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Chapter II - continued

Contents

Chapter II - continued

223

FIGURE 84.-Blood from the Blood Bank, ETOUSA, being administered at the 128th Evacuation Hospital, Normandy, 12 June 1944.

transfusion there is a possibility of exceeding the renal threshold for hemoglobin with consequent kidney damage * * *.

An excess of recipient sets was found in hospitals and in the Advanced Blood Depot. * * * It is estimated that approximately two thousand (2,000) sets were lost in the first few days of operation. Fewer sets are being returned to the Blood Bank daily than are being shipped.

Significantly, Major Hardin, Senior Consultant in Transfusion and Shock, observed: "It does not appear that blood is being used in excess. It is administered not only for treatment of shock but to combat gas gangrene and other infections and to quickly build up the hemoglobin level in exsanguinated patients."

As a result of his visit to the Continent, Major Hardin recommended that:

*    *    *    *    *    *    *

4. * * *

a. Blood be shaken vigorously before administration.
b. The filter chamber be completely filled by inverting when transfusion is started.
c. No. 15 needles be used when rapid transfusion is desired.
d. Hospitals keep the same number of giving sets and bottles of blood on hand thus avoiding tieing up of sets needed elsewhere.
e. Patients receiving more than fifteen hundred (1500) cubic centimeters of blood in twenty-four hours be alkalinized by the same procedure as used when administering sulphonamides.84

84Essential Technical Medical Data, European Theater of Operations, U.S. Army, for June 1944 dated 22 July 1944. Inclosure 4, subject: Report of Visit to Combat Zone, by Maj. R. C. Hardin, MC.


224

Activities of Surgical Consultants During Invasion Phase

By the end of June, a fairly clear picture could be obtained of the initial activities of the U.S. Army Medical Department during the Normandy campaign, and it was possible to assess trends and contemplate future actions. In reflecting on the activities of the consultants during this invasion phase,85 the Chief Consultant in Surgery made the following observations concerning his activities during the first week:

(1) Col. E. C. Cutler was permitted to remain with General Hawley, with headquarters at the 1st General Medical Laboratory, and from that point visualize the reception of casualties at both the Southampton and Portland hards and their distribution through the subsidiary transit hospital areas and final evacuation to the base area by hospital train. This permitted a full evaluation of the system used to evacuate casualties from the far to the near shore, the limits and advantages of professional care as given whilst casualties were on craft in the Channel, received at the hards and cared for in holding and transit hospitals.

He described the activities of the other consultants during the first week, as follows:

(2) Lt. Col. G. K. Rhodes was assigned to the holding hospitals at the Portland-Weymouth hards, Lt. Col. R. M. Zollinger was assigned to the holding hospitals in the Southampton area, and Lt. Col. E. M. Bricker was assigned to the hards in the Torquay-Brixham area.

These men were of the greatest assistance in advising regarding the professional care of the serious, nontransportable wounded in their respective areas and in designating what cases could be reclassified as transportables and therefore removed from the nontransportable hospitals to the transit hospitals.

(3) The surgical consultants in the specialties confined their work for the first week largely to the area of the transit hospitals. Here, they were able to assist greatly in the professional care of casualties, the proper choice of priorities for surgical procedures and the evacuability or transfer of patients from transit hospitals to the base area and on occasions directly to special hospitals, where competent specialists were present. Indeed, on more than one occasion they were able to advise in the proper location of specialist teams at hospitals in the transit area, such as the moving of a neurosurgical team (a) to the 28th General Hospital, and (b) to the 217th General Hospital, where neurological cases tended to concentrate and where it seemed wise to provide expert professional care.

The characteristics of the activities and assignments of the surgical consultants, after the first week, were described by Colonel Cutler as follows:

*    *    *    *    *    *    *

b. * * * By this time it was clear that the advice of the surgical consultants could wisely be used in the area of the holding or nontransportable hospitals as well as in the transit hospital areas, and from time to time the surgical consultants visited these institutions. Colonel Vail's advice was necessary regarding certain difficult items and [that of] Colonel Tovell to help with anesthesia supply and administration. On the whole the surgical consultants continued to confine their work to the transit hospitals and continued increasingly to visit these institutions and to assist in establishing a high level of professional care. At the same time, the surgical consultants began to follow the cases back

85Memorandum, Chief Consultant in Surgery to Chief Surgeon, ETOUSA (through Chief, Professional Services Division), 30 June 1944, subject: Synopsis of Activities and Reports of Surgical Consultant Group During the First Two Weeks of the "Liberation Invasion."


225

into the general hospitals which, unused to the sudden influx of a large convoy, were at first thrown into some confusion, but gradually straightened their organization out and on the whole functioned in a highly satisfactory fashion, * * *. By this second week also air evacuation began to flourish and visits to the 217th General Hospital, which bore the brunt of air evacuation at first, assisted this hospital in the proper care of large numbers of casualties.

In his synopsis of activities during the first month of the operations, Colonel Cutler gathered professional comment from each of the senior consultants on his specialty and showed how their help and observations were contributing to the success of the medical support of the invasion. He ventured to hope that "this brief citation of the work of the surgical consultants in the first weeks of the 'Liberation Invasion' will justify the request that they be permitted as soon as accessible to visualize the problem on the far shore, that they in turn may benefit the professional care there as well as that they in turn may learn more and benefit the casualties returning to this shore." And his hope was to be fulfilled, for, as has been noted, Major Hardin was already in Normandy, and Colonel Cutler was instructed to establish priorities and schedules for each of his other senior consultants to visit the Continent at an early date.

Observations, recommendations, and actions

By the end of June 1944, as previously mentioned, a fairly clear picture could be obtained of the initial operations. As combat on the Continent changed from the area of the immediate beachhead to hedgerow fighting further inland, trends became more clearly established, and patterns for the immediate future became manifest. The Normandy campaign ended on 24 July, and the Northern France Campaign began. The Third U.S. Army officially engaged in combat a few days later on 1 August 1944.

Colonel Cutler and his surgical consultant group made the following observations of surgical activities during the Normandy campaign.

Evacuation by sea.-The LST and hospital carrier operations during the invasion were described by Colonel Cutler as follows:

*    *    *    *    *    *    *

c. Surgery

*   *    *    *    *    *    *

The care on ships during the Channel crossing was carefully coordinated and worked out with the Navy and perfect collaboration was obtained. LST's had two Navy medical officers and one qualified Army surgeon, were equipped with small operating rooms and liberally supplied with surgical instruments, surgical supplies, penicillin, and refrigerated whole blood. All of this equipment and personnel proved valuable. Only life- and limb-saving surgical measures were carried out on LST's, but probably some ten abdomens were operated upon and a similar number of sucking chest wounds closed in the first few days, thereby possibly saving life. Moreover, adjusting splints, reapplying and reinforcing dressings and the giving of plasma and blood kept the entire medical personnel on both ships and LST's busy without let-up from embarkation to debarkation. Members of the Professional Services Division boarded many LST's and hospital carriers, discussed problems with the medical staff and were able to evaluate the care given on such ships. It


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FIGURE 85.-An aid station and rest point in a captured farmhouse, during the battle of the hedgerows, 14 July 1944.

was universally noted that LST's were easy to load and unload. At the same time, they were dark, often cold, sanitary facilities were extremely difficult, and feeding anything more than a "quick lunch" and a hot drink was out of the question. LST's carried as many as 350 casualties at the maximum, though sometimes as few as 60 to 70 casualties. When the larger numbers were aboard, the number of personnel assigned was scarcely sufficient to give even routine sanitary care and food, let alone professional skilled care. There was general agreement that the hospital carriers were unsuitable for stretcher cases because of difficulty in carrying litter patients down narrow stairways, et cetera. More over, the double decker system of beds on some carriers was inappropriate for litter cases on the top bunk (fig. 85).86

The hospital carrier had its advantages over an LST in other respects (fig. 86). For one thing, it had better feeding and sanitary facilities. Colonel Cutler advised, moreover, as follows:

* * * in arguments as between hospital carriers and LST's one must consider the safety of the casualty once aboard a hospital carrier, [painted] white and properly marked as per the Geneva Convention with its green strip and its Red Cross. Should we have an LST sunk with 300 wounded men aboard and at the same time have a hospital ship we could with justification be bitterly criticized. It appears to us that, with greater air evacuation and a more rapid turnabout of hospital carriers which could at least take care of the prisoners of war and the lightly wounded, we would have an optimum evacuation system for this kind of a cross-Channel effort. Moreover we must recall the hospital ship

86Essential Technical Medical Data, European Theater of Operations, U.S. Army, for June 1944, dated 22 July 1944.


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had nurses, Red Cross workers and a chaplain. It is warm compared to an LST and these arguments in its favor counterbalance in our minds the ease with which the LST is loaded and unloaded.87

"On the whole," the Chief Consultant in Surgery said in summary, "the professional work accomplished during the trans-Channel crossing was highly creditable and very beneficial to the casualties."88

Air evacuation - "Air evacuation proved excellent from the beginning and should be enlarged," Colonel Cutler said. Elsewhere, he noted that the reception and holding facilities were not ideal at the terminals for air evacuation. But, the important point, as Colonel Cutler later observed, was as follows:

FIGURE 86.-Facilities aboard a converted hospital carrier. A. A ward with double-decked beds. B. An operating room.

What lessons have we learned from the Normandy experience? It early became apparent that definitive surgery for all could not be performed in our forward units because of the load. At one 400-bed evacuation hospital, for example, I saw 250 men waiting for surgery, when empty planes were going to the United Kingdom the same day. Had these casualties been lifted at once their first surgical treatment would have come earlier. The policy was then changed so that only nontransportable cases were given definitive surgery on the Continent.89

"Near shore" medical service.-Colonel Cutler's first comment on the near shore operations follows:

The S.O.P. is laid out in Administrative Memorandum #62, 3 May 1944. It worked well as a whole. A comment might be made that its rigidity in the first few days had some unhappy results in that at certain transit hospitals definitive surgery was not being done and men were being held several days until enough casualties accumulated for a train

87See footnote 85, p. 224.
88See footnote 86, p. 226.
89Tidy, Sir Henry (ed). Inter-Allied Conferences on War Medicine, 1942-1945, Convened by the Royal Society of Medicine. New York, Toronto, London: Staples Press, Ltd., 1947, p. 426.


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evacuation. Also the rule that the FMR should not start [with] anyone who is not kept over 48 hours was unfortunate when definitive surgery had to be done at a transit hospital, for the paucity of information that went on with the casualty mitigated against his proper care. A further suggestion arose in the early days, that possibly neurosurgical and maxillofacial specialists should be in transit hospitals near hards so that cases with this type of damage could early be placed under specialists for care.90

Otherwise, Colonel Cutler was satisfied with the overall results of the hospitalization and evacuation procedures that were carried out on the near shore. His account of his views follows:

The reception on this shore, whether from planes or ships, was organized on a similar basis; i.e., close to the unloading points field hospitals were set up, to which were attached surgical teams who were to care for the heavily damaged, nontransportable casualties. These field hospitals were of the greatest value during the first few days of the invasion, when surgery on the far shore was at a minimum, or nonexistent. Later, when an evacuation hospital was set up with the Army on the far shore and a larger percentage of the cases arrived already having had definitive surgery, the pressure on the holding hospitals for nontransportables decreased. These holding hospitals were adequately supplied with whole blood and penicillin daily, had a generous allotment of expert surgical teams and proved themselves to be a highly desirable part of such an undertaking.

The less seriously damaged patient passed by these holding hospitals for nontransportables to "transit hospitals," which were either station or general hospitals within a radius of 30 miles of the beachhead where, according to the pressure exerted by the numbers being evacuated, either definitive surgery was carried out or the patient was dressed, his splints readjusted, blood and penicillin given, and he passed from these transit hospitals into the rear areas either to a hospital center or to an available general hospital by train. The number of casualties passing through some transit hospitals was very high, perhaps the heaviest service being at the 110th Station Hospital, where some two thousand casualties were received in a period of 24 hours. At these transit hospitals were also located attached surgical teams, but the major function of the transit hospital was to properly sort cases and only allow those to go on who were in a suitable condition for further travel. The dispatching of patients from the transit hospitals to the back areas by hospital train worked well. The medical personnel aboard such trains worked well, were able to give hot drinks, sandwiches, and see that where dressings had slipped or splints needed to be readjusted suitable care was given (fig. 87).91

General surgery and wounds.-The following thoughts were recorded as of the end of June by the Chief Consultant in Surgery:

It is our overall opinion that the level of the professional care is very high, certainly better than in the last war. The evaluation of early and good surgery and of the sulfonamides and penicillin in combatting infection cannot now be stated. Both undoubtedly contribute to this happy result. There may be a relation between controlling ordinary pyogenic infection and the low incidence of gas gangrene and subsequent low incidence of amputation. The surgeon is certainly pushed nearer to the wounded soldier and the decreased interval of time between wounding and surgery may be a dominant factor in the unusually satisfactory results. In addition, the early application of secondary suture is going to restore a large body of men to active duty within a period of a few weeks.92

90See footnote 85, p. 224.
91See footnote 86, p. 226.
92See footnote 86, p. 226.


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FIGURE 87.-Care aboard hospital trains during the Normandy campaign. A. A hospital train medical officer checking the condition of a patient. B. An attendant giving a patient liquid while a nurse observes.


230

Essential Technical Medical Data, ETOUSA, for June 1944 reflected his views substantially as follows:

The percentage of infection was surprisingly low, even at 4 or 5 days after injury and without surgery. Indeed, some surgeons with experience thought it wiser not to explore battle casualty wounds that looked well. It is in a way unfortunate because eventually practically all of these wounds need debridement, since the sulfonamides and penicillin tend to prevent widespread cellulitis but leave an abscess above bits of cloth which are carried in with the missile. There can be no question whatsoever but that spreading cellulitis as seen in the last war is now a rarity, and one must feel that the sulfonamides and penicillin play a definite role in this betterment. Gas gangrene was present in but few cases. We have at this time no final figure, but the impression of all surgical consultants is that it is not a major problem at this time. Moreover, the separation of cases infected with the clostridia into those with simple cellulitis and into those with widespread myositis resulted in the saving of many extremities, for the simple cellulitis cases (Do not need amputation and do well with widespread incision and debridement.. Abdomens usually reached this shore having had surgery. Sometimes this had been done on the far shore, sometimes on the LST carriers or APA's (transports, attack). Many of these cases did surprisingly well and proved again that early surgery in abdominal injury is the important factor. One case arrived by air 3 days after operation and was in a critical condition on arrival. This patient was seen shortly afterward by Colonel Cutler, and he was of the definite impression that it was not the air transport that caused the trouble but moving the patient and that had he come on an LST his condition might well have been worse.

In July, Colonel Cutler reported, the load of surgical work was extremely heavy. In May, the total number of surgical admissions to fixed hospitals of the communications zone had been 23,375, as revealed by the monthly surgical reports. In June, there had been 53,124 surgical admissions. For July, the figure had risen to 71,623. Colonel Cutler further reported, as follows:

We have maintained the closest liaison with the combat forces on the Continent so that what we have learned here concerning bettering the care of casualties might be implemented by the Army. The most cordial and happy relations exist and have certainly led to great benefit for the soldier. This liaison has been particularly useful in improving the treatment of shock, by the segregation of the seriously injured from the less seriously injured and in the proper utilization of whole blood and plasma. It has led to an extension of air evacuation particularly involving the special groups such as neurosurgery, maxillofacial surgery and thoracic surgery. We have attempted as a principle to push the early closure of battle wounds, and from large spot surveys are content that some 75 percent of our wounds are being closed by early secondary suture between the fourth and the fifteenth day. Many of the hospital and hospital center reports show an extremely high percentage of primary union after secondary suture. Thus, at the 15th General Hospital primary union occurred in 93.4 percent after secondary suture. The 82d General Hospital shows primary union in 94.1 percent after secondary suture. The 83d General Hospital had primary union in 83.7 percent of 93 wounds. These are merely samples of information which will be amassed later and submitted in tabulated form.


