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Chapter XIV

Contents

CHAPTER XIV

Ninth Service Command

John J. Loutzenheiser, M.D.

ASSIGNMENT AND ORIENTATION OF ORTHOPEDIC CONSULTANT

    It was not until December 1943 that an orthopedic consultant was appointed in the Ninth Service Command. This consultant was Col. John J. Loutzenheiser, MC, who had entered military service more than a year earlier. His prior service as chief of orthopedics in a general hospital proved to be useful and had allowed him to obtain full knowledge of many of the problems that concerned an orthopedic section in a general hospital. With such a background, a consultant had more sympathy with the multiple difficulties which existed on the home ground of the various hospitals in his command.

    On reporting to the Ninth Service Command headquarters at Fort Douglas. Utah, the new orthopedic consultant was briefed on his duties by Co1. John B. Flick, MC, Consultant in Surgery, before reporting to Brig. Gen. John M. Willis, who was surgeon of the command. Colonel Loutzenheiser's introduction to the consultant group with which he was to work was an important moment in his military service. As he recalls it, General Willis said: "We have a great medical team here, and we will insist that you be a team player." It did not. take long for Colonel Loutzenheiser to realize that this command had taken a group of brilliant individualistic doctors and had welded them into an efficient consultant team for military medical purposes. Col. Verne R. Mason, MC, Col. Lauren H Smith, MC, and Colonel Flick were the medical, psychiatric, and surgical consultants. These consultants gave Colonel Loutzenheiser a few words of advice which should be noted here because undoubtedly this advice helped him in his relationship with hospital commanders as well as with his fellow orthopedic surgeons in service. They stated: "We make an effort. to work harder than anyone else in the hospital we are inspecting and you must do likewise if you expect. to gain the respect of your confreres, be helpful before you are critical, study the commander's personality as well as his personnel, and report only accurate, factual, existing circumstances."

AREA AND MEDICAL TREATMENT FACILITIES

    The geographic area of the Ninth Service Command was comprised of the eight Western States of Montana, Idaho, Washington, Oregon, Nevada., Utah, California, and Arizona. This area contained 12 general hospitals, 11 of which were located in the coastal States of California, Oregon, and Wash-


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ington, and the other in the State of Utah. There were in California two regional hospitals at Oakland and Pasadena and large station hospitals at Fort Ord, Camp Roberts, Camp Haan, and Camp Stoneman. In addition, there were large station hospitals at Fort Lewis, Wash., and at Fort Huachuca, Ariz. There were other hospitals to be visited, such as those of the ports of embarkation at Seattle and San Francisco and the prison camp hospital at Phoenix, Ariz. Air Force hospitals were occasionally visited when the need was indicated. When one considers the great distances which had to be covered in the Ninth Service Command and the number of hospitals to be inspected, it is evident, that the consultant spent almost as much time traveling as he did in actual work.

    In order to design a practical plan for inspecting this command, the area was divided into four sections: Northwest (Washington and Oregon); northern California and Nevada; southern California and Arizona; intermountain--Idaho and Montana, where there were no general hospitals; and Utah, where the service command headquarters and amputation center were located. Ideally, one needed a 3-day stay in a large general hospital to accomplish the optimum good, but, often, no more than 1 or 2 .days could be spent because of the time required to cover the service command. A consultant should not have been absent from his headquarters for more than 2 weeks. That length of time allowed one to visit from four to six hospitals on each inspection trip. In an area as large as the Ninth Service Command, it might have been better if a regional consultant system had been set up which would have allowed all the station hospitals within a given area to come under the consultation of a top orthopedic surgeon from a nearby general hospital. Such a plan should have worked well and improved the care of patients in the smaller hospitals. Unfortunately, it was difficult to divide responsibility or delegate authority when one was personally responsible to the surgeon of a command. As it was, the mission of the orthopedic consultant would never have been accomplished, and the job could never have been done, had it not been for the extraordinary efficiency and cooperation of the Surgical Consultants Division in the Office of the Surgeon General, the service command surgeon, and fellow service command consultants. It can be stated also that the chiefs of orthopedic surgery in the general hospitals of the Ninth Service Command were highly competent surgeons who made the work of the orthopedic consultant much more a pleasure than an irksome duty.

