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Chapter XVIII

Contents

CHAPTER XVIII

Seventh U.S. Army

Frank B. Berry, M.D.

THE LANDINGS IN SOUTHERN FRANCE

    The invasion troops of the Seventh U.S. Army, which landed in southern France on 15 August 1944, consisted of the 3d, 36th, and 45th Infantry Divisions (fig.88). All had had long combat service, either with the II Corps in the operations in North Africa, during the campaigns in 1942-43, or with the Fifth U.S. Army in Italy. These troops were therefore battlewise and were also thoroughly familiar with the functioning of their own first and second echelon medical services in combat, as well as with the functioning of supporting corps and army medical organizations.

    With a single exception, the 51st Evacuation Hospital, all the hospital units originally assigned to the Seventh U.S. Army for the invasion had seen service in the North African, Sicilian, and Italian campaigns, and all were well staffed. When the 51st Evacuation Hospital landed in southern France, it had not even unpacked its equipment since loading at the port of embarkation in the United States. It was therefore an unknown quantity at the time of the landings. It had, however, a well-balanced and well-trained staff of surgeons who had been carefully selected for this particular mission, and it had functioned as a unit on extensive desert maneuvers in the Zone of Interior. As a result, it was soon able to carry heavy loads for sustained periods.

    The teams of the 2d Auxiliary Surgical Group which landed on D-day in southern France had also seen service in all previous campaigns in the North African theater.

    As a result of their previous experiences, these organizations were all familiar with the professional policies developed by Col. Edward P. Churchill, MC, Consultant in Surgery to the Surgeon, MTOUSA (Mediterranean (formerly North African) Theater of Operations, U.S. Army), and had profited by his instructions. They were also familiar with the professional aspects of medical care of military casualties as these policies were promulgated in the technical circular letters issued from the office of the theater surgeon. The surgical care of all patients in Seventh U.S. Army installations was origina1ly based upon the principles developed in previous campaigns and set forth in these letters. Later, it was also based upon the principles set forth in publications from the Office of the Chief Surgeon. headquarters, ETOUSA (European Theater of Operations, U.S. Army).


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FIGURE 88. - Landing of the 3d, 30th, and 45th Infantry Divisions, Seventh U.S. Army, and their maneuvers from beaches to Blue Line, 15 August 1944.

PRELIMINARY MEDICAL PLANNING

    Plans for the provision of professional medical services for the invasion of southern France fell into the following four categories:

    1. Definitive surgical policies were established in Circular Letter No. 2, Office of the Surgeon, Headquarters, Seventh U.S. Army, dated 18 July 1944 (appendix B, p.583).
    2. Additional personnel were provided for the field hospitals and 400-bed semimobile evacuation hospitals to be employed during the landing phase, as well as for the hospital ships, LST's (landing ships, tank), transports, and the First Special Service Force. The latter organization was a mixed Canadian


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and American group, which, like rangers and commandos, had a special combat mission.
    3. An adequate supply of fresh blood and adequate supplies of penicillin were provided to be landed with the assault forces on P-day. Provision was also made for the daily delivery thereafter, beginning on D+1, of blood and penicillin from Naples to France.
    4. Assistance was offered to the First French Army, which was to accompany the Seventh U.S. Army, particularly in respect to supplemental training of medical officers, hospital supplies, and the delivery of blood.

Surgical Policies for the Invasion

    Standard surgical policies for the care of the wounded in the Seventh U.S. Army were set up under the supervision of Col. Myron P. Rudolph, MC, army surgeon, and in consultation with Colonel Churchill.

    The NATOUSA (North African Theater of Operations, U.S. Army) circular letters for 1943 and 1944, as well as Circular Letter No. 71, Office of the Chief Surgeon, ETOUSA,1 were freely utilized in the preparation of aforementioned Circular Letter No. 2 which set forth the principles of professional management for the invasion and thereafter.

    Plans were also made for a continuing flow of medical information to the consultant in surgery from army hospitals during the entire campaign, in order to assure the best standards of professional care by continuing analysis of the incidence of special types of wounds, the performance of special operations, the incidence of special complications, the use of whole blood, and similar matters. These data were requested in Circular No.15 in August 1944 2 and are discussed later in this chapter under appropriate headings.

Hospitals and Medical Personnel

    Planning for the invasion provided for the landing of hospitals and medical personnel by the following schedule. No nurses were put ashore with any unit until D+4.

    1. Provision was made for the landing on D-day, with the first assault troops, of beach clearing companies, which were to be under Navy control until the landing forces had secured the beachhead. In the 3d and 45th Division sectors, the surgical teams attached to the field hospitals landed with the clearing companies and remained with them until the beachhead had been secured.

    Two field hospitals were also to be landed with the next wave of assault troops. Two platoons of the 10th Field Hospital were to support the 3d Division, and two platoons of the 11th Field Hospital were to support the 36th

1 Circular Letter No. 71, Office of the Chief Surgeon. ETOUSA, 15 May 1944, subject: Principles of Surgical Management in the Care of Battle Casualties.
2
Circular No. 15, Seventh U.S. Army, 31 Aug. 1944.


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Division. The third platoons of these hospitals were to land with the 45th Division.

    Also to be landed with the invading troops was a detachment of the 2d Auxiliary Surgical Group, composed of 14 general surgical teams, 3 shock teams, 3 orthopedic teams, 2 thoracic-surgical teams, and 1 neurosurgical team. These teams were to be divided among the field hospitals.

    The field hospitals which landed with tile invading troops were also augmented by teams drawn from the 750-bed evacuation hospitals and the general hospitals designated for later landings. These teams, which were also intended to reinforce the 400-bed evacuation hospitals to be landed late on P-day and on D+1, included (1) general surgical teams, consisting of a surgeon, an assistant surgeon, an anesthesiologist, and two technicians, and (2) shock teams, consisting of one medical officer and three technicians. Skilled technicians were also drawn from the same pool and attached to field hospitals, to perform nursing functions until the nurses assigned to these hospitals were landed on D+4. All reinforcing personnel were to be automatically returned to their own units as soon as their units had been landed.

    The forward distributing section of 6703d Blood Transfusion Unit (Overhead) also landed with the invading troops on D-day.

    2. Plans were made for the landing on D-day and D +1 of three semimobile (400-bed) evacuation hospitals. Two maxillofacial teams, two dental-prosthetic teams, and one neurosurgical team, all from the 2d Auxiliary Surgical Group, were attached to these hospitals.
    3. The nurses assigned to the field and 400-bed evacuation hospitals were to be landed on D +4, as were the nurses assigned to the teams of the 2d Auxiliary Surgical Group, which had been landed earlier.
    4. Four 750-bed evacuation hospitals were to be landed between D+10 and D+15.

    In addition to the personnel attached and assigned to the organizations just mentioned, other personnel had to be provided, as follows:

    The First Special Service Force required six additional medical officers and one additional enlisted technician.

    Forty medical officers were needed on transports and LST's, to care for the troops on them and for such wounded as might be evacuated by sea.

    One or two additional surgeons were required for each of the hospital ships to arrive on the far shore on D +1 and D + 2.

    These special needs, as will be pointed out elsewhere, were underestimated in the initial planning.

MEDICAL ASPECTS OF THE INVASION

    The landings in southern France were conducted as planned in almost all respects (fig. 89). The 3d Division landed on a beach to the west of Saint-


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FIGURE 89. - Operations in southern France, l5-25 August 1944.


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Tropez and the 45th Division landed on a beach to the east. The 36th Division, which landed at Saint-Raphael, encountered considerable enemy resistance and was unable, until 48 hours after the first landings, to use one of the beaches which, according to plans, it was to occupy. The three areas on which troops were landed were about 50 miles from each other. Headquarters, Seventh U.S. Army, was located at Saint-Tropez.

    Beach detachments (fig. 90) were set up almost immediately after the troops began to land, and, by the night of D-day, two field hospital platoons were in full operation. Shortly after the landings, the division surgeon of the 36th Division reattached two of the general surgical teams, which had landed with the 11th Field Hospital, to the beach clearing station of the 56th Medical Battalion, to permit more work to be done in it.

    Each division had been made responsible for its own loading. The ETMD (Essential Technical Medical Data) reports for the 36th and 45th Divisions and for the 56th Medical Battalion reported too great dispersion in the loading of both personnel and equipment, with resulting delay and confusion in unloading and in the establishment of beach clearing stations and field hospitals.

    The personnel and medical supplies of the 3d Division had been so loaded that both attached platoons of the 10th Field Hospital could be unloaded promptly on D-day. One platoon had been set up and was receiving patients late in the evening, and the other began to operate the following day. One of these platoons was located in the same area as the beach clearing station of the 52d Medical Battalion.

    The personnel of some of the 400-bed evacuation hospitals landed on D-day. Their equipment began to be unloaded on D+1. The 93d Evacuation Hospital, supporting the 45th Division, began to operate on D+2, and the 11th and 95th Evacuation Hospitals on D+3. These three hospitals were reinforced by surgical teams and other teams from the 9th, 27th, and 59th Evacuation Hospitals (750-bed hospitals), which were to be landed between D+10 and D+15, as well as by teams from the 21st, 36th, and 43d General Hospitals. There was thus an abundant supply of medical officers and enlisted medical personnel on shore at all times. As later convoys arrived, some of the medical officers who had been withdrawn from general hospitals for temporary assignment to troopships were attached to evacuation hospitals then in operation while awaiting the arrival of their parent organizations.

    Medical facilities to care for lightly wounded casualties who could be returned to duty, as well as for neuropsychiatric patients and patients with venereal disease, were set up and in operation by D+4.

    The 6703d Blood Transfusion Unit (Overhead) landed as scheduled on D-day and was immediately attached to the 52d Medical Battalion. Later, it was attached to the platoon of the l0th Field hospital supporting the 45th


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FIGURE 90. - Views of naval aid station on Red Beach, just east of the town of Cavalaire-sur-Mer, France, in 3d Division Zone, shortly after landings on D-day, 15 August 1944.


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Division. Still later, this unit was attached to the 93d Evacuation Hospital. There was an ample supply of blood at all times. The plane and boat service first employed, like the plane service which assumed the responsibility later, operated smoothly from the very beginning, and the courier on the plane was frequently used by other staff sections of the Seventh U.S. Army for the delivery of messages.

    Distribution of penicillin for the landings was made the responsibility of blood bank personnel. The field hospitals also brought in a small initial supply with them, and 2,000 ampoules accompanied the blood shipment which arrived on D+1. Additional amounts continued to be brought in by the planes transporting blood until all the penicillin required could be supplied and distributed through normal medical supply channels.

    Two medical officers became casualties during the landings, when a half-track in which they were riding struck a mine. They were evacuated immediately by ship. The enlisted technician who had landed with the surgical consultant and who was trained in both anesthesia and operating-room technique took over the duties of the injured anesthesiologist (p. 515). The plastic surgical team to which the other injured officer was assigned was reconstituted as a general surgical team (p.562).

CRITIQUE OF THE MEDICAL ASPECTS OF THE LANDINGS

Qualifications of an Army Surgical Consultant

    The surgical consultant to a field army, who always works under the overall direction of the army surgeon, has the following important functions:

    1. He establishes surgical policies for the army. While they are necessarily more detailed, these policies must be consistent with the policies established by the theater consultant in surgery, with whom the army consultant must be in frequent and close contact. The army consultant, however, provides specific as well as general direction and must meet given situations on his own authority as the needs arise.
    2. He must be familiar with all the organizations assigned or attached to the army and must know their approximate troop strength and their tactical use. He must know which organizations are to make the initial landings and which are to be phased in, at later dates. If an amphibious or oversea movement is planned, he must know the loading order.
    3. He must know intimately all the details of medical support available for assignment and must be aware of the training and experience of the staff


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of each medical unit, as well as of its composite experience, so that all assignments may be made in the light of this knowledge.
    4. He is responsible, at all times, for the appraisal of the quality and adequacy of surgical equipment.
    5. He is responsible also for assuring the adequacy of supplies of fresh blood and antibiotics for army medical treatment facilities.
    6. He must know the medical facilities of the country in which the army is operating.

    During the campaign itself, the duties of an army consultant in surgery, in addition to those just listed, include the following:

    1. Provision of the best possible surgical care for battle casualties from the most forward medical units in division areas through convalescent hospitals in the rear army area, in order to insure the recovery, within the army area and within the shortest possible period, of the largest possible number of men who can be returned to combat. Provided that the tactical and other circumstances permit, it is highly desirable to hold within the army area those casualties whose physical condition will allow their return to duty within the established evacuation policy.
    2. Cooperation and coordination with the operations section of the army surgeon's office, in order to insure that all hospitals are well placed and that their movements are timely.
    3. Cooperation and coordination with the personnel section of the army surgeon's office, to insure that personnel for various installations are correctly selected and placed, so that they can do the best possible work in the light of their own abilities and the needs of the situation.
    4. Collection of certain surgical statistics and the institution of special studies.

    The outline of these duties of the consultant to a field army before, during, and after an invasion carries certain implications concerning his own qualifications and his place in the general military scheme.

    It is almost essential that the consultant be a surgeon with academic standing in civilian life, who has held positions on the staff of a civilian hospital, who has had experience in the training and education of younger men, and who belongs to leading surgical societies.

    These specifications obviously imply that the consultant will be a surgeon with the required training and experience, that he will know how to teach, and that he will have contacts with a wide circle of friends and acquaintances on a level of experience and training similar to his own. These are important considerations. An important phase of the consultant's duties will be the teaching of inexperienced surgeons, and another important phase will be the evaluation of personnel attached to units coming into the army area.


