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Tours of Hospitals
When a new senior consultant in orthopedic surgery (Col. Mather Cleveland) was appointed in the European theater shortly before D-day, one of his first duties was to visit as many hospitals as possible in the United Kingdom. A total of 40 were visited before the invasion occurred. The wards had been stripped of patients, as far as was practical, in all of them, in the expectation of the heavy casualties to follow D-day, and the planned demonstrations of diagnosis and management, including plaster techniques, were necessarily limited.
Otherwise, most of the visits fell into the same general pattern. The qualifications of personnel were reviewed, and notes were made of suggested changes of assignment. General problems of orthopedic management were discussed with the chiefs of the surgical services and of the orthopedic sections, and matters of policy were discussed with commanding officers. It was suggested to the latter that they utilize the services of orthopedic surgeons to instruct all personnel in the management of bone and joint injuries and in the application of plaster.
After D-day, the practice of visiting hospitals was continued as far as time and other duties permitted. The situation in the United Kingdom was not too difficult, because distances were short. On the Continent, however, as the fighting moved farther and farther away from the beaches, distance introduced a considerable problem, and some hospitals were visited only twice in the 11 months that elapsed between D-day and V-E Day.
Two hospital tours made by the senior consultant in orthopedic surgery late in 1944 are reported because they illustrate a number of points, including (1) the various functions of a consultant; (2) the unevenness of the qualifications, both in training and experience, of chiefs of surgical services, under which orthopedic sections functioned; (3) the resulting differences in the concepts of orthopedic surgery in the various hospitals; (4) the difficulties of providing orthopedic sections with trained and competent personnel; (5) the techniques of instruction employed in the management of battle-incurred injuries; and (6) the effectiveness of consultant supervision in detecting errors of management and in providing for their correction.
For comparative purposes and as a matter of convenience, the reports of these two tours are summarized under general headings, instead of being presented chronologically.
The first report deals with a tour of 17 hospitals and 1 hospital center in the United Kingdom in early November 1944, when casualties with bone and joint injuries were being treated in considerable numbers (table 2). The second report deals with a tour of 8 hospitals and 2 headquarters on the Continent in late November and early December of the same year.
Tour of Hospitals in the United Kingdom Base, November 1944
The general plan, at each of the hospitals visited, was to hold conferences with the commanding officer and the chiefs of the surgical and orthopedic sections. Special reports were received from the chiefs of orthopedic sections who were also serving as junior consultants in orthopedic surgery under the system described elsewhere (p. 8). Newly assigned personnel were evaluated, and arrangements were made for the evaluation, by competent officers, of orthopedic personnel to be assigned to the orthopedic section in the immediate future.
TABLE 2.-Sample distributions of hospital populations in the United Kingdom, November 1944
Sample reports of these evaluations and corollary recommendations follow. Precise identification is omitted for obvious reasons.
At the 102d General Hospital, several wounded Free French soldiers were encountered, and the consultant was questioned as to their disposition. Apparently, British hospitals no longer received them. A note was made to investigate this situation.
At all hospitals visited, it was emphasized that patients who were neurosurgical problems should be transferred without delay to a neurosurgical center. Similarly, patients with complicated hand injuries were to be transferred to special hand centers.
At the 117th General Hospital, no operative work was being done on the neurosurgical service, because the neurosurgical officer was suffering from a dermatitis which precluded his scrubbing. It was recommended that this
officer be replaced or be given a competent assistant. This hospital is capable of doing excellent bone and joint work and should be fully utilized.
At the time of this visit, the 22d General Hospital was serving as a holding hospital and had not received battle casualties for a considerable period of time. Because of its superior equipment and staff, the senior consultant considered it wasteful to use this hospital merely as a holding unit and recommended that it be given a high priority for the treatment of battle casualties.
