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s F

MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II

,DTCnout 15*ft--- QULT 

DTmc QAIM.•' NI~~-m
MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR II

ACTIVITIES OF SURGICAL CONSULTANTS

Volume II

Prepared and published under the direction of

Lieutenant General LEONARD D. HIEATON

The Surgeon General, United States Army

Editor in Chief Accesion For

Colonel JOHN BOYD COATES, Jr., MC, USA NTIS CRAM&

Editor for Activities of Surgical Consultants DTIC n TAB d Unannounced 7

B. NOLAND CARTER, M.D. Justitication .........

Associate Editor

ELIZABETH M. McFETRJDGE, M.A. Distribution I

Availabilhty Codes

Avail al arv o I 

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D.C., 1964
SURGERY IN WORLD WAR II

Advisory Editorial Board

MI('IIAEI, E. DEBAKEY. M.I).. Chairman

FRANK B. ]]ERI{Y. M.I). Jot[.•" B. FLICK. MAt.

BRIAN BLAI•F:S. M.I). FRANK {h.EX.•, M.I).

.]'. BARRETT BROWN. M.I). M. EI.IIOTT RANI}OLPII, M.I).

*•TERIING BUNNELL, 3[.l•. (de('.) IsIDOR S. R,\vDIN, M.I).

•ORTON [•ANFII'•I.D, 3I.D. Jost:Vll R. ,•IlAEFFER, •|.]).

B. NOLAND C, ARTI,:R, M.D. ALFItI,:D R. SHANDS, Jr., M.1).

EDW,\RD I}. CHURCIIILL, M.I). IIOWARD E. SNYDEU, M.I}.

MATIIER ('I.EVELAND, 31.1). R. (•LFN SPURLING. 3I.D.

I)ANIEL C. ElKIN, M.I). (dec.) BAR.'X'E8 WOODIIALI,, M.I).

ROI•ERT •[. ZOLL1N(;I..R. •[.I}.

Brigadier General JAMES E. GRAHAM, I'SA (ex officio)

Brigadier Gelleral DOUGLAS B. KF,.X'•RICK. Jr., USA (ex officio)

Colonel JoH.• BOYD COATES, .•r., •[C, USA (ex o•cio)

The Historical U•tit, Ullitt'd ,'•tat{'s Army Medical ,'•€'r;'iee

Colonel JoiLx" BoYD COATES, Jr.. MC, USA, Director

CIIARLES J. SI.XIPSON, Exccutirc O•iccr

Lieutenant Cohmel |}OUGI.A8 HESFORD. MSC, USA, Chirr, ,•pccial Prf#jccts Branch

CIIARLZS M. WII.TSE, Ph. I•., Litt. I).. Chit'f. Historittns Branch

ERNEST ELI.IOTT, Jr., Chic'f, Editorial Branch

Lieutenant Colonel 3EROX[•: Rl:lmE•c,, MSC, USA. Chi¢'f Information A etirities Branch

RODF, RICK M. EN(•ERT. Chit'f, General Re/eren¢'¢' atld Research ?,ranch

HAZEL G. HINE, Chief, Administrative Bra•wh

Library of Congress Catalog Card Number: 62-60004

i i l l HI I ill I I i II
ACTIVITIES OF

SURGICAL CONSULTANTS

Volume II
MEDICAL DEPARTMENT, UNITED STATES ARMY

"The vohlues comprising the official history of the Medical D)epartmnent

of the Ulnited States Army ill World War II are prepared by The Historical

limit, I lmited States Army Medical Service, and published under the direct ion of The Surgeon (General, U.S. Army. These volumes are divided into

two series: (1) The administrative or operational series: and (2) the professioldI. or clinical and technical, series. This is role of the vohluies pibdished

in the latter series.

VOLUMES PITBLISIIEI)

AI)MINISTHATIVE SERIES

HoxIb pial;z/ ioyi and AI1'r,'tit;on. Zone of Interior

Orqan zathon (ll Admin.tJt .a l n .l ;iWorld WVar II

P~ersonnel ing World War HI

(CINI('AL SERIES

Internal Medicine in World War 11 :

1,o/. I. Ateft'u s of .lledh'l (Yon.11tatnt.

I(0l. !!. In feetwm I)Pi.axemw,

Prevent iwe Mediciine in Worlid War II:

Vol. II. liEmro' nmental ll!/qq'ne

IVol. Ill. Personal Health .1leasires and 1mmun;zat;on.

V"ol. i1'. ('ommuncable l);.tseaxex. Tr7, smlmttd Chiefly T'hrough Res-

)i;r, toetl and A lmentar.q Tracts

10ol. 1'. Coimminieabh. Diseases Transmnitted Throuqh Contact or

Bfy 1

t nknoien Meons

IVo. 17. Commu nicab'le isveases: Malatrhi

"U&
vill ACTIVITIES OF SURGICAL CONSULTANTS

Surgery in World War II:

Activities of Surgical ('onsultants, vol. 1

General Surgery, vol. II

Hand Surgery

Neurosurgery, vol. I

Neurosurgery, vol. II

Ophthalmology and Otolaryngology

Orthopedic Surgery in the European Theater of Operations

Orthopedic Surgery in the Mediterranean Theater of Operations

The Physiologic Effects of Wounds

Thoracic Surgery, vol. I

iascular Surgery

Miscellaneous:

(Cold Injury, Ground Type

Dent al Service in World War 11

Veterinary Service in World War H1

Wound Ballistics
Authors

EUGENE M. BRICKER, M.).

Associate Professor of Clinical Surgery, Washington University School of Medicine,

St. Louis, Mo. Chief Consultant ill Plastic Surgery to the Chief Surgeon, European

Theater of Operations, U.S. Army, 1943-45. Formerly Colonel, MC, AUS.

NoRToN CANFmLD, M.D.

Associate Clinical Professor in Otolaryngology, Yale U'niversity School of Medicine.

New Haven. Conn.; Consultant in Otolaryngology, U.S. Veterans' Administration

Center, San Patricio Hospital, San Juan, P.R., and Rodriguez U.S. Army Hospital,

Antilles Command, U.S. Army Caribbean: Consultant in Audiology to The Surgeon

General, U.S. Army, Washington, D.C., since 1946. Senior Consultant in Otolaryngology, Office of the Chief Surgeon, European Theater of Operations, U.S. Army,

1943-45; Chief, Otolaryngology Branch. Surgical Consultants D)ivision. Office of The

Surgeon General. 1945-46: Chief Consultant in Audiology, Veterans' Administration.

Washington. D.C.. 1946-55. Formerly Colonel, MC, AUS.

MATIIER CLEVELAND, M.D., Sc.D.

Consulting Orthopaedic Surgeon, St. Luke's Hospital and Presbyterian Hospital, New

York. N.Y.; Civilian Consultant in Orthopedic Surgery to The Surgeon General.

U.S. Army. Orthopedic Consultant, Fourth Service Command. 1943-44; Senior Consultant in Orthopedic Surgery, European Theater of Operations. U.S. Army. 1944-45.

Formerly Colonel. MC, AUS.

ELLIOTT C. CUTLER. M.I). (Deceased)

Moseley Professor of Surgery. Harvard Medical School, Boston. Mass.. 19322-47;

Surgeon-in-Chief, Peter Bent Brigham Hospital, 1932-47; Civilian Consultant to the

Secretary of War, 1.46-47: Chief Consultant in Surgery, Office of the Chief Surgeon.

European Theater of Operations, U.S. Army, 1942-45; Chief, Professional Services

Division, Office of the Chief Surgeon, European Theater of Operations, 1945. Formerly

Brigadier General, AUS.

LOYAL DAVIS, M.D.

Professor and Chairman, Department of Surgery, Northwestern University hMedical

School. Chicago, Ill. Senior Consultant in Neurological Surgery to the Chief Surgeon.

European Theater of Operations, U.S. Army, 1942-43. Formerly Colonel, MC. AUS.

REX L. 1)rvEr.EY. M.D.

Associate Professor of Orthopaedic Surgery, Kansas University School of Medicine.

Kansas City. Kans. : Area Orthopedic Consultant, Veterans' Administration, St. Louis,

Mo. Senior Consultant in Orthopedic Surgery, Office of the Chief Surgeon, and, later.

Chief. Rehabilitation Division, Office of the Chief Surgeon, European Theater of Operations. U.S. Army. 1942-45. Formerly Colonel, MC, AUS.

GEORGE 0. EATON. M.D., C.M.

Associate Professor of Orthopedic Surgery, The Johns Hopkins University School of

Medicine, Baltimore. Md. Orthopedic Consultant for the Southwest Pacific Area,

194.3-45; Civilian Consultant in Orthopedic Surgery to The Surgeon General, 1953-58.

Formerly Lieutenant Colonel, MC, AUS.

JoHx B. FLICK. M.D.. C.M.

Consulting Surgeon. Pennsylvania Hospital, Philadelphia, Pa., and Bryn Mawr Hospital. Bryn Mawr, IPa.; Consultant in Surgery, Valley Forge Army Hospital. Phoenixville,

IPa.; Secretary-Treasurer, The American Board of Surgery, since 1952. Consultant in

Surgery. Ninth Service Command. 1942-45; Consultant in Surgery, Pacific Ocean Areas.

1945. Formerly Colonel, MC, AUS.

Ix 705-4951- .-64--- 2
X ACTIVITIlES OF SURG(ICAL CONSULTANTS

A. STEPiirNS GRAHAM!, M.lD., M.1.. (11n Surgery)

Associate (Clinical Professor of Surgery, Medical College of Virginia ; Chief. Surgical

Service. Stuart Circle Hosp~ital ; Surgical Consultant. Veterans' Admninist ration Hospital. Richmiond. Va. Chief. Surgical Service, 45th General Hospital, ('amp Lee. Va., and

Rabat, French Morocco. 19)42-43: Surgical ('onsultant. First Service Commnand, 1143-44:

Su rgical Conisuil tant, lad la-Burnia anad (China Theaters, 1145. Formerly Colonel. 1MC.

Al' S.

Area ('onsultanit in O phthalmuology. Veterans' Administration, for States of Oregon.

Washington. Idahio. Utah. Nevada, and northern ('alifornia. Presidlent. Nevada State

.Medical Associat ion. Chief. Eye ('enter, Valley Forge General Hospital. Phoenixville.

Pa., 1943-ý-45: Senior Consultant in Ophthalmology. European Theater of Operations.

19)45. C'olomnel, M1C. USAR (Ret.).

PAVL. 11. HAwIVX,E.MI. LL.D.. Se*. D.

('hief Surgeon. Sp~ecial Observer Group. London, England. 19)41-42: Chief 'Surgeon,

1.S. Army Forces in the British Isles and Europeami Theater of Operations, UT.S. Army,

#111( later Chief. 'Medical Services. Services of Supply. European Theater of Operations,

U.S. Army. 19)12: Chief Surgeon. European Theater of Operations, 1,.S. Army, 1943-45;

concurrently Chief Surgeon, Services of Supply (later (Commnunications Zone), European Theater of Operation.,. U. S. Army, 19)44-45. Chief Mledical Director, D~epartment

of Medicine and Surgery. U. S. Veterans' Administration. 11W5-"7; Chief Executive

Offiver. Blue Cross andl Blue Shield Commissions, 19485-; D~irector. American (College

of Surgeons, 15-1.Major General. USA (Ret.).

JAMES C. KiNIiaoi-uMI. Colonel. 31C. USA (Ret.) (D1eceased)

Chief, Professionial Services D)ivision. Office of the Chief S:4urgeon. European Theater

of Operations. U.S. Ariny. 19)42-45 . (Comnmanding Officer, Percy JIones ('onvalescent

Hospital. 19)45-41); Chief. Genlito-Uriiumry Service, Walter Reed Army Hospital. Washington, D.C.., 19)40-53 ; Consultant in Urology. Walter Reed Army Medical Center,

195.3-56.

AsIILEY W. OI-GirrFRSON, M.D. (Deceased)

(Clinical Professor of Surgery, School of Medicine, Yale University, Newv Haven, Conn.,

1943-56. Formerly Colonel. MC', USAR.

W.M. BARCLAY PARSONS, 'M.D).

Professor Emieritus of (Clinical Surgery, (College of Physicians, and( Suirgeons. Columbia

University, New York. N.Y. Surgical Consultant. Services of Supply, Southwest

Pacific Area, 19)42-44 : Surgical Consultant. Sixth Service C'omamand. 1944-45.

Formerly (Colonel. ('81. AU'S.

BEnNARD.r. PISANI. 11.1).

Director, Obstetrics and Gynecology, St. Vincent',s Hospital. New York, N.Y.. since

19531: Assistant Visiting Obstetrician andl G;yniecologist, Blellevue Hospital ('enter.

New York. N.Y., since 1946: Chairman Advisory Committee, and (Consultant in Gynecology, Veterans' Administration Hlospital, East Orange, N.JT.. since 19.54 : Spec*ial

(Consultant in Gynecology, D~epartment of M1edicine and Surgery. Veterans' Admninistratiolll, Washington. D).C.. Sin(ce 1954; Consultant iii Obstetrics andl G ynecology, Community

Hospital, Glen Cove, N.Y.. and St. Francis Hospital, Pouglikeepsie. N.Y.. since 19)55:

Associate (Clinical Professor of Obstetric's and Gynecology, Newv York University, since

19)51. Chief, Surgical Service, 1219)th (Corps Area Service Command. 19)42 ; C'ommanding

Officer, 16th Station flospital, 1942; Pos4t Surgeon, all(l later (Chief of Mess School, Hleadquarters, American School ('enter, Services of ISupply, European Theater of Operations.

F.S. Army, 19)42-43 . Dilrector. Medical Field Service School. Sirl veil1han]. 1!44:

Executive Officer, Professional Services Division. Office of the Chief Surgeon, European

Theater of Operations, U.S. Army. 19)44-45. Formerly Lieutenant (Colonel. MC. AUS.
AUTHORS Xl

FoRRESTER IIAINE, M.D. (Deceased)

Consultanat in Surgery, C entral Pacific Area. 1942-45. Formierly C oloniel N(C. AU S.

RoBERT CRAWFORD RoilERTSON. M.[D., M1.S.

Orthopaedic Surgeon, Chattanooga. Tenni. Chief Orthopedic Consultant to the Surgeon.

1Hawaiian Depalrtment. Central P1acific A rea. Pacific Ocea n Area, and Mid-Pad tic. 1942-

45; Orthopedic Consultant to The Surgeon General ( Mobilization 1Designation ), 1951-5.~a

Colonel, MIC, USAR j(Ret.).

Jo1[N N. ROBiNso.N, M.D).

In private practice of urology. Formerly Associate Professor of e'linical Urology.

College of Physicians and 'Surgeons. Columbia University. New York. N.Y. Chief of

Urology, 2d General Hospital, 1942 ; Chief Consultant in Urology. Office of the Chief

Surgeon. European Theater of Operations. U.S. Army. 1942-45. Formerly Lieutenant

Colonel. MC. AUS.

RALPH M. TOVEL.. 3M.D., M. Sc.. F.F.A.R.C.S. (London)

D irector. D)epartmnent of Anesthesiology, Hartford Hospital. Hartford. Conni.: Special

Consultant in Anesthesiology to Central Offico, Veterans' Administration, Washington,

I).C. Senior Consultant in Anesthesia, European Theater of Operations. U.S. Army,

1V42-45. Formerly Colonel, M1C, AUS.

1. RIDGEWAY TRiIMBLE. M.D).

Associate Professor of Surgery, The .Johns Hopkins School of M3edicine. Baltimore. Md.;

(Civilian Consultant in Surgery to The Surgeon General. Chief of Surgical Service.

118th General Hospital. 1942-44; Chief Cionsultant in Surgery. Army Forces Westermn

Pacific and Army Forces Placific, 1944-46. Formerly Colonel, 31C, AUS.

ROBERT 31. ZOLLIiNGEi. M.D.

P'rofessor and Chairman, D)epartment of 'surgery, The Ohio State University. Columbus. Ohio. Senior Consultant in Surgery. European Theater of Operations, 1943-44;

Commanding Officer, -5th General Hospital, 1944-45. Formerly Colonel, MC, AUS.
Foreword

This volume, the twenty-sixth to be published inI the total series relating

the history of the U.S. Army Medical D)epartment in World War 11, is the

second of the two volumes dealing with the activities of surgical consultants.

Volume I, p)ublished in 19(2, describes the work of these consultants in the

Office of The Surgeon General, the extension of the system to the service comnmands in the Zone of Interior, and its operation in U.S. field armies overseas.

This second volume deals with the activities of the surgical consultants on the

theater level overseas.

As is in(dicated in the first of these volumes, no formal provision for the

consultant system existed in the office of The Surgeon General before the outbreak of World War II1, and this situal ion delayed its (levelolpment and created

many kinds of difficlilties. A major problem was that, consultants overseas

were hampered in their activities, at least initially, by the inconvenience and

ac'tunl inefficiency caused by the lack of direct channels of communication between themselves and the consultants in the Office of The Surgeon General.

The Situation led one consultant in the European theater to complain that

the theater had had little from the Zone of Interior in the way of directiv(s

or other information on the treatment of casualties.

Jumst as in the Zone of Interior, so overseas the surgical consultants occ.Iupied

themselves, withb the full approval of those in authority, not onlm with clinical

matters buti with a variety of related administrative matters. They evaluated

the qualifications of personnel and advised their assignment. They planned

sl)ecialized treatment centers and helped to implement the planning. They

sul)ervised such p)rofessional training I)rograins as were p)ractiical in an active

theater of operations. They organized ineetings and conferences on local and

general levels and planned the agenda for them. They prepared circular

letters and ETLMI)'s (essential technical medical data). They planned such

clinical studies and aiialyses as were practical in wartime. Finally, they held

themselves on constant call to aid in the solution of problems on any level

within their" competence.

Im short, consultants overseas followed the same pattern of endeavor as

the consultants in the Zone of Interior, expanding their functions, and adapting

them as necessary, in relation to the special conditions which they encountered.

As I noted in the foreword to the first of these two volumes, it is a tribute to

tile tact of tile consultants as well as to their competent performance that the

original opposition to them gradually died away. It is an even greater tribute

to them that, in the areas in which the consultant system did not op)erate, the

desire for it was frequently expressed and that, when conlsu|ltanlts were not

formally appointed, acting consultants served in various specialties for longer

or shorter periods of time.

XIII
XI1, ACI'I VITIES OF SURICI((AL CONSULTANTS

There is ai Certaini amlouint of overlappinig of other volumies by this volume,

biit it is almtost inevitable and warrants no ap)ologies. T1o have avoided it

woul1d have mleant tile setting up1 of rigidI and artificial (list itictionls. It wouldl

also have mecant tilie loss of somet hinig of real value, thle presenitat ion of miaterial

onl the same subject from different, but equally Competent, points of view.

I ami imipressed inl this volume, as I have beetlil in ll previous 'volumlles, by

tlie ailiotult of factunal niaterial it Contains and by the frankness with which thle

story is told. The Consultant sNystem dlid not a~asoperate smoothlyl. There

wvere many (difficulties, sonicl of themi Created iw personalities, others iy circull istanclies, and no purpose would be served by ignoring them. lit fact, becaulse thlese lprol)elelis h1ave h~eell b)-olrougt ouit into thle openl. it should be possible

to copebIetter with similar situations inl the future.

I tim also) impilressedl ill this volume, as I have been inl previously pulblished

volumies. by thle wisdom of the basic editorial p)olicy of ut ilizing thle p~ersonlal

exlper .ienves of present and formier medlical officers who recorded, and often

Creaitedl. the data upon which this whole history is based. It is (lesirable, of

Course, to nmake a record of events as they occuri, with ant eve to the future use

of these documnents, but inl wartime the ideal frequently gives way to thle pracI ical. atiol recordls, if they exist, are often no more than sketchy notes. If a.

formial record exists, that is good. If it (loes not, then we must rely upon the

recollect ions of tile medical officers who were there. There is scarcely a volume

inl this series lin which there are not recordled one or more major events for

which there is no formial dlocumenetation. Inl somec instances there is 110

d(wloiulenitationl at all1 for- decisions that altered the whole Course of therapy.

I Camnnot share the pedlantic view of the so-called historiographiers who regard

ll)lilras reliable unless it is corroborated by a bitofp erTom mid

there are no mnore valid sources of dlata than the medical officers whlo Served

inl World War II, who saw events happen, and who often played a part il

their creation.

For that reason I applaud the unorthodox inethod usedl inl this volunie of

tellin~g the story of the suirgical consuiltant service in the European Theater of

Operations and inl the Pacific by p)ublishling thle (edited) diaries of Brig. Genl.

Elliott C. Cutler and C'ol. Ashley W. Oughterson. .1C, who servedl as surgical

Consultanits litl those locations. Both officers (lied after the war enided, General

C utlecr before lie had done any work at all onl the hitradColonel Oughterson

when his work onl it was barely started.

The informiation which lxtli of these officers Ix)sse.--,ed was essential for

the history of t lie Consultanit systenm in both the European theater and the Pacific.

It. would have been unthinkable not to wvrite this history. The solution was to

use t heir official (diaries, which, like most official diaries, Often served ats p~ersonal

diaries as well. The material has been edited to eliminate irrelevant and extraneotis miaterial, p~erhlaps not ais drastically as it should have been, but. the editorial wvork was (lone from the standpoint of deleting nothing that wvould alter

the meanming or intent of the wvriters.
FOREWORD XV

Unfortunately, certain passages in these diaries require elucidation that

cannot now be secured. In other lpassages, one wonders whether tile diarists,

had they had the opportunity, might have wished to modify certaini of their

statements, or perhaps to comment on them. For these and other reasons, the

(diaries were submitted to the theater (area) surgeons under whonm the writers

serve(l. Maj. Gen. Plaul R. lhawley, MNC, I'SA (Ret.), Chief Surgeon, European

theater, has read and comnmente(I on the Cutler diary, while Brig. Gen. Earl

Maxwell, USAF (MC) (Ret.), Maj. Gen. John M. Willis, MC, USA (Ret.),

now deceased, and Maj. Gen. Guy B. Denit, MC, USA (Ret.), under all of whoim

Colonel Oughterson serve(l, have done the same for his diary.

After Worlh War I ended, a board of medical officers, al)l)ointed to investigate and report. upon the conduct of the Medical Department, Allied Expeditionary Forces, and to recommend imIl)rovements in it, stated that the chief

consultant in surgery in an oversea theater should be a medical officer of the

highest surgical attainnents. Wittingly or unwittingly, that recommendation

must li"-e been borne in mind over the years. The consultant system in tile

European theater in World War II began with the appointment in June 1942

of Col. James C. Kimbrough, MC, as Chief of the Professional Services I)iviSion, Office of the Chief Surgeon, and the appointlment the following month of

Col. (later Brig. Gen.) Elliott C. Cutler, MC, as Senior Consultant in Surgery.

It is hard to imagine more fortunate selections.

In February 1945, just, before Colonel Kimbrough left the theater and

General Cutler succeeded him as Chief of Professional Services, General Cutler

paid tribute to him as a mani possessed of "a canny imagination." Lie gave no

better proof of his canniness than in the imaginative use he ma(le of his Senior

Consultant in Surgery. General Cutler also paid tributA' to the Theater Chief

Surgeon who, while demanding the standardization of methods required in

wartime, was always willing to allow changes, once a better way had been

demonst rated.

Ill his comments oil General Cutler's diary, General Hlawley noted that,

while some of the observations in it are based upon incomplete or erroneous

information, they had been allowed to stand, with appropriate footnotes, because everything in the diary "* * * portrays faithfully his dedication to his

task, his resentment of everything which impeded its accomn)lishment, and wlhat

lie regarded as unjustifiable requirements of military administration. * * * he

was a devoted and loyal soldier, who contributed more than his share to the

success of the medical service of the European Theater of Operations."

Of all General Cutler's functions, p)erhap)s the most important was his

evaluation and assignment of professional l)ersomnnel. It was an extremely

difficult task, for nee(ds far outran qualified l)ei.nMIel. It was doub)ly dificiult

for him61, for, as General Hlawley also, pointed out, "an innate honesty often

coml)elled his p)rofessional judgments to I)e severe," and lie was "intolerant of

meed iocri ty."
XV I A(''1v1'tIIs orp suIImtaI., c('iNsuIrANTr.

Imminediately uponl his appointment Colonel (Cutler noted that while soldiers

ill biase hiospit als wer-e well provided for, the care of tilie soldier "ulp tili- Ititle"

was entilrelyv inadlequlate. For this lack he had a iiuinher of solut ions litcicdjing

first of all. iiioliility %v.wich -11llist he forcedl oni. ll medical services." As early

aIS August 1942 lhe declared t hat thle c-liplf nleed was for aulxilitary surlgica.l groulps.

Fromii tilie experience at D ieppe lie cocluelded that if 1iiiidile delay Ill treat ilent

were to) be a voildedhl.ospiit als imuist he set 11ip nen r points at wit iclii casita It ies would

he returned and tHat thle suiccessfuli operation of these hiosp~itals would require

tlie alitinof surical-*.1 and shock t ears Ito thle ntormnal hospitalI comp Ilemen'it.

Thelaerestl iliiiettof transit liosiittais cait perliaps be traced to iiiis colceit.

Colonel ( 'iiiler also st ressedl thle impijortatnce of triage oif casualties, and lie

I lioliglit t hat. siurgeonls at tilie fr-ont liiilist hek generllp- sit rgos s no j~ci it i

any1 parliciular hl'd. Ili, never lost sightl of tilie facet thatj It wa,,s '1n forwajrd are-as

that thle enld results o(f injuriies were det erminined ill termns of suirvi vaI, mnorbidityv,

anld lperillaliteiit deforuit it verslis colip I et e rest oraut [oil to ilornia I

liit Ilie coiirses (If inlst riict ionl t hat lie planned and tilie ci rciilar letters that

Ilie prepared, ill the lectures and talks that lie gave, ill fact, at every opportunity,

General (Otlder lost no chance- of elipi-i~)isizilig thet corr-ect inlitlil mnanagenient.

of wolli ids ill general a iud oif regionial1 wounds, %vit h spechiaI reference to iii ithiaI

wounld surgePry. I le founid tile a]lmost uiniversail hi-uiora lice (of such su rgerv

ext relielylelideressinhg. Every you hg phyNsician, lie said, should be t auight how

to handle t rautinla, for it would coinstituitte 20) to :10 p~ercent of his peaicetimne

pract ice. It, Voulld I* better, ill fact, if lled~ival stildents wvere taulght tilt prinei pies (f dehrideinent inlle i~egallt as ('el-a iiuly t hey should lear'n

theml as soo(li as thles' enitered thle A rnuv. 'Ira liinit ic siirgrery, lie emiphasized

againl and a.gaiii, is no~t a1 separaute specialty, and~ lie could1( no~t see the( logic-

;i.ppareit lv lie clea rlv) saw thle possible ha mi11-- of a1 special soc~iet. d (evot ed to it.

Ilie sluttered mllany frust ratijons ill his attempts to Solve the early pr'oblemis

associatedi with l iieie-lc1 sitppl)ies and1( equ ipmient. There were critical1 short ages

of biothi. Planning impilressedl hint ais tota-lly unrealistic. Battle provisions for

10,000) nien a inolithI iiicl uded three litters, several thlousand rolls of toilet paper,

and1( one biedpian, but, no1 oxygrel tanks and no tet anuis toxoid or ant itoxin. An

infantr1v divisioni of 17T,000) itieti was alithlorized two slpliyginloliilaI loll eteirs.

Closure of sucking wvound~s Nvollld save lives (and maike casutalt ies transportable),

))lt thie p~roper needles and silkwvorm guit r'eq uired1 to close the wounds were not

provided. General Oulder was perfeetly aware that inl wartihue it is frequenpltly

nlecessary to( accept, what, is available rat her t hani whlat is diesi rable, liut ipo

fulse with hiim went onily so far, and his iniitial supply activities marked the

begiiining of the liter stuperbily operated suppliiy service inl tile European thleater.

The provisioni of blood for forward casualties wats one oif G'eneral C utler's

miajor preocciipat ionls, as it, was oif Genleral H awley, and it, is interesting to note

how his thoughts Oil this subject. evolved. Ill 1942, aufter hearing it discnssion

oil blo0od( avid plalislia at it mieet ing of thle Royal Canadian Medical Corps P~athological Club, lie wrote iii his di ary that it seciemed to him that "thle rise of
FOREWORD XVII

plasma, etc., had let all forget the benefit of transfusion." "Our soldiers," he

continued, "are all grouped. They should be the best vehicle for getting blood

forward. No bottles to carry." Ile was soon to learn that it was not so simple,

and it was only two years later that. he was among the first to insist that local

prov ision of whole blood was entirely inadequate and that the only satisfactory

solution was an airlift of blood from the Zone of Interior.

His conversion to the perils of trenchfoot was similar. When lie first

observed it in Italy, in the fall of 1943, it seemed to him that the victims were

"using their pain very hard to get out of fighting." Later, when the troops in

the European theater were hard hit l)y ('o1l injury, there was no more ;igorous

proponent of preventive measures than lie was.

General Cutler approved of making casualties ambulatory as rapidly as

possible after surgery, but lie viewed early ambulation, which became popular

in civilian circles in the course of the war, with considerable suspicion, terming

it "a questionable acceleration of professional care."

lie made plans for special studies on abdominal wounds, thoracic wounds,

and other regional wounds, and for studies on gas gangrene, which fortunately

proved unnecessary. He also planned special studies on penicillin therapy,

again emphasizing that penicillin must be administered against a background

of good surgery if it was to fulfill its usefulness. He concerned himself with

securing texts and journals fori hospital and other libraries, lie directed the

preparation of the "Manual of Therapy, European Theater of Operations," so

successfully that during the war, and at the end, very few changes were required

to bring it into conformity with current practices.

General Cutler was instrumental in forming the American Medical Society,

ETOUSA, to which all U.S. medical officers in the theater automatically

belonged. He also played a large part in founding the Inter-Allied Conferences

on War Medicine, convened by the Royal Society of Medicine, and he lost no

opportunity to stress the importance of liaison with our Allies, particularly

the British. After his death, Sir Gordon Gordon-Taylor wrote: "The death

of Elliott Cutler * * * will occasion deep sorrow in the hearts of his many

friends in the United Kingdom. Perhaps no surgeon of the United States ever

yearned or strove more earnestly to forge lasting bonds of friendship, not only

between the surgeons, but between the peoples of the great English-speaking

countries on either side of the North Atlantic, and to this end lie directed both

written and spoken word."

The special reports by consultants in the various specialties in the European

theater all deserve careful reading. It is perhaps invidious to mention special

chapters because space does not permit me to comment on them all, but attention must be called to:

1. The investigations by Col. Loyal Davis, MC, of high altitude frostbite;

his development of protective helmets for Air Force crews; and his stabilization

of policies concerning herniated nucleus pulposus.
XViii ACTIVIIEir1S 0Fi SURGIC;(AL. C0(NIT''AN'rs

2. The adIvanuces inl rehaizilit at ion, whlich p)ermnitted tilet return~~i to dulty.

oftenl to full diuty, of great IV increased ijititibers oif imenl.

3. Tile dlevelolpmient of po~licie's Of rehalbiltitaionl for (~lefenled a111d blinldedl

('aS1tialt jes.

4. The mil itwes wroiught IY plastic surgery..

5. Th'Ie enlorilous adovanices il surica"'el thlerajiv iiiade pos'sible Ill- thle eta)!'-

111011 mdvances in, atiestliesiai undier coI. Rtahipl Nt. rovell, Mc.

General CuNt ler and C olonel ( )glitersonl Were tot ally di trerenit jiersotis findl

yet, odldly, iiiuicli thlat liftis lieellsid 2 about G enieralI 'ittler could Well be sa id

abloi~t C olonel ( utglter.2oii. Both wi~ere briillijant sulrgeotis. Whose tecltiv al

(dexterity Wa bf5hased( oil sound j udg-Itient. Both IWere biorn teacher's. BothI were

nien of ideas who Wei-pilot sat isfieid tint ii t heir ideas were t ranislatedI into0 actioins.

The commenlt'tts of t lie surgeonis uitioler Wlhomi Coloneltl ( )tgltei'soi served1-

andio whol did tiot always agree WithI his ideals-indicate thle kind of ileivielcl

officer lie Witus. Ceneral Maxwell W~rote thlat hlis dayrep~resenited thle titotiglts

of a great organlizer, --thle t Iiitiki ug of a1 miatutre minihd oil a VerY difficult subject."

It wats writtenl, hie said, liy a main who, if he hiadl had the opportunim ty to edit it,

would still think and write the same Way.

General I enlit wats evenl wlore exillivit. "I anfil not inclined." hie wrote,

TI.* to take excepltion to anything helielhs to sa v. A ft er aill lie gives life

pitctutre as lie sees it * * *. No otie wilo ha2sn't exp~erientced1 it Iwatr ill I Ilie

jlitlgiel cant bl1ieve thle d itfeliclt as eniconiltered * * *. I1a .12( great admiira-11

tion for Colonel ()ughtersoiz and1( gave' Ilifiltil in) 3) of 'th1ink-ing, andl adlvisintg

MPe onI how surlgery a tid cvare (of tile wouinded couild Ilie imiiproved. I didnl't

Want. him to halve any admtiin ist rat ive antihorit v. I wanted hlimi to (1) see, (2)

th ink n ~d (3) advise. ( ftenl whlen oiie trlies to correct lie loses Ii is %-ailue as

lilt adlviser."

Thle w~ars invll wili ( Geiteral ( ut ler and C olonel ( )ighitersomi served Were

it t erlv diff~erent ill 11121 n resplect s. lii thle E rop eatit t heat er. for ist a iie,

evautiont loll(f casultiat es Was oftenl 21 mat ter (if hou11rs. Ill [hle P acific aireas.

it. wits lisiiallY lv mat ter of daYs aind somiet imles it miat ter oIf weeks. The Pacific

Wa21r wits 21. Will o (f inceredible dista21nces. whichi had to lie t Ikeiii Int Ilccoiiit ill

every aspect oif mied ical care. I it t lhe Enrolpean itheater, Coin icidenta d1 1isease

seldom vo~illpl Watlted thle mniiageinent (of wolinldls. Ill tilie h.14cifiv. malaria wats

it pos'sihblt contcomitaitnt oIf every wolund tint il tilie war was miore thl hiali12 f over.

and( (ot her tropical (disealses were .1 possibility 2111 through tile Wall. ( Ius g~allree.Whi chi proved no probl emi inl lthe En~rol ea ithlea t er, was Soiiet imles a

Nevertheless, ill spite (of thle dlIereiices inl tilie Wars t ha~t were fought inl

Eulrope and tilie lPacifie, it is suirprisi ng how s411ii1arely v t(li views (if thlese two

etvililet. s1urgeonts coirresp)ond(ed W~ithI eachl lither ill b asic prin tc ipies if illit dilWays ill dletatils.

Colonel ( ughtersonl's c'onstanlit plea wa:s for tilie Jplaciiig oif qulilli tiellsill.-

geoits wetll1 fo~rwardI~ ill combllat 21reals, where thiei r ta~lenits were reqiui ired(Imhictitse
FOREWORD XIX

of the inevitable delays in evacuation. The shortage of qualified surgeons,

however, ill a theater in which each island was a unit in itself was always extremie and was enhanced by the concentration of talent in affiliated units, from

which it was often detached with great difficulty. Shortages of anesthesiologists with proper training and qualifications further complicated shortages

of surgeons. At one time, when Colonel ()ughterson surveyed six portable

hospitals, he found three of them competently staffed and three others completely unusable because of lack of qualified p)ersonnel. The portable hospital,

lie noted, was excellent in jungle warfare but ill adapted and wasteful when

communications were good. When it, was not properly staffed, he said, "It

gives the dangerous illusion that a surgical hospital is available."

His comments were always to the point. The. incidence of gas gangrene,

he noted, was an index of the kind of surgery being performed at the front,

but the omission of plaster because gas gangrene might occur was simply the

correction of one surgical mistake by making another. His continents on

"moderate debridement" were caustic. He had never seen a surgeon who (lid

good surgery at home do bad surgery iii the Army. Almost as soon as he

arrived in the Pacific, in November 1942, he began to comment that the principal cause of wvar neurosis was weak leadership, that men who were. not happy

were men who were not kept busy, and that the way to correct poor morale

and poor surgery in a hospital was to provide it (1) with a strong cominianding officer and (2) with a good surgeon. Whether Colonel O(ughterson was

evaluating surgical qualifications, correcting surgical errors, or trying to

provide washing machines for hospital linens, screens for operating rooms, or

hobnailed shoes for litter carriers, lie was b)oth practical and p)erceptive, and

many of his comments might well become aphorisms.

The brilliant study of casualties in the Bougainville Campaign, which

lie initiated and directed, is a lasting addition to the science of wound ballistics. Thie conclhusions lie derive(l, and the lessons lie drew, from medical care

in each campaign in the Pacific deserve the most careful reading aiid reflection. Like the Cutler diary, the Oughterson diary is a real contribution to

military medicine.

The consultant system was introduced late in the China-Burma-India

theater, but the chapter describing it, the final chapter in this volume, is another experience well worth recording of medical care in inhospitable terrain,

with constant shortages of personiel and supplies, in which not the least of

the problems was the attempt to improve the efficiency of the Chinese Army

Medical Service.

Again and again General Cutler mentions in his diary how desirable it

would have been to have worked in l)eacetime on the problems he encountered

during the war. le reminded himself frequently that one of his responsibilities as surgical consultant in the European theater would be to write the

story of the consultant service. The chief problems of this service, as lie saw

it, were the relations of the consultants with each other and the relations be-
XX ACTIvVITIES OF SURGICAL CONSULTANTS

tween Regular Army medical officers and the officers who had just come into

service from what lie called "thle well-oiled machinerv of civilian practice."

lie found more patient those who, like himself, had served in World War Ithough it might conie as a surprise to some of his associates to hear the word

patience attached to any activity of General Cutler's. At. any rate, it was

his urgent, wish that a permanent consultant system be established as an integral part of the Army Medical Department. lie would have been happy.

had he lived, to know that this ardent desire of his has been translated into

reality.

As in all volumes in this series for which it is my privilege to write the

foreword, it is a pleasure to express my gratitude to the editors and authors

who wrote and directed this volume, particularly the special editor for the

two volumes dealing with the activities of surgical consultants, the former

Col. B. Noland Carter, MNC: to the Advisory Editorial Board for Surgery:

and to the personnel in my office who are helping me to carry out what I regard

as one of nmy truly implortant missions, the preparation and publication ot the

history of the 1.S. Army Medical D)epartnent in World War I.

LEONARD D. HEATON,

L;etentant General,

The Surgeon General.
Preface

This volume is an account of the activities of surgical consultants in oversea theaters of operations excluding field armies. The experiences of surgical

consultants attached to field armies and of those in the Zone of Interior were

recorded earlier in volume I. The experiences recounted in this volume are

Ioth interesting and instructive and will undoubtedly be invaluable to those

individuals who inay be called upon at some future time to serve as oversea

consultants. Two of the chapters consist of diaries of consultants who have

died since the war. Thesel diaries hay'e been edited in an effort to preserve the

more interesting portions and to delete personal and nonessential details. It is

most unfortunate that an account of the experiences of the Chief Surgical Consultant to the North African (later Mediterranean) theater could not be obtained, since so many of the surgical concepts of the care of the wounded were

developed in that theater. The chapters in volume I by Col. Frank B. Berry,

M(', Consultant in Surgery to the Seventh U.S. Army, and by Col. Howard

E. Snyder, MC, Consultant in Surgery to the Fifth U.S. Army, however, give an

excellent account of the surgical problems encountered anl of how they were met

in portions of that theater.

It has been rightfully stated on many occasions that surgical consultants

in theaters of operations were potent factors in reducing the mortality rate.

Their services were invaluable and became increasingly appreciated as the war

progressed. Consultants to the oversea theaters came from civilian life and,

for the most part, had been connected with important teaching centers in

the U-nited States. They were untiring in their efforts, dedicated to their

duties, and magnificent in their accomplishments. One is impressed, as one

reads of their experiences, that all of them felt that they could have performed

their duties more efficiently if they had had better indoctrination, if there

had been a definite place for theni in the organizations to which they were

assigned, and if they had been given rank commensurate with the rank of their

counterparts in the Allied Armies and with the responsibilities which they

had assumed. The manner in which these men performed their duties has

demonstrated to the Armed Forces the necessity for surgical consultants and,

it is believed, has done much to establish them as important and l)ermanent

additions to the military effort.

In addition to acknowledgments appearing elsewhere to the various authors, deep appreciation is expressed to the following individuals who have

contributed materially toward the compilation of this volume.

Mrs. Elliott. C. Cutler, widow of the late Brig. Gen. Elliott C. Cutler, MC,

AUS, made avail able her husband's personal diaries, without which the chapter

xxi
XXII ACTIVITIES OF SURGICAL CONSULTANTS

covering the activities of General Cutler could never have contained the

personal insight it now has.

I)r. Bernard J. Pisani and Mrs. Pisani, to whom General ('utler's personal

diary was entrusted, together accomplished the laborious task of extracting

matters pertinent to this history from that handwritten diary. I)r. Pisani

also reviewed in detail the entire chapter p)ertaining to General Cutler's

activities and contributed one of the epilogues.

Maj. Gen. Paul R. Hawley, MC, USA. (Retired), carefully reviewed the

chapter concerning General Cutler; initiated inquiries on questionable matters

to )ir. Loyal Davis, Sir Gordon Gordon-Taylor, and others: contributed the

prologue; added annotations (now included as footnotes) which greatly

amplify the text; and graciously and firmly insisted that General Cutler's

remarks remain in the text, whether or not complimentary to the Chief Surgeon,

ETOUSA (General Hawley).

Dr. Robert M. Zollinger, in addition to contributing his own chapter, reviewed the chapter pertaining to General Cutler's activities and wrote one of

the epilogues.

The late Dr. Marion E. Howard (Mrs. Ashley W. Oighterson) gathered

together the personal papers of Dr. Oughterson upon his untimely death in an

airplane crash and presented them to The Historical Unit, U.S. Army Medical

Service. She also loaned The Historical Unit, the personal war journal of

D)r. Oughterson. Without these contributions on Dr. Howard's part, the chapter

pertaining to the, wartime activities of Col. Ashley W. Oughterson, MC, could

not have been compiled.

Maj. Gen. Guy B. Denit, MC, USA (Retired) : Maj. Gen. ,John M. Willis,

MC, USA (Retired) ; Brig. Gen. Earl Maxwell, ITSAF (MC, Retired) ; and I)r.

Maurice C. Pincoffs reviewed the chapter pertaining to Colonel Oughterson's

activities and made comments included as introductory matter and footnotes

thereto.

Dr. Julian A. Sterling very generously reviewed the manuscript of chapter

VI, which records the experiences of the consultants in orthopedic surgery

and rehabilitation in the European theater.

Miss Elizabeth M. McFetridge provided invaluable advice and help in

preparing portions of the chapter pertaining to surgical consultant activities

in the Southwest Pacific Area.

Maj. James K. Arima, MSC, in addition to functioning in other capacities,

searched out the photographs from which the illustrations for this book were

selected. Sp4c. Jacques Kornberg also helped.

Mr. Melvin T. Hadden prepared the excellent layouts for the illustrations

in this volume and handled thi artwork and the preparation of the illustrations

for printing.
PREFACE XXIII

Miss Elizabeth P. Mason, Chief, Cartographic Section, and Miss Jean A.

Saffran, Cartographic Section, of the Special Projects Branch, The Historical

Unit, prepared the maps.

Mrs. Claire M. Sorrell, Historian, of the General Reference and Research

Branch, The Historical Unit, rendered research assistance.

Miss C. Louise Brady, Editor (Printed Media), Editorial Branch, The

Historical Unit, U.S. Army Medical Service, edited and prepared the manuscril)t for 1)rinting and prepared the index for this volume.

B. NOLAN.)D CARTwIR, M.D.
Contents

Page

FOREWORD ------------------------------------------------------ xiIl

PREFACE- - .----------------------------------------------------- xxi

Part I

EUROPE

Ch a pter

I Surgical Consultants in the European Theater of Operations (Col. James C.

Kinthrough, MC, USA, Ret.) ---------------------------------------- 1

Consultant System in World War I ---------------------------------

Consultant System in World War II ------------------------------ 5

Sumnmary - ..------- -------------------------------------------- 17

II The Chief Consultant in Surgery (Elliott C. Cutler, M.D.) ----------------- 19

Prologue .---------------------------.----------------------- 19

1942: Getting Started ------------------------------------------- 19

1943 to Early 1944: Planning, Building Up, and Waiting-............. 55

Normandy --------------------------------------------------- 205

Northern France .---------------------------------------------- 239

The Rhineland -------.----------------------------------------- 251

Campaign in Central Europt ------------------------------------- 319

V-- E )ay -------------------------------------------------------- 333

After V-E Day: Getting Out ------------------------------------ 334

Epilogue I ---------.---------------------------------------------- 353

Epilogue It ----------------------------------------------------- 356

III General Surgery (Robert .1. Zollinger, M.D.) --------------------------- 359

Appointment as Senior Consultant -------------------------------- 359

Organization, Functions, and Activities ----------------------------- 361

Preparations for Normandy Invasion- ----------------------------- 366

Activities During Normandy Invasion ----------------------------- 374

Activities on the Continent ----------------------------------------- 378

Conclusions ..-------.-------------------------------------------- 387

Recommendations-- ----.-------------------------------- 388

IV Neurological Surgery (Loyal Davis, At.D.) ----------------------------- 391

Getting Acquainted ----------------------------------------------- 392

Analysis of the Situation and Recommendations- 396

The Surgeon General's Visit -------------------------------------- 403

Attempts To Improve the Consultant Group ------------------------ 405

Year's End ---------.-------------------------------------------- 409

1943: First Half --------------------------------------------------- 410

Surgical Mission to the U.S.S.R ..------------------------------------- 420

Washington and Release From Service ------------------------------- 439

xxv
XXVI ACTIVITIES OF SURGICAL CONSULTANTS

Chapter Page

V Ophthalmology (James N. Greear, Jr., M.D.) -------------------------- 443

Organization ------------------------------------------------- 444

Policies and Procedures ----------------------------------------- 445

Hospital Centers ---------------------------------------------- 450

Supplies and Equipment ---------------------------------------- 452

Optical Supply ------------------------------------------------ 452

Training --------------------------------.------------------------- 455

Summary and Conclusions --------------------------------------- 457

VI Orthopedic Surgery and Rehabilitation (Rex L. Diveley, M.D., and Mather

Cleveland, M.D., Sc.D.) ---------------------------------------------- 459

Orthopedic Surgery, August 1942-May 1944 ------------------------- 459

Orthopedic Surgery, May 1944-July 1945 --------------------------- 468

Rehabilitation ------------------------------------------------ 477

VII Otolaryngology (Norton Canfield, M.D.) ------------------------------- 503

The Chief Surgeon ----------------------------------------------- 503

Activities and Observations -------------------------------------- 504

Reassignment in the United States -------------------------------- 509

Summary ---------------------------------------------------- 509

VIII Plastic Surgery (Eugene M. Bricker, M.D.) ----------------------------- 511

Introduction -------------------------------------------------- 511

Administration ------------------------------------------------ 512

Professional Responsibilities .,nd Problems -------------------------- 521

IX Urology (John N. Robinson, M.D.) ---------------------------------- 573

Justification for a Senior Consultant in Urology ---------------------- 573

Activities of the Senior Consultant in Urology ----------------------- 575

X Anesthesia (Ralph M. Tovell, M.D.) ---------------------------------- 581

Call to Active Duty -------------------------------------------- 581

Orientation in the United Kingdom -------------------------------- 582

Early Activities and Recommendations ----------------------------- 584

Consultant Duties --------------------------------------------- 594

Extension of Activities in 1943 ----------------------------------- 595

Preinvasion Activities ------------------------------------------ 605

D-day and Its Aftermath ---------------------------------------- 605

Visit to Normandy ----------------------------------------------- 608

Move to the Continent -------------------------------------------- 610

Activities During the Final Campaigns ----------------------------- 611

Victory in Europe --------------------------------------------- 618

After V-E Day ----------------------------------------------- 619
CONTENTS XXVII

Part 11

THIE PACIFIC AND ASIA

Chapter Page

XI Pacific Ocean Areas (John B. Flick, .lf.D., Forrester Raine, M.D., and

Robert Crawford Robertson, M.D.) ------------------------------------ 625

Surgical Consultants --------------------------------------------- 625

Duties of the Consultant - ..------------------------------------ 628

Personnel --------------------------------------------- ------- 62'

.. ,',cation and Training ---------------------------------------- 635

Centers for Specialized Treatment --------------------------------- 637

Directives Concerning Professional Practice ------------------------- 642

Visits to Hospitals --------------------------------------------- --- 643

The Okinawa Operation -----------------------.---------.--------- 645

Hospital Center at Tinian -------------------------------------- 650

Notes and Formal Reports ----------------------------------- L--- - 651

Central Pacific Area -------------------------------------------- 651

Consultation in Orthopedic Surgery ------------------------------- 655

XII Southwest Pacific Area (Win. Barclay Parsons, M.D., I. Ridgeway Trimble,

M.D., and George 0. Eaton, M.D.) ------------------------------------ 687

July 1942 Through August 1944 --------------------------.. ..---- 687

August 1944 Through January 1946 -------------------------------- 706

Orthopedic Surgery -------------------------------------------- 757

XIII From Auckland to Tokyo (Ashley TV. Oughterson, M.D.) ---------------- 767

Introductory Note --------------------------------------------- 767

Lessons of the New Georgia Campaign ----------------------------- 784

Management of Casualties in the New Georgia Campaign -------------- 790

Utilization of Medical Facilities in a Theater of Operations ------------ 792

Summary of the Fiji Tour --------------------------------------- 801

Notes ----------------------------------------------------------- 835

Summary of Medical Care and Evacuation During the Lingayen Campaign --------------------------------------------------------- 866

Notes on Recommendations for Major General Kirk --------------- 874

XIV India-Burma and China Theaters (A. Stephens Graham, M.D.) ----------- 889

Historical Background -------------------------------------------- 892

Medical Service, U.S. Forces, India-Burma Theater ------------------- 906

Medical Service, U.S. Forces, China Theater ------------------------ 908

Functions of the Surgical Consultant ------------------------.------ 912

Surgical Personnel ----------------------------------------------- 916

Education and Training -----------------------.------------------ 920

Physical Facilities and Equipment ---------------------------------- 9 21

Special Problems ------------------------------------------------- 925

Comments on Individual Hospitals ------------------------------- 932

Field Trips, India-Burma Theater -.-.------ ----------------------- 933

Field Trip, China Theater -------------------------.-------- L---- 938

Summary and Conclusions ------------------------------------ ---- 951
XXVIII ACTIVITIES OF SURGICAL CONSULTANTS

APPENDIXES Page

A Report, Surgical Mission to Russia-------------------------------------- 953

B Circular Letter No. 71. Principles of Surgical Management in the Care of Battle

Casualties -------------------------------------------------------- 63

C Circular Letter No. 142, Guidance to Disposition Boards --------------------- 973

1) Circular Letter No. 23, Car(e of Battle Casualties --------------------------- 977

E Evacuation by Landing Ship, Tank, From the Normandy Beaches ------------- 985

F Treatment of Maxillofacial Injuries (Manual of Therapy, ETOUSA) ---------- 989

G Treatment of Burns (Manual of Therapy, ETOUSA) ------------------------ 993

H Recommendation for Care of Hand Injuries in Zone of Interior ---------------- 999

I Treatment of Hand Injuries ------------------------------------------- 1001

INDEX ------------------------------------------------------------ 1003

Illustrations

Number

1 Col. James C. Kimbrough, MC ----------------------------------------- 6

2 Maj. Gen. Paul R. Hawley ---------------------------------------------- 7

3 Consultant group at Cheltenham, England, mid-1944 ----------------------- 11

4 Weekly meeting of consultant group in European theater ------------------- 12

5 Convalescent patients at 307th Station Hospital, England ------------------- 16

6 Professional Services Division, Office of the Chief Surgeon, ETOUSA --------- 18

7 Brig. Gen. Elliott Carr Cutler ------------------------------------------ 20

S Headquarters, ETOUSA, at 20 Grosvenor Square, London ------------------ 24

9 Office of the Chief Surgeon, ETOUSA, London ---------------------------- 25

10 Col. Charles B. Spruit, MC ------------------------------------------- 26

11 Surgeon Rear Admiral Gordon Gordon-Taylor, Royal Navy, with General

Hawley ----------------------------------------------------------- 27

12 Blood transfusion kits being packed at British Army Blood Supply Depot .--- 33

13 Bottled wet plasma being prepared at British Army Blood Supply Depot - 34

14 Royal Navy cruiser Aurora, escorting a convoy to North Africa -------------- 42

15 The beach at Saint-Leu, Algeria, North Africa, on D-day ------------------- 43

16 Maj. Gen. James C. Magee, The Surgeon General, visiting Stonehenge ------- 44

17 Hospital Ship No. 38, the Newfoundland of Liverpool ----------------------- 48

18 Interior of the Newfoundland ------------------------------------------ 48

19 Headquarters, V Corps, U.S. Army, at Clifton College, Bristol, England ------ 63

20 Colonel Kimbrough congratulating Colonel Cutler upon his being made an

Honorary Fellow of Royal College of Surgeons ------------------------ 66

21 Lt. Col. William F. MacFee, MC --------------------------------------- 67

22 Medical Field Service School, ETOUSA, at Shrivenham Barracks, England _ 68

23 Maj. Bernard J. Pisani, MC------------------------------------------- 69

24 Transfusion set improvised by Capt. Richard V. Ebert, MC, and Capt. Charles

P. Emerson, MC ------------------------------------------------ 72

25 Col. Walter L. Perry, MC -------------------------------------------- 75

26 36th Station Hospital, Exeter, England ---------------------------------- 79

27 Maj. Robert M. Zollinger, MC ----------------------------------------- 80

28 A U.S. Army Air Forces patient at Royal Cornwall Infirmary, Truro, England. 81

29 Maj. Gen. Max Page, RAMC, and Air Commodore Geoffrey Keynes, RAF,

with Col. Oramel H. Stanley, MC ----------------------------------- 84

30 Transport for a mobile surgical unit ------------------------------------- 85

31 Equipment and supplies for a shock team, mobile surgical unit -------------- 87

32 Chest containing orthopedic supplies and equipment for a mobile surgical unit- 87
CONTENTS XXIX

Nuniber Page

33 Tray used by the anesthetist of at mobile surgical unit ------------ 88

34 Suction apparatus used by at mobile surgical unit --------- ---- 88

35 Expendables and at sterilizing (Iruni of at mobile surgical unit - ------- 89

36 Pitching anl operating room tent of at mobile surgical unit ---------------------- 90

37 Portable operating light equipment of a mobile surgical unuit.--------------- ---- 91

U8 Arrangement of the operating tables of at mobile surgical uniit ------------------ 91

39 John G. Winant, U.S. Ambassador to the Court, of St. Jamles's, and Mrs. Wiiianlt

with Glen. D)wight D. Eisenhower -------------------------------------- 93

40 American memibers of the surgical mission to the U.S.S.R. with Surgeon Rear

Admiral Gordon Gordon-Taylor, RN ----------------------- ------------ 94

41 Copy of Academician Lt. Gen. Nicolai N. Buirdenko's speech upon his being

made an Honorary Fellow of Americanu College of Surgeons ---------------- 10

42 Copy of Prof. Serge Yudin's speech upon his b~eing made an Honorary F'ellow

of American College of Surgeons---------------------- ---------------- 102

4:3 Maj. Glen. Albert W. Kenner ------------------------------- ----------- 108

44 D)emonstration of anl improvised splint for at fractured jaw -------------------- 110

45 Training in the application of p~laster at the 298thi General Hfosp~ital, Bristol,

England ---------------------------------------------- ----------- 1I

46 Hospitals established primarily to serve Army Air Forces in Enlglanld-----------113

47 Maj. ('en. Carl Spaat z awarding the P~urple Heart to mien of thet( 97th Bombardmient, Group ----------- --------------------------------------------- 115

48 Col. David E. Listoni, NMC- ----------------------------------------------- 118

49) A clearing station of 85th Infantry Division in Italy ---------------------- --- 122

50 Part of transport network in the North African theater, Oran Harbor, Algeria- 12:3

51 Air (vacuiation from Fifth U.S. Army area by ('-47 aircraft ------------------- 124

52 A te*nted expansion are*a of the 21st General Hospital, Italy ------------------- 125

5:3 Seriously woundled soldier re~ceiving transfusion while his gastric contents are

asp~irated, 33d Field Hlospital, Italy ---------------------------------- 2(

54 94th Evacuation Hospital, Fifth U.S. Army, Italy----------------------------127

55 Maj. Geji. Malcolm C. Grow, Maj. Gen. D)avid N. W. Grant, Maj. (i'tl. Pault R.

Hawley, and Maj. Glen. Norman T. Kirk ------------------------------- 133

56 Col. James B. Mason, MC ------------------------------------------------ 148

57 Col. Angvald Vickoren, MC -------------------------- -------------------- 149

58 Mobile bleeding team, beginning first collection of blood for European t~heater

blood bank, Shootend Camp, Wiltshire, England, March 1944 ------------- 1.55

59 Whole-blood service in Mediterranean theater ------------------------------- 157

60 Bottled whole blood from Blood Banik, ETOUSA, ready for delivery orstorage._ 159)

61 Eutropean theater blood banik truck at an airfield in England --------------- 16:3

62 Convalescent p~atient,, at 203d Station Hospital, surmounting a wall in obstacle

course ------------------------------------------------------------- 164

63 Lt. Glen. John C. 11. Lee, SOS, ETOUSA, observing a surgical team from 3d

Auxiliary Surgical Group --------------------------------------------- 169

64 Training at Assault Training Center, ETOUSA----------------------------180O

6.5 Special slings onl LST's for handling litter patients --------------------------- 186

66 Litter p)atients in an LST that had been converted with wall brackets to hold

litters -------------------------------------------------------------- 187

67 U.S. Army hospital train ward cars in United Kingdom ----------------------- 192

68 Lt. Col. Fred H1. Mowrey, IC ----------------------------------------- 1913

69 46th Field Hospital at Chandler's Ford, Hampshire, England, .June( 1944 -------- 195

70 Exercise SPLIANT in arid about Newquav, Cornwall, England, April 1944-- -- --- 198

71 Marmite cans adapted for transporting whole blood ---------------- _---------20:3

72 Medical service on Normandy beachhead, 1)-day, 6 .June 1944 ---------------- 120(i

73 American equipment, ships, and men at Plymouth, England, awaiting orders.- 207
xxx ACTIVITIES OF SURGiICAL. CONSU'LTANTS

Number Page

74 50th Field Hospital at Weymouth, England, during Normandy invasion -------- 210

75 Unloading of hospital traini at Sherborne --------------------------------- 212

76i Portland area and Weymouth, South D~orset, England ---------------------- 213

7-7 Ambulances on a (lock at W~eymouth awaiting unloading of casualties ---------- 214

78 T.,S.S. LCT 217, beached at Weymouth, England-------------------------- 215

79 Unloading of LST's by transfer to an LCT and direct beaching of the LCT,

W~eymouthl------------------------------------------------------ 216

80 WAoundled German p~risoners being unloaded on Normandy beachhead ----------- 218

81 Reception of air-evacuiated casualties at Memiburv airfield -- ------------ 219

82 Omiaha Beach, 2:3 June 1944-------------------------------------------- 220

83 Whole blood being loaded on evacuation aircraft returning to Normandy

beachhead----------------------------------------------------- 221

84 Blood being administered at 128th Evacuation Hospital, Normandy, 12 June

1944 ----------------------------------------------------------- 223

85 An aid station and rest point in cap~tured farmhouse, 14 July 1944 ------------ 226

86 Facilities aboard a converted hospital carrier------------------------------ 227

87 Care aboard hospital trains during Normandy campaign ---------------------- 229

88 U'nit of the Blood Bank, ETOUTSA, hitching a storage refrigerator, mounted on

an artillery carrier, to a cargo truck --------------------------------- 235

89 Line of G;ermana prisoners of war being marched ashore at W~eymouth ---------- 237

90 A "Buzz Bomb" cutting its motor and (living into Picadilly ----------------- 238

S91 Maj. Gen. Norman T. Kirk visiting the 160th General Hospital, Cirencester -- 240

92 Air evacuation to the Zone of Interior from Prestwick, Scotland --------------- 242

93: Office of the Chief Surgeon, ETOUSA, at Valognes, France ------------------ 250

94 Offie( of the Chief Surgeon, LTOUSA, Paris ------------------------------ 251

95 The stage of an amiusemvent hall being utilized by a surgical team ------------- 254

96 10)8th General Hlospital, Paris ------------------------------------------ 255

97 Interior of a loaded C-54 aircraft evacuating casualties from Paris ------------- 259

98 Inter-Allied Censultants' Conference, Paris, France -------------------------- 260

99 Litter hearers bringing in woundied soldier in southern France ---------------- 265

100 Casualtie-s being sorted1 at a clearing station in France ------------------------ 267

101 A shock tent of :34th Field Hospital, First U.S. Army ------------------------- 269)

102 C'ol. Frank 11. Berry, MC, speaking at Inter-Allied Consultants' Conference,

Paris, 15 October 1944 ----------------------------------------------- 270

1031 Colonel Cutler, Colonel Osipe'v, General Hawley, and Major Birch-.Joncs in

General Hawley's office, Paris, France ---------------------------------- 272

104 194th Gene'ral Hospital arriving in Paris, .January 1945 ----------------------- 276

105 The Siegfriod Line ------------------------------------------------------- 277

106 Higgins boats bringing casualties of Sekvvnth U.S. Army to U.S. Army Hospital

Ship Shamnrock ------------------------------------------------------ 281.

107 Col. Charlvs F. Shook,--( ----------------------- ---------------------- 2S2

108 D~estruction in Antwerp, Belgium --------------------------- --------- -- 288

10 W lDeliv'ery of whole blood under freezing Conditions, 16th Field Hospital --------- 296

1 10 Caring for immobilized casualties in a hosp~ital train ----------------------- 298

III 91st Medical Gas Treatment Battalion opJerating as an air evacuiation holding

unit --------------------------- ------------------------------------- 313

112 L~t. Gen. George S. Patton. Jr., with some members of his staff, and other key

officers ------------------------------------------------------------- :314

11:1 Armored m edical vehicls - - - - - - - - - - -- --- - - - - - - - - - - 315

114 Colonel Midldleton, Colonel Kimnbrough. General IHawley, and Colonel Cutler

at Colonel Kinibrough's farewell (]inner --------------------------------- 316

115 First I .S. Army pouring across the Rineagen Bridge'----------- --------------- 1184

116 Fifth and Seventh U.S. Armies meeting at the Brenner Pass-------------------320

11 7 IDelousing Soviet-recovered p~risoners at Prisoner of War Exchange Camp -- - -- 322
CONTENTS XXXI

Number Page

118 Holding and evacuation facilities of the 91st Medical Gas Treatment Battalion,

Euskirchen airstrip --------------------------------------------- 323

119 Glider evacuation of wounded ----------------------------------------- 324

120 First U.S. Army medical troops using captured launch to transport casualties- -_ 325

121 Four-tiered compartments in a so-called hospital ward, Buchenwald ---------- 331

122 Evidence of starvation policy at Buchenwald Concentration Camp ----------- 332

123 Colonel Shook, General Hawley, and Brig. Gen. Elliott C. Cutler ------------ 340

124 Inter-Allied Consultants' Conference, May 1945, 108th General Hospital ------ 343

125 General Cutler being decorated with l)istinguished Service Medal ------------ 350

126 Lt. Col. Ambrose H. Storck, MC, at reception for General Rankin ----------- 360

127 Col. Maxwell G. Keeler, MC, on occasion of The Surgeon General's visit to 5th

General Hospital ----------------------------------------------- 361

128 It. Col. William A. Howard, MC, lecturing at Medical Field Service School--_ 367

129 One of first classes to graduate from Medical Field Service School ------------ 368

130 Rubberized sheets replacing cloth drapes in a mobile surgical unit ------------ 369

131 Ample stores of sterile goods being prepared for Normandy invasion --------- 373

132 The reception and transportation of casualties from Normandy invasion ------ 376

133 Field hospitals functioning ------------------------------------------- 380

134 9th Evacuation Hospital --------------------------------------------- 382

135 First hospital train movement on Continent ------------------------------ 383

136 Lt. Col. Robert M. Zollinger, MC, Commanding Officer, 5th General Hospital-- 386

137 Entrance to 5th General Hospital ---------------------------------------- 387

138 Lt. Col. Loyal l)avis, MC -------------------------------------------- 393

139 Tanks of 29th Infantry l)ivision on maneuvers --------------------------- 408

140 A flash radiograph of a German HEI shell, Mk. I ------------------------- 412

141 Protective helmet for flyers ------------------------------------------- 414

142 Waist gun position in the B-17 bomber --------------------------------- 416

143 Flyers' clothing ---------------------------------------------------- 417

144 Mena House Hotel at Al Jizah, Egypt ---------------------------------- 422

145 Hon. Alexander C. Kirk, U.S. Minister to Egypt, and Maj. Gen. Russell L.

Maxwell ---------------------------------------------------------- 423

146 Maj. Gen. Donald H. Connolly and Soviet officers ------------------------ 425

147 Capt. "Eddie" Rickenbacker in Teheran, Iran, July 1943 ------------------- 426

148 Headquarters of U.S. Army Forces in the Middle East --------------------- 437

149 A parting look at the airfield at Heliopolis, Egypt ------------------------ 438

150 Col. R. Glen Spurling, MC ------------------------------------------- 440

151 Col. Derrick T. Vail, MC -------------------------------------------- 444

152 Lt. Col. James N. Greear, Jr., MC ------------------------------------- 445

153 Ophthalmological service in a general hospital --------------------------- 448

154 St. l)unstan's Institute for the Blind, Shropshire, England ------------------ 450

155 Eve clinic in an evacuation hospital ------------------------------------ 451

156 Technician in a mobile optical repair unlit checking a lens ------------------- 453

157 Nurses receiving instruction at the .Medical Field Service School, ETOUSA 456

154 Lt. Col. Rex L. l)iveley, MC----------------------------------------- 460

159 Brigadier L. E. H. Whitby, RAMC, Brigadier R. W. Bristow, RAMC, and

Maj. Gen. I). C. Monro, ? .%MC, at reception given by General Hawley

and consultants ---------------------------------------------------- 462

160 Maj. William J. Stewart, MC ----------------------------------------- 463

161 Surgery in the North African theater ------------------------------------- 464

162 Instruction in plaster technique ----------------------------------- 469

163 Col. Mather Cleveland, MC ---------------------------------------- 470

164 Orthopedic casualties in a general hospital ------------------------------- 471

165 198th General Hospital arriving in Paris -------------------------------- 472

166 25th General Hospital at Lison, France, September 1944 ------------------ 474
XXXII A(,1i'ITII1ES OF SURIGIC'AL CO)NSULTANTS4

Ntuimiber Page'

167 221st Gen'ieral Hospital on the move, .January 1945 -------------- 475

168 Maj. Frank E'. Stinchfield, MIC, at All-Saints, Hospital, England ------- 478

169 Capt. Marcus .1. Stewart, MCI(----------- ---------------------------------- 479

170 Remedial exercises at Rehabilitation ('enter No. 1 ------------ --------------- 480

171 Lt. G;en. ()ntar N. Bradley, at 307th Station Hospital, 194:1-------------------41%

172 Full-scale rehabilitation activities at Rehabilitation Center No. I -------------- 482

173 Rehabilitation in hospitals ------------------------------------- ----- 488

174 Maj. Gen. Normani T. Kirk inspecting the 307th Station Hospital -------------- 490

175 Lt. (Gen. Carl Spaatz listening to an explanation by Colonel Stinchifield of

treatmneit bein~gprovidledL-------------------------------491

176 'Major Stinchifield at demonstration for stud(en~t officers at llronisgrove-- -- ,- ---- 492

177 ('lass in anatomy for physical training instructors at 307th Station Hospital 493

17S C'onstructioni of a tentedl rehabilitation area at 10Sth General Hospital ------ 499

179) Col. Norton Canfield, MIC--------------------- 5- 50

180 ( tolaryngologic clinic in a general hospital--------------- -------- -50

181 Audioinetric testing for hevaring acuity- -------- -508

182 Lt. Col. James B. Birown, MC------------------- - 512

18:3 Lt. Col. Eugene M. Blricker, NIC - - - - - - - - -5 13

184 (Col. Roy A. Stout, D)C- - - ------------------------------- 5 14

185 Extensive injury, associat~ed with extensive loss of tissue------------ --- 24

186 Powder "'tattooing,'' associatedl with blindness- -- ---------- -- ------ ----- 525

187 Blast injury resulting fromt mine explosion ----------------------------- 526i

188 Treatment of at comlpoundl facial wound at evacuation hospital ---- 8

189) Casualty w ith severe wouni(l of thei ch i i-------------------------529

19() Major facial wound with loss of nose, mnaxilla, and mnandible-----------53 0

191 Compound injury with fracture and loss of bone and overlying soft tissue -------- 5311

192 Results of early dlefinitive treatment of compound facial injuries------------- 5:32

193 Penetrating woundl of the antrilin with inf'ection ------------------- -- ------ 5):: 1

194 (Conmpound facial wound with loss of mnaxillary alveolus aind overlying soft tissue

and a fracture of thenmandible----------------------5:34

19.5 Seconidary closure of a comp~ounid facial wound -------------------- 536

196 Poorly advised secoindary closure of at soft-tissue wound of face- -- -- - . 5:3 7

197 'Major facial dlefect at time p)atient arrived at a general hospital --- ------------ 5:38

198 Burni centers with corpsmen trained( to handle patients in bathis andl to handle

dIressings-------------------------------54:3

199 lEctrojpiol fromt burns requiring correction by grafting before evacuation fromt

theater --------------------- -- - - - - - - - 546

200 A needlessly a4pplied eyelid graft ------ ------ --------------------- 547

201 Futility of trying to control lid contraction, following burns, by the formation

of interpalpebral adhesions --------- ---------------------------------- 548

202 Case illustrating principle of active motion andl early grafting for burned haind - 552

203 Result of early radical graft to the dorsuni of severely burned hands -- - 554

204 Case illustratiing possibility of secondary closure of large, soft-tissue dlefects

by extensive undermining and direct wound approximation- -- -- -- ------ 556

20.5 Result of closure of large defect by mobilizing the skin edges and by free skingrafting that portion of the wound which could not be closedL - 55 7

206 Ideal illustration of type of injury in which pediele grafting should be done

without delay ----------------------------------------- 5603

207 End result of replacement of large soft-tissue loss of tipper armn by use of tandehaved pedicle graft fromt the chest wall --- --------------- --------- - 562

208 Compound fracture with extensive loss oif overlying tissue is converted into

simple fracture by use of undelayed pedicle graft - 564

209 lPedicle graft------- - - - - - - - - - -566

210) (Cross leg pedicle graft covering a compound defect of the tibia -5618
CONTENTS XXXIII

Number Page

211 Soft-tissue loss from dorsurn of hand, associated with underlying hone injury_ 570

212 Illustration of urgent demand for palm covering in relation to subsequent

function ---------------------------------------------------------- 572

213 Maj. John N. Robinson, MC ------------------------------------------ 574

214 Portable tidal drainage-cystometer set ---------------------------------- 576

215 Improvisation to permit complete cystoscopy with retrograde pyelography ---- 577

216 Genitourinarv clinic at the 45th General Hospital ------------------------- 578

217 Hospital train being loaded at Li6ge, Belgium --------------------------- 579)

218 Col. Ralph M. Tovell, MC -------------------------------------------- 582

219 British anesthetic apparatus supplied to U.S. military hospital units --------- 586

220 Portable British anesthetic equipment supplied to U.S. Army hospital units

in September 1942 ------------------------------------------------ 587

221 "Marriage" of anesthetic machines and expendable rubber parts shipped separately ---------------------------------------------------------- 590

222 Adaptable substitute expendable anesthetic equipment from British sources__ 592

223 Adapters obtained from British sources to permit utilization of British cylinders

on American anesthetic machines ---------------------------------- 593

224 Primitive preparation in 1942 against gas attack ------------------------- 597

225 An ETOUSA resuscitator and ether vaporizer, developed at Depot M-400 ---- 602

226 Student officers attending a second course in anesthesia, 1944 ---------------- 606

227 Central oxygen and nitrous oxide manifolds at 298th General Hospital ------ 607

228 Col. John B. Flick, MC ------------------------------------------------ 626

22`) Col. Paul H. Streit, MC, and his staff ------------------------------------ 627

230 76th Field Hospital, ()kinawa, June 1945-------------------------------- 628

231 Medical Library, 39th General Hospital, Saipan, 1945 ---------------------- 633

232 Living conditions and recreational facilities ------------------------------ 634

233 Exhibit of an operating room set up in the field, Hawaii -------------------- 636

234 Nurse administering ether anesthesia by the open-drop method, Okinawa ---- 637

235 Patients at 21Sth General Hospital, after having been fitted with plastic eyes,

August 1945 ----------------------------------------------------- 638

236 Debarkation activities at Tanapag Harbor, Saipan, spring 1945 ------------ 639

237 Postoperative care after thoracic surgery, 148th General Hospital ---------- 640

238 39th General Hospital, Saipan, 1945 --------------- ------------------- 641

239 Exterior view of a sterilizer and steam boilers at 148th General Hospital ------ 643

240 Fluoroscopy facilities at 148th General Hospital ------------------------- 644

241 Exterior installation of air-conditioning equipment at 148th General Hospital,

Saipan, 1945 ------------------------------------------------------- 645

242 Nurse on Okinawa checking the administration of whole blood ------------- 646

243 Treatment at 69th Field Hospital, Okinawa, May 1945 -------------------- 647

244 Patients being prepared for air evacuation by converted C-54, Okinawa ------ 648

245 Th. Surgeon General, making ward rounds in the 147th General Hospital ------ 653

246 Litter bearers of 7th Infantry l)ivision, bringing in wounded soldier, Kwajalein 654

247 Courtyard of 147th General Hospital ------.----------------------------- 661

248 The landing on Guam, 23 July 1944 ------------------------------------ 665

249 An operating room, established in a building that had been recaptured from the

Japanese, Guam ------------------------------------------------- 666

250 Casualties being loaded on I)UKW's for evacuation ---------------------- 667

251 Shoreline of Leyte Island at invasion point, 20 October 1944 ---------------- 668

252 Casualties aboard the U.S.S. J. Franklin Bell, Leyte, October 1944 ---------- 670

253 Church used by 7th Medical Battalion as collecting and clearing station, Leyte- 671

254 7th Infantry D)ivision and XXIV Corps medical installations on Leyte- 672

255 Surgical ward of 165th Station Hospital, Leyte, November 1944- 673

256 Maj. 6en. Norman T. Kirk, touring the Middle Pacific ----------------- 676

705-0951--64---3
XXXIV ACTIVITIES OF SURGICAL CONSULTANTS

Number Page

257 An orthopedic ward at 39th General Hospital, Saipan ---------------------- 677

258 The ships that carried men and supplies to Okinawa, 4 April 1!145 ----------- 678

259 An aid station on beach at Okinawa, L-day, 1 April 1945 ------------------- 679

260 Whole blood being administered to casualty at clearing station of 102d Medical

Battalion, Okinawa, April 1945 ------------------------------------ 680

261 Sth Station Hospital, Hawaii ----------------------------------------- 683

262 Col. Wm. Barclay Parsons, MC --------------------------------------- 688

263 Wounded, being transferred to C-47 aircraft at Dobodura, New Guinea ------ 690

264 Portable surgical hospitals on New Guinea ------------------------------- 692

265 Australian soldiers wounded in action near Sattelberg, New Guinea ---------- 694

266 Base area at Oro Bay, New Guinea, December 1943 ----------------------- 694

267 Development of a major base at Milne Bay, New Guinea ------------------- 695

268 11Sth General Hospital, Sydney, Australia, July 1943 ---------------------- 696

269 47th General Hospital, Milne Bay, New Guinea, May 1944-------------- 697

270 10th Evacuation Hospital, Port Moresby, New Guinea, February 1943 ------- 697

271 27th General Hospital, Hollandia, New Guinea, 1944 ----------------------- 698

272 Col. I. Ridgeway Trimble, MC ---------------------------------------- 699

273 Development of portable surgical hospitals ------------------------------- 702

274 Colonel Trimnble and General MacArthur on a visit to hospital in Australia ---- 706

275 Maj. Gen. Guy B. Denit receiving the Legion of Merit --------------------- 7W

276 Japanese emissaries arriving aboard U.S.S. Missouri to sign surrender terms-- 711

277 10th Evacuation Hospital, Oro Bay, New Guinea, December 1943 ----------- 712

278 Hospital sites on Leyte, Philippine Islands, December 1944 ----------------- 713

279 Invasion fleet in harbor, Leyte Gulf, October 1944 ------------------------- 714

280 8th Portable Surgical Hospital at Yellow Beach, Zamboanga, March 1945----- 716

281 Methods of evacuation in Southwest Pacific Area, 1945 --------------------- 722

282 Headquarters. Philippine Base Section, Manila, 25 May 1945 ---------------- 725

283 Col. Dwight M. Kuhns, MC, Commanding Officer, 19th Medical General

Laboratory, Hollandia, 1945 ----------------------------------------- 729

284 Captured Japanese armored vest ----------------------------------------- 730

285 Metal plates designed by Colonel Trimble for a protective vest -------------- 731

286 Red Beach, Los Negros Island, Admiralty Group, October 1944 ------------- 732

287 American casualty being loaded aboard ship in Leyte Harbor, October ]944--- 736

288 First aid measures at an aid station on beach at Leyte --------------------- 737

289) Difficult litter carry on Leyte ----------------------------------------- 737

290 58th Evacuation Hospital at Tacloban, Leyte, October 1944 ----------------- 738

291 Definitive surgery in a portable surgical hospital, Leyte --------------------- 739

292 LST handling a surgical load during the Leyte invasion --------------------- 740

293 49th General Hospital, Tokyo ------------------------------------------- 746

294 Prison Camp No. 1 at Canlubang, Luzon --------------- 749

295 Japanese prisoner patients and ward attendants in New Bilibid Prison, Luzon 750

296 Serving a meal at Prison Camp No. 1, Canlubang, Luzon ------------------- 751

297 Base 7, Sydney, Australia, and 118th General Hospital, 1943 ---------------- 758

298 Station hospitals in Southwest Pacific Area ------------------------------ 760

299 An orthopedic casualty in 54th General Hospital, Hollandia ----------------- 764

300 Col. Ashley W. Oughterson, MC ----------------------------------------- 768

301 Tontouta Airfield, New Caledonia, August 1943 --------------------------- 771

302 Noum6a, New Caledonia ------------------------------------------------ 772

303 Munda Airfield, New Georgia ------------------------------------------- 774

304 Clearing station, 37th Division, August 1943 -------------------------- 775

305 Evacuation to beach by litter bearers and jeep, New Georgia, 1943 ----------- 776

306 A truck evacuating casualties to beach, New Georgia, 1943 --------------- 777

307 Screened underground operating room at 17th Field Hospital, New Georgia__- 778

308 Surgical team completing a thoracic operation ---------------------------- 781
CONTENTS XXXV

Nunmber Page

:309 Blood specimens being taken to determine index of malaria in native labor

camp near military base, Guadaleanal, August 1944 -------------------- 783

310 Casualty of jungle fighting being loaded aboard Higgins boat for evacuation by

sea, New Georgia, July 194:3 -------------------------------------- 785

311 Evacuation by C-47 transport plane from Munda Airfield, New Georgia, 1943-. 787

312 Aid station on Rendova Island, Solomon Islands, July 1943 ----------------- 790

313 Aerial view of 27th Station Hospital. New Caledonia, February 1943 --------- 798

314 Staff of 142d General Hospital at New Caledonia, June 1943 ---------------- 800

315 Construction of native-style barracks for 8th General Hospital, New Caledonia,

September 1943 ------------------------------------------------ 803

316 Surgical team with equipment, Bougainville, December 1943 ----------------- 807

317 Surgical team at work 5 days after landing, Bougainville, November 1943 ..... 810

318 The 24th Field Hospital, New Georgia, October 1943 ----------------------- 813

:319 Screened and dugout operating room, Bougainville, December 1943 ---------- 816

:320 Surgical teams, Bougainville ------------------------------------------ 818

321 Survivors of torpedoed U.S. Army Transport Cape San Juan ----------------- 820

322 Difficulties of litter carry over rugged terrain of Bougainville, 1944 ----------- 823

323 Wound ballistics team at Bougainville ---------------------------------- 827

324 Men of 129th Infantry Regiment, 37th I)ivision, turning flamethrower on

pillbox ------------------------------------------------------- 829

325 Casualty being transferred from jeep to halftrack, Hill 700, Bougainville ------ 830

326 Underground operating room, 21st Evacuation Hospital, Bougainville, 1944_-- 832

327 Fiji Scouts returning from patrol into enemy territory, Bougainville, 1944 ----- 834

328 Patrol crossing the Piva River on Bougainville ---------------------------- 837

329) V4.S. Army nurses participating in native dance at Saint-Louis Village, New

Caledonia----------------------------------------------------- 839

330 Training in how to live in and on the jungle, at Jungle Training School, Hawaii-. 842

331 U.S. Army Hospital Ship Mercy --------------------------------------- 845

332 A-day, Leyte Island, Philippine Islands --------------------------------- 848

333 Brig. Gen. William A. Hagins, Surgeon, Sixth U.S. Army ------------------- 853

334 Scene at 116th Station Hospital, Leyte, December 1944 --------------------- 857

335 Wards of 165th Station Hospital, Leyte, December 1944 -------------------- 859

336 Troops of 37th Division coming ashore. Lingayen Gulf, January 1945 -------- 864

337 Extent of supply operations, Lingayen Gulf, January 1945 ------------------ 867

338 Ground being hollowed out for bomb shelter and beach aid station, Lingayen

Beach, January 1945. ------------------------------------------- 868

339 Patients being transferred from ambulance to beached LST, Lingayen Gulf -- 870

340 Aboard U.S.S. Blue Ridge, 3 January 1945 ------------------------------- 872

341 Destruction in the Walled City, Manila, May 1945 ------------------------ 879

342 Quezon Institute, Manila-------------------------------------------- 881

343 The 120th General Hospital, Santo Tomas University, Manila, June 1945-------882

344 Main entrance of Philippine General Hospital, Manila, October 1945 ---------- 883

3-15 U.S. Army Transport General Sturgis departing Manila harbor for Japan,

26 August 1945 ---------------------------------------------------- 887

346 Col. A. Stephens Graham, MC ------------------------------------------ 890

347 Brig. Gen. Raymond A. Kelser inspecting Ramgarh Training Center, India -- 891

348 Lt. Gen. Joseph W. Stilwell with Brig. Gen. Frank D. Merrill --------------- 892

349 Deogarh training camp of Merrill's Marauders, Burma, December 1943 ------- 893

350 Merrill's Marauders moving up along Ledo Road -------------------------- 894

351 Admiral Lord Louis Mountbatten ..--------------------------------------- 895

352 U.S. convoy ascending famous 21 curves at An-nan, China, March 1945 ------ 896

:353 High ranking Chinese and American officers, donating blood at K'un-ming -.-- 898

351 73d Evacuation Hospital, Shingbwiyang, Burma --------------------------- 900

:355 Medical support of a jungle operation in Burma -------------------------- 902
XXXVI CONTENTS

Num ber Page

356 Light aircraft evacuating wounded from a makeshift airstrip near

Hsanishingyang, Burma ------------------------------------------ 904

357 Airstrip at Myitkyina, Burn.% May 1944 -------------------------------- 905

358 Inadequate medical supplies bei ng sorted at a Chinese medical collecting station- 910

359 Hospital construction in India ---------------------------------------- 922

360 Locally reproduced apparatus designed to aid remedial exercises ------------- 926

361 Improvised testing equipment used by ophthalmologists -------------------- 928

362 Improvised baker and exercise weight and pulley arrangement at 14th Evacuation Hospital -------------------------------------------------- 930

363 20th General Hospital, Ledo ------------------------------------------ 936

364 18th General Hospital ----------------------------------------------- 940

365 Chinese soldiers constructing an operating table for surgeons of a portable

surgical hospital ------------------------------------------------ 943

Charts

1 Organization of the Division of Professional Services, Office of the Chief Surgeon,

ETOUSA, in 1942 -------------------------------------------------- 5

2 Organization of the consultant system in ETOUSA, 1944 --------------------- 8

3 I)isposition of 34,761 convalescent patients discharged from rehabilitation and reconditioning centers in the United Kingdom, 7 April 1943-31 l)ecember 1944-- 496

4 Disposition of 14,247 battle casualties discharged from rehabilitation and reconditioning centers in the United Kingdom, 7 April 1943-31 December 1944.- 496

5 Disposition of 1,637 officer patients (classified as disease, battle and nonbattle

injuries), discharged from the 833d Convalescent Camp (Officers), 7 April

1943-31 D)ecember 1944 -------------------------------------------- 496

6 Table of organization for consultants in surgery, U.S. Army Forces, Pacific ------ 710

Maps

1 Medical support in the United Kingdom for the Normandy invasion, 1 July 1944-_ 174

2 Southwest Pacific Area ------------------------------------------------ 689

3 Allied advance from Townsville, Australia --------------------------------- 707

4 Distances from mountini. areas to Lingayen Gulf --------------------------- 708

5 Medical units on Bougainville, March 1944 -------------------------------- 828

6 India-Burma Theater, approximately January 1945 -------------------------- 907

7 Services of Supply hospitals in India, Burma, and China, early 1945 ----------- 909

8 Selected hospitals of the Services of Supply in India early in 1945, showing concentration in the Calcutta district ----------------------------------------- 938

Tables

1 Comparison of infection rates, with respect to wounds, in patients receiving

penicillin prophylactically and in controls ------------------------------ 139

2 Average duration of hospitalization and convalescence, April 1943-June 1945, of

trainees returned to duty from convalescent centers ---------------------- 500

3 Shortages of surgical officers in AFWESPAC (including Sixth and Eighth U.S.

Armies), 17 July 1945 --------------------------------------------- 717

4 Medical Corps surgical officers in AFWESPAC (including Sixth and Eighth U.S.

Armies), 15 July 1945, by specialty and rating -------------------------- 717

5 Operations, blood transfusions, and deaths, by month, 148th General Hospital,

Saipan, Philippine Islands, August-November 1944_- 852
Part I

EUROPE
CHAPTER I

Surgical Consultants in the European Theater

of Operations

Col. James C. Kimbrough, MC, USA (Ret.)

It may be said that the foundation for the consultant system in the European theater of World War II was laid during World War I. Many of the

camnpaigns in Europe in the Second World War were fought over tile same

battlegrounds of the only major theater in which American Forces were involved

in the First World War. The AEF (American Expeditionary Forces) in

World War I eventually developed a full-fledged system of consultation in both

medicine and surgery. Lessons learned in the metamorphosis of the consultant

system during the first great conflict were recorded and available for reference

in the medical history of that war. Thus, a review of consultation in surgery

in the European theater during World War I must begin with World War I.

CONSULTANT SYSTEM IN WORLD WAR I

At first glance, it would appear that the AEF in World War I was amply

supplied with consultants.' At various times, consultants were assigned to

every echelon of command from combat divisions to the Chief Surgeon's Office

and in headquarters and hospital centers of the base sections. The system under

which the consultants were appointed, organized, and operated took two

quite distinct forms during the war. The earlier of the two may be simply

characterized as a more-or-less unsystematic form in which consultants worked

independently and entirely on their own. The second, and later, form may be

said to have been an attempt at systematization and unification of the professional services.

Under the first system, there were eight "directors" in the Office of the Chief

Surgeon, AEF. A director was appointed for each of the following: General

medicine; general surgery; orthopedic surgery; surgery of the head; urology,

and skin and genitourinary diseases; laboratories; psychiatry; and roentgenology. This "director" system was implemented throughout the army corps,

administrative sections of the lines of communications, larger hospitals, and

other commands. Many assistant consultants were appointed in various echeI Most of the material in this section Is based on the discussion of the professional services, AEP,

contained in "The Medical Department of the United States Army in the World War, Volume II,

Administration, American Expeditionary Forces" (Washington : U.S. Government Printing Office, 1927).

1
0 ACTIVITIES OF SURGICAL CONSULTANTS

Ions of the medical service. At the start, each infantry division also had a

surgical consultant. The assistants and consultants at the division level were

commonly known as junior consultants.

Under this system, each consultant was directly under either the surgeon

of a command or the commander of a hospital center. The Chief Surgeon's

circular establishing the system emphasized that professional authority did not

include administrative control. This was indeed an open-end statement since

nothing was said as to what, specifically, "professional authority" entailed.

At General Headquarters, AEF, the directors were supposedly under the control

of the Hospitalization D)ivision of the Chief Surgeon's Office at Chaunmont,

some 45 kilometers from where the directors were stationed at Neufchateau.

Their activities were uncoordinated. Each director sought to solve in his own

way the very different and difficult problems which confronted him. No specific

instructions had been issued governing their status.

The confusion which often resulted is readily understandable under the

circumstances. First, the new professional directors did not have the military

background and experience which would have made their tasks easier of accomplishlment. Moreover, there was really nobody to help them. Each director

was an enthusiast in his own specialty, and his zeal-as well as the misnomer

of his title, "director"-not infrequently led him to misdirected activities. Some

of the best clinicians were assigned to divisions and other commands which had

little need or use for their talents during most of this period. Even the seemingly simplest matters became problems of no small proportions. For example,

someone in authority had most generou.sl. ruled that each director at General

Headquarters, AEF, was authorized the use of an automobile for unlimited

periods of time! Considerable embarrassment was caused by a shortage of

automobiles for this purpose and by the absence of an arbiter to coordinate the

use of the few vehicles that were available from time to time.

In spite of the difficulties encountered, the initial work accomplished by

the specialists was of very great importance, and there were many basic simnilarities in their modes of operation. As their functions became more clearly defined,

it was evident that consultants were expected to direct and supervise the professional services in all echelons of the medical service, to provide for continuity

of treatment from front to rear, to modify, as need be, accepted methods of treatment. and to inaugurate new treatment methods.

On 18 April 1918, the Chief Surgeon appointed Lt. Col. (later Col.)

William L. Keller, MC, Director of Professional Services for the purpose of

coordinating professional medical activities. Among the missions given

Colonel Keller, the following were most significant:

By virtue of this appointment, you are empowered to represent the chief surgeon,

A.E.F., in all matters pertaining to the administration, direction, and coordination of the

professional services. You are responsible for such professional matters relating to hospitali- zation, evacuation, laboratories, sanitation, and other activities as may pertain to the

proper sorting, distribution. and evacuation of sick and wounded through the channels that

will best insure efficient treatment from the front to the rear.
81Ui0,il(AL CO N5ULTAN'vi's IN El~ I'A ~IAitl 3

All reqetll-St for teit- movement oif l)Q-rslblIkl~ andtt supplies originathig in thle p~rofessionial

services will he forwarded by or throuagh you i t) thle chIie-f surat-oit. A.E.F.. or to somie oine

deSigna ited by hint1.

Youl wI.v Illirect the( comipilatIion of a vhassilhed roster by3 enchI craiif voaastltiant. (if Ol

jprotessbtntl personanel. such ias sjKt-cia lists. contsultantts, or surgical tennis amnong the( Various

strnay tunits of our own anid allied foriniattions, so ats to facilitate their prope-r distribution

tand utilization lin emnergencies its well ats inl routinue. WVhena the organization oif thet professional service Is vonalleted. you will direct Its workings. either fronm geiteritt i eadolutrters

or suich oither places its best serves thet interests of Iithe se'rvice.

With tithe three original divisions. mnedicine. surgery. aiid laliorationes a1s at bisis, you11

wiull soi coordiiatte Ililt act ivitijes of the subdlivision thereof that scientific researtch aind

cliniicial protiviency 11113 ip(e effetuaIljlly proijjtvtoted

With the ap)pointmtent of the( D)irector of Professional Services, a reorganaizat iolt-act till1' I111til organlizat ioul-of the rest of thle professiotnal services Was

dlirected oil aI triial basis. Tile orgailizat Iot Nvas fully adop)ted1 and( officially

annoituac1(ed by General Orders No. SS, Genietal Headquiarters, AEF, oti 6 little

11.)18. This wvas the beginniiig of I lie second systema previotusly referred to, that

of it coordlinatedl professionaal service for thle AEF. Tlhie titles of dlirectors were

ait t his timue chatngedi to c()lstllt ait s. Ihe publ)1icat ion of thlese general orders

gave them a stattits Which they hadt niot p)reviously etnjoyed and~ priomtoted

Ibroadler app reciatiiota of their respontsib~ilities.

Undter the D)irector of Professional Services, who, incidlentally, was still

ulnder tile H ospital izat ion 1Division, were a Chief C'onsultiant inl Surgery and

a C hief (Constult ant inl Medjitine. Thte Ch'Iief C'otnsultatnt inl Surgery wats Brg

(Tetl. Johnt M. TI. Fitnney, MC. Ile was given the overall responsibility for

sutpetvisilig ( lie professionatl activities of thle surgicail subdivisions inl tile AEF.

Ilie was itnstrttctedl to organize and1( coordlinate these subldivisionis itt a mantner

wlitch would p)ermiit hin to anticipate 2and( reqiest, ais far ill adivance ats possible.

necessaryu changes lin personntel. Ilie was chargred with the formnatiotn andt fituict ionitig of surgical teams andi collect ing t ititely relports f ront tihema. Ilie wats to

manke recommtaendatijonts for inlsptectin aO~s21 to techntical procedutre anid inistrttct lollin the specialty of saatgery.

Und~er thle Chief (Cotnsultatnt ill Surgery were nine senior cotnsult ants ill

v'arioits sp~eciallt ies rep~resenit ing Ithe subdivisions of surgery which were to lbe

recognitzedl inl the AEF. These were stttgicatl research :, roemitgeli(logy . neurosuirgery: orthiopedlic surgery; ear, nose, an'hotsrgr: ceeal stlrger%

venereal and~ skill diseases amnd genlitoutrinau~ry surgery; miaxil lofacial surger%

211(1 1)11 lalnohoy. he tt ssimi f teses br111 Cotis1utalttts was to Coor)dinatet(

professiona~l activities relat ing to t heir specialities inl sutbordiniate commtiandls.

Thtey were specifically inst ructed to miake recommtittedations to tile C'hief ('onlstaltant so tha~t b list raIdt ionts relative to p~rofessionllh subjects could1 he dlirectedl

to stil iorittaiite conitittitiiis with diispa:tchI a 11( eXe('litedl prmt)lItl.N

Ik Ltte'r, ('itef Surge'on, At'P. to Lt. C'ol. W. L. Klle't.r. AW, 18 Apr. 19191. sub~ject -. Dtatnl ag Director

705 095, (64-4
4 ACTIVITIES (OF SURGHCAL CONSILTANTS

A consultant who reported directly to the Chief Consultant ill Surgery

on professional matters was appointed in each army corps. His title was senior

divisional surgical consultant. He was responsible for the supervision and

direction of all surgical activities in the infantry divisions, a responsibility,

formerly, of the division surgical consultant. It was the duty of the senior

divisional surgical consultant to relieve division surgeons of the necessity for

supervising strictly technical work, since it was considered that division surgeons

would have their hands full with other operational and administrative matters.

Aiding the senior divisional surgical consultant-who, it is to be remembered,

was assigned to an army corps-were divisional surgical consult ants. These

were assigned to the corps, usually on the basis of one per division, to supervise the immediate surgical activities of operating teams within the divisions.

Toward the end of hostilities, these divisional surgical consultants were withdrawn as superfluous when the First and Second U.S. Armies were organized

with their full complement of consultants.

To round out the surgical services of the AEF, there were consultants

-it hospital centers, specialists in base hospitals and tactical divisions, and

surgical teams. Consultants at the hospital centers were named in the various

specialties, as required, and were available for consultation to nearby units as

well as within the hospitals of the center. While the need for them was evident

early, it was not until near the end of hostilities that, they could be supplied in

any number. At the end of 1918, 16 hospital centers had surgical consultants.

Specialists were also designated at hospitals in eight of the nine surgical specialties previously mentioned. (There were no consultants or specialists locally

designated in surgical research.) Each infantry division had a specialist in

orthopedic surgery and one in urology. In 1918, surgical teams were first

organized from personnel of base hospitals. These teams, numbering some

three hundred by the end of October 1918, were used wherever necessary, including the division areas, and were composed of one operator, an anesthesiologist,

two nurses, and two orderlies.

The Chief Surgeon, AEF, subsequent to the signing of the armistice,

convened a board of officers to investigate and report upon the conduct of the

Medical Department, AEF, and to make recommendations with a view to the

iml)rovement of that department. This board approved fully the system of

professional services which had been developed (luring the war. Specifically,

it stated that the Director of Professional Services should be a colonel selected

from that scarce category of Regular Army medical officers who knew the

routine of Army administration well and, at the same time, were well informed

as to the professional qualifications of large numbers of civilian l)ractitioners

so that they could be assigned to duties wherein the greatest efficiency in performance would result. The board went on to say that the Chief Consultant

in Surgery should be a medical officer of the highest surgical attainments and

that his surgical subdivision of professional services should be further subdivided into the nine surgical specialties heretofore mentioned. The board

also reconlmen(le(l assignment of consultants to field armies, corps, and divisions
SURGICAL CONSULTANTS IN EUROPEAN THEATER 5

only during active campaigns. Assuming that the theater surgeon would

also function as Surgeon, SOS (Services of Supply), for the administration of

base sections, th- board emphasized the need for consultants in general surgery

and orthopedic surgery to supervise and direct all surgical activities throughout

base sections of the Services of Supply.

CONSULTANT SYSTEM IN WORLD WAR II

Organization

The activities of the surgical consultants of ETOUSA (European Theater

of Operations, U.S. Army) were coordinated by the Chief Consultant in Surgery, Col. (later Brig. Gen.) Elliott C. Cutler, MC. These surgical consultants

functioned under the Division of Professional Services, Office of the Chief

Surgeon, ETOUSA (chart 1).

CHART 1.-Organization of the Division of Professional Services, O/lcc of the ('hicf Surgeon, ETOUSA, in 1942

SCHIEF SUJRGEON

DIRECTOR OF

PROFESSIONAL SERVICES (2)

CHIEF SURGICAL CONS=ULTANT CHIEF MEDICAL CONSULTANT (2)

SENIOR CONSULTANTS SENIOR CONSULTANTS

General Surgery General Medicine (2)

Plastic-Jew-Burns Got Defense Officer

- Orthopedic Acute Infectious Disease (1)

-Nurosergery Cardiology (1)

- Chest Sergery (I) Tuberculosis (1)

- Anesthesia Gastroenterology (2)

- Transfuslen & Shock (1) Dennatelogy

I Urology (2) Neurology (2)

-OIolaeywooluop Psychiatry (2)

Ophilleimlegy

Redlolegy

(1) Pert-time positios held by medical officers assigned permenent duties elsewhere then in the Office of the Chief Surgeon.

(2) Deal positions. Director of Professlenal Services wes else conseltant in urology; likewise, neurology and psychiotry were

handled by one officer, end general medicine end ges•reenteIlogy by the chief medicol consultant.
(6 A( 'Ti\ IT JIII,1 !'1{( IP 1v'.\1, ('sIN, l'l 'NTANrs

The D)ivision of lProfessioiial Services was activated on 19. ,Tune 1942 with

('ol. James (C. Kinibrougli, M(N', as chief (fig. 1). Thie coonsultant, orgahiization Was set up1) avc)ording to the Regithir A.%.IIuV surgical service in tile large

Anny liospitals. III such an organli zation, tile general surgeon was chief of

tle surgical serwice and tle specialist surgeons--such as those in orthopedics.

oplithalilnology, and ( neurosurgery-were chiefs of the variolus surgical sevt iolns.

(later, about 1945, s1)ecialties in army hospitals were given the status of a

service, or depart ment, similar to tile organization ill large 'ivilian hospitals.)

Since all the c'onisullants ii tihe European theater held high positions inl university hospitals and Iiiedical schools in tile U nited States, this suhordination

to a general surgeon caused sott1 dissatisfaction. The specialist, surgeons objected to the designation "senior consultant, as contrasted to thlie title "chief

(1oiisiiltalit." They were, however, all such patriots and of such high caliber

as surgeons that thiis reginlientation at. no time interfered with their efficiency

or their de\'ot iou to dilty.

FIGUEi. l.-(ol. .Jamines C. Kimilrough, .%C.

Anesth lesia was represented lby a senior l()siiSIlIt alit fiiuIct ioliing itlideer ureneral surgery. It like m~ianner, radiology hecame a part of thlie surgical service.

After the Professional Services D)ivision had been established and meldical oflicers to fill tile c.onsult ant positions began to arrive in the theater, it

"was necessa1ry to Iromi ulgalte an oflicial statement relating to tile organization

for .oiisultatioll in uiedicinue and surgery. This was done bly an unaddressed

do'ililielit, signed by the ('hief Surgeon, ('ol. (later Maj. Geen.) Paul R. Hlawley, M( (fig. 2). and dated Is August 1942. Tit led "Organization of Professional Services E.T.O.1T.S.A.., Services of Supply," the p)ronouncement, read:
.•1~~~~~ IIII\'". II IIP'• ~ ~~ :1,;,*\. \ P';\I '"11 \1 ••I' 

Jln ,,l',h 't" l i l I• Ih it- I I', , -- ,I -n l ,,n'l\ i,-'q .0, 1 Ill- - I' IIJ : l l • ;I fllJ I 114 n• .4l, ; i-- 

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I _ S. Lý4-,1, ,,,I// • t "S h , t 1' ,l l t~ l l. - I' w 1 I •1\i ,. ' i\, ill I, lJ.l, ho' Il I,',

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,~~~ ,,l ~ ~ 1:l1'. \\1 II'i'l Io'l It'lf

A f I I I ,• I• L:li I, I, I' . I" .I• Ih / ,, I ; Il,,I I-I,11- ;O 1', V' l 'V\ ' , nL",:, O Ih .

,, ,; l 1 , ; I, , •,, , ,I ' 1" 1. l ito.I l .-, ;I I ll i i\ I I,, I Il - II I~f • l ; I t I,, ;' l-I ' 1, ' t1, 1,, :.1•, . - ,].

I, I .f Ii t II. l~ l f I',o I ..l r .i .',t i,, .h, i . l, l 1..:.' '.~ll~ l l I" ~ l: -1 - 1•, ~ li ,

li,' -' : t' It-f 1,, f, ) S,1li~ h I o I I II lf ti ,,- i I, -Ii, Ii~t~ i l rf I I I,, I - , t - IIII', i I*'si , t 

I ,, , • , o , I It l Iia ' Ii III'' i- It I 'f .• , I~o li ( , . I if l l ;I -. l-11 A F -,.li 1 'li 1

w .,, ." j Ih : t Ii . ,, if - , JI I , i- l, 11 ,-l 1 1t - I,' JI I• I, -I' , • ;Ii~ I , I , l i l i , l %t Il ' I,' I k '

.,, r,,I , ! l , l Ii l -i r\• ,, it l, - ,, , J - I t i q' ' t l i " • o , i g , -•n l ' i t'' i , ,
S ACTIVITIES OF SURGICAL CONSULTANTS

5. Xpceialixt,•-Under the supj•ervision of the Consultants, the sleccialists oil duty

with hospitals, divisions and other formations will organize and carry out the work of

thir reslective specialties in the most efficient manner possible.

The surgical consultants in the European theater were eventually arranged in five groups (chart 2) :

1. Consultants assignied to the Chief Surgeon's Office. This group consisted of ('ol. Elliott C. Cutler, MC, as chief and the surgical specialists fuictioning under the overall supervision of the Chief Surgeon.

2. Base section surgical consultants. These changed frequently and functioned under the direction of the base surgeons.

3. Regional consultants and coordinators in the hospital centers. These

were usually the senior outstanding surgeons of one of the general hosp)itals

of the (center who performed the duties of consultant in addition to their duties

as chiefs of the surgical services or sections of the hospitals to which they were

assigned.

CIIART 2.-Organization of the consultant systcm in ETOUSA, 1944

SCHIEF SURGEON

I

Chief of

FProfessional Services]

MEIINE (1 ScetfcOeainl SeialSR

Chief Reseach Research Conosltnot Chief

Consultant Director Sedies to W.A.C. Consltant

r-Consultants Consultants q

General Medicine (1) Gonwel Surgery , Tuberculosis (2) Orthopeics Acute infectious diseose (2) Plastic Surger

' Cordiology (2) Hourerp

* Gaostleoterology (I) Anesthesia

- Dermatology ,Trsfuseion & Shocd (2) Neuorology (I) ,Ophthlmology

Psychiatry (1) ,Radiology

• Urology

•Chest Surgery (2)

•Oftolryagelogy

• Mexillofecial Surgery

--------- ----------- ------ ------ : -------------- a

Field Army Bass Section Army Air Forces

Medicine Medicine Medicine

Surgery Sorgety Surtery

Psychiott- Psycih"ry

Regionol Consultonat Hospital Center

Ceordi Clors

In spociolties as needed Medicine

Administrative and technical control - - Technical control

(1) Duel positions. Chief medicol consultant woe else consultant in teerel medicine and gostreenteroley; neurology end psychiatry were hondled by one officer.

(2) Part-time positions held by nmedicol officers assigned peronent delies elseweire then in hte Office of the Chief Surgeon.
SURGICAL CONSULTANTS IN EUROPEAN THEATER 9

4. Army surgi'al consultants. Each field army had an assigned surgical

consultant who functioned under the direction of the army surgeon.

5. The A1rmy Air Forces developed a limited system of consultation as

necessary within their own commands.

As the continental activities increased, appropriate continental base sections and advance sections were set up after the Chief Surgeon's headquarters

was moved to continental Europe. All activities in the United Kingdom were

consolidated under Headquarters, United Kingdom Base Section.

Personnel

The following individuals were consultants to the Chief Surgeon:

1. Col. Elliott C. Cutler, MC, Moseley Professor of Surgery, Harvard

Medical School, was chosen Chief Consultant in Surgery and reported to Headquarters, ETOUSA, on 9 August 1942.

2. Lt.. Col. (later Col.) James B. Brown, MC, professor of clinical and

oral surgery, Washington University, St. Louis, Mo., reported for duty as

Consultant in Plastic Surgery on 8 June 1942.

3. Colonel Brown was accompanied by Maj. (later Lt. Col.) Eugene M.

Bricker, MC, from Washington University, who eventually succeeded Colonel

Brown on 12 January 1943 and rendered superior service in that department.

4. Lt. Col. (later Col.) Loyal Davis, MC, professor of surgery, Northwestern University, Evanston, Ill., reported as Consultant in Neurosurgery

in September 1942.

5. Lt. Col. (later Col.) Ralph M. Tovell, MC, Hartford Hospital, Hart-

,ford, Conn., arrived on 28 September 1942 and was placed in charge of

anesthesia.

6. Lt. Col. (later Col.) Derrick T. Vail, MC, professor of ophthalmology,

University of Cincinnati, came in on 5 October 1942 to become Consultant. in

Ophthalmology.

7. During the fall of 1942. Lt. Col. (later Col.) Rex L. Diveley, MC, of

Kansas City reported to take over the role of orthopedic consultant.

8. Lt. Col. (later Col.) Norton Canfield, MC, professor of otolaryngology.,

Yale University School of Medicine, came in to take charge of otolaryngology

in January 1943.

9. It. Col. (later Col.) Kenneth D. A. Allen, MC, radiologist, Presbyterian

Hospital and other hospitals of Denver, reported on 9 February 1943 in charge

of radiology.

10. Maj. (later Lt. Col.) William J. Stewart, MC, reported on 17 January 1943 afld acted as the consultant in orthopedic surgery when Colonel

])ivelev was absent in North Africa and continued to assist in orthopedics until

the arrival of IA. Col. Mather Clevland, MC.

11. Maj. (later Lt. Col.) Am rose H. Storck, MC, Charity Hospital, New

Orleans, reported on 2 March 1943 as Consultant in General Surgery.

12. Lt. Col. (later Col.) Robert M. Zollinger, MC, professor of surgery,

Harvard Medical School, took over from Colonel Storck on 1 July 1944.
10 ACTIVITIES OF SI'RGI(CAL CONSULTANTS

13. Maj. (later Lt. Col.) John E. Scarff, MNC, assistant professor of neurosurgery, Columbia University, succeeded Colonel Davis on 10 September 1943.

14. Col. Roy A. Stout, D)C, was placed in charge of maxillofacial surgery

on 8 November 1943.

15. Capt. (later Maj.) Charles 1). Rancourt, MC. was designated Assistant

Consultant in Radiology, on 14 June 1943.

16. Lt. Col. (later Col.) 'Mather Cleveland, MC, assistant p)rofessor of

anatomy and instructor of orthopedic surgery, College of Physicians and Surgeons, Columbia University, was p)laced in charge of orthopedic surgery after

colonel Diveley became chief of the separate Rehabilitation D)ivision on 3 , anuary 1944.

17. Lt. Col. (later Col.) R. Glen Spurling, MC, clinical professor of surgery (neurosurgery), University of Iouisville School of Medicine, became Consultant in Neurosurgery on 15 March 1944.

18. Maj. (later Lt. Col.) Johm N. Robinson, MC, Columbia University,

was designated Consultant in Urology in the spring of 1943.

19. Lt. Col. (later Col.) Paul C. Morton, -MC, was designated surgical

consultant for the United Kingdom Base Section on 10 September 1944.

20. IA. Col. James N. Greear, Jr., MC, came in as Consultant in Ophthalmology, succeeding Colonel Vail in March 1945.

In considering the great achievements of this group of eminent surgeons,

it is believed that never before has an army at any time had available such

expert advice in caring for and treating every type. of casualty (fig. 3).

Base section and regional consultants.-The base section and regional

consultants changed so many times that it is impracticable to attempt to list

them by name. They all rendered superior service.

Surgical consultants to the field armies.-Each field army had a surgical

consultant whose duty it was to supervise the treatment and transportation of

patients from aid stations through the evacuation hospitals. They had technical control of the auxiliary surgical groups assigned to the army and in general were advisers to the army surgeons concerning the treatment and transportation of surgical casualties.

Col. J. Augustus Crisler, Jr., MC, was consultant surgeon for the First

IT.S. Army; Lt. Col. Thomas B. Jones, MC, and later Col. Charles B. Odom,

MC, for the Third IT.S. Army, Col. Frank B. Berry, MC, for the Seventh U.S.

Army; Col. Gordon K. Smith, MC, for the Ninth U.S. Army ; and Col. William

F. MacFee, MIC, for the Fifteenth U.S. Army.

The great responsibility of the surgical consultants can best be appreciated

when it is realized that. approximately 80 percent of the battle casualties in

the European theater required surgical management. The excellent results

obtained are everlasting testimony to the outstanding ability of these surgeons

who supervised and directed the transportation and treatment of the wounded.

The great I)ersonal and professional sacrifices made by this group in voluntarily

leaving their families and professional activities is outstanding evidence of

their great patriotism and their intense desire to serve their count ry.
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SURGICAL C(O)NSU'LTANTS IN El'ROPFAN THEATER 1,

It is the policy of this division to have consultation service immediately available at all

times.

c. Arrangements have been made with the British authorities whereby the consultants

are made available to American personnel in the hospitals of the British Naval. Army and

Air Forces and the Emergency Medical Service hospitals, and the Canadian Military

hospitals.

3. Liaison with British Research and Development in Professional Scrrices.

a. The appropriate personnel of the Division of Professional Services will be authorlzed to attend the meetings of the British Medical Research Council and other medical

conferences pertaining to their respective specialty.

b. The attendance of meetings and conferewces and professional contact with British

personnel and institutions with a view to promoting general good will and obtaining professional knowledge is encouraged.

4. Physical Standards.

a. In reviewing the physical examination of applicants for commission, promotion,

re-classification. etc.. the standards provided in Army Regulations governing each type of

case will be maintained.

5. Professional Training.

a. Arrangements will be encouraged whereby United States Medical Officers may be

assigned to British hospitals for the observation of their activities for periods of one to

two weeks. Allotment of United States Medical Officers to British service and civilian

medical courses has been arranged.

b. Courses of instruction for the medical department personnel of base section, divisions, station and general hospitals will be carried out.

Duties and Functions

To implement the policies mentioned, the Director of Professional Services

circulated the following statement of the duties of consultants for the information and guidance of all concerned and as a directive to the consultants

themselves:

1. The consulting staff of the Chief Surgeon's Office will function under the direction

of the Division of Professional Services and are the responsible advisers to the Chief

Surgeon on all professional and technical matters pertaining to their particular branch of

medicine.

2. They will submit their reports and recommendations, thru the Director of Plrofessional Services to the Chief Surgeon.

3. They will be available to visit Medical Department Units for the purpose of giving

their opinion and assistance with regard to technical and professional matters.

4. They will advise on the selections and assignment of junior consultants and specialists and will report from time to time on the standard of professional efficiency maintained

by such officers.

5. They will be instrumental, in collaboration with the Operations Division, Chief

Surgeon's Office. in arranging Courses of Instruction, Medical Meetings, and Training

Schools. and will k(eep the officers of the Medical Department in touch with the latest

developments in minedical s('ience.

6. They will initiate and carry out research amd investigations with a view to conservIng manpower in the field and restoring to health the sick and wounded.

7. They will maintain liai.mo with consultants and sle.ialists in 0al branches of mmmedicine of the British armed forces and civilian practice.

S. They will advise its to the suitability of druig, Instrummients. euluipmlemnt. and ac('cillunodations and on other matters pertaining to the health of the Armed Forces.
14 ACTIVITIES OF SURGICAL CONSULTANTS

Specifically for tile Chief Consultant in Surgery, the I)irector of Professional Services dictated the following duties:

1. Hie will advise the Chief Surgeon thru the D)irector of Professional Services on questions of surgical policy.

2. Hle will advise on the selection and allocation of surgical et4uipunent.

3. lie will advise, in collaboration with the Chief Consultant in Medicine. on the

selection of drugs for use in the ETOUSA.

4. He will advise the Chief Surgeon regarding the selection and duties of surgical consultants and specialists.

5. Hle will visit Medical Department Units and correlate the military surgical pr4Kcedure

as it whole.

6. lie will establish liaison with the surgical service of the Medical IDlpartment of

other U.S. Forces and with the medical service of the British Forces both civilian and

military.

Significant Activities

It was the chief concern of the surgical consultants to initiate and ituplenient the policies of surgical treatment for the theater. This duty involved the

methods of transportation of the wounded and the selection and allocation

of surgical equipment.

Contact was maintained with the hospitals in England, and the surgical

procedures and end results of treatment were supervised. After landing on the

Continent, they followed the armies in the field and supervised the treatment

and methods of evacuation. On several occasions, they made visits to the Zone

of Interior in order to ascertain the condition in which the wounded reached

the Zone of Interior hospitals.

Upon arrival in the theater, each medical unit was visited, the qualifications of the personnel were verified by the appropriate consultant, and recommendations were made to effect the most efficient assignments.

Special treatment facilities were set up in hospitals under the supervision

of the appropriate consultant for patients requiring highly specialized treatment such as those with cold injury and burns and those requiring neurosurgical,

urological, and plastic procedures. These special hospitals were usually located in the hospital centers.

During the summer of the Normandy invasion, it was realized that the

sup)p)ly of blood for transfusion which was obtainable in the European theater

would be inadequate and that supplies from the Zone of Interior would be

necessary. Colonel Cutler, Colonel MacFee, and Maj. (later Lt. Col.) Robert

C. Hardin, MC, returned to Washington to inform The Surgeon General of the

urgent need for whole blood from the United States. The plan for procurement,

l)reservation and transportation of this b)lood from the Zone of Interior to the

European theater was implemented by the Office of The Surgeon General under

the supervision of Lt. Col. (later Col.) Douglas B. Kendrick, Jr., MC. The

actual transportation of blood early became a function of the SUplly service.

At no time was there an overall shortage in the supply of whole blood for the

American wounded.
SURGICAL CONSULTANTS IN EI'•IO'EAN TIIEATEI 1t

Rehabilitation

In June 1942, at the time of arrival of the 1)'.S. Army in the United

Kingdom, the rehabilitation facility had become a well-established institution

of the British Army Medical Service. These rehabilitation hospitals were

visited and the organization was reviewed by Colonel Cutler and Colonel Diveley. Under the sulpervision of Colonel 1)iveley. a rehabilitat ion "canip" was set

up ati Bromsgrove, England, on 1 April 1943. Iii the beginning, an 8 weeks*

course of training was carried out, designed to p)repare the recently recovered

wounded for tile hardships of field duty. The activities increased so rapidly

that it was necessary to move the "canip" to more extensive quarters at Stoneleigh, which had a capacity of 300 (fig. 5). Rehabilitation activities were

released from the Professional Services I)ivision and established in a separate

division-the Rehabilitation Division-on 3 January 1944 under the direction

of Colonel Diveley, w-ho was replaced by Colonel Cleveland as Consultant in

Orthopedic Surgery.

Colonel D)iveley visited the Zone of Interior to advise The Surgeon General

on the establishment of rehabilitation facilities in the Zone of Interior. These

facilities were the forerutners of tile convalescent hospitals in the I nited States.

Miscellaneous Activities

In order to insure a uniformity in the management of the wounded, the

European Theater Manual of Therapy was prepared by the consultants of the

Chief Stirgeon's Office. The mantial wvais l)dlislied l)efore l)-day (,(1une 1944)

and made available to all medical officers of the theater. The value of this

booklet justified the great anmount of labor expended in its preparation and

publiication.

The medical I)epartinent sutpply tables of surgical instruments and drugs

were reviewed with a view to eliminating tnnecessary items. rhe equipment

obtained from tie British was cataloged to correspond to the item numbers of

the U.S. Army sutpply tables. This work was carried out by the consultants in

cooperation with the medical supply service.

It. was noted early that the Zone of Interior clinical record for patients was

too extensive for use in the Europ)ean theater. A special clinical record was

prepared. This record was of such size that it could be carried in the field

medical record envelope so that, on return to the Zone of Interior, the entire

history and record of treatment were in a single cover.

The European Theater School of Medicine and Surgery and tile Medical

Field Service School at Shrivenham were contribtted to in great mneastire by

the surgical consultants who served as supervisors and instructors in these

schools.

The auxiliary surgical groups were under the control of the Operations

Service of the Chief Surgeon's Office and were allotted to field armies where

their activities were administered by the army surgical consultants. Teams
Eilghuid. I nvgotiate #1 Jacob's hidder 411tin pst.14-h4 1i( 4.1prse.

fromI tilie auixiliary sio-rgical wroltl)s tiiict iolie(I at tilie evaciiat ion lio~spit als or

field lhosptitals ofa(ield .11((1) aiV.

A miobiile field surgical ulti it %vas i iiiileiiieiile(I bY ( oloujel Zol i ligzer at tile,

5t It (4 1elier I I lospit a 1. 'Illbs tilt it. was comlpleted(I it Novembier 194:1 an id del ivered

to tilie :)d Auiixliarv Surgical ( hroip. Tile plant ev-ent ial lY evolved it titlie

mobilhe a ruii suric-ial hospital late adopted by lie Alm.'lett t~a on

plet e Withi equlipilleiit . teuitage. beds. II11d tilie likew. to care for Q16 1'enIC Ievs1urgICal1

vases at tlet froiitl tie level.

( olotiel A Ileii. Sen io. ('otisufitalt. ill Rad iolotrv. 'Isseliblede a Ii ioiiile fieldi

X-raY 11n it Nvli lic was Idelvered to thle :)d A uixiii Ia Suirgical G rouip of lie F'irst.

17.S. Armiy ]ii Novemiber 1943.

A si iiipie field blood I rauisfuisioii unlit Was created by )Ali. (later It. C ol. )

CIha ries 1'. E I I erso I. JIr.. MC( '. a1d M.aj. (late er Ili. C ol.) I ? it Aia rd V. Elbert . A ft

of lhe -)Ill ( eiieral1 H ospit al.

Liaison with the British medical service,.-l-it 19t42. t he suiurg:al conisulForce for lie at t etida lice of U .S. A iliivnedIical otlicers at tilie follow i ti schlools

ant1i coiurses: A ilt iga,,s schlool aIt A l(lersliol Lonldon School ofIivgieiie anidt

Iroltical Mfedicinle: Arimy Sch ool of I y-e l: gas school. Leeds I 'iiiversity

blodo i1 niisfiisionl schlool, sottlihiliead II ospiit:, alllristol :;a tid tien rosit r.rica i a ii
SURG(IC'AL C'ONSU'LTANTS IN El*IO nEAN 'I'll EATERI 17

ing tit Ox ford. 'These couirses were arranged by t lie surgical1 consiiltaiits ill their

individual fields.

Liaison with the Russian medical service.-In order to obtain inforination regardiiig thle m~edlical serv*ice of the Soviet Armiy andi~ to promIiote amiiicaible

diplomatic relat 1011 With tilte I .S.S.IZ., a -onlliiu ssionl of proni inleut siurvgemI1S

fromn tilie All iedl ari'iies Nvas Selec*tedl to visit. Riissia. T1w Uiilited( Stautes5 was

represented by Coloniel (Cuttler alld Colonel D~avis.

Major I~0biii5oli, (oiIs~ilaloit hi U rology, visited the Zone~ (of Interior in

November and D ecembher I194-1 for thle piurpose of p)reseuit~ing inlfornlat ionl to thle

Office of Th'le Surgeonl ( iencral regardingo tlie mianlagemlenit of wvounlds of thle

uirogenlital Inlct.

Medical Society, ETOUSA.-Early in tile inedical activit ies of the Europeallthr:1er. til w Medicai Societyv. E'I'( ) A. was organlized. Meetiltugs were

hlehi ~it ral I ho~spIttls uhfi ii t lie- dispersion of t lit ftei lit ies mtade suich mieetinigs

Ilipilad ical, at Which t lline tilie mleet tnigs were coinducted miidei' thme direction of

thle base siurgeIims. 'I'lie SuricaZ~l 0()iisuiltaiits con)1tribu~itedl matterialIly to the prIogrant11ils of (1 1is society.

Operational research.-1In May 11944, the Operat ioiial Rteseairvh Sect ion

of tile. Professionial Services D)ivision was established at Cambridge M1ilitary

Cemnetery. *Withi thle cooperation of quart ermnaster graves registration personniel. facilities were establishied for stu(Iyiing thle killed-ini-action with a. view to

determininig the types of wounds causinig deaths, the missiles producing fatal

wounds, anid the circumstances under which death occurred. Trhis op~erat~ionl

was suipervisedl by the surgical conisultants who assembIled at great. (leal of

valuable information.

D-day activities on 6 June 1944.-iDuring the early p~art of thle cointinental

liberationi thle, members of the conistltant, group were. lpresent atit tile recep~tion

points onl the beaches in England and ait the tranisit h~osp~itals supervising the

care of the wounded traiisported back fromn Normandy. As it result of this

observatiott, Circular Letter 101, Office of the Chief Surgeon, ETOI'jSA, conlcern tug care of battle casualties was 1)ullisliedl onl 3o July 1944.

Liaison with the French.-On airrivatl of the Office of thle, Chief Surgeon

in Paris, tile surgical contsultantts were welcoined to thle F~rench National Academy of Surgery and the Val (de Griice.NMilitary Hospital (Frenich).

SUMMARY

It, is not practicablie to mueit ion even a few of the numerous outstanding

contribut ions rendleredl by individual contsult ants. Akll surgica:lecoiistiltiiiits were

onl duty constantly, giving the American soldlier the hbest suirgical care that has

ever been recorded in the history of w~arfare, (fig. 6).
IsACTIVITrIE*S "I., SlUIIUICA.\I 4' ).. s 1~I.I.1\N'tS

- It -
CHAPTER II

The Chief Consultant in Surgery

Elliott C. Cutler, M.D.1

PROLOGUE

The war diary maintained by Brigadier General Elliott C. Cutler, MC

(fig. 7) is an invaluable contribution to the overall history of the medical service in the European Theater of Operations. As Chief Consultant in Surgery,

General Cutler occupied a position in which he could observe the many activities of the medical service in the theater, and this position, combined with

an inquisitive mind, and limitless energy, enabled him to pursue the paths

which his observations-including those not confined to his immediate field

of responsibility-opened up.

Some of his observations were based upon incomplete or erroneous information. To have edited or deleted such entries would have marred the reflection of his strong personality in his writing. Where an inaccuracy may present

a distorted picture of an important event, an appropriate footnote has been

supplied.

Cutler's diary portrays faithfully his dedication to his task, his resentment of everything which impeded its accomplishment, and his intolerance

of what he regarded as unjustifiable requirements of military administration.

Notwithstanding his occasional caustic criticisms, he was a devoted and loyal

soldier who contributed more than his share to the success of the medical service

of the European Theater of Operations.

PAUIL R. HAWLEY

Major General. M7C. USA (Ret.)

October 1958

1942: GETTING STARTED

The Beginning

Dr. Elliott Carr Cutler, Moseley Professor of Surgery at the Harvard

University School of Medicine and Surgeon-in-Chief, Peter Bent Brigham

Hospital, Boston, was at Martha's Vineyard, Mass., when, quite by coincidence,

Except where other sources are specifically cited, this nccount has been compiled and edited from

the official diaries maintained by Elliott C. Cutler, M.D., deceased, as well as from other records, by

MaJ. James K. Arlma. MSC. The H1is*orical Unit. U.S. Army Medical Service.

19
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CHIEF CONSULTANT IN SURGrERY 21

Maj. ( len. I-Zobert. 1' P atterson, was D r. Cuitlecr's commandling officer while

lie was with Base Ilospital No. ;-. Subsequent Surgeons General were wvell

knowni to I )r. Cu'tleir, and 'I'lie Suirgeon General at thiis timie (1942), Maj.

Gren. janiles C. Magee, was also a, close ac(luiaintance from World War 1 days.

The immediate, relation of D~r. Cutlecr to the presenit coniflict caine inl the

fall of 1941 when hie was asked by the dean of the Harvard University Medical

School to reactivate Base Hospital No. 5i as the 5tlh General H~osp)ital. This

was readlily accomplished, but býy the time the un:c was pressed into active

service 'n Feray 1942, The Surgeon General had requested that Dr. Cutler

be relieved of his post as commandIing officer and awvait further assignment.

Shortly thereafter, IDr. Cutler was offered the position of Chief Consultait

iil Surgery, ET( )I 5 ( European Theater of Operat ions, 1.S. Arnivl), a po~st

which lie eagerly acceptedl inl spite of the ob~ject ions by the p)resident. of H-arvard

Un1i-er-sit V anld thle trustees of Peter Bent Brigham; Hospital.

Washington Orientation, 18 July to 5 August 1942

Tlei tiir5t.1(1 olavs, iii watshinigtoii were crammned fill] of instruction, news,

and renewing, and making new, ac~iuintances. Dr. Cutler's rank was the

prob~lemn of immediate concern. While hie hadl been a, lieutenant colonel since

1924 and had been offered a. colonelcy for lesser assignments on three p~rior

occ~asionls, there had beeni no choice but. to come onl active diuty as a lieutenant

colonel. The situation was soon rectified, however, and Dr. Cutler's promiotion to colonel reached himt onl 22 .Jiily 1942.

While lie was getting ready mentally and equipping himself with all

the information hie. could gather, plans gradually emergedl. At. this time,

29 .July 1942, Colonel Cutler learned that thle consultant group for the Eulropean; theater would p~rob~ably consist of the following compartments and

subdlivisionls

Me~ e, A8%uI'gery 'e uro ps.ychhitiy

William S. 'Middletoul Elliott. C. Cutler Lloyd J. Thompson

Ort hopedic Surgery

Rex L~. IDiveley

Xii roxiturqe ry

LoyVal I)avis

Otolariyngoloqy

Lyman Gii. Richardls

Oph thalmology

D~errick T'. Vail

IBlood/ 1n/1, Pisuma Venere~al 1).;'ajme Lbiortitorh'.

Cornel ius 1'. Rhloads .James C. Kimblroiigh Ralp~h S..Nimekenftiss
ACTi I'VITES OF SURGICAL. CONSULTANTS

Colonel Kiiubroughilie thought, might b e chianged and placed over the whole

group, and perhaps DIr. A. Winternitz could be called for later to augmient

th hilawatory group).

H o felt thalt the groiuj sholdo ( be a1 cabIlinet of ldvisers to tilie Chiief Surgeon amid tha~t, its membillers shold~~~ rep~ort as it group, and. t hereforl~, have frequent. commonot gatherings and meetings. lie- thbought thlat tihe ( Thief Siurgeon

shouldl seind them into0 the field for sp~eciftic iniformiat ion aund should ask thelien

togive him specifi advice. SU(*eess lie' calclalted, votilo depend oi~lreain

ships With tilte Chiief Surgeon and oii tilie men in the( field equiall.Y, lie reasonedl that. contacts with p~rofessional colleaguies in Eniglandio wouild also Ile

highly desiralble.

TIhe problem wh~ichl b)otheredl hiim mlost was t hat, a Ilmost 110 provision

lhad been made for thle professional care of the Amierican soldier "up the line"

or at. "thle front." Ile wrote. in his diar-y

It seemls to Ine thaiit, the bajse' area has had lots of thought. Base or general hospitals

are well set. 11p and well equippedl. I have stud1(ied iii iletail lists (if ehi~luipent until my

eyes are soiri-lists of drugs never to he usedl.

uat. what of the front where it seemns i)toime men are suaved or amarred for life? I

vannot. flind any happy solution here. TIhere is loose talk of station hospitals b~roken up,

an(lI (of niew hut never assembhied imobile evit('uation hospitals, but the latter depend onl 10-

tonl trailer truicks whichi will probably never ibe deleivered. And there is talk of a light

tie-lit hospital of 400) beds.

moreover, lin a st udy of teams (surgical affiliated untits) I thid i tendency to miake

them righd andh to set themn up here eiquippedl in dliverse ways with at basic general equipnment and then separa te equipument for heis t s-neu rosu rgery, niaxillofacial surgery, orthoimilie teams~, etc.

1. It is vertain the old fixed American hmospitals (evacumationl. mnobile. or surgical hospitails. U'.S. Army :casualty clearing stations, British) have been of little us-e and dangerous

iii thle present mobile, fluid conflict.

2. 1 believe the above is, true andi that early surgical thierampy. If properiy set upt. may

save many lives-pierimaps the( lives of my ch~ildrenl.

3. If the above two tire true, we must organize something new for the( U.S. Artiy

Medical IDepartnment.

4. 1 bielieve the answer lies in putt ing surgical teams in thle clearing stationi area.

at. Perhaps femtale nurses should not go.

1). Perhaps theit new field hospital c-an got there.

c. The team Ipersonnel should be general surgery, not sli'cialiists.

dI. Time teami should be complietely equ1iilpped i Le.. surgeon should have insis runnents

for hmead, ('liest. aibdomiiinal. amid] periphieral surgery. The temnit should also carry dtry goodls.

suppllies. aniesthmesia outfits, splints. etc.4

As ot result of voicing his thoughts onl this quest ion, C olonel Cut ler was

inst ructeol to draw upI ant equtipmient list for teams serving tilie front lilies. But

where were t lie teanis to coime f roii? Affiliaited grouplslbeinig orgaiiizetl ? Excess

in geiieril hospitals? 'lher-eaIl)l)eal'e(l tolbe no iiiiinieolia.te answer-. At any rate,

Colonel Cutler receivedl his bapt isnm into tile. complexities of supply lpt'(etlllles

hI illary entry wa, made to Washington before Gemmeral. Cutler caite to the .T.O. lie niever

haul a ny s~mli viilncern aifter arrival In the E-,.r.o. Yom may be sure that I had n,) thought of going

Iw o) eombuht wi thi~ it the very types of mobile medleouu units which we did have. The only niew tn It

sidi led after I left the U'.S. wam thme field hoomo tal i ma nl I mm ever t bugh t very im uch #ot It as 1a fronit-line

milt." M et ter. Pauil it. Iliiiwii*3. 1M.D.. too Cool. Johni Boydl I otes. .Jr., NIC. 25 Aug. 19~51.)
CHIEF CONSULTANT IN SURGERY 23

while working on the equipment for these teams, and the difficulties of medical

suipply continued to challenge hinm on many occasions thereafter.

As the long summer days of July turned into August and Colonel Cutler

found himself still in Washington, he became. increasingly restless and anxious

to leave. lie recorded:

As a matter of fact, Washington is slow, let down, or, if not worse, full of inefficient people. No one quite at it hammer and tongs. unless it is * * *. I cannot write more but it is

awful slow when our country is in danger-grave danger. I1ow few seem to realize the

seriousness of this! We are all too old, and yet the old men seem to have the right spirit.

That's what the country needs, a spiritual uplift! * * * If I had time, I should sit down

and cast into Shakespearean English what stirs my "innards" and stimulates my days.

As it is. I'm off for action. Perhaps that's my cue. Now to serve my country.

London

While the last few days in Washington were long, the last was barely long

enough. In something less than 12 hours from the time lie received notification

that travel priorities had been estal)lished for lhm, Colonel Cutler had to obtain

his Government transportation requests and tickets, clear administratively for

( .o,.rture, finish packing, bid farewell to friends and fTanily, run the last half

mile to the Washington station, and be at L.a Guardia Airport in New York

for a flight at 0100 hours on 6 August 1942. The Pan-American "Clipper"

discharged its passengers at Limerick Airport, Foynes, Ireland, the next (lay.

After two unsuccessful attemlpts to fly from Limerick to Bristol, owing to the

fog, the third attempt resulted in the aircraft's being grounded suddenly at an

intermediate airport because "Jerry" was reported overhead. Colonel Cutler

finally reached his destination, London, at 23(50 hours, 8 August 1942. and was

billeted at the Claridge Hotel.

Early the next morning, lie was off to 20 Grosvenor Square (fig. 8). headquarters of ETOUSA, where he registered, turned in his passport, and filled

out the numerous blank forms required upon arriving at a new command.

The next stop was 9 North Audley Street (fig. 9), the London office of

the Chief Surgeon, Col. (later Maj. Gen.) Paul R. Hawley, MC. There he

met another acquaintance, Col. Charles B. Spruit, MC, (fig. 10) who was now

Deputy Surgeon and represented the Chief Surgeon at Headquarters,

ETO SA. Colonel IHawley had moved to Cheltenham, headquarters of SOS

(Services of Supply), ET' TSA, wvh.a lie was also designated Surgeon,

SOS. All the medical officers Colonel Cutler met here, just as in Washington,

were bitterly critical of this new organization which ostensibly subordinated

the Medical Department to an overall supply service. It seemed to leave no

provision for integrating services, such as medical, for the Services of Supply

and the army in the field. The reorganization appeared to mean that there

was no jol) to correspond to that of Maj. Gen. Merritte WV. Ireland with the

AEF in World War I. If anything, the squabble over this reorganization was

worse in England than iii Washington. The immediate question confronting

Colonel Cutler as a result of this situation was whether lie was to stay in London

or go to Cheltenham.
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Till-III.I. n, :111d with 1114. Amerl'-:111 VIIIII:Iý-Y Ill I'mid"ll.
CHIEF CONSULTANT IN SVIGEIIY 25

Fic.ix, 9.-Office of the Chief Surgeon, ETOISA, at

9 North Audley Street, London.

Among other things, Colonel Cutler discovered that I)r. Turner had a very

complete file of National Research Council reports and publications and received

new items frequently and promptly. These papers were obviously of critical

importance to the maintenance of highest standards of medical practice among

the American forces in the United Kingdom. I)r. Turner, however, informed

Colonel Cutler that he was not permitted to release them to the U.S. Army.

They were strictly for his information to facilitate his dealhings with the British

counterpart of the American National Research Council. This situation was

disappointing, to say the least, and entirely at odds for the best conduct of the

war effort. Colonel Cutler later made a strong appeal to have the unfortunate

situation rectified. As a result, Dr. Turner was able to obtain State Department

approval for receiving extra copies of the American National Research Council publications to be turned over to the Chief Surgeon, ETOUSA. In exchange

therefor, Dr. Turner was later invited to attend all strictly professional meetings and conferences held under auspices of the Chief Surgeon.

In the next few days, Colonel Cutler went about the most pleasant task

of establishing himself with the staff of the AMD (British Army Medical Directorate) and the Canadian medical staff in England. Lunch on two occasions

at the RAMC (Royal Army Medical Corps) School in one fell swoop placed

Colonel Cutler in the midst of their activities. It was the custom of the DGMS

(Director General, Medical Service) to hold a monthly meeting of his consul-
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CHIEF CONSAI.TrANT IN $'IIIEIIY 27

Fi(-UII': 11.-Surgeoi Itear Admajirall (.4Ird3I (Gordoni-Taylor.

Royal Navy. with General Hawley.

In addition to these rel)resentatives of the lritisih Alr-my and the Royal

Navy. Colonel ('tilhlr also imtet and spoke at leigt ih with Tudor (Gardiner of

the Royal Air Force andl lP'of. .1. alttelrsol Ross, iteitrosurgical 'onsultant

to the Emergency Medical Servi'e.

Cohlmel (O'lder felt that he had acc'iompl islhed intich iin a mere few days as

lie left London by train in tlie early afternoon of 14 August 1942 and arrived

at Cheltenham sonie 5 hours laler. In a ieiorantui, a copy of which went to

the Chief Surgeon, ('olonel (iller presented these imlpession(s of hiis first few

days in England :

Observations on military surgery at this timea. Comb I'onat D )ivisional Medical setlup is (.K.. though wt ieesd tt get directives

to the medic'al unilts as tio proper professional halidling i i.e., very simple. hlxt to include use

of sillfoPllin Inides. splilnls ai1111 e llalatioll).

1). The 11 aIs Area hlosilitals (Station and (General) are admirable and when

brought lilt to tie' T.O. with A meri.aii equipment c(annot bh bettered.

c. The area Iietween the Wail of lie Dlivision anld the ,.ase, Area, is a so far

uncharted area. It ai•tears at first glance tlhat thie British may lbe getting themselves too

.'t (followinig on up their Libyani exlu'rien.c(,s whic.h prlrailically iteaves a plan that throws

705 09.5, 1 .
28 ACTi N ITIES OF SURGIICAL CONSULTANTS

out lith- C.C.S.'s [Casuialty Celearing Staitions] and3( other fobrwardl hosp11tal units aind

relies ai lmolst entirely on tile utliztiot4n of surgical teails Iin i~l(Iellenldet-. Sel f-VclitItItaied,

ino4t41r-tritilsported stuall unitts.

I beplieve wve must lie prepared bothl for the abo14ve mobJ~ile, surgical teamil set-up,. utilizing

thils clos5e to it ('letritig Complanly and1( possibly with part of our new fieldl losIpitill, its well

its for putting Iin ouir evzltemltion0IdWlsptIlS, thoiulig they iulust hle strlllped aumd cut downl ill

weight, for mobility. No one now (all piredict 'Whelk 1111d1 where, therefore. we mnust have

alternaite p)8las.

And whten wve Collie to voilteiiliplte at bietch-lhead and14 medical (lare, the maitter is further

volnllicated * * ol

A final thought brings upl the major plroblemms of evaclvat ion froml tile forwardI areai.

Try its one will there Is no4 escaping th*-e onvictioml which Ilecomles even tlrimler that the

optilu"Il sollt1Iioll is~ tin 1w Or!.'

Cheltenham, Headquarters, SOS

Cheltenhanm, C7olonel C'utler found, was quite p~leasanit. Il[e wats given a,

tiny, but adequtate, top-floo~r room at. tile Hotel Ellentborough. The officers, were

awakented at, 00-30, ht reakfast. was at. 01700 a hbts transp~ortedl theml to tilie office at.

0745, anld workinig hours were from 05tH) to 17M) daily. Saturdavs, however,

beganmi an hour later, all(Iot oi S111lays the officers were requiredl to Work onily inl

tlie forenioon. The office facilities, iunfortunately, were not the best, and later,

when lie full cotuillelneiit of conlsultanits wits o (ildt v, tilie nioise wats said to lbe

akini to at boiler factory (p. :162).

Col. .James C. Kimnhrough, IN(', had been made Di rector oif Professional

Services, Office of the (Chief Sul-rgeoni, Services of Supply, ETOUSA, as Colonel

Cu'ttl1r had anticipated, anid wits tints p~laced over all tilie contsultatits. Ilie was

alsoi acting as cotnsuilt ant ili urology, his specialty, and was responsible for t Ilie

qutal ity of treat inenit licing givenl lat melits withI veniereal disease.

L4t. C ol. (later C ol.) 'William S. Middletoti, M(', wats Chief (

1otisiltatut inl

Medicinie. The oltilv other coiisiiltatit ptesewl at the hieadlqutarters at this time

wats Lt. (Col. (later ('loh.) .Jamnes BI. Browni, MNC, ('oiisultant imi Plast ic Surgery

atit Hintits. ( oloniel M iddletoll, as lie had1( exiilaiimed to ( oloniel Oldte1r at thIeir

first meethiig ill Louotioi, did not expect to lhav e a ltarge fuilltimne staff. Ilie wvits

olielit itig tititler th lit'iriiiciiilt t hat meili of spiecial abuilit ies mind qitali ficationls ill

the genieral hiospitalIs could~ lie dlesignamtedI theater miid~ area conisiultanits inl additioni to their regular dutties inl most of thme sliecialt ies of medicine, Ile pilantned

to have fimil-tinlle cotisititmiits otiilv inl dermiatology and tieutrolpsycliatry. The

coiisumiltatits who wvere to intike upl thle h~ini al group of sttrgical conisult ants inl thle

European theater were expiectedl (and did arrive) ili the next few wveeks. They

were Lt. (Col. (l1tter Col.) Rex L. lDivelev, NMC. Senior ('otlisltatit inl Orthopedic

Surgetry; It. (1o1. (la1ter (Co1.) Loyal D avis, MC , Senlior (Consutltant ill Neurological Surgery; IA. (Col. (later Col.) Ralph M. Tovell, MC,' Seiiior Cotnsultant

itl Aiiest liesia; :and Lt. (Col. (later (Coh.) D~errick T. Va il, M( ' Seniior C onsultaint

ill O phithaltnology.

5Memon'randum113. C ol. R. C. 4 'lit vr. N('. to C'ol. J1. 4. K rmlinrmnzgl. MV*. 14; A~ug. 19342. xubjr.'t :Report

(of Aeititlivs. Ang. 11 14. 11142.
CIHIFW CONSULTANT IN SURGERY 29

Colonel Cutler had just arrived in Cheltenhanm late Friday, 14 Akugust ; but

Sunday, 16 August, found him off again to London. Innumerable trips to

London were to follow.

Oin Monday. lie called onl Air 'Marshal. Sir Harold Whittinghiain, DGMS

of thle RAkF ( Royal Air Force), and Sir Francis Fraser, dlirector of the Eunergency Medical Service. H-e also dined and had conferences with Col. (later

"Maj. Genl.) Mauholmn C. Grow, MC, Surgeon, Eighth Air Force, and thle aforemlentionedl Major 'Wright. The conferences with Colonel Grow and other

members, of the Eighth Air Force concernedl the curriculum of a proposed course

of instruction for medlical officers with no previous training in aviation medlicine.

Tile Eighth Air Force hoped to openl a provisional medical schlool at High

Wuycomjbe by thle end of Auguist.

Thle following day, Tuesday, 18 August, was a preview of things to come

anid the first. trip in the field for the recently arrived1 Chief Con1SUltallt, in

Surgery. With Sir Ha roldl Wh itt ingliaiii, Colonel Hawley, Colonel Grow,

Colonel SIl-ruit, Major Wright, and an engineer officer of the EF gigthi Air Force,

lie visitedl I tendlon Airport, London, to hinslect. the litter -arrangements for tranislport aircraft. Thle deniionstrattion showed olyontie thinigof signiificanciie. It was

very alplarent that. niore work wouild have to be. (lone to make the conversion of

transp~ort aircraft into evaciiation aircraft anl efficient, and simple operation.

The aircrew required 10 minutes to posit ion each of 18 littcr racks. It took some

20 minutes for a British amibulance crew to load 10 litter cases. Much time was

wastedl because thle litter racks were mnade to take smiall-pole litters awl not thle

Aknierican or British Ariny wooden litters. With p~roperly modlified litter racks

and a trainled crew, Colonel Cutler thought tluat-the whole operation of setting

upl the litter racks and loading patients couldl be accomplishied in .30 minutes.",

After thle (demnonstrat ion. Colonel Cutler inspected a dispensary located

at Hend1(onl Airport and then journeyed back to Cheltenham. There, hie p)V0

ceedle(l to write 11p rep)orts of thle trip to London and to put down onl paper

thle type of education and training that would be necessary for medical officers,

in the illllledliate future. Ile envisagred three areas upon which emiphasis in

this training p)rograin could he lplaced: (1) Early treatment at thle front, (2)

treatment (luring the evacuiation lphase, and (3) the type of treatment to be

given in base hospitals. Ile stressed particularly thle followinigpoinit

f'lief emphasis mu11st lie placed upon choice of soldier upon whom surgery is to be

carriedl out in the forward areas. A diret-tive regarding this ca.n be written but will have

to be Inodified by the necessity. Precedence should be given to) baenmiorrhage. shock,

suck lug chest wounds. major 4conicnpoid fractures. 'i'hie uini itarv sulrgeon nmust. lea rn that

the qunickest waly to win the war ( an(I this in the end saves the most suffering) is to get

back to hmuty as mnany nien as juossibie. Abdominal cases and time consuming major surgical

loroced~ures that offer little or no hope of return to (linty can never have first call on the

efforts of the good military surgeon.

7

6 Memnoraundumi Cid. F. C. C'utle-r. 1W. tip Col. J. C. Kinhrougli, MC, 19 Aug. 1942, subj~ect Report

re Viqit tfo fondon August 17 and 15. 1942.

see footnote is.
30 ACTIVITIES5 OF 81IWI(;1AL COfNSULTANTS

'I'is bit, of advice wits soniething which many medical officers,, including

sonme of the specialist senior consultants in surgery, were going to find most

dlifficult to accelpt.

hI this sane. paper on medical cour-ses to be conducted in the theater,

Colonel Cutler also stated: "I conlsider an Auxiliary Surgical Group our chief

necessity at, thlis time !" Hle went onl to report. that, tile comI)oient teams were

beinig varefully picked in the office of Brig. Gen. Charles C. Hlillmnan, Chiief,

Professional Ser-vice Division, Office of The Surgeon General.

I faying finished his London report and the suggestion for courses in mrilitary niedicine, Colonel Cutler found solace and cheer in thle accomplishments of

hiis first few days in the European theater. I usd(iary entry readl

For the first time I feel orderly and as if something had been done. Of course. I have

only beeni here 1t) (lays. Since I've cemiented mnyself with tile RAIMC. the RAF, and our

own Air in~edical people, I mnust have gotten somiething done. Also in touch with the

Royal Navy through Gordon-Taylor and the EMS through Francis Fraser.

Sol itamy reflection on the general outlook, hiowever, causedl Colonel Cutler

to 1)hi10501)lize:

The doctor at war is worth thought. He cools his heels in this prep1aratory phase with

those whose entire thoughts are directed toward imtplemnenting condlitions he is alreadly

trying to oppose. True, the commnon fear binds theiti together. All Iinust visuaslize the

necessity of the undertaking lest a greater evil befall our people. But uniiiistakably, lie

is set aside(-somietimes just as chaff, somnetimies in undue respiect as the necessity for his

ministrations seemis minore imminent, or as the Ilinilted Imagination of his colleagues looks

to the future.

Th'lere wats yet another reason for cheer onl thiis day, Coloniel Cutler's 10th

(lay of duty in. the Office of the Chief Surgeon, ETOUSA. The British and

('anadiatis, withi a few attached Americans, hiad stagedl a major raidl at. Dieppe.

Dieppe and Its Aftermath

Thie raidl at D~ieppe sounded goodI to Colonel Cutler. It shiowed that a

alandinlg -ould] ble achiieved. It proved thiat tanks could be, landed. Was it

wor-tiliwbile? Yes, for any offensive, no matter hlow smnall, would upset thle

0.eriiia111s.

A ('amiadian from Saskatchewan wvho hiad just returnied froiii the raid

toldl ('oloiiel Cumtler that it was at cinchi. lie had gOne in 2 miles. It was easy.

,No oile wvas frighiteined. This young man wenit onl to say thlat. the Al1lies uin igt

as well tell II it icr whien anl attack was conn beasro'n cudso t Ile asserteý(l thlat the G'Xermans knew .1- days beforehiand of the D~ieppe attack.

litit thlere were casualties, Americain casualties. Thle Chiief of Staff',

F1i'( )1SA. upon learning of the seriousness of thieir woundls, became extremely

COiicerup(t o-%erl the care. the Americans were, receiving in the Canadian Army

hlospitals to whichi they had been taken. Colonel Cutler, togethier withl Colonel

Middletoii, visitedl each of the three Canadian general hiospitals in whichl tile

American casualties were hospitalized and carefully reviewed each case. The
CHIEF CONSULTANT IN SURGERY 31

treatment and care being provided them was excellent. To a man, each patient

refused to be transferred to an American hospital when the choice of remaining

in the Canadian hospital or being transferred was proffered. They were happy

where they were and had utmost confidence in the Canadian medical officers

into whose care they had been entrusted.

There was one seriously ill case, a Colonel "UI." Colonel "II." had been

on the bridge of a destroyer when a direct hit blew off the bridge and amputated

most of his left foot. le tied on a necktie as a tourniquet and hobbled to the

gunwales of the sinking ship. As he was preparing to go overboard, a gunboat

hove alongside and Colonel "It." was handed over to it. "Go aft," he was

ordered, but, seeing that the forward gunner was leading enemy aircl'aft badly,

he crawled forward and continued to direct the gunner's fire. Some 30 hours

elap)sed before he was put ashore at Portsmouth, England. Another 24 hours

passed before lie reached the Canadian General Hospital where he received

his first surgical treatment.

At the hospital, Colonel "II." 's lower left leg had been amputated 5 inches

below the knee. Sulfonamide had been placed in the wound, which was left

open. The wound was clean. Ile had been given (loses of sulfanilamide for

24 hours. but this was st o p p ed because of nausea, mental confusion, and his

general poor condition. In the :1 postoperative days, lie had been given 2,800

co. of whole blood and 3,000 cc. of plasma. Repeated, continued transfusions

were urged by h)oth Colonel Cutler and Colonel Middleton, and the l)rofessional

statf at tile Canadian hospital concurred.

Tell days after injury, the l)atient's condition continued extremely grave.

Colonel Cutler was directed to review the case personally. In a midniight visit

to the hospital on 30 August, lie found Colonel "II." somewhat improved but

still apparently dying of a peculiar syndrome. His kidneys and heart were

failing, and tile etiology indicated multiple transfusions with reaction which

had compounded the effects of original blood loss. Colonel Cutler followed the

case daily, thereafter, until the patient was out of danger. This courageoms

officer made an excellent recovery, was returned to duty, and continued to serve

in the European theater after having been fitted with an artificial limb. His

vase becanme ami object lesson for nmuch of tile phlaning that followed.

As tile initial sensational aspects of the Dieppe raid wore off. there were

(loubts ini some circles as to its effectiveness or worthwhileness. The force had

sulstaiined 55 percent casualties. The lessons for the Medical I)epartient were

clear. An analysis of the sittuation in Enghdlan revealed the following facts:

If filings (eohid have liven done better our Canadian colleagues were the first to reeognize it. They pointed out to us * * * that it would have been better if all of the wounded

had beien kept near the landing areas [in England), even if additional teams had been

focussed there, or the local hospitals enlarged to care for such an influx * * * . It was

thought that there would be a larger number of wounded than could be handled locally,

and therefore tile first to arrive were sent by train to the Midlands, which was pe-rhaps a

miistake ftir they went without surgery, even after arriving in England. for a onmsiderailte
32 ACTIVITIES OF SURGI'CAL CONSULTANTS

period of time. The ('amadi'lls themIselves were the first to be self-critical about this. but

since * * * they handled individual cases so well. we can have nothing but gratitude for

their care.'

This analysis indicated that, with a ('ontineittal invasion, hospitals would

have to be set up near the points where casualties would be returned to England

in order to preclude undue delay in treatment, as was experienced by Colonel

"IT." If general hospitals were to function in this capacity of receiving evacuees

front an over-water op)eration, they couhl only do so after l)rovisioln had b)een

made for some 10 or more surgical teams to xork at riie time. The surgical

teams, too, would have to be added to the normal surgical complement of a

general hospital.

On the far shore, it was clear that small medical units wvith attached surgical teanms would have to i)e del)hoyeld near all possible lan(ling sites. The I)ieppe

raid proved once again that confusion reigns supreme in war. Owing to many

factors. significant among which was the destruction of small landing craft,

landing serials found themselves at points completely foreign to their original

intent, upsetting the most carefully prepared plans.

Finally, the important part which sorting or triage would play could not

be nminimized. Sorting at the invasion b)eaclhes and the receiving areas in

Eingland had to be done expertly and quickly so that the seriously wounded

would receive immediate attention, as would also the lightly wounded in order

tlat they might be returne(d to duty as early as possible.(,

British Army Blood Supply Depot at Bristol

One of the first itenis of official correspondence directed to Colonel Cutler

for action was a report on the. British Arnty Blood Sup)ply Depot submitted

by ('apt. (later Lt. Col.) Robert C. Hardin, MC, who was the American liaison

officer at the depot. Colonel Hawley, in turning over the report to Colonel

Cutler, signified that the Chief Consultant in Surgery would be responsil)le for

the technical aspects of providing blood, blood substitutes, crystalloids, and

related substances to the U.S. Army medical units in the theater.1o

Colonel Cutler, at the first opportunity, on 26 August 1942, made a trip

to Soutitmead HosI)ital, Bristol, where the depot was located. Colonel Kimbrough and Colonel Middleton accompanied him. Brigadier L. E. 11. Whitby,

RAMC, the officer in charge of the depot and Director, Army Blood Transfusion

Service, was absent in London, but the visiting officers were received by Major

Maycock, RAMC, and Captain Hardin. They learned that the center l)repared dll l)lasni and arranged for the supply of blood transfusion kits for the

British Army (fig. 12). The general setup was obviously geared for production.

In the previous one year, th•ý depot hald Sul)plied over 110,000 pints of llasini.

'5See footnote 2, p. 29.

S(I1 ) See, footnote 2. p. 20. (2) M enorailm. Col. E. C. Cutler. MC. and T1A. Col. W. R. Middletin.

MC. to 'ol. J. C'. Kinbrough. MC. 26 Aug. 1942. subjeet : Report of Survey of Americ.an and 'anadill m

Casulo, iltes From l)ii ie O)ltrations., A igust 2;. 1942. by Members of Profissioiud Services lDivision.

"I Medical Departmentt. United States A.rmy. Blood Pro gram in |1 World War II. Washingtonn

IU.S. Governnm.nt Printing Oflive. 1964.
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s1milld I I I A I I Iv 1-14-:111 Vf I.( -vý I r:I \.I, I'( I I f 01 wr:1 I It q I- I)III -](I,. fit, V I I I :I I I

Iý I. A I I Iv r 14 -:1 11 :1 - I I I ;I I I I :I - :11 n -:14 )1 k ( it 1

it I f I I 111 n I I I I r: I I t it I I I 1 -1 , 1, k

'--I I: 1,-i \14 '--1. 1 K it id ,i -ojý, h . N14

I:liTi-Ij 1:1- .1 

1 !) I!_, A ,1ý,. 19 1,2. 1 iit
A W 4-1 illll.\ 1' .1

;1 1 1 1-1 1 1. 1 .TI i l:
CHIEFIi CEI)NStLTANT IN SUIAMLILY

Figure U".-(~ hllmined. C, Piilasma bing112 packed fm- issuie.

plhistiia fitec tlY fi-oiii BI-It ish (vi~lters bu Wlill wudsliilliit requiiisit ioIIs to Auiiericali

mledlical s.il~ippl M4Iiike(.,s whlicl) Nvoiild stock( I lt'se Itemsii i&4i1III blk1I fro)nl the

Brit Is.

4. FaUr p-reat er use woIuld lbe maide of ( ';itaiui I Iarliii iii the fuitutre as an

atSsistaiit to thle thleaiter. coiisiiltawis md1( to) help with the orn;nuilzation and

traiui~ui of shock leaiiis. Briganhier 11,1611)v stauted that ( aptaiuu I lur-di I was

esseilt iat hoth Ii i 'iII & I te li plill a11lidil the 'lar-e ieachiuiig 141:14 whivicNh as Carriedl thiere, uiillld ad requiest e, I 111,t Ilie.~li ill Iis hi I jwsplit (11iii :e511i141 asign~igrin ''hit is. I .S. Ar u, v hosp~Jital s wvouild bleedl a few (hoil)5 vaqch week froum

a, prep~ared1 panlel (If (olo4r5 rehpreseuii ,i& gr tie t'ommiiiiIit iii which i tie hospital

was locatedl :111(l tilIiri thle bl(141ood to) II( lie a l-opii;1ie hanlk.

C6. It wouild be Iuiadvisaide lo Ilse Aiiiericauu t roops as douiors for this blood

hanik programi hiecviise 41$ ihe 1polit1ical Hip]iviiiat ioliiM. ItI was liel ieved ( hat -kilericalis at hioliiii an'irlit it(.eitl ri%-'Iihg 1)1141414 foi- t lie k\illpli4;ic 111 ](11p41 Nvhueui lie,

ill turn-1. Was hIiig 1)(,le foy I lle cit Izeuis of allot her. ( I.uu iv. Moreover, there

A'.is thle poss~ib~iliity 1m a ilie 4'oillliilmui 14) of blood14 1 i-oiii Negro) ;1111 whiite tropCIs

migh4rlt compilIic'ate the sit umitioul.
36 ACTIVITIES, OF SURII(CAL CONSULTANTS

6.Finally, Colonel Cutler promised to try to obtainl additional American

personnel to hielp staff the British Army Blood Su~pply IDepoqt.'1

This was indleed a humble beginning to a project which was to become,

literally, thle lifeblood of the thieater's medical efforts, andl Colonel Citier's

perslpicacity with regard to the greater use to b~e mnade of Captain Hlardin was

to be most. aiiiply vindicated.

First Supply Problem

Onl 24 August, just b~efore lie was calledl upfon to inspect thle Canadian hlos--

1)itals harboring American casualties froml the D~ieppe. raid, Colonel Hawley

hadl summllioned the Chief Consultant inl Surgery. Colonel Cutler was directed

to dIraw upl a list, of medical stipplies necessary for thle routine maintenance

of a field force of 770.000 with 140.(000 SOS troops. This was no small task.

Colonel Cutler started Colonel Brown. Consultan lt inl Plastic Surgery and

Burns, oin the list before embarking on tile all-nighIt trip) to thle Canadian

hospitals.

A few dlays later, Colonel Cutler met. with Lt. Col. (later Col.) George W.

Perkins, #Jr., CWS, inl London. Colonel Perkins worked with the central

procurement office of the ETOU-SA staff anl(l was concerned with the pr~cur1einent of medical supp~llies andl equlipment from British sources. This officer

p)olitely informed Colonel Cutler that the -Medical Department was "all wet"

onl its figures. I'Tve no dloubt," Colonel Cutler notedl inl hi-, diary. "anid this

puits meI iii a (difficuilt sp)ot * * * [with respect. to Colonel Hawley's request]J."

Another aspect of the pr1obulem~ was what was needled now-at this time--

-is conmparedl to what. idleally, might be required inl a hypothetical operation.

Phrased inl another way, thle. prolblenm became a matter of what was available

ais compilaredl to whiat wvas dlesiredl. Consuiltants visiting and inspecting liosIpitals had found critical shortages of necessary equipment and the p)revailing

use oif mnany unsatisfactory items. Onl the other hiand, the U.S. Army medical

slup)l),y depot at Tluatchtain was, from all reports, quite well stocked. The fact

remnainedl that, necessary eqIuip~ment for hospitals was. for reasons unknown

to Colonel Cutler, not getting out. Colonel Cutler wanted particularly to

have thle thlree genleral hlospitals inl the theater broughr~t up1 to their fulli antltorized equipimllenit, p referably their original American equ ipImenlt. TIhese

genea Ilhospita ls hlad professionial t alenmt of thle h ighiest caliber-, but t hey could

not be expected to p)rovide servic'es of a1 simniilar high caliber without the prop)ler

equ ipmeniit. Should I .5. Arniv sources inl tile the ater not be able to prov'ide

this eui ipinIIenlt. it was evidlent that Brit ishi sources wvould have to be ta:1pped.

Anud t ius. Colonel Cuitler had arranged the foregoing ineting with Colonel

Perk ins.

0 n 3; Se ptember'. Colonel ('it her anmd C olonel Browvn visited Lmidgershiall,

the ha r-gest Bri tishi A rnvy medical su~pply depot, top1 ick out inlst riiiieiits su1it able

Me I I I'' tI-41(II n. (3⁄4i14 E . 4' 4 '1 thIfr. NIV. tf 'iPIi. j1. 4 . K Iin I)rtDu g I i , MC. 9 ( )vt. 19142. s I I I j t:I Re t port

4)11 3feti' ng W~ith BiritIishI Offlleers 4'oiii.,.rned With tiIlie S ai ivil of' Blowid and PlI Iasmna fi ir t he Armned F~oresi.
CHII EF CONS4ULTANT IN SVIIOERY 37

for inlterchlangre withI Amlericaii ills( rumilents. Coloitel IDiveley and Coloniel

JPeikiiis hiad jolinneye(1 to tihe depot froiii Lond~on. III a(ldlitionl to tile RAMC

oflicer's conlceirned with ti lie dlepot, rejpresentilt ives from three British inlstriimeiett inantifactur-ers wvere presenit. The enltir-e day was sp)ent in going over

item by it em thle insti-runents l istedl inl American supply tables so that. deterillillat 1011 couild be Iliade as to whether a satisfactory substitute British itemn

existed1. Oil thle whole, thle B rit isli inistrulments were excellenlt, and, although

sOllewhat, heavier thani Antericani i list rninelits, each iteml accep~ted wVas a1 sat isfactors' slubstitulte. Thlere was some qItiestioll, however, as to whiether somle

items ('11(lit' b Ipro(liced ili stififhieiit (Ial;lititN. Thmere was a 1)art iciflar lack

of prodiiction in Eniglanid of all electrical apparatuts, and only a negrligible

supphly of heavy X-ray apparatits. Genierally, inst rumnents not. being p)1odlticed

ill Etglanid wvere niot essenitial, ani a good siu'greoml ('011(1o (10 satisfactory job

without themn. Colonel Ciftler was p)artieunlarly imnpressedl Nvi tI tile eleanli ess

aiiord(erliness of this depot. and1 the. wonderful selection of materiel offer~ed.- 3

I poiu retuilni in to Clueltenha'lin, C apta in Mart in, in chargre of the Anmerican

(lepot. at, Iliatcllainu. was cont acted1. Arrangements were made for C olonel

Brown to visit the dep~ot the next (lay to have a, firsthiand look at what was act iiBefore the Chief Sur'geon's first problem could lie aniswer'ed, another was

lposedl. This time, it. was not hypothetical, and1( it was uirgent.

Second Supply Problem

A Ipe1'isteiit runior had been that any atta('k on the Continent from England

had been called off for the time being, andl the basis of this ruminor s00on became

c'lear. BOLERO,~ the buildupl for inv'ading tile Continent. was being stibordliimated to Operation TORCH, anI attack in Africa, whuich1 was to coime off iii the

very near future. With thils as a, background, tile following c'amie allow olt01

5 and 6j Sep~tenmber, as chronicled by Colonel Cutler.

We work da~tily tand se('ii to inake no progress. largely beeause. as wvill he c'lear bielow.

we ire ('alight inl a niess! Our armny is still being trainedI broadly and( abtsolutely lacks

spe-cia lists. 'Take supply ats itea~mp(X letl). He(re' is ouir ('flef, 'Major General Lee [ Maj. Gen.

(late'r ILt. (h'.(t. .iohln ('. iI. JA'e. v sAt. ( 'oninnamiding (1eiieral. SOS,. ETOI'SAI. at very bright

nian antd well-I eqtipietsd wvith na~ttive intelliigenc'e. 'Moreover. hie is lilt engineer. but here

his., problem is supply. It is a professomial I Job. His training tin supply and logistic's is mnore

thanl imine. bilt ilit 'omletet('(. Ills I rinsiiott oltthe has tile job of the New~ York Central1 RRl.

(if c-ourse he( isn't equiuiis'id. we mutst c'itange thiis. 11114 out* army~ miiust have specialists!

Ill thle Medical C orps, it is just puierile.

Take thle last 24 ltiturs. At 9 :C0 last night, C oh ltn'l H awl'y's sergeanlt camle here wvith

a itote front the ('hiet' tbat the( livteml (if his otfi'es ('01114 to Itilti att 9):00 AM. It was a1 suppt~ly

piroblem. .J( K. WSM. anid ECC '('I ols. K inibrough. Middleton. and i'tiller] were gi vent a list

(if t114'4va 1i('ai utimtel'tltmce uinits for loINt( nitte lterm' tottli. We wvet' imtforine(l fill Africa.

~~'We '' wr warlie t .'1114lilt sec(revy. oif ('tilrse. ment 'ite too4 k Olet4 list an i( Jllt 101 It tirs oil it.

:,Me'moraufuimtg. 4 'd. I-. v'. c'tia,'r. MV'. Lt. c ol. .1. it. itrowg. 1i(C. an Itit .. ('411. It. 1'. IDive'Ii'y. NIi4. to'

011'. .1. C'. Kitmit',rim t. MC'. 4 Se'i't. 19442. soiiJectt Rep'orit oft Visiit loy Cot. C'ttfli'r. Lt. Vol. B~ro~wn ;tnd
38 ACTIVITIES OF SURGICAL CONSULTANTS

We could make additions and increase the number (if items, but there could be no deletions.

It was a tough job. The list was a riot. It was supposed to be under battle conditions for

1 month. There were 3 litters, no tetanus toxoid or antitoxin, no instruments (were they

supposed to last forever?), no oxygen tanks, but several thousand rolls of toilet paper!

One bedpanl !

The next day, 7 September, Colonel Hawley asked Colonel Cutler to drive

to Oxford (2d General Hospital) with himn. The Chief Surgeon seemed to have

much on his mind. Ile explained what hospitals would be going to Africa, a

relatively small force from England. Ile said that they would be sent well and

fully equipped, but otherwise didn't seem overly interested in them. The 2d

and 5th General Hospitals, two of the best units, were to stay. Colonel Hawley

implied that when the Operation TORCH forces had gone he would settle

down and clean up in England, and he realized there was much to do. As to

Colonel Cutler, the Chief Surgeon said that he would like to see him make

weekly visits to all hospitals, develop the instructional program (schools), and

stimulate high professional work.

It is elsewhere recorded that, as i)lans progressed further for Operation

TORCH, the European theater had to request that replenishment supplies to

support the operation be sent directly from the Zone of Interior. The basis for

this request was the realization that it would be more feasible to furnish these

supplies from the distant Zone of Interior than to attempt to find them in the

depots in England.14

Introduction to 1st Infantry Division

On 15 September 1942, a Captain Miller, MC, from the 1st Infantry Division visited Cheltenham to further activities for the professional education of

the division's medical personnel. He represented Lt. Col. (later Col.) James C.

Van Valin, MC, division surgeon, who had previously written Col. Oramel H.

Stanley, MC, the Chief Surgeon's executive officer, on this matter.

Captain Miller was referred to Colonel Cutler. When Captain Miller revealed the fact that the medical officers of the division would not be permitted

to attend the surgical courses being established in London, Colonel Stanley

proposed that the consultants give a brief series of lectures at the division. This

suggestion was quickly accepted by Colonel Van Valin and the II Corps surgeon,

Col. Richard T. Arnest, MC.

The lectures were conducted at Tidworth Barracks during 16, 17, and 18

September. On the first day, Colonel Cutler gave two exercises which covered

first aid surgical measures in the first and second echelons of medical service

within the division. There was no attempt to discuss definitive surgery as carried out in the evacuation, surgical, or general hospitals. He stressed the fact

that, the primary requisites for adequate initial surgical care of the wounded

soldier were the control of hemorrhage, relief of pain, adequate dressing of the

wound and use of sulfonamides to prevent further contamination, booster dose

" Medical Department, U.S. Army. Medical Supply in World War II. [In preparation.)
CHIIEF CONSULTANT IN SURGERY 39

of tetanus toxoid, proper sp)linting, closure of sucking chest wounds, and an

adequate appreciation of shock, crush, and blast so that proper theral)y could be

started as far forward as l)ossible.

On the following days, Colonel Brown presented talks on injuries to the

face and jaw, care of burns, and care of injuries in Air Force personnel ; Colonel

Diveley spoke on care of fractures and their transport and evacuation; Colonel

Davis discussed neurosurgery in war; and Lt. Col. (later Col.) Lloyd J.

"Thompson, MC, Senior Consultant in Neuropsychiatry, gave a talk on neuropsychiatric problems in the field.

The talks were well received, but this course of instruction, which had

begun as a one-way flow of information, provided a wealth of instruction to

the consultants themselves. When Colonel Cutler had completed his portion

of the program and a discussion of the basic first aid surgical measures had

ensued, it became remarkably clear that the 1st Infantry Division was not

equip)ped with instruments or drugs of the type to best facilitate and carry

out these necessary measures. This alarmed Colonel Cutler. There were no

morplhine Syrettes for forward work, no sulfonamide powder for dusting

wounds, and no local or intravenous anesthetics. There were only two blood

pressure apparatuses within this division of 17,000 men. The instrument kits

were iniadequate, and the equipment on hand was, in many cases, nearly useless.

A simple procedure which could be carried out by almost anyone and would

save life was that of closing sucking chest wounds, but there was no supply of

the necessary needles and silkworm gut sutures.

As a further check on the statements made by the medical officers, Colonel

Cutler inspected the equipment and supplies on hand in the division's medical

supply section. Ile also went over, item by item, the No. 2 medical chests which

were being used in the division's dispensaries and which were also meant to

be used under battle conditions for the care of casualties. Colonel Cutler was

again struck by the lack of equipment and supplies which he now knew from

personal experience were available and could be supplied from sources in

England.

U1)on returning to Cheltenham, he dictated a memorandum in which he

detailed simple, but specific measures which could be accomplished to correct

these deficiencies. lHe closed the memorandum with the following:

I consider these recommendations of vital importance. The material essential is all

here. We have been instructed to see that the care of the American soldier is as adequate

as it can be made under the conditions imposed by battle. The requests above are simple,

but nmy be life saving, and If they are neglected we should be and will be severely criticised.'"

Once back in his room, he wrote:

Well, I have been told my job is to see that the Americans get the best professional

care under circumstances presented by terrain, enemy resistance, etc. So I handed

" Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, IS Sept. 1942, subject: Teaching Exercises With the First Division at Tidworth Barracks, Sept. 16, 1942. (Copies to Colonel lIaw0•vy,

Colonel Stanley, and Colonel Middleton.)
40 ACTIVITIES OF SURGICAL CONSULTANTS

in a itiein( today practically stating that, if an American newspaper knew 17.0M00 picked

nien were going into battle with simple things lacking which every American hospital had.

then we all would bhe fixed.

This was the beginnilng of extensive medical supply operations in the

European theater in which many individuals participated following the realization that elements of the U.S. Army were not adequately provided with modern

medical equipient and supplies.

Inter-Allied Conferences on War Medicine

While Colonel Cutler and the consultants were planningg the teaching

exercises for the 1st Infantry 1)ivision, a secretary in another office of the

headquarters was transcribing a telephone message from N. B. Parkinson,

Director, home I)ivision of the British Council. Mr. Parkinson's message

stated that, the British Medical Association had recently been in touch with

the. British Council and had expressed their earnest desire that the Association (1o all it could to assist members of the medical professions of the allied

nations now resident in England and to insure that British members of the

profession benefit front the presence of so many medical persons from all over

the world. To further this end, the British Medical Association was willing

to provide certain facilities and privileges under its control. It had been suggested that an association or society be formed which would serve to bring

together medical men of the allied nations and promote a sense of professional

unity among them. Before any further steps were taken, Mr. Parkinson was

suggesting that, leading members of the various national groups meet to express

their views at the offices of the British Council.

Colonel Cutler had been aware of the fact that the Belgians had initially

attempted to form smich an inter-Allied medical organization. It was brought

to his attention in Colonel Spruit's office when he had first arrived in London,

but. Colonel Cutler had since given it little thought. This time, he and Colonel

K inbrough were selected toattend the proposed meeting to represent theAmerican point of view. The meeting was held as scheduled at the offices of the

British Council on 23 September 1942. In attendance were representatives

from Canada, Belgium, the Free French, Czechoslovakia, Norway, and The

Netherlands in addition to the British and American delegates. The Poles

could not come butt te:ephoned exp)ressing their interest.

Most of the particilants at the meeting expressed a desire to have joint

meetings, but there was little enthusiasm for a separate (lues-p)aying association with a name, ollicers, journal, ani l)erimannent fixtures The Belgians reported that an organization had already been formed, under the honorary

presidency of Mr. liddle and the active presidency of General Hood, whieh

was to hold its first (,pen meeting in D)ecember. These deliberations were duly

reported back to the British Medical Association by the British Council. but

the matter again fell through. Apparently, the British thought a club and

home were desired--the Belgians and (Czechoslovaks had said so-and, in their

usually astute way, questioned whether sucit an affair could be properly financed.
(CHIIEF CONSILTANT IN SUIIRGERY 41

Curiously enough, it was at a meeting of the editorial board of the Bllrt;.Rh

Jouirll of ,ur.qery. on 12 October 1942, that the niatter was again b)rought

ui). (Colonel Cutler had accepted the invitattion to become a ineniher of this

board, a signal Iillor, since previously the joiun'al was concerned only with

p)ublishing efforts from British surgeons.) Tihe chailrman of the hoar(l, Prof.

George ('ask, took keen interest in the p)roposed inter-Allied medical meetings.

I[e arranged for Colonel Cutler to meet with Maj. Gen. 11. L. (later Sir Henry)

Tidy, Plresident. Royal Society of Medicine, on Weednes(lay, 21 October. The

H[onorary Secretary, Mr. Broster, and Sir (Geoffrey Edwards, Secretary, also

attended the mneeting. The officers of the Royal Society of Medicine were most

willing and pleased to be able to sponsor such military medical meetings of the

Allies.

Colonel ('utler was greatly encouraged by the outcome of this conference.

Formerly, attempl)ts to ho1l medical ineetings of the Allies had been thwarted.

These meetings now had a sponsor with tie facilities and organization to see

the desires through to fruition. "'I think I kicked it on its way,"' he noted, "and

I believe these meetings will serve not only to educate us now for the war,

but will be a bridging force for all the Allies, helping us to organize the world

and civilization which is to follow."

On Tuesday of the following week. 27 October 1942, a meeting was held

at the Royal Society of Medicine attended by representatives of all His Majesty's

services and representatives from each of the Allied countries. It was passed

unanimously that monthly meetings should be held at the Royal Society of

Medicine, under the sponsorship of this organization, to which nmembers from

all the Allied forces would go. The D)irectors General of His Majesty's medical

services p)romised every assistance ill the way of speakers and advice.

To carry the story a little further, the first meeting was held auspiciously

enough on 7 December 1942, the first anniversary of the entry of the United

States into the war. There was a large attendance, and comnments were very

favorable. Colonel Cutler thought the meeting was only fair and would have

to l)e better in the future. Towards this end, he had already p)ersuaded General

Tidy to set up an executive committee to lend closer direction to program and

coordlinating activities. Thie meetings continued to imlprove and were held in

series throughout the years of the war. Medical officers of the U.S. Army contributed in no small measure to the success of the meetings. Selected lectures

from the entire series were published after the war unider the honorary editorship of General Tidy."

Operation TORCH: Hopes for an Early End

The attack on North Africa, to those in England, came off quietly and with

some surprise insofar as the actual timing was concerned (fig. 14). True, the

consultants had been called upon for advice on specific, limited aspects, but

6 Tidy, Sir Henry (Ed.). Inter-Allied Conferences on War Medicine, 1942-19.15, Convened by the

Royal Society of Medicine. New York. Toronto, London: Staples Press, Ltd., 1947.
it Ian: act. The Itcoliula Navyea ati ler Amlalite . t lieu ai c'oivfir Ito Nioitit event fitahh

ofthey cdlilt-it eheribeeniltse int Iuilain had cnidenlel oIt If lthei ptatons norase toe

iaticipa ltroui te lielitilexten Ibat t' l iid nitoi w as veoo iiee'5 ablie Coeloed toClith-1

siilnentile 011iwi isiui wat last h ii-t. esen trnle t ttriids fort perwasio rat -er %-ittitre

thet atorvle frtont 1e:1t, dolonebil ( ltlrwas I qu11ifte elate. 'Ie Wri jh cuiredi Noeeritl.1 ex 

be tlIw tel I I I va itit g'd e w waIsIo 11I worl 11. aunt ](.,1igtt s t faris st It i s i wt r. ti hs asI ir aled

A src wIitt wstuColonely hull.'ti itel hvaize thatgWV Vt'htte altiw wstrt oil )ll* afte w asom

rfalty comibut viT ell.~ivilut ill'~ Etlly 11 I had pulu:lacd otun oy sp eitug tisthaItions ufo t he

astagi. araI W heIII li w tut of.ii I hl it' as.:1. oi n Sui'* No~euti uaIiteiu 19-1 alutrive tuit ( . 1.ht 71),

~itt l' ii(tI* wit iiili i lt pr ss ti':u Hia*od!ew . ''l i ws ld t ol

Ih Iit I;lCh~ (IiisteLti'~'t rgat ha

THe fir, si lieeIe;lp t Eut'ol ;ea Wlifii thater Ifronit atvov is ttil thler It )lhie osf ale

