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Chapter XIII

Contents

CHAPTER XIII

Eighth Service Command

Bradley L. Coley, M.D., Henry G. Hollenberg, M.D., and Thomas L. Waring, M.D.

Section I. The First Consultant, 1942-44 1

PROBLEMS DURING THE TRAINING PERIOD, 1942-43

    During the latter half of 1942 and the entire year of 1943, the problems which faced Col. Bradley L. Coley, MC, as Consultant, in Surgery, Eighth Service Command, were related largely to the surgical care of more than one million troops who were undergoing training in the service command.

    One of these problems was to evaluate the skill and competence of medical officers assigned to the surgical services of the various station and general hospitals under jurisdiction of both the Eighth Service Command and the Army Air Force. Due to the frequent changes in personnel, the survey of hospital surgical services became a more or less continuous process. When deficiencies were found, a shifting of medical officers was often required.

    During the first half of the war, many operations were performed for the correction of defects that had existed before induction. Sufficient care in the selection of cases for operation was not always taken by surgeons who had had no previous Army experience. Soldiers were often operated upon in these early days without regard for the necessity of their return to a combat unit. In many instances, an operation which, judged by civilian standards, was successful left the soldier incapable of continuing a rigorous training program. As a result, the final disposition was reclassification for limited service or even a certificate of disability for discharge. This experience taught medical officers that, in the Army, operations frequently should be withheld and that the personality and psychiatric background of the individual should be very carefully evaluated before proceeding with the correction of conditions existing prior to induction. Illustrative of conditions in this category were internal derangements of the knee, herniated disks, recurrent dislocations of the shoulder, varicose veins, and certain congenital defects, such as maldescent of the testis and pilonidal sinus. The last-named condition was responsible for great loss

1 Col. Bradley L. Coley, MC, served as surgical consultant in the Eighth Service Command from the latter part of July 1942 to mid-March 1945, at which time he was succeeded by Col. Henry G. Hollenberg. MC. Colonel Coley's remarks pertain more to situations characteristic of the early and middle years of the war, while the comments of Colonel Hollenberg which follow were based on observations during the last year of the war - B. N. C.


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of manpower due to prolonged hospitalization following operation and frequent recurrences necessitating further operation.

    The experience with pilonidal sinus in the Eighth Service Command was, no doubt, duplicated by observations of consultants in other service commands. At first, the general practice was excision with open packing of the wound, which was then supposed to heal by granulation. This technique was used on soldiers with symptomless sinuses that had never given the slightest trouble. Such prolonged delay in healing followed this method that partial closures, following the technique advocated by MacFee and by DePrisio, were popular for a time. Later on, excision and primary suture was employed with various modifications, such as the use of fascial flaps as attempted by Shute, Burch, and others. Many of these cases, that is, complete closure by suture, appeared to heal satisfactorily and remained so for considerable periods, only to reopen and drain again. The writer holds no brief for a particular technique, although experience has prejudiced him against wide excision and packing and against extensive fascial plastics. He is, however, convinced that patients with symptomless sinuses should never be operated upon and that incision and drainage, where necessary for infection, is all the surgery that is necessary.

    In the first 9 months of 1942, there was an estimated loss of nearly thirty thousand man-days due to prolonged hospitalization for pilonidal sinus in 20 of the larger hospitals in the Eighth Service Command. At that time, the consultant proposed that no cases be operated upon unless their condition prevented participation in the active training program, and that simple measures be taken for inflamed cases. It was indicated that pilonidal sinus cases ought not have been accepted for full duty or that some better method of treatment than excision should have been devised. The wide variation in treatment employed for this condition was, in itself, testimony to the failure of any one method.

    From the viewpoint of the consultant, the methods for screening inductees were seriously deficient. Too many soldiers were being admitted to hospitals for defects which were disqualifying beyond any question. Too large a daily load of examinations was being carried out by too small a group of civilian doctors at the induction stations. This manner of screening left little doubt that serious errors would be relatively common. If the national emergency had been less acute, it would have been better to have had a group of medical officers who had been especially trained to recognize disqualifying defects perform all selective physical examinations. More care at this level would have resulted in an enormous saving of man-days and public funds. It would have spared the expense of future care in Veterans' Administration facilities of men whose disabilities marked them as incapable for military service.

    In this earlier period, most station hospitals had competent surgeons; but, as the number of units activated for oversea movement increased, the caliber of surgeons in station hospitals decreased steadily. The directives limiting the type of operations for elective conditions permitted in station hospitals


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was a cause for considerable complaint on the part of the surgeons. At first, many of these surgeons were as competent as were the surgeons in general hospitals. As a result of this policy, however, the wholesale transfer of such cases of elective surgery from station to general hospitals soon began to overtax the latter. It was therefore found necessary to designate a few station hospitals as regional hospitals where certain types of surgical cases originating in the Zone of Interior were treated. By strengthening the staffs of these regional hospitals, adequate surgical care was assured. This modification worked well and seemed sound.

    The 10 general hospitals of the Eighth Service Command were for the most part supplied with excellent specialists in the surgical fields and rendered service of high order. The establishment of centers for special types of surgery, for example, amputation centers, was a factor in obtaining the highest possible standards of surgical care.

    With regard to Air Force hospitals, Colonel Cole acted merely in an advisory capacity, and his recommendations were not necessarily followed. At times, perhaps, his recommendations were not welcomed by higher medical echelons of the Army Air Forces. Nevertheless, relations between individual surgeons in the Air Force hospitals and the service command surgical consultant were uniformly cordial.

