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Chapter III

Contents

Part II

ADMINISTRATIVE CONSIDERATIONSIN WOUNDS OF THE CHEST


CHAPTER III

Administrative Considerations in the Mediterranean (Formerly North African) Theater of Operations

Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D.

THE CONSULTANT SYSTEM

A consultant in thoracic surgery was not appointed in any theater of operations during World War II. While this was unfortunate, in view of the number (p. 61) and gravity of thoracic and thoracoabdominal wounds, the results of the omission were not so serious as they might well have been:

1.  Col. Edward D. Churchill, MC, Consultant in Surgery, Office of the Surgeon, Headquarters, Mediterranean Theater of Operations, U.S. Army, had a special interest, and a long experience, in this field, as did Maj. (later Col.) Howard E. Snyder, MC, Consultant in Surgery to the Surgeon, Fifth U.S. Army, which operated in this theater.

2.  Col. Frank B. Berry, MC, Consultant in Surgery to the Surgeon, Seventh U.S. Army, was also particularly interested in this field.

3.  In the Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, the Chief Consultant in Surgery, Col. (later Brig. Gen.) Elliott C. Cutler, MC, and had been one of the pioneers in thoracic surgery.

It was therefore possible for all of these officers, while carrying out their general responsibilities as consultants in surgery, to supervise and encourage the work in thoracic surgery. Their functions included:

1.  Evaluation, with recommendations for correction as necessary, of the physical conditions in which surgical patients were cared for.

2.  Evaluation of equipment and supplies, with recommendations for such changes as were indicated.

3.  Evaluation of the training, experience, and proficiency of medical officers to whom surgical duties were assigned, with recommendations for such changes of assignment of duties and of location as were indicated.

4.  Establishment of the surgical procedures that could suitably be undertaken at each echelon of medical care and by different medical installations under varying tactical conditions.

5.  Adaptation of evacuation procedures to the exigencies of surgical care, so that military necessities would interfere as little as possible with the welfare of all casualties.


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6.  Recommendations for the deployment of surgical teams for routine and special missions.

7.  Recommendations for the organization and staffing of special centers for the treatment of patients requiring specialized skills.

8.  Introduction into the theater of new and approved methods developed in other theaters and in the Zone of Interior.

9.  Dissemination of information on medical and medicomilitary matters to medical officers throughout the theater.

10.  Preparation of circular letters and occasionally of command circulars.

11.  Collection and interpretation of the overall experience in the theater as well as the experiences in special types of wounds and injuries and with special methods of treatment. Analysis of these experiences was perhaps the best method of evaluating the results obtained and comparing them with the results which might reasonably be expected under prevailing conditions.

These functions were discharged in various ways by the consultants in surgery. Their methods included inspection of hospitals, direct examination of patients, demonstrations of special techniques, formal and informal conferences with surgical staffs of the various medical installations, and planned meetings for division, army, and base area surgeons as military necessities permitted. Special educational efforts were directed toward indoctrination and orientation of surgeons accustomed to the practice of surgery in civilian life, or in the less urgent circumstances of the Zone of Interior, in the light of the different medicomilitary considerations that had to be taken into account in oversea theaters.

Important improvements in surgical care emerged from the stimulation of medical officers to collect and analyze their own results. Important sections of this and other volumes of the history of the U.S. Army Medical Department in World War II emerged from these studies.

THORACIC SURGERY PERSONNEL

Numerical shortages of thoracic surgeons existed in all theaters. Beebe and DeBakey (1), in their book on battle casualties published in 1952 and based on official records, estimated that if each surgeon were to operate on 7 casualties per day, nine thoracic surgeons would be required to perform initial surgery on each 1,000 wounded casualties. Even in the Mediterranean theater, where there were, proportionately, more thoracic surgeons than in any other theater, this ratio was never met.

Shortages of thoracic surgeons had to be made up in any manner possible. This meant using the limited number of experienced and well-qualified medical officers in this specialty to the best possible advantage, as described later in the discussion of auxiliary surgical group teams (p. 93). The most efficient solution of the problem was the proper assignment of the thoracic surgeons on the auxiliary surgical group teams (p. 92). It was not possible to put surgeons


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with training of only 3 or 4 months into positions of supervisory importance, no matter how carefully their training had been conducted.

The efficient use of thoracic surgeons was hampered by certain administrative roadblocks. By October 1944, the prediction had been amply fulfilled that special hospitals would be necessary for thoracic surgery and other surgical specialties. Yet at that time, the table-of-organization provision for thoracic surgeons was extremely limited. Constant difficulty was encountered in fitting these specialists into the inflexible hospital tables of organization and in supplying the additional help necessary to run a thoracic surgical service efficiently. The importance of this specialty, properly set up to function efficiently, was great enough to justify adequate table-of-organization provision for it in all echelons of medical care, yet neurosurgeons were provided for administratively long before thoracic surgeons.

Ideally, the personnel of a thoracic section in a thoracic surgery center consisted of a lieutenant colonel, who served as chief of section; a captain, who served as anesthesiologist; two captains, who served as surgical assistants and as ward officers; three surgical nurses; and three surgical technicians. Neither in rank nor in numbers was this ideal ever fulfilled.

EVACUATION AND TRANSPORT

In North Africa, nontransportable casualties were cared for in clearing stations (p. 216).

Development of Policies of Surgical Care

Sicily-In Sicily, the first casualties on D-day were handled by the Navy, in beach stations set up in each of the six landing areas. They were then evacuated to ships offshore. In the next phase of the operation, beginning in the afternoon of D-day and continuing through the next 24 hours, Company C of the 261st Medical Battalion was landed and was followed by other units. After some difficulties because of the landing of equipment without personnel or vice versa, evacuation of casualties to the beaches and thence to the boats proceeded with remarkably little confusion. On D+2, casualties began to receive initial care in the clearing station of the 51st Medical Battalion, with surgical teams attached, or in Company A of the 261st Medical Battalion. On D+3, two platoons of the 11th Field Hospital began to receive and hold casualties.

These details are important:

This was the first time in this or in any previous war that casualties had been cared for in field hospitals adjacent to division clearing stations, with the intrinsic personnel of the field hospital platoons augmented by teams from an auxiliary surgical group. As a result of these arrangements, the nontransportable casualties of the augmented II Corps (now the Seventh U.S. Army)


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received initial wound surgery within from 8 to 12 miles of the front. This plan, greatly expanded, was followed for the remainder of the war in the Mediterranean theater and was employed throughout the fighting in the European theater.

Anzio-For a variety of reasons, the most serious medicomilitary problems encountered in Italy were met on the Anzio beachhead (Operation SHINGLE). Shore-to-ship evacuation of casualties was predicated on the orderly return of casualties to the beaches. In the initial landings, casualties were less than 1 percent of the troops committed instead of the estimated 12 percent. After 48 hours, however, the tactical situation worsened, and the medical situation along with it. The original locations of the hospitals that had been landed became untenable at once, because of continuous bombing and strafing of the beachhead area, punctuated by heavy enemy attacks at intervals. The hospitals were therefore relocated in open terrain, as far as possible from military objectives, but at the best, this was not very far. Since the beachhead was only about 7 miles in depth, the usual functional distinctions between field and evacuation hospitals could not be observed. Both were practically on the frontline. Hospitals were seriously damaged by heavy shelling, and there were also losses of medical personnel.

From the beginning of the Anzio operation, an attempt was made to care for all casualties before they were evacuated by LCT's (landing craft, tank) and boat ambulances to hospital ships. If recovery was expected within 14 days or less, the wounded, especially if they were experienced combat soldiers, were kept in evacuation hospitals. Otherwise, they were evacuated to the Naples area by boat. After 26 May 1944, they were frequently evacuated by air. Occasionally, when the casualty load was unusually heavy, patients who were transportable were evacuated to the base hospitals in the Naples area for initial wound surgery, which they thus received earlier than they would have if they had been kept at Anzio.

The Chain of Evacuation

Thoracic casualties, like all other casualties (fig. 3), were successively evacuated from the frontline, through the division area and the army area to the zone of communications. After the early fighting in Sicily, the chain of evacuation was as follows:

1. Casualties were brought by company aidmen to a battalion aid station (fig. 4), whence they were removed to a collecting company and then to a clearing station. Here, triage was carried out, and nontransportable casualties were transferred to the adjacent platoon of a field hospital, where the necessary surgery was performed.

2. Transportable casualties were transported from the clearing station to a forward evacuation hospital, where the necessary initial wound surgery was performed. The nontransportable casualties who had been cared for in the


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FIGURE 3.-Chain of evacuation in oversea theater to and from thoracic surgery center.

field hospital were later transferred to the evacuation hospital, after the appropriate period of convalescence.

3. Casualties in evacuation hospitals, after a longer or shorter stay, depending upon the nature of their wounds, the therapy necessary, and their response to it, were transferred to general and station hospitals in the communications zone or to special treatment centers.


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FIGURE 4.-Aidmen unloading wounded at battalion aid station in Italy.

4. From these hospitals, they were transferred to convalescent hospitals for rehabilitation before being returned to duty or were evacuated to the Zone of Interior from a port of embarkation or an adjacent airfield.

Transportation.-Litter carries and ambulances furnished the principal means of transportation from the frontline to battalion aid stations. Ambulances were used for transportation from the aid stations to the collecting and clearing stations. In mountain warfare, however, ambulances were useless in many areas, and the company aidmen had to move casualties by long litter carries, on muleback, and sometimes by cables strung between mountain peaks.