Attica('otid ( ; tly falil.Ti t i s i s l'eti igi the li wehi ef 1411 ltat Sousu se"It t' lmerv xwa it hatso

~~~The Suiiroi iiet' . j Gei al Visites (the Et[ageea(n.I Theatera te
cu *'. ~isu.%NrI IMER

F( eiteal I.P 'Iawle. liappo ali saineut Algerea stimitd by a (p'lite D-rdayi. Nl fs eniera 392

11i1.reeto 1( ueet wvit I thle Imedical heads of thle British services, andti prel inliinarN,

dlist-ilssiolls were held -wit Ii (ieiteral I Iawle~v and Colonel Spriuit.

At 1.-1)()0 houirs, 21 Novembtler, a b usi ness meveting"" antd dinnter were hield for

The Sur.eoii (Genieral1 at 'I'liurlesta mle 11,all. H otel (Chelt enhami. Gluests were

tlie toit. ba nse Sect ion surge'onls, 11lieN' ( orp s sillrt~reou. .a11i froil tilie A I'ny Ai

Forictes, C olontel GTrow, Col. I tarrY G . Armistronig. N( C. C ol. Etlwairt .1. Tracy,

M ( '. and Colonel Wrigh t. As expect ed, The Silirgevolt ( reieral's chief Initerest

ill 1 Ills I Ip wa o101tuttifficiilt oirl ut(Ibtrate ies anld to arla)ws tlillereiices ill oplinion

for providing~ medie ( al ip ii)1olt 1t) Allr Force unlits. With it o warningz C oloinel

Cuthler was Ihe first to lie aisked for a ii opinition. "'I was pretY t ltO1COllltl11t It alI

lie litetr w rote, -excep t for say ingt A ir Force w%-,s slista linl injyi rt. casitalt1ies

aind. thI ere'fore. t lie meiin needet4 111p lie Iir-.t lid p.-' TheV prol )lenlls we-re b)-)lrougt well

into thle opt'lt. hiowever. iand C olone(lt Older I hioulgltt thle lieetill.r "asVery groo(L.

The asp ed s of tilie discuissioins whichi' colicti'lu' Colonel Cult ler were tilie desires b) tilet Arilii A ir For~ces for l'tcorli it ioul aidtti 5I~port oif thle Air Force

mietdical School, bet tel' e(julipmielit at Akill Force stat ionls, hospitals to caretfo

c"iS1lalt it's at tlie oper'atioiial a irlields. aiid consult auits.. or hleit' equlivalenit

TIhe following"' (1iv. suitida v. 22 Novelitlel'. C oloinel Cutllletr inotored to

"Pitiet i'e." 1i :,-, ItII A I rF oI 1e ltlq1u1- l iarter at1 11 igrll Wyi' il e, w-it IC ooloel
44 A'TI V'ITIESI1" O •1 'lFtM AL CONS.I ._rANTS

Iwi(uII. 1Gi.--Ma;j. (enl. JamesI,+ C'. Miagee, The tSurgeon

GonienIl, visitinig Stonehenge oi the Kalisbury Pllain,

Wiltshire. Englilmn. Novemb'er'l' 19)42.

(Grow, Colonel Armstrong, and (C'olone Wright. "To my v'onst ernat iot ,

Colonel C(it ler found, "(GrONw wIas .et\v bitter. Said the Medihtl Corps Wohlilhnt

help ii. lhe herea Itter wOihhlheleill) t hei. It irtay hlave been' a.show" for

)Daddv. I played it safe." UIp)on reachling "]Pilletre, the party lunched with

Nif[j. ( 1ei. l (l'. lE ker, ('()IIIm IIing (ieI,,ral EighthII A ir Force. After the

hliclieol. (<h Colonel (C'it lhr dliscl+ss(•I lp.ssi)h, lll, tIlls o)f salt isfN-ing Air Force desires biut. found (C'oloel (Grow not easily con.vin<ced that a haIppy anrd 'cordial

rela hon with tle tromid ( Forces cold be est.ald ished.''

Colonel ('utler proposed that, if the Air FIorces desireid conisultants. tihey

woituld b iost. welcoit)e to set've witlhiil the fraellewor;l of tile theater colstIllatt, plha a nid ( 1tt lhe ljrf)i iOsi i 5l•l), w1ii'h was J<)w l)eiog ('alliel

011 cOuth be integrated Int a11 ish<1(l for m edical1 offlicers ill greierl ], as distti 1't

fromi a scl hool j list for tile Arnmy Air Forces. The E1ighth Air Force ail'so desireti that .a sel)arate treatmbent. facility be esta blaished for tile care of a1 ir'-crews

with fl.fving fatignie or threatlelned with Iilacl 011I neuros..is. l ( Olhmel (O'td er suggestled that. ('dolotel Middletoni and (C'olontel 'Ihmilpsm.i, in whose hiandis this

res,•l•osibilitv LnV, would be miost williiI,4 to coolierate in tIhis project.

"Tile alnswer to all thisi ('olomiel ('utler reported "d, lepends ul pon whether

the Air Force will accept tlet intimt I relattion to the lPrfessimoul srvices

" .etter. Col. E. C. Cutlher. MC. to ('C.. J. C. Kimbrouigh. M3 '. 7 N•'-. 1942. sobiject : liRiiotiis of

Your Oll,+ to Air Forceu.
CHI1EF ('()NsuurA.N'1 IN SURG'ERY 45

as otitirl ed ahove, hilt1 lint ii such I inie ats we are Inst ructed not to serve thle Air

Force it appears to tile t hat we should lend every effort to keel) Iogrether thle

enitire Ilie(Iical service.-

D uring, thle next 2 weeks of General Mlagee's visit. It was C olonel C utlecr's

1ni v ilegre to accomipanIy The Surgeonl G eneral onl somle of hIls visits to nearlyv all

lie miajor Amiericani mI edical1 inst51allaitions ill tilie U nitedl Kingrdoni antd man Iv

of the British installat ions as wvell. Ini talks wvithI General MAguee. Colonel

Cutler hadl the opportunity to applroachi hini abouit the field dressing inl thle

indlividual soldIier's first. aid packet. Tlhis was a matt~er to which Colonel

( 'ttIcr had gi venm considlerabile. tilliought. C olonel C utlcr 1had( been able, to obtain

iniuch iniformuat ion onl the efficacy and requirenients of field dressings as a result

of an iniiivtation)1 to part ici pate inl the Brit ishli nrst. F~ieldl and Shell 1)ressinig

commnittee. rile British commnittee hiadl decidled that their (dressing had to ble

larger and had recommended that it lie put ill a cellophlanie packet. Colonel ( liiiletr bld eved that tile U .S. A riny tieldl (Ir-essi ng. whlich was still 1)ake l in a metal

conltainler. couldl also p~rofit by simiilar miodifticat ions ando adlvised 'ile Surgeoni

G enieral so. Ile recommndiiedil that further srtidies ble nmiuad und-er Thle surgzeon

Greneral's dhirection lin the Zone of Interior to see whether a cellophane packaing, could not. replace (lie metal conta iner anid thle b~andage itself Ile m~adle

larger. rile, Suirgeoii G'eneral was given a saml~e of thle new Brit ishi packet

to taike biack with hiim.'s

Colonel C utl1cr was also able to ask General Magee for ant assistant. Ifet

inforined (enera I Magee that such increasing needs for consultants as going in1to

EMS and RA F hospitals at night as wvell as during the day Inladle it implossib~le

for C olonel Cutler to fulfill comipletely his obligations inl such imatters becaulse

of oilier and muore weighty engagenments which could not he b~roken. Ile asked

that Maj. (later Lt. Col. ) Amlbrose It. Storck, 'MC, inl Brig. Glen. Charles C.

H illman's office ble selected for t ]its position as assistant to thle C hief Consult ant

inl Surgery inl tile EuAropeani thieat er. General Mge, reIin return, suggrested that

it would ble nice if the European theater -would invite Col. (later Brig. (Gen.)

Fred 11. Rankin. A('. Chief ( onusntant. in, Surg-ery in, thle office of Thle Surgeon

Generl,(l1l to visit tile theater.'"

hina more formnal vein, Colonel 'Middlet-on was given the project of collecting

answers front thle Professional Services IDivisionm to a list of questions which

Theu Surgeon General had brought with him from miembers of his office. QiuesI ions which concerned the Chief Consultant inl Surgery and his anlswer.. to

Colonel Middleton on tlhis occasion inl effect provided a r6sunuII of consultant

activ~itiles to dlate. Th'ley were:

1. Ediwat lol anIit training.

Manly courses inll de-niiay u)ct are b~einlg given to U.S. Medical D epartmnent

uiffivers. to bothi Ithom. ill the 'oillihat [unlits] and( ** those ill the( statioli, eviicuziltioii.

and general hiospiital s. as5 well is to the Air Force.

"~ Iemornnirui,, (Col. E. C. Cutler, MC, to Col. J. C. Kinibrough, AMC. 27 Nov. 1942. suhjeet First

Aid Pac ket for the. A nerlean iisold ier.

19Letter. Cot. E. C. Cutiler. MC, to Dlirector of Professioinal Services. 30 Nov. 1942. silliject Addftiobn I4i cos imi it Ini Genern I SurgicalI Field.
4 6 ACTIVITIES E)1q' SURIICAL CO )NSU'LT'ANTS

As it part of thie above genlerail courses, special atteutit llhas heen1 paid to the proper

treatmient of tlie wounids ill genleral, airgely y ('olonel ('ut ler, and wounds in special surgical

Ilells by the senior tconsultantls in ortholpedic surgery, neurological surgery. maxillo-facial

and plastic surgery and burns, oplit lnt mo ology, aitest htesia, thoracic surgery, and transfusion

1ind shtock. These surgical (bourse's have been given in turn tit the Air Force school, to the

nmedical oitvelrs of two A,\neric-ain divisiolns, to groupis of doctors in our base section areas,

and to indlivihuhl hospital assemblhages.

2. Activities of surgical consultants.

All of tlie surgical •olnsultanIts have the closest rehlaionshipis with their opposite

nmembers it tihe lBritish nmilitary set-up, including Army, Navy and Air Force. The Chief

tonsultlaint in Surgery attends tIhe meeting of the British Surgical ('onsultant Grounp each

tuotith, and the illeetling of tihte lirector General of Medical Services, RAMC. lie has it

similar relationiship with lti, t EMS, RAF. and Royal Navy. Through this liaison we have

been permitled to enter and study all of the organizations of the British Services, m1d have

thereby profited greatly.

Another activity of the consultants has been to aid hi establishing the high level of

professional work in all of the American hospitals-station, evacuation or general, In

ET()USA. This h111s meant (constant visits to Institutions, the stimulation of ward rounds,

(lliial mleet ings. 3lnd assisttance in acquiring the necessary material for proper professional

ietdeavour. This activity goes on constantly, and I am sure that much benefit has accrued

f'rom this intimate contact of the Consultant Group with the hospital setup.

A special fleli might be said to be our relation with the American Air Force. We

understand that we serve them as well as the Ground Forces, and we have been happy to

teach in their shthools and to look after their wounded its they enter our hospitals.

Ain uiexpected labor to the Consultant Group has been the constant denmands made

upon theni to assist in straighitening out the medical sulpply situation in ETOUSA. A

tremendous aniount of labor and time have had to go into supplying proper lists for the

medical requirements of both divisions and static hospitals, and a constant liaison has had

to •e established with those who purchased British medical material for the use of the

Aiterican Fo-ces.

"3. Ullit alssembldages.

The answer to this is coml)licated, for the Consultant Group is not entirely familiar

with unit assemblages. It should be said, however, that we have been instructed by Geineral

Hlawley to go over the arrangements aind nmaterial in medical chests Nos. 1 and 2 and delete

certain itemls and add others that are necessary * * *. We believe that there should be

another comphlete revision, by at group familiar with this matter, of material relluiredl in

[an] active theater of war * * *. It appears that some of the material being sent, which

was of value twenty years ago, is now out-mnoded.

4. D ried serum plisim.

Tile situation * * * is as follows. On hand Nov. 1"5--4,224 units. Issued ill Septeniber-10,238 units. Issued in October-2,735 units. We need more plasma innmediately,

in view of the fact that combat forces are instructed to take such material with themi.

5. lit ravenous fluids.

The answer * * * Is simple. If hospitals were supplied with adeiluate stills it would

be unwise to send over bottled intravenous fluids. Stills, however, cannot be acquired in

Great Britain, tit tills time, in sufficient number and of the type desired. They should

therefore he sent with a high priority rating.

6. Physical standards for Induction.

From visits to all of our hospitals, it Is apparent to the Surgical Group that 31

considerable number of physically unfit enlisted men are arriving in ETOI'SA. I have

persomally seen two Individuals In a single hospital with large defects in their skulls produiced by terrific accilents In youth, ard I have seen large scrotal hernias in inidividuals

taken Into tile Army; also two severe cases of Dupuytren's contracture of the hand. Another matter commented upon by Colonel I)lveley is the failure, apparently, to examie thfeet pmroperly before Induction.
CHIEF CONSULTANT IN SURGERY 47

7. Weekly medical newsletter from the Office of The Surgeon General.

It is my impression that a weekly medical newsletter would he highly acceptable.

Note that the Canadians do this, and do it very well. Undoubtedly a copy of their Newsletter is available from General Hillman.'

There were a few sidelights which appeared during General Magee's visit

which Colonel Cutler found inviting to reflect upon but which were quite

serious matters at the time of their occurrence, particularly to those involved.

For example, he recorded:

But now this curious story: Yesterday was Thanksgiving. I had worked hard and

hadn't paid any attention to an invitation by Lady Harding at St. James's Palace. Colonel

Stanley saw me and asked why I was here [Cheltenham] when the King had sent for

me. He said I couldn't refuse and had to go. So I worked all day, forewent lunch to get

more done, and left by car at 2:00 PM for London. By then I had found out that Harding

was the King's secretary. So I reported to C. Spruit and found General Hawley there

just in from Buckingham Palace. He looked sick and promised to let Bill [Colonel Middleton] examine him tomorrow (i.e., today, which has been done, and he goes in hospital,

2d GH, tomorrow). Then C. S. [Charles Spruit] and I went to St. James's. Great crush

of p)eople, all tired, and I was hungry.

Unfortunately, the Royalty were unable to appear, and the two colonels

later found it necessary to search elsewhere for food, but it was a unique honor to

have been invited to the Palace and a privilege to have met the important personages of the era who were there. Concerning General Hawley, Colonel

Cutler noted on a visit to the 2d General Hospital, 30 November 1942:

Came here [London] yesterday, stopping at the 2d General to see General Hawley

and to get my X-rays. The former is better, but his laryngitis is bad and his temper

is bad; the latter, beautiful and I have hardly coughed recently. Had long discussion re

sitting of party for General Magee. There will be 13 with ECC, so I was out.

Avonmouth, Disembarkation of Hospital Ship No. 38, the Newfoundland

With the attack on North Africa, it was inevitable that casualties would

sooner or later arrive in England. Colonel Kimbrough and Colonel Cutler

journeyed to Avonmuuth on the English south coast on 17 December 1942, to

see one of the first shiploads disembark. Colonel Cutler's account follows:

Arrived in time to see her dock. It was the Ncwfoundland of Liverpool; all white

with red crosses and a black "38" on her side (fig. 17). Could see American soldiers at the

rail as she came in. Then we boarded. We were shown about by the RAMC major in

charge. The men were in swivel beds that were set like tables in yachts so that when

the boat rolled, the bed did not. They, about 400, were packed pretty close (fig. 18). Saw

the sickest eight; just had morphine, so were comfortable. About one-half were Americans

and one-half British. There were a few British marines and a handful of prisoners. Just

through a stormy trip back. The unloading went on smoothly. There were plenty of

ambulances; separate ones from the Royal Navy for the Marines! All other wounded

went to the 298th GH (Michigan). The British were later sent to their own hospitals.

We went to the 298th and had a nice chat with Colonel Kirksey and Walter Maddock.

Am going to get them three teams from the 3d Auxiliary Surgical Group tomorrow. (Unit

just in at Oxford.) Will set up a questionnaire to study effects of sulfonamides.

"20 Letter, Col. E. C. Cutilee, MC. to Lt. Col. W. S. Middleton, MC, 20 Nov. 1942, subject: Memo for

General Muagee.
Ac, i'

r~i
CHIEF' (ONS1'LTANT IN SURtOEItY 49

U'ponl returningio to Chieltenhalin, C olonel (iit icr rep~ortedl to the Director

of Prof essional Services, as follows:

The mo1(st jinterestilig idnie WaIs thle visit to) lie Nvard4 con~ta ininig seriously wvounlded

or sick people. I talked to six seriously wounded Americans. My questions, other than

their genleralI coniditionI to cheer thentilup. wvere objected solely as t41 whether they li-id

takeni thle sulfoianiides wh~ich each American solddier presumably carries 4)11 his pesn

Not one individual had either taken tablets by miouth or dusted the powvder into his wounds.

They seeimed to know what these imedicines wvere for bilt had not bothered to use thetim,

par tly 1 eca use ill ea ch caisv I he in div~id ua wvas appa~rent ly 11n4 4oisci olis follo4 wi ng the aiccidlent, orl spitt ing upl blood if injured ini the chest. or was, so near the first a id inan ori tirst aid ~ po(st Inaiii statioii tha t he plreferredl to have the latter give himn thle miediciine. Th'le individmiiils I talked to camie fromi the 16th andm~ 15th Infantry I Itegineieits I ando 39)th Eingineers.

This lack of 44111 men taking sulfonmanidles brings illp the( pro~blemn rep4eatedly put to thle

Bri tishi. t ha t it is 1i1t wvise (or intelligenit tol tie up suc'h a vast :1 inolimut of a1 pre(lolls (Irmlig ill

p~ackets for soldiers whel tile d1rug ca.ll tIe bet ter and mlore sevclrely givenl by thle first a id

poists. The only~ c'riticism of this British attitude is that there may hle a long interval

lie t wt'(e being 1 wI liiie41 an rei achling ai first aid p11o st.

The arrival oIf these American c'asualities ill the Uniitedl Kiligdlami gives uts anl (Ijpprutillity tol 11hut ('it .1 quest ionniai re andmt stnidy thme mamitter o)f Wa) whether sulfonamides were

used I aiid I (b1) tilie interval after beinig wiiumided aimd tile use of sulfona mmides [inl order]

to check oni t heir valiue by stuioy o1f the cuiolit ions (if the wolund(s no(w. since imany (of the

1voIliinls Nv('ie sealedl 1iii iii plaster' almo1(st fromi the beginlning. Thius, the daniger of second~ary

intectio d411ismiissedh. we Iiitiv be ablle to arr'mive at somle fairly satisfactory scientific data .

2 '

3d Auxiliary Surgical Group

Onm 1S Ieceinber,9 I lie day following the Visit to Avonmnouth,. Colonel Cutler-,

inl the company of Colonel Kimbrilougli, hastened to visit the 3d Aitxiliary Suirgical Group, niewly arrived at Cowley Barracks. Oxford, from a temporary stattonl

inl Scotland. A pleasant mneettugir was hieldI with the grouip)s cotuinandingo oflicer,1 It. (101. (later (Co1.) *Johmn F. Blatt, MNC. The problem Was how to Ilse the

officers of tile g oroup inl gainiful p~ursuits inl ordler to mainitain their morale and

sp~irits at as hig-h n level as possible. Tile visitors exp~lainedl how these officers

cottld be tused inl hospitals, both Brit ish and American, andl sent to Amiericanl

andi Bnt ish schools. Arramigeeniits were imadle for the ilnimedliate dispatch of

fouir teamis to the 29Sth General H ospital and for Capt. (later Maj.) Benjamini

Rl Reiter, AMC. to inmit iate the sulfonamide studs'. Colonel Cutler was pmtrtietilarly iimphresse(l1) tile hligh professionl,1 calib~er of thle group as a whole. Ile

nioted : "Sonicl were amlongo thle best su-rgeons inl the United Slates. and it is a

grei~it ci'e(li t to t hose whio Itssenibuled stuchi a gYroiil) that so manly A-i stitlgeonis

(101i1i(le jgýot 1Q11 t ogethier.- ý

wtNas ju~st aillit C hirist itas Eve whieni General I tawley and Colonel Ctitler

coi feredfmi rtlier on) lit ilIizat ionl of teani1s froml tile 1(d 1ui avSi~ia

( r romp. Geiierail I[a wic le'eioed Ito oflerto thle Brit ishm illto2 2() eneral still rgicl

tea iis froti i thle grlol II for misc with Briit ish Forces ill Nortlm A fric~i. BothI (Telli..Lettr, (N-1. 1.. 4c. ciitlir. ItC. tol ('.d. T..C. Kimbroiirh,,r At(. Is Dec. 1942. subiject : isit to

(;raiip. ('uwler Iii rrnuk-, 4 Ir..niI. 11S Dow. 19442.
ACTIVITIES OF SURGICAL CONSULTANTS

eral Hawley and Colonel Cutler were aware of the acute shortage of doctors

in the British Army and knew that, in characteristic fashion, the British had

tightened their belts and had not asked the United States for additional medical

personnel, even though this possibility had been suggested. They realized, too,

that the experience which these teams might gain would be most valuable. It

was Christmas Eve when Colonel Cutler approached Brigadier Anderson, chief

surgical consultant, IAMC, on the loan of these 20 surgical teams to the British

Army.

On 28 December, Brigadier Anderson telephoned Colonel Cutler and

relayed General Hood's message accepting this offer. The Director General

was very grateful and most complimentary. Colonel Blatt also happened to

visit General Hawley's office on this day, and he was fully oriented on the

forthcoming dispatch of these teams to Africa.

The following day, Colonel Cutler returned to Cowley Barracks and

gave the group an hour's talk on professional matters-their job at the front,

the importance of debridement, their equipment, history of medical activities

in the theater to date, and so forth. At lunch with the group, Colonel Cutler

was dismayed to find a strong anti-British sentiment among members of the

group. "Made me mad," he later wrote, * * laid it down a bit, as gently

as possible. Told them it's no way to begin a war by criticizing a generous

ally."

The administrative difficulties in providing these teams for the British

proved most formidable, and final arrangements had to be worked out personally by General Hawley and Colonel Spruit with higher echelons of

command.

Summary of Miscellaneous Activities During 1942

In his annual report of activities for 1942, Colonel Cutler stated:

The multitudinous duties which confront a consultant group are hard to categorize,

for, with our broad instructions to see that each individual soldier has the best medical

or surgical therapy possible under the conditions imposed in this theater, we naturally cut

across all the usual boundaries of Army organization.

Thus, while the highlights of Colonel Cutler's first year in the European theater, 1942, have been briefly described in the foregoing pages, a still briefer

word in passing must be devoted to some of his other multifarious activities

in order to provide a faithful account.

American women doctors in England.-For various administrative and

political reasons resulting from the war, General Hawley asked Colonel Cutler

to investigate the status of women ldoctors in England of American citizenship and to look into the possibility of their employment as contract surgeons

in the U.S. Army. In eonferenves with Sir Francis Fraser, director, EMS, and

Dr. Murchie, the EMNS personnel officer, Colonel Cutler was able to determine

that, most of these women doctors were advantageously employed by the British

in their EMS installations. One was a major in the RAMC, Maj. Barbara
CHIEF CONSULTANT IN SURGEIRY 51

Stimson, cousin of the U.S. Secretary of War. The women were happy where

they were and did not want, to become contract surgeons, especially since, as

they later learned, the pay was less than that being received from tile British.

What was required was a mechanism for their commissioning in the U.S.

Army Medical Corps. Eventually, after many conferences and considerable

give-and-take by all concerned, most of the women were made contract surgeons and loaned to the British EMS to continue in their jobs. Major Stimson remained in the RAMIC and was sent to an active British theater, the Middle East. Colonel Cutler's final comment on this problem was:

Barbara Stimson back from talk with her cousin HLS [Henry L. Stimson, Secretary

of War] and Somervell [LI. ('en. Brehon B. Somervell, Commanding General. SAOS].

Guess women will get in Medical Corps soon. I have long advised they be taken in gracefully before they are put in against wishes of the Medical Corps. They will get in for

sure.

Acting senior consultants.-Senior consultants for the theater in radiologry and otolaryngology were expected momentarily, but, in the interim, individuals qualified and physically on duty in England had to be designated to

act. in such capacities as the needs arose. In accordance with the policy of

grouping all l)rofessional medical specialties under the Chief Consultant in

Medicine or the Chief Consultant in Surgery, radiology had been designated

to come under the purview of Colonel Cutler. Accordingly, Lt. Col. Robert

P. Ball, MC, and Capt. (later Maj.) Edmond P. Fowler, Jr., MC, both of the

2d General Hospital, were appointed to act as senior consultants in radiology

and otolaryngology, respectively, in addition to their regular duties.

British Medical Research Council.-Attendance at and membership on

the various committees of the British Medical Research Council "* * * have

been extraordinarily enlightening * * ** Here one sees science applied to

this devastating matter of war in an extraordinarily intelligent manner. * * *

The writer is satisfied that great progress has been made by the intelligent

few who sit with the British Medical Research Council." 23

In particular. Colonel Cutler found attendance at meetings of the War

Wounds Comm it tee and its subcommittees most l)rofitable. It was through this

committee that lie effected the promulgation of instructions to tile British

Army Medical Service and the EMS to use tetanius toxoid l)rol)hylactic (loses

rather than antitoxin in the prevelition of tetanus in wvounlded or ilnjured

American soldiers. The British habit uallyv used antitoxin for their wounded

or iiijured soldiers in danger of tetanus infection. When antitoxin had been

used on A inerican soldiers, some serious reactions had occurred. Conversely,

('olonel ('utler was able to have a circular letter plullished by tile (,'ief Surgeonl, ET()'SA, which instructed American medical units treating British

soldiers oii the proper prohlhylactie dose of antitoxin to be given.

Return postcard (surgical).-Froni his World War I days, and from

what lie had seen so far in World War II, Colonel Cutler realized that there

.' Se, fototfnot 2. pi. 20.
52 ACTIVITI'ES OFI SURG~;IC AL 4I INSUI IAN'IS

was vei-Y IIttl e it Ilei'c11,1 ige Elf ill formlHill11 bet weeli t lie- first eilielotis oIf Itiedical

seri'v e and14 t hose ('olldi cti Iig. (le-flili t ivp tire~tt ilielit ill I lie Yet,. N. it was inlpert 21lit thait ther~e lbe a1 colist2lit flo it)%- iii 14)r11121t uiii bet weeni t hose fir'st t reat -

ing it pa2t it-fit and t hose who sa1w hiimi later. ( olollel ('lt let' had IleuIll ioliell

t his nieed to t lie( 'lliel Sii~rge4II1 at one of I heir first con)I feretices anid had received

hIIIs zit )pr-o%- ;Ito d Iesigi I II I(I ha2ve pri I t ed 11 post varIA for IIi for tIIIIs purI Ipose.

Whenl t Ilie cvard was prin t ed, t he oiilY casliaI t les oclr i i ll Eniglanid wer'e

2Iilioilig operalto' i41121 :Irclems. Me(Iicvl officers ill lie( EighthI A ir Force, wleii

2isketd, Sh owed .1 keei 1 desirle to giv~e thle i'IvIII'I- po(stcr ('2 I' 1 steii a t11riaIl list.

A~crEIiug'.( 'i cn12 rLet ter' No. 79 was5 issiied onl 17 1 eveiiiber 1942 by life

( 'hief SurIgeoni. A port ionl of it follows:

Follo14w-up card'4s 1E'I'ii SAM ID Formii 303) :u~*11*4.bing (list riblited to 1411t tiil 5IIe4'III of tlii'

sill Air Fo rev4. The14 se are' rime-mi(41re'sst'( cards de4 s41'igned4 f' r then p~urpos ~ (ii f t ranlsmitt ting

bauck to the eiciivlln office4r %-Ili) first I rents 211i injury or haitI h' ezsuimity iniformation con '43-

ce'rninig the4 suI1bseqi3uIW pIr4gr4's of I lie'cais.

'I'li'leI'142 Ieva 41th4'4r gi vinag i11131&(1int1e I ret'2t 1it't lit (Ih ltO 14111t~l dHiK-tsary wvill loritit

his 11,1114'. gradle. and1( A.l'J.( I.iiniihet on fit( he miress sitli' of the& va2r(I. mi th i.'(lrdl* ca114 

will itev443inimn131 iii~jiired( and1( wVoliII14( 11211 ews to ho~siaitiil.

Thle lilediviE'1 4ltB'e'r I re'311 g s114ic vases4' at thei receiving'2l 15hosital kvill complle I('liii

re ve rse' sid o1'Ef the4 (c31rd its soo4n1 as ill le~li311'te flivruit j 3' s liven'I inlst ituIte((. si gn. 21114 nil31

I it I * * *. AtI will not3 bIe l4ivid lit 114I51t12tl5s 1111111 4'41I1111014-t3iI)l of thes clis4'.

JI'lieni gi-ouilll 11(1st ilit les were l1.11ter ehlcy.lge(1 ill oil I lie ( 'ouit mint, t his (lirect ive was5 modif1 iedl to perm'it it.is(- (if it w('2P- iIY by 1 i uits i iniit ially trea~tingi

('2n12Iat ies. This Simplile syste ilbworYkedt wVith ci(onsiderabl~e Successn5.

Special studies.-Ilit addIition11 to tile il'sl follainii ide Study~l iniit iated wvithI thle

first. reveipjt (If (-.Is11Ilt meS fr'om iNorthI A frical, limiit ed Studies l(' oi thler' ar~eas were

2also Ileglili.

Thle probllemi (It 121t igli( in long t r21 iii i g 111211 '('li was l2l *iving invest igated

1y th le 29thI In fanltr Di'v I)ision. Blood~ priessuire, p~illse ra2te1. 21114 1b1(oo( sligalr

1('v('1 b efoIre, (1111111g'. 21.11( 21fte- tlit'. t ra lilii g ('11(111s wei't' I (i g I-e('o(Ir~e(l ill

(Ir(Ier. to1 (bal~lt2 rel iablle (111(t 21 l~li whicl coulid lie based prop11er' (linisi(1i1 as 1t1

Ma~j . ( later' D. ( '(II.) llild(Ilp 1111 . Siliuliilinger. NU ' 24d ( itetieral H ospi~ta211

-it Ii is ownt requlest , was1 peiriii itt (d t10 lIl'OVI'(' I)Vlehilci l illii S11i.111 kkOlliit 5 11(1111

P roIf. IHoward E'(I FL ~lore ,v at O x ford 211 inIt oeXjeri'iiieit oIil its 4] iiia a4p121111iva2t 4in.

hu'le vo(Jsiiiht21lit 5were1 .1ske I to eval 12t e thle eflica14vy of gas5 galligreli(' ant nItoxiti .111(1 to hhi.1ke revohIniiieli(12t ions for its Itse' ill (the thlealter. lit t his ca2se to.1(

All iedI f411''' andhi I the4 Birit ishi MedIical lR'5e21r-4ii 1 Co1(1i 141 i4'iet ('( Ito1 4Iivi(l si ve

1esuilIts as to its etlicai4v .%. Sinlce. however, t here were'111 implict ions inll laoratol'v

('Xprltfieili'lt s tha12t thle antlit ox in Iii iglt assist ili lpr('venht i g til l de ((velopmen('t (If

iii feviion, ( ololuel ( lit l('I recommiii'IEened I li~i 21 smailli stoc14k lbe keplt inl tb In' ii(Ea4'i

SllIpIV% depllls wiVIlere it wlV~illiE' be V~ iaihle if tl ill'reons whoi4 wishe(d to1 111214 lise.

Eof it or. who woulid like tlo Iiinikl Speial sI A21 1d es (ill its 1'tliva'i' 211v4and1use. I he l'-4evilii-
('1111*' CONSULTANT IN SURGERY 5

mended thlat gas ganlgrenle alit iseiluiii not Ibe iiieltIdedl as a regular suppIly item

for all medlical Iiistal htitotis at tiliis t iie

Journals, books, and headquarters' library.-While the nieed for books.

journals, and lilbraries was unimiversally accepted, thtere was no p~rofessional

I ibrary at the. Chieltenliain headqutarters, and t lie sets of basic texts and journals

for hlospitals were lost in thle dlepots. Coloniel Cutler continually pressed thle

issue unutil thle hospital sets were found mid~ couldl Ile distributed, and onie of

the last thinigs lie did inl 1942 was to app1oinit himnself as librariani inl ordler to

establish a. priofessional medical library at. thle, headqutarters inl Cheltenham.

Assystem was iniitiatedl whiereby hiospitals would get copies of journials routinely

andl reserve sets would be. naiiltaiiiedl for thle liosIpitals whichl were later to

arrive inl thle. theater.

On. visitinig tile British libraries, particularly those oif the Royal Society

of ledlicine. and the Royal C ollege of Suirgeonis, it was miostdicnetg

to Colonel Cutler to finid Ihlat American miedical journals were arriviiig inl Eiglanid badly mutilated býy thle Americaii ceiisors. lie took it upon liiinisel f to

inivite thle attenitionl of thle W'ar D~epartmient to thtis dleplorab~le situation. Hle

stated:

* * * C'opies of these journials coine to the C'hief Surgeon*.- Office unlcenisoredl. and

the Dtivision of Professional Services * * * has niever beeni able to findi anyv article iii

these journals hi which censorship could in any way affect the war * * * The extent to

which such censorship is carriedi out is out of reason as wvell as- robbing American doctors

in this country of the ability to keep abreast of modern mledlicinle.

It is recommnendled that the War I)epartment take steps to see that Amierican medical

journals ijow going to the United Kingdom for use in iiuhiic libraries * e uncensored. Tlhounsandi~s of these journals are freely dlistrib~uted in America where their conitents

canl easily lie stud~ied. It seemls unnecessary to censor these journals b~ecause they travel

across the Atlantic to an allied nation with whoin we- should have the most cordial and

friendly relations.'

Medical field service school.-As indicated inl the prece(Iiilg narrative,

there. were many educational opportunities afforded thle medical officer inl the.

liiitedl Kingdom. Mlost of the contacts with tile teachiiig inlstitultionls hiad beenl

establdislied before Colonlel Culder's arrival inl Eiigland. After hiis arrival,

lie liadl ('ontiiiued to Supervise the iniput of surgical officers to the variouis courises

and hiad Itiniisel f. or ili cooperation with ]is is5Q1or consultaiits, createdl other

traininig olplorttilliit ies inl Britishi schiools and(1 hospitals anid inl certain of the

I .S. Arniy hioslpitahs. Tile. instruct ion heinig recei vedl by officers at teiidhinvX

litese cours4es was of great vatilue ili keepi iig till) and~ (levelopinig skills inl certaiii asp~ects of iliedliviie and~ surlgery. 'I'hmere was iieeded, liowvever. a centraillizedl

anid coord iniated inst ruct ion of thle civil ia ii doctor ill in i lit ai'Y miii forml as to tilie

1ia11y (dit ies expectedl of I1i m ill whlich lie hiad little or iio prior exl)Qriciice. It

Was also niecessa 1W to iniioortii ha te l1 i1i oil tile accep~t ed. I msic tenlets of imed ical

25 Me'morandums it. Vol . E. C . C utIli-r. M'm . to col i. JT. C'. Ki niirou rh. 31'. 1 '.Set. 11142. siihjrct: Ga

Guingr.'ne A ut I-isx iij.

TA'Ltts'r. Coli. R. C. C umtler. NE'. to the Wair Depaisrtmnsmt. 24i D ev. 111442. subiject: The' ('.'so~rtiug oif

M1e~dief I jnI 1. italis Now 1tl.'i Fo turwaurtimd to Librar ies (if Meivl' I instal lit loins In. (ren t Brita in.
54 ACTIVITIES OF SURGICAL CONSULTANTS

and surgical practice in the theater in order to standardize the treatment of the

more common conditions found as a result of military service or injuries incurred in combat. This obvious need was being met by plans to establish a

medical field service school in conjunction with the SOS American School

Center at Shrivenham, Berkshire.

Colonel Cutler had started work on the curriculum and courses of study

for this school as soon as lie had oriented himself in the theater. By early September, he had completed the courses of study in the surgical topics to be covered. He then discussed them and arranged for their incorp)oration into the

overall curriculum with Lt. Col. George D. Newton, MC, who was initially in

charge of establishing the school at Shrivenham.

Observations at Year's End

By the end of 1942, most of the positions for which senior consultants

were contemplated had been filled. The many duties and responsibilities of

a consultant had gradualy evolved through his day-to-day commerce with fellow officers in the headquarters and in the field and through his concern in the

medical matters of the theater. It was possible, at this time, to reflect on the

activities of the year and to make recommendations which only the knowledge

gained through experience could make possible.

Colonel Cutler had the following thoughts for The Surgeon General:

The niemorandum has been on my desk three months: it has been fully considered by

most of the present Consultant Group who give it their warm approval. It is presented

without bias or criticism as a piece of constructive thinking which has arisen during the

day's work. To my way of thinking, it is the most important contribution I can make in

my present office.

In this thinking, observation of and discussion with our British and Canadian colleagues have been helpful for medical and surgical problems are universal and do not belong

to nationalities. Always in these discussions the remark arises in those who are not members of a Regular Army Medical Corps but who have left their civilian positions to help as

best they (can at this time, "I wish we could have worked on these problems in peace time!"

And this desire to have played a role in peace time has many beginnings. It arises in

part from the findings that the Regular Corps are not on at whole. though there be brilliant

exceptions, as much abreast of modern medical and surgical practice as the civilian profession is. It arises because what to the military doctor is an essential apparatus or medication long since was droppel from use in medical practice. And it arises bIecause the

civilian doctor finds he thinks and talks even a little different medical p)hilosophy from

his regular colleague and wishes they had had more in common in the past.

I believe tlat were an arrangement set up with a permanent Advisor or Consultant

Group established as a part of the Army Medical Department there would result a steady

flow of lenetit to our Army Medical Corps. Such a Board would bring an immediate (-lose

relationship between civilian doctors and the Medical Corps. Each would be led to the

other's domain. Each would attend the medical meetings of the other group. The interest

of the public as a whole would be aroused and once again the Army medical man would be

the real and actual colleague of his civilian prototype.

This would be especially true if a method of appointment to this Board was utilized

which [would] put the responsibility for apipointment on the leading meinlcal and surgical
('HIEF CONSULTANT IN SURGERY 55

societies in the USA * * * This wouhl put these leading societies squarely behind the

Medical D)epartment of the U.S. Army, for having assumed responsibility for an appointment the associations would inevitably follow through with an abiding interest. This

alone would le a great step forward. * * *

Such a Board with the great clinical societies squarely behind it would result in a new

attitude of civilian doctors to military d(octors. The two would closely approach each other,

the civilian group would feed personnel into the Army group. The advantage from common

meeting grounds in each other's associations and societies would have incalculable benefits.

And all the time the Consultant Group could be kept working on medical supplies and

methods for military movements. It is not proper to wait until we go to war to prepare to

bring proper medical and surgical relief to our soldiers. We must be prepared always with

material and methods. We must practice lest we fail in our responsibility. What amount

of labor by a doctor can equal the offering to his country of an infantry man, an aviator,

or any member of the fighting forces? There can be no demands upon his time and skill in

peace time along these lines that our profession would not gladly give.

The fact that the British Navy and the British Army have had for years civilian consultants in times of peace and the role they now play and all benefits to their service which

have flowed from this arrangement strengthens my temerity in offering this memoraindum.

In closing, Colonel Cutler made the following specific recommendations:

1. That an Advisory or Consultant Board in the fields of Medicine and Surgery be set

up as a Permanent Part of the U.S. Army Medical D)epartment. This is to function in times

of Peace as well as War.

2. That the Senior Consultants in Medicine and Surgery be nominated respectively by

the American Association of Physicians and the American Surgical Association. That the

Senior Consultants in the Medical and Surgical Specialties be nominated by their respective

Associations or Societies in the USA.

3. That confirmation of these nominations rest in the hands of the Surgeon General.

4. That this Board be a continuously active part of the medical department and be

consulted freely and continuously on all matters pertaining to the fields covered by its

memhership.'"

1943 TO EARLY 1944: PLANNING, BUILDING UP, AND WAITING

The First Half, 1943

The new year began with quite an experience for the Chief Consultant in

Surgery. lie left by auto from Cheltenham for London on 3 January in order

to attend the second session of the Inter-Allied Conferences on War Medicine.

"The high point of 3 January," lie later rel)orted to Colonel Kinibrough. "was

the unfortunate fact that My car rolled over on me while driving fromn Cheltenham to Swindon. Fortunately, no one was hurt, 1

but I reported the accident

immediately by telephone and dispatch rider to Headquarters and to the InterAllied Medical Meeting." The meeting, however, was very successful, aid

many favorable comments were made on General Ilawley's presentation and

upon that by Colonel I)iveley, Senior Consultant in Orthopedic Surgery.

- Letter. '(oi. E. C. Cutler, MC. to the Chief Surgeon. ETOUSA, and The Surge,-n General. 1V Jan.

1943. subject: A Plan for an Advisory or Consultant Board In Medicine and Surgery as a Part of the

US Army MD In Peace as Well as in War.
56 A-TIVITIES OF SUlRGI('AL CONSULTANTS

Problems of interpersonal relationships

Perhal)s the one thing which characterized the life and pursuits of the

consultants during the greater paart of 1943 was their atteml)t to acclimatize

themselves to the military, professional, and social milieu which prevailed in

the Chief Surgeon's Office and among its members. This constant effort to

adjust was still an un(lertone to the bustle of activity which marked later,

more active periods in the life of the theater and remained a matter of deep

concern to the consultants even after the fight was won. It was, however,

during this period of relative calm--a long, frustrating p)eriod of waiting for

the big things to happen-that these interpersonal relationships arose as manifest p)roblems to the welfare of the individuals involved and to the overall

effort of the niedical headquarters in the European theater.

Had Colonel Cutler been able to take the time to write this consultant

story, as he called it, lie undoul)tedly would have placed great emphasis on

this aspect of the total l)icture. His diary contained frequent reminders to

himself that he would have to write the consultant story somie day, reminders

inevitably tied in with these l)roblemns of interpersonal relations. I'n fortunately-or for that matter, fortunately-Colonel Cutler was, rather, a man

who preferred to do something about these things, and, thus, they were never

written.

Briefly put, there were two l)rob)lem areas. One prol)lem was the relationship b)etween the officers who had only recently come on active duty and

the officers of the Regular Establishment. The other problem concerned the

relationships of the consultants with one another. The officers in the Chief

Surgeon's Office had come from many walks of life with greatly varying backgrounds and experiences. The consultants were mnen of outstanding ability

an1 lprominence who, to a great extent, owed their success to their unique in-

(lividuality. It, was to be expected that a great amount of give and take had

to occur and that true communication was to he most difficult. In his annual

report for 1942, Colonel Cutler gave the following indication of the rising

prol)lem :

It is fair to state that on the whole the .onsultant. have been patient and forgiving.

We who are used to the fast well-oiled mac.hines of civilian life have often been irked

at the slowness of action or certain hidebound regulations which (io not seein to allow

us to put the best man in the right place, or the right material where it is ne.essarry.

Curiously, those who went through the last war in this groupj seem miore patient than

those who did not. Perhaps we learnt something about the Army in the last war. I am

sure that all the consultants see eye to eye in their main desire to render expert surgical

and medical care to every American soldier. Our own ('hief of the Professional Services.

and. in particular. the Chief Surgeon. have been immensely patient with us, and we are

happy to have thi.g opportunity to give then our gratitude in return.

The weather, among other things, had been "rotten," r:ainy, cold lind

miserable, and Colonel Cutler, himself, had felt no bet ter. lie noticed that

tie morale of his consultants was larticularly low. On Smnday, 25 ()ctober, he recorded: "hI the afternoon, the Iovs :* * gave me hell said we werent
CHIEF CONSULTANT IN SURGERY 57

getting anywhere and suggested it was partly miy fault !" The following day,

he wrote. "Staff meeting, 4:00 to 5:00, and this time the boys took it out oil

JCK [Colonel Kimbrough]. I think they are wrong, l)etuilant, and a bit childish. Anything they can do will help our soldiers, but they seem to feel that,

unless it is a great big jot), they might demean themselves by doing it." A few

days later, lie commented: "I appreciate they have little to do that looks important, but why cannot they see that everyday they serve their country, it

is at privilege. Why must all think: What are we doing? What do we get

out, of it.? Perhaps I'm just a stupid little boy, but anyway, I'm happy to

serve."

After these really uncalled for, but understandable, outbursts of temperament, Colonel Cutler tried, lie believed successfully, to mend damaged feelings and arrive at a better understanding among the consultants. On occasions,

however, things seemed to go from bad to worse.

The new year held no promise for improving the situation. On New

Year's Day, Colonel Cutler entered this rather despondent statement: "I seem

to feel that we are all stagnating and going to seed. though we work steadily

at organization." And on 4 February lie recorded: "All day I've felt bad, and

now I feel just rotten. Discouraged with a system which isn't calculated to

help a country at war, though that obviously is the reason for its existence.27

That this matter of interpersonal relationships was no trivial matter

can well be attested by the attrition rate among the surgical consultants. During 1943, four of the senior consultants in surgery returned to the Zone of

Interior for permanent change of assigment. Among reasons for their reassignment was that of failing health brought on by the environment and circumstances under which they worked. One of the consultants was seriously

ill. Another had to be reemoved from the Professional Services Division and

given a division of his own in order for the Service to obtain the maximum

contribution that was expected and needed of him and that lie was fully qualified to give. Apl)arently, from the written record, Colonel Cutler was able

to contain himself renmarkably well, considering the circumstances.

Another phase of this struggle, particularly as it might be applicable

to the professional personnel who made up the group of surgical consultants,

was the personality of Colonel Cutler, himself. These statements made by

General Hawley, however, could have applied to each of the other consultants

as well. Speaking in retrospect of Colonel Cutler, he wrote the following:

* * * An innate honesty often compelled his professional judgments to be severe;

but, whenever possible, they were softened with praise of other qualities. His high ideals

and his devotion to duty made him, in his younger and formative years, somewhat intolerant

of mediocrity; and this occasionally brought him into conflict with others. But the years

brought him the wisdom that recognizes the impossibility of universal perfection, and

2"Miuch of this was written I,. late 1942 and early 1943. At that time there was no firm war

plan for the E.T.O., and none of us knew what the eventual plan would be. Plans were changed every

week. The Air Force was still promising to "bonflo Gernhany to her knees' ; and certainly no ground

forces of the magnitude which were assembled In late 1943 and In 1944 were tlhn planned." (Letter,

Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., AC, 25 Aug. 1958.)
58 ACTIVITIES OF SURGICAL CONSULTANTS

a tolerance for hunman weakness that fell short only of abridging his high principles.

He required a lot of knowing, did Elliott Cutler; and casual contact rarely revealed the

true fineness of his character.'

It may be said with considerable certainty that Colonel Cutler's attitude

on the position of general surgery vis-h-vis the specialized branches of surgery

in war was an important factor in the conflict of ideas and aspirations among

the surgical consultants (i)p. 167-168). Iln a broader sense, this attitude could be

related to Colonel Cutler's convictions on the surgery of trauma and the

position of those in the fields of the more limited surgical specialties.

During the doldrums which gripped the consultants in late October 1942,

Colonel Cutler found it necessary to comment on the place of surgical specialists in an oversea theater. His memorandum, presented to Colonel Kimnbrough, read, in part, as follows:

1. This is a careful and thorough study deserving the most thorough consideration.

It reveals careful consideration of the problem not only of this surgical specialty but of all

surgical specialties.

2. The basic consideration that specialists are undesirable in the forward areas has

my entire apl)roval as does the corollary that the Surgeon General's Office, Washington,

does not appreciate this since it is committed to a heavy training program, expensive

and probably of no value.

3. * * * I have myself always been of the opinion that this is a small island and that

if transportation is available (and safe) all who can no longer serve here should be

evacuated to the Zone of Interior immediately.

4. The final suggestion that narrow specialists be sent home is not for my decision

but this may be said:

a. Any good citizen now here can be of immense service to his country and replacement is difficult.

b. Lt. Col. - has been a major element in whatever value the Chief Surgeon

may put upon his Surgical Consultants because he is loyal, faithful, a hard worker and

a man of sound judgment.

c. Patience is a noble virtue and far transcends surgical specialization."

The problem of traumatic surgery was not limited to the American forces

in England. If anything, it was apparently a greater problem among the

British medical profession. The 2 February meeting of EMS consultant advisers with the director, Sir Francis Fraser, brought out a heated argumnent

on traumatic surgery and the orthopedists' claim to it. Colonel Cutler was

asked to speak, and he did. As a result, he was asked to speak on the same

sul)ject at a forthcoming meeting of the British Surgieal Association, particularly with reference to the educational system and the organization of a

university teaching clinic. Ili his memorandum of 5 February 1943, reporting

the meeting to Colonel Kimbrough, Colonel Cutler stated:

In furtherance of the discussions that took place, it seemed to me obvions that a

p.sychological barrier has arisen between my general surgical colleagues anti my orthopedic

2 Hawley, Paul R.: Obituary--Brigadier General Elliott Carr Cutler. Med. Res. U.S. Army, Mll.

Surgeon, 101 : 351-352, October 1947.

-9 Memorandum, Col. E. C. Cutler, MC. to Col. J. C. Kimbrouigh, MC, 30 Oct. 1942, subject: Comment on Contribution of Lt. Col. -.
CHIEF CONSU'LTANT IN SURGERY 59

colleagues in Great Britain, in that the ortholedist has come to think he is tilhe only o(ie

who can look after trauma. Of vourse, this is ridiculous. lie canniot care for trauma

of the head, lnor care for the ruptured kidney or ruptured spleen, nor would he have a•iy

idea of what to do with nonperforating thoracic injury.

With the aforementioned mlemorandum of February 5, Colonel ('itler

submitted also a memorandum which he hai written, he stated, for his own

thinking after the last meeting of "this Committee."' The substance of this

mlemorandhum was as follows:

A (list uirbing finding in England is the lprofessional thinking, whi(.h seems general, that

only ortholwedi( surgeons c(an treat fractures and other forms of traimna. This seems to 11e

to create a grave danger in the broad outhlok of medical practice, both for the lweople we

treat. and(] for the profession.

It creates immediately a fundamental new speciality in that it carries the indliationI

that every fracture incurred on the street must go to an orthopedic specialist. Such a fundamental breakdown of medical practi(e is just the sort of treatment for the leo)Ple that is

sure to give rise to new cults. * * * It is always our mistakes which give rise to new cults.

Yet we keep bIlaming the lpeople for accepting them when we. the profession which should

have the responsibility of the Ielple always at heart, have been responsible for the change.

A study of what happened in Britain reveals the follo "ing. With the great

blitz, it was found that fractures were badly treated by the ordinary doctor.

Therefore, those responsible ruled that only experts should treat fractures, and

they thought that only orthopedic surgeons were experts in fractures. As a.

result, Britain now finds herself with only a few people able to treat fractures,

and the young man going out into the field with the Army has no training

in tratuma because at home such work has been not a part of his general

surgical education but a specialty. What Britain should have done when the

blow came was to have impressed upon the schools, the leaders, and the teachers

that all doctors must learn adequately the care of trauma. Traumna constitutes

between 20 and 30 percent of every young doctor's work, and the schools should

drill the students completely in its handling and care. Had this been done in

England, she would now have thousands of people trained in traimia, and not

just a pit iftil handful ready. It is the long run view which saves both people and

the l)rofession.

We can take a lession from this--a lesson not taken in any schools from a

critical point of view-because we can benefit from the experience of our colleagnes and our sister nation. We must now see that every young surgeon is

taught trauma. If we do not do this, the foolish separation already occurring

in our country of a specialty for traumatic surgeons, giving rise to even a society

with this name, will jeopardize the care of the people, which is our complete

responsibility.

Colonel Kimbrouigh forwarded both of the aforementioned memorandums

to General 1lawlev who, in turn, had them copied and forwarded to General

H-illman in the Office of The Surgeon General.

On 12 April, Colonel Cutler presented a talk to the British Consultants

Chlib on organization for surgical teaching clinics in the future. "Really an

705-0051--64--7
60 ACTIVITIES OF SU'RGIICAL CONSULTANTS

attempt to hold specialization in place,"' he wrote. In a, letter to Colonel Kimbrough, dated 1M April 1943, he mentioned the following points Wiade ill his

talk:

The real problem relates to the role to be played by specialists and the question is

becoming more urgent whether there should be separate clinics or institutes for the slpcialties in medicine and surgery, or whether they should form part of a general clinic. The reasons for a general clinic seem to be many, but in particular are included in the statement

that a general clinic, especially where the patients are mixed in vast wards and not segregated in special wards, is best:

For the patient, since this permits simple cases which are recoverable to be next to

more serious people whose outlook is hopeless.

For the students, and the Oath of Ilippxorates slates that every doctor must assist

in educating students-since if the patients of all specialties, etc. mix in wards, the students'

mental exercise in entering the ward is not simplified as it is when he knows that all eases

in that ward are restricted to diseases in a certain domain.

For the doctor, for under these circumstances the specialists and the general surgeons

find themselves willy-nilly next to each other in an open ward discussing their problems.

If they run separate institutes then they are shut away from each other, and open discussion and( conunon problemns [are] lost.

As for the Chief Surgeon, General Hawley announced on numerous occasions his policies on the use of specialists. Notes from a conference of 19 April

1943 show that General Hawley emplhasized the following points:

That it was not his policy to train specialists in the E.T.O. : that he considered a world

war and a theatre of operations were neither the time nor the place for medical education.

lie had found from experience in the last war that General Practitioners, nervous of

conditions when they returned home from the Army, had been anxious to spec.ialize. They

had attended short courses in varied medical fields and had then considered themselves

specialists. The outcome was that the mimen were useless in the theatre during the time of

their so-called training; that the soldier suffered and eventually time civilian lqpuhlation

from "half-baked" specialists. General Ilawley agreed * * * that some differentiation

should be made concerning those men who were either in the midst of training or about to

embark upon training as specialists when they entered the Army.

Significant activities

The first. half of 1943 found Colonel Cutler engaged in three l)rimary

projects. These were: (1) Preparations for participation in a British-Americall surgical mission to the U.S.S.R. (Union of Soviet Socialist Republics),

(2) providing a means for assuring the supply of whole W)lood in comalat, and

(3) creating mobile surgical units. These sulbjects will be discussed separately,

but, it should be noted here that they were interrelated in one respect. As plans

materialized for the trip to the U.S.S.R., it b)ecame evident that 'he mission

would leave some time near midyear. There was a risk involved in making

such an extended trip, particularly when plans called for visits to the combat

zone. The risk, small as it may have been, couhl not bIe ignore(d. At the same

time, it became increasingly evident to Colonel Cutler that there would have

to be a bountiful supply of whole blood in the conil)at zone and surgical units

as far forward as feasible in order to plrovide the optinium care for battle

casualties. The coml)ination of these factors meant one thing to the Chief
CHIEF CONSULTANT IN SURGERY 61

Consultant inl Surgery : lie ha(1 to comle~~lte p~lans for the provision of whiole

blood and surgical units before lie dlepartedl for the U.S.S.R. This objective

became anl inescapable, moral obligation to which hie rigidly adlheredl. Otherwise, the Chief Consultant. inl Surgery, iii addition to carrying onl with the

routines and p)rogramns alreadly inl effect, was dlirectly involved inl the followNN-14r

nioteworthiy developmlents.

Change and expansion of consultant system.-Coloiiel 1)iveley, Senior

Consultant in Orthopedic Surgery, visited NATOUSAX (the North Africall

Theater of Op~erationis, U.S. Armiy), (luring -thie )erio( 16 Feb~rua-ry to 19 MarchI

1943). M aj. (later Lt. (Col.) William .J. Stewart, 31C, was appohited Acting

Consultant inl Orthopedic Surgery onl 1 March 1943. -Major Stewart remainied

oin duty with the theater consudtant stall after Colonel Diveley's return. hIls

services were most. valualble because Colontel IDiveley was requiredl to give at

great amount of time to rehiabilitation activities and the making of traiiiing

films. Lt. (Col. (later ('ol.) Kenneth 1). A. Allen, MIC, upon arrival froin the

Zonie of Interior, was appointed Senior Consultant ]in Radiology onl 9 February

1943. Colonel Brown was returned to the Zone of Interior onl 29 Mfarch,

andl Maj. (later It. Col.) Eugene Al. Bricker, MC, of thie 298thl General Hospital, was appoinited Senior Consultant inl Plastic and Maxillofacial Surgery

and Burns inl his stead. IA. Col. Norton Canfield, MIC, arrived froin the Zone

of Interior inl January and w as appoinited Senior Consultanit inl (tola r.--Igology onl 1 July 1943.

IDuring this period were initiated the beginingiiis of a system of conlsultationi at. the local level. Colonel Cutler expla.in~ed the basis of the system at a

meeting of the Chief Suirgeon's- Consultants' Committee oin 3() April 1943

as follows:

With the dlesire to he preparedl for a ma~ximumn load in the near future, the surgical

consultant,, tire submiitting * * * a list of consultanits iii general surgery andl thle surgical

specialties mwhich consist of officers now on the roster of our general hospitals but who

-ire of suchi professional stani(lin that they might wvell be use(l in a consultative (almacit .y

Note that in some specialties they aire spaced at the rate of one to each base seetion :in

some. less freqluently: afl(l in major fields for Avork for a consultant front each general

hospital an(l evacuation hoslatal.

* * * The surgical Sub-Commi ttee feels that by making this mnatter a p~ermanent one

now they may be p)rotecting the patients subsequently to eoime to this theater, ensuring

themin adequate siirgieal care.

Gleneral Hawley approved of the idea wvholeheartedlv anll lurgedl that more

than the number p)reseutly necessary b~e appohited to plan for the future andl~

to assure the availability of anl alternuate consultant inl the event thle regularly

(desigonated consultant could not answer a call.

Another chiange which occulrred late ini this p~eriod was a reorgranization

of the theater comninind structure whlich involved the estab~lishmnent of base

coummands1( and a chiange ini thte initernal organ izat ion andl arrangemlent, of

the C hief Surgeon's Office. TIhe principal chanige in the latter was the reestal)-

lishnienit of General Hawley inl London and the subsequent shiifting of the
62 ACTIVITIES OF SURGICAL CONSULTANTS

deputy surgeon, Colonel Sprinit, to Cheltenhamn. The former change coin)licatedl matters greatly, but was an obvious necessity, just as it had been in the

First World War. It brought to the fore the question of who had the operational responsibility for consultatiolis at the local level, since tile base commander was to be supreme in his area. as Colonel Spruit informed the

consultants.

The change involving General Ilawley and Colonel Spruit, it soon became

obvious, was the reorganization which had been required to improve the manageuient of the Chief Surgeon's Office. General Hawley was one of the first

to admit this, for he observed at a conference held by him on 28 June 1943:

The only other thing that I want to say is that it is very obvious to me that this

office is working much better and that Colonel Spruit is doing [more] * * * to get [matters] working smoothly than I was ever able to do.

We are going to expand and decentralize. and more and more responsibility is going

to division chiefs. Obviously the time is coming very, very soon when many things come up

that cannot all l)e decided centrally. We are going to make mistakes. I have made several

mistakes and you are going to make mistakes. I think we can all forgive mistakes that

are honestly made but I cannot forgive a mistake that is camouflaged. Many of the mistakes in this office, many of the failures in this office, I feel personally, result from poor

leadership on my part. There are certain things that are not the result of that, and that is

absolute and flagrant disobedience of a direct order. I can forgive almost anything else,

but when I tell someone that I want something done I expect that to be done and done

promptly.

Expert surgical observation from battlefront to base hospital.-A

letter on this subject, dated 6 January 1943, was submitted by Colonel Cutler to

Colonel Kimbrough. The letter read as follows:

1. I have long been of the opinion that the next step forward in military surgery will

only come when experts can be placed in the forward elements of the Division, and can

observe the wounded soldier from the time he is hit until he is convalescing. You will

recall that it was the observations of a British R.A.M.C. Captain behind Ypres in the sumamer of 1917 that gave us the complete evidence of a lpisonous substance manufactured in

a traumatized extremity on the way from front to rear.

2. I believe we should at this time have the privilege of sending into Division teams :

a. In general surgery,

1). In orthope.dic surgery,

c. In thoracic surgery.

d. In neurological surgery.

e. In nmaxillo-facial surgery,

wih should o4iserve cases on the battlefield. certainly at the battalion aid station. and then

travel down the line at least through to the hospital where the first definitive surgical treatment is given. These men should have the privilege of operating upon individuals if In

their JuIdgment that seems wise.

3. I am sure that observations made by real experts even on 50 cases in each category

wouhl open up a new release for the wounded soldier.

4. I have been in long consultation with Colonel IIoltz. Chief Surgical Officer of the Norwegian Forces, who went through the Finnish campaigns as well as the present struggle.

He is an expert (chest surgeon. and should such a group of American officers be allowed

to go it wo}uld be a great benefit to us as well as to him if he could accompany this group.

His government would be willing to give him two or three months leave for this purpose.
I 11f Fugr mria Ior cxniain. I I e iiIrwl l

'[i~Il1444, 11 11' \ i4'it14 ii' lt 11~'4l~IXi i:i'i'jI~ 4414' l.141441~~l-ILI' 444

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64ACTI VITIES4 OF' SURIC~I(AL C( NSI'LTANTS

citizen who is willing" to oiler hlis services to his .ounltryN shouldl not thus be aidditionlally peiialized for patriot ismi. Our adlvice was to grive tilie examinlationis

either htere or iieither here nior iii thle U.S.A. for thle period of thle war."

Elective surgery.-As the troop and mnedical streng-th of thle theater inlcreasedl andl muore station hosp~itals came to England, thle miq~ualitied p~ersonnle

p)erforminhg, surgery in these hospitals b~ecamle a problem. The theater policy,

established by Geineral Hawley persoiially, was that no major elective suirgerv

wouild he p~ermittedl except. at tile 10th Stat ion H ospitail aui1( inl general hospitals.

Furthermiore, there wams a policy that patients who required more than :(0 (lays

of hmosp~ital ization Wouild not he held in station hospitals. Tfhere was, however.

tilie la rge realm of cases wvh ichl, conceivabi v, could have surgery and be out of

the hioslpital w~itliiii this p~eriodl. There were also station hospimtals assignied to

bases of the Arnmy Air Forces to which skilled p~ersonniel had been assigniedl in

ordler to lprov'i(le (lefiniit ive treatmlenit for air casualties anld the treatment of

essential p)ersonnmel which the Air F~orces (lid not want to lose through ordlinary

relplaveinenit chanlnels. Inl add~itionl, thlere was tilie strinig of stat ion hlospitals

wvhiich had been strategically plhacedl in southern Enlglanld with tilie idea that. they

miot onlly serve troops inl that area but11 also take care of evacuation from beaches

up1)01 the commiencement of hostilities on the. Continent. Colonel Vail, Senior

Coiisultmit. in Ophithalmology, was of the op~inioni that ophithalmi-ologists p)re~sently inl the station hospitals were p)erfectly capable of performinhg the usual

su11rgical pro~cedulres involving the eye. Thle real (difficuilty lay in trying to dlefine

elect ive surgrery accurately and so) that the definition would be uniformly understood1, p~articuilarly~ ini such olperations als the repair of hernias. General Ilawlev~s opinion was that, when something could not. be defined accurately, it was

impossible to enforce and~ conttrol it, rigidly. In the matter of station hospitals

being perliuttedl to perform special types of surgery, such as major01 ophithalmic

p~rocedlures, tile Greneral stated that thle surgeons in the theater at this time

(March 1943) miighit be competent but this woumld nlot hold( alwaVS.30

A pl)licy was then agreedl upon that no major elective surgery would be

allowed inl station hospitals except whenl application was submiitted by thle. hospital for -special permssiou to p~erforml them, aiid the appllicationl was approved

by tlie conisultanits conlce-imeol in the Professional Services D ivision.

Th'le p~roblemm was not one of great imagn it ude, but it cont iinued to occupy

thle t ine of the consultant,; because so many sp~ecific incidents continued to arise

in which differences of opinion resulted in ain ap)parent breach in theater policy

andl becaiise the status of stationl hospitals had to be conistaimtly reviewedl to ascertain whether they could be. permiittedl to p)erformil or conitinue to p~erformn operationis of elect ionl.

The Chief Surgeon. (luring this p~eriodl, did not. choose to accept. Colonel

Cutler's dlefinition of elective surgery based onl the criterion of time: that is, that

ureycoverhiig those, coud~it ions where delay iii transport. (does not endanger

3* Minutes. Chief Surgeon',4 Consulitants' Committee' meetinmg. 5 Mlar. 1943.
CHIEF CONSULTANT IN SURGERY (65

tile patient's welfare.31 Neither did lie permit tile publlication of a directive on

certain types of elective operations which could be performed in station

hospitals.

American Medical Society, ETOUSA.-At the suggestion of the Chief

Surgeon, Colonel Cutler was given the responsibility for creating a medical

society ill which all American mnedical officers in the European theater would

have a utomlatic ineinbershilp. General Ia wley specifically prescril)ed that the

management of the society Shouhl rest in the hands of officers outside the Office

of the Chief Surgeon. Accordingly, Colonel Cutler further delegated to Lt.

Col. (later Col.) Robert. M. Zollonger, MC, the responsibility for forming the

organization. An organizational meeting was held on 14 May 1943 in conjunctioit with the mee(ing in Cheltenham of the chiefs of medical and surgical services of all general hospitals. Lt. Col. Gordon E. Hein, MC, and it. Col. (later

Col.) Wale Kneeland, Jr., M'C, chiefs of the medical services of the 30th and 2d

General Iosl)itals, respectively, and Colonel Zollinger were elected as a teml)orary executive committee. The 298th General Hospital offered to sponsor the

first meeting of the proposed society.

This initial meeting was held on 23 June 1943. A business meeting was

held preceding the meeting proper. A simple constitution and bylaws were

drawn up which stated the purpose of the society to be as follows:

Upon authority of the Chief Surgeon, European Theater of Operations, this Society is

formed for the purp)ose of disseminating current professional ideas and methods of military

significance among officers of the Medical Corps of the United States Army in this theater.

This Society shall be known as The American Medical Society. European Theater of

Operations, United States Army.

The following officers were elected: President, Colonel Zollinger, 5th General HIosl)ital; Vice President, Lt. Col. (later Col.) William F. MacFee, MC,

2d Evacuation Hospital: Secretary-Treasurer, Maj. Clifford L. Graves, M(1 ,

3d Auxiliary Surgical Group; and Executive Committee at Large, Col. Edward

J. Tracy, MC, Surgeon, Bomber Conumand, Eighth Air Force, and Lt. Col.

Rall)ph S. Mu(ken fuss, MC(', 1st. Medical General Laboratory. Monthly meetings

on a rotational basis at. general hospitals were planned. Mornings were to be

d(evoted to clinical ward rounds in the various sections followed by short p)resentation of topics related to the sections, and afternoon sessions were to be given

over to topics of general interest. Provision was made for the submission of

p~apers, fromn individual inedical officers for presentation and the invitation of

well-known guest speakers. The chiefs of the medical and surgical services of

the sponsoring hospital were designated the program committee for the meeting

to be held at any l)articular installation.

Honorary Fellowship in Royal College of Surgeons.-While dining

with Surgeon Rear Admiral Gordon Gordon-Taylor on the evening of 16

March 1943, Colonel Cutler was informed by Admiral Gordon-Taylor that

lie was to be made an lnmorary Fellow of the Royal College of Surgeons in

21 Draft. by Col. E. C. Cutler. MC. of proposed circular letter, 5 Mar. 1943, subject : Policy RegardIng Surgical Therapy In Station Hospitals.
At "I'l V IT I I :S 11.1 1-1 A 0 ACA 1. 111 )NIII I.TA VIIS,

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CHIEF CONSULTANT IN SURGERY 69

FIGURE 23.-Maj. Bernard J. Pisani, MC.

When, after correspondence with General Rankin, it was apparent that

considerable amounts of penicillin would continue to arrive in England, Colonel

Cutler met with General Hawley on the morning of 19 May to determine how

the new drug would be used. General Hawley approved it for situations where

its use might be lifesaving. He did not approve its use, at this time, for

sulfonamide-resistant gonorrhea, as recommended. Some of the more specific

uses of penicillin agreed upon by General Hawley and Colonel Cutler were for:

1. All cases with gas gangrene.

2. Serious general infections, usually with osteomyelitis and preferably

infected with Staphyloeoccus aureus.

3. Eye infections (in a special ointment to be prepared by Colonel Vail).

4. Septic hands.32

Serious investigation into the efficacy of penicillin in surgical conditions

had to await Colonel Cutler's return from the U.S.S.R. and larger more frequent shipments from the Zone of Interior. As precious as it was at this

time, a generous amount of the drug was taken by the mission to Russia as a

gift to the Soviet peoples.

Schools and professional training.-A milestone in the theater's medical

educational activities was the opening of the European theater Medical Field

Service School at the American School Center, Shrivenham Barracks (fig. 22),

under the direction of Capt. (later Lt. Col.) Bernard J. Pisani, MC (fig. 23).

3 Letter, Col. E. C. Cutler. MC, to Col. J. C. Klmnbrough. MC, 22 May 1943, Subject: Talk With

Opneral Hawley re, Penicillin. Wednesday, 1.9 May.
70 ACTIVITIES OF SURGICAL CONSULTANTS

The first, course convened on 8 March 1943 and continued for 3 weeks.3 3 The

purpose of the school, as announced, was to train medical officers, particularly

those serving with field units, in aspects of military" medical practice not

ordinarily familiar to civilian physicians. Included in the curriculum were

22 hours of lectures and conferences on problems of combat as they affected

surgery, acute medical conditions, and neurol)sychiatry.

Before the opening of the school, Colonel Cutler had worked many hours

on the surgical courses of study, l)ut, an item of immediate concern to hin

shortly before the opening was the appointment of instructors on professioial

subjects. Some, apparently, had been appointed without knowledge of the

Professional Services I)ivision, and Colonel Cutler informed the Chief Surgeon

of his concern over this situation.

In reply, the Chief Surgeon stated at the February meeting of his Consultants' Committee the policy that all instruction in clinical medicine at the

school, except chemical warfare, would be controlled by the Professional Services Division and that no instructors on professional subjects would be sent

to Shrivenham without that. division's apl)proval. General Hawley further

explained that he wanted the course at Shrivenham for the man in the field,

but also wanted it to include essential teaching on frontline treatment to avoid

the necessity of sending officers to two separate courses.

Partially as a. result of this policy, l)rofessional training at the swhool

retained a high level, and instruction could be varied as circumstances indicated.

Most of the teaching on strictly l)rofessional subjects was given by the various

theater consultants concerned.

Another course, initiated during this period, l)ecame known as the London

tours course. This program was created at Colonel Cutler's request by Surgeon

Rear Admiral Gordon Gordon-Taylor, consulting surgeon to the Royal Navy.

A limited number of officers was accepted for a 1-week schedule of visits to a

different British hospital in the environs of London each day-to London,

Guy's, Middlesex, St. Mary's, and St. Bartholomew's Hospitals. Luncheon

was provided at each hospital, and, on certain afternoons, the American Red

Cross in London provided transportation and guides for tours to interesting

points in the city. The professional interests of candidates selected were

relayed to the hospital directors in advance.

Finally, an administratively difficult, but most. worthwhile. program was

begun of exchanging for short periods of time medical officers in line units

with those in hospitals. This program fulfilled the dual l)uri)ose of providing

a more varied experience in clinical practice for medical officers of line units

and served to acquaint, medical officers in hospitals with the problems of providing medlical service in line units. The plan was a good precursor for the

system later adopted of rotating ('combat- anid service-element medical officers

when active hostilities ensued on the Continent.

13 Circular No. 22, Hendquarters, ETOUSA, 23 Feb. 1943.
CHIEF CONSULTANT IN S%'R(ERY 71

Blood

Back in 1942, upon hearing a discussion on blood and plasnia at a meeting

of the Royal Canadian Medical Corps Pathological Club, Colonel Cutler had

recorded: "Very interesting It seemed to me that the rise of plasma, etc.,

had let all forget the benefit of transfusion. Our soldiers are all grouped.

They should be the best vehicle for getting blood forward. No bottles to

carryv! But, comments he heard later and reflection on the transfusion

)robllenis of World War I convinced him that the matter was not as simple

as this. The problem lay in the area of a practical unit usable under the

conditions of combat to effect transfusions.

In a letter to the Chief Surgeon on 27 March 1943, concerning standardization of the portable transfusion unit. for combat areas, Colonel Cutler

wrote the following:

The infornmation we have from the present battle fronts of all nations including our

own in Africa and elsewhere, is that transfusion as a inetho(d of resuscitation is steadily

on the increase. Colonel Diveley brings us this information from our own troops in North

Africa and Brigadier Whitby tells me that the use of wet plasma has practically been

given up, and transfusion used in its stead in the British Army.

He then proposed a simple transfusion kit to be used by American units

in the European theater (fig. 24). The kit was composed of items of standard equipment available in the theater, and, when packed in a chest, made

it possible for a shock team to provide a large number of transfusions. This

kit, developed by Capt. (later Lt. Col.) Richard V. Ebert, MC, and Capt.

(later Lt. Col.) Charles P. Emerson, MC, 5th General Hospital, included

equipment for grouping donors rapidly and satisfactorily, for these officers

had discovered that a 10-percent error existed on the blood types stamped

on identification tags of individuals.

Colonel Cutler recommended that a number of units of this type be assembled, packed, and held for distribution in the medical depots. There was

no immediate need for the item, since the British taking and giving sets currently in use were satisfactory for the type of medical service being provided.

Colonel Cutler, on 31 March 1943, was given a firsthand explanation of a

system used by the British in Africa. At the Post-Graduate Medical School,

RAMC, in Lojdon, Col. A. E. Porritt, RAMC (later Brigadier and consnltim., surgeon, 21 Army Group), gave a splendid discussion on how the

British Forces in the Middle East drew blood in Cairo, flew it to a distributing

point behind the lines, and then transported it in refrigerated vehicles to

forward units, such as field ambulances and advanced surgical centers.

In a letter, dated 2 April 1943, concerning his 30 March-1 April tour

of duty, Colonel Cutler reported to Colonel Kimbrough: "With us, we had

expected to send expert teams up the line who would then draw sufficient

blood at each medical installation from lightly wounded or hospital personnel."

Ile continued: "Both systems are open to the criticism that adequate studies

of the blood for syphilis, nmalaria and other diseases are not made, and this

needs critical thinking."
72 ACTIVITIES OF SURGICAL CONSULTANTS

IMPROVISED BLOOD TAKING

AND GIVING SETS

PLASMA

AIRWAY

CLOTH COVER FOR TUDING AND TOP OF SOTL

SET READY FOR SET FILLED WITH.BLOOD

TAKING BLOOD READY FOR STORAGE

IMPROVISED BLOOD TAKING

AND GIVING SETS

STERILE EQUIPMENT

-- __ , FOR GIVING SET

AMERICAN DRIED

PLAS•Ak TUBING

SODIUM CITRATE VIAL AND GLASS BEADS SET READY FoR. GIVING BLOOD

FIGURE 24.-A transfusion set improvised by Capt. Richard V.

Ebert, MC, and Capt. Charles P. Emerson, MC, of the 5th General

Hospital.

On 7 May, Colonel Cutler had a long session with Brigadier Whitby

and others at the British Army Blood Supply Depot, Bristol. This meeting

served to review and consolidate all previous thinking which had been given

to the problem of supplying U.S. Army units with blood and protein fluids

when the invasion bega .. The core of the problem w'is expressed in the

following three questions and answers:

1. Are a common apparatus and a common source of blood and plasma essential

for proper liaison between the British and American Armies?

Answer: Should we invade the Continent, the answer to this is that a common kit

is nt essential, for units using the materials would never be so closely mixed. Also,

the British would have great difficulty in supplying us with material in this field.
CHIEF CONSULTANT IN SURGERY 73

2. What is the optimjum time for resuscitation?

Answer: The answer is early. rapidly and adequattely. British figures show 10

percent of w-8ounded require transfusion. The Russian figure is 11 percent. Transfusion means blood or polasmna, or both. These figures mnay rise to greater heights. For

example, in a plrivate letter from the Tuntisian front to Brigadier Whitby 42 out of 180

serious casualties iii an 1M.L.S. reqluiredl transfusion, roughly 213 percent.

3. What is the problem in forward areas?

Answer: Everyone hats agreed it is dOfficult to procure b~lood for transfusion in the

most forward elements and the value of plasma is not fully appreciated by most medical

officers. For example, word has conmc back both from the Americanm and British sources

!in North Africa that. plasma was no good annbloo00( should be use(]. There can be no

qulestionl but w~hat repllacemnent with plalsiniti is highly efficacious aind the opinions from

frontline surgeonls (d0 not represent scienitific evidlence to the contrary but seemi to be

mostly hunches. It is its if these forward surgeons thought that certain serious casualties to Ahiiii phisnia was given might have been saved if blood had been given. True,

wvhen nmassive hemorrhage has occurred blood is essential, lbut we should have a directive

concerning the use of blood and plasmia amid the conservation of these.'

The British system contemp~lated for a continental invasion, as described

by Brigadlier Wlhitbv,- was to follow closely the North African exp~erience.

Freshlyl drawvn refrigerated whole. blood was to be delivered to the Continent.

by aitir Th~lence, refrigerated trucks carrying 400 b~ottles each were. to supply

-forw~ard( tr-ansfusionl teamsjý whielh, in turn, were to be equipped with 3-ton

refrig~erated trucks hiolding 8() bottles of blood and 200 units of plasma. The

British griaciously off eredl to fly 1.S. Armny blood( to the Continent, lblt from

there on the responsibility wvouIld have to rest with V.S. Army elements. Moreover, it was imnpressedl on the conferees that the British planned to draw only

200) Ipilts at day, which couldl le b)oosted with difficulty to 400. This absolute!,,

prohibited the, U.S. Army from counting on the British for a supply of fresh

blood(.

Considering the foregoing factors, the logical conclusions were fourfold,

andl these C'oloniel C utler expressed1 as his recominendlations to Colonel Kim-i

lbrolugh an teCifSreno 0My14. First., there was the need

to publish a1 (lirective concerning, the proper use of blood( andl plasmia in combat.

Seco)1nd lyie statedl that plasnima was now being sulppliedl to (livisional medical

elements, mobile hospitals, and fixed hospitals and1( requiredl no further elaboration except, that ample stocks had to be made ready. The third and fourth

recomnmnindat ions concerned the supply of whole blood( andl were dividled into

means of 1)rovidhing whole blood( (1) from doniors in the field and (2) from

sources in the United Kingdlom or the Un1ited States proper. They were

as follows:

We recommend that a satisfactory bleeding and giving set with the equipment for

gross agglutination to determinie comnpatiblility of blood be assembiled and set up in the

United Kingdom, this unit to go forward wvith our transfusion teamis an(1 be available for

other inedical use also. The equipment is contained In the T/BA of the mobile surgical unit

already 4ubmitted. We feel that the transfusion team -up the line" c-an bleed the lightly

14 Detter. Col. E. C. Cutler, "MC, to Brig. Gen. 1P. Rt. Hawley (through Col. J. C. Kinibrough. 11C).

10 May 1943l, subtj'ct: The Use and Procurement of Blood anfd Plasmia for tile E.T.O.
74 ACTIVITIES OF SURGICAL ('ONSI'LTANTS

wounded in sufficient supply for most of the needs for blood. provided lplasina and blood are

intelligently used.

It would seelm desirable to have an additional supply of refrigerated fresh whole blood

originating either in the U.S.A. or in the SOS or the V..S. Army in the United Kingdom.

This would require the setting up in the U.S.A. or in the United Kingdom of 1) Bleeding

centers, 2) the transport of such blood in a refrigerated aeroplane to the Continent, 3) the

use of refrigerated automobiles to take the blood up the line to medical installations who

would have refrigeration iii which to keep it. Blood, when refrigerated, has been used up

to 2, 4 and even 6 weeks after withdrawal. but it is perhaps not wisely used after 2 weeks.

(Calculating 72 hours from bleeding in I.S.A. to the Continent we would have plenty of

time to follow the Englis' and Russian system and have blood drawn in America reach

this forward area before any deleterious changes had taken place. If the air trvnsportation

of freshly drawn blood is too unreliable, blood could be seeured from the U.S. Army SOS

installations in the United Kingdom.)

The same day that the preceding recommendations were prepared, 10 May

1943, Colonel Cutler briefly apprised the Chief Surgeon and his staff on the

problems of providing blood to combat forces. Hie eml)hasize(l particularly,

at this informal conference, the difficlllties attendant on the air transportation

of blood from the United States and the fact that there was no machine suitable

for the use of U.S. Forces in the European theater for properly giving and

taking 1)loo(1. The American equipment. Colonel Cutler told the conferees,

was excellent, but when the slightest repairs b)ecame necessary, the equipment

had to be returned to the Zone of Interior.

On 5 June 1943, Col. Walter L. Perry, 'MC, Major Storck, and Captain

IHardin met. with Colonel Cutler in Cheltenham. Colonel Perry (fig. 25)

was the theater medical sul)ply officer, and Major Storck, the recently appointed

Senior Consultant in General Surgery. The meeting was arranged to expand

further the proposals submitted by Colonel Cutler on 10 May 1943 and to

recommendl more specific steps necessary for the implementation of Colonel

Cutler's suggestions.

The matter of obtaining 1)lood from the Zone of Interior was left in

ableyance since it was obviously a separate problem from that of obtaining,

processing, storing, and distril)uting blood within the theater. Moreover, once

blood from the United States had arrived in the theater, it p)resented a problem

no different from that for blood collected and processed in the theater. Therefore, the conferee.- concentrated on facilities and programs to be developed

within the capabilities of the theater itself-the only basis on which ab.mohutely

re7;eble plans could be made. They made the following decisions:

1. A depot-type unit wouhl I)e necessary in the United Kingdom to centralize and direct the many activities involved.

2. Bleeding of American troop)s ad(/or British civilians would I)e necessary.

:1. American bleeding teams and facilities would have to be used.

4. Provision had to be made for a unit to receive and further distribute

blood on the Continent, once a firm ibeachhead had1 been established.

5. Prol)er refrigeration equipment would be necessary throughout all

phases of the program.
CHIEF CONSULTANT IN SURGERY T5

FIGUURE 25.-Col. Walter L. Perry, MC.

Also discussed was the progress which had been made in establishing blood

banks and donor panels at each active general hospital and the work yet remaining to accomplish this objective.?

On 10 June, Colonel Cutler had a conference with General Hawley in

London. The general, after first expressing his surprise at finding Colonel

Cutler still in London, directed him to finish by all means the plans for providing blood and plasma before leaving for the Soviet Union.

June 11, Colonel Cutler's diary reveals, was spent "all day at work on

memo re blood, plasma, and crystalloids; all done."

"The purpose of this memo," he wrote General Hawley, "is to bring together all data concerning intravenous therapy for shock and allied conditions,

and to conserve the use of these precious materials (blood, plasna and crystalloid solutions) which are often misused and wasted at the present time." 36

Colonel Cutler listed for General Hawley all the directives which had been

published to date on blood, plasma, and crystalloid solutions; presented an

inventory of all plasma and crystalloids on hand, both American and British;

and reviewed procurement demands still outstanding on the British for these

items. Lie provided General Hawley proposed directives on the making of

crystalloids by general hospitals for their own use and on the economic use of

=• (1) Letter, Capt. R. C. Hardin, MC, to Col. E. C. Cutler, MC, 5 June 1943, subject: A Plan for

the Procurement and Delivery of Whole Blood for a Continental Task Force From the V.S.A. or TI.K.

(2) Letter, Capt. R. C. Hardin, MC, to Col. E. C. Cutler, MC, 5 June 1943. subject: Provision for

Procurement of Whole Blood for Transfusion In General Hospitals In the E.T.O.

sLetter, Col. E. C. Cutler, MC, to Brig. Gen. P R. Hawley (through channels). 11 June 1943,

subject: Tie lrocurennit sind vs#. or Blood. Plasma anti Crystalloid Solutions (Saline and Sugar)

for Intravenous Use In the E.T.O.
76 ACTIVITIES OF SURGICAL CONSULTANTS

blood and plasma by units in the field. Ile stated that the general medical

laboratory, when established, should also have as one of its duties the manufacture of crystalloid solutions.

On the matter of supplying whole blood, Colonel Cutler again referred

General Hawley to the basic tenets made in his letter of 10 May 1943; namely,

that a simple field-transportable transfusion set was necessary for bleeding

"on the hoof, and supplemental sources of blood were required within the

theater or the Zone of Interior. He submitted copies of the 10 May 1943 letter,

a revised and final version of plans for the field transfusion set, and letters

prepared by Capta in Hardin on the 5 June 1943 meeting.

In submitting plans for the transfusion set, Colonel Cutler noted:

1. The following TB/A for a Whole Blood Transfusion unit is the tinal product of

months of experimentation with Major Emerson and Major Ebert of the 5th General

HIospital.

2. In discussion with Colonel Perry we propose that if Field Medical Chests are scarce

the wooden boxes in which our U.S. Army plasma arrives would act as suitable containers.

3. Two types of units may be dispensed.

a. The complete unit as listed for teams going into combat area.

h. A unit for hospital use consisting only of those items not available in static hospitals (chiefly bleeding and giving sets with citrate and large needles).

4. We believe the officers responsible for this standardization, Majors Emerson and

Ebert. would be happy to assist in the original packaging.

Captain Hardin's letter reviewed the following necessities for any plan

by which whole blood could be supplied to a coontinental force:

Blood from tile Zone of Interior

Blood collected in the Zone of Interior can be delivered to the E.T.O. only by air

transport. The collection, processing. and initial delivery to a depot in the United Kingdom

would be a function of an agency in the Zone of Interior. Its reception, internal storage,

and distribution to the base unit and/or * * * transfusion teams would be the responsibility of the depot located in the United Kingdom * * *. The depot would necessarily

be located near an airport and would provide adequate refrigeration for the blood throughout its entire handling from the time of unloading the plane.

Collection of Blood in the U.K.

Blood can be obtained from two sources in the U.K.:

1. Base and SOS Troops.

2. Civilians (British).

The first * * * is somewhat problematical since the troops * * * are scattered over a

wide area and because the bleeding would take place during periods of activity when those

troops will be least available. The second source is probably the better. To put it into

operation would entail taking over an area in the U.K. where the civilians could be bled.

This area must be outside of the British Army Area (roughly Southern Command) and

* * * the London area where the EMS bleed heavily to secure plasma for drying.

Organization of such an area would include enrolling of donors and procurement of

bleeding centers. * * *

Bleeding Teanni.

These teams must be mobile and carry with themi all of the equipment necessary to do

one (lay's bleeding. Such a team when bleeding military personnel can bleed 150 per day
CHIEF CONSULTANT IN SURGERY 77

provided that a constant stream (if donors is made available. British teams bleeding

civilians average 75 per day.

Depot

This unit serves as a base from which the mobile [bleeding] teams ;work. It supplies

the teams with all the apparatus needed and maintains * * * vehicles. Records are kept

of the bleeding, apparatus [is] reconditioned and assembled, and blood [is] I)rocessed.

This includes serologic tests, typing, addition of glucose, and bacteriologic control. Here

also internal storage of blood must be undertaken, which requires the provision of adequate refrigeration.

Distribution to the Ficld

Behind any force there must be a base unit which draws blood from the depot and

distributes it to the shock teams. This unit may be small and simply concerned with

supply of blood or like the British unit be capable of producing crystalloid solutions as

well as distributing blood and plasma. It must be equipped adequately to be able to

recondition apparatus and carry out sterilization. It must also have mobile refrigeration.

Refrigera t ion

Blood is ideally kept at +30 to +6°C. It must not be frozen and undergoes considerable deterioration if the temperature of storage fluctuates greatly. Two types of

refrigeration may be used:

1. Ordinary refrigerator capable of maintaining the required temperature. This

type of refrigeration calls for fitting of airplanes and trucks with refrigerators. It is the

type of refrigeration used by the British Army Transfusion Service and has worked well

in practice.

2. Refrigeration by melting ice: Ice melts at +4°C which is the ideal temperature

for blood storage. By time utilization of compartment boxes into which ice and bottled

blood can be placed in separate chambers an adequate but simple type of refrigeration is

obtained. To utilize this to the fullest extent, lightweight well insulated containers could

be built to hold 10 to 20 bottles of blood. Such containers under ordinary temperature

conditions will hold ice for 72 hours.

Advantages: Simple, accurate refrigeration, with no machinery to break down. Dispersal of stores possible. Containers call be carried in any plane or vehicle without special

installation.

Disadvantages: Procurability of ice. Ice nmaking machines would be necessary in the

base unit and perhaps in the depot.'

In summary, Colonel Cutler had shown how transfusions could be accomplished by "bleeding on the hoof," by obtaining whole blood from the Zone of

Interior, by bleeding British civilians, and by bleeding U.S. Army service

troops. Each of these proposals posed an enormous logistical undertaking to

implement. It was certainly beyond the prerogatives of the Chief Consultant

in Surgery to decide which steps would be taken. Hence, his closing words

to the Chief Surgeon asked for "instruction to Professional Services concerning the method selected for supplying a Continental Task Force with whole

blood that we may assist in implementing such decision * * *."

I)uring Colonel Cutler's absence in the Soviet Union, General Hawley

approved the construction and assembly of the field transfusion units. At

his regular monthly conference with the consultants on 23 July 1943, General

Hawley told them that blood should not be transported from the United

SSee footnote 35(1), p. 75.
7S AC',t'IVITIE-'s OF S'IU;ICAL CONSULTANTS

Sttitt's.;" He di rec'ted tlint t he votistilt alit grolt) go flleild with I hi lnis foi- collect ion 1i11(1 ulist rihiltt on of bloodl 1and til~it tile BrIit isil he consuiltedl withI referencve to pre't'elv~it iol .1n1d storage.

Ini reply to tI quest ion by ( hnerall I Ia wlev Is to thle development. pro-

('iirenlielit, faind (list 'iblilt ilou of bloofld tnin:isftisioii kits for jinobile uinedivcal units,

his executive ofliver provided himt with tilte fol lowitng anlsfoers:

1. A b144ood t rainiftis hi eliest had I vice des ignedl an1d hai l Iiveti.pn apoved fo r 41leairinig

cInlipailt's. evaiciiat ion hosi 'tals. field hospitals. inad auixiliairy suirgical griuluts. 4 hllu hunidred oif ths ches' '1'ts were( leiving paicked4 at Medicai D epiot 4 -351. Clea ring ciompanfies and

evaielat olo ho spiitals werle to recelive 2 chests vacti, while livid4 holspitalis wlere to recelive

:1 chests, aild auxiia i iry suirgical groups. 14).

2. A sinailler iunit had:1 also. heeni designed whichi wa-s built around aI new quarternilast er

ittem known as the *iiiaiu pack catrrietr.- Two h iulni'dm Of thlese inai-pack-ea rriter. Wiooditranisfusioni sets wvere to i le assembilede as soonll as lithe pilot nioadef was aplproved4 .11141 the

quiartermnaster carriers lievatiie a1va ilablde. Two olf these kits, were to lie dlist ribultedl to

t'iih vo'ilect ing coumpany :and re-iunieltat Iinedli(al (letachlieInt.

:3. Thle stanl da rd. appj ro ve-d Iran sftiis oun bott les for bo4 th Iilt i chest s and4 Ihle mia I -j ackcaIrrier nitis were bh.iig assetiilileil ait the -ithI G,'uieratli Hospital!'

Mobile surgical units

Friomi his first dayIs ill WIAIsiingioti. ("ohmlel ( itle 1hi r-ea.lizt'uI tIil~it thle kev

to p)rovidinig opt itnitn i(art' foir lImt te e'astlaltie it'S i h gi tile sitllo t

tile wounded anul instead of bringing hlui back 1to thle surgeoni. This could

onl]y be levoillplisliedli e believed, by a1 tri'ily mtobile, self -vonlt a med surlgical1

te'ltn. At. eveurv opportlititity! lie 11.1d( disculssedl this possibility with thle Chief

Stlrgt'4)l.14 :ii iis col leagnes. both Briit ishi and1 Anierie-mn. ( )le of tlie first

luings lie iaul asked (of CGelierl' I lawl%-ey wa-s that. tile laItter r-equest. WA'.shiluzrtoni

for the issiguninent of an aiixil inry surgical groupj to the Etiropieain theater.

BYv early 1943, lie hail gminted considlerable explerienice inl current Armyi ways.-

anid felt. quit e ca1pable of copinhg With lthe problemus inlvolved ill com111ing forward

with specific recolintuetidat jolts for thle ol-galimzIt loll a11d t'qti lpuienit of .i silr-gica I1

tealit such as hie lind inl mind.

Ini enir FvIebrivry 1943. two thIiings lialpented which encouragred Colonel

Cuit leir to einhark itnuiiediitelY upo ti)4 1lie fornia.t ion of am1 illilt' surlgical te'li ii.

Ohil 16 Februn ry. heit' t Iended a session at the RANMC ( oh leg-e (lit ring which

Maj'l. ( eii. Da)vid C. '.1otirlo. RAMC. niewly .1pil~l4iited Conisultitnmg sittrgeonl to

tie Br'it ishi A rliv. gave a, 1 ilm11i-nut discoiirste o i his exp~erien'es oif 2 \ (ir~s Inl

"3 -There'ni Is stroli ng iti' lolleaIoi liti i'e arly part (fthe liii' niaisiriptl t hat li't'heCi'f $Ilrgiinl's

(limit lotriilii 1Is iif somei4 44f the iiitin'ittin of tile' voinstit antq we'ri' iiiri'Iy artiltra ry oid iiil ti~rli'liis.

Tnin t ruth 1-4 iIlint. t irouiiiihiii theii war. t lii' cili't Su rgi'on hatit top si'cri't hinto rinat oin wh ieli hi'# co~ili

noit mtikr ei 'vi'n vit ii ilts oi4'1411 tol toht 434 al 3 Of theiise nilveirse' di'ciiiis we'rei' l e iisi' iii in such'I

Infornination.

"Oneivi' 'xliphi ofi t is Is tle. aco'iiti:t lfth rlii'n.'utnioi' o elf t i ilecief stirrr,on early In tilei war

to litteiniult toiwi faIn witoli' mooiin froi n th' Zon mi .f In~te.rioir. Th li' tesioins for t lits wi'ri' (11 t hat thei

trnstlanintintIc airtlift at 4 hut titnle wo so IIinIlti'd. a1nil so ri'st r i'ild tio otIhi'r lirlonitIii'. that it con i41

not take lilt 14u('i a load:an 41(1 2) Ttii' Surgeonu (;ei'irai Iliniliiiii to ' 'the i'if stirgi'on tin tly that lie

wo401lit no t a pprovi'.- it.i't 4 ir. ho'lli It. flii Ii' M.Di.. to Colii. .1414111 Ioy I cii (4411i. .1 r.. Ni 4. 1T 75-et . i%-i~.)

-0(1) Oln'rutional Dirinitvi' Nio. 2S. oi111cc of' t ie (liiif st5irgi'mm, i. lr4 s.\, I01 Jolly 19!4:1. (2)

IA-tte r. (fit.i.ii .II mc i 'ii. NiV to Chu('ieif Sti rgeoin. ET )i' s.. *-I; .1ti13 1944:., subljiect :Stalum o f I 4i'ei'l mnient. Ilrin',rv'ii'ent anid D istribution elf utltloiiimi 'l'rnsinision K it fur 'Mobilei Medivaliil I'nit q. 4

)itirn I imo-i

Dir. =ý2S.
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S0 ACTIVITIES OF !SUIUI.CAT, CONSULTANTS

this area, thus precluding the transfer of American casualties to it. Moreover, this was the only specialized hospital in the theater, at neurolpsychiatric

facility with but a small surgical staff. Colonel Wright recommendled the procurement of certain buildings just outside of Truro and requested the assignmuent of surgical specialists to staffi d medlical facility to be activated there.

Colonel Cutler found many ob)ject ions to the plans submlittedl by Colonel

Wright. He p~rop~osed, instead. that the U.S. Army obtain from i1) to 20 beds

at the EMS Royal Cornwall Infirmnary at Truro, send a surgical team there,

and1, in recomplense, offer the services of the teami to the infirmary when it was

not fully engaged in treating U.S. Army Air Forces casualties.

FIGURE: 27.-Maj. Robert 31. Zollinger,

MC.

When t 11is suggest ion recei vedl General Hlawley~s app~roval. Colonel Cutler

asked Maj. (later Col.) Robert M. Zollinger. M.[C (fig. 27). of the 5th General

H ospital to work on a mnobile surgical unit with the following guidance ini mind:

(1) The equipment should not be built in a truck, (2) the equipment and tentage

should be for a mobile surgical team, such as a teami from an auxiliary surgical

group, and (3) the team should take all the materials necessiary for lighting

and for surgery to cover .50 to 100 major surgical casualties or 200 minor

caualt ieS.41

Aks things turned out, it was the ob~taining of beds ait the Royal Cornwall

Infirmary at Truro which prov)edl to 1bý the greatest obstacle to this program.

It. was only through the intercession of Colonel Cutler's close friends, Prof.

George (Task and Mr. Roc-k (Carling, that an allocation of 12 beds wits obtained

at. the. Royal Cornwall Infirmary for the hospitalization of U.S. Army Air

Forces casualties. The trustees of the infirmary approved Colonel Cutler's

p~lanl on 25 F~ebruary, l)It the space wats not immedliately availalble because repair

11Annual 114port. Chief Consula~tnt In Surgery, ETOUSA. 1943.
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82 ACri VITIES 0F SURGICAL4 CONSULTA NTS

0' April 1943, C'olonel Cuitler receiv-ed a, conunun illicat ion front the British War

Office, issued b~y the conisulting surgeonl, Genleral Monro, which q1uoted itemus

of information fromt thle Middle East theater Oil thle outstanding success the

field surgical units hadl encountered. GeneralI Monro, in commenting onl the

reports, agreed that. lighting was one of thle main prob)llemIs sinuce, as one unit

rep~orted, 80 p~ercent, of the work lhadl been (luring hours of darkness. A most

imp~ortant. point, General Monro noted, was as follow: "If F.S.IT.'s are to give

of their best, they mnust trhi? together' not oi#l, iii fleld exrerie'8 but f thiei

operatfliq theatre. Comnmands should( bie iiistructe(I to see to it, that. the

1F.S.F.'s 11ow molbilized in this country, relieve, as a team, one of the existing

surgical teams in a static unit, for a period of 3i to 4 week S.-4

Finally, onl 12 April, Colonel Cutler heard Genueral H ood, 1)GMS, British

Army, explain to at group) of miedical officers in the British Southern Coiiiaiud

the new organization of the RAMIC field medical service which currently

featured an adlvancedl surgical center. This adlvanced surgical center, comnlprisedl of a, field (iressing station, a field surgical unit, and a field transfusion

unit, had 20 cots and many litters and was to perform only urgent surgeryabdominals, sticking (-hest. wounds, wounds of the buttocks, and compound

fractures, especially in the joints. They were assignable oin the basis of two

per combat division.

Armedl withi this wealthi of recent, information onl the efficacy of mobile

surgical units in comb~at. pill,, (etailod and complete reports on the workings

of the team at Trutro, submitted Iuy Colonel Keeler and iMajor Zollinger,

Colonel Cutler dlictated at menioranmnl ill ated 1S April 1943, to thle Chief

Surgeon (throughi Colonel Kimbrough) which brought. ill) to (late hiis compiIlete

thinking onl the matter of mobile surgical teams for the U.S. Armly in the

European theater. The body of the memiorandum follows:

1. Introdluctoryi.

'This miemioralndumi oil surgical teamsi is aidded to I hose which have lire(Pded it becaluste

the needl for mobility in our forces is Increasing. and because of recent attempts to

reorganize the teamis ax they now appear in the Auxiliary Surgical Group.

2. The regrouping oif tennis !in the Auxiliary Surgical Grou wa s subt) itte to the

Chief Surgeon by Colonel Mason. In this. regrouping it wits iiiade clear that practical

exp~erience in this war had but corroboratedl the experience oIbtainedl in the last war,

that the surgeon in the forward area must hie at general surgeon. In the iast. war we had:

a. General surgical teanix. b. Shock teams. c. Splint teams. Tlisx resulted biecause experience showed that the general surgeon must bie the one to do the work in the forward area.

Also It was found ie( nieededl as it colleague somebody to hell) put onl the splinits when

conipiolindl fractures existedl. .Just as he( will today need such an ('xiiert colleague to put

on the plaster for imumobilization rather thani the Thomuas' splint used in the last war.

Also, if the general surgeon is to bie kept busy all the time at what hie is bound to do,

ILe. surgical ope-rations, lie( should have axs a further colleague at man trained lin resuiscitation and shock who c-an treat the cases bePfore an opieration and then care for themt afterwardsx. thus freeing the surgeon's time for contashnt application to his handicraft in the

omeritliig theater. This combination of experts needs highly trained personnel working

ait top spieed in their selectedl fields. and] accomplishes the maxiniuni overt urn of labor in

the shortest pieriod of timte. It would appeiar to ine that the Auxiliary Surgical (froup)

Ci~ismptel. The' War Offce, London, 2 Ap~ril 194:1, subhject: Fieild Vnitm FSU~ M.H.F.W.E.).
CHIEF CONSULTANT IN SURGERY 83

teanis should be re-organized on a balsis similar to the thinking above. In mny mind,

the best team would be one in which the surgeon was a general surgeon, the assistant

surgeon. however, an orthopedic individual or at least a surgeon properly trained in plaster

technique. In addition. each surgi•.al team would need a mnan traine(l in shock * * *

though I believe that where two surgical teams were out together to a single installation,

one shock teali niight care for the work of two surgical teams. The defect in tile

Auxiliary Group is that they only carry with them their instruments and would have

to he given all of the rest of the impedimenta of operating theaters by the hospital to

which they were attached.

":1. Mobile .xurqivial tacmio.

The use of the terin "mobile surgical teant" is coined to descrihe a setup somewhat

different to that above, for in this setup the team is to have its own transport and take

with it everything it needs in the way of professional supplies to cover the conipletion of

100 major surgical operations. This is to include lights, bandages, a shock team setup,

plasma, saline, basins to scrub up their hands in, soap. drugs, anesthetics, etc. Such a

teami could be sent at a inomnent's notice because it has its town transportation to any

point desired by the corps or airnmy surgeon. To my way of thinking it iuight best Ibe

placed at the clearing comutpany of a division, and the only matter which is not settled

in our minds is whether this mobile surgical group, with its team and shock men and

supplies should take its own temtage or not * * *

As stated in previous inenioranda, I am opposed to building in of the apparatus into

the truck, feeling that something might happen to the truck and thus immobilize the

team. If the material (-az be easily put into a truck and then taken out. then any truck

will suffice, and complete freedom and mobility is assured. The TB/A of such a mobile

surgical teani as opposed to the teams now organized in our Surgical Group is appended.

It is largely the system set up by the group from the 5th General Hospital. with changes,

both deletions and additions, as suggested in our Consultant Group and by our British

colleagues..

On 21 April 1943, Colonel Cutler conferred with General Monro and

Maj. Gen. Max Page, RAMC, at the British AMI), 39 Hyde Park Gate, London (fig. 29). Ile discussed with them the matter of tents for a mobile surgical

unit, a part of the plans which had not been firmed. He was also shown a

lantern which burned kerosene under pressure with a brilliance of some 400

cl). It seemed to be the ideal unit for providing emergency lighting for the

mobile surgical team in the event of power failure, and Colonel Cutler on

his return immediately ordered a sample unit for trial and study. Later that

week, lie was able, with the cooperation of Col. Charles E. Brenn, MC, the

U.S. V Corps surgeon, to select and set up tenting for the proposed mobile

surgical team. The feasibility of the tents for operating pavilions was tested,

part i('ularly under 'blackout cond itions.

In a letter, dated 6 May 1943, to General Hawley through Colonel Kimbrough, Colonel Cutler submitted ,omplete proposed tables of organization

and equipment for a mobile surgical unit ('omposed of a surgical team and a

transfusion-laboratory team. The proposed organization included:

For the .xur'q;itl temn :

I general surgeon, chief

1 assistant surgeon, preferably trained in plaster technique

1 anesthetist, officer or enlisted

3 operating room technicians, enlisted
,lillill, ' .l .L \ ,1.li ill IT ll,'i r " h n lo wi 1.\ ' l , I l I } i ,, l i l~ :1 l 1 L:t,' • II -, ,IllI,

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'34

i r

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cm-114-1. 11,4,41 1*,.1. lilt, 11-:111,114.1-1 4,11,
80 ACTIVITIES: OF11 SURlGICAL CONSULTANTS

was uised -%vith a few extra inlst ruments fromn Special sets for nieurosurgery,

ortlio1)edic sul-rgeryN (fig. 312), abdominal stirgery, et cetera. Inclulded also was

It compl)ete anlest hesia set, stock mnumber 93.512, enidotracheal, inhalation, intravenouls, regional, and spinal. 19)42 miodel (fig. 33), anld a Suct ion miachlme, colin1)Iete, stock imlunlber :)77.-) ( fig. 34). Exp)endables, such as dressings, bandages,

adhiesive tap~e, gauize, cotton,. platster, towels, sponges, stittire material, a nestlietics, niledicinlals. crystalloidls, and tile like, were packed inl quantities sufficient

for 200( surgical op)erat ions (fig. 35.

Thle tent (lecid( led 1101 for the operatinig theater was that known as a tent,

storagre, canmot-flaged, withl fly (figr. 36)). All p)ossib~le equipment and1( suppllies

for ell 1,-. -iuev sources of lighigimteyoeae laniternisand surgical lighits

an~l a2.5Zk .gsline-op)eratedl generator-were includ~ed (figr.:1)ThcoMoll oii-l)nrningll~ pot-bellied stoves were added for heatinig ltirlposes. Tlme finmal

list of supplies and equipment. Colonel Cutler advised the Chief Suirgeon, Was

mlade. ill conjunictionl with tile mjembhers of the ;-thi General Hospital who assi.4ted

inl tile prep)arat ion of the list and. had sonme further suggest ions after returning

from their temporary duty at Truro. Ile suiggestedl thlat the responsibility for

rep)lenishing suipplies of anyi lparticuilar' teanm wouild rest with thle parlenit unit

fromi which thle teamu personnl~e wvere (derived (for examplle. .ai, auxiliary surgical

grotiij), and tile parent umlit WoulId b~e based for sup~ply supp~lort onl a field army.

Onl Tuesday, 18 'May, General Hawley and Colonel Cutler journeyed to

the 5th General Hospital and held a showdown insp~ect ion of the umobile surgrical

unit as constitutdc~ inl the 61 M[ v letter to tile Chief Smrgeon. After their return

from the hospital, General hfawlev and Colonel Cutler had a long talk onl tile

p~rop~osedl unit. General Hlawley's ol~inions follow:

1. The .5th General Hospital should assemblle in Salisbury (where tile

hospitai was located) all the equipment finaily selected for a mobile surgical

unlit.

2. Thle 5-thi General Hospital should secure still andc moving pictures of this

unit. inl all phlases, including p)utting ill) tents and operating up1on1 a patient.

3. Officers inl the i5th General Hospital should write ill) separately how tile

unit functions as a whole and how the transfusion-laboratory team is to function.

4. The equip)ment. for a single mioibile surgical unit should then be tranisferred to the 31d Auxiliary Surgical Group after they have been tauight how it

functions, imeicludiiig the pulttinig upl and taking (lownl of the tents.

5. It will be tile responsibility of the 3d Auxiliary Surgical Groutp to teach

the rest of their teamls this saile miatter and to teach inl thle Medical Field Service

School lit Shrivenhiumm, if that was desired.

6. The hieadqu1arters of the auixiliary surgical group should acquire facilitfies for sterilizing dry groods so that, as the parent organization, it could keep

thle (1ispersedl un its supl)liedl wvith mnateri alS.43

13Letter. Col. B. C. Cutler. Me, to Col. J. C. Kinthrough, AMC. 22 MAny 1943. uhiject : Further

Regardling Mobile Surgh'iai Unit.
('1111A.' ciiNSVIA'ANT IN SI 101111k)l

Ale,

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FmIa;.1v 311;-P--il rinhiia.1 a oller-.1 ill" ro4oll Iteni of' a inldlobl sil-ic:e1 lilliji

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phial pior to IIti to th111V S.L ( 'olonel ('111T Wher Za INe to I'VIe)4)1 10 tilt'

C'IuIIef Sutr1zeon bY l etter, oil 1.)* J itne 1943. 1 lie fhllowvil.r:

Certain chaluiies IIIve' Ilveh tIllade ill the '1'lA sultiiit led 14; May 1943 . anid we liow

subiii11it L'TBA ill tiall1 forml after. repleated 4'xileri rIletat iq Il ill jlaekiluii1Z and i t lnjackill- and1

exeME'titiviel at iq Ill wvit 1i ('111 s.

M ItI Iy I dII)(In ItIoil;. s tia lievei. 14ýIII:I ket I I if I the I IhIijt 4111* 4j~jlig 1 1tfoe4('v4' of . sseinIit1lY

A tilmi inelulidi; Ohw sett tlug till operation .uItd tlikin,. dowt oif thet tunit. has bieen itade1t an1d is

now Ilin'tg 111ui ill order bly Ihte Sigunal C orps. :1n11 shiouldt a lso Ill ilk your. hall Is shortly.

U.. (,ot. Hobpert zottitigelr NN-11 has teenl v\1.'xI.iruieit ing, with thlis priititetii und1(er 111r1

gubtlanie. Since Februiary 19'43. is writling til the compiile.te 1111111lioring tinutllt .f In t he

hopve t hat You will Send this back toThe (eirltr forEt his ilitorillat ion aind purt1ltical iont.

We have arrti1:1grell with Ni Majorl lisatu1i. 1Wt'4.t IMedica~l F'ield Servive SetI,,Eo. I h1t11 hlis

unlit the demnitst rated as a1 tart o~f Ilii, exervise's ill tinv next etas~s,'s

Whtile lhe priniciples of :ssembil. tur lie tttvetssitt'Y equipilentf lor Ilie ýttIppl .v

of a ,tutnlical teatni itr tilie perfotmnatn11e of at1 lean-t a1 httuidred matjor' opertittonls

was~ followed 1) N atixi I atrv ott' roltl lt)tj. it X\-tI rat tt'l. ii 1, evvY. 1VTitC'SS:1tV 1'o r a

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MiZl.t onIIl ol letditiý(194A)II

1gi ig'. atnd otlier hetv Iupluilnuet. f.t'uct eitnt-s Invau'ilalll utilized the

f:14-ihitiil- of l't lie utit lo whvlth hley Nv ere ;ttt:tchtedl ltt1 I.,. lit'ld attd evV.actt:tI to
CHIEF CONSULTANT IN SURGERY 91

1⁄2 j

FIGURE 37.-Portable operating light, equipment of a mobile

surgical unit.

FIGURE 38.-The arrangement of the operating tables of a mobile surgical unit.

705-095'---4----9
92 ACTIVITIES OP SURGICAL CONSULTANTS

hosp)itals. The teams (a rried with them and frequently utilized certain surgical

instruments and other small medical silpply items organic to the auxiliary

surgical group).

Surgical mission to Union of Soviet Socialist Republics

Background.-Colonel Cutler, in a memorandum, dated 15 January 1943,

advised General Hawley as follows:

Some months ago when you were ill. I attended a dinner given by Mr. Broster. following his first Inter-Allied Medical Meeting. In responding for you I thanked President Tidy

and the group in the Royal Society of Medicine of our colleagues for all that they have

done for us. I then pointed out what I thought might be the value of all the Allied people

getting to know something of each other. At that time I said I was greatly concerned that

I had been unable to meet a Russian, and I thought this was a pity. and wondered if there

are any Russians in London. Sir Wilson Jameson and Sir Alfred Webb-Johnson and

other people who knew all about the Russian difficulty, and that a British hospital ship

had even reached Murmansk and had been turned back again, were much upset. They

have talked to ine repeatedly about this, and apparently had been to the Foreign Office

again. I learned yesterday that a request might shortly be made for three British medical

officers, and three American medical officers, to visit Russia. I thought you should be

apprised of this possibility early. It appears to me that a country who must have had

millions of casualties should be able to teach us a good deal about military surgery and

military medicine.

Colonel Cutler's diary states, for 21) January: "I'm getting worse at this

[keeping up the diary], just when it is getting interesting. For example,

Russia. I have long b)een worried I couldn't find a Russian. I've spoken of it as

a reason for the Inter-Allied Conferences. I spoke of it at a dinner with

Fraser, Sir Wilson Jameson, Sir Alfred Webb-Johnson, Dean * * * of the

Graduate Schools, and Broster (his dinner). As a result, I now have a coinmission of 3 British and 3 American medical officers to be asked to go to

Russia.-

Colonel Cutler had just returned to Cheltenham from a trip to London,

Basingstoke, and Chatham on the morning of Saturday, 10 April, when

General Hawley called him to his office in the afternoon and instructed him

to see the U.S. Ambassador in London about the trip to the Soviet Union.

Dutifully, Colonel Cutler turned around, went back to London the next (lay, and

saw John G. Winant, U.S. Ambassador to the Court of St. Jlames's (fig. 39),

in the late afternoon. On 16 April, he reported on this meeting by letter to

General Hawley (through Colonel Kimbrough). A portion of this letter

follows:

We discussed at great length the rumored joint medical mission of British and

American service personnel to Russia. Ile reported previous discussions re Russia and

happenings in Russia that bore small relation to this problem. IHe reported the Typhus

Commission was turned down. * * * The urgency of the matter was again brought to his

attention when I told him that on April 16 Surgeon Rear Admiral Gordon-Taylor was

lunching with M. Maisky, the Russian Ambassador, * * *. and that members of the

British Commission were now Instructed to get their passports. (British Commission

headed by Surgeon Rear Admiral Gordon-Taylor, other members, Maj. Gen. Monro. Mr.

Rock Carling.) Finally he promised * * * to see M. Maisky, Mr. Eden, and Sir Edward

Mellanby [on 15 April], and give you a final report.
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ClIllEF CONSI'LTANT IN SURIIERY 95

passports were obtained oln 11 May. O(n 13 May, Professor Sarkisov, an

assistant to Academician Burdenko, arrived in England from Vladivostok

and was introduced at a luncheon held at the Royal College of Surgeons. He

gave the most comforting assil:ance that the mission would, in all probability,

be warmly welcomed in the Soviet Union. And, finally, word was received

that Prof. Wilder G. Penfield of McGill University, Montreal, Canada, would

be added to the mission.

There was no further clarification, as of 15 May, as to when the mission

would leave. But, with the arrival of Professor Penfield, the membership

of the mission was complete, and amenities preparatory to departure continued

at a high ipace. As an example, on 24 May there was a luncheon given by the

British Council for the mission at ('laridge's in JLondon. There was also a

serious talk with the U.S. Ambassador on what to do and not to do while in

the Soviet Union. Finally, there was tea at the Soviet Embassy, 13 Kensington

Palace Gardens, given by Amlbassador Maisky. With respect to the Soviet

ambassador's tea. Colonel Cutler's comment was: "Tremendous." As to the

meeting with Amlbassador Winant, Colonel Cutler reported as follows in a

letter to Colonel Kimbrough, dated 30 May 1943:

* * * lie gave Colonel Davis and myself explicit verbal instructions. but s-1aid he (lid

not wish to give us anything in writing, emphasizing that we should use our own diseretion,

and hoping that we would get on well with our Russian colleagues. The latter was emphasized as highly important, since if this mission is happily received others of great importance may be allowed to follow. 'ambasmador Winant made it very clear that the

instructions to which we should adhere closely were to discuss nothing except professional

medical matters. lie emphasized this point by stories of diplomnacy wrecked on the rocks

of missions going beyond their protocol. lie urged us to take anything with us that could

enlighten the Russians on American surgical methods, and hoped we might bring back

matters of Importance to our people.

The Ambassador also promised Colonel Cutler a list of American diplomatic

officials in the countries through which the mission would travel en route to

and from the Soviet Union.

Soviet motion picture.-On 31 May 1943, Colonel Cutler was privileged

to see, at the Soviet Embassy, a motion picture depicting the care given the

wounded Soviet, Army soldlier during his evacuation from the front to tile rear

and through his rehabilitation. Ills account of the film showing in a letter

to Colonel Kinibrough, dated( 5 June 1943, follows:

This was a Ibattle picture and most interesting. Soldiers were picked up on the battle

field and given preliminary First Aid by a trained first aider. They then passed through

battalion and divisional aid posts and to hospitals similar to our surgical hospitals, where

definitive surgery was ca rrie(l out. ('ertainly a great attempt was made to give as adequate

(care its possible, mid every effort was miehe to restore the soldier to active duty as soon as

possible.

The most imlprtant olbservations of interest to me were:

The usc of erother i n the forward area. Women were even In the divisional aid posts

of casualty clearing companies, and from the expressions on soldiers' faces, even without

the spoken word, one felt sure that. their presence was of great moral value. * * * (claning and bathing facilities. Here, the Russians,. whom we have not thought of as

a clean people, can give all of its a very gosl lesson. They had excellent bathing facilities
96 ACTI VITIES (IF SAURGICAL CONSULTANTS

inl their iiioit forward hospit als. and1( spoke of1 such facilities as equally impoortant to good

surgery. * * *

A1ir transIporlt. This was greatly emiphasized l fipi thelin. anId is used inl the care of

wounided aniongst the guerillas. which is it part of the( obligation of the Russian Medical

Corps.

"Like politics at home."*-Th'e motion picture servedl to increasee thle

diesires of tile mnission members to see thle Soviet medical service first biand, but

tile act-t nd (epart ure was not to hie for quite some tinie. Partially, perhaps,

as a result of 1this initermlinlable waiting, the solidaritv amlong thle members

became st rained. By the time 131 .Juie arrived andl the mnission was still awaiting travel inlst ruct iaiis, Colonel Cutler was quite concerned. So, apparently.

wvas General I lawley. for lie called Colonel Cutler by telephione and asked himi

about thle situnat ion. nI'ere were varyinro claims as to blow thle mnission bad

originated andi who was resp~onsib~le for its establisbiment.. There was a, questioll as to whot was going to hlead t he mission. Instead of thle senior mnilitarv

members front the I nlited States and thle U nitedl Kingdlom, there were strongi

indlieatiauls that Coloiiel IDavis wvas bvini&r selected to rep~resent the National

Research Co'unucil of (lie U nited States and that Mr. Ernest Rock ( arliing

wotild relpresent thle British 'Medical Research C ouincil.

-Real t rotldbe is ]iiv worry aver tilie R'ltss~ia mi! i.i 1.i2 lie diary entryW for

13~ June reads, "Hlave warniedl ( enera I IIa whe d C . Spiullt-I le whale lhing

is loaded with di lviiamite.-

Tile following inkling of thils warning is mlentionled inl tile diarY on 17

Junle:

C'onference wvith Ambassador. 2 :341 I'M. and thenm witlh General Hawley. General

Hawley is to see the Ambassador at 4 :30. No dlefinite news. bout 11111 wrote our orders:

"To help Gordon Gordon-Tity br. head of mission,. and to carry out mmission's protocol

* *." Also. I saw lI'lIs wvire to Tihe Surgeon G eneral iwrit ten after phione call with

mie 2or :~days ago). Stated:

1. Mission amrraniged by British

2. Amnericani mmemmbers inivited by British~

3. Professional pirotocol 4 not miilitary)

4. Advises agaitlst further powi~ers miuxing into0 this.

Thie niext day, F~riday. IS .1Jille, (Colonel Cuittler reviewed General Hlawley~s ineet ing wvit Ii Ambassador Winanitas follows:

Sit'. Genemrnl Hawley aufter be saw Ambanssador Whinant. As I thought. tile Anibassamdor wants Loyal I D~avisl to represent National Research Council inl inufti. General

Hawley told the Ammbassador t hat was a miistake. Thie Ambmlassador asked if hie could

go to D evers ! O f course. Genmeral Hawley said yes. Genieral Hawley also saw at letter

froumi Edlen saying we leav e ill abouit a1 week via 'a iro. Good.

So Strong was t his rum11or aboout miembers of the mission go)ing to tilie

Soviet. Uimon inl imutift i that Admiiral Gjordoim-Trallor had1( grone to Surgeon

Vice Admiiral S. (Sir- Sheldon) 1)idlev, 1)(rMs' Royal Navy an9 a se

huimi aboult it. Sir Sheldonl had Simplyu~ stated t hat Adllintira Gordon-Taylor

wouiltl mo inl tniliforil or else lie woulld nlot gorat atll.",

'L .. ttf-r, Sir (vordmin (wmnqlon-Tnaylor to I';oil It. lliwlnwk. ALi .. 9 Od',lupr I il.-Pi
CHIEF CONSULTANT IN SURGERY 97

Finially, on Sunday, 20 June, after receiving a mnessage from Mr. Carling,

(Colonel Cutler felt Constraiinedl to adiniit that it was all "too bad-like politics

at hoine."

Departure.-The mnission finally departed onl 28 June 1943 with the military members in uniform. Admniral Gordon -Taylor, as one of thle two ranking military members of the mission and representing thle senior British

service, the Royal Navy, had been officially recognized as the hlead of the

mission. Colonel Davis had been confirmied as the representative of thle

Committee for Medical Research of the National Research Council, U.S.A.:

Mr. Carlinig, as the representative for the Medical Research Council of Great

Britain: andl Professor Penifield, for the Medical Research Council of Canada.

M1r. Watson-Jones was g~oing, as ac ivilian consultant to the Royal Air Force.

General h1awley had ap~provedl thle taking of 2.000,000 units of penicillin

from the stockp;ile at thle 2d General Hospital as a' grift for the Soviet peop~les.

And, finially. all official papers wvhich were to be taken by thle mission had

beeni censored and sealed .4"

Desires of mission expressed.-The mission, upon arriving in Mtoscow,

was (lelavedl in getting about its business for reasons unknown. The members

of tile mission took tilie opport unity to compose a ilieilioraindliim to thle Soviet

authorities on its intents and dlesires, as follows:

The D elegation of Amnericant. British and Canadian surgeons wishies to thank the Soviet

anthorities for hiaviung so kindly made pjossible their visit to the Soviet Un~ionI and hopes

during its stay to study the nmethods used by Soviet surgeons in the treatnment of battle

casualties, reports oin the success. of which have mnade so deep anl impression on the

medical authorities in Canadam. Great Britain and the United States.

The study of the methods used by Soviet surgeons- for the treatnment of fractures

caused by Avealions of war is the primary object of thle Deplegationi.

The second object of time 1)elegation is to confer (on Professors Burdenko and Yudin,

who are knowni abroad as, two of the most (listi nguishe(l surgeonis of the Soviet. Union.

Honorary Fellowships of thle Royal College of Surgeons of Englaind and( Honorary Fellowships of the American College of Surgeons.

As regards the secondl of these objects, thme D~elegation is anxious to come to anl agreemient with the People's Comnmissariat regarding time dlate and place of the ceremony

at which the Fellowships will be conferred. The Delegation trusts that the ceremony

will he conducted with due dlignlity and publicity and that the People's Commnissariat

will agree that the diplonmatic representatives of Great Britain and thep United States

should be invited ito attend. For purponses oif record in ('reat Britain and the United

States it would be appreciated if the cereniony couild tie photographed and prints made

available to the( D elegation before its departure.

As regards the first object of the mission. the( study13 of Soviet methods of treating

fractures causedl by wveaponis of wvar, the( I)plegation trusts that it wvill be given opportunities of seeing time work oif Soviet surgeons at all stages in thep treatment of battle

casualties, and that each member of the D elegantion will lie able to (liscuss wvith Soviet

*'.An acemint of the obse'rvationls of Lt. Col. Loyal Daivis, while he was en route to the Soviet

Union, his comnmentary on activities engaged in while hie was in that country, and his remarks concerning the return trip comprise pages 420-4:39 oft this volume, Any personali papers whiceh Colonel

Cutler may have nmaintainedi duiring the trip to time U.S.S.R. were not available to the compilers of this

chapter. Thie fullm official report prepared jointly by Colonel Cutler and Colonei Davis is added to this

volume as appendix A. It should be referred to as an Integral part of Colonel Davis' chapter as well as of this chapter. JT. It. C., Jr.
I9S ACTIVITIES OF SUHIWI&AI. ('()NSUI~irAN'rs

surgeons specializing in his tield the piroblemis iii which hie is particularly interested.

The D~elegation believes that this could best bie accompjlished if facilities were granted

for visiting forward inedlcitl units. inspiect ing methlolds for the evacuation (if the wounded,

and visiting hospital units. medical institutions a ind rehabilitation cenitres in the( base

area.

The* 1Delegat ion, in addit ion to fulfilling the t wo basic objects dlescribed( above, would

he glad to learn of any (other surgical procedures which the Soviet aut horities may

consider of interest in the treatment of battle caksualties. and the nmemnbers of thle 1Delegation, if requested to do so. will gladly furnish any iniformnat ion which they may theinselvest possess.

The British miembers oif the D elegat ion have beeni requested by various medical

orgainizations in the U'nited Kingdomn to piresent to the Soviet authorities at list of medical

questions which it has not been possible to raise hitherto owing to thle absence of any

convenient channlel of conmmunicat ion. Thme D elegation wvould lo be ost grateful If facilities, could bet offered to its inemnlers to study these questions during their visit.

The D~elegation hits brought a nunmber (ot publicationls and photographols which may

be of interest not mnerely to individual surgeons. but to the Soviet medical authorities

in genetraml. whoi ay already haive been made acquainted with I hein by their representat ives abroad, such ats Professor Sarkisov in (Great Britain and Profes~sor Lebedenko

iii the Unmitedl States. T'he D~elegatIion would be glad to learn whether books anid jotirnals

of this nature are oif assistanice to the Soviet authorities and if so wvhether the Soviet

authorities would like to be regularly supplied with similar publ icat oions.

The D~elegamtion hats brought 2,000,).(I units of Penicillin wvhichI thle United States

Medical Corps wish 1t) present to the Soviet inedical authorities.

Certain members of the D~elegation have also brought at numbewr of new surgical

Instruments for p~resenitationi to the app~rop~riate umedical authorities at the discretion

of the P'eoplle's Conmmissariat.

Several members of the D)elegation carry with themt letters of introduction and

greetinig addressedl to prominent Soviet surgeons. They wvould bet grateful for advice

as to the correct procedure for transmitting these letters to the( adldressees.

A nuniber of members of the Delegation have also brought in their individual

d'npzmcities certain puiblicaitionls (411 surgery wvhich they wvould like to present to individual Soviet surgeons interested In the various fields (if surgery which thle publications

cover. In some instances the menmbers oif tile D~elegation have in mnind the Individual

Soviet surgeons to whom they wvish to present these publ Ica tions. In others they would

welcome the advice of the P~eop~le's Commnissariat regarding the most suitable candidate

for presentation. In bo0th cases the advice of the People's Coummissariat is sought

regarding the procedure to be followed.

The Ministry of Supply have requested tile Soviet Trade De-legation ini London

to clear uip certain questionms conniected with imedlical suppllies ordleredl by the Soviet

authorities. While not wilshing to dluplic'ate their request for elucidation of certain

items which they have not properly understood. tile Ministry have informed Mr. Rock

Carlling of the points onl whlich they requnire further Information. amnd Mr. Rock Carling

would be glad to discuss these points with the competent Soviet autihorities if thle latter

should consider It desirable. There are Iii ad~ditioniione- or two other (iluestlolls of detail

regarding medhical supplies to the Soviet Vnion whlich the D~elegation Is antxious to raise.

Genleral Mionro ha~s burought with him certain mnemoranuda regardinig thle work of the

Directorate of Army Psyc'hiat ry. If the Soviet military autihorities are interested In

this branch oIf medicine lit- wouuld bet glaid to imlake ava'iilablle to4 tmemin the nmaterial which

he hats brought with hint.

L~astly, If t he Soviet authorities should wvish tto (lismcss question41s 4)f mntetlicl research

or exp~lore the possibility (if establishing clo~ser tinedical 1i1ii54411 betw~ee'n the Union of

Soviet Socialist Republics andl the countries repr'esenmted 1)y the D~elegation, the Delegation

would be glad to disc'uss thlese qluestlions with theumi. The surgeons wilo repiresent tile
CHIEF CONSULTANT IN SURGERY 99

Surgical Conmmittee of (1) The Medical Research Council of Great Britain M31r. Rock

Carling) : 2) The Committee for Medical Research and the National Research (1ouncil,

U.S.A. (Lt. Col. Loyal Davis) ; (3) The National Research Council of Canada (Prof.

Wilder Penfield) will also gladly discuss the work of these Committees and the methods

by which surgical information is now being exchanged between these three countries for

the use of the various combatant services.

Investiture of Burdenko and Yudin into Royal College of Surgeons

and American College of Surgeons.-One of the hlighpoints of the delegation's visit to the Soviet Union was the conferring of honorary fellowships

to Academician Lt. Gen. Nicolai Nilovich Burdenko and Prof. Serge S. Yudin

in the Royal College of Surgeons and the American College of Surgeons.

Academician Burdenko occupied a position in the Soviet. Army Medical Service equivalent to that of chief consultant in surgery. Professor Yudin had

been outstanding for his surgical accomplishments at the Sklifossowsky Institute. The investiture of these two eminent Soviet surgeons into the American

College of Surgeons was accoml)lished by Colonel Cutler and Coloilel Davis.

The formalities were preceded by the following address presented by Colonel

Cutler:

This gathering is momentous. We doctors now signify to the solidarity and common

purpose of a majority of living peoples. The occasion justifies the hope that this junction

of our races is but the beginning of a friendly and cooperative liaison for all time. As

a token of this spiritual union Colonel Davis and I are empowered to grant Honorary

Fellowships in the American College of Surgeons to two distinguished Russian surgeons,

a function which heretofore has never occurred beyond the confines of our own country.

We congratulate ourselves that in this tumultuous world men of such eminence have

found in service to the State a way of life that brings satisfaction to all.

Academician General Burdenko's acknowledgment (fig. 41) of this unprecedented and unique honor of being made a member of both these great

organizations simultaneously and on soil foreign to the sponsoring organizations

follows:

I am deeply moved by the honor of electing me member of the American College of

Surgeons.

I understand this honor as a generous approval of my papers and my work in the

past and present. It makes me think about my work in the future, particularly now when

the fight against Fascists has reached a decisive stage.

I recognize this election to be of deep and wide meaning.

The last decade has shown that the United States is now the center of medical science,

and scientific problems are to be solved from the point of view of American science.

During this year I have received very many proofs of attention from the United States.

My contributions to world science and field surgery are but modest. It pleases me to

share this great honor with all surgeons of my country.

The acknowledgment by Professor Yudin (fig. 42) of the honor bestowed

upon him follows:

You will easily understand my animation when immediately after one high honor

the surgeons of a second great Allied country-the U.S.A.-bestow on me another.

705-0951-64---10
100 ACTIVITIES OF SURGICAL CONSULTANTS

Illustrious Colleague,

I am deeply moved by the honour of electing ve

bember of the American Surgeon Society.

I understand this honour as a generous appr,val

of miy papers and my work in the past and present.

It makes me think about my work in the future,particularly now when the fight agaimst fascists has

reached a decisive stage.

I recognise this election to be of deep and

wide meaning.

Last decade has shown that the United States

is now the center of medical science and scientific

problems are to be solved from the point of view of

American Science.

During this year I have recei-ved very many

proves of attention from the United States.

My tributions to world science and field surgery are but modest. It tends me to share this great

honour with all surgeons of my country.

Yours very respectfully,

Academician ,GeneTal

FIGURE 41.-A copy of Academician IA. Gen. Ni.olai N. Burdenko's .peech ulmn his being

mnde nl Ilon,,rary Fellow of the American College of Surgeons.
('HIEF C'ONSULTANT1 IN SURGER1Y 101

I know little of your beautiful country. I atil proud of my persoanal acquaintanceship-and even friendship--with George ("rile, Howard Kelly, tilt late Mayo brothers,

and some other American surgeons of world fault.

Hutfl could I dream 15 years ago that the timae Nvomuld come when I should not only

b~ecomle an honorary fellow of the( Amiericoan College of Surgeonas, bult should also receive

my degree andi this majdlonia fronm the hands of the great Harvey Cushitng's successor.

BY thle wvay it is an1 astonishing faict that the( day of any deocoration by 'he Allies

comipletely coinlcides with the day I Wvas severely wvoundted by a German shell onl the eve

of JTuly 15, 1915.

For the sevowtl time in thet samie quarter of a centur'y our naatiumns are united in their

hard efforts too save their count ries andl the wvorld's civilization. Now, just as it was the

first tim~e. wve are fighting with thle saine eternail dangerous eneinv-(erinany. But ats

it wvas onl the first. ovcasiolt, our British Allies are fighting again onl our side.

Vict ory wvill he ours. Nobody has any (doubts about it, even our enemies. Let our

scient ific relations wvhich have begun iii a time of such strained military needs get stronger

anti flourish more and more after this victory anid the wvon peace.

In the timie of struggle. surgery is as necessary for victory as arams, transport, andi

all kinds of supp~lies. But when thme last. gun of the enemny ceases and released humanity

t urns with hlol~e to thle restoration of great destruction caused by the wvar, we surgeons

wvill have to heal thme wounds and] injuries of hundreds of thousands of people, w~ho have

wvon for us this victory.

Your high election of mae as honorary fellow of tlte American (College of Surgeons wvill

serve as a ntew additional stimulus for further dlevelopmenlt of my scientific work in surgery. which has already received fronm you such high estimation.

I once more deepl)y and~ sincerely thank you.

The official acknowledgment. of this ailspicious evenit onl bliehtf of the SOviet, Government was made by Vice Commnissar Kolesnikov, who said:

The admissiona today of two outstaniding Russian surgeons, Academician Burdeniko

nd Professor Yudin to the honorary fellowship of the Royal College of Surgeons of England presents itself to us. witnesses of this act, as an occasion of great cultural and political meaning.

TIhe Royal College of Surgeons of Englaind since long ago has beeni famed as anl organtization, responsible in not small way for the (level ofpmen t of surgery both in Englan1d( and

outside her boundaries. Amongst the fellowvs of this College have been, and are nowv

somre (of the outstanding representatives of English surgical thought. The greate~st exponients of surgery of other countries halve earned the honor of being honorary fellows

of this College. since its creation, in ai'tordlaace wvith its established and glorious traditions.

Onl every occasion the selection of honorary fellows aniongst foreign scientists has been

anl unbiased and just appreciation of their really great technical contributions. Therefore,

selectioni to anl honorary fellowship of the Royal College of Surgeons of England has always

beena a distinction in the eyes of the world's scholars. Similarly, the glory of the American

College (of Surgevons is wvell knowvn.

We are, glad ira the knowledge that, today, tile choice of the Royal College of Surgeons

anmd the American College of Suirgeons should have faillen on thle. two b~est. representatives

of our native surgery. Both time newv honorary fellows of the Colleges, Academician Burdemiko amnd Professor Yudin, a re deservedly famned in our country, all(] outsi1de her boundaries,

ats leadinig experts in the realmn of their specialties. Not for nothing are they bothI worthy

of the highest scientific decorationm of our country-the Stalin Prize : wvhilst Academician

Burdenko with honor holds the title of Hero of Socialist Work.
102 ACTIVITIES O SURGICAL CONSULTANTS

C manca ,NffJW3NSOU 'c it•u ica.

Colonel Cutler, Gentlemen,

You will easily understand my animation when immediately

after one high honor the surgeons of a second Great Allied Country

- U.S.A. - bestow on me another one.

I know a little your beautiful country. I am proud of

my personal aoquantanoe - and even friendship - with Geoge CRILE,

Howard KELLYthe late MAYO brothers and some other American surgeons

with the world fame.

But could I dream 15 years ago that time would come when

I should not only become an Honorary Fellow of the American College

of -urgeonsbut also should reoieve my degree and this diploma from

the hands of the great Harvey CUSHINGtS successor.

By the way, it is an astonishing fact that the day of my deooration by the Allies completely coin-ids waith the day I was severely wounded by a german shell on the eve of July 15-th 1915.

For the second time in the same quarter of a century our

nations are united in their hard efforts to save their countries and

the world's oivilisation.Now, just as it was for the first timetwe are

fighting with the same eternal dangerous enemy - Germany. But as it

was on the first oocassionour British Allies are fighting again on

our side.

FIcURE 42.-A copy of Prof. Serge Yudin's speech uipn his being made an tIonorary Fellow

of the American College of Surgeons. The letterhead Is of the Sklifossowsky Institute.
CHIEF CONSULTANT IN SURGERY 103

Victory will be ours.Nobody has any doubts about it, even

our enemies...And 1 et our scientific relations which have begun in

time of such strained military needs,get stronger and flourish more &

more after this victory and the won peace.

In time of struggl surgery is as necessary for victory as

arms,transports and all kinds of supplies.But when the last gun of

enemy will cease and the released humanity will turn with hope to the

restoration of great destroyments caused by the war, we,surgeons will

have to heal the wounds and injuries of hundreds of thousands of

people,who have won for us this victory.

Your high election of me as Honourary Fellow of the American

College of Surgeons will serve as a new additional stimulus for

further development of my scientific work in surgery,which has already

received from you such high estimation.

I once more deeply and sincerely thank you.

FIGURE 42.-Continued.

The ,outstanding contributions of Academician Burdenko in the development of neurosurgery, his brilliant experimental work, and his elaboration of the basic principles of a

new type of field surgery, which have proved so brilliantly successful in the present war,

make us certain that lie will be a worthy member of the glorious family of the finest representatives of c.intenipjorary surgery that. is combined in the Royal College of Surgeons

and the American College of Surgeons. Professor Yudin will bear the title of Fellow of

the Colleges with equal honor and worthiness. His name is tied with great successes in

abdominal surgery, in plastic operations on the alimentary tract, in blood transfusion, and

In the prophylaxis and treatment of infected wounds, etc.

Wt.. the represeiutatives of the family of Soviet. medical workers, are todity justifiably

proud of the great honor bestowed on Academician Burdenko and Professor Yudin. At

the same time we express our sincerest appreciation to the Royal College of Surgeons of

England and to the American College for this mark of distinction. In the name of the

People's Commissar and In our name I ask you, Mr. Vice-President and Colonel Cutler,

to convey our thanks to your organizations. In the name of the People's Commissar and

In our name I congratulate Academician Burdenko and Professor Yudin on their selection

for the honorary fellowship of the Colleges.
10)4 A(l'TIVITIIE 411" ST(1t1'AlI (CONSI'LITANTS

Today's (.c(.asiiol tlakes lavl('e ill days of iltter warfairt, aigainslt the cruel enemiy (it

pirogressivetness -litlhr's Fi' isiiin! Ihi this war. our inedivaIl teichiltng hias extitesivtely

beioe tit(n emlthit I g if wia r ind ictie, anl it helpis onur arimit's in their strulggh, ag gle .st this

ertiel foe. 'tll(e iitlitilsslotl Of t lie Illost flliills Ktiviet scit'tists to the( holloltrry fellowship

of the ('olleges intarks in itself ; strengthlhenintg of the svientilh" ties lietlweett lihe allied

inatttions. I till certain thait those ties will sIretigthien further ill the con itnutattion of this

stlrugghl to ti comllet e victory over oitu"r t*( oniio'll etlle lly.

Summary of observations on military medicine and surgery in

UT.S.S.R,--( )n their ret tint to tile I'n ited K illgdolo, (Colotnel ('tit her a l Ctdolnel

D)avis plrepla,'ed jointly It concise SUtImInv'. of their fill rel•ol't (aplplendix A,

1). tJ:3) for (General ll wlewhI. They asked tlhat special cotnsidettititi le giveui

lhe followitig topics .iet'an.se they alppealred to Ibe of v'hief vaihue to the Medic'al

l)epnll'tilttlt ot t hie I '.S. Arty.

('Cre of thi, ligltlhi troundlel ii.

T'hese aire vi rly segl'grlltt'4 ittili special hiIsplal s and aIre preferably kept ill tliese

hospitalls ill lilw foVrwardl itreit. not selnt to hit' lose. Sectindairy stlitre orf iill wolilllds is

pracliIved early. Ilelvhiltlita i aoltid recontiiditoilotig exertises begin at olince :iid tlli lh elI

art' l'vslore~d o~ften wilhiln •I lnimlth Ito ilt'i\t' uy.

'lt.i-ii.ing fiwilitil.. i.x., both anivd borhc'rs ihi all ho.z'jilsl.

This is it gret coilllttiliutioll to iltililitry surgery * * * every soldlier. illilhss It(l he

uirgetitly 1-44'lti'e41 ilt lhi tITlie:il lug loolnli, goies lirst o t le iltlrber andtl zi roonli where lie va"n

Ihe washed. This is sint'erely pllprec'ialted bIy like t roolps anl is somnne'thitig we should

(.ll11hl11w ill olII" ollillioll.

e ot'ililite t or olldl Tranfu.ion.

The I fulll 171 e l tn' etl ,lipiasizes IInh, great antiint of blood used il I lie Rulssian Arnmy

1intil its easy alniilii ility. 'I'Tlhugh this doultless witsht slls t Ie blooid it iltiii I ttcrt ain ltha

evt'ry w\unVlledith i 181 t olith g't li(itll if titt witslt' desirabhl. We shlilhIt tastbhlish It .iysylmit

tiutlkillg bliood as wt'll its Ilasinh l t atall1l4e Ito otur friw•itrdl hlositals.

Ili tlet ]Russiall Ar~lny Ilhe ilediv'al depalurtment controls laundries serv'ing (lit- ho~slilals.

Ilk lithe ]Russihll Army hlaundries airte set lill and serve it groupl of atdljact'tit hositlails. We

suggest. thli a sluiihir set till I provihd irt for h it' tntdiil dtleplrntml U.S. Arnny. Thlis

lmlight lie h Ik likt riltio (of Onet' lillillly Ito it (orps surgteont.

S urqieul mpweeiali:atijn.

,mhte |lssia s liegin Inititir slpeiallizatiIon ait th' forward hlospltal Itvtel. This lrovhhes

thalt i t lit' ontore linliortani flelds of surgt'ry soldliers are given what th slciiilist thlnks

Is wisest. front lite very beginning of his treatment.

Sorting and triaging.

ThIs Is carriol| out betautifully ait the ftorward hospitals tlnd epllihasizet's thii' tiganizalitn Oif forwarrd hoislpltals foutnd tIe'tessary in thit' last Greal War. If liarge nnttnl-i'S Oif

woitlt',l peole' sirt, t -t llt'ttilIt'titly '111med for, stmeu' systematlitch' s.ortling ltIISt oc-cur. Ill

tlith Russian Arnmy lhis liriiittttd lit' stegrtegation (if slightly woutndedll In lhoslplals Ilt lite

forward arin mill t.hitlr raildl rtsttoratmi tIo dtiu.ty: It favcllltatled liht tarto ly slt1'clttllsts Of

i ost'e needlling spec'il' v'tlt' andit It grt'atly facilltahtd lit' major lprlollem of t'vaiUtiIltioII."

Soviet Union and it.- people.-( ohoel (C'tiler could hot help hult Ie itkpressed with the Soviet s.ene in general, and, patriot that he Was, he felt it. his

dulty to make the.se imptressions known to those who inight •e aihe to take advanalge of themi in their oflicial ditties. lie realizedl tnt hi.s o)port unil ies for oIh-

"41 Letter, Col. I. C. Cutler, MAf', and Col. L. lDavlg, MC, to Chhef Hurgeon, I-ETOUtSA. 7 Aug 11143.

i0bjtct : tHurglettil Mls tlon to R sishlt.
('IIIEF CONSULTANT IN SURGERY 105

serving the Soviet p)eople and their ways were quite unique at this time-a time

when the Soviet Union was allied with the free world against a common enemy,

when its people had undergone an untold aimount of suffering, yet had renmained

steadfast, in their determination to resist the Nazi aggressor and had actually

begun to turn the tables on the Wehrm'acht on the Eastern front. Under the

dateline of 7 August 1943, Colonel Cutler wrote the following to Ambassador

Winant

The opportunity to enter Russia and c(ontact people there inevitably led to certain

impressions' being created in the mind of the visitor and since these thoughts may be of

value to the State D)epartment I have tried to put them into writing.

We were shown every courtesy officially and we gathered the impression that those

with whoei we camne into contact were delighted that we had come. Intimate contacts and

dinners up the line with the armny oflicers of our own rank and responsibilities made us

feel quite at home and at ease. Every opportunity was given us to see the things we asked

to see, both in Moscow and when forward with Army hospit:ls. but all the time one felt

that there lay over the officials taking us about an iron hand. which nlade themn cautious

in their remarks and which often led to a change of conversation in an abrupt fashion.

Thus, oin several occaSions when wve asked questions and the conversation started to give

us tile answer. the Vice (Conlmnissar who accolmpllaniedi us would make a remark and the

(onversation on tihe question ceased and began on some totally unrelated matter. It was

as if only special lpeople could speak on special problems and that no one was ever allowed

to express an opinion beyond his own special field where the problem had been set tio him

by someone "oon toll."

This imlpression of a strong "fist" on top was strengthened hy observation of the

mission in Moscow itself. The people were not cheerful. They kept their eyes fixed on

the ground as a rule. Of course no independent Russian could talk to us, beclause were a

Russian seen talking to a foreigner lie would immediately be taken aside and, if not

ipunished. certainly have a difficult time. Up in the army there was a different feeling.

It was as if they were away front that threatening something overhead. The people were

cheerful. they laughed; they had simple dances. and seemed entirely happy.

The power of this something overhead turned up in mnany ways. In intimate dis-

'ussions with General Martel. the British military attache or observer in Moscow, who

seeme(d to get on very well with the Russian Army officers, it was quite clear that his

dealings with the armny were very satisfactory, but that when something had to coime out

of the army and go to the Government in Moscow, then everything was different.

A further sense of the overhead power came to the mission directly. We flew into

Russia in a British plane, which was I believe the second plane on this southern route.

and which we were told had(1 all been arranged for through the Ministries. Our plane was

to return for us in 21/,. weeks. It reached Teheran but was never allowed to enter Russia

and a great deal of dilplomnatic tangling went forward. Apparently the British had signed

the agreement for this southern route but had not signed the agreement for the northern

route. The Russians wanted (certain things added to the northern route agreement and

when the British refused to sign this, then they refused to sign the southern route agreement.

My own personal observations of the Russian character were that he was really

[a] pretty frank, open, very direct and entirely rational person. Ile had not forgotten the

official attitudes of the U.S.A. and B tain toward his country a few years back. He was

not going to be fooled again, and he was going to stand on his own feet. Moreover, he

had suffered horribly during this war, certainly more than 6 million casualties and perhaps

8 million, lie confidently expected to win the war, and to win the war alone if necessary.

but would like our help. Everyone spoke of our starting a second front. They don't think
106 ACTIVITIES OF SURGICAL CONSULTANTS

the Mediterranean fights were much. and were glad to quote to us the battle casualty

figures as measurements of that effort. They refused too sleak of tihe Japanese war. though

they knew of its existence. However, it should be said in defense of the opinion of the

ordinary Russian that their newspapers and their radio announcements dii't give very

miuch information concerning what was going on in the war except in Russia. The propaganda about Russia was tremendous and the personal propaganda for Stalin and Molotov

was equally conspicuous. Each room in every hospital up the line, let alone the places in

Moscow, (ontained a picture of very large size of both Stalin and Molotov.

I took the occasion to remind the Commissar, when he spoke as though we were doing

nothing, of the efforts of ourselves and our allies, the British. I must say he took this

smilingly, said he knew of all our efforts and thanked us. At the same time I am sure none

of this would ever get to the people.

My impression of Russian medicine was that it was good. not excellent. but surprisingly

good in view of what we had been led to think of them. Their effort in medical education

Is enormous, and though 90 percent of inedical graduates are women, 40,000 were graduated

from Government medical schools last year, and these students go through a six year

course.

Finally, I came back with a very strong impression that Russia is a really good country

with fine people in it, who are bound to take their rightful place as one of the great

peoples in the coming civilization. Anyone who fails to take this into consideration

and who deals with them with old fashioned diplomacy and not honesty and directly will

fail miserably and to the discomfort of his country. We are fortunate in having in

Moscow such a directly spoken man as Ambassador [William H.] Standley. ite serves

his purpose well and is regarded with affection and esteeni by the Russians. They like

his honesty and frankness and even when he speaks to them contrary to their desires

they take it well because of that honesty and frankness. Because of this he stands out

among the diplomats at Moscow. He has of course a tremendous advantage in having in

Moscow General Faymonville, who apparently is admitted by the British as well as the

American people there [to be] the one person persona grata with the Russian people,

both the ordinary people and the government. One cannot speak too highly of the eminent

qualities of these two citizens who serve our country so well in Russia.

Late 1943-Early 1944

Thus wrote Colonel Cutler in his diary on 15 May 1944, a few weeks before

D-day in Europe: "Time flies with increasing agility. The deluge will be upon

us soon and will we be ready? No, never fully satisfied, but to begin is

something."

These few words truly characterize this period for the Chief Consultant

in Surgery. The pace was quickening upon his return from the Soviet Union.

At the turn of the year, it had definitely accelerated. By May 1944, the surge

of activity was a headlong gallop to the day of destiny-D-day, Europe,

6 June 1944.

D)uring this period, American Forces in the I nited Kingdom were built

up from a few divisions to those making up the First U.S. Army with supporting troops and the nucleus of the Third U.S. Army. In August 1943, upon his

return from the U.S.S.R., there were 6 general hospitals, 17 station hospitals,

and 2 evacuation hospitals in operation. A few months later, at the beginning

of 1944, these had been increased to 17 general hospitals and 34 station hospitals acttiilly iii operation. The final SOS plan for mounting the assault on
CHIEF CONSULTANT IN SU RGERY 107

fortress Europe called for 79 fixed hospitals in the United Kingdom alone.

This figure did not include those medical units staging to be moved to the

Continent at the first opportunity or the evacuation, fiehl, and convalescent

hospitals assigned to the armies.41

This expansion of the theater troop basis required reorganization and

decentralization. Hosp)ital centers were created to ol)erate groups of hospitals.

Base section surgeons were given almost complete control over nmedical facilities in their areas, except for the control of beds in general hospitals. Colonel

Cutler had to expand the consultant system to provide for consultants in

these centers and base sections. The growth in numerical strength of troops

and units and the delegation of many functions to lower echelons shifted the

emphasis of activities in the Office of the Chief Surgeon, including those of

the Chief Consultant in Surgery, from direct supervision to that of liaison,

coordination, and the development and enunciation of policies.

Conferences.-This change in emphasis meant that Colonel Cutler had

to attend more routine staff conferences. Weekly meetings of all the consultants in the Professional Services Division were held, preceded by preliminary meetings of the surgical and medical consultants held separately. On

each fourth Monday of the month the consultants and the Chief of Professional Services met with the Chief Surgeon. There were also fortnightly

meetings of base section surgeons, and the weekly staff meetings instigated by

Colonel Spruit after he became Deputy Chief Surgeon at Cheltenham. Starting in January 1944, General Hawley held weekly meetings with his division

chiefs, which Colonel Cutler usually attended with Colonel Kimbrough.

In addition, there were the regular RAMC meetings which Colonel Cutler

attempted to attend with regularity, especially as the (lay for the invasion

drew ever nearer. There was no consultant in surgery appointed by the

Americans at the Allied Supreme Headquarters level, and Colonel Cutler,

by mutual understanding of all concerned, acted in that capacity: (1) Through

his superior officers and staff at the theater level, (2) through Maj. Gen. Albert

W. Kenner, MC, USA, Chief Medical Officer, SIIAEF (Supreme Headquarters, Allied Expeditionary Force) (fig. 43) and (3) in meetings of the

various committees of the British AMD and EMS.

Changes in senior consultants.-Colonel Zollinger served as Acting

Chief Consultant in Surgery in the European theater during Colonel Cutler's

visits to the U.S.S.R. and, later, to NATOUSA (the North African Theater

of Operations, U.S. Army). After Major Storck's return to the United States,

Colonel Zollinger was appointed Senior Consultant in General Surgery. Maj.

(later Lt. Col.) John N. Robinson, MC, 2d General Hospital, was appointed

Senior Consultant in Urology, in addition to his other duties, since the supervision of urological activities in the theater had grown to be too great an activity

4* (1) Annual Report. Chief Consultant in Surgery. ETOUSA. 1943. (2) Annual Report, Professional Services Division, omfl of the chief Surgeon, FTOUSA. 1944. (3) SOS. ETOI'SA Mounting

Plan. Medical corps. Annex No. ,: Medical Plan-Mounting the Operation.
for. 4)444lo Kl4i(4llZI) 114i-I 14) per'form11 III add4itio to)1 4e1g Ch ief 4)f Profvslo-i4al

faicial siII.."erv (41 S Nov4ember'1 1913. Ir'l evin- (oo- B)411] ricker of thiese 41)11 ie:

Maj. (III hter Il . ( 441.) .14)n oIII . Scaiiit. NH W. 211 (i'vilent I Ios p ItI:a . stI*vet I fort

401 c4Ii4Ierabl)e I illt. aIs Avit lu 4Il4'((1$lt;lit i Nelar44smlgerv (Jliil-*

( (4144114 1 ):lI%-M It'll)) t1 ltheI *U'.S'.IS. 1i1 and 'IIvi e Ils etuulir 1i the I Ililt'4 States..

IFimiUII. 4411 I.) Nhi-utv 19-4,. D4. C'ol. ( I~tr('(41) I,. (le %j41lllI. III N('.Ilit

Ill thle t heater a1114 wai, z14 1 4i11oted Senijor ( Cm~isutantid II NeuI4)lrosti'ry. Lt . Col).

hlter ( '4).) MIat her ( I ej-phul, MC,( ' arriv'ed f romh 1 prev ious 2ussiga)1l(IIei s a

Se'rvice 4'4)IiIli~aiIl 'oJllsillitaiit ill t lit Z4out' of hilherio~r mid1( ill Mla v 1941 wa~s

21.1ppi11'41 Selli lot. otisul~t' aIll ill ( hilopjt'11' ui*'i't'v1- rep 1ac i tev (4) t-Ie D i velev\

whlo. itl 11)1, )(ahille 411i' f of th1e4 Rket'Iili )lit'all41 Io Diiion154 1.

Significant activities.- ItI emis of sgrigh -I In'I)4 Irti t Ii s ppt-ioih, 111544fart

21 heylle i ivve Old4IV'4I(41)14 t er, I ich IIIt'4 varol P145iIeasislreto5 14) et readtl foPl-ii'

iii vasioti of thle ( '4)1) ilnetit-( )lpet'at 1441 ( VEIRHL( )R1. fiurt Iitr devlopmen)4)ItsIill5

the efforti t4) )pr) oid' w41 hoe blood)4 for combaiiht 4)jer.lt 14 4115. etenst'ive "''stitdY of

111t'he 'etli(v of hie ll viHill, a1 trip4 to lt'e Nort1hi A~fritati theateri t'*dI , 54115514 411

with Ti1hie Sturgeonl ( T'Ilt'le oil th1 le thosttrt'. 4f wol1tt)(1 a111( atuihplitt l)olls, .11141 thle

expanstion of tilt-~ uullisuhialid system' . Thiese arePt discussed5'4 5t'pa) rti-I but.14 Iliev
cHIEF CONSULTANT IN SI'UR;ERY 101)

followving iteills of no less iipl)ortallce, though perhaps itiore limited in scope

in some instances, were also his concern.

American Medical Society, ETOUSA.-Foilowing the August general

meeting of the American Medical Society. ET(I'SA. General Hawley informed Colonel Cutler that the general nionthly meeting of the society couhl

no longer be held after the one for the current. nionth. lie suggested means

of having smaller, decentralized iteetings. As a result, tile responsibility for

forming local societies and holding meetings was eventually decentralized

to the base sections. With decentrralization. however, there was a lack of

coor(diilat ion with tile result that areas for local societies were overlapping,

and s4 forth. Originally, Colonel Cutler had been tohl, tile intent was to have

a society completely independent of any control from tile Chief Surgeon's

Office, but a coordinating center had to be established. Actually, this coordinatioti, ('olomel ('utler thought, benetited the local groups since it p)rovided services such as helping to fornmlate p)rograms, obtaining guest speakers, and

collecting papers from local ineetings for forwarding to ap)propriate in(lividuals and offices withini the theater and, in some cases, to tile Office of The

Surgeon General. The last general meeting during this pheriod was held in

January 1944 at, Widewing, Eighth Air Force headquarters. At a business

session of this general meeting, (oonel Wright, Chief of Professional Services

for tile theater Army Air Forces, was elected president of the society.

Throughout this period, there were many stimulating meetings held

locally in tile various base sections (fig. 44). Colonel Cutler and his consultants were able to attend niany of these local meetings and were gratified to

find participation at. the grass-roots level extremely healthy.

Education and training.--The European theater Medical Field Service

School at Shrivenhani continued with its full curriculum, as did the Air

Force school at "Pinetree." The London tours course was discontinued before

tile Americans "wore out their welcome" at the busy London hospitals. InI

spite of some initial reticence on the .part of the Chief Surgeon and his Education and Training lBranch, a very extensive program in the training of anesthetists was begun under the direction of Colonel Tovell, Senior Consultant

in Anesthesia. ('olonel l)iveley, as Senior Consultant. ill Orthopedic Surgery.

initiated a badly needed course of instruction in plaster work (fig. 45). This

instruction was carried out in 3-day periods, mostly for medical officers of the

First 1.S. Arily.

Selected U.S. Army medical officers were sent to the various courses at

the British Post-Graduate Medical School in continuation of a program which

had been established in the very earliest days of the theater. The courses

which were being offered (luring this time in successive weekly intervals were:

Recent advances in war injuries, treatment of fractures, war surgery of the

nervous system, war medicine, war surgery of the extremities, surgical care of

the soldier in training, war surgery of tile abdomen, and war surgery of the
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112 AC'TIVITIES "F SURGtICAL CONSULTANTS

uniits of dried l iasniu were given. Ill this first niothily surgieal report we comiputed the

i rwidelive of woliIW infect ions inl six of tile seven hospit als inl East An~glia where airmen

injured ini mi.simns over enemy t errito ry are, treated:

Ifiuttle iiijuiip 'i --- -- --- - - - - 214

Number infeced v---- 15

Incidenice 7- 7ix-rcrit

havibitth' iDnjIriEX.- ~x 388- 

Nnumber juifeced- - ---- S

lnci(Ielive - - - - -- - - ---- 2 p04-nen1t

C'han vpt-rvtinn.-.4---- 730O

Niumber infteced - - --

Incidence ------ - 0. 4 pervent

Thle Obove& is it samipjle oif t he coniut rol suchi a simuple report. has oin professional wo. rk.

'Iblis rep)ort. was rePceivedl froili all hospitals ill thet (ol)iMillluiCv)tio)ii5 Zoiie

fr tilie enitire period oif thle w~ar-fho~spitaIs inl Wli icl iuiost ouf tilie repairat ive stigr(IYv pJ'ovidedl in tile. t heater wasclS 'id~licted(. Tile last report Sulbuni tte(I by

t lese hlosp~itals was for thle 1110outh of May 1945.

Activities in conjunction with Army Air Forces.-One of the first things

Coloniel Cuitler (lid u1ponl his return.1 froml thle 1.S.,S.R. Was to t or ealch of tile

Ilos1)itflls whtichi had bieeni estab~lished 1 )rifluarilv to serve. tile. Air F~orce ( fig.

46). These were at this time either inl fill] operat ion or juist about ready to start

operations, and the. Air Force mnedical staff inl thle theater was very Pleased

with tilte resuilts. For one thinig. the sul-rgical service at these hospitals had to

lbe first I-ate bwecauls they 'Vwere treatinig air comlbat, caslualties, and Colonel Cutler

liadl (oloe everythinig inl his powver to make thiem so. H owever, thle growth of

the air armi, whihel paralleled the bulildulp inl thle thleater of the other armns and

serv ices. soonl ouitstrippIed tile services t liese hiospitals could( p)rovidle. As mnore

hieretofore stalihidb airfieldls were act ivatedl, their (listaii('e to hiospitals became

a seriouls problem inl t Ilie eyes of the Air Forces. ain(l. inl spite of ot her priorities,

Genleral H awvley gave first conlsidlerat ion to buildinig anil activating additional

hiospitals to ser~ve tdiemi. Tile duity of seeing that the surgical service in these

hiosp)itals iilclidedl thle requ iredl high-grade 1 )rofessionial persoimiel b efell to

colonel Cuitler and his conlsultants. Tile providling of this personnel becamle

a most. d ifficul t undertakinig wheni well -qual i ied i id liv idua Is were required to

auigmenit thle staffs of newly arriving- hospitals with very little specialized talent

anid when surgical teal-is whiceh had bween attachied to t(lie hospitals servinig thle

Air Forces hiad to be wit hdrawvn in lrehparatioii for thle land campaign onl thle

Cotit iiient.

In addition, as the Air F~orces in the theater grew. it became niecessary for

thle tlheater A ir Force mined ical staff to sulperv ise activities on) a b~roadler, less

lpersoinal scale. Contsequently, thle theater .onlsullt litt st a i, was called iij)011 froml

tinit' to time to htelp) formulate policy anld write jirofessioutal direct ives wvhich

wvere issuied by t(lie t heat er A ir F~orce colaitlia r1ider, or. 1) % tilie Mu rgeoli. G enleral

G'row. Onle of t liese, persoiilivl worked ouit by Colonlel (Olttder, was a basic

directive oil the recejption atlld initial t reatitteint of casmia it as at airl mses.
I I:$'Ill".I tilI I II I, I ll II' I 'II\11I - ?oII .- I.
114 ACTIVITIES OF SURGICAL CONSULTANTS

Maj. Gen. David N. IW. Grant, the Air Surgeon, visited the theater in

September 1943 and inl March 1944. General Grant was all avowed advocate

of a separate medical service for the Air Forces, but he was forced to adhnitupon advice of the Eighth Air Force medical personnel-tthat arrangements

in the theater were as satisfactory as they could be under existing circumstances

and (lid not require any immediate major change. Colonel Cutler was pleased

at this outcome and felt pride in having done nmuch to cement this ooperative

close relationship-largely through his associations with Colonel Wright and,

also, through his intense interest in the combat casualties of the Eighth Air

Force (fig. 47).51

Study of casualties with respect to causes of death and causative

agent.-Colonel Cutler had urged since his early days in the theater that provision be made for the study of wounds and wounding, the distribution of

wounds, and the relationship of wounds to the causative agents. In his reports

to the Chief Surgeon and The Surgeon General, lie had always tried to indicate

at least the distribution of wounds (regional frequency) whenever the data

were amenable to such a tabulation. In his trip to the U.S.S.R., lie had made it

a point to obtain some data on the Soviet experience in the frequency by which

various regions of the body were hit. Shortly after his return from the Soviet

Union, he formally suggested that a group be established for the purpose of

studying the wounds of war. The minutes of the Chief Surgeon's 23 August

1943 meeting with his consultants show the following discussion on this

proposal:

The Surgical Subcommittee's proposal to establish a pathological group for the study

of fatality statistics in the army was discussed. Colonel Cutler pointed out that the group

might serve a double purpose: i.e.. to tind out what kind of wound causes death, and

what kind of missile causes the wound. He felt that some valuable findings might result.

and that the group might work with the graves registration people. Colonel Spruit said

that the responsibilities of the medical department were directed in one line--to get men

back to duty. He felt that there were two aspects of the proposal, (a) That this pathological group would lhave to be put in the front line, and that the Division would have the

burden of carrying them along, and (b) That if the schemne was practicable it might prove

valuable, but that at present it was only possible to formulate ideas.

Finally, Maj. Gen. Norman T. Kirk, The Surgeon General, officially announced the need for obtaining such information in an article prepared for the

Bulletin of the U.S. Army Medical Department.12 In January 1944, however,

before publication, copies of the article were sent to all theaters of operations

requesting that programs for the collection of data on missile wounds be set up.

Colonel Cutler again recommended that teams consisting of pathologists

and enlisted men be set uip to collect and make studies along these liles. But

it. was not until The Surgeon General visited the theater in March 1944 that

51 Minutes, Conference of the Deputy Chief Surgeon. 12 Sept. 1943.

s2 Office of The Surgeon General: Need for Data on the Digtribution of Mlissile Wounds. Bull.

U.S. Army M. Dept., No. 74. March 1944. pp. 19-22.
4'l11IIF c'ON,-VI,.'I. T' IN SIAMERY 115

Fl(;uiia: 47. Ma~~j. (ui.It( Carl Sjlwaiz. I iiiiii11.iiutiiig (evliierli .Ailtii Air t(Ir-f4s. ETI'4UtSA.

aw~ardiiig, i ti 'rerf l-e 1R l'it- l4 IR1-11v ii(ai to iiiei hf the 1)th BmIidi-tarlineii (,roupi. Pl'hlh'hi,'k,

Emdgai~. 114.4' Sefldendw 19 112.

-1Slicill~ei iiiilel IS is wa givellto 14 1Iv" Iprogrram to Iiwing~ tort i, ( ienriief iiawlvys

auIl"Imil fobr thle est alblisliiiielt of a1 vastialty vsiurvey teaiii ill thle t heater. h In

2 QArL. (M Wooel(~tlr statedl in n miiieiorandmluinto (Coloinel inibilotigrli:

For abomuit a yea r ithe P rofessiounal Serv ives g-roi uij have. at flit a juirovaI (if ('eiieral

Ihiwley. cohllfiilitllv Siiti4die ot ho4w to4 iipei~t-~lPit a groull of livopIe aciv4liirilig iiif'rimii loll

-is il tip'. tajtut k iedIl ill ha11le t. aii1t When. they Avee I(liii w~hIe ilijrlj4. DI linlg l ti re'enit

visit 11f The14 Siui-geol ii-leiend ait 111 Gei1ral (inill,i. ai (istiissioll or ileiihis i, ii i-Ijitmiies. Nviiit

till mlI~ission. over (ilevilly territories led1 Io th lie ifllillg t1.1 pet t(rsolilelt ar1rliving deald were

114it aiiitotIsieu. I was 1114-1ii isi ieit 4- t11v by eilE'i'at II:110ey ii' seq'tiill a gi*(hlp for siith stiiiiies.

It So liajpeiied 1:11 MIaj. All:11i laliiier. MC. chief of I lie patliologry Serviev.

30tht ('weileral I lo~spital. imid ;t iiipainied P~rof. S. ( I'iler Sir- Sohlv ) Zlickertiiaii1

oif ( )x fort I ttlivritvi ("I a 'special casitalty vsurlvey tiissioni to Italy N aind was

well ii:1t iIedl ini lOw p~roceduri es iiivol ve illii conducting ii wit Ii rigid Scientifi c

pl-vvisioli f liv tiecess:1- iNStud41ies to) provide 1usefull and iiaealinriiigtl dat a: oni wvar

wotitids. Ab;l. P:1 1ahtiier wa-t4 assigie' ito) C oloniel ('itt ler to tiiieriletak tliv orgratiizat 14):11iad eStalbdi-diiiieiit of :I team to Stlldy casiiltivs and~ f lie- killed ill

act iou . Si ice.t .1 Ili- Is ille. It( li )t ' vl freji ctsluu it ies Iletving receitved l fiii lie

I heat1er were t he re(Sultl of ;1ir combilat. Major I :i Iniet'> unit1 called lhe Medical

O peiat iotial IResv:trchl Sect ion. IProfessioti'il Ser-viceps IDivisioni. ( )fhic oft ilie

( 'Itief Sill. uivoti Nv;s 4.týi~lbhslid :it the ( atliihridlge .\tieicii1at Militar1Y ( ene

tery 'wit i full fitvilil ies for votincluin' g autt1lopMies of thle Air Forces* dem;il. iiiaklug phologt4)p!tl slll( nive. d and' prleserving ! -lNIilleiis.
116 ACTIVITIES OF" SWRGICAL CONSULTANTS

One sttlnd)!ing block ill thle bulildingf of the laboratory, it is initerestingir to

note, was thie fact thiat, there was a stately and ancient. tree growing exactly

inl the midd(le of the plot, of grouind which lial lbeen. desigYnated1 for the lab~oratory b~uildling. Apparently, Dr. Rosamond E. M. h1ardingr, the owner of

Mfadingley H all, Camnbridgeshi re-t lie, estate withIiin whichl the cemetery was

locatedl. had specified that the UT.S. Army could use the groinnis but thiat no

trees wouild lbe cuit down. The U.S. Army Engineers, accordingly. steadfastly

refuised to cutit down thtis particular tree so that. Major Palmer's laboratory

coidd lbe bluilt. Finally* , it was necessary for Colonel Cutler to call onl Dr.

H~ardling personally. This lie did onl 30 April 1944. The visit, whichl was

most pleasant, endled with talk over the possibility of Dr. Ilardingrs colining"

to Amnerica, to see Colonel Cutler after tile war Iin ordler to continute certain

stuilies site was interested in. The tree was cult, but suich were the dulties of a

Ciiief Consultant in Surgery that thiey often carried himi far afield from the

hospital op~erat ing 1om.001S5

Free-French surgical teams.-Late in thtis p~eriodl, a group of emtinently

(11i'liaied Frenchl surgeons, rlgesin En1 gland, voluniteered their services for

thle impending attack on the European mainland. Thiey were. welcomied b~y

the Chief Constiltant in Sur-gery who initiated the necessary steps to organize.

activ-ate, and equip theni as lll(;ile suirgical teams, It was' contemplated thiat

they coiildl miost gainfully be emlployedl in support, of thme Free-French Forces

which-I were schieduiled for part ici pation as a, p~art of tilie. Allied effort."

".Vetting" newly arrived units.-Especiahly chiaracteristic of this period

was the necessity on the part of all tile thieater-levNel consuiltants to meet. and~

ev-alulate tilie professioinal capabilities of tilie nimninerolis illedical 1in its niewly

arriving iii the theater. Thiis became known as -ett ing." Of partll

impijortance was the(- nie(l( to assess carefuilly tile mierits of thle, professional

p~ersonntiel, sinuce the supplY of well -ifuali tied phiysicimmiis anid sit -rgeons was beginning to I-unl low and man11Y tin its were beiiig senit ov-erseas withi the assumiptiol t hat ke 'y professional p~ersonniuel could1( be supp)1l ied fromt ijitits al ready iii

TI tlere were it ii it protl eiimsassoc i ated Ivit it tilie v-et ti iigan 11Sublseq1uent nieed

for- excliaitgjir imgl)(soiiiiel. First of all. C olonel Cu'tler reiterated, it was jillperat i e t hat 1t)iI tul ilifed officers arriv-ing vi t il t liese new unitis be in1 tilie lower

orr~a(les huecauuse the( tiheater. .ouldl miot. assiitiilate well thlose wh-o wer.Ie inl highier

trratles. Thl~is was trite I eca use. in inaiav Cases, a1 profession.ial lvw~ell-q hll i etil

jilhi fithiial1 bping senit jilto I htese itewN uinits1 as I liechief of a serv1ice or sectioii was

htimsel f a relativ-elyv young, juniior. officer. Furlthlermlore, miost of thle wellqulifI ied t alenmt wsiii the affiliated nitits, a imt( hley believ-ed t lies- were being"

"6robduett" of I hici better p~ersoninel. and, of courlse, resented it. Before long(.

-ait (-sui is or t hie st uf ties, eII I I dI IetedI iiy I h v Mv(I'Iellen 0 )I ern t Ioiiii it I Itesere It Seet ioll it tthe CajiinhIfrhig.

AineIrleaniil Miitiry Veineliry as~ weil as, Maijor 1ai'neiir',s ramial~ty stirvvy reili~rf on hisi Itaianii exjNeriviies. are ;imbimi f-oiei fii foii Iin: Mledical l~einrtineimt. U'nitedi Stliti Armyi. WvuoniI Ballistics. Wishsii lJert :i'reiih Su rgeons'.
C'HIEF ('ONSULTAN'U IN SURIGERY 117

these 11ii0ts recognized1 the ov-erall nweeds of the thleater anid responlded well.

Colonel Culder was dleeplyV ,ratified b~y this resp~onse and nev-er ceased to moimnendl these units which were calledl i11)01 agrain and again to give i1l) p~ersonnel

and vet continued to maintain their high standards. Ini a way, it was to file

1)eneiit of these units becaulse such transfers permitted their Junior officers to

b)e promiioted1, whereas promotion p)ossibil ities were extremely limnitedl if the

jun11ior officers colitiiiued to stav with tile original units. Fiinall y, there was

the matter of commiandl authlority to effect transfers b~etween units to sp)read tile

talent, more. eqlulallv. On)i more thanl ote occasionl, a consultant hiad to be repri -

ma nded for oj vi n- instruct ions, wvlicli-in many cases un witt ingly-were. takeit

at tile local level to b~e comnmfandls. n1le dlesiredl changes in personnel had to be

offeredl as suggestions to tile base sect ionl surgeons, who were usually very coop~erat ive in accep~ting and~ imiplemnenting t hem. It was mlore (difficult, C olonel

(Cutler niotedl, whlem t wo or. iliore base sect ionls were involvedl ill a series of

tranlsfers., as was of tenl tile case.

General Hawley took a very firm p)osition Onl this matter of exchanging0

Iersollinel, real iziniig fuill1 well the necessity for it, while also recognizing the

needl to respiect tile authoritv of commanders at the lower levels, Ile. i1aole tile

followii,( stateiieint ait his 25 October 1943 conference with b~ase section

surgeonls:

I do inot nieed to tell you ll .1, that we are never building up one Base Se'ctionl at the

exp~ense of another and if these changes that wve have aire aolvisahlde. while You may get

a little short cihanige oil onle change you are going to make it tip on the siext. Wve are trying,

to get .1 balanced seti up. The t hing which converns uis very largely is to get thiorouighly

compejten~t C hiiefs of Services inl thlese hospitals.

Col. David E. Liston, MC, Chief. Personnel D)ivision (later D~eputy (Thief

$i rgeoii) (fig. 48), was imost hielp~ful in undertaking the iiecessarv details to

coordhinate ando effect tilie transfers 'which were desi redl by tile professional

coiisiiltaiits. At a1 coiiference with b~ase 5ectioil surgeons onl 2 August. 1943. lie

iiado the following"' st atenment:

SoniethIines we are told to move three mien wvho have a spark of genius and it menvls

we havi e to mlove thbree ment who do, not have this sp~ark of genius. * * * Nobody wvants

these peop~lel I without the spark of genius] blut wve have to dho somnet hing with them. I f we

art going to uinake a capt ain a major, that is an easy decision. The (difficult olevisii in is

where to put that manl we kicked (out where lie ('anl get proper' training.

Ev-entuially* , tile need to providle not onily chiefs; of service but nearly all

the specialist"a well fo ~ tlie. t ~ neswly arri viing liii its beam a very serionsprb

lemn. Colonel Culder and C'oloniel Zoll inger couldilol eet thlis prob~lem only by

preparring lists iin ad vance of those officers in the theater whlo were qual ified to

b~ecomie chief., of' surlgical services ini hiospitals and those inl the variouls spevialties who could be iCnsed to 1oloster the iilC-(Ilillr lugiiiits. Phsfreih o h

p)art of tilie C h ief ( 'oiisiiltalit iii ~lrglery anld tile Senior Consuiltanut ill General

Suii'geiw pro~vedl pariticularlY eflect ile when, as 1)-day neared, m1anly of tilie bet -

ter. iiiore exp~erien(edl umedlical tunmits of the theater were eairmnarked for mov-enieuut to thle Cont inenut an th1 leir p ersonnuel were frozen. O fficers in these uniits
118 AC'TIVITI OF 'IES S GIHCAL c'ONSI'LTANTS

Fim(HUE 4.S.-CoI. David E. Aiston. MC.

who had been selected to become chiefs of surgical service or specialists il Other

units were relieved from assignment to their units before the personnel freeze

was effected and remained with their units after they were alerted oni anl

attaqched unassigned basis until the need for a l)articular individual arose.

As tinie went. on, assaying and recnommending the shifting of personnel

became one of the primary functions of consultants at the theater headquarters,

in the base sections, and in the field armies.

Expansion of the consultant system

An attempt to establish a system of consultation at. the local level was mentioned as having been initiated immediately before Colonel Cutler's trip to the

Soviet Union. This embryonic system of regional consultants and the "mother

hospital" scheme was further expanded during this period, which also saw the

appointment of coordinators in medicine and surgery at hosl)ital centers and

surgical and medical consultants at the base section level. The changes and

innovations which were made duriiinr this immediate l)reinvasion period formed

the framework for the duration of the war in the European theater, and it was

not until well after V-E lDay that that this consultant system required at complete overhaul, and then only to gear it. to the needs of an army of occupation.

Regional consultants.-At General Hlawley's insistence, more than

enough regional consultants in the various specialties had been al)pointed.

They were first, announced by the Chief Surgeon's Circular Letter No. 89,

dated 21 May 1943. At that t ime, the directive listed eight. regional consultants

in general surgery, one in 1)lastic surgrery and burns, five in neurosurgery, two

in orthopedic sulgely, seven ill otolaryngology, nine in urology, and four in
C'HIEF CONSULTANT IN SURGERY 119

anesthesiology. This directive required immediate amendment later in May

and in early June to provide for additional consultants in ophthalmology,

roentgeiiology, orthop)edic surgery, and p)lastic surgery. From the outset, this

method of appointing and controlling regional consultants centrally from the

Office of the Chief Surgeon was doomed to Ibe unwieldy. When, in June, the

operation of medical facilities in the United Kingdom was delegated to base

sections, the system became all the more cumbersome-a point which was

consistently belabored by the newly al)pointed base. section surgeons. From

time to time, Colonel Kimbrough rel)orted that the surgical consultants were

attemnjthiug to bring the original directive up to date, but changes were occurring

so fast that revisions never p)assed the draft stage. Eventually, General

Hawley directed that consultation at the local level be made a responsibility

of the base section surgeon and that the Office of the Chief Surgeon be informed

of the actions taken.

Accordingly, Circular Letter No. 21, Office if the Chief Surgeon, 7 February 1944, was p)ublished and set the policy for consultative services for the

American Forces which remained in effect for the duration of the war in

Europe. It stated:

5. Regional Conmultant.b. The personnel of general hospitals and specially designated

stations hospitals will be available for consultation in the vicinity of their stations and

will conduct their activities under the direction of the base section surgeons. Base

Section surgeons will inform each hospital where it will apply for consultant service

in each of the several specialties.

In actual practice, the system of regional consultants did not work out

quite as simply as may be implied in the foregoing excerpt. First of all,

as Colonel Cutler explained on one occasion, there were not enough good men

to place in all the general hospitals so that every general hospital could be

a, mother hospital to station hospitals in its vicinity for every specialty. Consequently, specific hospitals had to be designated for certain specialties as the

mother hospital. In cases, this crossed boundaries of base sections so that,

in some fields, surgeons of two or more base sections had to agree on the area

to be covered by a l)articular regional consultant. Finally, the hospitals which

had designated regional consultants were hard pressed for transportation and

could not afford to maintain a standby vehicle for the consultants-a problem

which had existed in World War I. On this occasion, however, an extra jeep

was eventually authorized for each general and station hospital having regional

consultants for the specific use of these consultants. The reader is also asked

to note that this system of administering regional consultants could not have

been estab)lished without creating base section consultants in general surgery

and medicine, a program which was carried out concurrently with the development of the regional consultant system.

Base section consultants.-By far the most important step taken during

this period in expanding the consultant system was the appointment of base

section consultants. At first, base section surgeons objected to their appointment, for no positions had been established in their tables of organization for
120 A('TIVITIES OF SURGICAL, CONSULTANTS

consultants. There was also considerable question in the minds of the base

section surgeons as to what such a consultant would do, or as to whether

he would even have anything to do. On 20 December 1943, General Hawley,

said, at his regular meeting of base section surgeons; "There is scarcely a base

section whose job is not going to be bigger in a, month than the whole theater

was in the beginning of this month. I think your consultants for the t ime being

should be limited to medicine and surgery, but I do feel that you need consultants for medicine and surgery. It may be that, in Southern Base, you will

need more than oine.'

The need for having base sect ion consultants, when considered in this light,

was apparent. For the time being, there was no other course but to appoint

themi in addit ion to their other duties in hospitals to which they were assigned.

The policy concerning base section consultants was announced in aforementioned (Circular Letter No. 21, emanatintg from the (Oflice of the Chief Surgeon.

It statedi:

4. Bit(se Section Consultants

a. Upoln recommendation of the Office of the Chief Surgeon, base section surgeons

will appoint consultants in general medicine and general surgery for their respective base

sections. These consultants will be available to all organizations of the American Forces

in their base sections. They nlay render service, on request of the commanhnding otli,-ers, to

C(anadian and British Ilosoitals in which patients of the U.S. Forces are under treatment.

They nuay be obtained by request nmade to the office (if the base section surgeons. In urgent

cases this request should be made by telephone.

b. Reports. The base section consultants will render reports as required by the

base section surgeons and will send a copy to the Office of the Chief Surgeon.

At, a soniewhiat later (late, Colonel Cutler found it necessary to state his

policy with rega'rd to the duties of base section consultants. In a memorandum

dated 2 April 1944, which was apparently issued to each base section consultant

personally, he wrote:

1. Keel) familiar with level of professional work carried out at all hospitals in your

base section. This means constant personal visits. Written directions and circulars can

never take the part of the influence of a real surgeon at the bedside of the patient.

2. As a part of the above you must see all new units wlhich enter your base section

shortly after arrival, and evaluate the personnel. Your opinions should be turned into the

Office of the Chief Surgeon, attention of Chief Consultant in Surgery. as soon as investigation has been completed. In addition to your evaluation of new units representatives of

the consultant group in the Division of Professional Services will also make their vown

appraisal. Copies of these opinions will be forwarded to you.

3. Attend all meetings of the Professional Services I)ivision. This includes automatically: a. General Ilawley's monthly meeting with the Professional Services Division,

b. Meeting of the Professional Services D)ivision each Saturday morning at 10 a.n., Headquarters, SOS. If you wish to bring up spe'ial subjects for discussion at either mineting

send notice for agenda one week in advance. At the weekly Division meeting you will be

expected to inake a brief report.

4. In your visits you should see that the professional directives are lived up to. that

sitationu hospitals in pIartiicular (1o not (1do niljor elective surgery or undertake professional

matters beyond their professional capacity. You should also keel) an eye on evacuation

and see that hospitals are prompt in evacuating peolde either to the Zone of Interior. if

they are of the type that should be retui'rned to the Zone (if Interior, or to the rehabilitation
E'iiitE c(( NsvUl1'ANT IN slulIOEIy 121

hospitals. that t heir ha rdeninig priires miay biegini as piromnptly as possiblle. lit particular

you inuist keel) a i eye on hiter-hospital con~sultations. Eiicouragre this, and see that reports

mtade by youIr regional co.nsultanits coline tit you promIIptly.

5. tlt of your lioisjit a reports sho0uld be rendered top thle Base Section surgeon. but

icopies -should voine to thle Chief Consultant iin Slirgery.

Coordinators in hospital centers.-l it t he overaill dlecenltralizat ion prograiti1. it wits necessary to est'Ibl)isli hlospiltal ceniters to itinttt litstel- an1d oIelerate

grioulps of hlospitals ll(id toblriig toget-ler itmieron OtiC in~ttistrattion tl e facilities

andI personntel I'e(ltlir-ed to 1-1eat an type of injury. hlospital centers estal)-

lished in the 1 nited Kingdom (itiritig, thtis period were at Malvern WXehls,

Worcestershirie ( 12thi H ospital Center) ,Cireneester Park, (GIoucester~hire

(1511 iH~osp~ital Center-) :anld Wliitclntrch, Flintshire (6810th Hospital Center,

Provisional). Thiere were. inl eachi of these centers, hospitals provided with

Cejtt 1 )ttettt and p11 ersonn iel for Itighly specitl izedl treatment illn ieurostirgerv

t I or-acic. surgery. plastic anid nitaxillofacial Sutrgery, urological surgery. and~ the

surgwical treatment of extensive buirnis."" It is readlihy a1pparent thiat, Avit h such

extensive faicilities lin men tindl equip)ntent, tile center commniniler required ant

officer to imanage thle surgical care carried out in tile center. To difflerenitiate

titis officer f rom th riegna anii base sect ton consuilt ants, hie was called a coor-

(ltator. in surgery, and( such coord'(inator's were applointtedl at eachl hospital

center, at this tittle and( inl those estaildishied later during the operations tha-.t

followed.

Visit to North African Theater of Operations and Fifth U.S. Army

Perhiaps one of tile wisest nmoves lnadle by the Chiief Surgeon in p~reparatiton for thle evenitual1 assaulit onl continental Europe wns1 to send key medical

persontnel to thie North Afric-an theatter to observe firsthiandI the combat and

suphport aictivities in p)rogress. Colonel Cutler's t urn camne inl Novembher 1943.

IlFe depairted by air from Prestwick, Scotland, onl 27 November and returned

to Lond~on oin 24 D)ecember 1943.

Di uring his Visit, Colonel Cutler wits able to observe a hospital traini

mnovemuent ; general, stat ion, and convalescent. hiospitals inl thle base sections:

and cent-i Sta ion (fig. 49), urgicl teni, n field, evaculatioti. intdcn

valescent hospitals in the Fifth U.S. Army area. Ile inoted the great dtifferenlces

between the North African theater and the European thieater, and, on hIls

return,1, reported,ais follows: ý,

lit NATOUSA the dlistances are great, the transport problem a nightmare (fig. 5PO).

thme hospitalization with tile difficulties of evacuation (fig. 51) seemted hiideialeuate andi the

supply probley is magnified by tile ab~ove coulsieratillns. lin spite of all this thle inieoiiat

dtepartmneit of NATOUS,4A inutst have our wa rut congrat ulat ions.. H ospitals as-sume t reinendous toads: for examplte Genieral Ho~spital No. 21 ( fig. 52) once had as utaniy as 2.4;(N)

patients and 111allY 500n bed station hiosp~itals went over 1,04M) patients! * * * lin the Army

airea, even greater loads were necessary, Moreover, at large share of this load were battle

casualties diemanadinig oil adm11ission i mumediate at tentionu an mid any requiring careful daiilycmi re.

55See~ footnote 48 (2). p. 1047.

" Letter, Cot. E. C. Cutler. 31C, to Chief Surgeon. ETOUSA. 27 to(er. 1943. siiituert :lItmuiort on

Vtsit to NATOUSA arnd Fiftha U.S. Army.
64A-

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1-21 A~CTiIVrITIE 411' SURG;ICAL CIINSI'I'I.N'FS

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128 A('TIVITIES OlF' SURGICAL CONSULTANTS

Closure of wounds

In a global war, such as World War 1I, it was indeed difficult for those

at. the hub in Washington to establish policies which would be applicable

under most circumstances anywhere. Even if it was possible to do so, there

remained the major problem of communicating the ideas in such a manner

that all would receive them and interpret them identically. The incident

next, to be reported, in which Colonel (Cutler was involved, brought. out thes

problemns well.

Colonel Cutler had attended a meeting of the surgical consultants subcommittee of the British Army consultants comnnittec on 12 January 1944.

He was impressed by remarks made by Sir Harold Gillies. lie reported lie

following to Colonel Kimtbrough by letter on 16 January 1944:

Sir IIarold Gillies, lion. eonsultant, RAMC, was present at a Consultants' Meeting

for the first time in four years. He came to emphasize the value of early covering of

surface wounds. IHe emphasized that there was great delay in the use of either plastic

procedures or skin grafting, and urged that the Consultant Group promulgate through all

theaters the desirability of utilizing modern ideas of plastic surgery. I felt he made a

good point and will some day try and write a note for the Bulletin of the Chief Surgeon

.onteerning covering of wounds. whether by delayed primary suture, secondary sutures,

skin grafting or flaps.

These observations by Sir Harold Gillies were most apropos at this time

since the early closure of wounds had only recently been a matter of concern

to the (Chief Consultant in Surgery. The causes for his concern resulted from

two directives which had been issued by The Surgeon General. The earlier

of the two, Circular Letter No. 91, dated 2(; April 1943, concerning amlputations, stated: "Priniary suture of all wounds of the extremities under war

conditions is never to be done. it is permitted after debridlement in certain

abdommiinl, c'hest, and maxillofacial injuries only." The .directive further

stated that the nfillotine or open circular method of amputation was the

procedure of choice in traumatic surgery under war conditions and permitted

the flap-type oplen ol)eration to "be done only in cases in which early evacuation is not contemplated and subsequent closure at the same station is deene(l

possible."

The later directive, Circular Letter No. 189, concerning surgery of the

extremities, was a followup of the earlier. Issued on 17 November 1943, it

noted that cases of gas gangrene infection were still occurring as a result

of treatment of compound fractures and wolmunds of the extremities with

closure of the wound and without thorough debridement. The directive made

the following clear statements: "It is ASICI? 'LY FORBIDI)EN that any

comi)ound fracture or extensive wound of the extremities be treated with

closure of the wound(l * * * It is STRICTLY FORBIDDEN that * * *

amputation be done higher than necessary or that the stump be closed." The

directive, in closing, warned: "Commanding officers of all general and station

hospitals will be held resl)onsible for the abandonment of the improper lpro-
CHIEF CONSU'LTANT IN SURGERY 129

cedures described above and for the necessary instruction and con-iliance

with these directives."'

On 30 December 1943, Colonel Cutler, in a memorandum to Colonel

Kinibrough, called his attention to the fact that these circulars had not been

reproduced in the theater as theater directives. Colonel Cutler informed

Colonel Kimbrough that they had reached commanding officers of hospitals,

however, and that, if they were blindly followed, certain cases would be

forced to have two operations where one would suffice. He asked whether it

would not be proper to request The Surgeon General to reconsider these directives as they might apply to casualties occurring in the Army Air Forces

and to nonbattle injuries, lie suggested that perhaps The Surgeon General

had not given full consideration to the casualty of the Army Air Forces.

In exp)lanation of his stand, Colonel Cutler wrote:

In both of these categories previously healthy and often clean, vigorous young men

reach a hospital within two hours of injury thus simulating civilian hospital practice.

Several have had to have immediate amputation and in selected cases short flap amputation has permitted early secondary closure and even primary closure with highly satisfactory results. It appears to us that there should be a difference in therapy according to

terrain an(d environment. Thus. a sailor knocked into the sea water by a shell fragment

and immediately picked up and taken to a hospital ship and an aviator wounded in clean

clothes. in a clean airplane and reaching a hospital within three hours -nd a wounded

infantry soldier who has lived in a foxhole, covered with mud and clothes in filthy garments

for one or two weeks and who reaches a hospital in 6-12 hours need entirely difTerent treatment at the hand of the surgeon.

Colonel Kimbrough passed Colonel Cutler's memorandum to General Ilawley. The general's decision was to leave matters where they stood with respect

to the directives and to take care of the exceptions to The Surgeon General's

policies Iby l)ersonal instruction within the theater.

Colonel Cutler, however, did not bel:eve that the Chief Surgeon's decision

went far enough. In a memorandum to the Chief Surgeon, dated 24 January

1944, concerning the amputation circular, he made the following suggestion:

I believe it would be unwise to issue confidential instructions which are in any way

contrnry to those recommended by The Surgeon General. It was the intent of my memo

(of 3;0 D)eceember that you might send a professional opinion to The Surgeon General outliniug the situation concerning amputations. I have tried to outline this for you in the attached letter. Would not this be the wisest policy?

General Hawley accepted Colonel Cutler's recommendations and sent the

letter to The Surgeon General asking the question of whether casualties of the

Army Air Forces, for example, did not justify a different type of therapy according to the environment in which they were wounded and the prompt availability of surgical care. The letter also inclosed a "short note" prepared by

Colonel Cutler for pul)lication in the MedicaI BIullet;n., F.TO USA. Titled "The

Importance of Wound Closure," this article read as follows:

"D)o not suture" Is accepted as a major principle in the surgery of battle casualties.

It, however, must be applied Intelligently. For example, it (loes not mean, never, at any

time hereafter, suture these wounds, nor does It imean keep this wound open forever. Yet

the dictum has had the above unfortunate connotation. In fact. many surgeons, once
130 A('I\ITIIS OF SUTGICAL CONSULTANTS

at wound has bieen debrided, sten to relax their interest ill thl wound unless it becomes

septic. This leads to long hoslpitalization and late return to duty. Moreover, to let a

wound heal by cicatrization often leads to urt iwessary stiffness in the lipart and even liinitatioln of function.

We inust all consider aniother lprilnciple when we leave ia WOuld open, which is, the

best way to sterilize a wound is to close it. No antiseptic is eflual to overlying complete

eI)ithelizatiol, whether it be achieved by delayed primary suture, early secondlary suture,

skin graft or flap procedures. Indeed, we owe much to our plastic surgical colleagues who

conistanitly reiterate tile ililportanice of a closed wound.

With these two principles in mind let us return to it consideration of the battle casualty

and the relation of his injury to terrain and environment. The man wounded in the battlefield where he has been wearing the same suit of clothes for three weeks and wilo is covere(d

with iiud and dirt experiences the saite wounds as an airman in his clean clothes, fresh

from a bath, or the sailor blown off the deek of his ship by a lbimb splinter. True, when

surgery is first applied it is wiser to follow the diettim "do not suture the wonid". But

there analogy ceases; the foot soldier's wound is inevitably seriously contaminated, that

of the airman or the sailor swimming in salt water has a minimum of infection. It the

case of thie foot soldier, delayed primary suiture or secondary suture ({'ii only Ie practiced

infrequently ; in the case of the airman and the sailor it should be practiced almost as the

rule.

A recent study in E.T.O. with early closure yields light upon this point. A study was

inade of the wounds of casualties who had been given penicillin therapy, or sulfonamide

therapy, or no chemotherapy. An outstanding observation was that those wounds closed

early, irrespective of chemotherapy or none, healed well. When there was delay in closure.

infection resultetl. And 110 great choice was made which woumls to close early and wvhieh

to leave o(peln.

This matter is again bIrought forward because it appears that tlie inestimable advantages of all epithelial covering are not generally recognized. If early closure cannot

be accomilished. then early grafting or even flap procedures should be carried out. The

difficult ies of these latter procedures are increased by cicatrization.

Not to suture a wound initially is good practice. To fail to close it at the first safe

moment is neglecting an opportunity to protect the soldier against further infection and

loss of function.

The reaction in Washington, upon receipt of General Hawley's letter and

Colonel Cutler's inclosure, was quick and sensational. First, there was a reply

from General Rankin, Chief Consultant in Surgery, Office of The Surgeon

General. The letter, dated 3 February 1944, stated:

General Kirk showed ine your letter of January 2411h relative to amputations and.

since there was an enclosure froii Cutler on The Importance of Wound Closure. lie asked me

to drop you a line relative to this. I believe he intends to answer your letter, insofar as

amplliUtlations tire con(erned, himself.

In a word. we neither of us agree with nip modification of the amputation program.

I ami sure that the wide experience of General Kirk and other men fromn tei last war who

dealt with amputations has resulted in giving us a program which is pretty nearly as

satisfactory as one (can have, aind when it conmes to fashioning tfaps. et cetera. I think that

we will have to disagree with our colleagues. I just can't go along with the hypothetical

case of the young airnman, either in the question of flaps for his amputation or in the proposed wound closure such as Elliott Cutler outlines. If there is one thing that I thought

we had learned from the past war and from our experiences in this war. it is do tiot closc

wounds primarily. I don't believe there is any evidence ait till that this should be deviated

from. I eannot agree with Cutler that infection results when there Is delayed closure
CHIEF CONSULTANT IN SURGERY 131

because of the delayed closure only. Infection results because infect.ion is there. I am

perfectly sure that any deviation from this principle will be followed by profound repercussions. There may be 1 percent, or even 5 percent. of wounds which, when operated upon

early, may be closed with relative safety, but the 95 percent (and prolbably M) percent) of

war wounds, regardless of what service they are in, are better left open, in my judgment.

One cannot visualize experien, I surgeons always present when people are wounded under

seemingly satisfactory conditions for closure and the great difficulty, as I see it, is that

the example will be followed by inexperienced men in unfavorable conditions. We had the

same thing to deal with here in the States in the treatment of compound fractures occurring

near canips produced by accidents in motor vehicles. These fractures resembled in all

details those of civil life and were frequently gotten into hospital within one to three hours.

It was with the greatest difficulty and only after numerous directives that the Surgeon

(;eneral's Office was able to compel the surgeons to leave these wounds open, more as an

example and a lesson than anything else because many of them could be closed safely, but

not in war wounls. I have no hesitation in placing myself oil record that we still adhere

to the principle of no closure. I think that I can buttress this with the experience of the

surgeons in the Tunisian and Sicilian campaigns and I am sure that their records show

that a great imany people developed serious complications both in the closure of wounds

and in the packing of wounds, which is equally undesirable.

On 4 February 1944, Maj. Gen. Norman T. Kirk wrote a letter to General

Hawley containing the following:

Much bone length has been sacrificed by these methods. I am sure that the chances of

infection are less in Air personnel and in the Navy with men aboard ships. However, I

have seen many infections occur in operating rooms under what were supposed to be ideal

aseptic conditions and when elective rather than emergency surgery was being performed.

I don't believe that a wound has to be full of mud, manure or cinders to have streptococcus,

staphylococcus or even gas bacillus present in it. Peterson, in a recent tour of our hospitals.

found three amputations here at home where debridement and primary suture were carried

out within the critical period and gas gangrene occurred requiring amputation to save

life. I have seen other cases so treated and the wound closed. The doctor said he took

a chance and got away with it. The patient took the chance, not the doctor. Also. the

patient didn't have a vote and wouldn't have knowin how to vote.

The Consultant in North Africa finds that many of these wounds, at the end of eight

or ten days. with the assistance of penicillin, sulfa drugs or none of these agents. may be

safely excised and secondary suture performed. I am in accord with this, particularly

in superficial wounds, to get men back to duty earlier. It may be applicable to compound

fractures with destruction of large muscle masses. I am not too sure about this. however.

It is accepted that the flap type guillotine may initially be performed if that patient

is not to be transported and can ire held under observation in a given hospital but the

following must be weighed and when this is considered: traction is applied with difficulty

and traction made by the us(e of sutures through flaps causes necrosis of tissue followed

by infection. Bone length almost always has to be sacrificed when this method is employed.

We are getting back too many below-knee stumps from overseas that are too short to be

fitted with prosthesis. We are also getting many back with skin grafts. This is not at all

necessary. The circular type guillotine of the thigh with promper traction will lie healed

in six weeks and will stay healed. If it is closed primarily, too many cases of osteomyelitis

will develop, too much shortening will be occasioned and the resulting stumps will frequmently not be satisfactory from the prosthetic standpoint.

As you can see from the above, I am not at all in accord with your policy of handling

your Air casualties. I know everything is going to speed these days and speed is a great

thing butt no matter how fast, a plane cmanl fly if the motor is cut out in flight it, soon flops

70_-O95' 64- 12
132 A('TI V1TIEs O S1URG(ICAL CO NSU'LTANTS

anid it. doesn't -arrive ait its (lest hint ion. A lot more spleed calli be obItahined if $011114 prinlciples of surgery tire at the saile' timie observed. In the( last war lives were lost, ~is well as

extremities, front primary closure ats wvell as too early 5e4'ond~ary closures. .No surgeon,

no mnatter how expert. (taill alwvays do it compillete (leIridlemielt oIf at wound. If t hat were

true we would not he having thle increase in thle Incidence of gas gangrene in Italy. And

I aia very afraid of wvhat that inacidence is going to Ile Whvle we get into thel (Continent.

I stil also a fraid that at lot of it is going to develop uinder plaster, with disastrous results.

IT iider thiese~ c~ii itlinstatces, G;eneralI Hawley's instruct ions to thIe Chief,

Professional Services Division, oil 16 February 1944, were simply: "This policy

will he followed iii. ET0. Impl)emeneit.''

Tito impjlemenetationI was (lone 1)3 publllishinig Thle Smrgeon (3elei'al~s ('if--

citAr eter NO. M) as Circular Letter No. 28, Office, of tile Chief Sit-rgeonl,

E'1' )IsA,, 1 March 1944, Sect ion I of whichi wats titled1 "Surgery of the

Extremities." Oni 21. Februa1rN 1944, C olonel Cutlier ilifomnled General Ranikini

I)V letter thlit, this wvns lbeing donle. li[e exp~lained as follows:

I feari you (lid not. quite umnderstan 1114 y little note onl *1'he imiportanice oif wound

closure'. It biegins w~ith ti li senitence: " 'IM not xtititrc' is accept ed ats thle mlajor pirinciple

inl thle surgery of baiitile casualties". What I was interested iii was to have our surgeonsm

remieimbe(r t ha t there also wats somiething to hel dlesired iii closing the wound eventually so

that the mani could1( be returned to (luty. Everyone hill- emiphdasizAed *do not stitutre .1 wounid"

so mnuci that the( young surgeon takes no0 interest iii his wvound after it is once iiiade, and

wvolii~ls which could lbe closed oili the( secolild to fifth (lily by delayed secondary suiture or by

sklin grafts during the samie period tire left to slowly grainulate. thlus keeping a miani in

hiosplitai Somiietie iti4' iiiouitl or imore after hie should have been (discha rgedl. I hope y'ou

and thle 'Surgeou1 General dto not for at mnomlent think that we are- prac'licing tile primary

closure of wvounds.

The Surgeoni Genmeral iIn his letter says: "I amn not ait all iii a(ccordanice with your

Ix)licy of handling your air casualties". I canno~t find we have done anything lie would not

approv(ile (If. TIhere have been fewv ampi~utations with thle Air Force and only one( in wvhich

very short flapks were uiiade. In this case the wound was closed 113' deliayed secmondary suiture

the( next day, anud healed forthw~ tli. It wats anl arii which laid been blown off by rimcket

shell iii the Schiweinfurt raid, at about tite jUnCtioii (If thel moiddle an1d ul1Iller third. Every

at temipt is made hiere to leave ats iiiuoli bone as poissibile andl( I feel certain that if you and

the Suirgeon Genieral could visualize our work in those hospitals serving f lie Air Forve you

would lhe most hiappiy, as are Genieral G;row~ and those responisible for the medical care oif

the( Air Force Itself.

IFoi'utuimtely. only a few weeks later, General Kirk anid Genieral Gr'ant

(fig. 55) , thle chiief mted ical officers of thle Armiy andt( the Army Air F~orces,

resjiectively. wvere sent. to time European theater for thle sp)ecific. p~urpolse of

reviewving h~osjpitalizat ionl facilities for' tile Army Air' 1orees inl tile ITnitedI

Kinmgdomi. It wats Colonel Cutlter's privilege to accomnpany and gutide thlemm

through tilie mlay inst it 11 hionbs dlevotedl to tite car'e of air- casianitie's. Ill their

tolif. of tit(e hospitals, whlichi Iegaim onl 9 Ma rch 1944 and cold inued almnost.

wit~hout, a break through 17 Ma rch. there wvas coimpl1 et e sat isfact ion ill tilie

su~rgicail Carec which was beinmg provided.--.

1- Meuiorim rid u,i C'ol E. 14'. . Cutle'r. INC. for Maj. (w n. N. TI. Kirk. 24) Afa r. I1944. sibJeet : Tolir of

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134 ACTI VITIES OF SURGICAL CON)SULTANTS

duicting at the 2d1 General Hosp1 ital Nvith the adlvice and hielp of Prof. Howard E.

Florey and Dr. M~ildred Florey, his wife. By the op1)ortune arrival of more

penicillin inl September 1943, Coloniel Schutllinger was able to continue his

work andl bring it to a conclusioni in 'March 1944. Colonel Schullinger gave

the following account of these early experimenes: 5

Shortly after thle Second General Hospital arrived at Hleddington. Oxford. in July

1942. the University faculity as well as some of the hospital staff members held a reception

for the "invaders" at Christ College. It w'as a most interesting and enjoyable occasion.

Here it was miy good fortune and privilege to mneet 1'rofessor Howard Flore~y. 1Director o'f

the Sir Willianm Dmiiii Research Laboratory, and his wife, Doctor 'Mildred IFlorey. In the

course of our conversation, they spoke of their exciting studies with penicillin and invited

mie to visit their lab~oratory. The invitation was eagerly accepted. The attractive and

well built laboratory was situatedl onl a quiet street. not far fromn Rhodes House. Once

insidle, the visitor could sense an atmosphere of considerable activity. As one passedi the

various research units,. it was apparent that doctors and technicians were busy and intent

onl their wvork. Professor Florey's studly was a spacious oval room on thle second floor

flanked wvith bookshelves and tiles. In the center was a large table covered with papers

anol periodlicals inl -orderly disorder" and, at the end, nearest the wvindow, wvas Professor

Florev's chair. No matter how busy he was wvith his studlies, correspondlence. and writings,

the visitor was always received wvith a wvelcomne smile andl anl invitation to join his

comnpanfy.

It soon became applarent that here a great project was in full play. Professor Florey

was at the helm, dhirecting the technical aspects in the production and refinement of

penicillin, aild consulting wvith his wvife, w~ho carriedl out the clinical application of this

new antibiotic. The process of preparing penicillin wvas so laborious in tile early phases

of this wvork that only carefully selected (cases could be chosen for this therapy, In fact,

thle amlount. of penicillin was so limited that the urine of patients undtergoing treatmlent

was saved and returned to the laboratory for extraction andl repuritication of the penicillin

for subsequent use. S.omnetimes the supply of penicillin gave out completely, thus niecessitating temporary discontinuance in critically ill patients%. These were trying :Ind discouraging moments.

Thus, (luring the autumn and wvinter months of 1942-1943, the writer enjoyed the

unusual privilege (of wvitnessing the clinical application of penicillin to patients in some

of the British military, civilian, and E.M.S. hospitals. Several trips wvere also made to the

RAP Hospital at Hlolton. Wherever she wvent, Doctor Florey took careful notes, and

maeasuredl out the dosages wvith precision (perhaps two to five thousand units per (lose)

for the inext twvo or three (lays. The results wvere usually (dramatic. Here was a boy

wvith a fulminating heinatogenous osteomyelitis whbo responded promptly to "large (loses"

(10,000 units every four hours) of penic'illin and required no operative interference. Ill

the Radeliffe Infirmary a young army officer with cavernous sinus thrombosis andl sepsis

recoveredl after a fortnight of penicillin therapy. Infected wounds seemled to improve

ralpidly wvith local app~lications of penicillin. A penicillin cream wvas used for certain

types of burns.

Observing the clinical aspects wvith D~octor Florey, and discussing the overall problem

at various times with Professor Florey, it was obvious that here wvas anl agent that wvould

be of enormous benefit both for military and( civilian purposes. Colonel Elliott Cutler was

coinsutlted and it w~as decided to requisition a supply of penicillin "through channels" via

tile Chief Surgeon. E.T.O. Unrfortunmately. tile supply in U.S.A. was quite limited and

1,Thim account was ohtnine(I from Dr. 8-chullinger loy William S. 'Midd~leton. .DChief Medical

IDireetor. V,.teranm' Admnimlttratlomu. D~r. Middletoni. who wa-4 formerly a colonel in the Medical Corps

and ('lute ('omsimitant In Medicine' 1m the- Emurolemum theater forwardbed the paper to CIol. iT. It. Comites, Jr.,

Mtc. Iy letter, 26 A~umgust 195T7.
CHIEF CONSULTANT IN SURGERY 135

there was none available through British sources. After a considerable interval another

attempt was made to obtain the precious material by enlisting the British Research

Council to make a ldirect appeal to the O...1). Meanwhile, Professor Florey had flown

to the Eighth Army in North Africa to study the effect of penicillin in its local application

to septic war wounds.

Finally, on 8 May 1943 a consignment of one million units, valued at one thousand

dollars, arrived at the Second General Hospital. It was prepared in powder form, sealed

in 10.0WA unit vials. The consignment was locked in the ice-box next to the main kitchen.

A consultation was then held with Professor Florey. Colonels Cutler, Kimbrough. and

Storck, as well as Major Sloan and the writer, in order to formulate certain policies on

usage and dosage.

Although the penicillin was to be administered only to members of the U.S. Forces,

it was difficult indeed to deny urgent requests from neighboring British military and

civilian hospitals. The first case to be treated was a young Air Force lieutenant with

staphylococcus osteomyelitis of the left femur secondary to flak and shrapnel wounds of

the thigh and pelvis. Other cases soon followed, chiefly infections secondary to injuries

and wounds. This continued through the late spring and summer of 1943. At the same

time. instruction courses on the use and preservation of penicillin were given at the

Second General Hospital to officers on detached service, and this was continued well into

the spring of 1944.

During the winter of 1943-1944 the writer presented results of penicillin therapy

administered to patients in General Hospital Number Two at various U.S. Armur Installations in England (Tavistock, Winchester, Leamington, etc.). Of considerable nterest was

the reported recovery in January 1944 of a British soldier, at the military hospital in

Shaftsbury, stricken with Staphylococcus aurcus pyemia and endocarditis. IHe received

a total dosage of five million units. Finally, on 11 February 1944, through the kind offices

of the late Sir Arthur Hurst, it was the writer's privilege and honor to address the faculty

and students at Guy's Hospital on penicillin therapy, based on clinical studies at the

Second General Hospital.

During March 1944, sufficient penicillin had been received as to permnit formulation

of directives for its use at various U.S. military hospitals in the United Kingdom.

Already plans were being drawn up for penicillin therapy in advance combat areas.

On 29 March, the documented report on penicillin therapy at the Second General

Hospital was submitted to Colonel Elliott Cutler.

Thus, in brief, the reader may appreciate the role played by one of the U.S. Army

hospitals in Britain in the clinical application of penicillin therapy during the earlier years

of its development (1943-1944). It would be impossible to give adequate expression of

appreciation and gratitude to Sir Howard and Lady Mildred Florey for their many kindnesses, gracious hospitality, and warm friendship, not to mention their unselfish expenditure of time and interest in counseling and encouraging the writer during this stirring

period of study at the Second General Hospital in Oxford.

An abbreviated version of Colonel Schullinger's final report was forwarded by Colonel Cutler to The Surgeon General.6 ° The summary portion

of the report read, in part, as follows:

A somewhat varied group of forty cases, treated with penicillin in this theater between

May 1943 and March 1944, has been collected and presented. Twenty-six were improved or

cured, seven had doubtful or equivocal results and seven were failures. Five deaths

occurred, In which three may have succumbed to other causes or, at best, to distantly

related circumstances. * * * The forty cases comprised two main categories, namely

SEssential Technical Medical Data, European Theater of Operations, U.S. Army, for May 1944.

dated 14 June 1944.
136 ACTIVITIES )!' SI'RGI('AL CONSULTANTS

infections and prolph1ylactically treated wounds. This report does not include sulfaresistant gonococcal urethritis, lues, fresh hattie wounds or medical infections, such as

meningitis or pnliumonia. * * *

An effort has been made to point out the necessity for strict adherence to the

criteria governing proper penicillin therapy. The indications for therapy should be carefully considered and evaluated, before resorting to active treatment. Actual dosage

should not be according to fixed or dogmatic rules. but should be governed by careful

bacteriostatic control, because of the variability in excretion rate. Inadequate dosage

predisposes to the development of penicillin-fast strains. However, complete bacteriostasis, throughout the whole interval between doses, may not be essential. On the other

hand. some strains have a natural resistance even though the family is ordinarily

sensitive. Contrariwise, we have encountered two sensitive strains of Streptococcus

0iriduns. The duration of treatment should be ample, particularly in the staphylococcal

infections. * * * Many of the patients, with successfully treated infections, followed a

fairly typical lattern: the improvement was gradual, the temperature fell by lysis, they

looked and felt better, the appetite increased, sometimes quite markedly, there was less

need for opiates, and the hemogram became normal. In those cases with infected wounds

there was a marked diminution in pain, swelling and discharge, with rapidly appearing

healthy granulations and accelerated healing. The route of penicillin administration

was intramuscular, intravenous or local, sometimes in two, or even all three combinations. * * * The locally treated infections illustrate the remarkable efficacy of relatively

small amounts of penicillin. * * * The number of equivocal results and failures in the

present series suggests a lack of proper selection or inadequate therapy or p)oor management.

* * * * * * *

The prophylactic treatment of the group of compound fractures wias most encouraging.

This was due, in large part, to the short duration between injury and operation, the

relative cleanliness( of the wounds in the successfully treated patients. the skillful management by the experienced surgeons, and the local and parenteral administration of

penicillin. The advantages of converting a compound fracture into a simple one is

obvious. * * * The treatment of these compound fractures unfolds new possibilities in

war, as well as civil surgery. Nevertheless, with few exceptions, primary closure of

compound fractures must itrcr be practiced in the forward areas.

Elsewhere in the report, Colonel Schullinger warned: "* * * the writer

cannot too strongly emphasize the importance of adhering to sound surgical

principles in the treatment. of patients with penicillin. To neglect such practice,

with the expectation that penicillin (-an perform miracles, is pernicious, and

may even jeopardize a patient's life. It demands too much of penicillin

and nothing could place it more readily into disrepute.'

The study by Colonel Schullinger was, actually, a clinical trial of penicillin

and not an experiment in the classic sense. The question of the efficacy of

penicillin when used prophylactically was a paranmountt one because of its

great implications for surgery in the field. True, Colonel Schullinger's studies

had included eight. compound fractures in which penicillin h(ad been administered prophylactically. Six of the eight had improved or been cured, one

was a failure, and the other resulted in death in which the result of the i)rophylactic use of penicillin was equivocal. Furthermore, except for a clinical

appraisal, there was no way to he absolutely certain that, the improvement or

,cure of the six cases was due as much to other extenuating circumstances and
CHIEF C'ONSULTANT IN SURGERY 137

the exp~ert surgery available as it was to the prop)hylactic use of p)enicillin.

Therefore, oin 10 Sep)tembder 1943, Colonel Cutler conferred with General

Hawley and later the same day reported to Colonel Kinibrough lby nilemoranldnas follows:

The experience thus far in the use of this bactericidal agent has been largely ill thle

treatment of chronically infected wounds. Our own experience as well as that of Mrs.

Fiorey does not reveal that this agent is as universally satisfactory as has been wvrit ten.

Recently, Professor Florey and Brigadier Hugh Cairns have returned froin North Africa

andl Sicily. where penicillin is now being placed in fresh battle casualty wvounds wvith a

sulfonamide. Thus there is no proper control of the efficacy of the agent.

We have an opportunity with fresh battle casualtie-s in our Eighth Air Force of testing

out the value of implanting pe-nicillin shortly after wounding. I have prop)osed to General

Hawley. and it has his approval, that we conduct proper conltro~lled experiments with casualties fromn the above source, treating every other battle casualty in each of our 6 station

hospitals with the 8th Air Force with penicillin.

The proposal wvas also approved by General Grow, Surgeon, Eighth Air

Force. Initially, Lt. Col. (later Col.) Williamn F. MacFee, 2)d Evacuation

Hospital, was placed on one inon1th's temporary duty as a special consultant

with the Eastern Base Section to supervise and control thle study. Later., as

the project continued with the advent of more penicillin, Lt. Col. (later Coi.)

Paul C. 'Morton, MC, and Capt. (later 'Maj.) William R. Sandlusky, M C, wvere

assignied to the project. Colonel Mlorton eventually assumed primary responsilbil ity for the study after the relief of Colonel MlacFee.

The first problem in getting the study started was penicillin itself. Where

was the supply to come from ? Of the original su~pply which had atrrivedl in

May 1943, there was little left. In thle London (depot, howvever, thle re were T_2)00,-

000 units remaining of a sup)ply which had been sent to he used for sulfonamnideresistant gonorrhea. The only other purp~ose for which this could be, used was

in cases, of overwhelming infection where the saving of life was involved. Coloniel Cutler calculated that 5.100,000 units of th1e original penicillin had been

used[ for lifesaving purposes or for the treatmenit of gonorrhea and wvas able to

recoup this amnount, in exchiange. fromn the stock in the depot.(" This supply

enabledl the studyl to gret. underway. Slhortly thereafter, General Hawley ruiled

that. any amnount of the penicillin being received for the trea~tment. of sulfonamidle-resistant gonorrhea, could be used for the surgical p~enicillini work . -

This decision permitted the distribut ion of 5.000,000 additional units to thle

stuldi mnare onl air force personnel and thle .5,000,000 units previoulsly mnentionedl

to the 2d General Hospital for Colonel Scluillinger's project.

Meanwhile, to insure a continuing supply of p~enicillin for the limited

purposes for which it was then boeing used, over and .evond that which had

been requested for sulfonamide-resistant gonorrhea, Colonel Cutler had advised the Chief Surgeon to make a request, for an increase in thle, proposed

"I Memorandum. Col. E. C. Cutler. MC, to Col. J1. C. Kinibrough. '.t(. 14 Sept. 1943, subject:

Re withdrawali of 5,100O.000 Units of Peneicllin Nowv in London 'Medicnl Depot.

62 Memiorandum, Coli. F. C. Cutler. MC, to Col. .1. C. Kimbrougli. Me. 18 Sept. 194:1, s-ubject

Penicillin Suppiy.
138 ACTIVITIES OF SURGICAL CONSULTANTS

monthly allotment of penicillin for the theater. When the Chief Surgeon accepted this advice, thie following letter was prepared by Colonel Cutler for

General Hawley to send to General Kirk:

This communication relates to additional supplies of penicillin desired In the ETO.

Our instructions from your office are that you will send us a supply of penicillin for treatment of sulfa-resistant gonorrhea only. We have already submitted data on the number

of units of penicillin necessary to treat the expected incidence of this disorder according

to the troop basis. You have already shipped to the ETO for this purpose 20 million units.

Preliminary reports suggest highly beneficial results.

In addition to the above supply for "sulfa-resistant gonorrhea only" there was donated

to this theater, on 3 May 1943, 18 million units. This has been used in close cooperation

with Professor Florey and at present writing less than 2 million units remain on hand.

Our Professional Services Division are extremely anxious that additional supplies of penicillin be available for use in the ETO for the following purposes:

a. Treatment of cases with gas gangrene

b. Pywoccal septicemia and serious osteomyelitis cases

v. Treatment of certain of the meningitides

d. For a study of the value of penicillin when instilled into freshly acluired battle

wounds.

We feel that we have an Ideal set-up for properly controlled studies in the last category.

Amongst casualties returning daily In our "bombers" the flow of patients is steady but

not so pressing as to detract from the careful care and consideration. No other group of

patients will present a better opportunity. We would like to treat every other patient

without choice by placing penicillin in the wound and using a certain amount parenterally.

We will have the opportunity to conduct proper bacteriological and other laboratory tests.

Heretofore in this theater the use of penicillin has largely been carried out in chronically

infected wounds where the multiplicity of organisms and the extent of infection mitigate

against great success by any single remedy.

The British penicillin group, of which Professor Florey and Brigadier Hugh Cairns

are the leaders, have just returned from the active theater below us. There, penicillin

is being instilled into fresh battle casualties, but always in conjunction with a sulfonamide,

which will give us no absolutely positive evidence.

Supply

For the above categories of penicillin therapy we would like a monthly supply amounting to 50 million units a month for the present, in addition to that sent for the treatment

of sulfa-resistant gonorrhea. We could easily use more and we are disturbed that our

Canadian colleagues have been promised large amounts when it appears to us that we

have a great opportunity for a competent study. If this request is granted. could a prelimninary fraction be flown over shortly?

Because penicillin loses potency rapidly after being removed from the refrigerator

and when in any other form than when dried and hermetically sealed, we would greatly

prefer our units to come in the 10 thousand unit ampoules, as in our first lot, than in the

100 thousand unit ampoules, as In the second lot."

The supply of penicillin seemingly assured, the controlled study on the

effiwacy of penicillin used l)rol)hyhactically in combat-incurred woun(is of aircrews was continued until March 1944, as was the study being conducted by

Colonel Schullinger. The March termination of these studies was decided

upon in order that final reports could be prepared for inclusion in a penicillin

0 Letter, Brig. Gen. P. R. Hawley to MaJ. Gen. N. T. Kirk. 17 Sept. 1943.
CHIEF CONSULTANT IN SURGERY 139

fasciculus to the April issue of the i Brit ish Joiutal of Surgery. (The fasciculus

was itter postponed to the July issue.)

In the study made on air force personnel, there were eventually 250 wounds

occurring in 146 patients which were available for comparison. In the penicillin treated group, there were 68 patients with 123 wounds; in the control group,

78 patients with 127 wounds (table 1).

The final report of the studies mentioned some of the following

observations:

It should be clearly understood that the object of this study is not to determine

whether penicillin is effective in established wound infections, but rather to learn whether

penicillin, used prophylactically, will prevent or lower the incidence of infection in the

wounds of aerial combat in a theater of war where early definitive surgery and continued

observation can be carried out.

The wounded patients were divided into two groups. Those in one group were given

parentera. and local penicillin prophylactically * * * Those in the other group received

no ehemotherapeutic agent and serve as controls.

TABLE 1.-Comparison of infection rates, with respect to woundl, in patients receiving penicillin prophylactically and in controls (patients receiving no chemotherapeutic agent)

Wound category and patient group Wounds Infections Infection rate

Number Number Percent

Compound fractures: 1

Penicillin-treated patients ----------------------- 38 6 15.8

Controls -------------------------------------- 28 5 17.9

All patients --.------------------------------ 66 11 16. 7

Soft-part wounds:

Penicillin-treated patients ---------------------- 85 5 5. 9

Controls -------------------------------------- 99 6 6. 1

All patients ---------------------------------- 8 4 11 6.0

Total wounds:

Penicillin-treated patients ---------------------- 123 11 8. 9

Controls -------------------------------------- 127 11 S. 7

All patients.-------------------------------- 250 22 8. 8

Excluding skull fractures.

Penetrating wounds of the abdomen or thorax or burns are not included in this study.

The policy has been to administer sulfonamides or penicillin or both to all such patients,

therefore no group of control cases is available for comparison.

The local dosage for wounds involving only soft tissue varied from 5,000 to 20,000 units

In accordance with the size of the wound. Wounds associated with compound fracture and

soft part wounds In the region of the anus or buttocks received from 10,000 to 40,000 units.

In a limited number of instances, doses as great as 100,000 units were administered.

The usual method of preparation for local application has been to dissolve the sodium

salt of penicillin in sterile physiological saline solution in amounts of 1,000 units of penl-
140 ACTIVITIES OF SURGICAL CONSULTANTS

cillin per cubic centimeter. This solution was sprayed on the wound by means of an

atomizer. Another method only recently developed has been the insufflation of a mixture

of penicillin powder and dehydrated human plasmna on the wound surface. Ten thousand

to 20,000 units of the sodium salt of penicillin to 0.1 to 0.2 gin of plasma has been found

to be a satisfactory combination.

The local use of penicillin was combined with parenteral administration. The practice

was to give intramuscularly 10,000 units of the sodium salt dissolved in 1 cc of physiological

saline solution. This dosage was given immediately following operation and was repeated

at three-hour intervals. Early in the study parenteral administration was continued for

three days, but subsequently this was reduced to 48 hours.

At the time of operation the debrided tissue from the majority of the wounds was

placed in sterile wide mouthed bottles and saved for culture. Following debridenlent and

irrigation the wound was again sampled for bacteriologic examination. This was done by

gently and thoroughly passing, over all parts of the wound, a sterile cotton swab. which was

later cultured. In the beginning of the study only aerobic cultures were done. Later, four

of the hospitals had facilities for anaerobic, as well as aerobic cultural methods.

The results have been judged solely from the standpoint of wound infection. The

criteria for infection required the presence of one or more clinical signs such as tenderness.

swelling, redness, lymphangitis, lymphadenitis, the presence of purulent discharge or Infected hematonla. In wounds which were left open a distinction has been made between

those having simple surface contamination and those showing clinical infection. The

presense of organisms on the surface of an otherwise healthy wound is not considered

infection of that wound.

The findings are presented in the tables [table 1]. The differences in percentage

between the infection rates in the penicillin group and control group in each instance are

not of statistical significance.

Time results indicate that penicillin, used in conjunction with early definitive surgery

did not lower the incidence of infection in such wounds. We cannot too strongly emphasize

that our findings are not to be compared nor confused with other studies in which penicillin has been used to treat established surgical infections.

It is obvious that penicillin used prophylactically in the manner herein described did

not p)revent the development of gas gangrene in two patients. The role of this agent in

modifying the infection, altering the toxicity, or in combatting secondary invaders cannot

be evaluated at the present time.

* * * there are several points of interest from the bacteriologic standpoint. One has

been the finding of a high percentage of contaminated wounds in aerial casualties [1.5

percent.] * * * The predominant organism has been the staphylococcus. Another containinant worthy of note is the clostridium. Tile Incidence of this organism in cultures of

the debrided tissue increased as improvements were made in the anaerobic methods in

the different laboratories. In one of the laboratories, when anaerobic as well as aerobic

cultures were (lone routinely tile incidence of clostridia (anaerobic gram positive bacilli

in the debrided tissue was 24 percent. Equally noteworthy has been the infrequent recovery of streptococci and(] enterobacilli. Another interesting finding has been the persistence of contaminating organisms in almost three-fourths [71 percent] of the wounds after

debridement and irrigation."

Early in the course of these studies, three cases of gas gangrene developed,

and ultimately, there were seven cases of gas gangrene occurring in patients

who had received therapeutic penicillin. Six of the seven were in wounds in-

" E.ssential Technical Medical Data, European Theater of Operations. U.S. Army. for May 1944.

dated 14 June 1944. Inclosure 9, subject: Observations on the Prophylactic Use of Penicillin in the

Wounds of Aerial Warfare.
CHIEF CONSULTANT IN SURGERY 141

curredl as a result of air coiml)at or air crashes, an(1 five of the seven had also

received p)enicillin p)rol)hylactically at the time of initial definitive treatment.

The occurrence of these cases, Colonel Cutler knew, was very significant,

since, at this time, many had high hopes that penicillin couhl forestall or prevent

the serious comp)lications of gas gangrene in war wounds. Penicillin in vitro

had exhibited a bacteriostatic effect upon the organisms frequently associated

with gas gangrene. Certain clostridial infections, experimentally induced in

laboratory animals, had also been treated as well as prevented by the inoculation

of penicillin. On the other hand, there were very little data on its effects on

clinical gas gangrene.

At the first opportunity, Colonel Cutler presented a report on the findings

in the three early cases. This was at a meeting of the Section of Experimental

Medicine, Royal Society of Medicine, on 9 November 1943. A final report of

all seven cases was prepared by Colonel Cutler and Captain Sandusky to accompany the reports of the other two studies-those of Colonel Schullinger

and Colonel Morton. The early report and the final report emphatically

brought, out that the use of penicillin in these cases had not p)revented the development, of gas gangrene.

The final report observed:

While it is unwise to draw conclusions from so small a group of cases, we are so linpressed with the fact that out of seven cases of gas gangrene. only one proved fatal and

two recovered without loss of limb. [The fatality occurred after amputation as a result

of uremia. Microscopically the kidneys showed hemoglobinuric nephrosis. At time of

death, the local clostridial infection appeared to have been controlled.]

Equally impressive Is the fact that of the recovered cases in no instance was a fatality

apprehended. Each of the seven patients had the benefit of early diagnosis, prompt surgical extirpation of the infected tissue, therapeutic penicillin, large amounts of gas gangrene

antitoxin and frequent blood transfusions. With so many factors tending to influence the

outcome, it is difficult to estimate the value of any single one. * * *

For the group as a whole one conclusion is obvious and outstanding: Penicillin used

prophylactically in the manner herein described did not prevent the development of gas

gangrene. * * *

There can be little doubt but that penicillin is effective against many of the organisms

which are found amongst the multiple contaminants in the wounds of battle casualties.

Also a reduction in the devitalizing and even destructive effects of such other organisms

tends to prevent a suitable medium for growth of the clostridia. At the same time this

small experience does not fall in line with published and confidential reports to us that

"penicillin is extremely effective in gas gangrene." '

In addition to these experiments, Colonel Cutler had information from

many other sources, chiefly from the British. Of particular importance, in this

respect, were meetings of the Penicillin Clinical Trials Committee and the War

Wounds Committee of the Medical Research Council. As early as the 12 October 1943 meeting of the Penicillin Trials Committee, there was already information available to Colonel Cutler on the results of penicillin used prophy6 Esspntial Technical Medical Data, European Theater of Operations, V.S. Army. for May 1944.

dated 14 June 1944. Inclosure 10, subject: Treatment of Clostridial Infections With Penicillin.
142 ACTIVITIES OF SURGICAL CONSULTANTS

lactically and theral)eutically in actual combat, for much of this meeting was

spent inl discussion of the Florey-Cairns report.bb In a memorandum, dated

16 October 1943, Colonel Cutler wrote to Colonel Kimbrough:

Professor Florey gave us a summary of the report of the Penicillin Commission which

recently visited North Africa and Sicily. Ile made it clear that experience in that area

had shownt that placing some 50,000 units of penicillin even in a septic wound as late as

3 days allowed a great percentage of the wounds to close immediately and prevented the

occurrence of osteoinyelitis in compound fractures. This report will be of the utmost

importance to us, for the matter of dosage now assumes a major prohlem. Professor Florey

reported that calcium salt was as a rule used in conjunction with a sulfonamide in soft

part injuries, hut that where fractures were present larger amounts were used uip to

750,00) units, and here sodium salt is used.

While these efforts were being made to gain as much information as possible

on penicillin, Colonel Cutler also had to define the purposes for which it could

be used. who could use it, and how it was to be used as greater amounts became

available.

The first "penicillin circular," prepared in draft by Colonel Cutler, was

Circular Letter No. 176, Office of the Chief Surgeon, ETOUSA, issued on

7 December 1943. The circular letter stated that penicillin was being issued

to all general hospitals and the 49th and 121st Station Hospitals. It limited

therapy to: (1) Patients suffering from overwhelming infections whose lives

might be saved by the use of penicillin, (2) patients suffering from sulfonamide-resistant gonorrhea, and (3) patients suffering from infections which,

although not immediately endangering life, manifested symptoms which did

not respond to the usual treatment. The selection of patients at hospitals

supplied with penicillin was made a responsibility of the commanding officer.

In hotpitals not supplied with penicillin, commanding officers were instructed

to request base section surgeons for permission to use penicillin in any particular case. If the request was approved, penicillin could be obtained from

the nearest hospital supplied with it. The circular letter further stated that

instructions regarding local and systemic administration of penicillin would

be issued, as necessary.

The instruction to using hospitals was, of course, given to individuals

concerned at the 2d General Hospital, as previously mentioned. Obviously,

too, this extended use of penicillin provided an opportunity to expand the

clinical studies being conducted at the 2d General Hospital, and, accordingly,

elaborate laboratory checks and records were required.

The minutes of the 17 January 1944 conference of base section surgeons

state that Colonel Kimbrough made the following announcement at the

conference:

The supply of penicillin has increased so that it has become available for more general

treatment. The plan now, and the Circular No. 6 has just been issued, is that a supply

6 Preliminary Report to the War Office and the Medical Research Council. H. W. Florey and

Hugh Cairns, October 1943, subject ; Investigations Concerning the Use of Penicillin In War Wounds.
CHIEF CONSULTANT IN SURGERY 143

will be kept in all hospitals-field, evacuation, convalescent, station and general. The only

check this office keeps on it is that all requisitions will be referred to the Chief Surgeon's

Office for approval."7

The still wider use of penicillin within the theater made it necessary for

Colonel Cutler to have the original penicillin circular changed. This was

accomplished by Circular Letter No. 22, Office of the Chief Surgeon, ETOUSA,

8 February 1944, concerning penicillin therapy. The new circular rescinded

the former and (lesigniated the following conditions for which penicillin therapy

could be given:

1. Patients with serious infection, which will include injury and battle casualty cases

as well as pneumonias, septicaemias, meningitides, etc., proven to be sulfa-resistant.

2. Patients with gonorrhea proven to be sulfa-resistant, and patients with gonorrhea

untreated by sulfonamides, the importance of whose duties make it desirable that they

should be absent from duty for the shortest period of time.

3. Patients suffering from chronic infections, usually osteomyelitis or prolonged wound

sepsis, where the condition though not endangering life greatly prolongs convalescence.

It was now necessary to train nearly all of the medical officers in hospitals

in the use of penicillin. Procedures to be used in carrying this out were announced by Colonel Kimbrough at a conference of base section surgeons on

31 January 1944, as follows:

Previously our plan was to have * * * a new hospital that was authorized to use

penicillin send personnel to the nearest general hospital to be indoctrinated. It has gone

so far now that all the personnel of the station hospitals need some training and it seems

advisable to have an officer from the Medical Service, Surgical Service, and Laboratory

Service visit their nearest general hospital for maybe a day or two's indoctrination in

the methods of penicillin therapy. As a rule, all the general hospitals have officers that are

trained. Rather than have one officer responsible for all penicillin, it was thought better

to have medical, surgical, and laboratory officers. I was trying to avoid having penicillin

put out to hospitals whose personnel were not familiar with its use and laboratory check.

Commenting on this statement, General Hawley warned:

The conditions for which penicillin can be used in this theater are very definitely laid

down. I am going to take very severe and very summary action against any lnedical officer

and any hospital comman.ler and the Chief of Service that wastes stocks of penicillin in personal experimentation: I do not want any mistake about that. We need all the penicillin

we can get for the use for which we have authorized it.

Assured by Colonel Kimbrough that the selection of cases had been

definitely stipulated, the Chief Surgeon continued:

Professional policies are laid down by this office and will be carried out. We have got

the best professional advice in the world and that is the way we are going to practice

medicine in this theater.

With so many medical officers who would now be using penicillin receiving

instruction from various sources, it was evident, this time, that a statement of

official policy on methods of therapy was necessary. In consideration of this

r Circular No. 6 pertained to the extension of penicillin treatment for sulfonemide-reslstant

gonorrhea.
144 A(CTIVITIES OF SURGICAL CONSULTANTS

need, the Chief Consultant in Surgery submitted the following instructions on

the local and l)arenteral treatment of wounds which were included in the aforementioned new directive ( 'ircular Letter No. 22.

Mlcthods of thratpy

(2) Local and gcicral therapy * * *

(a) Make aerobic and anaerobic cultures of the wound before and after debridement.

I. All debrided tissue will be placed in a sterile jar and sent to the laboratory for

study * * *

2. After debridement and irrigation, wound to be swabbed with cotton swab which

should be sent to laboratory for making cultures * * *

(b) The debrideinent shoull be conservative with respect to living tissues particularly skin and bone fragments.

(c) Irrigate the wound thoroughly with physiological salt solution at body temperature during and at the end of debridelent ; penicillin works best in a slightly alkaline

medium.

(d) Penicillin will be provided as a powder in ampules of 10,000 units or 100,000

units eactil.

(e) Local use of penicillin: For local use in wounds 10,000 units are dissolved in

10 cc. of sterile physiological salt solution. (strength 1,000 units per cc.).

1. For small wounds of the soft parts 5,000 units are sprayed into the wound.

2. For wounds of medium size 10,000 units should be used in the same nmanner.

.3. For wounds of large size 20,000 units are simil:,rly employed.

4. For comlplounl fractures of the large bones the dose shoull be from 30,10. to

60,000 units * * *

(f) After debridelnent and treatment with penicillin, the wound may be closed by

primary suture, by secondary suture, or left open as circumstances warrant.

(g) Parcntc'ral use of penicillin: For parenteral use. 10,(XY units of penicillin are

dissol ved in one (1) cc. of physiological salt solution immediately before injection * * *

1. For small wounds of the soft parts and medium sized wounds with little contamination, no pIarenteral use of penicillin is necessary.

2. In large wounds, in compound fractures. and in badly contaminated wounds of

any size, the patient should receive 20,000 units intramuscularly every three (3) hours for

two (2) (lays.

(h) If the wound has been left open following debridement, as in a compound

fracture, the initial treatment of the wound with penicillin is followed by further penicillin

sprayed into the wound as well as by intramuscular injection * * * The wound dosage

In such cases is 5.000 units sprayed twice a (lay.

(i) For wounds in the vicinity of the anus, buttocks, perineuni, upper inner side of

thigh an(l lower back. the standard (losage should be double(].

(j) The initial dressing of the wound should be ample in size and well secured. Frequent changes of dressing are undesirable because of the risk of secondary contamination.

(k) In solution, penicillin deteriorates rapidly. It should he freshly prepared before

each use. It is unfavorably affected by heat in both powder and liquid form and should

be kept in the refrigerator or il the coolest Iplace available. The solution will remain

potent however, for 5 or 6 days, if prepared under aseptic conditions and kept in the

refrigerator.

(1) Penicillin is a bacteriostatic agent and not a bactericide. It is excreted rapidly

in the urine: fluids, therefore. should be moderately restricted unless other considerations

precllde this measure.

(im) Penicillin affects particularly staphylococci, streptococci, gonococci. mieningococci, pneunlonosocci and the clostridii. It is most effective in unmixed infections. It

does not affect the colon group of grain negative organisms, the diphtheroids nor pyocyanus.
CHIEF CONSULTANT IN NU'RGERY 145

(n) Sensitivity and bacteriostatic tests must be carried out in every case.

(o) Rccords. All observations of wounds treated with penicillin will be recorded

on the forms provided, in order to determine applicability of this drug in the treatment

of war wounds. * * * All three forms will become part of the Clinical Record of the

patient.

(p) All clostridii isolated in bacteriological laboratories at station or general

hospitals * * * will be sent to the 1st General Medical Laboratory for final identification.

(q) Laboratory instructions, wound treatinent. These instructions may be obtained

from the Office of the Chief Surgeon * * *

.ks the second long English winter ended for the Chief Consultant in

Surgery, there was no doubt that the new spring would finally see an invasion

of the Continent by the Allies. The production of penicillin at home had been

stel)l)ed up tremendously. The shipment to the European theater for the

month of March was 500,000,000 units. There were indications that this would

be increased soon to 3,000,000,000 units. Other sources had said that the supply

was now unlimited. Col. Silas B. Hays, M1C, the new theater medical supply

officer, said at the conference of base section surgeons on 13 March 1944: "In

fact I would not be at all surprised if by the summer time we dont get too

much penicillin."

In spite of the great amount of data on penicillin now available, much of it

was tentative and some of it, contradictory. Current instructions on the use

of penicillin were obviously neither intended for, nor applicable to, a combat

situation. But what were the instructions to be? This question was of constant concern to Colonel Cutler, and there was not much time left. In a

memorandum, dated 3 April 1944, he wrote the following to Colonel

Kimbrough:

On 29 March 1944, I held a meeting in the Office of the Chief Surgeon of a group

consisting of Colonel Schullinger, Colonel Morton and myself in order to discuss the

present situation of penicillin in this theater.

In particular we met to discuss the material being assembled for publication in the

British Journal of Surgery.

• * * * * * *

The Committee took up further the matter of revising our penicillin circular. This

is much too bulky and demands too much for actual battle conditions, and by the time

we have the next meeting we must have a simple circular telling the surgeon just how

much penicillin to put in the wound, and we mnust rid ourselves of elaborate laboratory

tests. Such a circular is now being drawn up.

And, on 10 April 1944, he wrote to Colonel Morton:

I have sent you a copy of the Florey & Cairns report. There is no one here much to

help you with gas gangrene, though if we can arrange some kind of a meeting with

MacLennan, who is back from the Mediterranean now, I will see you are implicated.

* * * * * * *

Wve will call another meeting about the end of the month, but before then harden

your mind as to exactly what you wish to put in a circular covering the use of penicillin

in Army hospitals. My own ideas are crystallized as follows:

a. It will Pot be used in small wounds.

h. In large wounds of soft parts 20,000 units will be given in some suitable vehicle.

and I presume this will have to be sulphanilamide.
146 ACTIVITIES OF SURGICAL CONSULTANTS

c. In all fractures we will lift the (lose to 40,000 units.

d. I am dubious about additional dosage by intramuscular injection, but perhaps

we should attempt it, and you nuust specify over how nmany doses this is to be used.

The meeting alluded to was convened on 18 April. In his diary, Colonel

Cutler noted that he worked with Colonel Schullinger on the penicillin directive and with Colonel Morton on the gas gangrene directive. But lie informed

Colonel Kimibrough by memorandum on 22 April 1944:

VS and( 19 April was put in mostly working on penicillin, the greater part of the

time with Lieutenant Colonels Schullinger and Morton.

Attached to this is a fairly final draft of the use of penicillin for battle casualties as

it will be incorporated in the l)rofessional directive now being drawn up for our combat

forces. In general I would like to state thmat we have presented in this document the

optimum method: that is. we begin the parenteral use of penicillin its far forward as it

seem.s possible to get the drug and we continue it for as long a period as we think ideally

necessary. In addition, we Iplace penicillin in the wound. I have heard that the U.S.

Army in Italy is not using penicillin in the wound and I believe we have reached that

point in our knowledge of this agent where we can say it is best used as are the sulfonamides; that is, by maintaining an adequate b0lood level which can be done without placing

penicillin in the wound. However, if we do not limit our thinking to terms of the supply of

the agent, then the method cited in our draft is optimum. Note that if we utilize penicillin

as outlined the amount of drug required runs in to astronomical figures.

a. Each soft part injury requires 420.000 units.

b. Each compound fracture, 580,000 units, and both of these amounts are doubled

when the wound is about the perineum or buttocks.

c. If we take 6,000 injuries per day, which one might say is 1,000 casualties a (lay from

each of ;( divisions. one corps of a 3 corps army in fighting, then the requirements would

be, for 4.000 soft part injuries 1,680.000,000 units, and for 2,000 fractures 1.160,000.000

units, or a total of 2,840,000,000 units, and if 10 percent of the cases were wounds of

the Iuttock, upper thigh or perineum, i.e. 600 cases, in which the dose would be double,

then these 600 cases would need roughly 300,000,000 units or a total daily demand of

3,140,000,000 units. This for one month would mean 94.200.000,000 units which would mean

940.000 vials. Recommend that you transmit a demand for at least 75,000,000.000 units per

month. once operations commence.

We believe there is no contradiction to, and indeed desire that sulfonanide therapy

continue at the same time as penicillin therapy.

In addition to the recommendations made on the attached draft concerning penicillin

in the Army, we are now revamping the circular for the use of penicillin in S.O.S.

installations.

On the same day, recomnmendations for the treatment of gas gangrene

were also submitted in final form. Both the penicillin and gas gangrene statements were included in Circular Letter No. 71, Office of the Chief Surgeon,

ETOUSA, dealing with the treatment of battle casualties in the combat zone

(appendix B, paragraphs 7 and 10). These instructions were lublished on

15 May 1944, not any too soon, and only 3 weeks before D-day. The important

fact, however, is that the necessary decisions had 1teen made and the command

had been informed. Moreover, the decision had been independently made. The

British, at this time, had not yet hardened their minds as to what their policies

wouldl be for the use of penicillin in the continental invasion.
CIIIEF CONSULTANT IN SURGIERIY 147

Status of the blood bank

A question asked on more than one occasion by the Chief Surgeon during

this period was: "What is the status of the blood bank ?"

And therein lies the clue to activities at this time in the field of transfusion and resuscitation for thie Chief Consult ant in Surgery, ETOUSA. Unlike penicillin, facts in the case had been assembled, and he had made his recommendations. lie had determined that probably 1 out of every 10 casualties

would require parenteral fluids for resuscitation and that the proportion of

plasma to whole blood used would be about two to one. Instructions had been

issued to begin making some 3.50 field transfusion kits of the EIbert-Emerson

type, and their assembly had begun. The Chief Surgeon had decided that

whole, blhood wouhl not, l• lbrIIured from the Zone of Interior, which left. only

one, alternat ive-to provide for supplemental sources of whole blood within the

theater itself.

The problem at. this stage was to present the overall objectives to the theater

comnmnder for his approval, since the plan involved all elements of tihe commnd(. Following approval of the plan, if granted, there would be an enormous

amount of staff work to set up and establish the desired organization for tile

whole blood service, obtain the pIersonnel and equipment, and gain further

apl)roval for specific operations involving elements other than the medical. In

other words, tile problem was no longer primarily professional. It was now

a matter of operations mid supply. Accordingly, the guiding force in establishing a whole blood serviee devolved upon Lt. Col. (later Col.) James B.

Mason, MC, of the Operations and Training Division, Office, of the Chief

Surgeon (fig. 56). Later, Lt. Col. (later Col.) Angvald Vickoren, MC (fig.

57), replaced Colonel Mason in this responsibility. Initially, the supply aspects

of the problem fell upon Col. Walter L. Perry, MC, then the theater medical

supl)ly officer.

Actually, much of the ,work on this project was done in committee fashion

with Colonel Cutler representing tile profesional services: Colonel Perry,

medical supply: (olonel Mason. operations: Lt. Col. Ralph S. M[%uckenfnss, LC,

the 1st. Medical (General Laboratory: and Captain Hlardin, transfusion and

resuscitation. Obviously, efforts of the operations and supply officers would

have been limited without the "ammunition" and advice provided by the profesional members of this voillilnittee.

The first meeting of this group was on 19 August 1943. In addition to

those mentiomned above, Lt. ('ol. Ambrose It. Storck. M1C, thel Senior Consultaut in General Surgery, also attended. The l)urlpse of the meeting was to

consider the matter of implementing the supply of whole blood and the entire

prbl)lemh of blood tiransfusion for tile European theater. Colonel ('utler's

report of the meeting mentioned certain points, substantially as follows:

1. After full discussion of tile present transfusion field kit set originally

laid down by Majors Ebert, and Emiersoni, of the 5th I (eneral H ospit al, it was
148 ACTIVITIES OF SURGICAL CONSULTANTS

decided to place with each kit issued a printed list of instructions of its use.

In this instruction sheet it will appear that 50 cc. of 2.5 percent sodium

citrate should be added to 400 cc. of whole blood, giving a final concentration

of sodium citrate of 0.27 percent. Colonel Perry believes he can now implement

the securing of a sufficient number of these sets for our requirements.

2. The securing of whole blood in the SOS and its transport to combat

forces on the Continent.

a. Source of blood. The source is to be SOS troops and lightly wounded

and the ground personnel of the Air Force (about 40 percent of American

FIGURE 56.-Col. James B. Mason, MC.

troops are in Group 0 and are therefore satisfactory donors). The source

above should be ample for our requirements.

b. The giving of blood by the above troops should be coinpulsory (General

Lee).

c. Collection of blood. This requires mobile units with a refrigeration

plant. for 120 pints. It is suggested we use 11⁄2/2-ton trucks. Personnel and

T/lAB. of these mobile bleeding units already laid down and in the hands of

Colonel Mason, and copies to be given to Colonel Muckenfuss.

d. Storage. This should bee at, 1st. Medical General Laborlatory. The

refrigerator plant should be the large Navy refrigerators already acquired by

Medical Supply. We should need 2,000 pints in storage and should be prepared to supply 200 pints per (lay to the Army. The General Medical Laboratory will need: (1) Storage space, (2) cleaning space. and (3) personnel for

cleaning. They will require 2,000 bleeding sets. 5,000 bottles, an(d 5,000 giving

sets.
COIIll ' NSULTANT1 IN SI1UREIIy 149'

e. 1)eliverNv to (Ilie Akriiiy. I)lieyfromi tI~ lelii orat orv to Owli ArIii v

51144111( be b y air il ii cedl or Thlermoi(s conita:Iiners. C olonel P err ,v is to 10(1ki into

lhe supplY of thlese and Colonel Malsoni shouild imikel colit act with ltle Air Force

for ti1w priv-ilere of uisilg slic.1 phi lies.

f. Di)rii-ig delivery from thle Ar *i v MedIical D epot to~ thle A riiiY hospitals

the blood wvIll be kept, ill iced or Tliertiios colitailiers. The resjioiisiiil itY for tile

ret iriiiug(if iviir sts ht tvs a id otainlers wvill be t(hat o i rivslro

&.Nonie fIt Illis li4 iiliiIdbe tillp~lenilen ted liii ess fi rst priorit ties cani

be secured for I lie hluil(iiuz 411 slich .1 prepciouls .111id %itil toteiiIs whjole blood.

TI'iis ililelliles itemis of coiI1P41bit. stonrge, I vaiisjIortal 0111,aiil re' ititil of N-11.11Iv

iiimprtnti:11:jj~ a t ~lleliIIa 1W11Pceiiih :11 euse.

Air FlTV lreIiead14 ia rt ers, for ext 44 raIorv taIlks o)i ilie Ily.6u1- of blood to Iliev

('411it ileiat. At a coniference oil 21) SelhIveIIi t'i, C olotiel .AIbsoii was5 reyflvest byll

tI ti ( 'hief S1urgeoii to tIi'el),1 r4' tith I lle le.utdhi'frsl~i Isoltlle('ie

of. Opi erat ions. SO S. (let ails of planis for I liewle N40. Iblood Iserv ire. A fte~r ililfti hgI i e4 iliedival sliipplY olli:er oII t Ii Is re(Ill ireiii Ic III( 'ololiel P erry Iniformiedt

C oloniel Matsoti th~Iat ics~i 1111iS W We re ~IvadahI e In' Iiile Iliulet' ler

vt'liicles to 14 evoiiverted I itio refri-gervIeItpI n111-ics. Th'lese. ; Iejr Ca jt:I illI 11;Itt'dii

badu ctieck4'( ove a~ 11 I YI4'~41~'ice o t~pallt.W4le~t)i ;~t*sot

wllpee-bnise~l cargo I rluckis. C oloniel IPeirrv Il I I 1:1lv t e req I esls hIroIgI-i II I tIeI t heatIer

( 'lef of Ordntain~ce to) I lie Zone ofl InIterio~r for 30of thle-wo I ruioks. (Later, fourl

1tqtliti~lloi: I 1I n-iks of hlis I * (' e we1v r4'4h114'5I4. ) PI*rvISIoliI 41f thlese t nicks, be~-

C:11I4'P known, ill slupply Iarl-:Iiuce. :us Pr'o~jet GS 22 and14 (;S 22 SoII~ldvt4iII4'Iit l.
150 ACTIVITIES OF SURGICAL CONSULTANTS

In addition, Colonel Muckenfuss and Captain Hardin were asked to prepare a paper which would show the entire project inl detail. This they did with

their paper broken down into the following sections: Operating procedures.

volunteer blood panel, estimate of requirements, operating agencies, the blood

collection section of the base blood depot, the laboratory section of the base

blood depot, distribution during the assault phase, personnel requirements, and

necessary organic equipment.

Their report showed that 200 pints of blood per dlay would be required

during the period from D-day to D+90 and that the whole blood service could

collect 600 pints per day as a nmaximum. Beginning at about D-7, they estiinated that 3,000 pints of b)lood could be collected by D-day. Following that.

they contemplated maintaining a level of 1,000 pints at the base blood depot

and 200 pints in advanced blood depots.

It was prop)osed that each SOS unit would maintain current lists of volunteer donors. Each SOS unit woulhl report monthly the number of donor.

available to their base section commanders who, in turn, would consolidate

these reports and notify the Chief Surgeon of the total number of donors availal)le in their areas. The sum total of these volunteers would be known as the

ETO Volunteer Blood Panel.

The operating agencies of the whole blood service were to consist of a

headquarters section located at the 1st Medical General Lal)oratory, a base

1)lo(1 depot, and advanced blood depots. The headquarters would include

the director of the whole blood service; a Medical Administrative Corps or

Sanitary Corps officer in charge. of administration, records, and supply; and

clerks, orderlies, drivers, and automotive and refrigeration mechanics.

Vnder the headquarters, there would be a base blood depot with four bleeding teams and a laboratory section. The base blood depot was to be located

at the 1st Medical General Laboratory with additional refrigerators at the

5th General Hospital for emergency storage and dispersion. The blood collecting section was to be composed of four bleeding teams, each having one Medical

Corps officer and seven enlisted men with a refrigerated truck and other equipment necessary to operate mobile bleeding stations. The laboratory section was

to recondition. clean, assemble, and sterilize equipment, process and store the

blood; and prepare blood for shipment. One offi'er, an expert in transfusion

and resuscitation, was to head tlhe laboratory service and the base blood depot.

Ile was to have 33 enlisted men to operate the washing room; the assembly

room: the supply, still, and sterilizer facilities: the glassblowing and needlesharpening faceilities; the blood-processing facilities; and the refrigerators.

('ontemlplated for the other side of the channel were advance(t blood depots

to )e attached to armies and those to l)e attached to communications zones. The

functions of advance blood (lepots were solely to store and distribute 1lood under

thl supervision of the army or communications zone medical supply depot to

which they, would be attache(d. The primary difference between an army type

of unit and a communications zone type of unit was that, in the former, there
CHIEF CONSULTANT IN SURGERY 151

were to be eight refrigerated trucks and, in the latter, only four. In addition

to the refrigerated trucks, each unit was to have all unmounted storage

refrigerator.

The operation of each of these agencies was described in minute detail,

as well as proposals for operating the service during the initial phase of the

attack on the Continent.

Needless to say, p)r'eparation of a document of this sort, accompanied by

charts and figures, required time. An equally lengthy period was required

by the Operations Division, Office of the Chief Surgeon, to review, revise, and

dress it up for formal presentation in sufficient copies.

In order to submit the proposed plan, Colonel Mason required a succinct

statement as to why it was so essential, and he asked Colonel (Cutler for this

"ammunition." On 15 November 1943 Colonel Cutler provided Colonel Mason

the following statement concerning the whole blood service in the European

theater:

2. The evidence that whole blood is valuable in caarlig for battle casualties seems

completely established.

a. We have the analysis of 30,000 givings of blood from the British North African

campaigns. In these campaig-rns blood was drawn in Cairo, flown to forward areas and

delivered by refrigerated trucks to forward medical units.

1). We have evidence that certain cases suffering from severe blood loss can only

be saved by restoration of the volume through whole blood. Plasma alone may prove

insufficient, and has been proven so by physiological experimentation as well as by clinical

trial.

c. The Russian and British armies have a setup similar to that proposed.

d. Correspondence with our own medical units in the North African campaign

shows that the forward medical units greatly desire blood in addition to plasma and some

observ. -s felt lives could have been saved had blood been supplied in sufficient quantity.

c. Direct communications from British officers follow:

From General Ogilvie, ( ,nsulting Snrgeon. British M.E.F.: "Blood is being used

more frequently, earlier and further forward. Blood transfusions save more useful lives

than ever before."

From C,,lnel Porritt: "The best thing in the British medical services in North Africa

was the Blood Transfusion Service."

On the same day that he submitted the foregoing information, Colonel

Cutler also wrote to the chief of the Operations Division, Office of the Chief

Surgeon, substantially as follows:

1. I am worried what might happen in this theater If a big attack started and great

quantities of wounded people were brought to this island and our blood bank was not

working.

2. Should we set up blood banks in station hospitals as well as In general hospitals

now, or cfan we countt upon our blood bank's supplying station hospitals with blood, should

the necessity arise?

Colonel Mason assured Colonel Cutler that the (listribution plan for whole

blood provided for the emergency supply to station and general hospitals in

the United Kingdom.
1 52 ACTIvITIEs OF~ SURG6ICAL CONSULTANTS

lie. also indicated that it 'was p~rob~able that, each hospital could providle

enoughl blood for transfusion fromt donors availab~le in and about, the hospital.

Authorization of the. Blood Panel, ETOUSA, aind commlandl arrangements

for shipp)ing, Colonel Mlason stated, were b)eing hiandled in the London office.

As of that date. Col. Thomas .J. Hartford, MIC, had not sent out the letters to

thle Coniniandhi i General, SOS, although hie had indicated this would be (lone

in the very near future. Colonel 'Mason addled that lie would like to dliscuss

with Colonel Cutler theimatter of the supllly of blood to SOS units in the United

Kingdom at, Colonel Cutler's earliest convienilence.

The miatter of supp)lying blboodl to SOS units in the United Kingdomn was

set tled most op~portunely at a1 later (late. Mleanwhile, Greneral Hawley had

Sub~mitted his revonliiiiendationls (based Onl iniformnat ionl submitted by time whole

blood committee) for- a whole blood( service for time theater, as follows:

l. TIhr pro blem To furnish fresh, whole blood for transfusion (if battle casualties as

far forwardl as division clearing- staltions5.

2. Facts locarjnuq pon. tflu prob/cm a The experience of the British and luistsian

Akrmies. as well ais the exp~erience of U.S. forces on all fighting fronts. is tha~t dlried l asnia

mneets t he requirements of only ab~out twoi -thirds of all cases requiring- replacement of blood

volume.

b One-third of all battle casualties reqluiring repllacemnent of blood volume mutst

have whole wlood as well as plasmna.

c Early transfusion with whole- blood in many vases greatly reduces the time spent

in hospital and hastens the restoration oif the casualty to full (luty.

i. A small amiount of whole b~lood is available "on the hoof" in all mnedical installations bunt this cannot mneet the reqluirements for the following reasons:

(I ) it must be tyl)edl undler 11ie(1 conditions which favor inaccuracy, and( death

may resul t fromn giving uninatched blood.

12 No tests can be minade for syphilis and other comnamunicable diseases: and the

haitile casualty may be gliven a (disease by such transfusions.

(3) The efficiency (of (duty personnel is greatly reduced wAhen they muist (donate

Mooixd.

c Fresh bl1o0d ca.n be collected ill the SOS. provessedl, stored and (delivered to frontline divisions ill small trucks carrying refrigerators.

f A total of 1 officer and '22 enlisted men, an(l 8 21 --toit trucks;, 2 mnotorcycles, and

one '/4-ton car will be reqluired for each field army. Mll wflrPCxiqri per.vowiel and( ('(uipflltflt

im alre-tedy on harndl in the Thcater and the troop baxis is-ill not bec inrreased.

:3. Rcroimndiniation-R a That the policy of furnishing refrigerated w~hole blood to

medical units, as far forwvard its div-ision clearing stations, inclusive. be established in this

Theater.

b That eaich arumy commander be informed that the necessary personnel and equipinelit * * " wiill bie antta~lchd to the immedical (leloot assigned tol his army * * *

r That all agencies t ranspoirting suppolies be dlirectedl that refrigerated whole blood

will be shipped on the highest prilority.'"

Follow-ing approval of the plan by thme Commanding General. SOS, and the

theater commander. the basis for the whole blood( service wias tiri'mlv established

with instruct ions to the C omlmanding General, First U.S. Arlny Group, and

4111Memoranthnn. Brig. G~en. P. R. Hanwley to Commanding Ge.neral. 808, FTOUS9A, 26 Nov. 1943',

subjiect :lProvision of Whole' Wood0 for Batth.. Vastialtie4s.
('H WI? CONSULTANT IN SURG ERY 153

instructions front the Commnanding, General, SOS. to set lip time ETOUSA

bl100( paniel.

The coniman(1 letter, (dated 2 .Januiary 1944, from Lt. Gen. (later ('enl.)

Jacob L. IDevers, Commanding General, ETOUSA, to thle Conmmniandinlg (tenleral, First U.S. Army Group, contained1 the followinig statement:

1. The p~rovisioni of whole bloodl for the treatment of casualties in this theater,

throughout all echelons down to and including division clearing stations, is approved.

2. Whole blood will be anl item of medical suppJly andl will lbe distributed through

medical supply channels. It will be given the highest priority in transportation.

3.* * * personnel and spe~cial equipment will he furnished to each Army icithout

'cfjuisitUifl from sources available to the Commanding General, SOSA, ETOUSA, * * *

The ETOUSA blood paunel was estab~lishedI by a command letter from

Maj. Gen. J101hn C. It[. Lee~s SOS headquarters, onl 6 .Janiiarv 19)44. The siubstance of thle letter was as followvs:

1. The establishment of a blood panel for the theater, to furnish whole blood in the

treat mient of casualties. has beeniapproved by the theater coninander.

2. It is desired that:

a. Ini each unit of the SOS, a nominial list of volunteer donors of TYPE 0 be preparedl

and1( r(-taincel in the unit headquarters.

1). A record oif the wintlc, of TYPE 0 volunteers, by unit, in your comianand be maintalinedl in your headquarters.

c. Trhe re'ordls required by subpamragraphs a and 1) be corrected1 as of the 15th of eac-h

m1onith: and. immediately following each such correction, a report of the number of TYPE 0)

dlonors in each unit of the SOS in your command be sent to thle Commanding Officer. Blood

Bank, ETOUS A, 1A (t eneral 'Medical Laboratory.

dl. U ponl call (of the C'onmmanding O fficer. Blood Bank, ETOUSA, the volunteer TYPE0

doniors (of the unit specitied be assembled at a (designated bleeding station (ordinarily the

unit dispensary) at an hour, to be determine(] by you, which will not seriously interfere

with the niornial (duties oif the unit and wvhich will be reasonably convenient for the bleeding team.

e. Only light (duty be required of donors from thle time of bleeding until reveille the

following morning.

3. The general rule will be that four-fifths of a pint of blood will be taken at each

bleeding. anid that donors will not be bled oftener than once in each 3 months. This amount

of bleeding will have no ill effect upon any dlonor andl will neither reduce his physical capacity- for work nor predispose hiin to illness.

4. Your active interest in obtaining as mnany volunteers as possib~le is enjoin(-(].

As slow andl p)onderouls as progress onl the prmoject might hiave seemied,

there was no doubt, that it, was b~einlg carefully and thoroughily established.

('ololmel Cutler was p~leasedl withm time work being (lone and nuist have felt. considerab~le p~ride iln seeing what hmad been but a year before ant idlea of his

maturinig into a fuill-fledged theaterwide op)eration. After onle app~arently

miost. satisfactory conference with Gieneral Hawley onl the wihole blood service,

lie wrote mi his diary: "Blood pr1oject OK. H~ope I got Jhim Mason promlotedl.

Thme grolundwork having been laid, there Wits Still mil1cim to be accompIl ished1

before tile whole blood( service (could( he a reality. There w~as thle question

of hlow to provide the mianmpower for tile service, and opinion varied1 between

iimerely augmlenting, the 1st Mfedical Greneral LalboratoryV or 115mglo a separate
154 ACTIVITIES OF SUR(ICAL CONSULTANTS

unit. The decision was made on the latter and a special table of distribution

was made up for the 152d Station Hospital, which became the Blood Bank,

ETOUSA. In December, both Colonel Mason and Colonel Cutler urged that

it was high time to appoint an officer to be in charge of the whole blood

service and command the 152d Station Hospital. Some names were suggested, but none proved acceptable for various reasons. The only position on

which there was complete agreement was that Captain Hardin should be in

charge of the base blood depot and the laboratory and bleeding sections under

it. Eventually, Colonel Muckenfuss was placed in charge of the whole blood

service and in conmnmand of the 152d Station Hospital. This was in addition

to his duties as the commanding officer of the 1st Medical General Laboratory

and as the theater consultant on laboratories. Since the headquarters and

base blood depot, of the whole blood service were to be located physically within

the, premises of the 1st Medical General Laboratory, and, since there would

be no need to move either the whole blood service headquarters or the 1st Medical General Laboratory soon after the invasion, the choice was reasonable.

Moreover, Colonel Muckenfuss had been acting, for all intents and purposes,

as the head of the whole blood service up until this time. These arrangements solved the personnel aspects of establishing the blood project.

In late December 1943, not long after initiating the request for trucks,

Colonel Perry had been notified by a message from PEMBARK, the New

York oversea supply depot, that the trucks, as requested, had been approved

and that 12 trucks were at the port awaiting shipment and the others soon

would follow.

On 31 January 1944, General Hawley asked at the meeting of base section

surgeons: "What is the status of the blood bank?"

Colonel Kimbrough, replying to the questions, said: "The last report

they were 10 days from having the construction done---that was a week ago.

The equipment is almost in. Refrigerators are frozen, allocated but not

delivered. The people are there under the direction of Colonel Muckenfuss

on the administration side, and Captain Hardin is carrying out the professional

side. They have not called on us for any more personnel."

Two weeks later, at the 14 February 1944 conference of base section

surgeons, General Hawley again asked: "What is the status of the blood

bank?" This time, he added: "When are they going to be ready to start

some bleeding?"

Colonel Kimnbrough said that the physical plant was practically complete

and that they should be able to begin bleeding at an early date (fig. 5,).

Lt. Col. (later Col.) Raymond E. Duke, MC, Operations Division, Office of the

Chief Surgeon, said that, according to Colonel Muckenfuss, they should be

ready to go within 2 weeks.

The bottleneck was in trucks and refrigerators. An incoming message

from PEMBARK, 16 March 1944, said that the 30 trucks requested on project

GS 22 were in port, and were expected to go forward soon and that the four

trucks requested in project GS 22 Supplemental were also in port and were
I -:1'tli' I'.1 t -I' I Ihu 1-11;11, II t I S I. \tIt -I t'Il ';I1 III lit' \V I-t I i V I lit II'i

I l;I i.lui~. \Iult' i ;IIt' r -u (ý ,liutI \j' ls iui'i ht'Ijhtl C ti hhiel V .l' t'iiuiluu\II2

li' It'lvi I 'I. 1i .2i kt'; I It X\ Iii it ;iu l I I1 I I- i Iit t w( Iu Ivit Ii riu IIi

i' :il I tI ii r I ucki 1'rtli (t' u'u i rl Hc h i l ti' lit' ii 11141,1 i tl ck-I tI It I Itll.t I I1. i l Ii -I :

\\v~~v I lit, t, i I ~I :; i, 1 i c \ Y w \I(I'IIi-v A T \1,1 h - - r
156 ACTIVITIES OF SURGICAL CONSULTANTS

The story was the same with the refrigerators. They were approved

and available on paper but could not be gotten physically. It was not until

mid-February that the first refrigerators were received, but a relatively steady

trickle continued to be received thereafter. Even at three per week, however,

this represented four-fifths of the output of the British supplier. The remainder was being used by the British for maintenance of existing equipment. The delay in obtaining the original shipment was due to demands

from active theaters.

At this time, when it appeared that the barest needs for establishing a

whole blood service to support one army in the field seemed assured, Col.

Thomas J. Hartford, MC, Executive Officer in the Office of the Chief Surgeon,

London, returned from North Africa and Italy with some startling details.

Certain of these bothered General Hawley and, in a memorandum to his

Professional Services Division, on 28 March 1944, he wrote the following:

1. * * *

b. This not to be discus8ed outside the Division. Less and less reliance is being

placed upon plasma. Plasma seems to be quite effective if nothing is done to the patient

afterwards, including transportation. But, if the patient is operated [on,] or if he is

placed in an ambulance and moved, if he has had only plasma he relapses rapidly into

shock.

In the early days of the campaign, one pint of whole blood was used for each eight

casualties. Now, one pint of whole blood is used for each 2.2 casunities (fig. 59).

2. The increasing use of whole blood makes me concerned about the capacity of our

own blood bank.

We cannot count upon an average useful life of more than 10 days for whole blood.

I am informed that, under the best conditions, we cannot deliver whole blood to the front

in less than 4 days after procurement. This means that an average life of usable whole

blood is not more than 6 days; and, to be safe, we should not count on more than 5 days.

This, in turn, means that the blood bank must be able to replace the total demands for

blood at the front every 5 days.

Can it do it?

Colonel Kimbrough optimistically replied that plans were being made to

furnish whole blood in the ratio mentioned and that the blood bank would be

able to replace whole blood in the time and amount required. Colonel Liston,

acting for General Hawley while the latter was in the United States, insisted.

however, that a firm figure for planning purposes be provided of the ratio of

whole blood required to the number of casualties.

The problem was put to Colonel Cutler, who advised as follows:

British plans (from talk with Colonel Benstead in office of Major General Poole, British

War Office, 6 April 1944)

1. Original British planning after North African campaign was tha, 1 in every 10

casualties would require fluid replacement including blood. When this is necessary, give

1 pint blood and 2 pints plasma-repeat S.O.S.

2. Reeenit planning calls for greater use of blood. Colonel Boyd who was in charge of

British Medical Blood Banks, favors 1.5 pints for every 10 casualties.

U.S. Army plans

1. Originally we planned as In paragraph 1 [Under British plans], 1 pint for every 10

casualtieg, supplemented with plasma.
CHIEFI (CONSIULTA~kNT i-N sui(;EHY I 5

b A

Uniiit ref'rig4*r;tel t i~i k, Ieliverin.- 11141nI to IiInlI-side for 1I fl)iWJortaiom n to lhe Fifth U.S.

A~rmuy ;u vu. B. A refrigerated ruilck (I(I-(ivein ,II,( blodtoI Fif ltI U.S *nuly evacilat ionl

f s It . .
158 ACTIVITIES OF SURGICAL CONSULTANTS

2. Colonel Hartford, recently returned from Italy and North Africa, brings back use of

blood after establishment of blood bank at Naples in Army Med. Lab.

Recent 5th Army beachhead statistics show: U.S. Forces used 1 pint blood to each 1.85

casualties, British used 1 pint blood to each 2.71) casualties. Total 5th Army statistics equal

15,000 casualties, show use of 1 pint of blood to each 2.2 casualties (this is field hospital

and evacuation hospitals).

Comment: (1) Note Colonel Hartford's figures are for pints used. not blood per

casualty. Thus, if 2 pints per casualty, it would be at following rate: blood would be

required by each 4.4 casualty.

(2) In Italy donors are paid $10 per bleeding.

Recommend: U.S. Army E.T.O. Blood Bank be equiplped to supply combat force with

whole blood at rate 1 pint for every 5th casualty.7

While this recommendation and the logic by which it was attained might

appear to he not entirely satisfactory, the fact of the matter was that the

demand for a new planning ratio was merely an academic question at this

time. It was obvious enough that the original objective of one pint of blood

for every 10 casualties was going to be difficult to realize. Moreover. it had

been necessary for the Commanding General, SOS, ETOUSA, to issue another

command letter, on 6 April 1944, notifying SOS subordinate commanders

that the nmnber of donors had fallen far short of expectations and requirements and that action would be taken to increase the number of whole blood

donors.

On the brighter side of the picture, however, were these factors. When

Colonel Cutler had visited the blood bank on 31 March 1944 to discuss the

possible extension of blood production, he had learned that six of the large

walk-in type of storage refrigerators had been installed at the 1st Medical

General Laboratory and were ready for use. Eleven trucks had been fitted

with refrigerators and were also ready for use. And, with these facilities

available, the blood bank was ready to engage in trial distributions of blood

to the East Anglia area as an experiment-to ascertain how the service was

actually going to function. Colonel Cutler noted, too, with pleasure, that

Captain Hardin had finally been promoted to major.

Arrangements for the air delivery of blood to the Continent had long

since been completed by Colonel Mason. In conference with Col. Edward ,.

Kendricks, MC, Surgeon, Ninth U.S. Air Force, Colonel Mason had obtained

complete agreement on the following procedures: (1) Troop carrier aircraft

from the Ninth Air Force would deliver blood from the vicinity of the base

blood depot to the vicinity of the army medical supply depot on the Continent,

(2) an enlisted man from the base blood depot could accompany a shipment

of blood to insure proper handling and delivery, and (3) aircraft would return

empty containers and equip)ment from the far shore and bring back the

70 (1) Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 7 Apr. 1944, subject:

Demands for Whole Blood. (2) "If the full truth be told, It was not until fighting was well under

way that the consultants discovered that their estimates on the amount of blood needed were far too

low. Until that time, they had thought that the capacity of the ETO blood bank would be sufficient."

(Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 17 Sept. 1958.)
(1III1F (CNSII'.\F IN tIii(15

.it~

~A

N Ilt Ii Air Fmove wasM 411111' f1)111111,1 NIat II IItie 11M1)4Wt at i4)1l 4)f blood1. MiIIce

they '~ vt I, frllsi)orteblood fo001 4r the BIjI ksit Eil.t It Ari'lvy 41I Illte -North

AfriC:1t )illllpi)U 1r1.

blood4 SI'rVi~e. W.I% 11t4, 11(h (ll ableito 1)c4)idi(14 its ili 1IllIssimll of ,Itjpp)viII1r

whole 1)100( InI 5111)1)4t ftt tile InIvasion of th iuC ont ilieuit (l. 601t.

11i1hlile lt' whohbloo 1)10041 5'.*'wats e beli1r devlopedi4)) III ti 11j:1' lltiIer. thelre

WV'rV ;lIskos M-iIlficni'Il 4eve10)illivltill tIle 1 Illattt'r f)1 troniislsioii sets for 'Ifieedlt-e11 linesiral~elcails (4'4 4)1 ti' Ilitev P4'ellIZ'4i I ht it ilaul Ittti mlt.V~t4 wthe

ft I vY re -'iv v(.4 r1 t iefll 5j)it;dw sevi.T'r aI le ,aNIva 11z 4 1i11 i1- 1~ht~ 14)weI1 v)4 ;l~II;,I vI tlI

I t. 14' h 4114 10 1)('i 'Iv4 I Ilat Ij(I I 10115 gls -y('ll for 41('aI1MiI 1~ alidl str I'i I' Iu,~i

le14) lIl' l'l ')l 4li'a ()I1 I rahlsf'llsi4)uls aild 'lilt IilV4'Il4)11 so)lu~tionis. L.t. (,()1.

(later CoI. ) DIglowius 11. K4'mldick. .Jr.. MC. sti.ag-Psteo1 that It m1i.-,rt ibe better
160il A(.~ivi ITI's (IF SURIC;( AL ('ONSUUINANTS

to followv Ihli sy' steml nsing enlip jIv plasma conltainers as described inl (irciilar

Letter No. I 0X, ( flice of Th Ie Suirgeon Genteral, 1 943. The ideal solutiion to

the problemi. lie suggested, was tile expendable vacuuml)botttles and exp~endalble

reciIpienit, sets wit il filter's, hi were l~piilgrproposedl as regullar iiied itvl s5I11lvl

itemts. I lnfort itiatitelI. hiowever. t he'se revoiiiitiendat lolls could not. be applIied

ln1t il tilie hItcssa 1WI eq(liilpillet couIld b~e obtflhlt(d(.''

lritere were d isadvNallitages, too. to tlie met hod recomimeneded Iv Ty he SuirgePOli ( veneral inl ('i rcuhr Ljetter No. 10S. 271May 1943. uttilizing tile dried I)Ia1ilm

appatrati u'. Ma jor Emtersont broughxlt t hese to C olonel (Cutler's attenution. TIhe

object jonts were pointed out ill aIt memorandum111, dlated 27 Sept. 1 943. to Maj.

(later IA. Col.) _Michael E. 1)eBakey, MNC, in the Surgeon General's Oficev, anid

iltlu-ldedl tilie fol lowi tig:()('oshtt(11g as reeohtltll le le. was ntot feasible

with equipmtent. available inl the field, (2) the open techinique was liable. inl the

field,. to intrduce t appin'&'iable alhlioutiits of foreign matter into the blood, (3) the

typ)e of aiwaIil leaparatus wou lld cauise air pressure inl Ite bottle to be below attitospI~heric. pressure1 , andthis1. Phis1 a laver of glass bteads, two nteedlles, antd

filter, would utaterially limit. tile rate at. whichi blood could be adminilistered, and

(4) the timaterial andi equipmtentt. required for thle cleanting and sterilizat ion

p~roceduriies recomtmenidedl would not always be available inl the fieldl. The pri'-

))ary-* objection, htowever, w~as to the fact. t hat. only' :00-cc, flasks of diried platsimf

were available Iin the Eulropean t heater andl whien these wvere used for collectIng sets with tile requisite inltrodluct ion of -50 cc. of citrate solution, the amount

of Ilo)hx1 collected would scarcely muake t lie effort wvorthwhuile.

III view of this situlat ion, -Major Emterson wvas detachied to the medical supply (depot at Tliatcltmt, Emiglanld, witit enllisted men~i to hielp him. ando continued

to assemilde ilie. transfusiont ulits (devised by him ando 'Major Ebert.. Some 800

sets of inlst ruct ilof weve jprinted to gro into the uinit paickinugr. whichi eventually

was oloiie ill used *.h50 caliber aiiiiumtit ion cases repainimted to mnedical standlards

-withI tble G eneva (Cross. A 25-t)itititite 1 ra itI ilig flilni ill color was also itmale to

show hlow t lie tranisfusion kit, wvas to 1be used~. Withi only mnliltlr plroblemit of

ob~ta ining tile mlevessar LW items at thle righlt time (fli~te produtct ion of tbhese transfusion unlits p~roceedeid well.

Ini the mteaniwhile, Major Ebe-rt. was sentt. to the Office of The Surgeonl General to present the European thteater plans for providintg whole blood(1 inl the

field. I poii his returint, lie pireptared a, r'epor1t of his visit for Colonel Cutler.

Th report was subtstantially as follows:

A brief interviewv with Thle Surgeon General andl a long dliscuission wit~h

Colonel Kenmdrick. Special Repres~ent at i e inl Transfuisions ando Inttraveitous,

Solut ions inl the Sm-rgeon Gemmerai~s Offtice. were hield onl 6 December 1943 and

sulbsequeitt. days.

The surgeon (',eneral was of the op~iniion that whole blood was not necessary

inl the most. forward areas aind that plaltsmat shotild be used for the treatmient of

". Niernorandcun, Lt. Cot. It. N. Carte'r. 11C. for General ihllran, 28 Oct. 1943, subiject :Esmential

Teln iea I n itt. F.T( I A . nod I inmlo~ire I lierpt o.
('IIIEF cONSU'LTANT IN SURGER~iY 161

Shock unider these eond(itionUS. III greneral. lie (lid not1 believe whole b)100(1 houl1(

be used forward of thle evacuiat ion or field hosp~ital.

A1 compllete discussion was held with Colonel Kendrick concerning the

nature and relat ive advanitages of thle equlipmlenit tisedlat p)resent inl thle Eulropeanl

theater and the equipment recommliendled byN thle 1-urIgeoll (genIeral's ( )tfice. ('()Ionel Kendrick describedl the eqluipment for blood tranlsftisionis now inl production

but. not~ available at. thle. presenlt timue. This consists of 75O-cc. vacuium bottles

containing ~201) cc. of sterile .1Mc~ill solution (anil anticoagullanit containing

so(liIin citrate and1 glucose whlichi is suitab~le for storage and blood). These

bot tles are mnanufactulred by thle Baxter C'o., are expendable, and are us~ed once

and then discardled. Inl a(llit ionl, donlor sets and exp~endlable recipient. sets are

provided. The recipient sets are ilnade of viscose (cellophane) tubing, are

packaged uinder sterile condit ions, and are ready for inimediate uise. A, simplle

wire mjesht filter is included inl each recipient set. This transfusion equip~menet

is suitable for' fresh blood transfusion or for thle. storage of whole blood.

Inl the discussion with Colonel Kendlrick, the advantage of having all thle

equipment necessary for performingz a blood transfusion includedl inl a single

container' was pointed out. As a consequence it. was dlecidedl to package thle

equipment. inl a fiber box which will contain 11 vacuumi transfusion bo~ttles, 11

recilpient. sets (sterile expendable), 1 donor set, and a box each of aniti-A. and

ant i-B1 typ~ing serumi. Thlis eqluipmilent will not be ready for distributilon linit l

ap)1roxilnatelv February 1944. The eqjuipmenem should, however, 1e requisitiolned ininlmediatelv. Thme equipmjfent. has not. yet. been given anl order number.

It canl be requisitioned as follows:

Complete transfusion set conitaining the following: :11 vacuumii transfusion

b~ott les Avitlu -Mecill solution. 11 recipient. sets (sterile exp~endlable), I dlonor

se. bx ftvilg euman-iA 1 box of typing serum lant i-B.

InI view of the fact that thle exact (late of delivery could not be guaranteed,

it, was recomimendled that the pr'esent planis for transfusion equipment inl the

European theater should be continued unt il such a. time as the new equipment

should be subst itulted.

A 4-cubic- foot. electric refrigerator designed for storage of whole blood

is available. This has sufficient capacity to hiold approximately i-O bottles of

blood. The refrigerator canl be, olperate;l from thle usual powerline supplly as

well as by a simall 5OO-watt generator whlich is supplliedl with it. It is recomlmended that these refrigerators be placed inl all general, evacuiation, and field

hospit als. Tie refr-igera.tors can be equeIiisitionieda.s follo)vs:

Ref rigerator for storagre of wvhole blood.

Gienerator for above.

It was stroingly felt by all concerned inl time discussion that transfusion services should iew estalbl islied inl all hbosp)itals unmder the supervision of a transf usion

officer. This service wvould be responsible for thme formation of a (loner panel,

typing of blood, wvithdrawal and administration of blood andl storage of blood.

It was felt that, lprovision should he made for training mien illnumodern tratisfusion technique.
16t:2 ACTIVITIE"S OF SURGICAL CONSULTANTS

Through the courtesy of Capt. John Elliott, SiiC, Army Medical School,

and D)r. Louis K. I)ianiond, of Harvard Medical School, 20 cc. of anti-Rh serum

(in dried form) was obtained for use in this theater.

In accordance with Major Ebert's suggestions, Colonel Zollinger. acting

for Colonel Cutler, took the necessary steps through the Operations Division

and the Supply I)ivision, Office of the Chief Surgeon, to procure 4,000 complete

transfusion sets of the expendable type and some 200 refrigerators and generators for storing whole )lood(. Sufficient refrigerators, over and( l)eyond( those

already available in the theater's hospitals, were requisitioned so that not only

the general, evacuation, and field hospitals-as recommended by Major Ebertbut station and convalescent hospitals and general dispensaries as well could

be equipped with blood-storage facilities.

By : mid-March, the Emnerson-Ebert transfusion units were readv for distribution and were issued to units of the First U.S. Army on the following

basis:

Tra.xf vion

Fir.mt U.S.Arn.iri U'llit xct

Evacuation Iospital (750-)------------------------------------- 2

Evacuation Hospital (400-bed"2------------------------------------2

Field Hospital (2 each phltoon) _ -- -------------- 6

Convalescent Hospital -------------------------------------------- 1

Auxiliary Surgical Group ---------------------------------------- 20

Clearing Company, Medical Battalion ------------------------------ 2

Colonel Zollinger explained that these units varied from the original in that

sufficient ,•eruni for typing only 25 donors was included instead of enough for

the original 50. In addition, the number of transfusions possible from each

kit. was 11) or 11 instead of 18, as originally planned. These changes were

necessitated because it was necessary to use British sodium citrate solution,

which was more bulky in its packing than American supplies of the solltfion.72

On the basis of issue determined by the Operations Division, the First

U.S. Army required some 175 of the transfusion units. When the decision was

made that the Third U.S. Army would be equipped with the new expendable

type of unit being develol.ed by the Surgeon General's Office, the excess transfusion nnits developed in the European theater were provided Army Air Forces

medical units at' operational airblases in the 17nited Kingdom for emergency

use. It, was further contemplated that replacement of the Emerson-Ebert

transfusion sets would be accomplished l)y using the new expendable type.

The equipmnent and facilities for transfusion and restoration of bloodI

having been completed, the entire programn was finally tied together with intensive courses conducted throughout the medical units in the theater on the

reconstitution of blood plasma for administration, attendance of First U.S.

Army medical officers at. the course on transfusion and resuscitation at the

British Army Blood Supply Depot, and instruction on the use of the European

theater transfusion unit utilizing the motion picture which had been prepared.

72 Memorandum, Lt. Col. R. M. Zollinger, MC, to Lt. Col. A. Vickoren, MC, 13 Mar. 1944, subject:

Concerning Field Transfusion Units.
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CHIEF CONSULTANT IN SURGERY 165

activities of the Chief Consultant in Surgery will not. belabor the subject. Let

it be sAlid, however, that Colonel Cutler and the other consultants all saw eve

to eye in the needs for a sound rehabilitation prograin regardless of their individuial ditierelnces as to how the program should be carried out. And Colonel

Cutler, with characteristic energy, strove to develop the rehabilitation progrrain

while keeping it in hounds. Although the object of the rehabilitation program

was to return as many patients as possible as early as possible to some useful

form of duty in the theater, it is mentioned here because there was also the

contingent need to make the lmost efficient use of hosl)ital beds by transferring

elsewhere those who were amnbulant. and could convalesce with little professional

medical care.

Care of lightly wounded.--The care of the lightly wounded was a topic

near to the heart of the Chief Consultant in Surgery, for it was in the optimum

management of these cases that surgery could make its major contribution for

returning the greatest. mumber of wounded to the battlefronts. This matter had

been frequently discussed within the Professional Services Division, but at the

aforenmentioned mleeting of 22 November 1943, there was enough agreement of

opinion to permit Colonel Cutler to recommend that some 10 miles behind time

400-bed evacuation hospitals supporting (livisions on the line, there should be

750-bed 65 evacuation hospital. "This," Colonel Cutler stated. "should be a

hospital for the care of the lightly wounded and the nonseriously ill medical

[patients]. At a moderate distance from this evacuation hospital should be

the convalescent, hosp)ital, centered for the army, and the lightly wounded and

nonseriously ill medical I-patients] should be able to stream through this 750-

bed evacuation hospital for initial treatment, and then recover in the convalescent hospital, from which they could be restored to active duty without traveling

further down the line. Indeed, some personnel could go directly from this

750-bed evacuation hospital to active duty."

The overall system using platoons of field hospitals close to division clearing stations, 400-bed evacuation hospitals farther to the rear, a 750-bed evacuation hospital well in the corps rear area, and a convalescent hospital in the army

service area would allow for the care of the nontransportable seriously injured

individuals either in the field hospitals or small evacuation hospitals close to

the line, and the care of the lightly wounded and others restorable to active duty

in a 750-bed hospital and a convalescent hospital.73

At the 22 November afternoon meeting of all the consultants with the

Chief Surgeon, the subject was again presented. Col. (later Brig. Gen.) John

A. Rogers, MC, First U.S. Army surgeon, wanted to know what size army

Colonel Cutler was referring to for his suggested use of 750-bed evacuation

hospitals, and Colonel Spruit offered the thought that perhaps an evacuation

hospital was not the correct type of unit to provide care of this sort. Colonel

Cutler replied that he was thinking of one 750-bed evacuation hospital for an

73 Letter, Col. E. C. Cutler. MC. to Col. J. C. Kimbrough, MC, 22 Nov. 1943, subject: Minutes of

Surgical Sub-Committee Meeting, 22 Nov. 1943.
1663 Ai'INITIES (1" SUItuItAL CONSUT1'ANTS

:ilyCIoj). To (oblilel Spruit Cs.sser-t oll t hat tiit- equji pmentIi of all evtw Icat ion

lhospiita:l wais too extelisi vt tol he uistd ill t his sitinat ion. C oloniel ('in icr sbiiit t td

I lie opiniioni tlitt, if t Ilets(, woliiided were to fih '14" ill tli' he edd!goIa

C olonel lRoi..ers dfirected tilie at t ct ioul of the conl ft're'ts to thle fact thbat thlere'

"Ter IVIIot enlonir I Tht-ht'dX( evatcIuat it) IIIosI) I it alIs in It I Ie I I Ieater to be u sed at flIit' ratev

of onle petr corp~s andi t hat th liFIirst U .S. A riiiv was goilig. to havec oniy (bll'.

C olonetl ('Ut ltr inisistedt(lIhat I Iwo woilild bit liectssarv. bill ad deud thlat ltperhaps

two fieltd hiospittals v(Ililt replaceit oit' of hienil. C olonel ('lit ltr mlent ione'd that

thero were 111.111Y of lie Inr er eactint iol hiospi tal s ill Nortiil A rita. Colonel

Iovt'l I ouilirmiet thlis stat eiiit'it liv rt'1 ort in-tr that theitre werte 14 inl thie North

A fricani t heat er. C oloniel C utle icrlosed lie dAl i~ssoni by ex plainiing thiat lie

was not So Initerested l ik tIt t. Nt'(of unlit as inl the care of flit'- lightlytNvwonliided

ill hosp1itals.

"-We could sav~e .i lot of personiiinel for I lie A rniv. Ilit minn t a ined, 'anld it

would niz U'a big steI foirward.-

T1he iiiiplenlitntm aloll of suchi a progani t'stel sqiuar-ely WitlIi thle army

surgeon.1 Withi tiiu lit limits o~f facilities aivailablet to him. And (Colonel (Oilder

was very gratif ied to learni thlit ( 'olouiel Rlogers saw tilt jprobleltli andI its solintloll ill mu11ch tlit saint'e luigt as Ilit.

Auxiliary surgical groups.---( )it 0 St'pteninber 1943. C'oloiiel ('itt let' visitedl

thle iewvlv arrived 1st. Alixilar lirgiva 1 (T roup which hiad revelit ly arri ved ill

Englandt anid was quiarte'red ait t lit' Wst Ii St at ioul I [ospitazl. I Ilen had .11 xcellet'ut

talk with flIt'. group's Colt mm nder(W. (ol. ( 'lilto Sfl . L , ver, 1H . whto. he d iscovered,

had soilit texcetllenit idetas abouilt tilt teiiploymiient of miobile siurgical teamns.

Colonel ( 'ut ltr also learined, inl his h'uugthli visit Withlli t'l unlit thlit soli of theii

Medical oflict'rs werte "purle- sptecial ist s ill lie st'iise liat theay we'rt' Special ize'd

ill suchl a narirow fie'ld t hat. tile%, could niot be emiiio ed oil mlore gtelteral tyIpes

oif surgtery. F~or ilist alce. thr li e'wtro two nuituroloigitcal siirgtoiis who, could not

bie Countetd oii to carr-Y olut sliuriic4il proct'durt's elsewhitrte than onl thlit braini.

I'lt'. 1W ouslv, oud ave to he remiio~ved froni th li'-rolup silct' the luw 'ibld

be of Ito izrt'at list' uuindt' t'onhnt condititions. Colonel Lvter also iniformedI

C'oloniel ( 'ittlet'rIhat thiere' was a ne'w tablieof'organiizat ion wli-icl grt'n ly reluict'(

the strenthugl of filit grotij) andit moret o1r less5 Ilimitted teamsu to) gelit'u'ea surgtery,

a Cliaiigt' whiholonlel ( 'utielt' approvt'd heartilhy anid had lie'euu 110ecounuut'nding

sinct'his fii'st tlays inl tIR'Armyn inl this wni.

Latter, (Colonitl Cuit ltr .1;iid Colontel LYtt'i Iliutt Witlli Major Gruavtes of fthe

3d Aulxiliairy Sul-rgical (Gruoupl anid planined to rteplacte tenams fr'omi tilit' 3d ktixihauv uricl( e~i)(i tliipol-ra i'vilityi at Nva riolus installations ilizinl an bolut

tile UnIitecd K inigdlom by letanis fronii tilit 1st kluixi liary Surgical Groulp. 11(1we'ver, oiii 2 Ochtober, wvord wa1s i'eeiv'd tha lint lie miiembetrs of tilie 3d1kiuxil iarv

Suirgica I Groulp Who had bt'en loan'id to f lit' Noirthi A frivai t hitater Werte retuiruu-1

111g. Thmis news llt'essituitedl vauucellit ion of planiis to exchmange teamis ill tile

Vnited Kingdomi linit ii miorte uleillitI' informial ionl was availablet as to flthe1- iltl-it

of filt' 3d klixil iary Surlgical CT roiip's bugl-absent mi'llembes.
CHIEF CONSULTANT IN SURGERY 167

One specific measure was initiated as a result, of these meetings. Under

instructions front Colonel Mason, Colonel Cutler asked Major Graves to turn

over the property in the hands of the 3d Auxiliary Surgical Group relating to

mob)ile surgical teanis to the 1st Auxiliary Surgical Group.74

At the conference of the Deputy Chief Surgeon on 3 October 1943, Colonel

Cutler mentioned the arrival of the 1st Auxiliary Surgical Group and the expected return of that part of the 3d Auxiliary Surgical Group that had been in

Africa and Italy. The immediate prol)lemn, iie explained, was what to do with

300 doctors with nothing to do and nowhere to go.

Colonel Cutler met with General Hawley on 5 October 1943 and, among

other things, there was a long discussion about auxiliary surgical groups. General Hawley asked Colonel Cutler to have the consultants draw up a comiprehensive plan for the use of these group)s, differentiating functions and personnel,

as seemed wvise, for a group) with an army and for a group when employed

within the SOS. Colonel Cutler advised General Hawley that lie should ask

the North African theater to return immediately an officer from the 3d Auxiliary Surgical Group for the purpose of training members of the newly arrived 1st Auxiliary Surgical Group. In a letter, dated 7 October 1943, written

after his return to Cheltenham, Colonel Cutler informed Colonel Kinmbrough

of the conference with General Hawley and reported that lie had drawn up a

plan for the employment of auxiliary surgical groups tinder the dichotomous

situations stipulated lby the Chief Surgeon.

Colonel Cutler's recommendations entailed the following:

Regarding the use of auxiliary surgical groups with a field army, he

thought that their function should be to carry out definitive surgical procedures

in the forward areas by b)eing attached to evacuation hospitals, field hospitals,

and, possibly, even division clearing stations. The professional requirements

for team members working in an army area and the need for specialists, lie

stated, were as follows:

The professional requirements of chiefs of surgical teams should he those of well

trained general surgeons. The chiefs of teams should be competent to deal with injuries

of any part. Strict specialists in the sense that they are competent to deal only with

injuries to the brain, to the chest, to the extremities, the abdomen, the face and jaw are

ideally undesirable. However, surgeons specializing in certain fields and at the same time

competent to work in other flelds wouil be desirable. And finally, the prosthetic teams,

providing they were scattered and never concentrated in one place, should prove of great

value to those surgeons dealing with injury to the jaws. Similarly, the orthopedic teams,

as sent over with the 1st Auxiliary Surgical Group. (coJuld he of continuous vaiue to all

teams dealing with compound fractures. This was the arrangement in the last waIr when

such teams were called splint teams.

As for the distribution of tealus in any army area, lie calculated that general

surgical teams should be used in the ratio of two or three to one orthopedic

team and that a prosthetic team was only needed for from four to six general

teams. Further, he thought that the prosthetic teams would be needed only

,4 Letter, Col. FR. C. Cutler, MC, to Col. J. C. Klmbrough, MC, 3 Oct. 1943, subject: Visit to 1st

Auxiliary Surgical Group.
168 ACTIVIT~IE~S ()p SIICAL(ONSULTANT.,

ait v~ery hard -pr't~.esse anid active ililit Ii ~ ~ t. i~l le~ jd l Ia~l~ a i

teams wvould he reqluired. accvordingp to hIls phlans, oinly as thle nleeds for them

arose. This dlist ribut ion of tearn1s, Colonel Cut letr stipula'ted. was h.ased onl tile

assumplItion that teamls wvould be nleeded for 24-houir duty ill thme liosl)itils to

which they would be it tavledl, thlus niecessitati jug tile ass'mgnnmeit. of two teamis

to every One team wh~iech would be wvorking~ at anyv specific time and place.

Turning to t he utse of muxiliary sum'gical group)s Iin communiicat ions Zonle

facilities, Colonel Cutler stated that their mission wouild be to strengthen thet

professional capaicity of hospitals anld should be employed only inl sta.tionl anld

genieral hospital1s. S41peci.ml IteamslisI e pointed ouit, CoullId I*lways h~e usedl to greaz.t er

aldvanltage lintonnu (011iciat ionls zonie facilities titan inl t hose of a fieldl a iimi. This

would he esp~ecially true if parts of several general hospitals were set aIsidle as

cent ers for thloracic. iieurtositigical. or wailfail~ork.

After thle usual Stindav meet iiig of thle Professional Services D ivision oni

10 O ctober 1943. t lie surlgical; consult ants. w'it hi Colonel Cuttler, decided itpon the

temp~orary -'sinlin.of the various teams of the 1st AuiiiySurgical Group

to hospitals thlen act ive IinI lie theater and turiired over* tilie phlan to tilie ( perat ions

D~ivision for iliillemelietat ionl.

Later, certalin specialists were gradually removed fronm the t w( gri-oups,

DWI~, as revised a,11des of o)Itgamiizat p -,I wer'e rec(eived fr'om the W~ar Departmenit.

t he com poielit tea iiis weire reconst it tit ed. T1hme latter p~roedlurmes w~ere, pt'imari ly.

aI function of thle Op~eraitions,, and Personnel Divisions and the comiinaidets of

hie grroups. Th'leV coll(-et'ield Colonel C utler little is thle professional qualifivations of those beimmt, realined withjin tilie gt'olps wvas of thle necessairy high standa Thl lose qual ifiedl specialists who were dlroppled frmot the groups were r'eaIssignied miost adlvantageously to hmospita~l centers w~hmere their speciail talents

were iii greapt liee(l. By% the( time I)-(lav dlrew~ near., inl addition to anl auxiliarv

sur'gic'al groulp assignedl to the ('oiinilminiat ions zomie. there w*Nas anl auxiliary

silritgica group~ to be assignte(I to eaich of thme two U.S. field am-iies-onie of theml

to he. use-d inl thle UnlitedI ]xingdoill to au1gmienit niedical facilities ditritig the

nuit ial reveilpt of casualt ies from the fair shore, as die Third U.S. Army was not

scheduled for nimmediate lplt iciplat ion inl Operat ion OVERLA)RD. and the

other to accompanm' the First U.S. Army (hiring the. assauilt onl Normandy

0(ri. 63).

Publications and directives.-Sliort ly after returning from the Soviet

Uni1onl. CIolonlel Cutler relported that the project of revising Wair D)epartment

'I'M (ehicl aul)S-210), Guidii~es to Therapy for' Medical Officers, to make

it more applicablde to tilie E~uropean tlmeat et had Weeli (onmit inig for almnos.t a

yearin. lie stated t hat, actuiallv. it had been necessar-y to rewrite rather thain

revise anld that. t here was still con fusion inl the revision concerninga fi'ontlinle

care and thle type of care to be given ili fixed hospitals. The fina~l revision,

( olomiel Cu'ttlet: Voi isideted. emilta iled cu1tting" down thle inalstill mlore, anld

(leletimit! somie of thme philosophica'l dissertatmoims;'.

-3minviti-s, lotti m4.1tifa af m, Ciii*f tiargeon's Consuiltants' Commi~ittee, 2:1 Aug. 1943.
I F V A : v ~II l I 1.11 I N,'-l I I hivI ER Y 11 i) I i 'li1111T ~i t ~li G9l'jIII i

Fii 1' 1 it' G:..I i L I (;411 l. Il .11111C.1 I 've 11( ETIWll 1 :11. lit Ilt' sit) 'i'i114 lit' 1 I':lll'(llt1 111

Fi. I A rn~. li1i-v. PvI:,r \ o7 l IIi.. C mvIii S n'i 1,i~~I : ili l ]9111.rlile I1.I2 
170 ACTIVITIES OF SURGICAL CONSULTANTS

which he asked the Chief Surgeon to prepare an introductory note. Colonel'

Cutler stated that tile manual contained the principles underlying professional

care of medical and surgical emergencies which may be encountered in the

European theater-well-established principles which had been correlated with

recent experience gained by the Americans and the Allies in the present

war. Colonel Cutler further explained that the material was divided into three

parts: (1) Primary surgical treatment of the soldier intended primarily for

medical oflicers inl division areas, (2) definitive surgical treatment as may be

applied to hospitals regardless of type, and (3) treatment of medical emergencies. (The last. part had been composed by the theater medical consulta.nts

under Colonel Middleton, the Chief Consultant. in Medicine.) 1,astly, it, was explained, medical officers would be expected to adlhere to the policies contained

in thie manual insofar as possible. 7

By early May, the booklet had been received from the printer. Distribution had started. An appointment was made with General Lee for General

Hawley and Colonel Cutler to p)resent and exl)lain the handbook to the SOS

commander in the European theater. Wlat happened at the meeting with

General Lee is well explained in Chapter III of this volume (p. 366).

Tile same dual purpose of War Department TM 8-210 prompted the conipilation of the circular for establishing policies with regard to surgical treatment and management. That is, one portion of the circular was written primarily for emergency surgical treatment and another portion was aimed at fixed

facilities which would be providing definitive reparative care.

Colonel Cutler took upon himself the onus of compiling the first part. on

emergency surgical care. He was given hell) by all the surgical consultants,

but particularly by Colonel Zollinger, Captain Hardin, and, as previously

shown, by Colonel Morton and Colonel Schullinger on the gas gangrene and

penicillin portions. Colonel Bricker, the Senior Consultant in Plastic Surgery

and Burns, was given the responsibility of compiling the second portion of

the proposed circular dealing with definitive care in fixed hospitals. Colonel

Bricker experienced more difficulty than Colonel Cutler since his portion was

of a more detailed and specific nature involving each of the specialist consultants. As a result, that portion dealing with the emergency management

of battle casualties was finished first, and it became very apparent that the two

parts were quite separate and distinct from each other. So, as time grew short,

Colonel Cutler advised the chief of the Professional Services Division in a

memorandum, dated 6 May 1944, as follows:

After a great amount of work we have decided that it is necessary to have two circular

letters concerning surgical professional care. One is the major circular largely covering

SOS fixed units, upon which Colonel Bricker has put so much work, and which he has

-Letter, Col. E. C. Cutler. MC. to Chief, Professional Services Division, subject: Minutes of

Surgical Sub-Committee, 24 Jan. 1944.
CIIIEF CONSULTANT IN SURGERY 171

about finished. The other is a circular dealing largely with battle casualties: that is,

Army surgical therapy. It is attached, and I believe will be implemented immediately,

as the Army needs this now.

Circular Letter No. 71, Office of the Chief Surgeon, ETOUSA. was published on 15 May 1944 and was titled "Principles of Surgical Management in

the Care of Battle Casualties." It, was as succinct a statement as could l)e

made at the time on the emergency care and initial treatment of battle casualties in the combat zone. It included: (1) A definition of the functions and

responsibilities of the various echelons of surgical service in the combat zone,

(2) administration of morphine with l)articular eml)hasis on contrainidieations, as well as the causes of morphine poisoning, (3) blood transfusion, (4)

definition of certain nontransportable cases, (5) dressings, debridemetit, and