231

It is interesting that, though great attempt has been made to use penicillin liberally, many wounds have been closed in which no chemotherapy was practised, either sulfonamides or penicillin, with equally satisfactory results. The major difficulty with secondary closure has been where too great tension was put on the lips of the wound by trying perhaps to pull together the area which should have been grafted rather than closed with sutures. Out of a mass of material is slowly merging what was known early, that the earlier a wound is closed the more easily it closes and the less apt it is to break down, also that wounds which are too large to close should be immediately grafted. As a part of this effort we have begun to close compound fractures, utilizing penicillin therapy in all cases in which this is done. It is too early to report results, but at least we have no bad consequences to speak of. Again, in relation to wounds we have a large number of patients in whom Bacillus welchii and Bacillus pyocyaneus have been cultured from wounds healed without difficulty when submitted to secondary closure. In relation to this, our report from last month should be noted, [p. 87 ff.], which included the study of wounds with the 8th Air Force in which a high percentage of the wounds showed clostridia, but almost none showed any clinical evidence of invasion by these anaerobes.93

As a result of these and previous observations, the need to revise and add to certain clinical policies contained in the Manual of Therapy and Circular Letter No. 71 was apparent. Circular Letter No. 101, Office of the Chief Surgeon, ETOUSA, was therefore published on 30 July 1944. It included the following instructions under the heading of wounds:

a. Wounds will not be plugged or packed with Vaseline gauze. Only sufficient gauze should be used to keep the wound temporarily open.

b. Sulfonamides are being dumped in excessive quantities in wounds, and this makes subsequent repair difficult.

c. Wounds must not be closed by sutures at the time of the first debridement, except for the following:-

(1) Neurosurgical injuries.
(2) Thoracic injuries.
(3) Wounds of eyelids.
(4) Certain maxillofacial injuries, as outlined in the Manual of Therapy, ETO.

d. Penetrating wounds of the paranasal sinuses should be thoroughly explored, foreign bodies and blood removed and external drainage provided at the original operation. Drainage of the antrum into the nose is the method of choice unless the wound has destroyed so much tissue that external closure is not possible. The frontal sinuses should be drained through the wound or through an incision to allow opening in the floor of the sinuses.

e. The routine culture of wounds is unnecessary, and wasteful of time and materials. Cultures should be limited to those wounds where there is clinical evidence of infection and where they may contribute to its subsequent clinical management.

f. Wounds seen late, after wounding, without debridement, may be debrided in the usual manner.

g. Wounds can usually be closed within 3 to 5 days after debridement. A satisfactory preparation of the wound for secondary closure has been the application of warm saline dressings. Chemotherapy locally in the wound at the time of secondary closure is not necessary; penicillin therapy should be resumed before and after secondary closure in all large wounds.

h. As a rule, foreign bodies which interfere with function or wound healing should be removed. Modern chemotherapy obscures the signs of local infection only temporarily and

93Essential Technical Medical Data, European Theater of Operations, U.S. Army, for July 1944, dated 17 August 1944.


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many times delayed infection, with breakdown of the wound, may result after a long interval.

i. Continued local and excessive applications of sulfonamides in wounds are detrimental to wound healing, produce dermatological lesions, often increase blood levels above safety limit, and are unsupported scientifically as the proper therapy.

Gas gangrene.-While some mention was made in the foregoing of the occurrence of gas gangrene in battle casualties being received, Colonel Cutler noted the following:

An attempt has been made to gather in all the cases of true gas gangrene. Up to the present we have been able to collect 198 cases in whom there were 14 deaths, a mortality of 7.07 percent. These figures must not be considered final, for some of these 198 cases may not be true gas gangrene, for one must distinguish between simple anaerobic invasion of an avascular extremity, or simple anaerobic cellulitis and true clostridial myositis. Bacteriology is of no assistance here, for, as pointed out above, many wounds without the slightest evidence of gas gangrene contain the Welch bacillus, and many of these have been closed by early secondary suture with primary union. Of the above 198 cases, 76 (38.3 percent) had amputations. Thirty-one percent of the amputations were done in the forward area and twenty-five percent of those cases amputated in the forward area were reamputated in SOS units later.94

The "gas gangrene" portion of Circular Letter No. 101 was extensive and informative as well as instructive. It read:

a. Incidence of serious infection with clostridia is fortunately low up to the present time, and surgeons have shown a wise discrimination between diffuse myositis and cellulitis. This has restricted amputation, led to recovery by simple incision, excision of involved muscle and adequate drainage.

b. Routine culture of wounds is unnecessary unless there is clinical suspicion of gas bacillus infection. Gas-forming organisms can commonly be cultured from a wound, and such findings should not influence the surgical treatment unless consistent with the clinical diagnosis. Only in clinical cases of gas gangrene infection should cultures be taken and sent to the First Medical General Laboratory for final identification of the organisms.

c. Amputations have in some cases been too radical. Always demand a consultation and always explore locally in wound before amputation. In many cases the apparent diffuse involvement, as shown by a swelling, crepitation and discoloration of the skin, has extended far above the actual muscle involvement. Failure to appreciate that amputation or muscle excision can be carried out at a much lower level has at times resulted in the needless high amputation of the thigh or upper arm. Extensive incision and drainage above the level of amputation is commonly required in such instances.

d. Following amputation for widespread clostridial myositis, skin traction should not be applied for the first 24-48 hours, since some cases thus treated have had unfortunate results because of restricting dressings. Such cases should be held as nontransportable until skin traction is applied.

e. In performing the circular amputation, the skin should always, if possible, be longer than the underlying soft tissue and bone. Except in amputations following clostridial infection skin traction should in every instance be applied immediately. * * *

f. There has been an unfortunate waste of both material and effort in applying to clostridial infected wounds the hospital precautions usually applied to virulent and easily transmissible organisms. There is no reason for special isolation for ward care of gas gangrene cases other than simple hospital routine and cleanliness. However, the group-

94See footnote 93, p. 231.


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ing of such cases may be desirable as a matter of efficiency in their management. It is wise to have special dressing sets prepared for gas gangrene cases, since these instruments should be sterilized by autoclaving. These should not be mixed with other instruments on the surgical cart which may not require autoclaving. Linens and blankets directly in contact with discharges from wounds infected with clostridia should be autoclaved before laundering.

g. Radiographic depiction of gas in the tissues, regardless of its distribution, does not necessarily indicate gas gangrene, and, unless other clinical signs and symptoms are present, should be disregarded.

Use of penicillin and sulfonamides.-Colonel Cutler reported at the end of June that 500,000,000 units of penicillin were being supplied to the First U.S. Army daily, an amount which he said should be sufficient for the present and immediate future, and a quantity which could be supplied with reasonable assurance. The buildup to this daily maintenance supply was described as follows:

The demands for this drug increase daily in spite of heavy deliveries earlier. Far shore deliveries were 300,000,000 units by carrier, early, 100,000,000 twice by air up to 17 June. Since 25 June we have been delivering 500,000,000 by air daily. Some of this may not have been properly used, but we are convinced from observations here and on the far shore that the casualties are receiving all of it and observations make us believe it is beneficial.95

Colonel Cutler's views with regard to the part played by penicillin and the sulfonamides in the control of wound infections, as witnessed in these early days, are set forth in Essential Technical Medical Data, ETOUSA, for July 1944, as follows:

It may be said that the low incidence of serious infection in the present campaign is still a source of wonder to those who were in the last war. The fact that the wounds of those who have never had sulfonamides or penicillin are not to a great extent more infected than in those who had penicillin seems to point out that other factors than just chemotherapy must be studied. We must not forget that the American soldier today is far better fed than in 1917-18, that he is physically in a great deal better condition, that he individually knows much more about looking after himself, including first-aid, that the [Medical Department] soldiers * * * are far better trained than they were in the last war, and that the resistance of the individual himself may be so much greater that even without chemotherapy his wounds do well. Moreover, plasma and whole blood are given liberally and must be weighed in the scales when one discusses immunity and infection.

With reference to the penicillin section of the new directive, Circular Letter No. 101, Essential Technical Medical Data, ETOUSA, for July, states:

Circular Letter #101, which is the followup on Circular * * * Letter #71, contains further data regarding penicillin in wounds and fills in what we have already learned from our brief experience. It is fair to point out that sulfonamides are liberally utilized, and penicillin also. Perhaps we would have liked to give penicillin to one army and not to another, if this [had been] just a scientific question, but, there being evidence that penicillin benefits infection, we felt forced to give every American soldier the benefit of penicillin. This is going to modify and make difficult suitable controls, but an attempt

95See footnote 85, p. 224.


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is being made to find enough wounds amongst our own troops, or in prisoners-of-war, who did not get penicillin or sulfonamides, that these cases may be used as controls against the remainder.

The penicillin instructions in Circular Letter No. 101 were simple and explicit. The earlier "penicillin circular," intended for the instruction of those using penicillin in the fixed hospitals of the communications zone (p. 142), was rescinded. The new circular stated that dosages as given in Circular Letter No. 71 should be adhered to. It warned that some medical officers have on occasion tripled the dosage without scientific justification, and the supply would be imperiled if such experimentation is carried out. The newer directive also took cognizance of the fact that no special forms for reporting casualties treated with penicillin existed. Consequently, medical officers were instructed to record the words "Penicillin Treated" after the diagnosis on the emergency medical tag or field medical record as required by Circular Letter No. 71.

Whole blood.-Colonel Cutler was immensely pleased with the work of the blood bank and, at the end of June, reported the following:

The tremendous demand for blood completely justifies the establishment of the blood bank and from reports and observations it is clear we must have saved life by the establishment of an ETO blood bank. 2,000 pints with sets went over by hospital carrier or air. About 1,000 pints have been given up by medical officers on LST's to far-shore medical groups. Landing troops took in 240 pints and sets on landing. Lt. Riordan of the blood bank is now on the far shore. He has a large Navy-type refrigerator buried in the ground at the Omaha air strip, and [8] trucks (each taking 80 pints) are well working with the First Army delivering blood at this time (fig. 88). Almost all LST's and hospital carriers either gave up their blood to people on the far shore or used it up on casualties on the trip back.96 Little was actually wasted. The major difficulty about blood has been the return of kits and sets and marmite jars.97

As the Third U.S. Army joined the fray, and it was evident that the conflict in Europe was to expand ever larger, there were ominous and unmistakable signs that the European theater blood bank could not come close to providing the demands which would be made. The First U.S. Army required 500 pints per day. The Third U.S. Army insisted upon a daily supply of 550 pints. Moreover, the First U.S. Army had been borrowing 200 pints per day from the British with no possible way of ever replacing this loan. But, this is a story which highlights the period of the next campaign in Europe. At the close of the Normandy campaign, there was a comment to the effect that whether or not blood was being wasted or used without adequate reason had been carefully considered, and that there was a firm opinion in the whole European theater that the Army needed blood.

The instructions in Circular Letter No. 101 pertained to the mechanical difficulties which had been encountered in using the whole blood supplied from

96"Medical supply dumps were established at each port of embarkation in the Southern Base Section. LST's were supplied from them, and unloaded them on the far beach. Each outbound LST carried twice the amount of blood estimated to be needed on the return trip. The excess was unloaded on the far beach. This was the way in which blood was supplied on the early beachhead." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 17 Sept. 1958.)
97See footnote 85, p. 224.


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FIGURE 88.-A unit of the Blood Bank, ETOUSA, with the First U.S. Army, hitching a storage refrigerator, mounted on an artillery carrier, to a cargo truck.

the European theater blood bank and the alkalinizing of patients who had been given massive transfusions. This circular letter stated:

*    *    *    *    *    *    *

14. * * * The following instructions should be observed in the use of blood obtained from the ETO Blood Bank:-

a. Return of sets. All used sets must be returned at the first opportunity to the drivers of the delivery trucks. Sets should not be kept on hand in excess of a level of one (1) per pint of blood.

b. Observance of the following will facilitate the administration of blood:

(1) Plasma should be given first except in exceptional circumstances (exsanguination).
(2) The blood must be vigorously shaken before administration.
(3) The filter (both steel and gas mantle) chamber must be completely filled to utilize all of the filtering surface. This is accomplished by inverting and filling the chamber before starting the transfusion.
(4) When a transfusion must be given rapidly, a No. 15 needle should be used.
(5) When the transfusion is started the air vent should be checked and, if necessary, cleared by positive pressure.

c. Any patient receiving more than 1,500 cc. of blood or exhibiting evidence of intravascular hemolysis including hemoglobinuria as shown by chemical test, will be alkalinized according to one of the following procedures:

Oral.

(1) Initially: 8 gms. sodium citrate, dissolved in water.
(2) Maintenance: 2 gms. sodium bicarbonate by mouth every two hours.
(3) Fluid intake to be 3,000 cc. per 24 hours.


236

Intravenous.

(1) Initially: 4 gms. sodium citrate in twenty-four hours by intravenous drip, or 1½ gms. every two hours intravenously.
(2) Maintenance: 16 gms. sodium citrate in twenty-four hours by intravenous drip, or 1½ gms. every two hours intravenously.
(3) 3,000 cc. fluid intake.

The urine will be tested chemically for hemoglobin and with litmus or other suitable indicator for pH. Alkalis may be discontinued when hemoglobin disappears from the urine which in the average case will occur in less than twenty-four hours.

Sorting.-Circular Letter No. 101 also presented the following advice and instructions on sorting-triage:

*    *    *    *    *    *    *

15. Sorting. On the perfection with which sorting is accomplished, will depend the proper care of many soldiers, and lives may be lost if improper sorting under pressure occurs. Sorting (triage) should separate into at least three categories.

a. Those in shock and critically ill, possibly moribund.

b. Those awaiting their turn at the operating table in preoperative ward (and not necessarily in shock).

c. Lightly wounded individuals who may be evacuated with nothing more than a fresh dressing. In this group may be placed, unless the Commanding Officer desires separate wards, the medically sick, if they are evacuable. Observations have revealed that the division of seriously ill and shocked people and those merely awaiting their turn has been poorly accomplished. This has resulted in men with simple injuries being unnecessarily damaged psychologically by being placed in beds next to dying or critically ill individuals. Also, this mixture of critically ill and lightly wounded had taken up the time of those working in the shock wards, who should devote all their energy to the critically ill.

Other instructions.-Circular Letter No. 101 also warned that evisceration had resulted in cases where retention sutures had not been used in abdominal wounds. It directed that all abdominal wounds should be liberally supported with retention sutures. In addition, it stated that small bowel enterostomies should not be performed unless this was the only possible procedure in a special case and that colostomy should always accompany the repair of injuries to the large bowel with exteriorization, when possible, through a separate incision.

The circular letter stated that plaster splints were being applied too thick and that, if bilateral spicas were applied, they had to be litter width and reinforced with a strut placed posteriorly. All initial circular plaster of paris dressings, the directive went on to say, following trauma, manipulation, or operation had to be split to the skin and slightly spread.

There were also instructions with regard to thoracic surgery, vascular surgery, spinal cord damage, ocular injuries, blast ears, radiographs, laboratory procedures, prophylactic tetanus antitoxin, sterilization of ampules, and the coloring of cocaine to insure ready identification.

Joy and tragedy - On 19 July, Colonel Cutler learned that some 60,000 German prisoners had been taken since D-day, and he was most elated (fig. 89). "Pretty good. We're on our way!" he wrote. There was no doubt but that


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FIGURE 89.-A long line of German prisoners of war being marched ashore at Weymouth, England, on 10 June 1944.

a good start had been made in Normandy. But at the same time, the "Buzz Bombs" were beginning to fall on England, and over 3,500 had been counted (fig. 90). A Britisher had been killed for nearly every bomb counted, and the total killed and injured was over 25,000. At about the same time, Colonel Kimbrough became sick and was hospitalized with pneumonia. Colonel Zollinger had been sent to the Continent for temporary duty with the Advance Section, Communications Zone. Colonel Cutler had to do the work of both. And then, on 23 July, Lt. Col. George K. Rhodes, MC, who had been of immeasurable help, passed away.

It was Sunday morning, 23 July. Colonel Rhodes had not felt well at breakfast, and Lt. Col. (later Col.) Yale Kneeland, Jr., MC, medical consultant for the Southern Base Section, had persuaded Colonel Rhodes to rest. When Colonel Kneeland came back to see him in 1300, he was dead, the body was still warm, there was no disturbance of the clothing, and it appeared that he might have died in his sleep. Autopsy later proved the diagnosis, coronary occlusion. His body was taken to the Cambridge Cemetery by Colonel Kneeland, and there he was buried.

At various times Colonel Cutler had said that the sacrifice a medical officer makes in war cannot compare to that of the infantryman or airman


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FIGURE 90.-A "Buzz Bomb" (German V-1 rocket) cutting its motor and diving into the Picadilly section of London.

who must constantly expose himself to direct enemy fire. But, in this instance, there was no doubt that Colonel Rhodes had made the supreme sacrifice. In his characteristic brevity on such occasions, Colonel Cutler stated in his diary merely: "G. K. Rhodes died of a coronary today; my age. Hell, Terrific pressure." To the Chief Surgeon, he wrote in a memorandum, dated 24 July 1944, as follows:

1. Lt. Col. G. K. Rhodes arrived in this theater as chief of the surgical service of the 30th General Hospital, of which he was the original organizer and civilian director, and which was one of the earliest general hospitals to reach the ETO. This hospital was comprised largely of University of California Medical School people with a smattering from Leland Stanford University Medical School. It proved to be staffed with personnel of high professional caliber.

Because of his maturity, excellent clinical judgment, ability to get on well with people, he was moved to the important post of Consulting Surgeon, Southern Base Section, when that base section became large and active. In that capacity he proved himself an ideal candidate for the position. The Surgeon of the Southern Base Section and the Commander of the Southern Base Section were unanimous, as were other officers in that section, in their praise of his work and abilities. During the early days of the invasion his judgment at the nontransportable hospitals serving the hards in the Portland-Weymouth Area undoubtedly saved some lives and several amputations. He never spared himself, and was always available for duty wherever and whenever called. His relations with the Headquarters Group, Professional Services Division, of your office, were of the most amicable and satisfactory type. The immense load of properly vetting new insti-


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tutions and moving candidates of proven quality to weak institutions, etc., was an onerous one in which Colonel Rhodes played a major and beneficial role.