Ambulances were also used to move casualties from clearing stations or field hospitals in the division area to evacuation hospitals in the army area. The long ambulance hauls, over rough ground, that were often necessary in Tunisia, contributed materially to the state of shock in which many casualties were received in evacuation hospitals. Some died en route. In Tunisia, as well as during the first weeks of the fighting in Italy, some ambulance hauls were materially longer than they should have been because medical officers and ambulance drivers had inaccurate information about the location of hospital units nearest to the frontline.

Transportation difficulties were seldom serious in Sicily, and both evacuation and transportation were greatly improved in the Italian campaigns, particularly when hospital policies were clarified early in 1944. Hospital trains were first employed in Italy in November 1943.


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Air evacuation.-After the Tunisian campaign, a questionnaire was sent to 38 medical officers working in evacuation, station, general, and convalescent hospitals, requesting their comments on methods of evacuation. Without a single exception, all of them recommended that air evacuation (fig. 5) be used for long hauls. Thoracic casualties came to consider it the preferred mode of evacuation.

Air evacuation was begun in Sicily about D+5. It proved a safe and expeditious way of removing casualties to hospitals in North Africa. It was particularly useful in moving casualties from the Anzio beachhead to Naples for reparative surgery and sometimes, as already mentioned, when the beachhead hospitals were crowded and the casualty load was heavy, for initial wound surgery. During the fall and winter of 1944-45, many casualties were transported by air from the field or evacuation hospitals at which they had received initial wound surgery to the 24th General Hospital in Florence, or the 70th General Hospital in Pistoia. Casualties with less serious injuries were flown to base hospitals in Leghorn and Rome. Most of these casualties were transported by means of C-47 (civilian DC-3) planes.

Air evacuation of individual patients by L-5 planes was begun experimentally in Italy early in March 1945. Careful selection was necessary, for no medical care was possible en route. These small planes proved extremely useful during mountain fighting and still later, when the Army broke out into the Po Valley. At this time, medical services, depleted by withdrawals for the Seventh U.S. Army, had to be spread over hundreds of miles.

Routine evacuation of thoracic casualties by air was not possible, since a high altitude flight in nonpressurized planes, with the consequent respiratory strain, might prove harmful, or even fatal, to patients with any degree of respiratory difficulty. With careful selection, however, most casualties tolerated flights at from 4,000 to 5,000 feet remarkably well.

TRAINING

There was no formal training in thoracic surgery in the Mediterranean theater, but a considerable amount of informal training was carried out. Lectures on the surgical and other aspects of the management of casualties were given by members of the surgical staffs of various hospitals to medical officers, nurses, and enlisted men. Because of the unusually large number of thoracic surgeons assigned to the 2d Auxiliary Surgical Group, these officers were frequently called upon to lead discussions and to give lectures and demonstrations on thoracic surgery. Newly arrived medical officers were attached to thoracic surgical teams for indoctrination and training, and other officers were attached to thoracic surgery services in general hospitals and to thoracic surgery centers for training in this specialty. A great deal of useful teaching was also done in field hospitals.

In 1944, the standards of thoracic surgery were greatly improved in a number of evacuation hospitals by the attachment to them, for from 1 to 3 months, of experienced thoracic surgical teams. During these periods, intensive


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FIGURE 5.-Air evacuation of wounded in Italy. A. Transfer of casualties from ambulances to plane. B. Plane loaded and ready for takeoff to general hospital in base.


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FIGURE 5.-Continued. C. Medical care en route.

efforts were made to teach the intrinsic surgical staff the refinements of management of thoracic and thoracoabdominal wounds. This was an extremely important and useful effort. All thoracic surgery on transportable casualties was handled in evacuation hospitals, and casualties with thoracoabdominal wounds sometimes reached evacuation hospitals from forward areas in which there were no intervening field hospitals. The surgeons in evacuation hospitals therefore had a great deal of thoracic surgery to do and had to be equal to the task.

All of these measures helped to alleviate, though they did not compensate for, shortages in trained thoracic surgeons. Of them all, none was more effective than the training given in thoracic surgery centers. In fact, from the long-range point of view, these centers were regarded as scarcely less important as instructional vehicles for the dissemination of the principles and practices of sound management of combat-incurred chest wounds than as specialized hospitals for the care of thoracic casualties.

Observation in British hospitals-Some of the U.S. surgeons attached to hospitals which went into North Africa from the United Kingdom in November 1942 had been able to observe the work of British thoracic surgeons and to see some combat casualties. When the 77th Evacuation Hospital arrived in England in August 1942, Major Snyder, who was in charge of the thoracic


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surgery section, requested permission for himself and the members of his section to go to London, to observe the work of Mr. A. Tudor Edwards, who was head of the thoracic surgical services of the British EMS (Emergency Medical Service). The original plans for a comprehensive 8- to 9-week tour of duty in British thoracic centers were delayed, and the invasion of North Africa was imminent when they were finally concluded. The extensive tour planned therefore had to be telescoped into 8 days. In the interim, however, Major Snyder had been able to work with Mr. Ronald Belsey, head of the thoracic surgical service at the Kewstoke Emergency Hospital (EMS) at Weston Super Mare, near Frenchay Park, where the 77th Evacuation Hospital was located.

During the official tour of chest surgery centers and clinics, the U.S. surgeons watched their British confreres in the operating room; made rounds with them; studied their preoperative and postoperative techniques; and attended their conferences, at which cases were presented, roentgenograms shown, and all phases of thoracic surgery covered. The information thus obtained proved of great value when combat-incurred injuries of the chest were encountered in North Africa a few weeks later.

CONFERENCES AND MEETINGS

Thoracic injuries were frequently discussed at the numerous conferences held in medical installations in all echelons in the Mediterranean theater, and several times the entire program was devoted to them. Colonel Churchill, in his visits to various installations in the theater, held what he called chautauqua meetings, to discuss various phases of military surgery. Because of his interest in the subject, his discussions of thoracic wounds always attracted considerable attention.

The first formal meeting in which thoracic surgery was discussed on the European Continent was held at Fifth U.S. Army headquarters in the King's Palace at Caserta on 11 November 1943.

In November 1943, Col. L. Holmes Ginn, Jr., MC, Maj. Floyd H. Jergesen, MC, and Major Snyder, Fifth U.S. Army consultant in surgery, talked to the medical staff of the 3d Division at a clearing station near Riardo. Their presentation and the ensuing discussion covered, among other subjects, the management of shock, the correct use of morphine, and the management of sucking chest wounds. Early in December 1943, Major Snyder discussed wounds of the chest before the surgical section of the 8th Evacuation Hospital. Later that month, Colonel Churchill, Consultant in Surgery, Mediterranean theater, addressed an all-day session at the 15th Medical General Laboratory, in Naples, on the general principles of wound management; a major portion of his remarks concerned chest injuries.

In February 1944, a meeting at the 38th Evacuation Hospital was devoted to this subject, with special reference to the management of wet lung, the use of atropine and morphine, and intercostal and paravertebral nerve block.


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On 25 March, at the 401st Evacuation Hospital (French), an animated discussion was devoted (1) to hemorrhage, (2) to Pentothal sodium (thiopental sodium), which the French regarded as contraindicated in shock, and (3) to abdominal, thoracic, and maxillofacial wounds. On 30 March, at Marcianise, Italy, Major Snyder talked to the entire 2d Auxiliary Surgical Group on triage at the division clearing station, surgery in field hospitals, and chest surgery in field and evacuation hospitals. On 31 March 1944, a discussion at the 52d Station Hospital concerned surgery in forward hospitals and wounds of the chest. On the same day, a special meeting was held with thoracic surgeons of the 2d Auxiliary Surgical Group on the indications for chest surgery in forward hospitals (p. 200).

A special session of the Congress of the Central Mediterranean Force Army Surgeons held in Rome, 12-19 February 1945, was devoted to chest surgery.

Fifth U.S. Army medical conferences-Chest surgery was a frequent subject at the Fifth U.S. Army medical conferences, which were held weekly, with very occasional exceptions, from their institution in the Royal Palace at Caserta on 11 November 1943 until just before the fall of Rome in June 1944.

The first of these meetings and the meeting on 24 February 1944 were entirely devoted to wounds of the chest. The participants in the first conference were Maj. (later Lt. Col.) Lawrence M. Shefts, MC, Maj. Lyman A. Brewer III, MC, Maj. (later Lt. Col.) Daniel A. Mulvihill, MC, and Maj. (later Lt. Col.) Henry K. Beecher, MC, who spoke on anesthesia for thoracic surgery. At the second conference, the participants were Maj. Benjamin Burbank, MC, Maj. Thomas H. Burford, MC, Lt. Col. Paul W. Sanger, MC, and Capt. Arthur J. Adams, MC, who spoke on anesthesia for thoracic surgery. The majority of the speakers at both of the conferences devoted entirely to chest surgery were heads of thoracic surgical teams of the 2d Auxiliary Surgical Group.

Other Fifth U.S. Army medical meetings devoted to such subjects as shock, hemorrhage, and anesthesia were also extremely useful in the development of policies on chest surgery.

All of these meetings proved a valuable means of disseminating information on chest surgery, particularly during the first winter (1943-44) in Italy, when educational needs were greatest. At this time, the front was generally stable, and Army medical installations were not too widely scattered. The Fifth U.S. Army medical conferences could therefore be attended by medical officers of all echelons in the Army area, as well as by many officers from station and general hospitals supporting the Fifth U.S. Army. The first meeting, as already mentioned, was held at Caserta. When headquarters moved forward, the conferences were held in one or another of the evacuation hospitals in the Army area.


