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Chapter XVI - A

Contents

CHAPTER XVI

Fifth U.S. Army

Howard E. Snyder, M.D.

Section I. Administrative and Related Considerations

APPOINTMENT OF THE SURGICAL CONSULTANT

    The appointment of Maj. (later Co1.) Howard E. Snyder, MC, as Consultant in Surgery to the Surgeon, II Corps, and later to the Surgeon, Fifth U.S. Army (fig. 54), initiated the consultant system in field armies in World War II.2 His appointment came about, however, by a series of almost fortuitous circumstances.

Observations in the United Kingdom

    Major Snyder was assigned to the thoracic surgery section of the 77th Evacuation Hospital, the affiliated University of Kansas Medical School unit, which, after completion of its basic training at Fort Leonard Wood, Mo., was sent to England, where it arrived early in August 1942. At the suggestion of Sir Harold Gillies, then head of the plastic surgery services of the EMS (Emergency Medical Service) in England, he requested permission to go to London. to observe the work of Mr. A. Tudor Edwards, who was head of the thoracic surgical services of the EMS. Similar permission was requested for the other members of the thoracic surgery team of the 77th Evacuation Hos-

1 Unless otherwise indicated, data in this chapter were derived from the following sources in addition to the official diary of the consultant in surgery. Fifth U.S. Army : (1) Fifth Army Medical Service History, 1944. (2) Fifth Army Medical Service History, 1945. (3) Starr, Chester G. (ed.): From Salerno to the Alps. A History of the Fifth Army, 1943-1945. Washington: Infantry Journal Press, 1948, and (4) Medicine Under Canvas. A War Journal of the 77th Evacuation Hospital. Kansas City: The Sosland Press, Inc., 1949.
2
Dr. Snyder, a graduate of Jefferson Medical College of Philadelphia, served a rotating internship at the Pennsylvania Hospital and received his surgical training under Dr. John H. Gibbon. Sr. at the same hospital. His training was unusually comprehensive because Dr. Gibbon believed that thoracic surgery, urologic surgery, gynecologic surgery, and traumatic surgery are all part of general surgery. Dr. Snyder's surgical training was completed under his father, an expert general surgeon, who could use a cystoscope as dexterously as a bronchoscope and who, like Dr. Gibbon, believed that general surgery covers a wide range.
    The 77th Evacuation Hospital. the affiliated Reserve hospital unit of the Medical School of the University of Kansas, was organized in the summer of 1940 but was not activated until 10 May 1942. Dr. Snyder was commissioned in the rank of major and was assigned to the thoracic surgery section. He was promoted to lieutenant colonel in July 1944 and to colonel a year later.
    Colonel Snyder is another of the many medical officers whose excellent civilian training and comprehensive experience could be immediately adapted to the responsible duties they were called upon to assume in World War II. In his service, his broad general training peculiarly fitted him for the duties of consultant to the surgeon of a field army. - J. B.C., Jr.


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FIGURE 54. - Maj. Howard E. Snyder, MC, Consultant in Surgery to the Surgeon, Fifth U. S. Army.

pital. One of the members, Capt. (later Maj.) Wendell A. Grosjean, MC, was a general surgeon, and the other, Capt. (later Maj.) Harwin J. Brown, MC, was a well-qualified anesthesiologist.

    It was Mr. Tudor Edwards' idea that this team should spend 10 days with him in London, 4 weeks at the Horton EMS hospital at Epsom, and an additional 4 weeks in some other thoracic surgery center. Arrangements for the tour of duty in these hospitals, however, were slow to be consummated, and the invasion of North Africa was imminent when they were finally concluded. Instead, therefore, of the approximately 10 weeks of observation and training originally proposed, only 8 days could be devoted to this purpose.

    While arrangements for this tour of duty were under way, Major Snyder's time was spent very profitably. He came to know Mr. Ronald Belsey, then head of the thoracic surgery service at the Kewstoke EMS Hospital at Weston-super-Mare, near Frenchay Park, where the 77th Evacuation Hospital was located. Mr. Belsey had completed his training in thoracic surgery under Dr. (later Col.) Edward D. Churchill, at the Massachusetts General Hospital, Boston, Mass., as well as elsewhere in the United States.

    The British at this time were quite short of medical personnel. Anesthesia at the Kewstoke Hospital was in charge of a pediatrician, and Mr. Belsey had no surgical assistants. He was therefore delighted to have a surgeon to help him, and Major Snyder took advantage of every opportunity to work with him. Most of the chest surgery at this hospital was secondary surgery, on old wounds, but a certain amount of fresh work came in irregularly.


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    The tour of chest surgery centers and clinics began with 3 days' observation of Mr. Edwards' work. Part of the time was spent at the Brompton hospital in London and part at the King Edward VII Sanatorium in Midhurst. It was a revelation to a thoracic surgeon who was used to the elaborate setup and teamwork of Jackson, Clerf, and Tucker to observe the performance of bronchoscopies in an operating room which had been set up correctly but in which there were no surgical assistants, no nurses, and no attendants of any kind.

    Major Snyder and his associates next visited the Horton EMS Hospital, where they observed the work of Mr. N. R. Barrett and Mr. W. P. Cleland. Mr. Barrett, in addition to his work at this hospital, frequently served as consultant in thoracic surgery at various hospitals in Wales. The U.S. surgeons watched these surgeons and their associates in the operating room, made rounds with them, studied their preoperative and postoperative care, and attended their conferences. These conferences, at which cases were discussed, roentgenograms shown, and all phases of thoracic surgery covered, were particularly helpful exercises.

    All of the British surgeons were uniformly courteous, hospitable, and generous in the sharing of their experiences. They included, in addition to those already mentioned, Dr. Clifford Hoyle, Mr. C. P. (later Sir Clement) Thomas, Mr. R. C. (later Sir Russell) Brock, and Mr. A. R. Hunter. The anesthesiologists at the hospitals visited, Dr. M. D. Nosworthey and Dr. S. W. Magill, were equally courteous and helpful.

    The information obtained from all of the hospitals visited proved of great value when combat-incurred injuries of the chest were encountered in North Africa a few weeks later. Perhaps the most important 1esson learned was the value of early and repeated aspiration of hemothoraxes without air replacements.

Experiences in North Africa

    Two weeks before the 77th Evacuation hospital sailed for North Africa on 1 November 1942, it was assigned to the II Corps, Central Task Force. Col. Richard T. Arnest, MC, was corps surgeon. and Maj. (later Col.) William H. Amspacher, MC, was his deputy (fig.55).

    The hospital debarked at Mers-el-Kebir on 11 November 1942 (D+3) and immediately took over the civilian and military hospitals at Oran, 12 miles away. As no transportation was available, Oran was necessarily reached by hiking. Chaotic conditions were found at both the civilian and the military hospitals. The patients, including the military casualties, who had been in charge of French interns, had received little medical or other care. It was a rather terrifying introduction to combat surgery.

    On 24 November, the 77th Evacuation Hospital was relieved of its duties in the Oran hospitals and moved into tents (fig.56) in a red clay vineyard about 31 miles south of the city. Here, patients from the immediate area


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FIGURE 55. - II Corps medical officers. A. Col. Richard T. Arnest, MC, Surgeon. B. Lt. Col. William H. Amspacher, MC, Deputy Surgeon.

were treated in ward tents, and boatloads of casualties, chiefly British wounded, were occasionally received from Algiers.

    Since the patient load was not enough to keep the hospital staff occupied, Major Snyder (on the casual suggestion of an Air Force medical officer who had delivered patients to the hospital) requested permission to observe the work of the teams of the 2d Auxiliary Surgical Group which had been attached to the British Eastern Task Force and were then working in the British Cottage Hospital at Algiers. Permission was at once granted, with the understanding that Major Snyder's observations would be reported on his return. This was done (p. 369).

    On 20 January 1943, the 77th Evacuation Hospital was moved to an area south of Tebessa, Algeria. On 14 February, it was alerted to receive casualties from the breakthrough at Kasserine Pass, and within 48 hours it had treated 150. The tactical situation then required the removal of the hospital to the rear. The move was completed in snow and freezing temperatures during the night, and by dawn 480 additional patients had been received.

Appointment as Surgical Consultant, II Corps

    On 15 March 1943, Major Snyder reported on temporary duty to II Corps headquarters near Tebessa with instructions to evaluate the use of surgical teams in clearing stations. For this purpose, he traveled with Colonel


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FIGURE 56. - Operating room, 77th Evacuation Hospital, North Africa.

Amspacher to various corps and other installations and also spent 6 days at a clearing station staffed by the 1st Platoon, Company D, 51st Medical Battalion, whose intrinsic personnel was augmented by two general surgical teams and one shock team from the 2d Auxiliary Surgical Group. Various recommendations were made as a result of this tour of duty (p. 369)

    Shortly afterward, Col. Edward D. Churchill, MC, Consultant in Surgery in the Office of the Surgeon, NATOUSA. (North African Theater of Operations, U.S. Army) , suggested to Colonel Arnest, the Corps surgeon, that Major Snyder be retained at Corps headquarters in the capacity of surgical consultant.


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Colonel Arnest at first hesitated to act on the suggestion because the headquarters table of organization had no provision for such a position. Eventually, however, Colonel Arnest appointed Major Snyder as his ptofessiona1 service officer, though his duties were confined to surgery.

    Major Snyder remained with 11 Corps headquarters, though he was not formally assigned to it until just before the invasion of Sicily on 10 July 1943. He went ashore with the invading troops on D-day, at H+3.

Appointment as Surgical Consultant, Fifth U.S. Army

    The Sicilian campaign ended on 17 August 1943. On 20 September, Major Snyder received orders for temporary duty in the Office of the Surgeon, NATOUSA, in Algiers. On his arrival, he was informed that Brig. Gen. Frederick A. Blessé, Surgeon, NATOUSA, was then in Italy with Col. (later Maj. Gen.) Joseph I. Martin, MC, Surgeon, Fifth U.S. Army, and that it was General Blessé's intention, on Colonel Churchill's suggestion, to ask Colonel Martin whether he would like to have Major Snyder as surgical consultant for the Fifth U.S. Army.

    On his return to Algiers on 5 October 1943, General Blessé reported that Colonel Martin had willingly acceded to Colonel Churchill's suggestion. Major Snyder was ordered to return to Sicily and join II Corps headquarters, which was then preparing to move to Italy. After overcoming a variety of transportation and other difficulties, he finally reached Fifth U.S. Army headquarters in Naples on 11 October 1943. Until 19 November, while still assigned to II Corps headquarters, he acted as consultant in surgery to the Fifth U.S. Army. On this date, his permanent orders were received, he continued to serve in this position until 1 October 1945, when Fifth U.S. Army headquarters disembarked at Boston (fig.57).

    As this account indicates, Major Snyder's appointment as consultant in surgery, Fifth U.S. Army, developed by a series of chance circumstances. His appointment was the prototype of the consultant system in all U.S. armies in World War II.

TACTICAL CONSIDERATIONS

Sicily

    Major Snyder, who had been assigned to the II Coups as surgical consultant (p.337) shortly before the invasion of Sicily, landed in Sicily on D-day (10 July 1943) at H+3, with the 261st Amphibious Medical Battalion. He was in the first group to go ashore from the U.S.S. Samuel Chase, on which this unit, with its headquarters, had been transported. For some reason, never clear, the headquarters of the unit was landed 4 hours ahead of any of its three companies.

    The first casualties on D-day were handled by the Navy, in beach stations set up in each of the six landing areas. The stations were set up promptly, and


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FIGURE 57. - Lt. Gen.. Lucian K. Truscott, Jr., Commanding General, Fifth U.S. Army, congratulating Lt. Col. Howard E. Snyder, MC, Consultant in Surgery, Fifth U. S. Army, after awarding him the Legion of Merit for exceptionally meritorious service in the performance of his duties.

their personnel did excellent work in instituting first aid measures and then evacuating the casualties to ships offshore.

    Company C of the 261st Amphibious Medical Battalion landed, as planned, on D-day at H+7, but without its equipment. It set up a station with the equipment of Company B, whose personnel were not landed until the afternoon of the next day. A number of other units experienced similar difficulties in the landing of equipment without personnel or vice versa, but evacuation of casualties (fig.58) to the beaches and thence to the boats proceeded with remarkably little confusion.

    On D + 2, the APA's (transports, attack) and XAPA's (experimental APA's) finished unloading and left the beach. Thereafter, all casualties in this area received initial care either in the clearing station of the 51st Medical Battalion with surgical teams attached or in Company A of the 261st Amphibious Medical Battalion, both of which were corps units.

    On D+3, two platoons of the 11th Field hospital began to receive and hold casualties, and the 93d Evacuation Hospital began to function on D+6. The 15th Evacuation Hospital had been landed on D+4, but its equipment did not begin to arrive until 2 days later, and it was D+10 before all of it was received.


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FIGURE 58. - Evacuation of wounded from Sicily. A. Loading of wounded on landing craft. B. Wounded aboard landing craft.

    After D+3, the medical service problem was to provide support for troops which were pursuing a retreating enemy. The solution of the problem was the use of platoons of field hospitals set up in close support of division clearing stations and augmented by varying numbers of teams from the 2d Auxiliary Surgical Group.

    Triage at the division clearing stations was excellent, as the small proportion of the total casualties admitted to field hospitals reflected; all were severely


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wounded. Surgical care in the platoons of the field hospitals was prompt and excellent. When the division clearing station moved forward, the field hospital platoon beside it was closed to admissions and served as a holding hospital for postoperative cases, while another platoon came forward and set up alongside of the division clearing station. As a result of these arrangements, the medical care supplied was, Up to that time, the best in the theater. The nontransportable casualties of the II Corps received initial wound surgery within 8 to 12 miles of the frontlines.

    Excellent surgical care was also provided for transportable casualties at evacuation hospitals. The 400-bed semimobile evacuation hospital proved to be a satisfactory and practical unit. One reason was that hospitals of this size could be moved rapidly into new locations, a policy which proved necessary at frequent intervals during the fighting in Sicily.

Italy

    The Sicilian campaign ended with the fall of Messina, Sicily, on 17 August 1943. On 3 September, the British Eighth Army landed on the toe of the Italian Peninsula, and 6 days later, on 9 September. the Fifth U.S. Army landed at Salerno, south of Naples (fig. 59). Italy surrendered the same day.  Naples fell to the Allied armies on 1 October, and 12 days later, on 13 October, Italy declared war on Germany. The Germans were slowly pushed up the Peninsula until 3 February 1944, when they forced the Allies to a standstill at Cassino, on the Gustav Line.

    Meantime, on 22 January 1943, elements of the Fifth U.S. Army and other Allied troops had made a landing at Anzio, south of Rome, with the expectation that union with the other Allied forces in the south would occur in about a week. It did not occur until 25 May, more than 4 months after the invasion (p. 410). Rome fell on 4 June 1944, 2 days before the invasion of Normandy.

    All through the early summer of 1944, the Fifth U.S. Army pursued the fleeing German troops. The medical problems of the first months in Italy, which had been the care of casualties while new hospitals were being acquired and inexperienced medical officers were being trained, were now exchanged for the problem of keeping hospitals near enough to the front to receive and care for the wounded.

    Concentration on the events in the European theater often clouded the realization that fighting was also extremely heavy in Italy. German resistance became increasingly strong as the summer of 1944 advanced. As an illustration, Rosignano, a small town on the road to Leghorn, was reached on 4 July. The southern third of the town was occupied on that date, but the northern edge was not reached until the evening of 7 July. Even then, the enemy held houses on the outskirts of the town and in the country immediately behind it. Leghorn fell to the Allies 18 July. The last 20 miles of the advance to the Arno were extremely difficult and there were numerous hard-fought engage-


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FIGURE 59. - Campaigns in Italy, 9 September 1943-8 May 1945.

ments because the Germans were trying to delay the Allied advance until their fixed defenses on the Gothic Line were completed. This line was to prove even harder to breach than the Gustav Line, which had held the Fifth U.S. Army below Cassino so many weeks during the first winter of the fighting in Italy.

    After Fifth U.S. Army troops and their supporting medical installations had been withdrawn for the invasion of southern France (p.396), the army in Italy underwent considerable regrouping before the North Apennines Campaign was launched on 10 September 1944. The drive to the north came to a halt with the heavy rains in late October (fig. 60). Enemy resistance increased,


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FIGURE 60 - Evacuation hospital in Italy during the wet season in the fall of 1944.

and supply routes were so clogged with mud that they were almost impassable. The advance was not resumed until the middle of April the following year. When it was stopped, the forward troops could see their objectives; Bologna was barely 9 air miles away in the center, and the Po Valley was only 4 miles away on the right flank.

    Winterizing of hospital installations was delayed because, on a number of occasions after the drive to the north came to a halt, it was thought that another attack was to be launched. On at least one occasion, Christmas Eve, hospital units were informed that the drive would start that night, but a few hours later word was received by courier that it had again been postponed. Shortly afterward, the Surgeon, Fifth U.S. Army, received permission to provide wooden floors for the hospitals, install enough potbellied stoves to keep the wards reasonably warm, and undertake such other winterizing as was possible.

    Even thought there was no active offensive during the winter of 1944-45, the situation was never entirely static. Early in February 1945, for instance, the 92d Division successfully completed a brief assault to consolidate its position and secure several dominating hills. At about the same time, the 10th Mountain Division captured the bitterly contested Monte Belvedere (fig. 61), and in the first week of March, in another limited offensive, the same division gained 8 miles.

