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Chapter XVI

Contents

CHAPTER XVI

Noncombat Lesions

General Considerations

If, at the outbreak of World War II, the official history of World War I had been made required reading for every newly inducted Army surgeon, in the senior as well as in the junior grades, and if the advice of World War I surgeons had been heeded, a great many elective operations, particularly on the feet and the knee joint, would not have been performed in World War II. Many of them were unnecessary; they were often meddlesome; and they usually failed to achieve their objective, which was to increase the number of combat soldiers.

Elective operations done in the United Kingdom prior to D-day included operations for hammertoes; bone grafts; operations on the spine, particularly for herniated intervertebral disks and spondylolisthesis; operations on the shoulder; and, most frequently, arthrotomy of the knee joint. Eventually, after a great deal of time and effort had been wasted, it was realized that most of these operations were, for all practical purposes, complete failures. It was the exception rather than the rule for a soldier to be able to do full combat duty after any elective procedure. Usually he could do no more than before he was operated on, and sometimes he could not do as much.

Some of this misplaced surgical zeal could be attributed to the paucity of surgical work in the early days of the European theater, but more of it could be explained by a lack of mature judgment. With the approach of D-day the problem practically solved itself. There was a general realization that the performance of elective orthopedic surgery is not the function of the medical corps of an expeditionary force and that in most instances the difficulties of the individual soldier are better resolved by reassignment than by attempted rehabilitation by means of surgery. Thereafter, with the exception of a few carefully selected officers, whose services were of special value in the theater, officers and enlisted men who absolutely required elective surgery were returned to the Zone of Interior. Few of them ever came back to the theater.

Elective Surgery

Shoulder

Chronic dislocations of the acromioclavicular joint were relatively frequent and always troublesome. At the 298th General Hospital, excision of the outer inch of the clavicle was found to be an excellent reconstructive procedure, particularly when it was compared with other operations designed for the same purpose. It was simple, the period of hospitalization was short, and the immediate results were good. On the other hand, the end results were


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not known, and there was a good deal of hesitancy over performing a procedure that was irreparable until the results could be accurately assessed.

Spine

Herniation of the intervertebral disk is discussed in detail in the neurosurgical section of this history. In the early days of the European theater, there was a great deal of indiscriminate surgery for this condition. Later, the responsibility was shared jointly by the senior consultant in orthopedic surgery and the senior consultant in neurosurgery, one or the other of whom had to give his consent before operation could be performed. With a few notable exceptions, even this restricted policy failed to increase the number of combat soldiers. Eventually, the great majority of the officers and enlisted men who really required surgery appeared before disposition boards and were returned to the United States. Few of them ever came back to the theater.

Knee Joint

Arthrotomy for internal derangements of the knee joint was performed more often than any other elective procedure and probably accomplished more than any other, but at that the results fell far short of what might be expected from the same operation in civilian practice. One reason was the successive reduction in the theater holding period. When a long holding period was possible, some soldiers were salvaged for combat duty, though details as to the number are not available. Information is therefore lacking on what amounts to the acid test of the value of this procedure. When the holding period was reduced to 120 days, and later to 90 days, it became obviously impossible to rehabilitate a man after this operation, and, as had become the policy with other elective procedures, those who clearly needed it were returned to the Zone of Interior for surgery.

The more mature surgeons who undertook elective arthrotomy for internal derangements of the knee joint had the best immediate results, because of their careful selection of cases. They did not perform the operation often. Patients were selected for it only after careful evaluation of their status on the basis of a detailed history, a painstaking physical examination, and multiple excellent roentgenograms. One thing that the experienced surgeon always realized was that it was as necessary to evaluate the soldier's personality as to examine his knee. Good, stable soldiers seldom manifested prolonged postoperative disability and sometimes could return to full combat duty within 60 days after exploration of the knee, removal of the menisci, and similar procedures. These results, however, were exceptional, even in the hands of competent surgeons.

Disabilities of the Feet

Elective surgery in disabilities of the feet needs no extended discussion. Numerous operations were performed on these indications, and practically all of them were failures.


