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Management of war injuries to peripheral nerves
MANAGEMENT OF WAR INJURIES TO PERIPHERAL NERVES W. K.
LIVINGSTON,
Portland,
T
HE purpose behind this series of papers dealing with the handling of specia1 types of war casuaIty cases is to frankly evaluate the fauIts in the methods adopted in the Iast war, with a view to bringing out constructive suggestions as to the handIing of such cases in the event of another war. It must be realized at the outset of this discussion that each one of us saw but one smaI1 segment of a most complex situation so that the criticisms we may voice may be unfair to the overburdened authorities against whom they appear to be directed. We must also reaIize that the fauIts as we saw them in the last war beIong in t&o categories, in only one of which couId our opinion be considered authoritative. The first category incIudes the fauIts inherent in any miIitary regimen suddenIy called upon to dea1 with Iarge numbers of wounded men after a long period of reIative stagnation during peacetime. The second category covers those fauIts appIicable to the handIing of particular kinds of war injury. Perhaps we shouId confine our discussion to this latter category of fauIts which invoIve our own specialty fields. Yet the two categories are so intimately reIated that it is impossibIe to consider one without regard to the other. AIthough each of us represents a different specialty in the fieId of surgery, we had one experience in common. At the termination of the war each of us was fortunate enough to be handIing the particuIar type of patient which our training and experience best qualified us to treat. We had reason to beIieve that we were contributing to better end results in these cases. We were justifiabIy proud of the fact that our efforts might we11 Iessen the permanent disability for these wounded men and proportionately diminish the economic burden that they wouId ultimateIy impose on society. The principa1 regret that each of us had in this cuIminating phase of our war experience was that the improved care of these surgica1 problem cases had not been instituted at an earIier date. The essentia1 question with which we are
November,
1948
M.D.
Oregon concerned today is how the deIays and fauIts we encountered in the last war might be lessened or eliminated in future wars. I believe that the best approach to this question is to reIate our individua1 experiences and by pooIing our impressions we may be abIe to agree on valid criticisms of past procedure and, from these, constructive suggestions may emerge. During the greater part of the war our NavaI HospitaI acted as a receiving hospital through which great drafts of men poured from the Pacific area to be distributed to other mainIand hospitals. The wounded were handIed in drafts, and not infrequentIy the hospita1 admitted more than 1,000 new patients in a singIe day. At the peak of our Ioad in 1944 there were 57,000 new admissions which meant approximateIy a compIete turnover of our fuI1 bed capacity each month. There were times in which we had a serious shortage of medica officers to handIe these wounded men. Yet within a few miIes of us were two great camps in which hundreds of naval medica officers were marking time whiIe they waited for orders from Washington. Among these men were many speciaIists whose services would have been invaIuabIe to us and hundreds of younger men eager for the hospita1 experience we could have offered them. These medical oflicers “stewed in their own juices” for months at a time and no one in our nava1 district had the authority to give these men temporary assignments or to see that when they received orders from Washington the duty was such as to fit their particuIar taIents. The waste of specia1 taIent was aIso apparent within the hospita1 itself. Not only was there insuffIcient cIerica1 help on the wards, but nurses, corpsmen and Waves were constantIy changing. Proper care of those with peripheral nerve injuries requires special skills, and no sooner did one of these persons begin to acquire that ski11 than they were moved eIsewhere. The need for specia1 training was even more obvious among the medical officers assigned to heIp with the work on our wards. Not onIy was
537
i-38
Livingston--Injuries
special skill needed in the surgical treatment of nerve injuries, but in the study of these cases upon which decisions as to treatment and prognosis must depend. For the first half of the war the average stay of these young medica officers on my ward was less than one month. In addition, the necessity for filling the outgoing drafts required that we ship out nerve patients regardIess of the stage of their investigation and treatment. In the final phase of the war this grim picture changed considerably. Much of this change was due to the efforts of our commanding officer. He appreciated the improved care of surgical problems that couId be afforded on the specialty wards, and he made every effort to provide the speciaIists with the equipment they needed and to assure some continuity of service in personne1. There was also evidence that the Bureau of Medicine and Surgery in was becoming aware of the Washington speciaIty care of surgica1 probIems. Centers were established to which particuIar kinds of cases were to be assigned; young medical officers were sent to these centers for training and with some prospect of greater continuity of service and greater efforts were made to supply the centers with the equipment and personne1 that they needed. Our hospita1 was designated as a center for periphera1 nerve injuries, and in a smaI1 measure we