    These and other actions, even in the absence of a large-scale offensive, produced temporarily heavy casualty loads for Fifth U.S. Army hospitals, in


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FIGURE 61. - Evacuation of wounded by aidmen of 10th Mountain Division during Monte Belvedere offensive. A. Vertical evacuation down side of cliff and by so-called Tyrolean traverse. B. Litter bearers working along crest of mountain.


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addition to the usual flow of casualties, which was small but continuous. The 8th Evacuation Hospital, which had been set up at Pitramala and had been thoroughly winterized, received the largest. numbers during the first 3 months of 1945.

    During the winter months of 1944-45, it was the policy to move casualties with severe injuries directly from the installations at which they had received initial wound surgery, whether field or evacuation hospitals, to either the 24th General Hospital in Florence or the 70thGeneral Hospital in Pistoia. Casualties with less serious injuries were evacuated to base hospitals in Leghorn and Rome.

    The campaign for the Po Valley, the last campaign of the war in Italy, began on 14 April 1945. Bologna was captured on 21 April, and on 2 May German troops in Italy, with those in southern Austria, surrendered unconditionally to Allied forces.

    Medical planning. - Medical planning was progressively better in each campaign in Italy, and the planning for the terminal campaign resulted in better medical support for the troops than they had ever before received. This excellent record was achieved in spite of two difficulties, as follows:

    1. The casualty load was greatly increased. The medical service, though it had never received adequate increments to replace the trained personnel which it had been obliged to surrender for the invasion of southern France (p.396), had to came for Brazilian and Italian troops as well as troops of the Fifth U.S. Army.
    2. Frequent moves were necessary during the last weeks of the fighting, to keep up with the advancing Allied forces. All units, including medical units, were ordered to reduce their equipment to the barest essentials and to employ any improvisation which might increase their mobility.

    Colonel Snyder's participation in the planning for the final campaign was more intimate than in any previous campaign. He had access to all tactical plans, he was consulted on all points which involved medical planning, and his advice was accepted concerning the placing of field hospital platoons and other administrative matters, as well as concerning the staffing of the medical units to be committed.

The Anzio Beachhead

    For a variety of reasons, the most serious medical problems encountered in Italy were met on the Anzio beachhead (Operation SHINGLE).3 The operation was planned to weaken the German Gustav Line, which was holding the Fifth U.S. Army forces in check at Cassino. It developed into a holding operation against a numerically superior enemy, the outcome of which, on at least half a dozen occasions, was decidedly in doubt.

    Special medical planning was necessary for the Anzio invasion because shore-to-ship evacuation of casualties would require closer and longer coopera-

3 Bauchspies, R. L.: The Courageous Medics of Anzio. Mil. Med. 122: 53-65, 1l9-128, 197-207, 267-272, 338-359, and 429-448. January-June l958.


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tion between the Army and the Navy than had previously been necessary. The basis of the planning, which was well rehearsed in advance, was the orderly return of casualties to the beaches and their transfer thence to ships. It was due to General Martin's foresight and careful planning that the medical operation, in spite of all time difficulties which attended it, continued to be efficient throughout.

    Landings. - The initial stages of the landings went off remarkably well. The landing, which was apparently a complete surprise to the enemy, was effected without resistance, and by noon of D-day the VI Corps had reached its preliminary objectives ashore. Medical units were put ashore many hours ahead of the estimated times, with ample supplies (p. 394). The 2d platoon of the 33d Field Hospital was landed at H+6, with attached surgical and shock teams from the 2d Auxiliary Surgical Group. The 1st and 3d Platoons of this hospital were in the bay but were not landed until D+1 because they were not needed earlier. Casualties were less than 1 percent of the troops committed in the landings, instead of the estimated 12 percent.

    The campaign. - These satisfactory conditions continued for only about 48 hours. Then the tactical situation worsened, and the medical situation along with it. The light bombing raids on D-day increased in intensity and thereafter were a permanent part of the picture. Hospital ships were bombed in the bay, and one of them, with 75 patients on board, was sunk. By 1 February, no area was safe from enemy planes. Practically continuous bombing and strafing of the beachhead area were punctuated by heavy attacks at intervals.

    The original locations of the hospitals which had landed on the beachhead promptly became untenable. They were re-located in open terrain, as far as possible from military objectives, but the best this could be was not very far, for the beachhead was only about 7 miles in depth. There were no functional distinctions between field and evacuation hospitals. Both were practically on the frontline. There was no protection in depth from enemy fire. Antiaircraft batteries, ammunition dumps, an airfield, and other military installations were of necessity located on the edge of the medical areas.

    Since enemy fire could reach every part of the beachhead, casualties were heavy. The 95th Evacuation Hospital was practically destroyed by bombing early in February, and the 37d Field Hospital was also heavily shelled. There were heavy casualties after both incidents. In addition to the wounded, 4 nurses, including the chief nurse and her assistant, 2 medical officers, and 16 enlisted men of the hospital complement were killed at the evacuation hospital, and 2 nurses and an enlisted technician were killed at, the field hospital. It is doubtful that the medical installations on the beachhead were deliberately bombed. They were clearly marked, as prescribed by the Geneva Convention, but it was practically impossible to separate them from legitimate military targets. The bombing of the 95th Evacuation Hospital was definitely accidental. The pilot of the German plane jettisoned his bombs when he was try-


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big to escape British Spitfires. The plane was shot down, but the pilot escaped by parachute and was captured on the beachhead.

    Personnel on the beachhead lived in a world of unpredictable violence, in which medical personnel shared. Most of the damage and casualties were caused by air raids and artillery fire, but on one occasion, in February, German tanks almost broke through to the hospital area. It. was not unusual for patients to have to be evacuated from one hospital to another, sometimes with attendants continuing transfusions en route, one holding the bottle while another steadied the needle.

    Had it not been for the 700-year-old wine caves on the beachhead, which served for billets, headquarters, and other purposes, casualties would undoubtedly have been much heavier. In March, after the soil had begun to dry out from the incessant rains of the winter, the medical services went underground (fig.62). Excavations were prepared to a depth of 3 1/2 feet, with revetments around them, and sandbag baffles were placed around double ward tents. Sheet metal was placed over pyramidal tents and covered with sandbags. Patients, nurses, and medical personnel on the wards were thus fairly well protected.

    Operating rooms were similarly constructed and protected. This was most important. Previously, when an air raid warning had sounded while an operation was in progress, the personnel engaged in it had had no choice but to continue with what they were doing. With the protective measures now taken, only direct hits need be feared.

    Evacuation. - From the beginning of the Anzio operation, an attempt was made to care for all casualties before they were evacuated by LCT's (landing craft, tanks) and boat ambulances to hospital ships. If recovery was expected within 14 days or less, the wounded were kept in evacuation hospitals on the beachhead. If it was believed that it would take longer, both soldiers and any of the remaining civilians who had been wounded or who were ill were evacuated to the Naples area as soon as they could be moved. As many effectives as possible had to be retained, and experienced combat soldiers were never evacuated unless there was no other course. Slightly wounded and sick were evacuated because the bed space had to be saved for the wounded who needed it more. Eventually, a 200-bed hospital was set up on the beachhead for the diagnosis and treatment of venereal disease, and a 400-bed holding hospital was also set up to take the pressure off the field and evacuation hospitals. These two plans made it possible to retain on the beachhead many thousands who otherwise would have had to be evacuated.

    In the opinion of surgeons on the beachhead, casualties were often evacuated to the base earlier than was desirable. On the other hand, when Colonel Churchill visited the hospitals of the beachhead on 2 June 1944, in the course of the breakout, he expressed the opinion that casualties were being held too long. Air transportation had begun only a week before, on 26 May.


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FIGURE 62. - Tents of 50th Evacuation Hospital being dug in on Anzio beachhead, April 1944. A. Construction of side walls for tent B. Erection of tent.


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    Occasionally, when the casualty load was unusually heavy on the beachhead, men who were transportable were evacuated to base hospitals in the Naples area for initial wound surgery, which they thus received earlier than they would have if they had been kept at Anzio.

    Workload. - The routine at the 33d Field Hospital was typical of the demands on a frontline installation at the Anzio beachhead. Four operating tables functioned almost continuously. The six surgical teams attached to the hospital from the 2d Auxiliary Surgical Group were divided into three groups of two teams each. Each group was on first call for 12 hours, on second call for another 12 hours, and off duty for a third 12-hour period.

    When casualties once reached a hospital, the timelag was seldom more than that necessary for resuscitation, thanks to careful planning and supervision. At one time, for instance, the 56th Evacuation Hospital had a backlog of 150 cases, which was heavier than the workload of any other hospital, though all were busy. As soon as the other hospitals had cleared up their smaller backlogs, 75 patients were transferred from the 56th Evacuation Hospital and distributed among them, thus equalizing the timelag. Later, it was found necessary to enlarge this hospital, so that it had eight operating tables and three tents for preoperative preparation.

    Wounds were not the only medical problem on the beachhead. There was a high incidence of trenchfoot (p. 431). Casualties from malaria were also high. Malaria was endemic in the Anzio-Nettuno area, which was part of the Pontine Marshes, and it was estimated that at least one in every 20 of the civilians (most of whom had been evacuated to Naples by Allied Military Government) had chronic malaria. Malaria was also present in U.S. Army troops who had been in North Africa and Sicily and in Italy below Rome. An aggressive antimalarial program, including the administration of quinacrine hydrochloride (Atabrine) and an all-out sanitation attack, helped to bring this disease under control.

    Random statistics from the Anzio beachhead indicate the amount of surgery required there. Between 30 January and 22 February 1944, the 56th Evacuation Hospital admitted 5,345 patients and operated on 3,663. The 93d Evacuation Hospital, which was heavily bombed during the same period, averaged just over 44 operations per day, the number ranging from 4 on one day to 111 on another. During the final offensive, hospitals on the beachhead received 1,400 casualties during the first 24 hours and 800 during the second. Figures for the period 12-16 May (table 5) are typical of the number of operations performed in hospitals during this final phase.

    Between 22 January and 22 May 1944, U.S. Army hospitals on the Anzio beachhead handled 33,128 casualties from all causes, and between 23 May and 5 June they handled 15,200. The figures for British hospitals for the same period are, respectively, 14,700 and 2,196. In all, 47,193 persons were evacuated from Anzio during the course of the operation. Capt. Eugene F. Haverty, MC, evacuation officer from the Office of the Surgeon, Fifth


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TABLE 5. - Operations performed in hospitals on Anzio beachhead during the final phase, 12-16May 1944

U.S. Army, was killed by a shell while supervising the loading of casualties on an LST (landing ship, tank). Otherwise, there was no loss of life among casualties or medical personnel in the course of the evacuation.

Weather

    The weather in Italy added immaterially to the difficulties of medical care in a combat area. During the summer months, it was extremely hot. During the fall and winter of 1943-44, there was almost unbroken cold, rainy weather, which complicated the evacuation of casualties in mountain warfare and also resulted in a serious outbreak of trenchfoot. During the succeeding winter, the weather was much the same, but fighting was generally less intensive. The 8th and 94th Evacuation Hospitals, however, as well as several field hospital units, operated in the mountains in snow for several months. The temperature went below freezing in November, and thawing did not begin until after the middle of February.

    Some hospitals also suffered catastrophic damage as the result of weather. Early in November 1944, the Arno River broke over its retaining wall and inundated the area of the 38th Evacuation Hospital, then set up near Pisa. Almost 500 patients and the attendant medical personnel had to be moved to a building 300 yards away, which housed the advance platoon of the l2th Medical Depot. The water, which ultimately reached a height of 6 feet in some areas, was almost 4 feet high before the last patient had been moved. A great deal of equipment was lost, including part of the surgical consultant's personal instruments for chest surgery.

    In December 1944, after most of the hospitals had completed their winterizing, which had been delayed in the belief that an offensive would be launched, heavy rains and high winds from the central Apennines nullified much of the work already done. At the 8th Evacuation hospital, then set up near Pitramala, 8 ward tents were blown down, and 40 patients recently operated on had to be transferred to the 15th Evacuation Hospital. Later


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in the day, when additional tentage was uprooted, all the other patients in the hospital were evacuated as a precautionary measure.

    In Italy, tents were frequently set up in the form of a cross or side by sidle, to simplify lighting and heating and reduce exposure of personnel. This plan also lessened the chances of the tents' being uprooted and blown over.

FUNCTIONS OF AN ARMY CONSULTANT

    The duties and responsibilities of the consultant in surgery, Fifth U.S. Army, were, in general, those of all army consultants. His basic function was to assist the army surgeon in providing care of the highest quality for wounded men and for all others who for any reason required surgical care in the combat zone. His functions were peculiar to this army only in the sense that they were evolutionary.

    Although Major Snyder's duties varied according to the special phase of combat, they were, in general, as follows:

    1. He evaluated for the army surgeon and his executive officer the professional capabilities of all surgical personnel (p.353). This frequently required the recommendation of transfers of personnel from unit to unit, to channel off excesses of surgical talent in some organizations and to improve the level of performance in other, weaker organizations.
    2. In cooperation with the theater consultant in surgery, he directed the educational programs by which medical officers, fresh from civilian life, became acquainted with the requirements of military surgery, he also occupied himself with modifications of planning and techniques by which errors could be corrected and the level of surgical performance elevated.
    3. He served, in effect, as a channel of surgical information between the various installations in the army area. This made possible the rapid transmission of suggest ions, techniques, improvisations, and other useful ideas which otherwise would have been disseminated slowly or perhaps might have been lost entirely.
    4. He worked in close liaison with the corps surgeons who directed the movement and operations of field hospital units set up adjacent to division clearing stations. In particular, he recommended the assignment of teams from auxiliary surgical groups to these units.
    5. He endeavored to improve the performance of individual evacuation hospitals in special aspects of surgery by attaching to them, according to their needs, highly trained surgical teams to assist and train organic personnel.
    6. He assisted in the planning of the surgical component in the support of combat operations, Working in close cooperation with the chief of the operations section in the army surgeon's office. This cooperation was fullest, and therefore most fruitful, in the later phases of the fighting in Italy.
    7. He advised the army surgeon on such matters as triage, evacuation, the nature and limitations of the surgery to be performed in the various echelons


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of medical care, and the holding period after operation in field and evacuation hospitals.

    8. He made regular tours of inspection of medical installations in the army area, advising and assisting the staff as necessary. On his return from these tours, he reported his observations to the army surgeon and to the consultant in surgery to the theater surgeon, evaluating the qualifications of each hospital staff and the total hospital performance.
    9. On these tours, he saw seriously ill patients in consultation or examined other patients in the hospital on request. Also, in compliance with a number of suggestions made to him to this effect, he demonstrated the techniques of forward surgery in newly arrived hospitals. In other hospitals, when the patient load was heavy during rush periods, as frequently happened on the Anzio beachhead, for instance, he took his turn at the operating table with the hospital staff.
    10. He advised the army surgeon and his medical supply officer on all matters of surgical equipment (p.391) and also advised the installations he visited on the most efficient use of their equipment.
    11. He analyzed clinical records and post mortem reports on all battle casualties who died in army hospitals (p. 399), in order to weigh the relative merits of various surgical procedures and to evaluate the correctness of the therapy employed in the individual fatalities. These observations led to recommendations for changes in policies and techniques as well as to other recommendations.

    Major Snyder also performed a number of other duties not particularly related to his position as consultant in surgery, Fifth U.S. Army, but arising in the course of the war. One of these duties was to serve on a general court martial. Another, the most painful task he had to perform during his entire military service, was to serve as medical officer at the hanging of four rapists in Sicily and to pronounce these men dead.

    It was most important, in the performance of his numerous duties, that Major Snyder immediately establish frank, correct relations with the staffs of the Fifth U.S. Army hospitals. Early in his experience, he encountered a considerable amount of suspicion of both his functions and his motives; some of it was covert, but some of it was quite openly expressed. This attitude was almost inevitable as already pointed out, this was an entirely new assignment, and there was no past experience to serve as a point of reference. Once the proper relations were established, however, and the potential usefulness of the consultant system was realized, Major Snyder was always received with great cordiality, and his visits were utilized to the fullest.

    From the beginning of his assignment, Major Snyder spent most of his time in the field, sleeping at Headquarters, Fifth U.S. Army, no oftener than once or twice a week. Periods spent in individual hospitals varied from a few hours to several days, depending upon their location, their special needs, and the tactical situation. Both the number and the duration of his visits were chiefly determined by the workload. His repeated visits to Anzio, for instance, were


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required by the continuing seriousness of the tactical situation, which kept all the hospitals in the area taxed far beyond their normal capacity.

    In March 1944, when Major Snyder was provided with his own transportation and a driver, he was able to increase the number of hospitals visited because he was no longer dependent on others for his movements.

EVALUATION AND ASSIGNMENT OF PERSONNEL

    The questionnaires, which all medical officers completed, provided a reasonably adequate record of the officers' medical training and civilian experience. These records were kept up to date in the army surgeon's office. The information which they contained was available to the commanding officers of hospitals, and assignments could be made in the light of recorded professional qualifications.

    It was a fairly common experience that paper qualifications, however fairly they might be recorded, were not always matched by performance in the field and under stress. It was not possible to judge the potential of any medical officer until he had met such tests. Evaluation of the capacity of individual surgeons, as distinguished from their training and experience, required observation of their work. Their correct assignment was based upon these observations, and this function therefore came to be one of the most important duties which the surgical consultant for the Army had to perform.

    Major Snyder spent considerable time at this task, but, because of the large number of hospitals in the Fifth U.S. Army area, he could not always undertake it himself and had to rely upon the estimates of the chiefs of surgery in the hospitals. To accept their evaluations, however, it was necessary that they first be evaluated themselves. Their judgment of others depended upon their own training, experience, ability, and potentialities.

