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Chapter V

Contents

CHAPTER V

Administrative Considerations in the Zone of Interior

Brian Blades, M.D., B. Noland Carter, M.D., and Michael E. DeBakey, M.D.

When the United States entered World War II, thoracic surgery was not yet a fully developed specialty. The American Association for Thoracic Surgery, stimulated by the advances in the specialty in World War I, had been formed in 1918, but The Board of Thoracic Surgery, Inc., was not set up until 1948. The amount and variety of thoracic surgery performed at the various chest centers overseas and in the Zone of Interior provided a stimulus that took this specialty out of tuberculosis sanatoriums and initiated its postwar advances.

THE CONSULTANT IN THORACIC SURGERY

No consultant in thoracic surgery was ever formally appointed in any oversea theater during World War II, probably because of the still uncertain status of this specialty at the beginning of the war. In the Zone of Interior the situation, fortunately, was different. In July 1942, Capt. (later Col.) Brian Blades, MC, was assigned to Walter Reed General Hospital, Washington, D.C., with the specific mission of setting up a thoracic surgery service. Shortly afterward, he was appointed Consultant in Thoracic Surgery, Office of The Surgeon General, and he served in both positions until the end of the war.

When Captain Blades assumed his duties at Walter Reed General Hospital, there was no thoracic surgery service there or at any other hospital in the Army system. At Walter Reed General Hospital, however, thoracic surgery had a status of sorts. This was chiefly because of the continuing influence of Col. William L. Keller, MC, who, almost singlehandedly, had cleaned up the backlog of chronic chest infections that were the heritage of World War I. His work was so brilliant that the most eminent chest surgeons of the day came long distances to observe it.

The connecting link between Colonel Keller and the thoracic surgeons who came to Walter Reed General Hospital in the first months of World War II was Col. (later Maj. Gen.) Norman T. Kirk, MC, who had served under


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Colonel Keller and who had maintained his interest in chest surgery after the latter retired.

Incidentally, it was the vivid recollection of the chronicity of those World War I infections and the length of time-almost 10 years-it had taken to dispose of them that made General Kirk, then The Surgeon General, so unwilling to release thoracic surgeons from service at the end of World War II.

In July 1942, when Captain Blades assumed his duties at Walter Reed General Hospital, there were not more than a dozen civilian clinics and centers in the United States at which thoracic surgery was being done as a separate specialty or in any volume. Some tuberculosis surgery was being done at Fitzsimons General Hospital, Denver, Colo., but at the Walter Reed General Hospital, chest surgery was chiefly limited to the type being done just after World War I. In September 1942, when Captain Blades did the first pneumonectomy performed at any Army hospital, it was characteristic of the opinion then held of the operation that there was considerable disapproval of his boldness in undertaking it. The patient, fortunately, made an excellent recovery.

By the time the first casualties arrived from North Africa, late in 1942, the thoracic surgery service, which had originally shared a ward with the neurosurgical service, had its own ward and its own personnel. In March 1943, Walter Reed General Hospital was designated as a thoracic surgery center (p. 171), and as such it continued to expand until the end of the war. It is interesting to recollect, since it was the first thoracic surgery center to be designated in World War II, that it had served the same purpose in World War I, under Colonel Keller's direction.

In his capacity as Consultant in Thoracic Surgery to The Surgeon General, Captain Blades responded to requests for advice from that office or offered advice himself as the situation demanded. Relations between himself and the personnel of the Office of The Surgeon General were always cordial and close. General Kirk, as already mentioned, had a special interest in thoracic surgery because of his association with Colonel Keller, and with Maj. (later Col.) Michael E. DeBakey, MC, and Lt. Col. (later Col.) B. Noland Carter, MC, of the Surgical Consultants Division, who had practiced this specialty in civilian life. There was therefore a meeting of minds on policies and practices.

One of Captain Bladies' duties as Consultant in Thoracic Surgery to The Surgeon General was the inspection of thoracic surgery centers. Each of these centers was visited at 3- or 4-month intervals during the war, and occasionally, if special problems required solution, they were visited oftener. This necessity, however, was not usual. All of the centers were directed by well-trained and experienced thoracic surgeons, and while there were sometimes differences of opinion about details, there was practically always complete agreement upon principles.


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SUBCOMMITTEE ON THORACIC SURGERY, DIVISION OF MEDICAL SCIENCES, NATIONAL RESEARCH COUNCIL

The Subcommittee on Thoracic Surgery was one of the numerous subcommittees formed by the Division of Medical Sciences, National Research Council, to act in an advisory capacity to the Surgeons General of the Army, Navy, and Public Health Service (1). Its membership consisted of Dr. Evarts A. Graham, Chairman, Dr. Isaac A. Bigger, Dr. Edward D. Churchill, Dr. Leo Eloesser, Colonel Keller, Col. (later Brig. Gen.) Charles C. Hillman, MC, Capt. (later Col.) James H. Forsee, MC, and Comdr. (later Rear Adm.) Frederick R. Hook, USN (MC).

The general functions of the Subcommittee on Thoracic Surgery were to give advice on the organization of hospitals from the standpoint of thoracic surgery, on the care of thoracic wounds, and on any other phases of thoracic surgery on which advice might be required. This Subcommittee was also to consult with the Subcommittee on Anesthesia, National Research Council, which was organized a little later, and to prepare a small manual on thoracic surgery. Work on this manual had already begun (p. 167) when the Subcommittee was organized.

The Subcommittee on Thoracic Surgery held two meetings, the first on 25 July 1940 (1), before the United States entered the war, and the second on 16 January 1942 (2), some six weeks after Pearl Harbor. At both meetings, the chief discussions concerned thoracic surgery personnel, and at the first, the general point of view seemed somewhat unrealistic, the chief dissenter being Colonel Keller. Contrary to the views of most of those present, he doubted that the supply of trained thoracic surgeons would be in any way adequate to the demand. In his opinion, therefore, these surgeons should be carefully assigned and employed only in the largest installations, where they could be utilized to their full capacity. He repeatedly emphasized that the more generous assignments visualized by the other members of the Subcommittee must be regarded as tentative. By the second meeting, others had come to share Colonel Keller's views.