ORTHOPEDISTS IN THE COMMAND

Outstanding Orthopedic Surgeons

    A list of the orthopedic surgeons who did fine work in the Ninth Service Command would necessarily be long, but they must be named. Many of them not only carried on their regular duties, but also assisted the orthopedic consultant in establishing teaching centers for the training of surgeons in certain


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limited phases of orthopedic surgery. These officers are not identified with a particular hospital because they often served in more than one. Where possible, the chiefs of orthopedic surgery are listed with their assistants, as they worked as a joint team. In all instances, however, the chief of service, was responsible for the high character of the work, loyalty, and enthusiasm of his assistants, Lt. Col. Ernest E. Myers, MC, and Maj. Harold W. Woughter, MC, Lt. Col. Richard B. McGovney, MC, and Capt. Mario F. Tagliagambe, MC, Maj. Carroll O. Adams, MC, and Capt. A. Luckey, Lt. Col.. Edward K. Prigge, MC, and Capt. Frederic W. Rhinelander, MC, Maj. Thomas H. G. Aitken, SnC, and Capt. Alvin J. Ingram, MC, Maj. Robert. F. Warren, MC, and Capt. Robert B. Portis, MC, Maj. George E. Waters, MC, Maj. Norman II. Brown, MC, Capt. Harold Unger, MC, Maj. Robert H. Denham, MC, and Capt. Walter Carpenter, MC, Maj. (later Lt. Col.) Maurice M. Pike, MC, and Capt. Donald R. Pratt, MC. Maj. Donald B. Slocum, MC, and Capt. (later Maj. Donald E. Moore, MC. and Maj. Robert King, and Capt. Joel Hartley, MC. These were the men who made a. great contribution to orthopedic surgery in the Ninth Service Command. There were others who played an almost equal part in this command but did more important things elsewhere. Undoubtedly, the latter will be listed for their accomplishments in the reports of other consultants.

Relationship of Consultant With Orthopedists

    The relationship of the consultant with the orthopedists in the various hospitals was one of mutual respect. Open criticism of procedures was never made except in private. Ward rounds were a procedure for observation, information, and note taking for later critical survey. Criticism of care in the presence of patients was prohibited, but useful discussion was allowed. Orders from higher authority were enforced by the consultant, but he never tried to force a confrere to his opinion. There were times when criticism was better accomplished by asking for a written review of patient care when some particular procedure was in question. This procedure may have been a favorite of the orthopedist on duty, and one that was not in full accord with overall surgical policy. After he had made a review of his patient care he often came to the proper decision without any comment from the consultant. Another approach to the problem of getting an orthopedist to change his ways was to discuss the success that some other hospital was having with an approved procedure. If these methods failed, one gained cooperation either by bringing an important orthopedic civilian consultant on hospital rounds to criticize, while making valuable suggestions, or by bringing another capable orthopedic officer in to work alongside the recalcitrant chief of section. Soon the competitive effort of fine work would improve the entire orthopedic service. It was necessary to have a personnel officer in the headquarters of the service command who was willing to work with the consultant in order to accomplish these ends. Forcing a chief of section to agree with the consultant, going over his head to the hospital commander, or undermining him with his chief of


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surgery were not proper or effective methods. If the surgeon was competent but stubborn, there were better ways of handling the situation. On the other hand, if he refused to be cooperative, it was advisable to move him immediately. Rarely was there a surgeon who did not have some real value. A man who was considered to be incompetent in one job might prove to be competent in another. The consultant was obligated to find a proper place for each man.

RELATIONSHIP OF CONSULTANT WITH HOSPITAL COMMANDERS

    It took the consultant a little time to realize that others had problems as well as he. It took time for a hospital commander to develop an adequate organization, and, once it was obtained, any commander was understandably unwilling to have the organization disrupted. In the movement of personnel, it was necessary to replace able officers with officers equally able, thus maintaining harmony with efficiency. To attain this harmony and efficiency, the consultant was advised to make an effort to establish understanding with the command officers of the hospitals. Where this was possible, it always led to mutual benefit. Occasionally, when the commanding officer of a hospital was desirous of having some change made in his orthopedic service, the consultant was able to meet his desires and better his service. At the same time, such changes made it possible to improve orthopedic service elsewhere which could make better use of the medical officer subject to transfer. Colonel Loutzenheiser did not desire to be considered overly politic during his inspection trips. Notwithstanding, he considered it a duty as well as a privilege to know commanding officers well. There were a few commanding officers who considered the consultant system a nuisance, but most of them appreciated its usefulness.