    It was extremely important that the chief of surgery in any forward hospital be an officer of special competence in surgery; that he be levelheaded under stress; and that he possess the administrative ability to organize and direct the work of the surgical section. Previous experience with forward surgery in North Africa and Sicily was a most valuable qualification for officers who served in these positions in the Fifth U.S. Army. Most of them were extremely capable men, who rendered outstanding service both professionally and administratively. A small number were not competent and had to be replaced.

    The evaluation of the surgeons in the surgical and shock teams of the auxiliary surgical groups was another function of great importance. These teams served in field hospitals (p. 385), which took care of urgent, first priority surgery, and it was essential that highly competent surgeons be assigned to them. Here, also, paper qualifications did not always prove an infallible index of ability, though these teams had an unusually high proportion of surgeons with special ability and training.


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FIGURE 63. - Col. Edward D. Churchill, MC, Consultant in Surgery to the Surgeon, NATOUSA, Col. Frank B. Berry, MC, Consultant in Surgery to the Sturgeon, Seventh U.S. Army, Col. James H. Forsee, MC, Commanding Officer, 2d Auxiliary Surgical Group, and Lt. Col. Howard E. Snyder, MC, Consultant in Surgery to the Surgeon, Fifth U.S. Army.

    Whenever possible, all newly arrived surgeons worked first in evacuation hospitals, where their work could be supervised and evaluated before they were assigned to the hospitals still farther forward, in which special qualifications and initiative were required.

    Once the surgical personnel of any unit had been evaluated, conferences or recommendations for transfers were held with Colonel Churchill (fig. 63), and the army surgeon and his personnel officer were then advised of the results of the hospital inspection, with particular reference to deficiencies which required correction.

    There were two ways of correcting these deficiencies. Whenever possible, weak personnel were replaced by properly qualified personnel, while the less qualified officers were transferred to units in which they could work under supervision. It was surprising how often such supervised training converted initially weak personnel into entirely reliable surgeons. If immediate changes in assignment were not possible, weakness in a hospital unit was overcome by augmenting the organic staff with surgical teams from an auxiliary surgical group or with surgeons on temporary duty from other hospitals. If the hospital deficiency was in one or another of the specialties, it could often be corrected by the temporary assignment to the hospital of thoracic, orthopedic, and maxillofacial surgeons and neurosurgeons from auxiliary surgical groups.


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    In December 1944, arrangements were made in the Office of the Surgeon, Peninsular Base Section, to send teams from evacuation hospitals to base hospitals for 6 weeks' temporary duty, while similar teams from base hospitals served for the same length of time in forward units. This policy, which proved very profitable, was continued until the heavy fighting during the breakout into the Po Valley in April 1945 made it impractical.

    Nurses and enlisted personnel. - In August 1944, before the invasion of southern France, there were 14 medical units in the Fifth U.S. Army area to which nurses were assigned. Of the 14 units, 4 were field hospitals, with 18 nurses each; 5 were 400-bed evacuation hospitals, with 40 nurses each; 4 were 750-bed evacuation hospitals, with 53 nurses each; and 1 was the 2d Auxiliary Surgical Group, with 65 nurses.

    Nurses were always in short supply, and the nursing care of first priority casualties after surgery was a continuing problem. When the patient census in a field hospital platoon exceeded 20, as it frequently did, the 6 nurses provided for by the table of organization could not handle the load. The deficiency was usually met by sending forward nurses from evacuation or base section hospitals to augment field hospital personnel during the rush periods.

    The nurses of the Fifth U.S. Army rendered superb service and contributed incalculably to the morale of the troops. This was particularly true at the Anzio beachhead (fig.64), where six nurses were killed and a number of others were wounded.

    Enlisted men who helped to care for the wounded in all capacities, from the battlefield to the rear of the Fifth U.S. Army area, are deserving of the same high praise. There were many casualties among them and many instances of almost incredible bravery and devotion to duty. Pfc. Lloyd C. Hawks, Medical Detachment, 30th Infantry Regiment, was awarded the Congressional Medal of Honor for devotion beyond the call of duty at Anzio.

    Rank. - The numerous contacts necessary between medical officers of the Fifth U.S. Army and the British medical officers serving in the same command were often complicated by embarrassing discrepancies in rank. Throughout the war, at medical conferences as well as at conferences between officers in all other branches, the British were usually represented by officers who outranked U.S. Army officers by at least one rank and often more. The counterpart of Col. (later Maj. Gen.) Joseph I. Martin, MC, Surgeon, Fifth U.S. Army, for instance, was the Surgeon of the British Eighth Army, who was a major general.

    These discrepancies often made for embarrassment if not actual difficulties. The explanation of the higher British rank was frequently inherent in their system. In the British Army, an officer, on being assigned to a task which called for a certain rank, was given that rank temporarily if he did not already


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FIGURE 64. - Nurses on Anzio beachhead. A. Nurses digging foxholes. B. Nurses loading sandbags around their tent.


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possess it. When the task was finished, he reverted to his original and permanent rank.

EDUCATIONAL ACTIVITIES

    Many of the surgical techniques of previous wars have become obsolete at the outbreak of another war. More important, the lessons of past wars are readily forgotten, if indeed they are ever fully learned. Finally, while there is always a progressive evolutionary improvement in surgical techniques between wars, some of these techniques are not applicable to combat surgery, and others are applicable only after they have been modified.

    Mistakes, therefore, are almost inevitable in the management of the wounded in the first days of any war. New methods of merit develop rapidly, it is true, but they are learned and applied only if deliberate efforts are made to educate newly inducted medical officers into the principles of wartime surgery; to teach them the modifications of peacetime methods which wartime requires; and also to teach them that the techniques of peacetime, however admirable they may be, usually cannot be applied wholesale to military surgery.

    There were two reasons for the confusion in the management of combat-incurred injuries which occurred in the early days of the North African fighting. The first was that the lessons of World War I, explicitly set forth in the official history of the Medical Department, had to be relearned. Only a few medical officers in the North African theater even knew of the existence of these very useful volumes, and even fewer knew what they contained.

    The second reason was that there were almost no medical officers in the North African theater who were familiar with the lessons the British had learned during the 3 years in which they had been in the war and in which they had had an extensive experience in Africa. It might be sound policy between wars to send consultants and other medical observers to foreign countries, to study their medico-military techniques. Certainly, it should be the practice, whenever friendly countries permit it, to send observers to conflicts in which the United States is not participating. Finally, once the United States enters a war, every effort should be made to capitalize on the previous experience of her allies.

    These principles were not put into practice in World War II. It has already been pointed out that when Major Snyder's hospital was in England in 1942, before it was ordered to North Africa, his endeavors to capitalize on the British wartime experiences in chest surgery were successful only after a long delay, and in the end the time thus spent was only a fraction of what originally had been planned (p. 334).

    The experience in other theaters was the same as in the North African theater, and for these reasons the educational activities of a consultant in surgery to a field army were always extremely important.


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Methods

    The educational program for surgery in the Fifth U.S. Army was, in both its formal and informal aspects, primarily the responsibility of the army surgical consultant. It was the consultant's duty so to plan and implement this program as to insure the accomplishment of three objectives, as follows:

    1. Rapid dissemination of knowledge of medico-military methods among medical personnel already within the Fifth U.S. Army area.
    2. Rapid education of newly arrived units in the principles and techniques of combat surgery.
    3. Transmission of reports of accumulating medico-military experience through channels (the Surgeon, Fifth U.S. Army, to the theater surgeon), so that surgeons in general hospitals in the base section might know the problems encountered in the army area.

These objectives were accomplished in the following ways:

    1. Both informal and formal meetings were held (p. 362). The presentation of special problems and new techniques at these meetings and, even more, the free and uninhibited discussions which followed these presentations proved an invaluable as well as extremely interesting means of instruction.
    2. The surgical consultant visited all installations in the army area as often as possible. Personal contacts with individual surgeons in field and evacuation hospitals as well as in battalion aid stations, clearing stations, and collecting stations materially reduced what might be termed the educational timelag. Conferences with small groups and sometimes with the entire surgical staff permitted the exchange of ideas, the suggestion of changes, and the tactful correction of errors.

    If all the surgeons on the staff could not be seen personally, conferences with the chief of surgery and ward rounds with him and his associates provided opportunities for the evaluation of the work being done and the care the patients were receiving. These rounds also furnished opportunities for informal consultation on difficult and obscure cases. Observation of work in operating tents could be followed by appropriate suggestions to the chiefs of service or to individual surgeons, as the opportunity presented.

    All of these plans permitted effective teaching which was, perhaps, the more valuable because it was both practical and unobtrusive.

    3. Conferences with individual surgeons in divisional medical services served to keep the consultant informed of the problems which arose in the division area and promoted better management in all echelons because of the ensuing discussions and the decisions reached at them. These decisions were rapidly conveyed to all the medical installations in the Fifth U.S. Army area. Medical officers of line divisions were encouraged to visit hospitals and other medical installations in the rear, on the ground that an understanding of the needs and problems of all echelons by all echelons made for better care of the wounded in every echelon.


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    4. The policy of keeping surgeons in forward installations informed of the condition of their patients as they were received in installations farther to the rear proved unexpectedly useful from the teaching standpoint and also provided a competitive stimulus. As noted elsewhere (p.373), this policy was not devoted only to the report and correction of errors. Quite as much attention was devoted to outstandingly good results achieved by special techniques of management.
    5. Major Snyder frequently demonstrated the techniques of combat surgery to newly arrived units without previous medico-military experience. Early in the war, this proved a rapid and useful method of teaching and one which was frequently requested, particularly in thoracic and thoraco-abdominal injuries. As the war progressed, this sort of teaching became unnecessary, because there had come into existence a sound nucleus of qualified surgeons capable of doing surgery on every kind of combat-incurred wound and doing it well. Major Snyder continued, however, to assist during rush periods, as on his numerous visits to the Anzio beachhead (p. 410).
    6. Before any division was sent into combat, a meeting was held with all its medical officers. The discussions particularly concerned the special medical necessities of the offensive about to be undertaken, any new methods to be employed, and the errors to be avoided. During rest periods, meetings with the same personnel permitted critiques of the medical performance in the offensive just concluded.
    7. When a hospital was found to be weak in a particular department, such as thoracic surgery or orthopedic surgery, standards could be elevated and care of the wounded improved by placing a qualified team from an auxiliary surgical group in the hospital for a sufficient period of time to permit training of the assigned personnel in that specialty.
    8. Contacts between forward and base surgeons proved to be highly educational. Arrangements were therefore made, as circumstances permitted, for officers in base hospitals to go forward to observe special types of surgery, such as chest surgery, at first hand in more forward hospitals.
    9. Special visits of instruction by medical officers particularly qualified in certain subjects provided another highly practical means of indoctrinating medical officers in correct use of established techniques and in new techniques. Among these visits were the following:

    Lt.. Col. Harvey S. Allen, MC, spent several weeks in army hospitals in 1944 lecturing on hand surgery and the correct splintering of wounds of the hand.

    Lt. Col. Oscar P. Hampton, Jr., MC, lectured on, and demonstrated, the correct techniques of surgery and splintering in wounds of the extremity. This was in February 1944. Later in the year, Colonel Hampton and Maj. Champ Lyons, MC, worked in one hospital for 6 weeks, demonstrating surgery of the extremities, with special emphasis on adequate debridement, correct splinting, the liberal use of whole blood, and the correct use of penicillin.


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This agent was just becoming available for general use, and its limitations as well as its potentialities were stressed. Later, these officers conducted seminars on the same subjects in all the other evacuation hospitals in the theater.

    In the fall of 1944, an extended tour of Fifth U.S. Army medical installations by Col. Eldridge H. Campbell, Jr., MC, was of great value in the development of the neurosurgical program. Colonel Campbell, who was then serving as acting consultant in neurosurgery, devoted much of his time to the management of peripheral nerve injuries; casualties with intrachranial wounds, with particular reference to their transportability; and spinal cord injuries.

    On 28 October 1943, Capt. (later Maj.) Floyd H. Jergesen, MC, began to work in the evacuation hospitals on the Garigliano Front and at Anzio for periods of from 5 to 14 days in each hospital. Captain Jergesen, who was serving as consultant in orthopedic surgery to the Surgeon, Fifth U.S. Army, demonstrated surgery of the extremities, with particular emphasis on thorough excisional surgery, fasciotomy, and dependent drainage. His activities grew out of the high incidence of clostridial myositis in Italy at the time. All hospitals were instructed at this time to notify him of all cases of actual or suspected gas gangrene. For the next several months, Captain Jergesen saw every case which developed in Fifth U.S. Army hospitals, as well as many cases which developed in base hospitals.

    By July 1944, the Mediterranean theater had ceased to receive new hospitals and new divisions, and there was therefore no further need to train inexperienced organizations and personnel. Most of the lessons of wartime surgery that had been learned in Africa, Sicily, and the early fighting in Italy had by this time been very well learned indeed.

    Major improvements in the surgical care of casualties were not confined to any single echelon in the medical service. Educational activities had extended from battalion aid stations through evacuation and convalescent hospitals, and improvements were equally widespread. The improvements were, in part, the consequence of the increased experience of individual medical officers and other personnel in combat surgery, but they were also, to a large degree, the result of the intensive and carefully planned educational program, which had extended through the whole medical service of the Army. In this program, the role of each echelon of medical care was clearly defined, and their relations with each other were indicated with equal clarity.

Circulars and Circular Letters

    Circular letters in one sense proved the most useful method of all of disseminating information, for they specified official policy, heaving no excuse for misunderstanding.

    Some of these letters were prepared almost as emergencies, in response to needs which were evident and highly urgent. Thus, the first circular letter from the Office of the Surgeon, Headquarters, II Corps, which dealt with the


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treatment of casualties, was prepared by Major Snyder after his first inspection of the work of surgical teams in clearing stations in North Africa early in 1943.4

    The second circular letter from this headquarters, which dealt with gas gangrene and which was published in August 1943,5 was precipitated by the alarming incidence of clostridial myositis in the Sicilian campaign. Medical circulars on this same subject were necessary from the Office of the Surgeon, Headquarters, Fifth U.S. Army, in October 1943,6 shortly after the landings at Salerno, and in May 1947.7

    Another circular letter from the Office of the Surgeon, headquarters, II Corps, published early in August 1943, was devoted to the care of the wounded in Sicily.8 It was prepared at the conclusion of the tour of medical installations on that island made by Colonel Churchill, Lt. Col. (later Col.) Perrin H. Long, MC, and Major Snyder. The necessity for it was explained in the introduction, as follows

1. Introduction.

    a. Surgical procedures in the present campaign indicate that many of the lessons learned in Tunisia are not being universally applied in Sicily. Rules and recommendations are not expected to replace the exercise of individual judgment by the surgeon or provide for exceptional circumstances. Deviation from certain basic principles, however, is not acceptable when based on inexperience or unfamiliarity with those principles.

    This letter dealt with basic principles of management of the wounded which remained substantially unchanged throughout the war.

    Medical circulars from the Office of the Surgeon, Headquarters, Fifth U.S. Army, dealt with trenchfoot; 9 sulfonamide therapy; 10 the disposition of battle casualties in forward echelons, based on careful triage at the clearing station; 11 blood transfusions; 12 and the correct use of Pentothal sodium (thiopental sodium) anesthesia,13 from which a regrettable number of deaths were occurring. Several of these circulars were prepared by the surgical consultant, with the assistance of appropriate officers qualified in the particular field in question, and the consultant assisted in the preparation of those which he did not prepare himself.

4 Circular Letter No. 1, Office of the Surgeon, Headquarters, II Corps, 12 May 1943, subject Treatment of Casualties.
5
Circular Letter No. 2, Office of the Surgeon, Headquarters, II Corps, 5 Aug. 1943.
6
Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army, 20 Oct. 1943, subject: Gas Gangrene.
7
Medical Circular No. 9, Office of the Surgeon, Headquarters, Fifth U.S. Army, 5 May 1944, subject: Anaerobic Infections.
8
Circular Letter No. 3, Office of the Surgeon, Headquarters, II Corps, 7 Aug. 1943.
9
Medical Circular No. 6, Office of the Surgeon, Headquarters, Fifth U.S. Army, 24 Nov. 1943.
10
Medical Circular No. 1, Office of the Surgeon, Headquarters. Fifth U.S. Army, 21 Jan. 1944.
11
Medical Circular No. 4, Office of the Surgeon, Headquarters, Fifth U.S. Army, 7 Apr. 1944, subject : The Disposition of Battle Casualties in Forward Echelons.
12
Medical Circular No. 10, Office of the Surgeon, headquarters, Fifth U.S. Army, 6 May 1944.13 Medical Circular No. 7, Office of the Surgeon, Headquarters, Fifth U.S. Army, 22 Apr. 1944, subject : Pentothal Sodium Anesthesia ; Blood Transfusions Post Mortem Examinations.


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MEETINGS AND CONFERENCES

    Meetings and conferences in the Fifth U.S. Army were of various kinds, in addition to the staff meetings, already described, in the hospitals which Major Snyder visited on his tours (p.358). These conferences were usually held at the end of his visit. Meetings were also held whenever he visited a hospital accompanied by any of the distinguished visitors to the theater (p.368).

    Some hospitals held weekly staff conferences for their own personnel. An excellent series of this sort was conducted at the l6th Evacuation Hospital, where Lt. Col. (later Col.) Manuel E. Lichtenstein, MC, Chief of Surgery, held weekly conferences, almost with out exception throughout the war.