were able to carry out parts of the program for their care that had been so we11 estabIished by the British. In my opinion neither the Navy nor the Army ever approximated a fuI1 implimentation of the exceIIent British program for the handIing of nerve injuries. And the sad commentary on the British pIan was that it was avaiIabIe to our miIitary authorities in its compIete form before the United States entered the war. To return to the probIems peculiar to nerve injuries we learned something about them even during the diffIcuIt and confused earIy phases of the war. At this time the lack of transport delayed evacuation of wounded men from the Pacific area to the mainland hospitaIs for long periods. Even during the second year of the war the time interval between wounding and admission to our hospita1 for these nerve patients averaged five and one-half months. In this interva1 most of the men had been moved from one hospital unit to another, rareIy staying long enough in one place to permit adequate
to
Peripheral
Nerves
investigation or treatment. This Iong delay was certainIy regrettable, but it taught us two lessons which might otherwise have escaped attention. First, we were surprised to find that after months of complete nerve paralysis some of our patients were showing signs of spontaneous recovery of function. In certain of these cases one could fee1 a neuromatous enlargement of the nerve trunk near the IeveI of wounding, and yet both sensory and motor function were aIready we11 established dista1 to the IocaI Iesion. High veIocity missiIes reIease enormous energies in their wake which tear or stretch nerves to produce disruption of nerve fibers without actua1 interruption of the nerve trunk. Our observations indicated that in a considerabIe number of “Iesions in continuity” a spontaneous recovery of function occurred that was more compIete than a surgeon couId hope to confer by resection of the IocaI lesion and end-to-end suture of the nerve trunk. Yet I am convinced that had we expIored these patients whiIe their paraIysis was complete we wouId have resected the IocaI Iesion. UnIess we had seen for ourseIves how comptete spontaneous regeneration may be through many of the Iesions in continuity, I know that we would have resected many of them without ever questioning the advisabiIity of this procedure. These observations Ied us to be very conservative in the treatment of any nerve Iesion in which there was any reasonable chance for spontaneous regeneration. A second Iesson that the last war taught was that attempts to repair surgicatly nerve injuries immediately after wounding are ill advised. The British have cIearIy shown that entirely aside from the hazards of infection and inadequate surgery in the front areas, the end resuIts are better after early secondary repair of nerve Iesions than after immediate repair. The optimum time for nerve suture seems to be three or four weeks after a nerve has been severed although under war conditions any time within the first three months could properly be considered as early secondary suture. These facts have a bearing on the handling of nerve casualty patients, in that it does not seem to be imperative that trained surgica1 teams operate in the front areas. These patients couId be handled by general surgeons exactIy as are those with wounds uncompIicated by nerve injury except that a American
Journal of Surgery
Livingston--Injuries carefu1 record shouId be made as to the exact status of the sensory and motor findings during this earIy period of observation. If good records were kept, there would be no necessity for giving nerve patients a high priority in being evacuated so long as they reached a center designated for their care within the first month or two after wounding. The deIay that occurred in evacuating the wounded to mainIand hospitaIs in the Iast war taught one other lesson which was that pIaster casts shouId not be used to support paralyzed muscIes in the uncompIicated case of nerve injury. Our medical officers had been taught that a11 paraIyzed muscIes shouId be supported to prevent overstretching and contractures. Since light splints were not avaiIabIe to them, they used pIaster casts. In the months that eIapsed between wounding and the time these men reached us they wore these pIaster casts continuously. They were moved so frequently from one hospita1 unit to another that no one had time to investigate them we11 and as Iong as the pIaster cast was reasonabIy comfortabIe and rigid it was Ieft on. If it had to be removed for some reason and the paraIysis was stiI1 present, a new cast was appIied. By the time these men reached us the muscIe atrophy and joint stiffness resuIting from the Iong period of immobilization were often of as serious consequence as the nerve Iesion itself. The first standing order issued on the periphera1 nerve wards of our hospita1 was that a11 plaster casts must be bivalved within twenty-four hours of the patient’s admission. It was most unusua1 to find any justification for a re-application of a rigid support. Active use of the affected Iimb was of such importance in these cases that we seIdom used even the Iightest spIints. In fact, our staff came to doubt the advisabiIity of routine splinting for any uncompIicated case of periphera1 nerve injury. I shaI1 not attempt to justify this view here, but there can be no argument over the fact that rigid immobilization of paraIyzed muscIes for extended periods can do much more harm than no spIinting at aI1. There are other problems relating to the surgica1 handIing of peripheral nerve injuries which might be mentioned, relating to suture materia1, grafts, protective sIeeves, prognostic testing and the Iike, but these are technical problems which have no place in this group discussion. If specialty patients are segregated November,
