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ACCESS TO CARE
Chapter II - continued
serving the Soviet people and their ways were quite unique at this time-a time when the Soviet Union was allied with the free world against a common enemy, when its people had undergone an untold amount of suffering, yet had remained steadfast in their determination to resist the Nazi aggressor and had actually begun to turn the tables on the Wehrmacht on the Eastern front. Under the dateline of 7 August 1943, Colonel Cutler wrote the following to Ambassador Winant:
The opportunity to enter Russia and contact people there inevitably led to certain impressions' being created in the mind of the visitor and since these thoughts may be of value to the State Department I have tried to put them into writing.
We were shown every courtesy officially and we gathered the impression that those with whom we came into contact were delighted that we had come. Intimate contacts and dinners up the line with the army officers of our own rank and responsibilities made us feel quite at home and at ease. Every opportunity was given us to see the things we asked to see, both in Moscow and when forward with Army hospitals, but all the time one felt that there lay over the officials taking us about an iron hand, which made them cautious in their remarks and which often led to a change of conversation in an abrupt fashion. Thus, on several occasions when we asked questions and the conversation started to give us the answer, the Vice Commissar who accompanied us would make a remark and the conversation on the question ceased and began on some totally unrelated matter. It was as if only special people could speak on special problems and that no one was ever allowed to express an opinion beyond his own special field where the problem had been set to him by someone "on top."
This impression of a strong "fist" on top was strengthened by observation of the mission in Moscow itself. The people were not cheerful. They kept their eyes fixed on the ground as a rule. Of course no independent Russian could talk to us, because were a Russian seen talking to a foreigner he would immediately be taken aside and, if not punished, certainly have a difficult time. Up in the army there was a different feeling. It was as if they were away from that threatening something overhead. The people were cheerful; they laughed; they had simple dances, and seemed entirely happy.
The power of this something overhead turned up in many ways. In intimate discussions with General Martel, the British military attache or observer in Moscow, who seemed to get on very well with the Russian Army officers, it was quite clear that his dealings with the army were very satisfactory, but that when something had to come out of the army and go to the Government in Moscow, then everything was different.
A further sense of the overhead power came to the mission directly. We flew into Russia in a British plane, which was I believe the second plane on this southern route, and which we were told had all been arranged for through the Ministries. Our plane was to return for us in 2½ weeks. It reached Teheran but was never allowed to enter Russia and a great deal of diplomatic tangling went forward. Apparently the British had signed the agreement for this southern route but had not signed the agreement for the northern route. The Russians wanted certain things added to the northern route agreement and when the British refused to sign this, then they refused to sign the southern route agreement.* * * * * * *
My own personal observations of the Russian character were that he was really [a] pretty frank, open, very direct and entirely rational person. He had not forgotten the official attitudes of the U.S.A. and Britain toward his country a few years back. He was not going to be fooled again, and he was going to stand on his own feet. Moreover, he had suffered horribly during this war, certainly more than 6 million casualties and perhaps 8 million. He confidently expected to win the war, and to win the war alone if necessary, but would like our help. Everyone spoke of our starting a second front. They don't think
the Mediterranean fights were much, and were glad to quote to us the battle casualty figures as measurements of that effort. They refused to speak of the Japanese war, though they knew of its existence. However, it should be said in defense of the opinion of the ordinary Russian that their newspapers and their radio announcements don't give very much information concerning what was going on in the war except in Russia. The propaganda about Russia was tremendous and the personal propaganda for Stalin and Molotov was equally conspicuous. Each room in every hospital up the line, let alone the places in Moscow, contained a picture of very large size of both Stalin and Molotov.
I took the occasion to remind the Commissar, when he spoke as though we were doing nothing, of the efforts of ourselves and our allies, the British. I must say he took this smilingly, said he knew of all our efforts and thanked us. At the same time I am sure none of this would ever get to the people.
My impression of Russian medicine was that it was good, not excellent, but surprisingly good in view of what we had been led to think of them. Their effort in medical education is enormous, and though 90 percent of medical graduates are women, 40,000 were graduated from Government medical schools last year, and these students go through a six year course.
Finally, I came back with a very strong impression that Russia is a really good country with fine people in it, who are bound to take their rightful place as one of the great peoples in the coming civilization. Anyone who fails to take this into consideration and who deals with them with old fashioned diplomacy and not honesty and directly will fail miserably and to the discomfort of his country. We are fortunate in having in Moscow such a directly spoken man as Ambassador [William H.] Standley. He serves his purpose well and is regarded with affection and esteem by the Russians. They like his honesty and frankness and even when he speaks to them contrary to their desires they take it well because of that honesty and frankness. Because of this he stands out among the diplomats at Moscow. He has of course a tremendous advantage in having in Moscow General Faymonville, who apparently is admitted by the British as well as the American people there [to be] the one person persona grata with the Russian people, both the ordinary people and the government. One cannot speak too highly of the eminent qualities of these two citizens who serve our country so well in Russia.
Late 1943-Early 1944
Thus wrote Colonel Cutler in his diary on 15 May 1944, a few weeks before D-day in Europe: "Time flies with increasing agility. The deluge will be upon us soon and will we be ready? No, never fully satisfied, but to begin is something."
These few words truly characterize this period for the Chief Consultant in Surgery. The pace was quickening upon his return from the Soviet Union. At the turn of the year, it had definitely accelerated. By May 1944, the surge of activity was a headlong gallop to the day of destiny-D-day, Europe, 6 June 1944.
During this period, American Forces in the United Kingdom were built up from a few divisions to those making up the First U.S. Army with supporting troops and the nucleus of the Third U.S. Army. In August 1943, upon his return from the U.S.S.R., there were 6 general hospitals, 17 station hospitals, and 2 evacuation hospitals in operation. A few months later, at the beginning of 1944, these had been increased to 17 general hospitals and 34 station hospitals actually in operation. The final SOS plan for mounting the assault on
fortress Europe called for 79 fixed hospitals in the United Kingdom alone. This figure did not include those medical units staging to be moved to the Continent at the first opportunity or the evacuation, field, and convalescent hospitals assigned to the armies.48
This expansion of the theater troop basis required reorganization and decentralization. Hospital centers were created to operate groups of hospitals. Base section surgeons were given almost complete control over medical facilities in their areas, except for the control of beds in general hospitals. Colonel Cutler had to expand the consultant system to provide for consultants in these centers and base sections. The growth in numerical strength of troops and units and the delegation of many functions to lower echelons shifted the emphasis of activities in the Office of the Chief Surgeon, including those of the Chief Consultant in Surgery, from direct supervision to that of liaison, coordination, and the development and enunciation of policies.
Conferences.-This change in emphasis meant that Colonel Cutler had to attend more routine staff conferences. Weekly meetings of all the consultants in the Professional Services Division were held, preceded by preliminary meetings of the surgical and medical consultants held separately. On each fourth Monday of the month the consultants and the Chief of Professional Services met with the Chief Surgeon. There were also fortnightly meetings of base section surgeons, and the weekly staff meetings instigated by Colonel Spruit after he became Deputy Chief Surgeon at Cheltenham. Starting in January 1944, General Hawley held weekly meetings with his division chiefs, which Colonel Cutler usually attended with Colonel Kimbrough.
In addition, there were the regular RAMC meetings which Colonel Cutler attempted to attend with regularity, especially as the day for the invasion drew ever nearer. There was no consultant in surgery appointed by the Americans at the Allied Supreme Headquarters level, and Colonel Cutler, by mutual understanding of all concerned, acted in that capacity: (1) Through his superior officers and staff at the theater level, (2) through Maj. Gen. Albert W. Kenner, MC, USA, Chief Medical Officer, SHAEF (Supreme Headquarters, Allied Expeditionary Force) (fig. 43) and (3) in meetings of the various committees of the British AMD and EMS.
Changes in senior consultants -Colonel Zollinger served as Acting Chief Consultant in Surgery in the European theater during Colonel Cutler's visits to the U.S.S.R. and, later, to NATOUSA (the North African Theater of Operations, U.S. Army). After Major Storck's return to the United States, Colonel Zollinger was appointed Senior Consultant in General Surgery. Maj. (later Lt. Col.) John N. Robinson, MC, 2d General Hospital, was appointed Senior Consultant in Urology, in addition to his other duties, since the supervision of urological activities in the theater had grown to be too great an activity
for Colonel Kimbrough to perform in addition to being Chief of Professional Services. Col. Roy A. Stout, DC, was appointed Senior Consultant in Maxillofacial Surgery on 8 November 1943, relieving Colonel Bricker of these duties; Colonel Bricker remained Senior Consultant in Plastic Surgery and Burns. Maj. (later Lt. Col.) John E. Scarff, MC, 2d General Hospital, served for a considerable time as Acting Senior Consultant in Neurosurgery during Colonel Davis' trip to the U.S.S.R. and after his return to the United States. Finally, on 15 March 1944, Lt. Col. (later Col.) R. Glen Spurling, MC, arrived in the theater and was appointed Senior Consultant in Neurosurgery. Lt. Col. (later Col.) Mather Cleveland, MC, arrived from a previous assignment as a service command consultant in the Zone of Interior and in May 1944 was appointed Senior Consultant in Orthopedic Surgery replacing Colonel Diveley, who, in turn, became chief of the Rehabilitation Division.
Significant activities -Items of significance during this period, insofar as they involved Colonel Cutler, included various measures to get ready for the invasion of the Continent-Operation OVERLORD, further developments in the effort to provide whole blood for combat operations, extensive study of the efficiency of penicillin, a trip to the North African theater, discussions with The Surgeon General on the closure of wounds and amputations, and the expansion of the consultant system. These are discussed separately, but the
following items of no less importance, though perhaps more limited in scope in some instances, were also his concern.
American Medical Society, ETOUSA -Following the August general meeting of the American Medical Society, ETOUSA, General Hawley informed Colonel Cutler that the general monthly meeting of the society could no longer be held after the one for the current month. He suggested means of having smaller, decentralized meetings. As a result, the responsibility for forming local societies and holding meetings was eventually decentralized to the base sections. With decentralization, however, there was a lack of coordination with the result that areas for local societies were overlapping, and so forth. Originally, Colonel Cutler had been told, the intent was to have a society completely independent of any control from the Chief Surgeon's Office, but a coordinating center had to be established. Actually, this coordination, Colonel Cutler thought, benefited the local groups since it provided services such as helping to formulate programs, obtaining guest speakers, and collecting papers from local meetings for forwarding to appropriate individuals and offices within the theater and, in some cases, to the Office of The Surgeon General. The last general meeting during this period was held in January 1944 at Widewing, Eighth Air Force headquarters. At a business session of this general meeting, Colonel Wright, Chief of Professional Services for the theater Army Air Forces, was elected president of the society.
Throughout this period, there were many stimulating meetings held locally in the various base sections (fig. 44). Colonel Cutler and his consultants were able to attend many of these local meetings and were gratified to find participation at the grass-roots level extremely healthy.
Education and training -The European theater Medical Field Service School at Shrivenham continued with its full curriculum, as didthe Air Force school at "Pinetree." The London tours course was discontinued before the Americans "wore out their welcome" at the busy London hospitals. In spite of some initial reticence on the part of the Chief Surgeon and his Education and Training Branch, a very extensive program in the training of anesthetists was begun under the direction of Colonel Tovell, Senior Consultant in Anesthesia. Colonel Diveley, as Senior Consultant in Orthopedic Surgery, initiated a badly needed course of instruction in plaster work (fig. 45). This instruction was carried out in 3-day periods, mostly for medical officers of the First U.S. Army.
Selected U.S. Army medical officers were sent to the various courses at the British Post-Graduate Medical School in continuation of a program which had been established in the very earliest days of the theater. The courses which were being offered during this time in successive weekly intervals were: Recent advances in war injuries, treatment of fractures, war surgery of the nervous system, war medicine, war surgery of the extremities, surgical care of the soldier in training, war surgery of the abdomen, and war surgery of the
FIGURE 44.-A demonstration of an improvised splint for a fractured jaw at the meeting of the American Medical Society, ETOUSA, at the 315th Station Hospital, Axminster, Devon, England, on 22 March 1944.
chest. Mr. Tudor Edwards' 2-week course in thoracic surgery for American medical officers was likewise continued at several British thoracic surgery centers in and around London. The British Army Blood Supply Depot continued to accept a limited number of U.S. Army medical officers for training in the principles and techniques of bleeding, processing, storing, refrigerating, and shipping whole blood-together with the clinical aspects of shock, whole blood transfusion, and resuscitation.
The previously stated policy of General Hawley that specialists would not be trained in the theater had to be modified, upon the insistence of Colonel Cutler and the other consultants, to allow for the further training of those who had had some preliminary training in a surgical specialty. The instruction was conducted at selected station and general hospitals for individuals or small groups. The length of instruction was flexible, as was the scope of instruction, and was dependent upon the advice of the senior consultant concerned.49
Monthly report of surgical service -In order to maintain a closer touch on the pulse of surgical activities in the theater-something which was exceed-
ingly necessary because of the decentralization of activities and the impossibility of the theater-level consultants personally supervising all surgical activities-Colonel Cutler had Colonel Zollinger, Senior Consultant in General Surgery, devise a monthly report of surgical services to be submitted by all fixed hospitals in the theater. A daily operating room log was also devised to be used as a standardized record in these hospitals, a log which would permit easy compilation of the monthly surgical report. The reporting requirement was approved by the Chief Surgeon and promulgated on 12 March 1944.50
From the outset, the report proved very satisfactory, and Colonel Cutler was most pleased by the control it offered. He reported in the monthly Essential Technical Medical Data report for April 1944, as follows:
The report may from time to time be inaccurate, but it should prove informative and should provide us with information concerning the relative incidence of wound infections, battle injuries and nonbattle injuries in the various specialties.
In a recent report * * * the number of whole blood transfusions amounted to 172. Of these, 168 came from stored blood in a blood bank in a hospital. At the same time 637
units of dried plasma were given. In this first monthly surgical report we computed the incidence of wound infections in six of the seven hospitals in East Anglia where airmen injured in missions over enemy territory are treated:
The above is a sample of the control such a simple report has on professional work.
This report was received from all hospitals in the communications zone for the entire period of the war-hospitals in which most of the reparative surgery provided in the theater was conducted. The last report submitted by these hospitals was for the month of May 1945.
Activities in conjunction with Army Air Forces -One of the first things Colonel Cutler did upon his return from the U.S.S.R. was to tour each of the hospitals which had been established primarily to serve the Air Force (fig. 46). These were at this time either in full operation or just about ready to start operations, and the Air Force medical staff in the theater was very pleased with the results. For one thing, the surgical service at these hospitals had to be first rate because they were treating air combat casualties, and Colonel Cutler had done everything in his power to make them so. However, the growth of the air arm, which paralleled the buildup in the theater of the other arms and services, soon outstripped the services these hospitals could provide. As more heretofore standby airfields were activated, their distance to hospitals became a serious problem in the eyes of the Air Forces, and, in spite of other priorities, General Hawley gave first consideration to building and activating additional hospitals to serve them. The duty of seeing that the surgical service in these hospitals included the required high-grade professional personnel befell to Colonel Cutler and his consultants. The providing of this personnel became a most difficult undertaking when well-qualified individuals were required to augment the staffs of newly arriving hospitals with very little specialized talent and when surgical teams which had been attached to the hospitals serving the Air Forces had to be withdrawn in preparation for the land campaign on the Continent.
In addition, as the Air Forces in the theater grew, it became necessary for the theater Air Force medical staff to supervise activities on a broader, less personal scale. Consequently, the theater consultant staff was called upon from time to time to help formulate policy and write professional directives which were issued by the theater Air Force commander, or by the Surgeon, General Grow. One of these, personally worked out by Colonel Cutler, was a basic directive on the reception and initial treatment of casualties at airbases.
FIGURE 46.-Hospitals established primarily to serve Army Air Forces in England. A. The 160th Station Hospital in Lilford Hall, Northamptonshire, England. B. The 348th Station Hospital, Grantham, Lincolnshire, England, a model tented hospital. All concrete pathways and flooring were planned and laid before the tenting was erected.
Maj. Gen. David N. W. Grant, the Air Surgeon, visited the theater in September 1943 and in March 1944. General Grant was an avowed advocate of a separate medical service for the Air Forces, but he was forced to admit-upon advice of the Eighth Air Force medical personnel-that arrangements in the theater were as satisfactory as they could be under existing circumstances and did not require any immediate major change. Colonel Cutler was pleased at this outcome and felt pride in having done much to cement this cooperative close relationship-largely through his associations with Colonel Wright and, also, through his intense interest in the combat casualties of the Eighth Air Force (fig. 47).51
Study of casualties with respect to causes of death and causative agent -Colonel Cutler had urged since his early days in the theater that provision be made for the study of wounds and wounding, the distribution of wounds, and the relationship of wounds to the causative agents. In his reports to the Chief Surgeon and The Surgeon General, he had always tried to indicate at least the distribution of wounds (regional frequency) whenever the data were amenable to such a tabulation. In his trip to the U.S.S.R., he had made it a point to obtain some data on the Soviet experience in the frequency by which various regions of the body were hit. Shortly after his return from the Soviet Union, he formally suggested that a group be established for the purpose of studying the wounds of war. The minutes of the Chief Surgeon's 23 August 1943 meeting with his consultants show the following discussion on this proposal:
The Surgical Subcommittee's proposal to establish a pathological group for the study of fatality statistics in the army was discussed. Colonel Cutler pointed out that the group might serve a double purpose; i.e., to find out what kind of wound causes death, and what kind of missile causes the wound. He felt that some valuable findings might result, and that the group might work with the graves registration people. Colonel Spruit said that the responsibilities of the medical department were directed in one line-to get men back to duty. He felt that there were two aspects of the proposal, (a) That this pathological group would have to be put in the front line, and that the Division would have the burden of carrying them along, and (b) That if the scheme was practicable it might prove valuable, but that at present it was only possible to formulate ideas.
Finally, Maj. Gen. Norman T. Kirk, The Surgeon General, officially announced the need for obtaining such information in an article prepared for the Bulletin of the U.S. Army Medical Department.52 In January 1944, however, before publication, copies of the article were sent to all theaters of operations requesting that programs for the collection of data on missile wounds be set up.
Colonel Cutler again recommended that teams consisting of pathologists and enlisted men be set up to collect and make studies along these lines. But it was not until The Surgeon General visited the theater in March 1944 that
sufficient impetus was given to the program to bring forth General Hawley's approval for the establishment of a casualty survey team in the theater. On 2 April, Colonel Cutler stated in a memorandum to Colonel Kimbrough:
For about a year the Professional Services group have, at the approval of General Hawley, continued studies of how to implement a group of people acquiring information as to what killed men in battle, and where they were hit when injured. During the recent visit of The Surgeon General and General Grant, a discussion of deaths in airplanes while on missions over enemy territories led to the finding that personnel arriving dead were not autopsied. I was then instructed by General Hawley to set up a group for such studies.
It so happened that Maj. Allan Palmer, MC, chief of the pathology service, 30th General Hospital, had accompanied Prof. S. (later Sir Solly) Zuckerman of Oxford University on a special casualty survey mission to Italy and was well initiated in the procedures involved in conducting with rigid scientific precision the necessary studies to provide useful and meaningful data on war wounds. Major Palmer was assigned to Colonel Cutler to undertake the organization and establishment of a team to study casualties and the killed in action. Since, at this time, the only fresh casualties being received in the theater were the result of air combat, Major Palmer's unit-called the Medical Operational Research Section, Professional Services Division, Office of the Chief Surgeon-was established at the Cambridge American Military Cemetery with full facilities for conducting autopsies of the Air Forces' dead, making photographic studies, and preserving specimens.
One stumbling block in the building of the laboratory, it is interesting to note, was the fact that there was a stately and ancient tree growing exactly in the middle of the plot of ground which had been designated for the laboratory building. Apparently, Dr. Rosamond E. M. Harding, the owner of Madingley Hall, Cambridgeshire-the estate within which the cemetery was located, had specified that the U.S. Army could use the grounds but that no trees would be cut down. The U.S. Army Engineers, accordingly, steadfastly refused to cut down this particular tree so that Major Palmer's laboratory could be built. Finally, it was necessary for Colonel Cutler to call on Dr. Harding personally. This he did on 30 April 1944. The visit, which was most pleasant, ended with talk over the possibility of Dr. Harding's coming to America to see Colonel Cutler after the war in order to continue certain studies she was interested in. The tree was cut, but such were the duties of a Chief Consultant in Surgery that they often carried him far afield from the hospital operating rooms.53
Free-French surgical teams -Late in this period, a group of eminently qualified French surgeons, refugees in England, volunteered their services for the impending attack on the European mainland. They were welcomed by the Chief Consultant in Surgery who initiated the necessary steps to organize, activate, and equip them as mobile surgical teams. It was contemplated that they could most gainfully be employed in support of the Free-French Forces which were scheduled for participation as a part of the Allied effort.54
"Vetting" newly arrived units -Especially characteristic of this period was the necessity on the part of all the theater-level consultants to meet and evaluate the professional capabilities of the numerous medical units newly arriving in the theater. This became known as "vetting." Of particular importance was the need to assess carefully the merits of the professional personnel, since the supply of well-qualified physicians and surgeons was beginning to run low and many units were being sent overseas with the assumption that key professional personnel could be supplied from units already in the theaters.
There were many problems associated with the vetting and subsequent need for exchanging personnel. First of all, Colonel Cutler reiterated, it was imperative that unqualified officers arriving with these new units be in the lower grades because the theater could not assimilate well those who were in higher grades. This was true because, in many cases, a professionally well-qualified individual being sent into these new units as the chief of a service or section was himself a relatively young, junior officer. Furthermore, most of the well-qualified talent was in the affiliated units, and they believed they were being "robbed" of their better personnel, and, of course, resented it. Before long,
these units recognized the overall needs of the theater and responded well. Colonel Cutler was deeply gratified by this response and never ceased to commend these units which were called upon again and again to give the personnel and yet continued to maintain their high standards. In a way, it was to the benefit of these units because such transfers permitted their junior officers to be promoted, whereas promotion possibilities were extremely limited if the junior officers continued to stay with the original units. Finally, there was the matter of command authority to effect transfers between units to spread the talent more equally. On more than one occasion, a consultant had to reprimanded for giving instructions which-in many cases unwittingly-were taken at the local level to be commands. The desired changes in personnel had to be offered as suggestions to the base section surgeons, who were usually very cooperative in accepting and implementing them. It was more difficult, Colonel Cutler noted, when two or more base sections were involved in a series of transfers, as was often the case.
General Hawley took a very firm position on this matter of exchanging personnel, realizing full well the necessity for it, while also recognizing the need to respect the authority of commanders at the lower levels. He made the following statement at his 25 October 1943 conference with base section surgeons:
I do not need to tell you all, that we are never building up one Base Section at the expense of another and if these changes that we have are advisable, while you may get a little shortchange on one change you are going to make it up on the next. We are trying to get a balanced setup. The thing which concerns us very largely is to get thoroughly competent Chiefs of Services in these hospitals.
Col. David E. Liston, MC, Chief, Personnel Division (later Deputy Chief Surgeon) (fig. 48), was most helpful in undertaking the necessary details to coordinate and effect the transfers which were desired by the professional consultants. At a conference with base section surgeons on 2 August 1943, he made the following statement:
Sometimes we are told to move three men who have a spark of genius and it means we have to move three men who do not have this spark of genius. * * * Nobody wants these people [without the spark of genius] but we have to do something with them. If we are going to make a captain a major, that is an easy decision. The difficult decision is where to put that man we kicked out where he can get proper training.
Eventually, the need to provide not only chiefs of service but nearly all the specialists as well for the newly arriving units became a very serious problem. Colonel Cutler and Colonel Zollinger could meet this problem only by preparing lists in advance of those officers in the theater who were qualified to become chiefs of surgical services in hospitals and those in the various specialties who could be used to bolster the incoming units. This foresight on the part of the Chief Consultant in Surgery and the Senior Consultant in General Surgery proved particularly effective when, as D-day neared, many of the better, more experienced medical units of the theater were earmarked for movement to the Continent and their personnel were frozen. Officers in these units
who had been selected to become chiefs of surgical service or specialists in other units were relieved from assignment to their units before the personnel freeze was effected and remained with their units after they were alerted on an attached unassigned basis until the need for a particular individual arose.
As time went on, assaying and recommending the shifting of personnel became one of the primary functions of consultants at the theater headquarters, in the base sections, and in the field armies.
Expansion of the consultant system
An attempt to establish a system of consultation at the local level was mentioned as having been initiated immediately before Colonel Cutler's trip to the Soviet Union. This embryonic system of regional consultants and the "mother hospital" scheme was further expanded during this period, which also saw the appointment of coordinators in medicine and surgery at hospital centers and surgical and medical consultants at the base section level. The changes and innovations which were made during this immediate preinvasion period formed the framework for the duration of the war in the European theater, and it was not until well after V-E Day that that this consultant system required a complete overhaul, and then only to gear it to the needs of an army of occupation.
Regional consultants -At General Hawley's insistence, more than enough regional consultants in the various specialties had been appointed. They were first announced by the Chief Surgeon's Circular Letter No. 89, dated 21 May 1943. At that time, the directive listed eight regional consultants in general surgery, one in plastic surgery and burns, five in neurosurgery, two in orthopedic surgery, seven in otolaryngology, nine in urology, and four in
anesthesiology. This directive required immediate amendment later in May and in early June to provide for additional consultants in ophthalmology, roentgenology, orthopedic surgery, and plastic surgery. From the outset, this method of appointing and controlling regional consultants centrally from the Office of the Chief Surgeon was doomed to be unwieldy. When, in June, the operation of medical facilities in the United Kingdom was delegated to base sections, the system became all the more cumbersome-a point which was consistently belabored by the newly appointed base section surgeons. From time to time, Colonel Kimbrough reported that the surgical consultants were attempting to bring the original directive up to date, but changes were occurring so fast that revisions never passed the draft stage. Eventually, General Hawley directed that consultation at the local level be made a responsibility of the base section surgeon and that the Office of the Chief Surgeon be informed of the actions taken.
Accordingly, Circular Letter No. 21, Office of the Chief Surgeon, 7 February 1944, was published and set the policy for consultative services for the American Forces which remained in effect for the duration of the war in Europe. It stated:
5. Regional Consultants. The personnel of general hospitals and specially designated stations hospitals will be available for consultation in the vicinity of their stations and will conduct their activities under the direction of the base section surgeons. Base Section surgeons will inform each hospital where it will apply for consultant service in each of the several specialties.
In actual practice, the system of regional consultants did not work out quite as simply as may be implied in the foregoing excerpt. First of all, as Colonel Cutler explained on one occasion, there were not enough good men to place in all the general hospitals so that every general hospital could be a mother hospital to station hospitals in its vicinity for every specialty. Consequently, specific hospitals had to be designated for certain specialties as the mother hospital. In cases, this crossed boundaries of base sections so that, in some fields, surgeons of two or more base sections had to agree on the area to be covered by a particular regional consultant. Finally, the hospitals which had designated regional consultants were hard pressed for transportation and could not afford to maintain a standby vehicle for the consultants-a problem which had existed in World War I. On this occasion, however, an extra jeep was eventually authorized for each general and station hospital having regional consultants for the specific use of these consultants. The reader is also asked to note that this system of administering regional consultants could not have been established without creating base section consultants in general surgery and medicine, a program which was carried out concurrently with the development of the regional consultant system.