The time of arrival after wounding of patients transported from the Continent to the United Kingdom hospitals showed a wide range. Up to 3 or 4 weeks before this visit, which was in early November, many of the hospitals visited had received patients within 4 or 5 days. When air evacuation was available, some patients were still being received within a week after wounding. In many installations, however, the average time had lengthened to 2 weeks. The 192d General Hospital received patients from Holland and from Belgium by air within 6 days, and sometimes as early as 2 days, after wounding. These patients, who were mainly paratroopers, were flown in by the British.
At the 104th General Hospital, several patients with compound fractures had recently been received too late for skeletal traction, and 1 patient had not been received for 36 days. The position of the femoral fragments was not too unsatisfactory in another, similarly delayed case, but shortening amounted to almost an inch. Since these patients had already been evacuated to the Zone of Interior, their names and serial numbers were not available. It was stressed to the hospital staff that careful record should be kept of all patients delayed in transit long enough to interfere with their care, so that such errors could be investigated and corrected.
Experience varied from hospital to hospital. At the 106th General Hospital, 4 hospital trains had been received since 25 July, but at the time of the visit patients were chiefly being received by ambulance from the 79th General Hospital and the 110th Station Hospital. Ambulance convoys brought from 60 to 90 patients per trip. At the 121st General Hospital, convoys were received by air, train, and ambulance. In the first 3 convoys, the wounded were received from 24 hours to 5 days after wounding. The timelag for the fourth convoy was 8 to 10 days, and for the fifth it was as long, for some cases, as 21 days. At the 74th General Hospital, a total of 13 trainloads of patients had been received, the most recent from 10 days to 2 weeks after wounding. No patient had ever been received too late to be put in skeletal traction. At the 216th General Hospital, the last trainload of casualties, 50 percent of whom were neuropsychiatric, had previously passed through from 3 to 9 hospitals.
During the last 12 weeks, the condition of the patients on arrival was not as good as it had formerly been. The average timelag after wounding during this period was 12 to 14 days, but some patients had been delayed for 21 days or longer.
At the 187th General Hospital, 90 percent of compounding wounds were closed by delayed primary suture, and healing was usually complete when the patients were evacuated to the Zone of Interior. At the 216th General Hospital, closure of wounds over compound fractures was similarly successful.
At the 102d General Hospital, wounds were closed by suture over compound fractures in about 80 percent of all cases and by skin grafts in the remaining cases. The 15th Hospital Center had treated approximately 3,500 compound fractures since D-day. Preliminary analysis of the material showed that healing had been satisfactory in 80 percent of the first 1,500 wounds closed by suture or skin graft.
At the 67th General Hospital, 62 compound fractures of the femur had been treated since D-day; in 21 of these cases the wounds were infected when the patients were admitted. Spontaneous closure occurred in 18 of the 62 wounds, and closure was undertaken in 23 others. Healing occurred in all 11 cases in which delayed primary closure was carried out from 5 to 16 days after wounding. In the 12 closures done later, in slightly infected wounds, primary healing was not accomplished, but all wounds were healed before the patients were evacuated.
At the 192d General Hospital, 71 compounding wounds closed by delayed primary suture healed satisfactorily, and healing was partially successful in 18 others. Both surgical and orthopedic section chiefs agreed that patients who were evacuated from the front in circular plaster-of-paris splints seldom presented wound infections and were best suited for early closure of compounding wounds. Secondary debridement was seldom necessary in these cases. Recently a number of patients whose wounds had not been debrided had been received through British hospitals, but this was an exceptional experience.
The chief of the orthopedic section at the 121st General Hospital reported that debridement of compounding wounds had been almost universally necessary before wound closure could be undertaken. As a result, relatively few wound closures were being performed. This experience was entirely contrary to that of most other hospitals in the United Kingdom, where wound closure was seldom delayed more than 5 to 10 days after the patients' arrival. The senior consultant in orthopedic surgery wondered whether so many debridements were really necessary and suggested, instead, that wounds which did not look healthy be treated by wet dressings for 2 or 3 days.
Very few compound fractures had been closed at the 103d General Hospital in the past 6 weeks, because of the attitude of the surgeon in charge of the orthopedic section toward delayed primary wound closure. This policy was to be remedied.
