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Chapter XV

Contents

CHAPTER XV

Third U.S. Army

Charles B. Odom, M.D.

Section I. Administrative Considerations

    The Third U.S. Army created a number of records. It traveled farther and faster on the ground than any army in history. In the 281 days between 1 August 1944, when this Army became operational, and 8 May 1945, when the instrument of German surrender was signed, it moved from the invasion beaches of France to the Austrian Alps. During this period, the Third U.S. Army captured 1,280,688 prisoners, killed 144,500 enemy troops, and wounded 386,200 others.

    The medical service of the Third U.S. Army also set records.1 During the period cited, it treated a total of 313,686 persons, including 5,225 civilians and 23,536 enemy personnel.

    Between 1 August 1944 and 30 April 1945, the following casualties were hospitalized in Third U.S. Army hospitals:

Designation..................................................Casualties

U.S. troops....................................................   91, 454
British Army troops........................................          506
French Army troops.......................................       2,095
U.S. Navy and Marine Corps personnel.........          265
British Navy and French Navy personnel........              6
Enemy forces personnel..................................    16, 989
Civilians.........................................................        2,635
Others, specifically French Forces of the interior        188

    For the 91,454 U.S. Army battle casualties admitted during this period, the case fatality rate was 2.73 percent. Wounds in these casualties were divided into 23,283 serious and 56,676 slight, excluding the 11,495 wounds incurred in December for which no breakdown is available. The 91,454 wounds are classified as to anatomic location in table 3. The case fatality rate for the first 5 months during which the Army was operational, 2.9 percent (table 4), was reduced to 2.6 percent during the remaining months of combat. The highest case fatality rates were in wounds of the abdomen, wounds of the head and spine, and wounds of the chest (tables 3 and 4).

1 (1) Semiannual Report. Surgeon. Third U.S. Army. ETOUSA. 1 Jan.-30 June 1945. (2) Annual Report. Surgeon, Third U.S. Army, ETOUSA, 1945.


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TABLE 3. - Admissions for and deaths due to wounds among casualties hospitalized in Third U.S. Army hospitals, by wound classification, 1 August 1944-30 April 1945

TABLE 4. - Analysis of 48,354 U.S. battle casualties treated in Third U.S. Army installations,1 August 1944-1 January 1945


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FIGURE 42. - Lt. Gen. George S. Patton visits the 12th Evacuation Hospital to award decorations to the wounded.

    It would be impossible to report on the work of the surgical consultant to the Surgeon, Third U.S. Army, without making mention of Lt. Gen. (later Gen.) George S. Patton, Jr., USA, the Commanding General. Contrary to the impression held by many who did not know him, he was an extremely kind and very humane individual. This was reflected in his interest in those under his command. He had the greatest concern for the welfare of all his troops, most particularly those who had been injured in battle (fig. 42). He was not satisfied with mere statistical reports of casualties. He wanted to see for himself that the wounded were properly cared for, and, while this plan was not generally practical for an officer in his position of command, he made many unscheduled and unheralded visits to hospitals to see the sick and wounded. When he could not see them himself, he wanted direct reports from medical and other officers who had seen them. From the campaign in Sicily when General Patton was the Seventh U.S. Army commander, to the end of the war, preparing these reports was one of the chief duties of the surgical consultant.


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FIGURE 43. - Col. Charles B. Odom, MC, Consultant in Surgery to the Surgeon, Seventh U.S. Army, and, later, Consultant in Surgery to the Surgeon, Third U.S. Army.

    General Patton had the faculty of inspiring truly magnificent loyalty in those who were associated with him. As a result, although his demands frequently verged on the impossible, somehow or other the impossible tasks that he asked his staff and his troops to perform were usually accomplished with skill and dispatch.

THE CONSULTANT SYSTEM

Evolution of the System

    When the United States entered World War II, there was no consultant system, and no provision for one, in the Army Medical Department, although World War I had seen the development of a very complete consultant system in the AEF (American Expeditionary Forces). The system was again developed in World War II because it was found to be necessary.

    It was of gradual evolution. It was first employed in ground combat in the Southwest Pacific and Central Pacific Areas. In the North African (later Mediterranean) Theater of Operations, Col. Edward D. Churchill, MC, served as Consultant in Surgery to the theater Surgeon, and Maj. (later Col.) Howard E. Snyder, MC, who was later Consultant in Surgery to the Surgeon, Fifth U.S. Army (p. 333), served as Consultant in Surgery to the Surgeon, II Corps.


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    The Sicilian campaign, which was short and brilliant, did not produce a great number of battle casualties. Shortly after it began, Lt. Col. (later Col.) Charles B. Odom, MC, (fig. 43) was appointed consultant to the Surgeon, Seventh U.S. Army, but, because of the brevity of the action, the role of consultant did not come to the full realization which it was to assume later in the campaign in Italy and in the campaigns in the European theater.Nonetheless, the Sicilian campaign furnished a background of experience which later proved valuable.

Functions of the Surgical Consultant

    The surgical consultant in a field army served first of all to bridge the gap which had previously existed between Regular Army medical officers, who

   2 Colonel (then Major) Odom began his military service with the 134th General Hospital, the Louisiana State University School of Medicine Unit, which was sent to Fort Jackson, S.C., in 1942 for training. Shortly afterward Colonel Odom was transferred to Fort Knox, Ky., where, in order to create additional hospitals, personnel from a number of general hospital units were being assembled. The staff of the 91st Evacuation hospital, in which he was appointed chief of the surgical section, was organized with officers transferred from the affiliated units from the Louisiana State University School of Medicine at New Orleans and the medical schools of the University of Oregon, the University of Rochester, Yale University, and Harvard University.

The 91st Evacuation Hospital was sent to North Africa in November 1942, as a component of the II Armored Corps (Western Task Force ), under the command of General Patton. The mission of these troops was to secure beachheads         and bases on the coast of Morocco.    

   Following the Tunisia campaign the 91st Evacuation Hospital was ordered to Algeria, where itbegan training for the invasion of Sicily. Just before the invasion, Colonel Odom was placed at the head of a surgical team which was assigned to the S.S. Monrovia, General Patton's command ship. On the morning of the invasion, Colonel Odom went ashore with the assault troops at Gela, and in July 1943. during the course of the Sicilian campaign, he was a appointed surgical consultant to the Surgeon, Seventh U.S. Army.

   In December 1943, after sitting out the storm of publicity precipitated by the so-called slapping incident, General Patton departed from Palermo alone by plane. The officers left behind in his headquarters had no idea whether he would receive a new assignment or would be retired. The answer came 2 weeks later when Brig. Gen. (later Maj. Gen.) Hobart R. Gay, USA. his chief of staff, and a number of other officers from various sections of the Seventh U.S. Army were ordered to England. Colonel Odom. who had remained with the Seventh U. S. Army Headquarters after the Sicilian campaign, was the medical officer selected to accompany him

   Upon their arrival in England, by way of Algiers, Algeria, Casablanca, Morocco, and Prestwick, Scotland, these officers joined General Patton, who, meantime, had been appointed Commanding General, Third U.S. Army, at Peover, a small village near Knutsford in the Midlands. Here, preparations were in progress for receiving the Third U.S. Army headquarters from Fort Sam Houston, Tex. When the headquarters arrived, General Patton assumed command, and the officers who had been ordered up from North Africa were integrated into the headquarters staff.

   Colonel Odom became surgical consultant to the Surgeon, Third U.S. Army, remaining in this position throughout the fighting in Europe. In June 1945 he was appointed chief of surgery at Brooke General Hospital, Fort Sam Houston, and remained in this position until he was separated from service in December 1945.

   It would he impossible to report on the work of the surgical consultant to the Surgeon, Third U.S. Army, without making mention of General Patton's relation to him. Colonel Odom's first contact with General Patton was in the hospital unit set up in Mostaganem, Algeria, which was receiving casualties in May and June 1943. He went ashore on the same landing craft with him in the Sicilian invasion and was billeted at the same place with him on the first night ashore.

   Colonel Odom's position thereafter was not only that of surgical consultant but, in a sense, that of personal physician to General Patton throughout the war in Europe. This relation undoubtedly played a part in the roll of the surgical consultant to the Third U.S. Army surgeon. One of its first results was that during the planning in England for D-day, Colonel Odom lived with General Patton's immediate staff and had full access to all planning, including the top secret plans developed in the war room. Unlike consultants of some other armies, he therefore had the advantage of knowing all that was necessary to know for the preparation of medical facilities for the invasion and could thus fulfill his own duties and responsibilities as efficiently as possible. - J. B. C., Jr.


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had been trained in Army discipline, line of command, and other medicomilitary matters, and the medical officers fresh from the civilian practice of medicine, who were individualists, who were concerned only with medicine, and who had to learn that the sick and wounded must be treated with regard to medicomilitary considerations as well as by the techniques of civilian practice.

    The surgical consultant to the Surgeon, Third U.S. Army, had the same duties as surgical consultants in other field armies. He advised the Surgeon on a variety of matters, such as (1) evaluation and assignment of personnel, (2) organization and functioning of surgical sections of hospitals in the forward area, (3) the quality of medical service rendered, with suggestions for its improvement, (4) changes in concepts and techniques of surgical management of combat injuries, (5) indoctrination of new medical personnel, (6) the results being obtained in the care of battle casualties, and (7) future planning.

    Colonel Odom, as already noted, was closely associated with all medical planning for invasion of the Continent. Although the Third U.S. Army did not become operational until 1 August 1944, Colonel Odom arrived in France with the Third U.S. Army surgeon on 6 July, and from the onset of the campaign he worked from that portion of the office of the army surgeon which was located at the forward echelon of Third Army headquarters.