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While the tendency was sometimes observed to diagnose static foot disturbances without sufficient objective evidence, there was no doubt of the seriousness of these disabilities and of the manpower losses which resulted from them. The experience of the 29th Infantry Division is illustrative.1

The training marches undertaken by this division in the fall of 1942 resulted in complaints of pain and fatigue in the lower extremities so far exceeding expectancy that at the suggestion of the senior consultant in orthopedic surgery, Col. Rex L. Diveley, MC, a detailed investigation was undertaken. It was carried out by Capt. (later Lt. Col.) Marcus J. Stewart, MC, with the cooperation of the commanding officer, Maj. Gen. Leonard T. Gerow, MC, and the division surgeon, Lt. Col. (later Col.) William H. Triplett, MC.

The mean strength of the 29th Division when the survey was undertaken was 9,753 men and the marching strength 6,820 men. During a 2-week individual survey of all foot troops, 820 men (12 percent) presented themselves with complaints of pain and disability referable to the feet. The survey was not extended to the artillery battalions, which spent much of their time on the firing range and were not subjected to the same marching program as the remainder of the division. This program consisted of weekly or biweekly hikes, usually for 25 miles, with field pack and equipment, over hard-surfaced roads.

The troops in the 29th Division had been in the Army of the United States for approximately 2 years. A large number of them had previously been in the National Guard. They had been on active, large-scale maneuvers twice. Their training had included frequent long hikes on dirt roads and only a small percentage of man-days had been lost because of foot injuries until long hikes on hard-surfaced roads had been started.

Of the 820 men examined after they had complained of foot disabilities, 20 were found to have normal feet. In seven cases, the trouble could be traced to poorly fitted shoes. In the remaining cases, there was objective evidence for the complaints, chiefly as follows:

Congenital malformations of bony structures, 325 cases, including low anterior arches (123 cases), low longitudinal arches (67 cases), short first metatarsals (50 cases), and cavus foot (33 cases).

Developmental malformations of bony structures, 40 cases, including 11 instances of bunions.

Soft-tissue lesions, 199 cases, including 125 instances of tenosynovitis, in 87 of which the Achilles tendon was affected.

Acute injuries to soft tissues, 221 cases, including 17 sprains, 29 blisters, and 172 instances of foot strain from overtraining.

As the report pointed out, in a certain number of cases the deformities were so severe and of such long standing that the soldiers should never have been sent overseas. The error was open to two explanations: (1) Improper

1Report, Capt. Marcus J. Stewart to Lt. Col. Rex L. Diveley, 28 January 1943, subject: Report on a Study of the Foot Injuries in the 29th Division.


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medical examinations, and (2) the desire to retain men who were of special value in operational clerical work or who had some other special ability. In all, 198 soldiers were reclassified because of foot disabilities. It was thought that the others, under a less exhausting training program and with proper foot care, might be expected to return to full duty and remain 100 percent efficient.

A change in the shoes worn was recommended in 16 cases, and corrections in the shoes were recommended in 187 cases, in 54 of which the corrections would be permanent. If these corrections were not made and if they were not supplemented by a program of foot training, it was expected that these 54 men would also have to be reclassified.

When the situation was again reviewed in March 1943,2 it was found that in the Infantry, Engineers, and division special troops, 739 men had fallen out of line on test marches because of trouble with their feet, against 131 who had fallen out for all other causes. One hundred and fifty-one of the men who complained of their feet were recommended for reclassification, against 39 of the 131 who fell out of line for other causes. Captain Stewart noted in his March 1943 report that no change or alteration had been made in the foot training or marching program in line with the recommendations made in his January report, and that only 23 of the 187 shoe corrections recommended had been made.

Difficulties with improperly fitted shoes continued throughout the war. Shortly before D-day, a survey in replacement pools conducted by Maj. Irvine M. Flinn, Jr., MC, of the 801st Hospital Center revealed a large number of foot complaints. The men in these pools had been sent from the Zone of Interior to serve as combat replacements after the first wave had gone ashore on the invasion beaches. Most of them had been in the Army for only a short time. Many were in their late thirties or had done desk work all their lives. Little could be done for their difficulties except to suggest arch supports and better fitting shoes. The impression was that the majority of the troubles of which these men complained could be attributed to badly fitted shoes which sometimes, the report stated, seemed to have been "given away at random."

The situation revealed by this survey and the detailed statistics secured in the investigation conducted in the 29th Infantry Division in 1942 and 1943 indicate clearly why surgery for foot disabilities had so little success in the European theater and why operations to relieve these conditions promptly fell into disfavor.

2Report, Capt. Marcus J. Stewart to Lt. Col. R. L. Diveley, 22 March 1943, subject: Test Marches in 29th Division.

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