It is a great pity that the potentialities of the Subcommittee on Thoracic Surgery were not utilized as they might have been. There was no real liaison between it and the operating personnel responsible for thoracic surgery in the Office of The Surgeon General. Some of its members, particularly Dr. Graham and Colonel Keller, had had extensive military experience in World War I, and this experience might have been of great value, and prevented many errors, if it had been properly utilized in World War II. In retrospect, it almost seems that the Subcommittee met and made its suggestions in a vacuum. Certainly its advice did not reach the quarters in which it might have been useful.


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PERSONNEL

By 1938, the American Association for Thoracic Surgery, which had been formed in 1918, had 14 honorary members, 99 active members, 69 associate members, and 30 senior members. It was from the group of active and associate members that the thoracic surgeons who served as directors of thoracic surgery centers, as heads of thoracic surgery services, and as members of thoracic surgical teams were chiefly drawn; they numbered 168. As already pointed out, The Board of Thoracic Surgery, Inc., was not founded until after the war, and the reservoir of qualified specialists provided by diplomates of other boards thus did not exist for thoracic surgery.

One of the more useful actions of the Subcommittee on Thoracic Surgery was to group the membership of the Association, on the basis of their qualifications, for the use of The Surgeon General in assignment, as follows (2):

Class I, capable of being a consultant in thoracic surgery.

Class II, capable of being the chief of the thoracic surgical service in a large hospital.

Class III, capable of being an assistant chief of the thoracic surgical service in a large hospital or chief of service in a small hospital.

Class IV, capable of being a ward officer or assistant ward officer on a thoracic surgery ward.

On Dr. Churchill's suggestion, a supplementary list of thoracic surgeons was obtained by writing to all the surgeons in classes I and II and requesting them to submit the names of young surgeons who had received all or part of their training in thoracic surgery under their supervision within the last 5 years.

Early in the war, the assignment of thoracic surgery personnel was far more difficult, and far less satisfactory, than it should have been because the Personnel Division, Office of The Surgeon General, made assignments arbitrarily, without full knowledge of the capabilities and experience of the specialists involved, and without consultation with the Surgical Consultants Division, Office of The Surgeon General. As a result, there were some wasteful misassignments. A medical officer, for instance, born in China and speaking Chinese, requested an assignment for thoracic surgery in the China-Burma-India theater, where his peculiar combination of abilities would have made him most useful. He was assigned to making physical examinations in the North Atlantic Patrol, and it required almost a year to change his assignment.

Eventually, after about a year of difficulty, The Surgeon General issued an order that no assignments were to be made in the surgical specialties without the approval of the Surgical Consultants Division of his office. It was still necessary, as it was to the end of the war, to locate thoracic surgeons by personal contact with the heads of civilian services, but at least the misassignments made early in the war were practically ended.


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The Consultant in Thoracic Surgery was, of course, consulted by the Surgical Consultants Division on all personnel assignments and was of great help in making them.

TRAINING

The possibilities of training in thoracic surgery were considered at the first meeting of the Subcommittee on Thoracic Surgery, Division of Medical Sciences, National Research Council, in July 1940 (1). The question had already been discussed by the parent Committee on Surgery, with special reference to the training of Reserve officers, but nothing had been done because of lack of funds.

It was the opinion of the Subcommittee that more thoracic surgeons should be trained, and all who were present at the meeting expressed themselves as glad to assist if funds could be made available. There were, however, fundamental differences of opinion as to the courses to be set up. Colonel Hillman thought that they should not be longer than 2 weeks. Dr. Graham thought that nothing desirable could be accomplished in less than 2 or 3 months.

Training was again discussed when the Subcommittee met on 16 January 1942 (2). There was general agreement that it was feasible to train thoracic surgeons for the Army in civilian hospitals. Dr. Churchill displayed a map of the United States on which he had designated certain large civilian clinics which could provide the necessary facilities and personnel. Three months was considered the minimum length for the courses, and Dr. Churchill thought that, in certain instances, officers assigned for this training might be of greater eventual value to the service if they were retained for longer periods of instruction. It was agreed that officers assigned to these courses should be selected most carefully. If they proved unsuitable for the work, or if they did not apply themselves, the Office of The Surgeon General would be notified at once and they would be relieved from the assignment.

The Subcommittee agreed to advise The Surgeon General shortly of the availability of courses in thoracic surgery in civilian institutions which could be attended by medical officers.

The courses were set up at Columbia University, New York, N.Y., The University of Michigan, Ann Arbor, Mich., the University of Pennsylvania, Philadelphia, Pa., and Washington University, St. Louis, Mo. Like the similar courses in neurosurgery, these intensive courses proved a very satisfactory way of providing intensive training in thoracic surgery for men who already had some training in general surgery. In the beginning, the selection of students was not handled as wisely as it might have been. Those selected did not always have a background of general surgery, and it was sometimes difficult to see on what basis they had been chosen. Inappropriate volunteers were also permitted. Eventually, these difficulties were straightened out, and the end results were excellent. The majority of the graduates were sent overseas, where many of them rendered outstanding service in various capacities in thoracic surgery


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centers and on thoracic surgery services. A few were retained in this country. It is interesting to note that one or two of the most outstanding graduates had begun this course with great reluctance and with no interest at all.

In spite of the casual fashion in which students for these courses were originally selected, the instruction was frequently of great value from the standpoint of the medicomilitary effort. Sometimes, in addition, it had a great impact upon the careers in service and the future medical careers of some of the students. The following letter from Dr. (formerly Maj., MC) David J. Dugan, written in response to an inquiry concerning his instruction at the University of Pennsylvania, makes this quite clear. Dr. Dugan wrote, in part, as follows:

My enrollment in the thoracic surgery course at the University of Pennsylvania was entirely unsolicited. I was doing general surgery in Cleveland before I entered the service in September 1942. I was assigned to Walter Reed General Hospital, but as soon as I arrived I received orders to report to the University of Pennsylvania to take a course in thoracic surgery, a specialty I barely knew existed. There were nine in the class. At the same time, courses were being given there for medical officers in neurosurgery and in surgery of the extremities. Both courses, as I recollect, had enrollments of 30 to 35 officers. Thoracic surgery was certainly in the minority.