    Frequent informal meetings and group discussions were held with the visitors to the theater and with others. They ranged in size and formality from discussions in pyramidal tents late at night (with half a dozen officers huddled around a potbellied stove) through surgical clinics and ward rounds (which could be set up at any time) to the Fifth U.S. Army Medical Conferences, at which more than 300 medical officers were often in attendance.

Informal Meetings

    The following meetings are typical of the informal, unscheduled meetings held at irregular intervals, in various medical installations in the army area, as the place and the person came together.

    In November 1943, Col. L. Holmes Ginn, Jr., MC, Captain Jergesen, and Major Snyder talked to the medical staff of the 3d Division at the clearing station near Riardo. Their presentation and the discussion which followed ranged widely, covering emergency and transportation splinting; the management of shock; the arrest of hemorrhage, with special reference to the use of tourniquets; the correct use of morphine; and sucking chest wounds and abdominal wounds.

    On 2 December 1943, Major Snyder talked to time surgical section, 8th Evacuation Hospital, on wounds in general, wounds of the chest and abdomen, and shock and hemorrhage. On 11 December, at an all-day session at the 15th Medical General Laboratory, presided over by Col. Virgil H. Cornell, MC, its commanding officer, Colonel Churchill spoke on the prophylaxis of wound infection and the principles of wound management. Captain Jergesen, Maj. (later Lt. Col.) Fiorindo A. Simeone, MC, and Major Snyder spoke on gas gangrene. On 15 December, Major Snyder talked to the 3d Platoon, 33d Field Hospital, on wound excision, vascular injuries, amputations, and shock. On 28 December, at a meeting held at the 1st Platoon of the 33d Field Hospital near Venafro, Maj. (later Lt. Col.) Samuel A. Hanser, MC, discussed the duties of a chief of surgery in a field hospital. Major Snyder compared them to the responsibilities of a senior resident on a surgical service, who must make rounds on all patients and be responsible to the chief of surgery (here Major Snyder) for the quality of the surgery done by all assistant residents; that is, the sur-


363

gical teams attached to the hospital. This meeting was held to the sound of guns: the U.S. Long Toms were 500 yards behind the field hospital, which meant--as had happened on one of Major Snyder's previous visits--that if an enemy shot at our artillery fell short, the hospital would be hit.

    On 24 February 1944, a meeting at the 38th Evacuation Hospital was devoted to chest injuries, with special reference to the management of wet lung, the use of atropine and morphine, and intercostal and paravertebral procaine hydrochloride (Novocain) block. The speakers included Lt. Col. Paul W. Sanger, MC; Maj. Thomas H. Burford, MC; Maj. Benjamin Burbank, MC; and Capt. Arthur J. Adams, MC.

    On 20 March, anaerobic infection, with particular reference to gas gangrene, was discussed at a meeting at the 21st General Hospital. Participants, in addition to Colonel Churchill and Major Snyder, included Colonel Hampton, Maj. (later Lt. Col.) Tracy B. Mallory, MC: Capt. Louis DeS. Smith, SnC; Major Lyons, Major Simeone, and Captain Jergesen. On 22 March, at the 23d General Hospital, Lt. Col. (later Col.) Michael L. Mason, MC, spoke on injuries of the hand.

    On 25 March, at the 401st Evacuation Hospital ( French), the meeting was presided over by General Hugenot, Chief Surgeon, French Medical Corps, and Maj. Etienne Curtillet was one of the participants in the animated discussion devoted to Pentothal sodium. The French regarded this agent as contraindicated in shock, hemorrhage, and chest and maxillofacial wounds. They used it in head injuries but not in abdominal injuries.

    On 30 March, at Marcianise, Major Snyder talked to the 2d Auxiliary Surgical Group on triage at the division clearing station, surgery in field hospitals, and chest surgery in field and evacuation hospitals. On 31 March, at the 52d Station Hospital, the discussion concerned surgery in forward hospitals and wounds of the chest. On the same day, a special meeting was held with the thoracic surgeons of the 2d Auxiliary Surgical Group on the indications for chest surgery in forward hospitals.

    On 7 May, Major Snyder addressed the entire staff of the 33d Field Hospital on a number of subjects, including blood transfusions and the management of anuria. Many surgeons expressed themselves as afraid to use potassium chloride, as advocated by Lt. Col. (later Col.) Marion H. Barker, MC, Chief of Medicine, 12th General Hospital, because of its possible toxic effect on the heat.

Fifth U.S. Army Medical Conferences

    The Fifth U.S. Army Medical Conferences were the only formal medical conferences held in the Fifth U.S. Army area. They were instituted by General Martin in November 1943, when the army headquarters was located in the palace at Caserta; here, the meetings were held in the Royal Opera House. When headquarters moved forward, the conferences were held in one or another of the evacuation hospitals.


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FIGURE 65. - Brig. Gen. Joseph I. Martin, Surgeon, Fifth U.S. Army, addressing rehabilitation conference at Castel Fiorentino, Italy, in 1945. Lt. Col. Howard E. Snyder is seated on the general's right.

    These meetings proved an extremely valuable means of disseminating information on surgical subjects, particularly during the first winter in Italy, when the educational needs were greatest. At this time, the front was generally stable, and army medical installations were not too widely scattered. The conferences could therefore be attended by medical officers of all echelons in the army area, as well as by many from station and general hospitals supporting the army. At the 17 February 1944 meeting, when peripheral vascular lesions were discussed, the audience overflowed the tent and attendances of 250 or 300 were not unusual.

    The Fifth U.S. Army surgical consultant planned all surgical programs. The speakers were selected because of their grasp of important current problems or their proficiency in special fields. General Martin, Surgeon, Fifth U.S. Army, presided at almost all of the conferences, which he ran with efficiency and dispatch (fig. 65). At his request, Major Snyder always closed the discussions on surgical subjects, making certain that accepted principles, as they were laid down officially, were clearly delineated. The only form of censorship exercised at these meetings, in fact, was Major Snyder's insistence that no policies and practices be advocated which did not conform with those approved by the theater and army surgeons.


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    Discussions from the floor were always animated and were frequently very useful. At the 4 November 1943 meeting, for instance, when the subject was gas gangrene, Maj. (later Lt. Col.) Henry K. Beecher, MC, discussed anesthesia in this condition. During the discussion at the 25 November meeting, the general subject of which was anesthesia, it was brought out that Pentothal sodium had been employed too freely, and its use in head injuries was condemned.

    With occasional exceptions, these Fifth U.S. Army conferences were held weekly from their institution in November 1943 until shortly before the fall of Rome in June 1944. Most of them were on surgical subjects, but a few were devoted to other subjects, including neuropsychiatric casualties, typhus fever, pneumonia, infectious hepatitis, and malaria.

    Table 6 gives some idea of the range of the material covered at these conferences and the outstanding caliber of those who made the presentations.

    There was general regret when tactical circumstances made it impossible to continue these conferences, and there was universal agreement that they had served their purpose well.

Other Meetings

    On 11 February 1944, at a meeting of the Peninsular Base Section Medical Society in Naples, Captain Jergesen and Major Snyder spoke on clostridial myositis, and Maj. (later Lt. Col.) Benjamin W, Rawles, ,Jr., MC, and Maj. Harvey S. Allen, MC, spoke on burns. Brig. Gen. Leon A. Fox, MC, spoke on typhus. By the time this meeting was held, the Naples epidemic, which had reached its peak in the middle of January, had been conquered. More than 1,500,000 men had been dusted with delousing powder in the course of the campaign. The mildness of the single case of the disease which occurred in an American soldier was attributed to his vaccination.

    Major Snyder attended the Congress of the Central Mediterranean Force Army Surgeons, held in Rome from 12 to 19 February 1945, together with other medical officers from the Fifth U.S. Army and the theater. The whole field of war surgery was covered, and special sessions were devoted to wounds of the chest and wounds of the abdomen. The closing address was made by Maj. Gen. Morrison C. Stayer, Surgeon, MTOUSA (Mediterranean Theater of Operations, U.S. Army). He emphasized, as did his opposite number, Maj. Gen. William C. Hartgill, C.B., O.B.E., M.C., K.H.S., that war surgery in the Mediterranean theater had been a pooled experience, with British and American medical personnel part of one team and with patients from all the Allied armies treated in forward hospitals as if they too belonged to one team. General Hartgill particularly stressed the fact that in this war the wounded man was not brought back to the surgeon; rather, the surgeon was brought in to the wounded man, and his chances of life were thus increased many fold.


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TABLE 6. - Presentations at Fifth U.S. Army Medical Conferences


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TABLE 6. - Presentations at Fifth U.S. Army Medics Conferences - Continued


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VISITORS TO THE ARMY AREA

    The visits to the Fifth U.S. Army area of Col. Edward D. Churchill, MC, consultant in surgery to the theater surgeon, were always welcome and helpful. Earlier, in July 1943, in the course of the Sicilian campaign, Colonel Churchill, Lt. Col. Perrin H. Long, MC, Consultant in Medicine to the Surgeon. NATOUSA, and Major Snyder, Consultant in Surgery, II Corps, made a tour of all II Corps medical installations and all Seventh U.S. Army medical installations as far to the rear as Palermo. The divisions of the Corps, under the command of Lt. Gen. (later Gen.) Omar N. Bradley, were making such rapid progress across the island that medical evacuation and supply were sometimes rafter difficult. The installations visited included battalion aid stations, collecting and clearing stations, field hospital platoons, and 400-bed and 750-bed evacuation hospitals. The circular letter prepared at the conclusion of this tour has already been described (p.361).

    On this visit, as in all others, Colonel Churchill's high standards were reflected in improvement in the work of the installations visited and in the excellent quality of all the surgery finally done in this theater. The reports which he published for the information of theater and army surgeons and which he submitted to the Office of the Surgeon General were equally helpful.14

    In the spring of 1943, Dr. Allen O. Whipple, professor of surgery at the Cornell Medical School, spent some time in Tunisia, on his return from the Middle East, where he had been observing the work done in British hospitals. His clinical observations on delayed primary wound closure and penicillin are discussed elsewhere (p.425). In company with Major Snyder, he visited many of the installations at the Bizerte medical center, and both of them addressed members of the 2d Auxiliary Surgical Group, which was then stationed there.

    Col. Johan M. Holst, Surgeon-General of the Norwegian Army and professor of medicine and director of the surgical clinic at the University of Oslo, made an extended stay in the Fifth U.S. Army area in the winter of 1944. He visited many of the hospitals in the army area, including those on the Anzio beachhead. His talks, which were all informal, were of great value.

    Visitors from the European theater before D-day in that theater included Col. (later Brig. Gen.) Elliott C. Cutler. MC, Chief Consultant in Surgery in the Office of the Chief Surgeon, ETOUSA, who had recently returned from Russia and who had much interesting and useful information about medical practice there; Lt. Col. (later Col.) Ralph M. Tovell, MC, Consultant in Anesthesia; Col. Kenneth D. A. Allen, MC, Consultant in Radiology; and Col. James Snyder, MC, Executive Officer, First U.S. Army. Brig. Gen. Fred

14 Before Colonel Churchill assumed his duties as consultant in surgery to the Surgeon, NATOUSA, in March 1943, much useful advice and assistance were received from Lt. Col. Frank B. Berry, MC, chief of the surgical service of the 9th Evacuation Hospital, the affiliated Roosevelt Hospital unit. As long as Colonel Berry remained in the theater (until August 1944, when he participated in the invasion of southern France as chief surgical consultant for the Seventh U.S. Army), Colonel Snyder found his associations with him very helpful in his own work.


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W. Ramkin, Director, Surgical Consultants Division, Office of the Surgeon General, visited the Mediterranean theater in 1944, and in the spring of 1945 Lt. Col. Michael E. DeBakey, MC, Chief, Surgical Branch, Surgical Consultants Division, Office of the Surgeon General, was another visitor.

    During the first winter of the war in Italy, the 36th General Hospital was stationed at Caserta, immediately adjacent to Fifth Army headquarters. Its close proximity made it possible to utilize the advice of the many competent surgeons on the staff, including Lt. Col. James M. Winfield, MC, Chief of Surgery, and Maj. (later Lt. Col.) William M. Tuttle, MC, thoracic surgeon. At this time, medical officers from the 12th General Hospital were attached to the 36th General Hospital, and their services were also utilized. Among them were Lt. Col. Michael L. Mason, MC, Chief of Surgery, and Maj. (later Lt. Col.) Harvey S. Allen, MC, hand surgeon. These officers made major contributions to the evolution of policies of medical management in the Mediterranean theater.

    During the second winter of the war in Italy, the 24th General Hospital was stationed in Florence, and, again, it was possible to make use of the advice of the many excellent surgeons on the staff, among them Lt. Col. (later Col.) Francis J. Cox, MC, Chief of Surgery, who was an experienced orthopedic surgeon, and Maj. (later Lt. Col.) Bently P. Colcock, MC, a general surgeon.

    While the 24th General Hospital was stationed in Florence, seriously wounded casualties were evacuated to this general hospital when they left field and evacuation hospitals. At one time during the winter of 1944-45, this hospital had 60 patients with colostomies on one ward. The proximity of the general hospital to the army hospitals often made it possible for the surgeons in the general hospital to confer with the surgeons who had performed the initial wound surgery in the cases they were then treating.

    The visits of all of these medical officers and professional men to the Fifth U.S. Army area and the contacts possible with officers in the base hospitals contributed materially to the studious and scientific approach to the problems of war surgery which characterized all medical organizations in that army.

EVALUATION OF SURGERY

North Africa

    Major Snyder's first evaluation of oversea surgery was in the North African theater, when he was placed on temporary duty in II Corps headquarters for this particular purpose. His report to the Surgeon, II Corps, on 3 April 1943 was based on his observations in the following installations:

    1. The French Hospital in Gafsa, in a II Corps clearing station, set up and staffed by the 1st Platoon, Company D, 51st Medical Battalion. The organic personnel of the platoon was supplemented by the general surgical teams and one shock team from the 2d Auxiliary Surgical Group.


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    2. The 2d Platoon of the Clearing Company, 1st Medical Battalion, also at Gafsa
    3. The treatment stations of Company A and Company C, 47th Medical Battalion (1st Armored Division), at Maknassy Road.
    4. The treatment station of Company B, 2d Battalion, l6th Medical Regiment, Maknassy Road. One general surgical team from the 2d Auxiliary Surgical Group was attached to this installation.

    Casualties from the 1st Division evacuated on the El-Guettar-Gafsa Road were sorted at the clearing station of the 1st Medical Battalion, at which they arrived between 1 and 5 hours after wounding. Nontransportable casualties and severely wounded casualties were transferred immediately to the clearing station of the 51st Medical Battalion. Other casualties were sent on to the 48th Surgical Hospital (fig. 66), 50 miles to the rear.

    Casualties from the Maknassy area passed first through the treatment stations of the 47th Medical Battalion, 1st Armored Division, them through the clearing station of the 51st Medical Battalion, at which they arrived from 5 to 24 hours after wounding. Here they were sorted, the nontransportable being held for surgery there and the remainder being sent back to the 48th Surgical Hospital.

    Sorting was generally well done, and as a result surgical personnel in the clearing stations could utilize their time in the care of only the seriously wounded. For the most part, excellent judgment was also used in the selection of cases for surgery by the teams of the 2d Auxiliary Surgical Group, and the surgery performed was generally commendable.

    The 48th Surgical Hospital, as just mentioned, received the presumably less seriously wounded casualties who were regarded as fit for evacuation before undergoing surgery and also received casualties evacuated after having undergone surgery in the clearing stations.

    The 21 deaths which occurred at this installation revealed some grounds for criticism, as follows:

    1. Among the 32 patients operated on at the 51st Medical Battalion, 4 deaths occurred from 5 to 27 hours after operation (2 other patients died before evaluation ). It was concluded that less speedy evacuation of patients who had undergone surgery might have saved some lives. A number of these men had been evacuated before they had reacted from anesthesia.
    2.At the other extreme, 10 deaths occurred in patients who had passed through the clearing stations forward but had not received surgery in them. It was concluded that a few of these lives might have been saved if primary surgery had been performed earlier at the forward installations.
    3. Of the seven remaining deaths, five occurred in patients who had passed through other clearing stations without surgery and two in patients who had reached the hospital from a battalion aid station and a collecting company, respectively.


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FIGURE 66 - The 48th Surgical Hospital, North Africa.


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        The following recommendations with respect to other subjects were made:

    1. A more convenient method of blood transfusion should be made available.
    2. A source of blood other than clearing station personnel should be provided.
    3. Provision should be made for oxygen therapy.
    4. A shock team from the auxiliary surgical group should be assigned to every clearing station set up to act as a forward surgical hospital.
    5. An orthopedic surgery team, or at least an orthopedic surgeon, would add greatly to the efficiency of each forward surgical installation.
    6. Caution should be used in the administration of morphine. An analysis of the records suggested that overlarge doses of morphine might have played a part in some of the fatalities, while other records seemed to point to the same conclusion, though they bore no notation concerning administration of the drug. It was suggested that a directive be issued warning against any but small doses of morphine in chest injuries, prohibiting its use entirely in intracranial injuries, and outlining other precautions in its administration.

    Excessive morphine dosage was a well-recognized clinical problem from the beginning of the war. Whenever Major Snyder talked to medical officers and corpsmen and to division medical services, he always advised that a half Syrette be administered rather than the full (grain 1/2) Syrette dose. Necessary instructions concerning the judicious use of morphine were contained in Circular Letter No.1, Office of the Surgeon, Headquarters, II Corps, dated 12 May 1943, concerning the treatment of casualties, and specific instructions concerning the dangers of overdosage were given before the invasion of Italy.