amputation, (6) sulfonamide therapy, (7) penicillin therapy, (S) closure of

wounds, particularly early secondary closure, (9) general princip)les to be followed in the use of plaster casts, (10) treatment of anaerobic infections, (11)

radiology in forward areas, and (12) identification of gases in cylinders, with

particular reference to the difficulty caused by different British and American

markings. The complete circular letter appears in this volume as al)l)endix B

(1). 963), an(l, in subsequent discussions, it may be referred to merely as Circular

Letter 71.

The other circular letter entered the publication mill during the very

height of activities for D-day, 6 June 1944, and did not appear until 10 June

1944. It was 1publis!wd aws Circular Letter No. 80, Office of the Chief Surgeon,

ETOITSA. It concerned policies and p1rocedures governing care of patients

in the European theater.

The new circular letter rescinded 33 prior directives which had been issued

by the Office of the Chief Surgeon over a period of nearly 2 years. To place

all pertinent items in these many directives into one was an accoml)lishment

in itself which certainly helped to ensure compliance with these policies and

procedures which had been built up over such a length of time-policies and

Piocedures which many had forgotten or, as in the case of those newly arrived,

had not known of their existence.

Circular Letter No. 80, calling attention to the Manual of Therapy,

ETOUSA, stated:

The Manual of Therapy, ETOUSA, sets forth principles of treatment which have been

tasted in active operations by both our own forces and those of our Allies. In it are incorporated many of the professional policies of the medical service of ETO. These policies

will be followed habitually. Any one of them may, and should, be disregarded in an

Individual case where there Is sound reason for departing from policy. Personal preference

for other methods of treatment as a routine is not "sound reason." Departures from

policies will be made only because of special circumstances associated with individual cases.

There was a lengthy and detailed explanation of all practices to be followed with respect to the procurement of )0ood and transfusions in general
172 ACTIVITIES OF SURGICAL CONSULTANTS

and station hospitals. It required all hospitals: (1) To develop a "casualty

organization" to facilitate the reception, resuscitation, triage, and treatment

of multiple casualties, (2) to utilize officers from the surgical, medical, and

laboratory services, and (3) to make specific preparations in advance to meet

great numbers of such conditions as burns, hemorrhage, profound shock, exhaustion, and chemical warfare casualties.

One of the items which had held up this directive was that of hospitals

for special treatment. From the outset, General Hawley had insisted that

there would be no specialized hospitals, except for treatment of the psychoneurotic and psychotic. At the 6 December 1943 meeting of base section

surgeons, the only concession General Hawley would make was that in the

following statement:

Unless it can be thoroughly justified, we are not going to specialize hospitals. There

may be a time, after we get trains running and battle casualties, we may specify certain

hospitals for certain cases, but at the moment it is just complicating our evacuation

system.

The Chief Surgeon never permitted any hospital to become "specialized,"

but, when the need became apparent, he eventually permitted the location of

personnel and equipment at certain hospitals or hospital centers to provide special treatment. Circular Letter No. 80, compiled by Colonel Bricker, described

these hospitals with facilities for special treatment as follows:

Certain hospitals where special types of treatment are available will be designated

from time to time in separate directives from this office. The policies enumerated below

will govern the treatment of patients requiring therapy in which a high degree of specialization is necessary.

a. Surgery: Selected patients requiring special surgical treatment will be transferred

at the earliest practical time to those designated hosl)itals where additional facilities for

their care have been provided. Such hospitals will include those for-Ncurosurgery,

Thoracic Surgery, Urological Surgery, Plastic and Maxillofacial Surgery, Trcatmcnt of

Burn Cases, and other surgical specialties as may be found necessary.

(1) In those hospitals designated for the treatment of cases requiring * * * [special

surgical facilities], it is recommended that separate sections of the Surgical Service be

formed for each specialty. Administratively, these sections would function as all other

sections of the surgical service.

(2) The surgical specialists in charge of these sections may be used by the Base Section

Surgeons as Regional Consultants in their respective fields.

Another circular letter issued under the same date, 10 June 1944, designated

the three hospital centers with special treatment facilities for neurosurgery,

thoracic surgery, plastic and maxillofacial surgery, surgical treatment of extensive burns, and urological surgery. This additional directive, Circular

Letter No. 81, Office of the Chief Surgeon, ETOUSA, designated other hospitals in which special facilities had been established for neurosurgery (with

special urological facilities to care for the paraplegic) and for plastic and
CHIEF CONSULTANT IN SURGERY 173

maxillofacial surgery (with special facilities for the surgical treatment of

extensive burns).

Circular Letter No. 80 also specified adminihtrative policies and procedures

for X-ray therapy, hospitalization and disposition of neuropsychiatricl patients,

rehabilitation of the blind at St. Diustan's Institute, the holding of regular

medical meetings in hospitals -s a part, of the educational program, and care

of members of the WAC (Women's Army Corps). There were also specific

professianai policies pertaining to certain conditions which were listed under

the headings of general surgery, neurosurgery, orthopedic surgery, plastic

surgery, and X-ray diagnosis in fixed hospitals.

In closing this section on publications and directives, a case must be noted

wherein the Chief Consultant in Surgery thought lie had nothing to do with

a directive which to him was nearly all professional. As will be seen soon, the

subjects discussed in this directive were the very items on which he and Colonel

Zollinger were devoting their utmost energies at the time. And he was startled

to see the directive for the first time a month after it had been written and

promulgated. It was published not as a circular letter but as Administrative

Memorandum No. 62, Office of the Chief Surgeon, ETOUSA, to Base Section

Surgeons and Transit Hospitals. Dated 3 May 1944, it stated:

1. General.

a. Patients will be evacuated from the Continent to the United Kingdom in vessels

manned by the Navy and in aircraft of the Troop Carrier Command. Patients returned

by water will be disembarked at hards or ports having been classified into evacuable and

nonevacuable patients prior to disembarkation. Evacuable patients are those who can

withstand further evacuation by ambulance to "transit" hospitals (15 to 30 miles).

Patients who are nonevacuable will be given emergency treatment in "holding units" in

order to prepare them for further evacuation to "transit" hospitals. Patients arriving at

"transit" hospitals will again be classified into evacuable and nonevacuable patients;

evacuable patients being those who can travel 12 hours by train with reasonable safety.

Nonevacuable patients will be prepared for further evacuation as soon as possible.

b. Patients evacuated by air will be removed to a "holding unit" at the airfield or

a nearby fixed hospital, fromn whence evacuable patients will be evacuated to a general

hospital for definitive treatment.

c. Designated general and station hospitals functioning as "transit" hospitals, will

streamline their administrative procedures, and will function similarly to evacuation

hospitals. "Transit" hospitals will be called upon to admit large numbers of patients

expeditiously, and to evacuate them in trainload groups.

3. Profcssional Carc in. "Transit" Hospitals.

a. The scope of professional care in transit hospitals will be the same as that in

evacuation hospitals, bearing in mind that those wounded who may travel safely for

another 12 hours will be immediately evacuated without definitive surgery. [Italics are

the editor's.] As a rule, all casualties will have their wounds debrided; no wounds will be

closed; immobilization apparatus, splinting, or plaster of paris will be applied for all

fractures; and patients will be given the necessary supportive treatment. Post-operative

abdominal cases are usually not transportable for 7 (lays. Ambulatory and lightly wounded
174 ACTIVITIES OF SURGICAL CONSULTANTS

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CHIEF CONSULTANT IN SURGERY 175

casualties will be evacuated through transit hospitals as rapidly as possible. This type of

casualty represents a primary responsibility of the Medical I)epartment because these

patients, with good treatment, can be restored to active duty in the combat forces at an

early date.

When Colonel Cutler first saw the directive on 2 June 1944, invasion fever

was running high, and it was very obviously too late to do anything about it.

At the same time, he was having a most difficult time trying to obtain approval

for stationing his consultants in key areas lduring the invasion phase. It was,

in a way, the last straw. Ile wrote most bitterly in his diary: "SOP's get written, and I never see them. God, how they have opened themselves to criticism.

It is a colossal blunder. Oniy today I [saw] Administrative Memorantidumi No.

62, 3 May 1944. None of it is our responsibility [doing] and yet it is all the

l)rofessional system." On second thought, he added: "Well, maybe it will be

0K." And well might he add that thought, for the words in the, directive

were very much those of Colonel Cutler as he, from time to time, reported on

the progress being made for the care of patients in transit through the evacuation chain on the southern shores of England.

][owever, he had advised: " * * IBearing in mind that if the pre.•.?ure for

eraeatation is great, tlwse wounded who may travel safely for another 24 hours

will then be immediately evacuated viithout definitive surgery at the 'trans8it'

hospital.s." He had further qualified this statement with his definition: "An

eacuable patient varies with the pressure of work and the demands for beds."

Colonel Cutler was greatly exercised and chagrined to learn that base section

surgeons and transit hospital commanders had been directed to evacuate all

patients who could travel for 12 hours without definitive surgery. The clear

intent of Colonel Cutler's recommended policy was that all patients in need of

definitive surgery would receive such in transit hospitals except when (1) the

pressure for evacuation was great at these hospitals and (2) the patient could

travel safely for an additional 24 hours.

But now, more about. these preparations to which the discussion of this

directive has brought us.

Specific preparations for Operation OVERLORD

General Hawley explains.--Colonel Cutler attended a conference held by

the Chief Surgeon at 9 North Audley Street, London, on 10 January 1944.

The I)eputy Chief Surgeon and executive officer, chiefs of divisions in the Chief

Surgeon's Office, Col. Alvin L. Gorby, MC, from the Office of The Surgeon

General, and Maj. Gen. Robert 11. Mills, DC, director of the Dental Division,

Office of The Surgeon General, were there. The minutes of the meeting show

that General hawley outlined plans formulated by his office for the reception,

hospitalization, and evacuation of casualties in connection with the projected

operations (map 1).
17 6 AC TI VITIES OF. SURIGICAL CO NSULTANTS

"Thie planl~s for the medical support for the Normandy invasion included

the following hospitals and depots:

(h'ueral h1ospitalft Location

ald & -P22d (compllosite unit) -- Ansoni & Craddock Barracks, Pimperne. D~orset

22d1 (detachment) ------ IRenhowv Barracks, Plniperne, D~orset

28th~ ------------ Kingstoin Lalcy, Winiborne Minister. D)orset

40t I -------------- iDagiingworth, Gloucester

48th ------------ Stockbridlge, West Hampshire

62d1 ------------- I jleniwoodl. Cheltenihami, Gloucester

6R(1 d(detachment) ------ Prince Maurice Barracks, D evizes, Wiltshire

617th ------------ Musgrove P'ark, near Taunton, Sotmerset

91st ------------- Churchill, Ileadington, Oxford

!list, (detaechment), aug- Norton 'Manor Barracks, near Taunton, Somerset

Inente(I %ith a dletachmlent

of the 127th.

94th------------------------Tortwort Ih Court. near Falfield, Gloucester

97th-t-----------------------Hlolton Park. near Wheatley, Oxford

97thI (detachmient). aug- Waller Barracks, D~evizes, Wiltshire

niented with at detachment

of the 25-th.

98th------------------------ Hermitage, near Newbury, Berkshire

9Nth (detachmient) ---------- Busigny & V.owler Barracks, Perhaia D)owns, Wiltshire

Mt-------------Kingston Lacey, Wlmhorne Minster, Dorset

141st ----------------------- Erlestoke Park. near Erlestoke. Wiltshire

1 ý,41t ----------------------- Chisledon Camp, Chisledon. Wiltshire

1;58t I-----------------------Odstock, near Salisbury, Wiltshire

1.19 th-t----------------------HIound~stonp. Barracks, near Yeovil, South Somerset

159th (detachment) --------- Lufton Barracks, near Yt-ovll, South Somerset

160th----------------------- Stowell Park, near Stowell. Gloucester

185)th and (185th (composite SandbhllI Park, Bishop's Lydeard, Somerset

unit).

186th and 6,86th (composite Fairford Park, near Fairford, Gloucester

unit).

187th and] 687th (composite Ev'erleigh Mlanor, near Everleigb, Wiltshire

unit).

187t hi (detachment), aug- Rawlinson Btarracks, near Newton Abbokt, D evon

men ted wi th a dletachment

of the 32d.

188thm-----------------------Cirencester No. 1. Gloucester

192d ----------------------- Cirencester No. 2, Gloucester

203Id----------------------- Broadwell Grove, Burford. West Oxford

216th-----------------------Longleat Park. nmear Warminster. Wiltshire

216th (detachment). aug- D~rake Barracks, Fast, I'inperne, D~orset

mentedl with a detachment

of the 127th.

217th-----------------------Burderop Park. near Wroughton. Wiltshire

217th (detachment), aug- D~rake Barracks. West. Plinperne, Dorset

mnented with a detachment

of the 32d.
CHIEF CONSULTANT IN SURGERY 177

Station Hospitals Location

3d ---------------------- Tidworth, Wiltshire

36th --------------------- Exeter, Devon

38th --------------------- St. Swithins School, Winchester, Hampshire

68th --------------------- Ramsden Heath, Ramsden, Oxford

77th --------------------- Erlestoke Park, Erlestoke, Wiltshire

110th -------------------- Royal Victoria, "E" Block, Netley, Hampshire

115th -------------------- 'lasterdown, Tavistock, Devon

120th -------------------- Charlton Park, Charlton, Wiltshire

127th -------------------- Odstock. Salisbury, Wiltshire

130th -------------------- Chisledon, Wiltshire

152d --------------------- Odstock, Salisbury, Wiltshire

160th -------------------- Bath, Somerset

228th ------------------------ Sherborne Park, Ilaydon, Dorset

250th -------------------- Grimsditch, Coombe Bisgett, Dorset

302d --------------------- Lydiard Park, Swindon, Wiltshire

304th -------------------- Kingwood Common, Rotherfield Peppard, Oxford

306th -------------------- Checkendon, Oxford

313th -------------------- Fremington, Devon

314th -------------------- Polwhele. Truro, Cornwall

315th -------------------- Axininster, Devon

316th -------------------- Stover Golf Club, Teigngrace, Devon

318th -------------------- Middleton Stoney, near Middleton, Oxford

327th -------------------- Northwick Park, lBlockley, Gloucester

347th ------------------------ Marlborough Common, Marlborough, Wiltshire

365th -------------------- Rainsden Heath, Ramsden, Oxford

Field Hospitals Location

6th ---------------------- Tunbridge Wells, Kent

DEPOTS: Taunton, Bristol, Witney, Thatcham, Reading, Romsey, London

The minutes of the 10 January conference state:

He [General Hawley] gave first a broad picture of the overall plan for the reception of casualties. * * * All the hospitals, including the general hospital at Stockbridge, but excluding other general hospitals in a designated area along the south

coast of England had been made available to the Southern Base Section for the purpose

of receiving casualties. Casualties would be unloaded and given immediate attention

on beaches and hards and then evacuated to the hospitals in this area [later called "transit" hospitals]. Evacuation of patients from these hospitals by hospital train to hospitals elsewhere In the United Kingdom would ensure that beds were constantly

available in the designated area. Certain beaches and hards were to be designated as

medical and the Navy would deliver casualties here as much as possible. A fixed holding

unit of at least 50 beds would be placed at a maximum distance of 500 yds. from each

medical beach and hard; situated preferably in whatever buildings were available. Here

casualties which could not be transported by ambulance without immediate treatment

would be transported by hand. These units, being so close to the beach or hard, would

be exposed to bombing, but in order to deal with patients who could not be transported

by ambulance without treatment, this was unavoidable. Ambulances and buses, for walking wounded, would be used to transport all other types of casualties to the nearby

hospitals.
1ST AC'riVITIES OIF SUI;iCAL, CONS ULTANT4

Owving to (lthe mlany diffticult it's at teiidm it uplon briniging te vastciaiultie baclltk-the

diversion (of i~srs dute t4 suddien emer gencies-. fthe piossibilitijes of damlage to fihe craft,

Ihe facet I hat. t rips were mtade at niight anid the crewvs were yo'ung anid iniexp'erienicedthere woiuldl lie, frequienit occasios (tillo whichi casmiilt les were brought to betachies anid mi rds

ot her t han Iii ose dlesigniatedi as miedicalI. There Wvere large numixers oif stiiihlibachies

anid liaruls which wol'ild allt have to lie "ceiverel." For this purpose, with close linison

esi aidished bet weeit the Navy anid jitliel Sm4lit herii Base Set-tion, it large reserve (if anibiilailcts and liersonliel for uniloading LST's would have to lhe kepit availiable to moi~ve

to ally 110liit. Onl call1. It was essentital t hat anly congestion11 should tie a voided and a

ciii isidera Ide num11 ber. po ssiblly it s 11111 ly ats twenit y- ti e, ai tibl iihi nics wouildh have to)i lie

available to uniload each0 lS1', lin order that all thle iasualties on board should Ihe evacuiated

iinnieif-diately. Ill adihtioin there would have to) be under it cenitralh control (not that of

tht- ShlI I SoutIIhern Base Sect ion I ) two big reserve piools of aniiillaiice and bus t railsportation to reiniforce that for bo0th niedival and1( nonimiedical lieaches and hards and meet

any sudden emergencies that iniiglt arise.

Colonel Cutler asked thle ge neral about provisiont filr t riattg at thle beachles

and holding units. ( enleral I lawley replied that nto sorting Would lhe donle at

thle beache~S and ba.rds or il tilie Ilolding," units and that all those casualties

thlat c ldpossibly be transp~orted Nwould be lInove(I immnediately to hospitals.

Thew nIjitites state:

General hlawley then wvent onl to explain, lin slightly more deftail, the nietliods for

dealinig with the caisualtiles reo-eived. All hospitals inl the areat would lie- reinforced with

surgical teams and resuscitat ion andu shock teams wvould lhe present onl the beaches or

hards. To'i meet requirements lin fthe Initial stages, of the operation, and until ',tile

ronte of evacutat ion wats eatiialized.' tellingiiand anlibulatice coililipaulies would have to lie

hiorriiwedi from areas northl of the southern Base Sect ion.

General H awvley explaiinedl how it wa-is the resjionilisllity of thle Evacua tioin Division

to keep the hedls lin the reveltitoi area thd"It wits (.rmseptiVII that piatients shiitl(I not

he immobililizedl in these hospitals 11114 beds thus "frozen.- Therefore only essential

suirgical treatmnent. such ats that givenl inl Evacuation IHospitals. mu11st lie gi veut therein.

The Indlc of the pat jents should lie evaclintod within 24 hours.

The Chief Surgeon then explained what, measures wouldI have to be inmplemnented to care for the great influx of troopis into thle stalging areas.

Ini the discussions that followed, Colonel Cuitler again. brought up1 thle

desire for sorting at. the beaches and stuggestedl that hospital trains evaecuate

less seriously wounded and neuropsychiatric patients from thle reeiv-ing areas.

General Ifluiwley sa id thlit evactmat ion 1)1, htospitall train of suchl patientls r(iiIjj

not, hle considered since there were no facilities for parking the trains in the

vic-inity of the beaches ando liards. Ile insisted that sorting of patijents collti

not be donleat thle beachles. Ile stressedi t hat it was essential for all1 to Ile Illovedl

away imnmediately, and lIe- add~ed tile conjecture that the run11 of neuropsvchliatric cases Would not ble high. Ile also said that very little t reatnilent. would]

be given by the Navy onl LS'1"s, althoulgh flie Naval medicafl officer in) charge of

iTsMT operat ions was ,ltost cooperative. Colonel Spruit said that naval medical

personntel inight need reinforcing iiy Army p~ersonnlel. G'eneral Hawley agreedI

ando dlirectedi that this quest ion hle looked inito.
CHIEF CONSULTANT IN SURGERY 179

To a question oi air evacuation by Colonel Gorby, General Hawley replied:

* * * the possibilities of Air Evacuation of casualties had been considered, but it was

not estimated that it would start until -)+10 or D+ 15. In the early stages, aircraft would

have to return to specified troop carrier co.mmand airfields. Since there were no fixed

hospital facilities in the vi(cinity of these airfields, tented hospitals would have to be used.

Later it might he possible for aircraft to "touch down" near fixed hospitals. General

Hawley pointed out that the demands on the air forces would be so great that it was

extremely unlikely that aircraft would be available for evacuation of patients from hospitals in the reception area in the event of a dislocation of rail traffic, at any rate initially.

General Hawley concluded his explanation with comments on the supply

situiat ion and the need for decentralization, lie said that supplies which would

have to be furnished would be largely maintenance, but that a reserve must be

kept to replace equipment lost by sinking or from other causes. For an example,

lie mentioned the fact that a whole evacuation hospital might be needed, and

that arrangements must be made in advance to provide replacement for immediate and speedy loading on LST's. Provision must be made, he added, for

the transport of blood and its storage at ports.

So this was it, pondered Colonel Cutler. The big effort was finally going

to be made soon-but when? He recalled with some apprehension that, just

before Ch,'istmas, General Hawley had warned the base section surgeons that

in a month there would be scarcely a base section whose job would not b)e bigger

than the theater was at the beginning of the month (l)ecembler 1943). He

could not help but conjure up memories of those southern shores of Devon, the

European theater Assault Training Center, which he had visited not long ago.

Visit to Assault Training Center, ETOUSA.-On 5 November 1943,

Colonel Cutler departed Cheltenhamn to visit the Assault Training Center,

ETOUSA, near Braunton, D)evon. On the way, lie had stopped by at First

U.S. Army headquarters and learned the happy news from Colonel Rogers

that General Hawley had suggested Maj. William J. Stewart, MC, as orthopedic consultant for the First U.S. Army. Ile knew that Major Stewart would

be an excellent consulting surgeon for the First U.S. Army and of great assistance to Colonel Rogers and to Maj. (later Col.) J. Augustus Crisler, Jr., MC,

its surgical consultant, but this suggested appointment did not materialize.,-

At the European theater Assault Training (Center, Colonel Cutler was

pleasantly surprised at the realism and practicality of the demonstration he

observed on the employment of the medical services upon a&saulting a hostile

beach (fig. 64). However, lie stated in a memorandum to Colonel Kimbrough,

dated 7 November 1943, that, while the role of the Naval beach control officer

had not been made entirely clear, the Chief Consultant in Surgery had been

somewhat taken aback by the impression he had received that the Navy controlled entirely evacuation from the beach. Colonel Cutler also had a ride

in a "duck" [DUKWV (amphibious truck, 21/2 ton cargo)] and found it quite

a task for a healthy man unencumbered by the paraphernalia of war to mount

71 Memorandum. Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, BIC, 6 Nov. 1943, subject: Orthopedic Consultant for the First Army.
1-'[I ~ r ill- ~ ~ tT ~ ~ ~ olil- Ia: ~ 6- C -l ~ ,A -S 

oil 111 i11:1 141 :111il 4.,114k ~r ) .I-s l. 

- S-41 i II11 44
CHIEF CONSULTANT IN SURGERY 181

into one. From this experience, lie could not help l)but conclude that the means

for getting walking wounded and even litter cases into a "duck" are inadequate.

As a substitute, he suggested that everything should be done to land jeeps

for use as light ambulances at the earliest possible time. Jeep ambulances,

he said, would save much time for the wounded and p)erhap)s make it unnecessary to set up what was called, in the demonstration, a reinforced regimental

aid post.

British EMS plans.-And recently, just, a few days before General

Hawley's talk, Colonel Cutler had participated in a similar discussion on

the British side. Mr. Willinck, the new Minister of Health, was present at

the meeting of consultant advisers to the EMS held at the ministry offices,

Whitehall, London, on Tuesday, 4 January 1944. The Director General, EMS,

newly knighted, was chairman as usual. Sir Francis Fraser led the discussion

on the care of battle casualties by the EMS when the Continent was invaded.

The British were going to use three selected ports for the receipt of their

wounded. The wounded, upon their return to England, would be taken to

"transit" hospitals in the general locality of these ports. After surgical

therapy, or immediately in medical cases, the wounded were to be sent to base

hospitals in the north and west of England. They did not plan to use the great

London hospitals as base hospitals, since heavy retaliation on London by the

Germans was expected. Following treatment at the base hospitals, selected

cases were to be sent as necessary to special hospitals for maxillofacial surgery,

neurosurgery, and so forth. The need for basic surgical directives and mobile

teams was cited, although it was stressed that their professional men would

be sent to transit hospitals as well as the many base and special hospitals to

which they were already assigned. Colonel Cutler offered to send the EMS

copies of the NATOUSA circular letters on surgical therapy which he had

recently brought back with him from Italy, and the EMS consultants implied

that they would like to model theirs after the NATOUSA directives-just

as Colonel Cutler, himself, was to do later.

After returning to Cheltenham, Colonel Cutler submitted to Colonel Kimbrough on 8 January a brief memorandum summarizing the highlights of this

meeting with the EMS. Lie concluded his memorandum with: "I believe

this meeting makes it clear that we should keep in close liaison with the British

setup for the care of casualties returning from possible continental invasion."'

Elsewhere, he wrote this enigmatic afterthought of the meeting: "The

EMS is to look after all returned battle casualties, and, after 4 years, are still

surprised over it !"

The buildup begins.-As General Hawley had foretold, the remainder

of January 1944 set the pace for the busy months that were to follow. Taking

a quick respite on Sunday, 23 January, Colonel Cutler noted in his diary:

"Catching up; things moving. Hospitals arriving daily. Hard to keep up

with work. Robert. Zollinger is a great help."
182 At'TI VITIE- OP (1 SURIC( (AL CONSU'LTANTS

Problems in Allied coordination.-Colonel Cutler had said tilint thle

Atinericati -Alioiid keep) close I aino w51 Vith titlie Brit ish ill tilie working out of

procedures for t he receptlion of casualties. It Sooni becaiiie apparent that. tile

British thinking~ wvas veysimiilar. Sir Francis F'raser asked Colonel Cutler

to Ilieet. with lrit ishi representat ives for thle joint working out. of certain probleins which hald appeared. O n 28 .January, Colonel Cutler journeyed to Oxford and miet wvith Prof. (ieothrey Jeflersonl. adviser in nieurlosulrgery to the

EMS, anti Brigad ier Ifiugh Cairns, Consultant in Neturosu -rgery to the British

P~rofessor Jefellesonl stated thiat the EM~S had a very iniager supplly of special ist s to mleet thle trelinentlous demndaus which were expeeteoi. While tilie

Brit ishi Arniy could help to a limnitedl extent. it was p)art icularly in neurosurgery

where thev feared tile greatest shortage of qulalified Lprofe~ssiollal hielp. Profes'sor Jeffersoln asked if 'the Amierican Army would be willing to have British

1n0uirSn11rgival. casualties sent to their hospitals for care. It was applarent to

Colonel C

1utlher that, s inliiar decisions were (desiredi for ot her types of cases as

well. Significant, anid. nlost. obvious, was thle. fact that thle, EMS hiad not been

iliifolIiiied oil thlese matters, and Colonel Cutler did not hav'e the answers either.

lHe could but say that there was an overall p)lannling group~ which had probably

settled these p~roblemis and that. certainly, representatives of the Canadian,

British. and I .S. Armyv medical services had to mneet, settle, and integrate plans

for th l-iecre of all casualtiesvirriving in the reception vreas.

Ill a ilieulior-andlnuu, writ temi oil 29 .Januar v after his return to Cheltenhani,

Colonel Cutler advised thle Deputy Chief Surgeon, through the chief of the

Professional Services D~ivision, that thle following~ specific questions should he

1)11 to thle AlliedI plann11ing group:

1. Will UT.S$. Army hospitals. Canadian Armyv hos-pitals, and EMNS lioslpitahs in thle. recelption areas take in and care for Allied casualties just like their

own'?

2. Can thle. EMAS count upon01 U.S. Armny h~ospitals taking in and caring for

sp~ecialty injuries over and above the general run of casualties?

3. Should the answer to question 2, above, be. favorable, canl a list of U.S.

Army hospitals in the reception areas, with information as to where what specialists are assign~ed be submitted to the EMNS so that thle EMS maly route

1)at ient S to such hospitals?

And here, the reader should note, was thle first instance where Colonel

Cutler was acting as tile American surgical representative for Allied planning

of thle invasion-a function which was to grow andl become miore. involved as

timie passed. andI which devolved upon01 himi naturally in tile course of events

without lily specific ordlers.

At thle nionihly ineeting of adlviser's and consultants to the EMS hield onl

8 February, it was still obvious to Colonel Cutler that the EMS was in ignorance

about overall plans, and thle. professional board of the EMS felt that its planning

could not be reasonable until they had further information. Colonel Cutler

notedl, too, that the specialists dlesiredl early triage so that casualties requiring
CHIEF CONSILTANT IN SURGERIY 183

special treatment coulh receive that care within a reasonable period of time.

As it was, if the general plan were followed, 3 to 5 days would be consumed

before this special care would be available to casualties needing it, and mortality

and morbidity would be increased by such delay. The Director General, EMS,

spoke of the need for gradually vacating beds in the better hospitals, the possibility of triage at transit hospitals, the necessity for rapid passing of cases

through transit hospitals where long holdovers would be undesirable, and securing additional special instruments for work in special fields for use in transit

hospitals.7'9 These problems, with which the EMS was contending, were to

Colonel Cutler the very problems that the U.S. Army had yet to face, and matters of serious concern.

Following this last meeting, Colonel Cutler visited the Chief Surgeon's

London office and spoke with Colonel Liston, the Deputy Chief Surgeon, on the

various matters which had been b)rought up by the EMS. Colonel Cutler told

Colonel Liston that planning wak .ot his problem and that lie had asked the

EMS to put in writing to him any specific desires they had so that lie, Colonel

Cutler, could pass them on to the Chief Surgeon, ETOITSA.

Critical shortage of qualified officers in ETOUSA.-On Thursday,

10 Februarjy, a teleprinter conference was in progress l)etween the Chief Surgeon and the Office of The Surgeon General in Washington. Perhaps C(,lonel

Cutler was unaware of the conference, itself, but, as has been shown, lie was

certainly aware of the problem which was its subject (pp. 37-38). The coiiference concerned personnel, particularly supply personnel. The tenor of the

conference also in(licated how critical activities were in this immediate preparatory period prior to launching Operation OVERLORD. An excerpt from

the teleprinter conference of 10 February 1944 follows:

This is Hawley speaking: Colonel Voorhees and his group have done a splendid job in

diagnosing the troubles and pointing out the cure. I am implementing their suggestions at

once, but I must have help to implement them properly. Until recently this theater was of

minor imlmrtance in the large picture. Realizing this, I have refrained from asking for

the ablest officers available, with the result that, with a few notable exceptions, the officer

personnel furnished me was not of high quality. We have tried to carry on during this

period of relative inactivity and we have barely succeeded. This situation has now changed.

This is the most important of all theaters and we have fully demonstrated that the quality

of personnel furnished us in the past is totamlly inadequate for the task that lies ahead of

us. We must not fail. Yet we cannot succeed unless we are given the tools to work with.

The best officers to be had are none too good for the jobs to be done here.

The most critical time of all is now. After plans are made and operations are proceeding smoothly, some key personnel can be released and thei places taken by subordinates

who they have trained. I realize fully the many positions that have to be filled and the

few really qualified people there are to fill them: and I shall be unselfish when the time

comnes that the need for able people is greater elsewhere than it is here. But now, for the

first time in more than two years, I am really begging for assistance.

"Rotten ships for care of wounded American boys."-Colonel Cutler's

impression of LST's, after his first two encounters with them, was that they

79 Memorandum, Col. E. C. Cutler, MC, to Chief, Professional Services Division, 11 Feb. 1944,

subject: E.M.S. Preparations.
184 ACTIVITIES OF SURGICAL CONSULTANTS

were "irotten ships for care of wounded American boys.- These initial impressions, however, were but a challenge to Colonel Cutler to make them the

best possilble vehicles for evacuation by sea under the circumstances. To this

end, Colonel Zollinger, his consultant in general surgery, was of inestimable

help.8 0

Already, on 4 February 1944, Colonel Zollinger had met with Colonel Liston, the Deputy Chief Surgeon, and Capt. George B. Dowling, MC, U.S. Navy,

who was the Naval medical officer in charge of LST operations for the evacuation of casualties. On 8 February, he had met again with Captain Dowling

and a Lt. William A. DuCharme, 1IC, U.S. Navy, to go over and evaluate

medical supplies and equipment which the Navy planned to load on LST's for

the care of 200 casualties. And, on 14 February, he had gone to the Southern

Base Section and discussed with the base section surgeon the placing of surgical

teams on LST's and the scope of treatment to be given. They had also discussed the advisability of placing general surgical and shock teams at the field

hospitals to be located right at the hards for the care of nontransportable casualties. They also believed that it would bee necessary to break up one or two

general surgical teams to obtain experienced medical officers to supervise triage

at the bards. There was talk, too, of the placement of general surgical and

orthopedic teams at the transit hospitals and the use of the specialty teams in

hospitals for the definitive treatment of casualties.

With this as a backgrouki4, t;oloniel Cutler, Colonel Kimbrough, and

Colonel Liston joined Colonel Zollinger on Tuesday, 15 February 1944, at

Plymouth, Devoushire, to look over an LST. Colonel Muckenfuss and Captain

Hardin from the Blood Bank, ETOUSA, also joined the party. The inspection of tihu JST, which had been arranged through Captain Dowling, was

conducted by Comdr. Luther G. Bell, USN (MC). Colonel Zollinger informed

the group that the ship had been used at the Salerno landings but that it was

not of the type which had been converted to carrying casualties.

"We were able to inspect the entire LST.," Colonel Cutler wrote of the

expedition in a 15 February memorandum to the chief of the Operations Division, through Colonel Kimbrough, "including the main deck, on which was

the upper battle dressing station in ward room, the middle deck, where a second

battle dressing station was contemplated in the crew's messing compartment,

and the lower or tank deck."

Colonel Cutler noted that the usual difficulties of movement on a ship

were present. There were narrow doorways, sharp right-angled turns, and

steep ladders or stairways between decks-difficulties which could not be

changed but had to be recognized in the proper planning and loading of casualties on such ,a ship. A primary consideration underlying all planning for the

care of casualties and returning sick personnel on such ships. Colonel Cutler

mentioned, was the fact that "loading of casualties and patients must proceed

simultaneously with the unloading of the ship." With this in mind, he believed the following sequence of care should prevail:

SMep also ('olonel Zolllnger'r iwrs,,iw1 narratlve of his activities In ('hapter III.
CHIEF CONSULTANT IN SURGERY 185

4. * * *.

a. Casualties will come up over the side in special stretcher slings developed by the

Navy * * *. These deliver patients to upper deck (fig. 65).

b. From the deck the casualty may go either to: (1) The battle dressing station

iii the ward room, or (2) the battle dressing station in the crews messing compartment

on the middle deck. There, adequate dressing facilities for all types of wounds must be present with additional splints. There, proper notation should be made on the EMT as to some

sort of categorization concerning the ability of the individual to withstand transport on

reaching the near shore. If surgical procedures are necessary to save life or limb, such as

ligation of a vessel or the amputation of an extremity hanging on by a few parts, then the

FMR must be begun and proper notation made on it.

c. After primary first aid care has been given, as above, the casualties will then go

either to the area known as the crew's quarters, which is adjacent to their messing compartment, or to the tank deck, if they are on stretchers. As there is space for some 78

stretchers in the crew's quarters it would be advisable for all stretcher cases to be held

in this area if possible. Those who are ambulatory, both sick and wounded. can go down

to the middle deck and be held in the space allotted as "troop quarters," which can provide

for 175 men. The number of stretchers or other casualties which can be placed on the tank

deck will depend upon whether we are utilizing a converted ship with wall brackets for

stretchers or not (fig. 66).

5. Comincut on battle dressing stations or first aid posts: Of the two areas provided

for this service, i.e., the wardroom on the upper deck and the crew's messing compartment

upon the middle deck, the latter would seem more reasonable, for if there be only one surgeon he would have near him in the adjacent crew's room (sleeping quarters) practically

all of his stretcher or seriously injured people. Both stations, however, are suitably lighted

and supplies could be assembled there. Moreover, both stations have tables which could

serve as operating tables. The crew's quarters stations are near the kitchen, so that sterilization by boiling would be more simple, unless an electrical hotplate is added to the wardroom, where there is a plug for such a receptacle on a table.

The visitors, particularly the two from the blood bank, ol)served that there

were two types of cold rooms on the ship. One was for ineats where the temperature was kept at 200 F. This room was obviously unsuitable for storing

blood. But there was another space for storing vegetables and fruits where

tile te erattire. was held at 48' F. Fortunately, they discovered, tie temperature could be adjusted to 400 F. which would be appropriate for storing blood

and still not hurt the fruits or vegetables.

On his return from Plymouth, Colonel Cutler reported: "No intelligent

regulation can be drawn up concerning the care of casualties on such ships

until knowledge is available as to time liiuitatiuns." Time, he showed, would

affect considerations in professional care o01 LST's in the following manner:

If casualties will Ie on such ships up to and beyond 20 hours after being wounded,

then one would have to advise and provide for abdominal surgery, since the percentage

of recovery in the cases of abdominal injury becomes almost nil after 24 hours. A similar

attitude on definitive surgery of all types must be dictated according to the time interval.

If instructions are to be given to medical officer personnel on LST's as to what they

are to do, that would depend entirely upon this time interval, and if indoctrination courses

are to be given to the medical officer personnel who are to be on LST's, some rough estimate

of this time interval should be known to the instructor before speaking, else Ills advice

will be inappropriate and possibly damaging to the American soldier.
AI 'T I VH I F III. S1 NN H 'A 1. 1 LTA XTS

Air

ý41

k- A

['14.1 m G.-'. S114-iol ýHIIL-' "ll A. A 'Hwu hviltý: fl'o'd 1'.

1140i'l :I liffor 1*1,10111 1114. 44, :111 LST . 1'. A SHIIL' bvil[Lý 11,4.41 1.0 bm i.l. ;I Hllor.
CHIEFii CONS4ULTANTl IN SUl4.1l:HY 11,7

Fvua i;. L~it ter pati jul1s ill .tfl iL'r I I1;1 hadlvl PI iuoiielt ed wit Ii wall t) irk hold111(

lit ters.

It is myv hople I hat Ilite initerval AviIL be so ShorIt thit the profession1al work oll .111

LSTl will hie largely liirst aid. i.e.:

1. 4 olltjl 40(of heiiiuuIrrliage.

2. Tireat ineitt of slnucl ifor wliiel bldou'1and lul;Isilla wvilI In' iuiovidedl

:,,. lirojner (iressinfirg wom'~uil(is.

-1. Proper spint ofg ;unictstuiu orl 

it'. i~owevir. 1 lie 1 jiuuu is it, ln( over 21 Ijimirs. or evenl if I here is ulmiiger I hat it is

aIf) beiii. 2 1 homrs. thlen :ill (.1i1 ielMY difflerenit set (of (ireculllist anies w~ill prevniil and14 dil''rvill

inls niHc ions mujist hei givvil I lhe Ililvic.il oficei*(rs ill n(iiiljtn 1li4rgi' -ewjli a

wrau aga liltth, A\nivric.auu soldier ill this event if we did( not1 provide for deliiuit ive

s1urg1ery ili I lie v.iit' f effases all I le LST's.

( u otdtvfoIwiit.21 e I elutmlt-t. ( ()14te1 (.1 '1 t I ev joie A) w(IaII1)111is I I -

t'ludtet Maj. (;(ell. Albuert 11. 1(ezuier.C( Itel' Medliedi )ffiver,' SI]AFF. a 11(1 (Ol.

Al ~itu L. ( ;ohv, MCl wt \\-;is Ia)()\\- ass-ig'tt'(I to thle F'irst U .S. Aniliv (iit

the ovet':li phl ;laill gtI&1 ai'& ;ttI izaoll ()I1 Ht.h Aiiieieatn 'ide fAtl ( pernlIimn ( )VE1zLAM' )I ). Ille djlivt'eihius frpltil'it (d, the( Rio)vat Nalvv and Ille Brit ish Ai'lllv

1ilvdcila S er'vices Itivled i tlie thuislis dtle-~:1mi(tl. will;i lieu'11 t'esp(,j\l *(tlý ia
188 ACTIVITIES OFI- SURGICAL CONSULTANTS

consultants, Admiral Gordon-Taylor and Maj. Gen. David C. Moniro. There

were also Surgeon Rear Admiral Cecil P. G. Wakeley, a consulting surgeon

to the Royal Navy; Brigadier Arthur E. Porritt, RAMC, then consulting

surgeon with the British 21 Army Group, the British counterpart of the

First U.S. Army Group; and other officers from the British 21 Army Group.

Colonel Cutler was quite disconcerted with the British attitude toward the

handling and care of casualties on LST's, since, if their opinions were to prevail,

much of the planning and work so far accomplished by Colonel Zollinger

would have been for nought. Yet, there was on evading the fact that this

particular inspection of LST's was conducted primarily from the viewpoint

of the British Army and the Royal Navy medical services. Colonel Cutler's

28 Fel)ruary report of the trip to the Chief of the Operations Division in General Hawley's office contained the following statement:

1. The British seemed to have hardened their opinion even before visiting the ship that:

a. The ship must load casualties via the ramp through the bows.

b. They prefer not to use the ship's company's quarters, as these people will be

working very hard and should not be disturbed.

c. They wish to keep all casualties on the tank deck and have plans to construct

a small first-aid post. screened off, at the rear end of the tank deck.

d. The medical personnel for an LST will consist of two general duty mledical

officers, one qualified surgeon, one anesthetist and 32 men of noncommissioned ranks,

about 20 of whom would be trained Navy medical personnel. Others would be largely

used to clean the tank deck after tanks have left and before the casualties are brought in.

2. The British group felt certain that it would be impossible to take casualties up

over the side in units or by any other method. They believe it will be necessary to beach

the ves-sel, leave her on the beach throughout the fall and flow of one tide and take her

off afterwards. This opinion is contrary to that of American Naval officers when inspecting.

:l. On travelling back with Lt. Gen, Hood [DGMS, British Army], he expressed the

opinion that the LST was an unsuitable vessel for carrying back wounded peol)le. that

it was outrageous that better provision could not be made, and that lIe might take this

to the Prime Minister and General Eisenhower. He expressed the opinion that an LST

was a "(,old, dirty trap."

4. (hit of the above objections, many of the professional peopfle present, notably

General Monro aid Brigadier Porritt. as well as myself, felt it might be better to try

and hold certainly all litter cases on the far shore, rather than aept the risks of translm~rt back on these vessels. Certainly the "Collecto-clearing company" or the platoon

of the field hospital could be landed with the second wave and give the necessary surgical

ca(re.

Much of the meeting of the Chief Surgeon's Consultants' Committee on

25 Febrluary 1944 was taken up with the subject of care of casualties on LST's.

Colonel Zollinger gave a summary of the existing plrollems and plans which,

so far, had been worked out. with the Navy. One of the remaining problenms

was the treatment. of al)lominal woun(ls, he rel)orted. The Navy was estimating a 16-hour journey on LST's, once they were loaded, but risk of mortality

in adinominal cases rose. pre(cip)itously after 6 hours. Ihere was a general desire to (10 abdomens, if necesstrv, on the LST's. but there were no provisions

for the equipment or l)el'sonnel. Furthermore, p)lanning to ol)erate on abdomens on the far shore had its disadvantages in the initial stages because

there wouhl not Ie facilities to l)erform such ol)erations and. because it was
CHIEF C'ONSU'LTANT IN SU'RGERY 189

thle general policy not to move for aboutit a week eithier abdominal or chest

cases which hial beeni operatedl upon0. Of thle situiation at. the time, Colonel

Zollinger said: "If a manl happens to be qualified to operate onl [board] LST's,

good ; if not, hie wvill have to depend uiponi norlplline."

Greneral Hlawley was quite taken ab~ack by the p)rosp~ect, and said: "Thlese

are young chiaps-recent, graduates. lliev wvill not, have done1 any kind of

residency. To op~erate onl a belly onl an LSýT! ! The question is whlethier it is

better to operate onl tile far shiore. and~ p)ut himn imnmedliately onl anl LST ; is that

worse thian operating on an UST?"

In answer to his own quest ion, General Hawley said1 tiat. it, wouild be

better to op~erate anyway rathier t han go so long as 16 hiours and thlat it wouldl

probably be better to operate onl tile. far shore and thien have thle [patient. taken

aboard, with special care availab~le onl the ship. The reason, lie said, was thlat,

there wouldl be a better concentration. of talent. onl the farl shiore a111( "we have

to thiink of the most groodl for the largest number and establish a ruling for it."

Colonel Kinibrouigh, however, inlsistedl: '41 would like to stick to thle i'ecomlniendlation that there 1)e facilities to operate oin any case that might arise

olttLST."

"1 agree," Gener'al I awley rep]liedl.

The discussion oil LST's was closed with strong exhortation fromt thle

Chief Surgeon that tile consultants crystallize their olpinions onl what, had to

be (lone and hlow and to "get. it dowvn into ain operating p~rocedu~re thiat. the

Navy thoroughly understands."811

Tille readler may recall that shiortly after this, in March 1944, Thle. Surgeon

General and the Air Surgeon arrivedl il tile theater for anl extendled touir of

medlical facilities servinlg the Armly Air Forces and that, Colonel Cutler was

requiired to accompany time visiting, officers. Tile, hispeetioll touir and its aftermath requiredl thle services of the Chief Consultant in Surgery fom the best

part of a montli at. this critical time. Thle bul1k of tile work to develop tile

necessary operative procedurmes with the Navy fell onl Colonel Zollinger.

Physical standards and disposition boards.-At the aforementioned

meeting of thle Chlief Surgeon's Consultants' Committee onl 25 February, General Hawley saidl, "Now I hlave, a p~robleml. Whiat canl we (10 to get. thlese (isposition boards to realize, more fully t1ieir responsibilities in thle. coiservatioll

of manpower. I think it is getting better, but, I thiink we are still evacuating

too many people. Whait caii we (10ab~ouittlmatU

The disposition bo~ards hiad been establisliedl at nmost. greneral hiospitals

and certain station hospitals iii August. 1943 .12 Each board consisted of thle

""' The emergency operating rooms on the LST's were built In the center of the tank deck along

the after bulkhead. Each such room took tip the space of one vechicle, hilt the combat troops were

not advised by general headpuarters; of this alteration. The loading tables had been prepared for

each 'unit:; so, when the troops embarked, eziei unit had one truck, or other vechicle, which couuld not

he loaded and had to be. left behind. There was a lot of hell raised about this. but nobody ever

eriticized the Chief Surgeon. These changes had been made through command channels." (Letter,

Paul Rt. Hawley, M.D., to Col. John Boyd Coates, Jr., MIC, 17 Sept. 1958, and personal conferences,

Dr. Hawley andi Colonel Coates, during October 1958.)

52 CIrcular Letter No. 122, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 17 Aug. 1943.
190) ACTIVITIES OF SU'R(GICAL CONSULTANTS

chief of medical service, the chief of surgical service, and tfle ward officer of

the particular patient. If a chief of service was uuavailahle, the appropriate

assistant chief was directed to act for his chief. The directive further required

a review 1) a disposition board of all cases in which it was believed a patient

"should be returned to the United States for further observation, treatment,

and disposition. The recommendations of the boards required final approval

by tile hosp)ital commander.

The action of these b)oards had 1been notably inconsistent an(l, in many

cases, unduly delayed. To General Ilawley's question, Colonel Kinibrough

rep)lied that the al)prol)riate consultants had been reviewing reports and spot

checking final reconmmendations. Ile said that, a great many cases which the

consultants felt could l)e retained for (duty in the theater were still being sent

to the Zone of Interior. In such cases. Colonel Kiml)rough continued, telephone calls were being made to hospitals involved to check on the validity of

the decisions.

General lHawley then instructed the professional services to continue just

that action and to submit recommendations for improving the procedures.

The emphasis at this time was on the conservation of manpower, and

General Hawley's feelings were well expressed at this meeting, as follows:

* * * The point is this. We all want to protect ourselves. We have to conserve manpower. We have to stop getting people out of the Army who can do any kind of a job at

all. Can we be in a position to say there is nothing wrong with this man? He might walk

right otit and drop dead. That is just too bail. We have done everything we can, but it

is going to save hundreds of other people for duty if we establish a policy and stick to it.

I want you to think it over. We have. all of us, to get out of the family doctor's psychology

here and we have to know that we are going to make some mistakes. ('an we keep those

mistakes dolwn within reason and can we assure our preventing a lot of mistakes being

made on the other side? If we can almost break 50/50 on it I think it will be worth trying

beanuse we have to preserve manpower.

Colonel Cutler, in his visits to hospitals, had found that one source of the

p)rol)lem lay in the lack of guidance to disl)osition boards. For example, lie had

found that, many officers would have liked a list, of conditions which would be

appropriate for returning a soldier to the Zone of Interior. With his senior

consultants, the Chief of Consultant in Surgery worked out such a list, as did the

medical consultants. The list was submitted, but General Hawley was reluctant about publishing a list of this type because he thought that, each individual case had to be judged oti its own merits, especially with regard to thle

duty which the patient would be expected to perform should he be retained

in the theater. Yielding to the advice of his consultants, however, the Chief

Surgeon permitted the list to be published on 24 March 1944, as Circular Letter

No. 45, with the following qualification: "It is to be remembered that this list

is to be used only as a guide. each case to be decided on its individual merits."

Aftermath of Operation CRACKSHOT.-When the general plan for

medical ol)erations in England to support, the invasion had been more or less

firmly established, General Hawley had called for trial evacuations from transit

hospitals to the southern belt of general hospitals which were being designated
CHIEF CONSULTANT IN SURGERY 191

for the primary definitiive treatment of patients. These were actual movements

of real patients using ambulance and hospital train units which had been earmarked for the evacuation mission in England (fig. 67). One of these trials

was Operation CRACKSHOT. The Chief Surgeon was quite l)lease(l with

CRACKSHOT because it showed where weaknesses in the plan were and

because the observers of the trials had made such a thorough and careful analysis of these weaknesses. The Chief Surgeon calledI a meeting of his key staff

officers on 24 March 1944 at, which he opened proceedings by saying:

We have to button up some things here before operations.

There will le a stenographic report made of this but * * * anything decided here

ought to be put out as a directive and by the time I get back [from the Zone of Interioir] I

would like to see most of it either aecomnljishe(d or well on the way. We have not much

longer now. All our mistakes have to be behind us.

The first thing is this report in detail on the Operation CRACKSIIE)T. I understand

that we have had, in a few days, something which has pointed out Ihe weakness of things

in general.

From this beginning, the conference proceeded in rapid-fire fashion, most

of the decisions being madle by the Chief Surgeon followed by his specific directions as to the actions to be taken. "nhe following topics concerned the Chief

Consultant in Surgery.

"Here is a very important thing," said General Hawley reading from the

Operation ('RA('KSII()T rel)ort, "Recolnmend that the scope of treatment

given at these transit hospitals be definitely outlined and that Professional

Services be consulted as to the necessity for augmenting personnel with surgical

tealus." The Chief Surgeon continued: "Now, these are evacuation hospitals

and they have definitely to limit the amount of work that is done. You cannot

immobilize patients there any more than in ainy other evacuation hospital."

"That has been considered," Colonel Kimubrough answered, "and that is a

general policy."

General Hawley then directed, "Will you give us something that can be

published that we can hold them to?"

And then a little while later, "Question of procedure," said General Hawley, "slightly wounded ambulatory patients to be separated from serious cases."

Colonel Kimbrough explained, "That triaging is planned to start on

LST's."

General Hlawley's comment : "It will work on LST's, but it wonit be complete and final. Every hospital has to triage its own patients. Hosl)itals cannot. (el)end up)On triaging Oil LST's; every unit has to do its own."

('oloiiel Kimbrough then made a recommen(lation which had continually

been made by his division. Ile state(l: "It is recommended that a responsible

medical officer, not just a junior officer, be at the hard to do triaging."

Thinking aloud, General Hawley said:

When these patients get to a general hospital they have to be tringed again. We have

to keep those beds for seriously wounded. If a patient does not get definitive treatment

In transit hospital he has to get completely definitive treatment in some station hospital

some place else to eleatr that Ibed for at seriously wounded uaini who cannot bie moved].
AJH4 1

PON-
CHIEF CONSULTANT IN SURGERY 193

Our first run of patients will be from transit hospitals to the southern belt of general

hospitals. We cannot let that southern belt of general hospitals get full of minor casualties.

We have to keep those beds for people who cannot be moved any farther than that.

We have a lot of beds in East Anglia not going to be full, perfectly competent for

taking care of arms and things after first definitive treatment. The point is, you have to

keep those southern belt general hospitals for serious cases that cannot be moved after

definitive surgery.

And then, after a very brief discussion, General Hawley made a decision

and issued to the Operations Division the following instructions: "Incorporate

in the plan the further evacuation to station hospitals of slightly wounded

whose initial definitive treatment has been completed, in order to keep the

FIGURE 68.-Lt. Col. Fred H. Mowrey, MC.

beds in the first row of general hospitals fluid for serious cases that cannot

be moved."

This discussion brought to General Hawley a thought on the spur of the

moment. "A second thing on that," he added, "it is to keep these general

hospitals indoctrinated that as soon as the patient can safely be moved to the

Zone of Interior he is out and on his way home. I cannot impress that too

much."

"64I would like to emphasize that they do that now," explained Lt. Col.

(later Col.) Fred H. Mowrey, MC, the hospitalization and evacuation officer

(fig. 68). "However, some of them have been keeping patients more than

180 days. I would like to have all of those boarded so that we get rid of them

within the next 6 weeks."
194 ACTIVITIES OF SURGICAL CONSULTANTS

"I approve of that," agreed the Chief Surgeon, "In every case right now,

let's start unloading beds-every case that will not be fit for duty in 180 days

to be boarded and reported for evacuation." Then, addressing Colonel Kimbrough, he stated: "Responsibility of Professional Services. The hospitals are

keeping up their bed strength unnecessarily. Professional Services, you have

to stop that."

"We have been working on that, both with hospital commanders and at

base section meetings," Colonel Kninbrough assured the general, "We checked

up to see about it. When we find they are not. doing it we tell them to get. this

mlan or that man out."

General Hawley warned with portent, "We have to get tough with somebody here-or else."

Colonel Kimbrough took these and other discussions at this meeting to

mean that his division would have to work out an SOP for the care of patients

in near-shore installations and transit hospitals. lie also emphasized the necessity for checking on and instructing hospital disposition boards, not only in

their responsibilities for conserving manpower, but for acting quickly and

early on all cases to keep their hospital beds free.

General Hawley went one step further. Ile issued a directive applicable

to each consultant in the Chief Surgeon's Office which made it his personal

responsibility to check on disposition board procedures at each hospital visited,

regardless of the original purpose of the visit, and to see that hospitals were

not k,,eping patients who should have been transferred elsewhere.

SOP (standing operating procedure) for professional care of casualties.--Three days after the Operation CRACKSHOT meeting, Colonel

Zollinger had prepared and submitted to Colonel Kimbrough, with Colonel

Cutler's approval, a statement of the professional care to be provided casualties

in the various echelons in England during the attack on the Continent. Colonel Zollinger also prepared the necessary correspondence for obtaining the

personnel required to provide the care stipulated.

With respect to surgical treatment on board LST's. the substance of the

SOP was as follows:

Surgical treatment on board LST's will be similar to that of a divisional

clearing station. Definitive surgery is not contemplated except. in those instances in which it. is necessary to receive patients with abdominal wounds,

or similar casualties, occurring on board ship as a result of direct enemy action.

The decision to perform major definitive surgery on board LST's will be governed by the type of wound, the estimated time interval from wounding until

near shore definitive treatment is available, the professional qualifications of

medical personnel, and, finally, the volume of casualties.

The casualties will be triaged on board ship into two major classes, ambulatory and stretcher cases. The stretcher cases will be further triaged into

"transportable" and "nontransportable" * * *. The nontransl)ortable casualty will be defined as a casualty requiring immediate resuscitation or surgical

intervention after unloading from the LST.
CHI1EF' CONSULTIANT IN SUIIUERY19

Atf thle hard,~1 the plani called lm t'w oI (wi I liree exiwrieficed ,-III;- vlsIi'mfo

tr~ie 'leeofiesW lilIittr it~i~ljildluriltellt were I () reevail lile vaC i

ties 11114) I rai11p)4)tablle andImI~l 011 rim1ofiliale cases. 'Ille 1ihiii tl'(i itote( flufft

ali11il)Iancie evatcutit1411 %%,IS 110W ViI( , -11) ) C1Ct5 I V1~ I 4 lIva I iirest

Iiiedicotl he:iq-l , v, af whlichdiwre Nvere 1to be tx%"4) I .y.pes- -fieldl Imspital jil.W ())IS

feaiii-.. The S(ijiC 441 "rC:tilivill:i at these& iciflt e*s wats N1 lie s..ibsi;1iit :tllv as.

PiI4 !ui.jitd iif~lls of~i ' )1 li -lied ftiv~ill w lie l~iEoiedl iEIlvl I liree od

fliv i1i1tj.il' 11:1 1415. 'Illes- II~IIW-S will r-eveive dwI ieiolt ratiisiorI-1lie c:~itI e il~l

thle Iv~n. ieI-v(i11i-1ig n-siisciillW ai ;s w~ell usdeilelitit e siurg-erv. It li.I.s beenl s.i4res~E v1 I~ h-11 I Ev) Ireilern Iur-W sliLI Ial~iis n Ii4 I WE-) 5IicEI{ te illis I w ;issi-mited W() 4tchI

of I hIC( I II'ts. I 

A Weill ed field hiosi )it nu Iwit hi ai ijliEIWY ()f -111 bII eds, will lie locwttedl. of 7

miiiles frout evtcl of, thle 11v Ileeiatill.o htatrds O(fi. 69). IBec'llise ()J the Iur."emwc

of tiii)ldfligi1. hjS%15 raidlYII. iiSt Is :1 I.awl'E I liat it will lie uIecessativfry Im lie

libiltuIfiIvtie c4mE ilujiiues if) t11(iiil tlIv I e 111 oim - * if 4t i lwe casiiuaIties niW 1!ueSe sI ;iW 101.

Major (lefifl IiVe ii2evOf al II vhis. chiefly (mi I ltmse enltiai:IhW 1CS l)leled liontrai1wridit abl)C exceptW I1Ctii*(4I5Ii*(rXei.l'. 111:10]i h4:14-1:11 siliZey.i11Ileesiiieit

(AlCst 511 i!4,iW.Y will be pel'rtiritoil iiWluese I Iiiilt s. It will lie lileessatpY. i herefote.

70)5 09!5' #;4 11;
196 ACTIVITIES OF S1 ItGICAL ('ONSILTANTS

that these units be heavily reinforced with surgical teams. It has been suggested that three surgical teams and one splint team be assigned.

For the general and station hospitals designated to act as transit hospitals,

the plan called for procedures substantially as followvs:

If time permits and the condition of the patient warrants, the ambulance

companies will deliver casualties directly to these hospitals. Furthermore,

they will evacuate the casualties from the field hospitals to these units as soon

asI possible. Casualties will be subsequently transported inland from the transit

hospitals by hospital train.

It is essential that the professional qualifications of the medical i)ersonnel

of these designated transit hospitals be evalhated by the Professional Services

Division. Furthermore, it has been suggested that three surgical teams be assigned to each of the nine transit hospitals to insure adequate perso'nel to cover

the 24-hour period. The surgical chief of one. of the three teams assigned to

each unit should be an orthopedic surgeon.

The plan was forwarded by Colonel Kimbrough to the Operations Division,

Office of the Chief Surgeon, on 3 April 1944 for guidance and information in

the formulation of operational plans and directives.

On 27 March 1944, when the SOP was prepared, Colonel Zollinger addressed a memorandum to Colonel Kimlbrough through Colonel Cutler requesting e augmentation of transit. hospital staffs so that the care called for in the

plan could be carried out. In this communication, Colonel Zollingermentioned

that personnel of the 1st Auxiliary Surgical Group could not be considered for

these augmentations, since most of the teams would 1)e assigned to the field

hospitals and field hospital platoons working independently. A surgical team

for transit hospitals, Colonel Zollinger recommended, should consist of two

surgeons, ome anesthetist, one nurse, and two surgical technicians. He reiterated

the portion of the SOP which called for three teams to be assigned to each

transit hospital, the chief of one of the teams to he an orthopedic surgeon.

lie asked also for two or three experienced surgeons for triage of casualties

at each of the hards. Finally, the recommendation was made that these teams

be organized sufficiently in advance of their actual employment to permit individual members to learn to function as a unit.

The request was forwarded to the Personnel l)ivision, Office of the Chief

Surgeon, which assessed quotas to each of the four base sections for 18 surgical

teams and 9 orthopedic teams. The requirement for providing triage officers

at the hards was placed on the Southern Base Section.

When Colonel Cutler finally had more time to devote to these plans, he

submitted ad(litional items for the SOP on the care of casualties in the forthcoming operations.

With respect to transit hospitals, lie offered the following in a memorandum

to Colonel Kimbrough, dated 10 April 1944:

In the event that the transit hoslitals are crowded with casualties needing definitive

surgery then the ambulatory and lightly wounded personnel should immediately be evacu,
CHIIEF CONSULTANT IN SI'IGEIIY 197

ated .o thle General Hospitals in the base area in order t hat t here shoild lbe jio great delay

!in their surgical treatment. This category of casualry represents a primnary' responsibility

of the Mledicail Department, for these mnell with good surgery at an early date can be restored

to active diuty iii thle combat forces.

Ini the samne memorandum, hie submitted tile following item, with respect

to general hospitals in the base area:

Thle general hospitals inl thle base area %vill carr~y iiut primary definitive surgical treatimient onl all casualties reachbing theni in w~honil such care has not alreadly been given. This

may largely consist of thle lightly wounded ambulatory cases who are- expected to streaml

through the transit hospitals without opportunity for definitive surgery at that level. The~se

aire extremely valuable personnel atnd dleserve op1 tiiiillhin surigicaul caire since they represent

ret urnable imanpowver to the combat forces.

Cases also will reach the general hospitals after detimmitive surgery hats been carried oait

at thle transit hospitals. Manilly of these wvithi the assistance of chenmotherapy. either thle

sulfonamnides or penicillin, or both, will be found sutitab~le for secondary suture of the wound

1111( thus have the' period oif dlisablility limited.

Another function at the general hospital level wvill lbe the transfer of Allied forces

casualties, chiefly British. to their own hospitals. Trhis funiction will he inmplemtentedi

throughI the Office of the Base Section Surgeon. Transfer of tile British casualties to

British hospitals mnust not occur until the base area has been reached.

Personnel requirements confirmed.-At about the saine time that Colonel

Cu1tler was dictating these additions to thle standing operating p~rocedulre for

p~rofessional cai're (luring the invasion, Colonel Zoll inger notifiedl thle Chijef C onsultant in Surgery, in a utemnoranduni, (dated 8 April 19-14, that there was some

question ais to the number of surgical teamis requiredl or dlesirab~le ill the transit

hospitals. Colonel Zoll inger said that there mnight. be changes, also, in thle finual

numnber' of transit hospitals. Colonel Cutler informed the chief of thle. 1"rofessional Services Division that there was no( reason to chiange the original professional. opinion for two general surgical teamis and one, orthopedic team11 to

augment. each of the transit hospitals.

Exercise SPLINT.-A few (lays later, Colonel Cutler was able, to catch

up1 with the mlost recent planning onl thle. contemplated UIST operations. With

Colonel L~iston, lie journeyedl to the souther:i port. of Newquay onl 12 April 1944.

There, the entire morning was spent ill observ-ing anl exercise involving beach

operations and the loading of casualties into ILST's (fig. 7-0). Ini thle afternoon, General Kenner, Chief Mfedical Officer, SIIAEF, presided over a critique

of thle, experise, following which General L~ee flew Colonel Liston andl Colonel

Cutler back to London inl his private aircraft.

Amiong other miatters, there was a good dliscussionl onl the timte reqluiredl to

load an LST with casualties. The Navy pointedl out that it took '3 hours to uinload ain LIST, andl perhalps more. With the pr'oposed single-tding loading of

casualties over thle sides of LIST's from smnall, boats, one castialty couild be.

loaded each miniute, thus miaking a goodI load of 180 casualties inl 3 hours.

Furthermore, the Navy pointedi ont, there was no reason to load the LIST any

faster Ibecaulse there was no room for casualties until the material onl the ship

was mfoved out.
liii I AI Vii IT ,z
-A 1,1ANII\ 

S
200 ACTIVITIES OF SURGICAL CONSULTANTS

With respect to tile weather hampering operations, the Navy stated that,

if LST's could be unl')aded, they couldl be loaded. That is, if the operation was

on, casualties could be returned. But, p)erturbing, at this critique, was the estimnate now entertained by some that casualties would be on IST's for 48 and

even 72 hours!

"The above expectation of the time a manl awaits surgery," warned Colonel

Cutler, b"demand.v the pre.vence o/ a good surgeon on each LST." "Moreover,"

he added, "we must remember that the first casualties, irrespective of the condition, will be shovelled into the nearest boat and, also, serious casualties may

occur on any ship."

Colonel Cutler was pleased to learn, however, that the Navy wouldl provide

2 general medical officers for each LST and would accept a complement of 100

Army surgeons, with assistants, for assignment to these ships. Col. (later Brig.

Gen.) Thomas D. Hurley, MC, Surgeon, Third U.S. Army, said that he was

providing 45 good surgeons for this purpose. The others were to come from

Air Force and Service units in the United Kingdom. Captain Dowling of the

Navy stated that a course of instruction would be given these surgeons, who

would be doing the major work on the LST's, some 4 or 5 days before the

operation.,5

However, on 24 April, at the conference of base section surgeons, it was

necessary for Colonel Cutler to make this rather dismal announcement:

With reference to furnishing the Navy fully qualified surgeons for LST's, a directive

was sent out asking for nominations, and we have been checking on those we have received.

We promised the Navy well-qualified surgeons. I think the Base Section Surgeons may

not have fully appreciated this as we have received nominations of very young and inexperienced men.

"I think everybody understood thoroughly," commented General Hawley

pointedly. And then to Colonel Cutler, he said: "I think you are going to have

to get those people by looking over their * * * cards in this office, deciding

whether they can be spared from that unit or not and ordering them."

Early ambulatory management.-General Hawley-ever concerned with

having a sufficient number of available beds before and during the continental

invasion-directed the Professional Services Division to look into the matter

of accelerating professional care by early ambulatory management of postoperative patients. Ile referred to precedents' having been established in the

United States in this direction and suggested that it might even be better for

the patient, himself. The matter was brought to the attention of Colonel Cutler,

who stated in a memorandum to the chief of the Professional Services Division,

dated 24 April 1944, that the Professional Services Division exerted constant

pressure to assure that personnel hospitalized for surgical reasons were out of

bed at the earliest, possible moment. He continued:

The tendency In the U.S.A. to get people up on the first or second day is now widespread. * * * In the Peter Bent Brigham Hospital, Boston, Mass., I have heard recently

8 Memorandum, Chief Consultant in Surgery to Chief, Professional Services Division. 16 Apr.

1944, subJect: Comment on Exercise SPLINT.
CHIEF CONSULTANT IN SURGERY 201

with joyous comments from my junior associates that the average patient is out of bed the

day after his surgical ordeal. This I consider to be unfortunate and an undesirable practice

for the advance of surgery. We must remember that the art of medicine and surgery has

attached to it just as many fads and fancies as other walks in life, and we must recall that

it take time for wounds to heal. We know many ways by which wound healing is prevented,

but we have as yet discovered no agent and no method for hastening Nature's process.

Certainly to keel) people in bed unnecessarily long merely weakens their general condition

and probably therefore somewhat delays healing, but to force Nature beyond her powers

is even more foolish.

The U.S. Navy has stated that they get people out of bed earlier than we do in the

Army. Maybe they do. That does not make the wound heal faster, and moreover we must

recollect the people in the Navy and in the Air Force do not have to walk with 50 odd

pounds on their back over great distances. Rehabilitation for the soldier is rehabilitation

for the maximum effort, and that is not true with other branches.

Colonel Cutler then called attention in the memorandum to the fact that

a manual for bed exercises was being prepared and that the period of bed rest

couhl probably be considerably shortened with specific setting-up exercises.

Ile also made the following recommendations:

That the Division of Professional Services continue their influence to reduce the

period of bed rest to the shortest period of time compatible with solid healing of the wound,

and this of course varies with the position of the wound, for all those except those with

wounds of the abdomen and lower extremity may be out of bed within a few days of their

surgical ordeal.

While these recommendations were no doubt acceptable, there was apparently a decision that a directive was also necessary to make a program of accelerated care mandatory upon hospitals in the theater. Accordingly, under dateline of 14 IMay 1944, Colonel Cutler submitted in draft a directive entitled

"Early Ambulatory Management Following Surgical Procedure." In submitting the l)rol)osed directive, Colonel Cutler advised Colonel Kimbrough: "When

the document is presented to General Hawley I believe it should contain a statement that 'Professional Services Division believes that a greater contribution

to the saving of time in hospitals will result from acceleration of the administrative program than from this questionable acceleration of professional care.'"

With minor modifications, Colonel Cutler's document was published as

Administrative Memorandum No. 74, Office of the Chief Surgeon, ETOUSA,

22 May 1944, and directed that all patients be made ambulatory as soon as

possible following surgical procedures. Certain obvious exceptions to the

policy were specified, and the directive warned that abdominal incisions,

except for the McBurney type, now had to be supported by "through and

through" or retention sutures. Colonel Cutler was able, however, to have inserted in the directive instructions requiring the number of days of total bed

rest to be noted on each patient's record. General and station hospitals were

also required to make an evaluation of the results of this regimen in their

monthly surgical reports. To Colonel Cutler, it was a matter of waiting and

seeing if the results bore out the contention of this directive, which opened with

the statement: "Recent observations have suggested that the traditional duration of bed rest following surgical procedures can be shortened materially with
202 ACTIVITIES OF SURGICAL CONSULTANTS

benefit to tile patient. This leads to a reduction in the patient's recovery

period, a conservation in manpower, and a saving of hospital beds."

Curiously, the same proposition was brought up in a meeting of the British

Arly's consultant committee meeting, but. Lt. (]en. Sir Alexander lIoox and

his consultant accepted Colonel (Cutler's recommendation that the British

Army await results of the American experience before committing themselves

to such a program.

Recapitulation.-At the Chief Surgeon's meeting with his division chiefs

on 2 June 1944, Colonel Cutler heard General Hawley close the meeting with

these words:

I don't know when D-day is, and if I did I (ouldn't tell you anyhow. But it is logical

to assume that it is not too far off now; if we have left anything undone, the time is falling

short. We must be ready to go. I think in the transit areas they are ready to go.

What had the Chief Consultant in Surgery done to be ready to go.? In

summing up, the following things stand out:

1. Everything possible from the professional side liad b)een done to clear

beds in anticipation of the expected casualties. I)isposition boards had been

trained, checked, and exhorted to carry out their functions rapidly and properly. A program of early ambulatory management had been instituted to get

the patient on his feet more quickly. When it was discovered that administrative p)roceedings, rather than profes•sional, were hohling up the disposition of

patients, the consultants had adamantly brought this to the attention of those in the position to do somethingabout it. The rehabilitation program had been

put, in full force to clear hospital beds and return men to duty earlier and in

better physical condition.

2. The blood bank was ready to go, and bleeding sets had been constructed and distributed to augment the distribution of whole blood. Last

minute l)rocedures had been coml)leted to supp)ly LST's with 10 pints of

blood each. Marmite (Thermos) cans had been procured so that whole blood

could be packed in them and taken along by the leading assault elements

(fig. 71). Too late, possibly, it had been realized that the supply of whole

blood available from local sources might be insufficient. It would be sufficient for the initial phases, however, and plans had been made for increasing

blood-collecting facilities.

3. Penicillin for the initial assault had been assembled or was on its way.

Quantities required to sustain sul)sequent ol)erations had been calculated

and requisitioned. Decisions had been made on how penicillin was to be

used, and the command instructed accordingly.

4. LST's had been carefully studied and the lifesaving procedures necessary on shipboard had been agreed upon and were well understood by all

concerned. Surgical instruments, scarce as they were, had been assembled

into kits and placed on these ships. Linen was obtained and rolls of disposable rubberized sheeting had been supplied to be used for surgical drapes.

Finally, a handpicked comp)lement of 100 qualified surgeons was ready to board
CHIEFi: )ONSULTANT IN SVIM-R(Yi203

Uii 7 T ---1liarmiite cni1s ~idapl~ed fior traiispo~rthii whiole 111041(.

'[le tray in itiiu siutuliers left 11a11d is filled wi xin iiep.

tile sltips--o--ute to all L.ST. Thiey lhad beeni ltiefetil)V .olontel (x Olde hr and~ his

as.t~ It.(ooe a I Tlgl. Iile%, were. a iso being I al.e led bv the Navy.

5.Principldes of triagre ott I ST's- had( been formutlat ed, a 1(1 cards for

t~ t iitlie c'asualtites had I Ieeit prtepaired. Sutrgeonts of thatit te and solititt

jitdhritteit had b~eeni Selected to atct ats t rtit- officers at thle ltm t s atIti( p)orts.

IThe siiipervtstoti of I Itese 1I riage oflicers andth le conttrol of siil.r~iva teais, III

I lie t ransit arteas wvere illtilie able lI alin s of L.1. C ol. ( Teor.- K. U"liodes. MC.

5ltrit(';IC1 cotisit It ant to So uthtlerit Base Sectioln. lie had also personally illspeovd Ib( te lpersoltittel and facilities at all filie hospitalIs ill hIls a reat to b~e Sure

thatt ilie, work to be done at each favilityv was b eintg SupIerv'isedl bY a1 I iot cli

Stily*-r(.oil a itoI thaIt all utnd~erstood julst what wvas to be donle and What wvas to

be left uiidoine.

6;. slti'(zicna I eauiis had I eeii picked. oriiz aize 1. b riefeti. a1t(d sta1t oltedl at

"bl ih , a1( it ;isit liosi it ljs to) a tigtnen(.t t heir rgla.%assignied stall's.

Pol ic'Ieýs for t Ille :ssi'triliieilt a11n1Ilise of stil.riv:1cal earnis itthle fieldI a riiv and inl

othter areas ol' the commtuniuicatitoins Zone had beeti elaborated aind aiitioitn1(eeo.

7. Policies aind prcei&(lre'~s forth le professional adiminist rat iont and nian11-

:14rei1ipill of l I ttie casliia t es fromt thie fronttlinte a reas to lhospit al., ill thle real.

ltaoi beeii est abl ishied ando lwonnIIlgatp( I. A pocket -sized editioni of the Manu tal

of '1'hiet'a p. had 1 eeit priintted a'Inod (list riii (tted so dinht ea'hi mnedical ofhicer car ng

for patienit.sI titlie 'oitimut zotte our- iii I lie iuttii. WOii5loe would htave

a rea(1 v referenice asý to) how injurt ies anid~ diseases wvere to Ile cared foi, ill tlie

European 4tiiIheater.
204 ACTIVITIES OF SURGICAL CONSULTANTS

8. A close and sympathetic understanding had been established between

the British and the Americans as to the surgical plans each was following.

They were ready to accept each other's casualties and care for them until they

reached the base areas.

These were the preparations. Was there anything yet undone? There

was.

Use of consultants during assault phase.-On Thursday, 1 June, the

day before the 2 June meeting with the Chief Surgeon, Colonel Cutler had

approached Colonel Mowrey and Colonel Liston as to what the professional

men might do during the assault on the Continent. Hle had proposed that

certain of the consultants might help out at the holding hospitals for the

nontransportables, the orthopedic men could help out at the transit hospitals,

and the remainder of the specialist consultants might work out of Cheltenham and be used wherever their services were required. Now some had been

opposed to these thoughts, but on this occasion, both Colonel 'Mowrey and

Colonel Liston were agreeable to the idea.

Earlier during the Chief Surgeon's meeting on Friday, 2 June, Colonel

Cutler had managed to mention, in passing, his hopes for the use of consultants

during the attack. "They may be used in transit hospitals best iy pushing

patients through,'" he said. And then, dwelling on General llawley's favorite

theme during this period, Colonel Cutler added: "Hospitals tend to keep

patients too long."

"I agree with you," the general replied, "but those people down there

have a responsibility, and if these consultants are used in that capacity only,

that is fine, but none of us, short of an extreme emergency where the system

will fall down, none of us can step in down there to operate the system. That

is the funict ion of SBS I Southern Base Section]."

To Colonel Cutler, this reply was noncommittal and discouraging. He

took it to mean that, General Hawley was against the proposal. So, he remnained after the meeting and, in the afternoon, was able to see General

Hawley with Colonel Liston. Both General Hawley and Colonel Liston were

entirely in favor of the proposed use of consultants. Moreover, General

Ihawley asked Colonel Cutler to be with him, personally, during the early

p)hases of the attack. To Colonel Cutler these reactions were wonderful. le

was elated, but at the same time he was cautious. "So I laid it on in a memo,"

lie wrote in his (liary. The 4 June 1944 memorandum, the subject of which

was the utilization of surgical consultants during operations, was addressed

to the Chief Surgeon through the Chief of the Professional Services D)ivision. It stated:

I. During perimis of great activity, the function of c'acuation must be the prime

concern of the Medical Department.

2. The surgical consultants are senior officers with a long experience in this theater,

and are fully cognizant of the Importance of evacuation. They realize that to choke a

hospital with more casualties than the surgical teams assigned there can handle in a

24-hour perIox i means undesirable delay in the period before definitive surgery can be
ChIIEF CO NSI'ITANT IN SUIRIGERY 205

carried out. If (evmiti;It ion is prompt and efi('ieit, caiisualtlies passing Ihrough transit

hospitals withlitt definitive surgery will actually have surgicail care at an earlier period

in some general lioslital belhind fihie rainsit hlositl area.

":. There are(, two points at which evicillio Ill1ima lie unnei-essarily delayed.-

a. Ily holding "trzinslortalle'" casualties as "uimnt ransport'lle" in ihl hoepilifis.

1). Ity attempting to liolh too many casalities for elaborate surgical care at the

"t ranlsit" hospitals..

4. To assist iii facilitating eviaculation aid equally to hioldi in fiehl and transit hospitals

those who should h, he ld there I recommend that the following officers he assigned as

designated below during the first hilase of thit operation until a proper preWedure is

estalblished.

at. To t lie held hioslitals for at itnilnslortalles each area ias follows:

ilard A-S I Soliithamipton areal WFl 46. F11 28, S 11 liC -- IA. (ol It. 11. Zollinger.

]hard B-I' [lI'ortland-Weynioulh area] (FIt 12, FII 510, El l[ 109, Ell 12)--lt. Col.

G. K. Rhodes.

lHlard C-IB [Torqluay-Brixhamn area] FII 7. FlI 49)--Lt. Col. E. M1. Bricker.

h. To the transit hoslitals aomve A - (GII 95P.G l 48, 11: "I,'-LI. ('o. M. ('heveland.

To the transit hospitals above 1-II ' tG; -s. SI 22S, sl 3115)-I-t. ('ol. W. Ktewart.

To the trinsit hospitals above C It (111 106. S111 -- Speial assiglmient 1luiec'tessary.

5. The renmining senior consultants in the surgical specialties. Colonels Stout. Vail:

Colonels Spurling. Allen. Cailiield. and Tovell will remain at hlehumhu'rters. SOS. prepare•l to go where their services are reqluired. Since deftnitive surgery will largely be

done in the general hospitals behind the level of the transit hospital, their activities will

be largely in that area.

The memor'nldum was returned quickly to Colonel Cutler withI one word

01 it in General Ilawhle vs bold scrawl. "Approved," followed by his iujitials.

This document facilitated the pr(mWurenient of necessary passes for the cons -liaits to permit their etitry into and egress from the sta in area. It was

difficllt etotlgh to enlter the ('ritical areas., biut it. was more difficult to get, out.

Olcie at person was in. The actual date for the invasion was still obscure.

but t lie surgical consultants were now ready.

NORMANDY

D-Day Week

On Tuesday, 0' June. Colonel Cutler was off on a trip with Colonel Kinibroughh and ('olonel Zollinger in the direction of the A-S hard to check on

prelarations imade by holding and transit hospitals in lhe area. They first

visited the 38th Station Hospital at "Wincliester. Hlamlpshire, and found everything satisfact~ory. Next was the 110th Station Ihospital at Netley, Ilampshire.

The Southernl Base Section surgeon. Col. Robert E. Thomas, was there. lie

appeared surprised when three officers from headquarters apIleared oil a

relatively routine visit. The invasion was on, lie told them (fig. 72). Colonel

Cutler could scarcely believe hmii. The radio was turtied on, aid, sure enough,

the salme story appeared. With relnewed purpose, tlhe three officers continued

their tour. At the Royal Victoria Hlospital, which had recently been turned
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208 ACTIVITIES OF SURGICAL CONSULTANTS

Thursday, 8 June, Colonel Cutler wrote, was a "wonderful day with P1111

[General Hawley], all day." He was up at 06,30, had breakfast at 0700, and

embarked on the following:

1. Off with PRII at 8:00 a.m. * * *

2. Southern Base Section and reports on wounded arriving and evacuated on.

3. 12th and 109th Evacuation lIospitals. In tents, pretty good-not too good-interesting femur and buttock at 109th. Bad jaw and chest at 12th. Sent jaw, chest, fem',r,

and 1 other by ambulance to K7ti General HIospital.

4. Lunch at 50th Field ilospital in Weymouth (two platoons) (fig. 74). George Rhodes

there. Bad eye case; sent for 1). Vail. Many eases were treated. GKR [Rhodes] had

stee 3 abdominal cases all operated on LST's. Good work * * *

5. To Bristol, hard. Other platoon of 50th Field Hospital close by. Did not visit

and did not go to 12th Field Hospital. Roads full of LCP's; went on one. U.S.S. Quincy

in harbor: 1 major general and 1 brigadier general [aboard]. Skipper told of tough time

on beach. Many dead * * * underwvater stuff.

6. To 305th. Interesting cases. Spleen, :36 hours. Eye and brain case.

7. To Sherborne to see train unload; late (fig. 75).

8. Visits to 3d Armored D)ivision to Meet General Hawvley's son-in-law, Captain Towsey. All in pup tents.

1). To Southern Base Section headquarters.

10. Here Salisbury. Thomas caine to call. Ile said (a) Orders not to do surgery

but evacuate means no evacuation 'till hospital fills: negative number of cases, therefore nothing doing. (b) No record if in hospitals under 48 hours-wvrong. Field Medi(cal Record (F3MR) should start with first definitive proe(lure. (c) Thomas reported

cases at various hospitals, including 60 PW's, largely at 110th Station Hospital.

11. Call in from First Army re penicillin. I said General Hawley had written letter

to Colonel Rogers.

12. Now I must write something for Colonel Thomas.

At the end of the (lay, Colonel Cutler had these thoughts in mind:

The war is on here. Have been about, as one (can see. * * * But is it going OK?

Where are the LST's? They are not conming back and wounded are coming in on APA's;

no good staff, poorly cared for. One femur with no splint. Stories from wounded: Left

on beach between 0:00 and 8:00 a.m., lay on beach, no assistance * * * got wet as tide

camte up, crawled to rocks (one with fractured femur), help to one at 4:00 p.m.

The next day, 9 June, was D)+3. Colonel Cutler arrived at Southern

Base Section headquarters at 0830 for a long talk with Colonel Thomas. They

discussed further the problem of hospitals erroneously assuming that they

were to do no surgery and just. wait, until enough patients accumnulated to be

evacuated l)y train. They also spoke of means to rectify the situation with

respect to initiating field medical records at the time of first, definitive treatment. Later, Colonel Cutler visited Maj. Gen. Eric Barnsley, RAM(C, the

surgeon of the British Southern Command. General Barnsley said that the

British had had 400 wounded on D+1 an1d 1,200 on i)+2. Next, Colonel Cutler

went on to the 109th Evacuation Hospital, where lie had lumch and spent the

remainder of the day at the beach at Portland (fig. 76). It was a great day'

and experience. Some 19 to 22 LST's came in with about 2,000 wounded (fig.

77). Care on the LST's had been good, but Colonel Cutler noticed considerable

crowding and disorganization on some of theni. Ships with casualties were
CHIEF CONSULTANT IN SURGERY 209

waiting an inordiniately long time in the harbor in order to come ill and unload

their precious cargo.

The next day, Saturday, 10 June, was spent in catching up with the events

of the past week and reflection uipon what lie had observed. In the morning

Colonel Kimibrough held a. meeting of the Professional Services Division, and

the remainder of the day was spent by Colonel Cutler in writing letters, preparing reports, and putting some order into the data being assembled. The

following recommendations were submitted to Colonel Kimbrough in a memorandtum, dated 11 June 1944, as a result of the observations made during the

first week:

1. Medical record. In all hospitals visited found F.M.R. was not started following

surgical therapy for fear of staff that this was not allowed (see SOP'). Because of this

feeling, and with the desire for some record, most hospitals had mimeographed a form

of their own with a clinical chart. so that sonme record could be kept of surgical cases.

Rccommcndation: The F.M.R. shall begin at the time any definitive medical or surgical

care starts.

2. Surgical care. At all hospitals visited I found that the staff and the commanding

officer had interpreted the SOP to mean that only the first aid care couhi be given in

transit hospitals. This had led to men being given first aid care and then. since there

were few admissions, the staff sitting around waiting for the patients to he evacuated,

but, as only a trainload could dictate when a hospital was to be evacuatedl, casualties

were not being evacuated and were sitting around with nothing but first aid care. when

a surgical pro.edure might have greatly increased their opportunity for rapid restoration

to duty and survival with better function.

Rccommnendation: a. Surgical procedures shall he carried out in transit hospitals as

indicated by the nature of the casualties and in relation to the pressure exerted by the

number of casualties admitted. Thus, when there are only a few casualties, most of

them could have definitive surgery in a transit hospital. When there are large numbers

of admissions. only those urgently requiring surgical care should have it at the transit

hospital level.

h. In siwxcial instances where ambulances are available and the condition of the

iatient justifies travel and the treatment of the condition can best be done at a neighboring hospital. then that patient shall be transferred by ambulance to the appropriate hospital

where the facility is available.

3. In observing the unloading of LST's at Portland, it is clear that only 5 LST's

can uiload at one time, 2 on the hard and 3 at the pier. It did not appear to us that more

than 6 LST's would be unloaded and loaded in a 24-hour period, for the loading of an LST

after the wounded are evacuated takes ;6 to S hours. This delay is injurious to the condition

of casualties. and another method must be found for unloading critically ill people.

Rceommendation: When the hards and the pier are filled with LST's and more are

waiting' in the roads than can be unloaded in the next 12 hours, smaller crafts. such as

LCT's tfig. 78) shall go out to the LST's. take off the casualties and land at the many

beach areas where such smaller craft can unload.

The "SOP" Colonel Cutler was referring to in his recommendations was,

as the. reader may have realized, Administrative Memormandum No. 62, which

is discussed on pp. 173, 175. To Colonel Cutler, his fears had been realized. The

arbitrary changes which had been made on his recommendations bad resulted

in a situation where patients who could and ,-hould have received definitive care

were being neglected, andll proper records were not being prepare(].
A" I.T V

",,. - . I I ;o 4, 

B J... : ili I 'ipt. . t
VIi' . , 7n 1. Cm'ith ed. C. Ani 4IIIl;1Ilj3I, 111 i I. I A slin i.iI 1flick %% ilth III .4 lied
ACT[%A*I'lV" I of-, "FUNat .%[.

Ae

L

w7

''.1 7

61

I I. 14 11 1 ;11 1 1 A fill 1111:1 N 1. -. I
CHIEF CONSULTANT IN SURGOERY 213

F7

1FI(tim-i T.-A view of the Portltand areai and W eymouth, South DorsetI England.

Second Week, Di-5 to D '11

Thle seconid week after D 1)day wvi pretty v11c Iieslumpt :. ioni of tile first.

few (days. On)i Mondayl 12 Jine, Colontel Cutler accomfpaniled Gieneral Hawley,

(o foI. Io~r11X'. II' I oaii. MC( C.(oloniel 1 Iiulih)Irev. and 'Mr. LJittell, war. Corr'esp)ond~ent for The flcwhb' rX I)qct~. oil a field1 trip) to tilie P ortland~ area. Cn

(Tvliniiig a. v isit, t o tilie 10 9thI Elvaciiat loll II ospit al (liling this t ripj, Colonel

C utlher recordIedl : saw buad case blown lip) oil shuip: left foot "Onie, openl

Iliuctilr I*~oil right leg i1nto kiiee. jo int. Very ill, not yet dressed: 6; (avs. Bad

JXI, but. niot vet in fectious. Siuggeste b~loo an1d( 11( helle dress under et lier.' Ill

coliuilect loll withI thle, visit to thle 50 th FiIieldl I lospit al, lhe recordledl ha** ive

h ad f ive or six cases of gas gangrene: not. all amnpuitat ions, yet 6days old!

WhyIN no miore iiifect ion e Sullfonlamlide and penlicillin ? Saw (ierinanl w$Ait I

right 1 ower-quanri er abdx omiinial wound. P~risoner said: 'We G erm ans have

nuo ic-e aelei 510 not alIlowed.' " ýt. tilie Po rt land hard, C olonel Ol't -

her was sh ocked to .see mniy pi risoiners of war wAithi wounded hia iis 1being takeai

oft L( 'T's as litter J.-It jents.

C oloniel (Otlder wvas miost. pleased to see that L( T's were goiing ouit to tile

LS'1's to unload pat ients as lie 11:1(1 sugge(stedj (hle week before (fig. 79). The

enitourage wenit. ouit. onl a H igginis bloat, to watch the pro~cedulre. Akt 14 5 5,r

they founid: "Bob Whit e aboard as t riigre [officer] . Captain Stewardl of 85ý'th
ACT IN" IT I 1:!ý F I I It I I S I I \,I's

ARV

Vlt-i m -97. Ambuhmi-vsm ;i (hwk nf Wevillmll 11 ;1\\:Iii ill- Ill, 11104-:141ill-, i-.

ivIlvl-;II I lf)ý,pll :11 ill clull. gv ":,-I) I I I ivrlwl I iý, ( h.gr. ',I 1): 264; pIckvi I

up \\(mlidol ()it 1) - 2. hill \v;I!,j ý-lmv Ill ref if I'll I A I A I I lel I

LST NO). :01. ("'41milld lmvv ý.vvll Gellend Illawle v _-() m-cl. ý-Hlv ';I Ill ;I Ill

Kelviler. D;I It ivilerni I Ill _-( ý . I It, lind ( 1()11(ý 4 lilt- :11 ( 14 ml 111:11 11111d

K v I-:I r I lo )I I I v I I IIIIIII iple %\ 1,1111(k, I ()f I lit,

I : I I I I I I if I v I I ci I I I I : I I vo I A I , I I , ri Ile I'm. 111:1 hirizi mid Levitt

1\,11(.,)X. 2141 ( ivilt-1-:1 I I a I I, :I n I Iý I I-1:1.g"k, ()HIct.r. S: I

ill CIViliml :1ý, w(milded 111\-ý-. American I lm-ý- luld I Illev

11:141 '-folle 1(, help Fivilch. * vo Frellch w4mlell Irld -ýllfll flivi it.*'

It wný ;I hliý- v (1:1 v ;11 llmfl:md. B v I I'M I. 71,T) lmd hvvii i:ikvii ()Il'

:111d 1) v ]:oll). Ille tf)l:ll 11:141 riý-vll 1() 1.16-2. The .1().\ ()I* ýwvill_(r

till 14);Id I il-- LST*ý, ý-lmrf-llvcd. zlý Ille 1):11.1 I-villi-livil 14) fill- Field

l1wY \\tTv 1111*4willed 111:11 LCT*ý- f-wild 114) he 1,411. lliiýhnck ;[I the 1ý'l Gellend Molic:11 Ill.ghl. flivre \\:I-ý

11mi-ob 1:11k :1114,111 wmilt'll :11111, O dmi(d ('1111vi. Wl'olle. "P11111 ý;llfl Pm

llv.\I \\ vvk

I . I h we I I I I F I .; I I I , -t 't 4 ) I I I I I \v I I 1 4 ) I I I v I I it, riwol

4 111 4 1 4-:1 -11;1 11 1 v VA [:I 1 (14 1 v :11 r. A I I, v I I I I I I I I 1 :111 1 v;I Id I I I I I Iv

I I I I I I . I )c I ;I lý, , I I I I I ) - I I ; I \v n

It 1%;1 11 1ý-hil I.Y V;Iý-f W lllý-lillv. :111d :i phlfmli ill' lilt- 2-111 Field 111 )11:1 1. :11

\14,1111 llin. 1 41 r(welve ;11I,-vV;lrII;l1(,4I I I i _qr . " I ) . ( , I ) 1 4 111 ( .I ill It'l- \ I'llol

I w -1. f;1,*-i I it iv- , )II I 1 .1 it liv. I ( ý ý-; II rvv I ll;l 11( .ý, I I I I I ( 1:1 ( lo I I I 1 211 ill 11111111- . ;11) 1

I I It -A I . Th I- I - I I it, ýwrrvl w I'l it it I.I. _-1 of .:I I.c. I ml --:I ý.t .!. I I I it -1 1 w
CIEFiii C(4 NS1i.'IAN'F IN SiI-(;ERA.2.

Ii, liehe \V111 I" 10; I(311 U-S.a (1 LCT 2 ii l pille Jille.( 

t- ed Il) Im'lu~i Ivet 4114(ImIl11'ltajlla caseseI. k I41;ti lle Ll. d Ciii li W 1~11 14.

i*,,,..-.. ( 'lla /',, i me'~t. li oloi&wl 'm f lierNoke II I411 heel loand 1i l ie AtI h e t'ti11:1111 III ivv.iI I ' wn Ie Is. iiue Inw t1 i if le( "C l 1 ilit'' bYi~ It 141 11 Nltiter A t I i t wtIt U4

ý- t1:11 IdIlw ld lw lC on lO er
1759. 1 St fD/i

1 Jsilif /nhv/ /in ris )#. it
(CHIEF C(')NSI*LTANT IN SUII(EIY 217

C7

79.. The tinfla':iiiigz or Li'\in 1y ratisrier to an jx11 ma u':zddrect

live:1chinik ''I 114.e U 1. NWeynimioii . Eimgla.111 A.~ IAi 1'j 1i( alod:~ngside ani

LST'I. 1.. A\ paitiilt beving hiwerva t nu :1 ix1'. c. .% TA iT, ~iwing iwa;c~i4iv

( nleral I inwlev an Cl( oloniel (Otlder. retutrnied to Sal Isl II v ftcw tile ilialut

of 23 Jun il(f ig. ~S2 )'1 ut le ft varl v th 1 nexlQ.t mornin mg Iv air f ol tie( Normianidy

1 Inclil ial.a rri V .ati lle I t a I ah. stri1p at os)45- (mif 24 .JUime. Tlhe*v deparlted1

fromu Omiiahia aisti~dplat 20001) lhe next hlaIv. lint ill lie imuteriuli1 ( 'olontel ( 'litt 1er Was

abIle 14o visit the three p.latoonis ot the 4a"tli Field1 H ospital. the 3d( PlaitoonII of

the 1:4t1 Field Hospital, the 621ls ( leariiig ( omipaiu at the Utahi airstripl,

aund the -,f it. 24th. 41st. -11th. 45-thi, 67th 1i, ad 97th~ Evacuaion 1(111 osplitls. lit

adi~l(t on. lhe hlln thle (Ihplnrtilil 01111 V IPlmuntI diireiies Wiit hi Ile First U .S.

Armiiv suirgical colusilht nut. C olonuel ( rish'r. anld also C olontel AMacFee. I point

1('t iit11imii±r. lhe Ch'ijef C onuuiltanit Ini SiiP."fem reported 1(o ( eiieral I I aw~leY it) It

iii1.1le dliiirecly urn 4 olonell 4rislI4r aiinl manIuy or Nvl~icl Nveri' embodH.Iied in flt,.. nivinoii for the

F*irst U. lilAry M~edic.1l l,1iittet II whivil he wasi J~pirelming :it th lim ie we were t here for

(ol.iielItr'e~rs inl a :ii1 si-glI 1i1ren. hill Il It(,lfollowing co.iiin'Iitil~l 1ay I1.e of vi.

Tin iliv:1es. us jirniwever. wheire I tell Iit~l 11fl4'lhi lint at iil imivi~e~ (ih'sjrnwlI foir if,( treatmienit or c;15lml t if. sitiowil flrIsslilre (lefremse. pI'rllnlis moiire pdas,,in 4clii be used~ inl pro-
1¶l I I' l 4 1 -1: v r

m1 iii. \ 1111;14 5' w ri i i .li 11 i 1I I sI s I i i. I ti ll- - ill- \1 ti.. V Ii i-i isv II.x .i

iii~ iimtiil '' i I;ljmsIl Ii~ simpr s.it-1 lit \\:I tIm. Thu 1 ii-. Iummjm A- m iiis- i It

:11/1, mm 011 0i ip/miAl

:1 ~ I ~ ~ i, \\ ii . - lmm Iii-- tm - I- - :1mmI 1mm -IiI- : -111 I s ii x lI -I mI l- m I mii mi li m

mstmimillii xxii im it 41s Ilsmi 'iii .. I* -Ill .I-m . ittm[li ti iiim mi it m xiI 

xi ~ utim ~ tu ~;i-. itiiti 11 1- l mitts\;-m immi e it-is-nil \III itim .I lell ims-.inHi tim-l li- m- i-il

mtmim sIl l xxi? .1imt -\\:til li;ij- r 11 :1mm. ll .it ll
CHIiEVi i'iNSVI.'I'.N'IN i siiav;i*:itv 21

;iii1le ;i~lig a liii I lit' jI1 Iilt? 11. I. k\ c~ii ptilpi vicw ofi ;i iii lti iii! ixu1iniiiig .1

evpS11g;) . .. N tiff I hvj list- fi it' S im lt s11 wlittist lit iiii!is. It 

I; 17
2 -D.AC'I'IVI I'sI OV sllo4IcAI. ,1 cIuNsi-ý LTANI'S

ce" 44

116-~

I X I% it'lk i i Is I L" NN1 i 4 arr it 414 .1 114 I It It S4.i.4.

.11 it a i pIs tt.I tt 4:ll, sd I,, IuLI11. , 1pIlr II II \ IIil Il r 4- ifC N 4.4 f-S u, lt, X e t 1 1
ClHIF ('(ONSULT'I'AN' IN SI'RGEIRY 2 22

FtIG;URE: X3.--\\'hole Ibloo d for illr t ( Fie '. s I .S. A rmy living hinaded1 oil ('Vaell(tiit i a irtcrat ft

retnirninig to the Normantdy tIeclilehad from the Metibury airfiehld, 14. Juine 1.)44.

Rogers. I also saw two (-:Is(es ill w'hich the slut'geoni did oit exteriorize large bowel wVoIInds

but. cloised thetim withoult, a co1o)tlility. I believe this to ie ain jitforltl1ltate(, mistake atid

if freqjuently occurrinig would surely bring disaster.

f. T'hJ'I itret find thie oo,'-rihdo-lon thi il i idI.'.

Tihll wol111d. I S.IN" ( e )Ie at field lospietaillats brin tg forth lily im ost shi ti(.(l', I appire•l'iattion.

I still recollet. a very difficult vase of this t ypt, being don(e by Parlitxgton at a 4.| Ii I Field

Hlos.pital I platoon which had every elhielleit of perfect sulrgical perforntm.ie.

g. I1.0. 1".'s..

At oie, lihospital. wvhero sotmie MM) prIl'4ope'iti(',t v'ases had acc'(illilihltt,. I foutid three

prisoitei's being I liratted uitpi aliad o)f otir own\-i soliers.

hi. (•hijirnl cfommi n t.

It is lily overall opillioin that the level if pi'4(fessio(llil ca(II!re is very hiigh. (',,i'taily

better tan l i Ill the last war. h'le(- fatct lhat iembers uof the 3rd Auxiliary Surgical (;rolup.

who a re wet ' t rnraine(d(1 and lthorou.hli y insirucls ted illttle c'as1utlt 1ly var11"e' iare d|oingt Itit"!

It)tter work thanl tih( 4th Gru'piil) as a whohe. who ha.d little ill Ith(, way oif orientalion and

ilisttlltutill, etiliha sizes agalin t he illmploirt anci*e of Armiy intstruictiin eve'lIn ill Irof('ssiontll

woirk. The Iow intcilentc(e (if seri•i•s inf(•ection was striking 'anil Inust be related to the

Ibct . ii .stai agtenits, i xii .illiin aind the sll foll ilnlidiies, now employed il military i surtgery.

'rThe it idtI.ive (if nampu)1tat"IIoit!is setiled happily tow. I he incidncilie (if gas gilllil'telle laiso 1111101

lower tHam was expe'lcted or was pIretili ill th le Ernope•lan War., 1914-1-.

In d.osing hi.s repott, ('olonel (C'ler rec,'ommendehd that ttediical elvlnetn s

of the First F.S. Arttyv, at tIis tij(,. ,sh11)jj1h tlii'etI thir. p,)p'gteS to l)I,)V'hlitg

first, aid tare for thet W(ounde(h(l and stl'-gery ony for tho i,, in whi11h it wohlld
222 ACTIVITIES OF SURGICAl, ('ONSI'UTANTS

save life or limb. These priorities should be adopted, he explained, for the

following reasons:

Casualties given expert first aid care arrived in the United Kingdom even two or

three days later in excellent condition, but a good many did not have this. Many wounds

had lost their dressings because they were improperly applied, many were improperly

splinted, and some, even compound femurs (personally observed), reached the United

Kingdom totally unsplinted. If every medical officer in the first week devoted himself to

the control of hemorrhage, adequate dressing, adequate treatment of shock with plasma

and blood, and perfect immobilization, a perfect task would have been performed. When

surgery is permitted early, many hands treat but a few, and many others must go carelessly dressed or improperly splinted.

Even at the present time I would suggest less emphasis on immediate surgery for all

and more emphasis on properly evacuating those who can travel safely. This must be a

large number, and it seems most unwise to allow any evacuation hospital to carry a

backlog of unoperated cases of much over fifty cases.

Major Hardin Visits Normandy

On 28 June 1944, when Colonel Cutler submitted his report, Major Hardin

was already on his way to Normandy to determine whether whole blood was

being used in excess and what difficulties were being encountered in its administration. In the 3 days that he was there, he contacted members of the Medical

Section, Headquarters, First U.S. Army; 1st Medical Depot; Advanced Blood

Bank, ETOUSA, Detachment A, 152d Station Hospital; and the 45th, 67th,

and 128th Evacuation Hospitals (fig. 84).

He informed Colonel Cutler, on his return, as follows:

* * * * * * *

3. The problems encountered in the use of stored blood were first discussed with

Colonel Crisler, Consultant in Surgery, First U.S. Army. The difficulties were mainly in

administration of the blood in that the speed of flow was inadequate. The general opinion

seemed to be that the filter was at fault.

* * * * * * *

Other errors in the use of the equipment which when corrected will help increase the

speed of flow were failure to thoroughly mix the blood by shaking and improper use of

the filter. * * *

In the three hospitals visited the ratio of blood to casualties was one (1) pint to four

and seven tenths (4.7) casualties. The ratio of plasma to casualties was one (1) unit

to three and two tenths (3.2) casualties.

The ratio of blood to plasma was one (1) pint to one and four tenths (1.4) units plasma.

Many casualties receive plasma before admission to hospitals, so that these figures do not

present a wholly accurate picture of the ratio of pladsmam to blood.

Reactions to blood as reported are extremely low. It is not believed that this paucity

of reactions is possible. Undoubtedly, minor febrile reactions are being overlooked in

the rush of caring for numerous casualties. No serious hemolytic reactions were encountered and consequently no deaths from transfusion have been reported. A few instances

of jaundice have been encountered in patients who have received large amounts of blood

(3,500-5,000 cc's). In each case complicating factors were present such as hepatic injury,

sulphonamide therapy, and collections of blood in body cavities or muscles. There was no

case in which the jaundice could be attributed solely to blood transfusion. IHowever. * * *

all stored blood, regardless of age, contains some free hemoglobin and * * * with massive
*~J441I~i4i. I444l '41- 14Iji I41-16 A. 14 44, y1 2 .1I''' 1t. I~is*hi' 11. 11 1

444.l'4'ii 1 l~t,' 141 Ip~ t 'ihIl Y~'I~ i 11 11441 I II -f-4l I I " -'I4- 1.' 1"L. I bi

4" 1 ' " I ' l ' l i\ I l11' ql•l l I 1 111 ill I I i A ; I 1 4 4'

I v

I~l,. I~l " 1. I \I,,, t'', J (h,I. lI l,,, I I I lI. - '•1"n 1". .\ I'[l :•;m tI nl ti. T ,r :m - ! Ih, . 1ill m id S I ,). k.

ll4l- ' i , l I , ll 11'- I, kl ,- -il ili , 1 ,' 1 it,' I I',IiII Iq I',' v vel In' .. l , II I -,, II h .r, I , I1 ,I it 1 ilh1 ;

4.\ 1.f'. ' I'il V-- I 4't- I, I I I',11111 ,I il hI.hl 144I'M4,,I ll .i , ,1 I I, I. I

1 ill n •- IIIII 1 1 1"- I,1 I 1 111 11 1 I \ I i ' I 

"IiI 4, 1 11 s Il' I,,I I I,,I I, II I• • I-,r , f,,.I i > Il ILZ, Ii it ," 14 , , 14:, ,. - l ,• •

l ' '' I• I I l l r•l I' l I I' k; I I I I 'I I .1 1" v -u l I;1 11,6 J,) -', -1 •1 -4" ,I:• -1> lt l |ll i-I ,in l

'1. ~ ~ ~ I•H ~ I h ~ "Stl' ~ ~ ; llll , ' 1tlJll- 1 Io •'1 fjjl• I I I~'- ,, I I~,, I I' I~lu I h -
224 ACTIVITIES OF SURGICAL CONSULTANTS

Activities of Surgical Consultants During Invasion Phase

By the end of June, a fairly clear picture could be obtained of the initial

activities of the U.S. Army Medical Department during the Normandy campaign, and it was possible to assess trends and contemplate future actions. In

reflecting on the activities of the consultants (luring this invasion phase,8 5 the

Chief Consultant in Surgery made the following observations concerning his

activities during the first week:

(1) Col. E. C. Cutler was permitted to remain with General Hawley, with headquarters

at the 1st General Medical Laboratory, and from that point visualize the reception of

casualties at both the Southampton and Portland hards and their distribution through

the subsidiary transit hospital areas and final evacuation to the base area by hospital train.

This lpermitted a full evaluation of the system used to evacuate casualties from the far

to the near shore, the limits and advantages of professional care as given whilst casualties

were on craft in the Channel, received at the hards and eared for in holding and transit

hospitals.

He described the activities of the other consultants during the first week, as

follows:

(2) Lt. Col. G. K. Rhodes was assigned to the holding hospitals at the PortlandWeymouth hards, Lt. Col. R. 31. Zollinger was assigned to thr holding hospitals in the

Southampton area, and Lt. Col. E. M. Bricker was assigned to the hards in the TorquayBrixham area.

These men were of the greatest assistance in advising regarding the professional care

of the serious, nontransportable wounded in their respective areas and in designating what

cases could be reclassified as transisrtables and therefore removed from the nontransportable hospitals to the transit hospitals.

(3) The surgical consultants in the specialties confined their work for the first week

largely to the area of the transit hospitals. Here. they were able to assist greatly in the

professional care of casualties, the proper choice of priorities for surgical procedures and

the evacuability or transfer of patients from ,transit hospitals to the base area and on

occasions directly to special hospitals, where competent specialists were present. Indeed,

on more than one occasion they were able to advise in the proper location of specialist teams

at hospitals in the transit area, such as the moving of a neurosurgical team (a) to the

28th General Hospital, and (b) to the 217th General Hospital, where neurological cases

tended to concentrate and where it seemed wise to provide expert professional care.

The characteristics of the activities and assignments of the slirgical consultants, after the first week, were described by Colonel Cutlet as follows:

1. * * * By this time it was clear that the advice of the surgical consultants could

wisely be used in the area of the holding or nontransportable hospitals as well as in the

transit hospital areas, and from time to time the surgical consultants visited these institutions. Colonel Vail's advice was necessary regarding certain difficult items and [that of]

Colonel Tovell to helpl with anesthesia supply and administration. On the whole the surgical consultants continued to confine their work to the transit hospitals and continued

increasingly to visit these institutions and to assist in establishing a high level of professional care. At the same time. the surgical ('onsultanits began to follow the cases back

81- Memorandum, Chief Consultant in Surgery to Chief Surgeon, ETOU'SA (through Chief. Professional Services Division), 30 June 1944. subject: Synopsis of Activities and Reports of Surgical

Consultant Group During the First Two Weeks of the "Liberation Invasion."
CHIEF CONSULTANT IN SURGERY 225

into the general hospitals which, unused to the sudden influx of a large convoy, were at

first thrown into some confusion, but gradually straightened their organization out and on

the whole functioned ini a highly satisfactory fashion, * " *. By this second week also air

evacuation began to flourish and visits to the 217th General Hospital, which bore the brunt

of air evacuation at first, assisted this hlosplital in tihe proper care of large nunibers of

casualties.

In his synopsis of activities during the first month of the operations,

Colonel Cutler gathered professional comment from each of the senior consultants on his specialty and showed how their help and observations were

contributing to the success of the medical support of the invasion, lie ventured to hope that "this brief citation of the work of the surgical consultants

in the first weeks of the 'Liberation Invasion' will justify the request that they

be permitted as soon as accessible to visualize the problem on the far shore,

that, they in turn may benefit the professional care there as well as that they in

turn may learn more and benefit. the casualties returning to this shore." And

his hope was to be fulfilled, for, as has been noted, Major Hardin was already

in Normandy, and Colonel Cutler was instructed to establish priorities and

schedules for each of his other senior consultants to visit the Continent at an

early (late.

Observations, recommendations, and actions

By the end of June 1944, as previously mentioned, a fairly clear picture

could be obtained of the initial operations. As combat on the Continent

changed from the area of the immediate beachhead to hedgerow fighting further

inland, trends became nmoi-e clearly established, and patterns for the immediate

future became manifest. The Normandy campaign ended on 24 July, and the

Northern France Campaign began. The Third U.S. Army officially engaged

in combat a few days later on 1 August 1944.

Colonel Cutler and his surgical consultant group made the following observations of surgical activities during the Normandy camnpaign.

Evacuation by sea.--The LST and hospital carrier operations during the

invasion were described by Colonel Cutler as follows:

c. ,Iurgery

* * * * * * *

The care on ships during the Channel crossing was carefully coordinated and wvorked

out with the Navy and perfect collaboration was obtained. LST's had two Navy medical

officers and one qualified Army surgeon, were equippled with small operating rooms and

liberally supplied with surgical instruments, surgical supplies, penicillin, and refr~gerated

whole blood. All (of this equipment and personnel proved valuable. Only life- and limbsaving surgical measures were carried out on LST's, but probably some ten abdomens were

operated upon and a similar number of sucking chest wounds closed in the first few days.

thereby possibly saving life. Moreover, adjusting splints, reapplying and reinforcing

dressings and the giving of plasma and blood kept the entire medical personnel on both

ships and LST's busy without let-up from embarkation to debarkation. ME(mbers of the

Professional Services I)ivision boarded imany LST's and hospital carriers, discussed p:'obleins with the medical staff and were able to evaluate the care given on such ships. It
ACT IV IT I I-:*., )V "I* W ; 14 'A 1. 4 IN "I LTA VI'S

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CHIEIF (ONSU'L'ANT IN SURGERtY 227

hlad liii It-s. Rled Cro ss wE rkers anid a'Il chap lain. It is wari'i ii n)l~lpared to .1 aIiiS'~a iid I Iest.

,irguui11110i1S ilk its favor (llinitt'rIlilanII' ill our ininds1(1 the east. withi Which i lie 1L5,1 is lontded

"( n tile vioe thle ('lijef Consu~iltanit inl siirgetrv Said iistiii ',tli

pr1ofes'sional I vork ;Icc(i )I jpisIIe( I (ItIIrilig the( t ai-('Iu iecossiligr w';s IiilioII

credlitabI le an vel eiv blueneiehil to (tlie vitasuIt ie-."

Air evacuation.-'. kirevavuatlwio prroe(1 exvel lent fIron It Ie IpIeri jljl hor 111(j

sliti1( le e h ige12 ')14 el( 'iii1ev. sa id. E Isewilvere.lie nioted ti nit til e recepSioul and I hiodi ii, facil itijes Were not i deal lat thel te Cminaii~ls for a ir evalilhit ion.

Bitt. tile iniiil4)r anit point., as C olonel ( 'it le later observed. was as follo)ws:

1"icm;i S6 N'.-F-- i'l(IitIies aboalrdl Ii converted1 hoispital carr~ier'. A. A ward with tloidiie-dti'cked

What lvs 1 oii ha~ve wve lea1rned( fromith le Nomandi~iy 4'xperielilev It early llve(afl)C

apparliIent that 4(etlillit ive surier for tiii liltilild not3 bel lierformIned ilk our forward un1its 1becaulse

(if thle lo~ad. At (oil( 410l?-i?4'( ('vcilat ioll ho~sjlil:iI. for e'xample~. I saw 250~ mtenl waiting for

surgevry. whteni vinlty planlies wev(i goinig to tile Uniitedl Kinigdom hiiIie sainie d1.1y. Had theseC

castialliehs been lifted .11 oince their firsi surgical trieatimient wouldi have coline earlier. The

policy wals t lvie 'l~l1(' so lhat onily Ii'upill ralispoIrta lde vases we-tre givenl detinit ive smrgery

((il tIbe C ouitjileitil

"Near shore" medical service.-- 'oloitel ( Ctilei-s itirst voinniietit til tile

liear shore.( opeuit iolls fil lows:

Thei .(1.' is lid 41111li ilAd~iiiiiiit ivtle 11vll'ior:Illinh~~ #612. :1 May 1944. It worked

Well ats I whofle. A vo'E11111414'Iitaght he4 filade(11,t h11 its rigidify ill Ibe first few daiys 11ail soalil'

iuihllklly roi4Siis ill thatl ait. ce4rtaijll transit hospitals del-illit ive surgery3 WUS. lnot l4iving done11

alld( OienI wereI liviiii lieild syeI'd l ays lull ii (14111.1,0gh nl'Ulilltit5 necE'llllililitedfl or .1 ralhl

5.'' t'stuote' Sj. 3 1. 22-4.

o.'.' f ir... sE;* p. 224-,;.

70)5 09.55' G4 1s
228 ACTIVITIES OF SURGICAL CONSULTANTS

evacuation. Also the rule that the FMR should not start. [with] anyone who is not kept

over 48 hours was unfortunate when definitive surgery had to be done at a transit hospital,

for the paucity of information that went on with the casualty mitigated against his proper

care. A further suggestion arose in the early days, that I1mssibly n'-tirosurgical and maxillofacial sliecialists should be in transit hospitals near hards so that case.s with this type of

damage could early be placed under specialists for care."'

Otherwise, Colonel Cutler was satisfied with the overall results of the

hospitalization and evacuation procedures that were carried out on the near

shore. His account of his views follows:

The reception on this shore, whether from lplanes or ships, was organized on a

similar basis : i.e., close to the unloading points field hospitals were set up. to which were

attached surgical teams who were to care for the heavily dainaged. noutranslNortable

casualties. These field hospitals were of the greatest value during the first few days of the

invasion, when surgery on the far shore was at a minimum, or nonexistent. Later, when

an evacuation hospital was set up with the Army on the far shore and a larger percentage

of the cases arrived already having had definitive surgery, the pressure on the holding

hospitals for nontransportables decreased. These holding hospitals were adequately supplied with whole blood and penicillin daily, had a generous allotment of expert surgical

teams and proved themselves to be a highly desirable part of such an undertaking.

The less seriously damaged patient passed by these holding hospitals for nontransportables to "transit hospitals," which were either station or general hospitals within a radius

of 30 miles of the beachhead where, according to the pressure exerted by the numbers being

evacuated, either definitive surgery was carried out or the patient was dressed, his splints

readjusted, blood and penicillin given, and lie passed from these transit hospitals into the

rear areas either to a hospital center or to an available general hospital by train. The

number of casualties passing through some transit hospitals was very high, perhaps the

heaviest service being at the 110th Station Hospital, where some two thousand casualties

were received in a period of 24 hours. At these transit hospitals were also located attached

surgical teams, but the major function of the transit hospital was to properly sort cases

and only allow those to go on who were in a suitable condition for further travel. The

dispatching of patients from the transit hospitals to the back areas by hospital train worked

well. The medical personnel aboard such trains worked well, were able to give hot drinks,

sandwiches, and see that where dressings had slipped or splints needed to be readjusted

suitable care was given (fig. 87)."

General surgery and wounds.-The following thoughts were recorded

as of the end of June by the Chief Consultant in Surgery:

It is our overall opinion that the level of the professional care is very high, certainly

better than in the last war. The evaluation of early and good surgery and of the sulfonamides and penicillin in combatting infection cannot now be stated. Both undoul)te(lly contribute to this happy result. There may be a relation between controlling ordinary pyogenic

infection and the low incidence of gas gangrene and subsequent low incidence of amnputation. The surgeon is certainly pushed nearer to the wounder soldier and the decreased

interval of time between wounding and surgery may be a dominant factor in the unusually

satisfactory results. In addition, the early application of secondary suture is going to

restore a large bohly of inen to active duty within a perioi o(f a few weeks."-

90 See footnote .45, p. 224.

14 See footnote 86, p. 226. 92 See footnote 86, p. 226.
('lIEVI CONSULTiANT I-N $UI(*1t UY 229

t raiji III((i(vI officer (]Ie-khilg thle condI~itionI to' 1 pal lett. it. .%n .0t tidaiit giviuug a pal lenit

liqidiu wh1Ii le a miirse i~s~v~
230 ACTIVITIES OF SURGICAL CONSULTANTS

Essential Technical Medical Data, ETOISA, for June 1944 reflected his

views substantially as follows:

The ,percentage of infection was surprisingly low, even at 4 or 5 days

after injury and without surgery. Indeed, some surgeons with experience

thought it wiser not, to explore battle casualty wounds that looked well. It is

in a way unfortunate because eventually p)ractically all of these wounds need

debridement, since the sulfonanmides and p)enicillin tend to prevenit widespread

cellulitis but leave an aibscess al)ove bits of cloth which are carried in with the

missile. There can 1be no question whatsoever hut that, spreadinig eellulitis as

seen in the last. war is now a rarity, and one must feel that the sulfonamides

and penicillin play a definite role in this betterment. Gas gangrene was present

in but few cases. We have at this tiIne no filial figure, but the inimpressioni of all

surgical consultants is that it is not a major lprobleli at this time. Moreover,

the separation of cases infected with the clostridia into those with sinuple cellulitis and into those with widespread ityositis resulted in the saving of many

extremities, for the siuiple cellulitis cases do( not need amputation aitol do well

with widespread incision anil debri(lemeiit. Abdomens usually reached this

shore having had surgery. Sometimes this had been done on the far shore,

sometimes on the LST carriers or APA's (transports, attack). Many of these

cases (lid surprisingly well and proved again that early surgery in abdominal

injury is the iinportant factor. One case arrived by air 3 (lays after operation

and was in a critical condition oii arrival. This patient was seen shortly

afterward 1v Colonel Cutler. and le was of the delinite impression that it

was not the air transl)ort that caused the trouble but moving the patient and that

had he come, on an LST his condition might well have been worse.

In July, Colonel Cutler reported, the load of surgical work was extremely

heavy. In May, the total number of surgical admissions to fixed hospitals

of the communications zone had been 23,375, as revealed by the monthly surgical

reports. In June, there had b)een 5'3,124 surgical admissions. For July, the

figure had risen to 71,623. Colonel Cutler further reported, as follows:

We have maintained the closest liaison with the combat forces on the Continent so

that what we have learned here concerning bettering the care of casualties might be implemented hy the Army. The most cordial and happy relations exist and have certainly

led to great benefit for the soldier. This liaison has been particularly useful in improving

the treatment of shock, by the segregation of the seriously injured from the less

seriously injured 3n1( in the proper utilizution of whole blood and plasnm. It has led to

an extension of air evacuation particularly involving the special groups such as neurosurgery, maxillofacial surgery and thoracic surgery. We have attempted as a principle

to push the early closure of battle wounds, anld from large spot surveys are content

that some 75 percent of our wounds are being closed by early secondary suture between

the fourth and the fifteenth day. Many of the hospital and hospital center reports show

an extremely high percentage of primary union after secondary suture. Thus, at the 15th

General Hospital primary union occurred in 93.4 percent after secondary suture. The

82d General Hospital shows primary union in 94.1 percent after secondary suture. The

83d General Hospital had primary union in .3.7 percent of 93 wounds. These are merely

samples (f information which will le ana.ssedl later andt(1 submitted in tabulated form.
CHIEF CONSULTANT IN SURGERY 231

It is interesting that, though great attempt has been made to use penicillin liberally, many

wounds have been closed in which no chemotherapy was practised, either sulfonamides

or penicillin, with equally satisfactory results. The major difficulty with secondary

closure has been where too great tension was put on the lips of the wound by trying

perhaps to pull together the area which should have been grafted rather than closed

with sutures. Out of a mass of material is slowly merging what was known early, that

the earlier a wound is closed the more easily it closes and the less apt it is to break down,

also that wounds which are too large to close should be immediately grafted. As a part

of this effort we have begun to close compound fractures, utilizing penicillin therapy in

all cases in which this is done. It is too early to report results, but at least we have no

bad consequences to speak of. Again, in relation to wounds we have a large number of

patients in whom Bacillus wclchii and Bacillus pyocyancns have been cultured from

wounds healed without difficulty when submitted to secondary closure. In relation to this,

our report from last month should be noted, [p. 87 ff.], which included the study of

wounds with the 8th Air Force in which a high percentage of the wounds showed clostridia,

lint almost none showed any clinical evidence of invasion by these anaerobes.'

As a result of these and previous observations. the need to revise and add

to certain clinical policies contained in the Manual of Therapy and Circular

Letter No. 71 was apparent. Circular Letter No. 101, Office of the Chief Surgeon, ETOUSA, was therefore published on 30 July 1944. It included the

following instructions under the heading of wounds:

a. Wounds will not be plugged or packed with Vaseline gauze. Only sufficient gauze

should be used to keel) the wound temporarily open.

h. Sulfonamides are being dumped in excessive quantities in wounds, and this makes

substsiuent repair difficult.

c. Wounds nu.st not be clo.cd by sutures at the time of the first debridement, except

for the following:-

(1) Neurosurgical injuries.

(2) Thoracic injuries.

(3) Wounds of eyelids.

(4) Certain maxillofacial injuries, as outlined in the Manual of Therapy. ETO.

d. Penetrating wounds of the paranasal sinuses should be thoroughly explored, foreign

bodies and blood removed and external drainage provided at the original operation. Drainage of the antrum into the nose is the method of choice unless the wound has destroyed so

much tissue that external closure is not possible. The frontal sinuses should be drained

through the wound or through an incision to allow opening in the floor of the sinuses.

e. The routine culture of wounds is unnecessary, and wasteful of time and materials.

Cultures should be limited to those wounds where there is clinical evidence of infection and

where they may contribute to its subsequent clinical management.

f. Wounds seen late, after wounding, without debridement, may be debrided in the

usual manner.

g. Wounds can usually be closed within 3 to 5 days after debridement. A satisfactory

preparation of the wound for secondary closure has been the application of warm saline

dressings. Chemotherapy locally in the wound at the time of secondary closure is not

necessary; penicillin therapy should be resume(] before and after secondary closure in all

large wounds.

h. As a rule, foreign bodies which interfere with function or wound healing should be

removed. Modern chemotherapy obscures the signs of local infection only temporarily and

""Essentifal Technical Medical Data, European Theater of Operations, U.S. Army, for July 1944.

dated 17 August 1944.
232 ACTIVITIES 01F SURGICAL CONSULTANTS

many times delayed infection, with breakdown of the wound, may result after a long

interval.

i. Continued local and excessive alplications of sulfonamides in wounds are detrimental to wound healing, produce dermatological lesions, often increase blood levels above

safety limit, and are unsupported scientifically as the proper therapy.

Gas gangrene.--While some mention was made in the foregoing of the

occurrence of gas gangrene in battle casualties being received, Colonel Cutler

noted the following:

An attempt has been made to gather in all the cases of true gas gangrene. Up to the

present we have leien able to collect 198 eases in whom there were 14 deaths, a mortality

of 7.07 lpercent. These figures must not be considered final, for some of these 198 cases

may not be true gas gangrene. for one must distinguish between simple anaerobic invasion

of an avascular extremity, or simple anaerobic cellulitis and true clostridial myositis.

Bacteriology is of no assistance here, for, as pointed out above, many wounds without the

slightest evidence of gas gangrene c(ontain the Welch bacillus, and many of these have been

closed by early secondary suture with primary union. Of the above 198 cases, 76 (38.3

percent) had amputations. Thirty-one percent of the amputations were done in the forward

area and twenty-five percent of those cases amputated in the forward area were reamputated in 80S units later."

The "gas gangrene" portion of Circular Letter No. 101 was extensive and

informative as well as instructive. It read:

a. In(cidence of serious infection with clostridia is fortunately low up to the present

time, and surgeons have shown a wise discrimination between diffuse mnyositis and cellulitis. This has restricted amputation, led to rtwovery l)y simple incision, excision of

involved muscle and adequate drainage.

b. Routine culture of wounds is unnecessary unless there is clini(al suspicion of gas

bacillus infection. Gas-forming organisms (can (ommonly be cultured from a wound, and

such findings should not influence tie surgical treatment unless consistent with the clinical diagnosis. Only in clinical cases of gas gangrene infection should cultures be taken

and sent to the First Medical General Laboratory for final identification of the organisms.

c. Amputations have in some cases been too radical. Always demand a consultation and always explore locally in wound before amputation. In many cases the apparent

diffuse involvement, as shown by a swelling, crepitation and discoloration of the skin,

has extended far above the actual musc.le involvement. Failure to appreciate that amputation or muscle excision can be carried out at a much lower level has at times resulted in the needless high amputation of the thigh or upper arm. Extensive incision

and drainage above the level of amputation is commonly required in such instances.

d. Following amputation for widespread clostridial myositis, skin traction should

not be apliled for the first 24-48 hours. since some cases thus treated have had unfortunate

results because of restricting dressings. Such cases should be held as nontransportable

until skin traction is applied.

e. In performing the circular amputation, the skin should always, if possible, be longer

than the underlying soft ti.ssue and bone. Except in amputations following clostridial

infection skin traction should in every instance be applied immediately. * * *

f. There has been an unfortunate waste of both material and effort in applying to clostridial infected wounds the hospital precautions usually applied to virulent and easily

transmissible orgainismis. There is no reason for sj"'ial isolation for ward care of gas

gangrene cases other than simple hospital routine and cleanliness. However, the group-

" See footnote 93, p. 231.
CHIEF CONSULTANT IN SURGERY 233

ing of such cases may be desirable as a matter of efficiency in their management. It is

wise to have special dressing sets prepared for gas gangrene cases, since these instruments

should be sterilizedt by autoclaving. These should not be mixed with other instruments

on the surgical cart which may not require autoclaving. Linens and blankets dircetly

in contact with discharges fromi wounds infected with clostridia should be autoclaved before laundering.

g. Radiographic depiction of gas in the tissues, regardless of its distribution, does

not necessarily indicate gas gangrene, and, unless other clinical signs and symptoms are

present, should be disregarded.

Use of penicillin and sulfonamides.-Colonel Cutler reported at the end

of June that 500,000,000 units of penicillin were being supplied to the First

U.S. Army daily, an amount which he said should be sufficient for the present

and immediate future, and a quantity which could be supplied with reasonable

assurance. The buildup to this daily maintenance supply was described as

follows:

The demands for this drug increase daily in spite of heavy deliveries earlier. Far

shore deliveries were 3%.(0)0,000 units by carrier, early, 100.000,000 twice by air up to

17 June. Since 25. June we have been delivering 500,000,000 by air daily. Some of

this may not have been properly used, but we are convinced from observations here and

on the far shore that the casualties are receiving all of it and observations make us

believe it is beneficial.'

Colonel Cutler's views with regard to the part played by penicillin and

the sulfonamides in the control of wound infections, as witnessed in these

early days, are set forth in Essential Technical Medical Data, ETOUSA, for

July 1944, as follows:

It may be said that the low incidence of serious infection in the present campaign

is still a source of wonder to those who were in the last war. The fact that the wounds

of those who have never had sulfonamides or ienicillin are not to a great extent more

infected than in those who had penicillin seems to point out that other factors than just

chemotherapy must be studied. We must not forget that the American soldier today is

far better fed than in 1917-18, that he is physically in a great deal better condition, that

he individually knows much more about looking after himself, including first-aid, that

the [Medical Department] soldiers * * * are far better trained than they were in the

last war, and that the resistance of the individual himself may he so much greater that

even without chemotherapy his wounds do well. Moreover, plasma and whole blood are

given liberally and must be weighed in the scales when one discusses immunity

and infection.

With reference to the penicillin section of the new directive, Circular

Letter No. 101, Essential Technical Medical Data, ETOUTSA, for July, states:

Circular Letter #101, which is the followup on Circular * * * Letter #71, contains

further data regarding penicillin in wounds and fills in what we have already learned

from our brief experience. It is fair to point out that sulfonamides are liberally utilized,

and penicillin also. Perhaps we would have liked to give penicillin to one army and not

to another, If this [had been] just a scientific question, but, there being evidence that

penicillin benefits infection, we felt forced to give every American soldier the benefit of

penicillin. This is going to modify and make difficult suitable controls, but an attempt

' See footnote 95, p. 224.
234 ACT1VITIE.S (IF SUIMICAL ('0INSULJiANTS

Is being nmad~e to tind einoughi Wounds amoungst our own troopis. or iii prisoners-of-war.

whvlid, n141ot, get penicillini or suilfonamlides(1. t hat I liese cases5 may1 lin i15Pel its cotrlllrs agaiinst

the remiainder.

11w ll penicillin i i list ruclt ionls ill ( i vii hir Letter No. I0 %%-ere simpllle an

explicit . Tile earl ier "jpeiiici liil irihir i n ttenided for thle inst ruct ion of t hose

uising" penicill in ill tilie fixed hosp1 it als of tile communiiiict~itions zone (1p. 142),

wits rescind(ed1. Tilie new circullar statedI thlat dosage asj gien inl 'i rcula i Let -

ter No. 71 should lbe ndliered to. It wnrnied thiat somne nIedical ollicers have

oil occasion trip~led tile (dosage wititout scieit ifie just ificat ion, anid the suppIly

Would be impileriledl if such expernimentat ion is carriedl out. The newer (direct ive

also took cognizance of the fact. that. lno special forms for rep)orting castialties

treated wvithI pen ici lii i existed. Consequently. mnedicalI officers were Inlstruct ed

to record thle words "1'eniiiill in Treatedl' after tilie diagnosis Onl the emiergenicy

iiied ical tag or field miedical record as required býy Circular Letter -No. 71.

Whole blood.-Colonel Cutler was immnensely p~leasedl with the work of

thie blood bank and, at. t lie en(1of .Iine, repo4rtedl the following:

Thle I reenemulos deumaind for l1400(1 coin1pietetly JUSIHP il le l(- Ptiiii~hiIii4.It of tile lulooKl

luaink and14 front reports and4 oIbserFvationsi It i.s clear we inust. hallve saIved life by i lie establlishmiient of ali EIN 14)01 bloiank. 2,000 pinits wvith sets wenit over by hospital carrier or

aiir. About 1,00() pinits have been given uil by mledicail officers (ol LKT's to) far-shore med44ical

groups. 1IIIandiig trooqwe tooik in 2140 pints amnd sets (on landing. Lt. Itiordaln of tile 11lussi

banmk is mnow omi the( filr shoire. lie hass at la rge Na vy-typte refrigerator buried iii the ground

lit thle Omahat air strip. amnd I-S I truc~ks (each taking SO) pints) lire well'1 w4)rkimig with Iithe

First Army dieliverinig blood4 at this timie (fig. 8,S). Almnost. all LSST's aild ho~spitail carriers

either gaive upl their blod (4) teo pele onl the fair short- or usedl it upi on1 caisuialties onl the trip

back." Little wits actually waisted. The miajor difficulty about blood hitis beeni the return

of kits and sets and inaniiite Jimr.'

As the Third U.S. Armiy joinied the fray, and it was evident, that thle conlflict in Europe was to exp~andl ever lairger, there were on1ilnouis anid iunmistakable

signs thiat. the European theater 1b100( bank -ould( not. come close to p)rov~iding

thle demand1s which wouild lbe made. The First U.S. Army required W00 pints

per day. TIhe Third UT.S. Army inlsisted upon a (hilly sup~ply of .550 pinits.

Moreover, the First, IT.S. Army had b)een borrowing 200) pinits per day froml the

British wvith nto possible way of ever replacing this loanl. Buit, thbis is a story

which highlights the period of thle ntext camipaign inl Europe. At tile close of

the Normandy canipaigni, there wats at comment to time effect. that whether or

]lot, blood was being wasted or uised without. adlequate reason had b~een carefully

conisidlered1, andi that there was at firm Opinion ill the whole European theater

that, the Army needled blood.

The inst~ructions inl Circular Letter No. 101 p~ertainled to the mechanical

difficulties which had been encountered inl using the whole 1)100( sulpllie(l froml

"5 "Medi~cal supply du1mphm were' estblithlie(l at each port of embarkation In the Southern Blase

Section. lqTS? were supoplIed front theni, andt inionfled theiii on the far biench. Fach oimthoiinqt ST

carried twice the amount of Wod~uw emtlminted to he neededl on the return trip. The excess wast unloaded on the. far beach. This was the way In which blood wam supplied on the early beuichhead.' ( Let ter.

Pa81l It. Hlawley, M.D.. to Col. .Joint Boyd Coates, Jr., MV. 17 Sept. 1 958.)

q7 ee footnote 85, p). 224.
cli1',F c()Nl'l.TAN'f IN snim.(Eity 23 5

givei miassive t ranfustitons~. Thist (-iirclda lettIer St ated

14.** The following in~struc'tioins should lbe obiserved ill lt(e use uif loliitml oi~tatilied

front the ET'f ) Jtooil Banik

,I. lieturn, of sets. All usedl sets imulst lbe ret urnedl at the first opotimlllnty to thle

drivers of thle delivery trucks. Sets should not he kept on liand14 ~in excess (it a level of oiliv

11 per joint of blood.

Fm~iaju, 88.-A unit of the Blood Bank. ET( I SA, wi1th the First U.S. Armiy. hitchinig a

storage refrigerator. nmounted. onl Ili artillery carrier, to a cargo truck.

to. oloservance (of fthe followuing wilil facilitate the admnifistraition of Wood0(:

(1 1'lauisi shliotld be giveti first excolpt li excepitionalll (ireniiistan ces t exsaliguiiiationii

(2) The blood miust Iw vigorously shankenl before admIiniist rat ion.

13 me fh ilter t Iotli steel anill gas miantle ) chuiiiier miust Ie( compilletely tilled to)

utilize all of t(he filtering snirface. This is accomplished by inverting and filling t he chamber

before start ing the transfuision.

(4 t When it transfusion miust lNe given rapidly, a No. 13 needle should lbe iised.

(5) Whlen the transfuision is starte-d fthe air venit should be echecked and., if necessary,

clealred boy positive pressure.

c. Any pa1t ient receivilig more thani 1 .549) cc. of tdi iii or exhibit jug evidence of intrava scula r hen l ysis ii ctludi ng hien iiglo inuri uIa -is sho wn toI y chlemica la test. will lbe aIka liii ized

according to fille of the followving lirotwedures

0Oral1.

(1I) I tii it ial I I g inIis. ,odifum iiI citI r.aIte,. d is sol ved in w ,ater-I.

(2) 'Ma intenninee: 2 gils. sod juin bica rhlfiiute by mouiithi every two hours.

(3) Flniid intake to ip 3.(N xEir 24 hours.
236 ACTIVITIES OF SURGICAL CONSULTANTS

Ittrarcnous.

(1) Initially: 4 gins. sodium citrate in twenty-four hours by intravenous drip, or

11/j gins. every two hours intravenously.

(2) Maintenance: 16 gins. sodium citrate in twenty-four hours by intravenous drip,

or 11/2 gins. every two hours intravenously.

(3) 3,000 cc. fluid intake.

The urine will be tested chemically for hemoglobin and with litmus or other suitable indicator for pH. Alkalis may be discontinued when hemoglobin disappears from the urine

which in the average case will occur in less than twenty-four hours.

Sorting.-Circular Letter No. 101 also presented the following advice and

instructions on sorting--triage:

15. Horting. On the perfection with which 8orting is accomplished, will depend the

proper care of many soldiers, and lives may be lost if improper sorting under pressure

occurs. Sorting (triage) should separate into at least three categories.

a. Those in shock and critically ill, possibly moribund.

b. Those awaiting their turn at the operating table in preoperative ward (and not

necessarily in shock).

c. Lightly wounded individuals who may be evacuated with nothing more than a fresh

dressing. In this group may be placed, unless the Commanding Officer desires separate

wards, the medically sick, if they are evacuable. Observations have revealed that the

division of seriously ill and shocked people and those merely awaiting their turn has been

poorly accomplished. This has resulted in men with simple injuries being unnecessarily

damaged psychologically by being placed in beds next to dying or critically ill individuals.

Also, this mixture of critically ill and lightly wounded had taken up the time of those

working in the shock wards, who should devote all their energy to the critically ill.

Other instructions.-Circular Letter No. 101 also warned that evisceration

had resulted in cases where retention sutures had not been used in abdominal

wounds. It directed that all abdominal wounds should be liberally supported

with retention sutures. In addition, it stated that small bowel enterostomies

should not be performed unless this was the only possible procedure in a special

case and that colostomy should always accompany the repair of injuries to the

large bowel with exteriorization, when possible, through a separate incision.

The circular letter stated that plaster splints were being applied too thick

and that, if bilateral spicas were applied, they had to be litter width and

reinforced with a strut placed posteriorly. All initial circular plaster of paris

dressings, the directive went on to say, following traumnia, manipulation, or

operation had to be split to the skin and slightly spread.

There were also instructions with regard to thoracic surgery, vascular

surgery, spinal cord damage, ocular injuries, blast ears, radiographs, laboratory procedures, prophylactic tetanus antitoxin, sterilization of ampules, and

the coloring of cocaine to insure ready identification.

Joy and tragedy.-On 19 July, Colonel Cutler learned that some 60,000

German prisoners had been taken since D-day, and he was most elated (fig. 89).

"Pretty good. We're on our way !" he wrote. There was no doubt but that
CHIEF C()NSV1.TANT IN S I'l 0; 1: 10

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CHIEF CONSULTANT IN SURGERY 239

tutions and moving candidates of proven quality to 'yeak institutions, etc., was an

onerous one in which Colonel Rhodes played a major and beneficial role.

5. I know of no otfiver in your command who has better performed his duties than Lt.

Col. G. K. Rhodes. * * * His example of devoted service and his abilities professionally

were of the highest order, and your Command has profited by his having served within it.

At the next meeting of the Chief Surgeoins Consultants' Committee, General

Hawley, in closing the meet ing, said :

The only thing I have is to express to you what we all feel about the great loss that we

have suffered in Colonel Rhodes. He worked very hard during this push, and this. I have

no doubt. hastened his leaving us in the manner lie did. by death.

I was very impressed with his work and his approach to it. You could never get hin

excited or worried, and he had the keen affection as well as the respect of the young stirgeons he advised. Ile is very difficult to replace. We are very fortunate in having

Cohmel Morton to replace hiiii. Colonel Morton has done outstanding work with casualties.

I welcome hiii in this group of (consulltaints.

NORTHERN FRA NCE

The Northern France Camlpaign was short-lived, beginning on 25 July and

ending 14 September 1944. In that period, thie Third U.S. Army broke out from

the Normandy beachhead and immediately threatened German positions in

northern France. The Seventh U.S. Armny landed in southern France on 15

August with relatively light resistance. ()n 25 August, the Allies liberated

Paris. In early September, most of the area of the Benelhx countries hiad been

freed, and abortive attempts had b)een made to establish a bridgehead across

the northern Rhine at Aachen. By mid-September, the fight for Gernmany itself was beginning.

Trip Home

Blood.-Fromn the outset, the supply of sufficient quantities of whole blood

was a critical l)rolblem. "A trying thing that came up is blood," ('olonel Cutler

reported at the Chief Surreon's Consultants' Committee meeting of 28 July,

"Everybody who has been to the Continent says that blood is being. used improperly. I was asked to ask you [General Hawley] to make one more try to

obtain 1)lood from the United States by sending a cable to The Surgeon General

requesting the shipment of blood by air to the ETO Blood Bank."

General Hawley was concerned about the time it would take to get the blood

to England, making the project. futile if the blood (lid not have sufficient life

after arriving in Europe. "There will be a minimum of 72 hours before the

blood leaves the U.S.," he maintained. But, after discussion of procedures

which would probably be implemented in the United States, Colonel Cutler convinced the Chief Surgeon that whole blood could leave the Zone of Interior

within 24 hours after drawing. Major Hard in then assured the general that the

life of the blood, after receipt, would l)e a good two weeks.

"We all believe in this," Colonel Cutler said, "We think it can be gotten fromn

the U.S. It should be given precedence."
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CHIEF' CONSULTANT IN SURGERY 241

ULnited Kingdlom. At a London conference hield by the Chief Surgeon onl 4

August 1944, Colonel Kimibrougli inquired: "Since von are sending such highp~ow~ered speakers back, why call.t they take upl with General Kirk this p~roposition of strippinig key p~ersoninel from the hospitals coming over here froin the

States ..!

"You're absolutely right," rep~lied General Haly,"nd they wvill (10 that."

"~Anothier hospital camne in without. a chief of medical service," Colonel Kimbrough warned, "We are rnigout of key personn~el ."

Evacuation to Zone of Interior.-When General Kirk had visited the

theater, hie had mentionedl the fact that the air evacuation of patients was not as

g~ood as it couldl be. H e said1 tl is with p~articullar reference to thme condlition of

p~atilents b~eingr returnedl from the European terminal, Prestwick, Scotland, to

the receiving hospital, Hlalloran General Hosp1ital, Staten Island, New York

(fig. 92). Well, this was not news. Among other inadequacies in the prIevailing evacuation system, many had recognized the problem which existed at

Prest wick, a nd steps h ad bieen t aken to correct thle situat ion. At this timie,only

a detachmiienitfrom thie25th 1-IosI)ital Traiiinwais there. Momentarily, the 574th

Field Hospital was exp~ected to move in and take over the holdling and evaculation function at Prest wick. Later, when thie British wouldble. able to turn over

certain buildings at. the airp~ort to the.Americans, p~lans called for setting up a

station hospital at P~restwick to p~rovidle local hiospitalization service in adldit ion

to acting as time air evacuiation hospital. Colonel Cutler hiad asked for thle, opportimnity to inv~estigate thor'oughly thle receiving amid holding of p~atienits at

Prestwick and subsequent~ steps in their evacuation to the Zone of Interior.

This opp1ortunity was now his.

Colonel Zollinger fills in.-Fortunately, Colonel Zoll inger had retumrnmed

froil tile Continent, where lie hiad been of inestimiable. value, in organizing

surgical and shock teams from general hospitals in transit to augmnent hiospitals

of the First~ U.S. Army andl the Advance Section, Communications Zone. D~uring this period, Colonel Cutler had sorely lamented thle fact that the best

general hospitals with top~notchm peop~le could not lbe lisedl because they had b~een

closed and earmarked for early movement tot tie Cont inent. Colonel Zollinger's

efforts had attenuated time loss when hie was able to put minany of these officers

to goo(l use whiere the(yweresor~ely nee(led. And now hie was present in E~nglandl

to fill in for the Chief C onsultant in Suirgery dur-ing his absence. There were

many items which required his imimedliate attention. Certain station hospitals,

.selectedl to function as general hospitals, requiired review and augmentation of

their personnel : 16 general hospitals had recently arrivedl, and all1 required

extensive bolstering of professional personnel with qualified individuals. including chiefs of services: thle newer auxiliary surgical groups, the 5th and 6th,

needled reshuffl in g of personnel inl the comp~onenlt teams andl augmentation with

teinlporary-(luty p~ersonnel f rom general hospitals before they could he profitably

emp)loyedl; and a, list of those LSTl. iedical officers meriting Conl 'llendlatioll was

d1ue in tilie imnmnedi ate flitumre.
4
CHIEF CONSULTANT IN SURGERY 243

Prestwick, Scotland, "Very Sloppy Place."-At the last minute, onl

Saturday, 12 August, a cable from Waslhington was received which saidl that

The Surgeon General had agreed to sendl 250) pints of blo00d per dlay beginning

onl 21 August and that. the amiount wonl([ be increasedl later. In view of this

response, General Hawley was asked whether all three of the officers now had

to return to the Zone of Interior. Greneral Hawley relplied that they dlil, anid

hie insisted that they try to get off that. night or the next day, Sunday. Colonel

M1acFee had not even arrivedl from the Conthinet at this time. Colonel Cutler

and .Major H~ardlin p~roceededl imlmediately -with their plans. TI'ley were ready

to leave Sunday morning. Colonel Cutier's account of the first (lay follows:

Left London by l)lane 9:30 a.m. Arrived at Prestwick 12 :30 p.m. Visited "holding

h~ospital'. Commnanding Officer, 'Major Roth of the 25th Hospital Train. Comiment: Very

s14loppy plaice. No good (doctors. 124 p~atienits in 1312 empty beds but patients arriving conmtantly. Very little p~rofessional care or supervision. Critically ill p~atients sent by

mistake for evacuation to Zone of Interior sent to 112th General Hospital by officers at

"holding hospital". Feel they have no right to reverse decision of disposition [boards]

and1 tiocy must he qiren this rig;ht. When the newv fieldl hospital takes over. an A.1

orthopedic surgeon and at competent physician muust be on its staff to review all cases

and have full right, to reverse dlispoEsitionl board proceedings. While reviewving cases oui

ward, found at batch fronm 79th General Hospital that seemed inap)prop~riately boarded

to Zone of Interior, including five N.P.'s.: 1 broken muetacarpal. Wrote Colonel Kinibrough

re this. -Sent one maxillofacial wound wvith albscess to the 112th General Hospital. Visited

112th General Hospital. just giving over to 316th 'station Hospital.

31y interpretation of the wvhole mnatter at Prestwvick is that we need a 750 bed station

hospital, at the airport. We needl nothing at Cowglen and the hospital at i'restwivik muust

have the right to studly and reboard peopule, to change disposition and to hold( or return

to (duty or turn~ over to another hospital anyone. they wvisht. Boarded ship) at 11 p.m.

16 ambulatory p~atients with us, including one wvith rheunnatic fever; one G.S.W.. forearm

left, with nerve damage : one F.C.C. radius and ulnar left (nerve (lainage) ; two tumors

testicle ; one arthritis of knee: twvo N.P.: one- osteochondritis ; one penetrating wvound,

left thigh: one cancer of the tongue; one G.S.W. humerus left; one conipoundl fracture,

left lower leg; one epilepsy, one [patient] * * * diagnosis : constitutional psychopathic

state; * * * one fracture, left humerus; one chronic tenosynovitis miuscle, right leg.

One of the patients, an Air Corps cap~tain, appearedl fit for (lltv'. His

woundl had b~een skiiu-grafted and seemned satisfactory. Colonel Cuitler believed tat. hie was not a1 neuropsychiatric casulalty bult was b)ordlering onl it.

The psychlopath sat, ilunedliately in front of Colonel Cutler. His complaint

was a headachie.. Colonel Cutler b~elievedl that lie p)robably had the mental

age of a, 10 year 01(1. "If these are a sample of soldiers returning to the Zone

of Interior," Colonel Cultler notedl in his record of the trip, "it, is not (good

ani(Il sould l)e stud~ied in thielighitof my argulnents alove."

The plane. took ofl' at 2:330 and arrived at La Guardia, Airport, 'New York,

N.Y., at 1700 the next (lay, 14 August. Stops hadl been muade at. Iceland~ and

Newfollndland. An hiour after arrival at La Gruardia, they were oin their way

anl(l reached Wrasihington 2~ hour later.

Wash ington.-Ti esd ay, 15i August, wa spent in the Office of The Surgeon

Genieral. At a conferencee held in the offices of the chief consultant in surgery,
q44 ACTIVIT1I•S OF SURGIAL CONSULTANTS

the business of providing whole blood to the European flteater was di.wussed.

General Rankin, Col. B. Noland Carter, MC, Lit. ('ol. Roger G. Prenitiss, Jr.,

MC, Colonel Kendrick, D)r. Bates (American Rled ('ross), Maj. (later Lt.

('ol.) Frederic N. Schwartz, MAC, and several others were present inl addition

to the two individuals from Europe. Colonel (Cutler's account of the conference was substaiitially as follows:

Ill putting up the proposition, I explained that we had secured the airlift for one thousand pints, refrigerated, each day from thie Zone of I niterior to

the United Kingdom, the United Kingdom to the Continent. It, was proposed that blood preserved in Alsever's diluent be used. I immediately

questioned this, stating that it was no time to experiment on ilie American

sohlier, that the airlift was ready for refrigerated blood, and that Alsever's

diluent. dihlted blood 50 percent. I was assured that the National Research

Council approved the transportation of blood preserved in Alsever's solution

unrefrigerated, that they had carried blood to I[awaii and back, to Bermuda

and back, and to Scotland and back, minrefrigeerated, and had tralnsfused kinlerican ,soldiers entirely satisfactorily.

This matter of unrefrigerat ed blood was new to us and seemed experimenial, and we constantly repeated our desire for refrigerated blood. We

were told every time that unrefrigerated blood and Alsever's solution was entirely satisfactory. As this would make the airlift simpler, we accepted unrefrigerated bloo)d. (Since that meeting, further discussion with experts not

in the Army has brought to light the fact that the cells preserved in Alsever's

solution (tagged and studied) live but, a little while in the recipient's cireulation, and I shall take this up agafin in Washington.)

Deliveries promised: Beginning 21 August, 250 pints a day; beginning

29 August, 500 pints: b)eginning 4 September, 750 pints: and from 11 Septeml)er on, 1,000 pints.

It, is our understanding that, this b)lood will be delivered in carts-liter

hot tles cont aining 500 cc. blood and 500 cc. Alsever's solution: that there

will be a recipient-giving set, sterile, in the package with each bottle. We

shall refrigerate this at Prestwick; when chilled, it will be shipped by air

to the (oult ineunt : it will be refrigerated again at the airport on tile ('outinent

anid t lien del ivered by our t ticks as usual.

In addition to the above, they will give us "re-suspended" 0 red blood

cells in 10 percent corn syrup in 6;00 cc. Baxter intravenous bottles, this again

to go mirefrigerated to Scotland. Afterwards, we shall refrigerate it. (The

first of these cells will go over with Major Ilardin who shall see that a proper

(list ribut ion of these cells is made to hospitals in which tile persoilel is suitably trained for the use of such blood.)

D)uring the day. tle following items were reviewed with The Surgeon

General, General Kirk:

a. The mnatter of utilization of experts for special jobs and tle fact that

if these experts are so detached from their fixed units their opportunities for
CHIEF CONSULTANT IN SURGERY 245

promotion vanish (cited the case of William Sandusky). I was informed

by The Surgeon General that nothing call be done about this. Men will have

to suffer for their country!

b. The Surgeon General suggested "N.P." cases be used in labor battalion

in SOS and should not be called malingerers and used up front by Army.

I explained our "recovery' center and The Surgeon General was satisfied. 98

c. Long discussion of medical education. It appears that Procurement

practically prevents intelligent, healthy young men from entering medicine.

All must go in the Army. A study of this would seem to show that the

medical schools in the Fall of 1944-45 will contain only women and physical

crocks which would seem to be a terrible blunder in regard to the future care

of the American people.

d. No more hospital ships for the United Kingdom. Must use "troopships" and begin at once. (The Surgeon General says put patients in hospital beds in troopships.)

e. The Surgeon General would like to have us use the rubber traction

material sent to the United Kingdom for amputation stumps. Will see that

in the future elastic is less powerful. Suggested using ring splints and litter

bars for traction to fasten to.

f. Evacuation from the Continent to the United Kingdom. (The Surgeon General hoped new general hospitals on the Continent would care for

the majority returnable to duty.)

g. The Surgeon General also approves the attempt to send simple and

compound femurs with skin traction (not in plaster) from the Continent to

the United Kingdom.

hI. Peripheral nerve surgery ought not be done in the United Kingdom

but should be done in the Zone of Interior.

i. Stumps should be reoperated upon in the Zone of Interior, not, in the

United Kingdom. (Comment on hi and i: Both these will save us beds.)

j. Long discussion concerning the availability of more specialists and

expert surgeons for the United Kingdom. I was informed that we would get

ab.solutely no more competent people.

k. Long discussion on history of the war. Apparently there is a quarrel

between the Office of The Surgeon General and the National Research Council.

We have nothing to do with the National Research Council, and Lt. Col.

Sanford V. Larkey, MC, is working for the Office of The Surgeon General

and not for the National Research Council. I reviewed all of the topics with

General Rankin and Col. B. Noland Carter and Major DeBakey. See my special

notes on this topic. Should get all consultants working on this immediately.

Send additional names with lpresent notes to General Rankin.

"IMedienl Department. United States Army. Internal Medicine In World War 11. Volume I.

Activities of Mdihal ('onisultants. Washington: U.1 . (ov,,rnmeiit Printing Office, 1961. ch. IV,

pt. III.
246 A( 'l'VT1'I FS 51.11 8 14"I' -- CO NSUT]IANTS

Long discussion onl wounid hallistics. Reviewved the excellent reploit

hl~ Colonel (Ashley 11.) ( )ighitersoti of tilie Bougaitnville C'ampaign (copy to

l'iiite(1 Kingdomi wvith tine) ."

Weit. to see (Col. Rob ert, ('ut Icr, P enitagon. I got. lost but littaily found

tile intelligeni~ce ollivers to whioti al iti()iiti oflicers titlist report. News of

landing near Marseilles just arriived.

'F'ile next day, W tednesda, 11; kiglist, C olontel (Cuttler gave a1 sh~ort talk

-it 'I'lie Surlgeonl ( jetIeral's weekly mneeting- Willi his stall'. III tile afternoon,

lit, visited Br'ig. (;(eIi. Geiorge It. ('al1lend~er. AM( T.''ile Siu-rgeon ( ieiieral's special

representative for Wvoutnd ball istics. (1,etteral (Calleiider point ed ouit. t hat Th'le

Su rgeon ( etienu I would1~ send~ a woundi lbal listic's teamii to' a partt iotilar theiater

if tile t heater o'oniiiinaiioer so~ requested. (General C alletnder urIged that Gleneral

H a wley take thle matter ill pWitlli ( itineral l~isenhluwer. Whien ( icueral K irk

had1 visited tilie ELttroqpean theatler a1 short Whtile he fore, lie Iaol4 gi veti essentially

thle 5fl te ibnforma t ion to) (itettera 1H a wley. l1iti. lait er oil fthis occiisioti, General

Kirtk intformnedl Colontel ( itt 1cr that thle ptiii I pretilise still appl ied. ontly

t here was tuobodY lhe knew of wh-]o coutld lhe sent. General Kirk siqggesteol that

C oloniel ('tItler feel ouit. hiis friend. D r. Mlort z of Biost ott, for siuch an assign"-

tinel t.

oti vihursday, t here was more dilscisstot w itIi, The s~urgeont General onl

tile niatters oliso'ttsst'ol ruesoiay, auill there was a hong olisetssioui Witlli (C01.

Auguisttus 'I'lorndlike. MC, conce(rtiling reliahi Iitat ion ill tile U n ited States.

Colotnel Cuitler was suirprisedl atnd nioniplused to learn that there were 140,000

patients etirreiltly iii thle rehiabil itatiton systemn. Inlt lie( afternloon lie Went b~y

train to New York and ott F~ridlay, to Bostoti. ()ti Satutrday and Stinllay, 19

and1( 20 August, lie visitedl thle H arvard Medlical School aitid tilie P~eter Benit

Bnig'liani Hosp1 ital. Ile also spoke wvith D r. I ianiond, anil expert, ili hematology,

concerining preservatives for whole blood. ()it 'Monday. Colonel Cuttler was

back inl the Offive of The Sttrgreon Genieral with Ii-fttlier- (isuip-ssuols onl blood,

Wound luallist ics, history of the war, and photography Which the Surgeon Greneral's Office desired.

Ont Tiuesia~y, 22 A ugiist, C'olonel Cujt her reported thle following:

(7onference with General Rlankin anl 'Major I Margaret D).1 traighili concerning new

pohi4'ies fo~r care of officers and etilisteot personnel, female, lbeeoniing pregnant in service.

'onferenve with MajOr General. [Ge~orge F.1 Lull, Colmel [Florence A.] Blancbtield and

Majo)r C ratigltitl c'oumvOrttitg the fac't t hat women officers in 'Medical 4 Orps are not. given

(1dIef(oendet tiltowaniops. Atl agreed tis~ -was wrotig, tittt the bill had( bleen loosely

drawnt folr woomn ieti Mediceal C('rp% in thait it dtid not spO'citilelll3 state that wonien niedicaul

officers t-milto have det-oendent allOWano .eo'iis 14118PIt wasSA 254' s -11Pecle ill tile bill setting forth

the ceratlimi opf theme service o)ffieprs. At the request of the, alioi'o grmip~. wrote a letter

to) Senatior Walsh. Mla."achtisotts Senato~r, and1( anl iold friendi of mnetio. askitig him to See

that fair polay and wo class ohist met imi ixs'urrel ill this miat ter.

0Oughtermson. Ashle.y W. 1111i1. Hnrry C., Sutherlandu. Francis A.. and~ Greiner, Daniel J. : Study

On W011tut t111it ti80-1- 11011911nVtII' 4 'j1nm~npng1. 1In M,'iti,'nt D epartme'nt. United Statem Army. Wound

Iiiiiistii's. W11V411igtnNton t'.S. Goenmn Prtiutingc Offlee', 11)(12, pp'. 2S1-4341..
CHIEF CONSULTANT IN SURGERY 247

The next day, Colonel Cutler visited the National Research Council offices

where he conferred with Professor Keefer and Dr. Guest, experts on blood.

The National Research Council group promised to report to The Surgeon

General of the Army what the best preservatives for whole blood were, refrigerated and nonrefrigerated. Iater, on this Wednesday, 23 Augoust, Colonel

Cutler visited the Air Surgeon with reference to a matter of considerable

concern to the Chief Consultant in Surgery from the European theater. Ills

record for the visit states:

Conference at office of Air Surgeon regarding information from Mitchel Field forwarded

to Surgeon General that cases arriving from ETO were improperly dressed and cared for.

It appears that some of the cases specifically cited were Navy cases not coming through

Army hospitals. Also it appears that the letter was written in an attempt to remedy defects

in our system. General Grant was away and the conference was held with Brig. Gen.

[Charles R.] Glenn, Lt. Col. [Alfred R.] Shands and Lt. Col. [Richard L.] Meiling. Colonel

Shands is in charge of this work and will send me a weekly report on cases which arrived

in bad condition or about which there may be criticism at Mitchel Field. The cases will

be specific instances and will include not only the name of the patient but the hospital in

the ETO where the patient was cared for. This should allow us to improve our care.

Prestwick again.-Colonel Cutler left the United States by air on

24 August. During the stop at Harmon Field, Stephenville, Newfoundland,

he looked into the small 30-bed holding hospital there and found it quite satisfactory. Friday, 25 August, found him back again at Prestwick, Scotland,

concerning which he recorded the following:

* * * had four hours at the 57th Field Hospital, and the blood bank set up. 350 pints

of blood and Alsever's solution arrived In the plane I was on. These were still cool on

arrival. Blood received at Prestwick as follows:

23 August: 259 bottles

24 August: 18) bottles

25 August: 336 bottles

Disposed as follows:

23 August, to ISalisbury: 5

24 August, to France: 300

25 August, to France: 130

On hand, 25 August: 338

Capacity of present refrigeration at Prestwick: 222 boxes of 6 bottles each.

Went over the roster of 57th Field Hospital. It is not good. See full vetting in

separate memo. Believe this hospital should have a physician and a surgeon so competent

that they can be given the right to change disposition board findings in order that certain

cases which arrive at this hospital may be returned to duty rather than sent to the Zone

of Interior.

London.-Colonel Cutler arrived in London late Friday, 25 August. On

Saturday, he telephoned Colonel Hays of the Medical Supply Division and

requested that lie cable the Zone of Interior immediately for donor sets. One

expendal)le (lonor set was to be packed in each crate containing 6 bottles of the

Zone of Interior blood. However, on opening a package at Prestwick, Colonel

Cutler had found no donor set. At a conference with Colonel Spruit, Col.

Joseph II. McNinch, MC, and Colonel Muckenfuss, the Chief Consultant in
248 ACTIVITIES OF SURGICAL CONSULTANTS

Surgery explained the new procedure by which Zone of Interior whole blood

would be supplied the European theater.

In a memorandum to the Chief Surgeon, dated 29 August 1944, he wrote

the following concerning the subject:

* * * The blood will be brought to airlports in the U.,..A. and held there refrigerated

until the 'plane is ready to leave. It will then be flown unrefrigerated to Prestwick. There

we will chill it again in our refrigerator, which means that it should be in the refrigerator

at least 4 hours. The blood will then be flown to the Continent. where it call be immediately delivered in our refrigerated trucks or can be at the base in the large refrigerators. This woudl Ile safe to use up to IS days; until we have further information from

Washington, this is the method we will use. • * * * * * •

The Surgeon General openly expressed the opinion at his staff conference that if the

surgeons of E.T.O. wish for blood they should have it, and every effort would be made to

provide us with what has been requested.

Evacuation

Immediately upon his return to London from the United States, Colonel

Cutler was also embroiled in a conference on evacuation. Various aspects of

evacuation from the Continent to the United Kingdom and from the United

Kingdom to the Zone of Interior had been bandied about for some time, but

it was now necessary to make some definite decisions--particularly in the light

of the information Colonel Cutler had brought with him from The Surgeon

General.

As for evacuation from the Continent to the Uinited Kingdom, the consultants had objected to the lack of opportunities for using extensive air evacuation. More fields were needed to prevent one or two installations from receiving all the air-evacuated casualties. They were also of the opinion that it was

no longer necessary or advisable to have transit hospitals in many cases. The

same was true of water-evacuated casualties. The seriously injured requiring

special care were of particular concern, since these patients were not getting to

the right hospitals soon enough. At one time, Colonel Cutler had, by way of

illustration, mentioned the case of a Private "S.", as follows:

* * * [He] was wounded through the right forehead on July 13th---cared for at 45th

Field Hospital---crossed on LST. Admitted on 14 July to 50th Field Hospital-transferred

from there to the 305th Station Hospital 17 July-transferred from there to the 314th

Station Hospital 18th July-transferred from there to the 185th General Hospital 22 Julystill unconscious with a cerebral leak.'

On that occasion, Colonel Cutler had said there were many such cases.

le had also objected to the fact that good general hospitals were being used

as transit hospitals or as holding hospitals for evacuation to the Zone of Interior. To him, this was a waste of talent and equipment, when a hospital with

less able medical officers and more limited equipment could perform the mission

adequately. Colonel Cutler had also suggested further evacuation to appro-

"16' Mlnute", Twenty-Firmt Conference of the Chief Surgeon's Consultants, London. 25 July 1944.
CHIEF CONSULTANT IN SURGERY 249

priate hosp)itals by light aircraft directly from planeside of evacuation aircraft

arriving in the I nited Kingdomn from the Continent.

As for evacuat ion to tile Zone of Interior, Colonel Cutler, at this conference

on 26 August 1944, said evacuation by air and by water had to he considered,

priorities had to be set for air evacuation, and a determination made of cases

to be evacuated by sea.

Fortunately, it was soon determined that patients could be evacuated directly from the Continent to the Zone of Interior and detailed instructions to

implement the decision were issued by the Chief Surgeon to surgeons of all base

sections on the Continent, and to commanding officers of all general hospitals

on the Continent. In this instance, direct evacuation by air from the Continent

to the Zone of Interior was to be provided patients for whom definitive treatment at special centers in the United States would be preferable to the treatment available in the European theater. The directive, dated 19 September

1944, stated that, normally, battle casualties should take precedence over nonbattle casualties. Particular priority for air evacuation was to be given to

(1) peripheral nerve injuries, (2) maxillofacial injuries, (3) brain tumors, (4)

patients requiring deep X-ray therapy, (5) patients requiring a series of plastic

operations, (6) carcinoma, and (7) ) lindness. There was also a comprehensive

list of conditions which were contraindicative of air evacuation.

These and other changes alleviated the evacuation situation somewhat, but

the general situation on the Continent was so fluid and changing, that some

decisions had to be held in al)eyance. In fact, for a period, many of the activities of the Office of the Chief Surgeon came to a temporary halt.

Valognes and Paris

The occasion for disrupting the normal routine of the Chief Surgeon's

Office was its move to the Continent. At an early date, the Forward Echelon,

Communications Zone, had crossed to prepare the way for the eventual move

of the Headquarters, SOS, ETOUSA, across the Channel. Each division of

the Chief Surgeon's Office had plans to move its personnel on a staggered basisa portion to go early, and the bulk to follow later. Some members of the '"'ief

Surgeon's Office had been designated to remain in England until the move could

be completed and the United Kingdom Base could be established with Colonel

Spruit as its surgeon. The Medical Records Division was to remain permanently in England with Colonel McNinch as its chief.

The first move of the Chief Surgeon's Office was to Valognes, France. This

followed a few days after Colonel Cutler's return to the European theater when

he was extremely busy trying to catch up with unfinished business and the

events which had transpired during his absence (fig. 93). The diary says

little about the crossing: "Trip [from] Cheltenham to here--Wow! Wish I

could write it in full. Trip with Ralph Tovell day after arrival here. Peninsular [base,] Caen * * * to Le Mans (2:00 AM). Next day beyond Chartres.

Great destruction in British area and bmrned out tanks belittle talk Americans

did it all !"
•-)qCT[ .\TrIErl.S q)Pi. Rll4;lNA\Lo 4 INSVI 'ITANTIS

Fi~l.; la-: 93.- Tlhe' ililtuxi .r 4-17 O w• 4 )ljp'l':l it ills :[tlll .\dmillisira:li~lm l•,llihlill¢g. 4i~llic't, ()f Iliv

C'hief S111-,l ll'lt I. E.T4r IVSA.. :11 \'ll40:.llt,-<. F ni celt. Ci'llmll'l Cullerl is svo:lled ill II. X ';I.V. !1

C'qd..I~ l I I. \'tw,:lI v. M (',. is aH I I:Ilh I b .'ll- llilld I 'I t4 tle,4,lll l I'vlh r. \V ilhI14'11 l o e,,h I' 'lit, lh r. lri )III

l If)IfJ 4)• |' , . ;l Ir ' l I' )I. I, l 11 it~r 1 ]- . I '•v l,,111l. M Cl . :lld 4 ',il..Ialllvs 4" K IIi t 1.l'1llgh I. N It'.

A\ft v F \ :'V( . ( (,)l Ile ( *ilhler flew 11:4 'k ItI) EII. _'d la.111 fi,, 4 )I" I,n wev i \vlI I v 1.vI

I ~ it- 'l 'l~ " t l '.1._- k 4 l1 .• ( )ll i t 't h a d l l1 m e d' l ,n + vit ll l l 't ,l v x I • I tI l it , ( ( ) l ll i n i lt t l . ( ', d m l, • l

( 'i ll hl r :I l ,, ~ ,l\ I tsd l it-, [ ' 11 t o I K i 1+a , )1''11. , n 1t ..t -l I r II I h- 1 t1 ( '( 0 m i , Nl .m r- •to . It II

K'IiI I ',l,, )IIi I ,-• I -',a l ) I' I1- l1111 \\-;I 1t.11 ,',l. ,lig,_, \,itl I 1~<lh IluI •.4 i tl nI ro 111l

l 11ýt :1iVm I\ •,tltl den ( , *11 '<•4)1 -I M l 1-4 t l+.l (',,ho tvol Illth I he ,_.tt>,t• t :l ll), -

wt, IIt •- ':n n '• I I ~ t I II tI. ( L I: l-1t IvI. t d l ;1 Ih n',~ S F. ": Iru. N I ( \v )I Il It : I k I a: I I

H eI' llf <w l'l ed C olo( n e<•.l O ld eh r tl lm tl~ h e w om hl lik e, if) - , l :- - m i errr 'tltl •', o <f••~ 

It IliI' he 11.2,' 1 ý1 l I-1-t i I v IIIv 'i-I I o Ii I IY II1: iv. t , F

W'' I q ' df )II k.1 (.'ItlIh'" N\\ Iý re'; I \IIv I• rel i 'll I, Ilt, m', ll l iill ~~. ItI v I, v:1 4 1lI l I< V: 1l,7-. A,: ;I Ire; I I I i~,v Im I1_," f< ] I): rI .I. ( '(d<,m e] 'il jer l'm rive,] ll ]n'Pni ýi ,fill

"I'I I. \V\':kr I h I r[tI I le \v :1 nh vI () l ,h>I vý gII ;I Iv I- Sit vtt~ I d w I ' r. I I I, v I IttI v f

tl. l t ',.I _-iIl it In -, ,f I he t' lll I . Ia ,':Itill ):Iifr' .
i'iiit~~~i~I NtTN IN S' *R,(;EtRY21

II(1Imi:914. '1Iie Office fj'd I ti ( 'lilef Sii Eui, 'fUSA, i(kv. einie Kleber, Pairis.

Franice.

THE RHINELAND

11w ()lice l I le (liel 24rifemi was, to (folotel C'Ittler'. Inia ot inuol1111IS

Iiproa i whlei it openled at the C(dolilliiia 1I tel. 16 Aventue Kielier. Paris (fig.

94I ). D esks an chal inrs cm)itil~lledl to go a lp :i11d down tilie stairiis. The col~iltltaill!s were live to ai rooiii Ill smiall oflices. o)n thle sevenith (top) Iloor. anid t here

1ve no 0 levalrors. AMa a of tile tievessal, N. %Vor'k ag ile wer e still p~ackedI away

ill imiXes, :Is was t hei complete m iedical I ibraar w ii i4-11 C oloniel ('ut her had ;issidn-

(ISItN V Iisembl led. Becaii-e all of tilie Britishi vivil ian hle1 p coiilul not a~ct-iiipaiiy

Ie~ ;Iliove to) Hie ( 'utineittl .secretarial service was at1 a1 PreaIIIniI. While Colonel

( Ittler. was foinliltiate enough1 10) be billeted at I lie Iloel ( eo-r~e V. liewssor

to dhiscover t hat 50)Ii1 o)f I lie seilior. conisultanit s w~ho vauuie over did not fire ,as

well. as5 I hey were plahcedil in eliipolarv- billets 1 or 2 ftill es a v. Fa Foil1111:itl

SI Ie v I iet*- 1t Iwas Colc.

'I'lie uuiove toi t lie ( 'mitilielid heralded a1 new era ill t Ilie watr aga i list ( erIiiaav1 N.

Fmr ( ooil( 'lit ler. tI iere a ro(Se. tiiitiediat el v t ie ll(. l uiii 14) retiew 1(1d

Itviemld-ii s with Fri'etliSi i rp-ival ciii lenagnes, luc-11(i lu l-euu RI Le H "ieiva. ýMeriv

J 'Atllbiuime. Marc Iselial. aid (Clauide 116chlee. Th'lere \%";s revsII1rVIIeic Of actIv-it N

aiiigFieticli iiwIedtIc oniIaliii/at ~itions, mwe uah.ii freed frontl ( evulliali don~iinaM a Id t lie C'hief 'slllliilia I( t Inl Stizl.rrvi was ito be aIsked to liar! icipalev fr(--

-jIilit lY. Now tio loinrer remioved bliv an expaliM ov ( ed ae.t i i~xilyo

S1.- f1!~ 1.-,, 14 19¶
252 ACTIVITIES OF SU'RGICAL CONSULTANTS

the field armies was to foster an ever closer working relationship among those

at theater headquarters, in the armies, and in the communications zone. Tile

United Kingdom Base gradually took on a different character, acting. as it

were, as an area fo," the Zone of Interior type of hospitalization of patients who

were neither in the category of those to be cared for on the Continent nor in

the category of those to be sent directly to the Zone of Interior, from the European mainland. To the south were a field arimy and sul)port commands whose

medical personnel were historically, professionally, and sentimentally rooted

to the theater from which they had newly been transferred, but who now had

to be integralte(d--)rofessioIIahly, insofar as Colonel Cutler was concernedwith the European theater.

Tactically, the swift progress of the Allies through France, which had

raised hopes for an early end to hostilities, was to come to a standstill before

tile heavily fortified Siegfried Line in spite of vigorous assaults on these positions in the late fall. A bitter-cold winter-the coldest and wettest in many

years-l)revented the Allies on the. Western Front from completely breaching at this timie these advantageous German positions. And then, on 16 December,

in frigid weather, the Nazi Wehrmacht struck suddenly and with great force

through the forest of Ardennes to begin the "Battle of the Bulge.- It was not

to be until late winter or early spring that the Allies. after containing and

repelling the German offensive, would generate enough inomentuni of their

own for an all-out offensive on the German fatherland.

September-October: Orientation to Life on Continent

Inter-Allied meetings and conferences

With this is a background, one of the first specific tasks for the Chief

Consultant in Surgery during this period was to carry out thle desire of the

Chief Surgeon to sponsor a ineeting of Allied constiltants on the Continent.

At this time, many, apparently, were breathing more easily because there

seemied no doul)t that the Allies were on the Continent to stay, and progress

had been quite satisfactory, once enemy resistance in Normandy had been

crushed. It was second nature, then, to look b)ack and reconsider what had

been done, by whom it had been done, and how. There was also the desire

to get together with those one might be associated with during the home str tch

on tile mainland. General Hawley had magnanimously thought of inviting

consultants of all the Allied Armies on the Western Front, and particularly

the French.

()n further consideration, however, Colonel Cutler sensed that such a large

meeting of consuiltants at this time might not l)e advisal)le. For one thing,

the French really had not time to reorganize and reestablish themselves on

firm footing. Besides, a meeting of representatives of many nations often

became more cooncerned with social responsibilities and protocol rather than

the conduct of business. And language l)rol)lems, at such gatheringrs, were

always a formidable barrier to both those sponsoring the meetings and thle
(CHIEF C'ONSULTANT IN SURIGERIY 2 5:3

members of tile audience. There was also the consideration that Sir I [enry

Tidy had laid the grounidwork for a new series of Inter-Allied Conferenices oil

War Medicine, sponsored by thle fltoral So)ciety of Medicine, which had been

so emninently successful inl tile past. III fact, Colonel Liston and Colonel

Cuitler had alreadyv accep~tedI invitations to speak at tile first mneeting of the

new series inl October 1944, andl perimissionl had b~een reqjuestedl to ase Maj.

Benjamin It. Reiter, .1C, of thme First U.S. Army as another speaker. Accordingly, Colonel Cu~tler proposed that the first, meeting onl the Continent lhe

primnarily with tile B~rit ish and Coilmmoinwealth consultants. Mleeti igs wvith

time Frenich, hie suigrgested, could easily lie arranged at any time. And sulre

enough, 1 .S. and Aillied imedlical officers s00on receivedl an invitation fromin time

stall' of the French Val (de (Grave nlijiitar-V hospital inl Paris to joinl inl a series

of exch1anlge. chuicis anld mleetings at monthly intervals, tile first suich mieetinig

to hie hield at the Val (de GrAce I foslpital onl 19 September.

Brussels and British 21 Arniy Group

On the morning of 23 Septeiimber 1944, Colonel Cutler was prejnirin~g t%;

motor to Bruissels for a talk with Sir Percy Tominison andl Brigradier I~orrit t,

thle DI)Ms (D1irector, Medlical Service), aind surlgical consuiltanlt, respect iveir,4

for the British 21 Armny Group, wAhen Coloniel Kenidrick, The Su-rgeont telleral's special representative oil b)100( and resuiscitation, retllrnie( fromi a visit

to tile First U.S. Armiy wneire lie hiad b)een ob~serviing the adni in ist rait ion anld

uise of blood( andl plasiiia. Colonel Kendrick had come to time Eurolwaii t heater

shlortlY after Coloiiel Cutler's retuirn fromn their mieetiiigs inl Washmiiigtoii.

Whiile there was not tiiie to dIiscuss at lenigth what lie laid ob~servedl. ( oloiiel

Kendlrick saidi( that lie had conltacted Colonel Crisler, as requested, anld thlat

arrang~emients hiad been mnade for Major Reiter to gro to Lonldon anld give a1 t alk

tliis welcom~e news from Coloniel Kendrick, Colonel Cuitler spoke 1 wieli.N vvi t Ii

the British Liaison Officer, It. Col. Brianl Brennan,11 RIAAMC.

Equipped1 with the latest i nforimatioin froml Colonlel Brennlanl, Colonlel

Clitler departed for Brussels shiortly after middlay and arrived there at 1800.

lie wa puit il) at the most comfortable IHotel Astoria, wh~ere Sir Percy

Tomnlinsoni and BrigadIier 1Porritt were b~illetedI. The next inorniiig, after

sonic, (iscuissionl it. was dlecidled that thle variouis consuiltaiits shouild assemnble

in Paris by 1600) onl 14 O ctober. Thme H otel George V' was selected as tilie point

ait. which to renidezvouls. Su~grgestiolois for anl agenl(la were re-eiv-ed fr-oiii

Brigradier lPorritt.

Eu pen and First U.S. Army

Akfter tile, m-eetinig with these officers of the British 21 Army Groutp, Colonel

Cutler traveled to Etipeni, via Lomi1vail ain :1(1ire, to visit H~eadq~uart ers

(Advanice), First V.S. Ariiiv. (

1oloiiel Crisler, the surlgical conlsultanlt, aiid

It. C

1ol. (later Col.) Neil L. Cronle, MC. thle nIedlical con1sultanit, wvere asked to
256 ACTIVIT1E$S O1F SURGIC'AL t'ONSULTrN'rS

Return to United Kingdom

Once again in England, Colonel Cutler visited the Operational Research

Se-t ion and rlleviewed Mal~jor- PlaIner's progress on a casualty survey report which

lie was pr~epar'ing onl the accidlental dletonat ion of ant M-41 fragmientation-type

a10rial bo0mb while it was lbeing loadled onl an aircraft at 1)eenethor-pe. Nrhip

tonsliire, Enigl and. Later, iii conference withi Dr. Hamilton Souithworthi, 1U.S.

Public H ealthi Service, at the Americani Embassy, Colonel Cutler learned that

the Intelligence D~ivision in the, Chief Surgeon's Office had a SIIAEF report

wvhich dletailedl the scientifi invest igationls which had bweet going onl in France rp.e

tindr (~rlna th ocupaton.Colonel (Cut ler was p~lealsant IV sutrlprisedl to lea rn

also that the Rockefeller Institute. and the American Library Associat ion had

jointly savedl cop~ies of American books and journals for (listribution to the

main 1 libraries of the European countries as they were liberated, Ile p~lannled

to ob~taini copies for (list ribut ioni froin the Chief Surgeon's Office to the French

Mfilitary Medical School at the Vaml de (3rfice Hospital.

Medical statistics.-The Medical Records D~ivision of the. Chief Surgeon's

Office had moved f romi Cheltenhamn to Londlon, andl Colone~l (Cutler miet with its

director, Colonel MeNinch., andl his assistant, Lt. Col. (ieorgge D. Williams, MNC,

to plan Onl the( IVýpe of statistical data the surgical consultants would find

useful and necessary. Colonel Cutler requested casualty data fromt the field

armies to includ~e those for killed in action and wounded in action. with the

latter dlividled into those dlying in hospital, returned to duty from army facilities, a nd evacuated1 tot tie ciiniaions zone.. fie further reqllestedl statistics

fromt fieldl armies as to tihe anatomical distrib~ution of wounds and identification

of cauisative agents. For the communications zone,, tile Chief Consultant in

Surgery requested statistics as to the number (lying in hospitals, the number

returnedl to full and limited duity, and the numibe~r returned to the Zone of

Interior. lIn add~ition, hie requestedl that the average leng-th of stay in hospital

per patient be caleulated to accompany these communications zone statistics.

Finally, lie arraiiured for all gas infection records to be sent. to himself, personally, , for Colonel Cutler wvas convinced titat, "the. records, to be accurate, munst

be studliedl 1)* surgeons themselves who canl separate saprophyt ic infect ion fromi

true clostridial in vosit is:.

Colonel 1c"Ninchi, in turn, gave Colonel Cutler a mnap of the United Kingdoin Base Sect ion which showed hlow all hospitals in that base section wvere

being organizedl into seven groups wvithi a central administration for each

grout) of hospitals. Colonel Cutler wa lple-ase~ to note that this new plan was,

doing alva 'v with the System of holding hospitals as previously contemplated.

Resumption of Inter-Allied Conferences on War Medicine.-One of

Colonel Cutier's prIim~ary reasons for returning to England onl tilis occasion

was to p~articip~ate in the first meeting of the new series of Inter-Allied C'onferences onl War Mledicine. This mneeting took p~lace onl Monday, 2 Octobem'

1944. As formerly. the location was tile Royal Society of Medicine, 1 Wimipole

Street, London, W1. 1, and lnallv klinerican lniedical officers were guests.
CHIEF CONSWLTANT iN suRGER.iy 257

Colonel Listoil, thle D eputy CI I ief Surgeon, gave at Iresenitation oil thIe orga nization andI operatioins of AmIerican iiedlical services onl the -far sliore" duiring

thle invasion of the Colifit biet. Coloniel Cutler grave a. shiilair talk onl thet "near

shor-e--the hanldling of casualties ill thle I nlite(I Kingdom during thle assault

oil Normiandyl. M, ajor Reiter presentedI t lie surgical experiences f rom 1)-day to

D+ ±7 of 106 teamis froml thle 3d Auxilialry Surgical (1rouip. '1'hes'e teams had

beeni attaelie(I to engineer sp~ecial b~rigades to fund cionl inl medlical b~att al ion

cleariigi Stations Which had1( beein suitablyl modiftied for the aiii1 libiolls

o1)erat Mion.

Colonel Cutler later' observed : -his meeting was as groo(i as any we have

had. Colonel Liston's talk was adlmirab~le andl Major Reiter mnid a young

Canladian., Captain Crosse, were the high points of the entire meeting. I was

greatly interestedl inl the fact. that, after 1 had talked about dlisp~osition inl the

afternloon, sonte 20 oflicers (-amte upl and asked dlispositionl qulest ionls, SlIoWilnt

tillsis 'still lot clearly1 un1(lerStoo(l inl thle ITnited Kingdom.-

At this t ime, C olonel ( Ut ler also arranged for C olonel Mortonl an1d Colonel

Knleeland to ineet. Sir iHenry Tidy andl to serve as represenitatives of the U.S.

Forces onl thle edlitorial1 commit tee for tilie Inter-Allied C onferences inl tile

event that thle regular nienihers., ( olonlel Cutler an1d Colonel Kimlbrolughl, could

niot, atteuill.

onl ruesdai.Y :t Octob~er. Colonel Cuitler met with a Professor Louceks. formner].% professor of sumrgery at I'm on Medical 1C ol lege, IPekinig, ( 'hma. Professor ~Umcks. recently repatriated fromi a voiweitrat~ioll camp, inl .apaul. was

being, senit by the State D)epartmnent to found a1 new mnedical slchol inl souithwvest emi (ii ma for the ( 'hun1gkihig Government. Colonel Cutler miadeairnuiovmneits for 16ini to be shlown thle U.S. Army facilities in FEnglandl bY Colonel

Morton ani(t tliten to b~e sent to tble ( 'ot mnent for anl orient at io tour there.

A ft erward'(s. tilie C~liief ( onlsult aiit inl Siu-rgeryN ret urniedto Pa r1is by planle.

I u riiig hiis brief stay ill Pa ris, ( 'olonlel u lttteii(le(i I tilie regula11 ( onlferencve of GTeneral h1awle -y wvitl Idhs staff and the weekly meeting of the

Professional Services D i visioni. Ile workedl, too, onl arrni~gemineit s for the

Anglo-Americal ii comislt ants' umeet iiig. And. onl Th'ursday. 5 October, lie had

a1 most sat isfyimi reumi ion wit Il Dri. A. Brachlot . president of the Acad6miei de

Cliri rugie. Dr)m. Brachot tol 011Colonel C'utler' t hat tilie academly was to openl

againl oil I Novembiler and i( hat it woulid ble available to all mienmber's of thle

Office, of t he Chief Sulrgeon. ETOVOISA. D r. B1rachot. said thle academy woudd~

be glad to sponlsor imiteriiat iona'l anid initer-Allied minedical mieet imigs as seeiiie(l

wis-est.

Fresh warnings on trenchfoot.-] e fore returning to thle United Kingdoni, tilie Clie f (Consultant ill SurgeryN againl wvarned C oloniel Kituibrouighi, inl .

Mllemi'"iilduimi dated 4 ( )t obem 1944, of thle problemi which trench lfoot miiglit ble

inl the *oliifiiig wiiitei'. TIlins timie, lie c'alledl attentionl to word received from

Colontel ( risler ouf the First U .S. Aruivl, ivlmo said that lie was fearful of

trloiihbl( wit Ii cold himmury inl thle coininlg weeks.and mont lis. -I agree wit Ii Iim$'
258 ACTIVITIES OF SURGICAL ('ONSILTANTS

noted Colonel Cutler, "after having vismalized the Italian Front, that we are

in for trouble." lie reminded (Colonel Kinibrough: "I have written a memo to

you and the Chief Surgeon and to the Quartermaster concerning this matter

in the past.- Colonel Cutler also informed Colonel Kimnirough as follows:

2. Colonel Crisler makes the suggestion that we set up in a forward general hospital,

preferably in Li(ge, near the First Army (and this should also be done for the Third

Army) a group of medical officers trained and interested in this particular field. In other

words, we will have a hospital for specialized care of the cold foot in each Army.

After reiterating his previous statements on prevailing misconceptions

and faulty footwear, Colonel Cutler wrote: "These mixt be changed now else

there will be dsa8ster."

Thoracic and hand surgery centers in United Kingdom.-Sunday,

8 October. found the Chief Consultant in Surgery back again in England, where

he participated in a round of conferences for the next 4 (lays. With Colonel

Morton, he reviewed the provision for and progress of thoracic surgery, and the

two agreed that Maj. (later It. Col.) John J. Cincotti, M(C. of the 16th General

Hospital should be ordered to assist Maj. (later IA. Col.) Dwight E. Harken,

MC, who was carrying a heavy load at the 160th General Hospital. With Lt.

Col. George N. J. Sommer, Jr., MC, at the 140th General Hospital, Lt. Col.

(later Col.) Arthur S. W. Touroff, MC, at the 155th General Hospital, Lt.

Col. (later Col.) Laurence Miscall, M(C, at the 137th General Hospital, and

Major Harken at the 160th General Hospital. Colonel Cutler concluded: "It

would seem that the United Kingdom Base Section has the four best thoracic

surgeons * and is adequately covered from the point of view of thoracic

surgery * Thoracic surgery has made more advance than any other

surgical specialty." It was also decided to establish special facilities for the

care of badly damaged hands at each of the three original hospital centers in

the United Kingdom in coordination with their conmanding officers, and

surgical coordinators.

There was also an important conference with General Hawley, Colonel

Spruit, and Colonel McNinch concerning evacuation to the United Kingdom

and from the United Kingdom to the Zone of Interior (fig. 97). evacuation

within the 30-day policy on the Continent directly to the Zone of Interior, and

the necessity to clear out the many prisoner-of-war casualties that were creating great hardship at this time. Emphasis was placed on the urgent need to

make better use of the "Queens" (the converted British liners, Qtteen Mary and

Queen Elzabeth) and other surface water transportation. Colonel Spruit announced that plans were progressing well for the organization of all hospitalizaI ion facilities in his base under seven hospital-center headquarters.

During this week, the Chief Consultant in Surgery "vetted" the 150th Station Hospital, conferred with the commanding officer of the 6th Fiehl Hiospital

on its defunct missions and lack of any workload in its holding facilities at the

Southaml)ton port and tle Memnburv airfield, attended the regular monthly
Fl(l u' 97.' C Th ilt t i i'iC ll. 4it, b 't adv It li C -. I I Ilrr.i I4'~ :III (; l ea Iv I'411 Ia r fite 1114,

ill,1 W N 11.2'' 1111l.ýIlt itt r l l c .
It

I

I
CHIEF CONSULTANT IN SURGERY 261

to inform General Hawley that he would be in Brussels ill November, at which

time lie might come down to visit some of the medical facilities of the U.S.

Army on the Continent.

After this meeting with General Hood, Colonel Cutler returned to Paris

by air.

First Inter.Allied Consultants' Conference

The weekend of 14-15 October was a busy one for the Chief Consultant in

Surgery. Saturday, 14 October, Colonel Cutler wrote, was devoted to the

"hospitality of our puests !"

The conference (fig. 98) was opened on Sunday morning, 15 October 1944,

with Colonel Kimbrough in the chair. He welcomed the delegates by saying:

This is the first meeting of the Inter-Allied Consultants' Conference. The principle of

the plan was conceived by General IHawley. in order to get together the men who were

responsible for making recommendations regarding the care of the troops in the field and

who are really the consultants of the Armies. It was the idea to get themn together to compare notes and discuss their problems.

General Hawley was first to be introduced, lie officially opened the coltference, welcomed the delegates, and thanked Colonel Rousselot and his staff

at the 108th General Hospital for their hospitality. Ile then proceeded to comment on what the consultants in his headquarters had meant to him as a group,

as follows:

I have given the matter a great deal of thought and I think, without any derogatory

inferences to any other group, I am convinced * * * that the consultant group has contributed more, and continued to contribute more, to the success of the Medical Service

than any other group of administrators, because they are, after all. administrators: that

is. they have regulated, prescribed, and coordinated the professional services. This is

tremendously important for the reason that one patient is treated by five. s.even, eight

different surgeons through the course of his illness and, right or wrong, in the long run,

it is better that a patient follow through a regulated course of treatment than that each

echelon through which he passes be permitted to exercise its own Judgment in his basic

care. I think that most of the surgeons doing the work are now reconciled to this point

of view, although, and qvite understandably so, it came sort of difficult to those who had

been following their own particular pet ideas for a number of years. But that is. in

my opinion, only one of tle great services that the Professional Services Division of our

army has rendered and is rendering. To me they are the most important eyes 'md ears

that I have. These people get around. Their Judgment is good in many thiags other

than the care of the sick patient, and I have called upon them collectively and individually

for advice upon many things not connected with the care of patients. I think, if they

have not been exploited to their fullest value, it is because some divisions of the office

have yet to learn of the tremendous Iotential value of this group. Some divisions have

already learned that. The Chief of my Supply Division [Colonel Hays] sat and talked

with mne an hour the other night and told me of the great help this group is to him

constantly, and that he would be unable to run his division without their help.

Then, for the benefit of the American consultants present, General }[awley

continuedl with a subject which had been discussed at considerable length among

the divisions of his office--the exchange of medical officers between the field
262 ATrI'VITIES OF' SURGICAL C(ONSILTANTS

armies and communications zone. The rea(ler niav recall that a similar program

had been tried with considerable success during the preinvasion days in the

United Kingdom (p. -0). Obviously, such a prograin would now be a most

complex affair, but an endeavor which many thought would be more worthwhile

than ever before. Colonel Cutler was a proponent of the plan. General Hlawley's explanation follows:

While the consultants from the Armies are here. I would like very much to have

you talk over with the chief consultant in your own specialty here in my office the

question of rotating your people in the Armies with people in fixed hospitals. I feel

that that should be done, not too fast, and probably at first on a temporary rotation

basis. We may be in for a long winter of slugging it out or of lessened activity. Many

of the peol)le in the field units up with the armies have been working very hard and

are tired. Maybe their morale has begun to waver a little. Nothing improves a person's

morale as much as a change.-a change of scenery. And, conversely, we have got a lot

of people in these fixed hospitals who are just itching for a chance to get to the front

and do some work there, and to get into some of the mud which the forward units must

contenl with all the time. I think it would be advantageous for both sides to let the

people at the fixed hospitals learn of the conditions under which the forward surgeons

work, and give them more understanding of the difficulties they encounter; and. conversely, let the people who are doing the work forward come back and see how the patients

are cared for after they leave them.

The conference then proceeded with the first item on the agenda, care

of the battle casualty up to the time of definitive surgery. As subtopics of

the item, there were the following: First aid in forward echelons, care during evacuation to the hospital where surgery is first carried out, sorting of

casualties, and l)reoperltive p)reparation of the casualty to include blood transfusion, chemotherapy, and the like. There were no formal presentations, and

informal discussion was the keynote.

Lt. Col. R. K. Debenham, RAMC, surgical adviser to the British Second

Army, opened the discussion of the topic with these remarks:

One of the problems of the Second British Army is whether to resuscitate in one

place and operate in another place. That is to say, whether a patient should be resuscitated forward and operated at the first available surgical level. I feel quite strongly

that you can't resuscitate in one place and operate in another. * * * your transfusion

teams must be with your surgery. * * * The best level for surgery appears to be behind

our guns. Sometimes we have had to operate forward of our guns and within shell

fire from the enemy. I don't think patients do so well there: it may be heroic, but

It isn't very satisfactory.

Colonel Debenham also explained that the British in general were of the

opinion that more than one-third grain of morphine was bad. lie mentioned

certain other complicating factors in the use of morphine, and stated that

the British Second Army was finding it difficult to resuscitate anyone after

thiopental sodium had been given, some 6 to 7 hours being necessary to recover

from its effects. Colonel I)ebenham stated: "We like to treat all our femurs

in Thomas' splints and we find they travel far better in a 'Tobruk' plaster."

This was an interesting observation on a most controversial issue at the time.
CHIEF CONSULTANT IN SURGERY 263

InI sununation, he brought forth the following four points on which transfusion and early surgery were based :

It is very interesting-there are four points: First, extent of tile wound. The

badly wounded patient is going to be shocked aid must Ibe reckoned as a shock case.

Second, time of wound: because, if lie is recently wounded, his chances are better.

Third, the general condition of the patient. And fourthly, the pulse. And these four

points are taken into consideration by the transfusion officer. Blood 1 pressure readings

are sometimes not very helpful. I feel ini general that the forward surgeon should be

essentially conservative. Heroic surgery is not required. The surgeon forward iuist

know who will travel and who will not. If he can estimate that, it is very helpful.

Thanking Colonel ])ebenhain for his remarks, Colonel Cutler asked that,

the Army consultants, particularly, provide the conferees with information

relating to the first subtopic, first aid. "We hoped that the discussions woulh

deal with the soldiers as far forward as they are wounded,* lie said. "I had

hoped that the first part of the meeting this morning would devote itself

to first aid, * * * as a simple thing," lie continued. As an example of the

type of information which might be desired, he asked: "Are your men trained

in first aid? how far does lie go? D)o you have any information on whether

your patients coming back have t'ie original dressig? What are you doing

to prevent infection? And in regard to sl)lints * * * Who puts it on?

Where are they put on ?" "It may I)e more important to l)ut on a good dressing

than to give penicillin and sulfonamides," lie observed.

Confessing that lie didn't know just exactly who (lid what at the site of

the wounding, Colonel Debenham replied: * * From the point of view of

the casualty, I have seen the results and most of the dressings have been put on

extremely well. If the man himself doesn't know, someone near him does know

how, and most of those that I have seen have been 100 percent marvelous."

"What does the individual soldier take?" questioned Colonel Cutler.

"Ile carries a little field pack," replied General Monro, consulting surgeon

to the British Army, "The individual field dressing is an extraordinarily good

dressing."

Colonel Crisler, when asked about conditions of first aid treatment in the

First U.S. Army, maintained that, from a few spotty observations, lie could

not say exactly what was being done for each patient or the percentage of welldone dressings. Ile did comment, however, on early treatment in the First

U.S. Army, as follows:

Our treatment of casualties forward Is taken from the "Manual of Therapy." It has

proved to be a splendid guide on all general principles of surgery and it has been followed

in general very closely. A few points need elaboration. Quite a few surgeons have

needed to be whipped into line about the policies. They have deviated from policies, but

after they had been treating casualties for a while, they conformed more or less throughout. * * * When we see them [casualties] come back, we judge them. At one time they

seem to be all handled well, and then again occasionally we see a patient come back who

perhaps has not been properly splinted: we see occasionally one who has been overlooked.

That varies with the number and the flow of casualties. Our percentage of approaching
264 ACTIVITIES OF SURGICAL CONSULTANTS

perfection with which this is accomnplished must be interpreted in the light of the number

of casualties, and the tactical situation, and to sit back and criticize is a bit unfair. It

seems to me that on tile whale, they (14 a very good joh.

"Ilave Vou any informta iou as to how many dressinigs put on on the battlefield are changed !" asked Colonel Cutler.

"I think that inost of them are not revised nor removed," answered Colonel

('risler. -They may fild it necessary to determine the extent of the wound, but

the dressing is not removed unless it is absolutely necessary in order to determine where that patient should go. It may be that. it is drawn a little too

tightly and in that case it is readjusted, but it stays on until the clearing station

is reached."

Col. Frank B. Berry, MC, the Seventh U.S. Army surgical consultant,

spoke in a similar vein. lie stated: "* * * There is one thing that constantly

comes to mind, and especially at this time of year and that is the morphine

S3rette which I wish had never beeii imvented-that is in that size [one-half

grain]-because we have already seen cases of overdosage of morphine."

Otherwise, he commented on the first aid type of treatment given in the Seventh

U.S. Army in glowing terms, as follows:

I have only the highest praise for the work that is done in the first aid and battalion

aid stations and by the aidnien going out in the field, as General Hawley and Colonel Cutler

have mentioned Ifig. IV)).

As a rule the splint is pretty good. At times, of course, they slip. We have all bweeu

very inuch interested in the very good and judicious use of the splint by the first aidnian

in the field.

As to the dressings, I am happy to say that there is less change in them than there

used to be, particularly in the Tunisian campaign, in the collecting station. There was

a great tendency during the Tunisian days to do some surgery at the collecting station.

I remember one particular clearing station which took pride in the major surgery that was

done there. The changes of dressings is gradually lessening. It is interesting to check

them, to see dressings inspected and changed, and I do think that there is more changing

than necessary. I think they are very good in establishing their priority to get the urgent

cases back to the hospitals. Very good judgment is being shown.

In his remarks, Col. Charles B. Odom, MC, Third U.S. Army surgical

consultant, spoke of p)enicillin and sulfonamides:

One thing: Penicillin of course Is not begun until we get back to a hospital: It is not

used In the forward areas, and, from the number of infections that we have had. I don't

think It is necessary to begin it forward. I think perhaps we would do well to stop using

sulpha in the wounds forward. In checking a group of cases In the convalescent hospital,

we have found some of these wounds well-healed and then when we begin to rehabilitate,

the wound softens down and in the wound we are finding sulfonamides there because they

have not been absorbed. In those that do break down, it increases the convalescence of

those patients sometimes anywhere from 2 to 3 weeks.

Judging from the dressings that have been applied, I think our first aid men have been

well trained and the effort that has been put forth has definitely shown results, because

the patients arriving now In the field hospitals have been well cared for forward. The men

know how to apply dressings and in most instances the dressings are well applied. However, there is a tendency in some cases to apply the dressings too tightly and, when swelling

occurs, then they become a tourniquet.
I, J

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:266 ACTIVITIES OF SURGICAL CONSULTANTS

the British service," lie began. "This is rather a quick one," he commented

wryly, "I came over here intending to enjoy myself and now I find my holiday

is Iot going so well."

On the subject of consultants in general, the consulting surgeon to the

British Army said:

If I may go back. sir, for a ionient. I should like to state how closely all that General

Hawley said appealed to me: how much he said al.bout the contrilbtion of the consultants

coincided with our own. It is, as a matter of fact, within the last two years. I think, that

our own senior direct.ors in the fieldl have ('onme to realize what the advice of tile conisultants

41an! mIVea1n. I an) hound to state that actually in .ertain cases there wvas a little olpolsition

to the work of the consultants to this all inll)ortant supervision by the technical officer who

is not only a technician but a born administrator.

On t lie subject of sort ing, General Monro noted:

WXe have at the inonlent undler disciussion this question of the selection of cases, U'nder

this new setup, tb's introduction of mobile surgical units undoubtedly gives us much

greater flexibility and ability to conc.entrate surgery where it is wanted thann was ever

supposed before. The field dressings station idea was a sort of modified field amnbulance

nmade 11 iore Illobilo. It was quite obxviouis that we must have somne sort (if orgainuizatioll

that would enable us to hold our cases further, so the field dressing station was evolved

to take care of cases when distances prohibited evacuation. I think you will agree, our

people will agree, that it is infinitely better than any other system we have had before.

The word "'triage" has been quite rightfully condemned. I think it is outlived and some

mnclnh mori'e sensible word such as grouping, or selection is the word of (.liof ,. I don't

think it matters very much that we have three groups-a. b, and e, or one, two, and three.

That, after all, is intended only as a guide for one who hasn't faced it before. It is, as

Brigadier Porritt said, common sense that matters.

As an afterthought, General Monro added:

We also apply that [common sense] to our first aid. A paragraph in our little hygiene

manual tells the soldier that first aid is simply common sense and then goes on to explain

what the princtples are and finally if he has any questions to ask the medical officer. Our

men. when it is possible. are all trained in elenmentary first aid. I will agree with everything that has been said about first aid dressings and I would accentuate the fact that

the main objective is to try to get the man back out of the field and keep that first original

dressing in position.

On the topic of sorting, Colonel Crisler remarked:

I regard sorting as something that is in two categories. One sorts cases to decide

which hospital they will be sent to, and then one sorts case'. within the hospital. There

are two different sets of criteria * * *. The sorting to decide which hospital they will be

sent to is guided as much by policy, by the tactical situation, by the employment of the

hospital at the particular moment, and under the particular phase of warfare, as It Is

determined by the condition of the patient. At the division clearing station the doctors

become very proficient In the selection of the so-called "non-transportables" * * *. I do

not feel that you mu- k .,.ve your most experienced man for sorting at that level * * *

[where they] may readliy seek the consultation of the surgical teams (fig. 100) * * *

Then In the hospital, sorting is governed by professional policies and I think that the

nuost important point albout that Is that the storting be continuous. That is to say. one

must not let a case become labeled and pin that label on him and make it permanent, but

you should keep going around, because In a half an hour or an hour the priority may

change. If you label him as a number two or three, in another one-half an hour he may

be a number one.
or

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2068 ACTIVITIES OF SURGICAL (ONSI'LTANTS

So far as the amount of blood or plasma used, I can't give you an exact figure. * * *

The overall average is somewhere between one to two bottles of blood to a bottle of plasma.

* * * Total quantities used might interest you. We find it very variable. Our budget

in the early days was fromi :"0 to 40 bottles for every 100 wounded men * * * but that has

gone up very considerably, and at the present moment it is running somewhere on the

far side-probably between 60 and 70 bottles per 100 wounded. Now, that does not mean

that each mlan is getting between six and seven bottles, but means that a large number

of patients are being transfused, and that is due partly to the different type of wounded

we are getting in this camp.align * * * There is much blood lost, and there is more necessity for transfusion.

Splealjilig of tl)e American experience with transfusion and resuscitation,

Colonel Crisler stated, with reference to the First V.S. Army (fig. 101) :

Up to the present campaign, there was no such thing as shock teams. It w'is an

idea gotten up in this theater, and I think Colonel Zollinger of General Hawley's office

worked on that and( that Job has definitely turned out to be worthwhile. The shock team

was (originally with the auxiliary surgical group and there were only four teams in the

auxiliary surgical group. Four shock teams for an army is just of no value whatsoever.

It has been found that two shock teams per evacuation hoslpital and two per field hospital is

the number that you should have. I have noted that with the Fifth Auxiliary Surgical

Group which has Juist arrived there is a considerable increase in the number of shock teams

in that particular organization. With the shock teams the patients have gotten better

care than they (lid previously so far as treatment of shock is concerned.

Continuing with his discussion of resuscitation in the First U.S. Army,

Colonel Crisler brought up a subject which was being noticed by many as a

potentially serious problem. He commented:

There have been reactions to * * * stored blood and they are continuing to have

reactions; we are trying to get some figures on it. They have increased in number and in

severity as the date of expiration Is approached. The unfortunate thing is that in our

Army the expiration date is getting pretty close in the blood coming from the States. At

the present time, there Is not more than 3 days remaining when the blood arrives until the

expiration date. * * * that expiration date is set only arbitrarily, and it is perfectly possible

that the actual expiration date is past; and that Is not a particularly good thing.

After General Hawley explained difficulties in providing whole bloodparticularly with respect to foreca-ting needs and determining the amount

to be kept on hand-Major Hardin gave his impressions of the situation,

as follows:

We have received rather sketchy reports about reactions. There Is no evidence in

any large well-controlled number of cases that the number of the reactions increases

with the age of the blood; and I do not believe that the answer to reactions is the age

of the blood. It is some other reagon. There are two possibilities that I can think of off

hand. As you know, the blood from the States is flown across the Atlantic without

refrigeration. It may be that there Is some contamination, and perhaps enough to give

a reaction. We have found so far no contaminated bottles. The other possibility, which I

think Is probably the answer, is that the sets through which the blood Is given are

dirty. * * * The other type of reaction which may be seen in stored blood Is the hemogloblin reaction which does Increase with the age of blood. That is the reason that

hospitals have been asked to examine the blood. because all henioli•ed blood has its own

degree of hemolysis. The blood coming from the States, no matter what the age is, has

less heniolysis than that fronm the ETO Blood Bank. So far as the age of the blood
40

will

N.

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141 ItIi lit Ii NT I ' .
(IIIEF (' )NSI*LTANTr IN SI'U(RERY 271

The 1st and 3d Auxiliary Surgical Groulps were short of personnel. The 5th

Auxiliary Surgical Group had only recently b)een assigned to the Ninth U.S.

Army, and the Professional Services Division of the Chief Surgeon's Office had

been busily bringing it ul) to strength. It now had 22 general surgical teams

(6 of the team chiefs had been borrowed from general hospitals), 6 orthopedic

teams, 1 neurosurgical teani, 4 maxillofacial teams, 3 dental prosthetic teams,

3 X-ray teams, and 22 shock teams. However, many of these teams had been

loaned to the Third IV.S. Armny, including those. with chiefs borrowed from

general hosl)itals. The 1st Auxiliary Surgical Group was being reassembled

in Paris, but. nine of the specialist teams were still in the U nited Kingdom

pending the day when they could lbe replaced by teams formed from hospitals

organic to that base section. There was a general shortage of competent chiefs

of general surgical teams which prevailed throughout all the groups.

To bring all the groups up) to their authorized strength and to return borrowed personnel and teams to their parent units were but typical examples of

the i)ersonnel problems which continued to exist and required solution by the

theater consultants (in coordination with the Personnel Division, Office of the

Chief Surgeon). In this instance, Colonel Cutler elicited a promise from

('olonel Odom of the Third U.S. Army that he would: (1) Return the six borrowed general surgeons on teams of the 5th Auxiliary Surgical Group to their

hospitals, (2) fill their positions as chiefs of general surgical teams with second

men from his 4th Auxiliary Surgical Group, (3) replace vacancies thus created

in his 4th Auxiliary Surgical Group by competent junior officers on the shock

teams borrowed from the 5th Auxiliary Surgical Group, (4) provide additional chiefs of general surgical teams for the 5th Auxiliary Surgical Group

from assistants on general surgical teams of the 4th Auxiliary Surgical Group,

and (5) return all teams of the 5th Auxiliary Surgical Group when they were

required by the Ninth U.S. Army. If the Third U.S. Army should be caught

short in an emergency as a result of these changes, teams were to be loaned to

them from the 1st Auxiliary Surgical Group being reassembled in Paris. These

and other steps necessary to bring the groups up) to strength were coordinated

on the spot with the senior consultants in their respective specialties and representatives from the Personnel I)ivision of the Chief Surgeon's Office.

Another noteworthy develol)ment from this meeting was the fact that all

the surgical consultants from the field armies were unanimous in pointing out

that surgical instruments were beginning to wear out, particularly hemostats.

They were being turned in for overhauling, but ol)viously this could only be

carried so far. Colonel Cutler, after this meeting, alerted the Supply D)ivision

of the possibility that there might, be a heavy demand for hemostatic forceps

soon.

Meeting with French surgical consultants

On the day following this meeting with the consultants from the field

armies, there was a meeting sponsored by the 21 7ith General Hospital for medical

officers in the Paris area with consultants from the French Army. In a memo-
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('lll1lF CONSULTANT IN SURIIERY 273

psychiatric and malaria patients and then spent the remainder of the afternoon

with various consultants in the Chief Surgeon's Office. The next, day was also

spent by Colonel Cutler in arranging the program for Colonel Osipov to see

and talk with most of the consultants and the chiefs of the various divisions in

the Office of the Chief Surgeon. Later there was a dinner given by General

Hlawley in honor of Colonel Osipov, at which another visitor, Brigadier J. R.

Rees, C(onsultant in Neuropsychiatry to the British Army, was also a guest.

The morning of 25 October was likewise spent. with the guest from the Sovietr

Union, but, for Colonel Cutler, this day was memorable, too, for another reason.

Reopening of Acad~mie de Chirurgie

In the afternoon of 25 October, Colonel Cutler attended the first meeting

of the Acad6inie de Chirurgie since the Germans had entered Paris years before.

The meeting place was crowded with distingnuished French surgeons, among

them Professors Le Riche, Roux, Berget, Bauzet, Quenu, Senec, Brocq, and the

president, Professor Brachot. The first item was the reading of the obituary

notice on Professor C'osse, following which was a speech welcoming officers

of the V.S. Forces. Professor Le Riche insisted that Colonel Cutler reply to

this address in French, which he did. Thereafter, Colonel Cutler had to sit

next to the president on the rostrum and help conduct the meeting. The meeting, Colonel Cutler reported, proceeded as follows:

The papers read were short, and during the presentation most of the members conversed with one another, paying little attention to the speaker but when this murmuring

became too loud the President rang a great big bell such as one uses in our country to call

in the cows with. No one seemed to pay any attention. but the President was relieved by

the noise, and the murmuring continued.

Colonel Cutler discovered that, this was not actually the first meeting since

the occupation of France by the Germans, for there had been a planning meeting the week before, but it was indeed a noteworthy milestone heraldic of the

peace and victory which was now surely destined to come.

Chief Surgeon's Consultants' Committee meeting, 27 October 1944

Evacuation.-The meeting on 27 October 1944 of the Chief Surgeon with

his Consultants' Committee was devoted extensively to improving evacuation.

Only the day before, Colonel Cutler had met with the chiefs of surgical services

of hospitals in and around Paris on one aspect of this problem, tihe classifying

of patients as transportables and nontransportables. Major Robinson, Senior

Consultant in Urology, had made a trip by hospital train to review the condition

and care of patients in transit by rail. Colonel Stout, Senior Consultant in

Maxillofacial Surgery, had made a similar trip by evacuation aircraft to the

Zone of Interior. There was a definite pinch on evacuation means, and General Hawley stated at this meeting of his Consultants' Committee: "Tile situation is really terrible." General Hawley exhorted his consultants, saying: "* * I want to emphasize again here, keep checking on the care of patients
ill tranisit. It is j ilst as impijortanit a par of oti i re'sponibii~iIitV as is t heir vaire

ill hospitals, andl I just Can't keep onl teniporizinig whien people are not carrying

oult (lirect ives.*

Long-bone fractures.-Casualties wvith fractures of the long honles providedl a special probldem of evaculationl at this t huie. Aki anialYsis of tilie probleii

follows:

Skeletal t ract ion to he usedl effect ivelv had to he inst itutedl witiliii a niaxiimum of a wveek or so after wounding, a requirement whichi sharply restricted

thle transportation periodl. It was often nip-and-tucek whether casualties with

thlese injulries could b~e evacuiatedl froni the C ont inent to thle I nited Kingdom

withini this limited time. If thley could not he evaeluatedl, there was tlie( tilireat

of C ont inental hiosIpit al b~eds* being occupied by milanly ortiliopedic patients ill

skeletal traction because4 Th'le Surgeon General had directed that all fractulres

of thle long bones must be firmly healed ( frozenl) before evacuiat ion to0 the Zonle

of Intterior w~as iund~ertaken.

( eneral I 1lawley's Solult ion of th11is (lual probljein wvas t o gi ve caslliaIt ies w ithI

fractumres of tilie lon~g honles nuaxililuinl priorityv inl evaculat ion. I'Whenl this was

not p)ossible% thley had to he held Onl tile Continent inl skeletal traction for thle

mininiuni of from 6;0 to 70 dlays requiredI for the fractures to become firnully

healed after which evacuiation to the Zone of Interior could be undertaken

witliout the risk of loss of position inl the tranisportation cast.

Other significant matters.-There was a (discussion oin thle Tobruk p~laster

wvith half-ring splint involving Colonel Cleveland and General IHawley inl whichl

the Senior Consultanit inl Orthiopedic Surgery exp~lained1 the mechianism of the

Tobruk p~laster and mentioned thiat the Niinth U.S. Army would give it ant

exp~erimuental trial.

Colonel Cutler reported that lie had conferred with 'Major Hlardin onl trainsfusion react ionls and that a1 new (lirective was being lprep~aredl which would

identify transfusion reict ions ats allergic. pyrogrenic, or heinolytic and would

exp~laini whiat to do inl tile face of such reactions.

Colonel Cutler nient ioined thlat the exchange of medical officers hiad started

off withl eighlt elderly, poor-ini-quality oficers who Would at best only (10 as

wa1rdI ofhcvers.

F'inally, Coloniel Kinibrough minoiiincedl the p~lanis miade by the surgical

colliisu it amus for special ize(I treatment facil it ies onl t lie Cont iiient. It was necessary that thiese facilities be established to take care of (difficuilt thioracic, nieurosulrgic-al, iurologic-al. and( niaxillofaceial surgery cases which could not be evaculated to sinmilar facilities ill tilie U nited Kinigdlom owinig to the condition of

the p~atient or the temporary unavailability of evacuiation nmeans. At the presemit timue, only thme 4N1t l an 10th~l General Hospitals inl Paris had been namned

to hiandle thiese cases, but it wats reported that similar facilities would need to be

established at a later' date which Avould be accessible to each of the field armies.
CHIEF CONSULTANT IN SURGERY 275

Notable guests.-l)r. Loucks, previously mentioned, gave a brief description of his activities in a Japanese prison camp as a "guest of the Imperial

Government" in North China. Ile painted a dismal picture of conditions

prevailing on the Asiatic mainland and in the cow'ent rat ion and prison camps.

Colonel (sipov was also present and, when given 'it oplortunity to speak.

stated through an interpreter:

The Colonel is very grateful for the warim reception he has received from all, and

for his contact with these modern consultants. iHe especially wants to draw attention

to the work in the evacuation hospitals., which he thought ideal examples of work done

under field conditions. Hle noted with great satisfaction the excellent organization to

bring home the wounded, and another thing. the very high level of cultural standing and

education. lie would welcome a discussion with a member of the organization or with

General Hawley himself. Any questions which arise on his own medical service, he will

be willing to discuss with your representatives. In conclusion, he thanks you very

warmly and wishes everybody the greatest success.

General Hawley, replying for tile consultants, said through the interpreter: "It has been a great pleasure to have him with us. Ile will be welcome

in our service, not only as an ally, but as a member of the [consultant] group

and we wish him to feel that he can come at any time and be quite welcome."

Immediately after this meeting, Colonel Cutler accompanied the Chief

Surgeon to England, where he followed up further the reorganization of

hospitalization in the United Kingdom under the seven groups of hospitals,

the selection of l)er'sonnel to staff the contemplated hand centers, and the

studies on delayed early suture of wounds being conducted at the 91st and 158th

General Hospitals. Colonel Cutler also planned with Major Palmer to turn

over the facilities of the Operational Research Section to the Army Air Forces

so that, the theater commander permitting, the personnel of the unit could be

reorganized to conduct casualty surveys of battle casualties occurring during

ground warfare.

An Extremely Busy November

Hospitals and hospitalization

On returning to the Continent, 2 November 1944, and for much of the

entire month, Colonel Cutler and his surgical consultants were particularly

busy on various aspects of hospitalization. New general hospitals were arriving

in numbers--hospitals with a dearth of well-trained personnel. In the last week

of October and the first of November, eight new general hospitals had

been completely evaluated and oriented on the Continent. Major Robinson,

Senlior C(onsultant in U rology, and It. Col. Rudolplh Sechullinger, MC', borrowed

from the 2d General Hlospital, had to be used to go over some of these

hospitals. Eleven new general hospitals had just arrived or were scheduled

to arrive immediately in the United Kingdom and were destined to be employed

on the Continent if and when their personnel could be strengthened to the

required professional standards (fig. 104).
276i AC•'IVITII OF SUITIl'AT, CO)NSULTANTS

FIIURE 104.-The 1M4th General Hlospital arriving in Paris.

France, in January 1V45 to establish facilities at Lve

Claude Bernard.

At the same time, a new table of organization and equipment. had been

published by the War D)epartment which cut down mediical officers in general

hospitals by live, and all general hospitals in the theater had to be readjusted

accordingly. Lt. Col. (later Col.) Norton ('anfield, M1C, Senior Consultant

in Otolarvngology, immediately called attention to tile fact that this flew table

of orgfanization and equipment gave the rank of captain to the otolaryngologist

in a general hospital. This was an iml)ossible situat ion, for most of the theaters

otolaryngologists were already majors, and it was soon to become painfully

obvious that very few of the junior medic(al officers were willing to take omi the

position of tile ENT (ear, nose, and throat) officer in a general hospital with

the certain prospect of spending the remainder of the war as a captain while

their associates could look for ad'valtcement in other areas.

Fmither to colmpli'cate matters was the fact that continued offensive

actions against the Siegfried Line were now beinig felt in the form of overcrowded hospitals in the communications zone (fig. 105). Moreover, the uniformly bad weather thronglhout November curtailed seriously all forms of

evacual ion, but icularly air evacuat ion ipart in tlie U nited Kingdoilt.
cii i uv ixs N Ia~;~ -277FN 

I 1-a.l ffor uifii ;iIlls' ix tatkeii lover rol. :iII I aid st :11 in 11Y A !anurciuin I rimseu.
278 ACTI'V1ITIES~ O1F SKiGICAL CONSULTANTS

Reestablishment of Blood Bank, ETOUSA.-On 3 Novembier, thle da '

followinig his ret urn), thle ( 1iief ( oliisItaiut III Slur"ery visited Vit ry-sur-Seine

where tile 1st Genleral H ospit al was beiilig estabilishied. Ile not ed thlat it %%',S

trV()ltV to b)e well houisedi anld that tilie buildings wvould be qu it e satlifaci otv%

for a hlospitalI. Ilie revonlinienlded t hat onie of t lie iiewl V ar~ri vedl llositals,

or .1 part t hereof, be at t'leliCe to tilie 1st General I 1051it.1 ato op~erate a tot1al

coni1binled bed capacity of froml 1 ,50() to 1 St)( beds. ( oloeld Cutler wvas iiiost

plea~sed to) note that thle I 52d St at ioii Hospit al. the E'l'( )l'SNk Blood Balk.

faslinally op~erational here, Ilie noted:

* * * The Blo4od Bank is occupying at wing of a large buiulding there anld is adiiiirahly adapiting t hese qiuarters to its piurpioses. This has mneant it great dleal (of eonsi met ion. Wihinibing work- and tither renovjttiolis. bolt all this ha~s bieeni neviilujoishedl by

the persmitinel of the( 152d Stat ion Iltosilital. wliieh is greatly to their credit. The tirst

blood( wats (drawnlit iiiaris today, ;li141 it was beinig jirqkieeSSeil this aifte'rnooni when we were

t here.

Limitation of professional missions assigned to hospitals on Continent.-( ii 6 Nov eiuilber 1944, the fol lowing" W~ordls of calt ionl and advl~ice -'vere,

givenl ill a ilteilnorandunIII to Colotel. K inihrotgh by thle Chiief ( oitsult alt inl

SurgeryN

It is elesir, front our anaklysis of fthe hoIspitalIs wliie li have recently arrived1 onl the

Continent * * * t hat these lioslititls eanifnut be4 br~ought iili to) aniy reasonably professiolnil

standard so that they miay nct ats general hoslilta Is. We 4do not have ijualift~le petrsonnel

to) accompihlishi what is desired.

With t his fact. est ll lihefi. Ive mutst not iis4' stich hospitals ats general hospiitalIs, foIr

wve wvouldl then be resliolisible fo)r Wiho Iinltrtaility and morbidity figures of which we

wm4Iill lbe ashamed(.

This brings upl a greait principlle. that hiospiltals should not be assig-ned to professional

tatsksi beyond their comipetence, anit that, when hospitals are assigned liy Operations

D ivision, that assignment should be coord~~inted with ti1e Professioinal %Services Division

lin order that reasoniably safe c-are he given to the Amierican soldier.

AS to the eight niew greneral hospitals, Colonel Cutler universally recommlnendedl

that. thley be uitilized to augment the b~ed1 capacity of an alreaidy existing and

c,()iull)etenit. greneral hospital, thus nmakinig Ils~e of thle supierior officers inl these

older hosp)itals in sup)ervising the work of the less able personnel of the new.

Thle Chief C7onsultanit in Surgery recommnendiedthalit, if they Could not be

employed inl this 111iner, these newv general hospitals be used as lloldiing

hospitals or conivalesceiit lioslitals-.-iiissimns within limits of their pro)fessionlal

comiijeteiice-to rep~lace the IIIore conlleteil hioslpitals whichi, inl spite of the

protests of tile consultanits, were still lbehlig wastedi in performing these

missions whien their abilities were sorely neededI elsewhiere.

( oloniel (lImt ler spenlt tilie ecut i e day of Tulesdany, 7 Novenmber, as well as

the previous afternooil, with each of the tlel(I armyv surgeomis ail(I miembers of

tl~e Supply I i visionl, Office of tilie Chief Surlgeomi, ill forn'ulat imig recoininelithat ionls for chuanges to the t ailes of organmizat ioii 2111 eqluipineiet of field lioslpit a s widi( 400t -lud evaicuiat ion liospitatls.
CHIEF CONSULTANT IN SURGERY 2711

Observations at the 62d General Hospital.-Colonel Cutler paid a routine visit to the 62d General hospital the next day, Wednesday. He made

the following two extremely significant observations:

At this hospital the first patient with a Blakeinore tube had been admitted sonfiC days

before. Apparently the femora) artery was severed, patient was seen first at the Sth Field

lhosliital. operated npon by Major tCharles A.] Rose of the 91st Evacuation Hospital and

a Blakemore tube was put in the upper femoral region where some 2 inches of femoral

artery had been removed. The patient arrived at the 62nd General Hospital in A 1 condition

with perfect circulation in his feet, though no palp)able pulse. This is the first instance of

the proper and satisfactory use of this tube in the U.S. Forces.

A good many men are being admitted with "cold feet." All have about the same

experience, that they have been in foxholes full of water for about 4 days. their feet feel

sore, they take off their shoes and their feet swell so rapidly they cannot get the shoes on

again. This is the condition I studied with the Fifth Army in Italy a year ago. At that

time it was recommended that the American soldier be given socks with more wool in them,

anti that our soldiers should be encouraged to use larger shoes. This is going to be a heavy

problem this winter unless very active steps are taken to prevent the disaster. In crder to

facilitate the studying of these soldiers with cold feet we must have thermocouples for

registration of skin temperature. These have been ordered from Supply, and also it would

be wiser if we set up a center at one of our general hospitals to concentrate on the problem.

This is now being integrated in the Professional Services IDivision.

Newly arrived general hospitals in United Kingdom.-On Sundav,

12 November, Colonel Cutler flew again to the United Kingdom where, the

next, day, he held a conference with Colonel Morton, Colonel Tovell, Colonel

Bricker, Colonel Cleveland, Colonel Kneeland, and Colonel Stout. He discu.ssed with them the newly arri ved general hospitals and the p)rocedures which

would l)e necessary to bring thenm up) to usable standards. It was decided that

Colonel Cleveland and Colonel Tovell would begin the very next day to "vet"

each of thein to determine first. the numerical deficiency of these hospitals in

professional personnel and to note the specific inadequacies from the l)rofessional point of view -so that detailed recommendations could be made to Colonel

Spruit as to: (1) the total number of medical officers necessary to bring the

units up to strength and (2) the specific professional requirements to meet these

deficiencies. They agreed also that all the operating general hospitals in the

United Kingdom would have to be evaluated according to the new tables of

organization and equipment so that the number and type of excess officers in

thee hospitals could be presented at the same time to Colonel Spruit with the

requirements for the newly arrived units.

Sometime later, after all these new hospitals ha(d been "vetted,- there was

the surprising revelation that their l)rofessional lpersonnel were of a, considerably higher caliber than had been experienced in newly arriving hospitals for a

long time. Most of them were adequately covered in medicine and surgery,

with only occasional shortages in pathologists, lenUropsych iatrists, and X-ray

personnel. None of these hospitals, just as it was true of those which had been

"vetted" earlier on the. Continent, had otolaryngologists.

Expedition of priority cases.-At the meeting of the Chief Surgeon's

Consultants" Committee on 27 October (pp. 273-275), the need for specialized
280A I' IIt SIl S1* l1 itAL ('I NSV LTANTS

treat ineilt facilitijes to care for severel v daiiialgetl ezisualt jes hadl Ieeln discussed.

( ziastutIt s ill t is cat t'Orv iiiclliiied liviu rostinrg .itf Il iaxi Ilofazcin I. th l-aircc sulrgica 1, uirologica 1 (wivith iet ni ologica I cou p ica t olos). awld sevri''e con poulled

fraotuire cast's. Exantitiat ionl of .1 great nunt11her of serioulsly itij tred fract ure

cas1es durinilg tite, time Coloitel O'tlder wvas inl the U iiited Kimgdom, fr'om 2S

Oct ober to 2 Noveinher, hadi revealed thlat it was takiing 10 days for I Iteni to

reach thet Iii ited( Ki ldigll. IIThese wre' t he type o f casliazi i is Nvi o Nere silpjposedly beiig givenl tilie highest prilority ill t'vaeztciioi n to Ilie I'iiited K iligdon'l.

slillce Skeleta :t tdilonl .I for t(lie reduict loll of fratcttilres had to bIle iii it izted eatrl v.

"wits obviouls, therefore, that thle serioulsiv dlamaiged caslialty wats nlot reachinig

Ilie 1Ititelltýilr iilgon sooli pliotI~rii for t lie: illnt iatI joul (f repain ralI e proced tres.

"Wile niulst, nlot equliviocaite abtloit thi s'- ('olotiel Cut her had Waunted inl a1 unleuorandun(im. dated ( Novemther. to ( olonlel K inihiroligh. E it her Ive evaculate

en irIi * * * or we' give til) thazit 1101)1 * * .

Asa.restilt or these wariliuigs, a nieethiin. was held onl I17 November 1944

attIenlded liv ('oh mel Kil ii rolui.Ii, ( oh mlel Mlowr-eY (Chiiie f. Elvactia tionl I ra uicl,

( perat ions I i vision), (Col. Robert El. 'eYt on (Ch idef, ( perat~ions D iv ision)

( olonlel Oldit er. anld C ol. William 8. Mliddleton. AFC. The nIleet ilg wvas caliedll

astleChief Conlsultanlt ill Suirl-zery repiortedi later, to arrive at a (lec 15101 onl

Iwo qulest ioiis: "Should we st ill hope)1 for early rapid evactiat ioul to tilie I illit ed

K ingdoloi wvhicli Wollil periiitit. s to 4r t patie'nt s to4 otur cenltetis for special ized

caire lin the iiited Khiiidomi * ** itlihi 5' days, or should Nve nlot st r'i.gle

againlst tili t- wehit'r t iil(I stet. til solitle ceuiters to cover jienifllds oif badt weat her

oil I lit Conitinlenit ?~

It Avas agreetl t hat vt'nter.- for tilie care' of cnuii ioverebra 1. thloracic, a111(

iiittxillofatt'ial in julries shtouldl bit stt lip) oil tile ('out ineit at ea:ch oif tile large

conceit'n atimis of act ivuitie's ill tile ('olliitiiicat imis Zoilt thlat is. Paris, Li6ge,

aiitl Naitcv. The Pa:ris hospitals, of courlse, were alr-eadyl staftied to take care

of l):ttienits ill thetse categories. Th e co inferees agiree'd. too, that airli ift shioutld

conit inut to b lt st't whlentvt'r it wa.s possib~le to t'vaetiat e thlese casualt ies to thle

U'nitted Kinlgdonil withinl 5 days followinig iiijitry. They thloughit thlit crite'ria

would hiav e to be established ia to what t.%pe (if eastes should lit selected't for

adimissioni to these conit in'iit al ceiitt'rs for special ize'd t rtat icuilt . ILess st'riolusly

wouiii~led pat eit'uts couild lit caired1 for ill ot her avai lablet hospitazls. Colonel

( 'ut ler also t holnglit tha~t sti(-ll a1 directive shiouldi spiecify how lonig pat it'nts

COtild remiain inl thlese facilities for spiecializedl treattmient, amid it was his

imupressioni that 14 days should lie the limit.

Southern Lines of Communication becomes P~art of ETOUSI4

( perat ional colit rol of tile' Seveult i I .. Aruiiy. mt(vancinig t hrotigl southe'rn

lFraitre for at 1ijk with ET()USA forces totilte Iiortli, liatd passtet to tile'

Eutitopt'ai t heater lit Septemiiber ( fig. 1 06) . As of 20 Novembiler 1944, tilie

101 Memnorandumli. ('let C onsuimiInt in Siurgery-. to Ch~ieft. P ri ,e's-ti na I 5rvie i I'M l 41iyil, i.21 Nov.

I1944. ,iubJni't : :Metigi i ri- t'ziri of Paien t sui on Cointi Inent.
Arinly I tospitai Shlip S/,vntroeI. Iliirinlg tile as".1uit .III beza'ilc of soutn,''l 1'l Fac.ii 17

Augus~t lt914.

Supp)ort arPeas III si lilt 1 iir Firialce for Oil s IoP'e 'were to b e'omt e ai part (of thle

(Coil Iii111111 icat foils Zone, IIT( ) A . Them overall cotlilinutill cat ioins zoite commiuanid

for' this ai'ea was called S( )L( ) ( Souitherni Lines of, C'oiiiln IIIicaI ioll), ami its

reI. .i waC ol. (Cha rles F. Shook. MC O i&r. D1 7 ). C olontel Shook, wi-it tIi is

11e1)ityv for admitniistratloln anidi jersoliliel. Lt. C ol. *Iaiiies TI. l1"ichtars. 1)iCi,

a rri vedI for cout rlet ices NA Ith mii enmbers of thIe O ffice of thle ChIiief1 Sln r--eou

E.TOV S A, ol 1 -5 Noveiibier 194-1 to( el'ei't Ii sit oot ii vjl11 it-oxpfe ofe'0 4'otIttII~llt~

tttsoflar as tleiieul'i act viti~ NTe5 wieCoiti'eriteii. C olonel Oldt er, who wvas III

Ittllflaitldi at tile I itite arfiittig - Iie Weti& of t lie 11 nw~ I~~e

gret eral 1hosp1 italIs, also returit te to thle ontit letit oil 1.') Novembe r, aindI spent

most of If; Nov'eiiibei. jst ttiw'i1: MfIt till co oi Irel(ieps "'tiitlie Sol()()( ' sit rgeoit.

lIn I Inittetorattdi tut to thle I epitt C hie f Silrgeon., dat ed i7 Novembher194

C oloinel ( itt ler stated t hat t lie flolowinig itemls wer'e of' pert iltetice to) thte Pr'ofessioita 1 Serines Divisio of501 1 lie ( )hc of tflie ( 'Iii i Sit i'geon

1. Techic ~~al1 cor-respouldeiice with itItI its ill S( L( ) was tote rouited IthIrough

tihe SuIrge,2oit, S( L(C.

T.hle Same evacitat toil po icY was to app lY to S( L( ( as to t he reuma intder

of ine('otiteti itine~',81)has itt SOIA ( hospitals, patmitnts 1lý'qitiriitg
"29829 ACTIVITIES OF SURGICAL CONSULTANTS

more than 30 but not over 120 days to be evacuated to the United Kingdom.

(The 120-day evacuation policy for the entire European theater had just been

proclaimed i n mid-October 1944.)

3. SOLOC had 14,000 beds, 5,000 of which were in Marseilles. With expansion, SOLOC bed capacity could be raised to 22,000 beds.

4. The Surgeon, SOLOC, stated that his hospitals expected to hold

seriously injured casual t ies-neurosurgical, thoracic, and maxillofacial--until

they could be evacuated to the Zone of Interior, but Colonel Cutler expressed

his views in the matter as follows: "I am sure this will need elaboration by a

l)ersonal visit of the Consultant Group to SOLOC."

FIGURE 107.-Col. Charles F. Shook, M.C.

As for consultants, Colonel Shook assured Colonel Kimbrough and

Colonel Cutler that lie would like the advice of the consultants in European

theater headquarters in setting up SOLOC consultants in medicine and surgery

and any of the other specialties, as required, and also regional consultants

according to the ultimate disposition of hospitals in SOLOC. Colonel Shook

suggested that the qualifications of Col. Ira A. Ferguson, MC, be looked into

for the position of surgical consultant to SOLOC. Colonel Ferguson was

now at the 43d General Hospital as assistant chief of the surgical service,

and Col. Edward I). Churchill, MC, had assured Colonel Cutler that he was

qualified to be chief of surgery in a general hospital. Colonel Cutler did not

want to commit himself on this item at the time, and Colonel Shook agreed

to delay his appointment until Colonel Cutler could visit SOLOC. Finally, Colonel Shook stated that lie would prefer not have any visit by European

theater consultants until at, least I)ecember, as they were just getting settled

and could carry on until then with their existing service.
CHIEF CONSULTANT IN SU'RGEiY 283

Cold injury studies

As cold injury continued to be a growing problem during November and

it, was apparent that, knowledge of the conditions being observed was too scant

even to estimate the degree of damage or possibilities of repair, the consultants

agreed that a concerted effort to study the condition was needed. The Chief

Surgeon agreed, and the 108th General Hospital was selected for the mission.

Capt. (later Maj.) Octa C. Leigh, Jr., MC, who had considerable experience in

the field, was reassigne"d from the 16th Station Ilospital to the 190th General

HIospital and then placed on temportry duty at the 108th General Hospital to

take charge of the studies. About this time, Maj. Leiv Kreyberg, Royal Norwegian Medical Corps, joined Captain Leigh in this project. Colonel Cutler

took it upon himself to arrange for the procurement of skin temperature thermocouples, Quinizarin, through Burroughs, Wellcome & Co., capillarry microscope, Novocain (procaine hydrochloride) in oily solution for sympathetic

blocks, and Diodrast (iodopyracet) to demonstrate vascular adequacy. Colonel

Tovell promised to find a skilled anesthesiologist to perform the sympathetic

b)locks for the study group, and all the consultants were asked to coitribute

their ideas and knowledge toward solution of the l)rol)lems which cold injury

was present ing.10 2

Activities and Situation at Year's End

Second Inter-Allied Consultants' Conference

Colonel Cutler had met with Brigadier (later Maj. Gen.) E. Phillips,

RAMC, and General Hawley on 6 November 1944 in the Chief Surgeon's

Office to discuss the next meeting of British and American consultants. Brigadier Phillips represenited the British 21 Army Group and was soon to become

its D)MS. It was decided that the next meeting would be held in Brussels at

Rear IIeadquarters. British 21 Army Group. Because the number of guests

would have to be limited, the Americans advised Brigadier Phillips that the

essential people would be the consultants in medicine and surgery from each

of the four U.S. field armies and those of Britain and Canada, the consultant

group in the Office of the Chief Surgeon, ETOUSA, and representatives from

the consultant group of the DGMS, British Army.

Plans for the meeting proceeded without compllications, and Saturday, 9

I)ecember, found Colonel Cutler on the ro.-d to Brussels with Colonel Tovell,

who was also scheduled to speak. They arrived in Brussels at 1830 hours.

The meeting of consultants was held at the British 8th General Hospital

beginning on Sunday mimorning, 10 Decenmber. Major General Phillips opened

the conference saying that lie hoped the meetings would continue and that the

I"* Minutes, Twenty-Fifth Meeting, Chief Siirgeon's Consuitnlts' Committee, Paris, 24 Nov. 1944.

705-0951--64--21
28-4 ACTIVITIES OF SURGICAL CONSULTANTS

pooling of ideas by the Allies was essential to success. Colonel Cutler's official

diary account of the first day's meetings follows:

The first professional topic was chest wounds, opened by Major Collis, RAMC. HIe

mentioned infection as a major item, a surprise to us, since at one of the chest centers in

the United Kingdom Major Ilarken has written that no cases of serious empyema have

occurred. Major Collis thought penicillin of little value except when instilled in the

pleural space. The next topic was "Penicillin," opened by Colonel Mitchell, RAMC. The

British use the intramuscular drip method, 100,0M) units in 24 hours in 540 cc. of salt

solution. They believe this maintains a satisfactory bacteriostatic level. He asked for a

solution of a more satisfactory vehicle than sulfonainides, and he presented, as evidence

of the great value of penicillin in abdominal wounds, the following statistics:-

2,712 abdominal operations

2,307 with intraperitoneal damage

405 with extraperitoneal damage

759 deaths (27 percent)

There was a lively discussion of this matter. Since the U.S. Army showed

similar or better statistics, and (lid not put penicillin in the abdomen, Colonel

Mitchell's suggestion that intraperitoneal penicillin was of value failed to find

general al)l)roval.

Colonel Cutler continued:

In the afternoon the medical and surgical sections met separately. The first afternoon

topic was abdominal wounds, opened by Colonel Cutler. Colonel Cutler presented statistics

showing the frequency of abdominal wounds in the A.E.F. 1917-18 was 1.1 percent and

the fatality 66.8 percent. The figures for the First Army June 6-30, 1944, showed an

incidence of 4.3 and a mortality of 21.2 percent. The 5th U.S. Army, 9 September to 12

November 1944, showed an incidence of 4 percent and a mortality of 22 percent. Finally,

individual hospital reports were presented. 128th Evacuation Hospital, a mortality of

19.3 percent overall, but 10.7 percent postoperative mortality. 91st Evacuation Hospital,

October report, shows 20 percent mortality, overall, and 12 percent postoperative mortality.

Meanwhile, the Canadian I Corps Surgeon reported a mortality of 35 percent in August

and September 1944, and the French figures for the Italian Campaign showed a mortality

of 44.6 percent.

Obviously, more people with wounds of the abdomen are now reaching the surgeon,

and of those who reach the surgeon in the U.S. Army an overall mortality is somewhere

around 25 percent and the postoperative mortality somewhere around 12 to 15 percent.

This improvement is perhaps more largely due to the fact that the surgeon of the day

devotes more care to the general condition of his patient preliminary to the surgical

ordeal. Colonel Cutler reviewed the care of the abdominal case from the time he is

picked up in the field to his disposition in a general hospital. The low incidence of

infection, possibly due to chemotherapy, was mentioned. The better treatment of shock

was taken up in detail. The immobilization of abdomens after surgery was considered

highly Important, and decompression by Indwelling catheters thought a great step forward.

The separate treatment of small bowel and large bowel Injuries was mentioned, and

the group was urged to see that all left large bowel colostomtes were made complete

so that the faecal stream was entirely turned away front the buttocks. In the discussion,

Brigadier Porritt wondered whether all abdomens should not be subjected to surgery. In

rebuttal, It was stated that there was no point in operating upon hopeless cases, particularly when the surgeon's time might be better devoted to more Important though less

seriously damaged soldiers.

The final paper was presented In the surgical section by Colonel Tovell, on Anesthetics

in the Field, and for this Colonel Tovell had prepared a mimeographed sheet revealing
CHIEF CONSUL'ITANT IN SURGERY 285

the percentage of different types of anesthesia according to the hospital in which they

were used. Thus, intravenous anesthesia is the predominant anesthetic iii U.S. Army

hospitals, reaching as high as 39.5 percent, whereas local anesthesia reaches 30.9 percent

and inhalation anesthesia only 7.06 percent. However, when we consider the field for

work we find the field hospitals doing chests and abdomens and using inhalation anesthesia

for 41.4 percent of their cases.

During the second day, 11 December, the surgical and medical consultants

again met separately. Again, there were morning and afternoon sessions,

but Colonel Cutler attended only the morning session where the principal

speaker was the surgical consultant for the Third U.S. Army. Colonel Cutler

gave the following brief description of this meeting:

In the morning the surgical group considered "Vascular Injuries," which was opened

by Colonel Odom, Third U.S. Army. HIe presented the overall figures for the Third Army

and revealed that the number of cases in which arterial repair may be attempted is

extremely small, sixteen out of 362 cases. Ile pointed out that 0.7 percent of 49,410 battle

casualties had vascular (]amage to large vessels. 346 of these had simultaneous ligation of

artery and vein and 50.7 percent of these came to amputation. The various vessels in

which ligation had been carried out were specified, and again the grave danger of ligating

the popliteal vessels was brought forward. The question arose as to whether the forward

surgeon was not too conservative by not amputating limbs whose circulation was totally

destroyed. It was pointed out that the figures for safe ligation in elective surgery might

be entirely different in the arm where all the collaterals were blown out. No one said a

good word for sympathetic block. The Canadians suggested that little glass tubes or a

tube of plastic material might be utilized to recanalize injured vessels. All agreed that

where a major vessel is ligated the patient must be held in the forward area for 4 to 6

days to see whether gangrene was to set in.10

After lunch, the delegates visited the British blood bank in Brussels

where blood obtained from troops in and around Brussels was being processed

for shipment forward. Colonel Cutler did not attend but spent the afternoon discussing the local situation with Professor Danis, professor of surgery

at the university, and with Dr. Mayer, president of the Societ6 Internationale

de Chirurgie. There was particular concern about the future of the organization of which Dr. Mayer was president.

Trenchfoot was not an item on the agenda, for the British were having

no great problem with ground-type cold injury, but there was considerable

informal discussion concerning the matter. Colonel Cutler made tle following entry in his diary concerning the discussion:

The total British figures were as follows:-21 British and 9 American soldiers have

been treated in all of the British hospitals from the Invasion to December 1. General

Phillips, commenting on this, spoke a) of the better footgear, noting that no constriction

can occur because the two sides of the boot meet, so that the laces cannot make the

shoe tight, and b) of better foot discipline as a command function. Brigadier Fenvwick,

who that night became Major General Fenwick and D.G.M.S. of the Canadian Forces. made

the same comment.

103 For a complete report on vascular injuries and vascular surgery in tfl Third U.S. Army. see the report entitled "Vascular Injuries in Battle Casualties" by Col. C. B. Odom. lit Inter-Allied

Conferences on War Medicine, 1942-1945, Convened by the Royal Society of Medicine (Sir Henry

Tidy, Editor). New York, Toronto, London : Staples I ress, Ltd., 1947, pp. 167-171.
286 ACTIVITIES OF SURGICAL C;ONSUL'ITANTS

The Second Inter-Allied Consultants' Conference caine to a close after

the second day's meetings with a dinner given byr General P~hillips which was

characteristic of the traditional British hospitality and spirit of camaraderie.

Colonel Cutler wrote in his journal:

That night the D.M.S. gave a bounteous dinner for the Consultant Group. I had

to sit between the DMS and Maj. Gen. Sir Miles Graham, Chief of Admin, 21 Army

Group, and respond to General Phillips' kind words regarding the American Forces

for General Hawley. I thanked General Phillips as best I could, intimating how much

better General Hawley would have done it, and presented his deep regrets at being

unable to attend. I then attempted to point out that this was the one time in the history

of civilization when the English-speaking people should get together, since they are the

only nations now functioning under free government.

Visit to Ninth U.S. Army

The next morning, Tuesday, 12 December 1944, Colonel Cutler and Colonel

Tovell were joined by Lt. Col. (later Col.) Gordon K. Smith, MC, surgical

consultant for the Ninth U.S. Army, in the drive to Ninth Army headquarters

in Maestricht, The Netherlands. En route, they stopped at the 30th General

Hospital in Antwerp, for lunch and a look at the installation. It was in nice

buildings, but the utilities were deplorable and sewage was even running out

onto the lawns. Colonel Cutler, Colonel Tovell, and Colonel Smith reached

Ninth U.S. Army headquarters that evening. Col. William E. Shambora,

MC, the surgeon, was away so they spent the evening discussing various

professional matters-particularly necessary personnel shifts-with Lt. Col.

Elmer D. Gay, MC, commanding officer of the 5th Auxiliary Surgical Group,

and the other Ninth U.S. Army consultants. During the evening, buzz-bombs

kept going over the headquarters, and Colonel Cutler surmised: " * * Apparently they start on the German side of the line and on their way to Antwerp pass over Maestricht. They could not have been very high because

the windows rattled every time they went over."

Colonel Cutler visited the Medical Section, Headquarters, Ninth U.S.

Army, the next morning where he met some of the staff and learned that some

300 casualties had been admitted in the last 24 hours to Ninth U.S. Army

hospitals. The remainder of the day was spent in visiting evacuation hospitals and one field hospital of the Ninth Army.

At the 108th Evacuation Hospital, Herzogenrath, Germany, Colonel Cutler learned that blood transfusion reactions were occurring about once in

every ten transfusions. He recorded: "Initial chill, pressure fall, pulse

becomes rapid, patient enters deeper shock, fever later. No haemolysis and

no evidence of protein shock reactions. These are unquestionably pyrogenic

reactions and probably due to improperly cleaned tubing. Plasma is giving

the same type of reaction, again a pyrogenic reaction * * *." Tobruk splint

experiments were being carried on at this hospital. The application of the

splints seemed well done, and Colonel Cutler believed that Colonel Cleveland

might be able to give an answer as to the efficacy of the Tobruk splint in another week or so.
CHIEF CONSI'L£ANT IN SURGERY 287

At the 111th Evacuation Hospital, Heerlen, The Netherlands, the Chief

Consultant in Surgery was pleased to meet again Maj. William R. Sandusky,

MC, who was chief of the surgical service, doing the thoracic surgery there

with the help of a, Captain Johnson, and conducting an intinmate study of

gas gangrene. Major Sandusky, the reader will recall, had conducted the

excellent studies on l)enicillin and gas gangrene in air casualties while he was

attached as a captain to the 49th Station Hospital in East Anglia. "The

hospital," Colonel Cutler noted, "has an A.1 professional service. Well organized, perfectly integrated and entirely competent."

The 91st Evacuation Hospital in Valkenburg, The Netherlands, Colonel

Cutler found, was located in a beautiful Jesuit college which could well do for

a general hospital some day. The chief of surgical service was Lt. Col. Charles

S. Welch, MC. Colonel Cutler recorded: "This was the best hospital we visited.

There is an excellent spirit of cooperation between the professional services,

administration, and the chief of the surgical service; Colonel Welch is one of

our best forward surgeons. This is the officer who is to speak at the next meeting

of the Inter-Allied Medical Conference on thoracic surgery in the forward areas.

I briefed him for his talk, told him and his commanding officer I would clear

his orders * * * for January 4 for 8 or 10 days." In a discussion of blood and

plasma reactions, the hospital personnel stated that plasma reactions occurred

with chills followed by anuria on occasions. In further discussion of anuria,

Colonel Welch agreed that crush syndrome might play a large role.

Colonel Cutler and Colonel Smith also visited the 105th Evacuation

Hospital and a platoon of the 48th Field Hospital during the day. Back at

their quarters, Colonel Cutler and Colonel Smith conferred on matters to be

discussed with Colonel Shambora the next day. And again, Colonel Cutler

uneasily noted: "Four buzz-bombs just missed the top of the house. Apparently these missiles start not very far away from Maestricht and scare

people on the way up, whereas in Antwerp they scare them on the way down

(fig. 108) !"

At 0800 the next morning, Colonel Cutler and Colonel Tovell joined in

conference with Colonel Shambora, the Ninth U.S. Army surgeon, and his

surgical consultant. Colonel Cutler asked and obtained permission to have

Colonel Smith accompany him on a visit to the neighboring First U.S. Army

so that Colonel Smith could participate in additional conferences on professional matters with the surgical consultant of the First Army. The many proposed personnel changes were also explained and discussed. Colonel Cutler

emp)hasized that such changes had to be initiated as requests from the field

Armies. There was discussion on the desirability for evacuation and field

hospitals furnishing monthly hospital reports so that they could be consolidated at the field army level and distributed to the army units as a part of the

educational program. Colonel Cutler advised the army surgeon on his impressions of the hospitals visited. They spoke of the unusual position occupied by

Lt. Col. John Gilbert Manning, MC, the Ninth U.S. Army orthoped Iic con-
• 441 ' * - 11 i 4 4: i ' 14 1: 1 41 "I 'I\ii ~IIII+ : i l I -1 l 4 t 41414 I '.l.. 41114 + I.'I( 41 4'.\ I'

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CHIEF CONSULTANT IN SURGERY 289

Alleur, Belgium

En route to the First U.S. Army headquarters, Colonel Cutler and his party

stopped by in Alleur, Belgium-several miles out of Liege-for visits to the

298th General Hospital and the 93d Medical Gas Treatment Battalion.

298th General Hospii•l.-Colonel Cutler was overjoyed at seeing many

old friends from the dlays in England still with the 298th General Hospital, the

affiliated unit from the University of Michigan and one of the first general

hospitals to be sent, to the European theater. Col. Walter G. Maddock, MC,

the cminmanding officer, was on hand to greet the visitors and provide them

linehi. The hospital was under tentage and Colonel Cutler noted: "* * * a

general feeling in this unit that a good unit like this should be in permanent

construction. I heartily agreed with this, and the same comment about too

frequent moving of hospitals as (came up in this hospital also came up at the

30th General Hospital in Antwerp and later at the 25th General Hospital in

In other discussions, it was brought out that 420 beds of this 1,000-bed

hospital were set aside in a separate unit to be used as a holding hospital for

air evacuation. The prevailing differences in opinion concerning the Tobruk

splint were again evident here. Colonel Maddock thought it was more comfortable and easier to transport, but the orthopedic surgeon at the hospital felt

the Tobruk splint was uncomfortable and that the half ring often rested on the

perineum, causing difficulty. It was also said that gas gangrene had been very

rare and that, delayed primary suture was being accomplished on cases which,

for some reason, had to be held for more than 5 days.

93d Medical Gas Treatment Battalion.-Colonel Cutler found the 93d

Medical Gas Treatment Battalion a unique organization. It was located at a

zinc mine about 2 miles from the 298th General Hospital. Detachment B of the

12th Field Hospital was attached to it. lie described what he saw, thus:

Colonel Palmer, who was so efficient at the Southampton Hard, is commanding officer.

Ile has 600 beds, 300 strptcher cases and 300 walking wounded. The patients come to him

from the Liege general hospitals, and may be held for as long as 4 to 6 day:, according to

the air lift. The patients are all flown baek to the United Kingdom. If any patient seems

too ill and requires specific therapy, he is returned to the general hospital from which he

came. In 3 weeks this hospital had returned 7.680 patients to the United Kingdom.

Colonel Palmer made the comment that general hospitals are slow in sending patients to

the holding hospitals. It was my impression that this holding group had done a bang-up

job * * *

First U.S. Army

Discussions with members of 3d Auxiliary Surgical Group.-Leaving

Alleur, the party motored to Spa, Belgium, and the headquarters of the First

U.S. Army. General Rogers, the army surgeon, was away for the day, but,

while the visitors were speaking with members of the medical section, Colonel

Crisler arrived. Colonel Crisler billeted the visitors with his 3d Auxiliary
290 A('T1VIT'IIS ()F. SUIC'AL CONSI'LTANTS

Group and then took them to the group's niess. After dinner, Colonel Cutler

led a discussion oni various professional matters-informally and openly, as was

his fashion.

One of the subjects discussed was trenchfoot. Statistically, the First U.S.

Army had no cases as of 27 September; by 8 October, there had been 140 cases;

and on 12 O(ctober, 320 eases had 4ctcurred. By that time, it. had seemed wise

to organize to meet this prob)lem, and the W1st (Cis Treatment Battalion had

been set ul) as a center for the study of t renchfoot. Apparently, an ordinary

triage was being accomlplishle-! in evacuation hospitals, and 7-5 percent of the

patients were being evacuated out of the army area. The other 25 percent

were sent to the gas treatment battalion, where, the discussion revealed:

Treatment was rest, repeated sympathetic blocks and later exercises. A suninary

of time sympathetic block work showedl that the feet were more comfortable, but, using

the other foot as a control, synmpathectomy proved to give no additional benefit. Pressure

bandages were tried with no benefit. Finally, exercises were tried, and these seemed to

bring so.me benefit. After 10 days in this specialized hospital. troops were sent to the

convalescent hospital, but only those with no evidence of disease. There they were

refitted with larger shoes, given exercises, and by 20 days 0 plercent were returned to

duty. In anlyzing one thousand cases, the following occurs :-At the divisional level, 20

percent. i.e. 200) cases, returned to duty as having had a mistaken diagnosis. i.e.. just cold

feet. Of the S00 left, 75 percent go to a general hospital and 25 percent to the Gas Treatment Battalion for slpecialized care and treatnmert Of ., ,, who go there, 25 percent are

returned to general hospitals and 75 percent v e 4th1 C'onvalescent Hospital to (Juty.

This makes a total of about 30 lPercent of the ori, 1y diagnosed trenchfoot cases to duty.

I brought up the matter, for insertion in their tienchfoot circular, that tetanus toxoid

should be given when the skin is broken, as also penicillin or sulfonamide for infection.

There then followed a, long discussion of the benefits which hand accrued

in sending medical officers from combat units to hospitals in the base sections,

either on the 60-da" temporary duty exchange program or on the short-visit

policy. Colonel ('risler pointed out that the greatest advantage had to do with

records. for the men in the forward areas had found out] how poor the records

were which came down to tle base areas and that it was not possible for

surgeons in communications zone hospitals to do intelligent work without adequate records. It was also asserted that these tours of duty in the communications zone revealed to the medical officers, who were characteristically initiating

rel)arative treatment of the battle casualty, the dangers involved when lie failed

to split, his cast or when he plugged wounds too tightly.

All were in agreement that new circular letters should be written stressing

the fact that abdominal retention sutures should not be removed until after

evacuation, explaining the difference in right and left colostomies, and detailing

the latest information on the surgery of major blood vessels. There was the

inevitable discussion on shortages of certain p)ersolnel and requirements for

changes in specialized personnel. Very satisfying to Colonel Cutler were remarks made by both Colonel Crisler and Colonel Smith that one of the greatest

b)oons to surgeons in medical facilities of the field army were the anesthesiologists supplied by Colonel Tovell. In his official journal of the visit, Colonel
CHIEF CONSULTANT IN SURGERY 291

Cutler remarked: "This may be taken as almost a personal triumph for Colonel

Tovell, who has worked indefatigably in his special field and now is reaping a

rich and well deserved harvest."

Hospital visits.-The next morning, 15 December, the Chief Consultant

in Surgery was up early and visiting hospitals of the First U.S. Army. At the

2d Evacuation Hospital, he was happy to see again old acquaintances from the

early days in England and had a long visit with Colonel MacFee. Colonel

Cutler and Colonel MacFee were in complete agreement on the following

points:

1. Vascular surgery.-Plastic tubes, over which suture could be done, might

be better than the Blakemore tubes presently in use. If a vessel is ligated, it

must be divided. All hospitals should make a definite assignment as to who

should do the vascular surgery.

2. Abdominal surgery.-For left side p)rocedures involving the large bowel,

comp)lete diversion of the fecal stream is desired; for the right side, an exteriorized opening is preferable. If the small intestine is damaged, it should be

closed and not left as a separate opening. For combined head and abdomen

casualties, the abdomen should be done first and the head later, by the 5th day,

and preferably under local anesthesia.

3. D)elayed suture should be practiced in evacuation hospitals if the patient

must remain for an appreciable l)eriod of time before being further evacuated.

Colonel Cutler also asked Colonel MacFee if he would like an appointment as surgical consultant for the Fifteenth U.S. Army, a new field army, the

headquarters of which had recently arrived in England. Colonel MacFee was

favorably inclined toward such an assignment.

Elsewhere during the day, Colonel Cutler visited the 45th, 128th, and 96th

Evacuation Hospitals and the 13th Field Hospital. On the whole, he found

excellent work being done in these facilities and thoroughly competent surgical

services. He found that a team from the 3d Auxiliary Surgical Group attached to a field hospital platoon consisted of one surgeon, two assistant surgeons

(one for shock work), one anesthetist, and four corpsmen. The nurses, he

found, were attached separately-four at a time-to a field hospital platoon

from the group. This permitted two for night duty in the operating room and

two for (lay duty. It had proved better than having nurses assigned directly

to teams. There were reports that plasma reactions had been mild, and blood

transfusion reactions were mostly of the pyrogenic type. It was the consensus

in these hospitals that the European theater blood from England had given

chills; the European theater Paris blood was full of clots; and the Zone of Interior blood was better, in that fewer reactions occurred, but contained too few

red cells in relation to fluid for casualties in severe shock.

Meeting with First U.S. Army surgeon and departure.-On Saturday,

16 December, Colonel Cutler visited at length with General Rogers, the First

U.S. Army surgeon, after earlier conferences with the chief of personnel in the

Medical Section, Headquarters, First U.S. Army. General Rogers approved

Colonel MacFe's transfer to the Fifteenth U.S. Army, if this were desired,

705 -0951 64 22
292 AC'i1 VITIES OIF SI'li(ICA1i CONSULTANTS

and he favorably considered all of the personnel changes which had been conditionally agreed upon and coordinated with General Rogers' )ersonnel officer.

Finally, Colonel Cutler wrote: "I told General Rogers that. such visits, particularly when two ariy consulting surgeons could be together with le, were

of tile miost valuable and instructive type, and thanked hint for the courtesies

extended." Just as Colonel Cutler was concluding his meeting with General

Rogers. reports arrived thlt. MAal nidy atid E upen in Belgium were being hard

hit by what was supposedly a new weapon, and the decision was made to pull

the 44th and 67th Evacuation Hospitals out of Malhndy.

On his return to Paris, Colonel Cutler visited the 25th General Hospital

at Lige and I[eadquarters, Advance Section, Conununications Zone, at Namiur,

Belgium. lie reached Paris at 2300 hours that night.

Comments to Chiej Surgeon on trip to Brussels

and to First and Ninth U.S. Armies

U "pon returning to Paris, Colonel Cutler provided the Chief Surgeon a copy

of his journal descril)ing his recent trip to Brussels and the First and Ninth

UT.S. Armies. The Chief Consultant in Surgery, in a cover menmorandum, dated

19 D)ecembter 1944, forwarding the journal of the tril, called certain imrlportant

aspects of his visits to General Hlawley's attention. One of the items which

pertained to tile Seventh IU.S. Army, follows: * * * * * * *

b. From the Seventh Arimy Consultants. while in Brussels, I found a sincere regret that

members of the Professional Services Division, ETO. had not paid them more visits. I am

afraid that we were scaredl off by at quotation fromt a letter from Colonel Rudolph (Seventh

U.S. Army Surgeon) to Colonel Liston which Colonel Kinmbrough circulated In the Professional Services Division, the following being quoted:--

"Tile commanding general issued instructions a long time ago to the effect that he

expected potential visitors to be 'cleared' before their arrival in his area. On more than one

(X.iasion the chief of staff has personally questioned mne as to the necessity and desirability

of a proposed visit by some member of tile medical section of a higher headquarters, and

often Inferring that the inedical people were the worst offenders. In addition, the commanding general has severely p)runed our headquarters throughout, and when he visits the

section he always wants to know exactly who each one is and what they are doing."

Colonel Berry wanted to know whether we really were ETO consultants, which hurt

a little bit. I had asked Colonel Kimbrough to run down the source of the quotation above,

because no one from this office had visited the Seventh U.S. Army, except Colonel Middleton,

and I am quite sure he gave no offence. This office took deep offence to tihe quotation from

the letter, and therefore had not visited the Seventh Army. I expect to in the near future,

unless Colonel Liston or you object to this.

Concerning Lt. Col. (later Col.) Gordon K. Smith of the Ninth U.S. Army,

tile (hief Consultant in Surgery aodvised the Chief Surgeon * * * * * * *

c. I would like to commend Lt. Col. Gordon Smith, Consultant to the Ninth U.S. Army.

It is my impression that he knows more about the iprsonnel In his field and evacuation

hospitals than any of our army consultants. I told this to Colonel Shambora. and am in

the hope that he will take steps to eventually elevate his rank to that held by the other

army consultants.
CHIEF CONSULTANT IN SURGERY 293

Colonel Cutler reported the following concerning the general hospitals he

visited:

3. Finally, and very important, I sensed iii our general hospitals a deep sense of bitterness about the irrelative uselessness, as they put it. This turned up in the 30th, 298th, and

25th General Hospitals. Most of our good hosl)itals have the feeling that they have excellent

personnel which has not been used. It is hard to counteract this, for they were stabled long

before D-day, then acted as transit hospitals without a chance for real professional work,

and are still acting as transit hospitals. or. as are the 25th, and 30th, stabling again.

Apparently they are to act as transit hospitals again. and (to not, therefore, have the opportunity to use their full professional talent. I have been consistently loyal in support of

the movements dictated by this office. I find it extremely difficult to continuously support

what from time to time seems to me not to be the best use of highly trained professional

talent. Perhaps we can stabilize some of our good units soon and let them do high grade

professional work for the good of the American soldier. I fully appreciate the flux and

flow necessitated by the military situation, but I aia equally sure that our good units could

be put in places where they could carry on high grade professional work, and less good units

could act as transit hospitals, under the present circumstances.

To Colonel Liston, Deputy Chief Surgeon, the Chief Consultant in Surgery

addressed a terse and poignant note on 19 December, as follows:

In view of your interest in obtaining suitable transport for the consultants, you will

be interested to know that the army consultants at Brussels arrived in nice big Packard

Sedans, while the ETO consultants came in jeeps and command cars! 14

New directives

During these first few months on the Continent, the consultants had been

able to observe more directly and frequently a variety of medical treatment

facilities, practices, and conditions. There had been many opportunities to discuss these observations with their fellow American medical officers and the medical officers in the services of the Allies. The initial implementation of new

ideas or changes in thought concerning past practices had been carried out to

considerable extent by personal contact with consultants in the subordinate

c. helons or through corrective action on the scene. But changes in policies

and procedures could only be thoroughly implemented by directive, and many

directives on professional matters were published toward the year's end as a

direct result of earlier experiences during this period on the Continent.

Additions to directive on care of battle casualties.-One of the first

directives to be published was Circular Letter No. 131, Office of the Chief

Surgeon, ETOUSA, dated 8 November 1944, a supplement to Circular Letters

No. 71 and 101, previously discussed, pertaining to the care of battle casualties.

This was sorely needed, especially as it pertained to the care of fractures.

Accordingly, the bulk of the directive concerned the treatment of wounds of

bones and joints which was worked out by Colonel Cleveland working closely

with the other senior consultants, the surgical consultant of the United

104 Not all consultants arrived In Packard sedans. Col. Frank B. Berry. MC. Consultant In Surgery to the Seventh U.S. Army, arrived In an open command car. Consultants to the field armies

routinely traveled In Jeeps and command ears.-J. B. C., Jr.
294 ACTIIVITIES OF. SURGICiAL CONSULTANTS

Kingdom Base, and the Chiief Conisultantt in Surgery. The port ions pertaininig

strictly to orthopedic surger~y htave been rep~roduced elsewhiere in this hiistorv.' 0 5

'Under the section dealinig withi thle treatmnent. of wounds of bonles anld

joints was also a subsection detailing policies and p~roceduires to be observed

in the care of injured1 hands. Earlier reference was mnade to efforts by Colonel

Cutler and his subordiniate consultants to establishi special facilitie" for the

adlequate treitmient, of injuries to thle hand. III this directive, emphiasis Was

placed onl early closure of fractured hands by secondary suitur e or skin graft

and thle inlsistentce of active motion as early as possib~le. "Amlpuitat buls of

han ds or fingers," the directive cautioned, "shiould be per formed only whlere,

there is no pmossibility of restoring some useful function or when circulatory

loss htas resulted in complete nc~rosis of the parti." Thle dlirective empliasized:" an tipper extremity lprost~lesis is not in anly sense to be. consielered

as an adequate sub~stitute for a band.-' As a ineai ýure furthier to implement

thiese lpolicies, a list, of hland centers Nvhlich hadI been establishied inl thle Unitedl

Kiingdoin was prepamred by Colonel Cumt ler, Colonel Mlorton., Colonel Cleveland,

and Colonel Bricker for p)romnulgat ion withtin thle Uniited Kinigdoml Base.

Circular Letter No. 1311 also directed special lileasures to be observed inl

handliing, neurosurgical probllemus, inl tile care of the bladder in 1)atients with

spinlal cord injury. inl thle care, of inijurled nlasal nui1cosa, inl tile anallgremenit

of colostoimnies, and in Whole blood tranisfusions. lit adlditiomm. this vircular

letter contained notes oil radiology, mnid lrecauItioiiarv mneasures withi respect

to thle condition of patients evacuiateol to the Zone of Interiot'. Witit resp~ect

to colostomnies, the circular letter warned agaiiist aI too short, applroximiated

septum inl thle formlation of a double-barreledl Mikulicz colostomy and a, too)

large init ial openinig in thle 1001) typ)e of colostomy. Thme direct ive also encouraged the closing of colostomlies as soonl as thle wound was free from infect ionl :1id tdie local edemla of thle b~owel hIad Subsided anld before t he patielit

was evacuiated to the Zone of Interior. Thle dir-ective called attention to the

fact. thaqt many cases could be returnted to duity ill the thepater.

Whole blood and transfusion.-Coloniel Cutler, at tile October meeting

of the Chiief Surgeon's Consul tantts' Commimnttee, hiad nliemut ioned ti at a1 new

directive would be publishted (defining transfusion react ions and( stating whtat

to do about t hem. This was accomplishied byAlminiiist rati ye Mleuorandutni No.

150, issuedl by the Office of the Chief Surgeonl, un1(ler the dateline of 2-4 Noveimber 1944. The directive accepted thle fact. that, reactions wvere bound to ocr'mar

in the great, number of trantsfusions being carried out. It dlis 1)elled nmajor

concern over allergic or pyrogenic reactions. For the relatively rare case Inl

w~ivhic bromiclospasmis occurred as ant allergic react ion, tile directive vc-Illed for

relief of the symptoms by subcuitanleous injections of an1 Atirenlahin (epimmepimrine) solution or iit ravemmous adminmist rat ion of ani inophlfivl ite. I lemolvt ic

I" Aedical Deiltirtm.'nt. unitedI states Army. Surg.'ry in World War It. OJrthopedlic Siirgety in

the European Thvzit,.r of (Iiierations. Washington . Us. (cov(rninent Pr~intin): Ofiiee. VCi)(C, Append(ix A.
CHIEF CONSULTANT IN SURGERY 295

reactions, the directive recognized, were not conniion but were to be feared

because death could result from hemolvtic shock or uremia following renal

damage. The administrative memorandum directed:

Heinolytic reactions must be treated immediately and vigorously if survival of the

patient is to be expected. Immediately upon the appearance of the symptoms of hemolytic

shock the transfusion must be discontinued. Almost all patients will recover spontaneously

when this is done. However, in patients with deep shock another transfusion of compatible

blood should be started. All patients exhibiting hemnolytic shock must be immediately

alkalinized * * *

The administrative memorandum also called for a report from each fixed

hospital showing the total amount of blood given during any one week and

the number of reactions encountered broken down into six subordinate categories. Fearing that the reporting provisions might be eliminated, Colonel

Cutler, in forwarding the draft for publication, justified the reporting requirement on the basis that transfusion reactions were a prevailing problem and

that good data were necessary if anything sound and constructive were to be

done about the situation.

Equally important to the issuance of a directive is the followup to ensure

compliance with it. With respect to the matter covered in the directive under

discussion, Colonel Cutler, before the end of the year, was able to call attention

to significant progress in following up the problem. At the Twenty-Sixth

Meeting of the Chief Surgeon's Consultants' Committee in Paris on 30 December, he announced: "We have been quite disturbed about reports of reactions

in patients who had received blood. Major Hardin has been up forward,

and has come back with information on that." Major Hardin then explained:

This report [the report called for by Admin. Memo. No. 150] that we have compiled

has been very useful in making up our minds as to what is going on. Out of 3,741 transfusions that were given, 188 reactions of all types occurred. These were 3.7 percent

pyrogenic and .48 percent hemolytic. That is high. It is four times as high as what

we would like to see. I find that there is a lot of misinformation on how to distinguish

between- hemolytic and pyrogenic reaction. I pointed it out. It is very easy. All you do

is draw 5 cc. of blood from the patient and spin it in the centrifuge. If the plasma

is pink, you know the patient has had a hemolytic reaction. If not, you know he didn't.

They were signing out a good many patients as heinoglobinuric nephrosis; patients who had

died with anuria. When you go through their histories, you often find that anuria was

present when they came to the hospital. Because the patient never put out any urine, they

felt that the blood had killed the patient. The cause of this anuria has been discussed,

and some think that in part it has been due to blast and in part to the shock and other

people thought that there was something * * * due to alkalinization. The more we learn

of patients not putting out urine, the more I am inclined to believe that it Is not due to

blood. There were some people who were giving patients 4,000 cc. of blood and then when

they had a little febrile reaction, they read the directions and saw that they were supposed

to have a 3,000 cc. intake, so they gave them 3,000 cc. of fluids more. This is particularly

true in patients in whom anuria is found. Now, I am personally well satisfied with this

reaction rate. I think it is pretty low, considering everything.

I found errors In hospitals In handling blood. In the attempt to lower this rate more,

there has been started a program to raise our own requirements about the handling

of blood and sets. We are ready to go over that now.
296 ACTI'VITE s OF *SURICIlI(AL. 4 'NSIULTNI'S ~

IFIGURCE 109t .- A dtl i lI*. (if Whol blooIdii ( 111141i'r t re4Ztll

.Tanunry 19)45.

IThe othl th*'i li Wich ( I Nv e htav d4 414 we ve have learni ed 11m blooI iiHd comintt g front tile

States is. nut ittsjx'eted biefore it le-a es the States. AWe have set upl anl iltsIKet ion systemi

here. It is ins1m'cietd biefore it is (list rihutedl.

We' warnted all of thet ad~van(ed1 blooxd lniatks aiout taking, full care of thle storage

of biloo d, Iieitiise we wvere runiniitg int o da inger of ft'eezintg of liii uid, evenl inl refrigerat ors

(1ig. 10 01. We hav e a skedI for sotmte a 111t.1 tn fee healtets. an itt e an.e actutally goi ii n to havye

to heat Some of it. We foiund at least one nlift tha.t was warming blood befiire tranisfusion.

Gener'al ILa wleY wasgrtl ple-aSpl Iýll w it t iis S1tmtitu11A r of thle situiat ion

by Major H ardini. -ITltal is all very ('ldtli~t4'ltilltg. antd it Is very comtifort ing.

the Chief Surgeonl said, "bec-ause these people howl, and I am glad we have

something ,,tolhowl 1)ack withi. I suspected tha-,t this anutria )oiit was duie not to

thle blood itself.- Tule Cit icf Stirgovotlti belt at tn iblted to Stollewal J1.1ackson,

who. he saidl. wvas. a1 nma of very few wvords, lith, followimtr statenmlent 'Icall

,guarid agaiiist evrtigr butt tlit sf 1I 1 iditY of 01 tv l assistants., JParapdtrasing

this qutotat ion, t Ite ('t ief Sittt'geolt aler-te(l t1( Ite onlsjj~lt ait. 5: yng:'oit arn' *

the same situation. Yout ('an gulard your bl1oo( andt use all pre'caultionls, but you

ýcan t gruard agra i mst thle Stupid itity of til pte ~ople Nvit() are Somuet imes usning the

blood."

Professional care on hospital trains.-Stipervision of professional care

on hospital trainis was effected 1it1y periodic vejieks at opp~ortun1e4 moments. Sincve

Major Robinson's trip onl a hospital train lnovoment. dlescribted vat'lier. there had

been a notable incident wherein a general hiospital had tutrned1 Over to a hospital

train a patient with dry gangrene of the ]landl~ iecaulse of a1 w01t114 abtove thle

elbow. This was (lone with the expectation that it would4 b~e better professional
CHIEF CONSULTANT IN SURGERY 297

care to let the line of demarcation be settled by time rather than to amputate

early. To the consternation of everyone, the surgeon on the hospital train had

proceeded immediately to amputate the extremity. On another occasion in

mid-November, a hospital train had been loaded with serious casualties far up

in the Third U.S. Army area. These casualties were to travel all the way to

the port of Cherbourg through Paris for further evacuation to the United Kingdom. They were being sent by rail owing to the uncertain air evacuation situation. Colonel Cutler had sent Colonel Bricker and Colonel Canfield to "vet"

the train when it arrived at Paris and had instructed them to use their judgment

in supervising the removal of any casualties who could not reasonably continue

through to Cherbourg. Colonel Cutler had gone to the 48th General Hospital

the next day to inspect cases removed from the train, while Colonel Bricker

had gone on with the train to Cherbourg.

Mindful of the dictum by the Chief Surgeon that professional care during

transit was equally important with professional care of patients in hospitals,

Colonel Cutler had conferred with members of the Evacuation Branch, Operations Division, Office of the Chief Surgeon, following Colonel Bricker's return

from Cherbourg. As a result of this conference on care provided during hospital t rain movements, and in the light of observations that had been made fro,,i

time to time, Colonel Cutler on 25 November submitted to the Office of the Chief

Surgeon a memorandum containing a proposed circular letter concerning profesional care on hospital trains. The proposed directive urged the continuous

sorting on trains of the seriously ill from those who could travel further without detriment to their recovery. It described the types of casualties that would

require special care and have to be removed at the first opportunity. It specified

where certain categories of injuries would have to be detrained in order that

they could obtain proper therapy. The proposed directive closed by giving

suggestions on the care of immobilized patients in transit on hospital trains

(fig. 110).

Since the scope of the directive pertained only to hospital train units, a

limited portion of the theater's medical service, and since all hospital trains

were directly under communications zone control, the directive was published,

on 9 December 1944, as a command letter from the Office of the Surgeon, Headquarters, Communications Zone, ETOUSA. to commanding officers of all hospital trains on the Continent.

Guidance to disposition boards.-On 5 December 1944, Colonel Cutler

submitted two directives for pl)ulication. One p)ertained to changes in a previous directive giving guidance to disposition boards and the other delineated

hospitals established on the Continent for specialized treatment. Shortly before

the invasion, Colonel Cutler had convinced the Chief Surgeon that some sort

of a yardstick was necessary to serve as a guide to hosl)ital disposition boards

for the early determination and selection of patients to be evacuated to the

Zone of Interior (p. 190). The previous directive had been published when the

180-day evacuation policy was in effect. But the evacuation policy had been

dropped to 120 days in October 1944, and instructions had lbeen given that a
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CHIEF CONSULTANT IN SURGERY 299

been promulgated. Portions of Circular Letter No. 142, issued by the Office

of the Chief Surgeon, ETOUSA. on 8 December 1944, which pertained to

surgical conditions making it advisable to evacuate a patient to the Zone of

Interior under a 120- or 90-day evacuation policy, are contained in apl)pendix

C (p. 973). The list should become of increasing historic significance with the

passage of years in view of the difficulty which always seems present when a

decision must be made as to whether a soldier or officer remains in a theater of

operations or goes home.

Hospitals for specialized treatment on the Continent.-Colonel Cutler's

proposed directive for the establishment of hospitals for specialized treatment

on the Continent had been worked out after careful and long planning. As

of the time lie had completed his draft (4 December) the hospitals designated

to provide the specialized treatment were equipped and in a position to carry

out their specialized mission, and the specialists necessary to provide the surgery

were present. Colonel Cutler submitted his draft of the proposed directive

on 5 December advising Colonel Kimlbrough as follows:

1. Attached is a draft for a circular letter on specialized treatment, which has

incorl)orated in it

a. All the suggestions made by Operations Division, and

b. Redesignation of certain hospitals after a more careful selection.

2. Recommend immediate publication of this circular.

3. When the matter of these specialized treatment centers was prol)osed, both the

Hospitalization and the Operations Divisions proposed moving hospitals selected for such

work into permanent buildings, if they are now in tented construction areas. Perhaps

final approval of this letter should therefore pass through Hospitalization as well as

Operations.

Colonel Cutler's proposed directive designated the following hospitals

for the treatment of patients requiring specialized treatment:

Neurosurgery units: Hospital Area

48th General Hospital --------------------------- Paris

298th General Hospital --.-------------------- --- Lige

100th General Hospital ---------------------.----- Toul

Thoracic surgery units:

48th General Hospital -------------------------- Pa ris

15th General Hospital - ---------------------- - Liege

5th General Hospital -------------------------.- Toul

Urological surgery units:

48th General Hospital --------------------------- Paris

298th General Hospital ------------------------------- Liege

100th General Hospital ------------------------------- Toul

Units for plastic and maxillofacial surgery and surgical

treatment of extensive burns:

108th General Hospital ------------------------------- Paris

15th General Hospital ------------------------------ Liege

5th General Hospita --------------------------------- Toni

The directive, in draft, specified: "Patients requiring treatment in neurosurgery, thoracic surgery, plastic and maxillofacial surgery, surgical treatment
:300 ACIvi E w . SURGUICAL Ct tNxsuT!IANT8

of extenisive burns and urological surgery, when transfer to the United Kintidoin is impracticab~le or inadvisable, wvill be sent. without delay to the fl1)lroIprat e hosp1 it al designiatedl*

Wlhen Colonel Cutler returned fromt his extended trip in the field, lie

found that, t he (directiv had 111(ot been puiblished. Investigating furt her, hie

learned that, the heavy boinha rdmient. e'xp eriencedl just. before leaving the First

U.S. Army area bad been in earniest and that the Germans hiad latuncledl a

largre counteroffensive. Ile conferred with members of the Evacuuat ion Branch

andl Operations D~ivision of thle Chiief Surgeon's Othice, who infornied Colonel

Cutler that the directive had to be. held ill in view of thle fluid situlation. They

decided, however, that there wouldl be 110 objection to thle Seine Base Section

surgeon's issuing a. directive pertaining to thle. special facilities inl the Paris

area. General Hawley, later in the nionth, decided that the (designation of thle

sp)ecialized facilities should 1)0 miate. but that there could not be the rigid enforcemnent of thle (list ribut ion of patients as was exercised in the United

Kingdlom.

Christmas and year's end

Even (luring, war in ant active combat tlheater. a few (lays of idyllic peace

may suddenly ap~pear. Colonel Cutler's third Chlrist mias in thle Eur111opeanl

theater was 0o1e of thiese, a day far-remioved fromt tile routines of war. Ile

was able to mleet, his sonl Capt. Elliott. C. Cumtler, .Jr., Inf., who had recently

arrived in England wvith -ita infantry dlivision. C olonel ('lt er, (lotinug parent

for thle day, toured London leisuirely with his youing WVest. Point Soil. Later,

the t wo joinied Admiral and Mrs. Grordon-Taylor for Christ mas (]inner.

Thme y'ear enuded wvith time lengthy but miost worthwhiile mleeting of the

Chief Sul-rgeonl's Consult ants' Commnittee onl Saturday, 310 December. This

timne, Colonel Cuitler wias ill tile chair simnce Colonel Kindbrommgh had been

returned to the Zone of Interior for a period of indefinite telmporary dluty.

Antong ot hier tihings, C olonel Cutf ler arranged for Colonel Toveil to pres~ent. to

the Chief Surgeon at very comprehensive analysis of various anesthetics and1(

pr'cedlurIes being usedl iii the theater according to the type of mnedical facility.

It had beenmienntionedl by tile other consultants, too, but, it. was after this rep~ort

liat. General lIawvley miade tile statement wvhich lperlial)s more than ever iniI)rM'Ss(l1 time- consiltanllts withi thle Chi1ef Sulrgeonl's trute, fine inettle. General

H~awley said:

This is it very splendid study here. It Ns very illuminatinitig. It only to ime emiphasizes. t he splenidid work that has bueen flon( ini nueIstliesin ini ails I he'fl r. I t is ai refieet lon oif timi energy, the abillit y, anid te lieggressive, amid I iumiglit say reIlgIlouis muploiiet ion

twat (oionl rnoveln hits sh~own. andi I would like to take thiis oliportunity to say~ thant, hiowever mnuchin nie te (arly (lays I inight not have abisorbied 11,4 nitiih oif his (inthuinin*51 ats

he t limigit. I should have mibsonhied. I hiave been commvertedt. ami1d I a11m qui1te commviiieed

hfia (lit, lume surgical results t lint have been gainied in this t heater are in no sinall way

:m irlil~utabde to Colonel Thovehll anid the Bine ***service that he hias broughtt here. I

saly thaiit very sincererly.
CHIEF CONSULTANT IN SURGERY 301

The New Year

Need for a united theater

One of Colonel Cutler's utterances as the new year began was to the effect

that the political implications of SOLOC were almost insurmountable, but

a united theater was essential. The reader may recall that Colonel Cutler,

following his return from Brussels, had given the Chief Surgeon due warning

that he fully intended to visit the Seventh U.S. Army in spite of apparent

reluctance by that Army to have visitors from theater headquarters. The

Surgeon, SOLOC, had also requested that consultants from European theater

headquarters refrain from visiting the SOLOC area until it could be established

on firmer footing.

Meanwhile, the situation in the Ardennes and Alsace areas had tied down

personnel of the Chief Surgeon's Office pretty much to the headquarters in

Paris. While the theater surgical consultants were awaiting an opportunity

to visit the units to the south and to observe the type of work being done, a letter from The Surgeon General questioned the Chief Surgeon, ETOUSA,

on the numbers of orthopedic casualties with internal fixation who were arriving in the Zone of Interior from the European theater. It was quite obvious

that most of these cases had been evacuated from Marseilles, and there was an

urgent need for visits to the areas of southern France so that responsible persons

at theater headquarters could speak intelligently on all aspects of the theater's

medical responsibilities.

At the aforementioned 30 December meeting of the Chief Surgeon's

Consultants' Committee, Colonel Cutler pointedly asked:

Some of the members of this group are going to visit SOLOC hospitals. There is

one thing that has been brought up that we need clarification on. Hospitals there have

been doing Internal fixation of fractures. We wish to go with a clear mind as to what

position we take. Shall we ask them to live up to ETO directives?

General Hawley replied:

Yes. I would like to stop at this point. I had to send that thing to the Surgeon

General; I couldn't postpone It any more. I stated frankly that in that type of case

where proper reduction could not be obtained by traction, which applied to only a very

small amount of the cases that a certain amount of internal fixation of fractures has

been done, but it is true that the number of that Is from the Southern Line of Communications.

Further explaining General Hawley's answer, Colonel Cleveland commented:

It must be, General Hawley. After I wrote a little memo for that letter of yours

in answer to General Kirk, I went over the disposition proceedings and I looked over

fairly carefully those of the 21st and the 26th, but these hospitals are in SOLOC. The

21st had a very high percent of the Internal fixation. It is often hard to get the information, but you know they are doing It, and I think it is only by going down there to

find out whnt they are doing.
3 )0 .wmvrivi'is oF"S'It;C ctNsl'lrAN'rS

"Yes'. ( tetieral I Iawley conflirmeltd, "they have got to stop) It." Ile vontitued1 "Whiere proper re(iltct oll catttiot be effected, then it is all right. I

thinik even (Ieneral K irk agrees thlat we have grot to (1o thIat." Theni, iin rep~ly

to C olonel ('Ut ler~s originial quiestiolt, he (- Chief Sul-rgeonl stated emiphat ically:

-Tllp tiev art going to adherpie to tilie 1)01iciesof thlis office. or else."

O n 31 1 ecembln eI hie 4l11y aifter theit( meet intg. C olonel O tlder I asteleneI to

write tie following in a letter to Colonel Shook:

I amn frightfully sorry but I have been unaable to get over to see you, mid. no0w that

I ami holdinig down Colonel Kinibrougl's dlesk its well as my own, it is impossible. Several

(of the- officers on our staff will lbe uover top see you shortly and1( I ala giving this note too

Colonel Spurln ig. the cotnsultanit Iin neurosuirgery. who is traveling with ('4donel C'anfieldl,

Ithe conisultanlt Ii otolaryngology and ololhthalinology. These officers Will see All your

hosplitalls mid1(. after at discussion with you, will al so visit y'our sout hern area and study

iewly arriVed hosld)talS. 1 11111 sure we aill have the keeniest dlesire ito be oif service to you,

and1( please' ask these officers to dto anythinig you wilsh.

Since I vali not comle tiiyself, and1( since1 youl and14 I have (iiso-ummed thle miatter of your

consultant Iin surgery, and aifter at long (discussionl with Colonel Berry. (Consultant in

Surgery, Seventh Army, wvlo turned till tit at meeting Ini Brussels, I ama haploly to) recommenemd

to) you that Colonel Ira Ferguson blecomie your consultant lit general surgery. If this Is in

aiccoirdance with your desires, Will you pflelkse take steps to impitlemient this and14 moive himi

to yo~ur headquarters. Perhaps bly the tlime this Is (14111- I will he (over 14) see you. MeanWhile. I hiate tip hold 111) aillytlihing impol~rtanit. for boetter service Ii your area.

( olotwel ( atitield and C olotnel Spurling retuirnedl from their visit to S( )IAC

andu tilie Seventh U .S. Armiy and contferred with Colonel Cutlter ott T .January

1945. 'i'heir visit laid beeni most. rewardling in r'espect to inftormnation galtheredl.

Greteral H awley, himusel f, also platiled to touir the S( )tAC and Seventh 11.S.

Army areas, andl asked C olonel Cutler to accomipany~ him. After mleetinig wvith

tile Chlief Suirgeonl ott !) f 1lintary and1( obitaitning a firm (late for thle pro~posed(

trill, Colotnel (';tlter telephoiied Colonel Shook ottit) 10anuiary antd informted

the S( L( C, sutrgeon that, General H awley and (Colonel Cutler would le. visiting

him onl 14 fiJailary.

Visit to SOLOC and CONAD.-On Sunday, 14 .January 19)45, General

I IawleY and Colonel Cutlter departed Paris at 0900 and arrivedl at. Dijon at

1630. lThe Chief Surgeon contacted Colonel Shook by telephtone andl joined

himi, whlle Colonel Cutlter proc-eeded to confer with Col. Ira Ferguisonl. Thle

twot quickly reviewed the profesisional statuis of allt hospitals int (NNAI) (('onltiitental Advance Section) and thle D~elta, Base Sect ion, th lt' t o (Ias~e 5('dt i(11

suhor-ditate to SOIOC. They spoke esplecially of the prob~lemt of bringing

upt newly arrived getneral hospitals to a, respectable p~rofessiontal standard,

atnd it st''teeme to Cololtel C'.tlter that, the older established hlospitals "bad p)lenty

of exp~ort. material * * * for helping utew instittutions." Coloniel Ferguson

also informted (Co(lontel Cutler' that lie would not particularly care for a full-timie

job as surgical conlsultanlt ait SOLO( headquarters. lie hoped thtat. antothier

officer c~otld Ix- found for the ptosit ion, or that, with consultants at each of the

two bases, a third at. SoOIAC headquatters would be unntecessary.

Later that. eveuitig, (Colontel Cut let' joined Getnerial I lawley, C~ohloel Shook.

Col. Haurry A. B ishiop, MC, a111( Col. Crawford F. 511111, MCff, for ditnner att the
CHIEF CONSI'LTANT IN SURGERY :103

CONAD mess and conferences in Colonel Shook's quarters. They decided

to defer the matter of appointing consultants until Colonel Cutler had completed his visit. Colonel Cutler promised to help obtain personnel from the

field armies to "shore up" vacancies in the new SOLOC hospitals. Colonel

Shook, in return, promised to distribute l)ertinen~t circular letters of the Office

of the Chief Surgeon, ETOUSA, so that all medical treatment facilities in

SOLOC could be apllrised of European theater policy. While the visitors

from Headquarters, ETOUSA, were most pleasantly entertauined, General

Hawley and Colonel Cutler could see that the SOLOC staff was not going

to acquiesce to theater policies and procedures without some difficulty.

The next (lay, Colonel Cutler " isited the 46th General Hospital at Besanqon

and was not impressed, although the orthopedic work and anesthesia were

good. Ile thought the hospital was not closing wounds as early as should be

done. After lunch at this hospital, Colonel Cutler returned to Dijon where

he inspected the 36th General Hospital. The hospital and surgical service

were excellent. The 36th General Hospital, with 2,000 beds available, had

had a census of as many as 3,000 patients on occasion and had 2,873 patients

on the day visited. After completing his hospital visit, Colonel Cutler took

the night train to Marseilles with General Hawley and Colonel Ferguson.

Visit to Delta Base Section.-At Marseilles, the headquarters of Delta

Base Section, the party was met by Col. Vinnie H. Jeffress, MC, base section

surgeon. After breakfast at the headquarters mess, Colonel Cutler visited the

70th and 80th Station Hospitals which were acting as holding hospitals for

evacuation to the Zone of Interior and were also providing local station

hospital service. As expected, there were a good many cases with internal

fixation. Soldiers with enucleations had been provided poorly fitted glass eyeballs not nearly as good as the acrylic eyes which were being made in the dental

laboratories in the rest of the European theater. There were many patients

earmarked for evacuation to the Zone of Interior who should have been retained in the theater. There then followed a visit to the 235th General Ilospital. Here again, Colonel Cutler was not satisfied with the work being done,

there was no clear idea of proper disposition procedures, and there was confusion because the hospital was operating partly under MTOUSA and partly

under ETOUSA directives. Lunch at a hostel for nurses provided the opportunity to meet the commanding officers of the 69th and 78th Station Hospitals

who had traveled from Cannes and Nice.

The afternoon visits were a revelation of another sort. Colonel Cutler

found the 43d General Hospital affiliated with Emory University, Atlanta,

Ga., and the 3d General Hospital, affiliated with Mount Sinai Hospital, New

York, N.Y., excellent in their professional work. Colonel Ferguson was the

chief of surgical service at the former, and there Colonel Cutler found the

orthopedic work particularly good, although many cases were being bone

plated. At the 3d General Hospital, Colonel Cutler was shown a ward for

alblominal surgery run by Maj. (later Lt. Col.) Leon Ginzberg, MC. Colonel
,3(4 A('T'I vITIES. OF SURGIt'AL CONSI'LTANTS

Cutler considered this the most interesting and bIeautifully run ward seen on

the whole trip.

Back to SOLOC headquarters and CONAD.-On the night train back

to l)ijon, Colonel Cutler was able to have a long discussion with Colonel Ferguson on the overall hospitalization plans for S()IOLC. Colonel Cutler recorded

that they were in general agreement on the following :* * * The forward general hospitals at. CONAD should absorb all the people who could go back to

duty within 3) (lays, an1 have a high-~owered reconditioning center. The rear

hospitals, that is those in Delta Base, should take up the cases retquiring long

hospitalization, whether going to the Zone of Interior or not." In such a

scheme, the station hospitals in and around the Marseilles area could act as

holding hospitals for water evacuation to the Zone of Interior. Too, there

would be a need for hospitals to provide specialized care. These should be in

the Delta Base Section, and Colonel Cutler suggested that. the 43d General

Hospital could well take care of thoracic surgery and neurosurgery and the Md

General H lospital, of niaxillofacial, abdominal, and hand surgery.

Back again in the Dijon area, Colonel Cutler visited the 23d General Ilospital, the affiliated unit from Buffalo at Vittel, France. Here, he met Lt. Col.

Baxter Brown, MC, chief of surgery, whom he d(escribed as "an excellent man."

Colonel Brown was a urologist, but his services had been requested by the

CONAI) surgeon as surgical consultant for the command. Colonel Cutler also

visited the Sixth Army Group headquarters where the surgeon, Col. Oscar L.

Reeder, MC. explained the French medical service of the First French Army,

a component of the Sixth Army Group.

In the afternoon, Colonel Cutler proceeded to the 21st General Hospital

at Mirecourt, France, which he described as follows:"* * * an enormous new

insane institution spread out over a mile, but well adapted." Commanding

officers and chiefs of surgery from nearby hospitals assembled at the 21st

General Hospital for meetings and dinner with the guests from up north.

The hospitals represented included the 236th. 237th, and 238th General Ilospitals, and the 23d. 35th, and 51st Station Hospitals. Colonel Berry from

the Seventh U.S. Army, Colonel Ferguson, and Colonel Brown were also present. Colonel Cutler had the wonderful opportunity to have a long discussion

with these chiefs of surgery and the surgical consultants-it was becoming quite

obvious, now, that Colonel Ferguson would be the consultant for Delta Base

and Colonel Brown, for CONAD. Colonel Cutler, as a result of his visits

to the various facilities in SOLOC, urged the early restoration to duty of all

patients and less use of internal fixation.

That evening, there were two meetings of great consequence for the fostering of close and cooperative relationships between those at Headquarters,

ETOUSA, and the personnel of SOLOC. Of pertinence to the Chief Consultant in Surgery were the following, as recorded in his official diary:

Later In the evening we had a long meeting, attended by General Hawley. Colonels

Bishop. Berry. Ferguson and Brown. regarding functions and duties of consultants. We

agr,4l it. was unnecmssary for the moment to have free [full-time] consultants for SOLOC,
CHIEF CONSULTANT IN SIUIRGERY 305

but accepted the consultants chosen for CONAI) and I)ELTA. These consultants will

remain in their hospital posts, will feel free to go out and examine institutions when they

desire, will not speak to Commanding Officers or members of units regarding any changes

they may deem wise and will not make promises to Commanding Officers or people concerning new (euil)ment, but when they have examined their unit will go back and give a

complete report to the Surgeon, SOLOC. Further, all consultants will feel free to correspond directly with their consultant colleagues In any base section or at ETO headquarters

without such letters going through the base surgeon. This facility of professional correspondence is fundamentally to better the professional care, and General Hawley urged this

strongly as the very basis of the consultant group. Colonel Bishop is to distribute ETO

circulars shortly. Colonel Shook will he given a report of all this, and then will establish

any other policies which lie deems wisest for SOLOC. At this discussion, the matter was

brought up as to whether men fresh from hospital who might later be general assignment

could go on limited duty for 3 months and then be reevaluated.

Still later in the evening there was a meeting of professional people at which there was

a long discussion * * *[concerningl the reasons * * * [for] internal fixation. These

would seem to be as follows:

1. Fractures into joints.

2. Multiple fractures, long bones.

3. Where fragments of fracture may possibly injure blood vessel, if reduction is not

perfect.

Visit to Seventh U.S. Army.-The following day, Thursday, 18 January,

General ][awley, Colonel Cutler, and Colonel Berry motored to Headquarters,

Seventh U.S. Army, Lun~ville, France, after making rounds at the 21st General

Hospital. At Seventh U.S. Army headquarters, they were met by Maj. Gen.

Arthur A. White, USA, Chief of Staff, and Col. Myron P. Rudolph, MC, army

surgeon. General Hawley impressed on Colonel Rudolph the importance

which was being placed on the rotation of medical officers between the field

armies and communications zone facilities. The Chief Surgeon made it clear

that requests for rotation had to be initiated within the field armies. Ile specifically instructed Colonel Rudolph that correspondence pertaining to such

interchanges was to be made directly to his office and not with the base sections.

Privately with Colonel Berry, Colonel Cutler discussed the administration of the 2d Auxiliary Surgical Group and the availability of qualified surgeons. The Seventh U.S. Army had one-half of the 2d Auxiliary Surgical

Group. The group's executive officer, Maj. (later Lt. Col.) James M. Sullivan,

MC, customarily remained forward of army headquarters and, from this forward location, disposed and supervised the teams. He habitually maintained

close liaison with Colonel Berry, who remained with the surgeon, Colonel Rudolph, at Seventh U.S. Army headquarters. This had worked well, and Colonel

Berry told Colonel Cutler that it would be a mistake for the consulting surgeon

of a field army to try to operate directly the auxiliary surgical group, as Colonel

Crisler was doing in the First U.S. Army, in addition to his duties as the surgical consultant. Colonel Berry also confirmed his advice earlier offered that

there were many surgeons in the evacuation hospitals and the auxiliary surgical

group to the Seventh U.S. Army who could go to the new hospitals in SOLOC

to strengthen their surgical services.
"306 ACTIvri E:,; O" S"l1GICAL CO)NSULTANTS

Return to Paris.-Before leaving the Seventh U.S. Army area, General

lHawley and Colonel ('utler visited the 9th and 95th Evacuatioll Hlospitals.

After this, they proceeded to the 2(d General Hospital which was just setting

up at. Nancy and spent, the night of 18 January there. The next day, they

went to H[eadquarters, 8th Armored l)ivision, atl Pont-a-Mousson, and were

given a guide by the assistant division commander to take themn to Raucourt,

where General Hawley's son was lxoated. After a pleasant reunion with the

son of the Chief Surgeon, General Hlawley and Colonel Cutler visited tle 58th

General H~ospital in Cominercy and, tinally, arrived back in Paris at 1730 oil 19

January.

Biack in Paris, Colonel Cutler provided the C(hief Surgeon with a sunmmary of items which had been discussed, a draft of a letter to Colonel Shook

confirming agreements made, and a draft of at letter for the Chief Surgeon to

send to The Surgeon General explaining the three general circumstances when

the internal fixation of fractures should be permnitted. Colonel Cutler initiated

necessary procedures in coordination with the Dental D)ivision in the Chief

Surgeon's Office to train dental personnel in SOIA)C to fabricate acrylic artificial eyes. lie also made the necessary arrangements to have shipped to the

Seventh U.S. Army some units of the mobile surgical team assembly for use by

attached French surgical teams which had been trained by the U.S. Army Medical 1Department.

It is interesting to note, in the letter on use of internal fixation under special

conditions, Colonel Cutler wrote: "We have not utilized these procedures in

ETO! TSA, but we are always willing and eager to improve our service to the

soldier, and I think we are convinced that under special circumstances these

procedures are desirable." Certainly, these thoughts clearly indicate that, however strong Colonel Cutler personally felt about. any matter, he always maintained an ol)eni mind to the suggestions and feelings of others. On this occasion, he had gone to SOLOC with a strong obligation to curtail the widespread use of internal fixation in the hospitals of that. command, hut., nevertheless, he had returned to vindicate their practices, where warranted.

Trenchfoot meeting

But a few days after Colonel Cutler's return from southern France, medical and surgical consultants from throughout the European theater began to

assemble in Paris for a combined meeting anod a coordinated assault on a major

problem which the winter fighting in the Rhineland had fostered for the Medical Departinent-tlhe problem of trench foot. Present also were representatives

of the theater's preventive medicine activities and members of the trench foot

study group (surgical) at the 108th General Hospital, Paris, and the medical

groutp in England at the 7th General Hospital.

The proceedings of this meeting held at the 108th General IHospital on 24

Janiary 1945 are more thoroughly covered in another volume of this history.'-•

'"Medlcai Department, United States Army Cold Injury, (round Type. Wasdhington: U.S.

Government Printing Office, 1958. pp. 179-194.
CHIEF (CONSUI,TANT IN SURGERY 307

But, in ;uinmary, General Hlawley opened the all-day sessions and expressed

the hope that agreement on the means to l)ireent and treat trenchfoot might

come from the meeting. Col. John E. Gordon, MC, chief of the Preventive

Medicine D)ivision, (ffice of the Chief Surgeon, demonstrated some intriguing

rates in relation to smaller units of battalion size and showed the prevalence

of trenchfoot with respect to the command of such units. By field armies,

Colonel Gordon showed, in order of severity, rates for the Third, First, Seventh,

and Ninth U'.S. Armies. lie recommended the rotation of combat troops and

better foot discipline. Lt. Col. Richard P. Mason, MIC, of the Preventive Medicine Division, Office of the Chief Surgeon, emphasized the value of discipline

and dry socks and the proper use of the shoepac.

Captain Leigh from the study group at the 108th General Hospital presented proposals for classifying patients for sorting and evacuation. He suggested that a circular letter now be published on the type of treatment which

Wbdl be beneficial in the army areas and the criteria under which patients

* L i be evacuated to the communications zone and to the Zone of Interior.

Colonel Kneeland, medical consultant for the United Kingdom Base, explained