    It was recognized that few of the general hospitals had adequate orthopedic facilities. Most hospitals were built on a 1918 plan, with a plaster room not much larger than a clothes closet and without adequate X-ray equipment nearby. There were no braceshops of any importance. Orthopedic departments were overloaded with inpatient and outpatient consultations. Patients waited for the operating schedules to provide time and space sufficient for their care. Consequently, the first reports sent in by the new consultant were extremely critical-not of the hospitals themselves, but of the facilities which they offered. Many hospital commanders were offended by such surveys and considered the consultant's report incorrect and unjust.

    On arriving back at headquarters, the consultant soon sensed that he was just about as unpopular there as he was in the field. It was presumed that some of the endorsements on his reports suggested that the orthopedic consultant. was attempting to force the hospitals commanders to request improvements and additional facilities which they did not believe necessary, on the basis that a good commander gets along with what he has and does the best he can with it. Fortunately, at about that time, The Surgeon General established a precedent for adequate orthopedic facilities, and clarification through his office allowed all improvements to be made which did not require new construction.


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    The Ninth Service Command immediately provided adequate orthopedic facilities in all its hospitals.

    Suggestions resulting from this conflict in opinion as to the adequacy of orthopedic facilities included the following : (1) That a consultant in the Medical Department should have rank commensurate with his position, (2) that, planning for improved facilities in all hospitals for specialized care was needed, (3) that the sick and injured should have the best facilities available and have them when needed, not months later, and (4) that the orthopedic consultants should be briefed in the Office of the Surgeon General before reporting to their assignments and twice a year thereafter, if possible.

    It should be stated that this consultant rarely found it satisfactory to deal entirely with the executive officer of a hospital. The commanding officer who considered it more efficient to have his executive officer deal entirely with a consultant never reached the degree of rapport necessary for the proper coordination of his hospital activities with the service command or with the Office of the Surgeon General.

EARLY INNOVATIONS AND IMPROVEMENTS

Orthopedic Consultation in Hospitals

    In the face of heavy workloads, it became necessary to solve the problem of providing inpatient and outpatient orthopedic consultation for the other hospital services. It was noted that patients were being referred for consultation from all sections of a hospital for trivial reasons; that is, nondisabling back ailments and shoulder, knee, and hip complaints for which orthopedic consultation was believed to be necessary. With the consent of the commanding officers of the hospitals, courses were established for training medical officers on other services in basic orthopedic examination. The routine examination of the feet, back, and other joints was not outside the province of any medical officer. After the development of these teaching courses, the consultation load dropped off markedly, and the valuable time of the orthopedic surgeons was released for longer periods in surgery. Concurrently, the youngest medical officers were grateful for the more adequate knowledge they had gained.

Screening and Grading Patients for Surgery

    As the consultant became familiar with his job, he soon realized that the remote wards of the hospital often contained large numbers of patients awaiting surgery. As capacity loads appeared, he found the most needed surgery being well done, but patients with chronic surgical conditions were waiting too long for their operations. As a result of this finding, the consultant reversed his ward rounds and from then on started with the convalescent wards and worked up through the hospital to the acute wards. This resulted in a different system of orthopedic care. With more exciting criteria for screening


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and grading patients, the chronic bone and joint infections were moved into acute wards and took their place on the daily surgical schedule. In order to accomplish this with only a few orthopedic surgeons, it was necessary to train junior medical officers with surgical background in limited surgical procedures. The technique of careful cleanup of chronic bone infections, secondary closures, and split-skin grafting allowed a better production line in the surgical pavilion.

    Some of the hospitals were staffed with medical officers who were much more capable of teaching than officers in other hospitals and consequently were selected as teaching centers. As young surgeons were assigned to the Ninth Service Command, they were further assigned to these teaching centers for later distribution overseas or into the hospitals of greatest needs. Such maneuvering demanded complete cooperation between the personnel officer and the surgical consultant.

