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Chapter X



Fourth Service Command

Mather Cleveland, M.D., and James J. Callahan, M.D.

Section I. September 1943 to April 1944

    The Fourth Service Command comprising the southeastern tier of States--North and South Carolina, Georgia, Florida, Tennessee, Mississippi, and A1abama--during 1943 and 1944 had approximately 2 million troops in training. To serve the medical needs of these troops, there were 130 station and 11 general hospitals.

    The Fourth Service Command surgeon, Col. Sanford W. French, MC, with headquarters in Atlanta, Ga., had the services of consultants in medicine, surgery, and psychiatry, and in September of 1943 a consultant in orthopedic surgery. Lt. Col. (later (Co1.) Mather Cleveland, MC, was added. At the time, only one other service command (the Fifth) had an orthopedic consultant.

    The training of troops, ground or air, entailed strenuous physical exercise with many fractures. The sports program probably contributed as many fractures as, if not more than, the obstacle courses. Accidents due to vehicles on and off the post added to this list of injuries to bones and joints. A large percentage of the surgical cases in all hospitals were injuries of this type and were under the care of the orthopedist. Even before casualties began to arrive from overseas, it was obvious that an orthopedic consultant was required for the large service commands.

    Colonel Cleveland's tour of duty in the Fourth Service Command as orthopedic consultant extended from September 1943 to mid-April 1944. During this period, the general hospitals were being increased in number and the large station hospital staffs were being depleted to supply medical personnel for oversea units. In many instances, adequately trained orthopedic surgeons were no longer available in station hospitals. Elective surgical procedures and major fractures, by directive, were supposed to be evacuated to general hospitals, and orthopedic surgery in station hospitals was confined to first aid, minor fractures, and an enormous outpatient service.


    Many of the station hospitals in the Fourth Service Command were very small, especially those serving a great majority of the smaller airfields. For instance, within a. radius of 50 miles about Finney General Hospital, Thomas-


ville, Ga., there were 5 or 6 small Air Force station hospitals, each completely equipped and stuffed with an average number of nurses and medical officers for the patient load. There were also large Air Force station hospitals, such as those at Keesler Field. Biloxi, Miss., at Gulfport Army Air Field, Gulfport, Miss., and at Maxwell Field, Montgomery, Ala. These were very well provided with nurses and competent professional personnel and rendered a high quality of professional care.

    The station hospitals of the Army Service Forces serving large numbers of troops of Army Ground Forces at the larger training centers, such as Fort Bragg, N.C., Fort Jackson, S.C., Fort Benning, Ga., Camp Blanding, Fla., Camp Van Dorn, Miss., and Camp Shelby, Miss., were enormous and, in the light of experience, were vastly overbuilt and, in time, professionally undermanned. Four of these hospitals had 4,000 or more beds, and the maximum census, the writer believes, was never over 50 percent of the bed capacity.

    The general hospitals in the service command were almost invariably well equipped and had a competent professional staff in each instance.

    Although the semiautonomous Army Air Forces were actually under Army command, it became increasingly evident, during the consultants tour of duty, that the service command consultants were less and less welcome at the Air Force hospitals. It was impossible not to call attention to the evident fact that the small Air Force station hospitals were too numerous and too overstaffed with nurses and physicians, while many of the hospitals serving the Army Ground Forces were lacking sufficient nurses and physicians for the patient load. These personnel discrepancies constantly called to one's attention became distasteful, and the service command consultants finally visited Air Force hospitals only on invitation. It is to be hoped that in any future emergency, there will be better distribution of physicians and nurses.


    The problems confronting a service command consultant in orthopedic surgery were mainly (1) personnel and (2) professional care of soldiers with injuries involving bones and joints. The field of military orthopedic surgery was well defined and well recognized in most instances. An occasional chief of surgical service considered himself competent to handle the entire field of surgery and overrode the judgment and neglected to use the operative skill of his orthopedic chief. This resulted, in one instance at least, in ill-advised elective knee joint surgery.

    The problem of having skilled personnel in the proper places was fairly constant. There were increasing inroads on the orthopedic services of the various large station hospitals as personnel were withdrawn to staff new hospitals intended for oversea service. Withdrawn also were orthopedic surgeons belonging to affiliated hospital units, which had completed their parallel train-


ing with the station hospitals and moved to ports of embarkation. It became evident that most of the station hospitals would no longer have trained orthopedic. surgeons to do a definitive type of surgery.