The object of all these courses was to train general surgeons in these particular specialties, so that they would have additional knowledge and experience when they were sent overseas, which, we understood, would be as soon as the courses were completed.

The thoracic surgery course lasted for 6 weeks. There were daily lectures, from 8 to 12, attended by the men in all three courses, and given by physiologists, biochemists, and anatomists. They were very general, and much of the time was spent on antibiotic therapy, then very new. These lectures were excellent.

In the afternoons, the students in the thoracic surgery course went to the various hospitals in Philadelphia, particularly to observe endoscopic work. We had no practical experience, but we did have the opportunity to observe such men as Clerf and Chevalier Jackson while they were at work. We also operated on cadavers in the afternoons, an experience I found very valuable, for we worked under the supervision of Dr. Batson, then Professor of Anatomy at the University of Pennsylvania, who had a remarkable ability to combine the academic and clinical aspects of anatomy. It was a real privilege to study anatomy under him.

An examination was given at the end of 6 weeks, and while none of us, so far as I know, ever found out how we had done, we all had the impression that our grades would determine how far away from home we would be sent. Whether that rumor was true I never found out.

At any rate, at the end of the course, I was sent back to Walter Reed. Almost as soon as I arrived, a large convoy of chest casualties was received, and my only qualification for assisting in their care was the 6 weeks' course I had just completed. Fortunately, my work was done under the supervision of Colonel Brian Blades, who was in charge of the thoracic surgery service at Walter Reed throughout the war.

I worked under Colonel Blades for the next 3 years, then was put in charge of the thoracic surgery service at Fitzsimons General Hospital in Denver until I was separated from service in September 1946.

The course at the University of Pennsylvania, although it was a totally unexpected introduction to my Army service, was a real delight and completely altered my medical career. When I left the Army, I came to Oakland, Calif., and I have been engaged here since in the private practice of thoracic surgery.


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ANESTHESIA

Anesthesia for intrathoracic surgery was generally satisfactory at the beginning of the war, since competent anesthesiologists, equipped to give intratracheal anesthesia, were available in all hospitals in which such surgery was done. It became increasingly satisfactory as the war progressed, as anesthesiologists gained experience, and as more of them became available through formal and informal training.

Equipment for anesthesia was uniformly good. Dr. Joseph Kreiselman, Consultant in Anesthesia to The Surgeon General, was of great assistance in the selection of the most efficient equipment for special techniques as well as for general techniques.

EQUIPMENT

The thoracic surgery equipment which Captain Blades found when he assumed his duties at Walter Reed General Hospital in July 1942 was chiefly that used for the operations performed after World War I. These deficiencies were shortly corrected by provision of the list of supplemental instruments drawn up by Dr. Eloesser and Colonel Kirk (2), which were supplied to all hospitals. As a matter of fact, most thoracic surgery was then-and still is-done with the instruments used in general surgery, and these were in ample supply.

Instruments for thoracic surgery were eventually of the highest quality and were provided in sufficient numbers, though those used by the hospitals supporting the North African invasion in November 1942 were deficient in both quality and quantity (p. 84). Part of Captain Blades' duties as Consultant in Thoracic Surgery to The Surgeon General concerned the revision of the lists of thoracic surgery equipment.

MANUAL ON THORACIC SURGERY

The work of the Subcommittee on Thoracic Surgery on a manual on this subject was initiated 10 July 1940, when Colonel Hillman, Chief, Professional Service Division, Office of The Surgeon General, notified Dr. Graham that among the technical manuals which his office considered necessary was one on thoracic surgery. He requested that Dr. Graham submit to him a list of subjects that should be covered in such a text.

Two weeks later, when the first meeting of the Subcommittee was held (1), a considerable start had been made on this book. The members of the Subcommittee were asked to study and comment on the 40 pages already prepared, and Dr. Eloesser, who had worked on the material with Dr. Graham, displayed a chart that tabulated the material to be included in the text and which was suitable for use in operating rooms.


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In discussing the manual at this meeting, Colonel Hillman stated that he wished the book to be loose-leaf, to be very brief, and to cover the treatment of chest injuries only from wounding until the casualty reached an evacuation hospital. The book was not to include definitive treatment, since the medical officers responsible for that phase of therapy would not need such a book. Colonel Hillman thought that a list of texts should be included. It was his idea that the manual be distributed only to medical officers responsible for first aid; the expense of a wider distribution would be too great.

Shortly before this meeting, Dr. Graham had written Colonel Hillman that the preparation of this manual had become more complex than he had anticipated. The final revision was not accomplished until the meeting of the Subcommittee on Thoracic Surgery on 16 January 1942 (2), when both the text and the illustrations were approved. By this time, the original concepts had been altered in a number of respects. The manual, which is described in detail elsewhere (p. 190), did not appear until 1943 (3), and did not play the role that had been visualized for it.

THORACIC SURGERY CENTERS

Historical Note

In World War I, certain hospitals were staffed and equipped by the Medical Department for the care of special groups of casualties. There were no thoracic surgery centers, as might have been expected. At that time, few surgeons were qualified in this specialty or interested in limiting their activities to diseases and injuries of the chest. In a few hospitals, suppurative pleuritis was segregated, but the patients with this condition were usually cared for on septic surgery sections. In any event, segregation went no further.

In the interval between the World Wars, a limited amount of specialization became the policy in Army hospitals, but it was chiefly confined to radiology and neuropsychiatry. If specialized surgery was required, it was provided by civilian surgeons working under contract.