*    *    *    *    *    *    *

5. I know of no officer in your command who has better performed his duties than Lt. Col. G. K. Rhodes. * * * His example of devoted service and his abilities professionally were of the highest order, and your Command has profited by his having served within it.

At the next meeting of the Chief Surgeon's Consultants' Committee, General Hawley, in closing the meeting, said:

The only thing I have is to express to you what we all feel about the great loss that we have suffered in Colonel Rhodes. He worked very hard during this push, and this, I have no doubt, hastened his leaving us in the manner he did, by death.

I was very impressed with his work and his approach to it. You could never get him excited or worried, and he had the keen affection as well as the respect of the young surgeons he advised. He is very difficult to replace. We are very fortunate in having Colonel Morton to replace him. Colonel Morton has done outstanding work with casualties. I welcome him in this group of consultants.

NORTHERN FRANCE

The Northern France Campaign was short-lived, beginning on 25 July and ending 14 September 1944. In that period, the Third U.S. Army broke out from the Normandy beachhead and immediately threatened German positions in northern France. The Seventh U.S. Army landed in southern France on 15 August with relatively light resistance. On 25 August, the Allies liberated Paris. In early September, most of the area of the Benelux countries had been freed, and abortive attempts had been made to establish a bridgehead across the northern Rhine at Aachen. By mid-September, the fight for Germany itself was beginning.

Trip Home

Blood.-From the outset, the supply of sufficient quantities of whole blood was a critical problem. "A trying thing that came up is blood," Colonel Cutler reported at the Chief Surgeon's Consultants' Committee meeting of 28 July, "Everybody who has been to the Continent says that blood is being used improperly. I was asked to ask you [General Hawley] to make one more try to obtain blood from the United States by sending a cable to The Surgeon General requesting the shipment of blood by air to the ETO Blood Bank."

General Hawley was concerned about the time it would take to get the blood to England, making the project futile if the blood did not have sufficient life after arriving in Europe. "There will be a minimum of 72 hours before the blood leaves the U.S.," he maintained. But, after discussion of procedures which would probably be implemented in the United States, Colonel Cutler convinced the Chief Surgeon that whole blood could leave the Zone of Interior within 24 hours after drawing. Major Hardin then assured the general that the life of the blood, after receipt, would be a good two weeks.

"We all believe in this," Colonel Cutler said, "We think it can be gotten from the U.S. It should be given precedence."


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FIGURE 91.-Maj. Gen. Norman T. Kirk visiting the 160th General Hospital, Cirencester, England, during his quick visit to the European theater in July 1944.

General Hawley, however, had another condition which he wanted clarified. And that was the arrangement for air shipment from the United States to England and thence to the Continent. "If," he said, "we arrange a special service all the way there with the ATC and the TCC to get it to the Continent, it would be all right."

General Hawley concluded the discussion with the promise in the following statement: "The Surgeon General is definitely opposed to it, but I am willing to put it up to him." And well could he say this, because General Kirk had just completed a quick visit with General Hawley at which time the shortage of whole blood had been briefly discussed (fig. 91).

The Air Transport Command, when approached with the request, signified willingness to provide the necessary special service for flying whole blood from the United States to the United Kingdom, and the Troop Carrier Command assured that the blood would be flown to the Continent daily, weather conditions permitting. To insure that proper arrangements would be made, and made quickly, General Hawley decided that Colonel Cutler and Major Hardin should go to Washington. Upon Colonel Cutler's request, Colonel MacFee, who was working with First U.S. Army and the Advance Section, Communications Zone, was also added to the list of those to go.

Key personnel - Before leaving, however, certain other matters were brought to Colonel Cutler's attention to be discussed in Washington. One of these was the lack of qualified professional personnel in units arriving in the


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United Kingdom. At a London conference held by the Chief Surgeon on 4 August 1944, Colonel Kimbrough inquired: "Since you are sending such high-powered speakers back, why can't they take up with General Kirk this proposition of stripping key personnel from the hospitals coming over here from the States?"

"You're absolutely right," replied General Hawley, "and they will do that."

"Another hospital came in without a chief of medical service," Colonel Kimbrough warned, "We are running out of key personnel."

Evacuation to Zone of Interior - When General Kirk had visited the theater, he had mentioned the fact that the air evacuation of patients was not as good as it could be. He said this with particular reference to the condition of patients being returned from the European terminal, Prestwick, Scotland, to the receiving hospital, Halloran General Hospital, Staten Island, New York (fig. 92). Well, this was not news. Among other inadequacies in the prevailing evacuation system, many had recognized the problem which existed at Prestwick, and steps had been taken to correct the situation. At this time, only a detachment from the 25th Hospital Train was there. Momentarily, the 57th Field Hospital was expected to move in and take over the holding and evacuation function at Prestwick. Later, when the British would be able to turn over certain buildings at the airport to the Americans, plans called for setting up a station hospital at Prestwick to provide local hospitalization service in addition to acting as the air evacuation hospital. Colonel Cutler had asked for the opportunity to investigate thoroughly the receiving and holding of patients at Prestwick and subsequent steps in their evacuation to the Zone of Interior. This opportunity was now his.

Colonel Zollinger fills in - Fortunately, Colonel Zollinger had returned from the Continent, where he had been of inestimable value in organizing surgical and shock teams from general hospitals in transit to augment hospitals of the First U.S. Army and the Advance Section, Communications Zone. During this period, Colonel Cutler had sorely lamented the fact that the best general hospitals with topnotch people could not be used because they had been closed and earmarked for early movement to the Continent. Colonel Zollinger's efforts had attenuated the loss when he was able to put many of these officers to good use where they were sorely needed. And now he was present in England to fill in for the Chief Consultant in Surgery during his absence. There were many items which required his immediate attention. Certain station hospitals, selected to function as general hospitals, required review and augmentation of their personnel; 16 general hospitals had recently arrived, and all required extensive bolstering of professional personnel with qualified individuals, including chiefs of services; the newer auxiliary surgical groups, the 5th and 6th, needed reshuffling of personnel in the component teams and augmentation with temporary-duty personnel from general hospitals before they could be profitably employed; and a list of those LST medical officers meriting commendation was due in the immediate future.


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FIGURE 92.-Air evacuation to the Zone of Interior from Prestwick, Scotland. A. A hydraulic lift being used to raise litter patients to the hatch of a huge 4-motored C-54 evacuation aircraft. B. Patients arriving at Mitchel Field, N.Y., the initial stop in the Zone of Interior.


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Prestwick, Scotland, "Very Sloppy Place."-At the last minute, on Saturday, 12 August, a cable from Washington was received which said that The Surgeon General had agreed to send 250 pints of blood per day beginning on 21 August and that the amount would be increased later. In view of this response, General Hawley was asked whether all three of the officers now had to return to the Zone of Interior. General Hawley replied that they did, and he insisted that they try to get off that night or the next day, Sunday. Colonel MacFee had not even arrived from the Continent at this time. Colonel Cutler and Major Hardin proceeded immediately with their plans. They were ready to leave Sunday morning. Colonel Cutler's account of the first day follows:

Left London by plane 9:30 a.m. Arrived at Prestwick 12:30 p.m. Visited "holding hospital". Commanding Officer, Major Roth of the 25th Hospital Train. Comment: Very sloppy place. No good doctors. 124 patients in 132 empty beds but patients arriving constantly. Very little professional care or supervision. Critically ill patients sent by mistake for evacuation to Zone of Interior sent to 112th General Hospital by officers at "holding hospital". Feel they have no right to reverse decision of disposition [boards] and they must be given this right. When the new field hospital takes over, an A.1 orthopedic surgeon and a competent physician must be on its staff to review all cases and have full right to reverse disposition board proceedings. While reviewing cases on ward, found a batch from 79th General Hospital that seemed inappropriately boarded to Zone of Interior, including five N.P.'s; 1 broken metacarpal. Wrote Colonel Kimbrough re this. Sent one maxillofacial wound with abscess to the 112th General Hospital. Visited 112th General Hospital, just giving over to 316th Station Hospital.

My interpretation of the whole matter at Prestwick is that we need a 750 bed station hospital, at the airport. We need nothing at Cowglen and the hospital at Prestwick must have the right to study and reboard people, to change disposition and to hold or return to duty or turn over to another hospital anyone they wish. Boarded ship at 11 p.m. 16 ambulatory patients with us, including one with rheumatic fever; one G.S.W., forearm left, with nerve damage; one F.C.C. radius and ulnar left (nerve damage); two tumors testicle; one arthritis of knee; two N.P.; one osteochondritis; one penetrating wound, left thigh; one cancer of the tongue; one G.S.W. humerus left; one compound fracture, left lower leg; one epilepsy; one [patient] * * * diagnosis: constitutional psychopathic state; * * * one fracture, left humerus; one chronic tenosynovitis muscle, right leg.

One of the patients, an Air Corps captain, appeared fit for duty. His wound had been skin-grafted and seemed satisfactory. Colonel Cutler believed that he was not a neuropsychiatric casualty but was bordering on it. The psychopath sat immediately in front of Colonel Cutler. His complaint was a headache. Colonel Cutler believed that he probably had the mental age of a 10 year old. "If these are a sample of soldiers returning to the Zone of Interior," Colonel Cutler noted in his record of the trip, "it is not good and should be studied in the light of my arguments above."

The plane took off at 2330 and arrived at La Guardia Airport, New York, N.Y., at 1700 the next day, 14 August. Stops had been made at Iceland and Newfoundland. An hour after arrival at La Guardia, they were on their way and reached Washington 2 hours later.

Washington.-Tuesday, 15 August, was spent in the Office of The Surgeon General. At a conference held in the offices of the chief consultant in surgery,


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the business of providing whole blood to the European theater was discussed. General Rankin, Col. B. Noland Carter, MC, Lt. Col. Roger G. Prentiss, Jr., MC, Colonel Kendrick, Dr. Bates (American Red Cross), Maj. (later Lt. Col.) Frederic N. Schwartz, MAC, and several others were present in addition to the two individuals from Europe. Colonel Cutler's account of the conference was substantially as follows:

In putting up the proposition, I explained that we had secured the airlift for one thousand pints, refrigerated, each day from the Zone of Interior to the United Kingdom, the United Kingdom to the Continent. It was proposed that blood preserved in Alsever's diluent be used. I immediately questioned this, stating that it was no time to experiment on the American soldier, that the airlift was ready for refrigerated blood, and that Alsever's diluent diluted blood 50 percent. I was assured that the National Research Council approved the transportation of blood preserved in Alsever's solution unrefrigerated, that they had carried blood to Hawaii and back, to Bermuda and back, and to Scotland and back, unrefrigerated, and had transfused American soldiers entirely satisfactorily.

This matter of unrefrigerated blood was new to us and seemed experimental, and we constantly repeated our desire for refrigerated blood. We were told every time that unrefrigerated blood and Alsever's solution was entirely satisfactory. As this would make the airlift simpler, we accepted unrefrigerated blood. (Since that meeting, further discussion with experts not in the Army has brought to light the fact that the cells preserved in Alsever's solution (tagged and studied) live but a little while in the recipient's circulation, and I shall take this up again in Washington.)

Deliveries promised: Beginning 21 August, 250 pints a day; beginning 28 August, 500 pints; beginning 4 September, 750 pints; and from 11 September on, 1,000 pints.

It is our understanding that this blood will be delivered in carts-liter bottles containing 500 cc. blood and 500 cc. Alsever's solution; that there will be a recipient-giving set, sterile, in the package with each bottle. We shall refrigerate this at Prestwick; when chilled, it will be shipped by air to the Continent; it will be refrigerated again at the airport on the Continent and then delivered by our trucks as usual.

In addition to the above, they will give us "re-suspended" O red blood cells in 10 percent corn syrup in 600 cc. Baxter intravenous bottles, this again to go unrefrigerated to Scotland. Afterwards, we shall refrigerate it. (The first of these cells will go over with Major Hardin who shall see that a proper distribution of these cells is made to hospitals in which the personnel is suitably trained for the use of such blood.)

During the day, the following items were reviewed with The Surgeon General, General Kirk:

a. The matter of utilization of experts for special jobs and the fact that if these experts are so detached from their fixed units their opportunities for


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promotion vanish (cited the case of William Sandusky). I was informed by The Surgeon General that nothing can be done about this. Men will have to suffer for their country!

b. The Surgeon General suggested "N.P." cases be used in labor battalion in SOS and should not be called malingerers and used up front by Army. I explained our "recovery" center and The Surgeon General was satisfied.98

c. Long discussion of medical education. It appears that Procurement practically prevents intelligent, healthy young men from entering medicine. All must go in the Army. A study of this would seem to show that the medical schools in the Fall of 1944-45 will contain only women and physical crocks which would seem to be a terrible blunder in regard to the future care of the American people.

d. No more hospital ships for the United Kingdom. Must use "troopships" and begin at once. (The Surgeon General says put patients in hospital beds in troopships.)

e. The Surgeon General would like to have us use the rubber traction material sent to the United Kingdom for amputation stumps. Will see that in the future elastic is less powerful. Suggested using ring splints and litter bars for traction to fasten to.

f. Evacuation from the Continent to the United Kingdom. (The Surgeon General hoped new general hospitals on the Continent would care for the majority returnable to duty.)

g. The Surgeon General also approves the attempt to send simple and compound femurs with skin traction (not in plaster) from the Continent to the United Kingdom.

h. Peripheral nerve surgery ought not be done in the United Kingdom but should be done in the Zone of Interior.

i. Stumps should be reoperated upon in the Zone of Interior, not in the United Kingdom. (Comment on h and i: Both these will save us beds.)

j. Long discussion concerning the availability of more specialists and expert surgeons for the United Kingdom. I was informed that we would get absolutely no more competent people.

k. Long discussion on history of the war. Apparently there is a quarrel between the Office of The Surgeon General and the National Research Council.

We have nothing to do with the National Research Council, and Lt. Col. Sanford V. Larkey, MC, is working for the Office of The Surgeon General and not for the National Research Council. I reviewed all of the topics with General Rankin and Col. B. Noland Carter and Major DeBakey. See my special notes on this topic. Should get all consultants working on this immediately. Send additional names with present notes to General Rankin.

98Medical Department, United States Army. Internal Medicine in World War II. Volume I. Activities of Medical Consultants. Washington: U.S. Government Printing Office, 1961, ch. IV, pt. III.


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Long discussion on wound ballistics. Reviewed the excellent report by Colonel (Ashley W.) Oughterson of the Bougainville Campaign (copy to United Kingdom with me).99

Went to see Col. Robert Cutler, Pentagon. I got lost but finally found the intelligence officers to whom all incoming officers must report. News of landing near Marseilles just arrived.

The next day, Wednesday, 16 August, Colonel Cutler gave a short talk at The Surgeon General's weekly meeting with his staff. In the afternoon, he visited Brig. Gen. George R. Callender, MC, The Surgeon General's special representative for wound ballistics. General Callender pointed out that The Surgeon General would send a wound ballistics team to a particular theater if the theater commander so requested. General Callender urged that General Hawley take the matter up with General Eisenhower. When General Kirk had visited the European theater a short while before, he had given essentially the same information to General Hawley. But, later on this occasion, General Kirk informed Colonel Cutler that the original premise still applied, only there was nobody he knew of who could be sent. General Kirk suggested that Colonel Cutler feel out his friend, Dr. Moritz of Boston, for such an assignment.

On Thursday, there was more discussion with The Surgeon General on the matters discussed Tuesday, and there was a long discussion with Col. Augustus Thorndike, MC, concerning rehabilitation in the United States. Colonel Cutler was surprised and nonplused to learn that there were 140,000 patients currently in the rehabilitation system. In the afternoon he went by train to New York and on Friday, to Boston. On Saturday and Sunday, 19 and 20 August, he visited the Harvard Medical School and the Peter Bent Brigham Hospital. He also spoke with Dr. Diamond, an expert in hematology, concerning preservatives for whole blood. On Monday, Colonel Cutler was back in the Office of The Surgeon General with further discussions on blood, wound ballistics, history of the war, and photography which the Surgeon General's Office desired.

On Tuesday, 22 August, Colonel Cutler reported the following:

Conference with General Rankin and Major [Margaret D.] Craighill concerning new policies for care of officers and enlisted personnel, female, becoming pregnant in service. Conference with Major General [George F.] Lull, Colonel [Florence A.] Blanchfield and Major Craighill concerning the fact that women officers in Medical Corps are not given dependent allowances. All agreed this was wrong, that the bill had been loosely drawn for women in Medical Corps in that it did not specifically state that women medical officers could have dependent allowance because it was so specified in the bill setting forth the creation of these service officers. At the request of the above group, wrote a letter to Senator Walsh, Massachusetts Senator, and an old friend of mine, asking him to see that fair play and no class distinction occurred in this matter.

99Oughterson, Ashley W., Hull, Harry C., Sutherland, Francis A., and Greiner, Daniel J.: Study on Wound Ballistics-Bougainville Campaign. In Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962, pp. 281-436.