I 948
to
Peripheral
Nerves
539
and are pIaced under the care of properly trained medical oficers, these questions will answer themseIves. The point which we must emphasize is that prewar pIanning must provide for such segregation and the deIegation of sufficient authority to the specialist to enable him to give his patient adequate care. I am aware that certain reservists are cooperating with the military authorities in the Medical Corps of both the Army and the Navy in making prewar pIans and that a few medical offrcers in active service are being certified by the speciaIty Boards. An authority has told me that, “as soon as a war is declared and mobilization we11 under way, the quaIified specialists in the Navy and among the Reserves wiI1 automaticaIIy get together and decide upon an over-a11 pIan from the time the periphera1 nerve is injured unti1 rehabilitation is compIete.” Personally, I have no faith in this optimistic prediction. There is no way for speciaIists to “automaticaIIy get together” unIess this is arranged for as part of a definite plan, and even if they are successful in getting together it is to be doubted that they will have the authority to impIiment their recommendations. Once mobiIization gets under way these men wiI1 again be Iost in the shufHe and their efforts wiI1 be effectively stifled by- superior officers who have neither insight into speciaIty problems nor toIerance for the specialist. UnIess there is a definite prewar plan for the handIing of speciaIty patients and some alteration in the genera1 attitude toward the specialist among the reguIars, I predict that we wiI1 witness the same waste of surgical taIent which was so distressing in the last war. If I were to Iist the things which I think prewar pIanning should provide for as a minima1 provision for the handIing of peripheral nerve injuries, these would be incIuded: (I) The establishment of centers for the specia1 care of peripheral nerve injuries. These patients should be evacuated from the front areas to a center as soon as possible after the more critical casualty patients have been cared for. (2) Provide that each nerve patient be sent to the mainland center nearest his home and keep him there until his fina disposition. (3) Put the best avaiIabIe specialists in charge of these speciaIty patients and provide them with the equipment and assistance they need for efficient service. (Adequate assistance should include cIerica1 help.) Strictly medical decisions relat-
340
Livingston-Injuries
ing to patient care shouId be in his hands even though ward responsibility may be shared by less we11 trained oficers of higher rank. (4) Give these centers the responsibility for training young medical officers in speciahy work. Give these trainees sufficiently Iong term assignments to this duty to assure continuity of service. (3) Provide for the patients vocationa training, recreationa facilities, and a IiberaI “Ieave” policy. PeripheraI nerve patients have long periods between stages in surgical treatment during which hospitalization is not a necessity. Judicious use of extended leaves tends to maintain good moraIe and to make additiona beds avaiIabIe. (6) Last, but not least, aboIish the saying, “You are a NavaI Officer first, a doctor second, and a speciaIist last, if ever” as we11 as the attitude which such a statement connotes. It is this Iast point that I would Iike to ampIify in my closing comments. I think the specialists from the medica reserve did a fine job in World War II. I am wiIIing to believe that the military authorities recognized this service in the Iast few months of the war and were sincere when they tried to get many of these men to remain in active service. If the authorities in Washington had been a Iittle Iess set in their ways and wiIIing to give assurance that these men wouId be retained in their specialist capacity to care for patients, to train young medica officers and to have an active part ;n prewar planning, some of these men would have remained in service no matter
to PeripheraI
Nerves
what personal sacrifice it might have entailed. But in the absence of any such assurances and with no reason to beIieve that the prewar pIanning wouId be any more apt to conserve medical talent than it did in the Iast war, the seIf-respect of these men demanded that they Ieave active service. It is exactIy these same considerations which have influenced most of these men to resign their commissions in the reserve corps. I am convinced that these resignations are not a sign of lack of patriotism. I am sure that if another war shouId come these men will be back in service, but they beIieve, and I for one beIieve they are justified in this feeIing, that their chances of getting an assignment for which they are particuIarIy fitted would be better if they were compIeteIy outside the reserves than if they retained their commissions. I am confident that there are many speciaIists formerly in the reserves who couId be persuaded to undertake the training of medical officers in their specia1 fieId of surgery right now, and I am sure that many of them would be gIad to assist in prewar planning, at least insofar as the handIing of specia1 types of patients is concerned. To enlist their aid shouId require IittIe more than good evidence that the reguIar’s attitude toward the specialist had undergone a change, and an assurance that what they heIped pIan for in the event of another war wouId have a reasonable chance of accomplishment.