Base section consultants -By far the most important step taken during this period in expanding the consultant system was the appointment of base section consultants. At first, base section surgeons objected to their appointment, for no positions had been established in their tables of organization for
consultants. There was also considerable question in the minds of the base section surgeons as to what such a consultant would do, or as to whether he would even have anything to do. On 20 December 1943, General Hawley, said, at his regular meeting of base section surgeons; "There is scarcely a base section whose job is not going to be bigger in a month than the whole theater was in the beginning of this month. I think your consultants for the time being should be limited to medicine and surgery, but I do feel that you need consultants for medicine and surgery. It may be that, in Southern Base, you will need more than one."
The need for having base section consultants, when considered in this light, was apparent. For the time being, there was no other course but to appoint them in addition to their other duties in hospitals to which they were assigned. The policy concerning base section consultants was announced in aforementioned Circular Letter No. 21, emanating from the Office of the Chief Surgeon. It stated:
4. Base Section Consultants
a. Upon recommendation of the Office of the Chief Surgeon, base section surgeons will appoint consultants in general medicine and general surgery for their respective base sections. These consultants will be available to all organizations of the American Forces in their base sections. They may render service, on request of the commanding officers, to Canadian and British Hospitals in which patients of the U.S. Forces are under treatment. They may be obtained by request made to the office of the base section surgeons. In urgent cases this request should be made by telephone.
b. Reports. The base section consultants will render reports as required by the base section surgeons and will send a copy to the Office of the Chief Surgeon.
At a somewhat later date, Colonel Cutler found it necessary to state his policy with regard to the duties of base section consultants. In a memorandum dated 2 April 1944, which was apparently issued to each base section consultant personally, he wrote:
1. Keep familiar with level of professional work carried out at all hospitals in your base section. This means constant personal visits. Written directions and circulars can never take the part of the influence of a real surgeon at the bedside of the patient.
2. As a part of the above you must see all new units which enter your base section shortly after arrival, and evaluate the personnel. Your opinions should be turned into the Office of the Chief Surgeon, attention of Chief Consultant in Surgery, as soon as investigation has been completed. In addition to your evaluation of new units representatives of the consultant group in the Division of Professional Services will also make their own appraisal. Copies of these opinions will be forwarded to you.
3. Attend all meetings of the Professional Services Division. This includes automatically: a. General Hawley's monthly meeting with the Professional Services Division, b. Meeting of the Professional Services Division each Saturday morning at 10 a.m., Headquarters, SOS. If you wish to bring up special subjects for discussion at either meeting send notice for agenda one week in advance. At the weekly Division meeting you will be expected to make a brief report.
4. In your visits you should see that the professional directives are lived up to, that station hospitals in a particular do not do major elective surgery or undertake professional matters beyond their professional capacity. You should also keep an eye on evacuation and see that hospitals are prompt in evacuating people either to the Zone of Interior, if they are of the type that should be returned to the Zone of Interior, or to the rehabilitation
hospitals, that their hardening process may begin as promptly as possible. In particular you must keep an eye on inter-hospital consultations. Encourage this, and see that reports made by your regional consultants come to you promptly.
5. All of your hospital reports should be rendered to the Base Section surgeon, but copies should come to the Chief Consultant in Surgery.
Coordinators in hospital centers.-In the overall decentralization program, it was necessary to establish hospital centers to administer and operate groups of hospitals and to bring together under one administration the facilities and personnel required to treat any type of injury. Hospital centers established in the United Kingdom during this period were at Malvern Wells, Worcestershire (12th Hospital Center); Cirencester Park, Gloucestershire (15th Hospital Center); and Whitchurch, Flintshire (6810th Hospital Center, Provisional). There were, in each of these centers, hospitals provided with equipment and personnel for highly specialized treatment in neurosurgery, thoracic surgery, plastic and maxillofacial surgery, urological surgery, and the surgical treatment of extensive burns.55 It is readily apparent that, with such extensive facilities in men and equipment, the center commander required an officer to manage the surgical care carried out in the center. To differentiate this officer from the regional and base section consultants, he was called a coordinator in surgery, and such coordinators were appointed at each hospital center at this time and in those established later during the operations that followed.
Visit to North African Theater of Operations and Fifth U.S. Army
Perhaps one of the wisest moves made by the Chief Surgeon in preparation for the eventual assault on continental Europe was to send key medical personnel to the North African theater to observe firsthand the combat and support activities in progress. Colonel Cutler's turn came in November 1943. He departed by air from Prestwick, Scotland, on 27 November and returned to London on 24 December 1943.
During his visit, Colonel Cutler was able to observe a hospital train movement; general, station, and convalescent hospitals in the base sections; and clearing stations (fig. 49), surgical teams, and field, evacuation, and convalescent hospitals in the Fifth U.S. Army area. He noted the great differences between the North African theater and the European theater, and, on his return, reported, as follows:56
In NATOUSA the distances are great, the transport problem a nightmare (fig. 50), the hospitalization with the difficulties of evacuation (fig. 51) seemed inadequate and the supply problem is magnified by the above considerations. In spite of all this the medical department of NATOUSA must have our warm congratulations. Hospitals assume tremendous loads; for example General Hospital No. 21 (fig. 52) once had as many as 2,600 patients and many 500 bed station hospitals went over 1,000 patients! * * * In the Army area, even greater loads were necessary. Moreover, a large share of this load were battle casualties demanding on admission immediate attention and many requiring careful daily care.
Colonel Cutler observed that, in the Fifth U.S. Army, a platoon from a field hospital was usually established adjoining a division clearing station. Casualties who might be endangered by further transportation were carried by litter from the clearing stations to these field hospital platoons, which were set up with from 40 to 100 beds (fig. 53). Four or five surgical teams from the 2d Auxiliary Surgical Group were attached to the field hospital platoons. Colonel Cutler was most favorably impressed by this system. He stated in his report:
I heartily approve the system for the care of the heavily damaged nontransportables in Field Hospital platoons. I even would urge an extension of this forward surgery, believing that "surgery should be brought to the soldier," not the soldier to the surgeon. In addition to chests and abdomens, perhaps all the femurs, all the lower leg wounds with vascular damage and some of the heads should be done here.
On the use of evacuation hospitals in Fifth U.S. Army (fig. 54), Colonel Cutler commented:
In Fifth Army, 400 to 750 bed Evacs were used interchangeably (* * * 750 Evac excellent and no one in this theater understands why Washington (S.G.O.) thinks they are bad). As a matter of fact 400 and 750 Evacs soon overflowed even with low percentage casualties coming in. * * * Evac Hospitals taking seriously wounded were unable to hold patients for sufficient time to ensure safe evacuation. It seemed to me that the forward hospitals did not keep a sufficient number of empty beds but this is not offered as a serious criticism since only those on top can gauge the necessity for free beds. In relation to my experience in forward hospitals in the last war where Evacs frequently took 1,000 cases a day and were only able to dress and pass on the bulk of the wounded,
I was favourably impressed with the far greater percentage of surgery now done in the forward area This is of course where it should be done.
In conjunction with the evacuation hospitals, he also noted that they had too much paper work in the way of required reports. There were 8 daily, 7 weekly, 9 periodic, and 12 monthly reports required of them. There was also a bottleneck in the radiology service. The equipment was adequate, but the personnel soon tired when overworked, indicating a need for at least double the X-ray personnel in an evacuation hospital. Colonel Cutler's views reflected in the following observation in his report were to become the cause for vigorous action on his part upon his return to the European theater:
I believe separate Evacs should be used for the care of lightly wounded. These are the men we should restore to duty, these deserve our best surgeons, these can be evacuated direct to a convalescent hospital. This means good sorting at the clearing station, but that is a function of clearing stations and if sorting is well done the multiple hospital transfers now going on will be minimized
Other aspects of the professional service in the North African theater were reported by Colonel Cutler as follows:
The professional care of neurological cases is excellent. These can as a rule reach an Evac Hospital for definitive surgery. There are criticisms in the forward areas of the tripod incision as practiced by Harvey Cushing in the last war but I saw no adequate tripod wounds and am writing to remind the Surgeons of this war that the flap method
now in use was given an adequate try in the last war and found unsatisfactory. The secret of success in this field lies in careful, thorough and gentle debridement of the intercranial wound and especially in the removal of indriven bone fragments, followed by closure of the wound. I am not convinced the Bovie instrument is necessary and its use adds to the injury and reaction. Also, I believe strong suction is a danger rather than an advantage.
The care of thoracic and the combined thoraco-abdominal injury is admirable and a chief advance. Emphasis on the chest wall rather than the lung as a chief source of hemorrhage has been proven and leads to competent debridement of chest wall with hemostasis and minimal pulmonary surgery. Early repeated evacuation of blood before clotting and infection will avoid many empyemata. Emphasis on frequency of the combined abdomino-thoracic injury is excellent and radiologic control needs continual emphasis.
Early abdominal surgery is the only road to success in this field. Resections of small bowel have been rarely necessary and exteriorization of large bowel injuries or closure rectosigmoid and colostomy above have given good results. I am not convinced that bowel surgery through the thorax via an injured diaphragm is wise, but the number of splenectomies via this route speaks for itself.
Extremity surgery -Here adequate debridement, preservation of bone, holding cases with vascular damage for fear of clostridium infections and transportation in plaster seems well done. The low-waisted spica sometimes including sound thigh seems better than the Tobruk plaster though Brigadier Weddell still votes for the latter except in upper femur cases.
Surgical Teams -These are essential and now that the Evacuation Hospitals have learned under pressure that with their intrinsic personnel only they cannot do the job, they will be in greater demand. In fact I am willing to recommend that an active army of 3 active corps or more needs two auxiliary surgical groups or an increase in the number of the teams as at present authorized.
Colonel Cutler also saw the advantages of having specialized hospitals in each base area and recommended that a similar organization be established in the European theater, including a convalescent hospital in each base section. Professional work in the base sections, he advised, had been greatly clarified and improved by the setting up of special centers. Not only were the individual cases better handled this way, he believed, but concentrating material at special centers was certain to develop new methods and policies.
Colonel Cutler closed his report to the Chief Surgeon, ETOUSA, with the following note of warning on the handling of fractures:
Fractures-This field needs further study. The tendency with femurs is to use skeletal traction at the base. This throws out the work of the Spanish and Russian schools and greatly increases professional labor. We had traction in the last war, we had some hope that early reduction and plaster might reduce work as well as give better results. I am not myself convinced that we are yet masters of the plaster technique. When we are, I have a suspicion less skeletal traction will be practiced.
Sometime after his return from North Africa and Italy, Colonel Cutler was reminded of certain observations he had made there and had, possibly, neglected to emphasize sufficiently. But, on 9 April 1944, he wrote the following memorandum, which was directed to the Chief Quartermaster, ETOUSA, through the Executive Officer, Office of the Chief Surgeon:
1. During December '43 I had the opportunity of visiting the U.S. Fifth Army and made a particular point while there of studying with my colleague, Colonel Churchill,
Consultant in Surgery, NATOUSA, the many men coming out of [the] line complaining of painful and swollen feet. The condition is not exactly similar to the "trench feet" of the last war, nor to the many cases of "immersion feet" so carefully studied by Navy medical personnel. It is however a great and growing concern to the U.S. Army, for the loss of manpower from this source alone is disturbing.
2. Studies by medical personnel of the feet of such casualties up to this time have not brought forward any method of therapy likely to restore the individual to combat duty in a short period of time. The general medical opinion is that prevention is the best method of treatment.
3. Colonel Holst, formerly Professor of Surgery at Oslo, Norway (now Chief Consultant in Surgery to the Norwegian Forces in the United Kingdom), has just returned from a two months' visit with the Fifth U.S. Army and the British VIIIth [Eighth] Army. He too made an exhaustive study of these "cold wet feet" and passed some remarks to me which should be in your possession. Note that Colonel Holst is a Norwegian, who participated in the Finnish-Russian War, and has had as great an experience with cold wet feet as any competent medical officer living.
It is Colonel Holst's opinion that:-
Later in the month, Colonel Cutler was asked to furnish suggestions for line officers whose responsibility it was to insure that proper disciplinary measures were carried out in order to prevent cold injury. Accordingly, in a memorandum, dated 25 April 1944, he provided the following suggestions:
Care of the feet is the responsibility of the company commander, but we are glad to furnish this draft for their use as they see fit.
1. The condition of trench or immersion foot incapacitates the soldier for one or more months and we have no specific therapy for this condition.
2. Prevention of the conditions giving rise to trench foot is largely possible if the following instructions are carefully adhered to.
a. Every attempt should be made to keep the feet warm and dry, using overshoes where possible and encouraging mobility.
b. Shoes should not be tight, and when fitted are preferably fitted over 2 pairs of heavy all-wool socks.
c. Canvas leggings, when worn, should not be tightly laced.
d. All-wool socks should be provided troops in areas where immersion or wetting is common.
e. Socks and shoes should be changed daily, even if at the change the soldier does nothing more than wring out the wet pair of socks, rub his feet and put on the wet pair of socks again. This routine, if the socks are all-wool, will be a major factor in the prevention.
f. When wet shoes and socks are changed it is advisable to rub in lanolin or Vaseline lightly after drying the skin.
It is not within the scope of this chapter to discuss further what actions were taken at this time on these recommendations by the Chief Consultant in Surgery. This is done elsewhere, but it is significant to note that the matter had been brought up and that simple remedial measures had been suggested.57
Closure of wounds
In a global war, such as World War II, it was indeed difficult for those at the hub in Washington to establish policies which would be applicable under most circumstances anywhere. Even if it was possible to do so, there remained the major problem of communicating the ideas in such a manner that all would receive them and interpret them identically. The incident next to be reported, in which Colonel Cutler was involved, brought out these problems well.
Colonel Cutler had attended a meeting of the surgical consultants subcommittee of the British Army consultants committee on 12 January 1944. He was impressed by remarks made by Sir Harold Gillies. He reported the following to Colonel Kimbrough by letter on 16 January 1944:
Sir Harold Gillies, Hon. Consultant, RAMC, was present at a Consultants' Meeting for the first time in four years. He came to emphasize the value of early covering of surface wounds. He emphasized that there was great delay in the use of either plastic procedures or skin grafting, and urged that the Consultant Group promulgate through all theaters the desirability of utilizing modern ideas of plastic surgery. I felt he made a good point and will some day try and write a note for the Bulletin of the Chief Surgeon concerning covering of wounds, whether by delayed primary suture, secondary sutures, skin grafting or flaps.
These observations by Sir Harold Gillies were most apropos at this time since the early closure of wounds had only recently been a matter of concern to the Chief Consultant in Surgery. The causes for his concern resulted from two directives which had been issued by The Surgeon General. The earlier of the two, Circular Letter No. 91, dated 26 April 1943, concerning amputations, stated: "Primary suture of all wounds of the extremities under war conditions is never to be done; it is permitted after debridement in certain abdominal, chest, and maxillofacial injuries only." The directive further stated that the guillotine or open circular method of amputation was the procedure of choice in traumatic surgery under war conditions and permitted the flap-type open operation to "be done only in cases in which early evacuation is not contemplated and subsequent closure at the same station is deemed possible."
The later directive, Circular Letter No. 189, concerning surgery of the extremities, was a followup of the earlier. Issued on 17 November 1943, it noted that cases of gas gangrene infection were still occurring as a result of treatment of compound fractures and wounds of the extremities with closure of the wound and without thorough debridement. The directive made the following clear statements: "It is STRICTLY FORBIDDEN that any compound fracture or extensive wound of the extremities be treated with closure of the wound. * * * It is STRICTLY FORBIDDEN that * * * amputation be done higher than necessary or that the stump be closed." The directive, in closing, warned: "Commanding officers of all general and station hospitals will be held responsible for the abandonment of the improper pro-
cedures described above and for the necessary instruction and compliance with these directives."
On 30 December 1943, Colonel Cutler, in a memorandum to Colonel Kimbrough, called his attention to the fact that these circulars had not been reproduced in the theater as theater directives. Colonel Cutler informed Colonel Kimbrough that they had reached commanding officers of hospitals, however, and that, if they were blindly followed, certain cases would be forced to have two operations where one would suffice. He asked whether it would not be proper to request The Surgeon General to reconsider these directives as they might apply to casualties occurring in the Army Air Forces and to nonbattle injuries. He suggested that perhaps The Surgeon General had not given full consideration to the casualty of the Army Air Forces. In explanation of his stand, Colonel Cutler wrote:
In both of these categories previously healthy and often clean, vigorous young men reach a hospital within two hours of injury thus simulating civilian hospital practice. Several have had to have immediate amputation and in selected cases short flap amputation has permitted early secondary closure and even primary closure with highly satisfactory results. It appears to us that there should be a difference in therapy according to terrain and environment. Thus, a sailor knocked into the sea water by a shell fragment and immediately picked up and taken to a hospital ship and an aviator wounded in clean clothes, in a clean airplane and reaching a hospital within three hours and a wounded infantry soldier who has lived in a foxhole, covered with mud and clothes in filthy garments for one or two weeks and who reaches a hospital in 6-12 hours need entirely different treatment at the hand of the surgeon.
Colonel Kimbrough passed Colonel Cutler's memorandum to General Hawley. The general's decision was to leave matters where they stood with respect to the directives and to take care of the exceptions to The Surgeon General's policies by personal instruction within the theater.
Colonel Cutler, however, did not believe that the Chief Surgeon's decision went far enough. In a memorandum to the Chief Surgeon, dated 24 January 1944, concerning the amputation circular, he made the following suggestion:
I believe it would be unwise to issue confidential instructions which are in any way contrary to those recommended by The Surgeon General. It was the intent of my memo of 30 December that you might send a professional opinion to The Surgeon General outlining the situation concerning amputations. I have tried to outline this for you in the attached letter. Would not this be the wisest policy?
General Hawley accepted Colonel Cutler's recommendations and sent the letter to The Surgeon General asking the question of whether casualties of the Army Air Forces, for example, did not justify a different type of therapy according to the environment in which they were wounded and the prompt availability of surgical care. The letter also inclosed a "short note" prepared by Colonel Cutler for publication in the Medical Bulletin, ETO USA. Titled "The Importance of Wound Closure," this article read as follows:
"Do not suture" is accepted as a major principle in the surgery of battle casualties. It, however, must be applied intelligently. For example, it does not mean, never, at any time hereafter, suture these wounds, nor does it mean keep this wound open forever. Yet the dictum has had the above unfortunate connotation. In fact, many surgeons, once
a wound has been debrided, seem to relax their interest in the wound unless it becomes septic. This leads to long hospitalization and late return to duty. Moreover, to let a wound heal by cicatrization often leads to unnecessary stiffness in the part and even limitation of function.
We must all consider another principle when we leave a wound open, which is, the best way to sterilize a wound is to close it. No antiseptic is equal to overlying complete epithelization, whether it be achieved by delayed primary suture, early secondary suture, skin graft or flap procedures. Indeed, we owe much to our plastic surgical colleagues who constantly reiterate the importance of a closed wound.
With these two principles in mind let us return to a consideration of the battle casualty and the relation of his injury to terrain and environment. The man wounded in the battlefield where he has been wearing the same suit of clothes for three weeks and who is covered with mud and dirt experiences the same wounds as an airman in his clean clothes, fresh from a bath, or the sailor blown off the deck of his ship by a bomb splinter. True, when surgery is first applied it is wiser to follow the dictum ''do not suture the wound''. But there analogy ceases; the foot soldier's wound is inevitably seriously contaminated, that of the airman or the sailor swimming in salt water has a minimum of infection. In the case of the foot soldier, delayed primary suture or secondary suture can only be practiced infrequently; in the case of the airman and the sailor it should be practiced almost as the rule.
A recent study in E.T.O. with early closure yields light upon this point. A study was made of the wounds of casualties who had been given penicillin therapy, or sulfonamide therapy, or no chemotherapy. An outstanding observation was that those wounds closed early, irrespective of chemotherapy or none, healed well. When there was delay in closure, infection resulted. And no great choice was made which wounds to close early and which to leave open.
This matter is again brought forward because it appears that the inestimable advantages of an epithelial covering are not generally recognized. If early closure cannot be accomplished, then early grafting or even flap procedures should be carried out. The difficulties of these latter procedures are increased by cicatrization.
Not to suture a wound initially is good practice. To fail to close it at the first safe moment is neglecting an opportunity to protect the soldier against further infection and loss of function.
The reaction in Washington, upon receipt of General Hawley's letter and Colonel Cutler's inclosure, was quick and sensational. First, there was a reply from General Rankin, Chief Consultant in Surgery, Office of The Surgeon General. The letter, dated 3 February 1944, stated:
General Kirk showed me your letter of January 24th relative to amputations and, since there was an enclosure from Cutler on The Importance of Wound Closure, he asked me to drop you a line relative to this. I believe he intends to answer your letter, insofar as amputations are concerned, himself.
In a word, we neither of us agree with the modification of the amputation program. I am sure that the wide experience of General Kirk and other men from the last war who dealt with amputations has resulted in giving us a program which is pretty nearly as satisfactory as one can have, and when it comes to fashioning flaps, et cetera, I think that we will have to disagree with our colleagues. I just can't go along with the hypothetical case of the young airman, either in the question of flaps for his amputation or in the proposed wound closure such as Elliott Cutler outlines. If there is one thing that I thought we had learned from the past war and from our experiences in this war, it is do not close wounds primarily. I don't believe there is any evidence at all that this should be deviated from. I cannot agree with Cutler that infection results when there is delayed closure
because of the delayed closure only. Infection results because infection is there. I am perfectly sure that any deviation from this principle will be followed by profound repercussions. There may be 1 percent, or even 5 percent, of wounds which, when operated upon early, may be closed with relative safety, but the 95 percent (and probably 99 percent) of war wounds, regardless of what service they are in, are better left open, in my judgment. One cannot visualize experienced surgeons always present when people are wounded under seemingly satisfactory conditions for closure and the great difficulty, as I see it, is that the example will be followed by inexperienced men in unfavorable conditions. We had the same thing to deal with here in the States in the treatment of compound fractures occurring near camps produced by accidents in motor vehicles. These fractures resembled in all details those of civil life and were frequently gotten into hospital within one to three hours. It was with the greatest difficulty and only after numerous directives that the Surgeon General's Office was able to compel the surgeons to leave these wounds open, more as an example and a lesson than anything else because many of them could be closed safely, but not in war wounds. I have no hesitation in placing myself on record that we still adhere to the principle of no closure. I think that I can buttress this with the experience of the surgeons in the Tunisian and Sicilian campaigns and I am sure that their records show that a great many people developed serious complications both in the closure of wounds and in the packing of wounds, which is equally undesirable.
On 4 February 1944, Maj. Gen. Norman T. Kirk wrote a letter to General Hawley containing the following:
Much bone length has been sacrificed by these methods. I am sure that the chances of infection are less in Air personnel and in the Navy with men aboard ships. However, I have seen many infections occur in operating rooms under what were supposed to be ideal aseptic conditions and when elective rather than emergency surgery was being performed. I don't believe that a wound has to be full of mud, manure or cinders to have streptococcus, staphylococcus or even gas bacillus present in it. Peterson, in a recent tour of our hospitals, found three amputations here at home where debridement and primary suture were carried out within the critical period and gas gangrene occurred requiring amputation to save life. I have seen other cases so treated and the wound closed. The doctor said he took a chance and got away with it. The patient took the chance, not the doctor. Also, the patient didn't have a vote and wouldn't have known how to vote.
The Consultant in North Africa finds that many of these wounds, at the end of eight or ten days, with the assistance of penicillin, sulfa drugs or none of these agents, may be safely excised and secondary suture performed. I am in accord with this, particularly in superficial wounds, to get men back to duty earlier. It may be applicable to compound fractures with destruction of large muscle masses. I am not too sure about this, however.
It is accepted that the flap type guillotine may initially be performed if that patient is not to be transported and can be held under observation in a given hospital but the following must be weighed and when this is considered: traction is applied with difficulty and traction made by the use of sutures through flaps causes necrosis of tissue followed by infection. Bone length almost always has to be sacrificed when this method is employed. We are getting back too many below-knee stumps from overseas that are too short to be fitted with prosthesis. We are also getting many back with skin grafts. This is not at all necessary. The circular type guillotine of the thigh with proper traction will be healed in six weeks and will stay healed. If it is closed primarily, too many cases of osteomyelitis will develop, too much shortening will be occasioned and the resulting stumps will frequently not be satisfactory from the prosthetic standpoint.
As you can see from the above, I am not at all in accord with your policy of handling your Air casualties. I know everything is going to speed these days and speed is a great thing but no matter how fast a plane can fly if the motor is cut out in flight it soon flops
and it doesn't arrive at its destination. A lot more speed can be obtained if sound principles of surgery are not at the same time observed. In the last war lives were lost, as well as extremities, from primary closure as well as too early secondary closures. No surgeon, no matter how expert, can always do a complete debridement of a wound. If that were true we would not be having the increase in the incidence of gas gangrene in Italy. And I am very afraid of what that incidence is going to be when we get into the Continent. I am also afraid that a lot of it is going to develop under plaster, with disastrous results.
Under these circumstances, General Hawley's instructions to the Chief, Professional Services Division, on 16 February 1944, were simply: "This policy will be followed in ETO. Implement."
The implementation was done by publishing The Surgeon General's Circular Letter No. 91 as Circular Letter No. 28, Office of the Chief Surgeon, ETOUSA, 1 March 1944, Section I of which was titled "Surgery of the Extremities." On 21 February 1944, Colonel Cutler informed General Rankin by letter that this was being done. He explained as follows:
I fear you did not quite understand my little note on ''The importance of wound closure". It begins with the sentence: "'Do not suture' is accepted as the major principle in the surgery of battle casualties". What I was interested in was to have our surgeons remember that there also was something to be desired in closing the wound eventually so that the man could be returned to duty. Everyone has emphasized "do not suture a wound" so much that the young surgeon takes no interest in his wound after it is once made, and wounds which could be closed in the second to fifth day by delayed secondary suture or by skin grafts during the same period are left to slowly granulate, thus keeping a man in hospital sometimes a month or more after he should have been discharged. I hope you and the Surgeon General do not for a moment think that we are practicing the primary closure of wounds.
The Surgeon General in his letter says: "I am not at all in accordance with your policy of handling your air casualties". I cannot find we have done anything he would not approve of. There have been few amputations with the Air Force and only one in which very short flaps were made. In this case the wound was closed by delayed secondary suture the next day, and healed forthwith. It was an arm which had been blown off by rocket shell in the Schweinfurt raid, at about the junction of the middle and upper third. Every attempt is made here to leave as much bone as possible and I feel certain that if you and the Surgeon General could visualize our work in those hospitals serving the Air Force you would be most happy, as are General Grow and those responsible for the medical care of the Air Force itself.