the benefits of active exercise in the treatment of patients restorable to duty.

Maj. Laurence B. Ellis, MC, studying trenchfoot at the 7th General Hospital,

called attention to the remarkable ratpidity of the disappearance of edema with

the use of a thoracic respirator. He pointed out that this result was more rapid

with the use of the respirator than with exercise or position of the patient, but

that an explanation was wanting. It was observed, however, that femoral vein

pressures were definitely diminished.

Colonel Crisler explained procedures used in the First U.S. Army in the

management of trenchfoot cases (p. 290). He spoke of recurrent trenchfoot, asked for tile criteria to differentiate trenchfoot and frostbite, and warned

of the importance of associated injuries. Colonel Odonm and Lt. Col. Guy H.

Gowen, MC, presented the experience of the Third and Seventh U.S. Armies,

respectively. Others spoke of the frequent superficiality of lesions studied and

of the finding of an intact nervous system in most cases.

During the general discussion, there was agreement that amputations

should rarely be done for uncomplicated trenchfoot and that pain was an

insufficient symptom for removing a soldier from duty. Cases to be evacuated

to the Zone of Interior, it was generally observed, should either show obvious

tissue damage or have associated combat exhaustion. Those who at the end of

5 or 6 weeks of treatment still evidenced disturbed physiology, it was recommended, should also be evacuated to the Zone of Interior. The conferees were

convinced that sympathectomy was undesirable, except for late manifestations

of Raynaud's disease.

Colonel Cutler recorded his opinion, as follows: "The remarks made by

Colonel [Sterling A.] Wood, [Regimental Commander,] 313th Infantry * * *

in both afternoon and evening were more effective than any of the professionad

discussion." Colonel Wood was an Infantry regimental commander. While a

patient in a general hospital for other reasons, he had become personally inter-
'108 AC'II 'TI'rII-,'s (F sumaGc.\I c()Ns1I.TA'NTs

ested ill thm tremendous wastage of manpower he had observed in the number

of patients coming through wvith cold injury, lHe had personally acquainted

himself with the facts then available and had studied the means by which a

unit commander could curtail this great loss. Colonel Woodl, before returning

to (Iiutv, had spoken to Gen. Omar N. Braidley, tile 12th Army Group coinnmander, about what the line should do in preventing cold injiry. At. this

trenclifoot. meet ing, he mentioned that, direct ives to the line had to be brief and

specili, liet explained that new socks were now coming up) at night with the

rations and recommended that each soldier keep extra socks inside his shirt. to

keep them warm and dry. Colonel Wood emphasized the difficulty of keeping

all company commanders apprised of the importance of plrventive ]neiasures

and of maintaining proper procedures in tile prevention of cold injury because

of heavy losses among his otficers. Since D-dav, he stated, the 313th Infantry

had lost 200 officers and 4,800 men.

The occasion of this trenchfoot meeting also gave the Chief Consultant in

Surgery the opportunity to speak with his surgical colleagues on many pressing

matters of the moment. A dinner was given by General Hawley for all the

participants at the meeting, and a period of lucid, informal discussions followed.

Not a few of the visitors also attended the meeting of the Chief Surgeo 's Consultants' Committee with General Hawley the following (lay. Further talks

on items which were discussed in Paris at this time were taken up again after

Colonel Cutler flew to the UTnited Kingdom on Sunday, 28 January.

One of the factors which permitted Colonel Cutler to fly to England at

this time was the return of Colonel Kinmbrough from the UTnited States one

week previously.

United Kingdom revisited

Thoracic pulmotor.-One of the things Colonel Cutler looked into on this

visit to the United Kingdom was the functioning of the thoracic pulmotor at

the 7th General Hospital, as used for the treatment of trenchfoot. The Chiif

Surgeon had classified all activities at this hospital in the possibility that, if the

experiments being conducted there were going to provide something truly constructive, the enemy should not have the benefit of our discoveries.

Colonel Cutler learned that the machine induced a negative pressure

of 10 or 12 mam. of mercury and was being used 1 hour daily for from 7 to 15

days per patient. Studies showed that trenchfoot patients submitted to this

treatment late d(id less well than those subm itted ea'rly. Moreover, l)atients originally apparently relieved of symptoms by this treatment were experiencing

recurrence of symptoms. Little scientific information had been gathered on

the physiological correlates to the machine's actions-decrease in femoral vein

pressure, elevation of diaphragn with inspiration rather than depression, and

unchanging pulse rate and blood pressure throughout the course of the machine's action.

Since little information had been gathered on the unusual action of the

diaphragm, Colonel Cutler suggested tint. fluoroscopy be carried out. lie
CHIEF CONSULTANT IN SURGERY 309

pointed out that the apparatus was aluminum and that aluminum would not

obstruct the roentgen rays.

Finally, Colonel Cutler noted in his journal: "I was not greatly impressed

with this machine."

The Chief Consultant in Surgery spent the remainder of the day individually checking cold injury cases on the wards in this hospital. He was appalled

to learn of the indiscriminate awarding of the Purple Heart decoration to frostbite cases of very minor severity. Such actions were making a farce of the

decoration, he declared.

Meeting of United Kingdom Base surgical consultants.-Colonel

Morton had arranged for a meeting of all the surgical con iltants in the United

Kingdom Base Section. These consultants-coordinators in surgery at the

hospital centers and specialist consultants strategically located at various hospital centers to act as regional consultants in their specialty-had assembled on

Thursday, 1 February 1945, at the 7th General Hospital. Colonel Wright from

the Air Forces and Col. Baxter Brown, MC, surgical consultant to CONAD,

were also present. Colonel Brown had come to England with Colonel Cutler

following the trenchfoot meetings in order to observe the organization for and

care of patients in the United Kingdom Base Section. General Hawley, who

had flown over to England, welcomed the group and pointed out the debt of the

Army to the doctors. He asked them to try to assume fully the responsibility

of the early restoration to duty of those who could be restored, pointing out the

danger of trying to restore to duty those who could not be brought up to the

standard. lie mentioned that the alleged sending to replacement depots of

those unfit for duty was currently a matter of joint investigation by the Chief

Surgeon's Office and the theater Inspector General's Office.

Colonel Cutler then discussed with the group the overall system for the

care of the wounded American soldier, beginning at the forward areas and

ending up either with restoration to duty or evacuation to the Zone of Interior.

He stressed particularly the importance of sorting and maintained that, if

sorting was properly done all along the chain of evacuation, most of the problems to which those in the United Kingdom were heir would disappear.

"The next matter under discussion," Colonel Cutler later reported, "was

early restoration to duty." lIe recorded:

I placed before the group the hope that within 2 weeks they could evacuate 5.000 beds

in the United Kingdom of patients and bring some relief to our pressing need for beds.

The matter of a more vigorous attack on the wounded soldier and a greater effort to make

him exercise and move was brought forward as being the most important factor.

The rest of the morning was devoted to the improvement of current circular

letters on the treatment of battle casualties. Particular str-ss was placed on the

improvement of instructions concerning abdominal surgery, fractures, trenchfoot, hernia, and thoracic surgery.

The discussion on thoracic surgery was continued throughout the afternoon. First, it was brought out by the thoracic surgeons from the special

treatment facilities that casualt ies were taking an extremely long time reach-
110 ACTIVITIES OF SUIGICAL CONSULTANTS

ing them--an average of some 30 days after wounding. This fact, they

stated, was completely nullifying the advantages of having special treatment

facilities, since the patients reached them in bad condition and unsuitable for

early primary treatment. Another difficulty, it was noted, was the reticence

of individuals to accept thoracic cases as fit for duty even when they had been

playing baseball and walking 4 or 5 miles a day. There seemed to be a prevailing psychological barrier that soldiers wounded in the thorax could not

go back to duty. Facing this problem squarely, the Chief Consultant in

Surgery was obliged to conclude: "I am afraid to do this whole thing properly

we will have to re-educate all of the doctors in the FFRS (Field Force Replacement System)." Finally, Colonel Cutler received many sound ideas on

specific items which would have to be included in a directive on thoracic surgery.

Before returning to the Continent, Colonel Cutler was able to work up the data

for the thoracic surgery directive in more or less final form with Colonel Morton

and Colonel Miscall.

End of Long Winter Campaign

Another round of directives

Colonel Cutler crossed the Channel to France on 3 February 1945 with

General Grow and Colonel Wright. In the afternoon, he spent his time preparing the new "professional circular" for publication. On 4 February, three

new directives were ready to be submitted for publication in rapid fashion.

One was the professional circular on the care of battle casualties, another dealt

with changes to the list of conditions issued to disposition boards for guidance

in selecting patients for return to the Zone of Interior, and the third was a

paper on priorities for air evacuation to the Zone of Interior. Before going to

the United Kingdom, in fact before the trenchfoot meeting, Colonel Cutler -..

submitted another directive, in draft, pertaining to information given to casualties. Immediately after, and as a result of, the trench foot meeting, the draft

of a directive on trenchfoot had also been submitted.

Information to casualties.-Colonel Cutler had originally intended to

include the item pertaining to information being given casualties in the new

directive on care of battle casualties. Colonel Bricker, however, convinced

him that the matter was so important that it should be published separately.

Consequently, it was issued by the Office of the Chief Surgeon on 31 January

1945 as Circular Letter No. 11. The reader will note that this directive pertained but little to professional matters outwardly; nevertheless, it had much

to do with the successful rehabilitation of a casualty to duty and without his

returning again to the medical chain of evacuation for the same injury. The

directive, as published, was terse and quite self-explanatory. It stated:

1. Under no circumstances will medical officers in forward hospitals, whether Army

units or general or station hospitals, tell casualties that their injury is such as to necessarily take themn to the Zone of Interior. Frequently, what appears to be an injury

necessitating evacuation to the Zone of Interior turns out to be recoverable, and, if the

soldier has been told that he is to go to the Zone of Interior, the reverse of this decision
CHIEF CONSULTANT IN SURGERY 311

leaves hint disappointed and embittered, and lowers his usefulness to the Army in the

future.

2. The practice of discussing the disposition of patients in hospital wards in the

presence of the patient himself (Jr of other patients must be stopped. All disposition board

proceedings must be held confidential. Giving the patient strong iml)lication that he may

go to the Zone of Interior should be guarded against until final movement of patient

commences.

Trenchfoot directive.-The trenchfoot directive was submitted on 28 January 1945 immediately following the meeting at the 108th General Hospital.

It stated that TB MED (War Department Tclhnical Bulletin) 81, which had

been reproduced in the European theater, was the basic directive on the treatment of cold injury. However, the new directive, Circular Letter No. 18,

Office of the Chief Surgeon, ETOUSA, dated 21 February 1945, gave additional

advice on therapy based on current information gained in the theater. This

guidance was in two parts-treatment in the forward area and treatment in

fixed hospitals. The important part of the directive was a greatly simplified

chart that attempted to show how to classify this type of casualty and to aid

in the evaluation and disposition of these casualties. Dividing trenchfoot cases

into mild (first degree), moderate (second degree), and severe (third degree),

the directive showed under each of these categories what to expect in the way

of history and physical findings and how the cases in the three categories were

to be disposed of. The physical findings were further broken down into those

observable during the hyperemic and posthyperemic stages and in the motor

functions of the foot.

When Colonel Cutler was in England shortly after submitting this directive for publication, he discovered in no uncertain terms how necessary it was.

During the meeting with the United Kingdom Base surgical consultants,

Colonel Cutler was informed by the consultants that the routine care of cold

injury was the responsibility of the medical service in the hospitals of that base

as differentiated from the surgical service, and that the internists had not yet

decided who could or could not be returned to duty.

Certain directives, however, by reason of the fact that they had been issued

by higher headquarters, could not be changed or countermanded at the

ETOUSA level. The directive pertaining to the awarding of the Purple

Heart. for frostbite was one of these. As it was seen, Colonel Cutler had found

that the awarding of the Purple Heart decoration was being badly handled,

but the basic directive permitting this had been issued by the War Department.

Accordingly, the only action Colonel Cutler could take was to prepare for

General Hawley's signature a letter to The Surgeon General requesting that he

take action to correct the situation. The letter, as prepared in draft by Colonel

Cutler, follows:

We are greatly troubled by War Department regulations stating that the Purple

Heart is given for "Severe frostbite". We have qualified severe frostbite as follows:-

"The words 'severely frostbitten' will be Interpreted to apply to only those cases of

frostbite In which the lesion is so extensive and lasting that cells are killed and the result

will show actual loss of substance; either loss of a digit or a slough which extends throughout the whole thickness of the corlum."
312 ACTIVITIES OF SURGICAL CONSULTANTS

The fact is that with the temperature just at freezing, one day above and one below,

and with "cold injury" the pathological agent, it is almost impossible to make a distinguishing diagnosis. Thus, some soldiers get a Purple Heart and others do not. As a

result our wards contain many embittered Infantry men. This is emphasized when the

"trenchfoot" victim has a greater injury than the "frostbite" casualty. It would appear

that the Medical Department is asked to apply a policy which it did not establish or

suggest and which it finds impossible to administer fairly. Forward units confer the

Purple Heart and under pressure from Line Commanders, who demand liberality in order

to keep troops reasonably mollified, are naturally not too strict. The Purple Heart is

gradually becoming worse than a joke.

I think this is going to give us all a headache, but, still worse, it has greatly disturbed

combat soldiers. Men with simple blisters from frostbite are getting the Purple Heart

and men with incapacitating lesions from trench foot get nothing!

If you agree in this, perhaps you will take this up with the War Department and see if

there can be any change in the present regulations. 10 7

Care of battle casualties.-Circular Letter No. 23, Care of Battle Casualties, 17 March 1945, issued by the Office of the Chief Surgeon, ETOUSA, was

the last comprehensive directive on the surgical care of the wounded to be

prepared under the direction of Colonel Cutler during the period of hostilities

in the European theater. This directive, together with the Manual of Therapy,

ETOUSA, Circular Letter No. 71, 15 May 1944, Circular Letter No. 101, 30

July 1944, and Circular Letter No. 131, 8 November 1944, all from the Office

of the Chief Surgeon, ETOUSA, constituted the sum total of basic policies

which prevailed during the period from D-day to V-E Day with reference

to the surgical treatment of the wounded. The Manual of Therapy and the

first circular letter, the reader will recall, were prepared before the invasion

and stood in good stead-good enough to be still applicable in most respects

at the war's end. The second letter published in July 1944 was a hurried affair

to correct the mistakes which had been observed during the initial stages

of the invasion. And, in November, with the difficult evacuation situation,

Circular Letter No. 131 had been published, dealing extensively with the management of fractures, care of hand injuries, colostomies, and other items

which were of immediate concern at the time and which required standardization.

And lastly, the new circular letter was the result of observations made by

Colonel Cutler, the senior consultants in surgery, and the many consultants

in subordinate commands-whether in field armies or base sections-throughout the course of this campaign in the Rhineland. This directive, together

with its predecessors, tells a story which might well be entitled, "Surgery in the

European Theater, World War II." The first of these circular letters has

been reproduced as appendix B (p. 963), and, in like fashion, the last of

the series, Circular Letter No. 23, Office of the Chief Surgeon, ETOUSA,

of 1945, is reproduced as appendix D (p. 977).

101 Memoradum, Professional Services Division (Col. E. C. Cutler, MC) to Chief Surgeon, ETOUSA,

4 Feb. 1945, subject : Letter to Surgeon General re Purple Heart Award for Frostbite and Trench Foot.
Hospitals for specialized treatment on Continent.-- Sometuuime later,

C olonel ('iliter's dIrI-et ve. prepareul III Nov-qIelbe 1!)14 ;111( perItatluiIIg( to lioSpid1 al br Specialized reatl liehut ()Il thle ( olit ilient * was approved br pihile.Icat ba.

Moif)iied 14)rlu It) 14) tolate. thle lirec I Ve evelittinilly :lppe:l i'ed1 as ( ircijiar1

Let iei No. 32. Offlice (d tIle ( le'In Siir'.1eoil. EI1'F )SA. I4llted 1 ; April 191.1

]I roiiicall ' v however. thle fivil :lriliies. 1) , 1:t lintlme. 11:1( Iliove(l So raly ~(I t hat

jI eY 11.1d plet thle ~eirlhospitals lit the bradSectin (A'1 ofilhe volimiit'l nvH0115 Zonie hIPl biehlind, .1iiu1 castialt ie's WereV re1ClIIIig hospit11als ill filie 1arls.is area

I )v allr mlore ra pidll t halii I hey% (1h4 I) Ihe veva(I laIv(tI I )Y 1:111( 1 1 rn I s I mil 411 tmIIo

f ile ii~ter-%eliiIII, Ilospata Is whlere SoIie o1' thle 1)eti~l ifimeu I real meavt l'ainlit ie's Inni

MIN'e cla ing li decks, as~ it were, ol, the St all, work which was refili r-ed

a fter every, period of vislts to th lie Ield--iliclidimllr lie Siilnimissoal of Iindicaited

lirIect ives for- publicat ionl. Coloniel Oldi er )text dleparIted()I on f ieldl trip to Iliev

Th'lird U .S. Ariinv where he laid lollir coi'tlvifeelves with Ci(oloniel harl1.ev. Sur-

?e( HrArl.a I11 11(ooeh()mn. lie was alile to) loate ('ap a ill OlderIt,

and1( oll thle even i~l!i of, G February11 191.,) Ilhey dinled withI Lt . (el C eonr-e S.

Patton. .I (olilimiaihi& (l ;eiieral. 'hird V.S. Ariii1Y. MIaj. (;eil. Hobart R,.

( av~. lef of Na if. and4 ot her-sof I i 'lil~l~il reIne-;i I*SStallI ( tag. 112).
II' A( I V liii TI~ 1 Ill' (I UIO 14 *AI1 4 IN\".I I AN \ I '

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(tCHIEF C(INStt.TIANTl IN SURGER~lY .

F'i(.vi I 13.-ArIUioedl medical vehicles.

were aItt;Il~ewt to the ariiioredl IraiII alill have reahedieI p Ioint where file armioredl dIivisions

.11-4 deliiiading thant these units becomie ant integral part of their miedical support. In

the tiehi. the( followingý use is made ot this~ unit :whienii th collecto-cleariiig station of

,IIaoll ;loredl (livifioli is sitl uip, the( ziiohih', silrgical team sets tipl next to it andi~ is iminediat ely a vailahle forl (letiliit lye sur~gical carie. If lthe airmioredl divisioni imoves a (lay or

even- hours hat er. Ibe team a~gain moves with it. 'The iuse of such. a mnilt .shoulhd be further

At unied. and~ it iiialy hie discoveredl that a unit anlticip~atedI for general service and~ use,

will iuild its Illost. logical platcemienit withI armored or miotorized infantry (divisions (fig.

Colonel Kim broiigh departs

At. ~tboltt. thittit tillie, it bcametU (lefiflitelv kinown t hat Colonel' K illiromlgh

wits to 1et0111-11 to i lie I n it d St at es. After coidferrno,~ with It(rentierat Kenner

ott it0 F'ebriiar ,v. its nivielont t(ie(1 eirl, C olottel ('~itler proceeded to a1 falrewiell

(tIIlII(ir for ( olo de lKtil)Polt±flij, Velb I)% (;)eItIIIt l~Ot 'V~Itt.i tirllIl(I

lit addressingz thle diuiler gulests- anud toast ing the departing chief of the

Prof) essionalt Serv ices D i vision1. C olotiel ( 'it hersa i I:

We itetto hid goodb~tye' auiiu to (lo bouior to a colleague anid aI friend. It wvill he hard

for -Tinii to) iisteii tf ome114 (if t his bcleuse lie( is essentit ally a1 mlodest ibiiilhl he uuiuist

hear with ls .11l4l fillur ecliei ini uims. for we jmust he iierniittedI this privilege.

Ini 21:2 Years I liat we in I ilie Professiona~l Serv-ices I ivisioil have beeni together. all

have imifde friends with 4 donel Kinibirouighm. not tightly, for inl fl(,'.-: adult years frienidls'eniual t'l'ctiiitc:u Medical Diata.,~~b5~ fo'r Mafirei 1945. If; MAly 194.51.

7115 0915' -14 23l
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CHIIEF," C'ONSULTANT IN SURGERY 317

amusing has cropped up, for he has an uncanny flair for rapidly judging the meat and truth

of any matter, lie has always said it was hillbilly common sense, but many of us who have

playedt at the game of life and success for years know that such intuition is not confined to

Tennessee, and we have learned that Jim's prognostications and judgments are usually

confirmed by subsequent happenings.

Our feelings of Jim have fortunately already been inscribed in the annals for posterity

by Sir Henry Tidy, President of the Royal Society of Medicine. In conferring an honorary

fellowship on Colonel Kimbrough, he spoke of one who had a suitable and kindly disposition

proven by the fact that he directed a diversified and motley group of independent scholars

who peculiarly, from the British point of view, spoke of him as "Uncle Jim"-Thus was his

fellowshi p conferred !

Jim Kimbrough, we who are your friends wish that happiness may (log your footsteps

and "Lady Luck" always sit on your shoulder and kiss your cheek.

I give you "Uncle Jim "

Colonel Kimbrough left for the Zone of Interior on 11 February 1945 via

the United Kingdom. Before leaving, however, he addressed the following

undated note to Colonel Cutler which, obviously, was intended for all the

consultants in the theater headquarters:

My duties with the Professional Services Division are terminated. I take this opportunity to convey my deep appreciation to each of the Consultant Group for your hearty

cooperation during these many months. A more proficient and splendid group of physicians

has never been on duty in any echelon with the United States Army. It has been a great

privilege and pleasure to have had the opportunity to be associated with you in a personal

and professional capacity.

Your efforts have assured the American soldier the best medical care that has ever

been given to any army at any time. Whatever recognition may be given you for your great

work, I am sure the greatest reward each of you has is the consciousness of having given

the best of your efforts and talents to the care of the U.S. Army personnel in this emergency.

Best wishes.

On the day of Colonel Kimbrough's leaving, Colonel Liston, Deputy Chief

Surgeon, informed Colonel Cutler that he was to assume the position of Chief,

Professional Services Division. Colonel Cutler's private feelings on the change

were: "If I succeed, I'll be tied down; if I don't, we're stalled." To be sure

that he would be neither completely tied down nor stalled, Colonel Cutler asked

for and received the assignment of Lt. Col. Bernard J. Pisani, MC, as his executive officer. Colonel Pisani was the officer who had so successfully administered

the Medical Field Service School, ETOUSA, while it existed at Shrivenham

Barracks in England. Capt. Wayne H. Jonson, MAC, who had been administrative assistant to the chief of the Professional Services Division, remained.

It is said that a new broom sweeps clean, and, without exception, Colonel Cutler

obtained concessions from Col. John C. Rucker, MC, of the Personnel Division

and from Colonel Doan concerning the Administrative Division so that lie could

effect "office changes leading to greater comfort and efficiency of personnel."

Rhine is breached

In early February, a series of coordinated onslaughts against German

positions west of the Rhine had begun. The announcement from Supreme
1 I~ll~lil ti~.Ailled Ex ped It WI41:1 r v Folly. v4)llfidetlt Iv Stated ('I I 11 tthese

Ihe I~liniie. B~v thle VIAd oF eiuiiimn. tl II~ ir-ZI U.S. ArIliv w,-; he-i.1vjmril

11:14 IaI fuiell to, I lle FhiS I.. Ar IIv. ( )ii 7 Febriar \.; ta ti- forte f'rmik

tue '.1 IiA\rIlml-ed~ DIN~-l-Iml cluldlIl irdllV Ielieve t 'v-.foP at Reinituireu a tIe,-

Fictll: 115. Fi~i . V.S. Ary ilivii anid el'1141id1m'llt pou'ring acir'-s lilt Utuilingen'l tBridgv,

It1:411 i Van i 1.-D

Illt'111101l' I .i14-rolI4) tiw S\\wo (.lleli 1 ve 11V. I)-r'ier re I I miI ledl tI Il at -. It IlaIs oftell

Ifee91 told ]I()\%. ( IIIoii all 11~1,V1411v u~flllltoll.- ureiliN a I'111vs-- ofl~k'l~4.~ ) the

( i4'rll;t f411IlEJitDllms offii'er. fIa~dt V filse-. alertille. ts tf lie U .S. rc~itiI-i

M41 1edhiIlel tht'iiioit Thl lii e I-ii-t U .". Ar~ilV 4Ix il.llr qulirc to) Seiz.e I iii-

.Ind joya~hl-di'/o'l II~ 11 m -aefuiillY pdl.1lehI ( itlli Ila ' ie~lll~a Ivvlv file Rhinie Ro~ileI

(o~w C1i1(il It'rl -a Ild If) iiu-t'I I': ''Wor jou well. I hele44v4' it XvIll 1)4'
CHIEF CONSI'LTANT IN SURGERY 319

CAMPAIGN IN CENTRAL EUROPE

Collapse of Enemy

True to Colonel Cutler's private prognostication, the tight on German

soil rapidly turned into a pursuit of (lemoralized Germnn forces. To the

extreme north the British 21 Army Group resorted to full-scale, amphibious

operations to cross the Rhine, secure strongly held enemy islands in the Baltic,

and advance across the Elbe River to occupy Wismar on the Baltic coast by

the end of April. The First U.S. Army also neared the Elbe by the end of

April and waited on the b)anks of the Fulda River for the Soviet Army, while

the Soviets waited on the banks of the Elbe for the Americans. On 23 March,

the Ninth U.S. Army crossed the Rhine in the vicinity of Dilsseldorf and by the

end of April, it too was on the Elbe-Mulde line to link up with the Soviet

Army. The Third U.S. Army crossed the Rhine in March, drove rapidly

through Bavaria and Hitler's "last redoubt" and was in Austria and Czechoslovakia by early May. The Seventh U.S. Army, in late March and early

April, breached the ul)per Rhine defenses in the area of Worms and, by early

May, a portion of the Army had made the complete circle and was back to its

starting base, Italy. There, it linked up with the Fifth U.S. Army south of

the Brenner Pass and received the surrender of all German forces in its area

on 5 May 1945 (fig. 116). Fighting alongside the Seventh U.S. Army in the

Sixth Army Group, were elements of the valiant First French Army.

Responsibilities of Chief, Professional Services Division

With this rapid collapse of the enemy's resistance, Colonel Cutler was

extremely harried by the many responsibilities which befell him as the new

chief of the Professional Services Division, Office of the Chief Surgeon. Some

of these problems were inherited immediately upon Colonel Kimbrough's departure, and others came his way soon thereafter.

The first of these problems was the examining, evaluating, and profiling

of the physical fitness of every enlisted man in the theater. The War Department had directed that a new PULHES system of physical profiling be accomplished rapidly so that the resulting profiles could be used in the redeployment

of personnel in the European theater to other theaters of war when active

hostilities in Europe ceased. Colonel Cutler could not help but recall with

some dismay that he had participated in British talks on this system of profiling

in January 1944 when it was devised by the Canadians. At that time, he had

submitted complete notes on the Canadian system. He stated: " * * for it is

felt that perhaps some other division than The Professional Services Division

would be interested in seeing this method of assessment." Even then, when

ground hostilities had not yet begun in Europe, Colonel Cutler had stated:
320,

V77

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CHIEF CONSULTANT IN SI'IGERY 321

respect, concurren ly taking some of the load off the rehabilitation centers.

Obviously, this lengthened evacuation policy for the continental hospitals

changed the complexion of the extent of treatment tobe given therein.

Colonel Cutler had to coordinate activities ained at establishing a "recovery center" on the Continent. The original recovery center in England had

been established by Cotl. loyd J. Thompson, Senior Consultant in Neuropsychiatry. The recovery center set up in a strictly nonhospital atmosphere, had

been extremely successful in salvaging manpower from borderline cases of adjustment, Such as tile mentally deficient and those with character and personalitv

disorders. The success of the center in E1ngland led line officers on tile staff

of the comniunications zone headquarters to desire strongly the establishment

of a similar facility on continental Europe.

The care and treatment of RAMP (recovered Allied military personnel).

liberated civilian lprisoners, alnd displaced German nat ionmls grew into pro)l)-

lems of monumental proportions as the subjugation of the Nazi forces liermeate(d ever deeper into the fatherland. Providing for the care of prisoners of

war had been a 1)rob)lem since the Northern France ('amlaign and continued

to mount in coml)lexity as ever-larger numbers of the enemy surrendered (fig.

117). Colonel Cutler was the writer of the basic directive regarding their

medical care and treatment.

There was also the program for establishing extensive educational opportunities throughout the theater following the cessation of hostilities. The

overall theaterwi(Ie program was being coordinated by ETOUSA headquarters

and theaterwide medical education and training by the education and training

branch of the Operations D)ivision, Office of the Chief Surgeon, ETOUSA.

But. it was the responsibility of ('olonel Cutler to make plans and arrange for

the professional education of medical officers during the posthostilities period

in the renowned civilian medical centers of France and England and in U.S.

Army general hospitals with qualified instructor p)ersonnel.

These, and many other problems of lesser scope, were to occupy much of

the time and energies of Colonel Cutler in his new position. To compensate

for the resulting loss of time and attention to his other position as Chief Consultant in Surgery, Colonel Cutler made more and more use of his specialist

consultants on general surgical matters. This was particularly true of Colonel

Bricker and Colonel Robinson who, p)erhaps, were in narrower fields of specialization than the others. There were many direct dealings with Lt. CoL. Theodore L. Badger, MC, the medical consultant in Normandy Base Section, on

whose able shoulders fell the brunt of the work in planning and supervising

the professional aspects for the initial reception and care of RAMP. Colonel

Zollinger, now commanding officer of the 5th General IHospital, helped Colonel

Cutler in the p)reparation of directives on rehabilitation in general hospitals

and, later, was to become a key figure in certain phases of the relocation and

selection of personnel for redeployment. Colonel Pisani, as mentioned earlier,

was of invaluable hell) on administrat ive matters peltaining to tie ent ire (livi-
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326 ACTIVITIES 01" SURGICAL CONSULTANTS

to the Ninth U.S. Army and visited Headquarters, XiII Corps, where he discussed the job of a corps surgeon with Colonel Shambora. O(n the morning

of Friday, 30 March, Colonel Cutler ".nd General Hawley discussed with

Colonel Shanibora certain aspects of the l)rofessional services in the Ninth

U.S. Army and the blood situation. As there was no aircraft available for a

return to Paris, General Hawley and Colonel Cutler borrowed Colonel Shambora's staff car and proceeded to the banks of the Rhine on the approaches

to 1)orsten. ThIiere they borrowed a jeel) and proceeded up to General Ilawley's

son's unit, the 399th Field Artillery Battalion of the 8th Armored Division.

Colonel Cutler recorded: "They were firing at targets twenty-seven hundred

yards away! It was a very interesting day. The Germans are apparently

short of artillery as well as air."

Colonel Cutler and General Hawley were finally able to fly back to Paris

later that (lay, arriving at 1900 hours. The one overall impression which prevailed was the relative inactivity of the evacuation hospitals of both armies,

most of which were either on the move or preparing to move.

Eminent Visitors

On Monday, 2 April, after his return from visits to the First and Ninth

U.S. Armies, Colonel Cutler first entertained Colonel Jurash, surgical consultant to the Polish Army in Exile. After a long conference with him, Colonel

Cutler took the Polish officer for an audience with the Chief Surgeon and then

escorted him to the G-5 Division, ETOUSA, for further conferences.

Later that day, Maj. Gen. Morrison C. Stayer, 'MC, Chief Surgeon,

MTOUSA (Mediterranean Theater of Operations, U.S. Army), and his surgical consultant, Col. Edward 1). Churchill, MC, arrived for a liaison visit

to the European theater. Colonel Cutler dined with them and had a long

evening with these colleagues whom he had not seen since November-December

1943. HIe continued talks with Colonel Churchill the next morning and also

spoke with Lt. Col. Michael E. DeBakey, MC, Consultant in General Surgery

to The Surgeon General.

Colonel DeBakey had arrived in the theater for a liaison visit following

a similar visit to the Mediterranean theater. On 9 March, after conferring

with him, Colonel Cutler had sent Colonel DeBakey off for a visit to the First

U.S. Army in the company of Colonel MacFee, who was opportunely in Paris helping Colonel Cutler on certain personnel shifts and being interviewed

concerning his contemplated reassignment to the Fifteenth V.S. Army. After

the First U.S. Army visit, Colonel l)eBakey had visited the Ninth, Third,

and Seventh U.S. Armies. Ills visits in the army areas had included conferences with the army surgeons and their surgical consultants and some corps

surgeons. Ile had visited auxiliary surgical groups, evacuation hospitals,

convalescent hospitals, field hosp)itals, and collecting and clearing stations, and,

in the 75th Division area, lie had visited a battalion aid station in action. lie

was at this time, 3 April, contining visits to comnmunications zone facilities

in and around Paris.
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CHIEF CONSULTANT IN SURGERY 327

In the afternoon, 3 April, Colonel Cutler left with the visitors from the

Mediterranean theater for the United Kingdom.

In the United Kingdom, they met with General Spruit and Colonel

McNinch and planned an itinerary for the officers from MTOUSA. The tour

included a visit, oil the first day, to the showpiece of rehabilitation facilities, the

327th Station Hospital; hospitals of the Cirencester hospital center the second

day, with special attention on the specialized treatment facilities of the center;

and, on the third day, a trip to Oxford University to visit with Professor

Florey and, later, visits to the 97th and 91st General Hospitals nearby. Colonel

Spurling and Colonel Morton were sent out to escort the visitors while Colonel

Cutler remained behind to arrange for their meeting with members of the

staff of the DGMS, British Army, and for a continuation of their tour by

visits to the First U.S. Army.

On Thursday, 5 April, however, Colonel Cutler learned during a telephone

conversation with Colonel Pisani on the Continent that General Hawley wanted

to see Colonel DeBakey soon. Colonel Cutler instructed Colonel Pisani to ask

General Hawley to defer any meeting with Colonel DeBakey until he, Colonel

Cutler, could get back, which would be the next day. Colonel Cutler returned

to the Continent on 6 April. Before taking his hasty departure from England,

Colonel Cutler had spoken by telephone with Colonel Spurling and Colonel

Morton on the trip being taken by General Stayer and Colonel Churchill. He

was pleased to note: "Reports were highly satisfactory."

Back in Paris, Colonel Cutler joined in conference with General Hawley

and Colonel DeBakey on Saturday, 7 April. In the conference, Colonel Cutler

emphasized the fact that the Army in the European theater, and the medical

service in support of that Army, were extremely busy. He stressed the point

that the professional care of patients must be planned and executed with the

single thought in mind of the influence of tremendous numbers of casualties on

professional activities.

On his return to the Zone of Interior, Colonel DeBakey reported to The

Surgeon General in a letter, dated 17 April 1945, as follows:

The therapeutic adjuncts and basic surgical principles utilized in the program of wound

management developed by the theater surgical consultant and his consultant staff and

presented in various publications of the Office of the Chief Surgeon are being effectively

applied by the surgeons In the Army hospitals. The Army surgical consultants have contributed immeasurably in the implementation of this program. In general, the policies

established by this program of wound management conform closely with those presented

In the recently published War Department Technical Bulletin (TB MED 147, March 1945).

The development of this rational program of wound management and its successful application have been largely achieved through the profound Influence of the theater surgical

consultant and his staff. The attainment of such a high standard of surgical practice and

the gratifying results achieved form a signal tribute to his broad vision, his untiring educational efforts, and his trenchant surgical judgment. The admirable manner in which he

has performed his function is further reflected by the fine spirits of cooperation that exist

between his staff and the Army surgical consultants and the respect and loyalty manifested

by the surgeons In the hospitals toward him.
328 ACTIVITIES (.)' SURGICAL CONSULTANTS

That sanie evenilg, after tie Conference with Colonel D)eBakey aml General Hawley, a telephone call camne in to the Chief Surgeon's Oflice from the

Third U.S. Ariiy-General lat ton urgent ly requested Colonel Cutler's presence

and was sending an airplane for hin. Colonel Cutler was inst ructed to be ready

to leave the first thing the next morning.

At. 0800 hours on Sunday morning, 8 April 1945, Colonel Cutler left. Paris

by air, taking Colonel lPisani with him. Some 2 hours later, t hey arrived at

Headquarters, Third U.S. Army, where General Gay, Chief of Staff,

and Colonel Odom inet them. Front the headquarte rs, they went to the 34hI

Evacuation HIosp)ital to look at, the oflicer for whom consultation had been

requested.

This officer, a Colonel "W." of Armor, had been capt ured by t lie Germans

in North Africa niore than 2 years earlier at the battle of the Kasserine Pass,

where he had (list inguished himself by bravery anid exemplary act ion. Ile had

been shunted through various prison canips by the Gernians and had recently arrived at the camp at Ilamnmelburg, east of Kassel. General Patton, learning

that there were American prisoners at the 'mlunp, in characteristic fashion sent

a special armored task force kniling through the enemy defenses to liberate

them. Colonel "WT.," the ranking oflicer among the Americans in the caoi)P,

accompanied the German camp commander out of the compound under a flag

of truce to surrender the camp to the oncoming Third U.S. Army task force.

As he did so, a sniper shot Colonel "W." from very close range, and he was taken

back to the carop for treatment. Meanwhile, the Germans surrendered the

camp, and sonie of the liberated prisoners were loaded on tile tanks for evacuation back to the Third U.S. Army lines. Strong andl persisltent pressure from

a retreating German Division, however, forced the task force to withdraw under

perilous circumstances. It was not until some 4 days later that Colonel Odoin

was able to fly to Kassel, join a combat patrol, and, skirting the fighting still

going on around H[aminelburg, enteer the camp. During the night, he gave

Colonel "W." what emergency treatment he could, including a transfusion of

whole blood. The next morning, lie called back to Third U.S. Army headquarters and requested that light aircraft be sent up. Two such aircraft. were

sent; Colonel "W." was evacuated to the 34th Evacuation Hospital in one, and

Colonel Odom returned in the other.

Colonel Cutler found the officer's wound most unusual. The sniper's

bullet had entered just below the right groin externally to the great vessels,

must have passed under the neck of the femur, and emerged through the anus

and buttock area, blowing out a considerable amount of tissue and the coccyx.

A Serbian doctor in the prison camp had debrided the wound as well as he

could with the limited facilities available to him and had sewed the sphincter,

which was now intact. The wounded officer was having his second transfusion.

He obviously required proctoscopy in order to determine the extent of damagre

to the rectum. Proctoscopy might reveal that a temporary colostomy was

indicated until the rectum could heal. To Colonel Cutler, lie looked well

enough to transport.
CHIEF CONSULTANT IN SURGEIRY 333

characteristic of the entire front at this time-what to do about German military personnel and civilians requiring care; the problem of Soviet nationals,

Poles, Czechoslovaks, Yugoslavs, and others liberated from the prison camps;

idle specialists in the First U.S. Army's medical service; and so forth, as

follows:

After leaving the camp, we had a talk with the commanding officer of the 45th

Evacuation Hospital and then went to headquarters of the First Army in Weimar,

where we discussed the care of these people with Colonel Snyder, Colonel Amspacher,

Colonel Crone and Colonel Crisler. The First Army have adopted the following system:-

they have a captured Major General of the German Army, Medical Corps, who has seen

33 years' service, and seemed to be able. They are giving him the responsibility of caring

for all Germans, whether Army personnel, wounded in their hospitals or the civilian

population. The First Army area has been broken up into districts under this German

General and they have attached certain Medical Corps officers to him and in his district

for overseeing the care of these people. The only difficulty that remains, since all the

German Army casualties will be kept where they are, is what to do with them when

they are ready for discharge from hospital (this matter was discussed in detail with

Colonel Fancher this morning and a paper submitted to him regarding it).

The care of RAMP is difficult and will be looked after by the teams of medical officers

set up by the Army for this purpose. Insofar as possible, the RAMP will be kept where

they are, their food improved and as much care as possible given to them. Every attempt will be made to utilize their own medical personnel. The only exceptions to be

made will be that all tuberculous people will be screened, removed from the RAMP

hospitals and taken to Bad Berka a few miles out, for improved care.

Conference with Colonel Crone [medical consultant]. If he is not to return to the

ZI he desires to take a course in tropical medicine to improve his usefulness in CBI.

Colonel Middleton is implementing this.

Conference with Colonel Crisler. The First Auxiliary Surgical Group, attached to

the First Army, are being returned to the headquarters. His own Auxiliary Surgical

Group, the 3d, is being pulled in and he would like to send them to our Communications

Zone hospitals soon. I approved this and hope he will send in recommendations so that

we may use this valuable professional personnel in our busy Coin Z hospitals.

Brought down a load of guns and swords for Colonel Doan.

Left by 'plane at 4:30, having picked up a full load of officers and newspaper men

trying to get out of the First Army area, back to Paris. The trip back took three hours;

it was by far the worst air trip I have ever taken, in spite of the fact that I have

flown, since I have been in the Army, some 25,000 miles, including the great trip to

Russia and back. It snowed hard while crossing the Rhine area, one could scarcely

see the wing tips and, barely visible a few feet below us, tree-tops, while mountains

were about us on all sides. I shall send a note of commendation to the commanding

officer of the unit to which the pilots who took us there belong, expressing our appreciation

for their excellent services.

V-E DAY

Victory in Europe, V-E Day, came as no surprise to anyone. For days,

its imminence had been the headline news. When it did come, there was

some conjecture as to whether it was 7 or 8 May; it was 8 May. Colonel

Cutler was in London at the time. Whether this was by coincidence or choice,

his diaries do not say, but it is not difficult to conjecture that it was the latter.
334 ACTIVITIES OF SURGICAL CONSULTANTS

AFTER V-E DAY: GETTING OUT

The period after V-E Day settled down into a routine uninspired but still

full of pressing items. All realized, with various feelings and motivations, that

there was still a war on, but there was very little enthusiasm left.

Miscellaneous Activities

Physical standards and redeployment.-The projects of physically

profiling all enlisted men and redeployment went hand in hand, for the second

could not be accomplished without the first. Accordingly, the making out of

the physical profile serials became a problem of extreme urgency in the posthostilities period. Colonel Cutler, himself, was more personally involved,

however, in the selection of professionally qualified surgical personnel for

redeployment and the organization of professionally balanced and qualified

units to be shipped to the Pacific and Asiatic areas. This eventually became a

nightmarish activity. "What a life," the diary states, "Redeployment a terrific headache." Then, later: "It has all been a jumble. We're all exhausted

and probably don't make sense, but I think there will be a Congressional investigation of redeployment-there should be. I've told Hawley so. Asked

him to exonerate Professional Services Division as we have no authority,

therefore no responsibility." Officially, in his semiannual report to the Chief

Surgeon for the first half of 1945, Colonel Cutler stated:

Following V-E Day, redeployment began rapidly and pushed the Professional Services

Division into greater activities, at a time when it was exhausted. While the theater was

feverishly searching for a critical score system, and even before it was available, we had

to assemble balanced professional units for immediate redeployment. During the phase

of redeploying the first * * * units direct to the Pacific, urgent cables from Washington

instructed us to send home about 1,000 doctors. Lists of certain critical specialists in fixed

numbers were included. These were rapidly gathered and were ready for transshipment

to the Zone of Interior by early July. This further depleted the supply of specialists to a

critical point, since this theater never had a sufficient quota for adequate T/O coverage.

Redeployment demanded the greatest co-operation between the Personnel and Professional

Service Divisions. The Personnel Division drew up plans and, although every attempt

was made to assist them, the result has not always been satisfactory. Redeployment of

professional personnel has not been on a strictly professional basis, and only irregularly

submitted to this Division. Although the point score may seem fairer than any other,

it has definitely compromised the setup of these units. In disregarding longevity of

service, it has worked hardship on a group of highly trained professional people. The

Army has lost many of its best and critically needed officers, who are more tired and worn

out than the general lack of battle stars, points and decorations might indicate.

Battle casualty survey team.-The Operational Research Section, Office

of the Chief Surgeon, under Maj. Allan Palmer, MC, had been reconstituted

as the 250th Medical Detachment, and, after 10 weeks of feverish activity,

the necessary personnel and equipment had been assembled and authority had

been obtained for independent action in the Third U.S. Army area. Colonel
CHIIEF~ CO)NSULT'ANT IN SUIMEi'RY 329

Back at Thliird U'.S. k riny lieal(plia rter,, ('oo~loel ( 'iiler ad v isedl ( iliera I

I a1ttoii that t(lie officer. should be taken havk to te liest ( iwnrnl H ospital1 iii

Panris to Cnarry' out til 1wiwcessnrv examiniations1 anid operations. T1'le (ieiieral

aigreed to follow niiv- advice tlie( consutltanits gave loin1 and exp~ressedIlhis

gratititude.

A fter iticli, ( icieral Pat toni loatiedtilt-li conisult ants his personal sint (-.car

S flint t hey could go to heidetlberIg to visit D~r. Richard KuhnI, tile wh*iniwi*of tilie

193S oe Prize in Chemwiistry~. D r. Kuhn,upj)to 11w 1ile of lie war, had bweei

the director of the Max Planck I nsfit ulte for Medlical Reseairchi at tilie- Uniiversity of HIeidelbierg. Ilie was one of tilt' first, to describle tle. colist it lit Miol ot

ribofllavin. vitamiin 11'. It was D~r. Ktiliti who had first isolated1 I grrain of rihofiavini vitamnii 1IL, from 53.0H) liters of skiiiiiied miilk. D~r. Kuhn bad also

isolated pyridoxine, vitaiiiiin ,1..

D~r. Kuhln mient ion~ed to the visitors, Coloniel ('ittler, C'oloniel (holoii, andl

Colonel Pisanii, that Ilie had placed himiisel f iii conisidlerab~le jeopardy by havting~

spoken openly against. the Nazi palrty. Ile sai(I that . an SS trooper lived inl tilie

institute and knew everythin g lint. went. ol. Ile iniformed the vissitors Ihat

D~r. Martin Kir-schner had passed away 3 years earlier (19)42) and had beeni

succeeded IW Dr. K. 1i. Balier. fornierlv of tt( 1wVniversitv of Breslaum.

Rteviewving his wartiiie work, Dri. Ktihn first corrected a prevailing iiisconicept~ion that lie had creat e( a substan11ce thlit acted as insuil in and could

be taken by moutith. Ile nient ioned I comiplex mnsatiurated hydrocarbon that

lie had1 isolated whlich wvas siimilar to soirie of his other diseoveries aniiong tile

long-cluii.cil 1NmvilUId Containing eonjugate doublhe 1)021(1. This dee)-bllue

liquid had1( been found to be ain effective bacteriostatic agent. in experiments

conducted in vitro against graint negat ive organisms. It had also been p~roved

very useful against mustard (gas injuries of thle skin, although it, had not. been

(leeloped for general issue in the Germian Ariii. Ile also mentioned a prodInet, "'306.5, . that, had been syiitliesized by a Professor Kahni. This prod(u1ct

alctedl like lpenicillin 2111( had1 been used extenisively iii experimients, involving

11121111 and1 animals. It, appeared especially efficavious against Staiphylococcus~

0I,,rC11M 2iid gonlococculs. With respect. to thle latter, it had p~rovedl part icularly

uisefuil in grenital in fect ions of woiien p~roved to be sul fonamiide resistant.

At, (dinner that. night, at, fie Third U.S. Army headquarters mness, Colonel

Cutler was p~leasedl to meet ~JohnI J. McCloy, Assistant Secretary of War, who

was in~specting in the area. Among other itemis, the Assistant. Secretary (declared, dutring 21 (isetission il ont le (lifhcult-ies iii paying troops in thle Europeanl

theater, thati his chief difficulty with thle, Finance D~epartment was having

suifficient. money printedU General Pqi1tonl singled out, as one of his difficulties,

getting (decorat ioins for acts of vailor occurrinlg ill the Third U.S. Armyv. Ile

stat~ed that, lie had been ab~le to obtain only two Congressional Medals of Ihonor

for members of the Third UT.S. Army, one of wvhich had been given to a mledical

aidnian.

The next mornin1g, the .onlsultalit 5s were tip) early to altt end~ tt1w departutre

of Assist~ant, Secretary Mc( 'by. Later, they went to (the 341h Ev bacuationi
3303 ACTIVITIES OF SURGICAL CONSULTANTS

IHospital with General Patton where they dressed Colonel "W." They then

put him in an ambulance, took him to the airplane, flew him to Paris, took him

to the 1st Genead HIospital, and arranged details for the proctoscopy to be done

the next day. Colonel "W." was eventually evacuated to the Zone of Interior

where lie recovered completely front his wounds and( continued to serve on

act ive duty, becoming a general officer in the U.S. Army.

Later that month, Colonel (Cutler also met with a neuropsychiatric mission

of distinguished civilian consultants headed by Dr. Karl Menninger to study

the changes occurring in neuropsychiatric casualties during their evacuation

front the front to the rear. There were conferences with ('ol. Esmond It.

Long, MC, Consultant in Tuberculosis in the Office of The Surgeon General,

concerning the care of recovered Allied military personnel. Colonel Cutler

was also pleased to renew his friendship and talk with I7.S. Senator Leverett

Saltonstall, when he. visited the theater late in the month.

"A Piece of Sadistic Thinking"

As more and more of German soil was conquered, the peoples of the Allied

nations were shocked to learn of the horror which had been perpetrated by

Nazi fanatics in their prison camps. In a way, too, they were hunibled at the

extremes to which man's inhumanity to mian could he carried. The stories of

these canips-Buchenwald, Pilsen, and many others-have oft been told by

the soldier, statesman, and journalist. Each has contributed from his particular frame of observation in the telling of the complete story, and the

doctor at war may tell his story, too, in a slightly different light fronm the others.

Colonel Cutler visited Buchenwald on Saturday, 28 April 1945. The following

account of his observations-unpolished and hastily written inmmediate recollections of his visit-were taken from his official journal:

We were given a 'plane and were lifted by air from Paris to a field near Weimar at

9 a.m. The party included Colonel Shook, Colonel Tovell, ('oonel Long (fromn SGO),

Maj. [Sarah] Bowditch, Major loizeaux. Major [Malcoln E.1 Beckhanm and Corporal

Sansone. Rough ride under low clouds, Just above trees, for 2"V4 hours. At the airport

near Weimar. I believe R-7, found an ambulanuc company. No. 429. who were working

for the evacuation hospitals in that area; set up and had lunch: it was raining.

We were given two ambulances to take us to the camp, and took with us the crew of

the aircraft, who were anxious to see the camp. and three corresponldents who attached

themselves to us. Found the 45th Evacuation Hospital set up next to the gate of the

camp, but Colonel Zehm was away for the moment. Went to the gate and it was obvious

that great restrictions had now been placed upon visiling this camp. Our orders were sulfllc(ent authority for us to enter but the newspaper correspondents were not allowed, though

I did get permission to take in the crew of the aircraft, who were grateful for the

opportunity.

We were shown around by two guides, one of whom was a doctor, a Slovak from

Prague, captured in 19.19. lie told us that the original camp was built in 19:17 for 7.000

people, and that In 1939 the first Czechs came in. the camp having been used for political

prisoners, not war prisoners. precedingly. We were shown the crematorium, with the

heating room beneath It. Wards, rooms off wards, where so many patients a day-usually

:1O or 40-were taken out for an Injection, died and never returned to the ward. We were
CHlI1F' CONSU'LTAXNT IN S111GER:IY:8

SIIVI i .. I121. F(II rI 4 (lilt e I Whc III II II llll t jill,. t sn I ii~ 11 Wh 11sI hiii ward Chi'lu~ciln 141el

:15 Iii 111(11. I his ~~~UirEI I II'r IIE til I r a I it ol l Ia l itiik. li~ Eiiliti~it :hui ;f

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wide. and sixilay lill Elile, 2.141 figEh ]:,1 iil 1.ii Th gtii isthtl.1111 deIi. h

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A aIn I f(I ra~t 'hif r 1 ll 1 41 I fig.t vey SiE4 aI 4IlwI Sectl ifi~ii lls Ii 111t11il1 ut Si it.%Ne I i cihr~l . I 11 411reitl

fEI~hlv is ii) crit icism i it is thie mIISt ititehi'lit411.14 111id bhe ist W.13 (( h EEI sVII SIlitlhtiEOi :1l(Nhe.llih.

The heatinug 1-4)(111 hlivilvth ilthu crivuitillrillili. where thlere w~ere* Iiomhs tilt thle walls w~here

in eest ranigledl. andi where fi 1P hitlad IiEi IifiiaE111iilil Soo tha Owl I iP(ies lf hips d111(yintg

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takeni ffir inijectifills1. al d ill 51S5'HIIIVIIt 13- (1 it'd. W:IS a1 Jlpio, fr s:1Eist if.I hliiikiiig iii hu e "-ith thle

G;ermanii attitudel. Th~ey3 uiiighit Saiy ill IIefe'ise tlinit this: was Euuthanai~sia. tha~t all1 these.

jIeoipIIE Nverte suitf'erilig :11111 :1ll(llit tol 1111. 'EWeE tEEiEI. lillever. that Simletl liies poling

dE'EIied (311 drSimiiiar circumistances'. w'hether liveECi5e their skitls with ft:iEs weree

dhesirable~. fir whether IIeEalSe thely were' polhitical Igjtaltfir5. liE1 411i4 wvill ever' kIIIIWV.
3:1, 2 ACTIVITIES (11.1 ,1 IONCAL

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soddier, sh"t ill the Ileck whell 11slellsibly Inickvil 11oked :I wall 1,4,1. 1114-:1NIII.-

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('11114-Cs joill-11:11 (.1111-Y I'm- Ole same oh.v. 2-S April 191.'1. vmilillllvlý

\6111 doall., fir held willl member-, Ill* ille Arm v

Iteadqual-wr" F i rs I I "S . A I -I I I .N.. ' F I I v I I I I v S I I I ) I I S 4 11 S( - I I ssi - I I W I I I I I ) hl - I ) I' - I I
CHIEF CONSULTANT IN SURGERY 335

Cutler had great hopes for the collection of significant data by the teamn-an

expectation which was the culmination of Colonel Cutler's efforts since his first

days in the European theater. He had personally arranged with the Third

U.S. Army commander, General Patton, and his chief of staff, General Gay,

that every consideration would be given for the efficient employment of the

team. But, even after the team was prepared to move into action, there were

many administrative obstacles to be overcome before such an unusual unit

could be moved from Camubridge Cemetery, England, to the Third U.S. Army

front in Bavaria and Bohemia.

When the unit finally reached its destination, but 2 days of fighting remnained before the surrender and the total number of casualties sustained during

the period in the area in which the survey team was to operate turned out to

be 21-12 killed in action and 9 wounded in action.

Colonel Cutler was disappointed that the casualty survey teamn0 could not

have functioned sooner. It was small recompense for his work, but, in the

period after V-E Day, the 250th Medical Detachment was singled out by

Washington as a unit to be retained intact for possible redeployment to the

Asiatic areas. At least, it seemed, someone else might obtain some use from

his work.1'

0

Transfusion reactions.-Maj. Charles P. Emerson, MC, who had been

sent to the Ninth U.S. Army to study transfusion reactions, completed his

studies and submitted a, preliminary, but extensive, report on his findings.

Other studies on the problem, notably that by the 43d General Hospital, were

also consummated to contribute to the pool of overall knowledge on transfusion

reactions. In a memorandum, dated 19 May 1945, bringing the Emerson

report to the attention of General Hawley, who was personally greatly interested, Colonel Cutler stated:

2. * * *

a. Investigations point that there is a case against old or aged blood. Apparently a

certain amount of blood becomes hemolyzed through the packing of red cells at the bottom

away from the diluent. This is always more extensive when the diluent is a small quantity,

such as the 160 cc. amount rather than the 500 cc. amount. The agent causing the reaction

is stronta of the red cells, not of the free hemoglobin.

b. Transfused cells disappear slowly.

c. There is a definite danger from old ["O" blood whether from the blood itself or

O plasma. This is a relatively new contribution and points out that the universal donor

is not without danger.

The renal failure cases seem to be largely due to anoxia, i.e., the period of low blood

pressure preceding the transfusion. Thus, it is not the transfusion but primary injury

of the cells through anoxia.

110 (1) Palmer, A. : Report of a Ground Force Battle Casualty Survey Initiated Two Days Prior

to V-E Day, With Appendix II, Diary of the 250th Medical Detachment. (Official record.] (2) Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing

Office, 1962.
:336 ACTIVI~'TI ES O F SI' lI( CAL CO( NSU LTANTS

Major Emierson, III his report, latid great emli)tasis onl the p)oint briefly

menetioned by Colonel Cuitler, the (danger of the conicept of the universal (donor.

Thle rep~ort stated:

'Thle implort anciie of thlese flindintgs, troin the practicall point of view, lies lin the

following inferenceis :

1) Ucticett-d inje~tion, Of gJroip 0 blood intio otlIP than0 f/r(np 0 pahtientshi inayg be

all ine-ffertnal oiivluineeonomir proccedure, except in einergeney repjlavenient. thlerapy.

2) TheI trasusif.ion~ Of rcrry Iiryc anionnix of group 0) blood, and -crn, of pooled 140Iu.na,

int1o r~cipicnt (iof othcr blood grjiupm iniel Prcitit in. *xcriou. heinudjtic elixeaoa, U.s h(Is b-cia

niotf-1 in rertaljf east'si Icith scrcrc* barns~ requiring ne1.sh-e p~lasm(,a tranIsfus~ions.

3)It is po~ ssibIle t hatI i I-Ievrsi b le organiv ichani iges invol iivinig thle kidni eys. li ver, vent IralI

nervous syste'iii, iiiii other orguans, couldi oceur as a result of prolonged anid diffuse jut inCHIill 1111 Iagglu1 t I mat Ion.

The inipijeaion. is 81-lruig that, wvhenev'er feasible, *xtrietlji1 rompatible bilood, of the

mIaiac f/coup (is~ the poiticnlt, shoti~lv be, scEd ; and that, uinder condi~it ions that render the

exclusive use or groupl () bulood. aIvisable, only blood of lowv titer should lie supplied. TIhecre

are s~trong reox.ons to xnxio.,Iet tha(t ('ven, pooledl hunan, plas~nio, with low agglutinin titer,

wheni admiinistered iii very large amifounits tol indiv(iduals oif blood)4 gro)ups other than

group 0), may har aindexmirnabl or cren. dlangf-rons c/feiels., 1111( that. the use of fractionated

hauman a lbuinnin would lbe far pireferabile Ilii such cases.",

Tobruk splint studies.-St It(ies onl thle eflicacy of tilie Tobruk splinht, so

popular~u with th(le Brit1 ish, w~ere coi iijpl4tedl unlder filie (lirect ioul of Colonel Manil11111g. ori hopediv consult ant to the Ninith I 1.S. Army. Thie results of his studl~ies

were readl at the last grand meeting of Anlierican ltand Br'itishi 'onisultants to be

dlescribedl b~elow.

Rank and promotion.-As the years pansseAd (luring the war, Colonel

Cu~tler becamle Inloxe anld nuwoe lincensedl at tilie inequalities of tile p~rom~ot~ion Systent iI at theater of operattions thlat was inexpl icably t ied to) t ables of organizait ion u)(l seemed to give the higher rainks to those. ill commandll1( and

adminilistrative Positions ait thle expense of those inl professionatl lpositimis. For

the last. 2 yeatrs of the war, Colonel (lflt em Iuiiae. tile correction of these. seeming

ine(lualities a p)ersonlal battle which lie fought at. every opportunity. The (iscussion at the mneeting of the Chief Surgeon's Consuiltants' Committee oil 30

Decemuber 1944 brought ouit well the faceets which mnade the p~roblhemm so tlifliciilt

of solution. Thle following minunttes show that, Colonel Cutler brought upl the

matter by Mentioning tile inequal:ity of the rank of otolaryngologists, previously

referred to, and the (liscussioni which ensuied:

rot. Cutler: it. has bieen brought illi repieatedhly that there are discrepancies in rank that

we find difficulty iii correc-ting. One InI the new T/0, for Instance, where the otolaryngologist Is listedl as captain. WVe hiappen it) have some otolitryngologists who are lieutenant

('(iloel'1 alhid mjuors. it does piresent a problem. We also have ninny expert people who

have servedl their country three yeiars as captains, but It will he difficult for themi to be pronioted, unliess we move them out Inito an administrative post. Then they will he promoted,

but we don't. want to lose them. What are we to say about the future of those cases?

't(1) Esse'ntila Technical Medical Datua, European Theater of Opernations, U.S. Army, for June

1945. duted 13 Augnst 1945. Inelosoire 9, inul'ject: Investigaition of Transfusion Therapy, Ninth U.S.

Armiy. (2) Emerson. C. 1'..rand Ehert, It. V.: Study of Shock in Battle Casualties; Measurements

of Blood Volumep Changes flieurring lit iiesl)ofse to Therapy. Ann. Siurg. 122: 745-772, Novem.

ber 1945.
CIIIEF CONSULTANT IN SURGERY 3,17

(en. h1awley: Everything you say is true. It so far as the specific case you mention

as the otolaryngologist being a captain, I think that we can make strong presentations to

the War Department to have things like that corrected. I don't know whether the War

D)epartment will do anything about it. It is a very difficult thing. Everything you can

say that these people deserve rank can't be refuted. When you compare their ability, their

training, their value to the government, when you compare them with officers of other

branches, or even to other officers within the Medical Department, it is obviously unfair

and unjust. There is no question about it. I agree with that wholeheartedly.

Col. Cutler: Would it be proper for us to write this up in the technical data report?

Gcn. Hawley: Yes, it is really irrefutable argument.

Col. Cutler: It might be good for the next war.

Gcn. Hawley: Yes, it might. You come into the question of a military organization.

Now, there has got to be in every organization-it may be a necessary nuisance, but there

has got to be a commnander, and the wide experience-I am not talking about the Medical

D)epartment now ; I am talking about the Army in general-nmany, many years of experience

has shown that it is always essential that the commander be of at least one grade higher

than anybody else in his organization. All right then, we come down, and nobody could

defend in a one-thousand bed general hospital, I think, of rating the commander as a general

officer. I think that colonel is all we can defend in a one-thousand bed hospital. Now,

we come down to the chiefs of services. They are more or less specialized; their training may be, and usually is, much better, much more comprehensive than that of the hospital

coommander. Then when we come down to the chiefs of services, we have got to have

section chiefs under them. When you analyze the ratings of our officers, and compare the

other branches of service with the ratings in the Medical Department, you find that there is

a much higher proportion of high rank than in any other branch of the service, with the

excel)tion, px)ssibly, of The Judge Advocate General's Department.

I don't believe that we are ever going to solve this problem on the basis of military

rank, because I think you run into that formidable thing of weakening the entire military

structure when you get into it. Now, if there is any other approach to the problem, some

other way-if we can discard rank from pay, for example, or any other way to give recognition to these people, we may be able to get them, but when we get right back into those

things which were tried for 74 years in our army, and it worked awful. It didn't make

for a very smooth staff, and particularly in the Medical Department, so they fought for

years and years and finally they got general military rank instead of rank within their

own branch, and I don't think that anybody who knows the history of those 75 years would

want to go back to that system. I think that the thins. that we have got to foster-this

may sound silly - you; I realize that I am talking from a different point of view. I am

trying to take into consideration your point of view. I know it is easy for me to 1k

and pat you on the back, because it was only through the channels of chance that I got

much more than I deserved.

I was down in Nicaragua with Dan Sultan, who is now in the India Theater * * *

That is separate from China-Burma now. Ile showed me several reports from some young

Engineer officers. I knew about what the second lieutenants out of the academy were

like, and these men were at the top of their class. Some of them were rated very, very

low, and yet they were better officers than those in the same grade in any other service, and

I said to him, "My God, man, what are you doing to these people? Compared to some

other branches of the Service, these lads -ire superior plus. They have got everything."

He said, "Yes, but that isn't the point. I am not rating them according to the other

services; I am rating them with Engineer officers. They may be superior pilus compared

to the rest of the Army, but I am rating them within the Corps of Engineers."

That is one point of view. I think we are going to have to go back to that oldfashioned hillbilly religion, where they take the attitude that we are not going to set

our rewards on earth, but in Heaven. I don't know of any way of recognizing by military
338 ACTIVITIES OF SURGICAL CONSULTANTS

rank the high professionally qualified experts and at the same time preserving the military

structure. If anybody can work out a more feasible plan, that will fit both of those requirements. I will go along with it. On the other hand, I think it is quite correct to put that in a

report, and I will send it to The Surgeon General.

Col. C0uthr: In the last war, it was felt that this terrible matter of rank consciousness

which is doing so much injury now is due to the fact that there has been too much rank

given. I was up in the Ninth U.S. Army, and I saw four evacuation hospitals with

young colonels commanding. I don't see why the commanding officer of a 400-bed evacuation hospital should be a full colonel. If they had left it down to a lower grade, there

wouldn't be this problem. There is vertainly a lot more trouble in this war than in the

last war.

(hGn. Hawley: I think that it is a good point to take up with The Surgeon General. I

think they are overrated. Well, all I can do is to say that I am terribly sympathetic, and

I will support any program that will solve this problem.

The first result of this discussion, and the General's promise to do anything

he could about it, was that, whenever necessary, hospitals were exhorted to carry

specially qualified professional persomiel as overstrength to be absorbed by

the total number in various grades regardless of the position for which these

grades were specified. This plermitted thle p)lacing of well-qualified specialists

wherever they were needed, regardless of vacancies, but it certainly did not

enhance their popularity. Moreover, this l)procedure had merely permitted the

unrestricted placement of "over in rank" professional medical officers, but did

not, per se, clear a path for their promot ion.

The alternative, within the existing system to provide positions calling

for higher rank was to obtain tables of organization for larger hospitals.

Quite fortuitously, at about that time, the War D)epartment inforined the

Eurol)ean theater that no more hospital units could be provided from the

Zone of Interior, and, if more beds were needed, some of the 1,000-bed units

presently in the European theater would ave lo be expanded.

When General Hawley received this information, he called Colonel Cutler

and Colonel Middleton into his office and instructed each to give him the names

of the twelve best chiefs of surgery and of medicine in the European theater.

H-e told them that the hospitals to be expanded had to be selected on the basis

of the adaptability of present p)lants and facilities to expansion, and that it was

unfair to afford the op)portunity for increased rank upon any such basis.

Therefore, lie said, before annotmcing the hospitals to be expanded, he would

transfer the best chiefs of surgery and medicine into them so that these men

would get tile promotions.-12

Colonel Cutler selected the surgical individuals personally with the advice

anid recommendations of the other consultants. Ile interviewed each individual selected as to whether lIe would leave close friends and working associates for the dub)ious reward of recognition by an adviance in rank at a strange

hospital. It so happened that most of those deserving promotion to the rank

of colonel were in hospitals in the ilnitedl Kingdom, while the hospitals with

"11 Letter, Paul R. Itawley, M.D., to col. j•hn Poyd Coates. Jr.. 'MC, 17 Sept. 1958.
('CHIEF ('ONSI'LTANr IN SI'URGERY 339

expanded tables of organization were on the Continent. Now, these individuals singled out for the new promotion positions were superior officers,

and everyone knew it. Hospital commanders and General Spruit, the United

Kingdom Base surgeon, were not inclined to release them. Again, through

the persuasive efforts of Colonel Cutler, and eventually, by the positive actions

of General Hawley, these objections were overcome. Meanwhile, individuals in

these hospitals with expanded tables of organization who thought they were

deserving of the promotion had to be pacified, and the hospital commanders,

from whose hands the requests for promotion had to emanate, required close

scrutiny so that they would not give the rank called for by the professional

position to some other officer.

After these herculean efforts, recommendations for promotion had finally

been submitted for the selected few. Periodically, Colonel Cutler was obliged

to ask what was happening to the promotion requests and to exhort their

rapid promulgation. For instance, on 19 May 1945, he wrote, in a memorandum to the Chief Surgeon, the following:

1. At your request we brought over to the Continent the seven best surgeons we could

find. This was done after considerable difficulty with General Spruit and all the Hospital

Comnmanders who were affected.

2. It was my understanding that these officers would be promoted to the T/O vacancies

of Colonel.

3. None of them have been promoted, and I have serious misgivings about their being

promoted, for at the 203rd I understand the Commanding Officer has put in the Executive

Officer for one of the colonelcy vacancies.

4. I believe failure to promote these men will be highly destructive of morale and

broaden the chasm between the Regular Army Medical Corps and civilian doctors which it

will be extremely difficult to heal.

5. Perhaps you feel this is important enough to take action personally.

The ultimate result was that, by theater policy, all promotions in a wide

category of units were suddenly frozen before these selected officers could be

promoted, although the necessary requests had b)een submitted. a long time

previously. The Chief Consultant in Surgery, on this untoward turn of events,

asked whether exceptions could not be made in the case of those whose promotion recommendations had been submitted prior to the restriction. He was

asked to cite specific examples as basis for p)ressing the case. Citing the case

of three officers on 22 July 1945 in a memorandum addressed to the Deputy

Chief Surgeon, General Cutler wrote:

1. * * *

Note that the original promotion request went in in February 1945 and was just

kicked around by the worst kind of red tape.

2. (eneral Hawley asked me to submit individual instances of this kind and said that

some relief could be had. It would. in my opinion, be a far better solution to have G-1

draw up a general re(omninen(lation, stating that officers whose request for promotion was

submitted in good faith and approved at all levels preceeding V-E D)ay. but whose promotion

did not go through because of red tape. should now be permitted the clhnnels for promotion.

If this cannot be done. something should be done to wipe out the most regrettable situation

which has occurred because of Army red tape and favoritism.
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CHIEF CONSULTANT IN SURGERY 341

prevailing system of appointing qualified specialists in hospitals of a particular

center as consultants in their specialties for the hospitals of the center and the

surrounding area was quite applicable for the contemplated centers of the

occupation force. Likewise, the system of surgical coordinators to coordinate

the surgical activities within a hospital center was quite appropriate. Thus,

new directives outlining the functions and operations of hospital centers included these plans just as they had been operating for some time.

In a memorandum, dated 6 July 1945, General Cutler advised the Deputy

Chief Surgeon concerning the plan for the constitution of the Professional

Services Division as it was to serve USFET (the U.S. Forces in the European

Theater), the posthostilities command. General Kemller, who had relieved

Genenrl •awley as Chief Surgeon, accepted in principle the concept exl)ressed

in the following excerpt from this memorandum:

2. I spent five hours on 5 July with General Kenner. discussing matters relating to

Professional Services Division, ETO, and redeployment. This conference resulted in the

following plan for the Division of Professional Services, ETO, being approved by General

Kenner:-

a. There are to remain in Professional Services Division the following officers:-

One Colonel. Chief of Division.

One Colonel, Chief Consultant in Surgery.

One Colonel, Chief Consultant in Medicine.

One Field grade officer, Psychiatry.

One Field grade officer, Orthopedic surgery.

One Field grade officer, Consultant to WAC.

One Executive officer.

b. In addition to these officers permanently assigned to the Office of the Surgeon.

ETO-Com Z at this time, and later to move to U.S. Forces Headquarters, Frankfurt, there

must be in the Paris hospitals thoroughly competent specialists in the following fields:

Radiology; Otolaryngology: Neurosurgery; Maxillofacial surgery; Anesthesiology: Ophthalinology; Urology; and Burns. These officers should be of high caliber, competent to

act as consultants, and holding the respect of their fellow officers for their professional

abilities. They in turn, or substitutes for them to be provided later, must be moved to

hospitals near Frankfurt when Professional Services Division moves to Frankfurt from

Paris-Versailles.

":. The group of consultants in Paris will be the only consultant group in ETO, other

than Army consultants, and they will continue to function to set proper professional standar(ls and policies for the optimum care of the American soldier. In particular, during

the period of redeployment, when confusion exists, visits to hospitals must continue in

order that there be no relaxation in the care rendered by the Medical Department.

4. In order that this program be implemented immediately, it is now requested that

orders be issued moving Lt. Col. Hall G. Holder, Lt. Col. Win. Field and Lt. Col. Currier

McEwen on D/S into the Office of the Chief Surgeon, so that they may become acquainted

with the duties that they must shortly assume in their entirety.

In the interim before General Cutler was ready to leave the European

theater, there were several minor changes to the original recommendations,

and General Kenner decided that a director of professional services was not

required. ItA. Col. Hall G. Holder, MC, had, however, been ordered to Headquarters, ETOUSA, to understudy tile position of Chief, Professional Services
342 ACTIVITIES OF SURGIi'AL CONSULTANTS

Division, and was still filling the job on 11 August 1945 when General Cutler

advised:

1. I hope to be flying from the Continent ovn 12 August.

2. Arrangements have been made for Colonel Pisani and Major Loizeaux to leave the

theater within a month.

3. By the end of this month, Professional Services Division will consist of the following

officers:

Chief of the Division-Lt. Col. Hall G. Holder

Chief Consultant in Medicine-Lt. Col. 0. C. MeEwen

Chief Consultant in Surgery-IA. Col. L. Miscall

Senior Consultant in Orthopedic Surgery-Maj. G. T. Aitken

Consultant to the WAC-Capt. Martha Howe

And, for a period of a few weeks, 1st Lt. Jean L. Beatty. PTO [IPhysical Therapy

Officer].

4. The enlisted personnel remaining will consist of 3 EM and 3 WAC. together with

3 or 4 British secretaries.n'

Third Anglo-American Consultants' Conference

The long-drawn-out period after V-E Day had its bright moments, too.

One of these was the continuation of the conferences between British and

American consultants. The first had been held under American auspices in

Paris, the second was in Brussels under sponsorship of the British 21 Army

Group, and the third reverted to Paris again. The site was the same, the

108th General Hospital; the dates, 25 and 26 May 1945. On each successive

occasion of these conferences, consultants who should have been invited to

p)revious meetings, and were not, had been added to the list and, by the time

of this third and final conference, there were American consultants from the

field armies, base sections, and theater headquarters plus Dr. Karl A. Meninger, Dr. Romano, and Dr. Kubie from the visiting commission of civilian

neuropsychiatric consultants to The Surgeon General. From the British side,

there were consultants from the headquarters of the British Army, the Royal

Navy, and the Royal Air Force and from the 21 Army Group. There were

rel)resentatives from the Canadian Forces. In addition, as observers, there

were Colonel Osipov representing the Soviet Armed Forces and guests from

the French Army (fig. 124).

The discussions were lively and the points made were vigorously indorsed

or opposed. Coming as they did so shortly after the cessation of hostilities, the

meetings were very much a review of thinking on the professional highlights

of the war-the failures, the successes, and the unresolved problems. It is

most unfortunate that space does not permit the reproduction of the complete

transcript of the meetings, for, together, the thoughts expressed represent the

combined and individual thinking of the officers who were the leaders in professional medical matters throughout the war in Europe and elsewhere in

their respective services and commands.

"ISee footnote 1:13 p. 340.
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344 ACTIVITIES OF SURGICAL CONSULTANTS

all had experience in the camlaign here. Now do we need more medical manpower or

can we do without some that we have? The subject has been livided into echelons of

service because obviously the problem varies with the different echelons of the fighting

forces.

Accepting General Hawley's suggestion that the meeting pick up the full,

fluid, and forceful discussions of previous meetings, the conference proceeded

at a lively Iace on the discussion of medical manpower as it affected the

division medical service, medical service in the field army, and fieally the communications zone. Fortunately, the transcript of the meeting contains a

summarization written by Colonel Cutler at a later date. His synthesis of the

opinions expressed was as follows:

1. The major matter brought up by all speakers, and approved by all. was that highlytrained professional personnel must be kept mobile. This principle referred to the personnel

not only in "Army" installations but also in Coin Z institutions.

2. The division personnel. It would appear that no cut could 1be had , the medical

battalion personnel attached to the division per se, which numbers about twenty-six (26),

but some further cut might be made in the attached personnel which brings the total

medical officers in [U.S.I divisions to around forty-four (44), as compared with the

British number of thirty (30).

3. Army. All but Colonel MacFee thought the surgical teams should be kept mobile

and there was even a suggestion that evacuation hospitals, as well as field hospitals, be

largely housekeeping units, though the evacuation hospital should have a medical and

surgical chief and a few officers to enable it to give competent assistance when acting as

a station hospital.

4. A suggestion was made that the surgical teanis should be cut down to one (1)

surgeon, one (1) anesthetist, and two (2) enlisted men.

5. The final suggestion was that difficulties of mobility, and thus saving nanpower,

were more wrapped up in:-

a. Transportation, or

b. Red tape,

which prevented easy interchange between the Army and the Coni Z units.

Few of the comments made can here be quoted; however, using Colonel

Cutler's summary as a jumping off point, the following excerpts from the

transcript were typical of the thoughts expressed.

Colonel Berry, Consultant in Surgery, Seventh U.S. Army, and with exl)erience in North Africa, Italy, and the campaigns in the European theater,

said of medical manpower in the field army:

General IIawley and guests. The [types of] Army medical installations of the second

echelon, as you know, in our army consist of the field hospital with the auxiliary teams

and two evacuation hospitals: a seminiobile one of four hundred (400) beds and one of

seven hundred and fifty (750) beds. We also have a neurop :chiatric center, a venereal

disease center, a convalescent hospital of three thousand (3,000) beds, a mobile army

laboratory, an optical unit, and a blood bank detachment. It seems to me our function

in the army is twofold: First aid medical care to the patient and retention of the maximum

number of Ill or wounded soldiers within the army area. The field hospital has been a

godsend to us. It was first used in the Sicilian campaign in its present type. It was easy

to adapt and carry over and it has been used essentially in the same manner by the various

armies conforming to at standard that was finally developedi by the Fifth Army where it

was perfected. It has operated largely as a housekeeping unit. It has a small head-
CHli:' CONSUITANT IN Sum' .RY :45

quarters detachment and it has three (3) platoons each conmmnded by a major with

three (3) medical officers. All of the professional work, all of the casualties, have been

handled by the auxiliary surgical teams. The three (3) officers have been used to help out

in resuscitation, assisting in the operating room and postoperative care. Immediately

behind that was the four hundred (400) bed sumiimobile hospital on the basis of one (1)

per division. Now discussion has centered particularly on this unit and the seven hundred

and fifty (750) bed evacuation hospital, which we have used on the basis of one (1)

per two (2) divisions or one (1) per three (3) divisions. The personnel of the four

hundred (400) bed evacuation hospital has twenty-seven (27) medical officers. The seven

hundred and fifty (750) bed evacuation hospital has thirty-five (35) inedical officers,

including two chiefs of services. Now, if you ration patient beds, you will find that the

medical officers in the seven hundred and fifty (750) bed unit have about five (5) or

six (6) more patients per officer. The seven hundred and fifty (750) bed unit is so styled

that it is capable of expansion up to double the number with tie same number of doctors

and enlisted men. It creaks and groans when it gets over twelve hundred t1,200) beds, but

it will go over. The four hundred (400) bed is so streamlined in personnel that it is

incapable of going over fifty (50) or one hundred (100) beds more than its table of

organization and equipment. The four hundred (400) bed has been made more mobile

than the seven hundred and fifty (750) bed. One argument that ha' been advanced for

the four hundred (400) bed evacuation hospital is that it is mobile. Well, the difference

is not in the size of the hospital but in the fact that the four hundred (400) bed evacuation

hospital is equipped with twenty (20) trucks and eighteen (18) trailers and the seven

hundred and fifty (750) bed evacuation hospital until recently has been equipped with

two (2) trucks and no trailers. It wasn't the size that made the difference in mobility.

That has been overcome by arranging headquarters transportation. Now, the question

of saving manpower comes on various stages and it seems to me first from the professional

standpoint that these large staffs in the evacuation hospitals could be cut down somewhat.

How nmuch I am not prepared to say and the auxiliary teams could be greatly expanded

to include groups of other specialists. Let's take the neurosurgical team. That is a highly

skilled group. They are needed badly. Having them permanently assigned as the staff

of an evacuation hospital ties them up because it is very difficult to move them from one

evacuation hospital to another. It is far less difficult to call up or send a message to

the comlinanding officer of an auxiliary group and say that the neurosurgical team is

needed and as soon as it is finished it could return to group headquarters. One evacuation

hospital has had the same neurosurgical team since August. It became part of the staff.

Two others have had theirs for two (2) or three (3) months; one throughout the winter.

It seems to me that the same type of team could he greatly expanded. On the latest T/O

of the seven hundred and fifty (750) bed evacuation hospital there are at least eighteen

(18) on the surgical side and thirteen (13) on the medical side and included in that

number are specialists-neurologists, thoracic surgeons, to say nothing of plastic, oral, eye,

ear, nose and throat, and other surgeons. It has been very difficult to get all the specialists and yet an army should have that within the army area. All of them should be

used where necessary. It is a waste of manpower to send a soldier back to the communica.-

tions zone for those specialist services * * *

Col. J. P. Ross of the RAMC, Consultant in Neurosurgery, to the EMS,

spoke also, as follows, of the problem of moving medical officers to where they

are needed when they are neededl:

* * * The difficulty with medical manpower is this. It is exemplified in this chart

very well. You have three (3) divisions leehelons] perhaps four (4) and you have cominunications zone, and these, medically speaking, are all water tight compartments. You

give to each of those regiments, divisions, corps, armies, etc., a number of medical men

and they think that they own them. They hesitate to allow them to shift, because they
346 ACTIVITIES OF SURGICAL CONSULTANTS

fear they will not get them back again. In any army or in any campaign a battle lasts

only so long and that must always be so. There may be a great many casualties or there

may be a few casualties, but the battle (.an only last a certain length of time because

of other factors. If you have an organization which will allow you to move medical men

from the front and back again without too much red tape, you can save medical manpower.

When you set up forward medical installations with certain skeletal staffs, then you require

a pool or a series of pools with medical officers who can be attached. The difficulty we

have had in our army, and I think it is the same in other armies, is that of movement

of officers. We decide there may be a fair number of casualties in this area and we want

to get some medical personnel from the back area. We have had the battle, we have had

the casualties, they have been evacuated, and the medical officers are needed in the rear.

The necessity is to have skeleton staffs on hospitals, on CCS [Casualty Clearing Stations],

and on teams and add to them. You see, what happens is that when a commanding officer

of twelve hundred (1,200) bed hospital thinks that he has thirty (30) or forty (40)

medical officers and he is quite convinced that he owns them and that if they get away

he will never get them back, he will not release them.

Brigadier H. C. Edwards spoke of the tremendous potential usefulness

of the British FSU (Field Surgical Unit).

General Hawley, the moderator, asked Colonel Bricker to say a few words

as Consultant in Plastic Surgery because most of the discussion had been

monopolized by the general surgeons. An earlier speaker had said that

specialists were not needed up front and that the more specialized a doctor

became, the further to the rear was his place of business. At any rate, Colonel

Bricker confined his comments to the specialist in the communications zone,

without arguing the point made earlier, as follows:

What I have to say * * * [concerns] * * * the efficient use of specialists in conimunications zone hospitals. We have a large number of one thousand (1,000) bed

general hospitals in the communications zone. It has obviously been impossible to make

them self-sufficient. The solution has been the obvious one of putting the specialty in the

designated hospitals and placing them in a strategical location and geeing that the patients

get to them. This has had serious difficulties because of our T/O in certain hospitals.

We need ihoracic surgeons, neurosurgeons and plastic surgeons. They have filled the

jobs of the assistant chief of the surgical and chief of septic surgery and ward officer.

We have had to use them. This means that once they are in the hospital they are assigned.

If the situation changes as it can change, we have to change the personnel, that means

making the [trade] between hospital center, commanding officer and finding replacement

and it takes time and in some cases It has taken weeks. In an emergency we can make a

trade quickly. Routine changes have taken a tremendous amount of time * * *. In England we had time to get our plan set up. It has worked very well. On the Continent. it

hasn't worked so well because the hospitals were coming in rapidly. The solution, I am

quite convinced, is the one mentioned by Colonel Seeley. It is putting specialist personnel

in cellular units * * *

Surgical meeting.-The surgical meeting took place the following morning, Saturday, 26 May 1945. Colonel Cutler was the chairman and moderator.

The initial topic was the management of combined bone and nerve injury,

procedures which had seen considerable improvement during World War II

with the realization and acceptance of the fact that a flail limb was a useless one,

regardless of the condition of bone, and that repair of the nerve in these cases

had to take precedemne over the fracture. It was mnentioned that asepsis of thie
CHIEF CONSULTANT IN SURGERY 347

wounds seen in World 11'ar II was a great factor in permitting the early repair

of nerve injuries. Colonel Spurling and Colonel Cleveland were very much in

evidence throughout the discussion, which was opened I)y the reading of a

report by Colonel Spurling on the experience of the, U.S. Army in the

European theater in the management of combined bone and nerve injury.

From the British side, Mr. Geoffrey Jefferson, EMS Consultant in Neutrosurgery; Brigadier Rowley W. Bristow, British Army Consultant in Orthopedics: and Air Commodore Osmond Clark, RAF Consultant in Orthopedics,

carried the discussion. Brigadier Porritt, surgical consultant to the 21 Army

Group also spoke at length.

The second subject for (liscussion was the Tobruk splint. Colonel Manning, orthopedic consultant. to the Ninth U.S. Army, opened the topic by

reading his paper on the studies conducted in that Army. Ile explained:

During the months of November and I)ecember 1944 five evacuation hospitals assigned

to Ninth U.S. Army applied the Tobruk splint to every fracture of the femur treated, with

the exception of those cases in which the ring of the splint would cause pressure on a wound

of the upper thigh or buttock and those in which skin traction could not be applied because

of wounds or fractures of the leg.

Every effort possible was made to obtain a supply of full ring leg splints so that the

British technique of application could be followed. However, this was found to be impossible. A technique (if applicat ion was standardized * * *

After giving detailed data on the results of the study, Colonel Manning,

in his summary, said that 19 percent of the total number of 63 splints were

considered to be superior to the spica cast as a transportation splint, 78 percent

were inferior, and 2 percentI were not recorded on the questionnaires returned.

Ile also mentioned that the comfort of the sl)lint and the opinion as to its

superiority did not coincide because 32 percent of the splints were considered

to have been comfortable, but only 19 percent were recor(le(d as being sul)erior

to tile spica cast. His conclusions follow:

The Tobruk type splint requires less plaster, time and work to apply than does the

spica cast, but it cannot be applied universally to all fractures of the femur, and does not

provide adequate splinting or (comfort. The results of the study are conclusive that the

Tobruk splint is inferior to the spica cast as a transportation splint for fractures of the

femur.

The barrage of opinion from the British side, following this report was

pretty iniich one sided. The minutes describe Brigadier Bristow's comments

on the British experience as follows:

He wouhl like it to he clearly understood that he was not going to try to sell the

Americans anything, he was not competing with Colonel Cleveland! IHe was just trying

to tell the experience they had had with this splint. The name "Tobruk" was perhaps

almost unfortunate because it appeared as if this was something tremendously new and

some great Invention. It was simply Hugh ()wen Thomas' splint, designed in the year 1870,

reinforced with a bit of lplaster of luaris around the outside to keep it snug on the limb while

the pat ient was on his journey. It was a transport appliance and nothing else. The British

experience had been that this splint, properly applied, helped latients on the whole to travel

back extremely well. The experience now was fairly large; they had seen them return

705-0951---64- ---. 25
348 ACTIVITIES OF SURGICAL CONSULTANTS

from long distances from the Western desert, had seen many in Italy and Africa, and had

had over 2,0X) femurs back to the United Kingdom out of this theater. We were speaking

of a considerably large section, and the experience was not that of any individual

manl. * * *

As regarded ease of apl)lication, he noted that the Americans were now in agreement

with the British that this method of splintage did save time and material. He had had a

report only a week or two ago from one of the hospital ships, from the surgical specialist,

who remarked that he wished peol)le would not send the patients with spicas because he

very often had to change them en route and it was difficult to change spicas on a hospital

ship. The meeting could take it that it was a considered opinion in Britain, by all types of

surgeons who had seen these patients return, that they were satisfied that they do travel

home pretty well, and they all thought this a good and useful appliance.

Colonel Eyre-Brook, orthopedic consultant, 21 Army Group, mentioned

that the result of finding 19 percent who were of the opinion that the Tobruk

plaster had been superior to the spica was very good as a start, considering the

difficulties involved in training people to put on the Tobruk as it should be put

on, and allowing for various technical difficulties which must have been

weighty. Colonel Eyre-Brook had come to the European theater from the)

Mediterranean completely uninfluenced and stated that he had been quite convinced that the Tobruk splint, properly applied, effectively immobilized the

limb and gave comfort.

There were other opinions from the British which generally coincided

with these. Colonel Cleveland said that this splint of the Americans was

not the Tobruk splint. They had not the same material and had not been

able to put it on as well. He stated that this was the Maastricht splint, and

it had not been as satisfactory as the spica. General Hawley said that this

topic was the "piece de resistance" which ]lad brought him to that particular

session. Colonel Cutler closed this subject with the remark that this slight

difference over the Tobruk splint served to put in very considerable relief the

fact that this was about the only thing concerning which they had had any

controversy in the past 3 years.

The meeting then continued on to similarly detailed discussions on anesthesia in war and thoracic surgery with active participation in the discussions

on the part of both the British and the Americans. Colonel Cutler, at the

close of the meeting, made the following speech:

I wish to take a moment before we part to speak about consultants in general and

this group in particular. The life of a consultant is difficult; more difficult in the

American Army than in the British Army because consultants are not on a regular T/O

and are not a part of our Army in peace time. I know also, as a background to these

remarks, that the United States Army Consultant Group in the last war did not have

a very happy relation with the officers of the Regular Army. As a result, officers

of the Medical Corps were in fact warned of the difficulties that might arise if consultants were used. Thus, officers now acting as consultants started under a certain cloud.

Those who had been through the last war and knew of this were able to discount some

of their difficulties. The life of a consultant is difficult for many reasons. It is difficult

physically and difficult intellectually. It is difficult physically because to be a good consultamit one should be steadily moving; it is a peripatetic existence. It is the Hippo-
CHIEF CONSULTANT IN SURGERY 349

cratic method of teaching. It necessitates continual visits to hospitals, ward rounds,

conferences with medical officers, all of whomn have a differing point of view. And

in each place and with each officer advice must be given so that treatment is of a high

order and standardized. It is difficult intellectually because you are always meeting

new people, always having to convince others by persuasion rather than force, which is

a very real strain. In addition, as deficiencies show up new standards must be set;

and where personnel are inadequate transfers must be brought about. To move continuously, with inadequate transport, shift your bed each night, eat field rations-to do this

day after day and talk to new people day after (lay is difficult and it is a life of strain.

I congratulate the United States Army officers here for having lived through it so well.

I know you have done a good job and I know that your Chief feels that way. I wish to

add my own deep conviction of satisfaction that you have done your job well; that is all

that any man should ask for. You have served your country well and you will be satistied in that service.

To our British and Russian colleagues I have a different message. We are under

a very deep debt of gratitude to each of you individually, and to the group as a whole.

You have offered us every facility, and you have offered us the kindest and most generous

personal hospitality. It is something we will probably never be able to repay. You all

cannot come to our homes, and we cannot thank you individually, and we cannot entertain you in the way we should like. But I know I can speak for all the United States

Army officers in this room when I say that if there are any of you who ever do

come to the United States of America, each officer here in this room will be happy to entertain you, lie will be grateful to see you again, and he, ill be privileged that you came.

General Hawley then addressed the meeting in the following words:

I think that from my point of view I realize that everything Colonel Cutler has said

is true. I was very young and unimportant in the last war, but I have heard handed

(]own to me by the older men who were in responsible positions that the situation in

our services in France was not always completely happy with the consultants. Well, I

think that the consultants lperhalps may have exaggerated that feeling here. Certainly,

no group around me has been more essential and more welcome at all times. It takes

a lot of adjustment on both sides, and I separate the sides into administrative and professiomal. It takes most of the adjustment on the administrative side. It takes some

little adjustment for the professional men to realize not that things cannot he done, but

to realize that we are treating hundreds of thousands of patients instead of one patient,

and that all methods and all procedures must be adjusted to that point of view. The policy

in our office has been that the only reason for the existence of the medical service has been

the care of patients, and there are no administrative reasons why a thing cannot be done

professionally for 100,000 patients.

The American soldier, in my considered opinion, has received better care than he has

ever received in his life, in former wars or in civilian life. There is only one reason for

this, because this Consultant Group of mine have completely directed and administered

the care of the soldier, and to them all credit for this is due. Wherever this, in a few

cases, has not been achieved, the reason usually is an admninistrative one, where we have

not. been able to get that patient and that doctor together at the proper time. and so I say,

without any effort at flattery, but most sincerely, that all the good in the care of plticnts

in this theater has comae froni this group of consultants, and all the bad l1ms conie fronm

the administrative side.

I am awfully happy to have hiad all of you here and. while I shall probably not be

having the privilege of meeting with this group again, these meetings we have had will

always stand out in all my life as very high spots. Thank you all.
A TIVIIE (1 A l#SLAT

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CHIEF CONSULTANT IN SURGERY 351

the battle casualty, nie(lical officer, and p1roper facilities must all be brought

together, and (3) restoration of the injured man to combat. He tilen

1)roceeded:

To accomplish this threefold mission, there must be a carefully integrated organization,

and some understanding of this is desirable if one is to appreciate the results which it has

achieved. A primary consideration is the complete interdel)endence of aidministration and

professional care, on which depends its effectiveness. The civilian doctor is prepared to

expend every ounce of energy and all of his time on a single patient, knowing that others

can be found to care for additional injured or sick people who might present themselves

at the same time. This policy, when one is confronted with thousards and not individuals,

must be forgotten in the greater good for the larger number. This change of outlook from

the individual to the mass is the chief difficulty confronting the civilian (ldotor when hel

enters military service. Moreover, if the three functions of the Medical D)epartment are

to be fulfilled-evacuation, medical and surgical care, and restoration to combat fightingattention must be focused more and more on those who can be returned to duty. By so

doing, eventually a greater good for humanity will be achieved, for. if large numbers of

men can be restored to the fighting forces, war will end sooner and thus humanity suffer

less. This need not result in neglect of the severely damaged soldiers.

After explaining in detail the complete accepted organization of the med-

,cal service of a theater of op)erations, he continued:

* * * only the perfect interdigitation of administrative and pr'ofessional personnel

can lead to a happy solution when thoisands of wounded men are handled daily. Professional personnel must be informed where the load is too be borne. how long casualties

can remain in one hospital, and what methods of evacuation are to be used if proper care

is to be given. And personalities must be forgotten. In spite of difficulties, the professional group always attempted to carry out the policies set by the Chie. Surgeon, both

those which placed a time limit on professional care and that which demanded of us that

the American soldier be given the best (clre possible under the conditions imposed by the

military situation. Administration must s, evacuation and hospitalization policies, but

these policies and the burden they impose are borne by others. Good results will accrue

only when both are completely informed of the labor and responsibility of the other. I)irectives are no substitute for good briefing, whether the goal be tactical or medical.

Next. General Cutler presented statistical data showing the load carried

in the European theater and comparing it with the other theaters of war with

respect to total numbers of casualties and the types of wounds received, lie

began his discussion of professional care provided in the European theater by

referring to the Manual of Therapy and the various circular letters on professional policies and l)procedures. Ile said:

* * * the Medical Corps. scattered throughout the entire theater, have been willing to

assimilate these standardized methods and have greatly improved the original directives

by suggestions and additions as experience hardened our opinion or showed flaws mind defects

in the original methods outlined.

This willingness to accept standardization, the thirst for education in military surgery,

and the ability to improve on original standards has characterized our professional colleagues from the very beginning.

Further, on professional care, the general pointed out

The one iRe n in professional care which distinguishes care in this war from care in

World War I, as well as the single factor most directly contributing to tile improvement of
352 ACTIVITIE*S OF SURGICAL CONSULTANTS

morbidity and~ mortality statistics, is the resuscitation of the wounded man. This tralscends in importance any single miethod of therapy, such as our ability to procure and deliver

blood and plasma to casualties, for it betokens that the Amierican surgeon has at last

alppreciated the im~portance (if the complete evaluation of his patients before therapy, Ile

has learned to care for the whole of man and not for any fragment or any particular

wounid. * * *

* * * It is this overall appreciationi of diminution in the amounit of circulating blood,

andl this overall dlesire to look at the whlole moan, and not the wound alone, that has led to

our greatest advance in this wvar.

Following the discussion of professional care. General Cuitler then described the v-arious surici(ial specialties andi their contribution to the war effort.

He madie a particular point of the impiortance of dIelayedl wound closure in the

restoration of thle lighting mian to early (lilty, emp~hasizing that. delayed closure

had to be attempted at thme first safe mlomnent, that (delayed closuire did not mean

asecondarily closedi wound lbecause it. had lever been loeibfradtt

(delayedi closure was not dielayedi primary closuire becauise there had been no

Primary closuire. General Cutler thenl attempted to outline the reasons for

improvedi statistics in WXorldl War 1I in the following words:

It would be impossible, at this time. to evaluate and put in proper perspective the

reasons wvhy the mortality rates in the Unlitedl States Army in World War 11 are one-half

,a~s great as those in World War 1. but there is every- reason to believe that the followving

have each played a role:

1. Resuscitation. The proper treatment of the patient in shock, chiefly by the use of

plasmia and blood.

"2. IBettcr first aid by the C'ompany Aid inan on the battlefield.

3. Pcnlicillill and xlut anateidecs, which hav-e vastly reduced the horror of infection.

4. Jun pro-red incthods of transport anid evacuationi, which allowv earlier meeting of

surgeon and casuialty, and more 'omifortable tin vel.

5. Good gceneral physical cndition of the soldier. This may be partly diet, or it may

relate to the physical training to wvhich lie has been subjected before battle.

6. Standardization of therapy and the great medical and surgical educational programs

emanating from thle Office of the Chief Surgeon, European Theater of Operations. This (lid

not exist in WVorldl War I.

7. Bletter surqery. through better anesthesia, better dlevelopmient of specialists and

better training of the young surgeon in the Army.

The surgical technique has been put last to give full credit to obvious new advances

that (lid not exist in World War 1, and because no amiount of goodl surgery could play such

a major role in freeing the- woundled from terrible infeetion. H~owever. the great debt oif

even- wound~edl soldlier to his surgeon rematins a hard fact.

A-nd, filnally, General Cutler paidI his respects to tile civilian doctor in

uniformn without whose efforts the fine results in the European theater could

never have been achieved:

In 'oniclusion, it is fitting to pay a tribute to the civilian doctors of the United States.

Of thme 16E,05.5 Medical Corps officers in the European Theater of Operationis. over 97 percent.

are civilian (doctors whlo have lxq-mi but, recenitl '11311 omimnssioned. These4 civilian doctors have

showvn a willingness to conform to it stand~ardized mnet hoh of therapy that (lops them great

credit. At the samie time, they have revealed1 all mniniense caliteity to learn front experience.

1111( it is suggestions froam the workers in the field, in all hinstalhmlaions, both in thme forwvard

and iii the rear a:'emms. wvhich haive lermiuittedl us to implrove consistenitly the methods of
CIIIEI? CONSU'LTANT IN SURlGERY 353

therapy originally outlined. Their ability to %vitlistantl great physical hiardship, to subordiumi I themiselves for the good of thet Armyx. t heir ability to) learni in the face of thle

cold it ionls Which have been iniliosed upon t hem inl the( forward aireas., all show how Very

real are the persoiial attriblutes of these dot-tors-.1 1

EPILOGUE I

Elliott Carr Cuttler's countributiion towvard tile physical care of tilie menl in

the European Theater of Operat ions is dtlicuvilt to overestimate. The p)receeling mledfical hlistoryV dlocumllents tifatolvtoo wl.I, ISeem t (I Itrg tIi fct onl well. It. to 1it. ,,n e

upon sonie of the p)ersonalI afttributes of this mnan who bore thle princip~al responsilbilit v of settinio tile level of professional surgical care in the European theater

which lie believed. by the endt( of the war, surp~assedl that inl other theaters.

General Cutler was an individualist, a forceful mian templered by experience

an1(1 eii(lowe(l with gr-ýieat charm, lie was not readlily adaptable to thle standlardlization requiredl by a gvreat war, buit hw madle ithis primnary mission to coolperate,

obey, and implement orders whtich. served the mnedlical bettermenet of the soldier.

Cutler could become volubly indignant over what ap~peared to him stupidity,

negligrence, or lack of foresight: onl the other hand, hie was relentless in his efforts

to gain promiotion or reward for tile. ineit lie, considleredl deserving. The observat ions lie had made during *World War I had given him a good concept, of imilitary procedures which often enabled himn to accomnpl ish worthwhile objectives

that might otherwise have been missed.

It is (ilittctlt to wriite an estimate of tile p~ers~on who was Elliott Cumtler

because hie had so many facets to his personality. InI retrospect, those qualities

that stand foremost are dedication, intelligence, and practicality, Ile had a

great sense of and feeling for history. Ile was inl fac~t a man of parts, wvith a

background in no way confined to medical and surg-ical knowledge. Extreniely

well read. anid with more than a nodding acquaintance with art,, hie was a fine

sp~ortsmiani, and, in everything lie (lid, his curiosity, conipetence. and enthitsmasml were boundless. Ilie could, and would, dliscuss at length anythin'g from

cattle raising to sailing to vintage wines. Cutler was not. a visionary by any

mnleallis but neither wvere his thoughts confined to present or personal problems.

]in 1942, hle was already conisidtering the eventual victory- over Germany. which

to huimi was inevitable, and remarked that lie thought thle Allies should take

over all teaching after the war. lIn other wvords, thle man whom all kiiew as

an ouitst andhing surgeon was also one of the most interesting and rewarding

f riends a man -ould( hope to have.

Whether onl philosophic nmatters or with the more practical concern of

sul)jplving time front withl bloodA and plasma, Cutler's mind was alwvays active,

inquiring, and inventive. No task was too smiall: no mission, unimiplortanlt.

His efforts weire unenthiiig, and)(, in view of what we now know about his increasI's Cutller. F. V'. :military Siirge'ry --Untle'd Stsitis Army--EIromiien mrienter 44 Operations, 1944-

1945,. Surg. Gyrie'. & 01mr. 28 : -"(;1 -274. March 1946.
354 ACTIVITIES OF SURGICAL CONSULTANTS

ingly poor health, it is the more amazing to realize what he accomplished. Ile

never spoke of himself but confided in his diary about sleepless nights, persistent cough, headache, and loss of weight. He fought this personal battle alone,

although it was int all probability the prelude to the disease that finally killed

him. InI the presence of others lie was all energy, and wherever lie went, which

was everywhere, he left the inspiration and heightened morale of his own great

spirit.

One thing the war availed him was the opportunity to teach, which he loved

to do and which no one could do better. His schedule was crowded with conferences at the Air Force School, at the American School Center, and with the

staffs of hospitals or field units. So high a priority did lie place on teaching and

so great was his power of persuasion that he had little difficulty in prevailing

on his British colleagues to help. Ile arranged for men like Grey Turner,

Gordon Gordon-Taylor, Lionel Whitby, Willie Anderson, Tudor Edwards,

and many others to address groups of U.S. Army medical officers.

Cutler undoubtedly made enemies, just as every purposeful man does; but,

he would never compromise with his own high standards, and most of the

quarrels involved the maintenance of these standards for everyone. Of far

greater imlportance are the friends he made for all of us. Some of these friends

he had met 25 years earlier during service abroad in the First World War, and

others knew of him through his own professional attainments. No man tried so

hard and so successfully to unite the efforts of the Allied medical forces. The

following eulogy written by Sir Gordon Gordon-Taylor in 1947 after Cutler's

death gives eloquent expression to this:

"Thee death of Elliott. Cutler * * * will occasion deep sorrow in the

hearts of his many friends in the United Kingdom. Perhaps no surgeon of the

United States ever yearned or strove more earnestly to forge lasting bonds of

friendship, not only between the surgeons, but between the peoples of the great

English-speaking countries on either side of the North Atlantic, and to this end

lie directed both written and spoken word."

Despite his sophistication, Cutler was delighted at being made an Honorary

Fellow of the Royal College of Surgeons of England and the Royal Society

of Medicine. lie was similarly honored by the Royal College of Surgeons of

Edinburgh, and, as a final, unique award, he was p)laced on the Editorial Committee of the Britsh Jourtud of Swurqei/. No other "outsider" had ever

attained such a position. Small wonder that, after the end of the war in 1945

when lie had been roundly applauded for his Hunterian Lecture, he recorded:

"Certainly the British make me feel they appreciate my services more than

my own people. It's rather sad when one has worked one's heart out. But I

am satisfied we have done a good job."

But Cutler probably took greatest pride in the Inter-Allied Conferences

on War Medicine, held within the precincts of the Royal Society of Medicine.

lie had been a main figure in the accomplishment of these meetings. As Sir

Gordon Gordon-Taylor wrote: "Elliott's wonderful tact and diplomacy at these
CHIEF CONSULTANT IN SURGERY 355

Inter-Allied Conferences will long be remembered by those privileged to

attend." Cutler was never happier than when the evidence submitted at these

conferences bore out his belief and pride in American primacy and efficiency.

At the sanme time, lie held in great resp)ect the British medical tradition, and lie

admired the individual ability of many of the men in surgery who, like himself, were devoting their skill to the war effort.

It. was to Cutler's great advantage that lie had on his side Maj. Gen.

Paul R. Hawley, Chief Surgeon, ETOITSA, an exceptional soldier-physician,

who dared to make operative a division of his office that in the past had

been mostly consultive and advisory. Cutler speaks of Hawley thus:

"* * * Though denianding standardization, you have always been willing to

allow changes in our form for practice, once a better way has been d(emonstrated. This opeinnindedness and the backing of new ventures * * * are

evidence of an unusual persp)ective andl critical appreciation in science. We

l)elieve in you, we acknowledge you as a stimulating and exemplary leader and

we are happy that we have been privileged to serve with you.,

Cutler, for his part, ably fulfilled his own descril)tion of the task of tile

consultant, and this fact was recognized by his chief, General Hawley, in the

following encomiuni:

"Obviously, the complexity of the functions of a Professional Services

Division, the l)eculiarity of its organization which makes necessary both action

as a whole and much individual action on the part of its memnbers-these

characteristics require the very highest type of leadership at its bead. Its

leader must be a man of force; otherwise, individual differences among its

members may create serious dissenltions. lie niust be a nman of courage because

lie risks his personal standing among his colleagues in the profession when lie

admonishes them or rules against them. And lie must be a nian of kindness and

understanding because lie imust keep discord out of his division and all of his

men happy and contented.

"Tlihese qualifications are not. often found in one. man. But it meant more

to the sick and injured soldier in the European theater than lie, or any of the

rest of us, can tell-that my Chief of Professional Services had all those

qualifications."

Because lie did consider the future and all its implications so thoughtfully,

forgetting his own increasing fatigue and ill health in his enthusiasmn, lie

became interested in General Hawley's urgent l)lea to help with a reorganization of the Department of Medicine and Surgery within the Veterans' Administration. He helped formuhlte some of the basic criteria iy which tIme medical

.service of the Veterans' Adniinistration is being run today.

This was Elliott, Carr Cutler, who diedl before lie could realize all of his

objectives but had accomplished far more than most of us even dream of. In

coMIclusion, let. us be generous enough to quote again from the British who

said of him: "* * * Perhaps the finest auitaibassador in surgery the world has

known.*

705-095 --64 --- 26
356 ACTIVITIES OF SURGICAL CONSULTANTS

And, for ourselves, we might reflect on this man of extraordinarly caliber

and stature. Many of us have our own personal feelings of bereavement, but

far more important is our sure knowledge of what his vision and statesmanship

could have accomplished today.

BERNARD J. Pis.%Ni, M.D.

February 1959

EPILOGUE II

The rugged individualism of the American physician was never more

apparent than after his indoctrii.ation into the Armed Services. His

antagonism to what he believed was the unnecessary regimentation of the

military tended all too frequently to interfere with his peace of mind and at

times his professional efficiency. While the consultants were usually older

and more seasoned in administrative, professional, and military experience,

they too were not immune to the same human emotions, especially during the

early part. of World War II. They tended to be discouraged by the interest

of the administrative planners in supply and evacuation during the early years

of the war. This, in the opinion of the consultants, did not provide adequate

consideration for the professional care of patients. Furthermore, they were

frustrated by their prolonged absence from heavy professional responsibilities,

irked by the lack of suitable transportation, aggravated by the discipline of

military red tape, and depressed by slow promotions which rarely approximated their counterpart in the Allied armies.

On the other hand, the administrative planners were impatient with the

consultants' "impossible" demands, their "ntentional ignorance on occasion

of military channels, the difficulties arising from a sympathetic ear lent to a

disgruntled medical officer who could think of nothing but a promotion,

memorandums prepared without due regard for the problems of evacuation and

theater policies, and, finally, the problem of pacifying commanding officers who

on occasion angrily objected to the consultants' raids on their personnel.

History must record these problems, although it is doubtful if the Chief

Consultant in Surgery, European Theater of Operations, Brig. Gen. Elliott

Carr Cutler, would have mentioned them had he lived personally to record

his own activities. There was, however, no doubt that he was very disturbed

in the early days when he encountered some of the same problems lie had known

as a medical officer in World War I. Yet, his intense patriotism and keen

desire to prepare young medical officers for things to come maintained his

spirit. Like his chief, Maj. Gen. Paul R. Hawley, to whom lie was devoted,

he was dedicqted to the ideal that American medicine must and would provide

the best surgical care in the quickest possible time, starting in the forward

areas, which was ever offered a soldier in time of war.

The lack of medical challenge to the consultant group by the Army

in the European theater during the early planning days was compensated

for by the medical problems presented by the Eighth Air Force, the problems
CHIEF CONSULTANT IN SURGERY 357

of medical supply, lectures at the Medical Field Service School, ETOUSA,

and the organization of medical meetings for the exchange of ideas with the

consultants and medical officers of the British and other Allied armies. Later

on, they eagerly welcomed a trip to the Mediterranean theater to gain firsthand

information of the problems to come on a much larger scale to their theater.

By this time, it was "their theater" in thinking and loyalty. As the time of the

invasion grew nearer, the consultants became more indoctrinated into the Army

and the Army in turn became more convinced of the value of the consultants.

It. was very soul-satisfying to General Cutler to observe the ever-increasing

usefulness of the consultant group. lHe was freed to give his energies to

projects more suitable to his background and capabilities. Few experiences

made as great an impression on him as his membership in the medical mission

to the Soviet Union. Lie was tremendously impressed, and some believed

so much enthusiasm was not. warranted. Subsequent events attest to his

astuteness in predicting the Russian people were a major force to be reckoned

with in the future.

The consultants came to their own with the invasion of Normandy. These

"nomads" of the Chief Surgeon were familiar with the professional background and location of thousands of medical officers who could be used to

meet the constantly shifting needs of combat. Their mobility tended to overcome one of the great weaknesses of military medicine by providing a followup

system on the effectiveness of treatment from clearing station to general hospital.

Despite failing health, General Cutler continued an aggressive interest in all of

the problems associated with the care of the wounded soldier. His spirits were

maintained in part by the active participation of two sons who were on active

duty in the European theater and the thousands of medical officers who looked

to him as their chief link with civilian surgery. This Master Surgeon, Inspiring

Teacher, Peppery Patriot, and Intense Anglophile, who had few equals in

personal charm and natural ability, assumed this responsibility with enthusiasm and determination. His natural talents toward the dramatic and

idealistic invariably lifted the morale of the individual medical officer, not only

during but in the hectic days after the war. His dream and active participation

in the Veterans' Administration to insure better care for the wounded veteran

and opportunities for the returning veteran medical officer were typical of his

complete devotion to his country and profession. Perhaps, his greatest contribution was to plant the seeds for the active participation of civilian medicine in

military medicine long after the war ended. The loyalty and continued interest

of the consultants to the Army Medical Corps since their return to busy civilian

life is ample proof of the fine esprit de corps that has continued, thanks to

leaders like General Cutler.

It was his hope and dream that military medicine would make adequate

provisions for the active participation of civilian consultants during peacetime as well as in wartime. To some, this may be hard to justify, since the role

of the consultant was so frequently of such an individual effort without docu-
358 ACTIVITIES OF SURGICAL CONSULTANTS

mented evidence that history may find it difficult to evaluate the consultant's

true worth. Test imon ials of thousands of individual medical officers would

be required to ferret, out their greatest contribution to the war effort. None

will be remembered longer or with more warmth and affection by American

and Allied physicians than the late Elliott Carr Cutler, Brigadier General, MC;

Chief Consultant in Surgery, European Theater of Operations; Moseley

Professor of Surgery of the I larvard Medical School; and Surgeon-in-Chief

of the Peter Bent Brigham Hlospital.

ROBERT MN. ZOLLINGER, M.D.

February 195,9
CHAPTER III

General Surgery

Robert M. Zollinger, M.D.

By the fall of 1943, Lt. Col. (later Col.) Robert M. Zollinger, MC, had

been serving for approximately 15 months as chief of the surgical service in

the 5th General Hospital, ETOUSA (European Theater of Operations, U.S.

Army). This was a unit affiliated with Harvard University and was the

first general hospital to be shipped overseas. The 5th General Hospital was

established in Northern Ireland early in the spring of 1942.

The incumbent Senior Consultant in General Surgery became ill, necessitating his return to the Zone of Interior (fig. 126). The possibility of Colonel

Zollinger's replacing him was first broached to the author by Col. (later

Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in Surgery in the European theater. At first, this new assignment seemed quite acceptable, since

the author had worked with Colonel Cutler for many years during his surgical

training and as a member of Dr. Cutler's immediate staff before the war.

The author conferred with Col. Maxwell G. Keeler, MC, the commanding

officer of the 5th General Hospital, concerning this proposed reassignment

(fig. 127). He was then sent to Cheltenham, England, to meet with Col.

James C. Kimbrough, MC, Director of Professional Services in the Office of

the Chief Surgeon, ETOUSA, in order that the actual appointment might be

submitted for formal consideration by the Chief Surgeon.

APPOINTMENT AS SENIOR CONSULTANT

There were both advantages and disadvantages inherent in an appointment as a senior consultant at the theater headquarters level at that particular

time. These were graphically pointed out by Colonel Kimbrough, who was

both a Regular Army officer and a urologist enjoying national reputation.

He discussed the advantages of taking care of patients as compared to those

of administering their professional care. Ile pointed out, however, that the

consultant could be of utmost value in the long run by coordinating the

utilization of personnel and standardizing therapy so as to provide optimum

surgical care. He also warned that a "desk job" incorporating the difficulties

of amalgamating the talents of various rugged individualists in the surgical

world could be particularly harassing.

Although, according to the letter of the protocol, the author had the privilege of refusing the appointment, it became obvious that it wias incumbent

359
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362 ACTIVITIES OF SURGICAL CONSULTANTS

Colonel Kimbrough's office was one room about 12 feet square. The Chief

Consultant in Surgery and tile Chief Consultant in Medicine had desks side by

side in an adjacent room of similar size. ()pp)osite. them was a room about 12 by

20 feet, which was used for a, vomnnion meeting p)lace. Activities of the week

were reviewed, and policies were formulated at meetings held each Saturday

morning in this room. Beyold this was a rather large room with desks around

the periphery. These desks were placed back to back. In other wor(Ls, there

were groups of two consultants sitting face to face around the sides of the room.

At one end of the room and in the mi(ldle were British civilian secretaries and

several enlisted( men who were used as messengers and file clerks. As one might

expect, the main room was quite noisy and inefficient for ordinary working

conditions. It was in many ways reminiscent of a boiler factory.

T'he amount of work done, therefore, del)en(led a great deal upon how many

of the consultants were present in the room at the time, how many were dictating, how many were holding conferences, how many were trying to make themselves heard over the telephone, how many were arguing with the personnel

officer, the supply officer, or the motor p)ool or trying to interview new hospital

personnel. These poor working conditions accounted in no small measure for

the high mortality which had existed among consultants up to this time. In one

room, gloom spreads rapidly. Certainly, these were working cold;'ions quite

dissimilar to any these surgeons had previously encountered. This does not

imply that they needed more comfort than the surgeons in the field, hut the

nature of their work required a lot of planning and discussion, which was virtually imp)ossible in the peculiar offices assigned to them.

Responsibilities of Senior Consultant in General Surgery

Although the specialty consultant ordinarily handled only those problems

in his field, the Senior Consultant in General Surgery served more or less as a

coor(inator of the surgical group. This difference in responsibility was in some

respects (tie to the fact that the Chief Consultant in Surgery was a general

surgeon who had a wide experience in 1)ractically all fields of surgery and one

who did not hesitate to make (lecisions upon 1)rofessional or administrative

matters in these particular fields. At times, however, the specialty consultants

felt that this was an infringement up)on their l)rovince; thus, perhaps, the

situation was resl)onsib)le for the creation of discord.

The specialty consultants were in close liaison with their counterparts in

the British Army. T11 the field of general surgery, however, the entire group

was represente( I)y (',Clonel Cutler, who maintained living quarters in London.

During the fall of 1943 and the winter of 194"-44, Colonel Cutler devoted

considerable time to liaison work with the British and to the study of the care

of wounnded air force casualties who were being treated in the V.S. hospitals in

East Anglia. The hospitals in East. Anglia were, at that time, the only hospitals

taking care of fresh casualties, since they were responsible for the reception

slnd care of casualties from tile U.S. Eighth Air Force.
GENERAL SURGOERY 363

Evaluation of Surgical Service in New Hospitals

One of the chief assignments of every consultant was to visit the various

hospitals as they came into the theater, in order to evaluate their professional

personnel in his particular field. If at all possible, the incoming hospitals were

visited in the staging area. In general surgery, each man on the surgical

service was interviewed and a record of his professional background was maintained. Special attention was given to the evaluation of the chief and assistant

chief of the surgical service, since the quality of professional care of any

particular hospital was closely related to the training bac? ground of the chief

of the surgical service.

The value of the intensive Halsted type of resident training was never so

clearly demonstrated as in those surgeons working in oversea hospitals.

Although they were far away from their ivory towers, they were never far away

from the surgical princil)les they had been taught.

After each hospital service had been visited, the entire surgical compleinent was reviewed and annotations were made with regard to the qualifications

of each surgeon. The probable efficiency and competency of the surgical service

was discussed and assessed. In the fall of 1943, the quality of the surgical servic' in the theater's hospitals was quite good, and evaluation was not difficult.

Eventually, however, as the theater began to he flooded with new hospitals, the

quality of the surgical services became more of a problenm. Also, at that time,

nianv medical officers were transferred from the Arniv Air Forces to the Army

Service Forces, and a number of officers of high rank b1ut limited p)rofessional

ability began to apl)ear--distributed here and there-iin the roster of almost all

of the new hospitals in the European theater.

The visiting of hospitals by the consultant was important, since it gave

each hospital's medical officers contact with men who were interested only in

the l)rofessional care of patients. Frequently. the new medical officers felt that

the Army was interested only in a type of surgical and medical care of which

they disap)proved. It was essential that the army directives and methods be

explained to them by men who had been in the European theater for some

time--men who had some idea of their possible future problems and of the

remisons for differences between military and civilian practices. The medical

officers in the hospitals did not hesitate to talk freely with the consultants

on a "doctor to doctor" basis, and the consultants' visits were very 1beneficial in

bolstering the morale of medical officers. On the other hand, the consultants

occasionally might have been a little too sympathetic with a man desiring to

make a change to further his own promotion.

Of greatest importance was the fact that at all times there were consultants

who had on record and also personally knew the professional qualifications of all

the me(lical officers of tile hoslpitals in the Eurol)ean theater. In case illness

incal)acitated a key surgeon, or if a particular hospital experienced an increased

professional load, the consultants knew whether or not the particular hospital
3(4 ACTIVITIES OF SURGICAL CONSULTANTS

involved was adequate and, if it was not adequate, where to find men who had

the qualifications to assume this additional load. In order to make the most

efficient use of this detailed knowledge of personnel, it was important that the

senior consultants be appointed for a long period of time. This knowledge

was invaluable, si,',.e the consultants could very readily supply the personnel

officer with the names of additional, trained men to speed up the organization of

new surgical services when the need arose among the many hospitals which

eventually entered the theater without. surgical personnel of the requisite high

caliber.

Tihe coiisultants, however, could only evalhate the professional personnel of

the service as a whole and act as advisers to the personnel officer. Only the personnel officer at the appropriate headquarters could initiate orders for the transfer of a surgeon from one place to another. The consultant could recommend

such a transfer, 1ut this (lid not make it automatic. It was important, therefore, that the consultant be in close liaison with the personnel officer in the

Office of the Chief Surgeon as well as with personnel officers in the base sections;

and it was equally important, that a spirit of complete confidence and cooperation exist between them.

Preparation of Manual of Therapy, ETOUSA

The Senior Consultant in General Surgery was also intimately associated

with the preparation of memorandums and directives. Information regarding

the efficacy of treatment being given casualties in England. Ireland, and

Wales was discussed as it was gained. Considerable time was taken to review previolus directives and to prepare directives incorporating the new information. Every effort was made to "nromulgate directives that would be clearly

understood by the surgeons and that would adhere to the best surgical standards

yet be in accordance with the tradition of military directives and objectives.

This led to the realization of a need for developing a standard manual of

therapy, including the medical and surgical aspects of care of the wounded

soldier. Colonel Zollinger's predecessor had obviously encoiintered many

obstacles in the preparation of such a manual, and practically no utilizable

material had been compiled. After considerable discussion, it was decided that

such a manual of therapy should (1) be small and compact so that. it could be

easily carried by the medical officer far into the forward area, (2) be up to date

and consistent with the directives of The Surgeon General and the Chief

Surgeon, ETOUSA, (3) contain the most recent information gained by experiences of the Medical Corps during the Italian campaignus as well as information from the. British and French Allies, and (4) serve medical officers in the

forward area as well as those carrying out definitive treatment in the base

areas. It was finally decided, therefore, that each chapter should be divided

into two parts--the first to deal with emergency treatment, and the second

to be concerned with definitive treatment.

In order to restrict the manual to pocket size, each chapter had to be very

concise and more or less in outline form. The medical consultants apparently
GENERAL SURGERY 365

had very little disagreement in the preparation of their chapters. The various

surgical specialists, however, submitted long chapters and were loath to endorse

the requirements of emergency therapy so vital in the most forward areas. It

took considerable time and experience gained from their visits to the North

African theater to persuade them that evacuation must take precedence over

definitive treatment. It was extremely difficult to convince the medical officer,

newly commissioned from civilian practice, that only the simplest things possible should be done in the forward areas; that is, cover the wound and then

evacuate the patient to a I)lace where definitive treatment could be carried out

under more satisfactory conditions. The desire to do too much and therefore

delay evacuation was a constant problem.

Since there was no consultant in thoracic surgery, this consultant was

responsible for the chapters on the treatment of abdominal wounds and thoracic

wounds. The directives issued from the Office of The Surgeon General were

utilized, but, for the most part, the material was gleaned from experience

gained in visits to various hospitals caring for Air Force casualties as well as

for those casualties returning from Africa to the United Kingdom. Information was also gained from the North African theater and from talking with

Colonel Cutler and others who had visited the North African theater and the

eastern front of the Soviet Army.

There was little disagreement regarding the general care of the wound.

Some of the major problems at that time were the use of chemotherapy and antibiotics-whether to use them locally or systemically, how much to use, and

whether to use them simultaneously or separately. The use of gas gangrene

sera and tetanus antitoxin and toxoid was also thoroughly discussed, and decisions were made as to their use.

It was this consultant's impression that the European theater had very

little in the way of directives or information from the Zone of Interior regarding the treatment, of casualties. However, it was frequently reemphasized

through channels from the Office of The Surgeon General that all wounds were

to be left open. Before the proofs for the Manual of Therapy, European

Theater of Operations, were sent away, Colonel Kimbrough again called the

author's attention to a recent cablegram stating that all amputations were to

be left open. These instructions were, of course, contrary to everyday experience in civilian life, when wounds had been seen early and under ideal conditions. Furthermore, Col. William F. MacFee, MC, had carried out primary

debridement and closure in a number of casualties in East Anglia which had

occurred in the Army Forces, and he had apparently obtained excellent results.

Men in the Army Air Forces, however, returned to their bases every (lay and

had baths and clean clothing. The surroundings of an aircraft were not apt

to be so contaminated as were those of the foot soldier who might be wounded

on soil which had been tilled over a period of centuries.

A great deal of space was taken to describe the debridement of a wound.

In order to demonstrate (lel)ridemnent with a simple sketch, a sergeant. who had

been interested in drawing was transferred from the author's old unit, the 5th
366 ACTIVITIES OF SURGICAL CONSULTANTS

General Hospital, to Cheltenham. Ile made some very helpful pen-and-ink

sketches illustrating various princiJples of first, aid treatment.

This consultant's experience ill preparing the Manual of Therapy convinced him that the most recent well-substantiated methods and principles of

treatment of war casualties shouhl I)e taught to all medical students and become

a part of the indoctrination of each medical officer. It seemed a great waste

of time and energy for surgeons to indoctrinate thousands of medical officers

scattered throughout the hospitals and bases in principles which could have

been given better during medical school or at least. during their basic training.

In May 1944, Maj. Gen. Paul R. Hawley, the Chief Surgeon, and Colonel

Cutler presented the Manual of Therapy at a conference with Lt. Gen. John

C. H. Lee, Commanding General, SOS (Services of Supply), in the British

Isles. They were very proud of this booklet which could be carried in the

medical officer's pocket. General Lee noted that it had not been dated and

asked for which war the booklet had been prepared. This omission was remedied by handstamping the date on the front of each booklet. It was the first

U.S. Army manual printed without having been officially dated.

Lectures at Medical Field Service School

One of the responsibilities of the consultants was to lecture at the Medical

Field Service School. Each man was assigned to lecture in his particular field

to a group of medical officers brought there from time to time for indoctrination

(fig. 128). The Medical Field Service School was under the direction of Capt.

(later Lt. Col.) Bernard J. Pisani, MC, an excellent director who cooperated

extremely well with the consultants, making the trip a most enjoyable one.

This was one of the functions of the consultant group which was always

pleasant, since it involved teaching younger men. Perhaps the teachers would

not have been so enthusiastic had they realized that many of their students

had l)een sent there for disciplinary indoctrination rather than for purely professional instruction. This consultant suspected that the mediocre medical

officers from many of the units were given a better medical education thereby

than the men who adhered to the line. This was not altogether true, however,

since many of the superior officers were originally sent to this school (fig. 129).

PREPARATIONS FOR NORMANDY INVASION

Planning LST Operations

In the latter part of February 1944. Maj. Gen. Albert W. Kenner, Chief

Medical Officer in General Eisenhower's Headquarters, SHAEF, held a meeting with General Hawley, Col. David E. Liston, MC (Deputy Chief Surgeon),

and representatives of the First U.S. Army, the British Army, the British

Navy, and the U.S. Navy concerning the professional care to be provided on

an LST (landing ship, tank). The Chief Surgeon's Office had made recommendations concerning the policies to be carried out on these ships.
11.ru:1 2-S. Ll.. ('(it. W ilium A. llimni~~a. MC . I hiel*. liuteliigviwve Sectionu. 41peraimisi ii!

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the Medical Field Service Schmi4,I. '()SA 111)4)11 its leojillillgý .11 the (li111altiaul 1 1,M1aais.

itiu';i P aris. Fra lece.

1almitiititt for' flie, tt'eat ieii1 4)f (aslatilvtie to be evanl~c~~e( oil L1' t'tt'iits

teti- iitl tiival~ot1 ot NotiiilaidY becinle ()tte (if ('olottel Zollittjrei"'' tel 401151-

Ibihit jes. Ile t hus lbe('Iitie ai 1 tias()t office], to 111 iVI.S. Nahv\ for' t i. preltliva~siOI1

h datiti t5. g Th e ii hut1 ei' o() I SI '%18li a ial hie. w~hicht was thIeti. of cours~e, secret

mforla'imia 1)1. wa;s 11lit.

I 'epanttg r I hes'e phl~ls ittu)1Vedl thle ol lo~wiiig prob)Ilemsi. F'irst . wvhat trPeat -

itlilit could1( be (';rivd ouel ol (I the I'ST afte~r it wvas loaded with11 ca.sitalt jes oit the

It i slioIe tt1 41 directedl bacIk to i lie flt-(( hieittoadlinitg point11 it 51hiernEl ot F 'gd Itht I d?

SecondNX(I,. ~~Iltiitiediva I het'')itieI wouldIn. livedieeie Ill add41itio lto 4 theII jiet'sOittte

of 1he LST liihird. whalt iuted ielI an Sitti1 sic sup 111IPS H'i'tI Nvotl(1 be liee ?t't

I' ' 4'ottvet't ed to pro'(videt ati ojtet'"It iiu-I'oolit platftormi were dlis-cussed.

O thler proposed ni111lno 4.hItttres te o I)(- eni to j.,slst 11t, he tioAiltj of a al

ties :hottt 11e1 shipj throtugh thte tt.1t'i'ow jptssatirwais. It Nvas 1)hinlttid thati

thle 4elisha It es woutld bev 14)adl(I 4)It st rel clers a tid plat'ed il t thle I11uot' of thle

iniidi~e deck af ter flt, letatiks 11114 it t'tts tiaitnspot'ted to Frntice had beeti landled.

Ti IS IsNolI I4 dpr'o vide a 1 ttI. I 'a Ir(t oie-' ott Iae spi) tl WI ward.

Thie t ' ye :11t41 ailliiottt of stit'getWY to be41 hpet'I(i'iedl woutld dhepend( 111)1)1 how

SOOlt fille't loiOit 1tr hosital, ('011( lbe Set III) ()tt the fhr Shore. It was apparent'i

tHim. Il li the 11, 1 'Insgres of' fthe inlvasioni. 111111 fr'esh, 1iSilialf Its w1ottild have
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37O ACTIVITIES OF SURGICAL CONSULTANTS

Discussions were held with the medical officer of the 1st Medical General

Laboratory, who was in charge of meeting the demand for whole blood on

each LST, and adequate plans were made.

Toward the middle of May 1944, recommendations were made for the

actual selection and assignment. of surgeons and surgical technicians for the

LST's. One-third of the group was to come from theater SOS units, onethird from the Third U.S. Army which was staging at that time, and onethird from the Armny Air Forces. These men were ordered to various places

in southern England for indoctrination preliminary to being ordered to a

part icular LST.

It was part of this consultant's responsibility to coordinate the indoctrination of these groups of men. They had not been aware, up to this time, that they

were to comprise the medical complement of the LST's. When the medical personnel assigned to these LST's were apprised of their mission, they were quite

shocked. Most of them regarded it as being more or less a suicide assignment.

They believed that the shores of France were loaded with heavy artillery, mines,

and multiple German divisions, and that poison gas would probably be used.

They had no way of knowing how poorly the coastline of France was defended,

compared to their expectations. Most of the line officers had already been

reassured.

Discussions as to procedure were started about 16 May 1944. On that

day, this writer visited the 28th General Hospital, at Trowbridge, and reemphasizedl conservatism in the care of the wounded aboard LST's. At this late date,

only 16 of the 34 men ordered to report to this collecting point, had arrived, and

some of these were without proper clothing. It was essential to supply the

physicians and their technicians with additional clothing, especially underwear.

The group at the 316th Station Hospital at Newton Abbot was also interviewed and briefed, and the men seemed well qualified and confident of their

capabilities to do major abdominal surgery, if necessary.

On 17 May 1944, a discussion was held with the group assembled at the

115th Station Hospital, near Plymouth. The majority of these men had been

taken from the Army Air Forces. One officer disclaimed his ability to perform

general surgery because he was a proctologist. Arrangements were made

for h is replacement.

In discussions with the physicians assigned to these UST's, it was amazing

to find that they invariably expressed concern over the qualifications of their

so-called surgical technicians. Since the true nature of the technicians' assignments was not known, many of them were, in reality, anything or everything

but surgical technicians. The officers evidenced real panic and attempted in

every way possible to contact their parent units to effect a return of the untrained enlisted men and to have them replaced with well-trained technicians.

Necessary steps were taken to facilitate these transfers.

Considering the operation with tile aid of hindsight, it would seem that the

commanding officer of a hospital dispatching a medical officer to serve on an

LST should have known the importance of the assignment. On the other
GENERAL SURGERY 371

hand, his consideration of the possible hazards involved might have made his

decision more difficult.

Planning Special Studies

Lt. Col. (later Col.) Joseph A. Crisler, Jr., MC, surgical consultant to the

First U.S. Army, visited Chelteniham rather regularly at the time of the surgical

consultant's Saturday morning meetings. In addition, other conferences were

held concerning his estimate(] requirements for penicillin, medical supplies,

specially trained personnel, and so forth. IPlan~s were also made for gathering

data oil abdominal wounds, thoracic wounds, and cases of gas gangrene, as

they were treated on the far shore by the First U.S. Army.

Several forms were proposed in an attempt to gain some statistical information regarding the treatment. and outcome of these wounds. It was hoped that

these reporting requirements could be printed and distributed to surgical teams

and that each unit in the hospital could be made responsible for collecting such

information. Actually, each form required too much information to be practical, and, although such information would have been invaluable, there was no

way that it could be secured easily. Certainly, it was regrettable that there

was no table of organization to provide for study groups which could have

developed special studies for the cases carrying a high mortality.

Distinguished scientists were present and available in the European theater,

who could have constituted a research study group, had an appropriate table of

organization been available. Such a group should have been assigned not. only

to theater headquarters but also to each base section and each hospital center.

It probably would have been most desirable to have hadl an officer in every

hospital, regardless of its size, designated as the responsible individual for

collecting such professional data or for the maintenance of an appropriate and

official diary concerning the treatment of patients-a diary which could have

been submitted to the Office of the Chief Surgeon at regular intervals for study

anti appropriate action.

Provision of Whole Blood

Several months before the invasion, there was considerable discussion concerning the use of l)roportions of l)lasma and whole blood in the treatment of

casualties. This aspect. of lplanning has been thoroughly covered elsewhere.

It should be mentioned, however, that Maj. (later Lt. Col.) Charles P. Emerson,

MC, and Maj. (later Lt. Col.) Richard V. Ebert, MC, of the 5th General

Hospital, devoted a great, deal of time to the development, of a mobile field

transfusion kit. Their kit could be stored in a wooden box used in the shipment

of 50-c(aliber aninnmition. It consisted of material for tyl)ing and cross-matching and all other material necessary for collecting and giving blood. These very

thoughtful, sincere indlividuals proved to their own satisfaction that it was

possible to wash out tlralisfusion lbottles withl distilled water and sterilize them

with alcohol. Actually, threy took blood front each other under these circumstances and readlninistered it to themselves without. ill effects. This was, to be
372 ACTIVITIES OF SUR(GICAL CONSULTANTS

sure, a very crude arrangement, but it would have made available whole blood

transfusions in any area, should it have become necessary as a lifesaving measure.

At that time, it was not clearly understood how sufficient. amounts of whole

blood could be delivered to the far shore, especially to forward areas. The

Signal Corps, in cooperation with these two officers of the 5th General Hospital,

developed a teaching film on the use of the field transfusion kit. It eventually

became apparent that blood would be flown from the United States, and these

kits would not be necessary; but it (lid show that, desl)ite great handicaps of

equipment and supply shortages, the ingenuity of the U.S. Army officer could

provide the best possible care for the American soldier.

Preparing for Reception of Casualties

In addition to attending conferences with the First U.S. Army consultants,

this consultant took part in several meetings in the Southern Base Section,

at which time the surgical chiefs of the various hospitals were gathered together. At these meetings, emphasis was placed on the rehabilitation of patients

and their early return to duty. It took constant surveillance by the consultants

to make certain that patients were not held for definitive surgery which would

prevent their being returned to duty within a period of 60 days. This became

increasingly important, for, as the time of the Normandy invasion drew near,

the necessity for providing empty beds in the transient hospitals, especially in

the southern part of England, became more r.cute.

The surgical consultants visited hospitals in the Southern Base Section

rather frequently during May 1944, urging clearance of all possible beds in

preparation for the reception of casualties. In addition, plans were drawn up

to provide surgical teams to the hospitals that were concentrated around the

reception zones for casualties returning from the LST's. Detailed plans were

made for the reception of these casualties and for the triaging of these cases in

order that specialty care would be made available as soon as possible, depending

upon the type of wound.

Last-Minute Activities, May 1944

Late in May 1944, there were constant changes in the maxima of demands

upon the consultants. The First U.S. Army had raised the requirements for

whole blood, and new transfusion sets had arrived which were being made

available for the Third U.S. Army. This occasioned changes in the supplies

to be provided LST's.

There was also considerable discussion regarding the proper use of sulfanilamide, as well as penicillin. The feasibility of providing the First U.S. Army

alone with sulfanilamide, to be taken by mouth as well as dusted on wounds, and

providing the Third U.S. Army only with penicillin was considered, in that

it would afford a well-controlled experiment to determine which was the more

effective in the control of infections in war wounds. It was the consensus, however, that the American public. would not approve such a study and that the

U.S. soldier was entitled to everything that was available for his care. The
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374 ACTIVITIES OF SURGICAL CONSULTANTS

ACTIVITIES DURING NORMANDY INVASION

A conference was held with LST surgeons at Southampton on 8 June

1944 concerning observations on the unloading of casualties. This procedure

was carried out quite smoothly, but the triaging officer was unable to carry

out the plan to sort the patients at that point because of insufficient time. The

LST's had to be reloaded quickly with fighting equipment.

Several LST surgeons were interviewed. One of these men stated that

he had brought back 46 casualties on his LST. He had been able to debride

some wounds and utilize his rubber sheeting, had given blood transfusions,

and had carried out, penicillin therapy. Ile seemed quite convinced that his

supplies were adequate and that he would be able to do the necessary surgery

in a satisfactory manner. When the casualties were received, those who needed

it were given a large amount of plasma and some were given whole blood and

prepared for early evacuation.

The surgeons who served on the LST's were req(uired to submit a report of

their experiences. One of these reports may be found in appendix E (p. 985).

Observations on Treatment of Casualties

One of the functions of the consultants was to observe and report on the

treatment of casualties from the time they were received from the LST's to the

time they were admitted to the various hospitals, including observations on

the methods of transportation used (fig. 132). The consultants were the only

ones who could provide any followup information and then report back to

the surgeon responsible for the initial treatment regarding his successes or

failures. The lack of adequate followup observations was one of the most

disappointing experiences of the military surgeon.

Treatment by these physicians was quite good, and the few cases of gas

gangrene seen during the everyday reception of casualties were usually in

prisoners of war. Scanty records, failure to continue penicillin therapy, inadequate immobilization, improperly made colostomies, and failure to evacuate

patients when the patient load b)ecame excessive were some of the mistakes

most commonly made.

Directives were quickly prepared by the consultant group in the Office of

the Chief Surgeon to point out the common and more serious mistakes. These

direetives were disseminated to all hospitals and surgical tams. For example,

some of the transient hospitals noted that abdominal cases were given fruit

juices quite early, and this, combined with early evacuation, resulted in considerable distent ion of the abdomen.

Study of Gas Gangrene and Wound Closure

Tlere was hope that an extensive study of gas gangrene could be carried

out and that facilities available at. the 1st Medical General Laboratory could

be used to develop a training film in gas gangrene. For example, it was oh-
GENERAL SURGERY 375

served that many patients with so-called cases of gas gangrene had received

the customary 18 ampules of gas gangrene serum but actually had never had

this dreaded infection. Some of these diagnoses were b)ased on the smear taken

of the wound, while others were based on inexperience-failure to appreciate

the fact that most gunshot wounds contained air in the tissues and that

crepitus was a common finding. Several illustrative cases were found, and

motion pictures were made of these particular patients, including their treatment.

Another function of the surgical consultant in the early days following

the invasion was to urge the principle of early secondary closure of wounds.

By 18 June, some hospitals were already taking cultures of wounds, with the

i(lea of making intensive studies in the proper method of treating such wounds.

Information gained regarding the proper del)ridement of wounds and proper

principles to be followed in secondary closure was taken to each hospital

by frequent consultant visits. This was the only way that such information

could be rapidly disseminated. Any directive issued would have lagged far

behind in the promotion of better care for thousands of patients.

Practically every hospital center began its own study, trying to determine

the best, princip)le of carrying out secondary closures. Some of the questions

in the minds of the surgeon follow:

1. How extensively should the wound be debrided before secondary

closure?

2. Could the wound including the skin be closed ?

.3. How soon after injury should the secondary closure l)e carried out'?

4. Should local chemotherapy or antibiotics have any place in the management of the secondary closure ?

5. Did the adminstration of these drugs systemically before and following

the procedure enhance the chance of success of the closures?

6. How long should the wounds closed secondarily be immobilized?

7. How soon could rehabilitation exercises be started without danger

of disruption of the secondary closure?

It soon became apparent that it was the thoroughness and care of the

surgeon carrying out the debridement in secondary closure more than the type

of chemotherapy or antibiotic which was used that determined the result.

If the surgical service of a hospital was in the charge of a very well-trained

surgeon-esl)ecially one who believed in attention to the fine details in technique

in care of patients--then the results in the hospital were good.

Regional Wounds

Eventually, thoracic wounds began to be concentrated in the various

hospital centers, and the principles of early closed drainage and early decortication were followed. The principles had been developed in Italy, and it was

the duty of all surgical consultants to impart this information wherever thoracic

surgery was being performed.
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I I i I ~ w H iiii P 
378 ACTIVITIES OF SURGICAL CONSULTANTS

Although the treatment of abdominal wounds was good and the majority

of these cases were kept on the far shore within a few days after the onset of

the invasion, the problem of the management of high intestinal fistulae was not

satisfactorily solved. Small bowel fistulae were noted for their poor response

to transportation. The surgeons were urged to avoid ileostomies or jejunostomies either by tube or exteriorization, if at all possible. They were further

urged to administer sufficient fluids to bring these patients into fluid and electrolyte balance and to make every attempt at early surgical closure of the

fistulae.

Tile management of vascular injuries of the extremities was also a pl)o1-

lem. There was a tendency at times to incorl)orate the extremity in a lot of

padding and a plaster case, which resulted in overheating as well as in covering

the tissues and making it iml)ossible to appraise the viability of the tissues

during the hours of evacuation. The closeness of the cast to the heel enhanced

the possibility of necrosis and infection. It was urged that these extremities

be covered with sterile towels and that the patients l)e evacuated from the

transit hospital in traction.

Before the end of June, many casualties were being received by air, and

the majority were in good condition.

ACTIVITIES ON THE CONTINENT

As Senior Consultant in General Surgery, the author was inforn-lr'r that

he would he assigned to the advance section of the communications zone, mnder

the overall command of Col. (later Brig. Gen.) Charles 13. Spruit, MC, as soon

as this headquarters was established on the far shore. After spending some time

in the staging area, this consultant finally arrived on the far shore on 1(0 July

1944. Reporting to the surgeon of the communications zone, he was advised

to report to Col. Charles I-. Beasley, MC., surgeon of the advance section headquarters, to work in the Professional Services Division of that headquarters

and on 19 July, he first contacted Colonel Crisler, surgical consultant to the

First U.S. Army.

Surgical and Shock Teams From Base Hospitals

After 19 July, the author met almost daily with the consultants of the First

and Third U.S. Armies. During these evening meetings, the needs for surgical teams anld other needs were discussed.

As soon as general hospitals had been set up in the staging area in France,

Colonel Zollinger contacted them and asked them to organize their l)rofessional

personnel into surgical teams. These teams were to consist of two surgeons,

one anesthesiologist, one surgical nurse, and two surgical technicians. Each

team was given the designation "A," and each was to be ordered out by number.

The First IT.S. Army was to keep by numiber and name the chief of each

team. It was planned that, insofar as possible, these teams would be assigned
GENERAL SURGERY 379

to evacuation hospitals to facilitate their relocation and eventual return to their

parent units. In1 many instances, these men in general hospitals had been in the

staging area in England for a considerable time and were more than eager to get

into active work as members of a surgical team. They were instructed to

report to a particular hospital, as designated by the army surgical consultant.

No official orders were ever issued for these teams, and probably no official record was ever made of the fact that between 60 and 70 of these teams were used

to supplement the surgical care of patients within the First U.S. Army during

the middle of July 1944.

When the flow of casualties was quite heavy, it was obvious that mortality,

especially in field hospital platoons receiving nontransportable wounded, could

be lowered if sufficient personnel were available to administer whole blood to

casualties awaiting operation. Accordingly, shock teams from the medical

service of these same general hospitals in staging were formed to consist of one

officer, one nurse, and one enlisted man. Two such shock teams were to be attached to each of the three platoons of a field hospital. These teams were to take

along with them a form to record the amount of whole blood and plasma given in

a clearing station both pre(operatively and postoperatively. It was believed

that in this way valuable information could be obtained as to the actual needs

for whole blood and plasma in the forward areas. These data were to be

gathered and correlated each week.

It was necessary for the author to visit the various field hospitals and

explain the setup and function of the shock teams, since the newly formed teams

were very much overworked. It was estimated that one surgical team could do

about 7 or 8 abdominal operations or 12 chest cases within 12 hours (fig. 133).

There were not eiiough personnel with the surgical teams to provide preoperative and postoperative care, and for that reason the shock team performed a

valuable service. After these shock teams were assigned, they were so busy

an(l emngrossed in their work that records were inadequately kept. It was

necessary, therefore, for this consultant to suggest that the nurse be made resl)onsible for keeping these records. A report of the activities of these teams

was submitted to communications zone headquarters for transmission to the

Chief Surgeon.

Approximately 104 surgical and shock teams were drawn from the various

general hospitals if] tile staging areas. These teams were returned to their own

units witihim a relat ively short t ime after the breIakthrough at Saint-lA), France.

The experience demoistrated that each hospital, regardless of its size, should

he subdivided and organized into surgical teams as well as shock teams. In this

way, all professional personiel, imcluding both surgeons and medical officers,

could be assigned a useful function. Certainly, a shock team should be available to sul)l)ort each surgical team during the time of reception of heavy casualties. These shock teams, previously organized and set up, probably served

as great a fumction in saving lives as did the surgical teams.

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GENERAL SURGERY 381

Evacuation and Sorting

This consultant visited various evacuation hospitals largely to maintain

contact with the surgical and shock teams on temporary duty from the general

hospitals and to make an effort to obtain data concerning the most. efficient use

of whole blood and plasma (fig. 134). On occasion, the consultants were also

directed to visit holding units to assist in the triage of patients. For example,

as many as 600 casualties awaiting air evacuation might be held by a medical

battalion. Patients with large wounds, casts, or wounds of the abdomen and

chest and those with complications were carefully checked before air evacuation.

Chemotherapy was not attempted unless these casualties were to be held overnight. Surgical teams from the 1st Auxiliary Surgical Group were assigned

to these units. Occasionally, surgery was necessary, especially when bad weather

prevented evacuation by either air or sea. Hospitals did not find it difficult to

supply auxiliary mobile surgical teams that had their own equipment. The

parent hospitals were all in need of additional help, and a great spirit of cooperation existed among them.

The problem of triaging patients from holding units to advance section

hospitals consumed increasing amounts of time. At first, those cases were

selected that had a reasonable chance of returning to duty within 10 days after

admission to hospitals in the advance section area. Allegedly, the first time

abdominal cases were kept 10 days instead of 7, the patient load in the field

hospitals was increased. The rapid forward advance of friendly armies after

1 August, however, resulted in a marked decrease in the number of casualties.

On 4 August., members of the Advance Section, Communications Zone, visited the holding unit at Omaha Beach. There were 1,100 patients in the particular unit, and 300 were selected for transportation on the first ambulance train

from Lison Junction to Cherbourg. The visitors attempted to select cases that

might have a reasonable chance of getting back to duty within 10 days or 2

weeks. Therefore, soft-tissue wounds, acute sprains, medical complaints, and

similar cases, for the most part, were chosen. No fractures, nerve, tendon, or

major blood vessel injuries, or wounds of the palm of the hand, the sole of the

feet, the scrotum, the peritoneum, or the buttock were selected unless they were

quite small.

Officers were instructed as a group and as individuals in triaging these

cases. Two hundred and twenty-one were sent by the first train. The author

accompanied this group to observe how well patients could tolerate transportation in the 40 homrne.s et 8 chevaux boxcars, which had been converted into an

ambulance train (fig. 13.5).

There were three tiers of litters, with the wounds of the patients l)ositioned

toward the aisle in order that they could be inspected frequently by the medical

officer. Several No. 2 medical chests were on the train, as were 1)lasma and

tourniquets. Fruit juice, K-rat ions, urinals, water, and so forth, were available

in each car. The train ride was extremely slow, the train fairly crept to Cherbourg, and time entire trip) took about 5 hours. The patients, however, withstood

it quite well and were delivered to the 298th General Hospital.
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384 ACTIVITIES OF SURGICAL CONSULTANTS

Evaluation of patients with hernias, varicose veins, and similar disorders

determined whether they should be operated upon at that time or should be

transferred to another type of unit. The entire policy of necessity changed

rather rapidly, dep)ending upon the bed space available in the advance section

hospitals.

On 5 August, the author visited the 5th General Hospital, which was functioning in Carenton. France, at the base of the )eninsuila. Tie hospital staff

estimated that no more than 10 or 20( percent of its cases could be returned to

duty within 10 days. The l)eriod of rehabilitation then had to be extended.

and it was suggested that triage be more rigid in order to make more beds

available for minor casualties that had a good chance of returning to duty

within 2 weeks. These types of cases usually included soft-tissue wounds

under 3 inches in length without associated damage to nerves, tendons, and

major blood vessels.

From time to tine, the consultants returned to England or other parts of

the United Kingdom to visit the various hospitals and hospital centers. On

these visits, they inade rounds with the chiefs of surgery in order to (liscover

any mistakes maide on tie far shore. It, was worthwhile to point out. to these

men the difficulties under which the surgeons on the far shore labored. It was

also necessary to check upon how well the patients were withstanding transportation l)y air, because there was some question as to how well thoracic and

abdominal patients would tolerate the airlift. When the consultants returned

again to France, they could report to the surgeons in the forward area couicerning the good work that they had done as well as note errors which might

be reetified with b)enefit to the patients.

In addition to visiting hospitals. consultants reviewed articles for inclusion

in the monthly medical bulletin which was prepared for the information of all

officers. Several meetings were held with the various thoracic surgeons in order

to develop general principles of thoracic surgery to be included in the medical

bulletin. Similar notations were made concerning the treatment of arteriovenous aneurysms.

The consultants shuttled back and forth between the United Kingdom and

France as the occasion demanded. Toward the latter part of August 1944,

a fair amount of the consultants' time was concerned with changes in policy.

More and more patients were being held in the general hospitals. which became

more completely established in France as the army moved eastward.

As patients were evacuated, it. became necessary to mark on the. outside

jacket or record whether or not they were to go to communications zone facilities on the Continent or to the United Kingdom. As a general policy, it was

suggested that all patients with fractures of the long bones and those with

hernias be sent. to the United Kingdoim. On the other hand, patients with

soft-tissue womnds were to be held for as long as, 30 days an( then be sent to

convalescent hospitals located in areas near the general hospitals in Normandy.

It was also plhmned that any patient whose condition would permit transfer
GENERAL SURGERY 385

to the Zone of the Interior at. tile end of 1 month would be treated in a general

hospital on the Continent. The same rule was to apply to prisoners of war.

It was necessary to at.'ange for the indoctrination of triaging officers at

the various field hosl)itals near airstrips. These triaging officers were selected

from general hospital personnel because they played a very important role in

the conservation of manpower and in keeping patients in France who might

be quickly rehabilitated and returned to duty.

Miscellaneous Activities and Observations

During the latter part of August, a circular instructed all general hospitals

to compile lists of various types of surgical shock teams, according to the new

table of organization that had been sent over from the Zone of Interior, for assignnent to the 12th Army Group, which in turn would determine their

distribution.

Arrangements were made to assign 'Major Ebert and Major Emerson of

the 5th General Hosl)ital to a forward field hospital to study shock. They

carried their own laboratory equipment. These men ultimately gathered very

significantl data which were later published in Anwila of Surgery. One of

their most significant findings was the fact. that, by actual measurement, many

of the compound fractures of ihe fenmur had lost, as much as 40) percent, of thier

total Wlood volume. These medical officers were impressed by the great need

for whole blood rel)lacement and eml)hasized that plasma was not an adequate

substitute for whole blood in a severely wounded soldier.

As the armies began to move forward farther and farther into Europe,

distances became so great that the role of the consultant became less effective.

Furthermore, the consultants in the ITnited Kingdom had been well organized

and were quite capable of functioning independently. More and more attention could be devoted to the development of principles regarding definitive

treatment of casualties. For example, some hospitals began to segregate all

their hand cases into a separate ward.

A number of surgical princil)les seemed to be violated from time to time.

Such errors as the inadequate exteriorization of the colon for a temporary

colostomy were studied, and corrective measures were then written up as an

editorial in the European theater Mediral Bulletin. Some difficulty was encountered in the evaluation of casualties in holding units before they were

finally sent back to the Zone of Interior. The holding units apparently were

too busy and did not assume the responsibility of continued treatment before

the patients were evacuated. It was obvious that more experienced surgeons

were needed to evaluate these cases and screen them before the patients were

evacuated, whether by sea or air.

Toward the end of August, this consultant visited various army areas

and continued a close relationsli1) with the very cooperative consultants in

the armies. Toward the end of Septeml)er, the consultants were directed to

visit the 16th Field Hospital which had received a numuber of wounded French
386 ACTIVITIES OF SURGICAL CONSULTANTS

from the -2d Armnored Division. The question arose why this hospital should

encounter such at high mortality. 'l9)1 visiting it, the consultants learned

that these patients were severely wounded because, like many brave Frenchmen,

they had left, their tanks and walked directly into the line of enemy fire.

Their distaste for taking cover, as practiced by other types of troops, accounted for the very extensive wounds.

As a nmatter of fact, a platoon of this hospital received 60 severely

Wolunlded during this sl)eific l)epriod, :14 of whom caine fronm the 2(1 Armored

I)ivision. Four of the thirty-four patients had been operated upon in the

clearing station of the French division. All four died within 2 days.

"FIGV'Rp, 136.--Lt. Col. Robert M. Zollin3MC, Commanding Officer, 5th General

rpital, Carentan, France.

LTCOL. ZOLLINGE

The average delay from admission to operation was 10 or 12 hours. This

was due to the fact that, during the first 24 hours, the platoon had but one

surgical team. This time interval was consistent with the delay observed in

many other field hospitals during the study on shock. Actually, when receiving casualties, the field hlospitals needed b)oth surgical and shock teams.

About the first of October 1944, it became a policy that affiliated units

which had been overseas for a long time should be commanded by members

of their own units. Accordingly, Lt. Col. (later Col.) Louis M. Rousselot,

MC, of Columbia University, was assigned as commanding officer of the 2d

General Hospital, and, on 9 October 1944, the author replaced Col. Maxwell

G. Keeler, MC, as commanding officer of the 5th General Hospital (figs. 136

and 137). Such a change was welcome, since the great distances involved

made the role of the consultant increasingly difficult. Furthermore, the various armies were well organized with their own consultant staffs, and the principles of treatment were by then well understood by all. Professional care

in the army areas was excellent, and the theater was filled with highly skilled

men. Base sections had been set up in France as well as iii the United King-

(loin. At this time, it would have been invaluable had research teams been
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388 ACTIVITIES OF SURGICAL CONSULTANTS

the field army back through the communications zone and finally to the Zone

of Interior, tile nomad consultant should be welcome in any area. He is,

after all, concerned with the p)rofessional care of patients and functions primarily as a doctor.

There was too great a barrier between the consultants in the headquarters

of the Office of the Chief Surgeoii and those in the various field arlnies. There

was no friction between the consultants themselves, but limitations did exist,

since each army was independently responsible for its own internal administration and resenteed any outside interference.

The consultants in the European theater were concerned especially with

their inability to requisition transportation. Perhaps it would have been

better, however, had they moved more as a. group. When several consultants,

each in a special car, arrived simultaneously at. a hospital, it was disturbing to

the officers of the hospital and tended to create a friction which persisted

throughout the war.

Because the duty of the consultant was to "observe and recommend,"

lie often lacked the authority to achieve his goal. It may have been due partially to the fact that he was not thoroughly informed as to the overall program

of the theater. Consultants should have been better briefed by administrative

officers concerning their l)rol)lens of sup)p)lies, ulen, and equilment.

Both the regular and the reserve medical officers who served as consultants

point to the fact that the morbidity and mortality rates were lower than those

of any previous war, despite the great mac. of casualties. These low rates are

attributed to many factors, among wiuich are planning, training, evacuation,

and indoctrination in the profession idl care of patients. Each group, therefore, played a vital role and should have made every attempt to understand thle

goals and l)rob)lems of the other group. By the end of the war, a much clearer

understanding had developed among them.

RECOMMENDATIONS

ITuder the system which prevailed in the European theater during World

War II, consultants could only recommend the transfer of individual medical

officers. The rapport attained with the I)ersonnel officer, therefore, became

a matter of utmost importance. It should have been incumbent upon the

personnel officer to accept without reservation the consultant's recommendations

for the transfer of professional personnel.

Tie tables of organization of headquarters of all levels should include

authorized positions for the entire group of consultants and l)rovide for their

ranks. Sufficient authority should be given consultants to carry out their

recolnmen dat ions. 'I'lTis, of necessity, includes tile granting of sufficiently

high rank, commensurate with the authority desired. Furtherinore, l)romotion

or apl)ointment, of one of the consultants in a table of organization headquarters

should not p)reclude the promotion of another because there is only one vacancy
GENERAL SURGERY 389

in that particular rank. This situation could be alleviated by the creation

of a separate table that provides for the positions and ranks of consultants.

In order to assure the most efficient application of tle;, time and energies,

consultants should have permanently assigned transportation on call, as does

a physician in civil practice. To enable consultants to visit various facilities

at will and coordinate l)rofessional activities by personal conferences would

greatly aid the standardization of p)rocedures, bolster the morale of surgeons,

and improve the professional care of patients. The consultant. should not

have to waste time trying to wrangle transportation from the motor pool.

The theater surgeon, the army surgeon, the base section surgeon, and even

the commanding officer of a hospital center should have a table of organization

and manpower allocations for research and observation teams. Such teams

should be accepted, in princil)le, as being just as essential for good surgical care

as are logistics, evacuation, and the like. These teams could then observe and

record the type of professional care casualties receive as they pass from first

echelon medical services all the way to the installations for definitive treatment

and rehabilitation.
CHAPTER IV

Neurological Surgery

Loyal Davis, M.D.

At the Arcadia ('Cofeil'ece, held in W-aihington from 24 D)ecember 1941

to 14 January 1942, a broad policy was decided upon for offensive actions

against (erimanly. It, was decided that, during 1942, Germany's resistance

would be worn down hy increasing air bombardment by British and U.S.

Forces, giving assistance to the Soviet offensive, and gaining possession of the

entire North African coast. This policy was examined many times, so that

it is not surprising that niany changes were made in the program. For

examl)le, the J.P.S. (U.S. Joint Staff Planners) believed that a considerable

land attack could l)e laumnched across the English Channel in 1942. This was

to be accomplished largely by British troops ill the b)eginning, but participation

of U.S. Forces, it was believed, (,oulld be built ul) rapidly. In fact, the planners

outlined a l)ossil)le cross-('hannel operation which would take place in the

summer of 1942 with a I)-day between 15 July and 1 August.

With this Iackgromid it is n difficult 1t 1to understand why 'T he Surgeon

General of the U.S. Army hastened to implement his share of planning in this

p)rol)osed operation and attempted to build up his medical forces rapidly.

A part of this planiting was to supply the Chief Surgeon, ETOUSA (European

nheater of Operations, U.S. Army) with a staff of consultants in the fields of

medici ne, surgery, neurological surgery, plastic surgery, ophthahianology, radiology, anesthesiology, orthopedic surgery, and otolaryngology.

On 2 July 1942, Col. (later Brig. Gen.) Fred W. Rankin, MC, chief surgical

consultant to The Surgeon General, telephoned the author anti arranged for a

conference in Washington on 5 July. Col. (later Brig. Geen.) Elliott C. Cutler,

MC, professor of surgery at Harvard Medical School: Lt. Col. (later Col.)

William S. Middleton, MC, professor of medicine and dean of the University

of Wisconsin Medical School; Maj. (later Col.) James B. Brown, MC, l)rofessor of plastic surgery at Washington University; Maj. (later Col.) Rex L.

I)ivelev, MC, of Kansas City, Mo.; and Maj. (later Col.) Lloyd J. Thompson,

MC, of Yale University School of Medicine, were either in England or on their

way to join the Chief Surgeon's consultant group. To the specialties of surgery,

medicine, plastic surgery, orthopedic surgery, and psychiatry, Colonel Ramnkin

explained, woulh b)e added neurological surgery. Though it was never at any

time during the conference so stated, the impression was gained that there

were several general hospitals in the European theater (and this meant the Brit-

:191
392 A('TI8ITIES OP SURGICAL CONSULTANTS

ish Isles) and that several would be added very rapidly. It is obvious that the're

was an immediate urgency to speed up Operation BOLERO, the buildup operation for invasion of the Continent.

Col. (later Maj. Gen.) Paul R. Hawley, MC, had been named as Chief

Surgeon, ETOUSA, by Maj. Gen. (later Lt. Gen.) John C. If. Lee, who had

been sent to England as the commanding general of SOS (Services of Supply), ETOUSA. Colonel lawley had been a member of the London Committee

which had been made up of representatives of various British supply ministries

and rep)resentatives of the U.S. Army who had functioned in mufti in London

during the entire year preceding the attack on Pearl Harbor. General Lee

had arrived in England, however, with another medical officer designated

as his Chief Surgeon, and it was a fortuitous circumstance which made him

appoint Colonel Haawley on the spot.

GETTING ACQUAINTED

Obviously, none of these circumstances were known to Lt. Col. (later Col.)

Loyal Davis, MC, the newly appointed Senior Consultant in Neurological

Surgery (fig. 138), when lie arirved in England by air on 6 September 1942,

after having been commissioned on 20 August. Soon after his arrival at

IHeadlquarters, SOS, in Cheltenham, Gloucestershire, the author was formally

introduced to the Chief Surgeon. Then the neurological surgical consultant

joined the staff of Col. ,James C. Kimnbrough, MC, Chief of Professional Services, a urologist, who had I)een on duty at Walter Reed General Hospital, and

whose good humor and patience were exemplified in his statement and belief

that the war spoiled the Army Medical Service.

It became evident ilnmediately that for some reason, unknown, the speed

of action had slowed considerably. There was one U.S. Army general hospital

in southern England, at Oxford, the 2d General Hospital, staffed by medical

officers from Columbia University College of Physicians and Surgeons, New

York, and Presbyterian HIosl)ital, New York. There was one in the Midlands,

at Mansfield, the 30th General Hospital, comprised of doctors from the University of California School of Medicine, San Francisco. Another, the 5th

General Hospital, had Ileeti for some time in Northern Ireland; the staff of this

hospital was composed of members of the Harvard Medical School faculty.

There was one neurological surgeon on the staff of the hospital at Oxford, Maj.

(later Lt. Col.) John E. Scarff, MC, who needed no help from the Senior

Consultant.

It had become the custom, and certainly it was logical, for each consultant

to make a tour of the theater and get acquainted with the U.S. hospital units

as well as the English and Canadian groups. Mr. Hugh W. B. Cairns, Nuflield

Professor of Surgery at Oxford, and an old friend who had studied at the Peter

Bent Brigham iHospital, Boston, had bcomne a brigadier and Consultant for
NEUROLOGICAL 8SURGERY 3 903

Neurological Sutrgery tothe R AMAC (Royal Army 'Med icalI Corps). There was

one implortant difference, however, in the respective p)osts of the British and

U.S. consul tant s. Brigadier Ca i rns was responsible for advice in neurological

surgery wherever the British Army was fighting, and his mobility and responsibilit3' created a unity which 1) ro(lucedl results in treatment and p~olicies far

surp)assing anythingl which the [T.S. Arniy attained.

On 17 September, this consultant submitted a memorandum describing Ihiinitial tour of inspection, and it was approved and returned by the Chief

Su rgeon with a request fliat ti e recolnimndi~at ions lbe implemented.

FIGURE 138.-Lt. Col. Loyal Davis. 31C, at

itis desk in the Office of the Chief Surgeon,

ETOUSA, Cheltenhamn, England.

Review of British Activities

A Military Hospital for Head lInjuries was located in the buildings of St.

Hugh's College for Womien in Oxford. This British hospital receivedl only

p~atienlts wvlio hiad receivedl craniocerelbral injuries of all dlegrees of severity, and,

ms a result of the careful andl scientifically p~rofessionail ser-vice which was griven

h~ere, thley dlemlonstratedl concelusively that a, high p)ercenitage. of imeni so injuredl

COUId( be ret urned to thieir mil itary units for dluty. O ne of the most irel iablo

sympjtomus upon which-I thiey prognost icated the. al~ility of the soldlier to return

to miiiiitary (lut y, ipart icula rlv in b)1un~t craniocerebral injuries, was the length

of the period of post-traumiatic amnnesia. Brigadier Cairns instituited thle

policy of treating open craniocerebral injuries by shavinig the hair, cleansing

thle woundl Carefully withI soap and water. applying a sterile dressing, andl

transporting the wounlded soldier as quickly as possibule to a hospital where lie

could~ receive definlitive treatment. Thle pat ients' recordls were car'efully made
394 ACTIVITIES OF SURGICAL CONSULTANTS

and kept so that they would provide a basis after the war for a study of the

immediate and prophylactic treatment of craniocerebral injuries.

The Middleton Park Convalescent Hospital, near Bicester, Oxfordshire,

was situated 10 miles from the head injury hospital in Oxford and to it patients

were sent from the latter hospital for convalescent care and rehabilitation. The

care at Middleton Park had been planned and was supervised by Brigadier

Cairns, and not by a student of physical medicine who knew nothing of the

residuals of head injuries. Even Radcliffe Infirmary, a hospital of Oxford

University, was utilized for the study of compound fractures of the extremities

and severe burns.

Within the environs of Oxford was the Wingfield Morris Orthopaedic

Emergency Hospital under the direction of Herbert J. Seddon, an orthopedic

surgeon who had received a considerable amount of surgical training at the

University of Michigan Medical School, Ann Arbor. The RAMC found it

possible to make use of Professor Seddon without insisting that lie be in uniform. To this hospital were sent all of the peripheral nerve injuries from the

British military forces and the civilian population. It was immediately obvious

that one of the most important contributions to peripheral nerve surgery would

one day come from this well-planned and well-organized hospital for study and

treatment.

In the aforementioned 17 September memorandum it was emphasized that

the U.S. Army records of examination, diagnosis, and treatment of the. peripheral nerve injuries in World War I were totally inadequate, were incomplete,

and were rarely available for study or for use in following up the few patients

who made their appearance from time to time in Veterans' Administration

hospitals. It was emphasized repeatedly that this should not obtain during

World War IT and that. the records at the Wingfield Morris Orthopaedic

Emergency Hospital could be used as models. Colonel Davis emphasized the

point that neurosurgical records need not be so elaborate that they would obstruct the care of the wounded but. that they should be complete so that future

military surgery would benefit from their study. This required unified direction

which was never obtained.,

Brigadier Cairns, through his friendship with Lord Nuffield, had initiated

a project at the Morris Garage in Oxford for the construction of mobile surgical

units for the RCAMC (Royal Canadian Army Medical Corps). These units

were 3-ton motor vehicles with 4-wheel drives and contained an electric generator so that the unit could pull up beside a church or schoolhouse and go to work

to help a forward hospital. Each unit carried two folding instrument and

operating tables, head rests, sterile drulns of supplies, sterile basins, and a water

tank but were not as elaborately equipped as were those originally designed by

Brigadier Cairns, one of wvhich was lost at Dunkirk.

'The recent five-center study of peripheral nerve injuries eonducted by the leterans' Administration with moneys made available through the National Researc-h ('onulli hn% pointed up this

glaring error of organization repeated through two world wars.
NEUROLOGICAL SURGERY 395

Other projects were underway at Oxford. Prof. S. (later Sir Solly)

Zuckerman was working upon the effects of blast as observed during the Battle

of Britain. In his opinion, blast did not produce cerebri'l damage but for the

most part affected the lungs. He was given the opportunity by Brigadier

Cairns of doing actual fieldwork. Professor Zuckerman accurately plotted the

scene of a bombing, the number and position of the individuals affected, the

exact character of the agent, and whether the injured individual was stationary

or moving, in an effort to determine eventually what prophylactic measure

might be worked out. By )hotographing and measuring the body in all conceivable positions assumed during coutbat, P~rofessor Zuckerman determined

that the head and neck offered a target equal to about 12 percent of the entire

body. Interestingly, a checkup on the actual location and nature of injuries

whiiclI he had investigated showed a remarkable percentage of correlation with

1Professor Zuckerman's calculations on the projection of various body areas as

targets. While he worked under the auspices of the British Medical Research

Council, Cooperation with thel military was maintained through Brigadier

Cairns.

In the laboratories of the Department of Anatomy at Oxford, Gralam

Weddell and Prof. John Z. Young were investigating the degeneration and

regeneration of nerve fibers to the skin and muscles following peripheral nerve

injuries. They found that any method of treatment which increased the blood

supply to the involved muscles was very important in the rehabilitation of these

patients. By recording the degree of muscle fibrillation following injury,

Weddell believed lie could determine whether or not a given paralyzed muscle

coull regain its function.

Canadian Activities in United Kingdom

The Canadian Neurological (1st General) Hospital was situated at Basingstoke, Southampton, and was built around Hackwood House in 1940. From

the beginning, it was designed and equipped as a neurological surgical installation. It was superbly organized and administered. In addition to giving

excellent care to the wounded, it served as a training place for young general

surgeons who could be taught the fundamentals of the immediate care of

neurosurgical injuries in forward hospitals. Personnel of this hospital had

called attention to the following important facts: (1) Small, apparently trivial,

scalp wounds often hid, erious underlying comminuted fractures of the skull

with destruction of brain tissue; (2) injuries of the head had been treated as

long as 36 hours after receipt of the wound in the Dieppe raid and after careful

surgery, aided by the use of sulfanilamide; (3) no infections had been observed

when the craniocerebral injury had been cleaned carefully, the head shaved,

sulfanilamide placed in the wound, a sterile dressing applied, and the wounded

man sent back immediately to the Canadian Neurological Hospital for definitive

treatment ; and (4) in the presence of a defect in the skull, in a patient who has

recovered function, repair of the defects by the use of a prosthesis could result
396 ACTIV1ITI ES 01F SURGI(ICAL CONSULTMANTS

inl the return- of the soldier to active military duity. This viewp)oint upon01 the

use of thle suilfoniamides was p~rior to the denmonstration that their general administration with determination of the blood level was as effective as, and less

(lestruet mve "o tissuie t 1)111, their local admflinlistraltionl.

Observed at. this hospital were several patients who had b~een op)erated

upon01 for herniatedl nucleus I)1ilposlus andt returnedt to duity'. This exp~erience

resultedl inl a memorandum, whlichl was adlopted as U.S. Army policy inl the

European t heater, to tile effect. that these p~atienlts shouild be operateduon Ub)11iy

neurological surgeons, lint onfly whlen tile clinical syndrome pathiognoinonic, of

this cond~itlonl existedl and whien careful X-ray studies usilng the new nlyelographiic material, Palltopaqiie, corroborated tile oliagniosis. Finally, it wvas

emph~iasizedl thiat. intenlsive anld suplervised pihysical rehabilitation exercises

shouild be carried out upon each p)atienlt.

Inadequate Facilities in U.S. Hospitals

This get.-acoquainted tour emuphasized tile comlplete lack of instrumilents and

eqtlpienelt onl handl ill tile 2d General Hospital for nleurological surgery. Ilii

comnpanyv with hilhe. Senlior I. onstilanlt. for P~last ic Surgery, thIiis consiltant visited

tile British su~rgicall inlstrumllent houises of Allen & 1-lanbibrys Ltd., and1( Down

Bros., Ltd., aiucl a, representative of the British Ministry of Supply, in ordler to

determline whlethler tihere wereC any1 ilIstruillents upon01 thleir shelves oi- inl their

stocks whlichiold b'1111e sup1plied to U.S. Army general hosp~itals. Tilis wvas an

tilllIprodlict ive olay lecallse tilose illstrilnuents available were completely olutin1oded ; thle fieldl of nietrl'ogoicall surer and its applliances andl instrumnlelits

had been developed ill tile Unitedl States,. It wvas, however, a, (lelionstratioll,

inniii t inles rep~eatedl, of tile facts t lat thle Army- could( put. suppllies into a dlepot

1)lt couldl not~ get them out; that, because anl officer was a doctor. it did not follow that hie wvas cap~able of gettinlg the righlt supplies whlere they b~elongedl; tllat

a good stock mianager from a mail-order Ilioise w~ou~ld have servedl far better;

and, finially, tihat tile p)rinc(iple of ordering a stip~ulated suplply of a par'ticiular

itein for a given ilndnier of men every 190 (lays wouldo restilt, ill enlough tluermiometers to roadblock all invadling force and enoulgh hypertonic, glucose solution to

float tile. British Navy.

ANALYSIS OF THE SITUATION AND RECOMMENDATIONS

As a result of this tourl, t his consultant wrote a dletailed linemlora dIn)ull of

tile prlinlciples learned 1., thle Brit ishl for tile ('are of nieurosuirgical injuiries and

requtested that it be sent to thme Office of nie suirgeon General ill waslmin4gtonl

for dissemination among military anld civilian nueurological silurgeollS 1ll tile

U~nited States. Ilie huopedl that. thils Illidlit, be started a1. mlethlod of c'oil]munllca -

tioll whlich wvolild nmake it olbviolls tllat a tinified inetlmod of care and handling

was essential for ob~tainingY resullts wvhichl later couilo be stud~ied to) tile ad~vantage, of the injllredl manl. Wlhethler tllis inenmoranduln wa~s ever sent to Washi-
NEUROLOGICAL SURGERY 397

ington. this consultant iiever knew; if it was, nothing came from it because,

throughout the war, it seemed to t he author that the European theater remained

a distinct, isolated entity instead of having a close liaison with the Office of The

Surgeon General. It became evident, more and more, that a Consultant in

Neurological Surgery should have been resl)onsible, through the Chief Consultant, in Surgery to The Surgeon General, for the proper organization of

the care of neurosurgical injuries in whatever theater of war they occurred.

Such a consultant could have been mobile enough to have spent the time necessary in each theater to have provided methods and means of obtaining results

which could later hav'e been the basis for valuable contributions to this field

of surgery. In the Mediterranean theater, there was no senior consultant in

neurological surgery. In the European theater, during Colonel Davis' tour

of duty, there were never more than two qualified neurological surgeons with

whom one could consult.

It was apparent on 19 September 1942 that the 1st Infantry Division was

preparing to leave for a combat zone (Africa). The author gave the medical

officers of this division an hour's talk on neurosurgery in war. They had had

no previolus instruction on this subject during the 18 months to 2 years they

had been on active service. Perhaps it was just as well, considering that they

lacked morp)hine Syrettes, blood pressure apparatus, anesthetic agents, and

sulfonamides, to name a few glaring shortages. Medical officers were being

used as transportation officers and in other cal)acities: the division surgeon did

not attend the meeting and had never attended a medical meeting of the division. The morale of the division's medi(cal officers was low.

St. Bartholomew's Hospital, which had been badly bombed, had its neurosurgical unit, under Mr. John E. A. OiConnell, at lll End Emergency Hospital, St. Alblans. London, and was visited on 28 Septemlber, as was the Canadian

15th General Hospital. On the same tour, this consultant visited the 30th

General Hospital. The Canadians presented a series of papers relating their

experiences in the treatment of casualties received following the Dieppe fiasco.

They empliasized the use of surgical teams consisting of two surgeons, two

nurses, an anesthetist, and an orderly. Tle recor(ls of their examinations and

operations were dictated to, and kept in order by, ambulatory patients and

enlisted men. Their data were uniform and provided excellent material for

future studies.

A young captain with some training in general surgery and with no

aspirations to be a neurological surgeon had been assigned to care for neurosurgical injuries, when and if they occurred, at the 30th General Hospital.

Colonel D)avis recommended that a census of the number of neurosurgical

injuries in each of the U.S. hospitals in the theater be provided the. Professional Services Division because there was no way of knowing where such cases

were or how they were being treated. It became known that. many American

soldiers, injured severely in jeep accidents in the blackout., were scattered

through British EMS (Emergency Medical Service) hospitals and were receiving treatment for their ('raniocerel)ral injuries which was below American
398 ACTIVITIES OF SURGICAL CONSULTANTS

standards of treatment. On 1 October, an example of an American soldier

taken to an EMS hospital instead of to the 2d General Hospital at Oxford

was cited as a reason for seeking a method to transport such injured American

soldiers to a U.S. hospital. As a corollary to this, and as a result of a line

officer's refasing to move one of his men from a British hospital even after

the British doctor and an American medical officer directed his transfer,

authority was also requested for the recognition of the American medical

officer's orders in such instances.

As a result of many conferences with Brigadier Cairns, Mr. Geoffrey

Jefferson, and Dr. George Riddoch, as well as with various members of Canadian hospital units, Colonel Davis recommended on 5 October 1942 that all

general hospitals have a qualified neurological surgeon assigned to their staff;

that instruction in the primary surgical treatment of neurosurgical injuries

should be given, in a teaching course, to battalion aid station, collecting station, clearing station, and evacuation hospital medical officers, since the final

results of the definitive treatment of those injuries depended upon the accuracy and effectiveness of the early treatment. It was recommended that this

be (lone without removing the officers from their units and before they reached

the combat theater where such periods of instruction might interfere with

more immediately urgent activities. Thus, another attempt was made to bring

about some sort of unity of effort. in the care of neurosurgical injuries.

On 13 October, this consultant wrote the first of seven memorandums to

govern the general principles of the treatment of craniocerebral, spinal cord,

and peripheral nerve injuries. Six of these memorandums were criticized on

the grounds of poor English, and the seventh was accepted and disposed of

most effectively by one of the Chief Surgeon's staff officers when he filed it

away among his effects.

On 15 October 1942, the author submitted a detailed memorandum about

the transfer of injured American soldiers from EMS hospitals throughout

the British Isles to U.S. Army hospitals. With reference to neurosurgical

patients (and it would have applied easily to other types of injuries), it was

recommended that:

1. All EMS hospitals be requested through the director of their service to

notify immediately the Division of Professional Services, Office of the Chief

Surgeon, ETOUSA, of the admission of American soldiers with craniocerebral,

spinal cord, and peripheral nerve injuries.

2. The Director, EMS, be requested to supply to the Division of Professional Services, Office of the Chief Surgeon, a list of the neurological surgeons

and the name and location of the EMS hospitals in which they are located.

3. In the absence at this time of an adequate number of qualified and

certified neurological surgeons in the American Forces, the Senior Consultant

in Neurological Surgery be given authority to contact the EMS neurological

surgeon of the region nearest, the EMS hospital to which the soldier has been

taken and request that he assume responsibility for removal of the soldier to his
NEUROLOGICAL SURGERY 399

own facility and there treat him, or direct his treatment if in his judgment

transportation is inadvisable.

4. An American soldier so injured be moved to a U.S. general hospital

where a qualified and certified neurological surgeon is available, just as quickly

as the condition of the patient warrants, in the judgment of the EMS neurological surgeon.

5. The treatment of American injured by EMS neurological surgeons be

discontinued as soon as neurological surgeons in U.S. general hospitals are

available in sufficient numbers to render this service themselves.

6. Authority be granted to employ indigenous ambulance service to remove a patient to a U.S. hospital in the event that the employment of American

ambulances is impossible or would involve unnecessary delay in the treatment of

the soldier in the judgment of the Senior Consultant in Neurological Surgery

or an individual to whom he delegates the responsibility for such judgment.

On 19 October 1942, this consultant wrote directly to General Rankin in

Washington and asked that he assign neurological surgeons to the 5th and 30th

General Hospitals. Evidently, this gentleman quickly recognized the failure

of this memorandum to stay within "channels" and by not answering it saved

the author momentarily from his ultimate difficulty.

On 22 October, a visit to the 30th General Hospital revealed that no suction

apparatus was available to the surgeons and that operations upon one patient

with a rul)ture of the spleen and upon another with a rupture of the kidney

had nearly resulted in fatalities, although the surgeons had improvised with

two bicycle pumps and the strength of an orderly. The first of a series of

requests for such a suction apparatus was written immediately and was followed

by several others containing minute descriptions of a suction pump available

from a supply company in Reading, England, for fifty dollars. The size of

valves, the overall size and weight, and minute specifications were given; in

fact, a pump for each of the general hospitals in the European theater was

available and could have been delivered by hand by this consultant, if necessary. The requests ended up without action in the Supply Division, Office of

the Chief Surgeon, ETOUSA, which was at that time the most persistent of

General Hawley's problems.

On 26 October, in answer to a query from the personnel officer, Office of

the Chief Surgeon, ETOUSA, this consultant emphasized the facts that (1)

the neurological surgeons suggested for the 5th and 30th General Hospitals

were already commissioned in the Medical Corps, AUS, and would not, therefore, be taken from civil life, (2) there was only one neurological surgeon in

the European theater, and therefore the need could not be supplied from the

European theater, (3) the request was not for consultants but for experienced

neurological surgeons capable of assuming responsibility for the treatment of

craniocerebral, sl)inal cord, and peripheral nerve injuries and, finally, (4)

dependence upon the British EMS head centers for the treatment and care

of neurosurgical cases in the European theater should not be continued.
400 iVIIIS OF I SU1IMI(AL CO NSU'LTANTS4

Nfany ineniraId tnillnis later, it Nvils evidentit hat thle C hief Surgeon htad

liWever Seell 1.111 of tilie iiillll* recommliendlat ions made by tilie Senlior. Consult ant

inl Neurologicall Sul-rgery. , 'l'leY were passed back antd forthi or conveniently

filedl byV i1 lersoli2IllY hqst ile miedicail offlicer whlo openly lioasteil t hat liel wouldl

puit tilie nlew lienit etant vololliel sIpeeiahist conisult ants iii t heir place. Sooni, therea fter, a roster of olitiers was issued for ahliliglit (hity to ainswver thle telephl~lle

to receivye reports of deathus of soldiers Ini tilte t heater. Ti'le roster began with1

tilie lieutenanit colonel colislititt its to thle Ch'lief Suirgeonl, and flie du1ty w1as

served~, IIat-least bY olie voiisi It it it. Iitint II le roster andu (hlity wer~e canclllepIti.'

( Jeiierall I laiwiley wh~ien it wa~is cal ledl to his at tellt ionl.

( )i 3 Noveimbler 1944, Ilcoiipiniedl by thle Senior C onisultanit inl Plast ic

Surgery, tilie alit lior gave the first of a series of lectures at thle Ei4ghthl Air

F~orce Illrovisioiiii Medical Field Service School to voiung ait force mied ica

officers. At this t iiiie. it was not apparent t hat a1 s-chiisiii existedl bet weenl thle

Armii Air Forces anid the rest of tile Armiy, based uipon tile Air lForees'

aittempi~ts to estabishdi a inellical service qulite sepalrate and( (list inct from t hat.

of the renininder of tile Armyv. At this samie time. the 92d Bomber Group

( oinhat. C rew Replacement ('Petter It1 Bovtiigdonl was visitedl. This tour alIso

included thle E~ast ( riiisteadl loval Victoria RAF' Plast ic Center, which wats

huller t lie direction of Mr. A. If. M Imldoe, Chlief (Consultant ill Plastic Surgery

to the RAF. .Mr. McInidoe made it possible to visit Griouip Cap11tainl Atelierly

of thle RAF, whvlo wats inl commndiii~ of a1 fighter'I group, and1( who personallyv

colil1lict ed tilie tw U( I.S. Ariv oiisililtants over hIls stat ion. Following theseI

visits, conIiiprehieuisi i-e miemioranidum~is were writ ten which recommiiended the

phiceiuieit of weill-stillyied. complet ely equipped, snialller types oif hiospital1s,

strategically lovated wit hin rapid evacuat ion distanice by ambulance from

lioiiihWr am1( Itighter ai rdronlies, andi~ the assignuielit of a1 liaiis~on iiiedical otlicet'

fromi thle I .S. ArniY Air Forces stationled ill tilie U nited K ingdomi to thle

( ffice of thle C hief Surgeon to 21(1 t5( in tilie eventual21 (1is9osit ion of ilijlirep

a ii- force ii oi'ituiel. It is fiow cleair t lint, at thle ttimie of thle writing ofths

mieinorandumls, tilie struiggle for i iidepenidencve inl mledical orgaliiizaltionl was

tak ing p~lace, a11n( thlese nienoranId 11ils couldi hot. hav1 e been iliore t imiely, thoughl

they were compijletely itietlect lye.

On !i) Novenliber 194t!, Colonel D avis wrote at detailed imemnorandum to) tilie

C hiief Surgeon, KrI( usA. 'r'ite auithior was quite 1Iiiiiiware of thle organization

of the ArIiiy 211nd tilie relait ioiisliiP of 21 theater of opleratitoils to the Wllar D epart1-

Ilit-lit ill Washington its far ais thme Medical D~epartment. was concerned. It. was

ievouinilig iiiore and1( more appai'eit thlit tilie Medical D ep~artmnent wals conlipletely

siibservieiit. to tlie SOS comimand a111( t hat tilie Chiief Sul-rgeon l hadiaccess to thle

C'ommuandhing General, ETI( 1 SA, only t hroughi lie (Commuandinig General,

S( S, KTOUSA. This fact, learned by (hiligrent stmtiy of thle volumesdIepict tug

the history of World Wilr I, Iluring whacitI tilie sanlie st'igrgle for direct. responisibility of tilie Medical D epart ment, to I lie comllilluil iiig genieral oc-curred. iiiade

it. ol v oils that Ilie Air Forces event tin I v wonl havm~ e their seprt 2Pite Iiiedivl ~
NEUROLOGICAL SURGERY 401

service. If they were not to succeed immediately in such a division, at least

it appeared they wouhl conduct their affairs in such a manner. The memoranhuln to the Chief Surgeon read:

1. The Consultant in Neurological Surgery in the European Theater of Operations held

the following views, which were expressed, when he accepted the post offered by the Surgeon General's Office:

(a) Military neurological surgery differs in many of its technical aspects from the

neurological surgery of intracranial tumors and other commlon civilian neurosurgical conditions.

(b) There is no plave for the trained, experienced neurological surgeon in forward

areas of combat.

Sc) Only careful, well-directed immediate general surgical treatment should be given

to neurosurgical injuries in forward combat areas.

(d) Properly instructed and trained younger medical officers should have the responsibility of giving the type of immediate surgical treatment in forward areas necessary

to obtain good definitive results.

(e) Meticulous, definitive surgical treatment should be given to neurosmurgical injuries in general hospitals only, located within reasonably rapid evacuation distance of a

combat area.

(fM Experienced, well-trained and recognized neurological surgeons should direct

definitive treatment for neurosurgical injuries in a general hospital.

(g) Neurological surgery should be a service in a general hospital and special neurosurgical hospitals have no pllace in an Army.

2. With the statement contained in Paragraph lb. the Chief Surgeon of the E.T.O. has

expressed complete agreement.

(a) This viewpoint is supported by the experience of the Royal Army Medical Corps

at lDunkirk and the Middle East and by the Royal Australian Medical Corps.

3. The Consultant in Neurological Surgery has (a) completed personal investigations

and observations of facilities. equipment and personnel of the U.S. Army Medical Corps in

the E.T.O.. as they apply to neurological surgery and (b) has visited and observed the

British and Canadian Army neurosurgical service in the U.K. and (c) the neurosurgical

services in the E.M.S. and the Scottish E.M.S.

4. As a result of the statement (contained in Paragraph 3, the following facts are

evident:

(ia) Competent. experienc(ed and self-reliant neurological surgeons are now assigned

to two of the four U.S. General Hospitals in this theater (#2 and #298).

(b) Ground and air force combat neurosurgical injuries in British hospitals in the

United Kingdom. both military and E.M.S.. are comparatively small in number. The majority of such cases have been the result of blitz or ordinary civilian accidents.

(c) Only one neurological surgeon in Great Britain and one from Canada are in

Army service.

( ( The overwhelning remainder of the neurological surgeons in the United Kingdorn are in the Emergency Medical Service.

(e) Very few, if any, peripheral nerve, spinal cord and compounded craniocerebral

injuries (fan be returned to military duty within the 1SO day evacuation period established

by the ('hief Surgeon of the E.T.O. Only relatively minor closed cranio-('erebral injuries

can meet the requirement of this evacuation period.

(f) Based upon neurosurgical casualty figures In World War I. on the figures available front British services thus far. and upon the combat casualties which can be projected

in the immediate future in this theater, four neurological surgeons will meet all the needs

for the highest type of surgical treatment for neurosurgical injuries.

(g) Equipment and supplies. for obtaining the best possible results for the soldier

suffering from neurosurgical injuries, are lacking in completeness in U.S. General llos-
402 ACTIVITIES OF SURGICAL CONSULTANTS

pitals in the E.T.O. This equipment cannot be obtained from English surgical instrument

firms.

(h) Younger medical officers in the division who have been observed in this theater

are poorly prepared by training and equipment to give proper immediate surgical treatment to neurosurgical injuries in forward combat areas.

5. The function of tihe Consultant in Neurological Surgery is to act in an advisory

professional capacity to the Chief Surgeon of the E.T.O. and to establish and correlate the

highest type of neurosurgical service In this theater to the end that eventually it will be

possible for the Medical Corps of the U.S. Army to make a significant and substantial

contribution to the surgical care of the injured soldier.

6. As a contribution to this deired result, the Consultant in Neurological Surgery

with the fullest sympathy of understanding on the part of the Chief Surgeon, has recommended :

(a) That experienced, comnpetent and self-reliant neurological surgeons be assigned

to U.S. General Hospitals #5 and #30 in the E.T.O.

(b) That medical clinical records, supplemental to the F.M.R., together with the

necessary clerical aid, be made available to U.S. General Hospitals in E.T.O. The purpose

of this recommendation was to afford the opposrtunity of compiling a record of the end

results of neurological surgery in this War which would surpass that of World War I.

(c) That a course of instruction to division medical officers be given in training camps

on the principles of the immediate surgical treatment of neurosurgical injuries.

(d) That neurosurgical injuries be transferred as soon as practical front station

hospitals in the E.T.O., and be evacuated as rapidly as possible front forward combat areas,

to general hospitals in the E.T.O. for definitive surgical treatment.

(e) That all equipment and supplies necessary to obtain the highest type of neurosurgical end results be furnished U.S. General Hospitals without delay so that these hospitals would be able by their work to represent the highest type of American medicine and

surgery.

(f) That a general directive governing the principles of the treatment of neurosurgical injuries be issued to general hospitals in the E.T.O.

(g) That a fixed general hospital with a neurological surgeon assigned be strategically located within rapid evacuation distance of the present dispositions of the American

Air Force installations in this theater.

7. The Consultant in Neurological Surgery has been able to effect the following service

to Injured American soldiers:

(a) Through personal contact with the Chiefs of the neurosurgical service in E.M.S.

and Sc)ttish E.M.S., American soldiers with neurosurgical injuries taken to E.M.S. hospitals

receive the immediate services of the regional neurological surgeons and are evacuated as

rapidly as possible to U.S. General Hospitals.

8. The Consultant in Neurological Surgery finds himself in disagreement with the Table

of Organization for U.S. General Hospitals, Issued in April 1942, which does not provide for

a competent, experienced neurological surgeon.

9. The Consultant in Neurological Surgery is in entire agreement as to his function

as a professional advisor to the Chief Surgeon of the E.T.O. and if the theater of warfare

was contained within the United States, it is reasonable to assume that he would act as

liaison between the Chief Surgeon of the forces and the Surgeon General's Office. The intervening distance which exists under the present conditions, and can be rapidly bridged,

should not be a deterrent to that function.

10. The Consultant In Neurological Surgery, therefore, is firmly of the opinion that to

accomnplish his function to the best interests of the Injured soldier, the Chief Surgeon and

the Army Medical Corps and because of the significance of the facts cited above, he should be

given the opportunities inherent In a liaison officer, representing the Chief Surgeon in

neurosurgical matters only, between this theater and the United States, particularly during the present period of comparative combat inactivity.
NEUROLOGICAL SURGERY 403

Recomnmendations:

1. The Consultant in Neurological Surgery should be given the opportunities of liaison

between this theater and the United States, in matters pertaining solely to neurological

surgery, to acc, niplish better the funetion.w of his aplxintmnent.-

On 17 November 1942, four circular letters were prepared by Colonel Davis

for the signature of the Chief Surgeon, ETOI'SA, to be sent to the coninmanding

officers of U.S. general and station hospitals in the United Kingdom, covering

the subjects of the treatment of: (1) Craniocerebral injuries, (2) spinal cord

injuries, (3) peripheral nerve injuries, and (4) ruptured intervertebral disks

(herniated nucleus pulposus). On 21 November, these circulars were included

in one, entitled "The Disposition and Treatment of Neurosurgical Injuries,"

which was included in Circular Letter No. 75, Office of the Chief Surgeon,

ETOUSA, issued 4 December 1942.

On 18 November 1942, this consultant visited the 298th General Hospital,

the University of Michigan Medical School unit, at Frenchay Park. Arriving

in England with the 26th and 29th General Hospitals, the units affiliated with

the Washington University School of Medicine, St. Louis, Mo., and the University of Minnesota Medical School, Minneapolis, respectively, the 298th

General Hospital had been kept in England while the other two had been sent

on to North Africa. The 298th General Hospital was sadly lacking in equipmnent and supplies, and much time elapsed before this hospital became effective

A quotation from the memorandum report of the visit written by the author

will make evident these difficulties: "The professional staff is working hard,

and because of their own efforts they will rectify many of the difficulties which

now exist, but they need prompt and sympathetic understanding, and imuplementation of their needs, none of which are extravagant."

THE SURGEON GENERAL'S VISIT

About. this time, Maj. Gen. James C. Magee, The Surgeon General of the

U.S. Army, visited the European theater, and the consultants were asked by

Colonel Kimbrough to prepare a list of questions which might be propounded

to him. The naive assumption was expressed that they would be presented

to The Surgeon General at the time of his visit and would be answered. Neither

part of the assumption proved to be correct. However, the questions prepared

and submitted by the Senior Consultant. in Neurological Surgery show the difficulties which existed in connection with the attempt to establish a medical organization patterned on the Office of The Surgeon General but without any relation to it whatever. They were:

1. Is neurological surgery recognized by the Office of The Surgeon General

as a surgical specialty in the Medical Corps?

2. If so, why has a neurological surgeon been removed from the latest published table of organization of general hospitals?

2 Memorandum. Lt. Col. Loyal Davis, MC, for Chief Surgeon, European Theater of Operations,

U.S. Army. 9 Nov. 1942, subject: Consultant In Neurological Surgery. ETO.
404 ACTI VITIES OiF SURIICi(A14 CONSULT'ANTS

3. If it. is not. recognized, why should a, consultant in neurological surgery

be considered essential in this theater?

4. In view of the latest table of organization of genieral h~osp~itals, why

have neurological surgeons b~een assigned to genieral ho)spitals in the Iilnited

States?

5. IDoes The Surgeon General agree that the stanidards of professional work

in g-eneral hiospitalls ill thle United Kingdlom should represent. the highest ty'pe

of mnedical and surgical care that -anl be given American soldiers ?

6). Should not the 1)rofessiotinl care given the soldliers inl general hospitals

in the United Kingdom compare favorably with that of U.S. civilian practice

and wvith neuro-surgrical pra~ctic'e in British and1 Canadiant military hospitals of a

similar type ?

7. if The Surg-eon Geiiera's answers to questions 5 and 6 are inl thle afirnliat ive, wouild hie agree that the supplemienital list of instruments phus a portalble

Boy ie electrical surgical apparatus, necessary to (t0 nieu rolo)gical surgery prop1-

erly, should he made available immediately to each of the general hospitals

in the United Kinlgdom?

8. Is The Surgeon General awvare that such a sulplleiental list of nleurosurgical instruments plus a portable Bovie electrical surgical applaratus wais

insp~ectedl in Washingtoni at the Walter Reedl Hosp~ital by Colonel D)avis onl

or about 1 September?

!). Imes The Surgeon General agree that the greatest compenisation for the

loss of life ill ally war is whatever contribution tile Mledical Corps canl make

from a huimanitarian stalldlpoint ?

10. If lie agrees, could not one contribution to military surgery and~ to

tile art and science of surer i geeal comie fromn the eomplilation1 of thle

results of iieurological surgrery inl this wvar'?

11. Would The Surgeon General agree that this would be a signlificanit.

Contrib~ution from his office, allod aloCol not tl.Consultaint in Neumrological Surgery be more effective in liringhig this about if lie had liaison p)rivileges

between th;is theater and thle Zone of Interior in order to correlate, to the highest degree, neurological surgery that is being done in genieral hospitals in both

1p] aces ?

12. Would rIhe Surgeon G1eneral agree that the Consultant inl Neurological

Surgery would be. of miiore service to the effort if, in this period of inactivity

in the Uniited Kingdom while the coitsultant. has, a total of 30) patients uponl

which to conlsult, lie was given thlis opplortunity of liaisonl

By 1 D ecembher 19)42, the consultamits wvere still atteiipthing to get lprop~er

recordls for thle genieral hospitals, and tilie senior conisultant. in neurological

surgery was still purimihiig the suction ap)parat us for tilie 3.0th and 298th

General H ospitals. The harassed supply dlivision was still denying anl undlerstandiing of Colonel Daivis' requests for "all-day suckers," even though onle

had been p)urchiasedl and installed in the 2d Genieral Hospital and was perfarminig ethicienitly.
NEUROLOGICAL SURGERY 405

ATTEMPTS TO IMPROVE THE CONSULTANT GROUP

With the coming of the 3d Auxiliary Surgical Group to the European

theater, the consultants were asked to evaluate and advise about the assignment

of the group's personnel. The Chief Surgeon's Office had b)een tohl to expect

the 2(1 Auxiliary Surgical Group, which was to be staged in England and

reorganized, and the majority of whose members were to be reassigned to North

Africa where fighting had b)egun. One of the consultants, Colonel Brown,

volunteered to go to Glasgow to meet this contingent as a representative of

the Chief Surgeon. lie hurried there and waited 2 weeks to greet the commanding officer of the, 2d Auxiliary Group by name, only to be told on

the dock that he, the commnaiiding officer, was Col. John F. Blatt, MC, and that

the group was the 3d.

The mud around Oxford, where the group was eventually billeted, was

ankle deep, and it was cold and rainy. They had no instruments and no

other equiliment worth discussing. Attempts were made to give them temporary assignments according to their surgical interests to relieve the frustrated

sense of having been hurried from their surgical practices in many instances

to meet an emergency which turned out to be a field of mud 2 miles from

Oxford. There was difficulty because the Personnel Division of the Chief

Surgeon's Office had no idea whatever of the character of the Military HIospital

(Ilead Injuries), Oxford. So, without advice, two officers who had no fundamental training or interest in neurological surgery were assigned to that

fine head injury hospital. This brought a protest from Brigadier Cairns

and required placing the matter before General Hawley to effect a solution,

which lie accomplished swiftly.

On 4 December 1942, the Senior Consultant in Neurological Surgery called

attention to the fact that the majority of craniocerebral injuries among T.S.

soldiers in the United Kingdom were due to accidents they met with while

driving jeeps at night under circumstances which were not strictly military

missions. The author reconmmended that the activities of enlisted men in

jeeps be restricted to purely military missions. This resulted in an ilmnediate

lowering of the incidence of these compound head injuries and a conimnendation for the consultant, apparently for the complex solution which had been

suggested.

It was obvious to anyone who gave it thought that the consultants were

being thwarted at every turn by some of the Chief Surgeon's staff and without

General I [awley's knowledge. lie had instituted dinner meetings with medical

officers from other countries, principally from the Royal Army Medical Corps,

and the group) of consultants prop)erly acted at. his invitation as his aides to

entertain his guests. This was only one of the many incidents which, at this

time, led some of the Regular Army medical officers to resent the consultant

group. For a time even Coloniel Kiinbrough, under whom the consultants

served, appeare(d suspicious of their motives until lie was assured that no one
406 A(TivITIEs OF SURGICAL C'ONSULTANTS

of themi soughW~t. his post anld that each conisultanit dlesiredolytge tlie job)

(bile 1111(1tobritg to himii whatever credit was tliie.

This situnation caulsed tilie Senior- C'onsultant in -Nellrological Suirgery to

at tempijt toi expiress a crit icail eu1ht oilf tilie sillrgica 1 coiisiiltatiit. gr-oup inl thle

C

1hief Surgeon's Offtice to Tilie Surgeon (imeera1 of thle U1.S. Army thlrouigl the

Chiief surgeon, I-'LN)18A.ý: nIie following three reasonls we~re assliumed to

haye been the basis for thle creation11 of tilie consultalit. group: (1) The Chief

8nrgeoiis need for ai professional advisory boudy inl order to minn t ain tile

hiighiest typ~e of suirgical service to the U .S. soldier iii thle European iitheater,

(2) time needl to perfect liaison iii professionial sern .e bet wveen the U.S. Arimy,

I rit ish I, and Canladianl lInedhicl services, and~ (3) tile need to establish lIaison

bet ween tilie Euiropeani theater andl thle ~uriaIprofessioti (if the 1-initedI States

amid tilie (m)fice of Tne Surgeoin (General. TIhe author reiteratedl the point, that,

lie innjwrit of tilie contislt ants (lid not seek Iieiri appoinut mentts bu~t were told

t hey were choseni because (if thIeiri professional atta inmlenits andl standing in

lieiri part icular sui-rgica I field anud biecauise of their potential abilit tooganize 111(d correlate the activities of tlieiri surgical speciaItyv inl thle Medical C orps.

( eiieral I [awle v knew none of thle consult ants before lie arrivedl ill his coin

iiia 11 an b11 ad nio voice lin his choice. The Senior C onisultant. inl Neurological

Surgery Was told thlit lie ailomie wvolld lbe responisible directly to thle Chief

Sitrgeonl for thle pol11icies governliig thle professional activ~it ies inl ieuirologicall

surgiery. At the (creatimon of the post of CThief Consultant. inl Surgery , it

biecamne necessary to pass recoiiiimienelda t ion s thlroughi thiree Channels be fore tilie,

Chiief Suirgeon could lbe reached lby tilie consult ants ill thle surgical sp~ecialt ies.

It Was pointed out, that. thle Chief Conisultant inl Surgery, Colonel Cutler,

was speaking for anl establi shing 1)01icies for surgical spiecialt ies ablout which

hie had only at sniatterinug oif general knowledge. 'I'lle siurgical1 consuilt ant group

hiad not. beenu includedl ill tilie plaluus for iiedlical care. of tilie Casualties Which

Wvould resullt. from minlit ary ohierat ionls inl North A frica and Which at. that. timle

Were at rfslpouisihiility of tilie European theater. It. applearedl illogical that the

miajority of the surgical spiecialt ies represeiited by c~onsuhltantsI were niot recognlized biy tilie O ffice of The Surgeon Gen-leral oflicially inl thle tabiles oif orgaiiizationl of geuieral hospitals.

Suggest ionis to ilmilrove tilie etfect iveuiess of tilie surlgical conlsultiants grouip

includled I

1. Impilemnent I lie recomuimiend~at ions of the surgical consultants thlit are

designed to raise thle stanldards of pirofess~ional service in U'.S. hiospitails inl tilie

Uniitedl Kiigdomii.

2. Make it. possibile for the surgical conisultanits to observe, correlate, and1(

give adivice concerninig the surgical treatment being giveni U.S. soldiers inl the

NorthI A fricaii operat ions.

1 .4-ttier. uA. Col. Loyal lijvis. mc. Consiltnnt In Neurologlenl Sugirgery, to The Sturgeon Generail,

IV.. Army. tbrough tlie C'iliet Surgeon. Duropean Theater of Operationg, U.S. Army, 1) Diee. 1942.

sobiJec t :Cr1iticle I vauat i on of t he Su rgicl c Consuiltmt Gu roup.
NEUROLOGICAL SURGERY 407

3. Improve the operations of the several divisions in the Office of tile

Chief Surgeon by changing personnel if necessary.

4. Change the organizational plan of the surgical consultants group and

restrict the duties and responsibilities of the chief surgical consultant to the

field of surgery exclusive of the surgical specialties.

5. Remove restrictions from the surgical consultants that limit their activities to the United Kingdom.

6. Make the surgical consultants more mobile by extending to them controlled liaison privileges in their own field of surgery with the Zone of Interior, the United Kingdom, and the North African theater.

7. Extend the functions of the consultant group to the general hospitals

sit uated in service connmands in the Zone of Interior.

8. Allow surgical consultants to establish contacts between the Office of

The Surgeon General and the civilian surgical profession to effect:

a. Better understanding of the problems of the Office of The Surgeon

General.

b. Support of the policies of The Surgeon General before the medical

profession and the American public.

9. Establish immediately the principle of advisory function to the Office

of The Surgeon General so that in peacetime the consultants' services as civilian

advisers may be utilized.

Whether these suggestions were p)assed on to General Hawley is to

question ; but, there is some reason to think that, without fanfare, the cons.xiai,,s

began to reach his attention directly. This consultant had written a long

memorandum to the Chief Surgeon on 22 December after a thorough study of

the neurosurgical aspects of injuries to tank crews. The investigation was made

at Tidworth Barracks with Capt. Thomas M. Mar, M[C, medical officer for the

751st, Tank Battalion attached to the 29th Infantry I)ivision (fig. 139). Tile

memorandum concerned recommended changes in the helmet worn for head

protection, certain aspects of armored tank construction to minimize the occurrence of vertebral and other injuries, the evacuation hatch, first aid equi)pment, armored amlulances for tank battalions, and the contents of the. field

chest for use by the medical officer of an armored tank battalion. Promptly,

a reply came from the Chief Surgeon, signed by him and dated 26 December,

stating that the report had been forwarded to the Chief Ordnance Officer and

expressing his interest in the comments and recommendations made concerning

the use of an armored halftrack personnel carrier as an ambulance since lie

had first I)ropose(] such an adaptation. A (late was made to visit the battalion

together on 5 Jammary, but unfortunately the joint. trip never materialized.

ITad the above corresl)ondence occurred sooner, it would undoubtedly have

prevented the author from sending copies of the ineniorandums he had written

for 3 months, arranged in chronological order and with the addresse's name

removed, as sel)arate letters, to Brig. Gen. Fred W. Rankin, Chief Consultant in

Surgery to The Surgeon General: Dr. Irving S. Cutter, dean of Northwestern

University Medical School, Chicago: and Dr. Howard C. Naffziger, chairman
the ll~es t mut t I: r liff 291 le r .IuAIt I4 (e ) ý-t m~ #?Iti (Inali lviii ii Ill simi14lrls-1 it 1-:11,111 hat1 

o le Ws oe col)-1vilt-l ()f t N e4 w Id( tl'le~I~l4t&I tof lIjlle :1 l1el-liYofw et llkliltlit o

I le i vhe 141r4 (i Ps ti; '1 w hiih w ildit'aw iik w o vill - i~itio li'2T mor aI-ailie

I1: Iv Itnl ie o hi' e('1-ýtl i tl 41: ll ý 11111. 1 II it'' l 1101 %ivtait' I tla' i 1 llg' 1 if(' I9 ~ ~ ioll '
NEUROLOGICAL SURGERY 409

men. The Chief Surgeon assured the author that there would be no courtmartial of one of his men, and he was sure organizational changes could be

made which would accomplish results more smoothly. The discussion made it

obvious to this consultant that the Chief Surgeon, on the one hand, and his

consultants, on the other, were separated by the chief surgical consultant, the

chief of the Professional Services D)ivision, and the remainder of the Chief

Surgeon's staff.

This interview with General Hawley put at rest the worries over arrest,

court-martial, and disgrace which had caused two sleepless nights. It also

formed the basis for the beginning of a close friendship and association which

exists at. the present. It ma(le p)ossible contril)utions to the care of the injured

soldier which will be described and which required the authority of the Chief

Surgeon to effect.

YEAR'S END

By the end of December 1942, the 298th General Hospital, the University of

Michigan Medical School unit, was functioning, and it was arranged to have

all of the peripheral nerve injuries from the North African combat zone sent to

that hospital where they could be cared for by Maj. (later Lt. Col.) Edgar A.

Kain, MC, a qualified neurological surgeon. Among the first group of patients,

the majority of whom were German prisoners and injured British Army personnel, were four patients with extensive soft-tissue injuries of the upper extremity, comminuted fractures of the humerus at the junction of the lower third

and upper two-thirds, and a paralysis of the radial nerve. The wounds had

been packed open with petrolatum-impregnated gauze, and a plaster cast had

been applied without support of the wrist. Attention was called to the desirability of better immediate care for these patients, the use of the sulfonamide

drugs, and proper dressings. These recommendations were based upon the experiences observed in the Wingfield Morris Orthopaedic Emergency Hospital,

which was devoted exclusively to the care of perihlheral nerve injuries under the

direct ion of Professor Seddon.

There was considerable discussion and certainly no unanimity of opinion

about the method of using the sulfonamides. A large number of observations

upon experimentally produced peril)heral nerve injuries had been made in the

surgical laboratory at Northwestern University Medical School prior to 1942

under a grant from the National Research Council. It had been shown that sulfonamides used locally in potentially infected, severely lacerated soft-tissue

wounds which involved nerves did not affect the results of nerve repair. However, it was believed that adhninistratiori of the drugs byl mouth, raising the

)lood level of the sulfonaniides, would be equally ormore efl'ective. At this time,

however, it was a moot question, and the colored photomicrogralphs which recorded the results of the controlled exl)eriments provided some basis for opposig tile prohibition of the sulfonamides locally in the wounds. There were
410 ACTIVITIES OF SURGICAL CONSULTANTS

other psychological factors surrounding the use of the "wonder" drugs which

affected the injured men and were not easily evaluated.

The Senior Consultant in Neurological Surgery attempted to establish the

298th General Hospital as a peripheral nerve injury center, similar to that

existing at Wingfield Morris, and recommended that this be accomplished.

It was possible through Mr. Seddon's cooperation to have Major Kahn assigned

for temporary duty at that British hospital to assume Mr. Seddon's duties

during his absence in Malta to investigate an outbreak of poliomyelitis. However, this effort to establish special facilities at the 298th General Hospital did

not come about because of the rule to hold the injured in general hospitals in

the United Kingdom not longer than 180 days after admission. They were

then to be returned to the Uniited States. Thus, one of the functions of a

qualified neurological surgeon in the European theater, that, of properly

treating a peripheral nerve injury definitely, was made impossible, and peripheral nerve centers in general hospitals in the United States assumed an

importance which should have been planned for in the beginning.

The qualified neurological surgeon belongs in the place where definitive

treatment can be given and postoperative and rehabilitation care can be properly supervised. This plan was effectively carried out by the British with the

assistance of Brigadier Hugh Cairns, the Consultant for Neurological Surgery to the DIGMS (Director General of Medical Services) of the British

Army. Well-trained and instructed young general surgeons can give the finest

immediate treatment for n1eurosurgical injuries, and their activities could be

supervised by a Consultant in Neurological Surgery who would also advise

The Surgeon General about policies in this field of surgery in the combat zone

and the Zone of Interior.

Another method of approach to the Chief Surgeon, ETOUSA, was initiated by Colonel Cutler in the form of one memorandum which would include

all of the suggestions from each consultant. These "Reports of the Surgical

Sub-committee" failed, in the opinion of the author, because the chief surgical

consultant frequently vetoed suggestions and recommendations made by the

senior consultants in their specialty.

1943: FIRST HALF

By the first part of January 1943, a new supply officer in the Chief Surgeon s Office had improved the flow of material and equipment to the hospitals, and good clinical records were made available to the hospitals in the

theater. A letter, dated 13 January 1943, from this author to Colonel Kimbrough contained a report for the period 7 September 1942-15 January 1943,

chronologically summarizing the author's opinions concerning the functions

and utilization of the consultants. At all times, General Hawley had the

greatest sympathy with and understanding of the aims, desires, and ideals of

the consultant group; this he proved by word and deed on many occasions.
NEUROLOGICAL SURGERY 411

Head Protection for Aircrews

On 13 January 1943, this consultant wrote the first of several coinmunications upon the subject of protection of the heads of airmen. The regular issue

steel helmet worn by the U.S. soldier admittedly furnished excellent protection

against craniocerebral injuries and (sometimes more important to the soldier)

had many other utilitarian advantages. However, it was not designed for the

use of the crews of aircraft or tanks and could not be used to advantage by

them, mainly because of its size, shape, and weight. Nevertheless, the desire

of a particular copilot for protection to his head from bursting 20-amm. Oerlikon shells led him to remove the liner of his helnet and pull on the outer

steel shell over his regulation leather flying helmet. The effectiveness of this

protection was emphasized when his pilot, wearing only a leather helmet, was

struck in the head by the fragments of an Oerlikon shell which burst between

them. The pilot immediately lost consciousness, developed a left hemiplegia,

and a complete left homonymous hemianopsia. While the copilot's helnet was

punctured in several places by the high velocity fragmlents, it afforded complete

protection from even a scalp laceration.

It became obvious that members of an aircrew needed adequate protection

from craniocerebral injuries. However, any helmet designed for their use

had to meet certain specifications. First, it had to be close fitting and comfortable so that it would simulate as closely as possible an ordinary leather

flying helnet and be considered a personal possession which might gather "good luck" like a favorite, battered felt hat; second, it had to allow free and

unrestricted movements of the head in all directions and not interfere in any

way with the field of vision; third, it had to be light in weight and afford

protection from the heat and cold; and fourth, it had to afford protection, at

least equal to that afforded by the regular issue steel helmet, against craniocerebral injuries produced by fragnenting Oerlikon shells, antiaircraft flak,

or concussion due to direct, blunt trauma.

The percentage of wounds to the head, comparing the head's surface area

to that of the body, was found to be approximately 12 percent. It was also

found that the largest number of craniocerebral injuries in airmen resulted

from the fragmnentation of 20-mm. Oerlikon shells. Craniocerebral injuries

next most common were injuries from the largest pieces of antiaircraft flak

and concussion due to direct trauma, in that order. When an Oerlikon shell

burst, it fragmented into thousands of pieces which varied in weight from less

than 1 mg. to 20 gm. (fig. 140). However, the largest number of "effective"

Oerlikon shell fragments bursting in an area 5 feet in diameter and capable

of causing incapacitation to the person exposed was 260. The majority of those

260 fragments weighed between 10 and 50 rag., and their velocity varied

between 400 and 600 m.p.s. (meters per second).

Many materials were subjected to accurate ballistic and other tests at the

ballistics laboratory of Oxford University which was made available by Briga705-095--64--29
412 ACTIVITIES OF SURGICAL CONSULTANTS

I,

FIGURE 140.-A flash radiograph of a German

20-mm. HEI (high-explosive, incendiary) shell,

Mk. 1, showing the fragmentation pattern. The

broken line gives the reference position of the

shell before static detonation.

dier Cairns. It was finally concluded that an acrylic resin, methyl methacrylate, properly manufactured, offered the largest number of advantages for the

purpose and most closely met the specifications laid down. This material was

obtained, through the friendship which existed between this consultant and a

civilian in England, from a plastics firm which had begun to make artificial

dentures. There are, of course, almost unending variations of the stages which

can be reached in the manufacture of the products of an acrylic resin. The

properties of the final product may vary within extremely wide limits so that

one may think of it as a substitute for glass, a denture, a surgical suture, or a

puttylike material. By modifying the amount or character of the plasticizer

added, the flexibility, resiliency, hardness, water and weather resistance, flammability, and ballistic-protective properties of the material can be varied at

will between wide limits.

The material tested was 4 mm. in thickness and had a velocity resistance, in

relation to its weight per unit area, of 440 m.p.s. when tested with a 52-mg. steel
NEUROLOGICAL SURGERY 413

ball fired and photographed electrically. The velocity resistance per unit

weight area of the same material of 8-nm. thickness, similarly tested, was 700

m.p.s. Velocity resistance per unit weight area of 1-mm. thickness manganese

steel, tested under identical circumstances, varied from 500 to 600 m.p.s.

The acrylic resin studied had a tensile strength of from 9,000 to 12,000

p.s.i. (pounds per square inch) ; a flexural strength of from 12,000 to 14,000

p.s.i.; an impact resistance of 0.1 to 0.3 ft.-lb., and a Brinell hardness greater

than gold. It had a specific gravity of 1.10, so that it almost floated on water,

and it absorbed less than 0.5 percent of water by weight upon immersion for 7

days. It was resistant to the rays of the sun and would not soften until a

temperature of between 1900 and 2400 had been reached. It was a good nonconductor of heat and cold. It smoldered if a flame was applied to it, but it

would not burn with an explosion; if it flamed, the slightest movement extinguished it. When the material was hit directly, the lines of shatter were at

right angles ta the force and not directly forward as in steel.

The consultant was able to mold pieces of the acrylic resin over a wooden

hat mold so that they would conformi to the frontal, teml)oml, occipital, and

vertex portions of the skull (fig. 141). These segments were hinged togrether snugly so that protection would not be lost and yet so that a certain

pliability wolild be gained and a sense of a solid, bucketlike structure would be

avoided. The helmet was then covered with the commonly used regulation

leather flying helmet and lined with chamois skin or fleece. Portions of the

protective material were brought down over the ears, and openings were left

into which the earphones could be fitted. This afforded further protection and

added the distinct advantage of the property of acrylic resin to exclude ambient

noises.

Such a helmet allowed for complete movement of the head in all directions,

provided complete protection over the skull, and in no way interfered with the

field of vision. As one molds a derby hat which may impinge slightly upon the

parietal eminences and be uncomfortable, so the individual flyer could mold

this helmet by applying heat to the protective liner so that it became an integral

and comfortable part of him. The pieces of molded plastic could be fitted into

pockets of the leather helmet and be removed when it was not being worn in

combat. The completed helmet, made of 4-mm. methyl methacrylate covered

and lined, weighed 18 ounces, and, if material 8 mm. thick was used, affording

more protection per unit weight area, the total weight was 27 ounces. The steel

body of the regulation helmet weighed 35.84 ounces.

It was also suggested that similar plastic panels could be inserted into the

regular-issue flying suit for protection against chest, abdominal, and extremity

injuries.

Several flights were made in a B-17 bomber on practice missions with Maj.

Daniel Wheeler, AC, and his crew, during which the model protective helmet

was adjusted and revised until it suited the entire crew.

At this time, Brig. Gen. (later Maj. Gen.) Malcolm C. Grow, Surgeon,

Eighth Air Force, had engaged the services of an armorer in England to devise
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NEUROLOGICAL SURGERY 415

lem of the results of cold injuries, ill a lecture given by Maj. C. ('. Ungley,

RAMNC, at the British 1Post-Graduate Medical School.

In a memorandunm dated 13 January 1943, the subject matter of this lecture

on inunersion foot was summanrized and the symptoms of the prehypereinic,

hyliereinic. and posthyperenlic stages were described in detail. However, the

most important portion of the memorandum called attention to the advantage

of sending t hes, ala tents to one general hospital where they could be studied as

a group and stated that severe injuries from cold would p)roduce similar synptoins. In other words, immersion foot was only one type of cold injury, and the

cold injury received on the ground or in tile air woul differ only as to the t ie

and telnl)erature of the exposure.

It. was not. long after that, tile first, airmnan was seen at the 2d General lIospital with tremendlous bullae upon the dorsum of his hands. It was believed at

first that these were burns, since his aircraft had crashed on landing and

burned. ('areful questioning elicited the fact that lie had been at a waist gun

position in a. B-17 bomber, which at that time was an open window (fig. 142).

ile had worn his electrically heated flying suit. at the time but had taken off his

gloves to urinate. The parts of tile suits, it was found, were wired in series, and

thus the entire suit was turned off coml)letely if one portion was disconnected.

The aircraft had been at an altitude of considerably over 20,000 feet, and the

teml)erature, -301. Instances of cold injuries to the hands, occasionally to the

feet. in isolated instances to the buttocks, and only once to tile cheeks and ears,

multiplied rap)idly through April and 'May and early in June of 1943. Exposure to low teml)eratures and airblasts at high altitudes with failures of oxygen supply and, most important of all, failure of, or lack of, electrically heated

clothing were the iml)ortant etiological factors.

Colored photographls were made of the striking lesions, which were resulting in the complete disability of the airmen, and studies were begun to

devise the proper treatment. and to I)revent these injuries. This consultant was

ordered by General Hawley to present his data upon 25 patients to General

Grow, the surgeon of the Eighth Air Force. An appointment was made, and the

author was allowed to stand for 15 minutes while General Grow carried oil a

discussion with Lt. Col. (later Col.) Herbert B. Wright, MC, of his office about

his own experiences with frostbite when he was in Russia following World War

I. General Grow did not, at this time, take the problem seriously. He was

inclined to believe tlat cold injury in airmen was the result of carelessness.

The author placed on General Grow's desk copies of the patients' own

stories and color p)hotograp)hs of their lesions, which included complete casts

of the skin of the fingers which had been slhed, dry gangrene amputation

stuml)s, and bullae of all degrees of severitV. 4 Colonel D)avis stated that lie

had been instructed by General Hawley to deliver this material and turned

to leave. When lie reached tile door. he was called back, asked to take off his

I For examples of tle's., phiotographs and for additional discussion of high-altitude frostbite,

sef, Medical I )epartment. V'nlted States .%rmy. ('old Injury. Group Type. Washinlgton : U.S. Go.vernment Printing Office. 195n.
416

4h

IiG i iai, 142.--h I lv ait gunl jIsil ion ini liv Bi- 17 lmiober. A. A B-17 on a tactic-al Inissionf over The NethIirhimik. showimig the openi Nvaist gnul posit ioul with 1.l'ot rullimig uuimuzzle of

a flexible numnchinieguni. sepjteriier 1944. 11. Waist gunners of thle Invatier 11 muodlel of the

B~-17 biherlhlI,Marc ihi 1943
() 1(:l :iid i l4 Vl. A. AeIll IIvcli;Iy hon11S01 4l 1 Su 4Xd'4 it. I 1t ai I t I I Ii-g Iic

a~tll it te pt'eva;tng oi thet parl t of ( ; ttral Grow. I ll dol(4tledthat ~lIhe t cWevMCL(. dlirector of the uEig.Ilt1 Air For Central~ Medicatl Esinhtihnii~tlet. was

calledieto ju4ile( tdisclitsi44t. Co(lontel Armstrong t4It :1id I qite frantkly t hat ]le 11ad(

114) id ea Ilo thW Iey we i redi ( Ilir, I I :) .

1ol )lo)wi I g, I hi ,X )et wiet't(. pee I I i i551 It was, gt;l I It ed 1~ 4V (et Iera IIa JNt wev t o

de(signia~te the 2d G eneral I ospIMIt as the eeiter to receive p etutns with cold4

iflhtries atttI to est ahh~li a lahoratort antd specialt wad foI4IS1 their AlI tidv. BY

!) MaY 193 ailr irsoicsidvlwr:11e w ,admll 1ue

pat11ientsl who ha~d 144woveredt Iwithll loss1 1(455 d44igits 5were b~eing studi~ied -:I fixedi

low ettl)Cat tresto if~ ihp he, m4)tl Ite mret l tone 114 ,vitguty wIii vt h satfetly.

R~equiests N~ver initiate forI14tjtVetL go to o ) operttiontal Eigi~hth Air

Force fieldto m( takeQ c'apillaryw mticrohscopji situdies upon)t :ttt'tteII initttediat1el ,

111)OU1 :landIingi. AN I I yi Iliethd w14l~~ere itt iesl igatted ill alltii eort, to4 preventt Ilte

ttljitrtes. andii it wtS recotttttetthollh t ha~t. the oclot bitt!! be Nvired tli Ileretitld , :11141

that, the opett waitst. !gttt phosit ionts be pro'4tected. All requtests to) visit ItirHieds

werT e 4leitetl 1by te it- P t Ii'-11 Air Fo rve. ando finatl l v. ti te5Q pat ienlts b eetltle So

Iilnwtr(41t5 as the act ivitijes ofl the( 1'i , aithI Air IForce itcreased duiring-~ Mayv and1

'11111 19 t3 that thie (Chief Sittt!Ze44ttl di15c1155e4 tilt' sititatioti d1icVt ly with Lt.
418 ACTIVITIES OF SURGICAL CONSULTANTS

Gen. (later Gen.) Frank M. Andrews, Commanding General, ETOUSA. Unfortunately, General Andrews was killed in an airplane accident in Iceland

soon after, and again it was necessary to brief his successor, Lt. Gen. Jacob L.

Devers. Eventually, permission was obtained, and observations were made over

a 2-week period by Major Scarff and this consultant at a bomber station of

the Eighth Air Force. A part of the report on these observations follows: 5

2. The observations and studies have included:

a. Skin temperature readings.

b. Microscopic capillary observations.

c. Black and white and colored photographs.

d. Complete physical examinations of the affected parts.

c. Personal observations of the Senior Consultant in Neurological Surgery upon the

effects of cold at 13,000 feet on a practice raid mission.

3. The following types of l)atients have been studied:

a. Chronic cases (2) previously treated in the acute stages at U.S. General Hospital

#2 and returned to duty at this Bomber Station.

b. Mild acute cases (12) which have not required hospitalization.

r. One severe acute case involving bloth han(ls removed to Evacuation Hospital #2

eompli(.nted by a severe intra-'lbdlinal injury.

4. Certain facts should be noted from the result of these studies to date:

a. Mild acute cases continue to occur in spite of the rise in ground temperature

because, at this altitude of the operational missions, the temperature has ranged at

-30 degrees C.

b. The mild acute cases warm up rather promptly at room or free air temperatures

without serious damage to the digits; but, the symptoms of tingling, stiffness and numbness continue for two or three days and require that the patients be grounded temporarily.

c. There Is no demonstrable microscop)ic damage to. or change in, the capillaries in

these mild acute cases.

d. Microscopic capillary studies of the severely frozen digits in the one patient show

a complete obliteration of the capillaries and extravasation of blood Into the subcutaneous

tissue within three hours of the trauma.

c. Capillary loops disappear with severe cold damage to the skin and in chronic cases,

three months after Injury, have not regenerated.

f. Defective clothing equipment and other technical defects pointed out in the first

memorandum on this subject continue to play an Important role in etiology.

g. The new type of "demand" oxygen mask provided is a distinct improvement and

answers the suggestions raised in the first memorandum written which would prevent the

injurious effect of anoxia common to all the cases observed early in the study.

h. Progress is being made to the end that an accurate, scientific method of treatment

can be outlined but this cannot be done at this time.

Cases continued to occur, and, during the 2-week period at the bomber

station where observations were made, 30 patients had cold injuries requiring

hospitalization for varying periods of time. One medical officer at a bomber

station denied that any of his personnel had received such injuries, until their

names, ranks, and serial numbers were supplied to him during the discussion.

, Letter. Lt. col. loyal D)avis. MC, Senior Consultant In Neurological Surgery, to Brig. Gen.

Paul It. Hawley, Chief Surgeon, European Theater of Operations, U.S. Army. 14 June 1043, subject: Cold Damage to Extremities.
NEUROLOGICAL SURGERY 419

Proposal for Acrylic Helmet

In the meantime, a detailed report ulo)n the number of craniocerebral injuries that had occurred in the European theater from 1 September to 1 May

1943 was reviewed for the Chief Surgeon. The number of patients returned

to duty, the number returned to the Zone of Interior, and the average number

of days in hospital were furnished to him. On 26 May 1943, another proposal

of a helmet for the protection of aircraft and tank personnel was sent to the

Chief Surgeon by the author, listing the following 16 advantages of the helnet.

3. The proposed helmet consists of segments of an acrylic resin product moulded to

fit the hea(d snugly, covered by soft leather and lined with chamois skin.

The advantages of this helmet are:

(1) Compared with manganese steel per unit weight, acrylic resin affords one third

more protection against the penetration of metal fragments.

(2) Acrylic resin of 8 mi. thickness has a velocity resistance to a 52 mgm. steel ball

of between 700 and 800 meters per second (2,100 to 2.400 ft./sec.).

(3) The model helmet made of 4 mi. thick acrylic resin weighs 18 ounces and has

a velocity resistance to a 52 mgm. steel ball of 500 meters per second. If 8 mm. thick

material is used, the weight of the helmet would be 27 ounces.

(4) Acrylic resin is one of the best non-conductors of heat and cold known to science.

(5) Acrylic resin can be moulded by heating so that this helmet will fit comfortably

and becomes an integral part of the soldier's head.

(6) The proposed helmet allows unrestricted movements of the head in every direction

and does not obstruct the field of vision of the wearer.

(7) Acrylic resin has a tensile strength of from 9,000 to 12,000 lbs. per square inch;

a flexual strength of 12,000 to 14,000 lbs. per square inch; an impact resistance of 0.1 to

0.3 ft. lbs., and a Brinell hardness greater than gold (500 kilograms on a 10 nim. gold ball,

17-20).

(8) Acrylic resin has a specific gravity of 1.10, so that it almost floats on wivter. It

will absorb less than 0.5% of water by weight upon immersion for 7 days. It is resistant

to the rays of the sun and will not soften until a temperature of between 190 and 240 degrees F has been reached.

(9) If driven into or buried in the brain or soft tissues, acrylic resin is absolutely

Inert and there is no tissue reaction.

(10) The lines of shatter of acrylic resin are at right angles to the force, and not

directly forward, as in steel.

(11) Acrylic resin smoulders if a flame is applied but will not burn with an explosion,

and if it flames the slightest movement extinguishes it.

(12) Shatter proof goggles can be made from the same material which can be so

attached to the helmet that the present use of elastic bands to support goggles can be

elimi!nated.

(13) Pieces of spring steel can be set into the acrylic resin which will catch the elastic

bands of the oxygen mask and will obviate the necessity for an airman to take off electrically

heated gloves to fasten the small clips nowv used to keep the elastic bands secure.

(14) This helmet can be vorn constantly by tankmen and need not be removed when

the head is thrust ibrough the tank turret, or when using a periscopic sight, as is true with

the helmet for tankmen now in use.

(15) Acrylic resin can be used in making a solid complete helmet similar to the present

steel helmet, if desired. It would afford one-third more protection for the same unit weight

against penetration and would not dent or cave in floma rough usage. It could have an inner

lining made of softer acrylic resin which call be moulded to the head by the soldier him705-095'--64-30
420 ACTIVITIES OF SURGIC. L CONSULTANTS

self. The inner softer acrylic resin will ruse inseparably with the harder material. The

proposed helmet would afford greater protection against penetration and impact resistance than the present steel helmet even if it was desired to have it weigh less.

(16) This material can be manufactured cheaply, easily and quickly into helmets, and

the use of high priority steel is eliminated. The number of manufacturers now necessary

for the production of steel helmets can be reduced.

Immediately, General Hawley indicated that upon return from a surgical

mission to the U.S.S.R., Colonel Davis would be sent to the Zone of Interior to

present the proposed helmet and its advantages to The Surgeon General.

Professional Activities in June 1943

On 14 June 1943, a request was made for additional suction units for the

2d Evacuation Hospital to which injured airmen were being taken. A portable

unit had become a part of the table of equipment of evacuation and general

hospitals, but one was insufficient. On the same date, further data were submitted concerning patients with cold damage to the extrelmities. On 21 June

1943, information obtained in experiments in the surgical laboratory of Northwestern University Medical School about the, local use of the sulfonamides in

experimental gunshot injuries in animals was presented to the Chief Surgeon

in a memorandum. Even at this date, it had not been completely established

that the systematic administration of the sulfonamides would offer the patient

sufficient protection from infection.

Policies for the surgical treatment of herniated nucleus pulposus were

established in a directive that required examination and consultation upon these

patients by the Senior Consultant in Neurological Surgery, the performance of

a myelogram, and performance of the operation by a qualified neurological surgeon in a general hospital. Pantopaque had just been prepared and was sent

to the theater for use before it had become available on the open market.

SURGICAL MISSION TO THE U.S.S.R.

In the latter part of April 1943, General Hawley asked the author if he

would be interested in a trip to the U.S.S.R. Nothing further was added after

an affirmative answer, and it was assumed that a well-laid plan undoubtedly

had gone astray. However, on 6 May 1943, the Public Relations Division of

G-2 (Intelligence), Headquarters, SOS, ETOUSA, requested of the author

that an interview on a proposed trip to the U.S.S.R. be granted to Mr. Frederic

Kuh, the London correspondent of the Chicago Daily Sun. After verifying

the fact that all the proper channels had been cleared and permission had been

granted, Mr. Kuh experienced a great disappointment. He was in complete

possession of all the facts regarding a surgical mission to the U.S.S.R., upor,

which Col. Elliott Cutler was also to be included with four British surgeons, at

least one of whom belonged to the RAMC. Mr. Kuh must have thought the

interviewee was an excellent security risk; the fact was that this consultant was

ignorant of all the information which Mr. Kuh gave him. He went on to say
NEUROLOGICAL SURGERY 421

that this was the first mission of its kind ever to go to the Soviet Union, that

Sir Archibald Clarke-Kerr (later Lord Inverchapel), British Ambassador to

Russia, had arranged for it, and that the Soviet officials had insisted upon professors of surgery. This explained why Colonel Cutler and the author were

invited to go because they were the only two professors of surgery in the U.S.

Army Medical Corps then in the European theater. Thus, this consultant

first learned that Mr. Reginald Watson-Jones (later knighted), Mr. Ernest

Rock Carling, Surgeon Rear Admiral Gordon Gordon-Taylor, and Maj. Gen.

D. C. Monro wouhl d)Ce oi tei surgical mission representing the British. Following this, there began a series )f episodes confusing to the Chief Surgeon no

doubt, as well as to his neurosurgical consultant. It was the latter's first personal experience in a joint effort between one of the armed services and the

State D)epartment.

About the middle of May, the memnbers of the mission had luncheon with

Prof. Semon Sarkisov,o recently arrived from the U.S.S.R., and Sir Henry

Dale, representing the Medical Research Council of Great Britain. On the

same afternoon, the mission had tea with Ambassador Ivan M. Maisky at the

Soviet Embassy. Before going to tea, Colonel Cutler and this consultant had

a 10-minute chat with John G. Winant, the U.S. Ambassador to the Court of

St. James's, who told them that Wilder G. Penfield would represent Canada

on the mission. Ambassador Winant indicated at that time that the mission

would leave London on 12 June.

ILater, Ambassador Winant requested the author to call upon him at the

Embassy. General Hawley was informed of the request and acquiesced. Ambassador Winant asked this consultant to represent the National Research Council while on the mission to the U.S.S.R. Ile also insisted that the author travel

as a civilian throughout the trip, and not as one of the representatives of the

U.S. Army Medical Corps. The reasons for making this unusual request were

not explained by the Ambassador. After consulting General Hawley, this

consultant decided to retain those advantages which could be obtained by being

in uniform if by slight chance the aircraft was forced down over enemy

territory.

Finally, the two members of the surgical mission to the U.S.S.R. from the

United States were given informal instruction by Ambassador Winant, General

Lee, and General Hawley, and travel orders were issued.

On 28 June 1943 the members of the mission were loaded into a bus at the

Swindon railroad station and driven about the countryside until it became

dark. They were given dinner at Marlborough and taken to the airfield which

was recognized as the one at Lyneham. The four-engine British airoraft carried the members of the mission and two Soviet nationals, who remained grim

and uncommunicative throughout the entire trip. The mission members were

informed that these two men were diplomatic-pouch couriers, but also members

of the NKVD, the Soviet secret police. The takeoff was at midnight, and,

0The variation In the spelling of the names of Russian individuals in this volume Is due to the

fact that there are two systems of transliteration In use.
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424 ACTIVITIES oF SURGICAL CONSULTANTS

on a desert airfield which became hotter and hotter, the leg of the trip from

Cairo to Teheran, Iran, began. Without oxygen and at 13,000 feet, one of the

mission became cyanotic, another had periods of apnea, and a third developed

scintillating scotoma, could not remember names, and had a homonymous

hemianopsia. All of these symptoms disappeared, and the mission presented

a unified front upon landing at Teheran late in the afternoon. A representative of the British Embassy met the mission but had been notified of the arrival

only 2 hours previously by the Soviet Embassy. There were no U.S.

representatives.

It was hot and dusty on the airfield, which was surrounded by high mnountains with snow on their peaks. There were many American soldiers to be

seen, and a station hospital was under construction. Water was running in a

small gutter along the side of the street, and people were washing their bodies

and clothes in it, watering horses in it, sweeping street cleanings into it, and

putting it into pails which they were carrying away. The Palace Hotel provided two iron beds, a wooden washstand with a flowered china bowl, and one

water faucet. The guests sprinkled insect powder on the mattress and pillow

in liberal quantities.

A visit was paid by the Americans to Maj. Gen. Donald H. Connolly,

Commanding General, Persian Gulf Command, an engineer who was accomplishing the project of supplying the Soviet Union through the Persian Gulf

and Basra, Iraq (fig. 146). General Connolly inquired about the purpose

of the visit to the Soviet Union, since he knew nothing of the mission. When

the purpose was explained, he expressed his doubts of the mission's learning

any more than what the Soviet hosts would specifically designate. From this

conversation, the author received the distinct impression that it would have

been more advantageous for the U.S. representatives to make this trip alone

because of the Soviet distrust of the postwar intentions of the British.

Sandfly fever, characterized by a high fever for 2 or 3 days and no fatalities, was a common disease amongst the natives. A form of malaria was

described as occurring in places where the Anopheles mosquito could not be

found. Typhus had been prevalent during the previous winter, and typhoid

fever had caused an unheard of number of deaths in the spring and summer

months. Trachoma was abundant, as was syphilis.

The following morning there was another delay on the hot, dusty Teheran

airfield while petrol was removed from the tanks so that the Liberator would

be able to gain altitude quickly enough to clear the mountains surrounding

the field. After a bumpy, rough trip, the mission landed in Moscow late

on the afternoon of 2 July at a field about 30 miles from the city. They

were met by Vice Commissar Vasillii Vassilievich Pairin, Vice-Commnissariat

of Public Health, and Leonid Aleksandrovich Koreisha, Secretary of the Medical Scientific Council, and a woman interpreter. Two U.S. Army Air Forces

officers, who, Colonel Cutler believed, would be their aides while the two

colonels were in the U.S.S.R., accompanied them to a cottage in a woods adjacent to the airfield where they were served tea, bread and butter, sausages,
jug. ait the So~viet accepItaiIce p~iilu. i II firs.t :ilAuiiv-u sa :1yIriii

frnthoi IlP ersiani 4;iulf. ini Maii'd 1914'..

wiliite vavlaI. anud Strawb v~erries~. Oni thle triip 14) Ililt 'NalI onl I 1l1el wh~ere thle,

Ut s,-IollU~ to b4 e Ii1lrt el'ed . it Nvas learnled t Ihat tIhe A nin v Air Forces o011ers

were ill N1oscwm with Capt:1). 1"Adlie" 11Hicleiliacker. 4)1 It IlissiOI1 Whidil he was

,lt(,lll~lll4r crlwoil o fo (i Wa uimson Oig (1 ld). 47 ( apt;in

1Riclellba('ker's m1is~sion concerned1 Ilivi compila)int., Vwi~lic I hie Soviel 1ii601l W~ts

iiiakill&r al)oilt the Air-acoIra W-3~;9) pilaivs that thle Uithed1 Statees was fill--

Iu'liir Ihl )1lId-IIe-re Pli ie l4)i~jlit was 14) I lie effect

I hat they 11olihut 1, staIl 'ld 111) l )4)Ihhl);I11 developed later t hat thle Soviet

uuihita- had'~ l(Imld contcep~t of -ý-Iomiildee to ser'Vive lhe auu a :d nf keep lhe

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that11 the plalles dlIi not stai1( this type of1 I real lleilt bloll eiloiirhl. :11141 1 lIp\

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1.11-ve i'oiIIIilll sitlt u 'Or ro u l ol i ad eIl il-4fIorliiil ror oilr on le wall.

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NET'ROLOGICAL SURGERY 427

velt, delivered by Mr. Harry HIop)kins, to supply everything possible to the

U.S.S.R., regardless and without thought of getting something in return. He

stated that other branches of the U.S. Government wished to barter with the

Soviet Union, using lend-lease material as leverage, on the grounds of protecting the United States. It became obvious quickly that the military attach6

and embassy officials were in direct conflict with General Faymonville and believed him I)ersonally responsible for a situation which was intolerable to them

in dealing with the Soviet nationals, without accepting the fact that General

Faymonville was carrying out specific orders from the President, and failing

to consider that his own personal views might be entirely different. General

Faymionville's knowledge of the Russian language, his long residence in the

U.S.S.R., and his familiarity with the Soviets' music and customs made them

friendly to him, and this was obvious at the social gatherings which were given

for the mission and at which he was present. However, this made him all

the more suspect by his colleagues of favoritism when the war had finished and

when the relationship between the United States and its former ally was

changed.

British Ambassador Clarke-Kerr met. the mission foirmally and indicated

that it had been made possible by his friendship with Serge Yudin who had

suggested such a visit by U.S. and British surgeons. This version of the origin

of the mission was at variance with the one which emanated from the U.S.

Embassy in London--that it had been arranged by the U.S. Ambassador to

Great Britain as the result of discussions between members of the National

Research Council and the Medical Research Council of Great Britain. The

truth probably is that all had a hand in the project and that priority of ideas

would be difficult to establish. Each member of the mission received 1,000

rubles from the British Embassy, but they could use them only for gratuities

to hotel employees, ,ince there were no shops or stores where one could purchase any kind of article without a ration card.

In the afternoon of 3 July, Monro, Cutler, Watson-Jones, Penfield, and

the author, with Brimielow, who was attached to them from the British Embassy, visited VOKS--the Soviet society to promote cultural relations with

foreign countries. Large posters of Churchill, Stalin, and Roosevelt hung

side by side in the hlrge museumlike room of the building to which they were

taken by Pairin and Koreisha. Oil paintings of Soviet soldiers in various

units, cartoons, and large photographs of Charlie Chaplin and Paul Robeson

completed the displh'y. On the return to the hotel, a stop was made at a park

where there were pictures of the party leaders lining the walk, a Ferris wheel

and various airplane rides for the children, an area for dancing to the music

coming from the loudspeakers distributed through the park, and a children's

library. The orthopedist in the group remarked that it was much like saying: "Come into the park and we'll give you culture, damn you."

At dinner, the mission members discussed when and how they would get

their visit underway, and Admiral Standley's admonition to be patient was
428 ACTI VITI ES OF SURGICAL C(ONSULTANTS

agreed upon to be tile line to follow. After dinniier. tihey walked around Red

Square, Lenin's tomb, the Kremlin, and the ('hurcli of St. Basil, a Byzantine

structure, highly colored and resembling a, giiigerlbread cake. This was their

first unaccompanied trip of any distance on tile streets, and they noted that

guards, walking along the top of the walls of the Kremlin, were either curious

about them or were very alert to their duties. There were no taxicabs, and

only the Intourist organization couhl supply t ransportat ion.

There were several discussions about drawing up their own agenda for

procedure and discussions with the People's Commissariat for Health. The

mission wished to see surgery of the war wounded in the forward areas ,and at the bases and to see and discuss the Soviet research projects and ways of

exchanging information. These were pleasant, periods of conversation with

each other but were like sladowboxing in a gymnasium.

During this interval while time mission waited for tihe date of a meeting

with Soviet authorities, a mnemorandum was written to be left. with the People's Commissar for Public Ihealth, which would explain the desires of the

mission (pp. 9)7-99).

So, July 4 was spent in viewing a large collect ion of captured ("ernmn war

material-guns, planes, trucks, and medical sulpplies-gathiered together on

the bank of the Moscow River and looking much like a World's Fair. Groups

of soldiers were taken thiroughi and given lectures onII tlIe material disilah'ed.

Large crowds of civilians were at the exhibition, and clothes and uniforms of

the visitors from the Western World were tile center of close. unaibaslied, personal inspection. The afternoon was spent. at Spasso House, the official home of

Amblassador Standley, which lla.d been occupied also yI his predecesso•s, U.S.

Amlabassadors Bullitt, D)avies, and Steinliardt. ('apt. "Eddie- lickenbacker

was present and brought lip the question of the damage airnien were receiving

from high-altitude frostbite, interesting the Ambassador in the discussion.

The evening was spent. watching the ballet "The Swan Lake" with

Dudinskya, the premiere danseuse. The audience that evening consisted of

workers from factories who had purchased tickets from allotments given to

tlheir factory. Whlen the mission inemll.ers went. into tihe lobby between acts

and returned, they had difficulty in regaining tiheir seats from inlividuals who

had moved into them from less desirable ones.

Eventually, at 1500 hours on 5 July, the mission was received in tile office

of the People's Commissar for Public health, Georgii Andreevich Miterev.

There were seven mission members and seven Russians; there were three of the

mission in uniform and three of them in mnufti. The Soviet military included

Lt. Gen. Efim Ivanovich Smirnov of the Soviet Army Medical Service, who

was 38 year.s of age and corresponded to The Surg'eon CGenenal, and Nivolai

Niloviclh Burdenko, the (chiief surgical consultant to the Soviet. Army, not a

regular medical officer and withi the added great. distimcltion of being a ieliber

of the Academy of Sciences. The meeting got underway with a formal speech

by tile Commissar, who described the existing organization for tile treatment
NEUROLOGICAL SURGERY 429

of battle casualties an(l provided a typewritten prograni of activities for the

week.

The care of the injured and sick in the army was directed from two departInents, the People's Coninissariat for l)efense and tile lPeople's (Coiniis'sariat

for Public Health. General Sm irnov's medical organization was resl)onsible

for the care of the soldier in combat units, in armny hospitals, and through all

evacuation steps to the base area. The care of the wounded soldlier in the base

area, as well as the care of all civilians, was the responsibility of the People's

Commissariat for Public Health. It was stated that the mnethods of treatment

were identical in both organizations in order to insure continuity in the p)atient's

care when he was transferred from the combat zone to the rear. The line of

d(emarcation between these two areas was never unchangeably fixed. When a

patient received a certificate of fitness from the civilian doctors, he was transferred b)ack to the military authorities for reassignment. Patients requiring

long convalescent care remained under the jurisdiction of the civilian authorities in hospitals which were required to devote their chief attention to the

treatment of the war wounded. The People's Commissar for Public Health

stated that 70 percent of all wounded were returned to the comlbat zone for duty,

and he was obviously proud of the small incidence of tetanus and gas gangrene.

A detailed description was given of the organization for care of the wounded

on the field at battalion, regiment, and division aid stations and in the sortingevacuation hospitals, placed 30 to 50 km. from the front, and from 1,000 to 4,000

beds in size. An explanation was provided of the methods of evacuation by

train, automobile, and plane. The percentage distribution of beds was described, and it was emphasized strongly that 0.2 l)ercent were devote(d to neuropsychiatry at the front and 0.1 percent, at the base area.

On 6 July, the members of the mission began their tour of the facilities

which the Soviet hosts wished them to see, and nothing beyond that was possible.

The Botkin Hospital, the Sklifossowsky Institute headed by Serge Yudin, tie

Central Institute for Trauniatology and Orthopedy, the Institute of Neurological Surgery (Burdenko's Hospital), a clearing hospital of the People's

Commissariat for Public Health, two frontline hospitals near Vyazma, a

hospital for the "lightly wounded," the first Medical Institute, the Pirogoff

Clinic, the Balneological Institute, the Central Institute for Blood Transfusion,

the Central Institute for Medical Research, and a final meeting with the

People's Commissar for Public Health fulfilled the agenda provided by the

hosts. At no time was any member of the surgical mission asked to present his

opinions about any surgical or research problem or to relate experiences of the

British or U.S. Army Medical Corps in treating the wounded.

In summary, the principles of Soviet surgical practice in the care of the war

wounded, as shown and explained to the mission, were: 7

Wounds were debrided as far forward as possible, usually in the sortingevacuation hospitals, although also in base hospitals. Excision, even in comnI See also appendix A, p. 953.
430 ACTIVITIES OF SURGICAL CONSULTANTS

pound fractures, was carried out as late as 10 or 15 days after wounding, and

the sulfonamides and immobilization were relied upon to prevent generalized

sepsis.

Large soft-tissue injuries, as well as fractures, were ininiobilized by wooden

splints of the Thomas type for evacuation to the place of first, definlitive surgical

treatment, after which plaster of paris was applied. This was put directly

over the wound, "skin tight" without padding.

Active immunization was obtained with tetanus toxoid. The booster dose

was given at. the regimental aid station.

A. potent antiserum was used in all serious wounds against the development of gas gangrene. It was usually given intravenously. Several surgeons

admitted privately that, the antiserum was not effective.

Sulfanilamide was used in both forward and base hospitals locally in the

wounds, by mouth, and intravenously. A small supply of sulfapyridine was

in existence at that time. A special form of sulfanilamide in which the drug

was broken down into small particles by subjecting it to ultrasonic waves was

used as a cream and applied to gauze dressings. The latter product was in an

experimental stage, it was said, and was not in mass production.

Secondary suture of wounds was practiced whenever possible, even more

than 7 to 12 days after injury.

Inhalant anesthetics were commonly used, especially ether. Spinal anesthesia was used only in base hospitals, but no nitrous-oxide or oxygen machines

were seen.

Sucking chest wounds were closed in forward areas; empyema was treated

by drainage for 3 weeks, following which two or three rib fragments were removel and the wound was packed. Only large foreign bodies were removed

from the chest cavity.

Tannic acid and silver nitrate were used in the treatment of burns, but

the Soviets preferred an open method in which a powder containing an analgesic

agent and an antiseptic was dusted on the burned area.

The best impressions of the Soviet methods of treatment were obtained in

their treatment of fractures. From the time of Pirogoff, in the Crimean War,

they had become masters in the use of plaster of paris. They had a line of

continuity in the treatment between surgeons at the front and in base hospitals

which represented the same institution and methods. Yudin at the Sklifossowsky Institute had cared for over 2,000 fractures during the war with Finland.

They preferred to splint the limb in the field with wooden, wire, or Thomas'

splints at the place of the first definitive treatment. The wound was widely

excise(l and( sulfanilamide was placed in it.. Often Ihe wound was sutured open

by uniting the skin edges to the deep fascia. "Skin tight" plaster was then

applied directly to the wound and skin. Casts were not split and they never

used windows.

An interesting sidelight resulted from the discussion which developed

between Dr. Serge Yudin, who was not a member of the Communist Party,

and the mission, particularly Mr. Watson-Jones, about the results of their meth-
NEUROLOGICAL 'SURGERY 431

ods of treating fractures. It was a give-and-take friendly exchange of opinions

until Watson-Jones indicated that it was difficult to believe the successes

claimed. Yudin, whereupon, inquired if Watson-Jones had ever treated 2,000

compounded fractures, and, when the reply was in the negative, Yudin stated

again that he and his associates had and these were the methods and results.

The Soviet Army Medical Service, used large amounts of citrated whole

blood and little or no plasma. An excellent technique was employed to collect.

the b)lood in the larger cities, but chiefly in Moscow, where 2,000 pints a day

were obtained. Donors were given a special food ration and a small amount

of money, but 85 percent of the latter was returned through gifts to the Government for airplanes and other military purposes. The name of each donor was

placed on each container, and the name of the recipient was given to each donor.

The blood was refrigerated at 6' C. and flown to a point near the front, from

which it was distributed in refrigerated vehicles to frontline hospitals. The use

of plasma was confined to regimental aid stations. Much time was taken to

describe many other fluids use(, but it was obvious that, this was done only to

indicate the extent of their knowledge.

Amputations, prostheses, and plastic surgery were well done in special hospital centers. One plastic surgeon, Frumnkin, had received publicity in the

Allied press for a series of patients upon whom lie had operated to create a

tubular graft which would simulate a penis through which the bladder could

be emptied.

WVhen the mission gave a dinner at the National Hotel where they were

billeted, the guestlist included Frumkin, a genial, intelligent, capable surgeon,

who spoke English well. Frumkin's name was removed from the list, as well

as several others, and other names were substituted, none of whom the mission

had met. This was done without asking the mission's approval, and no reason

was ever given for the action.

Lt. Gen. S. S. Guirgolave lectured to the mission at some length about

cold injuries received on the •round and in water but dismissed questions about

high-altitude cold injuries in flyers by denying their existence, an attitude

which appeared to be common among air force medical officers, Soviet or

American, who were in pxositions of responsibility. It was their opinion that.

treatment should be guided by rapid heating of the individual and the injured

part. Longitudinal incisions were made in necrotic tissue within 5 or 6 days

to promote the rapid development of dry gangrene.

All of the neurological surgeons in the U7T.S.S.R. had been trained undler

the supervision of General Burdenko, who also was a member of the Academy

of Sciences. The latter conferred far more distinction and privileges than any

other classification with which we came in contact. It was said that Academicians ranked in these respects just below the Politburo.

General Burdenko had established an Institute for Neurological Surgery,

and it was claimed that 16 neurological surgeons at the front had 3,200 beds

at their disposal and tlat there were .3,700 l)eds in the rear.
432 ACTIVITIES O)F SURGICAL CONSULTANTS

In brief, the neurosurgical techniques shown were those which developed

from World War I, without the subsequent refinements which were being

practiced in the United States. In no area could Soviet surgery make any contribution to this surgical specialty.

An incident occurred while the mission visited the Institute for Neurological Surgery which revealed more of the Soviet mind than was being disclosed surgically. General Burdenko demonstrated a microscopic slide which

purported to show the excellent regeneration which had occurred as the result

of the experimental use of a formalin-fixed nerve graft in the repair of a peripheral nerve injury. The specimen was poorly stained and showed nothing

conclusive, and one of the mission turned away without comment. Brudenko,

through the interpretress, insisted upon a comment about the demonstration,

stating that lie had a copy of the American's book on peripheral nerve injuries. Ile indicated that an opinion would be highly appreciated. The

answer was, of course, that it had been proved during World War I, and subsequently many times, that such formalin-fixed grafts were completely useless.

General Burdenko was asked to indicate how many patients had been operated

on and to demonstrate one who showed a return of sensation or motion in any

area in which overlap did not occur. General Burdenko replied with a smile

that 25 patients had been so operated on, that all had recovered, and that they

were unavailable for demonstration because they were at the front in combat.

The other members of the mission, and, in particular, the other member

from the United States, were not hesitant in indicating that such a doubting

attitude might well impair the entire success of the mission and, if carried

into other fields, might even destroy the alliance between the Western nations

and the Soviet Union and allow Germany to win the war. The sequel to the

incident occurred later at the dinner given by the mission in the National Hotel.

During the cocktail hour, General Burdenko was observed rearranging the

placecards. It was protocol to have a lieutenant colonel sit at the foot of the

table and certainly not on the left of General Burdenko. However, this is

what occurred-much to the embarrassment of the senior ranking officers on

the mission who believed it must be due to the ig-norance of the lieutenant

colonel or else his persistence in attempting to offend the Soviet officials. However, the placecard was authenticated by Ambassador Standley who viewed

the incident with amusement. During the dinner, General Burdenko summoned the interpretress and asked again the neurosurgical consultant's opinion

of the formalin-fixed nerve grafts and again was informed that they had been

proved to be unsuccessful beyond any doubt. Whereupon, General Burdenko

said he agreed completely but then inquired why the other members of the

mission, particularly the British, had been so complimentary in their praise of

the experiment. He went on to say that this was an example of how difficult

it was to trust and negotiate with people who did not always bluntly state their

views and position. Ending by a firm, pumping handclasp, he stated that

henceforth there would be no difficulty in understanding opinions expressed

by the American neurological surgeon.
NEUROLOGICAL SURGERY 433

Several clinical methods were under study which were emphasized as being

completely new and original ideas. These included the injection of 70 percent

alcohol with 2 percent Novocain (procaine hydrochloride) solution about fractures in the early days following injury to increase the blood supply and to

stimulate callous formation; the use of placental extract to stimulate healing in

chronic wounds or the growth of skini in severe burns; the use of a cytotoxin

made by injecting mesenchymal tissue into a horse and using the antiserum to

stimulate the healing of ulcers of the stomach, the healing of bone, and the

loosening of scars and stiffness in joints; the use of the smoke from burning pinewood to stimulate healing; the use of naphthalene broken down by ultrasonic

methods to stimulate healing; and the treatment of shock by the suboccipital

cistern injection of potassium phosphate solution to stimulate the vasomotor

centers in the medulla.

The mission visited Dr. Lena Stern's laboratory to observe an experimental

animal tested for shock by this method of cisternal injection. Allowing for

all of the difficulties which are inherent in the demonstration of any experiment to a group, the basic technical methods employed were so crude and inaccurate as to throw complete doubt upon any conclusion which had been

expressed. Dr. Stern was one of the few women Academicians, and her apartment, automobile, food, and gasoline rations could not be compared with those

of the average citizen.

One of the outstanding demonstrations to the mission was that of the organization which had been effected, without recourse to the more democratic

method of employing committees, to hospitalize the emergency injuries to the

civilian population of Moscow. In fact, when organization alone was considered, the Soviet plans were efficient and superior.

It was apparent that women held equality with men in the U.S.S.R. as

members of the street-repairing gangs and of other construction groups on

the country roads and as soldiers and officers in the Army. In the line, the

mission was informed that there was no woman with a higher rank than colonel;

several junior officers were seen with artillery and infantry insignia. In the

medical service, the Inspector General, Brigadier Surgeon Valentina Gorinovskaya, was a woman.

On 11 July 1943, the mission began a trip to the frontline hospitals near

Vyazmia. It will be remembered that, during the following month, the Soviet

Army opened an extensive and decisive campaign along the Orel-Kursk-Belgorod Line which extended directly south of Moscow. Vyazma was about 125

miles southwest of Moscow and represented a point to which the Soviet Army

had driven the Germans back from their advance on Moscow.

The entourage consisted of several automobiles containing the members

of the mission and their hosts. But there were two additional cars which served

to transport the mission when the cars in which they were riding broke down,

and this occurred four times going and coming. Extra cans of gasoline wei i

carried with the passengers, and the rugged, jolting ride was only a part of

the rigors which it is said every doctor-soldier should be trained to expect. All
434 ACTIVITIES OF SURGICAL CONSULTANTS

of the traffic officers on the way to Vyazma were women, armed with rifles,

whose demeanor and expression left no doubt as to their ability and willingness

to use them.

At about 1700 hours, the mission arrived at a casualty clearing station,

well camouflaged in a thick forest. After the mission was shown through the

wards, vodka, strawberries, caviar, atid smoked fish were served in a, tine example of a, Mongolial tent. Gemieral Faymionville had briefed one of the U.S.

delegates on the drinking of toasts in vlodka in the Russian fashion. It consisted of making ill) one's owii iiiind( ai)ouit how miany vodka toasts could be

tolerate(d and then going through tlhe motions, sul)stituiting wine or water if

l)ossil)le, or otherwis sieimply raising the glass. It became obvious at, this first

stop that, if one avvepted the Soviet rules, defeat was inevitable.

The mission arrived at a large evacuation hospital at about 2200 hours that

same night. It was raining and pitch dark, but the hospital too was obviously

placed in a thick forest and seemed to be constructed of logs. A sumptuous

d(inner had been prepared with an exact protocol of seating arrangement alon(g

one side of an enormous tIable which o(T.upied a hare dining hall. The seitior

military member of the mission sat in the center of the table, and on his left

was a young, blonde, Amazon-like woman with the rank of major of infantry.

Lower ranks and civilian representattives graluateed downward to the ends of

the table. Vodka, wine, champagne, and enormous quantities of all types of

food were served while representatlives of various Republics of the Soviet

Union, dressed in their native costumes, entertained the guests with folk music

ani d(ances.

The toasts came thick and fast, and, as was customary, by the time it came

to a lieutenant colonel, there wats little left to toast. The ruling heads of governiments, the Soviet Army, and the women of the Soviet Union had been lionored, and a few well-delivered mumbled words with the correct emphasis and

gestures now sufficed. It, wis evident that the young woman major had considerablk capacity for vodka and a technique of eating large pieces of bread between toasts. It was also apparent that her table companions were slowly but

surely becoming unable to accept her challenges. It did not help for one of the

mission to invite her to dance to the Ukrainian music in the hope that the exercise might, slow down her vodka-consuming abilities. As a matter of fact, her

vigorous dancing probably burned up the alcohol more rapidly and only exhausted her partner. She was physically superior to any one of the mission and

probably was devoting herself single-mindedly to carrying out an order.

The dinner was terminated abruptly, and the members of the mission

were guided to their billets by their Soviet hosts. They were bedded in one

of the wards of the hospital which was cleaned and had comfortable beds.

During the night, one of the mission had the first attack of severe renal colic and

experienced the nursing technique of Soviet nurses whose calloused an(d rough

hands were nonetheless geiitle and reassuring. The following morning the log

and plank structure couhl be admired. It had lbeen erected by officers, nurses.

aid enlisted l)ersomnel, and the mirse who had been on night d(uty was observed
NEI IOLOGICAL STURG ERY 435

using -i hanld ax as she, with others, worked onl a window frame inl a recently

add~edl portionl of tile hospital.

A breakfast of tea, smoked mneats, anld bread was followed by a visit to

Colonel D avis from the previous nigh-t's table comp~anion, a Soviet' mnedical

officer of thle same rank. Thle Soviet officer ap)ologizedl for attemp~ting to emibarrass a, inender of the mission by publicly calling attention to the fact that

lie hiad not drunk each toast in vodlka- lie con(cleded as quiite correct this

consultant's (direct, frank answer that if lie (,tile Soviet colonel) was a guest

inl thle UnIited States he wvould be permitted to drink as, often and as lie p~leasedl,

anld onl that basis the Amlericanl guest to thle S'w iet Fi lionl would condluct hillself. Thme Soviet officer wvent oil to Ni v that there was no reall miecessit v for

accelptingz tile Rutlssianl rules abou~ht dri miking, toasts, hut, if t hey were acceptedI,

thlen thle Soviet people wvent all out to dirink their guests under tilie table.

.A Ruissianl salut atilon oil both cheeks ended the apologry and ap)peared to cenelilet

aI friend~shiip bet ween at least two of the Allies.

The return to Mloscow was comlpleted late that nlight and tile nlext day was

sp~ent in rest andl at a Symp~hiony concert. The following day the Iniission visited

a hiospiital for lightly wvounded whlo wvere able to be qulickly rehiabil itated and

returiledl to the comnIbat, zonle. Oil 15 ~July, tile British and Amlericans con1-

ferred hionorary Fellowships upon Burdenko andl Yudin Iin the office of thme

Peoples Coummuissar for Pub~lic H ealthm with as mlanly Soviet oflicials as menmb)ers of tie mnission present. and no0 other guests. T1he British and U.S.

Ambassadors were not present, and both Soviet recipients promninenit4 dItsp)layedI their stars of thme Order of Stalin. It was a ceremiony completely

umiuworthy, in its setting, of thme Fellowships from the distinguished Colleges

of Surgeons of England and Amierica, both of which had broken ai precedent

in coniferring their Fellowship away from the home of the College.

Thle following activities occupied the remainder of the mission's stay Inl

Russia :A return visit to the Sklifossowsky Institute; visits to the Pirogoff

Clinic and to thme Balneological Institute, whlere it was claimed that a Ipile-oil

water and Odessa mud were miraculous curing agents; at visit to the Central

Iiist~itute foi- Blood Transfuision where, accidentally, it. was leairnedl that, the

imission's Const ant. Soviet. conipan ion, physiologist Pai rini, understood English

perfectly, though lie had never utteredl one audlible word of English, attendance

at a p~erformanace of the ballet from Otto Nicolails opera, "The 'Merry Wives

of ~Wimidsor," and at a p~erformiiance of 'Jsclmaikovsky's opera, "Tile Queen of

Spades;- at meetingrat, the Central Institute for.1Medical Research, at which Mr.

Carling, Professor P~enfield, and this consultant recited that Great Britain,

Canlada, uid( thle Un ited States freely* exchmanged research in format ion, wvit bout

elicitingc ( lie slightest signl of encouragement that the SovietlUnion would join iii.

O n 2:3 July, the imiission fiiiahly took off onl their retiurn flight. The last

Week had beein di flicuilt for the hosts as wNell as the menmbers of thle miiission,

anid it hamd beein hardl to keep) occupJiedl. Thme time allot ted to the mnission had

beenl oversta ' ed. It had b ieeni impossib~le to walk about alone, b~ecause, the everl)Ieseuum N K VI repreýeuit ati yes had b een nearblY. there were. no shops inl which
4.1(; ACTIVITIES OF SIURGICAL CONSULTANTS

to purchase mementos of the trip, and the members of the mission had become

slightly weary of one amother's frailties.

The obstacle, however, was the fact that no airplane was available to take

the mission back to their starting place. The British and Soviet authorities

had been negotiating an agreement whereby, in the summer months, one route

would be flown by way of the Mediterranean, Cairo, and Teheran, as the mission

had come, and another directly across Europe from London to Moscow. One

aircraft by each route each week was the schedule. In the winter months.

two p)lanes would fly the southern route. The British believed the agreement

to be firm, but flew two planes in one week in July via the southern route,

instead of one directly across Europe, because of operational difficulties, whi.ch

would quickly straighten out. The Soviet authorities considered this a violation of the agreement and refused to allow any plane to enter Soviet territory

by any route.

The week passed with the British Ambassador frankly admitting that he

could get nowlhere with the Soviet Foreign Office. The U.S. Ambassador

fimially demanded p)assage out of the U.S.S.R. for the two U.S. citizens and,

oi 2:, ,/liv. all of t(I me mbers of the miiissoim arose at ()300 hours amid arrived

at an airfield near Moscow at 0545 hours. They could see the two-mnotored

U'.S.-built plane sitting on the field. A large red star decorated its side.

After waiting 2 hours for Walter Citrine, a British labor leader and his

companions who had also been in the U.S.S.R. studying Soviet, labor relations,

they bvoarded the plane whose motors were still idle. The motors were started,

and, without, preliminary revving of the motors, the plane taxied to the end of

the field and took off. The flight was never above 1,000 feet because, recently,

anu order had been issued to tile antiaircraft crews to shoot at any plane above

that height, without attempting to identify it. Stalingrad was circled at

5)00 feet atid all hlat 'ouhl he seen staiidling was onle stone Ahimney. At 1730

that evening, the pilot, dove the field at Teheran, and, withi time smiell of

scorched rubber tires il their nostrils, the members of the mission were unceremoniously deposited on tie airstril). They were out of the U.S.S.R.

The unceremonious delivery of the members of the mission in Teheran

left the Americans stranded at the airport, while the British left by an automobile provided by Sir Reader W. Bullard, British Minister to Iran. A car

was commandeered, and, after a great. deal of shouting and gesticulating, the

billet. of General Coinollv was reached. Hot., dirty, anil tired, Colonel ('utler

and the anthor burst in upon the general and his staff wvho were having a

cocktail before dinner. The general quickly grasped their predicament and

sent an orderly outside to silence the Persian driver who was honking the

automobile horn and screaming Iranian curses on his passengers.

After hearing their story and realizing that they had no means of transportation from Teheran to Cairo, General Connolly arranged for hotel accoinmoda(t ions overn ighlt., removed two pass•eengers., from a. U.S. freight-passenger plane

that, was leaving in tile morninig for Cairo via Basra. and said he would send

a car to pick them up early in the morning and 1)ut theni on the airfield. With
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NEUROLOGICAL SURGERY 439

wing commander managed to get the plane off the short runway. Early the

next morning, 30 July, the plane sat down on the airfield at Swindon. As they

were getting their bags off, the pilot discovered that the flight had been particularly difficult for him because a cargo, placed beneath the floorboards of the

passenger cabin and sent from London to Cairo, had never been unloaded. Ile

had carried it all the way back to England again. This explained the difficulty

with which his plane became airborne.

The mission had learned little about new advances in surgery, but each

member had formed his own opinion of Soviet practices from observation of

the individuals with whom lie had come in contact. The Soviet people appeared

to be like 10-year-old American boys who brag about the size of their houses

and chimneys and recklessly claim that their fathers can lick anyone. They

were unsure of themselves and suspicious and could understand only directness,

frankness, and the show of confidence which comes from strength, both physical

and intellectual.

It was learned that medical education, formerly under the control of the

universities, was put under the Commissariat for Public Health in 1930. There

were, then, 72 institutes (schools) of medicine with 107,000 medical students.

Students were admitted after 10 years in secondary schools, and the medical

course was 5 years. The first, 2 years were spent in scientific studies, and the

last 3 years were clinical. During a part of the clinical years, the students were

farmed out to village and town clinics for practical experience. There was

specialization *with training for industrial surgery, military surgery, hygiene,

and bacteriology. Upon their passing a required state examination, a diploma

was issued which conferred the right to practice medicine. Higher degrees,

those of bachelor or doctor of medicine, were given after 2 or 3 additional years

of p)ostgraduate work, which could be clinical practice or continued work in

the institute. A thesis was required which determined whether or not additional

examninations were to be given. The percentage of students who become bachelors or doctors of medicine was small. From 1935 to 1940, there were 140 (doctor's degrees given at the First Medical Institute and 284 b)achelor's degrees.

From this group came the professors and teachers. When a chair was vacant,

anyone couhll apply, but a commission chose and appointed the individual. It

was said that they had a Research Council. also under the Commissariat for

Public Health, and that into that organization flowed problems from the army,

navy, iiduistry, and the faculties of the medical institutes. This council then

assigned special l)rol)lems to certain faculties or individuals.

WASHINGTON AND RELEASE FROM SERVICE

Colonel Davis spent the month of Auigust 1943 preparing reports s and accompanying General ][awley to tlme wards of the 2d General Hospital where

Major Scarff and his associates had been carinig for the high-atit tide frostbite

*1See pp. 92--106, and appendix A for additional ehronleling of the mission to the Soviet Union and

appendix A for a report on the mission prepared jointly by Colonel Cutler and Colonel Davis.
440 ACTIVITIES OF SURGICAL C()NSULTANTS

cases. Gen. Henry H. Arnold, Commanding General of the Army Air Forces,

Maj. Gen. David N. W. Grant, the Air Surgeon, and General Grow were also

present on that Sunday morning when General Arnold visited the men at their

beds and heard their stories of failure of clothing and equipment.

General Grow accompanied General Grant and General Arnold back to

Washington. Colonel Davis received orders the following week to go to Washington and present the colored photographs of high-altitude frostbite injuries,

the clinical histories, and all other data which had been developed during the

study of these patients. Hle was also instructed to present the data on the

protective helmet.

FIGURE 150.-Col. R. Glen Spurling, MC.

Maj. Gen. Norman T. Kirk, The Surgeon General, and his staff were

greatly interested in the high-altitude cold injuries. General Kirk took the

author to the Pentagon and arranged a presentation of the material to the

Air Surgeon's executive officer, Col. Walter S. Jensen, MC, and a group of

other Army Air Forces medical officers. General Grow appeared during the

presentation. He objected strenuously to any implications that he and his staff

had missed the injuries in the first place, had continued to disregard them, and

had failed at any time to study them. The facts, not the implications, needed

no defense.

Mr. Henry Field, a friend from Chicago, was in Washington engaged in

governmental work which made use of his great knowledge of the Middle East

and his abilities to bring important matters to the attention of those in high

places, who otherwise had to rely upon the complex lines of communication

between bureaus and departments. He was greatly interested in the story of

the high-altitude cold injuries and in the possibilities of the protective helmet.
NEUROLOCGI('AL SýUII(WIY 441

Thus it was that contacts were nmade with Colonel l)oriot and Mr. Brad ford

Washburn '9 of the Quartermaster Corps. These men had been working energetically to develop clothing for airmen which would protect theni against

extreme cold. Mr. Washburn had had considerable experience in mountain

climbing and exposure to severe cold. Unfortunately, this research group

had been ordered to stop working further on protective clothing for airmen.

Colonel I)oriot's group was also working on a new protective materialDoron-nanmed for Colonel I)oriot, and it was possible for the author to help

at length on the medical aspects of its development (p. 414).

After a tour as a, patient through three general hosp)itals enided on 30

March 1944, Colonel I)avis was released from active duty and returned to

his (luties as chairman of the D)epartment of Surgery, Northwestern University.

On 12 March 1944, Lt. Col. (later Col.) R. Glen Spurling, MC (fig. 150),

was appointed Senior Consultant in Neurosurgery in the Office of the Chief

Surgeon, ETOUSA.10

The Army Air Forces eventually requested the author's colored photographs of high-altitude frostbite and made educational posters designed to

instruct the airman on proper protective measures. Properly wired clothing

was issued, and the sidegun apertures on aircraft were closed in.

The p)lastic material for protective armor was field tested by the Marine

Corps and the Navy, and finally, on 15 September 1951, Maj. Gen. Edgar E.

Hunme of the Army Medical Corps announced that a plastic-protected vest

would stop a .45-caliber bullet fired from a distance of :1 feet. In an article

published in 1944, this consultant had suggested that the plastic material (lesigned for use in aviators' helnets could also be adapted for protective clothing." Such armored protective clothing was finally used in the field during

the Korean War with great success. At the time of this writing, the plastic

material forms the basic principle of protection for the jet pilot's acrosonic

helmet.

9 Director. Boston Science Museum, Boston. Mass., in 1959.

10 For accounts of Dr. Spurting's activities. see (1) Medical Department. United States Army.

Surgery in World War II. Neurosurgery. Volume I. Washington : U.S. Government Printing

Office. 1959, chapters III and VII: (2) Medical Department, United States Army. Surgery in World

War It. Neurosurgery. Volume II. Washington : U.S. Government Printing Office. 1959. chapters

IV. VIII, and XII.

"I Davis. I,. : Helmet for Protection Against Cranlocerebral Injuries. Surg., Gynec. & Obst.,

79: 89-91. July 1944.
CHAPTER V

Ophthalmology

James N. Greear, Jr., M.D.

The first Senior Consultant in Ophthalmology ill ETOUSA (European

Theater of Operations. U.S. Army) was Col. Derrick T. Vail, MC, (fig. 151).

Colonel Vail returned to the Zone of Interior on 26 December 1944 for a period

of temporary duty in the Office of The Surgeon General. His presence in the

Zone of Interior at that time permitted a desiral)le and indicated exchange of

certain key ophthalmologists. Colonel Vail was reassigned permanently to the

Office of The Surgeon General as consultant in ophthalmology, relieving the

incumbeent, Maj. (later Lt. Col.) Ml. Elliott Randolph, MC. Major Randolph,

in turn, relieved Lt. Col. James N. Greear, Jr., MC (fig. 152), as the officer

ill (-lrge of tile rehabilitation prograln for tile bIlind at Valley Forge (General

Hospital, thus freeing the author for assignmlient to the European theater as

Senior Consultant in Ophthalmology. Colonel Vail has recorded his experiences and activities as the first Senior Consultant in Ophthalnolog, in the

European theater in the volume. "Ophthalmology and Otolarvngology," of the

history of the Army Medical Department in World War II.1

During Colonel Vail's absence, Col. Norton Canfield, MC, the Senior Consultant. in ()tolaxryngology in the European theater, took care of problems in

ophthalmologT that demanded attention at the theater headquarters. When

Colonel Vail had not returned to the European theater by the enid of January

1945, Colonel Canfield recommended that Maj. Byron C. Smith, MC, of the

1st General Hospital be assigned temporarily as Senior Consultant in Ophthalmology in addition to his other duties. The recommendation was approved.

Major Smith was in charge of an active service in ophthalmology at his own

hospital: therefore, lie was unable to make extensive visits to medical units in

the theater. lie did keel) in touch, however, with the activities concerning tile

Senior Consultant in Ophthalmology and gave valuable assistance and advice

relative to problems of a specific nature which were constantly arising.

Colonel Greear reported for diuty at the Office of the Chief Surgeon,

ETOUSA. on 29 March 1945 and began his tour as Senior Consultant in OphAMedical Department, United States Army. Surgery in World War II. Ophthalmology and

Otolaryngology. Washington: U.S. Government Printing Office. 1957. Chapter V, "Administrative

Aspects of Ophthalmology in the, European Theater of Operations," and Chapter VI, "Clinical Policies

in Ophthalmology, European Theater of Operations."

705-095"--64-31 443
444 Atkii'iNITIE' OFi SURIC(1AL. CO NSULTANTrS

thalniologýy iii the European theater. Ile devoted the first few days after his