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    In short, the previous military experiences of the consultant in surgery to a field army, in addition to his surgical competence, in large measure determine his capacities for his work.3

Medicomilitary Experiences of the Surgical Consultant, Seventh U.S. Army

    Headquarters, Seventh U.S. Army, was in Algiers at the time of the assignment of Lt. Col. (later Col.) Frank B. Berry, MC, (fig.91), and the initial planning for the invasion, described elsewhere, took place there. Early in July, the headquarters was transferred to Naples, where the remaining plans for the invasion were made.

    Colonel Berry sailed with the invasion troops from Naples on 14 August 1944. Twenty-four hours later, the target area was readied, and his ship lay off Saint-Tropez, waiting for the opening naval bombardment. H-hour was 0630 on 15 August. He went ashore later in the day, between 1600 and 1700 hours. The 36th Division, which had landed at Saint-Raphael, about 25 miles overland from Saint-Tropez, where he went ashore, had run into trouble. The roads between the two towns were held by Germans, and it was D+2 before he got through to the medical units of this division. The area in which he was put ashore was heavily mined, and for the next several hours, while he thumbed rides from army vehicles for transportation from one medical facility to another, one of his important duties was to avoid mines.

    His immediate duties as army consultant in surgery were clear. Certain urgent questions had to be settled immediately. How were the beach clearing

3 World War I, Col. Frank B. Berry, MC, surgical consultant to the Seventh U.S. Army, had served as a medical officer in the Department of Supply (the World War I counterpart of the communications zone of World War II) in France.

    In World War II, he left the Zone of Interior in September 1942, as chief of the surgical service, 9th Evacuation Hospital (the Roosevelt Hospital unit). After staging in England for about 5 weeks, this hospital landed in North Africa in November 1942, 8 days after the first landings. The hospital was assigned to the II Corps, which was the main fighting element of U.S. Army troops, from the landings until the end of the Tunisian campaign, and it served in direct support of the combat units of the corps from the end of January 1943 until the enemy surrender in Africa in May 1943.

    The 9th Evacuation Hospital was assigned to the Seventh U.S. Army just before the invasion of Sicily. Early in September 1943, after the island had been taken, the hospital moved to Sicily, where it assumed the emergency and routine care of the troops staging to invade Italy.

    Early in January 1944, when the French needed medical help, the 9th Evacuation Hospital was moved to Naples and was attached to the Peninsular Base Section. From this time, until July 1944, the hospital acted as a general hospital, caring for all French patients received from the First French Army, which was operating with the Fifth U.S. Army. This was a unique experience for an evacuation hospital, which does not ordinarily see the end results of its own surgery.

    In May 1944, in response to a telegram from the War Department, Colonel Berry was declared available by the theater chief surgeon, Maj. Gen. Morrison C. Stayer, and was ordered to report to the Surgeon, Army Ground Forces, Washington, D.C. The assumption was that the Army Ground Forces was at last to have a much-needed consultant in surgery (p. 523). When he reached Algiers, Colonel Berry learned that Colonel Churchill had informed General Stayer that in the planning for the contemplated future operations of the Seventh U.S. Army, which had been designated for the invasion of southern Europe, he had been earmarked for assignment as consultant in surgery to that headquarters. General Stayer had not previously been informed of this contemplated assignment. Colonel Berry was given his choice--to report to Headquarters, Army Ground Forces, in Washington, or to be assigned to the Office of the Surgeon, Seventh U.S. Army, as consultant in surgery. He chose the latter assignment.- J.B.C., Jr.


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FIGURE 91. - Col. Frank B. Berry, MC, Consultant in Surgery, Office of the Surgeon, Seventh U.S. Army.

stations operating? What was the status of the platoons of the field hospitals? Did they need extra help? Had the supplies of blood been landed? These and other matters occupied his time for the next several days.

    Almost as soon as Colonel Berry had landed, he found work for the technical sergeant with training in anesthesia who had landed with him. They met a vehicle coming back from a field hospital and were told that the hospital anesthesiologist had been wounded by a mine. Colonel Berry instructed the technician accompanying him to go with the personnel on the vehicle to the field hospital, where he was put to work immediately.

    All clearing stations on time beaches were operating smoothly. The platoons of the field hospitals attached to the 3d and the 45th Divisions were beginning to establish themselves a couple of miles back from the beach, and Colonel Berry spent the first night ashore with a platoon of the 10th Field Hospital which was attached to time 45th Division. Both platoons of this hospital were caring for patients by night all on D-day.

    Until the field hospitals could receive patients, casualties from the beaches were being evacuated to hospital ships (fig. 92). Only surgery of the most


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FIGURE 92. - Evacuation of wounded from beach to LCVP's (landing craft, vehicle and personnel) for transfer to hospital ships on D-day, 15 August 1944.

urgent nature, such as the arrest of hemorrhage and operations for traumatic amputations, was being performed in the clearing stations.

    Loadings of personnel and medical equipment of LST's and troopships had, on the whole, been efficient. No losses were suffered from sinking, but, if they had occurred, both personnel and equipment were so distributed that, if one ship or even more than one had gone down, the loss would not have been disastrous from a medical standpoint, as it had been in the Gulf of Salerno in 1943 when all of the equipment of the 8th Evacuation Hospital had been lost.

    Each of the three divisions which landed in southern France had come ashore with supplies of blood (p.526), and the blood was already in use when Colonel Berry landed. For time next 2 days, blood was brought ashore by boat. Checking with the liaison representatives of the Air Force, he found that the plans to bring blood in by plane were well understood, and on D+3, blood began to arrive by air. There was never any real problem connected with either its supply or its delivery.

    One of Colonel Berry's first duties after the landing was to see what help was needed by the medical service of the First French Army (p.524). Such help as was necessary was rendered.


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Special Details of Planning and Execution

    The whole invasion of southern France was an efficiently planned operation, from both the military and the medical standpoint, and, on the whole, it went according to plan. Hospitals were moved, without special difficulties, with the divisions which they were supporting. Field hospital platoons were often right up with the artillery, within a few miles of the front. On one occasion, near Crest, France, a platoon was caught in the line of fire, between German and U.S. Army artillery; they could hear shells going over in both directions but fortunately suffered no hits.

    The following points deserve comment:

    In order to fulfill his duties with the greatest possible efficiency, an army consultant in surgery must be included in all the planning of the army staff which involves medical support. This means that he must be cleared for the receipt and handling of top secret information. There must be frequent free contact, as well as mutual understanding and trust, between the consultant and the army surgeon, and plans and strategy must be discussed frankly between them. To provide him with the proper stature, the army consultant in surgery, like other key officers, should be known by the chief of staff and by the army commander also. On the other hand, the consultant must clearly realize the differentiation between his own functions and authority and the functions and authority of the army surgeon. He must acknowledge the authority of the army surgeon and make every effort to support him at all times and to improve his position with the entire army staff. When basic relations are on this plane, responsible duties can be carried out in an atmosphere of mutual trust and confidence.

    Most of these requirements were fulfilled in the Seventh U.S. Army, but there were some deficiencies whose existence made for less competent planning than might otherwise have been possible. For one thing, the surgical consultant did not meet either the commanding general or the chief of staff until the troops were actually on the way to the invasion beaches. The initial contact, which was entirely accidental, opened the way to a cooperative future relationship.

    More important, full knowledge of the initial phase of the oversea movement and the landings came to him piecemeal, much of it by indirection, and then only because he kept his eyes and ears open. The place of landing, the total number of medical units assigned to the Seventh U.S. Army, and the phasing of the landings of the others which were to come in later for support, also came to him piecemeal.

    This was a basic fault. A consultant in surgery to a field army has heavy responsibilities, and, like other staff officers, he cannot fulfill them efficiently unless he was full information on all medical phases of an invasion or campaign. As it was, the surgical consultant to the Seventh U.S. Army had no broad, overall picture of the invasion beforehand, though in the planning of


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any medicomilitary operation the total needs must be known in order to assure its success. This generalization applies to professional care and personnel as well as to needs of materiel. Under exigencies of war, of course, many last-minute changes may have to be effected, but, ideally, the consultant should have the picture in its entirety rather than piecemeal, so that the problem may be evaluated as a whole and action not be taken as a succession of afterthoughts.

    If the total problem could have been visualized from the surgical standpoint well in advance of the landings in southern France, the total available medical personnel could have been utilized with much greater efficiency. The surgical consultant learned, for instance, only 5 or 6 days before the troops sailed, that a group of special Canadian and American ranger troops were to land on the Hyères Islands at H-6. The intrinsic medical leadership of this unit was good, but the medical staff required considerable strengthening. By the time the information concerning their needs had reached the surgical consultant, however, most of the additional personnel available from supporting units (p. 506) had been attached to the larger invasion commands. The mission of the rangers was important, but to supply additional personnel for them made it necessary to "scrape the bottom of the barrel." The results might have been expected. Three of the first group of supplemental medical officers attached to this force during their last days of training 125 miles south of Naples promptly developed time well-known military complaint of "severe lame backs." When, under appropriate authority, the consultant was seeking for replacements for them, the commanding officer of the general hospital from which he was seeking the replacements, himself a Regular Army officer, inquired whether he thought any of his men might get hurt. The consultant could have handled the rangers' medical problems better if he had known of their needs earlier.

    Similarly, he had no advance information about any hospital or other ships designated to care for casualties which were to arrive in the target area during the first 3 days of the invasion. Had he known of these needs earlier, the ships would have been better supplied with surgical and shock teams and would also have had more liberal supplies of blood. As it was, the ships were somewhat understaffed, and blood was in somewhat short supply.

Functions of Medical Units

    As noted elsewhere, the medical organizations designated to accompany the invasion troops which landed in southern France were well trained and, with a single exception, had had experience in previous combat. When the time for the invasion arrived, competent personnel were, as a rule, distributed to the best possible advantage in the light of the surgical consultant's somewhat incomplete knowledge of the invasion plans. With the arrival of new hospitals in the late fall, a number of additional changes were made. In some instances, poorly staffed evacuation hospitals were strengthened by


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the temporary or even permanent exchange of some of their personnel with experienced hospitals.

    In this consultant's opinion, the experience of the invasion confirmed the experience at Salerno that the equipment of beach medical battalions and of platoons of field hospitals should be combat loaded, each unit being loaded completely on the ship on which its personnel sails. When this plan is followed, if one unit (platoon) should be lost, another is able to take over and operate as a self-sufficient organization. Loading small units in several unrelated parts results in loss of equipment, waste of time, general confusion, and inefficient operation. Dispersion in the loading of large organizations, such as an evacuation hospital, however, is proper and essential. Personnel should accompany their integral components; the rest should go on other ships. Personnel assigned to transportation and supply, for instance, should accompany the supply equipment. The personnel operating vehicles to move equipment should be on the ship with the vehicles. This plan, which creates what amounts to small military cells, would safeguard personnel, without too much dispersion, and would assure the immediate availability of the equipment required for efficient operation of all installations.

    It proved an excellent plan to utilize for the invasion the personnel from the medical organizations in the Naples area which were to be landed later in southern France, whether in the army area or the communications zone. Col. Richard T. Arnest, MC, Surgeon, Peninsular Base Section, had lightened the load of the hospitals operating there and had granted permission to borrow heavily from their officer and nursing staffs. As a result, all invasion units, as well as the units phased to land in France during the first 2 weeks of the invasion, never suffered from shortages of personnel.

    Medical clearing companies are not equipped to handle any major surgery beyond the most urgent variety. They should, at all times, be kept as clear as possible of seriously wounded patients. Their principal function is triage. Anything else is subsidiary. Clearing companies are not normally provided with adequate operating facilities or with X-ray equipment, and their personnel are needed for the performance of their assigned function of triage.

    The attachment of general surgical teams from the 2d Auxiliary Surgical Group to the clearing companies on the landing beaches in southern France did not alter this concept. Two such teams, minus their nurses, should land with each beach medical battalion, both to assist in triage and to take care of the emergency surgery necessary for the first casualties. Some major surgical procedures are always necessary, but they should be held to a minimum. Such surgery is the function of the field hospital platoon, which, with adequate surgical facilities, and augmented by attached auxiliary surgical teams, lands as promptly as possible and sets up nearby the division clearing station.

    From D-day through D+3 or a later date, all casualties who require anything beyond emergency surgery should be evacuated to troopships, equipped


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with surgical facilities and adequately staffed, to LST's, and to hospital ships. These ships should be equipped for major and minor surgery on large numbers of casualties. Their use keeps the beaches clear for other military and medical necessities.

    The assignment of surgical and shock teams to beach medical battalions, field hospitals, and hospital ships further provides optimum initial care of the wounded during the first days of the invasion. It also assures a triple reserve against untoward eventualities.

    The experiences during the invasion of southern France demonstrated that the personnel of evacuation hospitals should not be landed on D-day. Since their equipment cannot land with them, their presence on the beaches merely increases the problems of food supply, tentage for bivouac areas, and other logistic support, with no return for the effort. Evacuation hospitals are best lauded between D+1 and D+4. The whole emphasis in the initial phases of a landing should be on (1) the beach clearing stations, (2) small, mobile units, such, as field hospital platoons, and (3) augmentation of these units by surgical and shock teams.

    In order to provide for the early return to duty of lightly wounded and ill personnel in the combat area, a medical unit equipped to handle convalescent-type patients must be set up within the first few days of a landing. Without provisions of this sort for lightly wounded casualties and for men with minor medical conditions and neuropsychiatric and venereal diseases, many soldiers who could return to duty within a few days will be evacuated out of the army area. It is obviously highly desirable to retain this type of patient in the army area; many of them, otherwise, will be lost to combat service.

Provision of Blood and Penicillin

    The utilization of a blood plane and the distribution section of the 6703d Blood Transfusion Unit (Overhead) proved, as already stated, a highly efficient operation. The use of the same setup for the distribution of penicillin was adapted from a plan which had proved extremely successful in Italy. It proved equally successful in southern France. It not only provided a complete and elastic coverage for hospitals in the army area but also relieved the normal medical supply system, with its rapidly shifting depots, of what might otherwise have been a troublesome storage problem in time days immediately after the invasion.