Fortunately, only a few weeks later, General Kirk and General Grant (fig. 55), the chief medical officers of the Army and the Army Air Forces, respectively, were sent to the European theater for the specific purpose of reviewing hospitalization facilities for the Army Air Forces in the United Kingdom. It was Colonel Cutler's privilege to accompany and guide them through the many installations devoted to the care of air casualties. In their tour of the hospitals, which began on 9 March 1944 and continued almost without a break through 17 March, there was complete satisfaction in the surgical care which was being provided.58
Spurred on by the war effort, knowledge concerning penicillin increased by leaps and bounds. There grew an ever-hopeful attitude that here was a new medical implement which would have profound effects in improving the care which could be given the wounded. There were indications that it might prove to be the greatest bacteriological agent yet produced, although Colonel Cutler thought it needed further assay in the human body before final opinion could be hardened. There were indications, also, that great strides were being made in devising methods for producing penicillin, methods which, early in this period, were still laborious and time-consuming processes. Thus, for the Chief Consultant in Surgery, ETOUSA, it was imperative that he gain all the data he could in order to be able with some confidence to advocate a standardized regimen of treatment using penicillin and to insure that adequate supplies of the antibiotic would be available to carry out the treatment recommended. Moreover, the opportunity to study the efficacy of penicillin in the European theater was unparalleled, for here in the United Kingdom were some of the persons who were at the forefront in its development.
As reported previously (p. 52), a beginning in this direction had been made by the studies which Lt. Col. Rudolph N. Schullinger, MC, was con-
ducting at the 2d General Hospital with the advice and help of Prof. Howard E. Florey and Dr. Mildred Florey, his wife. By the opportune arrival of more penicillin in September 1943, Colonel Schullinger was able to continue his work and bring it to a conclusion in March 1944. Colonel Schullinger gave the following account of these early experiences:59
Shortly after the Second General Hospital arrived at Heddington, Oxford, in July 1942, the University faculty as well as some of the hospital staff members held a reception for the "invaders" at Christ College. It was a most interesting and enjoyable occasion. Here it was my good fortune and privilege to meet Professor Howard Florey, Director of the Sir William Dunn Research Laboratory, and his wife, Doctor Mildred Florey. In the course of our conversation, they spoke of their exciting studies with penicillin and invited me to visit their laboratory. The invitation was eagerly accepted. The attractive and well built laboratory was situated on a quiet street not far from Rhodes House. Once inside, the visitor could sense an atmosphere of considerable activity. As one passed the various research units, it was apparent that doctors and technicians were busy and intent on their work. Professor Florey's study was a spacious oval room on the second floor flanked with bookshelves and files. In the center was a large table covered with papers and periodicals in "orderly disorder" and, at the end, nearest the window, was Professor Florey's chair. No matter how busy he was with his studies, correspondence, and writings, the visitor was always received with a welcome smile and an invitation to join his company.
It soon became apparent that here a great project was in full play. Professor Florey was at the helm, directing the technical aspects in the production and refinement of penicillin, and consulting with his wife, who carried out the clinical application of this new antibiotic. The process of preparing penicillin was so laborious in the early phases of this work that only carefully selected cases could be chosen for this therapy. In fact, the amount of penicillin was so limited that the urine of patients undergoing treatment was saved and returned to the laboratory for extraction and repurification of the penicillin for subsequent use. Sometimes the supply of penicillin gave out completely, thus necessitating temporary discontinuance in critically ill patients. These were trying and discouraging moments.
Thus, during the autumn and winter months of 1942-1943, the writer enjoyed the unusual privilege of witnessing the clinical application of penicillin to patients in some of the British military, civilian, and E.M.S. hospitals. Several trips were also made to the RAF Hospital at Holton. Wherever she went, Doctor Florey took careful notes and measured out the dosages with precision (perhaps two to five thousand units per dose) for the next two or three days. The results were usually dramatic. Here was a boy with a fulminating hematogenous osteomyelitis who responded promptly to "large doses" (10,000 units every four hours) of penicillin and required no operative interference. In the Radcliffe Infirmary a young army officer with cavernous sinus thrombosis and sepsis recovered after a fortnight of penicillin therapy. Infected wounds seemed to improve rapidly with local applications of penicillin. A penicillin cream was used for certain types of burns.
Observing the clinical aspects with Doctor Florey, and discussing the overall problem at various times with Professor Florey, it was obvious that here was an agent that would be of enormous benefit both for military and civilian purposes. Colonel Elliott Cutler was consulted and it was decided to requisition a supply of penicillin "through channels" via the Chief Surgeon, E.T.O. Unfortunately, the supply in U.S.A. was quite limited and
there was none available through British sources. After a considerable interval another attempt was made to obtain the precious material by enlisting the British Research Council to make a direct appeal to the O.S.R.D. Meanwhile, Professor Florey had flown to the Eighth Army in North Africa to study the effect of penicillin in its local application to septic war wounds.
Finally, on 8 May 1943 a consignment of one million units, valued at one thousand dollars, arrived at the Second General Hospital. It was prepared in powder form, sealed in 10,000 unit vials. The consignment was locked in the ice-box next to the main kitchen. A consultation was then held with Professor Florey, Colonels Cutler, Kimbrough, and Storck, as well as Major Sloan and the writer, in order to formulate certain policies on usage and dosage.
Although the penicillin was to be administered only to members of the U.S. Forces, it was difficult indeed to deny urgent requests from neighboring British military and civilian hospitals. The first case to be treated was a young Air Force lieutenant with staphylococcus osteomyelitis of the left femur secondary to flak and shrapnel wounds of the thigh and pelvis. Other cases soon followed, chiefly infections secondary to injuries and wounds. This continued through the late spring and summer of l943. At the same time, instruction courses on the use and preservation of penicillin were given at the Second General Hospital to officers on detached service, and this was continued well into the spring of 1944.
During the winter of 1943-1944 the writer presented results of penicillin therapy administered to patients in General Hospital Number Two at various U.S. Army Installations in England (Tavistock, Winchester, Leamington, etc.). Of considerable interest was the reported recovery in January 1944 of a British soldier, at the military hospital in Shaftsbury, stricken with Staphylococcus aureus pyemia and endocarditis. He received a total dosage of five million units. Finally, on 11 February 1944, through the kind offices of the late Sir Arthur Hurst, it was the writer's privilege and honor to address the faculty and students at Guy's Hospital on penicillin therapy, based on clinical studies at the Second General Hospital.
During March 1944, sufficient penicillin had been received as to permit formulation of directives for its use at various U.S. military hospitals in the United Kingdom. Already plans were being drawn up for penicillin therapy in advance combat areas.
On 29 March, the documented report on penicillin therapy at the Second General Hospital was submitted to Colonel Elliott Cutler.
Thus, in brief, the reader may appreciate the role played by one of the U. S. Army hospitals in Britain in the clinical application of penicillin therapy during the earlier years of its development (1943-1944). It would be impossible to give adequate expression of appreciation and gratitude to Sir Howard and Lady Mildred Florey for their many kindnesses, gracious hospitality, and warm friendship, not to mention their unselfish expenditure of time and interest in counseling and encouraging the writer during this stirring period of study at the Second General Hospital in Oxford.
An abbreviated version of Colonel Schullinger's final report was forwarded by Colonel Cutler to The Surgeon General.60 The summary portion of the report read, in part, as follows:
A somewhat varied group of forty cases, treated with penicillin in this theater between May 1943 and March 1944, has been collected and presented. Twenty-six were improved or cured, seven had doubtful or equivocal results and seven were failures. Five deaths occurred, in which three may have succumbed to other causes or, at best, to distantly related circumstances. * * * The forty cases comprised two main categories, namely
infections and prophylactically treated wounds. This report does not include sulfa-resistant gonococcal urethritis, lues, fresh battle wounds or medical infections, such as meningitis or pneumonia. * * *
An effort has been made to point out the necessity for strict adherence to the criteria governing proper penicillin therapy. The indications for therapy should be carefully considered and evaluated, before resorting to active treatment. Actual dosage should not be according to fixed or dogmatic rules, but should be governed by careful bacteriostatic control, because of the variability in excretion rate. Inadequate dosage predisposes to the development of penicillin-fast strains. However, complete bacteriostasis, throughout the whole interval between doses, may not be essential. On the other hand, some strains have a natural resistance even though the family is ordinarily sensitive. Contrariwise, we have encountered two sensitive strains of Streptococcus viridans. The duration of treatment should be ample, particularly in the staphylococcal infections. * * * Many of the patients, with successfully treated infections, followed a fairly typical pattern: the improvement was gradual, the temperature fell by lysis, they looked and felt better, the appetite increased, sometimes quite markedly; there was less need for opiates, and the hemogram became normal. In those cases with infected wounds there was a marked diminution in pain, swelling and discharge, with rapidly appearing healthy granulations and accelerated healing. The route of penicillin administration was intramuscular, intravenous or local, sometimes in two, or even all three combinations. * * * The locally treated infections illustrate the remarkable efficacy of relatively small amounts of penicillin. * * * The number of equivocal results and failures in the present series suggests a lack of proper selection or inadequate therapy or poor management.* * * * * * *
The prophylactic treatment of the group of compound fractures was most encouraging. This was due, in large part, to the short duration between injury and operation, the relative cleanliness of the wounds in the successfully treated patients, the skillful management by the experienced surgeons, and the local and parenteral administration of penicillin. The advantages of converting a compound fracture into a simple one is obvious. * * * The treatment of these compound fractures unfolds new possibilities in war, as well as civil surgery. Nevertheless, with few exceptions, primary closure of compound fractures must never be practiced in the forward areas.
Elsewhere in the report, Colonel Schullinger warned: "* * * the writer cannot too strongly emphasize the importance of adhering to sound surgical principles in the treatment of patients with penicillin. To neglect such practice, with the expectation that penicillin can perform miracles, is pernicious, and may even jeopardize a patient's life. It demands too much of penicillin and nothing could place it more readily into disrepute."
The study by Colonel Schullinger was, actually, a clinical trial of penicillin and not an experiment in the classic sense. The question of the efficacy of penicillin when used prophylactically was a paramount one because of its great implications for surgery in the field. True, Colonel Schullinger's studies had included eight compound fractures in which penicillin had been administered prophylactically. Six of the eight had improved or been cured, one was a failure, and the other resulted in death in which the result of the prophylactic use of penicillin was equivocal. Furthermore, except for a clinical appraisal, there was no way to be absolutely certain that the improvement or cure of the six cases was due as much to other extenuating circumstances and
the expert surgery available as it was to the prophylactic use of penicillin. Therefore, on 10 September 1943, Colonel Cutler conferred with General Hawley and later the same day reported to Colonel Kimbrough by memorandum, as follows:
The experience thus far in the use of this bactericidal agent has been largely in the treatment of chronically infected wounds. Our own experience as well as that of Mrs. Florey does not reveal that this agent is as universally satisfactory as has been written. Recently, Professor Florey and Brigadier Hugh Cairns have returned from North Africa and Sicily, where penicillin is now being placed in fresh battle casualty wounds with a sulfonamide. Thus there is no proper control of the efficacy of the agent.
We have an opportunity with fresh battle casualties in our Eighth Air Force of testing out the value of implanting penicillin shortly after wounding. I have proposed to General Hawley, and it has his approval, that we conduct proper controlled experiments with casualties from the above source, treating every other battle casualty in each of our 6 station hospitals with the 8th Air Force with penicillin.
The proposal was also approved by General Grow, Surgeon, Eighth Air Force. Initially, Lt. Col. (later Col.) William F. MacFee, 2d Evacuation Hospital, was placed on one month's temporary duty as a special consultant with the Eastern Base Section to supervise and control the study. Later, as the project continued with the advent of more penicillin, Lt. Col. (later Col.) Paul C. Morton, MC, and Capt. (later Maj.) William R. Sandusky, MC, were assigned to the project. Colonel Morton eventually assumed primary responsibility for the study after the relief of Colonel MacFee.
The first problem in getting the study started was penicillin itself. Where was the supply to come from? Of the original supply which had arrived in May 1943, there was little left. In the London depot, however, there were 7,200,000 units remaining of a supply which had been sent to be used for sulfonamide-resistant gonorrhea. The only other purpose for which this could be used was in cases of overwhelming infection where the saving of life was involved. Colonel Cutler calculated that 5,100,000 units of the original penicillin had been used for lifesaving purposes or for the treatment of gonorrhea and was able to recoup this amount, in exchange, from the stock in the depot.61 This supply enabled the study to get underway. Shortly thereafter, General Hawley ruled that any amount of the penicillin being received for the treatment of sulfonamide-resistant gonorrhea could be used for the surgical penicillin work.62 This decision permitted the distribution of 5,000,000 additional units to the study made on air force personnel and the 5,000,000 units previously mentioned to the 2d General Hospital for Colonel Schullinger's project.
Meanwhile, to insure a continuing supply of penicillin for the limited purposes for which it was then being used, over and beyond that which had been requested for sulfonamide-resistant gonorrhea, Colonel Cutler had advised the Chief Surgeon to make a request for an increase in the proposed
monthly allotment of penicillin for the theater. When the Chief Surgeon accepted this advice, the following letter was prepared by Colonel Cutler for General Hawley to send to General Kirk:
This communication relates to additional supplies of penicillin desired in the ETO. Our instructions from your office are that you will send us a supply of penicillin for treatment of sulfa-resistant gonorrhea only. We have already submitted data on the number of units of penicillin necessary to treat the expected incidence of this disorder according to the troop basis. You have already shipped to the ETO for this purpose 20 million units. Preliminary reports suggest highly beneficial results.
In addition to the above supply for "sulfa-resistant gonorrhea only" there was donated to this theater, on 3 May 1943, 18 million units. This has been used in close cooperation with Professor Florey and at present writing less than 2 million units remain on hand. Our Professional Services Division are extremely anxious that additional supplies of penicillin be available for use in the ETO for the following purposes:
We feel that we have an ideal set-up for properly controlled studies in the last category. Amongst casualties returning daily in our "bombers" the flow of patients is steady but not so pressing as to detract from the careful care and consideration. No other group of patients will present a better opportunity. We would like to treat every other patient without choice by placing penicillin in the wound and using a certain amount parenterally. We will have the opportunity to conduct proper bacteriological and other laboratory tests.
Heretofore in this theater the use of penicillin has largely been carried out in chronically infected wounds where the multiplicity of organisms and the extent of infection mitigate against great success by any single remedy.
The British penicillin group, of which Professor Florey and Brigadier Hugh Cairns are the leaders, have just returned from the active theater below us. There, penicillin is being instilled into fresh battle casualties, but always in conjunction with a sulfonamide, which will give us no absolutely positive evidence.
For the above categories of penicillin therapy we would like a monthly supply amounting to 50 million units a month for the present, in addition to that sent for the treatment of sulfa-resistant gonorrhea. We could easily use more and we are disturbed that our Canadian colleagues have been promised large amounts when it appears to us that we have a great opportunity for a competent study. If this request is granted, could a preliminary fraction be flown over shortly?
Because penicillin loses potency rapidly after being removed from the refrigerator and when in any other form than when dried and hermetically sealed, we would greatly prefer our units to come in the 10 thousand unit ampoules, as in our first lot, than in the 100 thousand unit ampoules, as in the second lot.63
The supply of penicillin seemingly assured, the controlled study on the efficacy of penicillin used prophylactically in combat-incurred wounds of air-crews was continued until March 1944, as was the study being conducted by Colonel Schullinger. The March termination of these studies was decided upon in order that final reports could be prepared for inclusion in a penicillin
fasciculus to the April issue of the British Journal of Surgery. (The fasciculus was later postponed to the July issue.)
In the study made on air force personnel, there were eventually 250 wounds occurring in 146 patients which were available for comparison. In the penicillin treated group, there were 68 patients with 123 wounds; in the control group, 78 patients with 127 wounds (table 1).
The final report of the studies mentioned some of the following observations:
It should be clearly understood that the object of this study is not to determine whether penicillin is effective in established wound infections, but rather to learn whether penicillin, used prophylactically, will prevent or lower the incidence of infection in the wounds of aerial combat in a theater of war where early definitive surgery and continued observation can be carried out.
The wounded patients were divided into two groups. Those in one group were given parenteral and local penicillin prophylactically * * *. Those in the other group received no chemotherapeutic agent and serve as controls.
Penetrating wounds of the abdomen or thorax or burns are not included in this study. The policy has been to administer sulfonamides or penicillin or both to all such patients, therefore no group of control cases is available for comparison.
The local dosage for wounds involving only soft tissue varied from 5,000 to 20,000 units in accordance with the size of the wound. Wounds associated with compound fracture and soft part wounds in the region of the anus or buttocks received from 10,000 to 40,000 units. In a limited number of instances, doses as great as 100,000 units were administered.
The usual method of preparation for local application has been to dissolve the sodium salt of penicillin in sterile physiological saline solution in amounts of 1,000 units of peni-
cillin per cubic centimeter. This solution was sprayed on the wound by means of an atomizer. Another method only recently developed has been the insufflation of a mixture of penicillin powder and dehydrated human plasma on the wound surface. Ten thousand to 20,000 units of the sodium salt of penicillin to 0.1 to 0.2 gm of plasma has been found to be a satisfactory combination.
The local use of penicillin was combined with parenteral administration. The practice was to give intramuscularly 10,000 units of the sodium salt dissolved in 1 cc of physiological saline solution. This dosage was given immediately following operation and was repeated at three-hour intervals. Early in the study parenteral administration was continued for three days, but subsequently this was reduced to 48 hours.
At the time of operation the debrided tissue from the majority of the wounds was placed in sterile wide mouthed bottles and saved for culture. Following debridement and irrigation the wound was again sampled for bacteriologic examination. This was done by gently and thoroughly passing, over all parts of the wound, a sterile cotton swab, which was later cultured. In the beginning of the study only aerobic cultures were done. Later, four of the hospitals had facilities for anaerobic, as well as aerobic cultural methods.
The results have been judged solely from the standpoint of wound infection. The criteria for infection required the presence of one or more clinical signs such as tenderness, swelling, redness, lymphangitis, lymphadenitis, the presence of purulent discharge or infected hematoma. In wounds which were left open a distinction has been made between those having simple surface contamination and those showing clinical infection. The presense of organisms on the surface of an otherwise healthy wound is not considered infection of that wound.
The findings are presented in the tables [table 1]. The differences in percentage between the infection rates in the penicillin group and control group in each instance are not of statistical significance.
The results indicate that penicillin, used in conjunction with early definitive surgery did not lower the incidence of infection in such wounds. We cannot too strongly emphasize that our findings are not to be compared nor confused with other studies in which penicillin has been used to treat established surgical infections.
It is obvious that penicillin used prophylactically in the manner herein described did not prevent the development of gas gangrene in two patients. The role of this agent in modifying the infection, altering the toxicity, or in combatting secondary invaders cannot be evaluated at the present time.
* * * there are several points of interest from the bacteriologic standpoint. One has been the finding of a high percentage of contaminated wounds in aerial casualties [85 percent.] * * * The predominant organism has been the staphylococcus. Another contaminant worthy of note is the clostridium. The incidence of this organism in cultures of the debrided tissue increased as improvements were made in the anaerobic methods in the different laboratories. In one of the laboratories, when anaerobic as well as aerobic cultures were done routinely the incidence of clostridia (anaerobic gram positive bacilli) in the debrided tissue was 24 percent. Equally noteworthy has been the infrequent recovery of streptococci and enterobacilli. Another interesting finding has been the persistence of contaminating organisms in almost three-fourths [71 percent] of the wounds after debridement and irrigation.64
Early in the course of these studies, three cases of gas gangrene developed, and ultimately, there were seven cases of gas gangrene occurring in patients who had received therapeutic penicillin. Six of the seven were in wounds in-
curred as a result of air combat or air crashes, and five of the seven had also received penicillin prophylactically at the time of initial definitive treatment.
The occurrence of these cases, Colonel Cutler knew, was very significant since, at this time, many had high hopes that penicillin could forestall or prevent the serious complications of gas gangrene in war wounds. Penicillin in vitro had exhibited a bacteriostatic effect upon the organisms frequently associated with gas gangrene. Certain clostridial infections, experimentally induced in laboratory amimals, had also been treated as well as prevented by the inoculation of penicillin. On the other hand, there were very little data on its effects on clinical gas gangrene.
At the first opportunity, Colonel Cutler presented a report on the findings in the three early cases. This was at a meeting of the Section of Experimental Medicine, Royal Society of Medicine, on 9 November 1943. A final report of all seven cases was prepared by Colonel Cutler and Captain Sandusky to accompany the reports of the other two studies-those of Colonel Schullinger and Colonel Morton. The early report and the final report emphatically brought out that the use of penicillin in these cases had not prevented the development of gas gangrene.
The final report observed:
While it is unwise to draw conclusions from so small a group of cases, we are so impressed with the fact that out of seven cases of gas gangrene, only one proved fatal and two recovered without loss of limb. [The fatality occurred after amputation as a result of uremia. Microscopically the kidneys showed hemoglobinuric nephrosis. At time of death, the local clostridial infection appeared to have been controlled.]
Equally impressive is the fact that of the recovered cases in no instance was a fatality apprehended. Each of the seven patients had the benefit of early diagnosis, prompt surgical extirpation of the infected tissue, therapeutic penicillin, large amounts of gas gangrene antitoxin and frequent blood transfusions. With so many factors tending to influence the outcome, it is difficult to estimate the value of any single one. * * *
For the group as a whole one conclusion is obvious and outstanding: Penicillin used prophylactically in the manner herein described did not prevent the development of gas gangrene. * * *
There can be little doubt but that penicillin is effective against many of the organisms which are found amongst the multiple contaminants in the wounds of battle casualties. Also a reduction in the devitalizing and even destructive effects of such other organisms tends to prevent a suitable medium for growth of the clostridia. At the same time this small experience does not fall in line with published and confidential reports to us that "penicillin is extremely effective in gas gangrene."65
In addition to these experiments, Colonel Cutler had information from many other sources, chiefly from the British. Of particular importance, in this respect, were meetings of the Penicillin Clinical Trials Committee and the War Wounds Committee of the Medical Research Council. As early as the 12 October 1943 meeting of the Penicillin Trials Committee, there was already information available to Colonel Cutler on the results of penicillin used prophy-
lactically and therapeutically in actual combat, for much of this meeting was spent in discussion of the Florey-Cairns report.66 In a memorandum, dated 16 October 1943, Colonel Cutler wrote to Colonel Kimbrough:
Professor Florey gave us a summary of the report of the Penicillin Commission which recently visited North Africa and Sicily. He made it clear that experience in that area had shown that placing some 50,000 units of penicillin even in a septic wound as late as 3 days allowed a great percentage of the wounds to close immediately and prevented the occurrence of osteomyelitis in compound fractures. This report will be of the utmost importance to us, for the matter of dosage now assumes a major problem. Professor Florey reported that calcium salt was as a rule used in conjunction with a sulfonamide in soft part injuries, but that where fractures were present larger amounts were used up to 750,000 units, and here sodium salt is used.
While these efforts were being made to gain as much information as possible as penicillin, Colonel Cutler also had to define the purposes for which it could be used, who could use it, and how it was to be used as greater amounts became available.
The first "penicillin circular," prepared in draft by Colonel Cutler, was Circular Letter No. 176, Office of the Chief Surgeon, ETOUSA, issued on 7 December 1943. The circular letter stated that penicillin was being issued to all general hospitals and the 49th and 121st Station Hospitals. It limited therapy to: (1) Patients suffering from overwhelming infections whose lives might be saved by the use of penicillin, (2) patients suffering from sulfonamide-resistant gonorrhea, and (3) patients suffering from infections which, although not immediately endangering life, manifested symptoms which did not respond to the usual treatment. The selection of patients at hospitals supplied with penicillin was made a responsibility of the commanding officer. In hospitals not supplied with penicillin, commanding officers were instructed to request base section surgeons for permission to use penicillin in any particular case. If the request was approved, penicillin could be obtained from the nearest hospital supplied with it. The circular letter further stated that instructions regarding local and systemic administration of penicillin would be issued, as necessary.
The instruction to using hospitals was, of course, given to individuals concerned at the 2d General Hospital, as previously mentioned. Obviously, too, this extended use of penicillin provided an opportunity to expand the clinical studies being conducted at the 2d General Hospital, and, accordingly, elaborate laboratory checks and records were required.
The minutes of the 17 January 1944 conference of base section surgeons state that Colonel Kimbrough made the following announcement at the conference:
The supply of penicillin has increased so that it has become available for more general treatment. The plan now, and the Circular No. 6 has just been issued, is that a supply
will be kept in all hospitals-field, evacuation, convalescent, station and general. The only check this office keeps on it is that all requisitions will be referred to the Chief Surgeon's Office for approval.67
The still wider use of penicillin within the theater made it necessary for Colonel Cutler to have the original penicillin circular changed. This was accomplished by Circular Letter No. 22, Office of the Chief Surgeon, ETOUSA, 8 February 1944, concerning penicillin therapy. The new circular rescinded the former and designated the following conditions for which penicillin therapy could be given:
1. Patients with serious infection, which will include injury and battle casualty cases as well as pneumonias, septicaemias, meningitides, etc., proven to be sulfa-resistant.
2. Patients with gonorrhea proven to be sulfa-resistant, and patients with gonorrhea untreated by sulfonamides, the importance of whose duties make it desirable that they should be absent from duty for the shortest period of time.
3. Patients suffering from chronic infections, usually osteomyelitis or prolonged wound sepsis, where the condition though not endangering life greatly prolongs convalescence.
It was now necessary to train nearly all of the medical officers in hospitals in the use of penicillin. Procedures to be used in carrying this out were announced by Colonel Kimbrough at a conference of base section surgeons on 31 January 1944, as follows:
Previously our plan was to have * * * a new hospital that was authorized to use penicillin send personnel to the nearest general hospital to be indoctrinated. It has gone so far now that all the personnel of the station hospitals need some training and it seems advisable to have an officer from the Medical Service, Surgical Service, and Laboratory Service visit their nearest general hospital for maybe a day or two's indoctrination in the methods of penicillin therapy. As a rule, all the general hospitals have officers that are trained. Rather than have one officer responsible for all penicillin, it was thought better to have medical, surgical, and laboratory officers. I was trying to avoid having penicillin put out to hospitals whose personnel were not familiar with its use and laboratory check.
Commenting on this statement, General Hawley warned:
The conditions for which penicillin can be used in this theater are very definitely laid down. I am going to take very severe and very summary action against any medical officer and any hospital commander and the Chief of Service that wastes stocks of penicillin in personal experimentation: I do not want any mistake about that. We need all the penicillin we can get for the use for which we have authorized it.
Assured by Colonel Kimbrough that the selection of cases had been definitely stipulated, the Chief Surgeon continued:
Professional policies are laid down by this office and will be carried out. We have got the best professional advice in the world and that is the way we are going to practice medicine in this theater.
