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Chapter I




Mather Cleveland, M. D.


The Consultant System

The first formal step in the establishment of orthopedic surgery as a recognized specialty in the European Theater of Operations was the appointment of Col. Rex L. Diveley, MC, as senior consultant in orthopedic surgery in July 1942. The Professional Services Division, Office of the Theater Chief Surgeon, to which he was appointed, had been set up about a month earlier.

Colonel Diveley held this appointment until May 1944, when he was relieved to devote his full time to the Division of Rehabilitation. He was succeeded on D-day minus 20 by Col. Mather Cleveland, MC, who served until the end of the fighting in Europe.

Throughout the war, both senior consultants in orthopedic surgery had ready and satisfactory access to higher medical authority as well as to other consultants in the various branches of medicine and surgery. This access had much to do with the success of the planned program in orthopedic surgery and with the competent treatment of casualties with bone and joint injuries.

Functions of the Senior Consultant

The principal duties of the senior consultant in orthopedic surgery, European Theater of Operations, were as follows:

1. To investigate the training, qualifications, and competence of orthopedic surgeons and other medical officers doing orthopedic surgery and to recommend adjustments of personnel to provide for full orthopedic coverage in all hospitals;

2. To visit medical installations in the theater as often as possible, in order to aid in the processing and treatment of casualties with bone and joint injuries by advice, suggestion, correction of errors, and general direction;

3. To provide special supervision for hospitals in which there were no trained orthopedic surgeons or in which medical officers doing orthopedic work were inexperienced and likely to require special advice and direction;

4. To formulate policies of treatment of the wounded by writing circular letters and directives to be issued with the approval of the Chief Surgeon, European Theater of Operations;

5. To disseminate, and to interpret by word of mouth, Army and theater directives pertaining to the professional care of casualties with bone and joint injuries and to carry, from hospital to hospital, policies and practices devised in the various installations, when they had been found to be useful and efficient;

6. To organize such professional training programs as the exigencies of wartime service permitted;

7. To supervise and encourage such clinical investigation as wartime exigencies permitted;

8. To assemble, collect, and preserve data on the management of battle casualties and the results of various methods of treatment of bone and joint injuries; and

9. To function in a liaison capacity between the theater and army surgeons and personnel in lower echelons.

Hospital visits-Visits of the consultant to the hospitals in the theater were of considerable practical value, especially when the units were isolated. Information as to specified techniques of management was disseminated more readily than through channels, and information as to methods devised in the various hospitals was thus transmitted to other hospitals. Techniques of management were surveyed, with the idea of keeping them as uniform as possible. Errors in management were also promptly detected, usually during the extensive ward rounds which were part of every visit. All incorrectly treated cases were fully discussed during these rounds, and, as far as was practical, personal conferences were held with the officers responsible for the errors.

Evacuation practices were also investigated and corrected as necessary. In some hospitals there was a tendency to hold patients too long, while in others evacuation was too rapid.

The consultant was often called upon for advice on both general problems and specific cases. One hospital, for instance, in the 802d Hospital Center, which had previously served as a transit hospital, was suddenly given the responsibility for definitive orthopedic surgery. No surgeon in the hospital had the necessary qualifications for its performance. The junior consultant in orthopedic surgery visited the hospital, reviewed the situation, and arranged for a team of qualified orthopedic surgeons to be placed on temporary duty in it. Before these surgeons left, they had been able to instruct the surgical personnel in the proper use of skeletal traction, in the technique of handling amputees, and in other orthopedic problems in which they previously had had practically no experience.

It was unfortunate that the senior consultant in orthopedic surgery could not visit the hospitals on the Continent more frequently. Some were visited only twice-once while they were still on the beachhead and once when the battlefront had moved farther inland. This was unavoidable, because of the increase in the number of hospitals and the increasingly great distances to be covered to reach them. Under these circumstances, the work of the junior consultants in orthopedic surgery was particularly useful.

Junior-Consultant System

The junior-consultant system was devised as the solution for two problems. The first, as just mentioned, was the inability of the senior consultant in orthopedic surgery to make frequent, regular visits to all hospitals. The second was the unavoidably uneven distribution of trained orthopedic personnel throughout the theater (p. 14). Junior consultants were appointed to serve in various


base sections and hospital centers in the United Kingdom and on the Continent. They assumed these duties in addition to their regular duties as chiefs of orthopedic sections in their own hospitals. All of them served with distinction.