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EQUIPMENT

North Africa-Equipment for thoracic surgery in the North African theater was originally poor. When the 77th Evacuation Hospital landed in England in August 1942, its equipment for this type of specialized surgery consisted of rib shears, a right and left rib raspatory, and a No. 14 F. ascites trocar. The explanation came later, in North Africa, when it was discovered from the newspapers in which the instruments and equipment for this hospital were wrapped, that the table of equipment was of World War I vintage, 1917 and 1918.

Observation at the British chest centers showed the type of equipment necessary for the proper management of combat-incurred wounds of the chest. It included long-handled instruments for work deep in the thoracic cavity, endoscopic equipment, various anesthetic agents (including cyclopropane), and the necessary equipment for the administration of these agents. The British also had cabinets to convert electrical current into high frequency current for cutting and coagulating and for converting current into low-tension current for use with endoscopic and other lighted instruments. A suction machine was attached to this cabinet, which thus took the place in U.S. medical equipment of (1) the Bovie apparatus for cutting and coagulation, (2) the suction machine, and (3) the battery case or rheostat that provided low-tension current for lighted instruments. The British considered this cabinet indispensable for chest surgery. Their mobile thoracic surgical teams in the United Kingdom had all the equipment just listed, and also had portable X-ray machines. Many months had to pass before U.S. Army thoracic surgical teams were as well equipped.

Medical officers of the 77th Evacuation Hospital personally purchased some of the equipment lacking for thoracic surgery, including a suction machine and a bronchoscope. When this hospital was assigned to the II Corps, for the invasion of North Africa, supply officers of the Corps, in spite of the purchase of supplies from British sources and other efforts, could not provide even the minimum equipment necessary for the competent performance of thoracic surgery. This hospital, and others similarly assigned, therefore went into North Africa in November 1942 with their equipment far inferior to that available to British chest surgeons.

Sicily-There was great improvement in Sicily in the equipment provided for field hospitals, which were serving, for the first time, adjacent to clearing stations, but there were still shortages, including a lack of anesthetic machines. Major Snyder reported that Major Shefts, a member of a thoracic surgical team of the 2d Auxiliary Surgical Group, did most of his surgery under Pentothal sodium and oxygen supplied by a Boothby-Lovelace-Bulbulian mask, with extremely satisfactory results, though this variety of anesthesia is ordinarily regarded as contraindicated in chest surgery. Evacuation hospitals were much better equipped.


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The portable hand-driven suction machines devised by Major Brewer and constructed from U.S. Army ordnance materials (figs. 6 and 7) were first used in forward hospitals in the Sicilian campaign. They proved very useful in tracheal and bronchial aspiration when electric power failed or was not available.

In Sicily, field hospitals had only a single X-ray machine for all three platoons, although each platoon, including platoons temporarily functioning

FIGURE 6.-Portable hand-driven suction machine, improvised from salvaged ordnance material and used in the Sicilian campaign. This machine, like the one illustrated in figure 7, was devised by Major Brewer, with the assistance of Maj. William C. Brewer, Ordnance Department, and 1st Lt. Earl R. Kverno, and Sgt. Eugene A. Novak, Ordnance Department. A. Machine constructed from 3-gallon contaminating spray pump and used to produce negative pressure: Handle (a), cutoff valve to regulate suction (b), 3-gallon tank (c), piston (d), cylinder (e), valve reversed to produce negative pressure (f), and angle iron (g). B. Detail of valve shown in position to produce positive pressure: Cylinder (a), and valve (b). In this position, the valve allows air to enter the tank and prevents its escape. In the position shown in view A, the air in the tank can escape but cannot reenter. Continued pumping of the piston exhausts the air from the tank and produces a vacuum.


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as holding units, needed its own to function properly. In 1943, as already mentioned, films were in somewhat short supply, and restrictions were necessarily placed upon their unlimited use. In 1944, these restrictions were removed, and no chest casualty went to operation without adequate roentgenologic examination. Large dryers were also provided, so that dry processed films were ready when the patient went to the operating room.

Italy-In Italy, after the first 6 months of combat, all hospitals came into the theater with modern, fully adequate equipment, and even the most forward hospitals were excellently equipped. Surgical instruments for all varieties of surgery, X-ray facilities, and anesthetic apparatus very closely approached those found in the best civilian hospitals. With the equipment used, as it was,

FIGURE 7.-Portable hand-driven suction machine improvised from fuel tank of standard Army field gasoline stove, with vacuum brake-booster from 2-ton truck used to exhaust air from tank. The parts of the machine appear as follows: Support to fix pump (a), Bendix-Westinghouse air valves (b), cutoff valve (c), fuel tank from gasoline field stove (d), vacuum brake-booster (e), piston rod (f), and gear shift handle (g). This machine produced more suction than the machine described in figure 6 and was more easily operated. Both, in the absence of electrically driven suction machines, proved most useful in both operating room and ward tents for evacuating the tracheobronchial tree in chest and other injuries.


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by well-qualified personnel, there was never any excuse for slipshod surgery in any field.

Shortages of equipment occasionally occurred till the end of the war, as the result of transportation difficulties. In the race across the Po Valley, for instance, in 1945, when supply depots and dumps were still back in Florence, the transportation of medical supplies sometimes had to make way for more critical needs, such as gasoline and ammunition.

Provision of the hospitals on the Anzio beachhead furnished special problems because of the local conditions. The supplies taken ashore in the original landings were brought in without incident. Later, supply dumps had to be abandoned because of losses caused by enemy shelling, and supplies had to be widely distributed.

Nonstandard equipment needed for thoracic and other specialized surgery in the Mediterranean theater was obtained on the authorization of the Fifth U.S. Army consultant in surgery, who, by direction of the Army surgeon, made his requests to the medical supply officer. Not all of the nonstandard equipment requested was supplied. Medical officers fresh from the civilian practice of surgery soon learned how to make do with the excellent and generally adequate equipment provided from late 1943 on.

There is no doubt that some credit for the good results of thoracic and other surgery in the Mediterranean theater must be attributed to good equipment. When equipment was in short supply, thoracic and other surgeons managed as best they could, making ingenious improvisations take care of deficiencies. At the beginning of the fighting in North Africa, for instance, the only suture material available was No. 0 and No. 00 chromic catgut. It was totally unsuited for pulmonary surgery, as well as for vascular and intestinal surgery. One thoracic surgeon supplied himself by having his wife send him some spools of cotton and silk thread from a 5- and 10-cent store. Later in the campaign, all types of suture material were available, including the atraumatic suture material (No. 0000 and No. 00000) particularly necessary for vascular surgery.

Thoracic Surgical Teams

Equipment.-When Major Snyder was placed on temporary duty in II Corps headquarters in March 1943, to report on the work of auxiliary surgical group teams in the Tunisian campaign, he made several recommendations concerning equipment for these teams, which then were doing surgery in clearing stations improperly equipped for this function (2). Two of the most important were for portable anesthetic machines and for more efficient apparatus for transfusions. He also recommended that teams be furnished with individual transportation.

In June 1943, after observing the surgical work in the chain of evacuation in North Africa and questioning many of the surgeons individually, Maj. Francis M. Findlay, MC, and Capt. Marion E. Black, MC, from Team No. 6,


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FIGURE 8.-Jeep used with 1-ton truck for transportation of personnel and equipment of 2d Auxiliary Surgical Group teams in Italy.

3d Auxiliary Surgical Group, reported to the Surgeon, II Corps, that the following equipment was essential for any surgical team to operate independently:

1. Adequate transportation assigned permanently to the team. The original system of depending upon other units for transportation was wasteful and unsatisfactory. A 1-ton truck plus a jeep (fig. 8) or a command car would furnish complete transportation for personnel and all equipment. The enlisted men on a surgical team should be licensed as drivers.

2. Candle power (200 watts) for each operating table. In Tunisia, bulbs of this size had not been obtainable, and the most satisfactory substitute was a string of several bulbs of lesser wattage, set up by the electrician available in every hospital unit.

3. A portable oxygen apparatus, with a large cylinder reducing valve, and a Boothby-Lovelace-Bulbulian mask. This complete, efficient outfit was essential for all chest surgery. Army Air Corps medical officers already had this equipment.

4. A simple transfusion set for giving whole blood by the citrate method. The equipment should include large-gage (No. 15) needles as well as No. 13 needles. A very satisfactory transfusion set could be improvised, if these needles were provided, from aluminum tubing from airplanes, empty vacuoliter bottles, and tubing and filters from used plasma sets.


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5. A large autoclave for sterilizing towels, gowns, and sheets. The upright British autoclave had three times the capacity of the U.S. Army type of pressure cooker being used for this purpose in some clearing stations.

6. Two covered metal sterilizers, each 18 inches long, for boiling instruments, gloves, and transfusion sets.

7. Two stoves for sterilizing. The Coleman stove, which burned leaded gas, though small, was quite efficient for this purpose. A third stove in reserve was a good asset, to heat water and to use in case one of the stoves in use broke down. Without heat, surgery had to stop.

8. Three large, 30-gallon galvanized GI cans, to use for washing, waste, and soaking dirty and bloody linen.

9. Linen, including 200 towels, 20 gowns, and 40 sheets. Drapes for the surgical tent were also necessary, to keep out dirt and dust.

10. A positive pressure apparatus of either the foot- or the hand-bellows type, or a portable anesthetic machine, which was useful even if anesthetic gases were not available.

