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ACCESS TO CARE
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 been successfully terminated. He was aware of the fact that he 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 he 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 he 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 Hart-
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 he would be ready to report when orders were issued.
It had been anticipated that the writer would receive a majority. However, when he discussed this matter with Dr. Wilmar M. Allen, director of Hartford Hospital, Dr. Allen expressed the opinion 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 he would report for duty in the grade of lieutenant colonel. On 20 August he was sworn in as an officer of the Army of the United States, and on 26 August Lt. Col. (later Col.) Ralph M. Tovell, MC, reported for duty in Washington. He was assigned to Walter Reed General Hospital, Washington, D.C., for the usual course of indoctrination which was hyphenated in order to permit him to spend 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 airsickness during the trans-Atlantic trip. At Shannon the passengers
were taken to the airport by bus, where they, as a combined force of civilians, Red Cross workers, and Army officers, were required to stand inspection by customs and immigration officers. For this procedure, the author was fortunate enough to stand in line behind a Regular Army colonel. Because three planes had landed within a few minutes of 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 the loudspeaker system that all military personnel were to come to the head of the line. This was a rather startling announcement to Army officers supposedly in disguise and particularly so to a lieutenant colonel who had been in the Army less than a month. After a quick whispered conference with the Regular Army colonel preceding him, the two decided that this was no trick leading to internment in a neutral country. The two colonels promptly moved to the head of the line where the necessary formalities were accomplished with dispatch. This incident made a vivid impression on the author, and he was forced to alter his concept of neutrality, particularly of the southern Irish variety. In subsequent conversation with military friends, he learned that there were 150,000 southern Irish in the British Army. He was asked: "Under those circumstances, what kind of neutrality could you expect?"
Soon, the passengers were winging their 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 25 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 good, and transportation was at hand for conveyance to the billeting office. It was surprising how well and how easily U.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. He was informed that he was to be reassigned immediately to Headquarters, SOS (Services of Supply), at Cheltenham, England, a city approximately 90 miles west of London and some 30 miles beyond Oxford. He proceeded to Cheltenham by train 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.
The next morning, the author reported for work, physically ready for it but mentally in very much of a quandary regarding the future. He met his new superior, Col. James C. Kimbrough, 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 surgery-individuals 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 Kimbrough 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 have been other than stupid in their practices at home, he was able to quote volubly from the Bible to illustrate his point. The personnel of the Professional Services Division, 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 Division 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 Division, Office of the Chief Surgeon, ETOUSA. Maj. (later Col.) James Barrett Brown, MC, Senior Consultant in Plastic Surgery, and Lt. Col. (later Col.) Loyal Davis, MC, 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 problems they knew he would face in the near future. Their help and advice were greatly appreciated because this author, as the first Senior Consultant in Anesthesia appointed in the U.S. Army, had no precedents to follow. Fortunately, great latitude subsequently was allowed him in organizing a program.
EARLY ACTIVITIES AND RECOMMENDATIONS
During this period of groping for information upon which to build, this consultant decided that the best part of discretion was to meet his counterparts in the British Army, the Royal Navy, and the Royal Air Force and in the Canadian Army. He learned that Air Commodore R. R. (later Sir Robert) Macintosh, the Nuffield Professor of Anaesthetics at Oxford University, was senior adviser to the Royal Air Force and that Dr. I. W. Magill of London represented the EMS (Emergency Medical Service) and the Royal Navy. Col. (later Brigadier) Ashley S. Daly, RAMC, was his counterpart in the British
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 an old friend, was senior anesthetist with the Canadian Army. This consultant immediately made plans 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 Canadian 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 phases of anesthesia such as would be conducted in British civilian hospitals, with the exception that, in military hospitals, 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 order and included many anesthesiologists of either national or international reputation.
Inspection of Canadian hospitals revealed 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 be well trained and adequately able to make an intelligent choice of agent and method to be used under varying circumstances.
Inspection 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, Headington, Oxford, did have one McKesson and one Foregger machine, but they were British owned. Equipment 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 type of practice encountered at the time, they were relatively satisfactory, but, in the opinion of the Senior Consultant, they were inadequately equipped to cope with battle casualties in great numbers. Problems, as reported, were substantially as follows:
1. Medical officers assigned as anesthesiologists in hospitals need further training.
2. Medical officers in hospitals and not assigned to anesthesia need training and experience in order to serve as alternate anesthesiologists to cover demands which would be placed on units upon the arrival of battle casualties.
3. There is need for training corpsmen of satisfactory personality and aptitude in the fundamentals of administering ether by the open-drop method under supervision of an assigned anesthesiologist.
4. Many hospitals functioning in the theater are urgently in need of equipment and supplies.
5. Hospitals moving out of this area for service in an active theater of operations need their equipment checked. Essential items not included in tables of equipment should be added. The need for checking is magnified when it is realized that expendable parts for equipment produced by the several suppliers in the United States are not interchangeable. Equipment is useless if accessories and equipment are not manufactured by the same company.
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.
This summary of problems was followed by a series of recommendations listed substantially as follows:
1. That facilities for training be established at the 30th General Hospital, Mansfield, and at the 2d General Hospital, Oxford, to provide courses in anesthesia for medical officers of the U.S. Army.
2. That two anesthesiologists of teaching caliber in the grade of captain or preferably major be requistioned from the Zone of Interior to take charge of anesthesia in the above-mentioned locations.
3. That, until such time as one or both of these facilities are functioning, the offer of Air Commodore Macintosh of Oxford to welcome observation of practice of anesthesiology at the Radcliffe Infirmary be accepted and that two medical officers be assigned for periods of one month.