    Colonel Odom's location in the forward echelon gave him the best possible opportunity to keep in close touch with the tactical situation and to be fully informed concerning casualties. Each morning, he was privileged to attend the war room conference of key members of the headquarters' staff, an experience which was extremely interesting in itself and which made it possible to anticipate where the heaviest action would occur and where the greatest number of casualties must be cared for. The Operations and Training Subsection, Medical Section, Third U.S. Army, at the forward echelon maintained a map on a day-by-day basis which showed the distribution of all medical units and all surgical teams. This information made it possible to provide prompt and efficient medical support for all units in action.

    Colonel Odom worked out of the office in the forward echelon, sometimes being absent from it for several days at a time. In such circumstances, days sometimes elapsed between his reports to the Army surgeon's office, but on his return an informal report, at least, was always made on time conditions observed.

    Movement from one medical unit to another permitted on-the-spot observation. In the Third U.S. Army, under General Patton's dynamic leadership, advances were frequently so rapid that keeping up with medical units was something of a problem in itself (fig. 44). Full provision, however, was made for Colonel Odom's transportation. A driver and jeep were regularly assigned to him, and, if hospital units were too widely separated for ground transportation to be practical, he was assigned a cub observation plane and a pilot. A


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FIGURE 44. - Evacuation by light tank for speed, protection, and negotiating muddy terrain.

plane of this size could be landed in the field next to a. hospital, and its use saved much time in moving around the army area.

    Col. (later Brig. Gen.) Thomas D. Hurley, MC, Surgeon, Third U.S. Army, and Col. John Boyd Coates, Jr., MC, Executive Officer, had the task of supporting the advancing Army by leapfrogging medical units which were leapfrogged across each other. Since the surgical consultant moved with the command post of the army, it was often possible for him to recommend advantageous hospital locations to the Operations and Training Subsection. Also being thoroughly familiar with the abilities and capacities of the various medical units, he was often able to recommend the use of one unit instead of another as better suited to the immediate job to be done.

    Finally, because of his close observation of their work, the surgical consultant was able to recommend that one or another unit. be given a few days' rest. These recommendations were almost invariably followed by the Operations and Training Subsection. This policy held for the larger units as well as the smaller units and even for individuals. When surgical teams had been


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through a particularly busy period, it was customary to transfer them temporarily into less busy hospitals in rear areas.

    Colonel Odom did a certain amount of surgical work himself, partly for demonstration purposes and partly to help out hard-pressed surgical teams when the number of casualties was particularly heavy.

    He also performed a number of operations in evacuation hospitals, some of which, except for the desire to keep key personnel in headquarters, would have been handled in general hospitals in the communications zone, or even in Zone of Interior hospitals.

    Between the Sicilian campaign and the invasion of Normandy, for instance, Colonel Odom performed a bilateral inguinal hernioplasty on the Chief of Staff, Seventh U.S. Army. The result was excellent, and the latter officer was able to remain active throughout the campaign on the Continent and, later, made an outstanding record as Commanding General, 1st Cavalry Division, in the Korean War. Also, General Patton's ordnance officer was operated on for intestinal obstruction; a segment of bowel was resected, and he was returned to duty in Third Army headquarters within 2 weeks.

    A unit commander who had sustained a serious abdominal wound was brought out of a German Army prison camp while the battle for the town in which it was located was still in progress. Two cub planes were flown into the camp, with Colonel Odom in one of them. After blood transfusion and sedation, the patient was flown out of the camp in the other plane and was soon on time operating table in an evacuation hospital a few miles behind the frontline, This officer is still in service.

    Still another officer in headquarters was operated on for acute appendicitis; he was back on duty within a week, without ever leaving the army area. The assistant G-2 lost an arm in a German hospital when he was taken prisoner in a skirmish late in the European fighting. When he was located and recaptured by U.S. Army patro1s, revision of the stump was carried out in an evacuation hospital, and he remained on duty until the end of the war.

    These and other operations were performed by the surgical consultant with the full knowledge and approval of General Patton, who believed most strongly in the doctrine of keeping all personnel, particularly key personnel, in the army area, so that they would not lose contact with their units. It was a tremendous boost in morale for a wounded soldier to return to his own unit, and an equal boost for the morale of the unit to which the man was returned. It also improved the prestige of the Medical Department, for it furnished concrete evidence to the troops that when they were ill or injured they would be cared for promptly and competently.

PLANNING IN THE UNITED KINGDOM BASE

    During the first 2 months after medical planning began in the United Kingdom for the invasion of the Continent, the weather was typically rainy, foggy, and cold, but physical circumstances were otherwise propitious for


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efficient operations. Field grade officers were billeted in private English homes, not more than a mile or two from headquarters, and other officers were also near at hand.

    Certain major problems faced the medical service of the Third U.S. Army before the invasion of the Continent (Operation OVERLORD), as follows:

    1. Preparation and intensive study of the medical plan for this operation.
    2. The reception, acquisition, preparation, training, and briefing of medical units assigned to the Third Army.
    3. The preparation of a medical supply plan and the procurement of supplies and equipment, including the improvisation of substitutes for what was not available in sufficient quantities for distribution to all units before the invasion.

Indoctrination

    Probably the major problem that confronted the professional service of the Third U.S. Army during the early months of 1944 was the dual necessity of orienting medical units for combat duty and of rounding out and balancing the specialty staffs of the hospital units.

    Among all the hospital units assigned to the Third Army, only the l6th Field Hospital had had any combat experience before it went into action in ETOUSA (European Theater of Operations, U.S. Army). Most units had had some maneuver experience, but a few had had little service or none at all in the field. The 9lst Evacuation hospital, which had had experience in the Mediterranean theater, went onto the Continent with the First U.S. Army, as did some of the other medical units originally assigned to the Third Army. These units, which landed in Normandy late in June and during July, functioned under the Surgeon, First U.S. Army, during this period, as did the surgical consultant to the Surgeon, Third U.S. Army. When the Third Army became operational on the Continent on 1 August 1944, these units reverted to it.

    To compensate for these deficiencies in training, which were immediately obvious when the planning for the Normandy invasion was begun, a formal orientation course was planned and carried out.

    Course of instruction. - Informal indoctrination and briefing were, of course, a continuous process, but a formal 7-day course was conducted at Peover Hall, Knutsford, Cheshire, England, in order to provide maximum background to personnel who would perform professional duties in the surgical and medical specialties in Army hospitals. The conference was attended by officers of the Medical Corps, Dental Corps, and Army Nurse Corps from the various hospital units assigned to the Third Army. The lecturers and other instructors included the chief and senior consultant for the theater in each specialty, as well as other medical officers with combat experience in the particular subjects under discussion. A wide variety of subjects were covered, with emphasis on the special procedures in each field which had been standardized in the light of the experiences in North Africa, Sicily, and Italy. Demonstrations were also pro-


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vided, such as the arrangement of surgical equipment under tentage (p. 312). Special emphasis was placed on rapid as well as efficient functioning.

    This 7-day course proved extremely beneficial. Among other advantages was the provision of a proper background on which medical commissioned personnel could base further study of the problems which they were to face in operations on the Continent. The planned, intensive instruction made it possible for many hospital units, even though they had no combat experience and many of their personnel had had little military experience, to adjust themselves rapidly to combat conditions and to treat and evacuate large numbers of casualties when the Third Army became operational on 1 August 1944 and the medical units were committed. The average medical officer, even without previous experience, soon learned to follow directions and comprehend why a certain routine was necessary, while at the same time he did not subordinate his own good judgment and individual initiative to it.

    Later in the war, policies and practices devised at one unit and found efficient in it were conveyed to other units by the surgical consultant as he moved about the Army area, and they were soon in general use. All such items were included in the summary of events which the consultant submitted to the historical Section, Third U.S. Army, at the end of each month and in the final summary submitted at the end of the campaign. It is devoutly to be hoped that these and other lessons learned in conflict will not again be forgotten, as so much was forgotten between World War I and World War II.

    The orientation course just described provided an excellent opportunity for the hospital staffs to become acquainted with the army consultants, as well as with the theater consultants in the Office of the Chief Surgeon, ETOUSA. It is believed that this preliminary acquaintance had much to do with the cordial relations always maintained between army and theater personnel during the fighting in Europe. Col. (later Brig. Gen.) Elliott C. Cutler, MC, frequently made rounds in Third U.S. Army units with Colonel Odom, and much of the credit for the low mortality rate in battle casualties in the European theater is due to his efforts. Like all personnel in the theater chief surgeon's office, he was always most helpful when he was called upon for advice or other assistance.

    Other courses. - In addition to the formal course just described, all existing facilities in the United Kingdom were used for the training of personnel in various specialties, particularly anesthesia and orthopedic surgery. Instruction in shock and transfusion at the British Army Blood Supply Depot, Southmead Hospital, Bristol, was made available for a small number of medical officers. A course for nurses, designed especially for time training of chief nurses and other key nurses, was conducted at time American School Center, Shrivenham, and proved extremely useful. A 1-day course in plaster techniques was conducted at the 10th Station Hospital in the Manchester area. All of these courses were planned to precede 30-day periods of temporary duty in these specialties in station and general hospitals.


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FIGURE 45. - Intratracheal anesthesia in a field hospital platoon, with simultaneous administration of whole blood.

    Perhaps the most useful of these special courses was the one in anesthesia, in which field one of the most serious shortages was discovered in the medical planning for D-day. This problem was solved by utilizing the experience of Maj. (later Lt. Col.) John R. Abajian, Jr., MC, who had taught anesthesia before entering the Army. He prepared a series of lectures and spent 2 or 3 weeks at a time in each field and evacuation hospital, demonstrating the administration of the various types of anesthesia and otherwise instructing the personnel assigned to anesthetic duty. By this means, it was possible to set up in each hospital a staff of three or four medica1 officers and the same number of nurses who had some fundamental knowledge of anesthesia. Anesthesiologists were trained in the same manner in auxiliary surgical teams.

    By the time Major Abajian left a unit, he had succeeded in giving valuable instruction in both the theory and practice of the administration of anesthetics and had also given valuable assistance in the handling of casualties in the operating room. His work elevated the standards of both anesthesia and surgery in the Third U.S. Army (fig. 45).