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The next day, Colonel Cutler visited the National Research Council offices where he conferred with Professor Keefer and Dr. Guest, experts on blood. The National Research Council group promised to report to The Surgeon General of the Army what the best preservatives for whole blood were, refrigerated and nonrefrigerated. Later, on this Wednesday, 23 August, Colonel Cutler visited the Air Surgeon with reference to a matter of considerable concern to the Chief Consultant in Surgery from the European theater. His record for the visit states:

Conference at office of Air Surgeon regarding information from Mitchel Field forwarded to Surgeon General that cases arriving from ETO were improperly dressed and cared for. It appears that some of the cases specifically cited were Navy cases not coming through Army hospitals. Also it appears that the letter was written in an attempt to remedy defects in our system. General Grant was away and the conference was held with Brig. Gen. [Charles R.] Glenn, Lt. Col. [Alfred R.] Shands and Lt. Col. [Richard L.] Meiling. Colonel Shands is in charge of this work and will send me a weekly report on cases which arrived in bad condition or about which there may be criticism at Mitchel Field. The cases will be specific instances and will include not only the name of the patient but the hospital in the ETO where the patient was cared for. This should allow us to improve our care.

Prestwick again.-Colonel Cutler left the United States by air on 24 August. During the stop at Harmon Field, Stephenville, Newfoundland, he looked into the small 30-bed holding hospital there and found it quite satisfactory. Friday, 25 August, found him back again at Prestwick, Scotland, concerning which he recorded the following:

* * * had four hours at the 57th Field Hospital, and the blood bank set up. 350 pints of blood and Alsever's solution arrived in the plane I was on. These were still cool on arrival. Blood received at Prestwick as follows:

23 August: 258 bottles
24 August: 180 bottles
25 August: 336 bottles 

Disposed as follows:

23 August, to Salisbury: 5
24 August, to France: 300
25 August, to France: 130
On hand, 25 August: 338

Capacity of present refrigeration at Prestwick: 222 boxes of 6 bottles each.

Went over the roster of 57th Field Hospital. It is not good. See full vetting in separate memo. Believe this hospital should have a physician and a surgeon so competent that they can be given the right to change disposition board findings in order that certain cases which arrive at this hospital may be returned to duty rather than sent to the Zone of Interior.

London.-Colonel Cutler arrived in London late Friday, 25 August. On Saturday, he telephoned Colonel Hays of the Medical Supply Division and requested that he cable the Zone of Interior immediately for donor sets. One expendable donor set was to be packed in each crate containing 6 bottles of the Zone of Interior blood. However, on opening a package at Prestwick, Colonel Cutler had found no donor set. At a conference with Colonel Spruit, Col. Joseph H. McNinch, MC, and Colonel Muckenfuss, the Chief Consultant in


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Surgery explained the new procedure by which Zone of Interior whole blood would be supplied the European theater.

In a memorandum to the Chief Surgeon, dated 29 August 1944, he wrote the following concerning the subject:

*    *    *    *    *    *    *

3. * * * The blood will be brought to airports in the U.S.A. and held there refrigerated until the 'plane is ready to leave. It will then be flown unrefrigerated to Prestwick. There we will chill it again in our refrigerator, which means that it should be in the refrigerator at least 4 hours. The blood will then be flown to the Continent, where it can be immediately delivered in our refrigerated trucks or can be at the base in the large refrigerators. This would be safe to use up to 18 days; until we have further information from Washington, this is the method we will use.

*    *    *    *    *    *    *

The Surgeon General openly expressed the opinion at his staff conference that if the surgeons of E.T.O. wish for blood they should have it, and every effort would be made to provide us with what has been requested.

Evacuation

Immediately upon his return to London from the United States, Colonel Cutler was also embroiled in a conference on evacuation. Various aspects of evacuation from the Continent to the United Kingdom and from the United Kingdom to the Zone of Interior had been bandied about for some time, but it was now necessary to make some definite decisions-particularly in the light of the information Colonel Cutler had brought with him from The Surgeon General.

As for evacuation from the Continent to the United Kingdom, the consultants had objected to the lack of opportunities for using extensive air evacuation. More fields were needed to prevent one or two installations from receiving all the air-evacuated casualties. They were also of the opinion that it was no longer necessary or advisable to have transit hospitals in many cases. The same was true of water-evacuated casualties. The seriously injured requiring special care were of particular concern, since these patients were not getting to the right hospitals soon enough. At one time, Colonel Cutler had, by way of illustration, mentioned the case of a Private "S.", as follows:

* * * [He] was wounded through the right forehead on July 13th-cared for at 45th Field Hospital-crossed on LST. Admitted on 14 July to 50th Field Hospital-transferred from there to the 305th Station Hospital 17 July-transferred from there to the 314th Station Hospital 18th July-transferred from there to the 185th General Hospital 22 July-still unconscious with a cerebral leak.100

On that occasion, Colonel Cutler had said there were many such cases. He had also objected to the fact that good general hospitals were being used as transit hospitals or as holding hospitals for evacuation to the Zone of Interior. To him, this was a waste of talent and equipment, when a hospital with less able medical officers and more limited equipment could perform the mission adequately. Colonel Cutler had also suggested further evacuation to appro-

100Minutes, Twenty-First Conference of the Chief Surgeon's Consultants, London, 28 July 1944.


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priate hospitals by light aircraft directly from planeside of evacuation aircraft arriving in the United Kingdom from the Continent.

As for evacuation to the Zone of Interior, Colonel Cutler, at this conference on 26 August 1944, said evacuation by air and by water had to be considered, priorities had to be set for air evacuation, and a determination made of cases to be evacuated by sea.

Fortunately, it was soon determined that patients could be evacuated directly from the Continent to the Zone of Interior and detailed instructions to implement the decision were issued by the Chief Surgeon to surgeons of all base sections on the Continent, and to commanding officers of all general hospitals on the Continent. In this instance, direct evacuation by air from the Continent to the Zone of Interior was to be provided patients for whom definitive treatment at special centers in the United States would be preferable to the treatment available in the European theater. The directive, dated 19 September 1944, stated that, normally, battle casualties should take precedence over non-battle casualties. Particular priority for air evacuation was to be given to (1) peripheral nerve injuries, (2) maxillofacial injuries, (3) brain tumors, (4) patients requiring deep X-ray therapy, (5) patients requiring a series of plastic operations, (6) carcinoma, and (7) blindness. There was also a comprehensive list of conditions which were contraindicative of air evacuation.

These and other changes alleviated the evacuation situation somewhat, but the general situation on the Continent was so fluid and changing, that some decisions had to be held in abeyance. In fact, for a period, many of the activities of the Office of the Chief Surgeon came to a temporary halt.

Valognes and Paris

The occasion for disrupting the normal routine of the Chief Surgeon's Office was its move to the Continent. At an early date, the Forward Echelon, Communications Zone, had crossed to prepare the way for the eventual move of the Headquarters, SOS, ETOUSA, across the Channel. Each division of the Chief Surgeon's Office had plans to move its personnel on a staggered basis-a portion to go early, and the bulk to follow later. Some members of the Chief Surgeon's Office had been designated to remain in England until the move could be completed and the United Kingdom Base could be established with Colonel Spruit as its surgeon. The Medical Records Division was to remain permanently in England with Colonel McNinch as its chief.

The first move of the Chief Surgeon's Office was to Valognes, France. This followed a few days after Colonel Cutler's return to the European theater when he was extremely busy trying to catch up with unfinished business and the events which had transpired during his absence (fig. 93). The diary says little about the crossing: "Trip [from] Cheltenham to here-Wow! Wish I could write it in full. Trip with Ralph Tovell day after arrival here. Peninsular [base,] Caen * * * to Le Mans (2:00 AM). Next day beyond Chartres. Great destruction in British area and burned out tanks belittle talk Americans did it all!"


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FIGURE 93.-The interior of the Operations and Administration Building, Office of the Chief Surgeon, ETOUSA, at Valognes, France. Colonel Cutler is seated in doorway. Lt. Col. John H. Voegtly, MC, is at table behind Colonel Cutler. With Colonel Cutler, from right to left, are Col. Robert E. Peyton, MC, and Col. James C. Kimbrough, MC.

Afterwards, Colonel Cutler flew back to England for one week where he spoke with Colonel Spruit and Colonel Morton about certain administrative and professional aspects of the medical service in the United Kingdom when the Chief Surgeon's Office had moved in its entirety to the Continent. Colonel Cutler advised the United Kingdom Base surgeon that Colonel Morton, the United Kingdom surgical consultant, was struggling with problems that had previously involved many consultants. Colonel Cutler suggested that there was a great deal of time-consuming work involved in the supervision of orthopedic care and that Lt. Col. (later Col.) Richard S. Farr, MC, would make an excellent assistant in orthopedics to Colonel Morton.

During this week in the United Kingdom, General Hawley also came over. He informed Colonel Cutler that he would like to sponsor a conference of Allied medical officers on the Continent as soon as things settled down a bit, and he instructed the Chief Consultant in Surgery to make the necessary arrangements.

When Colonel Cutler was ready to return to the Continent, the headquarters was already moving to Paris. Colonel Cutler arrived in Paris on Thursday, 14 September 1944. He moved into the Hotel George V, his new "home," and the beginning of a new era in the fight against Nazi Germany. The War Department was later to designate 15 September 1944 as the date of the beginning of the Rhineland campaign.


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FIGURE 94.-The Office of the Chief Surgeon, ETOUSA, 16 Avenue Kleber, Paris, France.

THE RHINELAND

The Office of the Chief Surgeon was, to Colonel Cutler, in a continuous uproar when it opened at the Columbia Hotel, 16 Avenue Kleber, Paris (fig. 94). Desks and chairs continued to go up and down the stairs. The consultants were five to a room in small offices, on the seventh (top) floor, and there were no elevators. Many of the necessary working files were still packed away in boxes, as was the complete medical library which Colonel Cutler had assiduously assembled. Because all of the British civilian help could not accompany the move to the Continent, secretarial service was at a premium. While Colonel Cutler was fortunate enough to be billeted at the Hotel George V, he was sorry to discover that some of the senior consultants who came over did not fare as well, as they were placed in temporary billets 1 or 2 miles away. Fortunately, the weather was nice.

The move to the Continent heralded a new era in the war against Germany. For Colonel Cutler, there arose immediately the opportunity to renew old friendships with French surgical colleagues, including René Le Riche, Merle D'Aubigne, Marc Iselin, and Claude Béclere. There was resurgence of activity among French medical organizations, once again freed from German domination, and the Chief Consultant in Surgery was to be asked to participate frequently. Now no longer removed by an expanse of sea water, the proximity of


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the field armies was to foster an ever closer working relationship among those at theater headquarters, in the armies, and in the communications zone. The United Kingdom Base gradually took on a different character, acting, as it were, as an area for the Zone of Interior type of hospitalization of patients who were neither in the category of those to be cared for on the Continent nor in the category of those to be sent directly to the Zone of Interior, from the European mainland. To the south were a field army and support commands whose medical personnel were historically, professionally, and sentimentally rooted to the theater from which they had newly been transferred, but who now had to be integrated-professionally, insofar as Colonel Cutler was concerned-with the European theater.

Tactically, the swift progress of the Allies through France, which had raised hopes for an early end to hostilities, was to come to a standstill before the heavily fortified Siegfried Line in spite of vigorous assaults on these positions in the late fall. A bitter-cold winter-the coldest and wettest in many years-prevented the Allies on the Western Front from completely breaching at this time these advantageous German positions. And then, on 16 December, in frigid weather, the Nazi Wehrmacht struck suddenly and with great force through the forest of Ardennes to begin the "Battle of the Bulge." It was not to be until late winter or early spring that the Allies, after containing and repelling the German offensive, would generate enough momentum of their own for an all-out offensive on the German fatherland.

September-October: Orientation to Life on Continent

Inter-Allied meetings and conferences

With this as a background, one of the first specific tasks for the Chief Consultant in Surgery during this period was to carry out the desire of the Chief Surgeon to sponsor a meeting of Allied consultants on the Continent. At this time, many, apparently, were breathing more easily because there seemed no doubt that the Allies were on the Continent to stay, and progress had been quite satisfactory, once enemy resistance in Normandy had been crushed. It was second nature, then, to look back and reconsider what had been done, by whom it had been done, and how. There was also the desire to get together with those one might be associated with during the home stretch on the mainland. General Hawley had magnanimously thought of inviting consultants of all the Allied Armies on the Western Front, and particularly the French.

On further consideration, however, Colonel Cutler sensed that such a large meeting of consultants at this time might not be advisable. For one thing, the French really had not time to reorganize and reestablish themselves on firm footing. Besides, a meeting of representatives of many nations often became more concerned with social responsibilities and protocol rather than the conduct of business. And language problems, at such gatherings, were always a formidable barrier to both those sponsoring the meetings and the


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members of the audience. There was also the consideration that Sir Henry Tidy had laid the groundwork for a new series of Inter-Allied Conferences on War Medicine, sponsored by the Royal Society of Medicine, which had been so eminently successful in the past. In fact, Colonel Liston and Colonel Cutler had already accepted invitations to speak at the first meeting of the new series in October 1944, and permission had been requested to use Maj. Benjamin R. Reiter, MC, of the First U.S. Army as another speaker. Accordingly, Colonel Cutler proposed that the first meeting on the Continent be primarily with the British and Commonwealth consultants. Meetings with the French, he suggested, could easily be arranged at any time. And sure enough, U.S. and Allied medical officers soon received an invitation from the staff of the French Val de Grâce military hospital in Paris to join in a series of exchange clinics and meetings at monthly intervals, the first such meeting to be held at the Val de Grâce Hospital on 19 September.

Brussels and British 21 Army Group

On the morning of 23 September 1944, Colonel Cutler was preparing to motor to Brussels for a talk with Sir Percy Tomlinson and Brigadier Porritt, the DMS (Director, Medical Service), and surgical consultant, respectively, for the British 21 Army Group, when Colonel Kendrick, The Surgeon General's special representative on blood and resuscitation, returned from a visit to the First U.S. Army where he had been observing the administration and use of blood and plasma. Colonel Kendrick had come to the European theater shortly after Colonel Cutler's return from their meetings in Washington. While there was not time to discuss at length what he had observed, Colonel Kendrick said that he had contacted Colonel Crisler, as requested, and that arrangements had been made for Major Reiter to go to London and give a talk at the Inter-Allied Medical Conference to be held on 2 October. After receiving this welcome news from Colonel Kendrick, Colonel Cutler spoke briefly with the British Liaison Officer, Lt. Col. Brian Brennan, RAMC.

Equipped with the latest information from Colonel Brennan, Colonel Cutler departed for Brussels shortly after midday and arrived there at 1800. He was put up at the most comfortable Hotel Astoria, where Sir Percy Tomlinson and Brigadier Porritt were billeted. The next morning, after some discussion, it was decided that the various consultants should assemble in Paris by 1600 on 14 October. The Hotel George V was selected as the point at which to rendezvous. Suggestions for an agenda were received from Brigadier Porritt.

Eupen and First U.S. Army

After the meeting with these officers of the British 21 Army Group, Colonel Cutler traveled to Eupen, via Louvain and Liége, to visit Headquarters (Advance), First U.S. Army. Colonel Crisler, the surgical consultant, and Lt. Col. (later Col.) Neil L. Crone, MC, the medical consultant, were asked to


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FIGURE 95.-The stage of an amusement hall in France being utilized by a surgical team attached to a field hospital, 3 October 1944.

attend the meeting of consultants in Paris on 14, 15, and 16 October. They accepted the invitation. Suggestions for an agendum were also received. In addition, there was ample opportunity during the 4-hour visit to discuss many other aspects of the prevailing situation of surgery in the First U.S. Army. Colonel Crisler said that some 1,200 newly wounded were being treated daily. He also informed Colonel Cutler that the truck and supplies comprising the unit for the mobile surgical hospitals were excellent and had all been utilized. But, he mentioned, the teams had very rarely found the need for or used the tentage (fig. 95).

Coming back to Paris through driving rain, Colonel Cutler found that the bridge across the Meuse at Givet was out. Consequently, he spent the night in a small Belgian hotel at Dinant. Upon returning to Paris, he warned in his résumé of the trip: "Those officers traveling Headquarters, First U.S. Army, remember to turn sharp left at entering Eupen up a steep hill. There is no sign."

Back in Paris

108th General Hospital and blood for ETOUSA.-On Tuesday, 26 September, Colonel Cutler visited the 108th General Hospital in Paris (fig.


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FIGURE 96.-The 108th General Hospital, Paris, France.

96), which was under the command of Lt. Col. (later Col.) Louis M. Rousselot, MC. This hospital was the site of the forthcoming meeting of consultants. Colonel Cutler inspected it completely and found its physical plant elegant and the personnel satisfactory, although professionally not up to the standards of some of the best general hospitals in the theater. Also visiting the hospital were Col. Silas B. Hays, MC, the theater medical supply officer, and Colonel Kendrick. They were experimenting with plasma tubing to replace Levin or Wangensteen tubes, which were scarce.

Colonel Cutler joined them and, during the afternoon, placed several of these tubes in patients, experimenting with the type of tip to be used. Six of these plastic tubes for intragastric decompression were placed in patients as a test of their efficiency.

Later that day, Colonel Cutler took the opportunity to discuss the whole-blood situation with Colonel Kendrick and Major Hardin. Colonel Kendrick had found the use of whole blood in the European theater entirely desirable and was anxious to bring the daily lift from the Zone of Interior up to 1,000 pints a day as promised. Major Hardin was concerning himself with the decision recently made to move the European theater blood bank to the Continent. He reported difficulty in finding a suitable facility for the blood bank, and he stressed the fact that it had to be relocated soon.