4. That anesthesiologists be advised to train medical officers of their own units in anesthesiology.
5. That anesthesiologists be advised to train suitable corpsmen in the fundamentals of the administration of ether.
6. That endotracheal tubes be approved in principle as essential and that appropriate equipment for endotracheal anesthesia be provided as standard to operating room units in general, evacuation, and surgical hospitals.
7. That the facilities for CO2 absorption be provided in equipment supplied to general and station hospitals.
8. That equipment contemplated for shipment with hospital units leaving this theater be checked by a competent anesthesiologist.
9. That each hospital unit stationed in this theater be supplied with the following British texts: "Essentials of General Anaesthesia" by R.R. Macintosh and Freda Pratt; and "Recent Advances in Anaesthesia and Analgesia; Including Oxygen Therapy" by C. Langton Hewer.
10. That authorities in Washington be requested to prepare supply lists for anesthetic chests suitable for general, station, evacuation, surgical, and mobile operating units. Anesthetic equipment and supplies issued in units would eliminate the hazards of lack of standardization of equipment.
11. That training medical officers in anesthesia in the Zone of Interior, along the lines planned in civilian hospitals and in replacement pool centers, be facilitated to the fullest extent immediately.
It was further pointed out that these recommendations concerning the practice of anesthesiology would in no way elevate this practice above the standards already established in British and Canadian hospitals in the theater.
On 2 December 1942, a report, entitled "Anesthesia," was prepared for submission to The Surgeon General. Much of the data that had been recorded in the preceding report of 28 October was provided in the report to The Surgeon General. The following points were made:
1. Tables of supply were inadequate to cover the requirements of modern anesthesiology.
2. Machines built by the several manufacturers in the United States were not standardized, and expendable parts were not interchangeable.
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 cooperation 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 staging period could not be trained to meet the demands that would be placed upon them in a field of active military operations; that is, the North African theater where operations had opened on 8 November 1942.
The report to The Surgeon General ended with a series of recommendations that 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 supply be amplified to meet modern requirements; that standardization of suitable equipment for each type of unit be achieved permitting interchangeability of rubber parts, endotracheal equipment, and masks; and that small pieces of equipment not connected with the gas machine (that is, ether masks, airways, tubes, needles, syringes, laryngoscopes, connecters, and drugs-particularly drugs usually supplied in ampules) be listed and supplied as a unit in order to simplify problems in supply. It was requested that the work of the Committee on Standardization, initiated through the efforts of the American Anesthetists Society, ETOUSA, be supported and that, with the cooperation of the Army and Navy, its functions be pushed to their logical conclusion. It was pointed out that this committee included representatives of manufacturers of gas machines and rubber accessories, manufacturers of oxygen and anesthetic gases, and the National Bureau of Standards, U.S. Department of Commerce. Representatives from the Army and Navy, to this consultant's knowledge, had been assigned for each meeting that he had attended before entering on active duty. It was further recommended that this effort be directed toward uniformity of threadings, tapers, openings, and valves and coordinated with projects in the Air Forces for standardization of methods of supply, storage, and administration of oxygen to aircrews. The urgency of augmenting the training programs pertaining to physicians in anesthesia in the Zone of Interior was emphasized, and in addition, it was recommended that the program be
FIGURE 221.-"Marriage" of anesthetic machines and expendable rubber parts shipped separately. A. Portable American military anesthetic machines, assembled after expendable rubber parts shipped in a separate container had been "married." B. Expendable rubber parts which were shipped in a separate container. Because expendable parts produced by American manufacturers were not interchangeable, problems of "marriage" (as usual) were very real.
expanded. This request was a reflection of the fact that hospitals had 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. Shiffler, MC, of the 48th Surgical Hospital, Tébessa, Algeria, then engaged in the North African operations. On 24 November 1942, he reported that his unit had taken over an ill-equipped local hospital and had started work immediately. The operating room was moderately sized, and there were two tables 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 he could give anesthesia to two patients 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. He wrote as follows:
Naturally, as you can readily understand, Lieutenant Marmer 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 immediately 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 preparation for the eventual invasion of continental Europe. They outlined fundamental problems to be overcome in relation to organization for training of personnel, 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 designed American equipment. Some of these problems entailed the establishment of long-term programs, particularly 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.
The one immediate pressing problem was to rectify the situation created by the shipment of gas machines in one crate and equipment of deteriorating quality in another. This situation was due to practice established in the United States on the principle that deteriorating rubber parts packed over a long period of time with nonexpendable equipment would deteriorate and be useless upon receipt in a theater of operations. This principle was well founded, but failure to "marry" deteriorating equipment with nonexpendable equipment at ports of embarkation created a serious situation whereby nonexpendable equipment received in a theater of operations was rendered useless so long as the corresponding expendable parts failed to arrive. This situation was particularly serious for hospital units unpacking their equipment for the first time upon their arrival in North Africa. The situation was less emergent, however, for those units arriving in the United Kingdom because there was an established industry to provide adaptable substitute expendable equipment (fig. 222). The supplies of expendable British equipment, however, were meager, and adaption and procurement were difficult. Another phase of the problem in Great Britain was the adaption of American machines to make it feasible to utilize anesthetic gases supplied in British cylinders. The British Oxygen Co. was very helpful in designing adapters permitting utilization of British deteriorating equipment and in designing adapters (fig. 223) per-
FIGURE 223.-Adapters obtained from British sources to permit utilization of British cylinders on American anesthetic machines. The first four, left, were yoke adapters (US No. 9-NO2101; British No. A3043) required for each anesthetic machine. The bullnose adapter, second from right, made it possible to link a large British oxygen cylinder to an American anesthetic machine. The nitrous oxide adapter, right, served a parallel purpose.
mitting employment of British cylinders on American gas machines. Due, however, to the necessity for time-consuming negotiations through the Ministry of Supply, authorization for procurement of these items was slow. Production, due to shortage of materials and manpower, was also time-consuming. Ultimately, the principle of obtaining expendable supplies through British sources raised the problem of identification of these materials by American anesthesiologists.