    Under the new system of ward arrangement. with regard to the patient's condition, the number of wards designated as convalescent decreased. When a patient reached a convalescent ward in the new system, he knew that he was on his way to recovery. The descriptive terms "acute," "subacute," and "chronic.'' with respect to wards were discontinued, and the terms "active surgical," "continuing surgical," and "convalescent" were used in their place. On acceptance of this classification, the number of patients available for transfer to special surgical-reconstruction centers increased, and the number of convalescent bedpatients decreased. Further benefit was derived by getting these patients to the special centers with their chronic bone infections cleaned up and the skin closed, thereby reducing the workload in the special centers and allowing them to move ahead with their particular type of reconstructive surgery. Before the establishment of this system of care, when the patient was recognized to have a combined bone, nerve, and skin lesion, he might have been wrapped up in plaster and shipped out with his chronic infection only to sit in the special center and await care first by the orthopedic section, then by the plastic section, and finally by the neurosurgical section. This led to the overloading of special centers, with consequent delay in elective surgery, and with the production of surgical backlogs. Acceptance by orthopedic sections of their full responsibility in the care of chronically infected bone and joint, lesions before transfer to special centers overcame this problem.

Diagnostic Screening in Unit Dispensaries

    In the Ninth Service Command, the orthopedic consultant had infrequent contact with line officers. Problems did arise in the command's large military camps, but, with few exceptions, they were efficiently cared for by the medical officers assigned to those stations. The line officers at Camp Roberts, however, never could be convinced that their training program created more casualties


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than necessary. Marching double time on paved areas when fatigued would keep a ward or two filled with march or fatigue fractures.

    On one occasion, Fort Lewis developed a sudden paralysis of its medical dispensary system when the troop concentration there became high. This failure of the dispensary system led to a breakdown of the station and general hospital services. In order to get patients out of the dispensary, they were sent for laboratory and X-ray investigation. Consequently, they stood in line waiting to get in dispensaries, laboratories, and X-ray stations, thereby creating a traffic jam in medical service. In the absence of other consultants, the service command surgeon was forced to send the orthopedic consultant for investigation of the medical situation at Fort Lewis. This is mentioned only because it gave the consultant an opportunity to provide a diagnostic screening service for the dispensary medical officers, thereby protecting both the station and general hospital inpatient and outpatient services from being overloaded. An internist., surgeon, psychiatrist., and orthopedist were put in charge of this screening and diagnostic service. These medical officers organized a course of instruction for the dispensary officers and trained them in techniques of examination so that only problem cases would come from the dispensary to the screening and diagnostic service. The dispensary officer's were allowed to attend consultations when possible. Such organization greatly improved the morale of the dispensary officers who had previously felt as though they were being left out of things. It also gave the service command an opportunity to use several medical officers of high rank whose ability had not been fully utilized in their former assignments. These officers made a real contribution and gained a sense of personal accomplishment which up until that time they had not enjoyed. The process of finding the right man for the right job and having him dedicate himself to it and consequently feel that he had served his country fully, gave this author a gratification probably as great as any other that he had while in the service.

Integrated Physical Rehabilitation

    After another tour of inspection of the general hospitals, Colonel Loutzenheiser found that little was required of him for the proper functioning of their orthopedic sections. Unanimously, the chiefs of orthopedic surgery had suggested that an improvement in the coordination of physical and occupational therapy was indicated. As the census increased in the hospitals, the physical therapy departments became overcrowded and it was difficult for the physical and occupational therapists to get their work done with the limited number of personnel assigned to these tasks. Inasmuch as these therapists were most important to the care of orthopedic patients, recommendation was made that they be coordinated and work as one therapy team.

    The orthopedic consultant, with his interest in establishing effective rehabilitation, soon found that he was involved with the reconditioning program.


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FIGURE 40 - Patient in rehabilitation program at Baxter General Hospital, Spokane, Wash., proudly displays completed boat.

    Some of the psychological aspects of this program were excellent ( fig. 40) A grouping of convalescent patients for physical restoration led to a greatly improved system of convalescent care. The employment of permanently handicapped for performing piecework in war industry while in the hospital was of great psychological benefit to these patients. There were many features, however, in the reconditioning program which led to confusion and bizarre interpretation. Many reconditioning activities should have been placed in a convalescent center or completely eliminated, as they had no place in a general hospital.

    Certain facts were learned in the reconditioning program, however, and these indicated the way to develop a productive system of physical reconstruction. A production line for rehabilitative therapy was set up in most of the hospitals. Selected Women's Army Corps personnel were obtained and trained to do limited portions of physical therapy so that the well-trained physical therapist was saved for the more important portions of her work. The departments of physical therapy were further assisted by the reconditioning officer and his assistants, who developed a heavy work and exercise program for patients who had reached that stage of recovery. In some instances, the patients were taught to treat each other when both would benefit from such treatment, particularly in cases of patients with hand disabilities or with amputations.