arrival to searlchlliu thet tiles of Colonel Vail inl anl effort to determhlie thle est ablishied policies of thle t heater and to famnil iarize himself wit lI the many problems

to be0 Considleredl.

ORGANIZATION

Thie originial planl for tilt organiizat iolu of thle P rofessional Servic'es DIx)iisioui. ( Mtice of thle Chief Surgeoni, as set iup early inl 1942 by Col. James C. Kimbroiugh. MIC, D~irector of Professional Services, was still ini effect. Ili brief,

thle (iivision conusistel of a1 (Chief ( n'ou1u t a t ii inI Medicille wvithI subordlinate 5&i se 1

C0uistiltaiits inl lieuropsychliatry. tuberctulosis, dlermatology, anid infect iou~s diseases and a Chief Consult ant il 'Surgery with subordinate senior consultants in

tile specuialt ies of orthopedic surgery, pl astiuc surgrery and burns, nieurosurgery,

auiest Iliesiut. I rans ftuisioi I I nl shock, ophut 11,ln)iohogY.ruiogyuolg.toargvologvy, and(I max iilofaciai surg-ery.

By January 1945, (decenltral izat ion of all1 act ivit ies had occurred owviiuz to

thle great numbher of wounded and the presence in tilie t heater of some 200 huosp~it als. The ha rger base sect ions hadi~ conusiltanuts inl Iledicinle aund surgery, who

reported ouu puurely professional mat ter's to thle Chiief. P rofessional Services

D ivisioni. ( ffive of thle Chief Sturgeon. t hirongli either thle Chief Consullt ant inl

Medicinie or thle Ch'Iie f Consultant ill Su rgery. TIhiis plan. alone, did not providle adlequate coverage of professional act ivit 'v wi tliin tilie th~eater. Therefore,

ill ordler to maintain close contaet. with p~rofession~al workh. consult ants in medicinme and suirgery were set tipl ill the hospital centers. These officers inl turn re-
OPHTHALMOLOGY 445

FIGuR 152.-Lt. Col. James N. Greear, Jr., MC.

ported on professional matters through the base section surgeons to the Chief

Consultant in Medicine or the Chief Consultant in Surgery. Consultations

in the medical and surgical specialties were also decentralized. In each hospital center, officers selected for their superior ability acted as regional or hospital center consultants while carrying on their regular duties. At a high level,

and separate from this intimate organization for the supervision of professional

work in communications zone hospitals, there always existed a close liaison

with the consultants of the various field armies and the air forces. This close

liaison with the tactical elements was essential, for it was believed that in any

single theater there should be but one professional policy if the soldier, whether

sick or wounded, was to receive proper therapy.

POLICIES AND PROCEDURES

The policies of the Professional Services Division as established in 1942

were designed to implement measures whereby personnel of the U.S. Forces

would receive promptly the highest standard of medical and surgical care.

The condition of all patients reported seriously ill in U.S. Army hospitals as

well as British hospitals could be easily and quickly determined. In order to

stimulate an(l maintain professional morale and disseminate recent medical

information, it was considered advisable that medical meetings be held regularly

at general and station hospitals. The type and frequency of these meetings

depended on local conditions at each hospital and on the general situation.
4463 ACTIVITiIECS OF SURGICAL CONSULTANTS

The sp~ecialtyV senior consultants inl Medicine and surgery submnit tedl 'written

dla ily reports of their activitijes to C olonel KillInrottgrI through thieirP reslpective

chlief conisultanits, C ol. Willijam S. Middleton, M( , Iin medicine, or- (Col. (later

Brig. ( ien. ) Elliot t C. Cut ler-, MC, in, surgery. ihese reports wvere consolidated

býy Colonel Mliddleton, Colonel Cutler, and Colonel Kimbrough for transmission

to thle ( hief Surgreonl. It was thle policy of the Professional Services 1Divisionu

to hav e cmistiltat lol service imlillediatel v a vaiilabile att all t limes. Senior coi-()

stilt ants for the various specialties in th ( fieo h lýe ugo ori

nated tile activities relatin~g to their resp~ective areas. They lla(Ie such recoinllelidat ions to thle approp~riate. chief (ousultant as were collsider-ed Ilecessa1PV

for tilie ilist md1v ionl of siilornlimate coilsum tamits and Specialists in hospitals and~

o1ther unlits. Undl~er the guidlance of the senior constl~taluts, tilie consultants for

field arim"i c and( base sections siipervised a 11( coord inatedl the wvork of specialists

functionled umi(ler Ilite dhirect ion of tile Chief, Professional Services I ivision, and

its mlembliers were the reslpoiisible ad~visers to thle Chief Surlgeonl oil all professionial mid~ techniical iliedl icl mal~tters.

The specialist senior con~sultanlts visited all M1edical Department units for

the puri1pose of g'%ivig their guidance and~ assistance with regard to technical and

prmofessionlal matters falling withiii their fields of acti vity. They adlvised o1)

the selection and assignment of junior consultants and specialists and rep)ortedl

front time to time o11 the standard of professionial efficiency miainltainled by such

officers. They collaborated with members of the Operations Division, Ofifice of

hie Chlief Surgeonl. in ar1ranging coturses of inlst ruct ioul, iilediical illeef hugs, and

training schools and in other measures designed to keep) the officers of the

Medical Department in touich with the latest developmients in mnedical science.

It was their dutyt to l~lit iate alldl calrry out research and investigattions wiha

viewv to conlservin~g m~anpower in tile field an([ restoring to health the sick and

wound~ed. It was their responsibility also to maintain liaison with thle, consultants and specialists in all branchies of iiiedicine of tle B~ritishi Amilled Forces

andl civil ian practice. They advised its to the suitabil ityv of drugts, inst ruiments.

ali(i eqttipmenhlt of a sp~ecific natutre and miadle recommndlll(ationls onl other mlatters

pertainling to the health of the V.S. Armyv in the Eutropean theater.

The most important ftunction of the Semlior Consultant in Ophthalmology

w1as to see thlat, everv U.S. soldIier requiring1 elye care, tin the European theater,

recei ve( tile highest, possible stand(ard of mnedical care (fig. U53 ). Thle best

method1( of accoln 1))hshing this wvas to determine the cap~abilities of thle ophithalniologists assigned to thle general and station hospitals. This informiation was

obtainied b~y p~ersontal conltact. amid( throughi the hospital center consultant inl

ophlt halmnology. Onl several occasions, groups of ophthalmologists from both

station and1( general hospitals were invited to mneet with the Senior Conisultanlt

in Ophthalmology. The meetings were very satisfactory, and miany important

p~hases of the handling of patients were discussed. Following the general
OPHTHALMOLOGY 447

discussion, individual interviews were held with most of the men who had

attended the meeting.

It was impossible for the Senior Consultant in Ophthalmology to cover the

entire area and to see the work that was being done in each individual hospital.

Neverfheless, he made every effort. to visit hospitals where the larger number

of eye cases were being treated. These hospitals were primarily those treating

large numbers of neurosurgical patients and maxillofacial injuries where,

naturally, many eye cases wouhl be located. ()n several occasions, group)s of

hospital center consultants met at some centrally located hospital or at a base

section headquarters, and informal discussions were carried on amiong these

consultants and the Senior Consultant in Ophthalmology. These discussions

proved of great b)enefit to all concerned insofar as the care of patients was concerned. Not infrequently, it was necessary for the center consultant in ophthalmology to have patients transferred from another hospital to his own to assure

adequate medical care, and this could be carried out without too much difficulty.

The hospital center consultant. had no authority to initiate transfers of personnel from one hospital to another: however. it was his duty to report, to the

Senior Consultant in Ophthalmology wvh( he felt. that such transfer wvas

necessary, and the transfer could then be initiated from the Senior ( 1'nsultant's

level.

Regular monthly reports were received by the Senior Consultant in

Ophthalmology from most of the ophthalmologists in station and general hospitals in the theater. These reports were informal, but they contained information pertinent to both the type and the number of ophthalmic lesions being dealt with in each particular hospital. This information was valuable

to the author in that it kept him acquainted with the needs for personnel and

equipment, in various units as conditions changed. A monthly report was not

received from some of the newer units.

Early policy in the European theater had dictated that newly blinded

casualties be sent. to St. I)unstan's Institute for the Blind near Shrewsbury.

Shropshire, England, for a period of training before evacuation to the Zone

of Interior (fig. 154). Since September 1944, however, the established policy

in the European theater was to evacuate. all blinded patients to the Zone of

Interior, at the earliest possible moment after they were transportable. Before his transfer to the European theater, this consultant had learned that

patients who had been sent. to St. D)unstan's in England for initial rehabilitation before returning to the Zone of Interior were usually critical of the. training they received at special rehabilitation centers in the Zone of Interior.

They coistantly compared procedures carried out in the two places. Therefore, personnel dealing with blinded casualties in the theater were instructed as

to the proper psychological approach. The necessity for these blinded patients

to become independent. as quickly as possible in order to regain confidence in

themselves was eml)hasized.
4thoptl k
tIIIIiITI.\.IA I.A 1 1. I ll;.

111M

1'-. .11liv 0: .4.I l
450 ACTIVITIIS OFI" SUR(ICAL (CONS'.ULTANTS

HOSPITAL CENTERS

Dhuring November and D)evenbl)er of 1944 and the early ilionlths of 1945.

thirty 1,000-bed general hospitals had arrived ill the European theater. In

addition, there were 10 new 400-bed evacuation hospitals and I new 70-1)ed

evacluation hospital (fig. 155). In sonme of these hospitals there Was D)

ol)ht halhologist, and in others tile oplhthalinologist had received meager trainiing in his specialty. Tihe rapid mnoventet of the armies had necessitated an

increased dispersion of hospitals and had thus made the author's lpersonal contacts with tile ol)hthiahlnol)gi(ts ill the theater mu'ch illore (liflicult. This greatly

increased the importance of compl)etent and active stllior(lilate vonsultants.

Fimit' I: 154.--St. I)u,•stan's Institute f'.r the Blind. Shrop•.•iire. Englanud. A. A blinded

allljlti•-tv lea;irl'ilur to type. It. Sir I1au FrI•ser. founde• " auI( director.

IHIospital centers wvere well estal)Iished ill Ithe lited Kingdom Base and

wvere wvell orga)lll ize(I. Ill each cenilter. there wvas a verv colnl)etellt (co)llslllltllt

ill Ol)ht ha] In()logv whon made regular visits to hosl)itals in tile center and wNho

worked. ill Ilost instanices, iIi close coperation withI thle 'oi ad in _ oflicer of

She ,enter. IliThs, tile (ounIandling officer was kept advised concerning ith

care of ophthalmological patients ill his veniter. Shifts in personnlel were recon(m (le(d through the center co.insultant ill oplhthalhology wher'ever it wa.s

d(eee(mle ne(es.ary. Tile more serious, eve l)rob)lemus "-ere 'oncentr'ated ill hosl)itals where miore 1.ap)ablle opht hahinological officers were assigned.

0)n the (Continent, hospital centers generallyv were less well organized,

aui(l. wh iile couisiuitants in ol)lithal nolo"gy had beet a.ssigned in a few instances.

tIley had not had their fuim-tions well (detined and were of the opinion that they

shuold 1n1 t visit hloslpitals ntil tilheI wvere invitedI. All eflort was made to

clarifv this situ at ion in or(ler that thi.is 1on.sultant Inight be kept inforilued as to
oviITIIALMO LOGY 451

the op)hthalnhic care of patients In widely scattered hospitals. Additijonal constultanits were app~ointedt to niew% c-enters which had been organized onl the Continent. and every effort was made to acquaint -themi with their duties and

resp~onsib~ilit ies. All alble ceniter )i- regional coinsuiltant was of iteý-t Iiiialle

value in coordinating the functions of his specialty inl his area.

The majority of the hospital center consultants in the European theater

were aptans.This wvas a gzreav handicap) to themt in carryingr out their duties.

sinc(e a 4rreat many of the eve, ear. nose. and throat mlenl assi~riiedI to a enera1

and1( staition liosp~italIs were miajors and resenited ani officer of a lowver gradIe Hti

L

FIGURE 155.-An eye clinic in an evacuation hospital.

sp)ecting their services and making recommendations as to the care of patients.

TIbis si tuat ion was commnon t hrouighout thle entire theater. The hospital center

cotistiltant had imuportaint responsibilities. It was his dhuty to visit. the hospitals

in the (center at least monthly and oftener if necessary: hie certainly had to

visit them often enough to ascertain that the patients in the hospitals of his

center were receiving the b~est possible eve care. It was important that hie gain

the confideince and reslpect of the. ophthalmologists assignedl to the hospitals in

his ceiiter in ordler that thev would freely seek the center conlsul tanlt's advice

Onl prob~leml p~atients. A higher rank would have made it easier for him to

carry out his resp~onsib~ilit ies.

Geographic dispersion of hospitals in each ho-spital center rarely offered

any-% real prob~lemn since most of the hospitals in the centers were situatedl within

705-09f5, -64 :12
45 2 ACTIVITIES OF SURGICAL CONSULTIANTS

a relat i el ' sumall rad ius andill mnoist inistanices couild easily b e reached withli

less than aii hour. Thle quest ion of transportation was never a seroious probloim. Most, hospital center cons~ult ants couldl obtain tranisportat ion fromn their

OW1 illuits; if not, transp~ortation wasm available from thle hiosp~ital center

lheadqula rters5.

SUPPLIES AND EQUIPMENT

Tilhe standalrd equipment 51i1)1 liedI to grenleral and ttio liospiltals i1n thle

Europ~ean theater was ext remlely deficient ill cerall aitems Which wvere essential

to acculrate diasmosis- of many eye disorders. Becausie of the iniabil ity of the

miedicalI officer to mnake early and aeccurate diagnoses as a result of a lack of

(diagnost ic i lst runlieit s or' 1ecalise of inadlequate equi pmient. alleviative nieaQures were not inst itutedl until the patient, reachedl aniother hospital where sutch

equipm)nent. was available.

The slit. lampul and( cornieal miicroscop~e are indlisp~ensab~le to thle accurate

d1iaignosis aliii t reatmnent. of injuiries or dliseases of tilie aniterior segniuent of t he

grlob~e. Ak good many11 of thepse inlst ruinent s wvere dlist ribuit ei to hiospit als ill thle

U nitedl Kiingdomi Base, b~ut very few ever reachled thet hospitals oni lie (Contineiit . In onle hospital cent er, t here was not one sing"le suchl it em. and, ill

anothler' center, there was only.% onle such iteml-anld tlhat was ill a rather isolated

hospital.

Abnormal fields of Vision could be a~ccurately determni ed only by plot I illg

suich chlaniges wvith tile ulse of a perimeter or tang~enit screenl. Nthrof these

itemls was onl tilie standaurd table of eqlii)uipenit for genieral1 or station Iiospit als.

Ill some inst ances, thlrouigl the ingenuity of some muedIical offierns or their

technicial assist ants. b othI tangrent screen anid perimet ers wvere constructed.

These pro~vedl to lhe very sait isfactorv and~ miost uiseful.

It. was thle opinion of all convernied that. every greneral, hospital should

have beenl supjplied with a gianlt mlagniet as standard equipment sincve thle hand

ilaglipt, wlas foundl~ to bep hot sulifmieiitlv powerful to remove inan v of the

smiIaller i lit raoculla . minagnet iv foreign bodies.

OPTICAL SlTPPL~Y

Full1 credlit. was gi vemi to Colonel Vail for establdishinlg tilie optical programn in thle Eulropean th~eater. Tnis, programn had workedl and~ was thloroluglmlv

orgranized at thle tine thle author arrived inl thle t heater. Lat e inl 1944. one

sect ion of the issue branch of tile, ETOUSA Base Optical Shop wvas mioved

from Blackpool, England. to Paris. Col. Silas B1. 1 lays. 11C. C hief of thle

Supply Division, ( )fice of the Ch'i ef Surgeon. FITOT SA. was mlost cooperative

ini inst it uting this t ransfer to thle C'ontinent. This init was (designied as the

Base Opt1ical Shop and1( located at tilie 7th Genieral D)ispensary to service

tile optical requirements of the U.S. Armly Onl thle Cont inent. TIhis facility

not onlyi filled presc riplt ioils for glasses arising from thle immediate area but,

also pr;)Vidt'd all opitical SlIpiplies to niobile units. 1)o th Services of Supply
(I I ITI I 1ALA1 ).11I4'IA'

1 141 I -Id 1-1 ,i t I Ili 'w I o wi ll. I '4' fill 4 i I 1' t4 44I 1* ~ l ~ II 44 1 i I4

14I~lp - 1,40114 11,\ fil Ii. I 44j 1 4r (J4 ll' ;i.j.;4444 4 1- .( I Ill \\4,I4 I4 4ll-.I 111c 1,I444

I l 1144 M i 4' l 4:141ý-f * l 1 : 144414 114114. 4: 114101i -I Hi ll \\1411 411,414 1 4441e \:ld 1 :1 14

4414 i~I ~ I1;1I4.l 11 if l it It Iij4114 IlI 1441 j i i t,114'441 f I I II fi 4 lli 14 1T4 (I i - I1'1 4411

I4'c' 41,41 lttiji ( 414441 v44'I1II \:..IiI ill )1J4,l~~~l4l44 Z1144 I11 vll.

if 1 if' :l 1 *11 Ii 1 -11~ ]; i 144--I41 r 1-4j 14'111 If 0 fil-l ~2 11: III 1- lvi m i 4,1III.vd ;I4 IlI44144 414 " II
4.54 ACTIVITIES4 (F SURG.ICAL CONSUULTANTS

sp~ectacles a Mn iask inserts. On 1S Ma 14, tilie aiiithl. wa~s ill Conlferencee with Iiolonel Cuttler: Co~lonel Hays: (Col. Anagvald Xickoren, 11C,

(citief, 'i'roops and [riaining Biiiwhvi, ( )perat iouis Division: C ol. ~John E.

Gordon, MC, (hijef, Preventive Medicine 1)ivisioii I. (t.'ol. Bernlard1 *. Pisani,

INC., Execut ive Officer., P~rofessional Services D)ivision: and Captain l~ore.

The (piest ion of suplply of eveghiss gas mask inserts and spectacles was the chief

top)ic 1111(1er dliscusi~on. I t was pr1oposedl that anl ETOFSA (directive b)e sent.

to all Itti it comiltanI( er.- con~cernled withI thle iiedlical process~5inug of t roops5 for

redleploymnent. Thle following day, a prop1osedl directive dealing with spectacles and1( g-as miask inserts was transmhittedl to the D)epuity Chief Surgreon. Trhe

(lirective wvas never pub1Ilishled oil the basis that. items coveredl lV thle p~roposedI

dietv eealreadyaeuaeycoee inl published ETOI SA conifmandl

(Ilrec.t i es oil redleploymnent. Onl 29 June 1945, this consultant submiitted a

letter to thle Chief Siurgeoni pointing~ out the necessity for miore sp)ecific instruc111iowý rel at ive to0 thiis phase of redleployment b eca use t here was so mnuch in is11n1lerstandlmng.

Accompanied biy 'Major Smith and Captain Rorie, the author visitedl

Twelfth Arnny Group hleadlquarters and then tile headquarters of thle Third,

Sevent it, and Fifteenth U .S. Armiies andl discussedI wvi h thle armly surgeonis

the e* e glass and spectacle reqjuiremlents for troolps beinig redeployed. This

information was well receivedl andl tile army surgeons were quite willing to

cooperate.

IDespite early planning, after V-E DaN (8 May 1945)), Some critic~al

pr1oblemls dlevelopedl wh ichi demuand~ed inmmledliate act ion. Some 2 nill ion troops

were to lbe redleployedl eithier directly or ind~irectly just as qulickly as tran sportation facilities wvould p)ermIit. All troops liavinig visuial error were to Ile redleployed1 with their maximunm specffl('le requiremeints of two pairs of issue

spectacles and. if visual acuityv was less than 20/70. one pair of gas mask

iniserts. Service troop~s wvere to b~e redeployed first, and this was the category

that miost Op~tical unlits Came und1(er. Inl 1ractically no timle at all, 6.5 percent

of optical facilities had (.easedl op~erations inl pre paration for redeplovyment.

TIhe p~ersonnIel onl tempijorary dlutyV inl thle Base O pt ical1 Shop had dlwind~ledl downl

to four.

The Commanding General, Assembly Area Conmmvand, had demanded six

miobile inits to serve tile assembly -area alone. Tile comumaiiding general of

tile L~e 1lavre area hiad requestedl anl extra unit, the Marseilles Port had requested

an additional unit there, time armies were (heniani(lgl adlditional units to replace

those that hiad(- easedl operations for redleploymlenlt, the Bremen Port had requested a unit, andl a unit was requestedl for Berlin. lit short, time requirements

hlad increased to albout 20 p~ercent more than they' ever had been at. any time

dlurinlg the war, and ablout 015 p~er'enlt of the optical supply lunits hadl ceasedl

operations. This, of course, crea te(] temp~orarily a serious cond~ition and "Inmedliate Act ionl was stampiled onl pract icallyv every requisition placed onl the

0Tperat ing 01 )t ical Supply units.
OPI1TI IA I,.M3 )I,0C, Y 455

This problem was solved ill the following mamnner. A teletype liessage

was sent to ail prisoner-of-war stock'udes directing that prisoners be screened

immediately for experienced opticians. Between 50 and 75 opticians were

located and allocated to various units. A 24-hour shift was put ill operation

ill the asseiibyiv area, and additiomal equipment was set upl). The stocks of supplies were doubled in all units having a large demand. Nine Belgian civilian's

were employed in Li'6ge. Twenty-seven French civilians were employed in

Paris. A unit was sent to Bremuen Port. Two portable units were sent to Berlin. In the last mnonth of operations prior to V-.1 D)ay (14 August), 37)i )40

pairs of glasses were processed. Again, Captain Rorie cannot be too highly

commuenlded for tile splendid jot) lie did in supplying the entire Army in Europe

with instant service omi optical supplies under the most difficult circumstances.

TRAINING

Early in May 1945. the Medical Field Service School. ETOUSA, was

reestablished near Paris. The Senior Consultant in Ophthalmology, assisted

by Maj. Kenneth Fairfax, M(C, and Maj. Byron C. Smith, MC, gave lectures

on war ophlthalmnology to the medical officers attending the school. These

lectures and demnonstrations were designed to impress upon the general medical

officers the need to handle patients with injured eyes carefully, particularly

patients with perforating wounds of the globe. Lectures were also given to

nurses attending the school (fig. 157). These talks emphasized the necessity

for nursing care in patients with severe eye injuries. Procedures pertaining

to the nursing of newly blinded soldiers were discussed.

During 1944, it was anticipated that there would be a period following

hostilities in which some type of training program or refresher courses in the

various medical specialties would be of tremendous value to the men in various

fields of medicine, either in continued service activities or in civilian practice.

Before reporting for duty in the Office of the Chief Surgeon, ETO(USA, the

author had conferred witIi Colonel Vail relative to posthostilities training for

the ophthalmologists in the European theater. Colonel Vail had given the

subject consideralile thought, l)ut no definite action had been taken. Prior to

the cessation of hostilities, this sub)ject was discussed with center consultants

and with individual ophthalmologists throughout the theater. L- was decided

that a didactic program in ol)hithaonmology would be inaugurated at Oxford

Vniversity under the direction of Prof. Ida Caroline Mann, Head of the D)ep)artment of Ophthalmology at the university.

A conference was held with Professor Mann, and plans were completed

for such a program to begin on 17 July and extend through 14 August 1945.

This course was to consist of lectures and demonstrations by Professor Mann

and her staff, supplemented by a number of invited lecturers from the United

Kingdom. Following this lecture course, ophthalmologists who were available

were to be assigned to various civilian ophthalmological services in the United

Kingdom for a period of 2 weeks. This consultant visited several of these
la:ic 1:-17.- Nuirse., rece~ivitl1ig isi~t 1.14. jill .ui IN.e MedicalI Field Servii-1 Scliii41. T'D 'ISA.

im()Iital-,. '1ii(1,In .:14. e i~l i1i1i1iiie. III(.Y ie il ifiI) have I .8. ArIii *v (Aifiers

:iiteiid elIIIIcS anid 4lbep-ve 1 lie .1t 1vi\i (Iv 1ol Ilie li'vit I iie':Illv. II Di. ( ()I.

(liter ( '(d. )E11iiar1 A ilidias--ei. AR ' (hIve of 4)' lie ()perai Hills I )Ivi:ýIoii. Meilical Sect kill. I It iiqiiaiiiers I iiiteil Bii.doi ase. asiý1tiimI the :iit home that I Ile

I S1 G v lent iI I 14.pI I al1\-4) ~Iilt 11 avIlaIeI \.Ii I fm bIllet I n oni iall d !iieii± the oflivers

ottiahilding the o~ii- t ()hflIiit-v. All himiajiial :iiagiitt~ fill

i lie fuuteSe werie cmiii1 eteul \\-iIl thle a ult 14)e~il jes (d ( )x f()Ie 1I iiiver-it v. ilt iliziii

I licatee iii toe~ii~(iat :ou 11dt eduivaHillt 14)11 itia. Maj. Feeditmia d 1. ( iut.1M(

oif thle 2d ( reiieral Hospiat wa s app;l~ointed'4 cooetidilliat of I lie c4J)Ilrse aniidl

feotIit 13 .11iuiv 14) :,i( I .1tliH. was at I;iledit t4) thle ( )hire o)f thle S1ii-em.tiu. I iited

ophu ilialitiolog-ists liouAoIt te Uitijed KiiU.r(Iml AIvivwr iinteirviewedl a1d4

ANvM~wd ilt(11) .1 lect ure I iiiiet ade. The Ci)ul im H'liatebi thattle lecti leeiS.

all1 jwoimiiieiit ill ophit hahiiolomw. were Iiii)A :1114 md~e tod :h1ti Ilwvhe

coliih. ilesjflie thu'- Iuicoiivelivielve otf pi41);aieil? " :i led tire~t and 441 eaveliii. o 1()

O xford I ot heir hiotties I hlrOigliomitt Ekuighain. IEx'ept foe)I Sir1, ; imwa 1ii 1 ),IkvEldi er. whiiiNk w I~ Veveltted 1) I iis 11111)4 irt :1t 1111 lit al dlliut i. ever-Y I ~rItIsI-A

o~hi laiilo.rstwho \\as. asked to pl-ai ittel:v avvel)tetl ilie iiivItalt iou. 'This

S~intwas 1 frbille1() ll(.frieiidlY 11 mpv-aiehtel

the 11-.S. ;iiid Butili ohhi viiuio( ý~-.etIldhIeIS~ d uhu Iit lie war.1 Iv )Y 4te
OPHTIA LMOIA)( Y 457

The course was eminently successful in providing a taste of academic

op)hthalmology to men who had been doing military ophthalmology for varying

periods of time. The men were unusually and uniformly appreciative and

eager to take advantage of the opportunity afforded them and were repeatedly

impressed by the education, poise, and affability of the British lecturers,

many of whom were internationally known. The scope and duration of the

course did not in any way qualify an officer for a certificate, diploma, or degree.

The intention of the course was merely to give the officer who had been doing

military ophthalmologry a review of academic ophthalmology, to refresh and

broaden him, and to stimulate his future serious study of ophthalmology.

Owing to unavoidable redeployment requirements at this particular time, only

about half the number of students originally scheduled to attend could attend.

SUMMARY AND CONCLUSIONS

The consultant system made possible the high type of medical and surgical

care that was available to the U.S. soldier in the European theater in World

War 11. A consultant in ophthahnology was always available in the hospital

center, and, if it was his belief that the Senior Consultant in Ophthalnology

should be called to see any individual patient, the latter could be reached

through the base section headquarters. The consultant system was essential

for the best surgical care of the Army in the European theater. It did not

work perfectly; however, in the event of any future conflict it should work

far more smoothly than it did in World War II.

No general or station hospital should have been sent to an oversea theater

without adequate equipment to render all the specialized services for which

the hospital was formed. Certainly, they should have had the essential equipment for specialties such as ophthalmology. The equipment should have included a perimeter, a giant magnet, slit lamp and corneal microscope, a firstrate ophthalmoscope, and a tangent screen. These items are mentioned because they were not included in the standard equipment of ophthalmolgical

departments in the hospitals of World War I.

In a theater of war, hospital centers should be organized and hospital

center consultants should be given very explicit instructions as to their duties

and responsibilities. One of the chief responsibilities of the hospital center

consultant should be to apprise his senior consultant in ophthalmology of any

hospital in which a low grade of ophthalmology is being practiced.

The sole purpose of any system is to provide the U.S. soldier with the

very best medical and surgical care, and this purpose certainly was accomplished in World War II. It is believed that the system could be improved

in any future conflict with only minor changes. Perhaps the most important

advance would be to commission ophthalmologists in ranks in keeping with

their professional attainments and previous training. This applies particulary to men who have been selected as regional or hospital center consultants.
CHAI'TER VI

Orthopedic Surgery and Rehabilitation'

Rex L. Direlcy, M.D., and Mat/her Cleveland, M.D., Se.D.

ORTHOPEDIC SURGERY, AUGUST 1942-MAY 1944

Ma. j. (]lat er (Col. ) I tex L. I )ivelIeY, AMI (I ig. 15 S), wvas otlered a ii d accevp Ied

l I e pos It ion of Sen Iior (Coiil dtant iii ( rt Iliopedic Sutrgery. E'I' )ISA ( European

Th'leat er of O perat ions. I .S. Ary).on 4 .1tily 1942. Ile reported to thle 0111cc

of Thle Stur-greoul (Tecueral, Washiiigrtoii, D .C.X, onl 241 11Jul 1942, wiiere hie was

ind~ct rinat ed for tilie oversea miiissioni. ( )n 3 Aurgust, hie was promiiotedI to the

ranlk of fiieutenlant, colonlel, aiu. oii 12 August 1942, lie receivedl orders to p~roceedl

overseas. C oloniel I iveleY arrived at H eadquliarters, ET( ISA.k onl 26 ktigust.

1942, where lie relport ed to (Col. (later Maj. ( enl.) Patil R". 11 awleY, M( '. Ch'lief

Surgeon, E'1()I 5A.

Early Observations anid Recommendationts

vie Professional Services D ivision inl thle Office of thle Chief Surgeon was

headled by a D i rect or of P~rofessional Servijces~ w~ho su perv ised tilhe professional

aict ivit ies of thle Medical D epartiment ill the EurIopeanl theater iiii( coordhiiated

tlie work of consultants and specialists. riihere was a Chief C onsultant inl

Surgery and a Chief Consultant inl M1edicine immediately sub~ordliniate to the

Director of Professional Services. Tiie senior consultant. of each surgical specialty was, ill turn, accountable to the Chief (Consultant inl Surgery.

Aks Senior Consultant inl Orthopedic Surgery, the author's missioni was to

orrllz andl supervise thle condulct of orthopedic services and~ activities inl the

theater.

Inl September 1942, there were very few U.S. Army hospitals inl thle theater.

Thier~efor'e, the first. task was to ascer~tain tile experiences of tie British and

Canadiant Allies, as their orgfanizations had been functioning mnianiimouths.

This conisultant immnediately contactedl Brigadlier Rowley WV. Bristowv, ort hopedic consult~ant to the British Armyv: Mr. Reginald Watsoi-.Jones, honorary

orthop~edIic consultant to the RAF (Roa i Force) ; Group Captain (later*

Air (Commiodore) Osmond C"lark, orthopedic consultant to the RAF: Mr.

It. A. T. Fairbank and Prof. Harry Platt, orthopedic consultants to EMS

(Emtergency M1edical Service) hospitals: M.1% G. RI. Girdlestonle. orthiolpedic

conlsultanti to thle Ministry of Pensions; anld Prof. TF. P'. Mc~turlrav and 'Mr.

I For de~tailed diitcusiolls of the ndininistrativie and clinical policies nd81 practices In orthopedi1c

surgery lin the European thieater diuring World War 11, see: 31etdicai D~epartm~ent. I fitch states Army.

Knrgery liu World War 11. orthopedic Surgery lit the- European Theater of operationsa. Washington

U.S. Glovernmuent Printing Office, 1956.

459h
460 ACTIVITIES OF SURGICAL CONSULTANTS

S. L. Higgs, regional orthopedic consultants to EMS hospitals. The EMS

hospitals, while civilian institutions, were receiving and treating service cases

in the various outlying sections of England.

The medical sections of the various headquarters of the Allied forces in

the theater were visited, to include headquarters of the RAF, the British Army,

and the Canadian Army. All of these offices were in London.

The principal British and Canadian hospitals and rehabilitation depots

were visited, and several of the larger EMS hospitals which were receiving service cases were surveyed and studied. This consultant was very much impressed

with the type of orthopedic work being accomplished in the British Army,

Canadian, and RAF hospitals. These units had had several years of experience,

FIGURE 158.-Lt. Col. Rex L. Diveley, MC.

and this study gave the Americans a basis for the organization of the U.S. Army

orthopedic services.

At this time (October 1942), there were some 10 or 12 U.S. hospitals, and

all of these units were inspected as to supplies, personnel, and type of work

being accomplished. The medical and surgical supply situation was quite

acute, and there was an alarming shortage of materials and surgical supplies

available to the U.S. Forces. To investigate further the supply situation, the

author visited the British medical supply depot at Ludgershall, the U.S. Army

medical supply depot at Thatchamn, and various medical and surgical supply

houses in London.

As a result of the observations made and the informat ion gained from these

tours and a general survey of the theater, the author recommended to the Chief

Surgeon that:

1. The medical and surgical supply situation in this theater being inadequate, the quantity of supplies should be increased, and a more efficient supply

service should be rendered to the various hospital units.

2. Photographic records should be made and retained in each major hospital in the theater. A photographic department should be established in the

Office of the Chief Surgeon for the making and filing of medical pictorial

records and for the production of motion-picture training films.
ORIH OIPEI )IS 5URGERY AND REIIABIIITATIO)N 461

3. If hospital records and/or X-ray films were to be retained as permanent

records, they should be preserved and stored by mass photography (microfilming). This would give a permanent record and conserve storage space.

4. An intensive program of military orthopedic training should be instituted and given to surgeons in the European theater, especially to those in

station hospitals. This training shouhl stress the techniques of imnmobilization and transportation of fractures in the forward areas as well as the definitive treatment at the base areas.

5. A rehabilitation depot should be established in the theater to care for

the convalescent patient and to recondition the underdeveloped soldier who

had broken in training.

6. Certain specialized bone and joint injuries and conditions should only

be operated upon by the orthopedic surgeon or the especially trained traumatic

surgeon.

7. More study and care should be given the problem of foot and march

injuries in combat troops undergoing training. This supervised care would

save many man-days lost to divisions in training.

This consultant spent the remaining few months of 1942 attempting to implement the foregoing recommendations. First, he immediately contacted

British militaryN and private surgical supply sources and was able to obtain

a limited quantity of instruments and supplies which would su~ice the U.S.

Army until standard U.S. Army types could be obtained from the United

States or be manufactured in the United Kingdom. The author contacted

the Signal Corps for the procurement of photographic supplies, but this branch

was unable to furnish supplies or personnel to the Office of the Chief Surgeon

or to the hospital units. Therefore, through Kodak, Ltd., Harrow on the

Hill, this consultant was able to procure sufficient photographic materials to

activate a central la!)oratory in the Office of the Chief Surgeon and to equip

photographic laboratories in six general hospitals. To train personnel, Kodak,

Ltd., established a medical photographic school in London. Medical Department personnel were trained at this school and then assigned to the central

photographic laboratory or to the general hospitals.

No equipment was available in the United Kingdom suitable for photographing records. Conferences were held with Kodak, Ltd., and, through its

research department, the company developed a photographic apparatus which

would photograph transparencies (such as X-ray film), hospital records, and

charts as large as 14 by 17 inches. Records were photographed on 35-mm. film

and could be viewed on a Recordak film reader and be reproduced to any size

by photographic enlargement. This machine, after perfection, was turned

over to the Medical Records Division in the Office of the Chief Surgeon.

The author presented orthopedic lectures and demonstrations in the major

hospitals and to medical personnel in the smaller units and the combat divisions.

In November 1942, approval was received to train personnel in rehabilitation. Negotiations were started to establish a rehabilitation depot. This

rehabilitation program as planned was to (1) provide care for the convalescent,
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w~OllidlC( ili tile two0 armies. TIlis was accomnplished bo0th b~y Conferences alidt

I)%-bu toigilo ,Il(l illsIpect ing~ line and( hosp~ital units inl both thle U.S. and the

Brit ishi Fort'(".. InI lie latter part of januIary, Bjrigadlier Bristow toured the

Vlited Sae, fluig lectures oil tite operations of the Allied arinies overseas

Nvith ISpecial1 reference to t heir orthopedic services.

Maj. (later Lt. (Co1.) Willalain J1. Stewart, MIC (fig. 160), joined the Senior

(Conisult ant inl OrthIopedic Surgery as Associate Consultant inl Orthopedic Sirl--

gerY. Major Stewart. sp)ent lmost. of his time. gi vinig lectures and (lenlolistrat ions

oil ortili(j)e(lic silr~'-,rY to va riouis active and stagaig hospitals. Four regional

conIsult ailits illrhoei surlgery had also been applointed. These consultants

1uhandledt or liopedic probl)emis inl their particular localityv.

FIGURE 16O.-11,j. William.1 . SteWart., MC.

III order to (lenionstrate and teach plIaster of paris technique to the medlical

officers of tlie command and especially to those inl combat units, schools were

estab~lish~ed inl key positions througl.mut the theater. Medical officers and their

corpsmien were ordleredI to these. schools for a 3)-day course inl the handling and

app1licatiloln of plaster of paris, sp)linits, and casts for the imnmobilizat ion of

fractures and rxtensive wounds prior to transp~ortation.

InI the latter pairt of F~eb~ruary 1943, the author was ordleredl oin temporary

duty to the North Africani theater to insp~ect hosp)itals and 1ime units there and to

stll Iyiethiods beinig tiievl inl the transp~ortation and~ treatment of orthopedic

Casualties (fig. 161). This consultant. retuirnedl to the Europ~ean theater in the

latter part of March 1943. D uring this trip, hie obtainled muitch information

for tilie. (Chief Stirgeon, ETOUSA, relative to medical suppIlies, field medical

serv ice, casualties, andl various aspects of professional services. For orthop~edlic sulrgery, tilie author obta inedl considlerable in fornint ion of value relative

to thle training and1( instruction of European theater medical personnel in thle

tranlsportat ion of frac tures, plaster of lparis technique inl forward units, first

aid treatment inl thle forward areas-especially inl the handling of fractutres, and1(

initial orthopedic surgery in thle forward areas.
ii; I

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iFll.I iiim d i4 :Iti.iil ,11 il lt
466; ACTiIVITiIES (1i Stlt(ICAI. CO NSVIt'ANTIS

TheIu 1 igith Ai ir Force was especial iv act ive wvith its dailyl houd ihig ruiis,

a mti lost. of thle A litllerca iicasuatie t ts i the Eurlopetani t heate (hir ing 1 943~

ori~xiiiateti as a result or air co)iiiIat Thierefore, t his alith lo Spent inicreasedl

aliioiilit s of. 1t il nit it il tilie EIligt i Air F'orce nit its. P ract ical Id~emoiist rat ionis

anl lect ii res were gi veti it) thle handlingI of tract illes. jruu1shlt, 1a4 firagmi ienit

AV4)lili(15. anid especial1ly ill tilie traniisport at ion of casulalties front aircraft to tilie

a irliehid first ai alStat ion andt thlenice to thle hiospitalI for definiit ive t reatilnetit

The Seti io. C onisul tanit ill O rt hoped ic Sii -rgerv andthItis asstocia Ies Spenit

coiu1sitleral e little Ill I lle inivestiqrat loll oif thle possibled use of resinls and phi ic

illt Ile t reat ilietit. of fractuiires. A fter coiisidera ide resea rcli1, it was bel ieved thIat

there wvere lielt her time nor faci litiles iii thle Eiiropeani t heat eneveli folvlr C T0Ii~

out a1 jrel i Iliiiiary invest igtation. It was coinsidered, however, t hat the use of

hislatic Splinjts for externial1 as well as interina I ixat ionl was a1 aIost impilortanut

sitbject. alitid sloulld he St tIdied at Some fuittire t hue.

Thie Eu rop~eali th1 eater Medlical F ~ieldI Service School at Sliri veuu I ia inwas

act ivat ed and tilie seii ion oulislit aiit ill Or)thlopedic SurgrerY wvas responisible for

several1 lectutres anid demionistraittions each wveek. especia lly iii thle ulse of spl1intiis

:1i1d dhressinugs ill thle field.

Thiis co(iisllti Itat was app oinutedl a miemuber of tilie EMIS coisilt alit groulp onI

ont I to pedic s II nge-rY oft It le I ý nit islIAIi MIIi ist rv of I l ea It lII. Si uIIe t Ilie EM S h Ios pIitals

Calletd for strvice p~ersoninel locally. thIiis ga yve tilie ailitlior all excellenit opport iliOit

to Nvork out at clos;e 1 iaisoii for t Ilie hand Iiligl~ a111(i exclitani~tv r U.S. sick-a adW01oiide(Ie persoiiiet. Montlilyv inviiee gs or tlie( cojisutltaut groupij were held ili

London(4)i.

There was Somiie (IItI'ereuice of op in ioul Iet weeuu greliera 1 anad orilhoped ic

si11 rgeouis as to %A wlit shuliIl4(I ha iid le cent aiii I iiie anid joinit condl~lit ions aiid I Iiifilines. (Teuieral IIa wle 'N issuied orders that these ix)iie anid joiuit coiidit ions aiid

all1 tracttirt's wvoluld he iaiildleth 1) 1 thle oirtlopedic Suirgeoni whlei available.

The orthlopedic stirgeotus ill U.S. Aruivl hiospitalIs hiadl beenl orgaii izi'd, andl

pilanus were ulad4 e for ia1oiuth lilyle&'t i iis. The first iiieeting of tilie commlianidIs

orthiopedic Surgeonis wvas hieldl at thle 2dl General H osp~it al near O xford oin2

A pril 1943~. Brigad ier* Brist ow alld Mir. G it rdlestoiie werep tilt, gulest lpet itreys

4 ni orth11)1ed i slil ject s. The 1 i en-A11it'4 (on C ferences oilt War Medicinle, hehid

IliolutIi l ti, nder tilie aulspices of tilie Royal Society~ of Medicinle, gave an1 oppon.-

tiiauit 'v for t lie iiiterchlaige of ideas amiiong tile miedical Iiieuiihers of thle Allied

forces ill tile United Kingdoml.

'I'le author worked closely with Col10. Lloyd .1. T'hiomipson, MC,' Seu io)r

Conisul talit ill Neunropsvcliiatt uy to correlate thlit rehiabil1itat ion programi whichl

h ad n'eei act i va tedo oivlseit ii't opvcl iiat rnc pillt ient s.

( 'euienrl II[wle'y a appo~intedlia commuuit tee oif three theater consult ants to

iislpect eatcl nlew i~osp~ita al initr aIS it aiiedinl tiltiheatet'r. Aftel. a tliorotigl

stti~ldy this comiimitt ee was to rep~ort to thle Chief Surgeon any dieficiencies inl

Suppihlies or personnel aiid to outlinile a course of inidoctrniationi for tile unitilli

tlit'. theater.
ORTHOPEDIC SURGERY AND REHABILITATION 467

On 23 and 24 July 1943, a combined conference of orthopedic sp)ecialists of

the British Military Forces, the British Ministry of Health, and the U.S. Forces

was held in London. Two of the previously mentioned motion picture training

films, "Medical Service in the North African Theater" and "Forward Plaster

Technique," were shown. These films were then made available to the British

Forces for showing and instruction.

The American Medical Society, ETOU1SA, held its first meeting on 23 June.

The majority of l)al)ers and addresses were given by the orthopedic personnel

of the theater.

The author returned to the Zone of Interior for a period of temporary diuty

extending from 20 September 1943 to 1 January 1944. Major Stewart assumed

the duties of Senior Consultant in Orthopedic Surgery during the author's

absence. During this temporary duty, this consultant presented many lectures

and the European theater motion picture training films throughout most of the

United States. I le visited a majority of the rehabilitation centers in the Zone

of Interior. At the request of The Surgeon General, the author helped to activate and e(IiI) a model rehabilitation center at England General Hlospital.

Atlantic City, N.J.

In October, during this consultant's sojourn in the I nited States, an orthopedic shoe repair program was instituted at the D)isciplinary Training Center

No. 2912, Shepton Mallet, Some.setshire. At this institution, corrective shoe

repairing services could I)e provided. This p)rogram not only gave service to

the Medical D)epartment but was very valuable in the rehabilitation of the

nimates of the disciplinary training center.

Activities Early in 1944

In 1944, after he returned to the European theater, the author placed great

stress on the rehal)ilitation p)rogram and devoted munch time to future planning

for expansion of the program.

It Febhruawry. this consultant, was al)l)ointed Director of Rehabilitation in

addition to his other duties. Therefore, a request was made for Lt. Col. (later

Col.) Mather ('leveland, MC, to come to the European theater and assumne the

duties of Senior Consultant in Orthopedic Surgery.

Much pressure was being exerted on General Hawley by Lt. Gen. John

C. I1. Lee, Commanding General. SOS in The British Isles, to use osteopaths

in the Medical D)epartment. General Lee asked that they be commissioned

in the Sanitary or Medical Administrative Corps and l)e used in the Medical

Department, especially in rehabilitation activities. General Lee held the

opinion that the osteopath could treat the hack case better and more efficiently

than could the orthopedic surgeons. General hlawley suggested a plan of

assigning a group of osteopaths to the rehabilitation center at Stoneleigh

where an osteol)atlic nmanilpilative department was activated. As the ca-es

were admitted to this unit complaining of low-back pain and disability. they

were asigned for treatment alternately. one to the manipulative del)artment

and one to the orthopedic section. G eneral Lee also reluired the assignment
468 ACTIVITIES OF SURGICAL CONSULTANTS

of orthopedic surgeons who were staying in the theater and were not busy

to observe this test of talent in the treatment of low-back pain and disability.

After several months of competitive treatment, the osteopathic department

was discontinued in complete vindication of the Medical Department's

treatment.

During the spring months of 1944, the author continued with his routine

duties as Senior Consultant in Orthopedic Surgery (fig. 162). Finally, in

May 1944, Colonel Cleveland arrived to relieve Colonel Diveley as orthopedic

consultant. Thence, Colonel Diveley's entire time could be devoted to rehabilitation activities (pp. 477-501).

REx L. I)IVELE. M.D.

ORTHOPEDIC SURGERY, MAY 1944-JULY 1945

Chronology

As Senior Consultant in Orthopedic Surgery for the European theater,

Col. Mather Cleveland, MC (fig. 163), arrived 20 days before D-day and was

completely unfamiliar with the hospitals and orthopedic personnel of the

theater. During a period of initiation from 20 May to 6 June 1944, he visited

42 of the hospitals in the United Kingdom in the company of Lt. Col. William J. Stewart, MC. Colonel Stewart was thoroughly familiar with all hospitals and orthopedic surgeons assigned to the theater, having served under

Col. Rex L. Diveley, MC, for considerably over a year. His evaluation of the

orthopedic officers and orthopedic sections of hospitals was accurate and stood

up well. During this pre-D-day period, everybody was tensely awaiting the

invasion of the Continent. Most of the orthopedic sections of the hospitals

visited had a very low patient census in anticipation of battle casualties due

to arrive.

With the invasion on 6 June, the author was assigned to consult at the 38th

and 110th Station Hospitals and the 48th and 95th General Hospitals in the

Southampton area. These hospitals were serving on a so-called transit basisreally as near-shore evacuation hospitals whose function was to perform

essential emergency surgery and then evacuate the casualties by hospital train

to the general hospitals to the north. For the most part, these hospitals received their first casualties on 8 or 9 June, gradually and in small numbers.

The 110th Station Hospital, however, did an excellent job in receiving and

sorting 1,000 battle casualties in 20 hours. By 12 June, the transit hospitals

were busy and the chain of evacuation was filled with casualties. There were

many blast injuries due to explosion of mines at sea. These casualties had profound vascular damage, with fractures or dislocations of the knee, and the like,

and amputation was usually necessary.

The author's duties next led him to the Normandy beachhead in July at

the time of the Saint-L6 breakout. At the time of this visit, the necessity for
AND RE AIl 1.1AHI 6

SMill" It I ll v. 'sooll I i4le"I fter. ;if Ill e ii r±VetIt requtest of lIhe ( 'ft ief sii lre4rvoi. whli4lt,

blood0( b~e tral 14)tiv fromt I lIe( Zonel( of tiltetior'.

Th~is tt1111i1:Illti I hell dIvo()edl inlitel of filM- I 111e to n1 coiil ittillolt, toltlfi

(Iul~ ~I-t~ to I Ie)Iv ;io .1mI Ii tiedlit :I1 :e0 ivit jes of I le 111vaeie. 232 11otlt).e her' Ill tile

i I ; o lIti Ill. fot luIIf %- I, 1-o:1v 1. 1ot~ 1. stt nI I II. evicial *I 1o . .11ti1l 1 elf filljitis

:I Mi 11 iree .11.1iiiY IeIlfi 4 imI1-1e(S Xer si 1 (.4 l. c()liisiitIt I 1loit 1,ýwere I eld . n Iiid rel HottI

oitl IeIN 1i- Its were tenidered Ito I IeII ( 'fuIelf Sli I 1-vtI. Ill tIIe followitu".~ :) IItoIttlII.

114 alie I lt!or i11:i4( le Ii17 !h u fll tn Ivllls M .114 ai ivisited I Ile-e :1111 v h nlill jI ora:i ten'. l :Is

wvell. DI)II- ii th~tle I I Ilionilst JMIhat a1ct ye I a st iiife W. ~s :,e il )t Ie ( otiIentIIII

allboxi~iief 3II ~IsWere fiade. to vnrioluM titedical 1act*%-*t lIs ILv tIle Senior

(Coii'liIia a1 ii )rt hi1oped I ill-tger~.y

l't'4)l4 io'.iIh C (are of WVoundedc

DIII Jtlli! Ilie 6- 1oilotI period I thet I4ill v~it-lot. lilt chile f previ'l'i I lat loll wa

of) :1e14 itfilý 111:1 liilltaItII.- :til op) ltlltII sI:Ittfhdi ofIll poeMsiotlmi 4care for tile

(0ioll~aif atal fItva v '-t i'ailt of hat tie ('11sitilt es fhiat flowved fromi th lie il fil;iile
470 ACTIVITIES OF SURGICAL CONSULTANTS

of resistance back through the field and evacuation hospitals to the general

hospitals (fig. 164). While the Manual of Therapy for the European theater,

published on 5 May 1944, dealt with the treatment of bone and joint casualties

in general terms along fundamental lines, it soon became apparent that more

specific instructions were necessary. These instructions, based on experience

gained by consultants and surgeons who were caring for the wounded, were

formulated in Circular Letters No. 101 (dated 30 July 1944) and No. 131

(dated 8 November 1944) issued by the (Chief Surgeon, ET()USA. These

instructions dealt with circular amputation, debridement of the wound, imFIGURE 163.-Col. Mather Cleveland. M1C.

mobilization of fractures for transportation, treatment of wounds over bones

and joints in general hospitals, delayed primary closure of wounds over compound fractures (then called secondary closure), and injuries of the hands.

The instructions in the circular letters were very specific and, in general, were

strictly adhered to. By this means, the function of each hospital in the chain

of evacuation was defined and thereby each medical echelon knew what treatment it was expected to perform, what had been done forward, and what

would be done in the rear.2

The hand wounds were under the care of orthopedic and pllastic surgeons.

Hand centers were established t)oth on the Continent and in the United Kingdoin Base. Outstanding salvage work was performed in many of these

centers.

2See footnote 1, p, 459.
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ORTHOPEDIC SURGERY AND REHABILITATION 473

The tables of organization of the various hospitals in the theater called for

a total of almost 450 trained orthopedic specialists, Military Occupational

Specialty 3153, B or C rating or better. There were only 217 medical officers

who could possibly l)e considered as possessing these skills. The proper utilization of available orthopedic surgeons was, and in the future will be, a matter

of great moment, since at least 40 or 45 percent of battle casualties and injuries

will invariably involve bones and joints.

It was the author's considered opinion that each field army should have

lhad as consultant a highly trained ortlho)edic surgeon with the rank of colonel.

Such a consultant could have supervised and trained younger surgeons in evacuation or other army hospitals where the bone and joint casualties were received

for delbridement and applications of proper splints for evacuation to hospitals

in the comunnications zone. The general hospitals needed one or, if available,

two orthopedic surgeons to treat compound or simple fractures and amputations

and to handle other bone and joint problems that were received. Large station

hospitals, if serving large bodies of troops in training or if acting as general

hospitals, also needed a trained orthopedic surgeon.

There will never be an oversupply of these officers in the event of another

great national emergency, and therefore careful planning will be required to

see that all are effectively use(l.

Proper Utilization of Experienced General Hospitals

The utilization and proper location of experienced. affiliated hospitals was

of the utmost importance. At the time of the invasion, most of the affiliated

general hospitals in the European theater during World War II (12 to 14 in

number) had been in the theater for from a year to 18 months. They were

given priority for movement, to the Continent. This was a reward for service,

but unfortunately it meant that during the first 6 or 8 weeks after D-day, the

"first team" was sitting on the bench. That is, they were staging, crossing the

Channel, and in the process of being set up. A good many of the personnel of

these hospitals were used on temporary duty to augment other hospitals, to be

sure. but the smooth operation of well-established hospitals was missing. At

the beginning, most of these hospitals were first set up on the beachland and

later moved to other parts of France or Belgium (fig. 166). In planning their

second moves, it would have been ideal if they could have been dispersed in such

a way as to serve as parent hospitals for the hospital centers and base sections

later established on the Continent. At times, two or more of these affiliated

general hospitals were assigned to a single center and, at the close of hostilities,

there were two hospital centers at Reims with some 17 new and inexperienced

general hospitals and with no older experienced hospital within call. These

older affiliated general hospitals furnished the junior consultants in all branches

of medicine and surgery.
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476 AC'TIVI'rTIES OF sUII(cAi, (()Nsui'rANTS

Rank for Orthopedic Surgeons

For the responsibility which the orthopedic surgeon carried, there was no

provision made for commensurate rank. There was actually no provision in

the tables of organization for theater consultants, and any promotion to the

grade of colonel had to be borrowed from some new hospital or hospital center

that entered the theater with vacancies in these higher grades.

There were approximately 12 outstanding orthopedic surgeons who had

served- as many as 3 years in the grade of major in various general hospitals of

the theater. It was the firm conviction of the Senior Consultant in Orthopedic

Surgery that each of these officers sl, uld have been promoted to the grade of

lieutenant colonel, and such recommendations were made. Of the 12 orthopedic

surgeons recommended for such promotion, only one reached that grade while

in the European theater.

It was difficult to explain to an orthopedic surgeo, Ylhy the dental officer,

the roentgenologist, the psychiatrist, the chief of labora ,ory, the chief nurse,

and so on, in a 1,000-bed general hospital should, by table of o'ganization, he

advanced to the grade of lieutenant colonel, while the orthopedic surgeon, who

was responsible for the professional care of 40 or 45 percent of the wounded,

could not. advance beyond a majority. Such discrepancies should be remedied

so that resporsible and outstanding officers can be given rank commensurate

with services rendered.

Meetings of Senior Consultants

TIhe position of senior consultant in the European theater carried great

responsibility and afforded endless possibilities for improving the professional

care of the sick and wounded and maintaining a high level of such care.

When possible, the senior consultants met weekly at headquarters in Cheltenham, London, Valognes, and Paris as the Office of the Chief Surgeon moved

forward, and once a month the Chief Surgeon met with his consultants. The

most. inspiring meetings to this consultant. were the informal weekly gatherings

presided over by Col. (later Brig. Gen.) Elliott C. Cutler, MC. These were high

level discussions of all prevailing problems, in which suggestions were freely

offered and were usually well received by all 12 or 13 surgical specialists present.

During active hostilities, two meetings were held with British and Canadian

consultants and one with all the Allied consultants. With the exception of

the polylingual meeting with translations into and out of French and Rus&van,

which instantaneous translation would have helped, these meetings were extremnely helpful.

The Chief Surgeon supported the consultants to the hilt if lie thought they

were correct and did not hesitate to correct or reprimand them if they were

wrong. The writer will always consider it a great privilege to have served with

the senior consultants in the European theater during World War II.

MATITER CLI•1,ELAND, M.D.
ORTHOPEI)IC SIURGERY AND REITABIILITATION 44-7

REHABILITATION

Activities Centered in the United Kingdom, 1942-44

Soon after arriving in England in August 1942, Lt. Col. (later Col.)

Rex. L. Diveley surveyed all U.S. Army Hospitals that were then functioning.

During this survey, he observed that a significant percentage of military personnel was being readmitted to hospitals because the men were unable to carry

on the physical rigors of their former duties. An examination of a sampling

of these l)atients revealed that their prolonged stay in hospitals had definitely

deteriorated them mentally as well as physically. No attempt was being made

to bring these hospitalized personnel to their former physical capacity before

discharge from the hosp)ital. The result was a great, loss of man-days to the

.\rmy.

('olonel Diveley immediately undertook to ascertain how the British services

had solved this problem. It was found that the RAF, the British Army, and

the Royal Navy had established special convalescent depots to which convalescent, sick-and-wounded personnel, after hospitalization, were being sent for

rehabilitation or reconditioning. In these depots, a complete and comprehensive program of exercises was given to restore these men to their former physical

C'ap)acity.

In the fall of 1942, Colonel Diveley outlined for the Chief Surgeon a plan

for the establishment of a convalescent rehabilitation center in the European

theater. Ile proposed the establishment of a center where sick or wounded

military personnel could be sent as soon as they became convalescent and no

longer needed active surgical and medical attention in a hospital. At these

centers, lie suggested a complete and supervised physical, educational, military,

and recreational program which could be given to restore patients to their

former physical and mental capacity.

This plan, in general. was approved by the Chief Surgeon. He issued orders

to select a site, to prepare a provisional T,'O&E (table of organization and

equipment), and to train personnel who would be required to operate such a

'onvalescent center.

Rehabilitation and reconditioning facilities

Rehabilitation Center No. 1.-After the author had inspected several

available sites, the All-Saints Hospital, Bromsgrove, Worcestershire, was selected and procured. A provisional T/O&E was prepared by the Operations

D)ivision. Office of the Chief Surgeon, based upon the personnel and equipment

of a 150-bed station hospital. Five officers and six enlisted men with proper

qualifications were trained at the British 102d Convalescent Depot at Kingston

and the British Army School of Physical Training at Aldershot. On 7 April

1943. the 16th Station Hospital, augmented by specially trained personnel,

opened Rehabilitation Center No. 1 in the All-Saints Hospital. The essential

staff consisted of Maj. (later Lt. Col.) Clayton H. Hixson, MC, Commanding
478 ACTIVITIES OF SURGICAL CONSULTANTS

Officer; Captain Gullingrud, Executive Officer; Maj. (later Col.) Frank E.

Stinchfield, MC (fig. 168), Chief of Professional Services; Capt. (later Lt.

Col.) Marcus J. Stewart, MC (fig. 169), orthopedic service; 2d Lt. (later Capt.)

Gerald F. Semlers, Inf., I)irector of Physical Training; and 2d Lt. Paul E.

Hall, MAC, Director of Military Training. Under the efficient professional

guidance of Major Stinchfield, a well-balanced physical and military program

was developed (fig. 170). Patients were admitted from station and general

hospitals as soon as they became convalescent, were able to be up and around,

and could care for their own toilet. Although the hospital load of the theater

was very light, the census of the center had rapidly iIcealused to 431 by 1 September 1943.

FIGURE 168.-Maj. Frank E. Stinchfleld,

MC, at All-Saints Hospital, Bromsgrove,

Worcestershire. England.

It soon became evident that the facilities at Bromisgrove and the staff

of the 150-bed station hospital were insufficient to handle the anticipated convalescent patient load of the theater. Consequently, a general hospital site at

Stoneleigh Park, near Kenilworth, Warwickshire, was secured, and the 8th

Convalescent Hospital replaced the 16th Station Hospital as the operating unit

of Rehabilitation Center No. 1. Key personnel of the lth Station Hospital

were transferred to and retained in the 8th Convalescent, Hospital, which

opene(d the center at Stoneleigh on 5 October 1943. Major Stinchfield assumed

command of the center at the new location.

By December 1943, the census of trainees at. the rehabilitation center had

reached 1,300 (fig. 171). At this time, it was necessary to release the 8th Convalescent, Hospital for assignment to a field army. This unit was replaced

by the 307th Station Hospital (750 beds). Key personnel of the 8th Convalescent Hospital were retained for assignment to the 307th Station Hospital, and

Major Stinchfield continued in command. This exchange of unitt- was con-
ORTHOPEDIC SURGERY AND REHABILITATION 479

sumniated on 5 December 1943. In January 1944, the census at Rehabilitation

Center No. 1 showed over 1,700 officers and enlisted trainees.

By the time D-day, 6 June 1944, arrived, the patient load at Rehabilitation

Center No. 1 had increased tremendously and, with the assault on the Continent,

further expansion of its facilities became extremely necessary. After many

unsuccessful attempts to obtain the Irish Labor Camp (Ministry of Works),

adjoining the center, the Camp was made available on 19 June 1944. This

allowed for an expansion of 700 patients and increased the overall capacity

at Rehabilitation Center No. 1 to approximately 3,700 (fig. 172).

Rehabilitation Center No. 2 (Officers).-Early during the operation of

Rehabilitation Center No. 1, it became evident that officers and enlisted men

FIGURE 169.-Capt. Marcus J. Stewart, MC.

should be segregated when undergoing a program of convalescent rehabilitation. Accordingly, a rehabilitation center for officers, Rehabilitation Center

No. 2, was activated at All-Saints Hospital, the original site of Rehabilitation

Center No. 1. A detachment of trained personnel from the 307th Station

Hospital was assigned to operate this facility by working with members of

the 1st Auxiliary Surgical Group, which was now temporarily quartered at

Bromsgrove. Later, when the 77th Station Hospital had been made available

for the rehabilitation program, Detachment B of this hospital relieved the detachment of personnel from the 307th Station Hospital in the operation of

Rehabilitation Center No. 2. This change took place on 23 February 1944.

Still later, the 123d Station Hospital was assigned the mission of operating

the rehabilitation center for officers.

Reconditioning Center No. 1--As the patient load of the theater continued to increase, and additional centers became necessary, experiences indicated that certain convalescent patients needed only general exercises or body

hardening to bring them to their former physical capacity (reconditioning),

as contrasted to others who required certain specific remedial exercises in addi-
4S0 ACTIvI'III'S OF SIURICAL CONSULTANTS

S00

FIGURE' 170.--lteleniial exercises at Rehabilitation

Center No. 1 (16th Station IIospital), All-Saints

Iosjpital.

tion to general Ibody hardening (rehalilItit loll). AC\.orldiigly. all additional

unit was requisitioned to establish 1 reIt• odi(iotil& center. A geteral hlospital

site was secured at Erlestoke Park, near I)evizes, Wiltshire. This site had

alccommodations for about, 1,50i e INalet Wit ieTt-tl'ainees. 'he 77th Station H ospital (750 beds) was designate(I the operating unit for this new venter.

The stalf of the 77tIh Station Hospital was ordered to Rehalbilitaition Center

No. I (307th Station IHospitil) for indoctrination and orientation. Since

the entire uintit wvouild not be required to operate Reconditioning (Center No.

1, a, detachment of tile 77th Station IHospital, as mentioned earlier, was ordered

to operate Rehaliltation Center No. 2 for officers. The remaining unit personnel

of the 77th Station lHospital, having completed their training and indoctrination at Rehabilitation Center No. 1, moved to Erlestoke Park, and during

March 1944 began to operate Reeonditionit•g (Center No. 1.

The facilities of Reconditioning (ent er No. 1 at Erlestoke Park, however,

wvere limited, and this plant was needed for a general hospital. It was necessary

to procure an additional site. A militazry campsite was secured at Pauckington

Park. near Coventry. rhe advaun e party of the 77th Station IIos•pital nuoved

into this site on 5 .July.
FI I e1:17h.il.(it.t 4ion (' tr Nlro. 3. W ;Im i lig w ii :i paiit'nst 1 at'Jl!il "'11 the Saif-I1

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a C. N- ~ l. % l- ;iil
484 ACTIVITIES OF SURGICAL (CONSULTANTS

Rehabilitation Center No. 4.-lW tile latter pairt, of August 1944, tile

facilities of thle three reilahilitat loll Centers and the R'conldit ioning- Center

were about fil led, ii{ an .1 uit and( a site for anl add~itijonal venter were requleste'd.

The 31 It i St at ioni Hosp5ital was commit tedl to tlie mission. 'Fie stair, then

operat lug ai teiite(. ~iosp~itali at rruro, I evonlshire, wvas ordlered to Reliabilitat ionl Center No. I for itidoct rillat ioul. A site wl1s selected( at I lonlitonl-Ileat Iifieldl whicit would accouilio(ate some 2,300) trainlees and wh-1ich, with tentedI

exp~ansion, colil(1 handle ai total of p144))lat ients. OnI 13 September 1944,

tilie unit wvas activated as I~ehlabil itat ion ('enter No. 4 and began to( receive

co01nvalescent patients.

Conversion to convalescent centers.-As the. first rehabilitat ion andh

recoulItit jontinig ceniters l)eganl operations,. it was Ver~y app1arenlt that thle stanldard TI' O&E for a 754)-bed stationl hospital dlid not p~rovide for suflicient persomnel with appropriate. qualiticat ionls to op~erate a1 large rehlahilit at ion ceniter.

General I [awley. when thle difhcvultv was hrloughlt to hlis a1ttenition,. directed

thlat thle O perat ions D)ivision of his office make a study of tilie conversioni of thle

'1',,(&E of a 7654)-bed station hiospital to that appropriate for a1 3.000-bed

rehlabilitationl center anld the conversion of a 2,5t-hed station hosliutal to a

1,4)40-bed recoll(l it ion jug center. Colonel I i veley andI Coloniel St i uichfield

collaborated inl this study. With conctirrencves fromn the ETI( USA G -1 ( personnlel and adninlistrat ionl) and ('-,I ( operat ionis and1( trainling), Speial t1ae

of (list rilbut ion and allowances were create(] for 1.00(4-bed reconlditionling ceuiters and 3.000-bed re!iabilitat lon centers. These, tables were sent to the WVar

D)epartment, which, thle. auithor learnedi on 2:3 *June 1944, had approvedI th~eii

for pulilicat iont as r,/( )&E's for 1,000-bed and 3.000-bed convalescent centers.

Early inl Decemuber 1944, the 'War Departmient orderedi conversion of five

hospitals onl the thieater troop) list to conivalescenlt Centers inl aecordalane with

tihe new T/O&E's. This was accomplishied by converting four station hiosp~italls (7654) beds) to 3.000-bed conivalescent centers and1( one station hospital

to a conivalescenlt cenlter of 1.0004 beds. The convalescent centers tints act ivatedi

were dlesignatedl as follows:

BedI

Neiw do-signat ion Old designatiton eapflritII

925th Convalescent C'enter- 77th Station Hlospital (Reconditioning Cenlter No. 1) . W,00

926th Convalescent Center- 307th Station Hospital (Rehabilitation Center No. 1) 3.,700

S27th Convalescent Center-. 313th Station Hospital (Rehabilitation Center No. 3)~ 3.000

928th Convalescent Center- 314th Station Hospital (Rehabilitation Centvr No. 4)- 2. 300

93.3d Convalescent Camp--- 12.Ml Station Hospital (Rehabilitation Center No. 2)--. 400

Convalescent hospitals on the Continent,- Upon thle request of the Chief

Surgeon, the author proceeded to tile. Continient inl August 1944 to survey thle

requirements for recondtitioning anid rehlabilitation and1( to exalmilne tile Condluct

of the collvalescent, trailling prograin within smill stat iont and general hospitals

as wvere operating. This conisultalit recommnintded that. because of thle shiort.

evacuation plm itv ill effect oil tilie ( onit inent. it would he. imipract icable to

('onduclt. a full rehabil it ation prograiti thlere ait tihis t ille..
ORTHOPEDIC SURGERY AND) REHABILITATION 485

On 12 September 1944, upon request of the Chief Surgeon, the writer made

a second trip to the Continent. He inspected the 7th and 8th Convalescent

HIosp)itals, which were operating under the communications zone. After this

visit, he recommended that additional physical- and military-training personnel

be assigned for the more efficient operation of these units, if they were to continue

functioning as communications zone units. This recommendation was concurred in by the Chief Surgeon. Cadres were selected from among trainees at

the training school at Rehabilitation Center No. 1 and were sent to these units.

This consultant followed up these actions with frequent visits to the Continent

to survey and maintain contact with the 7th and 8th Convalescent Hospitals.

The 7th Convalescent Hospital was established at Ptampes and had facilities for handling approximately 1,700 convalescent patients. With the addition

of military- and physical-training personnel, it established a commendable

convalescent training program. The unit was handicapped by the added function of operating as a station hospital to care for personnel of the 19th Reinforcement Depot, which was adjacent.

The 8th Convalescent Hospital had its initial location at Barneville, on the

Channel, later moving to Valognes, near Cherbourg. The Valognes site was

not ideal and was capable of housing only -,sip 2,000 convalescent patients.

But., with the addition of a cadre of nii'" ry- a..,t physical-training personnel,

this unit operated a fair convalescent t. 'ng program.

Organization for supervision

Rehabilitation activities in the Office of the Chief Surgeon were begun on

the initiative of Colonel Diveley and incidental to his primary duties as Senior

Consultant in Orthopedic Surgery. On 25 February 1944, Colonel Diveley was

appointed Director of Rehabilitation in addition to his other duties as Senior

Consultant in Orthopedic Surgery, and Major Stewart, who had just reported

to the Office of the Chief Surgeon, was named as his assistant. As a result of

a special conference attended by General Hawley, Colonel Eyster of the G-3

Section, ETOUSA, and Colonel I)iveley, it was deenied advisal)le to have a

representative of the Chief Surgeon on the G-3 staff section in order to correlate

the rehabilitation program. This was accomplished by the appointment of

Maj. (later Lt. Col.) Milton S. Thompson, MC, to this duty on 15 February

1944.

As the rehabilitation work in the office increased, Capt. (later Maj.) Julian

A. Sterling, MC, from Rehabilitation Center No. 1, was assigned to duty as an

assistant. Several clerks, artists, secretaries, and a physical training instructor were also added to the staff. Capt. (later Maj.) Blaise P. Salatich, MC,

Medical Liaison Officer from Headquarters, U.S. Strategic Air Forces,

ETOUSA, to the Rehabilitation Division, Office of the Chief Surgeon, reported for duty on 18 April 1944.

On 3 June 1944, by Office Order No. 32, Office of the Chief Surgeon, the

Rehabilitation Division was formally established as an independent division
486 ACTIVITIES OF SURGICAL CONSULTANTS

within the Office of the Chief Surgeon. Colonel Diveley was appointed chief

of the division. The functions of the division were listed as follows:

1. To direct and conduct research in rehabilitation procedures.

2. To control rehabilitation technical operations.

3. To direct the training of personnel for implementation of the rehabilitation program.

4. To formulate policies on rehabilitation.

5. To consult on matters relating to the conservation of manpower. All

these functions had been inaugurated during the previous 6 months by Colonel

Diveley, the Director of Rehabilitation.

On 16 June 1944, a conference was held with members of the ETOUSA

G-1 and G-3 staffs and the Field Force Replacement System at which Col.

David E. Liston, MC, Deputy Chief Surgeon, ETOUSA, clarified the obligations of the Chief Surgeon in carrying out the program of rehabilitation in the

theater, as follows:

1. The Chief Surgeon would expand the convalescent training program

as the need arose and insofar as such expansion would not jeopardize availability of beds for hospitalization. Hospital personnel would in each instance

be supplemented by branch immaterial personnel to supervise military training

coincident with physical reconditioning. Such personnel would not be charged

to the Medical Department.

2. The Chief Surgeon would discharge patients to the Field Force Replacement System when conditioning had proceeded to that point where the

individual would not be physically harmed by normal physical exertion and

would be capable of returning to his former or new occupation after 2 or 3

weeks further hardening in the Field Force Replacement System.

By the latter part of June, base section surgeons had appointed rehabilitation officers to their staffs. Maj. William N. Brewer, MC, was appointed in the

Western Base Section, and 2d Lt. (later 1st Lt.) Robe-rt S. Rice, MAC, was

appointed in the Southern Base Section.

On 12 July 1944, the forward echelon of the Office of the Chief Surgeon

moved from the United Kingdom to the far shore. By decision of the Chief

Surgeon, the Rehabilitation Division remained in the United Kingdom and

was attached to the Office of the Surgeon, United Kingdom Base.

In August 1944, a request was made that a rehabilitation division be established in the Office of the Surgeon, United Kingdom Base. Major Brewer,

who had previously been the rehabilitation officer for Western Base Section,

was appointed chief of this subdivision of rehabilitation in the Office of the

Surgeon, United Kingdom Base. He selected a staff of officers and enlisted

assistants.

Later in 1944, Maj. (later Lt. Col.) Richard F. Kelsey, MC, a staff member

of Rehabilitation Center No. 2, was added to the staff of the Rehabilitation

Division, Office of the Chief Surgeon. Maj. H. Heim, Ord, was assigned to

duty with the Rehabilitation Division, Office of the Chief Surgeon, to coordi-
ORTHOPEDIC SURGERY AND REHABILITATION 487

nate the information and education work within the convalescent training

program.

In the latter part of December, word was received from the Office of the

Chief Surgeon, then at Paris, that the Rehabilitation Division would move

from its location with the Office of the Surgeon, United Kingdom Base, to

Paris. At that time, the Rehabilitation D)ivision, Office of the Chief Surgeon,

in addition to an artist-statistician and clerks, consisted of the following officers: Colonel l)iveley, chief of the Division; Colonel Thompson, Rehabilitation

Liaison Officer from the Office of the Chief Surgeon to the G-3 Section, Headquarters, ETOUSA; Major Sterling, assistant chief of the Division; Major

Kelsey, Consultant in Rehabilitation and Hospital and Convalescent Center

Inspector; Major Salatich, Rehabilitation Liaison Officer from Headquarters,

U.S. Strategic Air Forces, ETOUSA; and Major Heim, Coordinator for Information and Education Activities.

Similarly, in the Office of the Surgeon, United Kingdom Base, Major

Brewer, was Chief, Division of Rehabilitation; Capt. IIerzl M. Daskal, MC,

was Hospital Inspector and Consultant in Rehabilitation; and 1st Lt. Andrew

M. Gould, MAC, was Administrative Assistant.

Special programs

Convalescent training program in hospitals.-With the guidance of

experience in the European theater and instructions from the Office of The

Surgeon General in Washington, a general program of convalescent training

and education was initiated for each station and general hospital in the theater

(fig. 173). Much oe)position was evidenced by hospital staffs to the introduction of such a program. This was due for the most part to a lack of understand(ling on the part of professional men in the concepts of convalescent

rehabiilitation. The program at the rehabilitation centers progressed most

satisfactorily, but the program within the station and general hospitals was

very sluggish, and little interest was evidenced. It became necessary to uidertake special indoctrination and training activities to encourage more activp

convalescent training programs in hospitals (pp. 492-494).

A constant check was maintained on the convalescent program in hospital

units. Two or three representatives of the Rehabilitation Division continuously inspected the programs and gave indoctrination lectures. Ward

surgeons were made aware of their responsibilities in the conservation of

manpower through an adequate convalescent program and through the proper

reclassification of sick-and-wounded military personnel to duty.

Reclassification.-Considerable difficulty was evidenced in both rehabilitation centers and hospitals in the proper reclassification of personnel being

returned to duty. Through the efforts of the Rehabilitation Division and the

Ground Force Replacement System (formerly the Field Force Replacement

System), classification teams were selected and trained. These teams were

placed in special hospitals, hospital centers, and rehabilitation centers to orient

personnel in the proper reclassification of sick-and-wounded personnel.
VS I I I

-----
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494 ACTIVITIES OF SURGICAL CONSULTANTS

12 October 1944, a conference was held at the 160th General Hospital for all

rehabilitation officers from hosl)itals iII the Western and Eastern Base Sections. The meetings were attended also by representatives from staging hospitals. These conferences provided an excellent medium for interchange of

ideas, indoctrination, and the demonstration of a model convalescent training

program.

Training films.-During the summer of 1943, a documentary motion

picture film was produced in sound and color depicting the program and activities of a rehabilitation center. The author took this documentary film to

the Zone of Interior, and, after a showing to The Surgeon General, and following his request, the film was screened for various hospital units throughout

the country with accompanying indoctrination lectures. This tour covered a

3-month period, which gave ample time for all to study the reconditioning

program that had been activated at Broxnsgrove. A model convalescent rehabilitation unit, based on experiences in the European theater, was set up by

this consultant at England General Hospital in Atlantic City, N.J.

By the end of August 1944, two additional motion picture films on activities of the program had been completed and distribution had been started.

One, an orientation film, titled "The Convalescent Training Program," was

shown to the staffs of all hospitals. The other, titled "Physical Training Instructors," was used in the Physical Training Instructors' School at Rehabilitation Center No. 1, for indoctrination and training.

On 24 August 1944, a group of visual aid coordinators arrived and were

immediately oriented in the conduct of the rehabilitation program. Their

mission was to establish film libraries, to screen films, to repair projection

apparatus, and to give other assistance to the conduct of the convalescent training program throughout the theater.

Supplies and equipment

In anticipation of an expanded program in the theater, sufficient gymnastic supplies, remedial apparatus, training films, and other training aids

were requisitioned and secured early in the program. Supplies, special equipment, and training aids for use in the convalescent training program in hospitals were secured for each hospital and distributed. Also, in May 1944,

through arrangements with Special Services, additional stocks of athletic,

recreational, and educational equipment were set aside for requisition and use

within the convalescent training program. Through special arrangements

with the Army Pictorial Service, 16 mm. motion picture and 35 mm. filmstrip

projectors were obtained for the rehabilitation program. The Rehabilitation

Division placed and d 'tributed the projectors. The limited supply of remedial apparatus and gymnastic equipment that had been obtained was exhausted. Requirements were computed for the ensuing 12 months, and

sufficient apparatus was secured through the General Procurement Authority
ORTHOPEDIC SURGERY AND REHABILITATION 495

from Spencer, Heath and George, Ltd., Enfield, England, to meet immediate

needs. Close liaison was maintained with the American Red Cross, which

was responsible for many of the recreational and diversional activities. The

latter organization was most cooperative at all times and provided personnel

and supplies to the centers and hospitals unstintingly.

Maximum use was made of improvised aids to physical rehabilitation

in which both construction (or fabrication) and use provided a means for

augmented physical reconditioning. Such apparatus included shoulder wheels,

knee pulleys, finger grips, and steps.

Statistics

December 1943.--At the end of the year 1943, Rehabilitation Center No. 1

had been in operation for 9 months, since April, at its two locations, Bromsgrove and Stoneleigh. During this period, there were 3,089 admissions and

1,808 dispositions. Of the dispositions, 83 percent were discharged back to

duty and 17 percent were sent back to hospitals for further treatment. The

caseload was divided approximately into: Orthopedic, 80 percent; general

surgery, 10 percent; and medicine, 10 percent.

On 31 December 1944, approximately 31,500 beds were available for convalescent patients in the European theater. In addition to the 12,400 beds

in the convalescent facilities in the United Kingdom, general and station hospitals had set aside areas for the use of 11,500 convalescent patients. Nine station hospitals had been completely set aside to handle approximately 3,600

convalescent patients. The 7th Convalescent Hospital at Iktampes, Seine Base

Section, France, and the 8th Convalescent Hospital at Valognes, Normandy

Base Section, France, were each rated at 2,000 beds for a combined total of

4,000 beds on the Continent.

Convalescent trainees actually in the five centers in the United Kingdom

and two convalescent hospitals on the Continent totaled 13,600 at the end of

1944. The total number of convalescent patients discharged from all rehabilitation and reconditioning centers in the United Kingdom from 7 April 1943

through 31 December 1944 was 34,761. Of these, 88.0 percent had been returned

to duty in the European theater (chart. 3). Among the aforementioned 34,761

patients discharged in the United Kingdom during this period, there were

14,247 battle casualties, 82.7 percent of whom were returned to duty in the

theater (chart 4). Overall dispositions from all convalescent facilities (five

in the United Kingdom and two on the Continent) during the period from April

1943 through December 1944 totaled 40,440, of whom 86.5 percent had been

returned to duty in the European theater. A greater number of days was

required for rehabilitation than for reconditioning; rehabilitation required an

average of 49 days per patient, and reconditioning, an average of 39 days. A

total of 1,637 officer patients had been discharged from the 833d Convalescent

Center during the period, of which 78.7 percent were returned to duty in the

European theater (chart 5).
496 ACTIV1T11S 01' SUR(;CAI. CONSULTANTS

CHAHkRT 3.-lDipo.xitiomn of .;;.7f;l eonral- Ciukwr 4.-Disposition of 14J.2-;7 battle

escen t pati en ts disch~iarged from all rek a- casmin t ics di.seciarqed from all relia bilitabilitation. and rceonvlitioning eenttrr8 in I/ic tion. anid iieoiditioning centcrx in the

Vnited K'ingdonm during thme period 7, April United Kin qdoni dnrinq the period 7, April

1943-31l D)eeembcr 194ý4 19.43-31 D~eeniber 1944.

(60. percent)

83cetY (60 pecnt)l~n ap(ffcs iim

tiX(3 JI 2i peode7 lpr:l:I::3'31 N ETOU1

TO GENERA .... . ........ . . . . .

JO L IM IT
ORTHOPEI)IC SURIGERY ANI) REHABILITATIO N 497

Activities Centered on the Continent, 1945

During final operations

On 8 January 1945, the Rehabilitation Division, Office of the Chief Surgeon, moved from London to Paris, leaving all adequate and competent staff

with the Office of the Surgeon, United Kingdom Base, London, and established

its officers at 127 Champs Alys(es. On 9 January, two veterans of World War

11 who had suffered limb amputations and who had been fitted with prosthetic

appliances at Walter Reed General Hospital reported for duty with the Rehabilitation Division. These veterans visited hospitals in the theater to meet

personnel who had lost limbs and to indoctrinate them as to their expected

normalcy in future activities. The two veterans were great morale builders

to these unfortunate patients.

During ,January, the hospitals of the European theater were operating

at fullest capacity due to the large numbers of battle casualties. This naturally

curtailed rehabilitation activities in hospitals but made for more efficient early

transfer of patients to the rehabilitation and convalescent centers. Particularly efficient convalescent reconditioning was being accomplished at the 7th

and Sth (Convalescent lHospitals op)erating in the communications zone on the

Continent. The economy of centralized convalescent care was never more

strikingly emphasized than during this critical phase of military operations

in the European theater.

Two officers were assigned to the Rehabilitation Division from the Special

Services and Information Services of the theater to coordinate the procurement of supplies and to advise in educational reconditioning. Arrangements

were made with the cinema branch of Special Services for the distribution of

recreational movies to hospitals and with the library section of Special Services

for the acquisition of additional books and magazines for the use of the convalescent patients.

Additional rehabilitation personnel were being trained at the school conducted by the 826th Convalescent Center in the United Kingdom. These personnel were greatly needed in the hospital programs. In early February, an

allotment of 150 officers and 400 enlisted men was made available for training

in the rehabilitation program and for subsequent assignment to hospitals and

convalescent centers.

During this period, a 30-day evacuation policy was operating on the

Continent; therefore, the conduct of a convalescent program was not universally

required. With the 60-day evacuation policy, beginning late in February, the

program of convalescent training was reinstituted within the hospitals in

France and Belgium. On 21 February 1945, at a special conference of hospital center commanders and base surgeons, plans for convalescent rehabilitation on the Continent were outlined. Tentatively, a convalescent facility was

to be established within each hospital center. It was also announced at this
498 ACTIVITIES OF SURGICAL CONSULTANTS

conference that trained rehabilitation personnel would be assigned to each hospital. Iater, conferences were held with surgeons of base sections and with

the commanding officers of hospital centers to assist in the reorganization of

the convalescent training program on tihe Continent. A series of lectures

was given by members of the Rehabilitation Division to the personnel of all

the hospitals.

Frequent indoetrination visits were being made to the convalesAeent hospitals within the field armies. The purpose of these trips was to recommend

methods of improving the program of convalescent activities for patients retained in the army area. It was difficult, however, to activate definite programs

due to the rapid advances being made. It was noted, however, that patients

in army convalescent hospitals had little or no problem of physical or morale

reconditioning and that patients were anxious to return to their units as soon as

possible.

On 25 February, Colonel Stinchfield was appointed supervisor of convalescent rehabilitation in the United Kingdom, in addition to his other duties. He

retained command of the 826th Convalescent Center.

In March, Colonel Thompson was relieved of his liaison duties with the

G-3 Section, Headquarters, ETOUSA, and assigned to the Rehabilitation Division, Office of the Chief Surgeon.

A continuing search was being made throughout this period for suitable

sites for convalescent rehabilitation facilities in France and Belgium. The Rehabilitation Division, in coordination with the Supply, Operations, Hospitalization, and Personnel Divisions, Office of the Chief Surgeon, completed plans

for the activation of six convalescent centers on the Continent. Selected locations and bed capacities were as follows:

Number

Area of beds

Mourmelon ----------- -------------------- 3.000

Toul-Nancy-Verdun ------------------------------- 3,000

Paris ------------------------------------------- 3,000

Namur ---------------------------------- 3.000

Ii-ge-Aaehen ------------------------------ 3,000

Suippes-Soissons --------------------------- 3. 000

Plans were also made to move the 828th Convalescent Center and several

selected station hospital units from the United Kingdom to the Continent.

Selected personnel from various rehabilitation units in the United Kingdom

were ordered to thie Continent for use in the activation of new units.

Since there were no true rehabilitation centers functioning on the Continent, and since, after 1 April 1945, patients were transferred to the Zone of Interior when they required more than 60 days of hospitalization, the burden for

convalescent management was placed on each hospital (fig. 178). Medical

officers if) busy hospitals were. not too favorably disposed toward their part in

the program unless they had a clear concept of the relationship of rehabilitation and reconditioning to the princip1 2es and practice of scientific medicine.
1 41.1

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500 ACTIVITIES OF' SURGICAL CONSULTANTS

As of the end of *Julne 1945, tile 1Rehiabilitation D)ivision consisted of 10

officers, 2 stenographers, and 2 clerks. l)uring tile period from I)ecember 1944

through June 1945, 138 officers and 585 enlisted men had been trained as rehabilitation training personnel. The convalescent centers had discontinued

operations and had disposed of all patients as of 6 June 1945. In the United

Kingdom, convalescent centers were in staging areas preparatory to movement to the Zone of Interior. Supplies and lpersonnel were being prepared to

maintain a convalescent facility in occupied Europe (U.S. Military Zone)

when required. The 7th and 8th Convalescent Hospitals had been recalled to

the armies. A convalescent training program was being conducted in all operating general and station hospitals. The activities for the convalescent patient were adapted to the local situation and the patient's requirements.

Statistics

Dispositions for the period from January through June 1945 indicate that

35,597 patients were discharged from the convalescent centers in the United

Kingdom. Of the 28,846 patients returned to duty, 55 percent were returned

to general assignment and 27 percent to limited assignment. During the total

period of operations of convalescent centers from April 194:1 through Juime

1945. there were 70,358 dispositions reported, of whom 84.5 percent were returned to duty after an average total period of hospitalization and convalescence of 95.7 days (table 2).

TABfE 2.-A-rverage duration of hospilalizalion and convalescence, during period from April

194.3 through June 19m45, of trainees rcturned to duty front convalescent centers

Average number Average number of Average number of

Category of trainee of days in (lays in convalescent (lays of hospitalization hospital center and convalescence

Battle casualties --------------------- 57.2 50. 9 108. 1

Disease and nonbattle injuries -------- 44. 7 36. 9 81.6

Aggregate -------------------- 51.0 44. 7 95. 7

The general and station hospitals in the United Kingdom, for the first, 4

months of 1945, reported that 259,834 patients were discharged, of whom

197,846 were ultimate dispositions. Of the latter, 29 percent, were returned

to general Iduty, 17.5 lpercent were sent. to limited assignments, and 53.5 percent

were transferred to the Zone of Interior. D)uring the first 4 months of 1945,

these hospitals transferred for advanced rehabilitation in their convalescent

sections 63,269 patients, of which 49,949 were ultimate dispositions. Of these,

53.8 percent were returned to general duty, 39.2 percent were given limited assignments, and 7 percent were transferred to the Zone of Interior. The average

duration of stay for a convalescent patient admitted to the convalescent section

in these general and station hospitals was 46.1 (lays in the hospital and 18.5

days in the convalescent section for a total of 64.6 days.
ORTHOPEDIC SURGERY AND REHABILITATION 501

Summary

Tire convalescent activities p)rograin in tlie European theater was conducted

most successfully during World War I with adherence to the following principles which were developed early in the program.

1. Each convalescent patient was graded periodically by his medical officer upon the basis of objective as well as subjective findings. The patient's

activities were prescribed in accordance with his rate of recovery and his military occupational specialty. The activities program was adapted to local requirements and was generally proportioned among physical and military reconditioning and recreational diversion.

2. The entire program was based on the fact that the mission of the Medical

D)epartment was the conservation of manpower and the preservation of the

fighting strength of the military forces. This was accomplished by furnishing

those who had become disabled with such hospitalization facilities as would

speedily restore them to health and finally to fighting efficiency. It was not

enough that the patient be cured of his disease, or that his wounds be healed,

but it was necessary that treatment cover the entire period from the time lie

became a casualty until lie was p)hysically and mentally nornial and could return to take his former place in his unit. Specifically, the rehabilitation program covered that phase from the time lie became a convalescent patient and

could leave the hospital until lie had coml)letely recovered and colild return to

his unit.

3. The rehabilitation center was a military unit that prepared convalescent

military personnel for further military service or for discharge to useful civil

life. The scope of a rehabilitation center included the acceptance of the patient

from the hospital as soon as possible after lie had reached the convalescent

stage. He was then treated with specific physical therapy or remedial exercises, as well as general reconditioning and hardening exercises, which cut the

period of convalescent days to a minimum and prepared the soldier to return to

duty in a strong, able physical condition. The rehabilitation (center had as its

aim mental as well as physical rehabilitation. With these goals achieved, the

soldier, when discharged to duty, had not only the physical ability to carry on

his task, but also the proper mental attitude to carry the task to completion.

The reconditioning center had none of the hospital atmosphere. Mental

and physical deterioration occurred while the soldier was in the hospital, and

the longer lie was hospitalized, the more permanent this deterioration became.

He was, therefore, removed as soon as possible from the hospital to an atmosphere of appropriate military and p)hysical training.

IREx L. DIVELEY, MI.D.
CHAPTER VII

Otolaryngology'

Norton Canfield, M.D.

Otolaryngology in the Office of The Surgeon General at the beginning of

the war was a division of general surgery, and so it remained both in the Office

of The Surgeon General and in most military hospitals, except in a few where

the administration wisely saw fit to make it a separate service. Where there

was a separate otolaryngology service, the specialty made its greatest progress

because the service was usually under the direction of professional talent which

was also responsible for separate services in the civilian teaching hospitals

associated with large medical centers. In a rapidly expanding medical service,

such as the Army was obliged to manage from 1941 to 1945, the administrative

wisdom of surgical specialties' being professionally responsible to the chief of

general surgery wits undeniable in many instances. But the inflexibility of

this policy as interpreted by some commanding officers led to patient care

which was often unfortunate. So rapid and frequent was the shifting of personnel in many medical units that a set professional "chain of command" was

deemed of major importance. Indoctrination of newly commissioned medical

officers was, however, often insufficient to make Army policies for the administrition of professional services completely acceptable to many civil ian-trained

specialists during their military service.

THE CHIEF SURGEON

In mid-1942 the European Theater of Operations, U.S. Army, was expanding, and the medical service was under the direction of the theater Chief

Surgeon, Col. (ltter Maj. Gen.) Paul R. HIawley, MC, whose military career

had been of long standing. His preliminary close association with the British

which was so manifestly the result of his professional knowledge, human understanding, and military acumen, coul)led wvith his absolute respect for professional integrity wherever it appeared, made him a superb "chief" in every

respect. In addition to his excellent, but unlderstandably not perfect, ability

to select men for important posts and his willinglness to replace officers who

did not meet his expectations, General Hawley was so often correct in his decisions that even the professional consulting staff was hard put to it to substantiate recommendations when they ran counter to his ideas.

I For amplification of matters briefly reviewed in this chapter, see: Medical Department. United

States Army. Surgery in World War II. Ophthalmology anti Otolaryngology. Washington U.S.

Government Printing Office, 1957.

503
504 ACTIVITIES OF SURGICAL CONSULTANTS

Those consultants who were on (luty in the Office of the Chief Surgeon,

ETOUSA (European Theater of Operations, U.S. Army), for the p)eriod

1942-45 can never forget the "battle of the anesthetists" under the amazing leadership of Col. Ralph M. Tovell, MC. Colonel Tovell's strategy was based on

solid professional polices and execution and was so keen that it took General

H-awley by s'irprise, which he did not fancy. The general took special pains

to make his displeasure emphatically obvious. The outcome, however, under

the guidance of Colonel Tovell was so beneficial to the troops who needed

p)rofessional medical care that the Chief Surgeon, in the presence of his professional advisers and his administrative sta ff, accepted completely Colonel

Tovell's magnificent work, thereby demonstrating his stature (p. 300). General

Hawley did this in a manner which was worthy of the finest of human

character, and he let it be known that he was mistaken in his previous emlphatic

opp)osition to policies which eventually made anesthesia one of the great services

during the war. This was but an example of the many instances in which

he acceded to the high-grade professional advice from the men whom he preferred to have associated with him.

ACTIVITIES AND OBSERVATIONS

Appointment of Consultant in Otolaryngology, ETOUSA.--In mid1942, Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in Surgery. ETOUSA, initiated a request to The Surgeon Greneral for an otolaryngologic consultant for the European theater. The Surgeon General responded

l)y requesting Dr. Lyman Richards of Boston and, later, Dr. Albert C. Furstenberg of Ann Arbor, neither of whom, because of their important civilian posts,

could accel)t the position. By the gracious recommendation of Dr. Furstenberg,

the post was offered to Dr. Norton Canfield (fig. 179). At that time, I)r.

Canfield was a full-time head of the Division of Otolaryngology, Yale University School of Medicine. Earlier, he had been designated as essential for

meldical school teaching, but, when this position became available, the dean of

the Medical School, Dr. Francis G. Blake, agreed to remove his name from

the essential list. Thus, on 28 November 1942, the author entered the Army

as a lieutenant colonel and was placed on temporary duty in Washington in

the Office of The Surgeon General to prepare for his duties in the European

theater.

At that time Col. (later Brig. Gen.) Fred W. Rankin, MC. was Chief

Consultant in Surgery to The Surgeon General. Colonel Rankin outlined the

functions that the otolaryngologic consultant in the European theater might be

called upon to carry out. Arrangements were then made for the author's

prompt transport to England. Within one week of landing in England in

January 1943, he reported to the Chief Surgeon and was assigned as Senior

Consultant, in Otolaryngology, Office of the Chief Surgeon, ETOUSA. The

author held this position from then until his return to the United States in 1945,
OTOLARYNGOLIAG Y 51}5

after V-.J )ay. Before this consultants aririval in the European theater, duties

of tile otolnh'yigologic consultant were perfornied Iby Maj. (later It. (ol.)

Frank I). Lathrop, M(N, fornierly associated withi tile Lalhey (hiii"ic il Boston,

and by Capt. (later Maj.) Edniond P. Fowler, Jr., MC, Chief, Otolaryngological Section, 2d General Hospital, then at Oxford, England. The preliliinary

work of these t wo officers was of great assistanice, esplecially in the l)rocurelent

of special surgical instruments from British sour,'es during the early part of

1943.

Chief Consultant in Surgery.--Under the wise counsel and able advice

of Elliott (Cutler, the otolarvngohogic coonsultant d(iring his entire tour of duty

was given full] professional authority. As he looks back upon the experience,

FIGcURE 179.-Col. Norton Canfield, MC.

it would be lard for this consultant. to believe that any superior could have

been more thoughtful and helpful in the execution of his duties. General

Cutler's experience in World War I as a medical officer with combat forces

admirably fitted him for the much more important post which he held as Chief

Consultant. in Surgery for the European theater in World War II. His military

knowledge, high professional integrity, consummate geniality, and untiring

efforts were largely responsible for the success in the handling of surgical problems in the European theater.

Associations with British.--Immediately upon the assumption of his

position in England, the author was placed in touch with the British authorities

in his specialty. His association throughout the rest of the time in Europe with

Brigadier Myles L. Formby, RAMC, was entirely satisfactory. Not only were

many professional ideas exchanged, but the actual surgical care of members of

both armies was at all times a matter of closest cooperation. One of the most

pleasant and beneficial associations of the specialty officers in Europe during

the period 1943-15 was the association with both British military and civilian
506 ACTIVITIES OF SURGICAL CONSULTANTS

specialists. The meetings of the Royal Society of Medicine in London were

open to all medical officers of the U.S. Army, and it was the pleasant duty of the

Senior Consultant in Otolaryngology to arrange for specialists in the theater

to attend these meetings. On their own initiative, U.S. Army otolaryngologists

attended meetings, both Army and civilian, at British installations near their

own stations.

Administrative considerations.-It was the policy in the European

theater not to train otolarygologists, although there were available men capable of conducting such training in several of the large general hospitals. As the

theater expanded, no one consultant could cover all of the hospitals; consequently, a system of regional consultants was initiated by General Hawley.

The outstanding men in any one locality were assigned as regional consultants

with orders to travel, if necessary, to nearby hospitals for consultation on

individual difficult cases. The transfer of patients from one hospital to another

was permitted under certain circumstances, always with the idea that the

injured or sick soldier would receive the best possible professional care. It was

the express policy of General Hawley that the administrative side of military

medicine justified itself only when it could make the best possible professional

care available to the sick and wounded (p. 349). Military considerations sometimes seemed to make this policy ineffective, but it never assumed this flavor by

any design of the Chief Surgeon whose professional qualifications were of an

exceedingly high order.

Relations with Army Air Forces.-The Army Air Forces in Europe had

their own unit medical service to which no otolaryngologic consultant was assigned during the war. At the operational airfields, much of the meW-" 1 support found to be necessary for the pilots and aircrews was in the field,. I

yngology, and a number of qualified otolaryngologists were assigned to the

various airl)ases. The U.S. Army hospitals in the area of East Anglia, where

Army Air Forces activities were the greatest, provided most of the medical service for the Army Air Forces, and capable otolaryngologists were always assigned to these hospitals. Before D-day, battle casualties were confined largely

to bomber crews flying between East Anglia and the European mainland. These

casualties were given preliminary medical attention at airfields and were then

quickly transferred to Services of Supply hospitals for definitive care. Much

credit is due Captain Fowler for his initiation in the theater of special attention

to aero-otitis and for his direction of the subsequent care given to aircrews by

otolaryngologists assigned to those medical units which directly supported

the Air Forces. The Senior Consultant in Otolaryngology and other highly

qualified specialists were active in medical training courses given at Eighth

Air Force headquarters for flight surgeons assigned to individual airfields.

Manual of Therapy.-The training of otolaryngologists before their

Army service had been largely directed toward providing definitive care to

an individual needing medical attention. In a theater of operations, however,
it w.,7,i~ tked 'I V, lm-sIll' fbr I 1we originial l fii1s iliial care. lif1lt w , te iitl wh~ichii .11 I ~ )c~ ý'v*lv -i*~'i:1111w. 44)11ailto N l io 4 lie. I '.w il

Otolaryngollogic service prior to D)-day. Iiili lZIlie I'iv ()wI'i Ille 1 (41Hp

( Im~ il 1: k el! I*(I.iH D-deI v. ill ±.~lleg"loli . sevIui~-v i It i f Pl lie I vnrml' .jiiitplV Iii was

hotawl hl 1()i 111:1 V~41 hrelde Wied ( :IllY 141IrY lie ail viiovwiii I heal 1 I'M~II) Ii,.r 1iai,SO

0ile plee l-. ' cluill Pe4I riet thil \-(.~i I .yel il It) :x ~ l hu ics I l i 111 t rie 114'tl 11 144eliOtollaryngologic service after D-day.-Al~i er1-d ay. f liet, imiure ()I pro

'.ZI'(1)i Ilthie-.este: li-I, '~rt atlpieIS iky ftre D1)-i iv. 'I'liere111 (ter.. llowevr.Ili-I i :lil I vitles wene til rectied towaird IIlie wmilhhidet 1;1 thliru Specat~ui . .1nti,

ill '.reiuerni. Illev wen. wvell foriil4 tti le mihi~lU1hiI oft tiistiaitles as ill(.\

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OTOLARYNGOLOGY 509

than 2 years of duty, it was necessary to assign many of them to duty in the

Pacific. V-J Day, however, came so soon after V-E Day that much of this

work was fortunately found to be unnecessary, and most of the specialists from

the European theater were returned directly to the United States.

REASSIGNMENT IN THE UNITED STATES

Following the duty in Europe, this author was assigned as Consultant

in Otolaryngology to The Surgeon General at his offices in Washington, D.C.

Upon his return, he found Maj. (later Lt. Col.) Leslie E. Morrissett, MC,

who had so ably directed the program for hearing rehabilitation centers in

the Zone of Interior. After the war, prompt demobilization was a source

of satisfaction to many of the specialists, but there was much more work to be

done in the Office of The Surgeon General. The author remained on active

duty until May 1946 attending co adrainistrative matters and collecting data

for the history of the Medical Department of the U.S. Army in World War

II. His recommendations for tne initiation of several clinical research projects which might have been carried out by officers remaining on duty were

not acted upon by The Surgeon General, although it would have been possible

to arrange for a very excellent facial nerve surgery service under the direction

of Colonel Lathrop at Cushing General Hospital, Framingham, Mass. In

addition, this consultant inspected the three aural rehabilitation centers and

found them to be of the highest possible order. These centers were gradually

closed, but The Surgeon General saw the wisdom of this extraordinarily fine

program and established a permanent aural rehabilitation center at the Forest

Glen Section of Walter Reed General Hospital, Forest Glen, Md. This involved a construction program in an old building, but a permanent hearing

and speech center with a highly qualified staff was established. So effective

was the program for aural rehabilitation that later the Veterans' Administration, also under the leadership of General Hawley, established a program

for those servicemen who were discharged and were found to have serviceconnected hearing impairment. That story is still being written and will constitute one of the brightest spots in the annals of military and Veterans'

Administration medicine.

SUMMARY

In looking back on his experiences as Senior Consultant in Otolaryngology

in the European theater during World War II, this author is convinced that,

if knowledge and experience in any way can be carried forward into future

years, much grief will be prevented.

One of the civilian medical profession's main objections to military medicine

is the fact that professional ability does not necessarily lead to a commensurate

advance in military rank. The history of this problem in the U.S. Army was

reviewed on several occasions by General Hawley, and he, at various times,

admitted that a solution was difficult to find (pp. 336-338).
510 ACTIVITIES OF SURGICAL CONSULTANTS

It is the belief of this writer, whose experience can be said to have been

extremely gratifying from his standpoint, that a small corps of well-trained

otolaryngologists with every oplortunity for professional advancement as well

as adlvancetnent in military rank should be the solid policy of The Surgeon

General during peawetinie.

The consultants' program fully justified the high importance placed upon

it during World War II, and the civilian organization which existed following

the war, namely the Association of Medical Consultants of World War II

(later The Society of Medical Consultants to The Armed Forces), attested to

this fact.
CHAPTER VIII

Plastic Surgery

Eugene M. Bricker, M.D.

INTRODUCTION

In a description of the activities of a surgical specialty consultant in a

theater of operations, the subject divides naturally into two main headings:

Administrative and professional. While, in fact, the functions of administration and professional care were inseparably related, they were so completely

different in nature that it appears justifiable to separate them in this account

for purposes of clarity. Two admissions are readily made: (1) The history

will be biased in that the author is convinced of the importance of plastic

surgery in a theater of operations if the best care is to be available to all

casualties; (2) any suggestions concerning the organization and use of personnel are made with an operation such as that in the European theater in mind,

and with the realization that a future war may be entirely different.

At the beginning of World War II, plastic surgery could still be considered

as a relatively new specialty. It was adolescent during World War I, when

it was practiced by few surgeons who approached it from various other fields

of p)rimary interest, including dentistry, otorhinolaryngology, and general surgery. Following World War I, plastic surgery grew to maturity, as a welldefined specialty, in very few clinics throughout the country. Its function in

a theater of operations was incompletely realized at the outbreak of World War

II, though the need for adequate coverage in plastic surgery was recognized

by Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA (European Theater

of Operations, UI.S. Army), and a full-time consultant in this specialty was

present in the theater throughout the campaign. It could be said that the

specialty, as applicable to a theater of operations, approached full maturity

during the war in Europe.

In the development of the Professional Services D)ivision, Office of the

Chief Surgeon, ETOUSA, a consultant in plastic surgery was one of the first

to be named. The value of adequate organization of this specialty had been

impressed upon members of the U.S. Armed Forces in the British Isles by the

great number of casualties resulting from the Battle of Britain that required

reconstructive plastic surgery. Lt. Col. (later Col.) ,James B. Brown, MC

(fig.182), arrived in England on 2 July 1942 in response to a specific request

for a plastic surgery consultant. Colonel Brown was accompanied by Lt. Col.

Eugene M. Bricker, MC (fig. 183), who succeeded him as Senior Consultant in

511
512 ACTIVITIES OF SURGICAL CONSULTANTS

Plastic Surgery, ETOUSA, on 12 June 1943, after Colonel Brown had returned

to the Zone of Interior to organize and direct a plastic surgery center at Valley

Forge General Hospital, Phoenixville, Pa. Throughout the entire campaign

until the dissolution of the Professional Services Division of the Chief Surgeon's Office in July 1945, the author worked in close cooperation with the consultants in the other surgical specialties. The work of the Senior Consultant

in Plastic Surgery was closely associated with that of Col. Roy A. Stout, DC,

Senior Consultant in Maxillofacial Surgery of the Dental Corps (fig. 184).

This relationship was maintained on a completely cooperative basis, the function of the two specialties being determined by the fundamental consideration

of surgical training and experience.

FIGURE 182.--Lt. Col. James It. Brown, MC.

ADMINISTRATION

The administrative duties of all consultants were concerned with the provision of a high standard of professional care for casualties at all echelons.

This responsibility became intimately involved with tables of organization,

tables of supply, professional qualifications of personnel, evacuation of casualties, and the establishment of professional policies. At the time of this writing,

and for the purpose at hand, it seems best to cover the subjects briefly and in

a general way as they concern the specialty of plastic surgery. The consultant

found himself continually traveling from hospital center to hospital center and

from hospital to hospital out of headquarters based successively in London,

Cheltenham, Normandy, and Paris. This was a remarkable experience for

a consultant out of civilian life. The enormity of the buildup in England for

the invasion of Normandy will probably never be equaled in the future. Indeed, if future wars are to occur, it is doubtful that such an enormous land
PLASTIC SITRGERY 513

force poised for invasion will be necessary. The magnitude of tile Channel

crossing and the problems ipresnted in caring for and evacuating the wounded were unique in the annals of military medicine.

Tables of Organization

At the termination of the conflict, it, was believed that the tables of organization should be brought abreast of the recent, advances in the development of

surgical specialties. and that t hey shohl l)artic'ularly allow for the possible

FIGURE 183.-Lt. Col. Eugene M. Bricker, MC.

limitation of the number of qualified specialists. There was a constant conflict throughout the campaign between the location of plastic surgeons according to the tables of organization and the actual location of plastic surgeons in

line with logical developments based on need. Thus, as a result of the size

of this operation and the number of hospital units involved, it was never practical or possible to supply each 750-bed and 400-bed evacuation hospital with

a qualified plastic surgeon as required by the tables of organization. The placing of plastic surgeons on field army unit tables of organization was founded

on the principle that a very important period for surgery of maxillofacial

wounds is early after injury. The progress of the campaign proved this con-
514 ACTIVITIES OF SURGICAL CONSULTANTS

cept to be correct, but the planning that called for an impossibly large number

of plastic surgeons to be in army areas was in error.

Plastic surgery in a theater of operations plays its major role at two levels:

(1) At the evacuation hospital level in army areas where definitive therapy is

required for compound facial injuries, and (2) in the general hospitals of the

communications zone where later definitive therapy can be given to massive

soft-tissue wounds, burns, and definitive therapy can be continued for maxillofacial wounds. The placement of plastic surgeons in the communications zone

general hospitals was accomiplished without table of organization provision for

them. This difficulty was not insurmountable, and it was one of the responsiFIGURE, 184.-Col. Roy A. Stout. DC.

bilities of the consultant to overcome it. However, the l)roblem seemed to be

of some magnitude at the time, both to the consultant, who was trying to manipulate hospitals and personnel, and to the personnel being manipulated into tables

of organization with no provision for them. The simple human characteristic

of desiring earned advance in rank was frequently thwarted as a result of these

administrative difficulties. It is recognized that some of these difficulties were

unique to the specialty which was still developing and the role of which in a

theater of operations was still not clearly understood.

Personnel

As the preceding discussion suggests, the problems of personnel were chiefly

precipitated by the tables of organization. I)uring the 2-year p)reparation for

the invasion of France, the need for qualified plastic surgeons to care for the

injuries occurring among thousands of staging and training troops was repeat-
PLASTIC SURGERY 515

edly demonstrated. During part of this period, there were only two plastic

surgeons in England who could be designated as qualified for the care of complicated cases. The situation was relieved in the latter part of 1943 by the

arrival of several plastic surgeons with incoming general hosl)itals and by the

return of army units from North Africa. D)uring this long period before

D-day, active combat was being carried on l)y the Eighth Air Force in East

Anglia. The Eighth Air Force was served by a group of station hospitals,

into certain ones of which specialist l)ersonnel were placed. The whole experience of providing specialist care for tremendous numbers of staging troops,

and for an active air force based in the comnmnunications zone, demonstrated

again and again the urgent need for highly qualified surgeons in all the sp)ecialties. In the specialties in which there was a shortage of qualified surgeons, it

became imperative that those who were qualified be placed in such a position

that they could cover a geographical area, and not have their activities confined

entirely to the unit in which they were assigned.

At the end of the war, there were present in the theater 70 medical officers

with the MOS (military occupational sl)ecialty) classification of Specialist in

Plastic Surgery. As 9 of the 70 were in administrative or other types of positions, it was impossible to use them in active clinical work in plastic surgery.

Of the remaining 61 surgeons, 24 had a "I)" classification; the majority of the

24 were general surgeons or specialists in some other branch of surgery. A

much more accurate alppreciation of the supl)l- of l)lastic surgeons in the theater

than is afforded by a survey of the 70 so listed can be obtained by realization

of the fact that only 15 of the 70 were classified as "B" or al)ove, and only 8

of the 15 were available for use in clinical plastic surgery. The total number

of plastic surgeons available for clinical use with classifications of -"` or above

was only 27. It seemed obvious that the place for the more experienced plastic

surgeons was in the hospitals located to the rear where a large number of

patients could be funneled to them, where the holding pleri(ol was longer, and

where they would have an opportunity to cover a broader field of surgery than

was possible in the forward units. Accordingly, insofar as possible, the more

capable surgeons were retained in the rear, and the excessive demands of army

unit tables of organization were met with the surgeons in the lower classifications. Of the 24 surgeons in the "D)" category, 13 were with evacuation hospitals. This consultant received wonderful cooperation from these men along

with the remarkable patience and courtesy with which they accepted his own

limitations.

The training of additional plastic surgeons within the theater proved to be

a completely impractical task. The very nature of the work made it mandatory that a relatively long period be devoted completely to the specialty

before any degree of proficiency could be attained. During the long, quiet

period in England, there were not. enough casualties accumulated in any one

area or location to offer training material of any value. The medical officers

who would benefit most from short periods of training were those who already

had an extensive background in surgery. Such officers in most instances were

705-095"--64-30
i 16 ACTIVITIES OF SURGICAL CONSULTANTS

loath to give up their chosen field of surgery which, in many instances. would

have resulte(d in forfeiture of chance for advancement in rank. There were

a multitude of officers who were anxious to get into l)lastic surgery. but almost

invariably the. meager surgical background of these men eliminated them

from being anything other than assistants. Advantage was taken of the presence of establishled British plastic surgery centers for training of U.S. Army

surgeons during the long periods of relative inactivity. The surgeons ordered

to these units were those with previous training in plastic surgery who would

be most benefited. The most extensively used British unit was that at, the

Queen Victoria Cottage Hospital, East Grinstead. Sussex East. Approximately 50 officers were sent there for 10 (lays of lectures and demonstrations

lby Mr. Archibald Mclndoe (later knighted). Other units at which American

officers were l)laced on temporary duty were the lill End Hospital at St. Albans

under Mr. Rainsford Movwlem and the Emergency Medical Service Hospital at

Park Prewett, Basingstoke, under Sir Harold Gillies. These British surgeons

and many others showed a marked degree of cooperation and courtesy throughout. the period of close association in England.

It would be impossible to pay individual tribute to the various surgeons

who did so much in this specialty during this plhase of the war in Britain and

Europe. To mention a few would be unfair to others. Much of the clinical

work was quite outstanding, and many of the surgeons had an opportunity to

demonstrate originality and imagination in their ai)proach to the various coinplicated clinical probllems. Furthermore, the administrative ability that, of

necessity, accompanied the clinical work of setting ul) a plastic surgery service

in a hosp)ital and hospital center was enough to deserve special recognition.

Supplies

Problems of supply were a rather minor but a constant source of concern

for each consultant. The Supply Division of the Chief Surgeon's Office was

always found to be very cooperative in the l)rocurement and distribution of

nonstandard items. Tables of equipment anld basic allowances were found to

be inadequate for the needs of the hospitals for special treatment that were

developed as the campaign progressed. The items concerned pertained to the

specialized types of surgery on large volumes of casualties. Detailed comments regarding deficiencies of supply were made in a report to The Surgeon

General completed shortly after the war. It was believed that, since the use

of hospitals for special treatment bad reached such a degree of development

and recognition in the European theater, in addition to the changes in organization aimed at facilitating the establishment of these hospitals, consideration

should be given to the need for supplementary tables of equipment to furnish

such units. The items concerned were such things as suction apparatus,

needles and suture material, needle holders, tissue forceps, skin hooks, small

hemostatic forceps, cotton-waste dressing material, dental arch bars, and dental

elevators, all of which, it can be seen, are instruments of a specialty nature.
PLASTIC SURGERY 517

The complete absence of photographic equipment as an item of medical

supply to both communications zone and combat zone hospitals was keenly felt

as a handicap throughout the campaign. The need for such equipment was

partially relieved by procurement from the British. "Photographic units"

were placed with most of the hospital centers. In most. instances, the equipment was placed in a hospital performing plastic surgery. It was found that

reliance on the Signal Corps for clinical photography was completely unsatisfactory. There always seemed to be plenty of photographs of British

nobility visiting the hospitals, but, when an overworked operating surgeon

wanted a photograph of some important clinical condition at an irreoular hour

or on an offday, it was often next to impossible to get it. Clinical photography

in the U.S. Army Medical Department was a sorely neglected field that cannot

adequately be discussed here. A single detachment of artists and photogral)hers from the Army Medical Musemn, such as was supplied in the European

theater, was not a satisfactory solution.

Evacuation

Careful supervision of the policies regarding evacuation and constant observation of the flow of casualties to insure that those which were an exception

to the general rule were promptly and adequately provided for proved to be

among the most important duties and responsibilities of a consultant. The

general picture of evacuation varied from day to (lay and was influenced by the

tactical situation, the number of casualties, and the weather. Maxillofacial

injuries were considered to travel well. Their early evacuation from army

areas was urged, and provisions had to be made in the communications zone to

insure against their being lost and not being transferred promptly into the

hospitals for special treatment. Burn casualties were also evacuated into specialty hospitals as soon as possible. No special provision was made for the large

number of extremity wounds which would require plastic surgery. These cases

were picked out of the hospitals in the communications zone and transferred

to hospitals providing plastic surgery service as soon as the need for this type

of surgery was recognized. Transit and holding hospitals played a very imuportant part of the evacuation of specialty type casualties. The following paragraphs from the Semi-Annual Report, Plastic and Maxillofacial Sections,

Professional Services Division, Office of the Chief Surgeon, U.S. Forces European Theater, for the period 1 January-30 June 1945, indicate the main features

of the evacuation problem presented by casualties with severe facial injuries:

The care of maxillofacial casualties is directly related to the efficiency and speed of

evacuation, since continuity of treatment must be maintained. Throughout the campaign,

one of the chief duties of the Senior Consultants in Plastic and Maxillofacial Surgery has

been to enforce priority of evacuation for maxillofacial casualties, to brief air holding

units in the preparation of casualties for air evacuation, and to see that patients were

properly dispersed from landing areas in which a high concentration of cases accumulated.

Train and boat evacuation also presented the problem of making Hospital Train crews and

Hospital Ship Platoons aware of the special problems involved in caring for and feeding
518 ACTIVITIES OF SURGICAL CONSULTANTS

the severe maxillofacial casualties. Arrangements were finally made with Evacuation

Divisions of the various Commands to have those niaxillofacial casualties going to the

Zone of Interior by water to go only on HIospital Ships, where care by properly instructed

medical lersonnet couhI be depended upon.

1. Air Evacuation: a. Front to Paris: Maxillofacial casualties were given a high priority of evacuation directly from the front to Paris. where they were accumulated in the

108th and the 1st General Hospitals. This relieved the 1oad con the forward transit general

hospitals and placed the casualties early in the hands of specialists, where they could

remain until read(ly for evac.utli!itlo thie Zon of Interior.

lh. Front to England: Any available air lift to England was taken advantage of by

priority nmaxillofacial casualties. There were periods when casualties were admitted to the

special hospitals in England within 36 to 48 ht.ars of ti', tine of injury. This proved to be

a tremendous advantage in securing the quality of specialist care (lesirted at an early

date and making it ummnecessary for the case to go through repeated stages wf evantiltion.

c. Li'(ge to England: The 15th General Hospital at Li(ge. lBelgium,n functioned as a

special maxillofacial hospital for the S20th Hospital Center and as a holding transit unit

for air evacuation to England. This arrangement funictioned very wvell during the heavy

Ardennes fighting and served to decrease the load arriving in Ihie Paris area. as well as

to keel) the casualties in the hands of specialists. Major Carroll Stuart. MCC, and Major

Leo La Dage's tealm of the 5th Auxiliary Surgical Group did a very comnmndable job at

this unit while the casualties were heavy andl Litge was being bombed. In Englanld the

air evacuated casualties were llasse.d through the 154th General Hospital near Swindon.

Personnel were added to this unit to care for the load of casualties. From the 154th General

Hospital. the cases were disllersed to the 117th. the 91st. the 19'2.ind, and the 158th General

Hospitals by amimbulance. and to other hospitals by train or hospital car.

d. Paris to Zone of Interior: Maxillofacial casualties were given first priority for

air evacuation to the Zone of the Interior. Paris was the departure point from the Continent. The 1st General Hospital fulctionedi as air holding unit where the adequacy of

preparation for air evacuation was checked.

e. England to Zone of Interior : From all special hospitals in England cases were evacuated to the Zone. of the Interior by air as air lift was available.

2. Train and Boat: Insofar as possible, all maxillofacial casualties were evacuated by air.

Evacuation to the Zone of the Interior by boat was confined to Hospital Ships during the

latter part of the campaign.

3. Furntion of Transit Hospitals at Lif~gc and Swindon: The designation of such specialty

transit hospitals was found to be a very necessary step to control the direction of evacuation

and to insure patients falling to the hands of surgeons and dentists with special training

a1nd interest. Approximately 3.000 maxillofacial casualties passed through the 154th

General Hospital at Swindon from D-day to V-E Day.

Plastic or Maxillofacial Surgery Centers

The establishment, of hospitals for special treatment, or "plastic and

maxillofacial surgery centers" presented problems that were inseparable from

those described in preceding paragraphs on tables of org.nization and personnel. As a matter of fact, the establishment of these specialty hospitals was the

solution to the tables of organization and personnel problems. On 30 March

1943, in a letter on the subject of patients requiring plastic surgery, the Office

of the Chief Surgeoi., ETOUSA, designated the 298th General Hospital, at

Bristol, and fhe 30th General Hospital, at Mansfield, as centers for plastic

surgery. During the following year eight more specialty hospitals for plastic

surgery were (leveloped in England. On 10 June 1944, Circular Letter No. 81,
PLASTIC SURGERY 519

concerning hospitals with facilities for specialized treatment, was issued by

the Office of the Chief Surgeon, ETOUSA, and designated hospitals for special

treatment and plastic surgery, neurosurgery, thoracic surgery, and urological

surgery. Thus 10 hospitals, scattered geographically to cover all areas of hosl)italization in England, were designated as plastic and maxillofacial surgery

centers. Subsequently, one more general hospital was so designated in England.

This arrangement proviided one plastic surgeon to approximately 10,000 hospital beds. If specialist care was to be made available to all casualties arriving

in England, it would be necessary to scatter the available surgeons geographically rather than to place them in a smaller nnl)er of hospitals and thus

allow each hospital a, larger staff. Previous experience warned, and it was

later vividly demonstrated, that during the heavy flow of casualties long

ambulance hauls of patients to specialized hospitals wonld( not be possible.

Plastic surgery could not have served the mass of casualties in England through

two or three ideally setup and ideally staffed plastic surgery services.

Preparation for the designation of a hospital as a so-called specialty center

usually consisted of moving a qualified specialist into the hospital chosen. This

move was preceded in eight of the centers by the installation of additional

facilities in the hospital plant for the late treatment of burns by saline baths.

From here on, development of the specialty section became largely the responsibility of the specialist himself. In the case of plastie surgery in 1,000-bed

communications zone general hospitals, the difficulties encountered resulted

directly from, the tables of organization. A new surgical section requiring

nurses, ward officers, trained technicians, and some items of special equipment

had to be fitted into a hospital which was considered to be already organizationally complete. In some instances, weeks or months transpired before a

section could be sufficiently developed to be considered possibly to l)e running

efficiently. The l)l'astic surgeon became an integral part of the hospital to

which he was assigned. This was an advantage so far as cooperation from

other members of the hospital was .oncerned, but it p)roved to be a great

disadvantage when movement of the surgeons became necessary. Replacements were always necessary or wanted when a surgeon was to be moved.

The finding of a replacement and the prolonged administrative details of

changing the surgeon's assignment from one hospital to another resulted,

in some instan<.es, in defeat ing the object of getting the surgeon quickly transferred to a place in which he was more urgently needed.

In England, the plastic surgery centers had the rmost favorable opportunities to develop and to work efficiently. The administrative (leceitralization that

started very early after the influx of large numbers of troops favored the efficient function of specialty hospitals. The breaking up of England into base

sections made it possible for certain hospitals to be designated for the coverage

of a base section. The desires and recommendations of the Chief Surgeon*s

enior consultants were enforced through a base section directive, and the base

section consultants were of inestimable value in seeing that such directives were

followed. Later, when England became designated as the United Kingdom
520 ACTIVITIES OF SURGICAL CONSULTANTS

Base Section, tile division of tile hosp)itals into hospital groups again facilitated

the use of sl)ecial hospitals. The most efficient organization prevailed at the

end of the campaign when all hosPitals in England were included administrati%'ely under seven hospital center headquarters. The areas covered by the

hospital centers were smaller, the hospitals were usually fairly well concentrated, and the contact between the surgeon of the hospital center and the comnmnding officers of various hospitals was direct. By the time this adniinistrative organilization had developed, the plastic surgery centers were established

and their functions understood. Transfer of patients from other hospitals to

the plastic surgery centers was carried out with a satisfactory degree of efficiency. The plastic surgeons in the designated hospitals acted as consultants

for the hospital centers, thereby furthering the good relationship between the

various hospitals and the specialty surgical services.

The situation as it existed in England during the terminal months of the

camp)aign could be considered as being ahnost ideal, with one exception: The

plastic surgery services in the individual chosen hospitals still had to be

develol)ed on an entirely imp)rovised basis. The additional help that was

necessary was not provided in the hospital organization. It was necessary

to beg, borrow, or steal it. The same often was true of adequate ward, dressing room, and operation room space. In addition, with the shortage of qualified plastic surgeons, it eventually semed advisable to close a service in one

of the hospitals and to depend for coverage of the area on transfer of patients

to a hospital in an adjoining hospital center. Withdrawal of the specialist

from a hospital nearly always met with opposition from the commanding

officer of the hospital as well as from the commanding officer of the hospital

center involved. This opposition was understandable, since it was the duty

of the hospital center commanding officer to insure adequate professional coverage for his command. Nevertheless, it was often difficult to fit the supply

of plastic surgeons to the obvious needs and at the same time supply the supposed needs of individual administrative subdivisions that were not acquainted

with the overall picture of supply and demand in surgical specialists. These

difficulties are enumerated not because they were insurmountable administrative obstacles but because they appeared to be unnecessary; that is, they could

have been avoided by better plaining for the distribution of specialist. personnel.

Professional Policies

Professional policies for the theater emanated from the consultants in the

Professional Services Division of the Office of the Chief Surgeon. The formulation of professional policies was influenced by many factors that required

serious consideration in planning for the care of casualties falling into a surgical

specialty. The factors of greatest significance were (1) the expected numerical

flow of casualties, (2) the average professional ability of the personnel that

were to handle the casualties, (3) the specific needs of the particular types

of injuries, and (4) the hospitalization policy for the theater (which was
IIASTI I'SR(ERY T 521

gradually shortened as thie reserve of hospital beds decreased) P1oliies were

made known from the Office of the Chief Surgeon by circular letters, administrative nmeorandum, subject letters, and contact of the Chief Surgeon's

consultants with the medical l)ersomiel in the various hospitals. The Manual

of Therapy, ET(L)ITCA, compiled l)y the consultants and p)ublished in May

1944, served as a guide to the general medical and surgical officers and to the

various specialists. With the reception of large numbers of casualties, certain

policies were changed and the changes made known in subsequent circular

letters on professional care.

The very close contact it, was possible for the Senior Consultant in Plastic

Surgery to maintain with the l)lastic surgeons throughout the various centers

in England and France proved to I)e of enormous value. Current professional

p)roblems could be discussed in this way and ideas of the various surgeons

interchanged. In addition, frequent visits between the surgeons of the different plastic surgery centers were encouraged. It was thus possible to define

the limits of plastic surgery to be carried out in the theater and to see that these

policies were uniformly adhered to. It was always the aim to do only what

was urgently indicated and to prepare the patients for evacuation to the Zone

of Interior as soon as possible. The Medical Iulletnii, ETOUSA. pul)lished

monthly, served as a very valuable unofficial means of getting information

to medical officers throughout the theater. This publication was used to advertise the specialty centers, to exl)lain their function, and to encourage the

trausfer of patients to these hospitals. The administrative professional policies

pertaining to the various types of casualties falling to plastic surgery are

discussed in subsequent paragraplis devoted to l)rofessional care.

PROFESSIONAL RESPONSIBILITIES AND PROBLEMS

It was the responsibility of a surgical consultant to see that, so far as

possible, each casualty was directed to the hands of a physician qualified to

provide the necessary care as rapidly as this could be accomplished after injury.

As indicated in the foregoing discussion of administration, this responsibility

concerned the consultant with all phases of the tactical situation, but chiefly

with the evacuation of casualties and the placement of professional personnel.

Since p)lastic surgery was coming of age and was represented by a consultant

in the Office of the Chief Surgeon, it seemed advisable to establish a definition

of what plastic surgery should entail. Accordingly, plastic surgery was defined, in Circular Letter No. 5, Office of the Chief Surgeon, Headquarters,

ETOUSA, by the Chief Surgeon on 12 January 1943, while Colonel Brown

was still in the theater, as follows:

1. Definition: Plastic surgery includes maxillofacial surgery and is defined as the

care and treatment, in all stages of:

a. Injuries of the face and jaws that may alter the shape of the bony structure or

leave disfiguring scars.

b. Injuries of any part of the body which require skin grafts or flaps, scar adjustments or surface tissue readjustment.
62AVT 11VIT1'1' OS(F SI ~m1C 1 AL, ('tINSt LTN''S

se-riouis builis whichi iii3*llly not be regarde iuiii iiitialy :is fiillig vit liiii (lie lt. se

ini siitiiilraigra itis Vi .11i It4 abo:lve.

2.'Icrhnicl Theri~ou ''li Se~liolo ( onllasit~it ill P11st iv Surgery is the adi(iser

of tilt- ChIiief Suirgeoni 2and will. miiie4r I lie dlircion' of tilte latter, exercise tlelimi42l stiim-rvision ofaI' 211ptist icsurgery inl Ei'4 )SA, ieg riltess of e4cli'e4oit.

The def'inititloln was5 a good 14 one a nd IServed a ve utsefitIltl purpos ill clarnfin 1 t1'eSPOn s IlInItt v ni I I I11t t els o f 1) r fessi oui.11 pol icvy. Th'le inclusion of Itiaxillot acial siurgery llhi(Ier p~last ic silltget' is di Ilictult to j ust ify c' uiplet el Si tic

tilie fIltttIjlilI~t~j atsoulrces of f-t riningo arp quite1 (i Tlerettt for (111Ili. and(I tlie Iv(wI

fields, thlough closely.N assocjatedl ill iitaii w:1V5, are (jutite dfivergenti jill ot hers.

I'lXcept~ ill th lii ast of ai few Suirgeoiis, quIalified1 ill bot Ii silt'gerV, andl( (Inlitstir

it, was aiIwa * Ns liecessa IN fill illte tw ~v)Speciallists to work as a1 It"eat if thle highlest.

Standa1:rd of care was to) be miainitainied. Pat ienits were admit ted1 to liosIpitals oi

lhe Sutrgical set'v' te undi~er thle rpol'Cj01ibIiiiit.N of thle chiief of Surgical Service.

Thie dental1 oflicers wvere t ised to thle fii lehst ext enti and11 fitrniishied v ojist :tt. antd

in valliablel assistantce ill caring for all1 cases of fracturttes and i nj itries abI out,

flie. Iliolilth. W~ithoiiit Ilie d1e11tal officers to help with ISuch cases, thle siu-rgical

Services woul d havye I eelu crippled. Sub sequtenit comimieunts ()Ii the I u'eaIlillent.

of itni xii lofaceia I casulIt ies ill tIill clta vis S~tepI t . collsidlerali vinto 0li W f ield (of

lie dlentalI oflicer. with Ii112xii I(facia I trainin1g. C olotnel St otit, Senior (Conisutltilt ill MIa xiilo facial sitrgerv,9 wolrked ISide iw sidle withI thle Senior C oiisul -

tanut In Pila2st ic Sit rger-v ill thle cvare anld Sipervit''siont of i ia xii ho facial inujutries,

alidmll ,itN. of thle views expressed 4)It thlis stiliject. steiil dlirectlyv from hiimi.

This ant 1hlo, ha~vinig beeti (mutled into t lie position (if Senlior. ( oisitltanit

inI'last ic Siur,,rerv. liis loligr had tliiXedl feeliiig's abu th)11Ile advisaliilit v oif a

111,111 who is liisivallv aL 4'etellp-1 Slirgeoli ac-l iti, :IS co)IISitltant1 ill S11(-11 a. Spjýecialty.

I [owever, the prof)essiotial pol0icies .11141 d eclstoltis t liat were IVejli red ill t dis

thieater of oplerationis wvere of such-I l)215ic 4iiiolsls 114 eir suriallw~

nat itre that. tlie Situtat ionl NNVIS ljot I.- a :Ic)giotS it Iiiiglt. Jae ee.i t

wvas foundi~ thai~t ill add~it ion to biedside contsulltat ionl, tili- Volltsitltlant coiuldpolh'4-

vidle 2111 imiporiitalit p~rofessionlal Service bYv tIhe ralpidl wordh-o~f-1I14ultt Iidisseliiiwit 4) ~ lt~uii ~ ~ ~l ~ ~ iii ? i Io ies. Ilie wais ill excellentl piosit ioit to

observe andi to tt il ize tilie k tlolwledp.r and14 explerienice of luau1 v fi rst -claiss Suirge~otis and1 thuts cry.%stallize ideas andio policies tha~t were gelierallv lietieliciail.

Itl was5 moist. itill~oi't :tit t1 hat tj- lipiit-ra ~oloess of lelriliig I)%, eperjieuceli

Sp leede Iil) as iiiii4'l as poss5ib le ill o~rdel' thai~ tOli good14 ill prlofIessionl~ 1 j)4I cis

be4 Separanted ftomt thle 11:141[ :11141 lrotillptIv puit ilit4I genrlp ractice Iip

COIIiSIIlI huit. was ill a. key posit ion to facil iat :thi iis prove's's and 14 ) appr~leciat e

lie uiecessity fo ai' tevn tg professional 1 1))1 aes ill accor-dat tie witIh thle d1ict at es

of tIlie tact ivill sit 11at 14)11.

Max illofacia I Injuries

Before World War* I , thle onlul (pleitlitekoldelviiaiecnenn

treatmenett. of thle Severe facial 1 W4)1ild1 s (If waill wais thait which i r esulteId(4 froti

World4 War 1 . Thie basic pr1incidpie oIf I reait liIlet oIf Severe faicial Woundl~s 011:a-
PLASTIC SURGERY 523

hating from World War I was that such wounds should be closed, or partially

closed, and that massive displacements of tissue were to be replaced as soon

as possible, with primary healing as the aim. This basic principle had been

supplemented because of two very important factors by the time the active

phase of World War II approached: (1) Twenty years of civilian experience

had been acquired in handling the severe injuries resulting from the speedup

and increase in motor transportation; (2) chemotherapy had established an

important place as a method of prophylaxis and treatment of infections. It

was believed that these two factors would allow aggressive extension of the

basic princip)les emanating from World War I. Thus, it was concluded that

the time for complete definitive surgery was immediately in the hands of the

first qualified specialist who received the patient, providing that the proce-

(hure was feasible and not complicated by such loss of tissue as to make it

impossible. Even the latter cases should be treated definitively as far as

possible, leaving only replacement and reconstructive procedures to be done

at a later date. The object was to produce definitive treatment that would

make it necessary, in niany cases, for later surgery to consist only of superficial wound revision or excision. The proper treatment of fractures was an

integral part of the procedure. In order to approach as nearly as possible

the theoretical ideal, definitive surgery at the evacuation hospital level was

urged to the limit, of the professional talent. available there. So far as Ix)ssible,

the most highly qualified plastic surgeons were retained in the rear medical

installations where they could handle a greater volume of casualties through

triage and where their talents could be used on a broader scope of surgery than

at thk front. The system produced results that were quite gratifying, considering the tremendous geographical area covered and the mass of casualties

handled.

A section of the Manuad of Therapy, ETOUSA (app. F, p. 989), indicates

the policies pertaining to the treatment of maxillofacial injuries that were in

effect at the time of the Normandy invasion.

The sources of severe facial injuries were multiple. Civilian-type injuries

resultinig from vehicle accidents and fist fights were always common, and, during the period before the invasion of France, provided the majority of maxillofacial injuries. Casualties from the Air Forces presented no notal)ly characteristic features. Landing and takeoff accidents resulted in a number of bluntforce facial injuries, many of them coml)licated 1)y associated burns. Flak

wounds varied from massive shearing injuries caused by large shell fragments

to small perforating ones resulting from small missiles. Some of the small

missiles from flak were of exceedingly high velocity and produced considerable

comminution and "blowing out" of the face. During the hedgerow fighting in

Normandy, there was an unusually high incidence of maxillofacial injuries

resulting from the close type of combat and the necessity for the men to expose their heads to see the enemy. These wounds were predominantly caused

by small arms fire and were characterized by being exceedingly severe and not
A,_• .\ ''l I 'FI' II i.,• 1 1." 11 'A 1.\l I , , l A N ' T'l ''' ,'\ 

"j"liid Lif III 11-1

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a 411,_ ral-' l ••I~ ..I(. -lI llII ilry' 111: i \\O .'le lwn . t,'l i~ llti. v ever.v.li'l \\,Il I ,I l-l, I hei ,, h r IItI'I f

Ai1l' M ill, Il k.1 -hl' il• n i ll't. Illi hill\ crl isI I' uii( ,I f I S ill gr r io IJIle.i11 I il \lilt,'l It l~ l sl

,'W ilT l 111i'4 :111 I,• ii*'•i'•I llimls. T' l he' Wi' ll','i vi I~l 'lýiM IiY W4(I ' p: vlll• 1l )X'i.• li ,•t' i Jt lre .f.elll

fl';1 1 gs i .,. tl- 11 ll l l ad i he l pl ill vlll .s, I 4rll en l .(l' lllfll li S(1\) : .1 1l1h ol thati 1111,1i. 4l-mild•

b di m e fhil' l•iil. II • li- fll'V. fl;l Il'l, - I, l 1 \I; 1.lr l ',ill .I, (, l~', " 11 I 4) li,,cm_' i,-r* \\ 11 if 1 il11 ii0,4
]FiG*uBE I J.-1Po~vder ~tItoigas ililiiti ited loy t his casually wans almoust invariably

assoiai~ted With bindijvilIt ill one or ])()Ili 4-ye. Thle afierit-1ecis oft Ihis~ -tattooinig" could

he greatly lessened byv vigorous early treatmient. It was ui posible ini some inistances for

the aiiestiiesioiiiigjst. to Scrub liIam] (ebit'I'e the( powder mi-i is (or ieii tmiee wi~iiie the surgical

team11 was takinig eare (if oilher ijie.It N%;s 1uifortiuiiate t hat tw lin signifiicancie of this

lpIrticulhir phase (if the pat jeni's injiury uiolidrtaini Ny led to) it., early ilegleci ill so fllimly

i lista lice".

small p)t'forat tigo Womitids NNvlmicli imial ly involved hot Ii eyes ( figs. 186 and

187,).

Evacuation hospital.])-'I mti Iiig for H ie numaoiaeinjeit~ of facial injuries

was basled ol Ht lie lbelijef t lit H ie t i me for f lie mtost effec'tive (lefiniut ie treatment.

wfls at the eN-a('lt ionl liosplita] level. Tltiis conicept was proi-ed to b~e correct,

Iflrt icillardv for tilose casutalties5 Witliout. muassive soft -tissue loss. Maxillofacial

sti*rgica Il teaiiis of thle ittixi 1iarvN sit rricul unmits were eIICcte i sCel lby beingo

placd ill evactattt oil hosp1 italls. At tlits level, the casuialty was treated for

shock, all bleeding was controlled, the airway~ Was 1in~suried, tlie extenit of thle illjury wvas surveIYed, and I lie patient, was restedl andl~ prepaured for op~erationl. If

thle Condlitionl of the patient perimit ted and tlue tactical situation allowed, a

compllete definitk iv op~erat ion was then done (filg. 1 88). Th'le bony skeleton
I t

' 1L .,

Al

-17

1,1i 1 l s
PLASTIC SURGERY 527

was reduced and the initial fixation applied. The wound was debrided and,

if advisable, closed in layers. The patient was continued on penicillin, which

was started upon arrival at the hospital, and held until he had passed the critical period before being evacuated. Tracheotomized patients were held for a

minimum of 4 days to become accustomed to the tracheotomy and to develop

some degree of self-reliance in case of emergency. Feeding problems were held

at least until the more acute probleni of maintaining fluid intake had subsided.

Tihe object was to get these casualties back as quickly as possible to a specialty

center in the conmluunications zone as soon as they could be transported safely

(fig. 189).

General hospital.-In the United Kingdom Base Section, there were 10

general hospitals, staffed and equipped as treatment centers for patients with

naxillofacial injuries as well as for burn casualties and casualties with massive

soft-tissue loss of the trunk or extremities. These specialty hospitals were

geographically dispersed over England, one such hospital being designated in

each hospital center. From the evacuation hospital where the initial definitive

treataient had been given, the casualty was transferred to the communications

zone and, if it was severe enough to warrant it, directly into one of the specialty

hospitals. The severe facial injuries were continued on a logical regimen aimed

at anatomical replacement of tissues, the promotion of healing as rapidly as

possiblo, the, reduction and fixation of skeletal derangements and through it

all, the maintenance of morale and the nutritional state.

It is obvious that this effort involved miauy more people than those primarily concerned with plastic surgery or the treatment of maxillofacial injuries.

Consultation with the general surgeons, the ophthalmologist, and the otorhinolaryngologist was an integral part, of the conduct of such a service. Dental

officers of the hospital staff became a part of the plastic and muaxillofacial team.

The Senior Consultant in Plastic Surgery was almost invariably accompanied

by Colonel Stout of the Dental Corps during his inspection of these centers.

The suggestions of Colonel Stout concerning the nmanagement of complicated

jaw and facial fractures furnished an invaluable and indispensible supplement

to the author's own inadequate exp)erience in this field. However, it was found

that the application of basic surgical principles and commonsense would usually

point the way to a solution for most of the complicated injuries.

The degree to which early facial reconstruction and repair could be accomplished was a continual source of amazement and stemmned directly from the

availability of antibiotics coulled with good surgical care. An effort was made

to take full advantage of the op)portunity i.%orded to obtain early tissue replacement and healing. Much of this was definitive plastic surgery at its best.

However, the majority of the surgery in the European theater was aimed at

preparing the facial casualty for ev:mcuation to the Zone of Interior in the very

best condition for travel with the wound in time very best condition for a continuation of whatever subsequent reconstruction might be necessary (fig. 190).

Many things were learned, only a few of the most important and obvious of
lifve'. Thurer. 41111 i r ISra l-1is. 1 so'cay 144. h h X itr .1 fr..14,h 1 h,,i4-f 1114. 111.1 iouu :11141llou Id* I is u
Flf1v1 Ict a Ii I l AI s I'm'. IlYi~ii ailh se 1(1 er %N40l sIplit, III(, chin anid 1:1diii I lit' Iiiiill, 1---itl t 

in-t e imn'iorr age.in z~ii'ii NoIi e II na t'r i4 1*vilthl t Itit'e whlich 1t'4)i r i of vl lt 1 i~l.1IrIa im3

hitl ' iii ajttiv was I,114 h it)-t 04.i ll'ltM~tI "tatl I., it r V liabe 4iioIIligeaije 1Motm l ]t: %%as fil plastitc

ofIlddiliofi. it a~lol nuies ofi war il hit' ail eltwho hiat ai atletjiatt' v;inleI. bt

Hem)~4 orrtihs age.' Whenacthiv ulgtliilt ii''ve aitio ao thue otrol ofli iliviit'41 l;tIi2't
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()hIti' ( ' II v I re I44 Iv he aI I4(. 'tIY .1)1t 1 tvl- h4l~ ue ttI W l lnt nt1'4'1e ihtr 1i1s. ret '. 1 1- ldt4

t'''I I Iivit IIIII s I Ill' :IIv lt s'~it It 114 I 111 I lst'S lt I l-i'l t'n I I, I(4l(vii I .I vv I hlitl~tlt :1(

V4 111n.4 (s debriVo l lj*li ii' l iltl Im Ia lld 11')-hbe Is !IIt II1(4(1 441 i141t \\I., f111 i .i-: II 'l 

when. Illosure0)41 r .- Ilt 5It't \\,:I S 141lllhII 4'4 ill't becIIs f:. i t~ wn)l s WiIS4 hinlw'' v 11. II~ 11 it 4 l it 11441 t e :Iilld ;.if Il IVIii4ll Ml e' It'm-l4141t'l Det'llt itt 1 ell :1 11dV'l&
11ISfit,~ iii IeIlyilig S411,1 I issli. Thle Skili too buiecAi niii''isa S1W tue iivuvides eairly iv1wIiug andI

;1 thle saiiil* I lime Sitiliiv. it,(, arie (or it* I I,(.~i rile Ulil and 114m (ofthIe Iinimh hy mi iakinig thbese

*1 eIs iiO.r1e1- .ieissiie. Any iv t Iq'ip ;1t varly cthIslire Uli1l 1teeolist 11110 if ulli f this facili~

(eif ctw %vi1IiIi~ii ebii ii;N serioua errior. N~otlice the m lile Nvn 4fl.;141 frtu .1111111jl-101*loii lit' tThe

1)(1111. fnitgiviiius by vlaist i I r~acl imi. I Case for It. ('11 1i. . Eu:1geiii Howyr. iAic 53:~(41iGenera

() t Ilint n-vere stcc~e-sII ( li&. 19it). Tlumhe at wen- II"sthmiissh wt'Int s-tyi fm' Itl

beeni cle:1t'le till antd tbe a:-sm-iautte s.keletal derangI~emen'ts stabl~ihzed(.

Infection,- lmutin le antiiot iv I herap l1eit) lai di(efillite Volt' ill thle 111W

Selliotr ( oIsIiItauit ill Platstic' StiIIlf&'I dlid 11(1 set' 01i&' CIt( (Of IOAI-lig's anina'.it

Spreadt~ing~ cehltihiti and~ e111trysile)tIi( iiifei'tjlos n-vepre)Iact ica;lly miilieXislenut

Th'le itifect ol~s observed Nvere Im-lltiized .111d. for the 111051 part, 411e to lIXlP

(IeI)Ii(IeIIeliI m.i lack o)f pniPO imIOI for ld('(hIlate drillageit~t off wOTIut(1 ini which

Reduction and fixation of fractures.-Befoie nT naoImmiipt( SiAiM mmutIl

WnT,S (1051(. Ilthe illithjl 114'(ltAIt j nl)ad lixal iU (of fractImi's nos nnitiplishle ~vitli

lie fol lowinug enl(s Iin ihIi :1(1 (1) Ui'sI orn! (1 of iioiiaml natundn! oiImAl oit IOu l ;

t'oitoltit, ( -?) r-eshwat lou (ff nlOI1III1t o((a'cltsal relatijoniship between thle ma~xilla

aull uiitiioible, (3) Iliniiiteitlio'e (If the KOMIt~ ar-ch andh prevenIt ion (of collapse
Fti' m, 192it.ii 4 PT cnc Ii P P idni~v lilti

Ir14 111f. rvlj , il f s llI' It-I 15 - 1114.wuijiplvi

I.141t4.141Ilrv I11 tiiuihs11:151u li4dpa wvr ll1411,lld

I' a:1 i ll4i]lP41 fi pl1S. I 14m41 A i.r. ~Ihe 4:1 (

ii~. I.I 11) :ti ur 11111 idiilVotl]1te11Ilvd her ixv;[i loll of e faiull 1 ;Iii jawl

tl~el t es IPP :11111 i 11M 4 I 4 el t i iet.r1 Sttfple I l 0sl 1111is l i~il- Ite tll f llt

Was ~ -A -lif P Pl 14 iS111l offtelaI etc iil 11:11 appI V Ld ot sif I I I tis e l):tI 1114it

W~ts-eet 11411 elI~ il a11(I II l~ :1ttp l lteimi W :0issiwilvla C. 1e ll~il injur wi~ill

Vell 1: el I t~~I 11:11 id (41. l~a I fit t i thmit1 l '4 i (41ft lai I 1(4 III Thetitt;l I led.s
PLASTIC SUIIGEIRY )i"3

FI(i['RE 193• .,- '" hIs Ill s ( ";( illustral'tle. .1 l(tl'lrell~a ing \volulld (if t he alll-l'llll wvith infect'ionl.

MoIst infectio.n obs.,lerve(,d were(' due1 ( il. iin (Iql,. 14. (lt.l ri ideliit ,i- lac.k of p rovis(ioni fr ahdeq l(te (Il 'inulg(e. Inf(e(.tiobn ill .1 ul(. uveN- (',as(e "111i41 tin,1' beneI lirvenited by dehiriden ient of

Ilihe allxillalry a il ii l! anld l ' prov'ision 4 41f a4Ie111,:11pe d railig(e t hroulgh t he iUci al fornix.

The mechanical means were miultipl 1e and( those used would v-ary with the

individual surgeon aid the iuii(lividual case. (Certain plrincililes, however,

were considered in the al)l ti'ation of these meian ical means. These principles

were: (1) To strive for simplicity; (2) to take advantage of every favorable

factor offered by the pectiliaritles of the ease (that is, the presence of key teeth

for applli'ation of a~pparatus, the holding of one fraggment in l)ace by imp)acting

it against another, or the holding of a p)osterior mandil)ular fragment in

position b)y a retaitned llolar) and (3) to avoid external applic]ations and

plaster head(' caps when l)ossille. It was in this p)hase of care that the "multiple

loop" wiring method of Colonel Stout wav lised most extensively (fig. 191).

Intermaxillary rul)berl)and( fixation, applied to multiple loop wires, served a

great purpose in the European theater both for the early care of maxillofacial

casualties and for the later (lefinitiive support of mandibular mid maxillary

fractures dring the final healing phase.
rViuumslin V14 Compound facal Nvoi lu~a ld (tie riav wiiii iialoss ofnini aitlr 'Os. li

]Drainage.--At thle tMein of (10-di i. t lie, indictat ions for establ)ishingi adequlate drainage1~Z hadlalwavs to he kept ill mindiu. UThis wvas a principle hlat was

vell oim erstoo 001 111 int World1 War I wIe ictiitfeetlioll afIter closure wvas mtuchl

miore likel ,N to be a1 criticeal compiilication ftital at (lhe Iitime of the present

coniflict whenl spreading~ inifeet ion coil'hd to a gyreat extent, lbe conitrolledI b

slfoainide or peniciillinI t hera py. F~ailuire to pbrovidIe adlequiate dril ~iige wals

ai not, ittiolittoti error. ini lie treatmitent of lhe fi rst casuia jes followvillg the

invasion of Norumandy. 11 Nwas I el je~ei t hat dlrainiagi~e shiomilied ])i tt ii-teol

rooit i Ile] * bfi the following types of woutndos

L. Wounds( inlvolvinig thle floor of' the ilioiitl. The floor' of the Itiomulih

should be closed. ano dlepiendoent external d (rainagl~e provided. This couild u1sually

be domie thrIiimghi an ext ernal pnwt jell of lhe voimni I.

0. Severe wolutds associated withI the eoniiiuimuted fracu tre of the maniablhe.

TIhie drained area should inielide the fractitre site.

3. 1 )eep wVounds~ oif thle uipp er uIeek. Such wvounds( were Millbject to avviluinilat ion of 1)1001 anod sermui I eea ise of t Ie una vidal de inmiotin follow lug swatlowinlga 11( breathliing.

4. Wounds involving (lie miaxillary sinlus were dlrainied inito the nose or

bucclCt forntix.
PLASTIC SURGERY535

5. Wounds wNA-1ch resulted inl the turning of a large flap). Accuinulat ion

of serumi and blood was gu11arded against by tile inlsert ionl of a smlall drainl

aifter replacing thle flap.

6. (Conmpounid wounds of tlie fronital sinus wvere (ira immed externally (providled tilie wvound dlid not Involve tilie posterior wvall and dui'a )

7. lExtensivye comnmtimnltedl fractuires of the imanidibl e, coilnIpollldedl into the

11io11tlh, bitt not associated withI external wvoitlls t h.(Ilroug whmich drainague

Couldl ealsily occur. Sicli wounids wvere treated by a p~rop~erly placed incision

and the insertion of a dralin.

Delayed primary and secondary closure.-Priniarv closure of facial

wouinds ait the evacuation hiosp~ital was tile general practice when poss5ible.

H owever. there wvere cases that, for various reasons wvere foundialvsle

to close in the evacuat ion lhosp~itals. For instance, anl evaculatloll hospital

group) swainiled wvith casualties mighglt be iii a p~osit ion to bypaflss inaxillofacial

inijuries that Were con1sidered t ransp~ortab~le through a.n air evacuation unit

(lirectir to hmospital ceniters in Engrland where they wouild arrive in only a few

hiours (fig. 19)2). AMans- facial injuries were then subijected to delbridemnent

and1( closulre With successful resuilts front a few hours to as long as 72 hiours

followinga injuryl.. Without question, penicillin therapy 1had( anl important b~earin(ig onl thle fact that complaratively late, radical, dlefinitive procedures were

P~ossib~le. The ab~senice of invasive in fect ion was the clinical finding supp~orting

the rationale of late closure. Technically, dlelayed primary closure didl not

ditIIer from earilY Closure.

The cases requiring sev-ondlary closure might be classified inl two categories,

as follows: (1) Those thiat. had previously lbeen closed with unsuccess-ful. resuilts: (2) those that were not closed previously and in which (elehved primary

closure had been adlvisab~le. Both of these types became characterized by surface infection. sloughing of devitalized tissue, and abscess formiation if drainage was inadleqiiate. The p~rob~lem~ resolved itself into one of nursing are

care of the wound, imaintenance of the nutritional state, and control of infection in prepara~tionm for secondary closure. Reduction and fixation of

skeletal parts pro~ceedled concoinitantly. and in these cases the procedure fre-

(uent ly became one of gradual I ract ion 'reduction.

Secondlary closure was (lone judliciously. with the realization that. the

results cou1ld not be accep~tedl as final and with the unders-tanding that the proceduire wvas never strongly indicated unless it wVould inicrease the comfort of the

patient or result ini produlcing" a healed woundl that would termninate pathological processes detrimental if allowed to lproceedl (fig. 195). Ani effort was mnade

not to lose sight of the fact that the nornial healing process of in open wound

produlces result., that are frequently difficult to surpass by surgical intervention.

If the wound was not resultimig 'in loss of bonle or imipo'rtanit loss of function,9

it was realized that closure or revision by experienced hands miany weeks later.

after the tissues had healed and softened, might be expected to offer the best

results (figs. 196 and 197).
40O

i' F'4 1$ia I 19: i' 1 This *4 $4''Ise il t Is IjtIrf' I llf, I I!4 ' (j41.11-v l~ I()4' 4.4 pll]i 1411111d filleial $44 (4411-

J4Iille44 caivllivt wenI. i~l litiji .VI %~II njl~l-4ll :11141 the cin14411j411s 4'(vs it 14I4Ivi4 4'IrcI11I i111 so'41l1

1)11'4 -5;11 11 V 1 11;t 4' 1 . y I' hl - s IIII I v(-4 -.1 n 4 -4 111i4 1~ 11 14 P(- ,I ( fII I I I P 1441 .442 1(-1* I 11t4441 I -I I .I ;iri 1 14 1111

gre'l4'1ilI1144$IISIilaI 5 ill- 1; 411 s 41144wilig injll j*.y. Therei~ is anl e4'el4lsive de414'4 (if 1114' IIIIxiIIl..

II sic cases(i4* ill wh~ich~ Illn 144'was 1ll) 4'N1'IIish4' hiss of2 tiss~liv I 14 li' I'. $422 15514' Ii s (.1011141

heI-epV1h1('4' as $444111 Its J444$$114. Thisi case$4 ilh ist I'd 24 Ill resilt'4sJI ot* .111] val *'i y q541411411 I'1Y

c(osi$lt4.e 4 (Cs ofP 441Mi. I)411gi W. AMctlll(ler44'IX . 91sl ~I4rI 144$i14i:i. I

Rotation flaps, pedicle grafts, free skin grafts. With Iilie except 1011 of

the fl.ee( Slim ii aftt. liolie of1 1i1le jW4)4'4ll-e'4s lisle' ill thle (illle of1 f il pa---p

Wee '0Iilerl to ha~ve .1 tole Ill 111 he ai*I I eitaliiit-Ii of IiutxihlofuIciill woviiIs.

this wats bette'r (10124' a .1t halter, Stage illi Ilie z(Iiie of I iitI'i'i4r. A t'cuIsi4)ll. ll 

WOUIiit( leitt itself to fivee sk~iii ;-nift as at U llel('Il$ (f p)I4)ilotl lg at lie'd e4 Isti rfaie,

th1ough It, was i1iut her howp'sil ittreqIteulIt Ill4 v~ Stich1 W4oillid were eulcotlillter-el.

Feeding and maintenance of nutritional state.--Ii uit ,x hospital lit

54)011 l)U'Iiit all ail~ltv( one'. Illi till- 5pect'i l * v hiospitl Ilill tli E114'h'ui'4[eill t htentei',

it bvilt'iuie tii'hill. lt as5 5(4l as tIlle uloa of pal1 wil'ls wit t'ritutld it. (If selt Inig 11p

Shpvciitl heedl it favi ltit . f' or hte'n' ctsuiai It . 'Ilii' A illerhivlul soldier, a itliost

1.e-ardlesIh(sf 4, l hie atllldi('itj)4 will gret e(o'dttgi lov) Ift i hi'Is e iveul the('(h)1p)It Iti ty.

A fewv of 112le cailattll es werv'& liefiliit('l I-elt ceuit 'iIbotit tt'edhi tu htt'iitsel v'le! before
WIIiiI( ee lit fclit lace11 .Th re li% (111114 (11 od dowl :ive idSk in th ilo I 1weigh. 111:11 I-441 ig

4of stvir e s ililix I %% lm- 41 i~ I1( twi-411(.;lis les dii t lie late y 4 1111 hi ll-% I ne m IIini g:1 ii let' o Y ciaimpl

it. ~dItii I'lie soithr Ilieri was Iinadiiiiahe iot1 It in t e rke Ichi eavkiol w.A1mvlihl W-M-edivii

1*11 st-Ie e II. iY i wie Ii 1ige, :1 si 4*;t re 0II-1 pittl ic(11 I-e isiol I hle iiiici iire srol

I ) 1 he , eI i ndh l Irt'(Iis lImel l IIv 114 to\(I\-. li tole liv Will v l~r l-l 4)1 11 * I've(~i I n I I IIIles'

I ft I( his -rj I .r~-.q~ I~I))4 \\-g it 11 4). he r paI t i~t-)lit Ws 11'e 1W 1 IP4'fro)I II I t . lilit- im f II;ite 1)

I If Is v4 l )a rnI*4' tvflt 4)1 d (I qwaItilt .1mIa 1411 S IIit' lIt offi \.:I~ r'~i'ctt v~ cileileb e gl'IIIate

-wvd Il Ieil In hIe xi I I( rs a41 ca ) )4)4 I I V4'I I I Iv .1g l~' Io 41 wa 111 v4 .11 InaII erioi (1iis~ilp v

SI~pi rlla injuiles. t- wlith ilijlabies frmnii lIIIlliltright' l~eelitt'l-ma livio'l Fivt I It11snii A~i 11 vit Iher1 t f-- 11 II v11,1W41 -t'vt'ie s(Ive jl b i' v Insert Iml n Id )1 a ht'.'Il I lie 141154',mi

~4I'm. I Il~ls I I 1 Iisie ei ))~i~4 to ; , 14 ¶.I~j I )111 %)1 l4 m t- l nit'b las ili v l l. ' '4)1111it't- Ill

III( eIlliW vt' Iea yp 14'li ()I* iW e Itls whicuhr Wmle it( Clilit-clie to11' e I his elice( luelil

('illivist N. In Of ilerv eArflm , ()f 6 1)14't(er.1ii' I4)Illl pe lt'iisii off il n t lit wlmiel Wit Ii it'

iiiti~il )1 al ellht'ilel Ip11Wil' ir 1s7) .(-il I\ 1)hvoisl,,r. loroigiv 1)
at *u gtuutuniI lhiisl~lIlu ill Eniglandit. I'iiiiiul uuututti.s;I lip ski ill lire11- t4i'leu is uIfi jitssibllt

uItiunt .1114l lildiat. hittul 4r11141ilhuuig setsis. uild ill Iuuinaiuutinuug I lt'leI .t'ieit's hutilt Iit iuIal stalte.

This~ vtype oft j11iel it'h s Ine t' Peijliulilig t'Nvt'i\j Vt iImr5iII tart' autil miu'l Iuvgit'iit. Ret'itiuiivt

w~iii 1 4 ii tihist jtt'ril .111r i w heI~EI s it i llt Ilat n g by~i~ t ;1t11 vari frefn s kiltlt I h a tl.: ailliljti hu

titt slusu lut whit'ui I his pre lirtet .114 iiut het lit' iust'tl no~t fI rt'i-u1it'uu

1)ecallst' ofi othter assoctlotel Ili)lor s'evere llujllrieps. Tile condtlit ion -esidliet llii

Summiuary.--1Tie cocetltted hat cerla111 Ii , ypes o 0 .1 lflIu.e bviih l 't. hi' iiiiredl bIhu)v t~veand ievavilaiirii ~toi( speiall 1I. huer *t the aolini lloi~eaio eZonted

Ii nes a.iue()I~ Ill'lIIIg ls .14aI~ld fora lo 1M'4'It It iti. ol' lierla illY prov edl( I uoncic l1isgt I ie.

'The ~i Isa llt, i IIlt ii'tiiu sa Idlullel fill ~ lbl he spe Iret olu~r fi a- lia evt 

111,1t pil-oppe JII(lgrliuellt llt eýxerci'ed l n dlermtn Just wvha~t and( hiow uIlvili

p olitio as i o lule was a sound1( one. Stichi a polic itw ate It po ssiblde t vcli

hue castialt u's to thle plast ic 511 rgelw cent erM ilil th Zone of InIlt erior Ill tule 1best

p~osslible tt)Idii(iloll for' fliial defitiiil wye surgical corlrect toll. The advenit of

thme ('lenloiollerei~tlItic dIruigs 1tli4l alit lbiott C iv had: i( jlrtoloiliti Impulact 111)01 (lie

SiuC(,essfl titi ul.irpilgelielt(it iifu 11,xii lfat'ia 1ci vsmii~iies ais well as of all1 othler's.
PLASTIC SiR(;I31IY 539)

Bur ins

1W direction of the Chief Surgeon, ET()USA, thle treatment of burns

that might require skini-grafting was made thle responsibility of the Senior

Coiisuiltaniti in Plastic Surger-y. Ini view oft tie fact that so ninny burn casualties

were. expected to fall into this categrory, the Chief Surgeon andl Col. Elliott C.

Cutler, 11C, Chief Consultant in Surgery, E'TOUSA, asked the Senior Consultanit ill Plastic Suirgery to formnulate the policies for the treatmeneit and

evacuation of all1111bur casualties. At tile timle Colonel Brown, the first Senior

Consultant. in Plastic Su rgerv, E'1')ISAt, and this author arrived overseas

in July 19)42. there was still conisiderable dlebate within the -National Research

(Couincil andl thle Surgreon General's Office over the problem of "closed" and

"4open' treatment of burns. At this time. "closed- and "open" methods referred to treatment by escbiar-formingr proteinl lrecilpitants Such as tannic

acid, andI non-eschiar-formning dlressings such1 as bland ointment or plaini gauze.

Since Colonel Browii hiad always beeni an advocate of openi methodls of

treatment, there was never any (quest ion inl the Eutropean theater about which

wouldl beC used1. At the out brea k of thle wvar. the use of tann ic acid for the

slirface treat ment of buirns was still the ollicial policy of the Army. By late

1942. this policy was changed by (direct ives- froni the Surgeon General's Office,

and 5 percent sulfadiazine inl a water soluble creani base was advisedl. Tannic

acid was taken oft tilie tables of supply' . andl 5-lerceiit-slilfadliazine c~reamu was

inisertedl. Early, in 1943, the Cocoantit G rove (disaster occurred in Boston and

tile yohililimiioiis writing' following the treatment and( st udy of these burn

casualties. along with furlther Stud~ies by thle -National Resea;rch Council, led

to tile withldra wal of Still fadiazine for local t reatmuent of burns by' the Office

of The, Surgeoni General because of the danger of tomie absorp)tioni of the

drug froii thle burii surface. These various occurrences ledl to complete confusion ill tilie ininds of tilie indi~ividuial medical officers who were to hav e the

esoisifiit y of treatiing burn casunlties under combat conditi bus. Studie

eiiiaiiat ing fromt treatmient of tile C ocoanuit Grove firec;1sualties led to the wideSpread belief lhat not only shouild treatment of the burnii surface be restricted

to tilie appl)1icat ion of a b~land~ oinlt ment but. any prelimininary cleansinig aIn

(lebrideleient of the burn-1 vould be dispensed withI.

Th'le Sen ior ( onslilt ant ill P last ic Surgery disagreed wit li1 both of these

coneepis inl thle treatmeiit of wvar b urns. A ~)oiinwas thenl instituted Inl

tho Eu ropeaii thea teir to brief all i ncoiminiig imed ical iiiiits concernling a1 St andardlizedl iiet hod of t reat iiig b urns aiid ito insure that each hiospital~ unit had1(

a well-definled Plan of admiitt ing, sort n1g. and treating these casiialt ies if they

should arrive in large mmiimbers. Ini all planning'- at that tiime, thought hand to

be givenl to the possibilityv of mass civil ian as well as ni iiit arv casua~ltie.s. It

was believed to be possib~le that mninn civilian casualties might result fromt

eemy11 b onmbing, as inl tile Battle of Britain. It was believed iuandatorv that

some1 smn1bianmce of sta nla rdizat ion of t reatmiient of biirii asiinlt ies be estabI ished. Thlmis was not neeolinpl ishied w ithiout, Somie d ilhicili v. Many first

71u7D0415- -0b4 ----- 37
540 A('TIVITIES OF SUIRGIGCAL CONSULTANTS

aid kits, particularly those kits supplied to the ,rmored divisions, were still

arriving in tile theater containing tannic acid jelly. It was also of interest that,

during the height of this educational program, a prominent visiting .•urgeon.

from the United States gave several very important lectures ill which he not

only deprecated the use of local antibacterial agents and of local cleansing and

debridement, but also created doubt and confusion concerning the efficacy of

plasma replacement therapy in resuscitation. With the endorsement of Colonel

Cutler, Senior Consultant in Surgery, and General Hawley, the C(hief Surgeon,

tile policy was established in the European theater that burns would be treated

by gentle and careful debrideeient and cleansing when possible, and the burn

surface would be covered withi a thin layer of fine-mesh gauze imnpregnated

with 5-percent-sulfadiazine cream over which would be placed a pressure dressitg. The policies con'erning the treatmnent of burns, is cr'stsallized in tile

Manual of Therapy. ETOUSA, appear in appendix G (p. 993) of this volume.

An interesting facet of this story was precipitated by the withdraN, t from

the tables of supply of the 5-percel'int-sulfadiazine cream by direction of the Office of The Surgeon General and upon the advice of the National Research

Council. Again, with the backing of the senior medical officers of the European

theater, it remained the policy that. sulfadiazine cream would be used, and an

atteml)t was made to l)rocure the drug from local British sources. Unfortunately, the British could not p)roduce sulfadiazine in adequate quantities at that

time. A substantial quantity of sulfadiazine powder was therefore ordered

from the United States, and arrange-mnts were made for its incorporation in a

cream b)ase by British drug firms. However, when the sulfadiazine powder

arrived (almost 2 years later) it was well past 1)-day, and the matter of local

chemotherapy in the treatment of burns had faded into insignificance with the

advent of unexpectedly adequate supplies of penicillin. It was suggested by the

Senior Consultant in Plastic Surgery that the sulfadiazine powder residing in a

warehouse in London be turned over to the British on reverse lend-lease. Two

weeks after this was accomplished, the Eighth Air Force had traced this supply

of the drug and requested it for use on their bomber crew personnel as a prophylactic to reduce the incidence of upper resl)iratory infections and otitis media

which were exacting such a toll from the crew members. What became of the

ton of sulfadiazine l)owder is not, known, l)ut this consultant was immensely

relieved to have heard no miore about it.

In retrospect, the advocacy of 5-percent-sulfadiazine cream in fine-mesh

gauze for the treatment of all burns was probably poorly advised. It was used

extensively during the early p)art. of the war and, so far as this author is aware,

there were no deaths directly attributable to overdosage from absorption of the

drug from the burned surface. However, it was recognized that this danger did

exist. There is no doubt in this author's mind that this was an effective way

of controlling infection of the burned surface in the early postumrn period.

However, when penicillin became available in adequate amounts, it was quite

logical to dispense with local chemotherapy and whatever hazard it may have
PLASTIC' S$1"ERlFY 541

entailed. It. was this Consulitant-s strong clinical imlpression that sulfadiazine

cream was most effectively used il tile treat ilelnt of hand burns. Here, there

was no danger of overabsorptlion, and sirface infection seemed to be better

controlled than I)" other metlhods. It is unfortunate that there were no reliable

controlled studies made oin this sllbject.

Etiology.-Accidents accounted for a large port ion of the I)rn c'asualties,

and, as might he expected, they occure'red most frequently in the wintertime.

Command directives were issued forbidding tile use of gasoline and other flammable materials for start inig fires, for cleaning clothes, and for cleaning garage

floors. Ini spite of these ellforts, high octane ga.•oline continued to be used for

slichl purposes, and1 sollie of the most severe burns occurred as a result. Because

of the experiences of the British during the Battle of Britain, a high incidence

of biurns from the Eighth Air Force was expected. Ilowever, burn casualties

from this source were never received ill tile numbers anticipated. It was believed that tile low incidlence of Air Force Iburns in tile early days resulted from

the fact that active air combat was carried out only across the Channel. Fighter

pilots fell ili Framce or G erunanv; antd bomber crews most likely to have been

subjected to burns did not get back to the bases ill England. Burns from tile

Air Force as a result of active combat were limited almost completely to those

received (luring takeoff ndii( landi(iing accidents il England. After the liberation

of prisoners at time end of the war, a large number of the Air Force casualties

were found to have suffered from burns and had lbeen treated ill enemy prisonerof-war hospitals.

The landing on the shores of Normandy did not produce the large number

of burns that might have been expected from closely packed troops in flammable

vessels landing Oil a hostile shore. The incidence of burn casualties increased

after the breakthrough at Saint-L6 wvhen troops practically lived il traveling

tanks and armored vehicles. These vehicles almost invariably burned upon

being hit, and, in tile case of the tanks which were hard to get. out of, the

resulting burns among the crew were very severe. Flash lurns from bazooka

iire were occasionally seen but were not common. Blirnis from white plhosphioruis

and chemicals were comparatively rare. An unexpected and not infrequent

type of burn was that occurring in plaratroopers when they struck high tension

wires during descent, with resulting limited but deep electrical burns.

An estimated 90 percent of all burns involved only the hands and face.

A majority of the hand and face burns were superficial and could have been

completely eliminated by the slightest degree of protection. In spite of continued efforts, it was imt)ossible to get air force personnel to wear gloves as a

precautionar- measure against, burns. The attitude of the young flier Nias that,

while flying in combat, protection against burns was the least of his worries.

He would not hamper himself by wvearing gloves, nor would lie consider any

face protection that would restrict motion or limit the field of vision. Essentially

the same philosophy was characteristic of the tank crewmen. Ordinary clothing

was adequate protection against flash burns elsewhere on the body.
542 ACTIVITIES OF SURGICAL CONSULTANTS

Evacuation hospital.-I)uring combat, the evacuation hospital provided

the first opportunity for the effective treatment of burn casualties. For resuscitation, reliance was placed on plasma and on saline and glucose solutions in

adequate amounts. After resuscitation, the burn casualty was taken to the

operating room and the burn surface was cleansed of dirt, clothing, and hanging

devitalized skin. The dirt and filth that covered many of these wounds made

it seem inadvisable to apply dressings without some effort at cleansing and

debridement. Frequently, a mild soap or detergent was used gently on the

burn if the condition of the patient permitted it. A good many burns were

of limited surface extent and were not associated with other injuries. Under

these circumstances, a meticulous debridement and cleansing seemed advisable.

Burn surfaces were covered with 5-percent-sulfadiazili cream, petrolatumimpregnated gauze, or boric acid ointment gauze, and a pressure dressing was

applied. Often, plaster splints would be added for imnmobilization. The

casualty was then held, and resuscitation therapy was continued until his condition was considered satisfactory for evacuation. Patients with severe burns

traveled poorly and often had to be held for several days before they could

1)e safely moved. Evacuation was through regular channels by hospital train or

air.

General hospital.-Upon reaching the communications zone, the bad

burns were transported to hospitals designated for their care within a hospital

center. In the United Kingdom Base Section, there were always hospitals that

had been designated for plastic and niaxillofacial surgery and had been prepared with adequate physical facilities for the management of complicated

burn casualties. The plastic surgeon and his team in these hospitals worked

with members of the general surgical service and medical service in preparing

the burn casualties for the necessary skin-grafting operations. The 10 specialty

hospitals in England treated the great majority of burn casualties occurring

in the European theater, and the standard of professional management was

uniformly high. The casualties were cared for by nurses, orderlies, and

medical officers with a special and detailed appreciation of their needs. Saline

bath units had been provided in eight of the specialty hospitals in England,

and they were used extensively to make the changes of dressing as painless

as possible and to promote hygiene of the wound (fig. 198). During the period

of preparation of the wound for grafting, the general care of the patient was

of utmost importance. His feeding and his state of morale were factors demanding constant attention. Corpsmen placed in charge of these patients

were often combat soldiers on limited duty after having been burned in combat

and having gone through treatment similar to that which they were now overseeing. The morale factor provided by these corpsmen as well as the enormous

physical effort. they expended in caring for the casualties in these burn centers

was tremendous and cannot be acknowledged adequately. During the heaviest

phase of the war, the burn centers were uniformly filled to capacity, and several
PLA.STIC IH IK~ 1

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544 ACTIVITIES OF SURGICAL CONSULTANTS

of them worked on a 24-hour basis in keeping up with the resuscitation, dressing, debridement, saline tubing, and skin-grafting of these badly injured

soldiers.

The saline bath units consisted of fronm one to four large tubs placed in

rooms provided with adequate heat in the hosl)ital selected and designated for

the handling of burn cases. Some of these hospitals were selected before and

during construction, and the burn units were incorporated in the hospital plan.

In other completed hospital plants, or in those taken over from the British,

an existing ward was modified and the saline bath units were added. The

tubs were obtained from a firm in Scotland and were large and of cast iron

with a thick, high-grade porcelain that would permit satisfactory cleansing

and sterilization. The units were used during the late stages of treatment of

burns and were considered particularly necessary for those burns involving

the trunk, buttocks, and lower extremities. The first burn dressing in the

general hospital was usually done in the operating room under light general

anesthesia. This first dressing was usually from 2 to 6 days, or longer, after

the initial application of the dressing in an evacuation hospital. Subsequent

dressings were usually done in the saline bath units, at which time debridement of sloughing, devitalized tissue could be done most advantageously.

This procedure greatly decreased the pain of dressings and facilitated the rapid

healing of the wound surface and its preparation for grafting if this was going

to be necessary. The bathrooms were supervised by medical officers and nurses.

Much of tihe actual work was done by corplsmen who were trained to do

the dressing, cleansing, and debridemelit of wounds and the filling, emptying,

and cleaning of the tubs. These were the enlisted men, a good many of whom

had suffered severe burns themselves and had been through one of the treatment centers. The possibility of cross infection received careful study and

consideration. Casualties with active hemolytic streptococcal infections were

either not subjected to saline batlis or were submitted to the procedure in a

bath reserved for their use. Other organisms presented no difficulty from

cross infection if the tubs were proI)erly cleansed. Cleansing of the tubs was

done with hot water and soap, followed by an antiseptic detergent. ('etyltrimethvlainmoniwni bromide, a British preparation, was the detergent most frequently tise(l. This detergent was also found to be very good for the primary

cleansing of the burned surfaces anid for the subsequent cleansing of the wound

and the surrounding skin. Submission of patients to saline baths had to be

done with some canution. Reactions were not uncommon, and occasionally a

sick patient had to have the baths discontinued. An effort wii5as made to keep

the teml)erature constant at about 105° F. and to keep the degree of salinity

at normal by manual nmanilulation of the inflow of water and the addition of

salt. It was not believed to be of great importance that these factors be absolutely controlled so long as the patient was comfortable and the solution was

not allowed to become hyipertonic. The baths offered an excellent opportinity for exermise of immiuscles and joints, and, with the muininmun of effort.
PLASTI( SURGERY 545

it was possible to prevent the marked deformities that so often have a tendency to occur before skin-grafting call be done. The baths were a very

great, factor in maintaining the morale of the patient, particularly if the patient had been unfortunate enough to have undergone a series of changes

of dressings without baths before admission to the specialty hospital.

With the professional talent available and the physical facilities provided, it seemed advisable to e.tablish the policy that all burns would be held

until they were healed or grafted. These same intensive efforts that were

aimed at gettin(r the burn wound ready for grafting were equally effective

in promoting healing. Care had to be exercised not to graft unnecessarily.

It was to the credit of the niedival offi'ers taking care of these patients that

hundreds of them were succes-,sfully grafted at an early (late with resultant

restriction in disability and loss of function. Immediate burn excision and

grafting was not practiced except in an occasional case of electrical burn.

The general practice was that of repeated debridement and dressings until

the wound was clean enough for graft. If, by that time, the remaining thirddegree loss was great enough and appeared to warrant it, a split graft was

applied. The advent of penicillin to help control infection contributed greatly

to the success of early grafting. The ma, tially operated Padgett dermatome

was available in the theater l)ut was not an unmixed blessing. Good blades

were available for those surgeons capable of cutting free hand grafts. Socalled stamp grafts and pinch grafts were used occasionally in special

situations.

Burns of various parts of the body presented different p)rob)lems, but

two areas in particular warrant special comment. Eyelid burns were very

frequently ohserved. If these were severe enough, the r1roblem of management

in a communications zone hospital in l)rel)aration for evacuation to the Zone

of Interior was a very trying one. The concern was primarily one of protection of tile globe and preservation of sight. Almost invariably, patients

with severe eyvelid b1urns would have severe burns of the hands amd could not

be depended upon to take care of themselves during evactuation. In those

cases iin which lid eversion inade it evident that the cornea was endangered,

it seemed adh'isable to make some effort to decrease the (Langer by promoting

lid adhesions or by. grafting the lids (fig. 199). A decision as to just what to

do for an iinmdividual casualty was frequently very difficult. It is beyond the

scope of this preselitation to gro into this matter iin detail. Suffice it to say,

grafting of lids should not be done in a theater of operations if it can be

avoided without. eindangering the cornea (fig. 200). It can be said also that

the promotion of lid adhesions is not an entirely effective method of protecting

the cornea since, iii the severely burned lid, the contracting force is great

enough to cause the adhesions to stretch and reexpose (lie cornea to ulceration

(fig. 201). The situation is one demanding the most stringent, nursing care

and time closest collaboration between ophthalmologist and plastic surgeon.
;'4 r";C L I T T

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5-18 ~~~~~ACTIVITIES OF' SUIIUWAT L)N UIA ''

MIMI

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550 A('TIVITIES OF SURGICAL CONSULTANTS

Burns of hands were obviously of very great imp)ortance from both tile

numerical and functional standpoint. It was with hand burns that the prevention of edema and early control of infection were found to be of such great

practical value, since the ultimate loss of full thickness of skin was as dependent

on these factors is on the initial thermal injury. A burned hand allowed to

develop uncontrolled edema not only resulted inl embarrassing the circulation

of the tightly stretched skin of the (lorsuin but made this skini more susceptible

to infection. In this way, large areas of skin that were not destroyed by the

initial thermal injury could be converted into third-degree burns. Therefore,

it was the aim to make hands surgically clean as early as possible and to control

edenma I)y effective pressure dressings and elevation. The position of the hand

and fingers during this period of immoioilization was, of course, considered to

be of great iml)ortance. The initial hand dressing was left on for from 6 to

8 days, following which exercise of the hand in saline baths and careful daily

debridement was started. From this time on, supervised active exercise was

emphasized in maintaining flexibility of the joint capsules. The burn was made

clean and debrided of eschar as rapidly as possible. When the hand was clean

enough for graft, it was carefully evaluated to determine whether the overall

function of the hand could be more benefited by grafting with its attendant

period of immobilization, or by continued exercises while spontaneous healing

p)rogrresýsed (figs. 202 and 203). A decision was made upon the merit of each

individual case, with the realization that preservation of function depended

upon early grafting when it. was really necessary but that function could be

lost by unnecessary grafting and its associated period of immobilization.

Summary.-1)uring the buildup phase before the invasion of Normandy,

this author had rather grandiose plans for detailed study of burn casualties.

He was even successful in having the Chief Surgeon's Office approve certain

directives and statistical forms and charts which lie hoped to accumulate by

the thousands and from which it was anticipated valuable information might

bee secured. Needless to say, from 1)-day until the end of the war, this type

of research was out of the question and all efforts were simply bent toward

adequate care of the injured and the maintenance of lines of medical evacuation.

The author had a feeling of guilt that more positive information did not result

froit this tremendous experience. At the same time, lie had a feeling of

admiration and resl)ect for the inediial officers who performed the terrific task

of taking care. of the burn casualties in the various centers. In retrospect, it

can lIe stated without equivocation that the establishment of the burn centers

was good p)lanning an'd paid off tremendously in the results which were

achieved. Regardless of later concepts of burn treatment and cross infection.

the saline baths, as used. were effective in the handling of mass casualties during
PLASTIC' SURGERY 551

World War II, and the writer would still want such facilities. The European

theater was well supplied with highly qualified personnel and, after combat

began, they were utilized to the very highest degree possible. Some perfectly

superb work was done by various medical officers in the management of burn

casualties, p)articularly in the management. of the severely burned hands, and

it is to be regretted that the patients involved were not subsequently followed

and the results of this experience properly recorded. For those readers who

may wish to be critical, the foregoing account is admitted to be an extremely

superficial exposition of the management of this important type of casualty

during World War II in the Europ)ean theater.

Wounds Other Than Head Wounds

If one examines the medical history of World War I, it will be found that

the possibility of delayed primary and secondary closure of wounds was recognized and practiced to a limited extent near the termination of that conflict.

However, the chief impression left by the First World War was that wounds

should be debrided and left open for secondary healing. This impression was

strengthened by the intervening experience of the Spanish Civil War and the

widely publicized plaster immobilization of wounds after debridement. The

wounds treated by this manner were those of the extremities, and after adequate

debridement the wound was dressed open, usually with petrolatum-impregnated

gauze pack, and a plaster encasement dressing was applied. The plaster was

not changed for many days. The wounds did well and, if debridement had

been adequate, usually at the time of first inspection of the wound the base was

found to be covered by healthy granulations and there was no evidence of invasive infection. The transportation of casualties was simplified by this procedure as was the nursing care. The disabling effects of prolonged immobilization and healing by secondary intention were minimized.

World War II was entered not only with the background of knowledge

from World War I and the Spanish Civil War, but also with more of an appreciation of the methods whereby function of an extremity could be preserved

after a severe wound. Furthermore, the day of the wonder drugs had arrived

and the sulfonamides and antibiotics were ready for exploitation. Another

factor of very great importance was that surgeons interested in reconstructive

and plastic surgery had been demonstrating for the past several years what

could be accomplished with variotis types of grafts in the healing of wounds,

and the importance of healing extensive burn wounds by early grafts was generally recognized. It was natural that these background factors led immediately to a more aggressive method of war wound management as soon as the

medical officers had an opportunity to start taking care of casualties.
.\t*1'1\ ITIV*, Ill-' ',1 1%4;14, AI .4 1 .\S1 LTANTS

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PLASTIC SURGERY 55

regarding their treatment. It was perfectly obvious that the provision of early

healing by secondary closure would limit scarring, fibrosis, edema, and disability. It was also perfectly obvious that. the same results could be achieved

with much larger and more extensive wounds, not amenable to secondary

closure, by healing the wound with split graft.. Many such wounds were

grafted very soon after the patients arrived in the hospital. The results of

these procedures were most gratifying. The plastic surgery service at tlh 298th

General Hospital pushed the princip)les of early closure and grafting. This

principle was extended subsequently to include pedicle grafting for compound

injuries with exposed joints, tendon, and bone. At the first ETOUSA Medical Society meeting held at the 298th General Hospital in Jule 1943. the results of an extensive grafting and secondary closure of war wounds were

demonstrated, and it was predicted that such surgical procedures would play

a very great role in the treatment of war casualties to be expected when the

Continent was invaded. The conception of excluding infection from the body

by making the body surface intact was promulgated. Just exactly when and

on what, type of casualties this conception could be successfully practiced was

not completely realized at that time. Early in 1943, a soldier was admitted

to the 298th General Hospital after receiving an accidental explosive wound

of the hand with exposure of bone and tendon. This man was successfully

treated with an immediate undelayed l)edicle graft 24 hours following his injury. In the light of this success and of the experience gained in treating

casualties from North Africa, it was believed that secondary closure and free

and pedicle grafting would be possible of application to war casualties on a

large scale during the approaching invasion. The plastic surgery centers

throughout England were set up with this as one of the important functions

in mind. It later proved to be a very major portion of the work done in these

hospitals.

The wounds under discussion were alnost all confined to the extremities.

A few of them were wounds of the shoulders and buttocks (fig. 204). They

were the result of small arms fire or shell fragments which had been treated

by debridement. at. the evacuation hospital level. The condition which had to

be treated at the general hospital could l)e considered as due to the primary

missile wound and its resultant necessary debridement. When received in the

general hospital, these wounds varied in age from 3 days to 2 weeks. Many of

them were associated with compound fractures. Since secondary closure of such

wounds can be considered as a general surgical procedure, the subject is not discussed in detail in this presentation. However, the role played by the plastic

surgery centers in the treatment of the complicated soft tissue and extremity

wounds is briefly outlined.
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50S A v'riVITIS OF SUIG'RIA. 2ONs1'IurANTS

The free grafts were applied ini a fairly stand(lardized manner which usually

involved imninobilizatiojl of the extremity and some type of presstire dressing.

It. was of some importance that proper judginent be exercised and that insignifi- cant wounds not be grafted. Many woumds which appeared almost certainly

to need a graft were found to be not worthy of a graft by the time they were

clean enough for this procedure. Needless to say, a few instances were seen in

which a small wound had been successfully grafted but the soldier remained

disalled as a result of an unhealed (lonor a'rea. It has been nlentione(d p)reviously

that the derinatome was not an ummixed blessing.

Pedicle grafts.-The wounlds suitable for covering by use of a, pedicle

graft were those of the extremities in which important structures (bone, tendon,

and nerve) are. normally covered by a relatively thin layer of superficial tissue

and skill. This situation exists in the feet, ankles, anterior portion of the lower

legs, knees, hanlds, wrists, forearms, and elbows. These are all vitally important

functional areas. A good many woumnls involving these parts were of the

avulsed type which, following adequate debridemient, presented exl)osed Imme

and tendon and often open joints, impossible of closure by any other means

than the use of a pedicle graft. If these important exposed structures were to

be preserved, the pedicle graft must be applied at an early (late. This was

considered to be one condition in which a definitive plastic surgery l)rox'edure

in a theater of operations was urgently indicated. If the procedure was postpooned until the casualty arrived in the Zone of Interior, iml)ortaut function

and structures would be lost. The recognition of the need for the procedure of

pedicle grafting and its effective application in a theater of operations was a

new development in war surgery. By effective application it is meant that, the

conditions requiring pedicle grafts were widely recognized and the casualties

were accumulated into plastic surgery centers where the procedure could be

properly controlled and well d(one. There were recorded 700 pedicle grafts of

this nature, done in the plastic surgery ceniters in England alone. During the

tour of the Senior Consultant in hllastic Surgery through tile plastic surgery

centers in the Zone of Interior in March of 1945, the evaluation of the procedure

of pedicle graft by the Zone of Interiors surgeons was carefully sought. It, was

found to be held in very high regard and to be considered in many cases to have

greatly simplified later reconstructive procedures.

The preparation of the wound for peedicle graft differed slightly from the

p)reparation of a wound f,;- secomlary closure, or for covering by skin graft,

in that it, did not have to be nearly so complete. All gross sloughing tissue obviouisly needed to be removed. ]Iowever, the covering of :a woulnd by tissue
PLASTIC SURGERY 559

which was viable, and which (lid not have to rely for continued viability on

nourishment from the woun-i itself, offered possibilities which had never been

exploited to the fullest. Not only was Ahis covering self-sustaining in that it

carried nourishing blood sul)ply, but it served as a viable vascular dressing for

the surface of the wonnd where it could actually contribute to the natural

processes of overcoming infection and healing. It was felt that pedicle grafting

to accomplish secondary covering of the wound was even more physiologically

sound than was secondary closure in that there was no embarrassment of the

circulation of the wound margin by' tension or deep sutures, ,-id the wound,

always a contaminated one, was not closed in the true sense of the word, since

comIplete drainage was afforded the entire wound through the wide lnargiin to

wlhich tile graft. was not sutured.

Since the only reason for holding a casualty long enough in a theater of

operations for the application of a pedicle graft was the early l)erformance of

the procedure to preserve function, the technique had to 1e developed for this

purpose. If the peculiarities of the case were such that the graft could not be

applied to the wound for 2 or 3 weeks or longer, there was no point in holding

the patient in the European theater for the p)rocedure. It was I)resumed that the

medicalI organization in the Zone of Interior would be able to accomplish the

procedure within that period of time. If the case was such that important

structures and function would not be lost if a temporary free skin graft N, as

applied, it was better that. the free graft be done and the patient be evacuate(t

to the Zone of Interior. The procedure was, therefore, reserved for those cases

in which the graft could be applied without delay and in which early application was mandatory. The technique of application of the pedicle graft was

consequently modified in order that it might be extended to as large a number

of cases falling into this category as possible.

The great majority of pedicle grafts were done as direct undelayed flap

grafts, elevated and attached to the recipient area at one sitting. The direct

abdominal wall (fig. 206) and thoracic (figs. 207 and 208) flap grafts were

the simplest to use. In the beginning, direct grafts from the lower leg were

done with some trepidation. As experience and ingenuity increased, it was

discovered that there were few wounds from the knee down that could not be

covered with a direct graft from the other leg. It can be stated that the direct

crossed leg pedicle grafts proved to he much better than attempts to close lower

leg defects by the use of local rotation flaps. When the defect required coverage

by skin and subcutaneous tissue, the results of pedicle grafts early in the war

surpassed those of local methods of closure and the latter were discarded.
1:1, 2416, Ylliý iý ;III idl-al illu'l I-:IIif.II 4.1, Hle I.% lov I'l, injill-Y ill hich 114-Ilich.

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PATCSURGERY 6(i

1'iGiicv'E 20- '#11 itizuil. ]Itw eiti" E''I11 lle 11 ; tyimje 111. l of (hiSlI;IýgQ oft this soldivir that

lie Would get uluuuttt 's5 perte lit r'ttrit ori Itijetiji of (lit liiiil. withouitt thie iwdiele graft,

there wvouul have beven coitijlele loss oif t'iuietion. 4 Was' (if Capt. William1 AV. L. Glenn,

MC. and It. Cil. ALig'tt MtBriceri' MU. 22d 4 eiieral Housjuitail. I
LFIidin 2017.--- 'IThis caise iltills rniles lthe viiit ipsilil oft -vjid-ic('iii(t tif a iar,.g f~t-ti~siie

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iiece-ii'ar if a 'graft is it, lie siiVctssttil. (cas 'i(ofi Mafl. 4 lifluiid 1:V. Kielii. M11C. 1171hi

O ne factor fin tt accounted for th lie se of thle lower ie.,, So frequentl av;s a

Iliettts of ait'iiiisiit -ossed le.'i pedicle i'Va fts wats liat t11mai1Y of Ihese

W(Ilfiills were 'oimplica t ed 1) 'v assoc'iat ed fractures (ftig. 20O9). It was a frequent

oC itITV''Ii(We that a letlice, (ria ft 1in i&lit I IQ fii'geiftj jjppneeded. 1)11t. its ajppjict-,io

was almifost imposs55 Iible I eI'aluse of au11 oi1aIfih find tii'11e. Ak fr e de ,1 I(f

ii~eufi itV wIs pxeri'isetlI ill sol vi uir t liese, 1jo)1.01 Ilis. Ill on c5011Wd St, it wats julst ifiablie to conidsuer app))1Idal *on oI5(f tie gzraft as I elig ii o noi lImprtn a t 0).111 Ihtii 11fiiita r

('o1isideraut ioul of the fractulre'. P roIperly appl)1iedt phlast er 51)1i lit 5 oiflid SomeUtiiiies Ile muadle to hol1(1t lie fi'uttt fine ill 1oSl 'il h (Iflinilig ui~~i'uti )1 of thep gra.ft

I'la is' o1('(f Andi ersoin Splinitts was resurrected to hiel p solve Vth este prob1 lemis. anid

the ' were fouiid Ito he 1 f (I list in'et vut 1 ie ill soliuie cases for uina i iteufanite of posit jolt

diiiiiing the( pIeriod (If pr'eparationt of Ithe woundit and appllicaitioni of the grraft
PLASTIC SURGERY 563

(fig. 210). The splint was left in place only until the graft was completed, a

matter of 3 or 4 weeks, after which it was removed and the generally accepted

methods of treating fractures were instituted from this point on.

Very few delayed flap grafts were done. Obviously, if delay was necessary,

the job might just as well be done in the Zone of Interior. However, there were

"a few instances in which the procedure could be simplified and the certainty of

"a satisfactory outcome increased by delaying the pedicle graft. This would

often be done while the wound was being prepared to receive the graft.

Tubed pedicle grafts were found to have very little application in solving

the needs of early grafting in a theater of op)erations. Even when tile time

element was of no importance, tubing of the graft was considered to be a sulperfluous procedure.

Pedicle grafting was not used for facial reconstruction in the communications zone. It was felt that this was a procedure better done in the plastic

surgery centers in the Zone of Interior.

Summary.-The opportunity of using l)edicle grafts in the treatment of

complicated war wounds on such a scale as was done in the European theater

was a unique exl)erience. There is no doul)t that it served a great piurpose in

the preservation of function in many extremities.

Treatment of Hand Injuries

Plastic surgeons had long been interested in the prol)]ems presented by

the injured hand. Long before the invasion of Normandy, burned hands and

the severe wounds of hands received accidentally in combat training were

recogiized as acute p)rol)lems. After the Normandy invasion, it was discovered

early that. hands were going to form an unexpectedly high percentage of

casualties and that the principles involved in treating hand injuries were not

generally recognized. The plastic surgeons were then interested prinmarily

in rep)lacing the soft-tissue loss in the avulsed type of injury (figs. 211 and

212). This had been practiced as an early procedure previously at the 298th

General Hospital in England. This problenl having been recognized, cases

were searched for throughout the hospital centers in England and those requiring pedicle grafts were transferred to the hospitals designated for plastic

surgery. This accumulation of the severely injured hands in the plastic

surgery hospitals led to the logical conclusion that the best method for handling

aill hand injuries was to l)lace themn in special services under interested, qualified personnel.

On 4 September 1944, a memorandum on the subject of development of

hand centers (app. 11, p. 999) was submitted to the Chief Consultant in Surgery

and referred to hand centers in both the communications zone and the Zone of
41b

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ACTIVITIES ()F SI'M;ICAL CONSI'LTANI'S

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PLASTIC SURGERY 569

Interior. Following this, hand centers were developed bothi ill Einiglan(d anid

on tile (Cot inent. It was the aim to have each center under the supervision of

b)oth a (u1111lified ortlopedic surgeon alnl( a plastic surgeon. Withi the coo(Mperation of Col. Mather Cleveland, MC,1 Senior Consultant in Orthopedic Surgery,

most of the hand centers were located in the hospitals designated for plastic

surgery. Altlough this was a very definite step forward, it Iby Io meianis solved

the prol)lem of adequate care for hand injuries.

With tie start that was made, it is believed lthat, had the w.r p)rogresse(,

the organization would have resulted in a standard of care for hand injuries

never before equaled. Iinfortunately, this state of affairs was far from being

reached by the end of the war. The difficulty resided ill the fact that the plastic

and orthop)edic surgeons themselves had much to learn, and the resp)ective consuiltaiits were slow ill recognizilng tie need for fundamental changes in overall

p)olicies. The surgeons in the hand centers believed at an early stage that

lhey had reached an iml)asse because they were not receiving the casualties

early enough after the injury. This led to the idea that possibly more (letinitive

surgery slhouhl bee done at the evacuation hosp)ital level. The standard of care

at the evacuation hospital level previously had not been high. Although it

Illay be ullnderstanlda)le tlat the surgeons at the evacuation hlospitals were illore

concerned with injuries of a more serious nature, it hardly justifies the delegation of injured hands to surgeons of the least experience, as was frequently

done. In March 1945, a directive was issued stating that hand injuries shouhl

be clcsed after they were debrided in the evacuation hospitals. The results

of this policy could never l)e determined with certainty b)ecause the war ended

soon after it was put into effect. It is, indeed, doubtful that much would have

been accomplished by this change in policy.

Hand wounds with such loss of soft tissue that important underlying

structures were exposed fell into the category of those amenable to pedicle

grafting. The procedure of pedicle grafting of such wounds had certain

shortcomings and limitations, the most notable of which was the unavoidable

limitation of motion and poor position often necessary during application

of the pedicle graft. With proper care, these objectionable features could,

to a large extent, be avoided. It was possible to have good position and active

motion maintained during the time the graft was being applied in most, but

not all, cases. It took fine judgment to weigh the disadvantages afforded by

these ob)jectionable features against the need for pedicle graft and to decide

whether the procedure should or should not be done. This author's views at

the time on the treatment of hand injuries were set forth in a memorandum,

dated 5 March 1945, to Colonel Cleveland, Senior Consultant in Orthopedic

Surgery, ETOUSA, (app. I, p. 1001).

Scleveland. Mnthir : Chnpter IV. Hand Injuries In the European Theater of Operations. In

Medical Department. United States Army. Surgery In World War 11. Hand Surgery. Washington:

U.S. Government Printing Office. 1955.
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CHAPTER IX

Urology

John N. Robinson, M.D.

Maj. Gen. Paul R. Hawley, MC, Brig. Gen. Elliott C. Cutler, MC, and

Col. James C. Kimbrough, MC, organized in ETOUSA (European Theater

of Operations, U.S. Army) the finest surgical consultant system the U*.S. Army

has ever known. The system was initiated with the arrival of U.S. troops in

Great Britain and was gradually curtailed after V-E Day. On 5 October

1943, Maj. (later Lt. Col.) John N. Robinson, MC (fig. 213), was aw)-,ointed

Senior Consultant in Urology, ETOUSA, in addition to being chief of arology

at the 2d General Hospital.' The small volume of troops and the small number

of urological cases at this time made this part-time arrangement possible.

Soon, however, the volume of work increased so much that it became necessary

for the author to devote full time to this job. Thus, he became the only

consultant in urology to be appointed at a theater headquarters level during

World War 11. The general duties of senior consultants in the European

theater have been enumerated elsewhere. Briefly, they may be characterized

as being "the eyes and ears of the Chief Surgeon."

JUSTIFICATION FOR A SENIOR CONSULTANT IN UROLOGY

How was a urological consultant justified when there were general surgeons available who might possibly cover this field?

First, it is necessary to recall that the development of Specialty Boards and

certification had grown between the wars and that urology had become a specialty recognized by the leading societies and medical schools. In ETOUSA,

as well as in the UT.S. Army as a whole, the many civilian doctors who had

volunteered for service were not qualified to do urology when compared with

a certified urologist. Hence, with one or two urologists in each hospital and

over 200 hospitals in operation, it was natural that there should be a urological

consultant. Only one urologist had been certified by the board in the peacetime U.S. Army immediately prior to the period of limited emergency declared

in 1939.

Second, in an oversea theater, it was not always possille to use civilian

consultants as in the Zone of Interior, and the Army wollld have been open to

criticism if the best specialty care had not been available.

SOffleq, Order No. 40, Ofeice of tlir Chief Surgeon, 1hiendqumrters, Europeazn Thiqater of Ope,'athons.

U.S. Army. 5 Oct. 1943.

573
574 ACTIVITIES OF SURGICAL CONSULTANTS

Third, the general surgical consultants were so busy that they did not have

time to attend to the details of urology, did not know the personnel, and, in

some instances, were not familiar with certain new developments.

Fourth, the positive reasons for this appointment, from the writer's point

of view, were that the urologist in a general hospital had no one to consult, no

one with whom to discuss new developments, and no one with whom to air

p)roblems. Also, the consultant's visits were often a means of solving problems

of a personal nature, especially in making some of the junior officers feel that

they were needed and that someone above the hospital level was interested in

their welfare. In other words, it, helped the morale of these officers. There

FIGURE 213.--Maj. John N. Robinson, MC.

were also times when the consultant helped in ascertaining the capabiliti es of a

hospital urologist as an aid to the chief of surgery and the commanding officer.

The commanding officers of hospitals were always most helpful and cooperative.

Fifth, as the number of hospitals and urologists increased, a need for

meetings developed for the purpose of discussing urological p)roblems and new

developments and formulating plans for the future. This author organized

and held ap)proximately nine, of these meetings in Greaxt. Britain and on the

Continent. Many of these meetings were held at the time of large Allied

medical meetings so that urologists in the theater were able to attend both.

From 15 to 45 urologists attended these sessions. Much of value came from

these meetings; and, nee(lless to say, they would not have been held had it not

been for the fact that there was available someone with the ability to initiate

and direct them.

Sixth, it is almost impossible to secure accurate and valid statistics after any

war is finished. Regrettal)ly, this collection of statistics did not start soon

enough in the European theater; but, eventually, worthwhile information, based
UROLOGY 575

on reports received from the evacuation, station, and general hospitals in the

theater, was compiled. One of the most important reasons for having special

consultants was to direct the gathering of medical information. Also, a

specialty such as urology needed representation in order not to be left out

in planning for the future.

Finally, the writer was of the opinion that, had Colonel Kimbrough, Chief

of Professional Services in the Office of the Chief Surgeon, not been a dedicated

urologist, there might not have been a Senior Consultant in Urology in the

European theater, in spite of all other cogent reasons for appointing such a

consultant.

ACTIVITIES OF THE SENIOR CONSULTANT IN UROLOGY

Colonel Kimbrough was the acting urological consultant from 1942, when

U.S. Army hospitals first arrived in the United Kingdom, until the appointment

of the Senior Consultant in Urology in October 1943. In these early days,

supply and administrative considerations were of the first order, with the

result that, at the beginning, there was not much urology practiced other

than some treatment of gonorrhea and a few operations. Often, the urologist

learned to become one of the best foraging officers in the units (fig. 214). At

times the British food and equipment were trying, but everyone soon became

acclimatized. The first responsibility was to get back to duty every soldier, in

preparation for the invasion. After the Senior Consultant in Urology was

appointed, monthly visits to each hospital were made; but this soon became

impossible due to the increasing number of hospitals.

In this period before the invasion, everyone was busy with the planning

and improvisation necessary to take care of expected casualties (fig. 215).

Most of this work was routine, but the use of penicillin in the treatment of

gonorrhea was of great interest. Its first use took place at the 2d General

Hospital, which was located near Oxford, where Dr. Howard E. Florey was

developing penicillin for clinical use. At first, small (loses of 10,000 units every

hour or 2 for 10 (loses were given, and then larger doses, until finally a large

single (lose was accepted as the standard methlod of treatment. The first war

casualties from air raids over the Continent were also received in this period.

Data gathered from the operational research unit. of the Office of the Chief

Surgeon, ETOUSA, showed that, of 147 airmen killed in action, 9.5 percent

had injuries to the genitourinary tract in addition to their fatal injuries.2

Another important service performed by the urological consultant was

the writing and editing in collaboration with Colonel Kinibrough and Maj.

Howard I. Suby, MC, of the urological section of the "M.Naual of Therapy,

European Theater of Operations," a guide to the handling of all severe genitourinary injuries.'

2 (1) Klmbrough, J. C.: War Wounds of the Urogenital Tract. J. Urol. 55: 179-189. February

1946. (2) Medical Department, United States Army. Surgery in World War II. General Surgery.

Volume I. [In pr-paration.] 3 .Manual of Therapy. European Theater of Operations, Surgical Emergencies, Section It. VIII.

Wounds of the Genito-Urinary System.
576 ACTIVITIES OF SURGICAL CONSULTANTS

During the early days of the invasion, before. hospitals could be established

on the Continent, Colonel Robinson's duties consisted of visiting hospitals set

up along the south shore of England to assure that urology was well taken

care of and. as did all surgical consultants, to carry out orders of the Chief

Surgeon concerning general surgical matters. As the hospitals began to function on the Continent, hospital .enters began working fully, and, in some of

RED COUNTING PIPETTE

SCALE FOR CYSTOMETRY

IRRIGATING SOLUTION

33" MOVABLE SYPHON

URINARY BLADDER

I S H

; E- 12" - ,

SYPHON CLAMP CLOSED

DURING CYSTOMETRY

FIGURE 214.-A drawing of a portable tidal drainage-cystometer set designed and built in the European theater.

these, special treatment. facilities were set up to take care of special problems. With the exception of neurogenic l)lad(lers associated with paraplegics,

there was no need for genitourinary special treatment. facilities because there

were a suflicient number of well-trained urologists. Thus, all plroblems could

be taken care of in any of the general hospitals (fig. 216). There was a

urologist, for all but one general hospital. All hut, a few station hospitals had

a urologist, and those that. (lid not. had consultation availal)le at a short distance.

The evacuation hospitals ha •at least one cI)apble urologist per field army available for consultation.
I'll H N -,77

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CtlAPTER X

Anesthesia

Ralph M. Tovell, M.D.

When this writer (fig. 218) was requested. in November 1954, to prepare

for publication a personal account, of his experiences as Senior Consultant in

Anesthesia to the Chief Surgeon, ETOUSA.. (European Theater of Operations,

U.S. Army), he was hesitant about acceding to the request, for he realized that

it would be difficult to recapture the spirit, and anxieties of the national effort

during World War II. In addition, failures of memory were likely to occur

when one attempted to recall events after the lapse of almost 10 years since

the European campaigns had b)een successfully terminated. He was aware of

the fact that lie had a copy of a factual account, of anesthesiology in the European theater that had been prepared at the end of the war as a part. of the

medical history of the theater in World War II. Little did he realize the difficulties that would be encountered once lie undertook to refer to source material in the preparation of this chapter. When this was attempted, there immediately arose a conflict between the recorded data worthy of publication

and the events that would be interesting to those who might read this volume.

It is in the shadow of this background that the writer attempts to capture the

reader's interest.

CALL TO ACTIVE DUTY

When the United States entered World War II on 7 December 1941, it was

expected that the writer would be declared essential and that military service

would fall to the lot of members of his staff at Hartford Hospital, Hartford,

Conn., who were younger. It was, therefore, with some surprise that he received

a call from Col. (later Brig. Gen.) Fred W. Rankin, MC, Chief Consultant in

Surgery, Office of The Surgeon General, on 3 July 1942. Colonel Rankin's

conversation was very much to the point. Colonel Rankin stated that there was

a job he wanted this writer to do and that lie would like him to come to Washington to discuss the program. In 1942, Independence Day fell on Saturday.

The writer intimated that because of the holiday Colonel Rankin might. not

want to see him until Monday. Colonel Rankin's reply was specific. He stated

that the Office of The Surgeon General was in full operation on Saturday and,

as civilians might well realize, there was a war on. The writer reported to

Colonel Rankin at 0900 hours on Saturday and was briefed regarding his

prospective duties and responsibilities as a consultant in anesthesia in the European theater. The interview ended with the instruction that he return to Hart581
582 ACTIVITIES OF SURGICAL CONSULTANTS

ford and coordinate the program with the medical director and the staff of

Hartford Hospital. On Monday, 6 July, the writer called and informed Colonel

Rankin that lie would be ready to report when orders were issued.

It had been anticipated that the writer would receive a majority. However,

when ihe discussed this matter with I)r. Wilnar X. Allen, director of Hartford

Hospital, I)r. Allen expressed the op)inion that the rank offered was not commensurate with the responsibilities to be undertaken. It was, therefore, with

some satisfaction that the writer subsequently received orders specifying that

lie would report for duty in the grade of lieutenant colonel. On 20 August lie

was sworn in as an officer of the Army of the United States, and on 26 August

FIGURE 218.-Col. Ralph 31. Tovell, MC.

Lt. Col. (later Col.) Ralph M. Tovell, MC, reported for duty in Washington.

He was assigned to Walter Reed General Hospital, W'ashington, D.C., for the

usual course of indoctrination which was hyphenated in order to permit him to

splend considerable time in the Office of The Surgeon General.

ORIENTATION IN THE UNITED KINGDOM

The author proceeded from New York City to London by flying boat via

Halifax, Nova Scotia, and Foynes in southern Ireland. His orders stipulated

that the trip be made in civilian clothes. The trip was uneventful until the aircraft landed in the harbor at Foynes. There, the crew found that the tide was

running in one direction and the wind was quartering from another. They

taxied the flying boat. over the choppy water for approximately 45 minutes,

during which many of the passengers became seasick even though they had

avoided ai rsickness during the trans-Atlantic trip. At Shannon t he passengers
ANESTHESIA 583

were taken to the airport by bus, where they, as a combined force of civilians,

Red Cross workers, and Arniv officers. were required to stand inspection ibv

custons and ilumigration officers. For this procedure, the ant hor was fortunatie

enough to stand in line behind a Regular Army colonel. Because three planes

had landed within a few minutes ,)f one another, the congestion of passengers

awaiting planes for England was considerable. As the travelers were slowly

making their way forward to the inspection points, it was announced over tie

loudspeaker system that all military personnel were to conte to tile head of tile

fine. This was a rather startling announcement to Army officers supposedly in

disguise and particularly so to a lieutenant colonel who had been in thle Army

less than a month. After a quick whisperel conference with the Regular Army

colonel preceding him, the two decided that this was no trick leading to interninent in, a neutral country. rile two colonels prompt lV moved to the head of the

line where the necessary formalities were accompl ished with dispatch. This

incident. made a vivid impression on the antthor, and he was forced to alter his

concept of neutrality, particularly of tile soutlhern Irish variety. In subsequent

conversation with military friends, he learned that there , ,re 150,000 southern

Irish in the British Army. lie was asked: "Un those circumstances, what

kind of neutrality could you expect ?"

Soot, the passengers were winging thleilr way to Bristol, England. in a

British plane that was entirely blacked out. The trip from Bristol to London

was made by train. The author arrived in London at approximately 2300 hours

on 2;- September 1942 and suddenly was thrust into the utter darkness of the

London blackout. It is difficult to describe this consultant's discomfiture. He

found himself in a strange land without. adequate knowledge of the Army

procedure to be followed in finding a billet. However, organization was goodi,

and transp)ortation was at hand for conveyance to the billeting office. It was

surprising how well and ]how easily [.S. Army drivers were able to wend their

way through busy streets of a great metropolis pulsating with life in the

darkness.

On the morning of the next day, 26 September 1942, the author reported

at ETOUSA headquarters, 20 Grosvenor Square. Ie was informed that lie

was to be reassignled immediately to Headquarters, SOS (Services of Supply),

at Cheltenhain, England, a city approximately 90 miles west, of LI)ndon and

some 3() miles beyond Oxford. He procee(le( to Cheltenhainl by traini and once

again went through the prescribed procedure of getting bedded down. this time

at the Plough Hotel, a hostelry about 200 years old that, in days long gone by,

had been used as a terminal for stagecoaches plying their routes in the Cotswolds

district. More recently, the hotel had been occupied by permanent residents

including elderly widows and spinsters and a smattering of British Army

officers, retired from the Indian Service. This hotel, along with many others

in the town, had been requisitioned by British authorities for U.S. Army personnel. In spite of the dislocation of the permanent residents, the reception

of a growing horde of Americans arriving to staff a continually growing headquarters was remarkably amiable.
584 ACTIVITIES OF SIURGICAL CONSULTANTS

The next morning, the author reported for work, physically ready for it

but mentally in very much of a quandary regarding the future. Ile met his

new superior, Col. Jamnes C. Kimibrough, MC, who had been assigned the unenviable job, for a Regular Army officer, of riding herd on a group of senior

consultants representing the several specialties in medicine and surgeryindividuals whom he could not help but look upon as civilians in disguise and

who were reputed to be prima donnas in their civilian practice at home. Colonel Kintbrough met the challenge of his assignment with fortitude and with a

diplomacy that might be unexpected of a Regular Army officer who had been

born in the mountains of Tennessee. His advice and his encouragement were

forthright. When all other attempts failed to orient civilians who could not

hav'e been other than stupid in their p)ractices at home, he was able to quote

volubly front the Bible to illustrate his point. The personnel of the Professional Services I)ivision, Office of the Chief Surgeon, Headquarters, ETOUSA,

were indeed fortunate to have as their chief "sheepherder" a urologist, professionally competent and renowned, who spoke in professional medical terms

rather than in military jargon. In addition, he was capable of orienting them

in military thinking. He guided them through the maze of military procedure,

the utilization of which was so necessary in order to accomplish their mission

in a growing Army that was preoccupied with tables of organization and equipment. They of the Professional Services I)ivision are ever grateful for his

leadership.

This consultant also met Col. (later Brig. Gen.) Elliott C. Cutler. MC,

Chief Consultant in Surgery, and Lt. Col. (later Col.) William S. Middleton,

MC, Chief Consultant in Medicine, Professional Services I)ivision, Office of

the Chief Surgeon, ETOUSA. Maj. (later Col.) James Barrett Brown, 31C.

Senior Consultant in Plastic Surgery, and TA. Col. (later Col.) Loyal Davis,

M(. Senior Consultant in Neurosurgery in the division, had been resident in

the theater for several weeks prior to the author's arrival. They were all very

helpful in orienting him in problems they had faced and in prol)lells they

knew he would face in the near future. Their help and advice were greatly

appreciated because this author, ais the first Senior Consultant in Anesthesia

appoinited in the IU.S. Army, had no precedents to follow. Fortunately, great

latitude subsequently was allowed him in organizing a, program.

EARLY ACTIVITIES AND RECOMMENDATIONS

D)uring this period of groping for information ulpon which to build, this

consultant (lecided that the best part of (liscretion was to meet his counterparts

in the British Army, the Royal Navy, and the Royal Air Force and in the

Canadian Army. lie learned that Air Commodore R. It. (later Sir Robert)

Macintosh, tihe Nuffield Professor of Anaest hetics at Oxford I niversity, was

senior adviser to the Royal Air Force and that Dr. I. W. Magill of ,ondon

represented tile EMS (Emergency Medical Service) and the Royal Navy. Col.

(later Brigadier) Ashley S. Daly, RAMC. was his .counteri)art in the British
ANESTHEESIA 585

Army. Dr. John Gillies, professor of anesthetics at the University of Edinburgh, was the senior representative of anesthesia in Scotland. Col. Beverly

Leech, commanding officer of the 5th Canadian General Hospital and all old

friend, was senior anesthetist with the Canadian Army. This consultant immediately made l)ians for conferences with (Colonel Leech and Commodore

Macintosh, whom he had known previously.

Through Air Commodore Macintosh, arrangements were made for this

author to meet Colonel Daly, adviser in anesthetics to the British Army, whom

he had not previously known except by reputation. But Colonel Tovell first

visited several of the U.S. Army hospitals and, subsequently, through the cooperation of his counterparts in the British Services, visited British and Caiadian hospitals. On 28 October 1942. he submitted Col. J. C. Kimbrough. MC,

Director of Professional Services, a report covering impressions gained during

one month of duty in ETOUSA, with summary and recommendations. Inspection of several British hospitals, both military and EMS hospitals, had revealed

that they were equipped to carry on all pliases of anesthesia such as would be

conducted in British civilian hospitals, with the exception that, in military hosl)itals, provision was not made for the use of cyclopropane and carbon dioxide

absorption (fig. 219). Endotracheal anesthesia was fully accepted as an

essential method. Equipment consisting of laryngoscopes, endotracheal tubes,

and connecters were provided for all operating room units. Anesthetic equipment was found to be standardized. and disposable deteriorating rubber parts

were found to be interchangeable. Anesthetics were administered by medical

officers only, and personnel were of a high or(der .nid included many anesthesiologists of either national or international re putation.

Inspection of Canadian hospitals reveal-d that their anesthetic equipment

equaled that seen in civilian hospitals in either the United States or Canada.

Anesthetic machines were of American origin, the models were standardized,

and they provided for use of carbon dioxide absorption and cyclopropane.

Personnel in anesthesia were found to 1e well trained and adequately able to

make an intelligent choice of agent and method to be used under varying

circumstances.

Insp)ection of American military hospitals revealed that. equipment for

inhalation anesthesia was of British origin and was British owned (fig. 220).

Admittedly, the 2d General Hospital, Ileadington, Oxford, (lid have one

McKesson and one Foregger machine, but they were British owned. Equipunent for endotracheal anesthesia was lacking in many hospitals and incomplete

in others. Assigned anesthesiologists in units based in the theater were found

to be insufficiently trained. and they were, in addition, inexperienced. With

the civilian t ype of practice encountered at the time, they were relatively satisfactory, )llt, in tile opinion of the Senior Consultant, they were inadequately

equipped to cope with b)attle casualties in great numbers. Problems, as reported, were substantially as follows:

1. Medical officers assigned as anesthesiologists ill hospitals need further

training.
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ANESTIIFSIA 587

j •a 150~~~~BYI I'"A"' i,

. .36040

FIGURE 220.-Portable British anesthetic equipment sMIpllied to U.S. Army hospital units

in September 1942.

6. Because so much of the equipment in use in the American hospitals is

of British origin, there is need for descriptive literature to be made freely

available to anesthesiologists with each unit if they are to requisition supplies

intelligently.
588 At TIVITIHE$ O1F SURICI( AL CONSULTANTS

Ibhis summnaryv of problemis was followed by a series of re'ommeiindaittions

listed slibstatit ially as follows:

1. That facilities for training b~e est~lblislledj at tile 30th GeirlHospital,

Manlsfield, anld at, the 241 General H~osp~ital, Oxford, to provide courses inl

anesthesia for medical officers of the IT.S. Army.

2. That two anesthesiologists of teaching caliber inl tile grade of captain

or preferably major be reoluist joned from thme Zone of Interior to take charge

of anesthesia inl thle above-ment ioned locations.

3. 'that, uint il such time as one or both of these facilities are functioning,

the ofler of Air (Cominodore Macintosh of Oxford to welcome observation of

p~ract ice of anesthesiolog7 at thle Radcliffe Infirmary be accepted and that two

mnedical officers be assignle( for periodls of one mont 11.

4. That anest hesiologists b~e advised to trainmi edlival officers of their

own tinits inl anesthesiology.

5. That anesthesiologists be adivisedl to train suitable vorpsnmlen inl tile

fundamientals of the administ rat ion of ether.

0*. That endlotracheal tubes be app~rov'ed inl principle as essential and that

app~ropriate equip)ment~ for endot racheal anesthesia be provided as st andarid

to operatinug room untizs inl general, evamcuat ion. and surg."ical hmosp~itals.

7. That. the facilities for CO.. absorption be provided inl equlipment sill)-

Plied to greneral andl station hlospitals.

S. That equipment contempjlatedl for shipment with hospital units leaving

this thmeater be checked by a coimp~etent. anesthiesiolog7ist.

9.That each hospital unit stationedl inl this theater be. supplied with the

following Brit ishi texts: "Essent ials of ( emmeral Anaesthesia" by R.R. Macintosh

andl Freda Pratt : and "Recenit Advances ill Anlaesthiesia anll; Analgesia : Inlchiding Ox 'ygen Therapy" by C. Langton I fewer.

10. That authorities inl Washington lhe requestedl to priep~are supp)ly~ lists

for anest hetic chests suitable for general, station, evacuation, surgrical, and

mobile op)erating timmits. Anesthetic equipment and supjplies issued inl inits

would eliminate tile hiazardls of lack of standardlizationI of equipment..

11. That training mledical officers inl anesthesia inl the Zone of Interior,

along thle linies p~lannmed inl civil ian hiospit als andl inl rep~lacemient p~ool c'enters.

he facilitated to the fullest. extent immediately.

It. was fin ther p~ointedl out. that. these. recoimmnendat ions concernii ng the

prIact~ice of anesthesiology w~ould 1in no way elev'ate this practice above the

standards al ready establ ished inl Bit isli and Canladianl hospit als inl thle theater.

On 2 1 eveinber 1942, a m'ejxwt, elnt it led "ýkliestlmesia,' was prepClared for

sulfhmission to rhe' Surgeon Genmeral. Mu11ch of thle dlata that had beenl recorded

inl thle p)mevedlilg report of 2S October was prov)~idedl inl the report to The Surgeon

General. Th'le f ollowinlg p)oints Were nina1de:

1. Tables of supplyl] wer'e inadlequiate to cover' the requiremenlts of ino()elermm

ainesthlesiology.

2. 'Mac~hinebs butilt by thle sever'al 11nainin fact iiieis ill til ho' Iiiteol States w~ere

not standadz ed'Ii',o, anmd expendlable plails wvere not initerchiangeable.
ANESTHESIA 589

3. Descriptions in the tables of supply were inadequate to eliminate the

possibility of obtaining a machine built by one manufacturer and accessories

built by another. This chance of nonconformity was enhanced by the practice

of shipping a gas machine in one crate and equipment of a deteriorating nature

(rubber parts) in another (fig. 221).

4. American machines were not equipped to use American and British

gas tanks interchangeably.

5. American equipment supplied to hospital units staging in the theater

(for North Africa) was not checked by either the anesthesiologists involved

or the Senior Consultant in Anesthesia for possible deficiencies due to losses.

The following impressions were stated. The problems involved in supplying British equipment, adequate for U.S. Army hospitals in the United

Kingdom could be solved in cooperattion with medical supply officers in this

theater. Anesthesiologists could and would be trained in the fundamentals

of the specialty. Anesthesiologists, however, who arrived in the theater inadequately trained and who remained only for a short stagirng period could

not be trained to meet the demands that would be placed upon them in a field

of active military oI)erations; that is, the North African theater where operations had oI)ened on 8 November 1942.

The report to The Surgeon General ended with a series of recommendations +liat seemed important at the time. For instance, it was recommended

that a competent consultant in anesthesiology be obtained to function in the

Office of The Surgeon General in cooperation with the Personnel and Supply

Divisions. It was further recommended that tables of supl)ly be amplified

to meet modern requirements: that. standardization of suitable equipment for

each type of unit. ble achieved permitting interchangeability of rubber parts,

endotiacheal equipment, and masks- and that small pieces of equipment not

connected with the gas imachine (that is, ether masks, airways, tubes, needles,

syringes, la rvngoscoj)es' cumnecters, and drugs-pa-irticularly drugs usually

supplied in ampules) be listed and supplied as a unit in order to simplify

prob)lems in supply. It was requested that. the work of the Committee on

Standardization, initiated through the efforts of the American Anesthetists

Society, ET)OISA, be supported and that, with the cooperation of the Army

and Navy, its functions be l)ushed to their logical conclusion. It was l)ointed

out that. this committee included rel)resentatives of manufacturers of gas

machines and rubber accessories, manufacturers of oxygen and anesthetic

gases, and the National Bureau of Standards, V.S. D)epartment of Commerce.

Representatives from the Army and Navy, to this consultant's knowledge, had

beeni a.Signed for each meeting that. lie had attended before entering on active

duty. It was further recommended that this effort be directed toward uniformnitv of threadings, tapers, openings, and valves and coordinated with

projects in tie Air Forces for standardization of methods of supply, storage,

anld .administration of oxygen to aircrews. The urgency of augmenting tile

training p)rograms pertaining to physicians in anesthesia in the Zone of Interior

was enm)hasized, and ill addition, it was recommmnmenmded tlat the p)rogram be
Al -1 F"Ill. IA "I 0;I AL IAN

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ANESTHESIA 591

expanded. This request was a reflection of the fact. that hospitals llad arrived

in the European theater without adequately trained medical anesthesiologists

before embarkation for foreign service. The report ended with a request. that

opportunity be afforded a consultant in anesthesia to observe operation of

hospital units in a theater of active military operations in order to evaluate

and to report needs in training of personnel, agents and methods to be employed,

and equipment to be supplied for future campaigns.

The 2 December report to The Surgeon General was supported by data

provided by Capt. Harry K. Shiftier, MC, of the 48th Surgical Hospital,

Tlbessa, Algeria, then engaged in the North African operations. On 24 Novemnber 1942, he reported that his unit had taken over ain ill-equipped local

hospital and had started work immediately. The ol)erating room was moderately sized, and there were two talbles on which the patient and litter were

placed. Two patients, therefore, were always being operated on at the same

time. It was necessary for him to put the heads of the tables together in a

V-shape so that. le could give anesthesia to two p)atientts at the same time. For

3 days, only two anesthetists were available, and each took 12-hour shifts. For

the first. 2 days, only chloroform and ethyl chloride were available. (There

were a few cans of ether, but, they lasted only a short time.) Since there was

a limited supply of chloroform, he had to save it for the longer operations and

use the ethyl chloride for the minor procedures. lie wrote as follows:

Naturally, as you (can readily understand. Lieutenant Mariner and myself were wishing for our own American supplies to come, as neither of us coming from the States had

ever had experience with chloroform. There was only one mask available, so I fashioned

another out of a Planter's Peanuts can-it worked quite well. Everything was done by

the open-drop method, of necessity. * * * As soon as our own supplies arrived. including

Pentothal Sodium and ether, we at least had a wider choice. * * * In my opinion. Pentothal Sodium is the most valuable single anesthetic agent for the anesthetist in the field

during combat conditions. Unfortunately, we had no 20 cc. syringes.; and we had to do

all our work with 10-cc. syringes. * * * The laryngoscopes you were kind enough to send

me were used to great advantage. I feel that every hospital set up to do surgery should

have, as part of its basic equipment, laryngoscopes and endotracheal tubes. * * * It

should be stressed that any unit going into action should have plasma inimuediately available. There is no doubt in my mind that it was lifesaving to many of our boys.

These reports have been cited in detail because they set the stage for future

activity to be undertaken in prel)aration for the eventual invasion of continental Europe. They outlined fundamental problemis to be overcome in relation to organization for tra;uing of persomnel, procurement of standardized

equipment, alteration of tables of equipment to meet the needs of the several

types of units, and the need for a competent observer to visit an active theater

of operations to evaluate the usefulness and possible deficiencies of relatively

recently and newly desigqned American equitpment. Some of these prol)lems

entailed the establishment, of long-term programs, l)articularly in reference

to training of anesthesiologists in the Zone of Interior and in the United Kingdom, and in standardization of equipment involving new designs to permit

employment of agents supplied from either American or British sources.
59 2 A\'TIVITI I 1 SUIGI('AI. C)NSUTI'ANTA s

FIG~i' 22.--\d~pt~ldeSubstitute expenalll)e lile..qI~eflV-elluitnIel't obtltliMe from British

sources.

The o0e immle(liate pressing lprohlemN was to rectify tile situation created

b)y the shipment of gas machines in one crate and equipment. of deteriorating

quality in another. This situation was (te to practice established in tile United

States oil the 1)rinc(ip)le that deteriorating rubber parts packed over a long

period of time with nonexpendable equip)ment, would deteriorate and he useless upon receipt, in a theater of operations. This p)rinciple was well founded.

but, failure to "marry" deteriorating equip)ment with nonexpendable equip)ment

atl ports of embarkation created a serious situation wherelby nonexpendalble

equipment. receive(l in a theater of operations was ren(lered useless so long as

the corresponding explendable parts failed to arrive. This situation was particularly serious for hospital units ullnacking their equipment for the first

time upon their arrival in North Africa. The situation was less emergent,

however. for those units arriving in the U nite(d Kingdom b)ecause there was

-inl established industry t(, ,rovide a(laptable substitute exp)endable equipment

(fig. 222). The supplies of exl)en(lable British equipment, however, were

meager. and a(laption an(l procurement were (lifficult. Another phase of the

problem in Great Britain was tile adaption of American machines to make it,

feasible to utilize anesthetic gases slu)p)lied in British cylinders. The British

Oxygen lCo. was very helpful ill designing adapters permitting utilization of

British deteriorating equipment and in designing adal)ters (fig. 223:) per-
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594 ACT1IVITIES OF SURGIC;(AL. CONSULTANTS

the ensuing 2 years. It was indeed fortunatate thlat. a U.S. Army destined to

inivade niortlhernt Franice wits balsed iii ai coutryi i that was highly ind(ustriailize'd.

D)eficiencies inl eyjui pment, t hat were a reflect iou of the unpreparedness for war

ait homne, and tilie all too successful suibmlarinet campaign against. Amlericanl

con voNs, colildl to a. certain extent, be allev-iated by requisitioinimz substitute

items fromi British sources. P roblemis iii personnel were nliore- d itlicult to solve,

but, it, was noted thlat anlestliesiologists in t lite theater were graduially receniing

eqliileltiet. sat isfactorv to mneet. fill]% tilie needs of mu it ary pract ice. Relat ively

inexperienced antesthlesiologists hadimprovll~ed thle chaiiracter of their work.

pa~rt icilar1V followingr teitilloarv (lilt N, for the puirposi' of observiitg and receivung instruct ion at lrit ishi .n~ A erican hiospitals.Thatsliiogitwo

had arri vedl with titlie 3d A uxil iarv Surgical ( rroulp conistitutted a1 pool from

whliiclh anest hesiologist s could be dira wn to replace less-experieniced medical

officers dluring their periods of absence for trininlg. I )urinlg this samle periodl,

several well -t raiited anl experienced aluest liesioloiists arrived fromt lite Zonte

of InItterior aissigined to unitit whiichi were to retuta in inl tile Eulropeanl theater.

This Inade it possible to plan oitltising thlese iteti as Iinstrtict ors ill 1 .. Arniy

hiospitails and~ led to thle hlope tilint tilie practice of assigniuig aitestliesiologists

to British units for trainting utighlt lIe allgniieitted bytrinn antesthbet ist s in

U .S. hospitals. It. was ill this atmnosphiere thlit tilie year of prel imin ary planininig, 1942, enidedl.

CONSULTANT DUTIES

The Senior Consultanit in Attesthlesia by this tlitte realized tlite significance

of his (liltties: To ob~serve, to relport , antd to recommietnd to the C hief Surgreon,

ET()USA. rThe D~ivision of Professionial Services, of which lie was a lpart,

was withlout. comtmiandl funict ion but was expectedl to formtulate 1)o1icies, obtainl

their ant liorizat ionl, anld check onl adherence to policies thtus established inl general. evacuation, stat ion, antd field hospitals and~ later inl base sections andl

hosp1ital centters. Hi s polem)il'ts were commltont to those of his associates, each

consultanit having a set of problemts with which lie had to dleal that were p~eculhiar

to his sp'ciaulty. Tile work of the Senior C onsultant. iii Anesthesia included

visits to hospitals, observationi of work being djoite withi criticisiti a111(l suggoest lonls,

regarding orgatnuzat ionl and lpraic ice. p~repalrat ion of rep~orts with recomiunendalions, preprtriolt i of mtaterial covering 1)01icies for issue as dlirect ives by the

Chief S11rgeonl. estabflishmnent of satisfactory relport fori'ts, collect ion ando evalniat ion of stilt ist ica I dat a. andl establ lishmuient andi mainittenanice of liaii onl with his

d1ll lit erpairts autuong tilie Allies.

It was thle respomisibil it v. of eacht senlior conisuiltant to evaluate tilie skill of

inelil iel's of his Specialty ilt all types of tunits iln relation to thle part which each

Un1it wats exp~ectedl to p)laiy. This role necessita~ted(ltlie interviewing of p~ersonnlel

of incouiming hospitals. A tile, sYst (lt was establ ishied containing a Sutmttarizedl

lmeiclct biography of each officer inl the speciadt y. Notes were adldedl recordling

observat ionls litadle subsequiently regarding thet skill of officers at work. This

intformiat ion wAas used as a gil de inl establ ishting- each ofieer's rating, and it was
ANESTHESIA 595

on the basis of this information that recommendations were made to the Personnel Division, Office of the Chief Surgeon, Headquarters, ETOUSA, when

it was necessary to reassign officers to fill vacancies. In the case of anesthesiology, it was also necessary to tabulate the training, experience, and skill of

anesthesia nurses attached to each unit.

EXTENSION OF ACTIVITIES IN 1943

Supplies and Equipment for Anesthesia

It was with some dismay that the work of the ensuing months was contemplated, with the realization that the tempo of it would be intensified remarkably as the buildup of the U.S. Army for invasion progressed. During the

month of January 1943, a survey of needs for anesthetic and oxygen therapy

equipment was completed. A report, entitled "A Consolidated Report Regarding Equipment for Anesthesia and Oxygen Therapy in the ETO," was submitted on 31 January 1943. The salient points in the report concerned the requirements for gas machines and provision of adapters to permit use of supplies of gases from British sources. It was pointed out that British machines

in American hospitals permitted attachment of cylinders containing pure

carbon dioxide, a practice which in itself was hazardous but which, under

circumstances of military effort, was complicated by the fact that British

cylinders containing carbon dioxide were painted green in accordance with

the British Code of Identification. To an American physician, this color

indicated safety and the presence of oxygen. It was, therefore, recommended

that supplies of carbon dioxide for anesthetic purposes be withdrawn. Subsequently, arrangements were made with Mr. H. A. Chapman of the British

Oxygen Co. that only mixtures of carbon dioxide in 7-percent concentration

with oxygen in 93-percent concentration would be made available to American

hospitals.

On 27 February 1943, a letter, entitled "Carbon Dioxide For Inhalation,"

was issued by the Office of the Chief Surgeon over the signature of Col. Oramel

H. Stanley, MC, Deputy Chief Surgeon, to base section surgeons and commanding officers of all U.S. Army hospitals. This command letter provided

for the recall of all cylinders containing pure carbon dioxide in exchange

for cylinders containing a mixture of carbon dioxide and oxygen. Attachment

to anesthetic machines of cylinders containing only carbon dioxide was to be

discontinued as soon as the mixture was available, and it was specified that

carbon dioxide in 7--percent concentration and oxygen could be used for stimulation of respiration when that was required. Hospitals possessing freezing

microtomes could still obtain pure carbon dioxide, but under no circumstances

was it. to be stored with gases for inhalation.

It was necessary on 15 February 1943 to issue Circular Letter No. 27,

Office of the Chief Surgeon, Headquarters, ETOUSA, stating that standard

U.S. and British color schemes differed and that, in order to identify gases in
596 AcTi VITIEs ()F SIlURIt'AL t'ONST'LTANTS

cv!ii~lders, tile labels aliways tiilist hie read. Color markings oil cylind~ers were

to lie conisidleredl oldik to corrObl)Oate( Ilabels. This wais followed With a descri pt ion of British and Amlericanl cvi inders, i nclwl lg their din racterist ics. by*

wlivii t hey might bie di fterent iated. linforili~it jolt of genleral interest regarding

cylindiuers and their g-aseouls conltenlt wa w irj'ell broad(ldist ribiut ionl.

This priobilemi of idenitificat lol of gases anid cylinders Was recognized by

authlorit ies outlside thle Medical C orps. ( )i 21) February 1943. Circuila r No.

1SM was issued lby H eadquiartiers, ET( HSA, under thle titlet Industrial and

lBreT,11iIig (11A'Se MAn 'V~i iiers.7 Meanls anld ilet lmios of protIIveilent of

oXygen1 lis Well as acet v1enle. livdrogeii, and nit rogeni foi- industrial purposes

,was st ated. (Con fusion Was subsequenit iv oCcasionled inl mledical units by t his

directive beca use tilie color Code for OXvgreli coroii to Brit ishi spec4ificat iOnIS

was stated as black. lThe dlirectivye failed to ind(1icate thatintiit rouls oxidet M ll -

tiers wvere aliso black lbut lpossessed(lia di flerent type oif valve. Tile directive 111als

stated: "Where facilities for paint ing according to British standard specdficat ions are not available. thle Reopiisit ioniaig ( )ficer ninly retilnest tilie Brit ishi

( )~gell ( onajmipv1IN to paint thle cyl inders. C orrect shades andit types of palint

are a va ilabile at H eadquartiers. SOSS E'1' )ISA. A 1l( -XT I.- Thlis statemienit

fa iled il intlie matt4er oif 4 lorotighily amsignii tg responsibiilityv for painting acCord ing to) thle Brit ishi stanida rd specifications, a1 u4d at thle sanie t inie int roduced

the hazard (if erroir where paintitng was und~ertazken lby orgatnizat ions ot her

liaii the supll iier. Aiiot her re'qu iremtent oif thle directive Was that, nulti -iill

U .S. Arilli V cvlitidt'rs we're relia tilll eit) vomm forill tO Brit ishi sttilandar sfX'difivailouis. it was essen tinal thlit a labelw clearilv inid icat i ii tilie t vpe of gas bie sectilrel v

paste I'tl th 4le cvli ilder. To paste labiels securely oii cvliiiders storedl inl the

oiieii was impiiossibule, andio it was impilliedl (lint iddlt ificatol Iof I gases and lilers by iv iten is of colored paIintt Woumld slil seqjieit lY Ile& adiequat e. Thiiis luol icy

tilt roi(ltice liaiza rds Where lie A mnerlen i coilor coid e (letiliitel iv oliiif it ed withi

tlie Brit ishi. Thiis di rectivye [Ind~ originltly bieeni issiued wit iout tlie kniowledge

(I OirclI~l oif thle ( Mlivce (if thle ( 'Iiief Siir-teoul. It was tili fort tliate thlat

(list ribliit ion incucided uiiiits of tflie, Medlical D epartmtetnt.

At. tdie titme of tl- prepar~'lation ol f the "( '(lisoidl i~ttd Repo)(rt Re-:i rdintg

I~phiiuiient for Anesthiesia aiid Oxygen TIherapy inl E.I.()..* which wals stibin itt o biv I liis colilsilltalit t (thle I irct vroro(f P rofessiotnal Servives ott :11 .1 a iiiin

1 943. thel hazarods of a gas at Iacl( were. vervy tii4-1icli thle minds10( of all ( fig.22I)

'Illo repo~rt, * tlrefoire. iniciluded thle io 1ec1iiiiil1 tha ech hiospiit al be providled withI ethicient (julick-coli lii g oxvgeti sets (if Brit ishi originl to provide it

an161611ii11iim coiverage oif 31 perven'it of lbed cii jinit ,v ill each lihospitali 1 additional

('(jilipIilivielt toble ret a i lico ill sIcvr2ercelit pnpiv(eii oif ft( lib ed capaicity.

Th'lis level was set a ftercoiisiiltat ioit withI ( 'il. Williaml 1). riviniiig. M(C. Ch'lief

Gahs ( asunll It ()hicer, G as ( asuanltv I ) i vision, and11 Colonel MIi Idlet oim, chief

itiedica I consult ailt to) tlie En roiean fitbeat er. Inlst tilht ion oif qiaick-l intinkge

pipelines was aiovoictited toi save Shipjpinig and( ..: ilize to) the best advaist:ige the

1 ililit ed 511 lllvtf cvii iolers iii t inileof real I need. It wasntoit eoItlint procua IleNllie'l I

(if BIAI (I Bootlilbv. LoMvelace. Bia 11111ian ) miasks anld 1reglnltt(I-s 11ino1 1 1ci sat -
ANESTHESIA 597

A

B C

FIGURE 224.-Primitive preparation in 1942 against gas attack. A. A pattern for a

face mask to be cut from oiled paper. B. A pattern of a face mask shaped for the administration of oxygen. C. Use of a face mask for the administration of oxygen.

isfactory, but, as a safeguard against, gas attack, it was recommended that 3.000

masks and regulators manufactured by the Oxygen Equipment Manufacturing

Co. of New York be procured from British sources where they were known to

be surplus. Subsequently, 50 units of the oxygen quick-coupling sets (sufficient

to supply 500 patients) were received ready for distribution. Fortunately, gas

attacks never materialized and the equipment was not used.

The use of oxygen tents was pointed out to be impractical in the European theater because ice was not freely available in quantity and because the

administration of oxygen in adequate concentration was incompatible with

good nursing care, in the presence of multiple wounds requiring frequent treatiment or ob)servation. The logic of discontinuing the import of oxygen tents

requiring the utilization of ice was manifest in a country where even chilled

beer could not. be obtained. Procurement of oxygen tents from the Zone of

Interior was discontinued.

D)uring the early months of 1943, anesthetic machines continued to arrive

in the European theater with deteriorating rubber equipment. This created

a prol)lem of major magnitude. After much difficulty, substitute equipment

was obtained from. British sources. Some delay was occasioned by lack of
598 ACTIVITIES OF SURGICAL CONSULTANTS

standardizat ion between Heidbrink Co. and McKesson Equipment Co. niachines

on tile one hand, and between the machines produced by the Boyle Co. and

tile Medical and Industrial Equipmneitt Co., both of Londmo, on the other.

This lack of standardization necessitated accunmulation of four pools of equipmeit. for maintenance purposes and was responsible for no little confusion.

Attempts to rectify this situation were without avail for many mioniths, but

progress was made through a subsequently established committee. known as

tile Service Consultants ('ommittee on Anesthetics. which included rel)resentatives front tile IT.S. Army and the several sections of the British Forces as

well as the Ministry of Health and the 1)epartmeint of Health for Scotland. In

addition, the Canadian Army had direct representat ion.

Adaption (fig. 223, p. 593) of Anericali e(qlipittelit to British cylinders

likewise constituted a problem. The original estimate of the number of uladpters required was predicated on the basis that the major sup)lply of anesthetic

mnachines and apparatus for oxygen therapy would be procured front British

sources and would therefore not, need adaptation to British cylinders. This

calculation was based u)pon the fact that the outcome of the submarine campaign seemed grim: but, with subsequent marked Allied successes ill dealing

with submarlines, delivery of equipmlltent fronm the Zone of Interior intcreased

beyond original hopes and the procurement of adap)ters laggred behind needs

thus created. Tile establishment of D)epot M-400 at Reading, England. on 1

February 1943, for maintenance and repair of anesthetic and X-ray equi)ipment,

proved to be a real boon. Lt. Col. (later Col.) Kenneth I). A. Allen, MC,

Senior Consultant in Radiology, was largely responsible for estabulishment of

this facility. The original need was to staff this depot with personnel skilled

in servicing anesthetic and oxygen therapy equipment. Attempts to obtain

skilled personnel from the Zone of Interior were without. avail. As a result,

technicians servicing such equipment were trained in England with the cooperation of the British Oxygen Co. Anesthetic and oxygen therapy equipeitent distributed to issuing depots throughout tile theater was screened through

Depot 1-400 for comp)leteness. American apparatus so screened had the

proper adapters added in order to make possible utilization of either British

or American cylinders.

Training

Medical officers trained in anesthesia continued to be in short supply.

Training seemed to be the only answer. Problems arising front the supply

of unlike pieces of equiptment fromt various manufacturers in America and

in Britain made training even more iml)erative. It. was stressed titat. each

hospital should have a trained p)hysician anesthesiologist and an aalterntate

p)hysician to cover for hitim, and in addition, depending ott tite size and type

of the hospital, should have a sufficient mnumber of assistants to cover periods

of peakload. rraining by app)rent iceship to skilled anestltetists was continued

and accelerated through the year. In case of need, arran gemeitts were made

for trainees to go oit temporary duty for a period of 30 days to hospitals
ANESTHESIA 599

possessing anesthesiologists of teaching caliber where they had sufficient clinical material for purposes of demonstration.

Early in the year, lack of clinical material in U.S. Army hospitals necessitated making an arrangement with British military hospitals and the EMS

for augmenting the training and experience of U.S. Army officers. In this

effort, Brigadier Daly, Air Commodore Macintosh, and Dr. F. Murchie of

the Ministry of Health cooperated wholeheartedly. In all, 99 officers received

one or more months of training outside their own unit, and others received

instruction and gained experience within their own unit. As the year 1943

drew to a close, it was less frequently necessary to allocate trainees to British

hospitals because U.S. Army hospitals contained more clinical material and

anesthesiologists of teaching caliber. The program of arranging temporary

duty for U.S. Army personnel at British hospitals led to its administrative

difficulties, sometimes with respect to rations, other times with respect to the

jealousy of hospital commanders in reference to their prerogatives. Apparently, the Senior Consultant in Anesthesia had been less than efficient in laying

on the program through the highest international channels. Instead, the arrangements had been made at the operational level. Occasionally, the commanding officer of a British hospital wanted to know why his unit had been

invaded by one or two American officers who had arrived without the proper

fanfare of announcement. To the Senior Consultant in Anesthesia, it seemed

that, if the British had patients and were short of personnel and if the U.S.

Army had physicians without patients, temporary duty for American officers

to British hospitals was the logical procedure to remedy the situation and at

the same time provide for training.

Throughout the year, the Senior Consultant in Anesthesia or his alternate, Maj. (later Lt. Col.) Fenimore E. Davis, MC, presented a 2-hour lecture

before each class attending the ETOUSA Medical Field Service School at

Shrivenham. The presentation included a discussion and slide demonstration

of intravenous anesthesia, drugs for regional anesthesia, and untoward reactions likely to be encountered in accomplishing blocks frequently employed in

military practice. Evidences of oxygen want and remedial measures were

outlined and stressed. In addition, lectures along similar lines were presented

before staff meetings at individual hospitals, on invitation.

Special Reports

In order to improve clinical anesthesia and to provide means for the

accumulation of statistical data, two forms for reporting the course of each

anesthetic administered were devised and circulated. The smaller form,

known as the ETOUSA MD Form No. 55-0-1, was for general use and was

designed to fit the EMT (Emergency Medical Tag) envelope. One side of

the form provided space for recording the preoperative examination of the

patient, and the opposite side was for recording progress of the anesthetic

procedure. A larger form, identified as Form 15 E.T.O.-P.S., was similarly
600 ACTIVITIES OF SURGICAL CONSULTANTS

designed and was for use in general hospitals using the larger-sized forms

throughout their complete r'el)o't illug systemi.

A nIonithly report covering activities of the anesthesia and( operating

room sect ion was requiredI fromi each hospital in the European theater by a coinuiand letter issued by the Office of the Chief Surgeon oil 2)4 February 1943.

Thog the cooperation of anesthesiologists in the theater, statistical infor- mnation was submitted to the Office of thle Chief Surgeon for analysis. TLhese

data, were collected to estab~lish exp~erience factors in reference to agents and

methods used and thus p)rovide the Supply D)ivision, Office of the Chief Surgeon.

(lata. from which to estimate requirements for future sup)ply. The data also

indlicated thle (direction in which emp~hasis should hle p~lacedl in the training of

anesthiet ists.

Visit to North Africa

Revision of TM (War Department Technical Manual) 8-210. Guides to

'I'hierapy for Medical Officers, issuedl onl 20 March 1942. wvas under conisidlerat ion

by' the IProfes'sinnal Services, Division throughout 19431. It became evident.

thiat, in order to intelligently prepare, such an mianual, a tour of observation

in a theater of operations actually involved in combat was necessary. Therefore, onl 11 September 194:3, a request for orders to visit NATOI7SA ( North

A frican Theater of Operations, U.S. Army) was submitted and eveintually

applrovedl. The pulrpose of this tripl was to collect (data, for completion of thle

port ion of the manual on aniesthiesiai and~ data relating to maintenance of a1

prop~er balance il til p~rogra for training, anesthe-siologists and oxygren thmerapists. Orders were issuedi onl 12 October 1943 byV I 1ead(qliaml-ers SOS,

ET()UsA. andt thle trip) was accompllishied between 20 October and 20 N~ovt--;i

her 1943.

A tour of dluty in NNATO17,SA,. for olbservational purposes in anl active

theater, p~roved t. beitretn and instructive. This author ob~served lhoslpitals in thle vicinity of Algiers, Algeria. and Bizerte and Tunis, Tunisia, in

North A frica: Paleriiuo0 and ('atan ia, inl Sicily: and Naples and Caserta in

Italy. Ile also went as far forward as divisional clearing stat ions in Italy.

Following his observations inl time Iieldl, a rep~ort was subm~iitted1 to tile Chief

Surgeon, E'I'()I A, eiit itledl -Ilnpressiomms Gained 1During a Trip to

NATOUSA amnd Fifth Arumy.-

Trhe authior ol)serve(l t hat there was a (list inct shortagge of trained anld experieiicedl anesthiesiologists to take care of lpeakloadls of casuialt ies. Soine hiosp~itals were without the services of a t rained anesthetist. TIhme greatest nteed for

lior-omigilly qum1m hi lied aumest iesi4ologrist 5 existe(l inl un~its sitilatedl ill forward areas,

where the severest injuries wvere seeni mid t reated. It was ili the forward areas

that anlestlet ists attached to auxiliary surgical groups were renlderinig thle nIost

min([ best service.

T[here was a grleat needl for lport al)le gas mlachlines ill each hio)spit ml lplatoon

of field hiospitalins, where intermintten'lt positive pres~sure was eszemilt ial for ade-

(plate care1 of nontranlslortahbles. A r-eal] leed for the samle types of equip-
ANESTHESIA 601

ment existed in evacuation hospitals of either the 750- or 400-bed type. An

inequality of distribution of portable gas machines and anesthesia sets existed.

In this regard, the situation was similar to that which existed in England, but,

unlike the European theater, the North African theater could not procure

machines from British sources to cover the deficiencies. Distribution of soda

lime for the machines was inadequate in quantity. When the need was extreme, Shell Natron was used as a substitute, thus diverting this specialized

material into unintended channels. This practice was not without its hazard

to both patients and anesthesiologists. Where continued, the use of Shell

Natron produced deterioration of already scarce anesthetic equipment. Because of these difficulties, this consultant reported that there was a real need

for developing light, sturdy, and freely portable equipment to provide intermittent positive pressure for resuscitation with either air or oxygen, if available. He further stated that this apparatus should be able to clean inflowing

air, if and when gas warfare was employed. HIe believed too, that such equipment, should incorporate facility for the administration of ether vapor when

desired.

Portable suction apparatus also was scarce. while there was a real need for

it in field and evacuation hospitals. Equipment designed in the United States

and provided in tables of equipment was satisfactory when electricity was

available. Situations were encountered, however, in which portable apparatus,

operated manually or by foot action, would have been of value. Such apparatus, aside from supplying the. need in far-forward areas, could augment

rather than displace ex;sting portable equipment that was electrically operated.

In his report, the author suggested that the reversal of the valve system in

foot-operated tire pumps, currently in civilian use in England, would be easily

possible, and that, with the addition of a vacuum bottle, suitable tubing, and an

aspirating tip, the apparatus would be satisfactory.

This consultant soon learned, upon his return, that in the Army one should

never make a recommendation unless he is prepared to follow through with it.

With the help of Major Davis, who was trained first as an engineer and subsequently as a physician, a sturdy and freely portable piece of equipment was

designed (fig. 225) and produced at Depot M-400 to provide intermittent positive pressure for resuscitation with air or with oxygen, if available. This

apparatus also provided a facility for the addition of ether vapor when desired. Through the cooperation of Down Bros. of London, medical equipment

manufacturers, foot-operated tire pumps, designed to service heavy trucks in

civilian use, were altered by reversal of their valve svst ems, and thus a footoperated vacuum plump was produced an(l supplied to augment suction pumps

electrically operated in U.S. Army hospitals.

In NATO(USA. anesthesia practice was noted to be circumscribed by the

lack of fully experienced anesthesiologists. This led to inexpert choice of

agent and method for l)atients in critical condition. The same shortage tended

toward the use of agents and methods beyond the boundaries of their known

wisest employment. On the one hand, surgeons advocated and undertook the
F~l_ A 1. -1I i I .\ ( " l' I 1 I~ \ l 1I 'l I- [. l. "r /.' .1 I Iq I- '\lv . I ' :I • I ,' ' \ ' '

I I o i l;t I I[ :-, . . . .h l I . I .%1 1 :' 1 .l . V 4 ,1 I' l i. l - ' ,,I lll I " 1l -f a l l I'j f i t ' i ' d f !' '\ , l Ih , ,I 1u -1 1 A I A • - ,

II,,:a~~~~lim .:.~~ I-r \h 1 n 1l '"..i ,. .- f•, q I' I•r~ - I\ 

L ;iri I', 

t~ , " ,. 1 .\ .\1 

:',l 

''

\\:i. ~ ~ ~ ~ ~ ~ ~ ziI - ohli ,.i.I , ,:l I,•l ,i i; ,.~ :• lI I\ I •. 'it-
ANFSTHESIA 603

administration of spinal anesthetics in instances in which, with the services

of all expert anesthesiologist, the same surgeons would have elected inhalation

anesthesia. ())n the ot her land, there was a tendency to eiiploy l'entothal

sodium (thiopental sodium) in contravention of known contraindications because of its ease of employment in periods of peakload. LTack of skilled

anesthesiologists, adequately equipped to undertake administration of inhalation anesthetics employing carbon dioxide absorption and intermittent positive

pressure adiiininstered through an endotracheal tube, accentuated this tendency. The need for conservation of time also dictated the choice of anesthesia.

In some instances, erroneous judgment was responsible for subsequent difficulties that, would not have occurred had the patients been in as good condition

as was first believed. Absorption of morphine administered subcutaneously

to patients suffering from exposure and exhibiting peripheral vascular constriction resulted in delayed absorption, and the pain frequently was not re-

]ieveed. A secoil (lose under these ('ircumistances might I)e given with similar

results; but,, when the patient was treated for shock by warming or administration of fluids, or when given an anesthetic, absorption was rapidly hastened

and morphine poisoning was exhibited.

An awareness of the hazards inherent in the use of Pentothal sodium in

the presence of shock, particularly following hemorrhage, was appreciated. It

was recognized that Pentothal sodium was hazardous in the presence of bleeding

lesionis within the mouth or in the presence of dyspnea from any cause. The

use of Pentothal sodium for surgical procedures within the thorax or abdomen

was contraindicated. Ether was recognized as the agent of choice for production of muscular relaxation for the recently wounded. Anesthesiologists in

the North African theater were of the opinion that availability of cyclopropane

was highly desirable, particularly for patients in critical condition. In relation

to l)roblems of supply, the value of cyclopropane seemed obvious l)ecause the

slpac.e required to transport cyclopropane in quantity equivalently useful to

nitrous oxide would be small in comparison.

The greatest need for portable gas machines existed in field hospital

iplatooiis fmiiti,,mlling ii(Ill)elldeltly anmd set up) adljacehmt to di% isiol' clearing

-tations for the treatment of nontransportables. This circumstance, the author

reported, would necessitate supplyi ng field hospitals in the Euroipean theater

with nitrous oxide, oxygen, and soda lime. He further recommended that,

provision be imade to supply each auxiliary surgical group with 10 p)ortable gas

mna,.huimes, 10 portable suctions, and the necessary gases for them. He suggesteI that these mnachinmes be distributed to those teams assigned to hospital

units operating under l)eakload, and that first priority be given to thoracic,

(reneral surgical, and plastic surgical teams. Supplies of these items in hospitals were inadequate to cover the needs of the teams.

Practice in hosp)itals in North Africa and Italy working under battle

conditions demonstrated the sagacity of planning to supply citrate(l bioo~d from

a blood bank established in a rear area. Such procurement made thorough

705-095'-64--41
604 ACTIVITIES OF SURGICAL CONSULTANTS

control possible in reference to syphilis, malaria, and jaundice and, at the same

time, relieved units in forward areas of the responsibility for setting up local

blood banks. This consultant observed that, without the availability of sufficient blood, adequate care of the wounded would be impossible. Upon the

author's return to England, this matter was thoroughly discussed within the

Professional Services Division, Office of the Chief Surgeon, and plans were laid

to establish a centralized blood bank with Maj. (later Lt. Col.) Robert C.

HIardin, MC, in charge of the operation. Major Hardin's organization ultiniately provided blood for the initial stages of the invasion of northern France.

Procurement of b)1od from troops in England, and later on the Continent. was

continued even after an adequate line of supply was established with ti e Zone

of Interior. D)uring the campaigns in northern Europe, Major HIardin's organization continued to distribute blood throughout the theater. If a patient

died, his death was attributed either to his iaving been given too nuich or too

little blood or too faulty administration of the anesthetic. Seldom woulh surgeons admit deaths were due to wounding, and never, it seemed, would they

admit that the surgical procedure was contributory. Major IHardin and the

author stood shoulder to shoulder on the same chopping block.

The trip to North Africa was a geographic revelation. The handicaps

under which an army in the field worked made a real impression. The disadvantage of a native population that on occasion was less than friendly was

observed. The native Arab was seen in his own habitat, with a discerning eye.

It was adequately demonstrated that Africa is a cold continent with a hot sun.

The trip back to England was more than interesting and a little frightening.

When this consultant arrived in Marrakech, Morocco, via plane from Algiers

on the return trip, he both expected and desired to be forced to remain there

for 2 or 3 days until air transp)ortation became available for the trip to northern

Scotland. After a very arduous trip across North Africa to Bizerte. Tunisia.

and then on through Sicily to Italy, he would have welcomed time to bask in

the sun. Much to his chagrin, upon inquiring about transportation to Scotland,

the author was told that there would be a C-54 plane on which he could leave

within 11/2 hours. He decided to accept the accommodation rather than wait

3 or 4 (lays or more for another vacancy that might be further delayed by high

priorities given to ferry pilots returning to the United States to bring back

still another plane.

The trip was uneventful during the first 13 hours. Subsequently, the passengers were told that the aircraft was bticking a headwind and getting low on

gasoline. The pilot was forced to break radio silence and asked for permission

to approach Scotland over the Irish Sea, rather than fly to the west of Ireland

on a course that was usually followed to avoid German fighter bombers based

in Brittany. His luck (lid not hold wvell. The plane was met over the Irish Sea

by a JV-88 which attacked from the rear. It was t physiologically stimulating

experience to descend to approximately 500 feet above sea level in the fashion

of a falling leaf, not knowing whether the plane was in control or out of it.

After the plane landed at Prestwick, Scotland, having been escorted in by two
ANESTHESIA60'

LP-40's, it was discovered that. one wing had been pierced by a 21)-liililitueter

shell. The shell had lodg-ed bet ween two wing tanks biut had failed to explode.

F'ortuniately, no onie ab~oardl Vwa inijuredl. It was theorizedl that p~erhiaps a ( zechi

hadl~ sabot~taged thle ( eriiiat war etlort. Tb is contsultant realized[ t hat, altlioligli

lie was a nionconilbat alit, Ile wvas not a neutral. -Not mlani f Ilontils w*%ere to pass

b)ef ore his statuis as a nioncomibat ant wvoultd be b routght into focus aga in. Whilhe

hie was accoin pall in aiy. full complement of wounded ill :I C-47 fromI France

to F'llglint (1 " t rigg(er-hiappy" Anmerican shore batittery. locate ol Ile th soiuthI

coast of Eniglanid, fired at thle plane. The t-light engineer quieki v shot oft a

copeof ident ify in g flares whiich wvere recognizedl bv tilie gunners btelow. Tilew

tirini- ceais~ed, and~ nio (hailage wats (h)Ii. The p)ilot was exasp~erated. I [e said

that Ile hiad approached the coast inl the. stipulated manner and was therefore

totally at a loss to) acc,(ount for tilie act ion of the gunlcrews.

PREINVASION ACTIVITIES

Mani'iv hoped that 1943 would be the year of act ion. This proved to be mipossib~le: and. inisteadl. thle invasion of northerii France was dlelayedl until June

1944. The buildup for invasion startedl with thle arrival of units of the First

U.S. Arniy ill the. theater. It was initediatelv obvious that anl accentuated

p)rogrami for training anesthiesiologists was niecessary. Three courses were

held inl 1944 at thle 120th Station Hospital. Tortworthi Court, thle first from

IT to 2'2 January iwnehsive, the second from i21 to 26l Februar-y (g. -2-26), and

tile third from 20J to 25 Marci inclusive. A1 fourth course was hieldl at the l0thI

St at ion Ho1sp)italI, Manchester. Lancashire, for Thliird I .S. A rmy Jperson-iel

(luring time period 1 to 4 May inclusive. Thle averagre attendaince A'*as :lpproxiIuiatelv -to, and~ at. least half of tile trainees were miedical officers. n'le progr-am

was intensive: butt. inl retrosp~ect. it seems to havre beeti p~it ifully inladcqulate.

Nevertheless, tile writer is still confidetit that nui1cli was accomnpl ishied in thle

way of orientat ion. Thle inany oflicers who pafrt icipatedl as lec turers deserved

colmutnetdatioti for their effort.

D-DAY AND ITS AFTERMATH

It is a well-known hiistoricalI fact that D -day occurred onl (3) Juiie 1944.

Oft 23 June, the antitor reportedI to thle (1 ief Surgreon hiis 'itiprion g_ I n

sinve. I -da v. It was wvith real sat isfact ion that this coawsultatit was able to

staite that Inl all echelotns anlest bet ic equti pnent had been adequtate withI only

,I few shortages of one or another article inl isolatedl instances fg 2)

Likewise, oxygen-therapy eqtipiiipent had been adequate to tieet thle imimedliate

needl onl thle Comit inent. Oncve again, however. thle problemi of sutpph v had ra isedl

tfs u1gly head. Adapters for uise onl British cylindlers wvete found to be lacking,

ill someto tunits (4huil~lpedl witll) comiplete hospital asseniblies shipped dlirecti

fromt the Zone o)f Initerior. i'ortttnatelv, adapters were availablte to cover

thlese deficiencies. American cylinders were. still being uised i nmainy fixed

fauci lit ies iii the I'n ited Kingdom. As a, result. (Col. Silas B3. ILaysI, MC,
606 ACTI VITI'ES OF 8I*11GIC AL C'ONSULTANTS

CC
AN ElSr I l.ES A (;07

4,

H(Ii l . 2T.- (2'27.i-ICe rI 4)xy.V( l • lII nil 1o.4 ,,xide ii ldfijholds which sitlip lied thlle t4'1i"

op(erating, lheaters at the 2.thII Ge(ieal Hosl.pital (I niver.sity of Miichigat unill) at

lrent lmy Piark. niear, lristol. England. Alln a ,.ile•ll ic 1iiiachiiie ofu lB'iti•h rigiin is il tllh

righl fiortgromid.

chidef o the Ulpplty D)ivision, Office of the 'hief Surgeon. r'ecalhled both

eml)tyt anl tilled cyliltders fromt IU.S. hosplitals in tile United Kii.,_,'loi for

transpiortation to the Continent. The 130,000 beds dist riblted in over 100

hospital.s ill tile Untited Kligdol were SUppliedl with, gases co•itatined ill

British c\'liineh's. The Iost evident Iteed for e(tlipmlteuit duit'iti.r tlie first

fortni ghlt of tile invasion was for suction alpparatus. Tamles of equiplment

were nhot aIefinlute to cover needIs. A nei'ricanl equipmltent could not Ihe tisedl

in Brithin itn wards wired with 230) volts without iti lization of tra nsformers.

adI transformers were not freely availahe. The need for foot -operat edl sucl ion. first r'ecogntti Ze(t ill Nort h Africa. was once agai evident.

lPentothal soIlium was thie nreltt most frequently used il t all echelons and

wit l generll sl t isftact jction and safety\. Il certaiel isolated instanlces. aiesilhelists 1had41 heell iullhlelticed to use this (II'ull• el"ud tuitWar''altled ci''illltstlla ces.

such ias tile incision ani dai'miite of a Iltlegaol of tI lie neck. Splunal atesthesia

walIs used ill generl' I taslitaIs P roviding_ deli ititie treatment but was seliom
608 ACTIVITIES OF' SURGICAL C'ONSULTANTS

1used for tile t reatmiuent of t hose reel vwounded. Thiis consult ant received

the nimpression that, although fluids hadi beeni freely adminnistered, undlert reatIiet-lt rat her thanl overt reatmnent existed. Ini one a rea at least, supplied froml

British sources. blood( ili relation to plasmna was Ibeing- usedl in l lite ratio of 10

units to 1. At t lie t ime, t his Nvas conisidered a lioljust iiable dleplet ion of supp)lies of bl1ood, but, as thle camp~aign pr-ogressed. thle need1 was muore and more

ealsilY justified.

VISIT TO NORMANDY

I inriiig he. first week of *July , this~ colisultamit v-isited liospit als inl Norlila ll(Iv. and1( a rep~ort ()f 0Ilýervait 1011 was pirep~ared. lie nioted1 that some

evaculat ion and field hospitals were in the process of packing inl preparat ionl for

moving forward while otlier hospitals still remaining lin operation were worku lg bevyonfiilie 1limiiits of thiei r cap~acity. ()nie 41)1 -bed evacuiation hospital had

520) patients on its secondl day of op~erat ion, with a preoperative b~acklog of

230 to :300. This was due to a sp~ecial ci rcumistanlce: Its normal1,1 line of evaclnalion was over I tali Beach anl tilie airstrip initendled for evacuation of thle

-oiiiidedl wvas needled for fighter squadrons. It was recognized that evacuaI ioln by hospital Carrier might take as5 long as it would take to wvork dowii

lie backlog of preoperat ive patieints. A problem inl sorting. therefore, existedI

rea ?ii oslc o fptIeit oh t ransp~orted1 b% surface carrier to ( ireat

Britain and patients to remain with the unit for surgical t reatmenit.

.A. platoon of the 13th Field Hospital was visited and found to be not

t(N) busy. It was supported by two teams from the 3d Auxiliary Surgical

Group. Equipment was adequate to meet. need1s with the exception that Shell

Xatron canisters were lacking- for closed-circuit oxygen thierapy applaratus.

These teamls had had nto (leatius onl thle op~erat ing tal)le. A nieighboxrinig unit,

thle I16th Field I lospital. Normuand(Y, F~rance. was at tachied to and1( working

withI the 67t1h Evacuat ion IHospital. whuilhe awaiting the arrival of equipment.

This unit had been in active operation iii E~gypt. Thme 47th Field Hospital.

Nor-naiadvN, F'raince, was 1likewvise awaitinug thle arrival of its equipmient. whichl

its persoiinel knew lacked gas machines and1( equiiipimeint for oxygren therapy.

Thlis unit. originially helomigiiii, to thme Thiiird U .S. A rmny. had arrivred last and

had b)eeni assignied to the First U .S. Armym. This circumstaince avý-oumnted

for failure to obtain those siuppleiientary itemis authorized for First U.S.

A rmny units inl the European theater. Aý lack of coordination between time

efforts of at tached auxiliary surgical group teams and the personnel of a

platoon of a field hiospita i Was ini evideiice. Two units never (ho well unlder

one roof unless the commanding officer of the facility has full] coordinating

control. Thiis matter was rep~ortedl for policy (lecisir)I inl relation to field

hospitals.

Penitothal 50hilliii waIs being 1ise(] ill ap~proimOiuately 715 percent of the operations. Oxygen was frequently given for support. For tile longer proceduriIes,

nitrous oxiode and oxygen was given, and ether was employed to pro~duce, relaxatiou. Thie imiusche relaxants of th lemuare series were not available at thle t ime.
ANESTHESIA 609

It was also quite the usual practice for hospitals to prepare atropine-inorplIine

and Pentothal sodium in bulk. This practice resulted in the conservation of

valuable time, facilitated preliminary medication in tie operating room, and

eliminated haphazard premedication in wards. In order to time properly the

administration of preliminary medication with the beginning of an operation,

it was necessary to give atropine and morphine intravenously in the operating

rooms. Because Pentothal sodium was being prepared in bulk, the prevailing

practice of procuring Pentothal sodium in small 1-gram ampules seemed extravagalit in terms of supl)lies and also in the time required to make the preparation.

This consultant suggested that 1Pentothlm1 sodium might, well be obtamied in

10-grant almipules and that distilled water for its dilution could better be silpplied in bottles containing 500 or 1,000 cc. In one instaince, faulty tilling of

a cylinder constituted a problem. An officer of the 3d Auxiliary Surgical

Group reported that. a cylinder, marked "O()xygen" and painted black with white

neck like its British standard. contaiined-in actual fact-carbon dioxide.

When tile gas was employed. it produced cyanosis following a period of hyperpnea. This was recognized, the contents of the cylinder were emptied, and tile

cylimler was returlmed for refill. No patients suffered. This circumstance was

amother facet of the overall problem of identification of gases in cylinders.

Some deaths had occurred in which anesthesia was considered to be contributory. In these instances, inhalation anesthesia was as frequently bhhned

as when Pentothal sodium was emp)loyed. Vomiting with aspiration during

the induction of anesthesia was recognized as a major hazard. It was noted

that the critical interval in which anesthetists should 1)e interested was the tine

between eating amd wounding, rather than wounding and operation, because

digrestion was inhibited immediately after wounding. This author advised that

accidents due to asl)iration could, in some instances, be prevented by initiating

vomiting prior to induction of anesthesia. Attempts to wash a stomach with

a Ivin tube in place had given only partial protection.

Plasma and blood were being used in the ratio of 1 to 1. In order to conserve blood, which was limited in sup)p)ly. this consultant expressed the hope

that the ratio of plasma might l)e raised to 2 units for 1 of Iblood. Along this

line. he also noted that, during hot weather or when patients were perspiring

or vomiting, there was a very real need to rel)iace chlorides by the amliniistration of normal saline. A common complaint, was that the needles in i)lasma

sets were too small in caliber to permit the administration of blood. The air

vent. in the blood bottle was too short to reach above the surface of the fluid.

Filters became clogged with fibrin. Pressure was necessary to ilmaintain flow

of fluid. The valves of blood pressure bulbs, used to create pressure, became

clogged. It, was recommended that the Office of The Surgeon General be, informed of difficulties due to small-caliler needles and be requested to include

larger, size-16 needles in plasma sets.

Arrangements for the treatment of shock seemed to entail some confusion.

There was a general tendency toward failure to isolate patients requiring major

effort in the treatment of shock. As a result, officers were confronted with
Wio AC'rI vi'rws OF SURICUIAL CONSULTANTS

patienits ill widelly dtxl-jt'1t'l jnirts of prpo~perat%- teleits and~ failed to treat

shock adequately. IThis coinsuilt ant a(Ivisett t hat it %vas (ltsiraible to segregate.

patients needing major effort iii thI e I reatinient of shof ck inl order that. thle it edica I

offhcer inl charge might. bie able to keep them undter his dlirect supervision iat all

t inies. Hie further advi-Aed that, an officer with naiarre experienuce Ibe assigned1

to thleseA duties. Surgeons found it impIossilhle to maintain contituuity of observatioti bet weeui op~erautions. It. was wvith these iiuatters, ill mind that, ai senior

Coiusuilltait ended his fi rst four of duty to tilie Normanady beachhead onl S July.

MOVE TO THE CONTINENT

Ont 2S August 19)44, mnoveiment. of the Professional Services D~ivision, Office

of tile Chief Siu~rgeon. Ito the C1ont inent, began. Tiravel was accompl~lished by

trainl to thle iiarshlaIing areal near Souit haiiijptoi. thIeince by boalt to t alt Bleachi,

and lastly to H eadquiarters, Coinmuniliicaltions Zonle, aIt, Viaognes. Fri'ance, b~y

truck. The group wats delayed for :1 days en route at, the miarshualinig area'I

b~ecause thle ship il)0 Which it. was schedluled for transport. to France had nto

accouluiii()tlat 14)11 for femiales. nhe p~arty incimlile(l two. thle chiief nurse .1itd

Capt. (12later Maj. ) Marion C. IXidze'llix, M(C. TIhie paurty -was subseAquentl iy ssignied Ito a Victory% Shiip. ca irrvillg sii' 5 ItrI mps, packed like sard iies ill

a1 vaii. FlThe )assagre acro~ss t(lie Engl ishi ( liaui iel ovviipiet 2 4 lioui s I va use o

the circuitous route that thit slhip was forted to take ili o)rder to avoid mniiefields. Oif I talb Beach. tile tratvele'rs wvere ti rnisferrel to a. fender. Tlhis

t ranisfer Ileocessit ateti climibing dlowni a rope net to the deck of thie tender whi icl

wats inl conIst ant, miotion. For a1 .landboiind Ariuiv man. t his wa-.s a new expericuice. Fort unately. tilie operatioii ent a iled no n1j ii ries to anly of tilie groulp.

From tilie tender, the Ilmembers Walked ashore over tile liardstantl. getting fno

moitre thanl their feet. wet. The evideice of smikeii ships and flthe litter of (lest rilict ioul oil the bt'acli Were still preseint. reiniiidiiig all] of thle contras21t between

I lie eaise of tliei r lantlling~ and1 the difficult ies inl thle origiinal in vasion by shock

t roojps.

As t hey proceededtlt iinland. it. was obviouis that. thle Annuiy had1( accompldishietd

aixet deal ill clearing. away tile b~its and pieces of glitders force'd to landit

ill fields that. Were too siiall because :1ll tilit laurger fields hiatd Ib'tii Well plant11ed

WillIi b"Rolliuuit.s asparaguis, posts approx imiately S fteet long ilinlwddt'd

iijprighit ill thlit groundit at re'gula~r iiitervalis. The it'11 llt)5t was to pre'vetit

the very* landing t hat ocvuirrt'tI ill spite of thIiis t'iu'iii act ion. It wats

amlazing how thoroughly an Army inl coimibat wits abhlte to clt'uui 1ii) its new

baickyartd in flt'e ltess thian 6 wteeks that had elapsed bt'tween thuis consltailtat's

firt. tot ri le watil ilul i arlYi 1il anddtlipe triialit'It tranuisfer of t ~lt fice

of tbCht'('iehf Surgeon inl Auigust. Not only hald tite supterficial evidencte of

tlesthriict.ionl oociisionlet by flt'i invasiont beein remioved, bu~t (lie fieltds 1121( b~teen

cleared of iiini litsas well1. Thiis totld a 'a hiati baeii cle'aredl to provide spaice

for iincominiig troops antd tilit buidii dp of a1 muajor supply leas~e.
ANESTHESIA 611

The headquarters remained in Valognes only a few days. At this time,

the advance of the Allied armies was extremely rapid. Orders were received

to move to Paris. This city continued to be the location of European theater

headquarters throughout the remainder of the fighting in northern Europe.

The first entry into Paris was memorable. Although the city had been secured a few days prior to the arrival of the headquarters group, the elation of

the populace was very much in evidence. The author was intrigued to learn

that he had been assigned a billet in the Hotel California. Subsequently,

after a tour of hospitals in the then existing forward area that required approximately one week for its accomplishment, he returned to the Hotel California to find that it was completely occupied by the Women's Army Corps.

His gear had been moved out. lie was temporarily dismayed with the idea

that he would never see it again. The personnel of the billeting office, however, were completely efficient. They informed him of his new assignment,

and there were equipment amid persollal belongings, completely intact with not

one item of importance, collected during 2 years' sojourn in England, missing.

ACTIVITIES DURING THE FINAL CAMPAIGNS

Thereafter, the work of the Senior Consultant in Anesthesia was divided

between the Continent and installations in the United Kingdom Base. With

the establishment of hospital centers in the United Kingdom Base, a consultant

in anesthesia was nominated for each of the seven centers. The author expected that, during the remainder of 1944, and until the termination of the

campaigns in northwestern Europe, hi.- work in the main would be confined to

facilities (00,000 beds) on the Continent with the hospital center consultants

functioning in the United Kingdom. The medical officers to whom this responsibility was delegated were as follows:

C(enter Officer Hospital a8siq•nment

------------ Capt. Gilbert Clapperton, M( ------------- 67th General Hospital,

Musgrove Park, Taunton,

Somerset

II----------- Capt. Lawrence F. Schuhmacher, Jr., MC__ 140th General Hospital,

near Ringwood, HIampshire

III----------- Capt. Arthur LeeRoy, MC ---------------- 154th General Hospital,

near Wroughton, Wiltshire

IV ---------- Capt. Charles Burstein, MC --------------- 160th General Hospital,

Stowell Park, Gloucestershire

V ------------- ('apt. Milton II. Adelman. M'. ------------- 155th General Hospital,

near Hlanley, Worcestershire

VI ----------- ('alpt. Jasper M. Hedges. M( -------------- 137th General Hospital,

Otley Deer Park, near

Ellesinere. Shropshire

VII ---------- ('apt. Phillip E. Schultz, MC -------------- 7th General Hospital,

North Mininns, Ilertfordshire

705-0951---64 --- 42
612 ACTIVITIES OF SU'IRGICAL CO.NSULTANTS

As rounds of hospitals and auxiliary surgical groups were made, it was apparent that accessory equipuhent beyond their authorized allowances would

facilitate thbeir operations. The priinary need was for a mianually controlled

al)p)aratus for resuscitation which would supply intermittent positive pressure

without the necessity of having cylinders containing oxygen. The second need

was for a suction apparatus that was foot operated rather than electrically

driven. At the same time, it was realized that the allowance of gas machines

to evacuation hospitals and field hospitals was inadequate to meet their needs.

During the last quarter of 1944, it was agreed that the authorized allowance

of these items should be increased so that each 400-bed evacuation hospital

would have four gas machines and each 400-bed field hospital would have six.

In November, this author was notified by the Supply Division, Office of the

Chief Surgeon, that 1,000 units of foot-operated suctions had l)een received,

500 from I)own Bros., London, and 500 from the Zone of Interior. These units

were distributed, one unit to each general and station hospital, two units to

each evacuation hospital, and three units to each 400-bed field hospital. The

latter made available one unit to each of the three hospital platoons in the

field hospitals. Distribution at this stage of the campaign was difficult on an

automatic basis, and not until all units learned of the availability of these

units for suction were requisitions placed for them.

Following practices established in the immediate 1)reinvasion period, hospital commanders and their chiefs of surgical service were urged, throughout

tile year, to assign medical officers and nurses for training in anesthesia and

oxygen therapy within their units where trained anesthesiologists of teaching

caliber were available. Admittedly, there was some reluctance to follow this

advice with enthusiasm, but in many instances it was undertaken with ultimate

benefit accruing after tile units were assigned their conmhat slupl)ort missions.

In September 1944, the lack of anesthetists in forward areas, particularly

in evacuation hospitals, was creating a bottleneck in the treatment of the

wounded. Anesthetists to meet attrition were not available. It was therefore proposed to the Surgeon, United Kingdom Base, that 25 general and

station hospitals possessing qualified anesthesiologists of teaching caliber be

or0dered to undertake the training of one medical officer and one nurse in

anesthesia. Col. (later Brig. Gen.) Charles B. Spruit, 11C, Surgeon, Inited

Kingdom Base, endorsed this program. Letters were written to the 25 selected

hospitals advising each commanding officer immediately to assign a medical officer and nurse from his unit to full-time training in anesthesia with the understanding that when training was completed one or both individuals would be

sul)ject to reassignmnent to units in greater need of their services. In Novemlber

1944, 10 general hospitals arrived in the United Kingdom from the Zone of

Interior without coverage in anesthesia. Officers made available through the

training program were assigned to these new units or to units already in operation requiring only minimal skills in anesthesia. Iii the latter instance, the more

skilled anesthesiologist of the operating unit was reassigned to the new general

hospitals. '[iie rate of attrition among anestlietists throughout the theater
ANEI.'IrIE i IA 613

was increasing due to illness, fatigue, and nonbattle injury. The pool of anesthetists in training was being rapidly depleted. It was therefore recommended

to the Surgeon, United Kingdom Base, that in each instance in which a

trained anesthetist was moved his replacement was to be similarly trained and

oriented in anesthesia. Thus, the training program was perpetuated.

Because fatigue became evident among anesthesiologists of auxiliary surgical groups and those assigned to evacuation hospitals, the policy was established in October 1944 that medical officers over 40 years of age 1)e permanently

reassigned from forward units to fixed facilities in the communications zone.

A second phase of the program rotated younger anesthesiologists in forward

areas to fixed facilities in the communications zone for a period of 60 days

and sent anesthesiologists forward from fixed hospitals for a similar l)eriod of

temporary duty in forward area hospitals. As a result of this exchange prograin, the experience of anesthesiologists involved was broadened, and each

had an opportunity to observe at first. hand the 1)roblemns of the other.

Throughout -the year until closure of the school, a lecture, illustrated

by slides on anesthesia and oxygen therapy, was delivered before each class

for medical officers at the ETOUSA Medical Field Service School, Shrivenham.

The practice, which had been initiated in 1943, of holding conferences for

anesthesiologists immedliately after eachl monthly meeting of the Section on

Anesthetics of the Royal Society of Medicine in London was continued throughout 1944. Interesting clinical topics were presented by selected members,

after which open discussion of problems was encouraged. By this means, use

of agents and methods tended to become standardized for the benefit of the sick

and woundled. Copies of three films, prepared by D)r. I. 1V. Magill and D)r.

G. S. W. Organe of London under the sponsorship of Iml)erial Chemical

Industries, Ltd., were made available as training aids through the Army Pictorial Service. These films dealt with ether anesthesia, endotracheal anesthesia,

and intravenous anesthesia. Throughout the year, they were shown to many

groul)s. Attempt was made through the Office of The Surgeon General to

obtain cop)ies of training films produced in the Zone of Interior, but. information was subsequently received that shipment of these training aids overseas

was not 1)ossilble.

As the war progressed in Europe, lines of communication lengthened

tremendously and the battlefront became far flung, extending from The Netherlands through Belgium and Luxembourg and eventually to southern France.

The problems of observation, supervision, and control of anesthetic practice

grew tremendously as the battleline was extended. Even changes in climatic

conditions from the heat of summer to the cold winter of 1944-45 created new

prol)lems. The character of wounds and injuries changed. The incidence of

exposure was magnified. Frostbite and trenchfoot became prevalent. It was

necessary to caution that (loses of morphine given as preoperative medication

for seriously wounded patients should be small. It was further emphasized

that morphine must be administered with caution to the walking wounded, to

patienits to be evaciiated iby air, or in the presence of jamndice, craniocerel)ral
614 ACTIVITIES OF SURGI('AL ( C)NSU'LTANTS

injuries, pneumothorax, hematothorax, or pleural effusion. With the arrival

of cold weather, the hazards of morphine poisoning were accentuated due to

slower absorption in the presence of shock. The syndrome became evident

when patients were warlmed and were given fluids to alleviate shock.

It was necessary to issue an administrative memorandum that the admninistration of spinal anesthetics would in all instances be undertaken by medical

officers only, although care of the patient during the operative procedure might

be delegated as the situation warranted. The use of spinal anesthesia was

discouraged except for definitive late treatment of wounds involving the

buttocks and lower extremities.

Material covering the subject of intravenous administration of procaine

hydrochloride had been prepared and distriluted to the Senior Consultants in Maxillofacial Surgery, Neurosurgery, Orthopedics, and Dermatology with

the request that, the niethod be. cautiously tried in suitable instances. It was

known that it was feasible to inject a dilute solution of procaine hydrochloride

intravenously in order to obtain relief from pruritus associated with jaundice.

It was considered that patients with syore burns might be similarly helped

without the production of respiratory depression. Sedation in the p)resence

of involvement of the tracheobronchial tree due to inhalation of smoke and

noxious vapor was recognized as a difficult problem. The incidence of burns

l)roved to he much lower in the European theater than had been contemplated.

Opportunity was afforded to give limited trial to the use of procaine hydrochloride administered intravenously. Reasonably satisfactory sedation was

ol)tained in many instances. This experience led to the administration of

procaine hydrochloridle for sedation in the presence of conditions other than

burns. In patients with fractures recently confined within a cast that included

both the trunk and either a leg or arm, tile administration of procaine hydrochloride intravenously alleviated restlessness due to the marked restriction

of movement. It was subsequently noted that reduction of swelling and edema

occurred in surprisingly rapid fashion. Orthopedists found it necessary to

change casts at shorter intervals in order to compensate for the ralpi(d reduict ion in size of a leg.

As the incidence of trenchfoot. increased, utilization of sympathetic block

became more frequent. During the first 5 months after D-day, sympathetic

block was reported employed in 1,300 instances for an overall incidence of

0.94 l)ercent. Its employment in the presence of vascular injuries associated

with marked edema was helpful. It was subsequently shown that utilization

of sympathetic block in the 1presence of cold exposure of extrelmities or trenchfoot was essentially noncontributory to impl)rovement. Statistical data regarding the incidence of utilization of other anesthetic agents and methods

have been reported elsewhere."

Sit "ro%,Pii. Ralph M.: 'roblems In Supply of Anesthetle Gases in the European Theater of

Operations. V'.S. Armny. Anesthesiology 9: 303-311. May 1947. (2) Tovell. Ralph 'A. Problems

of Training in and Practice of Anesthesiology In the Euroliean Theater of Operalions. Anesthesiology

8: 62-74. January 1947. (3) Tovell. Ralph M.. and Barhour. Charles M. : Comparative Uses of

]1fntothal Sodiunn In Civilian and Military iPra tive. Lancet 67 :437-44i. l)eember 11947.
ANESTHESIA 615

The problem of promoting anesthesiologists became more acute throughout

the year, and no solution was found. A new tal)le of organization and equipment No. 8-550 for 1,000-bed general hospitals had been promulgated by the

War Department on 3 July 1944 stipulating that anesthesiologists be in the

rank of captain. In August 1944, this consultant commented to the Chief Surgeon, ETOUSA, that there was a distinct correlation between the existing

shortage of anesthesiologists and the lack of opportunity for advancement in

rank. Medical officers had no incentive to qualify as anesthesiologists because

of the existing limitations. lie also pointed out that modern anesthesia denmanded adequate training and experience if the lives of the sick and wounded

were to be adequately p)rotected. Hle stressed the fact, that anesthesiologists

were responsible for the safeguarding of equipment in operating rooms, the

training and control of personnel, and the supervision of central supply and

oxygen therapy as well as the administration of anesthetics. The author

therefore recommended that in order to provide an incentive for medical

officers to qualify as anesthesiologists and in order that qualified anesthesiologists of long standing in the theater might receive the recognition they deserved, an urgent request for a. change of the new table of organization to provide for a majority for at least one anesthesiologist in each 1,000-bed hospital

be submitted to The Surgeon General.

The problem of promotions was not limited to general hospitals. The

situation in auxiliary surgical groups became acute, particularly in those

groups that had been overseas for 2 years or longer and had served in Africa,

Sicily, Italy, and France. In the 3d Auxiliary Surgical Group, there were 21

anesthesiologists with 2 years of service who had no opportunity under existing tables of organization to improve their rank, no matter how long the war

lasted. The situation was depressing to their morale in view of the fact that

they had seen junior surgeons of less training and experience become chiefs

of surgical teams and gain the rank of major. These anesthesiologists had

been caring for nontransportables in field hospitals, their skills were recognized and appreciated by their associates, but this appreciation was not reflected in the tables of organization. It was evident that a general overhaul

of tables of organization was warranted.

Miscellaneous activities continued to occupy a great deal of the time

of the Senior Consultant in Anesthesia. He attended meetings of the Medical

Research Council in London, particularly those dealing with blood, blood

substitutes, and shock. Several meetings of the Service Consultants Colnmittee on Anesthetics held at 1 Wimpole Street, London, afforded an opportunitv frr the interchange of information among consultants to the Ministry

of hIealth, Scotland; the British Army, the Royal Navy, and the Royal Air

Force; EMS hospitals; and tl e Canadian Army. Liaison through these meetings was particularly valuable. Meetings of the Inter-Allied Conference on

War Medicine were also attended. The Senior Consultant in Anesthesia also

attended two meetings of British and American consultants, one held in Paris

and the other in Brussels.
6(16 AC'TIVI'IES ()1 SIURGICAL C'ONSULT'1ANTS

From time to time throughout 1944, material was prepared for submission

to the Oftlice of Tile Surgeon General re-arding tile adequacy of equiplmlent and

sUl)l)lies for anesthesia and oxygen therapay. This material was forwarded in

ETMID (Essential Technical Medical D)ata) reports that proved to be an important mnediun for the suibmission of information to the Office of The Surgeon

General. Oin 29 Janmary 1945, a memorandum was submit ted to ('olonel (Olt der

regarding the preparation of sterile solutions of procaine hydrochloride from

bulk supplies of the drug. It was pointed out that two deaths had occurred,

one following the subcutaneous infiltration of procaine hydrochloride (presiumed) for the iinvestigation of a severed 1)ermmeal nerve amid tile other du-ri11g

the administration of a sympathetic block. These deaths had occurred at

different hospitals. At tile hospital where the death occurred following subcutaneous injection in tile popliiteal region, another p)atient exhibited convulsions

of a severe nature but recovered under al)l)rol)riate therapy. It was l)ointed

out that the prevailing piractice of sup)plying pIrm()aile hydrochloride in bulk

led to difficulties in preparation and identification of solutions of lprolper coilcentration and sterility, particularly in field and evacuation hospitals. Sterilization was carried out. either by boiling in a water bath or by autoclaving.

Frequently, excessive heat tended to minimize the anesthetic eflectiveness of

the resulting solution. As a result, there was a tendency to use a stronger

solution than was justifiable for infiltration. U nder' these circumstances, toxic

doses were rapidly al)p)roached. It was recommended that serious consideration

1e given to a change in policy in sup)plying procaine hydrochloride. It was

believed that many of the sources of hazard would be eliminated if the drug

were Sl1)l)lied in aml)ules containing 1.0 gin. in 5 cc. of solution. Such ampules

could be sterilized by immersion in any ap)proved colored antiseptic solution.

The proper dilut ion could be achieved using either sterile water or sterile normnal

saline in quantities of 95 cc. to p)roduce a solution of 1.0 percent or 195 cc. to

p1roduce a solution of 0.5 p)ercent concentration. This was the type of material

that was submitted in the ETM I) reports.

The ET'MI) reports moved oin a "two-way street." D)ifficulties encountered

in the use of piperocaine hydrochloride (Metycaine IHydrochloride) for spinal

anesthesia were rel)orted. In the ETOPSA Manual of Therapy, issued 5 May

1944, a table of dosage for tetracaine hydrochloride ( Pontocaine Hydrochloride)

and procaine hydrochloride comnbimned, l)rocaine crystals dissolved in spinal

fluid, and Metycaine Hydrochloride in sl)inal fluid was outlined. The dose of

Metycaine Hydrochloride was limited to a maxinnum of 140 iug. Difficulties in

the use of Metycaine Hydrochloride were experienced, and, as a result, the use

of Metycaine Hydrochloride was discouraged and supplies were allowed to

dwindle. The Office of The Surgeon General was ac(qmainted with these l)roblems because parallel difficulties had been experienced in the Zone of Interior.

On 16 June 1945, a memorandum from the Supply D)ivision to the Professional

Services Division drew attention to Section VI of War Department Circular

No. 134. dated 4 May 1945, which stated that Metycaine JIydrochloride would
AN ESTHIESIA 617

no longer be enlploved ill ArniNv hosp~ita~ls inl any formn. Major D~avis, acting

for this auithor, repl)iedl to this memorandum oil IS June 1945 anld advised withdrawal of Metycaine I lydrochioride fromm issue in the European theater.

Material submnittedl for the ETOUSA Essential Technical Mfedical Data

Ilelport for the mionth of April 1945 included a, statistical sumnnary of anesthetics administered (hiring the p)eriod 1 bJuie-31 D)ecemnber 1944. Comment

regardingo this sumnmnlar'V was as follows:

Although field blocks including local i'ifiltrations were employed less frequently during

Novemiber and D)ecembher 1944 than they had been in the previous live monthIs, the incidence

of emplhloymlenit of spec'ific regional blocks inlcreasedl iilal 1I YPe' of hiospitails. the greatest

increase being inl evidence in evacuation ho.-'dtals ; and significantly in evidlence iii Fieldl

Hospitals. Tfle overall average of eninlloyeyii. of specitic regional b~locks increased front

1.4:3 percent to 2.57 percent. This, too, is consideredl to be a dlevelopment iii a desirable

dlirection because wvithi propier organization of the sect ion onl anesthesia. tire time lag between opierationis caln tbe (leereiisCe. Pat ients maintain full control of their oN% i, airwvay,

(lehydration through vomniting is not inlcreasedl as it nmy be after inhalation anesthesia,

nursing care is kept at a minimium and patients are inmmediately evacuiablde if that is

necessa ry.

Incidlence of empjloymrent of sympathetic block increased in all types of hospitals wvith

the exception of field hospitals. This was in the inirin (lue to the increased inc'idence of

-trench foot." Present opinion regarding the efficiency of syinipaithetic block for the treatrment of trench foot is extremely guarded. It is felt that in no insrance did the accomnplishmnent of a sympathietic block tend to increase tlie patient's dlebility insofar as his injury

was concerned. In thec vast majority of instances, however, it could riot lhe thoroughly establishied that. accq Dili lishlutiett (of symipat het ic hlock improved the loatient s rate iif reeoveri-.

(Ine (death occurred during the aevoinplislimnent of stellate ganglion blocxk undertaken for

relief of peripheral vascular inadequacy of the upper extremity. This de'ath wvas p~robably

due- to inadlvert ent inject ion of procaine withbin the dural sheath whiere prolongation of the

sheath existed aind protrud~ed thnrouigh tihe foramnen.

Pentiitlal suipplemlenited by other anesthetic agents was the niethod that was employed

niore frequently in Novembler and1( Decemnber than in the previous 5 mnonths in all types

of hospitals except field hospitals. Statistical (data in relation to field hospitals has not

been broken dowvn onl the basis of their working status, but it is knowvn that throughout

November and D ecember a greater numbier of theini were working as Communications

Zonle units doin1g station hiospitail wvork. fit niany instainces, these units so employed

lacked theu benmetit of skilled mmliesthet ists where ainx ii a ry stirgica I teams were not Jlttiicliedl.

it is obvious, front these Statistical (data that the best qualified anesthetists shoul1d be

assigned-4 to anxiliary surgical groups and cviacunatiomn hospiitals. **

(Chaniges in 'T/O&E' S-580, :31 .January 1M.-5, for 7ý50-bed Evacuat ion Hospmitals are

also conisidlered to reflect experienice encouinteredl in this theater. H~owever, inclusion of

oinly one nurse anesthnet ist is inadequate to meet the needls for 24-hour operation (if 10-42

(iloerrt ing tablies. Six mirse anesthiet ists for suchi at union represents the nininlinum in ruunhoer required and lhemn it would lie necessary to orient thlree or four other nurses into thle

int racacies of aiies: hesia or else (lelIe~ld upon11 auigaentat ionl by Iiersoniiel froni aurxiliar-.

stirgical tea ins. Experience has been that seldomn is it necessary for 750-bed evaicuation

ousliltsills to lie thuis augmented. Iii thle 2d Evacuathion H ospitail. 10 nurses have been

or.,,ii iefi in the adnminist ration (if anesthbet ics.
618 ACTIVITIES OF SURGICAL CONSULTANTS

Comment in a similar direction was made with regard to 400-bed evacuation hospitals. It wP- stated that four nurse anesthetists were required as

a minimum to staff such a unit during active operations in spite of the fact that

a 400-bed evacuation hospital was frequently augmented by auxiliary surgical

teams.

Subsequently, statistical data covering the period from 1 January through

31 May 1945 were submitted in the semiannual historical report prepared by

Major Davis in this consultant's absence on a trip to the Zone of Interior,

undertaken on 28 May 1945.

This sketchy account of activities during 32 months in Europe would

be completely inadequate without comment upon a trip to the concentration

camps in Weimar and Nordhausen, Germany, within a day or so of their capture by units of the U.S. Army. Information had reached Headquarters,

ETOUSA, in Paris, regarding the deplorable condition of the unfortunates

incarcerated there. A small group of consultants, including this author, flew

to Weimar to investigate the situation. Upon arrival, the grou1) first visited

the pathologic museum, featuring tattooed skin taken from victims. The group

learned that approximately 51,000 individuals had died within the electrified

wire enclosure after 1 January 1945--many of them from starvation, others