At the 192d General Hospital, it was observed that when a patient was received with a large, metallic foreign body in the wound, healing almost never occurred until the foreign body had been removed. The delay was
attributed not to the metallic object itself but to the bits of clothing that had usually entered the wound with it.
Plaster of paris was, on the whole, well applied. At the 67th General Hospital, the circular plasters were rather bulky, but this was because it had been necessary to use cotton batting as a substitute for sheet wadding, which had been unobtainable.
At the 192d General Hospital, it was found that every patient who had been evacuated in a Tobruk splint had suffered a great deal of pain during transit. The chief of the orthopedic section said that in his experience it was as hard to apply a Tobruk splint correctly as to apply a plaster spica, which he thought was much more comfortable for the patient. It was also reported that there was some loss of the skin of the dorsum of the foot whenever the Thomas splint was used with the Army boot strap in place during evacuation.
The surgical coordinator of the 15th Hospital Center, who had recently traveled with a hospital train, said that in his opinion all patients in thoracobrachial spicas should be regarded as class 2. In a few instances, the spicas were too widely abducted. When plaster spicas were used for fractured femurs, he thought that a wicket should always be employed to protect the toes. No foul-smelling plasters were encountered on the train.
When the holding unit was investigated at the 22d General Hospital, 24 patients were found whose status was not considered entirely satisfactory for transportation. Their general condition was good, but the plaster casts in which they were encased were not well applied. Since these patients had all come from the 104th and 106th General Hospitals, it was suggested that the commanding officers and the chiefs of the surgical and orthopedic sections of these hospitals be asked to visit the 22d General Hospital and examine these patients with the chief of the orthopedic section.
At the 67th General Hospital, a similar criticism was made, and it was similarly suggested that commanding officers and chiefs of the surgical and orthopedic sections of the hospitals sending patients to be held should meet at the 22d General Hospital for briefing on the proper preparation of patients to be returned to the Zone of Interior.
It was noted that fractures of the humerus received from the 112th General Hospital had been put up in thoracobrachial spicas in wide abduction. It was agreed to correct this technical error in the future.
At most of the hospitals visited, fractures of the femur, tibia, and fibula were being correctly treated in skeletal traction. The use of traction in fractures of the femur was fairly general. At some institutions, it was not employed consistently in fractures of the tibia and fibula. It was also not employed uniformly in fractures of the humerus.
At some hospitals, the technique of skeletal traction had been greatly improved since the consultant's earlier visit. Some criticisms, however, were still necessary. At the 97th General Hospital, it was pointed out that more adequate provision should be made for motion in the knees and the ankle joints. At the 102d General Hospital, skeletal traction was adequate, but more than was necessary (up to 25 pounds) was being employed in injuries of the tibia and fibula. One patient was observed in traction with distraction of the fragments and some distraction at the ankle joint. Two men with compound fractures of the femur required dependent drainage which had not been instituted. At the 159th General Hospital, Army splints were found not in balanced suspension. One compound fracture of the femur was associated with an abscess of the thigh which needed drainage. At the 216th General Hospital, there was a slight tendency to overpulling in fractured femurs.
It was pointed out at every hospital that the great majority of fractures of the long bones should be treated by skeletal traction. When the technique was not used generally or properly, the attention of the chief of the orthopedic section was called to the directives on the subject, and he was urged to make a wider use of the method and to employ it for fractures other than those of the femur. At the 216th General Hospital, where the use of skeletal traction was limited almost entirely to fractures of the humerus, it was suggested that the chief of the orthopedic section and the chief of the surgical service visit the 22d General Hospital, which had an excellent and adequate program for the management, by skeletal traction, of all fractures of the long bones.
At the 106th General Hospital, the last convoy had brought only ambulatory casualties with no fractures of the long bones. Skeletal traction was employed in this hospital, but only a few patients were in it at the time of this visit. Two patients were observed in the Roger Anderson apparatus. The chief of the orthopedic section was reminded that the use of apparatus for external fixation should be limited to the special cases in which a pedicle graft was necessary. After the graft had been applied, balanced suspension skeletal traction should be instituted. Pedicle grafts were to be performed only in plastic centers, in which category this hospital was not included, and indications for the use of the Roger Anderson apparatus therefore should not have arisen in it.