In all, 7 orthopedic surgeons served as junior consultants in the United Kingdom, and 9 were later appointed to similar positions on the Continent. The situation on the Continent, however, never in the course of the active fighting presented the stability that was obtained in the United Kingdom, and frequent changes of consultant personnel were necessary as hospitals were moved from base to base and center to center. It was V-E Day, in fact, before anything approaching stability was accomplished on the Continent, and for this reason most of the junior consultants who served there were not appointed until near the end of, or after, the war. The interpretation of policies would have been greatly facilitated by their earlier appointment, whether they had served full time or part time.

The junior-consultant system filled a serious need and was regarded as extremely successful. The chief defect of the system was that the consultants did not have sufficient direct and personal contact with the senior consultant in orthopedic surgery. Provision for such contacts should be made in the event of a future emergency.

Some junior consultants rendered monthly reports to the senior consultant in orthopedic surgery. Others reported to him only after tours of duty. Some of the junior consultants also made complete reports at the conclusion of hostilities.

One such report, from the orthopedic section of the 802d Hospital Center, January-June 1945, is summarized statistically as typical of the work covered by a junior consultant in orthopedic surgery who, in addition to his consultant duties, supervised the work in this center, conducted a superior orthopedic service in his own hospital (the 22d General Hospital), and also found time to collect certain data of unusual interest, some of which will be commented on elsewhere. Other junior consultants had equally meritorious achievements to their credit.



Total admissions



Orthopedic admissions



Consultations (hospital and clinic)



Fractures of-






Radius, ulna, both






Tibia, fibula, both



Injuries of and about hip



Infected compound fractures



Plaster-of-paris splints



Skeletal traction



Open reductions






Delayed primary closure of compound fractures






Partly successful






No closures, or failures due to sepsis


The 802d Hospital Center consisted of 19 hospitals (13 general and 6 station hospitals) with 18,636 beds. The largest block of beds, 7,500, approximately 40 percent, was assigned to orthopedic surgery. The number of medical officers assigned to the orthopedic section averaged 64.

A summarized report from the orthopedic section of the 22d General Hospital, 10 June 1944 to 1 June 1945, is also included as typical of the work of a well-conducted orthopedic section in a general hospital.



Orthopedic admissions


Fractures of-






Radius, ulna, both






Tibia, fibula, both


Injuries of and about hip


Open reductions




Consultants in Army Areas

It would have been highly desirable if each field army could have had its own consultant in orthopedic surgery in the army surgeon's office, though he would have been useful only if he had had ready access to all hospitals in the area and complete freedom, within the limits of security, to move about the area and to visit these units frequently. The logic of such an appointment is obvious, namely, the uniformly large proportions of wounds of the extremities in all battle-incurred injuries.

During World War II, only 2 of the 5 armies which functioned in combat in the European theater had their own consultants in orthopedic surgery. One of these armies, the Fifteenth, became operational so late that it handled few battle casualties. In the Ninth United States Army, however, the value of the policy was clearly evident. The consultant in orthopedic surgery for this army concentrated his attention and efforts on evacuation hospitals, where casualties with bone and joint injuries were constantly received in large numbers. This left the consultant in surgery free to devote himself to field hospitals, where surgery of the chest and abdomen and other urgent operations were performed. The two officers worked in close liaison with each other.

The direct supervision of work in the evacuation hospitals by the Ninth Army consultant in orthopedic surgery was soon reflected in the status of the patients received in the general and station hospitals to the rear. They arrived in better condition. There was a striking improvement in the selection and


application of plaster casts. There were also notably fewer errors in evacuation practices.

Evaluation and Assignment of Personnel

Evaluation-A complete, up-to-date file of orthopedic personnel was maintained in the office of the senior consultant in orthopedic surgery, with all the information which could be secured about the officers assigned to this branch. The original material was secured on a special form (fig. 1). This permitted an immediate tentative evaluation of the officer, on the basis of data which he himself supplied, and served until additional and more authoritative information about him could be secured.