11. The basic surgical instruments supplied to all teams.

12. A wall or pyramidal tent to furnish living quarters for the surgical team.

The necessity for making such a list points to the deficiencies in the original supply and equipment of auxiliary surgical group surgical teams. By the time the Italian campaign was well underway, all of these items, and many times even more efficient items, were in full supply. Eventually, the equipment of a thoracic surgical team consisted of an Army basic instrument set and a special thoracic surgical instrument and equipment set. The latter included not only all necessary instruments for chest surgery but also a suction machine (a portable suction machine had been a major deficiency originally), a portable anesthetic machine, a bronchoscope, and full equipment for therapeutic bronchoscopic aspiration. This equipment, like all equipment used by auxiliary surgical group teams, was severely tested in respect to both durability and serviceability by repeated sterilization and by the rapid moves necessary over air and water routes and by motor routes over difficult terrain. It stood up admirably.

Transportation.-Transportation for the teams of the 2d Auxiliary Surgical Group remained something of a problem to the end of the war. In the Tunisian campaign, the teams attached to the II Corps were furnished transportation that was turned in when the special assignment was completed. The same arrangements prevailed in Sicily.

In Italy, a certain amount of transportation was authorized for the 2d Auxiliary Surgical Group; it was maintained in a motor pool and assigned as necessary when the individual teams were moved. A few teams had independent transportation, which was far more satisfactory when fighting was heavy and rapid advances were necessary. When progress was slow, the need for independent transportation was, of course, less urgent.


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The six by six truck was the most satisfactory vehicle, since all equipment and personnel could be transported in it. The jeep, in spite of its many advantages, could not accomplish this. It gave rise to so many difficulties, in fact, that surgeons of the 2d Auxiliary Surgical Group developed the habit of referring to it as Hitler's secret weapon.

BLOOD SUPPLY

U.S. medical officers found, as soon as they began to care for casualties in North Africa, how essential whole blood was for both freshly wounded men and for those with older wounds (3). The situation was not at all satisfactory. There were almost unlimited supplies of plasma, but the indications for its use were not nearly so extensive as had been anticipated. Whole blood was required, and it had to be obtained from clearing station and hospital personnel. Most units, furthermore, had come overseas with limited equipment for transfusion or with none at all. In the critiques of surgery in the Tunisian campaign, as already mentioned, attention was called to the need for more convenient methods of transfusion, and Major Snyder also pointed out that a source of blood other than noncombat personnel should be provided (2).

During the Sicilian campaign, as in North Africa, blood donors were secured from the personnel of hospital units or from neighboring service units, which was highly undesirable. Even these sources were not unlimited, for the frequency of malaria reduced the lists of available donors. Transfusion sets still had to be prepared, cleaned, and sterilized by hospital personnel, which took a great deal of time and was far from safe under field conditions.

By the end of 1943, most hospital units in the Fifth U.S. Army in Italy had provided their own small blood banks as a matter of necessity. Type-specific blood could be held in them for 24 hours, or, if necessary, a little longer. In February 1944, a central blood bank was organized, designed to supply whole blood to all Fifth U.S. Army units, and thereafter blood could be used in as liberal quantities as was considered necessary. A similar bank was set up in the Seventh U.S. Army before the invasion of southern France in August 1944.

The use of blood in thoracic casualties expanded as the supply of blood expanded, though it always had to be used with special precautions in these wounds (p. 253).

HOSPITAL INSTALLATIONS

Field Hospitals

Evolution of mission.-The evolution of the mission of field hospitals in World War II represents a major development in the care of combat-incurred wounds. In North Africa, these hospitals provided only the station type of


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medical care. Surgery on nontransportable battle casualties was performed at the division clearing station.

In his report in April 1943 to Col. Richard T. Arnest, MC, Surgeon, II Corps, on the use of surgical teams in the Tunisian campaign, Major Snyder pointed out that the primary function of clearing stations was triage and that to perform surgery in them interfered with this function and also had elements of surgical risk (2). Furthermore, if triage was not correctly performed, nontransportable casualties might be classified as transportable and lose their lives as a result, while casualties who could be returned to duty if kept forward were likely to be evacuated to the rear and become lost for combat purposes.

Major Snyder recommended that thereafter platoons of clearing companies should be designated for surgical duties in an installation adjacent to clearing stations rather than within them. This arrangement would make it possible for seriously wounded casualties to be operated on without delay and would, at the same time, leave the clearing stations free to perform their basic function of triage.

Before the invasion of Sicily, this recommendation was advanced another step. In his evaluation of the work of the teams (2d Auxiliary Surgical Group) (2) which had been assigned to a British hospital in Algiers, Major Snyder had been greatly impressed with the fine work of these teams and with their potential usefulness in a combat zone. It was therefore planned that teams from the 2d and 3d Auxiliary Surgical Groups should be assigned to the 11th Field Hospital, which was to support the invading forces. During the latter part of the campaign, when the 10th Field Hospital also came under II Corps control and a platoon went forward to care for nontransportable casualties, it was promptly evident that its organic personnel could not handle the situation alone, and auxiliary surgical group teams were attached to it, as they had been to the 11th Field Hospital. Thereafter, surgical teams were attached to all field hospitals in the Mediterranean theater and were used in the same manner after D-day in Europe.

Concept and functions of field hospitals-Field hospitals were operated on two concepts:

1. Some casualties, including those with thoracoabdominal wounds and certain types of chest wounds, as well as all casualties in deep shock, must receive surgical care at this level if they were to survive.

2. Casualties who had undergone the surgery required by such wounds must not be moved for a certain period of time, ranging from 8 to 14 days as a rule, and generally averaging 10 days.

About 10 percent of all casualties reaching a clearing station were nontransportable and required surgery in a field hospital at this level. Depending upon conditions of evacuation forward of the clearing station, casualties might be received within a few minutes after their evacuation from the battlefield; but as a rule, at least 1 or 2 hours had elapsed, and occasionally from 18 to 24 hours, or even longer, had passed since wounding.


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The patients treated in field hospitals were frequently in desperate condition. Shock was profound, and heroic measures were often required to resuscitate them. The terms of reference under which these hospitals operated made it inevitable that the mortality rate should be high. Since the selection of patients for surgery at this level depended upon the triage performed in the adjacent clearing station, the importance of the function of the clearing station is evident. Without field hospitals, however, the mortality rate would have been still higher, and a surprising number of casualties operated on in them were returned to duty. An overall mortality rate of 25 percent was not unusual, while a rate less than from 12 to 20 percent strongly suggested that casualties who should have been operated on at this level had not been cared for there. If a field hospital was not accepting first priority (nontransportable) casualties or if other than first priority casualties were being accepted, it was not fulfilling the functions for which it was set up.

Field hospitals received patients, usually by litter carry, from the adjacent clearing station as soon as triage in them had been accomplished. The fundamental requirements for the performance of good surgery in them were:

1. Experienced surgeons, anesthesiologists, and operating personnel.

2. Good nursing.

3. Reasonable accommodation under shelter.

4. Adequate lighting and water supply.

5. Adequate equipment, including simple facilities for roentgenologic examination. One of Major Snyder's recommendations in his report to the Surgeon, II Corps, in April 1943 had been that clearing platoons designated to do major surgery should be better equipped than they had been in the Tunisian campaign (2). This recommendation was acted upon, and the field hospitals that handled forward surgery in the Sicilian campaign were far better equipped than the clearing stations that had performed the same mission in North Africa.

6. Facilities to retain patients for an average of 10 days after operation.

Physical setup-The physical setup of a field hospital was fairly well standardized after its functions were standardized. The hospital was set up in ward tents, so erected that they formed a cross, the center of which was a pyramidal tent. The receiving and shock ward was located at the main entrance, with the postoperative ward directly opposite. The X-ray and laboratory equipment was in another ward tent, with the operating room directly opposite it. This compact arrangement reduced the movement of patients, concentrated supplies, made heating more efficient during the winter, permitted a complete blackout, and simplified nursing care.

Staffing-The organic personnel of a field hospital, as already indicated, was not constituted, either numerically, frequently, or by training or experience, to do the sort of surgery assigned to these hospitals after the North African campaign and throughout the remainder of the war in the Mediterranean theater and in the European theater. The solution of the problem was


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the attachment of teams from an auxiliary surgical group to field hospitals. As a rule, the intrinsic hospital personnel performed all administrative duties, and the attached teams performed most of the heavy major surgery required in medical installations located so far forward.

Each field hospital consisted of three platoons, each of which was staffed and equipped to care for from 40 to 50 newly wounded casualties, providing for them all services from resuscitation through postoperative care. While the number of teams attached was flexible, an active platoon required, as a rule, four general surgical teams, one thoracic surgical team, and one shock team. When their intrinsic staff was thus augmented, the number of surgeons and nurses provided in field hospitals was proportionately greater than in evacuation hospitals. This meant that seriously wounded patients could receive better individual attention and postoperative care than less seriously wounded casualties cared for in evacuation hospitals.

The establishment of field hospitals at the level of the clearing station proved highly advantageous for the morale of troops. Every man in a division thus supported knew that if he were seriously wounded, he would receive highly competent care and would receive it without delay.

At this level of medical care, segregation of injuries was not possible, if only because so many of them were multiple. Thoracic surgeons attached to field hospitals therefore had to have special qualifications. A thoracic surgeon must also be able to perform competent abdominal surgery; if no thoracic injuries required his attention, he had to undertake the care of casualties with abdominal and other injuries. In addition, a large percentage of thoracic wounds also involved the abdomen by continuity.