    By the spring of 1943, directives had been issued to transfer all major orthopedic problems, including elective surgery, to the general hospitals of the command. The 2 original general hospitals in the command were increased, during late 1943 and early 1944, to 11, and an adequate orthopedic section was provided for each of these hospitals. In sonic instances, well- trained orthopedic surgeons were left. in some of the larger station hospitals, but the scope of their professional work was curtailed. For the most part. the directives were complied with, and major orthopedic problems were handled in the general hospitals.

    During the authors 7 months as orthopedic consultant for the Fourth Service Command, he visited time 11 general hospitals, all of the large Army station hospitals, and many of the smaller ones, approximately 60 hospitals in all.

    A separate report was rendered on each hospital. Reports on class 1 hospitals at posts, camps, and stations were submitted to the Commanding General, Fourth Service Command, through time commanding general or officer of the installation. If the hospital was located on an installation of the Army Air Forces, the report. was submitted to the commanding general or officer of the airbase. Reports on general hospitals surveyed were submitted to the Commanding General, Fourth Service Command, attention Chief, Medical Branch.

    These reports were thorough. All orthopedic patients were seen and problems were discussed fully with the chief of section. The X-ray department, physical therapy, rehabilitation, and disposition of patients were reviewed. The operating rooms were inspected, and anesthesia, nursing, and personnel were commented upon. A hospital with a large orthopedic service or section might take 2 or 3 days to survey. At the end of such a survey, very complete data were available on which to evaluate the orthopedic care afforded in that particular hospital or medical installation.

    Colonel Cleveland considered his chief function to be teaching and the interpretation of the various directives related to medical care. The term "inspection seemed to connote a snooping and, perhaps, an effort to find fault. A consultant had to be fair and kindly, but he could not escape occasionally finding conditions which required warning or even reprimand through proper channels. The consultant needed to "walk softly but carry a big stick." He could only advise; the command surgeon could implement the advice if he saw fit. A consultant who hoped to be invariably popular was, above all, foolish.

    Personnel allotments for a service command headquarters carried no specific position or rank for medical consultants. It was Colonel Cleveland's considered opinion that, since time Armed Forces are constructed on a basis of rank and are thoroughly rank conscious, consultants should have had rank


equal to or higher than that of the commanding officers of all medical facilities they were called upon to visit.

    Occasionally, the consultants of the Fourth Service Command were sent out as a team to survey a trouble spot for the service command surgeon. In one instance, one of this service command's newly opened general hospitals received undue and unwarranted publicity by a radio commentator because of the confusion that attends any new staff which is overwhelmed by the arrival of a large number of patients. A complete survey of the hospital was made, all patients were seen, and some semblance of order was instituted. Additional orthopedic personnel were provided. Many of the patients admitted to this hospital could have been disposed of at the station hospitals, a majority by return to duty.

    On another occasion, all the consultants were sent together to Stark General Hospital, Charleston, S.C., to see the first casualties returned from North Africa. The wounds of the extremities with long-bone fractures had at this time all been treated by the closed-plaster technique--a method later abandoned. Many of the amputees had protruding bone ends visible in the stump due to failure to utilize skin traction on the stump. Stark General Hospital was transformed into a debarkation hospital and the casualties were shipped from this point to the general hospitals nearest the homes of the returnees.

    The relationship between the four consultants--medical, surgical, orthopedic, and psychiatric--in the command surgeon's office was cordial and helpful. Mutual problems were freely and fully discussed. The surgical consultant and orthopedic consultant frequently, on separate tours or consultations, noted and brought to each other's attention problems affecting the surgical service or the orthopedic section of various hospitals.

    It was a pleasure to serve under Colonel French and on his staff with Col. I. Mims Gage, MC, Col. F. Dennette Adams, MC, and Col. (later Brig. Gen.) William C. Menninger, MC. The staff made a constant effort to see that the sick and wounded of the Fourth Service Command received superior care. It was believed that, on the whole, they did receive such care.