The first few months in Britain had been revealing. Making the rounds of hospitals scattered throughout southern England, by car, proved to be a frustrating experience. Roads were blocked with pitifully weak log barriers, and directional signs were completely absent. The citizens were well trained in their refusal to give out any information. It was common experience to inquire of an old "gaffer," who probably had never been more than 20 miles from home, the direction of a town that one knew was within a 3-mile radius. He characteristically replied that he "never heard of the place." If he was particularly well versed in civil defense, he would refuse to tell you the direction to the nearest police station, which was usually your last resort for gaining information. A blanket of fog, which so frequently covers Britain during the autumn months, added to the difficulty of transportation. The English girls who were assigned as drivers from the motor pool were expert and very helpful.
Gradually, a bird's-eye view of problems was gained in relation to anesthesia equipment, supplies, and personnel that would face ETOUSA during
the ensuing 2 years. It was indeed fortunate that a U.S. Army destined to invade northern France was based in a country that was highly industrialized. Deficiencies in equipment that were a reflection of the unpreparedness for war at home, and the all too successful submarine campaign against American convoys, could to a certain extent be alleviated by requisitioning substitute items from British sources. Problems in personnel were more difficult to solve, but it was noted that anesthesiologists in the theater were gradually receiving equipment satisfactory to meet fully the needs of military practice. Relatively inexperienced anesthesiologists had improved the character of their work, particularly following temporary duty for the purpose of observing and receiving instruction at British and American hospitals. The anesthesiologists who had arrived with the 3d Auxiliary Surgical Group constituted a pool from which anesthesiologists could be drawn to replace less-experienced medical officers during their periods of absence for training. During this same period, several well-trained and experienced anesthesiologists arrived from the Zone of Interior assigned to units which were to remain in the European theater. This made it possible to plan on using these men as instructors in U.S. Army hospitals and led to the hope that the practice of assigning anesthesiologists to British units for training might be augmented by training anesthetists in U.S. hospitals. It was in this atmosphere that the year of preliminary planning, 1942, ended.
The Senior Consultant in Anesthesia by this time realized the significance of his duties: To observe, to report, and to recommend to the Chief Surgeon, ETOUSA. The Division of Professional Services, of which he was a part, was without command function but was expected to formulate policies, obtain their authorization, and check on adherence to policies thus established in general, evacuation, station, and field hospitals and later in base sections and hospital centers. His problems were common to those of his associates, each consultant having a set of problems with which he had to deal that were peculiar to his specialty. The work of the Senior Consultant in Anesthesia included visits to hospitals, observation of work being done with criticism and suggestions regarding organization and practice, preparation of reports with recommendations, preparation of material covering policies for issue as directives by the Chief Surgeon, establishment of satisfactory report forms, collection and evaluation of statistical data, and establishment and maintenance of liaison with his counterparts among the Allies.
It was the responsibility of each senior consultant to evaluate the skill of members of his specialty in all types of units in relation to the part which each unit was expected to play. This role necessitated the interviewing of personnel of incoming hospitals. A file system was established containing a summarized medical biography of each officer in the specialty. Notes were added recording observations made subsequently regarding the skill of officers at work. This information was used as a guide in establishing each officer's rating, and it was
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 1943Supplies 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
cylinders, the labels always must be read. Color markings on cylinders were to be considered only to corroborate labels. This was followed with a description of British and American cylinders, including their characteristics, by which they might be differentiated. Information of general interest regarding cylinders and their gaseous contents was given broad distribution.
This problem of identification of gases and cylinders was recognized by authorities outside the Medical Corps. On 20 February 1943, Circular No. 18 was issued by Headquarters, ETOUSA, under the title "Industrial and Breathing Gases and Cylinders." Means and methods of procurement of oxygen as well as acetylene, hydrogen, and nitrogen for industrial purposes was stated. Confusion was subsequently occasioned in medical units by this directive because the color code for oxygen according to British specifications was stated as black. The directive failed to indicate that nitrous oxide cylinders were also black but possessed a different type of valve. The directive also stated: "Where facilities for painting according to British standard specifications are not available, the Requisitioning Officer may request the British Oxygen Company to paint the cylinders. Correct shades and types of paint are available at Headquarters, SOS, ETOUSA, APO-871." This statement failed in the matter of thoroughly assigning responsibility for painting according to the British standard specifications, and at the same time introduced the hazard of error where painting was undertaken by organizations other than the supplier. Another requirement of the directive was that, until all U.S. Army cylinders were repainted to conform to British standard specifications, it was essential that a label clearly indicating the type of gas be securely pasted on the cylinder. To paste labels securely on cylinders stored in the open was impossible, and it was implied that identification of gases and cylinders by means of colored paint would subsequently be adequate. This policy introduced hazards where the American color code definitely conflicted with the British. This directive had originally been issued without the knowledge or concurrence of the Office of the Chief Surgeon. It was unfortunate that distribution included units of the Medical Department.