With so many medical officers who would now be using penicillin receiving instruction from various sources, it was evident, this time, that a statement of official policy on methods of therapy was necessary. In consideration of this
need, the Chief Consultant in Surgery submitted the following instructions on the local and parenteral treatment of wounds which were included in the aforementioned new directive Circular Letter No. 22.
Methods of therapy* * * * * * *
(2) Local and general therapy * * *
(a) Make aerobic and anaerobic cultures of the wound before and after debridement.
(b) The debridement should be conservative with respect to living tissues particularly skin and bone fragments.
(c) Irrigate the wound thoroughly with physiological salt solution at body temperature during and at the end of debridement; penicillin works best in a slightly alkaline medium.
(d) Penicillin will be provided as a powder in ampules of 10,000 units or 100,000 units each.
(e) Local use of penicillin: For local use in wounds 10,000 units are dissolved in 10 cc. of sterile physiological salt solution, (strength 1,000 units per cc.).
(f) After debridement and treatment with penicillin, the wound may be closed by primary suture, by secondary suture, or left open as circumstances warrant.
(g) Parenteral use of penicillin: For parenteral use, 10,000 units of penicillin are dissolved in one (1) cc. of physiological salt solution immediately before injection * * *.
(h) If the wound has been left open following debridement, as in a compound fracture, the initial treatment of the wound with penicillin is followed by further penicillin sprayed into the wound as well as by intramuscular injection * * *. The wound dosage in such cases is 5,000 units sprayed twice a day.
(i) For wounds in the vicinity of the anus, buttocks, perineum, upper inner side of thigh and lower back, the standard dosage should be doubled.
(j) The initial dressing of the wound should be ample in size and well secured. Frequent changes of dressing are undesirable because of the risk of secondary contamination.
(k) In solution, penicillin deteriorates rapidly. It should be freshly prepared before each use. It is unfavorably affected by heat in both powder and liquid form and should be kept in the refrigerator or in the coolest place available. The solution will remain potent however, for 5 or 6 days, if prepared under aseptic conditions and kept in the refrigerator.
(l) Penicillin is a bacteriostatic agent and not a bactericide. It is excreted rapidly in the urine; fluids, therefore, should be moderately restricted unless other considerations preclude this measure.
(m) Penicillin affects particularly staphylococci, streptococci, gonococci, meningococci, pneumonococci and the clostridii. It is most effective in unmixed infections. It does not affect the colon group of gram negative organisms, the diphtheroids nor pyocyanus.
(n) Sensitivity and bacteriostatic tests must be carried out in every case.
(o) Records. All observations of wounds treated with penicillin will be recorded on the forms provided, in order to determine applicability of this drug in the treatment of war wounds. * * * All three forms will become part of the Clinical Record of the patient.
(p) All clostridii isolated in bacteriological laboratories at station or general hospitals * * * will be sent to the 1st General Medical Laboratory for final identification.
(q) Laboratory instructions, wound treatment. These instructions may be obtained from the Office of the Chief Surgeon * * *.
As the second long English winter ended for the Chief Consultant in Surgery, there was no doubt that the new spring would finally see an invasion of the Continent by the Allies. The production of penicillin at home had been stepped up tremendously. The shipment to the European theater for the month of March was 500,000,000 units. There were indications that this would be increased soon to 3,000,000,000 units. Other sources had said that the supply was now unlimited. Col. Silas B. Hays, MC, the new theater medical supply officer, said at the conference of base section surgeons on 13 March 1944: "In fact I would not be at all surprised if by the summer time we don't get too much penicillin."
In spite of the great amount of data on penicillin now available, much of it was tentative and some of it, contradictory. Current instructions on the use of penicillin were obviously neither intended for, nor applicable to, a combat situation. But what were the instructions to be? This question was of constant concern to Colonel Cutler, and there was not much time left. In a memorandum, dated 3 April 1944, he wrote the following to Colonel Kimbrough:
On 29 March 1944, I held a meeting in the Office of the Chief Surgeon of a group consisting of Colonel Schullinger, Colonel Morton and myself in order to discuss the present situation of penicillin in this theater.
In particular we met to discuss the material being assembled for publication in the British Journal of Surgery.* * * * * * *
The Committee took up further the matter of revising our penicillin circular. This is much too bulky and demands too much for actual battle conditions, and by the time we have the next meeting we must have a simple circular telling the surgeon just how much penicillin to put in the wound, and we must rid ourselves of elaborate laboratory tests. Such a circular is now being drawn up.
And, on 10 April 1944, he wrote to Colonel Morton:
I have sent you a copy of the Florey & Cairns report. There is no one here much to help you with gas gangrene, though if we can arrange some kind of a meeting with MacLennan, who is back from the Mediterranean now, I will see you are implicated.* * * * * * *
We will call another meeting about the end of the month, but before then harden your mind as to exactly what you wish to put in a circular covering the use of penicillin in Army hospitals. My own ideas are crystallized as follows:
a. It will not be used in small wounds.
b. In large wounds of soft parts 20,000 units will be given in some suitable vehicle, and I presume this will have to be sulphanilamide.
c. In all fractures we will lift the dose to 40,000 units.
d. I am dubious about additional dosage by intramuscular injection, but perhaps we should attempt it, and you must specify over how many doses this is to be used.
The meeting alluded to was convened on 18 April. In his diary, Colonel Cutler noted that he worked with Colonel Schullinger on the penicillin directive and with Colonel Morton on the gas gangrene directive. But he informed Colonel Kimbrough by memorandum on 22 April 1944:
18 and 19 April was put in mostly working on penicillin, the greater part of the time with Lieutenant Colonels Schullinger and Morton.* * * * * * *
Attached to this is a fairly final draft of the use of penicillin for battle casualties as it will be incorporated in the professional directive now being drawn up for our combat forces. In general I would like to state that we have presented in this document the optimum method; that is, we begin the parenteral use of penicillin as far forward as it seems possible to get the drug and we continue it for as long a period as we think ideally necessary. In addition, we place penicillin in the wound. I have heard that the U.S. Army in Italy is not using penicillin in the wound and I believe we have reached that point in our knowledge of this agent where we can say it is best used as are the sulfonamides; that is, by maintaining an adequate blood level which can be done without placing penicillin in the wound. However, if we do not limit our thinking to terms of the supply of the agent, then the method cited in our draft is optimum. Note that if we utilize penicillin as outlined the amount of drug required runs in to astronomical figures.
a. Each soft part injury requires 420,000 units.
b. Each compound fracture, 580,000 units, and both of these amounts are doubled when the wound is about the perineum or buttocks.
c. If we take 6,000 injuries per day, which one might say is 1,000 casualties a day from each of 6 divisions, one corps of a 3 corps army in fighting, then the requirements would be, for 4,000 soft part injuries 1,680,000,000 units, and for 2,000 fractures 1,160,000,000 units, or a total of 2,840,000,000 units, and if 10 percent of the cases were wounds of the buttock, upper thigh or perineum, i.e. 600 cases, in which the dose would be double, then these 600 cases would need roughly 300,000,000 units or a total daily demand of 3,140,000,000 units. This for one month would mean 94,200,000,000 units which would mean 940,000 vials. Recommend that you transmit a demand for at least 75,000,000,000 units per month, once operations commence.
We believe there is no contradiction to, and indeed desire that sulfonamide therapy continue at the same time as penicillin therapy.
In addition to the recommendations made on the attached draft concerning penicillin in the Army, we are now revamping the circular for the use of penicillin in S.O.S. installations.
On the same day, recommendations for the treatment of gas gangrene were also submitted in final form. Both the penicillin and gas gangrene statements were included in Circular Letter No. 71, Office of the Chief Surgeon, ETOUSA, dealing with the treatment of battle casualties in the combat zone (appendix B, paragraphs 7 and 10). These instructions were published on 15 May 1944, not any too soon, and only 3 weeks before D-day. The important fact, however, is that the necessary decisions had been made and the command had been informed. Moreover, the decision had been independently made. The British, at this time, had not yet hardened their minds as to what their policies would be for the use of penicillin in the continental invasion.
Status of the blood bank
A question asked on more than one occasion by the Chief Surgeon during this period was: "What is the status of the blood bank?"
And therein lies the clue to activities at this time in the field of transfusion and resuscitation for the Chief Consultant in Surgery, ETOUSA. Unlike penicillin, facts in the case had been assembled, and he had made his recommendations. He had determined that probably 1 out of every 10 casualties would require parenteral fluids for resuscitation and that the proportion of plasma to whole blood used would be about two to one. Instructions had been issued to begin making some 350 field transfusion kits of the Ebert-Emerson type, and their assembly had begun. The Chief Surgeon had decided that whole blood would not be procured from the Zone of Interior, which left only one alternative-to provide for supplemental sources of whole blood within the theater itself.
The problem at this stage was to present the overall objectives to the theater commander for his approval, since the plan involved all elements of the command. Following approval of the plan, if granted, there would be an enormous amount of staff work to set up and establish the desired organization for the whole blood service, obtain the personnel and equipment, and gain further approval for specific operations involving elements other than the medical. In other words, the problem was no longer primarily professional. It was now a matter of operations and supply. Accordingly, the guiding force in establishing a whole blood service devolved upon Lt. Col. (later Col.) James B. Mason, MC, of the Operations and Training Division, Office of the Chief Surgeon (fig. 56). Later, Lt. Col. (later Col.) Angvald Vickoren, MC (fig. 57) , replaced Colonel Mason in this responsibility. Initially, the supply aspects of the problem fell upon Col. Walter L. Perry, MC, then the theater medical supply officer.
Actually, much of the work on this project was done in committee fashion with Colonel Cutler representing the professional services; Colonel Perry, medical supply; Colonel Mason, operations; Lt. Col. Ralph S. Muckenfuss, MC, the 1st Medical General Laboratory; and Captain Hardin, transfusion and resuscitation. Obviously, efforts of the operations and supply officers would have been limited without the "ammunition" and advice provided by the professional members of this committee.
The first meeting of this group was on 19 August 1943. In addition to those mentioned above, Lt. Col. Ambrose H. Storck, MC, then Senior Consultant in General Surgery, also attended. The purpose of the meeting was to consider the matter of implementing the supply of whole blood and the entire problem of blood transfusion for the European theater. Colonel Cutler's report of the meeting mentioned certain points, substantially as follows:
1. After full discussion of the present transfusion field kit set originally laid down by Majors Ebert and Emerson, of the 5th General Hospital, it was
decided to place with each kit issued a printed list of instructions of its use. In this instruction sheet it will appear that 50 cc. of 2.5 percent sodium citrate should be added to 400 cc. of whole blood, giving a final concentration of sodium citrate of 0.27 percent. Colonel Perry believes he can now implement the securing of a sufficient number of these sets for our requirements.
2. The securing of whole blood in the SOS and its transport to combat forces on the Continent.
a. Source of blood. The source is to be SOS troops and lightly wounded and the ground personnel of the Air Force (about 40 percent of American troops are in Group O and are therefore satisfactory donors). The source above should be ample for our requirements.
b. The giving of blood by the above troops should be compulsory (General Lee).
c. Collection of blood. This requires mobile units with a refrigeration plant for 120 pints. It is suggested we use 1½-ton trucks. Personnel and T/BA of these mobile bleeding units already laid down and in the hands of Colonel Mason, and copies to be given to Colonel Muckenfuss.
d. Storage. This should be at 1st Medical General Laboratory. The refrigerator plant should be the large Navy refrigerators already acquired by Medical Supply. We should need 2,000 pints in storage and should be prepared to supply 200 pints per day to the Army. The General Medical Laboratory will need: (1) Storage space, (2) cleaning space, and (3) personnel for cleaning. They will require 2,000 bleeding sets, 5,000 bottles, and 5,000 giving sets.
e. Delivery to the Army. Delivery from the laboratory to the Army should be by air in iced or Thermos containers. Colonel Perry is to look into the supply of these and Colonel Mason should make contact with the Air Force for the privilege of using such planes.
f. During delivery from the Army Medical Depot to the Army hospitals the blood will be kept in iced or Thermos containers. The responsibility for the returning of giving sets, bottles, and containers will be that of the Army surgeon.
g. None of this program should be implemented unless first priorities can be secured for the handling of such a precious and vital material as whole blood. This includes items of collection, storage, transportation, and return of vitally important apparatus to the laboratory for cleaning and reuse.
On 24 August, Colonel Cutler and Colonel Mason visited Widewing, Eighth Air Force headquarters, for exploratory talks on the flying of blood to the Continent. At a conference on 20 September, Colonel Mason was requested by the Chief Surgeon to prepare with the least delay for submission to the Chief of Operations, SOS, details of plans for the whole blood service. After informing the medical supply officer of this requirement, Colonel Perry informed Colonel Mason that all necessary supplies were available in the theater except vehicles to be converted into refrigerated trucks. These, after Captain Hardin had checked over all types of vehicles for adaptability, were 2½-ton, 6 x 6, short-wheel-based cargo trucks. Colonel Perry initiated requests through the theater Chief of Ordnance to the Zone of Interior for 30 of these trucks. (Later, four additional trucks of this type were requested.) Provision of these trucks became known, in supply parlance, as Project GS 22 and GS 22 Supplemental.
In addition, Colonel Muckenfuss and Captain Hardin were asked to prepare a paper which would show the entire project in detail. This they did with their paper broken down into the following sections: Operating procedures, volunteer blood panel, estimate of requirements, operating agencies, the blood collection section of the base blood depot, the laboratory section of the base blood depot, distribution during the assault phase, personnel requirements, and necessary organic equipment.
Their report showed that 200 pints of blood per day would be required during the period from D-day to D+90 and that the whole blood service could collect 600 pints per day as a maximum. Beginning at about D-7, they estimated that 3,000 pints of blood could be collected by D-day. Following that, they contemplated maintaining a level of 1,000 pints at the base blood depot and 200 pints in advanced blood depots.
It was proposed that each SOS unit would maintain current lists of volunteer donors. Each SOS unit would report monthly the number of donors available to their base section commanders who, in turn, would consolidate these reports and notify the Chief Surgeon of the total number of donors available in their areas. The sum total of these volunteers would be known as the ETO Volunteer Blood Panel.
The operating agencies of the whole blood service were to consist of a headquarters section located at the 1st Medical General Laboratory, a base blood depot, and advanced blood depots. The headquarters would include the director of the whole blood service; a Medical Administrative Corps or Sanitary Corps officer in charge of administration, records, and supply; and clerks, orderlies, drivers, and automotive and refrigeration mechanics.
Under the headquarters, there would be a base blood depot with four bleeding teams and a laboratory section. The base blood depot was to be located at the 1st Medical General Laboratory with additional refrigerators at the 5th General Hospital for emergency storage and dispersion. The blood collecting section was to be composed of four bleeding teams, each having one Medical Corps officer and seven enlisted men with a refrigerated truck and other equipment necessary to operate mobile bleeding stations. The laboratory section was to recondition, clean, assemble, and sterilize equipment; process and store the blood; and prepare blood for shipment. One officer, an expert in transfusion and resuscitation, was to head the laboratory service and the base blood depot. He was to have 33 enlisted men to operate the washing room; the assembly room; the supply, still, and sterilizer facilities; the glassblowing and needle-sharpening facilities; the blood-processing facilities; and the refrigerators.
Contemplated for the other side of the channel were advanced blood depots to be attached to armies and those to be attached to communications zones. The functions of advance blood depots were solely to store and distribute blood under the supervision of the army or communications zone medical supply depot to which they would be attached. The primary difference between an army type of unit and a communications zone type of unit was that, in the former, there
were to be eight refrigerated trucks and, in the latter, only four. In addition to the refrigerated trucks, each unit was to have an unmounted storage refrigerator.
The operation of each of these agencies was described in minute detail, as well as proposals for operating the service during the initial phase of the attack on the Continent.
Needless to say, preparation of a document of this sort, accompanied by charts and figures, required time. An equally lengthy period was required by the Operations Division, Office of the Chief Surgeon, to review, revise, and dress it up for formal presentation in sufficient copies.
In order to submit the proposed plan, Colonel Mason required a succinct statement as to why it was so essential, and he asked Colonel Cutler for this "ammunition." On 15 November 1943 Colonel Cutler provided Colonel Mason the following statement concerning the whole blood service in the European theater:
2. The evidence that whole blood is valuable in caring for battle casualties seems completely established.
a. We have the analysis of 30,000 givings of blood from the British North African campaigns. In these campaigns blood was drawn in Cairo, flown to forward areas and delivered by refrigerated trucks to forward medical units.
b. We have evidence that certain cases suffering from severe blood loss can only be saved by restoration of the volume through whole blood. Plasma alone may prove insufficient, and has been proven so by physiological experimentation was well as by clinical trial.
c. The Russian and British armies have a setup similar to that proposed.
d. Correspondence with our own medical units in the North African campaign shows that the forward medical units greatly desire blood in addition to plasma and some observers felt lives could have been saved had blood been supplied in sufficient quantity.
e. Direct communications from British officers follow:
From General Ogilvie, Consulting Surgeon, British M.E.F.: "Blood is being used more frequently, earlier and further forward. Blood transfusions save more useful lives than ever before."
From Colonel Porritt: "The best thing in the British medical services in North Africa was the Blood Transfusion Service."
On the same day that he submitted the foregoing information, Colonel Cutler also wrote to the chief of the Operations Division, Office of the Chief Surgeon, substantially as follows:
1. I am worried what might happen in this theater if a big attack started and great quantities of wounded people were brought to this island and our blood bank was not working.
2. Should we set up blood banks in station hospitals as well as in general hospitals now, or can we count upon our blood bank's supplying station hospitals with blood, should the necessity arise?
Colonel Mason assured Colonel Cutler that the distribution plan for whole blood provided for the emergency supply to station and general hospitals in the United Kingdom.
He also indicated that it was probable that each hospital could provide enough blood for transfusion from donors available in and about the hospital. Authorization of the Blood Panel, ETOUSA, and command arrangements for shipping, Colonel Mason stated, were being handled in the London office. As of that date, Col. Thomas J. Hartford, MC, had not sent out the letters to the Commanding General, SOS, although he had indicated this would be done in the very near future. Colonel Mason added that he would like to discuss with Colonel Cutler the matter of the supply of blood to SOS units in the United Kingdom at Colonel Cutler's earliest convenience.
The matter of supplying blood to SOS units in the United Kingdom was settled most opportunely at a later date. Meanwhile, General Hawley had submitted his recommendations (based on information submitted by the whole blood committee) for a whole blood service for the theater, as follows:
1. The problem To furnish fresh, whole blood for transfusion of battle casualties as far forward as division clearing stations.
2. Facts bearing upon the problem a The experience of the British and Russian Armies, as well as the experience of U.S. forces on all fighting fronts, is that dried plasma meets the requirements of only about two-thirds of all cases requiring replacement of blood volume.
3. Recommendations a That the policy of furnishing refrigerated whole blood to medical units as far forward as division clearing stations, inclusive, be established in this Theater.
Following approval of the plan by the Commanding General, SOS, and the theater commander, the basis for the whole blood service was firmly established with instructions to the Commanding General, First U.S. Army Group, and
instructions from the Commanding General, SOS, to set up the ETOUSA blood panel.
The command letter, dated 2 January 1944, from Lt. Gen. (later Gen.) Jacob L. Devers, Commanding General, ETOUSA, to the Commanding General, First U.S. Army Group, contained the following statement:
1. The provision of whole blood for the treatment of casualties in this theater, throughout all echelons down to and including division clearing stations, is approved.
2. Whole blood will be an item of medical supply and will be distributed through medical supply channels. It will be given the highest priority in transportation.
3. * * * personnel and special equipment will be furnished to each Army without requisition from sources available to the Commanding General, SOS, ETOUSA, * * *.
The ETOUSA blood panel was established by a command letter from Maj. Gen. John C. H. Lee's SOS headquarters, on 6 January 1944. The substance of the letter was as follows:
1. The establishment of a blood panel for the theater, to furnish whole blood in the treatment of casualties, has been approved by the theater commander.
2. It is desired that:
a. In each unit of the SOS, a nominal list of volunteer donors of TYPE O be prepared and retained in the unit headquarters.
b. A record of the number of TYPE O volunteers, by unit, in your command be maintained in your headquarters.
c. The records required by subparagraphs a and b be corrected as of the 15th of each month; and, immediately following each such correction, a report of the number of TYPE O donors in each unit of the SOS in your command be sent to the Commanding Officer, Blood Bank, ETOUSA, 1st General Medical Laboratory.
d. Upon call of the Commanding Officer, Blood Bank, ETOUSA, the volunteer TYPE O donors of the unit specified be assembled at a designated bleeding station (ordinarily the unit dispensary) at an hour, to be determined by you, which will not seriously interfere with the normal duties of the unit and which will be reasonably convenient for the bleeding team.
e. Only light duty be required of donors from the time of bleeding until reveille the following morning.
3. The general rule will be that four-fifths of a pint of blood will be taken at each bleeding, and that donors will not be bled oftener than once in each 3 months. This amount of bleeding will have no ill effect upon any donor and will neither reduce his physical capacity for work nor predispose him to illness.
4. Your active interest in obtaining as many volunteers as possible is enjoined.
As slow and ponderous as progress on the project might have seemed, there was no doubt that it was being carefully and thoroughly established. Colonel Cutler was pleased with the work being done and must have felt considerable pride in seeing what had been but a year before an idea of his maturing into a full-fledged theaterwide operation. After one apparently most satisfactory conference with General Hawley on the whole blood service, he wrote in his diary: "Blood project OK. Hope I got Jim Mason promoted."
The groundwork having been laid, there was still much to be accomplished before the whole blood service could be a reality. There was the question of how to provide the manpower for the service, and opinion varied between merely augmenting the 1st Medical General Laboratory or using a separate
unit. The decision was made on the latter and a special table of distribution was made up for the 152d Station Hospital, which became the Blood Bank, ETOUSA. In December, both Colonel Mason and Colonel Cutler urged that it was high time to appoint an officer to be in charge of the whole blood service and command the 152d Station Hospital. Some names were suggested, but none proved acceptable for various reasons. The only position on which there was complete agreement was that Captain Hardin should be in charge of the base blood depot and the laboratory and bleeding sections under it. Eventually, Colonel Muckenfuss was placed in charge of the whole blood service and in command of the 152d Station Hospital. This was in addition to his duties as the commanding officer of the 1st Medical General Laboratory and as the theater consultant on laboratories. Since the headquarters and base blood depot of the whole blood service were to be located physically within the premises of the 1st Medical General Laboratory, and, since there would be no need to move either the whole blood service headquarters or the 1st Medical General Laboratory soon after the invasion, the choice was reasonable. Moreover, Colonel Muckenfuss had been acting, for all intents and purposes, as the head of the whole blood service up until this time. These arrangements solved the personnel aspects of establishing the blood project.
In late December 1943, not long after initiating the request for trucks, Colonel Perry had been notified by a message from PEMBARK, the New York oversea supply depot, that the trucks, as requested, had been approved and that 12 trucks were at the port awaiting shipment and the others soon would follow.
On 31 January 1944, General Hawley asked at the meeting of base section surgeons: "What is the status of the blood bank?"
Colonel Kimbrough, replying to the questions, said: "The last report they were 10 days from having the construction done-that was a week ago. The equipment is almost in. Refrigerators are frozen, allocated but not delivered. The people are there under the direction of Colonel Muckenfuss on the administration side, and Captain Hardin is carrying out the professional side. They have not called on us for any more personnel."
Two weeks later, at the 14 February 1944 conference of base section surgeons, General Hawley again asked: "What is the status of the blood bank?" This time, he added: "When are they going to be ready to start some bleeding?"
Colonel Kimbrough said that the physical plant was practically complete and that they should be able to begin bleeding at an early date (fig. 58). Lt. Col. (later Col.) Raymond E. Duke, MC, Operations Division, Office of the Chief Surgeon, said that, according to Colonel Muckenfuss, they should be ready to go within 2 weeks.
The bottleneck was in trucks and refrigerators. An incoming message from PEMBARK, 16 March 1944, said that the 30 trucks requested on project GS 22 were in port and were expected to go forward soon and that the four trucks requested in project GS 22 Supplemental were also in port and were
expected to be shipped soon. It was disheartening to learn at this late date that the vehicles were still awaiting shipping. But Colonel Vickoren, with keen foresight, had anticipated such an outcome. PEMBARK had said in December 1943 that 12 trucks were ready to be shipped. As these had not arrived by the end of February 1944, Colonel Vickoren arranged to "borrow" 12 similar trucks from Ordnance maintenance stocks in the theater which were to be repaid by the 12 at New York when they arrived. These 12 were received from the theater Ordnance stocks late in March. When surveillance of the manifests revealed that none of the trucks from New York were on board any ships due to arrive soon, Colonel Vickoren requested that the remaining 22 trucks be supplied from Ordnance maintenance stocks. In the request, he stated: "These trucks are urgently needed, as approximately three (3) weeks' time is required to install refrigerators in these trucks after delivery is effected. The European theater blood bank cannot function without this vehicular equipment, yet each unit must be completely equipped prior to start of operations."69
The story was the same with the refrigerators. They were approved and available on paper but could not be gotten physically. It was not until mid-February that the first refrigerators were received, but a relatively steady trickle continued to be received thereafter. Even at three per week, however, this represented four-fifths of the output of the British supplier. The remainder was being used by the British for maintenance of existing equipment. The delay in obtaining the original shipment was due to demands from active theaters.
At this time, when it appeared that the barest needs for establishing a whole blood service to support one army in the field seemed assured, Col. Thomas J. Hartford, MC, Executive Officer in the Office of the Chief Surgeon, London, returned from North Africa and Italy with some startling details. Certain of these bothered General Hawley and, in a memorandum to his Professional Services Division, on 28 March 1944, he wrote the following:
1. * * *
In the early days of the campaign, one pint of whole blood was used for each eight casualties. Now, one pint of whole blood is used for each 2.2 casualties (fig. 59).* * * * * * *
2. The increasing use of whole blood makes me concerned about the capacity of our own blood bank.
We cannot count upon an average useful life of more than 10 days for whole blood. I am informed that, under the best conditions, we cannot deliver whole blood to the front in less than 4 days after procurement. This means that an average life of usable whole blood is not more than 6 days; and, to be safe, we should not count on more than 5 days.
This, in turn, means that the blood bank must be able to replace the total demands for blood at the front every 5 days.
Can it do it?
Colonel Kimbrough optimistically replied that plans were being made to furnish whole blood in the ratio mentioned and that the blood bank would be able to replace whole blood in the time and amount required. Colonel Liston, acting for General Hawley while the latter was in the United States, insisted, however, that a firm figure for planning purposes be provided of the ratio of whole blood required to the number of casualties.
The problem was put to Colonel Cutler, who advised as follows:
British plans (from talk with Colonel Benstead in office of Major General Poole, British War Office, 6 April 1944)
1. Original British planning after North African campaign was that 1 in every 10 casualties would require fluid replacement including blood. When this is necessary, give 1 pint blood and 2 pints plasma-repeat S.O.S.