Evolution of Policies

In 1939, when planning began for the war that seemed imminent, changes in the tables of organization of hospital units began to reflect the civilian tendencies toward increased specialization (4). New tables published during 1940 listed, for the first time, the specialists required to serve as chiefs of professional services and as ward officers. These tables also allotted to hospitals more enlisted men with specialist ratings and correspondingly fewer with only basic military training. The total number of officers and enlisted men assigned to hospitals was also increased. In a 1,000-bed general hospital, for instance, the number of officers was increased from 42, of whom 30 were medical officers,


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to 73, of whom 55 were medical officers. The number of enlisted men assigned to such a hospital was also increased, from 400 to 500.

As increasing numbers of specialists in various fields entered the Army, civilian emphasis upon specialization began to be reflected in Army policy. By the end of 1942, The Surgeon General made it clear that he intended to formalize and extend this policy. The circumstances were ripe for his action.

By this time, new general hospitals were beginning to open one after another, and it was soon clear that the limited supply of specialists in various fields would not be sufficient to permit the staffing of each of them for all varieties of medical and surgical work. At the same time, with the transition from defensive to offensive warfare which occurred with the invasion of North Africa, the Medical Department was obliged to visualize the arrival in the Zone of Interior of increasingly large numbers of combat casualties who would require specialized treatment. The plan of specialized centers therefore began to take shape.

There was, however, a serious obstacle to its implementation. In the fall of 1942, there was growing public insistence that casualties should be hospitalized as near as possible to their homes, and in December of that year, The Adjutant General proposed the establishment of hospitalization policies to meet this demand. If these policies had been adopted and applied rigidly, they would have conflicted with The Surgeon General's (still unpublicized) plan to transfer casualties who required specialized treatment to hospitals specializing in the treatment of particular diseases or injuries.

The Surgeon General proposed to resolve the conflict in two ways:

1. By sending patients who needed specialized treatment to general hospitals designated to supply such treatment.

2. By sending those who required prolonged, but not specialized, treatment to hospitals in the vicinity of their homes.

This policy was announced on 1 February 1943. For the next several weeks, the Hospitalization and Evacuation Division, Office of The Surgeon General, worked on the problem, and on 6 March 1943, upon their recommendation, the War Department designated 19 general hospitals for the treatment of 6 specialties, including chest surgery.

In 1939, only two hospital centers were conceived of in the medical planning,1 and until the middle of 1944, specialty centers in general hospitals were established piecemeal, to meet needs as they arose, without regard to eventual requirements. Up to this time, too, the beds allotted for specialized treatment in general hospitals occupied only a small proportion of the total hospital bed capacity.

1At the first meeting of the Subcommittee on Thoracic Surgery, there had been some discussion about concentrating casualties with thoracic injuries in specialized hospitals, but the plan was not then considered practical.


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There were at least two reasons for this chaotic situation:

1. An army in training, which the U.S. Army was, for the most part, in the first months of the war, had less need for specialized services than an army in combat.

2. Early in the war, it was difficult to predict the types and amounts of specialized care that would be needed. In the summer of 1944, the Facilities Utilization Branch, Office of The Surgeon General, engaged in a study of the anticipated need for specialized centers and the preparation of a comprehensive plan to meet it. By the time of the invasion of Europe, enough casualties had been received from the North African theater and from the Pacific to permit the breakdown of the anticipated casualty load in terms of wounds, injuries, and diseases.

The general features of this plan, which were announced in War Department Circular No. 347, issued on 25 August 1944, remained in effect throughout the war. They were as follows:

1. As far as practical, related specialties were grouped in the same hospital centers, in order to improve the quality of professional care.

2. Attempts were made to locate centers for specialized treatment in relation to population density, to permit the utmost compliance with the policy of hospitalizing patients as near their homes as possible. Success in this respect was limited by several considerations. One was the uneven initial distribution of hospitals: there were proportionately fewer hospitals in the densely crowded areas of the northeastern United States than there were in the South and Southwest, where, logically, they had been located to serve large concentrations of troops in training. Another reason for difficulty in hospitalizing patients in need of specialized care was that all specialties did not require the same number of centers. Neurosurgical and orthopedic casualties, for instance, required provision for many times the numbers of beds required for blinded and deafened casualties.

There was some disagreement concerning the most useful size for the centers. Professional consultants in the Office of The Surgeon General preferred that they be kept reasonably small. The Facilities Utilization Branch in that office considered it more economical to limit the number of centers and increase their size, in view of the increasing shortage of specialists, which required them to be so assigned that they could be utilized to the fullest.

As the patient load increased, much of this argument became academic. In the last months of the war, some centers had 2,000 or more beds, and in a number of instances, general hospitals became, in effect, specialized hospitals. When the peak of the patient load in the Zone of Interior was reached, in June 1945, there were 234 centers for treatment of the various specialties, located in 65 hospitals, and with a total of 132,178 beds.

Operation of hospital centers for thoracic surgery in the Zone of Interior was attended with all the advantages of their operation in oversea theaters (p. 98). In addition, these centers offered unusual opportunities for the


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study of diseases of the chest, many of which are seen in too small numbers in civilian practice to permit conclusions as to their management.

Thoracic surgery centers also had another highly practical advantage. The strict regulations that required patients in need of thoracic surgery to be sent to them kept surgeons untrained in this specialty from performing operations for which they were not qualified. This was an important consideration at a time when thoracic surgery was still a developing specialty.

Location of Centers

Four thoracic surgery centers were designated on 6 March 1943, at Walter Reed General Hospital, Fitzsimons General Hospital, Kennedy General Hospital, Memphis, Tenn., and Hammond General Hospital, Modesto, Calif. Within a short time, it was evident that these four centers would be unable to handle the anticipated patient load, and in May 1943, Brooke General Hospital, San Antonio, Tex., was also designated as a center for thoracic surgery. Bruns General Hospital, Santa Fe, N. Mex., although it was never formally designated as a chest center, received most casualties with tuberculosis who required surgery and also received a small number of patients who required chest surgery for other reasons.

In August 1944, Baxter General Hospital, Spokane, Wash., was designated as a chest center, to replace the center at Hammond General Hospital. In July 1945, consideration was given to relocating the center at Walter Reed General Hospital, partly for administrative reasons and partly because a thoracic surgery center was needed in the northeastern United States. Halloran General Hospital, Staten Island, N.Y., was recommended for this purpose, but the Hospital Planning Division did not agree, and the chest center at Walter Reed General Hospital was maintained even after other chest centers were closed.