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    In spite of administrative and other difficulties, which increased as the date for operations on the Continent approached, it was possible, during a 3-month period, to train approximately 1,000 medical officers and about 300 nurses in a number of professional and military subjects.

EVALUATION AND ASSIGNMENT OF PERSONNEL

    While the orientation courses just described were in progress, specific action was taken to evaluate the qualifications and experience of all medical officers in the Third U.S. Army. Each officer filled out a questionnaire on his professional qualifications, and on the basis of a careful study of these records a considerable number of changes in hospital staffs were instituted. Qualified Surgeons in the various specialties were transferred from posts in which their talents were likely to be wasted to posts in which their talents could best be utilized. In particular, a number of officers were transferred, for this reason, from other field units into hospital units or auxiliary surgical teams. In all, 78 Medical Corps officers were transferred to other posts between 30 March and 1 July 1944.

    Most shifts in personnel were made on the basis of the recorded training and experience which the various medical officers had had before they entered upon their military service. After the Third U.S. Army became operational, evaluation was on a more practical basis, by direct observation of work in the field. It was then necessary to make a number of additional changes. Deficiencies in training became evident, and lack of leadership ability and personality difficulties often became apparent only after units had begun to function. When the ability of a surgeon came into question, as it sometimes did, the surgical consultant always checked on the complaint by direct observation before recommending any action.

    The best method of adjustment, when these various difficulties arose, was usually to change the assignment. Medical officers who had been unhappy misfits in one organization were often happy and successful in another. In fact, the surgical consultant often served almost as a chaplain for medical officers who found it difficult to adjust to a military routine.

    When there was a great deal of activity, as there was throughout operations on the Continent, changes in assignment were fairly easy to accomplish without delay or red tape.

    When the Third U.S. Army embarked for the Continent, it was short about 25 Medical Corps officers, chiefly in the units which had been phased in late. The shortages were particularly serious in radiology, neurosurgery, and anesthesia.

    It had been expected that these shortages would be overcome by a wider use of Medical Administrative Corps officers, but by the middle of November, when the last of these officers had been furnished to the Third Army, casualties among Medical Corps officers about equaled the paper surplus, and shortages in the Medical Corps continued to the end of the war.


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    Ophthalmology. - In the entire Third U.S. Army, there were originally only three officers trained as ophthalmologists. Two of them were in time same unit, a situation which was promptly corrected by the transfer of one of them to another unit.

    The most experienced and best trained of these officers, in addition to his duties at his own unit, served as an auxiliary consultant, moving from one unit to another as his services could best be utilized. He was usually stationed in a forward evacuation hospital, where he could examine casualties with eye injuries and direct their treatment. His advice was very helpful in the preparation of directives concerning eye injuries.

    Radiology. - A well-trained roentgenologist in one of the evacuation hospitals, Lt. Col. Frank Huber, MC, served as an auxiliary consultant to the surgical consultant, in addition to his work at his own unit. He visited other hospitals upon request and checked the work of the personnel and the adequacy of equipment in the X-ray departments. His advice was of great assistance in obtaining the best possible utilization of the X-ray equipment supplied for use in the field. One of his important duties was to check on the health of personnel engaged in X-ray work. He made sure that proper precautions were taken for their protection and directed routine blood studies, to be certain that they were not being deleteriously affected by radiation.

    Colonel Huber also checked on the work of the three mobile X-ray units assigned to the Third U.S. Army. These units, which were part of the 4th Auxiliary Surgical Group, filled a dual deficiency. The table of organization for an evacuation hospital provided for only one roentgenologist, who obviously could not work day and night over the long periods of time the hospital was in active operation. The mobile units made it possible to reduce the waiting period in evacuation hospitals receiving a rush of battle casualties by providing qualified roentgenologic coverage over a- 24-hour period (fig. 46) . These teams were also useful in training inexperienced radiologic personnel in new units which joined the Third U.S. Army just before D-day and during active operations on the Continent.

    The amount of X-ray work required in a field hospital did not justify the assignment of trained roentgenologists to these units. On occasion, however, when evacuation was not practical because of the tactical situation, as in river crossings, a mobile X-ray unit was attached to the field hospital platoon and served a very useful purpose.

    Nursing service. - Nurses were always in short supply in both evacuation and field hospitals during rush periods, and the illness or incapacity of a single nurse could result in a serious situation. Too much credit cannot be given to the members of the Army Nurse Corps who worked side by side with surgical teams in units close behind the frontlines, often under shellfire, as well as in other forward installations. Their mere presence did a great deal for the morale of the troops.


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FIGURE 46. - Team of mobile X-ray unit operating in an evacuation hospital in France.

    Similar credit should also go to the enlisted men who worked valiantly and competently to care for casualties on the battlefield as well as in various forward installations.

MEDICAL UNITS

Field Hospitals

    Early in the North African campaigns, it was found that one of the chief factors contributing to a low case-fatality rate in battle casualties was their treatment as far forward as possible (p. 370), with the echelon in which they were treated determined by the nature of their injuries. The campaigns in Sicily and Italy and later in the European theater further proved the value of early, skilled surgical care.

    This care was best provided for nontransportable casualties in a reinforced platoon of a field hospital set up at the same level as the division clearing station, and sometimes in the same field or building. All casualties were funneled through the clearing station. Casualties were transferred to the field hospital, instead of being evacuated farther, when they were found to have multiple wounds or penetrating wounds of the chest and abdomen; when they were in


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FIGURE 47. - Initial stage of the establishment of a field hospital platoon. Hastily abandoned German equipment is in right background.

shock which did not respond promptly to appropriate therapy; or when for any other reason they required prompt surgical care and were unlikely to withstand movement to the rear without further deterioration.

    No field hospital in the Third U.S. Army was employed as a unit, with a single exception--when such a unit was set- up on the last day of 1944. Instead, field hospitals or portions thereof were attached to corps, which in turn attached active platoons of these hospitals to divisions for use in proximity to division clearing stations, as just described (fig. 47).

    Theoretically, field hospitals were staffed and equipped to go to work immediately after their arrival in the theater. Actually, personnel assigned to them were seldom trained to do major surgery and usually had had little or no experience in this area. The field hospitals assigned to the Third U.S. Army had usually been trained for operation as station hospital type units and were unprepared for operations in the field. It was the consensus that such hospitals in the future should be trained under tactical or Army Ground Forces supervision, not under the supervision of Army Service Forces, to insure their receiving proper field and maneuver training.

    Since it was at the level of the field hospital that the most crucial and exacting surgery would be performed, the most practical solution of the problem presented by the lack of training of these hospitals was to reconstitute them.


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    Partly trained or untrained surgeons were detached from them and transferred to evacuation hospitals or surgical teams, in which they would work under supervision. They were replaced in the field hospitals by trained surgical teams, made up from the staffs of general hospitals or from auxiliary surgical groups (p. 308). This meant that, in effect, the field hospitals were first pulled down and then built up again. The result was a surgical hospital in which the best surgical talent in the army was utilized to the fullest advantage.

    In the field hospital, shock teams prepared the casualties for surgery, and surgical teams (p. 308) performed the necessary surgical procedures. The greatest efficiency was usually attained by employing one shock team and one surgical team on each 12-hour shift. Organic personnel of the field hospital platoon assisted in preoperative and postoperative cane and were responsible for administrative duties. The qualities of leadership possessed by the platoon commander were extremely important in maintaining harmony and promoting efficiency.

    Soon after the Third U.S. Army became operational, it became evident that field hospital platoons set up adjacent to division clearing stations would not be able to move forward with clearing companies because of the nontransportable patients occupying the beds after surgery. This dilemma was solved by attaching the personnel and equipment of an army collecting company to each field hospital platoon. These companies were designated as holding units. When it became necessary for the field hospital platoon to move forward, all nontransportable patients were left in charge of the holding unit. The patients were evacuated as soon as they became transportable, after which the holding unit rejoined the field hospital platoon.

    This proved a very efficient plan. Few or no organic field hospital personnel had to be left behind with the holding unit, and very little equipment was necessary. The efficiency of the holding unit personnel was naturally greatly increased if the unit had worked previously with the field hospital and had an understanding of the care required by patients with various types of wounds.

Evacuation Hospitals

    While field hospitals accomplished the saving of an incalculable number of seriously wounded battle casualties who required immediate surgery, evacuation hospitals also handled their share of heavy surgery, especially when they were located close to the front lines and the flow of casualties was heavy. In addition, these hospitals cared for an enormous volume of less seriously wounded battle casualties, many of whom were returned to duty.

    The rapid treatment of battle casualties and the return of soldiers to duty within the army area required a well-balanced staff in the evacuation hospital, headed by a chief of surgery who had both sound surgical judgment and administrative ability; the latter was quite as important as the former in the care of wounded men at this echelon.


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    Evacuation hospitals in the Third U.S. Army were found to operate most efficiently when they were organized to staff 8 or 10 operating tables around the clock, day in and day out. The organic personnel of the hospital was not sufficient, however, to provide the two 12-hour shifts required to maintain such a schedule for any sustained period of time. It had been demonstrated early in the campaign in Europe that the efficiency of a surgeon in an evacuation hospital was definitely reduced if he worked longer than 12 hours at a time. His fatigue manifested itself in a lower standard of work as well as in his total achievement. A 12-hour period of relief provided sufficient rest for him to continue to work hard for long periods.

    The solution of this problem was the use of auxiliary surgical teams during the periods of peakloads, which were usually immediately after the hospital had been set up in a forward sector. The minimum requirement was two general surgical and two shock teams. The addition of these teams to the organic personnel of the hospital permitted efficient functioning and prevented surgical backlogs from pyramiding.

    The Medical Section, Third Army headquarters, had a very tightly integrated system of communication concerning, and control of, the casualty flow into evacuation hospitals. The system did not attain its full efficiency until the end of the first week of Third, U.S. Army operations, and there were, of course, occasions on which it was more efficient than others. Such subordinate units as the medical group with its very specialized facilities and with the excellent signal communication which was almost, constantly available, played a major role. Organization and constant supervision were necessary to achieve control of the flow of casualties into evacuation hospitals, but the results were so satisfactory that few persons outside of those intimately concerned with them realized how well the measures which were adopted to achieve these results were working.