2. Recent planning calls for greater use of blood. Colonel Boyd who was in charge of British Medical Blood Banks, favors 1.5 pints for every 10 casualties.
U.S. Army plans
1. Originally we planned as in paragraph 1 [Under British plans], 1 pint for every 10 casualties, supplemented with plasma.
FIGURE 59.-Whole-blood service in the Mediterranean theater. A. Blood Transfusion Unit refrigerated truck, delivering blood to planeside for transportation to the Fifth U.S. Army area. B. A refrigerated truck delivering blood to a Fifth U.S. Army evacuation hospital.
2. Colonel Hartford, recently returned from Italy and North Africa, brings back use of blood after establishment of blood bank at Naples in Army Med. Lab.
Recent 5th Army beachhead statistics show: U.S. Forces used 1 pint blood to each 1.85 casualties, British used 1 pint blood to each 2.79 casualties. Total 5th Army statistics equal 15,000 casualties, show use of 1 pint of blood to each 2.2 casualties (this is field hospital and evacuation hospitals).
Comment: (1) Note Colonel Hartford's figures are for pints used, not blood per casualty. Thus, if 2 pints per casualty, it would be at following rate: blood would be required by each 4.4 casualty.
(2) In Italy donors are paid $10 per bleeding.
Recommend: U.S. Army E.T.O. Blood Bank be equipped to supply combat force with whole blood at rate 1 pint for every 5th casualty.70
While this recommendation and the logic by which it was attained might appear to be not entirely satisfactory, the fact of the matter was that the demand for a new planning ratio was merely an academic question at this time. It was obvious enough that the original objective of one pint of blood for every 10 casualties was going to be difficult to realize. Moreover, it had been necessary for the Commanding General, SOS, ETOUSA, to issue another command letter, on 6 April 1944, notifying SOS subordinate commanders that the number of donors had fallen far short of expectations and requirements and that action would be taken to increase the number of whole blood donors.
On the brighter side of the picture, however, were these factors. When Colonel Cutler had visited the blood bank on 31 March 1944 to discuss the possible extension of blood production, he had learned that six of the large walk-in type of storage refrigerators had been installed at the 1st Medical General Laboratory and were ready for use. Eleven trucks had been fitted with refrigerators and were also ready for use. And, with these facilities available, the blood bank was ready to engage in trial distributions of blood to the East Anglia area as an experiment-to ascertain how the service was actually going to function. Colonel Cutler noted, too, with pleasure, that Captain Hardin had finally been promoted to major.
Arrangements for the air delivery of blood to the Continent had long since been completed by Colonel Mason. In conferene with Col. Edward J. Kendricks, MC, Surgeon, Ninth U.S. Air Force, Colonel Mason had obtained complete agreement on the following procedures: (1) Troop carrier aircraft from the Ninth Air Force would deliver blood from the vicinity of the base blood depot to the vicinity of the army medical supply depot on the Continent, (2) an enlisted man from the base blood depot could accompany a shipment of blood to insure proper handling and delivery, and (3) aircraft would return empty containers and equipment from the far shore and bring back the
enlisted men who had accompanied the blood shipments. Colonel Kendricks also revealed the encouraging note that the Troop Carrier Command of the Ninth Air Force was quite familiar with the transportation of blood, since they had transported blood for the British Eighth Army during the North African campaign.
As D-day approached, there was no longer any doubt that the whole blood service was ready and able to conduct its initial mission of supplying whole blood in support of the invasion of the Continent (fig. 60).
While the whole blood service was being developed in this manner, there were also significant development in the matter of transfusion sets for "bleeding on the hoof."
Individuals in the Office of The Surgeon General saw certain difficulties and undesirable characteristics in the Emerson-Ebert transfusion unit, when they received details of the set. They realized that it had been devised with consideration for material available in the theater and for use, possibly, in areas forward of hospitals where autoclaving facilities would not be available. But they did not believe that directions given for cleansing and sterilizing the set would eliminate pyrogens and contaminants. The special representative to The Surgeon General on transfusions and intravenous solutions, Lt. Col. (later Col.) Douglas B. Kendrick, Jr., MC, suggested that it might be better
to follow the system using empty plasma containers as described in Circular Letter No. 108, Office of The Surgeon General, 1943. The ideal solution to the problem, he suggested, was the expendable vacuum bottles and expendable recipient sets with filters, which were being proposed as regular medical supply items. Unfortunately, however, these recommendations could not be applied until the necessary equipment could be obtained.71
There were disadvantages, too, to the method recommended by The Surgeon General in Circular Letter No. 108, 27 May 1943, utilizing the dried plasma apparatus. Major Emerson brought these to Colonel Cutler's attention. The objections were pointed out in a memorandum, dated 27 Sept. 1943, to Maj. (later Lt. Col.) Michael E. DeBakey, MC, in the Surgeon General's Office, and included the following: (1) Cross-matching, as recommended, was not feasible with equipment available in the field, (2) the open technique was liable, in the field, to introduce appreciable amounts of foreign matter into the blood, (3) the type of airway in the apparatus would cause air pressure in the bottle to be below atmospheric pressure, and this, plus a layer of glass beads, two needles, and filter, would materially limit the rate at which blood could be administered, and (4) the material and equipment required for the cleaning and sterilization procedures recommended would not always be available in the field. The primary objection, however, was to the fact that only 300-cc. flasks of dried plasma were available in the European theater and when these were used for collecting sets with the requisite introduction of 50 cc. of citrate solution, the amount of blood collected would scarcely make the effort worthwhile.
In view of this situation, Major Emerson was detached to the medical supply depot at Thatcham, England, with enlisted men to help him, and continued to assemble the transfusion units devised by him and Major Ebert. Some 800 sets of instruction were printed to go into the unit packing, which eventually was done in used .50 caliber ammunition cases repainted to medical standards with the Geneva Cross. A 25-minute training film in color was also made to show how the transfusion kit was to be used. With only minor problems of obtaining the necessary items at the right time, the production of these transfusion units proceeded well.
In the meanwhile, Major Ebert was sent to the Office of The Surgeon General to present the European theater plans for providing whole blood in the field. Upon his return, he prepared a report of his visit for Colonel Cutler. The report was substantially as follows:
A brief interview with The Surgeon General and a long discussion with Colonel Kendrick, Special Representative in Transfusions and Intravenous Solutions in the Surgeon General's Office, were held on 6 December 1943 and subsequent days.
The Surgeon General was of the opinion that whole blood was not necessary in the most forward areas and that plasma should be used for the treatment of
shock under these conditions. In general, he did not believe whole blood should be used forward of the evacuation or field hospital.
A complete discussion was held with Colonel Kendrick concerning the nature and relative advantages of the equipment used at present in the European theater and the equipment recommended by the Surgeon General's Office. Colonel Kendrick described the equipment for blood transfusions now in production but not available at the present time. This consists of 750-cc. vacuum bottles containing 200 cc. of sterile McGill solution (an anticoagulant containing sodium citrate and glucose which is suitable for storage and blood). These bottles are manufactured by the Baxter Co., are expendable, and are used once and then discarded. In addition, donor sets and expendable recipient sets are provided. The recipient sets are made of viscose (cellophane) tubing, are packaged under sterile conditions, and are ready for immediate use. A simple wire mesh filter is included in each recipient set. This transfusion equipment is suitable for fresh blood transfusion or for the storage of whole blood.
In the discussion with Colonel Kendrick, the advantage of having all the equipment necessary for performing a blood transfusion included in a single container was pointed out. As a consequence it was decided to package the equipment in a fiber box which will contain 11 vacuum transfusion bottles, 11 recipient sets (sterile expendable), 1 donor set, and a box each of anti-A and anti-B typing serum. This equipment will not be ready for distribution until approximately February 1944. The equipment should, however, be requisitioned immediately. The equipment has not yet been given an order number. It can be requisitioned as follows:
Complete transfusion set containing the following: 11 vacuum transfusion bottles with McGill solution, 11 recipient sets (sterile expendable), 1 donor set, 1 box of typing serum anti-A, 1 box of typing serum anti-B.
In view of the fact that the exact date of delivery could not be guaranteed, it was recommended that the present plans for transfusion equipment in the European theater should be continued until such a time as the new equipment should be substituted.
A 4-cubic-foot electric refrigerator designed for storage of whole blood is available. This has sufficient capacity to hold approximately 50 bottles of blood. The refrigerator can be operated from the usual powerline supply as well as by a small 500-watt generator which is supplied with it. It is recommended that these refrigerators be placed in all general, evacuation, and field hospitals. The refrigerators can be requisitioned as follows:
Refrigerator for storage of whole blood.
It was strongly felt by all concerned in the discussion that transfusion services should be established in all hospitals under the supervision of a transfusion officer. This service would be responsible for the formation of a donor panel, typing of blood, withdrawal and administration of blood and storage of blood. It was felt that provision should be made for training men in modern transfusion technique.
Through the courtesy of Capt. John Elliott, SnC, Army Medical School, and Dr. Louis K. Diamond, of Harvard Medical School, 20 cc. of anti-Rh serum (in dried form) was obtained for use in this theater.
In accordance with Major Ebert's suggestions, Colonel Zollinger, acting for Colonel Cutler, took the necessary steps through the Operations Division and the Supply Division, Office of the Chief Surgeon, to procure 4,000 complete transfusion sets of the expendable type and some 200 refrigerators and generators for storing whole blood. Sufficient refrigerators, over and beyond those already available in the theater's hospitals, were requisitioned so that not only the general, evacuation, and field hospitals-as recommended by Major Ebert-but station and convalescent hospitals and general dispensaries as well could be equipped with blood-storage facilities.
By mid-March, the Emerson-Ebert transfusion units were ready for distribution and were issued to units of the First U.S. Army on the following basis:
Colonel Zollinger explained that these units varied from the original in that sufficient serum for typing only 25 donors was included instead of enough for the original 50. In addition, the number of transfusions possible from each kit was 10 or 11 instead of 18, as originally planned. These changes were necessitated because it was necessary to use British sodium citrate solution, which was more bulky in its packing than American supplies of the solution.72
On the basis of issue determined by the Operations Division, the First U.S. Army required some 175 of the transfusion units. When the decision was made that the Third U.S. Army would be equipped with the new expendable type of unit being developed by the Surgeon General's Office, the excess transfusion units developed in the European theater were provided Army Air Forces medical units at operational airbases in the United Kingdom for emergency use. It was further contemplated that replacement of the Emerson-Ebert transfusion sets would be accomplished by using the new expendable type.
The equipment and facilities for transfusion and restoration of blood having been completed, the entire program was finally tied together with intensive courses conducted throughout the medical units in the theater on the reconstitution of blood plasma for administration, attendance of First U.S. Army medical officers at the course on transfusion and resuscitation at the British Army Blood Supply Depot, and instruction on the use of the European theater transfusion unit utilizing the motion picture which had been prepared.
Finally, permission was obtained to classify the refrigerator trucks, which would be distributing blood, as surgical trucks so that they could be painted with the Geneva cross and receive protected status-and also, so that they would be given priority on the roads in carrying out their lifesaving mission of mercy (fig. 61).
Incidental preparations for invasion-Operation OVERLORD
General Hawley continually insisted that all planning should be done with combat operations in mind. For instance, at the 30 August 1943 meeting of base section surgeons, he stressed the point that no procedures should be established which could not be followed when combat started. Thus, all planning was, or should have been, directly related to contemplated combat operations. But some things were done specifically for the first phase of combat in the European theater, the assault upon the Continent-Operation OVERLORD. Other activities, while the intent was for their continuance during and after Operation OVERLORD, nevertheless had to be completed for OVERLORD or were conducted with OVERLORD specifically in mind. Among the latter, incidental preparations which concerned the Chief Consultant in Surgery were such programs as: (1) Rehabilitation, (2) care of the lightly wounded, (3) realinement of teams within auxiliary surgical groups, and (4) preparation of documents which would be readily available and would contain all basic policies on surgical care and management of casualties.
Rehabilitation.-The preliminary meeting of the surgical subcommittee preceding the meeting of the Chief Surgeon with his consultants on Monday, 22 November 1943, was lengthy and concerned chiefly the matters of rehabilitation and care of the lightly wounded. While Colonel Diveley, under General Hawley's direction, had initiated a huge, comprehensive rehabilitation program, there was yet a notable lack of agreement on many points (fig. 62). The program set up by Colonel Diveley, and at times looked upon with considerable alarm by Colonel Cutler, was based on large rehabilitation centers which were to bear the brunt of the rehabilitation program. There was also a requirement that hospital commanders, using their initiative, establish rehabilitation programs for their in-patients. Questions in this area now involved such items as (1) how much and what rehabilitation was to be conducted in hospitals, (2) who were to go to these rehabilitation centers and during what phase of their convalescence they were to go, (3) what the distinction was between hardening (reconditioning) and rehabilitation, (4) what the functions were of a replacement center as compared to those of the rehabilitation center, and (5) when a soldier was to be considered as rehabilitated? While the rehabilitation problem was of considerable concern to all the consultants during this period and had been a responsibility of the Chief Consultant in Surgery at one time, a separate portion of this chapter deals with the subject and this report on the
activities of the Chief Consultant in Surgery will not belabor the subject. Let it be said, however, that Colonel Cutler and the other consultants all saw eye to eye in the needs for a sound rehabilitation program regardless of their individual differences as to how the program should be carried out. And Colonel Cutler, with characteristic energy, strove to develop the rehabilitation program while keeping it in bounds. Although the object of the rehabilitation program was to return as many patients as possible as early as possible to some useful form of duty in the theater, it is mentioned here because there was also the contingent need to make the most efficient use of hospital beds by transferring elsewhere those who were ambulant and could convalesce with little professional medical care.
Care of lightly wounded - The care of the lightly wounded was a topic near to the heart of the Chief Consultant in Surgery, for it was in the optimum management of these cases that surgery could make its major contribution for returning the greatest number of wounded to the battlefronts. This matter had been frequently discussed within the Professional Services Division, but at the aforementioned meeting of 22 November 1943, there was enough agreement of opinion to permit Colonel Cutler to recommend that some 10 miles behind the 400-bed evacuation hospitals supporting divisions on the line, there should be a 750-bed evacuation hospital. "This," Colonel Cutler stated, "should be a hospital for the care of the lightly wounded and the nonseriously ill medical [patients]. At a moderate distance from this evacuation hospital should be the convalescent hospital, centered for the army, and the lightly wounded and nonseriously ill medical [patients] should be able to stream through this 750-bed evacuation hospital for initial treatment, and then recover in the convalescent hospital, from which they could be restored to active duty without traveling further down the line. Indeed, some personnel could go directly from this 750-bed evacuation hospital to active duty."
The overall system using platoons of field hospitals close to division clearing stations, 400-bed evacuation hospitals farther to the rear, a 750-bed evacuation hospital well in the corps rear area, and a convalescent hospital in the army service area would allow for the care of the nontransportable seriously injured individuals either in the field hospitals or small evacuation hospitals close to the line, and the care of the lightly wounded and others restorable to active duty in a 750-bed hospital and a convalescent hospital.73
At the 22 November afternoon meeting of all the consultants with the Chief Surgeon, the subject was again presented. Col. (later Brig. Gen.) John A. Rogers, MC, First U.S. Army surgeon, wanted to know what size army Colonel Cutler was referring to for his suggested use of 750-bed evacuation hospitals, and Colonel Spruit offered the thought that perhaps an evacuation hospital was not the correct type of unit to provide care of this sort. Colonel Cutler replied that he was thinking of one 750-bed evacuation hospital for an
army corps. To Colonel Spruit's assertion that the equipment of an evacuation hospital was too extensive to be used in this situation, Colonel Cutler submitted the opinion that, if these wounded were to fight again, they needed good care.
Colonel Rogers directed the attention of the conferees to the fact that there were not enough 750-bed evacuation hospitals in the theater to be used at the rate of one per corps and that the First U.S. Army was going to have only one. Colonel Cutler insisted that two would be necessary, but added that perhaps two field hospitals could replace one of them. Colonel Cutler mentioned that there were many of the larger evacuation hospitals in North Africa. Colonel Tovell confirmed this statement by reporting that there were 14 in the North African theater. Colonel Cutler closed the discussion by explaining that he was not so interested in the type of unit as in the care of the lightly wounded in hospitals.
"We could save a lot of personnel for the Army," he maintained, "and it would make a big step forward."
The implementation of such a program rested squarely with the army surgeon, within the limits of facilities available to him. And Colonel Cutler was very gratified to learn that Colonel Rogers saw the problem and its solution in much the same light as he.
Auxiliary surgical groups - On 30 September 1943, Colonel Cutler visited the newly arrived 1st Auxiliary Surgical Group which had recently arrived in England and was quartered at the 68th Station Hospital. He had an excellent talk with the group's commander, Col. Clinton S. Lyter, MC, who, he discovered, had some excellent ideas about the employment of mobile surgical teams. Colonel Cutler also learned, in his lengthy visit with the unit, that some of the medical officers were "pure" specialists in the sense that they were specialized in such a narrow field that they could not be employed on more general types of surgery. For instance, there were two neurological surgeons who could not be counted on to carry out surgical procedures elsewhere than on the brain. They, obviously, would have to be removed from the group since they would be of no great use under combat conditions. Colonel Lyter also informed Colonel Cutler that there was a new table of organization which greatly reduced the strength of the group and more or less limited teams to general surgery, a change which Colonel Cutler approved heartily and had been recommending since his first days in the Army in this war.
Later, Colonel Cutler and Colonel Lyter met with Major Graves of the 3d Auxiliary Surgical Group and planned to replace teams from the 3d Auxiliary Surgical Group on temporary duty at various installations in and about the United Kingdom by teams from the 1st Auxiliary Surgical Group. However, on 2 October, word was received that the members of the 3d Auxiliary Surgical Group who had been loaned to the North African theater were returning. This news necessitated cancellation of plans to exchange teams in the United Kingdom until more definite information was available as to the return of the 3d Auxiliary Surgical Group's long-absent members.
One specific measure was initiated as a result of these meetings. Under instructions from Colonel Mason, Colonel Cutler asked Major Graves to turn over the property in the hands of the 3d Auxiliary Surgical Group relating to mobile surgical teams to the 1st Auxiliary Surgical Group.74
At the conference of the Deputy Chief Surgeon on 3 October 1943, Colonel Cutler mentioned the arrival of the 1st Auxiliary Surgical Group and the expected return of that part of the 3d Auxiliary Surgical Group that had been in Africa and Italy. The immediate problem, he explained, was what to do with 300 doctors with nothing to do and nowhere to go.
Colonel Cutler met with General Hawley on 5 October 1943 and, among other things, there was a long discussion about auxiliary surgical groups. General Hawley asked Colonel Cutler to have the consultants draw up a comprehensive plan for the use of these groups, differentiating functions and personnel, as seemed wise, for a group with an army and for a group when employed within the SOS. Colonel Cutler advised General Hawley that he should ask the North African theater to return immediately an officer from the 3d Auxilliary Surgical Group for the purpose of training members of the newly arrived 1st Auxiliary Surgical Group. In a letter, dated 7 October 1943, written after his return to Cheltenham, Colonel Cutler informed Colonel Kimbrough of the conference with General Hawley and reported that he had drawn up a plan for the employment of auxiliary surgical groups under the dichotomous situations stipulated by the Chief Surgeon.
Colonel Cutler's recommendations entailed the following:
Regarding the use of auxiliary surgical groups with a field army, he thought that their function should be to carry out definitive surgical procedures in the forward areas by being attached to evacuation hospitals, field hospitals, and, possibly, even division clearing stations. The professional requirements for team members working in an army area and the need for specialists, he stated, were as follows:
The professional requirements of chiefs of surgical teams should be those of well trained general surgeons. The chiefs of teams should be competent to deal with injuries of any part. Strict specialists in the sense that they are competent to deal only with injuries to the brain, to the chest, to the extremities, the abdomen, the face and jaw are ideally undesirable. However, surgeons specializing in certain fields and at the same time competent to work in other fields would be desirable. And finally, the prosthetic teams, providing they were scattered and never concentrated in one place, should prove of great value to those surgeons dealing with injury to the jaws. Similarly, the orthopedic teams, as sent over with the 1st Auxiliary Surgical Group, could be of continuous value to all teams dealing with compound fractures. This was the arrangement in the last war when such teams were called splint teams.
As for the distribution of teams in any army area, he calculated that general surgical teams should be used in the ratio of two or three to one orthopedic team and that a prosthetic team was only needed for from four to six general teams. Further, he thought that the prosthetic teams would be needed only
at very hard-pressed and active units. Neurological, chest, and maxillofacial teams would be required, according to his plans, only as the needs for them arose. This distribution of teams, Colonel Cutler stipulated, was based on the assumption that teams would be needed for 24-hour duty in the hospitals to which they would be attached, thus necessitating the assignment of two teams to every one team which would be working at any specific time and place.
Turning to the use of auxiliary surgical groups in communications zone facilities, Colonel Cutler stated that their mission would be to strengthen the professional capacity of hospitals and should be employed only in station and general hospitals. Special teams, he pointed out, could always be used to greater advantage in communications zone facilities than in those of a field army. This would be especially true if parts of several general hospitals were set aside as centers for thoracic, neurosurgical, or maxillofacial work.
After the usual Sunday meeting of the Professional Services Division on 10 October 1943, the surgical consultants, with Colonel Cutler, decided upon the temporary assignment of the various teams of the 1st Auxiliary Surgical Group to hospitals then active in the theater and turned over the plan to the Operations Division for implementation.
Later, certain specialists were gradually removed from the two groups, and, as revised tables of organization were received from the War Department, the component teams were reconstituted. The latter procedures were, primarily, a function of the Operations and Personnel Divisions and the commanders of the groups. They concerned Colonel Cutler little as the professional qualifications of those being realined within the groups was of the necessary high standard. Those qualified specialists who were dropped from the groups were reassigned most advantageously to hospital centers where their special talents were in great need. By the time D-day drew near, in addition to an auxiliary surgical group assigned to the communications zone, there was an auxiliary surgical group to be assigned to each of the two U.S. field armies-one of them to be used in the United Kingdom to augment medical facilities during the initial receipt of casualties from the far shore, as the Third U.S. Army was not scheduled for immediate participation in Operation OVERLORD, and the other to accompany the First U.S. Army during the assault on Normandy (fig. 63).
Publications and directives - Shortly after returning from the Soviet Union, Colonel Cutler reported that the project of revising War Department TM (Technical Manual) 8-210, Guides to Therapy for Medical Officers, to make it more applicable to the European theater had been continuing for almost a year. He stated that, actually, it had been necessary to rewrite rather than revise and that there was still confusion in the revision concerning frontline care and the type of care to be given in fixed hospitals. The final revision, Colonel Cutler considered, entailed cutting down the manual still more and deleting some of the philosophical dissertations.75
FIGURE 63.-Lt. Gen. John C. H. Lee, SOS, ETOUSA, observes a surgical team from the 3d Auxiliary Surgical Group as they train for the invasion of continental Europe with the First U.S. Army, Pentewan Beach, Cornwall, England, 12 April 1944.
At the 14th meeting of the Chief Surgeon's Consultants' Committee on 28 December 1943, Colonel Cutler reported that much additional work had been done on the manual after discussions with medical officers who had had experience in the Sicilian and Italian campaigns. The original revision had been recast in simple form with short, directive, staccato statements. He suggested that it was just about ready for the printer. In addition to this manual of therapy, which was to be printed in pocket-size editions, Colonel Cutler asked the Chief Surgeon whether it would be possible to issue a circular covering the care of battle casualties in general and applicable to the whole European theater. He said that the circular might be similar to Circular Letter No. 178, published by The Surgeon General, and NATOUSA Circular Letter No. 13 on forward surgery.76 General Hawley approved the publication of such a circular and said that it was high time special policies were set up for the European theater.
A month later, Colonel Cutler reported that the manual was ready for the printer. He submitted, for General Hawley's consideration, remarks, from
which he asked the Chief Surgeon to prepare an introductory note. Colonel Cutler stated that the manual contained the principles underlying professional care of medical and surgical emergencies which may be encountered in the European theater-well-established principles which had been correlated with recent experience gained by the Americans and the Allies in the present war. Colonel Cutler further explained that the material was divided into three parts: (1) Primary surgical treatment of the soldier intended primarily for medical officers in division areas, (2) definitive surgical treatment as may be applied to hospitals regardless of type, and (3) treatment of medical emergencies. (The last part had been composed by the theater medical consultants under Colonel Middleton, the Chief Consultant in Medicine.) Lastly, it was explained, medical officers would be expected to adhere to the policies contained in the manual insofar as possible.77
By early May, the booklet had been received from the printer. Distribution had started. An appointment was made with General Lee for General Hawley and Colonel Cutler to present and explain the handbook to the SOS commander in the European theater. What happened at the meeting with General Lee is well explained in Chapter III of this volume (p. 366).
The same dual purpose of War Department TM 8-210 prompted the compilation of the circular for establishing policies with regard to surgical treatment and management. That is, one portion of the circular was written primarily for emergency surgical treatment and another portion was aimed at fixed facilities which would be providing definitive reparative care.
Colonel Cutler took upon himself the onus of compiling the first part on emergency surgical care. He was given help by all the surgical consultants, but particularly by Colonel Zollinger, Captain Hardin, and, as previously shown, by Colonel Morton and Colonel Schullinger on the gas gangrene and penicillin portions. Colonel Bricker, the Senior Consultant in Plastic Surgery and Burns, was given the responsibility of compiling the second portion of the proposed circular dealing with definitive care in fixed hospitals. Colonel Bricker experienced more difficulty than Colonel Cutler since his portion was of a more detailed and specific nature involving each of the specialist consultants. As a result, that portion dealing with the emergency management of battle casualties was finished first, and it became very apparent that the two parts were quite separate and distinct from each other. So, as time grew short, Colonel Cutler advised the chief of the Professional Services Division in a memorandum, dated 6 May 1944, as follows:
After a great amount of work we have decided that it is necessary to have two circular letters concerning surgical professional care. One is the major circular largely covering SOS fixed units, upon which Colonel Bricker has put so much work, and which he has
about finished. The other is a circular dealing largely with battle casualties; that is, Army surgical therapy. It is attached, and I believe will be implemented immediately, as the Army needs this now.
Circular Letter No. 71, Office of the Chief Surgeon, ETOUSA, was published on 15 May 1944 and was titled "Principles of Surgical Management in the Care of Battle Casualties." It was as succinct a statement as could be made at the time on the emergency care and initial treatment of battle casualties in the combat zone. It included: (1) A definition of the functions and responsibilities of the various echelons of surgical service in the combat zone, (2) administration of morphine with particular emphasis on contraindications, as well as the causes of morphine poisoning, (3) blood transfusion, (4) definition of certain nontransportable cases, (5) dressings, debridement, and amputation, (6) sulfonamide therapy, (7) penicillin therapy, (8) closure of wounds, particularly early secondary closure, (9) general principles to be followed in the use of plaster casts, (10) treatment of anaerobic infections, (11) radiology in forward areas, and (12) identification of gases in cylinders, with particular reference to the difficulty caused by different British and American markings. The complete circular letter appears in this volume as appendix B (p. 963), and, in subsequent discussions, it may be referred to merely as Circular Letter 71.