In view of the shortages of thoracic surgeons, it was often expedient, instead of attaching a surgical team to a field hospital, to attach a single thoracic surgeon. He performed the most serious operations himself, supervised other operations, supervised preoperative and postoperative care, and taught general surgeons the indications for, and the techniques of, thoracic surgical procedures. Many young general surgeons thus learned to do excellent thoracic surgery of the sort necessary in a field hospital. An experienced thoracic surgeon could also do much to elevate the standards of anesthesia for chest surgery in both field and evacuation hospitals.

Another possibility was to attach a senior thoracic surgeon to a field hospital and place two teams under his direction.

By whatever means the necessary personnel was provided, the proximity to the frontline of experienced thoracic surgeons (and other specialists) made it unnecessary for medical officers in clearing companies to indulge in heroic surgery for which their installations were not designed and for which they themselves were not trained.

A single thoracic surgeon could not usually handle all of the thoracic and thoracoabdominal surgery in a field hospital, even after indications for forward surgery were standardized. It was agreed that certain types of penetrating and perforating wounds which had earlier been considered first priority (non-


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transportable) problems could quite as well be handled in evacuation hospitals (p. 199). Even then, the number of thoracic injuries which required forward surgery was still large. In one unselected series of cases encountered during a 7-week period in a platoon of a field hospital in the Mediterranean theater, 92 patients had intrathoracic wounds that made them nontransportable (22 thoracoabdominal wounds, 16 wounds requiring formal thoracotomy, and 56 other perforating or penetrating wounds). During the same period, the thoracic surgical team that cared for these patients also cared for 44 patients with abdominal wounds.

Postoperative function.-At the beginning of the fighting in North Africa, the tendency had been to place the chief emphasis upon the operative act and to regard most patients as transportable almost immediately after operation. It was promptly evident that casualties who were moved too soon after major surgery might be in worse status than if surgery had been postponed until an evacuation hospital was reached. In short, it was learned in military surgery, at bitter cost, just as it had been learned in civilian surgery, that complete postoperative care is quite as important in the surgical result as is the operation itself. The hospital on wheels was an alluring concept but totally impractical. Surgery was not practical beyond the point at which facilities for aftercare could be provided.

Holding patients after operation was reasonably simple in both field and evacuation hospitals when the hospital was located behind a stable front of a slowly advancing front. In these tactical circumstances, one field hospital could serve two divisions in the line by using two of its three platoons at two division clearing stations. The third platoon held patients at a fixed location until they were all evacuated, then leapfrogged over one platoon or the other to set up beside the cleaning station that had moved forward.

When the front was moving rapidly, the postoperative situation was difficult and much more complicated. Every division then usually required the support of an entire field hospital, the platoons of which were set up in depth behind the front. Only the most forward platoon, adjacent to the division clearing station, received casualties. The other two platoons held patients in various stages of postoperative recovery until they could be evacuated and the platoons could move forward. When the forward platoon was closed to admissions, as it was when the clearing station adjacent to it moved forward, the rearmost platoon, whose patients had been operated on before those in the middle platoon, leapfrogged over the middle platoon to take its place alongside the clearing station in its new forward position. The platoon which had closed its admissions cared for its patients until they could be evacuated and it, in turn, could leapfrog forward and again receive patients.

In the beginning, only a skeleton staff was left with the platoon holding patients after operation. It was soon found that this was not adequate, for it made no provision for the management of complications and emergencies. The plan was then developed of leaving a surgical team with this platoon. It


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was also found necessary to leave facilities for roentgenologic examination and for surgery, which meant a complete operating room setup.

When field hospitals were urgently needed during active campaigns, an evacuation hospital sometimes moved to the site occupied by the holding platoon and took over its postoperative duties in addition to its own responsibilities for initial wound surgery. The holding platoon could then move forward and again receive casualties.

Evacuation Hospitals

Mission.-Evacuation hospitals (fig. 9) were located from 3 to 15 miles behind field hospitals in Italy. In Tunisia, the distances had frequently been considerably greater. After it had been established that thoracic casualties withstood transportation well, the majority were treated in evacuation hospitals. Most of them came directly from clearing stations, but a small number were received from field hospitals, in which resuscitation had been instituted in the shock wards.

Evacuation hospitals were of two types, 400-bed and 750-bed. The larger capacity was often an advantage, but 400-bed hospitals, if reinforced by the appropriate number of teams from auxiliary surgical groups, were capable of

FIGURE 9.-Tents used for officers' quarters at 11th Evacuation Hosptial, Anzio, Italy, in May 1944, dug in for protection from shellfire. On this beachhead, evacuation hospitals were so far forward that they served as field hospitals and frequently came under heavy fire.


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handling about the same number of casualties as 750-bed hospitals not thus reinforced. The smaller hospital, with extra bed capacity provided in the form of an adequately equipped clearing platoon, was far more efficient in a fluid tactical situation than a larger hospital. A 400-bed semimobile evacuation hospital, because it could be rapidly moved to a new location, proved a particularly practical unit in Sicily, where frequent changes of position were required.

The clearing platoons were left as holding hospitals when the parent hospitals moved forward. It was quite as important to hold patients after major abdominal and thoracic surgery in an evacuation hospital as after surgery in a field hospital.

When the load on field hospitals increased, evacuation hospitals received more seriously wounded casualties than in nonpeak periods, which meant that they received more thoracic casualties. The general policy, whenever it was practical, was to send the most seriously wounded patients to the most forward evacuation hospitals. It was not a desirable plan to send patients to evacuation hospitals who should have been treated in field hospitals, but it was sometimes an operational necessity, as during the Anzio phase or during the pursuit of the Germans north of Rome after that city fell. Very careful selection of patients was obviously necessary when this policy was employed.

The extent to which other than urgent intrathoracic surgery was done in evacuation hospitals depended upon the tactical situation as well as upon the distance between them and the fixed hospitals in the communications zone. Transportation facilities also had to be taken into account.

It was fundamental policy that evacuation hospitals must not engage in the performance of semielective surgery when there was any chance at all that their bed capacity would be required for battle casualties. In quiet periods at the front, however, and sometimes when evacuation facilities to the rear were slow and uncertain, certain surgical procedures usually reserved for base section hospitals were undertaken in them. These procedures included the removal of intrapulmonary foreign bodies and, very occasionally, pulmonary decortication for organizing hemothorax. One justification for this type of surgery in an evacuation hospital was that the patient might be returned to duty from it.

This policy was chiefly used in North Africa, when hospital policies were not yet stabilized, and to a lesser extent in Sicily. During the Italian campaign, after the establishment of general hospitals, these surgical procedures were almost always reserved for these hospitals or for thoracic surgical centers.

Staffing-When triage in the clearing station was efficient, evacuation hospitals received almost no abdominal or thoracoabdominal wounds, but they did receive the larger number of penetrating and perforating wounds of the chest, which frequently were associated with wounds of the extremities.

At this echelon of medical care, segregation of casualties for specialized management was entirely practical. Thoracic surgical teams proved particularly useful both in supplementing the thoracic surgical section of the hospital and in furnishing qualified personnel if there were no experienced


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thoracic surgeons on the intrinsic staff. During peak periods, it was desirable to have two thoracic teams functioning in an evacuation hospital and devoting their chief, if not their entire, attention to the treatment of wounded whose major injuries involved the thorax. Preoperative and postoperative care of these patients was the responsibility of the thoracic surgeons, and they also supervised the care of the thoracic wounds in patients on other wards who had multiple wounds, some of which took precedence over the chest wounds.

Fixed Hospitals

Mission.-General and station hospitals in the base area received thoracic casualties as soon as they could be transported to the rear from evacuation hospitals. The time of the transfer depended on the nature of the wound and the surgery that had been necessary for it in the forward hospital.

The policies that governed the management of thoracic and other casualties in fixed hospitals in the base were worked out at the base section in Bizerte in the North African theater during 1943. The mission of these general hospitals in respect to thoracic casualties was threefold:

1. To perform the final reparative surgery on wounded casualties who could be promptly returned to duty. From the military standpoint, the most important function in the base was the energetic treatment of this group of patients, most of whom had wounds limited to the chest wall or wounds without severe intrapleural involvement. Sometimes patients with clotted hemothorax fell into this category. The principal operations performed were delayed primary wound closure; thoracentesis, if hemothorax still persisted; and decortication. Later in the war, decortication was practically always performed in chest centers.

Whenever a choice had to be made from the standpoint of time, available surgical personnel, or facilities, the final care and rehabilitation of patients in this group had the highest priority unless, of course, other patients would have suffered from a delay in their treatment. It was a matter of great importance that soldiers whose return to duty seemed probable should receive treatment as far forward, and as promptly, as possible. The farther from the front a casualty was moved and the longer his return to it was delayed, the less inclined he was to return to active combat.

2. To improve the morbid state of more severely wounded patients, to make them transportable to the Zone of Interior. Since these soldiers were no longer useful in the theater, the sooner they could be prepared for evacuation to the United States, the less was the drain on theater resources.

Casualties from Sicily were evacuated to North Africa before being sent to the Zone of Interior, and the same routine was followed in the early days of the fighting in Italy, before Italian ports were open. Seventh U.S. Army casualties, even after the Army passed into control of the European theater, were evacuated to the 21st General Hospital in Mirecourt, then to a general hospital in Dijon, and finally to Marseilles.


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3. To preserve thoracic function and prevent chronicity and deformity. The preservation of physiologic function was the major objective in all casualties treated in the base, just as it was in the forward area. The institution of correct therapeutic measures prevented ultimate deformity of the lungs, heart, chest wall, diaphragm, and shoulder girdle. As a result of these measures, plus the absence of intrinsic (postpneumonic) infection, the number of so-called thoracic cripples after World War II was very small as compared with the very large number, absolutely and proportionately, after World War I (vol. II, ch. XI).