Section II. 1944 and 1945


    The consultant's general duties were twofold as follows: (1) To supervise the overall professional care of the sick in hospitals of the Army Service Forces in the service command, and (2) to evaluate professional personnel and make recommendations for their assignment in further detail, the orthopedic consultant, Lt. Col. James J. Callahan, MC, provided overall direction and supervision of the orthopedic services in each medical treatment facility, conducted regular rounds of orthopedic wards, maintained liaison with the Professional


Service in the Office of the Surgeon General and the other members of the service command medical section, evaluated professiona1 personnel assigned to orthopedic services within the service command, and made recommendations regarding assignment and transfer of personnel. Professional papers were submitted to the consultant for his approval for publication by the Medical Department. After reviewing these papers, he forwarded them to the Office of the Surgeon General. It was the consultant's purpose to encourage by precept the highest level of professional care of patients and the general improvement, with respect to professional information and skill, of the officers assigned to the orthopedic services, he had to be available for professional consultation concerning orthopedic cases. It was expected of the orthopedic consultant that he make suggestions for the correction of deficiencies in service.

    It may go into the record that, in Colonel Callahan's personal experience as an orthopedic consultant, he always received the fullest cooperation of the service command surgeon, who was, first, Col. Sanford W. French, MC, and, later, Brig. Gen. Robert C. McDonald. Both officers always gave a sympathetic ear to suggestions. Most observations were discussed with the commanding officer and chief of services at each hospital, and corrections or suggestions were made at the time of discussion. The commanding officer and the several chiefs of services in every instance gave the most constructive cooperation.

Area Served

    The orthopedic consultant served as adviser to the service command surgeon and, through him, advised the appropriate branch in the Office of the Surgeon General. The services of the orthopedic consultant of the Fourth Service Command were available to the 40 hospitals in operation at the close of 1944 in that command. Ten were general hospitals, of which three--Kennedy, at Memphis, Tenn., Lawson, at Atlanta, Ga., and Northington, at Tuscaloosa, Ala.--were designated as special centers for neurosurgery as well as orthopedic surgery. Lawson General Hospital was, in addition, an amputation center: and Northington General Hospital was also a plastic center where specialists performed plastic surgery. A creditable achievement may be recorded here because of the many corrections of deformities and disfigurements which enabled restored patients to be returned to society and even to duty.

    The Fourth Service Command did not have its own vascular center; thus, all vascular surgery cases had to be transferred out of that command.

    The remaining seven general hospitals were Battey, at Rome, Ga.; Finney; Foster, at Jackson, Miss.; Moore, at Swannanoa, N.C.; Oliver, at Augusta, Ga.; Stark; and Thayer, at Nashville, Tenn. All the general hospitals had qualified orthopedic surgeons who were certified by the American Board of Orthopedic Surgery.

    Stark General Hospital was the receiving hospital for the Fourth Service Command. There, patients were received from overseas; casts were changed or removed; wounds, dressed; new casts, applied; and the patients were made


generally comfortable before they were transferred for definitive treatment to hospitals close to their homes. The staff at Stark General Hospital did a superior service under pressing circumstances of great numbers of patients passing through in rapid turnover.


    During 1944, the orthopedic consultant visited each medical treatment facility in the Fourth Service Command at least once and in most instances twice. During these visits, ward rounds were made with the chiefs of the various services. The work of the several sections was reviewed, the quality of clinical records was assessed, and patients presenting special problems were examined on a consultative basis. The consultant was also called on to discuss current medical problems with the officers. Those consultations and general open forums contributed importantly to professional progress, for each of the officers had an opportunity to voice his opinion and to acquire knowledge from the other officers or the visiting consultants. This approach helped to unify the system of treatment, so that medical care to the patient was inevitably improved.

    A further duty of the consultant was to attend meetings of the different medical disposition boards in order to facilitate the disposition of cases and at the same time to insure that disposition was made in accordance with existing instructions of the War Department.

    It was required of the consultant that he supervise decisions to operate so as to eliminate unnecessary operations in cases in which disability existed be fore induction. It was in this regard, for instance, that recurrent dislocations of the shoulder and recurrent injuries or dislocations of semilunar cartilages-- particularly in those cases in which there was a severe atrophy revealing a long history of injury--were accurately screened before surgery was permitted. It. was evident in this type of condition that the patient would not return to active, duty. Limitations were never imposed on any type of reconstructive surgery that might yield the best possible functional result. Treatment, however, had to be planned with a view to the patient's ability to return to duty whenever this was at all a possibility.