American
Journal
of Surgery
LIVINGSTON,
Portland,
T
HE purpose behind this series of papers dealing with the handling of specia1 types of war casuaIty cases is to frankly evaluate the fauIts in the methods adopted in the Iast war, with a view to bringing out constructive suggestions as to the handIing of such cases in the event of another war. It must be realized at the outset of this discussion that each one of us saw but one smaI1 segment of a most complex situation so that the criticisms we may voice may be unfair to the overburdened authorities against whom they appear to be directed. We must also reaIize that the fauIts as we saw them in the last war beIong in t&o categories, in only one of which couId our opinion be considered authoritative. The first category incIudes the fauIts inherent in any miIitary regimen suddenIy called upon to dea1 with Iarge numbers of wounded men after a long period of reIative stagnation during peacetime. The second category covers those fauIts appIicable to the handIing of particular kinds of war injury. Perhaps we shouId confine our discussion to this latter category of fauIts which invoIve our own specialty fields. Yet the two categories are so intimately reIated that it is impossibIe to consider one without regard to the other. AIthough each of us represents a different specialty in the fieId of surgery, we had one experience in common. At the termination of the war each of us was fortunate enough to be handIing the particuIar type of patient which our training and experience best qualified us to treat. We had reason to beIieve that we were contributing to better end results in these cases. We were justifiabIy proud of the fact that our efforts might we11 Iessen the permanent disability for these wounded men and proportionately diminish the economic burden that they wouId ultimateIy impose on society. The principa1 regret that each of us had in this cuIminating phase of our war experience was that the improved care of these surgica1 problem cases had not been instituted at an earIier date. The essentia1 question with which we are
November,
1948
M.D.
Oregon concerned today is how the deIays and fauIts we encountered in the last war might be lessened or eliminated in future wars. I believe that the best approach to this question is to reIate our individua1 experiences and by pooIing our impressions we may be abIe to agree on valid criticisms of past procedure and, from these, constructive suggestions may emerge. During the greater part of the war our NavaI HospitaI acted as a receiving hospital through which great drafts of men poured from the Pacific area to be distributed to other mainIand hospitals. The wounded were handIed in drafts, and not infrequentIy the hospita1 admitted more than 1,000 new patients in a singIe day. At the peak of our Ioad in 1944 there were 57,000 new admissions which meant approximateIy a compIete turnover of our fuI1 bed capacity each month. There were times in which we had a serious shortage of medica officers to handIe these wounded men. Yet within a few miIes of us were two great camps in which hundreds of naval medica officers were marking time whiIe they waited for orders from Washington. Among these men were many speciaIists whose services would have been invaIuabIe to us and hundreds of younger men eager for the hospita1 experience we could have offered them. These medical oflicers “stewed in their own juices” for months at a time and no one in our nava1 district had the authority to give these men temporary assignments or to see that when they received orders from Washington the duty was such as to fit their particuIar taIents. The waste of specia1 taIent was aIso apparent within the hospita1 itself. Not only was there insuffIcient cIerica1 help on the wards, but nurses, corpsmen and Waves were constantIy changing. Proper care of those with peripheral nerve injuries requires special skills, and no sooner did one of these persons begin to acquire that ski11 than they were moved eIsewhere. The need for specia1 training was even more obvious among the medical officers assigned to heIp with the work on our wards. Not onIy was
537
i-38
Livingston--Injuries
special skill needed in the surgical treatment of nerve injuries, but in the study of these cases upon which decisions as to treatment and prognosis must depend. For the first half of the war the average stay of these young medica officers on my ward was less than one month. In addition, the necessity for filling the outgoing drafts required that we ship out nerve patients regardIess of the stage of their investigation and treatment. In the final phase of the war this grim picture changed considerably. Much of this change was due to the efforts of our commanding officer. He appreciated the improved care of surgical problems that couId be afforded on the specialty wards, and he made every effort to provide the speciaIists with the equipment they needed and to assure some continuity of service in personne1. There was also evidence that the Bureau of Medicine and Surgery in was becoming aware of the Washington speciaIty care of surgica1 probIems. Centers were established to which particuIar kinds of cases were to be assigned; young medical officers were sent to these centers for training and with some prospect of greater continuity of service and greater efforts were made to supply the centers with the equipment and personne1 that they needed. Our hospita1 was designated as a center for periphera1 nerve injuries, and in a smaI1 measure we were able to carry out parts of the program for their care that had been so we11 estabIished by