SPECIAL PROBLEMS

    During the course of Colonel Coley's tenure as the surgical consultant, many special problems arose. A discussion of some of these problems follows.

    Early ambulation. - At the outset, several large general hospitals were successfully practicing the policy of early ambulation. Interest in this method of postoperative management spread rapidly, despite the fact that the Office of the Surgeon General was opposed to it in hernia cases and was rather unfavorable toward it after other abdominal operations. As a result, several of these hospitals were unable to continue using the method, although their experience with it indicated that it was a definite advance.

    Psychosomatic disorders. - It became progressively more evident that surgeons were often quite unfamiliar with the complexities of psychosomatic complaints. Often when individuals had been operated upon, the outcome was disappointing and resulted in a certificate of disability for discharge or a reclassification for limited service. Having learned by experience, some surgeons refused, except in cases of emergency, to operate on any patient in which there was question of a psychosomatic element until the patient had been seen by a neuropsychiatrist and a clearance for operation had been given.

    Acute appendicitis. - In view of the large number of operations performed for this condition, the mortality rate in the Eighth Service Command seemed surprisingly low. There were, however, a sufficient number of deaths to stimulate the consultant to make a study of all cases coming to autopsy from hospitals in the service command. Although this investigation had not


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been completed by the time Colonel Coley left for oversea service, the following impressions had been gained:

    1. The most significant factor appeared to be delay in admission of cases to station hospitals. This was due to the reluctance or indifference on the part of the individual in seeking medical attention promptly. Less excusable were the occasional cases in which the dispensary doctor prescribed for the patient's complaints without examining the abdomen.

    2. Reliance on local instillations of the sulfonamides and the systemic administration of penicillin to combat peritonitis led to the late recognition of secondary pelvic and subphrenic or subhepatic abscess. A number of cases survived for several weeks only to die of sepsis; autopsy revealed the presence of these undrained collections of pus. More strict compliance with the precept that a patient with abdominal distress or pain should never receive medication until the abdomen has been examined would have resulted in earlier operative interference. Perhaps posters could have been utilized warning the soldier of the necessity of reporting abdominal pain to the dispensary immediately.

    Refusal of the soldier to undergo operation. - It was noticeable how frequently men undergoing basic training refused to have a hernia operation and how seldom disciplinary action was attempted to enforce the operation. This reluctance on the part of authorities to force the issue became common knowledge through the "grapevine," and the percentage of refusals increased sharply. It always seemed patently unfair to Colonel Coley to permit an otherwise healthy individual to escape the risk of foreign service because he feared the infinitely smaller risks of an operation for inguinal hernia and refused to submit to surgery.

    Hand infections. - Hand and finger infections caused concern. Usually, they were seen routinely in the dispensary, and, too often they were treated there on an ambulatory basis. Incisions totally inadequate were made without anesthesia, and the resulting drainage was insufficient. As a result, the service command surgeon, on the advice of the surgical consultant, issued a directive to all installations that cases of hand infections, regardless of their triviality, be sent directly to the station hospital for observation, hospitalization, and appropriate treatment.

    As a result of the consultant's experience with cases of hand infections, he offered the following suggestions:

    1. All hand infections should be admitted to the hospital without delay, and none should be treated on an ambulatory basis in the dispensary.
    2. It should be made a rule that all operations for hand infections be performed under a general anesthesia and with a tourniquet (preferably a blood pressure cuff pumped up to 280 mg. Hg).
    3. Penicillin should be used at the earliest stage of even the most apparently trivial case of hand infection. (A few cases had been seen in which such


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FIGURE 37. - Result of self-mutilation of the hand.

treatment seemed to abort an infection which at the outset appeared to be of a serious nature.)

    4. The institution of courses for instructing surgeons about hand infections and hand injuries has proved a very valuable measure. Dr. Sterling Bunnell's contribution in this respect was outstanding. In the future, such courses should be set up early in the training period in order that trainees might receive instruction in the intelligent handling of these cases from the outset. It would have been an enormous help if Dr. Bunnell's courses could have been given in 1942 instead of 1945.
    5. Consideration should be given the question whether hand infections, and especially hand injuries, would in the future be handled better by general surgeons than by orthopedic surgeons.

    Self-inflicted wounds. - The consultant was impressed with the number of cases of wounds that appeared to have been self-inflicted. The majority of these were missile wounds often sustained, according to the history, while the individual was cleaning an M-l rifle or carbine. A number were attributed to accidents in connection with squirrel shooting during furloughs. One case in particular, however, involved a soldier who used a hatchet to sever completely all four fingers of his left hand, requiring 11 strokes to complete the job (fig. 37). On the whole, it was extremely difficult to prove that many of these wounds were self-inflicted. It would seem, therefore, that the experiences of others should be correlated and the entire matter should receive extended study.


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    Reconditioning. - A well-coordinated plan for reconditioning patients in all of the Eighth Service Command hospitals was developed. This was due largely to the caliber of those in charge, to the provision of an adequate physical setting in nearly every instance, to close cooperation on the part of the surgeons, and to a general acceptance of the whole idea of the plan on the part of the patients. The following eight points concerning reconditioning appear worthy of special comment:

    1. Too often there was a feeling on the part of medical officers that higher authorities were going to measure the success of their reconditioning unit by the actual number of patients who were admitted and retained; that is, by the size of the unit. Unquestionably, thus, in some instances, resulted in an unnecessarily prolonged stay.
    2. A misconception arose as to whether every patient, regardless of his condition or of the nature of his illness or accident, was to be sent through a formal reconditioning process rather than be discharged directly to duty.
    3. Probably too much emphasis was placed upon the physical side of reconditioning at the expense of the mental and, especially, the spiritual side.
    4. Directing a large reconditioning annex was one of the more important jobs in a hospital, and the position should have been made more attractive by setting it up on a par with the other major services and giving it commensurate rank.
    5. Close proximity of the hospital proper to the reconditioning annex was a distinct drawback.
    6. Standardized periods for rehabilitation were to be deprecated; instead, more individualization by ward officers was desirable.
    7. For those convalescents who did well and who cooperated fully in the program, incentives, such as weekend passes, could have been furnished to advantage.
    8. A healthful competitive attitude, properly supervised, was considered desirable.