by lhanging, and still others in the furnaces that had been erected immediately

abov'e the gas chamber. A- pile of hiuman ashes, 6 feet. high, was seen. The

con(lit ion of the inmates of the several barracks defied description. Starvation,

superimposed upon tuberculosis, was universal. These humans wore masks

that were immobile and expressionless; they appeared not to care whether they

lived or died. Their diet of 600 calories per day was immediately increased,

but any undue increase produced a dehydrating, fulminating diarrhea. Deaths

continued to occur all too frequently following liberation. In order to take

care of the children, it. was necessary for the U.S. Army to divert a 400-bed

evacuation hospital for this purpose alone.

The situation at Nordhausen was bad, but not as bad as at Weimar. In

the Nordhausen internment camp, the internees had been forced to work in

the underground factories producing V-1 and V-2 missiles. For this reason,

the caloric intake of the workers lhad been maintained at. a higher level;

nevertheless, the death rate had been high. Arrival of new and more healthy

individuals had been scheduled to meet the attrition. This was cheaper than

feeding the working force adequately. It was brought home to the group

of consultants, once again, that the capacity of man's inhumamity to man was

infinite.

VICTORY IN EUROPE

When V-E Day arrived, this author was in London. The joy exhibited

by the British was real in a restrained way. Seeing the lights go on, even

though they were turned on, of necessity, in haphazard fashion, was a memorable experience. The next day the author flew tc Paris, and because of some

confusion in the announcement of V-E Day tile French people were one
ANESTHESIA 619

day late in their celebration. Therefore, he had the opportunity to participate

again iii this gala event. Lie spent the evening o)serving the festivities. At

2300, he was walking down the Champs Rlys<es when he noticed that a group

consisting of a man, a woman (apparently his wife), a 14-year-old boy, and

a woman who appeared to be the boy's grandmother were observing him

specifically and with keen interest. This author, in turn, observed that after

a hurried conversation among the four the younger woman was summoning

courage to speak to him, a complete stranger. This she did, in English.

She, Madame Cloup, stated that her -family had noticed by his insignia

that the author was a medical officer. Her husband was a surgeon, practicing

urology. They would be honored, she continued, if the author would accompany them to their home for an "after-the-theater" dinner to celebrate the

victory. Colonel Tovell was touched and pleased to be thus singled out for

participation in their victory party. He accepted rather hesitantly because

lie knew of the short rations that existed among the French population in Paris.

He explained that lie had just recently completed dinner but that he would be

very happy to accompany them and join in their celebration. Madame Cloup

surmised his thoughts and explained that her friend (the older woman in the

group) had just arrived from Normandy, where food was more plentiful, and

that she had brought a roast of beef which they wished to share with him. The

author accompanied them to their flat on the Left Bank of the Seine where he

was entertained royally. A friendship was established that has been maintained by sporadic communication throughout the years.

AFTER V-E DAY

Victory in Europe l)rought with it, its p)rol)lems. The war was not over:

Japan still remained to le defeated. Problems of selection and redeployment

had to be met. It was realized, ridiculous though it may seem, that, during

the period of redeployment of medical officers to other theaters, a new training

program in anesthesia and oxygen therapy should be set up. On 19 May 1945,

this consultant submitted a memorandum to the Training Division, Office of

the Chief Surgeon, outlining the proposed program. It was necessary geographically to divide the program into two sections, one for the Continent and

another for the United Kingdom.

On the Continent, certain hospitals, designated as teaching units for anesthesia, were to have one medical officer trainee and one nurse trainee. Active

training was for a period of not less than 3 months, the military situation permitting. Trainees were subject to reassignment in the hospital center in which

they were trained on the recommendation of the hospital center's consultant in

anesthesia. Names of trainees in excess of local requirements, who were. declared ready for reassignment by the hospital center's consultant, were to be

available for reassignment on recommendation by the base section consultant

in surgery or the Senior Consultant in Anesthesia, Office of the Chief Surgeon,
620 A'TIVITIES OF SUR(GI'AL C(ONSULTANTS

ETOL'SA. It was the intent to continue this system at the specified hospitals

-is long as clinical material was available and teaching anesthesiologists remained assigned. It was further planned that monthly conferences would be

held at each hospital center at the discretion of the center consultant in anesthesia. Presentation of palpers, exchange of ideas, and discussion of problems

were thus to be made possible. In addition, the center consultant was to Ie

authorized to make rounds of each hospital in his area in order to check on the

organ ization, practice, anid training within the section on anesthesia and

operating rooms of each unit. Furthermore, each hospital center was to receive four medical oflicer trainees and two nurse trainees on temporary duty

from communications zone and field army units for a period of 1 month's training in anesthesia and oxygen therapy. As a part of the training program, it

was proposed that during operating periods trainees observe or work as apprentices under the supervision of the chief anesthesiologist of the particular

facility. In or(ler to support the senior assineld anesthesiologist in this training program, it was further proposed that one medical officer of recognized

teaching ability be ordered from field army units to each hospital on a temporary duty status. In this manner, a pool of demonstrators and lecturers

could lbe established.

For the U nited Kingdom Base Section, a similar program was suggested

and initiated. The ETLT SA Society of Anesthetists was reactivated and held

monthly meetings in London at the Royal Society of Medicine headquarters.

Major Burstein of the 160th General hospital was chairman. Since there

was a shortage of anesthetists in the United Kingdom Base Section, and, since

those available had been closely tied to their work over a period of months,

they needed relief. On the other hand, anesthetists assigned to field army units

needed to gain general hospital experience in the administration of anesthetics

and the organization of the section on anesthesia and operating room. It was,

therefore, recommended that anesthetists from auxiliary surgical groups and

evacuation hospitals be given a tour of teml)orary duty for 60 (lays in United

Kingdom Base hospitals. The program in the United Kingdom was expandable beyond that possible on the Continent. The offer of anesthesiologists in

British universities to participate in the retraining program of the U.S. Army

was accepted with gratitude. It was therefore recommended that authorities

of the University of Edinburgh be contacted through Dr. John Gillies, Royal

Infirmary, Edinburgh, to establish courses for anesthesiologists in C and D

categories on the basis of 30 days' temporary duty for classes not to exceed 20

medical officers. It was postulated that similar arrangements could be made

at Glasgow through I)r. Andrew Tindal. Similar facilities, it was suggested,

could be made available through Professor Macintosh, head of the Departmnent of Anaestlietics, Oxford University.

Imperial Chemical Industries, Ltd., had undertaken to produce training

films in anesthesia and resuscitation. Three films, entitled (1) "Open Drop

Ether," (2) "Endotracheal Anaesthesia," and (3) "Intravenous Ainaesthesia,"
ANESTHIESIA 621

had been available to the U.S. Army in 1943. Arrangements had been made

with Army Pictorial Service to copy these films and to reduce them from 35

mun. to 16 amm. for distribution to hospitals. In the interval, Imperial Chemical

Industries, Ltd., had produced five other films. Four of these were reviewed

by the Senior Consultant in Anesthesia and were considered appropriate for

the U.S. Army training program. As a result, it was recommended that the

Army Pictorial Service make three copies of each of these new films for distribution to hospitals on rotation. On 18 May 1945, the day before the proposals for the training program were submitted, this consultant had previewed

a film produced in the United States, entitled "The Physiology of Anoxia, the

Basis for Inhalation Therapy." It was recommended that three copies of this

film be obtained from Washington at the earliest possible moment, one copy to

be allocated to the United Kingdom Base, one copy to be made available for

purposes of training, in the Paris hospitals, and the other copy to be made

generally available through the film library.

In furtherance of the plans submitted, courses in anesthesia were arranged

at Radcliffe Infirmary, Oxford, and at the University of Edinburgh. Various hospital centers on the Continent also conducted anesthesia courses. The

Faculty of Medicine, University of Paris, cooperated in this work furnishing

cadavers and a. dissecting room where the technique of regional anesthesia could

be demonstrated. Maj. Paul IV. Searles. MC. 5th General Hospital, was ill

charge of this effort.

Duties associated with termination of the campaign, collection of statistical data, establishment of the new training program for anesthetists, and

selection of personnel for reassignment to another theater of operations occupied

Colonel Tovell immediately after V-E Day. On his return to the Zone of

Interior late in May he held conferences with interested chiefs of service in

the Office of The Surgeon General, after which he attended a meeting of the

American Board of Anesthesiology in New York City and assisted in the conduct of the oral examinations. On 17 July 1945, he received orders relieving

him of duty as Senior Consultant in Anesthesia in the European theater. On

this same day Maj. Lloyd 1I. Mousel, MC, was appointed Consultant in

Anesthesia to The Surgeon General, but Colonel Tovell continued to serve in

an advisory capacity until 15 October 1945, when he was relieved from active

duty. Late in December of the same year he was invited to join the Veterans'

Administration, of which Maj. Gen. Paul R. Hawley had justl become Chief

Medical Director, as Chief Consultant in Anesthesiology. The passage of

Public Law 293, on 3 January 1946, which established the Department of

Medicine aud Surgery, Veterans' Administration, made it possible to formalize

the invitation.

The story of anesthesiology in the European Theater of Operations has

been told fully and frankly, with the hope that if another war comes, the documentation of lessons learned during one major war will contribute to the effective use of this specialty in another.
Part II

THE PACIFIC AND ASIA
CHAPTER XI

Pacific Ocean Areas

John B. Flick, M.D., Forrester Raine, M.D., and Robert Crawford

Robertson, M.D.

Prior to August 1944. the Pacific thieater of war wvas divided into three

parts: SWPA (the. Southiwest Pacific Area), SPA (thle Southi Pacific Area).

and CPA (the Central Pacific Area).- Eachi of these areas hiad its U.S. Army

component. Ini SWPA, there were 17SAFFE (the U.S. Army Forces in the Far

East) and ITSASOS (tile V.S. Army Services of Supply). in CPIA. thle Army

comlponent was known as I'SAFICPA (thle UT.S. Army Forces in the Central

Pacific Area) and in the SPA, as USAFISPA (tile I .S. Army Forces in thle

South P~aci fic Area). Overall command of the areas encompassed by CPA

and SPA. was placed uiponm Admn. Chiester L. Nimitz. U.S. Navy, whose headqluarters was known as ('iin(TOA (Commander in Chief, Pacific Ocean Areas).

This comninandl corresp~ondled to that of General Headquarters, SWPA, with its

commandler in chief, Gener-il of the Army IDouglas MacArthur, U.S. Army.

SURGICAL CONSULTANTS

Col. WVill. Barclay Parsons, MC, was Consultant in Surgery, Office of the

Chief Surgeomi, U SASOS, SWPA, and Col. Ashley W. Oughterson, MC, Consultant in Surgery, Surgery Section, 17SAFISPA. Both were, on a, full-time

1)asis. (o1. Forrester Raiiie. 'MC, was surgical consul~tant in VSAFICPA, in

add~ition to hiis duties as Chiief, Surgical Service. 147thi General Hospital. on

the outskirts of Honolulu. Also in the Central P~acific Area, functioning as

vonsultants in addition to othier duties, were Col. Robert Crawford Robertson,

MC, Consultant in Orthiopedics, and Lt. Col. Leslie M1. Garrett,1MC. Consultant

in Roentgenology. Colonel Robertson was Chiief, Orthiopedic Section, 219thl

General Hospital, Oahu11, 'l.MI. and Colonel Garrett. Chiief, Roentgenological

Service. 21 Sthi General I to- pital, Fort. Shiaf ter, Oaluml.

U-SAFP()A (thle U~.Army Forces, Pacific Ocean Areas) was set up1 as

an admiin ist rativye overall c1 ommandl in app)IroximaI~tely August 1944 to compare

with that of C~inCPOA. At that. time, USAFISPA and USAFICPA were

reducedl to the level of base commandls under thle jurisdiction of tile USAFPOA.

At' the saitue time. tilie arel1 thten kniown as thle -forward area"-thie Marianas

group of islands and, subsc luently, Ul1ithmi, Angaur, and Iwo Jiina-became the

Western Pacific Base C'ommiand. Duiring the, Ryukyu Island-, campaign. Okinawa. he-jima, ain(l adjaent, smaller islands were. under thme jurisdiction of thle

USAF1POA. Later,7 ill .Jumne 1945, the I'SAF1POA became I-SAFMIDPAC,

62.5
626 ACTIVITIES OFI SURIC;(AL CONSULTANTS

(thle U.S. Army Forces, Middle Pacific), a subordinate command Under thle

overall Army commaid~~~, AFlPA( ( Arnim Forces, Pavifiv).

When tiie USAFISPA became a, base commhiandl, Colonel Oughterson was

placed on temporary duity at, the Surgeons, Office. H eadqiuarters, U SAFP( A,

as full-thimeConsultaint in Surgery. C.olonetl ()ughrlter-son served( Iiithis cap)1city

from Augiust 1944 to D~ecember 1944. w-hen lie 'weiit. to tilie Philippiines. 1In

F~ebrua ry 1945, Colonel Oughterson returned from the Philippines. was assignied to time Western Pacific Base Coummand. mhid b~ecamne Consultant in Stirgery there. lie remiained until .June 194;-, wh-len hie was ordered to the -Medical

Section. General H~eadlquarters, AFPAC, as D)irector of Research and Consultault. inl Surlgery.

FIGURE 228.-CoI. John11 IB. F1ivk. ~11C

The lenitl U .S. Arniy, whose beadquarters anid somec of whose iiedical

units had been stai._,ed on the island of Oahun, T.HL.. subsequently was sent to

( k iiia wa. Thiiis arinv had tilie following consultantis in tie field of surlgeryN

C ol. George G. Finney, M(', ( osmiutanit in General Surgery. Lt. C ol. (later,

(C01.) Harold A. Sofield, MC, Consultant in Orthopedic Surgrery. and, after

arrival in Okinawa, Lt. Col. (later Col.) Douglas B. Kendrick, Jr., 11C,

Consultant onl Whole Blood and Shock.

C ol. -John B. Rlick, _MC ( fig. 22S), became C onsultanit in Surger-Y.

I-SA FPI( A, onl I April 1945. At. this t imie, thle surgical consultants were

( olomiel ( )uglitersonl for W1esterii Pacific Base ( oniiiaiid, Lt. (Col. (later C ol.)

Will is .J. Potts, M( ', for South Pi1aciftic Base., Coimnniid, both oil a full]-tinmie duty

basis, and Colonel Raine for Cent ral Pacific Base (Commnand, on a part-time

dluty basis.

( olonlel Robertsonl becamie fill-tiie ('oismiltamit inl O rthopedics. USA FPOA, oil 31 'MIay 194-5.
IRI

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1144 I44 1i'.X 441II-i14 ~h'I4ll for 44oi'4l ~ , 141 :14 tI4I~llI h14-4:I V :1 -. 41'14:411 l0

11114 4r 111 1114 *'tlvd III :Ili :1 '11\ iqd4V1:IIV 411v wi :1114 1'i-1 44':444141 lllthe- S 4 I'I'I'ulv

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1444'141:4-' 14 'VII''I I lt'' 4''4vvl~~44 1() II lml pd(1 'I141414 W441''-444 it'. 44I

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It '().:I ' Ith " 114 4 i f411 -llt I III I Ii:iI 1144 4 1111 , v' 4.4 0114'' 44l 1141 4'444'4 41141e 4Il f 4' it

14414 4114)ý-l liiiIIl fl44'.it, i1:41 ~4 I'I . ( 114 t pr i:I 441 '-14) 1 24'l h1 4'41114 11) 'h ivth4)14: 

1441W 4'. I:441- Il, 41rldlle 114' 1414 4 -I 4 144~ 11 v.41 ll ~ 4'4 w 1144', lwt 41'414. :14 1'I?141fit 44d4
PACIFIC OCEAN AREAS 629

of personnel. Also of importance were the indoctrination of medical officers

in the methods and policies of military surgery, the checking of equipment, and

the clinical supervision of work in the hospitals. III addition, the consultants

acted as technical advisers to the theater surgeon. Not the least of the consultants' duties was to listen with a sympathetic ear to the p)roblems of their

fellow medical officers serving in t lie Armed Forces.

Liaison between the Army, Navy, and Army Air Forces left much to be

desired. This was evidenced in maiiy ways, but particularly in the evacuation

of casualties. On one occasion, orders for the surgical consultant to visit the

Marianas Islands forbade him to visit Advance Hleadquarters, CinC(PA(1

(C7omiia ider- in-Chief, Pacific), during the period of temporary duty. This

occurred at a time when several joint problem.,s had become acute. Despite

orders to the contrary, conditions made possible a visit to CinCPAC advance

headquarters, and in justice it must be said that the surgical consultant was

received and the joint problems were discussed.

Unless the consultant gained the confidence and received tile wholehearted

cooperat ion and support of the theater surgeon, his duties were futile.

PERSONNEL

Shortage of Medical Corps Officers

Almost throughout the war, the strength of professionally qualified Medi-

(cal Corps officers in POA was inadequate to the needs for the high type

of professional work which was the goal of all concerned. It was only by

extending efforts almost to the breaking point of the individual during certain

periods that the goal was attained. The tables of organization of numbered

general hospitals were inadequate for the I y)e and volume of work demanded

for the care of casualties in the operations inI POA. For example, it was necessary in the forward areas for all hospitals to maintain a perimeter guard against

enemy infiltration of the hospital site with the organically assigned personnel

at hand. This was true in the .M[arianas until V-J Day. On those islands

where Army persommnel were admitted to Navy hiosIpitals, the burden of preparing the payroils, providing the clothing, recopying the admission and disposition forms, profiling, and so forth, of these patients fell to the lot of the

nearby Army hospitals on whose rolls they were administratively carried. On

27 July 1945, the 204th General IIospital, Oahu, was responsible, from the

adlministrative standpoint, for 934 Army patients in Navy hospitals on (Guam.

At the same time, there were 1,908 patients occupying beds in the 204th General

Hospital. The burden was too great for the tired staff of the 204th General

HLospital. The matter was presented to the Chief of Staff, WVestern Pacific

Base Command, and it was suggested that a team be organized with qualified

persomnel taken from each hospital in the Marianas and attached to HIeadquarters, Army Garrison Forces, Guam, to relieve the 204th General Hospital

of this administrative burden. This was done. Had similar personnel for
630~ ACTI'VlTIE ')S F A~ COUW1 ' NSULTANTS

guard, finiance, refrigeraition main~teniance. and the like, been furiiished. as

plannedl, thle problems woulldl have b~eeni Solved.

Thi number of Medical Corps ollicers auithIorized for Iiiiiiilbered lgeneral

hosplitals was p)art icularly inadequate for the wvorkioads iillposedI dur1iimg active

operaion bs algainist. thle enlemy. U~ltimaitely. th1is, Was corrected ill parlt. by1 auigmnienting these hosp1 itals withI special t eamls. but. this didl not take place. Iut ii

thle Ryukyu Island(s camupaign was almost comp~letedl. Eleven sp~ecial teamis

arrivred inl t lhe Marianas Islands and thbree inl (ahu during the month of ,June

193⁄44. In the mneantinme, thle stairs of buisy lhosp~itals were reinforcedl with

medical ollicers from the stairs of hospitals less busy'. Medical C'orps officers

from Armyv Air F~orces mnedical treatment facilitijes, fro Navy hsital. n,

f rom shi1ps ill hazrb~or were p~ressedl inlto service. reanis were organiize(1 oil tile

sp)ot. soiiietijutes compiIosed of AiyN vy, and Arinw Air F~orces mnedical

oflivers. Tliei r services were in val uable. Ill hospitals pred~omina i~ntiy sui.rgical.

hie initernists; becamei members of shock t eamos and surgical ward officers.

The actual uiuminer of 'Medical Corps officers in IPOA was close to time anlthorized allotment, but there was a, shortagre of specialists. This was no doubt

(]lie chliefly- to :1 shjortage amt tile source of supll)y onl the mainland, hbut. iii part.

thle shortage was dule to factors that crept. inl (luring thle early (days of thle

1Pacilic Campaignis and that. later were (lifilcult to correct. The theory that, a

Medical C orps officer should be able to serve inl ally capacity had lno sniall

part to do with tlie shortage. This theory was definiitely disproved to all as the

warif progressed, Init, ini tile. uieatintiie. positfion vacanviei*s were Iihhed wvith offiveri'

not, pir)fessiona~lly* qualifiedl for the posit ions to wvhich they were assigned and

were. givenl job classifications insteadI of p)rofessional proficienucy classificationts.

Suich p~ractices created a, problem which was difficult. to solve. The rigidlity

of tables of organizatioins, thle problemus of ranik and precedenc~te, anid~ a con mis-,

ing chain of command adlded to personal t roubldes. There were 1n0 pools of

Medical Corps oflicers fromi which to d]raw. There was a shortage of sp~ecialists onl the basis of authorized strength inl every categrory. There was no rapid

met hod of requisitioning anid secu'14ri lgPers)11 uwl uirgenitly needied.

A study of the rosters of all professional units inl tile IUSAFIPOA muade

ill .hiime 1H45 showed shortages of specialists oil tilie basis of ailtluwrized tables

of or'ganlizationi as follows:

Military Oevulfllth.'nva SNir'eiviltgi Shortagc

:1105 (;it stroen t Pr')ogst --------------------------------------- T

:3107 ('ardhiiogist ----------------- -------------------------- 12

:111:3 Allergist ------------------------------------- ------------- 12

330:3 Medicali Labioratour Offifrer--------------------------------- 17

31306 Radiolog~ist ~ ----------------------------- 11;

3 151. rhortivi stilreoII----------------------------- -----..--.--------- 2

:11:11 Neurostirgeon -------------- ------------------ 12

:115.-2 Pinstie Suurgeuu---------------------------------- ----------------- :

3153 Orthoi)(edie Surgeoui---------------------------------------- 13

:1104; ()p)it Ii.i Ii i'i oIog is t. & 4) )i or iii hI )I iiry iigoIog i si - - ____ 2S-- _

3 I1 25 7p011h t I j I io Ii og Ist---------------------------------------------2

:1115) A i ih*k t.-stI------- I------------ 2
PACIFIC OCEAN AREAS 631

There appeared to be an overage of officers classified "3150, Medical Officer,

General Surgery," but this was only apparent and not real. The explanation

was obvious when this group was studied. It included all Medical Corps officers who had had, or claimed to have had, any training ill surgery whatsoever.

Many of these were not qualified to fill vacancies to which they had been

assigned.

The study of the personnel situation that was made in June 1945 by no

means represented a true picture of shortages on the basis of actual needs. A

further consideration was the length of time many of the Medical Corps officers had served in the tropics or semitropics with consequent impairment of

their efficiency. The needs were evident, but there was no way of meeting

them at that time.

Requisitioning Medical Corps Officers

Requisitions for Medical Corps officers were made by theater units through

channels. These were screened by Headquarters, Replacement Training Command, USAFPOA, and at regular intervals were sent by that headquarters to

the War Department. Medical officers with a classification "3100, Medical

Officer, General Duty," were being used to fill specialist vacancies, and additional officers with the "3100" classification were being requisitioned by units.

Seldom were specialists in any other category requisitioned by units. The

theater surgeon could only advise; he could not screen requisitions. Therefore,

he could not correct deficiencies in the flow of personnel from the mainland.

It was not until the summer of 1945 that the professional consultants were

able to screen requisitions for Medical Corps officers and advise the Medical

Section, Headquarters, Replacement Training Command, concerning them.

At that time, 30 officers with the classification "3100" had been requisitioned

by theater units. It was known that there existed an overage of officers

classified "3100" and a shortage of officers classified as specialists. Thereupon, it was agreed to requisition 30 specialists and, when they arrived, to

assign them to hospitals where specialist shortages existed in exchange for officers who were classified "3100."

Classifying Medical Corps Officers

The classification coding of all Medical Corps officers in USAFPOA

was begun toward the end of 1944 and was continued through the winter of

1945. Classification and coding were done principally by evaluation on the

basis of questionnaires. Later, officers were reevaluated after personal contact and observation of their work. It was not uncommon to find that several

classifications had been entered on the qualification record of an officer in accordance with the position that the officer held at the time of recording. Finally, revaluation on the basis of personal observation by the consultants led

to many changes in classification and to the transfer of officers and brought to
6:1t2 ACTI VITIES OF~ SURICIOAL CO NSULTIANTS5

lighit, thle tact that thle short age of Specialists wa-is evel grieater. thati that which

app~jearIed inl the initial st udy of the situiatioti.

III compillian(e wvithi let teri diirect ive', dthued I I Juilv 19145, froiti Brig. G en.

B1. M. F'itchi, by! commaniid of ( 'elwi'Il D ouglas MacArthlur to Commnniidinig

generalIs ill AkF'I',W, concern ing ( 'Iassi licat lol of Medical C orps Officers, a

Rew Cl assi ficat ion sutrve 'N wats uIiade. Thiis colisist ed of t lie compii jleioll of ai new

WD 1)' A(~)Formi I `TS-2 a11d A 1ITA( MI) F'ormi No. I oiii each medical officer.

rue iase coninant i colisuiltanlt s and tilt, I SA FMIII)PA(' consult ants recoinmended it classi ficat ion iwv intlorseimieiit oill eachI formi. Finmal clau-si ivatntionl was

dleteriniiied by General I [eadquarters. A FPA( .

Surveys ill IRelatioin to Rotationi

As early as the first week [ill 11ul 194.5, a surveY of .ld C~uI(orps officers

ill thle Middle Pacific fronm tlie stanidp)oint of t heir Service rating scores was

coiiijiletetl. Thbis wats don)le iii order to enivisioni losses anid p~re'pare for reo1rganlizatio4)1 wliein tilie aliiiooullicenlielt of a1 given "crit ical 54*4re- wvould permiit

nila li Iliet Iica offi-er-s to r-otate ipe Ilkii ArguSt tilie sit rve(y was repeated,

N itll icoiisidlerat ion of thIiree at 14 olit lott fact ors: agte, lenlgthI of servicel oVerseas, and14 lenigthI of tot al ser-vice- --al1l of whichi hiad a hea ri g ill &-l (111n ill 111g

balm j tI st ekd- service rit i g 5cofl5 for rotatitoln.

Personnel of Medical Units ill Transit

Tile' professionial conisul tanuts oif C eiitral Paciflic Bas'e C'oimmtand a iud

I SA FP A. (later I S.XFMnil'ac.) inispect ed all mnedical units passing thlroughi

( ).tlt[ fromt thle St andpoint of professionial profic'ienlcy of thle stally aind adequacy

of equiipmen~lt. If hievessar%3, rejplaceileilts were made w~ith Medical Corps5

4)fficers t akeni fromi hospitals or ot her umed ical organuizat ions withbin the C entral

Pacifi Bw1ase C'ommand or ot her base Voiiilil~l itis. nhis arrangemtent was far

fronm sat isfacter~y Silive it weakened b~ase coiimuand units. But, relplavemients

could not. lbe securedl from tilie ma inland witiloit. great delay, and it, wits iiuipierativye to senid unit s forward with att least thle miii II IiinII of specialists and

good .1 staill as could he assembled wit hout. wrecking, thle stall's of tilie fixed

itistailtit ilOs inl tile Communiiiicaitioins zone. After V-E Day, certainl units originlall~v destinled for thle Eurllopean theater were senlt, to the Pacific. Flrequiently

these were short of specialists, and1( it. was imipossib~le to suplyll thenm front perSonneIP al readV ill tile Pacific.

Morale

Suit aile assiginment. wa-s perhIaps the ijo~St iiilor ltsiimle fal(-ft 0~ill

maiintain ing good miorale. At mledlical officer would tolerate hardships if oc-

(1ii jiedl by work iii which lie was interested and for which he had aptitude and

traininhg. Medival con ferences. journal chband attendance at mledical

mieet ings all bldstered miorale, as did filie establishment of l ibrary facilities

(fig. 2;I)and tilie circitlat ionl of medical journials. -joinit mued ical Iteetings
PPI IA('IF W 4if AN AR IAS 6:

oh Arti :1 4; 1:(1.2: 1~ Iilvdhic. 4PibnICI 3911 Geltivraltli II4P(tIsp h11 sipal-. V)W I.-..~ lII

IlS1i,1a 'iv were \%.(.I] I hoiil owt and1 excellent. ( olsillit :111 pa~rt icipaite w'~heiiVVVer Po-iid. li o'ei-v: Iita1t iov- .ert* m'll lY supplied1 with Inietlicail

tembt i k oipid- :14 (iml-Imi:l. I itwever'. f:14c1ilitit-, for a liiral-v .111d conf erelv iic P0)11

wereICo 1141 11 "I creat ed .

Livi1a! coPl1Iiitohs. :11141 Pec'evI 14-jl)1111i~IitC aedlet I';l(- eah hii.

lII:I :II td fill va:chl 1-ilth ( 23). 'i.-. 1 foiis~iilu. r. e4cItivlonl facilit ies. and( chllbs

Were ()I primeII 11111mi,11141 I 4)1sIIll II Ii sland I il II 1114*1c il w1 Pt iPe climIateCs. ItI wasukV d lel t at11,11lii I W ll~ Ihhl11 ll4Pi I the II I0I le of pel-4Phl II. I. . I : Vli VIlCVSsit v- flte copstr111(1101o d C~'M'lt lal * vht~i plojvvts ~was the P-easoli lel for1

no t okIn I 11i e - fax c ihlitijes where t hey did not1 vx 1st

On )ivi (11li at Iliw 201hti ( elierai II1osihit:l, thev 411h.1-f~ers Mi \0111c the ohliver-s

hiveol vroete clPV :i berall-e of1 1 41tim-Ina of p)ersiill~he, there wa;ls nio ciilliige ofI

u11:1 1it e oni (iltY Il here weirv few Pi4TCvit 14)11111 itS: Wii Mid( I livivt wni 1m chIlib.

hi''l coiljmr11 P 101wth ol \' Na vv h\ felit i Ws fin1 the same Ii shind1( niiide I liese dehiciehiiie-1

Ini Swlill i~t: IC. 14Ifies not a'hY (III sa poi. neii e 1:11 4 hhicel's were' I ioiit' I iiith1

Ilv iVCV imiiltive 4111a1It'P- andt Isii4'hfM1 4tind P~E111hilo 114)1 l voCI llpij)i't'4.

lt1`hiiiI rVi-ý illhi Pitmi ndIvv iii'lilll Ii' froll the I4IlllwlI Iod I~ moiio
1104

AM4

I - tiC.

kiti

Ii

1w,1
It %%;I, -4 il illlt.ies 4 -- ' 14) I 1:1I -141 4el 4Ii44lv r- % 1144 fivi 141 te 4 4141114)114 111

I 101.1111:-V (' I4 hel 1 I P I :11141 experivl velC :11141 f4ill %% 114111 I ieti i414 V It()I 11 m 44-il141 W

V;1l1:111414"- 44(M I he :1 (Ill I lit, lmspjitnk IS wh4~~ichI I IICv* w44I-i~l r~tI 111 WAS

I1)n111 irI I4 1: I v I 14 (d 111 I-it I io- Ii I( d 444 11 4If4i C11o t 1(1 111 Tlv i I 1'1 ,- t11 I-4 I )I :I4 I4

S 141 I I' I 4 I., Ik %vl I4 IT 11 14 : I I 4141 t 4I n. .I I v I~ Y121 ~I II I IP I k I l 1. I i I W-f11 I- I I I 4A t I

,4I11 44wI f11 :11 14 If )I I In '1 1 ' 11 4%11 1141w e I. wr1141 I \ 441 I llu I l itIII I 4 4k l l I4I44I I4 W41'

il mý. lll It11141 41 Ii h :I pr4)11 4 1 i 1.111 lit, uli14 \\ ;i r N( 1,1i

444114lllI 'm 414 4 I14 ii4wv -2') :1- % 1 411 14411 411, l~IvY 4,1) ~ illed ~ I.41 I) k 4111 k it rIl4 l ml Il44 Ii-.

46 I7 d,47 tl , 112l - 1t
ACTI\ ITIE" IlF SI I.TANT,-

I:]. All ill ilw fivId.

1:11-4 ý-1:1-111-4vall 0:illn :11111 \\vIll I*qlI-\\:II-d l():III_-I1lvIlI fliv 44 held 114,ý-pll:lk

flit. Ill' fillef-:11 ilill. A t I Iw -

lvollrý 44 11111-I'mr.

There %\:I, :1 ý.Iliwla (d,

1 '1_1A FP( )A. T I I I, ) 1.1 :1 -4re Hi I 111ý It v N% :1 - :1 IV;I I ;I I f I I I )I n -;I I v r I I I .

1 11 AM Ili 11VI.. I I xv;lý I'vit I v I 1w. I lin I evon Ill )'I )it :11 ;11 which

ý4 11 r I v \% ;I - I )I - I I -I- 1,( )1*11 w o It )I I 1 1:1 vv A 1._4rI IVI A 1111,4 -;1 1 'IIi4 .4 1-:1 1111.1 11

:11111 p ill ill ird' illo

1111- vild, the firýl '411(old 14 :1114-111v-1:1 \%;I,ý V-1:11,11-114.11 ;it 1114. 11"Ill

fff)ýpll;ll till S;IIp:III Ili .111fle 1!11:,. 1w,11,111,111111 %%:VIN VNI'llif-11 I'm

Ille 1111.1-cliwl Ill, 111v c()W-11Il;1l1I Ill :111ii-I I he

I'SAI-14).k. sllldvlllý I'm. Ilic vfllll'ý-v ohlolm-41 frimi the -2:',il Nephrvinent

Depill, -,Ih 111"pil:11. :11141 frfml

;I--1_.,md Ili :mc-1114--ki 11;Ill holl 111114. Ill. 114) 1,4)1.111:11

IY.

It \%;I, I'vIl 1, , v Iliv cml,ý1111:1111 Ih;Il 1(ll) 111114. villplm-ýI, 11;111 Ilvell

II:1cvfl ('11 1114. ]till m H o lirv fil, h il. lilt, (d, 11:11114.
PA('I FI1" 4 AR'EEN .IIAS 637

FIc'--1R 234.-A nurse administeriiig ether uiesthesia hy the olpen-droI) method. prior

14, 111' an1 tiutalI ion of a ga"ngrenous aruin at thie (!)h Field Hospital. Okinawa, May 1945.

in SAFUP()A, especially in the forward areas. In most hospitals, nurses with

some trailningr in anesthesia were in charge of the anesthesia section (fihr. 234).

These, however. had had little or 1no training in end(otracheal anesthesia, and

did not have the necessary knowledge of physiology and pharmacology to direct

diflicult anesthesias such ais in thora('ic sm'gerv mid neurosurgery.

Because of the shortage of anesthesiologists, nurse anesthet ist s were ohl iged

to adiniinister spinal and intravetious anesthietics.

CENTERS FOR SPECIALIZED TREATMENT

On (0)ahmu, the 147th General ilospitial was designated as center for thoracic surgery and the 218th General Ilospital. for iieurosuigery. The former

had a thoracic surgeon and the latter a -,t iurosurgeoni on the staff. l)uring the

Okinawa operation attempts initially were imiade to admit all fra'ctures of the

femur to the 147th General Ilospital. This pllan w.as alanldoned bec•au1se the

burden 1became too great for the staiff of a single general hosp)ital to handle.

In ,June 1945, preparation was made for fabrivation of altilicial eves at

the 218th General Hospital. The necessary personnel hia1i alreadlY been trained
.\,'I 1fI'11 Ill.' sl !z4f4'.I. 14 1NS f'TA N Ts

I )'iii ii.r li' ( 1 I : I(.~l 44 'rlc 14 1 I I'i I t I1'' Illi 1I I xI (2 . 11 44 ~ t 141

ii "I II (4 1'lI II' -Ihi:I - iv ''- I xli 2:1! ').' ) .i 'erl :111 1i )1 1.. I ill - 1 ;: I 4 1: x I ll

Ilil I:-4- I4 I 4f1A 11vrv':A lv 4'I I l ]: iijI v rI'4- xl' ) 1 u 441 lI I I I 'It- l I V :1114 -" I v2 144:1 hv
P'ACIF'IC OCEAN ARtEAS W-19

Fi~ip 234;.-1 )(IIrkatiloll activit ies ait 'fTanaloag IIlirhi r, SaIililil. inl the spiniig o)f 19)45.

A. The T:.S.S. Hopc lovinig ulfIoad~ed. It. Patients b IoalrdIing an1 ambujlaniitce of Owh 148th

Genteral HIospitalt. Sa ipani I~sInid. Matrialnas 1Islands~.
6340 A(iII"i 4? U{1A1 ' NSUi.AN'FS

Fl;', .23-. Pi'-I''i vrai% lye o 4i i'al 1iv t :it'ei Ilifi.nici sIizgery. I 1.,.l1i 4.vtienlrli

fo'(.r foriio batl caslpelac sohiiditli woaul an

All GI InuIi. IeI1( 21) It I ]'ieal 1SpII. s I Ita wvas dv,;s-ImIi ied :1 cen t er forI iliaraic

s I I I.n . 0I )I I I Iisis In I 14 1. 1 ItI I ros I I (.I I p j4 I le i I I ~VIs we t e vI 1( 1 41 ()t( 1 fI . IIe Fleat

they were 4:uIe( for :it the 20ItIli (eteraiI Hospita:l.

( )ii 1iiiui .\rIun % cas.ial ies- Avere1Iahhilitiedl to II~ Niai%:vy Uase H osp~ital

.111dto th le 37-It1 Ii St itl 1(111 (4p!it a]. there hlle~iL 1no Ariiui !eiih1 14(45111 on ii

th1is i:-,.lam 11111l tii i m uidd le of41 1:i Y AvvleiI) 11v 371111 St atio H41 ospit al was~

(lesi.-i-nated ai 1.1 444 -I ed g eiierai 1hosp1itl:. It Nvas Ilever p4ossibl4e. ho4wever. :44kt(iillhel % it) sIall' tIhe -3711 n i emieiI Hosp'~ital front4 the l4I44 ýIm~~(thla Standpo 1 4jint

for I ] lle (I f bat it Ihe vni-tIalt ivs 'IhifraviC Stl'4~Iler pit 'whils :lnt15. a*,Nilr )t''ll 1:11i1

NVV I*e (tI'll11(l taor t1 11 lie N'a A v~ II(4sp)i :4. where .1 Il h-i(4141 sitI-Z44 (4i was~ oil thle stall'I.

Pa;t ienits with 1e-iaiis ofI the brallntild :41141 cord,14 C4.if' I n1114nInsolabhe. were

1 i7-(Il~i I 4( ail ii ll. ~ 'I ' lli 1144! !Iei 11
" I/" • -..-- -- "...-

II

•1 /

"r it

,, ii',l , ,,, I:, A ,, 1tilt," b ;, l :• :. . ,.': l~ • V ,,I
642 AcTIVITIES OF SI'RGICAL CONSULTANTS

DIRECTIVES CONCERNING PROFESSIONAL PRACTICE

()fficial medical p)ubllications (other thiaii books or journals) anid directiives

were universally scarce in USAFPOA. This was noted by The Surgeoil

General on his visit of inspection early in 1945. The matter was taken up

in Washington, and imnprovement was effected. However. as late as Auugust

1945, "War Department Techmical Bulletin (TB MED) 147. concerning management of battle casualties. which had been issued in March 1945, had not

been distributed to Medical Corps officers in Guam and Tinian. Saipan had

received an allotment of this publication and distributed it to that island only.

None were left over for the other islands in the Western Pacific Base Command.

Apparently, medical publications were being sent promptly to I-SAFPOA

and Southwest Pacific Area, but there were deficiencies in distribution. In

the case of the Southwest Pacific Area, for a number of months, initial distribution involved mailing of publications to a number of p)oints in the widely

dispersed area. Redistribl~tion was. ill turnI, accoun)lished to sul)sidiary facilities and units. At certain bases, such as Ihollandia, Adjutant. Gemneral

publication depots were established, but the lack of manpower continued to

interfere with getting the p)ublications out. This was true all along the lines

of communications from depots to bases and to field army units.

In the case of USAFPOA prior to 1 March 1945. initial distribution of

publications was by mail from the Zone of Interior to a single Adjutant General

depot on Oahu. This depot, however, merely distributed these plublications to

the major technical services, with each service handling the distribution of

publications and forms pertaining to them. This decentralization was put into

effect at the request. of the theater Adjutant (Ceeral because of lack of space,

personnel, and experience by the Adjutant General depot in this area. After

1 March 1945, initial distribution was by mail from the Zone of Interior to a

number of bases, facilities, and units, as in SWPA. It was planned to establish

a central Adjutant General depot on Oahu to take over the initial distribution

within a specified area of all War Department publications and forms, and the

filling of requisitions from all activities and units in the USAFIM(A which had

been handled on a decentralized basis. To the best, knowledge of the authors,

this was not accomlplished during the war. During the Okinawa. ol)eration,

very few medical officers on Okinawa or in the Marianas had seen the aforementioned. TB MEl) 147. A number of important directives, however, including "Surgery in the Combat Zone," were written, reproduced, and widely

distributed by the Surgeon, USAFPOA.

The distribution of advance copies of directives to the various headquarters

was satisfactory and kept the consultants informed concerning the professional

policies of The Surgeon General. Even though directives reached hospitals,

there was no assurance that they would reach the individual members of the

staff or would be read by them. Thus, it became the responsibility of the consultants to see that policy was carried out.
PACIFIC" (I.AXN A ,tIAs 4:'

F1i;lIa" 2"!J.-Ain exlerior view of a slerilizer aidi steam boilers at the 148th (General

H~ospital, Saipan, 1945j.

VISITS TO HOSPITALS

Tle constiltants made ward rounds mu'h as a chief of service would mnake

ill a civiliam liosli tal. Patients were examiined. dressin-gs removed. records

perllse(l, and cases discussed. Not infrequently, roun|ds. piegun on the wards.

ended ill the Iil)rarT orW ll)oiiailtW. Rolitds not onl y Served to evaluate a 1eildical ollicer's professional ability lut, to test his knowledge of policy. Every

pllysiviani entering tie Aritmy needed inloct rilat ton ill Arminy policy concerning

Military s'llgrer. Not infrequently, he would resist direct ives nlit i the rationale of policy was made clear to him. lie contiimed to be an inlividualist and

Wished to Ibe convinced that certaii p1roe(htlre., which in his civilila experience

were sat isfa'ctiry, wer-e hot. necessarily so ill Army practice.

Slnsjlecloll of tihe Olperal ilg roooms, of q)perat iilg-irlon tecIlIlifille. of slerilizing ep(jtli ulielit, (fi . "239), of i list tiiiient s, and of olerati ng-roomn records were

ilutlded in the visit. The X-ray depall entlts were inspected, not. only in reference to (qjuilpment :and qualii ly of work but also with resl)ect io protection of

lpersonnell fromn undue exposuire to X-rays (fig. 240). In severn. hospitals,

where lead sheet was noto ava'ilabde. lhe silstl itlol (I)I ol'saldl-Iille(I pall it ions was

a practical iml)rovisation which on test was found to b e eflectiv'e. Equipl)ent

for sirgelr. %lJlmral ilclldilg steriliziql% us. for the illost. part was good. This

also applied to anestlhesia equiplmenl. There was a1n ample Stll)j)lly of puortable

715 0t95S 64 - 44
ii ' r t t 1ali 2 11.- h Fli orste i i p I ';init'w jv14)11 l l. t I'Ii Itit q s-1-ot IaI osIt a 1.aS ; llt't'o it. t

111: ('li lnl Ct' tl' -t-4 v a li it, It )I )il le~ l hi 111 -'i Iii I a It I it' I yil i lt' t ' fl n It tI -Ill'L 11-

le tI it I I st'I I w t lit - e i I Itt In.- w It I gl I~u Itt I I)IitiIII it ittt' Itl 1 I 1 i I Hlt' It I tti to1 l

)lit - i; 11 11 itt 1411 s.I I sI ; IllI IvI. t I tI I t' Inv~'t '1 Ii )4 ( w I t) (t' r I Iit'liels 1 vt'll I \\ liii tit'
PACIFIc OCEAN AREAS 6345

FItGUmi: 241 .- Exterioir iiest.i1hii ion of air-conlditiloning eqipmellnet at the liS'tl Genieral

HIospital, Saiiii~i. 19435. Note the muakeu1uift cainopy to protect the equnipment from strong

THE OKINAWA OPERATION

The lack. of evacuiation hiospitals andI a shortage of well-qualitied surgical

special ists at Okinawa gave rise to serious difficultiles, in p~rop~erly caring for

casulalties during the Okinawa operation. It was the consensus that each division shiouldi have b~een suppl ort ed wvith fieldl and evacuiation hospi tals and that

"blown ill) field hospitals did not functijonally take the plaice of evacuation

hospitals. The surgical teams, did excellent~ work, hut were too few inl number.

All hospital stalTs were wNell indoctrinated in the use of blood (fig. 242). Shock

was wvell ma nagmed by teams organ izedl froim anmonm avail able internists and

they did valuable work. Tents which were. equipp~ed to dleal with shock and

to preparIie patit ents for op)eration were set upl in close proximity to the surgical

op~erat ing, tents. Equ111ipment included oxAg-enl applaratus, mlater-ials ior blood

dletermniiations lw thme copper sulphiate specific-gravity method, anll the Levin

typ)e of stomach tube as wNell as thle usual materials for the emergency care of

the wounded. A Jeviiu tub~e was introduced1 in all patients with suspected

penetrating wolinlds of the abdominal cavity 'irt for operation was establ ishied for casualties Ii rgently ill need of it lw those ill att end~ance Inl the

"gshock tenit.'
1-'I 21~t' AI 2 Ii I II l lilts 'I '4ý1th lp'~ ) lI It' .I liii sii kit' "VI l~t-h c ii i 1111' ll( i i

litv i I I - :17 I lI I V: It It I :I 1 It -I I \v' It 1 11 I it II 1:1I I )1 tll :11 It1 i' -

ki I( I I mi I I I III I I'( k I I It' 7 I - I IX I I I I1 q v t- ;IA-It I I )(-( I , I it ':1 111 111v-nvI II It~ :11 It 1- 111w

I it-IN Ii II 1 111 I X t 1i 1111 ) I It'll!., 1 14 -1 ' ' 4: 111 7Il Il Jon l± litc t" IlV 1 I*. )nI I-I H: I~ I Xl I l
V i T1:1 I2 lil-tl'I; I Ill W il 11 I [- Ili ZI 1.1I~ Ii-' 

I liit, Itt1:1: iit lt will 411' T. I t iii - il 4,t i1( 1111-1 l It t \;1 \1. t 1' 11 -1.

.\ _-1 I- I I I 10! III ; I I t\ 11ilt 1' 1 :ifii It Iltl - it 1m it I*X hitv T l i 1)i ic :- )1. 1 1\ w l

I t, TI Itt it I:11 1 X Iit 'Ii I tI I l i I 11 let rI II Ii 2 Ii. llt t iI I 1II I I lIl

tw l. 11.i;1.:-
A1 ll IiohI

1ý,I -I I :1 I I w , 11 -: rj 1 Lh 1 11 I I 2 h 11; 1tI 

Ti i w(i i Ih lit- It h I hl if tIII, hil l~ it h hA I- I -it ( 1 th (,hI )[

T li1 :: ih hhl . t I((1 It i (hi hi It hl Ih I.
PACIFIC OCEAN AREAS 649

In some instances, between live hundred and a thousand p)atients arrived without prey ious notification, which led to confusion. Failure in properly

"tagrgring" patients led to improper triage.

Duriiig the Okinawa operation, the 148th General Hospital cared for the

majority of the serious casualties brought to the island of Saipan. The 39th

General Hospital was not ready to receive patients until the campaign was

well underwav. The 148th General Hospital was used exclusively as a surgical

hospital and was so organized with the formation of shock, plaster, and traction teams. Surgical teams were formed with officers assigned to the staff

of the 148th General Hospital, with Marine Corps and Air Force medical officers from local installations, and with Navy medical officers from ships in

the harbor. Nine surgical operating teams worked around the clock in shifts.

As the Okinawa operation progressed and hospital beds in the Marianas

became filled, the policy of retaining patients with fractures of the femur

temporarily was abandoned. Patients with compound fractures of the femur

were treated by debridement of the wounds if this had not been done, by secondary debridement if this was indicated, by skeletal traction, and, in suitable

cases, by secondary closure of the wounds 7 to 10 days after primary or seconldary debridement. Because of the need for beds, these patients, during the

height of the campaign, were evacuated to the rear before the fractures were

"frozen." Casts were applied, and Kirsl.hner wires were removed before the

patients were evacuated.

In the Mariamas, circular casts were not. split owing to thie p)revalent

climatic conditions and their instability when this was done. On the other

hand, patients were not evacuated after the application of casts until the danger

of interference with circulation was past.

The impression gained in the Marianas and at Oahu was that, surgical

patients who had arrived during the Okinawa operation had been better treated

and were in better condition than patients arriving during the Iwo Jima

operation.

In the Marianas, of necessity, battle casualties were sent to station hospitals as well as to general hospitals. An effort was made to admit only the less

seriously wounded to station hospitals, but, on occasion, the seriousness of

wounds was not recognized. This was particularly true of wounds of the buttock that had penetrated the rectum and of vascular wounds. The latter were

not recognized until progressive extravasation of blood produced noticeable

swelling in the region of the wound. The station hospitals were visited frequently by consultants who advised on treatment and transfer of seriously

wounded patients to general hospitals. It was evident that the professional

qualifications of staff members of station hospitals did not meet the necessary

requirements for the care of the seriously wounded. Directives dealing with

hospitalization of battle casualties were published by Western Pacific Base

Command, and by the Surgeon's Office, USAFPOA, but could not be followed

always since at times the urgent need for beds demanded that those vacant in

station hospitals be utilized for battle casualties.
6150( ACTI %irii-:s (1F' SURGIC;&AL ('0NNULTANTS

Duiring the height. of tile Okinawa operation. it. became niecessary to relieve

illedica I officers ill thle hospital' onl Sa ipan of n onlprofessionalI duties. This was

acCOililplislied by directive from thie Offlice of the Siirgreoi. H eadquarters. Island

commnand, saipanl. Medical. officers, badly nleededl for silrgical work inl the

op)erat ing rooms, were b~eing given such (duties as the cenIsoring Of mail, It

was directed that. officer p~atients convalescinlg inl hospitals be used for this pur-I

pose: also, that prop~erty account abiliit y and other nonprofessional (ltiet b~ e

aissigiieo to nonll rofess iol la I per-soit umel.

D uring .July% and thle early p~art of August. hospitals, in thle MAriatias Islands Were visited b) 'vtlie C onsultant inl Surgery. USAFMII)PAC, and the ('onl

sultant. inl S'urg.ery, Western Paciticý Base ('o1ninia1nd. All medical othicers were

revalulatedl from thle standpoint of tile positions to which they hiad beenl assigniedl andl replacements, whlen indiio at edl were advised. Sugevost ionim were

mmade regarding medical supplies andl equipment froin the standpoint of the

heavy load anticipated inl fuitulre operat ions. At this t ime, the hospitazl venter

aTiniian was inl thle poesof const ruct ion

HOSPITAL CENTER AT TINIAN

The hospital (center at TIinian complrisedl five 1 .001)-bed general hospitals.

The facilities for surgery, thle establ ishmnent of centers for specializedl work

ill individual hospitals. thle assignmllient of p~ersonniel, anid thle need for anld

re(quisitionhig of specialists were (liscussedl andl plannled inl (detail with thle,

commanding officer of the hiosp~ital center. It was exp~ected that 71) percenlt of

the beds of thle. center would be dlevotedl to surgery. Tile tentative plan for

professional service inl slllg-ery enlvisionedl a (livision of work inl units as

follows:

Un it, 1. Neilrosurlgery. abdoinall.1 siurgery,I orthlopedic surgery., and1(

urology.

In it, 2. Aimiputat ions, butrns, g4enleral surlgery, orti(opt-dic sul-rgery. andl

urolog.'Y

Uniit 3. Thoracic surgery, maxiilofacial surgery, 01 )lit ha lut ic surgery.

generalI surgery. ortliopedlic sill-grelv.and Iurology

I nit. 4. Internal inleoicinle and medical specialt ies, generlen surgery. orthopeic Surgery. aidtol rology.

Each hospital wvas designated as a center for specialized Work, and inl

:1(1it ionl-wit h tilie except ion of Uniiit 5-woulld have ca red for greneral surgery, nilthopedic sumrgery. andi urologyv. nle su-rgery performei.e in vinit .5

would have beeii limiuted to surgery which arose inl nieuropsychtiatric patients.

most of which woulol have lbeeil inl connect ion wvith self -iniflicteol w~ounids. This

planl didi not necessitate major chan11ges inl hospitazl si atfs. Anl actimng olirec-tor

of siurgery was selected. T'his officer was to have hbeenl resp~onsib~le for thme

Overall supervision of the suim'gival Services throulghoult the hosp1 itals coin1-

prising tilie center anod ill controml of thle surgical Iearns a1ssigneol to it.
PACIF'IC OCEAN AREAS 651

Twenty-eight surgical operating roonis wouhl have been available in the

four hospitals designated for surgical work. Oil the basis of the Okinawa

operation, it was expected that approximately 140 surgical operations would

be performed daily when the next military operation was under way. It was

estimated that each surgical team on -,, 12-hour shift, would average eight

operations per dlay. On this basis, 17 surgical teams wouldl have been needed.

Nine of these teams were to have been requisitioned, and eight, were to hrave

been organized from the staffs of the five general hospitals composing the

center. Teams were to have made up for the lack of certain specialists on the

hospital staffs.

Plans included a request that an Air Transport Command liaison officer

be assigned to the center on a full-time basis to facilitate evacuation of patients

by air.

It was planned also that the Consultant in Anesthesiology, USAFMIDPAC, would organize the anesthesia section and remain at the center for the

early part of the next. military operation.

Work on the hospital center was discontinued with the cessation of hostilities.

NOTES AND FORMAL REPORTS

Tihe Consultant in Surgery, USAFPOA, made daily notes concerning

visits to hospitals. These were too wide in scope and often too personal

to submit as formal reports, but they were the basis for formal reports. Formal reports were sent through medical channels beginning with the commanding

officer of the hospital visited and ultimately reaching the Surgeon, USAFPOA.

Only those things were reported formally which could not be dealt with locally, or which were informative in a general way and upon which it was

felt that the base command surgeon might wish to comment by indorsement.

At the end of a visit to forward areas, the personal notes of the consultant

were read by and discussed with the Surgeon, USAFPOA, often with other

members of the headquarters staff in conference. Thus pertinent matters

observed by the consultant came to the attention of the operations, personnel,

and supply officers in the Surgeon's office. These matters were dealt with at

once. Not infrequently, on visits to forward areas, notes were s-nt directly

to the Surgeon by courier. In the last month of the war, formal reports were

not made. Detailed notes, however, were kept and submitted to the Surgeon

upon return of tlic consultant from the Marianas Islands.

Joiii B. FLICK, M.D.

CENTRAL PACIFIC AREA

Examination of the situation in the Central Pacific Area in the fall of

1942 revealed that the principal problem was a dearth of trained p)rofessional

personnel. There was only one other diplomate of the American Board of

Surgery in the area and, in addition, over the next 3 years, only three other
(;)2ACrI vrri i-s 4 v siiIMICAL CONSULTANTS

j4'elloNV of t lie Ainericaii ('Ollege of Surgeons ill geiieral surg~ery Wvere In thle

area. With this personnlel, live gIeiieial Iospiltals ahll Julie stationl 1Io 1)ita1ls

had to be mantlued.

S'iiie adtil l oal traia ed sui'ge.,ons coild~ not b~e expect eil to arrive ill tilie

ar'ea, filie first import)iiant ta:sk w~as ant appraUisal of all flie existin . ugical

talenit followed iv tilie t rainingii ofthIlese mlenl ill order 14o pi-m-itltb adelfilate

s~it "ical care of pat ients. All miedlical (Iflivers inl tle area wh-]o ha~d had as

much as oiie vear's resideley trxaiiinming l Siii-g-v- Were int ervijewed. T1he iiiedwcal officers o~f dlivisionis t raining inl the( area were interviewed and, where it

seemed desi rabl e for tilie good of t ie( service, exchaniges were made to augiieint

soiiiewilat. thle percentage of at least, part ially t rained surgreomis. Wheni it,

was felt adlvisable, oflicers were p~laced l on teliporary1% duty at thle 147thI General

Hospital for a 4- to S-week period of observation so that t heir surgical skills

could be more accuratelv dletermlined and, ill addition. so that thev themiselves

could have a, Thrush-up" period inl surgery. D)uring 19)43 some 10 or 12 such

teimporary assignmients were miade. and1( duiring( V1,44 more than :30 oflicers wvere

rotated thirough thle surgrical servic'e of thle 147th General Hosp1 ital with a view

to enhbancillg their previous surgical training (fig. 24.5). Since some oif tilie

station hospitals were mnore than 1,4000 imiles fromi their. nearest nieigh0bor. It is

obvious that, collsilltat iolis oni iiiiiviiliial prob~lemls were imipossible and tli-at

thli fate of1 tilie pat ient rest ed withI those who were iiiiiedIia tely ava i a Ide.

Besides tile deficiencies in trainled surgical pers-onniel, there were ver-Y few

cor~suiien wvho had been trauined for operat tug-room 11$y Since soimei of the

sm~aller station hospitals were goiiig to forward areas wvhere no4 nurses wvould

be available, it was felt that, the training of corpsmien inl surgical techniques wais

most. imiportant. Accordingly, a trainling' school was set upl at the 147th GTelleral Hospital for corpsmtenl Inl oPerat ing-rooin techniques. TIhese mien~ were

Puit thi-)lroug anl iliteisive twvo mloiltlis* course. aind it was very gratify ing, as wvell

ais surprisinig. to see what excellent seruii nurses t hey miiadfe at t lie enl o Ili

period. Actual figures were not available at the tille of this writing. bult there

muist. have been at least 50 enlisted inen so trained (durinig the course of t lie wvar.

Tle war inl the Central Pacific Area, was under the command of tIlek

Navy and1( at no It itle was there anil appreciable number of fixedl Army hospitals

assignmedl to the care, of frontline casulalties. This meant that v-irtliall'i all tile

casualties received in the general hlospitals ill the Hawaiian Islands arrived

there froml 2 to -4 weeks after they were wounded. This nat urally piosedl all

enit irel v diffleren t probldem from thtat emncouniteredl in tile North ii friean and

Euiropea ii thieaters. It was, fort unate thliat, (luring early operations onl the

orlis!:1Illds, thuere had I iren 114) mi uIec iab1 e fertilization of thle groundl a nil gas

bacillus in fect ions wvere virt iually un knowvn. Furthlermiore, it. was found that

initial debridenlent could be carried out :3 weeks after woumnding with suirprisingly good results. The ideal tiime for secondary closure of those wounds

whlich had been (lebridedl was, of course, lost during tile. periodl of transportationl.

]lit again, it was found that secondhary closure could lbe satisfactorily accomip~lishied at the endl of 3 weeks' time instead of at the end of from 6 to 10 dlays.
i(' vni vrl it-hinic plol. ilite..114 C4ll1i m eitvit 11:114 )ICe 5 ~' ei t n1. le(ci a 1 iilt

Ahea atrvl al o f~ co1w iaii e 111111' d a ins os I he %o 'IicauI \ aha ci n id vielil , v

roI"hl Il hose Ciient era Paliefih'. Are at b(;le -;vas i p irat Hil eas of lieilth a Wan tceven 

pWivni' oth11 ai lut x ell e oi Is at ole s :(iui~d fo ll' it o( r w t ilei vý. Th lie ve'iieiii a v illaklclre'1se 4111Iv N aIhli~ thateji had. to be;) dioiiite lierefore. reIcl

frespl aoiliiu ilictlv foiti suIial-es iliiier bica ol'lS . T skirtll e I di ne Iiviot 0r .11-1 ol'liin til'

Area'S . ait ,b lt in h s'l~ ile 11111ka I s en' ll I Plle Not Africlit f'lut piuiterN i li 4Yieldeid

T'XIio v t(5 , o i isp i iond rv '..v Ill ut I he4'i *(or l i ra o laie Ol A l iea P4'Si iii s alt i(* v

frompt (Pos e li lay e lt'lihen r i(ite .Il:i les th fi s 2 e iSo Iiv\-t. I :vk_,

wen :le :Ig( liiit S11:1 let coral itis ci a nidu i le lr~iitile Oftilee o % f h i( ip S llr~r' v had A% 1

knocedo(I mii( bv(ats Nassis b iiibmdent luny 21).Ui Wounds.i~)lit1 t heefrl ('ejit ra I

filler p:t1c to Ii)lt l liS. did th A'rmyi'ip' grelladesl till'1 uio~el'lt So411 ofil ah l eitlound, w 
~ All~~i~ii 'Th I~ V. rE H~ Ih Si I'~ F~ Snt 10 'A I~i 'it IN. -

Fit h 216. vil- 1 Lit'l P41 b volv &I :I 11 1e:1111N Dit it' ioll.billgi 1 m will 0 i 111(qj oldiv'm rVt'111111 1)l llt'if ItIt's 4 wit li A lt im lig:l I olrt . 'o I 1-i t'iiiaiiI ~ll a hpeit'Ilde- pfriod of

l-1:1 eIt n I WfIern llw I it-i I i Iiite Ii sto Iet vv, .:s tli l~ i

1)-vImsli i ta Ship14 Ie nl ild :niiio aVli:t 1411W;Ij alvit'fo I 413V)111d tritllsIuit ptilizat 14) fil

ofi1111-1. TheI~ Sm l 1141o4' hoslie ~It'l :it~ Kwajneir t ~ i etk .. Oitp. W -b
PACIFIC OCEAN AREAS 655

management of casualties who were received long p)ast the ideal time for

treatment. It was believed that this accomlplishlment resulted from foresight

in anticipating the future and in attemnl)ts at training the many who arrived

with inadequate training before entering the service.

FOIMESTEII RAINE, U.I).

CONSULTATION IN ORTHOPEDIC SURGERY

The uncertainty of the United States* participation in W~orld War II ended

at Pearl Harbor on 7 December 1941. As an Infantry veteran of World War I,

and a long-time Medical Reserve Officer of the Arms and Service Assignment

Group, this author, Lt. Col. (later Col.) Robert Crawford Robertson, MC,

received a telegram that (lay requesting his early active duty. On 2(; I)ecemnber, a representative of The Surgeon General telephoned the author inquiring

if he would like assignment to HIawaii as orthopedic consultant. Orders to

Letterman General Hospital, San Francisco, which then contained many

Hawaiian casualties, soon followed. The kind and considerate help of Lt.

Col. (later Col.) Oral B. Bolibaugh, MC, Chief, Orthopedic Section, Letterman General Hospital, was invaluable in initiating the author into the professional and administrative problems of a large military hospital. Colonel

Bolibaugh soon left to assume command of an evacuation hospital and later

rendered outstanding service in the Mediterranean and European theaters.

On Friday, 13 March 1942, aboard the U.S.S. Republic, this consultant

entered Pearl Harbor, a "graveyard of once proud ships" where intense repair

activities were everywhere evident. At Fort Shafter, Oahu, T.H., he reported

to Col. (later Brig. Gen.) Edgar King. MC. Surgeon, Hawaiian 1)epartment,

whose farsighted planning, combined with the outstanding cooperation of the

civilian doctors in Hawaii, had resulted in superior medical service during and

following the surprise attack of 7 December. Colonel King was an officer with

long service in the Regular Army. One of his basic convictions was: "He is a

medical officer, he can do anything."

Hawaiian Department, 1942

The major Army hospitals on the island of Oahu were Tripler General

Hospital (later the 218th General Hospital), where Maj. (later Col.) August

W. Spittler, MC, was Chief of Surgical Service; and Schofield Station Hospital

(later North Sector General Hospital, and eventually 219th General Htospital).

where Maj. (later Col.) Leonard 1). hIeaton,. [C, was Chief of Surgery. Major

Spittler and Major Heaton were superior officers of the Regular Army who

had rendered outstanding service during and following the raid. Their kind

cooperation and help in the problems of medical supply, planning, p)ersonnel

and patient evaluation, and the professional management of battle and garrison

casualties were of the greatest aid in making the transition from an orthol)edist

in p)rivate l)ractice to a staff orthopedist in an oversea theater.
650; ACT! VITI E'S OF SURGICAL CONSULTANTS

True Ilawaiaiai D)epartmnent at the t time expected another attack by the

Jap~anese an([ was serving as an oversea defenise area. -Numbered ge'neral and

station hiosp~itals arrived anld establishedI oil thle ishlads of 0,11l1i, Kaulai, Mlaui,

and IHawa ii. bibles ofL organ izat lonl did11 ot mleet local needs, amli provisional

hiospit als were est ablished onl thlese islands as well as onl Molokiai and Lanai.

Throughout thle early. years of the war, many provisional units found it diflicult

to receive ant horizat ionl for obtaining necessary personnel. As a1 result, many

mnedical officers wvere lplavet onl tempilorary tint v at variouis inst allat ionls to meet

neet Is as t h eY .1 rose.

'[he, year 1942 was spent chiefly inl organin(Yllt to mleet ant icipatedl needls.

A shortage of specializedI personniel imumediately beca me apparentt. This remained the major problem throughout time war. The shortage of orthopedic

surgeons authorized by tables of organization ii .Jiint 1194.5 totaled 1:3 (26 percent). The assignment of Maj. (later Lt. C

7ol.) John It. Vasko, AMC, to Tripler

General I lospital, hlonoluli, and the arrival of 1st It. fliobert. W. Rav, MC), with

the 147th G~(eneral H ospital early in 1942 estab~lishedl a firmn founidation for

orthopedlic care in the D epartmnent. Both of thIese officers demnonst rated outstand~ing~ professional abil ityv and ret ained their assignments as chiefs of the

orthopedic sect ions, in t hese hospitals t hiroighiont thle war. Staffing, equipping,

and plann ing withbin tile various hospitals of the islands was further comnp1 icat ed by t he various provisional hiospi talIs comisidered necessary b)ecause of

theterai an lntiilate a tak.Plans had to include provision for the care

and evacuation of wounded onl each island and by ship among the islands

in case of attack.

In the. summer of 1942, reports were received that. there was a.n unusual

incidence of delayed union and nonunion in fractures treated in the military

hospitals. Reports of all fracture cases shiowing (delayedi union or nonunion

were obtained from the. various hospital conimanders andI a p)ersonial check

was made of all of these cases. No evidlence was found to substantiate these

rep~orts.

Amiong this consultant's early dluties were thle evaluation and assignment

of per~sonnel, the formiulation of p~rofessional lIoceelilres in accordance with

the evacuation p)olicy of 120 days, the providing of surgical support. for a

regimental combat. teamn in amphibious operations, the. inspection of the proficien&'v of all numbered hospitals and all tactical medical units in first aid

procedures, the establishment of facilities for orthopedic alterations on shoesby a quartermaster shoe repair shop on each of the, islands, the changing of

automatic medical supply i temms, tI e establishment of emergency and expansion

facilities within military mand civilian hospitals and ships in all of the islands

in ant~icilpat ion of attack, and the marking of tourniquet, cases in the field.

Employees of H a wa iian contractors who were p~erformini g construction work

for Armyn expansiou plans recei ved Arm y medical care to invl ide p)reetuployment physical examinations iy teams composed of Armny mnedical officers and

sub~sequenlt nmedical c-are giveni in Army medical facilities.
PACIFIC OIEANN AREAS 657

In June 1942, the Hawaiian Department received a few Army air and

ground casualties from the Battle of Midway. The Navy casualties, who were

far more numerous, were seen through the courtesy of the commanding officers

of the various Navy hospitals. The shortage of specialized personnel experienced by the Army was not then, and never became, apparent in the Navy

hosp)itals in the Pacific Ocean Areas. I)uring the late 1930's, the splendid

Navy medical service had commissioned into its Reserve Corps in advanced

grades many doctors from the staffs of medical schools and teaching hospitals.

The outstanding men so obtained formed a magnificent pool at the outbreak

of the war. In the author's opinion, the Army would do well to consider

similar methods in future Reserve planning.

Circular letters issued by the Office of The Surgeon General were extremely

helpful during 1942, as were subsequent Essential Technical Medical Data

reports and War Depti'tmnent technical bulletins in standardizing new professional methods and in the management of garrison and battle casualties.

The organization stage was fairly complete by fall of 1942. On 5 November 1942, this consultant was assigned as chief of a separate orthopedic service at

North Sector General Hospital, Oahu, T.H., in addition to his duties as orthopedic consultant, Hawaiian Department. General King's instructions were:

"You will keep me informed of the orthopedic situation from front to rear

at all times."

Replacements from the mainland arrived in large numbers. Many were

in the 40-year-plus group and presented various problems, chiefly those centering about unaccustomed physical activity. The majority were recruits of

only 1 or 2 months' service, and outpatient services at the hospitals became

extremely heavy. One muscular Texan who was inducted into the Army one

m(with after injuring his leg was seen as an outpatient one month later in one

of the Department's hospitals. X-rays showed a complete oblique fracture of

the proximal end of the tibia and neck of the fibula, with slight displacement

of fragments and with very good callous formation. Upon his being questioned, he revealed that he had received no medical care and had performed

full duty, including hikes. He stated: "They think I'm yellow, Doc, but I just

can't take those long hikes very well." The "low backs" p)resented a major

problem which continued throughout the war. Department policies were established as follows:

1. In the absence of objective physical and X-ray findings, treatment will

be given on an outpatient basis.

2. Hospital cases wil. be disposed of on an individual basis, and as many

as possible will be returned to limited service within the Department if they

are unable to perform full duty.

3. No case will be returned to the mainland in the absence of definite

pathology.

These policies continued in effect throughout the war, and proved very

effectivc.
W)8WT kri%*n'n-,, OF SURGOICAL ('ONSULTIAN'rs

1W t hv end oif 19.42, numv1 senlor101 reguilar iiwedical officers had beeni rot ated

to tile miainliand for reassignment. chellvinfl IIIounnanId p)osit ions. Several illfanitry divisions had arri1vitl., thle 25th 1Infant ry D ivision had1 departed foi- tile

souith Pacitic Area. tile D epartmenti's iiiiullleredl hospitalis were wvell established,

and they wvere -et n p) for eniergencvy antd expansion needs, incluid ing dhe treat -

Inlent. of "..s casuialtiles. The cooperatlonl of thle commaindinglin otficers, Chiefs of

srgery and the orthlopedic sect ion chiefs ill tilie various hospitals was excel lent.

Thieir problem cases were freely presented, and~ -hiideoit s' were very infrequent.

The Bantties of the (Coral Sea, Midwvay. and thle Solomlonl Islands hlad disclosed

that thle .1a panese wvere bravye mlenl, but not in vincible. Thle Ilawa iian D~epartnient~s primary problem cont inuited to be thle p~rocu'remlenit of specialized

p~ersonneli.

Central Pacific Area. 1943

The new year, 1943. was ushered inl iw thle followinig instruct ions fronil

General King: "You keep a check- onl all the hospitals inl this D)epartment. and

transfer any case to thle genleral lioslpitals as- indhicated wvithlout. ('ollsultiill e

General Kinig believed thiat adldit ional orhpdcsu-rgeons should lbe developed

withliin the D epa rtmient. instead of their lbeing reqluestedl froml thle mlainiland.

Search was miade of per~sonnell i'ocords and rep~eated many tunies th roughout thle

war for officers su Iitable for such (level opnletilt. When available, they were tranisferred to a genieral hosp~ital for traininig.

Largrely because of the relatively low hospital workload and the absence of

combat casualties, there developed a marked tendency onl the parit. of several

hospitals to attempt. professional p~roc~edlures beyond their professional ca laucit v*.

This wvas correctedl by dlirec-tives listinig the ty~) fcsst erfre ogn

eral hospitals for (lehinit ive treat nient.

The bracesl 101 at North1 Sect or General H ospit al was (levelopedl and served

the Department. Cases req~uiring braces were referred to that hospital for

fitting and applicat ion of the brace.

Analysis of tilie oultpatient, Clinics (lis-ciosed a very largre number of foot

Cases. Because of this a spot. chieck of eighlt complanies or thle equivalent. was

made, by anl oilthopedic teani. F~indings Indicated suich poor foot care that a.

Departmient. directive was issued emphasizing thle duties of unit conimanders inl

prevenit ingan 11(1 orr-ectinig this pr~oblemi.

First. aid fracture 1)! )eelires, including sp)linting, were chieck-ed at thle various hiospiitails Oil adm~ission of each patient. Instruct ions were isstied requirinmzaI report to thle 1Departmnent Surgeon (of all cases evidencing inisatis~factory care.

Onlyl an1 occasional iulspli it ed case appeared tliereaftei. St andard and improvise(I spd iltit ig and1( first aidl management of fractures was ehlevked inl each

tactical unit. These inspect ions wvere personally conducted, and Iniany amusing

incidents were encounutered. ()ne incident occurred inl a bat tal ion iiied ical detnclunlent. of an1 anltiaircr-af t art ihler -v regimlenit. Imnprovised methiods for treat -

ing a simiulated comlpounid fractulre of tile femiur were requested of two soldliers.

Whenl their job was comnpletedi. a1 siiiall gauize b~andlage had hbeenl Wrapped about
PACIFIC OCEAN AREAS 659

the mid-thigh. A large wooden stake had been driven into the ground in the

region of each axilla, and each foot had been tied to a similar stake for "traction"

and for -st ill more traction."

Internal derangements of the knee, including many unusual cases of osteocliondritis dissecans, were seen in quite large numbers in all of the general hospitals. Functional results permitting return to full duty were disappointing

following surger) . Fifty "..ividual cases were p)ersonally followed up after

surgery and formed the basis for a command directive published 0 July 1t4 restricting arthrotomy of the knee to carefully selected cases.

Recurrent. dislocation of the shoulder joint was also a difficult and fairly

frequent probleni. Surgery was coiisi(lered only if the dislocation was seen by

a medical officer. Initially the Nicola type of operation was favored, but follouup d0isclosed recurrences in an est imated 40 p)ercent, following return to duty.

Bankarts operation was first employed in 1943. The results of both types of

operation were so generally disappointing that surgery thereafter was restricted

to carefully selected patients who were returned to limited service.

Fractures of the carpal scaphoid were very numerous. Fresh cases responded well to conservative cast treatment and were returned to duty. Ununited fractures which were syniptoniatic and did not respond to conservative

or to operative procedures (an entirely satisfactory surgical procedure was not

developed) were. placed on limited service.

Following several requests for authority to visit the outlying islands of the

Department, Colonel Robertson went in June 1943 as representative of the

Department. Surgeon with a general and special staff group from the headquarters staff of Maj. Gen. Robert C. Richardson. Jr., Commanding General,

Hawaiian Department. The group visited Canton, Christmas, Palmyra, and

Fanning Islands. Small defense units held each of these islands. Medical personnel were adequate. Each island presentel individual problems, but, in all.

the medical plans both for garrison and for providing medical support in the

event of an enemy assault were considered sound. This trip was most informiative and stimulating, as it introduced new thoughts regarding the problems of

medical reinforcement in case of enemy attack, and the management and evacuation of casualties on an isolated island target.

On 14 August 1943, the Hawaiian Department became VSAFICPA. During the same month, Brig. Gen. Hugh J. Morgan, Director, Medical Consultants

Division, Office of The Surgeon General, visited UTSAFICPA and presented his

observations in other theaters. lie stated that penicillin was a promising drug

and would be made available. And, in October, small amounts of l)enicillin did

become available through the courtesy of good friends in the U.S. Navy. It

was in January 1944 that the conmmand obtained its first Sul)l)ly of p)enicillin

through Army sources.

Because of troop concentrations on the island of Oaliu, including the 7th

Infantry Division which had arrived following its capture of Attu, the orthopedic outl)atient. clinics becalme very large, each clinic frequently handling in

excess of 100 cases daily. This number of outlpatients combined with the limited
660 ACTIVITIES OF SURGICAL CONSULTANTS

orthopledic staffs seriously interfered with hospital care. At an informal meeting with the surgeons of the 6th, 7th, and 40th Infantry Divisions, it was

agreed that the problem could best be solved by the following measures: (1)

Giving minor orthopedic care in the clearing company of each division, and referring only more serious cases to a, hospital; (2) restricting to 50 the number of

hospital outpatient clinic cases on each of the 3 outpatient clinic (lays each week;

and (3) formation of a reclassification board within the area for disposition of

division cases rather than boarding them through the hospitals. These ieasures

proved effective.

On 7 November 1943, the Hawaii Chapter of the American College of Surgeons gave a most delightful scientific and social program for Fellows in the

Armed Services. In the same month, General King directed that each combat

division be furnished an officer trained in the management of fractures. He

accepted the suggestion that each division provide one medical officer for training in fracture management during its stay in the islands and that this officer

accompany the division on its departure. This plan was adopted, and subsequent. personal observation of the professional skill displayed by many of these

men during combat was gratifying.

Formally organized orthopedic training programs were established in December 1943 to take place in designated general hospitals on the island of Oahu

for officers and enlisted personnel. The courses were made available to selected

medical personnel of divisions and other tactical units. This policy paid off

handsomely in subsequent combat operations as well as in the fixed hospitals.

Largely because of the success of this program, a similar training program was

later established for all Army medical officers by order of the Commanding

General, USAFPOA, dated 20 October 1944.

During the latter part of 1943, the 204th General Hospital was without

an orthopedist because of the shortage of trained personnel, and orthopedic

cases were directed to other hospitals. It was again recommended that the Surgeon, USAFICPA, requisition three orthopedists with professional qualifications for section chiefs to be assigned to the area's large fixed hospitals, where the

orthopedic census averaged about 25 percent of the total hospital census. The

surgeon of each incoming unit was contacted for an officer with surgical background suitable for further orthopedic development, but rarely did such a man

become available.

A few battle casualties were received from the Gilbert Islands operations.

Analysis of 127 cases admitted to hospitals on Oahu showed wounds of the

extremities, spine, and pelvis in 90, or 70.8 percent, of the cases. Practically all

were wounds inflicted by small arms. The standard of treatment in the forward

area was good. No case of cast. constriction, major amputation, or gas gangrene

was seen. Sulfonamides were given en route. Limited air evacuation was used

in this operation. Initial impressions were favorable. The author requested

authority to participate in the coming invasion of the Marshall Islands but was

refused.
PACIFIC OCEAN AREAS 661

FIGURE 247.-The courtyard of the 147th General

IIospital. A patient exercising on a walking board.

By January 1944, the orthopedic training program in the general hospitals

was organized on a 13 weeks' basis, and several officers were attached to Tripler,

North Sector, and the 147th General Hospitals (fig. 247).

The Marianas and Leyte, 1944

The first group of casualties from the Marshall Islands arrived on 12

February 1944. At North Sector General H[ospital, 173 were received, of which

43 were orthopedic cases, chiefly patients with wounds inflicted by small arms.

Many had received initial definitive treatment aboard ship. By Navy standing

operating procedure, the medical officers of each ship decided prior to combat

the principles and methods of treatment which would be followed during the

action. This procedure was quite in contrast to the professional methods as

prescribed by The Surgeon General of the Army and, in combined operations,

resulted in confusion between the medical services. Colonel Raine, area surgical

consultant, Col. Charles T. Young, MC, Consultant in Medicine, Office of the

Surgeon, USAFICPA, and the author checked the 646 wounded in the various

hospitals, and made the following observations:

1. Selected cases were given plasma or blood shortly after wounding.

2. Sulfonamide therapy was well administered en route.

3. Clinical records and X-rays did not accompany the patients to the rear

area hospitals, but arrived several days later.
6;62 ACTIVITII:l OF SI'IUGICAL CONSULTANTS

4. Wound debridentent was uiiiat isfactory iin 13 percent.

.a. Closed wouinids were found in 13 percent. ()f these, 60 percent were

infeted.

;. treated Iy open nethods rarely showed 1uns infection.

7. Allm)utation stNniips were lnot treated by traction. Fifty percent, were

closed by flaps alid vere infected.

ZS. Tlhere wvas n1o gas galigrene or telanus.

9. Spllilting was goool.

In the joint rep)ort, the thliree oflicers reconinnended that the area surgeon

further emphasize directives that had been published on methods of treatment.

a-Id Iitilt agzreellienlt he obtainled with the Navy on methods of wound manageineit. This coiisiiltant was cony inced tint consultants should accomlpany each

inivasionl and attelmp)t to supervise the illalllagellielit of patients on the tarret.

IA. (0ol. (later (ol.) Laiuremie A. Potter, M(', Surgeon, 7th Infaitry D)ivision,

and ani outstaiidillg field Iliedical oflicer, with experience I1ar-in Attll l tile 

shiall Islandls. colncuirred, and so revolinieided to (General King. A. proninent visiting ci 'ilian consiltant. to tie Navy was impressed by

the Stader splint. which was ulsed quite extellsiveiy in that service. After

checking this method of treatment with several Navy orthopedists and seeing

their cases, this conisultant recolmlmieiided to General King that tile Army obt aini

tile item for evaluation ill each of the commands fixed general hospitals. The

Surgeon General disalpproved this requisition. Time proved him correct in

so doing because of the lillillerouls late Compf)licatiolns w'hich followed.

In the spring of 1944, Maj. John .1. Cawley, Jr., M[C, a "graduate" of tile

USAFICPA orthopedic training program, was assigned to the 204th General

I lospital, which was for at line, wit hout an orthopedic sect ion. lie reorganized

tie section, continued as chief throughout tihe renmainder of the war, and rendered superior service.

In tie hospitals, it was possible accurately to forecast combat operations

by the increased number of self-inflicted gunshot wounds of the extremities.

When self-inflicted wounds became miiierous, it was positive evidence that an

operation was pending. I'llfortlunatlely, nearly all of these cases were reported

by invest igat ing boarrds as "Lilee-O f-duty, yes."

On 15 May 1944, the author submitted a letter to General King requesting

temp)orary duty on a coml)at, mission "for the purp)ose of supervising and

assisting in tile care of orthloipedic casualties." Four days later, lie was Iniof&-

cialiy advised that hiis request had been fav'oral)ly considered.

Tile shortage of orthop)edic l)ersonnl coititilied to he acute. General

Kiillg adlvised ti is consultant thati orlholpedists were not. available from tile

mainland. Agaill the qualifi'at ion card of eacli iedical oflicer in IVSAFICPA

was reviewed ill a search for prospects. Training 1)rogralis in the general

hosp)itals were functioliing well, but practivally all of the otlicers in training

were oil teiiporary duty for oiily a few weeks and then moved on with their

divisions. Nevertheless, two excellent iien for develoh)ient and l)ermanent
PAC'IFIC OCEAN AREAS 603

retention in orthopedic assignments were obtained. They were Cap)t. (later

Maj.) Arthur M. Faris, MC, a diploinate of the American Board of Obstetrics

and Gynecology, from a military police battalion; and Capt. (later Maj.)

Lawrence L. Hick, MIC, from the 7th Medical Battalion.

Brig. Gen. Earl Maxwell, formerly Surgeon, USAFISPA, and Colonel

Sofield, formerly Orthopedic Consultant, USASOS, SPA, reported to Headquarters, USAFICPA, as the South Pacific Area was closing. Colonel Sofield

reported that USAFISPA had four general hospitals, three large station hospitals, and a total of nine orthopedic board diplomates. This relatively large

number of certified orthopedists was present because USAFISPA had affiliated

units. In USAFICPA, there were no affiliated units, and, as a result, there

were only two orthopedic board diplomates.

The Marianas operations

On 4 July 1944, the first battle casualties from Saipan arrived-six evacu- ated by air. By 14 July, the orthopedic census at North Sector General Htospital totaled 330, of whom 78 were battle casualties. On 15 July, General

King directed this consultant to go to Kwajalein to supervise the management

of the cases arriving there from the 'Marianas operations. On the author's

arrival on Kwajalein, he met Lt. Col. Byron A. Nichol, MC, Island Surgeon;

Brig. Gen. Clesen II. Tenney, Island Commander; and Capt. Robert F. Sledge,

MC, ISN, Atoll Surgeon. The ishmnd hospital-Provisional Station Hospital

No. 2, commanded by 'Maj. (later Lt. Col.) Maximilian C. Kern, MC--was

reinforced by i)ersonnel of the 51st and 52d Portable Surgical Hospitals, just

arrived from the South Pacific and without recent clinical experience. The

instructions were to evacuate the first 50 cases received each day to Guadalcanal

station hospitals because the Oahn hospitals were filling up.

There were 1,314 Army hospital beds on Kwajalein, obtained by using the

newly erected Army Air Forces barracks for emergency and expansion facilities.

All hospital enlisted personnel were made available for professional work when

one officer and enlisted personnel were detailed from tactical units to operate

the hospital messes, run water details, and so on. The Navy operated all atoll

hospitals except Kwajalein. Penicillin and volunteer blood donors were available. Colonel Nichol and the author agreed that white (14-day) cases be

retained on Kwajalein, blue (15- to 60-day) cases be evacuated to Guadalcanal,

and red (60-plus day) cases be evacuated to (ahi, insofar as practical. On

30 July, Kwajalein received 291 battle casualties from the hospital ship, 17.S.S.

So/ace. Casualties remaining on board were taken to the Navy hospital on

Burton Island. On the same (lay, 50 casualties came in by air. Cases arriving

at the Arimy hospital were almost entirely Marines, who for the most l)art had

l)een well treated, although many of the spica casts were broken and very few

amputation stumps were in traction. A few instances of inadequate debridement, primarily closed wounds, tightly packed wounds, unnecessary excision

of skin, unsplit casts, anklet traction still in place, and several cases of anerobic
6;64 ACTIVITIES OIF SURGICAL CONSULTANTS

cellulitis were encountered. Four aircraft were available for further evatcuation out of Kwajalein eachl day-two for ()alu and two for Guadalcanal.

These were C-54"s, and eac'h had two flight nurses and wfls equipped to carry

a total of 32 litter cases. The vast majority of patients were evacuated from

Kwajalein by air. (Oin 3 August, General Tenney advised thalt the Kwajalein

hospital beds would be limited to 4,50 upon arrival of additional units who

would require tlie Ariny Air Forces barracks for housing. Atoll beds a fter

arrival of these units were to be: Kwajalein 4t50, foi 4•50, Burton 450, and

Carlson 1150. Reserve Army medical supplies were stored on Carlos Island,

where it was possible to establish :100 additional beds, if necessary, but transportation to that island wias by boat, only. ()n tile samne day, 5t c'asualties

arrived fi rontTiiit.iiii, ninyv repluiriiigblood tr.unsf isioiis.

O(n 6 August, this consultanlt, sent. a memloranlstduill tto Col. Eliot. G. Colby,

M(', Surgeon, A riiy (Garrison Force, Ishnld ('ommand, Saipanl, report ing the

condition of eases received on Kwajalein. After one week, with practically no

battle casualties, a radio was sent to G(eneral King requesting temporary duty

in the Marianas. The author, meanwhile, visited Makin, one of tlie (filbert

Islanls, where Maj. lRobert 1). McKee, 'MC, was Island Surgeon and coinnmanding officer of the 1st Station I [ospital, which served the island and evacuated to

Kwajalein. Personnel and supplies were adequlate. On return to Kwajalein,

the author learned that hospital ships were expected on 20 August. On 16

August, reports were received that the wounded were being well evacuated from

Kwajalein. On 19 August, this consultant received radio orders frout General

King to proceed to the Marianas.

Colonel Colby was Island Surgeon, Saipan, where island spraying with

DDT was first done. The 369th Station Hospital was operating, and the 148th

General Hospital was just. getting established. The evacuation policy was 30

days. This consultant. immediately saw patients, checked supplies, reviewed

surgical principles and methods, and discussed the effects of the 30-day evacuation policy with the staffs of these two units and with Colonel Colby. On 24

August, the author proceeded to Guam where Capt. John B. O'Neil, MC, USN,

was surgeon of the V Amphibious Corps (fig. 248). The 77th Infantry Division with the 36th Field Hospital, operating a forward and a rear section, and

the 289th Station Hospital, which was just establishing facilities, formed the

Army contingents of this corps (fig. 249). Neither of these hospitals had an

officer trained in fracture management. Combat operations were practically

at a standstill because of mud. I)UTKW's (amphibious trucks, 21/-ton cargo)

were useful in the evacuation of wounded (fig. 250). D)engue fever was epidemic. Evacuation within the division was temporarily impossible because of

the mmud. The author reviewed cases and professional management. at, the 36th

Field Hospital. It. was impossible to visit, the tactical units. Captain O'Neil,

in discussions, emphasized the need for qualified medical personnel in the combat zone and for it direct ive covering professional manasnegelent in combat operations. On return to Saipan, ininor reconumnendations regarding personnel and

supplies were made to Colonel Colby.
PACIFIC' IW'IAN AREIAS

R~eturn to Ilaica'ii

O n t'luiiii n() General ~iiz th~is voiiii aill's mai~jor reepiiiniviedaimaIi(ts

Nve re t I a I

Ia r se in-iia Is.

2. All t-I 2liII I1., Cliii ~ Nss pM(lic:iIj I )e~Pp,1rl lililt personnel elinj ims ize pi

ciiiles' and1( Illitholdi to bie (iiljilli~ed l i tlive Cpiliblt zoile.

3. IReff-simii coIl rse, ill th le Ia fixe d hoslI iplita. b1Isle ()f at 1pa4 (; Nvveks

meal1 (P~livers (Pftact1( wiil 1iiiits shorPlt Iv %Ipeforie their depal-t iire (Pit COiI~libt ilIISI~si(1~.

5.Mobiile siil&1-icai I teaiii lie lillil valale Jl l for use IiMll cmiPll Pt. foPWl P11d. or

remrsra ini.i as n-4:I euIrIed.

G;. ( )livers (Ptf ilie Ar iiiv %III-e cnIps lie Iliai(e avai~liabe to lioliile 1imspjitat1s

S0011Puiatier 1eIr e'l--slabihuIillueilit

7. A Ii r .%:Icia~ti m I fri I It I lIe cmlIlI atI Zone I he slIm ier%, Ied Iw aYn aii evcIiatI .%. ion

(4l~icer.

-,.T I le mI Ie ()f Ibl w ll I Isillf II i~ii mIs e Ii Ivesed I in I l Iiv col Illl2It Zonle.

9. All attemlpt lie miade to (P oiat siiikini I actim mu etb1ods inl thle timimglrllent.

of 111lpifitli lolml st I IllIIlj )f P A rI I Ii lieil-ii I Il t reaited a boardSI pslp.

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41CEAN AREAS 667

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dilartarealieas tlt' iniau'n.r ,lIl. At .1 1-15 (minute1hs), tihe IA 'VP in

w Oic li .111m ait iiWIs rillin, W\-:s O)it Bieaich Yellow 2 at IDiila- ( hit. 2. ,1).

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their liine (If 41e1art lire..
P1

A('IF'IC O(C.AN AREAS 669

TLhe collecting company established in the remains of the church (which

faced the qluare) and evacuated to the medical shore party, which in turn

evacuated by LCVIP to ship (fig. 252). At about 1500, the collecting station

was joined by Captain Minden and his surgical team from the Clearing Company, 7th Medical Battalion. The team established itself inside the church

and began definitive treatment for ]ontransportable military casualties and

severely wounled civilians (fig. 253). Shore-to-ship e'vaciuation stopped before dusk, and, as the collecting company and surgical team were the only

medical units beIind the 184th Infantry, the group worked throughout the

night. The Japanese attacked the 184th Infantry shortly before dawn with

infantry and tanks, as the regiment was warned they would. Botlh the U.S.

Army and the L.S. Navy turned their full firepower onto the attacking Japanese, which made a deafening but magnificent display of coordinated fireworks

in the dark. On the following day, the clearing company arrived and establislied its station, and the collecting company moved forward. Two surgical

teanis from the 70th Station Hospital, Leyte, soon joined the collecting company, which then established a station with a military section for emergency

surgery and a civilian section for definitive care.

While with the 7th Infantry Division or with the XXIV Corps, this

consultant. observed professional methods or assisted in patient care in a battalion aid station of the 184th Infantry, all companies of the 7th Medical Battalion, 69th Field Hospital. Leyte, 76th Station Hospital, Leyte (fig. 254),

165th Station Hospital, Leyte, and the 394th Clearing Company of the 71st

Medical Battalion (Separate). Several of the mobile hospitals were not unit

loaded, and their supplies were widely scattered on the various Corps beaches,

causing much delay in getting them established. All medical units established

their own perimeter of defense. Personnel of the 51st and 52d Portable Surgical Hospitals were used as surgical teams to reinforce clearing companies

and field hospitals. Blood was obtained from patient. and volunteer donors.

Because of nearby airfields, ammunition dumps, and artillery positions, several

of the medical units received enemy fire of various types, which caused numerous casualties aniong their personnel. On 24 October, this consultant was

slightly wounded in the left thigh by a shell fragment, and a walking cast

was applied from ankle to groin.

Upon leaving the XXIV Corps, the author reported to Headquarters,

Sixth U.S. Army. The surgeon, Col. (later Brig. Gen.) William A. Hagins,

MC, was a delightful gentleman with the wisdom of having participated in

the establishment of 14 previous beachheads. lie felt that clearing companies

reinforced with surgical teams and evacuation hospitals provided the best

medical support for divisions in amphibious operations. Withmin the X Corps,

the 1st Field Hospital, Leyte, the 2d Field Hospital, Leyte, and the 3d Field

Hospital, New Guinea, were establishing hospitalization facilities, while their

surgeons were active with surgical teams reinforcing clearing stations and evacuation hospitals. The 36th and 58th Evacuation Hospitals were established
670 CINSVI'A

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674 ACTIVITIES OF SURGICAL CONSULTANTS

15. Refresher courses given in large fixed hospitals resulted in improved

surgical care on the target.

16. Refresher courses given in rear area hospitals for medical officers of

tactical units should further emphasize procedures and techmiques to be employed in the combat zone.

17. Training courses in the large rear area hospitals for selected enlisted

men should further emphasize training in the handling of trauma.

18. Consultants should be attached to each combat force.

In addition to these. recommendations, the author brought back a renewed

love and admiration for the combat soldier, regardless of his color, flag, or

religion.

Hawaii again

On return to Headquarters, USAFPOA. in November, this consultant

found that General King had been rotated to the mainland and Brig. Gen.

John 'M. Willis had replaced him. Lt. Col. William B. McLaughlin, MC, a

diplomate of the American Board of Orthopaedic Surgery, from the South

Pacific, was the new chief of the. orthopedic section at North Sector General

Hospital and doing superior work. Patients in all Oahu hospitals were receiving excellent care. Battle casualties found in a station hospital were

transferred to a general hospital.

General W1"illis recognized that the prevailing shortage of orthopedic personnel was acute and approved requisitioning the necessary personnel from the

mainland. He also approved this consultant's writing directly to Col. Leonard

T. Peterson, MC, Chief, Orthopedic Branch, Office of The Surgeon General,

and to IA. Col. John J. Loutzenheiser, MC, Consultant, Orthopedics and Reconditioning, Ninth Service Command. Personal letters were written to each

of them asking al)out, the condition of patients on arrival on the mainland.

Mobile orthopedic teams were requested by General Willis. Personnel for the

four that were to be formed were selected by the author. He continued to

give talks on orthopedic management in the combat zone before numerous

tactical, mobile, and fixed hospital units.

Back to the United States

Finally, this consultant submitted his request for temporary duty and

leave to the Zone of Interior. The request was approved. On 18 December

1944 lie left. Oahu, and on the following (lay at Letterman General Hospital,

San Francisco. Calif., lie checked the condition of patients evacuated from the

Pacific with the Commanding General, Brig. Gen. Charles C. Hillman, and

his chief of surgery, Col. Russel 11. Patterson, MC. Both reported that patients

arrived in gool condition. Their chief criticism was the manner in which

hands were splinted.
PACIFIC OCEAN AREAS 675

The author arrived at his home on 23 December, in time for Christmas and

a happy reunion with his family. He gained 14 pounds during the first 2

weeks at home.

By invitation of Colonel Peterson, this consultant visited Battey General Hospital, Rome, Ga., and made rounds with him and Maj. (later Lt. Col.)

James J. Callahan, MC, Consultant in Orthopedic Surgery, Fourth Service

Command. The principles and methods of treatment seen were essentially

those that had been followed in the Pacific. Hoping to find additional orthopedic personnel for USAFPOA, the author requested 10 days' temporary

duty in the Office of The Surgeon General. The request was approved, and

lie proceeded to Washington where much time was spent at Walter Reed General Hospital. Several of the Pacific wounded and other old friends were

seen. With Colonel Peterson, lie reviewed the qualification cards of all

orthopedic surgeons available for assignment and found no prospects for

USAFPOA.

Okinawa, Victory, and Demobilization, 1945

In San Francisco, it developed that air transportation would mean a

delay of at least 2 weeks. As this consultant had been alerted for the next

operation, lie returned to Pearl Harbor aboard the U.S.S. Okanagoan (APA

220) on her maiden voyage.

On Oahu, lie found that General Willis was in the forward areas with

Maj. Gen. Norman T. Kirk, The Surgeon General of the Army. The author

saw all orthopedic cases in the general hospitals on Oahu, and received his

anticipated orders for temporary duty as observer with the Tenth U.S. Army

for Operation ICEBERG (Okinawa). In the Tenth U.S. Army, Col. Frederic B. Westervelt, MC, was Surgeon; Colonel Finney, surgical consultant;

Col. Walter B. Martin, MC, medical consultant; and Colonel Sofield, MC,

orthopedic consultant. Colonel Oughterson was to be surgical consultant and

Col. Benjamin M. Baker, MC, medical consultant of the forward base area

with headquarters on Saipan. General Maxwell was to accompany the invasion forces and become Surgeon, Army Garrison Force, following the operation.

Lt. Col. (later Col.) Moses R. Kaufman, MC, theater psychiatric consultant,

and the author were to go with the task force in addition to being assigned as

Tenth U.S. Army consultants. There were no evacuation hospitals. Each

division was to have one field hospital, with two portable surgical hospitals and

four surgical teams attached, to act as an evacuation hospital. A directive,

"Surgery in the Combat. Zone," was to be i-sued to all medical units of the

Tenth U.S. Army. When General Kirk and General Willis returned from the

forward areas, the utilization of consultants in the various zones of the theater

was dis(cused with them (fig. 256).

705-095--64-46
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680 A('rlVIT'I'I.:s ()p SiIRGICA.L (CONSULTI'ANTS

FI(m-IE 260.--Whole blood being administered to a

casualty at a clearing statio n of thi 102d Medical

Battalion. Okinawa, 21 April 1945.

to all who wit nessed his work. The fiehl hospitals were slow in establishing

adequate shock facilities and postoperative care for thlie large numbers of serionsly woulltded whicli they received, largelyv Iecause of inexperience. Shoreto-shi) evacuation was oiten long delaye Ip because of darkness, ai,- attacks on

tie ships, or weather conditions. Tie, mobile orthopedic teams rendered professional care of superior quality. Medical supply ditliculties were markedly

reduced over previous operations. The medi.Al control ship greatly simplified

tihe evacuation of casualties from the shore to the proper ship and the movement

of medical supplies from ships to the proper bleach. The copper sulfate met hod

of henlatocrit determination was used in all clearing comlpanies. Whole 1lood

and oxygen were used iin the 7th Infantry D)ivision at the collecting station

level and proved to be of great value.

It was felt that informal meetings with the medical officers of all units and

on-the-spot correction of errors were l)articularly valuable functions for consultants during combat. Meetings within the divisions were normally held at

tihe clearing conlpally and were altemnded by practically all oflic('erl of the div-ision medical bathtlion anod the regimental medical detac'iments. nie consultant received many invaluable viewl)oiits and Suggestions during these mliectings
PACIFIC OCEAN AREAS 681

and will always be grateful for the opportunity lie had to learn from these

indispensable men. The chief difficulties encountered stemmed largely from

the fact that there was an insufficient number of trained personnel on the target.

In correcting this deficiency, the attachment to army hospitals of excellent specialized teams obtained from the Navy hospitals that did not operate as units

was of the greatest. value.

On 8 May, this consultant waw released from temporary duty with the

XXIV Corps and Tenth U.S. Army and reported aboard the IT.S.S. Relief.

After seeing cases and discussion with the surgical staff, he sent a memorandum

to the Surgeon, Tenth U.S. Army, concerning the condition of patients as received and seen aboard ship. Surgical principles aboard ship did not vary

appreciably from those followed in Army facilities on land, except that traction

was rarely applied to amputation stumps. At Guam, all patients were unloaded and taken to the hospitals of their respective services.

The author then visited all fixed army hospitals on Saipan, Tinian, and

Guam during the period 15-27 May, and each orthopedic case was seen and

discussed. Because of a shortage of hoslpital beds and l)ersonnel, it appeared

these hospitals could not long continue to hold ,ttien, with fractures of the

long bones in traction until "frozen." The ! )r made the trip from the

Marianas Islands to Oahu by evacuation aircratt. Excellent patient selection

and care was observed.

Experience in this campaign resulted in the following major

recommendations:

1. Medical officers with high professional qualifications should be assigned

as far forward as possible, normally at clearing company level.

2. Refresher training in fixed hospitals should be given on every possible

occasion to officers assigned to mobile medical units.

3. In the training of mobile hospitals preceding combat, additional emphasis should be placed on living in the field under combat conditions, rapid

establishment of facilities for the reception of large numbers of patients, the

treatment of shock, postoperative care, rapid evacuation, and the provision of

professional care on a 24-hour basis.

4. Company grade and selected field grade Medical Department officers

should be rotated between fixed and mobile units, preferably after 12 months'

service.

5. Air evacuation is particularly desirable for major fracture and amputation cases.

6. Halftracks serve well as ambulances in exposed areas because of their

protection against near misses and small arms fire. The chief limitation is

their capacity of only one litter case.

7. Female nurses should be brought to the target as soon as the danger of

their being captured by the enemy has passed.

8. Theater consultants should continue to accompany each invasion force.
682 ACTIVITIES OF SUIRGICAL CONSULTANTS

Following his return to 0Oahu on 28 May 1945, this consultant visited the

various hospitals where he checked and found the care being given patients

to be excellent. Great improvement il pat ient care was apparent in all echelons

during the Okinawa operation. This improvement was the result of the increased number of trained personnel on the target, the availability of whole

blood, improved methods in the management. of wounds and shock, and the

increased use of air evacuation. Because of the shortage of hospital beds in the

theater, it was not possible to hold the numerous casualties with fractures of

the long bones until the fragments were frozen in tract ion, as had been planned.

These casualties had to l)e evacuated in casts by air to the mainland.

General Willis was very critical of this consultant's long absence in the

colnlbat zone. Even after he explained the sit nation on the target and pointed

out that it was on the target, rather than in the rear areas, that mortality and

morbidity were reduced, lie remained in obvious disfavor until a letter of commendation arrived from Colonel Westervelt, Surgeon, Tenth IT.S. Army.

General Willis added a nice indorsement, brought it to the author in person,

and then asked if lie would like to go on the next. operation. This consultant

was restored to favor.

Preparations for invasion of Japan

Major activities now centered about medical plans for the invasion of

Japan. The author met; with all medical oflicers of the 98th Infantry I)ivision;

with the staffs of the 317th General Hlospital, the 97th and 98th Station HIospitals, and many of the island's fixed hospitals. Using prepared talks and

informal discussions, he stressed the space and other requirements for the

treatment of shock and hemorrhage, the importance of making hematocrit

determinations, the required standlards of resuscitation prior to and following

surgery, the necessity for adequate initial surgery and the splinting of fractures and soft-tissue wounds, the need for adequate postoperative care, and

the value of air evacuation. Field conditions in combat were also emphasized

before the mobile hospitals. Motion pictures of surgery during the Okinawa

operation were shown and discussed at. a meeting of the Air Transport. ComInand surgeons at llickam Field and before the staffs of several other tactical

and fixed units. This consultant made several visits to the 8th Station lHospital,

which operated the reconditioning center on Oahu (fig. 261).

On 1 July 1945, USAFI()A was redesigniated ITSAFMIDPAC, and placed

under General Ileadquarters, AFPAC, withl General MacArthur in overall

command. D)uring July, Colonel Potter arrived front Okinawa en route to the

mainland for teml)orary duty and leave, lie concurred in Colonel Robertson's

formal report on Operation I(CEBERG and ibrought news of mutual friends,

some of whom had been killed in act ionn 'd miany of whoni had been wounded.

On 25 July, this consultant. observed a (try run by the recently arrived 86th

Evacuation H0osp)ital, which wit-s attached to the 98th Infantry D)ivision. An

informal discussion was then held with the staff regarrding combat zone surgery.
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684 ACTiVITIES OF SIURGICAL CONSI'LTANTS

Victory and demobilization

The atomic bomb on Hiroshima caused much excitement. On 14 August

came the big news that the war was over! During the next few weeks, this

consultant, received several letters from medical officers wit h long and outstanding combat experience stating that they were being retained inl division medical

units doing no professional work while newly arrived officers with only 9

months' internship were being assigned to hospitals. General Willis, while

sympathetic, felt that, men with combat experience should be retained in tactical

units as there might yet be need for them in this capacity.

On 1 September, the author presented a paper entitled "Management of

Orthopedic Battle Casualties in the, Pacific" with slides showing the care of

wounded from battalion aid stations to rear area general hospitals. This

presentation was before the Hawaii Chapter, American College of Surgeons.

The slides were made from motion pictures taken for the official medical history, most of which were taken by Capt. Ted Bloodhart, SnC, and were very

complete.

Plans were rapidly developed to reduce medical installations and personnel.

Colonel Ottenheimer was assigned to the office to edit the theater medical history. On 17 September, the 40-hour week became effective. Aside from working on tile orthopedic section of the history, duties were very pleasant with

much golf and swimming. Colonel Potter, en route back from the mainland,

visited before returning to the XXIV Corps, (lesti ation Korea. Col. Elbert

DeCoursey, MC, Consultant in Pathology, AFMII)PAC, and Col. Verne R.

Mason. MC, Medical Consultant, AFMIDPAC. left for Japan to join Colonel

Oughterson in the study of the medical effects of the atomic bombs. The

author's orders for release from active duty appeared on 17 September. He

completed the orthopedic portion of the medical history and turned it over to

Colonel Ottenheinmer.

On 24 September 1945, the author boarded the U.S.S. .tzMdoa CqIy destined

for San Francisco. On 1 October, the returnees changed from khaki to olive

drab uniform. All hands were on deck, silent and thankful as the coast neared.

The underside of Golden Gate Bridge was lovely. Inside the harbor, a "Welcome Home" ship with flags flying and bands playing circled the U.S.S. Azalea

Cty several times, an unexpected and joyous weelcome. Never before had "The

States" appeared so beautiful.

Summary

The Pacific Ocean Areas, commanded by Adm. Chester IV. Nimitz, IT.S.N.,

consisted of numerous widely sel)arated small islands. The duties of

USAFPOA, commanded l)y General Richardson, were those of a defense force

operating a training and staging area and maintaining a base for, and conducting, amphii)ious operations. Cooperation among medical officers of tmictical

and fixed medical units, line officers, and medical officers of the Navy was excellent. As a consultant assigned to Headquarters, IJSAFPOA, the author
PACIFIC OCEAN AREAS 685

received authority to move and act within the theater in keeping with his assigned duties.

The major problem throughout the war was the procurement of adequately

trained personnel. The deficiency in trained personnel was met in part by

training courses for selected individuals who subsequently served in tactical

units and in the mobile and fixed hospitals. The shortage, particularly noticeable in the early invasions, wis corrected in part by the assignment o; qualified

individuals and orthol)edic teams to task forces. In attempting to correct the

overall theater shortage, the Surgeon, USAFPOA, was most cooperative in

approving recommended transfers and assignments for the more optimum distribution of available surgical talent.

Another difficulty arose from the fact that combAt operations in the POA

were joint operations involving both the Army and the Navy. The Surgeon

General of the Army directed principles and methods of treatment which, would

result in high standards of professional care and uniformity of methods

throughout the Army. In the Navy, principles and methods of treatment were

established at the local level. The differences in professional management

between the two services did not occasion friction at unit levels during combat

or garrison duty, but the differences were quite apparent to the other service

when large numbers of casualties were handled by one service. Such differences

can only be corrected centrally, either in Washington or at the theater level

by issue of similar directives to all services. Casualties were as a rule evacuated to fixed hospitals, operated by their respective services, rather than to the

hospitals, regardless of the service, best suited for the management of their

particular pathology. When separate hospitals are maintained in the same

area by the several services, the formation of interservice hospital groups and

the assignment of casualties, irrespective of service, to hospitals staffed for

their various specialized needs should result in improved case management and

in economy of medical personnel.

The third major difficulty was in establishing facilities during combat with

sufficient trained personnel and beds to provide complete 24-hour care on the

target. The need for 24-hour service was indicated in many instances because

of the unavoidable delay in evacuating from shore to ship, and was most marked

in the early phases of an invasion. During combat, the need for trained personnel was greatest on the target. When combat ceased, the need was greatest

in the forward and rear area fixed hospitals. These varying needs were best

met by the use of mobile specialized teams transported by air.

Medical officers who were assigned to tactical units lost much of their

specialized professional skill during their long periods of inactivity, while

officers assigned to rear area fixed hospitals often possessed skills which were

in greatest demand in the combat zone. The first mentioned deficiency was

met in part by the establishment of refresher courses in rear area hospitals to

which officers assigned to tactical units were attached for varying periods of

time prior to their entry into combat. The second deficiency was overcome by

the limited transfer of personnel from fixed to mobile hospitals. The initial
686 ACTI VITIs ESor~ SURG10ICAL CONSULTANTS

definit ive surgeryv received by a1 sel -rely Wounded man Was uisually the most

impo)rt1ant. single fact or inl determniiing his survival or evenit irl disability.

This treatmIent shiould be given as soon1 as p)ossible a fter wounding. For thlese

reasons all pyi5call ab tl Je compli~)iV grade miedlical othecers aid selected field

gradle oflicers shiould lxe rot ated bet ween tac'tical anld fiXed inst allat ions after a

periodl of one year. Mobile liospita I commndnl(ers shiould be carefully briefed

oil and envision situations whlich thieir units are likely to encounter in combat,

anld, duringti~ traininlg, thlese 1utilts shlould prepare foi- suich conditions. Areas

p~art icularly to be stressed wvere: ITnit. loadfing ami cýare of supllIies inl thle comb~at

zone; rapid establislinient. of facilities for thle treatment, of large miutin1bers of

wounded ; establishiment. of adequate shlock, X-ray, surgical, anmd p)ostoperat ive

facilities; and rapid definitive treatment. and evacuation. There was no substituite for combat experience. The best. alternative was wise briefing by

exp~erienced oflicers with combat.exIperience.

Prinent~~~, technical and professional i nformiiat ion shiould be d issemi inated to

all units andInd iiividuials and carefully stmIli ed prior to combat. This goal was

niever fully attained, largrely because inv'asionis coniducted inl the P~acific Ocean

Areas were coiI1lbinedl op~erat ions, part icilat ing uinits oftenl mlounltinig from

wi(dely scat teredl areas of departunre. This difficulty was inl patrt corrected by

the activities of consultants onl the targvet.

Members of the Army Nurse Corps proved invali mble in mobile hiospitals,

from bothl a professional andi~ a morale viewvpoint. They shiould be broughit to

the target oni call of the surgeon (if the, task force.

A ir evacuation was extivremuev valuable because of the great. distances

Covered by lines of evacuiation inl the Pacific Ocean Ar'eas. Orthopedic cases

were particularly suitable for evacuation by air. Whien p)ersonlnel or hospital

facilities~~~~~~ iieli noesatetr ar fajor fractures and amputees shiould

be, evacuated by air to the United States soon after initial definitiv'e treatment.

Consult ants, as Special stall' officers, must. be free to move about. and act

both iii adlvisor'y andl professionial capacities throughiout. tilie entire command.

RoBFIIT CRAWFORDi R )IEIOTSON,9 M.D.
CHAPTER XII

Southwest Pacific Area'

Wim. Barclay Parsons, M.D., I. Ridgeway Trimble, M.D., and George 0.

Eaton, M.D.

JULY 1942 THROUGH AUGUST 1944

This portion dealing with the activities of Col. Win. Barclay Parsons. .1C

(fig. 262), as the surgical consultant in USASOS (the U.S. Army Services

of Supply), SWPA (the Southwest Pacific Area), covers a period preliminary

to the engagement of large bodies of troops in combat; namely. fromn July

1942 through Au(ust 1944, when the writer returned to tile Zone of Interior.

At. the l)eginning of this period, U.S. Army combat elements in Australia consisted of two National Guard divisions, a few assorted antiaircraft and warning b)atteries, engineer regiments, and a small number of Army Air Forces

pursuit and boml)ing squadrons. At the end of the period, the air forces had

grown markedly, the Sixth U.S. Army had been organized, and the Eighth

IT.S. Army was being activated. In the beginning, an invasion of Australia.

by the e.:emy was assumed to be a real possibility, which fortunately did not

eventuate. Gradually, the Allies established a foothold in New Guinea, and

when the Japanese attacks on Milne Bay and over the Owen-Stanley Mountains

toward Port Moresby had been repulsed late in 1942, the ground and air forces

began the long tough road that led eventually to the Philippines.

General Characteristics of Operations in Southwest Pacific Area

It seems pertinent to review some of this history because the conduct of

combat conditions in the Southwest Pacific Area was strikingly different from

that in other theaters. The bases in Australia were far apart, as were those

in New Guinea (map 2). For a long time, the number of troops engaged

was comparatively small, and tropical disease of different types was for a time

an important n il itary problem.

The first combat with the enemy was the Buna, New Guinea, operations,

lasting from October 1942 to early January 1943. This was fought over almost unbelievably difficult terrain consisting of jungle swamps enjoying, if

I See Activities of Surgical Consultants, Vol. 1. chapters XVII and XIX for information relating

to the Sixth and Eighth U.S. Armies, both of which served in the Southwest Pacific Area during

World War II. See also chapter XIII, From Auckland to Tokyo, of this volume for the activities

of Col. Ashley W. Oughterson, MC, who served as a surgical consultant In the Southwest Pacific Area

temporarily (hiring the Initial stages of the invasion of the Philippines and was later assigned as

surgical consultant at Headquarters, U.S. Army Forces, Pacific.-J. B. C.. Jr.

697
688 ACTIVITIES OF SURGICAL CONSULTANTS

that is the word, an annual rainfall of about 12 feet, where, before Atabrine was

available, malaria caused five casualties for each man wounded in action. For

most of the Buna operations, only two regimental combat teams were engaged.

Their components, at times, fought as companies and sometimes as squads.

Transportation was at a premium. There were two grass airstrips on the north

side of the Owen-Stanley Range that would accept a G-47 type of aircraft

with difficulty. Flying was possible between Port Moresby and the north coast

at Dobodura (fig. 263) only during the morning hours because of the daily

blanketing of the mountains by clouds and the coastal area by rain each day

FIGURE 262.-Col. Wni. Barclay Parsons, MC.

by noon or earlier. There were few roads or tracks, and usually the wounded

had to be brought back from the front on native-type litters, carried by four

natives, after emergency treatment at a. 25-bed portable surgical hospital (fig.

264). This litter carry frequently took as long as 8 hours through swamp

and jungle to the nearest 50-bed station (fig. 265). The casualties had to be

taken thence by air to either a 750-bed evacuation or a 100-bed station hospital

at Port Moresby to await transportation to Townsville, Australia, by air or

freighter. From Townsville, they were taken by air or exceedingly slow train

on a narrow gage railroad to one of the general hospitals in Brisbane, Gatton,

Sydney, or Melbourne. Fortunately, battle casualties were few because of the

limited scope of combat activity, and the surgical caseload did not rise to really

large prop)ortions until the invasion of the Philippine Islands. As a matter of

fact, coiisiderable hospitalization facilities were planned and construction had
SOUTtlWEST PACIFIC AREA 689

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started in eastern New Guinet-, but. these were abandoned before completion

because of the rapidity with which the strategic situation changed.

The experience at Milne Bay was an excellent example of preparation

for a need that could have been of major proportions but never materialized.

After the Buna area was secure, a base was established at the small harbor of

Oro Bay (fig. 266) and a major base was begun at Milne Bay with its commodious deepwater harbor (fig. 267). Early in 1943, clearing of land, mosquito
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SOUTIhWEST PACIFIC AREA 691

appointed a joint American and Australian medical commission to deal with

this problem. Their mission was successfully accomplished. The important

point from all administrative standpoint was the fact that the carrying out of

proper Atabrine administration was made a command responsibility. It is

certain that this circumstance improved beyond measure the relationship between the line and the Medical Department.

On the other hand, the relationship between the consultants (including

the author) and the medical officers of the Regular Army was slower to improve. At the time of this writing, and presumably for the future, the role

of the consultant is well established, well understood, and appreciated. For

some time, it was clear that the Surgeon, USASOS, SWPA, had no inkling

of the role of the consultant and in fact resented his presence, although, in

fairness to him, it was doubtful that lie had ever received proper briefing.

For some weeks, there was reluctance on his part to allow this consultant to

travel for the purpose of visiting various hospitals in a professional capacity.

He insisted, instead, upon strict Army-type inspections. Gradually, by emphasis and persuasion, these inspection tours were officially changed to "instructional visits" and were so specified in travel orders. This change resulted in

an abrupt change in the reception accorded the surgical consultant by area

and base commanders and by the hospital commanders who, with few exceptions, were Regular Army officers during the first year. All these, men had

quite naturally resented another adjectival inspection but were glad to welcome

someone whose sole, or at least major, interest was the care of patients.

As mentioned earlier, the situation in the Southwest Pacific Area during

the first 2 years consisted of three elements: Great distances, limited combat

activity, anld a resultant relative excess of hospitals. The total number of

hospitals was not great, but the available space was useful until malaria was

controlled. Later, hospital facilities were in excess of the surgical load until

the invasion of the Philippines. One of the problems tha.t this fact. produced

for the surgical consultant was the maintenance of morale among many highly

trained general and orthopedic surgeons in the various hospitals who coml)lained, with considerable justice, that they had joined the Army to use their

skills and experience for the benefit of the wounded soldier but were idle, or

nearly so, month after month. Many of the hospitals were at great distances

from headquarters and other installations were in what seemed to the personnel

to be both God- and IHeadquarters-forsaken spots. The execrable climate, the

lack of recreational outlets, inactivity, and a feeling of uselessness were major

factors in the deterioration of morale. A visit of several days by the consultant

as often as possible to one of these "neglected" areas seemed to be refreshing

and stimulating to the local staff, even though no matters of much surgical

importance might have been involved. A similar need for close liaison between

the Office of The Surgeon General and the theaters of operations is discussed

later.
692 A4 TIN* IT I F.I.; V 1-1 1 v ;I CA 1. 414 INNI 11,11AN, TS

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SOUTHW I~EST P'ACIFIC' AREA69

Col.) George A. Marks, MC," were selected for these pos~itionls. Th'ley were

plcdoil temiporaryv (lity' from their affiliated units to (ijilereit, areas III 'New

Guiinea withI 2 or 3 bases under each man. Thiis arraigremlenlt furnishiedd(etaile(I

coinsultat ive act ivitv to the variouis rapidly growing base sections and also

afforded tile senlior consultant opportulnity to cover tile entfire area and~. when

necessary, to funiction within individual uits i.

FI(.uR 272.-Col. 1. Ridgewvay Trimble'.\tC.

Teacihing Functions of a Surgical Consultant

'11wl t wo major fliiict lols oft astirlylei1 coiisuiltant in a t heater of olperatimioS

we're, first, to insure thle empl)oymient of accepte(d( sunrical princi pies and proper'

-mirgica'l teclilii(jIles ill tile care. of tile woundedl. secnd, STld to plIace available.

jpersouiuiel ill heY posit lolls ill tile most advl~iut ageoiis iuiiiiier. Two mlethiods of

i lst ru('ct ioul were us~edl iuaunel ', diirect contact and( written directives.. Tile

dlirectivyes wvere (listribluited to .all units to correct errors t hat. had occurred, or ill

anmt icipat ion of theiri occurrence. InI thle early p)eriod. it was coimparatively

silmple to t ravel t hromughliot. thle area, even I honugii vachl tripj coveredl three or

folly' hlmousaid imiles, to visit all hospitals and to discuss inl Stati, mleeting-s problellns of smr tcllherapy as thle particular p)oinit inl tilie chain of evacuation

Occuit ~ed by each 1iui1it. a ffleet such t1(1Ireatmieint. After about 12 mionthis, new

unlits I e,,rui1 to ar1riv-e so frequpent I from the zone of Iiiterior anld at such wvidely

Sp~acedI polimts that assistant comisimitants were nieedled to assa VN their professiomial1

(flial it %. an a to b~rief thlem promuptl ' . This lbrielini ai i immed iately onl arrival was

iliost (const ruct ive. It, iunlpresse(l oil tile personnel thle fact that t here wvas a

707) 0495 (G4-- 47
TOO Am,'TI V1'IIES OF SIUIIGICAL C'ONSI'LTANTS

consultant interested in them an11d their professional l)erformnce, aInd it was

educational in that these newly arrived medical officers had but little knowledge

of war surgery in general. In particular, they had no appreciation of the influency transportation bore upon the repair process in a wound. Until the time

arrived when the wounded soldier could be held for a considerable period at a

relatively advanced un it where defin it iye treatiment could be given, the emphasis

in instruction had to be placed on the simpl)hest basic principle" of wound treatment, such as treatment of shock, thorough debridement without undue removal

of bone fragments, apl)roxinmtion of divided nerves, loose packing, and effective

immobilization for transportation.

An examl)le of how such instruction bore fruit. follows. The surgical consultant met a small evacuation hospital at Milne Bay on its arrival from the

Zone of Interior and just before it embarked for the attack on Manus in the

Admiralty Islands. This unit was composed of fairly well trained surgeons

lbit couhl not boast the pre~ence of a single board diplomuate on its staff, and

none of them had ever heard a shot. fired in anger. A directive had been

l)ub1ili.•hed covering the basic principles to be followed ir. the care of wounds

in a combat area such as that which faced this unit. At a personal conference

with the staff, the surgical consultant had an excellent opportunity to discuss

the subject in detail, to indicate what was required of the incoming surgeons,

and to review the operations that should not be undertaken and the reasons

for the policy. Perhaps as a result of this briefing, the casualties returned by

that unit were handled in a superior manner. Shortly afterwards, the surgical

consultant was invited by the Sixth U.S. Army to visit units of that. army.

This was the first time that any consultant from ITSASOS, SWPA, had been

invited to the army area, and, shortly thereafter, Maj. (later Lt. Col.) Frank

Glenn, MC, was appointed as the Sixth U.S. Army surgical consultant.

Utilization of Surgical Manpower

Portable surgical hospitals.-There were eventually several affiliated

general hospitals in the Southwest Pacific Area. There has been considerable

discussion as to the wisdom of forming such units, particularly in reference to

the concentration of a large, number of highly trained p)ersonnel in one unit.

In the experience of the Southwest Pacific Area during this period, these units

were of the greatest service. Not only was the care of the wounded in the

affiliated units of superior caliber, but these units also furnished a pool of talent,

available for drafting into key positions. I)iring the Brna fightinig, where the

movement and placement of even the smaller regularly constituted hospitals

was impracticable, portable surgical hospitals were developed (fig. 273).

They were formed from the per'sonnel of the affiliated units. These small

surgical hospitals did a magnificent job, and later others were formed for some

of the larger station hospitals. Still later, when the consultant could influence
SOUTHWEST PACIFIC AREA 701

the shifting of personnel, other individuals were drafted to fill certain key

positions. A striking example of how effective such a drafting could be and

how useful it was to have a pool available was indicated by the experience with

a station hospital at Port Moresby which had a ldistinctly inferior rating. The

hosp)ital commander was replaced by at medical officer of the Harvard unit, and

the chief of surgery, by a surgeon from the New York Hospital unit. These

two individuals in positions of responsibility transformed this station hospital

in a few months from 1)erliaps the worst into one of the best in the theater.

Surgical teams.--Another important use of available personnel was

accoml)lished after the arrival of Brig. Gen. (later Maj. Gen.) Guy B. Denit

as Chief Surgeon, USASOS, SWPA. He brought with him a refreshing

change, of attitude, as any recommendations made to him by the consultant

received immediate stuidy, and those ap)proved were put into effect. For examl)le, as it was certain that no auxiliary surgical group was to be sent to the

Southwest Pacific Area, this consultant had tried for a year to get approval of

a plan to organize surgical teams in the larger hospitals for reinforcement of

whatever small hospitals might be committed in the area of combat. General

Denit's predecessors had refused to sanction this plan. They had been unable

to comprehend its usefulness and had been afraid of losing control of the personnel. General I)enit, however, at once foresaw the probability of the need

for more manpower in the forward hospitals and knew that orders could be

worded to prevent the stealing of personnel. One or more teams, each consisting of medical officers, nurses and enlisted men, were thereupon organized il

all general, the two 750-bed evacuation, and certain larger station hospitals.

These teams, with their own instruments, were to be on call for orders placing

theni on temporary duty wherever, and for as long as, the need for them existed,

and until the parent organization might require their services. This arrangement had the virtue of flexibility in that many hospitals in the rear could readily

spare one or more such teams for service in a forward unit during the early

stages of an operation, while a later exchange could be effected as needed or

desired. Exactly this same plan had been used most advantageously by the

American and British Medical Departments in World War I and was being

used successfully by the Australians in the Southwest Pacific Area.

Which units might be committed to the combat area could not be foreseen

at this time. There was only one field hospital in the theater, but the Southwest Pacific Area had one medical regiment, the various components of which

had acquired experience in a station hospital at Port Moresby (which hospital

they had built themselves) and had also operated small station and portable

hospitals in New Guinea and New Britain. It, was expected that, some of these

units, as well as some smaller evacuation hospitals, might be the hosts, as it

were, of these teams. The second section of this chapter contains a discussion

by this consultant's successor of how they functioned.
ACTVIIE M, I'k4t4AI

AiA

I 1. I tiuila 'l I., unc *mlas lfuu hi ill .,v lflil-l "1 1:11 1-'1
.,011 pl' I iii 211hi uuf~ifulul sm.-ir oiI MsIu.'i 1 :i.11 31u14ifuu'. Nvw I 'Iititav. 2$ Apr~il 191$3.
704 ACTIVITIES OF SURGICAL CONSULTANTS

Equipment

Inl general, the equipmient. was satisfactory, but the smaller hospitals, part icularly the portable surgical hospital, lacked lan orthopedic tab~le. The sur-

"gical. consult ant, therefore, (lesignied and hadl constructed locally two types of

aluminlluml tables. One was similar to thle original Hawley table; the other was

it light, collaplsible mlodel, p~ackedl iii a box approximately 5 feet long by 18

inches inl cross sect ion.

Plasma and Whole Blood

D~ry lplasinii wa alay ii goodl supp)ly, but early inl 1943 whole blood

b~ecamie available from the first-class blood bank established in Sydnmey by the

Royal Australian Army Medical Corps and tile Australian Red Cross. The

blood supplied was pooled 0) typ)e, p~rocessed inl accordlance with the highest

standards, packed inl ice inl a. lo'uble-'va Iledl sheet mietal box, and shipped by

ai.Becaulse thle casualties Were, limited inl the early p)eriodl, time. supply of

b~lood was adequlate. Time thermos bottle effect of thip diouble-walled box served

to keep) the ice frozeni until arrival at New Guinea, and the timie taken inl

tranisit was reasonable until the combat area had moved far away. Before the

attack onl Iollandia, (where casualties were minimal) anil arrangement with

the Seventh Fleet nmadle blood( available from the bank established onl a, convertedl LST (lindinlg shmip, tanik). Well before the attack onl the Philippines,

fplatii hatd been imade for timetair shipment of blood from time ZoneP of Interior.:

Liaison With the Office of The Surgeon General

Teewas a dlistinct feeling at. the time, which is confirmeid inl retrospect,

that the liaison between the consultant inl a theater and the Chief Consultant

in Surgery to Thle Surgeon General could and should hav-e been closer. This

liaison could have beeni by frequent letters and by less frequent personal visits

by thle Chief Consultant inl Surgery himself or by one of his assistants. There

was, unfortunately, a in imnpenet rabl e barrier b~et ween the various theaters

through which information should lmv-e pamssed freely-inforinationl of a professional rather than a miilitary miature-as to the prlob~lem~s faced and time

measures devised to dleal with theni. It is certain that the experience gained

in any one- of thle theaters would have been of b~enefit, elsewhere. This Coinmunication, of course, should have b)een in 1b0th (directions, and, if authorized

by The Surgeon General, it couldl not have been ob~jectedl to by the theater

surgeon. At least one visit of reasonable length per year by the Chief Consult~ant in Surgery or his representative Wvould have been niost. welcomle, and, it.

is believed, constructive. Such visits wvould hiave givenm time opportutility to

exchange much information muot suitab~le for transmission by correspondlence.

Trhe chief conisultant inl medicine to The Surgeon Genieral did miake one

lengthy visit, p~assing several days at, various hosp1 itails andu including several

areas in New Guinea. This visit was valued miost highly by the medical

2 Medivru Departm~ent, U'nited Hitatq' Armyi. Bliood P'rogram i n world Wa'fr Il. [In prss1
SOUTHWEST PACIFIC AREA 705

services of these hospitals, and it is believed that the experience was educational for the Chief Consultant in Medicine. Unfortunately, the Chief Consultant in Surgery was able to pay only one fleeting visit, so that he never

became thoroughly aware of the local situation in general or particular, and

there was no opportunity for quiet, leisurely discussion by which many lesser

and certain major matters could have been clarified.

Military Rank of Consultants

One cannot be sure as to the importance of military rank for consultants,

but it seemed reasonably certain that a more flexible table of organization for

the staff of a theater surgeon would have been advantageous, that the surgeon

in the theater should have had the rank of major general, and his chief consultants, the rank of brigadier general. In this respect, it was interesting to

observe the ranks held by the senior medical officers in the Australian Army.

Their surgeon general was a major general, even though there were but nine

Australian divisions, and three of his consultants held the rank of brigadier.

Also of interest was the fact that in the Australian Army there was no line

drawn between the medical service and the combat forces such as that which

existed in the U.S. Army between the SOS and field armies. This homogeneous

arrangement led to smooth coordination, and one could not help but wonder as

to a possible loss of effectiveness in the American organization under the

existing system. Also, it was believed that the higher rank held by the Australian consultants was a large factor in their greater freedom and power.

Summary

In summary, one cannot be certain as to many of the problems that may

appear in a future conflict, should one arise. Many unforeseeable conditions

will of course have to be faced, although the peculiarities of the different areas

of almost the entire globe as they may affect combat troops are now well-known

and can therefore be taken into consideration in the plans for such a conflict.

There are three points that the writer would, however, like to emphasize. First,

a flexible table of organization for the professional services in the headquarters

of any theater, liberal both as to numbers and as to ranks, would insure worthwhile freedom and prestige to the theater surgeon and his consultants. Second,

it seems desirable to urge freer communication between the Office of The

Surgeon General and the theater consultants and to emphasize the importance of

personal contact at least once a year between the chief surgical consultant in

the Office of The Surgeon General, or one of his associates, and the surgical

consultant in a theater of operations. Finally, and of most importance, the

consultant system at the end of World War II was well established and must

not be allowed to lapse, as it was allowed to lapse between World Wars I and

II. If the consultant system is continued with strength and enthusiasm, there

will be in any future conflict immediate effectiveness of professional influence,

hand in hand with the purely military (levelopment of the Medical Department.

Wbi. BARCLAY PARsONS, M.D.
7( )G A( 'T I V IT I I I 11-1 1 10 14 1. 11 'tIN I LTANTIFni iaý 271. 1.1. Cid. 1. NjC. nvcfllljolliv:.ý q;vIl. DI'll-LIS MocArillill.

AI (J ST 1911 THRIM-Gil JANI \R) I R)

I A 1 1:11 vi. '4 1 . NIA 1--v\\ :1 v T1.11111 dv. AU '. ý-llrvvo( le, I

W ill. v NIC. :1ý, ow-ldl aill Ill Sill- u'l, I - )II it 4 ) 1* 11 it I I I I ý f

I*.SA-S()-S. `-;1kVPA H i.g. 21-1). Tlw, cmiý-ti 11:111 .()Ill I I I Ilel It() ý,vrvv a,

,,I I I'l-tv c:I I (,()I I ý,1111 ;I I It 1() 11 iv I I. A F AN' F's PAC (I he I '..%ý. A n I I v F(wr(ý-,ý

Wvý,Ivrfl P:14.1lic) ;I I'll.]. 1 *S.\.%4( 11S. SAVPA. wný- ;Ibýmlwql till,) I Ill!- tw_-.11imll mil

Ill .1111tv lit, :1, 11111ell IIIV 10f),111I)II :11 (Tvilera l

I I v;I 4 If I I m 1-1 vrý-. A F I "A A 1.111 v Fowl -(-ý I 'n 4.11 ir -4 11 it I it Ill it 111 it it 111 11 -27 1;111

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1;1ý1 (4 111v \\;I rl 1111o (.f lfl-ý1111;1 Ill I() ro III-11 11,111ex(mvid, 1111vi-14W.

The G,11-(111alit S\Acill

Ill 1h".4.111104.1. 191:l. Mioll it 11;141 I'tw(flilf. ;Ipp:11.1-Ilt 111:11 :1 -Ill.-dt, -Ilrg'.-:11

c(III-1111 :kill c(oll, 1 11,11 cm-vi. I he \\ [lIvIY 411ýpvrývql illed [--;I I :wl 1\ 11 H.- Ill I Ile S(1111 It

\\ 4 .ý- I I '; I - -I I i I - I I I I: I I ) 2. 1). ) . I he ;ml hill. Imd Ilvell p1:14-ed flit willpm.;I r , v (1111 Ill the nrc:i ;I, ý1:1111 'lit . h) (

_ 1 I o'lflIIIt;lII(

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1) :11141 A I I Nv\\ (imilva :Illq I I

4 .. 1 " 'llilpf w il .,I h i, d 'll i. - .1, :- i-l;l lit f;l I, t :111.1.

I.T. N, 4 f-. SAS, PS. VA. h. i I - .I

1.% [I- ,Ii. ;it -. 11w . 1-- s ill. 11, hod h- lt.-ljjlll
SOUTHWEST PACIFIC AREA 707

MEB 29 9444NE

Hollndia 194 22 AR C3 IRELAND

Ai:~top Cape Creain BISMARCK<

N E:- W Goodenough I

Cape Goucester

)Saidor Arowe NEW

G U I N E A Finschhatee 5 E -4 BRITAIN

L 22 zSEPT[

Kiriwino 1 0 9

22 JA \ .wo kI 1943 Goodenocugh I.

0- ALL.-D AOVANCE

0 100 200 300

MI LES AA U 'afrm S TR AL IA onIeAustralia

iP4

MAP 3.-TheAllied advance froin Townsville, Australia.

Afedical ('orps Reserve. tit thle I~th General Hospital. tite affiliated unit of the Johns Hopkins %ledieal

School where Colonel Trimble was assistant professor of surgery. When tlte 18th General Hospital

was divided Into two utit,& in Ap~ril 1942, hie hecanite chilef of the surgical service in the second unit,

the ll,1th (l'neral Holspitall. This hospital left Balitimiore on 211 April 1942 and, after It) days at

Camp Edwards. M1ass., was sent to the Plort of Embarkation. San Frneit-sco.

Upl to that time, the Hlopkins unit had bieen mterely at paper organization, with no military trainIn~g other tlatin occalsional it('l'tillg5 and lectures. It hadl haid no aictive duty and no sustained.

poractical. reallstic millitairy indoc~trination. Whien it left Italtintore. it had no enlisted cadre, and

its personnel consisted oIf only mnedical officers and nurses. When thle unit sailed from San Francisco.

it had its full compjlemtent of personnel, hut they were without training, and training could not lie

plrov ided en roti te. The cro wded conldlit ions on sh ipbloa rd (three other affiliated general Ihospi taIs. a

dozen stattion hospitals, and all their equiplment were also amlong the organizations transportedl

on tihe V.1%. Army Transpbort 11 'rict I'oitit ), and the necessity for almo~lst cont inuious tlllssitlg and for

frequtent boat d~rills, ats well as tile pirohibition against lights. nad~e any instructional work of it major

nature (luiring the voyage entirely impollssible..

Tble 118th General Hospital lanlled in Alelbourntc, Australia. on 4 June 1942. Ten (lays later It

was 1111ive-d to Syo-i 1ey. where It was su't upl at till Royn a P ri nel Al frel Ill sp it all. one1 (if till teachinitg

hospitals of the University of Sydniey. F~or ubilt a year. this untit wats till olnly ('.%. Armiy hospital

lit NI'w Soutl tWales to care for Army, Na vy, andi Air Force platienlts. The work was chie~fly of tile

stationa holspital type, though some combatt-ivltiideld eallsialtil's were rece'ivedl. amiong thein a1 few

FIli 1115ivo whol hlad beetn bIro ught oilt (if tile I 'lipii l lllst oni till S. 5. Mac tail, the (lonly hosptlllt shill tol

ha0ve' thle islantils before theilr sti rrenl ler. Tltese I li-t jel s blad lillil valrl'( foar lin Aulst ralIialn A riiy

ho~spitl lis blefo~re theil11SthI (0-'nera I Ilouli tall begana to funt ioein.

The next baittle clisuitletfs receivedl camne from Iluna-(iona on Newv Giditea. When as permanen t Intsta Illat ion for t he II 5th 1 ;etierail Ho~spiitall wits s1t tit), as pa111rt (If a5 holsp itatl cenlte r c(lst riiltcl'

at Herne Blay, Auistralia,. 2.5 tmill's south (if Sydney. with Len~d L~eils futtds. till sttrge-ry -als dlerived

chiltlei frotnt troopls staiginig iii the Sydntey ltinse Area atnd was still chiel'fy (If tile staltlion hospital

type. 'The only bottle caisttatlties rece'(ived'( were lbrolighIt Iin by Auist rai an hoIt spl ital sbtills antd were

chiefly patienits who rel'l hInr'llte e tI rthIollellIe catre,.

if'ol (it (' Trimb ile's ti rst rel' I dnti ti t wvi th 1111t tle vasmitItil's wats thlere'fore' In Illeceeiber 1 943l. when't

bes w~ent (In temnpollralry (lit ty for 4 miontIhs its alssistantIt sil rgl'ivn vsIltant it~i t Iti the- (MV otuef il( SIn'Xirgellal.

U SAS08), SWI-'1A. H~is e'xpIerieance duliciiated'( t hat o (f ma11ny (at lalr nitfll'l l ofI lfivet's Wh Io, hivll't the Ill'o'(

arose, were ablel to tranisfe'r their fine tralilItiig an litbroall l'xi~wrienceell(I Ilicvliani surgery to till' mlilitairy

situa~tions they eitcoutnter('l.- JT. D3. C.. Jr.

7 f1 !05-419 64 4.s
708 ACTIVITIES OF SURGICAL CONSULTANTS

12o0* 40130 

L Ingoyen * MOUNTING AREA

Gulf

PHILIPPINE 0 0oo

IANILA MILES

1, % P A C /F /C

X• Leyte 15o1-10

SULU - o # ""• Truk

~. ~o,', ~ A ' ~Is.

go 0 0 0 C E A N " C E L E 8 E $ ,\<,"• G.Wc o

% \ 0 \ -5' &,Oo

BORNEO _ I, ,c , -.

-0 "0 i 46BIk L\ 0

do. • , •, . Monu$ 1.

CCELESES Cýa I

j Ai"op. SEA R-,,,•• fl

\o u E i:N A ,, ,

.GUI Fin hhfen

.- ARAFURA SEAMoresb

Gulf of

Corpenloro aiO.

,2 o.AU TR A' L I A',"II /P

MAP 4.-LThe distances from mounting areas to ingayen Gulf.

Although the original plans for the consultant system worked satisfactorily enough with this expedient and others, it would have been better if the

table of organization for Headquarters, USASOS, SWPA, had been so set up

that the consultant section could have been enlarged as needs increased. Originally, there had apparently been no real appreciation of the services which

could be rendered by consultants. The situation changed when General Denit

became Chief Surgeon in January 1944 and as his position and authority were

widened in the successive reorganizations which occurred in the Pacific in 1945

(fig. 275). General Denit, who had served in the North African theater before

his appointment to the Pacific, was thoroughly cognizant of the accomplishments of the consultant system in that theater and of the improvement in the

care of battle casualties that had been effected through the system.
FIe I. 1, 2 11- A - eciaj ;4 l e1 ;11 , 1 11' o 1 14-r1 level 411 I LeA ol lot'\ Meit 1*ll4 ) h 1AJa ..4411.1:11 Ili's

I4 t Ill. 1i 14.1lt I ( A~ 14 1 11'- It E14c III i11 I daII I~ Ill ifmllgIl :1 11 :111 'Il llI \\I eIIwIr &I )II ofl Iv41-

; I - IIIIIor II IýV Iw ~ i , I w v1 f(I f i - 1ý 11 1Il! l
710 ACTIVITIES OF SU'RGICAL CON.NULTANTS

CuHsRT 6.-The tablfr of orIyallization~ foir ('fxiydtaInts in .Yurqcry. V.S. .4 roy Forecs, Pacific

General SSrgeryy

General Surgery 1Anesthesiology 1

Orthopedic$ Orthopedics I Anesthesiology1

Neurosurgery1

Thoracic Surgery I

u#aoillofeciel Surgery I

ophthalmology 1 Wes Poc: ~aseCm 1 Okinawo

Roentgenology 1 1seC! 

Resuscitation (Shock-Blood) 1Ieeo ugr General I Surgery1 e raSugy I

easgneda Ga torer hospital.y enra urer

1. AnesthernPaiicBsColmog d oIpm. 2.nePheiolpgin Bas St ioAn, M thik Ary SrIeCom d0.lgscasupotcmm d

forE the5 Sixth U.S. Army. Servic CommS. Army Cmy Eihh.. heEg U.S. Foitcarsprtcmanto Arm.SmB ,Tea~ y 

Leyte, Philippine Islands.

was dlroppIedl, andlihe ininiediately assumned the resp~onsib~ility for special studies

of the casualties at. Hiroshimia and Nagasaki.

A coitsultant in anesthesia was never appointed in the Southwest Pacific

Area. 'Maj. (later Lt. Col.) Forrest E. Jeffingwell, NIC. was appointed in

May 1945 to surv-ey anesthesia, practices in hospitals in tile Phiiippine Islands

andl to a('t as part-time consultant at H~eadlquarters, AFWESPAC. While hip

performed these diuties, until November 194.5, 'Major Leflingwell also (continuled

his duties mn anesthesia. in the 80th General Hospital in 'Manila.

Functions of the Consultant

Whlenl the. author was appIointed Akssistanlt Consultant in Surgery, Office

of the Chief Surgeonl. USASOS. SI1AT., lhis duties were to visit the hospitals

in the b~ases in New Guinea (fig. 277), evaluate tile surgical per'sonlnel in them,

evaluate the professional care that castialt ies were receiving, and make recoinmend~ations to the Chief Surgeon basedl o1 tllese observ-ations.
SM l*U I WE.'I' PAC IFIC AREA;. 711

Fiw i276. - .1lmnes j1em cIissai ries I rri v iz jig I 'a rdI 1 .S.S.11bj~oouri in 'u'lkyv Btay Wo Sign

Whien lie as.siiiieu his~ diii ies as COISI-.iili11 atIII Sii.1P~ryi. ( IieOf lhe Ch'ief

~ mI ~.X OS.SWI NA" iii Amnis~rit I94-1. Ili stiuicessioii 10 (OlOiiel Pa~:rsons.

hIls liiiiti 14)115 WINIT cotiside'ahldv lbiOadleiell~. Thei chief fiifc tol4) lit, Siiiri".cal

C&l)sidit alit lit t his Oflitce was to4 advise thle C htief 'SmrgielOii l wa vs -.11141 illealls Of

4trjI~ VIII' Ille 110 t xpert pl)4hMOlesimi1 care I 0 Nwoiiiuld soldiers. Thie 1114)5 eflicielit %\.I\ Vof alc( aiplishliii III. resuit~lt was the C)lt4tevaliai~it 14)111 ailalviieOiither diie ts of thle ( )Iiislilt aiil Ini Silo'±ri-Y iiilelle 111: ilIIIenlivi'e 4)f c14)5

li\is iiit Ii all Ollives 4) I lieMedical Seclim)o. I Ial~lhliarters. I SAS( )S. S1VPA'

esjpeciailiv I lm~se rI l)4)lib.Ile I'm iuitulcal pl.laiiiiiii&. ev"IIacllmn41. li()Sj)il~lliz~t *1011

5111)1)* v. miid pei'-SOIiiel uN iict 1,1 oll OfliiewlY a rrived pers.oiiiel Ill lIhe priniciples

of Ihle Siip*-ri4'aIl car~e Of b~at tle casualties, ('0 lrctil Of114) suil."iicil eIT41.Osb IW 11(11-

triliat 14)1 and4 deleiiiist rat imo dhisseminaion~i IOu f iiiforI.Il:tioI i 5evi11't'4 f14)111 q)luiet'

theater's and~ thle L)ine Of itl4r ~ulia 1411 lOf4)1' ohil for EITi'M ( Essentitali

'leclillical Medical DI)ita ) reppl-ots: plalilllgl~ foi iidua 5lIl~l)4)i of tiitirt'-j Operat Olis: anid coisti tlv rivillug to f14)liiiil1ttl planis to i'tltIle 4cirt4eo

caISuMl~ es :1i4l 1o iiii1prOve thle varie of thle woluilel. llease Of1 thle vas't d1isI alices and4 lhe (lilliciltit es Ouf cOiiulI~icat iou ill thle S()Iit hiwe(st I 'cilic (11iiiap 2,

1). IN9)) dwli ( o)Iisiilt alit ill 'uilreI1Y. lii lie. plet tlie ( )lice4t Of lilt Suirzeoi.Ol

SINAPA. had 14) be pi'epared4 14) filwiitloll ilidelpeldlently flv 14r Ong jperiOds of iiii1e.
11:14~~~~~~~~~~~~~ 4 iIiI4! 14 I4I 1 4441 4114'4 P S 4: Itt I:44 lt I4 I' I A 1 41 I 1 4 l S ' 14 

iii~ i :-141 41 Prot 41 II,

aa4'*4'144 ~-l 1411 1:1a 41i ~'Ii I 441 ~- 14- 14:11 ii t'a 4'1't'l44 . 14 It411 4a~iii- liI.It.

4'41,l~:Il a 444'14 4'14III Il'~i.:141 1:4 14' 414!'1:111'~ti' Orhul 4 

~slI~.ri14'-williI' 114:11III 144'ilm aadI the1h4 II 414 4441 II 41)1i1f4 v l i1.1 ' \0 1 1114 ,4 l~liv

Iii I~'a4 )A 411. 1 _-(t 44 ' I 4lit I,.\I I (i l I it-n14 1't 1 I li 14: i tIh i (lullitl f) a.:114 ll 
I 'Al I VI A I Z V A

11- pilol siles fill I"1:11141S. r 1! 11.
19 14.

it'll.I )o )J 4II e!.e 1.iiiiI'1:11.1. ;m44~ ht v14 which hadl'I Ininleul I t I4I4 Ith

1*114 w, -I I4' 14 - I3 ;1I4 c 4 1' 1 1:4 114 ) -.1 H ) 411 :1ý!i . h 1:v I 4)II It I IvI v4n1 I Ifl' -:(I4 I I-:I I ]414 . A 1

101?alo of p)(Fso1?icli
SOUTHW~EST PAC'IFIC AREA 715

3150" or "B3-3150-) surlgeonis arrived III Lie Southwest Pacific Area during

thie 3yearisof activ-efiligtling thiere. Sinee Ho traiine(1 surigeots wer-e made available as casual replacements to time eiil of thle. war, it was necessary to reinforce wveaker units b~y takinig more exlperieiicedl personlnel from other more

richly suppllied unit~s.

Shortages of tra ine(I personnlel could be partly explainled by a1 certain

amounlt. of wastage in newly. arrived1 unlits. It. was ]lot. possilble to renmle(I this

situiation t hroughoumt, thle war. Better p),lamming~ for e(lipi lnieiit . t raiisl)ort at ioll,

and ot her details would have sliortente( stag-ing periods and permitted surgit-~ lonlt b. 1 ltt vr atioce. This would have imp1 roved the

morale of the medical officers. who, quite naturally, resented lonig p)eriods of

enforced inaction.

Thle chief reason for shiortag(es, of lpersonlel, however, was thlat inl World

War 11, as ini previous wars, too little atteiition was paid to the essential qualifications of mnedical personnel. Tmvbles of organization were adlequate, but the

ability of the officers assigned to the various spaces was ofieii not correctly

evalulatedl. As a ruile, tme assignlmenit was Onl tilie basis of ranik, without sufficient

considlerat ion of the adequacy of professoiomal abilities.

Emphasis on rank was not, of course, a fault cminhnedl to thle Medlical D~ep~artnmenlt of thle Akii *n%-. ~

1

%lmei surlgical hielp %vas ofteredl to thle Navy, for the

LS'fs whlich were to participate in thle invasion of Leyte, it was refused as

not. needed, 'am the, ground that the ships wvere adIequately stafledl, some of them

by officers with time raimk of lieutemiant commmnder. It is true that, all1 LST's

had medical officers onl them, but many of these officers wvere not surgeons, let

alone exlperienceel surgeons, mnid the casualties had to get along with such care

as these. officers could providle them (uhirin the wveek's trip from Leyte to 1-lollandia. Tite classification of medical officers into specialty groups came too

late inl thle war to be helpful in thle Southwest P~acific, and exlpereienced persoiiiel wvere in short supply minit i thle lighthingended.

This con-sultant, like, his predecessor, followed the plan of stuidyinig all

newly arrivedl hoslpitals inl regardl to qualifications of personnel and recoinmndinmig such chaniges III assigniment as seemed necessary. As mnay be exlpected,

the best surgeons were not always those wvith the best training onillpapr.

Selection of personnel for p~ortab~le surgical hospitals (fig. 280) was a

major respoiisibil ity of thle surgical consult ant, a responsibility whlmich inicreasedl

in difficulty as thle, supply of experimened surgeons dw~indlled.

As of time nmiddle of July 1945, a month before time surrender of ~Japan, time

141 hospitals in kFWVESIPAC (including thme Sixth aimd Eighth U.S. Armies),

with 67,000) beds, needled :314 surgical officers to brinhg thenm up to authorized

table of organization str-ength (table 3). The 32 surgeons theni in time theater

wvith a rating of "B1-3 150," or higher (table 4), included thle surgical consultauts

in the Office of tile Surgeon, AFPM( , aold the coimniadi~liig officers of severa;

hospitals. There were only 14 orthopedic surgeons, :1 plastic surgeons, and 2

neurosurgeons with thme rating of "it" or hlighier. Time single surlgeonl inl thle
"oI -;I I I-o 1 14"-1 .It ' I'l 1\ I If t It I I* A 1 'I I i t- I h Il I :11 1 1 I . T .\' I' ) .-

'lii- ii I', ii 1 I ~ I i ~. ill141 I 7*-v i Ii f );lii I~ I :I--- 11.11 -- Ii I 1i 1ittlt 

'Al ill illo . m 1 I 1 1

it, - II I - It (Ii -t- til t lo I il 1 - 11

i- '-t -- I I I ' i•t | ,l I .• lil 'I It.(I f-t ; I| v v

:tr ,: \If l : , I I itr~ I i~ , • I v ,,,r:; .11,.1- 11-1' ', .,I: ,, \V r:,i,-_, I ,1 ,,, 1' ")h :'1. , ."

I .'l l I. I,1I I I I I\~ r -t . lq ll • l - ll 1 .. . I I . i '. ~ l l • - ,,'•l m I I , , I ,. ,
SOUTHWEST PACIFIC AREA 717

TABLE 3.-Shortages of surgical officers in .4FIESPAC (including Sixth. and Eighth U.S.

Armies), 17, July 1945

Type of hospital Number of hospitals Number of beds '%umber of surgical officers short of

authorized strength

General ------------------- 29 :37,500 1 103

Station------------------------ 36 11,950 62

Evacuation -------------------- 14 6, 650 65

Convalescent -------- 1 3,000 4

Field------------------------- 17 6,800 42

Portable surgical ------ 44 1,100 38

Total --------------------- 141 67,000 314

Number of surgical officers needed by specification serial number

Type of hospital

3150 3153 3106 3125 3126 3111 3131 3152 3151 3306 3115 Total

General ------------------ 2 12 16 9 10 7 21 4 4 15 3 103

Station ------------------- 6 10 22 1 - --- 9 ---- ---- ---- 5 9 62

Evacuation ---------------- 2 6 6-----------6 8 12 13 -- 2 12I 65

Convalescent ------- 2---2----- ---------------- ------------ I

Field -------------------- 1II1 -- 9---------------------- ---- 8 14 42

Portable surgical ---------- 31----- -------- -------- -------- ---- --------- 38

Total---------------- 54 28 55 10 10 22 29 16 17 28 245 314

I 3150-general surgeon; 3152-o*rthopedic suigeon; 3106--ophthalmologist and otorhlnolaryngologist; 3125-ophthalmolofrist; 31.96,-otorhinolaryflgologlst; 3l11-uiologlst; 3131-netuostugeon; 3152-plastic surgeon; 3151-thoracic surgeon;

3306-radiologist; 3115-anesthesiologist.

2Corrected figure. The original document showed 14 in this block, which would have made the obviously erroneous

shoi tage of anesthesiologists 47, the shortage of surgical officers in evacuation hospitals 67, and the grand total of shortages 316.

TABLE: 4.-Mfedical Corps surgical officers in AFIVESPAC (including Sixth and Eighth U.S.

Arinies), as of 15 July 1945, by specialty and rating (qualification)

Number of officers by specification serial number1

I

Officer's rating __

3150 3153 3 063125 1 31263111 3131 3152 3151 3115 Total

B -------------------------- 32 14~ 8 11 6 10 2 3 0 4 90

C---------------------------1180 31 15 15 26 23 10 1 0 13 314

D-------------------- '105 33 9 2 6 8 3 2 1 27 196

None-----------------------------70 0 2 1 1 3 2 0 0 6 85

Total -------------------- 387 78 34 29 39 44 17 6 1 50 685

I 3150--general surgeon; 3153-orthopedic surgeon; 3106-ophtbhalologist and otothinolaryngologist; 3125-ophthalmologist; 3126-otorbinolaryngologist; 31 11-urologist; 3131-neurosurgeon; 3152-plastic surgeon; 3151-thoracic surgeon;

3115--anesthesiologist.
Rt'toliiliitli(12t 11ion for Ilt'e InrliIsft'r of Surigical Im-rsoiiiiel Somietime's wert'

l)21t'( oil iii('oliiIwtteiice biut. liioret ofteni wer'ie based oit lie( hic'k (if ex~iwr1PCP

of t ile 1)11r t'vll 1211 offi('er ill a1 )Imsit loll ill wI Iit'iilriiI ex im-rie'ii4e w215 not oll~

4Iesiniblle but esselthiit11. N\ o u?,11t ler ho tigl , tle IrjiiSfet' imiigrlt Seei. however'. its 14.4-oiiill~lslillienit %%*,Is 211w~y tediou '101111(1 ; w.Is Soil let i lilt's Illisivevi4 (s.ill.

The chietf c4iiises of (lt'I1i N 'iwerethist'liiict' bett weetli unlits .11141 Iie.1~4fui11li'ters and1(

tI('lINV5 kt It2((111I?(l. v'it lioliglWt ei vommllii (2t 4iolls werle d41i5)2if ('i('

1)iN 21i1lini~ll, I hIls iiietliod ill wnil hilt' A%-Is (ftell Slower tli.iit orfiiti11iv mnail ill

Ipt:I4t't 1114'. For i'11t211icet. wbl Iti t( ult'21?hPW5 Io, IS.1- 't 2IS-d as Is 55 ist.it suil'gicj(- I

(101(il~ltmiit Ili lIhe winter of 1943~ 4 1. he migh~.lt re'(oinlinit'id. froint 1 biase hundl~redIs

of iii iles frotil i hemt(1q1121 ers z tI i~tt I1 verl 21lil 4 diver b e tran isfetrred. The revo i i -

Inl)Iili4 121 wo ul bOI1( e nizilep to tilie (' liif Silrgeoli Iii'-oluili ( 'olonuel I m-2il'5)i,

()'Iislltdlt 211 In Surgery ill I lle Chlief Slirgeots OffIice. cottlinilicio2t ion took

'weeks. and,(1 if C oloniel Par1sonls w215 4)1 of his (illive. Iiiore weeks uliligit elap1se'

before tilie revo'oiivilditei( oll voiihl lie lti1lle 2111d1 .Icted 111)(n).

'lThere Nvert2 also ot her (lthi1vs. Befoe :4In''21 olliver could( b e I ia us fe'rred. it

Was5 tilt ple 1i(vy 14) seo'tl1' Col4Ilel(t f (1 thle b1e S1ctio 5e1 o ((ii21ltdltr. nl which]

ill prnlct 1e lie;nlll his stilrgeoll. u11( (2~) file ('oluiliiatiier of thle llosh~iI 11 to) whi icl

til lie ed i('1 I ofliver toi 1e mto11 ved( W215 21sslgrned. The ICco lslilt 2111t 1121(d1no2 iittliorift%

Ito ordler tit' trnllsfer. of petrsonnettl. lI e (-4)111(1oniI , v it2ikt re('onimlendt(11 10115 2,l11d

the IloSI~jt 21 ('oillill 1k ioler ol d th11( in ik of 1ii1 Ily jiust i 1121)14 re~lsoiis whY a1 t ullsfer.

Should14 not be tii.tde. ,~ii'121l whlet it Av21s p-o~lmse(1 1111 21 goodl ofivner hbe

Iliove(1 0111 of thle 1111it.

Thllis exc'ess oIf ill ifi 121N vl'Vc11i- es , Wichlwis i i' W251 wa rt i lue dt'ielo1 u eiit,*r2 i

.1111(11inlted to ob struc41~tio. B efor'e tilie ne1 survl' il'eoli (Jelern Itxerc(iset'(12

('('litl'Iizedl (c0ntriol ovel' i11 'Med to'1 Dp1 'i121 i'?lii('tf J)ers( ill ietl :111d1 d icht ;ed Ii ieir1

2155 gltnltelt S. Thle concurrenlt'1ce' of po(st conlItlitllders AN"I5 hot Itece('5511'l Ivse-

('llred Ilii m1lv'1 ine. I urim tigflie Nvn, 11'. 111')V 'onl 111i:1 Iltdeis 1121( Iliiis 211111 ion? v

withi thei 11111'tl'ies, r mi11(, if tilie ''h12111&!es r'e'ommlien~dedl Avere4 Ilo(i w214'4eldt'1 I ere

W215 115112lly 21 Soundi( 1'e.lsoli. ('lietlV tilie shiollflgt' of I'el)2iatvienlits.

Proposal for temporary du lty of medical personne'l

At flt'e end of December 19144. this 4'ollislltlint prol)ost'd to1 Ilthe Chief Snil

geoll, JTSAkSOS, SWlI~k, I1 p1

2111 to 11(ll(Igttlt thle S? renlgt It (f flt'li4i ( 2 1 tIlit

ill tle. Sixthl 1.S. AlI'li OIl IA'Vle. ill NwlWiil c-,jsjlljtip %%es Weei ' lie l~iellig re(eived

in slih11('l hiillbtrs -,is to1 reojllilrt 1' iullentalt~t loll of tieflit' lle oIf 4Oi'grlliiz~lt (io

St rengt I1. 'I'lil' %%-;ISW21 tilint IliO5 itlI 21isf 111 fouind thlemiselvtes ill thiis situ 121 il

(XI('(llIit ioni~il skill desired. and iithIlese ul t requ1 isition 1(15wouIld be filled 1), lI~'l'

soIIi(lle, oil a1 feiilprlmlry duty 5121? us, front 1I4)SjIitlIS ill it'e rt'211, h.11? we*(Ie less

210'?i e oir wtert' builini~ g or st lgilig. IlosI itI? 2 Iscl~''ontolt 1 de o~ (f SA S( S,

SIVPA. would( lulk' their rtequ~isitiolls to I lie Chlief Siil'geoilli lirolgli flt'e base,

illeriei'lte( Sectt'itonIDl, or 1 12st' set'(t olt Surgeonils. IIoISI iitl1Is underl'l I lie conotrlol
SOUTHWEST PACIFIC AREA 719

army commndal~ at the discretion mid dlirection of the army surgeon. When

the emergency had( lpassedl, p~ersonniel onl temporary duty would be ret urned

promp)tly to thle pa~renit organizatiloll.

TIhe p~lan was alpproved informially by the Surgeon, Sixth U.S. Armly, but

was disapproved by the Chief Surgeon, U7SASOS, SWPA, whlo feared that

officers oin temporary dluty wvouldl he retainedl too lollg in anl army area when

they might be needed inl their own units or might be p)ermnanently lost to their

own units and thus pass out of U-SASOS, SWLPA, control.

Wheni this p~lan wa pr~oposedl, it was estimated that 40 lpereeiit. of the

hospitals inl the area would be inactive for one or another of the reasonls mlentionedl. This estimate was much too high, but the p~rop~ortion was still considerab~le, because of the character of military op~erations in this area. Had

the plan been approved, it would p)rob~ably have added six or eight trainedl

general surgeons and the same number of trainied orthopedic surgeons to the

hospitals inl thle Sixth U.S. Armly area. The inumber would have been no larger

b~ecause so mnany surgeons had already lbeen withdrawn from general and

station ho-spitals to serve onl surgical teams, and, for this andl other reasons,

these hospitals had already beenm strippledl to time b~are b~one ill professional persoinel. Even this silall ltnhimler of competent surgeons couldl, howvever, hlave

been assisted by less experienced surgeons, and the plan wvould have helped to

overcome the acute shortages of trainedl personnel that frequently existed in

army areas.

Training Policies and Problems

Long before World War 11. the whole subject of the proper treatment of

lbattle-incurred wounds had been wvell dis-cussed in thle. official history of the

U.S. Army Medical Department, inl World War 1. Not, many World War

II surgeons were familiar with these volumes (although General Denit carried

thle surgical volumies ashore with himi when lie landed inl North .Africa). The

information containedl inl these volumies, with the p)rop~er modlificationis for the

advances inl the muanagement of shock, anes-thesia, antimicrobial therapy, and

similar subjects, could AN-ell have, formed the basis of the directives concerning

iuedlical care p)romnulgatedl inl World War If. Few surgeons inl thle Southwest

P~acific Area kniew that this history existedl.

Practical training

D~idactic instruction was of great value in thle. indoctrination of newvly

arrivedl units. but actunal experience wvas necessary to convinice most suirgeonis

of the funldamlenital (Iifferences b et ween ci viiil and ami~militarv practice. The

misiinderstand ings wereý nit iversal. It was reniarkab le to nmote thle sameness

of tilie er-rors coimmiit tedl by suirgeons iniexp~eriencedl in miliit ary medicine, even

though they wvere exlperieimcedlaiill competent in civ-ilian pract ice.

mrnar , A slit nrc of wvoundls, iniadequate (lel)r-i(leinieiit-I)arit icuilarily of

iimnocelIt-:ij)pearilmg 1)erforathing wound~s of large mutscles, tight packing of
720 ACTIVITIES OF SURGIICAL CONS•U'LTANTS

wounds, and undue reliance on bacteriostatice ageents were among the cardinal

errors. It was hard to make surgeons without. combat experience realize that

transl)ortation of the combat casualty from one facility to another was inevitable and that his care must be geare(l to that fact. A p)rocedure which would

have been reasonable and appropriate in civilian practice, when the patient

could remain in bed until his wounds were healed, was therefore not safe in

military practice in forward hospitals from which the soldier must l)e transporte(l to the rear. Transportation under the happiest circumstances induced

fatigue and further shock. The jolting caused shifting of fascial planes. with

resulting hemorrhage or the collection of fluid in (lead spaces, which was an

invitation to infection. All of these possibilities were enhanced by the methods of evacuation necessary in the Pacific (fig. 281).

Personal visits to hospitals by consultants were found to provide the most

effective form of teaching, and a large part of the consultants" time was necessarily spent away from tle Chief Surgeon's Office. In a theater in which

hospital units were in isolated bases, these visits were especially appreciated

by the hospital staffs. For one thing, they indicated the oflicial interest, of the

Chief Surgeon in the prol)lems of all the hospitals and their staffs. For another, they 1)rovided opl)ortunities for discussion of professional problems.

The liaison thus established between the consultants and the base surgeons

proved most useful. The base surgeons came to rely upon the opinion of the

consultants concerning the care an(d disposition of pat ients, as well as the

placement of personnel.

New units arriving in the theater were met at the staging areas by the consultant. Meetings were held with the surgical staffs, and the surgical policies

of the theater were discussed. Whenever possible, surgical officers, were placed

on temporary duty with active hospitals, so that they could obtain instruction

in special problems and could see for themselves how battle casualties must

be managed.

Hospital units designated to accompany a task force were always visited

whenever possible by the surgical consultant before d(el)artiure.

The training courses in various specialties provided by the Medical Department in the Zone of Interior were excellent.. However, judgment and

skill cannot be learned in a matter of weeks, and most of the officers who had

taken these courses were still inexperienced and required careful supervision.

It was repeatedly observed that the selection of officers for these courses was

not as wise as it might, have been. It would have been better, for instance, to

train experienced general surgeons for neurosurgical duties rather than, as

happened in a number of instances, give the courses to officers who had had

little surgical experience or none at all. It was later found that the consultants

in neurosurgery in the Office of The Surgeon General had also arrived at this

same conclusion.

Except in anesthesia, no attempts were nmade at. training in the surgical

specialties in the Southwest Pacific Area. This single attempt was limited to

the training courses in anesthesia given at the 1I lth General Hospital, at the
SOUTHW\'EST PACIFIC AREA 721

request of the Chief Surgeon. The 4-month lperiod of instruction covered

the physiology alld pharmacology of anesthesia, care of anesthetic equipment,

and special techniques. There were 22 hours of lecture. The practical p)art of

the course consisted of the administration of anesthetics, under supervision, to

between 100 and 120 cases for each graduiate. The courses were discontinued

in July 1944, because of shortages of surgical cases in the hospital. When

the selection of students for this assignnlent was judicious-as it sometimes was

not-tthe graduates proved both capable and useful.

It. was recognized early ill the fightiing iin the Southwest Pacific Area that

some mealis mus;t be devised by which tours of active hosl)ital duty could be

l)rovided for iiexperieiiced medical officers serving in units in which no real

cliiical experience or training was possible. The basis of plainihig was that

officers who were assigined as battalion surgeons or to remote dispensaries or

who were engaged in duties that were chiefly administrative should be transferred teml)orarily to hospitals inl which they might receive the necessary training, while officers ill those hosp)itals would serve as their exchanges. The

refresher courses iii the designated hosl)itals were to include anesthesia, ophthahimology and otolaryngology, general surgery, orthopedic surgery, roentgenoh)gy, aid general mnedicine and allied specialties.

These plaits were discussed vigorously at intervals, but they were miot implemented unt iI Manila was taken and Luzon was secured, ehietly because of the

long distances, shortages of transportation, and difficulties in radio and postal

coninimicatimis ili the Pacific. Early in August 1945, 50 inedical officers from

the Sixth and Eighth U.S. Armies were finally placed on detached service in

greneral hosl)itals on Luzon for the plurposes just described.4 They had scarcely

begun their work when both armies were alerted for occupation duty in Japan

and they had to he recalled.

Dissemination of information

It would have been extremely profitable if exchange of information concerni ng policies, techniques, anid professional experiences had been permitted

directly between the medical section of a field army headquarters and that of

ITSASOS, SWIVPA, as well as between the Southwest Pacific Area and other

theaters. As it. was, all of this information was transmitted by way of the

Office of The Surgeon General. It was slow in reaching the Pacific and even

slower in seeping down to the surgeons who needed it most. Much of this

information was also not as detailed Ais it might have l)een.

Bases in New Guinea, including Port Moresl)y, Milne Bay, Oro Bay, Lae,

Finschhafen, ][ollaldia, and Biak, all had their own mnedical societies, as did

the bases at Tacloban oil Leyte and ill Manila (fig. 282). Medical mneetings were

difficult. to hold because of the conditions prevalent, in the area, but, in retrospect,

they could have beeti more widely utilized than they were. W:.rd rounds and

seminars should also have been more widely employed.

4Circular Letter No. :11, Office of the Chief Surgeon. Ilendquarters, U.S. Army Forces, Pacific,

28 July 1945, subject : Training Program For Medical Officers.
I I'J F
PAC11,4, ARA 72)

44

7,,

lob

"%1I nib,.14

D -
1724eWiil1l~v 'el I1Il Si~~~i~ ,S Ilp~ Slj(1CA14 j 1-iiNiii I:ulTANT

1wovidel~~ iiiil hilvd t e1 Il E.e LI0lt 

),4-1irecie. 11v -o I weI 1w 4 r re I I vst ~ II I Ie liv I eI. f Ivx ,i :md ji! )Ie I erI . Is hae I I levil

providedi~ ) I el (chI' 4ll, .ul CI' I, 11.111111 their (I x1eiIee IIýIL t'

Direc~t ivu es.i -I n Ii w I Sout I i~s hlt Pael I It'1Area.asI I I Ir4 Iiiiiii *Penes. oI elIIvlt II'S

t aiAW Ii/14'1 ~t:I I w h .I I oli vers :I) I) I4)it- I ~I l% IIreof I 4 rll Ie v aI exIll. 1*1114 CV 11111e ioli:II -rfo:Iiu

(f114 gren I Iva I o114 I '4 . 'l(l I I 1 g)-4'lI'I refI I 111 Sp' e e c ii I Iu ts here w m a s bel I Sl wd foi)-

I)('letI m(I o I4) i I h ; I I' le I. I o 1,t I\l4'i 14) Itd 14 I u;.IlaIIles AV&'i*4 I (.:I4' I 1) I fo I il k )111 i o II I wn 4'ssl4)II

Xil il Ie form 4 of leieIli&':ter1)1 :lvlo tt1151))111s pI ex).1' tpa e Ill' I lee Cher Sll -,te'~ -r I ptl's I(lMce

USo I lie NIII pibv~ ~lised A el.4 Ils S14 rli' lorie). kl% ) eols

The lust Ir l)wreIssl 4)1 ofi ll' \4'I )0iols Ill 'il v4I hosiw*:t11 co4il it er .Xiv Ws i lOlt

goloJ1l. 11115 m-ln4'l fromsIollII'it (li 1) ki4W 1 Ir hei In sle Ill-eexi 111111 i i -So ca~ist 1. 111141.
,m*,rmiiwrs8r PACIFIC AREA72

Fitm;21,-.--- 11vadquarl;rt'~. lliilippiiie BI~;st S(ection. .Maniila. Phiiilsiipine .A1ldu, 25 Mahy

o I wm ;I I \'I i I :Iv )PItI-vrel Itii I iiI )it -en' reprii, III -k o I II )Ivll ý14)vI1 1 eae-r

11411 iv( I W I liers h v(~ 1(il lie )tli4e ol tll ew ~IIIleoh (TI riepm;nl i ie :u If) (h e

'Indi1111 'IU (Ithimle 1,1: IiePioPI iiii swill-erv. Ite phitI.he liidiv i il 1LeIe(IOible as 

:1( it( thl~ I. 1:1515, 4 jr)e (I I~~~ll ici iiI i ~(IlI Ct a Isi id iti4( beA 1- 4 ~ 144C he~t

st)IIII( 1911. ptied If ill- *herpihlIW H9il..:1(1( iihiiiteloliir

I ) *1, I~ls i :ir I . f( jol~ ~ rstvi k ' t 11,ilI1 w :g1 1m 4 4r :4icIle m~- . ~Ib ~iiit -ac is 4d44 '14j41 ic4es.(d

hietili I)))iie41 ) 14 v41(i1 I Ol ii'i4i, ive (d, The4, 4 s 4ilrg 44 m 14 ll.4 m In Ille arvi~jl:. and441 444 be)4 

(ist:44441 ri il.H144 to 141 fpll-lu ... iiii4 si44 4 )444)4 4d 'I'l 44f4la 4:4 which4 was 444441) t l ed oiil4

r4)4V014i)1dwid 4)t114I:4 basis 41) 1111 w 1i)4 Ill tr1Wa t Ili :t4 v tmilu.I4)44rst P haciit.4 Area becal44.4 se4

411414 44 ibe 19II 4 11.I) ('vuhf lit .1:11. :11- 19:144 ti . and41 1()1 iii I, i ll the 4:il4), 1444

-' Tlwn i 4 s au jitifit 6 rti t m ( I siI ; v4:i'i : d i fa f'. . 44141 I (a %;I r1imI liii'j , 4')41if 4441 I#ti it, it 1)41 i I I ji i. , ii)) It

114e:4 1 l.4 il w4m4:41P cfi rn4Ti4s144. h ta t11fa d 1,wl S1111h v
726 ACTIVITIES OF SURGICAL CONSULTANTS

Surgical Teams

As pointed out elsewhere (p. 756), the concept. of surgical teams was not

accepted in the Southwest Pacific Area until April 1944, shortly after General

1)enit had become Chief Surgeon, USAFFE (U.S. Army Forces ill the Far

East), and SOS, SWVPA. The teanms which were then formed on paper were

offered to the Surgeon, Sixth U.S. Army, by General Denit in the summer of

1944, for the invasion of Leyte. The offer was declined, and no surgical teams

were lised to supplement. the medical units scheduled to sulp))ort the landings of

20 October. Shortly afterward, this decision was reversed, and four teams were

placed Oi templorary duty with the Sixth U.S. Army, with the understanding

that they would return to their original stations when the need for them had

ceased. The value of the team concept was so evident that other teams were

requested for sul)l)ort of the field anw evacuation hospitals which landed in

Lingayen Gulf in .Januarv 1945. In all, 23 teams were used in this invasion, and

others lauded elsewhere, with units of the Eighth U.S. Army. It was part of the

author's duties as surgical consultant to provide the personnel for these teams.

The objections originally raised to the use of surgical teams when they

were first proposed by Colonel Parsons in 1942 had been chiefly by medical personiel with limited clinical experience. The objections did not prove valid.

Testinmony from forward units was that the presence of these teams, far from

beinig resented by organic l)elrsonnel of field and evacuation hospitals, was

welcoimed. The second objection raised to the team system, that personnel

constituting them would be lost permanently to the parent organization, also

did not materialize: it was obviated by correctly written orders.

Although surgical teams filled an appreciable portion of the surgical

breach in the last. months of active fighting in the Southwest Pacific Area,

auxiliary surgical groups would have been more satisfactory for a number of

reasons. They were better organized. Their personnel had generally had

better training and more experience, and were therefore of more even ability.

Finally, the morale factor could not be ignored. The great, weakness of surgical teams as they were constituted in the Southwest Pacific Area was that their

makeup depended entirely upon the decisions of the commanding officers of the

hospitals from which they were derived. Some of these commanding officers

siml)ly used the opportunities thus afforded to get rid of undesirable l)ersonnel.

Many of the officers who served on the teams were well trained and highly

competent, but commanding officers, quite naturally, did not willingly release

their best surgeons. Therefore, the teams, like the staffs of portable surgical

hospitals, though competent on the whole, represented a very uneven array of

talent.

Specialized Hospitals

In both Australia and New Guinea, from 1943 on, a considerable amount of

specialization was p)racticed in hospitals. Several bases were large enough to

justifyv the establishment of hospital centers, one or more of the hospitals being

devoted to part icula m specialties.
SOUTHWEST PACIFIC AREA 727

When the idea of specialized hospitals in 1-ollandia was first proposed

by this consultant, the chief of the Professional Services Division, Office of the

Chief Surgeon, USASOS, did not regard the idea as practical because of the

long distances between hospitals and the extremely poor roads. The idea was

revived in Leyte but again was not regarded as practical in view of the bad

weather, the poor roads, and the difficult terrain. In retrospect, it seems to

have been an error not to have pressed the idea more vigorously at an earlier

date in the Southwest Pacific Area, in view of the excellent results obtained

by this method in the Mediterranean and European theaters.

The author's suggestion that casualties be moved from Leyte and Mindanao to Manila for specialized treatment was also not accepted because the

officer in charge of the evacuation section in the Office of the Chief Surgeon,

USASOS, SWPA, considered that evacuation from that city to the Zone of

Interior would present undue transportation difficulties. Actually, these difficulties did not occur, and failure to accept the plan was unfortunate. Because of the delay in their utilization, hospitals in Manila played no part at all

in the care of combat casualties, being utilized only for staging and for the care

of station hosp)ital type patients. The hospitals in Leyte, meantime, were

seriously overcrowded, and their staffs were greatly overworked.

A limited form of specialization became effective in February 1945, when

casualties with chest injuries were directed, as far as possible, from Luzon to

the 118th General Hospital on Leyte, while surgeons from other units were

brought over, as admissions required, to this hospital on temporary duty.

It should be emphasized that the idea of specialized hospitals to handle

sp)ecial types of wounds, including fresh wounds, like a number of other ideas

which did not win acceptance, was proposed by the theater Consultant in Surgery on the basis of his own observations and his clinical experience. The idea

was rejected in an office in which planning was largely by tables and charts,

and usually by officers whose clinical experience was limited and who lacked

firsthand knowledge of the surgical situation in forward areas.

Equipment

The theaters of operations in the Pacific were generally regarded as the

stel)children of the war, and in a sense they were, though the vast distances and

the difficulties of communication between them and the mainland always had

to be taken into account. In spite of the obstacles which had to be overcome,

equipment was, on the whole, very satisfactory. Smaller hospitals frequently

complained of the lack of certain items, but the explanation usually was that

these items were not on their tables of equipment and were not needed for the

mission of hospitals on this level.

Nonstandardized items could usually be procured when a real need for

them could be shown, though there was often a considerable delay before they

were received.
728 ACTIVITIES OF SURGICAL CONSULTANTS

Clinical Research and Investigation

No outstanding surgical research was accomplished in any of thle Pacific

areas, in contrast to the outstanding investigations in such medical fields as

malaria, dengue fever, scrub (bush) typhus, and schistosomiasis.

Original plans for the Southwest Pacific Area did not. include formal

research studies. The need for an organization for the correlation and encouragement of both clinical and al)oratory research was, however, prom ptly

evident, and in 1943 Col. Maurice C. Pincoffs, MC, Consultant in Medicine,

USASOS, SWPA. requested. through the Chief Surgeon, that a inedical general lahoratory be provided for Itis purl)ose. In March 1944, word was received from the Office of The Surgeon General that such a unit wouhld be sent

to the area. Because there were a umnber of medical officers in the theater

with interest and training in investigative work, as evidenced by their previ otis

acconplishmients, it had been requested that the laboratory arrive with certain

table of oricanization vacancies, to be filled by these officers. This request was

complied with. Inability to secure necessary priorities and other factors delayed the arrival of the unit, and it was not until August 1944 that the 19th

Miedical General Laboratory debarked from the United States, designated to

arrive in the Southwest Pacific in September.

From the surgical standpoint, it had always been considered highly desirable that the laboratory unit coming to the area should be operated in combination with hospital facilities. After considerable discussion among the

consultants involved, it was decided to use for this purpose the 250-bed 12th

Station Hospital, which was duly transferred from Australia to Iolhandia.

With the assistance of USASOS engineers, plans were drawn ul) to house

the laboratory and the hospital under one roof. Plans were also nmade for

changes and additions required to make the portable hospital buildings. suitable for use in Australia, satisfactory for scientific investigative l)purposes in

tropical New Guinea. A high priority was secured for the large amounts of

material and extra equipment required for these new purposes. The necessary

items were secured through the Office of the Chief Quartormaster, SWPA,

then located in Sydney, Australia, and were placed aboard a liberty ship

destined for Hollandia. During this period, steps were taken to locate personnel within the area who could contribute to the project.

In spite of these careful plans, nothing came of them. Not long after the

arrival in 1Iollandia of the 12th Station Hospital, the 19th Medical Gener-al

Laboratory. and the material and equi)mnent just described, the tactical prograin for the invasion of the Philippines was so stepped up that the investigative project had to be curtailed. The 19th Medical General Laboratory was,

however, established as planned at Ilollandlia (fig. 283).

Development of Body Armor for Infantrymen

Almost as soon as the author entered service, lie became interested in the

possibility of protecting particularly vulnerable areas of the body by the. development of some sort of body armor for the chest and abdomen of infantrymen,
F it,2,::. C'I. 4 \i)N i4-,i M4 Ku I n' \44 4 1111:11IIiL 441fi er ]1 Ai i li.I i q-14il1

L;I4I.:I'i4 I I 44 4 Ne 4 Iiiwn 11u14 1 191-5

just~ ns' 144'1414'1- 14:44 In-vi'4 414'\4lOI)(4'I14 I th 14m ' 4(444lim 4of thei I44': . III SIp eil

her'i 1912, M ille ý,14' 1 II I A ll;i ':1 4:4.. lit, Ivo 4i4'tIe 4I1:11 lIlle .: 444'~'~ 444 '- 44,1114' ;~III

:11*114410'1'd I v, fill~ 444 I ii'i ' i -Ill Ne G u~ ine O4'4 il--&. 2-1 '~'i i41~ 4. '*: a 

(i :14 1c:1412 (1144' l'i4 1 l it'- (1 4144 mw 4444:44144 I(. a 1 104 .\4444': to4 11:444 (l' : -44'4 VV' It'l VVl.

4444':4144 444I ( O . d l. i'' Ii'~r ;t'4. ) I4'vi('V .J. ( :44'r44 . M C1(. 4lel S44'4 "444jre44.

USA.\ 'II'. 11:1(1 144'4'4 444'm1444'4441 (d1 liit-' 4-4441 :4141 11:141 4'xplý'4'-Vd'

gre1 l 11 4144 4i4't Il4 i4.

114 .44:44-'~V~ V :4':4 4I4444 4- 4' 1 14' Ii o:4- 441:1 1 v4 4 I 444:41 141 4'stTess \I.' ti II ve-.st (?I' 141:1st ir 444:44P4'i:11 :4 4iII:lII4I4 :44114:1 4m i4444' ý-I444W d 1414:4 41 hev \\ IV4'

t':1-i ~ - -(-(~''4~ I :4 4ll r 4.44444tt I l I-v 4 v ii It( 4 I - ': Iihe it~ 444414 4 1,I(1 :44 14

I44444144 1h:lov4:4 l ,4''4 41444 Ii hI . le :4444'444~ I 44 ' 444 ''. 4,4 444

4 1 .l pill I 4 f,24 4V 1 ':11 )a 1 i4 114If'M4:M I I4it,4 4'ill4I4:41w 1I:441) I 1 4'4' 14 e 44(1 o 1 1 -404 ,1 :4-1 1 \444 4444 1 In 4'' e

4 441 ~ ~ ~ 444 ~ ~ 44'14' ~ ~ 4(Ill .4 l4I.~li Iin 11144441 hevii2.). 114 molded 4(4V4It n imi 444 -1 (Ive 71

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4144'e .1:4 I 1 : 1144454 4''-!wv~ g 
i~o ACTIVITIS t)F SURIINAL q.SLAT

titac() )Ili'ct' Ih mA().~ihol m,1 1) Brcighi. avl-o tiptit'tet C. lie sub-h1.

Uitit t c I le S e. lti' li. lie S1!i11:11 , Xc~.±t of sluie t11 ( itie ()tl tui' ( od armor.t III

of~ Ilv4-1piA tO he):titto . -i li ' %( t* hi e ( pof' )i ftoitu . ('.S. I rl itie it vcp it W liihi V 1)11 Itli

Ittle I'ci'tirt iv 191. he l-vltt his jlttt of ( bodY ;. ate lo. o 1hnv ( Ia ltau Or.

SIN'i I )A .to hem.1It Itau I I Ivi± ( ,IetI~ Iv .f I' t 11:11 Iret arI)I)1-1 I lo11c . e li W ý. I It )eI ~.tIa

JInitt I t ld I n )tiL-4li chlat ( I~ to IlieSi r.t-voit. FI'i iteuit ]I I '.S. A I'I Forre. ( 1,ie IIvrn

TFw Av III I I . tl I I ut''otill 'ilt crestI I'd jIwi it\ II Ic lieI was :1 atl i Ic I It he~ I I "It ( ;tutte :lle

I It i'-j ii 11a
SOUTHWI'ST I'ACIFIC AREA 731

F'it• la: 2.,s.- -Met3l plates designed by Colonel Trimble for a protective vest.

In April, a complete set of blueprints of this vest was made in the Office

of tile Surgeon. Fifteenth II.S. Air Force. Also in April, at the direction of

the (Chief Surgeon, I SA\S()S, SWILA, a complete report on the body a rnior

which he had devised was submitted by this consultalnt to the Office of ,cient ific

Research and Development. Washington, with an indorsenieent by General

Denit.

()n 4 August 1945. in a memorandum to General J)enit, (Chief Surgeon,

AFIV ESPA(', tihe author stummarized conferences he had had in Washington

with various ofilcers in the Office of the Chief of Ordnance, Army Service

Forces, and with Brig. (Tel. Edward S. (Creenbaim, USA. Executive Officer,

Office of the Under Secretary of War. tie learned d(ilring these conferences

that. 8,00) vests, 4,000 in a liglit and 4.000 in a heavier weight, were then on their

way to AFPAC l)y slii Ifhil adthat an additional 1(m,1)000 of tihe heavier variety

would beco'me available about I September. A recommen(lation that 400,000

more be produced without further delay had not yet been acted upon.

The surrender of tile Japaiiese on 14 August 1945 liimade unnecessary the

use of the protective vests sent to the Pacific. It is not likely that, these vests

would have proved satisfactorV. They were constructed as a sort of overhead

alpron. with a front and back. and were very awkward to pult on and take off.

More important, tile basic idea of protective overlapping plates liad been discarded ent irely.'i

"The stoiry of litie development of hbodya ariiiiir |i1 the l1'avitie, wiitli ilustrantiis. anld It,. iu'eq i.nt (levl oplimen t and its.c In thie Korean War, is told in griaitr detall Ii: Medical Department.

Uniteid States Army. WVouind Ballistics. Washington: U.S. (,o'iernment l'rinting mflite, 1962. It

14 utfo rtunate thliit thle wearing of protective armlror was not imsliedit as vitgorously ill W orld War I1

as it was In the Korean War. Tbh use, of p'rotective arhor o ulr ld lthn 1i ,tedly ha 1e s' veil nlilly

ll1e% J. 13. V.., jI.

705-°095,_-64- -- 49
IN

I'vo. I P -ch I .. NI .u k I I ii .141. I 7 I , .4.l~

4 141 1 41, t14 1V \t v 1 I1144 1 I l it, I itI I w 1 I ti P' lt i t ofI Nl miii 1 1 jl t' it tt p t I I it 4 11 1 i Ti V 1 %1,1 I'll ,

1 F .)it

1I Ill- o furlll N1111:11 l lu*a ) V '11p-M HillKI M i
SOUTHWEST PACIFIC AREA 733

first medical care on them. Casualties with abdominal wounds were operated

upon on them, with excellent results. Ships' personnel assisted in the care and

feeding of the wounded during their off-watch periods. Returning LST's

transported about 90 percent of the total casualties evacuated during the early

days of the operation, sometimes carrying as many as 150 to 300 on a single trip.

On 6 September and 8 September 1944, in memorandums addressed to the

Chief Surgeon, USASOS, SWPA, through the Chief of Professional Services,

this consultant commented on the plans for the Morotai operation in the light

of the D-day experience in Europe, and made the following recommendations:

1. Medical collecting and clearing company personnel should land with the

assault waves during combined operations. This recommendation was based

on General Hawley's criticism that during the landings in Normandy, only the

1st Division sent its medical troops in early; the clearing company that landed

with it cared for the division casualties and for casualties of combat teams on

either side of it for the first 24 hours.

2. Experienced surgeons should accompany the clearing company personnel. They could be selected from the list of surgical teams, each consisting of

two surgeons and six enlisted men, submitted by the Chief Surgeon, USASOS,

to the Sixth U.S. Army and the Seventh U.S. Fleet.

3. LST's to serve as hospital ships, especially staffed and equipped and

clearly marked to indicate their mission, should go in to the beaches as soon

as the task force commander deemed it suitable. These ships should not be

used for cargo purposes; they should be ready to take on patients immediately

and not have to wait until their cargoes were unloaded on the beaches.

4. An experienced surgeon and two assistant surgeons should be on each

LST to be used for hospital purposes. Present plans of the Seventh U.S. Fleet

called for an experienced surgeon on every fifth LST and a junior medical

officer, with two Navy corpsmen, on each of the other LST's. The beachmaster

was to direct casualties who in his opinion needed major surgery to the LST's

carrying experienced surgeons. The author considered this plan practical only

if the LST's not staffed with experienced surgeons were to be used only to

transport casualties from the beaches to hospital ships lying a mile or two

offshore for definitive surgery. If casualties were to be kept aboard LST's

for any length of time, it was essential that they be staffed by experienced

surgeons. The details of the plans were not clear in this respect.

5. Portable surgical hospitals with the best trained surgical staffs (the

1st, 3d, 5th, 16th, and 23(1) should go ashore about the sixth wave. Evacuation

hospitals would go ashore later, the time of their landing depending upon the

security of the position.

6. Army surgical teams could be used to supplement Navy medical personnel aboard the LST's. The professional training of the Navy medical officers

was not clearly known, but reports suggeste(d that they had had relatively little

surgical experience.
734 ACTIVITIES OF SURGICAL CO}NSIULTANTS

7. Evacuation by air of casualties given definitive care in portable surgical

hospitals and evacuation hospitals should begin as early as possible. In

Normandy, although no air evacuation had been anticipated before D+7 and it

was not expected to be significant before 1)+ 14, air evacuation began on D+3.

8. An oplhthalnologist should be available promptly, as previous experiences had shown that there would be numerous eye injuries.

9. Regularly scheduled conferences should be held by representatives designated by the Chief Surgeon, USASOS, SWPA, and the Senior Medical Officer,

Seventh U.S. Fleet.

Planning for invasion of Leyte

The Morotai operation, because of General MacArthur's strategy in outflanking the Japanese, was accomplished on 15 September 1944 without casualties. Operation KING I, the landings planned for the southern Philippines,

was therefore canceled, and Operation KING II, the invasion of Leyte, was

advanced to 20 October 1944.

The plan was that, during the assault phase of these landings, all casualties

requiring immediate hospitalization would be evacuated by assault Naval craft,

APA's (attack transports) and Geneva-protected hospital ships. To accommodate the casualties, certain changes were made in the structure of the LST's

and the APA's. LST's, each staffed with a surgical team of three officers,

were to care for 75 litter and 75 ambulatory wounded each. LST's without

surgical teams were to transport 15 litter and 15 ambulatory wounded each.

APA's with four medical officers were to transport 150 litter and 250 ambulatory wounded each. Naval medical personnel were to provide definitive surgical care to casualties en route from the target area to the New Guinea bases.

This consultant, with the approval of General Denit, visited the Senior

'Medical Officer, Seventh U.S. Fleet, several weeks before A-day, to review

with him the plans for care of the wounded and the professional qualifications of

the Army and Navy medical officers scheduled to provide definitive care. As

already mentioned, the records indicated that most of them had little or no

surgical training. The Senior Medical Officer had no detailed record of the

professional qualifications of the Navy personnel assigned to this duty, but he

stated that he was certain that they were competent. lie added that some of

them were lieutenant, commanders. The offer made by the author, on behalf

of General Denit, to supply experienced Army surgeons for duty on the ILST's

and APA's was declined.

The elaborate system planned for the Morotai operation by the Navy had

been further expanded for this operation. The wounded would be transferred

to the LST's with due regard for the nature of their wounds and the specialized

personnel aboard the ships, whose presence would be indicated by different

kinds of flags. The beachinaster was to decide where the individual casualty

belonged and was to start him on his way to the appropriate ship.
SOUTHWEST PACIFIC AREA 735

The difficulties ill this plan seemed obvious, and the author pointed them

out. They included the extent of the beaches; the confusion of battle, which

would make identification of particular LST's difficult if not impossible; the

frequent multiplicity of wounds, which would make it difficult for a lay person

to decide which of the injuries was the most important; and the possibility of

hostile air attacks. It was thought that all of these conditions would so complicate this specialized plan of triage as to make it impractical, as indeed it

proved to be.

On 5 October 1944, in another memorandul. to the Chief Surgeon,

USASOS, SWPA, the surgical consultant stated that the Navy planned to

use LST's for hospital purposes only after the cargo was removed. He recommended, as in an earlier memorandum, that these ships zliould be in the

landing force, ready to receive casualties immediately and not after the removal

of their cargo, sin(e a very large number of casualties might well occur during

the assault on the beaches. He also recommended again that every LST, instead of every fifth ship, carry an experienced surgeon pointing out the efficiency of this plan in the Normandy landings. lie recommended that several

l)ortal)le surgical hospitals, staffed with experienced surgeons, be placed on

the LST's which would act as hospitals during the invasion. Ile further recomniended that the portal)le hospitals serve as hospitals throughout the landing operation.

Report on Leyte invasion

ETMD reports from the Southwest Pacific Area for December 1944 described the early surgical care during the Leyte invasion as follows:

In the first phase of the landings, casualties injured on landing craft, after

being given primary care, were transferred to LST's and attack transports

staffed with surgical teams (fig. 287). Those injured on shore were treated by

battalion and regimental aid stations; they were given plasma as necessary,

and the usual first aid measures were carried out (fig. 288).

As the task force units moved inland, medical collecting and clearing

companies began to function. Casualties received primary treatment almost

immediately after wounding, ani then, with little delay, were put aboard

LST's, where blood was available and definitive surgery was undertaken. Although sewn LST's were offshore on D-day with surgical teams aboard, only

two were primarily hospital ships. The others could not take over t.e care

of patients until their cargoes were landed. Attack transport ships could be

unloaded faster than LST's, and they were therefore the firs, ships to leave

Leyte with casualties.

The 7th Division Clearing Company was ashore by H1+6 and performed

ap)proximately 150 definitive operations within the next 48 hours. From

D-day until D+4, however, most definitive surgery was done on Navy craft
I Iirlmir, 2444 h (Ow ~144 1.11.4.

I l -di 1 m Ii NIi l 14 vi Il \\ IIl IfIvI' \V411 I WII I * he' he1', 411 ileI II1' ~ I. I'4 ': ijie wm t ild-

"4 114')-l i ItI'I tI io I a v t' X I I I' l ~ I"t' 4 lt'I Ii VI i I It'I iV 1 11'4)*1v1 411 iio -11 ~~ I' )I 1o 414I~ I I 111111-ý It oit,

I ll114 III( s'tt''i"''t I l mýlt ' o he:l2'.I Il w ih h

L -'F, w r .vI dl' rbu v .'-:I1 ,il th.e ilv tlle i' -
SOUTIHWESTL PAcIFIC AREA77

~S ,'i'~taid mleasures beinig carried out at all aidl

stationi oil the beach at Leyte, 20 October 1944.

4.

F'aw a?: 289)-A dlifficuilt litter carry oil Leyte, inilanid from thle beach.
ii 1: 1.144 . \l ii l'l\A I'1" I' 111. I , 1iIo.t1 II';I' .\ \' . \V'I'

ho' pIi- III. if.-Ii II l11 '

i, iII F .lI I, I illl h .. c I: ' i I 1: 11 1

"_".'I i . I;, t'' ,, ii ."i it .. I \ll I ' , ,',11 i I I', ' III i I, ll I t'-. i41 ,4 , tI I 4I I t' :i I I,i , 

:i~ il ~ ,i l ,,l :, -,. i• ':, '; i, ._, T, • l1,. '1 ,, I- •t ,',111,'11•, I_ 1','- 

':i- i Ii :ill' , -,' 11, 111 :1'141, It I ', I- " II l l , ll: lt4111 . l':11 4i,, 1 1, 1-1 1 :1\ , 14.1" - l1

-, l1 'l4lI , hI'II' 1, 1 I 'I-. .\I4 .\ '-. , ,I .\ I,, I, ' lIi ll liI - l I l 1:111, 111 ' .., 44
s4 it "I' IX J' TI'M 'AI FI( Alt E AI73

F i~am 291. Ieii tutu ill -igery iiia pImiIaiih' Miirgijc.IL iiiisjita.I Leytle Ihiilipille hIsland~s.

1Ž4-; 464. whnic had1( been vovi~iverie for llospital ptin-poses. ,,(i sTr 1112.-P,

which hiiIad irgca Iv&anl al4(iiri but hadl( 11o1 leeil cOilvert ed. carriedl heavy

5Iiiti(icl loadt~s frOmi On o (-a fig. 292). Tlhese txNW4) ships). thle Sixth U11.S.

AriiivN suirlle"Ol st at ed. '-saved t heir 1Ilves' befOrev sulifhi('ilt 1144 1)it al al loll(I waIS

set 11ip ;shiOre to care for Iliev casua~lt ies of theiii Ivasionl.

TIlI Is cmoI sltaI :11. af ter. IIis ex peirieice at Lex-te (p1. 712). (-(it cllid(l I I tli. I I te

IST p rOp erl Y a11 e'ed~Ill aIi I I:1 41dY fulufilled thle ileevlS (Te-ate(1 1bY thle tiew t acicali~

sit ialu On41 that hiad (levelOIped there. Ii ra ~vii g ~sta.wti it.

wasl I itis. ailte red. it was ph-riiiiarily , a hospital slii 1-hOt .1 (rlr(m shipj. used~

seCtilIt Lilvl for hiosplit al purposes. It cOIIld thlerefore reiliutill 011t stat ioit iIII tlie

halbn -:ir ati be avai bible for use at all I IInes. A laiiri io,-mspit al ship iii lie harbor

W~Oiii1 havye seived tit(e saitie p~Imiii44es. 1411 thle risk of its leiving lilt. withI a

]-leltill' il~ ieuINv losof life, niiuide Stich(11 a arrilL,111eiviilt uilIwSe.

P/ann jug for invasion of Japan

Il-reliiiiiii'lar*v mledical pla flIiiiig, fO i tilie pi jecied ( )IPVhIC am11 COROH( -

NET iiis(15of tilie *Jaipillese island~s were begiuil bY G enleral I elil s (Ill*,(-

tions iii .\lav 19(4,'. 'I'lie first of these aildiligs. ()it lKviishili. was schiedulled

for I -NOveliiiler.

()il s MaY1)IS tlie( allitl 1a1':ddressed a1 uInleiioahill(I t 10 (4 Generall eulit . a

s1uiiiiiiiarv Of wVhiich follows.

7W4 44', 61i 4
740 ACTIVITPIES OP SVIHAICAL CONSULT'ANTIS

~ A7q

4I

Fiw~~~ A ~~ ~ ~ mnnigIs ~ -n* 9. -ia od(11igIh xlvivs n .A prtn
60,I

-OP

I'l i 11 2 2 II i III4 . C ls u f 411 e1: 1k 44 1 . I l k-1 f: 11 il 11 -1
742 ACTIVITIES OF SURGICAL CONSULTANTS

An amphibious landing anywhere within range of undestroyed Jap,',ne.-

air bases would be attended by daily attacks of enemy planes upon allied

troop and supply ships. Resulting casualties would be heavy. LST's and

APA's with surgical teams aboard would take care of casualties on D-day

through D±2, but then after having discharged their cargoes, they would

pull out, and their surgical teams would no longer be available. Large hospital ships of the Geneva type would run too mnuch risk by remaining in the

harbor. The establishment of hospitals on shore would not solve the whole

problem, for distances would be great, landing on beaches often difficult,

coin municat ions poor, and transportation scarce for some time.

This situation was first encountered on Leyte (p. 738). Immediately after

that operation, recommendations were mnade iy the Office of the Chief Surgeon, I-SASOS, SWIPA, at this consultant's suggestion, to The Surgeon General by letter and to the senior medical officers of the Seventh U.S. Fleet and

7th Amphibious Force, by interview, that multiple small ships, of the station

hospital type, based on the LST 464 model, be maintained in the harbor at all

times in all similar future operations. Lessons from the invasion of Leyte

and from the Okinawa operation, then in progress, indicated that renewed

and stronger representations should l)e imade for greatly increased numl)ers

of this type of hospital ship to care for Army and Navy casualties in all future

combined operations.

On 10 'May 1945, this consultant sent to General Denit ,' statement from

the Basic Concept of Operation OLYMPIC and pointed out that it was not

clear in it whether the 15 LST's planned as a minimum were to be equipped

as hospital ships, like LST 464, and would be staffed to render definitive care.

The statement that they would "administer emergency treatment and sort

patients for further evacuation" implied the contrary.

The author recommended that these points be clarified. In his opinion,

repeatedly expressed, the value of these ships rested entirely upon (1) their

availability in the harbor day and night, and (2) the provision on them of

adequate equipment and competent staffs to provide definitive major surgical

care. On 14 May, the Medical Section, General Headquarters, concurred in

the proposed use of the LST's; those ships whose primary function was to

provide definitive surgical care would be differentiated from those with minirnal equipment and surgical teams.

On 28 June 1945, in response to a request from the G-4 Section, General

Headquarters, AFPAC, to General Denit, this consultant and IA. Col. (later

Col.) Harold A. Sofield, MC, orthopedic consultant in the Office of the Surgeon, AFWESPAC, submitted recommendations for General Denit's approval

and transmission to the G-4 Section, General Headquarters, AFPAC. A

summary of these recommendations follows.

1. The use of the LST as an auxiliary hospital ship is of the greatest

importance in the care of casualties sustained in an assault, landing; in the care
SOUTHWEST PACIFIC AREA 743

of casualties sustained on shore for the first 2 or 3 days, while hospitals are

being established; in the care of casualties sustained on ships during the

ensuing days or weeks as the result of enemy air attacks; in evacuation parallel

to the beach when roads are obstructed; in triage of the wounded; and in the

mn intenance of a supply point for whole blood and medical supplies.

2. The proposed role of the LST in the forthcoming operation should be

clarified. At this time, it. is not knowin whether the LST's to be used will be of

the hospital type, such as LST 464, or only secondarily for hospital use, such

as LST 929. It is also not known whether the LST will act as a hospital ship

primarily; will carry troops and cargo and, after unloading, accept patients

for definitive major surgery while transporting them to a rear base; or will act

as a sorting station and evacuation point and be used for definitive surgery as

an emergency measure only. If the plan is to use the Geneva type of hospital

ship employed at Leyte, which retired from the combat area as soon as casualties

were received, a number of LST's of the 464 type should be provided, to function

as station hospitals in the harbor and provide specialized care for harbor and

beach casualties. If attack transports are to be employed as hospital ships and

remain with the assault shipping, they would provide definitive care for these

casualties, and the LST's could be of the 929 type, functioning as sorting and

evacuation points and doing only emergency definitive surgery.

Previous experience has shown that two LST's per assault division are

necessary to provide minimum coverage. If the APA's are to retire from the

assault shipping, LST's of the 464 type should be provided in the ratio of two

ships to one of the 929 type. If the APA's are to remain in the area, this ratio

could be reversed. The number of LST's specified would be in addition to

those equipped and staffed to transport wounded from the target area back to

a base area.

3. A careful study should be made of the professional qualifications of

surgeons designated to do definitive surgery. Army personnel should be freely

offered to the Navy when additional experienced surgeons are needed. The

experience of the Normandy landings showed that one experienced surgeon and

two assistants shou1 l be on each ship on which definitive surgery is to be

performed. The surgical personnel of all Army APA's should be carefully

reimterviewed and strengthened by the Surgeon, Port of Embarkation, San

Francisco. If, in the opinion of the surgical consultants, these staffs are not

ade(litate, surgeons from AFWESPAC should be placed on board on recoinmeillationl of tile Chief Surgeon.

On the recomnmenldation of this consultant, Col. Douglas B. Kendrick, Jr.,

MC, who had iimaugurated the blood program in the Office of The Surgeon

General amid who was then serving as consultant in blood and transfusion with

the Tenth iU.S. Army on Okinawa, was placed on temporary duty in General

Denit s office, to make 1)lans for the supply of blood for the invasioim of Japan.

Colonel Kenhdrick was also to orgaiize auxiliary blood banks in Manila and
744 ACTIVITIES 01' SURGICAL CONSULTANTS

on Okinawa to supplement the sup)l)ly from the United States via Guam in

case difficulties of transportation reduced the supply. Lt. Col. Mark M.

Bracken, MC, Chief of the Laboratory Seri-ice, 27th General Hospital, was

placed on temporary duty to work with Colonel Kendrick on the implementation of these plans.

Colonel Bracken was also directed to form medical teams, each consisting

of two medical officers and four enlisted men, from the general hospitals in

the theater, to serve as shock teams in field, portable surgical, and evacuation

hospitals, and clearing companies. This was an entirely new idea in the Southwest Pacific Area, suggested by the surgical consultant to increase the usefulness

of the surgical teams by removing some burdens from them, so that they could

pursue exclusively their work of operating on the wounded.

The planning for the invasion required a knowledge of troop strengths,

military objectives, the nature and amount of medical support, the airfields

to be designated for evacuation, the naval plans, and other vital data. General

Denit's office was given free access to all information, and the medical planning

was based on full military knowledge.

The surrender of Japan in August 1945 made it unnecessary to continue the

planning for Operation OLYMPIC. Planning for Operation CORONET

had not yet begun. To show, however, the immense size of the projected medical

support, as well as the variegated duties and opportunities of a consultant to

help in the whole theater planning, the following memorandum for General

Denit, prepared by this consultant in Washington on 4 August 1945, is quoted:

My dear General:

1. In my notebook marked "Surgery", which I have left with Colonel Baker, is the

latest Information on such items as Blood Plan, Briefing of Hospitals, Body Armor, Hospital

Personnel Equipment, Task Force Study, and Trench Foot.

a. In the Whole Blood Plan, Major McGraw of The Surgeon General's Office made

certain suggestions, as are attached [not reproduced]. A letter from Colonel Robinson to

you states that the Navy will cooperate in every way with Kendrick's plan.

b. I have talked with Colonel Studler of the Ordnance Dept. about Body Armor.

A Major Shaw from his office, and a Captain of Infantry, are already in Manila with

samples of armor. With Colonel Voorhees I interviewed General Greenbaum in the Office

of the Secretary of War. After the conference General Greenbaum prepared a radio for

General Somervell's signature addressed to General Styer of AFWESPAC, stressing the

favorable opinion of the War Department about the armor and asking for early information as to the Theater's needs for it. The latest information on the subject is contained

in my file.

c. Information on the Hospital Equipment problem which you asked me to take up

is contained in this file also in a letter to you from General Bliss on the subject.

d. Personnel. Satisfactory arrangements have been reached about surgical consultant personnel, and Colonel Carter Is having their orders cut. The 5th Surgical Auxiliary

Group should be In the Theater at the present time. Hospitals arriving In the next few

months are:
SOU'THWEST1 PACIFIC' AREA 745

kErpOciid Dalf

Hlospital of .lrriraI

L aI-I' lat Loll --- - - - - - - - - - - - --- 5 (Five) August

Field -- - - - - -- - - - - -- - - - - -- - - - - 1 (Ten) August

Stationl (250 ivt) -- ----- -- - -- - -- -- - -- - :t (Threi e) August

Auxiliary Surgical Group- ------- (Onle) August

Evacuat ioll -- - - - -- - - - -6-- - - - - - ( (Six) September

C'onlvalescenlt -- - - - - -- - -- - - -- - - - - (Onle) September

Clearing Comipaniies -------- 16 (Sixteenl) September

Collect ing ----------------- 5 (Five) September

Aniblxaxicet-- -- - - - - - - - - -- -- - - - - 16 (Sixteeni) Steptembewr

Genieral (1,000O Bed) --------- ----- 41 (Forty-one) Septemiber

Stat ion (75() Bed) * ---------- 5 (Five) Septembelr

St at ion (50t) Bedl) ----------- 16 tSixteenl) September

L'vacizatioii .- - - - - - - ---- - --- - - 1) (Nine) October

n;ieral - - - - - - - - - - - - - - - - - - - - 10 (Tenl) Octobe~r

medicail Professional ( ronu) --- --------- I (Onle) Octobe-r

Stationi (500t))- - - - - - - - - - - - - - - - - - 4 (Four) Octobier

Evacuiatioi-------------------------------------5 (Five) November

Station (5(X) Bed) -------- ------------ ------------- 1 (Onle) -Novembler

General (1,000 Bed) ------------------------- ------ 41 (Forty-one) "Later"

The importance of sending personnel in adlvanlce of T/O hospitals to wvhich they are attahel~d was emphas~flized to Dr. Ginsberg. Ile was likewise advised of the urgent need

to seud replacements for medical officers in the Pacific with three or more years' service

overseas. Three hundred and fifty (350) miedical officers from the European Theater

bave been dlischarged fromt the service, although they do not have so high a number

of service po~ints as (1o offleers; still left in the Pacific Theater. lit spite of Congressional

pressure, it would be fairer to keep men from the European Theater in the Army onl duty

in the Z.I. to release mien from the Z.I. to go to the Pacific as replacemnents.

e. Task Force Study. One of the points wvhich I asked Colonel Robinson and Colonel

KendIrick to) try it) settle in our abseuce from 'Manila was thme consent of time Navy to use

Army surgical teams onl ships carrying battle casualties mnot staffed with experienced

surgeons, lIn a recent comnnmunicationi to you fromn Colonel Robinson it is stated that the

Navy has agreed to t his arrangemient. The dlate of arrival of Geneva Convention hospital

ships at the target has not yet (definitely been estab~lished.

f. Trench Foot. Colonel Gordon and Major Shmaw from The Surgeon General's

Office are already in Manila. Colonel [Gordon] was Chief of Preventive Mledicine in ETO.

Postsurrender Responsibilities

The Japanese surrender

Almost immiiediately after the first, U.S. troops landled ill Jatpanl afl assuimed their oecupation duties, General M~acArthur issued an ordler dlirecting~

themn to carry 110 firearins. Events provedl the. wisdom of this directive. The

sur'rendler of .Japaniese troops was So Complete and so final that. neither mass

nor isolated acts of violence occturred after it. As a result, there were no more

batt le castu alt i es, and~ ocetupancvy of surgical wards consistedl of patients injutred

in traffic accident.- and street. fights. Burns from gasoline-driven equipment

were also f reqilent.
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SOUTHWEST PACIFIC AREA 747

in tile event of major emergencies. It was a wasteful use of personnel but was

the only possible plan under the circumstances.

One of the principal emergencies after the occupation of Japan was motor

traffic accidents, which were frequent and serious on the narrow, poorly lighted

roads traversed by a population untrained in the alertness and rapid reflexes

required by modern motor cars. In November 1945, admissions from this

cause were at an all-time high. At one time, traffic accidents accounted for 38

percent of all surgical admissions at the 165th Station Hospital, with compound fractures heading the list. It was not unusual to receive 5 or 10 patients

at a time over the weekend, as the result of a single accident. On one occasion,

38 Japanese prisoners of war were received en masse when the vehicle in which

they were being moved was overturned.7

Obligation in the Philippines

An unfortunate result of the rapid withdrawal of U.S. Army troops from

the Philippines at the end of the fighting in the Pacific was the hardship it

worked on the Philippine Army, including the Scouts. Medical care of these

troops was very poor at this time, as was the medical care of guerrillas and

civilians, because of the almost total destruction of medical services during

the Japanese occupation. Those who were aware of how many American

lives had been saved by Filipino troops and civilians, often at great cost to

themselves, were much disturbed by the situation.

After observing these conditions, this consultant made certain recommendations to the Surgeon, AFPAC, 7 December 1945, as follows: (1) Provision of additional technicians to supplement the single technician then

working in the braceshop set up in the 313th General Hospital in Manila; (2)

provision of additional technicians to instruct Philippine Army personnel in

the operation of the braceshop sent to the Philippine Army from the Zone of

7 Colonel Trimble. as a result of these experiences, considered the whole question of traffic accidents so serious that, on his return to the Zone of Interior In the spring of 1946. he addressed a

memorandum on the subject to The Surgeon General, through the Director, Surgical Consultants

Division, Office of The Surgeon General. In It, he pointed out that at the time of writing traffic

accidents were responsible for the great majority of deaths within the Army, for the largest proportion of seriously Ill patients in hospitals, and for an incalculable amount of morbidity and permanent deformity. These accidents, he continued, were largely preventable, and. while accident

prevention was a function of the Provost Marshal's Office, he believed that the Medical Department

should assume a share of the responsibility, if only because of its responsibility for the management

and end results of these injuries.

Colonel Trimble recommended that a special committee he appointed, tinder the jurisdiction of

the Preventive Medicine Division, Office of The Surgeon General, to study the problem along epidemiologic lines and to formulate definite and vigorous directives based upon the findings of this study.

The memorandum concluded with the statement that, since commercial transportation companies were

able to hold their drivers to strict accountability in the matter of accidrnts, it was unrealistic to

assume that the Army, with its far tighter control and discipline of personnel, could not achieve even

better results. A similar program had been effective in the Southwest Pacific Area when it waý set up

In the fall of 1944.

No action was taken on these recommendations, on the ground that in the Zone of Interior safety

eonmitltees were alreadly in existence at each post and station and that a medical officer with advisory

responsibility was usually assigned to them.-J. B. C.. Jr.
748 ACTIVITIES OF SURGICAL CONSULTANTS

Interior; (3) transportation of the 20-odd Scouts then in need of prosthetic

appliances to amputation centers in the Zone of Interior, for necessary plastic

procedures and fitting of prostheses; and (4) provision of a supply of prostheses, with a fully trained technician to take the measurements for them, to

provide for personnel in the Philippines in need of surgical care after

amputation.

It was not considered possible to implement these recommendations at this

time, but later, in April 1946, a complete unit was sent by The Surgeon General to establish an amputation center for Filipino personnel.

Japanese Prisoners of War

Until the invasion of the Philippines, U.S. Army medical officers had no

extended contacts with Japanese prisoners of war. This was partly because

prisoners were not taken in large numbers and paitly because they were chiefly

the responsibility, from the medical standpoint, of the Australian Army Medical Department. As the number of prisoners increased, large camps to handle

them were established on Leyte, Luzon, and the smaller islands of the Visayan

group. American medical officers were then detailed to these camps.

Management of a typical camp

Since all prisoner-of-war camps were managed on the same general plan,

the experience of the 174th Station Hospital may be cited as typical. This

hospital took over hospital facilities at New Bilibid Prison from the 21st

Evacuation Hospital on 2 June 1945. The report from which most of the

following data are summarized was prepared at the request of this consultant

by Maj. Joseph T. Kauer, MC, chief of the surgical service., Other data

have been obtained from the report of the official inspection of the station hospital at the prison on 2 and 3 Novemb)er 1945 by a committee of medical officers

of which the author was a member.9

The experience at this camp may be accepted as typical of the experiences

of all similar camps.

During the peak of activities after V-J Day, additional facilities had to

be provided at Luzon Prison Camp No. 1 at Canlubang, 5 miles away from

New Bilibid, and the personnel of the 174th Station Hospital had to be augmented by personnel from the 136th General Hospital (fig. 294). When the

facilities were enlarged, the policy was set up of treating all surgical patients

and all of the more seriously ill medical patients at New Bilibid. Other medical patients and convalescent patients were assigned to Canlubang. Medical,

surgical, and neuropsychiatric patients were segregated.

5 Essential Technical Medical Data, U.S. Army Forces, Pacific, for October 1945, appendix E,

subject: Medical Experiences in Luzon P.O.W. Camp No. 1.

9 Col. I. R. Trimble, MC, Surgical Consultant, for Army Forces, Pacific, through Surgeon, Base

X, and Chief Surgeon, Army Forces, Western Pacific, 7 Nov. 1945, subject: Surgical Care Afforded

Japanese Patients at the 174th Station Hospital, New Bilibid Prison, and at POW Camp No. 1

(Canlubang).
291F; .~J. P'risoni Campi No) I at ( 11111ubang. IAizon. A. .(Iihu'I 'fiel HI)llIs~,evouuI froumu

right, stlIuI(iug), inuspect ing tlue (vlffitiml ofI palu ellf. It. Mediclci silpply.
'-I c()NSULTANTS

.It.

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44 1 4
ACTI'VITI ES OPi SU IM(.ICAI. CONSU'LTANTLS

brodi'OIgetterall cateqVI)1ies.14 icordligi toi thle pr'esentitngI4 syViiiIto011. P1IN .sical1 ex-

~itui lt ions) were ciii1'sol-N111d i Ii iht ii thle J1apim lese 111141 ica I Ilivers were t 1:ighdt

ot~herwvise, I liey exa liii iled diii v 51 g caI ises onil~v .0 adist 1 anjce. r'egarid ing 1111%

other (4111'e 'Is IK'ilea1tl thIeir priofessiouial1 dignity~. Their a1pproachl to IuII

surgical prolems ~s wl~iii st eieot Ypet, auinl they w~ere liiilitleice( b~y t heir Ihast "elleall explerienice far miore 11.1 han 111 inditepiendtent considei'at ionl of tlie pIiysi()

logivca :1da piti Iologica I featuiires of tile pevi' al .:Ise uinder vonlsider't ionl.

.JIilmiwse l)Iwsici'liis neei led a grealt ileal of edthiat iolu inl operatifug roomi

techniquiiies, I'egiiiniiu1" with1 thle pr'eevi'v~ition of sterilit v. They were fitmiliair

"Wit h Iecliii iqhles oif local midl spinal mnalgesial. hult onlY two or: thlree ha.d ever

seen lilit u'aveiioiis aliesiliesia miliiiinistere(l, andI( none of t hentlmi hamd mvi per5011111 exper~ienice wit ii it. Thiey wer'e allso till fanlli ill.a with miiodern i anestbet ic

niachiiniles. '[heY were ignioranit of tile inde 1in 1nsa1l ath.(eter. c-ontinluous

intest ili.1l (Iecoiiijressolon. an1d closed drainag e ill einlpyelia.

Penicill in ineatit noth li.r. to themn eit her as a name or as a thlerzipenii c

agenlt. Tfhey' used sill f umiamidesa mcord lug to standard practives btt dlid not hesitato to place sitl falthljZole p~owder jinto) dlirect conitact with nterve t issute. T]Fluo

use of whole blod10011ad pilasma inl mnadlmitrit iol 'Ind thle use of plasmla for buirnis

and livpopi'oteinlenii were outside of their experience, hu relied onl plivsiologic saIlt. sol ut ion for jult ravenlous thlera1py and I reate(1 shoc~k by the intr i'-

venious adininiistrat ion of camphor. Burns wvere t reat eu by thle It annic acid

mlet hod .

All oft hIese pl-rat ices wvere obviously vbsed oil (Getrriu:i i nuedilc plm'at ices inl

voguie 40yar arir When t hey wvere discussed with them. tilie .1,a pnese

oficers r'epeatedeullv imade tilie point that. thlese pracetices, were far mlore suited to

their economnic sta1tus than1 tilie m1odern alld elabora1te syst em broughtll back bv thle

oVCcasionall phy.sicianls who 11.1l received their t ra iiii ngr inl thle I mI it ed tae.

Their Interest ill these modern prac-tices wahowever, initense. Tlhiey fully

reaflized HIM hateifi Ws iio longrer the fountaidihemd of imiedica limnowledgre

amInd ht tilie pleie of profe ,ssional at t-a inmnetnlt in thle immmuted iate fuitunre would

be set by N thle Uiiited Maites.

Nurses, .\~Nmiises wvere inI such short shlplY :I t 'New Bi Iibid thlat evenl whenl

thley were ain1"mmmemifed bv .[aaies iuises, I hey could be :Issighie only to wurds

il whiichi surgicall patient s a1iid thle Iiiost seriolisiy vIll uiediical pat ieuts Wvere caIred

for'. Th'le work of t hese .Tapanmlese nurIIses waIs genera li saItisfilfctor'y. Thle sevenl

nurIIses wvho hat[ beenl t rainedl;at St. Ludke's I lo~spit.l inl Tokyo and who wvere

us'ed inl tile operat inl rooli is coimillareil faivor'lbd.v. inlt ranliliul .ii 4r11abil it .v. with

U .S.nt rined iiiiise's.

Clinical considerations

The prisoners of war.1 received at Newv Bliiibid P~rison fell into two greleral

group~s, those i'ecei ved before thle .ftapanese suirrender and those received latter.

Manly of tilie Inat ieiit s.aduit ted to thle liospita I wan I4s before V--J Ri vecainle froml

U.S. Armly hiospit aIs, aiid t heir grood condlit ion wa-is in imarked coiitmrst to thle

stati o1 (f the prisoners tnlken di rectly to t he prison ~mi pii), mio~st, of whom were
SOUTHWEST PACIFIC AREA 753

in poor nutritional condition by U.S. standards. Of the 2,395 surgical patients,

about 50 percent had sustained gunshot wounds of various types without fractures; 14 percent had gunshot wounds with fractures associated with

osteomyelitis.

After V-J Day, combat wounds became increasingly less frequent, and the

chief patient load consisted of civilians, including women and children, some

300 or 400 of whom came out of the Luzon hills each day. All of them were

placed on suppressive Atabrine (quinacrine hydrochloride) treatment for malaria as soon as they were admitted. Many of them were suffering from irreversible nutritional and deficiency diseases. Their condition suggested that

of inmates of German concentration camps, and numbers of them died within

a few hours of admission.

Surgical conditions.-None of the l)atients with conibat-incurred wounds

had received adequate care by U.S. Army standards. No wounds had been

debrided, and all degrees of suppuration and gangrene were observed. Fractures, if they were splinted at all, were immobilized only crudely, with bamboo

splints. Very few combat-incurred wounds could be managed by early secondary closure, regardless of the time at which they were seen, because of the

patients' general status. Malnutrition and deficiency diseases p)resented a most

unfavorable background for the management of all surgical conditions. The

treatment of these diseases, in fact, had to take precedence over all but the most

(lire surgical emergencies.

Anemia and hypoproteinemia, even after intensive therapy, retarded the

response to ideal surgical management. Whole blood was used liberally in

these cases, donors being obtained from healthy prisoners of war on work details. Women and children with severe hypoproteinemia were treated by plasma transfusions. There were no serious reactions to these methods.

A few late closures of combat-incurred soft-tissue wounds were done with

good results, but most wounids of this kind were handled better by skin grafting

than by excision and closure. Results of skin grafting were, surprisingly, about

as goo( as among l7.S. Army casualties.

A number of cases of tetanus developed, as was to l)e exl)ected under the

conditions. Two patients died from this cause a few hours after they had been

admitted, and there were two other later deaths in the remaining thirteen cases.

Therapy was by standard measures.

There were also four cases of gas gangrene, one of which was fatal. One

of the remaining patients required amputation of the leg, but the other two

responded to wide incision, in one instance of the lower leg and in the other

of the upper arm. All of these patients received antitoxin.

As a matter of necessity, most surgery after V-J Day was (lone by Japanese

medical officers, U.S. Army surgeons limiting themselves to the most serious

procedures, such as intestinal surgery. During the June-October period of

the operation of the camp, there were 110 major and 706 minor operations, and

245 casts were applied. The lack of surgical experience and judgment of

Japanese medical officers was reflected in the 33 appendectomies done by them
754 ACTIiVITIES- OF SURG(ICAL. CON$UvrAxTS

inl Octob)er for supposed acute disease. Only 11 of these patitents really had

ateappIenidicitis, and the elenientary Io io f aseptic te~cliflitiiie p)ossessed

by- the J apanese surgeons w-as evident inl the 12 percent incidence of infected

wound( s.

Beriberi abscess.-An entirely niew -liniical ent ity t( new, at least. to 1-.S.

Arly medlical officers) .-as olservedi hin many of these patieits. so-called berib~eri

abiscess. The infect ion, which occurred onl the lower ext reunitv. usuially in thet

anterior t ibial area or onl thle (orsuin of the foot, began as anl extremely soft.

fluct mmauit swvelling". Neit her rhhl)4)r nor calor. was p~resenit. and teniderness Was

not1 signifiicanit. Whele tile swelling. was incised. silbcuit anHeos puis was released:

onl]y inl ]olongstanding cases was the fascia involved. Thle pus was thick, yellow,

andi of t lie typical Sb'phg1ococewx tyvpe, but tilie et iolo,(%v was not establishiedl for

the circumstances were not favorable for bacteriologic studlies and none wvere

mnade. riie al)scess cavity- was hled with niecrot ic suilelitanleolls tissule, and in

no misto-liecouldda dletinlite wall be demiouti ratedl.

As a rule, these abscesses appeared hin extremities that. were or had been

tlie site of Seriouls nuit iit iomial edelma. inl two instancves, tile edenia was so intense.

that necrosis of h le skini oeccurred. Their etiology was never clarified. It "-as

concluded that edenia, alt hough it wa~s probably not an essential predisp)osinig

factor. apparently favored the gro-wthl of orgranismls which had entered the

skini by way of tlie abrasions and scabiet ic lesions so promiinenit amiong t hese

patients.

Eraluation of medical care

Uponi orders of the Chief Sitrggeoii AF1'.kC, the prison camips at New

Bihibid and Canlubang were visited oil 2 and 3 November 1945. by a committee

of medical officers consisting of Col. Alb~ert R. 1)resibach, MC. chairman. Lt.

Col. Clarke If. Barnacle, MC'. recordler: and the authior.lo The objective of the

inslpection wvas to determine wvhethier the miedical care andl general treatment of

sick and wvounded Japanese prisoners of war and internees at these installations

accordled with the provisions of the Geneva. Convention. The committee report

wvas entirely favorable; both mnedical care and general treatment. including the

diet providedl. fully confornied with these Provisions. 'Not a fly was seein in

either camp.

iThe findings of this committee were iin agreement with those of BrigM. Gen.

Ifugh J. Morgain. and Col. Francis R. Dieuaidle,.NMC, who had v-isited the camps

previously as representatives of The Surgeon General, U.S. Army.

These formnal rep~orts confirmied the information ob~tainied onl informal attemp~ts to gain Somie idea of the attitude of the patients ili the cami-ps towvard

'U.S. Armiy p~ersonnuel and of their reaction to the treatmnimt which they wvere

cecei'-ing~. Interpreters were directed to imake inquiries along these linies at.

t imes wheni U.S. niedhical officers were not onl (lie wvards and were also instructed

to replor't Oil conlversa tionsa among thle pait lents.

"I Se'e footnote 9, p. T748.
SOUTHWEST PACIFIC AREA 755

Without exception, the patients were very grateful. Some said that discipline in the U.S. Army must be very strict, since they had never seen a commissioned or a noncommissioned officer strike a patient. Many expressed

amazement that American medical officers themselves examined and dressed

their wounds; in the Japanese Army, this was the duty of the corpsmen. They

also expressed amazement that. American medical officers answered night calls.

These and other instances of what Western physicians conceive of as only

normal medical care were to these prisoners signs of kindness and consideration

which were evidently unique in their experience. Their army training had led

them to expect only brutality and neglect from their own nationals, and propaganda had led them to expect the same kind of treatment from their U.S. and

other Western conquerors.

Lessons of the Pacific Fighting

Certain conclusions set down by the surgical consultant in the Southwest

Pacific Area after his return to civilian life may be summarized as follows:

1. It is strange that such an obvious principle as that of early and expert

definitive surgical care was not, automatically adopted at the beginning of

Worldl War II, when experts in tile various surgical specialties joined the Army

in such great numbers. It was slow to be adopted in the Southwest Pacific

Area, chiefly because the value of the consultant system was slow to be realized.

Consultants were assigned to headquarters in the smallest possible numbers.

There were no consultants to the armies operating in the Southwest Pacific

until after the landings in Leyte, in October 1944. The surgical consultant in

the Southwest Pacific Area was permitted to participate in the attack on Ikyte

but was refused permission to accompany the transports in the attack on Luzon.

More intimate contacts between theater and Army consultants and surgeons

would have enhanced the efficiency of medical care of casualties.

2. At the beginning of the war, there were only a handful of expertly

trained clinical surgeons in the Regular U.S. Army. To the end of the wvar,

there was still a scattered lack of appreciation of the difference between a medical officer de.gignated to do surgery and a medical officer trained to do surgery.

In the ,Pacific, at least, there was only slow realization of the extreme importance

of the wisdom of sending experienced surgeons of mature judgment into forward areas and assigning younger, less experienced surgeons to base hospitals,

where they could work under supervision.

3. The chief (luty of the surgical consultant in the Southwest Pacific Area

was the assignment of good surgeons to serve as chiefs of surgery in the 1x)rtable

hospitals supporting the various landings. This was an extremely difficult

task because of the p)aucity of well-trained surgeons in the Pacific: practically

all of them were sent. to the Mediterranean and European theaters, or were in

the Zone of Interior.

4. Tile vast distances in the Pacific greAtly coinplicated mlledical care of

casualties. Sometimes 2,004) miles separated the target area and the Ipint from
756 ACTIVITIES OF SURGICAL CONSULTANTS

which an operation was mounted. In hops to small. isolated islands, there was

no such thing as a chain of evacuation. Definitive surgical care had to be given

on the spot. Specialized hospitals were accepted as a practical possibility only

after the PhiliI)ipne invasions.

5. Distances in the Pacific also made communication extremely difficult.

Brig. Gen. Elliott C. Cutler, MC, Chief Consultant in Surgery, Office of the

Chief Surgeon, European Theater of Operations, U.S. Army, stated that he

could sit at his desk at headquarters in London and within a few minltes reach

by telephone the commanding officer of any hospital in England or on the

Continent. In the Pacific, even radio conmmnication was not possible, and

most business had to he. conducted by mail. Attempts to transfer medical officers might, take a mouth or more. A visit l)y plane to hospitals in the various

bases might take a minimum of 2 weeks, partly because of waiting for priorities

and the vagaries of the weather; the visit itself was likely to consume the smallest part of the time period.

6. Evacuation of casualties in the Pacific fighting was always a p•,,blemn.

Portable surgical hospitals were sometimes miles alhead of the artillery pieces

going into the jungle. The hospitals would follow the infantry and set up a

few hundred yarls from the enemy. Evacuation was necessarily I complicated

process. It was first by litter, sometimes borne by natives but more often by

Army litter bearers because the natives (lid not like to go forward. Then

native litter bearers would take over later. Sometimes, evacuation was by

ox-drawn cart or by amphibious vehicle.

Air evacuation, which was an outstanding success and solved many of the

prol)lems of transl)ortation in the Pacific, came late in the war.

7. Surgical teams were proposed very early in the Pacific fighting by Colonel Parsons, first Consultant in Surgery in the area, but the plan was not

accepted until April 1944. Auxiliary surgical groups never served in the

Pacific; all of them were sent to the Mediterranean or European theaters.

Portable surgical hospitals helped to solve the problems of forward care of

casualties but did not prove an entirely accel)table solution. Specialized hospitals, as already mentioned, were not permitted until the Philippines were

invaded and never really fulfilled their possibilities.

8. The difficulties of surgical care of casualties in the climate, terrain,

and vast distances of the Pacific areas were probably never fully realized in

the Office of The Surgeon General because there were no really intimate contacts between that office and the Pacific. The single visit, during the course of

the hardest fighting, was by the Consultant in Surgery in that office and was

very brief. The only other visit, by The Surgeon General, was also brief and

did not occur until after the Philippines had been almost secured.

9. The difficulties under which medical care was accomplished in the

Pacific are unlikely to occur again. For one thing, the value of the consultant

system is now fully appreciated in the Medical Department of the Army and

is firmly established in it. For another, the Medical Department has set up
SOUTHWEST PACIFIC AREA. 757

residencies in its largest hospitals in the various specialties and is thus assured

of a supply of fully trained medical officers in the event of another emergency.

10. Far and away the most valuable surgical lesson learned by the U.S.

Army Medical Corps during World War II was not the use of penicillin, or of

large quantities of whole blood, or of evacuation by air of the wounded-great

as these advances were. The most valuable lesson was the realization of the

validity of the concept, well known to all trained surgeons, and also learned

and then forgotten by the Medical Corps after World War I, that the mortality

and morbidity of combat casualties can be reduced to a minimum only when

mature, highly trained surgeons are available in forward areas of combat.

The consultant's own experiences, both triumphs and disappointments, and

the similar experiences of others, bear out this concept. Any acceptable plans

for surgical support of future operations must follow the same principle. If

any plans contain even the possibility of delay on the availability of immediate,

definitive surgical care by surgical experts, they should be discarded forthwith.

I. RIDGEWAY TRUIMBLE, M.D.

ORTHOPEDIC SURGERY

Maj. (later Lt. Col.) George 0. Eaton, MC, reported for active ditty on

20 April 1942 as chief of the orthopedic section of the 118th General Hospital

(fig. 297). Less than one month after activation, the unit proceeded to the

west coast and embarked for oversea duty. After approximately one year of

hospital duty at Sydney, Australia, Major Eaton received orders placing him on

duty in the Office of the Surgeon, USASOS, SWPA, as the Consultant in

Orthopedic Surgery. Headquarters at that time was at Sydney, Australia,

but was almost immediately moved to Brisbane, Australia, approximately 500

miles closer to the combat zone in New Guinea with still some 1,700 miles

intervening.

Functions and Activities

The orthopedic consultant served first under the direction of Col. Win.

Barclay Parsons, MC, Consultant in Surgery, I.SASOS, SWPA, and later

under Colonel Parsons* successor, Col. I. Ridgeway Trimble, MC. lie -\as

charged with the responsibility of care of wounds of the extremities and spine,

in addition to nonbattle injuries, which were at least 10 times as frequent.

The nonbattle injuries closely resembled civilian pra,.tice as regards clinical

management, except that transportation and evacuation policies had to be

integrated with treatment of fractures and soft-tissue injuries.

At. the beginning of the war in the Pacific, the reason for having consultants was little understood by those in command positions. When rep)orting

into a base in the forward area, courtesy, convention, and orders required his

reporting to the commanding officer as well as the base surgeon. It was the

exception rather than the rule that the mission of the consultant met with the

enthusiastic approval of those key officers. The fact that the consultantCs
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SOUTHWEST PACIFIC AREA 759

commanding officer to permit the reassigmnent of two of his three good orthopedic surgeons to units that had none, his answer was that his unit represented

their alma mater and was not to be molested no matter how urgent the need

was elsewhere.

The Southwest Pacific Area included all Australia plus New Guinea and

the nearby islands. A consultant's travel was almost entirely by air. The

usual procedure was to request approval to make a consultant trip when such

a move was indicated, and orders were generally promptly approved and

issued. Such a trip would include visiting all army hospitals in a given area,

so long as they were operated under command of USASOS, SWPA. If the

unit were under command of the Sixth U.S. Army or the Eighth U.S. Army,

the USASOS consultants were out of bounds unless especially invited by the

army command. A visit to a general hospital would consist of a 1-, 2-, or 3-day

visit, seeing all cases, approving or criticizing management of cases, giving

teaching ward rounds, spreading information as to newer development in the

management of specific problems, and, sometimes, explaining the rationale of

directives and technical memorandums. In smaller units such as station,

evacuation, and field hospitals, the orthopedic consultant's obvious duty sometimes was to teach a medical officer who was not especially or adequately

trained in orthopedics how to manage the usual orthopedic problems. It

should be mentioned in passing that the station hospitals, field hospitals, and

evacuation hospitals performed essentially identical missions in the Southwest Pacific Area. The smaller units seemed to value the visit of a consultant

and made him feel very much needed. The opportunity for teaching by working several days with an incompletely trained medical officer presented itself

very frequently and was utilized to the great advantage of the patient (lig. 298).

Management of Patients With Low Back Complaints

The Southwest Pacific Area was a wide geographical area, and this fact

led to the development of many minor changes in the treatment of the wounded

and injured because of geographical factors and evacuation policies. It was

necessary to develop a working rule for the management of patients with low

back complaints. The incidence of such complaints seemed to increase whenever service became less attractive and sometimes when it became more hazardous. Some of the younger medical officers who were incompletely trained

did not feel free to take on the responsibility of sending a patient back to duty

if lie was complaining of disabling, low back pain.

It became necessary to define by a technical memorandum the recognition

of spondylolisthesis by X-ray examination and how to avoid making a diagnosis of spondylolistlhesis when none was present. Spondyloschisis was also

frequently discovered in the study of a patient. In the case of spondylolisthesis, the recommendation was made that such patients be evacuated to the Zone

of Interior for disposition, with the application of a supporting plaster jacket

and with the lumbar spine in mild flexion for transportation if pain was severe
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SOUTHWEST PACIFIC AREA 761

or displacement very marked. A patient with preslipped spondylolisthesis,

or spondyloschisis, if the condition was accompanied by moderate or severe

complaints, was also recommended to be returned to the Zone of Interior.

Congenital anomalies of the spine (such as spina bifida occulta, sacralization of lumbar vertebrae unilateral or bilateral, lumbarization of sacral vertebrae, six lumbar vertebrae, ununited accessory ossification centers in the

transverse or posterior spinous processes) were found with approximately the

same frequency in patients with or without low back complaints. The discovery of such anomalies was not sufficient reason to hospitalize or change the

duty status of the complainer, and it was necessary to spread the word that

the discovery of such anomalies was not to be given weight when deciding on

the disposition of a patient. It was recommended that the degree and reality

of the disability in the function of the back, as determined by positive physical

findings, should in such cases be the basis for decision in regard to return to

duty, reassignment, or evacuation to the Zone of Interior. The rule was gradually developed that the medical officer would use the diagnostic facilities at

his command for the investigation of a low back complaint and, if insufficient positive objective findings developed, the officer was to send that soldier

back to duty rather than to send him to a rear and larger hospital for more

exhaustive investigation of his complaint.

Evacuation Policy

In the early part of the war, the evacuation policy was determined by

the relative frequency of opportunity to send patients back to the Zone of

Interior by water. Air evacuation had not yet been developed. Consequently,

the policy was that a patient who could not probably be returned to duty in

90 days should be tagged for evacuation to the Zone of Interior. It frequently

happened that the patient would remain in a rear base hospital for 30 to 60

days awaiting transportation by ship to the Zone of Interior. As transportation facilities improved and as air evacuation became more prevalent, the

evacuation policy was gradually reduced to 60 days, then to 30 days, and

even less.

Transportation of Fractures

The following rules were laid down in the treatment of fractures admitted

to any unit forward of the hospital that would give definitive treatment prior

to evacuation to the Zone of Interior. Three essentials were named: (1) The

treatment of shock, (2) care of the soft part wounds, and (3) immobilization

for transportation. It was estimated that about 68 percent of battle wounds

were of the extremities. About one-half of these were fractures, so that some

34 percent of battle wounds were compound fractures. Attention to length

and alinement, although desirable, was not stressed if it jeopardized any of

the three main essentials, prolonged the operative time, or involved manipulations which predisposed to infection. The main difference between military

and civil practice was the necessity for transporting the soldier. Transporting
762 A'CTIVITIES OF SU'IRGICAL CONSULTANTS

involved jolting which caused shock, shifting of the tissue phlaes, bleeding,

the accumulation of fluid i1 dead spaces, and infection. A lapse of 2 or 3

weeks after infliction of the wound was not too long a delay before the successful restoration of length and alinement could be obtained in the ordinary compound fracture encountered in combat. This statement is not to be taken to

mean that the bone wound was unimportant. The first. stage of bone repair

depended on vascularized tissue from the surrounding soft parts. The later

stages involved actual bone repair from the bone ends which therefore had to

be in contact. After transportation to a hospital where the patient could be

kept for the required period, the bone wound assumed importance equal to

that of the soft parts. Since all major fractures required prolonged hospitalization, they were to be evacuated to the rear as soon as their condition permitted.

The Thomas' splint was useful for the transportation of cases of femoral

fracture from the battalion aid station to the first hospital for definitive treatment. It. was not recommended and was not used for further transportation

to rear echelon hospitals as it did not provide the essential complete immobilization. Any of the methods of applying traction through the Thomas* splint

during extended transportation were unsatisfactory. The Tobruk splint,

which was developed in the famous defense of Tobruk in the 'Middle East,

was publicized for a while as an excellent method of management of compound fractures of the femur but proved to be entirely unsatisfactory. Properly applied, a one-and-a-half spica cast was the method of choice for the

transportation of femoral fractures, and other long bone fractures were transported in a solid plaster cast which was split the entire length of the limb. In

applying the cast the optimum position of the fragments was obtained if easily

accomplished, but it was again emphasized that, for transportation, inmmobilization was relatively of far greater importance than the position of the fragments.

To avoid the needless and often harmful frequent changing of casts, a note

was made on the field medical record as to any anticipated or feared complications, or if, on the other hand, evacuation without changing the cast could be

expected with confidence. Plating and operative fixation of fractures in any

of the forward units was discouraged because of the likelihood of infection and

tile danger of damage in transportation. The journey to the base hospital was

begun by the patient with a compound fracture after shock therap)y had been

completed, the wound had been debrided, and the fracture immobilized. In

the early days of the New Guinea campaign, the distance was about 1.500 air

miles, and evacuation might be by ship or plane with numerous stops and ambulance rides en route. Stops would be made at military hospitals, and a

tendency developed to change the cast at each stop in order to observe and

report the condition of the wound. For this reason, the rule was made that

a patient would not be subjected to change of cast if his temperature was norinal, the injured limb comfortable, and the circulation in the toes or fingrers

normal. This rule proved to be satisfactory and practical.

All patients with compound fractures had a normal expectancy of not

returning to duty within 4 months and were therefore destined to complete
SOUTHWEST PACIFIC AREA 763

their convalescence in the United States. Treatment in skeletal traction of

compound femoral fractures in forward units, such as field and evacuation

hospitals, had to be discouraged and eliminated. There was too much risk

of attack by air, in which case it would not have been possible to put the patient

into a, protective slit trench. Thus, the only place in the oversea theater that

a, compound fracture of the femur could be safely treated in skeletal traction

was at, the rear base hospitals, out of reach of possible enemy air attack. In

the later days when air evacuation became available, the patient was returned

to the Zone of Interior in his plaster spica cast by air evacuation and put up

in traction after arrival and assignment to a hospital in the United States.

The exl)erience in the Southwest Pacific Area with the immediate open

reduction of simp)le shaft fractures was not good, and the routine use of open

reduction and fixation as an elective method of treatment was discouraged

and frowned upon. In the forward areas, in field hospitals operating under

tents, in the jungles, or around air strips, contamination and infection played

too big a role to justify the hazard of open reduction as contrasted with the

relative safety of closed reduction.

The transportation of compound fractures of the humerus in traction

by means of hanging casts proved to be. so unsatisfactory that the Air Transport Command announced that, such patients would not be accepted for evacuation. The lack of immobilization led to swelling, bleeding, and pain and markedly increased the problems connected with the evacuation of such patients.

The only exception to the rule of not transporting patients in traction was

in the case of guillotine amputations. The maintenance of continuous, even

traction of the skin during evacuation of amputees was considered to be of

the highest importance to the end result of such cases. The use of elastic traction proved to be more effective in maintaining a continuous, even traction

during evacuation. Accordingly, an elastic cord for traction was provided

through medical supply sources, and this item became available on requisition for use in the transportation of amputees. The cord was constructed of

multiple rubber fibers and was supplied in a length of from 8 to 12 inches.

which was sufficient length for a single case.

Classification and Selection of Patients for Evacuation

In order to expedite the evacuation of major clinical problems to rear area

general hospitals for further study and treatment, station, field, and evacuation hospitals were advised to classify selected cases for evacuation to a general

hospital. The evacuation of such cases was ordered not to be interrupted at

subsequent station hospitals en route except when the patient's condition was

such as to require immediate interruption in the transportation journey. Tie

fact that the general hospital type of treatment was imlicated was shown by

placing "Gil" in red on the roster immediately preceding the name and number of the patient and on the face of the field medical jacket just above the

patient's name. In general, major orthopedic conditions, including fractures

705-095,----64---51
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SOUTHWEST PACIFIC AREA 765

imnprovement over those of World War I in the rate of survival and the escape

from permanent crippling disabilities of individuals suffering wounds of the

extremities. This improvement will be primarily the result not of advances

in chemotherap)y but rather of advances in shock therapy and in wound management. Further improvement will be possible.

The command and administrative branch of the Medical Corps must take

a more active interest in the clinical welfare of the patient. The visit of The

Surgeon (General to the Pacific areas in the early months of 1945 was a most

powerful and pleasant stimulus to the average professional medical officer.

H[ere was the highest ranking medical officer in the Army of the United States

on a tour of inspection, making clinical bedside rounds, and giving helpful instruction and criticism to the ward officer. The consultant system, begun in

World War I and enlarged in World War II, is the key to improving the quality of medical service rendered to patients. Particularly in the more forward

areas, the average young surgeon is loaded with more responsibility than he

has been trained to assume. He is notably conscientious and anxious that his

l)atients should receive the best possible treatment. He is unable to follow

the patient's progress after evacuation. Circulars and memorandums have a

way of not reaching him. Only by the visits of consultants can he learn of

his errors and of new methods and procedures.

Military surgery has made great strides, but even more progress will

be made if more emphasis is placed upon the quality of professional accomplishment. Command and administrative officers in the Medical Corps should

look upon the consultant as a teacher rather than an inspector and should not

use the consultant to check on activities other than those directly related to

the welfare of the patient. Provision should be made in the tables of organization for appropriate rank for consultants. Officers commanding medical

units should be expected to place a high degree of importance on the quality

of the medical care the patient in his unit receives instead of being nearly entirely concerned with the impeccable management of utilities and visits of Inspectors General.

GEORGE 0. EATON, M.D.
CHAPTER XIII

From Auckland to Tokyo

Ashle~y W. Oughterson, M.D.

INTRODUCTIORY NOTE

vlie material iii this chapter is dlerived fromt the official wartimle diary of

the late Ashley WV. Oughtersoni, M.D)., and is Ipresontedl inl substantially the

forml in which the thenl Colonel Oughterson prepared it. Thle original plani was

for D~r. Otighterson to write this chapter, front his (diary and other official

papers. With his untimely death, that plan became imipossible, amid, sincve no

one0 else possessed thle infornmationl, thle b~est. Solution seemed to he to use thet

material hie had recordedl (during fthe war.

I)m'. Oughterson, Clinicial Professor of Surgery at tlte Yale Vi iversitv

Medical Schtool, enteredl active dluty in the Medical Corps of thle U.S. Arily in

.Jamuarv 19)42 as a lieutenant colonel (fig. :300). His first assigmuent took lhimi

to the Airmy Medical School, Walter Reed Arnmy 'Medical Ceniter, Washinigtonl,

D).C. From April to June 194, li was at lIA)ell General Hospital, Fort

I )evens, Mass., as chief of thle surgical service. lHe wats next, assignied to the

39th General Hospital, a medical unit sponsored by and affiliated with thle Yale

IUniversity MNedical School. The unit, wats stagedl at. Camp EdAwards, Mass.,

and was subsequently shipped to New Zealand. where it established facilities

at Auckland in November 1942. Colonel Oughiterson served as chief of tile

surgical ser~vice of thle, 39th General Hospital until Marchi 19431, and then as

hospital commnandler until *July of the same year.

It was after this experience that Colonel Ouightersoni received his first. assignmuent, as at surgical conulntant. As the tempo of lightinig inl thle Pacific

accelerated, lie wats moved fromi one key assignment. to another, wherever thle

services of at medical officer of his capabilities were urgently needed. Aks at result, Colonel Oughterson eventually served as a surgical conisultanit in every

major command in the Pacific theater of war. His account, muay overlap portions of others in this section on the activities of surgical consuiltants inl the

Pacific -areas, but~ his outlook and perspective dlifferedl somewhat from those

whose interests were p~erhtaps more. parochial. Related accounts are. also presented Iin chapters XVII and XIX of "Activities of Surgical Consultants, Voltime I" of this historical series. These chapters, by Dr. Frank Glenn mtnd D~r.

Frank .1. McGowati, respectively, p~ertain to consultation in surgery ill thle

Sixth aimd Eighth U.S. Armies, which served in the Southwest Pacific krea.

767
768 ACTIVITIES OF SURGICAL CONSULTANTS

The diary material has been compiled and edited by Maj. James K. Arima,

MSC, and Pfc. Jacques Kornberg of The Historical Unit, U.S. Army Medical

Service, but editing has been kept to a minimum.

Since this account was prepared, for the most part, fro)m handwritten

notebooks maintained by Dr. Oughterson during his war service, as Editor-inChief of the historical series, I considered it advisable to have the manuscript

reviewed by the former chief surgeons of the commands in which D)r. Oughterson served. They were Brig. Gen. Earl Maxwell, MC, USAF (Ret.) Maj.

Gen. John M. Willis, MC, USA (Ret.) ; and Maj. Gen. Guy B. l)enit, MC,

USA (Ret.). These reviewers were asked to verify the general authenticity of

Fwi(;uF 300.--Col. Ashley W. Oughterson,

MC.

Colonel OuglitersoWs statements, and, especially, to add any comments whereever their broader knowledge of the events discussed utiglht place tile data in

better perspective for the reader. They were also asked to review the manuscript in the light of subsequent events, just as D)r. Oughterson might have done

had lie lived to do so himself.

The general comments of these reviewers follow in this introductory note.

Their comments on specific passages are included as footnotes in the appropriate places. The reviewer making the comment. is i(lentifie(l by his initials.

With respect. to the entire manuscript, General Maxwell commented:

I have made very few corre(.tions or coinmeits since it |the (liary l was so tyypi(.ally the

thomghts of such a great organizer. To chanlge the wording or to delete some of his c.ilst i.

remarks I t hink wouhl detract from tihe' entire theme of tlie mnanus(ript.

I will assure you that the entire distry is exactly ihfe thilukilug of at mautuire mind on a

very difficult subject. D)r. (h)ght erson, or "Scotty" its wi' ill callehd him, i.elievetd in saying

exa(etly what he thought anid I believe if lie could l1have edited tlis mnaunuseril)t he would

still think aiid wrilth I a1uu context.
FROM AUCKLAND TO TOKYO 769

General Willis wrote:

I do not inean to be disparaging toward Colonel Oughterson's service, because I think

he did a magnificent job. I do not. however, believe that he realized that the tactical use

of medical units had been a subject of study by experienced officers ever since the end of

World War I. nor do I believe he realized that these tactical units were "personneled" by

officers of little military experience, and necessarily there were many square pegs in round

holes and vice versa. These could only be "fitted" by removal from one place to another,

involving transportation which was at a premium.

* * * I firnly do not believe in placing the highly experienced surgeon in the Battalion

Aid Station or even an Advanced Surgical Hospital. I think they could be of greater use

to a greater number further back.

In explanation of the latte:" oint, General Willis noted: "[Dr. Oughterson]

entered active duty * * * with a wide experience in peace-timle general surgery.

Unfortunately, there were too few suchi qualified surgeons and even fewer who

were available to the Military Service." Had the type of surgeons Dr. Oughterson desired been provided, as he advised, in sufficient numbers "to man the

Clearing Stations, the Portable Surgical Hospitals, the Field Hospitals, and

the Battalion Aid Stations, the evacuees at the general hospitals, both advanced

and at home bases, would have suffered, and many of those still training would

never have arrived at the front to relieve the tired and wounded already engaged in combat."

General Willis also noted that certain conditions in the western Pacific in

late 1944 and early 1945, upon which Dr. Oughterson had commented adversely, existed as a result, of policies and practices in effect, before his (General

Willis') arrival on the scene, and "everything by that time had been formulated

and was going." Moreover, General Willis informed me in a telephone conversation on the Oughterson diary in February 1959: "1 * * I arrived in

Hawaii around the middle of November in "44 and left there on the 31st of

January or the 1st of February with Kirk, Simmons, and Welch and that group

down there and went over to the South Pacific. Of course I didn't have anything to do with the South Pacific-but it, [the tour] did include Saipan and

those places, so I went with them to see that, and, being with them, I had to

go all the way around."

Another point is evident from General Willis' remarks, that, when Colonel

Oughterson was himself in the Marianas, he might not have been fully aware

of the planning that was going on in H-awaii and also might not have appreciated the time required to put theater plmns into effect so that results

would be noticeable at the working level where he was. He might, General

Willis thought, have taken into more consideration the fact that many of the

problems that faced the medical service in the Pacific existed, and continued

to exist, as a consequence of circum••'aces outside the control of the Medical

Department.

Finally, General Willis wrote: (1) "Tie early sections of Col. Oughterson's

report deal with observations, comments and criticisms without giving the

credit to the younger and lperhaps less talented mnedical officers who were work-
770 ACTIVITIES OF SURGICAL CONSULTANTS

ing ini the most unfavorable conditions, but nevertheless were giving everything

they had"; (2) "The routine 1/1⁄4 gr. of morphine, the too-tight plaster bandage,

the poorly kept records and the failure to transmit themn with the patients

were the results of 'hurried-u1p training' at the home training centers, but such

was necessary because of the pressing need of replacements;" and (3) the slow

evacuation sometimes evident in the Pacific was "the result of the lack of sufficient transportation and t he distances involved."

General D)enit's comments were as follows:

Thank you for letting me see Colonel Oughterson's manuscript. I am glad it is to be

published. I think it is very interesting. I wish I had been able to keep notes as he did.

My general conmnent is that I am not inclined to take exception to anything he has to

say. After all he gives the picture as he sees it.

Let me say here about any medical history of the Pacific Areas, the organization of

the l'acitic WvasSo4 complicated that in order to understand how the medical services functioned, one would have to study the overall administrative volumes of the history of each

headquarters of the Pacific Areas. To do this would require ninny months of study.

Therefore. to write a correct history and to find out who did what in the various medical

headquarters would be impossible unless one had had experience in all areas of the Pacific.

Now take General MacArthur's headquarters. Ile did niot of his fighting with so-called

task forces. The CG of the task force, most often General Krueger, but not always by any

means, wouhl determine his needs to carry out his missions. This of course included medical units. I soinctinic. got a chance to review and comment but no amount of pleading

could change things if the CG. task forces, ruled otherwise. Of course I never thought

enough medical meatns were provided. ()! vii I was right.

Then when the means in wv;:- of organizations were provided, the task force commiander would not force his engineers to build minimum facilities for the hospital. Hence

my remark [1). 8521 that the Army wouldn't obey orders. Many times, in fact at all times

the engineers were way behind schedule in helping the medical service build its own hospitals. But uch is war in the jungles. No one who hasn't experienced it can believe the

difficulties encountered.

For instance * * * the Signal Officer * * * was next to General MacArthur and had

his ear. In every area he got the high ground for radio; I took what was left. Not only

that, but lie said our X-ray and diathermy machines caused interference with his sending

and receiving conmnunications. so we had to be a certain distance from his installations.

Hence the frog ponuds for hospital areas. In truth, though, all areas at certain seasons

in the tropics are mud holes.

I wish it were possible for me to tell of how the complex organization made it impossible

for the Chief Surgeon of the American Forces In the SWPA [Southwest Pacific Area] and

USAFFE [U.S. Army Forces in the Far East] to force upon the various commands his

ideas. Even when his recommendations to GIIQ were accepted they were not carried

out by the task force commanders. Possibly in a number of Instances tactical considerations governed.

I will say this. The medical service knew what It wanted, its planning was good,

and, considering all factors, the medical service of the Southwest Pacific Area was superb.

General MacArthur said so repeatedly.

I had a grent admiration for ('olonel Oughterson and gave him the job of "thinking"

and advising me on how surgery nod ,are of the wounded could be Improved. I didn't

want him to have any adnmitini r -•i i%, uthority. I wanted him to (1) see, (2) think and

(3) advise. Often when wit- ry'l,- - (orrec.t lie loses his value as an adviser.

* * *n *
1 UI.I 1,-P I I . 11 1i 1:i v4r 3 a 4)1 T 01411:C lt 1 I ii r iidd New Col vdmfi( a .- Aii a le 191.e.lii . iIli

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Col. .J14,1N liovi C( OvrIs. .1 ...MC. U SA

T~ik B21 (tl'illa t 030.Dow atToitmiiia. AlWividP~li. I (Aiiwi Io 

(.1ii1iiteieuI at Noliiiiiea~ I 1 lvidqu(Itiiers fiw I SAFISI4 A -was aM NotiuiI;t.
77-2 CIVITIVII: (ii.' cIIt)(\I fNSII.I.N'Is

V'if I I :i I. t' 11. NtiIIIIi I N ,\ C ~ '110 1 l w i lv v \411 w -i

At' Itit)fI 1 :1 V. A I I -ri Il
FROM AUCKLAND TO TOKYO 773

do elective operations on patients renaininug on the island--knees, removal of

large chondroma. Very few infections have occurred.

Visited the 122d Station Hospital.

Guadalcanal, Thursday, 19 August

Off at 0S00 in General Owens' IBrig. Gen. Ray L. Owens, Deputy Commander, Thirteenth Air Force] plane. Arrived at Guadalcanal at 1130.

Lunch at Thirteenth Air Force with Maj. Gen. (later Lt. Gen.) Nathan F.

Twining [Comnnnding General, Thirteenth Air Force]. Then to Service

Command Headquarters, Col. Russel J. Caton, MC, Surgeon. Watched LST

[landing ship, tank] unload 200 patients on the beach. Most of these were

wonlded on Monday. Today is Thursday; thus 72 hours have elapsed. Most

of the wounds were dressed in a short t ime except for the 20 caught on Baanga,

Island (?) for 4 days without medical care. Need better facilities on the LST.

Visited the 21st Medical Supply, "Hicks' Guadalcanal Pharmacy." Captain Hicks is a livewire from Shreveport, La. Visited the 20th Station Hospital. The buildings are thatch tents with grass and canvas, which last, about

3 months here. This is actually a 500-bed hospital with facilities for 840 beds.

The operating room is of the quonset type. They are doing little elective

surgery, but have done a few open reductions in the past. This island already

has miles of good road. The drainage system is improving.

Went to the 52d Field Hospital, which has done most of its major work

under Major Baker-well trained. Saw a patient who had suffered a compound fracture of the tibia yesterday at 1100, on an island off New Georgia.

He was brought here by boat and SCAT [Service Command Air Transport]

in 24 hours. A good debridemnent had been done, dry gauze left in place.

New Georgia, Saturday, 21 August

Up at 0330 and drove to Henderson Field. Took off at 0530 in a transport

plane. Landed at Segi, a small airstrip built in 10 days on the lower end of

New Georgia .2 The Russells are beautiful, and at 0630 the view from Segi is

the most beautiful that I have seen in the South Pacific. We were joined by

another transport and took off for Munda with four fighter escorts. The airfield is in good condition except for the litter of Japanese planes and materials

(fig. 303). Drove over some of the worst roads I have ever seen to headquarters

of the XIV Army Corps. Met Maj. Gen. Oscar W. Griswold [Commanding

General, XIV Corps]. Talked most of the morning with Col. Franklin T.

Hallam, MC, surgeon to the XIV Corps-a fine person doing a grand job. He

needs more help to do it.

Drove to Laiana Beach in the afternoon, through a, devastated area, and

was amazed at the size and number of Japanese foxholes at about every 30 feet

or less. Shellholes were almost continuous. Materiel and firepower played

2 The capture of New Georgia Island with its important Munda Airfield was accomplished by

MaJ. Gen. Oscar W. Griswold's XIV Corps. The first landing in force was made 30 June on nearby

Rendova Island. Elements of the 37th and 43d Divisions then landed on New Georgia enveloping

the western end of the Island. After our forces were reinforced by troops of the 25th Division.

Munda was captured on 5 August.
a il imprI~essive role Ini ýZtIliii&r thle J1aplallese out with so few casli'nItites oil ()hhh

Si(Ie. Thlen. N\a:s III eslii'iiIIedl 4,004) to 'OHM114 Ja 1 ) inese I there were 9,1)I'lp

a11,( these opS de feud Iiltr New (regia I oil f is isla 11(. Iitl it took4l thle b~ettIer par

of ilijee divisionis to '(rPhI theil out. Maitv Japaitese skelet itll were, lvilttr abou lit

ilIi hell ch 411ihs.

Visitued the vlearitig stationi. 3701 iI ivisioli-11t44 hit iets~--wel11 ui thg

3(04). These cleairhhi' _'r at.1 johs Iev( 1 lin. ejli et' a1 fill] complhhemhent of persolhileh orh

()hltshle htelp. ill ordier to Set 11I). Ill ishland Nviiarfhe ille(~v Sohhhet ifli(14'5S a ~itetlie R 

Ititict 141ll of ort~ia f1ieldl 1hospitalus. Thie 37t hi hs about 144(-plus caises of

(lini;4I prle~lrl (1:1 . reltrn m115 ore t hian 404 per* (Ii -mhore t hani most (leariuilr Stalions. Miust look into4 ilie seflat loll t hat is hilteutil tplo * ed here. TellI holusauuul

Uihhts~ till itoxihi ljehh)4r .rivell as prhop l~ It icfrgsghgel. ( hlest wvounids

are wvel handtl edl. 11here are hilol ets ill Ilse hiere.

'I'lp ;rh( S~tIhtoll i-s s1hhr-lhli~lde( b\) Iml-rledl Nire oil which til alls have

bleeni jlacvI. Souite .Tapaiese have raided Ow lhlospita~l. War hevre appears to

lbe ililore vicioush 11,1 illi mi host jtlaces.

Jlat jeitls ie eva~laltel if) i lie bleachi thrioiugl13 IoI.-) miles of vih'chhit(14s road~s

fig _k4) A [,("I' I Ia11(iuhii vra rt, tank] takes themt to the 17th Field i~osJpit :t oni Kokoraita Islanid. Fromt I here 1ll hev are I ratisjiorteil bY LSI' or b.N

SCATVI to (Giuudalvanail. 'I'lie trail1 for jeeps aini manihl'nulies IS very1 ouiilt

Someno with ISevere traicttilles div 1 asateslt of Idlie ride. VeryN impressed bYI
F I' N I A I K I A \ I ' I' I t I' K I'~ N I

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liiit ii :111112 :iit iti~i ii til t' ilti '11 I i'i- til i'I- l -i 111 liIl :11' ~t' ii ii
FROM AUCKLAND TO TOKYO 779

Evacuation has been a problem in this area. The LST's carry supplies

which they land at another island, and they do not like to remain around here

too long. They do not always take the time to run over to the 17th. The

movement of patients from island to island, or along the shore, is not under

unit or Army control. This lack of organization results in many delays. Can

this movement be correlated with the Navy? The suggestion that more surgery

be done on the LST appears umsound only because not enough good surgeons

could be obtained for this purpose. Why not?

Tuesday, 24 August

Remained at the 17th Field today. Talked long with Colonel Bell, the

commanding officer. The morale of this outfit is low; the old problem of

rotation and promotion.

Many ear conditions here, canal furuncles and fungus. It is thought to be

due to the moisture in the air and not due to swimming. Many of these ears

appear to be filled with scaly exudate. It occurs in both the healthy and the

malnourished. Another problem is refractions. There are many broken

spectacles and new cases requiring refraction, but no sets. Tonsils all bled, so

they gave up operating on them. They want tuning forks to test hearing.

There is a need for sulfamicro drugs for wound dressings. They must also

have more ready-made splints, sealing dressings against flies and ants, and

soap solution. The orthopedist says that cases arrive in good condition except

during a push. A few cases have arrived in a state of shock. He has seen a

few skintight p)lasters. He believes that a portable Hawley table would be of

great help in the field hospital.

Visited the 25th Division casualty setup adjacent to the 17th Field, in

charge of Major Klopfer. The clinic is excellent. This unit really functions

as a convalescent camp, since many patients enter from the 17th Field without

a diagnosis. Those with war neuroses may be kept here for one month to see

if they (can make use of them.

Major Klopfer believes that one month is too long a period to keep men in

the line. The men may have only three hot meals during the whole time. They

get little sleep and they must fight all day. As he said, "it takes a superman."

lie finds that a considerable number of the war neurosis cases are due to

exhaustion. He thinks the situation would be helped by shorter periods at

the front. The men should also be able to look forward to something in the way

of relief after the job is done. Malingering is not high here.

Conversation with Capt. Benjamin A. Ruskin, MC, a psychiatrist. He

divides neuropsychiatric cases into two categories: Group I, those who have

had trauma; and II, those who are afraid of trauma. The functions of these

psychiatrists seem to be: (1) Sorting out the patients who can be saved, (2)

educating officers and enlisted personnel, and (3) therapy. They do not appear

to have enough diversional activity; more books, movies, and games are needed.
780 ACTIVITIES OF SURGICAL CONSULTANTS

Rest cal1)s should be set up1) only where these activities can be provided. The

morale of the 25th D)ivision is poor because of the length of time away from

home plus the long campaigns. Efficiency is dropping rapidly.

New Georgia, Wednesday, 25 August

Left Kokorana Island at 1030 on a mail barge from Munda Beach. We

were accomlpanied by boats of all varieties: personnel barges, LC's, LCT's, et

cetera. All kinds and combinations of uniforms were to be seen. Some men

were stark naked; others wore only a hat or shoes. One sergeant had all sorts

of insignia on his hat. Asked why, he said that they all came in handy,

depending on where he was. A boatload of men went by looking more like a

band of p)irates than soldiers. One man in a mottled jungle suit appeared in

our boat. Someone asked him a question. Ile promptly lay down, saying "I

don't know or give a damnn,"-and went to sleep. We arrived at XIV Corps

headquarters, 1400, to find that Colonel IHallam. has been down with dysentery

for the last ; (days.

Although it had been on the same site for 1 month, the 17th Field Hospital

on Kokorana had screened only the mess building, and that just partially. It

would have taken very little more to have screened the entire mess. If not

with screen, mosquito bars would have done for 1 month. The latrines were

open and poorly constructed. Operating and dressing rooms were not screened.

No effort has been made to improve conditions, although it is true that they

have been expecting to move. Since only a minimum of lighting is available,

eve-..o e goes to bed at 1830. The 25th Division operating room is screened

with it mosquito bar, although they are working under more difficult conditions.

Thursday, 26 August

Slept soundly in spite of an alarm and the sounds of 105 mm. guns shooting over our heads. However, this morning my head feels as though it had

been pounded. Went over to the 37th Division clearing station (fig. 308)

and also visited the 43d Division. Men of the 37th say that they are handicapped because the clearing company does not function as a unit. They are

more short of enlisted men than officers, although the new T/O [table of organization] cuts their enlisted strength even more. Whenever they have had

to move, they have had trouble in getting help to set up and have not been

able to get bulldozers. Help is most needed in the initial stages, for screening,

etc. Anoplieles are getting worse in the Laiana Beach area, and there is not

enough mosquito bar for screening. There has also been some trouble and

confusion in connection with priority of location for the clearing station, and

some unmecessary moves were made. Headquarters seems to decide on one

location and then change its mind. Lt. Col. Hobart L. Mikesell, MC, is division surgeon [acting]. He thinks that the triangular division splits up medical

personnel too much for island warfare. Could doctors be obtained by substituting MAC [Medical Administrative Corps] officers to do the routine administrative tasks in the collecting company, since these units function chiefly during

bIat.tle?
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782 ACTIVITIES OF SURGICAL CONSULTANTS

are evacuated because of the lack of dental facilities. A dentist reported here

today. There is not much surgery to be done here. They have done only

one major surgical operation this month and a moderate amount of minor

surgery. Malaria and dentistry are the big problems. The splitting up of

these field hospitals takes away a certain amount of equipment and Cuts the

p)ersonnel, particularly corpsmen. As a result, these hospitals leave much to

be desired.

In this rapidly moving front of island warfare, a field hospital cannot

stay put very long. As a result, they (1o not put nmch effort into keeping ul)

to the highest possible standards and tend to get into slovenly habits. The

1st and 3d Platoons of this hospital were located on Kokorana instead of at the

forward area on New Georgia, thus adding 4 to 5 hours' delay to the care of

casualties. The hospital has remained there for nearly a month, though this

location is not particularly invulnerable. It has been bombed and had 8 or 9

deaths--more fatalities than even the dressing station on Georgia. With

better forward clearing stations and LST's with an adequate operating room,

the field hospital here would act primarily as a holding and evacuation station.

I caught, the 1530 plane for Guadalcanal and met Capt. Richard A. Kern.

MC, USNR, and Cdr. Theodore E. Reynolds, M1C, USNR, medical and surgical consultants for the Navy. There was an enormous amount of destroyed

Japanese shipping between Florida Island and Guadalcanal. The loss of

materiel and personnel must have been very great. This was the show that

definitely stopped the southward advance of Nippon. The Canal is one great

dust cloud and fairly cool in contrast to the steamy heat and mud in New

Georgia. I put up at. the Service Command in a new screened and floored

tent. The eternal cry is "screening."

Saturday, 28 August

I spent the day going about with Captain Kern and Commander Reynolds.

Visited several Seabee installations and they are splendid. Their ingenuity

is astounding. Washing machines were improvised out of gasoline drums.

The Seabees and the LST ships are the greatest innovation I have seen in this

war.

Filariasis has now been found here. Some native villages still remain

as close as one-quarter of a mile from the camps. This may be a problem (fig.

309). The Navy experienced a severe amount, of dysentery on landing here.

Again, screening is the answer. More dental equipment. and dental officers

are needed here too. This seems to be true in all echelons.

I visited the 'Mobile 8 [U.S. Naval 'Mobile Hospital No. 8]. Capt. William H. H. Turville, MC, USN, is commanding officer. He is an intelligent,

able disciplinarian, who has built the best naval hospital I have seen in the

South Pacific. The total area covered is 79 acres. The hospital is of prefabricated construction. It took 2 months to build, and has 400 patients at

the moment; it is expanding, however, to a 1,500-bed hospital.
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784 ACTIVITIES OF SU'RGICAL CONSULTANTS

Baker, who is well trained and has good judgment. The orthopedist is also

good. Tents are built off the ground. The operating room is well screened

with good fly locks. This hospital has an adequate amount of screening,

which is well distribllted, except that the mess kitchen and mess tables are

located in separate tents, while they shouhl be combined. The patient is

sprayed before he enters the lhospital. Ile is marked "today" for dressings.

A b'rge sterilizer was obtained, since the pressure cooker was too small. The

sterilizer is heated on a field range. They refill bottles and make their own

sterile water with an :dutoclave. They have averaged about 325 patients per

(lay and use about. 3,000 gallons of water per day, kept in tanks which last

from 2 to ") months. The 14 Japanese treated here have been good patients.

The only cases of tetanus seen have occurred among them. Many patients are

waiting for new spectacles.

It seems that the splinting done in the forward echelon is frequently inadequate to immobilize and does not extend over the adjacent. joints; for example, the ankle. Applying one layer of sheet wadding and then plaster,

would be a better method. The area should be shaved and washed with green

soai) anid water. l)ebridement is frequently inadequate, dirty clothing and

(lead tissue are not removed, and hemorrhage is not adequately controlled.

In the beginning of the New Georgia campaign many of the wounded

never went through a clearing station, and treatment was delayed for from 48

to 96 hours. The 17th Field was established about 4 weeks after the landing

on Rendova, and patients were then evacuated in much better condition. Before this there were, for example, casualties with the femoral artery and vein

severed that were not ligated upon evacuation.

LESSONS OF THE NEW GEORGIA CAMPAIGN

There is, in general, too much dependence on sulfonamides and not enough

on debridement. There is a tendency to dump sulfonamides into wounds that

are not deeper than 1 inch. The same is true for larger wounds in the application of debridement. One doctor here found that spores and grams and rods

are common in these wounds and sometimes exist in almost pure culture. The

only complications caused by sulfonamides were seen in five or six cases of suppression of urine with blood, and all of these cases recovered. Some throughand-through wounds have come in with a sponge in either end (plug), held

in by a catgit suture.

Fifty percent of the tags attached to the patients are useless, and rarely

do they contain clinical information. The chief question that is to be answered

is what was done when, and when the wound needs a dressing. The people

here would like to know what eventually happens to the gas gangrene cases and

if any new ones develop later on.

I have now collected data on 20 cases of gas gangrene from the 52d Field

and 20th Station Hospitals. There appear to be at least two underlying reasons for the occurrence of gas gangrene:
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786 ACTIVITIES OF SURGICAL CONSULTANTS

The following is all extract on the problem of gas gangrene from the sanitary report for July 1943, Headquarters, XIV Corps, Forward Echelon, New

Georgia Occupation Force:

Hospitals in rear areas began to report, early inl July, the occurrence of gas gangrene

among battle casualties arriving from the New Georgia area. Immediate investigation as

to the p)robable causes of gas gangrene infections was undertaken, both by the rear echelon

of the Corps at Guadalcanal and by the forward echelon at New Georgia. It was found that

the main causes were lack of early debridemnent, primary closure of wounds, tight packing

to prevent hemorrhage, and a lapse frequently as long as 72-96 hours from time of injury

before definitive treatment could be instituted at Guadalcanal.

Immediate steps were taken to minimize the incidence of gas gangrene among battle

casualties. The division in combat at that time was notified of the occurrence and probable

causes of the gangrene. Large quantities of gas gangrene antitoxin were sent to New

Georgia with instructions to administer prophylactic doses wherever indicated. Medical

facilities aboard LST's, which carry patients to the rear areas. were increased by the

Navy.

It should be remembered that, while the occurrence of gas gangrene among battle

casualties is unfortunate, division medical service was the only source of medical treatinent of battle casualties in the New Georgia area during the first 28 days of July. Facilities for definitive surgery were lacking north of the Guadalcanal-Russell Islands area.

The 24-36 hour trip by LST from the combat area to Guadalcanal, during which time the

wounds were not redressed, except in emergency, provided an excellent incubation period.

The establishment, toward the middle of July, of the policy that all casualties should

be cleared through the division clearing station before evacuation to the rear on the LST's.

did much to prevent long journeys to the rear by casualties who had received only aid

station care. The arrival during the latter part of July of 21 medical officer replacements

and elements of the 17th Field Hospital did much to provide adequate early surgical care,

and the occurrence of gas gangrene was reduced to a minimum.

FRANKLIN T. HIALLAM

Colonel, Medical Corps

It should be noted that the above use of antitoxin is of questionable value.

It should in no way minimize the surgical care (debridement). The increase

of medical facilities on LST's (September 1) consisted of two doctors instead

of one. Their facilities were still inadequate.

Tuesday, 31 August

A boy was riding on the fender of a truck when a bullet from a machinegun, one of ours, hit him in the back. He was instantly paralyzed. This happened at 1700. He arrived by plane at the 52d Field Hospital at noon next

day. A boy, the tail gunner in a B-24 on a bombing mission on Bougainville,

parachuted from his burning plane, and was strafed by the Japs. He was shot

through the belly and the right side, and had a large exit wound just to the

right of his spine. There were six perforations of the intestine and the missile

had passed medial to the right kidney. He was operated on at the 20th Station

Hospital within 21⁄2 hours and is doing well this afternoon. A boy, belly

gunner on a bomber, was shot through the upper third of the left leg. Both

veins and arteries gone, and a compound comminuted fracture-amputation

was necessary. He was operated on within 3 hours and is doing well. Air

transl)ort, of the sick can accomplish wonders, but it should not supplant proper
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788 ACTIVITIES OF SURGICAL CONSULTANTS

eral surgery. The latter is the most important. Too much assembly line treatinent occurs in forward hospitals. The extension arm splints were found to

be no good.

This hospital appears to be doing a good job. Their records are fair; eye,

ear, nose and throat care is okay; the X-ray service is good; the lab is fair;

the food is fair; the library is good. Staff meetings were held formerly but

are irregular now.

Wednesday, 1 September 1943

Visited the convalescent hospital under Major Kellefer, an orthopedist.

They have not begun to keep systematic records yet. I talked to him about

this. le thinks that 80 percent of the war neuropsychiatric histories are poor;

that sorting is done on snap judgement. The chief problem in choosing psychiatrists is separating the sheep from the goats. He raised the question of

reclassifying doctors at home.

The 43d Division attacked Rendova on 1 July. The beach was bombed

and strafed by the enemy on 2 July. There were more than 350 casualties.

No clearing station had been set up, and the casualties were loaded directly

onto an LST. For some reason the LST could not get off, and all the patients

were transferred to another LST during the night. The 43d never had a clearing station on New Georgia Island.

Major Barker, medical inspector of the 37th Division, is down with dysentery at the 20th Station Hospital. Barker thinks that some of the dysentery contracted was due to the use of halazone tablets. How many tablets to a

canteen would be safe? Look up the division sanitary reports.

The 37th Division medical service was operating with a shortage of 8

officers and 100 enlisted men. The eight officer replacements had no field

training but were put out into the field nevertheless, and one of them cracked

up within 24 hours. One officer and six enlisted men were killed.

Lt. Col. James H. Melvin, MC, Surgeon at the Service Command here,

and Major Barker both agree that a force medical supply unit should accompany the infantry in island warfare. Many of the units lost part of their

supplies during the landing, and there was no source of replacements short of

Guadalcanal. Captain Hicks, 21st Medical Supply, agrees that it would also

simplify his problem. He found it impossible to get supplies to the various

isolated units whose supplies would get lost on some island, since frequently

he did not know where they were. Recommend that the force medical supply

unit function as in quartermaster exchange of property on LST's. The problem here is chiefly one of making litters and blankets available for the wounded.

Since the men must frequently sleep in foxholes, it is to be expected that cots

or litters may be used for casualties, and allowance should be made for this

in the exchange of supplies. This new plan, by giving a division the things

it needs when they are needed, would avoid burdening the divisions unduly.

All agreed that. since clearing stations frequently function as field hospitals, they should also be provided with washing machines. The 24th Field

Hospital has three. There is no time to build these things during a "push,"
FROM AUCKLAND TO TOKYO 789

when they are most needed. Improvisations of all sorts can be done in a quiet

time, but by then the need has largely disappeared and the damage has been

done.

Thursday, 2 September

Spent the day reading, arranging transportation, writing, and treating

my feet for the "rot."

Espiritu Santo, Friday, 3 September

I rose at 0300, although we did not leave the airfield until 0630. Arrived

at Espiritu Santo [New Hebrides], 1030. Called Colonel Morgan Berry, MC,

and stayed with hin. Met Lt. Col. Benjamin M. Baker, MC, medical consultant for this command, who was on his way north to the Canal. He has

worked chiefly on the problem of malaria. I attended a session of the Esplritu

Santo Medical Society, which meets every other Friday. The hospital staff

put on a good program. Reports were given on: Subphrenic abscess, malaria

and dengue, internal derangement of the knee joint, anesthesia-very good.

Capt. Richard A. Rose, MC, 321st Service Group, wants a transfer for

duty as an anesthesiologist. I talked to Captain Miller, who was on an LST

that was bombed and saink off Vella Lavella Island. He agrees that they need

an oi)erat ing room aboard, preferably on the side forward where the carpenter

shop is. This side is relatively quiet and easier to lightproof. Better arrangements should also be made for keeping food dry.

The loading of patients must he planned out, before the boat comnes in,

so that, those who are seriously wounded will he put. in the proper place and

receive earlier attention. Miller suggested that two men be used for this purpose, one of whom would remain at the landing point. He says that two doctors aboard the LST would not be enough, and that four to six corpsmen were

needed, two of whom should be of top caliber. These measures would apply

only at the time of a "push."

I talked with Colonel Potts and Major Sofield regarding a policy on

leaves. Six months or more of continuous duty in the islands seriously affects morale. Moreover, some men have been here longer than others due to

lack of replacements. It is also important to keep up the morale of the men

who treat the sick.

Saturday, 4 September

I spent the morning on the wards with Colonel Potts and Major Sofield.

I saw a compound fracture of the lower third of the humerus with a hanging

cast, and unfinished at that. There was a knee case that had to be reoperated.

What was supposed to be a cyst turned out to be a ruptured muscle. Evidently

more information must be entered on the EMT [Emergency Medical Tag].

Baker left today. We will meet again in Suva [Fiji] on the 18th. I am scheduled to fly to Nandi [Fiji] on the 15th.

I saw another disturbing case. This soldier had been wounded in the

arm late one afternoon during the New Georgia fighting. The wound was

dressed almost, immediately. He was evacuated the next. morning at 1000

anid reached the 17th Field Hospital at 15(0, Only the 25th D)ivision clearing
IT IV IIA I I II I I Z I; WA I. 4I SIIT V

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FROM AI'CKLANID TO TOKYO 791

c. Debridement is inadequate in many cases because the men are pressed

for time. Furthermore, some of them do not even understand the principle

of debridement. Not enough soap and water are used. More instruments and

a larger sterilizer-or preferably two sterilizers-are needed. More good surgery is needed in the clearing station and nothing should be spared to make

this possible. In island warfare the field hospital may be so far from the clearing station that many serious cases must receive definitive treatment here. Better sorting of cases at the clearing station and a more efficient system of

transportation to the field hospital is needed.

d. Records on the EMT are poorly kept. Enlisted men should be trained

to put down what was done, and when the next dressing is due.

e. Fracture treatment is poor and is characterized by inadequate debridement, inadequate immobilization, and inadequate use of plaster.

f. Sanitation methods must be improved. The screening of messes should

include the space set aside for eating. Flies are present in abundance. The

operating tents must be screened.

3. Field hospitals should be placed as far forward as possible. The inadequacies mentioned above with regard to treatment in the clearing station

apply to the field hospital too. The field hospital should go in with a full

complement of supplies. Dividing up of supplies has proved a serious drawback in many instances. They should have help immediately on landing, in

order to set up one good-sized bomb shelter. The clearing station or the field

hospital should be located on or near the beach, in order to have the best possible

liaison with the LST's.

4. Hospitals that are to be used in the line of evacuation should have more

clearly defined locations. If station hospitals are to be used in evacuation,

their personnel should be picked accordingly, with at least, one first-class

surgeon. The less well trained men should be used in hospitals that are off

the direct line of evacuation. The 25th Evacuation Hospital is too far back

now to perform the functions of an evacuation hospital.

Sunday, 5 September

I spent the (lay with Harper [Lt. Col. Paul Harper, MC, Malaria Control

Unit] and Sapero [Cdr. James J. Sapero, MC, USN, CINPAC] who are

doing a fine job. Commander Sapero was teaching in the Navy school in

Washington before the war and has had some experience in malaria work.

He was ordered out here during the thick of the crisis, when 16 percent of the

men who had landed here [Efate Island, New Hebrides] were in the hospital

as a result -f malaria, the noneffective rate growing steadily. They had a

so-called commission on Efate Island when he arrived, which did not even

know to look for breeding places of Anophele8 but set out to destroy all mosquitoes. Malaria control is just now getting under way, 1 year from the time

of our arrival here. Only one educational directive has been published, and

a command directive is just now being written. Sapero should be encouraged

and his work recognized.
792 ACTIVITIES OF SURGICAL CONSULTANTS

Monday, 6 September

Visited tile 25th Evacuation Hospital-Col. Morgan Berry is commanding

officer. They have two good orthopedists. Maj. Harold A. Sofield is chief

orthopedist. lie could I)e used as a consultant in the teaching program, being

put on detached service at first. The orthopedic and surgical service in the

25th Evacuation is well covered, so that this is not entirely unfair to Colonel

Berry. At the 25th Evacuation Hospital, 35 percent of the casualties are

fractures, of which 93 percent are compound, 15 percent femur. Next. to general

surgery, the biggest, surgical problem is orthopedics. However, Lt. Col. Willis

.1. Potts, the chief of surgery, is well qualified. Ile is a competent surgeon

and a good administrator with a pleasing personality. The 25th Evacuation

Hospital is a well-run hospital doing profe%.ional work of a high quality.

UTILIZATION OF MEDICAL FACILITIES IN A THEATER OF

OPERATIONS

In general, the surgical care of the wounded does not. appear to be badly

done, and the Medical Department is doing a good job under difficult circumstances. However, there is room for improvement.

1. The problems are: To provide the best possible early treatment for the

wounded at the front during the "golden hours"; to insure the same high

quality of treatment all along the line of evacuation.

The above can be accomplished by:

a. Planning good locations for facilities to be set. up promptly when

needed, and a well-organized system of transport.

b. Adequate trained personnel: Since we are short. of trained personnel,

this problem resolves itself into one of distribution of the best-trained personnel

in key positions. The distribution of personmel along the line of evacuation

must be such as to make them available to the greatest number of patients.

This means that the line of evacuation must be planned out carefully, since the

number of trained specialists is limited. Transportation under conditions of

battle does not always allow for the proper sorting of casualties. The first

wave of patients that arrived on Guadalcanal were transferred to hospitals on

the basis of the seriousness of the case in relation to the condition of the roads

and distance of the trip. This whole problem might have been eliminated by

the proper location of facilities. Furthermore, not enough consideration was

given to the personnel available at these hospitals. Thus, if only one orthopedist or neurosurgeon is available at a certain hospital, the patients that

fall under these specialties should be sent there. This sorting should be a function of the island or service command surgeon, and should not be done solely

on the basis of the number of beds available. However, if there is only one

hospital on an island, this procedure is not necessary. Economy of supplies

and personnel is one of the advantages of centralizing hospital facilities.

2. Medical officers, especially those in the forward echelons, should receive some instruction in the care of wounds and the treatment and trans-
FROM AUCKLAND TO TOKYO 793

portation of fracture cases. These are the two major problems in the care

of battle casualties, and it is here that instruction is most urgently needed.

In order that this instruction may reach personnel in as short a time as possible,

the instructor should visit the forward echelons. It would be particularly

desirable that they first visit troops and installations that are about to go

into action.

3. Since there are extreme fluctuations in the casualty load in island warfare, a more flexible medical service should be provided. This can best be

done by using surgical teams, op)erating under the direction of the corps

surgeon. Such teams could be drawn from hospital installations in tile rear

echelons, provided that these are kept up to strength.

4. The policy of promoting officers in order to fill the T/O (table of

organization) of an installation-even when the best available men are chosenhas often resulted in placing officers in positions which they were not qualified

to fill. The promotion of any medical officer to the grade of lieutenant colonel

or colonel, should receive very careful consideration from both the professional

and the administrative standpoint. The essential problem is to find posts that

they are qualified to fill. When they are not qualified for such posts, either

professionally or administratively, the question of promotion should be

precluded.

It has rained buckets all day and night.

I visited the 122d Station Hospital, which is making excellent progress.

Major Camp has built a well-designed surgery, though it is much larger than

is necessary for a 500-bed hospital. They expect to open the surgery in 2

weeks. The personnel of this hospital is young and enthusiastic, but not well

qualified.

Capt. Gilbert N. Haffly, MC, of the 25th Evacuation Hospital, an excellent

EENT [eye, ear, nose and throat] man, is training a general practitioner to

do EENT work in this hospital. Captain Haffly says that nose and throat

maladies constitute 65 to 70 percent of his work. Not a single paracentesis

has been done here so far. He does not think anyone with a chronic ear condition, or with a history of recent ear trouble, should be taken in the Army.

Exposure to a tropical environment result.s in an acute exacerbation of chronic

trouble. Otitis externa is a big problem. Haffly intends to report further on

this. He recommends the application of 1 percent thymol in 50 percent

alcohol, or thymol iodide powder. He does not think that this inflammation

is contracted by swimming in the local waters.

It was raining by the bucketfull all day, and all flights were grounded.

My plans to travel to Efate must await the favorable decision of the gods. I

spent the afternoon talking with the Navy consultants, Captain Kern of Philadelphia, the medical consultant, and Commander Reynolds of San Francisco,

the surgical consultant, and with Cdr. Emile Holman, MC, USNR, and Lt.

Cdr. James C. T. Rogers, MC, USNR. They have just returned from Tulagi

and Florida Islands [the Solomons].
S~urgical aind niedical care for tilie Ma[irinte Raidlers appearsiii to lie a very

diflicult probllemn, since tile%. carry So little ittediciil equlipmienit. ThieyI do not.

even carry a stretchler-nlot hlung hutt fighting equtItipenit and a little fteod.

Losses Iin tile 4th Marine Raider Battalioni. which nIade linitial assaults oil

New ( 4eorgia, wvere: 33 killed, 1:34 wouind~ed, IT iiledlical ciisuilt ies, or 4S pervent casuialties, of which almnost haltf were surg-ical cases. In tilie act ion at

Ba irok() Harbi'lour Iew Georgia Ilanlh , thiere were apJproXimnatelY 600-pilns

catsualties. F'our hundred were evacuiated bw PBIY j_( 'atal i 1C]flytiing boats.

one hundred by API) [trantsport. (high sIpeed ) fast destroyer transplort, and~

01W unded y LSTI. The second wave of Ra iders carried some dressing

stat ionl,butl these did not usuially get set up tuitil soniceAor 3da(liy ater. hlence

there is veryv little substantial treatment until tile wounded are evacuated to

li hile at Iob.l tI 8Iaa. optl Ihadi.sael ht ic r

tically aos th Mbl aa optl Ihadi ttdtasne belltclyall head wvolnds, ms.chest wouinds. and the majority of tl el

w01uitlds turn ouit, to bie fatal, these catsualt ies should be contsidleredl lost and nto

attempt bie Inade to save thiemi. Soliiiotte add~edl that. perhaps tins w-as the

right. thingl to (10 a11d thlat. onlly thle minor cases should lhe t reated1. '[le p~oint

here, I suppose, is to utilize personnel and equlipnient ns viliciently as p~ossible.

I objected, for I b~elieve that every etrort shtould1 be made to save lives, if this

cauIi at, all be done without. materially jeopardizing thle outcomie of thle wvar. We

muiust conisider that. niorale would go to p)ot inl a hurr-1y if thle soldier liou11glit

that ill certainl instance's no attem)pt wouild be maltle to save him. It is true

that 111.1itV menl have been wvounded and a few killed while trying to save a,

wvounded inan. I know of onle instance when three were killed by Japanese

sn1iper w'dinhe trying to tell) one woundied titan. nue japaniese Itse mir. (casiallies asbiait for akill.

(Capt ain Kern t hinks t hat lhe mieni should lie inlst ructedl to( crawl for cover

whien wounded. The wh~ite dressing of a wounded man makes a beautiful

target. TheI Japanlese have foreseen I his and ulse a greenl triangular dIressing

as It cover1ing. Somne of oill 11W)) smnear i11i1d over t hmeir dressings So that they

are not. cotispicuouls. A notherci practice to correct is that. of giving all of our

wounded one-half gra in of niorphtine. Because of this, miany walking cases

are conver'ted into litter cases. Kern is muutchi concerned over thle atbsenice of

Camptl sanlitationl. P~iles of tinl ca-uts, part ly filled wit h food, act. as fly breedlers..

TUhe Navy lii~ll ,ivteedls 6-intel preplared lplast er. That is tlie( first t hinhg I

have hleard oif t hat thle Arnuv has. and that, the( Navy (hoesli~t haive. Th'le N\avv

bas given uts just about. everyt hi tug else, 111i(1 Ilerliai P, we call hell) thleti oth InI

thits vase. The \a vv has been well siippd iedl withI washing mai~ch ines, ref rigeruttor,, tables, qIitonset. huts, aind what -l nie-youl. Thteiru equ llput&'itt for t ropiical

warfutre, as one New Zealandl ofliver, Colonel 'Iwluigg [col. .Jolim M. Twhligg,

New Zealantd Arnuvy Medical C orp~sI remarked, incucitdes, -everythlintg thIat openls

anid slituts." HowevePr, Reynolds antd Kern ob~servedl t hat thle greaiter* iiolilit%

of Ariinv eqtuipmiient is uti timpjortanlt asset and1( thatt thle Navy is not prepared to)
FROM AUCKLAND TO TOKYO 795

move fast. However, most of the comforts of tropical warfare are furnished

by the Navy.

Kern and Reynolds are both in favor of surgical teams, particularly as

the Navy has a surl)lus of doctors in their rear echelons. They toldl me about

sone Marine divisions, which among their medical staff did not. number a

single qualified surgeon. 0)n the whole, their care of the wounded and their

organization of evacuation lines is in a worst state than #he Arimy's. We are

still making miany of the mistakes of the last war and Ire not getting all of the

square pegs into square holes. These Navy people are. beginning to recognize,

I think, the imnportance of hav-ing adequate medical facilities on the LST's.

However, "the skipper would never give up his carpenter shot)." We will see

what happens.

Efate, Wednesday, 8 September

I left Espiritu Santo Island this morning at 1000, had lunch at the Efate

Island airstrip, then drove to head(quarters of the island conmnand at Vila.

lleadquarters is sit uiated on a fine hUll overlooking a 1eaut i fail harbor. Colonel

Carroll is the island surgeon-a pleasant fellow. The 48th Station Hospital is

undler the conmman(l of Lt. Col. (later Col.) Lester F. Wilson, MC. It is the

only large Army medical installation on the island. Parts of two platoons are

set up on the far side of the island t•o act as a field clearing station for

emergencies.

U.S. Naval Base Hospital No. 2 is the largest hospital on the island and

has a beautiful location oi a. hilltop. It is well equipped and well run, although

I am a bit skeptical of some of their talent. They now have some 700 to 800

patients, half of which are Army personnel. Most of the patients from the

20th Station Hospital, and the 52d Field Hlosl)ital, b)oth at. Guadalcanal, have

been evacuated here. There, has been some troul)le with records and some

friction with the 48th Station Hospital. The Navy does not send their records

along with the patients. I don't see any reason why hospitals should keep the

records of their patients. Certainly all of his records, and not only the EMT,

should accompany the patient. There are a great many orthopedic cases here.

The 48th Station Hospital is being enlarged to a 500-bed hospital and has

about 300 beds at present. Colonel Wilson is a general traumatic surgeon and

(does some surgery. The hospital has a beautiful site on the hillside overlooking the harbor view. Most of the buildings are quonsets, with a boardwalk

running between them. The. messes are excellent, clean, and well screened.

Good planning is everywhere in evidence. A very good medical supply unit,

the 24th, is part of the hospital. The staff was drawn mostly from the 12th

General Hospital, which is the Northwestern [University] group. They are

young but energetic. The chief of the medical service is good. The. chief of

surgery, Major Douglas, is young but well grounded. Unfortunately, they have

no orthopedist. Captain Lindberg, laboratory head, is excellent. Morale is

good.

705-095--64--53
796 ACTIVITIES OF SURGICAL CONSULTANTS

They are having trouble with their water supply-inadequate filter. The

proctoscope bulbs are all out, owing to line fluctuation. Can a Castle light

battery be used instead? They have a good GU man, but no cystoscope for him

to use. It has been on order for 6 months. Is there one at Noumtca? They are

out of 21⁄2 percent sodium citrate ampules. Their needles and sutures are too

large. Check onl maintenance at Noum6a ; this is a general complaint. Opium

powder is needed for the pharmacy, and more class IV supplies for the laboratory: beakers, flasks, glassware. They also want washing machines and

gaskets for sterilizers.

Colonel Carroll says that the dental l)roblem is considerable here. Seven

to ten percent of new arrivals from the States have deficient teeth, but the

hospital is short of dental equipment. They have seen three cases of yaws

among Army personnel here.

Captain Lindberg has found that low glucose tolerance occurs in cases

with jaundice and small livers. He needs brown sulphaline. He has a new,

quick, thick-smear Giemsa stain-takes 10 minutes.

I saw a femur fractured up to the trochanter that had been kept here 12

weeks. The fellow also had a coml)ound fracture of the wrist and hand. He

should have been evacuated, since they have no orthopedist here. But apparently the boats do not come in often. Why can't air evacuation be used for

these cases?

I left Efate at 1400 and arrived at Noumna, 1615 hours, with Charles G.

Mixter. He says that only 50 percent of their planes are used for the evacuation of patients. Personnel is available, but the planes are being used for other

than ambulance transport purposes. There is too much of this lack of good

management. I have observed plenty of patients who would benefit by air

evacuation. This source of assistance has been neglected, however, simply

because people don't get together on these problems.

Noumna, Thursday & Friday, 9 & 10 September

I spent. these two days getting organized here at headquarters, writing

reports, letters, etc. Two eye magnets are available for shipment. I took up

the question of screening with Major Moore of the Engineers. How much

should a hospital or medical installation take with them to the forward areas?

Saturday, 11 September

Worked on reports today. I received a splendid report from Major Barker,

the 37th Division Medical Inspector. His findings sounded as though I had

written them up myself. It is amazing how closely our observations have

coincided.

Wednesday, 15 September

I was supposed to be in Fiji today and have my orders to proceed there.

But it seems as though fate orders otherwise. Went for a 5- or 6-mile walk

with Paul Harper Sunday evening and felt, fine. I had on a new pair of shoes.

Awoke that midnight with a very severe shaking chill. It was so severe that I

could not get out of bed for some time. By morning the chill had subsided,
FROM AUCKLANI) TO TOKYO 797

although I knew I was not quite all there when they took me to the hospital.

I thought surely it was malaria, but to my anmazemnent it turned out be a

lymphangitis. it is now subsiding. I sulppose it will be a week before I get

going again.

Friday, 17 September

Sulfadiazine is ertainly amazing. I now learn that. I came in here quite

balmy with a temperature of 104--my WBC [white b)lood count] was 19,000

on Monday. I now feel fine but. Captain Dietrich won't let me up). He has

done a good job of keeping tabs on my blood count, uriv,,, tic. My blood level

was 5.5, but WBC fell to 3,000, so he stopped the drug. I have a little ,esidlmal

redness, soreness, and swelling of the right leg. But, I don't think there is

any thrombosis, although the captain thinks differently.

Brig. Gen. Fred W. Rankin [Director, Surgical Consultants I)i vision,

Office of The Surgeon General] just walked into my room. Ile is along with a

troop of Senators, and they wouldn't leave him alone long enough to let him

chat with me. The Senators, as usual, were all interested in people from their

own State. lie has been to Australia. Colonel Pincoffs [Col. Maurice C.

Pincoffs, MAIC] is Chief of the Professional Service [Headquarters, USAFFE]

and, he says, a trouble shooter for Col. (later Brig. Gen.) Percy J. Carroll, MC

[Chief Surgeon, USAFFE]. Fred doesn't think he is as much use there as

he would be in the job of consultant. Fred says he wants to stop the practice,

among soldiers, of self medication with sulfonamides, but is a little afraid of

public opinion. I wish he had stayed longer, for I could have told him a lot

of things. However, it is nothing that he coul do much about. I presume it is

our job to try to straighten things out.

Tuesday, 21 September

Discharged from 27th Station Hospital today (fig. 313).

Listened to a talk by M.faj. Gen. Brehon B. Somervell, Commanding General, Army Service Forces. He says that in 3 months we will have as much

shipping available as we did at the beginning of the war, but that it will be

next spring before our facilities for passenger shipping reach that stage.

Wednesday, 22 September

Spent the day writing directives on medical specialty boards, and on debridenment and the care of wounds. Had a conference with Captain Kern and

Commander Reynolds of the Navy.

Fiji Islands, Thursday, Friday, and Saturday, 23, 24, 25 September

Arose at 0300 hours--turned my ankle in the dark. Arrived at Tontouta

Airfield 0500, from which we flew to Plaine de Gaiacs, New Caledonia. Had

fresh eggs for breakfast. Took off at 0945. Arrived at Fiji at 1430. Nandi

[on the western side of Viti Levu Island, the largest island in the Fijis] is in

a valley surrounded by high mountains. The grass is green and the island

appears fertile. Talked with a captain who had been at the 39thi General

Hospital as a patient. Ile was stationed at Bora-Bora, Society Islands, with

the 8th Station Hospital, 280 beds. There are only about 1,500 men stationed
79s*~~1 ~ i~i I I4VITWN k1.1)4 SIO i1( Atiii 4 Oxi I IiI 1913.S

ll. A~flIIi :1411(1 t viei(jwl ,I* thiioii lai a ole M s h) i. Ne i. p.1-t~lel Fe b 4 Ill; I e my1 3

ofivilees woe1 li(' b pfentl now Coie one hlo Sherwo (ivuim! ol:n soteil.g. thoet Beu

livil .ii wh haie 4lelV 11 liv oe hi Ii ' ve'lepback h)jIl;)-v: to s la iI14l fT4)W4. ofIIv ie vlol11itcl of 4)1) the iji.)Iirifls 4 \ i fti:() 4)pl ille2 ., t are l~ivede ihit 111ii, of- posiijiei

leall viulld b1he lok(at lwll.

New&~i set-I.lf~ hhiv li:16t:1li4e Wet \\-(,III hielvl slruiz' wero gl thae. :11)4 . ovetra

28') kv.sv] eethre o euluze. (1ihied into thve hioni/Ilt Pac ific Hot~iel. Mjei-l )lell

Spzew~ :111v wat dm) slI'ui/.(' IIr -:1er11 111441ta crowdi . Tihet~Il 111 ios

:veh fi(jil loc ll
FROM AUCKLAND TO TOKYO 799)

They have (],lime a fair amount. of work bft. less than the :39th General

I lospital and not. enough to keep tile men buisy or happy. Much of their work

is ordlinarily (lone in a stat ion hospital. These hospitals are chiefly taking in

malaria patients from the. Ainerical D~ivision. They hiave mi-ore surgeons than

thley need for thle work they have been doing. It seemis thatthrioughigni-ioranice

of the functions of the different tylpes of hospitals, thle 142d1 General Hospital

Was orliginally set upl in the field. Eventually, it. was brought over to Suva.

Now, however, there are two general hospitals at Suva. Colonel IDovell thinks

that the 7th Evacuation Hospital, part of which is onl Tongatahu, South Tonga,

is of no use at. Nandli and that it should come over to thle Suva area to function

,is a con)va'lescent hospital. While, it, is true that there should be a convalescent

lioslpital at Suva, thle personnel of the evacuation hospital should not be used

for this pulrpose.

Wednesday, 29 September

Spent the (lay at the 142d. Lt. Col. Murray Mf. Copeland, LNC, is coinmanding officer. Lt.. Col. Harry C. Hull, MC, is thle chief of surgery (fig. 314).

Their physical plant, an 0o(d Newv Zealand hospital, is better than that of the

18th General Hospital. Very little surgery is being done. There are 160

patients, with space here for 4.50. They still work on a 60-day evacuation

policy.

They have no intratracheal closed-tube anesthesia set, no Roger Anderson

splints, or tincture of Belladonna: are short of sodium mnorrhuate, phienobarbital, resorcinol, sodinnm citrate ampules 21/ percent, aluminum sulfate, traction. l)0w5,and woodl app~licators. Grigli's saw and Steinmiann pins are of poor

quality. They have anl extra water bath setup and flo-o National field sterilizers. Their biologicals, are getting out of date.

Thursday, 30 September

Baick at.thie 42d Genieral Hosp~itali. An e-xcellenitorthiop~edistlhere. They

are about. to lose two mien from their surgical staff of nine. The iness is excellent. ks at tile 18thi General, all of these men are anxious to go to the front

wvit~h a, surgical team. Colonel IDovell thinks that it is a great mistake to send(

(roodl men to the front where they may he lost. However, hie can be convinced.

Frida~y, 1 October 194'

Left. Suva' inl tile morning" with Col. Georg(e G. Finmev, MC, and Col.

Mu rraY C (opeland( and (drove to iNandi via the Queen's Road. H~ad a p)leasanmt

luncheon onl thle beach witih Colonel 1)ovell andl Miss IDonohute [I . Regina M.

JDoniohue, AkNC]! Chief NurIIse at the 142d. krrivedl in the evening at the 7th

Evacuation Hospital, which is situatedl in a dlelightfull val Icy near a mountain

rangre. about. 10 miles from the Nandi Airport and 18 miles fronm tile (lock.

It. Col. R!obert. B1. Lbhban, MC, is conmmanding officer. It. Col. McKelvie is

chief of nmledicilme, anid 'Maj. Robert S. Ackerly, MC, is chief of surgery. They

caine11 from tme, St ates last spring. first to Tongatahu and then to Fiji. They

niever funct ionedl as anl ev-acuation hospital and have (lone very little surgery.

TIhey acted as a stat ion Imospit a in delli Ia 1. a I izinig tile Aiilicniean D~ivision.
IWOI
FROM AUCKLAND TO TOKYO 801

A good staff, but no talent to spare. Most of their surgeons are young, with

few specialists and no orthopedist. This hospital was first built by the New

Zealanders and is now partly under wood and canvas. Had dinner-good

food with sauterne.

Satirday, 2 October

Made the rounds at the 7th Evacuation Hospital. They need portable

lamps, microscopes (now have one field microscope), antigen for Kahn test,

hlomatropine, and pyrogallic acid. They have a portable orthopedic table,

which could be used with a Hawley table. Scissors are of poor quality. Two

utensil ste,-ilizers, the 240 and large fie]ld sterilizer, have been acquired. No special anesthetist is assigned here. They would like Lt. Fred Dye, who is with

the Americal Division.

Visited Lt. Col. James F. Collins, MC, Division Surgeon of the Americal

Division. Appears to me to be a fine person doing a good job, and he has

plenty of ideas which lie promises to put down on paper. He is now short 15

men, and (6 of his d(h'tors are sick. Ile believes that the old system of three

clearing companies is better than the present one clearing company setup.

put George Finney on a, plane and spent the night at the 71st Station

Hospital, which is now under construction on a good location. They will be

ready to take patients in 2 weeks and could even do so now. Lt. Col. Anthony

Ruppersberg, Jr., MC, an obstetrician, is commanding officer. Ile is energetic

and is (loing a fine job. The hospital will have 250 beds and eventually expand

to 500. They need an EENT man. Check with the possibility of getting

Bodein from Americal. Are they getting the journals here? Major HIeyer,

chief of the medical service, wants an EKG machine. Carbon dioxide tanks

with proper connections for frozen sections are needed in all general hospitals.

Sunday, 3 October

Drove from Nandi via the King's Highway to Suva (180 miles), thus

circling the island.

SUMMARY OF THE FIJI TOUR

1. Hospitals.

a. The 18th General Hospital is about to expand to a 1,000-bed T/i.

They have excellent talent. Should this hosl)ital be enlarged, however,itwouhl

take considerable building.

b. The 142(1 General Hospital is also about to expand to a 1,000-bed T/O.

They also have excellent talent. This hospital is on a good site, which can

easily absorb some addit ional const ruct ion.

c. The 7th Evacuation Hospital should be divided up in order to provide

a conIvalesceiit hospital, and could be best placed in Suva iii the camp p)artly

occupie(l by the Quartermaster. The remaining units of this hospital could be

utilized to supplement, the 142(1 General Hospital, or to form a smaller evacuation unit.

2. At p)resent there are approximately 2,500 beds on Fiji and too nmch

(olwentration of umedicmal ad111 1 surgical talent. (h)e general hospital, the 142d.
802 ACTIvrrITI:s O'F SIURGICAL CONSULTANTS

with a capacity of from 1,000 to 1,501) beds, one convalescent hospital with

2,000 beds, and one station hospital on the north side of the island( would be

ample. This would leave from 3,50) to 4,000 beds on Fiji and free the talent

of the 18th General Hospital for assiginent nearer the zone of combat.

3. At least two well-equipped surgical teams can ibe provided from Fiji.

Colonel l)ovell tends, as usual, to l)ush off the less-ql|alified and less-experienced

men for duty at, the front. We should first give it a try with the best men.

Noumnea, Monday, 4 October

I was ill) at 04(00, took off at o6001 in a (1 clillpper ship, lan(led at Espiritu

Santo 1100 homrs, then to Efate, and arrived at Nou|immta 1500 hours.

Sundlay, 1) )October

Hal Thomas [Lt. Col. Henry M. Thomas, Jr., MC] arrived yesterday on

his way to the Southwest Pacific as medical consultant. I'm still working on

directives and hope to finish ul) in a few days. Ed (ttenheinier [Lt. Col. (later

Col.) Edward J. Ottenheinier, MC, Chief, Surgical Service, 39th Gener~al Hospital] says he will send us Claiborn [Lt. (

1ol. Louie N. Claiborn, MC] and Post

for the surgical teams.

Tuesday, 12 October

Completed the gas gangrene directive. Experimenlted with insutilators

for sulfanilamide; perhaps I can stop its too liberal use in wounds. Met Colonel Ward, who is going to Fiji. Col. (later Brig. Gen.) Earl Maxwell [Surgeon, T-SAFISPA] is off on a trip to New Georgia and will try to straighten

out the morale of the 17th Field HIospital. lie will see Maj. Gen. Robert S.

Beightler of the 37th Division and lay l)ans for our next iMiove.

Wednesday, 13 October

Dinner last night at. Mobile 8 with .Jack ('armody [ILt. (later C(dr.) John

T. B. Carmody, .1(, IT'SNR] and Frank Ihauter. Mobile S has a new clubhouse

with a large fireplace and a bar. D)rinks are the best ever. ren to fifteen cents

is what they echarge. Chatted with Captain D)earing after dinner concerning

plans ftor Botiga iln ile, our next major iMilitary objective." I le is a very pleasant fellow. General Rankin met, him at the hosl)ital.

Smnday. 17 October

Spent yesterday at the 8th General Hospital (fig. 315) with Colonel Miller.

'I'lTev have no urologist, and o(n' use a major or a calItaii. IHe nigh t Ie exch'anged for an anesthesiologist whoim they coulid train here. They also have noe nleur osu1rg.eon.

The prob)lem in Army medicine is. as in civilian medicine, one of getting the

right, man ill the right l)hu'e at the right timle. I[er,, under the coniditionis of