the British. In my opinion neither the Navy nor the Army ever approximated a fuI1 implimentation of the exceIIent British program for the handIing of nerve injuries. And the sad commentary on the British pIan was that it was avaiIabIe to our miIitary authorities in its compIete form before the United States entered the war. To return to the probIems peculiar to nerve injuries we learned something about them even during the diffIcuIt and confused earIy phases of the war. At this time the lack of transport delayed evacuation of wounded men from the Pacific area to the mainland hospitaIs for long periods. Even during the second year of the war the time interval between wounding and admission to our hospita1 for these nerve patients averaged five and one-half months. In this interva1 most of the men had been moved from one hospital unit to another, rareIy staying long enough in one place to permit adequate
to
Peripheral
Nerves
investigation or treatment. This Iong delay was certainIy regrettable, but it taught us two lessons which might otherwise have escaped attention. First, we were surprised to find that after months of complete nerve paralysis some of our patients were showing signs of spontaneous recovery of function. In certain of these cases one could fee1 a neuromatous enlargement of the nerve trunk near the IeveI of wounding, and yet both sensory and motor function were aIready we11 established dista1 to the IocaI Iesion. High veIocity missiIes reIease enormous energies in their wake which tear or stretch nerves to produce disruption of nerve fibers without actua1 interruption of the nerve trunk. Our observations indicated that in a considerabIe number of “Iesions in continuity” a spontaneous recovery of function occurred that was more compIete than a surgeon couId hope to confer by resection of the IocaI lesion and end-to-end suture of the nerve trunk. Yet I am convinced that had we expIored these patients whiIe their paraIysis was complete we wouId have resected the IocaI Iesion. UnIess we had seen for ourseIves how comptete spontaneous regeneration may be through many of the Iesions in continuity, I know that we would have resected many of them without ever questioning the advisabiIity of this procedure. These observations Ied us to be very conservative in the treatment of any nerve Iesion in which there was any reasonable chance for spontaneous regeneration. A second Iesson that the last war taught was that attempts to repair surgicatly nerve injuries immediately after wounding are ill advised. The British have cIearIy shown that entirely aside from the hazards of infection and inadequate surgery in the front areas, the end resuIts are better after early secondary repair of nerve Iesions than after immediate repair. The optimum time for nerve suture seems to be three or four weeks after a nerve has been severed although under war conditions any time within the first three months could properly be considered as early secondary suture. These facts have a bearing on the handling of nerve casualty patients, in that it does not seem to be imperative that trained surgica1 teams operate in the front areas. These patients couId be handled by general surgeons exactIy as are those with wounds uncompIicated by nerve injury except that a American
Journal of Surgery
Livingston--Injuries carefu1 record shouId be made as to the exact status of the sensory and motor findings during this earIy period of observation. If good records were kept, there would be no necessity for giving nerve patients a high priority in being evacuated so long as they reached a center designated for their care within the first month or two after wounding. The deIay that occurred in evacuating the wounded to mainIand hospitaIs in the Iast war taught one other lesson which was that pIaster casts shouId not be used to support paralyzed muscIes in the uncompIicated case of nerve injury. Our medical officers had been taught that a11 paraIyzed muscIes shouId be supported to prevent overstretching and contractures. Since light splints were not avaiIabIe to them, they used pIaster casts. In the months that eIapsed between wounding and the time these men reached us they wore these pIaster casts continuously. They were moved so frequently from one hospita1 unit to another that no one had time to investigate them we11 and as Iong as the pIaster cast was reasonabIy comfortabIe and rigid it was Ieft on. If it had to be removed for some reason and the paraIysis was stiI1 present, a new cast was appIied. By the time these men reached us the muscIe atrophy and joint stiffness resuIting from the Iong period of immobilization were often of as serious consequence as the nerve Iesion itself. The first standing order issued on the periphera1 nerve wards of our hospita1 was that a11 plaster casts must be bivalved within twenty-four hours of the patient’s admission. It was most unusua1 to find any justification for a re-application of a rigid support. Active use of the affected Iimb was of such importance in these cases that we seIdom used even the Iightest spIints. In fact, our staff came to doubt the advisabiIity of routine splinting for any uncompIicated case of periphera1 nerve injury. I shaI1 not attempt to justify this view here, but there can be no argument over the fact that rigid immobilization of paraIyzed muscIes for extended periods can do much more harm than no spIinting at aI1. There are other problems relating to the surgica1 handIing of peripheral nerve injuries which might be mentioned, relating to suture materia1, grafts, protective sIeeves, prognostic testing and the Iike, but these are technical problems which have no place in this group discussion. If specialty patients are segregated November,