The next day, 27 September, Colonel Cutler checked on the efficiency of the plastic tubing, proceeded to write a proposed circular letter on the use of the tubing as a substitute item, and completed drawings to accompany the circular letter before leaving Paris for London.


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Return to United Kingdom

Once again in England, Colonel Cutler visited the Operational Research Section and reviewed Major Palmer's progress on a casualty survey report which he was preparing on the accidental detonation of an M-41 fragmentation-type aerial bomb while it was being loaded on an aircraft at Deenethorpe, Northamptonshire, England. Later, in conference with Dr. Hamilton Southworth, U.S. Public Health Service, at the American Embassy, Colonel Cutler learned that the Intelligence Division in the Chief Surgeon's Office had a SHAEF report which detailed the scientific investigations which had been going on in France under the German occupation. Colonel Cutler was pleasantly surprised to learn also that the Rockefeller Institute and the American Library Association had jointly saved copies of American books and journals for distribution to the main libraries of the European countries as they were liberated. He planned to obtain copies for distribution from the Chief Surgeon's Office to the French Military Medical School at the Val de Grâce Hospital.

Medical statistics - The Medical Records Division of the Chief Surgeon's Office had moved from Cheltenham to London, and Colonel Cutler met with its director, Colonel McNinch, and his assistant, Lt. Col. George D. Williams, MC, to plan on the type of statistical data the surgical consultants would find useful and necessary. Colonel Cutler requested casualty data from the field armies to include those for killed in action and wounded in action, with the latter divided into those dying in hospital, returned to duty from army facilities, and evacuated to the communications zone. He further requested statistics from field armies as to the anatomical distribution of wounds and identification of causative agents. For the communications zone, the Chief Consultant in Surgery requested statistics as to the number dying in hospitals, the number returned to full and limited duty, and the number returned to the Zone of Interior. In addition, he requested that the average length of stay in hospital per patient be calculated to accompany these communications zone statistics. Finally, he arranged for all gas infection records to be sent to himself, personally, for Colonel Cutler was convinced that, "the records, to be accurate, must be studied by surgeons themselves who can separate saprophytic infection from true clostridial myositis."

Colonel McNinch, in turn, gave Colonel Cutler a map of the United Kingdom Base Section which showed how all hospitals in that base section were being organized into seven groups with a central administration for each group of hospitals. Colonel Cutler was pleased to note that this new plan was doing away with the system of holding hospitals as previously contemplated.

Resumption of Inter-Allied Conferences on War Medicine - One of Colonel Cutler's primary reasons for returning to England on this occasion was to participate in the first meeting of the new series of Inter-Allied Conferences on War Medicine. This meeting took place on Monday, 2 October 1944. As formerly, the location was the Royal Society of Medicine, 1 Wimpole Street, London, W. 1, and many American medical officers were guests.


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Colonel Liston, the Deputy Chief Surgeon, gave a presentation on the organization and operations of American medical services on the "far shore" during the invasion of the Continent. Colonel Cutler gave a similar talk on the "near shore"-the handling of casualties in the United Kingdom during the assault on Normandy. Major Reiter presented the surgical experiences from D-day to D+7 of 16 teams from the 3d Auxiliary Surgical Group. These teams had been attached to engineer special brigades to function in medical battalion clearing stations which had been suitably modified for the amphibious operation.

Colonel Cutler later observed: "This meeting was as good as any we have had. Colonel Liston's talk was admirable and Major Reiter and a young Canadian, Captain Gosse, were the high points of the entire meeting. I was greatly interested in the fact that, after I had talked about disposition in the afternoon, some 20 officers came up and asked disposition questions, showing this is still not clearly understood in the United Kingdom."

At this time, Colonel Cutler also arranged for Colonel Morton and Colonel Kneeland to meet Sir Henry Tidy and to serve as representatives of the U.S. Forces on the editorial committee for the Inter-Allied Conferences in the event that the regular members, Colonel Cutler and Colonel Kimbrough, could not attend.

On Tuesday, 3 October, Colonel Cutler met with a Professor Loucks, formerly professor of surgery at Union Medical College, Peking, China. Professor Loucks, recently repatriated from a concentration camp in Japan, was being sent by the State Department to found a new medical school in southwestern China for the Chungking Government. Colonel Cutler made arrangements for him to be shown the U.S. Army facilities in England by Colonel Morton and then to be sent to the Continent for an orientation tour there. Afterwards, the Chief Consultant in Surgery returned to Paris by plane.

During his brief stay in Paris, Colonel Cutler attended the regular conference of General Hawley with his staff and the weekly meeting of the Professional Services Division. He worked, too, on arrangements for the Anglo-American consultants' meeting. And, on Thursday, 5 October, he had a most satisfying reunion with Dr. A. Brachot, president of the Académie de Chirurgie. Dr. Brachot told Colonel Cutler that the academy was to open again on 1 November and that it would be available to all members of the Office of the Chief Surgeon, ETOUSA. Dr. Brachot said the academy would be glad to sponsor international and inter-Allied medical meetings as seemed wisest.

Fresh warnings on trenchfoot - Before returning to the United Kingdom, the Chief Consultant in Surgery again warned Colonel Kimbrough, in a memorandum dated 4 October 1944, of the problem which trenchfoot might be in the coming winter. This time, he called attention to word received from Colonel Crisler of the First U.S. Army, who said that he was fearful of trouble with cold injury in the coming weeks and months. "I agree with him,"


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noted Colonel Cutler, "after having visualized the Italian Front, that we are in for trouble." He reminded Colonel Kimbrough: "I have written a memo to you and the Chief Surgeon and to the Quartermaster concerning this matter in the past." Colonel Cutler also informed Colonel Kimbrough as follows:

*    *    *    *    *    *    *

2. Colonel Crisler makes the suggestion that we set up in a forward general hospital, preferably in Liége, near the First Army (and this should also be done for the Third Army) a group of medical officers trained and interested in this particular field. In other words, we will have a hospital for specialized care of the cold foot in each Army.

After reiterating his previous statements on prevailing misconceptions and faulty footwear, Colonel Cutler wrote: "These must be changed now else there will be disaster."

Thoracic and hand surgery centers in United Kingdom - Sunday, 8 October, found the Chief Consultant in Surgery back again in England, where he participated in a round of conferences for the next 4 days. With Colonel Morton, he reviewed the provision for and progress of thoracic surgery, and the two agreed that Maj. (later Lt. Col.) John J. Cincotti, MC, of the 16th General Hospital should be ordered to assist Maj. (later Lt. Col.) Dwight E. Harken, MC, who was carrying a heavy load at the 160th General Hospital. With Lt. Col. George N. J. Sommer, Jr., MC, at the 140th General Hospital, Lt. Col. (later Col.) Arthur S. W. Touroff, MC, at the 155th General Hospital, Lt. Col. (later Col.) Laurence Miscall, MC, at the 137th General Hospital, and Major Harken at the 160th General Hospital, Colonel Cutler concluded: "It would seem that the United Kingdom Base Section has the four best thoracic surgeons * * * and is adequately covered from the point of view of thoracic surgery * * *. Thoracic surgery has made more advance than any other surgical specialty." It was also decided to establish special facilities for the care of badly damaged hands at each of the three original hospital centers in the United Kingdom in coordination with their commanding officers and surgical coordinators.

There was also an important conference with General Hawley, Colonel Spruit, and Colonel McNinch concerning evacuation to the United Kingdom and from the United Kingdom to the Zone of Interior (fig. 97), evacuation within the 30-day policy on the Continent directly to the Zone of Interior, and the necessity to clear out the many prisoner-of-war casualties that were creating great hardship at this time. Emphasis was placed on the urgent need to make better use of the "Queens" (the converted British liners, Queen Mary and Queen Elizabeth) and other surface water transportation. Colonel Spruit announced that plans were progressing well for the organization of all hospitalization facilities in his base under seven hospital-center headquarters.

During this week, the Chief Consultant in Surgery "vetted" the 150th Station Hospital, conferred with the commanding officer of the 6th Field Hospital on its defunct missions and lack of any workload in its holding facilities at the Southampton port and the Membury airfield, attended the regular monthly


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FIGURE 97.-The interior of a loaded C-54 aircraft evacuating casualties from Paris to the Zone of Interior. Note the canvas straps for holding the litters in place.

meeting of the British Army surgical consultants, and lectured at the Medical Field Service School, ETO USA.

Conference with General Hood - At 0930 on Thursday, 12 October, Colonel Cutler had the privilege of meeting with General Hood, DGMS, British Army, to confer on the coming meeting of consultants in Paris on 15 October. When Colonel Cutler had been in London a fortnight before, he had laid the groundwork for this meeting with the Director General by presenting Colonel Brennan, the British medical liaison officer, a copy of the agenda for the proposed conference of consultants and the desires of General Hawley for representatives from the British Army. On this Thursday morning, General Hood said that he would be glad to send over General Monro, consulting surgeon to the British Army, and Maj. Gen. Sir Alexander Biggam, consulting physician to the British Army. He thought that possibly Brigadier Sir Stewart Duke-Elder and Brigadier Rowley W. Bristow, Consultants in Ophthalmology and Orthopedic Surgery, respectively, could also attend. The general said that these British consultants would fly over on 14 October, Colonel Cutler was pleased. He informed the Director General that General Hawley planned to billet the two senior officers at the Hotel George V and the others at the 108th General Hospital. General Hood asked Colonel Cutler


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FIGURE 98.-Participants at the Inter-Allied Consultants' Conference, held at the 108th General Hospital, Paris, France, on 15 October 1944.


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to inform General Hawley that he would be in Brussels in November, at which time he might come down to visit some of the medical facilities of the U.S. Army on the Continent.

After this meeting with General Hood, Colonel Cutler returned to Paris by air.

First Inter-Allied Consultants' Conference

The weekend of 14-15 October was a busy one for the Chief Consultant in Surgery. Saturday, 14 October, Colonel Cutler wrote, was devoted to the "hospitality of our guests!"

The conference (fig. 98) was opened on Sunday morning, 15 October 1944, with Colonel Kimbrough in the chair. He welcomed the delegates by saying:

This is the first meeting of the Inter-Allied Consultants' Conference. The principle of the plan was conceived by General Hawley, in order to get together the men who were responsible for making recommendations regarding the care of the troops in the field and who are really the consultants of the Armies. It was the idea to get them together to compare notes and discuss their problems.

General Hawley was first to be introduced. He officially opened the conference, welcomed the delegates, and thanked Colonel Rousselot and his staff at the 108th General Hospital for their hospitality. He then proceeded to comment on what the consultants in this headquarters had meant to him as a group, as follows:

I have given the matter a great deal of thought and I think, without any derogatory inferences to any other group, I am convinced * * * that the consultant group has contributed more, and continued to contribute more, to the success of the Medical Service than any other group of administrators, because they are, after all, administrators; that is, they have regulated, prescribed, and coordinated the professional services. This is tremendously important for the reason that one patient is treated by five, seven, eight different surgeons through the course of his illness and, right or wrong, in the long run, it is better that a patient follow through a regulated course of treatment than that each echelon through which he passes be permitted to exercise its own judgment in his basic care. I think that most of the surgeons doing the work are now reconciled to this point of view, although, and quite understandably so, it came sort of difficult to those who had been following their own particular pet ideas for a number of years. But that is, in my opinion, only one of the great services that the Professional Services Division of our army has rendered and is rendering. To me they are the most important eyes and ears that I have. These people get around. Their judgment is good in many things other than the care of the sick patient, and I have called upon them collectively and individually for advice upon many things not connected with the care of patients. I think, if they have not been exploited to their fullest value, it is because some divisions of the office have yet to learn of the tremendous potential value of this group. Some divisions have already learned that. The Chief of my Supply Division [Colonel Hays] sat and talked with me an hour the other night and told me of the great help this group is to him constantly, and that he would be unable to run his division without their help.

Then, for the benefit of the American consultants present, General Hawley continued with a subject which had been discussed at considerable length among the divisions of his office-the exchange of medical officers between the field


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armies and communications zone. The reader may recall that a similar program had been tried with considerable success during the preinvasion days in the United Kingdom (p. 70). Obviously, such a program would now be a most complex affair, but an endeavor which many thought would be more worthwhile than ever before. Colonel Cutler was a proponent of the plan. General Hawley's explanation follows:

While the consultants from the Armies are here, I would like very much to have you talk over with the chief consultant in your own specialty here in my office the question of rotating your people in the Armies with people in fixed hospitals. I feel that that should be done, not too fast, and probably at first on a temporary rotation basis. We may be in for a long winter of slugging it out or of lessened activity. Many of the people in the field units up with the armies have been working very hard and are tired. Maybe their morale has begun to waver a little. Nothing improves a person's morale as much as a change-a change of scenery. And, conversely, we have got a lot of people in these fixed hospitals who are just itching for a chance to get to the front and do some work there, and to get into some of the mud which the forward units must contend with all the time. I think it would be advantageous for both sides to let the people at the fixed hospitals learn of the conditions under which the forward surgeons work, and give them more understanding of the difficulties they encounter; and, conversely, let the people who are doing the work forward come back and see how the patients are cared for after they leave them.

The conference then proceeded with the first item on the agenda, care of the battle casualty up to the time of definitive surgery. As subtopics of the item, there were the following: First aid in forward echelons, care during evacuation to the hospital where surgery is first carried out, sorting of casualties, and preoperative preparation of the casualty to include blood transfusion, chemotherapy, and the like. There were no formal presentations, and informal discussion was the keynote.

Lt. Col. R. K. Debenham, RAMC, surgical adviser to the British Second Army, opened the discussion of the topic with these remarks:

One of the problems of the Second British Army is whether to resuscitate in one place and operate in another place. That is to say, whether a patient should be resuscitated forward and operated at the first available surgical level. I feel quite strongly that you can't resuscitate in one place and operate in another. * * * your transfusion teams must be with your surgery. * * * The best level for surgery appears to be behind our guns. Sometimes we have had to operate forward of our guns and within shell fire from the enemy. I don't think patients do so well there; it may be heroic, but it isn't very satisfactory.

Colonel Debenham also explained that the British in general were of the opinion that more than one-third grain of morphine was bad. He mentioned certain other complicating factors in the use of morphine, and stated that the British Second Army was finding it difficult to resuscitate anyone after thiopental sodium had been given, some 6 to 7 hours being necessary to recover from its effects. Colonel Debenham stated: "We like to treat all our femurs in Thomas' splints and we find they travel far better in a 'Tobruk' plaster." This was an interesting observation on a most controversial issue at the time.


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In summation, he brought forth the following four points on which transfusion and early surgery were based:

It is very interesting-there are four points: First, extent of the wound. The badly wounded patient is going to be shocked and must be reckoned as a shock case. Second, time of wound; because, if he is recently wounded, his chances are better. Third, the general condition of the patient. And fourthly, the pulse. And these four points are taken into consideration by the transfusion officer. Blood pressure readings are sometimes not very helpful. I feel in general that the forward surgeon should be essentially conservative. Heroic surgery is not required. The surgeon forward must know who will travel and who will not. If he can estimate that, it is very helpful.

Thanking Colonel Debenham for his remarks, Colonel Cutler asked that the Army consultants, particularly, provide the conferees with information relating to the first subtopic, first aid. "We hoped that the discussions would deal with the soldiers as far forward as they are wounded," he said, "I had hoped that the first part of the meeting this morning would devote itself to fist aid, * * * as a simple thing," he continued. As an example of the type of information which might be desired, he asked: "Are your men trained in first aid? How far does he go? Do you have any information on whether your patients coming back have the original dressing? What are you doing to prevent infection? * * * And in regard to splints * * * Who puts it on? Where are they put on?" "It may be more important to put on a good dressing than to give penicillin and sulfonamides," he observed.

Confessing that he didn't know just exactly who did what at the site of the wounding, Colonel Debenham replied: "* * * From the point of view of the casualty, I have seen the results and most of the dressings have been put on extremely well. If the man himself doesn't know, someone near him does know how, and most of those that I have seen have been 100 percent marvelous."

"What does the individual soldier take?" questioned Colonel Cutler.

He carries a little field pack," replied General Monro, consulting surgeon to the British Army, "The individual field dressing is an extraordinarily good dressing."

Colonel Crisler, when asked about conditions of first aid treatment in the First U.S. Army, maintained that, from a few spotty observations, he could not say exactly what was being done for each patient or the percentage of well-done dressings. He did comment, however, on early treatment in the First U.S. Army, as follows:

Our treatment of casualties forward is taken from the "Manual of Therapy." It has proved to be a splendid guide on all general principles of surgery and it has been followed in general very closely. A few points need elaboration. Quite a few surgeons have needed to be whipped into line about the policies. They have deviated from policies, but after they had been treating casualties for a while, they conformed more or less throughout. * * * When we see them [casualties] come back, we judge them. At one time they seem to be all handled well, and then again occasionally we see a patient come back who perhaps has not been properly splinted; we see occasionally one who has been overlooked. That varies with the number and the flow of casualties. Our percentage of approaching


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perfection with which this is accomplished must be interpreted in the light of the number of casualties, and the tactical situation, and to sit back and criticize is a bit unfair. It seems to me that on the whole, they do a very good job.