Facilities and Equipment

Some thoracic surgery centers occupied existing facilities throughout the period of their operation. At Fitzsimons General Hospital, for instance, active surgical patients were treated in two wards of 163 beds, with 23 of the 196 beds assigned to the chest service reserved for tuberculosis surgery. Ambulatory convalescent patients were cared for in outlying wards while awaiting ultimate disposition.

At Baxter General Hospital, the special facilities constructed for the chest center were not ready until 1 October 1945. They included offices for the director of the center and his assistants, conference rooms with view boxes, a recovery ward for postoperative patients (with provision for bedside oxygen and negative pressure suction), a complete roentgenologic and fluoroscopic unit, a central dressing room for ambulatory patients, an operating room for minor surgery and bronchoscopy, and kitchen facilities for the postoperative recovery ward.


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After the first months that the centers were operated, instruments and other equipment were generally both excellent and plentiful. There were, however, occasional exceptions. Thus in March 1945, the center at Baxter General Hospital still had no Heidbrink anesthetic machines, which were urgently needed for efficient intratracheal anesthesia. Intratracheal anesthesia could be given with the equipment available, but patients would have been anesthetized more safely and more easily had the proper specialized equipment been provided.

Policies and Practices

As part of the planning for special centers in the summer of 1944, Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery, Office of The Surgeon General, wrote to the Chief, Personnel Service, in the same office, that for a thoracic surgery center of 350 beds, he considered that minimum personnel should consist of a chief of service, an assistant chief, and two ward officers. This minimum was always met, in spite of the shortages of thoracic surgeons, and on busy services, it was frequently exceeded.

When the thoracic surgery center at Baxter General Hospital was opened, a medical consultant with wide experience in diseases of the chest was assigned jointly to the medical service and the thoracic surgery center, as liaison officer. This greatly facilitated consultation procedures. Similarly close liaison was established with the Radiology Section by the appointment of a junior officer to work on both services. At daily conferences, all newly taken roentgenograms were jointly reviewed by the roentgenologist, the staff of the surgical center, and the liaison officers. Treatment was facilitated and its quality greatly improved by these conferences, which, in one form or another, were held at all centers.

A certain proportion of the patients assigned to chest centers, averaging about 20 percent, required consultation with, and treatment by, other specialists. This was especially true of casualties with neurosurgical and orthopedic injuries. No time was lost in seeking these consultations, and the turnover of beds was rapid. At the Fitzsimons General Hospital chest center, the average period of hospitalization was less than a month.

Clinics for diagnostic procedures, and, occasionally, for therapeutic procedures, were an important phase of the work of all centers. In 1944, the clinic at Fitzsimons General Hospital carried out 1,665 such procedures, including 35 laryngoscopies, 474 bronchoscopies, 52 gastroscopies, 513 fluoroscopies, 23 esophagoscopies, 462 bronchographies, 71 other installations of contrast media, and 35 dilatations of the esophagus.

Associated Convalescent Hospitals

When convalescent hospitals were first opened in the Zone of Interior in 1944, they were frequently established on the same posts as general hospitals. At first, most of them were administered under separate commands and with


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a separate administrative organization for the control of patients and all other activities. Later, convalescent hospitals were operated as hospital centers, a policy which had a number of advantages. Under it, the administration, supply, and service activities of both installations were carried out in a single headquarters, which freed hospital commanders of much administrative detail, reduced personnel, and eliminated duplicating and overlapping effort.

Centralization also made it easier to shift personnel between the hospitals and the convalescent centers as they were needed. One of the chief advantages was the operation of a single registrar's office for both installations. This made it possible to move patients from one to the other by simple internal transfer rather than by the complicated procedures necessary when they were moved between separate installations.

The thoracic surgery centers began to close before final plans for the most efficient operation of the convalescent hospitals in connection with them could be put into effect.

REPORTS OF THORACIC SURGERY CENTERS

The methods of operation and the experiences of the thoracic surgery centers in the Zone of Interior varied in details, but policies and practices were much the same in all. The experiences of the Kennedy General Hospital thoracic surgery center during the war and of the Walter Reed General Hospital thoracic surgery center after the war are presented as typical.

Kennedy General Hospital

Population-The chest surgery service at Kennedy General Hospital began in June 1943, with a few patients in a single ward.2 At the end of the year, the service had an average census of 40 patients. By the end of 1944, it had spread to five wards, and the average daily census was more than 400. During 1944, 721 of the 6,237 hospital admissions were to the thoracic surgery service. During 1945, when the capacity of the center was 350 beds, 2,268 of the 12,813 hospital admissions were to the center. During this same year, 1,502 of the 6,010 operations performed were for chest conditions; the figures include 833 endoscopies.

Personnel-Lt. Col. Richard H. Meade, MC, was in charge of the chest service at Kennedy General Hospital from its inception until 1 December 1945. The medical officers originally assigned to the center, who remained for varying lengths of time, had had no training in chest surgery with a single exception, Capt. William I. Glass, MC. Maj. (later Lt. Col.) Felix A. Hughes, Jr., MC, who had a good background in thoracic surgery, was attached to the center on 22 July 1944. At various times thereafter, a number of other experienced chest surgeons arrived, including Maj. (later Lt. Col.) Earle B. Kay, MC, who had headed the chest service at Percy Jones General Hospital,

2This report was prepared by Lt. Col. Richard H. Meade, MC, in December 1945.


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Battle Creek, Mich.; Capt. Lawson S. Whitaker, Jr., MC, who had had a wide experience in the South Pacific; Capt. Joseph Estrin, MC; Maj. Theodore R. Hudson, MC; and Maj. Julian Johnson, MC, who had previously been assigned to the China-Burma-India theater.