At the time of the preparation of the "Consolidated Report Regarding Equipment for Anesthesia and Oxygen Therapy in E.T.O.," which was submitted by this consultant to the Director of Professional Services on 31 January 1943, the hazards of a gas attack were very much in the minds of all (fig. 224). The report, therefore, included the recommendation that each hospital be provided with efficient quick-coupling oxygen sets of British origin to provide a minimum coverage of 3 percent of bed capacity in each hospital, additional equipment to be retained in supply depots to cover 2 percent of the bed capacity. This level was set after consultation with Col. William D. Fleming, MC, Chief Gas Casualty Officer, Gas Casualty Division, and Colonel Middleton, chief medical consultant to the European theater. Installation of quick-linkage pipelines was advocated to save shipping and utilize to the best advantage the limited supply of cylinders in time of real need. It was noted that procurement of BLB (Boothby, Lovelace, Bulbulian) masks and regulators had been sat-
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 treatment or observation. 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.
During the early months of 1943, anesthetic machines continued to arrive in the European theater with deteriorating rubber equipment. This created a problem of major magnitude. After much difficulty, substitute equipment was obtained from British sources. Some delay was occasioned by lack of
standardization between Heidbrink Co. and McKesson Equipment Co. machines on the one hand, and between the machines produced by the Boyle Co. and the Medical and Industrial Equipment Co., both of London, on the other. This lack of standardization necessitated accumulation of four pools of equipment for maintenance purposes and was responsible for no little confusion. Attempts to rectify this situation were without avail for many months, but progress was made through a subsequently established committee, known as the Service Consultants Committee on Anesthetics, which included representatives from the U.S. Army and the several sections of the British Forces as well as the Ministry of Health and the Department of Health for Scotland. In addition, the Canadian Army had direct representation.
Adaption (fig. 223, p. 593) of American equipment to British cylinders likewise constituted a problem. The original estimate of the number of adapters required was predicated on the basis that the major supply of anesthetic machines and apparatus for oxygen therapy would be procured from British sources and would therefore not need adaptation to British cylinders. This calculation was based upon the fact that the outcome of the submarine campaign seemed grim; but, with subsequent marked Allied successes in dealing with submarines, delivery of equipment from the Zone of Interior increased beyond original hopes and the procurement of adapters lagged behind needs thus created. The establishment of Depot M-400 at Reading, England, on 1 February 1943, for maintenance and repair of anesthetic and X-ray equipment, proved to be a real boon. Lt. Col. (later Col.) Kenneth D. A. Allen, MC, Senior Consultant in Radiology, was largely responsible for establishment 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 equipment distributed to issuing depots throughout the theater was screened through Depot M-400 for completeness. 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 from the supply of unlike pieces of equipment from various manufacturers in America and in Britain made training even more imperative. It was stressed that each hospital should have a trained physician anesthesiologist and an alternate physician to cover for him, and in addition, depending on the size and type of the hospital, should have a sufficient number of assistants to cover periods of peakload. Training by apprenticeship to skilled anesthetists was continued and accelerated through the year. In case of need, arrangements were made for trainees to go on temporary duty for a period of 30 days to hospitals
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.
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
designed and was for use in general hospitals using the larger-sized forms throughout their complete reporting system.
A monthly report covering activities of the anesthesia and operating room section was required from each hospital in the European theater by a command letter issued by the Office of the Chief Surgeon on 24 February 1943. Through the cooperation of anesthesiologists in the theater, statistical information was submitted to the Office of the Chief Surgeon for analysis. These data were collected to establish experience factors in reference to agents and methods used and thus provide the Supply Division, Office of the Chief Surgeon, data from which to estimate requirements for future supply. The data also indicated the direction in which emphasis should be placed in the training of anesthetists.
Visit to North Africa
Revision of TM (War Department Technical Manual) 8-210, Guides to Therapy for Medical Officers, issued on 20 March 1942, was under consideration by the Professional Services Division throughout 1943. It became evident that, in order to intelligently prepare such an manual, a tour of observation in a theater of operations actually involved in combat was necessary. Therefore, on 11 September 1943, a request for orders to visit NATOUSA (North African Theater of Operations, U.S. Army) was submitted and eventually approved. The purpose of this trip was to collect data for completion of the portion of the manual on anesthesia and data relating to maintenance of a proper balance in the program for training anesthesiologists and oxygen therapists. Orders were issued on 12 October 1943 by Headquarters, SOS, ETOUSA, and the trip was accomplished between 20 October and 20 November 1943.
A tour of duty in NATOUSA, for observational purposes in an active theater, proved to be interesting and instructive. This author observed hospitals in the vicinity of Algiers, Algeria, and Bizerte and Tunis, Tunisia, in North Africa; Palermo and Catania in Sicily; and Naples and Caserta in Italy. He also went as far forward as divisional clearing stations in Italy. Following his observations in the field, a report was submitted to the Chief Surgeon, ETOUSA, entitled "Impressions Gained During a Trip to NATOUSA and Fifth Army."
The author observed that there was a distinct shortage of trained and experienced anesthesiologists to take care of peakloads of casualties. Some hospitals were without the services of a trained anesthetist. The greatest need for thoroughly qualified anesthesiologists existed in units situated in forward areas, where the severest injuries were seen and treated. It was in the forward areas that anesthetists attached to auxiliary surgical groups were rendering the most and best service.
There was a great need for portable gas machines in each hospital platoon of field hospitals, where intermittent positive pressure was essential for adequate care of nontransportables. A real need for the same types of equip-
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. He 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 existing 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 systems, and thus a foot-operated vacuum pump was produced and supplied to augment suction pumps electrically operated in U.S. Army hospitals.