"Have you any information as to how many dressings put on on the battlefield are changed?" asked Colonel Cutler.

"I think that most of them are not revised nor removed," answered Colonel Crisler. "They may find it necessary to determine the extent of the wound, but the dressing is not removed unless it is absolutely necessary in order to determine where that patient should go. It may be that it is drawn a little too tightly and in that case it is readjusted, but it stays on until the clearing station is reached."

Col. Frank B. Berry, MC, the Seventh U.S. Army surgical consultant, spoke in a similar vein. He stated: "* * * There is one thing that constantly comes to mind, and especially at this time of year and that is the morphine Syrette which I wish had never been invented-that is in that size [one-half grain]-because we have already seen cases of overdosage of morphine." Otherwise, he commented on the first aid type of treatment given in the Seventh U.S. Army in glowing terms, as follows:

I have only the highest praise for the work that is done in the first aid and battalion aid stations and by the aidmen going out in the field, as General Hawley and Colonel Cutler have mentioned (fig. 99).

As a rule the splint is pretty good. At times, of course, they slip. We have all been very much interested in the very good and judicious use of the splint by the first aidman in the field.

As to the dressings, I am happy to say that there is less change in them than there used to be, particularly in the Tunisian campaign, in the collecting station. There was a great tendency during the Tunisian days to do some surgery at the collecting station. I remember one particular clearing station which took pride in the major surgery that was done there. The changes of dressings is gradually lessening. It is interesting to check them, to see dressings inspected and changed, and I do think that there is more changing than necessary. I think they are very good in establishing their priority to get the urgent cases back to the hospitals. Very good judgment is being shown.

In his remarks, Col. Charles B. Odom, MC, Third U.S. Army surgical consultant, spoke of penicillin and sulfonamides:

One thing: Penicillin of course is not begun until we get back to a hospital; it is not used in the forward areas, and, from the number of infections that we have had, I don't think it is necessary to begin it forward. I think perhaps we would do well to stop using sulpha in the wounds forward. In checking a group of cases in the convalescent hospital, we have found some of these wounds well-healed and then when we begin to rehabilitate, the wound softens down and in the wound we are finding sulfonamides there because they have not been absorbed. In those that do break down, it increases the convalescence of those patients sometimes anywhere from 2 to 3 weeks.

Judging from the dressings that have been applied, I think our first aid men have been well trained and the effort that has been put forth has definitely shown results, because the patients arriving now in the field hospitals have been well cared for forward. The men know how to apply dressings and in most instances the dressings are well applied. However, there is a tendency in some cases to apply the dressings too tightly and, when swelling occurs, then they become a tourniquet.


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FIGURE 99.-Litter bearers of the Seventh U.S. Army bringing in a wounded soldier in southern France.

Brigadier Porritt, consulting surgeon to the British 21 Army Group, was asked to open the discussion on sorting. But before speaking of sorting, Brigadier Porritt commented on first aid treatment. He stated:

We feel about our stretcher bearers [aidmen] as you do about yours. Treatment at this level is not particularly skillful. It is a mixture of common sense and humanity-if they will only use common sense and stick to a routine treatment; simplification is what we want. They have to get the patients out, but they must get them out successfully treated so that nothing happens. They must give first aid medical treatment to get him back in at least no worse shape than he was when he started.

With respect to sorting in forward hospitals, Brigadier Porritt stated that the British had started the war with great ideas on classifying casualties for evacuation, resuscitation, and treatment. In actual practice, he remarked, these ideal-sounding plans do not work out. He made the following statement:

There is * * * no subdivision into classes, but there is again the essence of sound common sense. "Sorting" I much prefer to "triage." A man must learn the type of case he can treat at that surgical level or the type that he must send on. Anything he can send on saves effort. Surgery in forward areas should be very limited. Anything they do is merely to allow the patient to be taken back. A mediocre man may be much more valuable than a good surgeon who is going to complicate things by treating every case he sees.

General Monro was asked to say a few words as a representative of the consultant group for the Director General of Medical Services in the British Army. "I find myself in the same position as previous speakers representing


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the British service," he began. "This is rather a quick one," he commented wryly, "I came over here intending to enjoy myself and now I find my holiday is not going so well."

On the subject of consultants in general, the consulting surgeon to the British Army said:

If I may go back, sir, for a moment, I should like to state how closely all that General Hawley said appealed to me; how much he said about the contribution of the consultants coincided with our own. It is, as a matter of fact, within the last two years, I think, that our own senior directors in the field have come to realize what the advice of the consultants can mean. I am bound to state that actually in certain cases there was a little opposition to the work of the consultants to this all important supervision by the technical officer who is not only a technician but a born administrator.

On the subject of sorting, General Monro noted:

We have at the moment under discussion this question of the selection of cases. Under this new setup, this introduction of mobile surgical units undoubtedly gives us much greater flexibility and ability to concentrate surgery where it is wanted than was ever supposed before. The field dressings station idea was a sort of modified field ambulance made more mobile. It was quite obvious that we must have some sort of organization that would enable us to hold our cases further, so the field dressing station was evolved to take care of cases when distances prohibited evacuation. I think you will agree, our people will agree, that it is infinitely better than any other system we have had before. The word "triage" has been quite rightfully condemned. I think it is outlived and some much more sensible word such as grouping, or selection is the word of choice. I don't think it matters very much that we have three groups-a, b, and c, or one, two, and three. That, after all, is intended only as a guide for one who hasn't faced it before. It is, as Brigadier Porritt said, common sense that matters.

As an afterthought, General Monro added:

We also apply that [common sense] to our first aid. A paragraph in our little hygiene manual tells the soldier that first aid is simply common sense and then goes on to explain what the principles are and finally if he has any questions to ask the medical officer. Our men, when it is possible, are all trained in elementary first aid. I will agree with everything that has been said about first aid dressings and I would accentuate the fact that the main objective is to try to get the man back out of the field and keep that first original dressing in position.

On the topic of sorting, Colonel Crisler remarked:

I regard sorting as something that is in two categories. One sorts cases to decide which hospital they will be sent to, and then one sorts cases within the hospital. There are two different sets of criteria * * *. The sorting to decide which hospital they will be sent to is guided as much by policy, by the tactical situation, by the employment of the hospital at the particular moment, and under the particular phase of warfare, as it is determined by the condition of the patient. At the division clearing station the doctors become very proficient in the selection of the so-called "non-transportables" * * *. I do not feel that you must have your most experienced man for sorting at that level * * * [where they] may readily seek the consultation of the surgical teams (fig. 100) * * *. Then in the hospital, sorting is governed by professional policies and I think that the most important point about that is that the sorting be continuous. That is to say, one must not let a case become labeled and pin that label on him and make it permanent, but you should keep going around, because in a half an hour or an hour the priority may change. If you label him as a number two or three, in another one-half an hour he may be a number one.


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FIGURE 100.-Casualties being sorted at a clearing station in France.

The last subtopic on the agenda for the general session, transfusion and the preoperative management of the casualty, was opened by Col. J. S. K. Boyd, RAMC, consulting pathologist to the British 21 Army Group. He explained the evolution of the British system of resuscitation and transfusion and their use of wet and dry plasma and whole blood. Colonel Boyd explained that, to some of their divisions where there was a great enthusiasm for blood as opposed to plasma, the British were now shipping blood in small boxes holding three bottles and with a special compartment for ice to keep blood refrigerated for 24 hours. He went on to say:

The question of how much to transfuse is one that is very controversial. Transfusion is somewhat of a new toy and there is a great tendency to transfuse when it is quite unnecessary. * * * As to the level where it should start, I agree with the remarks made earlier in this morning's discussion. So far as possible, it should be minimal until the surgeon is prepared to operate on the patient. It has been found that, if a patient is transfused up to surgery level and then transported back from advance dressing station to casualty treating station, during that time he tends to go backwards, and, if he is allowed to recede, he is much more difficult to bring back. * * * As to the quantity required, that is a very variable factor. It depends very largely on what the patient has lost. The majority of severely wounded patients who arrive back at CCS have a hematocrit reading somewhere in the vicinity of thirty to thirty-five, taking the normal as forty-five. * * * But, in that, I think we must bear the scientific against the clinical, because, although many of the people who had a hematocrit reading under thirty were theoretically really ill, * * * in practice they weren't bad at all.


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So far as the amount of blood or plasma used, I can't give you an exact figure. * * * The overall average is somewhere between one to two bottles of blood to a bottle of plasma. * * * Total quantities used might interest you. We find it very variable. Our budget in the early days was from 30 to 40 bottles for every 100 wounded men * * * but that has gone up very considerably, and at the present moment it is running somewhere on the far side-probably between 60 and 70 bottles per 100 wounded. Now, that does not mean that each man is getting between six and seven bottles, but means that a large number of patients are being transfused, and that is due partly to the different type of wounded we are getting in this campaign * * *. There is much blood lost, and there is more necessity for transfusion.

Speaking of the American experience with transfusion and resuscitation, Colonel Crisler stated, with reference to the First U.S. Army (fig. 101):

Up to the present campaign, there was no such thing as shock teams. It was an idea gotten up in this theater, and I think Colonel Zollinger of General Hawley's office worked on that and that job has definitely turned out to be worthwhile. The shock team was originally with the auxiliary surgical group and there were only four teams in the auxiliary surgical group. Four shock teams for an army is just of no value whatsoever. It has been found that two shock teams per evacuation hospital and two per field hospital is the number that you should have. I have noted that with the Fifth Auxiliary Surgical Group which has just arrived there is a considerable increase in the number of shock teams in that particular organization. With the shock teams the patients have gotten better care than they did previously so far as treatment of shock is concerned.

Continuing with his discussion of resuscitation in the First U.S. Army, Colonel Crisler brought up a subject which was being noticed by many as a potentially serious problem. He commented:

There have been reactions to * * * stored blood and they are continuing to have reactions; we are trying to get some figures on it. They have increased in number and in severity as the date of expiration is approached. The unfortunate thing is that in our Army the expiration date is getting pretty close in the blood coming from the States. At the present time, there is not more than 3 days remaining when the blood arrives until the expiration date. * * * that expiration date is set only arbitrarily, and it is perfectly possible that the actual expiration date is past; and that is not a particularly good thing.

After General Hawley explained difficulties in providing whole blood-particularly with respect to forecasting needs and determining the amount to be kept on hand-Major Hardin gave his impressions of the situation, as follows:

We have received rather sketchy reports about reactions. There is no evidence in any large well-controlled number of cases that the number of the reactions increases with the age of the blood; and I do not believe that the answer to reactions is the age of the blood. It is some other reason. There are two possibilities that I can think of off hand. As you know, the blood from the States is flown across the Atlantic without refrigeration. It may be that there is some contamination, and perhaps enough to give a reaction. We have found so far no contaminated bottles. The other possibility, which I think is probably the answer, is that the sets through which the blood is given are dirty. * * * The other type of reaction which may be seen in stored blood is the hemogloblin reaction which does increase with the age of blood. That is the reason that hospitals have been asked to examine the blood, because all hemolized blood has its own degree of hemolysis. The blood coming from the States, no matter what the age is, has less hemolysis than that from the ETO Blood Bank. So far as the age of the blood


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FIGURE 101.-A shock tent of a hospitalization unit of the 34th Field Hospital, First U.S. Army.

is concerned, you have got to get rid of your oldest blood first. As General Hawley said, we have had some difficulty in getting blood from the States. The blood from the States stops in the United Kingdom and then [is] flown here. Flying conditions have often been unfavorable.

This, the first general session of the meeting, was concluded with plans for a similar meeting at a later date. "I would like, before you break up," said General Hawley, "to have you discuss among yourselves how often these meetings should be held and perhaps fix a date for the next one. I am sure that, so long as we are in Paris, we will have a large turnout. Perhaps the next one should be in Twenty-One Army Group sector. I understand they are comfortably located up there."

Meeting of American surgical consultants - The remainder of the day, after luncheon, and the morning following were devoted to smaller group sessions, the surgical and medical consultants going their separate ways (fig. 102). On Monday afternoon, the Chief Consultant in Surgery and the senior consultants met with consultants from the field armies and the surgical consultant from the United Kingdom Base, Colonel Morton.

Rotation of medical officers - The consultants agreed that the exchange of medical officers between the armies and communications zone should begin immediately on an experimental basis. For this purpose, they thought it wisest to involve only the First U.S. Army initially, the Third U.S. Army to be


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FIGURE 102.-Col. Frank B. Berry, MC, speaking at the meeting of surgical consultants during the Inter-Allied Consultants' Conference at the 108th General Hospital, Paris, France, 15 October 1944. Colonel Cutler, moderator, is seated at the table with his back to the camera.

brought into the plan soon thereafter. The consultants from theater headquarters promised highly trained and thoroughly competent surgeons from the best general hospitals for this interchange. It appeared also, from the conversation, that there were many highly competent surgeons in the field armies who, because of their age or long service in field army facilities, could now be better utilized as chiefs of services in general hospitals. Colonel Berry, particularly, said that there were highly trained men with a wealth of experience gained in 2 years of combat with the Seventh U.S. Army-men who would be much better off now if placed in general hospitals in the communications zone. And Colonel Berry was perfectly willing to give up these valuable men for such assignments to the rear.

Auxiliary surgical groups - Another item of importance was the discussion on auxiliary surgical groups. At this time, the groups in the theater were assigned as follows:

Group

Assignment

1st

Theater reserve under operational control of Headquarters, SOS, ETOUSA

3d

First U.S. Army

4th

Third U.S. Army

5th (-)

Ninth U.S. Army

 


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The 1st and 3d Auxiliary Surgical Groups were short of personnel. The 5th Auxiliary Surgical Group had only recently been assigned to the Ninth U.S. Army, and the Professional Services Division of the Chief Surgeon's Office had been busily bringing it up to strength. It now had 22 general surgical teams (6 of the team chiefs had been borrowed from general hospitals), 6 orthopedic teams, 1 neurosurgical team, 4 maxillofacial teams, 3 dental prosthetic teams, 3 X-ray teams, and 22 shock teams. However, many of these teams had been loaned to the Third U.S. Army, including those with chiefs borrowed from general hospitals. The 1st Auxiliary Surgical Group was being reassembled in Paris, but nine of the specialist teams were still in the United Kingdom pending the day when they could be replaced by teams formed from hospitals organic to that base section. There was a general shortage of competent chiefs of general surgical teams which prevailed throughout all the groups.

To bring all the groups up to their authorized strength and to return borrowed personnel and teams to their parent units were but typical examples of the personnel problems which continued to exist and required solution by the theater consultants (in coordination with the Personnel Division, Office of the Chief Surgeon). In this instance, Colonel Cutler elicited a promise from Colonel Odom of the Third U.S. Army that he would: (1) Return the six borrowed general surgeons on teams of the 5th Auxiliary Surgical Group to their hospitals, (2) fill their positions as chiefs of general surgical teams with second men from his 4th Auxiliary Surgical Group, (3) replace vacancies thus created in his 4th Auxiliary Surgical Group by competent junior officers on the shock teams borrowed from the 5th Auxiliary Surgical Group, (4) provide additional chiefs of general surgical teams for the 5th Auxiliary Surgical Group from assistants on general surgical teams of the 4th Auxiliary Surgical Group, and (5) return all teams of the 5th Auxiliary Surgical Group when they were required by the Ninth U.S. Army. If the Third U.S. Army should be caught short in an emergency as a result of these changes, teams were to be loaned to them from the 1st Auxiliary Surgical Group being reassembled in Paris. These and other steps necessary to bring the groups up to strength were coordinated on the spot with the senior consultants in their respective specialties and representatives from the Personnel Division of the Chief Surgeon's Office.

Another noteworthy development from this meeting was the fact that all the surgical consultants from the field armies were unanimous in pointing out that surgical instruments were beginning to wear out, particularly hemostats. They were being turned in for overhauling, but obviously this could only be carried so far. Colonel Cutler, after this meeting, alerted the Supply Division of the possibility that there might be a heavy demand for hemostatic forceps soon.

Meeting with French surgical consultants

On the day following this meeting with the consultants from the field armies, there was a meeting sponsored by the 217th General Hospital for medical officers in the Paris area with consultants from the French Army. In a memo-


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FIGURE 103.-Left to right, Colonel Cutler, Colonel Osipov, General Hawley, and Major Birch-Jones in General Hawley's office, Paris, France.

randum directed to the Chief Surgeon on 18 October 1944, Colonel Cutler reported that it had been a very pleasant and satisfactory occasion and that they had been warmly thanked by their French colleagues. He noted in his official diary: "An excellent program was provided at the hospital and in spite of language difficulties our French colleagues seemed greatly interested, and wish to give us a return meeting at the Val de Grâce hospital in 2 weeks."

Soviet visitor

On Thursday, 19 October, Colonel Cutler was again back in the United Kingdom. After conferences with Colonel Spruit and Colonel Morton, according to plan, Colonel Cutler met with Major Southworth who said that he had attended the recent international meeting at which the new penicillin unit had been established. Colonel Cutler was happy to note that it was almost one-to-one with the previously known Florey or Oxford unit, now so familiar to him.