Back wards. - Some of the general hospitals had organized back wards (wards for back disorders) collectively controlled by the orthopedic surgeon, the neurosurgeon, the physiotherapist, and the roentgenologist. When the many cases in these wards had been reviewed, it was decided to have a consultation with all the ward personnel. Each case was again reviewed and examined individually. At the conclusion of the examination of all the patients, it was decided that a back ward was not a wise method of grouping back cases. The patients discussed their symptoms with one another and found them


similar, although the findings were often different; thus, subjective symptoms increased. The back wards were as a consequence disbanded. Disbanding these wards did not eliminate the problem, however, because so many cases had been diagnosed as disk syndromes or as positive for a disk finding. The disk had become a too popular diagnosis. Certainly, disk cases occurred, but not so commonly as the diagnoses had been made: moreover, it was believed that when they did exist, treatment should be conservative. Patients were thereafter placed in traction. Many were placed in plaster of paris casts. Many others were manipulated either with or without a cast application. The number of operative disks was substantially reduced. On the other hand, when there were definite indications for surgery--that is, when the patient did not respond to conservative care--the orthopedic surgeon assisted the neurosurgeon. If congenital deformities existed in the vertebras or if there were beginning arthritic changes, then stabilization, either with cortical and cancellous bone or cortical bone alone, enabled the patient to have restored to him a stable back. Those patients who had fusions performed were in a large measure relieved of pain but those who did not have a fusion done frequently complained of the same pain postoperatively. Even though the patients thus operated on would usually have to be discharged because of disability, an effort was made to restore them so that they could return to gainful employment.

    Physical therapy under orthopedic service. - The Surgeon General placed physical therapy under the orthopedic service, which was an excellent idea inasmuch as the orthopedic service furnished most of the patients for the physical therapy unit. The close cooperation between the chief of physical therapy and the chief of orthopedics in a hospital meant better and quicker rehabilitation of the patient. More than half of the patients in most of the hospitals were under orthopedic care. For that reason, it was suggested that the chief of physical therapy make rounds with the orthopedic ward surgeon to permit frank discussions in evaluation and choice of treatment.

    Complete rounds innovation. - In point of fact, a logical suggestion was adopted pertaining to complete rounds. Each time the consultant visited a hospital, he saw every patient in the ward. Thus encouraged the, younger officers, improved the morale of the patient who then felt that he was given the benefit of consultation, as he was, and confirmed each chief of service in his judgments or helped him to resolve his doubts in difficult cases.

    Amputations and rehabilitation. - Lt. Col. Edward C. Holscher, MC, who was in charge of the orthopedic and amputation service at Lawson General Hospital, guided commendably the program instituted at the hospital in which, for example, every effort was made to preserve the involved joint, which was usually the knee joint. Conservative treatment, to be sure, as always, depended on careful evaluation so that the patient's life would not be endangered. Efficient traction, careful plastic repair, early physical therapy, and rehabilitation in all its facets all constituted care of such superior quality that many of the amputees could be reclassified and returned to duty.


    The formation of a large rehabilitation center at Daytona Beach, Fla., called the Welch Convalescent Center, significantly relieved that phase of the workload at the general hospitals. As soon as a patient was ambulatory, he was transferred to that large installation where care was geared exclusively to the problems of rehabilitation. There the will to get well was an active force. Under the direction of Maj. Newton C. McCollough, MC, the section on orthopedics provided superior care. As the service command consultant on an inspection visit, Colonel Callahan made the opportunity to examine every patient. Major McCollough and the consultant discussed individual problem cases to determine appropriate disposition regarding transfer to a general hospital or a specialty center for definitive care or for further surgery.

    Prevention of fractures by proper fitting of boots and socks. - A program was developed at Fort Benning to correct avoidable deficiencies in the wearing of boots and socks. First to be considered were the shoes and socks of the parachutists of the airborne divisions. Each soldier was measured for correct size of socks and boots. Many had been wearing socks that were too short and boots that were inadequate. This malpractice was evidenced by the number of needless injuries to feet and the number of fractures of the leg and ankle. The boots were designed with double straps which would not remain in the slot intended for them; frequently the straps would catch in the shroud of the parachute, throwing the foot, As a result, typical fractures of parachute jumpers were observed--fractures of the ankle and of the head of the fibula, as well as knee joint injuries. That defect in the boots was corrected.