    To summarize, it was believed that the idea should have been constantly borne in mind that reconditioning was only a means to an end; that is, the return of the soldier to duty as soon, and in as good general condition, as was possible with safety to himself.

    Rehabilitation. - It was felt that reconditioning as carried out in station and regional hospitals was more effective than was rehabilitation in general hospitals. The former hospitals were concerned with patients who, for the most part, were eventually going to return to duty, whereas the same was not true in the case of many of the oversea casualties which comprised the general hospitals' rehabilitation sections.

    It was also felt that the proximity of the rehabilitation annex to the rest of the hospital--apparently unavoidable in the case of the general hospitals--was a distinct disadvantage.


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    There was a marked variation in interest in occupational therapy. Efforts to make this activity more practical and less diversional might have enhanced its value.

    The same program of rehabilitation and reconditioning could not have been expected to function effectively under such basically different conditions as existed with respect to individuals returning to duty and those who were not. More attention should have been paid to providing for a well-organized program to bridge the gap between early convalescence and true vocational training.

    Prisoners of war. - The care of patients in the prisoner-of-war hospitals was generally satisfactory and was noticeably so in Glennan General Hospital, Okmulgee. Okla., during the period that this installation served in that capacity. On the other hand, some of the smaller hospitals were handicapped by language difficulties and by an insufficient number of trained medical officers. In these, the surgical patient was not cared for so satisfactorily. It was necessary to make changes in the personnel in order to correct some of the situations that arose in the hospitals attached to some of the prisoner-of-war camps.

MEDICAL EDUCATION

    The consultants in the Eighth Service Command and especially the surgeon, Col. (later Brig. Gen.) W. Lee Hart, believed that the program for medical education was a most important phase of the consultant's work. Teaching, round table conferences, grand rounds, and informal presentations of special topics were among the measures adopted in connection with this program of medical education. In addition, through the generosity of the Rockefeller Foundation, and as a result of the efforts of the service command medical consultant, Col. Walter Bauer, MC, a fund was provided which enabled the service command to make three further contributions to the improvement of medical education. The first of these entailed visits of from 10 to 14 days' duration by outstanding civilian practitioners, many of whom were highly experienced in teaching. these visits embraced a group of station, regional, and general hospitals. The visitors and the consultant made rounds, examined patients, conducted round table conferences, and gave talks usually illustrated by lantern slides; they were available for informal conferences with the various members of the surgical staff. Among the surgeons who participated in this program were Dr. Philip D. Wilson, Dr. Robert L. Payne, Dr. Dallas B. Phemister (fig. 38), Dr. Sumner L. Koch (fig. 39), Dr. Frederick W. Bancroft, Dr. Warfield M. Firor, Dr. Peter Heinbecker, and Dr. Harold L. Foss. in addition, a distinguished pathologist, Dr. Fred W. Stewart, visited a number of the general hospitals where special emphasis was laid on the pathology of cancer and its histologic diagnosis.


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FIGURE 38. - Dr. Dallas B. Phemister of Chicago and Col. Bradley L. Coley making rounds at the station hospital, Enid Air Force Station, Okla. (Dr. Phemister in civilian suit and Colonel Coley opposite him with left arm on patient's pillow.)

    Another effective medium for teaching was the clinicopathologic conference, the expenses of which were assumed by the fund of the Rockefeller Foundation. As a result, each hospital received at regular intervals two cases, together with pertinent X-ray reproductions and microscopic section. These clinical abstracts and! autopsy protocols were prepared from cases taken from the Massachusetts General Hospital material and were carefully selected for their interest and variety.

    Furthermore, the fund made it possible to supply certain medical textbooks to some of the hospitals to augment the excellent libraries which were furnished directly through the Office of the Surgeon General.

    It is believed that the expenditure of considerable time and effort on the various phases of this teaching program was fully justified by the results obtained. There is little doubt that these measures contributed to keeping alive in the medical officers the spark of clinical interest and enthusiasm which was somewhat dimmed at times by the nature of their assignments in the Army. 

BRADLEY L. COLEY, M.D.


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FIGURE 39.--Dr. Sumner L. Koch discusses a case of hand injury with medical officers at Camp Swift Station hospital. (Dr. Koch in civilian suit with Colonel Coley immediately to his left.)

Section II. The Second Consultant, 1945 2

An appraisal of the difficulties, the usefulness, the accomplishments, and possible improvements in the consultant system may be made from numerous points of view. Tue remarks which follow were written by a former medical officer, Col. Henry. Hollenberg, MC, who served 4 years in the AUS (Army of the United States) during World War II, all within the continental United States. During the first 3 years of the war, Colonel Hollenberg was assigned as chief of surgical service in Bushnell General Hospital, Brigham City, Utah. During the last year of the war, he was surgical consultant of the Eighth Service Command. His remarks were set down some 11 years afterward and without notes, so that only general impressions and outstanding events were recorded. These impressions were based upon three general areas of experience.