At the 103d General Hospital, amputation stumps were found in good condition, with adequate skin traction. The condition of the stumps had been greatly improved at the l04th General Hospital since the consultant's previous visit. At the 97th and 74th General Hospitals, the skin traction observed on some of the amputation stumps was not altogether adequate. This matter was called to the attention of the chiefs of the surgical and orthopedic sections to be remedied.
At an occasional hospital, amputation stumps had been closed by suture, in direct violation of the theater policy which required maintenance of skin
traction in all circular amputations until healing had occurred. This matter was called to the attention of the surgical and orthopedic staffs and of the commanding officers, and it was directed that skin traction be employed thereafter on all amputation stumps.
At the 121st General Hospital, patients with amputation stumps were received in good condition. Only one amputation for gangrene of circulatory origin had been necessary at this hospital.
At the 216th General Hospital, the question arose whether to amputate a viable foot which was functionally useless or to return the patient to the Zone of Interior for definitive surgery. The senior consultant in orthopedic surgery expressed the opinion that whenever a patient could be transported without risk, amputation should be deferred until he reached a hospital in the Zone of Interior.
Three patients with suppurative arthritis of the knee joint were observed at the 192d General Hospital. Symptoms had subsided under treatment with aspiration and instillation of penicillin, and a considerable amount of motion in the knees had already been gained.
Very little gas-bacillus infection was observed at most hospitals, but this was not invariably true. At the 67th General Hospital, 9 of 21 patients received with infected wounds had Clostridium welchii infections, and 1 died of gas gangrene. The other 8 were treated by debridement, and most of the wounds were well healed before the patients were evacuated to the Zone of Interior.
At the 216th General Hospital, 2 patients in 1 convoy were received moribund from clostridial myositis, and both died promptly. Inquiries produced no information concerning the hospitals through which they had previously passed.
The incidence of frank osteomyelitis had increased materially at the 216th General Hospital in the last several weeks. Healing of the wounds in these cases was seldom complete before the patients were evacuated to the Zone of Interior, though drainage had usually decreased. At this installation, every patient with a compound fracture of the pelvis had developed osteomyelitis, and many had required sequestrectomy.
At every hospital visited, an attempt was made to make the staff thoroughly conscious of the importance of early mobilization of wounded hands and fingers. In some instances, prolonged immobilization was still being practiced. Whenever possible, as at the 103d General Hospital, a clinic was held on hand injuries, and the importance of early, active motion was stressed. Emphasis was put upon the definitive management of wounds of the soft tissues, with secondary emphasis upon the skeletal injuries.
At some hospitals, as at the 117th General Hospital, plastic surgery on the hands was of a very high caliber.
At the 22d General Hospital, Capt. (later Maj.) Marshall R. Urist, MC, reported an interesting and useful study. After amputating a finger, he fixed the digit at various levels with Kirschner wire. He found that the entire proximal phalanx is influenced by the tendons, and that, with a single exception, it is not possible to insert Kirschner wire without transfixing them. The single exception, and the only area in the finger entirely free of tendinous structures, is a small triangle on the dorsal surface of the middle phalanx, just distal to the proximal interphalangeal joint. At this point, a small dental drill could be inserted into the marrow cavity, and adequate skeletal traction could be assured by passing a hook into the hole made by the drill. The consultant regarded this as the best means of skeletal traction of the fingers which he had encountered in his experience.
At the 22d General Hospital, a number of appliances had been devised for the management of compound fractures, including:
1. A suspended long leg cast, utilizing the Pierson attachment, which is incorporated in the plaster of paris above and at the knee (p. 45).
2. A rotating Bradford frame to facilitate the care of extensive wounds of the extremities and trunk associated with compound fractures (p. 50).