    It was Maj. Roy Ciccone, MC, who classified the fractures incurred and collaborated in bringing about the needed corrections in apparel.

    Multiple operations of the knee. - At the beginning of the war, many operations of the knee were performed without enabling the soldier to return to duty. Instead, certificates of disability for discharge had to be issued. Later, a program was instituted whereby the men were better screened in the first place. Those operated on were given appropriate preoperative and postoperative exercise and rehabilitation opportunities; thus, the numbers that had to be discharged were greatly reduced. This curtailment of surgery did not apply to those who had received injury in line of duty, although the new exercise and rehabilitation measures, under complete supervision, benefited them as well.

    Many of the cases of internal derangement of operative knees had been the result of insufficient care in evaluation before operation. There were, for example, two cases of arthrotomies in which no pathologic condition had been observed. An occasional soldier had been operated on for an internal derangement of the knee, although the condition had existed before induction. Inasmuch as half the orthopedic surgery at Fort Benning at one point concerned internal derangement of the knee, the opinion was submitted that each case be more carefully considered and evaluated. It had been true, moreover,


that soldiers who were operated on for internal derangements of the knee were allowed out of bed in less than a week after the operation. Rehabilitation was retarded and not hastened by such early weight bearing. Many distended, swollen, painful knees were observed as a result of too early weight bearing and early ambulation.

    Recurrent dislocations of the shoulder. - Again, many cases of recurrent dislocations of the shoulder had existed before entrance or induction into the service. With the rigors of military training, dislocations were bound to recur. Early operations to correct these conditions had not been successful, so that the soldier's had to be reclassified for limited service or discharged. As time and experience progressed, it was realized that it took at least 6 to 12 months before such patients could be returned to useful service. The number of operations thereafter authorized was greatly reduced. Surgical correction was attempted only when the prognosis gave reasonable justification.

    Fusion operations on the spine. - Fusion operations on the spine were authorized only when there was an unequivocal indication for the procedure. Backaches from conditions that had existed before induction into the service were rarely considered an adequate indication for surgery.

    March fractures. - Anther change that was instituted concerned fractures incurred during marches, designated march fractures. It was concluded that it was better not to transfer patients with march fractures to general hospitals because, by the time the diagnosis was made, the fracture was well on its way to healing. Two or three weeks of rehabilitation or of limited duty would enable the soldier to resume active duty.

    Traction for simple fractures of the femur. - In the treatment of fractures of the femur, an order had been issued to place the extremity with simple small fractures of the femur in traction. That was wise, for the alternative measure of placing the leg in plaster-although it afforded good immobilization-it did not give an opportunity to examine the limb for the presence of thrombophlebitis or phlebothrombosis. Neither did the plaster-encased leg permit early active physical therapy, including massage, muscle contraction, and movement of the knee and ankle--an essential motion. These difficulties, for example, were characteristically observed in fractured femurs evacuated from overseas in plaster spicas.

    Many orthopedic surgeons were under the impression that casts represented the optimum in treatment, so that it was necessary in making rounds or visits to the hospitals to explain the advantages of the traction and to insist that the order be executed. Deformities had frequently been found in those cases in which the fracture had been immobilized in a body cast. Traction, either skin or skeletal, resulted in fewer deformities and fewer cases of shortening; moreover, it facilitated the dressing and care of wounds.

    Open fractures and skin grafts. - There were many cases of open fractures of the shaft of the femur or of the tibia with a loss of bone substance in which skin grafts had been performed, a skin dressing had been applied, and


the leg had healed. Exercise had been ordered to keep the adjoining joints active so as to increase circulation and restore muscle tone, Later reconstructive surgery reinforced the shallow or narrow bone and resulted in excellent weight-bearing surfaces. This treatment certainly obviated the need for many amputations and prevented permanent disabilities in time weight-bearing extremity. The policy of saving what tissues remained so that something could be added to the preserved number was worthwhile as it gave a well-functioning limb as an end result.