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SPECIAL CENTERS

Integrated Reconstructive Surgery

    In the course of time, the Office of the Surgeon General established a number of special centers in selected hospitals. On visiting hospitals so designated, the orthopedic consultant realized that the activities of the special center were taking precedence over all others in the hospital, with consequent loss of a sense of proportion for combining the interests of the special center with the rest of the hospitals activities. It took a good deal of doing on the part of all the consultants to make some of these centers realize their full obligation in one instance, it was necessary to make a factual survey of the existing conditions within a certain hospital before full cooperation of the various sections could be gained for the development of a complete reconstruction surgical team. Recommendation was made for establishing a therapy conference of orthopedic and plastic surgeons and neurosurgeons who were to decide in each problem case the mode of procedure and the timing of the various and subsequent procedures that would be necessary to restore the patient. A follow up report of these patients was made every week. Experience with such an integrated special therapy program proved that this was an advantage over methods used formerly. The recommendation was then made that special centers be combined into special reconstructive surgical centers. This was not accomplished by 1946, but this consultant felt that it would have been a. better method than the one in use. Thoracic surgery might have remained as a single special center, but the other surgeries would have functioned more efficiently if they had been combined. Amputation centers might have been another exception to the idea of combined centers, as the need for group therapy, for amputation surgeons to work with limbfitters, and for special shops for prosthetic manufacture presented a problem best handled in a single special center.

Amputations

    Prosthetics research. - The amputation center in the Ninth Service Command was located at Bushnell General Hospital, Brigham City, Utah. This hospital was located within 60 miles of service command headquarters, and the orthopedic consultant was ordered as his first duty to make a comparative study of the Army and Navy amputation prostheses. As a result of this duty, an amputation prosthesis research center was established and financed at the start by Mr. John Northrop of the Northrop Aircraft Company. This consultant was responsible for Mr. Northrop's interest in this field and worked with him and his engineers during the last 2 years of the war. Improvements were made in upper extremity prostheses with the use of lightweight metals and plastics and with the application of latest engineering principles (fig. 41). On the artificial legs, plastic sockets were developed to replace those made of leather. The Committee on Prosthetics Services, National Research Council, reported these research activities in considerable detail with due credit to this consultant


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FIGURE 41. - Northrop prostheses for the arm. A. For lower-arm amputations. B. For upper-arm amputations.

at a symposium 1 on research projects held in Chicago, Ill., on 16 and 17 January 1946.

    By the end of 1945, the amputation center at Bushnell General Hospital maintained a census of between 1,000 and 1,500 patients, which made an operative schedule of 150 to 200 amputations a month necessary. The amputation prosthesis shop was enlarged to take care of this load, and new methods were instituted to allow the completion of 150 to 200 prostheses a month. Plastic sockets were now made in one-fifth the time that it had taken to make a leather socket, and it was proven that these plastic sockets were odorless and were better fitting and cheaper than, and just as durable as, leather sockets. Plastic material was also used in the manufacture of the upper-extremity prosthesis and gave the artificial arm a cleaner and more efficient appearance. Further research included an improvement on the elbow joint, which would allow automatic locking and unlocking, and arm improved mechanical artificial hand, which could be covered with an acrylic, specially treated latex glove which would have the natural appearance of a hand. This consultant felt that the ideal artificial hand should have three dynamic digits. Such a hand could take an object out of a

1 Research Reports on Artificial Limbs: First Annual Report of the Committee on Prosthetics, National Research Council. 1 April 1946, pp. 17-24.


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pocket. The rigid artificial hand could not do this. At that time, the grotesque hook was the only practical substitute for a hand.

ORTHOPEDICS IN GENERAL AND STATION HOSPITALS

    After study of the amputation centers and initiation of prosthetic research, the problems of the general and station hospitals occupied the major position of the orthopedic consultant's time. Inspection of the orthopedic services at 12 general hospitals and twice that number of station hospitals demanded too much time but, was a necessary background for learning the problems of each hospital, as they were all dissimilar. The major problems to be solved were (1) placement of personnel best fitted for their job, (2) development of adequate facilities within the hospital to allow the work to be done efficiently and rapidly, (3) arrangement for proper movement of patients with particular regard to the pathological situation, (4) coordination of physical and occupational therapies into one therapy program, and (5) organization of effective rehabilitation programs for the convalescent patient.