    The importance of this problem was particularly evident in the 100th Infantry Battalion (Separate), made up of American-born Japanese from Hawaii and the Philippine Islands as well as a small number of native-born Japanese. The same problem was encountered in the 442d Infantry Regiment (Separate). Japanese are so small that even the reduced amount of morphine received from half a Syrette affected them much more than it did U.S. troops, who were taller and heavier.

    7. More explicit instructions should be issued concerning the emergency treatment of head and chest wounds, as well as the disposition of these casualties. Casualties observed in the clearing stations and the 48th Surgical Hospital, as well as the records studied, indicated that specialty teams for the treatment of head and chest injuries should be located nearer to the front than evacuation hospitals, at least as these hospitals were then located. The 48th Surgical Hospital was between 50 and 85 miles from the main battlefront at various times, and the 9th and 77th Evacuation hospitals were between 60 and 145 miles behind it.

    Recommendations concerning anesthesia and equipment (p. 392) were also included in this report, in which it was noted that the recommendations concerning clearing stations were intended to apply only to those set up to act as


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forward surgical hospitals. With this report, Major Snyder submitted a short treatise on the emergency care of wounded in forward installations. One of the points repeatedly emphasized was that provisions must be made in whatever installation major surgery was performed to hold the patient for a safe period of time afterward.

Sicily

    Major Snyder's initial observations in Sicily showed that surgery was, on time whole, good, and some of it was extraordinarily good. On the other hand, surgeons without previous experience in combat-incurred wounds were doing inadequate initial wound surgery (debridement) and thus were responsible for at least some of the clostridial myositis which was then causing a great deal of concern (p. 445). Here, as all through the Italian campaign, it seemed inevitable that when new hospital units came into the theater they must acquire experience by making mistakes before uniformly good surgery could be expected from them. Many surgeons required time to learn the importance, for instance, of a bold approach to a wound and the necessity for an incision of sufficient length to permit adequate exposure of the wound depths.

    The circular letter issued from the Office of the Surgeon, Headquarters, II Corps, on 7 August 1943, was designed to correct these and other errors, some of which could be traced to an earlier circular letter issued from the Office of the Surgeon. Headquarters, NATOUSA.15 The most important of these errors was the direction that all wounds, without exception, be left open.

Italy

    As the war progressed, it was found that one of the most useful means of evaluating the quality of the surgery done in forward installations was by examination of casualties after they had reached base hospitals. After this plan was adopted, Major Snyder made it his practice to make notes on special cases, attempting to select those in which results had been outstandingly good as well as those in which errors had been made or complications had developed or the subsequent course indicated that the procedure at initial wound surgery was not too well advised or had been inadequate.

    By this means, it was possible to determine the quality of surgery done in forward hospitals and to identify the units, and even the individual surgeons, whose technique and judgment either required correction or had been unusually good. These data were given to the surgeon concerned or to his surgical chief.

    From the beginning, medical officers in the Fifth U.S. Army manifested an unusual interest in following up their patients in order to evaluate the procedures carried out on them in forward echelons. This was as true of the battalion surgeons and surgeons in clearing and collecting stations as of those in field

15 Circular Letter No. 16, Office of the Surgeon, Headquarters, NATOUSA, 9 June 1943, subject: Memoranda on Forward Surgery Especially Applicable to Amphibious Operations.


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and evacuation hospitals. Opportunities were provided, as far as possible, to capitalize on this interest by permitting surgeons from forward installations to visit fixed hospitals in the base.

    During certain phases of the Italian campaign, there were unusually good opportunities to follow up patients operated on in the combat zone. On the Cassino front, for instance, field and evacuation hospitals were located near each other, and base hospitals were established in nearby Caserta and at Naples. The close physical proximity of army and base installations provided exceptional opportunities for informal exchanges of visits and for the weekly army conferences. It was thus possible to study the management of wounds, assess the work performed in each organization, correct errors, and promulgate for early adoption whatever new surgical techniques had been developed.

    Similarly, during the offensive against the Gothic Line in the spring of 1944, the 24th General Hospital was located in Florence, within the army area, and another excellent opportunity was provided for chiefs of surgery in field and evacuation hospitals, as well as other medical officers, to follow-up their cases.

EVACUATION

    The successful utilization of field and evacuation hospitals in the army area depended upon successful triage (the selection of patients for surgery on the basis of priorities). Triage, which was carried out at the division clearing station, was based upon the following considerations: (1) Care of nontransportable casualties in field hospital platoons placed adjacent to division clearing stations and with their intrinsic personnel augmented by auxiliary surgical group teams and (2) evacuation of transportable casualties from clearing stations to evacuation hospitals farther to the rear.

    Evacuation hospitals were set up in depth along the main axis of advance in the zone which they were supporting. Early in 1944, it became the duty of the corps surgeon and the medical units under him, chiefly the corps medical battalions which handled evacuation from division areas to army hospitals, to execute triage of transportables. Efforts were made to keep the hospitals nearest to the front free for the care of the more urgent cases, while casualties with less urgent wounds were sent to the rearmost hospitals. It was also the policy to send the mainstream of casualties who could withstand prolongation of transportation to the rear during daylight hours and to use the more forward hospitals at night, to reduce the hazards of driving in the blackout.

    It had been repeatedly demonstrated in North Africa and Sicily, as it was evident until the end of the war, that the placing of field hospital platoons immediately adjacent to clearing stations not only simplified transportation of seriously wounded casualties from one installation to the other but actually saved many lives. Corps headquarters therefore always made every effort to place these units as close together as the terrain and the tactical situation permitted.


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Facilities for Evacuation

    As in all previous wars, litter carries and ambulances furnished the principal means of evacuation from the frontline to the battalion aid station and thence to clearing stations. On flat terrain, this presented only the usual difficulties. In mountain warfare, the situation was often extremely difficult. Some casualties were moved by mule pack, others by cables strung between mountain peaks. Nothing, however, took the place of litter bearers in mountain fighting. Those from a battalion aid station often had to evacuate casualties to the rear to ambulance collecting points, and litter bearers from collecting companies had to work forward and assist in collecting casualties from the battlefield. Even with Italian soldiers to assist, it was necessary to ask Allied Forces headquarters to allot 100 litter bearers above the number allotted by the table of organization for each division engaged in mountain warfare.

    Evacuation from the Anzio beachhead, which also furnished special difficulties, is described elsewhere (p.347). The decision concerning where the casualty should be delivered from the battalion aid station rested with the division surgeons. Most of them directed that patients be taken to the collecting station.

    From the standpoint of conservation of drivers, this was a desirable arrangement. The approach from the field station to the collecting station was generally hazardous, and limitation of the number of drivers meant the limitation of the number exposed to enemy observation and fire. If all drivers had made the run from the aid station to the clearing station, all of them would have been subjected to major risks, and more drivers and more ambulances would have been necessary.

    Air evacuation began in Sicily about D+5 and proved a safe and expeditious way of removing casualties to the hospitals in North Africa (fig.67). During the fall and winter of 1944-45, most patients who went to base hospitals were evacuated from Rome or Naples by means of C-47 (civilian DC-3) planes, as a responsibility of the base section.

    Air evacuation of individual patients by L-5 planes (fig.68) was begun experimentally in Italy early in March 1945. Patients had to be selected carefully for this mode of transportation since no medical care was possible during the flight. On the other hand, practically all of those thus transported had had initial wound surgery and were in good condition.

    Since ample ambulance facilities were available, these planes were not used widely in the Po Valley campaign, though they were extremely useful in flying blood forward from the blood bank in Florence. They were very useful, however, during the mountain fighting later, as well as still later, when the army broke out into the valley and the medical service had to be spread over hundreds of miles.

    Theoretically, the plan was that the base section would evacuate casualties by collecting them at specified holding points in the army area. During most


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FIGURE 67. - Air evacuation by converted C-47 transport plane, MTOUSA.

of 1944, the base lacked facilities to implement this plan and the army evacuated casualties either to transfer points designated by the base or directly to base hospitals. During the first 3 months of 1945, it became the policy to hold in army hospitals all patients except those whose conditions demanded treatment which could be secured only in base hospitals. During this period, several general hospitals were located in the army area, and if the patients who had to be evacuated to them could be returned to duty they were channeled back to the army area either through the ordinary agency of replacement companies or through the 3d Convalescent Hospital, Motecatini, Italy.

    The holding period in Italy varied from 60 to 120 days, the longer period being permitted when, its at this time (early 1945), the fighting was less active. Hospital trains were first employed in Italy in November 1943. A typical train was staffed with 4 medical officers, 6 nurses, and 33 enlisted men and could accommodate about 135 litter patients, placed in three tiers in compartments or along the sides, in addition to 215 ambulatory patients.

    The railroad equipment first used was defective and the service erratic. Later, when a loading point was established at Caserta and the trains began to be handled by railroad operating personnel with experience in the United States, this became a very satisfactory method of evacuation. The trip from Caserta to Naples, when this method of evacuation had become well developed, took 1 1/2 hours.


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FIGURE 68. - Evacuation by L-5 plane from Firenzuola to Florence. A section of the side of the plane opens, permitting a stretcher to be placed on the deck in the rear, where it is securely lashed.

MEDICAL INSTALLATIONS IN THE ARMY AREA

Battalion Aid Station

    At the battalion aid station, to which the casualty was brought from the battlefield, surgical measures were limited to those which would render him transportable. They included (1) inspection of the dressings and splintage applied on the battlefield, with such reinforcement or alterations as might be necessary; (2) control of hemorrhage by compression dressings, ligature, or tourniquet as necessary; (3) attention to the airway with, occasionally, the performance of tracheotomy; (4) attention to sucking wounds of the chest and relief of tension pneumothorax; and (5) administration of plasma (p. 416).

    Minor wounds in casualties who could be promptly returned to duty were also cared for at the battalion aid station.

Collecting Station

    The collecting station (fig. 69), whose function is implicit in its name, was regarded by most medical officers as an important point in the division medical service. During 1944, its elimination was advocated in some quarters, but there


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FIGURE 69. - Collecting station, 10th Mountain Division, Gothic Line.

were many good reasons for its continuation, and nothing came of these suggestions. 

    Most casualties were held at the collecting station only long enough to check their condition and render any further first aid necessary. Tourniquets, dressings, and splints were examined, and it was ascertained that the airway was patent. Additional plasma was administered if necessary. The general policy was to do nothing active unless there was a real indication for interference.

    The casualty's name and organization and other data required for official records, which had been recorded at the battalion aid station, were checked at the collecting station. Most regimental commanders required that regimental surgeons secure this information from these installations and render complete reports of battle casualties from the regiment. Details secured were concerning the number of casualties, the location of the engagement in which they had been wounded, the type of weapons used, and similar data were usually the first significant information to reach the regimental commander. These data were, of course, invaluable to him in assessing the progress of the battle in which his regiment was engaged. Unless all casualties passed through collecting stations, this highly essential information could not have been secured until the patients had reached the clearing stations farther to the rear, which was often many hours later.

    When an offensive was on or when early evacuation was not essential, casualties were usually held in the collecting station until an ambulance load had been accumulated. Those with first priority wounds, such as wounds of


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the chest or abdomen, and those in severe shock were often sent back singly, with individual attendants to supervise their care en route when personnel could be spared. This policy reduced the average timelag between wounding and initial wound surgery, but because triage was careful, no evidence was accumulated to suggest that the risk was increased for the casualties held until a full ambulance load was secured.

    Occasionally, if the clearing station was close at hand, the collecting station might be bypassed and casualties taken directly from the battalion aid station to the clearing station, but this was never a general policy, regardless of the location of the installations.

Clearing Station

    The experience of the Tunisian campaign had persuaded those responsible for the planning of medical care in the Sicilian campaign that facilities for surgery and for adequate postoperative care of casualties submitted to surgery should be established as far forward as the division clearing station. In April 1943, in his report on the use of teams from the auxiliary surgical groups (p.369), Major Snyder had supported thus policy of forward surgical care. He recommended, however, that, when the intrinsic staffs of clearing platoons of corps medical battalions were augmented by auxiliary surgical group teams, the equipment of the platoons also be increased. Their original tables of equipment were not adequate for their new mission.

    He further recommended, since the performance of surgery at division clearing stations would interfere with the proper functioning of these installations, that platoons of clearing companies designated to supply surgical care should be set up adjacent to the clearing stations rather than within them. This arrangement would make it possible for the serious wounded to be operated on promptly but would, at the same time, leave the clearing stations free to perform their basic functions of triage.

    From this suggestion, it was only a step to the final arrangement; namely, the use of field hospital platoons, rather than the clearing platoons of medical battalions, for forward surgery.

    The principal improvement effected in second echelon medical services in the Fifth U.S. Army in 1944 had to do with the functioning of clearing stations. After an analysis of the 80 deaths which had occurred in Fifth U.S. Army evacuation hospitals in January 1944, Major Snyder concluded that more careful triage in the clearing stations might have directed a larger number of casualties to the field hospital platoon immediately adjacent to them and almost probably have led to a reduction in the immortality rate. Of 44 patients in deep shock or with first priority wounds whose case histories he studied, 36 were sent directly to evacuation hospitals from the clearing stations, while the remaining 8, although they were sent to field hospitals, were merely observed there and then were sent to evacuation hospitals for initial wound surgery.


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FIGURE 70. - Field hospital, North Africa.

    These observations led to the institution of an educational program in the clearing stations, based on a medical circular dealing with the disposition of battle casualties in forward echelons.16 The prompt improvement which occurred in the triage of casualties at clearing stations was maintained until the end of the war.

Field Hospital

    When platoons of field hospitals were designated for the performance of forward surgical care in Sicily, they assumed functions quite different from the station hospital type of care which they had provided in North Africa (fig.70). In Sicily, they were set up immediately adjacent to division clearing stations, the location often being with range of enemy artillery, and they were provided with more surgical equipment than had been given the clearing platoons of medical battalions which had performed forward surgery in North Africa.

    The concept of forward surgical care in field hospitals was based on two considerations, as follows:

    1. Certain casualties, such as those with abdominal or severe chest wounds and those in deep shock, must receive surgical care at the level of the clearing station if they are to survive.
    2. Patients who have been submitted to major surgery must not be moved earlier than 8 or 12 days after operation.

16 See footnote 11, p.361.


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    The care of first priority patients at the level of the clearing station had many advantages. Prolonged evacuation of seriously wounded patients, which was deleterious, was avoided. When the intrinsic staff was augmented by teams from an auxiliary surgical group, the number of surgeons and nurses was proportionately larger in field hospitals than in evacuation hospitals, which meant that seriously wounded casualties could be cared for with less delay and could receive better postoperative care. Segregation of patients with serious wounds permitted closer observation and generally better care. Finally, the establishment of field hospitals at the level of the clearing station proved highly advantageous from the standpoint of troop morale. Every man in a division which was thus supported knew that a hospital staffed with competent surgeons and nurses was located so far forward that, if he were seriously wounded, he would receive superior care with a minimum of delay.

    Under exceptional circumstances, when a heavy casualty load had resulted in a backlog of patients in a field hospital, some patients in the group were selected for treatment by resuscitative measures and then were transferred to the nearest evacuation hospital. The objective was to reduce the timelag between wounding and surgery, but the practice was recognized as au undesirable emergency measure and was actively discouraged as a regular procedure.

    As a matter of convenience and to avoid repetition, the use of auxiliary surgical group teams in field hospitals is discussed elsewhere (p.385).

    The use of field hospital platoons augmented by teams from auxiliary surgical groups saved the lives of many severely wounded. Because the field hospital was only a short litter carry from the clearing station, many casualties could be operated on who would never have withstood operation after prolonged evacuation to the rear. Mortality rates in field hospitals were high, but they would have been much higher if this forward surgical unit had not existed, and the number of patients with serious abdominal and chest wounds who could be returned to duty after surgery in them and convalescence in base hospitals was really surprising.

    Postoperative management. - One of the important surgical lessons of the fighting in North Africa was that patients who had undergone major surgery, particularly abdominal surgery, did not withstand evacuation until 8 or 10 days, and preferably longer, after operation. The postoperative care of these casualties was thus one of the responsibilities of field hospitals (fig. 71).

    Holding the patients after operation was a simple matter when the hospital was situated behind a stable front or a slowly advancing front. In these tactical circumstances, one field hospital could serve two divisions in the line by using two of its three platoons at the two division clearing stations while the third platoon held patients at a fixed location until they could be evacuated and it could leapfrog over one platoon or the other when the division clearing stations moved.

    With a rapidly moving front, the problem was somewhat more complicated. Then, every division usually required the support of an entire field


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FIGURE 71. - Postoperative ward in 1st Platoon, 33d Field Hospital, Italy.

hospital, the platoons of which were set up in depth behind the front. Only the forward platoon, set up beside the division clearing station, received casualties. The other two platoons held postoperative patients in various stages of convalescence until they could be evacuated and these platoons, in turn, could move forward.

    When the forward platoon of the field hospital, which was adjacent to the clearing station, was closed to admissions, the rearmost platoon was moved forward to establish treatment facilities beside the clearing station in the latter's new forward position. The platoon which was no longer receiving new patients continued to care for its postoperative patients until they were ready for evacuation. Experience had soon shown that the skeletonized plan originally devised was not adequate. A surgical team had to remain with the holding unit, to care for patients who might require surgery for secondary hemorrhage, wound dehiscence, subdiaphragmatic abscess, clostridial myositis, and other complications. It was also necessary to leave an operating room set up, as well as facilities for radiography and fluoroscopy.