3. A Böhler-Braun type of traction cradle (p. 50).
At the 121st General Hospital, an autogenous bone graft had been performed on a compound fracture of the humerus before the compounding wound was closed, with the tibia as the donor site. The graft was put in place with four vitallium screws. In the course of the operation, the surgeon disposed of a number of bone fragments at the site of the fracture which, from the description, might very well have served as autogenous grafts if they had been left in place. Purulent exudate was present at the site of the fracture at the time of the operation, which, in itself, should have contraindicated the use of a large tibial graft.
In another case at this same hospital, open reduction and internal fixation were performed on a compound fracture of the femur with a vitallium plate and screws. This wound had previously been closed.
These cases are cited as instances of questionable surgical judgment, and the commanding officer, the chief of the surgical service, and the chief of the orthopedic section were directed to refrain from such surgery in the future. Whether or not the outcome in these cases would be favorable did not alter the fact that neither operation should have been performed.
At the 67th General Hospital, a patient was seen with an unrecognized dislocation of the elbow joint. He had been injured 25 October 1944, near
Aachen, Germany. At the second evacuation hospital to which he was admitted, roentgenograms were taken of the elbow joint while he was in an upper-extremity traction splint. The views were oblique, and, because of the presence of the traction apparatus, the nature of the lesion was not appreciated and the roentgenologist failed to discover the dislocation. The surgeon listed the lesion as a sprain. The patient was evacuated to the 203d General Hospital 4 days after operation and remained there for another 4 days. At this time, a note was made that he had a very marked regional swelling, probably resulting from a dislocation which had spontaneously reduced. When the patient finally arrived at the 67th General Hospital, 10 days after wounding, he was found to have a complete dislocation of the elbow, which was reduced with considerable difficulty. The case was cited simply to ensure a more critical and inquiring attitude on the part of medical officers through whose hands casualties pass.
At the 22d General Hospital, three interesting fractures of the hip were observed, all beautifully handled. One, a dislocation with separation of the symphysis, had been treated by vertical traction. The second, a trochanteric fracture, had been fixed with a Smith-Petersen nail. The third, another dislocation, had also been treated by vertical skeletal traction.
At this same hospital, a medical officer was examined with onychogryphosis of both great toenails. The condition had originally been diagnosed as ingrowing toenails. It was recommended that he be treated by excision of the nail and bed, with amputation of part of the distal phalanx and folding of the plantar skin over the dorsal surface of the remaining portion of the toe. This type of surgery was not indicated in an overseas hospital, and a disposition board had recommended transfer to the Zone of Interior.
At the 140th General Hospital, the roentgenologist was examined because of pain in the right wrist and arm. It had been present for several years but had recently become much more severe. Roentgenograms taken during the past 8 weeks showed punched-out areas in the right capitate and unciform bones, as well as in the head of the right humerus and in the right tibia near the articular surface of the knee joint. The wrist was swollen and tender. Although the officer felt well and had recently gained weight, he was frequently incapacitated by pain. The staff was of the opinion that the condition was Boeck's sarcoid but believed that an atypical gouty lesion should also be considered. The consultant suggested biopsy on the right capitate bone to establish the diagnosis, and also recommended the tentative use of colchicine for a long-enough period to see if it would relieve the symptoms.
At the 67th General Hospital, a patient was observed with a rarefying lesion of the tibia, probably an osteitis fibrosa cystica. A Brodie's abscess of the lower end of the radius with a perilunate posterior dislocation of the carpus was also observed. Open reduction was to be employed because the dislocation was a month old. There was no fracture of the carpal scaphoid.
Eight or nine patients observed at the 216th General Hospital were suffering from symptoms of mild immersion foot. Objective findings were minimal.
Treatment consisted of keeping the foot in a tent at room temperature, with injection of the posterior tibial nerve with Novocain (procaine hydrochloride), or Pontocaine (tetracaine hydrochloride). Weight bearing was permitted after the injection and was possible for a considerable period of time without pain.
Tour of Hospitals on the Continent
The following report concerns the visits of the senior consultant in orthopedic surgery to 9 hospitals (2 general hospitals, 5 evacuation hospitals, and 2 field hospitals) and 2 headquarters on the Continent between 23 November and 3 December 1944. The general plan of this tour followed the plan described for visits to hospitals in the United Kingdom Base.