Orthopedic Personnel

    The personnel problem was always difficult but not insurmountable. There was never adequate. personnel. The problem was solved in part by utilizing the well trained to the best advantage and having them train additional personnel to do limited surgery (the same procedures again and again until the junior surgeons had reached a. high degree of proficiency). This allowed the trained orthopedic surgeons to complete the major definitive surgery. The chiefs of orthopedic surgery were selected for surgical ability and quality of leadership. Their personal accomplishments, devotion to duty, and kindness to their patients were more than noteworthy. It was their outstanding character that inspired so many young surgeons to become orthopedic surgeons. The problem of personnel placement divided itself into several components as follows: (1) Selection of department heads (chiefs of sections), (2) evaluation and assay of personnel to work with the chiefs of sections, (3) training of medical officers for limited special surgery, and (4) movement of any orthopedic officer for betterment of service.

    Selection. - The method used for selection of chiefs of section was satisfactory. The Office of the Surgeon General assigned an orthopedic surgeon to the service command with a recommendation that he be made chief of section. The service command knew the needs and usually made proper placement of the qualified officer. In the Ninth Service Command, the service command surgeon ordered the consultants to work with the personnel officers in all problems of placement and transfer within the service command. This order resulted in many benefits as the consultants knew the personnel intimately as to person-


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ality, ability, and leadership; and the personnel officer knew only their names, grades, and classifications.

    Evaluation. - The evaluation or assay of orthopedic officers was accomplished soon after their assignment. Three months of on-the-job service was usually an adequate period for evaluation, although there were times when one month proved to be adequate. Only a few of the officers who had been certified as orthopedists by the American Board of Orthopedic Surgery were incapable of acting as chiefs of sections. These few had acquired little training in the surgery of trauma and were of necessity trained within the service command. Occasionally, the transfer of such an officer would lead to misunderstanding between the Office of the Surgeon General and the service command. The opportunity to evaluate orthopedic officers for particular assignments occurred in the Ninth Service Command by the end of time year 1943.

    Training. - As early as 1942, the problem of training officers for particular assignments was answered by the assignment of medical officers to permanent general hospitals, such as Letterman General Hospital, San Francisco, Calif. In this hospital, the surgical services were well organized, and teaching services were easily established with superior personnel working in a city where two medical schools were located and were wiling to assist in any teaching problem. Later, other hospitals had to be used for teaching and training centers since Letterman General Hospital became more and more concerned with the receipt and disposition of casualties from oversea theaters. Well-staffed and well-organized orthopedic, plastic, amputation, and neurosurgical sections were used to train and evaluate medical officers with surgical training assigned to the command. In this manner, particular surgical talents in the young surgeons were developed and they became more useful for oversea or general hospital assignments.

    Transfers. - The need for moving medical personnel from one hospital to another has been mentioned earlier in this discussion. One had to be certain that the transfer of a valuable medical officer was demanded by need for improvement of the service. All the reasons for the transfer of an officer had to be fully justified, or the consultant would have been considered fanciful and untrustworthy. When transfer was justified and allowed, there was considerable inconvenience and Government expense occasioned. Consequently, transfers or changes of station within the service command of married officers had to be infrequent. During war, there is no situation which can be considered completely static or stationary. The personnel one has today may be gone tomorrow, and the consultant's recommendations of last week may appear stupid and ridiculous next week because of a change in events over which he has no control. The safest course was to postpone the action believed advisable and save this move on one's mental checkerboard for the day he might be forced to make it. The following phrase is used by tacticians for this method of procedure: Never do today what you can do better tomorrow.


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Facilities

    The second major problem--that concerning adequate working conditions within the hospital for optimal care of patients--was a real and serious problem. General hospitals were built on plans which were outmoded for the existing needs. The development of facilities for efficient orthopedic care could have been planned in advance, but such facilities were totally inadequate in the newly constructed general hospitals of 1942. Recommendations should have been presented to hospital commanders for the best utilization of existing accommodations to provide adequate orthopedic space. As it was, hospital commanders opened their hospitals with these fixed plans and gave one the impression that they would be criticized by higher authority if the deviated from them. Also, the surgical consultants who were burdened with all the early problems had too many troubles to worry about orthopedic facilities. Should there ever be a "next time,'' orthopedic consultants should be appointed at the start along with other consultants in the major branches of military medicine and surgery. Although this consultant had the privilege of serving with a helpful, cooperative group of consultants under efficient and loyal commands, it remained his opinion that orthopedic surgery should have been given a place equally important as so-called general surgery. There was a need for a specially trained liaison officer to coordinate the surgical specialties for the hospital. Such an officer could have served on the same level with the executive officer under the hospital commander and eliminated considerable interservice and section friction. The presumed and actual higher authority of a chief of surgical service was too often a roadblock to the rapid improvement of facility for, and service, to, patients.2