On Monday, 23 October, Colonel Cutler returned to the Continent with Col. B. A. Osipov of the medical service of the Soviet Army and his attached British aide, Major Birch-Jones (fig. 103). Colonel Osipov had been visiting British medical activities and had now been invited and cleared to observe them in the U.S. Army. Upon arrival in Paris, Colonel Osipov was shown the 108th General Hospital, where he observed the reception of patients and their distribution to wards. He was taken through the surgical and orthopedic wards, and then he lunched with the hospital staff. In the early afternoon, he saw neuro-


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psychiatric and malaria patients and then spent the remainder of the afternoon with various consultants in the Chief Surgeon's Office. The next day was also spent by Colonel Cutler in arranging the program for Colonel Osipov to see and talk with most of the consultants and the chiefs of the various divisions in the Office of the Chief Surgeon. Later there was a dinner given by General Hawley in honor of Colonel Osipov, at which another visitor, Brigadier J. R. Rees, Consultant in Neuropsychiatry to the British Army, was also a guest. The morning of 25 October was likewise spent with the guest from the Soviet Union, but, for Colonel Cutler, this day was memorable, too, for another reason.

Reopening of Académie de Chirurgie

In the afternoon of 25 October, Colonel Cutler attended the first meeting of the Académie de Chirurgie since the Germans had entered Paris years before. The meeting place was crowded with distinguished French surgeons, among them Professors Le Richie, Roux, Berget, Banzet, Quenu, Senec, Brocq, and the president, Professor Brachot. The first item was the reading of the obituary notice on Professor Gosse, following which was a speech welcoming officers of the U.S. Forces. Professor Le Riche insisted that Colonel Cutler reply to this address in French, which he did. Thereafter, Colonel Cutler had to sit next to the president on the rostrum and help conduct the meeting. The meeting, Colonel Cutler reported, proceeded as follows:

The papers read were short, and during the presentation most of the members conversed with one another, paying little attention to the speaker but when this murmuring became too loud the President rang a great big bell such as one uses in our country to call in the cows with. No one seemed to pay any attention, but the President was relieved by the noise, and the murmuring continued.

Colonel Cutler discovered that this was not actually the first meeting since the occupation of France by the Germans, for there had been a planning meeting the week before, but it was indeed a noteworthy milestone heraldic of the peace and victory which was now surely destined to come.

Chief Surgeon's Consultants' Committee meeting, 27 October 1944

Evacuation.-The meeting on 27 October 1944 of the Chief Surgeon with his Consultants' Committee was devoted extensively to improving evacuation. Only the day before, Colonel Cutler had met with the chiefs of surgical services of hospitals in and around Paris on one aspect of this problem, the classifying of patients as transportables and nontransportables. Major Robinson, Senior Consultant in Urology, had made a trip by hospital train to review the condition and care of patients in transit by rail. Colonel Stout, Senior Consultant in Maxillofacial Surgery, had made a similar trip by evacuation aircraft to the Zone of Interior. There was a definite pinch on evacuation means, and General Hawley stated at this meeting of his Consultants' Committee: "The situation is really terrible." General Hawley exhorted his consultants, saying: "* * * I want to emphasize again here, keep checking on the care of patients


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in transit. It is just as important a part of our responsibility as is their care in hospitals, and I just can't keep on temporizing when people are not carrying out directives."

Long-bone fractures - Casualties with fractures of the long bones provided a special problem of evacuation at this time. An analysis of the problem follows:

Skeletal traction to be used effectively had to be instituted within a maximum of a week or so after wounding, a requirement which sharply restricted the transportation period. It was often nip-and-tuck whether casualties with these injuries could be evacuated from the Continent to the United Kingdom within this limited time. If they could not be evacuated, there was the threat of Continental hospital beds' being occupied by many orthopedic patients in skeletal traction because The Surgeon General had directed that all fractures of the long bones must be firmly healed (frozen) before evacuation to the Zone of Interior was undertaken.

General Hawley's solution of this dual problem was to give casualties with fractures of the long bones maximum priority in evacuation. When this was not possible, they had to be held on the Continent in skeletal traction for the minimum of from 60 to 70 days required for the fractures to become firmly healed after which evacuation to the Zone of Interior could be undertaken without the risk of loss of position in the transportation cast.

Other significant matters.-There was a discussion on the Tobruk plaster with half-ring splint involving Colonel Cleveland and General Hawley in which the Senior Consultant in Orthopedic Surgery explained the mechanism of the Tobruk plaster and mentioned that the Ninth U.S. Army would give it an experimental trial.

Colonel Cutler reported that he had conferred with Major Hardin on transfusion reactions and that a new directive was being prepared which would identify transfusion reactions as allergic, pyrogenic, or hemolytic and would explain what to do in the face of such reactions.

Colonel Cutler mentioned that the exchange of medical officers had started off with eight elderly, poor-in-quality officers who would at best only do as ward officers.

Finally, Colonel Kimbrough announced the plans made by the surgical consultants for specialized treatment facilities on the Continent. It was necessary that these facilities be established to take care of difficult thoracic, neurosurgical, urological, and maxillofacial surgery cases which could not be evacuated to similar facilities in the United Kingdom owing to the condition of the patient or the temporary unavailability of evacuation means. At the present time, only the 48th and 108th General Hospitals in Paris had been named to handle these cases, but it was reported that similar facilities would need to be established at a later date which would be accessible to each of the field armies.


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Notable guests - Dr. Loucks, previously mentioned, gave a brief description of his activities in a Japanese prison camp as a "guest of the Imperial Government" in North China. He painted a dismal picture of conditions prevailing on the Asiatic mainland and in the concentration and prison camps. Colonel Osipov was also present and, when given an opportunity to speak, stated through an interpreter:

The Colonel is very grateful for the warm reception he has received from all, and for his contact with these modern consultants. He especially wants to draw attention to the work in the evacuation hospitals, which he thought ideal examples of work done under field conditions. He noted with great satisfaction the excellent organization to bring home the wounded, and another thing, the very high level of cultural standing and education. He would welcome a discussion with a member of the organization or with General Hawley himself. Any questions which arise on his own medical service, he will be willing to discuss with your representatives. In conclusion, he thanks you very warmly and wishes everybody the greatest success.

General Hawley, replying for the consultants, said through the interpreter: "It has been a great pleasure to have him with us. He will be welcome in our service, not only as an ally, but as a member of the [consultant] group and we wish him to feel that he can come at any time and be quite welcome."

Immediately after this meeting, Colonel Cutler accompanied the Chief Surgeon to England, where he followed up further the reorganization of hospitalization in the United Kingdom under the seven groups of hospitals, the selection of personnel to staff the contemplated hand centers, and the studies on delayed early suture of wounds being conducted at the 91st and 158th General Hospitals. Colonel Cutler also planned with Major Palmer to turn over the facilities of the Operational Research Section to the Army Air Forces so that, the theater commander permitting, the personnel of the unit could be reorganized to conduct casualty surveys of battle casualties occurring during ground warfare.

An Extremely Busy November

Hospitals and hospitalization

On returning to the Continent, 2 November 1944, and for much of the entire month, Colonel Cutler and his surgical consultants were particularly busy on various aspects of hospitalization. New general hospitals were arriving in numbers-hospitals with a dearth of well-trained personnel. In the last week of October and the first of November, eight new general hospitals had been completely evaluated and oriented on the Continent. Major Robinson, Senior Consultant in Urology, and Lt. Col. Rudolph Schullinger, MC, borrowed from the 2d General Hospital, had to be used to go over some of these hospitals. Eleven new general hospitals had just arrived or were scheduled to arrive immediately in the United Kingdom and were destined to be employed on the Continent if and when their personnel could be strengthened to the required professional standards (fig. 104).


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FIGURE 104.-The 194th General Hospital arriving in Paris, France, in January 1945 to establish facilities at Lycée Claude Bernard.

At the same time, a new table of organization and equipment had been published by the War Department which cut down medical officers in general hospitals by five, and all general hospitals in the theater had to be readjusted accordingly. Lt. Col. (later Col.) Norton Canfield, MC, Senior Consultant in Otolaryngology, immediately called attention to the fact that this new table of organization and equipment gave the rank of captain to the otolaryngologist in a general hospital. This was an impossible situation, for most of the theater's otolaryngologists were already majors, and it was soon to become painfully obvious that very few of the junior medical officers were willing to take on the position of the ENT (ear, nose, and throat) officer in a general hospital with the certain prospect of spending the remainder of the war as a captain while their associates could look for advancement in other areas.

Further to complicate matters was the fact that continued offensive actions against the Siegfried Line were now being felt in the form of overcrowded hospitals in the communications zone (fig. 105). Moreover, the uniformly bad weather throughout November curtailed seriously all forms of evacuation, but particularly air evacuation in the United Kingdom.


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FIGURE 105.-The Siegfried Line. A. Miles of concrete antitank defense works. B. A heavily fortified pillbox taken over for an aid station by American troops.


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Reestablishment of Blood Bank, ETOUSA - On 3 November, the day following his return, the Chief Consultant in Surgery visited Vitry-sur-Seine where the 1st General Hospital was being established. He noted that it was going to be well housed and that the buildings would be quite satisfactory for a hospital. He recommended that one of the newly arrived hospitals, or a part thereof, be attached to the 1st General Hospital to operate a total combined bed capacity of from 1,500 to 1,800 beds. Colonel Cutler was most pleased to note that the 152d Station Hospital, the ETOUSA Blood Bank, was finally operational here. He noted:

* * * The Blood Bank is occupying a wing of a large building there and is admirably adapting these quarters to its purposes. This has meant a great deal of construction, plumbing work and other renovations, but all this has been accomplished by the personnel of the 152d Station Hospital, which is greatly to their credit. The first blood was drawn in Paris today, and it was being processed this afternoon when we were there.

Limitation of professional missions assigned to hospitals on Continent.-On 6 November 1944, the following words of caution and advice were given in a memorandum to Colonel Kimbrough by the Chief Consultant in Surgery:

It is clear, from our analysis of the hospitals which have recently arrived on the Continent * * * that these hospitals cannot be brought up to any reasonably professional standard so that they may act as general hospitals. We do not have qualified personnel to accomplish what is desired.

With this fact established, we must not use such hospitals as general hospitals, for we would then be responsible for both mortality and morbidity figures of which we would be ashamed.

This brings up a great principle, that hospitals should not be assigned to professional tasks beyond their competence, and that, when hospitals are assigned by Operations Division, that assignment should be coordinated with the Professional Services Division in order that reasonably safe care be given to the American soldier.

As to the eight new general hospitals, Colonel Cutler universally recommended that they be utilized to augment the bed capacity of an already existing and competent general hospital, thus making use of the superior officers in these older hospitals in supervising the work of the less able personnel of the new. The Chief Consultant in Surgery recommended that, if they could not be employed in this manner, these new general hospitals be used as holding hospitals or convalescent hospitals-missions within limits of their professional competence-to replace the more competent hospitals which, in spite of the protests of the consultants, were still being wasted in performing these missions when their abilities were sorely needed elsewhere.

Colonel Cutler spent the entire day of Tuesday, 7 November, as well as the previous afternoon, with each of the field army surgeons and members of the Supply Division, Office of the Chief Surgeon, in formulating recommendations for changes to the tables of organization and equipment of field hospitals and 400-bed evacuation hospitals.


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Observations at the 62d General Hospital - Colonel Cutler paid a routine visit to the 62d General Hospital the next day, Wednesday. He made the following two extremely significant observations:

At this hospital the first patient with a Blakemore tube had been admitted some days before. Apparently the femoral artery was severed, patient was seen first at the 8th Field Hospital, operated upon by Major [Charles A.] Rose of the 91st Evacuation Hospital and a Blakemore tube was put in the upper femoral region where some 2 inches of femoral artery had been removed. The patient arrived at the 62nd General Hospital in A 1 condition with perfect circulation in his feet, though no palpable pulse. This is the first instance of the proper and satisfactory use of this tube in the U.S. Forces.

A good many men are being admitted with "cold feet." All have about the same experience, that they have been in foxholes full of water for about 4 days, their feet feel sore, they take off their shoes and their feet swell so rapidly they cannot get the shoes on again. This is the condition I studied with the Fifth Army in Italy a year ago. At that time it was recommended that the American soldier be given socks with more wool in them, and that our soldiers should be encouraged to use larger shoes. This is going to be a heavy problem this winter unless very active steps are taken to prevent the disaster. In order to facilitate the studying of these soldiers with cold feet we must have thermocouples for registration of skin temperature. These have been ordered from Supply, and also it would be wiser if we set up a center at one of our general hospitals to concentrate on the problem. This is now being integrated in the Professional Services Division.

Newly arrived general hospitals in United Kingdom.-On Sunday, 12 November, Colonel Cutler flew again to the United Kingdom where, the next day, he held a conference with Colonel Morton, Colonel Tovell, Colonel Bricker, Colonel Cleveland, Colonel Kneeland, and Colonel Stout. He discussed with them the newly arrived general hospitals and the procedures which would be necessary to bring them up to usable standards. It was decided that Colonel Cleveland and Colonel Tovell would begin the very next day to "vet" each of them to determine first the numerical deficiency of these hospitals in professional personnel and to note the specific inadequacies from the professional point of view so that detailed recommendations could be made to Colonel Spruit as to: (1) the total number of medical officers necessary to bring the units up to strength and (2) the specific professional requirements to meet these deficiencies. They agreed also that all the operating general hospitals in the United Kingdom would have to be evaluated according to the new tables of organization and equipment so that the number and type of excess officers in these hospitals could be presented at the same time to Colonel Spruit with the requirements for the newly arrived units.

Sometime later, after all these new hospitals had been "vetted," there was the surprising revelation that their professional personnel were of a considerably higher caliber than had been experienced in newly arriving hospitals for a long time. Most of them were adequately covered in medicine and surgery, with only occasionnal shortages in pathologists, neuropsychiatrists, and X-ray personnel. None of these hospitals, just as it was true of those which had been "vetted" earlier on the Continent, had otolaryngologists.

Expedition of priority cases - At the meeting of the Chief Surgeon's Consultants' Committee on 27 October (pp. 273-275), the need for specialized


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treatment facilities to care for severely damaged casualties had been discussed. Casualties in this category included neurosurgical, maxillofacial, thoracic surgical, urological (with neurological complications), and severely compounded fracture cases. Examination of a great number of seriously injured fracture cases during the time Colonel Cutler was in the United Kingdom, from 28 October to 2 November, had revealed that it was taking 10 days for them to reach the United Kingdom. These were the type of casualties who were supposedly being given the highest priority in evacuation to the United Kingdom, since skeletal traction for the reduction of fractures had to be initiated early. It was obvious, therefore, that the seriously damaged casualty was not reaching the United Kingdom soon enough for the initiation of reparative procedures. "We must not equivocate about this," Colonel Cutler had warned in a memorandum, dated 6 November, to Colonel Kimbrough, "Either we evacuate early * * * or we give up that hope * * *."

As a result of these warnings, a meeting was held on 17 November 1944 attended by Colonel Kimbrough, Colonel Mowrey (Chief, Evacuation Branch, Operations Division), Col. Robert E. Peyton (Chief, Operations Division), Colonel Cutler, and Col. William S. Middleton, MC. The meeting was called, as the Chief Consultant in Surgery reported later, to arrive at a decision on two questions: "Should we still hope for early rapid evacuation to the United Kingdom which would permit us to get patients to our centers for specialized care in the United Kingdom * * * within 5 days, or should we not struggle against the weather and set up some centers to cover periods of bad weather on the Continent?"101

It was agreed that centers for the care of craniocerebral, thoracic, and maxillofacial injuries should be set up on the Continent at each of the large concentrations of activities in the communications zone; that is, Paris, Liége, and Nancy. The Paris hospitals, of course, were already staffed to take care of patients in these categories. The conferees agreed, too, that airlift should continue to be used whenever it was possible to evacuate these casualties to the United Kingdom within 5 days following injury. They thought that criteria would have to be established as to what type of cases should be selected for admission to these continental centers for specialized treatment. Less seriously wounded patients could be cared for in other available hospitals. Colonel Cutler also thought that such a directive should specify how long patients could remain in these facilities for specialized treatment, and it was his impression that 14 days should be the limit.

Southern Lines of Communication becomes part of ETOUSA

Operational control of the Seventh U.S. Army, advancing through southern France for a link with ETOUSA forces to the north, had passed to the European theater in September (fig. 106). As of 20 November 1944, the

101Memorandum, Chief Consultant in Surgery, to Chief, Professional Services Division, 21 Nov. 1944, subject: Meeting re Care of Patients on Continent.