The other circular letter entered the publication mill during the very height of activities for D-day, 6 June 1944, and did not appear until 10 June 1944. It was published as Circular Letter No. 80, Office of the Chief Surgeon, ETOUSA. It concerned policies and procedures governing care of patients in the European theater.
The new circular letter rescinded 33 prior directives which had been issued by the Office of the Chief Surgeon over a period of nearly 2 years. To place all pertinent items in these many directives into one was an accomplishment in itself which certainly helped to ensure compliance with these policies and procedures which had been built up over such a length of time-policies and procedures which many had forgotten or, as in the case of those newly arrived, had not known of their existence.
Circular Letter No. 80, calling attention to the Manual of Therapy, ETOUSA, stated:
The Manual of Therapy, ETOUSA, sets forth principles of treatment which have been tested in active operations by both our own forces and those of our Allies. In it are incorporated many of the professional policies of the medical service of ETO. These policies will be followed habitually. Any one of them may, and should, be disregarded in an individual case where there is sound reason for departing from policy. Personal preference for other methods of treatment as a routine is not "sound reason." Departures from policies will be made only because of special circumstances associated with individual cases.
There was a lengthy and detailed explanation of all practices to be followed with respect to the procurement of blood and transfusions in general
and station hospitals. It required all hospitals: (1) To develop a "casualty organization" to facilitate the reception, resuscitation, triage, and treatment of multiple casualties, (2) to utilize officers from the surgical, medical, and laboratory services, and (3) to make specific preparations in advance to meet great numbers of such conditions as burns, hemorrhage, profound shock, exhaustion, and chemical warfare casualties.
One of the items which had held up this directive was that of hospitals for special treatment. From the outset, General Hawley had insisted that there would be no specialized hospitals, except for treatment of the psychoneurotic and psychotic. At the 6 December 1943 meeting of base section surgeons, the only concession General Hawley would make was that in the following statement:
Unless it can be thoroughly justified, we are not going to specialize hospitals. There may be a time, after we get trains running and battle casualties, we may specify certain hospitals for certain cases, but at the moment it is just complicating our evacuation system.
The Chief Surgeon never permitted any hospital to become "specialized," but, when the need became apparent, he eventually permitted the location of personnel and equipment at certain hospitals or hospital centers to provide special treatment. Circular Letter No. 80, compiled by Colonel Bricker, described these hospitals with facilities for special treatment as follows:
Certain hospitals where special types of treatment are available will be designated from time to time in separate directives from this office. The policies enumerated below will govern the treatment of patients requiring therapy in which a high degree of specialization is necessary.
a. Surgery: Selected patients requiring special surgical treatment will be transferred at the earliest practical time to those designated hospitals where additional facilities for their care have been provided. Such hospitals will include those for-Neurosurgery, Thoracic Surgery, Urological Surgery, Plastic and Maxillofacial Surgery, Treatment of Burn Cases, and other surgical specialties as may be found necessary.
(1) In those hospitals designated for the treatment of cases requiring * * * [special surgical facilities], it is recommended that separate sections of the Surgical Service be formed for each specialty. Administratively, these sections would function as all other sections of the surgical service.
(2) The surgical specialists in charge of these sections may be used by the Base Section Surgeons as Regional Consultants in their respective fields.
Another circular letter issued under the same date, 10 June 1944, designated the three hospital centers with special treatment facilities for neurosurgery, thoracic surgery, plastic and maxillofacial surgery, surgical treatment of extensive burns, and urological surgery. This additional directive, Circular Letter No. 81, Office of the Chief Surgeon, ETOUSA, designated other hospitals in which special facilities had been established for neurosurgery (with special urological facilities to care for the paraplegic) and for plastic and
maxillofacial surgery (with special facilities for the surgical treatment of extensive burns).
Circular Letter No. 80 also specified administrative policies and procedures for X-ray therapy, hospitalization and disposition of neuropsychiatric patients, rehabilitation of the blind at St. Dunstan's Institute, the holding of regular medical meetings in hospitals as a part of the educational program, and care of members of the WAC (Women's Army Corps). There were also specific professional policies pertaining to certain conditions which were listed under the headings of general surgery, neurosurgery, orthopedic surgery, plastic surgery, and X-ray diagnosis in fixed hospitals.
In closing this section on publications and directives, a case must be noted wherein the Chief Consultant in Surgery thought he had nothing to do with a directive which to him was nearly all professional. As will be seen soon, the subjects discussed in this directive were the very items on which he and Colonel Zollinger were devoting their utmost energies at the time. And he was startled to see the directive for the first time a month after it had been written and promulgated. It was published not as a circular letter but as Administrative Memorandum No. 62, Office of the Chief Surgeon, ETOUSA, to Base Section Surgeons and Transit Hospitals. Dated 3 May 1944, it stated:
a. Patients will be evacuated from the Continent to the United Kingdom in vessels manned by the Navy and in aircraft of the Troop Carrier Command. Patients returned by water will be disembarked at hards or ports having been classified into evacuable and nonevacuable patients prior to disembarkation. Evacuable patients are those who can withstand further evacuation by ambulance to "transit" hospitals (15 to 30 miles). Patients who are nonevacuable will be given emergency treatment in "holding units" in order to prepare them for further evacuation to "transit" hospitals. Patients arriving at "transit" hospitals will again be classified into evacuable and nonevacuable patients; evacuable patients being those who can travel 12 hours by train with reasonable safety. Nonevacuable patients will be prepared for further evacuation as soon as possible.
b. Patients evacuated by air will be removed to a "holding unit" at the airfield or a nearby fixed hospital, from whence evacuable patients will be evacuated to a general hospital for definitive treatment.
c. Designated general and station hospitals functioning as "transit" hospitals, will streamline their administrative procedures, and will function similarly to evacuation hospitals. "Transit" hospitals will be called upon to admit large numbers of patients expeditiously, and to evacuate them in trainload groups.* * * * * * *
3. Professional Care in "Transit" Hospitals
a. The scope of professional care in transit hospitals will be the same as that in evacuation hospitals, bearing in mind that those wounded who may travel safely for another 12 hours will be immediately evacuated without definitive surgery. [Italics are the editor's.] As a rule, all casualties will have their wounds debrided; no wounds will be closed; immobilization apparatus, splinting, or plaster of paris will be applied for all fractures; and patients will be given the necessary supportive treatment. Post-operative abdominal cases are usually not transportable for 7 days. Ambulatory and lightly wounded
casualties will be evacuated through transit hospitals as rapidly as possible. This type of casualty represents a primary responsibility of the Medical Department because these patients, with good treatment, can be restored to active duty in the combat forces at an early date.
When Colonel Cutler first saw the directive on 2 June 1944, invasion fever was running high, and it was very obviously too late to do anything about it. At the same time, he was having a most difficult time trying to obtain approval for stationing his consultants in key areas during the invasion phase. It was, in a way, the last straw. He wrote most bitterly in his diary: "SOP's get written, and I never see them. God, how they have opened themselves to criticism. It is a colossal blunder. Only today I [saw] Administrative Memorandum No. 62, 3 May 1944. None of it is our responsibility [doing] and yet it is all the professional system." On second thought, he added: "Well, maybe it will be OK." And well might he add that thought, for the words in the directive were very much those of Colonel Cutler as he, from time to time, reported on the progress being made for the care of patients in transit through the evacuation chain on the southern shores of England.
However, he had advised: "* * * Bearing in mind that if the pressure for evacuation is great, those wounded who may travel safely for another 24 hours will then be immediately evacuated without definitive surgery at the 'transit' hospitals." He had further qualified this statement with his definition: "An evacuable patient varies with the pressure of work and the demands for beds." Colonel Cutler was greatly exercised and chagrined to learn that base section surgeons and transit hospital commanders had been directed to evacuate all patients who could travel for 12 hours without definitive surgery. The clear intent of Colonel Cutler's recommended policy was that all patients in need of definitive surgery would receive such in transit hospitals except when (1) the pressure for evacuation was great at these hospitals and (2) the patient could travel safely for an additional 24 hours.
But now, more about these preparations to which the discussion of this directive has brought us.
Specific preparations for Operation OVERLORD
General Hawley explains.-Colonel Cutler attended a conference held by the Chief Surgeon at 9 North Audley Street, London, on 10 January 1944. The Deputy Chief Surgeon and executive officer, chiefs of divisions in the Chief Surgeon's Office, Col. Alvin L. Gorby, MC, from the Office of The Surgeon General, and Maj. Gen. Robert H. Mills, DC, director of the Dental Division, Office of The Surgeon General, were there. The minutes of the meeting show that General Hawley outlined plans formulated by his office for the reception, hospitalization, and evacuation of casualties in connection with the projected operations (map 1).
The plans for the medical support for the Normandy invasion included the following hospitals and depots:
The minutes of the 10 January conference state:
He [General Hawley] gave first a broad picture of the overall plan for the reception of casualties. * * * All the hospitals, including the general hospital at Stockbridge, but excluding other general hospitals in a designated area along the south coast of England had been made available to the Southern Base Section for the purpose of receiving casualties. Casualties would be unloaded and given immediate attention on beaches and hards and then evacuated to the hospitals in this area [later called "transit" hospitals]. Evacuation of patients from these hospitals by hospital train to hospitals elsewhere in the United Kingdom would ensure that beds were constantly available in the designated area. Certain beaches and hards were to be designated as medical and the Navy would deliver casualties here as much as possible. A fixed holding unit of at least 50 beds would be placed at a maximum distance of 500 yds. from each medical beach and hard; situated preferably in whatever buildings were available. Here casualties which could not be transported by ambulance without immediate treatment would be transported by hand. These units, being so close to the beach or hard, would be exposed to bombing, but in order to deal with patients who could not be transported by ambulance without treatment, this was unavoidable. Ambulances and buses, for walking wounded, would be used to transport all other types of casualties to the nearby hospitals.
Owing to the many difficulties attendant upon bringing the casualties back-the diversion of LST's due to sudden emergencies, the possibilities of damage to the craft, the fact that trips were made at night and the crews were young and inexperienced- there would be frequent occasions on which casualties were brought to beaches and hards other than those designated as medical. There were large numbers of such beaches and hards which would all have to be "covered." For this purpose, with close liaison established between the Navy and [the] Southern Base Section, a large reserve of ambulances and personnel for unloading LST's would have to be kept available to move to any point on call. It was essential that any congestion should be avoided and a considerable number, possibly as many as twenty-five, ambulances would have to be available to unload each LST, in order that all the casualties on board should be evacuated immediately. In addition there would have to be under a central control (not that of the SBS [Southern Base Section]) two big reserve pools of ambulance and bus transportation to reinforce that for both medical and nonmedical beaches and hards and meet any sudden emergencies that might arise.
Colonel Cutler asked the general about provision for triage at the beaches and holding units. General Hawley replied that no sorting would be done at the beaches and hards or in the "holding" units and that all those casualties that could possibly be transported would be moved immediately to hospitals.
The minutes state:
General Hawley then went on to explain, in slightly more detail, the methods for dealing with the casualties received. All hospitals in the area would be reinforced with surgical teams and resuscitation and shock teams would be present on the beaches or hards. To meet requirements in the initial stages of the operation, and until "the route of evacuation was canalized," teams and ambulance companies would have to be borrowed from areas north of the Southern Base Section.* * * * * * *
General Hawley explained how it was the responsibility of the Evacuation Division to keep the beds in the reception area "fluid." It was essential that patients should not be immobilized in these hospitals and beds thus "frozen." Therefore only essential surgical treatment, such as that given in Evacuation Hospitals, must be given therein. The bulk of the patients should be evacuated within 24 hours.
The Chief Surgeon then explained what measures would have to be implemented to care for the great influx of troops into the staging areas.
In the discussions that followed, Colonel Cutler again brought up the desire for sorting at the beaches and suggested that hospital trains evacuate less seriously wounded and neuropsychiatric patients from the receiving areas. General Hawley said that evacuation by hospital train of such patients could not be considered since there were no facilities for parking the trains in the vicinity of the beaches and hards. He insisted that sorting of patients could not be done at the beaches. He stressed that it was essential for all to be moved away immediately, and he added the conjecture that the run of neuropsychiatric cases would not be high. He also said that very little treatment would be given by the Navy on LST's, although the Naval medical officer in charge of LST operations was most cooperative. Colonel Spruit said that naval medical personnel might need reinforcing by Army personnel. General Hawley agreed and directed that this question be looked into.
To a question on air evacuation by Colonel Gorby, General Hawley replied:
* * * the possibilities of Air Evacuation of casualties had been considered, but it was not estimated that it would start until D+10 or D+15. In the early stages, aircraft would have to return to specified troop carrier command airfields. Since there were no fixed hospital facilities in the vicinity of these airfields, tented hospitals would have to be used. Later it might be possible for aircraft to "touch down" near fixed hospitals. General Hawley pointed out that the demands on the air forces would be so great that it was extremely unlikely that aircraft would be available for evacuation of patients from hospitals in the reception area in the event of a dislocation of rail traffic, at any rate initially.
General Hawley concluded his explanation with comments on the supply situation and the need for decentralization. He said that supplies which would have to be furnished would be largely maintenance, but that a reserve must be kept to replace equipment lost by sinking or from other causes. For an example, he mentioned the fact that a whole evacuation hospital might be needed, and that arrangements must be made in advance to provide replacement for immediate and speedy loading on LST's. Provision must be made, he added, for the transport of blood and its storage at ports.
So this was it, pondered Colonel Cutler. The big effort was finally going to be made soon-but when? He recalled with some apprehension that, just before Christmas, General Hawley had warned the base section surgeons that in a month there would be scarcely a base section whose job would not be bigger than the theater was at the beginning of the month (December 1943). He could not help but conjure up memories of those southern shores of Devon, the European theater Assault Training Center, which he had visited not long ago.
Visit to Assault Training Center, ETOUSA - On 5 November 1943, Colonel Cutler departed Cheltenham to visit the Assault Training Center, ETOUSA, near Braunton, Devon. On the way, he had stopped by at First U.S. Army headquarters and learned the happy news from Colonel Rogers that General Hawley had suggested Maj. William J. Stewart, MC, as orthopedic consultant for the First U.S. Army. He knew that Major Stewart would be an excellent consulting surgeon for the First U.S. Army and of great assistance to Colonel Rogers and to Maj. (later Col.) J. Augustus Crisler, Jr., MC, its surgical consultant, but this suggested appointment did not materialize.78
At the Europeaun theater Assault Training Center, Colonel Cutler was pleasantly surprised at the realism and practicality of the demonstration he observed on the employment of the medical services upon assaulting a hostile beach (fig. 64). However, he stated in a memorandum to Colonel Kimbrough, dated 7 November 1943, that, while the role of the Naval beach control officer had not been made entirely clear, the Chief Consultant in Surgery had been somewhat taken aback by the impression he had received that the Navy controlled entirely evacuation from the beach. Colonel Cutler also had a ride in a "duck" [DUKW (amphibious truck, 2½ ton cargo)] and found it quite a task for a healthy man unencumbered by the paraphernalia of war to mount
into one. From this experience, he could not help but conclude that the means for getting walking wounded and even litter cases into a "duck" are inadequate. As a substitute, he suggested that everything should be done to land jeeps for use as light ambulances at the earliest possible time. Jeep ambulances, he said, would save much time for the wounded and perhaps make it unnecessary to set up what was called, in the demonstration, a reinforced regimental aid post.
British EMS plans - And recently, just a few days before General Hawley's talk, Colonel Cutler had participated in a similar discussion on the British side. Mr. Willinck, the new Minister of Health, was present at the meeting of consultant advisers to the EMS held at the ministry offices, Whitehall, London, on Tuesday, 4 January 1944. The Director General, EMS, newly knighted, was chairman as usual. Sir Francis Fraser led the discussion on the care of battle casualties by the EMS when the Continent was invaded. The British were going to use three selected ports for the receipt of their wounded. The wounded, upon their return to England, would be taken to "transit" hospitals in the general locality of these ports. After surgical therapy, or immediately in medical cases, the wounded were to be sent to base hospitals in the north and west of England. They did not plan to use the great London hospitals as base hospitals, since heavy retaliation on London by the Germans was expected. Following treatment at the base hospitals, selected cases were to be sent as necessary to special hospitals for maxillofacial surgery, neurosurgery, and so forth. The need for basic surgical directives and mobile teams was cited, although it was stressed that their professional men would be sent to transit hospitals as well as the many base and special hospitals to which they were already assigned. Colonel Cutler offered to send the EMS copies of the NATOUSA circular letters on surgical therapy which he had recently brought back with him from Italy, and the EMS consultants implied that they would like to model theirs after the NATOUSA directives-just as Colonel Cutler, himself, was to do later.
After returning to Cheltenham, Colonel Cutler submitted to Colonel Kimbrough on 8 January a brief memorandum summarizing the highlights of this meeting with the EMS. He concluded his memorandum with: "I believe this meeting makes it clear that we should keep in close liaison with the British setup for the care of casualties returning from possible continental invasion."
Elsewhere, he wrote this enigmatic afterthought of the meeting: "The EMS is to look after all returned battle casualties, and, after 4 years, are still surprised over it!"
The buildup begins - As General Hawley had foretold, the remainder of January 1944 set the pace for the busy months that were to follow. Taking a quick respite on Sunday, 23 January, Colonel Cutler noted in his diary: "Catching up; things moving. Hospitals arriving daily. Hard to keep up with work. Robert Zollinger is a great help."
Problems in Allied coordination - Colonel Cutler had said that the American should keep close liaison with the British in the working out of procedures for the reception of casualties. It soon became apparent that the British thinking was very similar. Sir Francis Fraser asked Colonel Cutler to meet with British representatives for the joint working out of certain problems which had appeared. On 28 January, Colonel Cutler journeyed to Oxford and met with Prof. Geoffrey Jefferson, adviser in neurosurgery to the EMS, and Brigadier Hugh Cairns, Consultant in Neurosurgery to the British Army.
Professor Jefferson stated that the EMS had a very meager supply of specialists to meet the tremendous demands which were expected. While the British Army could help to a limited extent, it was particularly in neurosurgery where they feared the greatest shortage of qualified professional help. Professor Jefferson asked if the American Army would be willing to have British neurosurgical casualties sent to their hospitals for care. It was apparent to Colonel Cutler that similar decisions were desired for other types of cases as well. Significant, and most obvious, was the fact that the EMS had not been informed on these matters, and Colonel Cutler did not have the answers either. He could but say that there was an overall planning group which had probably settled these problems and that, certainly, representatives of the Canadian, British, and U.S. Army medical services had to meet, settle, and integrate plans for the care of all casualties arriving in the reception areas.
In a memorandum, written on 29 January, after his return to Cheltenham, Colonel Cutler advised the Deputy Chief Surgeon, through the chief of the Professional Services Division, that the following specific questions should be put to the Allied planning group:
1. Will U.S. Army hospitals, Canadian Army hospitals, and EMS hospitals in the reception areas take in and care for Allied casualties just like their own?
2. Can the EMS count upon U.S. Army hospitals taking in and caring for specialty injuries over and above the general run of casualties?
3. Should the answer to question 2, above, be favorable, can a list of U.S. Army hospitals in the reception areas with information as to where what specialists are assigned be submitted to the EMS so that the EMS may route patients to such hospitals?
And here, the reader should note, was the first instance where Colonel Cutler was acting as the American surgical representative for Allied planning of the invasion-a function which was to grow and become more involved as time passed and which devolved upon him naturally in the course of events without any specific orders.
At the monthly meeting of advisers and consultants to the EMS held on 8 February, it was still obvious to Colonel Cutler that the EMS was in ignorance about overall plans, and the professional board of the EMS felt that its planning could not be reasonable until they had further information. Colonel Cutler noted, too, that the specialists desired early triage so that casualties requiring
special treatment could receive that care within a reasonable period of time. As it was, if the general plan were followed, 3 to 5 days would be consumed before this special care would be available to casualties needing it, and mortality and morbidity would be increased by such delay. The Director General, EMS, spoke of the need for gradually vacating beds in the better hospitals, the possibility of triage at transit hospitals, the necessity for rapid passing of cases through transit hospitals where long holdovers would be undesirable, and securing additional special instruments for work in special fields for use in transit hospitals.79 These problems, with which the EMS was contending, were to Colonel Cutler the very problems that the U.S. Army had yet to face, and matters of serious concern.
Following this last meeting, Colonel Cutler visited the Chief Surgeon's London office and spoke with Colonel Liston, the Deputy Chief Surgeon, on the various matters which had been brought up by the EMS. Colonel Cutler told Colonel Liston that planning was not his problem and that he had asked the EMS to put in writing to him any specific desires they had so that he, Colonel Cutler, could pass them on to the Chief Surgeon, ETOUSA.
Critical shortage of qualified officers in ETOUSA - On Thursday, 10 February, a teleprinter conference was in progress between the Chief Surgeon and the Office of The Surgeon General in Washington. Perhaps Colonel Cutler was unaware of the conference, itself, but, as has been shown, he was certainly aware of the problem which was its subject (pp. 37-38). The conference concerned personnel, particularly supply personnel. The tenor of the conference also indicated how critical activities were in this immediate preparatory period prior to launching Operation OVERLORD. An excerpt from the teleprinter conference of 10 February 1944 follows:
This is Hawley speaking: Colonel Voorhees and his group have done a splendid job in diagnosing the troubles and pointing out the cure. I am implementing their suggestions at once, but I must have help to implement them properly. Until recently this theater was of minor importance in the large picture. Realizing this, I have refrained from asking for the ablest officers available, with the result that, with a few notable exceptions, the officer personnel furnished me was not of high quality. We have tried to carry on during this period of relative inactivity and we have barely succeeded. This situation has now changed. This is the most important of all theaters and we have fully demonstrated that the quality of personnel furnished us in the past is totally inadequate for the task that lies ahead of us. We must not fail. Yet we cannot succeed unless we are given the tools to work with. The best officers to be had are none too good for the jobs to be done here.
The most critical time of all is now. After plans are made and operations are proceeding smoothly, some key personnel can be released and their places taken by subordinates who they have trained. I realize fully the many positions that have to be filled and the few really qualified people there are to fill them; and I shall be unselfish when the time comes that the need for able people is greater elsewhere than it is here. But now, for the first time in more than two years, I am really begging for assistance.
"Rotten ships for care of wounded American boys."-Colonel Cutler's impression of LST's, after his first two encounters with them, was that they
were "rotten ships for care of wounded American boys." These initial impressions, however, were but a challenge to Colonel Cutler to make them the best possible vehicles for evacuation by sea under the circumstances. To this end, Colonel Zollinger, his consultant in general surgery, was of inestimable help.80
Already, on 4 February 1944, Colonel Zollinger had met with Colonel Liston, the Deputy Chief Surgeon, and Capt. George B. Dowling, MC, U.S. Navy, who was the Naval medical officer in charge of LST operations for the evacuation of casualties. On 8 February, he had met again with Captain Dowling and a Lt. William A. DuCharme, HC, U.S. Navy, to go over and evaluate medical supplies and equipment which the Navy planned to load on LST's for the care of 200 casualties. And, on 14 February, he had gone to the Southern Base Section and discussed with the base section surgeon the placing of surgical teams on LST's and the scope of treatment to be given. They had also discussed the advisability of placing general surgical and shock teams at the field hospitals to be located right at the hards for the care of nontransportable casualties. They also believed that it would be necessary to break up one or two general surgical teams to obtain experienced medical officers to supervise triage at the hards. There was talk, too, of the placement of general surgical and orthopedic teams at the transit hospitals and the use of the specialty teams in hospitals for the definitive treatment of casualties.
With this as a background, Colonel Cutler, Colonel Kimbrough, and Colonel Liston joined Colonel Zollinger on Tuesday, 15 February 1944, at Plymouth, Devonshire, to look over an LST. Colonel Muckenfuss and Captain Hardin from the Blood Bank, ETOUSA, also joined the party. The inspection of the LST, which had been arranged through Captain Dowling, was conducted by Comdr. Luther G. Bell, USN (MC). Colonel Zollinger informed the group that the ship had been used at the Salerno landings but that it was not of the type which had been converted to carrying casualties.
"We were able to inspect the entire LST," Colonel Cutler wrote of the expedition in a 15 February memorandum to the chief of the Operations Division, through Colonel Kimbrough, "including the main deck, on which was the upper battle dressing station in ward room, the middle deck, where a second battle dressing station was contemplated in the crew's messing compartment, and the lower or tank deck."
Colonel Cutler noted that the usual difficulties of movement on a ship were present. There were narrow doorways, sharp right-angled turns, and steep ladders or stairways between decks-difficulties which could not be changed but had to be recognized in the proper planning and loading of casualties on such a ship. A primary consideration underlying all planning for the care of casualties and returning sick personnel on such ships, Colonel Cutler mentioned, was the fact that "loading of casualties and patients must proceed simultaneously with the unloading of the ship." With this in mind, he believed the following sequence of care should prevail:
4. * * *:
a. Casualties will come up over the side in special stretcher slings developed by the Navy * * *. These deliver patients to upper deck (fig. 65).
b. From the deck the casualty may go either to: (1) The battle dressing station in the ward room, or (2) the battle dressing station in the crew's messing compartment on the middle deck. There, adequate dressing facilities for all types of wounds must be present with additional splints. There, proper notation should be made on the EMT as to some sort of categorization concerning the ability of the individual to withstand transport on reaching the near shore. If surgical procedures are necessary to save life or limb, such as ligation of a vessel or the amputation of an extremity hanging on by a few parts, then the FMR must be begun and proper notation made on it.
c. After primary first aid care has been given, as above, the casualties will then go either to the area known as the crew's quarters, which is adjacent to their messing compartment, or to the tank deck, if they are on stretchers. As there is space for some 78 stretchers in the crew's quarters it would be advisable for all stretcher cases to be held in this area if possible. Those who are ambulatory, both sick and wounded, can go down to the middle deck and be held in the space allotted as "troop quarters," which can provide for 175 men. The number of stretchers or other casualties which can be placed on the tank deck will depend upon whether we are utilizing a converted ship with wall brackets for stretchers or not (fig. 66).
5. Comment on battle dressing stations or first aid posts: Of the two areas provided for this service, i.e., the wardroom on the upper deck and the crew's messing compartment upon the middle deck, the latter would seem more reasonable, for if there be only one surgeon he would have near him in the adjacent crew's room (sleeping quarters) practically all of his stretcher or seriously injured people. Both stations, however, are suitably lighted and supplies could be assembled there. Moreover, both stations have tables which could serve as operating tables. The crew's quarters stations are near the kitchen, so that sterilization by boiling would be more simple, unless an electrical hotplate is added to the wardroom, where there is a plug for such a receptacle on a table.
The visitors, particularly the two from the blood bank, observed that there were two types of cold rooms on the ship. One was for meats where the temperature was kept at 20° F. This room was obviously unsuitable for storing blood. But there was another space for storing vegetables and fruits where the temperature was held at 48° F. Fortunately, they discovered, the temperature could be adjusted to 40° F. which would be appropriate for storing blood and still not hurt the fruits or vegetables.