Promulgation of Policy

    In the initial planning phase of aim invasion, it is important that as much basic information as possible concerning army policy be issued as command directives. That this plan was used in the circular issued about the optical repair units was regarded as one of the reasons for their efficient operation

4 Circular No. 16, Seventh U.S. Army, 4 Sept. 1944.


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(p.532). A similar plan had been followed in the circular about trenchfoot 5 in Italy.

Consultants in the Surgical Subspecialties

    In the actual landing operation, it is important that the consultant in surgery be accompanied by one or more specialists and one or more enlisted technicians. The ophthalmologist and the technician trained in anesthesia who made the landing with Colonel Berry on D-day were both employed by night (pp.515, 531).

    It does not seem necessary to have consultants in the surgical subspecialties in the office of the surgeon of a field army. It was the policy in the Seventh U.S. Army to use medical officers trained in orthopedic surgery, ophthalmology, and neurosurgery, but assigned to hospitals, as informal consultants, and the plan proved far more satisfactory than the overstaffing and the top-heavy structure which would have resulted from the formal appointment of a number of consultants in these specialties in the army surgeon's office. The success of this plan, of course, depends upon the availability of trained and competent personnel in the medical units of the specific army concerned. It also is contingent upon the authority given to the consultant in surgery to a field army to select and handle his own personnel. This he should have. The consultant to the theater chief surgeon should select for the consultant in surgery to the army a medical officer who is experienced and reliable and who is acceptable to the army surgeon. Then, he should permit the consultant to select the medical officers whom he wishes to assist him and should allow the consultant to use these officers in the manner which seems best to him.

    Whether or not the consultant was a formal staff of consultants is immaterial. What matters is that he should have ready access to medical advice in problems arising in specialties outside of his immediate field.

Coordination Within the Office of the Army Surgeon

    During the Seventh U.S. Army's campaign in the European theater, there was, perhaps, less close liaison between the consultant in surgery and the chiefs of the operations and the personnel branches of the army surgeon's office than might have been desirable. This lack manifested itself in two ways. The first was in occasional staffing difficulties, although all personnel questions were coordinated with the personnel section of the army surgeon's office. The consultant in surgery should know the personnel in the medical units in the army area, both those already assigned and those coming in, so that he can place the best qualified medical officers in the places in which they can be most useful

5 Letter. Lt. Col. W. G. Caldwell, AGD, Adjutant General, to All Units, Seventh Army, 31 Dec. 1943, subject: Trench Foot.


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FIGURE 93. - The 27th Evacuation Hospital fully set up in France.

in the light of particular needs at particular times. This was usually, though not always, the situation in the Seventh U.S. Army hospitals.

    The second evidence of occasional lack of liaison within the army surgeon's office concerned the operations branch. As a result of this lack, the selection of hospitals to be moved and the timing of the movements sometimes could have been improved upon. Tearing down and moving an evacuation hospital after it had been fully set up (fig. 93) presented a sizable problem. A consultant in surgery to a field army should be qualified, and should have sufficient information on both the medical and the tactical situation, to make recommendations concerning both hospitals to be moved at given times and the hospitals to be designated for special missions, since personnel as well as logistics must be taken into consideration. On at least one occasion, a serious situation developed in the Seventh U.S. Army because an inexperienced evacuation hospital, newly arrived and not effectively staffed, was assigned to a very active sector without the knowledge of the consultant, while, at the same time, an experienced hospital, excellently staffed, was left on the near side of the Rhine as a holding unit. The consultant would not have agreed to either assignment had he been consulted. The competent personnel of one hospital was wasted, while the other, as soon as the misassignment was discovered, required daily visits from him, as well as the augmentation of its weak staff by auxiliary surgical teams.


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Assignment of Personnel

    In retrospect, perhaps the matter of chief concern to a consultant in surgery in a field army, both during the invasion and later, has to do with personnel. The assignment of personnel during the invasion has already been discussed. Later, the major problems of personnel had to do with the staffing of evacuation hospitals coming into the army area from the Zone of Interior.

    Evacuation hospitals carry a very responsible load, for the brunt of the initial surgery of the wounded falls upon them. Eyes, limbs, and lives will be sacrificed unnecessarily unless surgery of the highest quality is performed in them. In a field army, the consultant does not have sufficient leeway, or sufficient reserves of personnel, to correct staffing errors. An army in combat, in fact, never has a reserve of medical officers. On the contrary, it always has a deficit. Deficiencies in field hospitals can be covered by auxiliary surgical teams, but evacuation hospitals must, as a rule, take care of their own personnel problems. They must, therefore, be staffed with the greatest care in the Zone of Interior. This was not true of all hospitals which were assigned to the Seventh U.S. Army, and original errors in staffing were not always easy to correct overseas.

    It is easy to explain why these mistakes were made. During the period of mobilization and training in the Zone of Interior in World War II, medical units other than those directly supporting the Army Air Forces were trained under the general supervision and control of two headquarters; namely, Headquarters, Army Ground Forces, and Headquarters, Army Service Forces. The training of evacuation hospitals was generally the responsibility of Army Ground Forces.

    Early in the war, the Surgeon, Army Ground Forces, did not have detailed personnel records or other information to guide him in the assignment of professional officers of the Medical Corps. Such records as did exist were incomplete. They did not indicate the professional background of the individual officer or his stature in the civilian profession. Unless he was personally known to the Surgeon, Army Ground Forces, or to his immediate staff, he had to be assigned without the benefit of detailed knowledge concerning his professional and other capabilities.

    Surgeons of the various armies in the Zone of Interior during the mobilization and training period of special units and before their departure for overseas were similarly handicapped in the assignment of medical officers for specific duties. An army surgeon, of course, had delegated to him by the army commander the authority to reassign medical officers within the army, the assignments being handled by normal staff procedures. An army surgeon, however, often had little or no more information about the various medical officers than did the Surgeon, Army Ground Forces, or, indeed, the Personnel Division, Office of the Surgeon General. Adequate, complete records were simply not available. The evaluation and classification of medical officers


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according to specialties and their proficiency ratings within their specialties were a later development. Thus information, in fact, became available only after the planning for the European campaigns was over and could, in actuality, be put to use only after much of the fighting was over.

    These facts explain why, during the period of training and mobilization in the Zone of Interior, medical officers were sometimes assigned to key spots in hospitals which they were not qualified to occupy, while other officers, junior in rank in the particular organizations, were sometimes better qualified to hold the more important posts.

    The surgical consultant was fully cognizant of these difficulties and, was quite aware that, under the circumstances, one of his principal duties was to visit newly arrived medical units and to develop, by all means at his disposal, full information concerning the professional as well as the military training and background of the various members of the hospital staff. The point to bear in mind is that, while theoretically the solution of the problem is simple-- merely the movement of personnel from one post to another--practically this is never a simple matter because of demands for personnel in an army area overseas.

    The problem in the Zone of Interior might have been at least partly resolved earlier, and with ultimate economy in medical personnel, if the surgeon of each army had had on his staff consultants in surgery, medicine, and neuropsychiatry. These consultants, however, were likely to be assigned just before the army departed for overseas. In the meantime, the personnel officer in the army surgeon's office, and, for that matter, the personnel officer in the Office of the Surgeon, Headquarters, Army Ground Forces, were most often medical administrative officers whose training and background in no way qualified them to evaluate the training and capabilities of professional medical officers.

Assistance to the First French Army

    The First French Army had its own medical officers, but it was shorthanded, and assistance was rendered to them when it was requested. By a semiofficial arrangement, the Seventh U.S. Army consultant in surgery acted as an assistant consultant in surgery to them in cooperation with Col. Etienne Curtillet, who was organically assigned to this army as consultant in surgery. Colonel Curtillet was a member of the faculty of the University of Algiers, in which the level of surgical work was excellent.

    During the staging period, the Seventh U.S. Army consultant frequently visited the French field and evacuation hospitals based in Naples, to maintain contact with them and to help them as much as possible with their organization and supply problems. Some of these hospitals were newly created. Others had served with the French forces in the Fifth U.S. Army during the winter and spring of 1943-44.

    Colonel Curtillet landed in France, a few days after D-day. He and the Seventh U.S. Army consultant sometimes traveled together visiting U.S. Army


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and French units as they were encountered. The Seventh U.S. Army did not furnish the French Army with medical officers but accepted two or three of their officers at a time for training in Seventh U.S. Army field hospitals. Thus, these hospitals would be jointly staffed by French and U.S. medical officers. The French appreciated the training, and they provided, in turn, much useful assistance. Some French casualties were also cared for in Seventh U.S. Army field hospitals.

    Particular attention was paid to the French transfusion service, whose laboratories and main drawing unit were in Algiers. After many conferences with the Surgeon, First French Army, and with officers of the transfusion service, it was planned that blood would be flown daily from Algiers to Naples, in refrigerated boxes, and would be delivered to the French Army hospitals through the Seventh U.S. Army blood bank service. From Naples, the French supply of blood was delivered with the U.S. Army blood by courier on the beaches or to the advanced airfields, according to the stage of the campaign. The responsibility for maintaining liaison with the forward distributing section of time 6703d Blood Transfusion Unit (Overhead) as well as with the planes that transported the blood rested with the French. Minor difficulties were experienced in the implementation of this plan. The French liaison service frequently failed to maintain prompt contact with the airfields to which the blood was delivered, and some confusion in the supply of blood resulted, while at times there was a considerable accumulation of stocks of their full and empty blood containers at the airfields.

THE BLOOD PROGRAM

    The story of the blood program in the Seventh U.S. Army falls into three phases as follows: (1) The provision for supplies of blood before the invasion, (2) the provision of blood during the landings and immediately thereafter, and (3) the routine provision of blood during the remainder of the campaign.

Preinvasion Planning

    In February 1944, a central blood bank, designed to supply whole blood to the Fifth U.S. Army, was organized by Colonel Churchill with the full support of the Surgeon, NATOUSA, Brig. Gen. Frederick A. Blessé, who was succeeded on 1 March by Maj. Gen. Morrison C. Stayer. The project also had the full cooperation and support of Brig. Gen. (later Maj. Gen.) Joseph I. Martin, MC, Surgeon. Fifth U.S. Army. The blood bank, which was attached to the 15th Medical General Laboratory in Naples, under the command of Col. Virgil H. Cornell, MC, was officially designated as the 6713th Blood Transfusion Unit (Provisional) in April 1944.

    The work of thus transfusion unit was so satisfactory in supplying blood for the Fifth U.S. Army that a second, similar unit was activated for the purpose of drawing whole blood from base troops for the Seventh U.S. Army.


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Field and evacuation hospitals would thus be relieved of the almost impossible burden of drawing their own blood in the large quantities needed in forward installations, while the undesirable practice of bleeding line and service troops in forward areas would also be eliminated.

    The second unit, designated the 6703d Blood Transfusion Unit (Overhead), was made up of personnel withdrawn between February and April 1944 from (1) an inactivated station hospital, (2) the 1st Mobile Medical Laboratory, and (3) the original blood transfusion unit set up in February 1944. The second unit, like the first, was attached to the 15th Medical General Laboratory for instruction and training. Eventually, two other bleeding stations for this unit were set up, one near Caserta, Italy, and the other, after the invasion, in Marseilles (p.527).

    The organization, training, and operation of both of these units were greatly facilitated by the hearty cooperation and interest of Colonel Arnest, Surgeon, Peninsular Base Section, and Colonel Cornell. As a result of their efforts, the 6703d Blood Transfusion Unit (Overhead) was a trained and smoothly functioning blood bank when it was assigned to the Seventh U.S. Army for invasion. All of its members deserve very great praise and credit for the superb backing which they gave to Army medical units throughout the campaign in southern France.

    Before the invasion, the unit was divided into two functional sections. One was assigned to the 1st Mobile Medical Laboratory for the invasion. The personnel of the forward distributing section of time 6703d Unit which landed with the assault troops on D-day was attached to field hospitals for the landings. The base collecting section remained with the 15th Medical General Laboratory in Naples until adequate facilities could be set up in France (p.527).

The Invasion

    Personnel of the 6703d Blood Transfusion Unit (Overhead) were distributed as follows for the invasion:

    An officer and an enlisted man were attached to a platoon of the 11th Field Hospital, which was attached to the 45th Division. They were supplied with seven box containers, containing a total of 188 bottles of blood. They also had with them the main refrigeration unit on a vehicle.

    Two enlisted men were attached to a platoon of the 10th Field Hospital, which was attached to the 3d Division. They were supplied with four insulated box containers containing a total of 144 bottles of blood and with a refrigeration unit on a vehicle.

    Two enlisted men were attached to a platoon of time 11th Field Hospital, which was attached to the 36th Division. They were supplied with seven box containers, containing 168 bottles of blood, and with a refrigeration unit on a vehicle.


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    The Special Service Force (p.518) was given 100 bottles of blood in box containers, and additional amounts of blood were placed on some of the hospital ships supporting the invasion. More would have been supplied if the details of the use of these ships had been known earlier (p.518).

    All of the blood to be used on D-day was loaded just before departure, and a supply of whole blood not over 7 or 8 days old was thus assured for the immediate needs of the invasion. In planning for supplies of blood for the landings, the sound principles of combat loading were carefully observed; the blood was loaded late, so that it could be taken off the vessels early, and the supplies were distributed among several ships. To accomplish this required considerable persuasion of both corps and division surgeons and line officers.

