Lincoln Army Air Field, Lincoln, Nebr., and Jefferson Barracks, Mo., presenting the subject of burn therapy. At the AAF surgical conference in September 1944 at Lincoln Army Air Field, he presented the subject of wound healing.

    Civilian consultants. - This additional consultation service was inaugurated by The Surgeon General late in 1943. It was Colonel Penberthy's privilege to accompany the civilian surgeons in their visits to medical activities in the Seventh Service Command. Dr. Robert D. Schrock, orthopedic surgeon of Omaha, Nebr., in December 1943, visited station hospitals at Lincoln Army Air Field, Camp Carson, Col., and Camp Hale, Col., and Fitzsimons General Hospital, Denver, Col. Dr. Frank D. Dickson, orthopedic surgeon of Kansas City, Mo., in January 1944, visited Winter General Hospital, Topeka, Kans., and O'Reilly General Hospital, Springfield, Mo., and the station hospitals at Fort Riley, Kans., Camp Phillips, Kans., Fort Leonard Wood, Mo., and Camp Crowder, Mo. Dr. William Jason Mixter, neurosurgeon from Boston, Mass., inspected the neurosurgical service at O'Reilly General Hospital on 3 July 1944. In September 1945, Dr. Schrock again visited the orthopedic services at Schick General Hospital, Clinton, Iowa, and at O'Reilly and Winter General Hospitals. The contributions made by these surgeons were constructive and most important. Each submitted a report on his visits. The officers at all installations gave unanimous, favorable expression to this additional consultation service. In turn, the civilian consultants no doubt benefited and couldn't help but be impressed with the superior quality of the surgical service being rendered by the officers in these two major branches of surgery.


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The temporary service of Dr. Sterling Bunnell in the Seventh Service Command to conduct conferences on surgery of the hand was another outstanding contribution. Two such conferences, with an intensive program extending through 4 days, were lucid at O'Reilly General Hospital in February and August of 1945. The course consisted of didactic lectures illustrated by lantern slides depicting the anatomy and physiology of the hand, diagnostic and clinical conferences, and operative clinics. The officers in attendance were from installations of both the ASF and AAF and numbered 27 for the February refresher course. For the course in August, 97 medical officers from ASF facilities and 11 from the AAF attended. The officer personnel on duty at O'Reilly General hospital were also in attendance, which gave an overall enrollment for each course of approximately 70. The available clinical material, of great variety, was inexhaustible. There were 200 to 300 crippled hands in the wards, not including a large group of brachial plexus and other neurological injuries. At the clinical conferences, free discussion was encouraged after Dr. Bunnell's presentation of the cases and their evaluation relative to possible surgical procedures to restore at least partial function of the injured member. The benefits derived by the officers in attendance would be difficult to evaluate, except that it was observed that many returned to their respective surgical services with a new interest, a new enthusiasm, and a better concept of the surgical management of the crippled hand. In a few of the hospitals, hand clinics were set up for discussion and evaluation of new cases and postoperative results.

    War-Time Graduate Medical Meetings. - Colonel Penberthy participated in two programs in Denver of the War-Time Graduate Medical Meetings. Dr. Charles G. ,Johnston, Professor of Surgery at Wayne State University College of Medicine, Detroit, Mich., accompanied Colonel Penberthy in June 1946 and met with medical officers at the regional hospitals at Camp Crowder and Fort Leonard Wood and at O'Reilly General Hospital. In addition to ward conferences with discussion of cases, Doctor Johnston presented the subject of intestinal obstruction at a general meeting. This presentation was supplemented by a motion picture depicting the rise of the Miller-Abbott tube, which emphasized statistically the disadvantages and advantages to be gained by its use in selected cases.

    Promotions and morale. - The surgical consultant shared in sponsoring recommendations for promotion of worthy officers in consultation with the service command surgeon, with Colonel Everitt, assistant to the surgeon and in charge of officer personnel, and with the medical consultant. In many instances, opportunities for promotion were inadequate, due perhaps to the fact that too little attention, apparently, had been given to this deserving activity by those responsible. Many medical officers with long periods of preparation for their duties had entered active military duty equipped and trained to render competent professional service, but in many cases these facts, unfortunately, were not given proper recognition.


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    The need for the maintenance of morale became apparent early and was more noticeable in the later months. Colonel Penberthy made every attempt to maintain a high level of morale by encouraging presentation of personal problems to him, by commendation for work well done, by a change of station or assignment to an oversea unit in individual cases insofar as this was possible and advisable, and by encouraging officers to submit experiences and observations for publication. Also, support was given to officers interested in securing places on national medical programs.