Proper Movement of Patients

    The third of the listed major problems pertained to the need for proper movement of patients with particular regard to the pathological situation. This problem could be further divided into three areas where improvement was needed: (1) Selection of patients to be held for continuing care upon their arrival at a general hospital, (2) transfer of appropriate patients to special centers where their care could be better accomplished, and (3) movement of patients within a hospital to give them a proper psychological attitude toward their own individual problems.

    Experience in the Ninth Service Command noted the difficulties and dangers of mass movement of patients in their evacuation from one hospital to another, both within the command and from overseas into it. Fractures of long bones were subject to multiple changes of immobilization apparatus during a period of repair which resulted in displacement of fragments, delay in healing,

2 The organization plan for a general hospital now includes the position of a chief of professional services to coordinate all professional activities, but a chief of surgical service still retains the direct responsibility for supervising all surgery in the hospital. - J. B.C., Jr.


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and loss of joint function. Delay in early wound cleanup (after wounding) led to serious surgical disaster. The Army Air Forces performed a magnificent job in air evacuation, but failure by medical officers to think in terms of pathological time caused irreparable damage to occur in a wounded extremity which should have been surgically cleaned up or debrided within the so-called golden hours before bacterial fixation in avascular tissue Air transport might have allowed emergency surgery to be performed at considerable distance from the place of wounding, but it had to be performed within the time limits decreed by the pathological situation. Simple bullet wounding occurring where gas bacillus contamination existed resulted in extremity amputation when the patient was transported by air for too many hours before stopping for surgical cleanup. Grafting that there may have been overriding military situations, many patients who would have benefited from air evacuation spent excessive periods in oversea hospitals in the Pacific awaiting ship transport to centers for definitive care. In a number of instances, the care could have been provided where they were. Mass evacuation and "thou shalt not" orders from higher authority presented greater dangers than the evils they were designed to prevent when careful screening of pathological conditions and selection of patients for evacuation did not occur. Every medical officer should have recognized that care of the patient was a personal responsibility and the orders designed for overall improvement in care did not lessen his personal obligation to the patient.

Effective Rehabilitation and Convalescent Programs

    Long-term planning. - Efforts to coordinate a complete rehabilitation plan for the sick and wounded were made in the Ninth Service Command before the inception of formal reconditioning programs. Ideas prevailing in the Ninth Service Command differed considerably from those presented in some portions of the reconditioning program. Rehabilitation, in the Ninth Service Command concept, began prior to definitive care. Orthopedic surgeons were requested to plan the entire surgical reconstruction before performing the first definitive operation. Surgery was considered an important part of rehabilitation and often the most important part. Envisioning the entire course of rehabilitative care often eliminated procedures which promised little benefit, in the total care. The important question that arose in such planning conferences was the following one: What will be the optimal end result if all goes well? The next important question, which had to be answered in the monthly follow up review of such problem cases, was the following: Should our original opinion regarding optimal end result be changed? An optimal end result was considered the best that one could obtain in a given pathological condition. Once this type of thinking governed decision as to surgical procedure and follow up care, a satisfactory base was established for a sensible productive system of reconstructive surgery and patient rehabilitation. After


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one year's experience in a general hospital with such a plan, the consultant encouraged other hospitals to design a system of orthopedic care based on long-term thinking rather than on short-term thinking.

    By 1945, this consultant was convinced that the plastic surgeons and the neurosurgeons should participate with the orthopedic surgeons in a planned system of surgical reconstruction. Thereafter, the procedure was adopted wherein a weekly group meeting of these specialists determined the future surgical course of patients whose pathological problem involved the three specialties. The benefits in patient care accruing from these methods suggested that hospitals with these three surgical specialties should act as centers for reconstructive surgery and should be so designated.