On his return from Plymouth, Colonel Cutler reported: "No intelligent regulation can be drawn up concerning the care of casualties on such ships until knowledge is available as to time limitations." Time, he showed, would affect considerations in professional care on LST's in the following manner:
If casualties will be on such ships up to and beyond 20 hours after being wounded, then one would have to advise and provide for abdominal surgery, since the percentage of recovery in the cases of abdominal injury becomes almost nil after 24 hours. A similar attitude on definitive surgery of all types must be dictated according to the time interval. If instructions are to be given to medical officer personnel on LST's as to what they are to do, that would depend entirely upon this time interval, and if indoctrination courses are to be given to the medical officer personnel who are to be on LST's, some rough estimate of this time interval should be known to the instructor before speaking, else his advice will be inappropriate and possibly damaging to the American soldier.
It is my hope that the interval will be so short that the professional work on an LST will be largely first aid, i.e.:
1. Control of hemorrhage.
If, however, the time is to be over 24 hours, or even if there is danger that it is to be over 24 hours, then an entirely different set of circumstances will prevail and different instructions must be given the medical officers in charge. We would be committing a wrong against the American soldier in this event if we did not provide for definitive surgery in the care of cases on the LST's.
On the Monday following, 21 February, Colonel Cutler joined a most illustrious group in the inspection of an LST at the chief British naval base, Portsmouth. The American representation, in addition to Colonel Cutler, included Maj. Gen. Albert W. Kenner, Chief Medical Officer, SHAEF, and Col. Alvin L. Gorby, MC, who was now assigned to the First U.S. Army Group, the overall planning organization on the American side for Operation OVERLORD. The directors general of the Royal Navy and the British Army medical services headed the British delegation, with their respective surgical
consultants, Admiral Gordon-Taylor and Maj. Gen. David C. Monro. There were also Surgeon Rear Admiral Cecil P. G. Wakeley, a consulting surgeon to the Royal Navy; Brigadier Arthur E. Porritt, RAMC, then consulting surgeon with the British 21 Army Group, the British counterpart of the First U.S. Army Group; and other officers from the British 21 Army Group.
Colonel Cutler was quite disconcerted with the British attitude toward the handling and care of casualties on LST's, since, if their opinions were to prevail, much of the planning and work so far accomplished by Colonel Zollinger would have been for nought. Yet, there was on evading the fact that this particular inspection of LST's was conducted primarily from the viewpoint of the British Army and the Royal Navy medical services. Colonel Cutler's 28 February report of the trip to the Chief of the Operations Division in General Hawley's office contained the following statement:
1. The British seemed to have hardened their opinion even before visiting the ship that:
2. The British group felt certain that it would be impossible to take casualties up over the side in units or by any other method. They believe it will be necessary to beach the vessel, leave her on the beach throughout the fall and flow of one tide and take her off afterwards. This opinion is contrary to that of American Naval officers when inspecting.
3. On travelling back with Lt. Gen. Hood [DGMS, British Army], he expressed the opinion that the LST was an unsuitable vessel for carrying back wounded people, that it was outrageous that better provision could not be made, and that he might take this to the Prime Minister and General Eisenhower. He expressed the opinion that an LST was a "cold, dirty trap."
4. Out of the above objections, many of the professional people present, notably General Monro and Brigadier Porritt, as well as myself, felt it might be better to try and hold certainly all litter cases on the far shore, rather than accept the risks of transport back on these vessels. Certainly the "Collecto-clearing company" or the platoon of the field hospital could be landed with the second wave and give the necessary surgical care.
Much of the meeting of the Chief Surgeon's Consultants' Committee on 25 February 1944 was taken up with the subject of care of casualties on LST's. Colonel Zollinger gave a summary of the existing problems and plans which, so far, had been worked out with the Navy. One of the remaining problems was the treatment of abdominal wounds, he reported. The Navy was estimating a 16-hour journey on LST's, once they were loaded, but risk of mortality in abdominal cases rose precipitously after 6 hours. There was a general desire to do abdomens, if necessary, on the LST's, but there were no provisions for the equipment or personnel. Furthermore, planning to operate on abdomens on the far shore had its disadvantages in the initial stages because there would not be facilities to perform such operations and, because it was
the general policy not to move for about a week either abdominal or chest cases which had been operated upon. Of the situation at the time, Colonel Zollinger said: "If a man happens to be qualified to operate on [board] LST's, good; if not, he will have to depend upon morphine."
General Hawley was quite taken aback by the prospect, and said: "These are young chaps-recent graduates. They will not have done any kind of residency. To operate on a belly on an LST!! The question is whether it is better to operate on the far shore and put him immediately on an LST; is that worse than operating on an LST?"
In answer to his own question, General Hawley said that it would be better to operate anyway rather than go so long as 16 hours and that it would probably be better to operate on the far shore and then have the patient taken aboard, with special care available on the ship. The reason, he said, was that there would be a better concentration of talent on the far shore and "we have to think of the most good for the largest number and establish a ruling for it."
Colonel Kimbrough, however, insisted: "I would like to stick to the recommendation that there be facilities to operate on any case that might arise on an LST."
"I agree," General Hawley replied.
The discussion on LST's was closed with strong exhortation from the Chief Surgeon that the consultants crystallize their opinions on what had to be done and how and to "get it down into an operating procedure that the Navy thoroughly understands."81
The reader may recall that shortly after this, in March 1944, The Surgeon General and the Air Surgeon arrived in the theater for an extended tour of medical facilities serving the Army Air Forces and that Colonel Cutler was required to accompany the visiting officers. The inspection tour and its aftermath required the services of the Chief Consultant in Surgery for the best part of a month at this critical time. The bulk of the work to develop the necessary operative procedures with the Navy fell on Colonel Zollinger.
Physical standards and disposition boards - At the aforementioned meeting of the Chief Surgeon's Consultants' Committee on 25 February, General Hawley said, "Now I have a problem. What can we do to get these disposition boards to realize more fully their responsibilities in the conservation of manpower. I think it is getting better, but I think we are still evacuating too many people. What can we do about that?"
The disposition boards had been established at most general hospitals and certain station hospitals in August 1943.82 Each board consisted of the
chief of medical service, the chief of surgical service, and the ward officer of the particular patient. If a chief of service was unavailable, the appropriate assistant chief was directed to act for his chief. The directive further required a review by a disposition board of all cases in which it was believed a patient should be returned to the United States for further observation, treatment, and disposition. The recommendations of the boards required final approval by the hospital commander.
The action of these boards had been notably inconsistent and, in many cases, unduly delayed. To General Hawley's question, Colonel Kimbrough replied that the appropriate consultants had been reviewing reports and spot checking final recommendations. He said that a great many cases which the consultants felt could be retained for duty in the theater were still being sent to the Zone of Interior. In such cases, Colonel Kimbrough continued, telephone calls were being made to hospitals involved to check on the validity of the decisions.
General Hawley then instructed the professional services to continue just that action and to submit recommendations for improving the procedures.
The emphasis at this time was on the conservation of manpower, and General Hawley's feelings were well expressed at this meeting as follows:
* * * The point is this. We all want to protect ourselves. We have to conserve manpower. We have to stop getting people out of the Army who can do any kind of a job at all. Can we be in a position to say there is nothing wrong with this man? He might walk right out and drop dead. That is just too bad. We have done everything we can, but it is going to save hundreds of other people for duty if we establish a policy and stick to it. I want you to think it over. We have, all of us, to get out of the family doctor's psychology here and we have to know that we are going to make some mistakes. Can we keep those mistakes down within reason and can we assure our preventing a lot of mistakes being made on the other side? If we can almost break 50/50 on it I think it will be worth trying because we have to preserve manpower.
Colonel Cutler, in his visits to hospitals, had found that one source of the problem lay in the lack of guidance to disposition boards. For example, he had found that many officers would have liked a list of conditions which would be appropriate for returning a soldier to the Zone of Interior. With his senior consultants, the Chief of Consultant in Surgery worked out such a list, as did the medical consultants. The list was submitted, but General Hawley was reluctant about publishing a list of this type because he thought that each individual case had to be judged on its own merits, especially with regard to the duty which the patient would be expected to perform should he be retained in the theater. Yielding to the advice of his consultants, however, the Chief Surgeon permitted the list to be published on 24 March 1944, as Circular Letter No. 45, with the following qualification: "It is to be remembered that this list is to be used only as a guide, each case to be decided on its individual merits."
Aftermath of Operation CRACKSHOT - When the general plan for medical operations in England to support the invasion had been more or less firmly established, General Hawley had called for trial evacuations from transit hospitals to the southern belt of general hospitals which were being designated
for the primary definitive treatment of patients. These were actual movements of real patients using ambulance and hospital train units which had been earmarked for the evacuation mission in England (fig. 67). One of these trials was Operation CRACKSHOT. The Chief Surgeon was quite pleased with CRACKSHOT because it showed where weaknesses in the plan were and because the observers of the trials had made such a thorough and careful analysis of these weaknesses. The Chief Surgeon called a meeting of his key staff officers on 24 March 1944 at which he opened proceedings by saying:
We have to button up some things here before operations.
There will be a stenographic report made of this but * * * anything decided here ought to be put out as a directive and by the time I get back [from the Zone of Interior] I would like to see most of it either accomplished or well on the way. We have not much longer now. All our mistakes have to be behind us.
The first thing is this report in detail on the Operation CRACKSHOT. I understand that we have had, in a few days, something which has pointed out the weakness of things in general.
From this beginning, the conference proceeded in rapid-fire fashion, most of the decisions being made by the Chief Surgeon followed by his specific directions as to the actions to be taken. The following topics concerned the Chief Consultant in Surgery.
"Here is a very important thing," said General Hawley reading from the Operation CRACKSHOT report, "Recommend that the scope of treatment given at these transit hospitals be definitely outlined and that Professional Services be consulted as to the necessity for augmenting personnel with surgical teams." The Chief Surgeon continued: "Now, these are evacuation hospitals and they have definitely to limit the amount of work that is done. You cannot immobilize patients there any more than in any other evacuation hospital."
"That has been considered," Colonel Kimbrough answered, "and that is a general policy."
General Hawley then directed, "Will you give us something that can be published that we can hold them to?"
And then a little while later, "Question of procedure," said General Hawley, "slightly wounded ambulatory patients to be separated from serious cases."
Colonel Kimbrough explained, "That triaging is planned to start on LST's."
General Hawley's comment: "It will work on LST's, but it won't be complete and final. Every hospital has to triage its own patients. Hospitals cannot depend upon triaging on LST's; every unit has to do its own."
Colonel Kimbrough then made a recommendation which had continually been made by his division. He stated: "It is recommended that a responsible medical officer, not just a junior officer, be at the hard to do triaging."
Thinking aloud, General Hawley said:
When these patients get to a general hospital they have to be triaged again. We have to keep those beds for seriously wounded. If a patient does not get definitive treatment in transit hospital he has to get completely definitive treatment in some station hospital some place else to clear that bed for a seriously wounded man who cannot he moved.
Our first run of patients will be from transit hospitals to the southern belt of general hospitals. We cannot let that southern belt of general hospitals get full of minor casualties. We have to keep those beds for people who cannot be moved any farther than that.
We have a lot of beds in East Anglia not going to be full, perfectly competent for taking care of arms and things after first definitive treatment. The point is, you have to keep those southern belt general hospitals for serious cases that cannot be moved after definitive surgery.
And then, after a very brief discussion, General Hawley made a decision and issued to the Operations Division the following instructions: "Incorporate in the plan the further evacuation to station hospitals of slightly wounded whose initial definitive treatment has been completed, in order to keep the beds in the first row of general hospitals fluid for serious cases that cannot be moved."
This discussion brought to General Hawley a thought on the spur of the moment. "A second thing on that," he added, "it is to keep these general hospitals indoctrinated that as soon as the patient can safely be moved to the Zone of Interior he is out and on his way home. I cannot impress that too much."
"I would like to emphasize that they do that now," explained Lt. Col. (later Col.) Fred H. Mowrey, MC, the hospitalization and evacuation officer (fig. 68). "However, some of them have been keeping patients more than 180 days. I would like to have all of those boarded so that we get rid of them within the next 6 weeks."
"I approve of that," agreed the Chief Surgeon, "In every case right now, let's start unloading beds-every case that will not be fit for duty in 180 days to be boarded and reported for evacuation." Then, addressing Colonel Kimbrough, he stated: "Responsibility of Professional Services. The hospitals are keeping up their bed strength unnecessarily. Professional Services, you have to stop that."
"We have been working on that both with hospital commanders and at base section meetings," Colonel Kimbrough assured the general, "We checked up to see about it. When we find they are not doing it we tell them to get this man or that man out."
General Hawley warned with portent, "We have to get tough with somebody here-or else."
Colonel Kimbrough took these and other discussions at this meeting to mean that this division would have to work out an SOP for the care of patients in near-shore installations and transit hospitals. He also emphasized the necessity for checking on and instructing hospital disposition boards, not only in their responsibilities for conserving manpower, but for acting quickly and early on all cases to keep their hospital beds free.
General Hawley went one step further. He issued a directive applicable to each consultant in the Chief Surgeon's Office which made it his personal responsibility to check on disposition board procedures at each hospital visited, regardless of the original purpose of the visit, and to see that hospitals were not keeping patients who should have been transferred elsewhere.
SOP (standing operating procedure) for professional care of casualties - Three days after the Operation CRACKSHOT meeting, Colonel Zollinger had prepared and submitted to Colonel Kimbrough, with Colonel Cutler's approval, a statement of the professional care to be provided casualties in the various echelons in England during the attack on the Continent. Colonel Zollinger also prepared the necessary correspondence for obtaining the personnel required to provide the care stipulated.
With respect to surgical treatment on board LST's, the substance of the SOP was as follows:
Surgical treatment on board LST's will be similar to that of a divisional clearing station. Definitive surgery is not contemplated except in those instances in which it is necessary to receive patients with abdominal wounds, or similar casualties, occurring on board ship as a result of direct enemy action. The decision to perform major definitive surgery on board LST's will be governed by the type of wound, the estimated time interval from wounding until near shore definitive treatment is available, the professional qualifications of medical personnel, and, finally, the volume of casualties.
The casualties will be triaged on board ship into two major classes, ambulatory and stretcher cases. The stretcher cases will be further triaged into "transportable" and "nontransportable" * * *. The nontransportable casualty will be defined as a casualty requiring immediate resuscitation or surgical intervention after unloading from the LST.
At the hard, the plan called for two or three experienced surgeons for triage. These officers with mature surgical judgment were to reevaluate casualties into transportable and nontransportable cases. The plan also noted that ambulance evacuation was now going to be necessary from ships to the nearest medical facility, of which there were to be two types-field hospital platoons augmented by surgical teams and full field hospitals also augmented by surgical teams. The scope of treatment at these facilities was to be substantially as follows:
Field hospital platoons of 100-bed capacity will be located near three of the major hards. These units will receive the nontransportable casualties and other casualties which might occur about the hard. Such cases should be of the type requiring resuscitation as well as definitive surgery. It has been suggested that two general surgical teams and two shock teams be assigned to each of these units.
A tented field hospital with a capacity of 400 beds, will be located 5 or 7 miles from each of the three major hards (fig. 69). Because of the urgency of unloading LST's rapidly, it is anticipated that it will be necessary for the ambulance companies to unload the majority of the casualties at these stations. Major definitive surgery of all types, chiefly on those casualties labeled nontransportable, except neurosurgery, maxillofacial surgery, and the less urgent chest surgery, will be performed in these units. It will be necessary, therefore,
that these units be heavily reinforced with surgical teams. It has been suggested that three surgical teams and one splint team be assigned.
For the general and station hospitals designated to act as transit hospitals, the plan called for procedures substantially as follows:
If time permits and the condition of the patient warrants, the ambulance companies will deliver casualties directly to these hospitals. Furthermore, they will evacuate the casualties from the field hospitals to these units as soon as possible. Casualties will be subsequently transported inland from the transit hospitals by hospital train.
It is essential that the professional qualifications of the medical personnel of these designated transit hospitals be evaluated by the Professional Services Division. Furthermore, it has been suggested that three surgical teams be assigned to each of the nine transit hospitals to insure adequate personnel to cover the 24-hour period. The surgical chief of one of the three teams assigned to each unit should be an orthopedic surgeon.
The plan was forwarded by Colonel Kimbrough to the Operations Division, Office of the Chief Surgeon, on 3 April 1944 for guidance and information in the formulation of operational plans and directives.
On 27 March 1944, when the SOP was prepared, Colonel Zollinger addressed a memorandum to Colonel Kimbrough through Colonel Cutler requesting the augmentation of transit hospital staffs so that the care called for in the plan could be carried out. In this communication, Colonel Zollinger mentioned that personnel of the 1st Auxiliary Surgical Group could not be considered for these augmentations, since most of the teams would be assigned to the field hospitals and field hospital platoons working independently. A surgical team for transit hospitals, Colonel Zollinger recommended, should consist of two surgeons, one anesthetist, one nurse, and two surgical technicians. He reiterated the portion of the SOP which called for three teams to be assigned to each transit hospital, the chief of one of the teams to be an orthopedic surgeon. He asked also for two or three experienced surgeons for triage of casualties at each of the hards. Finally, the recommendation was made that these teams be organized sufficiently in advance of their actual employment to permit individual members to learn to function as a unit.
The request was forwarded to the Personnel Division, Office of the Chief Surgeon, which assessed quotas to each of the four base sections for 18 surgical teams and 9 orthopedic teams. The requirement for providing triage officers at the hards was placed on the Southern Base Section.
When Colonel Cutler finally had more time to devote to these plans, he submitted additional items for the SOP on the care of casualties in the forthcoming operations.
With respect to transit hospitals, he offered the following in a memorandum to Colonel Kimbrough, dated 10 April 1944:
In the event that the transit hospitals are crowded with casualties needing definitive surgery then the ambulatory and lightly wounded personnel should immediately be evacu-
ated to the General Hospitals in the base area in order that there should be no great delay in their surgical treatment. This category of casualty represents a primary responsibility of the Medical Department, for these men with good surgery at an early date can be restored to active duty in the combat forces.
In the same memorandum, he submitted the following item, with respect to general hospitals in the base area:
The general hospitals in the base area will carry out primary definitive surgical treatment on all casualties reaching them in whom such care has not already been given. This may largely consist of the lightly wounded ambulatory cases who are expected to stream through the transit hospitals without opportunity for definitive surgery at that level. These are extremely valuable personnel and deserve optimum surgical care since they represent returnable manpower to the combat forces.
Cases also will reach the general hospitals after definitive surgery has been carried out at the transit hospitals. Many of these with the assistance of chemotherapy, either the sulfonamides or penicillin, or both, will be found suitable for secondary suture of the wound and thus have the period of disability limited.
Another function at the general hospital level will be the transfer of Allied forces casualties, chiefly British, to their own hospitals. This function will be implemented through the Office of the Base Section Surgeon. Transfer of the British casualties to British hospitals must not occur until the base area has been reached.
Personnel requirements confirmed.-At about the same time that Colonel Cutler was dictating these additions to the standing operating procedure for professional care during the invasion, Colonel Zollinger notified the Chief Consultant in Surgery, in a memorandum, dated 8 April 1944, that there was some question as to the number of surgical teams required or desirable in the transit hospitals. Colonel Zollinger said that there might be changes, also, in the final number of transit hospitals. Colonel Cutler informed the chief of the Professional Services Division that there was no reason to change the original professional opinion for two general surgical teams and one orthopedic team to augment each of the transit hospitals.
Exercise SPLINT - A few days later, Colonel Cutler was able to catch up with the most recent planning on the contemplated LST operations. With Colonel Liston, he journeyed to the southern port of Newquay on 12 April 1944. There, the entire morning was spent in observing an exercise involving beach operations and the loading of casualties into LST's (fig. 70). In the afternoon, General Kenner, Chief Medical Officer, SHAEF, presided over a critique of the exercise, following which General Lee flew Colonel Liston and Colonel Cutler back to London in his private aircraft.
Among other matters, there was a good discussion on the time required to load an LST with casualties. The Navy pointed out that it took 3 hours to unload an LST, and perhaps more. With the proposed single-sling loading of casualties over the sides of LST's from small boats, one casualty could be loaded each minute, thus making a good load of 180 casualties in 3 hours. Furthermore, the Navy pointed out, there was no reason to load the LST any faster because there was no room for casualties until the material on the ship was moved out.
FIGURE 70.-Exercise SPLINT in and about Newquay, Cornwall, England, April 1944. A. Gen. John C. H. Lee and Allied officials inspecting a jeep, modified in the European theater with brackets to hold litters. B. An LCT (landing craft, tank) tying up to an LST to transfer casualties for further evacuation.
With respect to the weather hampering operations, the Navy stated that, if LST's could be unloaded, they could be loaded. That is, if the operation was on, casualties could be returned. But, perturbing, at this critique, was the estimate now entertained by some that casualties would be on LST's for 48 and even 72 hours!
"The above expectation of the time a man awaits surgery," warned Colonel Cutler, "demands the presence of a good surgeon on each LST." "Moreover," he added, "we must remember that the first casualties, irrespective of the condition, will be shovelled into the nearest boat and, also, serious casualties may occur on any ship."
Colonel Cutler was pleased to learn, however, that the Navy would provide 2 general medical officers for each LST and would accept a complement of 100 Army surgeons, with assistants, for assignment to these ships. Col. (later Brig. Gen.) Thomas D. Hurley, MC, Surgeon, Third U.S. Army, said that he was providing 45 good surgeons for this purpose. The others were to come from Air Force and Service units in the United Kingdom. Captain Dowling of the Navy stated that a course of instruction would be given these surgeons, who would be doing the major work on the LST's, some 4 or 5 days before the operation.83
However, on 24 April, at the conference of base section surgeons, it was necessary for Colonel Cutler to make this rather dismal announcement:
With reference to furnishing the Navy fully qualified surgeons for LST's, a directive was sent out asking for nominations, and we have been checking on those we have received. We promised the Navy well-qualified surgeons. I think the Base Section Surgeons may not have fully appreciated this as we have received nominations of very young and inexperienced men.
"I think everybody understood thoroughly," commented General Hawley pointedly. And then to Colonel Cutler, he said: "I think you are going to have to get those people by looking over their * * * cards in this office, deciding whether they can be spared from that unit or not and ordering them."
Early ambulatory management - General Hawley-ever concerned with having a sufficient number of available beds before and during the continental invasion-directed the Professional Services Division to look into the matter of accelerating professional care by early ambulatory management of postoperative patients. He referred to precedents' having been established in the United States in this direction and suggested that it might even be better for the patient, himself. The matter was brought to the attention of Colonel Cutler, who stated in a memorandum to the chief of the Professional Services Division, dated 24 April 1944, that the Professional Services Division exerted constant pressure to assure that personnel hospitalized for surgical reasons were out of bed at the earliest possible moment. He continued:
The tendency in the U.S.A. to get people up on the first or second day is now widespread. * * * In the Peter Bent Brigham Hospital, Boston, Mass., I have heard recently
with joyous comments from my junior associates that the average patient is out of bed the day after his surgical ordeal. This I consider to be unfortunate and an undesirable practice for the advance of surgery. We must remember that the art of medicine and surgery has attached to it just as many fads and fancies as other walks in life, and we must recall that it take time for wounds to heal. We know many ways by which wound healing is prevented, but we have as yet discovered no agent and no method for hastening Nature's process. Certainly to keep people in bed unnecessarily long merely weakens their general condition and probably therefore somewhat delays healing, but to force Nature beyond her powers is even more foolish.
The U.S. Navy has stated that they get people out of bed earlier than we do in the Army. Maybe they do. That does not make the wound heal faster, and moreover we must recollect the people in the Navy and in the Air Force do not have to walk with 50 odd pounds on their back over great distances. Rehabilitation for the soldier is rehabilitation for the maximum effort, and that is not true with other branches.
Colonel Cutler then called attention in the memorandum to the fact that a manual for bed exercises was being prepared and that the period of bed rest could probably be considerably shortened with specific setting-up exercises. He also made the following recommendations:
That the Division of Professional Services continue their influence to reduce the period of bed rest to the shortest period of time compatible with solid healing of the wound, and this of course varies with the position of the wound, for all those except those with wounds of the abdomen and lower extremity may be out of bed within a few days of their surgical ordeal.
While these recommendations were no doubt acceptable, there was apparently a decision that a directive was also necessary to make a program of accelerated care mandatory upon hospitals in the theater. Accordingly, under dateline of 14 May 1944, Colonel Cutler submitted in draft a directive entitled "Early Ambulatory Management Following Surgical Procedure." In submitting the proposed directive, Colonel Cutler advised Colonel Kimbrough: "When the document is presented to General Hawley I believe it should contain a statement that 'Professional Services Division believes that a greater contribution to the saving of time in hospitals will result from acceleration of the administrative program than from this questionable acceleration of professional care.'"
With minor modifications, Colonel Cutler's document was published as Administrative Memorandum No. 74, Office of the Chief Surgeon, ETOUSA, 22 May 1944, and directed that all patients be made ambulatory as soon as possible following surgical procedures. Certain obvious exceptions to the policy were specified, and the directive warned that abdominal incisions, except for the McBurney type, now had to be supported by "through and through" or retention sutures. Colonel Cutler was able, however, to have inserted in the directive instructions requiring the number of days of total bed rest to be noted on each patient's record. General and station hospitals were also required to make an evaluation of the results of this regimen in their monthly surgical reports. To Colonel Cutler, it was a matter of waiting and seeing if the results bore out the contention of this directive, which opened with the statement: "Recent observations have suggested that the traditional duration of bed rest following surgical procedures can be shortened materially with
benefit to the patient. This leads to a reduction in the patient's recovery period, a conservation in manpower, and a saving of hospital beds."
Curiously, the same proposition was brought up in a meeting of the British Army's consultant committee meeting, but Lt. Gen. Sir Alexander Hood and his consultant accepted Colonel Cutler's recommendation that the British Army await results of the American experience before committing themselves to such a program.
Recapitulation - At the Chief Surgeon's meeting with his division chiefs on 2 June 1944, Colonel Cutler heard General Hawley close the meeting with these words:
I don't know when D-day is, and if I did I couldn't tell you anyhow. But it is logical to assume that it is not too far off now; if we have left anything undone, the time is falling short. We must be ready to go. I think in the transit areas they are ready to go.
What had the Chief Consultant in Surgery done to be ready to go? In summing up, the following things stand out:
1. Everything possible from the professional side had been done to clear beds in anticipation of the expected casualties. Disposition boards had been trained, checked, and exhorted to carry out their functions rapidly and properly. A program of early ambulatory management had been instituted to get the patient on his feet more quickly. When it was discovered that administrative proceedings, rather than professional, were holding up the disposition of patients, the consultants had adamantly brought this to the attention of those in the position to do something about it. The rehabilitation program had been put in full force to clear hospital beds and return men to duty earlier and in better physical condition.