    Osteomyelitis and skin grafts. - Chronic osteomyelitis following open wounds was observed often, because of the program of treatment of open or compound wounds. At first the cases were protracted, but later, after the wound had healed or at least had begun to granulate, either early grafting was done or a skin dressing was applied. Because of the early skin dressing, the wound remained clean. Operation was performed early in such cases with a full thickness graft or pedicle graft. The entire program was well worth the time and effort as it reduced the morbidity and saved many an arm on leg that might otherwise have been lost.

    To be sure, it was discovered early that the antibiotics were helpful, but they were not wholly responsible for the improved results Antibiotics could not substitute for good debridement, skin coverage, or dressing in cases of chronic osteomyelitis or cases of large open wounds.

    Massive bone grafts. - If the skin graft had fulfilled its purpose of a closed clean wound, then the consideration for definitive treatment was in order. Thus it was that large defects were soon closed with bone grafts. Many were successfully accomplished because of the clean wound and bed furnished by the skin graft; otherwise, in cases of large defects, it would have been necessary to amputate. In many instances, this important procedure prevented regrafting and the unnecessary loss of precious bone. Dr. John Flanagan at Kennedy General Hospital was responsible for some of the excellent surgery of these massive bone grafts which saved many arms and legs.

    Regrettably, a bone bank was not available at that time. Bone from such a bank could have bridged the defect without sacrificing the patient's own bone and would have permitted the patient to be ambulatory early, without the risk of fracturing the good member at the donor site,

    Hand surgery. - Hand surgery centers were established with the initial instruction given by Dr. Sterling Bunnell to all the officers from the general and regional hospitals. The benefits of this experience in how to salvage as many hands and fingers as possible and in making tendon and nerve grafts carried over into civilian life, Many hands which would otherwise have been useless were saved and rehabilitated. That effort represented the first time that emphasis was placed on the specialty of hand surgery.

    The braceshop. - An important facet of the orthopedic organization was the braceshop. Most of the braceshops were in charge of civilian bracemakers who worked commendably for long hours in the performance of their duties and


in instructing Army personnel. Their trainees were able to produce professional braces and calipers. Many of the military trainees have carried the skill of bracemaking over into civilian life from the Army where they had performed so essentially in an auxiliary service vital to successful orthopedics.

Miscellaneous observations. - It was interesting to observe in the orthopedic clinics how many soldier's had objective symptoms, how many subjective, and how many had symptoms entirely without foundation. Of all symptoms recorded in the clinics, foot disorders represented about 70 percent; knee disabilities, about 15 percent; and backaches, from l5 to 20 percent. These proportions varied, to be sure, particularly in regional hospitals with large numbers of trainees. At Moore General Hospital, at one time, there were 40 cases of self-inflicted gunshot wounds.

    It was interesting that there were so few cases of thrombophlebitis or phlebothrombosis among the vast number of injuries treated in the Fourth Service Command.

    At Lawson General Hospital, there were four cases of temporary paralysis as the result of using the pneumatic tourniquet--three in the lower extremity and one in the upper. All patients recovered.

    The large prisoner-of-war camp at Camp Forrest, Tenn., presented many serious orthopedic problems. Lt. Col. Clarence W. Hullinger, MC, was in charge, with the assistance of Maj. Ernest Dehne, MC, and other surgeons. Their program was notably efficient. Col. Mims Gage, the service command surgical consultant, and the Orthopedic consultant frequently visited Camp Forrest for review purposes and, on occasion, participated in surgical procedures to rehabilitate patients. Colonel Gage's advice and constant vigilance for complications were noteworthy. The close cooperation between the surgical service and the orthopedic service was largely due to his interest.

    All the commanding officers and personnel of the hospitals in the Fourth Service Command performed excellently during the writer's term as consultant. It was the exercised aim of all to give each injured serviceman the best possible result in the shortest possible time. To further that end, the best available professional personnel were invariably assigned to the positions of chiefs of services. As a consequence, during his tenure Colonel Callahan enjoyed the fullest cooperation of certain chiefs of orthopedic surgery who have not been credited in previous reports, such as Lt. Col. T. Campbell Thompson, MC, Lt. Col. Frank G. Murphy, Lt. Col. Everett I. Bugg, Jr., MC, Dr. I. William Macklis, Lt. Col. Saul Ritchie, MC, Lt. Col. Edward Parnall, MC, Lt. Col. Harold C. McDowell, MC, and Maj. F. Bert Brown, MC.