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Chapter II - continued

Contents

Chapter II - continued

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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."


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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


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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

79Memorandum, Col. E. C. Cutler, MC, to Chief, Professional Services Division, 11 Feb. 1944, subject: E.M.S. Preparations.


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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:

80See also Colonel Zollinger's personal narrative of his activities in Chapter III.


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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.


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FIGURE 65.-Special slings on LST's for handling litter patients. A. A sling being used to hoist a litter from the deck of an LST. B. A sling being used to lower a litter.


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FIGURE 66.-Litter patients in an LST that had been converted with wall brackets to hold litters.

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.
2. Treatment of shock (for which blood and plasma will be provided).
3. Proper dressing of wounds.
4. Proper splinting of fractures.
5. The elimination of pain through medication.
6. The giving of tetanus toxoid.

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


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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:

a. The ship must load casualties via the ramp through the bows.

b. They prefer not to use the ship's company's quarters, as these people will be working very hard and should not be disturbed.

c. They wish to keep all casualties on the tank deck and have plans to construct a small first-aid post, screened off, at the rear end of the tank deck.

d. The medical personnel for an LST will consist of two general duty medical officers, one qualified surgeon, one anesthetist and 32 men of noncommissioned ranks, about 20 of whom would be trained Navy medical personnel. Others would be largely used to clean the tank deck after tanks have left and before the casualties are brought in.

2. The British group felt certain that it would be impossible to take casualties up over the side in units or by any other method. They believe it will be necessary to beach the 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


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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

81"The emergency operating rooms on the LST's were built in the center of the tank deck along the after bulkhead. Each such room took up the space of one vehicle, but the combat troops were not advised by general headquarters of this alteration. The loading tables had been prepared for each unit; so, when the troops embarked, each unit had one truck, or other vehicle, which could not be loaded and had to be left behind. There was a lot of hell raised about this, but nobody ever criticized the Chief Surgeon. These changes had been made through command channels." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 17 Sept. 1958, and personal conferences, Dr. Hawley and Colonel Coates, during October 1958.)
82Circular Letter No. 122, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 17 Aug. 1943.


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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


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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.


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FIGURE 67.-U.S. Army hospital train ward cars in the United Kingdom. A. The exterior of a ward car. B. The interior of a ward car.


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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."

FIGURE 68.-Lt. Col. Fred H. Mowrey, MC.

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."


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"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.


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

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, 


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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-


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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.


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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.


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FIGURE 70.-Continued. C. Simulated litter patients in the tank deck of an LST. D. Litter patients being taken off a beached LST through the open bow and ramp.


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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

83Memorandum, Chief Consultant in Surgery to Chief, Professional Services Division, 16 Apr. 1944, subject: Comment on Exercise SPLINT.


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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


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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 recomendation 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


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FIGURE 71.-Marmite cans adapted for transporting whole blood. The tray in the soldier's left hand is filled with ice.

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.


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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


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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.-

a. By holding "transportable" casualties as "nontransportable" in field hospitals.
b. By attempting to hold too many casualties for elaborate surgical care at the "transit" hospitals.

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.

a. To the field hospitals for "nontransportables" at each area as follows:

Hard A-S [Southampton area] (FH 46, FH 28, SH 110)-Lt. Col R. M. Zollinger.
Hard B-P [Portland-Weymouth area] (FH 12, FH 50, EH 109, EH 12)-Lt. Col. G. K. Rhodes.
Hard C-B [Torquay-Brixham area] (FH 7, FH 49)-Lt. Col. E. M. Bricker.

b. To the transit hospitals above A-S (GH 95, GH 48, SH 38)-Lt. Col. M. Cleveland.

To the transit hospitals above B-P (GH 28, SH 228, SH 315)-Lt. Col. W. Stewart. 
To the transit hospitals above C-B (SH 316, SH 115)-Special assignment unnecessary.

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.

NORMANDY

D-Day Week

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


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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.


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FIGURE 73.-American equipment, ships, and men at Plymouth, England, awaiting orders that will send them to the Normandy beachhead.

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."


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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


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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.


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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).


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FIGURE 74.-Continued. C. An operating pavilion. D. A surgical truck with attached operating tent.


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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.


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FIGURE 76.-A view of the Portland area and Weymouth, South Dorset, England. 

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


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FIGURE 77.-Ambulances on a dock at Weymouth awaiting the unloading of casualties.

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-


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FIGURE 78.-U.S.S. LCT 217, beached at Weymouth, England.

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.


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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. Blood

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


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FIGURE 80.-Wounded German prisoners being unloaded at a collecting point on the Normandy beachhead (Omaha Beach) near Vierville-sur-Mer, France, 10 June 1944.

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.

b. Penicillin

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.


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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.


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FIGURE 82.-Omaha Beach, 23 June 1944.

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


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FIGURE 83.-Whole blood for the First U.S. Army being loaded on evacuation aircraft returning to the Normandy beachhead from the Membury airfield, 14 June 1944.

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.

g. P.O.W.'s

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


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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


Chapter II - continued

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