2 Col. Henry O. Hollenberg. MC, succeeded Col. Bradley L. Coley, MC, as surgical consultant in the Eighth Service Command during the last year of the war. Rather than write a factual account of his activities as a consultant, he has chosen to give his views on the consultant system in general. His comments are pertinent, understanding, and most interesting - B. N. C.


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    In the first area were those impressions obtained while he was not a member of the consultant team but observed it from the outside, so to speak, as chief of service in a general hospital. This was a period during which the Army was being built to its maximum size and effectiveness, and the general morale was high. The second period was the final year when Colonel Hollenberg was, himself, a consultant. During this time it was obvious that the general conduct of the war was coming to a successful conclusion. The buildup was entirely over, and enthusiasm for the Army was decreasing and, finally, was extremely low. The period of demobilization occurred at the end of this year. While it cannot be said that morale was low, certainly interest in the Army was almost nonexistent and everyone was anxious to return to civilian life. The third period is that since the war when this writer has observed in a general way the utilization of consultants during peacetime and in the oversea armies of occupation.

THE CONSULTANT SYSTEM

    Until World War II, the Medical Department of the U.S. Army did not recognize or encourage much specialization among its medical officers. The fields of ophthalmology, otolaryngology, and certain forms of surgery constituted exceptions to this general situation. A doctor was a doctor and could be put to work doing surgery or medicine or whatnot. This was the attitude also in civilian medicine to a large degree. But at the outset of World War II and with the great mobilization which was under way, it was recognized that the advantages of specialized work, so clearly apparent and prevailing in civilian medicine, should also be utilized in the Army. The decision to utilize specialization was obviously made at high levels of authority. Many changes were made to accomplish this end and to improve the effectiveness of the Medical Department in general.

    Among certain innovations was a widespread system of consultants. The men so assigned were physicians recruited almost exclusively from civilian ranks. An attempt was made to procure men a little older and more experienced than the average and, ideally, men with some national standing. From the beginning, they were made to understand the overall plans and pitfalls involved in the program and were assigned to headquarters of service commands, field armies, and so forth. It was the duty of these consultants to make periodic visits throughout the command or theater to see that professional work was actually set up and operated according to a well-thought--out plan, to see that men were properly assigned and utilized, and to insure that proper procedures were being carried out in accordance with good general medical practices and in accordance with every changing Army order. It was their further duty to work closely with higher authority and to act as liaison and coordinating officers between the headquarters of the command to which they were assigned and the various hospitals.


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GENERAL CONSIDERATIONS

    Relations between medical officers of the USA and those of the AUS. - One needs to recall that at the very beginning of mobilization in World War II there was a small group of regular medical officers well trained in the operations of the Army Medical Department. Practically all of the vast number of new medical officers were completely unfamiliar with the manner in which the Army and the Medical Department operated. A small number of the older men called to service in World War II had seen service in World War I. This situation may not obtain to a similar degree henceforth when many young physicians will have served previously. These regulars were, in all cases, men familiar with Army regulations, accustomed to command and to obey, and, in many but not all cases, quite proficient in the care of sick and wounded. The new medical officers were all recruited and commissioned as temporary wartime officers in the AUS. Many were commissioned in field grades and were mainly without one day of training as soldiers. They brought to the Army a vast amount of patriotic enthusiasm, a high grade of professional ability and attainment, and fine fellowship; but they had no awe of rank and, occasionally, even showed disrespect for some phases of Army manners and customs.

    The author has on the whole great respect for the understanding and tolerance on the part of most of the Regular Army officers in this situation. But there were those among them who took a harsher position toward these new men because of their clumsiness with strictly Army matters, on account of the rapid attainment of their rank, and for other reasons. This situation furnished fertile ground for unhappiness and stubborn resentment all around. Likewise, nearly all the newly recruited personnel realized that there were reasons for Army regulations and forced themselves to adapt promptly. In fact, some attempted this so completely as to make themselves almost, comical. But there were others who took the unjustifiable attitude that soldiering was a Boy Scout affair to be resisted.

    Another point of tension existed between officers of the Regular Army and those of the AUS pertaining strictly to professional matters. There was no question but that the new officers brought to the Army a higher overall professional skill than had existed before. Due consideration immediately needs to be given to certain regular officers who had high peacetime reputations and ability in the field of amputations, tuberculosis, certain infections, and so forth. But, on the whole, the proposition stated above would have to be accepted. As a result of this condition, awkward situations arose. The most serious was that a regular officer of high rank in administrative or command authority could dictate by his influence or order professional treatment which the AUS officer knew to be outmoded or less effective than some other form of treatment. This not only resulted immediately in less effective treatment but completely undermined confidence in these commanders. Most often, such orders were circumvented or disobeyed causing the responsible officer to


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feel frustrated and resentful toward his subordinates. This is not to say by any means that the professional thoughts and suggestions of such regular officers should not have been made or should not have been considered or were not in many cases quite helpful. Quite the reverse was true. In the matter of early ambulation, for instance, it was largely the members of the Regular Army who put forth this idea which was finally generally accepted. But, on the whole, it was eventually necessary to create a situation wherein the regular officers had their province of complete administrative and command authority (where certainly they only were thoroughly capable) and wherein the AUS officers had more or less complete domain over the care of the sick and wounded. This happy solution came about in no small part through the activities and influence of the consultants and, of course, by the spirit of cooperation and the good will of all concerned.