The Military Occupational Specialty (MOS) rating for orthopedic surgery was 3153:

An officer with the rating of A-3153 was professor of orthopedic surgery at a class A medical school, or a nationally or internationally recognized leader in the profession, or an officer who had made a definite contribution to advancement of the knowledge of this specialty.

An officer with the rating of B-3153 was a diplomate of the American Board of Orthopaedic Surgery or a fully trained medical officer who had not yet been able to take his examination for certification. This group also included an occasional American Board of Surgery diplomate with qualifications in traumatic surgery.

An officer with the rating of C-3153 had almost completed his civilian training in orthopedic or traumatic surgery and had augmented his experience in these fields during Army service.

An officer with the rating of D-3153 had had little or no basic surgical training in civilian practice and a varying amount of experience during his Army service.

In 1944, when the invasion of the Continent occurred and mass management of battle casualties was necessary for the first time, there were 820 living diplomates of the American Board of Orthopaedic Surgery. Sixty-three of these were then serving among the approximately sixteen thousand medical officers assigned to the European theater.

Three of the sixty-three diplomates were serving as consultants in orthopedic surgery, and three were assigned to the rehabilitation service. The other diplomates in the European theater were assigned to general, station, and evacuation hospitals or headed orthopedic surgical teams in auxiliary surgical groups.

The 63 certified orthopedic surgeons in the European theater were supplemented by 95 other medical officers who had some training in orthopedic surgery. At a minimum, each of them had had 3 years of surgical training, including a year or more of training as a resident in orthopedic surgery. There were also 85 other surgeons who had completed residencies in general surgery or who had served as surgical residents for varying periods of time. These 3 categories


FIGURE 1.-Special form used for securing information about officers assigned to the orthopedic surgery branch.


TABLE 1.-Assignment of medical officers with MOS 3153, Orthopedic Surgeon, 6 June 1944



Auxilliary surgical group













































































1See p. 11 for requirements for each rating.

provided a more or less solidly trained nucleus of 243 medical officers, who carried most of the orthopedic responsibility in the theater. (See table 1.)

In the early spring of 1945, there were in the European theater 146 general hospitals, 47 station hospitals, and 63 evacuation hospitals whose tables of organization called for one or more specialists in orthopedic surgery. If these requirements had been fulfilled, the theater would have utilized the services of 446 specialists in this field, 2 for each general hospital, each 750-bed station hospital, each 500-bed station hospital, and each 750-bed evacuation hospital, and 1 for each 400-bed evacuation hospital and each 250-bed station hospital.

To fill existing vacancies in these various hospitals, it was necessary to utilize the services of 174 medical officers who had had no basic civilian training that qualified them as surgeons. Some were very recent graduates. Some were older practitioners. Some had specialized in other fields of medicine. For the most part, these officers received their training for orthopedic work on the orthopedic sections of Army general hospitals in the theater, under more experienced orthopedic surgeons. Their instructors were well qualified, and most of the untrained officers were willing pupils. It was therefore perfectly possible to teach them quickly the relatively simple surgical techniques of military traumatic surgery of the extremities.

It should be noted, however, that there were two reasons why this system succeeded so admirably: (1) Definite regimens of management were set up and followed precisely; and (2) there was careful supervision in all echelons. To fulfill the technical minimum requirements in orthopedic surgery in the European theater, it would have been necessary to use several times the number of qualified surgeons who were available for service. By adherence to the criteria just stated, it was possible to maintain high standards of professional care in the absence of a full complement of professionally trained orthopedic surgeons.

The 243 fully or partially trained orthopedic surgeons and the other officers trained in the theater to do orthopedic work provided service in this specialty for a maximum troop strength in May 1945 of 3,065,505 men.1 Between 1

1Strength reports of the Army, prepared by office of Chief of Staff.