    The surgical consultant was kept fully informed of the casualty situation; his office in the forward echelon received daily reports of the number of casualties admitted to each evacuation hospital, together with information on the surgical backlog and on the distribution of surgical teams. There were many instances in which this liaison proved extremely valuable.

    The organic transportation of evacuation anti field hospitals was not sufficient to move evacuation hospitals completely from one location to another, though moves were frequent. During August 1944, for instance, these hospitals averaged about four moves each, the distances ranging from as little as 10 miles to as much as 100 miles. Before the campaigns in Europe started, the Medical Section, headquarters, Third U.S. Army, had been advised that additional transportation could be obtained as necessary from quartermaster truck companies. As soon as operations got under way, it was evident that this source of transportation would not be available; General Patton commandeered all trucks and other available extra transportation to move petroleum products and ammunition.


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    The Operations and Training Subsection of the Medical Section solved this difficulty by setting up a provisional truck unit consisting of all available trucks from the medical units under Third U.S. Army control. A chart was maintained, and enough trucks were dispatched to meet the particular needs of evacuation and field hospitals whenever they were obliged to move.

    Estimates indicate that about 43 percent of all casualties handled in Third U.S. Army evacuation hospitals were returned to duty in the army area. They were practically always sent back to duty in their original units. Getting personnel back to their own units, as mentioned elsewhere, was as much a must in General Patton's command as was neatness in dress. He recognized the tremendous morale factor for both officers and enlisted men inherent in this plan. No directive was written on the subject, but seeing that this particular policy was adhered to accounted for one important segment of the duties of the surgical consultant.

Auxiliary Surgical Groups and Surgical Teams

    The teams of the 4th Auxiliary Surgical Group, which functioned under the Third U.S. Army during the whole period of combat on the Continent, contributed greatly to the high standard of surgical care achieved in this army. For the most part, the chiefs of the various teams were well trained in their specialties before they entered service. Although they lacked actual experience in the handling of battle casualties, their previous training permitted them to adapt their talents rapidly to the exigencies of wartime situations, and their surgical techniques left little to be desired.

    A single auxiliary surgical group, even though it consisted of 64 teams, was not sufficient to care for the casualties of an army which often had from 12 to 15 divisions in action. When the teams of the 4th Auxiliary Surgical Group proved insufficient for the necessities of special situations, additional teams were requested. They were provided either from the 1st and 5th Auxiliary Surgical Groups or by temporarily attached teams made up of qualified personnel from general hospitals not active at the time.

    The field hospital platoons attached to each division clearing station (p. 306) had to be staffed according to the immediate combat necessities. The number of surgical teams functioning in any one unit thus varied with the number of casualties who had to be cared for at the particular time. Surgical teams and shock teams were most usefully employed in field hospitals (fig. 48). As a rule, two general surgical teams and two shock teams were attached to each field hospital platoon in operation. When casualties were very heavy, they were supplemented by additional teams, which remained only long enough to reduce the existing surgical backlog.

    The organic personnel of an evacuation hospital, as just pointed out, no matter how well qualified they might have been, could not cover the needs of such an organization over a 24-hour period in which battle casualties were often admitted at the rate of from 100 to 150 per day. For most efficient operation,


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FIGURE 48. - An auxiliary surgical team operating with a field hospital platoon.

an evacuation hospital required the assistance of two general surgical teams, one orthopedic surgical team, one neurosurgical team, and one maxillofacial team. The specialty teams usually covered the 12-hour period which would have remained uncovered if there had been available only the single qualified representatives of these specialties on the organic hospital staff.

    Specialty teams functioned best at this level. This was because the great majority of casualties with extremity wounds, head injuries, and maxillofacial injuries were readily transportable and could be moved 15 or 30 miles, or farther, behind the lines to the area in which evacuation hospitals were set up.

    Surgical teams were also of great value in bridgeheads across rivers. In these circumstances, the wounded could not readily be evacuated. Even when troops were on the offensive, it was found that definitive surgery could be accomplished by these teams much farther forward than had previously been realized.

    The best medical support for armored divisions was provided by the use of a unit staffed by two surgical teams and two shock teams. The necessary tentage, surgical equipment, and other supplies could be moved in two trucks. A unit of this kind could move along with, and be set up next to, a company of the medical battalion of an armored division. A field hospital platoon followed this unit, taking over the casualties who had been operated on and


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leaving the surgical teams free to move forward again with the armored division..

    Assignments of surgical teams were always so arranged that a few teams were held in reserve, to throw into areas in which unexpected needs might arise. This system also permitted periods of rest for teams which had been working under pressure for long periods of time.

    One of the chief points which had been stressed to teams of auxiliary surgical groups when they first began to function in North Africa was that they must operate in harmony with the organic personnel of the hospital units to which they were assigned. In the first days of combat in France, there was some friction between the teams and the hospital staffs, but it promptly disappeared as the help which could be provided in the teams became evident. In the few cases in which personality difficulties developed or persisted. it was a simple matter to switch the team assignments.

    The constitution of field and evacuation hospitals and their supplementation by auxiliary surgical group teams illustrate the cooperation which existed within the Third U.S. Army. The executive officer, Col. John Boyd Coates, Jr., MC, was responsible for the location and setup of these hospitals, but, with his full cooperation, all shifting of surgical teams was carried out through the surgical consultant, who made his decisions from his knowledge of the status of the hospital (that is, the number of casualties admitted and the surgical backlog) and of the capabilities of the available teams. The office of the army surgeons was kept informed of all movement of the teams, and assignments were accomplished without friction or other difficulties because of the cooperation of the army surgeon and his executive officer. The information which the surgical consultant obtained, usually by on-time-spot observation at points at which heavy casualties were expected, was acted upon immediately, and the need for additional help, of the precise quantity and quality needed, was often met within a matter of hours. As a result, the highly specialized personnel of auxiliary surgical group teams was used in the most effective manner possible.

    During the Battle of the Bulge, in December 1944, information was received at Third Army headquarters that many casualties were piling up in Bastogne, Belgium, and that help was needed to care for them because the medical units attached to the 101st Airborne Division were completely exhausted (fig. 49). A volunteer surgical team, consisting of five medical officers and five Medical Department enlisted men, was formed from the personnel of the 12th Evacuation Hospital, which was then located in Nancy, France. This team, with sufficient medical supplies, was transported to Thionville and then was flown into Bastogne by glider. This was about 36 hours before the Allied breakthrough and the relief of the besieged forces by the advanced element of the 4th Armored Division. The surgical consultant, who entered Bastogne with these troops, was able to assess the casualties at first-hand and to direct their treatment and evacuation.


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FIGURE 49. - Two members of the 101st Airborne Division drag badly needed medical supplies which were airdropped to the besieged at Bastogne, Belgium.

SUPPLIES AND EQUIPMENT

    Medical supplies and equipment were of the best quality and were provided in adequate quantities, so that all the units which landed in France after D-day were fully equipped. This was generally true through the whole period of fighting. In addition, at intervals, U.S. Army equipment was supplemented by captured equipment. During August 1944, for instance, more than 200 tons of German medical supplies were captured. About a third of this material could be used by U.S. Army medical units and was channeled accordingly.

    During the 3 months before the Third U.S. Army was committed on the Continent, the various medical units drew their equipment, and their personnel became acquainted with its use. The cooperation of Col. Elliott C. Cutler, MC, Chief Consultant in Surgery to the Chief Surgeon, ETOUSA, made it possible to augment the equipment supplied by tables of equipment with certain other items which had been found in the Mediterranean theater to be useful and often to be necessary for the proper functioning of various units. These items included additional anesthesia machines; generators for electric-light plants and nonstandardized supplies for certain technical procedures, such as Vitallium tubes for blood vessel anastomosis and fibrin foam and other items used in neurosurgical procedures.

    During the orientation course in England before D-day, various improvisations and alterations in the routine use of equipment were demonstrated because


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they had been found to be of value in Africa., Sicily, and Italy. One of these demonstrations concerned the setting up of tentage so that the central supply unit was really central. The supply tent was set up at the center of four operating tents, which branched off from it in cruciform fashion. The original plan had been for the dispersion of all such facilities. The substitute plan simplified heating, reduced the number of personnel needed, reduced the time necessary to secure supplies, and made it necessary for personnel to face mud, rain, and snow in order to get them.

PROFESSIONAL MEETINGS

    Because of the pressure of events, no medical societies were organized in the Third U.S. Army, and no regularly scheduled conferences were set up. Several times, however, during lulls military operations, representatives of the surgical staffs of field and evacuation hospitals were summoned to meet at some central point for the discussion of problems of general concern. These conferences were of great benefit. Medical officers, from the beginning, had been encouraged informally to record experiences of special interest, and many of them were presented at these conferences.

    Conferences arranged by the theater consultants were also of great value. They kept everyone posted on routine and special practices, especially advances in the treatment of casualties, and provided a useful forum for the exchange of ideas. Officers who had become interested in special clinical problems were asked to present them at these meetings. The substance of the discussions and the conclusions arrived at were passed along to the surgical teams and hospital staffs by the surgical consultant.

    Colonel Odom also attended several meetings of the medical staffs of all Allied armies. One of these meetings, held in Paris two months after the invasion of the Continent, was particularly helpful because of the opportunity afforded for the evaluation of the work of forward units. It was gratifying to hear only minor criticisms from the hospitals in the communications zone. When Colonel Odom returned from another of these general meetings, which was held in Brussels in December 1944, he reached Third U.S. Army headquarters by passing through the area in which the Battle of the Bulge was to erupt only 24 hours later.