In NATOUSA, anesthesia practice was noted to be circumscribed by the lack of fully experienced anesthesiologists. This led to inexpert choice of agent and method for patients 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
FIGURE 225.-An ETOUSA resuscitator and ether vaporizer, developed at Depot M-400, Reading, England, by Maj. Fenimore E. Davis, MC, and Colonel Tovell. A. An experimental prototype, utilizing a gas mask canister. B. The final type incorporating a first aid kit container in place of the standard gas mask canister. The bellows bag was that originally designed for the Oxford vaporizer. A gas mask canister could be attached to the air inlet, right rear, in the event of a gas attack during operation. Liquid ether was delivered to the vaporizing chamber by syringe.
administration of spinal anesthetics in instances in which, with the services of an expert anesthesiologist, the same surgeons would have elected inhalation anesthesia. On the other hand, there was a tendency to employ Pentothal sodium (thiopental sodium) in contravention of known contraindications because of its ease of employment in periods of peakload. Lack of skilled anesthesiologists, adequately equipped to undertake administration of inhalation anesthetics employing carbon dioxide absorption and intermittent positive pressure administered 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 relieved. A second dose under these circumstances might be 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 lesions 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 problems of supply, the value of cyclopropane seemed obvious because the space 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 platoons functioning independently and set up adjacent to division clearing stations for the treatment of nontransportables. This circumstance, the author reported, would necessitate supplying field hospitals in the European theater with nitrous oxide, oxygen, and soda lime. He further recommended that provision be made to supply each auxiliary surgical group with 10 portable gas machines, 10 portable suctions, and the necessary gases for them. He suggested that these machines be distributed to those teams assigned to hospital units operating under peakload, and that first priority be given to thoracic, general surgical, and plastic surgical teams. Supplies of these items in hospitals were inadequate to cover the needs of the teams.
Practice in hospitals in North Africa and Italy working under battle conditions demonstrated the sagacity of planning to supply citrated blood from a blood bank established in a rear area. Such procurement made thorough
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. The 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. Hardin, MC, in charge of the operation. Major Hardin's organization ultimately provided blood for the initial stages of the invasion of northern France. Procurement of blood from troops in England, and later on the Continent, was continued even after an adequate line of supply was established with the Zone of Interior. During the campaigns in northern Europe, Major Hardin's organization continued to distribute blood throughout the theater. If a patient died, his death was attributed either to his having been given too much or too little blood or too faulty administration of the anesthetic. Seldom would surgeons admit deaths were due to wounding, and never, it seemed, would they admit that the surgical procedure was contributory. Major Hardin 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 transportation 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 1½ hours. He decided to accept the accommodation rather than wait 3 or 4 days 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 bucking 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 did not hold well. The plane was met over the Irish Sea by a JU-88 which attacked from the rear. It was a 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
P-40's, it was discovered that one wing had been pierced by a 20-millimeter shell. The shell had lodged between two wing tanks but had failed to explode. Fortunately, no one aboard was injured. It was theorized that perhaps a Czech had sabotaged the German war effort. This consultant realized that, although he was a noncombatant, he was not a neutral. Not many months were to pass before his status as a noncombatant would be brought into focus again. While he was accompanying a full complement of wounded in a C-47 from France to England, a "trigger-happy" American shore battery, located on the south coast of England, fired at the plane. The flight engineer quickly shot off a couple of identifying flares which were recognized by the gunners below. The firing ceased, and no damage was done. The pilot was exasperated. He said that he had approached the coast in the stipulated manner and was therefore totally at a loss to account for the action of the guncrews.
Many hoped that 1943 would be the year of action. This proved to be impossible; and, instead, the invasion of northern France was delayed until June 1944. The buildup for invasion started with the arrival of units of the First U.S. Army in the theater. It was immediately obvious that an accentuated program for training anesthesiologists was necessary. Three courses were held in 1944 at the 120th Station Hospital, Tortworth Court, the first from 17 to 22 January inclusive, the second from 21 to 26 February (fig. 226), and the third from 20 to 25 March inclusive. A fourth course was held at the 10th Station Hospital, Manchester, Lancashire, for Third U.S. Army personnel during the period 1 to 4 May inclusive. The average attendance was approximately 70, and at least half of the trainees were medical officers. The program was intensive; but, in retrospect, it seems to have been pitifully inadequate. Nevertheless, the writer is still confident that much was accomplished in the way of orientation. The many officers who participated as lecturers deserved commendation for their effort.
D-DAY AND ITS AFTERMATH
It is a well-known historical fact that D-day occurred on 6 June 1944. On 23 June, the author reported to the Chief Surgeon his impressions gained since D-day. It was with real satisfaction that this consultant was able to state that in all echelons anesthetic equipment had been adequate with only a few shortages of one or another article in isolated instances (fig. 227). Likewise, oxygen-therapy equipment had been adequate to meet the immediate need on the Continent. Once again, however, the problem of supply had raised its ugly head. Adapters for use on British cylinders were found to be lacking in some units equipped with complete hospital assemblies shipped directly from the Zone of Interior. Fortunately, adapters were available to cover these deficiencies. American cylinders were still being used in many fixed facilities in the United Kingdom. As a result, Col. Silas B. Hays, MC,
FIGURE 227.-Central oxygen and nitrous oxide manifolds which supplied the four operating theaters at the 298th General Hospital (University of Michigan unit) at Frenchay Park, near Bristol, England. An anesthetic machine of British origin is in the right foreground.
chief of the Supply Division, Office of the Chief Surgeon, recalled both empty and filled cylinders from U.S. hospitals in the United Kingdom for transportation to the Continent. The 130,000 beds distributed in over 100 hospitals in the United Kingdom were supplied with gases contained in British cylinders. The most evident need for equipment during the first fortnight of the invasion was for suction apparatus. Tables of equipment were not adequate to cover needs. American equipment could not be used in Britain in wards wired with 230 volts without utilization of transformers, and transformers were not freely available. The need for foot-operated suction, first recognized in North Africa, was once again evident.