February 1942 and 8 May 1945, 381,1932 casualties with battle-incurred injuries and 278,5003 admissions with nonbattle injuries were treated in the medical installations in the European theater. Between 35 and 40 percent of battle casualties and some 36 percent of nonbattle injury admissions had involvement of the bones and joints.4 This small number of orthopedic surgeons (243) was called upon to treat between 220,000 and 250,000 hospitalized patients, aside from wounded prisoners of war and the patients managed in outpatient clinics.5

Assignment.-The personnel problem in the European theater was a matter of assignment as well as of number of trained orthopedic surgeons. A shortage of adequately trained orthopedic personnel will undoubtedly occur in any war, because so much of the patient load consists of injuries to the bones and joints. The solution of the shortage in World War II was twofold: The effective distribution of such qualified personnel as were available and the performance of forward surgery by surgeons without specialized orthopedic training.

Orthopedic responsibilities began with the arrival of the first United States troops in the United Kingdom early in 1942. The orthopedic sections of the 6 general and 7 station hospitals which had reached the European theater by the end of that year were all occupied with the treatment of civilian-type accidents and the various injuries which always occur in mass training for combat. The 2d Evacuation Hospital, at Diddington, Hunts, was kept busy with Air Force casualties.

At first, there was no shortage of orthopedic personnel in the theater, and assignment presented no difficulties. Even as late as the fall of 1943, some hospitals were arriving in the theater with two or more qualified orthopedic surgeons among their personnel. These were usually affiliated hospitals. As time passed, the situation became very different. From 1943 until the end of the war, some hospitals arrived in the United Kingdom with only partly trained orthopedic surgeons on their staffs, while other hospitals had none at all. It was always nonaffiliated general hospitals which came into the theater without orthopedic personnel. Furthermore, the medical officers in many hospitals of this kind had been engaged in administrative problems and had been without professional contacts for so long that they were inadequately prepared for the clinical problems presented by hundreds and thousands of soldiers with battle-incurred injuries of the bones and joints.

The problem of supplying qualified personnel to staff the orthopedic sections of the hospitals in the European theater therefore became acute long before the invasion of the Continent. As D-day approached and the military

2Army Battle Casualties and Nonbattle Deaths in World War II, Final Report. Note: Personnel killed in action and battle-wound or injury cases carded for record only (CRO admissions) are excluded from the figure cited.
3This figure included CRO admissions. Data for 1942-44 were obtained from tabulations of individual medical records; data for 1 January-8 May 1945 are estimated. The estimate was based on sample tabulations of individual medical records and data compiled from summaries of the Statistical Health Report (WD AGO Form 8-122). Provisional tabulations such as these will be supplemented in time by final tabulations.
4These battle-casualty estimates represent the general opinion of the medical staff, based upon personal experience. The nonbattle estimate is provisional, awaiting publication of final tabulations.
5Semiannual Report, Professional Service Division, Orthopedic Surgery, Office of the Chief Surgeon, European Theater of Operations, 1 January-30 June 1945.


exigencies became keener, it was necessary that hospitals with an oversupply of qualified personnel be plundered to supply the needs of hospitals which had arrived without orthopedic surgeons on their staffs. The objective was to supply all general hospitals, as well as all station hospitals in the United Kingdom, with orthopedic surgeons. Later, as the need increased with the increase in combat casualties, station hospitals, except for those in East Anglia which served the Air Forces, themselves had to be plundered of their orthopedic personnel to supply the general hospitals which came into the theater without qualified chiefs of orthopedic sections.

Needs of hospitals.-Normally, an orthopedic surgeon is unnecessary in a field hospital, and qualified orthopedic surgeons were not used in this manner in the European theater.

The great bulk of work in an evacuation hospital consists of casualties who must undergo debridement. At various times in the European theater, 4 teams of surgeons, each team working 12-hour shifts around the clock, could scarcely keep up with the admissions. This did not mean, however, that orthopedic surgeons would have been properly utilized in these forward hospitals. Theoretically, the argument is sound that, if injuries of the bones and joints are treated correctly initially, the results will be better and correspondingly less secondary surgery will be necessary in rear areas. On the other hand, even if there had been enough trained orthopedic surgeons to assign 2 to each evacuation hospital, these 2 surgeons could not possibly have taken care of the casualties. The solution, therefore, was to use trained general surgeons as well as other less well trained surgeons who, after some instruction, proved able to perform perfectly satisfactory debridement. This was what was done. In times of stress, even otolaryngologists worked in evacuation hospitals, outside of their specialty, it is true, but they performed entirely acceptable debridement.