I 948
to
Peripheral
Nerves
539
and are pIaced under the care of properly trained medical oficers, these questions will answer themseIves. The point which we must emphasize is that prewar pIanning must provide for such segregation and the deIegation of sufficient authority to the specialist to enable him to give his patient adequate care. I am aware that certain reservists are cooperating with the military authorities in the Medical Corps of both the Army and the Navy in making prewar pIans and that a few medical offrcers in active service are being certified by the speciaIty Boards. An authority has told me that, “as soon as a war is declared and mobilization we11 under way, the quaIified specialists in the Navy and among the Reserves wiI1 automaticaIIy get together and decide upon an over-a11 pIan from the time the periphera1 nerve is injured unti1 rehabilitation is compIete.” Personally, I have no faith in this optimistic prediction. There is no way for speciaIists to “automaticaIIy get together” unIess this is arranged for as part of a definite plan, and even if they are successful in getting together it is to be doubted that they will have the authority to impIiment their recommendations. Once mobiIization gets under way these men wiI1 again be Iost in the shufHe and their efforts wiI1 be effectively stifled by- superior officers who have neither insight into speciaIty problems nor toIerance for the specialist. UnIess there is a definite prewar plan for the handIing of speciaIty patients and some alteration in the genera1 attitude toward the specialist among the reguIars, I predict that we wiI1 witness the same waste of surgical taIent which was so distressing in the last war. If I were to Iist the things which I think prewar pIanning should provide for as a minima1 provision for the handIing of peripheral nerve injuries, these would be incIuded: (I) The establishment of centers for the specia1 care of peripheral nerve injuries. These patients should be evacuated from the front areas to a center as soon as possible after the more critical casualty patients have been cared for. (2) Provide that each nerve patient be sent to the mainland center nearest his home and keep him there until his fina disposition. (3) Put the best avaiIabIe specialists in charge of these speciaIty patients and provide them with the equipment and assistance they need for efficient service. (Adequate assistance should include cIerica1 help.) Strictly medical decisions relat-
340
Livingston-Injuries
ing to patient care shouId be in his hands even though ward responsibility may be shared by less we11 trained oficers of higher rank. (4) Give these centers the responsibility for training young medical officers in speciahy work. Give these trainees sufficiently Iong term assignments to this duty to assure continuity of service. (3) Provide for the patients vocationa training, recreationa facilities, and a IiberaI “Ieave” policy. PeripheraI nerve patients have long periods between stages in surgical treatment during which hospitalization is not a necessity. Judicious use of extended leaves tends to maintain good moraIe and to make additiona beds avaiIabIe. (6) Last, but not least, aboIish the saying, “You are a NavaI Officer first, a doctor second, and a speciaIist last, if ever” as we11 as the attitude which such a statement connotes. It is this Iast point that I would Iike to ampIify in my closing comments. I think the specialists from the medica reserve did a fine job in World War II. I am wiIIing to believe that the military authorities recognized this service in the Iast few months of the war and were sincere when they tried to get many of these men to remain in active service. If the authorities in Washington had been a Iittle Iess set in their ways and wiIIing to give assurance that these men wouId be retained in their specialist capacity to care for patients, to train young medica officers and to have an active part ;n prewar planning, some of these men would have remained in service no matter
to PeripheraI
Nerves
what personal sacrifice it might have entailed. But in the absence of any such assurances and with no reason to beIieve that the prewar pIanning wouId be any more apt to conserve medical talent than it did in the Iast war, the seIf-respect of these men demanded that they Ieave active service. It is exactIy these same considerations which have influenced most of these men to resign their commissions in the reserve corps. I am convinced that these resignations are not a sign of lack of patriotism. I am sure that if another war shouId come these men will be back in service, but they beIieve, and I for one beIieve they are justified in this feeIing, that their chances of getting an assignment for which they are particuIarIy fitted would be better if they were compIeteIy outside the reserves than if they retained their commissions. I am confident that there are many speciaIists formerly in the reserves who couId be persuaded to undertake the training of medical officers in their specia1 fieId of surgery right now, and I am sure that many of them would be gIad to assist in prewar planning, at least insofar as the handIing of specia1 types of patients is concerned. To enlist their aid shouId require IittIe more than good evidence that the reguIar’s attitude toward the specialist had undergone a change, and an assurance that what they heIped pIan for in the event of another war wouId have a reasonable chance of accomplishment.
American
Journal
of Surgery