2. The blood bank was ready to go, and bleeding sets had been constructed and distributed to augment the distribution of whole blood. Last minute procedures had been completed to supply LST's with 10 pints of blood each. Marmite (Thermos) cans had been procured so that whole blood could be packed in them and taken along by the leading assault elements (fig. 71). Too late, possibly, it had been realized that the supply of whole blood available from local sources might be insufficient. It would be sufficient for the initial phases, however, and plans had been made for increasing blood-collecting facilities.
3. Penicillin for the initial assault had been assembled or was on its way. Quantities required to sustain subsequent operations had been calculated and requisitioned. Decisions had been made on how penicillin was to be used, and the command instructed accordingly.
4. LST's had been carefully studied and the lifesaving procedures necessary on shipboard had been agreed upon and were well understood by all concerned. Surgical instruments, scarce as they were, had been assembled into kits and placed on these ships. Linen was obtained and rolls of disposable rubberized sheeting had been supplied to be used for surgical drapes. Finally, a handpicked complement of 100 qualified surgeons was ready to board
the ships-one to an LST. They had been briefed by Colonel Cutler and his assistant, Colonel Zollinger. They were also being briefed by the Navy.
5. Principles of triage on LST's had been formulated, and cards for tagging the casualties had been prepared. Surgeons of mature and sound judgment had been selected to act as triage officers at the hards and ports. The supervision of these triage officers and the control of surgical teams in the transit areas were in the able hands of Lt. Col. George K. Rhodes, MC, surgical consultant to Southern Base Section. He had also personally inspected the personnel and facilities at all the hospitals in his area to be sure that the work to be done at each facility was being supervised by a topnotch surgeon and that all understood just what was to be done and what was to be left undone.
6. Surgical teams had been picked, organized, briefed, and stationed at holding and transit hospitals to augment their regularly assigned staffs. Policies for the assignment and use of surgical teams in the field army and in other areas of the communications zone had been elaborated and announced.
7. Policies and procedures for the professional administration and management of battle casualties from the frontline areas to hospitals in the rear had been established and promulgated. A pocket-sized edition of the Manual of Therapy had been printed and distributed so that each medical officer caring for patients in the combat zone or in the communications zone would have a ready reference as to how injuries and diseases were to be cared for in the European theater.
8. A close and sympathetic understanding had been established between the British and the Americans as to the surgical plans each was following. They were ready to accept each other's casualties and care for them until they reached the base areas.
These were the preparations. Was there anything yet undone? There was.
Use of consultants during assault phase - On Thursday, 1 June, the day before the 2 June meeting with the Chief Surgeon, Colonel Cutler had approached Colonel Mowrey and Colonel Liston as to what the professional men might do during the assault on the Continent. He had proposed that certain of the consultants might help out at the holding hospitals for the nontransportables, the orthopedic men could help out at the transit hospitals, and the remainder of the specialist consultants might work out of Cheltenham and be used wherever their services were required. Now some had been opposed to these thoughts, but on this occasion, both Colonel Mowrey and Colonel Liston were agreeable to the idea.
Earlier during the Chief Surgeon's meeting on Friday, 2 June, Colonel Cutler had managed to mention, in passing, his hopes for the use of consultants during the attack. "They may be used in transit hospitals best by pushing patients through," he said. And then, dwelling on General Hawley's favorite theme during this period, Colonel Cutler added: "Hospitals tend to keep patients too long."
"I agree with you," the general replied, "but those people down there have a responsibility, and if these consultants are used in that capacity only, that is fine, but none of us, short of an extreme emergency where the system will fall down, none of us can step in down there to operate the system. That is the function of SBS [Southern Base Section]."
To Colonel Cutler, this reply was noncommittal and discouraging. He took it to mean that General Hawley was against the proposal. So, he remained after the meeting and, in the afternoon, was able to see General Hawley with Colonel Liston. Both General Hawley and Colonel Liston were entirely in favor of the proposed use of consultants. Moreover, General Hawley asked Colonel Cutler to be with him, personally, during the early phases of the attack. To Colonel Cutler these reactions were wonderful. He was elated, but at the same time he was cautious. "So I laid it on in a memo," he wrote in his diary. The 4 June 1944 memorandum, the subject of which was the utilization of surgical consultants during operations, was addressed to the Chief Surgeon through the Chief of the Professional Services Division. It stated:
1. During periods of great activity, the function of evacuation must be the prime concern of the Medical Department.
2. The surgical consultants are senior officers with a long experience in this theater, and are fully cognizant of the importance of evacuation. They realize that to choke a hospital with more casualties than the surgical teams assigned there can handle in a 24-hour period means undesirable delay in the period before definitive surgery can be
carried out. If evacuation is prompt and efficient, casualties passing through transit hospitals without definitive surgery will actually have surgical care at an earlier period in some general hospital behind the transit hospital area.
3. There are two points at which evacuation may be unnecessarily delayed.-
4. To assist in facilitating evacuation and equally to hold in field and transit hospitals those who should be held there I recommend that the following officers be assigned as designated below during the first phase of the operation until a proper procedure is established.
Hard A-S [Southampton area] (FH 46, FH 28, SH
110)-Lt. Col R. M. Zollinger.
To the transit hospitals above B-P (GH 28, SH
228, SH 315)-Lt. Col. W. Stewart.
5. The remaining senior consultants in the surgical specialties, Colonels Stout, Vail; Colonels Spurling, Allen, Canfield, and Tovell will remain at Headquarters, SOS, prepared to go where their services are required. Since definitive surgery will largely be done in the general hospitals behind the level of the transit hospital, their activities will be largely in that area.
The memorandum was returned quickly to Colonel Cutler with one word on it in General Hawley's bold scrawl, "Approved," followed by his initials. This document facilitated the procurement of necessary passes for the consultants to permit their entry into and egress from the staging area. It was difficult enough to enter the critical areas, but it was more difficult to get out, once a person was in. The actual date for the invasion was still obscure, but the surgical consultants were now ready.
On Tuesday, 6 June, Colonel Cutler was off on a trip with Colonel Kimbrough and Colonel Zollinger in the direction of the A-S hard to check on preparations made by holding and transit hospitals in the area. They first visited the 38th Station Hospital at Winchester, Hampshire, and found everything satisfactory. Next was the 110th Station Hospital at Netley, Hampshire. The Southern Base Section surgeon, Col. Robert E. Thomas, was there. He appeared surprised when three officers from headquarters appeared on a relatively routine visit. The invasion was on, he told them (fig. 72). Colonel Cutler could scarcely believe him. The radio was turned on, and, sure enough, the same story appeared. With renewed purpose, the three officers continued their tour. At the Royal Victoria Hospital, which had recently been turned
FIGURE 72.-Medical service on the Normandy beachhead, D-day, 6 June 1944. Upper view, an aid station of the 8th Infantry Regiment, 4th Infantry Division. Lower view, casualties being collected at a field hospital platoon.
over to the Americans by the British, quantities of ammunition crates littered the beach where they had drifted in after being thrown overboard from combat ships of the Navy on their way out (fig. 73). The three officers completed their tour with visits to the 46th Field Hospital, a holding unit, and to the 48th General Hospital, one of the transit hospitals supporting the A-S hard, and returned to London.
Arriving at 9 North Audley Street the next morning, Colonel Cutler learned that General Hawley had packed and motored to Cheltenham. Colonel Cutler hastened to the 1st Medical General Laboratory at Salisbury, Wiltshire, which had been designated the command post for the Chief Surgeon during the assault phase. There, he learned that penicillin was a problem and that the fifty billion units ordered for June had not arrived. "Ordered 50 billion," he wrote in his diary, "only 600 million now here. Half on beaches 'far shore,' half on LST's and for distribution here. But it is a mess. All write lots of penicillin! We order and none comes." At midnight, he was still preparing a letter to Col. (later Brig. Gen.) John A. Rogers, MC, First U.S. Army surgeon, for General Hawley, saying there was no penicillin. Nevertheless, he did have time to note: "The continental invasion is on at last. All are excited; too much so. Here I am with General Hawley sleeping in next room to me. I wouldn't have believed it possible 2 weeks ago."
Thursday, 8 June, Colonel Cutler wrote, was a "wonderful day with PRH [General Hawley], all day." He was up at 0630, had breakfast at 0700, and embarked on the following:
1. Off with PRH at 8 :00 a.m. * * *.
2. Southern Base Section and reports on wounded arriving and evacuated on.
3. 12th and 109th Evacuation Hospitals. In tents, pretty good-not too good-interesting femur and buttock at 109th. Bad jaw and chest at 12th. Sent jaw, chest, femur, and 1 other by ambulance to 67th General Hospital.
4. Lunch at 50th Field Hospital in Weymouth (two platoons) (fig. 74). George Rhodes there. Bad eye case; sent for D. Vail. Many cases were treated. GKR [Rhodes] had seen 3 abdominal cases all operated on LST's. Good work * * *.
5. To Bristol, hard. Other platoon of 50th Field Hospital close by. Did not visit and did not go to 12th Field Hospital. Roads full of LCP's; went on one. U.S.S. Quincy in harbor; 1 major general and 1 brigadier general [aboard]. Skipper told of tough time on beach. Many dead * * * underwater stuff.
6. To 305th. Interesting cases. Spleen, 36 hours. Eye and brain case.
7. To Sherborne to see train unload; late (fig. 75).
8. Visits to 3d Armored Division to Meet General Hawley's son-in-law, Captain Towsey. All in pup tents.
9. To Southern Base Section headquarters.
10. Here Salisbury. Thomas came to call. He said (a) Orders not to do surgery but evacuate means no evacuation 'till hospital fills; negative number of cases, therefore nothing doing. (b) No record if in hospitals under 48 hours-wrong. Field Medical Record (FMR) should start with first definitive procedure. (c) Thomas reported cases at various hospitals, including 60 PW's, largely at 110th Station Hospital.
11. Call in from First Army re penicillin. I said General Hawley had written letter to Colonel Rogers.
12. Now I must write something for Colonel Thomas.
At the end of the day, Colonel Cutler had these thoughts in mind:
The war is on here. Have been about, as one can see. * * * But is it going OK? Where are the LST's? They are not coming back and wounded are coming in on APA's; no good staff, poorly cared for. One femur with no splint. Stories from wounded: Left on beach between 6:00 and 8:00 a.m., lay on beach, no assistance * * * got wet as tide came up, crawled to rocks (one with fractured femur), help to one at 4:00 p.m.
The next day, 9 June, was D+3. Colonel Cutler arrived at Southern Base Section headquarters at 0830 for a long talk with Colonel Thomas. They discussed further the problem of hospitals erroneously assuming that they were to do no surgery and just wait until enough patients accumulated to be evacuated by train. They also spoke of means to rectify the situation with respect to initiating field medical records at the time of first definitive treatment. Later, Colonel Cutler visited Maj. Gen. Eric Barnsley, RAMC, the surgeon of the British Southern Command. General Barnsley said that the British had had 400 wounded on D+1 and 1,200 on D+2. Next, Colonel Cutler went on to the 109th Evacuation Hospital, where he had lunch and spent the remainder of the day at the beach at Portland (fig. 76). It was a great day and experience. Some 19 to 22 LST's came in with about 2,000 wounded (fig. 77). Care on the LST's had been good, but Colonel Cutler noticed considerable crowding and disorganization on some of them. Ships with casualties were
waiting an inordinately long time in the harbor in order to come in and unload their precious cargo.
The next day, Saturday, 10 June, was spent in catching up with the events of the past week and reflection upon what he had observed. In the morning Colonel Kimbrough held a meeting of the Professional Services Division, and the remainder of the day was spent by Colonel Cutler in writing letters, preparing reports, and putting some order into the data being assembled. The following recommendations were submitted to Colonel Kimbrough in a memorandum, dated 11 June 1944, as a result of the observations made during the first week:
1. Medical record. In all hospitals visited found F.M.R. was not started following surgical therapy for fear of staff that this was not allowed (see SOP). Because of this feeling, and with the desire for some record, most hospitals had mimeographed a form of their own with a clinical chart, so that some record could be kept of surgical cases.
Recommendation: The F.M.R. shall begin at the time any definitive medical or surgical care starts.
2. Surgical care. At all hospitals visited I found that the staff and the commanding officer had interpreted the SOP to mean that only the first aid care could be given in transit hospitals. This had led to men being given first aid care and then, since there were few admissions, the staff sitting around waiting for the patients to be evacuated, but, as only a trainload could dictate when a hospital was to be evacuated, casualties were not being evacuated and were sitting around with nothing but first aid care, when a surgical procedure might have greatly increased their opportunity for rapid restoration to duty and survival with better function.
Recommendation: a. Surgical procedures shall be carried out in transit hospitals as indicated by the nature of the casualties and in relation to the pressure exerted by the number of casualties admitted. Thus, when there are only a few casualties, most of them could have definitive surgery in a transit hospital. When there are large numbers of admissions, only those urgently requiring surgical care should have it at the transit hospital level.
b. In special instances where ambulances are available and the condition of the patient justifies travel and the treatment of the condition can best be done at a neighboring hospital, then that patient shall be transferred by ambulance to the appropriate hospital where the facility is available.
3. In observing the unloading of LST's at Portland, it is clear that only 5 LST's can unload at one time, 2 on the hard and 3 at the pier. It did not appear to us that more than 6 LST's would be unloaded and loaded in a 24-hour period, for the loading of an LST after the wounded are evacuated takes 6 to 8 hours. This delay is injurious to the condition of casualties, and another method must be found for unloading critically ill people.
Recommendation: When the hards and the pier are filled with LST's and more are waiting in the roads than can be unloaded in the next 12 hours, smaller crafts, such as LCT's (fig. 78) shall go out to the LST's, take off the casualties and land at the many beach areas where such smaller craft can unload.
The "SOP" Colonel Cutler was referring to in his recommendations was, as the reader may have realized, Administrative Memorandum No. 62, which is discussed on pp. 173, 175. To Colonel Cutler, his fears had been realized. The arbitrary changes which had been made on his recommendations had resulted in a situation where patients who could and should have received definitive care were being neglected, and proper records were not being prepared.
FIGURE 74.-The 50th Field Hospital at Weymouth, England, during the Normandy invasion. A. The admissions area. B. A sandbagged surgical area with a mobile X-ray unit set up nearby (the truck and two adjoining tents on the left).
FIGURE 75.-Unloading of a hospital train at Sherborne. A. The interior of a war car (a converted box car). B. Ambulances stand by to take patients to the 305th Station Hospital at Warden Hill, St. Quintin, Dorset.
Second Week, D+5 to D+11
The second week after D-day was pretty much a resumption of the first few days. On Monday, 12 June, Colonel Cutler accompanied General Hawley, Col. Howard W. Doan, MC, Colonel Humphrey, and Mr. Littell, war correspondent for The Reader's Digest, on a field trip to the Portland area. Concerning a visit to the 109th Evacuation Hospital during this trip, Colonel Cutler recorded: "* * * saw bad case blown up on ship; left foot gone, open fracture on right leg into knee joint. Very ill; not yet dressed; 6 days. Bad Rx, but not yet infectious. Suggested blood and then dress under ether." In connection with the visit to the 50th Field Hospital, he recorded: "* * * have had five or six cases of gas gangrene; not all amputations, yet 6 days old! Why no more infection? Sulfonamide and penicillin? Saw German with right lower-quarter abdominal wound. Prisoner said: 'We Germans have no chance-replacements not allowed.'" At the Portland hard, Colonel Cutler was shocked to see many prisoners of war with wounded hands being taken off LCT's as litter patients.
Colonel Cutler was most pleased to see that LCT's were going out to the LST's to unload patients as he had suggested the week before (fig. 79). The entourage went out on a Higgins boat to watch the procedure. At LST 59, they found: "Bob White aboard as triage [officer]. Captain Steward of 85th
General Hospital in charge. 85-plus Germans (fig. 80); 266 casualties picked up wounded on D+2, 3, 4 but convoy [was] slow in returning." And then: "To LST No. 501. (Should have seen General Hawley go over side!) Captain Keleher, 16th General Hospital, in charge. He had done one abdominal wound on LST; OK; and one tracheotomy-died from multiple wounds [of the] chest. Needs blood and more penicillin; needs Atabrine for malaria and Levin tubes. Major Wilcox, 2d General Hospital, aboard as triage officer. Saw women snipers in civilian clothes as wounded PW's. American boys had thought they had come to help French, yet French women had shot them."
It was a busy day at Portland. By 1400, 715 casualties had been taken off LST's, and by 1500, the total had risen to 1,052. The joy of seeing LCT's unloading LST's was short-lived, for, as the party returned to the 50th Field Hospital, they were informed that LCT's could no longer be used for this purpose. Back at the 1st General Medical Laboratory that night, there was more talk about women snipers and, Colonel Cutler wrote, "PRH said you (ECC) and I go [to] France next week-goody!"
But, before going to France, Colonel Cutler was able to observe the reception of casualties evacuated by air. Air evacuation had started early in the campaign, perhaps as early as D+4. A platoon of the 6th Field Hospital was at Ramsbury, East Wiltshire, and a platoon of the 28th Field Hospital, at Membury to receive air-evacuated casualties (fig. 81). Colonel Cutler visited these facilities on 14 June. He saw three planes unloaded in 20 minutes, and thought: "A-1. This is the secret for future good care, but cases must be se-
lected: no post-operative abdominal cases. Almost killed Lt. Col. [William D.] McKinley."
On Friday, 16 June, Colonel Cutler worked in the morning at the Cheltenham office. He was back at the Salisbury "CP" by noon, where General Hawley had said he would meet Colonel Cutler.The Prague and Normandy
The period from 17 through 22 June was spent on the hospital carrier, Prague. The Prague was one of four hospital carriers loaned by the British to the Americans during last-minute preparations for Operation OVERLORD. It was a 4,100-ton vessel with British crew and a complement of U.S. Army medical personnel. These hospital carriers were protected by the Geneva Convention, and were painted white with prominent markings using the Geneva Cross. The Prague was the largest of the four vessels loaned to the Americans and could carry 194 litter and 228 ambulatory patients at one time. Its complement of medical personnel included female nurses and attached American Red Cross workers. The record is notable for the absence of any information concerning this period on the Prague. But, in thanking the ship's captain on behalf of General Hawley and himself, Colonel Cutler wrote: "It was pleasant and the enforced rest did us much good." It also gave Colonel Cutler the opportunity to observe the evacuation of a group of casualties from the time they were loaded on the continental shores until they disembarked in England.
FIGURE 79.-The unloading of LST's by transfer to an LCT and direct beaching of the LCT, Weymouth, England. A. An LCT tied alongside an LST. B. A patient being lowered to an LCT. C. An LCT being beached where ambulances and trucks await.
General Hawley and Colonel Cutler returned to Salisbury for the night of 23 June (fig. 82) but left early the next morning by air for the Normandy beachhead, arriving at the Utah air strip at 0845 on 24 June. They departed from Omaha airstrip at 2000 the next day, but in the interim Colonel Cutler was able to visit the three platoons of the 45th Field Hospital, the 3d Platoon of the 13th Field Hospital, the 621st Clearing Company at the Utah airstrip, and the 5th, 24th, 41st, 44th, 45th, 67th, and 97th Evacuation Hospitals. In addition, he had the opportunity for lengthy conferences with the First U.S. Army surgical consultant, Colonel Crisler, and also Colonel MacFee. Upon returning, the Chief Consultant in Surgery reported to General Hawley in a memorandum, dated 28 June 1944, as follows:* * * * * * *
4. It is unnecessary here to take up individual professional comments which were made directly to Colonel Crisler and many of which were embodied in the memo for the First U.S. Army Medical Bulletin which he was preparing at the time we were there for Colonel Rogers' study and signature, but the following comments may be of value:-
A large quantity of blood is being used by the First U.S. Army (fig. 83). I saw no instances, however, where I felt it was not helpful and indeed desirable for the treatment of casualties. Should pressure decrease, perhaps more plasma can be used in proportion to blood. I could not judge from statistical data the exact relation between
blood and plasma but I had the impression it was being used almost as frequently as plasma; that is, in the ratio of 1:1, whereas one has some justification for the hope that a smaller amount of blood, backed up by plasma might yield almost as beneficial results, i.e. in the proportion of 1 of blood to 3 of plasma. * * *
There were numerous complaints about the "set" not working well. Some thought it was the filter, some the size of the giving needle in the vein, which was a part of the plasma set, and some thought it was the needle which let air into the bottle as the blood ran out. * * * I am of the opinion that a chief difficulty lies in the method by which air enters the bottle, * * * or if the blood is not shaken and carefully mixed it becomes clogged by the buffy coat and coagulum which always settles out on top. This matter was discussed in detail with Major Hardin on my return, and he hopes to make a trip immediately to the First U.S. Army and see if the difficulties cannot be smoothed out. Not all officers made complaints, so that the difficulty certainly is not insurmountable.
I believe the theater stocks will be able to keep up to the demand for 500 million units of penicillin daily. * * * 500 million units will treat only a little better than 2,000 casualties a day. * * * if the casualties are of a less serious type, the dose is halved and therefore 500 million units would suffice for 4,000 casualties a day. I am of the opinion that as pressure decreases and the hospitals become well stocked, 500 million units of penicillin will be ample for the present. Also, during my visit I found one surgeon who was giving 100,000 units per injection instead of the 40,000 prescribed. This is neither proper nor scientific and * * * I warned him it was unwise for individual surgeons to experiment with doses at this time.
FIGURE 81.-The reception of air-evacuated casualties at Membury airfield. A. The unloading and triage of patients. B. A closeup view of a medical officer examining a casualty. Note the use of simple sawhorses to hold litters.
c. Wound debridement
This, on the whole, was being well carried out, but Colonel Crisler and I did see some assistant team surgeons operating while their chiefs were resting who were not sufficiently well trained for this purpose, and it would be wiser for the assistant to go off duty while his chief is resting, and the casualty shipped by air to the United Kingdom, where there are hundreds of capable surgeons waiting, than to do inadequate debridement under the circumstances imposed. In commenting on surgery as a whole, I thought it was a little better in the field hospital platoons than in the evacuation hospitals, but my visit was very short and perhaps some brilliant surgeon's work in one of the platoons of the 45th Field Hospital and one platoon of the 13th Field Hospital overweights my judgment, or it may be that Colonel Crisler has wisely placed his best surgeons with the field hospitals, where the nontransportables are being cared for.
d. Plaster of paris
I thought the general level of plaster work excellent but I did notice a tendency for all femurs to be put in double spicas with a good deal of abduction. It must be recalled that plaster is used to immobilize the fracture in the period between the evacuation and general hospital and that this period should be short. In the general hospitals, plaster would invariably be removed and replaced by skeletal-suspension traction. This merely requires temporary immobilization and low-waisted single spicas should be sufficient for transport. If double spicas are to be applied, the abduction must not exceed litter-width, else transport becomes difficult.
e. Abdominal surgery
I found four eviscerations in two days. This was due to failure to use retention sutures. Colonel Crisler has called attention to this in his professional memo for Colonel
Rogers. I also saw two cases in which the surgeon did not exteriorize large bowel wounds but closed them without a colostomy. I believe this to be an unfortunate mistake and if frequently occurring would surely bring disaster.
f. Thoracic and thoraco-abdominal wounds
The wounds I saw done at field hospitals bring forth my most sincere appreciation. I still recollect a very difficult case of this type being done by Partington at a 45th [Field Hospital] platoon which had every element of perfect surgical performance.
At one hospital, where some 300 preoperative cases had accumulated, I found three prisoners being operated upon ahead of our own soldiers.
h. General comment
It is my overall opinion that the level of professional care is very high, certainly better than in the last war. The fact that members of the 3rd Auxiliary Surgical Group, who are well trained and thoroughly instructed in battle casualty care are doing much better work than the 4th Group as a whole, who had little in the way of orientation and instruction, emphasizes again the importance of Army instruction even in professional work. The low incidence of serious infection was striking and must be related to the bacteriostatic agents, penicillin and the sulfonamides, now employed in military surgery. The incidence of amputations seemed happily low, the incidence of gas gangrene also much lower than was expected or was present in the European War, 1914-18.
In closing his report, Colonel Cutler recommended that medical elements of the First U.S. Army, at this time, should direct their energies to providing first aid care for the wounded and surgery only for those in which it would
save life or limb. These priorities should be adopted, he explained, for the following reasons:
Casualties given expert first aid care arrived in the United Kingdom even two or three days later in excellent condition, but a good many did not have this. Many wounds had lost their dressings because they were improperly applied, many were improperly splinted, and some, even compound femurs (personally observed), reached the United Kingdom totally unsplinted. If every medical officer in the first week devoted himself to the control of hemorrhage, adequate dressing, adequate treatment of shock with plasma and blood, and perfect immobilization, a perfect task would have been performed. When surgery is permitted early, many hands treat but a few, and many others must go carelessly dressed or improperly splinted.
Even at the present time I would suggest less emphasis on immediate surgery for all and more emphasis on properly evacuating those who can travel safely. This must be a large number, and it seems most unwise to allow any evacuation hospital to carry a backlog of unoperated cases of much over fifty cases.
Major Hardin Visits Normandy
On 28 June 1944, when Colonel Cutler submitted his report, Major Hardin was already on his way to Normandy to determine whether whole blood was being used in excess and what difficulties were being encountered in its administration. In the 3 days that he was there, he contacted members of the Medical Section, Headquarters, First U.S. Army; 1st Medical Depot; Advanced Blood Bank, ETOUSA, Detachment A, 152d Station Hospital; and the 45th, 67th, and 128th Evacuation Hospitals (fig. 84).
He informed Colonel Cutler, on his return, as follows:* * * * * * *
3. The problems encountered in the use of stored blood were first discussed with Colonel Crisler, Consultant in Surgery, First U.S. Army. The difficulties were mainly in administration of the blood in that the speed of flow was inadequate. The general opinion seemed to be that the filter was at fault.* * * * * * *
Other errors in the use of the equipment which when corrected will help increase the speed of flow were failure to thoroughly mix the blood by shaking and improper use of the filter. * * *
In the three hospitals visited the ratio of blood to casualties was one (1) pint to four and seven tenths (4.7) casualties. The ratio of plasma to casualties was one (1) unit to three and two tenths (3.2) casualties.
The ratio of blood to plasma was one (1) pint to one and four tenths (1.4) units plasma. Many casualties receive plasma before admission to hospitals, so that these figures do not present a wholly accurate picture of the ratio of plasma to blood.
Reactions to blood as reported are extremely low. It is not believed that this paucity of reactions is possible. Undoubtedly, minor febrile reactions are being overlooked in the rush of caring for numerous casualties. No serious hemolytic reactions were encountered and consequently no deaths from transfusion have been reported. A few instances of jaundice have been encountered in patients who have received large amounts of blood (3,500-5,000 cc's). In each case complicating factors were present such as hepatic injury, sulphonamide therapy, and collections of blood in body cavities or muscles. There was no case in which the jaundice could be attributed solely to blood transfusion. However, * * * all stored blood, regardless of age, contains some free hemoglobin and * * * with massive