    Time and events did not permit formal publications from the Third U.S. Army, but Colonel Odom made a personal study of amputations and vascular injuries in the Third U.S. Army and reported the analysis at one of the Inter-Allied Conferences on War Medicine convened by the Royal Society of Medicine in May 1945 3 (p. 324). A supplementary report on the same subject was published in Surgery in 1946.4

3 Odom, Charles B.: Vascular Injuries in Battle Casualties. In Inter-Allied Conferences on War Medicine, 1942-1945. London: Staples Press Limited, 1947, 167-171.
4
Odom, C. B.: Causes of Amputations in Battle Casualties With Emphasis on Vascular Injuries. Surgery 19: 562-569, April 1946


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FIGURE 50. - Nazi hospital unit surrenders in Germany.

RECORDS

    The records kept in all hospitals of the Third U.S. Army were regularly examined by the surgical consultant in frequent spot checks, and their importance was stressed whenever a hospital was visited. The constant emphasis upon these matters resulted in consistently good records, even when the units were extremely busy.

    Almost all hospitals kept their records in duplicate. The original was sent with the patient when he was evacuated, and the carbon was retained. This system had time advantage of maintaining a continuous record of all patients handled in each hospital, and it also permitted medical officers assigned to the unit, to review the cases which they had handled personally.

PRISONERS OF WAR

    During the early months of the campaigns in Europe, when only German field medical units were captured, wounded enemy casualties were evacuated through normal U.S. Army channels of evacuation. As the Third U.S. Army advance continued, ever-increasing members of German military hospitals were uncovered (fig. 50). A directive was issued on 11 April 1945 defining the specific responsibilities of the army medical service in regard to these installa-


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tions. 5 German prisoners of war uncovered on the field of battle and requiring prompt care were to be treated and evacuated through normal medical channels. Those uncovered in German military on civilian hospitals were to be managed by a "stay put" policy, the tactical situation permitting. Battlefield enemy casualties who did not require immediate care were to be sent to these hospitals. When the casualties were ready for discharge from the hospital, they were to be sent to prisoner-of-war enclosures.

    Consolidation of German patients in military or civilian hospitals was accomplished whenever the circumstances permitted, and maximum use was made of German medical department supplies and equipment. Medical supplies, as far as possible, were replenished from captured German stocks. Whenever possible, German medical officers were left in charge of these intact hospitals, but administrative details were provided by U.S. Army medical units.

    The surgical consultant visited the prisoner-of-war hospitals and saw to it that the treatment instituted was commensurate with U.S. standards of medical practice.

    One morning, shortly after the German surrender, Colonel Odom was instructed by General Patton to examine Field Marshal Karl von Rundstedt; he had been captured and was housed in a small resort town with his personal German physician, who contended that he was too ill to be moved. Colonel Odom found him in excellent physical condition except for a mild hypertension. A few hours after this report had been given to General Patton, Field Marshal von Rundstedt was on his way to a prisoner-of-war camp in England.

Section II. Clinical Considerations

DISSEMINATION OF CLINICAL POLICIES

    In addition to the Manual of Therapy, European Theater of Operations, issued in May 1944, surgical policies in the Third U.S. Army were chiefly determined by the second (surgical) part of the medical plan which formed Annex 16 to the Third U.S. Army Plan for Operation OVERLORD, dated 11 May 1944. These Third Army surgical policies were revised by a directive published on 13 October 1944. 6

    The surgical consultant prepared the directives pertaining to surgery which emanated from Third U.S. Army headquarters, insuring that they conformed with the appropriate directives from the Office of the Surgeon General and the Office of the Chief Surgeon, ETOUSA. After a directive had been issued, the consultant ascertained, on his next visits to army units, that it was fully understood and was being followed.

    As a matter of convenience, as well as to point up the changes in policies, the surgical policies set up in May 1944 and revised in October 1944, after 3 months of combat, are described together.

5 See footnote 1 (2), p.291.
6
Annex No. XIV, After Action Report, Office of the Surgeon, Third US, Army. 15 May 1945.


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GENERAL CONSIDERATIONS OF FORWARD SURGERY

    In the Third U.S. Army medical plan for Operation OVERLORD, dated 11 May 1944, it was pointed out that early, skilled surgical care of battle casualties is the principal function of medical installations supporting a field army. This care was based on the following principles:

    1. First aid and primary care include only dressing of wounds, control of hemorrhage, splinting of fractures, and treatment of shock. These measures are carried out at battalion aid stations and at collecting and clearing stations.
    2. Definitive surgery is not to be undertaken in installations forward of field hospital platoons.
    3. A most important consideration in the early care of the wounded is the proper sorting of casualties. This sorting (triage) permits lightly wounded to be returned quickly to duty, while seriously wounded casualties are evacuated to field or evacuation hospitals, the echelon at which they are treated depending upon their transportability.

    In this medical plan, casualties were divided into two groups, as follows:

    (1) A transportable group, consisting of those who could withstand movement to the rear without deterioration; and (2) a nontransportable group, consisting of casualties who would do poorly when moved and whose wounds (or the status resulting from whose wounds) required immediate treatment.

    There were a number of categories in the nontransportable group, as follows:

    1. Casualties, usually those with multiple wounds, who remained in shock in spite of intensive resuscitative therapy.
    2. Casualties with abdominal wounds, particularly those with possible concealed hemorrhage. In evaluating these patients, it was emphasized that another fact, had to be taken into consideration, that all previous experience had shown that patients who had undergone laparotomy could not be safely moved for at least 7 or 10 days. In other words, the triage of this group required the evaluation of both the postoperative circumstances and the casualty's present status.
    3. Casualties with large sucking chest wounds or massive intrathoracic hemorrhage.
    4. Casualties with transthoracic or thoracoabdominal wounds. It. was pointed out that these wounds are difficult to diagnose and are likely to be missed because the path of the missile is frequently unexpected. In wounds of the buttocks, for instance, the missile may come to rest in the thorax, while in wounds of the shoulder, it might lodge within the peritoneal cavity. If X-ray facilities were available, it was recommended that they be used to settle the matter.
    5. Casualties with wounds about the face and neck causing mechanical interference with respiration. Patients in this category would usually require tracheotomy before evacuation.


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SHOCK AND RESUSCITATION

    Shock was the most important cause of death in casualties who did not die immediately of their wounds. If it was not treated promptly and vigorously, it was likely to become irreversible. Its prolongation, even if the patient did not die immediately, often led to a subsequent fatality from anuria. Among the casualties who died in anuria, prolonged, profound shock seemed to be the single constant factor; transfusion reactions did not seem of great importance in this connection. Alkalinization and other methods were found to be of no value in either the prevention or the treatment of this complication. The important consideration was to bring the casualty promptly out of shock.

    Adequate shock therapy, based on the use of plasma and stored whole blood, was probably the most important single method of lowering the immortality and morbidity from combat wounds. Operation was performed as soon as possible after resuscitation and was regarded as part of the resuscitative routine. Teams were set up in all forward hospitals for the treatment of shock and the administration of blood. The chiefs of laboratory services were responsible for the supervision of the hospital blood program.

    Plasma was available to all medical units as far forward as battalion aid stations. It was used in liberal quantities in the prevention of shock and in resuscitation until a field hospital could be reached. It was of value, however, only as a temporary expedient. No casualty could be properly prepared for surgery without the use of whole blood. Plasma and whole blood were originally used in the proportion of 2 pints of plasma to 1 pint of blood, but, as the campaign progressed, more and more blood was used.

    Before D-day, the policy was formulated that the Third U.S. Army would have attached to it a blood bank detachment for the receipt, storage, and delivery of whole blood. The blood was to be delivered daily to all hospitals on a so-called "milk run." Plans were also made, and hospitals were equipped, to obtain whole blood from hospital personnel.

    These plans were based on the provision of blood by the theater blood bank in the United Kingdom Base. During initial operations, 190 pints were delivered daily for the use of the whole Third U.S. Army. This supply was entirely inadequate, even with supplementary provision of whole blood secured by bleeding hospital personnel. Late in August, supplies from the Zone of Interior became available, and from 500 to 700 pints of blood were received daily. This was an entirely adequate provision. There was only one occasion thereafter on which whole blood was badly needed and was not available in sufficient quantities. Colonel Odom was dispatched by the army surgeon to theater headquarters, then in Paris, and a conference with Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, and General Cutler, his consultant in surgery, insured an adequate supply for all immediate needs and future necessities.

    The blood was delivered in refrigerated trucks and stored at a temperature of 35 to 40 F. (approximately 2 to 4 C.). All blood which had passed the


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expiration date marked on the bottle or which had been allowed to become warm was discarded; warming involved the risk of hemolysis, and all transfusions were made with cold blood.

    Final statistics for the Third U.S. Army blood-plasma program show that 4,826 transfusions were accomplished with fresh whole blood, 39,529 with stored whole blood, and 56,937 with dried plasma. Other blood substitutes were used 1,834 times.

ADMINISTRATION OF MORPHINE

    Because of the early experiences in the Mediterranean theater, morphine was used more cautiously in the European theater. In Italy, it had been found that the repetition of a dose of morphine, even when the original dose did not seem effective, was extremely dangerous and could lead to morphine poisoning. The explanation was that absorption of the original amount was at first inhibited by cold and damp, as well as by high altitudes, but was facilitated when the patient was brought into a warm environment, or a lower level. If the original dose had been repeated, both doses were absorbed with dangerous rapidity.

    When morphine was indicated, a dosage of one-quarter of a grain (15 mg.) was usually adequate, although occasionally one-half grain (30 mg.) was required for the control of pain. Larger doses were never repeated. The time and amount of the injection were always recorded.

    Morphine was administered subcutaneously or intramuscularly if a gradual, prolonged effect was desired and intravenously if a rapid effect was desired. Intravenous injection was in the amount of one-sixth of a gram (10 mg.). Massage at the site of intramuscular on subcutaneous injection hastened absorption.