The management of thoracic casualties in the base areas permitted the continuity of treatment essential to avoid infection. The mission of hospitals in the base area was fundamentally to minimize the incidence and gravity of this and other complications. If a delaying or expectant policy was followed, the immediate mortality rate perhaps did not vary greatly from the rate associated with active therapy, but the degree and frequency of permanent disability was inevitably higher. A hemothorax, for instance, not completely evacuated in the forward hospital, was not likely to develop into hemothoracic empyema if it was treated promptly in the base hospital. Decortication could be done with minimal risk and a high expectation of good results. If the removal of foreign bodies was indicated, it could be undertaken before infection developed or pulmonary function was permanently reduced.

While the functions of base hospitals were generally as described, the tactical situation sometimes required that they assume other missions. These hospitals were occasionally far enough forward to receive freshly wounded patients, while during the first few days after a landing or other operation, particularly when air evacuation was possible, casualties also occasionally received initial wound surgery in them.

Thoracic Surgery Centers

Establishment-Their early experience with thoracic casualties in North Africa convinced Major Burford and Maj. (later Lt. Col.) Paul C. Samson, MC, that the only really efficient way to handle these patients would be in thoracic surgery centers (fig. 10) equipped for this type of surgery and staffed by thoracic surgeons. Major Burford's first specific assignment in North Africa had been at the 21st General Hospital, then at Bou Hanifia, which had been receiving heavily infected thoracic casualties, consisting of both U.S. Army wounded personnel and German prisoners of war. It was here, incidentally, that he did the first decortication and established the precedent for the management of clotted and infected hemothorax and hemothoracic empyema in World War II (p. 27).

His own observations convinced Colonel Churchill of the soundness of Major Burford's and Major Samson's position, and the management of tho-


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FIGURE 10.-Thoracic surgery center, 300th General Hospital, Mediterranean theater. A. Main operating room. B. Typical ward.


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racic casualties in chest centers became standard policy in the Mediterranean theater throughout the war.

The first such chest center was set up on 7 July 1943 in the 53d Station Hospital at Bizerte (4), where the 53d and other hospitals, commonly referred to as "hospital row," were already in operation. At the request of the surgeons who made up the thoracic surgical staff of this center (Major Burford, Major Samson, and Captain Brewer), an internist, Major Burbank, was also attached to the service. This center received casualties from evacuation hospitals and from general hospitals in North Africa. After the invasion of Sicily, in July 1943, some freshly wounded casualties were flown directly to it.

There was almost no overlapping of the operation of chest centers in the Mediterranean theater, the policy being that not more than one should function at any one time. When the center at the 53d Station Hospital was closed at the end of October 1943, the 28 patients then hospitalized were transferred to the 24th General Hospital, also at Bizerte. The Salerno landings had been made in September, and casualties were then being received from Italy. This center was closed on 31 January 1944, just after the Anzio invasion, and the next center was established in Italy, at the l7th General Hospital located near Naples.

When the center at the 17th General Hospital was closed in March 1944, its functions were assumed by the 300th General Hospital at Naples. The last center to be established during the war was opened in March 1945, at the 70th General Hospital, located at Pistoia, just before the drive on Bologna. The hospital was at first so close to the frontline that during the first few days of the drive, it functioned, for all practical purposes, as a field hospital, and thoracic casualties were received shortly after they had been wounded.

The first chest center in the Mediterranean theater was established at a station hospital, but it promptly became evident that the limited bed capacity and the lack of certain essentials for the proper care of thoracic casualties made hospitals of this type unsuited to serve as thoracic surgery centers. All centers subsequently established were therefore at general hospitals. The influx of casualties to the centers proved the wisdom of this change of policy. The facilities of general hospitals were required to meet the variegated problems of a large specialty service dealing with difficulties of the magnitude encountered in combat-incurred chest injuries.

When the policy of chest centers was instituted, it was necessary to change the lines of evacuation (fig. 3) so that thoracic casualties would be evacuated from evacuation hospitals to the centers, without the delay and wasted motion involved in their going first to general hospitals. There was no selection of cases. Casualties sent to the chest centers represented an overall distribution. As a result, the observations made in the centers in the Mediterranean theater have a validity that was not possible when centers were used only as the last resort for patients with complicated and intractable wounds.

The system of staffing and operation evolved in the thoracic surgery centers and other centers for specialized treatment established in the Mediter-


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ranean theater served as a pattern for the similar centers later established in the European theater, both in the United Kingdom Base and on the Continent.

Advantages.-The establishment of centers in base section hospitals for the study and treatment of specialized surgical problems had the same far-reaching influence on thoracic surgery that this policy had on other specialties. There were a number of obvious advantages:

1. The concentration of casualties with thoracic wounds under one roof meant that the thoracic surgeons, who were in such short supply, could be assigned to these centers and could use their talent and experience with the greatest economy and most effectively. This was a serious consideration. At the end of 1943, aside from the thoracic surgeons in auxiliary surgical groups, there were, at the most, six surgeons in the 17 hospitals in the Mediterranean theater who were qualified by training and experience to handle complicated thoracic wounds.

2. The concentration of thoracic casualties under trained personnel in a hospital with specialized equipment provided better opportunities for their observation and care than was possible when they were scattered through the general hospitals in the theater.

3. The opportunity of studying large numbers of casualties permitted an objective evaluation of the efficiency of previous treatment. It was then possible to alter therapeutic policies when they were not proving effective. The constructive criticisms that emerged as the result of these evaluations were disseminated to other installations by Colonel Churchill and others designated by him for this duty. They were also disseminated by means of circular letters. Numerous new techniques, of which decortication is an outstanding example, were thus introduced and standardized.

4. The establishment of special centers made possible the best timing for the reparative phase of the management of thoracic wounds. Numerous soldiers were returned to duty in the theater because their wounds were closed at the optimum time and, when indicated, retained foreign bodies were removed. Numerous empyemas were prevented because decortication was carried out at the optimum time in massive organizing hemothoraces. Many operations for which the optimum time had arrived before transportation to the Zone of Interior was available were also carried out in these centers.

5. As a result of these various policies, treatment was expedited as well as made more effective. The incidence of infection in thoracic casualties received in general hospitals and managed in them by surgeons without experience in chest surgery provided additional proof of the wisdom of, and necessity for, the policy of establishing chest centers. Manpower losses were diminished. Disposition of patients was accelerated, and the number of soldiers who could be returned to active duty in the theater was greatly increased. Finally, the crippling sequelae of chest injuries, which had been a continuing problem after World War I, furnished only minimal problems in World War II.

6. Not the least advantage of the thoracic surgery centers was the means they afforded for training younger officers with general surgical experience in


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chest surgery and in preoperative and postoperative management of thoracic casualties. These officers, as already pointed out, received concentrated experience, under supervision, which they could not possibly have obtained if they had had to take the entire responsibility for the small share of chest injuries that would have come under their observation if the casualties had been scattered diffusely through the general and station hospitals of the theater.

Special experiences-The thoracic surgery centers in the Mediterranean theater cared for a total of 1,538 intrathoracic wounds during World War II. The first centers established, the 53d Station Hospital and the 24th General Hospital, together treated 390 thoracic casualties, with the aid of Thoracic Surgical Teams Nos. 2 and 3 and Miscellaneous Team No. 1 from the 2d Auxiliary Surgical Group. These figures include 26 cases of thoracic disease, of which 22 were spontaneous idiopathic pneumothorax. In the remaining 364 cases, the wounds were limited to the chest wall in 185. There were 83 fractured ribs; 188 instances of traumatic hemothorax, pneumothorax, or hemopneumothorax; and 16 instances of blast lung (the figures are overlapping).

There were 3 deaths among the 390 patients. Of the survivors, 100 were returned to duty or to convalescent hospitals with the expectation that they would be returned to duty; 104 were evacuated to the rear and were probably later evacuated to the Zone of Interior; and 124 were transferred to other services or to other hospitals for active therapy. When the center at the 24th General Hospital was discontinued on 31 January 1944, 59 patients were still hospitalized, not all of whom were hospitalized because of their thoracic wounds. It should be remembered that even in a thoracic surgery center, the presence of other wounds frequently made certain modifications, sometimes not altogether desirable, necessary in the management of chest injuries.

AUXILIARY SURGICAL GROUPS

Early Concepts

In 1943, while the 2d Auxiliary Surgical Group was still at Lawson General Hospital, Atlanta, Ga., its commanding officer, Maj. (later Col.) James H. Forsee, MC, prepared an article on the management of thoracic combat-incurred injuries with two of the group thoracic surgeons (Major Shefts and Major Burford); an internist (Major Burbank); and an anesthesiologist (Maj. Leo J. Fitzpatrick, MC) (5).

The statements in this article about administrative considerations in chest injuries were to prove prophetic:

1. The single factor which can reduce the high mortality of chest injuries as recorded in previous wars is earlier definitive treatment by trained thoracic surgeons.

2. To effect this in the mobile type of war now occurring, it is necessary to have an equally mobile system of evacuation and management, which is


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flexible enough and mobile enough to handle casualties soon after their injuries are incurred.

3. To accomplish these results requires the special training of surgeons and their assistants in the care of chest wounds. It also requires an organization whereby such personnel are available on short notice to function in properly equipped medical installations at the point of maximum casualties close to the battlefront.