    Manuscripts. - Many manuscripts prepared by officers on surgical subjects were reviewed and either returned with comment or forwarded to the Office of the Surgeon General for consideration. Encouragement was given to the officers to submit their experiences for publication.

    Relation of the surgical consultant to the commanding officers of hospitals and chiefs of surgical service. - Colonel Penberthy's association with commanding officers and chiefs of surgical services in the various hospitals was a friendly one. Problems, both professional and pertaining to personnel, were discussed informally. The position taken by the consultant was to lend support to the respective installations being visited, rather than to be critical. Mutual understanding between those in authority at the hospitals and the consultant was productive of beneficial results and the establishment of a sound relationship with the service command surgeon's office. Informal correspondence between hospital commanders and chiefs of surgical services and the consultant was encouraged, except where official matters discussed would require the information to be forwarded through channels. The understanding and leadership of both the commanding officers and the chiefs of surgical service were reflected in the general setup and in the contribution made by the various hospitals.

SURGICAL PROBLEMS OF INTEREST

    The surgical services, with perhaps a few exceptions, throughout the command in both the ASF and AAF hospitals were considered superior. This superiority was reflected in the high standard of surgical practice which was maintained and in the comparatively low incidence of serious complications. Surgical mortality was reported to be minimal.

    The more common conditions requiring surgical operation during the period when troops were in training were for hernia and appendicitis. The incidence of both was apparently high in the larger camps.

    Hernia. - The frequency of hernia operations and the low incidence of recurrences following operation was shown in statistics for the year 1943. Sixty-seven hospitals, which included station and general hospitals, replied to a questionnaire and reported 3,996 operations performed for the correction of inguinal hernia (some bilateral). There were 11 recurrences reported from 10 hospitals. Four cases had previously been operated on, and of this num-


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ber two had been operated upon previously on two occasions. Some of the recurrences had been operated on elsewhere in Army hospitals, The low incidence of recurrences reported-none at all in some instances--was explained by the fact that many of the postoperative cases were in time moved to other stations, a consequence of which was that the followup was limited.

    Appendicitis. - The incidence of this surgical lesion was perhaps no higher than would be seen in a comparable civilian population, but the number of operations performed did appear to be relatively high. This may be explained by the fact that the soldier who reported to sick call was hospitalized early in this illness in most instances and encouragement was given to operation when the clinical and physical findings warranted a diagnosis of appendicitis. This did not mean that unnecessary operations were performed, but following this program of management no doubt contributed to a minimum of complications and also to the low mortality. In many instances, patients with complications had not been seen until late in their illness. They had been transferred from another station where they had not reported ill for fear of not being included with their associates in changes of station.

    Pilonidal cyst disease. - The incidence of infected pilonidial cyst with draining sinus tracts was comparatively high during the training period of the Army, especially at the larger stations. There were many instances of long periods of morbidity and a resultant loss of duty time in the early months of the war. The lesion had seldom been seen in the surgical clinics during World War II, and, because of the high incidence in World War II, many theories were advanced as to possible contributing factors, such as riding in jeeps, trucks, airplanes, and other vehicles. These conclusions, however, were not always valid, as many patients admitted for surgical care gave no history of exposure to possible trauma from such causes.

    Experiences with this lesion as reported from a general and a station hospital may be considered representative of those of other clinics. The general hospital reported the following:

    A complete comprehensive study was made of 102 patients. The pilonidal cyst, although considered a congenital anomaly consisting essentially of embryonic inclusion of skin structure in the subcutaneous tissues of the sacrococcygeal area, appeared primarily in the age group 20 to 30 years. The loss of duty time and manpower were evaluated in this study, which showed that 90 lost on an average of 5 months, 75 men lost five-and-a-half months and 6 lost more than 1 year; time longest reported time lost was seventeen-and-a-quarter and seventeen-and-a-half months.

    At the time of this particular visit in April 1943, it was reported that 40 of the 45 in the service in September 1942 had been before the disposition board and had been discharged to a duty status.

    The following experience was reported at the AAF station hospital:

    132 cases were operated upon from the time of the opening of the hospital August 6, 1942 to September 1944. Before the present forum of treatment was instituted following the SGO Circular Letter No. 169, September 25, 1943, subject Pilonidal Cyst and Sinus, 33 cases were reviewed and it was found that the average hospital stay was 57.5 days, 18


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having been hospitalized 99 days, the longest, 158 and the shortest, 12 days. The acute crises are only incised and drained. Excision was practiced subsequently in 71 cases with 4 reported as failures. The average hospital stay for the first operation has been 9.1 days and for the second, 18.4 or 27.5 days in all. The excised cases were closed using cotton sutures without retention sutures, and the patient was kept in bed 12 days.