If an orthopedic surgeon was assigned to an evacuation hospital, he was most useful in the supervision of other surgeons and in the making of frequent spot checks of the quality of the work. He could occasionally undertake particularly difficult cases himself, but it was unwise for him to tie himself up in run-of-the-mill cases if he was working in a hospital with surgeons inexperienced in the management of bone and joint injuries. It is under such circumstances as these that a consultant in orthopedic surgery assigned to a field army has his widest field of usefulness.

Originally, teams of orthopedic surgeons from auxiliary surgical groups were attached to evacuation hospitals. This did not prove to be a particularly economical use of trained personnel. A corpsman was a satisfactory assistant, and sometimes a better assistant than a trained surgeon, in almost all of the operations permissible in an evacuation hospital. The feeling was frequently expressed that it would have been better to give the assistant surgeon on the orthopedic team a table and an operating crew of his own and to let the orthopedic surgeon on the team operate with the assistance of corpsmen.

The opinion was also often expressed that the orthopedic surgeons in evacuation hospitals in reserve could profitably have served on auxiliary


surgical teams during their periods of waiting. This plan would have provided a more flexible group of qualified orthopedic surgeons, without any increase in personnel, and would undoubtedly have given satisfaction to the surgeons themselves, who were always restless and unhappy during the long periods of inactivity required by the Army policy of holding some evacuation hospitals in reserve. Theoretically, this was a sound suggestion. Practically, logistic difficulties would probably have made it extremely difficult to carry out as a routine procedure.

According to the tables of organization, a general hospital was supposed to have a chief and an assistant chief of the orthopedic section, both of them well trained. In many instances it would have been desirable if this requirement could have been fulfilled, but it would have necessitated 3 to 4 times as many adequately trained (MOS 3153) orthopedic surgeons as were ever available in the entire European theater.

As a practical matter, most of the trained orthopedic and traumatic surgeons in the theater, especially those with the highest ratings, were assigned to the general and the large station hospitals. It was frequently necessary to plunder evacuation hospitals and auxiliary surgical teams to fulfill the orthopedic needs of these hospitals. When the fighting on the Continent began, all auxiliary surgical groups had orthopedic surgeons in their complement. By the end of hostilities, most of these surgeons had been released and reassigned to general hospitals which had entered the theater without orthopedic specialists on their staffs.

Level of training-Even when orthopedic surgeons were in numerical sufficiency on hospital staffs, the level of training was not always adequate. In the 19 hospitals which comprised the 802d Hospital Center, for instance, 7,500 of the 18,636 beds were assigned to orthopedic surgery. Of the 18 surgeons in charge of these beds only 3 had B-3153 ratings. The training of the average chiefs of orthopedic sections in the C and D categories in this center, as well as in other centers and hospitals, was often frankly inadequate, though, with careful supervision, they were able to handle the compound fractures which made up the bulk of the work.

Before D-day, when the situation was not urgent, it had frequently been possible, when officers in charge of orthopedic sections of newly arrived hospitals were regarded as inadequately trained, to send them on detached service to one or another of the older hospitals in the United Kingdom to serve on the orthopedic sections under chiefs of known competence. After several weeks, the officers under whom these inexperienced officers were serving prepared an evaluation of their current abilities and future potentialities. Certain chiefs of section rendered extremely valuable service in this way; their judgment proved almost unerring, and they were responsible for the training and assignment of many originally poorly trained officers who later rendered valuable service in their own hospitals. After D-day this plan of training naturally had to be discontinued.


Utilization of qualified personnel.-From May through October 1944, most of the older affiliated units in the United Kingdom were engaged in staging, so that they could be set up on the Continent in the wake of the invasion. They were replaced, in the hospitals which they had formerly manned in the United Kingdom, by more recently arrived units. The arrangement was perhaps unavoidable under the circumstances, but the first result of it was that the most experienced orthopedic staffs in the theater did not participate, as units, in the first 2 months of the invasion, though teams from some of them did participate in the early care of battle casualties.