Pentothal sodium was the agent most frequently used in all echelons and with general satisfaction and safety. In certain isolated instances, anesthetists had been influenced to use this drug under unwarranted circumstances, such as the incision and drainage of a phlegmon of the neck. Spinal anesthesia was used in general hospitals providing definitive treatment but was seldom
used for the treatment of those recently wounded. This consultant received the impression that, although fluids had been freely administered, undertreatment rather than overtreatment existed. In one area at least, supplied from British sources, blood in relation to plasma was being used in the ratio of 10 units to 1. At the time, this was considered a nonjustifiable depletion of supplies of blood, but, as the campaign progressed, the need was more and more easily justified.
VISIT TO NORMANDY
During the first week of July, this consultant visited hospitals in Normandy, and a report of observations was prepared. He noted that some evacuation and field hospitals were in the process of packing in preparation for moving forward while other hospitals still remaining in operation were working beyond the limits of their capacity. One 400-bed evacuation hospital had 520 patients on its second day of operation, with a preoperative backlog of 250 to 300. This was due to a special circumstance: Its normal line of evacuation was over Utah Beach and the airstrip intended for evacuation of the wounded was needed for fighter squadrons. It was recognized that evacuation by hospital carrier might take as long as it would take to work down the backlog of preoperative patients. A problem in sorting, therefore, existed in regard to selection of patients to be transported by surface carrier to Great Britain and patients to remain with the unit for surgical treatment.
A platoon of the 13th Field Hospital was visited and found to be not too busy. It was supported by two teams from the 3d Auxiliary Surgical Group. Equipment was adequate to meet needs with the exception that Shell Natron canisters were lacking for closed-circuit oxygen therapy apparatus. These teams had had no deaths on the operating table. A neighboring unit, the 16th Field Hospital, Normandy, France, was attached to and working with the 67th Evacuation Hospital, while awaiting the arrival of equipment. This unit had been in active operation in Egypt. The 47th Field Hospital, Normandy, France, was likewise awaiting the arrival of its equipment, which its personnel knew lacked gas machines and equipment for oxygen therapy. This unit, originally belonging to the Third U.S. Army, had arrived last and had been assigned to the First U.S. Army. This circumstance accounted for failure to obtain those supplementary items authorized for First U.S. Army units in the European theater. A lack of coordination between the efforts of attached auxiliary surgical group teams and the personnel of a platoon of a field hospital was in evidence. Two units never do well under one roof unless the commanding officer of the facility has full coordinating control. This matter was reported for policy decision in relation to field hospitals.
Pentothal sodium was being used in approximately 75 percent of the operations. Oxygen was frequently given for support. For the longer procedures, nitrous oxide and oxygen was given, and ether was employed to produce relaxation. The muscle relaxants of the curare series were not available at the time.
It was also quite the usual practice for hospitals to prepare atropine-morphine and Pentothal sodium in bulk. This practice resulted in the conservation of valuable time, facilitated preliminary medication in the 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 l-gram ampules seemed extravagant in terms of supplies and also in the time required to make the preparation. This consultant suggested that Pentothal sodium might well be obtained in 10-gram ampules and that distilled water for its dilution could better be supplied in bottles containing 500 or 1,000 cc. In one instance, faulty filling of a cylinder constituted a problem. An officer of the 3d Auxiliary Surgical Group reported that a cylinder, marked "Oxygen" and painted black with white neck like its British standard, contained-in actual fact-carbon dioxide. When the gas was employed, it produced cyanosis following a period of hyperpnea. This was recognized, the contents of the cylinder were emptied, and the cylinder was returned for refill. No patients suffered. This circumstance was another 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 blamed as when Pentothal sodium was employed. 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 be interested was the time between eating and wounding, rather than wounding and operation, because digestion was inhibited immediately after wounding. This author advised that accidents due to aspiration could, in some instances, be prevented by initiating vomiting prior to induction of anesthesia. Attempts to wash a stomach with a Levin 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 supply, this consultant expressed the hope that the ratio of plasma might be raised to 2 units for 1 of blood. Along this line, he also noted that, during hot weather or when patients were perspiring or vomiting, there was a very real need to replace chlorides by the administration of normal saline. A common complaint was that the needles in plasma 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 fibrim. Pressure was necessary to maintain 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-caliber 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
patients in widely dispersed parts of preoperative tents and failed to treat shock adequately. This consultant advised that it was desirable to segregate patients needing major effort in the treatment of shock in order that the medical officer in charge might be able to keep them under his direct supervision at all times. He further advised that an officer with mature experience be assigned to these duties. Surgeons found it impossible to maintain continuity of observation between operations. It was with these matters in mind that a senior consultant ended his first tour of duty to the Normandy beachhead on 8 July.