5lhIgnainville was to provide the Allied forces with Important airfields from which Rahaul and

the remaining .apa nese installations in the Solonions could be neutralized. New Zealand troops

occupied two islands in the Trrasiiry group of the northern Solonions lIte in October. The 3d

Marine Division of tle I Marine Amphibious ('orps landed on 1 November at Empress Augusta Bay

in western 11loigainviile. In 11 November. ei•mtiits of the 37tih DivisiAbn entered the line. On

1 ) December. command of the leachhead passed to the A.merlean XIV Corps. which had been

reinfi••iei 1y the Ameri•al Division.
I I A I~ K I A' I I I II,

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4 4 I :,I

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4''"',-. -I411,' III•'ll lii ' I;4't' 414.,1 4444 - 441:411 ' I' \\:41,• 21 , 1 , n ',, l~t'4 - '1't ,,4 .11 1 1'1 , k', -I

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804 AC'riVITIES' 4)1" SURGICIAL 44)NSVLIA'ANTrs

lTuesdlay, 19 Octob~er

L4t. Col. Paulit K isni.. M('. nd I left Noutl-a in a stall varn! at 07:30 to drive

tol 1latiiA de ( a iacs, a dlistan lce of 1604 miljes. Th road 1l, * % . (I 114)tlioltpar Wa

ver rou11gh. We arri ved at IBotI rail. II eady jimtier-s. New/Zn alin I Forces. S utt I

PtI ailiv, at, 12(m41 and had 1 iinei Witlli C olonel Twhligg. I avcqitired a ntew pair olf

New Zealand( army boo(t s, and thlen onl to M1'aine de a iavs at 1041). Wse looked

over the h~ospital there anid hlad a good supper.

Theu 331:st Stat ion H osp ital 110w ha~s 5(1O bleds andl 50 mlore that are ailmost

ready for occuipancy. Maj. I Iu1go A. A-mcli, MC,' is commnnnding officer and has

oelieutenant Who assists 11111!. H~e is doing a1 goodt job d~evelop)ing thie

hosp~ital. Laboratory facilities are meagrer. lie has had1 quite a nuimber of

accidents frotil thle A'F( (.kit- Tranisport C ommanatd) base. Eight pat ienits

-with burn-Is have Ilecli treatedl. one oIf whoiti died. Tbe groun(ds are very dirty,

andl iunder thlese condIit ions 1)11111 t reated wvithi paraflin call easilyV Iweotle

inlfec-ted, as th~ese (lid~. nhey soon1 after adioptedi tilie practice of i)ala(Iaging these

b~urins. Hi s equipment is goodE anudo lie has no nieeds excep~t for miore Iiie(ical

A fter supper We drove baek to) Boura ii w1here we sloppledI at tile New

Zealand H osp~ital. U p at M15A4)and arrived1 back at Nomniua, Iloolit itie. D uring

this 2-day trip, I Wore file seat out oIf a1 new pair. of coltolo t rouisers. There is

11(1 arffttll~ellt ablout t riitiiti aggVraivaint p141111a cysts.

Friday,2 October

Visited the :; 1st Statio Hot llspital toda 'y. Lt. C ol. C orrell P. Youllials. MIC.

is commtiand~inig officer. Ibis is thle b~reakdlownl of tile I liiive-s-ity of Minnesota51t

hosplital group after' a cilailgre it, 'v/"( ). '1'ere are five yountg and14 energretic

suirgeotis here. They should( hav1 e .1 ('hlief of 5111'grery Sent inl if t hey ar~e goting

to expand 1o) a 500)-hedl hosp1 ital. Not that thle young mieni are bad. I ll t hey

are imm atuitre.

Six hiundred p~atienits have ibeeui t ransportedl here by atit- silli-( 1-) September.

TIhese are seen at Tontotita Airfield by the 31st Station IHospital mnen. The

sick cases are kept at.t the 31st Station H ospital and thle others are senit onl to

the 8th General Hospital. 'Matiy pat11ients Wh1o) have recentitly b eeti op~erated1 oil

have been shipp~hed dlown here. Thlese surgeonis are object ting t4) wh~at ha~s heeti

(lone at. other hospitals. A dlirective is needed regardlinig re-or(Is and~ X-ray

p~rocedlures. They think thlinto 101niaiiv cases Withi simpijle a ilmenets are beitig

evacuiatedl. Besides, palt ieints wvith lps~closis arte b~eing~ sent (dowin W~ith Ian

ot'gatil dC itagnosis, Whliich thow hS tiO em oft thle trail here anid obv iously imakes

treatmtient mio~re dlifficulit. Thiis is a ranther dIi-t v hlospital. hot. and14 oil low,

Iliosoptlito-ridlole grolIinls.

l;slliritui Santo0, Monduay. 25 ( )tober

I left this morning with Ben Bahker oti a, Navy- 11 ' ing bloat. Left at 1204H).

Sindhwichies and10 coffee seorveol ell rolitte. Stopped at E fate-I[a vatilali H a rbour

is full witll) bat I ewagonls. Arruived at Espiritui Santo. 17:34 houirs. St ayed at

the 2-5th E'vactiat tonl I lospitatl.
FRIOM AU'CKLAND Tro TOKYO 80 5

Tuesday, 26 October

Saw Lt. Col. Arthur G. King, 31C [Surgeon, Service Command]. lie is

not doing a had job-efficient. Sotiehl's orders arrived (assigning him to SPA

[the South Pacific Area] as orthopedic consultant). The 10th Medical Supply

Depot uAder Capt. E. Lucas is doing better and is nearly all undercover. Found

three anesthesia chests and two field sterilizers. Visited the 122d Station ]Hospital. Major ('amp seems the head here and he has done at good job planning.

The hospital now has 500 patients, although capacity is rated at 1,000.

(4uadalcanal, Wednesday, 27 October

Arose at 0400 and after a good breakfast of ham and eggs we took off

for Guadalcanal in a 11-24 Liberator.

Arrived at (ruadalcanal 0930 and reported to the 37th Division headquarters. Met Col. Edward J. Grass, MC, a pleasant division surgeon from

Washington, I).('., who was very cool)eratiive. lie plans on using surgical teams

in the collecting stations. This should work out. well, since there is a collecting

company with each combat team. For a second echelon hospital, we shall use

the clearing station. Will the combat operation be such as to make this

practicable? Distance is the determining factor. Major Bliun, Commanding

Officer, Company 1), 112th Medical Battalion, is a fine fellow. There is the

utmost spirit of cooperation, and I think that the venture will succeed.

The supply problem has not been cleared Ul). Plaster of paris in cans has

been issued in quantity for the combat, teams, but only 24 dozen bandages are

on hand. We will change that. Prophylactic kits are still being issued, with

no females within 1,000 miles of here. Other uses have been found for them,

such as covers for pistol barrels, watches, and pocket drug kits. Started Atabrine therapy today. Two ships were sunk offshore carrying power generators

for the 37th D)ivision. Mono was taken i)y the Marines today.7

Tlhrsday, 28 October

Went over the supply question with Lieutenant Rhodes, medical sup)ply

officer of the 37th D)ivision. The maintenance lists are not adapted to this area.

There is a surplus of some items; for example, mops, prophylactic kits, tons

of cotton, and not enough of other items. What good are mops with no floors

to mop? 'We talked about the plan for surgical teams. Since they still do not

grasp the principle of time relationship in the treatment of casualties, it will

take a lot of conversation to convert them. There will be trouble getting

lighting facilities, since there are no generators.

Visited Capt. George Ellis [Capt. James AV. Ellis, MC, USN], Surgeon, 1st

Marine Amphibious Corps, at the old Imnerial Japanese Headquarters--a

lovely site on the beach. Emile Hlolman I[Cdr. Emnile F. Hlolman, MC, USNR,

Surgical Consultant, 1st Marine Amphibious Corpls] was there as a consultant

surgeon to the Marine Corps. They plan to evacuate serious casualties from

Bougainville to Vella Lavella Island 1w destroyer, which again means from 3

I See fttotnote 5. p. 802.
806 A(1'INITIEs OF SURlGICAL. CONSULTANTS

to 4 hours by boat, and a total delay of alpproxinitately S or 12 hours. It will

be interesting to compare Armny methd Nv(1 ith those of the -Navy ill tis XSop)-

eration. Only the two anlesthet ists, Lieberutian and Ros, hae arrived so far.

Friday, 29 October

Plaits today for the miovem-ent of three comb~at. teamis. The plan is to use

suirgical teamis in the collecting stat ions. Time two surig-eonis, one anesthetist

andl two) corpsnien of the surgical team. with its extra equipment, will1 be attachedl to the four officers and meti of the collecting comp~any.

W~e have no generators for time collecting Comnpanyv, so I have spent the day

in pursuit of three light generators and so far have. fo;und none. "Major Sinith,

a plasn fellow from the Engineers, offered one 5-kilowatt. generator weigrhing

1,800) pounds-a line pieve of eqllipinent, but a white elephant to mlove. Eleven

grenerators were lost. iu the two boats the Japanese smunk oif the shore the other

(lay. Why (10 they still put all their eggs, in one basket? The -Navy dloesn't

have. any either, so they say. The Seabees are making three plaster supports

for shiouilder sp~icas,iusiniglheav-y steel since it. is the only thing available. Weight

couldlbe saved by using an alloy.

Acquiredl a carbine today. This is a tine ouitfit :Colonel Grass, surgreon;

Maj. John Blitin, commanding officer of thle clearing company; and Vie Kolb,

ani excellent. officer. They put on a fine review this afternoon.

Saturday, 30 October

Went to see tile the 11 7thi Engineers about digging in for operating rooms,

and so forth. Surgeons for tile teamis arrivedl today. They are Shackelford,

Watson, Manwel I, P~ost, and Troland. Three anesthietists, Schulman, Rose,

andl Lieberman, an bceiologist, Michael, also arrived (fig. 316) ."

Monday, 1 November 1943

Navy satdselnBogivleyterday. Had conference with General Beiglttler [Maj. Gen. Robert S. Beighitler, Commnanding General, 37th

Division] aimd staff this morning.

Fridlay, 5 Novemtber

Abusy few (lays, mostly spent in gathering supplies. Eighty-eight hulndred pounds of sup~plies were supposed to arrive onl tile ('irreg and ldid not.

H~eadq(uarters, I-SAkFISPA, informed its by radio that thley were Putt oil tile

b~oat. After I btad givenl them a rep~ly, we receivedl a radlio saying~ thlat tile

supllhies had been found andl were to lbe shtipped by air. 'Yesterday 3 4 o f 4,8

boxes arriveol. Today they were sortedl and~ pult aboard shipu. Almost. all p~er-

"soltnel were onl boardl todlav. )on~t knowv whtere I ain supposed to be. hblt I

will board thie Pie.;(denit Attfimtoltilorrow.

lite cooperative spirit and itmorale of this division, atnd of tile officers and~

mtent of time forward area, appear womtilerfill. Tite soldiers are nlot wvorriedl

ab~out tilie outcome of thme war,9 bittt -ae fill] of doub~ts antd fears for tile

So far as~ t hey eou ii lie lIden t ified, thesei officeers were : ( a ;'t. willhia G. Waitsn Nii M . '. Mn j.

Edwanut JT. Ninnweil. Mc. va:pt. Cliairl..-u E. Troiandu. MC. Capit. Hiarold C. Schuinimai. Capit. M1ax 'Michael.
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808 ACTIVITIES OF SURGICAL CONSU'LTANTS

leaving them open for infiltration. The Engineers have promlised to dig us in

with bulldozers, if the road comies up with us.

The weight and transportation of equim)nent is a big problem in island

warfare. Each team has a 250-pound chest full of instruments, et cetera. In

addition, I have provided sterilizers, autoclaves, anesthesia machines, suction,

generators, orthopedic tables, etc. The equipment should be as light as possible for this type of warfare. For example, the horizontal field sterilizer

weighs I350 pounds crated. Equipment could be lpermanently attached to a

light truck without great loss, since the truck engine could be used to run the

generator. So far I have seen no operating installation where a truck could

not get to. IHowever, one disadvantage to a truck would be the difficulty of

digging in and the fact that it might be damaged as a result of bombing. This

campaign should enable us to discover the best method of handling our

equipment.

It is obvious that the clearing company T/O is not adapted for this type of

-warfare in which combat teams operate independently. The clearing company

has one set of equipment and two clearing platoons to be divided into three

small hospitals, which is impossible. I would suggest that, given this situation,

each combat team should operate as a self-sufficient unit with one collecting

station and two small hospitals for each team. Two hospitals are needed in

order to "leapfrog." If need be, the collecting stations could be combined with

the two hospitals, one of which would operate as a surgical hospital, and the

second would care for routine cases not requiring skilled surgery. Thus, if

there is a danger of infiltration, they can be combined: hospital number one

with number two, or number one with the collecting station. A field hospital

can be used to back up the division, both as a rehabilitation camp and to hold

patients for evacuation. We will watch this operation to see how the arrangement functions.

The President Adam-9, Sunday, 7 November

We left Guadalcanal last night at 0100, just as the moon went down. I

had a good sleep in spite of the fact that it was hotter than Hades, even with

the fan working. This morning we had a wonderful breakfast of ice-cold

grapefruit, ham, eggs, toast, and coffee. I can't tell how large the convoy is,

for the ships extend further than I can see. We are sailing up through The

Slot. New Georgia is on our left and Choiseul Island will soon be on the right.

The news says that the Japanese are sending down large convoys from the

Truk Islands naval base. A lovely day, with a gentle roll to the sea and lots

of flying fish. Apparently we have plane protection from the adjacent islands.

Bougainville, Monday, 8 November

Bougainville, 1400 hours. An uneventful night, but hotter than Hades;

cloudy and raining, so there was no bombing. A lovely clear morning-could

not see land yet. It appears that we came straight. in. The cargo ships are in

line, with destroyers on either side. The island has a beautiful skyline wvth

rugged mountains and two volcanoes that are said to be active. One of them
FR()M AU('KLANI) To TO)KYO 809

is directly behind the landing point [Emplress Augusta Bay]. Our guns are

firing west at the Japanese lines, where they landed several barges last night.

As far as we know they have no artillery. We were ordered to land at 0850,

and in less than an hour there was nobody left on board but the crew and some

supplies.

The terrain near the beach is lava sand, with some swami) behind. However, it is fairly dry now. Tremendous confusion on shore, but after about

two hours we found the clearing station and the collecting station. We will

stay 1)ut here for the night until a plan of the campaign is given us. At 1100

hours, the Japanese came over. I guessed that there were ab)out 25 to 30

planes, later found out there were 70. The ships had 15 minutes' warning and

pulled out to sea. The sky seemed full of ack-ack and planes. I hear that

one of our ships was hit but stories fly so thick and fast that you can't tell

what is really happening. hlal Sofield just came ul) and told me to put in

my diary: "The Adrms was hit in the stern a half hour after we debarked."

The boys already have the barbed wire up around the clearing station. I have

dug a foxhole and put my jungle hammock in it, since we must all stay underground at night.

Tuesday, 9 November

There has been very little infiltration of Japanese. Only a few casualties.

The 37th is to take the left half of the 1)erimeter. The Marines have a clearing

station in this sector, and so far are doing the surgery under poor conditions.

They don't have screening and the debridement is very crude. There is a

division hospital (3d Marine Division, I Marine Amphibious Corps), with a

D)r. Bruce [Lt. Cdr. Gordon M. Bruce, MC, ITSNR], an ophthalmologist from

New York, in command.

Wednesday, 10 November

Some trouble today on the right flank, about 90 Marine casualties. The

beach along the left flank is being evacuated by amphibious tanks. I saw

returning tanks, loaded with our dead. We are not yet set up for operating,

although fortunately it would make little difference if we were. The planning

of this clearing station has been noticeable by its absence, partly due to lack

of information, and partly because we are waiting to take over after the

Marine division hospital moves out. Finally found Captain Ellis of the

Marines in his headquarters about 100 yards b)ehind us in this extraordinarily

d(ense jungle.

Thursday, 11 November

0800 hours. Armistice day and a good joke on the well-known human

race. On the present model, all days will eventually be armistice days. Six

hours of bombing and strafing last night, from 2000 to 0200, with many

humorous situations and much shouting and conversation in one syllable

words. Some fellows stayed in the foxhole, but with a little practice, I found

I could beat the best of them in the race back. The only trouble was that the

first in was at the bottom of the heap. The landing craft carrying the 'Marines
fI.4w~ II 44v11:1111 :11kick I4'll4I4Ile -'i Ii Il. \IIm 11I4 ~±44I ov '-Ir I'2i:I '':4 ' Ii- 4111 r, v4III

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FROM AUCKLAND TO TOKYO 811

ing with six of them inside my net. Air raids last night at 8, niidnight, and

2, 3, 4 and 5 in the morning.

Sniper tire getting closer this morning. The NCO's at the far end of one

tent started shooting at what they said were Japanese. The Japanese had

infiltrated throuzh this area at the beginning of the week, and shot at the

corplsmen in the Marine hosl)ital. I was not too coifident and so got out my

carbine. The orders are to shoot anything outside the area that moves. Hence,

the boys are likely to try out, their gnus. Sone of the Japanese snipers are

broulght down l)y this method, and. of course, if one of our boys imioves about out

there after dark, he can only blame himself for the consequences. The .Japanese

infiltrates in the night and usually climbs a tree to await his opp)ortunity at

daylight. One of them waited until the middle of the day when there were

plenty of people about the hospital, and then opened up with a machinegun.

Fortunately no one was killed, but several were wounded. This is of course

suicide for the Ja')anese, for lie never gets away after that. The 129th Infantry

came in, but could not land all its men owing to the high surf. Ben [Baker]

and Kaufman [Lt. Col. Moses R. Kaufman, MC, Consultant in Neuropsychiatry, USAFISPA] arrived.

There is dissension between the surgical team and the clearing company.

The surgeons were restless because of the slow progress and lack of organization. Surgical patients were coming in, and the surgeons were not being asked

to see them. The clearing station personnel, who are not surgeons, were attempting to do the work in the same old fashion. I have asked Hal Sofield

if he can get the teams organized and build an operating room. We have, been

here 6 days with nothing much to do, and still no adequate operating room.

There is no provision for blood transfusion, no hemoglobinometer or microscope. These were to be b)rought up later. I am not. yet sure how this experiment of ours will work out. This is a loyal outfit, and for anyone to show

them up is of course disastrous. Even though they admit they are not firstclass surgeons, nevertheless, the demonstration of this in front of their own

company is too much for them to take. I am inclined to think that surgical

teams must function as separate units under a separate command. They

cannot be held responsible for good surgery without good surgical equipment.

and it appears that the teams do not have enough authority to get things done.

The unit should have the responsibility under the division surgeon for all

surgery in the forward area. Clearing stations, which are without first-class

surgeons. cannot. )e expected to turn out high caliber work.

Sunday, 14 November

We are experimenting with putting one surgeon and one anesthetist from

each team with the collecting station and using three of our surgeons with the

three doctors in the clearing station, all this in the interest of harmony. I

am putting up General Breene's sign, "We are fighting the Japs and not each

other." ][al has been working on the surgery. He has it above ground in a
812 ACTIVITIE iOF SUIRGI('AL C0NSUITANI's

tent. General Beightler came over and immediately perceived that being

situated next, to the antiaircraft guns was not the right place for us. We will

miove ill 10 days, but having a surgery is worthwhile even for so short a time.

The Japanese are trvyig to come over here thbroughl two mountain passes.

Moinday-, 1.5 Noveu)eme

We opened the surgery today although it is not yet screeiied. The plaili

facts are that the medical men of this outfit. (1o not believe in the lacterial theory of disease, or. if they do, they do not appreciate its significance. It is

almost. hopeless to expect that directives or conversations will quickly change

the prevailing concel)t of surgery. I have yet to see a surgeon who did good

surgery at home do bad surgery in the Army. It is miy opinion that the sloppy

surgery I have observed in the Army is merely a reflection of slol)p)y surgery

ill civilian practice.

The T'abot, Guadalcanal, Wedlnesday, Thiursday. 17, 1S Noveml)er

Sofelhl and I were at tile beach at 0730 in ordler to go to Vella Lavelhla

with I)atielnts. A Japanese attack came at OSO0. I don't know how many

1)lanes there were, for the air was full of both theirs and oturs. It was fascinating to watch fhe 90-mnm. shells following tile plan)es. The marksmanshipl was

very poor, for the crews were not leading the aircraft. sufficiently. They were

too excited and shot at anything ill sight.

We finally put off for the Talbot. an API) (transport, high speed), and

ha(l the 40 l)atients aboard by 1030. For some reason, we circled around mitil

1400. Then we started out for Vella Lavella, at 22 knots.

Wlhen we approached Vella Lavella, our orders were changed anid we went

on to (Gadalcanal, arriving at 1000. Ihence, the trip by fast destroyer trailsport took about 24 hours. There was only one doctor on thie ship, and operating

facilities were meager. P)atienits were carried ul) and down steel) companionways--no way to treat an acute belly. The captain said this was a usual performian'e and that the schedules of the API's were not correlated with the

needs of the wounded. Two patienits have (lied in transit. Both were in shock

wheul p)ut aboard. We went to tile. 37th Division real- echelon headquarters,

where Colonel Moore gave us some beer and clean clothes, and then to the 20th

Station HIosp)ital.

Friday, 19 November

The 20th Stat ion Hloslpital h,,, poor niorale and is doing p)oor surgery. The

least that should l)e dlone is to give them a strong conimandingr officer and a

goodl su rgeoui.

Saturday, 20 November

The 251 ih Division needs more doctors. They now have 235 anld should have

49. They could then send out two anesthetists to train others. The 21st

Evacuation HIosp)ital is being set ulp, as is also the 137th Station Hospital. The

9th Stat ion I osl)ital has not Yet openeld its surgery. Sofield and I talked to all

the doctors on (Guadalcanal today, including Army surgeons at the 20th Station,

137th Stationt. and 21st Evacuation Hlospitals.
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814 ACTIVITiE'S OF1 SURICO(AL CONSULTANTS

stilted in. late treatment. with loss of life or hlld) and~ p)r(long-ed Convalescence.

It sholdOl illustrate the imp1 ossibility of laying downi a standlardl T,/( for a worldwide war fought undler varving conditions. The surgical teanms should carry

mtore than t w() miedical teclllliciailS-I)05ihlyl six. Men sent. into thle area f resh

from the States slhouldl not be sent directly to divisions in coinbat. One-third

or one-hialf of thenil will usually Show 1ii) IpoorlA.

TIhere is a, general request. from (doctors for sonme sort of postgrahduate

trainingr, since ninany of themi have done not hinc, but administrative work since

thle war startedl.

A urologist and an nellrosujrgreon are ticeded at. the Sth General Hosp1 ital [New

Caledonia]. They need three-way stop cocks for anuesthesia. Order book,

"Fundamentals of Anesthesia,- for distribution here. Emergency 'Medical

Tags and~ indelible p)encils are needed. Recordls of the p)atienits comie downi

late. D)ivision will not. send time service records of their men to hospitals because

they are afraid of p~ermnlenltly losing their hosp)italized p~ersonlnel.

The 109th Station Hospital [New Caledonia] hias 24 officers, andl it should

have 33. Theiy want Liebermnan and~ need a Medical Administrative Corps

officer, an EEN T luau, and] some more. enlisted men. An optometrist is needed

for both the 17th and 24th Field Hospitals. The 43(d Division is short. eight.

medical officers, two dentists, and a large number of enlisted men.

The evacuat~ion from B~ougainville was p~lannied by Captain Ellis of the

Marine I Amphibious Corps. While at Gruadalcanal, we wvere told that everything was settledl and that. casualties could be evacuated by APD in 3 to 4 hours

to Vella Lavella Island. Just before leaving GuadalIcanal, Ellis saidl this was

a~ll off; that all work would be done at Cherry Blossom [Bougainville], and

the Armny could have the installations at Vella. On arriving at Cherry Blossomn, wve saw that all of thie work was not. being (lone there. Some pant ients were

b~eing taken directly to APD~s and transported to unknown (test inat ions. I

later met someone wvho had just comle front Vella Lavell~a. Ile told mie that,

t hey had not, received a, single patliiet, t here. Mloreov-er-,thieti-il)fr-om louigam-ii

ville to Vella. take,- 10 to 12 hiours and not 3 to 4 hiours. Emnile H olmian was

there, tearing his hair out..

Tuesday, 23) November

The above was written while sitting on the beach at -New G1eorgia. We

took off in a Higgins boat. The youngster in chargre dr-ove to the wrong side

of the marker, ran on a reef, andl then finially dlepositedl us on shore. After

a, 4-hiour wait, we got another b~oat that took uts to Ondongo Islandl. Cordially

receivedl by the Marines, wve, were treatedl to excellent. food, had clean towels,

and setbeweshts in onie of their quoniset huts. Tomorrow there w~ill

be a p~lanle to take uts back to Bougainville.

Bouga inville, Wednesday. 24 'November

We took oil at ntooni with Genmeral Harris [-Brig. Geni. F~ieldl Harris. U.SMC,

(Comumander, Air Conmmand, -North Solomuons] in a Di)unbo (patrol lboinber.

"CatnI inn") wvithi a very competenit pilot who had beeni decoratedl at MidwaY.
FROM AUCKLAND TO TOKYO 815

Escorted by 10) fighter planes, we arrived at Bougainville inl 112' hours without

incident.

They have madle great p)rogress here. and thle clearing stations have been

mnoved1. The boys had inany stories of bombhing. strafing. anld shelfling. Ben

[Banker] produced the head of a 90-nun. ack-ack shell, which came through his

tent and p~unctulred his rubber mattress.

The Marines rep~ortedl having had eight cases- of gas gangrene. Their

evaculation is not comipletely controlled, aind soime of the patients have beeni

pult onl the. boat without receiving prior treatment. A considerable number of

patients dtied inl transit. Colonel Melvin toldl me of 12 onl one LST. Twvo dlied

on an APD from Bougainville. A complete aInd uimified con trol of craetatioll

from. aIn ;Wandl~ is )eewCC8.a)

Thutrsday, Thanksgivning Day. 25 Novemiber

O nly one plaine dlroppled its bombs onl us last night. 'rue ~Japanlese have

some art illery inl and are shelling the beach. We had a fine Thanksgiving dinlner; very gotukyw th stufing, catiii flowver, peas, mashed potatoes, pumpkin

l) ie, Ilusecious lbiscu its, anld coffee. I ate too mnuch as iisutal.

Thle construction onl the island is developing very rapidlly. Planes are

now making emergency landings and takeoffs.

Friday, 26 -November

Last nighlt we were shelled by Japanese artillery anld today everyone is

(igligrTi~ deep~er. There is still inertia about gfetting patients umnderground.

They are screening the operating room todlay (fig. 319). The surgical teams

muilst, have the resp~onsibl~ity for b~uildling andl operating the surgery and filr--

nishing its supplies. Supp~llies, suich as screening. sandbags. et cetera, should

not be left, under thle supervision of any other branch of the service. Experience

showvs that thev- are not likely to be onl hand wvhen needed. Furthermore, these

supp)Ilies shouuld go in with the first wave. when casualties are likely to be heavy.

Saturdav. 27 -November

Last night. the first night onl Bougainville without ail alert, I had a wonderfuill cool, refreshing sleep) Onl mly air, mattress. Army casualties are still light

here. T[le doctors of the 37th Division have requested that wve give nightly

lectures onl mledical top~ics.

Sunday, 28 -November

An unieveiitful dlay. Listenedl to Chapla in Kirker I Lt. C(ol. Kirker, 37th

D~ivision chiallainl] talk onl "Tlruie and~ False Trutlm7 I remarked that the boys

seeilie(l very initerestedl. "Thmat group) was christ manized by bomlbs biefore we

got. here." said lie.

Monday. 29 November

*Went out on tlie rig-ht flank to vi]sit a biattal ion of the 145th Infaimtry Reginii-lt. wh-]o are wvithI time Marines. Went tipl to wvithiin 500 feet of time fronthines.

boot I (oiiltl see nto .Tapamiese. probably owing' to thme fact that time la1i1d is a dlense

swvainl excepit along t lie beach. AboutIw D)00 -Mamrines si nick the beach I Koinris

Beach] below here last nighit. 'I'lev sufferedl -to percet casualties and were

luvky to get back with the help of a dest roverl. Last iiighit tilie .11panlese shelledl
I~ ~ ~ ~ ~ il ~ ~ i ~ t vtll'IIIl ~tilVII'II ~ ~ ~~~\ T~ lI 'i V Isi It II " Fti tIl St lo It 'A1 tINS1 ~ t 1; AN . 1' 

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FROM AUCKLAND TO TOKYO 817

Fresh supplies of meat, oranges, et cetera, are being unloaded today. The

food on the whole has been very good, and there are some excellent cooks and

bakers here. Sanitation is not all that it should be, owing to the laxity of the

medical otilcers and their failure to appreciate the importance of good sanitation. There were almost no flies when we first landed; now there are swarms

of thiem. Even after a month very few niesses have been screened. However,

we have had no dysentery problem.

The mobile surgical units, mounted on trucks. wouhld l)e a tremendous asset

in this kind of warfare. This type of setup would save much labor, while providing facilities in the early stages of combat. I have vet to see a place

where a hospital was needed that could not be reached bya these trucks.

The foreign body localizer is valuable, but. it should be constructed to

stand u1) under (lamip trol)ical conditions and function on a battery. A blower

is needed to dry plaster casts.

Guadalcanal. Monday, 6 December

Took off from Cherry Blossom in a Catalina yesterday at 1600. We skirted

the edge of the island with 10 fighters, then over to the Treasury Islands, and

landed at Ondongo at 1730. There were no planes going to Munda, so we

started out. in a personmel boat. With the aid of a light, great caution, and

good luck, we made a landing in pitch dark at 2030. Colonel Hanson came

down to take us to the 24th Field Hospital, where we had a good meal and

quarters.

This morning we took off by SCAT for Guadalcanal. Colonel Caton is

using the 21st Evacuation Hospital for all initial admissions on the island.

Patients are distributed from there to the other hospitals. Visited Colonel

Taber at the 52d Field Hospital.

Tuesday, 7 December

Two years today since Pearl Harbor. What would people in the States

have said if they were told at the time of Pearl Harbor that in 2 years Japan

would have achieved most of its imperial aims and have conquered the Philippines, Malaya, and the D)utch East Indies, and that all we would have taken

back were two or three islands in the Solomons that few had even heard of

before.

Spent. the (lay with Paul Kisner at the 20th Station Hospital. He is already beginning to bring order out of chaos. He wants a chief of surgery, for

he cannot raise the level of surgery by himself. He also wants a laboratory

man, a trained lab technician, and an eye man.

Visited Mobile 8 and talked about (lebridemnent and( gas gangrene. They

hav-e had about 300 compound fractures with 20-phis cases of gas gangrene,

resulting in 2 deaths. The estimate is that 8 to 10 percent of the patients with

compound fracture have gas gangrene. Treatment was conservative for the

most part. The cases from Bougainville came in with either poor debridement

or none at all. I saw some cases, in which the patient had not even been

sha vedl.
Srl '
FROM1 AUCKLAND TO TOKYO81

Nouinica, Wednie~sday, ý IDecenihier

Off at 083'( for -New Caledonia with freight cargo incluldinge a a,000-pound

Allison motor, It, was railmiimi, and we wvent up over 10.000 feet to get out of

the bad weather-very bumpy ride. I kept. wvondlering what we would do0 if the

nmotor got loose. However, we landled at 1430 withiout mishap, and once again

sat dowvn for cocktails at the Grand Hotel Central.

Friday. 10 D~ecember

Much surprised and pleased to receive a promotion to full c'olonel today.

It. looks as though IhalI Solield wvill be assigned with me as orthopedic consultant.

Tuesday, 14 December

Spent. the last 2 days trying to gret boat passagre to Fiji, but gave up owing

to the wveather and wvill try 3LATS [ Naval Air Transport Service].

Wedlnesday, 15 IDecember

Foun B ou Baer tht nd aufan hd rtured.I [ardlthat inolile

surgical hospitals were oni thme way. Will thievy have q~iajihed sulrgeonls? Read

Churchiill's [Col. Edward I). Churchill, M1C, Consultant in Surgery. North

African and 'Mediterranean Theaters of Operation, 1.S. Army] report on

-North Africa. H~is problems aire the same as thos-e mnet in this theater.

Fiji Islands, Thursday, 16 December

Off at 0800 for Suva. arrived 1330.

Saturday, IS D~ecember

Flew to 'Nandi wvhere I was met by (101onel Ruppersberg, 71st. Station

Hospital. While at supper. imuch to myl sUrprise, in walked G4en. George C.

Marshall. Ilie stayed for a few minuitecs and rushied on. Ile appears to be

vigorous and full of energy. I talked to thme hospital staff this eveniniig.

Sunday, 19 December

'Went to the 7thi Evacuation Hospital in thme morning, and gave a talk there

at lunch time: thien to Amnerical Division headquarters from 2 to 4 o'clock foiatalk; after that back to the 4 1st, and a talk from 6 to 8 in thie evening.

Mondlay, 20 D~ecemuber

Flewv over to -Suva this morning and spent. the afternoon at the 142d1 Gemioral H~oslpital. Talked to the 182d Infantry [Anmerical D~ivision] in the evening, abo0ut to embark for ('herrv' Blossom. The 142d General H-ospital hias a

fine plant, and I amn told that the Fiji Government prop~oses, to take it over

after the wvar. T1his hospital is doing a g-ood job in pilonidals. Tfhey had a

large numiber of cornmeal uilcers amiong the survivors of a torp~edoedl ship (fig.

321). Trme exact. cause of this is iinknownim nd the really bad ulcers, cause

permanent (damage.

Lmmc.;m 3t20.-T'hey are Well pleasedl witi ilie surgical teamis.- Bougainville. A. A

surgieal team opterating in its un(lerg-round surgery. The floor is ab~out 4 feet beiow ground

levei: the sides are built up) with sandbags. and it is rooted with hieavy log-, (Left to

right: Capt. Charles E. Truhiaid. 'mC. Assistaiit surgeon : Sgt. William T. Mamrsden, Scrub

Nurse; captr. William (;. wat-sfon. 31C. Chief Suirgeon (Capt. Harold ( '. Sdinliman, mc,

Antestheptist.) 1B. A surgical team, operatiiig iii a (ieariiig statimn, 17 1 )ecenm1er 1943. Note

hle improvised ligihting anda the use of cE)IIbiflod intra vel415ii tid elidotracheal anesthIesia.
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FROM AUCKLANI) TO TOKYO 821

talent in the affiliated hospitals, which appears to me to hinder the total war

effort. Such men may set a high standard in these hospitals, but, as in civilian

life, they have too little influence on the total problem. Their influence is even

less than it would be were they in civilian life, for these rear area hosp)itals

cannot function as educational centers. Tlhe portable surgical hospitals, as

judged so far, are not fulfilling their fiinction, because they lack qualified

surgical personnel. -No amount of good surgery in the rear can Imiake ill) for

poor surgery at the front.

Wednesday, 5 January

I atil starting an educational program--have acquired a 35-)-1m. l)rojector

and am now baving film strips made. It seems to me that this has great

possibilities. I have designed a fly net to be used inside the tent.

Met Captain Hook [Capt. (later Rear Adm.) Frederick It. Hook, MC,

USN], Chief Force Surgeon, Navy. lie is a fine person with a good knowledge

of surgery and a determinat ion to get things done-the best of the lot. Surgery

in this neck of the woods will unquestionably improve under his influence.

Guadalcanal, Tuesday, 11 January

Off at 0500, island hopping to Bougainville. Left Tontouta Airbase, my

first. stop, at 0900. Arrived at Espiritu Santo, 1200. Left at 1300, arrived

Guadalcanal, 1700. Stayed with Colonel Caton at the service commanud. lie

is dubious of the 137th Station Hlosl)ital, and the 9th Station hospital has

not yet p)roven itself surgically. The 21st Evacuation Hospital is now ready to

move forward.

Bougainville, Wednesday, 12 January

Up) at 0400 and left Hlenderson Field at 0530. Landed at Munda where

we picked up a fighter escort and left again at 0810. Arrived in Bougainville

at 1000 and landed on the new bomber strip. There has been an amazing

transformation on this island in 6 weeks. Forty miles of roads have been

built.

Thursday, 13 January

Went over the sul)l)lies of the l)ortable surgical hospital with Colonel

Hlallam. Together they weigh 8 tons, so our next 1)roblem is to break them

down for at least three l)Ur)oses: (1) To function intact (adjacent to a

clearing station or in a stable situation), (2) to function adjacent to a colledtingr

station in a forward area-cal)al)le of being easily l)roken down and relocated,

and (3) to function o'er ldistances and thus be air tras!sportable. Max Michael

will instruct. on blood transfusions a id faliliig-drop l)roteili imiethod I for

henmatocrit determination ].

Visited Colonel Coll ins, diivisioln surgeon, at the Akinerical i)i vision. They

have an excellent operating room setup, neat and screened. They have no

definite scheme yet for a convalescent camup. Each division plans on operating

its own caop, and there must be a third one for the nondi visional units. This

setupp has its advantages in that the doctors know thei men from their division.

But. no one has considered tile inefliciem'cy of operating three camps when one

would do.
822 ACTIVITIE'S OFI SURGICAL CONSU'LTANTS

vi'e i52d Field H ospital is lbeing~ set ili). Major D avidson, a l)1,(rgllt yolimg

chap, is Chief of Surgery. Ile may (t0 all righlt, or b~et ter. Thle surgical teamis

left. B~ougainiville thlis muorming.

I've. been giving talks every night. The 37th D~ivision has had an increlase

of nieuropsyclijat vic pat ients andl raises the question of a correlation between

this and thle use of Atabrine. The mosquito niet tent has prov~ed a success.

We. will nieedl 15 per (division for a1 start, though the teiits wvillI have to lbe reinlforced at the top and at the door. Collecting companies shouldl have a larger

sterilizer (14- or 20-inch) and blood pr1essure~ al~laratus. They iieedl a small

autoclave. for these, units often occupy) isolated p)osit ions. Each clearing st ation needls a horizontal field sterilizer. Manmy of the gas casualty kits have

dleteriorated andl needl replacement. Ambulance lleadlli~rl~ts shiould be sent up

for thle Amlerical, and tive sets should be supplied to each dlivision. The

Ainerical nleedls Mayo standls. They could uise an aniesthietist. They have

Stokes litters, which should be providled foi. tile other (livisioiis.

I visited the frontlinies today and could see the Japaniese lpositions. This

is beautiful mountain country, andl I was amnazedl at hlow well our positio.as

have been (bigl, in. Some of the aid stations were right onl the rifle line.

Those wounded whvil~e out onl patrol have a bad tune, for a. litter carrv

through1 the jungle takes 8 or 10 hours. Each battalion should have about 30

more mien for litter bearers, as it takes 8 men to carry back 1 casualty over this

niQwedl terrain, anl thle battleljine is so thin) that inifantrvimen cannot be spared

for this purpose (fig. 322) . There are no natives here that could be iisedl as

carriers.

Sunday. 16 Jamniarv

hlal andl I spent. thle Sabbath watching thle, bombing of "Unknown Hill."

As I wvent upl to within 100 feet of the line, we. were greeted by strains of

"Vienna, Waltz." This camne from the 14,5th Infantry and I have never seen

a, more. spic and span outfit. Everything onl the frontline is clean and inl its

pirop~er place, sanitation is p~erfect, anid thle food is superior. The climax of

the mnornimii was the large bamboo settee constructedl by thle conumand post,

with its signi, "for visitors only."

Wle(1liesdlav. 19 .January

I have been giving talks each evening. Each night brinhgs tilie air raids

and tile ineed to get. upl and take cover. Those who are protected ili foxholes

are almost l100 percenit safe. The papers have stated that there is 110 imalaria

on Bougainville, yet the 2)d Mfarine Division camne down with malari a t all

almost, 1 to 5) ratio.

Tile portable surgical hospital nieeds electric headlighits, gowvns, caps, and

hialf sheets. Having 110o generators or sinkers, they are forced to function close.

to the clearing stationl.

Guadalcatial. 'fhirsdiay 20 January

Left, Boimga iiivilhe this m1ornling wit bout a1 fighter escort. Sýi ice one plane

recenitly dlisa ppea red withI all oii board, evervoiie miust nlow weal. Ii feiwlts. No
VOI[A I KLAI ( T4 KY

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824 ACTIVITIES OF SURGICAL CONSULTANTS

the Armed Forces. Colonel Bolend has his hospital well covered from every

angle and call spare three surgeons. We could use such men on our surgical

teamls.

Sun(lay, 23 January

Visited the 9th Station Hospital. Colonel Walker says that he and his

men have lost their pep--and they have. There are 14 officers here who have

been out of the States for 2 years, and they certainly need some new blood. The

20th Station Hospital needs three surgeons--a chief of surgery, an assistant

chief, and a genitourinary mau.

This afternoon we had a meeting of the portable surgical hospitals. Three

of them are good and the other three cannot be used, for they lack qualified

personnel. I cannot understand why such unqualified personnel are given

rank and sent out here to do a jol) they cannot do well.

Monday, 24 January

Visited 40th Division headquarters. Major General Brush [Maj. Gen.

Rapp Brush] is commanding general. The division surgeon, Colonel Ghormley [IA. Col. (later Col.) Verne G. Ghorniley, MC] is a fine person. Ile says

that. they have already weeded out the senile and incompetent. This looks

like a good outfit., but Ghorlnley says that the exact quality of the surgeons is

an unknown factor. Much equipment is still lacking: Three number 2 chests

so that the clearing company can be split up for the three combat teams, three

anesthesia sets, X-ray apparatus, 5-kw. suction generator, NMayo table, instrument table, laundly or washing machines. refrigerator, and reefer.

The National Guard divisions range from good, indifferent, to bad. The

medical personnel of those I have seen have, in the initial periods of their

operation, always had poor leadership, which resulted in unnecessary loss of

life among our men. This tragic situation is due to the two types of men kept

on as division surgeons-the senile and the incompetent. It apparently takes

about 2 years to get rid of these people. Commanding generals usually do not

know enough a bout medical problems to be able to do anything about this

stumbling block. One cannot blame them. One commanding general, who

is a good tactician and has splendid morale in his division, does not know the

difference between general hospitals and field hospitals. I have never seen

a comnanding general who did not want to do the best job pos i)le. But,

just as they do in civilian life, some unqualified and incompetent doctorls sell

themselves on the basis of their personality or loyalty. There. should he some

method of weeding out. such division surgeons b)efore going into combhat, so

as to avoid the unnecessary sacrifice of human life.

Espiritu Santo. Wednesday, 26 -January

Plane yesterday to Espiritu Santo. Visited the 122(1 Station Hospital.

They need an EENT man and a young orthopedist. They are also short three

doctors, but two could hold them for now. 1Moreover, the hospital has 21 nurses

of 2-yea.ms-plus service, of whom 10 are sick ar present. There is a question
FROM AUCKLAND TO TOKYO 825

as to whether promotion of nurses should be done on the basis of .50 percent of

T/O strength or 50 percent of actual strength. As for technical difficulties.,

there is a dust problem in their operating room.

Thursday, 27 January

Visited the 31st General Hospital. The hospital is on a beautiful site overlooking the bay and shows promise of development. They are building the

surgerly and have not as yet taken any surgical patients. The chief of surgery

is a proctologist.

Nouni(a, Friday, 28 January

Off at 0330 by NATS to Noumnta, where I found a pile of mail and other

documents waiting for me.

Sunday, 30 January

Conference with Captain Hook, Captaiii Kern, Commander Reynolds,

and Emile Hohnan. The Navy is loathe to adopt the idea of consultants, since

they have not had the long experience with this type of work that the Army

has had. Captain Hook says that. they must "go slow." They would be

pioneering and would have to proceed by trial and error. The Navy likes the

surgical team idea and wants to use it on its next move. We should supply

them with material on this subject.

Guadalcanal, Saturday, 11 March 1944

This book has been neglected this past month owing to several factors.

For one, I suffered a pigskin heat, rash and probably some mental depression.

I have been engaged in a long struggle to get some things done. The major

projects I've been trying to push through are adequate record and filing systems,

on which the general [General Maxwell. Chief Surgeon, USAFISPA] finally

agreed to back me. I think that lie remained very skeptical though, and I

hope that I have not asked for too much. The following information on each

patient should be recorded: Name, serial number, diagnosis (according to

nomenclature), operation performed, total days in hospital, and disposition.

This will enable me for the first time to answer some questions on surgery. The

Surgeon General's Office has been asking repeatedly for information which

we could not hitherto furnish. A study on wound ballistics has been organized.

Ben [Baker], Hal [Sofiel] and Max [Michaeli got off to New Zealand, and 10

days later, after my work was cleaned up, I joined them.

The 39th General Hospital, with formal flower gardens, is spic and span

as an insane asylum. The interior is also shipshape. I wonder what the feeling of the staff will be when they go home to the ordinary dirt of civilian hospitals. It was good to see all my friends again-good for the ego. Col. Don

Longfellow, MC [Commanding Officer, 39th General Hospital, S. Army

Forces, Pacific], did not want to part with Eddie [Colonel Ottenheimer, Chief

of Surgery. 39th General H-ospital], so we may take Frick on our next] move.

I left Auckland via NATS stopping 4 days at Headquarters [No<umda]

to catch Ill) on some last. minute things. Then I was off to Guadalcan:l. leav-
826 ACTIVITIECS OF' SURGICAL C(JNSULT1AN'fS

ingLotoua t 030andarivig t Gadlcaal 160.Welhad awarm front

and( some. very rough weather bet ween Elspiritu and Guadalcanal. It wvas rainiing, hard at. Gruadaleanal whlen wve arrived. and I went to the 20th Station Hosp~ital with Paud Kisner.

At Guadalcanal, I went ovetr platis and supp~llies with Colonel Ghormiey.

Surgeon, 40th Division-a superior fellow. Saturday night. festivities were

lhe b~est inl tilie Itacvih andl betler t han the miajority of New York ('1111). The

local talent is amlazing and1( inl sharp contrast. to tile WerT a ver1age talent Sent

downvl from tho States. Saw Emile. Holmnan, Bruce, Cahlowvav MeýMa ster and

Rogers. They still know little of the plaus.9

Monday, 13' March

FinneyI Slitherland. 111111, Greiner. MvQttintoni, Trolanid, and Sofield ar--

ri ved todlay. I spent. the day iasingr supplies. Sawv Colonel Lobban and his

stair playiiig poket' ]in the muld, and I extracted three X-rayv techniicians and

tivo stenlogrra pleiers from tile groiij).

WXedliesdala 15, March

Worked on finial preparations and wentf with Colonel Ghlorlinley. Bell

[Baker] andl Mfoe [Kaufmian] to visit Captain Hughes of the I Marine Amiphibious Corps, wvho told its that the show iwas off. Apparent lY. final plans

had b~een complletedl as of mnidnight last night. Quite a letdown ! Reasonls

unknown.

Sat urdav. 1Is Marchl

Thle. FOREARM plan beingr off, our plans are changred. and htil exira

surg1(eons are1p greatly d isapplointedl. Had1( cocktails and a1 Swim in-111i Advii ii al

Halsey and then saw General Hai'inon [Lt. Gen. Millard F. Harmon, Comnmanding Gienerail, I-SAFISPA], who had ju11t returned from Che:rry Blossom

and is havingr rouble with his knee. I had a talk with Greneral Hlarnilon anld

had no trouible. inl convincing him that a wound ballistics study wvas desirable,

and he wiredi inistrucetionls.

Sunday. 19) March

Ev-eryone is feeling optimiist ic Over tile. recent chaigre inl plans. for it looks

as thloughi ma ny lives m ight have been lost.

Tiiesdlay. 21 March

The wvounid ballistics tealli wrill g-o to Bougainiville bY ordler of General

Ha rmon aind at thle re(piest. of Genieral Griswold of the XIV C orps. Persi-sten1ce cert ainlY paid off in this case. The teamn consist s of Ha:1rry Mull, surgeon:

Danl G rei ner, pa thologist ; Frank Siitherlamiui, suirgeon ; two enlisted men, and

oneC phiotograp)her (fig. 323).0

Tbe'hi plin i wfere for the piroposed Invasioin of Kavieng. New% Ireland. Territory of New Guinea, re ferredl to lieren fter liv Its cmode imme14. FORii ARNi, m On 12 Ma rch, te1w aJoint Cii efs of Stijff ean iceimil

tbe Kaisn opieration. P'reparaton iituf ha heni Cur advaniedl. towivvr, aml titi limen mtid ships ftiat

were to Invaude Kavieng ba haluiready assemeibledl at 0 iuadlaiaiu inI

"ISee : Oihi tIerisiii, A shiley W., 1INIi). Iar *n y (7.. Sn I erin iiii. 1Franci is A.. anid Gi(reiner. Dauniel J..

Stuiidy on wound nil1ai1sf ivs-Itoiigu I at Ilie CaHiii14u 191t. /it 310d len I Ieliu rt ment I. I' 71it n Staiies Armyv.

Woiund ialulistics. Waushinigton: U.S. Government P'rinting Office, 1962. pp. 281-43i6.
F~i(;ia; 3:2:11. '!The w'ound balistics 1c:11 t.au Bout higainiville. I. eRva1. le'ft to Hiight. -NLzj.

raii A. Stuttieriatud .~. M C. ('I. Asuley NN. ( tuughter-4 't. 114' Lt. ('11. Mirny C . 111ll, 'Mc'

31.1. I )attiel I.1I.,ii'. kneelin~g. Itft t", right. TF 4 Clma lv., .1. Ih'rzenuvi. '1 4 Chiarles It.

Itt'sl ifi). an1d4 Sgt . Reud N. Fitch. I

Gem.t-v Fittitev. Bill lPots. anfd C aptainiM~iiti are SUaVIItIr oil to

]fell)t ithe- htosp~it als stra un It en out sm ile' o)f thI eir problems'1t. I fouand that they

NAvere in ject illt (r1, gai1n1ie titioxiti fillt( o itl- ando lilt() tilit 1ISS ;~It' :tPO1fld

itheviin- luut Iout liltto(tit' ent 'lt littitoxill jut ntvt'ttotsl v. C'asets Avert

contilii liu.- mvii firuii thle fi-tttt withlouit adequo~ate iniformation (O )I1 opert1tions or'

fiave 1bteen stlit d owntit II P001 (*)lit l()l 4w too S0) oot afIte .111 a t )Itpvtttoat. ( )rlers.

Nvit h cmiilpollitld fract tilt'-e of tlie h1111iu ileti. A'rt' Ini cats Once a 1rain1

it ititist he cmicthtidlt' that not ei~tnI (itIlpIIsis I~ishiig)laor o 0)11 retting,' tile

best int'tIl alto thet fiwwairl hospit als.

1-1 at1 0:130 with tlife binIlist 145 leantl anti off to limon(ailiville map )11) *We

landedo at (N-30 oil tilit light er strip. si ttct'ttle other tN\wo striips wvere 1betIng shtelled.

The Torokina Ilirt ei stripl Is .1lso Itinder fire. butt is utevt'rtliels-S ItiwtllicliftII.

Coloitel I l lan Iliuiet its at tilie ni 11)4 a-a ver-Y etiioeliti. )lt'asi ttg". 1utl o1dta

tive fellow. Ilec took the tentin to) the 21sr E'vaciat IIon 111loslntal, for nu ouions ani(

(pliarteris andthenttu sihowedl 1tottt hIls and~ il) bl~titio'rtl c4111e4'tlol .,1141 hit rodtlreo

lthem 14)th 31' '7th D~ ivisioni cri)vdh.

7 1. '!I- '14 55:
828 ACTIVITIES OF SURGICAL CONSULTANTS

.l A,+ 3 ','"0

xI:

Toro iPto S g

SU.S. PERIMmrTR Lt'VP*P,.•3

I I .,iLES ,

A MS

MIAP 5.-MIedical units on Bougainville, March 1944.

Thursday, 23 M2rch

Troured the frontlines of the 37th Division. The collecting station of the

129th Infantry is about 200 yards behind the front, and they have cleared out

a lbeautiful garden here in the jungle with lots of tomatoes, cucumbers, melons,

radlishes, andl some corn.

The Japanese came over the Numa Numa Trail with one-regiment-plus

and hit the 1'29th at a strongly fortified point (fig. ,324). Some 400 of them

are now b~eing buried by our bulldozers. By climbing over their own dead

until our inachineguns jammed, they had managed to take some of our forward

pillboxes. They would also walk in file straight across a minefield, advancing

over the bodies of those wvho had blown up the mines. However, their losses

were too heavy, and exceplt for a• few snipers the main body wvithdrewv today.

There is no question ab~out their morale and courage. :No prisoners are being

taken.
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FROM AICKLAND) TO TOKYO 831

We visited Colonel Collins of the Anierical who has a splendid clearing

station, really more elaborate than is needed. But now that they are getting

a number of casualties it has come in very landy for taking in a heavy load.

They have underground operating rooms and wards with forced ventilation.

This clearing station has been shelled ailnost daily, and a direct hit was made

on the (livision surgeon's office. Fortunately, he wasn't there at the time. The

52d Field Hospital has also been shelled and took a direct hit on one of its wards.

Several patients were wounded although there were no fatalities.

The Japanese hand grenades do not appear to be too effective.12 It seems

that the explosive charge is too small. Five grenades were thrown into one

of our foxholes without killing a man, though no one escaped being wounded.

Two men are needed to fire our bazooka; the forward man frequently gets

powder burns while the man behind may suffer hand injuries. We will examine

this problem.

Saturday, 25 'March

A small sector of the 129th Infantry was infiltrated the night before last

by about 200 Japanese. As a result of this action, 100 of our men were wounded

and 30-plus were killed. The ballistics team had more work than they could

handle at one time.

The surgical service at the 21st Evacuation Hospital is doing a good job,

although the hospital is inadequately designed for the load that it has to carry.

For example, the original operating room was made far too small (fig. 326).

An operating room in a 750-bed evacuation hospital should provide facilities

for eight tables to function at once. It. should be. centrally located and easily

accessible to the laboratory and X-ray. The shock room should be adjacent to

the operating room and large enough to hold 30 to 40 patients at one time.

When the operating room is placed in front of the artillery, as is the case here,

underground wards should be available for at least 200 patients. At the present

time this hospital has nearly 100 litter patients aboveground and approximately

120 below ground. Many of these patients are thrown into a state of shock

during the process of being transferred underground. Fortunately, shelling

and bombing have b)een light in this particular area. Furthermore, X-ray

equipment has been kept together, and one hit could have done away with it

all. Part of the X-ray equipment should be located in. or adjacent to, the

shock ward, and part in the op)erating room. This hospital could bIenefit by

instruction on such subjects as sterile technique, the use of plaster, records, et

cetera. This will have to be arranged.

Visited the EENT clinic. There are many middle-ear cases, a large number of whom can give no story of how their drum was perforated. One man

even had a. complete absence of the drum. I believe that a great many men

suffer ruptured (rumis from explosions and (to not report this fact. Many of

them probably don't recognize any symptoms until their ears become infected.

12For data on this and other Japanese, missiles, see: Beyer. James C.. Arina. James K.. and

Johnson, Doris W.: Enemy Ordnance ,Materiel. hi Medical Department. United States Army.

Wound Ballistics. Washington: U.S. Government iPrinting Office. 1962. ppo. 1-9;0.
A' *l*I A Iii I:s if SI IIrA! ii i\I II A \IS

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4t h

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2

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.4
FROM AUCKLAND TO TOKYO 833

There are many men in combat who have defective vision and bad hearing,

which are particularly dangerous in jungle warfare. I heard about one man

who was up for court-martial during the fighting on New Georgia. He had

turned his Browning automatic on a patrol returning to our lines, with disastrous results. The fellow could barely distinguish a man at 200 feet, let alone

be able to tell the difference between friend and foe.

Saw Maj. Paul Troop of the 145th Infantry this morning. He had a minor

wound caused by a "hung bomb" which had caused a tree to burst within the

area, killing one and wounding nine.

A Japanese message intercepted yesterday indicated that they would begin

an attack. Hence, our heavy artillery barrage last night. Our Cubs have

spotted most of their gun positions, and we can only hope that we have knocked

them out. Anyway, it appears that we have stopped them for the time being.

Yesterday, the Japanese used machineguns to shoot down several of our planes

which were flying low over the lines. Americal headquarters is jittery, for

the Japanese naval 6-inch guns on Empress Augusta Bay are dropping shells

around the general's tent. Everywhere the story of Japanese morale is the

same. The Japanese soldier when cornered shouts back that the Japanese

Army never surrenders. So far they are right.

Saw Capt. Carnes Weeks [Cdr. Carnes Weeks, MC, ITSN] who now appears

to be Halsey's personal physician. Ilad luncheon with him and Admiral

Halsey several t imes on Guadalcanal.

The Fiji Scouts are here in force (fig. 327). Their officers are New Zealanders. Both officers and men have won the admiration of all the units here.

I just watched a battalion go down the road with a snap that is never seen in

our troops. Their casualties are heavy, and the Japanese fear their courage

and their ability as natural jungle fighters.

The dead are not coming in so rapidly now, only about 10 to 15 per day,

so that Greiner, assisted by Hull and Frick can keep up with the post morteins.

Two stenographers are there to take dictation, and they have a photographer

there to take the pictures. We have two undertakers who take charge immediately after our work is done. They sew up and wash the body and wrap

it in a mattress cover. This project shows earmarks of being a valuable study.

Monday, 3 April 1944

The action is quieting down, although Greiner still averages about six post

mortems a day, about half of which are Fij is who were on patrol duty. Opinion

differs as to their value as soldiers. They are universally liked, and everyone

agrees that they are good on p)atrol, l)ut apparently they do not stand mortar

fire well.

The morale of our troops is high, although we have quite a few neuropsychiatric cases. Hlowever, the vast nmajority of these were neuropsychiatric

problems before they entered the Army and cannot serve as an index of the

morale of the troops in general. One lieutenant cracked up because lie had to

lead his men on six assaults of a hill, incurring 50 percent casualties. Ile felt

that, lie was to ])lame for the casualties, althiough lie was only obelying orders.
~c; I ACI 1Ul~ 4)1' ,Sl R~INCAI. CI4;I~l.TlAN I'S

M.af rch 1944f.

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FROM AUCKLAND TO TOKYO 835

early in the battle, which wiped out. their equipment, including even the pots

and pans in the kitchen. All the personnel were in foxholes, and there were

no casualties, although the bomb dug a 20- x 6-foot crater. They have been

reequipped since then and have only had to contend with mortar ire and sniping.

The operating room should obviously have been placed underground. Digging

tools and one power saw should be a permanent part of their equipment.

Thursday, 6 April

The cards have been made for all those killed in action and wounded in

action on Bougainville since February 15, and some 200 are completed. We

found some wooden bullets yesterday. They are said to be used by the Japanese

for close-range fighting in order to avoid injuring their own men.

I had dinner last night with General Beightler of the 37th Division. General Griswold, XIV Corps, told me that the 37th was the "banner division' of

the South Pacific. General Beightler is one of the world's fine people-simple,

modest, and direct. lie can also be tough if that is necessary. The general is

intent on maintaining high morale and a pride of accomplishment among the

men. This is best attained by the careful selection of leaders, fairness, and

recognition for a job well done.

NOTES

1. The 9th Station Hospital needs an EENT officer. He will be provided

by the 29th General Hospital.

2. Complete field X-ray equipment should be kept in the forward area.

In general, more supplies should be kept in the forward area rather than at

Noun6a.

3. It should be possible to return an officer from the tropics without a

recommendation for either promotion or reclassification. Many of them are

inefficient in tropical service and do not fall into either group. Here is a case

in which administrative redtape is working against the best interest of hie

service.

4. More of the following items must be obtained: Scales, blood pressure

apparatus, otoscope, sterilizer (Wilmot-Castle), small burners for sterilizer,

orthopedic tables; powersaws, axes, and ventilation fans for underground

wards and operating rooms; headlights; sclerosing solution for hemorrhoids,

eye anesthetic, copper sulfate for phosphorous wounds.

5. Spectacles are still a 1)roblein. D)o all the men have a second pair?

6. The journals are still not. coining through.

7. Replacements should come in early enough for prior training.

8. The Japanese make better use of cover than we do and dig in quicker,

using smaller, better constructed foxholes. Every recruit should learn how to

dig fast. This is of more value than walking in jungle warfare. The men

must also learn to dig deeper and narrower foxholes. They are far too large.

Many buttocks wounds are seen in the wards. The soldier must be advised to

get his ba1kside (town. Careless exposure of the silhouette is too frequent.

705 095.-..64 - -56
836 ACTIVITIES OF SURGICAL CONSULTANTS

We must learn to crawl more often. The Japanese stick closer to the ground.

Furthermore, our boys frequently don't wear their helmets on patrol, for they

soon find the helmet too tiring.

9. Should patrols (fig. 328) be accompanied by a medical officer? Not

unless the medical officer has enough equipment to do more than an aidman's

job. Small patrols of less than nine men have an aidinan along, and many of

them are lost on patrol. One patrol had a battalion aid section of 28 men of

whom 10 were wounded in action and 4 seriously. General Hodge [Maj. Gen.

(later Lt. Gen.) John R. IHodge, Commanding General, Americal Division]

gave orders for a doctor to accompany a reinforced company of 175 men, although no equipment was carried. Citations for medical aidmen are insufficient. However, an infantryman who takes no more risks gets a citation.

One battalion commanding officer insisted on bringing back his dead at great

risk to the aidmen. Aidmen have been used to carry the dead down from the

aid station. Since there are a limited number of aidmen, they should not be

used for this task.

10. The 37th Division clearing station performed primary suture of the

minor wounds of about 30 men. Almost all healed per primam.

11. More instruction is needed on sucking chest wounds and the proper

way of sealing them, which is with a tight adhesive over a pad and gauze, the

latter impregnated with petrolatum jelly.

12. Statistics gathered from the 21st Evacuation Hospital:

41 cases of penetrating chest wounds-12 percent mortality.

21 cases of sucking chest wounds-18 percent mortality.

27 cases operated open-29 percent mortality.

Note: Second echelon medical service must have thoracic surgery.

13. We need a movable metal pillbox. It would be of great value in going

over a ridge against Japanese positions. A periscope could be attached, so

one could look over the ridge. Many Japanese are killed by heavy fire because

of their concentration prior to an attack.

14. Captain Dick states that about 5 percent of the men take sulfa tablets

by mouth when wounded. It might be better to discontinue this practice entirely, unless they are out on patrol. The full dose, given by a doctor, would

more quickly assure an adequate blood level.

15. The Japanese hand grenade is grooved, but does not fragment along

its grooves. Having so much powder, it is almost pulverized; hence, its burst

is not effective very far. Men sitting in a foxhole in which a grenade has been

tossed have been known to put up their feet and come off without serious wounds.

However, the blast effect is considerable. Small skin puncture wounds and

extensive damage to muscles occur as a result of the blast. A Japanese grenade

was seen to go off under a man and lift him 2 feet in the air.

Sunday, 9 April

I was under the impression that the Japanese had finally been driven away,

but I was awakened this morning by the shelling of the fighter strip. Last
4.4

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838 ACTIVITIES OF SURGICAL CONSULTANTS

telephones should be attached to the ear ill order to leave the. hands free. Our

logging trails, which were cut for timber, were used by the Japanese for their

main attacks. Flanet-hrowers woull be useful on the defensive aigainst mass

attacks. A flamethrower with a, long hose is more efficient than a tank when

the position of the dug-in enemy is known. Our minefields limit our means

of withdrawal, but kill many Japanese. A bulletproof vest might be useful in

this type of warfare. Inside the pillbox, the noise of firing is intensely annoying, and the helnet makes it even worse. The 60-amm. mortar shell flare is okay,

but the airplane flare. is too bright. The frontlines should be cleared for

3-0-vard lanes of fire. The bazooka is very useful against banyan trees. More

men are needed who are trained in the use of bazookas, as many of these gulls

were available and stood idle. More Browning automatics are needed, and

every pilll)ox shouhl have one.

Tuesday, 25 April

Went over our results with General Griswold. He is skeptical about our

figures on machinegun casualties, probably because of the gun's highly lethal

effect.

Russell Islands, Saturday, 13 May 1944

Off this morning for the Russells. Went to the 222d Station Hospital.

Colonel Currie is commanding officer. This shows promise of being a fine hospital, and the morale is good. Visited Colonel Bell at the 17th Field Hospital

where the same. old problem seems to exist. Went. to the. 41st Station hospital

where construction has been stopped. Colonel McLaughlin [Lt. Col. William

B. McLaughlin, MC], Commanding Officer-a fine type. They need a laboratory officer. None of these hospitals has a well-trained anesthetist.

Noumia, Monday. 15 May

I am now back at -Nouln6a. Left Bougainville the first week in May for

New Georgia Island. Stopped at Ondongo Island, then by boat to Mundla.

Stayed at the 144th Station Hospital on New Georgia. Colonel Haines [U.

Col. Hilton I). Hlaines, MC] is hospital commander.

Friday, 14 July 1944

Today is Bastille Day, and tonight the natives are in the square across from

Le Grand Hotel Central, beating tom-toms and having a great time shouting

and singing-a regular old shakedown (fig. 329). I felt rather under the

weather from around May 15th until early in June, although I kept going.

Had no appetite, which caused a loss of weight, and had sporadic diarrhea.

Stool examinations did not reveal any ameba.

Hull, Greiner, and Sutherland stayed on to help with the reports. I have

learned how necessmary it is to be careful when choosing people for such work,

and I would never again attempt it with anyone whom I did not know was

definitely interested in the problems.

Admiral Halsey and his staff departed on about June 15th. and General

Maxwell, Hal Sofield, and General Harrison left for Washington 5 days later.
F ~ 'T ~ ~ ~ ~ ItN ~ ~ ~ V 

4111

Ii ~ ~ 11'X ~ ~ S ii Arno, (11'1 11:1 \1Ivill:141 ill- i wil XXII i~ Ii:mcl. :1.'III 4 I14 4

I4'I~~vN iiIii -I 14411 .
840 ACTIVITIES OF SURGICAL CONSULTANTS

Tuesday, 1S July

Ifeard that we will go uinder the Central Pacific but do not know as vet

what is to be done with the consultants. 15 The ballistics report has been completed except for the typing.

Auckland. Tuesdav 8 Aug(ust 1944

Today I received orders to go to New Zealand. The plane coming over

flew at 10,000 feet, and I was uncomfortably cold in spite of the woolens 1 wore.

Arrived at, Auckland at 1600 hours and went out to the 39th General Hospital.

Colonel Longfellow is looking well. They have 300 patients, and inost. of

these will soon be gone. The grounds are beautifully landscaped, and the hospital itself is immaculate. It has stood up very well. Gave two talks on wound

ballistics.

Nouni6a. Sat urdav, 12 August

Received orders from the Commanding General, South Pacific Base Comnmand. to ret urn. I was having a gastrointestinal series done and had to leave

in the niiddle of the series. Arrived August 15 at Noumn6a to find that I have

been ordered to Headquarters, USAFPOA (U.S. Arlmy Forces, Pacific Ocean

Areas), Hawaii.16 Eddie Ottenheimer's orders are out, following Colonel

Longfellow's okay. Ile will be invaluable in compiling surgical statistics for

the theater. Furtlermore. General Maxwell. who has returned, wants to use

him as a historian.

Saturday, 19 August

Eddie arrived today, and I have started him on the analysis of surgical

records. General Gilbreath [Maj. Gen. Frederick Gilbreath], who is now

Commanding General, South Pacific Base Command. has made many reforms,

and life for the officers is not, generally as pleasant as it was. But there are

coinpensat ions in better discipline.

Tuesday, 22 August

Drove out to Tontouta and spent the night with Colonel Shope, now

commanding ollicer of the airbase.

Wednesday, Thursday, 23, 24 August, Oahu. T.H.

At 1300 I got on a C-54 coming through from Sydney. These planes are

like huge flying boxcars. Arrived at Nandi Airport at 1715 and had supper.

Took off at 1815 in a. beautiful sunset. Arrived at Canton Island, Phoenix

Islands, at 0200. As the plane taxied down to the end of the field on takeoff, it

was discovered that the hydraulic system was leaking. This was repaired by

about 0600, and we finally took off. We landed at Hickani Field at. 1600.

1 The U.S. Army Forces in the Central Pacific Area was the forerunner of the U.S. Army Forces,

Pacific Ocean Areas, referred to and discussed later.

10 USAFISPA was redesignated in July 1944 SPBC (the South Pacific Base Command).

USAFPOA was established at the same time as a superior headquarters with jurisdiction over the

South Pacific Base Command and what had been USAFICPA (U.S. Army Forces in the Central

Pacific Area) which was similarly reduced to a base command, CPBC (the Central Pacific Base

Command). Colonel Oughterson was placed on temporary duty as surgical consultant at Headquarters, USAPPOA from the South Pacific Base Command, since there were no position vacancies

for consultants of his rank at Headquarters, USAFPOA.
FROM AUCKLAND Tro roKyo 841t

Passed throughl Armyi (Aistonis and went out to Fort Shafter. (Jalmt. TI.11

[HIeadqu~iarters. USAFL'OA]. where I signed in and looked upl Colonel Young

[Col. Charles TI. Young. MC. medical consultant] who fixed ine up for the

night Iin the old lrilpler H~ospital. Htere everyone is dressed lit), and there is

little evidence of war. Today. Wednesdlay (liaviniz crossedl the dlate line againi),

I met Brig. G en. Edgrar Killg, kChief Surgzeon, VSAFPOA). myv new cornlnianldiii- othicer. Althioiili hie has a fearsome reputation. my first impressions

tir vrygod.Colonel Gates [Col. Kermit 11. Gates .NIJ Deut Surgron,

is avery buyan leasant person. Thursday. I visited [It.. Col. (later Col.)

Forrester Elaine. 31C. of Milwaukee, who has been acting surgical consultant

for the Cent ral Pacitic Base Command, Ile tells mne that there are only four

board inenibers, in the wh-lole area and that. there is a great. dearth of 11zood

Saturday. 26 Autilust

The gieneral had asked ine to write dtown some of my ideas on t lie funct ion

of a conisultingr ugonl. whlichl I dI'd and which hie appoe.le a)ae

quickly to all my suggrestions. and I thmink that I am going to like workinl"

with himi. Time only% aspect of time work that I dislike is that I also have some

functions as anil inspector. I aii afraid that this may strain my pleasant

relations withi the surgeons. Perhaps this need not happen,

Monda . 2S Augutst

Today I lectured to a miedical group and afterward traveled to the northern side of thle island to deliver the samne lecture to the 71st Medical Battalion.

I ani beginning to think that my illustrated lecture onl debridenient. must be

good. as I could hiardly fool all thie peop~le all of the time.

Tuesday. 29 August

Spent the day with General Bliss [Brig. Gen. Rlaymiond 1W. Bliss, Chief

of Operations. 0111cc of The Surgeoni General. and Assistant to The Surgzeon

General] and General Rankin [Brig. Gen. Fred IV. Rankin. Director. Surgical

Consultants Division, Office of The Surgeon General] visiting the North Sector

Hospital [219th General Hospital]. Colonel Green [Col. Philip P. Green,

MC] is commanding officer, Fisk of Boston is Chief of Surgery, amid Robertson

[Col. Robert C. Robertson, MNC] is Chief of Orthopedics [and Consultant in

Orthopedic Surgery, USAFPOA]. Then we. were off to the 204th General

Hospital of which Clol. Tracy IL Bryant, 31C. is commanding officer. I had

not, seen himi for the past 25 yer.Thence to Doris D~uke's and to the Mloana

Hotel for drinks.

Thursday. 31 August

Off at 0630. visited the jungle course over the Pali [Camp Pali]-a very

profitable forenoon (fig. :330). 'Maj. Bryant -Noble,1MC, in chargfe of medicine,

is doing a good job. Thence to Koko hfead, to visit the field and portable

surgical hospitals just out of Saipan. Colonel Pettit-very able. Major

Tinker, who is the sonl of Dr. Tinker of Ithaca. was iii command of a portablde

su11rgical hospital onl Saipan and( (lidl a tinle jol)-2 to 5 p~ercent. mortality onl the
.41*

II: IIIii:

it I I~ :I~ Iit I I Ii . I ': It IýIi

I lt Ii I it WI Iii II Ii -

1 ta121i t' ht' III' illii 'I Ii i-j ii aI. I It 'tt~'l i 1:1 itti Ii lii 1 i' i I1I,1
FROM AUCKLAND TO TOKYO 84:3

apl)pears ill-adapted and wastefi ] when communicatiolis are good. Furthermore, their talent is poor and not as well attuned to needs as is the personnel

of the surgical teams. Generally speaking, the larger installations are more

efficient as regards such things as sl)ecialized talent, p)rotection (guards),

laundry, triage, and the treatment of shock. On the other hand, in amlphibions operations, size is a limiting factor. The 400-bed evacuation hlospital is

about right for these op)erations, as is also the tiehli hospital if properly staffed.

Talent is wasted l)y using two smaller hosp)itals to take the place of one

larger one. Dumbea Valley is a good examl)le of this. Another mistake is

to require station hospitals to do the work of general hospitals, as was the case

on Guadalcanal. The fact is that there were too manny station hospitals there,

and, taken individually, they were too small for the job. We now have a 750-

bed station hospital which has been organized by combining three 250-bed

station hospitals. We expect to use it as an evacuation hospital, though the

staff is inadequate. The chiefl lack is qualified surgeons. I looked over two

portable surgicals and a field hospital and found only two surgeons with ratings

better than "C."

Thursday, 7 September

Talked to the 76th Station Hospital this forenoon. This is a good station

hospital. If this next. action is severe, I would expect trouble, for the 165th

Station Hospital is made up of three 250-bed hospitals, and consequently the

personnel is poor. The conversion of several smaller hospitals into a large

hospital is unsomnd policy. They don't. seem to realize that the quality of personnel in a small hospital is, and must be, different than that of a large hospital.

The 69th Field Hospital hasn't any well-qualified surgeon. To expect these

hospitals to function adequately as evacuation hospitals requires more optimism

than I possess. The 51st and 52d Portable Surgical Hospitals are short on

surgical talent. Certainly the portable surgical hospitals are wasteful, and

unless their talent is better than in those I have seen, they only succeed in giving the dangerous illusion that a surgical hospital is available.

The general has been very kind and considerate toward the consultants.

When I told himi of the lack of surgical talent., he said: "I didn't know your

standards would be so high."

I looked up some of the anesthetists today, and they are scattered in all

sorts of positions. One of the best, with 6 years' experience, is an executive

officer.

Friday, 8 September

To Koko HIead where I talked at the 69th Field Hospital, which is not

too strong in p)ersonnel. Spent, the afternoon with Robertson who insists that

he wants to do hospital work as well as act as a consultant. Thinks catgut is

better than silk or cotton.

A three-star general here burned his fingers when a matchbox caught on

fire. I went down to see him in response to a call and a two-star general who was

there asked why such high-powered talent was needed for such a little thing.
844 ACTIVITIES OF SURGICAL CONSULTANTS

I said: "I thought perhaps things had gotten so hot that there was danger of

a general conflagration." This seemed to please the general to the extent of

relieving his pain.

Saturday, 9 September

Visited the new hospital ship Mercy, which had Army personnel aboard

(fig. 331). Seven. hundred patients and only two operating rooms, inadequate

for a combat mission. There were only eight medical ofticers aboard, five of

whom are would-be surgeons. The ship should have had the personnel of at

least a 400-bed evacuation hospital.

Spent the evening with the general. lie is a fine person to work for. Unfortunately, he has not had enough advisers to whom he could delegate

responsibility.

Monday, 11 September

Spent yesterday writing a directive on surgery for the forward echelon.

The general, to my amazement, insisted I sign it. "It would come better," he

said, "from a doctor."

Some doctors are against the use of plaster in the next operation because

of gas gangrene. Correcting one surgical mistake with another it would appear. I am more than ever convinced that, as a whole, the amount of gas gangrene is an index of the quality of surgery at the front, and admittedly it was

not, of the best on Saipan.

Tuesday, 26 September

I am still laboring to get out: (1) An educational directive (none has been

issued) ; (2) a statistical directive (no method exists for gathering statistics

on surgery, and one should be set up for POA) ; (3) a plan for a wound ballistics study (none has been contemplated) ; and (4) ETMD (Essential Technical Medical Data) reports to this theater, and a plan for developing our

own. Discussed some revisions of this plan for ETMD reports with General

Bliss. The classification was too high, and subject matter should be concentrated just as in any other medical paper. A consultant, or some one on his

staff, should act as editor.

The great shortage in this area is talent. There is only one surgeon here

who can qualify as chief of surgery in a 2,000-bed general hospital, and there

is a dearth of specialists.

One of the chief functions of a general hospital should be to act as a teaching center; however there is a shortage of good teachers. Very few lives can

be saved in a general hospital (area Naval hospital had 1 death in 6,000). The

patients die before they reach a general hospital. The shortage of qualified

men here is due to the fact that there are no affiliated units. Those from the

South Pacific Base Command are tied up by agreement with the Southwest Pacific Area, and personnel cannot be moved although many are idle in that area.

The 39th General Hospital has 100 patients.

The portable surgical hospital is too small to function as a hospital and

too large to function as a team. It should be disbanded.
. I'~ I I 'Flr 'I' 1kI~ I i I( I.. s i I 1 
846 AC'TIVITII.ES (I' CIONI('.\L tONSULTANTS

Ma li Isla nld. .I.. Monday, 2 October 1944

Flew fromli *Johln lRogers Field to .olohka i Island, :an1d the niice to Ma[ui

Island to visit. t lie st Ih Slat ion I lospial. TIhiis init was foriiierly on lora-Bora.

IAt. Col. 'Jililis Sobi n. MC. is C(ommanding Ollicer-F.A.('.S.. a good stirgeon.

C hief of siar.ery is Maj. C'harles F. Town. M(C'. llis su ap'ears aperv to Ib,

go )d1. and lie is capalde of hadmling a .,00-b ed hoslital. ( 'a pt. Irvin 1. SilnMons. .. MC, '.T man. is youig I)but a ppears ca)apable. ('aplt. Rosario lProvenzano, MC, is iII charge of orthopedies young. but. also seems capable. Capt.

ie( Tvyer. 1( ', is tle aietletist . This iospital, develolpd lby the litlt It at iol

I los1 ital frout some former school buildings. has harracks-tylpe wards of 7,5)1-

bel caplacitv. It, has a, pleasing lohatlion at I .S0) ft.. cool. exceptdionally well

adapted to a station hospital. T'ey now have 600 patients; average census

for 1944 was 300. A Marine division is now training here. and they expect

a•i increase in patients. The 250-bed personnel is not enough for presenlt needs.

and the Navy has supplied 15 medical and dental officers. The equipment, is

superior to most. general hospitals. III fact, no extra buildings or equipment

would be needed to make this into a 500-bed hospital. and their key personnel

would be adequate. However, the laboratory does not use the copluer-sul fate

method. Attended an excellent medical meeting. The staff does not have

help eniough to offer training courses. They need a dietitian and more enlisted

men for the , asic jobs.

I[awai i. Wed lnesday, 4 October

Off to tile Large Island [Lhawaii] and landed at 1100 hours. Went directly to the 75th Station Hospital, which was organized as a' 750-bed and is

functioning as a 250-bed hosi)ital. Colonel Underwood of Brooklyn is commanding officer and also finctions as district surgeon-a fine fellow doing a

good job. Cohlnel Mayer is Chief of Su-rgery. lie is one of the two or three

best-trained surgeons in the (PA (Central Pacific Area). They need a good

orthopedist. Pliffer, general surgeon-young. but has al)titllde: Goldman.

genitourinary specialist-good: Freidman, ENT-good; Captain Foster

(nurse) is the anesthetist. They have one physiotherapist. This service

should be developed. One dietitian-good. They need more. The library

is good-six textbooks of Christopher and six of Cecil. They do not know

the copper-sulfate method at any of these hospitals.

Friday. 6 October

Started off at 0800 to drive aroind the island through the Kouua country.

At 1400 we arrived at the 26th Station Hlospital on the Parker ranch-3%5,000

cattle and 10,000 sheep and goats-looks like Wyoming. This hospital has

150 beds and two surgeons. Captain Amstutz is doing an excellent. job here.

Captain Bigliani, an orthopedist, is assisted by numerous doctors from the

Marine division. Cooperation is excellent. with the Navy. They need an

X-ray man and an ENT man. Anesthesia is done by the nurses-two good

ones. Captain Spalletta, laboratory officer, also does cvstos(.ol)v. They are

doing a lot of work on app)endlixes anld pilonidal sinu.ses. On the whole they

are doing as well as cal be expected, and Akistutz is a sulperior officer.
FROM AUCKLAND 10 TOKYO 847

Saturday, 7 October

Off at 1230 from Ifilo and landed at John Rogers Field [Naval Air Station, Honolulu], 1430 hours.

Oahu, Sunday, 8 October

After 6 weeks, I have still not accomplished any of my original projects.

There has been a tremendous passing of "buck" slips. It is almost as difficult

to get something done here as in a university medical school. The educational

directive is under way, stated by G-3 as being long needed. Reproduction of

ETMD will be delayed indefinitely, as the photo lab burned down last week.

The statistical project is at status quo with more and more excuses developing,

such as no help or no room.

There are three ways of determining the quality of medical care: (1) Insplection of hospitals and l)ersonel 1y consultants and others; (2) statistical

record of results (as the, cash register is to business, so is the statistical record

to surgery) ; and (3) questions and answers on what the soldier thinks of his

medical care. With these three methods correlated, we should be able to determine the quality of medical care and devise means for improving it where

needed.

Sunday, 15 October

Still no news from Washington, and General Maxwell is still in New

Caledonia. 7 The educational directive is about to be published, so my number

one project is done."s Must now get out a directive on reparative surgery and

another on penicillin. Penicillin has not been used to the extent that it should

be. Reports coming in indicate that we are making the same mistakes in medical planning here that were made in the South Pacific one and a half years ago.

This also applies to matters other than medical. This theater is fighting its

first battles, and, since none of these men have had experience, they must

necessarily learn through trial and error.

Sunday, 22 October

Got out the directive on penicillin. We have not been using enough in

this theater, and there is confusion as to when to use sulfonamides and penicillin. Arranged program for a territorial medical meeting. Abstracting

and getting out ETMD for all hospitals, divisions, corps, and armies-this has

not I)een done before. I'm working on a gas gangrene, anaerobic wound infection report. Have not yet been able to establish a record system.

I would like to go forward, for the flow of Philippine casualties will soon

be coming through. The invasion was announced 2 dlays ago and is going well

27 Brig. Gen. Earl Maxwell had been notified of impending assignment to the U.S. Army Forces.

Pacific Ocean Areas: however, when official request had been received In South Pacific Base Command,

General Gilbreath had radioed back to the Commanding General. the U.S. Army Forces, Pacific Ocean

Areas. that General Maxwell was not available as he had no replacement.-E. M.

"' The directive published at this time was promulgated by Headquarters, U.S. Army Forces.

Pacific Ocean Areas, on 20 October 1944 as Training Memorandum Number 8, subject: Training

Program for Medical Officers. Colonel Oughterson later rewrote this directive, adapting the principles in it to Headquarters. U.S. Army Forces In the Pacific, when that command became the superior

headquarters in the Pacific.
I Ii~. Saw 832) a Ineill le i Luu of(a 1 i~ Weks.itI Aii alIInIev

en~vy Ills 5&'li&, the show. SpeitI n1 pl)4as.1 :IIaft er-iloii l .1 lhe hieacii today x,

SNVImini IIIIz wvith C( 'ololel I e( 4)oIse-Y IC('o. Elbiert Ik. )(A4)Ise ' . N ( I and Colon41el

('III Ils h4o il line fellows. This week Amldll~ bI4IIll- cAIariciatl iof 4 Il SlesIt I-

:11 loll1 hiete.

Eddie 14 [0~ tI411vi1e11mol. j :11-1e 144 wda4I \iV it Inai V11les. ta:1 sonlm ll4,\\, sIo4 414'.

111e 4vrt:1111 iI.:hV Wals 1145 wvelo)ike as I Illee III litii1) lif III spirit)11s. I11,1111g here

liiyeIeell IIlm.st 41 15mi44111:iI ll-. ;III11 4tl.ZII I wvoiii11 1d Io lia e iii i-vi I h le exjpeliet11e.

which 141 IS 1111 14114IllII 1IY ArIIIiv 411 Iverl*. 1 1wgl IIppr(4 toW ae N0:1 IS iii':1

thle wordl'4l 1114 4ý-ll I 1iii tik N1:,I~illa' evllis- are I )lmhi:l4* v10k Ioe x4411 I Xlie t1lIlll. 4)1 1i44 lll i41 4 I i41'I we. . h er :1ht' bhi mi-e14(411 forh4)1.4'le 141. yIeltl,

:11141 t -a11 I 'ug VII IsI( v15 l441 I15. P()

:1 il: ved :114(4111- &..4 av :1.-r. :44Ilie I-etswiIlel ltinv' hieelile l--111i'dtiet 144 Sle wsfe.

On)ie (4pliver, Ill v'I-.('v of1 the pe I)4'ifeII4l (of :I 1144-hiitl. lleV4'1' dlv\v4'l444e :Ili %11 hi1iiir

W I h t lii' 11iatIIv ( :41a 4 4:111- niviit'i. Ther i \'i W s 1144 11:1 111v' W ho e 14 P( c 11- hs-Iiv:1 i 14411 4if
FROM AUCKLAND TO TOKYO 849

personnel. The general filing system in the office was reminiscent of my grandmother's attic. Things were probably there, but no one could find them. It

was not uncommon to find everyone looking very solemn, as though in conference, then to discover that they were only looking for a lost document.

The prevailing idea seems to be that the consultant is here primarily to make

inspect ions, write long-winded reports about trivial matters, sit on boards, and

see patients. In trying to accomplish something, I have encountered resentnment and a feeling that I was interfering with things that were none of my

business. The consultant takes no part in planning, although the office is

making the same mistakes in planning that. were made in the South Pacific a

year and a half ago. Results: The mortality of wounded on Saipan was twice

as high as on Bougainville, and one-third the number of patients returned

to duty.2-

I spent the evening with the general and accomplished much business very

pleasantly. My first imnpr.ession of the general is that lie is outstanding in his

desire for, and insistence on, a high standard of work. Being new, he of course

does not wish to move rapidly against tradition, although he sees the need

clearly. This is a fine education on how to win friends and influence people,

but not much help yet to the war effort.

Thursday, 30 November

Dinner tonight with George Finney. Says lie: "How can we plan when

we don't have anything to plan with ?" 21 1 have now been in this headquarters

over 3 months and still have not been asked to take part in future planning;

nor after my request, have I been permitted to take part in planning. A field

hospital is going in [to the Philippines] with the Marines. They say it will

function as an evacuation hospital. The Army says it will not, and I suggest

that it should have surgical teams if it is to function. Responsibility is being

shifted along. Only God cares for the little fellow! I am wondering when

this will crack. It can't go on forever. Once again I must speak to the general or be derelict in my duty. I would rather be out of the thing than in it

and wrong.

Friday, 1 December 1944

Ben Baker arrived today. The role of consultants in the Army needs

clarification, and Regular Army personnel must be educated as to the medical

problems of a theater. There is only one partially qualified neurosurgeon in

this area. The determining factor in the distribution of battle casualties was

the number of the doctors available, including those in station hospitals.

Anesthesia departments, headed by doctors, have not been established. Essen20 Attention is called to Colonel Oughterson's statements on the function of a consulting surgeon

(p. 841) and his participation in planning, such as It was (p. 842), written before the undersigned

reported for duty. The comments on this instance were made only 5 days after my arrival. Consultants working under my command, including Colonel Flick, Colonel Mason, Colonel Loutzenhelser,

Colonel Oughterson, and Colonel Ottenhelmer, were always consulted on every phase of my duties

and at all times were kept aware of any plans involving the medical service.-J. M. W.

m I believe Colonel Finney's comment has reference to the lack of "qualified personnel" previously

commented on from time to time. Surely that decision had been made prior to my arrival.-J. M. W.
850 ACTIVITIES' OF SURGI(CAIL CO)NSULT'ANTS

tial Technical Medical. Data have not been distributed to hospitals. I suggested that it was by the ETMI) more than anything else that the world judged

the theater and was met by stubborn incomprehension.

Saipan, Thursday, 7 D)ecember

Yesterday, having a chill and after numerous inoculations, I received

notice at 2200 to appear at Hickam Field at 0015. We took off at 0130, and,

fortunately, being the senior officer on board, I had a bunk. Owing to repeated

chills, I staved aboard until Kwajalein where there was a dismal rain, making

this dismal place look worse than usual. I have sympathy for the men whose

lot it, is to stay in such an unattractive part of the world. Arrived just before

dark at Saipan.

Today, with Col. Eliot Colby, MC, Surgeon, Army Garrison Force, Island

C(ommand_, Saipan, we had a hurried 1)reliminary survey of the island, which

is far more attractive than I had anticipated. There was a Japanese air attack

this morning, and on getting up I was a bit disconcerted to find no foxholes.

Found the colonel in charge of ATC digging a foxhole, asked him why, and he

l)ointed to his teeth marks on the floor. The 148th General Hospital is still in

tents although prefabricated buildings are under construction. Headquarters

is built in quonset huts, and the labor has been used to improve this and other

sites. Colonel Colby says that hospitals have "No. 1" plrio "ty, but then "No.

1- becomes subdivided into "a, b, c, et cetera." Visited the supply depot in

charge of Captain Phillips. Most sutpplies are out of doors on the ground,

although covered with tarps.

Visited the 369th Station Hospital, where I saw Major Goldsmith who is

in charge of a civilian section which will be taken over by the Navy on 1 Jannary. According to Colonel Colby, in the original plan the Navy had designated one medical officer and one corpsman to treat civilian casualties. There

were a large number of civilian wounded, even on the beaches. One platoon

of the 31st Field Hospital was designated as a civilian hospital. This platoon

with 100 beds soon had 880 patients. A second station hospital of 500 beds is

under construction adjacent to the 750-bed 369th. This total of 1,250 beds

requires a duplicate setup of surgeons, administration, equil)inent, and so on.

This does not. seem to be good economy of plrsonnel or equil)ment, h)ut owing

to the difficulty of putting these hospitamls together under one T/O they must

be set up separately. Certainly T/O clanges should be made more easily.

Guam, Saturday, 9 December

Left by :lane at 0800 for Guam. Visited the 273d Station HospitalColonel Battcrton, Commanding Officer. This is a 750-bed station hospital at

about 20 miles from the port, but fairly close to the airfields. The hospital is

now under construction and should take patients in about 2 weeks.

Tinian, Sunday, 10 December

Visited the 289th Station Hospital, under construction at the edge of the

depot field-a- splendid location. Quonset hut construction, a 100-bed unit expanded to a 200-bed unit. Maj. Paul S. Read, MC, is commanding officer and
FROM AUCKLAND TO TOKYO 851

also does some surgery. The surgical personnel seems to be about as good as

can be expected in a small hospital.

Left Guam at. 1900 and arrived at Tinian, passing close to Rota Island

which lie .Japanese still have in. their possession. Found Major Shaw, island

surgeon-a pediatrician anrod very energetic.

Saipan, Monday, 11 December

Visited U.S. Naval Base lHosl)ital No. 19 undler the command of Captain

Mueller, VSN. The station hospital at Tinian, the personnel of which have

not yet arrived, will be constructed of quonset hiuts by the Seabees. Shaw had

driawn up some very good plans, and this should l)e a superior station hospital.

These. two hospitals can provide facilities for 2,000 beds if they get the additional personnel. Flew to Saipan in the afternoon to attend a medical meeting.

P~athologist reported Endings on autopsies of 60 civilians. About 70 percent

were tuberculosis and beriberi, frequently nixed. The next largest group was

dysentery and colitis.

Tuesday, 12 December

Drove around the entire island [Saipani] in the afternoon looking at hospital sites. The two general hospitals are toward one end of the island, and

the station hospitals are together at the other end. While this is undesirable

geographically, it. would be unsuitisfactory to try to convert. the station hospitals

into a general hospital. It is understood that. all battle casualties will pass

through the general hospitals and that the station hospitals will be used primarily for garrison work. The 39th Generl IHospital is 8 mile.; from the airstrip, as is also the 14Sth General ; and the 39th is 5 miles from the (lewks, while

the 148th is only 11/2 miles from the dock. At. )resent, the 148th General is

(loiig about. 40 p)eerc.ent station hospital work. Yesterday, evacuation policy for

patients was increased to 60 days for the general hospitals, 30 days for the

station hospitals. The 21st Bomber Command has 100 beds to act as a clearing

station at. tIIe strips, and the ATC has two quonset huts to care for casualties

that have arrived or are awaiting evacuation.

Summary of Informal Report to General Willis

There has been a need for sometime for a consultant in this area. The

chief problems are: The planning and construction of hospitals; shifting of

personnel: and professional questions, especially in relation to the functions of

various hospitals.

The 148th General Hospital is now under construction, although they are

now functioning in the area under tents. The surgery should I)e in quonset

huts in 2 to 3 weeks. The p)ersonnel of the surgical service of this hospital will

require strengthening. Further observation at a later date is required for

pl)rper evaluation. Approximately 40 percent of the surgery in this hospital

involves the garrison forces. Twice the number of beds may be maade avwil:ihle

for battle casualties by allocating most. of the garrison work to station hospitals.

This has been discussed with Colonel Colby who has given splendid cool)eration.
852 ACTIVITIES OF SURGICAL CONSULTANTS

The 369th Station Hospital, 750 beds, is also under construction and is

now functioning in tents in the same area. Lt. Col. Joseph Kuncl, Jr., MC,

Chief of Surgical Service, is doing an exceflent job, although he is short two

Medical Corps officers. The 176th Station Hospital, 500 beds, is also under

constructior adjacent to this hospital and will be functioning within a few

weeks.

I understand the 39th General Hospital is coming here. Neurosurgery

and thoracic surgery can be allocated to this hospital, which has qualified specialists. There are also some board memLers available in this hospital qualified

to act as chiefs of service.

I have seen the plans of the 39th General Hospital and there is room for

much improvemnent to insure a better functioning unit. I would strongly reconmnmend that Lt. Col. Edward J. Ottenheimer, MC, be sent here as soon as

possible to assist in the planning and construction of this hospital. Colonel

Colby concurs and has radioed a request.

With the arrival of the 39th General, the surgical services on this island

can l)e staffed with qualified men, and, with the proper allocation of functions,

all specialties could be covered in a superior manner. Guam will be well staffed

with qualified specialists, except in neurosurgery.

148th General HospitaL.-Of 303 battle casualties received in the 148th

General Hospital, Saipan, 149 were evacuated to Oahu and 154 were returned

to duty forward. Table 5 shows the number of operations performed during

4 months (August to November, inclusive) in 1944.

TABLF 5.--Operations, blood transfusions and deaths, by month, at the 148th General Hospital

Saipan, Philippine Islands, during the period August-November 194,1

Month Operations Blood trans- Deaths

fusion$s

AuguMt .---------------------------------- 108 30 6

Septemb.r -------------------------------------- 221 10 3

Octobr 248 2---------------------------------------- 35 1

Noveimber -------------------------------------- 263 54 1

Leyte, Wednesday, 13 December

Amid wind and rain, arrived at Isley Field, Saipan, 2200 hours. Wetslept in ATC holding tent for p)atients. Plane left at 0200. Sat up all night,

arrived Tacloban, Leyte, at 1000 hours and circled for an hour before landing.

Drove to Tacloban and met General Denit [Brig. Gen. (later Maj. Gen.) Guy

B. 1)enit, Chief Surgeon, I-SAFFE, and SOS, SWPA, and later Chief Surgeon,

AFPAC]. General Denit: "This damn Army won't even obey orders. Supposed to have 12,000 beds by this time and we have only a fraction." I like

the general.

Drove to Sixth U.S. Army headquarters and met Col. (later Brig. Gen.)

William A. Hagins, MC [Surgeon, Sixth U.S. Army], a Regular Army

surgeon (fig. 333). The most outspoken man I have seen in a responsible
FROM AUCKLAND TO TOKYO 853

position in this war. Says lie: "The casualties are not high enough in headquarters." They do not like the PSH (portable surgical hospital) as a tactical

unit, although individual surgeons and units deserve high praise.

Saturday, 16 December

This is a fine country for ducks and it might well be left to them. Instead

we fight over it.

Drove to Dulag. Visited the 165th Station Hospital and skidded around

the mudholes in which it operates. Tlis is a 750-bed station hospital functioning as an evacuation hospital-840 beds available and 899 patients. The hospital is insufficiently staffed to act as an evacuation hospital. Nurses are b)adly

needed here. Colonel Sneidemiani, Commanding Officer, appears to be doing

FIGURE 333.-Brig. Gen. William A. Hagins,

Surgeon, Sixth U.S. Army.

a goo(d job under difficult circ'nistane(es. Lt. Col. Philip L. Battles, MC, is

doing excellent work on disrupted wounds.

Across the road or pond was the 76th Station Hospital. Colonel Bramble

[Lt. Col. Russell B. Bramble, .11C] is Chief of Surgery. This hospital is on

a drier site; it is better laid out, is more compact, and has a splendid underground surgery. Saw many cases coming in from the 36th Field Hospital

across the island, a 2-day trip by road from Baybay. Records were good and

the patients were in good condition. Observed numerous cases described as

trench foot, but they do not appear to me to be typical.

The evacuation of patients has not been good. Too many patients have

been evacuated from Leyte. Fifty percent of the Leyte patients sent to Saipan

have been returned to duty in 1 month. However, there were not enough beds

available on Leyte. They were supposed to have 9,000 beds by D+20. Now,

D+60, the only general hospital functioning is the 118th with 600 beds. With

the beds of the station hospitals this adds up to approximately 2,000 beds availal)le. The reasons for this failure seem to stein from rain and the difficult
854 ACTIVITIES OF SUIGICAL CONSULTANTS

engineering problems in this area. Hospitals have not, gotten help from the

Engineers. Also, hospital sites were poorly clIosen.2 Headquarters has one

of the best. sites along the. beach, which I enjoy, but which is not fair to the

hospitals and the sick. The evacuation route is hospital to l)each, but there is

often no LST to pick up the patients. Talked with the skipper of an LST, and

lie said that. the patients were never oin the beach when requested. Obviously,

an evacuation station should be estal)lished on the 1beach as a, holding station to

correlate evacuation. Thiuss, there has been inadequate control of evacuation

from the island, and much unnecessary evacuation of patients who could well

have recovered here if facilities had b)een availal)le.

Sunday, 17 December

Went out this morning to visit the. laNaft.lch, flagship, and Captain Walker

[Capt. Albert T. Walker. 31C]. USN. surgeon of the Seventh Fleet. Colonel

Kendrick [Col. Douglas B. Kendrick, Jr.. 'MC, Special Assistant for Shock

and Transfusion, I SAFI( ).1] and I had a long talk with Walker regarding

the blood bank. Ile impresseed me with the soundness of his ideas and has a

better grasp of the surgical problems of combat amphibious troops than anyone I have seen in the Pacific, Ocean Area. Moreover, lie has accomplished

more than anyone else. We then visited LST 464, which is undoubtedly the

finest medical unit. afloat. This is an LST that. has been converted into a 200-

bed hospital ship--clean, good food, laundry, good operating room. Here is

the most concentrated and( best organized surgical care I have seen in a forward

area in the Pacific.

They're( doing excellent investigative work on shock and burn patients,

whom they have in great numbers. Japanese suicide bombing results in many

l)urns. For burns, they are using plasma and serum albumin in large quantities. all controlled by hematocrit and protein levels--as much as 1.200 units

per patient--plus blood. They find serum albumin better than plasma when

the condition is severe. They have their own blood bank. The donors are

Army personnel who are picked up on the l)each. The LST proceeds to pick

up patients while the donors are bled, then the donors are disembarked on the

way back. Only 1-qt. containers, discarded vacoliter bottles, are used. For

pooled group 0 blood, eight. donors are bled into 10-gallon bottles. Nine

thousand cc. blood, l)hus I)lasma, were given to one patient.-°:

22 I saw these installiations when I was with General Kirk and party in February 1945. The

locations were miserable but were all that were availahle at the tinie. By February. they had either

moved or were in the process of moving. I think the medical service (lid very well. as did the

patients with whom I talked.-.J. M. W.

" Dr. Ernest Eric Mulrhead. formerly the director of the blood hank on LST 464, In a telephone

conference with MaJ. J. K. Arlma, 11 December 1958. stated that Captain Walker. surgeon of the

7th Amphibious Force, wanted whole blood and had picked I)r. Muirhead to get It. since Dr. Muirhiead

had had some experience with whole blood before the war. The Red Cross blood was not then avail.

able. So LST 464 was set up in New Guinea and then went to Leyte. According to I)r. Muirhead,

they (on LST 464 "uhad to do with what we had.- Two kinds of hottles were used--the 1.000-cc.

vacoliter bottles and the 20,000-cc. regular laboratory water bottles. Preservative was made from

citrate and dextrose because the ACD solution was not yet available. Any number of donors with

group-0 blood were bled directly into these bottles, appropriate amounts of citrate and dextrose were

added. and the bottles were stored in the ship's walk-in type of refrigerators. The blood was not

typed for Rh factor, neither was it titered. In times of stress, transfusions were effected directly

from the large bottles, which had been adaptted for giving purposes with pressure bulbs. -J. K. A.
FROM AUCKLAND TO TOKYO 855

Large amounts of citrate may result in carpopedal spasms which are

relieved by calcium gluconate. The Navy makes up and distributes sets of

copper sulfate for bedside work.

Casualties received earlier were given better treatment, than casualties now

being received. When the S.S. Roti•ti fid took in one load of patients, nearly

every comp)ound fracture was infected owing to the poor setup and overloading

of shore facilities. The 7th Amphibious Force now has 70 LST's with surgical

facilities and 23 surgical teams.2- Each team is composed of 5 surgeons and

18 corpsmen. These are quickly shifted from one LST to another. This ship

[LST 464] also moves about among the fleet, taking cases from ships that have

been hit.. The LST goes in on the initial landing and remains as a floating

emergency hospital. The 60 well-trained corpsmen work most efficiently. The

LST unloads its patients to an APA [transport, attack], APH [transport for

wounded], or other ship which takes them to hospital ships outside the combat zone. He, Walker. is not informed regarding beds available in the Marianas. See Admiral Laning [Rear Adm. Richard H. Laning, MC, USN,

Inspector, Med ical D)epartment Activities, Pacific Ocean Areas] about entire

theater correlation. Will these LST's and surgical teams later be available

for Western Pacific operations?

Captain Walker first described these procedures for the Bureau of Medicine and Surgery in May. They consented to equipping LST's with surgical

facilities, but refused to build LST hospital ships on the grounds that conventional hospital ships were being built. They apparently missed the point

that hospital ships outfitted in accordance with the Geneva Convention cannot

operate in these waters during combat. Three attempts were made to bomb

hospital ships, one at night when the ship had to be lit up. Captain Walker

asks that I take up the LST hospital ship problem with Admiral Laning. This

was the program I tried to institute in the South Pacific a year ago, and which

met with Captain Hook's approval but. was turned down because of construction difficulties.

Observations on Blood Program

When General Rankin and General Bliss visited USAFPOA, I advocated

a blood bank program for all Pacific Ocean areas and suggested that someone

who had had experience in the European theater should set it up, Doug Kendrick if possible. Apparently the Navy had also been working on a program,

and the first I heard of this was when Blake and Brown came through Hawaii

with the blood, on their way West. This had developed into a combined ArmyNavy program on the West Coast. The Army was collecting blood in San

Francisco and the Navy in Los Angeles. Blood was transported by NATS

to Guani under the dlirection of the Naval District and Capt. Newhouser [Capt.

Lloyd R. Newhouser, MC, USN]. The ATC was landing on Saipan, so

refrigeration was set up there. But the blood arrived in the Marianas before

24 The 7th Amphibious Force under Rear Adm. Daniel E. Barbey, USN, comprised one of the two

attack forces of the Seventh Fleet in the asault on the Philippines.
856 ACTIVITIES OF SURIGICAL CONSULTANTS

any real 1)reparation had been made to receive it. Unfortunately, no one ill

the Pacific Ocean knew about the program, so it. got off to a bad start. Tile

Naval surgeons in CINCPAC [Commander in Chief, Pacific Fleet I were

peeved but cooperative. When Kendrick and I arrived at Leyte, considerable

time and effort was needed to establish cordial relations. Both Army and

Navy had had blood banks functioning for some time in the Southwest Pacific,

and the LST 464, especially, had l)erforlied outstanding service. The people

in the Southwest Pacific Area were perturbed that the first they learned of

the blood program was from the newspapers. Consequently. their ihrst. inclination was to say that they wanted no part, of it. However. in spite of the

excellent blood bank already established here. there was a need for still more

blood. Many of the hospitals did not know that blood was available. The

loss in early shipment of blood to Leyte amounted to ap)proximately 50 percent

owing to the fact. that arrangemnents had not been made for proper refrigeration or distribution. The chief reason for this loss was lack of ice. There is

a need for a directive on the use of blood and an educational program among

the medical officers.

There has been a heavy loss of men from the line because of the lack of

hospitals. Although the hospitals are here, there are few good sites, and these

have been used for other purposes, such as headquarters. Result: Engineering

prol)lems are so great that hospital building has been slowed down. Now,

D+60, a 15-day evacuation policy is in force. Patients have had to be transported 1,500 miles to the nearest hospital, and since many are returned to duty,

time and transportation are lost unnecessarily.

Tuesday, 19 D)ecember

Saw Colonel Wills, Base Surgeon, who was very cooperative in helping

to arrange the blood l)rogralm. Visited the S.S. .lbwtam, the last ship on which

Colonel Carroll came out of Manila. It now serves as the surgeon's office.

Major Steinberg is in charge of planning, another young officer with a large

job. The Southwest Pacitic Area has 44.000 beds, but about 25 percent of these

are inactive due to moving. There are 2:1 general hospitals. Ob)viousl, general hospitals are being used for station hospital work, which is one of the

reasons that there are not enough specialists to go around.

The overall plan is to support. each division with one 400-bed evacuation

hospital, one 400-bed field hospital, one separate clearing company. one separate collecting Company, one company fron the engineer special brigade, and( three

portable surgical hospitals. Portable surgical hospitals are used because surgical teams are not, available. The general impression is that the portable

surgical hospitals are not adapted to this type of hind fighting, but that they

are useful as 25-bed station hospitals, for examp)le, to support. an isolated

airstrip.

Saw Colonel Weston, 44th General Hospital. They' were set, up near an

airstrip. About 60M Japanese l)aratrool)ers landed on the strip, and a few

Ilights later reinforcements caine ill to join them. O(ur men decided to hohl

the perimeter, as they had about 200 patients in tents mid the road in was im-
.111 41i"I 44' I: 1. A ;1 W h4I'-.i 11. i-I~ id 9 1

44111- ()III It 1114c Itt: -141

. ,4i4' 1114i..:14. 11 I). ,f ý I~lle 11141 1144 -t l 41:1 4:-

1114 :Ilt4' 1 44:1 12the Ni 41!-iIl : 11 ,114'I 1Ii 1-:111Ili--,I I : fllIll.\N 1 I ku ll1 1-14 ;1 : 111ii 111- 4j 11-:11 Il411 _
858 ACTIVV'1Es OF SURG;IC'AL CONSULTANTS

cal ilicti are to assume aidmiinist rat ive responsibiilities for medical care, they'

shold~~~ be ('( Iivated ill Ille(Iivfl proIble~ills. at. least to tilie extenit of beinig able to

iutlentif -v a1 comlpetenit surgeonl.

This morningm. i visitedI tilte geeral*.- (.MacArthur's) qularters situiatedl oil

tlie bec.Adjacenit to ihme.e qolarters are framie Iuilidilng-s for thle staff. Tile

geiiera Is house is hutge and beautiifullY furnished.

Sunday, 24 D~ecemnber

Saw Col. Morris Bradtmer [Col. 'Morris It. Bradnter. %IC] of New York.

All exlel lenit smmr-'eolm A%.Ito timooghit lie could do umlore good inl this war. ill aim

mitliiii iist rat i e capacity, lie was surlgeoii of thle 2-IN i Garr'isoni Force at tachied

to lie XXIV Corps. Th'ley started for tilt 1Palaus from H[awaii, target timeit

chmiainzed to Yap. I hel clmalmgedl to tilie llilliie.'They were at sea for -54

(lays and debarked onl IA'vte D+2 12. Of this force. apparenitly only thle XXIV'

Co;rps was walitCel. anld ;low. D)+601. the garrisoim force hais nlot been) used and)4

tile*V (10 not, knlow what their assignment is to be. Trhese imospit als have therefore gone thlroug-h 4 1mou1ths of trainling' inl H awaii and have 'spent 54 (days at,

sea and 2 monthIs onl Ley-te. Coloniel Bradner is discourag-ed. lie has offered

his service.s tilhrough. the usuial channiels-, but nto onle seem" to wanit them. Anlother groodl surgeon grone to waste in a campaign where surgeons were at a

Monday. 25- December

visitedt 14 T 10 I8-Lieuteimnt M~cI~ermiot. surgeont. They- had cut waterfight, doors bietween the tank deck and the troop quarters. where they made a

dresshin room and washing roomi for patients and ant operatingc room. There

wvas space there for the seriously wouniled and 200 patienits could hle put on

lie tank (leek. Certain equipment, wavs la1ckingl such as anIhei m hies

water pitchers, anil some means of keeping ]hot soul) or coffee. They- were

stalffed( withi a lliniitiiiini crew of 2 oloctors andl 10 corpsilen, whinch is not enlough

tluriimg ant assault. All UST's are to he convertedl inl this manner-they now

have 17 convertedl. In addition, such ships as the UST 464 are uneeded as

floatinig hospitals.

7/lh Am,ph.)1bioiv Force : 760 LST s, 17 now converted for surgery; No. 464,

a hospital UAT with complete staff andl 60 corpsmien : and 23 surgical teams

(5 surgeonis. 1IS corpsmen each).

Navy doctor,, say that. the initial phase of surgery oil land is poorly (lone.

Onl S.S. Ilowitfidt every CC [compound comminutedl] fracture was found to be

infected. Captain Walker, 7ith Amphibious Force, gets a report-niame, rank,

andl serial number-in all cases of inmproper handling.

Thle handling of blood is improving but still needs much supervision.

-Need a system for dropping blood from "Cubs" by p~arachlute when the roads

go out. TIhmere is at plan for 96 1,--'s ("Cubs") to transport casualties. They

canl carry one litter and two sitters anio operate f rom anl 800-ft. runmway.

231ow could~ anything but confusion result from gueh a chnnge of plansm? Yet tile ,%idicaen

Department had no choicee-Yap Island was never Invaded !-J. M. W.
FROMP~ AUCKLZANDP 1114) 'I'0KYO S .5 9

F;1m,~i:.5-', WankI' of1 Ihe 35111 sll a~tioil I11Spi~i~Il, Leyte Ic Isl 111 vi vbl. 1 9'iul 11.

plant4Pol of a veivrilig cmlopalnv is 1iere to t iiesfer pail ents 11o J)UKAVW Jami

phlbinois truicks 21 ..-t oii I to) g() 0) I inilg about 2011 dailly. Thiose who di f41 ht

tAmidI I lie trip11 well I I holurS over, bad V4414L.) foiti K, avba ,v are held here at

Alm v()or. A14W selimloi pat huuts collie fromi (rm ) h b Yo bat. All.* evacliat loll1

frf Pi Va lelicla. be-fral oDI i + 60.

WedIles-11 hY. 27 1 )eceiiier

Thie 11, I mlm lllf l4)SIiia (7.')() b~eds) was S~ent il ,is i'111 ;M 14,)1111i4m a l)sjilal to) ý-llj) 1 )t thle 961th Iiv151011. 'Ilhie 11.1l I~wo a414l ioi)ljih siliiieolis attachied. Thie 761t StaNtioni Ilospital ( 114-I~41s) Ava., to act as aii1 ev;14'lai~ioll

lhosp~itall Iii supJpjort of the 7111 I ivslson."' lBev.1iise of the terrall). wealther. :I1nd

I acticdiIst 11)1aim. 1 hiese 1\\W(P Imptwere 1))115 picaiu-i ai4jacei'41 t eaich otlher andiu

recei veul patilenits from b ))I ihiv d islons. Th1ey w-ere sitluiat ed about :4)1vds. froml

jljie bea It I )uuhlug. 'I'lp S't wa er )(P(P. so 1()N\ and~ li1li(ldly that it se-verelv

Iiaiui Ii-a~pped thle I'lil It imoiiiiug of thlese 11451) itas.

The h1thSatlol ispit.il llsilahllV hihis 1ltolit :'()() stil-r*ictul pat plen- ti1

ru-ptar Iiieilical ( fig. 33,) . Sillve I I )Pcelllber, tI hey have purfli4l~led 17 Ina, 4)

Mid( Ili: 111 or 4)perat imis1. There were 4-I deat us, (; whli al wi~ere os4)eri

five (54 al)(Iilell~. !)(P Olier) and 30 were lmimoperhat ''." The~u 4)l001111 iIS'l~r 

well Set 111). b)1 il4()ve~.rr(l-li~l and14 Avlmt 11411 -lildbai--r lpr4Ptue loll. Ward; ais:re of

ther "'T" wantv ith i lralilildol tentl jullict p41. lE4Iuuipineuit is adevlllate. Tills

hnospital cmlldl lbe iimil-ome41 bYV a better plaimued layout . All hospitals that. have

"O The 106th :4 m fi u IInfalir I Phlvisimis 4'.tIiprised4 th I X NXIV cm''i-s awl4.1 I k latin 44 ~w ni imai

In ndings; ait .i

705 0 9i 7p 4 -57
S60O ACT1IVITIES o (ii' $TiWI('L CONSULTANTS

not functioned ill the field shlould~ receive ilistiructioi ats to p)lanninig from those

wh-]o have had ISuch exp~erienice.

On A + 1, 21 October. w~ordj was receivedI onl shipboa.rd that, four surgical

teanlis wereQ ntteeded ashore. LThey started ashore b~ut were (triv en oft bv iii rtar

fire. t hen Vwent -) miiiles dowin thle beacii towan I'umbyog- alt(l landed. [hey foundi

a few soldiers there who knewv iotltimnr of th e I ocal situatiiton. They then

sstartedl ill) tile beacht afl(l dug inl for thle night. Next day they still could not.,

tin~t ouit. who htimi wanitedt tilie stirgical teams, TheY set ulp at t Iiis site onl A + 4

antd immiied iately~ received 200 civil ian casutalties inl bad condition. The (G-2

[intell igence I was nlot grood.1 andi 111114-t of tilie hland and roads that. were thbought

to be uisable wvere actually undler wvater. Thit(.% had mniai miore castiaht ies thani

could be handled durinlgg the first week. and large niumbners were evactiated wvithout. ibeingz seen. After the first week. by dlint of very hard work, tihey were aile

to see mlost of thle casualties. Howevoer, the job donle forward was not. entirely

sa t I s ra('t i'r. Ag~ain, thisi was (tilie to tlie t'xeesstvt work thatit was lenianall(l

of tile forward installationls. Many pat ienits had inicomptlet e debrideinent.

[his niecessit atedl thle frequlenit chu1loi liglg of dIressiigs ill ordler to (leternilmle thle

con1ditionl of wolunds, some of whiv ih were hlhbeled "mnoderat e (lebrileinent."

Since thle four surgical teamis couldl not. work 24 hours a day, onIly% two suirgical

tealims were operating at a1 time.

'I'he numix-tr of beds available ill sup jport of the divisions was inaidequiate:

15i -bed ISta:t ionl hospital. -)01-bted stat ion hospital, two 404)-bed field hospitalstotal 2.0().) beds. These were situnated beluihid thle clearing station to serve three

tlivisioiis-aioiit TOO) beds per di vision. Result :Largre numbers wereC evacuiatedl

froml tilie islalu iid who iijiglit otherwise hlave been ret urned to dulty: inadequate

surgerv% anti lack of beds prohibited reparative sul-rgery.

There is too much4-1 emphdasis onl planning thle rear echelon hospitals. 'More

etmphdasis is nleeded oil staty plainning for hlospital iZat ion ill for.ward. j~aiaS.27

Frniday, 29) D ecember

Flew over to Valencia. Boliol Isfla nd-a former .Japanese striip-t iiis mornSlug in1 : a Pli per Cub."

D rove over to H[eadiquarters. 77th, i)ivision.2-- v'ie roads were crowtled

with tihouisanids of natives transporting their household goods onl their heads

or onl thle 1backs, of water bidflaloes. This umiigrat ion was coming front thle

nionit1ta Ills. Tile GIt and thle native women were all bathling togrether inl thle

St ream- ns e crossed-fialager of scliisto050111iasis.

Colonefl Ivinls [lt. (C01. .John C.* Ivinls. 'MC], suirgeonl of thle 77th Infantry

Division, was ouit. The P5hIortable Surgical Hospital was funlctionling with

the clearing stationt here. Thle surgeons of the clearing stat ion were alternating

with the surgeons of the por'tab~le hospital so that. they each did about the

Sammile anio1011nt of surgery. Reports fromn th letield hospital indicated that. the

I ag~ree. hilt task fEorve' commndeo nl'rs4 det erm inIedE th mi.'ntheir 'if lieds in forward o re'ls.-G. B. D).

T ihe 77th iiI iv li~on. whic .ho .1 i.i beenl~ engaed ii thei rvai' t Hr.' (if Guam.n was sent to Leyste In

late Novembher 1944 to reinforce the embattled XXIV Corpis. Oni 7 D~ecemibter 1944. It had made a

sitrpirl si landing tiHenr I epoiti .s and nlm h d iri ven, ithrough t hie ( r~n e Valley ta e~.ffectiit Ju nct ion witiIh

the 1st Cavaolry Divi slot neaor Vohdalenctia Bool l 151011 E.
FROM AUCKLAND TO TOKYO 861

surgery of the clearing station was not good and that tile.% were doing other

than emergency surgery. Furthermore, the emergency surgery was not well

done.

Talked with General Bruce [Maj. Gem. Andrew I). Bruce, Commanding

General, 77th Division] who is very medically nimided. lie says that the foot

problemn is most important and he wants one pair of socks brought up with

the rations each day. I[e was unhapv'y with Navy evacuation and stated that

100 wounded men were left oil the shore býecause the boats would not wait.

Broken glasses are a major l)rol)lenI. lie wants an extra case issued to each

man for replacement lenses and frames, especially as he has many nien of 35

years or older (average age in the 77th I)iv-ision, 29 years). Morphine seems

to he very beneficial for morale: the surgeon said lie had seen no ill effects.

General Bruce also wants a bag in the hat for a latrine at, night. Evacuation

is being done extemsively 1y (-'l) amid this is good for mora'ale. They -badly

need aml)ulauce Cubs.

l)rove to Ormoc, Leyte, to visit the "36th Field Hospital. Lt. Col. Devine

[Lt. (•o. Jolhn ,L. I)evime. Jr., M(I is commanding oticer--a superior officer.

This hospital is set. ul) in a shelled 10th century cathedral. There is no roof,

but. the thick walls p)rovide( goo(d protection. They will need much equipment

and some 1)ersommil before their next operation. Generators and X-ray machiles are worn out. They need two surgeons capable of heading a teamone general, one orthopedic. They are short 3 officers and 12 enlisted men.

Colonel Devine believes that many of the officers and men, having been on five

missions, are fatigued. In common with other conunanding officers, lie emphasizes the need for nurses early in a campaign.

The 36th Field HIosl)ital had 1,884 patients in 17 days, mostly surgical.

They averaged 125 per day, 250 patients on the top day. They (lid definitive

surgery mostly-2,600 in a month with three moves. This hospital has kept

permanent records for its own use. They are abstracted and typewritten on

all field records. The surgical records are superior. They received casualties

from the 7th l)ivision, the 77th Division, and the 1st Cavalry Division.

More directives and instruction are needed. Limbs are still being lost due

to tight casts. One. patient had a cast on over a clove hitch. Result: loss of

foot. These hospitals, the 36th and 69th Field had never heard of the coppersulfate method for protein determination. The 36th Field does not have a

qualified anesthetist or anesthesia apparatus.

Saw Colonel Kamnish [Lt. Col. (later Col.) Robert J. Kamish. MC] division

surgeon of the 7th I)ivision, and talked with General Arnold [MNaj. Gen. Archibald V. Arnold, Commanding General, 7th Division]. lie is very medically

conscious and recommended Kamish for the Legion of Merit. Tile XXIV

Corps uider General Hlodge has offered full support and recognition to the

Medical Corps, and any shortcomings cannot be attril)uted to lack of support

by the comumanding generals. Unfortunately, many of the good division surgeons (to not and cannot be expected to appreciate surgical principles, since

they are not surgeons. Hfavinig developed through the field service, they are
862 ACTIVITIES OF SI'RGICAL CONSULTANT8

prone to believe that field surgeons are better qualified to do surgery than is

act ually the case.

Saturday, 30 D)ecember

After seeing Colonel Kamish this morning, I drove to the 69th Field

Hospital which has been set up for about a week near tie airport at Valencia.

The losp)ital conunan(ler is ill and has been evacuated. Maj. Fielding Williams

[Maj. Fielding 1. Williams, MC] is acting hospital commander. They have no

anesthesia machines. This hospital needs at least one surgeon qualified as

chief of service. The laboratory has never heard of the copper-sulfate protein

method.

Waited at the airstrip and watched a number of patients evacuated by

Cub. Compound comminuted fracture of the femur, belly, head wounds,

and so on; all evacuated sitting ip. They appeared to stand tile trip from

tile clearing station (20 minutes) very well. Ambulance Cubs are needed for

econonly of operation (three 1)l'anes needed now where one ambulance. plane

could stiflice) and welfare of patient.

Sunday, 31 December

Spent, the night at the 69th Field Hospital and on to the airfield the next

(lay. While at, strip, saw General IHodge., Commanding General, XXIV

Corps. who stated that he was pleased with the medical service but felt that

hospitalization was inadequate. General Richardson [Lt. Gen. Robert C.

Richardson, Commanding General, U.S. Army Forces, Pacific Ocean Area]

came in. and a guard of honor was present. Came back to Sixth U.S. Army

headquarters [the Sixth U.S. Army was comprised of the X and the XXIV

Corps] in a "Cub" and spent the afternoon looking over the harbor for Captain

Walker.

Monday, 1 January 1945

Japanese started the celebration by bombing last night, and at midnight

our boys responded. Felt less safe than in an air raid. Arrangements made

for Lingayen operation. I am to go on an LST (H) [landing ship tank

(casualty evacuation)] and remain at target."-

Aboard LST 1018, Wednesday, 3 January

Boarded the general's crash boat, then on to IWTsoatch, flagship. Left

some luggage with Captain Walker who invited me to join him after we reach

the target. Left lVasatclh in search of LST 1018. The coxswain of the boat

had received instructions, but got mixed up between true and relative bearings, and we ended up on the opposite side of the bay. We boarded the LST

1018 at supper time after two hours' search.

There is a surgical team aboard of four doctors pilus the ship's doctor.

This appears to be a capable surgical team that is well organized, but they are

"The Biennial Report of the Chief of Staff, U.S. Army, for the period from 1 July 1943 to

30 June 1945, to the Secretary of War states: "In the first week of January [1945] a new American

assault force gathered east of Leyte, slipped through the Nurigao Strait * * 0 and passed into the

Mindanao and Sulu Seas. This American force was treading its way through the heart of the

Philippine Archipelago and through waters where the Japanese Navy and air forces had for two

years maintained unchallenged supremacy, to Invade Luzon by effecting a landing in Lingayen

Gulf * * *." D-day was 9 January 1945 and, it this case, was formally designated "S-day."
FROM AUCKLAND TO TOKYO 863

short of supplies because they were not notified that they were going to function as a hospital ship. Supplies were not available in Leyte, and they could

not return to Hollandia or Manus. Furthermore, the other hospital ships

have not had the supplies, or they have been reluctant to part with them.

Thursday, 4 January

('lear, set sail at 0600, about 80 ships in sight in the convoy.

1600. Have met a large convoy presumably from Hollandia-numerous

battlewagons, cruisers, destroyers, flattops.

1800. Apparently, this convoy is to be about 75 miles long and we have

joined up too soon, so we are now going back past innumerable ships to get into

position before darkness.

2000. We have now turned around and are heading into Surigao Strait toward a golden glow beneath thick laden clouds.

Friday, 5 January

1400. Sailing through Mindanao Sea-smooth and hot Bohol fading and

Cebu Island can be seen in the distance off starboard.

1830. Negros Island off starboard, like a camel's hump in the clouds-a

beautiful golden sunset.

Saturday, 6 January

Negros still off starboard. Smooth sailing through the Sulu Sea.

Sunday, 7 January

Peaceful ships and a clear, bright, hot morning. Japanese attacked at

0600. We are about 8 miles off the lower end of Mindoro Island.

Monday, 8 January

1100. The mountains of Bataan are plainly visible off our starboard. It

has been quiet since 0900, and two carriers can be seen between us and Bataan.

The convoy plows steadily northward.

Tuesday, 9 January

D-day, reveille 0500.

0600. Up on the bridge; clear starlight with a sliver of an old moon. The

dim outline of Mount Santo Tomas on the portside. We are well into the

Lingayen Gulf and moving steadily ahead. The dim silhouette of the battlewagons can be made out.

0700. All the battleships opening fire on the portside, followed by the guns

on the starboard. We are in the middle. There are two task forces, one off the

port (the landing is to be made on WHITE, RED, and BLUE beaches near

Mount Santo Tomas) and the other off the starboard bow, preparing for a landing at the town of Lingayen. The shelling starts rather slowly and continues

with increasing tempo.

0815. We have moved through the haze nearer the shore, and I can now see

the church in Lingayen.

0850. Bombardment continues. Our bombers can now be seen bombing

the shore, and great clouds of smoke and dirt shoot into the air in 1-2-3 order.

The first wave of small boats loaded from the transports behind us are now

passing. They are scheduled to reach the beach at 0930 (fig. 336).
(4;14 In:4 33G~i.- T I.4411Slt ike 371h)( I lhie im ci lml4.4, ishm:'v .14I4;-' i141 C441144' 9 lie unr 44 1 941-o

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FROM AUCKLAND TO TOKYO 865

Sasnow of San Frar, *sco. They, as well as LST 1018, are short of supplies

and equipment for adequate performance in case of heavy casualties. They

tried to obtain these from the hospital shilps but were unable to do so. Apparenitly, hospital ships are not fulfilinig their function as supply ships. This

ship was unable to receive casualties until D+2 as it was not loaded for assault

shipping. They have shot down five Japanese planes. As near I can learn,

out of some 230 LST's, only one has b)een hit on this mission, and that by a

torpedo. The risk to an UST therefore seems to be slight. Furthermore, they

now carry a lot of firepower-ten 20-mim. and seven 40-am,. guns. (Interrupted

by another air raid.)

The 1aWasatch, Friday, 12 January

0700. Heavy air raid. This afternoon I went to the l1asatch to see Capt.

Albert, Walker and Lt. Col. Stuart Draper, MC. The latter is a Sixth U.S.

Army evacuation liaison officer with the 7th Amphibious Force. I found out

that two other LST's are functioning as surgical ships on A VJTE beach, where

most, of the casualties lm ve been received.

Returned to LST 1018, packed my duffle, and returned to the *Wasatch at

Captain Walker's invitation. This is Admiral Kincaid's flagship.

Saturday, 13 January

Visited all the beaches today and went up a river to deliver a Filipino to

his family. This chap had 25 years' service in the Navy and had hidden out

in Manila for these 3 years. Yesterday he reported to the flagship for duty.

He went ashore proudly, dressed in white, to visit his family. On the beaches,

the surf wa-s very high, and not one LST was unloading although several were

beached. The pontoons were washed up on the shore.

The Blue R;dge, Sunday, 14 January

Went with Captain Walker and Commander Klein, who is Walker's assistant, to visit two LST's that are functioning as surgical ships. Water and steam

are piped to the tank decks. There are auxiliary lighting facilities and surgical

faucets. Steam and water are available in the head for cleaning bedpans.

About 50 percent of the cases here have had debridement and casts applied in

the clearing station. Some were well done and others poorly. The blood appeared to be in good condition, dated 1 January, "West ('oast,' and was well

ref rigerated.

DUKW's bring patients out from the beach and drive them up on the ramp

for unloading. However, when weather is rough this may be difficult. The

beach setup is splendid. A Navy medical officer and four corpsmen are assigned

to the beach, lie sets Ul) adjacent to or with a medical company of the special

engineer brigade. The engineer medical coi ipany desiegnates patients for evacuation and the Naval b)each officer is responsible for obtaining the ships and

supervising the loading. This plan has been slowly evolved through experience and is the best that I have seen in the Pacific. It could be improved upon

with better equipment [in the IST's], such as (1) portable anesthesia machines

Ileidbrink, (2) intratracheal anesthetic apparatns, and (3) portable orthope(lic tables. The l)ersonlnlel of these ships may be overworked, and Army sur-
866 ACTIVITIES OF SURGICAL CONSULTANTS

gical teams functioning on these ships would be of great assistance until shore

installations were ready.

This afternoon I heard that the Blue Rh/ge, Admiral Barbey's flagship of

the 7th Amphibious Force, was to return to Leyte, so I transferred to her.

SUMMARY OF MEDICAL CARE AND EVACUATION DURING THE

LINGAYEN CAMPAIGN

1. The plan.

a. General objective.

(1) The distance involved in evacuation made it imperative that definitive surgical care be provided at the target. Emphasis was placed on early

and adequate surgical care at the target rather than on speed of evacuation to

the rear areas.

(2) Cooperation of Navy and Army planning was emphasized, and a

close liaison was maintained between the commander of the Seventh Fleet and

the commander of the Sixth U.S. Army and subordinate units.

b. Fleet surgical facilities and supplies at combat area.

(1) Numerous and varied types of vessels carrying combat supplies

and personnel to the target. were equipped to provide surgical care. Evacuation from the Lingayen Gulf to Leyte was by APH, APA, and LST.

(2) Near the beaches, main reliance for surgical care was placed on

the LST's. Eighteen of these ships had been converted to provide facilities for

surgery. Six of these converted LST's were staffed with augmented surgical

teams (5 doctors and 18 corpsmen). These ships were under the control of

CTF [Commander, Task Force] 77. After unloading, they were to anchor

near the flagship for ease of communication. The medical representative of

the Comniandling General, Sixth 1'.S. Army, was also aboard this ship. The

ships were to remain in the combat area, receiving casualties day and night,

and be on call to proceed to beaches or go along the side of damaged ships as

needed. One of these LST's was assigned as sul)l)ort for each beach. As they

became loaded, and according to the comdition of the patient, the casualties were

transferred to APA's or APH's for evacuation to Leyte.

(3) In addition to servicing the ships in the harbor, three PCE (R) 's

[patrol crafts, escort (rescue) ] were stationed near the flagships. These ships

proceeded immediately to any vessel that was hit.

(4) Whole blood was available from S-day onward on flagships, on

any surgical LST, and at reefers on BLTE and ORANGE Beaches.

(5) Supplies were available, as follows (fig. 337) :

Location OrganizationI Period of time

WHITEii leach- I Corps Medical D)ump ----------- S-day onward

ORANGE Beach ..........- XIV Corps 'Medical D)ump ------- S-day onward

[ST's 564, 118, 704, 202--------- Medical Exchange Un it,----------- S + 2 onlwar(l

WHITE, Beach --------------- 21st Meldical Supply Platoon- -- ----- S+ 4 onward

)atgupan, Luion . 49th Medical Supply Depot -------- S + 4 onward

ORANGE Beach ------ 55th Medical Supply D)epot -.-.-.- S + 4 onward
V . 7, ,,p:,:; Th Iv ~
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FROM AUCKLAND TO TOKYO 869

500 feet from the shore; the remainder of the distance had to be spanned by

pontoons.

b. T'ie surf was so heavy that when pontoons could not be maintained

only DUKW's were suitable for the transfer of casualties to the LST's.

c. The LST's appeared to be relatively immune from air attack as there

were so many more profitable targets. It is likely that LST's are hit only when

they become targets of opportunity.

d. The equipment of the surgical LST's could be improved upon by

the addition of portable anesthesia apparatus, intratracheal anesthesia sets,

and portable orthopedic tables. Those ships acting as surgical stations should

also have portable X-ray apparatus. An additional number of pitchers and

bowls should be provided to facilitate the distribution of liquids and soul).

3. Observations.

a. The LST converted, equipped, and staffed as a surgical hospital for

use during the initial phases of the assault has many advantages:

(1) They p)rovide adequate facilities for early definitive surgery at

a time when this cannot be provided on shore.

(2) They provide adequate facilities for handling a large number of

casualties (185 casualties) in comparative comfort.

(3) They remove the wounded from the immediate frontline and

provide a sense of relative security.

(4) The LST is less likely to be attacked than a larger ship). It carries more firepower than the smaller craft and is less likely to incur serious

damage when attacked as a target of opportunity.

(5) When beaching is possible, the transfer of casualties from shore

is accomplished with the greatest ease (fig. 339). Transfer of casualties to

the deck of APA's or APH's is facilitated from the deck of the LST.

(6) A surgical hospital available to the beach at all times is essential

until surgical facilities can be established on shore. This can be provided by

the LST with a minimum loss to combat shipping. Inasmuch as several ships

are available, they may be dispensed with as the need diminishes.

(7) The presence of such a hospital facility afloat diminishes the

need of establishing operating facilities ashore until this can be accomplished

adequately and in safety.

(8) There are now 60 LST's converted for surgical use. It is desirable that all LST's be constructed or remodeled so as to be used for patients.

(9) Two types of LST's are needed for surgical care. One functions

primarily as a cargo ship, with casualties incidental, and does not remain at

the target. A second type, with adequate equipment and a surgical team

aboard, remains as a hospital ship at the target.

b. Shore units and control of evacuation.

(1) Thle l)eachl medical officer and two corpsmen are stationed at, each

beach and fuict ion with the lne(dical company, ESB. The mnedical company,

ESB, performs three functions: Care of beach casualties: triage for casualties
ACTlI V ITlIES 'IIP SURG(ICAL CiINS4ULT1AN'fS

Guilf, Febrl 'ruy 19)15.

bef ore evacuiation ,and4 I od(I Ingr casialt ie, oin I IeI( beach so I ha it51I11)5 (do no01 nie(I

to wait. for c-asiallieis.

(21 ) The 1 aiali mied Iical othicer is essenialt ly V triaflic officer, for 1Ila 1501

lbetween the A rInY ashore an th le Xa vv a float. 1Ile is fami ii ar wvithI lite suirgi -

alship jja iva Ilalile andi I.,~ responisibl e for seeil i th at casuial tiI IIV arepe1ly

41id Pu ible ;o -;( 111ha1 sili Iosipit a Is n1ot b11Iec' le Overtia Xed. For exul I) I le. w Ilien

caslia It W., a re hen v v, Ir In or wvol 1in Is ca II Iot. ai w Nays Ile I PeatI ed a1siliore( a IId A lioti11

be svIII 14Ilii alY sip that 1:ias a d betor ab~oarid, -whle Ith le ser'iouis casliaI t les shlant14

14', seiit to) 1lie sui ai ju1 1 whienil te oIwrll~ ion is oil It. Ila- Scaea pcil

izedl sunrga teaiis iia b le sp~ot ted on certain I~sT's.

(3) In heavyv surf, as at Lungavyeii. thle D1)101K appi ears fill ;fs

'11141 for- I *jI'ia t%

1,. 1 -e of' bench Iiied Ical (4llicer (NavY) 14) co4riolaiev A i'iiiv-NavY' sliorv-114)-

ini; he r. l iiM'41 oe irri:illVs.-riice losieloaoi aiivesl fii4)dit' .11 LSTIS So) 1iiiol

))e cowi 1jodlulf1 m-c'o~rl41±11g to Alipj. ( cit a ii 1LST'-- I hat halve v':iII-I p1'io'tv mi

iiiioaloinhig shiouilild be1seoh as eul4111iiat Imulisplinils aitid 1-4eiiiai1l oil tIeI 'av l

111t iAl sinel';'i *Ic Ids are10 ('tavsI4 oile to) vau bah III Ariiiiv division)
FROM AUCKLAND TO TOKYO 871

These ship)s must be adequately equipped for major surgery, including

anesthesia.

d. At least one of the surgical teams to be employed (five per division

during combat) should function aboard the LST until the shore facility is

ready for use.

e. More indoctrination of corps and division surgeons concerning the

function of various units, such as clearing stations, surgical teams, field hospitals, and evacuation hospitals.

f. Clearer definition of evacuation policy. Too many men are evacuated

who are well before they reach the next echelon.

g. More prompt establishment of convalescent hospitals or units so as

not to overutilize the beds of acutely needed surgical hospitals [for those with

minor wounds] and so as not to force evacuation of minor wounded from the

island.

h. Clearer definition of policy concerning priority for hospital sites and

assistance in construction. When hospitals are expected to provide their own

construction, they should have the requisite equipment.

Saturday, 13 January

Set sail at 1700 with two APA's and a convoy of destroyers. This should

be a fast trip.

Leyte, Wednesday, 17 January

Not one single Japanese attack. Today we passed a slow convoy going

south and another one going north. The Sulu Sea seems like an American lake.

Tonight Admiral Barbey invited me up on the bridge for a chat (fig. 340).

He is known as "Uncle Dan the amphibious man." The admiral is a large,

dark-complexioned man with a friendly, jovial, simple direct manner. He is

medically curious and deserves great credit for his cooperation and enthusiasm

in developing the medical service for amphibious warfare. He thinks the

Japanese conceded the Philippines after the Leyte Campaign, and that Luzon

will be only a delaying action while they marshal their forces for the next line

of defense.

Sailed into Leyte Gulf and over along the coast of Samar, then straight into

our anchorage in front of Tolosa. It began to rain, and I went ashore to what

was left of Sixth U.S. Army Headquarters with the Admiral's jeep. The storm

increased and reached typhoon proportions during the night.

Thursday, 18 January

Went down to stay in the 118th General Hospital. In the mud and confusion of construction, I had a fine talk with Col. Jim Bordley [Col. James

Bordley III, MC] and his colleagues, in the middle of their frog pond.

Peleliu Island, Friday, 19 January

Signed out at Sixth U.S. Army. Boarded plane at Tacloban Field at

1000 hours. Landed Pelelin Island [Palau Islands] at 1400. Went directly

to the 17th Field Hospital, now tinder Navy management. Its chief function

is to act. as a f rasfer or holding l)oint at the field. Still raining, bu the island

is coral and not muddy. Cordially received by Commander Kelley, pediatrician.
8> At 1W'I'I ES <1if' SIR<It'. (I<NS'1'.'ANTS

/ .-

• • ~ ~.'• ......... i

I[(;Ut.E ;310.-Aboard U.S.S. Blue Ridge, 3 January 1945. (Left Ito right: Maj. Gen.

I1nis P'. Swift. Comiimanding General, I Corps; Vive Adm. Daniel E. Barbey. COimniander.

7111 .\ pIblifi mu lFm-rv : and Maj. 4;vln. lx.ilard F. \Wing. Collmmanldinlg (;elleral, 43d

After clealinigr ull I was taken to I U.S. Na vall Base lospital Noi. 20 and

sIIownI tlt' sighls i" flhy Nose lRid..e. There I fI' d Eiidlmile Hlhlman, somewhat htitiely, Ua l~it d ii uraiget. hut carrying ml.As usual. a lille type of

qytoset ]Init mist rulctimia-- ,1letIs. i rihere is ]n a'hoidltge here. andt the

only %- asialtI ts g i t V 't ' Ctet I1 " air.

(m m., Sa I urn lvy. 20),Ja iutary

O11a Il' 1)4Jilfhlll, hous.II and 'iaver Ived (at G1111 at 1715 hou rs. aIfter severe 11rough

weatrlet'. A\muazed at the t rlalisforlllat ion here si live In1v last visit. After Leyte

the air lermitial here looks like ( ran! ('enlral Station, and the paved roads

are impiressive. Went dhirect'ly t lite 211•1h h i(iieral I lospital.

Sunday, 21 ,Jamtarv

"T1 ie 1t 4thi (ieneral lh fsI)itil is set ip iin ]eits, wit Iih lhe exception of the

operattillg rfoOll. lIaiorattiry, X-ray, a nd( iurses" quartl'ers. ThIeir sItnipterma-

]lent installation is 1leing Iiih1t. They are now operatigIz more thiaiI 1.00) hIeds

but at present l aveoldy 15a1 lat ilits. owing to tile fact that evactllt foil to G11:1111

by ATC will not Ibgin until I Feblruary. This hospital is one of tie Ibest set uI)

tent hospitals I ha'ive ever seen.

Gium. Flriday 26 J.auary

Have sp)ent the last 4 days recuprat ing from .1 v'old and visiting tile

37:14l Stat fipll I Ifllital.
FROM AUCKLAND TO TOKYO 873

Saipan, Monday, 29 January

Arrived at Saipan. Saw Colonel Longfellow and learned of the arrival

of the 39th Genera. Hospital. He had sent in an advanced party from Auckland. Ottenheimer had not been sent forward to check on the plans.

Wednesday, 31 January

Construction started on the 39th, and ground cleared. Some of the best

level land was not used for the site. No thought to future expansion to 2,000

beds.

Friday, 2 February 1945

Have spent tle last 3 days at the 148th General Hospital, which is slowly

evolving into a hospital. Construction has been very slow. It still has only

a 1,000-bed capacity (total beds available on Saipan, 2,000). Airfields and

headquarters have p)riority.

Saturday, 3 February

Worked on logistics and visited the 369th Station Hospital a well planned

and constructed hospital. Colonel Lubitz [Col. Benjamin Lubitz, MC], the

commanding officer, was formerly surgeon with the 27th Division.

Monday, 5 February

Visited the 176th Station Hospital, a stone's throw from the 369th. Both

have excellent quonset construction. Why two station hospitals should be

placed so close together is beyond me. They care for garrison troops scattered

over the island. Since these hospitals are not geographically suited for this

purpose, they wish to combine them into a general hospital for casualties,

thereby correcting one mistake with another. This would entail an unnecessary

duplication of skilled personnel as well as equipment.

Tuesday, 6 February

Radio today assigning Baker and me to the 204th General Hospital

[Guam]-as this is the only hospital with vacancies for full colonel-and to

temporary drty with the Surgeon's Office, Western Pacific Base Command.3 0

Also, a teletype for me to return to Headquarters, USAFPOA, by 15 February.

En route to Oahu, Hawaiian Islands, Thursday, 8 February

At 0615, just daylight, we got off and flew all day. At 1800 we landed

at Kwajalein, and a nice Navy lieutenant came on board and said that they

would give us dinner on the plane and that we cou"Id leave in half an hour

if it was all right with me. As though I would have nerve enough to tell the

Navy what to do! So we left at 1900, and I played poker with four aviators

until 0300 of the same day, because we had crossed the dateline. I then went

to sleep soundly on my air mattress on the floor until they poked me to tell me

that we were starting down. At 0600, with the east in a pink glow, we landed

at Johnston Island.

*The Western Pacific Base Command was activated on 25 April 1945. Included In this command were Army units on Saipan, Guam, Tinlan, Iwo Jima, Peleliu, Ulithi. and Angaur Islands. The

Western Pacific Base Command was subordinate to Headquarters, U.S. Army Forces, Pacific Ocean

Areas.
874 ACTIVITIES OF SURGICAL CONSULTANTS

En route to Saipan, Friday, 23 February

Arrived at Fort Shafter, Oahu, and found Eddie Ottenheimer very indust riously acting as consultant, working on history, personnel, etc. Ben Baker

was about to leave for Saipan. Many new officers have arrived. The port

still has a peacetime atmosphere and everyone is griping about the red tape,

et cetera. Most, of my time was spent in helping to lpit together a concise directive for the Tentih U.S. Army on surgical care in the combat zone.31

Finally, I got the orders through and escaped with Eddie as though from

an asylum. We took off on 22 February at 2300 hours. The nurses who were

liberated at Luzon were at the field on their way to the States. The band was

there playing "Show Me The Way to Go Home" and other similar tunes, and

everyone wore leis.

Sailpan, Sat urday, 24 February

Spent the day touring the island with General Kirk [Maj. Gen. Norman T.

Kirk, The Surgeon General], General Simmons [Brig. Gen..James S. Simmons,

Director, Preventive Medicine Division, Office of The Surgeon General I. General Willis, and General Jarman [Maj. Gen. Sanderford Jarman, Commanding

General of the Army Garrison Forces, T"SAFICPA and USAFPOA].

Found that only one opera " roci was functioning at the 148th General hospital. We spent tie rel ier of the day trying to get some sembilance

of organization. We transferred harge numbers of the 39th General Hospital

staff and a large number of nurses. These changes were quickly accomplished

wvith the support of General Kirk and General Willis.

Note [written, apparently, sometime between 24 February and the next

entry, 15 March]: The hospital was soon running on a 24-hour basis with

four operating teams working continuously, averaging 60 majors per day. In

all, 2,200 [sic] serious casualties were treated, with a mortality of 1.1 percent.

Considering the circumstances and the character of the casualties received,

this was a splendid record.

Had a meeting with Ben Baker, Colby, General Willis, and General Kirk

this evening. Discussed evacuation policy with 'Willis, with a view to avoiding

the loss of shipping and manhours brought about by having to evacuate patients

to Oahu, nearly 4,000 miles away. 32

NOTES ON RECOMMENDATIONS FOR MAJOR GENERAL KIRK

1. The essence of good surgical care in the Army is to get the right man

at the right place at the right time, in adequate numbers and with adequate

equipment. None of this can be accomplished without planning. Consultants

in the Pacific Ocean Areas have not been consulted in planning as of 10 Februiary 1945. The efforts of a consultant whli has not taken part in l)lanning are

.1 This directive, the subject of which was "Surgery in the Combat Zone," was promulgated by

Headquarters. U.S. Army Forces, Pacific Ocean Areas, on 27 February 1945. Colonel Oughterson

was later to rewrite this directive at Headquarters. U.S. Army Forces, Pacific. where it was published

in that command's The Journal of Military Mc(dicine in the Pacific, September 1945, pp. 11-23.

"J The situation wav corrected.-J. M. W.
FROM AUCKLAND TO TOKYO 875

chiefly limited to trying to lock the stable (loor after the horse is gone. Under

these circumstances, there is a great danger of the consultant assuming a onesidedly critical attitude, since there is little left for him to do. His mission in

planning, to improve the care of the sick and wounded, is blocked at the source.

2. Clinical research, for the benefit of the sick and wounded in this war

aid ill ftutrtire wars, is a1 responsibility of the Medical Departmnent of the U.S.

Armny. It is recognized that the first responsibility is the care of the patient,

but there is an equal responsibility for itnvestigative work which will improve

the care of the patient. Theater surgeons should be made aware of their responsibility in this field.

3. The essence of good surgical care is to provide good surgeons. The

limited number of good surgeons available requires planning in the distribution

of skilled talent. Surgeons can be conserved by careful planning of the geographical distribution of hospitals, the size of hospitals, and the type of hospitals. Two or more smaller hospitals should not be used where one larger

hospital can do the work. This policy has resulted in a great waste of highly

skilled medical talent as well as equipment. Also, the less-skilled surgeon can

function satisfactorily in a station hospital, if he is limited to the station hospital

type of work.

4. There has been too great a tendency to keel) skilled surgical talent in the

rear, whereas the most difficult surgical tasks are to be found in the forward

area. The wounded soldiers who die, usually do so at the front. Greater

mobility of these surgeons tlirough the use of surgical teams is recommended.

5. In the vast stretches of the Pacific Ocean there are a great. number of

hospitals, large and small. The leapfrogging of these hospitals umuay involve

distances of a few hundred miles or as much as 4,000 miles. Between the time

the hospital ceases to function and the time it receives casualties at its new

localtion, several months to a year nay elapse. In this manner the 7th Evacuation HIospital was inactive for at. least a year. This results in a great loss of

highly skilled manpower, as well as a lowering of the morale of the unit. At. the

same time, the shortage of mnedical officers, nurses, and technicians in the forward areas has been increase(]. Air t ransl)ort should l)e used to make this idle

manpower available.

Saipan, Thursday, 15 March 1945

The major l)art of the Iwo .Jila casualties halve now been treated. Plans

are now being laid for Operation ICEBERG [the Ryukyus offensive, 25 March

19451. The shortage of personmel has necessitated that the hospital facilities

on this island be organized as a hospital center. Furthermore, the small numbier

of medical casualties has made it. necessary to nearly abolish the medical service.

Colonel Colby and Colonel Baker have given full cooperation in the face of

most. trying circumstances. All inedical cases aro to be. transferred to the 176th

Station Hospital which, together withi the 94th Field IHospital, has five psychiatrists plus other l)ersonel, and functions as a station hospital for medical

cases. This frees tile 14Mth and 39t.Ih General Hospitals, plus the 369th Station
876 ACT1VITIE3i OF SURGICAL CONSULTANTS

Hospital, for surgical cases. The 148th General will take any surgical cases

except for neurosurgery, while the 39th will take any surgery, but not thoracic

cases. The 148th will have a thoracic team, and the 39th will have a neurosurgical team. The 369th Station Hospital, which is short of qualified surgeons, will handle only soft-tissue wounds.

Thursday, 22 March

The chief of the surgical service, 148th General Hospital, Colonel Cornell,

has been transferred to chief of surgery, 176th. Station Hospital. Ile deserves

great credit for the cooperative spirit and equanimity that he has shown uider

these trying circumstances. Colonel Ottenheimer was made chief of the surgical

service of this hospital and again demonstrated his rare capacity for surgical

organization and judgment. Colonel Bishop became chief of surgery at the

39th, and Major Sutherland was transferred to the 148th General, leaving

Major Claiborn at the 39th as assistant chief of surgery. Captain Post and

Major DeSopo were placed on temporary duty at the 148th to strengthen the

thoracic team. This has necessarily weakened the 39th General, but still leaves

it with the strongest professional staff in the Marianas.

A meeting was held with General Kirk, General Willis, Colonel Colby,

Colonel Baker, Colonel Oughterson, and Colonel Welsh [Col. Arthur B. Welsh,

MC, Deputy Chief, Operation Division, Office of The Surgeon General] regarding the medical problems of the Army in the Western Pacific. The question

of the medical support of the Tenth U.S. Army was discussed. It was agreed

that this was inadequate, but I am not sure that the shortage and seriousness of

the situation was fully realized. The need for hospital beds in the Marianas

was discussed, and the great shortage of beds was pointed out. The need for

investigation of wound ballistics (requested in a previous letter by The Surgeon

General), shock, and related problems was discussed. The meeting adjourned

after assurances had been made that everything possible would be done.

I made a visit to Guam and found the situation there comparable to the

situation on Saipan. However, no effort at triage has been made here. Control

was in the hands of the Navy. Had a long conversation with Captain Anderson

[Capt. (later Commodore) Thomas C. Anderson, MC, USN], Admiral Nimitz'

surgeon, who was most cooperative. The Army does not have the specialized

personnel necessary to provide adequate care for the patients on Guam. Only

by making Guam a hospital center can adequate care be provided. General

Kirk agreed to the consolidation of small station hospitals as a means of saving

personnel, and to the use of surgical teams and the inactivation of portable

surgical hospitals.

Friday, 23 March

Received word that 5,000 additional beds may be put on Tinian Islandsource of personnel unknown. At least some arithmetical facts are sinking

into the planners' minds. Had a conference today with the Commanding Officer, 148th General Hospital, and with Colonel Colby, Colonel Ottenheimer, and

Colonel Baker. The problem discussed was how to use the engineers in converting the 148th from an old broken-down farm in appearance and function
FROM AUCKLAND TO TOKYO 877

to a modern hospital. There are inches of mud and dust in the wards and

operating rooms. CinCPac has ordered A-1 priority for hospitals, and not

without reason.

Thursday, 29 March

The Tenth U.S. Army has been with us. George Finney, Hal Sofield,

Doug Kendrick, Ben [Baker], and I, are in the sane pyramidal. All that was

needed was a little aisle between the bunks. My orders to go along (to Okinawa) have been canceled, much to my chagrin. They sailed on the 27th.

The best that can be hoped for is that casualties will be light.

Guam, Sunday, 1 April 1945

I went to Guam with "Red" Milliken. Stayed at the 204th General Hospital. Colonel Bryant is doing a superior job. This is one of the best organized and planned hospitals, and certainly the best Army hospital in the Marianas. It appears that the Navy has given preference of materials and workmen

to its own hospitals. The Army hospitals are not as well equipped as the

Navy's, which appears to be the Arninys own fault. There appears to be little

justification for the great difference, since both Army and Navy hospitals must

perform the same functions.

Had a very satisfactory chat with Admiral Laning, Navy medical inspector

for Pacific Ocean Areas-a practical, forthright, capable officer. His observations on the Iwo campaign bear out mine on the Luzon campaign, and corrective

measures are under way. There was much delay at Iwo in getting casualties

from the beach to the ships, which the small boats had trouble contacting.

Besides, the medical teams aboard the APA's were inadequate, both in number

and quality of surgeons, to cope with the situation. The admiral says that the

APA should not be used as a hospital ship, and that we must have more hospital

ships. However, as Captain Walker so aptly enunciated, the primary consideration must be that of providing definitive surgical care on the spot, and not

that of insuring speedy evacuation.

Visited Tom Rivers [Cdr. Thomas M. Rivers, MC, USNR] and his MRU

[Naval Medical Research Unit] No. 2 which is under construction and promises

to be de luxe. Rivers was burning with indignation as his first request for

research was for a chemical analysis on a ton of beer. Requests for help in

investigation far exceed his capacity. His interest in problems with the natives

is overshadowed by the Navy demand for military medicine.

Carter [Lt. Col. George G. Carter, MC] started as Chief of Medical Service

in the 204th. Woodruff [Maj. William W. Woodruff, MC] has many interesting chest cases and many hemothorax cases needing aspiration. Very few

of these cases (Marines) were aspirated, due to lack of adequate surgical help

at the front.

Saipan, Wednesday, 4 April

There is, today, no hospital on Saipan able to do elective surgery. There

are plans to make a hospital center on Tinian, with an additional 5,000 beds.

It appears that the medical bed requirement of the Marianas is finally being
878 ACTIVITIES OF SURGICAL CONSULTANTS

recognized. However, it should be noted with emphasis that to date no consultant has been used for medical planning by the Surgeon's Office, Pacific

Ocean Areas.3 Many lives have been needlessly sacrificed. The hospital planning could have been greatly improved, and both medical and nonmedical personnel could have been more efficiently utilized.

Friday, 6 Ap)ril

Lt. Col. P~te Bishop came to see me regarding the morale of the 39th General Hospital. They complain that they are not getting a fair break in construction and personnel, which is a complaint common to all hospitals. It

appears that their primary need is for leadership among themselves. Some

don't like this and some don't like that, and they fight with the engineers doing

the construction. One hopes that with the coming activity most of their

problems will vanish.

Manila, Tuesday, 15 May 1945

John Flick [Col. John B. Flick, MC, Consultant in Surgery, USAFPOA]

arrived, and for the past month I have had a delightful time traveling over

the Western Pacific Base Command. The formation of this command has

been in process for some time. The new command of the Pacific, MacArthur

and Nimitz, was announced, the WPBC [the Western Pacific Base Command]

(p. 873) was announced immediately afterward.

John Flick and I visited all the institutions on Guam and were in agreement as to what should be done, but JF asks continually: "What can be done

about it?" There are not enough station hospital beds on Guam, yet it is

proposed to change the 373d Station Hospital, which is miles from the port,

into a general hospital, and without personnel to staff it. One of the chief

sources of wasted personnel in the Pacific Ocean Areas has been the failure to

distinguish between the personnel and functions of a general and station

hospital.

We journeyed on to Tinian. Colonel Shaw is here, doing a splendid job

as island surgeon. He has no inferiority complex and seeks advice wherever

he can find it. Result-splendid planning. Had a long conference with General Kimball [Brig. Gen. Allen R. Kimball] who emphasized two important

points: Plan for what you want in the future and don't try to do it by hidden

figures; and the need for recreational facilities (morale and physical). Don't

send out people-we have them to burn-but send the equipment we don't have.

Went to Iwo Jima, referred to as a "solidified burp." It is almost as

desolate as the atolls of the South Pacific. Colonel Currey, Island Surgeon,

is doing an excellent job.

There are three hospitals on this small island-the 38th Field, the 41st

Station, and the 232d General Hospitals. Certainly the two smaller hospitals

should be combined.

• Colonel Flick was Rurgicai consliltant at Headquarters, U.S. Army Forces, Pacific Ocean Areas,

at this time, and he was consulted in all planning as were the other consultants at the Headquarters.

colonel (Oighterson's comment Is not a fact.--J. M. W.
FU 01' AiIV: I ' LAN :i ITi- :1 2'I ()I1 N 4W II tL 2'1l1-u ~'- 'l' 41~4I4 *iiI4

4~- I('d I'4\'4

v-('4.I '11, 1 114) I~ ;dj41;II-v 144' - 1 it114''I I. II\.I N14:411: i 1 , :Left 144 v 1 :11111 f 4 ill 2:' 4'

:111d r Irri e I t rI,.I ill 1',rjr',r.,.4 :11Th p a'iiil~l
880 ACTrIVITrIES OF SURIGICAL ('()NSuIrANTS

.salesiiaiisiliip wasi reqpliir('d. Sp~ent thle remiaiiider of t le da. t ?_lg orert

a. (lirectivo for surgery inl tile combat. area. M na.4Jli

D~rove out to Sixth UT.S. Army headquarters w-ith Earl Moore fDr. J1. E.

Moore, Civilian Consultant. ill 'Medicine (Venereal Disease) to Thle, Suirgeon

General]. Lt. Col. Tomi Sternberg I L. Col. Thomas IIL Sternberg. MCI, Chief,

Venereal IDisease Control Division, Oflive of The Surgeon General, and1( Major

Bouidvan of the 1USAFFE Boarid. General Illaginls was ill hIls usual go0od

form. After lunch we discussed woundl ballistics abo~ut. which hie I 6eneral

Ilagins] is very skeptical, but I left hini tile Bolligainville report and will Ileturn inl a week for disvussion.

Saturday, 9 June

Have been engaged for the last fewv days inl surveying the I eedl for civilian

miedical cvire in Manila. Thiis has beýomte neceýssary from a,. miilitary standpIoinit

because civilians are. oc-cupying- many b~eds in miilitary hospitals. The Philippine vivil afflairs office originially tried to provide sitch hosp)italization. Bunt

their eltorts have proven to b~e inademiate to the need.

Eveni before the wvar. lhosp~ital b~eds were inadeq1uate to m]eet tile demiand.

Approximiately 4,000 lbeds wvere avalilalble. InI add~ition,. there was one 1.500-

bedl hospital for thle insane withI :1,000 patients. Tile .Japanese set these inmiates

loose, anid mlost. of them are said to hlave starved. although their exact status

is unknown. AtM present. there are 1.419 provisional hospital beds for the mentally ill, part. of which are in the 01(1 hospital for' the insane, and1 the remiainder

inl schtools. There are 2.457 governmitent. beds andl 1,16:3 p~riv'ate beds. many nlow

occupied hy nionpaying lpatients. O)n I July. thle private bleds will all revert.

to private-paying patients, leaving approxim) iately 3.1800 governmient. bleds

*avi 1able.31

The Quezon Institute for Tubercmm(-Ilosis-1.500 b~eds b~efore the war-was

always full (fig. :142). 'rthe T11 deathi rate wvas very high. At present. the low-

('st, rep~orted llT death rate for 'Manila has been '80 p~er week, and the highest

was200o:1" H owever, it is kinown that. the rate exceedIs this Iliiumuer.

'I'Iie former dIirector of thle Quezon lnst it ute, D r. M1. ( on izares, is nlow

illetl ical ad v iser to President 0sniena. General Valdez, chief of stafIf of thle

Pi~lipiiJpinie A riliv. Illemilei of tilie ('ahi iet. alitd politivo, is Sa id to lbe tile best.

doctor ill the P~lhil~ippines. Sonmp think it. would hie better if the krmyv cont rol led thle huospi t als an ut ack led the heal thi problem onii the isl a nds. The prob-

]pili is one of admitIi ill civilians to Anvhospitals inl those cases Ill whichl lifeS~aviiigr prtveutlures IntlA he emiployed, andi of providing facilities for those case~s.

15The Jatpa nese 1n1l owed %it ib t-mit n rvimi hant moist (of tiv he mitnts I it O liospl ta i for the insaimp

wi'rv asld tio fine irve.f. ta T'I'Ite- were mmtiolit ~ti eft nitfe whoi we took i.vier. I ami very qhmilotitil

n% tooithe fnoirvm heo gIvo-s for tMle stitoiher r ittella nit i ~inilrnmiental i ho'ttal hioots for 'ivi~liaiits lin

Ma oust. %vitlelt seeiiis tii, moi~. ho~we-v-r. I kniii oot imi way now ofr iimlti~iis:imor nilirin tivinl estItist test

f-or maist 1wio-rl.I. iLetter, Dr. 'Mairlo - C. I'lic~iffs lip Ciii. .Jo~lm illo~yI ct'o tes. Jr. mv ME -sdi l, 

T-he Ch'it Affairm hendoluiarlerit at this~ tjIls.' e-ttilisiati the- eoimiiilsloin pif Maiiilsa at stiiiroximati'ly tine mililloi. ilettvr. Dr. Matuinee V. i'ne~offs toi Oil. .loltn Boydi Comstes. Jr., MIC. S Feb. 9!i
PI1p NJi .%1-4 .AN iik NP lIS

Will~

wruuwu u~ ~:-1-r

Timms

'Flt;' In 312 Quz

I It Iii Iiýi III, I iv M a iaIS iioIN( .- 1IIS

t 1)i .I O i i Ie 1 \l'~1:1ma . lon Iitlial hal i l, i (d, who tii l re lt tl'e'it'li cases. 'tiu2t'

13 lt't . 1111 '1 i.l'. I iieah~ I het''' i flii' 1i 1-)'_4 ill 'lI' i''ii t'' il ttl 'I t' - ttt
F i I :'it' Tht. li li'I'i ]'-'(fill iii~ t i lt ill T 11:1144 tikelit'll N~l~lfll .11 i 1~4 . 9tt'Is'.

lilt 411:11 4.1 it 6 1 I'I 14 :111)1 i~* Il I~i41 'll i it'i I l i 4;v1. 4 I st' pittI A 1 --.

lii 4)4.' 1 t I 11: lii It'.- X61ll ()Iith hok liv t T ii41 he: gm i'I l vit11 I'lll 111111 l 1i 

I I I itt : ,.it (w '. lu ' le ilki f )ti I t't' l ii :111 i III' 111 Nts)- "I,:1 1.1 Ii 'I 4 1ii' 1111'Ii

II Ii' I I 11 4 tl 1 1'l t 1~ 1i X I I 4 I1 ii . )1 v it ''IIII 1 I r t I - l)1 144 li 1 411 ý II 1 I I I i I~ : I I [ Ilt I * I t'I

vi I : , II Ii 1 II 17, . 111 ' IT TIi-I I ,I rI I I rI, lite AI-I.ij' vT :11 TTtI f II I It 1 II 4 I v 4 o lr w
Nv II I e1al e1 4)11 1 -ie o ina.I i I Iiit I ve sw4x1111 te hit' vas I wlloI a AII et ~ (I

2. I'iiizl~ld Ifoirrmii l all hvva in ethic ( ti4 i t'rs Iti i foi-~ls il( Il

1. lust Mu 4 li ahsptl

Ait Ive be 4) ilt'ave iai it'alidermle co epli llv

2.ii T ( 'uulisll1tal111 I. IIIIIIIg Ihu flitu IIII dII -at' lul' (Asjuis iveIt'st )cl In ., ;i5iX) s f111 liti Itt4l

l :1.' 1'htla' ia lise-1c i h~u.t 11: ho sp iit' i~l ot1. u'suii'. l'onu tt -iuiu

litit 14'i ~ list' 1-to114-1 )5)[ 1 iow liht'- 1 li' ulhieei is t111 llt I v'l. Thi is- It('. ' hti~

En h lt'Vt' I1 u It hii;Iti 11 AR5 )S Ii ~ t ithIet H~ ; l II*Y qW ll, a v t ila 1 s ' 411) tYb I 4-u' e v tsif 4I.
884 ACTIVITIES OF SURGICAL CONSULTANTS

4. lecord.'.--A uniform report on individual cases 1)y the chiefs of all the

surgical services. Reports should include all deaths and complications, and

their causes. A report should be made on each illness or injury on duty, and

each death or discharge to the States. The report would be incorporated with

machine records based on the standard Arlny diagnosis.

5. Plniidnq ol operations.-Consultaiits should be used in planning. Their

advice must be given more weight so that the facilities and personnel commensurate with the mission to be perforined will be made available.

6. Consultants shouhl be heeded on plans for anesthesia, ophthalnology,

nellrosurgery, reconditioning

7. Sp1eemazatioL.-Ilospitals shouhl specialize in specific battle casualties

and diseases. This will result. in better care and a greater opportunity to study

diseases.

8. Research investigation of special problems in missile ballistics, body

armor, shock, et. cetera, should be initiated.

Friday, 13 July

We had a long teletype conference with the Surgeon General's Office for

the purpose of finding out why, when we ordered 550 medical officers. they sent

us 12. We had a lot of conversation but never found out the reason for the

deficit. They said that they would answer by mail.

Monday, 23 July

Have been working the last week trying to get up enthusiasm for a study

of body armor and missile ballistics. Splendid cooperation from Colonel

Alexander, President, Pacific War Board.

Tuesday, 24 July

Gave some data to Col. Roger Egeberg [Col. Roger 0. Egeberg, MC,

Aide-de-Camp (Medical) to General MacArthur] in the hope that we may get

General MacArthur accustomed to the idea of attaching a missile ballistics

team. Working on trenchfoot and wet-cold projects.

Wednesday, 25 July

It appears that, for most people, becoming accustomed to a new idea is like

a woman with a new hat. It all depends on what other people think of it.

Friday, 27 July

Today, Japan turned down our surrender terms. Most of the betting here

is that the war will end within 3 months.

Visited Sixth U.S. Army headquarters, and spent the night at ASCOM

[Army Service Command, SWPA] headquarters. Will try to coordinate the

machine records with USAFWESPAC [U.S. Army Forces. Western

Pacific. successor on 20 June 1945 to TUSASOS (the T.S. Army Services of

Supply), SWPAI' and the training program of UTSAFWESPIAC with ASC'OM

and tile Sixth U.S. Army.

Weednes(lay, 1 August 1945

Today I flew out to Cabanatuan, Luzon, to visit, the 43d Division medical

battalion. We flew along the edge of the momntains on the way there and

spotted a small group of Japanese who ran off at greatm speed.
FROM AUCKLAND TO TOKYO 885

Had lunch with General Wing [XNaj. Gen. Leonard F. Wing, Commanding

General, 43d Division] of Burlington-a rugged, popular fellow. Listened to

the usual complaints about not having enough medical personlel, of always

going in short, and then attaching porlable surgical hospitals, the personnel of

which could not be sent into the field. They had been visited by the army

consultant only once. Monday, 6 August

Feverish activity to get the trenchfoot program underway. General Denit

left it in my charge. The Quartermaster had already gotten out a wet-cold

directive.38 Since the quartermaster activity is primarily for the purpose of

preventing trenchfoot, I have developed a program that combines information

on the preventive medicine aspects and the clothing aspects of the problem in

the following way:

1. A letter from the commander in chief to the commanding generals of

all higher echelons emphasizing the importance of the problem and telling them

what trenchfoot is.

2. A letter from General Denit to all division commanders emphasizing

the command resp)onsibility.

3. A medical directive to doctors.

4. The use of information and education facilities.

a. Directive for training officers, telling them how to do the job.

b. Booklets for all soldiers.

c. Movies-shorts combined with entertainment.

d. Use of radio for short programs combined with entertainment.

e. Yank Magazine and news releases.

Morotai Island, Indonesia, Tuesday, 7 August

A Japanese hospital ship was captured in the Banda Sea and brought into

Morotai Island, Indonesia. With Col. IHollis Batchelder of the U.S.S. Mercy

to assist, I was dispatched to Morotai by special plane, arriving at Morotai at

1600 hours. We reported to Maj. Gen. Harry H. Johnson, Commanding General, 93d Infantry Division. He is National Guard from Houston, Tex., and

a forceful pleasant Texan who gave us real southern hospitality, and as good

a steak dinner with hot biscuits as I have ever had. Colonel Jackson is his

chief of staff.

Wednesday, 8 August

Went with the division surgeon, Colonel Melaville [Lt. Col. Eugene F.

Melaville, MC], to see the port director, Commander Harrison, who gave us

permission to board the Japanese hospital ship, Tachi Banae Jaru. This ship

had been intercepted in the Banda Sea on 3 August. A destroyer flotilla had

gone out for this purpose.

Verne Lippard [Lt. Col. (later Col.) Vernon W. Lippard, MC] just came

up to tell me the radio announced that the Japanese have accepted the Potsdam

ultimatum.

ssMedleal Department, United States Army. Cold Injury, Ground Type. Washington: U.S.

Government Printing Office, 1958, appendix H, p. 533.
886 ACTIVITIES OF SURGICAL CONSULTANTS

After boarding the Japanese hospital ship with a walkie-talkie [radio],

they [the boarding party] found contraband and summoned an armed boarding party to take charge. There were so many Japanese (1,600) on board

that they did not dare go below to search. The exterior of the ship was marked

according to the rules of the Geneva Convention. The patients were sleeping

on mats spread on top of the cargo, which was mostly contraband and consisted of boxes and bales that were packed with rifles, inachineguns, mortars,

grenades, and ammunition. Boxes were nmarked with large red crosses.

There were no seriously ill patients aboard, and all personnel walked off

the ship. About a dozen were examined on the dock and sent to the 155th

Station Hospital with diagnoses of beri beri, inalaria, and fever of unknown

origin. There were no wounded, and there was only one surgical patient with

an infected leg ulcer. The patients, about 1,500, were said to be the slightly

ill. On the whole, they appeared healthy and well nourished.

We visited a compound where 97 officers were interned. They were polite,

said they were satisfied with their care, and that no one was sick. A visit to

another comp)ound of enlisted men showed several sick men. The chief surgeon

of the ship said that he did not know that the boxes and bales contained

contraband. No records were available to prove whether these had been bona

fide patients before embarkation, and the confusion on shipboard was such that

records could not be located. Looting by sailors undoubtedly caused part of

the confusion. The ship was in a wretched sanitary condition. The stench

was terrific. Clearly, this is a violation of the Geneva Convent ion.

Manila, Thursday, 9 August

Flew back. Left Morotai at 1000, arrived on Leyte at 1500 hours.

Monday, 13 August

Peace seems near, and speculations are mixed as to whether the Japanese

will accept. Certain it is that the majority of people here, as well as at home,

are tired of war.

Wednesday, 15 August

News that the Japanese have accepted the ultimatum, which included the

proviso that the Emperor may remain. The morning news contains the Emperor's rescript to the people, which, true to form, contains no admission of

guilt or moral and spiritual defeat. It only speaks of the military decision

against them: "The enemy has used a new and cruel bomb * * * anid to continue would mean the total extinction of human civilization." This clearly

puts the onus of destroying civilization upon us. "Such being the case, how

are we to atone oursehles l)efore the hallowed spirits of our ancestors? By

working to save and maintain the structure of the imperial state. Unite your

total strength * * * so ye may enhance the glory of the imperial state." We

are so tired of war thlat we accept these words as mimean ing a pledge of denio-
FRO'M AUCKLAXID TO TO'(KYO -S S7

Fuait w 34: : -F.--TS. Armiy Tratislort GE'cn era Sturgist depafrt ing, Manila IIIIEI Imir)r fo~r Jap~:i.m

26 August 1945.

crat it gPoverIllmlen t. Truly. so far Ave have gained a m it arv (levisj(Io onlly, not

their uilt imate defeat.

Tokyo-bound, Satulrdayv, 25 August

Boarded the U.S. Army Transport (,Yneral 8turgts today at 1)00 hirs.

General Denit had returned, and '¶ (drew I lie lucky iiuiiier for this rIp11. So.

wvith 24 hours to pack- and gather up what information I could, I am off for

Irokyo (fig. 352

'"Almos~t imm~ediiately upon li, arrival in Tokyo. Colonel Otightersoin was nained chairman of

the AFPAC group that was to participate In tile Joint Commission for the Investigation of the Effects

of the Atomlic Bomib in Japan. The other two groups of thils joint commission were the Manhattan

Irojowt 4;rmllp. iheade.d by Brjv. Geui. l'rauvii W. Farroll, and a grioup of .Japalies.. iiators anid S0i..ii

tists, headed by Dr. Masaol 'rsilzki of Tokyo Imperial University and the Japanese National Red

Crossr. The formal report of the efinlllli-ssion was edited by Colonel Oughterson In Washington and

published under the auspices of the National Rtesearch Council. (See: Oughterson, Ashley W., and

Warren, 51111.1dM: Medical Effecets of tile Atomice Bomb in Japan. New York: McGraw-Hill Book
CHAPTER XIV

India-Burmia and China Theaters

A. Stephens Graham. M.D.

On 5 .Januiary 194.5, Lit. (ol. (later Col.) llerrinan L~. Bluingart, MC, and

Lt. Col. tlater C'ol.) A. Stcplheiis Grahiam, MC (fig. 346). lprowe~e(Ie from

H eadqua rt ers, Second Service Command, Governors Island, N.Y.. to 'Miamni.

T1here they boardled a, transl)ort plane and flew by way of JBerinuda, t le Azores,

North Africa., and the Middle East to New IDelhi,'India, arriving at Readquarters, ITSFIJ3T (IT.S. Forces, India-Buria, Theaiter), on 2S January 1945.

Late in Noventber 1944, they had been given the op)portunity by Maj. Gen.

Norman T. Kirk, The Surgeon General, UT.S. Armny, to become the first professionial consultants assigned to thme India-Bunrma Theater. Since there was a

pressing need for these con-sultantts, as had been indlicated in the. Keiser Mission

rep~ort. I suibmittedl to The Surgeon General onl IS November 19)44. General Kirk

dlesired to send. officers withI prior' experiencve in this field. At thme timue. C olonel

lluniga rt, and thet auIthor i(v(ve ser~ving as C'onsltaniUt ill Med(icline an C11 Onstilt ant. in Surgery, resl)ectivel v, Second Servive C ommniaid, where thev had

p~ioneeredl as consultants somewhat more than a year previously. Moreov-er,

thme author had servedl in an oversea combhat area-the North African theateras chief of surgical service of a 2,000-bed general hiosp~ital. Therefore, hie had

had experienice in the care and[ disposition of battle casualties. As one of the.

Organizers of filie 45-th General Hospital, an afiliated unit of the Medical

College of Virginia, Riclmiondl, the author had, early in 1942. served a tour of

duity under ('ol. Norman T'. Kirk, MC, then Chief of Surgical Serv-ice, Walter

Reed General Hospital, Washington, D).C. ITnider the guidance of Colonel

Kirk andl Col. Arden Freer, MIC, Chief of 'Medical Service, Walter Reed General Hospital, the chief's of niedical and surgical services of the units affiliated

with H arvard. Yale, Maryland, and Johns I10o)kifls 1 Universities and with the

University of Maryland and the Medlic~il College of Virginia had comnpletedl

time organization of their units an( hiad rev-eive(1 indloctrination in the operation

of a general hospital.

The author's assignmeiit to I'S~iII was contingent. 1upon the action

of fthe dlispos4ition board of Fort .Jay Regional H~ospital, Governors Island,

Report, i4rIg. Coen. Raymond A. Keiser, and Col. Rlobert TI. Kennedy. MIC. to Tile Surgeon

Gleneral. 1.4 November 1944. mnbJeet :Report of Mledical Department Mission to ChinahIturnia-mndin.

S 189
890 ACTIVITIIES OF SURGICAL CONSULTANTS

N.Y. This board, fortunately, changed his physical status to general duty

from duty limited to tlie conittiental Iiiited States. hi D)ecember 19.43. the

disposition board of Walter Reed G(eneral IHospital had established the limited

duty status after Colonel Graham had been evacuated to the Zone of Interior

from the North African theater in 'November 19)43.

There were other experienced service command consultants who had not

had a tour of duty overseas and who were most anxious for this particular

assignment in the India-Burma Theater. This was particularly true of Col.

R. Arnold Griswold, MC, formerly Consultant in Surgery. Fourth Service

FIGURE 346.--Co. A. Stephensl. Graham.~lll MC.

(CoImmnmmid. At tile tlime. ('olouel (Criswold was (Chief of Surgical Service,

Walter Reed General Hospital. Unfortmnately for these officers, I Ieadqnarters,

USFIBT, refused to accept consultants in grades higher than lieutenant

colonel. For the first time in their Army careers, Colonel Blumgart and the

author were pleased that long-awaited promotions had not materialized. These

came later.

Two weeks prior to departure, Colonel Bluiigart and the author spent

several days in Washington where they were intensively briefed on the medical

situation in the India-Burma and China Theaters by officers in the Office of

The Surgeon General. The briefing included a careful study of the previously

mentioned report of the Medical D)epartment Mission to China-Burma-India.

The Mission was composed of Brig. Gen. Raymond A. Kelser, Chief, Army

Veterinary Service (fig. 347); Col. Robert It. Kennedy, MC, eminent New

York surgeon, who had served as Chief of Surgical Service, Percy Jones
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INDIA-BUICIMA AND ('IIINA THEATE'RS 895

At this critical point, thlie War I)epartment suddenly recalled General

Stilwell. ('iomnader-in-('hief. USAF(BI, on 19 October 1944 and 5 days

later, on 24 (O)ctober, recounstituted tile theater as two seplarate iheaters, China

and India-Bulrma. Maj. (ien. (later It. (ren.) Albert C. Wedeniever w:.is

appointed (Commanling General, [USF( T (U .S. Forces, ('hina Theater), an(d

Lt. Gen. I)aniel I. Sultan, formerly D)eputy Theater Commander, was named

('ommanding ( eneral, U .S. Forces, India-ml,-tria Theater. ('hina thereby b)ecame the operational arm of the American Asiatic eflort. and India-Burmna,

b)ecame the supplv and administ rative base for the operation. ()nly India possessed ol)el ports, Karaichi and Calcutta. for receiving Allied materials. Both

theaters continued as integral and( sul)ordinate elements of the overall high com-

.'1-;uRi: :351.--Adnmiral Lord Louis Montbatten.

0 s

mand, tle Southeast Asia ('omnand, tinder tlhe Supreme Allied Commander,

Admiral Lord Louis Moutlbatten (fig. 351).

In (China. American ground troops were only vused for advisory, logistic,

and traininl purposes. In B11urma, no mIore than two regiments of American

troops with supporting arms and services, exclusive of air forces. were coinmitted to battle. Service troops, intiuding miedical tin its, tilled gaps in the

Chinese ArmiY, which lacked spec'ialists. The average strength of U.S. Forces

in China--Burma-India during 1944 was 1(68,71m0. They were spread thinly

over the cutirearea. Thime varPious (counianmds aind uin its were eigage(l in the

stupendous task of transporting personnel, Supplies, and( eqtuipment over long

supply lines bet ween the ports of India and the fronts in Burma and China

(fig. 352), principally by means of air transport. They had to construct,

maintain, and operate the Stilwell Road, gasoline pipelines, and the communications system which conne•tel India, throurh Burma and across the H1imalayas, with K'mi-mig, ('ita. lrge 1m11ilmeri's of tiroops cariued out these

seri%'ie ail construc.t ion operations (111mher l"izardhlots coflilions iisteiidi of in
Al 'TIV IT'IENI 4)1 IF SI'It, I N.'A 444INN'I. I A NI'

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INDIA-BURMA AND CHINA THEATERS 897

1944, New Delhi was designated the main headquarters and Forward Echelon

Headquarters, USAFCBI, remained at Chungking. Colonel Williams justified his maintenance of the theater surgeon's office at Forward Echelon Headquarters, USAFCBI, in these words:

In all other headquarters the Surgeon's Office is found in the Rear Echelon. That

location was tried at the inception of this theater. It did not work, because all major

decisions and iong-range l)lanning were performed at Forward Echelon. * * * the Chinese

Surgeon General, Red Cross, and National Health Administration simply would not do

business with an assistant and it placed on the assistant the responsibility of formulation

of policy.

Deputy theater surgeon, Col. George E. Armstrong, MC, remained at Rear

Echelon Headquarters, USAFCBI, in New l)elhi. This arrangement continued until 14 May 1944 when, in accordance with a new theater policy, the

theater surgeon and his staff were ordered to reestablish their offices at the

main headquarters in New Delhi. When the China Theater was established

on 24 October 1944, Colonel Armstrong, who had been moved to Forward

Echelon Headquarters, Chungking, was appointed Surgeon, USFCT. In view

of the fact that staff officers and responsibilities had been transferred from forward echelon headquarters at Chungking to the main headquarters at New

Delhi, the creation of two separate theaters caught the China Theater short

of personnel and many other necessities. Colonel Armstrong's staff, inherited

from forward echelon headquarters of the China-Burmna-India Theater, consisted of two officers and one enlisted man. On 10 December 1944, a rear echelon

of Headquarters, USFCT, was established at K'un-ming, and the entire Medical Section, Hleadquarters, USFCT, moved to that location.

Relations with the Chinese.--By the very nature of its function, the

medical service of the U.S. Army Forces in the China-Burma-India Theater

was drawn into very close association with both Chinese military and civilian

personnel (fig. 353). First of all, the concept of a military medical service

had not been firmly established in the Chinese Army. As a matter of fact,

for all practical purposes, it was nonexistent. The Americans found it necessary to start at the bottom. An appareat disregard for human suffering and

a depreciated concept, which prevailed in the everyday struggle for existence,

of the value of human life had been carried over into the Chinese Army. To

a Chinese accustomed to seeing Chinese civilians dying along the road with

no one paying heed. the sight of Chinese wounded soldiers left to die on the

battlefield seemed to cause little outward concern. The soldier was apparently

considered expendable, and there was a. resultant indifference to the wounded.

It followed, therefore, that. the medical service of the Chinese Army, whose

function it was to conserve life, would be held in little repute.

The Chinese division surgeon was usually a ma'jor and a political appointee

without, adequate medical training. ]Properly trained and qualified personnel

were notoriously scarce. There were few modern medical schools and only

one Class-A school in (luina. .Moreover, the available trained l)ersommel were
1:1:.1.Mhig r~likiimsi *hiieit '44 Aiil .ieic14jtI (dfivers st-I ani example,1 byV 4iiii1.i jug

44)II~!e~.r~I ed iiithe f eal 11140414r : K111o1iig' oif~ China.l;ILliI1 lehiDlia,

ah ChiLl~lev fphiii i~iavvh)s1 found ~~I 1 vmiii hen orai 141celiv)jiil toW jolv 4)I th ilsV 4111YV

SP IW I (T.

The sto-t4Y ofIf()\\- I le U.S. Arl iv , lie lped 4)to for ,i lie miedicalI selVIC oif

ille ( 'im-ise Forces. as all ititegral part of the overall p1:iii know~il as~ -Opera-I

111)11 ilati sitepchiild", hias heell rcore ill11( 1II lrhly reveaihlii!a andi 'liteotin I it II I I w 1:-;. 11The plal ilv isliiolied loti oildv thle pro~visioni (t Ineiica1C 4viIP for

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INDIA-BURIMA ANID (CIIINA TrHEA"ATEIIS 899

Morbidity.-The U.S. Armly nmedical oflicer in China-Burnma-India was

called upon to care for accidentally injured and diseased U.S. Army personnel

to a far greater extent than he treated battle casualties. In 1943, when the

average strength of U.S. Army personnel in the USAFCBI, was 39.600,

them were 49,900 hospital admissions for all causes. Among the total admnissions were 4,300 for nonbattle injury and only 200 for battle wounds and injuries. The remaining 45,400 were admitted for disease. During 1944 the

average strength rose to 168,700, and (luring this year there were 173,900 hospital admissions: 157,600 because of disease, 14,500 for nonbattle injuries, and

1,800 battle wounds and injuries.s In the same period, however, their were

12,739 Chinese battle casualties admitted to the hospitals of this theater in

addition to strictly U.S. Army admissions.

Hospitals.--Battle casualties from the Burma camnpaig7s with a few exceptions received definitive treatment in what was known as the Advance Section, comllprised of that territory in ulpper Assam, India, and northern Burma.

in the area of the Ledo Road. Hlospitals were first established there in March

1943 in the vicinity of Margherita, Assam, India, about 8 miles from the town

of Ledo in upper Assam and at the head of the Ledo Road. These were the

20th General Hospital and the 48th and 73d Evacuation Hospitals. By the

end of 1943, hospital beds were provided for 3.705 patients by the following

eight hospitals: The 20th General Hospital; the 14th (at the 19-mile mark,

Ledo Road), 48th, and 73d Evacuation Hospitals, tile 25th Field Hospital,

Ledo; and the 40th, 42d, and 46th Portable Surgical Hospitals, Ledo, which

for a short period functioned as fixed hospitals. This represented somewhat

more than half the number of available beds at that time in India and Burma ;

in China, there were 1,465 additional beds.

The bed capacity of these hospitals in India had by 3March 1944 increased

to 4,310, of which 2,963 were for Chinese soldiers. At the end of March, the

73d Evacuation Hospital moved to Shingbwiyang, Burma, at the 103-mile mark

on the Ledo Road, where it was established as a fixed hospital on the sides of

jungle hills, 5 miles from a newly constructed airstrip (fig. 354). It functioned as an evacuation and station hospital for American and Chinese troops

and also as a general hospital for the Chinese.

During June 1944, the 69th General Hospital and the 28th, 32d, 34th, 35th,

50th, and 53d Portable Surgical Hospitals arrived in Ledo. The general hospital was established at Margherita, several miles from the 20th General Hospital, and the portable surgical hospitals were flown over the Himalayan

"Hump" to support the Y-Force operating in the Salween River area.9

8 Provisional data based on sample tabulations of individual medical records, Medical Statistics

Division. Offh-e of The Surgeon General.

9 The Y-Force consisted of Chinese Army units operating in Southern China and Along the French

Indo-C'hina border; the Infantry and Field Artillery Training Centers at K'un-ming; the Technical

Service School at h'ili-ching (Kiitsing). China ; the Medical and Veterinary School at Ta-li, China

traveling instructional groups ; and the Burma Road Engineers.

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INDIA-BURMA AND CHINA THEATERS 903

Most of the work in the l)ortable surgical hospitals was done at night

since litter bearers usually brought in patients after dark. Except for occasional instances when portable units were relatively fixed, all op)erating had to

be done with the aid of an ordinary flashlight. The fact. that battle casualties

of the Burma campaign had such excellent medical care and experienced such

a low mortality is largely due to the men who worked in the portable surgical

hospitals." It. was obvious that hospitals working under such conditions could

not hold patients. It was equally obvious that few patients would survive

transportation over mountain jungle trails anti the almost impassal)le roads

from these, forward hospitals to the field and evacuation hospitals well to the

rear. It was for this reason that the system of air evacuation was l)erfected.

Air evacuation of the wounded.':-At dawn on 15 October 1943, the

Chinese Army in India initiated a drive which was to culminate in the reconquest of northern Burma. With the advance eastward into Burma. the Chinese

troops were isolated from fixed hospitals in the base by difficulties of evacuation.

The road, witlhin any reasonable distance of the area of coml)at, existed only

on engineering blueprints. The Seagrave Hospital Unit and Company I),

151st. Medical Battalion, moved in on foot to p)rovide medical service for the

Chinese Army in India. With the capture of Sliingbwiyang, the first forrward

airstrip was constructed. It. was, however, still frequently necessary to transport. patients by litter for several days before this airstrip could be reached.

At this point in the campaign, the evacuation period was often as long as fromn

7 to 14 days from the time of injury to the time of admission at, a fixed hospital

in the base.

Gradually, as Chinese and American troops (committed in February 1944)

advanced through the northern Burma jungle, 20 additional airstrips were

constructed to keel) pace with the troops. From 6 March to 14 April 1944,

the interval between injury at the front and admission to fixed hospitals at the

rear averaged 48 hours. Paddy fields were leveled by Chinese combat troops

to receive the small liaison planes which were emp)loyed to evacuate the

wounded, and occasionally sandbars were utilized. Tile remotest reaches of

the densest jungle country in north Burma were l)enetrated by these planes

which landed and took off with wounded soldiers from the most primitive

and wholly inadequate strips (fig. 356). Both the planes and the strips

were frequently within range of mortar, small arms, and machinegun fire.

The difficulties of evacuation were increased manifold with the onset of

the monsoon rains in .June. Motor ambulance evacuation catne to a standstill.

In the valleys, bullock carts wit 1i water buffalo "tractors" were employed. Yet,

despite flooded airstrips and constant pouring rains, approximately 380 battle

casualties reached the Ledo airstrip during June 1944. An additional 900

It Report. 2i1 Lt. James i1. Stone. MAC, Office of the Surgeon, U.S. Forces, India-Burma Theater,

to The Surgeon General, U.S. Army, 10 June 1945, subject: The Portable Surgical Hospitals in

Northern Burma.

12 Official unpublished historical report, Office of the Surgeon, Northern Combat Area Command,

U.S. Army Forees. India-Burma Theater, 214 July 1945, subject: A Report Summarizing the Activities

of U.S. Army Medical Department Units Assigned to Northern Combat Area Command During the

Northern andi Central Burma Campaigns.
pat ieum 'xi \vI It i'-e-. ~*ImIlbI Ivi Ieiij IIIits \'.iLe1 v:ial Vi Ih ii I Ili- l I t~a v1 

Quality of surgical care in the India-Burma Campaign. It was f lip

fqilimiiil 44, i Ilel-I-s ill fixed 1iwipif~lk 1I4 tIle( rearl Illat thle 4iI1:11l1 (d of 1_-Iitier

1111 iiýla erilk Ill foirward-4 1tii11. (1t11-ii1" the lti'lia-Buititiia ( :111lpai±-4ti NV'a-. 0411 t11e

llle. *el letit. 11,114.1 vit-we4 Ill Ilie ligrili id (4414111t4411- mtiller witlit1 i lie fqw1-

Ill tihe 1111611jls~~' (if the 114)i-11 hieii II-ti:1 (itlti-iye aettiti pnwI~tiee,!- I1(

41(4 11 it I tiv ~ Itil tI iiit'-. h(41l Ii14 lhlm ldit .11141 ii 41 lt rat I-. Ih)II :.- Ilie exI vit'tetii'e 44f Irwe)i, illh ilHillth lotwward a ld teri 1'et a iittlt: ec.Ihe

41iivutlt :e_ý Awete. Ito a1 (4)14t1(1,'iulelhdv eXtetit . ovetIVIatie Ill seeral,:1 ways )tI I April

191 1. lw41he ii4'I, (4d lile ,(i±!41 ''Vt-ilite )lilt. "thi. ;1114 7311 Evai1:ti141,14

I1) I:1t~ls I~ flie ~ltli ( etiendt I I(i-hiitai were l gIltiri 0) ±Zet her for I Ile plitlrils
INI'IA-IUiI.'IA AN! CI IJINA TIIFA'I' VHS 905

whilei Ou aDfirt's rill is IIIfeIEr fiire. Bi. Sick ImenI ipf Merrill's Miiariiilis. 1e'iileil ini a ( 47 fo)r
906 ACTIVITIES OF SURGICAL CONSULTANTS

byV Col. Vernoni W. lPetersen, M1C, Surgeon, Northern Combat Area Command,

and the otlicers had been assembled by Col. (later Brig. Gen.) I. S. Ravdin, MC,

Conmmanding Officer, 20th General H hosl)it al. The report and recommendat ions

of this conimiittee formed the basis for a doc'ument, "E[)itome of Surgical

Managementt" which was (list ri)uted by the theater surgeon to forward units.

There is little doul)t that the "epitome" on wound management was responsible to sonie extent. for t lie improvement subsequent ly noted at base hospitals in the initial treatment of wounds. Officers from these base hospitals

observed, however, on visits to forward units that the "epitome" was not too

well received. _Not only was criticism implied (which was unavoidable), but.

surgical officers in the forward medical units considered that the proper orientation of SOS (Services of Supply) surgeons in working conditions at the front

would have made for more sound. intelligent, suggPestions based O0 l)ractical

familiarity with the problems of portable surgical hospitals. Similar complaints were made to Colonel Graham when, some months later, lie visited these

forward units after their transfer to combat areas of China.

These criticisms of the "epitome" were well taken and resulted in an occasional exchange of officers between the rear and forward units. It was recoinmended that officers assigned to thie forward units be relieved from dlilly at

relatively frequent intervals and returned to rear installations for short periods

of time. It was believed that, after a month of steady operation unler the

severe conditions of jungle operations, surgeons of the p)ortable hospitals inevitably grew too fatigued to render the type of service of which they were

normally capable. Return to a rear installation would, it was believed, restore

the keenness of these officers' capabilities and in the long run result in greater

efficiency of the portable surgical hospital. The disadvantage of medical officers

working only in one type of unit was that the difficulties encountered by forward

units were not appreciated by personnel in the rear, and that, on the other hand,

officers at the front were unable to follow up their cases in order to determine

the validity of their techniques or to correct errors. The benefits which could

be obtained from increased medical liaison were considered to be signiticant,

and efforts were made to achieve it by the exchange of officers as well as by

other means.

MEI)I(C'AL SERVICES, 'U.S. FORCES, I NI)IA-BUIRMA TII EA'I'EIl

On 28 January 1945, when the consult ants arrived in the India-Burna

Theater, there were 27 hospitals in active operation: fl general, 14 station, 4 field,

and 3 evacuation hospitals. [ie total bed calpacity of these hospitals was 19,772,

and 512 Medical Department officers were assigned the care of 9.819 patients.

From a one-man organization in 1942, the medical service had expanded to aln

organization of 13.7180 officers and nien.

The theater (map 6) extended west to east from Kar~ichi, India, to Lashio,

Burma, a distance of 2,200 miles." Theater headquarters, at New Delhi, was

4 All distances are expressed in terms of regular Air Transport Comnmand routes between the

points mentioned.

S.,, liiln Bi nmlmmll n I i~i~~iwronNoiw i ~i• 
ýc -d

c zj

< LJ -9

0N c .

) )

C)C

00

w :~ z k .*r C3

LLI Zý

pn
908 ACTVIVITIES OF1 SURGItCAL C'ONSULT'ANTIS

situated in north-eentra~l India, in thle Punjal) Desert ¶50') mniles fromn Karficlii.

New 1)elhli was 1,300 miiles from IAWIo in dhe upper port ion of the province of

Assain, w,%here a number of hospitals were located1. T1he most sout herly sit outed

hospital was al, Kandy, Ceylon, H~eadq~uarters of (lie Southeast. Asia, Comimiand (of which the india-Burina Theater was a part), 1.60t) miles; from New

D)elhi. Th'le imost. northlerly situate'd hospital iii Burmai: was at rLagap) .a. onl

tie Ledlo RoadI at thle 52-mile miark. If tHie short est, air rootie bet weeni tliis

hiospital1 and Newv Delhi were takeni, oiie w~ouldI fly over Bhut ani, Tibet (just,

north of Motint Everest), and tilie King-doin of NepalI.

Seventy percent of the Imospit als- -live general. ighl stlat ion, I he three field,

and1( thle M ire evacoatiom hospitals-were estahldished ini a rectamigitar area 114)-

p~roximiately 9,50 bly .1;')0 miles ill tile ext remne east ern portion) of Inmd ia anmd en -

tirely across nort hern Burmia, (mmmal) 7). TJhis area, was slightly hi gr~em than

the mnOiil)ted square mi les that Coimprlise thle I1I eastern coastal St at es, phlis,

V\eruiomit, P Iennsylvainia, and W'est. Virginia. lIt was roughly of thle same shape

a 11141 di mmensioins. Moreover, it was coma pa ma to thle area inculode in I Ilie Firs,

second. Third, and[ Fourth Service Commnands, as thlen constit.itteol, or almnost

twice the size of Texas. Thie (list ance from t heat er headquarters in D elhi i to

lie center of this rectangular area was ab~out 1,2010 miles, almost. tile same air

(list ance fromi the Office of lThe Surgeon General in W~ashi ngt on t o lie center

of Texas.

E~xcept. for the area of fight ingr in central and eastern Burmia, thmis vast

.a rea vienoimi~assi!1g the India- Burmall Theater was subdivided into area cornlimiamis known as the BaseI iteriiieoliate, and Advance Siectionis. The NorI hemn

Combat. Area (2oninmand was coinprised! of t he hlea~lpmirt es and1( troops comndlucting op~eratin a015iga inlst. thle J1apanese in time ar~ea of const ruct ion onl the

LeoloRod and, latr. inmiii etaianud easiem Ihirmi.

MEDICAL SERVICE, U.S. FORCES, CHINA TIHEATER1

Th'le med ical service, of tilie 1U.S. Army ii Chinma had alway* s been badly in

needof almost everythinig: hospital imiits, pimalilied p~ersonnlel ( both officer and

enl isted(), and~ mnodermn equipmiienit (fig. 358) . It, was onie of tilie lowvest of lowpriorityv theaters. F'or thle mo4st. part, the theater had been entirely dlependent

for logistic support on air transport at~ion over thle HIimialayan "1Imimp': Food,

clothIin1g, equo i)neiit , suipplies, high-oct ane gas for both fighter and transport4i1

I lamies, an minuimiit~ion , mioto4r veieles, ind] so forthI. The overlanid "back dolorm"

supply route, thle lA4do-Bummna11 IRoad, an1d thle gasolinie pipelimle had afforded

SoHiMi relief but. Co1lit ions were st.i II far fromi ideal. '[li first 111S. Annym~ suil~lyl

conlvoy eniteredl China over th le Ldo- hirinma Hoad on 2S *Jaumim rv 414. thle day

thme consult ants arrived in I mida.

Colonel Armostrmong's task of organizing th lie edical service of the China

Theater had b~een ruggedl. Oni 2 Novemnber 1944, 5 dlays after lie had been
INDIA-BURMA AND CItlNA TIIF .TERS 909

000

-'1 14 Evac 000 000

"-" 335 Sta 000 --- I8 Gen 000 000 Q1-- 234 Gen-i 000 2Gn

"-- 383 St 20Gen

\69Gen 000

"-. e---- 69)Gn o- 7Evac00

000 ___ 7, 3 

4 18 -8e Gen 2- 

000 (Ma r) 000 000

48Evac . . 21 FId 95So

-- J44 Fld

xxxx + 25 Fid

MAP 7.-Services of Supply, U.S. Army, hospitals in India, northern Burma, and China

during the first half of 1945.

advised of his appointment as theater surgeon, Colonel Armstrong wrote to

Colonel Williams, Surgeon, USFIBT:

Returned to 879 [Chungking] yesterday morning and am now so thoroughly confused

that I honestly do not know where to turn. Apparently there are so many big problems

to iron out that no one has time to settle any of the little (mine) ones. I am unable to find

out whether this office will duplicate all the things done in your office or whether your

office will continue to perform many functions for us. Obviously Cavenaugh [Maj. (later

Lt. Col.) Robert L. Cavenaugh, MC], Sergeant Copeland, and I cannot go far in running

a medical section for a Theater.

A letter from Colonel Williams, which had crossed Colonel Armstrong's in

transit had stated the former's views substantially as follows:

As Colonel Williams saw it, very few changes would be required for adequate medical service for both theaters. Practically the only change was that

it would not be necessary for Colonel Armstrong to continue reporting to him.

However, until circumstances altered things, Colonel Williams intended to

send Colonel Armstrong carbons of everything that might interest him. He

anticipated that Colonel Armstrong would reciprocate. Of necessity, the two

theaters would be so closely booked together that constant interchange would be
WII" I\ IIl i ' > . ; 1 1

4 AL

fi i t i li I' t

* 'Ii it' 1:11Pill. ti 1 'iiit~ A i I I it I iii ii f it- f .Ii .*i i -Il I i'ill Id

tll Ciii1 1 11' :11 K - 11 Iii 11 -- 1- \ I .flt

: It I ' I hc it , 10-:11 litc Ii 14 ofI. I ::1 1:1 it #ii -Ii -. l S I F l'~Tt. Irl I Il H Il i-T A 41

-11110 II -1.1 1\ I o I' A, I W . I lji I f~l "lftw I i Ti II. lr 4 1t :1 11 lilt., I w:1 I i t (I i
INDIA-BURMA AND CHINA TIIEATERS )11

3. Hofs pitaliwtiotn.-The India-1Burma Theater served as a reservoir for

cases from China requiring hospitalization exceeding the established 90-day

evacuation policy of the China Theater. Patients en route to the Zone of

Interior also had to rely on holding facilities in India-Burma, as no other route

was available.

In all other respects, the Office of the. Surgeon, IUSFCT, functioned as

that of an independent theater. The theater surgeon's office continued to grow

and the staff had increased considerably by the time this consultant arrived

in India-Burma. Care had to be taken in accomplishing this not to draw

keymen from medical units of the theater, since medical officers and enlisted

men were at so high a premium in China that the loss of one man could interfere with the function of an installation. The possibility of replacing him in

such a low-priority theater was remote.

The work of the Medical Department, of course, could not wait until all

needs had been met. With his limited staff at K'un-ining, and in the early

days at Chungking, and with only a skeletal medical organization throughout

the new theater, Colonel Armstrong undertook the difficult task of lifting the

Chinese medical service from the depths of demoralization and disorganization

which attended the threatened collapse of China through the rout of the

Chinese Army in southeastern China. At the same time, lie had to implement

plans for the medical care of U.S. troops who were coining into the theater in

increasing numbers.

Inasmuch as the medical service of the USFCT remained throughout

the war essentially that of a military minsion aimed at improving the efficiency

of the medical service of the Chinese Army, it became necessary for the theater

surgeon to devote a large part of his time to work with the Chinese medical

authorities. These were the Director (Surgeon General) of tie Army Medical

Administration, and representatives of the National Health Administration,

and the National Red Cross Society of China. In addition to these were a

considerable number of foreign philanthropic associations with whom the

theater surgeon maintained liaison in an effort to coordinate the many diverse

aspects of medical service in China bearing on the Allied military effort. In

this atmosphere of confusion, division of responsibility and widespread disorganization, it is remarkable that the theater surgeon and his small, but

intensely loyal and inspired, staff accomplished as much as they did.

Long before activation of the China Theater, the need for additional

hospitalization in China was referred to in communications to the War Department as critical. When, finally, the 70th Field Hospital, designated for

China, arrived in the India-Burma Theater in October 1944, it was retained

for combat service in Burma until June 1945. In March 1945, two station

and three field hospitals were assigned to the China Theater with a total of

1,800 beds. An additional five field hospitals and one general hospital ( 1.000-

bed) were scheduled for transfer to tile theater from the India-Biurmna T'heater

to make a total of 4,300 fixed beds for the China Thleater.
912 ACTIVITIES OF SURGICAL CONSULTANTS

In June 1945, however, when the author departed from the China Theater,

there were still only one station and two field hospitals functioning, there were

no provisions for establishing a general hospital, and none of the five field

hospitals had arrived in China. The most pressing problem was what to do

with Chinese casualties, since the War Department would not provide U.S.

Army fixed beds for Chinese troops in China, as had been authorized in IndiaBurma. In China, hospitalization of Chinese troops was considered the responsibility of the Chinese Army MNedical Administration. This administration and the Chinese Red Cross established a number of hospitals in the

various categories, but practically all of them were woefully lacking in just

about everything: Physical facilties, skilled personnel, supplies, and equipment. The Medical Department, U.S. Army, at the time of this consultant's

visit to the China Theater, was committed to care for only casualties near the

front who were brought into portable surgical hospitals manned by U.S. Army

personnel. The manner in which the portable surgical hospitals functioned

is described later in this chapter (pp. 942-945).

FUNCTIONS OF THE SURGICAL CONSULTANT

General Considerations

In addition to the medical and surgical consultants, Maj. John R. S. Mays,

MC, Consultant in Neuropsychiatry, Maj. (later Lt. Col.) Richard W. Britt,

MC, Reconditioning Officer, and four M[edical Administrative Corps officers

arrived on 28 January 1945 for assignment to the Office of the Surgeon, Headquarters, USFIBT. Brig. Gen. James E. Baylis, MC, the newly appointed

Surgeon, SOS, USFIBT, arrived several days later. General Baylis' last

previous assignment had been that of Commanding General, 'Medical Replacement Training Center, Camp Grant, Ill. Somehow during the period of briefing in Washington and as a result of conversations with officers returned from

the theater, some of the newcomers had developed the feeling that their reception at Headquarters, USFIBT, and perhaps even in the field as well, would be

somewhat less than cordial. Actually, they were welcomed with genuine

warmth, not only at headquarters, but almost everywhere they went in the

theater.

There was little doubt that this fine reception was, to a considerable extent,

influenced by the character and personality of General Baylis, who was esteemed

throughout the Army as an officer of superior ability as an organizer and administrator. He possessed a genius for inspiring subordinates, to whom he delegated great responsibility. ife encouraged them to take the initiative in the

development of their respective sections in the Office of the Surgeon. He never

questioned professional opinions and recoimmendations of the consultants. The

consultants were told to make corrections "on the spot" when they observed

irregularities and deficiencies that required prompt action during visits to

hospitals. At the same time, they were given to understand that their decisions
INDIA-BURMA AND CHINA THEATERS 913

would be reversed if subsequently it was determined that they had erred. This

arrangement in a theater spread out over the entire area of India and Burma,

with many installations situated more than a thousand miles from theater

headquarters, greatly facilitated and hastened the accomplishment of the consultants' mission. At the same time this implicit confidence in the professional

judgment of the consultants had a sobering influence on them in curbing any

tendency toward precipitate action of making recommendations without due

deliberation.

The functions of the surgical consultant were concisely stated by Brig. Gen.

Fred W. Rankin, MC, Chief Consultant in Surgery to The Surgeon General,

in the annual report of the Surgery Division for fiscal year 1944, substantially

as follows:

The surgical consultants exercise their functions by assisting and advising

the service command or theater surgeons on all matters pertaining to surgical

practice, including particularly the organization and program of surgical

services in medical installations and the quality, distribution, and proper assignments of professional personnel, by providing advice on newer developments in

diagnosis and treatment, by stimulating interest in professional problems and

aiding in their investigation, and by encouraging educational programs such

as conferences, ward rounds, and journal clubs. These consultants are concerned essentially with the maintenance of the highest standards of medical

practice. It is their function to evaluate, promote, and improve further the

quality of medical care by every possible means, to interpret the professional

policies of The Surgeon General and to aid in their implementation.

The formulation of many policies and the making of decisions in regard to

the solution of many problems required coordination of the medical, neuropsychiatric, and surgical consultants. Colonel Blumgart and the author were

fortunate in that they had, during the preceding year, functioned as a team

along with the service command neuropsychiatric consultant in the consideration of many common problems. Major Mays readily fitted into the team, as

did the newly appointed chief of personnel in the Office of the Surgeon.

In August 1944, Col. Alexander 0. Haff, MC, Surgeon, Services of Supply,

USAFCBI, had also been designated deputy theater surgeon and Chief of

Professional Services for both the theater headquarters and SOS medical sections. In February 1945, after arrival of the new consultants, these two sections

were consolidated and Colonel Haff was evacuated to the United States without

replacement. With the position of Chief of Professional Services discontinued,

the consultants functioned directly under the theater surgeon rather than

through an intermediary chief.

The aforementioned chief of the Personnel Section, Office of the Surgeon,

SOS, USFIBT, was Lt. Col. Casey E. Patterson, MC, an officer of high professional attainments. Colonel Patterson cooperated in the consideration of

routine professional matters as well as matters pertaining to personnel. In

both instances, lie screened material before referring it to the consultants.
914 ACTIVITIES OF S'ROICAL CONSULTANTS

When the .onsultants were absent front the offi'e of the tfheater surgeon, he

disposed of all matters except those which definitely required the attention of

the consultants. When inlmediate act ion was required. lie contacted tlieni in the

field ly teleplhone, radio, or courier mail. Actually, this organization of the

professional services officers with the l)ersonnel oflicer might be described as

a committee on professional services and personnel, with the theater surgeon

serving as chairman. Its successful operation was insured b)y the wholehearted

cooperation of all members and their ability to discuss problems hationiously,

frankly, and critically. Decisions reached by this group were presented directly

to the theater surgeon for consideration. Colonel Blumgart and the author were

in a position to compare this simplified organization with the conventional one

they had exl)erienced in the Second Service Command, where the chief of professional services undertook activities of a technical and specialized nature

with a minimum of consultation with the professional consultants. The simplified system was definitely more satisfactory, at least for the India-Burma

Theater. Although no need occurred for the addition of administrative assistants to the professional services organization, such additions could have relieved

the specialists of the burden of routine work which would have accumulated in

a larger and more active theater.

Soon after the arrival of the consultants in the theater, General Baylis

obtained permission of the theater conmnander to route the consultants' reports

through technical medical channels. General Baylis also apl)roved the consultants' recommendation that information copies of these reports be sent to

commanding officers of hospitals which had been visited, a practice not hitherto

carried out by the SOS or theater surgeons. Almost immediately upon return

to theater headquarters from field trips and before formal reports had been

compiled, the consultants submitted to the theater surgeon brief, confidential

summaries of observations which would require p)rompt action. If on the tour

there were noted deficiencies in physical plants, the need for air conditioning,

or other similar nonprofessional matters that required corrective action, a

memorandum to the effect was sent to the Chief of Staff, USFIBT.

Considerably less than half of the author's time was spent in the office of

the theater surgeon. tfere, as a member of the theater surgeon's staff, many

activities claimed his tinme: Preparation of the section on surgery in ETMI)

(Essential T

Ieclmnical Medical I)ata) report. review of all publications on

surgical subjects reaching the Office of the Surgeon: p)reparation of material

on current surgical problems for the monthly Field Jedical Bulletin, USFiBT. p)reparation of theater circulars, directives, and memorandums on professional surgical subjects; review of clinical records and post mortem findings

in all deaths due to surgical causes: review of p)roceedings of boards of officers:

conferences with the other consultants and with the personnel officer: and,

finally, compilation of reports on hospitals which had l)een visited. Moreover,

a raither large corresl)ondence was conducted with the Surgeon, China Theater,

with comnmiianding officers of hospitals relative to prollems of the surgical
INDIA-BURMA AND CHINA THEATERS 915

services, with General Rankin, Chief Consultant in Surgery to The Surgeon

General, and with Col. B. Noland Carter, MC, Assistant Chief, Surgical Consultants Division, Office of The Surgeon General. Practically all of these

letters, or pertinent portions of them, were brought to the attention of the

theater surgeon, or members of his staff, for information, gfidance, or specific

action.

Editorial Duties

The surgical consultant was respGnsible for the preparation of the section

on surgery in the ETMD report submitted monthly to The Surgeon General.

This consultant found that "feeder" reports submitted by hospitals had become

routine and lacked material of clinical interest. The theater surgeon, therefore,

advised all installations and the headquarters of the various base sections of

the type of information desired.

During the visits of the consultants to the various hospitals, further effort

was made to stimulate studies of unusual cases. Much valuable material was

thereby accumulated and many excellent papers were submitted for publication

in medical journals, particularly by officers of the 20th General Hospital (University of Pennsylvania affiliated unit).

The consultants were also responsible for articles or comments in the

monthly Field Medical Bulletn., USFIBT. The surgical officers of the

theater were encouraged to submit reports on their studies, and many of these

were published. This bulletin also provided a valuable means of conveying

information regarding recent advances in surgery. The policy recently instituted by the former deputy theater surgeon of reprinting in the theater advance

copies of important War Department technical bulletins was continued.

Distribution of these bulletins to the theater through normal publications

channels was extremely slow, and many times essential bulletins never reached

the hospitals. Thus, it was most fortunate that the consultants had brought

with them the complete medical series of those that had been issued up to the

time of their departure from the Zone of Interior. On the other hand, considerable numbers of bulletins consisting of 50 or more pages relating to the

water supply of Germany and Czechoslovakia and sanitary data on the Aegean

Islands and Finland were received with great promptness.

In some instances, where no suitable official guides or directives were available, appropriate circulars or memorandums were submitted to the theater

surgeon and, following his approval, were reproduced and distributed. Restraint, was practiced in the number issued. Moreover, the spirit of these

publications was that of guidance rather thanm mandatory direction. Specific

directions, however, had to be issued on the transfer of patients to general

hospitals and on operations for deranged knee cartilages, chronically dislocated

shoulders, and cases of herniated nucleus pulposus. These 1)roblemns are discussed later.
916 ACTIVITIES OF SURGICAL CONSULTANTS

Review of Clinical Records and Post Mortem Findings

Soon after arrival of the consultants, the theater surgeon approved their

request that, in nonbattle casualties, the full clinical records and results of post

mortem examinations be submitted to the theater headquarters for review. This

practice proved of exceptional value. Theater headquarters was kept informed

of some of the most interesting cases. A review of the medical care of the most

seriously ill was thereby accomplished, and occasional suggestions were made

or deficiencies were noted. Deficiencies were made the subject of correspondence or, more often, a conference with the staff concerned was held on the

author's next visit to the installation. It was believed also that this procedure

had anticipatory value in that it was generally understood that the clinical

record of any seriously ill patient might eventually be scrutinized in the office

of the theater surgeon.

SURGICAL PERSONNEL

Personnel Problems

Basic to all other considerations in achieving a high standard of surgical

care was the question of personnel. A combination of circumstances prompted

the consultants on their arrival in the theater to give personnel matters priority

over all other activities. First, Colonel Kennedy, of the Kelser Mission. had

personally emphasized to Colonel Graham the need for the consultants to make

a prompt survey of personnel. Second, Lt. Col. (later Col.) Durward G.

Hall, MC, Director of Military Personnel and Chief of Personnel Services,

Office of The Surgeon General, had set a deadline of 1 April 1944 for (1) the

execution of the new WD AGO Form 178-2, Supplemental Data for Medical

Officers, which had not been accomplished in this theater since its activation, and

(2) assignment by the consultants of proper SSN (specification serial numbers)

and ratings for all medical officers in the India-Burma and China Theaters.

Third was the fact that the personnel officer in the Office of the Surgeon, USFIBT, was a young first lieutenant in the Medical Administrative Corps. The

consultants' initial recommendation to the theater surgeon was the appointment

of a highly qualified Medical Co rps officer as Chief of Personnel. Colonel Patterson was immediately assigned to this position and proved to be an excellent

choice. As has already been remarked, Colonel Patterson and the consultants

functioned in a most satisfactory fashion as a committee on personnel and professional services.

Professional Classification of Surgical Officers

The information on the officer's qualification forms and the obsolete Medical

Department questionnaire, prepared by the individual officer, was of little value

since, in most instances, the information had been entered 2 or more years previously. It was most natural that the classification and proficiency ratings of

these officers, based almost entirely on the interpretation of this meager infor-
INDIA-BURMA AND C'IIINA THEATERS 917

mation by a nonmedical officer, should result in a number of incorrect classifications and malassignments.

As quickly as the new supplemental data forms were executed and returned

to the Office of the Surgeon, USFIBT, the consultants reviewed them and appen(ded their recommended classifications and proficiency ratings. Since a mnajority of the officers had been in the theater for 20 months or longer, it was not

surprising that changes were made in almost every instance. In a moderate

number of cases the officers had been incorrectly classified as to their appropriate

specialty, owing to insufficient available data or invalid recommendations of

their commanding officers. A far greater number had been given proficiency

ratings which were either too high or too low. The most significant observation was the fact that many officers had been classified "general duty" who,

through opportunities afforded them by chiefs of surgical services or by their

own diligent al)plication, had acquired p)roficiency in general surgery or one of

the surgical specialties and because of demonstrated ability deserved a specialty

classification.

Although by 31 March 1945 copies of the newly completed forms, with the

revised classification and proficiency ratings, were ready to be forwarded to

the Office of The Surgeon General, in only 60 percent of instances had the

changes been made on the basis of personal interview and observation of the

officer's professional activities. The theater surgeon, however, informed The

Surgeon General and conmmanding officers of hospitals that the ratings made

solely on the basis of the newly acquired personnel information were subject

to revision after these officers had been observed by the consultants.

The individual statements of educational training and postgraduate surgical experience were not sure guides to individual surgical proficiency. Certain

surgical officers, for instance, with a wide range of surgical knowledge-some

qualified by an American Specialty Board-lacked conservative, sound. clinical

judgment. others lacked necessary qualities of leadership. Conversely, other

officers with little postgraduate training, who had taken advantage of their

opportunities to acquire proficiency in assignments in the Army as surgical

assistants, were found fully qualified to be chiefs of a surgical service at a 250-

or 500-bed station hospital. The Chief Consultant in Surgery to The Surgeon

General, himself one of the organizers of the American Board of Surgery, repeatedly insisted that absence of certification by the Specialty Boards did not

prohibit inclusion of an officer in the higher proficiency classifications, as "Group

A" and "Group B."

Appraisal of the intrinsic qualifications of the surgical officer could be made

only on the basis of personal observation during actual ward rounds and in

the operating room. This consultant spent at least one and usually many additional hours with each officer on his wards reviewing in detail physical findings,

clinical records, treatment, and administrative dispositions of the patient. Informal discussions of related general subjects formed part of such visits. In

some instances, personality clashes rendered an officer's services ineffective at

a particular installation and could be obviated by assignment elsewhere. Oc-
918 ACTIVITIES OF SURGI'CAL CONSULTANTS

casionally, the commanding officer of a hospital was encountered who failed to

recognize the distinction between efficiency and proficiency classifications. He

would question the propriety of the consultant's high proficiency rating in the

case of an officer with superior training and demonstrated ability to whom he

had given a relatively low efficiency rating. Others were mistaken in the

belief that the proficiency rating was influenced by age, rank, length of service,

and by the successful completion of advanced Army extension courses conducted

for the Officers' Reserve Corps.

Actually, there was a superabundance of officers of field grade in both

theaters who, although well versed in the details of Army medical administration. were nevertheless classified as general duty (MOS 3100) medical officers.

In civilian life they had begun general medical practice after a 1-year internship). They were too old and possesseed too much rank to be assigned as ward

officers, yet lacked adequate surgical training and experience to warrant their

assignment to positions of responsibility commensurate with their rank. Many,

however, had requested such assignments. and a few had become chiefs of surgical services in small station hospitals.

Qualitative and Quantitative Studies

From an initial survey of records in the office of the theater surgeon, this

consultant was inclined to believe, as was Colonel Kennedy, that there was an

urgent need for many additional medical officers qualified as general surgeons

and specialists. Actually, however, as the author was to determine later, there

was no lack of capable surgical officers except for a few key specialists, notably

experienced orthopedic surgeons. This discrepancy was quite easily explained.

First, a large number of officers designated in personnel files as general-duty

medical officers had, through earnest effort and careful supervision by highly

competent surgeons, become eligible for classification as general surgeons or

surgical specialists, "D" or "C." Second, a large excess of surgical talent was

concentrated in three affiliated medical units in the Advance Base Section.

These affiliated units were a 2,000-bed general hospital and two 750-bed

evacuation hospitals, the latter serving as station hospitals for U.S. Army

personnel and as general hospitals for the Chinese. Sixty of the seventy-eight

officers assigned to their surgical services were considered capable of undertaking operations without supervision. The census of surgical patients in these

three hospitals seldom reached 2,000. This inequitable distribution of surgical personnel was not the fault of the theater surgeon. The trouble stemmed

from a policy established in the Office of The Surgeon General around 1939.

At that, time, written agreements were negotiated with universities in which the

it'ivel-sity medical sck'hools agreed to organize and staff the professional services

of general and evacuation hospitals which were to be activated in the event of

war; The Surgeon General, in turn, agreed not to dlismnember the units except

with the consent of the school or the unit, itself, or as an urgent military necessity. It is understood that in any future war su:ih a situation as regards

personnel in similar affiliated umits will not recur.
INDIA-BURMA AND CHINA TIHEATERS 919

In sharp contrast to the quantity and quality of surgical officers present

in the three foregoing affiliated units in the India-Burma Theater was the

situation at three general hospitals in the Second Service Command which the

author had inspected during his last month as surgical consultant for the command. These three general hospitals-Tilton, at Fort Dix, Wrightstown,

N.J., Rhoads, at Utica, N.Y.. and England at Atlantic City, N.J.-had a combined authorized capacity of 6,000 beds. There were 3,889 surgical patients

at the time of the survey. Of these, 2,395 were orthopedic cases, mostly battle

casualties with multiple compound fractures. All patients were U.S. Army

p)ersonnel, whereas some 75 percent of patients in the hospitals of the IndiaBurma Theater were Chinese. Only 37 of the total 62 surgical officers in the

Zone of Interior hospitals were classified in categories which would ordinarily

p)ermit them to undertake operations without supervision. A quantitative and

qualitative comparison of officers assigned to the three hospitals in India-Burma

with those assigned to the three hospitals in the Second Service Command

showed:

Number in Number in

India-Burnia 2d Service

Classification of officers Theater Command

Certified by Specialty Boards ------------------------------ 26 16

Qualified for certification ----------------------------------- 8 4

Classified by consultant, "A" or "B" 3------------------------2 20

Classified by consultant, "C" ------------------------------ 28 17

Classified by consultant, "D" __----------------------------15 13

Classified "General Duty-". . . . . ..------------------------------ 3 12

The disproportionately large surgical staff provided the evacuation hospitals (25 officers each) as compared with the number and quality of officers

assigned to other fixed hospitals of comparable size was due to the fact that

evacuation hospitals were originally organized to function as mobile field units

situated close to and in support of actively engaged combat troops. Employment in this manner would have required a 24-hour operating schedule in which

surgical teams would have alternated between surgical activities and periods

of relaxation and sleep. The character of the warfare and terrain over which

battles were fought in the Burma campaigns precluded the employment of

evacuation hospitals in the conventional manner. It was not until near the

close of the Central Burma Campaign that a number of these officers were

transferred to other hospitals in order to insure balanced, efficient surgical staffs

throughout the theater.

By May 1945, through the acquisition of qualified officers, including experienced orthopedic surgeons and other specialists from the United States,

and reallocation of officers already in the theater, every surgical service in the

hospitals of the India-Burma Theater was satisfactorily staffed. Moreover,

the USFIBT was prepared by then to transfer to the USFCT a number of

competent surgical officers to offset personnel deficiencies in the China Theater

and to replace officers eligible for rotation.
920 ACTIVITIES OF SURGICAL CONSULTANTS

In April and May, a large number of officers became eligible for rotation.

Among these were 29 key surgical officers who were due for reassignment in

the United States. A brief summary of this consultants' impression of their

capabilities was sent to Col. B. Noland Carter, MC, Assistant Chief, Surgical

Consultants Division, Office of The Surgeon General. Colonel Carter, in turn,

conferred with Colonel Hall, Director of Personnel, in regard to these officers.

As a result, by the time these returnees reached redistribution centers, reassignment orders awaitedl them. The initial success of this process prompted Colonel

Carter to request that this information be forwarded in the case of every officer

with a classification of "C" or higher.

EDUCATION AND TRAINING

The scarcity of surgical officers-except in affiliated units-sufficiently

skilled and personally qualified for positions of responsibility and leadership

made it imperative that hospitals be considered as training centers. Key personnel, lost through illness or rotation, could thereby be replaced. An additional incentive for high standards of performance possibly leading to promotion was provided. The accelerated wartime program of civilian medical education frequently resulted in producing young medical officers of considerable

innate ability but with meager clinical knowledge or experience. Whenever

possible, such officers were assigned to duties under the immediate supervision

of mature, seasoned surgeons and, after varying periods of time, were qualified

to be chiefs of surgical service in small station hospitals or heads of sections

in the surgical services at general hospitals.

The policies governing treatment of various surgical conditions varied

greatly from hospital to hospital and indeed from ward to ward. This was

due to the fact that the medical officers largely represented a cross section of

the American civilian medical profession with widely different types of training experience and personal views and had not received the fundamental directives and guides issued by the Office of The Surgeon General. Few if any TB

MED's (War Department technical bulletins, medical) had been received, and

but few overall professional policies had been established in the theater. To

raise the quality of medical care to the highest possible level, each installation

was directed to prepare a list of the TB MED's that had not been received, and

adequate distribution was effected. It was further directed that a complete

file of such bulletins as well as circulars and other directives issued by the theater

surgeon be maintained by the commanding officer and in the offices of the

chiefs of medical and surgical services at all fixed hospitals.

The consultants attempted to stimulate professional interest by recommending the establishment at hospitals of a suitable reading and conference room,

even when a tent had to be erected for that purpose. Steps were undertaken

to supply each installation with its authorized allowance of professional books

and periodicals. Through the generosity of the Josiah Macy Jr. Foundation,

New York, N.Y., reprints of outstanding articles appearing in current medical

periodicals were distributed to the medical officers in the India-Burma Theater.
INDIA-BURMA AND CHINA THEATERS 921

Medical officers were thereby encouraged to keep abreast of advancing medical

knowledge.

Medical officers were urged to review series of cases at their own installations and prepare reports summarizing their experiences. In some instances,

these reports were used solely as the basis for a talk at one of the medical conferences, at other times they were found suitable for publication in the Field

Medical Bulletin or even in current leading periodicals in the United States.

A schedule of at least one medical conference a week and one "grand ward

round" for the discussion of the most interesting and perplexing cases was

established at the various hospitals. The value of such an educational program in providing improved medical care, in heightening the professional interest of the medical officers, and, consequently, in raising the morale was

gratifying.

The major portion of the time spent at each hospital by the surgical consultant was utilized in a careful review of medical practice on each of the wards.

Each patient was examined, the clinical records were reviewed, and the clinical

management was discussed.

PHYSICAL FACILITIES AND EQUIPMENT

Hospital construction.-Hospital construction of every type imaginable

was observed: brick, cement (mostly sand and mud), basha, pinewood, teakwood, and tents (fig. 359). A few were excellent, most were highly satisfactory,

and with only two or three exceptions, the remainder of the hospital plants

were adequate. Some of the units occupied former missionary hospitals.

Others moved into administrative buildings of tea plantations and added

additional wards of basha construction for patients and erected pyramidal

tents for personnel. The basha construction with thatched roof was satisfactory in the climate of India and Burma but it was difficult to maintain in a

proper state of repair.

Supply liaison activities.-Evidently there had been a marked improvement in the supply situation following the visit to the theater of the Voorhees

Mission in 1944. Although in most installations there was found adequate

equipment, in only the 20th General Hospital and a few of the most recently

established units was most of the equipment and appliances of the more recent,

standard models. Ingenius improvisations were satisfactory substitutes for

the standard apparatus in most instances. The relatively few serious deficiencies in equipment which were observed by this consultant appeared in his

reports to the theater surgeon with recommendations that the equipment be

supplied. Invariably, Maj. Claud D. LaFors, PhC, the medical supply officer

in the Office of the Surgeon, USFIBT, a most cooperative individual, handled

these requests in a most expeditious manner. Officers in the field were grateful

for this service, and unquestionably the professional consultants gained prestige

as a result of this and also the manifestations of confidence in the consultants

at theater headquarters.
B -~ .- AWL&

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- 'tk.

Alto.-

aW

'-f fto flit-: I fl-ii' r :if :ffatl 1 i~t ,-;t' Ii -iflit 11; It flit .\ i i -I-ii l dvifif-. l ,\ Ii 4it.-f14

If :II 1 Ili t1t I fi t ov1111 t ' if 1 I Ii I i ti -1- :1 -li I I .\ I fl it I I .. lI I I I ;I Iift, t tf -- fI~ flit "IfIw I I Irv

1 1i1 1 1- - I o- e l -III h lfr Il i , I ' ll e
924 ACTI VITIES OF SURIUCAL CONSULTANTS

t ion b~eenl processed thbrouglh normnal channels, this in~t t er, whiichi Thle Surgeoni

General considered of extreine imllortaflce, Would not h1,ae rc~eivedl such expedlitious handling.

Improvised equipment.-This cownsut ant observedl, on his Iniitial tour of

the theater, remarkable improvisations of eqjuipiluent. IIn nmany instance,,, the

improvisations were alm-ost exact. replilcas of standard equipmenelt found in

hospitals in the Zone of Interior. Particularly striking was the hilghly satisfactory reproduction of costly, critically scarce apparatus by enlisted personnel

at the 69th General H~osp~ital. At the author's reqluest, thle hosp~ital forwarded

to the theater surgeon detailed blueprints andl photographs of these improvisations in order that. a, manual on their construction and use mnight, be compiled

and distributed throughout the Indlia-Thmrna and China Theaters. Capt.

Stanley C. Gillette, MNAC, Reconditioning Consultant, Office of the Surgeon,

USFII3T,'51 extracted material from this rep~ort pertaining to p)hysiotherapy

equipment and sent. it. to all 1h0s1)italIs authorized physiotherapy departmients

with the recommendation that. the apparatus designedl to facilitate remedial

exercises be reproduced locally and used in conjunction with the reconditioning~

program. The apparat us to be locally imiprov ised i ncluded pla ns for a Ka na vel

table, quadriceps exercise table andl chiest weights, foot inversion b~oardl, chinning

bar, shoulder wheel, stall bars, shoulder ab~duct ion ladder, Sayre ]lecad sling,

exercise steps, thierapeutic bicycle, rowing mnachinle, and Whirlpool b~ath (fig.

360).

On his second tour of the thieater, Colonel Grahiam noted widespread

acceptance, of this advice to improvise equipment locally. One of the more

useful pieces of equipment for the surgical services was an overhead, mnultibeam-I operat lug-roomn lighlt constructed eut irely of salvaged material. In fact

nimost of thle improvisations were construlctedl from salvage, most often front

wrecked airp~lanes and motor vehicles. Perhaps eveni more practical was the

improvi sed testing equ iplment used by the ophithal mologist s. Eqjuipment, unavail.bei hetetr and which was accurately reproduced, included Jacksomi crossed cylinders, ill iterate charts, lens centering devices, perimeters,

tangent screens, occluders, trial frame wall brackets, andl adjustable stools for

patients during perimnetry and scotometry stud ies (fig. :161).

Equipment for evacuation hospitals.-Thme evactiat ion hospitals perhiaps

experienced thle greatest trouble acquiring adlequate equipment. Whereas they

glined a large surplus of surgical Personnel througrh fuinctioning as a, fixedl

facility, they were handicapped in that, their table of equnipmlent was decidedly

inadlequate when serving as a station or geimeral hospital. Although some of

the deficiencies had been corrected, at thle end of thle campaigns in Burma

they still had not receivedl essential1 eqjuipi)mnet (fig. 3162). Req-uests for this

" Cap-tain Giliette was one of the four Medical Administrative Corps officers who arrived in the

Tndia-liurnin Theater with Colonel Grahamt (p,. 912). Hie wit. first a in assistanat to 'Major Britt and] then replaced Manjor Biritt ais thie theater reconditioning' vonsfl tan't In 'May 1945~, when 'Major Britt wam given command of thie :30th station Hjospital.
INDIA-BURMA AND) CHINA THEATERS 925

additional equipment, in accordance with the p)revailing theater policy, had to

be approved by the War Department. Finially, when the need for equipment

in excess of tables of equipment no longer existed, the War Department informed the theater that changes in basic allowances should be accomplished

by the theater on the basis of individual needs of the various units since "such

a flexibility results in a more efficient medical service and is common practice

in other theaters of operation."

SPECIAL PROBLEMS

Transfer of Patients to General Hospitals

The most significant directive pertaining to the surgical service of the

theater was issued on 2 April 1945. The directive was entitled "Transfer of

Patients to Numbered General Hospitals" and was modeled on WD Circular

No. 12, 10 January 1944, which applied to the transfer of patients to named

general hospitals in the Zone of Interior. In the course of this consultant's

initial tour of hospitals, he had noted that formidable or specialized surgical

procedures of an elective nature were being undertaken at field and station

hospitals by officers with inadequate formal training or practical experience.

There was even less reason for this in the India-Burnma. Theater than in the

Zone of Interior, since, with only two exceptions, these smaller hospitals were

situated within several miles of major airfields from which patients could be

transported by regularly scheduled evacuation aircraft to general hospitals

located not more than 2-hours' flying distance away. Compliance with this

directive was uniformly satisfactory, and, in most instances in which the condition of the patient precluded transfer, consultation was requested of a general hospital. In this manner, the quality of professional care afforded patients

in the India-Burma Theater was materially enhanced: furthermore, a more

equitable and economic distribution of key professional personnel was thus

facilitated.

Treatment in Dispensaries

Along these lines there existed one problem for which a completely satisfactory solution was never reached. The same problem was encountered in

the Second Service Command, but to a much less degree. Reference is made

to the treatment of patients in dispensaries, which in the majority of instances

were controlled by the Army Air Forces. Many patients, who should have

been transferred to hospitals. were given definitive treatment in these dispensaries. Most dispensaries had established sickbays in which from 10 to

30 beds were maintained. These were, for the most part, operated by generalduty medical officers of recent graduation who had completed an accelerated

medical course of 3 years, followed by an internship of 9 months.
1.;4 l t."l1 * T

-A
machine.
928 ATIVITES Il
INDIA-BUIIMA ANi (HIlNA THEIIIATEIRS 929

FiGurie: "36i.-Co11tiInue. C. A trial frame wall bracket.

Scores of patients were observed in hospitals who had been improperly retained in (lispensaries, miay with peritonitis from a ruptured appendix, others

with nmalalineienr of fractured bones which eventually required open reduction, others with severe second- and third-degree burns with infection and

contractures, patients with severe local and systemic infections resulting from

the late primary closure of lacerations, and patients with many other evidences

of poor surgical judgment and treatment of an inferior quality.

This problem was made ili , subject of a memorandum to the theater

surgeon, in Nwhich were listed the followingr reconiniendations: (1) Inactivate

those dispensaries situated within several miles of hospitals or else place these

dispensaries under the control of hlie hospitals which would I)po\ ide personnel

for conducting sick call, (2) prohibit the maintenance of beds in dispensaries

except when specifically authorized ty the theater surgeon, (3) require dispensaries to render a monthly report listing diagnosis, treatmnenit, and disposition of each patient admitted to a sickbay, and (4) require hospital comimanders to report to the office of tie theater surgeoni all instances of iiiiproper

treat Jimeii. in f) Itieuts •mdniitted from (di:•lJesaries.
930 .ACT'I VITIivS 11i*' SI1AOirW.1 C ENSV LTA J.N'IF

1'I.( In: :1,G2..\An iuhhlo-vied baker andu txervise Nveig1Itll- an 1l1ley arrlr.hgn-11hit1 at the 14th

Thie 1iieit er. -ll..ri~onIl. ill piite of Illsr posit loll. xv~ls liiiii d ill thek .1ii ions lhe

Ai orvelhl thk (I lien I4 livi. I-ide llil~l(tlll whose h eilt, WWl5~1 Most of the(41i (411 tIlt* Aniiv4

uilVoivedl. All elellieilt ý oft liet ArIlly Al 1 l. Frces ill liet hlenter. wit II Ie hexc

I11 loll o li Ihv14i:14( 111i1:1 Witigr of Ilie Allr Trans~port ( olillimaild ilit icw114M.

the 'Ieviit A ir F~orce, were iliniei' Ilie admI~ilitfri rat V'alldi~it :I conitrol

of I Ih1 A i... N All. Forces. Illiah-ia-litiiaSeir whose headqularters wvert' located

t.1 H asting's M~ill. Caiiciittal. 'I'ihl olid I this 1 IiIdi~it le vs \iii All. Force,

werV oe rl('tliouia liv conitrolled bY th le E,;I~t rll All Ci(ommandi 14 of Ite Sou~thleast

Asiit. ( ommniutd--a sit iiat on \\11i4ci finllilen W:v I.-'iriit Ho Owa voelmilu ainid

sepmnirtestatuisof tile Aiii Air iForct's ihil 141 to otliven eileiieitsol,1 the Army1N

ill tilv' theater. Th'le Armiiv A I~c' I' PtIV lie I eIatIer coli iit 11ied t o operateIv wiieji

(hisplls:1iiintts oti tile Conltentitn 1(41at too uinaiiv 11iiaii-ha vs were lost whieti Air

Foivcespixrsoliiei had 4to be t i:iui'-Inied ito Ihit ixed hoor 14it~uk ofie tlteater. for

the I ieatlii('iit oi rentutivelY Iuitiion. medielha :11id 11ur1igiv1 volidii otll. Some liiiproveatlou.l was it ased ril jel' ,dciteh. lb ally*. s.-ai-fltol -( loluo the1 lni-it lrl4I~lli

At;tlot hetre pri Iilll) wit'n114 ye voi c Its4lle 1:t h'is 5 "ho were hllt af'ltt er Il., 41
INDIN-BURNIA AN) CIhINA TIIEATEWA 931

Until thle appendix had ruptured. It was determined, after a careful study of

clinical records and conference with some of the officers involved, that the foblowing factors were influential: (1) TIhe pr1evalenice in Arimy p~ersonnel of

diarrheal dliseases which mimticked appendicitis, especially amiebiasis; (2) retention in dispensary sickbays of patienits wýith aj)j)ein(licitis, nianyv of whomn were

adininisteredI purgatives, unitil abscess or greneralized peritonitis developed (32

such cases were, observed dlurinig the author's initial tour of hospitals) ; (3)

undlue caution of officers whbo had been criticized biy the Surgeon, SOS, ISFIBT, for removal of normal1.1 appendixes (hospitals hadl been instructed that, all

a~ppend~ixes removed should1( he sent to tile Central Laboratory for microscopic

stud~y). The Latter no( dloubt served as a dleterrent to the overzealous young

Surgeon, but at the samne tune, it tendled to warp, the judlgmnlut of the conscienltiouls, tinilid ind~ividual who hadl been officially re prinianded or dlreadedl such anl

rthe combination of abdominal pain, voinitit ig, and right-i ower-quadra mit

tendlerness frequently resulted inl tile admission of patients with ainebiasis to

tile su rLyical service. Thle, auiieliasis-nihid~e( surgeon was not readily deceived,

for a history of diarrhea, abdominal tenderness also over other portions of the

large, bowel, and induiratedl, tender seggments of time large intestines indicated the

adiablt o tolctuiiimtoilioctoscol)y, and other dIiagnostic tests. The

presence of am-ebic colitis was, however, no guarantee that thme patient, did not

also a ccueIlenlitsndrequire surgical inutervention. It was therefore

advised that, whenl any) patient showed conlvinicing signs of acutte appeindicitis,

delay in surg-,ery wavs not to he countenanied~. The surgeons were giveni to understandl thlat, if, after carfl study and1 the ise ofaailable v c--fils-o onsultation, a nornial

alpen~imix was removed, they wvould not be criticizedl or penmalizedl by the theater

surgeon. Thids attitudec, it, is believed, hiad a salutary effect onf the officers and

to sonicl extent was resp u1sible for a diminution inl the number of deathis from

app)lendlicit is.

Effect of Climate

Thle consistentlY highi temperatures p)revailing inl many parts of tile InidiaBurm-na Theater, thle iniager recreational facilities, and thle isolation of mians'

of thle pos5ts had a protound effect on mnedical personnel. Even imu thle, relatively

brief experience of the consultants of somewhat. less thans a year, it. wvas strikinig

to 'w~itiness alert, aggressive, uit husi ast iv m edlicalI officers gradlually "flat teli out~

during tile second monsoon of t heir stayv. The saine influences were apparent

inl mlaly of tile patients.

Heat exhauist ion and heatstroke. surprisingly, were. not prevailent and( conStituited at relatively. mlimior prbe.I )Iuriln thle hot, hum11id um1omitils of the

fol'is~oii sea~sonl, oral afternloon teimperat ir-es as high as 1000 F. inl a pparentIy

healthy mailes and( ais high as 100.40 F. inl feinnties were obse:n.t 4 inl nonliospit ;liZedl personniel ellgagedl ill rouit inc activities. Simiflar elevat ions aimmomg pat icilts

were ob~served inl thle A%-t r(ls of hospitails iii the absence of aniy oither e xjlaniationi.

7 05) 0() 5A 04- - r 02
932 ACTIVITIES OF SUIRGICAL CONSULTANTS

The widespread use of sul fonam ides, particularly sufadiazine, led to occasional renal complications during tile hot season. Every effort was made to

impress medical personnel with the necessity of maintaining an adequate urinary

output rather than emphasizing fluid intake. Injection of even 3 or 4 liters of

fluid a day led, under certain circumstances, to oliguria, hematuria, loin pain,

and the like, even when only moderate doses of sulfonamides were administered.

Owing to the occasional occurrence of anuria, a circular was distributed which

related the advantages of spinal anesthiesi in the relief of this state.

COMMENTS ON INDIVIDUAL HOSPITALS

It is difficult, after reading again the author's reports to the. theater surgeon on hospitals visited, not to follow a strong inclination to write about each

of them. The scope of this undertaking, however, will not permit, this, although certain impressions obtained (luring field trips are reported in later

sections of this chapter.

There were several outstanding hospitals in each category, a goodly number of highly satisfactory ones, and only a few definitely mediocre units. Some

of the hospitals with the poorest physical facilities were rated by this consultant

at the top of the list, for performance. That is. esprit de corps was excellent,

scarcity of equipment had been remedied by clever improvisations, and the

quality of professional care was superior. In others with fine modern physical plants and the latest in equipment, the author found the morale poor and the

quality of professional care below standard. The difference very often was

owing to the character, qualifications and. or, state of health of the commanding officer and chiefs of services. In seven instances, the consultants and the

chief nurse. Lt. Col. Agnes A. Maley. ANC, on their first field trip observed

an urgent need for prompt repatriation of hospital commanders. For the

most. part, they had remained through one too many monsoon seasons and were

physically and nervously exhausted. There was also a (legre of doubt in some

of these cases as to their initial qualifications to command. Replacement of

these ill or derelict officers often would alone suffice to improve tremendously

both the morale and quality of professional services.

Too frequently, this surgical consultant observed in India, Burma, China,

North Africa. and, to a somewhat lesser extent in the Second Service Command,

a tendency to assign to administrative posts. including that of hospital commander, officers of field grade rank for whom there was no available clinical

assignment commensurate with their rank and military occupational specialty

number (usually 3100, general duty). Often they were lacking in both efficiency

and proficiency, in aptitude to command, and in administrative ability. Furthermore, it appeared to be somewhat more the rule than the exception in oversea hospitals for a relieved commander to be replaced by the ranking medical

officer of the unit, who had acquired his relative position of rank solely by

chance and who, consequently, more often than not lacked the qualities necessary to command such a complex organization as a modern army hospital.
INDIA-BURIMA AND CHINA THEATERtS 933

FIELD TRIPS, INDIA-BURMA THEATER

Somewhat more than half of this consultant's 9 months in the IndiaBurmna and China Theaters was occupied in field visits to the various installations. Travel was almost entirely by regularly scheduled transport, aircraft,

although occasionally, as a matter of expediency, bombers or 15 liaison planes

were used. Nearly 200 hours were required to travel approximately 30,000

miles, and probably half as many hours were spent in airports waiting on repairs to planes or, during the monsoons, waiting for what was said to be reasonably satisfactory flying weather.

The isolation arising from the wide dispersion of units and the poor lines

of communication made it the more important for the consultants to be regarded as two-way ambassadors between the theater surgeon and the hospitals,

interpreting locally the policies of headquarters and acquainting headquarters

with the problems confronting officers in the field. For the most. part. medical

officers had had no opportunity to discuss professional matters with anyone

other than their immediate associates and had but little information regarding

experience with comparable problems at other hospitals or other theaters. The

opportunity to display their own accomplishments was an important morale

factor. At many hospitals, the experience and ingenuity of the medical officers provided constructive suggestions which could be transmitted to the

officers at. other hospitals. Colonel Plumgart said that this function of the surgical consultant as a "circuit rider of good ideas" was probably one of his chief

contributions. Through a sincere endeavor to be as helpful as possible, the surgical consultant established confidence among hospital personnel, who accepted

suggestions without, resentment. In some instances, a surplus of medical talent

was present; two or three highly competent surgeons would be found serving

in a station hospital. In other instances, however, no surgeon with ability

and sound, conservative surgical judgment. had been assignied, and it. would

become necessary to prohibit further surgery in these hospitals until a qualified

officer arrived. These instances were, however, relatively few and invariably

were immediately rectified by the personnel officer in the office of the theater

surgeon in response to a radiogram or telephone call from the consultant.

Advance Base Section No. 3

Sooni after Ihis arrival in tile theiter, this surgical v(,tsuitant toured hospitals in the Advance Base Section comprised of upper Assam, India, and

northern Burma (map 7. p). 908). Most of the battle casiialties of the Burma

campaigns were hospitalized in this area. Base Setion headquarters was at

Ledo, where the road of the same name began. The 691th General Hospital

was located just outside of Ledo: several miles fiurther along the Ledo Road

was the 20th General Hospital (University of Peziisvlvania-affiliated unit) ; at
934 ACTIVITIES OF SUIRGICAL CONSULTANTS

the 19-mile mark of the road was the 14th Evacuation IHospital (New York

City IIospital-affiliated unit) ; at. the 52-mile mark, at Tagap Ga, Burna, was

the 335th Station Hospital; and at the 103-mile mark of the road, at Shingbwiyang, Burma. was the 73d Evacuation Hospital (Los Angeles County General Hospital-affiliated unit). The Base Section surgeon, Lt. Col. John T.

Smiley, MC, a relatively young career army officer, impressed the author as

being an exceptionally able administrator.

The 60th General Hospital was an excellent example of what could be accomplished in the organization of a general hospital in a theater of operations

when an officer possessing aptitude for command was assigned the task. Evidently, this unit had got off to an inauspicious start late in 194-4, at about the

time of ('olonel Kennedy's visit. (Coonel Kennedy was of the opinion that

the. unit was far from strong and urged the. consiiltants to give it their initial

consideration. Subsequent to his visit, Lt. Col. (later Col.) Edward M.

DeYoung, 3C, a young Regular Army officer, was designiated commanding

officer, and under his wise an(d effective direction the hospital became an efficient organization, with the p; )spects of becoming one of the outstanding general hospitals of the theater.

The 20th General Hospital was unequaled in the Southeast Asia Command.

It is difficult to contemplate a discussion of this installation without becoming

overwhelmed with superlatives. Suffice it to say that it was outstanding in

every resl)ect, and so it should have been, with a hopsital commander of the

caliber of General Ravd in-eminent surgeon, educator, and able administrator-and a staff that had remained nearly intact since its arrival in the theater

21/. years earlier, composed of officers practically all of whom possessed superior

professional qualification. The physical plant, facilities, and equipment left

little to l)e desired. Particularly impressive were the central supply service,

the blood bank, operating rooms, and the unit ward system in which surgical

wards were divided into administrative units, each consisting of one or more

active an(l two or more convalescent wards. This hospital, together with the

14th, 48th, anl 73d Evacuation Hospitals, performed a noteworthy service in

the care of battle casualties during the Burmia campaigns (fig. 363).

The 14th and 73d Evacuation Hospitals were also outstanding units, staffed

(as has already been related) with an overabundance of highly talented surgeons. Their hospitals were of basha construction and were in a poor state of

repair, owing io the monsoons and a l)redoninaiwe of C(hinese patients. The

73d Evacuation IHospital was established on the sides of jungle mountains, and

all personnel, including the nurses, lived in pyramidal tents. Despite the tremendous handicaps of more-or-less constant rain. mildew, and mivriads of insects and pests, these units succeeded in maintaining asceptic conditions while

undertaking formidable and highly technical surgical procedures with comnmendable low iimortalitv andi morbiditv rates.
INDIA-BURMA AND CHINA THEATERS 935

The 335th Station Hospital was unique iin that the entire personnel of the

unit consisted of Negroes. The hospital was situated on the most imposing,

and ahnost the most isolated, site in the theater. with an elevation of about 3,000

feet on a hairpin curve of the Ledo Road and on the side of a hill in northern

Burma from which could be viewed a vast expanse of territory including the

mountain ranges of Tibet. While visiting the 73d Evacuation Hospital, this

consultant was driven in a jeep by Lt. Col. Clarence J. Berne, MIC, able chief

of the surgical service of that hospital, through 20 miles of almost impenetrable

mud to the 355th Station Hospital. Despite its isolation and relative inactivity

(its main p)urpose was to provide medical service for the Negro troops working

on the Ledo Road), the morale of this unit was not surpassed by that of any

other organization in the theater. Moreover, from the author's observation

and those of Colonel Berne, who visited there frequently, it was (juite evident

that they were rendering superior nursing and medical care.

Base Section No. 2

Base Section No. 2, with headquarters at Calcutta (map 8), contained one

general hospital, nine station hospitals, and one field hospital. This base section served the Calcutta district through which port practically all the waterborne supplies for the theater arrived, the 20th Bomber Command, and Air

Transport Command installations, a total personnel of about 60,000.

The 142d General Hospital, Calcutta, a unit affiliated with the University

of Maryland, Baltimore, Md., took over an already established installation from

the 263d General Hospital, which was inactivated in November 1944. There

were 2,000 beds established in modern, well-equipped buildings in a 1-mile long

area in a rather congested outlying section of Calcutta. Despite the fact that

the personnel of this organization were under the impression they were being

repatriated on leaving the South Pacific Area after a stay of 29 months, they

undertook their new task in a remarkably fine spirit. It. was necessary for them

to reorganize their staff and expand from a 1,000- to a 2,000-bed hospital. This

was accomlplislied in a highly commendable manner under the direction of the

able hospital commander, Col. Murray M. Copeland, MC, himself a distinguished surgeon and formerly chief of the hospital's surgical service. The hospital was outstanding in almost every respect.

It was unfortunate that this unit and the 18th General 1Hospital, sponsored

by The Johns Hopkins University, Baltimore, Md.. were redeployed in the

India-Burma Theater. Of the 33 Medical Corps officers at the 142d General

Hospital, 22 had become eligible for rotation; 48 of this hospital's 83 nurses

had become eligible for rotation. All of the personnel of thie 18th General Hospital, which had been fulctioning for more than 30 months in the Fiji Islands,

were eligible for rotation to the Zone of Interior. When it was learned that
escortin iii T.1: d MiIiititteii 11 (conter) andi (diler vi.it4'rs on ani iinsped 1411 (tr The Iiostiital.
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938 ACTIVITILS OF SURGICAL, C( NSVULTANTS

KT I B E T

NEW 0ELH~t `1 A' Ae P. Qr Ledo181,Gen Agra to~. I ]

Kordch, N.,1. d8on~bo

centration in theCalcuttaditc.

duty~~~ hnTetr in th 
INDIA-BURMA AND CHINA THEATERS 939

Ten days hlter, on the coml)letion of his first tour of hospitals in the IndiaBurma Theater, this consultant l)roceeded by plane over the Himalayan

"Hump" to K'un-rinig, Rear Echelon Headquarters, China Theater, a distance

of about 1,800 miles from Headquarters, USFIBT, in New Delhi. The author's reception in K'un-ming left nothing to be desired. Along with many

other visitors to Rear Echelon Headquarters, he was impressed with the spirit

of friendliness and cooperation that was more wholehearted than was usually

encountered. It great part, it was believed, this spirit was influenced by the

character and personality of the Commanding General, Rear Echelon, USFCT, Maj. Gen. Douglas L. Weart, and of the theater surgeon, Colonel

Armstrongr16

The theater surgeon was optimistic that the consultants would be able,

from their observations, to indicate in their reports the most serious deficiencies

in personnel and equipment and thus assist in expediting the procurement of

much needed relief. At the same time, as was strongly emphasized by Colonel

Armstrong, he desired that all irregularities and all evidences of professional

incompetence be recorded or brought to his personal attention. He earnestly

desired criticism, advice, and help.

Visit to the Combat Area

It had been arranged for this consultant to remain at the Rear Echelon

headquarters a few days for orientation, but the day after his arrival the opportunity was afforded him to accompany Col. Benjamin J. Birk, MC, Surgeon of the Chinese Combat Command (Provisional), on a tour of field units

in the active combat area."7 Accordingly, on 17 May 1945, they flew to Chihchiang, the most forward fighter base after the fall of Kuei-lin, in a Combat

Cargo Command plane filled with drums of aviation gasoline. From Chihchiang they went by jeep over mountains and a makeshift ferry across a river

to An-chiang, headquarters of the Eastern Coiniuanid, Chinese Combat

Command.

Although the local military commanders showed little concern over a

pincer movement that the Japanese were attempting in this area, they were

nevertheless bothered about the considerable number of Japanese disguised as

Chinese civilians reported by Chinese military intelligence and the Office of

Strategic Services to be in Chih-chiang and An-chiang and the intervening

territory. As a consequence, contrary to practices in most other theaters,

Colonel Birk and Colonel Graham were issued carbines and pistols and told

to display them prominently. All tactical medical units in the combat zone

were not only well armed but were also given a special course in the function.

10 Later The Surgeon General, U.S. Army.

"1 The Chinese Combat Command (Provisional) along with the Chinese Training Command (Provisional) comprised the Chinese Training and Combat Command, which was formed as a result of the

consolidation in November 1944 of the predecessor Y-Force and 7--Force operations staffs and activities. The new command continued the training and logistic programs in support of Chinese Forces

In Central and southern China which had been the missions of the Y-Force and Z-Force.
VAV

14 1

B .I ;-141a f-pl1. A (lit 6 1ii a f.*- .n Iv--lla il a
INI IA-BUICNITA A\NID CHIlNA 'I'I FATERS :\ll I

Jll4)ipsI) s4ill .iialI icliegiiii1 AlI4Iem)VIr. it Nvas Ilic:11er, 1141IicY 11,1 th e Glt(eieva

otilei :if ext reville nul. "ets 44)111ttoInlat~ lc ire.-

()firlci' ;itid I() ( '(d. IP:iii ( ". I [ate-eu. NIC. Slrei.Eaisterun ( 'tiiad I )IIIill-,I hi (lx 2i thlt s.: I 4iI1vI Birk W' (' C&s ' hI4I~td e 1lIlwell.rl .111d fi wlit, al illi. I a Iie :111'~

T'llvYv sI w lI~li ( liliei~se' \\ mIlde l('l I iiiii :112 ilmi~i ie i'o4id \\-il Ihe:14 a (ofa st ick

m. riflev. m.i 1)4.111( sIijpl)0ij-41 lby. mr r ielol fi fhelit bnv ic . 44r)(hlel. M()lflier. [ I i

ot liei's. tillable ho walk. weeI' (iiIn Ow'~Z~ll beside the( rfmdl. Their plea:s foi asi-I aice " l grliml-dIY L the w im-st'e S'iillvý \ieI' Who q j)eMIltlieiii. ,v 'The icn

rnI It Iv f ee it11Wl'expl iiie t1ot lie :1111 mlor L li( Ilehillese. intfer'preter.

wosl'i i ~ll I alI liel(, li Iv Wulided et \\11 11ll) 4:1 P11141 for 111:11iv Iliis Ia' more4)'

(Wi wAVs :1 1VIiiibtijl. o)f hIls squlal ()I- p):4lahmn* He I1' iiirIlt evell (Other smilei llevasýIlie

()f atidl tol ;I Inellitli' of hIls l'4)tiplj):iiIVVll, wa, ill .1:ii~ller platoou. bilt Iie~'lid

tha~t lie vo ll ilitl It':ssist :1tice IllIl) 41)() 'm. l'e~nini'Ilt-sý lIf I lil(- ei' ()f Ili(,
942 ACTIVITIES OF SURGICAL CONSULTANTS

At the most likely points of entry to the road were stationed U.S. Army

medical corpsmen to guide or litter-carry casualties to nearby portable surgical

hospitals established in tents or Chinese temples or combinations of these two.

The Portable Surgical Hospital

At this time there were only four portable surgical hospitals in the area,

and only one section (2 officers and 18 enlisted men) of the 34th Portable Surgical Hospital was then functioning. They had been treating casualties more

or less constantly for 36 hours. Scores of wounded, both Chinese and Japa- nese, were stretched out on the ground surrounding the ancient and quite

dilapidated building in which the unit had set up a. temporary operating room.

Since the two officers were operating on an "assembly line" basis, it was necessary that enlisted men conduct the triage of patients, deterinining the order in

which the casualties would undergo operation. Corpsmen would undress the

patients, clean the injured area, accomplish a superficial debridement of wounds.

and, when necessary, administer intravenous Pentothal sodiumi (thiopental

sodium) anesthesia. The surgeons progressed along the line of tables as

quickly as possible, performing a simple suture of a superficial wound in one,

enucleating an eye in another, or amputating a leg or an arm.

The quality of the surgery performed under considerable pressure was,

for the most part., highly satisfactory. Working under such trying conditions

and in the face of many handicaps. these officers and enlisted men rendered outstanding service (fig. 365). Many lives were saved in instances of the severely

wounded and injured, and a considerable number of the lightly wounded were

enabled to return to the front after a short period of time.

Certainly this was not the time or place for criticism of surgical judgment

or of techniques. From this consultant's observations of officers in action in

these small units and from his conversations with them during periods of inactivity, it became clear that most of their surgical training had been acquired,

in many instances, in the field by the trial and error method. Even where competent, well-trained surgeons were on duty with the units, they seldom had

time to supervise the operating of inexperienced members when there was the

great pressure of a large bac.1dog of patients awaiting operation. The author's

inclination, soon after arrival in the India-Burma Theater, was to be critical of

the assignment to the portable surgical hospitals of so many officers with little

or no surgical training and an overabundance of pediatricians, obstetricians,

and general practitioners. A study of personnel records of 19 of these units,

however, revealed that in well over 80 percent of instances the assigninlnts had

been made by the Office of The Surgeon General before they were sent to C(hilaBurnma-India. The theater surgeon's error had been to assume that tihe Office

of The Surgeon General had selected qualified personnel for tile portable surgical hospitals. Certainlyi. il ny- fture war only highly skilled young men

l)referably undler 35 years of age, should be emnl)loved ill such uilts.
INDIA. BURIMA AND) CHINA 'i'IE.'ll~ EATER 93

F in- r 3 45 Chinvsv~ sodiviirs :111 Pi 14 .1,0ing- I ;I111v1'l fir Sill'

In,1 mill a ills ill 1114. il'kgroi 1 nd. 11

F 4)1 ench ( liili1t'm. '-4)14 hIT l hey sav iv . Ililiii (it hiers died1. Smiile 41e41 Ill I rl'isiit 14)

1 hieir ()-ltI- 01' Sl4Itv - a ittv rivn btw:iiiste 4)f 1 Ilie 14)11,r ~Ilviit~i I21 lieiii

iii.111v 4.'nsliilt ies okelIvev 1) v Ills C4t)lisilllt ant hadtm leeli wollitled -1 mW.1 (In v

l)*tNi(~i)Ilsly ) . Ot),hers died after ec 1,0VIVlig tretI*,Ieil p viem Ill he ile],( to) suri- IVe

th 111)IXev ri lie ( ills!:1ll.1l j)lis ()lI' lhe ( iiiiiese Ar iv , fl Irt I e r toI I lit, Ivanr. It. C(').

J ()l I1. II S I Ini'p1. (NI ( '. NNlI mse I i-IItvk S I raI':Iis p)orletl I I Iese ( -asinla Ijes. I 4)l d I Ie :iit-111( lir

11: li m l mw14 4)4'(1ioi4) nlI-)ti4xiiIuitelvI 2011) ()11f ( (f itit Ili) C iekse diedl IIiI tlte Inilcks

st.iii4l:ibl)4 Siiite ie 11:11 p elivis werei4 I ralimis))ned Ill trck 114(5 4VI r4)Iioil iii4iit.1lii

I'10;Id-.4)11 whiich liv I eewere l~ I~i File~ie':ll 1 I'I''~ 11 -1w i'i s were 41r1veti

rals )1 .1)4ed Ily , v''' ( Al4-e41'il5 I)''lm-emP. the wmiliiidel

( 'iiie-e'-(htlelS(-) evei' ')lie W'illii wvicmiili Iluls ('4)lsill ilEll vm41 1 ired :1u-rreevl. received lplactt icall . 114 14IIImilisieilt I Ilii'o.mizloi tile cm4ill't. ()f his evn'lliat i(Iu fro)Iii

IIle trowt. excepti *(14 1 lie 5114)11t jperio)4 lie relil iiieo ill I Ilie pIm:llI4.l 5lill'.ica]i

h114)1)l . Tills' 4l4)1)imlale sit 11.11 mlo existIed dlespitle tilie fact 11lint :iiiiple supplies

off food)4 lint eil fiheeu11. Ilje N. I lie I '.S. A u'iiuv 14) (hiiiiise l'eISP4lIsIble fool leliir

11:1 vlelill Iu raisul. FuIII lierniiioue. it xvai, believedl I lint I lie 1~t10,111 bae Ivaslinit Ites

:11141 illjjuries 44 ali elill ire ( 'hliuis Arntiiv ( smllielt- nt In11 aitle 1~ei h fuill 4'4Iildle-
9144 tTVT S0"sl4lA 'I~''A''

lilt-lit of a1 U.S. liliifzud r division) 'ould nlot 1)1 Pl'0~lvb~t Cared1 for by file perSoitnelI of one ha.1If of a st andtard[ portalble sul-rgicaIl lloiostit~.

A mlost (Iisvoin oira , ob~servat ion wa-,s lith- 11l~ilnd oin of fracture cases. partiviilarlv thloste Ilhat had Ileti1 colitijotituleti byv shlell fl-IragmenIts or buIjllets. '[hley

(101141 nIot be properly t reatedl ill these small units. Iphlose frafhtiIres' ill which

1liii oil occu rred I usna lv presenit ed ma rkedI de forimiit y ( as observed I in Chiinese

atlid Aniierical fi ield hospitals to the rear) for two reasons: First, there were no

X-rav immaclii li1es :iva ilahie for thle port able siu-rgical units; and( Secondl, evenl if

alinemtent wn~s perfect whien the plaster cast was applied, the C hinese soldier

inivariably remioved tthe vast w~it bin a1 few days.

Onl the basis of the experience of the pot:besurgical hospita;l Withi tile

Y-F1orce in t liet Sil ween V\alley operations.'" the theater Surgeon p~roposedl :

revision ill tile table of organ izat ion andl equ ipmient for Such units to be vemploved inl Chlina. The mnedical planl had provided for time use of 1S Amlericaui

Port able sullrgical hospital uinits for the 's-Force. Actuially, however. only 10

arrivedilli t ime to pa rt 1(1pate. as S Were divert ed for- Service inl fi dil-i-llurma..

Colonel Armist rongs suppjort ing :urg"ument s for thle p~roposedl cagsWere

Substanitially as follows:

The p~ortab~le surgrical hosp1 it als. as Originally organizedl ill Table of Orgranizat ion and FEquipment S-572, were planned for a specifiv purpose. : nmely,

giving front line surg~ical t reatmnent. inl support of A merican units inl combat.

IUnder this plan., there were alwaIv., larger ,1 hlospitall unlits to thle rea:r, wvliieh1

cou1ld t ake care of any Ineolica pro~blemns Htht mnight a rise. Inl the C hina.

Theater, however, the uise of t lie portalble sul-rgica1l hospitals was enltirly(I diffe renit. '[le patients were almost excilusively Chinlese4 soldiers, and usually

there Were llo longe~r Amlericanl hospitals to th~e rear whichl could handle coin1-

Jplictemel p~roblemts. lTherefore. it waus necessary that por-table surgical hospitals

also funmct ion as field. station, evacuiation, and general hospita:ls (for thle

Chinese) :inl other words. they' had to he equi pped to handle all types, of surgical an 11(1 edicni 1 cses and at thle sanme t ime renmain relatively mobile imu ordler

to be abile to umlainltainl close Siupport of the Chiniese lumuits ill com1bat. AS nlielnt ioiteil previols usv. 11ian 'v of these unlits wvere Split. into two sect ions inl order to

provide surlgical and14 meI(d icvi care to thle gzreat est numbher of (hii iese patients,

and t here fore it was necessa rv that each sect ion be :udeqiiatelv equmiipped to

Op~erat e seIlmrat ely.

(Colonel Ariuum.t rolig indicated change1-s that should lbe effected. Four oflieers, lhe noted, wvould he :lssmguie(I as ill tilie o-iriginal organlizationl, buIt, sinc(e

thle units Would be Split, emphasis Should be placed oil the assignment of

more11 qualified siu.rgeonls. ]EleJvenj enlistedI mlen were to heý dropped, leaving

twenty-two.

At' thle time of this consultant's visit, t here was no indication that the

war woiuld end inl such a short tune, and1( it, was Considered anl urgent niecessity

to increase thle efliciency of the p~ortable siurgical hospitals to tile fullest extent,

"11See footnote 9, P. 899.
INI)IA-11I'IMA AND CHINA THEATERS 945

since the War Department had disapproved the further utilization of fixed

beds in 17.S. Army hospitals for Chinese casualties. The commnding general

of ('hinese troops in the Eastern Combat Command expressed to the author

his deep concern over the change in policy. His comments paralleled those of

the division comnmander of the 130th Chinese Division, who, according to the

Aiierican Surgeon for the Y-Force, stated, in effect, that his soldiers were

much braver in this campaign than in previous ones because they knew that a

portable surgical hospital was close by. The Chinese division commander, it

was held, stated also that in previous camp)aigns the Japanese bullets were

not so much of a lazard as the infection resulting from them an(l that the

techniques used by the portable units rendered this danger and fear less inportant b)oth in actuality and psychologically.

The officers of the portable surgical hospitals that this consultant visited

apparently applreciated his visit and the discussions of new concepts in surgical

treatment. They expressed the desire, however, to have a surgical consultant

assigned to their command who would visit each unit every week or so. The

theater surgeon, on the author's recommendation, selected an excellent officer

for this post, but before he could start on a tour of duty at the front the war

ended. In conferences with the Chinese Surgeon General, Gen. Robert

K. S. Lim, a distinguished physician and physiologist who was well known

and esteemed in the United States and Great Britain, it was suggested that

he arrange for the repatriation of two Chinese surgeons, friends of his and

the author's, both highly skilled and possessed of superior surgical judg(nent,

to serve as counterl)arts of the U.S. Army theater surgical consultant and the

contemiplated combat area consultant. The suggestion was favorably received,

and it is believed that an effort was made to acquire the services of these outstanding countrymen of General Lirm, 1ut the plan was never consummated.

Practically none of the highly trained Chinese physicians and surgeons, sent

to the United States before the war for medical education or for postgraduate

training, returned to China during the wvar.

The Field Hospital

Both the Chinese so-called field hospitals and the U.S. Army field hmospitals were visited during this consultant's tour in China.

Chinese field hospitals.-The Chinese field hospitals were l)rimitive. A

typical Chinese field hospital was described by the commanding officer of the

U.S. 47th Portable Surgical Hospital, I-Jiang, as follows:

This hospital consisted of several British 'four-man' tents, which are approximately

12 x 15 feet, plus a fairly large adjacent temple, the court sides of which were open. * * *

Eight patients were placed in each of the tents, four on each side lying head to head with

about a foot of space between each patient. The patient's bed consisted of boards elevated

about a foot above the ground on mud bricks. On the boards was placed a thin straw mat.

The more fortunate patients had a thin cotton blanket to put over the straw beneath

them *
946 ACTIVITIES~ OF SURGICAL CONSULTANTS

The paitients hoiused inl the temple were simiilarly arranged ill the rooms of this bouildlug except that ill somle of the smaller rooms1 there were large comm~fon beds, extending the

len.gth of the room. inl which several patients were placed.

Thle food al1lowvanice of thet patients inl the hospital w-as Ililt same as that allotted for

other Chinese, soldiers :namely. 25) ounces of rice per man per day. Inl addition to this, the

hospital was allowed 240 Chinese dollars [ appro ximiatel y 25 cents. U.S. currenvy] poer malli

per daiy to buy products availablell oil the local miarket. This was later increased to 120)

dolla rs, but even this didn't buy very inuch w.1ith the inarkedl inflation as illmist rated bly the

fact that all egg cost about 90t dollars and the prices of other products were inl IrotHortioin.

Nu11triit io nal anid deticienicy dhiseases compilrisedl a goodly numbier of the patients ill the

hospital. aiid. as cain he real ized bY t he above diet which they received,. their recove ry was

not very niuch enhianved in the ho'spit at.

The nursing care wvhich the sick received was essentially nil. Thet soldiers assigned

to the hospiltal ~ere w tech 'I(ivaly called nursing soldiers bumt they bad never received anly

trainingi. inl these dut ies. N ci harts or records were kept onl thle patients. There was- nol

routine for the givinig (If miedicationis. and other t han thle bringing of rice into the center

of thet tent area twice a day for feeding of thet patients, no other care was attemipted.

If thle pa tienit had to visit the lat rinie. whichi was onily a fewv feet away fromin the templde and

wasti'en. lie had to( iimake it under his ownvt power or witai thle assistance of a fellowv

patient. The sicker ones, being unabtle t(o imake this joiirney resorted to the area julst outside

tie t ent * *[or I to tilt ground in thle tent. Nip water wvas providled for the patients

to4 wa sh I I

***No effort wats miade to1 selgregalte t lie inifect ious (or conitagiouls dliseaises. Thetre

-was not p~relimiina ry examiniiation41 or delouisinug.

Tile intere-t of the Chlinese mledhical officers ini the platienit was only0113 slightly

better than t hat of thle nursing soldiers. They niade irregular and indifferent rounlds* *

somewhere b~et ween eli (o'clock ill thle mio rninig and nloonl, foullowing which the pat ienit s. were

giveni (rugs which they prescribed. No drug wvas given without the p~rescription of thet

miedical officer for each hitiividllal dose. As a result of this, regular mledhicationl was niever

gi veli.

T.Ihere w~ere btetter ('lhiese hosp1itatls thian this, the aulthor' wals informied,

butt ill too 1niaiil inistanIces were mianyv of these 'ond~itionls reprtodulced. The

Chitiese. hosp~itals this consutltant visited were aboult tile same as that. described.

Not on1ce oil visits to thlese ithacts (11( lie see anyone who even claimled to b~e a

doctor, and1( the nutrsi ng soldiers were extremely scairce.

U.S. field hospitals.-( n lea vi tu An-cu lang, Colonel Birk anid the author

retulrnedl to C'ilh-ciliang. where they visitedi an Air F~orce dlisp~ensary and two

sectionts of thle 21st F~ieldl Hospital, only one of which was funlctionling~. The

third pilatoon., situatted ailotlt 600 milles, away, was visited as thils conlsultantl

returned to tile India-Burlma Thleater. Thlere wvere am~ong~ tite officers a nitumber

of Chinese-American dloctors and1 oild China hlandls, whlo were former muissionaries or sons of missionlaries to China. Among titese were a numb~er of cotnipetent. generai sttrgeotls. butt there was anl urgenlt need for surglical specialists.

espec iailiy orthopedic surgeonls. 'Moreover, most of thle exp~erieniced offivers were

due for rotation, as was the case inl tile other field hlospitals and ai numbtler of

tile p~ortablle surgical hlosp~itals.
INI)IA-BURM1A AND CIIINA TIIHEATERS 947

95th Station Hospital

On his return from the combat area, the author visited the only station

hosp)ital in the theater, the 95th Station Hospital, which actually functioned

as a general hospital and had been granted the privilege of conducting disposition boards. This hospital was situated on the outskirts of K'un-ming. It was

one of the most unimpressive hospitals visited in either theater, from the standp)oint of both structure and physical facilities. Most, of the station hospitals

in the India-Burma Theater were superior to the 95th Station H-ospital in

almost every respect.

Facilities.-In January 1944, the table of organization had been increased

to accommodate 250 patients. On 1 October 1944, the hospital had again b)een

reorganized and designated a 750-bed station hospital. Actually, however, the

bed capacity had not exceeded 522 until 10 days prior to this consultant's visit,

when it had reached 643. The normal bed capacity had always been lower than

the actual census. For instance, on 1 October 1944 there had been 81 patients

in excess of normal beds, and on 1 May 1945 there had been an excess of 38

patients. In or(ler to hospitalize these extra patients, it. had b)een necessary

to resort to the expedient of installing double-decker beds and cots, which had

materially reduced the normal cubic feet, of space per patient below the minimum

permitted in army hospitals.

Without exception, all of the physical facilities were inadequate as to space

and essential equipment. In most instances, they did not. meet the normal requirements of a 100-bed station hospital. These included the physical therapy

and X-ray departments; the orthopedic, and ear, nose and throat, and eye

clinics; the library; wards: and, from the standpoint of essential equipment,

the operating rooms as well. Yet, paralleling the increase in patient census,

the workload of the clinics and laboratories had steadily increased, although

the facilities, which had been inadequate from the first, had not been expanded.

Clinical laboratory.-The clinical laboratory was perhal)s greatest in

need of expansion. It functioned as a central laboratory for the China Theater,

yet the existing facilities were below the minimum requirements for a 200-bed

station hospital. Since space for equipment and personnel necessary to accomplish blood chemistry analyses was not available, it had been necessary to

send specimens for such determinations to the 234th General Hospital, at

Chibula, or the 142d General Hospital, in Calcutta, both in the India-Burma

Theater. The pressing need for additional laboratory sl)ace, which this consultant, in his report, urged be given priority in the new construct ion, was emphasized by the high incidence of amebiasis and other diarrheal diseases, typhus, plague, hepatitis, venereal diseases, and other conditions in which diagnosis and guide to therapy were almost entirely dependent on lal)oratory st udies.

X-ray Department.--Althougrh )ossessillg nearly ade(quate space, the

X-ray * )eiv nlrtimmeut. had not l)eeim )rovided adequate l)rotectivye measu'es agaimist

the radiation hazard for either the X-ray personnel or the patients waiting for

exanmination. "iii'e it. was higly l)rol)lehilatic when this departimmemit would
Ns' ACT1IVITIES I OF~ ii' Ii( AT, ('( NS4ULTLANTS

b~e relocal cit. Ileailhllla rt el'. S( )S, I SF'CT. was liirget to p rovid e as promplt ly

:Is po'sllble atuxil iarv prot ective mieastires sulch as lead screens andl brick partitios :111d. a I.IIi tilie new conist ricttion, to coitipi w .ith TB MEl) 62, 1 .July 1944,

which priescrihed tilie necessary pro~tect ive mueasures. E~videnitly, this important

1)11liet iii had mIt been received in the theater or SO S headquarters.

A ol,11tigerouis pract ice wvas observ-ed ill the X-ray departmient of this hiositl-apractice Which had1 also been noted[ in a niinulier of station hospitals

Iin the I iioia-Biiriiia Theater. Tlhere was a teilielicy anionog the less well trained

riti Iiolog.st s to, X-aytenp to a1 ititicl greater extentuthlain dlid thle

I oarid-cert ified, hi iglilv comp~etent radhiologists Iin general hospitals. As a mattcr of fact, Ini onlly two hosp1 it als in thle Souitheast Asia, Coinmand, the 20th and

1-12d Geteral H ospitals, dlid there exist thie two pi'rerequisites to unider'takinig

i'adloti erapv iii a U.S. Army, hospital: niamely. a radliothlerapist cert ified by

tilie Amliericani Boa rd of Radiology~ a 11d aIli accurately cal ibratedl X-ray m achinie

(and aIli apparatus withI wh ichi cal biiat i ii couild he unidoert aken at frequent

iut ervals).

Personnel.-Tlie mnedical officers assumried to thle surgical service appeared

adequate inl nuimber and sufficiently prhin 1 cigcIfofsria

service was oii tenmpon'ary dluty from tilie 172d G eineral H ospita:l, which antitcipated evientual ly being esta aId sl Ied Inl Kunll-n iin. It was believed, however.

that. Iin a hospital that p)ossessedl the p)rivileges and functions of a general liosi)it :t1, thle cili ef of the X-raN Deart ineut si ioulld have had foral-1 radiologric

training and extensive experienet, if not. Board certification. At this liosI)itatl,

however, thle, radliolo-ist's sole trainino' had been received in the couirse of a

rotating initernship and while conducting a general practice, duriing which time

lie luad reaid fiunis N\ itli experienced radiologists onl anl entirel 'y informal basis.

Thle quality of professional service rendered surgical patients inl this hiospital. Jiidgiiig from observations made onl coiiplete wyard rounds, from discuissions wit h iiieiihers of the siurg~ical service. andi from recviewv of niany clinical

recoi'ils,.z was onl thle whole very satisfactory. '[here. was amiple evidlence of

Soun1d, conlser-a ti ye suilrgical juldgmient, and conlletence iilsugia unidertakings.

Reconditioning.-liivsical recondit ionling for hiospitalizeid pat ientls had

not beenl instituted at this hospital. At a nearby convalescent, facility. however,

under the able direct ion of 2d1 Lt. Ben Rubin, 'MAC. who was emuineintly (utaltied for lie un1dertakiing, a1 comprehensive reconditioning, program for Clas's-2

anid Chass-3 pait icuits wableing developedl and was found to be superior in

every respect. It wa-,s believed thiat this prom.nimu couilid beC of inlest iniable. valule

in hastening thle. recovery andl return to duty of irnivy personnmel. TIhe success

of thle p)rograin was to a consiiderable extent dependent onl thle establi~hishent. of

anl effective, phyisical reconditioning p)Iogi'aiit for pat ienits in the hospital. AcCord i gly, an efflort was iimaile to convince thle comminandilng officer and mnemlbers

of thle sulrgicafl stair of the tremiendous importance of their cooperation in this

1und~ertakimn. Inl both tme. China Theater an tle Inidia-Burmna T1heateri. this

consultant, had occasionally met, with resistance iii attempt inIg to "sell" reconl-

(litionling. and( it was pari't iclarly difficult if the comiinandiing officer ilid not
INDIA-BURMA AND CHINA TIIEATERS 949

favor the program. However, units that had finally become aware of the

therapeutic value of remedial and conditioning exercises in speeding recovery

were enthusiastic converts. Pre-emptory orders from the theater headquarters

that such a, program be established were not sufficient; it was essential that

wholehearted cooperation be obtaiined from the entire professiolal staff, the

nurses, and the corpsmen of a hospital and that they become thoroughly conversant with TB MEl) 137, published in January 1945, and the coordination of

physical and surgical theral)y ot orthopedic cases, as described in TB MED 10,

published in February 1944.

Failure of Headquarters, SOS, USFCT, to proceed more energetically

with new construction that would expand the theater's sole fixed installation

capable of undertaking major elective surgery on U.S. Army personnel made

the likelihood of a physical plant's being constructed for the 172d General iHospital, committed to the China Theater for June 1945, extremely doubtful.

Scarce materials allocated for use in such construction had, apparently, been

diverted for other purposes.

Other Hospitals

The 21st and 22d Field Hospitals were also visited. The former, situated

at Pao-shan, southern China, was in the foothills of the Himalayan Mountains

and was visited on this consultants' return flight to India. The 22d Field

Hospital at Chan-i, 100 miles east of K'un-ming, was reached by jeep in the company of Lt. Col. Robert L. Cavenaugh, MC, able executive officer to the theater

surgeon and assistant theater surgeon.

In both units there was observed a deficiency in qualified personnel competent to perform major surgical operations. Owing, however, to the excellent

character of the officers conducting the surgical services, there had been, in most

insthaces, proper transfer to the 95th Station Hospital of patients requiring

the more formidable surgical procedures.

Departure

On the morning of 3 June 1945, this consultant departed from K'un-ming,

following a festive evening during which for 5 hours lie was honored with a

fabulous Chinese dinner of innumerable courses, interspersed with many toasts.

The dinner was given by Colonel Armstrong and Gen. Robert K. S. Lim,

Chinese Surgeon General, and section chiefs of their respective headquartelr.

Return to Headquarters, India-Burma Theater

On completion of his tour of temporary duty in China, the author was discouraged and not at all satisfied that he had materially assisted the Medical

Section, China Theater, despite the more than generous expressions of appreciation by the Commanding General and the Surgeon, China Theater, to him

personally, and later, in a communication to the Commander and the Surgeon,

India-Burma Theater. The U.S. Medical D)epartment in China was woefully
950 Acm'I IrIFs or suma W n A. m 'Nst L't'ANTs

hickillog In altmost everyti ng. Ili1ere Nva5 hot( a S ingle hiospit al tif niioleti11 (-()Iistructi Oll. St antdard( e(Ilthtlutetit wats scarce, and1 lthere wveie (m)) few qual ified

lpto~tis~ioltil Iperso)titwl. The whole selti Il)was mtovet ili ke&jtqlitg, with I amtentatl

ltIIIa~xV(It' cemitittolls ii at existed IIIt Ille h'onit el it vas o)f th Fw ari Wes-t or Ini lit(

Sollil (It dtttig' th Ct' ivil War. Mild antd lilth pr ~tevaile'd everywhere, inlud-ingll~

(ilte wvas lhesi t ant aiulmlit ct'i Iic i'/iiq! otlicers who ~V~~'cotisiietit wer) ioitsl dointg

their best unider' ittost tilltfaxo)Palble vir-cuiitst atives. Alt l4itmligh lieu'. best was

fr'equnettly ntot grooti ettotwit. It wvas tttIm ltheir fautlt thIat . il tI taiiv Itistances t hey.1le

bad bee assigned ito lnt't akinlg's for wit i1ch they did nm o sesaenat

1)t~)l tietic ,v. ( )ti the Olewr htand. tflie SO S anud theat er sit t'reoits Iitl th Cw( It i

Th'leater' had ino alteirnat ive 0)tohle etttploytttetit o)f peirsonntel Sent to tilit-il by thle

Intlia-Butt'tia Theat ert. Antd, actuial lY, the latte1 et'Iheatetr haid little Suptlertot

talent to 4Spare. outtside th 1 titl ivet'sit v.-allil iat ed il tiits thIat the ltvwere 4Ii eisitii ed

to dlisniltl~et'e. It. wasottlv ttatua itt'I Irefot'e thlat, ill filililliutiz t'equsllmtt is ft'oiti

Ch1 inta. like Sutrgeotn. ITSF1 HI. did not t'elitu(iitisli his ltio()S. c'ap~able stirgeotils.

Ililt finahtl aiaI sis. lienl, it would apipeal t Ihat 1wst ote ag()1 ollivers Ill Chinia~

qutalifiedto pefl-1 mai~jor 4)Ipei'zit ll wa (~ to lie War' D epartmtnent s failttte

ill the firtst intstance to Iss*1gri I stIll~icietit uiutiti leq' (if o)lliiet's in1 tiS s (-It atgory% to

severnt weeks atftetr this cotisit Itant *s t,0t1it1i to Indit a, lie received a votlittIthii tcatil fb-mt 1r4)ti (01)l A rtutsti tl'otr. thIe sutbstan tce of1 wvIticli fol lows:

Hie wvas still wvoeftitl 1 slto)i't o) II t(iwdicos atit1 wasIStit to 1wu'stiade t1e

findia- l1ittniii Th'leater's u'eplaceiteitt center to facilitate the Chinta Tlwater's

requiitst 1)ts. I n ort' ttately, lt(e Chita Theater at t1e l ittw had 7 mtedlival (Aflicers wh'lo hadl beenl cvet' t here for 30 litotit hls. .1l)Iwo~ittiately :20 who had '"politi

11o'e bove 1(0), ititu 1 aboutt 8 who Nvete patlientst itl hospiita Is at the ti tue of

w rit luI g. Anliong liii' tuwedical ofljcei's ill thle China '1'lteater. there wvere three

or lotirit-All)were ilvet' S') year-is of age whom Cobm ~ p A l 'tst i'otig wsatS ttenII)ting~

Two weeks lat er, thle allt hor wl'4ot e 14) Colonel Arnilst rongo as follows:

A great efforit tins beetii n mde' b y P att~erso ni Ch'i ef (if P ersonniiel, TheatIer Sit rav ill's Offic14e.

and m y selfto secure fo'r yo'u tuaif ie th'I igeol ct ea si ted C - or I 1).in order 14 o meet youir

reqtuest for eleven'i so rated. a uid at li n' saint, tu ime assign 11 suffliviett miiiiitir (if otlicers (if

sanniu quanlifction t ou1) Ihle 701h I and 71st Field Hoispititas I iprior to t ranstfer too c'uana). Ini

orider it) acrompiltisli thits %%.( have iIll1'el 1 hospitails of this theater o)f all tbut key meneu

and a fewi utuulifled Iimitiiileto-d ottleers.

A vm414ellt rat i'i ell'ot Nvats coltit i 11ed1I) by ii cm 4)tlll t :ltaitts atnd Co414lonel I alItet'-

Sol), 114)1 01'' l vII) treplace'I)4ttltI oflivet's Nv'Ii wer'e rotated ft'otti th InC(Iitta

Thellater, blit 4 toepl ave ltheni Witlli ollice's of t1lie hi igltest pta I'i tha tjtims avail ahl d.

Tlii wat' eitldeu (m)) Sootn to jiudge t he ef'evt iveluess ()f thles-v inlt ei'essions. blitt it

Was bielievedu that had Ilie( watt* emlint iltlth'l Iese ell'mwts w011141 h~aAve iesitltel ill
INDIA-BURMA AND CHIINA THEATERS 951

SUMMARY AND CONCLUSIONS

A coml)rehensiv-e review has been made by this consultant of the activities

of tile surgical consultanit in tle Souithieast. Asia Conunand, whic.h comprised

thie India-Ilurma, and tChina Theaters. Also, the stated mission and activities

of I .S. Forces in these theaters has been narrated in order that. the l)roblems

alnd activities of surgrical officers can be more readily comprehended.

Certain observations and experiences of the consultants would seem to indicate lessons which could be profitably studied 1)y medical officers who might lie

involved in any future war. Some of the practices of which the consultants

were critical were common to All theaters and the Zone of Interior and stemmed

from policies formulated in tile War Department; others represented policies

estal)lished in an individual command. Some of the policies which were considered objectionable have been appropriately corrected, others which pose

serious p)rob)lemls have not. A brief outline of the more significant lessons

learned is here recorded:

1. Improvement in the effectiveness of the consultant system was observed

when the position of chief of professional services was discontinued.

2. Similar benefits resulted when the reports of consultants were routed

through technical rather than command channels of comnnunications to theater

headquarters.

3. Benefits accrued from close relationship between the consultants and the

chief of personnel in the medical section at theater headquarters.

4. Supply liaison activities of the consultants b)etween the hospital medical

supply agencies were considered decidedly worthwhile by all concerned.

5. Direct communication between the consultants in the theater and the

directors of their respective divisions in the Office of The Surgeon General,

prohibited in some other commands, prov~ed equally helpful to The Surgeon

General and in promoting the success of the consultants' activities.

6. ])isadvantages were noted in the theater pract ice of referring all the way

to the War Department, for approval, requests for changes in basic equipment

allowances of units functioning in capacities other than originally intendedsuch as evacuation hospitals employed as station or general hospitals.

7. Failure to send to hospital commanders copies of the consultants! reports

with the theater surgeon's indorsement tended to lessen the effectiveness of the

consultants' visits.

8. The advantage of making all military units, including the air force,

subordinate on medical policies to the theater surgeon was conclusively demonstrated to the consultants of the India-Burma Theater.

9. The unfortunate policy was formulated in the Office of The Surgeon

General, prior to the entrance of the United States into the war, that prohibited

the transfer of officers out of affiliated hospital units. This policy resulted in

the excessive concentration of talented specialized personnel in a few hospitals,

while most of the hospitals of the theater woefully lacked competent general

surgeons and specialists capable of independent surgery without supervision.
ACTIVITIES OF SUTRGICAL, CONSULTANTS

10. Perhal)sp the most unfortunate practic.e noted by hie consultants in all

tile theaters in which they served (to a lesser extent in the Zone of Interior) was

a tendency to assign to a(lIIIhliist-rati%'e positions, particularly that of hosp)ital

comnlanilder, olticers of field grale rank for whom there was no available clinical

assignment commensurate with their rank and military occupational specialty

(M[OS 3100, general duty). These officers were too often lacking in both efliciency and proficiency, in aptitude to command. and in administrative ability.

The solution to this )problem, it would seem, is the. formulation of a long-range

plan (huring peacet ime ill which carefully screened reserve officers with aptit ride

for command are aforolded the ol)l)portunity to attend special courses sup)l)lemented by yearly periods of trainingl directly 1n( der highly coml)etent commanders of various types of Army medical installations.
APPENDIX A

OFFICE OF THE CHIEF SURGEON

EUROPEAN THEATER OF OPERATIONS

:3 Au•t•'s 1943

SUBJECT: Surgical Mission to Russia.

TO: Chief Surgeon, European Theater of Operations.

1. Through the British Ambassador to the U.S.S.R., a medical mission was established.

The U.S. Army Medical Corps, E.T.O., was asked to participate. A Canadian member was

added later. The British Medical Research Council and the British Council assisted in

the preparations and organized the transportation.

2. Brig. General Paul R. Hawley appointed Colonel Elliott C. Cutler and Lt. Colonel

Loyal Davis as the U.S. members of the mission.

3. Informal instructions to the U.S. members were given by the U.S. Ambassador to the

Court of St. James's, Maj. Gen. John C. H. Lee. and Brig. General Hawley. Travel orders

were issued by the A.G.O., E.T.O.

4. The purpose of the mission was (1) to learn as much about Soviet military medicine

as possible in order that U.S. troops might benefit from the experience, and (2) to cultivate

friendly relations with our Soviet allies.

5. The mission * * * arrived at Moscow at 5:45 p.m. July 2, 1943 * * * It returned

by airplane leaving 'Moscow July 2:3 and reached the United Kingdom. July :30 * * *

6. The mission established highly friendly relations with the U.S.S.R. medical authorities, both military and civil. It was warmly welcomed at the Moscow airport by Soviet

officials, including two Vice-Commissars of Public Health; was welcomed at a special

sitting, by the People's Commissar of Public Health, and shown every courtesy while in

Moscow. It was permitted to visit all of the important hospitals in that area. The mission

met and had the most friendly relations with Lt. General Smirnov, Chief of thc Red

Army medical organizalon; [Vice Admiral] Dganaleidge, Chief of the Surgical Division

of the Red Navy; [Rear Admiral] Andriev, head of the Red Navy medical service, and

Lt. General Burdenko. Chief of the Surgical Division of the Red Army, as well as many

other leading medical authorities.

7. General Medical Respon8ibility.

The care of the injured and sick is in two departments in Russia:

A: The responsibility for the care of Injured soldiers in the forward areas is that

of the Commissariat of I)efence and the military medical organization of which Lt. General

Smirnov is the Chief Officer, and Lt. General Burdenko the Chief [of surgery]. This

included the care of the soldier in combat units, in Army hospitals and through evacuation

to the base area.

B: The responsibility for the care of the wounded soldier in the Base Areas, as well as

the care of all civilians, is that of the People's Commissariat of Public Health. Some, but

not all, base hospitals have army officers as their administrators for purposes of discipline.

Each province has an army as well as a civilian representative of the People's Commissar

of Public Health in touch with all hospitals within that province. Many of the chief

surgeons of the civilian or base hospitals, are officers in the Red Army Medical Service

and are in uniform. Officers and men are treated alike in all hospitals and in some hospitals

are bedded in common wards, whereas in others there are separate officers' wards.

8. Organization for Care of Wounded in Red Army.

A: Wounded are picked up on field by sanitary corps. (Some of these individuals

are women who dress wounds and control hemorrhage).

953
9,)54: ACTIVITIES OF Sl'lv(;ICA.l, CONSULTANTS

I: Battalio!n Aid lPost--A nurse is here who a(ljusts ha udages and gives first aid.

adminiisters nmorpdinie. sullfaiilaniide o'rally and applies spltits.

C: Regitental Aid Post-First iiedici..l oftvei.r is hkere. T'trealnent for shlock is b~egunI

Ib If•l antd p1 :lllalsm : I N'ltt"er clt roli of Iieliiomrrllage : nial nl.1 s ;V djUsle VII: l 1 W('a ilIiZaltioln

Of fractit les if very phainful : splints applied: tetanusI toxoid a111d Mtlorphine given. anid gas

ganlg'renlle selrullmI adliiillistered if la'rge and badly lacera ted wvo uinds are present. Sulfanilaiiiidh ipIlM'ced ill larger wounlds.

ID: D)ivisional ,Aid Post ((;-.S kms. froin front) C'onsists of a sin.ail hospital for

emllergency surgery only (sollie abdomijnal wolunds. a few chest wounds an(l enmergency

aimputations Carries '. out the sorting of patients : redressing and adjusting of splints

further treat'niet of sho ick iblood and pl'isla). -May add 20)11-bled mioldle hospital at this

loinlt oi" senId ill addiliolanal surgical tea:ins. is muilitary situatlion (leumalnlds anld ju.stities.

E : Sorting-Evac.uation hospital 130-50 knis. from froont * * * 1.(000-4.(Wk) beds)

Careful sorting of patients into medical, lightly woundedl and serious litter cases. D)istributed to slecial wards in this hospital or to specialized atlaached lnudiile field hospitals of

'M141 beds each for alhdotiiiiotliiravic wiunmds. exlreinity injuries. nlelir' dogival wvo(llds"

facio-maxillary wounds : mnedical diseases or wvalkillg wounded. These latter patients may

be kept up the line or sent diowni the line as far as Moscow 1200 kmis.) but they remain

in the Army hospitals and never conie under the control of the Public Health Service.

(This permit. nsore rapid restoration to active duty.)

F: Evacuat ion from the above hospitals by train, motor cars or by air. The latter

method is reserved for the critically ill patients. special eases #eye), guerrillas (this is a

very large undertaking and a major part of the Russiani Army), and in special circumsta o des. (hependitng Ilpolt air control and the availability of planes.

G : Air Force and Ground Force personnel cared for in the same hospitals by the

sanle staffs.

11 : Organization within Army hospitals is well standardized, set up for a maximum

flow of sick and wunmded and reveals a high ability for organization. Exranpl(: 200 bed

Mobile Ficld Ilospitail:

(a) Admitting Room : This is both for records and sorting. Personnel come in

with simple field niedical tag pinned iin, simple record form filled out and put in envelope:

special portion torn off and sent to me(lial headquarters: colored tag placed on patient

(red=surgery. ldue=-urgent dressing, white=evaudate).

(bW Patient goes to barber if well enough for hair (lipping and shaving.

ic) To wvashroom where clothes are renioved and ttkein away for cleansing and

mending. Patienits thoroughlyl washed. Separate room for women. (This is one of the

major contributions of the Red Army.)

(d) Dressing room-several tables and sterile supplies ready. Patient rebandaged

and given fresh clean clothes.

(e) X-ray room.

(f) Operating room for those selected. Up the line only serious cases done.

Abdomen, chests and femurs held in hospital for 7-10 days preferably.

(g) A supply of blood (sent front base area refrigerated ) is kept in a deep cellar

with some ice which is cut in the winter and stored. Blood not used after 3 weeks.

(h) Stretchers are used for cots and two tiers are set upon wooden frames.

Ambulatory patients use upper tier. In dressing room and sorting room have an excellent

wooden horse which can be broken down by turning a wingnut and can be packed into a

very small space.

(i) For each group of frontline hospitals (6-S) there is a laundry controlled by

the medical department.

(j) Equipment of forward hospitals: Russian field tent is excellent; 15 feet

wide and commonly 30 feet long with excellent windows in walls and often inner cloth

lining. Autoclaves, sterilizers, X-ray apparatus, instruments of which a good many are

American or British seemed to be sufficient.
APPENDIX A 955

Distribution of Beds for Surgery Front Rear

General surgery ------------------------------- 1.5 83.0

Neurosurgery ---------------------------------- 2.9 4.3

Facio-maxillary-plastic --------------------------- 1.6 3. 1

Ophthalmology --------------------------------- 1.3 2.0

Otolaryngology --------------------------------- 0.9 1.3

Neuropsychiatry -------------------------------- 0.2 0. 1

Amputations ----------------------------------- 0.9 5.3

Gynecology ------------------------------------ 0.2

Distribution of Wounds

Levitt (In charge of hospital for chest, limbs and joints in base

area) : Percent

Heads ------------------------------------------ 10

Chests ----------------------------------------- 6. 7

Abdomen --------------------------------------- 2. 4

Limbs --------------------------------------- 68-70

Vorshofsky (Chief Surgeon, Western Front) : Percent

Heads ---------------------------------------------- 1

Abdomens - -------------------------------- 2

Chest ------------------------------------------- 4

Arms ------------------------------------------- 40

Legs ------------------------------------------- 35

9. Principles of Surgical Practice in care of wounded in Red Army.

A: Excision of wound (debridement) is practiced as far forward as possible, usually

In sorting-evacuation hospitals, but, in instances where great numbers of wounded exist,

this may be done in base hospitals. This Is best practiced early, but Russian surgeons

practice excision up to 10-15 days, including compound fractures; relying upon sulfonamides

and immobilization to prevent generalized sepsis.

B: Immobilization of large soft part Injuries as well as fractures by wooden splints

(Deitrich) or Thomas type, for evacuation to place of first definitive surgical treatment,

after which plaster of paris is applied. Plaster of paris is put on as early as possible and

is used directly over the wound, "skin tight" and without padding. Not usually applied

before 3 days after injury.

C: Tetanus-Active Immunization with tetanus toxoid is practiced. The "booster"

dose is given at the Regimental Aid Post.

D: Gas gangrene-A potent antiserum is used in all serious wounds, usually intravenously. A toxoid is in the experimental stage. Several surgeons told us that the antiserum was not effective.

E: Sulfonamides-sulfanilamide Is used both in forward and in base hospitals by

introduction into the wounds, by mouth and intravenously. It is not carried on the person

of the individual soldier. They also have a small supply of sulfapyridine. Observation of

actual patients indicates that they use it more profusely In wounds than we do. A special

form of sulfanilamide in which the preparation is broken down into very small particles by

subjection to ultrasonic wave lengths Is used as a creani applied to gauze and placed into

the wound. It is thought to be very efficacious, but it is still in the experimental phase

and is not In mass production.

F: Secc,ndary suture is practiced wherever possible even after 7-12 days. Skin

grafts are used when It seems advisable.

G: Inhalants uncommonly used. usually ether. Novocain commonly used and we

saw many iatients incompletely anesthetized writhing In pain. Spinal anesthesia used

705-095.---64- 63
9.56lTIVITIIES t)F SIUI(;ICAL, CONSULTANTS

chiefly ill base hI41sjlilals. Ilexonal i like lenltotal i used bNot IIIn gas ox13ygel namachines seenI

and not told .anywhere Elf its lose.

10. I'ifrlipilE. ovf Pructic•' ill Speiul Fic'hid of Sil uryc'11.

A : 'r'holrawit.'urgery--Thoracic Wolutnds treateld co.nservatively. Iin forward areas

sticking clhest woiluds are closed. Ileniotho rax treated by tappling; enpyenn! by drainage

for three weeks. then 2 or 3 rib fragments are renmoved and the wounds packeid. Only large

foreign boldies are reniove•. l'rof. Levitt gave figiure of 6.7 percent as prolNlrtion of clhest

wounds. IAt. General Iurdtenko said that the oIriginal mortality of chest wounds 4 plercent i llhad now been relucedl to 18 Ipercent. lit 1!42. only 11) percent Eof chest wounds were

of ipenetratling type, and of the 12 percent sUbllnitlt(l to operation the mnortality was 20.5

Iereenlt. A simple lkisitivye pressure 'inatchine was develoloed by lBurdenko I bellows led

air via a Wolff bottle 47 c.Ins. of Wiater I to ordinary gas mnask).

It: Burns-t se somne 4oagulahlnts (tanniuc acid and silver nitrate) but prefer olln

illethEd. ill which they (dust on ai ll•owler voolttaininig ail anestheliet and lin antisepftic ilot

sulfonainile I. Said blurns were very infr14lilent and most ly in air force personnel. Pillacential extrct covering stinuihltes mIlore' rapid (overing over with new skiun. i??)

C: Frac'ttres-We visited hospitals both in the forward and Base areas where fractures were .onicentrated. The care given these cases and their results mandle an ex(ellent

imnpression lls. asind since plaster has been the ilroceolure Ef choice in Russia ever since

l'irogoff, in the Crimean War. wrote about its wonderful prolperties (book pulblihed in 1.S.)

we folund themi masters of this tecihniqlue. Professor Yuldin had cared for over 2,0)00 fractires in the Finnish %var before this war began. Their lprinciples of fracture care arte:

(1 ) splint in the field witlli woldln or wire splints or Thonmas' splints. They prefer the

Iietrich wovtlen splint which has all axilla: and groin e.rutch': 12) at si rt ing-evaculat i li

hospital, or imobile hospital. or base hospital where first definitive treatlent is given, all

dead and idevitalized tissue is Widely excised, sulfanilanmide is placed in tlie wound. They

often sillire the wounid op!en 4skin edges to deep fas'ia) and prefer no gauze packs: (3)

",Skint ight'" plaster is applied without dressing o1il the wound. They (t1 not transport the

eases for a few days. They ex('i.4, Wotulnlds 5-10 days old in the samie way and are not afraid

of spreading sepsis. llbslitals lip the line had goodl fracture tables and one used a piece of

rubber over the dorsuln of the foost which wvas later removed after the east hold set. Casts

are not split ind( never uset windlows. For best work up the line. a r-ood fracture surgeonll

with s assistants must have three tables going: one for careful lpreparation. one for the

actual operation and one for the application of the cast.

lra(turc andl J•int Statistics

Time table rc'Iition of iroundinf to .urigvrp (Yudin) : Pl cclot

1 tol3 days . '---------.-

:1tlo 5 days ....... ... .. . ......... .- 24.2

6; to Ill days -------.---------------------------------- 36.9 S.3 Ierent

11 to 15 days- --------- --------------- -- 21.9

Beyond 1.5 days ------.--------.----------------- 15.4J

Reasons for chalpo/in original plastcr east:

Ilemnorrhag- ------------- -- ---- 2.4

Acute cellulitis ----- ------------------------------- :4.1

SeIsis .---------------------------- 2. 5

Continuied fever ---------------------------------- 7.4

Rising tenillerntre -------- ----------------------- 13.91

Iislohation of fragments ---- --------------------- 4. 7

Soiling of plaster --------.----------------- 14.0

Changed at prolper tite ---------------------------- 17. 4)

Conmplete recovery in first cast --------.---- -------- 3.0
APPENDIX A 957

Percent

Mortality in closed cast ------------------------------- 5. 4

Hemorrhage ------------------------------------ 1.6

General intoxication ------------------------------ 0.3

Sepsis - 9

Tetanus ---------------------------------------- 0.3

Accidental -------------------------------------- 0.3

Treatment o0 Joint Injuries Percent

Mortality

Conservative treatment (drainage) --------------------- 20

Removal of head ----------------------------------- 20

Resection of head and fragments. ---------------------- 36.2

Removal of fragments only --------------------------- 27

311 Joint cases (Yudin) (Practice excision of knee joint frequently) :

Hip joint (73k -------------------------------- 5

Knee joint (121) --------------------------------- 6

Shoulder (41) ------------------------------------ 2

Elbow (68) ------------------------------------- 1

Fingers (7) ------------------------------------- 0

Followup study of 500 cases of wounds of joints showed 58 percent incision and drainage and 42 percent resection. Of these 22 percent of the first group were unhealed at 6

months and 28 percent of the resections were unhealed at that time. Arthroplasties were

done in 42 percent of the cases incised and drained and In S percent of the resections.

D: Supply of Blood and Transfusion Service: The Red Army medical service uses

great amounts of citrated whole fresh blood and little plasma. The blood is collected in

the larger cities, chiefly Moscow (about 2,000 pints a day and in one hospital bleed 600

people daily). Use excellent technique, physical examination of donors including Wassermann reaction: grouping is done twice; bleed into 250 cc. ampoules with open ends which

have rubber tube attachments which are bent over and sealed with paraffin. Blood is

refrigerated at 6 degrees C and flown to fronts where it is distributed in refrigerated cars

and in frontline hospitals is kept In deep cellars iced at 6-10 degrees C. It is not used

after three weeks.

Cadaver blood is still being used at the Sklifossowsky Institute by Professor Yudin.

From 1935 to 1943, 2964 cadavers have been bled yielding 5,092 liters of blood. Of this

quantity 1,332 liters were discarded (240 for positive Wassermann reaction; 54 for acute

bacterial endocarditis; 80 generalized tuberculosis). Bled from jugular vein in Trendelenburg position under aseptic precautions. If yield is small they wash out by injecting

Ringer's solution in the arterial side. Sulfanilamide .06 percent is added for preservation.

Other medical men do not approve of this method.

At the Central Institute for Blood and Transfusions in Moscow (Director, Professor

A. A. Bagdasarov) daily bleeding of donors averages 600 in number. 250 ccs. is taken by

gravity method into 2 ampoules (500 ccs. per donor) ; bleed into citrate solution (using 5

percent sodium citrates). Donors are given a special food ration and some money, but 85

percent of this is given back for airplane construction and other military purposes. Name

of donor goes on each ampoule and often is the source of many romances. The donors are

largely women. The Central Institute has 79 allied institutions and all plasma and serum

is sent to the Central Institute for bacteriological testing before it goes to the army.

Transportation to the army and civilian hospitals is by air and motor. The blood is )od

for 30 days under refrigeration if it is not moved; if transported. 35 to 17 days. Small

insulated boxes with Ice container hold 4 pints of blood.
958 Ac'TIVITIES O1F SURGICAL CONSULTANTS

Types of flidas used : 0a) Whole blood (5 percent citrate and glucoxe to isotonicity);

(b) Salt solution: ici Special preservative fluid for use with whole. blood which renders

it useful twice ats long as simple citrated blood but it niust be added in proportion of 50)

percent special fluid IC.I.li.T.) and 50 percent blood. (This C.I.B.T. fluid contahins sodliumi

chloride 7.5- gramns. potassium chloride 0.4 glins., magnesium chloride 0.1 gins., sodium

potassium pihosphate 0.20S gins., sodium acid phosphate 0.111) gins., and glucose 10.0 gins.

with distilled water to mnake IMX( ces. ) ;(d) Alcohol-sugar solution ( Silsovsky's Solution)