    It was sometimes possible to provide postoperative care by moving evacuation hospitals to sites occupied by field hospitals, leaving the platoons of the field hospital free to move forward. This was perfectly satisfactory. The


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important consideration was the provision of postoperative care in the installation in which the patient had received surgical care. If casualties were moved too soon after major surgery, the results might easily be worse than if surgery had been postponed until they reached evacuation hospitals. The original tendency had been to regard most patients as rapidly transportable, the emphasis being placed upon the operative act. It was not long before it was realized that complete postoperative care was equally important.

Evacuation Hospital

    The evacuation hospital proved the ideal unit in which to provide definitive surgery for the majority of wounded in World War II.

    Admissions to evacuation hospitals were mixed, both medical and surgical cases being received, though the medical load was lightened when special hospitals were set up for the treatment of venereal disease and the care of neuropsychiatric casualties. With first priority casualties diverted to field hospitals, the evacuation hospitals were capable of providing excellent surgery, though their accomplishments depended, ultimately, upon the extent and care with which nontransportable casualties had been filtered out in clearing stations and field hospitals. When this task had been well done, an evacuation hospital was capable of caring for 80 surgical casualties per day and could push the number to 100 or more for periods of days in times of stress.

    An attempt was always made to balance the number of lightly and seriously wounded in the daily admissions. The officer in corps headquarters in charge of hospitalization and evacuation knew the number of patients who could be received by any single hospital in the course of a day and also knew to which hospitals to divert casualties when the first hospital had reached its limit.

    When serious backlogs developed, it was sometimes found wiser to transport a casualty who would not be harmed by further evacuation to another hospital in which the workload was lighter and he could receive immediate surgery. During the pursuit north of Rome, some casualties who would have been held in army hospitals under more static conditions were evacuated for surgery to base hospitals earlier than ordinarily desirable. This was another operational necessity which was regarded as expedient but not desirable.

    The 400-bed evacuation hospital, reinforced by two or more surgical teams. proved capable of handling the same number of casualties per day as a 750-bed evacuation hospital with its intrinsic staff. The larger capacity of the 750-bed evacuation hospital was an advantage, but a hospital of this size was cumbersome to move. When a 400-bed hospital was provided with extra bed capacity in the form of adequately equipped clearing platoons. it proved to be far more efficient in a fluid tactical situation than the larger hospital. This arrangement had another desirable aspect--time clearing platoons which furnished the additional beds could be left as holding units when the patient evacuation hospitals moved forward. These hospitals frequently had patients who had had


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thoracic or abdominal or other major surgery shortly before, and it was just as important to hold these patients in these units for the proper length of the after operation as it was to hold the seriously wounded in the field hospital platoons for a certain period of the after surgery.

    The rapid movement of evacuation hospitals was quite important. During the advance north of Rome, for instance, in the summer of 1944, gains of 15 miles a day or more by the Fifth U.S. Army were not uncommon. 0n one occasion, the 11th Evacuation Hospital was 15 miles behind the frontline on one day and 30 miles behind it on the next day. The 8th Evacuation hospital, one day in June 1944, was placed only 6 miles behind the frontline and, within a few hours, found its forward location fully justified by the speed of the advance.

    In spite of careful triage at the clearing station, it was inevitable that, as the load on field hospitals increased, the number of seriously wounded casualties in evacuation hospitals also increased, the most forward hospitals naturally receiving the most seriously wounded (p.381). At the beginning of the offensive which culminated in the breakthrough into the Po Valley in April 1945, one evacuation hospital received so many casualties with extensive and often multiple wounds that it could not care for more than 40 in a 24-hour period, although its surgeons were experienced and competent and were aided by three auxiliary surgical group teams. The rearmost of the evacuation hospitals supporting this offensive, on the other hand, although it was augmented by only one surgical team, cared for 140 less seriously wounded casualties over the same 24-hour period with no difficulty at all.

    During 1944, several significant changes and improvements occurred in Fifth U.S. Army evacuation hospitals, as follows:

    1. The standard of thoracic surgery in a number of hospitals was greatly improved by the attachment to them of experienced thoracic surgical teams for periods of from 1 to 3 months. During this time, sustained efforts were made to teach the intrinsic surgical staff refinements in the management of wounds of the chest. This was a matter of considerable importance, since all chest surgery, except in nontransportable casualties, was done in evacuation hospitals. In addition, casualties with thoracoabdominal wounds often reached evacuation hospitals from forward areas in which there were no intervening field hospitals. Surgeons in evacuation hospitals who had the responsibility for these patients were kept busy, and it was essential that they be competent.
    2. Most neurosurgery was also done in evacuation hospitals, and several hospitals which had no neurosurgeons on their staffs were strengthened by the temporary attachment of neurosurgical teams, which were withdrawn when the special need had passed.
    3. The same plan was also followed with maxillofacial teams.
    4. All evacuation hospitals adopted the policy of holding casualties in shock or preoperative wards before surgery. The assignment of cases to in-


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dividual surgical teams and the decision as to the optimum the for surgery were sometimes the responsibility of the chief of surgery or his representative and sometimes that of the medical officer in charge of the shock ward. Postoperative care was usually supervised by the operating surgeon.
    5. No elective surgery was performed in evacuation hospitals during periods of sustained combat activity. In quiet periods between offensives, minor elective surgery, including delayed primary wound closure, was sometimes permitted if it seemed likely that the patient could be returned to duty from the evacuation hospital or from the convalescent hospital in the army area. No major elective surgery was ever permitted in an evacuation hospital.
    6. It became established practice for the surgical staffs of most evacuation hospitals to meet once a week or oftener for the presentation and discussion of clinical material.

Auxiliary Surgical Groups

    Major Snyder's first assignment, before he was formally appointed professional services officer to the Surgeon, II Corps, was to evaluate the work of the teams from the 2d Auxiliary Surgical Group which were working in a British hospital in Algiers. His first orders when he reported to II Corps headquarters in March 1943 for temporary duty were to evaluate the use of similar surgical teams in clearing stations. He therefore became acquainted promptly with the excellent work of which these teams were capable as well as with their potentialities for usefulness in a combat zone.

    Assignment to field hospitals. - Surgical teams from auxiliary surgical groups were used in field hospitals for the first time in the Sicilian campaign. Before the invasion, Colonel Amspacher and Major Snyder spent considerable time with the professional staff of the 11th Field hospital and with members of the teams of the 2d and 3d Auxiliary Surgical Groups which were to augment its organic staff. Much of this time was devoted to the discussion of functions of field hospital platoons which were to serve as forward surgical units. During the latter part of the Sicilian campaign, the 10th Field Hospital also came under II Corps control.

    Originally, field hospitals had functioned as little more than station hospitals. During the Sicilian campaign, when platoons from the 10th Field Hospital had been sent forward to install themselves beside clearing stations and provide surgical care for nontransportable casualties, it had become evident that, for this type of organization to function efficiently, its organic personnel must be augmented by teams from an auxiliary surgical group. Such teams were therefore attached to the 10th Field Hospital, just as they had been attached to the 11th Field Hospital before the invasion. This plan was used thereafter.

    The professional personnel of auxiliary surgical group teams sent to field hospital platoons had to be selected with special care. Young, healthy general surgeons, capable of performing major surgery of the abdomen, chest, and extremities, proved most desirable. The specialist who was not also a good


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general surgeon did not belong in a field hospital. Chest and abdominal wounds formed the major portion of the workload. The team on duty at any given time, however, had to be able to handle all the patients admitted while it was on duty; otherwise, extra loads had to be carried by other teams. This meant that such specialty teams as orthopedic surgery teams, neurosurgical teams, and maxillofacial teams were not ideally suited for work in field hospitals and were better attached to evacuation hospitals, in which these special wounds were chiefly handled.

    Thoracic surgery teams capable of doing good general surgery were extremely valuable in field hospitals, though there were not enough of them to handle all the thoracic surgery which had to be done in them. The problem was best solved by attaching one thoracic surgeon to a field hospital platoon to perform some operations himself, to supervise preoperative and postoperative care, and to teach general surgeons the indications for, and the finer techniques of, thoracic surgical procedures. Many young general surgeons thus learned to do good thoracic surgery of the sort necessary in a field hospital.

    Anesthesiologists with surgical teams also improved the efficiency of less well trained anesthesiologists in field hospitals by teaching them the technique of endotracheal anesthesia, the use of the bronchoscope for aspiration of the trachea and larger bronchi, and other techniques. In this connection, surgeons with experience in thoracic surgery did much to elevate the standards of anesthesia for this kind of surgery in both field and evacuation hospitals.

    Assignment to evacuation hospitals. - Auxiliary surgical group teams also functioned in evacuation hospitals. As already mentioned, a 400-bed evacuation hospital, if augmented by two or three surgical teams, could do essentially the same volume of surgery as a 750-bed hospital with its organic personnel. In times of great activity, as many as six surgical teams were often assigned to an evacuation hospital.

    Administrative considerations. - Originally, the auxiliary surgical group teams were not used to their full capacity. The teams which were attached to field and evacuation hospitals had to stay with these hospitals, even after their usefulness was ended. The II Corps surgeon in Africa and Sicily and the Fifth U.S. Army surgeon in Italy moved them only when they were needed elsewhere.

    When the group headquarters was established in Italy in 1944, close coordination was effected between the Office of the Surgeon, Fifth U.S. Army, and the group headquarters, under the command of Col. James H. Forsee, MC. For example, when a team had finished work at a field or evacuation hospital, it was recalled to group headquarters, to rest up and get ready for the next job.

    All teams had to be kept on the alert, to be prepared to move on very short notice to field hospital platoons which were receiving more casualties than the teams already assigned to them could handle. The fact that it was possible to shift teams rapidly to the units in which they were needed did much to improve the caliber of surgery in the Fifth U.S. Army. In fact, the Sicilian experience


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proved that the attachment of surgical and other teams from auxiliary surgical groups to field hospitals provided far better surgical care than had been provided earlier, when surgery was done in clearing stations. On 12 May 1944, for instance, Major Snyder found a backlog of surgical cases at time 11th Field Hospital, which was supporting the 85th Division in the breaching of the Gustav Line. Colonel Forsee was notified, and additional surgical teams were at once sent forward to supplement the three teams already assigned to the hospital. Three days later, the 56th Evacuation Hospital also had a large backlog of operations. Several complete surgical teams were immediately sent forward to help it. Rapid movement of this kind would have been impossible without the proper administrative setup).

    The number of teams attached to a field hospital had to be flexible, first, to compensate for the increase in surgery which resulted from a broadening of the concept of the nontransportable casualty, and, second, to meet the increased workload in peak periods. Two teams could readily handle all the work during static periods, but at least six surgical teams and two shock teams were acquired during an offensive, while the use of eight surgical teams was not at all unusual.

    When the mission of field hospitals was extended to the surgical care of nontransportable casualties, it was found, as already noted, that the organic staff was not sufficient to handle the new responsibilities. Late in 1943, as a partial solution of this problem, it became the practice to appoint the chief surgeon of some one of the auxiliary surgical group teams attached to the field hospital as chief of the surgical service in it. The appointment was made by the commanding officer of the field hospital, with the advice of Colonel Forsee and Major Snyder.

    This plan did not prove particularly satisfactory. One reason was that, occasionally, early in the war, the ranking officer was not the officer best qualified professionally to serve as chief of the surgical service. Another reason was that the professional work of this officer with his own team left him little time to supervise the whole surgical service adequately.

    These difficulties were gradually overcome. In December 1943, Major Snyder was given permission by Lt. Col. (later Col.) Clement F. St. John, MC, Chief of Plans and Operations, Office of the Surgeon, Fifth U.S. Army, to confer with Colonel Forsee about the placement of auxiliary surgical group teams in field hospitals and the use of one of the surgeons as chief of surgery. Additional discussions were held with Lt. Col. Samuel A. Hanser, MC, Commanding Officer, 33d Field Hospital, and with Maj. James M. Mason III, MC.

    At this time, there was considerable feeling between field hospital personnel and auxiliary surgical group personnel; field hospital personnel, rather naturally, resented the alterations in their functions required by the addition of surgeons to take care of surgery which they had been led to believe they would perform themselves. Major Hanser took a broadminded and highly intelligent view of the new arrangements and was most cooperative and under-


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standing. Major Mason was a competent surgeon, who understood the professional and administrative problems of forward surgery and could advise Major Snyder concerning the new problems likely to arise with the appointment in a field hospital of a surgical chief who was not part of its organic personnel.17

    The problem was eventually solved by the appointment of the most experienced officer among the teams assigned to a field hospital platoon to perform the duties of surgical chief for the platoon. It was soon found that the most practical plan was to relieve this officer of all duties on his own team, so that he could devote himself entirely to the supervision of the work in the hospital. His duties included triage; supervision of preoperative preparation, resuscitation, and postoperative care; and consultation, as necessary, on wounds of particular severity or difficulty. His work in the operating room was limited to assistance in cases of this kind and to the demonstration of new techniques and of modifications of established techniques to the hospital staff.

    Not the least important of the functions of the chief of surgery was cooperation with the commanding officer of the hospital in the correlation of administrative and professional functions. In the last 6 months of the war, the chief of surgery in a field hospital came to be known, very properly, as the coordinator. The title was first employed in the 2d Platoon of the 3d Field Hospital, in which Lt. Col. Sigurd C. Sandzen, MC, of the 94th Evacuation Hospital, was serving as chief of surgery. Colonel Sandzen had requested this assignment.

    A similar request was made by Col. Eldridge H. Campbell, Jr., MC, of the 33d General Hospital, who served as surgical coordinator at the 1st Platoon of the 33d Field hospital during the Po Valley offensive, in April 1945. Colonel Campbell, earlier, had brought a complete team of anesthesiologist, nurses, and enlisted men to serve with him for several weeks in a field hospital.

    During the spring of 1944, it was proposed that a forward surgical unit be made up from the staff of the 38th Evacuation Hospital (fig.72), to handle first priority cases. The tables of organization and equipment for this unit were prepared, but the hospital found itself with so much to do that the proposal was dropped.

LIAISON WITH MEDICAL UNITS OF OTHER ALLIED ARMIES

    Part of Major Snyder's duties as consultant in surgery to the Surgeon, Fifth U.S. Army, included liaison with, and assistance to, Allied medical units

17 Both General Martin and his executive officer, Col. Charles O. Bruce. MC, thought that the difficulties which had arisen in the operation of field hospitals in the Mediterranean theater might be eliminated by the formation of a mobile army surgical hospital in which the commanding officer, a competent general surgeon, would serve as chief of surgery. This unit would have the proper number of qualified surgeons as part of its integral personnel, or its personnel could be supplemented, as necessary, by teams from an auxiliary surgical group. The tables of organization and equipment for such a unit were drawn up in the Office of the Surgeon, Army Ground Forces, to which Colonel Bruce was assigned after the war. It was a disappointment to Colonel Snyder that mobile army surgical hospitals were not used in Korea as field hospital platoons augmented by surgical teams bad been used in Italy.


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FIGURE 72. - Lt. Gen. Mark W. Clark, Commanding General, Fifth U.S. Army, visiting 38th Evacuation Hospital near Leghorn, August 1944. A. Visiting Pvt. Naka Masato, an American of Japanese descent, who was awarded the Oak Leaf Cluster. B. Visiting Pfc. Steven Auer.


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serving with the U.S. Army. The following activities are typical of this phase of his duties:

    On 26 November 1943, he visited a French field hospital near Monte Cassino. The unit was supposed to have three surgical teams, each working an 8-hour shift, and an attached mobile surgical unit. Each team, which consisted of a surgeon, an anesthesiologist, 2 nurses, and 2 corpsmen, was expected to handle 16 surgical cases in each 8-hour operating period. Since only two teams were presently attached to the unit, the staff was working 12-hour shifts. Two operating tables were in continuous use. The third table was supplied with fluoroscopic facilities. Tentage was limited, and sterilizers were in short supply, but otherwise the teams had all the equipment they needed. The surgical work at this hospital was excellent.

    On 9 January 1944, U.S. station and general hospitals at the Fair Grounds at Naples, which were receiving French wounded, were visited, to determine whether the complaint that surgery performed in French forward hospitals was too radical was justified. No instance of overzealous debridement was found in the patients examined, all of whom seemed in excellent condition.

    On 4 February 1944, Major Snyder, accompanied by Maj. Oscar P. Hampton, Jr., MC, then serving as acting consultant in orthopedic surgery for the theater, visited the 401st Evacuation Hospital (French), then located between Alife and Pratella. They came away with only admiration for the work being done. A suggestion made by Maj. Etienne Curtillet was promptly adopted in U.S. Army hospitals; namely, that plain fine-mesh gauze rather than petrolatum-impregnated gauze be used in wounds. Major Hampton was particularly impressed by this suggestion and did much to disseminate it.

    When a Brazilian Expeditionary Force joined the Fifth U.S. Army in the summer of 1944, U.S. Army medical officers were designated to supervise their training in first aid measures and field sanitation. Professional Brazilian personnel were at first assigned to the 38th Evacuation Hospital, which was supporting U.S. troops holding down the left flank of the Fifth U.S. Army sector; Brazilian troops had been integrated with these troops. When the 16th Evacuation Hospital moved to Pistoia in November 1944, Brazilian medical personnel were attached to it, and it was designated to care for Brazilian casualties. Lt. Col. Manuel E. Lichtenstein, MC, chief of surgery at this hospital, organized the Brazilian personnel into teams, with definite assignments, and they rapidly became an excellent working organization.