ANTIMICROBIAL THERAPY

    Chemotherapy. - In the Third U.S. Army medical plan for Operation OVERLORD, soldiers wounded in action were directed to take, by mouth, 4 grams of sulfadiazine in tablet form from their first aid package as soon as possible unless the wounds involved the abdomen. At least half a canteen of water was to be drunk within the next 5 or 10 minutes.

    The medical officer who first dressed the wound was instructed to frost it lightly with sulfanilamide powder. The powder was available in 5-gm. packets, and, under no circumstances, regardless of the size and number of his wounds, were more than two packets (10 gm.) to be used for a single casualty.

    Sulfadiazine by mouth was to be continued with definitive surgery had been accomplished. The maintenance dose was 1 gm. orally every 4 to 6 hours or 2 gm. parenterally every 8 to 12 hours. After debridement, or after definitive surgery, all wounds were again lightly dusted with sulfanilamide powder, and sulfonamide therapy was also continued by the oral or parenteral route.

    Medical officers were instructed to be constantly on the alert for a possible reaction to the sulfonamide drugs. If a reaction occurred, the medication was


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to be discontinued entirely or continued in decreased dosages and under strict observation.

    By the time the May 1944 medical plan was issued, the experience in the Mediterranean theater had shown that the sulfonamide preparations in a wound act as foreign bodies. The local use of sulfonamides was therefore discontinued entirely within a few months after the invasion of the Continent. They were found to be of no therapeutic value, and wound healing was actually delayed when crystals were used. Local reactions were not uncommon, and after the wounded man had resumed his activities the wound sometimes broke down.

    Antibiotic therapy. - Penicillin was available for general use in military hospitals when the Third U.S. Army became operational. It was administered parenterally in clearing stations, and the same regiment was continued in field and evacuation hospitals. The administration of penicillin by the parenteral route, combined with early, adequate debridement, was regarded as the most important single contribution to the low incidence of wound infection reported in Third U.S. Army Hospitals. If local therapy was employed, it was instituted in the field or evacuation hospital in which definitive surgery was performed.

    The dosage of penicillin, as well as the time of administration and the route (parenteral or local), was recorded in units on the emergency medical tag and the field medical record. In spite of repeated spot checks and constant emphasis upon the importance of these notations, these instructions, unfortunately, were not always carried out.

WOUND MANAGEMENT

    In all instruction of Third U.S. Army medical personnel, as well as in the medical plan issued in May 1944, it was emphasized that all battle injuries must be debrided and that debridement was the most important single phase of correct surgical care. The operation was to include removal of minimal amounts of skin but of maximal amounts of devitalized tissue, as well as thorough mechanical cleansing to remove all dirt, debris, and readily accessible foreign bodies; foreign bodies at a distance from the wound were to be left in situ. After debridement. had been performed in a forward hospital, the wound was to be left unsutured, with the edges kept separated by strips of petrolatum impregnated gauze. Tight packing of the wound was to be avoided, since a pack acts as a plug and invites infection.

    It was often extremely difficult to make medical officers fresh from civilian life realize the importance of radical debridement in battle-incurred injuries. In the directive issued in October 1944, emphasis was again placed on the necessity for the wide excision of all damaged muscle, the thorough mechanical cleansing of wounds, and the removal of minimal amounts of skin. Particular stress was put on adequate incisions. The circular excision of skin around small wounds was specifically forbidden; this technique resulted in prolongation of the convalescence and made delayed primary wound closure very difficult.


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    Although the first principle of military surgery was to debride the wound and leave it open, it was equally essential that, closure be effected as promptly as possible, to limit infection--the incidence of which was remarkably low--and fibrosis and to facilitate the casualty's return to duty.

    If primary debridement had been adequate, wounds could usually be closed as early as the third day after operation, though it was preferable to leave them open for another 24 or 48 hours. Whether a wound could be safely closed or should be left open for a longer period was a clinical decision, which was not made until the debrided wound was uncovered in the operating room. Preliminary inspection and repeated dressings were avoided, on the ground that these procedures invited contamination.

    Closure was considered safe in the absence of such signs of inflammation as discharge, reddening, pain, and swelling. The wound edges were brought together loosely, without undermining of the edges. Sharp instruments were avoided. Retention sutures, which were of silk or silkworm gut, were spaced widely and tied loosely.

    If mild infection was apparent in the debrided wound, hot moist dressings were applied before closure was undertaken. Healing was usually prompt. If evidences of infection became apparent in a wound after delayed primary closure, immediate removal of the sutures was indicated.

REGIONAL INJURIES

Bone and Joint Injuries

    Wounds of the extremities (table 3) accounted for more than 61 percent of the battle-incurred injuries treated in Third U.S. Army hospitals between 1 August 1944 and 30 April 1943. The majority of these injuries involved bones, joints, or both.

    Fractures. - In the initial surgical plan, directions were given that all compound fractures be debrided and left open and that the injured limbs be immobilized in splints or plaster casts before the casualty was transported to a hospital in the communications zone.

    No external or internal plating or other fixation was permitted in field or evacuation hospitals of the Third U.S. Army. Definitive reduction of fractures was not regarded as the mission of forward hospitals. In the October 1944 directive, it was again. emphasized that field and evacuation hospitals were responsible for the debridement of compound fractures, transportation splinting, and preparation of the patient for early evacuation in comfort and safety but for nothing else in bone and joint injuries.

    When plaster of paris casts were used, circular bandages or other circular dressings were not used under them. All casts were padded. All circular casts were split through all layers, including the layer of wadding, down to the skin. Casts on the lower extremity were split from the tips of the toes to well above the knee. Casts on the upper extremity were split from the tips of the fingers


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to above the elbow. This precaution was taken in the operating room, as an integral part of the surgical procedure.

    Thomas' full-ring or half-ring splints were permitted only in emergencies in forward medical installations. They were replaced as soon as possible by plaster of paris circular splints.

    Regional splinting. - Instructions for immobilization in the October 1944 directive were more specific than in the May 1944 plan. In accordance with the October directive the procedure was as follows:

    1. Fractures of the humerus were immobilized by plaster of paris spica bandages. The arm was held forward and rotated medially, so that the forearm was in front of the body. The elbow was flexed at least 90. A plaster of paris Velpeau's bandage was less satisfactory than a spica, and hanging casts were prohibited.
    2. Fractures of the forearm, wrist, and hand were immobilized by circular plaster of paris casts extending to the midbrachial region. A cast applied to the forearm and hand was cut back to the proximal palmar sulcus, to permit free and unimpeded motion of the fingers, except in injuries of the metacarpals or phalanges. Then the cast was extended to the tips of the fingers.
    3. Fractures of the femur were immobilized in a double circular plaster of paris spica extending from the toes of the affected leg and from just above the knee of the sound leg to the pelvis. The spica was reinforced by a posterior strut, and the legs, with the knees slightly flexed, were spread apart, the separation being gaged to the width of the litter. The use of the Tobruk splint was permitted in selected fractures of the femur.
    4. Fractures of the tibia and fibula were immobilized in circular plaster of paris bandages extending from toes to groin. The foot was placed in neutral position at a right angle to the leg.

    Joint injuries. - Wounds of the joints were treated, as soft tissue wounds were treated, by debridement, with removal of all foreign bodies and devitalized tissue within the joint. Closure of the joint was essential, though the soft tissue wound was left open, as in the usual debridement. Penicillin solution was instilled into the joint immediately after closure.

Hand Injuries

    By the time the October 1944 directive was issued, the dangers of prolonged immobilization in hand injuries had become fully evident, and much emphasis was therefore placed upon them. The objective in all hand injuries was early, active motion, which was militated against by prolonged immobilization.

    The policy was to treat all injuries of the hand as soft tissue injuries. Special efforts were made to close the wound promptly by suture or skin graft.

    When tendon and bone fragments were exposed, the patient was transferred as promptly as possible to the nearest plastic surgery center.


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    Amputation was performed only in the most extreme cases, and then at the most distal point possible. There was one exception to this generalization, as follows: In compound fractures of the distal portion of a finger, accompanied by destruction of the flexor and extensor tendons, the digit was amputated promptly, and early, active motion of the remaining fingers and the entire hand was practiced.

    In selected cases, when skeletal traction was necessary to secure reduction and immobilization of metacarpal fractures, it was applied through the proximal phalanges. Again, there was emphasis on early active motion; immobilization was permitted for no longer than 2 weeks. The intact phalangeal and metacarpophalangeal joints were left free. Pulp traction was never permitted.

Maxillofacial Wounds

    In the May 1944 medical plan, it was emphasized that wounds of the face must be treated with special care at debridement. Excision should be as conservative as possible, and as much as possible of the skin, muscle, bone, and cartilage should be preserved.

    These instructions were expanded in the directive issued in October 1944. If it was thought that the missile had penetrated the nasal mucosa, a complete preliminary examination was conducted, to determine possible internal damage. If the nasal mucosa was injured, the cavity was packed with gauze strips impregnated with a sulfonamide drug ointment, to insure healing on both surfaces of time mucosa and to prevent closure of the airway by adhesions. The gauze, which protruded from the nostril, was replaced every 5 or 10 days.

    Before a patient with a nasal injury was evacuated, a thorough examination was made, to insure that the nasal airway was open. If adhesions were found, they were severed, and the nostril was again packed, to prevent their re-forming.

Abdominal Injuries

    The importance of colostomy in wounds of the colon and rectum was a lesson which had been learned in the Mediterranean theater by painful experience and which was emphasized throughout the campaigns in Europe.

    Whenever possible, when the double-barreled type of colostomy was employed, the large intestine was mobilized to permit approximation of 2.5 or 3 inches of bowel within the peritoneal cavity. When loop colostomy was employed, the initial opening seldom exceeded an inch in length. The incision was made in the region of the presenting taenia, parallel to the long axis of the bowel. It was emphasized that in injuries of the rectum or the sigmoid the bowel must be severed in order to secure complete interruption of the fecal stream below the site of the colostomy.