sodium chloride 7.0 gins.. potassiumi chloride 0.2 gnils.. magnesium sulphiate .04 gins..

VobeI's solution 31.3 ccs.. glucose 54 gins. dlistilledl water upl to 1.00M ccs. (To this is addedl

80 ecs. of 96 percent alcohol) ; (e) D~ried plasina-aikl sugar to isotonieity before drying.

(Send forward. with sterile distilled water, needle and connections. Plasma is kept labelled

by groups-if over 750 ccs.. it inust be used in a compatible group) ; (f) 1"ederov's solution80 percent saline andl 20 percent serum (not usedl much) ; (g) Blood serum-allow this to

be imade in other institutions but not p~lasma : (h1) Colloid solution from caseini-treat

caseiin to detoxify of aintigeinic ali(l anaplIhylactic properties, use as 2 or 4 percent solution;

(i ) Anesthetic and antishock solution-eplihedrine. salt solution andl codleins (amioumit not

given).

Ini the army, they use plasma at regimental aid posts an(l transfusions of wvhole citrated

blood( at front hospitals. Believe blood iii best treatment for traumatic shock and believe

Academician Lena Stern's suboccipital injection of potassium p~hosphlate solution piurely

experimental.

E : Amiputa tions--pract iced as little ais possible and rarely in the ulpper extremities.

When (lone short flap technique and early use of bucket and stick to keep nmuscles ill training.

Of amputations donie ill forward hospitals. 50 p~ercent are reamlplted in special centers in

base area where pirosthetic appliances are specialized in. In such base centers they practice

sonme kineplastic amp~utations such as forearm wvith ulna and radius separated for useful

stunip. They continuously improve prosthe~ses by the utilization of new ideas of the patients

wvho work out inidividuial problemmls accordling to thle type of future work andl the length of

the Stump. Points of election for amnputatiomn are roughly our owvn. Use button of preservedl bone iii mnedullary cavity endl of stulnp.

F: Plastic surgery-Orders are issued ill the front areas not to remove bone and

skini in jaw andl face wvounds amld not to suture but to leave for experts iii base area centers.

Ini facio-miaxillary and pllastic centers, excellent wvork is being done, using tubular waltzinig

grafts wvell. By the use of early secondary sutures they reduce the plastic wvork. One

specialist. Professor Frumakin, had made 12 new p~enises out of tubular grafts containing

some cartilage from thoracic cage which he waltzed down.

G.: Frost bite-The Russian soldier wears woolen wrappings about his feet andl thic'k

felt ilocca1sin b~oots ill the winter time. It is in tile season of thawing that the large number

(of frostbite cases occur. Lt. Gen. .S. S. Guirgolave. who is accepted as the authority onl

frost bite in thme Red Army, emnpha sizes the following points:

D amange produced by cold niny be divided into the local and general effects. Congelationl (formation of ice in the tissues) never follows the local effects even wvith the dlescent

oif thle tissue temlperature to zero (degrees. Tile pathological processes, and in particular

necrosis. are secondary and are a conlsefjimenc(e of changes in the viability and metabolismn

of Ihle tissues and are not an iimmedliate primary effect of refrigeration. The local effects

are the result of meteorological and other factors wvInch lower thme local and general resistanice of thle organism. so that the lesions p~rodluced are equiv~ilent to those caused] by long

exposure to inltense cold. Ini the development of time local effects, there is .l"rervamctive'

period during wvhich. by proper treatment, many of the serious lesionis (-i be prevemnted.

At a body temperature of plus 2W) to plus 28 degrees C, the thermoregulatory mechanism

of a hoineotherinic animal ceases to function andl it becoiies isotherimmic. Ali animial, under

such coinditionms. canlnot re-establish a normal temperature by nioria il means and mlust be

actively heated. By a special techniique (elect ro-thermiomet rie) in wvhich the central

nervous system plays it specific a111( preponderant role, the damlnaginig effects oif cold ca;n
APPENDIX A 959

Ie reversed. Carbohydrate metabolism. tihe adrenal glands an(l the sympathetic nervous

system play important roles in this treatlment. Intensive and active heating of the frozen

larts and of the body must be carried out in line with these pathogenic conceptions in order

to treat rationally and prevent the lesions produced by cold. Rapid heating for 20 or 30

minutes causes no damage to the affected parts or to the body. An animal rapidly heated

loses less tissue than one slowly heated. Rapid heating has a beneficial effect upon the

functions of the cardiovascular and respiratory systems.

Longitudinal incisions should be made in necrotic tissue within 5-6 days and should

extend as far as there is no pain or bleeding. In the presence of subcutaneous edematous

fluid such an operation (necrotomy) causes a dry gangrene of the part to develop rapidly.

If bones are involved amputation of the necrotic portion should be done 6-10 days after

injury. These procedures reduce by two to three times the length of time necessary to

treat tissue damaged by cold.

II: Neurological Surgery-There are 16 neurological surgeons at the front who have

at their disposal 3.200 beds and there are three large hospitals in the rear with clinics which

provide 3,70) beds. In other words there are 6.900 beds in the Soviet Union devoted to

the care of neurosurgical injuries and diseases. At the front. 2.9% of all surgical beds

are for neurosurgical patients, and in the rear hospitals the percentage is 4.3.

Neurosurgical surgeons in the U.S.S.R. have all been trained under the supervision of

Lt. Gen. (Academician) Burdenko who dictates and directs all policies and the expression

thereof.

The sorting and evacuation of neurosurgical injuries to special hospitals is practiced

as far forward as possible in the combat zone and the one neurosurgical group inspected

by the mission was on the Vyazma sector in Sorting-Evacuation Hospital No. 290 located

about 70 kilometers from the frontline. The maximum distance for evacuation to such a

hospital should not exceed 48-72 hours from the receipt of injury. The most seriously

wounded are not moved and not operated upon, and it is concluded that they are expected

to be mortally wounded cases. Those injured in whom an operation is possible but who are

in shock are kept until shock is treated and then evacuated. Hemorrhages and a rise in

intracranial pressure are indications for operation on the spot. Neurosurgical definitive

care must be located, according to their dictates, at a maximum distance of 2-3 days from

the frontline with trained neurosurgeons, neurologist, neuropathologist, ophthalmologist

and otolaryngologist in attendance. Evacuation must be rapid, smooth and preferably

by air at altitudes not exceeding 5,000 meters. It is agreed that craniocerebral wounds

stand evacuation better before than after operation. Postponed operations in well-equipped

and staffed hospitals are preferred to immediate operations under poor conditions.

Sulfonamides locally placed in craniocerebral wounds is advocated, but General

Burdenko complained that they were not used immediately as systematically at the front

as they should be. Sulfonamides are also given to the patients orally and intravenously.

In the first 24 hours after injury 21% were treated in the "First Line"; 20'/; in the

"Second Line"; and 145o in the "Third Line." In the second 24 hours the percentages

respectively were 59, 62, and 65 and in the third 24 hours the percentages were reslpctively

19, 19, and 11. The mortality of craniocerebral wounds in the rear hospitals is 8% and for

spinal cord injuries 56%.

Indications for operation in spinal cord injuries are not clear. but they are stated as

(a) prophylaxis against infection; (b) symptomatic, and (c) morphological. The clinical

conditions for which operation is advised include progressive paralysis, traumatic edema,

subarachnoid space block, pain, and meningitis.

The surgical technique employed in the treatment of craniocerebral wounds consists

of irrigation of the wound tract with a bull) syringe and suction removal of the blood and

injured brain tissue. Treatment of the dural, wound is not considered necessary and tie

lacerated dura is never sutured. Rubber ring pressure dressings are employed to treat

cerebral fumigi or herniations. Well-encapsulated brain abscesses are removed in toto by
9060 ACTIVITIES OF" Sk •IMUCAL CONSULTANTS

electroeoagulation, and drainage is seldom emlployed. Contrast media for the diagnosis

of abscesses and the location of fragmients a round thie abscess are used.

Formalin fixed nerve and spinal cord grafts are used for the repair of large continuity

defects il peripheral nerve injuries. The grafts are fixed successively in alcohol, athoholic

ether, alcoholic glycerin, mnagnesiunm chloride, and glucose. Twenty-seven patients have

been so operated ulpn, but none of these were presented for demonstration or examination

of the results obtained. The microscopic evidence of the exoeriniental studies was not

conclusive.

At the Institute of Experimental Medicine, Prof. Propper tlraschenko has 150 neurosurgical beds and is conducting problems of clinical research both in the frontline area

and at this Institute so that he has continuous control over patients selected for study.

lie is studying (1) the character of head injuries, their course, and the influence of infection upol the healing of the wounds. (2) the clinical and bacteriological application of

sulfonamides to craniocerebral injuries: (3) the diagnosis of early and late traunmatic

encephalitis and cerebral abscess and (4) the rehabilitation therapy of craniocerebral

and peripheral nerve injuries, lie has at his disposal an auxiliary microbiological laboratory staff, half of which is at the fro:,t and tIhe remainder ill the rear zone.

In the short time at his disposal lie presented his work upon gas gangrene infections

and other anaerobic infections of the brain. Under field conditions, 100 cases of craniocerebral injuries were studied bacteriologically and in 20.3% pathlogenic organisms were

present; in 24% aerobic organisms were cultured; in 12.4% sporogenic (putrid anaerobes)

organisms were present: in 26.8% coccal infections were present; in 16.5% lmiscellaneous

organisms were found. These cultures were made from 48 to 72 hours after receipt of the

injury. In 620 cases examined bacteriologically, only 2 were found to be sterile.

After 3l to 4 weeks wounds showed a flora of pathogenic anaerobes in 12% ; aerobes

in 20% ; cocci in 70% and S to 10% were infected with putrid anerobes. Of the 20.3%

in which pathogenic anaerobes were found. 1.4% died in 6-7( days of severe gas gangrene

infections. Subacute anaerobic infection of the brain is found in all large brain fungi, and

of 12 such cases, 9 died. Thirty-two cases of chronic anaerobic infection of the brain were

studied, and of these 10 died. The course was long 3-4 months, and often encapsulated

abscesses formed which often opened on to the surface or into the ventricles with the

production of a severe meningitis. In 34 cases of mild anaerobic infection of the brain.

there were no deaths.

The types of anaerobic infection of the brain found included ('lostridim pfcrfringcnm

(Cl. iclchii), C1. sordellii, C1. fallax, C1. oedcmaticitn, CI. ocdctatie'ns maligi and Streptococcus anacrobius. A serum is used against gas gangrene infection which is polyvalent and

contains C1. histolyticuni, Cl. pcrfringcns, C1. ocdcmaticna and (1l. ocdcmniticns naligni.

A prophylactic dose of 10,000 international units is given intramuscularly and therapeutic

doses of 3-40,000 units are used intravenously and intramuscularly.

I: New Clinical Methods under Study-

(a) The injection of 70 percent alcohol with 2 percent Novocain solution about

fractures in the early days following injury to increase blood supply and to stimulate

callus formation. (The mission was not convinced of the us-efulness of this procedure.)

(b) The use of 1)lacental extrict to stinulate healing in chronic wounds or the

growth of skin in severe burns.

(c) The use of a cytotoxin made by injecting niesenchymal tissue into a horse

and using his antiserum to stimulate the healiig of ulcers of the stomach, healing of bone.

loosening of scars and stiffness in joints. (The mission was not convinced of the usefulness

of this procedure.)

(d) The use of smoke from burning pine wood to stimulate healing (2?).

(e) The use of naphthalen (a heavy oil) broken down by ultrasonic method to

stimulate healing( ??).
APPENDIX A 961

(f) Treatment of shock by the suboccipital cistern injection of potassium phosphate solution to stimulate the [vasoniotor] centers in medulla. 'See article by Lena S.

Stern in Lancet Nov. 14, 1942, page 572.)

J: City Accident and Medical Service: Here we saw an excellent demonstration

(if the Russian ability at organization which surprised us. The Sklifossowsky Institute

is the center of this work for Moscow but has 6 or 7 "district" hospitals. All telephone

calls come into a central telephone room at this Institute where there are many switch

boards and an elaborate system of interconmunication and directing officials. Apparently

patients. d(octors, police or friends may call in and state facts. Ambulances go out imimnediately either from the Central Institute or from the nearest hospital to patient after

the information is relayed to that hospital. If a doctor is not necessary he does not

go on ambulance, but if there has been an accident or if the case is questionable the

ambulance contains a doctor, nurse, and(1 driver. As the message leaves the telephone

central room in writing, a time clock is started and officials in the room know when the

ambulance leaves, for the doctor, nurse, and (driver all press separate buttons [which flash

lights on in the central telephone roonm] Is they leave. A check list is also kept by

director of the time consumed by each operator per case and number of cases per day.

Also, the director in a separate room can plug into any line and listen to incoming and

outgoing calls. The system, in part, was like that of an Air Raid Warden's set up in some

American cities.

K: Gifts to U.S.S.R-At our original meeting with the People's ('ommissar for

Public Health we spoke of our gifts, letters. etc. Letters cannot be delivered directly to

the inlividual, and conversation with a Russian is safe for him only when some other

Russian is present. Two days later Professor Koreisha came to the hotel and took away

the penicillin, our letters, and other gifts. General Smirnov, and General Burdenko came

to us personally to ask that their thanks lie transmitted to General Hawley for his letter.

Both stated they would write him in length. General Smirmhov toasted a meeting to General Hawley in Berlin as suggested in the latter's letter. No more information regard-

,ug the gifts has been forthcoming.

L: Women in Russia: One of the most impressive things is the obvious equality of

men and women, and the latter do everything that men do. They are in the Army as

soldiers and officers. In the line, we were told there was no woman with a higher rank

than colonel. We saw several junior officers with artillery and infantry insignia. In

the Medical Service the Inspector General (Brigadier Surgeon Valentina Gorinovskaya)

is a woman. Most of the traffic officers all the way from Moscow to Vyazina were women

carrying rifles. Trolley cars are run by women. Women help lay car tracks in the city.

The nurses not on duty at the 290 Evacuation Sorting Hospital were doing the major share

in the construction of the new log houises for future wards.

/s/ Elliott C. Cutler

ELLIOTT C. (CUTLER

Colohel. Medical Corps,

Chief (Consultant in Surgery

/s/ Loyal D)avis

ILOYAL, DAVIS

Lieutenant Colonel, Medical Corps,

Senior ('onsultant in Neurological Surgery
APPENDIX B

OFFICE OF THE CHIEF SURGEON

EUROPEAN THEATER OF OPERATIONS

15 MAY 1944

CIRCULAR LETTER NO. 71

SUBJECT: Principles of Surgical Management in the Care of Battle Casualties.

1. Surgical Echelons.

2. Morphine.

3. Blood Transfusions.

4. "Transportable" an.. 'Non-transportable.'"

5. Surgical Procedures.

6. Sulfonamide Therapy.

7. Penicillin Therapy.

8. Secondary Closure.

9. General Principles to be followed in the Use of Plaster Casts.

10. Treatment of Anaerobic Infections.

11. Radiology in Forward Area.

12. Identification of Gases in Cylinders.

1. Surgical Echelons.

This first paragraph has been extracted, with only minor changes, from a circular

letter, Office of the Surgeon, North African Theater of Operations. The policies expressed

herein are sound, are based upon experiences in combat and will in general govern the

activities of Medical Department personnel in this Theater.

a. The welfare of the patient and the tactical necessity for rapid evacuation demand

a clear understanding of the function or mission of each unit of the Army Medical Corps.

This is best arrived at by dividing the treatment of a casualty into two stages, primary

and definitive. Separate groups of units provide each stage of treatment. In general,

the equipment of each group is designed for that purpose only.

b. Stations of the first and second echelons, Aid Stations, Collecting Stations and

Clearing Stations, are equipped and staffed for the primary phase of treatment. Arrest of

hemorrhage, splinting of the injury, resuscitation measures needed to make the patient

transportable, and administration of sulfonamides are the urgent functions of these stations. In addition, the treatment of minor injuries that allow immediate return to duty,

is carried out without evacuation. A Clearing Station or functionally similar medical

installation, is not designed to provide definitive treatment for battle casualties.

c. It must be remembered that the lightly wounded soldier or a casualty due to

accident may regain full combat status within the l'Ieater if proper surgical treatment

is carried out, but the Theater may be deprived of his service by faulty surgical judgment.

Because a surgical procedure appears simple is not sufficient reason for performing it in

a Clearing Station unless the man can be returned to immediate duty without evacuation

to the rear.

d. Hospitals of the third echelon, Evacuation Hospitals and Field Hospitals with

attached Surgical Teams, are designed to initiate definitive surgical treatment to battle

casualties. The more delay there is before reaching this echelon, and the more hands th2

patient passes through in reaching it, "he poorer will be the final results. The evacuation line is not an assenbly linc in which ench surgeon does his bit to the patient. It is a

705 095' 64 - 64 963
964 ACTIVITIES (OF SUR(GICAL CONSULTANTS

eoprcycr line, along the course of which the progress of the patient may he halted to save

life or limb, or to render him transportable.

e. Although Field and Evacuation Hospitals with attached Surgical Teams are

adequately equipped and staffed to perform rehabilitation operations, they are not designed

for this function. Even in quiet times, patients requiring rehabilitation operations will

be evacuated to a fourth echelon hospital except when the Commanding Officer decides

otherwise, based on knowledge of the tactical situation as well as the surgical aspects of

an individual case.

2. Morphine.

This note appears because, although morphine is one of humanity's greatest aids

in warfare, it is also often misused and frequently given in unnecessarily large and dangerous quantities.

a. Dosage. Morphine sulfate gr. 1/4 (15 mgm.) is usually adequate; '/, gr. (30

migm.) may be required and is safe unless repeated. Always record amount and time of

injection.

b. Administration. Subcutaneous or intramuscular injection is employed when a

gradual prolonged effect is desired. Massage at the site of injection will hasten absorption.

Intravenous injection (gr. 1/8, 8 mgin.) is employed when a rapid effect is desired.

c. Contra-indications. The (loses of morphine given as preoperative medication for

seriously wounded patients should be small (gr. l4%, 10 mgm. or less). Morphine must be

administered with caution to the walking wounded, to patients to be evacuated by air;

or in the presence of jaundice, cranio-cerebral injury, pneumothorax, hemothorax or pleural

effusions. Morphine will never be used as a sedative for manic or hysterical states.

d. Poisoning Overdosage with morphine is characterized by pinpoint pupils and

slow respirations. The outstanding serious effect Is anoxia, caused by respiratory depression.

e. Delayed Morphine Poisoning in Battle Casualties. Subcutaneous injections of

morphine are poorly absorbed in patients who are (cold, or who have a low blood pressure

and are in shock, under which circumstances pain may not be relieved. As.a result, repeated

doses given in an attempt to relieve pain may be followed by morphine poisoning when the

peripheral circulation is re-estabished and the unabsorbed deposits of morphine are absorbed rapidly. The intravenous adm,,inisi ration of morphine in patients who are cold, or

who have low blood pressure and .-re in shock, will eliminate this problem. Always check

for previous adininist r! I ion of morphine and always record the amount and time given.

f. Treatnic'nt of Morphine Poisoning. Provide a clear airway. Administer oxygen,

under intermittent pressure if necessary. A maximal dose of ephedrine, gr. 1/( (30 mgm.)

administered intravenously. using rise in blood pressure as a guide to dosage, may be

employed. Caffein sodium benzoatc, gr. 0/., (0.5 gin.) intravenously, may be useful. Empty

the stomach prior to development of coma. Stimulate diuresis by means of intravenous

glucose. Change position of patient frequently.

3. Blood Transfusion.

a. Blood used in the treatment of casualties in shock will ordinarily be administered

in the ratio of one part blood to two parts of lplasnia (one pint of blood to four units of

plasma).

b. l'roeurcmcnt of blood within unit: Units equipped with the Field Transfusion Kit

will follow the instructions contained therein for bleeding lightly wounded and noncombatant personnel and for care of the apparatus.

c. Procureinent of blood from ETO Blood Bank: Evacuation Hospitals, Field Hospitals, LST's, Holding Units and Transit Hospitals will be supplied with blood from the ETO

Blood Bank. All blood from this source Is Type 0 and will not be cross-matched. On the

bottle label is an expiration date, beyond which the blood will not be used. The following

rules will be strictly followed In the use of Bank blood!:-

(1) Blood will be refrigerated constantly between two (2) and four (4) degrees

above zero centigrade (+35 to +42 F.) and kept in the dark.
APPENDIX B 965

(2) Blood will be removed from the refrigerator and administered cold. It will

under no circumstances be pre-heated.

(3) Blood which is allowed to rise above six (6) degrees centigrade will be used

within four (4) hours and will not be re-cooled.

(4) All used equipment will be exchanged at time of delivery of blood.

d. Non-transportablc Casualtic.4.

The proper sorting of casualties into transl)ortable and non-transportable classes

is of prime importance in evacuation. The following listed types of casualties are usually

non-transportable and should be submitted to surgery early. This classification can only

serve as a guide, and each individual case deserves separate appraisal.

4. Non-transportable Casualties.

a. Wounds of the abdomen.

b. Wounds of the chest which are serious, either because of-

(1) a large sucking wound, or

(2) such massive intra-thoracic hemorrhage that the patient's condition is unsuitable for transportation.

c. Trans-thoracic or abdomino-thoracic wounds. These are often difficult to diagnose

and are frequently missed-note that in wounds of the buttock the missile may lodge in the

thorax or, similarly, with wounds of the shoulder the missile lnay lie within the abdominal

cavity. If X-rays are available, final lodgement of the missile will make diagnosis easy,

but if not, the medical officer must always examine the opposite cavity from wounding to

rule this out.

d. Casualties who remain in "shock" after therapy, and whose condition cannot be

made suitable for transport. In this group are included multiple fractures, casualties with

injury to major vessels, and avascular extremities in which gas infection is likely to occur,

and those with concealed hemorrhage.

e. Certain casualties with maxillofacial wounds, where mechanical difficulty m

breathing endangers life during transport.

5. Surgical Procedures.

a. Dressings. Ideally, the primary phase of treatment will be completed in the

first unit reached that is equipped to provide it. The dressing is to then be left undisturbed

until the patient reaches a third echelon unit for operation. There are certain safeguards

and adjustments that must take place en route, but these do not include inspection of the

wound by removal of the dressing unless definite indications for so doing are present. A

compound fracture case may be halted at the Clearing Station for more adequate immobilization or resuscitation, but the wound should not be re-dressed unless necessary to

arrest continuing hemorrhage. A wound will not be re-dressed solely for the purpose of

re-applying local sulfonamide. Oral administration Is sufficient safeguard.

The same principles apply after operation has been completed and the patient

is being evacuated to the rear. Uninformed hands do unnecessary dressings. The best

safeguard for a patient Is an adequate and legible record that accompanies him, which

makes it possible for a receiving officer to refer to the record rather than looking at the

wound. Infection arising from contamination incurred at the time dressings are changed

may make Impossible secondary suture of wounds after debridement and arrival at a third

echelon unit.

b. Debridement of wounds. This is the basis of the proper treatment of all battle

casualties. It is definitely more important than chemotherapy, and reliance on the latter

must not diminish devotion to the proper surgical treatment of wounds. Use ample incisions, practice minimal removal of skin and bone, and maximum removal of all dead or

devitalized muscle. Never close primarily wounds debrided under field conditions. Pack

wounds open lightly, never plug tightly.

Under favorable circumstances, It is desirable that severed nerves and tendons

should be approximated, preferably with metallic or non-absorbable sutures (see Manual

of Therapy, European Theater of Operations).
966 ACTIVITIES OF' SURG~ICAL CO(NSI*LTA.NTS-'

c. Amipttatiotis. Amputations11 for trauma will be a circular open (guillotine)

amputation at the lowest possible level, followedl by the application of sk-in traction. Skin

traction wvill be applied immiedliately and must be maintained (luring all stages of evacuathinl. including evaculationl to the Zone of Interior, and until the stunip is comlpletely healed.

Skinigraftilug wvill not be used aI~,,.s asustituite for skiimt racItion.

0. S11ifolan, ide Therapy.

a. A soldier wounded in act ion is instructed to take boy mouth, as soon as possible.

4 gins. (8 tablets) of sulfadiazine. front his own First Aid packet, except whenm wounded

in the abdomen.

1b. The medical officer first dressing the wound should frost it lightly, with sulfanillainide powdler. Not mnore than -- gins. tcontents of onie packet) should be placed in the

wounds of any individual, irrespective of the number and size of the wounds.

e. Continue sulfadiazine orally until definitive surgery is instituted. Thle maintenance (dosage is 1 gin. orally every 4 to 6 hours, or 2 gins. pareulterally every 8 to 12

hours. Chemotherapy should bie given cautiously in the presence of dehydration (for

dangers, see Manual of TFherapiy. European Theater of Operations).

41. Sulfonamide and penicillin therapy wvill be carriedl out concurrently.

P. Both penicillin and a sulfonamide should be pdlaved in woundls after definitive

surgical treatment (see par. 7hi).

f. Sulfonamide therapy will be continuedl after surgic-al treatmtent by oral or parenteral routes. as instructed in the 'Manual of Therapy. Europeani Theater of Operations.

g. Sulfonamide therapy for buirns shall consist only of parenteral therapy or local

application, never both.

7. Penicillin Thcrapy.

a. Penicillin therapy (parenteral) w~ill begin at Clearing Stations. andl will bie

continuedl at Field and] Evacuation Hospitals. Its local use iii wounds will begin in Field

and Evacuation Hospitals where dlefinitive surgery is carried out.

1i. The phrase "P'enicillini Tlreated" will be entered onl the EMT or Field 'Medical

Record after the( (liag-nosis in every ease so treated. Additional dlata. including dos-;age

inl units. mnethod of admuinistration (parenteral or local) andl time andl (late of administration wilt lie entered onl thle back of the [EMT]~r or onl Clinical Record form inl cases wvhere

a Field M.%edical Record has been initiated.

c. Penicillin is unstable and is best preserved at 40 centigrade. Where refrigerators

are not. available, keep in coolestd ,qot possible and away from sunlight. U~se as soon as

posqsible affer re~nortif front hernictieally scaled vial, whether in nornmal saline or sulfanilamnide potvder. Vials which are out-dated will not bed(iscarded.

d. Do not use in small superficial wvounds of gutter type, or where muissile lies close

to skinm a nd no f racture.

e'. Parcn tral Tl (rapyl.

(1) For paentercal usc penicillin is dissolved in normal saline. Add 10 cc. cold

normal saline to 100.00 unit vial of penicillin and inject intramuscularly 2 cc. per casualty.

Needles andl syringes must not be sterilized by use of antiseptic solutions andl must be cold

because both chemicals and heat inactivate penicillin.

(2) P'enetrat ing andl perforating wounds of soft parts: give 2(I.(X)1( units intramnuscularly every 4 hours fromt Clearing Station through period of definitive surgery and for

49 hours thereafter.

(3) Wounds wvith comnpound fractures: give 20,000 units intramuscularly every 4

hours from Clearing S.tation through period of (eletnitive surgery and1( for 72 hours thereafter.

f. D~oublde above doses, liaras. (- (2) and (3), wvhere woundls are in region of buttock.

perineum, tipper thighs and popliteal space.

g. Penicillin therapy may be extended beyond thle 48 and 72 hour specified post-operatlve time. paras. e (1 ) and (2). if sepsis becomes a major pruoblemi.

Ih. Local u~sc in wounods (both soft part wvounds, and1 comnpoundl fractures) tit tline of

definitive surgery ; Dust 20.0X) units of penicillin miixed wvith 3i graujis 11 teasp-oonful)
APPENDIX B 967

of sulfanilamide into the wound at tile close of the debridement. This is best accomplished by mixing the contents of a 100,000 unit vial with 15 grams (5 teaspoonfuls) of

sulfanilamide, and using 1 teaspoonful per wound. All containers must be absolutely

dry and cool before mixing. Where wounds are multiple, use up to 40,000 units of penicillin in 6 gramis of sulfanilamide, distributing proportionately according to severity of

wounds. The use of penicillin in wounds is not mandatory but is advisable in all wounds

where there is severe destruction of tissue. Should the supply of penicillin be limited,

omit local application.

1. Penicillin therapy does not contradict or interfere with sulfonamide therapy.

8. Secondary Closure.

a. Although the first principle for the military surgeon to bear ini mind is not to

close the wound he has freshly debrided, it is essential that he close this wound at the

earliest possible moment that is safe. Early closure means limitation of infection and

fibrosis, and an earlier restoration to duty. If the primary ldebridement has been thorough.

small wounds may be closed as early as the third day, though the average wound not until

the fifth day. Observation of the signs of inflammation, such as discharge, reddening.

pain and swelling, will determine whether or not a wound can be closed. It is wiser not

to dress the originally debrided wound until the day when secondary closure might be

practical, since each dressing invites contamination of the wound. If closure is considered

safe, it should be done loosely without undermining the edges or using sharp instruments,

and by using retention sutures of silk, or silkworm gut, spaced widely apart and loosely

tied. Should mild infection appear, hot, moist dressings may save breaking down of the

wound and hasten the healing process. Any signs of severe infection require immediate

removal of the sutures.

b. Closure of wounds with fractures should only be undertaken when full penicillin

therapy is being practiced and when all the signs of infection are absent.

c. Wounds closed early, before the establishment of granulation tissue or scar tissue,

are easier to close than those closed after one or two weeks. In wounds that have been

open for a long time, skin grafting is often better than closure by suture. If the original

debrideement has been practiced with the minimal of skin removal, as suggested above,

closure by sutures will be simple.

d. Removal of sutures from such secondary closures should not take place before

10 days unless stitch infection develops. After removal of the sutures it may be wise to

maintain approximation of the wound edges with adhesive plaster.

9. General Principle.s to be followed in the U, se of Plaster Casts.

a. No circular bandages, dressings, or strips of adhesive shall be used under a

plaster east, as these constrict the extremity and may cause extensive damage if swelling

of the puart occurs.

b. Adequately padded lplasters are probably safer in average hands. Padding should

be applied to all bony prominences such as malleoli and heels, knees, particularly over the

head of the fibula, wrists and elbows. In addition, sufficient padding should be used over

the soft parts to permit some swelling within the cast.

c. tll layers of plaster, sheet wadding or (dressings must be cut through down to the

skin iinnicdliatcly after the application of a east following an operation or manipulation.

$irclling of the part will occur and, unlc.os all laycrs of the plaster padding and dressings

are cut through, it itill be impossible to spread thc east to prcrent extensive damage when

swelling occurs.

d. Attention should be paid to the position of the extremity encased in plaster. The

foot should be at a right angle to the leg, the knee should be in 10°-15° of flexion, the hip

should be in neutral position or slight flexion. The wrist should be supported in neutral

position to prevent wrist drop, and the elbow ordinarily is best supported at a right angle.

In these positions the patient will transport comfortably, will not take up undue space,

an(d the tendency to develop troublesonme fixed deformities will be minimized.
968S A(CTIVriTi.s 0,P Sl't((AM 14 CO4 NSULTANTS

e. A hule duaigraiiia ilk indelible jietivil shoild lie ainscribed oli t(e (list4 lindI~icting tile

aliproxhiiiiie locatiton of fraicttare and posit ion of fragments. The niumnber 4 f the uaiit, dlate

of injury, date oif operat ion antd type oIf ope-ration should likewise lie written oin thle vast

84) thbat if fihe lpaeld Medicail 11ecord is lost, at reausonably satisfactory suilst i~t te record wilt

be readily available.

f. Either at phlatformi or at loop4 or wicket of Idaster should lbe at Iqlied to the foot oft

the cast in order to protect thle toes front pressure of bilanakets, bed clothles, et cetera. Plaster

applied to t(lie hand should be t rinmmed bac1k to the ptroximial pailniar crease to piermit full

flex ioni of thle ti igers antd miet acmlat tpa lia laingeal Ijoinits.

10. 'Ircotbntpt of .1nuavrobic Infectimns..

it. (Ju.' aqr'e

(1) 7'ypcx' of Woundiv. Wouitds dlestroiyintg tmitsce. either dlirect ly or by mnt errilitivii (Of tile 1400,1d S1hiplilY. are paurticuidi ily suscepitible to anaaeroblic infections. Such iunfectionis are- more frequent ait tilie following sites oif wounds :- () hiatt ik ; ii ta) pper thigh

cinipuiiiaivlll fracture (if femtur) :( III) anterior t ilial group; .iv shoild~er girdle: (,v short

tlexors aind e*xtentsors (if forearmn.

(2) T'ype.x of lufccluio. The followinig types of infect iotn iiiist lie recoignized.

saive t hey reilutired(itfereult t heraupy :---

U. U'is gantgretie (clostrldiatl).

(I) MIT iuse aityositis.

(2) 1,ocalIIZed ayo0sit is.

(3) Cellilit Is, "gals ablscess."'

Ii. (hs gatigretie (st relit(Kcicail ). ratre.

(I) 3.1yosit is.

ai. C linicual. The differ'entialI diaignosis amoniig the vatriiits t ylit- of clositrlliail

gais gatigretie andi( st reptociiKCcal aayisit is umust lie miaide toi aivoid utnaecessaury rad~ical surgicail

t reatmeinet.

(I 1) lo.strvivIa ,nIositi.s. uf usefm: This miaay deveblop withlin 4) imhors from th le

I atiie (if woundinig. usually wit hin 3 dlays. The ontset Is acute with iat severe systetmic reavtion. Loict 13 there is pa in, marked swellhing, frequently profusv' *wrotvt cruvnte, slightI

gas foirmnatihon. ruiriui h/ odor of decaiy andtipatle or bhtae-graiy ailileairaitte oif involved atuscie.

Tbe skiti Is tense amid often whilite, hilt tHilly lie Mtiit tled With Iat IIvid .t ipeairautie if f ie( pia'wess

is widlespreaid.

(2) CUostridiail ,n/iomifix. loralized: In 5-10) iercealt (if the cases. bica11iiziol o

of the jirwess to at sinigle muscle or gr'oup oif muscles occurs. Synmptoams and1( signs are the

same its for thle d1iffuse type.

(3,) ('loxtrittivul euhluitim: Tbis prociess Is limited to the imimtediaite airea oif

tile wountti. rhe oniset is gruidutal, istiatlly after 3 (lalys. with slight systemlic r'eaictioni.

Lec-ally, there Is ab undant g ~as fortiait iot with at foul odor, slight swellling. and il ly Inevloa

changc of the imiscle aiad overlying skitn.

(.J) Streptoeoreavl milositim: Thle ontset is dlellayed for 31-4 dlays, atid severe

systenfle reatetbtis dto hot appear until thle late st ages iof the intifectiota. Locailly, there is

markcd'vi selling with prvifume puruulent vhixelarge. slight gamei formal~tion, andio shlight odor.

The involved muscle Is slightly Memhaatous and lthe overlyhig skiff is tv'nsc. often with hia

c'OhWlK-ry tlinge. Streptowuicv'i aiyosistls cotaul'ist- only at fewv of the eaises oif gals gatigretie.

b. Laboratory. R~ecogntiton of Infections with alnaeroichi baicteria is maaide onl

cllinicatl findings, whicht shoiuld be chiecked1. wvhere p~ossib~le. wvithi i stmear miatde front tile

mnaterial Iti the dlephtI of thle wvound. A stmall plece of intvolhved muscle, rubbed on at glass

slide anid stainedl by the ('taini maethod, Is examinied under tile milcroscop~e. In the presence of elost rillatl gas gangrene, such minpairs usually showv at piredlomniainice oif hatrge gramnij~ssltlve rodis. Pus cells are scanity and degenerate. Itn streptococcai inyosit Is, grainpositive bacilli aire abisent and in t heir Ilace lairge atnimbers of stittll-sized streptociiccl aire
APPENDIX B 969

found among masses of pus cells. Whenever facilities are available, anaerobic wound and

blood cultures should be carried out.

The finding of anaerobic bacteria in a wound is not uncommon, and such finding should not intluence the surgical treatment, unless there are local clinical signs of

anaerobic infection.

(4) Prophylaa'i.m. Early. adequate debridenient of wounds is the best prophylaxis

for anaerobic infections. Debridenient where there hais been massive destruction of tissues,

more particularly in the region of the buttocks. perineum and upper thighs, and where

major vessels are injured. mUust. be radical a11nd1 t horougli. using long incisions. If heniatonla

is present, deep fascial planes must be incised, especially in the popliteal area. Bilateral

incisions in the popliteal space just inside the hamstring tendons should be made. The

fascia over both heads of the gastrocnemnius should be incised--all clots should be evacuated

and any continued bleeding controlled by ligature or suture. Gas gangrene antitoxin,

sulfonamides and penicillin are not to be considered substitutes for early, adequate debridement. However, where circumstances delay debridemnent of the wounds mentioned in para.

10. a. (1), for 24 hours or longer, one (1) ampule of gas gangrene antitoxin may be given

intramuscularly. Penicillin and sulfonamides are to be used as directed in paras. 6 and 7.

(5) Therapy.

a. Surgical. This depends upon the extent of the disease and the type of

anaerobic infection. Diffuse clostridial cellulitis is encountered in approximately 80 percent of cases in these categories.

(1) Clostridial mnyositis, diffuse: Amputation as far above visible evidence

of involvement as possible 111u,1t be carried out immediately, using the guillotine method,

and leaving the wound open.

(2) Clostridial myositis, localized: Extirpation of the involved muscle, or

group of muscles, should be practiced through long incision.

(3) Clostridial cellulitis: Incise the localized process and remove the devitalized tissue. Radical surgery is not indicated.

(4) Streptococcal myositis: Extensively incise and drain the involved muscles.

Radical extirpation or immediate amputation are not indicated.

b. Serum therapy.

(1) Clostridial infections: Three (3) ampules of gas gangrene antitoxin should

be given intravenously and repeated hourly for 6 doses (see Manual of Therapy, European

Theater of Operations, page 35, para. 27). This may be modified according to the condition of the individual case. Test patient for allergy to horse serum before administration

of antitoxin. Adrenalin in a syringe should be at hand.

(2) Streptococcal infections: No serotherapy is indicated.

c. Chemotherapy.

(1) Penicillin: Give initial dose of 20,000 units, intravenously and 20,000 units

intramuscularly, followed by 20,000 units intramuscularly every 2 hours for a period of 3

days. Period of therapy may be modified as seems necessary. Place in the wound 50,000

units mixed in 4 gins. (1 teaspoonful) of sulfanilamide, and repeat at dressings.

(2) Sulfonamidcs: Give 5 gmis. of sulfadiazine by mouth initially and 1 gin.

every 4 hours.

d. Supportive treatment. Since there is rapid destruction of erythrocytes, frequent whole-blood transfusions will be necessary.

e. All instruments used in anaerobic infections should be sterilized by autoclaving, when available, and the instruments must not be covered with oil, since bacteria surrounded by oil cannot be wetted and therefore are not killed at the usual temperatures.

I. If gas gangrene antitoxin is used, record number of ampules used and name

of manufacturer.

b. Tetanus.

(1) Types of Wound. Any wound, regardless of size or location, is a potential

source of tetanus, particularly small puncture wounds.
970 A("iX'liTIE.S OF1 sCuiCr (NSULTANTns

(2) Prophylaxris.

a. EvWery wvounded muan will reveive I cc. of tetamis toxoid. subcultaineously, as

soonI 11 ImissibIC. This will loert- Vorqled oill thet Emiergenicy Medc~tl(i Tag, or onl the Field

Medical Rlecord. If there is no record of the adminiist rat ion of toxoid. (or anyv dmubt ats

to its previous adininismt rt on. 1 cc. of tetanus toxoid wvill he given and so recorded.

h. Early. adleqluate debridement.

r. 1 cc. of tetanlus to)Xoidl will lbe given prior to the muanipulation or explorationi

Elf :iii old( wounid.

d. After appropriate tests for sensitivity, members of Allied Force-s (except

('11na.lialhi). civilians and others wvill receive 3,000 units of tetalnus antitoxin intramluscularly. The' Canadian Forces w~ill receive 1 ce. of tetanus toxoidl. A syringe containing 1

*ce. of I1:1.000O of epinephrine (adrenlalinl) should alwvays be at hand wheat te-tanus, an1titoxinl

is given.

(3 Sign.m and Symnphontq. The rarity of this disease must not prevent its rec-

((gnition). Tiji earlier tetanus is recognized, the mlore effective treatment will he. The

earliest sign is trisnius. The patient away complain of pain and stiffness In the neck, back

and abidomnen. Dysphagia may be present. Localized tetanic contractions are not

(4) Trcutoment.

(t. (;cnefrfil. At the appearanice of the earliest signs of tetanus, immeiitdiaite

therapy is indiciated. All cases must be treated vigorously. The loatient should be isolated

!i it quiet, darkened roomi.

b. Control of spasninR. Trismnus may be controlled by administration of barbiturates, e.g. Neiuliutal. whlich are essentially auti-spasmodlic in ilction. Nembutail. grs,. 3

10.2 gnis.) minily lhe given rectally in a well-lubricated capsule that hits, beeun perforated several tiniles wvith a pill. 'More rapid absorption wvill be effected if thle 'onitenits of at capsule

are dissolved in wailter and the solution injectedi rectally through a catheter of smnall caliber.

The dose many be repeated as reqluired, care being taken to guard aigainast cumiulative actilon

and)4 the production of anesthesia. Sodium Amnytal. grs. 01 (0.4 ginls.) represenits anl eqluivaklemt (lose and for treatment over a periodl of (lays this drug is to be preferred. Overdosage wllI be indicated by evidence of byperpyexia lind incipient ateiectaisis or plml~lonlary'

edenla. For spasm involvinig maniy nmuscular groups wvhere anoxia is a feature, adlminiiitration of Pentotlial sodium in 2.51 percent solution initravenlously is; indicated. The objective is to give just sufficiemit to conitrol the seizure amld to permit effective artificial respiration. Front 2 to 4 ce. may be reqluired. l1bliger acting barbiturates tire preferable for

prolonged control of spasms, but sup~plelmientary adminllistration of Pemltothal. may be neeessilr3 to control acute episodleq producing anoxia. For tile saine purpose, 0.5 g-n, of

Sodliumi Anlytll. dlissolvedl in 10 ce. of sterile (dist illed wvater, may be injected intravenously

at.t the ratte of I cc. per miinute. Avoid use of long acting barbiturates slit-it as Veronal or

Lii uiiimal becaluse of its cumulative actiomn.

S'uppolrtive treatmuient. ndministrntion of saline. glucose and/or plasnma. is essentiall I. The prime reqluisIte Is to maimntain oxygenatilon, producing muscular relaxatlion to

permhit effec'tive respiratory- action. All efforts will be dlefeated if obstruction of the uipper

respiiraitory tract is permlitted.

Tracheotomy should be pe'rformedN if la ryngeal spasmn is causing suiffocatlonl.

(1) Locally. After appropriate tests for senlsit izationi, 10.000 units of tettlilis

antitoxini should bie used for intiltration about thle wvound.

2.1) Intrasntmettlarly. Tllerapeutie administration of tetaimus anititoxin shlouldl

lie. early andl adlequate. After appropriate tes-ts of senisitization, an iniltial (lose of 40,00m0

tunits of anltitoxini should he given Intramuscularly.

(3) Intrarctionsly. 20,000O units may be administered initralvenlously 61 hours

aufter tihe Iintrmmliscular injec-tion. This dosage may be repeated on tile second~ and third
APPENDIX B 971

days If conditions require. Extremely large doses of antitoxin are no longer considered

helpful.

(.J) Intraspinal. Antitoxin should not be given intrathecally.

d. Surgical.

(1) Local debridement. This is based on the fact that the bacterial anaerobes

are the sole source of the toxin. The wound must be widely opened and kept open. Amputation must be considered if other reasoning is suggestive of such a radical procedure.

Such debridement should be preceded by the local injection of antitoxin as described in

para. r. (1) above.

11. Radiology in Forwrard Area.

Attention to the following general principles will improve the efficiency of a forward

area X-ray service, especially when casualties are received in large numbers.

a. Housing. Evacuation hospitals should be arranged to do radiography, fluoroscopy

and processing simultaneously. One way to accomplish this is to use a ward tent plus two

darkroom tents, one for radiography and one for fluoroscopy, at least the processing

tent inside the ward tent. Most hospitals place both within the ward tent. A second

inside tent can be improvised from a latrine screen if a second darkroom tent is not

available. Improvised duckboards in the darkroom are advantageous. Waiting room

for walking cases can be made with empty X-ray chests for seats between the darkroom

and fluoroscopic tents, and one low side of the ward tent. Field hospital units have only

one X-ray machine, therefore will not require two darkroom tents.

b. Power. The utmost skill should be exercised in the care and operation of electric

generators. The instructions issued with each generator should be meticulously studied

and followed by the radiologist and technicians.

c. Radiography.

(1) The field unit X-ray machine on a mobile base can be used beside a table

more efficiently if a board or other type of track is improvised to guide the movement

of the machine up and down the length of the table.

(2) Positioning should be standardized according to the guide for forward

areas furnished each X-ray department by the Office of the Chief Surgeon.

(3) Filn drying will be hastened if it can be accomplished outside the darkroom.

unless a free current of air can be forced through the darkroom by an improvised lightproof trap. The ventilator alone is inadequate. Item 60120, clips, photographic, will

amplify hangers and permit easy stringing of roentgenograms on wires or rope.

(4) Water inlets and drain outlets from the processing units, by improvised

hose or pipe "plumbing," will inc-ease the darkroom efficiency.

(5) Roentgenograms should be identified accurately as per existing directives.

d. All patients transferred to other hospitals will be accompanied by their roentgenograms. A filing system should allow easy availability of roentgenograms to those who

want to see them and, at the same time, make it possible for them to be accumulated and

leave with all patients of a convoy on short notice.

e. There should be a uniform and well-defined policy between the receiving or triage

officers and the radiologists as to what type of case will require X-ray examination, and

the priority and volume in which they will be sent to the X-ray department. The use of

litter bearers to and from the X-ray department should be mutually pre-arranged.

f. Requests for X-rays should be brief and exact throughout the hospital, so that

the specific purpose of each request is evident, assuring that the proper technique and

psositioning can be immediately selected by the radiologist. This will obviate retakes.

g. X-ray examination should only be requested when the findings will affect treatment or, more rarely, the disposal of the patient.

h. Paticnts in shock, or thrcatcpwd shock, should not hare X-ray cxamninations crrcept

in rare emergencies.
972 ACTIVITIES4 OF SURGICAL CONSUILTANTS

i. .iniSilh Ihonnds.

(1) Upper thighs and buttocks-should have additional A.P. or P.A. radiographs

of the pelvis and lower abdomen, because complicating involvement is frequently found

here.

(2) Thorax-should have additional A.P. and lateral radiographs of the upper

abdomen, because of frequency of transdiaphraginatic involvement.

3) l'pper arns. shoulder and ne-k--should be considered for additional A.P.

(or P.A.) radiographs of the thorax to exclude upper lung involvement.

J. All soft tissue wounds of the extremities should have an A.P. and lateral X-ray

examination of the injured part. including the nearest joint, prior to surgical treatment.

k. Transportahle cases with woundds (if the fare and skull should generally not have

X-ray exitnminat ion until special treatment is available.

1. Localization of foreign bodies in e'xtrcunitic. is generally best avcomnplished by A.P.

and lateral radiographs. Fluoroscopic orientation by the table device is generally not as

practical in extremities as A.P. and lateral radiographs because bandages and wounds prevent marking the skin, and because the surgical approach to the foreign b(dly may not be

determined until after the X-ray study, and thus skini marking, even when possible, may

not be placed on the proper aspect of the extremity. Lateral radiographs of extremities

can, and should be made with the patient supine, when turning the patient causes pain.

in. Fihoroseopy is seldom as satisfactory as radiography. It is most useful in thoracic

cases as an adjunct to radiography. and in localization of foreign bodies in the pelvis where

late• 1 view, -e impractical and stereoscopy is not available. It is used for other types of

cas iinly when facilities for radiography are not adequate to keep abreast of the volume

of i its. Fluoroscopy. when not expertly supervised,( can be a mnenace to patients and

operators. It should never be attempted until the eyes have been accommodated at least

15 minutes.

12. identfication of Gase.s in Cylinders.

a. Identification of gases in cylinders may be difficult. In order to avoid serious

accidents, great caution must be exercised in properly identifying contents of any particular

tank.

b. Identification of a gas in a cylinder will lie nmade by the following mnethods:

(1) By reading the chemical symbol of the gas imprinted in the metal of the valve of

British cylinders.

(2) By reading the chemical symbol or name of the gas imprinted in the metal at the

shoulder of the cylinder (symbol on British cylinders, full name on American cylinders).

(3) By reading the paper label or tag on British or American cylinders.

(4) By reading the symbol or name of the gas stencilled on or near the shoulder of

a British or American cylinder. Arrangements for employing this means of identification

have recently been made with the British Oxygen Co. and may not be found on all cylinders

for some months to come. Cylinders are also being stencilled in U.S. medical depots.

(5) By interpreting the color or combinations of colors with which British or

American cylinders are painted. Color markings on a cylinder must be considered owily to

corroborate labels and are never to be used as a single mcans of identification. In no

Instance will the color of valve caps be considered significant.

(6) To identify gasesq in cylinders. eheck for all these ,neans of identifleation. Unless

all means in cridene(' ayrce, the gas shouild not be tused.

For the Chief Surgeon:

/s/ J. II. McNineh

J. I1. McNINCH

Colonel, Medical Corps. Executive Officer.
APPENDIX C

HEADQUARTERS

EUROPEAN THEATER OF OPERATIONS

UNITED STATES ARMY

Office of the Chief Surgeon

8 DECEMBER 1944

CIRCULAR LETTER NO. 142

GUIDANCE TO DISPOSITION BOARDS

* * * * * * *

2. Attention is invited to Circular Letter No. 124, this office, subject, "Evacuation of

Patients to the Zone of Interior," dated 17 October 1944. In the event that there is an

insufficient number of 120-day cases to fill lift provided, enough cases will be selected which

would fall within a 90-day evacuation policy to make up the deficit.

3. The decision as to disposition should be made as soon after the patient reaches a

hospital as possible; i.e., when a diagnosis is made. Hospitals have been lax in this relation

and must expedite evacuation. Further guidance, chiefly relating to fractures of long bones,

is outlined in Circular Letter No. 131, this office, subject, "Care of Battle Casualties," dated

8 November 1944.

4. The following list of medical and surgical conditions is published for the guidance of

Hospital Disposition Boards. It is to be remembered that this list is to be used only as a

guide, each case to be decided on its individual merits.

a. Medical Conditions: * * *

b. Surgical conditions. The following list of surgical conditions demand return of

personnel to hospitalization in the Zone of Interior.

(1) Maxillo-facial, plastic antd burn cases.

(a) Severe maxillo-facial injuries associated with loss of tissue, which will

require long-term reconstructive plastic surgery.

(b) Extensive loss of oral tissue in an amount that would prevent replacement

of missing teeth by a satisfactory denture.

(c) Malignancies about face or mouth which will require extensive surgical

treatment.

(d) Deep, extensive burns of the hands and face and extensive burns of other

parts of the body.

(e) Wounds of other parts of the body which will require extensive plastic

surgical procedures for correction.

(f) Severe compound, comminuted fractures of mandible or maxilla, with or

without loss of bony substance.

(g) Patients with deforming b~ut not disabling injuries in whom plastic repair

should not be done within the 90-day period.

(2) Ophthalmic cases.

(a) Those cases (officers) covered by AR 40-105, par. 9, 14 Oct. 1942.

(b) Those cases covered by MR 1-9, par. 18. 15 Oct. 1942. except "g." also

changes 22 Jan. 1943.

(c) Retinitis, pigmentosa, organic night blindness.

973
974 ACTIVITIES OF SURGICAL CONSULTANTS

(3) Ncurosurgical case..

(a) All cranio-cerebral injuries in which there has been gross injury to brain

tissue, as in penetrating wound of the head and compound comminuted fracture of the

skull, with indriven bone.

(b) All injuries to major motor peripheral nerves. (Disposition of VIIth [sic]

Cranial nerve injuries should be decided according to the severity of the disability.)

(c) Tumors of the brain or spinal cord.

(d) Cases of chronic low backache associated with sciatic nerve pain, and

accompanied by objective neurological signs. Exceptions may be made in officers occupying

key administrative positions and noncommissioned officers with special skills.

(4) Orthopedic cascs.

(a) All compound fractures of upper and lower extremities involving major

joints, or where the infection incident to compounding will not permit solid bony union to

occur in four months, or where the healing will cause enough scar tissue formation in the

overlying soft tissue to interfere materially with the function of the extremity. This in

general will involve compound fractures of humerus, radius and ulna, femur, tibia, and

extensive injuries of carpal and tarsal bones, shoulder. elbow. wrist, hip, knee and ankle

joints. Possible exceptions may be made in certain selected instances of compounding forces

resulting from clean, high velocity missiles where the continuity of the shaft of the bone

has not been extensively disturbed.

(b) Simple fractures of femur and tibia. where the continuity of the shaft has

been completely broken.

(c) Extensive compression fractures of vertebrae with or without dislocation.

(d) Osteoarthritis of joints with disability.

(5) General surgical cases.

(a) All cases of proven malignant disease (pre- or post-operative) except those

of the integument which seem capable of complete local removal. (Exceptions may be

made where surgical excision offers hope of cure and the patient desires to remain in the

ETO.)

(b) Perforated gastric and duodenal ulcer.

(c) All complicated cases of cholelithiasis.

(d) Large recurrent postoperative hernias.

(e) Abscess of lung, unless acute and making rapid recovery following operation.

(f) Established vascular disease, such as Raynaud's Syndrome, thromboangiitis

obliterans, serious thrombophlebitis with edema and cases with frostbite, immersion foot

and trenchfoot in which there is demonstrable severe organic disease.

(6) Genito-urinary cases.

(a) All cases of malignant disease except solitary papilloma of urinary bladder.

(b) Kidney.

1. Diseases or injury requiring plastic operation of the kidney pelvis.

2. Bilateral renal disease--calculi--hydronephrosis.

(c) Ureter. Disease or injury requiring secondary or late plastic repair.

(d) Bladder. Neurogenic bladder without definite improvement in 1 month.

(e) Prostate hyperplasia causing symptoms incompatible with duty.

(f) Urethra and external genitalia. Wounds and injuries requiring extensive

plastic procedures.

(g) Tuberculosis.

(7) Otolaryngological cases.

(a) Hearing loss below a level which makes a patient incompetent for all

military duty.

(b) Chronic polypoid sinusitis, with severc symptoms.

(c) Allergic rhinitis (severe).
APPENDIX C 975

(d) Chronic suppurative otitis media and mastoiditis which requires radical

mastoidectomy.

(e) Permanent tracheotomy.

(f) Destructive deformities interfering with mastication, speech and breathing.

(g) Ozena.

By order of the Chief Surgeon:

Is/ 1H. W. Doan

H. W. DOAN

Colonel, Medical Corps,

Executive Officer
APPENDIX D

HEADQUARTERS

EUROPEAN THEATER OF OPERATIONS

UNITED STATES ARMY

Office of the Chief Surgeon

17 MARcH! 1945

CIRCULAR LETTER NO. 23

CARE OF BATTLE CASUALTIES

The following instructions are supplemental to Manual of Therapy, ETO, 5 May 1944;

Circular Letter No. 71, 15 May 1944; Circular Letter No. 101, 30 July 1944, and Circular

Letter No. 131, 8 November 1944. Office of the Chief Surgeon.

Transfusion Instructi(ns --------------------------- -------------------- 1

Orthopedic Surgery ---------------------------------------------------- 2

Penicillin Therapy ---------------------------------------------------- 3

Sulfonamides -------------------------------------------------------- 4

Hernia --------------------------------------------------

Chronic Suppurative Otitis Media ---------------------------------------- 6

Peripheral Nerve Injury ----------------------------------------------- 7

Gunshot Wounds of the Spine with Neurological Involvement ------------- 88---- 

Abdominal Surgery --------------------------------------------------- 9

Vascular Surgery ---------------------------------------------------- 10

Notes on Radiology --------------------------------------------------- 11

The Care of Immobilized Patients (avoidance of decubiti) -------------------- 12

Maxillofacial Casualties ------------------------------------------ 13

Thoracic Wounds ------ ---------------------------------------------- 14

Closure of Wounds of the External Genitalia ----- -------------------------- 15

Eye Casualties ------------------------------------------------------ 16

Records ---------------------------------------- 17

1. Transfu8ion Instruetions

a. (1) The following test will be found useful in making differential diagnosis

between pyrogenic and hemolytic transfusion reactions. It can be employed with accurate

results as early as fifteen (15) minutes after the appearance of symptoms.

(2) Procedure

(a) Draw five (5) ccs. of blood from the patient, employing a clean, dry syringe.

(b) Remove the needle from the syringe and eject the blood gcatly into a clean,

dry test tube.

(c) Centrifuge Immediately for five (5) minutes at three thousand (3,000) r.p.m.

(d) Read grossly for presence of free hemoglobin in the serum.

(3) The presence of hemoglobin in the serum is indicative of Intravascular

hemolysis. The presence of as little as ten (10) milligrams per hundred cubic centimeters

will produce a faint pink tinge and can be detected In this manner.

b. Alkalinization

Alkalinization Is useless In cases In which there Is no Intra-vascular hemolysis.

and will not be carried out in those cases In which the above test Is negative.

977
978 ACTIVITIES OF SUIR(;ICAL CONSULTANTS

c. Deaths from transfa.ion

Analysis of reports received shows that one of the major (causes of death following

transfusion is cardiac overload. The 'ardiac reserve of patients who have suffered wounds

and prolonged shock is definitely lowered. Antiria may also result froin prohlnged shock.

In the attempt to produce iiuresis by the a(lministration of intravenous fluids, the cardiac

reserve is sometimes exceeded. Ordinarily, three thousand (3,000) cubic centimeters fluid

intake daily is sufficient. In the presence of hyperprexia this may be proportionately

increased. Blood and plasma received must he taken into account in calculating the total

fluid intake.

d. Sodium

When sodium salts (citrate) are given to produce alkaline urine, the administration of sodium chloride (physiologic salt) is to be avoided. De-xtrose in distilled water

may be used to maintain adequate fluid intake. The administration of excess amounts of

sodium may produce an alkalosis of a degree resulting in itself in anuria, or the excess

sodium may be taken up by the tissues and result in edema.

e. Care of blood in hospitals

(1) Blood will be stored in refrigerators at temperatures ranging between two

(2) and six (6) degrees above zero centigrade (35.6-42.S degrees F.).

(2) Blood will not be heated before transfusion.

(3) Blood left unrefrigerated for more than 30 minutes will not be used for

transfusion.

2. Orthopedic Surgery

a. Notcs for disposition boards

Under the present evacuation policy to the Zone of Interior, very few simple or compound fractures can be rehabilitated to full duty in this theater. Among the exceptions may be certain fractures incurred by key personnel occupying sedentary positions.

A fracture of the clavicle, an undisplaced fracture of the head of the radius or of the

lateral mnalleolus, some fractures of the metacarpal bones, metatarsal bones or phalanges

are cited as examples of fractures that may be returned to full duty within the present

evacuation policy. There may be a few other instances of minor fractures which will

require careful evaluation in order to determine whether there is any possibility of salvaging the officer or soldier involved for further duty in this theater within the time allowed.

Patients requiring elective surgical procedures for internal derangement of the

knee joint or recurrent dislocation of the shoulder joint should almost invariably be returned to the Zone of Interior for this surgery. Time utmost care should be exercised in

arriving at a diagnosis of either of these conditions. A sprain of the knee joint which may

be rehabilitated should not be confusel with an internal derangement. A recurrent dislocation of the shoulder joint should be thoroughly authenticated before this diagnosis is

made.

Osteo-arthritis of a major joint with definite disability as a result should be returned to the Zone of Interior.

b. Almputationts

Skin traction on amputation stumps must be instituted immediately and maintained adequately and continuously except as stated in par. 5d, of Circular Letter No. 101,

this office, subject: "Care of Battle Casualties." dated :30 July 1944. In general hospitals.

this traction may be advantageously maintained by a weight suspended over a pulley.

This fornm of traction must also be continuous. The most effective means of nmintaining

skin traction on the amputation stump during transportation has been described in par.

5e, Circular Letter No. 101. Offi.-e of the Chief Surgeon. 30 July 1V44. This skin traction

should be inspected in each medical unit charged with the care or the evacuation of the

patient, and, if found to be inadequate, it should be reapplied imnnediately.

Closure of amputation stumps by suture or skin graft is not authorized in this

theater. Amputees should be evacuated to the Zone of Interior as promptly is possible

with skin traction maintained throughout all stages of their journey.
APPENDIX 1) 979

c. ll'oiUIld ii rtoli'ir thie knit joint

These wountds have been most satisfactorily treated in the following nmanner:

(1) A thorough exploration of the joint is performed through adequate medical

and/or lateral incisions. A bloodless field should be insured by the use of a tourniquet

if there is no associated damage to the femoral or popliteal arteries. The joint is completely irrigated with saline solution which should remove all blood Ind debris. With

adequate retraction, a careful debridement of all damaged tissue, bone. cartilage and synovla

is performed with removal of all foreign bodies from the joint cavity. If a meniscus is detached or damaged it should be excised. After further irrigation the synovia and capsule

are snugly closed with a single layer of interrupted sutures. If there is loss of capsular

substance, the closure may require, in some instances, the utilization of a fascial flap.

(2) After closure of the capsule, 10,000 units of penicillin in 5 cc. of normal

saline are injected into the joint cavity. The tourniquet should be releast d and hemostasis

insured by the ligation of all bleeding vessels. The knee joint should be immobilized by

means of a plaster of paris spica bandage, knee slightly flexed, with a window over the joint.

The joint is aspirated 48 hours after operation, gently washed with saline solution, and

another 10.000 units of penicillin instilled into the joint cavity. This procedure may be

repeated several times at intervals of 24 to 48 hours if necessary. Parenteral penicillin

therapy is carried on throughout this period. The skin wounds may be closed 5 days

after prinmary surgery if there is no evidence of infection.

d. Compound fracture.

(1) Supracondylar fractures of the femur with sharp spicules of bone which may

damage the popliteal vessels should be immobilized with the knee flexed at 20-25 degrees

to minimize the danger of this complication. At the time of primary debridement, if there

is found to be direct pressure against the popliteal vessels by a sharp spicule of bone, it

should lie excised. The excised piece of bone should be replaced at the fracture site and not

discarded.

(2) I)tcrnal fixation of compound fracthres

A recent report from the Office of the Surgeon General on the condition of

battle casualties returning from the ETO has been received February 1945. The concensus

of opinion expressed by qualified chiefs of orthopedic sections, chiefs of surgical services

and consultants in nineteen named general hospitals in the Zone of Interior was that

metallic internal fixation of compound fractures resulted in infection in 25 to 50% of

the cases so treated. The metallic fixative agent in all of these infected cases had to be

removed. Delayed or non-union has resulted in many of these patients.

In view of the adverse report on the progress of these, c.asualties, internal

fixation of compound fractures is prohibited as a routine procedure. It should be resorted

to only after a thorough trial of skeletal traction has failed to secure adequate reduction,

and after healing of the skin has been accomplished by suture or skin graft. The concurrence of the local orthopedic or surgical consultant will be secured in each instance

where internal fixation of a compound fracture is deemed necessary. Combined i.,juiries

involving compound fractures and peripheral nerves present special problems:" These will

be treated at specialized hospitals designated for neurosurgical problemn.

"3. lPcnitillin Thcrapy

The following abrogates these parts of Circular Letter No. 71, 15 May 1944, with

which it is in conflict.

a. Penicillin therapy will begin at (.learing stations.

b. Penicillin therapy will be given to all casualties except those with very minor

battle wounds.

c. The use of penicillin locally in all wounds is not reqluired, but its local use in

joints and chests is necessary for best results.

d. Data concerning dosage will he recorded oni Eawrgency Medicail Tags and Field

Medi.a I Record.
980 ACTIVITIES OF SURGICAL CONSULTANTS

e. The distilled water in the plasma set should not be used as the vehicle for

injecting penicillin, since it contains citric acid which inactivates penicillin. (Citric acid

may inactivate other substances, and the distilled water in plasnia sets should not be

used except as a vehicle for dried plasna.)

f. The rate of withdrawal of penicillin from supply depots indicates that all wounded

are not receiving penicillin ats per Circular Letter No. 71. This must be corrected, since

there is no more striking advance in the treatment of battle casualties than the relative

freedom from infection. In this, penicillin mmay play a dominant role.

4. Sulfonamides

The dusting of a sulfonamide powder into open wounds has proven harmful to early

closure of the wound and adds little to the ability of the body to defend itself against

bacterial invasion. Such use of sulfonamide powder is condemned hereafter unless there

be special indications.

5. Hernia

Under the present evacuation policy, all direct and recurrent hernias should be

evacuated to the Zone of Interior. Exceptions are for key personnel only.

6. Ch(ironic Suppurative Otitis Media

Radical unastoidectomies will be donie only on patients in whom there is imninent

danger from a spread of infection. This danger is indicated by severe pain around the

ear, labyrinthine imbalance, or severe metastatic infection. Other cases of chronic suppurative otitis media and nastoiditis which cannot be treated so that they can return

to full or limited duty in this theater within the present evacuation policy will be returned

to the Zone of Interior.

7. Peripheral Nerve Injury

a. Primary suture of major nerve trunks in war wounds is undesirable and should

never be attempted. The contusion of the nerve which invariably accompanies such

wounds, precludes accurate trimming of the ends without unnessary sacrifice of tissue.

However, when nerve ends can be identified they should be approximated as nearly as

possible with a single through and through suture placed not more than 1 cam. from each

end. Preferably a fine metallic suture should be used in order that subsequent X-ray examination may visualize the site of the lesion. This fixation-suture is important in that

it prevents retraction of the nerve ends.

b. The optimum time for definitive suture is three weeks. Usually at this time it

Is possible to trimi the nerve ends accurately to normal tissue before suture, and the

perineurium is sufficiently toughened to permit accurate approximation with fine interrupted sutures.

8. Gunshot Wounds of the Spine with Ncurological lnvolrcntmnt

Patients with spinal cord injury are the most difficult of all nursing problems.

Facilities at the evacuation hospital are not ideal for their care. Therefore, early evacuation to fixed hospital installations is always desirable. The following rules for the care of

these patients should be adhered to wherever possible:

a. No gunshot wound of the spine should be operated upon in an evacuation hospital

when it is l)ossible to transport the patient to a special treatment hospital for neurosurgery

within :16 hours from injury. When such evacuation facilities are not available, the neurosurgeon of the evacuation hospital may perform a laminectomy when it is indicated after

consultation with the chief of the surgical service and the orthopedic surgeon.

b. Through "holding units" these patients should be sorted for early evacuation to

the nearest special treatment hospital.

c. No body cast will be applied In an evacuation hospital solely for the spinal injury.

All patients (except those with injury to the cervical cord) will be evacuated in the prone

position, care being taken to prote,.t pressire points, especially about the iliac spines. An

Indwelling catheter will be used until the patient reaches a general hospital.
APPENDIX D 981

d. In those cases subjected to operation in evacuation hospitals, movement to a general hospital for nursing care will proceed within 48 hours, condition of the patient and

evacuation facilities permnitting.

e. These rules do not apply to patients with associated injuries, i.e., chest, abdominal

and serious extremity wtilnds, where the associated lesion may take precedence in treatment over the spinal injury.

f. Cervical cord injuries will be handled according to instruction in the ETO Manual

of Therapy, and Circular Letter No. 131. Office of the Chief Surgeon. Traction by either

Crutchfield Tongs or Halter is not indicated unless there is fracture-dislocation of the

cervical vertebrae. Simple gunshot wounds involving the lainia or the body of the cervical

spine do not often require traction.

9. Abdominal Surgery

a. Colost.onics

(1) Wounds of the large bowel should be treated by simpile exteriorization of the

involved portion, except the rectosigmoid, where the wound in the bowel will be closed and

a "loop" colostomy performed above and at the top of the "free" loop. In this instance

there must be complete diversion of the fecal stream, and it is advisable to divide the exteriorized bowel transversely and completely at the time of the operation. The distal

end may be occluded by a clamp or a suture, as indicated.

(2) The Mikulicz type of procedure has been unsatisfactory in the experience of

ETO surgeons and should be abandoned. It has been found to be the cause of post-operative obstruction and much intra-abdominal discomfort. The spur has rarely been sutured

over a long enough area, and it is unsatisfactory for complete diversion of the fecal stream.

Moreover, Mikulicz developed this operation as an emergency procedure in the early days

of abdominal surgery. It is not satisfactory for young people who must live with it for

forty years. In the repair of colostoinies in base areas, most surgeons have come to complete exteriorization of the lesion and end to end suture in the operative wound. Infection

has not resulted from this procedure, and late results are far better than with the Mikulicz

type of procedure.

b. Wounds involving the caecum alone or the caecum and ileum require repair of

the ileum and caecostomy, i.e., exteriorization of the defect. Ileostomy should be avoided,

and double-barrelled opening of ileum and caecum has been proven unwise and undesirable.

c. In concurrent injuries of head and abdomen the abdominal injury takes

precedence.

10. Vascular Surgery

Every attempt must be made in forward hospitals to repair vascular defects, first by

direct suture, secondly by use of improvised tubes or the Blakemore sets. If an extremity

can be given some blood for two or three days, even if greatly diminished, collateral circulation will usually develop and save the limb. The repair of the original lesion or an improvised method of getting some blood through the injured vessel need only function therefore

for perhaps 48-72 hours.

11. Notes on Radiology

a. Unexposed X-ray film can be fogged in many ways. Two important causes are:

(1) By stacking the paste board X-ray boxes flat, either in depots, medical supply

departments of hospitals or in X-ray departments. This presses the boxes open and l)revents using the bottom film boxes in turn as new ones arrive.

(2) By storing films near a source of heat which is either severe for a short time

or above 90 degrees F. for a longer period of time. Cold does not injure X-ray film.

1. All X-ray film will be stored at all times on edge and away from excessive heat.

c. Many kinds of glass can be depicted in the body by regular type of examinations.

When glass from mines or other sources is suspected and needs to be located, X-ray examination should be requested. Since radiographs made properly dense with lower kilovoltage will depict still more kinds of glass than high kilovoltage technique, the radiologist
sho(uldt lbt notitiedt whelet glass is slislietcted. F"ragmienits fotI'ii Iplast ic ori wooden hiines caninot

lie dei cted lo X1'-ray e'xamnilationl.

12. Thc 'tirc of I tit mo bi Iizcd PUto I iCUIS( Voidianct (It 4144-11 b it iI.

it. Path-nlts whol are unhconisciouls t. it- pratlyzAed. oPr whot lire immI~obilize'd as the resnlt of

serioius injury 1)toe I l'bttt(vk-, chest or extremaitijes. neetd special care. Suich pat ients cannot

Ililii't thIemnselves. and linlt'ss moved''( frequently. serious pressure sortes and li'rnianlent disabi~it its will e'nsue. Puilmona ry conlgest ion resultinug from immobihility' inicreases tin' risk tif

serious pulmounary complications.

11. IA'SSP'nilig of the' disabhilities~ enta21iled biy lack oif m~ovemenht Iit 211P'lt l aCC4'tIh~llsittil

thlrough instructions1) to lit'rsohihitl to shift the position of these patients frequtently. D~eep

birethitng exercise's (-;tit be convenienntly given at thet saint' linn't that thIn litositio 15 s11 4'lgeil~tt.

The at tendanttt nurse or enlisted personnlel should1( move tih' pat1ienit by genlyt13 shift ing thep

potsit ion of hiis lielvis. Whe're t here is at large but toc'k woiund oir he'avy cast. moire thanii onte

atte'ndant. Will haviie to assist in such mnovement. Thet patijent -an lip' slightly3 rolled to out'

side, all trna tilig t he sides onl which his weight rests. Such nmovemeitnt not only re'lieves the

local piressure' whiichi give's rise to dt-cubil i, lbnt shifts the dethltI of res-pirat 1411. It oifteni

the're'fore. assists in clearing tlie re'spiratory passage thlroiugh thet cuiighiing which may13

follow~ such at chiamigt ill posit ion.

13. .11fij'illofaciaCiui (taytihtie

it. Lilter Es'actiatiopt

Ili thlt litter ev1ac'uatiton of fresh nIaxillofacial casualtit's. adequate attt'ntion 04'-

casitiiially has ult it een paid to tilte prope'r positioni for sittli case-,. Impilrope'r poisit ion may

result Iin fatality tdurinig evacuation. Instructions on this mnatter should lIe, prtovitdt'd all

li'rsonnel handiling fresh casuailtites. Severe cast's should lip arranged Ii at prone position11

oil thlit litter with1 t let head supiportedt biy bilanketts. Such posit ion gives the grealtest assuraince that tilt' airway will lbe miaintained't and1 provides against thet danger of aispirationi of

bloodI and( toral secret'ton1s.

b. Jaw1 FeIixration for Eu'aetiatiomi

Par. 1. Circular Letter No. 122. Office' (if the C hiet't Surgeon. "Prepiiratioiu of

Maxillofacial Casualtit's for E'VaitctatiOli by St'a Or Air." 7 OI httlier 1144. is ampliftiedi as

follows

(1) In preparing casualties for evacuat ion intermaxiliany elastic t ractiton1 shoultd

be re'tducetd to on111y that almounlt rt'ituirt'd to hold( the lower teeth iii gentle conitact with thep

tpipers when fthe jaw is at rest. (Two plastic bands oil eaich side art' usually enotuighi t4i

aiccompillishi this 'i.

(2) The traction shouildt hie applied in such a manner that it will defhinitely and

iI~mmed(iate'ly bie releasted by3 pulling dtowin onl 21 stittire passt'd through the lumen of thet

t'lastie bands.

14I. '1heorac(ir' llouiiist

2). IcsiItsitfltionD

(I) (',ralve thoiracic womitits ats seen Iin forward hiospitails lire commnonly associtated4

with severeCt pa in and1( shoc'k. Ili atddi tion thlert' may13 leit'2 suicking wound, and( a1 lacerat ion

(if flhp lung or din gihiragm. The coughi Ine'chn uils m ay2113 conISequs'I-itl 1b' lin'adequatesIli ill clearinig jt'e I ra('leo-lbroInthiall I ret' of blood and1( secretlions.

(2) These patiietntsi ar 1. dsii '5 1'Ic and presen'(54I1t sigis oS(f anoxitXat. ('oalrss t rache'lt:

rates may13 lit pre'senit. Palpiablet rales are often ftelt over thep affected lung. .Secrt't ions

shouldbe t aspirated immnediately, pirefetralthy through at bronchoscope or by Imitaus oif ant

mit rat rat 'ale I sltin't er. '.1 a113'if these5t 12 pt ientIs ar a( 112lmit'tli ot r se11 iniP1111inost' antI 414 i ot

needt an alnesthbetic. Tiht pwatients shoulti be move'd as little Itas possibl1e. aind alspiraltionl

tihrmigh Ig 21lrotichsisc lit' or Ititrat rai('1eai catheter shouuldl be d]one with the patlie'nt iii zI

asllirat hion. Wh'len theliprouichoscolpe is usetd, the flow of oixyge'n should lit direct u't through

the( slth'a ril of this i lst I'llt',it a fter thet glottis hias been'i pahssedl.
APPENI)IX 1) 983

1. Sucking Wounds

(1) Debridement of thoracic wounds is aimed at excision of devitalized tissue

and removal of foreign bodies, including pieces of splintered rib. This procedure must be

done meticulously if the objective of primary closure is to be obtained and if infection of the

pleural cavity is to be avoided. The operation should be performed under endotracheal

gas-oxygen-ether anesthesia. The wound should not be prepared before the endotracheal

tube is in position. Wounds complicated by shattered ribs invariably become sucking during the removal of rib fragments.

(2) The fractured rib ends should be trimmed smoothly and rib fragments bare

of periosteum removed. All blood should be aspirated and clots evacuated from the pleural

sac. The pleural space should be examined and all foreign bodies removed since they

usually will cause empyema. Missiles seen in the X-ray film at the level of the 12th rib are

frequently in the costophrenic sinus.

(3) It is desirable to remove foreign bodies from the lung and suture lacerations

of the latter when the patient's condition permits. Adequate exposure for this purpose can

almost always be obtained without additional rib resection by enlarging the wound and

making an intercostal extension.

(4) Drainage of the pleural cavity should be established through a stab wound

in an intercostal space at the level of the inferior angle of the scapula in the midaxillary

line (never through the operative wound). Under field conditions it has been found that

the conventional sized catheter becomes occluded quickly. A size 26 or 28 F catheter, or

tube, is considered preferable. The tube should be sutured to the skin and connected to a

sterile water seal system. It should be removed in forty-eight hours.

(5) The wound should be closed in layers.

(6) Instillation of penicillin, 40,000 units in the pleural sac and aspiration of air

from the latter are the final steps in the operation. Air is aspirated preferably from the

second interspace anteriorly with the patient lying on his back.

e. Thoracoabdominal Wounds

(1) Late complications are common in this group when the right side is involved.

These include liver abscess, subdiaphragmatic abscess, empyema, and diaphragmatic

hernia. They can best be prevented by proper drainage of the spaces involved.

(2) Wounds of the liver are usually best managed by packing. The packing should

be exteriorized through the most accessible point of the body wall below the level of the

costophrenic sinus. Foreign bodies in the liver commonly cause abscesses. When accessible, they should be removed.

(3) The diaphragm should be repaired with medium silk.

(4) Intercostal drainage as desc.ribed in 1) (4) above should be established.

d. Hemothorax

Hemothorax is the most common complication requiring further treatment in rear

areas. Frequent aspiration without air replacement is the best prophylaxis against clotting

and infection. Following the first operation, 40,000 units of penicillin should be instilled

in the pleural space. Patients having a hemothorax should have a final attempt at aspiration before they are evacuated if there is reason to believe residual blood or fluid is present.

Aspiration of henothoraces is often neglected in hospitals passed through in the chain of

evacuation. Many aspirations are attempted at too low levels. The most satisfactory point

for aspiration is usually at the level of the inferior angle of the scapula at the posterioir

axillary line. Later, because the lung may become adherent posteriorly, it Is commonly

necessary to aspirate in Ihe axillary area or anteriorly.

v. Emnpylcma

(1) Many patients are reaching general hospitals with empyemas which are already chronic. This is usually due to too prolonged treatment with aspiration and penicillin instillation, to inadequate drainage, or because of retained foreign bodies.

(2) Empyema Is best treated by rib resection drainage at the most dependent

lprtion of the cavity. The most advantageous site for drainage is usually the ninth rib at
984 ACTIVITIES OF SURGICAL CONSULTANTS

the posterior axillary line. Mediastinal fixation sufficient to make open drainage safe

occurs within ten to fourteen days after wounding.

(3) Postoperatively the patient should sit up at once and be made ambulatory at

the earliest possible date.

f. Intercostal Nerve Block

The relief of intercostal pain associated with thoracic wounds contributes to a

more satisfactory convalescence. The raising of secretions is facilitated, and less morphine

is required. This can be accomplished by intercostal injections of 1 percent Novocaine.

Ihiring the course of operation. readily accessible nerves may be- crushed to accomplish this

purpose.

g. Thoraeotomy

(1) Necessity for intrathoracic operative procedures usually occurs in patients

having sucking wounds. Such operations can almost always be performed by enlarging the

original wound as described in par. b (3) above.

(2) A formal thoracotomy is rarely necessary except in thoraco-abdominal wounds

where it is planned to perform both the thoracic and abdominal operation through a single

incision.

15. Closure of Wounds of the External Genitalia

Experience has shown that wounds of the genitalia, especially the scrotum, tend to

break down when they are tightly closed primarily. It is desirable either to leave the

wounds open or to suture them loosely.

16. Eye Casualties

a. Atropine Sulphatc

To prevent the formation of posterior synechia whenever possible, all casualties

with evidence of intra-ocular trauma will be treated with one (1) percent sterile atropine

sulphate solution or atropine ointment three times per day. Regardless of the evacuation

status of the patient, this treatment will be continued until ordered otherwise by an

ophthalmologist.

b. Penicillin and Su•iphadiazine in Nonbattle Injuries

Systemic administration of sulphadiazine and/or penicillin are indicated in penetrating injures to the eyeball or orbital contents exactly as used in other wounds or injuries

of the body.

17. Records

Field Medical Records must contain all pertinent clinical factors relative to preoperative and post-operative care. Inadequate records hinder proper care in general

hospitals after evacuation of patients from Army areas.

By order of the Chief Surgeon: /s/ H. W. Doan

H. W. DOAN

Colonel, Medical Corps,

Executive Officer.
APPENDIX E

Evacuation by Landing Ship, Tank, From the

Normandy Beaches

D. P. Hall, M.D.

Operation OVERLOAD), destined to break the po•wer of Nazi Germany. was directly

dependent on landing craft which could transport a grand total of 20,111 vehicles and

176,475 men on an amphibious assault against the shores of Normandy. The LST (landing

ship, tank) was said to be the most important instrument of war in the European theater.

Sir Winston Churchill once observed: "The destinies of two great empires seemed to be tied

up by L.S.T.'s."

On 10 May 1944, U.S. Army hospitals in the United Kingdom received orders from

Headquarters, ETOUSA, to send selected enlisted technicians and medical officers capable

of performing surgery of trauma to designated channel ports in England for a period of

training in the handling of casualties on LST's from the invasion beaches back to English

Channel ports.

The LST was the only available craft suitable for the dual role of evacuating large

numbers of casualties front the invasion beaches and carrying supplies front the United

Kingdom to the Normandy coast. It was wisely decided to equip LST's so that they might

carry from 150 to 200 litter and hundreds of ambulatory patients from France back to

England. For the actual assault phase of OVERLORD, it was decided to staff a given

number of LST's with competent operating surgeons and surgical technicians provided by

the Army.

All of the selected army personnel were sent to U.S. Army hospitals on the Channel coast

of England to be thoroughly indoctrinated as to their various responsibilities before and

during the invasion. The following tasks were specifically stressed for the surgeons: (1)

Perform such third-echelon surgical treatment as was practicable, consisting in the main

of lifesaving surgery and early debridement of mangled and traumatic injuries; (2) act

as surgical consultants to the LST crew. For planning purposes a load of 200 litter casualties was considered to be maximum for an LST. Medical materiel, therefore, was supplied

to each LST on this basis. Each LST was provided two standard surgical kits consisting

of all surgical instruments that might be used for general traumatic surgery and a medical

technician's kit for each technician. In addition, a special surgical outfit which consisted

of instruments that might be needed In abdominal or thoracic surgery was issued to each

army surgeon. Eight beach bags were provided which contained sufficient battle dressings,

morphine, sulfanilamide, and splints to care adequately for the maximum number of

wounded. Ten pints of whole blood, biologicals, plaster of paris, dextrose solutions. chemical warfare ointment, and 12 units of plasma were placed on board to be carried on the first

trip of an LST to the beachhead. Automatic replenishment of expendable items was to be

provided on the return of LST's to the English coast.

During the preparatory phase of organization and training on the Channel coast of

England, Lt. Col. (later Col.) Robert M. Zollinger, MC, Senior Consultant in General Surgery

for the ETO, visited all training groups and gave wise counsel as to emergencies that might

arise and directed the final preparations. Credit for the idea of using rubberized cloth

(Batiste) in the place of sterile drapes should go to Colonel Zollinger. This material could

be easily cut to any desired dimension and sterilized by boiling for 15 minutes. It proved

to be quite an Innovation in the more speedy draping and handling of wounds.

985
986 ACTIVITIES OF SURGICAL CONSULTANTS

On 3 June 1944, all U.S. Army surgical teams were transported to different ports along

the English Channel and fplaced upon waiting LST4s. Aboard the LST. each medical officer

oriented himself and saw to it that the operating theater, which had been built at the rear

of the tank deck, was in order. lie also made sure that medical supplies were dispersed at

different stations on the LST so that if one source of supply should be destroyed in battle

others might be available.

On 4 June, the LST's, with overhead barrage balloons and loaded with combat soldiers,

tanks. anl vehicles. put out into the English Channel. There was. however, such a heavy

gale that. when they made their rendezvous, orders were received to return to port and wait

for 24 hours.

On 5 June, the LST's in convoy made for open Channel to become an integral part of

the greatest armada in history. There were 9,000 ships and landing craft protected by 702

warships and 25 minesweeper flotillas. Some were destined for Omaha Beach: others.

for Utah Beach. Those carrying British and Canadian personnel were routed to Juno.

Gold, and Sword beaches.

On 6 June, D-day, almost all LST's were within easy reach of the Normandy coast.

Most of them had beached by D+-1/, and a few were beached later on D+2 day. Disgorging their cargo of combat soldiers, tanks, and vehicles, they were made ready for receiving

casualties.

On arrival off Normandy, excitement and tenseness was everywhere very apparent

because of going into the battle area under the constant bombardment of the French shore

by friendly combat ships with 4-inch to 16-inch naval guns, followed by flashes from the

German shore batteries all along the coastline. The first night on the beach was indeed

revealing. Some of the LST's had opened antiaircraft fire on German planes against

orders for the night. This fire immediately brought about rapid retaliation by the German

air raiders, who dropped phosphorous and magnesium bombs along the beach. When the

enemy planes ceased their attack at daybreak, many casualties were found on the beach,

and the work was cut out for the surgical teams. On Omaha Beach most of the casualties

were from the 1st and 29th Infantry Divisions of the U.S. V Corps. Those received and

treated at Utah Beach were from the 82d and 101st Airborne Divisions, U.S. VII Corps.

On D+-/2 and D+2 days, LST's began to receive casualties in larger numbers on the

beaches, and routine surgical treatment, such as control of hemorrhage and shock by

plasma and whole blood transfusions, was instituted. Fractures were immobilized with

splints of plaster of paris. Pain was eliminated by morphine and, when necessary, by

ether or Pentothal sodium (thiopental sodium). Infection was combated by the use of

sulfanilamide and penicillin; tetanus toxoid and gas antitoxin were given. In any case

where there was obstruction of the airway, a tracheotomy was done.

Definitive surgery was done only as a lifesaving measure with careful consideration

in favor of conservatism, due thought being given to the possible time interval before

definitive treatment could be provided at U.S. Army hospitals on the English coast. Definitive surgery was done in severe chest and abdominal wounds. traumatic injuries of the

buttocks. and compound fractures of the extremities with damage to the main blood supply.

Triage became a very important duty of each army surgeon on the beach, as sorting

was a necessity in the proper handling and treatment of the casualties. This triage was

done so that, upon arrival of casualties from France at the English shore, pertinent information was at hand and available to medical units receiving the evacuated casualties.

The wounded were divided into ambulatory and litter cases. The litter cases were further

diviled into transportable and nontransportable patients. Casualties were classified as

transportable when it was considered that they could safely tolerate overland transportation, after debarkation in England, before requiring surgical attention. All those who

would require inmmnediate surgical attention and, or, early surgical intervoition upon reaching the English shore were classified nontransportable.
APPENDIX E 987

An EMT (Army Emergency Medical Tag) was used on all wounded. On the back of

this tag, a supplemental record was kept, for use in the event the patient should require

definitive surgery. A brief indication of the type of wound, such as head, chest, or

abdomen, was placed on the EMT.

Some of the wounded transferred from the Normandy beaches to LST's had received

first aid treatment but had lain on the beach for 12 hours in the clothes in which they

were wounded. Most wounds were covered by a shell dressing, and few had received any

other medication except morphine. Many were dehydrated and anxious because of loss

of sleep. Supportive treatment in crossing the Channel to the English hards and quays

required much time. Several chest and abdominal wounds necessitated operation. But.

by far the greater number were compound fractures requiring immobilization and wounds

of soft tissues-including the buttocks-requiring debridement. Because of associated

rectal wounds, several colostomies were done on casualties with wounds of the buttocks.

A few German casualties were received. All these prisoners had been psoorly treated

and dressed, but none had received tetanus antitoxin. Most of their wounds had not been

debrided but only packed with petrolatum-impregnated gauze to prevent hemorrhage. Unfortunately, the petrolatum-impregnated gauze became a plug and not a drain. The result

was a grossly contaminated wound with an occasional gas gangrene infection. All these

wounds were debrided, cleansed, and dressed, and the prisoner patients were given tetanus

and gas antitoxin, plus sulfanilamide, en route to England.

Of the wounded received on LST's, the relative regional frequency of their injuries

was estimated to be: Extremities, 50 percent; abdominal. 12 percent: thoracic, 9 percent;

thoracoabdomninal, 1.5 percent; and all other, 27.5 percent.

Many of the LST's caring for casualties made three or four crossings of the English

Channel. after which time the Allied invasion forces had gained a good beachhead on the

Normandy coast, and airstrips were quickly laid down from which wounded could be

evacuated by air to England. Evacuation hospitals and field hospitals were set up at

nearly the same time as the airstrips, thus ending the need for LST's as casualty carriers.

As a consequence of mission accomplished, all army personnel were ordered back to their

respective hospitals.

The army surgeons and technicians who participated In the LST evacuation operations during the Normandy invasion deserve the highest commendation for outstanding

courage and devotion to duty under fire. Remember, many had been civilians only a few

months before. The writer is sure that the aid, comfort, and lifesaving services given by

the relatively few men who made up the surgical staff on the LST's deserve much credit

for the reduced mortality and morbidity rate attained among American wounded during

the invasion of Normandy.

The Normandy countryside is now green and peaceful. The townfolk of Sainte MLrefRglise are free to stroll along Omaha or Utah Beach, but one wonders if they remember

the beached LST's, one of the vanguards of their freedom and the refuge of the wounded

Yank.

705 095- -64- ..-. 65
APPENDIX F

Treatment of Maxillofacial Injuries

(Extract from Manual of Therapy, European Theater of Operations)

A. Primary Surgical Treatment.

I. General Considerations.

1. A correlated plan of treatment, if carried out from the time the wound is incurred until definitive treatment is available, will greatly shorten the period of disability

of patients with face and jaw injuries, and a larger number will be restored to approximately normal function and appearance than if haphazard methods are followed. Certain

things should be done and others should not be done. Hence, attention to these points

will save many lives and facilitate later treatment.

2. The use of local and systemic chemotherapy is indicated as for wounds of other

parts of the body. This is particularly important in the treatment of massive wounds involving the floor of the mouth and those associated with compound fractures.

3. Primary care, points demanding special attention.

a. Control of hemorrhage.

b. Provision of adequate respiratory airway.

c. Temporary approximate reduction and fixation of maxillofacial fractures and

adjustment of parts to anatomical position. (Relief of pain, treatment of shock, and other

emergency measures as indicated.)

d. Early evacuation to a hospital for definitive treatment.

If. Specific Considerations.

1. Control of hemorrhage.

a. Control moderate hemorrhage by pressure from gauze compress and bandage.

b. Hemorrhage not controlled by pack and pressure will require clamps and ligature of the bleeding vessels. In case ligature is not available and clamp is left on. it should

be included in the bandage and marked.

c. _,a severe hemorrhage, life may be saved by application of digital pressure to a

bleeding vessel at a control point in its course, until a clamp and ligature can be applied.

d. DO NOT increase respiratory difficulty by the application of gauze compress

and bandage. Bandages should not create backward pressure or traction distally on

fractures of the mandible.

2. Provision of adequate respiratory airway.

a. Clear mouth and throat of tooth fragments, detached bone fragments, broken

or dislodged dentures, and all foreign matter.

b. Insufficient respiratory airway can be improved by the insertion of "a rubber

tube through the nose or mouth to the nasopharynx.

c. Critical cases may require intra-tracheal tube.

d. Tracheotomy should be done promptly if more simple measures fail to provide

an adequate airway. In some cases of massive injury about the jaw and pharynx,

tracheotomy will be necessary as an emergency life saving measure

e. In case of collapse of pharynx and floor of the mouth, or loss of control of the

tongue, an airway can be maintained by holding the tongue forward. This can be aecomWdished by passing a suture through the tip for holding it forward. (In extreme emergency

cases safety pins have been used to transfix the tip of the tongue.) Fractures of the superior inaxillae frequently disphlae the loose structures downward and backward and(] definitely

interfere with respiration. Bilateral comminuted fractures of the posterior part of the

989
990 ACTIVITIES OF SURGICAL CONSULTANTS

mandible may cause the chin segment to drop downward and backward, likewise causing

respiratory interference. In either case, the front of the jaw may be held forward by a

simple emergency splint.

(1) Material.

Wooden tongue depressors, 4

Adhesive tape.

Bandage, 2-inch.

Ligature wire.

(2) Construction.

Two tongue depressors are placed end to end and are held by two others overlapping them iii the middle, all being bound together with adhesive tape.

(3) Application.

(a) This unit is secured vertically in the frontal region with a circular

bandage so that the lower end is projected in front of the mouth. The upper end is attached

to the bandage in the occipital region with a piece of tape.

(b) A wire ligature is attached to the lower teeth or passed around the chin

segment of the mandible, and the ends of the wire fastened to the lower end of the tongue

depressor piece, either directly or with a rubber band.

(c) The spring of the tongue depressor piece or elastic traction effectively

keeps the anterior segment of the mandible forward. Likewise in cases of backward displacement of the maxillae, forward traction can be obt'Woed by attachment of the upper

teeth to the apparatus.

3. Temporary approximate reduction and fixation of maxillo-facial fracturcs a•ul

adjustmnent of displaced parts to anatomical position.

a. Institute adequate measures for relief of pain and prevention of shock. Morphine should be administered cautiously to patients with respiratory difficulty and is contraindicated for patients with associated cranial injuries.

b. Cleanse wound superficially, removing tooth fragments, detached bone particles

and foreign matter.

c. Displaced parts should be gently adjusted to anatomical position and gauze

compress and bandage applied. Avoid collapsing bone segments and prevent backward

traction on the mandible.

d. Maxillary fractures and fractures of the adjacent facial bones should be gently

supported by stable bandaging. In primary treatment, this stabilization can be improved

by the application of gauze compresses and bandages used to control hemorrhage. It is

essential to aid at re-establishing the former occlusion of the teeth, therefore all bandages

applied should be supportive in this direction. Wire ligatures and suture material, if

available. can be applied to the teeth of the same jaw across the line of fracture, to assist

in stabilization of parts during evacuation. Multiple loop wiring, with intermaxillary

elastic traction for reduction and stabilization of certain fractures, should be accomplished

as early as time and facilities permit. Rigid intermaxillary fixation with wire is definitely

contra-indicated In primary treatment for any case that might become nauseated or develop

respiratory Interference during evacuation. Edentulous cases require bandages that gently

support the parts and avoid the tendency to collapse the segments. Dentures should be

located, if possible, for use with adjustment and splinting of alveolar parts. These should

always be transferred with the patient (even if broken).

e. Stabilization of parts is essential to avoid recurrent hemorrhage, reduce pain

and prevent shock.

f. A stimulating dose of tetanus toxoid is indicated as for wounds of other parts

of the body.

4. Evacuate patients to a hospital or station where definitive treatment can be provided early.

a. Ambulant or semi-ambulant patients with oral or pharyngeal wounds should

travel sitting up, if possible.
AlPPEFNI)iX F 9)91

b. Litter paltients should( lie pilalced ill 3t comifortaible positio 1411311 pronle (faice down)

so that there is Ito possibility of interference with respiratoiry airway or alspirationu of fluids.

B. D efinitive Surgical Treatment.

1. General CoNsiderations.

1. Superficial wounds tire classified as those wounds of the face in which there is no

evidlence of fracture of facial hones, or deep penetration. T1hese wounds.. when seen early,

nmay be closed by plrimary suturing, prorided they are relatively clean and catn be thoroughly cleansed and carefully debrided. Severe naxilllofaclal woundos with loss of tissue,

esp~eciall~y those resulting fronm gunshot, should not be closed by pirlimary suturing. SpieciaIl

izedi care should he institutedl 3s early its personnel, timie 3111( facilities permit.

2. Anest hesia is seldomn required for tile initial care of mnaxillofaclal injuries before

evacuation to ain installation where definitive surgical treattin-nt can be acom'iplishied.

When tin anesthetic is Indicated, first consideration should be given to regional infiltration

or nerve block anesthesia for surgical treatment of severe trainuiatic lesions about the face.

General anesthlesia mlay he necessary if t rauhmia involves structures in the nose. inouth or

pharynx. Maiintenmanc'e of all airwaly a111d prevention of seepage of blood into the trachea

is essential. Tile use of Pentothal [ sodium] is hatzardous and is cont ra-indicated iii presence

of shoc-k. Inhalilation anesthesia is indicatedl. Introduction of ain entlotraclleal tube. eithler

through the monothl or nose, as cond~itions dictate, Is highly desirable. Maintenance of

Trendelenburg position (100 ) will protect against seepage into the lung by promloting drainage of blood allo secretions Into tile phlarynx where they can easily bie reirioved by suction.

Inlsertionl of wvet packs into the p~harynx is ailso Indicated to establish a closed system. If

extensive traunia withiln the mouth or phalryn~x is likely to be followed by eclenta or emphysenia, it, may be necessary to establish 31 tracheall stonma prior to surgical treatment of the

p~rimary lesion, anol to use thlis avenue of approach for administration of tile anlesth~etic by

Inhalalltion amid subpsequently for aspiration of excess secretions.

11. Specific Considerations.

1. Reduction and )1zatioti of fractures andl adjusnt meat of part s to aniatontieal position.

31. Secure consultation and aid of dental surgeon if avalilable.

1). IDo not manipulate fractured fragmlents of maxillae In the plresence of fractures

of the base of the skull and accompi~anying injury of tile brain until drainage of fluid 1131

ceased anad patilent's condition11 a pproximnates normal.

c. Fina~l control of hemorrhage. 1.se small hemostats and fine ligatures. Ligate

locally arid not in course of tile vessel and mlaintain maximum blood supply to the parts.

d. Tihe wvoundl should bie cleansed thoroughly under the best surgical conditions.

Remove til1 tooith fragmlent-,. foreign nmatter, detached pairticles of bone and dislodged teeth

In line of fracture, since these are elements that Invite Infection. Do conservative debridement of soft tissues. Excise only tissue that is% completely devitalized and tissue wvhich

obviously has no chance of survival. Protect nerves, vessels, ducts an(1 glands. The use

of smaill cutting needles and fine sutures placed niear approxinmating skin edges will aiid in

pirevenltion of stiture sca~rs. Skin suitures should be remioved early.

e. /tonic particles that still p088(55 pcriostcal attachment Rhould nicrer be rc~norcd,

since thcst, sma(ll vital attachments mnay make all the difference bet wccep eoposolidatiopi and

nemv bone formation with rcstorcd function, and collapsed fra gments with the attendpant

eopnp~ieuitions: cevenp coniminuted viable bone should be saved.

f. In cases of mnassive loss of substance. adjust soft tissue arid restore torn flaps

to normlial popsition. Suiture mucous miembranme to skini edgc..' to cover raw surfaces and0 to

preserve skin and milucous mlemubrane. Avoid closures under tension I hatt lrotluce (overlappling of fractured ends of bone or colliipse of hone fragmnents. Provide adequate (dependent drainage to deep penetralting wvounids, and espieclially those commnunicating witll thle

mouth. Immediate sulture is only advisable In supierfichil wounds and wvounds Ihait can

receive proper care wilthinl a few hours aifter injuiry.
992 ACTIVITIES OF SURGICAL CONSULTANTS

g. Fractures of maxillae and mandible.

(1) Complete roentgenographic studies should be an integral part of definitive

treatment.

(2) Aim at re-establishing the former occlusal relationship of. the teeth, and

ultimate restoration of dental function. Collapse of bone segments should be avoided in

cases with loss of structure.

(4) The use of labial arch bars or wiring of the teeth of the same jaw across

the line of fracture may be indicated for stabilization during evacuation.

(5) Rigid intermaxillary fixation of the lower teeth to the upper shoidd not be

used prior to unattended travel. Intermaxillary elastic traction may be used safely for

this stabilization since the mouth can be opened in ease of nausea and the elastic bands

easily removed or tension regulated as indicated.

(6) Immobilization of fractures can be accomplished by the application of intramaxillary multiple loop wires and intermaxillary clastics, for reduction and fixation, when

sufficient teeth remain in each jaw. The application of a vertical circular bandage with

lnild buecal elastic traction may be indicated for auxiliary suplport of maxillary fractures.

(This bandage, made of plastic material, will eliminate the collapsing tendency of ordinary

bandage.)

(7) Sectional dental splints of proper design and construction may be used

to advantage in the treatment of complicated cases for immobilization when limited function is desirable.

(8) Edentulous fractures require the skillful application of supporting bandages

to maintain the parts in proper position, without causing collapse of segments or interference with airway. Dentures are particularly important as they can often be used in

connection with supporting bandages or circumferential wiring.

(9) Another method of reduction and retention of edentulous cases, or those

with displaced edentulous fragments, is afforded by the application of the extra-oral skeletal

pin and bar fracture appliance.

2. Every effort should be made to provide trained personnel for the care of maxillofacial injuries throughout the combat area. Adequate life-saving measures and early

treatment are necessary to insure the casualties getting to the hospitals of the next

echelon for more definitive treatment. The execution of a well-correlated plan of treatment throughout will not only save life but result in many casualties being returned to

duty after a minimum period of hospitalization. End results are of great concern and

usually said to be directly proportionate to the nature and character of the early treatment

received. Patients with maxillofacial injuries, requiring extended care and reconstructive

surgery, should be transferred to the Zone of Interior when the treatment has progressed

to such a stage that evacuation ('an be safely accomplished.
APPENDIX G

T1reatment of Burns

(Extract from Manual of Therapy, European Theater Ot (tpcrations)

A. Primary Surgical Treatment.

1. General Considerations.

1. A high erct ýtage of burns are received accidentally tl'oiogh carelessnless and

negligence. Efforts should be miade to prevent huruis by emphiasizing the dangers associatled

with handling gasoline and other inflaminmalle materials, and instituting suitable safety

imeasures.

2. Iii the early management of a b~urn casualty, the primary considerations are: -

at. Prevention and control of shock.

1). P'revention of contamination of the burn surface during trea tnient amd

evacuationi.

11. Specific Considerations.

Initial care.

1. Control of pain by miorphiine admlinistration. In extensive burns, '/._ grain doses

of nmorpihine may lie necessary. If anoxia is present, large (loses of morphine are dangerius, and under such circunmstances the dlose should not exceed 1/4 grain. If the patient

is iii shock, ablsorpitioni of subcutaneous or intramuscular morphine imay be delayed, in

which c'ase repeated doses of miorpihine should be givenl with caution. Relief of shock and

limprovem-nt, iii lH'nilheral circulation inay lead, to rapidl absorption and Eiver-(losage if

morphine hans loeen repieated in smch cases. Cnreful admilnist ration of intravenous nmorphine

has the advantage that pain is more promptly and certainly controlled. andl the danger

of over-(losage from repeatedl subcuitaneous or intra muscula r administration is nullified.

Doses of 1ý1 to l'/4 grain, given slowly in 10 cc. of sterile dIstilledI water or salinle, and

repeated as necessary, is perhaps thle safest method of intravenous nmorpihine administration.

2. Early pilasma replacement therapy should be instituted. If evacuation cannot be

carried out quickly to a place for (definite therapy, plasma should be started as Part of

the first aid measures. If one( or two units of plasma ('all be given early, even in the first

half-hour, lives may be saved. Quantities of pilasma upl to twelve units mnay be required

in the first twenty-four hours for extensive burns. If thle patient is in shock when pilasnma

is started, the first two or three units should lie given rapidly.

3. From the first, efforts should be mnade to prevent c'ontanmination of the burn

surface lby nose and throat organismns. Those hiandlinig thme patient should always lie

mnasked. If imasks are not available, they can lit e impirov-ised. Asepliem technitiquie, w'ith

gloves andl instruments if possible, should be usedl at all times.

4. C'asualt ies wvit 15'I ((or oiver (of bmody surface biurnied shold h114 e t reaited !is litter

Pat lents inmmmedliately.

.0. C'lothlinmg need-4 not. lbe removed uniless too dirty, charred, contaminated or soaiked

with oil or chemicals.

(;. No c'leanmsing ir (lelridellemit should lie! att emupted in thle field. This procedure

should onily lie doloe ill hospitals w~here complete facilities for definitive treat menit are,

avail ablle.

7. Coveri'~ the wounid with sterile d(Iresings. trnianigula r bandages. or ('leana sheets.

Evacuiate ito)litspita I for definitive treat imiemt. of the bumrnedl area as quickly as poissibile.

Boric acid oiintmenmt tor Vaseline applied to a grossly 'contaminatedl burn 'omplia';les thle

later cleansing o f teIm br m surfac'e. If at local appl ication is considered nmics-sarmy, 5'7

9913
994 ACTIVITIES OF SURGICAL CONSULTANTS

sulfadiazine cream is preferred because of its bacteriostatic effect and its relative ease of

removal later if cleansing and debridement are considered necessary.

8. Application of sulfadiazine cream. boric avid ointment or petrolatum to a grossly

contaminated burn are not to be considered as definitive treatment.

9. Eyes should be gently irrigated with saline or boric solution, and a mild ointment

(4% boric acid ointment), or oil instilled. Do not apply sulfadiazine cream to the eyes

or lids, since it is extremely irritating to the conjunctiva. The lids should be closed with

a pad of dampened gauze over them and a dry one held with adhesive, if possible, as the

best dressing for the cornea is the lid. Cocaine or other anesthetics should not be used,

as anesthesia of the cornea might lead to damage. If there is evidence of corneal injury,

the case requires the attention of an ophthalmologist as early as possible.

10. Severe burns of the hands, or of one hand alone, should be considered as major

burns and evacuated to a hospital for definitive treatment.

11. Tetanus toxoid is indicated for all patients with second or third degree burns.

12. Tannic acid, tannic acid jelly, triple dye, gentian-violet, gentian-violet jelly, and

other membrane forming applications, should NOT be used.

13. RAPID EVACUATION TO DEFINITIVE TREATMENT SHOULD BE EFFECTED.

B. Definitive Surgical Treatment

I. General Considerations.

1. Each hospital should be prepared at all times with a burn team and a plan for

admission, sorting and treatment of multiple burn casualties.

2. In the very early stages the treatment of shock and hemoconcentration takes

precedence over local treatment of the burn.

3. Definitive treatment of the burned area is given at the first opportunity presented

by the condition of the patient and the presence of adequate hospital facilities. It is

aimed at obtaining and maintaining a v-und free of contamination and infection.

II. Specific Considerations.

1. Sy8temic Treatment

a. Plasma must be given to maintain blood volume. A simple method of estimating the amount of plasma necessary is that of adding 100 cc. of plasma for every point the

hematocrit determination exceeds the normal of 45. Another rough method is that of

administering j00 cc. of plasma for each 10% of the body surface burned. The adequacy

of plasma administration can be determined by frequent red blood cell, hemoglobin, and

hematocrit determinations. An effort should be made to keep the red blood cell count at

5.5 million or below, the hematocrit reading below 50, and the hemoglobin down to 100%.

The general condition of the patient, the pulse and blood pressure, are other invaluable

guides.

Continued plasma therapy for three or four days may be necessary, and, following this, plasma should be given at intervals to maintain the blood proteins at a normal

level.

b. A standard met hod of estimating body surface burned is by use of the ilerkow

formula, as follows:

Head -------------------------------------------------------- 6%

Upper Extremities:

Both arms and forearms -------------------------------------- 13%

Both hands -------------- ----------------- 5%

Total ---------------------------------------------------- 18%

Trunk and Neck:

Anterior surface - ------------------- 20%

Posterior surfac( ----------------- ----------- 18%

Total ------------------------------------------------------------ "-8r
APPENDIX G 995

Lower Extremities:

Both thighs ------------------------------------------------- 19%

Both legs ----------- --------------------------------------- 13%

Both feet --------------------------------------------------- %

Total ----------------------------------------------------- 38

c. The need for whole blood transfusion will develop in some cases as early as 2-3

days after the burn is incurred. Plasma is not a substitute for whole blood if secondary

anemia is present.

d. A urinary output of 1.000 cc. to 1,500 cc. daily must be established as soon as

possible. In the first 24 hours after an extensive burn, it is more important to effect adequate plasma replacement, than to give parenteral crystalloids. During this period it is

believed that the -salt requirements are met by the salt content of the plasma administered.

The daily fluid intake should be maintained at 3,000 cc. to 4,000 cc., and, if parenteral fluids

are necessary to reach this level, chief re'iance should be placed on 5% glucose in distilled

water. Saline should be given sparingly, usually only if there is vomiting or some other

cause for salt depletion. As a general rule, not over 1,000 cc. of normal saline should be

given over a 24-hour period.

e. During the critical phase (which may last up to 72 hours or longer), the

patient must be closely observed for tile development of pulmonary edema, shock, morphine

overdosage, or the development of cerebral manifestations. Oxygen therapy is often

indicated during this period.

f. From the first, the importance of maintaining the nutritional state of the

patient should be kept in mind. Every effort should be made to give adequate food and

liquids with a high content of carbohydrate, protein and vitamins.

g. A prophylactic dose of polyvalent gas bacillus antitoxin may be given for deep

burns at the discretion of the medical officer.

2. Clcansing and Dcbridcmcn t.

a. No attempt will be made to clean or debride the burn surface until shock is

adequately controlled.

h. The wound will always be treated under standard operating room technique

with patient and attendants fully masked.

c. Morphine sedation will be adequate to allow debridement and cleansing of the

wound in the majority of cases. Intravenous morphine may be indicated in some instances.

If general anesthesia is necessary, first consideration should be given to light intravenous

Pentothal sodium. Inhalation anesthesia is contra-indicated if an associated blast injury

Is present or suspected.

d. In some cases, if the patient is received a short time after the burn is incurred,

and if the wound is free of gross (contamination, cleansing and debridement may be considered unnecessary.

e. Those burns showing gross contamination should be cleansed with neutral soap

and water, and irrigated with saline. Lard, mineral oil or ether, in small amounts, may be

used for removal of grease and heavy oil. The cleansing should be done gently with gauze

or cotton swabs. Green soap and brushes will not be used. The cleansing should include

the skin surrounding the burn.

f. Removal of loose shreds of epidermis and large blisters should be done after

thorough cleansing. Small blisters may be left undisturbed, or removed, depending on the

extent of the procedure necessary and the condition of the patient.

g. Immediate excision and grafting of burns has such limited application that It is

not recommended.

h. Debridement should not include excision on loose skin from the cyclids, cars

or fln qcrs. Blisters in these areas may be incised after cleansing.

3. Drcssing.

a. The burned area should be covered with single strips of fine mesh gauze (44-

mesh gauze bandage), impregnated with 5% sulfadiazine cream, boric acid ointment or

705 095- 64--- 66
996 ACTIVITIES OF SURGICAL CONSULTANTS

petrolatum. S'idfadiazine cream is preferre.d because of the early high local concentration

of the drug obtained. It does not stand autoclaving and should be prepared at the operating

table by spreading thinly on 44-mesh gauze bandage. Sulfanilamide powder may be used

with boric acid ointment or petrolatum, but the total dose should not exceed 10 grams.

Local sulfonamide therapy is only of value as a prophylactic against virulent infection in

the early stages. It is useless after pus has developed from ordinary lpyogenic infection of

the deeply burned areas. Ordinarily there will be no indication for continuation of local

sulfonamide therapy after the first dressing, which, in a favorable case, (cn be lxostponed

to between seven and fourteen days.

1). The remainder of the dressing will consist of gauze, absorbent cotton, cotton

wvaste. or (ellulose. The (dressing will be thickly applied over all the burn and will be

bandaged on snugly with even pressure throughout. Stockinette or some form of elastic

bandage may beI used. if available, to maintain pressure. (Care should be taken to prevent

the pressure dressing from forming an area, of constriction. In the case of extreimities, the

pressure dressing should include the entire extremity distal to the burn.

c. Immobilization of the part by plaster splints placed over the dressing should be

effected when possible. Skin-tight plaster casts should not be used. If a (conmplete plaster

casing is applied, it should be split to allow for swelling.

d. Burned hands should be carefully dressed with pressure to, and including, the

tips of the fingers. The hand should be in the position of function with fingers separated

and flexed. Edema is further prevented by elevation, which is best accomplished by

overhead suspension attached to plaster arm splints applied over the pressure dressings.

e. Pressure dressings are applied to the face as elsewhere, taking care to protect

the eye, pad the ears, and leave an adequate respiratory airway.

f. Genitalia should be covered with 5% sulfadiazine cream and simple dressings.

The dressings should be applied in such a manner that they can be changed separately as

necessary.

g. Dressings should be changed infrequently in the early stages of a burn, and, if

possible, tie dressings should be done in the operating room with standard aseptic technique.

h. In some instances it may be necessary to change the dressing at four to five

days on a clean and uninfected case, because of external soiling or soaking of the dressing

by exudation of plasma. In such cases, it is often satisfactory to change the bulky outer

portion of the dressing and not disturb that immediately over the burn surface.

4. Sulfonamide Therapy

a. If a sulfonamide is used locally, oral or parenteral administration of the drug

should be postponed until adequate kidney function is demonstrated by a daily urinary

output of 1,500 cc., and the blood sulfonamide has dropped to a low level. After this period,

if evidence of sepsis develops, oral therapy should be instituted and continued as indicated.

b. All cases with moderate to severe burns, that have not had local sulfonamides

applied, will be started on oral chemotherapy. Sulfadiazine is the drug of choice for oral

administration (sulfanilamide may be substituted). It should be given with caution in

the early stage of a burn, and the dose should not exceed 0.5 gram every four hours until

the urinary output has reached a normal level. Frequent blood level determination should

be done.

5. Further Care of Burned Surface.

a. If virulent infection is prevented, healing of superficial burns will take place

rapidly.

b. After a period of about two weeks, infection of deeply burned areas by ordinary

pyogenic organisms will make frequent dressings necessary in order to maintain cleanliness a nd promote separation of slough.

c. Wet dressings using saline, boric, I)akin's or azochloranmid solution for irrigation

should be applied and changed daily.

d. Dressings should be wet before removal.
APPENDIX G 997

e. If possible, saline baths should be used for ease of removal of dressings, for

cleanliness and to promote active exercises.

f. Unhealed areas should be prepared for grafting, and grafts applied as early as

possible. It is often possible to begin grafting within three or four weeks after the burn

is incurred.

g. Active motion should be instituted in severe hand burns not later than seven

days following the injury. This can be facilitated by removing the dressing and placing

the extremity in an arm basin filled with saline.

6. General Care.

a. Whole blood transfusions may be necessary as early as three or four days after

the burn, and at regular intervals thereafter until the case is healed or grafted.

b. A diet high in calories, protein, carbohydrate and vitamins should be maintained.

c. The blood protein level should be observed and kept at a normal level by plasma

transfusions as necessary.

d. Careful and sympathetic nursing care is an absolute essential.
APPENDIX H

4 SEPTEMBER 1944

MEMORANDUM TO: Colonel Elliott C. Cutler, MC, Senior Consultant in Surgery, European Theater of Operations.

SUIBJECT: Recommendation for Care of Hand Injuries in the Zone of Interior.

1. Many severe hand injuries are being seen on the plastic surgery services of the

general hospitals in the United Kingdom. An attempt is being made to accumulate these

cases from other hospitals into hospitals for plastic surgery, where they can be cared for

jointly by plastic and orthopedic or general surgeons. The experience with these cases

has given the distinct impression that most surgeons do not realize the possibilities of

plastic surgery in obtaining early and adequate closure or covering of the wounds with

massive soft tissue and skin loss. Many wounds are left open too long, with the result

that prolonged splinting, infection of the open wound, sloughing of exposed bone and

tendon, will result in crippling that is out of proportion to the severity of the original

injury.

2. Of all cases that deserve special consideration, none are more deserving than hand

injuries. It is the responsibility of surgery in this theater to see that the soft tissue

loss is replaced early in order to limit progress of the disabling pathological processes

that result from an open wound. This procedure should be done early, before evacuation

to the Zone of Interior. An Article has been submitted to the Medical Bulletin, European.

Theater of Operations, pointing out that hands and other injuries of the extremities that

require extensive soft-tissue and skin replacement should be referred to hospitals in which

plastic surgery is being done. The number so far subjected to early plastic surgery procedures is only a small percentage of the total that must be in hospitals of the Theater.

3. An increasing number of hand injuries are being sent to the Zone of Interior,

following pedicle grafting here. These injuries are of all degrees of severity and many

of them will require late reconstructive surgery. The pedicle grafts, in addition to halting

the increasing incapacity that results from an open wound, will make it possible for

the early institution of physiotherapy and reconstructive operations. The cases will

present problems of bone, tendon, and nerve grafting that are completely beyond the

scope of the ordinary surgeon. It is very strongly felt that these cases should not be

operated upon by any but surgeons who have had some background in this type of work,

and in hospitals where the work can be controlled.

4. It is the opinion of this Office that such cases should be accumulated, for their

later care, in special hospitals, under the joint care of specialists qualified in this type

of work.

/s/ Eugene M. Bricker

EUGENE M. BRICKER

Lieutenant Colonel, MC

Senior Consultant in Plastic Surgery

999
APPENDIX I

5 MARCH 1,45

MEMORANI)UM TO: Colonel Mather Cleveland, MC, Senior Consultant in Orthopedic

Surgery. European Theater of Operations.

SUBJECT: Treatment of Hand Injuries.

1. The following are the simple principles which I think we should make an effort

to see practiced in this Theater in the treatment of hand injuries:

a. Conservative, meticulous, and proper debridement of the primary wound. The

wound should not be closed primarily in an evacuation hospital, but displaced skin flaps

can be dressed back into place.

b. "Purposeful splinting" always, with maintenance of the palmar arch, and flexion

of the metacarpal phalangeal joints.

c. Closure as early as possible, preferably on the third or fourth day. It should be

accomplished by secondary closure, split graft, or pedicle graft.

d. Traction only in those cases in which it is urgently indicated, and then for a minimum length of time. The fishhook traction which has been developed at the 22nd General

Hospital is probably the best.

e. In some of the severe types of injuries, forget about the restoration of the injured

part and concentrate entirely on maintenance of function of what is left. This may mean

amputation of an irreparably damaged finger in order to get a healed hand.

f. Active motion should be instituted as early as possible. When the hand is healed,

this should be further encouraged by occupational therapy.

g. An effort should be made to avoid the development of a markedly edematous hand

with an infected open wound. Proper debridement, proper dressing, proper splinting, and

effective elevation of the hand will prevent such a development.

h. So long as there is an open wound in the hand, it should be treated aseptically.

This means face masks and instruments or gloves, whether the wound is infected or not.

2. The following points are what I consider to be the requirements of a satisfactory

hand service:

a. The availability of both an orthopedic and plastic surgeon.

b. The segregation of patients so that they are all together and can receive their

exercises simultaneously and benefit by the development of a competitive spirit.

c. Adequate facilities for physiotherapy, with physiotherapists particularly interested

in rehabilitation of hands. In a busy center, this may mean additional physiotherapists.

There should be special provisions in the physiotherapy department for hand exercising

machines, et cetera. If possible, noncommissioned officers who have had hand injuries

themselves should be placed in charge of ward exercises.

[s] Eugene M. Bricker

EUGENE M. BRICKER

Lieutenant Colonel, MC

Senior Consultant in Plastic Surgery

1001
INDEX

AACII, Maj. H. A., 804 Allies, the 41, 170, 239, 252, -293, -.30, 594,

Aachen, 239,524 687, 689, 892

Abuyog, 859, 860 All-Saints Hospital, 477, 479

Academie de Chirurgie, 257. 273 Alsace, 301

Academy of Sciences, U.S.S.R., 428,431 Alsever's solution. 244

ACKERLY, MaJ. R. S., 799 AMD. Sce British Army Medical DirecA-day, 734 torate.

Administrative Division, Office of the Chief Amebiasis, prevalence of:

Surgeon, ETOUSA, 317 in China Theater, 947

Administrative Memorandum- in India-Burma Theater, 931

No. 62, Office of the Chief Surgeon, Americal Division, 799-801, 819, 821, 822,

ETOUSA, 3 May 1944-173, 175, 209 823, 831, 833,836

No. 74, Office of the Chief Surgeon, American Anesthetists Society, ETOUSA,

ETOUSA, 22 May 1944--201-202 589,620

No. 150, Office of the Chief Surgeon, American Board of Anesthesiology, 621

ETOUSA, 27 Nov. 1944-294-296 American Board of Obstetrics and GyneAdmiralty Islands, 668, 700 cology, 663

AEF. See American Expeditionary Forces. cg 663

Aegean Aegen 915American Isands Board of Orthopaedic Surgery, Islands, 91547,4

AFPAC. See Army Forces, Pacific. 472, 674

AFPAC MD Form No. 1-632 American Board of Radiology, 948

Africa, 365,397,604,615 American Board of Surgery, 651,917

AFWESPAC. See U.S. Army Forces, West- American Board of Surgery examinations,

ern Pacific. European theater, 63

Air Command, North Solomons, 814 American College of Surgeons, 94, 99, 435,

Air conditioning in Pacific, 644 652, 660,684

Air Force medical care controversy, 43 American Expeditionary Forces, 1, 2, 3, 4,

Air Force School, American School Center, 20. 23

354 American Library Association, 256

Air Surgeon. the, 114, 189, 247, 440 American Medical Society, ETOUSA, 65,

Air transport, importance of, in utilization of 109. 467

manpower in Pacific, 775 American Red Cross, 70,215,494, 583

Air Transport Command, 240, 651, 654, 682, American School Center, Shrivenhatu, Berk7%63 804, 8)0, 851, 852, 855, 856, 872, 935 shire, 53, 69,354

Al Jizah, 422,437 Amphibious Force, 7th-742, 855, 858, 865,

Aldershot, 16, 477 866

ALEXANDER, Brig. Gen. C. C., 730) Amputation stumps:

Algeria, 422, 591,600 reoperation upon, in Zone of Interior, 245

Algiers, 600,604 skin traction methods In management of,

ALZ PASHA InRAHIM, 437 665,667

ALLEN, Col. K. D. A., 9, 16, 61, 598 treatment of, 662,665,667

ALLE., Col. R. E., 830 use of rubber traction material for, 245

ALLEN, W. E., 582 "Amputation Technique," 465

Allen, S. Ilansburys Itd.. 396 Amputations:

Alleur, 289 directives on:

Allied Expeditionary Force, 107, 187, 197, Circular Letter No. 91, Office of The

256, 318 Surgeon General, 1943-128, 132

1003
10V4 INDEX

Amputations-Continued Appendicitis, in India-Buenia Theater. 930-

Circular Letter No. 101. Office of the 931

Chief Surgeon. ETOUSA. 1944-470 Arabs, 604

Circular Letter No. 131. o)flie of the Arawe, 696

Chief Surgeon, ETOUSA, 1944-470 Arcadia Conference. 391

method of choice in traumatic surgery. Ardennes, 252, 301

128 ARIMA, Maj. J. K., 768, 854n

training film on, 465 Armies:

"A'nAputee morale team," 491 British Eighth Army. 159, 422. 438

An-chiang, 939, 941, 946 British Second Army, 262

ANDERSON, Commodore T. C.. 876 Chinese Army, 903

AN DERSON, Maj. Gen. W.. 26. 50. 354 Eighth U.S. Army, 687. 715, 721, 726, 751.

Anderson splints, use of. in skin-grafting. 767

562 Fifteenth U.S. Army. 2-9,1,322,326. 454

ANDREASSEN. Col. E. C., 456 Fifth Chinese Army, 893

AND.REws. Gen. F. M., 418 Fifth U.S. Army, 121-127, 319

Anesthesia, 348 First French Army, 304, 319

endotracheal, 585. 588, 603, 620. 637 First U.S. Army, 4. 16. 106, 109. 162. 166.

in European theater, 581-621 168, 179, 221. 222. 233, 234, 240, 241,

inhalation, 585, 586, 588, 589, 592. 595, 253-254, 257, 263, 268, 269, 287, 289-'293.

596, 598. 601,603, 609, 621 299, 300. 305. 306. 307, 318, 319. 322-323.

intravenous, 599. 603, 607, 608. 609. 620, 325. 3-26. 327. 333, 366, 371, 372, 378.

621,637,942 035, 608

spinal, 603,607, 614, 616, 637 Ninth U.S. Army. 270-271, 274, 286-288.

Anesthesia and resuscitation training films- 292-29.3, 298, 307, 319, 322, 324-325, 326,

"Endotracheal Anaesthesia," 620 335,336.347

"Intravenous Anaesthesia," 620 Seventh U.S. Army, 239, 264. 270, 280, 292.

"-Open Drop Ether," 620 301, 30-2, 304, 305-306, 307, 319. 326.

"The Physiology of Anoxia. the Basis for 344, 454

Inhalation Therapy," 621 Sixth Chinese Army, 893

Anesthesia program, in European theater, Sixth U.S. Army, 667, 669, 687. 698. 700.

581-621 712, 715, 718, 719, 721, 726, 733, 7T9,

organization of, 584, 587-605 767, 816. 839, 862, 865, 866, 871

supplies and equipment for, 595-605 Tenth U.S. Army, 626, 635, 648, 675. 678,

Anesthesiology, practice of, in European 679. 681,682, 743, 874, 876,877

theater, recommendations of Senior Con- Third U.S. Army, 106, 162, 168, 200, 225,

sultant in Anesthesia, concerning. 588. 234, 239, 264, 269-271, 285, 297. 307,

589. 594, 595, 603, 615 313-314, 319. 326, 328, 329. :334, 370.

Anesthetists, shortage of, in field hospitals 372,378, 454, 605, 608

in Pacific, 646 Armor:

Angaur. 625 body, for infantrymen, development of,

Anglo-American Consultants' Conference, 729-731

Third, 342-349 helmet, acrylic resin, proposed, 412-413.

Annals of Surgery, 385 419, 420

Anomalies, congenital, of the spine with helmet, plastic, 441

respect to low back complaints, 761 helmet, plastic, proposed, 412-413, 419,

Anopheles mosquito, 424, 780, 791 420, 441

Antibiotics, Importance of, in successful proposed flying suit. using plastic. 413,

management of inaxillofacial casualties. 414, 441

538 research investigation in. 884

Antigas school at Aldershot, 16 vest. plastic-protected, 441

Antwerp, 286,287,289 Armor, Japanese. 729

APA. See Transport. attack. Arms and Service Assignment Group. 655

APD. Sec Transport (high speed). AiRMSTRONNG, Col. G. E., 897, 908, 909, 911, 938,

APH. See Transport for wounded. 944,949, 950
INDEX IWI5

ARMSTRONG, Col. II. G., 43, 44, 417 Australian Red Cross, 704

Army Air Forces, 39, 43, 44, (4. SO, 81, 109, Austria, 319

12291, 132, 162, 189, 2(•", 243, 275, 309, 363, Auxiliary surgical groups, 10, 270-271, 612,

365, 370, 400, 424, 440, 441, 489, 4W0, 53(), 613, 756

523, 589, 6-29, 630, 649, 663-664, 687, preparation of, for Operation OVER707n, 714, 738, 925. 9310 LORI), 166-168

Sec also Eighth Air Force; Fifteenth Air specific:

Force; Ninth Air Force. Tenth Air lst-166, 167, 168, 196, 270-271, 37:3. 381,

Force; Thirteenth Air Force. 479

Army Air Forces, ETOUSA, system of con- 2d--122, 305, 405

sultation in, 9 3d--16, 49-50, 65, 81, 86, 166, 167, 2.57,

Army Air Forces, India-Burma Sector, 930 270, 289-2-1, 323, 405, 64)8, 609, 615

Army Air Forces school at "Pinetree." 109 4th-271

Army Forces, Pacific, 626, 632, 682, 74N), 7(0J, 5th-241. 270-271, 286

731, 742 6th-241

Army Garrison Force, Island Command, use of:

Saipan, 850 in communications zone facilities, 168

Army Garrison Forces, Guam, 629 with field army, 167

Army Medical Musemn, 517 Avonmouth, 47, 49

Army Medical School, Walter Reed Army Azores, 889

Medical Center, 162. 767

Army Nurse Corps, 665, 673, OS6 11-24 Liberator, 805

Army Pictorial Service. 494, 6;13. 621 Bad Neuenahr, 324

Army School of Hygiene. 16 BADGER, Lt. Col. T. L., 321

Army Service ('ommand, Southwest Pacific Bairoko Harbour, 794

Area, 884 BAKER, Col. B. M., 675, 784, 789, 798, 804,

Army Service Forces, 731, 797 815, 819, 825, 826, 849, 874, 875, 876, 877, 879

Army Veterinary Service, 890 BALL, Lt. Col. R. P., 51

ARNEST, Col. R. T., 38 Balneological Institute, 429, 435

A.RNOLD. Maj. Gen. A. V., 861 Baltic coast. 319

ARNOLD. Gen. H1. H., 440 Banda Sea, 88.5

Arthrotomy of the knee, directive on, 659 Bankart's operation, 659

ASCOM. See Army Service Command, BARNACLE, Lt. Col. C. IH., 754

Southwest Pacific Area. Barneville, 485

Assam, 893, 8&99,906,933, 937 BARNSLEY, Maj. Gen. E.. 208

Assault Training Center, ETOUSA. 179, 181 Base Hospital No. 51-20, 21

Assembly Area Command, ETOiSA, 454 Base Section, Indian-Burma Theater, 908

Assistant Secretary of War, 329 Base section consultants, 10

Association of Medical Consultants of World Base Section No. 2, India-Burma Theater.

War 11-510 93--937

Atabrine administration, 68.8, 690, 753, 822 Basingstoke, 92, 395, 516

ATC. See Air Transport Command. Basra, 424, 436, 437

Bastille Day, 838

Atropine-morphine, preparation of, in bulk, Batiay, 83

609 Bataan, 863

BATCIIELDER, Col. HI., 885

Attack transu, )rt. See Transport, attack. Battalions:

Attiu, 659, 662 3d, 165th Infantry, 27th Infantry Division,

Auckland, 767, 771, 825, 840, 873 679

Aural Rehabilitation Center, Forest Glen 7th Medical, 662, 668, 669, 679

Section, Walter Reed General Hospital, 71st Medical (Separate), 669. 6719

509 102d Medical, 679

Australia, 687, 693, 696, 707n, 726, 728, 729, 118th Medical, 777

757, 759, 797 151st Medical, 901, 903

Australian Army, 705. 707n 321st Medical, 679

Australian Army Medical Department, 748 Battey General Hospital, 675
1006 INDEX

Battle casualties, in European theater, per- Blood, whole, 234-236, 239-240, 704, 757, 854

centage of, requiring surgical management, demands for, 156. 631-636;, 734

10 from England, characteristics of. 0291

Battle of Britain, 395, 438, 539, 541 from Paris. characteristics of. 291

"Battle of the Bulge," 252 from Zone of Interior, characteristics of,

BAUER, K. H1., 329 291

Bavaria, 319,.335 need of, in European theater, 385, 469

Baxter Co.. 161 provision of, in combat, 60, 76-78, 108.

Bay of Biscay. 422 147-163, 202, 267-268

Baybay, 853, 859 provision of, in European theater, 371-372

BAYLIS, Brig. Gen. J. E., 912, 914, 938 reactions from transfusion of, 286, 335-336

Beach Yellow, 2-668 service, in European theater. 147-162, 234-

BEASLEY. Col. C. 1I., 378 235, 239-240

BECLERE, C., 251 shortage of, 239

"Bed Exercises for the Convalescent Pa- supplying of, to U.S. Army units during

tient," 493 invasion, recommendations of surgical

BEIWIITLER. Maj. Gen R. S.. 802, 806, 807, 812, consultant concerning. 72-74

816, 835 transfusion of, directives on:

Belgian civilians, employment of, 455 Administrative Memorandum No. 150.

Belgians, 40 Office of the Chief Surgeon, ETOUSA,

Belgium, 40, 289. 292, 298. 473, 497, 498. 579, 1944-294-296

613 Circular Letter No. 108, Office of The

BELL, Cdr. L. G.. 184 Surgeon General, 1943-160

Benelux countries, 239 Circular Letter No. 131, Office of the

Beriberi, prevalence of, in Pacific, 851, 886 Chief Surgeon, ETOUSA, 1R4-4-294

Beriberi abscess, in prisoner-of-war camp, transfusions of:

754 reactions from, 286. 335

Berkshire, 54 recommendation of orthopedic surgery

Berlin, 454. 455 consultant concerning, 665

Berman locator, 772 transportation of, from Zone of Interior,

Bermuda, 244, 889 14

BERNE, Lt. Col. C. J., 935 unrefrigerated, with Alsever's solution,

BERRY, Col. F. B., 10, 264. 270. 304. 305. 307 244

BERRY, Col. M., 789. 792 value of, 680

Besanqon. 303 Bhutan, 9303 - also Transfusion, blood: Transfusion Biak, 671,721 anl resuscitation; Transfusion kit;

Bicester, 394 Transfusion-laboratory teams for moBIGGAM, Maj. Gen. Sir ALEXANDER, 25, 259 bile surgical unit.

BIRK, Col. B. J., 939, 941, 946 Blood and plasma program, ETOUSA. 21,

BIsIOP, Col. H. A., 302 147-163

Bizerte, 600, 604 Blood bank. 854

Blackpool, 453 establishnent of, in a rear area to supply

Bladders, neurogenie, associated with para- citrated blood. under battle conditions,

plegics, 576 604

BLAKE, F. G., 504 utilization of LST as. 67's

Blakemore vitallium tubes, 291, 646 Blood bank, ETOUSA, 147-162. 184. 202.

BLATT, Col. .J. F., 49, 50, 405 234-235, 239-240

BLB (Boothby, Lovelace, Bulbulian) masks, collection of blood for2 142. 202

596 llen of blood f 1.

BLIss, Brig. Gen. R. W.. 666, 841, 842, 855 headquarters, 150

BLIUN, MNaj. J., 805. 806 reestablishment of. 27.

Blood, 71-78, 147-163 shipment of blood to. 23!9-240

Alsever's diluent diluted, 244 source of blood for. 14S. 110

"re-suspended" 0 red blood cells, 244 storage of blood for, 14.5
INDEX 1007

Bood bank program. British. 35 Brisbane, 688, 693, 696, 757

Blood delepts, advanced, in European thea- Bristol, 16. 23, 32-36, 72, 518. 553. 5-3

ter, 150 BIuSTOW. Brig. R. W., 259, 3441. 347, 459. 463,

Blood ph5iIIma. 21. 147. 267 466

Blood program, lPaciic Ocean Areas, 855-856 British. the, 208. 364. 369. 517. 5Y4). -41. 5N3,

Blood transfusion kit, 71, 76,78. 147 591, 592. 594, 595, 59, 597. 598, 599, 601,

Ebert-Einerson type of, 147. 159, 162 607, 618, 620, 893

Blood transfusion school, Southnead lIos- British Ambassador to U.S.S.R.. 421, 427,

pital, 16 435, 436

Blood transfusion unit. simple field, 16 British Amputation Center. 465

BLOODUArT, Capt. T., 684 British Army, 16, 26, 27, 29, 32, 37. 50, 78,

BMoody Nose Ridge. 872 128, 182, 187, 188, 202, 25), 263, 265, 266,

Bluc Ridge, 865, 866 273, 283. 342, 362, 366, 409, 439, 460. 477,

BLUMGAR'r, Col. 11. L., 889, 890. 913. 914, 9)33 583, 584, 585, 615

Boards, specialty, 573 medical supply depots, 36

Bohemia. 335 shortage of doctors in, 50

Bohol Island, 860, 863 British Army Blood Supply DeI)lt. 32-36, 72

BOLERO, 37 training of U.S. Army medical officers in.

BOLIBAU(;H. Col. 0. B., 655 110, 162

Bomber Command: British Army Blood Transfusion Service, 32

"2Oth-9"15 British Army Medical Directorate, 25, 33,

21 st-8:.31 83, 107

lora-Bora. 797, 846 British Army Medical Service, 15

BORDLEY. Col. J., II1I-S71 British Army School of Physical Training at

Botkin IHospital, 429) Aldershot, 477

Bougainville, 246, 786, 802, 805, 806. 807, 808, British ('ode of Identification, 595

813, 814, 815. 817, 821, S22, 826, s27, 830, Uritish Consultants Club, 59

835, 838, 839. 849, 880 British Council, 40

Bouloupari, 804 British Eighth Army, 159. 422, 438

Bourail, 804 British 8th General IIospital, 2S3

Bovie electrical surgical apparatus. portable, British Field Surgical Unit, 346

404 British First Field and Shell D)ressing ComBovingdon, 400 inittee, 45

Boyn, Col. J. S. K., 267 British Forces, 43:8. 446, 467, 598

Boyle Co., 598 in North Africa, 41)

Braceshop: in the Middle East. 71, 82

at North Sector General IHospital. Ilawai- British 48th General Hospital, 422

ian Department. 658 British Isles, 366, 438, 511

Philippine Islands, 747 British Journal of Surgery, 41. 138, 354

BIACmrOT, A., 257 British Medical Association, 40

BRACKEN, Lt. Col. M. M., 743. 744 British medical instruments, quality of, 37

BRADFORD, Lt. Col. B.. Jr., 323 British Medical Research Council. See

BRADLEY. Geu. 0. N., 30.8 Medical Research Council of Great BritBRADNER, Col. M. R., 858 ain.

BaAN1mmH:. Lt. Col. It. B., ,53 British Minister of Health. 181

Braunton. 171) British Minister to Iran, 436. 437

BREENE, Maj. Gen. R. G., 772. 811 British Ministry of Health, 466, 467, 59,1. 5,99

Bremen Port, 454, 455 British Ministry of Supply, 396, 592

BRENN, Col. C. E., 83 British National Research Council. 25

BRENNAN, Lt. Col. B., 253, 259 British 102d Convalescent Depot, 477

Brenner Pass, 319 British Oxygen Co., 592, 59)5, 596, 598

BREWER, Maj. W. N., 486, 487 British Parliament, 67

BRiCKER, Lt. Col. E. M., 9, 61, 108. 170. 172, British Post-Graduate Medical School, 415

279, 294, '297, 310, 321, 346, 511 British Second Army. 262
1008 INDEX

British Southern Command, 82 Burns-Continued

British Surgical Association, 58 treatment of, 854

British 21 Army Group, 188, 253, 265, 267, by "closed" and "open" methods, 539

269, 283, 319, 342, 347, 348 iii evacuation hospitals in European

British War Office, 481 theater, 542

British-Indian Forces, 892 in general hospitals in European

BRITr, Lt. Col. R. W., 912 theater, 542-.551

Brittany, 604 Burroughs, Wellcome & Co., 283

Bromsgrove, 15, 477, 478,479, 494, 495 BURSTEIN, Maj. C., 620

BRowN, Col. B., 304,309 Burton Island. 663

BROWN, Col. J. B., 9, 28, 36, 37, 39, 61. 391, Bush typhus, 728

405, 511. 521,539,584

BRUCE. Maj. Gen. A. D., 861 C-47 aircraft, 688

BRUCE, Lt. Cdr. G. M., 809, 826 Cabanatuan, 884

BRUSH, Maj. Gen. R., 824 Cactus, 816

Brussels, 253, 259, 283, 285, 292-293, 301, Caen, 249

342,615 Cairns, 696

BRYANT, Col. T. L., 841, 877 CAIRNS, Brig. H. W. B.. 182, 392, 394, :195,

Buchenwald, 330 405, 410,412

BULLARD, Sir READER W., 436 Cairo, 71, 422, 423, 424. 436, 437-439

Bulletin of the U.S. Army Medical Depart- Calcium gluconate, 855

ment, 114 Calcutta, 895, 930, 935, 947

Bulletins, technical, Office of The Surgeon CALHOUN, Maj. F. P., 456

General, 653-654 CALLAHAN. Lt. Col. J. J., 675

Buna, 688, 689,690, 696, 700 CALLENDER, Brig. Gen. G. R., 246

Buna-Gona, 707n Cambridge, 115,335

BUNSHAW, Lt. Col. R. H., 776, 777 Cambridge Military Cemetery, 17

BURDENKO, Academician Lt. Gen. N. N., 94, Cambridgeshire, 116

95.99,428, 429, 431,432,435 Camp Edwards, Mass., 707n, 767

investiture of: Camp Pali, 841

in American College of Surgeons, 99. Campaigns:

101, 435 Bougainville, 246

in Royal College of Surgeons, 99, 101, Burma, 892, 893, 896, 899, 903, 904. 919,

435 93,3, 934

Bureau of Medicine and Surgery, U.S. Navy, Central Burma, 899,919, 93•3, 934

855 Central Europe, 319-333

Burma, 892. 893, 895, W96, 899, 901, 903. 908, in European theater, 344

911, 912, 913, 921, 923, 924, 932, 9.33. 934. India-Burma, 893n, 899, 904-906. 919. 9.33-

935 934

Burma Road, 892, 893. Italian, 169, 344, 364

Burmese Forces, 892 Iwo Jima, 877

Burn casualties: Lingayen, 862

evacuation of, to specialty hospitals, 517 Leyte, 842, 871

treatment and evacuation of, formulation Luzon, 877

of policies for, 539 Marianas Islands, 842

Burns, 14 New Georgia, 784. 789

extensive, healing of, with early grafts, lessons of, 784-786, 787

551

in European theater, 539-551 management of casualties in. 790-791

of hands, treatment of, 5 New Guinea, 762

skin-grafting in treatment of, 545, 550 Normandy, 2"24, 225, 358, 512. 523, 524, 534,

surgical treatment of, hospitals for, 541, 550, 56

in United Kingdom, directive on, Cir- North African, 159

cular Letter No. 81, Office of the Chief Northern France campaign, 225, 239

Surgeon, ETOUSA, 1944-172-173 Rhineland, 250
INDEX 1009

Ca mpa igns-Ciont inued ('are of-A'on t inued

Ryukyu Islands. 625. W0 hhtdder in patients with spinal cord inSecond Burma, 8193, SIP), 904-900.933. 934 jury, directive on, Circular Letter No.

Sicilian. 169 131, Office of the Chief Surgeon,

Canada, 40, 421, 435. 582, 585 I)ETOI-SA, 1944-294

Canadian Army, 182, 319, 342, 459. 460, 584, burns, instruction in, 39

598, 615 craniocerebral injuries, establishment of

Canadian Army general hospitals. excel- centers for, 2,80

lence of care in, 30 feet, instruction in, 462, 658

Canadian Army hospitals. 30. 36 foot and march injuries, recommendations

Canadian 15th Gekueral Hospital. 397 of surgical consultant concerning. 461

Canadian Neurological Hospital, 395 fractures, 39, 293-294, 312

Canadians, 30 hand injuries, 312, 470, 563-571

CANFIELD, Col. N., 9, 61, 276, 297, :302, 443, injured nasal mucosa, 2294

504 lightly wounded, in European theater,

Canlubang, 748, 750, 751, 754 165-166

Cannes, 303 maxillofacial injuries, establishment of

Canton Island, 659, 84W centers for, 280

Cape Gloucester, 696 patients in European theater, policies and

"Carbon Dioxide for Inhalation," 595 procedures governing, 171-173

Care: thore-ic injuries, establishment of centers

adequate medical, failure to provide, in for, 280

forward areas in New Georgia campaign, vascular wounds, 649

785 war wounded, principles of Soviet surgical

adequate postoperative, importance of, 682 practice in, 429-431

definitive surgical, by surgical experts, wounds, directive on, Circular Letter No.

importance of, 757 178, Office of The Surgeon General,

medical, and evacuation, recommendation 1943-169

of Consultant in Surgery in Pacific areas wounds, training of medical officers in,

concerning, 792-793, 870-871 792-793

medical, three ways of determining qual- wounds of the buttock, 649

ity of, 847 Sgee al.qo Management; Treatment.

('are of- Carentan, 384

battle casualties: CARLING, E. R., 80,93,96, 97, 421,435

during evacuation to hospital for sur- Carlos Island, 664

gery, 262, 264-269 CARMODY, Cdr. J. T. B., 802

principles of surgical management in, Caroline Islands, 667

directive on, Circular Letter No. 71, CARROLL, Brig. Gen. P. J., 729, 795, 796, 797,

Office of the Chief Surgeon, ETOUSA, 856

1944-146, 171, 231, 232, 234, 293, 312 CARTER, Col. B. N., 244, 245, 915, 920, 923

iip to time of definitive surgery, 262, CARTER, Lt. Col. G. G., 877

264, 265-268 Caserta, 600

battle casualties, directives on- Cases, neuropsychiatric. categories of, 779

Circular Letter No. 23, Office of the Casts, circular, handling of, in Marianas, 649

Chief Surgeon, ETOUSA, 1945--312 Casts, plaster:

Circular Letter No. 71, Office of the Chief difficulties with, 772

Surgeon, ETOUSA, 1944-146, 171, skintight, 772, 779, 861

231. 232. 234, 293, 312 tight, as cause of loss of limbs, 861

Circular Letter No. 101, Office of the Casualty survey team, European theater,

Chief Surgeon, ETOI'USA, 1944-17, establishment of, 115

231.2236, 293. 312 "Catalina" flying boats, 794, 810. 814,,817

Circular Letter No. 131. Office of the Catania, 600

Chief Surgeon. ETOI'SA, 1944-29.3- CATON, Col. It. .. , 77:1. 817, 821. 823

"2914, 312 CAWE.NAUG3, lt. Col. I. L., 949
1010 1)!IEX

C.AWi.iy. Maj. .1. J., Jr., 6m)2 C'hfibua. 9447

CelA1 Island, 6S3 ('han-i, 949

Centers: ('HAPI.IN, CUi.,IEm, 427

burn, 327. 542 -551,638 ('CHAPMAN, I1.A., 595

for casualties with soft-tissue wounds. 603:, Charity Hlospdtal. 9)

640 Charlevilie, 6943, 6496

for fabrication of artificial eyes, 637 C 'hartres. 2491

for neurosurgery, W.7 (Chatham, 92

for ophthallmic surgery, 03S Chlaumount, 2

for thoracic surgery, 6'37. 63s. 640 Cheltenhamin. 23. 24. 27-30. :12, :17, :38. 39). 4!).

for treatment of casualties with massive 53, 55, 62. 74, 92, 107, 1417, 179, 181, 182.

soft-tissue loss of the trunk or extremi- 204, 207, 215, 2516, 3)59. 366. 371. 392. 476,

ties, 527 .512, ,583

for vascular surgery, 646 Cherbourg, 297, 381, 485

for wounds involving brain and spinal Cherry Bloissomn, 814, 816, 817, S19, 826

cord, 638, 640 Nct.' also Bougainville.

hand. 470, 564 CHIANG KAI-SIIEKK, Generalissimo, 892

hospital: Chief(s), ofrole of surgical consultants in, 5-7 Army Veterinary Service. 81K)

special treatment facilities in, 576 Division of Rehabilitation, Office of the

maxillofacial surgery. 51,S-520, 527, 538 Surgeon, United Kingdom Base, 487

plastic surgery, in European theater, 518- Epidemiology Division, Preventive Medi520, 53S, 555, 557, 563 cine Service, OTSG, 891

facial reconstruction in, 521, 522-538, Operations Division, Medical Section,

545 United Kingdom Base, 456

plastic surgery, in Zone of Interior. 527, Orthopedic Branch, OTS(1, 674

536, 538, 56.3 Orthopedic Section:

facial reconstruction in, 545, 563 Letterman General Hospital. 655

specialty, in European theater, 535 North Sector General Hospital, 674, 841

preparation for designation of hospitals 118th General Hospital, 757

as. 514-520 219th General Hospital, 625

specialty, in Pacific Ocean Areas, 637-640 Personnel Section, Office of the Surgeon,

Central Institute for Blood Transfusion, SOS.XSFIBT, 913

429, 435 Preventive Medicine Division, Office of the

Central Institute for Medical Research. 429, Chief Surgeon, ETOUSA, 454

435 Professional Services Division, Office of

Central Institute of Traunmatology and the Chief Surgeon, ETOUSA, responOrthol*dy, 429 sibilities of, 319-322, 341

Central Laboratory, India-Burma Theater, Professional Services I)ivision, OTSG, 30

931 Rehabilitation Division, Office of the Chief

Central Pacific Area, 625, 651-655, 658-661, Surgeon, ETOUSA, 487

062, 6643, 840. 846 Roentgenological Service, 218th General

decortications in, 653 Hospital, 625

necessary delay in secondary closure of Surgical Service:

wounds in, 652 39th General Hospital, 802. 8'2

peculiarities of wounds in, 653 147th General Hospital, 625

professional training of medical officers 148th General Hospital, 627

in. 6552 Troops and. Training Branch. Operations

shortage of trained professional person- Division, Office of the Chief Surgeon,

nel in 651-652 ETOXSA, 454

Central Pacific Base Command, 626, 627, Venereal Disease Control Division, OTSG

6•32, (38, 683, 841 880

Cetyltrimethylammoniuni bromide, 544 Chief Consultant in Anesthesiology, VeterCeyloi, 1M)4 ans' Administration, R121
INDEX 1011

Chief Consultant in Medicine, Office of the Chief of Surgery:

Chief Surgeon, ETOUSA, 28, 51, 170, 361, Letterman General Hopsital, 674

362, 444, 459, 584 Schofield Station Hospital, 655

Chief Consultant in Medicine to the Surgeon 75th Station Hospital, 846

General, 320, 704 76th Station Hospital, 553

Chief Consultant in Plastic Surgery to the Chief of Surgical Service:

RAF, 400 174t'h Station Hospital, 748

Chief Consultant in Surgery, Office of the Percy Jones General Hospital, 890

Chief Surgeon. ETOUSA, 5. 8, 9, 19-358, 73d Evacuation Hospital, 935

359, 361, 406, 444, 459, 504, 505, 539, 540. Tripler General Hospital, 65,'

563, 584, 756 Walter Reed General Hospital. 889, 890

duties of, 14 Chief of the Professional Service, USAFFE,

Sce also Cutler. Brig. Gen. E. C. 797

Chief Consultant in Surgery, Professional Chief of Urology. 2d General Hospital, 573

Services, AEF, World War 1-3, 4 Chief Ordnance Officer, ETOUSA, 407

Chief Consultant in Surgery, Royal Army Chief Ordnance Officer, USASOS, SWPA.

Medical Corps, 50 730

Chief Consultant in Surgery to the Royal Chief Quartermaster. ETOT'SA, 125

Navy, 26 Chief Surgeon, AEF. World War I-1, 2, 4

Chief Consultant in Surgery to The Surgeon Chief Surgeon. ETOUSA, 7. 8, 9, 22, 23, 27,

General, 45, 130, 397, 407, 505, 581, 666. 37, 38, 51, 52. 60, 64, 65. 68, 70, 71, 73,

704, 705, 913. 915, 917 74, 77-79, 82, 86. 90, 107. 109, 111, 114,

Chief Gas Casualty Officer, Gas Casualty 121. 125, 129, 138, 143, 147, 149, 150, 164,

I)ivision, Office of the Chief Surgeon. 165, 167, 170, 175, 178, 183, 190-191,

ETOUSA, 596 194, 202, 204, 207, 239. 241, 248-249, 252,

Chief Medical Director, Veterans' Adminis- 258, 272. 273, 275, 283, 292, 296, 297, 300-

tration. 621 302, 305, 308, 326, 334, 339, 341, 355, 358,

Chief Medical Officer, General Eisenhower's 359, 364, 366, 379, 391-393, 398, 400, 403,

Headquarters, SHAEF, 107, 187, 197, 366 40--410, 414, 417-420, 446, 454, 455, 459,

Chief Nurse, U.S. Forces, India-Burma 460, 463, 465, 466, 469, 476, 477, 482, 485,

Theater, 932 486, 490, 491, 498, 503-505, 511, 520, 521,

Chief of Laboratory Service, 27th General 539, 540, 573, 576, 581, 594, 600, 604-605,

Hospital, 743 615, 732

Chief of Medical Service, Walter Reed Gen- 8cc also HAWLEY, Maj. Gen. P. R.; Office

eral Hospital, 889 of the Chief Surgeon, ETOUSA.

Chief of Operations- Chief Surgeon, MTOUSA, 326

Office of The Surgeon General. 841 Chief Surgeon's Consultants' Committee, 61,

Services of Supply, ETOUSA, 149 169, 188, 189,239, 279, 301,308, 336

Chief of Ordnance- meeting of, 27 Oct. 1944-273-275, 294

ETOUSA, 149, 155 meeting of, 30 Dec. 1944--295-296.300, 301

War Department, 730 Chief surgical consultant to the Soviet Army,

Chief of Professional Services: 428

Office of the Chief Surgeon, ETOUSA, 392, Chief Veterinarian, USAFPOA, 842

408 Chih-chiang, 939,946

Office of the Surgeon, USASOS, SWPA, Chin Hills, 893

7.33 China, 257, 892, 893-895, 899, 906, 908, 910,

V.S. Army Forces In China-Burma-India. 911, 912. 923, 932, 944, 945. 946, 949, 950

913 mnedical schools in, 897

Chief of Staff:

ETOUSA. 30 China Theater, 8,9-9525

Third U.S. Army. 313 equipment, 921-925

F.S. Forces, India-Burmna Theater, 914 field hospitals in, 945-946

Western Paciflc Base Command. 629 field trip of surgical consultant in, 938-

(Chief of Supply Division. Office of the Chief 950

Surgeon, ETO'SA, 452 hospital construction in, 921
1012 INDEX

China Theater-Continued Cireular Letter-- (ontinued

physical facilities and equipment in, 921- No. 45, Office of the Chief Surgeon.

925 ETOUSA, 24 Mar. 19"4-190

portable surgical hospitals in. 942-945 No. 71. Office of the Chief Surgeon,

professional training of medical officers in, ETOUSA, 15 May 1944-146, 171, 231,

920-921 232, 234, 293, :"2

China-Burma-India Theater, 897-899 No. 75, Office of the Chief Surgeon,

Ch in ,.sv. the, 892, 897, 918. 934, 939 ETOUSA. 4 Dev. 1942--403

Chinese Army, 893. 895, 897, 899, 903, 911. No. 79, Office (if the Chief Surgeon.

9:37, 941, 942, 943, 944, 945 ETOUSA, 17 I)ec. 1942--52

Chinese Army Medical Administration, as- No. 80. Office of the Chief Surgeon.

sistance of U.S. Army medical service to. ETOI[SA. 10 June 1944-171. 173

897-898. 911, 912, 942-946 No. 81. Office of the Chief Surgeon,

Chinese Combat Command 1I'rovisional . ETOUSA, 10 June 1944-172-173. 518

9:19,941,945 No. 89, Office of the Chief Surgeon,

Chinese Fifth Army, 893 ETOUSA, 21 May 1943-11S

Chinese Forces, 892, 893. 898 No. 91, Office of The Surgeon General, 26

Chinese National Health Administration. Apr. 1943-128, 132

911 No. 101, Office of the Chief Surgeon,

Chinese Sixth Army, 893 ETOUSA, 30 July 1944-17, 231-236,

Chinese Surgeon General, 945, 949 293, 312, 470

Choiseul Island, 808 No. 108, Office of The Surgeon General. 27

Christmas Island, 659 'May 1943-160

Chungking, 892, 894, 896, 897, 910,911 No. 131, Office of the Chief Surgeon.

Chungking Government, 257 ETOUSA. 8 Nov. 1944-293-294, 312,470

CHURCHILL, Col. E. D., 282. 326, 327, 81•9 No. 142. Office of the Chief Surgeon.

CIIHURCHILL, WINSTON, 427 ETOUSA. 8 Dec. 1944-299

CINCOTTI, Lt. Col. J. J., 258 No. 176, Office of the Chief Surgeon,

CinCLPAC. Sc Commander in Chief, P'acific. ETOUSA, 7 Dec. 1943-142

CinCPOA. ,ecc Commander in Chief. Pacific No. SA, 7 D e 1943-142

Ocean Areas. No. 178, Office of The Surgeon General.

Circular No. 18, Headquarters, ETOUSA, 20 23 Oct. 1943-169

Feb. 1943-3596 No. 189, Office of The Surgeon General.

.cc also War I)epartment Circulars. 17 Nov. 1943-128

Circular Letter- Cirencester, 327

No. 5, Office of the Chief Surgeon, Cirencester Park, 121

ETOUSA, 12 Jan. 1943-521 CITRINE, W., 436

No. 11, Office of the Chief Surgeon, Civil War. 950

ETOUSA, 31 Jan. 1945-310 CLAIBORNE, Lt. Col. L. N., 802

No. 13. Office of the Chief Surgeon, Claridge IHotel. 23

NATOUSA, 15 May 1943-169 Claridge's. 95

No. 18, Office of the Chief Surgeon, CLARK, Air Commodore 0.. 347, 459

ETOUSA. 21 Feb. 1945-311 Clark Field. S64

No. 21. Offiep o~f the Chief Surgeon. CLARKE-KER~R, Sir AuculnA~l). 420, 427. 43:5

ETOUSA. 7 Feb. 1944-119, 120 No. 2, of Ofic he CiefSurgon. Classification, professional. o~f surgical of- No. 22. Office of the Chief Surgeon. i es 1 -1

ETOUSA, 8 Feb. 1944- 143. 144

No. 23. Office of the Chief Surgeon. Classification and selection of patients for

ETOUSA, 17 Mar. 1945-312 evacuation. 763

N). 27, Office of the Cl.ief Surgeon, Clearing Company:

ETOUSA. 15 Feb. 1943- 595 7th Infantry Division, 736

No. 28, Office of the Chief Surgeon. 7th Medical Battalion, M69, 679

ETOUSA. 1 Mar. 1944--132 394th. 71st Medical Battalion (Separate),

No. 32, Office of the C hief Surgeon. 669. 679

ETOUSSA. ; Apr. 1945--- 313 621st-217
IND)EX 1013

Clearing station C ommander

in island warfare. 791 Air C ommnaid, Nort It Sodoinons, 81 4

surgery in. 861 'South Pacitic Area, 81(1

use (of, for secVond( echelonl liospit IsII, 805I Southi Pacific Fo~rces. S10

CLEVELANDl, Col. 'M., '), 10), 15, 108, 274. 2794. Task Force 77-W6(i

286, 293, 294, 301, 346-348, 46i7-46SX. 475. C omnmander in Chief

564, 3;9 Paitlc, 629)

Climate of India-Burina Theater, effect of, Pac1ific Flee-t. 856

I931-932 Pacific Ocean Areas. 625

Clinics. ortllopweie outpiatient, measures to U.S. Army Forces in China-Burina-India,

relieve, crowding of, 059t-660 S, M)

Closure: Conmmanding General

dlelayed: Americal Division, 836

of wounds, importance of, in restoration Army Air Forces, 440

of fighting man to early duty. 3.52 Army Garrison Forces, USAFICPA and

of wounds over compound f ractures, 471 I7SAPPOA, 874

delayed primary, of wvounds over comn- Army Service Forces. 7197

150111( fractures, directive on. Circular Assenmbly Areai Command, ETOITSA, 45)4

Letter No. 131, 4 t11*e of the Chief Sur- Chinese Army, 892

geon, ETOUSA, 1944-470 E~ighith Air Force, 44

early, and grafting. -.Id.5 ETOI'SA, 152. 153, 400, 418

of facial Wounds: Fifteenth Air Force, 730

dlelayedl primary andl secondary, 537p First Army Group, 152.1533

primary, 530~-531 40thk Division. 824

of wvounds, 108, 171 43td D)ivision, KS5

secondlary: XIN'Corps, 773, 8.34)

as a means of limiting scarring. fibrosis, Hawaiian Department, 659

edemta. an(l disability, 555 Letterman General Hospital, 074

classification of cases requiring, 535 Medical Replacement Training Center,

COA'rFS, Col. J. B., Jr., 771, 880ii Camp Grant. Ill., 912

CCHRuANE:, Lt. Col. 1B. It., 6;78 93d Infantry Division, 885

Cocoanut Grove tire casualties, treatment of, Persian Gulf Conmmand, 424

539 Rear Echelon, U.S. Forces, China Theater,

Couty, Col. E. G., 66j4,, 850), 852. 875,. 876 9.39

Cold injury, 14, 414-418, 441 Services of Supl ply, ETOU SA, 152, 153, 158,

ground1 type, 285 170, 400)

prevention of, 125 Services of Supply in thme British Isles, 306,

studlies oif, 28:3 467

College of Medical Evangelists, QW34 7th D)ivision, 861

College of Physicians and Surgeons;, Cl1umn- 77th Division, 861

Iiia University, 10), 39)2 Sixth U.S. Army, 816, 866

COLLINS. Lt. Col. .1. F., 84)1, 82l,1, 30 South Pacific, 771

Cologne, 318 South Pacific Base Command, 840

Colostomnies, management (if, directive onl, Third U.S. Army, 313

312 Thirteenth Air Force, 773

Colostomy, double-barreled Mikulicz, forma- 37th D)ivision, 806

tiolk of. 29)4 XXIV Corps, 842, 862

Colostomy, looip type! of, initial ol-inieimg inl, U.S. Army Forces, P'acific Ocean Areas,

directive (il, 294 660. 862

Columbia Unmiversity, 14), 3,164 U.S. Army Forces in China-Burmna-India,

Columibia Unkiversity College of Physicians 8912

andl Surgeonis. 10), 39'2 U.S. Army Forces in the South P'acitic

Conkmbat C~argo C onmnmmm(1. 9391 Area, 826
1014 INDEX

Commanding General-Continued Conferences and meetings in European

U.S. Forces, China Theater, 895, 949 theater-Continued

U.S. Forces, India-Burma Theater, 895, concerning redeployment of convalescent

949 centers and personnel to Zone of InCommanding Officer: terior, 499

Blood Bank, ETOUSA, 153 First Inter-Allied Consultants' Conference.

Company D, 112th Medical Battalion, 805 261-271

Eastern Command, 941 Inter-Allied, 40, 55, 252-253. 256-271, 283-

86th Evacuation Hospital, 63 286, 287, 342-349, 354, 466, 615

41st Station Hospital, 838 Inter-Allied Conferences on War Medicine,

North Sector Hospital. 841 40-41, 55, 252. 253, 256-257, 283-2K, 355,

144th Station Hospital, 838 466, 615

142d General Hospital, 935 Inter-Allied Medical Conference, on thoRehabilitation Center No. 1-477 racic surgery in the forward areas, 287

69th General Hospital, 934 rehabilitation orientation conference. May

36th Field Hospital, 861 1944-493

33d Portable Surgical Hospital, 834 Second Inter-Allied Consultants' Confer369th Station Hospital, 873 enee, 2s3-286

20th General Hospital, 906, 934 Third Inter-Allied Consultants* Confer21st Evacuation Hospital, 830 ence, 342-349

204th General Hospital. 841 trenchfoot meeting, 306-308

Commercy, 306 CONIZARES, M., 880

Committee for Medical Research, National CosN•oLLu, Maj. Gen. D. H., 424, 436

Research Council. 97 Consultant in Orthopedics, RAF, 347

Committee on Standardization, 589 Consultant staff, SWPA. expansion of. 698

Commonwealth of the Philippines, 750 Consultant system, 706-710

Communication between theater consultants importance of, 705, 765

and directors of their respective divisions in European theater, 1, 5-17, 388

in Office of The Surgeon General, impor- at local level, 61, 62

tance of, 951 change and expansion of 61-62, 108, 118-

Company A: 120

7th Medical Battalion, 67912 7td Medical Battalion, 679 duties and functions of consultantb in 102d Medical Battalion, 679 321st Medical Battalion, 679137 13-17

Company B: expansion of, 61-62, 108, 118-120

7th Medical Battalion. 679 in Army Air Forces, 9

102d Medical Battalion, 679 organization of, 5-8, 361-362

321st Medical Battalion, 679 personnel of, 9-10

Company C: policies of consultants under. 11

7th Medical Battalion, 668. 679 rehabilitation in, 15

102d Medical Battalion, 679 significant activities of consultants in,

321st Medical Battalion. 679 14

Company D: in World War 1-1-5

7th Medical Battalion, 679 recommendation of Consultant in Surgery,

102A1 Medical Battalion. 679 Office of the Surgeon, USASOS. SWPA,

112th Medical Battalion, 805

151st Medical Battalion. 90r m concerning, t 7 321t attlin, Mdial 79recommendations concerning, in the 321st M edical Battalion, 679 f t r , 8 -8

CONAD. Sce Continental Advance Section. future, 387-389

Concentration camps, Japanese. 275 recommendations of Consultant in SurConferences and meetings in European gery, Southeast Asia Command, concerntheater, 40-41, 55, 107, 252, 253, 256- ing, 951, 952

272, 2S0, 283-286, 287, 309-310, 342-349, Consultant(s), base section, apponintment of

354, 355, 445, 463, 466, 476. 493, 499. 574, 119-120

615 Consultant (s). junior. 474--475
INDEX 1015

Consultant(s), regional, 514 Consultant (s) in Orthopedic Surgery:

appointment of, 118-119 British Army, 259

directive on, Circular Letter No. 89, Civilian, to the Royal Air Force. 93

Office of the Chief Surgeon, ETOUSA, duties of, 656, 658. 685

1943-118 Fourth Service Command, 675

system initiated by General Hawley, 506 Hawaiian Departmeat, 655-58

Consultant(s), use of, in combat zone, rec- Marianas Islands and Leyte, 661-674

ommendations of orthopedic consultant need for, 5

concerning, 665 Office of the Chief Surgeon, ETOUSA, 15,

Consultant (s) in Anesthesia: 463

U.S. Army Forces, Middle Pacific, 651 Office of the Surgeon, U.S. Army Forces,

U.S. Army Forces, Western Pacific. 710 Western Pacific, 742

Consultant(s) in General Medicine. Office of Office of the Surgeon, U.S. Army Forces

the Chief Surgeon, AEF, World War I-1 in the Central Pacific Area, 625, 658-661

Consultant (s) in General Surgery: Office of the Surgeon, U.S. Army Services

need for, 5 of Supply, Southwest Pacific Area, 698,

Office of the Chief Surgeon, ETOUSA, 9 757

Tenth U.S. Army Okinawa, 675-683

to The Surgeon General, 326 Southwest Pacific Area:

Consultants in General Surgery, Office of difficulties of, 758-759

the Chief Surgeon, AEF, World War I-1 functions and duties of, 757-759

Consultant(s) in Laboratories. Office of the Tenth U.S. Army, 626, 675

Chief Surgeon, AEF, World War I-1 U.S. Army Forces, Pacific Ocean Areas,

Consultant (s) in Medicine: 626, 655-686,841

Civilian, to The Surgeon General, 880 U.S. Army Services of Supply, South

Office of the Surgeon, U.S. Army Forces, Pacific Area, 663

Middle Pacific, 684 Consultants in orthopedic surgery, Office of

Office of the Surgeon, U.S. Army Forces in the Chief Surgeon, AEF, World War 1-1

the Central Pacific Area, 661 Consultant(s) in Orthopedic Surgery and

Office of the Surgeon, U.S. Army Services Reconditioning, Ninth Service Command,

of Supply, Southwest Pacific Area, 728 674

Office of the Surgeon, U.S. Forces, India- Consultant(s) in Otolaryngology:

Burma Theater, 889 Office of the Chief Surgeon, ETOUSA, 504

Second Service Command, 889 to The Surgeon General. 509

Consultant(s) in Plastic Surgery, 346

Tenth U.S. Army, 675 Office of the Chief Surgeon, ETOUSA. 9

Consultant (s) in Neuropsychiatry: Consultant(s) in Plastic Surgery and Burns,

Office of the Surgeon, Army Forces, Pa- Office of the Chief Surgeon, ETOUSA, 28

cific, 706 Consultant (s) in Psychiatry:

Office of the Surgeon, U.S. Army Forces, Tenth U.S. Army, 675

Pacific Ocean Areas, 842 U.S. Army Forces, Pacific Ocean Areas, 675

Office of the Surgeon, U.S. Forces, India- Consultant(s) in Psychiatry, Office of the

Burma Theater, 912 Chief Surgeon, AEF. World War I-1

U.S. Army Forces in the South Pacific Consultant(s) in Radiology, Office of the

Area, 811 Chief Surgeon, ETOUSA, 10

Consultant (s) in Neurosurgery: Consultant(s) in Reconditioning, Office of

Emergency Medical Service, 27 the Surgeon, U.S. Forces, India-Burma

Office of the Chief Surgeon, ETOUSA, 9, Theater, 924

10 Consultant(s) in Rehabilitation and HosConsultant(s) In Ophthalmology: pital and Convalescent Center Inspector,

British Army, 259 Rehabilitation Division, Office of the Chief

Office of the Chief Surgeon, ETOUSA, 9, Surgeon, ETOUSA, 487

10 Consultant(s) in Roentgenology, Office of

to The Surgeon General, 453 the Chief Surgeon, AEF, World War I-1
1016 INDEX

Consultant(s) in Roentgenology, U.S. Army Consultant(s) in Surgery-Continued

Forces in the ('entral Pacific, 625 (Office of the Surgeon. Southwest Parific

Consultant s) in Skin and Genitourinary Area. 687-765

Diseases. Office of the Chief Surgeon. AEF, Office of the Surgeon, U.S. Arnmy Forces,

World War 1--1 Middle Pacific, 650

Consultant (s) in Surgery: Office of the Surgeon. U.S. Army Forces.

authority of, in the transfer of medical Pacific Ocean Areas, 626, 647, 651, 666,

officers, recomnmendations for, 3-S8 878

duties of, 627-629, 643-(44, 649, 651, 656. Office of the Surgeon, U.S. Army Forc.es,

65,1, 675-676. 682. 683M-66 Western Pacific, 706

ETOUSA. 1-17, 19-389, 391-441. 44:3-457. Office of the Surgeon, V.S. Army Services

459-501, 50.3-571, 573-579, 581-621 of Supply, Southwest Pacific Area,

contributions of, 17 625, 687-705, 706, 706n, 710, 711, 716.

in base sections. 8, 10 718. 725, 727, 756. 757, 839

in field armies, 9, 10 dutis and functions of, 710. 757

in hospital centers, 8 I)stsurrender responsibilities of. 745-

liaison of, with British medical service, 748

16 Office of the Surgeon. U.S. Forces. Indialiaison of, with French, 17 Burnma and China Theaters:

liaison of, with Russian medical serv- (41itorial dut(ltie of, 915

ice, 17 field trips of, .)33-350

liaison of, with tactical elements, 445 functions of. 912-916

miscellaneous activities of. 16-17 review of clinical records and post

regional, 10 morteim findings by, 916

selection of medical officers by. for re- Office of the Surgeon, U.S. Forces, Indialdeployment to the Paci tic. 50S-5(0 . Burma Theater, N14-952

significant activities of, 14 Office of the Surgeon. Western Pacific Base

Fifteenth U.S. Army, 10 Command, 626. 627

First U.S. Army, 10 Pacific Ocean Areas, 625-765, 767-S$7

Fourth Service Command, 89) recomnmendations concerning authority of,

Free French Army, 271 in the transfer of medical officers, 388

functions of. 710-757 recommendations concerning transportaliaison of, with chief of personnel in medi- tion facilities for, 3S9

(cal section at theater headquarters, responsibilities of, 512, 517, 521

importance of 951 Second Service Comnmand, 889, 890

liaison of, with Office of The Surgeon Gen- Seventh U.S. Army, 10, 344

eral, importance of, 704, 705, 951 Sixth U.S. Army, 700

Ninth U.S. Army, 10 Southeast Asia Command, 819-952

Office of the Chief Surgeon. ETOUSA, 9-10 Surgery Section, U.S. Army Forces in the

activities of, during invasion phase. 224- South Pacific Area, 625

2:.9 teaching funct ions of. 699-700

duties of 1:3-14 Third U.S. Army. 10

observations, recommendations, and ac- to base sections, 8, 10

tions of, in Operation OVERLORI), to Emergency Medical Service (British).

225-2"39 :145

Office of the Surgeon, Army Forces, Pacific, to field arnies, 9, 10

706, 709, 882 two major functions of, 699

Office of the Surgeon, Central Pacific Base U.S. Forces, China Theater. 8,99-952

Command, 626 Western Pacific Base Command. 650

Office of the Surgeon, Mediterranean and Consultant(s) in Surgery of tile Hlead, Office

North African Theaters of Operations, of the Chief Surgeon, AEF, World War

U.S. Armny, 819 I-1

Office of the Surgeon. South Pacific Base (Consultant(s) in Surgery to Infantry l)iviCommand, 626 simoms, AiFt.F W lorl War I--I
INDEX 1017

Consultant (s) in Urology, 17 Corps-Continued

Consultant(s) in Urology, Office of the Chief III Amphibious, 678

Surgeon, AEF, World War I-1 V Amphibious, 664

Consultant(s) on Whole Blood and Shock, X-669, 862

Tenth U.S. Army, 626 XIII -325

Consultation in medicine in European XIV-773, 780, 786, 813, 826, 830, 835

theater, 7 XXIV-666-669, 678, 679, 681, 858, 861,862

Consultative services, policy for, directive Cotswolds district, 583

on, Circular Letter No. 21, Office of the Coventry, 480

Chief Surgeon, ETOUSA, 1944-119-120 Cowley Barracks, 49, 50

Continent, the, 37, 52, 64, 70, 73, 74, 90, 107, CPA. See Central Pacific Area.

108, 112, 117, 145, 148, 149, 151, 158, 163, CRAIG, Brig. Gen. C. F., 807, 816

181, 194, 204, 223, 225, 237, 240, 241, 243- Craniocerebral injuries:

245, 248-252, 255, 257, 258-259, 272, 274- cause of, 405

275, 280-281, 293, 297-298, 310, 313, 320- treatment of, directive on, Circular Let321, 327, 350, 350, 392, 452, 453, 468-470, ter No. 75, Office of the Chief Surgeon.

473, 474, 479, 482, 485, 495-500, 555, 564, ETOUSA, 1942-403

574-576, 579, 591, 604-605, 610-611, 619- use of sulfanilamide in, 395

620. 726 Craniocerebral injuries in airmen, 411,419

activities of Senior Consultant in General use of helmets in prevention of, 411-414,

Surgery, ETOUSA, on, 378-387 441

hospital centers in, 450 Crimean War, 430

orientation to life on, 252-275 CRISLER, Col. J. A., Jr., 10, 176, 217, 253, 254,

supplies and equipment, medical, in. 452 257, 263, 264, 266, 268, 289, 290, 305, 307,

Continental Advance Section, Communica- 323,324, 371, 378

tions Zone, ETOUSA, 302--305,309 CRONE, Col. N. L., 253

Control ship, medical, importance of. 680 Crowding of orthopedic outpatient clinics,

Convalescent activities program, European measures to alleviate, 659-660

theater, principles of, 501 Currey, the, 806

Convalescent Centers: CUSHING, H., 20

826th-497-499 Cushing General Hospital, 50J

828th--498 CUTLER, Brig. Gen. E. C., 5, 8, 9, 14, 15, 17,

833d-495 19-359. 361, 362, 365, 366, 391, 406, 410,

"Convalescent Training Program. The." 494 420-422. 427, 436, 438, 446, 454, 476,

Convalescent training program in hospitals, 504, 505, 539, 540, 573, 584, 616, 756

487 Sec also Chief Consultant in Surgery to

Conversion of hospitals to convalescent cen- the Chief Surgeon, ETOUSA.

ters, 482 CUTLER, Capt. E. C., Jr., 300

Cooktown, 696 CUTLER, Col. R., 246

Coordination. Allied, problems in. 182-183 CUTTER, I. S., 407

Coordinator for Information and Education Cyclopropane, 585,603

Activities, Rehabilitation Division, Office value of, 603

of the Chief Surgeon. ETOUSA, 487 Czechoslovakia, 40, 319, 915

Coordinators, visual aid, for rehabilitation Czechoslovakia, 41, 333

program in European theater, 494

Coordinators in surgery in hospital centers, DALE, Sir HENRY, 421

121 DAI.Y, Brig. A. S., 584, 585, 599

COPELAND, Lt. Col. M. M., 799, 935 I)ASKAL, Capt. H. M., 487

Copper-sulfate protein method, X62 D'AUBIGNE. M., 251

('oral Sea, 658 DAVIS, Lt. Col. F. E., 599, 601,616, 618

Cornwall, 79 Davis, Col. L., 9, 10. 17, 21, 28. :39, %3, 94,

Corps: 96, 97, 99, 104, 108, 392, 394. 397, 39S. 403.

1st Marine Amphibious, 805, 807, S09, 814, 404, 408, 415, 420, 422, 435. 439, 440, 441.

"S"26 584
1018 INDEX

D-day. 15, 17. 106. 117. 146, 1-50. 159, 171,236, Deputy Commander:

257, 309, 312, 372-373, 391, 469, 473, 481, Thirteenth Air Forces, 773

506. 507, 50), 549, 550, 605, 607, 614, 667, U.S. Army Forces in China-Burma-India,

668. 671, 732. 7X3, 735. 7:39, 742. 8)3 895

D-day week. Operation OVERLORD, 205-209 Deputy Surgeon:

DI)T, spraying of Saipan with, 664 U.S. Army Forces in China-Burma-India,

DEBAKEY, Lt. Col. M. E., 160, 245, 326, 327. 897-913

328 U.S. Army Forces, Pacific Ocean Areas,

DEBEN. 1A.I, Lt. Col. R. K., 262-263 841

Debridenment. 128, 662 Dermatitis, ear, prevalence of, 776, 779

directive(s) on: DEVERS, Gen. J. L., 153, 418

Circular Letter No. 101. Office of the I)EVINE, Lt. Col. J. L., Jr., 861

Chief Surgeon, ETOUSA. 1944-470 Devizes, 480

Circular Letter No. 131, Office of the Devon, 176

Chief Surgeon. ETOUSA, 1944-470 I)evonshire, 184, 481, 482

in preparation of facial wounds for DIzYoUN, Col. E. M., 934

closure, 530 DGMS. See Director General. Medical

inadequate, 720, 784, 785, 787, 791, 817 Service.

in forward installations, 460 I)IAMOND, L. K., 162

thorough, without undue removal of bone Diarrhea and dysentery, prevalence of, 774,

fragments, 700 778, 782, 788, 930, 947

DECoURsEY. Col. E., 684, 848 Dieppe raid, 30-32, 36, 397

Deenethorpe, 256 aftermath of, 30-32

Delhi, 908 German intelligence concerning, 30

Delta Base Section, 302, 303-304, 320 D)IEUAIDE, Col. F. R., 754

Demobilization, 684 D)ijon, 302, 303, 304

Dengue fever, 728 I)inant, 254

DEN-IT, Maj. Gen. G. B., 701, 708, 712, 719, D)iplomates. American Board of Orthopaedic

726, 731, 734, 739, 742, 743, 744, 768, 770, Surgery, 663, 674

852, 879, 882, 885, 887 Directives concerning professional practice,

Dental Corps, 512, 527, 751 distribution of, 642

Dental Division, Office of the Chief Surgeon, Director:

ETOUSA, 306 British Army Blood Transfusion Service,

Dental Division, Office of The Surgeon Gen- 32

eral, 175 Emergency Medical Service, 51, 181, 391

Dentistry, problems of, on Guadalcanal, 782 Home Division of the British Council, 40

Department of Commerce, 589 Medical Consultants Division, Office of

Department of Health for Scotland, 598, 615 The Surgeon General, 659

Department of Medicine and Surgery, Vet- Medical Service, British Eighth Army in

erans' Administration, 355, 621 Cairo, 438

Department of State, 25, 421 Medical Service, British 21 Army Group,

Depot(s) : 253, 283

Adjutant General publications, 642 Preventive Medicine Division, Office of

M-400 at Reading, 598, 601 The Surgeon General. 874

Medical Supply: Surgical Consultants Division, Office of

10th--WS The Surgeon General, 747n, 797, 841

10th-805 823Director General, Medical Service:

21st-3788, 823 British Army, 25, 50, 82, 259, 283, 327, 410,

23d Replacement, 8th Convalesent los- 765

pital, 636 Royal Navy, 96

Deputy Chief, Operations Division, Office of Director of Military Personnel and Chief of

The Surgeon General, 876 Personnel Services, Office of The Surgeon

Deputy Chief Surgeon, ETOUSA, 23, 107, General, 916

117, 167, 175, 184, 257, 281, 293, 317, 339, Director of Pathology. British Army Medical

341, 366,454,486,595 Directorate, 33
INDEX 1019

Director of Professional Services, AEF, DoAx, Col. H. W., 213, 317, 325

World War 1-2, 3, 4 Dobodura, 688, 696

Director of Professional Services, Office of Doctors, civilian, in uniform, importance of,

the Chief Surgeon, ETOUSA, 13, 14, 28, in World War II, 3752

49, 107, 132, 204, 317, 355, 359, 444, 446, DoNolluE. Lt. R. M., 799

459, 575, 585, 596 DoRior. Brig. Geen. G. F., 414, 441

Director of Rehabilitation, Office of the Doron, 414,441

Chief Surgeon, ETOUSA, 467, 485, 486 Dorsten, 325

Director of Research and Consultant in DOWLING. Capt. G. B., 184, 200

Surgery, Medical Section, General Head- Down Bros., Ltd., 396, 601, 612

quarters, Army Forces, Pacific, 626 Drainage:

"Director" system, World War I-1, 2 in closure of deep wounds of the upper

Disciplinary Training Center No. 2912, 467 neck, 534

Discs, ruptured intervertebral. See Her- in closure of facial wounds, 534-535

niated nucleus pulposus. indications for, 533-535

Dispensaries in India-Burma Theater, treat- DRAPER, Lt. Col. S., 865

ment in. 925-930 DRESIBACH, Col. A. R., 754

Disposition boards, guidance to, by surgical Dressings, initial circular plaster of paris,

consultants, 297-299 directive on, 236

DIVELEY, Col. R. L., 9, 10, 15, 21, 28, 37, 39, Drugs, chemotherapeutic, importance of, in

55, 61, 108, 109, 164, 391, 459, 468, 477, 482, successful management of maxillofacial

485, 486, 487, 499 casualties, 538

Division of Professional Services, Office of DUCIIARNIE, Lt. W. A., 184

the Chief Surgeon, ETOUSA, 5, 6, 398 DUDLEY, Surgeon Vice Admiral S. (Sir SHELDivisions: DON), 96

Armored: DUKE, D., 841

2d-385, 386 DUKE, Col. R. E., 154

8th-306, 325 DUKE-ELDER, Brig. Sir STEWART, 259, 456

9t--•318 Dulag, 668, 853, 859

Cavalry, lst-861 Dumbea Valley, 843

Chinese, 130th-945 DUsseldorf, 319

Infantry: Dutch East Indies, 817

lst-38-40, 397, 73:1 Duty, temporary, of medical personnel, rec6th-660 ommendation concerning, by Consultant in

7th-622, 660, 669, 679, &60, 735, 859, 861 Surgery, Office of the Surgeon, USASOS,

25th--58, 776, 777, 780, 789, 812 SWPA, 718-719

27th--679, 873 DYE, Lt. F., 801

29th--52, 407, 462 Dysentery. See Diarrhea and dysentery.

37th-778, 780, 781, 788. 802, 805, 807,

809, 812, 815, 822, 827, 828, 834, 835, EAKER, Maj. Gen. I. C., 44

836 Ear drums, ruptured, 831

40th660, 826 East Anglia, 158, 287, 506, 515

43d-780, 788, 814, 884, 885 U.S. hospitals in, 362, 365

75th--326 East Grinstead, 516

77 th--164, 86W861 East Grinstead Royal Victoria RAF Plastic

96th-859

98th-682-683 14--682-6829, Center, 400 East Indies, 751 182d--820 East Wiltshire, 214

See also Americal Division. Eastern Air Command of the Southeast Asia

Marine: Command, 930

2d--676 Eastern Base Section, 137, 494

3d-822 Eastern Command, Chinese Combat ComDMS. ,cc Director, Medical Service (Brit- mand, 939, 941, 945

8ish). EATON, Lt. Col. G. 0., 698, 757, 765

705-095-64--67
1020 INI)EX

FIIERT, Lt. Col. It. V.. 16. 71. 148, 1610, 1612. Education and training, professiinIal-

"371. 3185 Continued

Edinburgh, 620 of U.S. Ariny Iiedical officers in European

Education and training, professional: theater--('ontinued

films on- in practice of anesthesiology, 588. 591,

emnergency anputation, 465 598, 599.. 0044, 405, 612, 613, 615, 619,

manufacture and fitting of prosthesis 620. 021

for below-knee amputation, 465 inl practice of anesthesiology and remedical service in North African the- suscitation, 588. 391, 598, 59l9, 60.), 003,

auter, 465 612, 613, 619-621

rehaibilitation, 465, 494 in rehabilitation and reconditioning, 461,

rehabilitation center program and ac- 489, 490, 491-494, 497

tivities, 494 in thoracic surgery, 10M

transportation plaster of paris tech- in transportation of fracture cases, recnique, 465 ommendation of surgical consultant

use of transfusion kit, 160 concerning, 461

of nmedical units on HIawaiian Islands, of U.S. Army medical officers in IndiaM"5-4130 Burma and China theaters, 92-0-921

of reserve officers ('oinan~les. in pxeacetimne as hospital. f V.8. Arnny medlical officers in lPaeific,

commanders. reconmnendations of surgi- 037-637, 632. 658. 600 601. 602. 065,

cal coInsultant concerning. 952

of specialists in l'Eurolpan theater. 110 666, 673, 674, 681, 682-683, 685-686,

of U.S. Army miedical officers in Central 699, 700, 719-725, 792, 793, 814, 815,

Pacific Area, 652 816. 821, 822, 831, 836, 844, 882. 883,

in orthopedic surgery, 662 8835

of V.4. Army medical officers in European in anesthesia, 721

theater. 15. 16. 30. 3N, 09, 70, SO, 109- in care of wounds, recomnmendations of

110. 160. 25). 317, 321, 357, 366, 400, surgical consultant concerning. 792.

455-457. 460. 461, 462-466, 489-490, 793

491-494 in combat zone principles and niethods,

at Army Air Forces school at "Pinetree," recommend ations of surgical consult144.9 ant concerning, 665

at Medical Field Service School. in simplest basic principles of wound

ETOUSA. 69, ,6. 109 treatment. 699

at Post-Graduate Medical School. in transportation of fracture cases. recRAMC, 19) onninendations of surgical consultant

during posthostilities period, 321 concerning, 792, 793

in blood transfusion, 10 recommendations of surgical consultant

in British Army Blood Supply D)epot, concerning, 792, 793

110. 1612 of U.S. Army medical officers in Pacilic

in convalescent care and rehabilitation Ocean Areas. 633-6.37, 052, 658, 660,

of Air Force pIersonnel. 461. 410 (001. (6(62. 6465, 606, 673, 674, 681, 682-

in delinitive treatment of fractures at 683, GS5-08(1

imase areas, rn'connmendaltion of su'gi- in orthopedic surgery, 662

cal consultant. concerning, 461 re'omlmndeildatiolis of orthopedic consulin first aid surgical measures. :38 taWt concernling. 6(65

in Mr. Tudor Edwards' 2-week (.oirse in of IU.S. Army nimegial officers iii 8:,ut hwest

thoracic surgery, 110 l'acilic Area. (C009, 704), 719-725

in ne mm'olpsychiatric Iri lolms. 394 in a nestlhsia. 721

in neui rosunrgery ill war. 16. 39t in simplest Ibasic IprinicipIes of Wouandl

in oolmithalnnmogy at Oxford U'niversity. treatment. 74K)

455-4-57 Elduication and Training Branch. (tfliie of

ii oirtholiedic surgery. 4611 tlie ('hief slirgemmre. .T( 4I' .. 1(4.
INI)•EX 1021

1 .ýl'hIW-s. Sir (.Eo'ý:''Y. 41 English Channel, the, 249, 310, 391, 473, 485,

Eow.mts. Brig. II. C.. 346; 512. 541, W10

EDWARms, TuDoR, 110, 354 Eniwetok, 667

2-week course in thoracic surgery by, in Epidemiology Division, Preventive Medicine

European theater, 110 Service, Office of The Surgeon General, 890

Efate Island, 791, 793, 795-796, 802, 804 "Epitoine of Surgical Management," 906

EGEBRFO, Col. R. 0., 714, 884 Equipment:

Egypt, 423, 608 ophthalnie, recomnmendations of Senior

Egyptian U.Iniversity, 437 Consultant in OplhthlthnIdogy, Office of

Egyptians, 422. 423 the Chief Surgeon, ETOUSA, concernEighth Air Force, 24, 29, 44, 52. 65, 79, 109. ing, 457

114, 137, 149. 357, 413. 415, 417, 465, 466, portable, to provide intermittent positive

489. 506, 515, 540, 541 pressure for resuscitation, 601

medical activities in, training filn: "Med- surgical:

ica1 Service in the Air Force." 465 for evacuation hospitals, 924. 925

Eighth Air Force Central Medical Establish- improvised, in India-Burnia Theater,

ment, 417 924

Eighth Air Force Provisional Medical Field in India-Burma and China Theaters.

Service School, 400 921-925

Eighth U.S. Army, 687, 715, 721, 720. 759, 767 in Southwest Pacific Area. 727

EISEN IIOWER. Gen. D. D., 246, 366, 746 shortages of, 772. 779. 790, 791. 796, 798.

Elbe River, 319 799, 801, 805, 806, 822, 823. 8:35, 8336, 861,

Elbe-3Mulde line, 319 863, 865

ELIO'rT, Capt. J., 162 transportation of, problemi of, SOS

ELims. Capt. J. W., 805, 807. 809, 810. 814 Erlestoke Park, 480

Em.ims. Maj. L. B., 307 Errors committed by surgeons inexperienced

Emergency Medical Service, 26, 27, 29, 51, in military medicine, 719-720

58, 107. 181, 182, 183, 345, 397, 398, 399. Espiritu Santo Island, 772, 789-790, 795, 802.

459. 584, 585, 599 804-805. 821, 824, 826

plans of. 181 Espiritu Santo Medical Society, 789

Emergeney Medical Service Hospital at Park Essential Technical Medical Data reports.

Prewett. 516 657, 711, 724, 725, 735, 844, 850, 914, 915

lEhmergeney Medical Service. Royal Cornwall ETOI"SA. 111,230, 233, 616, 617

Infirmary. N0 "Essentials of General Anaesthesia." 588

Emergency lMedical Tag. 59)). 789. 795. 814 iftanipes, 485,495

Emergency Medical Tag Records, miade- Ether, value of, as an anesthetic. 603

quacy of, 791 ETOUSA (European Theater of Operations.

ElS.KoN. Lt. C'o. C'. P., Jr., 16, 71. 147. 160. U.S. Army). See European theater.

:351, 336, 371.3:5 ETOUSAMID Form 30.3-52

Enmry University, 303 Eupen. 25:1-254, 292

Empieror of Japan. S86 Europe. 1-17. 19-358, 359-389, 391-441, 443-

Emplress Augusta Bay. 808, 816, 833 457, 459-501. 503-510, 511-571, 573-579.

Enfiehl, 495 581-621

Engineer Corps, 116. 8M06, 808. 853 European theater, 632, 652, 655, 727, 732. 755,

Engineer special brigade. 868, 869. S70 75A), 901

England, 14. 15. 17, 25, 27, :1. :32. 33. 37, 38, American Board of Surgery examinat ions.

42. 52, 53. 5s, 59, 69, 181. 215. 2:"7. 249, 250, 63

256-259. 275. 289). 291, 300. 30S, 309. 317. American Medical Society. 45. 109. 467

321, 335, 359. 3•4. 367, 368. 370. 372. 379. a mestliesia program in. 581-621

384. 391. 392. 3!0, 403. 405, 43 5. 4:18. 439. Ar.mmy Air Forces in. system, of colisulta447, 452. 45(;. 460, 465. 477, 495. 505, 511. lion ii. 9

512, 515. 518, 51). 520. 521. 527, 541. 542. Assail! 'l'raim.iiig ('enter. 179. 1s1

55:3, 56:. 564. 576. 579. 582. 58-3. 593. 59)S. bhlod supply ill. 14

001,6004, Z 61, 756 burn casualtis,. treatment of. ili general

England General lHospital, 467. 494. 919 hospitals in. 527, 541. 542 551
1022 INDEX

European theater-Continued European theater--Continued

burns in. 539-551 general hospitals in--Continued

campaigns in, 344 treatment of maxillofacial injuries in,

care of- 527-529

casualties with massive soft-tissue loss general surgery in. 228, 230-232, 359-389

of the trunk or extremities in general hospital centers, 14, 121, 450-452, 457, 493

hospitals in, 527 hospitalization, 275-280, 291

facial injuries at evacuation hospitals initiation of regional consultant system in,

in. 525 by General Hawley, 506

maxillofacial injuries in general hos- Inter-Allied conferences and meetings in,

pitals in, 527-529 40-41, 55, 252, 253, 256-272, 2:13-286, 287,

urology patients in general hospitals in, 342-349, 355, 466, 615

576 Inter-Allied Conferences on War Medicine,

Chief Consultant in Surgery in, 19-358 40-41, 55, 252, 53, 2'56-257, 283-286, 355,

complicated soft-tissue and extremity 467. 615

wounds, treatment of, in general hos- load carried in, with respect to total numpitals in, 527, 555, 556-571 bers of casualties and types of wounds

conferences and meetings. Scc Confer- received, 351

ences and meetings. Medical Field Service School, 15, 53-54,

consultant system, 1, 5-17, 388 69, 86, 109, 259, 317, 357, 366, 455, 466,

expansion of, 61-62, 108, 118-120 599, 613

policies of, 11 medical meetings, regular, at general and

consultants in surgery, 1-17, 19-358, 359- station hospitals in, 445

389, 391-441, 443-457, 459-501, 503- neurological surgery in, 391-441

510, 511-571, 573-579, 581-621 ophthalmology in, 443-457

duties and functions of, 13-17, 60-70, optical supply, 452-455

108, 112, 224-9239, 259, 261-272, 275- orthopedic surgeons in, 472-473

300, 334-352, 362-367, 370, 371, 372, orthopedic surgery and rehabilitation in,

373, 374, 375, 379, 381, 38-4, 386, 387, 459-501

388, 398, 399, 400, 405-407, 410, 411, placement of personnel in, recommenda419, 446-447, 454, 455-457, 459, 460- tions of senior consultants in Office of

461, 462-468, 468-471, 474-475, 476, the Chief Surgeon concerning, 594, 595

482, 48.5, 486, 493-494, 504-505, 506, plastic surgery centers, 518-520, 538, 555.

508-509, 510, 512, 517, 521-571, 574, 557

575-579, 594-595 plastic surgery in, 511-571

establishment of casualty survey team in. policies and procedures governing care of

115 patients in:

evacuation from, to Zone of Interior, 241, directive on; Circular Letter No. 80,

294 Office of the Chief Surgeon, ETOUSA,

evacuation hospitals in: 1944-171-173

definitive treatment of facial injuries factors influencing formulation of, 520-

at, 525 521

treatment of burn casualties at, 542 problemsFirst Inter-Allied Consultants' Conference in practice of anesthesiology in, 585-

in, 261-271 588, 589, 591, 592, 594, 598, 599, 600,

general hospitals in: 603, 605, 612

handling of urology patients in. 576 of interpersonal relationships of contreatment of burn casualties in, 527, sultants in, 56-60

542-551 of personnel and tables of organization,

treatment of casualties with massive 514

soft-tissue loss of the trunk or extrem- of supply, 36-38, 452-455, 516-517, 585,

Ities In, 527 586-587, 588, 589, 591, 592, 594, 598,

treatment of complicated soft-tissue and 601, 603, 605, 612

extremity wounds in, 527, 555, 556-571 of traumatic surgery in. 58-60
INDEX 10',23

European theater-Continued Evacuation-Continued

problehns-Continued directive on, Circular Letter No. 142. Office

of unqualified personnel perforning sur- of the Chief Surgeon, ETOUSA, 1944-

gery in, 64-65 299

professional training of medical officers in, improvement of, 273

15, .'29, 30, 38, 39, 53, 54, 69-70, 86. 109- in Pacific Ocean Areas, 648-664, 6635, 679-

110. 160, 259, 317, 321, 357, 366, 455-457, 680, 681, 682, 686

460, 461, 462, 466, 489-490, 491-494, 588, of casualties with severe facial injuries,

589, 591, 59K-599, 600, 605, 612-613, 619- 517

621 policies in European theater, changes in,

programs for collection of data on missile 320

wounds in, 114, 115 priority in, 274

rehabilitation in, 461.467, 468, 477-501 problems. 777, 779, 853

schools in, 15, 16, 53-5-4, 69-70. 86, 109, 259, responsibilities of a consultant in, 517

317, 357, 366, 455-457. 466, 599. 613 shore-to-ship, 870

Second Inter-Allied Consultants' Confer- to United Kingdom from Continent, 245

ence in, 283-286 to Zone of Interior from European theater,

shortage of qualified officers in. 183 241

supplies and equipment, medical, in. 452 directive on, Circular Letter No. 131,

surgical consultant system in. 573 Office of the Chief Surgeon, ETOUSA,

Third Inter-Allied C4nsultants" Confer- 1944-294

ence in, 342-349 Evacuation and medical care, recomnmendatransportation of blood to, 14 tions of Consultant in Surgery in Pacific

urology in, 573-579 areas concerning, 792-793, 870-871

urology patients, handling of. in general Evacuation and sorting on the Continent,

hospitals in, 576 381-385

U.S. hospitals in. 275_280, 291 Sec also Sorting; Triage.

inadequacy of facilities in, 396 Evacuation Branch, Operations Division,

woundls and general surgery in, 228, 230- Office of the Chief Surgeon, ETOUSA, 297,

232 300

European Theater School of Medicine and E

Surgery, 15 Evacuation Center. Tenth U.S. Army, 679

Euskirchen airport. 322 Evaluation and placement of surgical perEvacuation : sonnelby air. 688, 734, 738. 756, 861. 862,903 in Pacific Ocean Areas, 6•6

from combat zone. recoinniendations of in Southwest Pacific Area. 711. 714-718,

orthopedic consultant concerning, 665 755

from the Continent. 248-249 Evaluation. an(l recommndation for reasfrom the U nited Kingdom. 248-249 signment, of personnel by senior consulImportance of, 665. 681, 6,82, 686, G.9, tants in Office of the Chief Surgeon,

756, 757. 861, ,62..903 ETOUSA, 594. 595

In Operation OVERLORI), 227 Examinations, American Board of Surgery,

by litter, 903. 942 European theater, 63-64

difficulties of. 771, 781, 790, 813, ,22 Executive Officer:

by litter or ox-drawn (cart, 756 Office of the Chief Surgeon, ETOUSA, 125

hy otor ambulanc(,..(1: Office of the Under Secretary of War, 731

by "Piper Cub," 861., 862 Professional Services Division, Office of

as morale builder, 861 the Chief Surgeon, ETOUSA. 4.54

by sea during. 64ý849,656. 679-680, 734, Exercise SPLINT, 197, 2(X)

809. 815. 853, 861, 864. 865. 866-870 Exeter. 79

Operation OVERLORD. 225-227

by water buffalo drawn carts. 903, 904 Expedition of pm iority cases, 279-280

classification and selection of imientit for, Eye infections, 69

76M Eyeglasses. 835. 861

sc 4lso Sorting: Triage. Eyes, artificial. 306, 1G37
1024 INI)EX

Facilities. phylsical, and equipment, in India- First U.S. Army-Continued

Burma and China theaters, 921-925 ('on.3ultant in Surgery to, 10

FAIRSANK, II. A. T., 459 First U.S. Army Group, 187

FAiRWAX. Maj. K.. 455 FnciT, Brig. (;en. B. M., 432

Fanning Island, 659 FLEMING, Col. W. 1)., 596

FARIs. Maj. A. M., 063, 666, 667 Fi.ICK, Col. J. B., 626, 651, 878

FARR. Col. R. S., 250 Flintshire, 121

Fatigue study. 52 FIORFY, 11. E. 52. 68, 134. 142. 327, 575

FAYMONVII.E, Brig. Gen. P. R., 426, 434 FLOREY, M., 133. 141

Federal Security Administration, 923 Florida Islands., 782. 793

Femur.: Followup lwstcards on medic.ai c are. 52

compoundl fractures of. with skin trac- Food amlI )rug A.dministration, Federal Setion. 245 curity Administration. 923

fractures of. 637, 649, 862 Foot problems, 861

simple fractures of. with skin traction, 245 FOREARM plan, 826

FERGUSON. Col. 1. A., 282. 302. 303. 304 Foregger anesthetic machine, 585

FIELD. 11., 440 FORM BY, Brig. M. L., 505

Field Artillery Battailion. ";99th-:--25 Formosa, 746

Field dressing in first ai(l pa(cket. 45 Formosans, 750

Field Force Replacement System, 310, 486. Fort I)evens, Mass., 767

487 Fort I)ix, N.J., 387, 919

Field hospital platoons, geographic relation Fort Jay Regional Hospital. 889

of. to division clearing station. 122 Fort Shafter, T.HI., 625, 055. ,41. 874

Field Me-dical Bulletin, USFIRT. 914. 915. Forward Echelon. New Georgia Occupation

921 Force, 786

Field Surgical Unit, British, 346 Forward Echelon. U.S. Army Forces in

Fifteenth Air Force. 730, 731 China-Burmia-India, 897

Fifteenth U.S. Army, 291, 322, 326, 454 "Forward Plaster Technique," 465, 467

Consultant inl Surgery to, 10 Forward surgery. Sec Surgery, forward.

Fifth U.S. Army. 121-127. 319 Fourth Service Command, 675. 890, 908

Fiji Islands, 789, 796, 797, 798. 799, 801-802, FowLER, MIaj. E. P., Jr., 51,505. 506

819. 935 Foynes, 23, 582

Fiji Islands Government. 819 Fracture procedures, first aid, checking of.

Fiji Scouts. 833 658-659

Filariasis, prevalence of, in Fiji Islands, 79T Fractures:

Filipino troops, 747, 748 cast fixation of, 667. 682

Filipinos, 805 comlpound :

Finland. 430, 915 delayed primary closure of wounds over.

FINNEY, (ol. G. G., 626, 675. 799. 801. 826. directive on. Circular Letter No. 131,

827. 849. 877 Office of the Chief Surgeon, ETOUSA,

FINNEY. Brig. Gen. J. M. T.. :. 20 1944-470

Finschhafen, 690, W96. 721 of the humerus, 763

First aid: percentage of, amnolig battle wounds. 761

care of fractures, 658-659 compound comnminuted. .958

in forward echelons, 262.263-264,265,266 (of the femur, 862

surgical measures, lectures on, 38 handling of, by portable smrgieal hospital,

First French Army, 304,319 944

First Medical Institute, U.S.S.R., 439 immobilization of. for transportation, diFirst Service Conmniand, 908 rectives:

First U,.S. Army, 4, 16, 106, 109, 162, 166, 168. Circular Letter No. 101, Office of the

179. 221, 222, 233, 234, 240, 241, 253- Chief Surgeon. ETOUSA, 1944-470

254, 257, 263, 26,. 269. 287, 289-293, 299, Circular Letter No. 131, Office of the

300, 305, 306. 307. 318, :0,9. 322-323. 325, Chief Surgeon, ETOUSA, 1944-470

326, 327, 333, 306. 371. 372, 37-S. 379, 605. Inadequate treatment of, in New Georgia

008 campaign, 791
INI)EX 1025

Fra.t ures--(C' it inued Gas gaingrene-(ont i iued

nanmagenient of, 125, 30() in war wounds. 69, 12,14, 141. 146

directive oln, Circular Letter No. 131, reasons for occurrence of, in New Georgia

Office of the Chief Surgeon. ETOUSA, campaign, 784-787

1944-312 treatment of, directive on, Circular Letter

of carpal scaphoid. prevalence of, 659 No. 71, Office of the Chief Surgeon.

of femur, 245. 637, 649, 796, 862 ETOUSA, 1944-146;, 171, 232

of long bones, management of. 274, 474, Gas gangrene and wound closure. study of.

676, 681,682 374-375

simple shaft, open reduction of. 763 Gas sch(ool, Leeds University, 1;

translportation of, 761-763 Gases in cylinders, identification of, direcFrance, 214, 239, 249, 252, 256, 273. 280-281. tive on. Circular Letter No. 27. Office of

:101, 304, 305, 306, 310, 321, 367. 370. 378. the Chief Surgeon. ETOI'SA, 1943-595

379. 384, 385, 386, 473, 495, 497, 498. 514. GASK. G.. 41. I0

521, 523, 541, 594, 604, 605, 608, 610, 7:32 GATES, Col. K. 11..,S41

FRASER, Sir FRANCIS. 29, 0.54 58, 181 (;atton,. 688. 693

Free French Army, 40, 272, 342, 364 GAY, Lt. Col. E. D.. 286

surgical teams, 116 (GAY, Maj. Gen. 11. R., 31"1 328. 335

FREER, Col. A., 8M!) General Dispensary, 7th-452

Fremington, 481 General Orders No. 88, General 1HeadquarFrench, the, 20. 252, 253. 618, 619 ters, AEF, 6 June 1919-3

French civilians, employment of, 455 General Surgery. ASce Surgery, general.

French Military Medical School, 256 Geneva ('onvention, 215, 754, 855, 886

French National Academy of Surgery. 17 Geneva ('ross. 160, 163, 215, 939

Frenchay Park. 403 German Army, 30, 181. 273, 300. 318, 328, 329

Frostbite, 307, 309, 311. 314 Germany, 239, 250, 251, 286, 314, 323, 353,

high-altitude, 414-418. 441 :191, 499. 541, 018, 752. 915

l)revalence of, in European theater. 613 GIoIML.EY. Col. V. G.. 824, 826

Fulda River. 319 Gibraltar, 422, 4:18

"Fundamentals of Anesthesia." 814 Gigli's saw, 7!Y)

Fungus infection, prevalence of. 775 Gilbert Islands, 1410, 664

I"URSTENBERG, A. C., 504 GILRRE-TlI. Maj. Gen. F., 840

GILLrTE. Capt. S. C.. 924

G-1 (personnel and administration) Section. GILLIES. Sir HAROLD. 128, 516

ET()USA, 482, 486, 491 GILLIES. J.. 584, 0i20

G-2 (intelligence), 860 GINZIBERG. Lt. (Cd. L., 30.1

G-2 (intelligence). SOS, ETOIUSA. 420 GIRDLESTONE, G. It., 459), 466

G-3 (operations and training) Section, Givet, 254

ETOl'SA. 482. 485. 486. 487, 498 Glasgow. 40)5, 620

G-4 (logistics) Section, General Ileadquar- GLE N N, Lt. Col. F.. 700, 767

ters. A FI'AC. 742 Gloucestershire, 121. 392

(;-5 Division. ET()USA, 326 Gonorrhea :

(.,\m.N:Iit, T.. 27 sulfonamide-resistant. 137, 142

GAmRETTr. Lt. ('oI. L. 6., 625 treatment of, 575

Giarrison Force, 248th-85S Goodenough Island, 69;

Gas C'asualty I)ivision, Office of the Chieif GoRaY. Col. A. L., 175, 17!9. 1847

Surgeon, ET()USA, 596 GORDON. Col1. J, E.. 307. 454

Gas gangrene, 2:0, 232. 233, 784, 786, 787, GOR)ON-TAYLOR, Surgeon Rear Admiral G.,

817 26. 65, 70. .3,. 94. 96, 97, 188, 300. 354, 355.

acc' l •ma nyin g ('cOmlpioulnd fractire. 817 421,422

clinicil,. study of effect of penicillin on1, GoRINovsKAYA, Brig. Sirg. VAI.ENTINA, 43.3

141 Gou'i). Lt. A. M.. 487

directive on, Circular Letter No. 101, Office GOWEN, Lt. ('ol. G. II., 307

of the Chief Surgeon, ET()USA, 1944- ( Grafting in treatment of burns in European

2:12 theater, 544. 545, 550
14)241IN I)EX

11.11). 411relPt 1111414114'4lye. 559) 1IA.-N so-.'~ IA. 4 'ol. L. B1.. 783

f rt-4 s k i. sI , 530 -.5 P5. ',i .55 7. 11551) AtI 1 N, lit. Col. It. C., 14. 32. :35. 36;. 7-1. 76.

P.edhch'. 536, ---1555 556, 5-57 7-63. 569 147. 149., 154). 154, I.5s. 1740. 184. 222. '223,

dir'ct. crossed Ii'g. 559. 521 225, 239, 240, 243, 2-55. 26S. 274. 29.5. :124.

for 4'(4lk[I)4)iiii(l inijuies~I, 553- 6444

spit iI, 555. visit of. t41 Norumaundy. 222 223. 22-5

924. !)31t. 93:3:, 935, 93911, 9)41. !1445, !)4.to !)III 1 1AICKE:N. 1,4. ( 'o1. 1). E., 255-

GRIANT', lohj. 1)ii I. N. W., 11-1, 1:12, 414), 490 IIAICM4N. 1A. (i.11. F.. S241

11; Icss, Col. E~. L1. s4), 04. si.S:j t HaIlrmoinField414. 247

11IAVEs, 11:1j. 4'. 1 ~, 4;5-. 166t, 167 HARER lt. (COL. 1'.. 791. 7M)4

-ravvs Re4gistrat ion Service. Quart i'urill.isi yr I IARiIIS. B~rig. (fit. 1F.. 814

Corps. 830 1IIAIIF4)RIP, C'ol. 'I'. J.,. 152. 1664

(;rvait Britain. 519. 4135, 5731,574. 592. -031. 6os), I lrt ford Hosp51ital. 9. -5sl, 5S2

!

1 45 IHarvard MedIical Schnool. 19. 19.. 241, 21. 1462.

it lit. C'ol..1.......1.111. -1:13 2 Ito. :~,!I. 392.8s!)

4; uI*:, 4 'o1. 1P. 1 1., S-41 HaInrvarid UniiiversitWy. 21. 16M. 704l)

(nt*:NIIAIr'M, Blrig. (.en. H. S., 7:11 1 lust jugs Miii. 9344

41 Riswoi.1v, Maj. (;(it 4). NV., 77:1, S26;, 8:34), 1Fi'u.1.. S0)2

sx1." s.15 I lavuiinaIli Illirloolir.-S4M

GluI5WoI.l.) 4 t1.I. A.54 K9 Haai. 244, 4655, 41546. 665s 6647, 4174. 796. S-10.

4f roullni Fo rce 4 Iti 'jlacemeni 1 't Svst 4'i . S'' M, S '4. 55, S5 8

4 1'S 487.491)11 Hawai C hapter, A ni4ricanu 4,iolhg(- of Suir-

(;flcow, M :uj. Gen'i. M. C'.. 29, -:13, 1-4. 51. 1121. geo lls. W144, 6;S1

137. :110, 4131. 41 1, 415. 441), 489. 4190 Ha:1wa hiia 'n u rW riollt f.-1'. 6154SS

(1uuiuiIi1c:iiai Isuland, 663-661-;; . 77:1. 774. 774;. Hawaiiani Ishmiids. 635;:s41641 67o2. S73

781, 7852, 7,S5-, 787, 755. TIM(, 79-22, 7115. 80:1), 31.1.~yMj. (.e. 1'. It., 6. 23, 24I. 29. '32.

811S, 812, S131. 514, 816. SIT 7.821, S2:3. 82:1. 346, :1. 43. 47. 41). 50). 55. `17, .594. 464. 461. 462.

826, S33:, 8-43 63. 6414 467. 419. 70. 757, 761. 77. 7-S, 79. SO). SI.

Guuxuu. 613S. 644), 4642, 414. 64S4, 4654. 6414*. ELSI. S3. s0, 92,!.1 9-94. !H;, 97, 1404. 14)17. 14P), 110.

7441. 554. S-51. S52, S72. S731. S741. S77. S7S 112. 115. 117. 1 S. 124). 129) 1:3). 1:11. 1:12.

Gutides (toE Th'ersipy for Me'dical i )hers: 1:37. M:s. 143. 153i, 15-1. E-to. 141, 10W. 1417,

d1irectWive fill, Wa r I )4pi tlillell t't-c~hniilll 1411. 174). 172. 175. ITS. 17!). IS], ISS. 15S).

-Maniual I (TM) S 214), 19)42 1691. WK4)) 1904. M1,1 1931, 1M. 211)4). 241., 20)2. 211". 24) 5.

(;UIRGOLAVE~, lit. 4;-l S. S.. *4:11 2447. 20-S. 21:1. 215. 217, 2:1.14 . 244). 241. 2:13.

2416. 254)11. 25 2. 257, 25 -.1 215!)1. 2411. 24G2. 26;S,

I hickwouuI I billsi, 3:19p 241!) 272. 27:1. 217 I. 27 5. 2S3. 2112, 2"! ;. :i4 K).

I IAT ('411. it. 0).. 913 :014)1 :10)2. 303):, :14.)5. 3114;. :30-N. 3109. :;i11. :115.

II .wu-j.v. t.(. G N.. 793: 3:125. :14;327. 328. 335. 33:S. :3391. :11: 1, :1411,

I IAGlN S. Blrig. 4 P~IL AV. 4A..16). 712. S-53. S%4) :116;. :115, :1419. :15-- 5, 3-56;. 366. 31)2. 3 :1!4, 44)4),

HINEi ~S. ltA. CO It I. 1D.. 535S 440)5. -104)4 -1117. 40S5. 44109. -414),.1415, 4117, 4120),

I Ll.~i. Col41. I I. (I. 114. 1424) -503. 50-1. 54)4, 54)1) . 5P11. -P-1). 57:3. 4621, 7:12,

1 h i~i,. 2d1 LW. 1. V-. 17-S 7331

I IA LS E J. Vi 4 - A(I I ii. W. F.. S 10. S261. %,:1. : I, " I('iiCo. ~ s S. It.. 1-45. 247. 25.):P 4M2, 151. 6045

H~alstedi tylI El-f l'Pi414't I rainling.36 H11;IeadI pro~Itection :

I lamintiuuehuug. 312S for 1lirei'ws. -111- 414. 411!). 420). 1-11

I Iaiipsluire. 20.5 ac~ryicE rf-sill Iu'to. plropoEsedu. 4112 11M3,

1jan41 iii juries. care' of. 5413:, 571I *l II), 424)

dlirectiv fill'li. 4 ilr'uu1al. Ikt.r1-1 NI). 131. 4 )f- for fink pl'rsomiii41, jpr41jl454'. -41!). 120)

4ii(., oJf fill.' luiiefI suuu'gq-u'ii 1'I'4)i ., SE-c Vitlmo Armnor.

1911 312. 74 ITO l~itdinlgtoll. 555'

Ilail. I'1i4'~tII ~I'. n rut in't lf.41) Hi'ariingth-I'fnels. 5447
INDEX 1027

HIEATON, Col. L. D., 655 HOOD, Lt. Gen. Sir ALEXANDER, 26, 40, 50, 82,

Hleerlen, 287 202, 259-261

IHeidbrink Co., 598, 865 Se'c al.,o Director General, British Army

HElIN, 1Naj. 11., 480, 487 Medical Service.

HEI,, Lt. Col. G. E., 65 HOOK, Rear Adm. F. R., 821, S25, 853

Heliopolis, 423, 438 HoPKINs, H1., 426

Helmet. See Armor. Hospital, surgical, 48th-591

Hematocrit determination: Hospital centers:

copper sulfate method of, 68;0 AEF, World War T Consultants in, 4

importance of, 682 at Tinian, 650-651

Hemorrhage, control of, 529 in European theater, 14, 450-452, 457

Hemostats, scarcity of, 271 consultants in ophthalmology in, 457

Henderson Field. 773. 821 coordinators in surgery in,. 121

Hendon Airport, 29 15th-121, 493

Hepatitis, 947 68l0th, Provisional, 121

Hlerne Bay. 707n 12th-121, 493

Hernia, 309 in Southwest Pacific Area, 726

Herniated nucleus pulposus, treatment of, Hospital commanders, essential qualities of,

396 for efficiency, 952

directive on, Circular Letter No. 75, Office Hospital construction in India-Burma and

of the Chief Surgeon, ETO[TSA, 1942- China theaters, 921-925

403, 420 Hospital Inspector and Consultant in ReHlerzogenrath, 286 habilitation, Office of the Surgeon, United

IIE WER, C. L., 588 Kingdom Base, 487

HICK,.Maj. L. L., 663 Hospital Ship Comfort, 712

Hlickam Field, 682, 840, 850 Hospital Ship No. 38-47-49

Higgins boat, 814 Hospital ships in the United Kingdom, use

Ili(;c,s. S. L., 460 of "troopships" as substitute for, 245

High Wycombe, 29, 44 Hospital train, 25th-241

Hill End Hospital, 397, 516 Hospital trains, professional care on, 296-

HI.L.•AN, Brig. Gen. C. C., 30, 45, 59, 674 297

hIilo. ,47 Hospital units, in Southwest Pacific Area,

Himalayan "IHump," 894, 899, 908, 939 693-698, 700, 720

Himalayas, The, 895, 949 Hospitalization:

Hirosbhima. 6,84, 710 in European theater. 275-280, 291

Historical Unit, The, U.S. Army 'Medical in forward areas, staff planning for, 860

Service, 768. 898 in Pacific Ocean Areas. inadequacy of, 860,

History of the 'Medical Department of the 862

t'.S. Army in World War 11-509 in Philippine Islands. 880, 881, 882

HHrLEic, 30, 319 in Southwest Pacific Area, 693-6-96, 700,

Ilixson. Lt. Col. C. H1., 477 726-727, 754;

H~ODGE, lit. Gen. J. R., 836, 842, 862 in united Kingdom, reorganization of, 275

Ilokka ido. 746 Hokkaido, 76 Ginadequacy of. in Pacific Ocean Areas, 860, Hi .D F:RE , Lt. C('o l. I I . G ., 3 4 18 0

H1ollandia, 642, 696, 704, 712, 715, 721, 725, H 02

727, 728. 863 Hospitalization I)ivi.ion, Chief Surgeon's

~oLM.., Cdr. E. F.. 793, 8005, 814, 825, 826, Offic'. AEF, World War 1-2. "1

872 Hlospitalizattion D)ivision, Office of the Chief

Hlome D)ivision of the British Council, 40 Surgeon. ETOI'SA, 498

Ilmig Kong, 898 Hospitals. ('hinese field, 945-946

Iloniton-Ileathfield, 482 Ilospitals. convalescent. 278

Honolulu. 625. 626, 8.47 sth---478. 4.<5. 495, 497, 5(9), 636

Hlom•orary Fellowship in Royal College of in base sections, 125

Surgeons for Ciolonel C,mtler. 65--66 on Continent, 4S2-485

Honshu. 746 7tt--485. 495, 497, 5M

7,05 0•5 614 #;s
INDEX

IHoslpitals, evailcuatioin, 11M6. 1,22. 1231, 27S. 6751. Ihospit als, field ( oilt Ilnued

733 inflividu1al- -(C'ontinu i1ied

iItillortane oif., 671 24t1--- -7, 7 M, I3, S 14, 817

in Europelan t heater: 25th-899

definit ive treat nmeit of facial injuries at. 2Xth - 214

523 31st--6T78, 6T9. SO

treatment. if burn casualties at. 542 44;th1- 61-1", K.53. X(I1

illdiVidlili: 38t h-- 87

Ist--(196 42d---324

2d1---6.7, 67, 137, -2!1. 40,1. 420 45th--217

5th--217 4;t h--207

Till 71111, s(Si,). 875 47thI - Ao)

9th- 31m; 4Itt- -287

141 It- -5911. )1)4, 934 50th-- 2131, 21-1

21st -7-48. 812. S17, S21. s2;3. 8-27, 830. 52d--773. 7TIC. 754. 786. 795. S1-7. 22. X23.

S31, 831; 830

24th-217 37th-- 2.41

25th-T772, T90 792, 7,3. sist 04h- -4179

3l-Ith--328, 3;{( 69th. 641M, 67S, S-13, 841, SW!2

364th--669 7oth -911

41st -217, 255S 941h----875

4411h---217, 2!12 reeomniendations concerning, by a ('on45th - 217. 222. 2111. 3'12. 323 suiltani in %urgery in Placitic areas. 791

48th-SIll), IN"1. 934 eC" 1Is80 14l11`t0011, flh'h4l hi.illitlal.

5PtIh---4W9. 7:135 Hospitals. general. 1061. 119. 201. 29.3

222, 2112. _.Ith-21T WS5 elective s•irgery Ili. 64

73;h---.Si. M 1. 9F33. 934, 935 eXlm-rie.nced, proIir tit ilizat In of. 473

SAM I ALS*212--1<15 in EIurolim~I1 theater:

dry run by. 4152 handling of uroi-logy lpatientls i I. T,5

D Ist--27T. :124 treat tneit of burn caisua.lities in. 527,

95th1- 3M( 542 551

1)11th 2911 treatment of cvistllhtes with mu.assive

I7th- 217 soft-tissue loss of the Irink or exI(02d 324. 325 treniltie•s iii, 527

1051ht - 257 treat ient of comnlil icated soft-1issll, lilt(]

1,1th- -2.S6 extrelility Woidul(1s Ill. 335 55tf 557

1640th 24(.• 213 trenlti ent of i11ixillofati2li hjuries in,

111th---2,S7 527 -521

12it It --222., 2111, 322 ma rued

va lise of. 84-13 thltty. 6175

Hos(1pitals, field Cushing, 509

in China Theahtr. 9145-96111 Enlghmnd, 4617. 49 1. 1919

in l'mlrolfan t heater, 27S I !ihlloran. 241

Indivi4dunl l..'tterman, 6.55. 671

1st - lovell. 76;7

2d--611 Norih Sel.c' 65-5. 6IS7, 655s. 661, 6fn, (664

:l--6;09 67, 174

6lth --21 I. 23S Percy .1i105 SIN)

12t11 --2s'

1311h 21T, 291. 324, (608 lalolud.s, 919

161 h---385, I (1i5 TIllton, 919

1701- -671, 77.1, 777, 77s, 7791, 780, 781, TrIlder, 6155, 616, 661. , SI11

7,4, 7-189. 802, S13. , 1-1. M. 871 Valley FIorge, 4-13. 512

"list 916t, 991! WaIthr I6441. 3i12. 401. -l4i9, 700,, -552. 675.

22•-1 !1-19 ,SI1, S• l)
INDEX 1029

Hospitals, general-Continued Hospitals, general-Continued

numbered: numbered-Continued

lst-278, 329, 330, 443 120th-881

2d-38, 47, 51, 52, 65, 68, 97, 107, 108, 136th-748

134, 142, 275, 306, 386, 392, 396, 397, 137th-258

404, 415, 417, 439, 456, 467, 505, 573. 140th-258

575, 5K8, 588 142d--696, 799, 801, 802. 819, 820, 935,

3d-303, 304 937, 947, 948

4th-696 147th--625, 652, 656. 661

5th-16, 21, 38, 65, 71, 80, 81, 86, 147, 148th--627, 636, 638, 644. 649, 664. 676,

150, 321, 359, 365, 368, 371. 372, 384, 850, 851, 852, 873, 874, 875, 876. 877

385,386. 387,399, 621 155th-258

7th-306, 307,308, 309 158th--275

8th--802, 804, 814 160th-258, 493, 620

9th--696 172d-940. 949

12th-422, 795 190th-283

13th-696 204th-629, 633, 638. 640, 660, 662. S41,

16th--259 872, 873,877

18th-706n. 798, 799, 801, 802,935, 937 217th-271

20th-899, 903, 904, 906, 915, 921, 933, 218th-625, 637, 638, 655. 68:3

934, 948 219th--625, 655. 68:1, 841

21st-304, 305 232d--638, 878

23d-304 233d-638

25th-289, 292 234th-947

26th-40l 235th--4.303

27th-743 236th-304

28th--370 237th-304

29th-403, &35 238th-304

30th-l15, 286, 289, 392, 397, 398. 399, 263d-935

404. 518, 588 298th-49, 61, 65, 66, 289, 381, 403, 404,

31st-825 409, 410. 518, 553, 563

36th-303 313th-747

38th-423, 437 317th--682

39th--68, 649, 676, 767. 797. 799, 802. 374th--638, 640

825, 840, 844, 851, 852. 873. 874, 875, transfer of patients to. in India-Burma

876, 878 theater, directive on, 925

43d-282, 303, 304, 335 Ilospitals, portable surgical, 700, 756, 87)3,

44th-696, 856, 857 885. 903. .906 942-945

45th--89 lst-733

46th-303 3d-73.3

47th-696 5th-733

48th-205. 274, 297, 468 16th-733

49th-882 23d-733

55th-493 28th--899

58th-306 32(1-81Y)

62(1-279 34t h-899, 942

69t h-8•..), 924, 933. 934 351th-89•)

80th-710. Sl1 40th-899

91st-275. 327. 456 42d-899

95th-468 461I h-899

97t h-327 471 h-945-946

105th-696 50th-899

IORth--254, 259, 261, 272, 274. 283, 306- 51st--663, 669, 679. 843

307, 311,342 52d--M3, 669, 679. 843

118th-C6AM, 707n, 721, 727. 730. 757, 871 53(i---99
1030 INDEX

Hospitals, portable surgical-(Continued Hospital, station--Continued

66th-679 numbered-Continued

67th-679 122d-773, 793, 805, 824

95th-8460 123d-479

96th--679 137th-812, 821

98th-679 144th-X38

Hospitals, provisional, in island warfare, 150th-258

problems of, 656 152d-154, 222, 278

Hospitals, relative excess of, in Southwest 155th--86

Pacific Area, 691 160th-493

Hospitals, specialized: 165th-669, 747, 843, 853, 859

in Pacific, 756 174th-748

in Southwest Pacific Area, 726-727, 756 176th-852, 873, 875, 876

on Continent, 313 222d-8.38

Hospital. station, 106, 119, 791 273d-850

named: 289th---664, 850

Schofield, 655 307th-478. 479. 4S0

numbered: 313th-481

lst-664 314th-482

Sth-794, 846 316th-370

9th-812, 821, 824, 835 327th-327

10th-44, 60,5 331st--804

12th-728 335th-933, 935

16th--283, 477, 478 369th--M38, 664, 676, S50, 852, 873, 875

20th-773, 783, 784, 786, 787, 788, 795. 373d-872, 878

812. 817. 823, 824, 826. 846 374th-640

23d-304 Hospitals, station, provisional, No. 2--663

26t h-846 Hospitals, transit, augmentation of, with

27th-797 general surgical teams and orthopedic

31st-772, 804 teams, 196, 197

35th-304 Hospitals, U.S., in European theater, 275-

38th-205, 468 280. 291

41st-838, 878 inadequate facilities in, 396

48th-795 Hospitals, U.S., in North African theater,

49th-142, 287 604

51st-304 Hospitals, various:

68th-166 All-Saints Hospital, 477, 479

69th-303 Australian Army, 707n

70thl-303 Base Hospital No. 5-20, 21

71st--0l, 819 Botkin Hospital, 42)9

75th-946 British Army hospitals, 460, 585, 588, 594,

77th-669, 843, 853, 859 59!

77th-479, 4SO Brit ish 8th Geeneral Hospital, 2N3

78th-303 British 48th General Hospital, 422

8O~th--303 9Sth-947-949 Canadian Army hospitals in European the- 97th--682 ater, 30, 36. 460, 585. 588

98th--682 Canadian 15th General Hospital, 397

109th-814 Emergency Medical Service Hospital at

110th-205, 468 Park Prewett. 516

115th-370 Emergeuicy Medical Service hospitals, 45,

11th--857 459. 460. 44. 5.85, 615

120th--05 5th Canadian General Hospital, 5,S5

121st-142 Fort Jay Regional Hospital, 889
INDEX 1031

Hospitals, various-Continued IBR.AIIIM, Am PASHA, 437

Guy's Hospital, 70 Iceland, 418

Hartford HIospital, 581, 582 Identification of gases in cylinders:

lill End Hospital, 397, 516 directive on, Circular Letter No. 27, Office

Institute of Neurological Surgery, 429, of the Chief Surgeon, ETOUSA. 1943-

431, 482 595

London Hospital, 70 Ie-jima, 625

Los Angeles County General Hospital. 933 Immobilization, effective, for transportation,

Middlesex Hospital. 70 700

Middleton Park Convalescent Hospital, hInmobilization of fractures for transporta394 tion:

Military Ilospital for Head Injuries. 393, directives on405 Circular Letter No. 101. Office of the

Mount Sinai Hospital. 303 Chief Surgeon, ETOUSA. 1944-470

New York Hospital. 696, 933 Circular Letter No. 131, Office of the

New Zealand Hospital. 804 Chief Surgeon, ETOUSA. 1944-470

Peter Bent Brigham Hospital, 19, 21. 246, Imperial Chemical Industries. Ltd.. 613. 620

3,58, 392 Improvisation of equipment:

Presbyterian Hospital, 392 for physical rehabilitation in European

Queen Elizabeth Hospital, 465 theater, 495

Queen Victoria Cottage Hospital, 516 in India-Burma Theater, 924

RAF hospitals. 45,.460 ophthalmological, in European theater.

Royal Prince Alfred Hospital, 707n 452

St. Bartholomew's Hospital. 70, 397 India. 889. 892, 893, 895, 896, 899, 908, 912,

St. Elizabeth's Hospital, Cologne. 322 913, W21, 1923, 932, 933, 949, 950

St. Luke's Hospital in Tokyo, 752 India-Burma Campaign, 893n, 899, 904-906,

St. Mary's Hospital. 70 919, 933-934

Southmead Hospital, 16, 32 quality of surgical care in, 904-906

U.S. Navy, 640. 657, 663, 681, 877 India-Burma Theater, 889-952

Naval Base Hospital, Tinian. 640 climate of, effect of, on medical personnel.

Naval Base Hospital No. 2-795 931-932

Naval Base Hospital No. 19-851 equipment, 9221-.9255

Naval Base Hospital No. 20-872 for evacuation hospitals in, 924

Naval Mobile Hospital No. 8-782. 790, improvised, 924

794, 802., 817 field hospitals in. 925

3d Marine Division Hlospital (I Marine field trips of surgical consultant in. 933-

Amphibious Corps), 809 937

Val de Grfilce Hospital, 253. 256, 272 hospital construction in, 921

Wingfield Morris Orthopaedic Emer- mortality from appendicitis in, 930-931

gency Hospital, 394, 409, 410 physical facilities and equipment in, 921-

Hospitals in island warfare, problems of, 925

656 professional training of medical officers

Hospitals in the United Kingdom. 66 in. 920-921

planned by Services of Supply for mount- special problems in, 925-932

ing the assault on fortress Europe, 106 station hospitals in, 925

HhowARD. L.. 422 treatment in dispensaries in, 925-930

HULL, Lt. Col. II. C.. 7.99. 826, 833, 838 India-China Wing of the Air Transport ComHi'MF., Maj. Gen. E. E.. 441 niand, 930

Hhuntingdon, 408 Indian Service, 593

HUVRLFY. Brig. Gen. T. I).. 200, 313 Indoctrination of units in staging, 63;5-36

Hygiene, Army School of, 16 Indonesia. 885

Hygiene and Tropical Medicine. London "Industrial and Breathing Gases and CylinSchool of, 16 ders." 596
1032 INDEX

Infections: Intermediate Section, India-Burma Theater,

clostridial, studies of effect of penicillin 908

on, 141 Interpersonal relationships uf consultants,

eye, 69 problems of. 56-60

respiratory, 507 Invasion of Continent, incidental preparaInformation: tions for, 163-175

lack of interchange of, between first eche- Invasion of Japan, planning for, 739-744

lons of medical service and those con- INVERCIIAPEL, Lord, 421

ducting definitive treatment in the rear, lodopyracet, use (of, to demonstrate vascular

52 adequacy, 283

professional, dissemination of, 721-725 Iran, 424, 436

Information Services, ETOUSA, 497 Iraq, 424

Injuries: Ireland, 23, 364, 582, 604

arterial, repair of, 646 IRELAND, Maj. Gen. M. W., 23

blast, 537 Irish Labor Camp, 479

foot and march, in combat troops under- Irish Sea, 604

going training, 461, 462 Iselin. Marc. 251

maxillofacial, 523-538 Island Surgeon:

centers for treatment of, in general hos- Kwajalein. Marianas Islands. 663

pitals in European Theater. 527-529 Makin. 664

evacuation of patients with, to specialty Isley Field. 852

hospitals, 517 Italian Army, 422

feeding of patients with. 536 Italian campaigns. 169, 344. 364

imiportance of chemotherapeutic drmigs Italian Front, 258

in successful management of, 538 Italy. 115, 125, 166, 167, 181, 344, 600, 604,

maintenance of nutritional state in 615

patients with. 536 Iuvxs, Lt. Col. J. C.. 860

of the hands, management of. directive on, Iwo Jima, 625.628. 638, 648, 649, 873, 878

Circular Letter No. 131, Office of the Iwo Jima Campaign, 877

(hief Surgeon, ETOUSA. 1944--312, 470

severe facial, sources of. 523-524 JACKSON, STONEWALL, 296

spec-ialized bone and joint, management Jackson crossed cylinders, 924

of, 461 Japan, 257, 619, 683, 684, 7M6, 715. 721, 745,

to the face and jaw. instruction in care of, 747, 884

39. preparations for invasion of, 682-643

Inspector. Medical Department Activities, Japanese, the, 6756, 669. 678. 6S7. 709, 729.

Pacific Ocean Areas. 855 731, 734, 745, 747, 750, 772, 774. 775, 7,%,

Inspector General. 765 784, 794, 806, 808, 809, 811, 812, 815, 822,

Inspector General, Medical Service, Soviet 828, 829, 831, 833, 8.35, 836, 8:17. 83S, S50,

Army, 433 851, 857, 862, 863, 864, 871, 880, 884, 885-

Inspector General's Office, 309 886, S92, 893, 894. 895, 90S, 939, 942, 945

Institute of Neurological Surgery, 429, 431, Japanese hospital ship, 885-S$6

432 Japanese islands, 739

Intelligence Division, Office of the Chief Sur- Japanese kamikaze raiids, 678, 712. 714. 7:16,

geon. ETOUSA, 256 854

Inter-Allied Conferences on War Medicine, Japanese physicians, 751, 752., 75:,

40-41, 55, 252, 253, 256-257, 2-3-286, 355, Japanese surrender. 745-747

466, 615 JARMAN, Maj. Gen. S., 874

Inter-Allied Consultants' Conferenes : Jaundice, 796

First, 261-271 JEFFEISON., G.. 182. 347, 398

Second. 283-2s6 Jefferson Medical College of Philadelphia,

Third, 342-349 423

Inter-Allied Medical Conference. on thoracic JEFFRESS. Col. V. II.. 303

surgery in the forward areas, 287 JEIN:sEN:. Col. WV. S., 404
INDEX 1033

John Rogers Field, ,46, S47 KIsCnINER, .1M., 329

Johns Hopkins University. 'he, S89, 935 Kirschner wires. 649

Johns Hlopkins U'niwversity Medical School, Kis.NEI. lft. Col. 1.. 04, ,17. 823. 826

The, ;ON Knee, internal derangements of. 659

JoltNSON, MNj. G(en. 11. 11.. 985 KNEELANI, Col. Y., .Jr.. 65, 2.7, 257. 27S, 307

Johnston Island, 873 Kodak, Lad., 461

JONES, IA. (Co1. It. 11.. ) Koiaris Beach. s15

JoNSo.N Capt. W. 11., 317 Koko Ilead, 841. 843

Josiah Macy .Jr. Foundation, 920 Kokorana Island, 774, 777, 7S4, 7S2

KOLESNIKOV, Vice ('ommissar, 101

KAh•N, Lt. Col. E. A., 4(09, 410 Kona. 846

Kamikaze raids. 678, 712, 714, 7391, S54 Korea, 684, 746

KAISI, V01. t. .J., 666 W89, 861, 862 Korean War. 441

Kanavel table. W24 Koreans, 750

Kandy, !198 KOREI.4:,I A, LEONI) ALEKSANi)OVI(Ii. 424, 427

Kariichi, 8915, 1906 KoR.nBE;. PfC. .1., 768

Kassel, 328 Koromokina River, 810

Kasserine Pass, 328 KREY.:uR(. MIaj. L., 2S3

Kauai, 65-A KRUrEcER. (en. W., 067,.816

KA-ER., Maj. J. T., 748 Kuei-lin. 894.9 391

KAUFMAN, Col. ]N. It., 8175,1, S19, 826, 842 KuIi, F.. 420

KEEI.IIR, Co.I. M.., 81, 82, 359, 386 Ku uIN. R., 329

KE.LER. Col. W. L., 2 K'un-ming, 894, S395. 910. 911, 9)39. 947, 948,

KEUSER. Brig. Gen. R. A., 890 1941. 950

Kelser Mission. 88)}, 810, 4916. 9137 Kwajalein, 654, 661-1M4, 873

KEISEY, Lt. ('ol. It. F., 486, 487 Kyushu. 739, 746

KENDRICK, (2C1. 1. It., Jr., 14, 159. 164). 161,

244, 253, 255, 626, 743. S54, 855, S77 5---858. ,64) N. 81, 8412

KENDRICIKs, Col. t'n. J., 158, 15-) Laboratories Division. Preventive Medicine

KENImWORTII, 478 Service, )ffi'ce of The Surgeon General.

KENNEDY, Col. R. 11., 890, 916, )18, 923, 934, !123

9137 Laboratories. general. medical:

KENN-El, Maj. Gen. A. W., 107. 187, 197, 315, 1st-65. 147, 148. 15-0, 153, 154, 158-, 207.

341, 366 214, 370

KE:RN, Lt. Col. 'M. (C., 6W13 I.th -- 72,.'. 750

KERN, Capt. It. A., 782, 793, 794, 795, 797. 825 L1ae. 696. 721

KESTER. Col. V. (0., 842 LAFoRs. Maj. C. D)., 921

KIMnALL. Brig. G(en. A. I., 878 Lalhey Clinic, 50f5

KImNRou-;II, Col. J. C., 6, 21. 28, :32, 40, 47, Laiana Beach, 773, 780

491, 55, 57. 58. 59, (10, 62, 63. 66, 71, 73, 82, anui. 656

83, 92, 95, 107, 108, 115. 111), 128, 1210. 137, Lancashire. 605

142, 143, 145, 146, 154. 15-1. 167, 274. 278, l,anding craft, tank, 21:.214, 771, 780

2.0, 282, 29),8, 2.•9), 3(), 3118, 315. :317. 319, Landing craft, vehicle and Il-rsonnel, 668,

359, 361, 365, 3.2, -103, 4M)5, .110, 44-1, 446, 669. 678

573, 575, 584, 585 Landing ship, tank. 178. 179). 18I 1811, 194-

KING, Lit. Col. A. (;.. 805 197, 2MN). 202 203, 208 200), 21:3 214. 225-

KING, Brig. Gen. E., 655, 657, 658, (W6, 662,

663, 6M4.665,0666, 674, 841,8402 227. 230, 2t1, 7094, 713, 732, 733, 734, 735.

KIN•, Col. W., 941 736, 738, 731. 742. 773, 774, 779, 782, 785,

Kingdom of Nepal, 1)08 788, 810. 815, 85.3, SA5, 8s. . 86S, S69M, 870,

Kingston, 477 871

KIRK, A. C.. .123. 437 Landing ship. tsank 14casualty evacnuition),

KjRK, MaJ. (;,n. N. m.. 114. 131, 132, 13M. 244) 733, 7:31, 735. 736. 73-., 73"9, 742, 743, 782.

241. 241, 246, 3Q02. 4-10, 490, 675. S74, 876, 786. 78•, 789), 791. 794I. 8,55, 85)s, 862, 815,

881) MWi, 8Ms. 6 1). S70, 871
1034 INDEX

Landing ship. tank (tasualty evacuation)- Leytt--Continued

Continued invasion of:

inadequacy of medical facilities aboard, planning for, 7:.4-735

786 report on, 7:.5-73:9

operations of, planning for, 366-371 Liaison activities in supply matters, imlporopinions and observations of surgeons who tance of, !21. 951

served aboard, 374 Liaison activities of theater surgical conplanning for operations of, 366-371 sultant with Office of The Surgeon Genproviding supplies and personnel for, 366, eral, 923

367-370 Liaison among the Army, Navy, and Army

specific: Air Forces, 6'29

LST 44--739, 742, 743, 854, 855, 858 Liaison between oversea theater surgical

LST 911--864, 865 consultants and Office of The Surgeon

LST 929-678, 743 General, 704, 705, 951

LST 1018-858, 862, 8MM Libya, 422

LST 1&25-739 Liege, 253, 280, 289, 292, 455, 579

value of, in evacuating wounded. 866-869 LIM, Gen. R. K. S., 945, 949

Landings, amphibious, in Southwest Pacific Limerick Airport, 23

Area, 732-744 Lingayen, 863, 870

LANING. Rear Adm. R. H., 855, 877 Lingayen campaign, 862

LARKEY, Lt. Col. S. V., 245 medical care and evacuation during, 866-

Lashio, 896, 906 871

LATHROP, Lt. Col. F. D., 505, 509 Lingayen Gulf, 726, 863, 866

LATON, Col. H.. 787 LIPPARD, Col. V .W., 885

LCT. Scc Landing craft, tank. LisToIy, Col. D. E., 117, 156, 183, 184, 197,

LCVP. 8cc Landing craft, vehicle and per- 204, 253, 257, 293, 317, 366. 486

sonnel. Litter carry, 688, 756, 903, 942

Ledo, 893, 899, 903. 906. 933 difficutlies of, 777, 781. 790, 813, 822

Ledo Road, 894, 899, 908, 933, 935, 937 LOIBBAN, Lt. Col. R. B., 799, 826

LEE, It. Gen. J. C. H., 148, 153, 170, 197, 366, Locations for facilities, recommendations of

392, 421, 467 surgical consultant for careful selection

LEECH, Col. B., 585 of, 792

Leeds University gas school, 16 LOIZEAUX, Maj. M. C., 610

LEFFINGWELL, Lt. Col. F. E., 710 London. 23-27, 29. 32, 37, 38, 40. 55, 61, 66,

Left Bank. 619 70. 71, 75, 92, 109, 110, 121, 137, 175, 181,

Legion of Merit, 861 183, 197, 247-248, 255, 256, 259, 300. 302,

Le Havre, 454 333, 362, 368, 392, 397, 427, 436, 439, 460,

LEIGH, Maj. 0. C., Jr., 283. 307 461, 466, 467, 475. 476, 497, 506. 512. 540,

Le Mans. 249 582, 583, 584, 598, 601, 612, 613, 615. 618,

Lend-Lease Administrator, 426 620, 756

LE RicIIE, R., 251 London Committee, 392

Lessons of- London School of Hygiene and Tropical

New Georgia campaign, 784-786. 787 Medicine, 16

Pacific fighting. 755-757 LoNG. Col. E. R., 330

Southeast Asia Command, 951-952 LONGFELLOW, Col. D.. 825, 840

Letterman General Hospital, 655. 674 Los Angeles County General Hospital. 933

Levin tube, 600

scarcity of, 255 LOUTZENHEISEB, Lt. Col. J. 3., 674

use of, in patients with suspected ls'inetrat- Louvain, 253

ing wounds of the abdominal cavity, Lovell General Hospital, 767

645 Low back complaints:

Leyte. 661. 667-674. 696, 712, 714. 715, 721, in patients with congenital anomalies of

7241. 727. 728. 742. 743, 748, 755. 852. S53. the spine, 761

856, •58. 863, 866, 871, 872, 886, patients with. management of. 759-761

Campimign, 842, 871 LST. Scc Landing ship, tank.
INDEX 1035

LST, converted. See Landing ship, tank Malaria, 688, 691, 728, 791, 886

(casualty evacuation). in Iran, 424

LST, surgical. See Landing ship, tank prevalence of, in-

(casualty evacuation). Pacific, 781

LST (II). Scc Landing ship, tank (casualty Southwest Pacific Area, 690

evacuation). Malaya, 817

LST hospital ship (LST(H)). See Landing MALEY, Lt. Col. A. A., 932

ship, tank (casualty evacuation). Malmddy, 292

LUnrTZ, Col. B., 873 Malta, 410

LucAs, Capt. E., 805 Malvern Wells, 121

Ludgershall, 36, 460 Management:

Iudwig's angina. 531 early ambulatory, 200-202

LUNDEBERG, Col. K. R., 890 early ambulatory, following surgical pro.

Lun~ville, 305 cedure, directive on, Administrative

Luxembourg, 613 Memorandum No. 74, Office of the Chief

Surgeon, ETOUSA, 1944-201-202

Luzon, 712, 721, 727, 748, 753. 755. 864, 871, first aid, of fractures, 658-659

874,884 first aid, of fractures, for transportation,

Luzon Campaign, 877 directives on:

Luzon Prison Camp No. 1-748 Circular Letter No. 101, Office of the

Lyneham, 421 Chief Surgeon, ETOUSA, 1944-470

LYTER, Col. C. S., 166 Circular Letter No. 131, Office of the

Chief Surgeon, ETOUSA, 1944-470

Maastricht splint, 348 of amputation stumps, recommendations

MACARTI1UR, Gen. D., 625, 632, 682, 712, 714, of orthopedic consultant concerning, 665

734, 745, 858, 878, 884 of battle casualties, directive on, War DeMIAcFEF, Col. W. F., 10, 14, 65, 67, 137, 217, partment Technical Bulletin 147, 1945-

240, 243,291,322,323, 326, 365 642

Machines, anesthetic, 585, 592, 595, 598 of battle casualties from frontline areas

American. 5&5, 589, 592 to hospitals in rear. 203

adaption of, to use of anesthetic gases of battle casualties in New Georgia camsupplied in British cylinders, 592. 595, paign, 790-791

598.605 of battle casualties in U.S. Army Forces,

lack of standardization in, 588-589, 598 Pacific Ocean Areas, anesthesia in. 636-

means of eliminating hazards of, 588. 637

5019. 591, 598 of colostomies, directive on, Circular Letmaintenance and repair of, 598 ter No. 131. Office of the Chief Surgeon,

Machines, gas : ETOUSA, 1944-294 maintenance and repair of, 598 of combined bone and nerve injury, 346 portable : of fractures, 125, 309

inadequacy of supply of, in North Afri- by portable surgical hospital. 944

can and European theaters. 601, 603. compound. 470.763, 862

60Co 612 directive on. Circular Letter No. 131,

inequality of distribution of, in Euro- Office of the Chief Surgeon, ETOUSA.

Iean theater. 600. 601 1944-312

MACINTOSih, Air Commodore R. R., 584, 585, first aid. 470, 65,-659

588, 599, 620 in transportation. 761-76.3 MA58CK, Col. W. G., 289 of femur, 649, 862 of humerus, 763

Maestricht, 286, 287 of long bones, 274. 474, 676, 681-4, 6(32

MAGEE, Maj. Gen. J. C., 21, 42, 45, 47, 403-404 of specialized bone and joint injuries, 461

See also Surgeon General, The. orthopedic, in combat zone, 674

MAGI.L, I. W., 584. 613 1"Management of Orthopedic Battle CasualM1AISKY, I. M., 95, 421 ties in the Pacific," 684

Makin. 664 Manchester, 605
1036 INDEX

Man-days lost from foot and march injuries, Medical Administrative Corps, 150, 467, 780

461, 462 Medical and Industrial Equipment Co., 598

Manila, 710. 721, 725, 727, 743, 746, 748. 750, Medical Battalion (s)

S56, 805, 878, 879, 880, 881, S86 71st-S41

MANN, I. C.. 455, 4536 ll2th-8-05

MANNING, Lt. Col. J. G.. 288, 336, :347 Medical Bulletin, ETOUSA, 63, 129, 385, 521

Manpower, medical, 343-346 Medical College of Virginia, 889

in the fiehl army, 344 Medical company engineer special brigade,

Manpower, surgical, utilization of, 704-701 868, 869, 870

Mansfield, 392, 588 Medical Corps officers:

Manual of Therapy, ETOUSA, 171. 203, 231, classifying of, in Pacific Ocean Areas, 631-

351, 369, 470, 475, 506-507. 508, 521, 523, 632

540, 616 maintenance of good morale in, 632-633

preparation of, 364-366. 575 promotion and rank among, 635

Manus, 668, 700, 863 proposal for temporary duty of, 718-719

MAR, Capt. T. M., 407 rank and promotion of, 6:15

Margherita, 899 replacement of, in medical units in transit,

Marianas Islands, 625, 629, 630, 6-38, 642, 644, 032

648, 649, 650, 651, 661-664, 681, 769, 855, requisitioning of, in Pacific Ocean Areas,

876, 877 631

Mai "anas Islands Campaign, 842 shortage of, in Pacific Ocean Areas, 629-

Ma, anas Islands operations, 663-664 631,656

Marine Corps, 441. 794, 795, 805, 807, 809, specialized, recommendation of surgical

814, 815, 846, 849, 877 consultant concerning. 665

Marine Corps medical officers, 649 surveys of. in relation to rotation in

Marine Raider Battalion, 4th-794 Pacific Ocean Areas, 632

MARKS, Lt. Col. G. A., 698 trained, shortage of, in Southwest Pacific

Marlborough, 421 Area, 714-715, 755, 757

Marrakech. 604 Medical Department, AEF, World War I-4

Marseilles, 246, 282, 301, 303, 304 Medical Department, mission of, with respect

Marseilles Port, 454 to military surgery, 350-351

MARSHALL. Gen. G. C., 819 Medical Depot Company, 24th-795

Marshall Islands, 660, 661, 662 Medical Detachment, 250th-334, 335

MARTIN. Col. W. B., 675 Medical Field Service School in European

MASON. Col. J. B., 147, 148, 149, 150, 151, 152, theater, 15, 69, 86, 109, 259. 317, 357, 366,

154, 158, 167 455, 466, 599, 613

MAsoN, Lt. Col. R. P., 307 lectures at, 366

MASON, Col. V. R., 684 plans for establishment of, 53-54

Maui Island, 656, 846 Medical Gas Treatment Battalion (s)

Max Planck Institute for Medical Research, 91st--290

University of Heidelberg, 3-99 93(1-289

MAXWELL, Brig. Gen. E., 663, 675, 683, 768, Medical Inspector, 37th Infantry )ivision.

802, 825, 8438, 840, 847 7W6

'MAYS, Maj. J. R. S., 912, 913 Medical Liaison Officer from U.S. Strategic

MCCLOY, J. J., 3291 Air Forces. ETOu.SA, to Rehabilitation

McGill solution, 161 I)ivision, Office of the Chief Surgeon, 485

McGill University, 95 Medical officers, advantages of sending, from

McGOWAN, Col. F. J., 767 combat units to hospitals in base 5e'-

MCINDOE, Sir ARCiIBAI}L 1., 400, 516 tions. 290

3McKEE, Maj. R. I)., 664 Sec also Rotation.

McKesson Equipment Co., 398 Medical Recorrds I )ivision. Office (of the Chief

McLAUGHLIN, Lt. Col. W. B.. 674. ,;38 Surgeon. ETOI`SA, 249. 256. 461

MCMURRAY, T. P., 459 Medical Research Council of Canada, 97

McNINcI!, CA). J. II., 247. 249, 256, 25.-, 327 Medical Research Council of Great Britain,

MD Form No. 55-0-(-, ETOUSA, 599 51, 52, 96,97, 141, 421, 423, 427
INDEX 1037

Medical Research Council of London, 615 MILLS, Maj. Gen. R. H., 175

Medical Reserve Corps, U.S. Navy, 657 Milne Bay, 6(87, 689, 690, 693, 61I)4, 700, 706,

Medical Scientific Council, U.S.S.R., 424 721

Medical Section: Mindanao, 727, 732

General Headquarters, Army Forces, Pa- Mindanao Sea, 863

cific, 626 MI.NDEIN, Capt. J. H., 669, 679

Headquarters, Replacement Training Comn- Mindoro Island, 863

mand, U.S. Army Forces. Pacific Ocean Ministry of Pensions, 459

Areas, 631 Ministry of Works, 479

Headquarters, U.S. Army Services of Sup- Mirecourt, 304

ply, Southwest Pacific Area. 711 MISCALL, Col. L., 258, 310

Headquarters, U.S. Forces, China Theater, Missile ballistics, research investigation in,

897, 0)10, 949 884

"Medical Service in the Air Force." 465 Mission, surgical, to U.S.S.R., 92-104, 118

"Medical Service in the North African The- departure of, 97

ater," 465,467 establishment ot, 93

Medical Society, ETOUSA, 17, 555 observations of, on military medicine and

Medical Supply Depot(s) : surgery in U.S.S.R., 104, 105

10th-SO5 preparations of, for departure, 93-95

21st-788, 823 statement of purpl se of, 97

Medical Supply Division, ETOUSA. 247 Missions, professional, assigned to hospitals

Mediterranean Sea, 436 on Continent, 278

Mediterranean theater. 303, 326-327, 357, MITEREV, G. A., 428

397. 655, 727, 755, 756 MIXTER, C. G., 796

Meetings. $cc Conferences and meetings. Mobile field surgical unit, 16

MELAVILI.E, Lt. Col. E. F., 885 Mobile surgical units, European theater:

Melbourne. 688, 693. 707n creation of, 60, 78-92

MELVIN, Lt. Col. J. 11.. 788, 812, 815 supply support of, 86

Menibury airfield, 214. 23.4 tent as operating theater for, 86, 90

MEN NIN(GER, K. A., 330, 342 transfusion-laboratory teams for, 86

Merck & Co.. 68 Mobile surgical units, RCAMC, 394

MERmILL, Maj. Gen. F. D).. 937 Molokai Island, 656, 846

Methyl methacrylate helmet, 412-413, 419, Mong Yu, 893

420, 441 MONRlo, Maj. Gen. D. C., 79, 82, 83, 93, 188,

Metycaine IHydrochloride, difficulties en- 259, 263, 265, 266, 421, 422, 427

countered in use of, for spinal anesthesia, MOORE, J. E., 880

616 Morale ofMIeus•e River. 254 medical officers, factors bolstering, 632-633

Microfilming of hospital records, recommen- patients, bolstering of:

dations concerning. 461 by administration of morphine, 861

Middle East, 51, 71. 71 440. 762. 989 by air evacuation, 861

MIIDDLETON, Col. W. S.. 21, 28. 30. 31. 32, 44. 25th Division, problems of, 780

45. 170, 280. 319. 338, 361, 391, 446, 584, MoRw;A.N, Brig. Gen. II. J., 320, 659, 754

0196 Morocco, 604

Middleton Park Convalescent hospital. 394 Morotai Island, 7:32. 885, 886

Midlands. 392 Morotai operation, planning for, 732-734

Midway, 657, 658, 814 Morphine:

MIKEsP:.L, Lt. Col. H. L.. 780 absorption of, 603

Mikuliez colostomy, double-barreled, direc- administration of, 673

tive on : (ireular Letter No. 131. Office of caution exercised in use of, in cold

the Chief Surgeon, ETOUSA, 1944-294 weather, (;13

Military Hospital for Head Injuries, 393, limitations on use of. 61:3

405 poisoning by, 603. 613

Military Occupational Specialty 3153-473, use of, in first aid, 262, 264

515 use of, limitations on, 61:3
1038 INDEX

M[ORRISSETT, Lt. Col. L. E.. 50) National Research Council, 25, 96, 244, 245,

Mortality due to-- 247. 4119, 421, 427, 539. 540

chest wounds, 836 NAT)I'SA (North African Theater of Oppienetrating chest wounds, 836 erations, U.S. Army). ,c. North African

sucking chest wounds, 836 theater.

MORTopi, Col, P. C., 10, 137, 141, 145, 146, NATS. ,cc Naval Air Transport Service.

170, 250, 257, 258, 269, 272. 279, 294, 298, Naval Air Station, Honolulu, 847

310. 327 Naval Air Transport Service, 819, 825, S79

Moscow, 97, 425, 431, 433, 435, 436 Naval Medical Research Unit No. 2-877

Moseley Professor of Surgery, Harvard Nazi Party, 329

Medical School, 9,19, 358 "Near shore" ineulical s'rvice, Operation

Motion picture training films- OVERLORD, 227-228, 257

on emergency amputation, 465 Negros Island, 863

on manufacture and fitting of prosthesis Netherlands, The, 40, 286, 613

for below-knee amputation, 465 Netley, 205

on medical service in North African Neufehateau, 2

theater, 465 Neuropsychiatric cases, use of, in labor baton rehabilitation, 465, 494 talions in SOS, 2J

on rehabilitation center program and ac- Neuropsychiatric pi ,blenis, instruction in,

tivities, 494 39

on transportation plaster of paris tech- Neurosurgery, hospital with special facilinique. 465 ties for, directive on, Circular Letter No.

on use of transfusion kit. 160 81, Office of the Chief Surgeon, ETOUSA,

recommendations concerning, 460 1944-172-173

Mount Everest, 908 Neurosurgery in war, instruction in, 39

Mount Santo Tomas, SC" Neurosurgical injuries, directive on, CircuMOUNTBATTEN, Adm. Lord Louis, 895 lar Letter No. 75, Office of the Chief

MOUSEL, Maj. L. H., 621 Surgeon, ETOUSA, 19422-403

MOWLEM, R., 516 Neurosurgical problems, directive on, CircuMOWREY, Col. F. H., 193, 204. 280 lar Letter No. 131, Office of the Chief

MTOUSA (Mediterranean Theater of Opera- Surgon, ETOUSA, 1944-294

tions, U.S. Army). See Mediterranean Neurosurgical trainingat Oxford, 16, 17

theater. New Bilibid Prison, 748, 750, 751, 752, 754

MUCKENFUSS, Lt. Col. R. S., 21, 65, 147, 148, New Britain, 696, 701

150, 154, 184, 247 New Caledonia, 771, 797, 814. 819, 820, 825

Munda, 773, 775, 776, 777, 780, 813, 817, 821, New Delhi, 889, 890, 897, 906, 939

838 New Georgia campaign, 784, 789

MURCHIE, F., 599 failure to provide adequate medical care

Myitkyina, 904, 937 in forward areas in, 78.3

Myositis, clostridial. See Gas gangrene. lessons of, 784-786, 787

management of casualties in, 79)0-791

NAFFZnIER. H. C., 407 New Georgia Island, 773, 774. 778, 78t 781,

Nagasaki, 710 782, 788, 794, 802, SOS, 813, 814. S33, 838,

Naha, 678 839

Namur, 292 New Guinea, 669, 687, 688, 693, 6N,, 698, 701,

Nancy, 280, 306 704, 706, 721, 726, 728, 72-9, 734, 738, 757,

Nandi, 789, 797, 798, 799, 801, 819 759

Nandi Airport, 799, 840 New Guinea c. !ipaign, 762

Naples, 600 New Hebrides, i72, 78), 791

National Bureau of Standards, U.S. Depart- New South Wales, 707n

zient of Commerce, 589 New York Hospital, 696, 700, 933

National Guard, 687, 824, 885 New Zealand, 767, 799, 804, 825, 840

National Red Cross Society of China, 911- New Zealand Army Medical Corps. 794

912 New Zealand Forces, South Pacific, 804
INDEX 1039

New Zealand Hospital, 804 Northwestern University Medical School,

New Zealanders, 7M9, 833 407, 409, 414, 420, 441

Newfoundland, 243. 247 Norway, 40

Ncvwfoundlaad, the, 47 Nose and throat maladies in Pacific areas,

NE~WjiousE, Capt. L. R., 855 793

Newquay, 197 Noumna, 771, 796, 802-804, 819, 820, 8295, 835,

NEWTON, Lt. Col. G. D)., 54 838, 840

Newton Abbot, 370 Nova Scotia, 582,633

Nice, 303 Novocaln, 433

Nicnor, Lt. Col. B. A., 663 NUFFIELD, Lord, 394

Nicola type of operation, 659 Nuffield Professor of Anaesthetics at Oxford

NIMITZ, Adm. C. L., 625, 684, 876, 878 University, 585

Ninth Air Force, 158, 159 Numa Numa Trail, 8298

Ninth Service Command, 674 Nurses, 752

Ninth U.S. Army, 270-271, 274, 286-288, 292- need for, early in a campaign, 861

293, 298, 307, 319, 322, 324-325, 326, 335,

336,347 Oahu, 625, 626, 629, 630, 636, 637, 642, 649,

Consultant in Surgery to, 10 654, 656, 657, 659, 660, 663, 664, 674, 675,

NKVD (Soviet secret police), 421, 435 681,682, 840, 847, 852, 873, 874

NOBLE, Maj. B., 841 O'CONNELL, J. E. A., 397

Nordhausen, 618 Odessa, 435

Normandy, 17, 384, 608-610, 733, 734, 735 ODmO, Col. C. B., 10, 264,307, 313,328, 329

Se 8also Operation OVERLORD. Office of Scientific Research and DevelopNormandy Base Section, 321, 495 ment, 731

Normandy beachhead, 239,468, 609 Office of Strategic Services, 939

Normandy campaign, 224, 225, 358, 512, 523, Office of the Chief of Ordnance, Army Serv524, 534, 541, 550, 563 Ice Forces, 73

See alao Operation OVERLORD. Office of the Chief Quartermaster, SWPA,

Normandy invasion, 14, 205-239, 252, 256, 728

367, 372 Office of the Chief Surgeon, AEF, World

activities during, 374-378 War I-1, 2

preparations for, 175-205,366-373 Office of the Chief Surgeon, ETOUSA, 5, 8,

North Africa, 3, 37, 38, 41, 47, 49, 50, 52, 66, 15, 17, 24, 30, 56, 61, 62, 65, 107, 109, 119,

328, 344, 391, 403, 405, 406, 515, 555, 589, 120, 125, 142, 151, 154, 156, 162, 171, 175,

600, 604, 719, 819, 889, 932 194, 196, 231, 249, 250, 251, 256, 257, 270,

North African campaign, 159 271, 272, 281, 283, 294, 297, 299, 300, 301,

North African theater, 61, 107, 108, 121-127, 303, 306, 309, 310, 312, 319, 321, 324, 328,

156, 166, 167, 181, 365, 407, 409, 463, 465, 334, 364, 366, 371, 374, 388, 398, 399, 400.

589, 591, 592, 600, 601, 603, 604, 605, 652- 405, 406, 407, 410, 441, 443. 444, 446, 452,

653, 708, 889, 890 455, 459, 460, 461, 476. 477, 48.5, 486, 487,

medical services In, training film on, 465, 490, 497, 498, 504, 505, 511, 519, 520, 521,

467 550, 575, 584, 595, 596, 600, 604, 605, 610,

observational tours of, by key medical per- 612, 619, 620, 621, 756

sonnel from office of Chief Surgeon, consultants assigned to, 8

ETOUSA, 121-127 visits of key medical personnel of, to North

U.S. hospitals In, 604 African theater, 121-127

North Sea, 414 Office of the Quartermaster General, 414

North Sector General Hospital, 655. 657, 658, Office of the Surgeon:

661, 663, 666, 667, 674 Central Pacific Base Command, 627

Northamptonshire, 256 Fifteenth U.S. Air Force, 731

Northern Combat Area Command, 906, 908 Headquarters, Communications Zone,

Northern France campaign, 225, 239 ETOUSA, 297

Northern Ireland, 359,392 Headquarters. Island Command, Saipan,

Northwestern University. 9, 795 (650
1040 INDEX

Office of the Surgeon-Continued Operation OVERLORD, 108, 168

Headquarters, U.S. Army Forces. Pacific, air evacuation in, 227

661, 746 beginning of buildup for, 181

Headquarters, U.S. Army Forces, Pacific D-day week, 205-209

Ocean Areas, 626,627,636, 649, 651 evacuation by air in, 227

Headquarters, U.S. Army Forces in China- evacuation by sea in, 225-22-7

Burma-India, 897 general surgery and wounds, 228,230-2.32

Headquarters, U.S. Army Forces in the incidental preparations for, 163-175

Central Pacific Area, 661 "near shore" medical service during, 227-

Headquarters, U.S. Army Forces in the 228, 257

Western Pacific. 746 planning for, recapitulation in, 202, 204

Headquarters. U.S. Forces, China Theater, second week of, 213-215

911, 9"8 specific preparations for, 175-205

Headquarters, U.S. Forces. India-Burma the Prague in, 215

Theater, 910, 912, 913, 916. 917. 921 See al8o Normandy; Normandy campaign;

Services of Supply, U.S. Forces, India- Normandy invasion.

Burma Theater, 913 "Operation plan Stepchild," 898

United Kingdom Base, 456, 4W6. 487, 497 Operation TORCH, 37,38, 41-42

U.S. Army Services of Supply. Southwest Operational Research Section, Professional

Pacific Area, 265, 698, 706, 706n, 710. Services Division, Office of the Chief Sur711, 720, 724. 727, 732. 742. 757 geon, ETOUSA, 17, 115,256, 275, 335

Western Pacific Base Command. 627. 873 Operations and Training Division, Office of

Office of The Surgeon General, 14, 17, 42, 59, the Chief Surgeon, ETOUSA, 147

68, 109, 130, 160, 161, 162, 183, 243, 245, Operations Division, Office of the Chief Sur246, 365, 397, 406, 443, 459, 487, 503, 504, geon, ETOUSA, 151, 154, 162, 446, 454. 477,

509, 539, 540, 581, 582, 589, 609, 613, 616, 482, 498

621, 65.3, 657, 6.59, 674, 691, 705, 720, 721. Operations Division, Office of The Surgeon

725, 729, 743, 756, 765, 825, 884, 890, 908, General, 876

914, 917, 918, 920, 92,3, 942, 951 Operations Service, 15

lack of contact of, with Pacific Ocean Ophthalmologists, 734

Areas, 756 Ophthalmology in European theater, 443-457

8cc also KIRK, Maj. Gen. N. T.; MAGEE, Optical Shop, United Kingdom Base, 452. 45;3

Maj. Gen. J. C.; Surgeon General. Optical supply, European theater, 452-455

Office of the Under Secretary of War, 731 Oran, 422

Office Order No. 32, Office of the Chief Sur- Orel-Kursk-Belgorod Line, 4,13

geon, ETOUSA, 485 OROANE, G. S. W., 613

OGILVIE, Maj. Gen. W. II., 438 Organization of medical serviceOkinawa, 625, 626, 628, 636-638, 644, 645- in Hawaiian Department in 1942 to meet

650. 675-684, 744, 877 anticipated needs, 656-6557

Okinawa operation, 645-650, 6531, 676-682. in Pacific Ocean Areas, 656-657,685-686

742 Organization of Professional Services,

Omaha airstrip, 217 ETOUSA, Services of Supply, 7

Omaha Beach, 381 Ormoc, 859,861

Ondongo Island, 814, 817, 8.38 Oro Bay, 689, 696. 721

O'NzIL. Capt. J. B., USN, 664 Orthopedic Branch, Office of The Surgeon

Operation BOLERO, 392 General, 674

Operation CORONET, 739, 744 Orthopedic Section, 219th General Hospital, 625

Operation CRACKSHOT, aftermath of, Osi6ov, 2 ol. B. A., 272, 275,342

190-194 Osteochondritis dCssecans, 659

Operation ICEBERG, 675, 676, 682, 875 Otit edIa. 507

Otitis media. W02

Operation INTERLUDE, 732 Otolaryngologlcal Section, 2d General HosOperation KING 1-732, 734 pital, ,05

Operation KING 11-734 Otolaryngology in European theater, 503-510

Operation OLYMPIC, projected, 739, 742, 744 administrative considerations of, 506
INDEX 1041

OTTENHEIMER, Col. E. J., 627, 684, 825, 840, Pacific Ocean Areas--Continued

848, 852, 874, 876 See also Central Pacific Area: Pacific theOUGHTERSON, Col. A. W., 246, 625, 626. 627, aters; South Pacific Area; Southwest

666, 675, 684, 687n, 709, 767, 768, 769. 770, Pacific Area.

771, 876 Pacific theaters:

Owen-Stanley Mountains, 687, 688 overall medical plan in, 856

OWENS, Brig. Gen. R. L., 773 professional training of medical officers

Oxford, 17, 38, 49, 52, 68, 182, 392, 393, 394, In, 635-637, 652, 658, 660, 661, 662, 665.

395, 398, 405, 456, 466, 505, 575, 583, 585, 666, 673, 674, 681, 682-683, 685-686, 699,

588, 621 700, 719-725, 792, 793, 814, 815, 816, 821,

Oxford University, 327, 392, 393, 395, 412, 822, 831, 836, 844, 882, 883, 885

455..456, 584,620 s'Žhistosomiasis in, 860

neurosurgical training, 16, 17 specialized hospitals In, 756

Oxfordshire, 394 Pacific War Board, 884

Oxygen Equipment Manufacturing Co., 597 Packing, loose, 699

Oxygen therapy, 588, 595, 596, 597, Packington Park, 480

Oxygen the 605,8, y, 095, 561, 63, 619, 620, Padgett dermatome, 545

601, 603, 605, 608, 609, 612, 613, 619, 620 PAGE, Maj. Gen. M.. 83

equipment, 596, 597, 598, 01, 603, 605, PArRIN, Vice Commissar V. V., 424, 427, 435

608, 612 Palau Islands, 671, 858, 871

Pacific Ocean and Asia, 334, 625-686, 687- Palermo, 600

765, 767-887, 765,767887,889952PALMER, 889-952 Palmyra Maj. Island, A., 659 115, 256,275, 334

Pacific Ocean Areas, 508, 509, 755, 756, 757, Pantopaque, 396,420

875, 879 atpqe39,2

air-conditioning in, 644 Pao-shan, 949

blood program of, 6 Paris, 17, 20, 2.39, 249-251, 253, 254, 255, 257,

classifyingra of, Medical Co259, 261, 270, 272, 274, 280, 291, 292, 295, classifying of Medical Corps officers in, 300, 301, 302, 305, 308, 313, 323, 325,

631-632 326, 327, 328, 329, 330, 342, 455, 475, 487,

consultants in surgery in, 625-686 497, 508, 512, 579, 611, 615, 618, 619, 621

difficulties of communication in, 756 Park Prewett, 516

difficulties of evacuation in, 7o56 PARKINSON, N. B., 40

evaluation and placement of surgical per- PARSONS, Col. WM. BARCLAY, 625, 687, 705,

sonnel in, 656 706, 711, 718, 726, 732, 756, 757, 839

fighting in, lessons of, 755-717 Patrol bomber, "Catalina," 815

hospital center in, 650-651 Patrol craft, escort (rescue), 866

hospitalization in, 860-862 PATTERSON, Lt. Col. C. E., 913-916

importance of air transport in utilization PATTERSON, MaJ. Gen. R. U., 2

of manpower in, 875 PATTERSON, Col. RUSSEL H., 674

indoctrination 65- of units in staging in, PATTON, Lt. Gen. G. S., Jr., 313, 314, 328, 329,

636 330, 335

lessons of fighting in, 755-757 PBY flying boats. 8cc "Catalina" flying

on-the-spot definitive surgical care in, boats.

75th-7i sPCE(R). Sec Patrol craft, escort (rescue).

orthopedic surgery in, 655-686 Pearl Harbor, 392, 655, 667, 675, 817

professional training of medical officers Peking, 257

in, 635-636, 652 Peleliu Island. 671, 871

requisitioning of Medical Corps officers in, PEMBARK, 154, 155

631 PENFIELD. W. G., 95. 97,421,427, 435

shortage of Medical Corps officers in, 629- Penicillin, 68-69, 133-146, 202, 659, 663, 667,

6.31, 656 752, 757, 847

shortage of specialized personnel In, 638, Florey or Oxford unit of, 272

656, 657, 658, 662, 674, 683 In control of wound infections, 233-234,

surveys of rotation of Medical Corps offi- 575

cers In, 632 In treatment of gonorrhea, 137, 138, 142
1042 INDEX

Penicillin--Continued Peter Bent Brigham Hospital, 4, 21, 246, 358.

in treatment of sulfonamide-resistant gon- 392

orrhea, 137-142 PETERSENF, Col. V. W., 906

intraperitoneal, 284 PETFRSON., Col. L. T., 674, 675

proper use of, discussion regarding, 372 PEYTON, Col. R. E., 280

studies of effect of : Philippine Army, 747, 880, 881, 882

on clinical gas gangrene, 141 Philippine Islands, 626, 667-674. 687, 688,

on clostridial infections, 141 691, 704, 706n, 710, 728, 732. 734, 738.

study of, by Lt. Col. R. N. SCHULLINGER, 748, 756, 817, 849, 858, 871. 880

52, 134-136, 137, 138, 146 hospitalization, 880, 881, 882

therapy, 133-146, 171, 233-234, 264 obligation in, 747-748

directives on. 142, 143, 144, 146, 171, 231, PHiLLIPS, Maj. Gen. E., 283, 286

232, 1234 Phoenix Islands, 840

in surgery, 133-146 Physical fitness, examining, evaluating, and

units, 272 profiling of, in European theater, 319, 3,34

Penicillin Clinical Trials Committee, 141 Physical standards, 334

Pentothal sodium, 603, 607, 608, 609, 942 Physical standards and disposition boards.

hazards inherent in use of, 603 180-190

preparation of. in bulk, 609 "Physical Training Instructors," 494

People's Commissar for Public Health. 428, Physical Training Instructors' School at Re429 habilitation Center No. 1-494

People's Conmnissariat for Defense. 4229 Pilonidal cysts, 819

People's Commissariat for Public Health, Pilonidal sinus, 846

428, 429, 4,35, 439 Pilsen, 330

Percy Jones General Hospital, 890 PINCOFFS, Col. M. C., 728, 790, 839, 880

Peripheral nerve injuries, 638 "Pinetree," 44, 109

degeneration and regeneration of nerve "Piper Cub." &33, 860, 861, 862

fibers, 395 Piperocaine hydrochloride, difficulties enexamination, diagnosis, and treatment of, countered in use of. for spinal anesthesia,

394 616

treatment of, directive on, Circular Letter Pirogoff Clinic, 4-29, 435

No. 75, Office of the Chief Surgeon, PISANI, Lt. Col. B. J., 69, 317, 321, 325, 327,

ETOUSA. 1942-403 328, 39.-9 355, 360. 454

PERKINS. Col. G. W., Jr., 36, 37 Plague, 947

PERRY, Col. W. L.. 74, 147, 148. 149, 154 Plaine de Gaiacs, 797,804

Persian Gulf, 424 Plan. overall medical support, in Pacific, 856 Planning as an important function of the

Persian Gulf Command, 424 surgical consultant, 875, 878, 884

Personnel: Plasma, 704

orthopedic, acute shortage of, 656, 660, for burns and hylmproteinentia. 732

662-66.3, 674, 683 Plaster of paris technique, transportation,

placement of, in European theater, recom- used in forward areas, training filn on.

mendations concerning, 594, 595 465. 467

placement of, in Southwest Pacific Area, Platoons, field hospital, geographic relation

recommendations concerning, 711, 714- of, to division clearing station, 122

718. 715 PLATT, H., 94. 454

selection and assignment of, 715-71S Plymouth, 184, 185, 370

Personnel D)ivision, Office of the Chief Sur- Poles. 40, 33.3

geon, ETOUSA, 168, 196, 271, 317, 405, 498, Policies, professional, in European theater,

595 factors influencing formulation of. 520-

Personnel Division, Office of the Surgeon 521

General, 589, 595 Policies and procedures:

Personnel Section, Office of the Surgeon, for the professional administration and

Services of Supply. U.S. Forces. India- management of battle casualties from

Burma Theater, 913 frontline areas to hospitals In rear, 2N03
INDEX 1043

Policies and procedures-Continued Problem (s):

governing care of patients in European anticipated, of combat zone, recommendatheater, directive on, Circular Letter No. tion of orthopedic consultant concern80, Office of Chief Sargeon, ETOUSA, ing, 665

1944-171-173 dental, 782, 796

Polish Army In Exile, 326, 333 in plastic surgery in European theater,

Pont-iA-Mousson. 306 521-571

Pontocaine Hydrochloride, 616 in practice of anesthesiology in European

POOLE, Maj. Gen. L. T., 33 theater, 585-588, 589, 591-592, 594, 598-

PoiulTT, Brig. A. E., 71, 81, 188, 253, 265, 347 601, 603, 605, 612

Port Darwin, 693, 696 Problem (s) ofPort Moresby, 687, 688, 696, 700, 701, 706, deficiencies of supply, 39, 460, 516, 517,

721 772, 779, 790, 791, 796, 798, 799, 801,

Portland, 208, 213, 214 835, 836, 861, 863, 865

Portsmouth, 31,187 identification of gases and cylinders for

Post-Graduate Medical School, Royal Army use in anesthetic machines, 595, 596

Medical Corps, 71, 82, 109 interpersonal relationships of consultants,

training of U.S. Army medical officers at, , 109) Potsdam ultimatum, 885 personnel, 916 Potsdam ultimatum, 66, 6personnel and tables of organization, 514

POTTER, Col. L. A., 662, 666, 668, 678, 682, 684, provisional hospitals in island warfare,

842656

POTTS, Col. W. J.. 626, 772, 789, 792, 827 shortage 656 of--

Practice, professional, directives concern- anesthetists, 598-0, 822

ing, 642 medical officers in Pacific, 814. 885

Praguc, the, 215 medical personnel in Pacific, 814, 820.

PRATT, F., 588 821, 822, 824, 825, 844, 846, 885

PRENTISS, Lt. Col. R. G., Jr., 244 orthopedic surgeons, 656

Presbyterian Hospital, 9 qualified clinical surgeons in Southwest

President Adams, 806, 807, 808, 809 Pacific Area, 755

Prestwick, 121,241,243, 244, 247, 604 qualified surgeons in Pacific. 820, 824,

Preventive Medicine Division, Office of the 825, 844-p846

Chief Surgeon, ETOUSA, 307, 454 specialized personnel In Hawaiian DePreventive Medicine Division, Office of The partment, 656

Surgeon General, 747n, 890 specialized personnel in Pacific Ocean

Preventive Medicine Service, Office of The Areas, 638, 656, 657, 658, 662. 674. 683 Surgeon General, 9Si3 specialized personnel in U.S. Army

SureonGenral ~Medical Department, 6k30-632. 636;,

Principles of Surgical Management in the 645, 476 aten 65,( 674, 681,

Care of Battle Casualties, directive on, 683 647, 755, 814, 817. 2, 624, 844,

Circular Letter No. 71, Office of the Chief 683, 6856 , 755, 814, 817. 820, 822, 844,

Surgeon, ETOUSA, 1944-146, 171, 231, tel

2.32, 2.34, 2f.3, 312 trained professional personnel in CenPriority cases, expedition of, 279-280 tral Pacific Area, 651-652

Prison camps, Japanese, 275 supply, 36-38,452-457, 51G-517

deficiencies, 39, 460, 516-517, 772. 779, Prisoner-of-war camp: 790, 791, 796, 798, 799, 901, 835, 16,

beriberi abscess in, 754 790, 79, 76,0 clinical considerations in, 752, 7547 6• 6 evinicaluationsodedatical cae 7, 754 evalu ation of m ed ical ca re in , in practice of anesthesia in European 7 14--755th a e , 5 r, 5 " 7. : S 58 91

Japanese, 748-755 theater, 585, 586-587, 588-589, 591

professional personnel in, 751-752 592, 594. 601, 60.3, 605, 612

nurses, 752 supplying U.S. Army units with blood and

physicians, 751-752 protein fluids during invasion. recomsurgical conditions in, 753-754 mendations of surgical consultant for

typical, management of, 748-750 solving, 72-74
1044 INDEX

l'roblemn s ) of-( tint imued I'lUIES system, 319

training of personnel in anesthesiology, Pulhnotor, thoracic, 308-309

,-541. 581), 591, 504 Punjab. 908

training of personnel in Southwest Pacific Purple Heart, 309,311,316 Areat. 719-725 Area.71!ý-25 luruata Island, 815

traumatic surgery in European theater.

58-"0 Pyramids. the. 422, 437

treatment of patients in dispensaries in

India-Burnm Theater, 925-930 Quartermaster Corps, 441, 801

unqualified personnel performing surgery Quartermaster graves registration personIn European theater, 64-4;5 nel. 17

Problem(s), special, in India-Burma The- Quccn Elizabcth, 258

ater, 925-932 Queen Elizabeth Hospital, 465

Procaine hydrochloride, 433, 616 Queen Institute for Tuberculosis, 880, 881

In bulk, preparation of solutions from. 616 Quecn Mary, 258

In oily solution for sympathetic block. 283 Queen Victoria Cottage Hospital, 516

Intravenous administration of. for sedation. (14 Radcliffe Infirmary, Oxford University, 394,

Professional medical library, Headquarters, 58, 621

European theater. 53 Ridiology:

Professional Service Division, Office of The directive on, Circular Letter No. 131, Office

Surgeon General, 30 of the Chief Surgeon, ETOUSA, 1944-

Professional Services, Eighth Air Force, 24 994

Professional Services, ETOUSA, 44 RAINE, Col. F., 625, 6226, 661, 841

Professional Services Division, Office of the RAMC. Sce Royal Army Medical Corps.

Chief Surgeon, ETOUSA, 15, 45, 57, 64.

70. 107, 156. 165, 168. 170, 196, 197, 200. RAMP. cc Recovered Allied military

204, 209, 257, 270, 280, 315, 317, 319-32"2, pRersonnel.

341-342. 355, 409. 444. 446, 459, 511, 520, Ramsbury, 214

584, 594, 600, 604, 610, 616 RANCOURT, Maj. C. D., 10

Operational Research Section of, 17 RANDOLPH, Lt. Col. M. E., 443

policies of, 11, 445"-447 Rank and promotion, 336-340, 514, 579

release of rehabilitation activities from, 15 of anesthesiologists, 615

Professional Services Division, Office of the of Medical Corps officers, 628, 635, 793, 803

Surgeon, U.S. Army Services of Supply, Rank forSouthwest Pacitic Area, 727 anesthesiologists, recommendations of

Professional services for the occupation Senior Consultant In Anesthesia,

army, 340-341 ETOUSA, 615

Programs for collection of data on missile consultants, 705

wounds, European theater, 340-341 recommendation of Co.nsultant in OrthoProject GS 22-149. 155 pedic Surgery, SWPA, concerning, 765

Promotion of anesthesiologists, 615 recommendation of Consultant in SurPromotion of medical officers, 336-340, 514, gery, SWPA, concerning, 705

579, 615, 628, 635, 793, 803 recommendations of surgical consultant

recommendations concerning, 793, 883 concerning, 387

Sec also Rank. ophthalmologists, recommendations of

Prosthesis for below-knee amputation, man- Senior Consultant in Ophthalmology.

ufacture and fitting of, training film on, ETOUSA, concerning, 457

465 orthopedic surgeons, recommendations of

Provisional Station Hospital No. 2--6W3 Senior Consultant In ETOUSA, concernProvost Marshal's Office, 747n ing, 476

Public Relations Division, G-2, SOS, ETO- well-trained otolaryngologists, recommenUSA, 169-175 dations of Senior Consultant in OtoPublications and directives, in preparation laryngology, ETOUSA, concerning, 509-

for Operation OVERLORD. 169-175 510
INDEX 1045

RAINKIY, Brig. Gen. F. W.. 45. 68, 69, 13A), lTomon mend41a1 ions of-Continue1d

1:32, 244. 245. 391, 3919, 407, 5044, SN1, 666, Consultant in Orthopedic Surgery, Pacific

797, •02, M41, 842. 855, 913, 915. 917 Ocean Areas. concerning-Continued

Raucourt. 306 use of consultantts in combat zone. 665

RAVD)N, Brig. Gen. I. S., 906, 934 Consultant in Surgery in Pacific areas.

RAY, Lt. R. W.. 656 . concerningRCAMC. $cc Royal Canadian Arny Medi- combat teams, composed of collecting

cal Corps. stations and small hospitals. 8).S

Reactions, hemolytic, directive on: evacuation and medical care. 792-79,3.

Administrative Memorandum No. 15). S70-871

Office of the Chief Surgeon, ET4)USA, field hospitals, 791

1944-294 flexibility in medical service in island

Rcader's Digest, 7"hc, 213 warfare, 793

Reading. 399, 598 locations for facilities. careful selection

Rear Echelon Headquarters, U.S. Army of, 792

Forces in China-Burnm-India, K)(;, ,49T7 medical care and evacuation, 792-7M.

Rear Echelon Headquarters, U.S. Forces, 870-"71

China Theater, 939 neurosurgery In forward echelons, 787

"Recent Advances in Anaesthesia, and organization of a system of transport,

Analgesia: Including Oxygen Therapy," 792P

588 orthopedic surgery in forward areas,

Reception of casualties, preparing for. 372 787, 827

Reclassification, in rehabilitation centers pillboxes, 836

and hospitals, of personnel being returned planning of gol locations for facilities,

to duty, 487 792

Recommendations of- planning of opera tions, 884

Chief Consultant in Surgery, Office of the portable surgical hospital. 844

Chief Surgeon. ETOUSA, concerning professional training of U.S. Army mediutilization of new general hospitals, 278 cal officers in Pacific, 792, 79.3

Consultant in Orthopedic Surgery, Office provision of flexible medical service In

of the Surgeon, USASOS, SWPA, island warfare, 793

concerning- records. 884

rank for consultants. 7675 research Investigation of special probrole of the consultant, 765' leans in missile ballistics, body armor,

transmission of information to all and shock, 884

theaters by Office of The Surgeon G(en- selection of locations for facilities. 792

erml. 765') specialization of hospitals. 804

utilization of surgical consultants, 765 surgeons in forward echelons, 787, 802,

Consultant in Orthopedic Surgery, Pacific 827

Ocean Areas. concerning- thoracic surgery in forward areas, 7N7

air evacuation from combat zone, 667P training program for medical offieers,

bloml transfusion, 665 792-793, S83

length of refresher courses, 665 use of best surgical personnel In for- management of amputation stumps. 06.5 wardl are:.8)2, 827

mobile surgical mobil teams, 66.5 eams,(Wo surgcal onsultant lin Surgery, Office of the Surpersonnel of portable surgical hospitals, ('on . in S, SWr A, cofcef ieS671 goon. USASOS, 8WPA, concerningprovision for complete definitive surgery consultant system. 705

ashore. 6T71 plabceent of personnel, 711, 714-71,.

specialized medical officers, 64W5 7,3

surgical teams in combat zone, (171, 673 rank for consultants. 705

surgical teams In division clearing coni- table of organization for professional

panies. 671 services, 705

training of Medical Department person- temporary duty of medical personnel,

nel, 665, 673 718-719
1046 INDEX

Reconmmendations of-Continued Recommendations of-Continued

Consultant in Surgery. Southeast Asia Senior Consultant in OphthamnologyCommand, concerning- Continued

consultant system, 951,952 equipment for ophthalmology in general

forwardance of copies of consultants' or station hospitals sent to oversea

reports, 951 theaters, 457

liaison activities of theater consultants equipment for specialties in general and

with chief of personnel in medical sec- station hospitals, 457

tion at theater headquarters, 951 organization of hospital centers, 457

liaison activities of theater surgical con- rank for ophthalmologists, 457

sultants with Office of The Surgeon role of hospital center consultants. 457

General, 951 Senior Consultant in Orthopedic Surgery,

peacetime training of screened reserve Office of the Chief Surgeon, ETOUSA,

officers as hospital commanders. 952 concerning- 459-462, 476

personnel for portable surgical hospitals care of foot and march injuries. 461

in a future war. 942 establishment of rehabilitation depot,

position of chief of professional serv- 461

ices, 951 installation of photographic records sysrouting of theater consultants' reports, tent in theater hospitals, 460, 461

951 management of specialized bone and

supply liaison activities of consultants, joint injuries, 461

951 microfilming of hospital records, 461

Senior Consultant in Anesthesia. Office of motion picture training films, 460

the Chief Surgeon, ETOUSA, concern- rank for orthopedic surgeons, 476

ing- supply service, 460

checking of anesthesiology equipment training of medical officers in definitive

destined for hospitals leaving ETO- treatment of fractures at base areas, USA, 598 461

courses in anesthesiology for medical of- training of medical officers in transpor- ficers, 58, riigo mdclofcrsi rnpr

tation of fracture cases, 461

equipment for C02 absorption, 58tu

equipment for endotracheal anesthesia. Senior Consultant in Otolaryngology, Of88 frice of the Chief Surgeon, ETOUSA,

insurance of standardization of anes- concerningthesiology equipment, 588 otolaryngologic service, 509-310

professional training of medical officers rank for well-trained otolaryngologists,

in theater. 588. 591,615 509-510

rank for anesthesiologists, 615 surgical consultant group during Olertraining of corpsmen in the administra- ation OVERLORD, 225-239

tion of ether. 588 surgical consultants concerningSenior Consultant in Neurological Sur- air evacuation from combat zone, 6(65

gery, Office of the Chief Surgeon, authority of consultants in transfer of

ETOUSA. concerning-- ETOUA. cncering-professional personnel. :g,.14389 neurological surgeons in general hos- atrifetion pesonn 355. 389

pitals. 398 authorization of positions for all consulrole of surgical conusltant, 406-407 tants in tables of organization, 388

transfer of neurosurgical patients from blood transfusion. 6675

EM1S hospitals to U.S. Army hospitals, braceshop and prostheses in Philippines,

"39S 399 747

utilization of surgical consultants. 406- care of foot and miarch injuries, 461

407 checking of anesthesiology equipment

Senior Consultant In Ophthalmology, Of- destined for hospitals leaving ETOflce of the Chief Surgeon, ETOUSA, USA. 588

concerning- comlat teams composed of collecting

consultant system. 457 stations and small hospitals. S0S
INDEX 1047

Recommendations of-Continued Reconmnendations of-Continued

surgical consultants concerning-Con- surgical consultants concerning--Continued tinued

consultant system, 387, 388-389, 457, peacetime training of screened reserve

705, 765, 951,952 officers as hospital commanders, 952

courses in anesthesiology for medical personnel for portable surgical hospitals,

officers, 588 in a future war, 942

equipment for CO2 absorption, 588 personnel of portable surgical hospitals,

equipment for endotracheal anesthesia, 671,942

588 pillboxes, 836

equipment for ophthalmology in general placement of personnel, 594, 595, 711,

hospitals sent to oversea theaters, 457 714-718, 755

equipment for specialties in general and planning of good locations for facilities,

station hospitals, 457 792

establishment of rehabilitation depot, planning of operations, 884

461 portable surgical hospital, 844

establishment of specialized hospitals in position of chief of professional serveach base area in European theater, ices, 951

125 professional training of medical officers

evacuation and medical care, 792-793 in European theater, 588,591, 615

field hospitals. 791 provision for complete definitive surflexibility in medical service in island gery ashore, 671

warfare, 793 provision of flexible medical service in

forwardance of copies of consultants' re- island warfare, 793

ports with theater surgeon's indorse- rank for anesthesiologists, 615

ment, to hospital commanders, 951 rank for consultants, 387, 705, 765

future consultant system, 387, 388-389 rank for ophthalmologists, 457

installation of photographic records sys- rank for orthopedic surgeons, 476

tem in European theater hospitals, rank for well-trained otolaryngologists,

460,461 509-510

insurance of standarized anesthesiology records, 884

equipment, 58 research, 884

length of refresher courses, 665 role of hospital center consultants. 457

liaison activities of theater consultants, role of surgical consultant, 406-407, 765

951 routing of theater consultants' reports,

locations for facilities, careful selection 951

of, 792 selection of locations for facilities, 792

management of amputation stumps, 665 solving of problem of supplying U.S.

management of specialized bone and Army units with blood and protein

joint injuries, 461 fluids during invasion, 72-74

medical care and evacuation, 792-793, specialization of hospitals, 884

870-871 specialized medical officers, 665

microfilming of hospital records, 461 standardization of procedures, 389

mobile surgical teams, 665 supply liaison activities of consultants,

motion picture training films, 460 951

neurological surgeons in general hos- supply service In European theater, 460

pitals, 398 surgeons In forward echelons, 787, 802,

neurosurgery in forward echelons, 787 827

organization of hospital centers, 457 surgical teams In combat zone, 671, 673

organization of system of transport, 792 surgical teams in division clearing comorthopedic surgery In forward areas, panies, 671

788,827 table of organization for professional

otolaryngologic service, 509-510 services, 705
10418 IN DEX

llie( Iitiiiitidat Iifillis of' Coilt i linedt Ilgiuuiewst 5, 1 nt'try

surgival cnul~SItantIs converilug- -C( on- 17Tth 7~t i I iiision ), (171

thinned 321d ( Tth I livision ) , 6T91

teniporary dlitty oif mnetical i jsronnitel, 1053th f27thi I livlsiom ) ,6711

718-'-T~ll 1016th (27th Dilvisioni . 6179

tlhoracuc surgery ill forward areas. 787 I 29thl--8 1). S811., 828, 8:11I

training or' ourv.S.nien it, tile OmI~imiilstra- 1451 th-S15

tiol at' et her, 58,1 1(;sth (27th D i vision). 6171)

training of U .S. Ary Medical Depart- 18S4th (7th D)ivision ). 604). t6711

t raining of U'.S. Army mnedjical officers. Rtehabilitation. 465

4611. 792. 7913, 88S1 Army Air Forces lisirtii'ilpation lin. 4891-49)(

tratining of U'.S. Army' niielic'Jl offivers deplot, establishiment of. lin Europlean theiI European t heateor. 588. 5111ll, 615 titer, recuoimnmentlattlou of surgical (o- mi 

training of U .S. Army Iuiedicaui office(rs sult ant mu'ic'(rmiuug, 4161

inl Paificl, 792. 7913 falCilit ieS inktr'ansf'er of siargifcil Ipersonnel. 718 Eurojiemit theater. 477-485

transmission of iniforumation to) all Zone ofi Interior. establishmenit of, 15,

theaters by ontie f rthe Smgeon Gen- in European theater. 61, 164. 461, 467. 4(18.

eral, 765 477-5011

tra nsport at ion facilities, 3149 act ivities cenitered li n i ted Kingdom.

use of best. surgicail personnuel Ili for- 477 -495

ward areats, MU1. S27 ac(t iviit ies 4't'tere(I oilCn t~i inentt 1)45--

uset of ('oniS~ltultits in coumbat. zone, 6415 497-54H(1

utilization (if new, general lnspiitals lil Pr'Ii4'il4i (t'S 'if oivil' esceiit act ivitijes pro

Euiropeani theater, 2781 gramin, i39511

ut ilizatio(n1 of suirgical ('4nstiltants, 406-- training filhin oi, 465

4017, 7615 Itllehahlitatj4)u and14 reo4''illitioiihuhg, training

Iteconditiolnimg Center No. 1-IS("l-8 lin. 481). 4W.11 4911-4914

Reconditijoninjg facilities iii Euiropeanuu Itebabilitaition Center--

theater, 477-485 No. 11-477-4791, 481, 4S2. 485,) 4.110, 4111. 4112.

Reconditioning Officer, Offie or' the Surgeon, 4914. 4953

Re('unstru't ion, fac'ial :No, :1 --481

in Etiropeimin theater. 521, 522, 523-538. 5470 No. 4 - -482

lin phist h' surgery centers lin 701iP Of Ill- Rlehabilitation vi'eter lin Eniglanid. urological

i'riiur, 527. 5211. 536, 538, 5)63 rehabilitation facilitiesi at. 37M)

Itecorrdak tilm reader, 4411 Rehiabilitation center pirogrami and au'tiv'iR~ecords. iiel ival, dlifficult y lin preparatilon ties. training tulnis omit. 4914

of, '50,14 Rehablilhtation)1 Division. Office of' the Chief

Riecord-s system. photographic, linstallation Surgeon. ET(1USA. 15, 485, 4M4, 487-489.

of. lin Eiariqean theate r hospit tils. 469. 461 4114). 4913, -1114. 49T., 4918, 499. 5M1(

Recoveredl Alliedl nillita ry personnel Rehabilulitation11 Liaiisonl ( Itiver fromn Offive

11AM IP). care aluil t reatmenit (if, 321. 3301 of thle C hie'f Siau'geonl to tile G(--3 Sect ion,

-Recoiivery crenter," estabulishimient (if, on (oui- ETOU1'SA, 4.S7

tiuient, :121 Itehllblitalt ion Linisi is 4 ( Itticer fronm U .S.

lti'uhi'phi)'innt. 334. 5018- -5W, 'Strate-gic Alt' Forces tit Itehialoilitaitio4)1

lit' inedica I personn~el and14 unults inl Euro- iII visioti, ( )fit'e ofr tile C hief Suirgeon.

pe'ait t hena I er. 3201 ET(rm'SA~, 487

lIetluctluun and1( fixation11 of fractures lit fachial Itliniis. 47.1

Wounds, 3-53'14 hiiit'iii'i',miiu'tt D epot. 19Itth ---4%.-

Rv~s. Brig. J. It., 273 Itelatt ions, interpersonal. Mm1( mil1

Rtegimienutal C'ommianuder. 313th Inifanitry. 3117 HItumuluii' Islaml. 77:'v, 777. 7,s4, 78N
INDEX 1049

Replacement Center, W2d Bomber Group Roi Islet, 664

Combat Crew, 400 Role of the surgical consultant:

Replacement Depot, 23d, 8th Convalescent recommendations of Consultant in OrHospital, 636 thopedic Surgery, Office of the Surgeon,

Replacement Training Command. U.S. Army USASOS, SWPA, concerning, 765

Forces, Pacific Ocean Areas, 631 recommendations of Senior Consultant in

Reports of consultants: Neurological Surgery, Office of the Chief

importance of routing of, through techni- Surgeon, ETOUSA, concerning, 406-407

cal rather than coniniand channels, 951 ROOSEVELT, F. D.. 426-427

importance of sending copies of, with RORIE, Capt. C. E., 453,454, 455

theater surgeon's indorsement, to hos- RosE, Capt. R. A., 789, 805. 806

pital commanders, 951 Ross, Col. J. P., 27, 345

Research and investigation, clinical, in Rota Island, 851

SWPA, 728 Rotation flaps, 536

Research, clinical, as a responsibility of Rotation of medical officers:

Medical Department, 875 between rear and forward units, 906

Research, operational. 17 between tactical and fixed installations,

Responsibility in otolaryngology, contro- importance of, 290, 658, 673, 681, 686,

versies concerning, 508 755

Resuscitation, 267, 268, 351 European theater, 269,290

importance of, in professional care, in ROUSSELOT, Col. L. M., 255, 261,386

World War II, 351 Routing of consultants' reports through

need for a manually controlled apparatus technical rather than command ?hannels,

for, 612 importance of, 951

required standards of, 682 Royal Air Force, 16, 27, 29, 97, 342, 422, 438,

REYNOLDS. Cdr. T. E., 782, 793, 794, 795. 797, 459. 460, 477, 584, 615

825 Royal Army Medical Corps, 25, 37, 393, 394,

Rhine, the, 239, 318-319,322-326 4(r5, 420

Rhineland, the, 251-318 College, 78, 79

Rhineland campaign, 250 meetings, 107

RnoA.%s. Col. C. P., 21 Post-Graduate Medical School, 71, 81

Rhoads General Hospital, 919 Royal Australian Army Medical Corps, 704

RHOADS. Lt. Col. G. K., 203, 237-238 Royal Canadian Army Medical Corps, 25, 26,

RIcE, 1st Lt. R. S., 486 394

RICIHARDS, Lt. Col. J. T.. 281 activities of, in United Kingdom, 395-396

RIcIIARDS, L. G.. 21, 504 Royal Canadian Medical Corps Pathological

RIcTnARDSON', Lt. Gen. R. C., Jr., 659, 684, 862 Club. 71

RICKENBACKE, "EDDIE." 425, 428 Royal College of Surgeons of Edinburgh, 354

RIDDocn, G., 398 Royal College oe Surgeons of England. 53,

RIvERs, Cdr. T. M., 877 65, 66, 95, 99, 350. 354,435

ROBERTSON. Col. R. C., 625, 626, 655. 659. Royal Cornwall Infirmary, 80. 81

682, W6,. 841 Royal Infirmary, Edinburgh, 620

ROBESON., P., 427 Royal Navy, 26, 27, 70, 96, 97, 187, 188, 342.

ROBINSON, Lt. Col., J. N., "0, 17, 107, 273, 366,396,477,584,615

275, 296, 321, 573, 576 Royal Norwegian Medical Corps. 283

ROBINSON, Col. P. I.. 879 Royal Society of Medicine, 41, 53, 141. 253,

Rockefeller Institute. 256 256, 354, 466, 506, 613, 620

Roc.khamnpton, 696 Royal Victoria Hospital, 205

Roehampton, 465i

Roentgenological Service, 218th General Royal Victoria RAF Plastic Center, East

Hospital, 625 Grinstead, 400

Roger Anderson pins, 772. 799 RUBIN. 2d Lt. B.. 948

Rocwits. Lt. Cdr. J. C. T.. 793. 826 RucKEE. Col. J. C., 317

ROGERS. Brig. Gen. J. A., 165. 166, 179, 207, RTDOLP1. Col. M. P., 305

2,49. 2-91, 322 RUPPERSSERBO, Lt. Col. A.. Jr., 801, 819
105O INDEX

Ruptured intervertebral discs: Scotland, 49, 121, 241, 243, 244, 247, 544, 585,

treatment of, directive on, Circular Letter 604

No. 75, Office of the Chief Surgeon, ScoTT, Capt. K. M., 898

ETOUSA, 1942-403 Scottish Command, 26

RusSKIN, Capt. B. A., 779 Scrub typhus, 728

Ruý.ell Islands, 773, 781, 838 Seabees, 782, 783, 806

Russia, 17, 69, 357, 415 Seagraves Hospital Unit, 901, 903

Ryukyu Islands, 875 SEARLES, Maj. P. W., 621

Ryukyu Islands Campaign, 625,630 Second Burma Campaign, 893, 899, %94-906,

933, 934

Saidor, 611 quality of surgical care in, 904, 906

St. Albans, 516 Second Service Command, 889. 890, 908, 914,

St. Bartholomew's Hospital, 397 919, 925, 932

St. Dunstan's Institute for the Blind, 173, Second U.S. Army, 4

447

St. Hugh's College for Wowen, 393 Secretary of War, 51, 425

Suint-Lb, 379,468, 541 SEDDON, H. J., ,94, 409,410

Saipan Island, 627, 633, 636, 638, 639, 640, SEEDERS, Capt. G. F., 478

642, 644, 648-&650, 654, 664, 675-676, 681, Segi, 773

738, 769, 841, 849, 850, 851, 852, 853, 855, Seine Base Section, 300, 495, 619

874, 875, 876, 877, 879 Seine River, 619

SALATICH, Maj. B. P., 485, 487 Senior Consultant in Anesthesia, Office of

Saline bath units for treatment of burns, 542, the Chief Surgeon, ETOUSA, 28, 109,

545, 550 581-621

Salisbury, 86, 207, 215, 217 duties of, 594-595

SALTONSTALL, U.S. Senator L., 330 Senior Consultant in Dermatology, Office of

Salween River Valley, 892, 899,944 the Chief Surgeon, ETOUSA, 614

Samar, 871 Senior Consultant In General Surgery, OfSAMS. Col. C. F., 302, fe of the Chief Surgeon, ETOUSA, 74,

San Fabian, 864 107,111,117,147Sur9-361,362,3 74

Sandfiy fever, prevalence of, in Iran, 424 107, 111,r117, 147,359-361,362, 364

SANDUSKY, Sanitary Corps, MaJ. W. R., 137, 141, 245, 287 responsibilities of, 362 150, 467 See also ZOLLIN0ER, Col. R. M.

Santo Tomas, 881 Senior Consultant in Maxillofacial Surgery, SAPERO, Cdr. J. J., 791 

Sapporo, Office of the Chief Surgeon, ETOUSA, 746 108, 273, 511, 522, 614 Sappor, 746 (e also STOUT, Col. R. A. SARKISOV, SEMON, 94, 421 cas TUCl .A Sasebo, 746 Senior Consultant 

Saskewan, in Neurological Surgery, 30Office of the Chief Surgeon, ETOUSA, Saskatchewan, 30 28, 392, 398, 399, 400, 403, 404, 405, 406,

Sayre head sling, 924 410, 414, 415, 420

SCARFF, Lt. Col. J. E., 10, 108, 392, 418, 439 Sec also DAvIs, Col. L.

SCAT. Scc Service Command Air Trans- Senior Consultant in Neuropsychiatry, Ofport. fice of the Chief Surgeon, ETOUSA, 39,

Schistosomiasis, 728 321. 467

danger of, in Pacific, 860 See also THOMPSON, Col. L. J.

Schofield Station Hospital, 655 Senior Consultant In Neurosurgery, Office

Schools In European theater, 15, 16, 53-54, of Chief Surgeon, ETOUSA, 108, 441,

69-70, 86, 109-110, 259, 317, 357, 366, 455- 471, 584, 614

457, 466, 599,613 See also SPURLONG, Col. R. G.

SCHULLINGER, Lt. Col. R. N., 146, 170, 275 Senior Consultant In Ophthalmology, Office

penicillin study by, 52, 134-136, 137, 138, of the Chief Surgeon, ETOUSA, 28, 64,

141,146 443-444,446, 447,455, 457

SCH 1, LMAN, Capt. H. C., 806 functions of, 446-447, 454-457

SCHWARTZ, Lt. Col. F. N., 2!44 Sec also VAIL, Col. D. T.
INDEX 1051

Senior Consultant in Orthopedic Surgery, Service Command Air Transport. 773, 774.

Office of the Chief Surgeon, ETOUSA, 817

28, 55, 61, 84, 108, 109, 274, 459, 463, 465, Service Consultants Committee on Anes466, 467, 468, 469. 471, 475, 476, 485, 614 thetics, London, 5.98. 615

See also DIVELEY, Col. R. L.; CLEVELAND. Service Group, 321st, 789

Col. M. Services of Supply, ETOUSA, U.S. Army,

Senior Consultant in "itolaryngology, Office 23, 28-30, 153, 167, 245, 249, 34)2, 420, 452.

of the Chief Surgeon, ETOUSA, 61, 276, 506, 583, 596, 600

443, 504, 506. 500 l)Ians of, for hospitals in United Kingdom

relations of. with Army Air Forces, 506 for mounting the assault on fortress

relations of, with French, 508 Europe, 106, 107

ecC also CANFIELD, Col. N. troops of, as source of whole blood. 148.

Senior Consultant in Plastic and Maxillo- 150

facial Surgery and Burns, Office of the Services of Supply, U.S. Army, 625, 687. 906

Chief Surgeon, ETOUSA. 61 Services of Supply, U.S. Forces, China TheSenior Consultant in Plastic Surgery, Of- ater, 948, 949

rice of the Chief Surgeon, ETOUSA. Services of Supply American School Center,

:396, 400, 511, 521, 527, 531, 539, 540. 557, Shrivenham, Berkshire, 53, 69

584 Services of Supply in the British Isles. 3675

duties and functions of, 512-571 Seventh U.S. Army. 239, 264, 270, 280, 29W2,

.- c( also BRICKER, Lt. Col. E. M.; BROWN, 301, 302, 304, 305-306, 307, 319, 326, 344,

Col. J. B. 454

Senior Consultant in Plastic Surgery and consultant in Surgery to, 10. 344

Burns, Office of the Chief Surgeon, Seventh U.S. Fleet, 733, 734, 742. 854. 866

ETOUSA, 108, 170 SHAEF. Sec Supreme Headquarters, Al-

,ec also BRICKER, Lt. Col. E. M. lied Expeditionary Force.

Senior Consultant in Radiology, Office of SIAMRA, Col. W. E., 286, 287, 288, 324, 32.75,

the Chief Surgeon, ETOUSA. 16, 61, 598 326

Sec also ALLEN, Col. K. D. A. Shanghai, 898

Senior Consultant in Transfusion and Shock, Shannon. 582

Office of the Chief Surgeon, ETOUSA, SHARP. Lt. Col. J. H., 943

223 Shell Natron canisters, 608

14cc also HARDIN, Lt. Col. R. C. Shepton Mallet, 467

Senior Consultant In Urology, Office of the SHIFFLER, Capt. H. K., 40

Chief Surgeon, ETOUSA, 107, 273, 275, Shlngbwlyang, 899, 903, 904

573 Shock:

activities of. 575-579 research Investigation in, 884

consultation, inspection. and l)ersonnel treatment of, 603, 60M, 613, 699

placing by. 579 wards, organization of. 678

justification for, 573-575 SHOOK. Col. C. F., 281,282, 302. 30.3, 306

Sce also RoBINsoN, Lt. Col. J. N. Shortage ofSenior consultants, AEF, World War 1, 3 anesthetists, 598, 600, 822

Senior consultants, Office of the Chief Sur- (hoctors in British Army, 50

geon. ETOUSA, duties of, 446 expertly trained clinical surgeons, 755

Senior divisional surgical consultants. army folding fracture tables for field hospitals.

corps, 4 790

Senior Medical Officer: instruments and drugs, 39, 460, 772. 779.

1st Marine Amphibious Corps, 805. 807 791, 796. 798, 799, 801, 835, 861. 863

7th Amphibious Force, 742 medical officers, 814, 885

Seventh U.S. Fleet, 734. 742 medical personnel In Pacific. 814, 8-20, 821.

Service Command: 822, 824, 825, 844, 84, 885

First. 908 orthopedic surgeons. 656, 660. 662-663, 674.

Second. M89, 890, 90m. 914. 919. 932 683

Third. 190 qualified surgeons in Pacific, "20, 821, 824.

Fourth, 890, 908 825, 844, 846

705-095-64- 69
1052 INDEX

Shortage of-Continued Southampton, 258,374,395,610

specialized personnel in U.S. Army Medi- Southeast Asia Command, 895, 908, 930, 934.

cal Department, 630-632, 636, 645, 647., 948

656, 657, 658, 665, 674, 681, 683, 685, 755, Eastern Air Command of, 930

814, 817, 820, 822, 844, 846 lessons of, 951-952

surgical supplies, 460 8ce also China Theater; India-Burma

Shoulder joint, recurrent dislocation of 659 Theater.

Shrewsbury, 447 Southern Base Section, 184, 196, 204, 205, 208,

Shrivenham, 15, 53, 54, 69, 70, 86, 466. 599, 237,372, 486, 495

613 Southern Lines of Communication, inclusion

Shrivenham Barracks, 69,317 of, in ETOUSA, 281-282, 301, 302, 303,

Shropshire, 447 304-305,306

Sicilian campaign, 169 Southmead Hospital, 32

Sicily, 437, 600, 604,615 Southmead Hospital blood transfusion

Siegfried Line, 252, 276, 524 school, 16

Signal Corps, 372, 465, 517 Southwest Pacific Area, 625, 642, 687-765,

SiMimo.Ns, Brig. Gen. J. S., 522 839, 844, 856

Sinusitis, 507 amphibious landings in, 732-744

Sixth Army Group, 304, 319 clinical research and investigation in. 728

Sixth U.S. Army, 667, 669, 687, 698, 700. 712. consultants in surgery in. 687-765

715, 718, 719, 721, 726, 733, 719, 767. 816. development of body armor for infantry839, 862, 865, 866, 871, 884 men in, 729-731

Skeletal traction, use of, 274 education and training, professional, in,

Skin-grafting in treatment of burns, 544, 699, 700, 719-725

545, 550 equipment In, 727

Sklifossowsky Institute, 99,429,430,435 evaluation and placement of surgical perSLEDGE, Capt. R. F., USN, 663 sonnel In, 711, 714-718, 755

Slot, The, 808 expansion of consultant staff in. 698

SMILEY, Lt. Col. J. T., 933 bopital units in, 693-696, 700, 720

SMIRNov, Lt. Gen. E. I. 428,429 hospitalization in, 693-696, 700, 726-727.

SMITH, Maj. B. C.. 443,454, 455 756

SMITH, Col. G. K., 10, 286, 287-288, 290, 292 invasion planning, 732-744

Socit&6 Internationale de Chirurgie, 285 operations, general characteristics of,

Society Islands, 797 687-689

Society of Medical Consultants to the Armed orthopedic surgery in, 757-765

Forces, 510 plasma and whole blood in, 704

Sodium citrate, 148 prevalence of malaria In, 690

SOFIELD, Col. H. A., 626, 663, 675, 678, 742, professional training of medical officers

772, 789, 792, 805, 809, 811, 812, 819, 822, in, 699, 700, 719-725

823, 825, 826, 838, 877 recommendations of Consultants in SurSOLOC. Sce Southern Lines of Communi- gery concerning placement of personnel

cation. in, 711, 714, 755

Solomon Islands, 658, 793, 817, 830 relative excess of hospitals in, 691

Somersetshire, 467 shortage of trained Medical Corps officers

SOMERVELL, Maj. Gen. B. B., 797 in, 714-715, 755, 757

SOMMER, Lt. Col. G. N. J., Jr., 258 specialized hospitals in, 726-727, 756

Sorting and evacuation on the Continent, training problems in, 719-725

265-266, 381-385 SOUTHWORTH, H., 256

See also Triage. Soviet Ambasador to the Court of St. Jame's,

SOS. See Services of Supply.

Soviet Armed Forces, 347

South Pacific, 663, 674, 847, 878, 97 Soviet Army, 17, 272, 319, 365, 428, 431. 433,

South Pacific Area, 625,658,663, 805, 937 434

South Pacific Base Command, 626, 627, 844 Soviet Army Medical Service, 99, 104, 428,

South Tonga, 799 433
INDEX 1053

Soviet Embassy, London, 95 S5 Bountiful. 855, 858

Soviet Foreign Office, 436 SS Mactan, 707n, 856

Soviet Government, 94, 101 Stader splint, 662

Soviet motion picture depicting care given Staging, indoctrination of units in, in Pacific

Soviet soldier during evacuation and Ocean Areas, 635-636

through his rehabilitation, 95-96 STALIN, 425

Spa. 289 Stalingrad, 436

SPA. Sec South Pacific Area. Standardization:

Spanish Civil War, 551 of anesthetic equipment, 589, 591, 597

Special Assistant for Shock and Transfu- of procedures, recommendations for effectsion, U.S. Army Forces, Pacific Ocean ing, 389

Areas. 854 Standing operating procedure for profesSpecial Representative in Transfusions and sional care of casualties, European theaIntraveneous Solutions, Office of The Sur- ter, 194-197

geon General, 160 STANDLEY, Adm. W. H., 426, 428, 432

Specialist in Plastic Surgery, 515 STANLEY, Col. 0. H., 38, 63, 595

Specialists, use of, lpolicies on, in European Staphylococcus aurcus, 69, 329

theater, 58-60 Stations, clearing, in New Georgia camSpecialization of hospitals, recommendations paign, 790-791

of consultant concerning, 884 STAYER, Maj. Gen. M. C., 326,327

Specialized treatment: Steinmann pins, 799

Cirencester hospital center, 327 Stephenville, 247

facilities, plans for, on Continent, 274 STERLING, Maj. J. A., 4&5, 487

hospitals for, on Continent, 299-300 STERN, L., 433

hospitals with facilities for, in United STERNBERG, Lt. Col. T. H., 880

Kingdom directive on, Circular Letter STEWART, Lt. Col. M. J., 478

No. 81, Office of the Chief Surgeon. STEWART, Lt. Col. W. J., 9, 61, 179, 463, 467,

ETOUSA, 1944-172-173 468,485

Specification serial numbers, 916 STILWELL, Gen. J. W.. 892. 893, 895, 896

Spencer, Heath and George, Ltd., 495 Stilwell Road, 894, 895

Spinal cord injuries: STIMSON, Maj. B., 51

treatment of, directive on, Circular Letter STIMSON, H. L., 425

No. 75, Office of the Chief Surgeon. STINCIIFIELD, Col. F. E., 478,498

ETOUSA, 1942-40:1 Stokes litters, 822

SPITTLER, Col. A. W., 6755 Stoneleigh, 15, 467

Splinting: Stoneleigh Park, 478, 495

difficulties in. 781 STORCK, Lt. Col. A. H., 9, 45, 74, 107, 147

inadequate, in forward echelons. 784 STOUT, Col. R. A., 10, 108, 273, 279, 512, 522,

of fractures and soft-tissue wounds, ne- 527, 533

cessity for, 682 STREIT, Col. P. H., 842

of hands, 674 STRUBLE, Maj. H. P., 678

use of, in skin-grafting, 562 STUART, Col. S. E., 772

Splint (s) : Studies:

Anderson, 562, 790, 799 cold injury, 283

extension arm, 788 fatigue, 52

Maastricht, 348 of casualties with respect to causes of

shortage of, 779, 781 death and causative agent, 114-116

Stader, 662 of transfusion reactions. 335-336

Thomas', 430,673, 762 of wound closure and gas gangrene, 374-

Tobruk, 286. 289, 336, 347-348, 762 375

SPRUIT, Brig. Gen. C. B., 23., 209, 40, 43, 50, qualitative and quantitative, of surgical

62, 107, 166, 178, 247, 249, 250, 258, 272, personnel, 918-920

279,298,327, 339,378,612 special, planning for, 371

SPURLINO, Col. R. G.. 10, 108, 302, 327, .347, sulfonamide, 49,52,66-67

441 trenchfoot, 290,308
1054 INDEX

Suny, Maj. 11. I., 575 Supreme Headquarters. Allied ExpeditionSuction apparatus, foot-operated, need for, ary Force. 107, 187, 197, 256. 318. 366

during invasion of Normandy, 605 relport of, 2.d6

Suction apparatus, portable: Surgeon:

improvisation of, front foot-operated tire Advance Base Section, U.S. Forces, Indiapumps, 601 Burma Theater, 9.33

need for, (601 Americal D)ivision, 801

scarcity of, in European theater, 01. 605 Army Forces, Pacific. 747. 754. 852

"Suggestions for Medical Liaison Officers Army Garrison Force, Island ('ommand,

With Chinese Units," 898 Sai pan, 664, 8SW)

Sulfadiazine. 797. 932 British Southern Command, 20,8

Sulfanilamide. S02 Central Pacific Base Comnmand. 842

proper use of, discussion regarding, 372 ('ontinental Advance Section. .*4

use of, incraniocerebral injuries, 395 D)elta Base Section. 303

use of, in Russia. 430 Eastern Comumand, 941

Sulfathiazole lpwder. 752 Eighth Air Force, 24. 29. 137. 413. 489

Sulfonamide studies. 49, 52, 66-07 Fifteenth Air Force, 730

Sulfonamides. 395, 40W), 420, 429. 430. 752. ' p 43. 63. 83

797, 847 First U.S. Army, 207. 289. 291

in control of wound infections. 233-2:4 40th Division. 824, 826

use of, 2.3X-234. 264. 661. 932 X IV Corps, 773

oHawailan Department. 6155

938th Infantry Division. 683

SUI.TAN. Lt. Gen.. 1). I.. 895 9)3d Infantry Division. 9<5

Sulu Sea, S63, 871 Ninth Air Force, 158. 159

Supplemental Data for Medical Officers. 916 Ninth U.S. Army. 286, 287, 324

Supplies and equipment- Northern Combat Area Command. 906

for anesthesia, in European theater, 585. Port of Embarkation. San Francisco. 743

586, 587, 588. 589, 592, 594, 595-598. 601. Scottish Command, 21

103, 4105. 608, (112 Ii Corps. .3

for rehabilitation program. in European Seine Base Section.:1)0

theater, 494-495 Services of Supply 5

shortage of, 39, 460, 5161, 517, 772. 779. 71), Services of Supply, U.S. Forces. India791. 796. 798. 799, 81, 835, 836, 861, 1:2. Burma Theater. 912,913, 914. 931, 954

$63, 81r5 Services of Supply, U.S. Army Forces in

Supply Division, Office of the Chief Surgeom. China-Burnu-Ihdlia. 913

ETOUSA. 162, 271, 278, 399, 498, 516. (6. 7th Infantry Division, 642. 4141. 4178. S61

605. 612. 616 77th Infantry Division. 810

Supply Division. office of The Surgeon CW Sixth It.S. Arnby, 669, 712. 719, 726. 739.

eral, 589 852

SOTLOC. 281. 28•2. 301. 302.

Supply matters, lialson activities in. impor- SOS ETO.9SA, 23

tance of, 921-923, 951 Southern Base Section. 205

Supply problems, miedical. hn European the- Tenth U.S. Army. 675. 681. 6(2

ater, .36-3 Third U.S. Army. 200, 313

optical supplies and (Mluipment, 452-455 37th Division, 778

Supply Service, Office of The Surgeon Gen- XXIV Corps, (4141, (178. 842

eral, 923 United Kingdom Base, 250, .338, 497. 612

Supply service in European theater, recoin- U.S. Army Forces, Pacific Ocean Areas,

mendations of Senior Consultant in Ortho- 627, 628, 642, 651, 685, 841, 848

pedlc Surgery, Office of the Chief Surgeon, F.S. Army Forces, Western Pacific. 7:11.

ETOITSA, concerning. 460 743

Supreme Allied Commander, Southeast Asia IT.S. Army Forces in Ching-Burma-India.

Command, 895 816, 913
INDEX 1055

Surgeon-Continued Surgery-Continued

U.S. Army Forces in the Central Pacific initial definitive, importance of, 667, 685-

Area, 660 686

U.S. Army Forces in the Far East, 726, maxillofacial, 304

72-9, 797 hospitals with special facilities for, in

U.S. Army Forces In the Far East and United Kingdom, directive on, CirU.S. Services of Supply, Southwest cular Letter No. 81, Office of the Chief

Pacific Area, 852 Surgeon, ETOUSA, 1944-172-173, 518

U'.S. Army Forces in the Middle East, 437 neurological, In European theater, 391-

U.S. Army Forces in the South Pacific 441

Area, 663, 802, 825 of major blood vessels, 290

U.S. Army Services of Supply, Southwest of the extremeties, directives on:

Pacific Area, 691, 698, 701, 708, 710, 711, Circular Letter No. 28, Office of the

716-718, 719, 720, 726, 728, 731, 733, 734, Chief Surgeon, ETOUSA, 1944-132

735 Circular Letter No. 189, Office of The

U.S. Forces, China Theater, 897, 908-909, Surgeon General, 1943-128

914, 938, 939, 949 See also Amputations.

U.S. Forces, India-Burma Theater, 909, orthopedic, in914, 938, 949, 950 European theater, 459-501

U*.S. Strategic Air Forces, 490 Pacific Ocean Areas, 655-686

Surgeon General, The, 14, 15, 20, 42-47, 54, Southwest Pacific Area, 757-765

108, 114, 128, 129, 132, 135, 159, 160, 161, peripheral nerve, 245

189, 2.39, 240, 243, 244, 245, 246, 247, 248, plastic:

253, 274, 301, 305, 311, 320, 327, 342, 364, definition of, directive on, Circular Let391, 397, 403-404, 406, 407, 410, 420, 440, ter No. 5, Office of the Chief Surgeon,

467, 490, 494, 504, 500, 510, 516, 588, 589, ETOUSA, 1943-521

591, 621, 642, 655, 661, 662, 675, 685, 718, hospitals with special facilities for, in

742, 748, 754, 756, 765, 874, 876, 880, 889, United Kingdom, directive on, Cir913, 915, 917, 923, 951 cular Letter No. 81, Office of the

visit of, to European theater, 42-47 Chief Surgeon, ETOUSA, 1944-172-

visit of, to Pacific areas in 1945, impor- 173

tance of. 765 in European theater, 511-571

Sce also KIRK, Maj. Gen. N. T.; MAGEE, thoracic, 309, 348

Maj. Gen. J. C.; Office of The Surgeon centers in United Kingdom, 258

General. hospital centers with special treatment

Surgeon General of the Chinese Army Med- facilities for, In United Kingdom, diical Administration, 911 rectives on, Circular Letter No. 81,

Surgeons, mature, highly trainedl. impor- Office of the Chief Surgeon, ETOUSA, Surgonsmatre, ighy trine, imor-1944--172

tance of, in forward areas of combat, 757

Surgeons, orthopedic: urological, hospitals with special facilities

in European theater, 472-473 for, in United Kingdom, directive on,

rank for, 476 Circular Letter No. 81, Office of the

Surgery: Chief Surgeon, ETOUSA, 1944-172

abdominal, 291, 303,304,309 vascular, 291

adequate Initial, necessity for. 682 Surgery Division, Office of The Surgeon Genelective, in European theater, 64 eral, 913

forward, directive on, Circular Letter No. "Surgery in the Combat Zone," 642, 675

13, Office of the Chief Surgeon, NATO- Surgery Section, U.S. Army Forces in the

UISA, 1943-169 South Pacific Area, 625

general, In European theater, 228, 230- Surgical care, early and expert definitive,

232,359-389 necessity for, 755

hand, 258,294. 304, 312 Surgical Consultant, 1st Marine Amphiblcenters In United Kingdom, 258 ous Corps. 805
1051i6 INDEX

SIurgical consultants. vee ('Cnosultaut4s) Teams, general surgical-Continued

Ili Aniesthesia: Consultant s) in General utilization of, 49-.41. 257, 270

Surgery: Consultant(s) In Neuropsy- Teams, mnobile specialized, importance of,

chiatry : Consultant 4 s) in Neurosurgery : 68.W

('onsulttnt t(s) Il Ophthalnology : ('oil- Teams. mobile surgical, recommendations of

sultantis) Ihi Orthopedic Surgery. ('on- Consultant lin 4)rthopedle Surgery, Pasultant 4 s) lin Otolaryngology : Consul- ctic 4 )"ean Areas, concerning. 065.

tant (s) lin Plastic Surgery . Consultant (s) Teams. shock, fromi base hospitals. 378-379)

in Surgery; Consultant(s) in Urology. Teams. surgical. 701, 72-1, 73:4. 7546. i11. •14.

Surgic•ul Consultants D ivision|. Office of The M58. 864)

Surgeon General, 915 froim base hospitals. 378-379

Surgical observation from battlefront to base mobile, reconnmendations of Consultant lin

hospital. 62-4M3 )rtholedlh Surgery. Pacitlh Ocean

Sulrgical Service,. evaluamtion of. 3413-144 Areas. concerning. 6675

147th Gemneral llospital, 625. 637 organiiation of. in general, evacuation,

Surgical units. provision of. in forward and station hospitals, ill %olltllwest Paa reaa, 61 (lflc Area, 701

Surigao Stra it. 863 stationmed at holding and transit hospitals,

Sussex East, 516 IN1a

Sutures. abdomninal retention: use (if. In collecting stations. 8041

inllsirta'tie of use of, in abdoininal value of, 671. 67:1. 675, 6OR). 681. 843

Woundlls. 2341 Teams. surgical research and observatthn,

removal of. 2I9) recomnmendations concerning. 3.81)

SUVa. 7S9). 798. 799). 8041. 819 Tebte.ssa, 591

Swindon. 55. 421. 4:1) Technical Bulletins (TiH MElt's). Sce War

SWIPA. Ncc Southwest Pa(ific Area. liepartinent Technical Bulletins.

Sydney, 688. 6M13. 707n, 728. 757, 840 Technical Manuals O TM's). See War IDeSydney Base Area. 707n Imrtment Technlcal Manuals.

Synmimithetic block. 283. 614. 6141 Teheran. 424, 436

Syphilis. prevaulence of. in Iran. 424 TEN N.EY. Brig. Genl. C. 11., 41413. 64

Tenth Air Force, )30 Table of Organizattion and Equipmnent. 8 Tenth U.S. Army. 61:26. 63•5. (148. 675. 678. 679.

)72--1I-44 681. 682. 743, 874. 876. 877

Tables. ahlumninumn ortholpedic, for snlalh'r Territory of Hawaii, 625. (157.1840), 844

hospitals and Iiortable surgical hospitals, Tetanus toxoid prophylactic doses versus

fashioning of. by surgical xicnsultaint. 704 auntitoxin hli the prevention of tetalnus, 51

Tables of organization. recommnendations Tetracaine hydrochlorlde. 616

of-- Thatcham, 36, 37. 160, 460

(ontsuiltanit In Surgery. Office of the Sur- Thiopental sodium, 643 W2

geotn, USASO)S, SWPA. concerning. 705 ums' of, it f a14. 262

Senior Consultant in General Surgery, Third Anglo-American Consultants" ConferOffice of the Chief Surgeon, ETOIUSA. ence, 342-49

concerning. "t88,3 38 Third Service Command. 908

T'arhi Hana .lar., the. 885

Tnloban, 671, 7 12, 721. 73M, 852 Third U.S. Army, 10U1. 162. 141S. 200, 225., 234,

Tac.loban Field. 871 2319. 264, 269-271, 2M. 297. 3407-31.. 314,

Tagap (1ia. 908. 1)34 311), 326. 328. 3U9, 3.34, 370, 372 37S, 454,

Talbot, the. 812 6tr)., 414)

Tamnk Battalion. 751mt. 4M)7 Consultant lit Surgery to, 10

TBt MEDs. 'ce War telpartnwent Technical Thirteenth Air Force, 773

Bulletilns. TilOMAS, t. ('ol. [1. M., Jr.. W02

Teams. general surgical, from auxiliary sur- TiiOMAN, ('Ol. R. 2.. 405. 2•8

gical groups: Thomas' arm splint, 673

instruction of. concerning mobile surgical Thomas' splint, 430, 76V2

unit etquipmnent. 841 TlooMPsoN. Col. L. J.. 21, 39, 44. 321. 391. 4417
INDEX 1057

THOMPSON, Lt. Col. M. S., 485, 487,498 Transfusion, blood-Continued

Thompson submachine gun, 941 reactions from, 286, 335-336

Thoracic survey in the forward areas, con- directive on. Administrative Memoranference on, 287 dum No. 15A), Office of the Chief SurTIIORNDIKE. Col. A. 246 geon, ETOUSA, 1944----.294-296

Tibet, 908, 935 preparation of directive on, 274

Tidworth Barracks, 38, 407 studies of, 335-336

Tiny, Maj. Gen. H. L., 41, 253, 257 recommendation of orthopedic surgery

Tilton General Hospital, 919 consultant concerning, 665

Time magazine, 848 Transfusion and resuscitation, 267, 2%8

TINDAL, A., 620 Transfusion kit, 71, 76, 78, 147

Tinian Island, 638. 640, 642. 644. 649. 650- Ebert-Emerson type of, 147, 159, 162

651. Z54, 664, 676, 681. 850, 8-51. 876. 877, field, mobile, 371

878 Transfusion-laboratory teams for mobile

Tobruk, 762 surgical unit. 86

Tobruk plaster with half-ring splint, 274 Transport, attack, 230, 675, 734, 735, 738,

Tobruk splint. 286, 289, 336, 347-348, 762 742, 743, 855, 866, 869, 871. 877

Tokyo, 746, 752, 887 Transport aircraft conversion of. into evacuTolosa, 871 ation aircraft, 21)

TOMLINSON, Sir PERCY, 253 Transport for wounded, 736, 738, 85.5. 866,

Tongatabu. 799 869

Tonsillitis, 507 Transport (highspeed), 794, 812, 814. 815

Tontouta Alrbase, 772,821, n6 Transport system, recommendations of surTontouta Airfield, 771,797, 804 gical consultant concerning organization

Torokina Fighter, 827 of, 792

Tortworth Court, 605 TransportationTOUROFF, Col. A.. S. W., 258 facilities for surgical consultants, recomTOVELL, Col. R. M.. 9, 21, 28, 109. 166. 249, mendations concerning. 3W9

279, 283, 286, 287. 290, 291, 300, 504, 582, of fracture cases, training of medical offi585. 619, 621 cers In, recommendations of surgical

Townsville, 688, 693 696 consultant concerning. 461, 792, 793

Tracheotomy Importance of, 529 Treasury Islands, 817

Trachoma, prevalence of, in Iran, 424 Treatment, definitive, delayed, 778

Traction, elastic, during evacuation, 763 Treatment, definitive, of fractures at base

TRACY, Col. E., Jr., 43, 65 areas, recommendation of surgical consulTraining. professional, in U'.S. Army theaters tant concerning, 461

of operation. Sec Education and training. Treatment ofTraining Division, Office of the Chief Sur- appendicitis, 930-931

geon, ETOUSA, 619 battle casualties in the combat zone, direcTransfer of patients to general hospitals. tive on, Circular Letter No. 71, Office of India-Burma Theater, i25a the Surgeon, ETOUSA, 1944-146, 171,

Transfer of personnel, 718 231.232, 234, 293, 312

authority of consultants In, recommenda- burns:

tions of surgical consultant concerning. in European theater, 539-540

.388, 389 of hands, 550

Transfusion, blood: casualties, observations on, 374

directives on: hand injuries, 563-571

Administrative Memorandum No. 15), directive on, Circular Letter No. 131,

Office of the Chief Surgeon, ETOUSA, Office of the Chief Surgeon, ETOUSA,

1944-294-296 1944-312, 470

Circular Letter No. 108, Office of The patients in dispensaries of India-Burma

Surgeon General, 1943-160 Theater, 925-930

Circular Letter No. 131, Office of the shock and hemorrhage, space and other reChief Surgeon, ETOUSA, 1944-294 quirements for, 682
1058 INDEX

Treatment of-Continued TURVILLE. Capt. W. II. 11., 782

wounds over bones and Joints, in general Twelfth Army G.roup. 308, 3M5, 454

hospitals, directive on, C'ircular Letter Twnio. Col. J. M., 794, 804

No. 1:31. Office of the Chief Surgeon, TWINiNG, Lt. Gen. N. F., 730, 773

ETOUSA, 1944-470 Typhoid fever, prevalence of, in Iran, 424

,ce also ('are of; Management. Typhus, 947

Treatment on the Continent, spevialized. hos- prevalence of, In Iran. 424

pitals for, 313

Trenchfoot, 285, 290, 30), 311 Ulcers, corneal. 819

control program, 885 Ulithl, 625

directlves (in: Ixoj.P(.Y. Maj. C. C., 415

Circular IAitter No. 18, Office of the Chief Union Medical College, Peking. China. 257

Surgeon, ETOUSA, 1945--311 Union of Soviet Socialist Republics, 17, 60.

War Department Technical Bulletin 81. (il, 68, 619, 75, 77, 90, 96, 104. 106. 108,

1944-311 112. 114. 168, 272, 357. 420. 424-436

in the Rhineland, fresh warnings on. 257- niedleal education In, 439

258 Surgical Mission to, 92-104. 11S, 423-439

meeting on. 306-308. 311 departure of, 97

prevalence of, in European theater. (113, observations of, on military medicine

614 and surgery In U.S.S.R., 104, 105

studies, 290. 308 prepirations for departure of, 93-95

utilization of sympathetic block in pres- statement of desires and intents of 97

ence of, 614 Umnited Kingdom, 9, 15, 25, 45, 53, 66. 73,

Triage. 194-191. 203, 262. 265-21641, 391-3,. 9W1, 104. 107, 119, 121, 132,. 1.3.3 151. 152,

385, 523. 53S, 1438. 449, 7413. 79.2, 843, 8415. 113, 16, 168, 200, 240, 241, 244, 245. 248,

41, $70 249, 250, 256-261, 2102. 27). 272. 274, 275,

directive on, Circular letter No. 101. Of- 276, 279. 280, 281. 214, 297, 298. ,W8), 308-

flee of the Chief Surgeon. ETOUSA, 310, 317, 327, 338, 354). 154, .345. 3M4. 395,

1144-234; 386, 4(W,) 403, 404, 405. 4041, 407, 410, 453,

Scc also Sorting. 4.56. 461, 441, 4Q8, 474, 475, 477-495, 497,

TauMnLE, Col. I. R., 698, 7(M. 707n, 747n. 757 49N, 5A0, 575, 5K2x-584, 589, 591, 592, 605,

Tripler General Hospital, 1155, 67M, 1,661 611. 6112, 119. 620

Tripoli. 4'2 United Kiugdom Base, 249, 251, 269, 293.

TrEybrland Islands, 696 294. .307, 311, 338. 3•39, 456. 474. 486,

TkOLAND, Capt. C. E., 46,. 826 487. 417. 611,(112, 620, 621

Tnooe, MaJ. I'., 8$:3 hand centers in. 470

Troop Carrier C'ommaand, 158, 240. hospital centers in, 450

Troops and Training Branch. Operations DI- Optical Shop, 452. 453

vision, Office of the Chief Surgeon, supplies and equipment, medical, in 452

ETOUSA, 454 United Kingdom Base Section, 9, 256, 258.

Trowbridge, 370 309-310, 519-520, 527, 542, 620

Truck, amphibious, 2'%-iona, 8591, 867P, 849. United States, 6. 17, 20, 49, (13, 6M. 73, 74. 96.

870 156, 190, 200. 231-240. 247, 248, 249. 309,

Trucks. mobile surgical. 8111. 8417 315, 354,. 387, 396. 410. 421, 4251. 432. 435,

Truk Islands, W0 461, 4412, 463, 407. 509, .40. 581. 5K2, 585.

Truro, 0,. 81, 82, 8O, 482 586, W8, 592. 601, (1M4, 621. 6&M1, 728, 744.

Tuberculosis, prevalence of: 751, 752, 763, 817, 8.41, 884, 893, 919, 9W-11,

in Pacitlc, 851 92-3. 945, 9W1

in Philippine Inlands, 8840. 81 convalescent hospitals In. 15

Tu-chou. 941 flying whole blood from, 372

Tulagi Islands, 71)3 N4ce also Zone of Interior.

Tunis, 400 University of Breslau, 329

Tunisia, 600, 6W)4 University of California School of Medicine,

TtRNF.a, K., 25 312. 408
INDEX 1059

University of Cincinnati, 9 U.S. Army Forces in the Middle Pacific, 626,

University of Edinburgh, 585, 620, 621 627, 632, 638,650,682, 684

University of Heidelberg, 329 U.S. Army Forces in the Pacific Ocean

University of Louisville School of Medicine, Areas, 625, 626, 627, 628, 630, 631, 632, 635-

10 637, 642, 647, 666, 674, 675, 682, 684, 685,

University of Maryland, 696, 889. 935 840, 841, 873

University of Michigan Medical School, 289, U.S. Army Forces in the South Pacific Area,

394, 403, 409, 553 625, 626, 663, 771, 772, 806, 848

Universty of Minnesota, 804 U.S. Army Forces in the Western Pacific,

University of Paris, 621 706, 709, 710, 715,743, 884

University of Pennsylvania, 915, M33 U.S. Army Hospital Ship Mercy, 844

University of Sydney, 707n U.S. Army medical service assistance to ChiUniversity of Wisconsin, 696 nese Army Medical Administration, 897-

University of Wisconsin Medical School, 361. 898, 911, 912, 942-946

391, 696 U.S. Army Services of Supply, 625, 687

Urology, in the European theater, 573-579 South Pacific Area, 663, 698, 700, 706, 708,

USAFCBI. Sce U.S. Army Forces in China- 712, 718, 721, 72,5, 726, 730, 759, 772,

Burma-India. 819

USAFFE. See U.S. Army Forces in the Far Southwest Pacific Area, 839, 884

East. U.S. Army Transport General Sturgis, 887

USAFICPA. Scc U.S. Army Forces In the U.S. Army Transport West Point, 707n

Central Pacific Area. USASOS. See U.S. Army Services of SupUSAFISPA. See U.S. Army Forces in the ply.

South Pacific Area. USFCT. See U.S. Forces, China Theater.

USAFMIDPAC. See U.S. Army Forces in USFET. See U.S. Forces in the European

the Middle Pacific. Theater.

USAFPOA. See U.S. Army Forces in the USFIBT. See U.S. Forces, India-Burma

Pacific Ocean Areas. Theater.

USAFWESPAC. See U.S. Army Forces in U.S. Forces, China Theater, 891, 895, 897,

the Western Pacific. 910, 911, 919, 938, 939,949

U.S. Ambassador to the Court of St. James's, medical service in, 908-912

92, 95, 96, 105, 421, 427 U.S. Forces, India-Burma Theater, 889, 890,

U.S. Ambassador to U.S.S.R., 426, 428, 432, 891, 895, 909, 912, 913, 914, 915, 917, 919,

435, 436 924, 931, 938, 939, 950

U.S. Army Forces in the Central Pa,:ific medical service In, 906. !08

Area, 625, 651--655, 658-661, 662, 663, U.S. Forces in the European Theater, 341

840n U.S. Joint Staff Planners, 391

decortications in, 653 U.S. Marines, 663, 671

necessary delay in secondary closure of U.S. Military Zone, Europe, 500

wounds In, 652 U.S. Minister to Egypt, 423, 437

peculiarities of wounds in, 653 U.S. Navy, 178, 179, 184, 188, 189, 197, 200,

professional training of medical officers in, 207, 366, 367, 368, 441, 589, 625, 629, 630,

652 640, 652, 653, 657, 659, 661, 662, 669, 685,

shortage of trained professional personnel 704, 706, 715, 732, 733, 734, 735, 736, 738,

In, 651 739, 742, 743, 779, 782, 791, 794, 795, 797,

U.S. Army Forces in China-Burma-India, 804, 805, 806, 821, 825, 844, 846, 855, 865,

892, 805, 896, 897, 899 866-871, 872, 873, 877

hospitals of, 899-903 U.S. Navy medical officers, 649,676

medical activities of, 896-906 U.S. Navy surgeons, 712,733, 734

mission of, 892, 895 U.S. Public Health Service, 256

morbidity in, 899 U.S.S. Azalea City, 684

U.S. Army Forces In the Far East, 625, 726, U.S.S. Comfort, 676

729, 879, 880 U.S.S. J. Franklin Bell, 667

U.S. Army Forces In the Middle East, 437 U.S.S. Mercy, 885
1060 INDEX

U.S.S. Montauk, 676 WAC. See Women's Army Corps.

U.S.S. Okanagoan, 675 WAKELEY, Surgeon Rear Admiral Cecil P. G.,

U.S.S.R. N•ee Union of Soviet Socialist Re- 1&S

publics. Wales. 364

U.S.S. Relief. 681 WALKER, Capt. A. T., 854. 97551, 865, 877

U.S.S. Republie. 655 Walter Reed Army Medical Center. 767.

U.S.S. Solace. 663. 676 Walter Reed General Hospital, 392, 404, 497,

U.S. Strategic Air Forces. ETOUSA, 481, 509, 582, 675, 889, 890

487, 490 Wangensteen tubes, scarcity of, 255

U.S. Typhus Cominission, 437 War IDepartment. 53, 168. 250, 276, 311. 319.

Utah airstrip, 217 338. 400, 482, 615, 631, WH2. 657. 895. 911,

Utah Beach, 608, 610 912. 925, 937, 945. 950, 951

Utilization of- War Delartment AGO Form 178--2--632

medical facilities In a theater of opera- War Department Circulartions, 792--793 No. 12, 10 Jan. 1944-925

new general hospitals in European the- No. 134, 4 May 1945-616

ater, recommendations concerning. 278 War D)epartment Technical Bulletin (TB

surgical consultants, recommendations MEI))-

concerning, 396-403, 406-407, 765 10, February 1V44-948

62, 1 July 1944-948

VAIL, Col. D. T.. 9, 10, 21, 28, 64, 69, 443, 444 81, 4 Aug. 1,944-311

452, 45-N3, 455. 456 137, January 1945-948

Val de Grfice Military Hospital (French), 17 147, March 1943-642

Valencia. 859, 860, 862 War Dlepartment Technical Bulletins (TB

Valkenburg, 287 MEI's), 915. 920

Valley Forge General Hospital, 512 War Department Technical Manual (TM)

Valognes, 249-250, 476, 485. 610, 611 8-210, Guides to Therapy for Medical OfflVAN VALIN. Col. J. C., 38 cers. 20 Mar. 1942, revision of, 169--170. 600

VASKO, Lt. Col. J. R., 656 War Wounds Committee of the Medical ReV-E Day. 118. 312, 33M. 3.34. 3:5. 342. 454. search Council of Great Britain, 51, W2

499-500, 509, 573, 579, 618, 621, 632 Warminster, 481

Vella Lavella Island, 776. 789, 805, 810, 812, Warminster Barracks, 481

814 Warwickshire, 478

Venereal diseases, 947 Wasatch, the, 8514, 862, 86.5

Veterans' Administration, 355, 358, 394, 509, WASHBURN, B.. 441

621 Washington University, 9, 391.403

"Vetting." 116-118, 279,281 WATSON-JONES, Sir REGINALD, 93, 97. 420,

Vice-Commissariat of Public Health, Union 427, 431,459

of Soviet Socialist Republics, 424 WD AGO Form 178-2-916

VICKOREN. Col. A., 147, 155, 454 WEART, MaJ. Gen. D. L., 939

Victoria College, 798 WEDDELL, G., 395

Vila, 795 WEDELL, Brig. J. M., 26

Visayan Islands, 748 WEDEMEYER, Lt. Gen. A. C., 895

Vision, defective, 833 WEEKS, Cdr. C., 833, 848

Vitt Levu Island, 797, 798 Wehrmacht, 10.5, 252

Vitry-sur-Selne, 278 Weimar. 618

Vittel, 304 WELCH!, Lt. Col. C. S.. 287

V-J IDay. 455. 545., 509, 629. 748. 751, 752. 753 WELSH, Col. A. B., 876

Vladivostok, 95 Western Base Section, 486,493

Voks, 427 Western Front. 252

Volcano Islands, 638 Western Pacific Base Command, 625', 626.

Volunteer Blood Panel, European theater, 627%. 628, 629, 642, 649, 650, 873, 878

150, 152 Western Reserve, 696

Voorhees Mission, 921 WESTERVELT, Col. F. B.. 675,682

Vyazma, 429, 433,434 WHEELER, Maj. D., 413
INDEX 1061

WHITRY, Brig. L. E. H., 32, 33, 35, 72, 73, 354 Wounds-Continued

Whitchurch, 121 in Central Pacific Area, difference in type

WHrm, Maj. Gen. A. A., 3015 of, from those in other theaters, 653

Whitehall, 181 of the extremities, self-inflicted, 662

WHrrrINGHAM, Air Marshal Sir HAROLD, 29 over bones and joints, treatment of, in

Whole blood service, European theater. See general hospitals, directive on; CircuBlood, whole. lar Letter No. 131, Office of the Chief

Widewing, 68, 109, 149 Surgeon, ETOUSA, 1944-470

WILLIAMS, Maj. F. P., 862 over compound fractures, delayed primary

WILLIAMS, Lt. Col. G. D., 256 closure of, directive on; Circular Letter

WILLIAMS, Col. R. P., 896,909,910 No. 131, Office of the Chief Surgeon,

WILLIS, Maj. J. G., 778 ETOUSA, 1944-470

WILLIS, Brig. Gen. J. M., 674, 675, 679, 682, packing of, 720

684, 768, 769, 770 848, 851, 874, 876 regional, 375-378

WILSON, Gen. H. M., 438 sucking chest, proper way of sealing, 836

WILSON, Col. L. F., 795 treatment of:

Wiltshire, 480, 481 by open methods, results of, 662, 667

WINANT, J. G., 92, 95, 96, 105, 421, 427 directive on; Circular Letter No. 101,

Winchester, 205 Office of the Chief Surgeon, ETOUSA,

WINo, Maj. Gen. L. F., 885 30 July 1944-231-232

Wingfield Morris Orthopaedic Emergency vascular, 646

Hospital, 394, 409, 410 Wounds and general surgery, European theWinnipeg, 693 ater, 228, 230-232

WINTERNITZ. A., 21 WRIGHT, Col. H. B., 24, 29, 43, 44, 79, 80, 109,

Wismar, 319 114, 309, 310, 415, 489

Women's Army Corps, 173, 611

WooD, Col. S. A., 307 X-ray therapy, administrative policies and

WOODRUFF, Maj. W. W., 877 procedures for, 173

Worcestershire, WorldsterWire, 121, 477

World War 

1- 21, 477 5Yale University School of Medicine, 9, 391, 1--20, 21, Z3, 52, 62, 1199 353, 0,77 8

354, 356, 394, 400, 415, 432, 505, 508, 511, 504, 767, 889

523, 534, 551, 655, 705, 719, 757, 765 Yap, 667, 858

consultant system in, 1-5 Yaws, 796

Worms, 319 Y-Force, 899, 944, 945

Wound ballistics, 246, 880 YOUMANS, Lt. Col. C. P., %0

Wound closure, primary, 530-5.31 YOUNG, Col. C. T., 661, 841. 842

Wound closure and gas gangrene, study of, YOUNG, J. Z., 395

374-375 YUDIN, S. S., 94, 426, 427, 429, 430, 431, 435

Wounds: investiture of:

caused by multiple shell fragments, char- in American College of Surgeons, 91, 101,

acteristics of, 679 435

closed, percentage of Infection in, 662 In Royal College of Surgeons, 99, 101,

delayed closure of, Importance of, in res- 435

toration of fighting men to early duty, Yugoslavs 333

352

delayed early suture of, 275 Yfinnan Province, 892, 893

facial:

delayed primary and secondary closure ZEJIM, Col. A., 323

of, 535 ZOLLINGER, Col. R. M., 9, 16,65, 80, 81,82, 107,

drainage In closure of, 534-535 111, 117, 162, 170, 173, 184, 188, 189, 194,

primary closure of, 530-531 196, 197, 203, 205, 236, 241, 314, 321, 358,

Importance of delayed closure of. In res- 359,364, 367, 378

toration of fighting men to early duty, Sec also Senior Consultant in General

352 Surgery, ETOUSA.
1062 INDEX

Zone of Interior, 14, 15, 17, 38, 45, 50, 57, 61, Zone of Interior-Continued

69. 74, 76, 77, 108, 147, 149, 190, 239, 241 597, 598, 604, 605. 612, 613, 616, 618, 621,

243, 244, 245, 246, 247, 248, 249, 251, 255, 636, 642, 674-675, 687, 699, 700, 704, 706,

"256, 258, 273, 274, 282, 291, 294, 297, 298, 711, 720, 727, 746, 747n, 748, 755, 759, 761,

299, 300, 301, 303, 304, 307, 309, 310, 317, 763, 890, 911, 915, 919, 9'24, 925, 935, 951,

327, 330, 338, 359, 360, 365, 385, 386, 388, 952

404, 407, 410, 419, 420, 443, 447, 467, 469, establishment of rehabilitation facilities

474, 494, 499, 500, 512, 521, 527, 536, 538, in, 15

557, 559, 563, 564, 573, 588, 589, 591, 594, ZUCKERMAN, Sir SOLLY, 115, 395

0
History of the Medical Departmcnt, US. Army in World War H

DISTRIBUTION LIST

ACTIVITIES OF SURGICAL CONSULTANTS, VOLUME H

AO.L.." ARMY:

OSD (1) 08 MaJ Comd (2) except WRAIR (5)

SA (1) USAREUR (4) AFIP (5)

US of A (1) SHAPE (2) Def Log SptCen (1)

ASA (FM) (1) OS BaseComd (1) Def Med Spt Con (1)

ABA (I&L) (1) Log Comd (2) USAPERSCEN (1)

ABA (R&D) (1) MDW (1) USA TRANS TmI Cmd (1)

USASA (1) Armies (8) Army Terminal (1)

DASA (1) Corps (1) PG (1)

DCSPER (2) Div (2) Med Lab (1)

ACSI (1) SF Gp (1) USA Med R&D Units &

DI)SOPS (2) Med Bn (1) Lab (1)

DOSLOG (2) Med Gp (2) AFES (1)

ACSFOR (2) TC (1) Arsenals (1)

ACSRO (1) USMA (5) Med Fld Maint Shope (1)

CARROTC (1) Svc Colleges (2) DB (1)

Cofi (1) b: Svc Bch (1) except Disp (1)

CINFO (1) MeSS (5) USA Corps (1)

CNGB (1) Med Specialist Sch (2) MAAG (1)

CIA (1) Med See, GENDEP (1) Mil Men (1)

CRD (1) Med Dep (1) JBUSMC (1)

0MH (1) Gen Hoep (5) Units organised under felTAG (1) Named AH (4) lowingTOE's:

TIG (1) USA Hosp (25-100 Beds) 8-500 Team AH (1)

TJAG (1) (1) 8-510(1)

TPMG (1) USA Hoop (100-500 Beds) 8-1 (5)

Cot~b (1) (2) 8481 (1)

Tech Stf, DA (1) except USA Hoop (500-750 Beds) Historical Unit, USAMEDS

TOG (80) (4) (2,0OO)

Med Bde (1) Med Cen (1) except

USCONARO (2) WRAMO (5)

ARADCOM (1) BAM0 (5)

NO: Div (1) ; State AG (1).

USAR: Log Comd (1) ; Div (1) ; Bde (1) ; USA Hoop (1) ; TOn's 8-00 Team ANM 8-510,

8-51, 84- (1) ; Med Op (2).

Request copies remaining on hand after initial distribution be returned to The iostorical Unit, U.S. Army Medical Service, Forest Glen Section, Walter Reed Army Medical

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