    Brazilian casualties who required evacuation from the Fifth U.S. Army area were sent to the 7th Station Hospital, which was then serving as a general hospital in Leghorn, and those who required evacuation from the theater were sent to the 45th General Hospital in Naples.

    On 5 December 1944, Major Snyder visited a platoon of the 32d Field Hospital beyond Pistoia, in which a Brazilian surgical team was working. The team was headed by the professor of surgery at the University of São Paulo, a well-qualified surgeon, whose team was doing excellent work.


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EQUIPMENT

Early Deficiencies

    When the 77th Evacuation Hospital arrived in England, the only equipment which it had for thoracic surgery was a pair of rib shears, a right and left rib raspatory, and a No. 14 French ascites trocar. Other general and special surgical equipment was also lacking. The explanation of some of these deficiencies came to light in North Africa, when it was discovered, from the 1918 newspapers in which the instruments were packed, that the table of equipment by which they had been provided was a World War I table.

    Observations in British chest centers (p. 333) showed that the British were well equipped for thoracic surgery at this time. Their sets had been standardized, and more than 50 had been distributed to Army, Navy, and Air Force units. They included long-handled instruments for working within the thorax; endoscopic equipment; adequate anesthesia apparatus; and various anesthetic agents for chest surgery, including cyclopropane. The equipment also included tables or cabinets equipped to convert electrical current into high frequency current for cutting and coagulation, as well as for converting the current into low-tension current for use with endoscopic and other lighted instruments. This type of table also had a suction machine attached. It thus took the place of (1) the Bovie apparatus used for cutting and coagulation, (2) the suction machine, and (3) the battery case or rheostat which provided low tension current for lighted instruments. The British regarded this particular piece of equipment as indispensable for chest surgery. Mobile thoracic surgery teams functioning in the United Kingdom were also supplied with all the equipment just listed, as well as with portable X-ray apparatus.

    The proper steps were at once taken to report the inadequacy of the 77th Evacuation Hospital equipment. Meantime, the medical officers on the staff each donated a small amount of money, which proved sufficient for the purchase of a suction machine and a Bovie electrosurgical unit for neurosurgery. Members of the thoracic surgery team personally purchased a bronchoscope and a number of instruments for thoracic surgery. The equipment was secured at the Genito-Urinary Manufacturing Company Limited in London, an old and well-established firma which had originally supplied only cystoscopes and other instruments for genitourinary surgery but which now handled equally excellent surgical equipment of all kinds.

    Even with the equipment supplied personally by members of the thoracic surgery team in the 77th Evacuation Hospital, its equipment, like that of other U.S. evacuation hospitals, did not begin to equal the British equipment for even their mobile surgical units. When the 77th Evacuation Hospital was assigned to the II Corps, Colonel Arnest and Major Amspacher did all in their power to bring the equipment up to standard requirements, but in the 10 days before the unit sailed for North Africa this was an impossible task. The deficiencies were


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unfortunate, for competent thoracic surgery is impossible without proper equipment.

    When the 77th Evacuation Hospital reached Oran and had to assume the care of casualties immediately (p.335), it found some of the equipment of the 38th Evacuation Hospital, which had landed at Arzew a little earlier, at the hospitals it was taking over. This was fortunate, for the 77th Evacuation Hospital did not receive any of its own limited equipment until several days after it had landed. The situation of this hospital in respect to deficiencies of equipment and delayed receipt of such equipment as had been provided was unfortunately characteristic of the situation of many other hospitals during the early fighting in North Africa.

    Recommendations. - When Major Snyder was placed on temporary duty in II Corps headquarters in March 1943 to evaluate the use of surgical teams in clearing stations (p.336), he made a number of recommendations to the Surgeon, II Corps, concerning the equipment of these teams, as follows:

    1. Portable anesthetic equipment is essential for the care of patients with certain types of wounds and must be provided if surgery is to be provided in clearing stations.
    2. A larger autoclave for sterilizing linens and dressings is a basic need, as is a field range burner unit for heating the sterilizer.
    3. A satisfactory portable operating table is also a basic need in each clearing station.
    4. A pelvic rest or a portable Hawley fracture table must be available for all general surgery teams as well as for all orthopedic surgery teams of auxiliary surgical groups.
    5. A portable suction machine would be of great value in the surgery of perforating wounds of the abdomen.
    6. Teams of auxiliary surgical groups should have their own transportation. These recommendations were all eventually carried out, though the question of transportation for teams from the auxiliary surgical groups was never entirely settled. In southern Tunisia, teams attached to the II Corps were provided with their own transportation by Colonel Arnest. When they returned to their headquarters, this transportation was turned in. The arrangements in Sicily were similar. After the headquarters of the 2d Auxiliary Surgical Group was moved to Italy, the group was authorized a certain amount of transportation, and Colonel Forsee maintained it in a motor pool, sending it forward as necessary when the teams had to be moved.

Sicily

    Before the invasion of Sicily, the field hospitals, which replaced clearing stations of medical battalions as the most forward installations in which surgery was to be performed, were provided with much more in the way of surgical equipment than the clearing platoons had possessed. There were, however, still a number of shortages.


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    One of the most conspicuous shortages was in anesthetic apparatus. In Sicily, evacuation hospitals had anesthetic machines, though the number was somewhat limited. Auxiliary surgical group teams working in field hospital platoons were still ill-equipped in this respect. Maj. (later Lt. Col.) Lawrence M. Shefts, MC, did most of his intrathoracic work, as a matter of necessity, under Pentothal sodium and oxygen, the oxygen being supplied through a BLB (Boothby, Lovelace, Bulbulian) mask. His results were extremely satisfactory. In fact, he performed so many operations with this sort of anesthesia without untoward consequences that he almost convinced himself and his associates that this was the ideal anesthesia for intrathoracic work, in which it is generally regarded as contraindicated.

    In Sicily, field hospitals had only a single X-ray machine for each hospital. It was promptly evident that if a field hospital's three platoons were to function satisfactorily as individual platoons, each must have its own X-ray equipment. X-ray equipment was also necessary in all holding units if adequate postoperative care was to be supplied.

    In 1943, when X-ray films were in short supply, limitations had to be placed upon the number used. In 1944, when supplies became more abundant, these limitations were removed. Then, almost without exception, roentgenograms were made before operation unless the surgeon was absolutely certain that there were no fractures and no retained foreign bodies. Some hospitals improvised large dryers, so that the dry processed films were ready when the patients went to the operating room.

    Transportation difficulties explained some shortages of equipment in Sicily. In one collecting station, for instance, three patients with compound fractures of the femur were brought in by litter between 12 and 18 hours after wounding, all of them unsplinted because the battalion surgeon, who was receiving his supplies by pack mule, had run out of splints and his fresh supplies had not arrived. It is a tribute to the atraumatic fashion in which these patients had been handled that none of them was in shock.

Italy

    After the first 6 months of the campaign in Italy, except for such special circumstances as have just been described, surgeons in the Fifth U.S. Army usually had the best equipment available for field surgery and had it in ample amounts. Some annoying and wasteful shortages, however, still persisted. A small electrical unit, equipped to resharpen operating knife blades, for instance, would have relieved the frequent shortages of these blades and would have prevented the discarding of instruments which otherwise might have been used for many more months.

    Some equipment, such as audiometers, was always in limited supply, and patients who required a study of possible hearing loss were sent to the special centers which possessed them. This was not an unreasonable arrangement. Similarly, casualties who required electrocardiograms had to be evacuated to


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the base until the 8th Evacuation hospital was established as the army center for all such investigations.

    Transportation of supplies was a considerable problem in Italy in April 1945, during the race across the Po Valley, when supply depots and dumps were still back in Florence. Medical supplies then often had to give way to more crucial needs, such as gasoline, ammunition, bridging materials, and rations.

Nonstandard Equipment

    One of the duties of the surgical consultant to the Surgeon, Fifth U.S. Army, was to advise him and his medical supply officer concerning the surgical equipment needed for all army medical installations. In line with this duty, requests for items in excess of tables of equipment were submitted to Major Snyder for comment and advice. His advice was always followed. Some of the additional equipment was really needed, but a great deal was not. It often took newly inducted officers some time to learn that they were not operating under conditions of civilian life and must make do with what they were given. As a matter of fact, a directive from the theater commander permitted the army surgeon to make additions to the equipment lists of hospitals in the area as he considered it necessary. This permission was a great aid to efficient functioning when demands on a hospital were abnormally high or when special equipment was really needed.

Anzio

    Supplies at Anzio furnished a number of critical problems, though the original landings were without incident. The first section of the Advance Platoon, 12th Medical Depot Company, arrived with the second wave of assault troops on D-day. After the first landings, however, no other medical supplies could be landed for the next 5 days. Fortunately, enough had been brought ashore to cover this period. So many supplies were destroyed by shelling when they were concentrated in the usual dumps that it was necessary to distribute them widely, in order to protect them.

    Acute shortages of blankets, litters, and similar items developed because, when patients were loaded on LST's for evacuation to Naples, there was no time, and it was not the place, for exchanges and bookkeeping. Eventually, a plan was set up of placing an empty 3/4-ton truck on every boat which took casualties to Naples. When the ship arrived at the base, the truck was loaded with litters and blankets which were provided by the hospitals receiving the patients. The truck was returned to the beachhead on the LST.

Improvisations

    The development of improvised equipment to overcome shortages and of special devices to improve techniques was heartily encouraged in all hospitals, and information concerning these items was promptly disseminated. The improvisations ranged from the simple bending of the rod in an ammunition box


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to fit it for use as a plasma stand to the construction of a refrigerator for the storage of whole blood.

    The 47th Armored Medical Battalion, when a shadowless light for the operating room was required, constructed one by reclaiming the headlights of several vehicles destroyed by enemy action and inserting the frosted, cross-ribbed glass in front of a light bulb. When the light was attached to a swinging arm, it could be focused on the wound without casting a shadow. When medical officers of the same unit were called upon to explore eardrums without an otoscope, a very efficient one was constructed from a flashlight, an aluminum cone salvaged from a crashed enemy aircraft, and a magnifying glass.

    At the 38th Evacuation Hospital, an excellent vacuum bottle was devised from an old Baxter saline bottle. A tire patch was used to cover the two holes in the rubber stopper. A small amount of citrate solution was then placed in the bottle which was autoclaved with the rubber stopper inserted loosely. As soon as the autoclave was opened, the stopper was jammed into the neck of the bottle. Enough suction could be developed with this improvised vacuum bottle to withdraw a liter of blood. The same bottles were used in donor sets as well as for aspiration of the chest. They worked very well for all of these purposes. One improvisation, the use of Baxter bottles in which saline solution had been put up to collect urine, proved of great clinical usefulness. It was essential that accurate urinary output records be kept on all patients in field hospitals, but there was very little time and very limited personnel for this purpose. The problem solved itself when a Baxter bottle was kept by the cot of every patient in a field hospital unit and the contents were measured each time (usually twice daily) the bottle was emptied. This proved a very practical method of recognizing oliguria and impending anuria.

    Suction for intra-abdominal surgery was provided by an ingenious plan in the clearing station at Gafsa and in the 48th Surgical Hospital at Fériana. A jeep or command car was moved close to the operating tent, and a long rubber tube was connected to the suction apparatus which ran the windshield wiper of the car. The tubing was brought into the tent and connected to a suction bottle, after which the windshield wiper was turned on. This meant the sacrifice of a needed vehicle, but commanding officers were more than willing to give up a car to provide this very essential aid to abdominal surgery.

The Relation of Equipment to Results

    After the Peninsular Base Section was established, all Fifth U.S. Army medical supplies were secured from it, as were supplies for the French and Brazilian units, and sometimes for the Italian and British units, which served with this army. During the Italian fighting, 2,524 tons of medical supplies were received by the l2th Medical Depot in the Peninsular Base Section, and 2,402 tons were issued.

    Surgery in the Fifth U.S. Army showed steady improvement and increasingly good results after the landings in Salerno. While there is no doubt that


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part of the considerably less good results originally secured can be explained by inexperience of surgeons untrained in military surgery, equipment shortages also had something to do with them. Later, when experience had been accumulated and supply shortages had ceased, the surgical results in the Mediterranean theater were outstanding, and a continuous flow of highly efficient equipment undoubtedly played some part in them.

REASSIGNMENT OF MEDICAL UNITS FOR OPERATION ANVIL

    In July 1944, in preparation for the invasion of southern France (Operation ANVIL) by the Seventh U.S. Army on 15 August 1944, the following medical support was withdrawn from the Fifth U.S. Army:

    1. The 52d and 56th Medical Battalions.
    2. The 10th and 11th Field Hospitals.
    3. The 11th, 93d, and 95th Evacuation hospitals, each of which had a capacity of 400 beds.
    4. Half the teams of the 2d Auxiliary Surgical Group.

    The surgical burden thus thrown upon the remaining medical support of the Fifth U.S. Army, while enormous, was not felt immediately because the fighting had slowed down considerably when these units were withdrawn. When, however, the character of combat changed from the battle of pursuit which had occurred during July and August to the bitter fighting during the North Apennines campaign in the fall and winter of 1944-45, the changed tactical situation produced the heaviest sustained combat load in the history of the Fifth U.S. Army.

    The medical service of the Army was called upon to handle this load with seriously impoverished resources; at first only one new unit (the 15th Field Hospital) was assigned to it to replace the two field hospitals and the three evacuation hospitals which had been withdrawn to support the Seventh U.S. Army. Medical personnel worked at top speed to try to keep abreast of the constant flow of admissions, but there was a limit to the physical endurance of the surgeons, and it was necessary to acquire surgical teams from base hospitals to augment their depleted numbers.

    The use of these teams, for a number of reasons, was not the solution of the problem, and the difficulties of the medical service were brought to the attention of the Commanding General, Fifth U.S. Army, in a letter from time Surgeon, Fifth U.S. Army, and were in turn brought by him to the attention of the Commanding General, NATOUSA, on 15 December 1944, as follows:

    Based on the assumption that Fifth Army would consist only of one U.S. Corps (with not more than three divisions actively engaged) with a very narrow front, an unusually large number of Fifth Army service units were assigned to Seventh Army to support adequately French and U.S. Operations. Since 15 July 1944, the 92nd Infantry Division, a Brazilian Infantry Division, the * * * Infantry Regiment and the * * * Tank Battalion have been added to the Fifth Army troop list without addition of any service units other than those being activated. * * * Not only has there been an increase of combat troops,


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but Fifth Army has been required to commit two corps on a wide front * * * with the result that a very critical shortage of service units has developed and is severely handicapping the Fifth Army operations at one of the most critical times of the Italian Campaign. Fifth Army now has seven Evacuation Hospitals to support six U.S. divisions, one Brazilian Division and one separate infantry regiment * * * One complete surgical group is necessary to provide adequate surgery for Fifth Army * * * Fifth Army has operated several months with an insufficient number of surgical teams and it has been necessary to provide teams from Evacuation Hospitals for Field Hospitals in forward areas and this has seriously reduced the surgical service of the Evacuation Hospitals * * * A few teams have been provided from base units at various times * * * If it was necessary to attach these teams during the time Fifth Army was regrouping, additional teams will be necessary when active operations begin * * * Duration of attachment of Base Section Hospital teams to Evacuation Hospitals has been limited and the teams are often recalled during the time when their need is critical. The solution most desirable to Fifth Army is the return to Fifth Army of that part of the Second Auxiliary Surgical Group which was assigned to Seventh Army * * *

    "The solution most desirable to Fifth Army" did not come to pass, and the medical service problems were resolved as follows:

    1. The 29th Station Hospital was converted to the 170th Evacuation Hospital. The responsibility for its conversion, the training of unit personnel, and the assembling of appropriate equipment for the operation of an evacuation hospital was assigned to the Surgeon, Fifth U.S. Army.
    2. At the same time, the 15th Field Hospital was assigned to the Fifth U.S. Army. The headquarters and two platoons were withdrawn from Corsica and the remaining platoon was withdrawn from Seventh U.S. Army control in southern France.

    Medical service in the Fifth U.S. Army was not further augmented through the remainder of the war in Italy.

RECORDS, SPECIAL REPORTS, AND PUBLICATIONS

    Records. - In all tours of hospitals, Major Snyder made it a practice to discuss clinical records, examine them at random, and insist that they be kept complete and up to date. He made detailed notes of special cases in his official diary, especially those from which lessons could be learned concerning good management as well as poor management and frank errors. These case histories, as already noted, proved very useful in the educational program.

    Essential Technical Medical Data reports were carefully read before they were transmitted to the Surgeon, Fifth U.S. Army. Major Snyder added such comments as seemed indicated, but the reports were neither condensed nor edited. He also submitted with them any material of value which he had collected himself.