    Relations between the Medical Department and other branches of the Army. - Another area of tension existed occasionally between certain line officers and the Medical Department personnel associated with them. Actually, officers of the line and all Army personnel, including post and army commanders, had respect, great friendliness, and even affection for the Medical Department, which was so useful to them in time of need. But, during any rugged period, the Medical Department could be visualized as a softer berth. Commanders might have felt that unreasonable demands were made by the Medical Department as regards supplies, personnel, and so forth. As a result, line commanders of high rank might have seriously interfered with the program of the Medical Department. Their action usually did not concern the medical officers of the AUS but involved a dispute between brother officers of the Regular Army. In all these encounters the Medical Department, without outside help, frequently came off second best because of their lesser rank and because they exercised no command outside the Medical Department. This resulted, again, in a feeling of resentment on the part of hospital commanders, for instance. To do justice, however, it needs to be polluted out at once that, here again, a post commander, for example, might often have been right and have been acting with information not generally held. The consultant frequently and suddenly found himself in the middle of a problem of this sort on the occasion of a routine visit. It might be pointed out that the consultant at the time of each visit to a post first visited the post headquarters and made himself available for a conversation with the post commander. And this occurred likewise at the time of this departing from the post. In all cases in the author's experience consultants were warmly received and cordially regarded. They were recognized as individuals visiting various camps and in touch with high authority. Problems of all sorts could be brought up and freely discussed. In many of these instances, the consultant, using a good deal of tact and diplomacy, could intercede very successfully and bring about a solution to local problems by his own efforts. In other instances, the matter


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could be properly taken to a higher authority much more quickly and informally than through other Army channels.

    Personnel problems. - The problems which could arise concerning personnel were legion. This might have been more pronounced among medical officers than among any others. There were personality conflicts between individual officers of the AUS, great unhappiness as to assignment, violent conflicts as to professional ideas between officers of the same grade or of different grades (officers of the AUS really had little awe of rank, though they all earnestly sought higher rank), and strongly felt differences between chiefs of services and hospital commanders. In all of the problems, and possibly here best of all, the consultant was helpful. Everyone concerned could talk to the consultant with confidence in the fact that he was having an interested and unbiased hearing which was entirely off the record, if necessary. The consultant had a better overall picture as a rule than anyone at an individual post and, in almost all instances, could offer helpful advice or a downright solution to local problems. The acceptance of his opinions was amazing. Yet, in this connection, it might be brought out that in the last analysis he had no direct authority. His influence was more like that of one physician among others in civilian practice. The only real authority could be obtained by requesting specific action through the service command surgeon, and service command personnel officer, and so forth.

PROFESSIONAL MATTERS

    Stimulation provided by consultants. - In strictly professional matters, every honest physician needs and desires consultation frequently. Groups working within a hospital or any medical organization soon became familiar with each individual's thinking and need for stimulation of new ideas and new personalities. The consultants furnished this stimulation admirably and in direct proportion to their individual personality and professional attainment. In the Eighth Service Command during World War II, a rather successful and unique plan of utilizing civilian consultants was in effect. With funds generously donated by the Rockefeller Foundation it was possible to invite an older and usually distinguished civilian physician to accompany a military consultant of like specialty during his rounds of a number of hospitals and usually over a period of a week or two. The funds were sufficient to pay the expenses of this civilian and to furnish a small honorarium. The professional stimulation furnished by this additional consultant was profound. Their visits were of interest to nonmedical personnel. And these civilian physicians themselves greatly appreciated the chance to be of service and the opportunity to see so intimately the workings of the Army. They were unanimous in expressing their appreciation after each visit. The favorable effects of this sort of plain were obtained, the author would imagine, through the system of utilizing different civilian consultants from month to month in the oversea armies of occupation after the war. It was certainly a good plan as far as strictly


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professional matters were concerned; the usefulness of such civilian consultants was limited in certain respects inasmuch as they were not members of the Military Establishment.

    Policing of hospitals and services. - As regards policing of hospitals and services, the consultants fulfilled a highly useful, though to them disagreeable, service. The different sizes and types of hospitals were nicely organized and equipped with the personnel to do varying degrees of professional work. Furthermore, certain general hospitals are set- up as centers for such interesting disorders as arteriovenous aneurysms and other vascular conditions, plastic procedures, and so forth. And, for very good reasons, it was highly desirable that specialized work of certain exceptional sorts be done in a special place by highly qualified specialists. But, physicians are a queer lot in such matters. Confidence or overconfidence, boredom or great professional pride and interest influenced medical officers in many cases to overlook orders which limited their work to certain types of cases and caused them not to refer proper cases to the specialized centers. Under the worst circumstances, the hospital commander himself might have been unsympathetic with any referral plans; he might have ha such pride in his hospital and such confidence in his medical officers that he did not require them to follow orders to refer particular cases. He might not have permitted them to do so.

    Although it must be admitted that some major and specialty work was well done in smaller hospitals and smaller groups, the reverse was too frequently true. This writer has seen common duct injuries in simple cases where the patient should have been referred according to orders to another hospital where thoroughly capable surgeons were in waiting. In their routine rounds, consultants were alert to this situation of medical officers waiting to do more than they were permitted to do. Monthly checkups at headquarters on all deaths furnished clues in these unfortunate cases not properly referred. In fact, the system of consultants was a deterrent to these errors happening at all because, in the first place, the consultant could make the regulations clear and, in the second place, it was known that there was some system of check. In practice, however, the search in hospitals for such cases, which were visually well hidden away, constituted something of a game. The stakes were high, the rules were charged too often, and the penalties were ill-defined for the offender. For the innocent victim, the penalty was often clear cut.