    The postoperative cases presented on ward rounds at the time of this visit showed the wounds to be clean and healed. The skin at the site of the scar was freely movable. The conservative management, as outlined and observed throughout the command, materially shortened the period of morbidity, and the loss of duty time was kept to a minimum. Improvement in the surgical management of this group of patients was further noticeable following the circulation of War Department Technical Bulletin (TB MED) 89, Pilonidal Cyst and Sinus, dated 2 September 1944.

    Fractures. - Training activities developed a variety of fractures which were handled in much the same way as in civilian practice. Skeletal traction was emphasized in the management of selected fractures of the long bones, although plaster immobilization was no doubt more commonly used. Early ambulation was universally practiced where it was practicable, with various types of walking supports, such as the walking iron, a rocker arrangement, a rubber heel, or a piece of an old rubber tire casing. There was nothing unusual observed in the treatment of fractures except for the problem of delayed union, which attracted attention simultaneously at two stations; namely, Station Hospital changed on 18 June 1944 to Army Air Forces Regional Hospital), Buckley Field, Denver, Colo., where the altitude was about 5,000 feet, and Camp Hale, where the altitude was reported to be over 9,000 feet. No satisfactory explanation was arrived at, although it was observed that some patients who had come originally from a lower altitude manifested X-ray evidence of delayed union. The majority of the fractures treated at Camp Hale were of the lower extremities close to or above the ankle joint and were the result of skiing accidents.

    Knee injuries. - This group of injuries, particularly meniscal tears and ligamentous rupture, comprised a very considerable portion of the operative material during the training period at several of the camps. It became apparent early that meniscal removal as a rule was seldom followed by return to full dirty status in less than 3 or 4 months. For this reason, more conservative therapy was instituted, and surgical treatment was resorted to only when the patient had a history of recurrent disability. It was further found that operative ligamentous reconstruction in the absence of arthritic changes could restore otherwise permanently disabled knees to a limited duty status.

    Other problems. - There were many other interesting surgical problems and numerous instances of outstanding achievement in the Seventh Service Command. Fractures of the femur, trenchfoot, and hand surgery deserve mention in this connection, but these subjects have been covered in detail in other volumes of the clinical series of the history of the Medical Department, United States Army, World War II.


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COMMENT

    Colonel Penberthy's assignment to duty in the Seventh Corps Area, later designated as the Seventh Service Command, in July 1942 as the surgical consultant was enjoyable and, in many respects, profitable. The reception given him at the many stations and hospitals visited from time to time was friendly. The exceptions were few and came early in his experience when it was possible that there was a misunderstanding of the responsibility and position of such an officer. The resistance was minimal, and in most instances good cooperation was given the consultant by both the commanding officers and those engaged in the professional and administrative work.

    The purpose of the consultant service was intended to be constructive, and every attempt was made to fulfill the desired purpose. The overall professional surgical service was maintained at a high standard, Weaknesses, where noticeable, were easily corrected. The high type of surgery performed and the clear judgment shown by medical officers clearly demonstrated the results of higher education and the good intern and resident training.

    In looking back with the idea of forming some constructive suggestions from his experience, the writer has little to offer as an improvement over the teamwork (group practice) developed by officers in various hospitals, especially where key personnel were kept intact.

    The changes in personnel made to meet the needs and exigencies of war often temporarily disrupted a service, but generally the change was made with no appreciable lowering of the high standard of surgical care given the patients.

    The program of professional training as directed by The Surgeon General and carried out by the hospital commanding officers and chiefs of services provided an excellent opportunity for the continuance of one's education. The program gave officers the privilege of participation, thereby adding, no doubt, to their own security. Although there was the need for assigning medical officers to combat units, it often occurred to Colonel Penberthy that sufficient consideration was not given to a selected group of already partially trained young officers in the various surgical specialties to continue in their respective fields to meet postwar professional needs and to replace trained surgeons deserving of consideration for early return to civilian practice.

The morale of medical officers throughout most of the active period of war was good, with a few exceptions where promotions on the basis of age and contribution were not given proper and full consideration. With the end of active warfare, the morale problem stemming from the small number of promotions was intensified although there was no noticeable letdown in professional care given the sick soldier, one sensed an apparent feeling, on the part of the officers, of indifference to their responsibilities. This lack of interest on the part of some of those who were responsible for giving recognition by promotion for services rendered was in part corrected. However, for the


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overall benefit in stimulating interest, it is believed that the change of viewpoint came too late. The need for good morale was understood by all. In the future, in the event it becomes necessary to enlist the help of a similar, highly trained and patriotic group of civilian physicians, more recognition in the way of promotion will no doubt be given by the Department of the Army to maintain morale to a high degree in keeping with the traditions of the Army Medical Corps.