    Full records were always kept by the teams of the 2d Auxiliary Surgical Group, first by the members themselves. In the course of the fighting in southern Tunisia, Major Amspacher directed that the teams send copies of their clinical records on all II Corps casualties to the corps surgeon's office. Colonel Forsee continued this policy, and during 1944 and 1945 team records of surgical


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cases were kept on special forms and in duplicate. The analysis of the material for 1944 and 1945 represents the most complete and most careful study of a series of combat-incurred abdominal injuries ever to be recorded. It forms the major portion of one of the surgical volumes of the history of the U.S. Army Medical Department in World War II 18

    Special reports. - A number of special surgical investigations were made in the Fifth U.S. Army and were formally reported to the army surgeon, as follows:

    1. Shock, with special reference to hematocrit and plasma protein values, by Capt. Joseph J. Lalich, MC (p.412).
    2. Shock, by Maj. D. Stewart, MC (p. 413).
    3. Transfusion therapy in battle casualties with evidences of circulatory failure, by Captain Lalich.
    4. The surgery of abdominal wounds, by Maj. Fred J. Jarvis, MC.
    5. Intrapleural and intrathoracic wounds, by Capt. (later Maj.) Leon M. Michels, MC.
    6. Thoracoabdominal battle casualties, by Capt. Henry L. Hoffman, MC, and Capt. Aaron Himmelstein, MC.
    7. Trenchfoot, by Maj. Fiorindo A. Simeone, MC (p.428).
    8. Arterial injuries, by Major Simeone (p.431).
    9. Gas gangrene, by Maj. Floyd II. Jergesen, MC, and Major Simeone (p.445).
    10. The physiology of the severely wounded, by a special board from the theater surgeon's office, which partly elucidated, but did not solve, the special problems of oliguria and anuria in wounded men. This report forms another of the volumes of the surgical series in the history of the U.S. Army Medical Department in World War II.19

    Publications. - Major Snyder consistently encouraged individual medical officers who were accumulating a wide experience in war surgery and in the management of shock and other related conditions to keep their own detailed records and, later, when their data were sufficiently comprehensive, to prepare it for publication in scientific journals. He read all of the articles to be submitted for publication and returned them to the authors for necessary alterations before they were cleared for the journals of choice.

    In all, some 50 articles were submitted for publication from the Fifth U.S. Army, covering a wide range of subjects, as follows: Administrative considerations, including the use of surgical teams from auxiliary surgical groups; shock and resuscitation, including the use of whole blood ; anesthesia; gas gangrene; trenchfoot; chemotherapy and antibiotic (penicillin) therapy; causes of death in battle casualties; craniocerebral wounds; maxillofacial

18 Medical Department, United States Army. Surgery in World War II. Volume II. General Surgery. Washington U.S. Government Printing Office, 1956.
19
Medical Department, United States Army. Surgery in World War II. The Physiologic Effects of Wounds. Washington: U.S. Government Printing Office, 1952


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wounds; chest injuries, including contributions on wet lung, nerve block, decortication in empyema and hemothorax, and wounds of the heart; thoracoabdominal injuries; wounds of the abdomen, with special reference to wounds of the colon and rectum; urogenital wounds; and vascular surgery, including the use of the tourniquet.

STATISTICS

    From the beginning of combat in North Africa in November 1942, much emphasis was placed upon the importance of performing post mortem examinations on all patients who died in army hospitals. Theoretically, this should have been a routine matter; the understanding was that autopsy would be performed in all such deaths. Actually, for a variety of reasons-not all of them based upon the pressure of work--autopsy was omitted in many cases.

    This was the situation in the North African theater late in 1943 when Major Snyder initiated a special project concerned with the detailed analysis of deaths from combat-incurred wounds in Fifth U.S. Army Hospitals.

    On 31 December 1943, Colonel Martin, the army surgeon, sent a letter to all hospitals in the Fifth U.S. Army area directing that complete records of all deaths in these hospitals, including the autopsy protocols, be submitted to his office. Reports began to come in promptly, but some hospitals were negligent or careless about the details required, and on 22 April 1944 the attention of commanding officers of hospitals was called to Colonel Martin's original letter.

    There was a progressive increase in the percentage of post mortem examinations reported as time passed (table 7), the proportion rising from less than a third of the deaths reported in the January-March 1944 period to more than 80 percent in the January-May 1945 period. There was also a corresponding rise in the number of histologic examinations in autopsied cases.

    From the time the project was initiated, the analysis of these reports occupied the attention of the surgical consultant for at least part of his time several days a week. Each case history was carefully studied, and an unexpectedly large amount of information was secured from them. For one thing, it was possible to evaluate the results of various methods of treatment as well as the overall care the casualties were receiving in army hospitals. For another, the analysis proved extremely useful in the educational program which was still underway because inexperienced units were still coming into the theater. If errors were disclosed which needed correction, they were discussed immediately with the responsible personnel. This proved a rapid and practical way of instructing inexperienced surgeons in the principles and practices of military surgery.

    The medical circular issued from the Office of the Surgeon, Headquarters, Fifth U.S. Army, on 7 April 1944, 20 is an illustration of the practical applica-

20 See footnote 11, p.361.


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TABLE 7. - Periodic analyses of post mortem studies in Fifth U.S. Army hospitals, 1 January 1944-2 May 1945 1

tion of these analyses. It was prepared by the surgical consultant as soon as certain errors in triage became evident in the survey of these post mortem reports. Paragraph four of this circular follows:

    4. Intra-abdominal wounds have been overlooked particularly when the wound of entrance was not in the abdominal wall. Patients who have received plasma for shock at Battalion Aid Stations, Collecting Stations, Clearing Stations, or Field Hospitals, have been sent on to Evacuation Hospitals, when their blood pressure readings returned to normal. This group of patients is particularly prone to develop severe shock with further evacuation and should receive surgical care in the most forward Field Hospital unit. Failure to recognize first priority cases in other categories has been costly. Careful triage or sorting in the clearing station will save lives.

    Analyses concerned with various periods of the Italian campaign showed a progressive improvement in the results of surgery on combat casualties. It was thought that this study, which was based upon insistence on good clinical records, played no small part in the continued improvement in results in army hospitals and in the high level of achievement finally attained.

    In March 1945, Capt. (later Maj.) James W. Culbertson, MC, 8th Evacuation Hospital, was placed on temporary duty in the office of the army surgeon to work with Colonel Snyder in the preparation of a formal report on these studies.21 Captain Culbertson devoted his entire time to this project. until it was completed early in September 1945.

21 Snyder, Howard E., and Culbertson, James W.: Study of Fifth U.S. Army Hospital Battle Casualty Deaths. In Medical Department United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962, pp. 473-530.


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Analysis of Hospital Deaths

    Between 1 January 1944 and 2 May 1945, the date of the German surrender in Italy, 1,562 deaths from battle-incurred injuries in Fifth U.S. Army hospitals in Italy were reported to Major Snyder. Sufficiently detailed records on 1,450 of these reached him in time to be included in his analysis. When these records were examined in detail, it was found that 39 of the cases included in them did not entirely fit the terms of reference of the study, as these patients were dead on arrival. The number of the complete analyses, therefore, was necessarily limited to 1,411 cases.

    The data analyzed by Colonel Snyder and Captain Culbertson (tables 8 through 13) included the distribution of wounds and deaths by periods according to the anatomic location of the injury, the wounding agent, and the place of death (field or evacuation hospital); and the principal causes of death. The tables reproduced herewith represent only a small proportion of the enormous amount of data secured in the analysis.

    It is difficult to make precise statements about battle casualty deaths because of the large number of variables concerned, some of which are beyond control. Misleading conclusions, furthermore, are readily arrived at unless statistics are interpreted in the light of circumstances.

    It is generally agreed that, in all wars, the proportion of casualties who die on the battlefield of their wounds is about 20 percent, or one in every five. This was true in Italy, in which the percentage for the January 1944-May 1945 period was 19.86. The proportion was highest (20.7 percent) in the January- March 1944 period and lowest (18.84 percent) in the August-December 1944 period.

    A valid method of analyzing the efficiency of a medical service is on the basis of the number of wounded who reach hospitals alive. Hospital case fatality rates, however, are dependent not only upon the efficiency of the

TABLE 8 - Percentage distribution of wounds and deaths according to anatomic location of injury in 71,000 casualties admitted to Fifth U.S. Army hospitals, 9 September 1943-31 May 1945


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TABLE 9. - Percentage distribution of wounding agents, and deaths therefrom, in 71,000 casualties admitted to Fifth U.S. Army hospitals, 9 September 1943-31 May 1945 1

medical service that the hospital provides but also upon the efficiency of the evacuation service which brings casualties to it. At Anzio, where hospitals were located very close to the frontline, casualties reached the hospitals rapidly, and the hospital case rate was as high as 5.7 percent. At other times and in other areas, when hospitals were further removed from the front, hospital case fatality rates were much lower. Generally speaking, however, the overall mortality is improved by rapid evacuation, which brings the patient to surgery more promptly.

    In Italy, between January 1944 and May 1945, inclusive, a number of surveys produced the following data:

    1. In the January-March 1944 period, 35.3 percent of all casualties who died in army hospitals died before the induction of anesthesia. The percentage fell during successive surveys and reached 21.6 percent during the January-May 1945 period.
    2. In the January-March 1944 period, 7.3 percent of all battle casualties who were killed in action or died of wounds died in hospitals after the induction of anesthesia. The percentage also fell during successive surveys and reached 5.3 percent during the January-March 1945 period.
    3. In the January-March 1944 period, 1.515 percent of all battle casualties (including those killed in action and those injured or wounded in action) died in hospitals after the induction of anesthesia. The percentage also fell


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TABLE 10. - Comparative frequency of wounds according to anatomic location of injury in 22,246 casualties admitted to Fifth U.S. Army hospitals, 1 August 1944-31 May 1945

during successive surveys and reached 1.05 percent in the January-March 1945 period.

Other Data

    Certain other statistical data might also be listed, as follows:

    1. During 1944, 17 percent of all casualties in the Fifth U.S. Army were killed in action, and 72 percent were wounded in action. The remainder were missing in action or were taken prisoner.
    2. Of the 72 percent wounded in action, 2.5 percent were returned to duty from division clearing stations after treatment, and 9 percent were given surgical care in field hospitals. The remainder received initial wound surgery at evacuation hospitals.


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TABLE 11. - Comparative case fatality rates according to anatomic location of injury in 22,246 casualties admitted to Fifth U.S. Army hospitals, 1 August 1944-31 May 1945

    3. Of the wounded in action who reached medical installations, 2.9 percent died of wounds. Of these, 7 percent died in division clearing stations, 33 percent in field hospitals, and the remainder in evacuation hospitals.
    4. The case fatality rate in wounded casualties who received emergency surgery in field hospitals was 10.9 percent, against 1.9 percent in casualties evacuated to evacuation hospitals for treatment.
    5. Of the 97.1 percent of wounded casualties who were treated in army hospitals and survived, about 17 percent were returned to duty from the army area. The remainder were evacuated to base hospitals.


405

TABLE 12. - Distribution of 1,450 deaths from battle-incurred wounds in Fifth U.S. Army hospitals, 1 January 1944-2 May 1945, by location and type of wound 1

VISITS TO ARMY MEDICAL INSTALLATIONS

    As already mentioned, Major Snyder spent most of his time in the field, particularly in the period immediately after his appointment as consultant in surgery to the Surgeon, Fifth U.S. Army. At this time, there were numerous newly arrived hospitals in Italy, without previous combat experience, and it was essential that they be indoctrinated promptly in the principles and techniques of military surgery.

    When this immediate emergency had passed, there were numerous other problems to solve, and, until the end of the war, Major Snyder continued the practice of visiting hospitals. As figures 73, 74, and 75 indicate, these visits were far too numerous to be recorded in detail within the limits of this chapter. The following summarized accounts, however, are representative of Major Snyder's activities during these visits.

    95th Evacuation Hospital. - Major Snyder's first tour of Fifth U.S. Army medical installations after his appointment as surgical consultant to the army began with a visit to the 95th Evacuation Hospital in Naples on 13 and 14 October 1943. The method he employed there was substantially the same as that used in all his subsequent tours.


406

TABLE 13. - Percentage distribution of principal causes of death in 1,450 battle casualties admitted to Fifth U.S. Army hospitals, 1 January 1944-2 May 1945 1

     His first conference, which was with the chief of surgery, consisted of an evaluation of the qualifications of the surgical personnel of the hospital and their assignments. He then made rounds with the chief of surgery and the other surgeons on the staff, discussing with them techniques of management of the various wounds encountered. He also observed operations. He lost no opportunity of taking informally to the members of the staff, doing a great deal of indirect teaching in this way.

    At the conclusion of the visit, he met with the entire staff. The subjects discussed included the management of injuries of the extremities, with special emphasis on the importance of adequate debridement in those in which gas gangrene was a possibility; the routine in abdominal wounds and in chest surgery; the rise of the sulfonamides (penicillin was not yet generally available); the importance of holding patients after surgery until they were safely transportable; and the importance of careful recordkeeping, his suggestions being based upon his random examination of the patients' charts.

    36th Division. - Medical units of the 36th Division were visited during the period 25-27 October; a day was spent in each of the infantry regiments.


407

FIGURE 73. - Medical installations in Italy, visited by Maj. Howard E. Snyder, MC, during March 1944.

    Here, Major Snyder talked to medical officers and first aid men on the use of Thomas' splint; the techniques of control of hemorrhage, with special emphasis on the dangers connected with the application of tourniquets; the precautions necessary in the use of morphine and the dangers of overdosage; and the importance of complete and accurate recording of the data required on the emergency medical tag. In his later talks with medical officers, Major Snyder reported to them on the surgery he had witnessed in hospitals in the theater. He recommended that they visit hospitals in the army area whenever the opportunity presented itself, so that they might see, in rear units, results of their own work in forward units.

    On the third day of this tour, the division surgeon called a meeting of the regimental surgeons, the company commanders of the medical battalion, and


408

FIGURE 74. - Hospitals near Anzio, Italy, visited by Major Snyder during March 1944.

other medical officers for a general discussion of surgical problems in the division. The discussion covered gas gangrene; the use of tourniquets; the danger of circular bandages; the contraindications to packing of wounds; and the management of abdominal injuries in forward installations. It was arranged that battalion surgeons be equipped with 30-cc, syringes and ampoules of serum albumin and with sulfadiazine crystals for intravenous use.

    33d Field Hospital. - On 2 and 3 November 1943, Major Snyder with Captain Jergesen, visited the 2d Platoon of the 33d Field Hospital, which was located beyond Dragoni and west of Alife. The outstanding impression of this visit was the observation of an extremely severe case of clostridial myositis involving the right upper extremity and the chest wall.

    On 6 November, the 3d Platoon of this same hospital was visited, with Maj. Henry K. Beecher, MC; this platoon was supporting the clearing station of the 45th Division south of Venafro. Although the hospital had not been very busy previously, Italian casualties from a mine explosion had been brought in just before these observers arrived, and there were so many serious chest and abdominal wounds associated with deep shock that an auxiliary surgical group team from the 94th Evacuation Hospital had to be brought up to help with the necessary surgery. Some of the surgery was excellent, some not so good. On


409

FIGURE 75 - Medica1 installations in Italy, visited by Colonel Snyder during December 1944.

the following day, a conference with the surgeons in this platoon was participated in by Major Beecher, Captain Jergesen, and Major Snyder. The importance of blood replacement was particularly emphasized. One patient with gas gangrene was observed at this platoon.

    On 7 and 8 November, the 2d Platoon of the 33d Field Hospital, which was now near Pratella was revisited. Operation on a thoracoabdominal wound was observed, and the surgery on a complicated chest case was performed by Major Snyder, with Major Beecher giving the intratracheal anesthesia.

    At this time, many of the hospitals were quite close together, and it was therefore possible, on 8 November, to conclude the visit at the 2d Platoon of the 33d Field Hospital, visit the l5th Evacuation Hospital that night and the next morning, and go on to the 93d Evacuation Hospital the following day, 9 November.

    On 10 November, the 1st Platoon of the 33d Field Hospital was visited. It was set up adjacent to the 1st Division clearing station, near Venafro, about 4 miles from the frontlines. The clearing station was surrounded by a battery of British 5.5-inch guns, and the noise was terrific. Several patients who had been operated on were observed, all obviously in need of blood, more liberal


410

use of which was recommended. Several cases of gas gangrene were also observed. Captain Jergesen talked to the staff on anaerobic infections, and Major Beecher spoke on blood transfusions.

    A brief visit to the 94th General Hospital on the afternoon of 10 November ended this particular tour of army hospitals. On many other tours, quite as many installations were visited.

    The Anzio beachhead. - The first of the nine trips which Major Snyder made to the Anzio beachhead after the landings there on 22 January 1944 lasted (including the travel time from Naples to the beachhead and return) from 6 February to 10 February, inclusive. The other trips were made in February, one in March, one in April, three in May, and the last in June. All of these trips were for periods of several days, and between 23 May and 6 June Major Snyder was continuously on the beachhead.

    The first trip from Naples to Anzio was complicated by a German air raid just as the LST docked at Nettuno. The Germans were shelling the docks at rather frequent intervals, and bombing continued off and on during Major Snyder's inspection of the 33d Field Hospital and the 56th, 93d, and 95th Evacuation hospitals, which were grouped together a few miles from the beach. The casualties from these raids have already been described (p. 346).

    On his second trip to the beachhead, from 13 through 17 February 1944, Major Snyder began to take his turn at time operating table, as he did our subsequent visits.

    The final offensive on the Anzio beachhead was launched on 23 May 1944. As soon as word of it was received, Major Snyder went up by the first available transportation (LST). Casualties were heavy, and immediately on his arrival, after he had made rounds at the 33d Field Hospital and the 11th, 15th, 38th, and 94th Evacuation Hospitals, he began to assist with the heavy backlog of operations at the 38th Evacuation Hospital. For the first 48 hours, he and Captain Jergesen operated together. Then each of them acquired an assistant and worked separately. During this period, Major Snyder made daily morning and evening rounds in all the hospitals in the area.

    Shortly after the fall of Rome, on 4 June 1944, the 38th Evacuation Hospital was set up in Rome, and Fifth U.S. Army headquarters were moved to Anzio. Thus, one phase of the medical responsibility in Italy ended.