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Neurosurgical Injuries

    Spinal injuries. - Compression fractures of the spine were reduced by hyperextension, and a plaster of paris jacket was applied while the patient was still in this position. In fractures of the lumbar or lower dorsal vertebrae, the jacket extended from the symphysis pubis to the sternal notch. In cervical and upper dorsal fractures, the head was included in an extension of the jacket.

    Gunshot wounds causing fractures of the spine and damage to the spinal cord were treated in evacuation hospitals, where the extent of the injury could be determined by the combined efforts of the orthopedic surgeon and the neurosurgeon. If surgery was required and operation would be possible within 36 hours of injury, the patient was immediately evacuated to the nearest general hospital in the communications zone. If this was not practical, exploratory laminectomy was carried out by the neurosurgeon in the evacuation hospital; the exploration was undertaken whenever there was an doubt that the cord was completely severed. Transportation of patients with spinal cord injuries in plaster was prohibited.

    If the patient with a spinal cord injury could not void, he was catheterized, and the catheter was left in situ. Tidal drainage was instituted as soon as possible and was continued until complete neurologic evaluation was possible. Special care was taken to insure that the bladder was emptying completely. After this evaluation, tidal drainage was continued if there was evidence of early bladder recovery.

    Early high suprapubic cystostomy was recommended if bladder recovery was not promptly evident, in cord bladder secondary to permanent cord damage. A large mushroom or Malecot catheter was used and was changed frequently, to prevent infection and incrustation. Daily bladder irrigations were also practiced.

    Peripheral nerve injuries. - Nerve damage was sought for in all injuries of the extremities, even if the lacerations were slight. The objective in all peripheral nerve injuries was early repair at a specialized neurosurgical center. Primary repair was not undertaken in hospitals of the Third U.S. Army; the established technique was delayed repair, within 21 to 90 days after wounding and after complete healing of the soft tissue wound.

    Exposed nerves were, however, never left exposed in a forward hospital. Whether or not they were found to be injured at debridement, they were covered by fascia, muscle, or both. The severed ends of a damaged nerve were frequently loosely approximated by one or two nonabsorbable sutures, to prevent retraction. If the defect was so extensive that this was not possible, the severed ends were marked by single nonabsorbable sutures.

Vascular Injuries

    All surgeons of the Third U.S. Army were thoroughly indoctrinated with the importance of attempting repair of vascular injuries, since in their repair lay the greatest possible chances of salvage of limbs.


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    The Vitallium tubes and heparin necessary for a large-scale application of the nonsuture technique of vascular anastomosis were not available in large quantities, but sufficient supplies were available to permit a fair trial of the method. Glass or plastic tubes were used in a few cases in which Blakenmore tubes were not available. Reports by Blakenmore and other vascular surgeons on the nonsuture repair of blood vessels were reproduced, and copies were placed in the hands of every chief of surgery and every chief of a surgical team. It was the consensus that these procedures were usually impractical for general use in the field, for the following reasons:

    1. Recognition of injury to a blood vessel was essential for successful application of repair techniques. Diagnosis could not be expected of the corpsman who first cared for the casualty on the battlefield, and even if he should recognize the injury he could not institute therapy. Civilian surgeons who repeatedly recommended the repair of muscular injuries during the war failed to take into consideration the limitations of first aid men and the conditions under which they worked.
    2. A major part of the discrepancy between the results in vascular injuries encountered in civilian life and those encountered in military practice could be explained by differences in the timelag. The lapse of time between wounding and surgery is seldom excessive in civilian practice. In World War II, the timelag averaged at the best, between 6 and 12 hours.
    3. There were other differences between civilian and military practice. The battle casualty, in contrast to the civilian patient, who usually was in good condition, was often exsanguinated and in shock. The battle casualty's blood was low. His tissues were anoxic. There was often hemorrhage into the fascial planes of the injured extremity, with resulting hematoma formation and pressure on the collateral circulation, which itself was often injured. The disappointing results of sympathetic block, which was used routinely before and after vascular surgery, could frequently be accounted for by these conditions rather than by badly performed blocks.
    4. The preparation of fresh vein grafts was too time consuming to be generally undertaken in military practice. Had frozen grafts been available, another objection to the repair of combat- damaged blood vessels might have been removed.
    5. Heparin must be used to prevent clotting at the site of repair in all nonsuture techniques of vascular anastomosis. This measure, however, would have been attended with considerable risk, for a third or more of all casualties with vascular injuries had multiple wounds. Fatal hemorrhage occurred for this reason in a number of patients who had been heparinized.
    6. The institution of surgical procedures in the battalion aid station, where only resuscitation and first aid measures were employed, would have required the revision of the entire system of management of casualties in forward areas. This might have been justified if there had been large numbers of casualties with vascular injuries susceptible of salvage. The lives of other casualties


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could not justifiably be imperiled, however, for a group of casualties who constituted less than 1 percent of the total number of wounded.

    Analysis of cases. - A single laceration or a single puncture wound of a major artery was uncommon. Most often, the vascular injury was associated with other injuries.

    In 92,030 battle casualties treated in the Third U.S. Army during its entire operational period, only 837, or 0.9 percent, had wounds classified as vascular.7 This was a much smaller proportion than civilian surgeons might suppose. It is believed that this figure is accurate; because all surgeons were on the alert for vascular injuries, excellent records were kept.

    Of these 837 injuries to major arteries, 423 came to amputation. In no case in which removal of the limb was unnecessary was the operation performed without consultation. In retrospect, it almost seems that conservatism was overemphasized; it is believed that an occasional life was lost in the laudable attempt to save a limb.

    Only 70 blood vessels are known to have been repaired in Third U.S. Army hospitals. When these cases are compared with the 592 comparable injuries in which ligation was done, it is seen that gangrene developed in 37 percent of the ligated cases against 38 percent of the cases in which repair was undertaken. The comparison, however, is scarcely valid. One reason is that the repair series is disproportionately small. The second and principal reason is that only the most favorable cases were selected for an attempt at repair, and the comparison of the series is therefore not a comparison of parallel cases. On the other hand, the distinct advantage in vascular repair is evident in this small series and is an indication that the technique should be employed whenever it is practical.

    Repair of damaged vessels by suture was always the method of choice, even when it involved reduction of the caliber of the damaged vessel by as much as 50 percent. Only the larger arteries, including the subclavian, axillary, brachial, iliac, femoral, and popliteal vessels, lent themselves to this technique of repair.

    Arteriovenous aneurysms and false aneurysms were treated conservatively in forward hospitals. Definitive treatment was usually undertaken in hospitals in the communications zone 6 weeks or more after wounding. In the interval, because of the development of an adequate collateral circulation, gangrene of the extremity seldom resulted.

AMPUTATIONS

    There were more amputees in World War II than in World War I, partly because there were more casualties and partly because more men who had lost an arm or a leg lived to return home. The use of more destructive missiles explained the higher amputation rate, particularly the extensive use of land-

7 See footnote p 312.


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FIGURE 51. - Preparation of a mangled arm prior to amputation in a field hospital.

mines, which were practically unknown in World War I. The direct result of injuries from landmines is shown in the study of 1,833 amputations conducted by Colonel Odom 8 in which there were 1,375 amputations of the lower extremity compared with 438 amputations of the upper extremity.

    By far the largest number of amputees observed in the Third U.S. Army, as in other armies, had lost the member immediately upon wounding, or the limb had been so badly mangled that the damage was beyond repair and completion of the amputation was the only practical method of treatment (fig. 51). Sixty-five percent of the amputations performed in Third Army hospitals were for mutilating injuries, which often involved bone, blood vessels, nerves and soft. tissue en masse. Medical officers who treated these patients in forward hospitals knew that no known surgical methods could save these limbs. The picture of a lower extremity hopelessly mangled by an exploding German mine was not visualized by the enthusiasts in the Zone of Interior who believed either that 90 to 100 percent of all amputations could be prevented by sympathetic

8 See footnote 4, p. 312.


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block or sympathectomy or that blood vessel anastomosis could effect a 50-percent reduction in the incidence of amputations for vascular injuries.

    In addition to primary trauma, vascular injuries and clostridial myositis provided the chief indications for amputation in World War II. It is noteworthy that the chief cause of amputation in World War I, secondary infection, was practically unknown in World War II, in which it was eliminated by early, adequate debridement, supplemented by chemotherapeutic and antibiotic agents.

    Sympathetic block was performed routinely whenever the blood supply was interfered with, but it was not of great value, as a rule, because the collateral circulation was likely to have been damaged also.

    Amputation was performed by the open circular technique described in Circular Letter No. 101, Office of the Chief Surgeon, Headquarters, ETOUSA, 30 July 1944. Skin traction was applied to effect closure of the stump.

ANAEROBIC INFECTIONS

Clostridial Myositis

    During the operational period of the Third U.S. Army, 445 casualties with clostridial myositis were encountered, of whom 258 came to amputation.. Characteristically, wounds which produced destruction of muscle, either directly or by interruption of the blood supply, were particularly susceptible to this type of infection. It was most frequent in wounds of the buttock, upper thigh (in compound fractures of the femur), anterior tibial muscles, shoulder girdle, and short flexors and extensors of the forearm.

    In order to prevent unnecessary amputation on th mistaken diagnosis of clostridal myositis, particular attention was paid to the classification of clostridial infections, as follows:

    1. Diffuse clostridial myositis. In this condition, amputation was performed immediately, as far as possible above the visible evidence of infection. This type of infection accounted for 14 percent of the total recorded infections, and 15 percent of the amputations, in the Third U.S. Army. The rate of amputation was four times as high in German prisoners of war treated in U.S. Army hospitals. The most reasonable explanation of the difference was the greater delay from the time of injury to surgical care, which was almost inevitable in prisoners and which was sometimes a matter of days. Once the prisoners were received, they had the same treatment as U.S. Army casualties.
    2. Clostridial cellulitis involving only a muscle or a group of muscles. In this condition, wide excision of the devitalized local tissue was all that was necessary. Amputation was never indicated.
    3. Localized clostridial abscess. Incision and drainage were sufficient. Amputation was never indicated.