    Through the cooperation of the Navy and the Army Air Forces, arrangements were made to deliver whole blood to the target area, beginning on D+1 and continuing until an airstrip could be established. The plan involved flying blood from Naples to Corsica and then carrying it to the landing beaches by patrol vessels, motor torpedo boats. In all of this planning, the consultant in surgery received invaluable help from Colonel Cornell, who personally arranged for all contacts along the route of delivery of the blood, so that delays would be avoided. As a result, more blood than was necessary was always available during the landings, as well as later in the campaign. Contact with the collecting unit in Naples was maintained by daily cables and through the couriers who accompanied all shipments of blood.

    Battle casualties for time first 3 days of the landings had been estimated at 1,881. Previous experience had indicated that about 0.6 pint of whole blood per battle casualty would be required. In addition to the small amounts provided for hospital ships, a total of 1,400 bottles of blood was provided for this period, which was an excess of 271 bottles over the calculated need of 1,129 bottles. The surplus was regarded as essential insurance against possible loss. Actually, battle casualties numbered 989, and nonbattle casualties, whose requirements for whole blood are generally less than those of battle casualties, numbered 205.

Postinvasion Experiences

    The Seventh U.S. Army was fortunate in landing in territory occupied by friendly civilians. This made it possible, in October, to bring the collecting section of the blood transfusion unit from Naples into the rear of the army area and establish it at Marseilles, where it was located on the principal street, and where it was shortly handling about 200 donors a day, though it had been originally set up to draw only 100 bottles per day. A local supply of blood was thus available to supplement what came from Naples, and, later, when control of the Seventh U.S. Army passed from the Mediterranean theater to the European theater, to supplement what came from Paris.

    When the collecting section of the blood transfusion unit was moved to France, this section and the 1st Medical Laboratory established a collecting


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unit in the 59th Evacuation Hospital at Épinal. This unit, which operated for only 3 weeks, drew and processed during this time more than 2,400 bottles of blood. In order to use donors more efficiently during this period, group A as well as group O blood was supplied to hospitals. The 375 bottles processed were plainly labeled, and there were no untoward incidents.

    Blood from the European theater reached Seventh U.S. Army hospitals for the first time in November 1944, when the logistic support of the army passed to that theater. The first shipment consisted of 350 bottles of blood drawn and processed in the European theater. Still later, blood was supplied to Seventh U.S. Army hospitals from the Zone of Interior through the European theater blood distribution organization; most of the blood used in these hospitals eventually came from that source.

    The forward distributing section of the blood transfusion unit encountered increasing logistic difficulties in southern France from the time of the landings until March 1945. The distances were always long. The roads, through mountains, often were poor and frequently were snowbound and icebound. During December 1944 and January 1945, because of the Colmar Pocket, the front was divided into two rugged sectors. For this reason, in addition to the run of 130 miles to the rear, to pick up the blood from CONAD (Continental Advance Section, Communications Zone, ETOUSA) at Dijon, it was also necessary to make daily runs of 100 miles to each sector. Communications with the base were always difficult, often uncertain, tortuous at best, and, occasionally, impossible. After the air service had to be temporarily abandoned because of very bad flying conditions in October 1944, it often took 2 to 4 days for the two sections of the blood bank to communicate with each other, or to communicate with Paris through the Southern Line of Communications. It is remarkable that, in spite of these handicaps, there was never a lack of available blood. It is equally remarkable that this result was accomplished by a forward section that never consisted of more than one officer and five or six enlisted men and that operated entirely with its own three trucks and two borrowed weapons carriers.

    On the other hand, poor liaison, bad roads, long hauls, and lack of adequate refrigeration resulted in a regrettable waste of blood both by hemolysis and by outdating. During January and February 1945, the loss by hemolysis alone (from shaking of the containers) amounted to about 30 percent of the blood supplied.

    Early in March 1945, the supply of blood was greatly simplified when the services of two blood distributing sections were obtained from the 127th Station Hospital. These sections were attached to CONAD, and by CONAD to one of the air holding units, to act as a rear blood station. By this time, an effective means of daily communication had been set up with the blood bank in Paris. The rear blood station received all incoming blood from Paris, stored it, and shipped the containers back to Paris. This station was now able to care for the needs of most of the army hospitals and also the needs of time for-


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ward distribution section of Blood Transfusion Company 6825, which was attached to the 132d Evacuation Hospital and which provided for the needs of the hospitals in the southern sector until the end of hostilities. After this company and the units from the 127th Station Hospital had returned to their parent organizations, late in May 1945, the hospitals in the Seventh U.S. Army became responsible for the operation of their own blood banks.

    Table 14 shows the supply and distribution of blood and plasma in Seventh U.S. Army hospitals from D-day (15 August 1944) to 30 April 1945. A total

TABLE 14 - Recorded receipts and distribution of blood and plasma in Seventh U.S. Army hospitals, 15 August 1944-30 April 1945 1


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of 2,080 units were received during August, including 800 units landed on D-day, and a total of 84,640 units were received during the period September 1944 to April 1945. Of this amount, 8,558 bottles were distributed to the base, and, according to the records, 191 bottles were used in clearing stations, 18,077 bottles in field hospitals, and 25,915 in evacuation hospitals. The records show that 7,958 units were discarded. There is obviously a very wide discrepancy between the amount of blood received and the amount of blood used and otherwise accounted for. This can be explained in the following two ways: (1) The keeping of poor records, particularly the failure to record the amount of blood used for the large number of casualties who were resuscitated in field hospitals and then sent to evacuation hospitals for necessary surgery; and (2) the hoarding of blood which was later discarded without record, a practice which played a particularly large part in the wastage of blood during the winter months.

Transfusion Reactions

    At the request of Lt. Col. (later Col.) Ralph M. Tovell, MC, Consultant in Anesthesia, Office of the Chief Surgeon, ETOUSA, an analysis was made of the reactions following 7,780 transfusions on which data were available in that office. The number of reactions recorded, 69 (0.9 percent), is regarded as much too low. The obvious explanation, again, lies in inadequate records; in field and evacuation hospitals, because of the heavy load of severely wounded casualties, only the serious reactions were recorded, and minor reactions were either missed or went unrecorded.

    Blood secured in the European theater was preserved with acid citrate dextrose solution. Blood received from the United States was preserved with Alsever's solution which requires an excess of fluid and which is particularly undesirable when transfusion is necessary in head and chest cases. The age of the blood received from the United States and the early lack of refrigeration also accounted for some of the reactions which occurred. Another practical consideration was that the 1,000-cc, bottles which had to be used for blood preserved with Alsever's solution required almost twice the amount of space required for blood preserved with acid citrate dextrose solution.

    Of the four deaths which occurred after blood transfusions, three followed the use of blood preserved with Alsever's solution. In two of the three cases, positive cultures were obtained from the blood which had been used; in one of these cases, the same micro-organisms were grown in a culture of the patient's blood. In the third case, no cultural studies were made, but the blood had a foul odor, and hemolysis was evident when it was examined later. All three of these patients went into profound shock after transfusion of 100 to 300 cc. of blood, and none of them responded to intensive resuscitative measures. All three, unfortunately, had had smooth and uncomplicated postoperative courses and were transfused merely to elevate the blood level before evacuation.


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    The fourth fatality occurred 3 days after the transfusion of 1,500 cc. of blood. Other causes perhaps played some part in the fatality, but the severe hemolytic reaction was unquestionably a contributory cause.

    Medical officers from certain field and evacuation hospitals, especially the 9th and 51st Evacuation Hospitals, were particularly interested in transfusion reactions, the problem of anuria, and the use of type-specific blood in patients who required repeated transfusions. Their comments and suggestions were most helpful, and the records in these hospitals were particularly accurate.

SUPPLY AND TRANSPORTATION

    Lt. Col. Augustus J. D. Guenther, MAC, Chief, Medical Supply Branch, Office of the Surgeon, Seventh U.S. Army, and the 7th Medical Depot Company deserve the highest praise for their efficient cooperation in the procurement of supplies for army hospitals. Many items in excess of basic allowances, such as suction apparatus, portable orthopedic tables, anesthesia apparatus, and laboratory equipment, were approved for issue by Colonel Rudolph, Surgeon, Seventh U.S. Army, and were supplied because their use would enhance the professional care of patients.

    One service performed by the Medical Depot deserves special mention, the maintenance of surgical equipment, including sharpening and repair of instruments and repair of suction apparatus, sterilizers, and other essential equipment. Their repair had been a difficult problem in North Africa. Instruments and apparatus turned in for repair or salvage lay about on shelves or floors for weeks and sometimes were never returned. Sometimes, unacceptable substitutes were received in place of the original equipment. At that time, it was often simpler for hospitals to invoke the services of the Ordnance Corps for repairs than to try to have the work done by Medical Supply, whose rightful function it was. Problems of this kind did not arise in Seventh U.S. Army hospitals.

    Transportation. for semi-mobile (400-bed) evacuation hospitals was basically adequate. The 750-bed evacuation hospital was not intended to be semi-mobile but could have been made so if sufficient trucks had been provided. It is only fair to add, however, that all shortages of transportation were not attributable to shortages in the basic allotment but were due to the number of extras, captured accessories, and other excess items being moved by the hospital unit.

THE OPTICAL PROGRAM

    Capt. (later Maj.) David B. Solouff, MC, ophthalmologist with the 9th Evacuation Hospital and a diplomat of the American Board of Ophthalmology, landed with the Seventh U.S. Army consultant in surgery on D-day and served throughout the campaign as an unofficial consultant in ophthalmology.


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He visited all evacuation hospitals in the army area twice, discussing with the ophthalmologists on their staffs the problems of outpatient work, special surgical problems, and the efficient use of the optical repair unit. As new hospitals came into the army area, he evaluated the ophthalmologists on their staffs and advised concerning their training and capabilities. His work was of great value and was of great assistance to the surgical consultant.

    The optical program for the repair or replacement of broken or lost spectacles is an excellent illustration of the detailed medical planning necessary for an invasion. From conversations with Brigadier Sir Stewart Duke-Elder, Consultant in Ophthalmology to the British Army, the surgical consultant had become fully aware of the importance of the prompt repair or replacement of spectacles. On one occasion, early in the campaign in North Africa, a replacement pool of 3,000 British troops had been held outside of Cairo solely because their broken or lost spectacles had not been repaired or replaced. For the same reasons, it was later necessary to evacuate a large number of men from the Anzio beachhead.

    In the planning of the medical program for the invasion of southern France, arrangements were therefore made for the early landing of a mobile optical repair unit, which was in operation, with complete services on D+4. Many persons are completely incapacitated or seriously handicapped without their glasses, and it is natural that soldiers should desire to escape danger and avoid hazardous duties. For these practical reasons, the provision for the mobile optical unit so soon after the landings conserved a considerable amount of military manpower.

    Circular No. 16, Seventh U.S. Army, dated 4 September 1944, directed that prescriptions for glasses and Government-issue glasses for repair should be sent to the 7th Medical Depot Company. The circular also provided that soldiers who were completely incapacitated without glasses (those with vision less than 20/200 O.U.) should remain in the hospital and that their glasses should be repaired on a first priority list. Later, one of the evacuation hospitals was designated as an alternate official collecting and distributing center for broken and lost spectacles, the glasses being sent to this hospital or to the medical supply depot, whichever was most convenient.

    Colonel Guenther displayed a constant interest in the optical repair unit and made many helpful suggestions concerning it. The unit, which was under his operational control, deserves great credit for the promptness and efficiency of its work. From 15 August 1944 until the end of May 1945, 12,921 pieces of work were completed, and a daily average was maintained of 24 new pairs of spectacles and 6 repair jobs.

    All evacuation hospitals were equipped with a trial lens case, in excess of tables of equipment. The load of refractions was at no time excessive, though some hospitals occasionally questioned the necessity for them.


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EDUCATION AND TRAINING

    It was routine practice in the Seventh U.S. Army, whenever a new unit designated for the care of combat casualties came into the army area, for it to undergo a period of training before it became operational. First of all, the consultant in surgery for the army visited it while it was staging and discussed major problems of personnel and procedure with the appropriate medical officers. Then, one of the following two plans was carried out:

    1. The new unit was reinforced by experienced surgical teams, the senior member of one of the teams being designated as temporary chief of the surgical service of the hospital.
    2. A key group of surgeons, nurses, and enlisted personnel from the new hospital was exchanged, for periods of 2 or 3 weeks, with a similar group from one of the older and more experienced hospitals. By this plan, a double type of teaching was provided, first by the older group attached to the new hospital, and second by the members of the more experienced hospital to which personnel from the new hospital were temporarily attached.

    In addition to these formal plans of training, arrangements were made with nearby general hospitals for members of the staffs of newly arrived evacuation hospitals to visit them frequently, observe the wounded as they were received from the forward area, and witness the initial wound dressings and certain reparative procedures.

    Experienced teams from auxiliary surgical groups were attached to new field hospitals, to instruct their staffs in procedures in the field. Lt. Col. James M. Sullivan, MC, 2d Auxiliary Surgical Group, who commanded the detachments of auxiliary surgical groups attached to the Seventh U.S. Army for the duration of the campaign in Europe, frequently visited the new hospitals, to instruct and assist their personnel.

    The training supplies for medical officers of the First French Army has already been described (p.524).

    As far as was practical in an army area, all hospitals were encouraged to hold staff meetings. Three meetings of the Vosges Medical Society, Seventh U.S. Army, were arranged by the army surgeon. The subjects discussed at these meetings were, respectively, penetrating wounds of the knee joint, neuropsychiatric problems, and resuscitation and traumatic shock. The meetings were all well attended, and discussions were free and fruitful.