    Convalescent hospitals. - In 1945, the Ninth Service Command was ordered to establish convalescent hospitals which actually were to function as rehabilitation centers, should the war continue into 1946-47. Complete facilities for these centers were set up at Fort Lewis and at Camp Mitchell, Calif. These camps had some accommodations already available which made the early establishment of such centers possible. Unfortunately, neither convalescent center was climatically suited for its purpose. The handicapped and disabled soldier in actual need of rehabilitation should have had a comfortable climatic environment. Although there was an excellent group of officers in charge of the convalescent centers and an efficient rehabilitation plan was in action, it soon became obvious that the patients were not happy in their surroundings. The following two conclusions were drawn from observation of the two convalescent centers of the Ninth Service Command: (1) The truly disabled and handicapped were anxious to receive adequate medical care in addition to retraining for a new occupation which they could carry out with their known handicap and (2) many patients who had no real need for convalescent care were sent to a convalescent center. It was further concluded that careful study of the rehabilitative needs of various types of patients was necessary before designing a convalescent hospital. A common fault in hospitals seeking to rid themselves of the ambulant chronic complainer was to send him to a convalescent hospital. This was the type of patient who did not belong in a rehabilitative facility which dealt with the truly handicapped and disabled.

Résumé of Hospital Orthopedic Care

    During the last year of the war, orthopedic sections geared to care for 400 orthopedic patients found themselves with a census of 800 to 1,000 patients. The total census increased until in late 1945 a peak load of 13,000 orthopedic patients, excluding those in station hospitals, were being called for in the Ninth Service Command. By that time, the hospitals were well equipped to handle their surgical load,. A few hospitals which never should have been anything more than medical centers were obliged to carry on with large censuses of surgical patients with only three available operating rooms. The staffs of


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these hospitals deserve special commendation for taking exceptionally good care of their patients. The training systems devised one year before were now paying dividends, and there were now many young surgeons able to assist the limited number of orthopedists in doing their work.

    Experience during the period of 1944-45 occasioned two recommendations. One of these was that smaller station hospitals should not have an orthopedic section inasmuch as directives from the Office of the Surgeon General prohibited the performance of any major orthopedic surgery in that type of hospital. The other recommendation was that reconstruction centers be created which would allow neurosurgery, plastic skin repair of the extremities, and orthopedic surgery to be performed in the same hospital. It was found that orthopedic care in convalescent hospitals was best accomplished when officers trained in disability evaluation were placed in charge of the convalescent physical restoration of these patients. It was further recommended that each of these medical officers be trained in a center for surgical restoration, supervising both physical and occupational therapy and the physical reconditioning of his patients.

COMMENT

    The Ninth Service Command owed a debt of gratitude to Dr. Leroy Abbott, Professor of orthopedic surgery at the University of California School of Medicine, who on several occasions toured the service command general hospitals offering advice and stimulating the orthopedic medical officers on duty. This consultant has already praised the work of the orthopedic surgeons who served in the Ninth Service Command, but he would be remiss if he failed to emphasize the dedicated work of Colonel Myers at Bushnell General Hospital. This great gentleman and accomplished surgeon worked 16 hours every day caring for his patients, and his tremendous workload brought him well past the point of physical exhaustion from which he never fully recovered.

SUMMARY

    In summary of Colonel Loutzenheiser's experiences as consultant in orthopedic surgery for the Ninth Service Command in the year's 1944 and 1945, the following final suggestions are offered for further consideration:

    1. The orthopedic consultant to a service command should be carefully indoctrinated before reporting to his assignment.
    2. The War Department should design a military hospital planned for needs of the future rather than for those of the past.
    3. Orthopedic surgery should be recognized as a major branch of surgery in relation to the care of war wounded.
    4. A combination of orthopedic surgery, plastic surgery, and neurosurgery into reconstructive surgical centers is most important.


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    5. Contrawise, separate centers for orthopedic surgery, plastic surgery, and neurosurgery are disadvantageous and lead to multiple transfers and delay in patient care.
    6. Reconstructive surgical centers should be located near large centers of population and their medical schools. Convalescent hospitals should be placed in optimal climatic areas for final rehabilitative care.
    7. The consultant should have adequate rank in order to meet commanding officers on a proper military level, and it should be established that the consultant represents the Office of the Surgeon General insofar as his duties require implementation of clinical policies and practices promulgated by that office.