The second result was that the early care of these orthopedic casualties was left to the newer and more inexperienced units, whose orthopedic sections, in many instances, were staffed by officers who were not qualified orthopedic surgeons. The professional personnel of these hospitals was frequently a source of great anxiety. On the whole, the work that was done was excellent, but it would have been better if the surgeons of experience could have been fully utilized in the first weeks of the invasion, to establish standards of orthopedic care and to lighten the burden of the less experienced surgeons who were called upon to assume heavier responsibility than their professional training qualified them for.

The situation on the Continent was equally uneven. The hospitals which went over first, as well as the hospitals which came up from Italy, were the oldest and most experienced of the affiliated units. There was, in all, a nucleus of perhaps 30 such hospitals. It may be, again, that under the tactical circumstances which prevailed, the uneven distribution of experienced and inexperienced hospitals could not have been prevented. It left, however, large areas in which it was difficult to maintain a high level of professional care. In retrospect, from the orthopedic standpoint, it would have been a better plan to scatter the older hospitals, especially the affiliated units, in such a way that they could have served as a nucleus or parent installation for the hospital centers set up on the Continent.

This was not done, and the orthopedic setup on the Continent was often far from ideal. One hospital center, for instance, consisted of four affiliated units. Another, in a total of 6 hospitals, had 4 affiliated units. A third, in a total of 11 hospitals, had 3 such units. In contrast, two hospital centers located adjacent to each other consisted of a total of 18 component hospitals, all of them newly arrived, none of them with previous experience as functioning organizations, and none of them with a single adequately prepared and trained orthopedic surgeon in their personnel. As a result, it was necessary to transfer a trained orthopedic surgeon, with an active orthopedic service, from another center to these centers to serve as orthopedic consultant for both.

Exchange of personnel-A few orthopedic surgeons in the European theater served at various times in both the army zone and the zone of communications. This was a highly desirable practice (p. 86). It gave these officers a more complete experience and also provided them with a fuller and a greatly


needed understanding of the problems in both areas. Had this policy been carried out consistently, it would probably have ended most of the (unadmitted) dissatisfaction of the orthopedic surgeons who worked entirely in forward areas and who would have preferred to work in base areas where they could have done definitive or reparative surgery which, of course, could not be performed in forward areas.

It was the plan to develop more extensively the exchange rotation of personnel from forward to rear areas and vice versa, but the war ended before it could be put into practice to any considerable extent. There were two practical objections to this policy. One was the unwillingness of commanding officers to lose competent personnel. The other was the unconscionable length of time it usually took a medical officer to travel as a casual from the rear to the front and vice versa, though the actual distance was seldom more than 600 to 800 miles. Officers were known to spend as long as 10 to 14 days in various depots awaiting transportation. This waste of time naturally tended to cool the ardor of commanding officers of hospitals, whose orthopedic sections might be left uncovered for long periods of time while exchange officers were en route from one assignment to another.

Rank.-The matter of rank naturally had nothing to do with the treatment of patients, but it played its part in the morale of orthopedic surgeons in the European Theater of Operations just as it did in the morale of all other specialists, particularly toward the end of the war. At this time a few 1,000-bed hospitals were raised to 1,500-bed status, which theoretically provided for an increase in rank for some specialists. With a single exception, the hospitals in this group were not the original affiliated units which had been in the theater from the very beginning but were new hospitals, whose officers, in terms of service, were not always entitled to increases in rank. A number of last-minute shifts in personnel were effected, in an attempt to secure promotion for outstandingly qualified officers with long and meritorious service, but few of these promotions went to orthopedic surgeons.

Some hospitals entered the European theater from the Mediterranean theater with 1,500 beds and with some of their specialists already lieutenant colonels, though their service had been no longer than that of the orthopedic surgeons in the European theater who had been denied promotion. The comparison in rank naturally was unfortunate.

It was the feeling of the senior consultant in orthopedic surgery that some 10 of the approximately 400 surgeons doing orthopedic work in the European theater should have been advanced to the rank of lieutenant colonel by the end of hostilities. All of this group had served approximately 3 years in grade, and all had made significant contributions to the Army effort. Because of redeployment and freezing of promotions, 9 of the 10 recommended increases in grade were never accomplished.