    Medical officers in the Seventh U.S. Army were encouraged to produce reports for publication. The response was good. The 93d Evacuation hospital submitted a report on intra-abdominal wounds. The 9th Evacuation Hospital prepared reports on neurosurgical problems and injuries of the knee joint and was preparing reports on intra-abdominal wounds when the medical meeting for which the papers were intended had to be canceled for reasons of combat. The 117th Evacuation Hospital presented an excellently worked up symposium on severe burns; the studies included detailed data on blood volume


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hematocrit, hemoglobin, red and white blood cell counts, plasma proteins, and blood chlorides. Members of the 2d Auxiliary Surgical Group prepared papers on the differential diagnosis of abdominal injuries, the application of the principles of war surgery to thoracic injuries in civilian life, the early closure of soft-part defects by skin grafts, and wounds of the heart.

    The surgical consultant to the Seventh U.S. Army presented a paper on wounds of the knee joint at a MTOUSA medical meeting in Naples in January 1945 and another on wounds of the chest at the 819th Hospital Center in Verdun in April 1945. At the request of the editor of the ETOUSA Medical Journal, he prepared a paper on surgery in the field for wounds of the abdomen. The consultant in surgery also attended three meetings of the U.S. and British Army consultants, two in Paris and one in Brussels.

MEDICAL UNITS

    As has already been pointed out, all of the hospital units assigned to the Seventh U.S. Army for the invasion of southern France, with the single exception of the 51st Evacuation Hospital, had seen service in previous campaigns in the Mediterranean theater. The 51st Evacuation Hospital compensated for its lack of experience by an excellent and carefully selected staff. Five of the other six evacuation hospitals had participated in the North African, Sicilian, and Italian campaigns, and the 27th Evacuation Hospital had had some experience in Italy, while acting as a general hospital for the care of French troops. All of the field hospitals were experienced, and all were augmented by experienced teams from the 2d Auxiliary Surgical Group.

    During the fall and winter of 1944-45, several new field and evacuation hospitals were assigned to the Seventh U.S. Army. The field hospitals included the 54th, and 66th, and the 81st Field Hospitals. The evacuation hospitals included the 112th, the 116th, and 117th, the 127th, and the 132d Evacuation Hospitals. The 57th and 64th Field Hospitals and the 103d Evacuation Hospital were also assigned to the Seventh U.S. Army for varying periods of time.

    These hospitals varied in their experience and professional competence. The 54th Field Hospital and the 103d Evacuation Hospital had served with the Third U.S. Army. The 57th Field Hospital had functioned as a station hospital. The other hospitals were fresh from the Zone of Interior and had had little training as integrated units. Moreover, their professional staffs had been provided hurriedly just before the hospitals were sent overseas, and, as a result, inadequately trained and inexperienced medical officers were serving as chiefs of services and as senior surgeons.

    The 81st Field Hospital and the 127th Evacuation Hospital, which arrived in the theater in March 1945, designated at first to care for prisoners of war and displaced persons, were assigned later to German concentration camps. They therefore did not require as numerous personnel changes or as close supervision as hospitals assigned to the care of combat casualties.


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    Measures were at once taken to train the new hospitals and instruct them in the general principles of military surgery. This was chiefly done by effecting exchanges of personnel between them and the more experienced evacuation hospitals. Even these changes did not bring the inexperienced units up to the level of more experienced organizations. This was especially true of the organizations that arrived in 1945. The theater could not supply the deficiencies in personnel, for just at this time, to complicate matters, the Chief Surgeon, ETOUSA, was calling on the hospitals in the army area for experienced surgeons to take charge of surgical services in newly arrived general hospitals in the Communications Zone.

Field Hospitals

    The employment of field hospitals in southern France, both in the landings and later, followed the plan by which they had been employed with such great success in the Fifth U.S. Army. Difficulties of relationship were encountered in only one division, whose medical officers took, or seemed to take, the position that the field hospital was encroaching upon the rights and duties of the clearing station. This particular division sometimes left the field hospital to feud for itself, and it did not always choose sites for it which would place the hospital and the clearing station in the close proximity to each other required for each organization to perform the most efficient possible work. As a matter of fact, there is never any quarrel between these two types of organizations; their duties are clearly defined and sharply differentiated.

    Although field hospital platoons were permitted to operate with as many as 50 beds each, it was found in the Seventh U.S. Army that the more nearly the census could be kept to 30 beds the better the hospitals functioned and the more mobile they were.

    The work of field hospitals was limited to the care of nontransportable casualties. About half of these casualties could be sent back to evacuation hospitals after examination and resuscitation, though to maintain this proportion required careful evaluation and triage. The casualties who were retained and cared for in the field hospital were chiefly those with wounds of the abdomen and chest and major traumatic amputations (fable 15). These casualties received prompt and expert care. Field hospitals in the Seventh U.S. Army were never employed as forward evacuation hospitals. Instead, they were used as a useful screen for the evacuation hospitals, increasing the ability of these hospitals to handle the main surgical load.

Evacuation Hospitals

    The chief function of evacuation hospitals was the performance of initial wound surgery. All the evacuation hospitals in the Seventh U.S. Army rendered daily reports, as of midnight, concerning their surgical status; that is, the number of patients awaiting surgery and the number of hours estimated


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TABLE 15. - Summary of casualties, by body area, treated in field hospitals in Seventh U.S. Army, December 1944 - April 19451

as necessary to clear up the backlog (surgical lag). A continuing effort was made to equalize the loads of the evacuation hospitals and to prevent the surgical lag from exceeding 8 hours, though this objective was naturally impossible of attainment in periods of sustained offensives, when casualties were heavy and hospitals moving rapidly.

    Control of the surgical lag was, for all practical purposes, a matter of traffic regulation. A liaison officer, or a representative of the ambulance company who was either a commissioned or a noncommissioned officer, was stationed at each evacuation hospital, to control the flow of patients. When he saw the surgical lag becoming excessive, he took action to remedy it upon the advice and at the request of the chief of surgery. Several expedients would be employed. Priority II patients who could not return to their duties within the holding period of the army would be sent to general hospitals if they were transportable, particularly if, by the transfer, they would receive surgery earlier than in the evacuation hospital. A second possibility was a request to the Commanding Officer, Detachment 2d Auxiliary Surgical Group, to send whatever teams might be available to the evacuation hospital to help clear up the backlog.

    Still another possibility was the diversion of casualties to hospitals in another army corps area. In times of stress, the representative of the ambulance company was not too closely confined by corps boundaries. Hospitals supporting different corps were often located close to each other, and it was only reasonable, if one hospital was overloaded, to divert patients to another whose work was lighter. Elasticity of services, resourcefulness of chiefs of surgery, evacuation officers, and liaison personnel, and coordination of administrative functions and professional services did much, in these circumstances, to decrease the surgical lag and insure earlier surgery for the wounded.


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    This whole concept was admirably stated in War Department Technical Bulletin (TB MED) 147, Notes on Care of Battle Casualties, dated March 1945:

    a. The ever present necessity for evacuation of the wounded to the rear is in fundamental conflict with ideal surgical management of the individual patient. To minimize this conflict, close coordination between the functions of administration and professional services is required. It is the responsibility of the medical officer charged with the surgical management of the patient to place technical procedures properly, both in time and in space, with due regard to the tactical situation on the one hand and to the welfare of the patient on the other. Unless the surgeon visualizes his position and the function of his hospital in relation to other surgeons and other hospitals, he may become confused in the mission he is to perform. Although some needed operation may be performed correctly, the military effort may be impeded and unforeseen harm done to the patient if the operation is done at the wrong time or in the wrong place.

    b. It is the responsibility of administrative officers charged with the establishment of evacuation and hospitalization policies to adapt the schedules of movement of patients to the maintenance of highest standards of surgical treatment. Priority of movement must be accorded to patients with certain types of injuries just as the duration of hospitalization in a given zone must be differentially adjusted to the urgent surgical needs of the patients.

Auxiliary Surgical Groups

    The teams which participated in the landings in southern France in August 1944 were all from the 2d Auxiliary Surgical Group (p.505). In November 1944, additional teams, all from the 1st Auxiliary Surgical Group, were assigned to the Seventh U.S. Army. This component consisted of eight surgical teams, two shock teams, two orthopedic teams, one thoracic-surgical team, one neurological team, one maxillofacial team, one dental-prosthetic team, and one X-ray team. These newly arrived teams were immediately attached, for operations and administration, to the detachment of the 2d Auxiliary Surgical Group already in the theater. Later, four surgical teams, two thoracic-surgical teams, one orthopedic team, one neurosurgical team, and one X-ray team, also from the 1st Auxiliary Surgical Group, were also assigned to the Seventh U.S. Army.

    In order to facilitate their assimilation, new teams from the 1st Auxiliary Surgical Group worked, at first, with experienced teams of time 2d Auxiliary Surgical Group. Some of the new teams required considerable instruction. It was provided by this plan, as well as by the tireless efforts of Colonel Sullivan, Commanding Officer, 2d Auxiliary Surgical Group Detachment. The temporary union of components of two different auxiliary surgical groups proved a very wise plan. The groups served as a stimulus to each other. Some of the new teams had never before worked in field hospitals, and some teams which had had this experience were accustomed to being shifted about much more frequently than was the practice in Seventh U.S. Army hospitals.

    Originally, some thought had been given to assigning an experienced surgeon from each team as commanding officer of each field hospital unit. The idea was abandoned, chiefly because it would have reduced the number of available teams, all of which were needed. Much the same end was


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attained, and attained in a more effective fashion, by leaving the teams with the same field hospitals as long as possible rather than shifting them from hospital to hospital. In this way, a spirit of cooperation, and of semipermanence at least, was created.

    An excellent source of instruction for both new and experienced teams was provided by the monthly autopsy reports. After the surgical consultant had studied these reports in his own office, they were forwarded to the teams which had handled the particular cases, with his own comments and with whatever additional details could be obtained.

    In Seventh U.S. Army hospitals, all auxiliary surgical group teams were used as they were constituted, the nurses assigned to the various teams remaining with them permanently. In the First U.S. Army, nurse assistants assigned to the teams were apportioned among field hospitals and allowed to remain with them. The teams were then reconstituted, so that each consisted of four officers, including an anesthesiologist, and four enlisted technicians. The Surgeon, First U.S. Army, considered that the rearrangement increased the capacities for work of the whole group, which was essential with the heavy load of casualties cared for in hospitals in this army. The plan obviously has much to commend it, including the advantage of making life somewhat easier for the nurses.

    Neurosurgical and maxillofacial teams were of maximum usefulness in evacuation hospitals and were usually attached to these installations. Other teams from auxiliary surgical groups, or their counterparts, served with field hospitals. If evacuation hospitals required assistance during rush periods or for other reasons, the necessary teams from these groups were temporarily attached to them. A surgical or thoracic-surgical team and an orthopedic team were usually attached to newly arrived evacuation hospitals for a week or two after they became operational.

    Surgeons from the teams of the auxiliary surgical groups, as well as the teams themselves, were frequently given special assignments. Thus, one senior surgeon acted as chief of surgery in a Seventh U.S. Army evacuation hospital for 2 months. Another surgeon from a thoracic-surgical team spent 4 months on an exchange basis in an evacuation hospital, both to furnish instruction in thoracic surgery to the hospital staff and to permit two surgeons from the staff to see service in a field hospital. A maxillofacial and a thoracic-surgical team spent 3 months building up these special services in a busy general hospital. An X-ray team was permanently attached to an evacuation hospital that had lost its radiologist. Member's of a surgical team were flown into Crailsheim, Germany, when the 10th Armored Division was temporarily surrounded. One team supported the 13th Artillery Brigade, First French Army. Another team was dispatched with a task force which had bottled up pockets of the enemy in Bordeaux and western France in April and May 1945.

    In retrospect, it appears to this consultant that a number of changes might have improved the functioning of the teams of the auxiliary surgical


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TABLE 16. - Summary of casualties, by body area, treated by teams of 1st and 2d Auxiliary Surgical Groups in Seventh U.S. Army hospitals, 15 August 1944-9 May 1945

groups. Personnel of the teams might have been better balanced. There should have been, for example, a larger number of shock teams, at least two for every field hospital of three separate platoons committed to action, or at least two shock teams per division, based on a concept of one field hospital per division.

    Orthopedic teams would have been more useful at the evacuation or general hospital level than in field hospitals. Definitive surgery on the extremities is not performed in field hospitals to any great extent, and orthopedic surgeons are not usually experienced in the type of surgery performed in them. Field hospitals need, above all else, surgical, thoracic-surgical, and shock teams.

    X-ray teams did excellent work in augmenting the organic radiologic personnel in the hospitals, but it is questionable whether X-ray equipment is necessary for every team. Frequently, when the load of casualties is heavy, extra hands are needed, not extra equipment.

    Statistics showing the work performed by the teams of the 1st and 2d Auxiliary Surgical Groups during their service with the Seventh U.S. Army are presented in table 16.

Convalescent-Type Facilities

    The primary mission of the Army medical services in forward areas, as set forth in aforementioned TB MED 147, is twofold, as follows:

    1. They must care for battle injuries and must care for, as well as prevent and minimize, nonbattle injuries and illness. All casualties must be given the best possible care, and, at the same time, hospital bed space must be conserved amid the maximum number of casualties must be restored to duty.


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    2. In order to maintain mobility and keep hospital beds free for future casualties, prompt evacuation of the long-term sick and wounded from the combat areas is essential.

    Convalescent-type hospitals, set up in the army area, lighten the strain on army hospitals and at the same time facilitate the return of sick and lightly wounded men to duty. Convalescent-type hospitals, as already mentioned, also care for neuropsychiatric patients and for patients with venereal disease.

    In the Seventh U.S. Army, a clearing station was utilized for these purposes after the landings until authorized convalescent hospitals arrived. The experience in southern France proved that the prompt provision of a facility of this type was essential. The utilization of army medical collecting and clearing platoons (collecto-clearing platoons) solved the problem very satisfactorily. If these facilities had not been provided at once, lines of evacuation would have been further strained, and many men who were returned to duty within a few days would have been evacuated from the army area and would, perhaps, have been permanently lost to combat duty.