    Relations with the Army Air Forces. - This writer, while a consultant, also visited hospitals of the Army Air Forces, as was customary in the Eighth Service Command. Certain well-recognized difficulties between the medical service of the Army Air Forces and the rest of the Army were never apparent on any such visit. The cordiality and cooperation even exceeded that at the hospitals with which this consultant was more directly connected. For instance, on one occasion the service command surgical consultant, accompanied by a civilian consultant, found insurmountable difficulties for convenient travel by air or otherwise between Santa Fe, N. Mex., and Amarillo, Tex. The result


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was a bus ride. When the general commanding the Air Force base at Amarillo heard of this, his assumed air of wrath was considerable and his directions to telephone on the next occasion for a plane were quite explicit. From his viewpoint, he had hundreds of aircraft flying about on mock assignments for training. It would have been a proper mission for one of his officers to fetch a consultant on orders to visit the base. Certainly his offer was accepted on the next occasion, but, to have asked for such a service without such an invitation might well have been considered presumptuous.

    On all visits made by this consultant to these Air Force hospitals, suggestions and criticism, while given more guardedly, were well received and acted upon. On a professional basis, visits seemed to be received with even more enthusiasm. Everyone apparently recognized that there even some differences at higher levels and beyond the control of those concerned at the local level. Relations with other consultants of the Air Forces were, of course, cordial in the extreme for the reason that they were in many cases good friends and all civilians in uniform trying to do a good job with the armed services. It would seem that in later years and with changing conditions there will still need to be different groups of consultants for various branches of the service for the reason that some of the overall problems differ widely in the various branches. At the same time, much of the work could be unified.

    The life of a consultant - The life of a consultant is usually active and interesting, though, in some respects, rather trying and out of keeping with that of a doctor in the usual sense. A consultant's duties are perhaps 25 percent of a clinical sort regarding patients, and that rather strictly in the true sense of a consultant. A surgical consultant, for instance, rarely operates. This is a situation which may cause a strange void in his heart. There is a vast amount of tiring travel, in hot or cold weather, and a great amount of small chatter and social amenity. Although the latter duties may at times be pleasant and at times boring, they are always important and it is in such conversation that goodwill between various fractions may be brought about. The making of routine reports is troublesome but not arduous. Decisions as to personnel problems may be difficult or heart-rending. The individual consultant works out his own most effective way of going about his business. Some utilize an austere and firm manner. As a rule, the kindly, gloved approach--always fair and thorough--is most appreciated and effective. For these various reasons, consultants in specialized fields of medicine need, of course, to be true specialists in that category. But the work so largely concerns overall problems that the men need to be broad. Orders as to their conduct and duties can be given only in general terms as the situations are always different. Judgment and freedom of action are required and must be exercised properly. For these reasons, a man in any specialty can act as a consultant in many respects. For the same reason that general surgeons are usually the directors of surgical departments in schools and that general internists are directors of medical departments, it is usual that these two categories head up the two main groups of consultants.


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    The Army has such a vast volume of work in the fields of psychiatry and orthopedics that the men in these departments are in some respects more helpful in a clinical way than any others.

    The ideal consultant. - An ideal consultant needs to be a bit older man, thoroughly trained and capable in his specialty. He needs to be articulate, tactful, and socially agreeable. Certainly he needs good judgment in routine and in unexpected situations. He should be either forceful or persuasive. He should be interested, to some degree, in teaching and should be sympathetic with personnel problems in various categories of personnel. A degree of modesty after considerable unaccustomed attention is a great asset. He should not be downcast when overruled. One with a strong stomach and good bowels will go far.

THE FUTURE OF THE CONSULTANT SYSTEM

    It would be useless in many respects for this writer to attempt to predict the need for this system in the future. Yet, many of the problems discussed are present in an army of any size and under any conditions. In the event of any large mobilization again, the same problems will recur. Fairminded men with a broad vision and with a wide acquaintance with men in American medicine an again head up such a consultant system and, with proper modifications, again put it into good use.

HENRY G. HOLLENBERG, M.D.

Section III. The Orthopedic Consultant

    During the latter half of 1940 and the entire year of 1941, the physicians, both civilian and military, in the induction stations were, for the most part, not sufficiently acquainted with or oriented in the military standards of physical fitness and allowed many men with musculoskeletal disabilities to be taken into the Army. The endeavor which was made to qualify these inductees for general military service was not too successful and will be explained in detail later. In 1942 and thereafter, training and combat injuries added greatly to the caseload of orthopedic conditions which, with a corresponding increase of other surgical conditions, made it impossible for the service command consultant in general surgery to supervise the entire surgical part of the medical situation. Hence, there came into being the orthopedic consultant, Col. Thomas L. Waring, MC.

DUTIES AND FUNCTIONS

    The administrative and professional duties of the orthopedic consultant paralleled those of the surgical consultant. Among the many duties of the orthopedic consultant was the evaluation of the competence of the medical personnel assigned to the orthopedic service. When deficiencies were found, their correction usually required a shift of personnel. This often could be accom-


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plished quite easily in the case of the ineffective officer; but, in the case of the competent officer, considerable resistance was encountered at times. The attitude of many capable hospital commanders greatly interfered with the program of rotating medical officers in the Zone of Interior with those already overseas. These hospital commanders were understandably reluctant to give up a surgeon of proven ability for one of unproven ability.

    Because of the shortage of trained orthopedic surgeons, it was at times difficult to staff a hospital adequately, and, due to frequent changes in personnel, the survey of orthopedic personnel in hospitals became a more or less continuous procedure. Full cooperation usually was given by the service command surgeon; in fact., had it not been for his wholehearted support, it was certain that in some instances recommendations could not have been accomplished.