MOVE TO THE CONTINENT
On 28 August 1944, movement of the Professional Services Division, Office of the Chief Surgeon, to the Continent began. Travel was accomplished by train to the marshaling area near Southampton, thence by boat to Utah Beach, and lastly to Headquarters, Communications Zone, at Valognes, France, by truck. The group was delayed for 3 days en route at the marshaling area because the ship on which it was scheduled for transport to France had no accommodations for females. The party included two, the chief nurse and Capt. (later Maj.) Marion C. Loizeaux, MC. The party was subsequently assigned to a Victory Ship, carrying some 1,500 troops, packed like sardines in a can. The passage across the English Channel occupied 24 hours because of the circuitous route that the ship was forced to take in order to avoid minefields. Off Utah Beach, the travelers were transferred to a tender. This transfer necessitated climbing down a rope net to the deck of the tender which was in constant motion. For a landbound Army man, this was a new experience. Fortunately, the operation entailed no injuries to any of the group. From the tender, the members walked ashore over the hardstand, getting no more than their feet wet. The evidence of sunken ships and the litter of destruction on the beach were still present, reminding all of the contrast between the ease of their landing and the difficulties in the original invasion by shock troops.
As they proceeded inland, it was obvious that the Army had accomplished a great deal in clearing away the bits and pieces of gliders forced to land in fields that were too small because all the larger fields had been well planted with "Rommel's asparagus," posts approximately 8 feet long imbedded upright in the ground at regular intervals. The purpose was to prevent the very landing that occurred in spite of this enemy action. It was amazing how thoroughly an Army in combat was able to clean up its new backyard in the less than 6 weeks that had elapsed between this consultant's first trip to the beachhead in early July and the permanent transfer of the Office of the Chief Surgeon in August. Not only had the superficial evidence of destruction occasioned by the invasion been removed, but the fields had been cleared of mines as well. This total area had been cleared to provide space for incoming troops and the buildup of a major supply base.
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. He 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 and personnel 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, his work in the main would be confined to facilities (60,000 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:
As rounds of hospitals and auxiliary surgical groups were made, it was apparent that accessory equipment beyond their authorized allowances would facilitate their operations. The primary need was for a manually controlled apparatus 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 been received, 500 from Down 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 preinvasion period, hospital commanders and their chiefs of surgical service were urged, throughout the 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 the units were assigned their combat support 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 ordered to undertake the training of one medical officer and one nurse in anesthesia. Col. (later Brig. Gen.) Charles B. Spruit, MC, Surgeon, United 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 subject to reassignment to units in greater need of their services. In November 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. In the latter instance, the more skilled anesthesiologist of the operating unit was reassigned to the new general hospitals. The rate of attrition among anesthetists throughout the theater
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 be 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 period of temporary duty in forward area hospitals. As a result of this exchange program, the experience of anesthesiologists involved was broadened, and each had an opportunity to observe at first hand the problems 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 immediately after each 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 wounded. Copies of three films, prepared by Dr. I. W. Magill and Dr. G. S. W. Organe of London under the sponsorship of Imperial 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 groups. Attempt was made through the Office of The Surgeon General to obtain copies of training films produced in the Zone of Interior, but information was subsequently received that shipment of these training aids overseas was not possible.
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 problems. The character of wounds and injuries changed. The incidence of exposure was magnified. Frostbite and trenchfoot became prevalent. It was necessary to caution that doses 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 patients to be evacuated by air, or in the presence of jaundice, craniocerebral
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 warmed and were given fluids to alleviate shock.
It was necessary to issue an administrative memorandum that the administration 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 distributed to the Senior Consultants in Maxillofacial Surgery, Neurosurgery, Orthopedics, and Dermatology with the request that the method 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 severe burns might be similarly helped without the production of respiratory depression. Sedation in the presence of involvement of the tracheobronchial tree due to inhalation of smoke and noxious vapor was recognized as a difficult problem. The incidence of burns proved to be 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 obtained in many instances. This experience led to the administration of procaine hydrochloride 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, the 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 rapid reduction 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 percent. 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 presence of cold exposure of extremities or trenchfoot was essentially noncontributory to improvement. Statistical data regarding the incidence of utilization of other anesthetic agents and methods have been reported elsewhere.1
The problem of promoting anesthesiologists became more acute throughout the year, and no solution was found. A new table 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. He also pointed out that modern anesthesia demanded adequate training and experience if the lives of the sick and wounded were to be adequately protected. He 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 Committee on Anesthetics held at 1 Wimpole Street, London, afforded an opportunity for the interchange of information among consultants to the Ministry of Health, Scotland; the British Army, the Royal Navy, and the Royal Air Force; EMS hospitals; and the 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.
From time to time throughout 1944, material was prepared for submission to the Office of The Surgeon General regarding the adequacy of equipment and supplies for anesthesia and oxygen therapy. This material was forwarded in ETMD (Essential Technical Medical Data) reports that proved to be an important medium for the submission of information to the Office of The Surgeon General. On 29 January 1945, a memorandum was submitted to Colonel Cutler 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 (presumed) for the investigation of a severed peroneal nerve and the other during the administration of a sympathetic block. These deaths had occurred at different hospitals. At the hospital where the death occurred following subcutaneous injection in the popliteal region, another patient exhibited convulsions of a severe nature but recovered under appropriate therapy. It was pointed out that the prevailing practice of supplying procaine hydrochloride in bulk led to difficulties in preparation and identification of solutions of proper concentration 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 effectiveness of the resulting solution. As a result, there was a tendency to use a stronger solution than was justifiable for infiltration. Under these circumstances, toxic doses were rapidly approached. It was recommended that serious consideration be given to a change in policy in supplying procaine hydrochloride. It was believed that many of the sources of hazard would be eliminated if the drug were supplied in ampules containing 1.0 gm. in 5 cc. of solution. Such ampules could be sterilized by immersion in any approved colored antiseptic solution. The proper dilution could be achieved using either sterile water or sterile normal saline in quantities of 95 cc. to produce a solution of 1.0 percent or 195 cc. to produce a solution of 0.5 percent concentration. This was the type of material that was submitted in the ETMD reports.