STATISTICAL DATA

Admissions, Deaths, Distribution of Wounds

    During the course of the campaign in Europe, this consultant in surgery personally collected data on a total of 55,085 battle-incurred casualties treated in Seventh U.S. Army hospitals. These data were secured by providing, before the invasion, for their submission to the consultant at specified intervals (p.507). They are not, of course, entirely accurate, and they differ, as personally collected statistics always differ, from official data. It is believed, however, that they are sufficiently reliable to permit certain conclusions to be drawn from them. They also show the volume of work handled in the various medical units of the Seventh U.S. Army. Most of them need little comment.

    Table 17 shows the monthly distribution of admissions and deaths in the army hospitals and clearing stations for the whole period of the campaigns in France and Germany.

    Tables 18, 19, and 20 show the distribution of admissions and deaths according to body area in Seventh Army field and evacuation hospitals. Table 21 shows the distribution of wounds according to body area based on division reports. Although the opportunities for careful examination of casualties in division medical facilities are less good than in other hospitals, the agreement between table 21 and table 18 is surprisingly close.

    Table 22 shows the percentage distribution of wounds according to body area in the Mediterranean and European theaters in World War II in comparison with the distribution in other wars in United States history. The only notable discrepancy, that in the percentage of chest wounds in World War I, can probably be explained by the omission from this group of cases of injuries of the shoulder girdle.


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TABLE 17. - Monthly distribution of hospital and clearing station admissions and deaths, Seventh U.S. Army, 15 August 1944-7 May 1945

TABLE 18. - Distribution by type of hospital and body area of 55,085 battle-incurred wounds in Seventh U.S. Army hospitals


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TABLE 19. - Case fatality rates according to type of hospital and body area in 55,085 battle-incurred wounds in Seventh U.S. Army hospitals

TABLE 20. - Distribution, according to type of hospital and body area, of 1,360 deaths in 55,085 combat-incurred wounds in Seventh U.S. Army hospitals

    The most striking point in these tables is the extraordinarily how case fatality rate, 2.5 percent, in a war characterized by the use of enormously destructive weapons. The good results can be attributed to a combination of factors, beginning with the alertness, intelligence, and resourcefulness of the enlisted aidmen of the Medical Department on the battlefield and ending with expert and devoted nursing care on the part of the Army Nurse Corps, supplemented by the work of wardmasters and other nonprofessional ward personnel. From the surgical standpoint, a variety of factors must be taken into account, including an excellent regimen of resuscitation and postoperative management, with special emphasis on whole blood transfusions; excellent anesthesia; and the administration of penicillin and the sulfonamides as adjunct measures. None of these considerations, however, equaled in importance the performance of good surgery by well-trained and experienced surgeons.


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TABLE 21. - Distribution, by body area, of 48,299 wounds in Seventh U.S. Army casualties, according to division reports 1

TABLE 22. - Percentage distributions of body area and of wounded- or injured-in-action cases, by anatomic location, U.S. Army, in the Civil War and World Wars I and II


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Ballistics

    It is curious, in view of the interest always evinced in the causative agents of combat-incurred wounds in all wars, that the figures for all recorded wars should be so grossly unreliable on this point. In an endeavor to improve this situation, it was requested that pertinent data be submitted each month by division clearing stations, from which, it was believed, the most accurate information could be secured because casualties are first observed in them and are most likely then to give a correct account of their injuries.

    Of the more than 50,000 casualties whose wounds were analyzed from this standpoint, about one-quarter had sustained their wounds from small arms fire, and about three-quarters from high explosives. Wounding agents in 50,204 battle-incurred wounds were recorded by Seventh U.S. Army division clearing stations, as follows:

Wounding agent

Bullets :........................................ Wounds

Unspecified...................................  4,790
Rifle..............................................  5,882
Machinegun..................................   1,774
Total............................................. 12,446

High explosives:

Shell (artillery)...............................    5,389
Mine.............................................    1,868
Blast concussion............................    1,711
Bomb............................................       557
Boobytrap.....................................         81
Grenade........................................         22
Unspecified...................................   28,130
Total.............................................   37,758

Grand total...................................    50,204

    In Fifth U.S. Army hospitals, the relative proportions were 18 percent and 78 percent; no information was available on this point in the other armies. Forty-three wounds caused by bayonets and other cutting weapons are not included in Seventh U.S. Army data.

    Of the 251 deaths which were reported among the 50,204 battle-incurred injuries analyzed, 72 (28.7 percent) were caused by small arms fire and 179 (71.3 percent) by high explosives. These percentages correspond rather closely with the percentages of wounds caused by each type of weapon. The case fatality rate for small arms fire injuries was 0.57 percent and for high explosive injuries 0.47 percent.

    Changes in the distribution of causative agents as the war progressed reflected the changing type of combat. In December 1944, 21 percent of the casualties were caused by small arms fire and 79 percent by high explosives.


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    As the breakthrough in the late winter and spring of 1945 became more and more complete and as the German Army progressively disintegrated, sniping, resistance by localized groups, and guerrilla tactics took the place of organized warfare. As a result, there was an increase in the proportion of wounds caused by small arms fire. In April 1945, in contrast to the December 1944 figures, 40 percent of the casualties were caused by small arms fire and 60 percent by high explosives.

Returns to Duty

    The proportion of patients returned to duty from forward installations is shown in tables 23, 24, and 25. The total number returned to duty was 40 percent, the proportions for disease, non-combat-incurred injuries, and combat-incurred injuries being, respectively, 56 percent, 36 percent, and 16 percent.

TABLE 23. - Hospital and clearing station admissions and dispositions, Seventh U.S. Army, 15 August 1944-7 May 1945

TABLE 24. - Returns to duty from clearing stations and hospitals, Seventh U.S. Army, 1 September 1944-30 April 1945


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TABLE 25. - Returns to duty from 400- and 750-bed evacuation hospitals in Seventh U.S. Army for a selected 3-month period

    A number of suggestions were made concerning the alteration of medical facilities within the army area, or the increase of the facilities then provided, so that the percentage of returns to duty could be increased, with, at the same time, the conservation of medical manpower. These suggestions included special medical evacuation hospitals; special neuropsychiatric hospitals; the assignment of small surgical hospitals to each division; the provision of evacuation hospitals of uniform size (400 to 600 beds); a greater use of 750-bed evacuation hospitals; reorganization of the intrinsic staffs of evacuation hospitals by a reduction in personnel, to be compensated for by a wider use of auxiliary surgical teams; the use of an army field type of general hospital; and the conversion of convalescent hospitals into smaller, more mobile units or companies.

    There is no doubt that, under certain tactical conditions, an increased utilization of smaller and more mobile hospitals of the convalescent type would increase the percentage of returns to duty within the army area. If evacuation hospitals were of two sizes, one should be kept relatively small and the other, which would be larger, would fill the needs then filled by existing evacuation hospitals. In both types of evacuation hospitals, the intrinsic staff would be augmented, as necessary, by the full employment of teams from auxiliary surgical groups.

    Compared with smaller hospitals, a 750-bed evacuation hospital has the following two major disadvantages: (1) It is more difficult to displace the larger hospital, particularly if a withdrawal must be made and (2) when a 750-bed hospital is moving, it clogs the roads to a much greater degree than a 400-bed hospital.

    On the other hand, experiences in the Seventh U.S. Army in World War II indicated that, from the standpoint of returns to duty, the 750-bed hospital is somewhat more efficient (table 25). The 400-bed and 750-bed hospitals listed


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in table 25 were all similarly located over the 3-month period surveyed, all were employed during the same active offensive, and all had the same missions. The greater efficiency of the 750-bed hospitals may be attributed to their greater holding capacity, their ability to expand more rapidly than smaller hospitals, and their more diversified medical and surgical staffs.

CLINICAL POLICIES

    The information on which the clinical portion of this chapter is based was secured, in part, from the information requested in Circular No. 15, Seventh U.S. Army, dated 31 August 1944 (p.507). The data requested included the following:

    1. Deaths by name, rank, Army service number, and organization, with a brief analysis of each case and pertinent comments.
    2. The same information for all enucleations or eviscerations of the eye.
    3. A breakdown of all major amputations (thigh, leg, arm, and forearm). Details of the case were to be supplied whenever it was thought that amputation could have been prevented.
    4. Information on all injuries to major vessels and their management, with special attention to amputations.
    5. Information on all cases of anaerobic myositis (name, rank, Army service number, and organization, with details of the management of the case and the results).
    6. The same information on all wounds of major joints in which suppuration had occurred.
    7. Information on all major infectious of special interest or significance.
    8. Data on transfusions, including the number given, the number of patients transfused, the total amount of blood used, the details of reactions, and any other information that might be useful concerning the use of whole blood.

    The data secured by this command circular were recognized as not inclusive and, in some instances, as not altogether accurate; but they were ample to show clinical trends and to permit conclusions concerning special methods of treatment and other matters.

Resuscitation

    One error never made in Seventh U.S. Army hospitals was to conceive of resuscitation as being limited to the administration of plasma or blood transfusions. On the contrary, resuscitation was regarded as a routine which required, in addition to the use of plasma, blood, or both, according to the indications of the special case, the following measures, also according to the indications of the special case: Control of hemorrhage; splinting of the wound; application of dressings; administration of morphine, if required for the control of pain, on the field or in the battalion aid station; administration of oxygen; aspiration of blood and air from the chest; injection of the intercostal nerves with procaine hydrochloride (Novocain) ; emptying of the stomach, the blad-


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der, or both; maintenance of a free, dry airway; and a multitude of other procedures designed to make the patient a suitable candidate for surgery. Resuscitation, in short, ranged from protection of the casualty from unnecessary exposure immediately after injury to the final performance of initial wound surgery; even inexperienced surgeons soon came to realize that the act of operation was frequently an integral and essential phase of the routine of resuscitation.

    Emphasis was constantly placed upon adequate blood replacement and the proper timing of surgery in relation to the administration of blood and the response to it. Excess administration of blood, however, particularly in wounds of the head and chest, was discouraged as both unnecessary and, occasionally, dangerous. The collected statistics show that administration of blood was at the rate of 0.54 pint per patient when both combat-incurred and noncombat injuries were considered and at the rate of 0.72 pint when only battle injuries were considered. The minimum monthly average was 0.54 pint per battle casualty in August 1944 and the maximum, 0.91 pint per battle casualty in April 1945. The increase is an index of the increasing experience gained by surgeons in army hospitals and clearing stations as the war progressed. The average amount of blood used in field hospitals, 3.9 pints per persons transfused, was, for obvious reasons, higher than the amount used in evacuation hospitals, which was 1.8 pints per person transfused.

    The shock teams of the auxiliary surgical groups rendered invaluable assistance in all field hospitals, and all evacuation hospitals maintained an aggressive attitude toward this condition. Shock wards were well organized amid were always under the direct supervision of experienced medical officers. A shock ward was no assignment for a medical officer who did not appreciate all of the problems and risks of shock in casualties with combat-incurred wounds, however competent he might be in civilian practice.

Anesthesia

    Well-trained anesthesiologists were attached to all army hospitals and served on all auxiliary surgical teams. Anesthesia in forward hospitals was therefore always competently administered. Capt. (later Maj.) Daniel Massey, MC, 9th Evacuation Hospital, a diplomat of the American Board of Anesthesiology, was utilized informally as a consultant, just as Captain Solouff was used as an informal consultant in ophthalmology.

    All new hospitals arrived with two officer anesthesiologists on their staffs. While their organizations were staging, these officers were placed on temporary duty in experienced field and evacuation hospitals, so that, when their own units went into action, they had already had some experience with combat-incurred injuries and had come to appreciate the difference between surgery for them and elective surgery, or even emergency surgery, in civilian practice.

    At the request of Colonel Tovell, statistics on anesthesia were collected for a 6-month period in Seventh U.S. Army hospitals (table 26). The difference


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TABLE 26. - Distribution of anesthesia by type, and by type of hospital, Seventh U.S. Army, 1 November 1944-30 April 1945

between the methods used in field hospitals and those used in evacuation hospitals reflects the differences in the surgical problems encountered in the two types of installations. The much smaller percentage of endotracheal anesthesias given in evacuation hospitals (31.2 percent, versus 83.0 percent in field hospitals) is a further reflection of this fact.

    Early in the experience in North Africa, the advantages as well as the added safety of a combination of intravenous anesthesia (thiopental sodium) and nitrous oxide anesthesia were not recognized. Had the war lasted longer, there is no doubt, considering the trend already evident, that this combination would have been employed even more frequently in evacuation hospitals, chiefly at the expense of some of the other techniques.

    The inhalation agents most often used were ether and nitrous oxide, with induction by ethyl chloride. Chloroform was rather frequently used for induction in the 9th Evacuation Hospital, always under the direct supervision of Captain Massey. There were no reactions and no deaths.

    Anesthesiologists in various army hospitals provided well-planned instruction in anesthesia for both nurses and carefully selected enlisted personnel on their staffs. As a result, most hospitals had 8 or 10 additional anesthetists who had had some special training, and bottlenecks because of anesthesia therefore seldom existed. The 9th Evacuation Hospital began to train enlisted personnel as anesthetists early in the Tunisian campaign. Instruction was given over a 2-year period b practical demonstrations, personal supervision, study groups, group discussions, and, eventually, clinical practice. This plan had several advantages. It assured the surgical section of a permanent group of trained anesthetists. It did not deplete the nursing section, which was always shorthanded. It provided an excellent stimulus for the enlisted personnel of the hospital. It was one of the trained technicians of this unit who went ashore with the surgical consultant on D-day and who was immediately


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attached to the l0th Field Hospital, to replace the anesthesiologist who had been wounded during the landings. He served in this hospital until D+12, thus solving a problem which otherwise might have seriously delayed the care of the wounded.