Most of the hospitals visited on this tour were either in or supporting the First and Ninth United States Army areas. The Ninth Army had both a surgical consultant and a consultant in orthopedic surgery. The First Army had only a surgical consultant.
The 62d General Hospital had a population of 1,307. At this time, 302 patients had bone and joint injuries. During October, there had been 3,337 admissions, 1,039 of them to the orthopedic service. Of the 2,484 surgical admissions, 1,884 had been battle casualties. On the whole, 50 percent of the battle casualties received in this hospital were handled on the orthopedic section.
The 77th Evacuation Hospital had 800 patients, 602 on the surgical service. Most of them had already had as much surgery as was permissible in this area.
The 2d Evacuation Hospital had had 15,117 admissions since 2 October, the first 2,000 of them during the period the hospital was acting as a transit hospital. Since it had arrived on the Continent in June 1944, it had been in 2 previous locations and had received approximately 27,000 patients; 3,583 operations had been performed, with 137 deaths.
The 44th Evacuation Hospital had been in six previous locations since its arrival on the Continent. During the busiest period, from 8 July to 4 August, inclusive, it had received between 600 and 700 patients daily for several days. It had done a considerable amount of station hospital work. The total population between 21 June and 31 October had been 11,094. Between 35 and 40 percent of all battle casualties had compound fractures.
At the time of this tour, the sector immediately in front of the Ninth United States Army was relatively quiet. At one clearing station visited, only five patients had been received during the day; all had minor complaints and none were battle casualties. At the 53d Field Hospital, only 25 patients had been admitted.
At the 41st Evacuation Hospital, the chief of the surgical service reported that he had sent out between 750 and 800 cards on nontransportable patients whose subsequent condition he was anxious to check. He had received only 21 replies. Possibly many of these cards were overlooked because the field medical record of evacuation was not completely studied. It was suggested that the matter be taken up with the surgical consultant at the United Kingdom Base.
At the 2d Evacuation Hospital, the consultant attended a meeting at the office of the commander of the 68th Medical Group. This was a daily meeting at which a tactical report was made on the entire Army situation. It was an extremely interesting meeting and seemed a worthwhile plan.
At ADSEC (Advance Section) Headquarters, it was reported that evacuation was progressing much more smoothly than at the time of the last report. On one day, there had been an airlift to the United Kingdom of 1,200 patients and on another day an airlift of 800.
Much of the discussion at the various hospitals had to do with the advantages and disadvantages of the Tobruk splint.
At the 62d General Hospital, only one patient had arrived in a Tobruk splint. The case was well selected, and the patient was comfortable. The splint was changed to a plaster-of-paris spica before he was evacuated to the United Kingdom. At this hospital, it was reported that plaster-of-paris splints in which the patients arrived from evacuation hospitals had to be changed in about 10 percent of all cases before their transshipment to the United Kingdom.
At the 41st Evacuation Hospital, a number of patients were observed in Tobruk splints. All appeared comfortable. In each instance, the knee had been put up in about 15 to 20 degrees of flexion, and elastic cords had been used to secure traction. It was pointed out that the use of this splint achieves an enormous saving in plaster. The plaster splint requires four 6-inch rolls of plaster for the posterior component and another four 6-inch rolls for the outside casing which grips the wide bars of the Thomas splint.
At the 44th Evacuation Hospital, the chief of the orthopedic section had had a good deal of experience with the Tobruk splint and much preferred the plaster spica. If the patient's general physical condition at the end of debridement in a compound fracture of the femur did not warrant the application of a spica, it was his opinion that a Thomas splint with adhesive-plaster traction should be employed until there was sufficient improvement to permit the application of the plaster spica.