The ETMD reports moved on a "two-way street." Difficulties encountered in the use of piperocaine hydrochloride (Metycaine Hydrochloride) for spinal anesthesia were reported. In the ETOUSA Manual of Therapy, issued 5 May 1944, a table of dosage for tetracaine hydrochloride (Pontocaine Hydrochloride) and procaine hydrochloride combined, procaine crystals dissolved in spinal fluid, and Metycaine Hydrochloride in spinal fluid was outlined. The dose of Metycaine Hydrochloride was limited to a maximum of 140 mg. 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 acquainted with these problems because parallel difficulties had been experienced in the Zone of Interior. On 16 June 1945, a memorandum from the Supply Division to the Professional Services Division drew attention to Section VI of War Department Circular No. 134, dated 4 May 1945, which stated that Metycaine Hydrochloride would
no longer be employed in Army hospitals in any form. Major Davis, acting for this author, replied to this memorandum on 18 June 1945 and advised withdrawal of Metycaine Hydrochloride from issue in the European theater.
Material submitted for the ETOUSA Essential Technical Medical Data Report for the month of April 1945 included a statistical summary of anesthetics administered during the period 1 June-31 December 1944. Comment regarding this summary was as follows:
Although field blocks including local infiltrations were employed less frequently during November and December 1944 than they had been in the previous five months, the incidence of employment of specific regional blocks increased in all types of hospitals, the greatest increase being in evidence in evacuation hospitals; and significantly in evidence in Field Hospitals. The overall average of employment of specific regional blocks increased from 1.43 percent to 2.57 percent. This, too, is considered to be a development in a desirable direction because with proper organization of the section on anesthesia, the time lag between operations can be decreased. Patients maintain full control of their own airway, dehydration through vomiting is not increased as it may be after inhalation anesthesia, nursing care is kept at a minimum and patients are immediately evacuable, if that is necessary.
Incidence of employment of sympathetic block increased in all types of hospitals with the exception of field hospitals. This was in the main due to the increased incidence of "trench foot." Present opinion regarding the efficiency of sympathetic block for the treatment of trench foot is extremely guarded. It is felt that in no instance did the accomplishment of a sympathetic block tend to increase the patient's debility insofar as his injury was concerned. In the vast majority of instances, however, it could not be thoroughly established that accomplishment of sympathetic block improved the patient's rate of recovery. One death occurred during the accomplishment of stellate ganglion block undertaken for relief of peripheral vascular inadequacy of the upper extremity. This death was probably due to inadvertent injection of procaine within the dural sheath where prolongation of the sheath existed and protruded through the foramen.* * * * * * *
Pentothal supplemented by other anesthetic agents was the method that was employed more frequently in November and December than in the previous 5 months in all types of hospitals except field hospitals. Statistical data in relation to field hospitals has not been broken down on the basis of their working status, but it is known that throughout November and December a greater number of them were working as Communications Zone units doing station hospital work. In many instances, these units so employed lacked the benefit of skilled anesthetists where auxiliary surgical teams were not attached.* * * * * * *
It is obvious from these statistical data that the best qualified anesthetists should be assigned to auxiliary surgical groups and evacuation hospitals. * * *
Changes in T/O&E 8-580, 31 January 1945, for 750-bed Evacuation Hospitals are also considered to reflect experience encountered in this theater. However, inclusion of only one nurse anesthetist is inadequate to meet the needs for 24-hour operation of 10-12 operating tables. Six nurse anesthetists for such a union represents the minimum number required and then it would be necessary to orient three or four other nurses into the intracacies of anesthesia or else depend upon augmentation by personnel from auxiliary surgical teams. Experience has been that seldom is it necessary for 750-bed evacuation hospitals to be thus augmented. In the 2d Evacuation Hospital, 10 nurses have been oriented in the administration of anesthetics.* * * * * * *
Comment in a similar direction was made with regard to 400-bed evacuation hospitals. It was 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 group 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 hanging, and still others in the furnaces that had been erected immediately above the gas chamber. A pile of human ashes, 6 feet high, was seen. The condition 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 had 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 inhumanity 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 to Paris, and because of some confusion in the announcement of V-E Day the French people were one
day late in their celebration. Therefore, he had the opportunity to participate again in this gala event. He spent the evening observing the festivities. At 2300, he was walking down the Champs Élysées 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 he knew of the short rations that existed among the French population in Paris. He explained that he 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 brought with it, its problems. The war was not over; Japan still remained to be 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,
ETOUSA. It was the intent to continue this system at the specified hospitals as 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 papers, exchange of ideas, and discussion of problems were thus to be made possible. In addition, the center consultant was to be authorized to make rounds of each hospital in his area in order to check on the organization, practice, and training within the section on anesthesia and operating rooms of each unit. Furthermore, each hospital center was to receive four medical officer 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 order to support the senior assigned 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 be established.
For the United Kingdom Base Section, a similar program was suggested and initiated. The ETOUSA 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 temporary duty for 60 days 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 Dr. Andrew Tindal. Similar facilities, it was suggested, could be made available through Professor Macintosh, head of the Department of Anaesthetics, 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 Anaesthesia,"
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 mm. to 16 mm. 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 W. Searles, MC, 5th General Hospital, was in 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 H. 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 just 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 and 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.