    The 11 deaths in Seventh U.S. Army hospitals which apparently must be attributed, wholly or in part, to anesthetic agents or to the accidents and complications of anesthesia were distributed as follows:

    Three deaths were due to Pentothal sodium (thiopental sodium) anesthesia alone. The collected statistics show that this is a ratio of 1 to 7,211 anesthetics when Pentothal sodium was the sole agent and 1 to 8,799 anesthetics when it was combined with other agents. These ratios compared very favorably with those of civilian hospitals.

    One death was due to combined Pentothal and spinal anesthesia.

    One death was due to procaine poisoning following sympathetic block. The assumption was that the injection was probably too deep; the anesthetic agent was found in the spinal fluid.

    One death occurred after ether anesthesia. In this case, open ether was administered through a mask held over an endotracheal tube and too high a concentration was undoubtedly given directly into the trachea. Death occurred on the second postoperative day, and autopsy revealed an extremely diffuse purulent capillary bronchitis.

    One death followed the preanesthetic administration of morphine and atropine. The patient, who had acute appendicitis, went into collapse after the subcutaneous administration of 0.010 gm. of morphine and 0.0045 gm. of atropine. He did not respond to intensive efforts at resuscitation and died within an hour, without anesthesia or surgery. Although these are standard (loses of the drugs, which are used routinely in preoperative preparation, the death must be charged to the medication.

    One death was due to unrecognized obstruction of a bronchus by the endotracheal tube.

    Three deaths were due to aspiration of vomitus with bronchial occlusion.

Chemotherapy and Antibiotic Therapy

    The NATOUSA policy of administering penicillin to all casualties except the most lightly wounded immediately upon their arrival in forward army hospitals was followed in the Seventh U.S. Army. Later, when this army came under ETOUSA operational control, the first dose of penicillin was administered in clearing stations.

    The protection afforded by penicillin permitted broadening of the scope of all surgery and, particularly, it permitted thorough debridement of wounds, regardless of the timelag between wounding and initial wound surgery. Penicillin proved to have many advantages over the sulfonamides previously used routinely. It was more potent. It had none of the untoward complications of the sulfonamides, particularly the renal complications. It. did not depress


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the bone marrow. On the other hand, while its use greatly improved the results of the operations performed in Seventh U.S. Army hospitals, penicillin was never regarded its a substitute for good surgery.

    Penicillin was used locally as well as systemically, but only in delayed debridements, wounds of the chest and abdomen, and wounds involving the cerebrospinal system. Its topical use was discouraged under all other circumstances.

    As a general rule, the administration of the sulfonamides was left to the discretion of the individual surgeon until the publication of Circular Letter No. 7, Office of the Surgeon, Seventh U.S. Army, dated 13 April 1945, which discouraged their local use as an adjunct to initial wound surgery. By this time, the concept had developed that their use within wounds was not only not beneficial but might be harmful.

    There was no proof, one way or the other, that the employment of sulfonamide powder on first aid dressings had any real effects. There is, however, an inherent urge in man to put something out a fresh wound beyond a simple, dry, sterile dressing. It was thought, wiser, therefore, not to interfere with this first-echelon practice, on the ground that it was not harmful and might be beneficial and that, in any event, it was superior to the application of iodine or a mercurial.

General Surgical Policies

    General policies of surgical care of casualties in Seventh U.S. Army hospitals were stated in Circular Letter No. 2, Office of the Surgeon, Seventh U.S. Army, dated 18 July 1944. They were reiterated in Circular Letter No. 17, Office of the Surgeon, Seventh U.S. Army, dated 30 December 1944. The latter letter stated again the fundamental principles of initial wounds surgery and dealt with specific types of wounds, particularly wounds of the right colon (p.556) . Both these letters, like the letters issued later dealing with special types of wounds, simply contained formal instructions for policies which had already been in effect and which experience had shown to he useful or necessary modifications of, or additions to, the policies officially established before the invasion of southern France.

    The chief difficulty in new units was failure of their surgeons to realize the extreme importance of performing debridement. according to fundamental principles. They fully appreciated the necessity for it in theory, but in practice they failed to consummate the theory. They were inclined to excise skin and superficial tissue while failing to incise fascial planes widely and to debride deeper tissues adequately. The resulting wound was relatively small and bulging, packed with gauze murder tension, often infected, and seldom ready for closure at the first dressing.

    As medical units in the Seventh U.S. Army gained in experience, their techniques of debridement improved. They came to realize that correct debridement is not a rough hacking away of tissues in hit-or-miss fashion but is,


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instead, a precise operative procedure which demands good light, adequate assistance, wide incision of fascial planes, exposure of all recesses of the wound, careful hemostasis, anatomic dissection of tissues, complete removal of all damaged tissues, and a consistently atraumatic technique throughout all steps of the procedure.

    Inexperienced medical officers also made other errors. They administered excessive doses of morphine. They sent patients to the rear inadequately protected with blankets, particularly blankets underneath the body. They were inclined to charge dressings more often than was necessary in collecting and clearing stations. They evacuated patients from hospitals with intact or inadequately divided casts, tight dressings, poorly immobilized parts, unaspirated chests, retracting colostomies, and insufficient blood replacement.

    These errors, which were all fairly common, were partly attributable to inexperience in military surgery and partly to failure to comprehend the entire medicomilitary situation. They were soon rectified by visits to, and comments from, more experienced general hospitals and older field and evacuation hospitals. When these errors were called to the attention of corps and division surgeons, these officers were always most cooperative and took immediate steps to correct them. As new medical officers gained in experience, they themselves came to appreciate the value of sound initial surgery and to realize that it protects the patient from infection and other complications, makes early reparative surgery possible, and achieves the greatest possible conservation of manpower.

REGIONAL INJURIES

Wounds of the Extremities

    Wounds of the extremities accounted for about two-thirds of all admissions for battle-incurred wounds to Seventh U.S. Army hospitals. Wounds in the lower extremities were considerably more frequent than in the upper. In evacuation hospitals, these wounds made up about 70 percent of the workload. In field hospitals, they accounted for only about 30 or 35 percent, the rest of the load being made up of thoracic, abdominal, and thoracoabdominal wounds. First echelon care was generally good. Tourniquets were used with discretion and efficiency, and their use seldom gave rise to complications. Occasionally, particularly in newly arrived medical units, morphine was administered in excess. At times, patients were received inadequately protected from exposure and with fractures unsplinted. It was sometimes difficult to impress upon inexperienced personnel that a properly dressed litter required blankets under the patient as well as over him.

    The initial surgery of compound fractures in army facilities consisted of adequate resuscitation, proper debridement, careful appraisal and repair or other management of major vascular injuries, and the application of transportation casts. Patients with vascular injuries had to be held until viability of the limb was assumed or amputation was obviously necessary. The principle


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FIGURE 94. - Preparations for administration of blood to wounded soldier in evacuation hospital near Dijon, France, September 1944. Note the diagram of the fracture on time cast. Note also that the cast has been split, in accordance with regulations.

of complete debridement paramount in modern military surgery and is nowhere more important than in compound fractures and wounds of the joints.

    Some difficulty was encountered in impressing upon surgeons in new units the importance of such matters as firm but nonconstricting dressings and the correct position and support, of the injured limb, as well as the vital necessity of completely splitting all casts and all layer's of circular bandages and dressings (fig.94). Unless casts were split before evacuation, preferably while they were still wet, patients were likely to be received in general hospitals with painful, swollen limbs, with the risk of serious infection increased, and with convalescence greatly prolonged.

    The definitive treatment of major fractures was not the responsibility of field army hospitals. This function pertained to hospitals in communications zones and the Zone of Interior. Patients with serious fractures were given, as far its possible, early priority in transportation to general hospitals (fig.95), so that they would arrive within 5 or 6 days after wounding, within the optimum period for initial wound dressing, delayed closure or redebridement, and initiation of treatment of the fracture.

In the rush of work, surgeons sometimes forgot that the institution and maintenance of traction were important phases of the routine of resuscitation in patients with fractures of the femur or tibia. and that the practices also


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FIGURE 95. - The 2,000-bed 36th General Hospital at Dijon, France, one of CONAD general hospitals in close support of the Seventh U.S. Army during the winter, 1944-45.

expedited initial wound surgery. Lt. Col. Donald McNeil, MC, attributed the exceptionally efficient management of compound fractures of the femur at the 51st Evacuation Hospital to strict adherence to this policy. In this hospital, after a wire had been placed through the lower femur or upper tibia, the limb was suspended to an overhead frame, at right angles to the body. This technique reduced or prevented shock, and the position gave complete access to all parts of the thigh, greatly simplifying the operative procedure, which otherwise would have been laborious and tiring. After debridement, traction was maintained until a transportation cast was applied.

    Hand injuries. - Special instructions for the management of hand injuries were given in Circular Letter No. 7, Office of the Surgeon, Seventh U.S. Army, dated 13 April 1945. In this letter, it was also directed that the local use of sulfonamides be discontinued and that plain fine-mesh gauze be substituted for petrolatum-impregnated gauze as an initial wound dressing.

Wounds of the Joints

    Major contributions to the initial management of wounds of the joints had been made in Fifth U.S. Army hospitals in Italy by Lt. Col. Oscar P. Hampton, Jr., MC, Consultant in Orthopedic Surgery to the Chief Surgeon. These policies, which were based upon the work of Pool 6 in World War I, were first

6 Pool, Eugene H.: Wounds of Joints. In The Medical Department of the United States Army in the World War. Surgery. Washington: Government Printing Office, 1927, vol. XI, pt.1, pp.317-341.


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employed in the 9th Evacuation Hospital in Italy, while it was serving French casualties. They included formal arthrotomy in all wounds of the joints; complete debridement, with the removal of all foreign bodies, free bone fragments, and damaged and devitalized cartilage; thorough lavage; closure of the joint capsule; installation of penicillin; and immobilization of the limb in a plaster spica or Tobruk splint.

    Patients with wounds of the knee joint treated by this technique were followed up in general hospitals, and, its far as could be ascertained on informal surveys, the only infections which were present occurred in joints which were already grossly infected at the time of initial wound surgery and those in which the instructions concerning formal arthrotomy and complete debridement had not been followed. In the 9th and 51st Evacuation Hospitals, which conducted a special study of arthrotomies of the knee joint, only 2 infections were observed in 227 cases. One patient had undergone initial wound surgery 10 days after wounding and the other, 14 days after. Gross infection was present at the time in both cases. None of the other wounds showed any signs of infection when the patients were evacuated to the rear.

    Compound fractures of the hip joint were, fortunately, not frequent. In previous wars, the subsequent course of these casualties had often been tragic, with long-drawn-out sepsis and, eventually, destruction of the joint to such an extent that major problems of reconstructive surgery were posed. In March 1945, two of the more experienced surgeons in the Seventh U.S. Army were requested to apply to wounds of the hip joint the bold policy which had met with such great success in wounds of the knee joint in both British and U.S. Armies. Before this policy was instituted, it was discussed informally with Brigadier Sir W. Rowley Bristow, Consultant in Orthopedic Surgery, RAMC, at a chance meeting. The procedure is much more formidable in the hip joint, but the urgent necessities of these wounds warranted its trial.

    Colonel McNeil, of time 51st Evacuation Hospital, whose remarks on the preoperative use of traction have already been mentioned, had good results with it. Lt.. Col. James E. Thompson MC, reported in detail the nine formal arthrotomies of the hip joint which he had performed in the 9th Evacuation Hospital. In several of these cases, damage to the deep layers of the gluteus medius muscles and destruction of the gluteus minimus had been so extensive that no concept of the true situation could have been gained through the usual type of incision. The destroyed muscle tissue and the dirt and bits of clothing embedded in the wound could not have been completely visualized or completely removed unless a formal arthrotomy had been performed.7

7 Colonel Thompson and Colonel Berry reported the followup on seven of those nine cases at the meeting of the American Surgical Association in 1948. (Thompson, J. E., and Berry, F. B.: Penetrating Wounds of Major Joints. Tr. Am. S.A. 65: 567-584, 1947.) The late results were a convincing demonstration of the value of a bold approach to wounds of the hip joint.


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Wounds of the Abdomen

    In Seventh U.S. Army hospitals, contrary to the usual experience, approximately 40 percent of casualties with abdominal injuries received their initial treatment in evacuation hospitals instead of field hospitals. This was necessary because of the tactical situation. During one period of the fighting, an evacuation hospital was only about a quarter of a mile from the field hospital, which made it possible to distribute casualties to both according to their workloads. During three other periods of fighting, the same situation prevailed in respect to several field and evacuation hospitals. As a result, when field hospitals were under pressure, evacuation hospitals received casualties which would ordinarily have been cared for in hospitals farther forward. Finally, when field hospitals were moving, it was frequently the practice to take casualties directly to evacuation hospitals, in which, even though the ambulance haul was slightly longer, they could be cared for more promptly.

    Patients with abdominal injuries were treated according to the sound policies already established in the Mediterranean and European theaters. The objective was to perform operation as soon as possible. With this idea., resuscitation was expedited, and in most cases was accomplished within 3 hours or less, the assumption being that, if a response was not observed within this period, either hemorrhage was continuing or massive peritoneal contamination was responsible for the continued state of shock. In both circumstances, surgery was regarded as a part of resuscitation and was proceeded with promptly.

    In order to avoid ileocolostomy, which had given somewhat inferior results in hospitals in Italy, the following technique was employed in wounds of the right colon: 8

    1. If the wound of the ascending colon was small and clean cut, it was either exteriorized or repaired in two layers; in either case, a large cecostomy was provided.
    2. If the damage was irreparable, resection of the involved area of the bowel was carried out, either in a single stage or in two stages, depending upon the extent of the lesion, the degree of peritonitis present, and the condition of the patient.