4. Since there are too few specialists in thoracic surgery of field age to staff all hospitals, the deficiency must be remedied by the training of general surgeons in the fundamentals of thoracic physiology, preferably in hospitals in which chest cases are concentrated. Centers of this sort would also permit training in bronchoscopy and provide training for anesthesiologists in the techniques of endotracheal and positive pressure anesthesia, both essential for safe thoracic surgery.

5. Reduction of the timelag after wounding, which is also concerned with distance, resolves itself into (1) having the surgeon immediately available behind the frontline, even if it is a rapidly moving line, or (2) evacuating the wounded to him by ambulance or airplane.

Such a program of early definitive treatment by trained personnel, the authors concluded, would reduce the mortality of thoracic injuries, decrease their morbidity, reduce the hospital stay days, and eliminate a large proportion of the patients with chronic empyema who linger on long after a war is over. These so-called thoracic cripples are the obvious result of treatment applied late and frequently applied incorrectly. The elimination of this group of patients, who would require hospital care for many years, would have the additional advantage of accomplishing enormous monetary savings.

Implementation of Concepts

This statement of principles for the most part was translated into action in World War II (6). Never before in history had battle casualties received such prompt surgical care by such highly skilled specialists. This was made possible by two policies. The first was the provision of medical service in the combat zone in such locations that the period between wounding and competent surgical care was decreased. The second was the availability of young, formally trained medical officers, who were not only well qualified technically to perform good thoracic surgery but who, even more important, were schooled and grounded in the fundamental principles upon which good surgical practice is based.

The availability of these highly trained surgeons was a reflection of the carefully nurtured system of postgraduate medical education in the United States. Their superior performance was a measure of the progress made in this special field. The brilliant results that they achieved were accomplished because they were properly utilized and correctly fitted into the organi-


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zation of medical service in the forward area. The keynote of the plan of medical care in advanced battle zones was that the sooner a wounded man received adequate first aid and subsequent surgical care, the better would be the outcome of his injuries. For this concept, much credit is due Colonel Churchill, theater consultant in surgery.

In short, everything that the surgeons of the 2d Auxiliary Surgical Group wrote in 1943 came to pass in the ensuing years of the war. The case fatality rate of chest wounds was sharply decreased, their postwar morbidity was even more sharply reduced, and thoracic cripples ceased to be seen.

Organization and Utilization of Auxiliary Surgical Group Teams

Although some specialty teams had been used during World War I (7), thoracic surgery did not then exist as a specialty and was therefore not represented among them. All of the teams operated independently and not as a group. The unit known as an auxiliary surgical group and utilized as surgical needs arose was employed for the first time in the U.S. Army in World War II.

Teams from the 3d Auxiliary Surgical Group supported the II Corps in North Africa and Sicily before the group was put under the control of the European theater. Some teams of the 5th Auxiliary Surgical Group also supported the Fifth U.S. Army. In November 1944, teams from the 1st Auxiliary Surgical Group attached to the Seventh U.S. Army included eight general surgical teams; two orthopedic surgical teams; two shock teams; and teams representing, respectively, thoracic surgery, neurosurgery, maxillofacial surgery, radiology, and dental prosthetic surgery. Later, other teams were added, including four general surgical teams; two thoracic surgical teams; and teams representing, respectively, orthopedic surgery, neurosurgery, and radiology.

Teams of the 2d Auxiliary Surgical Group served with the II Corps in North Africa and in Sicily, with the Fifth U.S. Army in Italy, and with the Seventh U.S. Army for the invasion of southern France and until the end of the war in Europe. In preparation for the invasion of southern France, half of the teams of this group, including two thoracic surgical teams, were attached to this Army and remained with it even after control of the Army passed to the European theater in December 1944. When this change was effected, fighting had slowed down considerably, and the loss of the teams was not immediately felt. When the character of combat changed from the battle of pursuit in July and August to the bitter fighting that characterized the North Apennines campaign in the fall and winter of 1944-45, the changed tactical situation produced the longest sustained combat load in the history of the Fifth U.S. Army. Surgical teams made up from base hospitals, valuable as they were, did not prove a substitute for the experienced teams that had been withdrawn.


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The teams of the 2d Auxiliary Surgical Group cared for a total of 22,000 casualties during their service in the Mediterranean theater, of whom 1,364 had thoracic injuries and 903 thoracoabdominal injuries.1,2

Early policies-While some auxiliary surgical group teams were used in the North African campaign in 1942-43, thoracic surgical teams were not among them. Chest surgery was done entirely by the staffs of the forward hospitals and the general surgical teams, though some thoracic casualties from this campaign were later treated in the first thoracic surgery center established at Bizerte in July 1943.

There were a number of reasons for failure to use the chest teams at all, and to use the other teams properly, in this campaign. For one thing, the fighting was in eastern Algeria and later in Tunisia, while the headquarters of the 2d Auxiliary Surgical Group was in Rabat, Morocco. There was no clear concept in the minds of hospital staffs or in the headquarters of the theater surgeon of either the availability or the usefulness of these teams. The number of troops committed was small, at least as compared to the number committed in later campaigns, and the mobility of the front and the tenuous lines of communication furnished difficult problems of logistics.

Major Snyder's first special mission in North Africa, before he was appointed professional services officer to the Surgeon, II Corps, and later consultant in surgery to the Surgeon, Fifth U.S. Army, was to evaluate the work of the teams from the 2d Auxiliary Surgical Group that had been assigned to a British hospital in Algiers (2). He was immediately impressed with the potentialities and great usefulness of these teams in a combat zone, and it was on his recommendation, as already noted, that they were attached to field hospitals. They were used in this capacity in Sicily and throughout the remainder of the war. They were also attached to evacuation hospitals and, in some instances, worked in general hospitals and in general hospitals that served as chest centers.

Administrative considerations-An auxiliary surgical group was composed of a headquarters and of a varying number of teams, including general surgical, thoracic surgical (thoracosurgical), orthopedic, maxillofacial, neurosurgical, and shock teams.

The coordination of functions and the employment of the teams of the 2d Auxiliary Surgical Group were effected through Group headquarters. The need for the use of the teams in special installations was worked out between the theater surgeon and Colonel Churchill, who, as consultant in surgery to the theater surgeon, participated in medical planning and was at all times fully aware of the tactical situation. When it was determined which field

1The work of the 2d Auxiliary Surgical Group is referred to frequently and in great detail throughout this volume for the reason that its records, which were carefully planned in advance, provide data on thoracic injuries not available from any other source.-F. B. B
2To round out the picture, it might be mentioned that the 9th Evacuation Hospital, which was supporting the Seventh U.S. Army and was stationed in Naples from January to August 1944, was loaned to the French Army in the winter of 1944. It remained under the control of Maj. Gen. Morrison C. Stayer, Surgeon, Mediterranean theater-F. B. B.


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hospitals and which evacuation hospitals would be employed in a given operation, Colonel Churchill decided upon the number and kinds of teams to be employed, and the commanding officer of the group, Colonel Forsee, arranged for them to be properly deployed. In other words, these particular hospitals were augmented by surgical, thoracic surgical, and other specialty teams in anticipation of heavy casualty rates.

The number of teams attached to forward hospitals was flexible. During a slack period, two teams could handle all the work, but at least six surgical teams and two shock teams were required during an offensive, and the assignment of eight teams was not unusual. The hospitals that participated in amphibious landings required the assistance of teams from the group, and numerous teams were used during the Anzio operation, in which the Army had major forces in two areas separated by intervening territory held by the enemy.

Originally, auxiliary surgical group teams were not used to their full capacity. In Sicily and later in Italy, for instance, between 10 July 1943 and 1 February 1944, a thoracic surgical team cared for 100 casualties, of whom only 6 had penetrating wounds of the chest and of whom only 5 had thoracoabdominal wounds. This was a serious waste of trained personnel.

Another of the earlier policies which resulted in similar waste was the keeping of teams attached to field and evacuation hospitals with those installations even after their mission had been completed. In North Africa, in Sicily, and in the first months of the fighting in Italy, they were moved only when they were needed elsewhere. When the headquarters of the 2d Auxiliary Surgical Group was moved to Italy in 1944, these wasteful practices were discontinued, and thereafter, when the teams finished their special missions, they were recalled to headquarters at once for a period of rest and preparation for the next assignment.

All teams were kept on the alert, and were prepared to move to any assignment on very short notice. The Sicilian experience proved that attachment of these teams to field and evacuation hospitals resulted in a much higher grade of care for wounded casualties than the previous policy of surgery in clearing stations; the ability to shift the teams rapidly had much to do with the improvement.

Components of a thoracic surgical team-All thoracic surgical teams were so constituted as to be complete operating units. Each team consisted of a thoracic surgeon (major), an assistant surgeon (captain), an anesthesiologist (first lieutenant), a surgical nurse, and two enlisted technicians. Each possessed special qualifications:

1. The thoracic surgeon was expected to have a precise knowledge of the surgical physiology of the chest, technical skill in thoracic surgery, and sound surgical judgment. It was also necessary that he have had a thorough training in general surgery as the basis for his training in thoracic surgery.

The latter requirement, which is highly desirable in civilian practice, proved essential in military surgery, when the exigencies of the military situa-


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tion often made it necessary for the thoracic surgeon to work in the abdomen, and sometimes elsewhere in the body. The majority of patients admitted to field hospitals had multiple wounds because they had been injured by high explosive missiles, such as artillery shells, mortars, mines, and antipersonnel bombs. The general surgical training possessed by the thoracic surgeon (and the assistant surgeon) of a well-constituted thoracic surgical team fitted them for the assumption of responsibilities outside of their special field and greatly limited their usefulness if they could not assume them.