The center was most fortunate in the ward officers, the nurses, and the technicians assigned to it. The ward officers included Capt. William B. Blake, Jr., MC, Capt. (later Lt. Col.) Prince D. Beach, MC, Capt. Max A. Forse, MC, and Capt. Henry G. Mundt, Jr., MC. Captain Blake and Captain Beach assisted in the operating room, in addition to their ward duties. Captain Forse and Captain Mundt for a long time had charge of the wards through which the patients passed who needed little treatment; they kept the rate of disposition on these wards at a very high level. Nursing care was under the supervision of Lt. Alison Bolyea, ANC. T. Sgt. Samuel P. Crucilla was in charge of dressings and also handled intravenous therapy for all critically ill patients.

Additional personnel were assigned to the Kennedy General Hospital thoracic surgery center, chiefly for training purposes. They included medical officers from Lawson General Hospital, Atlanta, Ga., from 1 January to 3 March 1944; from the 141st General Hospital, which was stationed on the reservation from 1 January to 10 June 1944; and from the 4th Auxiliary Surgical Group, surgeons from which were assigned to the center on detached service.

In spite of the help furnished by these officers, the ratio of patients to officers was usually undesirably high. It required unceasing effort to keep the backlog of operations and dispositions under control.

Organization and operation-Patients were received in the center from overseas, from other hospitals in the country, and from other services at the Kennedy General Hospital. Each week, at a special conference of the staff of the center, all new patients were discussed, and the problems that concerned them and other patients were worked over and settled. The staff of the center had excellent cooperation from all other services in the hospital.

In addition to the wards occupied by bed patients, the center had other space which could be designated for such special purposes as they wished. Until late in 1944, operations were done in the general operating rooms. Thereafter, the center had its own operating room.

While battle casualties accounted for most admissions to the center, the majority of the surgical work performed was for conditions unrelated to warfare. After his assignment, all lesions of the esophagus were handled by Major Kay. The remainder of the surgery was quite evenly distributed among the other thoracic surgeons.

Battle casualties-Up to December 1945, more than 1,950 patients with battle wounds had been admitted to the center. The great majority had been so well treated overseas that they required little major surgery. The principal treatment necessary was maintenance of previously established drainage of empyema. The distribution of cases was as follows:


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1. Of 113 patients with chronic empyema, 99 had sustained combat wounds. Of these, 76 were treated by drainage, 28 by decortication, and the remainder by some form of thoracoplasty.

2. Of 113 patients who had had decortications overseas, 91 had healed wounds when they were admitted. The remaining 22 had empyema or had draining wounds which required treatment.

3. In all, 64 operations were done for the removal of foreign bodies. Only those objects were removed that were more than 1 cm. in diameter; were giving rise to symptoms; were irregular; or were in contact with the esophagus or with some other structure that, it was feared, might be damaged by the contact.

4. A number of patients had defects of the chest wall, but operation was done in only five cases, in which the location of the defect introduced elements of danger. In two instances, the defect was over the heart, and the soft tissues were adherent to the pericardium; in both cases, the insertion of a protective plate was thought safer than an attempt at plastic repair.

5. The majority of the 21 operations for diaphragmatic hernia were done for residua of perforating wounds of the diaphragm or crushing injuries. Several of these hernias, which are discussed in detail elsewhere (vol. II, ch. IV), were not apparent until several months after the original injury.

6. The 19 patients with lung abscess were all treated by drainage and all recovered.

7. The single patient with suppurative pericarditis was treated by drainage and penicillin and recovered smoothly.

Non-combat-incurred lesions.-Operations for civilian-type thoracic lesions at Kennedy General Hospital were distributed as follows:

1. The most frequent disease for which surgery was required was bronchiectasis, for which 129 lobectomies were done, with 1 death. These lobectomies are analyzed in detail elsewhere (vol. II, ch. X). Two total pneumonectomies were also performed for bronchiectasis.

2. The next most frequent indication for lobectomy was pulmonary cysts, for which 14 operations were done. Other indications included tuberculosis in two cases, on the mistaken diagnosis of infected cysts; bronchial adenoma (two cases); chronic suppurative lesions which did not respond to simple drainage (three cases); and actinomycosis (one case). There were no deaths in these 22 operations.

3. In addition to the 2 pneumonectomies already mentioned for bronchiectasis, this operation was performed in 14 other cases, for bronchial adenoma (6 cases, in 1 instance malignant); for carcinoma (2 cases); for chronic nonspecific inflammation (2 cases); for bronchial stenosis (2 cases); and for actinomycosis and multiple cysts (1 case each).

There were 3 deaths in these 16 pneumonectomies, 2 on the operating table, as the result of complete blockage of the contralateral bronchial tree with tenacious mucoid material; both occurred immediately after removal of the


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involved lung, though in both, there had been repeated aspirations of the tracheobronchial tree during operation.

Three of the patients who had undergone pneumonectomy later required thoracoplasty. The others did well.

4. Tumors or cysts were removed from the mediastinum in 19 instances. Subtotal removal of the growths in two other instances ended fatally. One patient had a malignant teratoma, and death was caused by cerebral anoxia during operation. The other patient, who had a tumor of the thymus associated with myesthenia gravis, died of his disease.

In a number of other instances, exploratory thoracotomy was carried out, but the malignant lymphomas and other tumors thus revealed were considered inoperable.

5. Although the Kennedy General Hospital thoracic surgery center was not intended for the treatment of pulmonary tuberculosis, it treated five patients who were receiving therapeutic pneumothorax and all of whom were referred for division of adhesions. This proved possible in only one instance. The other four patients underwent thoracoplasty, with excellent results in all.

6. Ten patients with chronic spontaneous pneumothorax of nontuberculous origin, which had lasted from 2 to 18 months, were treated surgically. In three instances, the pneumothorax was the result of rupture of large pulmonary cysts. In two instances, only a small amount of pulmonary tissue had to be removed along with the cyst. In the third case, subtotal resection of the lobe that contained the cyst was necessary. In one case, the only surgery necessary was division of a band of adhesions that was maintaining the patency of a bronchopleural fistula. In the six remaining cases, the procedure was limited to removal from the pulmonary surface of the constricting thickened pleura that had apparently followed the complete collapse of the lung after rupture of a peripheral bleb. In all instances, there was prompt reexpansion of the collapsed lung.