    The two-stage operation was regarded as safer than single-stage surgery and was performed, whenever it was feasible, by the following technique:

    After ileotransverse colostomy had been performed, the distal stump of the resected ileum was exteriorized, as a mucous fistula, well out in the right lower quadrant. A loop of transverse colon or the hepatic flexure just proximal to the anastomosis was then delivered through a subcostal incision. This loop was divided, and the ends were left open. The wounded portion of the colon was exteriorized either through the lower incision, with the ileum, or through the upper incision, along with the colon, whichever was simpler.

8 Circular Letter No. 17, Office of Surgeon. Seventh U.S. Army, 30 Dec. 1944.


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    Although this technique was employed in only a limited number of cases, surgeons in both army and general hospitals reported good results with it. It caused less excoriation of the abdominal wall than the standard operation, nursing care was simpler, and patients seemed to recover more promptly.

    In the collected series of 55,085 admissions for battle-incurred wounds, the case fatality rate for abdominal injuries was 19.2 percent. The rate in field hospitals was 24.6 percent and in evacuation hospitals 11.5 percent.

Wounds of the Thorax

    Almost all casualties with wounds of the thorax were sent first to field hospitals for examination, evaluation of their wounds, and such resuscitation as might be necessary. About 40 percent were held in field hospitals for treatment; the remainder were regarded as safely transportable to evacuation hospitals for definitive treatment.

    Early in the Seventh U.S. Army experience, some surgeons believed that formal thoracotomy should be performed rather frequently at the time of initial debridement. and that the official policy of conservatism would produce less satisfactory results. As the campaign progressed, it became clear that results were better and fatalities fewer when the official policy was strictly followed. When these patients were evacuated to general hospitals, they were usually well on their way toward regaining normal lung expansion and function. Reports by general hospitals and observations in visits to these hospitals indicated that these results were permanent and not ephemeral.

    Indications for primary thoracotomy, either by extension of the wound or by a separate incision at a site of election, were based on the policies which had been promulgated and practiced in the Mediterranean theater. They were as follows:

    1. Continuing intrapleural hemorrhage not controlled by hemostasis in the course of debridement of the chest wall.
    2. Anatomic or clinical evidence of penetration of time diaphragm.
    3. Suspected visceral damage, the suspicion being based on the fact that a missile had traversed the mediastinum or lodged in it.
    4. The presence of large intrapleural foreign bodies or debris readily accessible by extension of the traumatic wound.
    5. Wounds of large bronchi or of the intrathoracic portion of the trachea.

    The following conditions were not regarded, in themselves, as indications for initial formal primary thoracotomy:

    1. The presence of foreign bodies (metallic fragments or bits of rib) in the lungs or of small fragments in the pleural space.
    2. Hemothorax. (The evacuation of blood from the pleural cavity by suction at the time of debridement of the chest wall was not regarded as thoracotomy.)
    3. Laceration or contusion of the lung in the absence of definite evidence of continuing hemorrhage.


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    Emphasis in all wounds of the thorax was placed on such details of effective resuscitation as complete aspiration of blood and air from the pleural cavity, aspiration of the tracheobronchial tree, and the administration of whole blood and oxygen as required. Warnings were issued against the rise of excessive amounts of blood and other intravenous fluids in patients with wounds of the chest.

    In the 55,085 hospital admissions for battle-incurred wounds analyzed, the case fatality rate for thoracic injuries was 5.4 percent.. The case fatality rate in field hospitals was 8.7 percent, and that in evacuation hospitals, 3.3 percent.

Thoracoabdominal Wounds

    Thoracoabdominal wounds accounted for about 5 percent of all admissions for battle-incurred wounds in Seventh U.S. Army hospitals. As surgeons gained more and more experience with them, it became the general practice to approach them first through the chest. This policy favored prompt restoration to normal of deranged cardiorespiratory physiology, and it permitted abdominal exploration and the necessary intra-abdominal surgery under the most favorable possible circumstances.

    In the 55,085 hospital admissions for battle-incurred wounds analyzed, the case fatality rate for thoracoabdominal injuries was 21.7 percent. The case fatality rate in field hospitals was 26.5 percent, and that in evacuation hospitals, 15.0 percent.

Wounds of the Head and Spine

    The Seventh U.S. Army was particularly fortunate in its complement of nine experienced neurosurgeons, and neurosurgery, as a result, was extremely well covered. Five of these highly trained neurosurgeons were assigned to hospitals, and four to neurosurgical teams. One of these teams was attached to a field hospital for the landings, but it was soon realized that the services of a neurosurgeon could be better utilized in an evacuation hospital, and the appropriate transfer was made. Full use was also made of three other surgeons who had some previous experience in neurosurgery.

    At the suggestion of Col. R. Glen Spurling, MC, Senior Consultant in Neurosurgery, ETOUSA, four of the neurosurgeons attached to Seventh U.S. Army hospitals and neurosurgical teams were given 60-day temporary duty transfers to neurosurgical centers in the United Kingdom Base, and four of the surgeons from those centers served in the Seventh U.S. Army hospitals for the same period. This plan proved highly beneficial, not only in the variety of experience which it permitted but also because of the opportunities it gave to each group to comprehend the problems of the other group.

    At Colonel Spurling's request., data for injuries of the head (tables 27 and 28) and injuries of the spine (table 29) in Seventh U.S. Army evacuation hospitals were analyzed for a 5-month period.


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TABLE 27. - Management and results in 717 penetrating wounds of the head in eight Seventh U.S. Army evacuation hospitals for a selected 5-month period

TABLE 28. - Results in 616 surgically managed wounds of the head in relation to dural penetration in eight Seventh U.S. Army evacuation hospitals for a selected 5-month period.

Wounds of the Blood Vessels

    Many of the amputations performed in Seventh U.S. Army hospitals were necessitated by wounds of the major arteries. Amputation was necessary in nearly 30 percent of 1,086 vascular injuries on which data were personally collected (table 30). On the basis of this analysis, Circular Letter No. 9, dated 18 May 1945, 9 was prepared, but its distribution was accomplished too late for it to be useful during hostilities. The policies which it stated, however, had already been in effect for a considerable time.

9 Circular Letter No. 9, Office of the Surgeon, Seventh U.S. Army. 15 May 1945.


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TABLE 29. - Essential data in 182 spinal cord injuries in eight Seventh U.S. Army evacuation hospitals for a selected 5-month period

    The first principle of management of vascular injuries was that it should be conservative, with amputation the last resort. Repair of the damaged artery was to be effected whenever possible. Sympathetic lumbar blocks were done routinely with procaine, and lumbar sympathectomy was performed in a few instances.

    Suture was always employed when the technique was feasible. Evaluation of the techniques in which prostheses were employed is difficult because no single procedure was carried out in a large series of cases. Survival of the limb followed the use of vein transplants in two of four cases. One limb survived after the rise of a polyethylene tube transplant and another after the use of a glass tube. It is impossible even to comment on such small numbers of cases, though, of the artificial grafts and prostheses employed, polyethylene tubing was thought, preferable to Blakemore metallic cuffs and vein grafts because the technique was simpler.

    In March and April 1945, heparin became available in limited quantities and seemed to be of some value, though it is known that in at least one instance serious delayed oozing followed its use. It was thought that a more extended trial might have demonstrated it to be of real usefulness if it were used with the proper precautions,

    Actually, the outcome of every arterial wound depended in large measure upon the nature of the injury: Whether the wound was small and clean, or large, contaminated, and infected, with widespread destruction of tissue; whether the vessel was completely or only partly divided; whether the injury


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TABLE 30 - Essential data in 1,086 injuries to major arteries, Seventh U.S. Army, 15 August 1944-30 April 1945

was situated at, or near, an important vascular anastomosis; whether circulation was still active in the limb when the patient was first seen; and whether thrombi had already formed.

Amputations

    Exclusive of immediate traumatic amputations, the collected figures show that, in Seventh U.S. Army hospitals, 1,211 major amputations were per formed on Army personnel, in addition to 252 amputations on non-Army personnel, and 277 amputations in which the origin of the casualties was not stated (table 31). If the first and third of these groups were considered as though they were composed entirely of U.S. Army personnel, the ratio of amputations to battle casualties would be 1:40.9 in the 55,058 hospital admissions for battle-incurred injuries on which data were personally collected. If nonbattle casualties are included, the ratio would be 1:53.6. These high ratios are explained by the numbers of landmines encountered during offensive operations, particularly in the fighting in November and December 1944 and March 1945.


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TABLE 31. - Anatomic location and origin of casualties in 1,211 amputations in Seventh U.S. Army hospitals

Maxillofacial Wounds

    Three Seventh U.S. Army hospitals, the 9th, the 27th, and the 117th Evacuation Hospitals, had strong maxillofacial sections, and the policy, as far as it was practical, was to send most maxillofacial injuries to them. The other hospitals showed varying degrees of interest in this special problem.

    One of the two maxillofacial surgery teams which landed on D-day lost its senior surgeon, by wounding, almost immediately (p.512). It was reconstituted as a general surgical team, the need for which was then greater; this team thus had the added advantage of having, as one of its members, a surgeon with some experience in maxillofacial surgery. For the same reason--that the need for general surgical teams was greater--a third maxillofacial surgery team which arrived in southern France, in December 1944 was reconstituted as a surgical team.

    As the experience in the Seventh U.S. Army area showed, serious maxillofacial injuries are best handled in evacuation hospitals, in which trained oral and maxillofacial surgeons are available to treat them. Maxillofacial teams are also more usefully employed at this level rather than in field hospitals. If hemorrhage is arrested and a proper airway is established and maintained, casualties with this type of injury tolerate transportation very well, prone or sitting forward, though they may require the attention of special attendants while they are in transit. If, for any reason, a casualty with a maxillofacial injury had to be held in a field hospital, a maxillofacial team could go forward to treat him, exactly as was the practice when other specialized injuries required treatment in a more forward hospital.

Wounds of the Eye

    Only the simplest and most urgent ophthalmologic surgery was performed in army facilities. Every effort was made to conserve the eyes. There is no doubt that some wounds required additional surgery in the com-


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munications zone, but there were only four known instances in the army area in which both eyes were lost, which is remarkably low, in view of the nature of modern combat. It is possible that some eyes had to be removed in hospitals in the communications zone.

    The collected figures show that 193 enucleations or eviscerations of injured eyes were performed in 189 patients, which is 0.32 percent of the approximately 60,000 admissions for battle-incurred injuries officially reported in the Seventh U.S. Army. An additional 136 enucleations or eviscerations were performed in prisoners of war and non-U.S. Army personnel. Whenever it was feasible, a glass sphere was implanted in Tenon's capsule after the eye had been removed.

ANAEROBIC INFECTIONS

    In World War I, excluding wounds due to chemical warfare, theme were-

* * * 128,265 wounds of the soft parts with 9,719 deaths: of the wounded in this group, 1,389 developed gas gangrene, which amounts to only a little more than 1 percent (1.08) The death rate among those who received wounds of the soft parts which became complicated with gas gangrene was 48.52 percent, the actual number of deaths being 674.

    Among the 25,272 whose wounds included bone fracture there were 2,751 deaths. The incidence of gas gangrene among the bone fracture cases was much higher than among those who sustained wounds of the soft parts only, the total being 1.329 with 593 deaths. The incidence in this group of the wounded was therefore 6.26 percent and the case mortality rate 44.66 percent. 10

    The combined incidence of gas gangrene in these two groups of World War I casualties (153,537) was thus 1.8 percent.

    In World War II, the situation was very different, though, unfortunately, the records do not differentiate between anaerobic cellulitis and anaerobic myositis. By 1 November 1944, 24 anaerobic infections had occurred in U.S. Army personnel, with 2 amputations and 10 deaths, and 47 such infections had occurred in undifferentiated personnel, who may have included U.S. Army personnel, with 15 amputations and 2 deaths.

    From the end of November 1944 until the end of April 1945, there were 152 anaerobic infections in U.S. Army personnel, with 90 amputations and 38 deaths: over the same period, there were 46,630 U.S. Army battle casualties. The incidence of anaerobic infections during this period is thus 0.3 percent, and the case fatality rate for this type of infection, 25 percent.

    Between November 1944 and April 1945, there were also 93 instances of anaerobic infection in personnel other than Army personnel, with 40 amputations and 15 deaths.

    The very considerable improvement in respect to the incidence and results of gas gangrene in World War II calm be explained in several ways. Anti-

10 Coupal, James I. Pathology of Gas Gangrene Following War Wounds. In The Medical Department of the United States Army in the World War Pathology of the Acute Respiratory Diseases Gas Gangrene Following War Wounds. Washington: U.S. Government Printing Office, 1929. vol. XII, p.412.


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toxin was used in some cases, but the results were not convincing. Earlier surgery, routine complete debridement, transfusions of whole blood, and the use of penicillin undoubtedly played a part in the improved results. The chief credit, however, is attributable to the performance of good surgery by well-trained surgeons, who were available in far greater numbers in World War II than in World War I.

    The cases of clostridial infection known to have occurred in non-U.S. Army personnel, were attended with a much higher case fatality rate than those which occurred in U.S. Army personnel, as might have been expected, since the great majority of casualties in this group were prisoners of war who had been wounded and had been without treatment for many hours before they arrived in Seventh U.S. Army hospitals.

BURNS

    The 1,284 burns which were included in the statistics collected in forward hospitals in the Seventh U.S. Army were chiefly produced by field ranges and similar equipment. A few phosphorus burns were encountered in the winter and spring. Routine treatment consisted of the application of petrolatum impregnated gauze and pressure dressings.