    When casualties were received early, that is, within 24 hours after wounding, clostridial myositis was seldom a problem. It was preventable, in almost


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all cases, by adequate debridement of all wounds, one of the points which the surgical consultant never failed to stress in all visits to all hospitals.

    Once clostridial myositis had developed, there was not a great deal to be done about it, though all available measures were employed, including fasciotomy and the administration of penicillin and gas gangrene antitoxin.

    The general impression was that gas gangrene antitoxin was of little value, though it was used regularly, in the prescribed doses. The liberal use of penicillin, in dosages much above the ordinary, was also routine, though it was thought that the whole value of this measure was to control secondary infection and that the antibiotic had little effect upon Welch's bacillus.

    Amputation was useful if it could be performed distally. If the infection was in the thigh, it was almost never lifesaving.

Tetanus

    Tetanus can occur in any wound regardless of its size and location, and it was quite frequent in prisoners of war. It was practically nonexistent, however, in U.S. Army casualties and in the Canadian casualties handled in U.S. Army hospitals, since the Armed Forces of both nations had been immunized upon entering service.

    U.S. Army and Canadian casualties received 1 cc. of tetanus toxoid subcutaneously as soon as possible after wounding. If its administration had not been recorded on the emergency medical tag or the field medical record and the wounded man could not be entirely definite about it, the injection was repeated. An injection in the same amount was given before manipulation or exploration of an old wound.

    Wounded Allied soldiers who had not previous1y been immunized, as well as all wounded civilians, and prisoners of war, were given 3,000 units of tetanus antitoxin intramuscularly. Even though appropriate tests for sensitivity had always been conducted before the injection, a syringe containing 1 cc. of adrenaline (epinephrine) in 1:1000 solution was kept at hand, to be prepared for unexpected reactions.

COLD INJURY

    The Third U.S. Army had the unhappy distinction of having in it the first case of trenchfoot to be reported in the European theater. It appeared on 21 August, 1944, in a First U.S. Army hospital unit then attached to the Third Army. 9 By 12 October, 23 or 30 cases of trenchfoot had been reported in the 35th Division; some of them, which were attributed to lack of overshoes, had occurred as early as 6 October.

    These cases heralded the beginning of a widespread epidemic of trenchfoot in early November and a second epidemic, this time in the form of frostbite, the following month, during the Battle of the Bulge. In each of these epidem-

9 Annual Report, First US. Army, 1944.


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FIGURE 52. - Medical troops of the 4th Division bring up equipment, using an assault boat as a sled over wet snow.

ics, the Third U.S. Army had the largest number of cases in the theater. A third epidemic, in February 1945, took the form of trenchfoot.

    The story of cold injury in the European Theater of Operations is told in detail in another volume in this series.10 It need not be repeated here, though it should be said that the Third U.S. Army, which along with the First U.S. Army had the hugest number of cases of cold injury in the theater, also had the heaviest and most difficult combat assignments. Both armies also suffered from shortages and actual lacks of proper protective clothing and footgear during the worst of the winter weather. The winter of 1944-45 was the most severe in western Europe in many years (fig. 52).

    In addition to the energetic preventive action taken by the Chief Surgeon, ETOUSA, several directives on the subject of the prevention of cold injury were issued from the office of the surgeon of the Third U.S. Army. General Patton's support and participation were characteristically vigorous. He recognized at once that this was a command responsibility and stated unequivocally that the excessive development of cold injury in any organization in the Third Army would be regarded as an indication of inadequate supervision and control.

10 Medical Department, United States Army. Cold Injury, Ground Type. Washington, U.S. Government Printing Office, 1958.


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    0n 21 November 1944, in response to a command directive issued by Lt. Gen. Omar N. Bradley, Commanding General, 12th Army Group, General Patton made the blunt statement that the current menace was not the German Army, which the U.S. Army had practically destroyed, but the weather. General Patton stated further that, if they did not exert themselves, the weather might well destroy them through the incidence of trenchfoot. It is not surprising that when the first epidemic of cold injury began to lessen in intensity, the most precipitous decline in incidence was in the Third U.S. Army.

    The question of whether or not the Purple Heart should be given for trenchfoot did not arise in the Third U.S. Army. General Patton simply directed that it not be given.

    During the fall and winter of 1944-45, admissions for cold injury required a large bed occupancy in forward hospitals and an enormous amount of medical attention and nursing care. No satisfactory treatment was ever devised, and the medical problems were almost as serious as the losses in manpower. When the overloading of evacuation hospitals with this type of casualty became evident, an Army clearing company was instructed to set up a cold injury facility, to which many patients in the army area were evacuated. This installation, at least to some degree, removed the pressure from Third U.S. Army evacuation hospitals.

    In addition, a company of the 94th Medical Gas Treatment Battalion was designated to receive from other Third U.S. Army medical installations certain casualties whose cold injuries were mild. These patients were held for from 10 to 20 days to determine whether they could be returned directly to duty within the army area. In a significant number of cases, this proved possible.

EVALUATION OF SURGICAL CARE

    One of the chief responsibilities of the surgical consultant had to do with ways and means of improving surgical care in all forward medical treatment facilities. When he visited a hospital, after he had talked with the commanding officer and the chief of the surgical service, it was this consultant's practice to make rounds with the latter. On these rounds, questions of clinical policy were thrashed out, and the care which individual patients had received was evaluated and corrected as necessary.

    Constant vigilance was required to insure that surgical directives were being fully complied with. The adequacy of debridement and the splitting of plaster casts, for instance, could never be taken for granted. Even during the last month of operations on the Continent, when every medical unit in the Third U.S. Army had had several months of experience in the field, it was necessary to continue to emphasize basic surgical policies, in order to avoid occasional slip-ups during rush periods.

    One of the best ways to evaluate the care which casualties were receiving in army hospitals was to check the condition of patients ready for evacuation in holding units, as well as at airstrips and at train terminals (fig. 53). From


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FIGURE 53. - A holding unit in the chain of air evacuation. As a rule, these units were operated by medical gas treatment battalions.

them, it was possible to get an overall idea of the type of surgery performed in the hospital units feeding casualties into these points, as well as to spot errors made by particular hospitals or by individual surgeons. When errors were discovered, the hospital responsible was promptly notified, or the individual case was traced back to the surgeon responsible, not to reprimand him but to prevent a recurrence of the error. Errors were remarkably infrequent, and came was generally on a very high level.

    Observation at evacuation points also made it possible for the surgical consultant to keep the army surgeon informed of the condition of patients about to be evacuated to general hospitals in the communications zone. It was soon learned, incidentally, that it was essential to station a surgeon with sound surgical judgment and considerable experience at all holding units and evacuation points if the best interests of the patients were to be served.

    A report to the surgical consultant by Maj. Dudley W. Smith, MC, based on 500 cases collected at the 94th General Hospital from the First, Third, and Ninth U.S. Armies is an excellent summary of the errors which had to be avoided in forward hospitals in the management of wounds of the extremities. The essential errors, all of which attested the paramount importance of adequate initial surgery in the combat zone, were as follows:

    1. Wounds sometimes could not be closed either because they contained dead muscle and damaged fascia which had not been removed at initial debridement or because they had been blocked by heavy petrolatum-impregnated gauze wicks or improper drains.


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    2. Casts were sometimes not completely split, and sheet wadding was occasionally not split at all.
    3. Extremities in which vascular injuries were associated with bone and joint injuries had sometimes not been correctly immobilized during transportation.
    4. In a few instances, all foreign bodies in joints had not been removed
    5. Some patients subjected to amputation were grossly anemic and needed massive transfusions.
    6. The existence of nerve lesions and skin losses was not always noted on the plaster cast or the field record.

    The value of this sort of specific report by a competent forward surgeon (Major Smith was assigned to the 4th Auxiliary Surgical Group and was on detached service with the 94th General hospital) is too obvious to need elaboration. It was certainly one of the best possible ways of identifying errors and having them corrected.

CONCLUSIONS

    The most important lessons in the care of casualties learned in Third U.S. Army hospitals during the campaign in Europe may be summarized as follows:

    1. Early, skilled care of the wounded, as near the front as possible, conclusively proved its worth. Such came can best be provided by proper triage, with diversion of nontransportable casualties to the platoon of a field hospital staffed by trained surgical teams and located in close proximity to the clearing station.
    2.The staffs of evacuation hospitals should also be supplemented by surgical teams to accomplish the rapid treatment of battle casualties and the return of soldiers to duty in the Army area.
    3. Surgical teams were of great value in providing medical support for armored divisions and in bridgeheads across rivers, when prompt evacuation of the wounded was often impossible.
    4. By the use of these methods, it was found that definitive, lifesaving surgery could be accomplished much farther forward than had previously been realized.
    5. Adequate shock therapy is founded upon the use of stored whole blood, with plasma used only as a temporary expedient until blood is available.
    6. If resuscitation is not accomplished promptly and adequately, shock becomes irreversible. Profound shock was apparently the single constant factor in the fatal anuria observed in battle casualties.
    7. Infection can be prevented by early, adequate debridement, supplemented by routine parenteral penicillin therapy. The local use of sulfonamides proved ineffective and often retarded wound healing.
    8. Extreme conservatism should be the rule in respect to amputation, though injuries were often so mutilating that this policy was completely impractical.


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    9. The repair of damaged blood vessels was not feasible as a routine policy in forward hospitals in World War II. It should be practiced, however, in selected cases, with due care not to risk a life in the endeavor to save a limb. At the best, gangrene is likely to develop in about half of all vascular injuries, though the proportion is smaller in the small group of cases in which repair is considered feasible.
    10. The solution of the problem of cold injury is prevention by the provision of proper clothing and footgear and by effective command discipline. Once cold injury had developed, no method of treatment was found really effective.

    The morale of troops is greatly enhanced by the return of wounded men to duty in their own units. This was routine policy in the Third U.S. Army, and one which paid large dividends.