In an additional case, a patient with three recurrences of chronic spontaneous pneumothorax over a 2-year period refused surgery, and complete expansion of the lung finally occurred without it.

7. The 137 patients treated at the chest center with various lesions of the esophagus are described in detail elsewhere (vol. II, ch. X).

Endoscopy-As in all other chest centers, the performance of peroral endoscopy was a responsibility of the thoracic surgeons. Practically all members of the staff were qualified, and during the period the center was in operation, they performed 966 bronchoscopies, 525 bronchographies, and 50 esophagoscopies.

Results-The excellent results obtained in the lobectomies and other operations performed at the Kennedy General Hospital chest center can be attributed to a combination of factors: The patients were young and in generally good condition. Their wounds had been well handled overseas. Their diseases were usually of relatively short duration. Anesthesia was excellent. Surgery was competent. Adjunct therapy included the liberal use


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of whole blood. Finally, the postoperative nursing care was of the highest quality.

Walter Reed General Hospital

Facilities-In May 1945, facilities for the thoracic surgery center at Walter Reed General Hospital were of four types:3

1. Two open wards, each containing accommodations for from 30 to 45 enlisted men. Additional facilities were obtained as necessary by borrowing beds from other specialty services.

2. A smaller ward containing accommodations for from 15 to 25 officers.

3. Wards for ambulatory enlisted men and officer personnel. These wards were temporary structures on the hospital grounds, capable of accommodating from 50 to 100 patients. These patients reported daily to the central nursing station in the center for dressings or, if necessary, changes of therapy.

4. Convalescent wards at Forest Glen Annex, Forest Glen, Md., a converted girls' school about 3 miles from Walter Reed proper.

Population-The population of the Walter Reed General Hospital chest center consisted of the following groups of patients:

1. Occasional single admissions, particularly transfers from other hospitals in the Zone of Interior.

2. Chest casualties from overseas, who were usually received in groups after they had been returned to the Zone of Interior by plane or hospital ship and had been designated for a chest center after triage at the port of embarkation.

3. Patients from overseas with intrathoracic neoplasms or other chest conditions, which might or might not have existed before induction.

4. Patients with neoplasms or other chest conditions found after induction or on separation from service. Roentgenologic examination was a routine part of the preinduction examination, but neoplasms were occasionally overlooked or, as inquiries of the patients suggested, roentgenograms were occasionally not made. The surprising number of asymptomatic lesions detected on the final survey clearly indicated the advantages of this method of case finding. In all such cases, the patients were referred to chest centers.

5. Patients referred from other chest centers as they were closed. When Walter Reed and Fitzsimons General Hospital chest centers were the only centers to be kept open, patients remaining in the other centers were referred to them. As a result, the Walter Reed chest center did not show the steady decline in population which occurred immediately after the war in other centers for specialized care. Unfortunately, as the patient census rose, the staff of the center suffered a gradual attrition as key personnel in it returned to civilian life.

3No final report of the Walter Reed General Hospital thoracic surgery center was prepared, but at my request, Dr. Donald B. Effler searched his files and his memory and prepared the material summarized herewith. It is of particular value because of the light it sheds upon the opportunities for training in this specialty which were available to a medical officer whose sole concern was the professional care of his patients and his own professional education.-J. B. C., Jr.


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The population of the chest center provided three chief clinical problems: battle wounds, suppurative disease, and tumors. From 60 to 70 percent of the casualties with war wounds arriving from overseas needed no active treatment, simply routine clinical and roentgenologic examinations before discharge. As the war drew to an end, the surgery of trauma decreased, and civilian-type diseases occupied most of the time of the staff; these conditions were not related to military service but were, of course, considered in line of duty. The distribution of the work in chest centers was in contrast to that in neurosurgical and orthopedic surgery centers, in which practically all therapy during their entire period of operation was for combat-incurred injuries.

Organization-The thoracic surgery service at Walter Reed General Hospital did not depend on surgical officers of the day from other services. Instead, it was covered 7 days a week, 24 hours a day, with its own staff. This was probably one of the reasons that disciplinary problems were almost unheard of among the patients on this service.

Departmental conferences, usually informal, were held at least 5 days a week. Here new patients were surveyed, problem cases discussed, and surgical schedules for the following week drawn up. The patients were assigned by the chief of the center (in May 1945, Colonel Blades) to the medical officers best equipped to handle them. Patients were proposed for operation by the various officers on the staff, but all decisions concerning major surgery were ultimately passed on by the chief of service. The schedule for elective surgery was so heavy that it ordinarily ran from 2 to 5 weeks behind.

A tumor board met weekly, at which all patients suspected of harboring neoplasms were presented and discussed. This policy resulted in the best possible care for these patients and also provided a most instructive teaching technique.

There was close liaison with all other departments in the hospital, particularly the departments of anesthesia and radiology. Both furnished excellent supporting services.

Processing and disposition of patients-Many patients with chest injuries received at the Walter Reed General Hospital chest center required no treatment. They were admitted simply for processing and ultimate disposition; that is, either return to duty or separation from service.

Each of these patients was interviewed and examined by a member of the staff of the center, and a complete record was compiled for him. Although this plan sometimes resulted in a duplication of paperwork, it seemed justified: In many instances, the original records had either been lost or were entirely inadequate. Most professional personnel who had treated these patients initially were not thoracic surgeons but harassed medical officers, who were frequently swamped by the tremendous volume of casualties.

This policy was executed smoothly and in a surprisingly short time; one reason for this was the competent service of the Women's Army Corps and civilians who supplied secretarial aid. Each patient thus had a satisfactory,


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complete record that assisted in his disposition and also protected both him and the hospital from the military standpoint.

Patients who had recovered from major surgery were transferred to the convalescent section of the hospital if supportive therapy such as physical medicine or remedial exercises was needed. Otherwise, they were given 30-day sick leaves. When they had returned from leave, they were reexamined, and, if no further professional care was indicated, their disposition was undertaken. If they were to be returned to duty, they were transferred to a nearby reassignment center.