    It was of importance to advise the service command surgeon in matters of training and physical conditioning of troops, for from time to time certain phases and tempos of training were causing a very high rate of injuries. Studies were made of the training programs, and remedial measures were suggested. These suggestions were usually adopted and resulted in increased training efficiency and a lower accident rate.

    The medical facilities of the Eighth Service Command were so numerous and far flung that it was quite difficult to get around to all posts, camps, stations, and airfields as often as was desirable. This deficiency was overcome in part by the cooperation of all the consultants. When a visit was made by one of the consultants, he would go beyond his usual scope of duties and note deficiencies in any of the services which, then, could be corrected by the consultant concerned. If the medical facilities were found to be quite adequate, a visit by another consultant was not immediately necessary, In the aforementioned manner, a more complete coverage was possible. It was the belief of the surgeon of the Eighth Service Command that individual consultant visits were of greater benefit than group consultant visits. This was later borne out.

    The consultants in the Eighth Service Command were also fortunate in having the privilege of visiting the Army Air Forces hospitals which shared in the invited-guest program and the educational facilities available to the Army Ground and Service Forces through the Rockefeller Foundation (p. 261). The consultants' association with Army Air Forces hospitals was of mutual benefit; here, the consultants acted merely in an advisory capacity.

    It was difficult at times to impress upon the commanding officer of a hospital that the function of the consultant was just what the name implied. Too often, the consultant was considered an inspector; and when this multitude prevailed, the benefit of the visit was considerably lessened, for in certain instances the entire working structure of the hospital was upset by his visit. As little interruption as possible of the normal function of the hospital should have been permitted, and only those particularly concerned with his visit should


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have been affected. When this rule was observed, the value of the consultant's visit was enhanced.

PROBLEMS WITH PHYSICALLY UNQUALIFIED INDUCTEES

    It was frequently noted in the evaluation of an orthopedic service that the orthopedic surgeon did not exercise sufficient care in the selection of cases for operation; for example, a patient was operated upon without sufficient regard for the probable outcome insofar as returning him to combat duty was concerned. This error in operative indication was no doubt due to the fact that the orthopedic surgeon in question was not fully indoctrinated into military medicine. The most glaring examples that could be cited were in those conditions that had been incurred prior to induction. By civilian standards, these operations were justified; however, by military standards, the reverse was true. Most frequently, these operations were for the following orthopedic conditions: Internal derangement of the knee, recurrent dislocation of the shoulder, congenital deformities, fracture deformities, ruptured disk, and bunions. Rarely was a patient returned to general duty after an operation for such a condition incurred before induction; a few were assigned to limited duty; but the majority of the patients received a certificate of disability discharge. The orthopedic surgeons in the command soon learned that, even when the aforementioned conditions were incurred in the line of duty, great care in evaluating the personality and psychogenic background of the patient was necessary before giving an absolutely valid indication for operation. Thus experience taught all that great care should be exercised in evaluating the patient, and that, frequently, operation should be withheld.

    Many of the directives limiting the type of operation for elective conditions permitted in a station hospital did not concern the orthopedic surgeon, for in the majority of the station hospitals no trained orthopedic surgeon was assigned. The surgical service was habitually covered by a general surgeon who usually did not have much interest in orthopedic surgery and was glad to be relieved of it.

    It became quite evident that better methods and more careful orthopedic examinations were necessary in order to weed out inductees with disabling orthopedic conditions. The large number of men inducted with such disabilities certainly attested to the deficiencies in the method of screening inductees. The mistakes were due to (1) inexperience of the civilian physician or of the examining medical officer in military medicine, with failure to realize the significance of the danger of minimizing or overlooking defects, (2) too few medical personnel to handle the number of inductees examined, and (3) too little attention given to the inductee's statement on his disability.

    It was well known that certain orthopedic conditions could only be diagnosed by an adequate history in a period of quiescence; for example a knee with a torn semilunar cartilage might have shown no physical evidence of this condition when the torn portion of the cartilage had been temporarily replaced.


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Similarly, a recurrent dislocation of the shoulder would have shown no physical finding except when it was dislocated. Too often, an attitude was taken by the examining medical officer that the inductee was trying to keep out of the military service, with the result that he was inducted with a disability which made him useless to the military, and his ultimate fate was a certificate of disability discharge in due course of time with much inconvenience to the Government and needless expenditure of public funds. These deficiencies were overcome by staffing induction stations with adequate medical personnel specially trained to recognize these conditions and by taking a more realistic attitude toward the medical statements of the examinee.

SPECIAL ORTHOPEDIC PROBLEMS

    Many musculoskeletal problems were encountered which required special consideration. A discussion of some of these problems considered worthy of note follows.

    Compound fractures. - In the early days of the war, it was most difficult to convince orthopedic and other surgeons treating compound fractures that in military surgery the use of internal fixation and primary closure was a dangerous procedure and should not be followed. Later, a directive from the Office of the Surgeon General prohibited the practice of internal fixation and closure.

    March fractures (fatigue fracture, insufficiency fracture). - March fractures, especially of the metatarsals, presented a major problem in infantry training centers. The disability resulting from this condition interfered with the continuation of basic training. In the beginning, trainees with this condition mere hospitalized and the extremity was placed in a short leg plaster cast with a walking bar. The average period of disability was from 6 to 12 weeks. It was soon realized that, although this was a painful condition, it was not serious. A method of treatment devised at Camp Wolters, Tex., and used successfully in the Eighth Service Command, did not require hospitalization and allowed continuation of training, excepting only forced marches. Treatment consisted simply of a rigid steel shank in the shoe which prevented flexion of the foot at the metatarsophalangeal joints. March fractures of the metatarsals were the only type of fracture in this classification that could be treated on an ambulatory basis. Fatigue fractures of the major bones of the extremities and pelvis required hospitalization.