At ADSEC Headquarters, it was reported that a detailed investigation was being conducted by the consultant in orthopedic surgery for the Ninth United States Army on the advantages and disadvantages of the Tobruk splint in compound fractures of the femur. It was hoped that this report would be
available at the next meeting of the Anglo-American consultants. The study was to be correlated with the senior consultant in orthopedic surgery. It was felt that this investigation (p. 110) would be of great value.
The Tobruk splints observed in the various hospitals were usually well applied, and the patients put up in them were comfortable. Their chief advantage in a busy evacuation hospital was that they could be applied in 12 to 15 minutes. An orthopedic surgeon who was thoroughly familiar with plaster techniques could, however, apply an adequate plaster-of-paris spica almost as rapidly and was therefore much more likely to use it. It was the consultant's opinion that the chief field of usefulness of the Tobruk splint was in certain selected fractures involving the supracondyloid region of the femur.
On this tour, a considerable amount of trenchfoot was observed and discussed, though cold injury was not a true orthopedic problem. The following experiences were typical:
At the 41st Evacuation Hospital, trenchfoot was of a mild type, and very few severe cases had been seen. Patients were treated on the medical service. The observation was made that anybody with a sore foot was now supposed to have trenchfoot. About 50 percent of the patients with this diagnosis had minimal physical signs, or none at all, but it was believed that not more than 10 percent of them were in any sense malingerers.
At the 77th Evacuation Hospital, about 100 patients with trenchfoot had been received daily over a period of several days some 3 weeks ago. At the present time, relatively few were being received. The unit from which these men came had not been properly instructed in the care of the feet. It was reported that some soldiers who had fought in Holland had worn overshoes over felt slippers and two pairs of socks and had escaped cold injury entirely; this arrangement kept their feet warm and provided room for adequate movement of the toes. The chief of the surgical service at this hospital felt that exercise must be taken and constriction must be avoided if this crippling disability was to be prevented.
At the 102d Evacuation Hospital, 85 of 119 surgical patients recently received had come in with the diagnosis of trenchfoot. They were chiefly from the 28th Division where, they said, little or no instruction was given about the care of the feet necessary to prevent this condition.
The professional services of the Ninth United States Army were extremely foot conscious. The chief of the Preventive Medicine Division had had an effective poster made, embodying the salient etiologic features. Immobilization and constriction of the extremities were thought to be the chief causes. The term "trenchfoot" was thought to be a misnomer. In large, roomy trenches the men could move about freely, and the condition seldom occurred. In foxholes they could not, and "foxhole foot" was suggested as a much better term.
A total of 511 patients with this condition had been received from the 84th Division, within 12 days. The great majority of these soldiers came from a single infantry regiment which had bogged down in a swamp, where it was pinned down by gunfire and unable to move. Each patient admitted with trenchfoot had to fill out a questionnaire on the details of the injury.
At Headquarters, First United States Army, the subject of trenchfoot was discussed in detail. The 91st Medical Gas Treatment Battalion had been taking care of these cases, the number of which was now decreasing. One company, set aside as a study center, had 70 patients. Another had 200 under treatment. Patients considered convalescent were sent to the 4th Convalescent Hospital for a 10-day period. The total holding time for this Army area was only 10 days, but for purposes of study some patients had been held as long as 21 days.
All patients who presented discoloration, marked edema, or associated injuries of the feet were evacuated as promptly as possible. The possibility of a psychic factor had been recognized promptly, and it was now the policy to hold these men in corps and division areas in the absence of positive physical findings. Buerger's exercises were instituted at the walking stage, with unilateral sympathetic block, but this regimen seemed of no help in the earlier stages. The first patients treated were now returning to duty and would be observed carefully for possible recurrences.
It was clearly recognized that control of trenchfoot is a command function, and medical officers were investigating how control was being carried out.
Amputation stumps were generally in well-applied transportation plaster of paris with skin traction obtained by stockinet and elastic attached to a wire ladder loop incorporated in the plaster.
At the 44th Evacuation Hospital, many casualties had been received after injuries from land mines and had to be treated by amputation. It was observed, however, that if a good covering of snow was on the ground, traumatic amputation did not occur, as it usually did when the ground was bare and there was a direct hit on either the foot or the leg, which was totally or partially torn off.