Recommendations for separation from service were made by the staff of the thoracic surgical section, to the surgical staff, and thence to a disposition board, which recommended either retirement or disability separation. As indicated elsewhere (vol. II, ch. IX), a great many patients in World War II were classified as partly or totally disabled because they had undergone lobectomy, excision of nonmalignant tumors, or other chest surgery, or because they harbored retained foreign bodies. In the light of present knowledge, they would not be so classified. During World War II, however, and immediately afterward, the time factor was too short, and knowledge of the specialty was too incomplete, to determine the ultimate fate of the casualty who had undergone major chest surgery. As a result, doubts were resolved in his favor, which worked an economic hardship on the Government. There is no doubt that many a casualty who was honorably discharged on full disability in World War II would now be considered to have undergone a routine elective operation that would not require him to be away from his duties for more than from 6 to 10 weeks.

Clinical policies-Surgical policies at the Walter Reed General Hospital chest center were essentially the same as at other centers. Two points might be commented on:

1. The recovery room that is now standard in most hospitals was a novelty in World War II, and it is believed that the one set up on the thoracic surgery service at this hospital was the first of its kind in Army hospitals, at least in this specialty. It was provided with constant wall suction, oxygen, and other mechanical devices and equipment for routine care and to meet any emergency.

2. Penicillin was used aggressively by the depot technique devised by Romansky.

3. Early ambulation was an important part of the postoperative program, though it was still not generally accepted in either military or civilian hospitals. What this plan really amounted to was the application of outpatient principles to an inpatient service. As soon as a patient was classified as ambulatory, he reported as necessary to the central dressing room, where dressings were changed, sutures removed, and empyema cavities treated. This was excellent treatment for the patient, who recovered his strength much more rapidly when he was permitted to get out of bed promptly. It was also a laborsaving plan,


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for 20 patients could be processed in this manner by the short-handed professional staff in the time it would have taken to care for 5 bed patients. This plan also facilitated the training of new corpsmen.

Training-The quality of the training received at the Walter Reed General Hospital thoracic surgery center is apparent in the comment on it in a letter received from Dr. Donald B. Effler, on 1 September 1960. He wrote, in part:

When I reported to Walter Reed for duty, after a year's internship and 2 years of oversea service, I made it quite clear to Colonel Blades that I had absolutely no knowledge of thoracic surgery. This seemed to delight him, on the ground that he would have one man on the service who would offer no suggestions for changing anything.

*   *   *   *   *   *   *

I received an immediate impression of high professional and patient morale not only in thoracic surgery but throughout the whole hospital. I doubt if any civilian or military institution ever had staff or faculty of a higher overall quality. Administrative problems were always subordinated to patient care. I believe all of the men in the thoracic surgery service are now heads of thoracic surgery departments in important medical schools.

*   *   *   *   *   *   *

The intensive training program offered me was accompanied by a steady increase in my professional responsibilities. This was almost necessary. As the war drew to a close, with the capitulation first of the Germans and then of the Japanese, a mass evacuation of civilian physicians from the Army began. Those who had the most experience and were oldest in service were naturally the most anxious to leave. Along with the attrition of the staff went the increase in the population of the center as other centers closed. At the same time, there was an influx of civilian and military visitors, most of whom were greatly interested in the functioning of the thoracic surgery service. Many ranking medical officers returning from administrative posts overseas also returned to Walter Reed for refresher courses.

*   *   *   *   *   *   *

When Colonel Blades was separated from service, he was immediately appointed by The Surgeon General as civilian consultant in thoracic surgery at Walter Reed. He visited the hospital regularly, and he was always available for telephone consultation, or he would visit the hospital aside front his regular visits if I needed his opinion on any patient. Maj. Vincent M. Iovine, who left the hospital to become chief of surgery at Mt. Alto Veterans Hospital in Washington, also retained his interest in the department and was very helpful to me.

At this time I was still a captain in the U.S. Army Medical Corps, perhaps the only captain in the history of Walter Reed who was chief of thoracic surgery (and also in charge of ward 8, later converted into the Presidential suite). Considerable humor was added to the situation by the fact that my two senior residents were full colonels and my assistant resident a lieutenant colonel (this was Lt. Col. Jack Paul, who 2 years later became chief of the thoracic surgery service). I doubt if in the hospital annals anybody with the rank of captain carried as much professional responsibility or had as much rank under him as I did in the last months of 1946. I was still a captain when I was separated from service January 1, 1947, but I was promoted to major the following day. This was a source of great amusement to many of my friends, as indeed it was to me. But the training at Walter Reed was so superb and the opportunities so tremendous that in themselves they furnished the only reward I wanted.

A letter such as this needs no editorial or other comment.


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REGISTRY OF FOREIGN BODIES

A proposal during the war that a registry of retained foreign bodies be set up, along the lines of the Peripheral Nerve Registry, did not materialize, chiefly because the statisticians consulted did not think it feasible to obtain sufficient controls. After the war, another attempt was made to initiate such a study through the Veterans' Administration, but again the plan did not prove workable. It was easy enough to find patients from whom foreign bodies had been removed but more difficult to persuade patients with retained foreign bodies to report to the Veterans' Administration for observation and roentgenologic studies; many of them frankly stated that they feared the loss of disability pensions. It is unfortunate that the proposed registry could not be established because only such a study will eventually settle the question of whether or not retained foreign bodies should be removed, and, if they should be, on what indications.

References

1. Minutes of meeting, Subcommittee on Thoracic Surgery, Division of Medical Sciences acting for Committee on Medical Research, National Research Council, 25 July 1940.

2. Minutes of meeting, Subcommittee on Thoracic Surgery, Division of Medical Sciences acting for Committee on Medical Research, National Research Council, 16 Jan. 1942.

3. Neurosurgery and Thoracic Surgery. Prepared and edited by the Subcommittees on Neurosurgery and Thoracic Surgery, Committee on Surgery, Division of Medical Sciences, National Research Council. Philadelphia and London: W. B. Saunders Co., 1943.

4. Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1956.

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