The thoracic surgeon was also responsible for preoperative preparation, determination of the optimum time for operation, postoperative care, and the designation of the time of evacuation for thoracic casualties.

It was always desirable to have a senior team chief act as senior officer for the teams in a hospital, and if the thoracic surgeon was senior to the other team chiefs, he had this responsibility also.

2. The assistant surgeon ideally had had a minimum of 2 years of surgical training and had devoted several months, at least, to the study of the mechanical aspects of thoracic diseases.

3. Since good anesthesia plays an important role in all chest surgery, the severity of the thoracic injuries sustained in World War II simply compounded this necessity. The anesthesiologist had to be capable of administering endotracheal and positive pressure anesthesia; of clearing the tracheobronchial tree of secretions by catheter suction or, if that was ineffective, by bronchoscopy; of recognizing and correcting disturbed cardiorespiratory physiology; and of directing the management of the shocked casualty. In addition to administering anesthetics, he had to share with the surgeon, the assistant surgeon, and the ward officer the responsibility for the preparation of casualties for operation and for their postoperative care.

4. The surgical nurse on a thoracic surgical team began by being a good surgical nurse. In addition, she had to have a detailed knowledge of the technical features of this specialty. She had to possess the temperament and adaptability to endure frequent operative ordeals during long periods of sustained tension. She also had to be an able instructor in operating room technique, capable of teaching the principles of asepsis and other techniques to corpsmen without previous medical experience.

5. The surgical technicians had to be good, well-disciplined soldiers, with a capacity and willingness for long, hard work. They were necessarily young, and they had to be in sound physical condition. They preferably possessed inquisitiveness concerning the accomplishments and potentialities of modern surgery. They had to be thoroughly reliable and responsible, since their duties included the preparation and sterilization of surgical supplies. They also had to be gentle and careful enough to serve as good assistants at the operating table.

6. All of the members of the team had to have sufficient physical stamina to endure long hours of taxing work at the operating table and also had to have a capacity for quick, decisive action.


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Hospital Responsibilities

Field and evacuation hospitals-In the field hospitals of the Fifth and Seventh U.S. Armies, auxiliary surgical group teams carried the chief responsibility of the professional service, while the organic personnel were chiefly responsible for administration. In evacuation and general hospitals, teams from the group augmented the regularly assigned surgical staff. No other arrangements would have been practical in these particular field hospitals, in which the assigned personnel were practically always numerically insufficient to handle both administrative and professional responsibilities.

In the early days of the war in North Africa, the teams were not always welcome. Organic personnel of both field and evacuation hospitals resented their presence and took the attitude that they could take care of their own responsibilities without outside help. Proper indoctrination of commanding officers of hospital installations and chiefs of service, and the careful placing of auxiliary surgical group teams in positions in which casualties were heavy and the need for help obvious, solved part of the difficulty. Quite as important was the performance of the teams themselves. Only second to their professional requirements was their ability to adapt themselves to varied and changing situations. Their own attitude and tact determined the reception they got from organic hospital staffs. Unless a spirit of cooperation existed on both sides, casualties suffered. Fortunately, when the usefulness of these teams was realized, cooperation was invariably excellent, and the original, quite natural, resentment over their assignment and assumption of responsibility quickly disappeared.

General hospitals-Over a 2-year period in the Mediterranean theater, three thoracic surgeons of the 2d Auxiliary Surgical Group (Major Burford, Major Brewer, and Major Samson) supervised eight major thoracic services in base section hospitals, five of which were at various times officially designated as chest centers.3 The personnel of such a service might be permanent or might consist of a thoracic surgical team on temporary duty. The limited availability of thoracic surgeons and the need for their services in forward hospitals made it impossible to spare more than one team at a time to work in a general hospital, whether or not it served as a thoracic surgery center.

Records

The maintenance of accurate individual case records was a requirement for all teams. Enforcement of this policy made it possible for the 2d Auxiliary Surgical Group to compile the statistical and clinical data that serve as a point of departure for this history of thoracic surgery in World War II. Similar

3Major Samson later supervised the thoracic surgery service for 2 months at the 9th Evacuation Hospital in eastern France.


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basic data (3,154 abdominal injuries) form the background for the extensive section on that subject in the second general surgery volume in this series (7).

Conclusions

The following comments were made in February 1945 by Colonel Forsee, commanding officer of the 2d Auxiliary Surgical Group, which was the first such group to function in World War II and which also had a longer experience than any other surgical group. His conclusions concern the thoracic surgical teams of the group, but for the most part, they are applicable to all teams:

1. The function of thoracic surgical teams, like that of all other surgical teams, is to augment the staff of hospitals throughout a theater when the requirements for surgery exceed the capacity of the regular staff. Teams of the 2d Auxiliary Surgical Group functioned in installations as far forward as divisional clearing stations, which was not an efficient mission, for these installations lack the facilities necessary for the proper care of first priority cases. They also functioned as far to the rear as general hospitals in the communications zone. They functioned in all varieties of hospitals in the Fifth and Seventh U.S. Armies and in the II Corps, in many hospitals in four different base sections, in British casualty clearing stations, and in British general hospitals. Teams of the group also supported the assault forces in amphibious operations.

2. A team assigned to a hospital should become an integral part of the staff during its temporary stay and should take its turn on the operating schedule with the intrinsic surgical staff.

3. The chief of the team should be responsible for preoperative and postoperative care, determination of when to operate, and designation of patients for evacuation when he considers them ready for transportation.

4. Teams should be relieved and returned to their own group headquarters as soon as the flow of casualties has so decreased that the organic hospital staff can care for them.

5. It is highly desirable that all teams function in as many types of hospitals as possible, so that they may be able to function efficiently on short notice in any of them.

6. During inactive or quiet periods at the front, surgeons should be attached individually to duty in base hospitals, to augment their experience.

7. The World War II policy of assigning to thoracic surgical teams the responsibility for the professional service in a chest center in a fixed hospital has proved highly successful. This plan permitted continuity of treatment of many patients who had received their initial wound surgery from other surgeons of the same auxiliary surgical group. A detailed followup of many problems of traumatic thoracic surgery was thus possible and permitted significant advances in this field.

8. The maintenance of accurate individual case records is a function of all teams.


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DISPOSITION

Appraisal of the duty status of casualties recovered from chest wounds gained in accuracy with accrued experience. Clinical evaluation and psychologic estimates proved more valuable criteria in this appraisal than laboratory tests such as spirometry. Definite progress was made toward retaining more men for duty in the theater as the war progressed. Early in the war, almost every patient who underwent thoracotomy was evacuated to the United States, as was almost every patient with empyema. Later, it was possible to return significant numbers in both categories, especially the former, to duty in the theater. Furthermore, a great many of the patients who were returned to the Zone of Interior-some estimates were three of every four-were surgically well when they reached the United States. The principal reason for returning them was to evaluate their potential for military duty; this was necessary because of lack of previous experience with fully recovered patients with such severe injuries.

A large number of patients sent to the Zone of Interior were also evacuated because of associated wounds and not because of their thoracic status. Thus in 870 thoracic injuries analyzed by Major Burford and Maj. Edward F. Parker, MC, 379 of the patients were returned to the Zone of Interior, but only 86 (9.9 percent) of the number studied were evacuated because of their chest injuries and disability resulting from them.

Beyond these generalities, it is difficult to go. It was impossible to obtain adequate followup studies overseas. It is thought that perhaps from 40 to 45 percent of all patients with thoracic injuries could be kept on duty in the theater following hospitalization, but how many were later admitted to other hospitals because of symptoms and disability and how many of these were sent to the Zone of Interior remains unknown. It is unfortunate that prolonged observation was not possible during the war on a sufficiently large group of patients to warrant conclusions concerning the sequelae of intrathoracic wounds. It was these sequelae, actual or potential, which influenced ultimate disposition.

There were not many deaths in general hospitals and chest centers. Those which occurred were chiefly due to the complications for which the patients were under treatment.

The figures reported by Maj. (later Lt. Col.) William M. Tuttle, MC, and his associates from the thoracic surgery service at the 36th General Hospital, showed 2 deaths in 320 cases. Of the surviving 318 patients, 20 percent were returned to full duty and 33 percent to limited duty in the theater. The remainder were evacuated to the Zone of Interior. These statistics are typical of immediate results at other general hospitals and chest centers. That all of the soldiers who were returned to full or limited duty were able to maintain a duty status is in the highest degree doubtful.


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References

1. Beebe, Gilbert W., and DeBakey, Michael E.: Battle Casualties: Incidence, Mortality, and Logistic Considerations. Springfield: Charles C. Thomas, 1952.

2. Snyder, Howard E.: Fifth U.S. Army. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington: U.S. Government Printing Office, 1962, pp 333-464.

3. Kendrick, Douglas B., Jr.: The Blood Program. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington: U.S Government Printing Office, 1962, pp. 121-163.

4. Medical Memorandum No. 3, Office of the Surgeon, Headquarters, Eastern Base Section, 7 July 1943, subject: Surgical Policies for Bizerte-Ferryville-Mateur Area of EBS, Effective July 1943.

5. Forsee, J. H., Shefts, L. M., Burbank, B., Fitzpatrick, L. J., and Burford, T. H.: The Management of Thoracic War Injuries. J Lab. & Clin. Med. 28: 418-440, January 1943.

6. Carter, B. N., and DeBakey, M. E.: Current Observations on War Wounds of the Chest. J. Thoracic Surg. 13: 271-293, August 1944.

7. Medical Department, United States Army. Surgery in World War II. General Surgery. Volume II. Washington: U.S. Government Printing Office, 1955.

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