    So-called sprained wrist. - Undoubtedly, the majority of injuries to the wrist from falls resulted in simple sprains, but, from bitter experience, it was found that a certain percentage of the so-called sprained wrists actually were fractures of the carpal navicular bone. When this condition was allowed to prevail for a long period of time, severe disability resulted. In order to detect the fracture, it was determined that all injuries to the wrist should be X-rayed in four planes-anterior-posterior, lateral, right and left oblique. Initially,


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these views may have shown no fracture; however, the injury had to be treated as a fracture until proved otherwise by a similar set of X-rays 2 weeks later.

    Ankle fractures. - Many poor results were noted following bimalleolar and trimalleolar fractures of the ankle when the fractures were not reduced anatomically. Minor fractures could usually be satisfactorily reduced by manipulation with anatomic replacement of all elements, especially those involving only the medial malleolus, but all other types of ankle fractures should have been reduced by open operation.

    The painful low back. - This condition was very common in all service commands, and only the experienced surgeon could differentiate between the legitimate and the feigned. Consequently, it was common knowledge that this condition was difficult to evaluate, and outpatient physical therapy clinics were overburdened with these patients. However, as a more thorough understanding of this condition was gained, and as consultation with the neuropsychiatrist became more frequent, complaints of low back pain decreased appreciably.

    Self-inflicted wounds. - The majority of self-inflicted wounds, especially those of the feet and hands, were incurred while the soldier was on furlough. In a significant number of cases, the opposite lower or upper extremity from the handedness of the soldier was injured. These cases always presented a very delicate situation as to line of duty.

    Hand injuries and infections. - In the early stages of the war, treatment of hand injuries and infections was so haphazard that headquarters of the Eighth Service Command sent out corrective directives to all medical treatment facilities. One of these bulletins directed that all hand injuries and infections should be handled by the section with the most experienced surgeon in this field, regardless of whether he was a general surgeon or an orthopedic surgeon.

SPECIAL CENTERS AND REHABILITATION

    The establishment of special treatment centers was a definite step forward in providing better care for the soldier. This was especially true with regard to the hand, neurosurgical, and paraplegic centers, which required highly specialized personnel in scarce categories.

    The hand centers, with Dr. Sterling Bunnell as the chief consultant, contributed much to the knowledge of hand injuries. Information and indication of treatment of these injuries were disseminated widely and a decided improvement was reflected in the care of hand cases. Many outstanding surgeons of postwar days have received their training in these centers and have continued to contribute to the knowledge of hand surgery.

    The rehabilitation program as established in the hospitals, rehabilitation centers, and annexes to the various treatment centers did much to lessen the convalescence period. It was the consensus that the rehabilitation centers located at a distance from the hospital were more effective because, at times, patients were retained in the center longer than was necessary, especially in those rehabilitation activities connected with the named general hospitals. It


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was realized, however, that the program in connection with a general hospital differed in certain respects from that in a regional hospital. In the latter, a greater number of patients were expected to return to duty. The reconditioning program was a very important part of the treatment.

MEDICAL EDUCATION

    It is the impression of this author that every physician is better off professionally for having spent some time in the military service. There may be exceptions to this statement, but they should be relatively few. The medical officer had an opportunity to associate with other medical officers, ranging from general practitioners to the highly specialized, from all parts of the country. In most hospitals, the educational program was excellent and was keyed to the dissemination of medical knowledge useful to all concerned. The specialist with practice and association narrowed to a very limited field found out that was going on in fields other than his own. The consultant system contributed much to the dissemination of medical knowledge.

    Libraries in most fixed establishments were equipped fairly adequately, with the except ion of reference files This defect was overcome to a certain extent by the excellent photostatic reproductions obtainable from the library of The Surgeon General.

    In the Eighth Service Command, through the efforts of Colonel Bauer, additional educational advantages were obtained through the Rockefeller Foundation; for example, the purchase of medical books, periodicals, and clinical pathological material and visits of outstanding physicians and surgeons. Arrangements were made with these specialists to spend a prescribed period of time in the service command, visiting the various medical facilities with the service command consultant. It was impossible for such a specialist to visit all facilities. Consequently, in order that full advantage could be taken of his teaching, the institution so favored would invite interested medical officers of neighboring institutions to be present. Full cooperation was obtained in this by service command headquarters and other facilities involved. The visiting specialist and the consultant made rounds, examined patients, conducted round-table conferences, gave formal talks, and, generally, were available to all concerned literally 24 hours of the day.

    The orthopedic surgeons participating in this program were Dr. Arthur Steindler, Dr. Marcus N. Smith-Petersen, Dr. Ralph K. Ghormley, Dr. J, Albert Key, Dr. J. Spencer Speed, Dr. William W. Plummer, and others.

COMMENT

    The writer wishes to comment, not through a sense of duty but because of the very sincere belief, that the primary concern of the Eighth Service Command surgeon, Colonel Hart, was to see that every soldier received the best


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medical care possible. No shortcuts were tolerated; rank did not enter into the picture. The most capable medical officers were assigned to positions of responsibility, regardless of rank. That this policy created very little animosity was really surprising and, in the opinion of the writer, was due to the most hearty cooperation of all echelons of the medical service of the Eighth Service Command.

THOMAS L. WARING, M.D.