Tour of Field Hospital
The 8th Field Hospital was visited 3 December. At this time it was located near an airfield in the Seine Base Section and was serving as a holding unit. It had 750 patients, all to be transported to the United Kingdom. Patients arrived from 5 to 7 days after wounding, and the average holding time was 24 to 36 hours, with a maximum of 5 days. The order of priority for evacuation was head wounds and maxillofacial injuries, chest wounds with hemopneumothorax, multiple fractures of the long bones, and amputations.
Up to 1,400 litter cases had recently been evacuated from this hospital in a single day, November having been a better month for air evacuation than
October. The weather was the one great stumbling block. Approximately 1 in every 500 litter patients was returned to the receiving hospital as nonevacuable. This was an excellent record.
Approximately 150 patients were observed in the 2 wards visited. They were all in good condition, and the plaster work seen was on the whole excellent.
Fractures of the femur were for the most part received in plaster-of-paris spicas. Only a few were in Tobruk splints. The officers stated that plaster techniques had greatly improved and that very few casts now had to be changed.
Practically no orthopedic surgery had been necessary at this hospital. No gangrene had developed and no amputations had been required.
Four patients were encountered who were improperly prepared for transportation:
1. A staff sergeant with a compound comminuted fracture of the first left metacarpal, caused by a gunshot wound, had had pulp traction applied at a field hospital 22 November. On 24 November, he was evacuated to the 203d General Hospital, where he remained until 26 November. His wound was inspected, and pulp traction was continued. It was also continued when he reached the 8th Field Hospital.
2. Another staff sergeant, who was wounded in action by a land mine, also sustained a fracture of the second metacarpal. He was evacuated through the 111th Evacuation Hospital to the 76th General Hospital, where pulp traction was applied through the soft tissue of the distal phalanx of the second finger. He was then transferred to the 40th General Hospital, where he remained until 2 December. He was still in traction when he was seen at the 8th Field Hospital 3 December.
The senior consultant suggested that pulp traction be discontinued at once in both of these cases. Neither patient up to this time had showed any untoward effects from it, but the danger of ulceration and of loss of fingertips had been established by experience, and pulp traction had been forbidden in the most recent Circular Letter (No. 131, 8 November 1944),1 Office of the Chief Surgeon, European Theater of Operations. It was suggested that this matter be called to the attention of the officers responsible for instituting this kind of traction, and that its further use be avoided.
3. A private wounded 28 November received a compound comminuted fracture of the right tibia, a perforating wound of the right leg, and cold injuries of both feet. Circular plaster of paris was applied at the 45th Evacuation Hospital, but the cast was not split through to the skin and was not spread. Thereafter, the patient was passed through the 46th Field Hospital and through a general hospital in Paris, the number of which was not available. When the patient was seen in the 8th Field Hospital by the senior consultant in orthopedic surgery, he complained of considerable discomfort. Examination revealed that the circulation in the foot was apparently adequate, but that the plaster was too snug.
4. Another private, wounded 17 November, sustained a penetrating wound of the urinary bladder, penetrating wounds of both legs with compound comminuted fractures of both patellas and the lateral condyle of the right femur, a penetrating wound of the right buttock, and a penetrating wound of the right arm, with a compound comminuted fracture of the right radius and ulna. Circular plaster was applied to the left leg at the 51st Field Hospital, a Tobruk splint was applied to the right leg, and a circular cast was applied to the right arm. The splints on both legs were incompletely split and were not spread at all. The man arrived at the 48th General Hospital on 30 November and at the 8th Field Hospital on 3 December. When he was seen by the consultant shortly afterward, he was complaining of pain around both ankles.
These two patients were both examples of failure to carry out the specific instructions from the Office of the Chief Surgeon that circular plaster casts should be split to the skin or to the dressing overlying the wound and should then be spread.2 It was suggested that the plaster in both these cases be split at once and that the officers responsible for its application be notified of their error and requested in the future to follow instructions about splitting and spreading primary circular plaster-of-paris casts.