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FIGURE 106.-Higgins boats bringing casualties of the Seventh U.S. Army to U.S. Army Hospital Ship Shamrock during the assault on beaches of southern France, 17 August 1944.

support areas in southern France for this force were to become a part of the Communications Zone, ETOUSA. The overall communications zone command for this area was called SOLOC (Southern Lines of Communication), and its surgeon was Col. Charles F. Shook, MC (fig. 107). Colonel Shook, with his deputy for administration and personnel, Lt. Col. James T. Richards, PhC, arrived for conferences with members of the Office of the Chief Surgeon, ETOUSA, on 15 November 1944 to effect a smooth changeover of command insofar as medical activities were concerned. Colonel Cutler, who was in England at the time arranging for the "vetting" of the 11 newly arrived general hospitals, also returned to the Continent on 15 November, and spent most of 16 November participating in conferences with the SOLOC surgeon. In a memorandum to the Deputy Chief Surgeon, dated 17 November 1944, Colonel Cutler stated that the following items were of pertinence to the Professional Services Division of the Office of the Chief Surgeon:

1. Technical correspondence with units in SOLOC was to be routed through the Surgeon, SOLOC.

2. The same evacuation policy was to apply to SOLOC as to the remainder of the Continent; namely, 30 days in SOLOC hospitals, patients requiring


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more than 30 but not over 120 days to be evacuated to the United Kingdom. (The 120-day evacuation policy for the entire European theater had just been proclaimed in mid-October 1944.)

3. SOLOC had 14,000 beds, 5,000 of which were in Marseilles. With expansion, SOLOC bed capacity could be raised to 22,000 beds.

4. The Surgeon, SOLOC, stated that his hospitals expected to hold seriously injured casualties-neurosurgical, thoracic, and maxillofacial-until they could be evacuated to the Zone of Interior, but Colonel Cutler expressed his views in the matter as follows: "I am sure this will need elaboration by a personal visit of the Consultant Group to SOLOC."

FIGURE 107.-Col. Charles F. Shook, M.C.

As for consultants, Colonel Shook assured Colonel Kimbrough and Colonel Cutler that he would like the advice of the consultants in European theater headquarters in setting up SOLOC consultants in medicine and surgery and any of the other specialties, as required, and also regional consultants according to the ultimate disposition of hospitals in SOLOC. Colonel Shook suggested that the qualifications of Col. Ira A. Ferguson, MC, be looked into for the position of surgical consultant to SOLOC. Colonel Ferguson was now at the 43d General Hospital as assistant chief of the surgical service, and Col. Edward D. Churchill, MC, had assured Colonel Cutler that he was qualified to be chief of surgery in a general hospital. Colonel Cutler did not want to commit himself on this item at the time, and Colonel Shook agreed to delay his appointment until Colonel Cutler could visit SOLOC. Finally, Colonel Shook stated that he would prefer not have any visit by European theater consultants until at least December, as they were just getting settled and could carry on until then with their existing service.


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Cold injury studies

As cold injury continued to be a growing problem during November and it was apparent that knowledge of the conditions being observed was too scant even to estimate the degree of damage or possibilities of repair, the consultants agreed that a concerted effort to study the condition was needed. The Chief Surgeon agreed, and the 108th General Hospital was selected for the mission. Capt. (later Maj.) Octa C. Leigh, Jr., MC, who had considerable experience in the field, was reassigned from the 16th Station Hospital to the 190th General Hospital and then placed on temporary duty at the 108th General Hospital to take charge of the studies. About this time, Maj. Leiv Kreyberg, Royal Norwegian Medical Corps, joined Captain Leigh in this project. Colonel Cutler took it upon himself to arrange for the procurement of skin temperature thermocouples, Quinizarin, through Burroughs, Wellcome & Co., capillary microscope, Novocain (procaine hydrochloride) in oily solution for sympathetic blocks, and Diodrast (iodopyracet) to demonstrate vascular adequacy. Colonel Tovell promised to find a skilled anesthesiologist to perform the sympathetic blocks for the study group, and all the consultants were asked to contribute their ideas and knowledge toward solution of the problems which cold injury was presenting.102

Activities and Situation at Year's End

Second Inter-Allied Consultants' Conference

Colonel Cutler had met with Brigadier (later Maj. Gen.) E. Phillips, RAMC, and General Hawley on 6 November 1944 in the Chief Surgeon's Office to discuss the next meeting of British and American consultants. Brigadier Phillips represented the British 21 Army Group and was soon to become its DMS. It was decided that the next meeting would be held in Brussels at Rear Headquarters, British 21 Army Group. Because the number of guests would have to be limited, the American advised Brigadier Phillips that the essential people would be the consultants in medicine and surgery from each of the four U.S. field armies and those of British and Canada, the consultant group in the Office of the Chief Surgeon, ETOUSA, and representatives from the consultant group of the DGMS, British Army.

Plans for the meeting proceeded without complications, and Saturday, 9 December, found Colonel Cutler on the road to Brussels with Colonel Tovell, who was also scheduled to speak. They arrived in Brussels at 1830 hours.

The meeting of consultants was held at the British 8th General Hospital beginning on Sunday morning, 10 December. Major General Phillips opened the conference saying that he hoped the meetings would continue and that the

102Minutes, Twenty-Fifth Meeting, Chief Surgeon's Consultants' Committee, Paris, 24 Nov. 1944.


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pooling of ideas by the Allies was essential to success. Colonel Cutler's official diary account of the first day's meetings follows:

The first professional topic was chest wounds, opened by Major Collis, RAMC. He mentioned infection as a major item, a surprise to us, since at one of the chest centers in the United Kingdom Major Harken has written that no cases of serious empyema have occurred. Major Collis thought penicillin of little value except when instilled in the pleural space. The next topic was "Penicillin," opened by Colonel Mitchell, RAMC. The British use the intramuscular drip method, 100,000 units in 24 hours in 540 cc. of salt solution. They believe this maintains a satisfactory bacteriostatic level. He asked for a solution of a more satisfactory vehicle than sulfonamides, and he presented, as evidence of the great value of penicillin in abdominal wounds, the following statistics:- 

2,712 abdominal operations
2,307 with intraperitoneal damage
405 with extraperitoneal damage
759 deaths (27 percent)

There was a lively discussion of this matter. Since the U.S. Army showed similar or better statistics, and did not put penicillin in the abdomen, Colonel Mitchell's suggestion that intraperitoneal penicillin was of value failed to find general approval.

Colonel Cutler continued:

In the afternoon the medical and surgical sections met separately. The first afternoon topic was abdominal wounds, opened by Colonel Cutler. Colonel Cutler presented statistics showing the frequency of abdominal wounds in the A.E.F. 1917-18 was 1.1 percent and the fatality 66.8 percent. The figures for the First Army June 6-30, 1944, showed an incidence of 4.3 and a mortality of 21.2 percent. The 5th U.S. Army, 9 September to 12 November 1944, showed an incidence of 4 percent and a mortality of 22 percent. Finally, individual hospital reports were presented. 128th Evacuation Hospital, a mortality of 19.3 percent overall, but 10.7 percent postoperative mortality. 91st Evacuation Hospital, October report, shows 20 percent mortality, overall, and 12 percent postoperative mortality. Meanwhile, the Canadian I Corps Surgeon reported a mortality of 35 percent in August and September 1944, and the French figures for the Italian Campaign showed a mortality of 44.6 percent.

Obviously, more people with wounds of the abdomen are now reaching the surgeon, and of those who reach the surgeon in the U.S. Army an overall mortality is somewhere around 25 percent and the postoperative mortality somewhere around 12 to 15 percent. This improvement is perhaps more largely due to the fact that the surgeon of the day devotes more care to the general condition of his patient preliminary to the surgical ordeal. Colonel Cutler reviewed the care of the abdominal case from the time he is picked up in the field to his disposition in a general hospital. The low incidence of infection, possibly due to chemotherapy, was mentioned. The better treatment of shock was taken up in detail. The immobilization of abdomens after surgery was considered highly important, and decompression by indwelling catheters thought a great step forward. The separate treatment of small bowel and large bowel injuries was mentioned, and the group was urged to see that all left large bowel colostomies were made complete so that the faecal stream was entirely turned away from the buttocks. In the discussion, Brigadier Porritt wondered whether all abdomens should not be subjected to surgery. In rebuttal, it was stated that there was no point in operating upon hopeless cases, particularly when the surgeon's time might be better devoted to more important though less seriously damaged soldiers.

The final paper was presented in the surgical section by Colonel Tovell, on Anesthetics in the Field, and for this Colonel Tovell had prepared a mimeographed sheet revealing


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the percentage of different types of anesthesia according to the hospital in which they were used. Thus, intravenous anesthesia is the predominant anesthetic in U.S. Army hospitals, reaching as high as 39.5 percent, whereas local anesthesia reaches 30.9 percent and inhalation anesthesia only 7.06 percent. However, when we consider the field for work we find the field hospitals doing chests and abdomens and using inhalation anesthesia for 41.4 percent of their cases.

During the second day, 11 December, the surgical and medical consultants again met separately. Again, there were morning and afternoon sessions, but Colonel Cutler attended only the morning session where the principal speaker was the surgical consultant for the Third U.S. Army. Colonel Cutler gave the following brief description of this meeting:

In the morning the surgical group considered "Vascular Injuries," which was opened by Colonel Odom, Third U.S. Army. He presented the overall figures for the Third Army and revealed that the number of cases in which arterial repair may be attempted is extremely small, sixteen out of 362 cases. He pointed out that 0.7 percent of 49,410 battle casualties had vascular damage to large vessels. 346 of these had simultaneous ligation of artery and vein and 50.7 percent of these came to amputation. The various vessels in which ligation had been carried out were specified, and again the grave danger of ligating the popliteal vessels was brought forward. The question arose as to whether the forward surgeon was not too conservative by not amputating limbs whose circulation was totally destroyed. It was pointed out that the figures for safe ligation in elective surgery might be entirely different in the arm where all the collaterals were blown out. No one said a good word for sympathetic block. The Canadians suggested that little glass tubes or a tube of plastic material might be utilized to recanalize injured vessels. All agreed that where a major vessel is ligated the patient must be held in the forward area for 4 to 6 days to see whether gangrene was to set in.103

After lunch, the delegates visited the British blood bank in Brussels where blood obtained from troops in and around Brussels was being processed for shipment forward. Colonel Cutler did not attend but spent the afternoon discussing the local situation with Professor Danis, professor of surgery at the university, and with Dr. Mayer, president of the Société Internationale de Chirurgie. There was particular concern about the future of the organization of which Dr. Mayer was president.

Trenchfoot was not an item on the agenda, for the British were having no great problem with ground-type cold injury, but there was considerable informal discussion concerning the matter. Colonel Cutler made the following entry in his diary concerning the discussion:

The total British figures were as follows:-21 British and 9 American soldiers have been treated in all of the British hospitals from the Invasion to December 1. General Phillips, commenting on this, spoke a) of the better footgear, noting that no constriction can occur because the two sides of the boot meet, so that the laces cannot make the shoe tight, and b) of better foot discipline as a command function. Brigadier Fenwick, who that night became Major General Fenwick and D.G.M.S. of the Canadian Forces, made the same comment.

103For a complete report on vascular injuries and vascular surgery in the Third U. S. Army, see the report entitled "Vascular Injuries in Battle Casualties" by Col. C. B. Odom. In Inter-Allied Conferences on War Medicine, 1942-1945, Convened by the Royal Society of Medicine (Sir Henry Tidy, Editor). New York, Toronto, London: Staples Press, Ltd., 1947, pp. 167-171.


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The Second Inter-Allied Consultants' Conference came to a close after the second day's meetings with a dinner given by General Phillips which was characteristic of the traditional British hospitality and spirit of camaraderie. Colonel Cutler wrote in his journal:

That night the D.M.S. gave a bounteous dinner for the Consultant Group. I had to sit between the DMS and Maj. Gen. Sir Miles Graham, Chief of Admin, 21 Army Group, and respond to General Phillips' kind words regarding the American Forces for General Hawley. I thanked General Phillips as best I could, intimating how much better General Hawley would have done it, and presented his deep regrets at being unable to attend. I then attempted to point out that this was the one time in the history of civilization when the English-speaking people should get together, since they are the only nations now functioning under free government.

Visit to Ninth U.S. Army

The next morning, Tuesday, 12 December 1944, Colonel Cutler and Colonel Tovell were joined by Lt. Col. (later Col.) Gordon K. Smith, MC, surgical consultant for the Ninth U.S. Army, in the drive to Ninth Army headquarters in Maestricht, The Netherlands. En route, they stopped at the 30th General Hospital in Antwerp, for lunch and a look at the installation. It was in nice buildings, but the utilities were deplorable and sewage was even running out onto the lawns. Colonel Cutler, Colonel Tovell, and Colonel Smith reached Ninth U.S. Army headquarters that evening. Col. William E. Shambora, MC, the surgeon, was away so they spent the evening discussing various professional matters-particularly necessary personnel shifts-with Lt. Col. Elmer D. Gay, MC, commanding officer of the 5th Auxiliary Surgical Group, and the other Ninth U.S. Army consultants. During the evening, buzz-bombs kept going over the headquarters, and Colonel Cutler surmised: "* * * Apparently they start on the German side of the line and on their way to Antwerp pass over Maestricht. They could not have been very high because the windows rattled every time they went over."

Colonel Cutler visited the Medical Section, Headquarters, Ninth U.S. Army, the next morning where he met some of the staff and learned that some 300 casualties had been admitted in the last 24 hours to Ninth U.S. Army hospitals. The remainder of the day was spent in visiting evacuation hospitals and one field hospital of the Ninth Army.

At the 108th Evacuation Hospital, Herzogenrath, Germany, Colonel Cutler learned that blood transfusion reactions were occurring about once in every ten transfusions. He recorded: "Initial chill, pressure fall, pulse becomes rapid, patient enters deeper shock, fever later. No haemolysis and no evidence of protein shock reactions. These are unquestionably pyrogenic reactions and probably due to improperly cleaned tubing. Plasma is giving the same type of reaction, again a pyrogenic reaction * * *." Tobruk splint experiments were being carried on at this hospital. The application of the splints seemed well done, and Colonel Cutler believed that Colonel Cleveland might be able to give an answer as to the efficacy of the Tobruk splint in another week or so.


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At the 11th Evacuation Hospital, Heerlen, The Netherlands, the Chief Consultant in Surgery was pleased to meet again Maj. William R. Sandusky, MC, who was chief of the surgical service, doing the thoracic surgery there with the help of a Captain Johnson, and conducting an intimate study of gas gangrene. Major Sandusky, the reader will recall, had conducted the excellent studies on penicillin and gas gangrene in air casualties while he was attached as a captain to the 49th Station Hospital in East Anglia. "The hospital," Colonel Cutler noted, "has an A.1 professional service. Well organized, perfectly integrated and entirely competent."

The 91st Evacuation Hospital in Valkenburg, The Netherlands, Colonel Cutler found, was located in a beautiful Jesuit college which could well do for a general hospital some day. The chief of surgical service was Lt. Col. Charles S. Welch, MC. Colonel Cutler recorded: "This was the best hospital we visited. There is an excellent spirit of cooperation between the professional services, administration, and the chief of the surgical service; Colonel Welch is one of our best forward surgeons. This is the officer who is to speak at the next meeting of the Inter-Allied Medical Conference on thoracic surgery in the forward areas. I briefed him for his talk, told him and his commanding officer I would clear his orders * * * for January 4 for 8 or 10 days." In a discussion of blood and plasma reactions, the hospital personnel stated that plasma reactions occurred with chills followed by anuria on occasions. In further discussion of anuria, Colonel Welch agreed that crush syndrome might play a large role.

Colonel Cutler and Colonel Smith also visited the 105th Evacuation Hospital and a platoon of the 48th Field Hospital during the day. Back at their quarters, Colonel Cutler and Colonel Smith conferred on matters to be discussed with Colonel Shambora the next day. And again, Colonel Cutler uneasily noted: "Four buzz-bombs just missed the top of the house. Apparently these missiles start not very far away from Maestricht and scare people on the way up, whereas in Antwerp they scare them on the way down (fig. 108)!"

At 0800 the next morning, Colonel Cutler and Colonel Tovell joined in conference with Colonel Shambora, the Ninth U.S. Army surgeon, and his surgical consultant. Colonel Cutler asked and obtained permission to have Colonel Smith accompany him on a visit to the neighboring First U.S. Army so that Colonel Smith could participate in additional conferences on professional matters with the surgical consultant of the First Army. The many proposed personnel changes were also explained and discussed. Colonel Cutler emphasized that such changes had to be initiated as requests from the field Armies. There was discussion on the desirability for evacuation and field hospitals furnishing monthly hospital reports so that they could be consolidated at the field army level and distributed to the army units as a part of the educational program. Colonel Cutler advised the army surgeon on his impressions of the hospitals visited. They spoke of the unusual position occupied by Lt. Col. John Gilbert Manning, MC, the Ninth U.S. Army orthopedic con-


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FIGURE 108.-Destruction in Antwerp, Belgium, following the detonation of a German V-1 rocket. U.S. Army medical units helping to care for civilian casualties.

sultant, since this was the only field army with an orthopedic consultant. Colonel Shambora explained that Colonel Manning operated under Colonel Smith, that he was useful, and that he would be kept in his position for the time being. Colonel Cutler promised to add Colonel Manning's name to the list of consultants so that he would be invited to attend and otherwise participate in activities of the theater's surgical consultants. Pros and cons for uniting the position of surgical consultant and the commanding officer of an auxiliary surgical group under one officer, as was done in the First U.S. Army, were brought up. The arrangement had worked well in the First U.S. Army. "I did not urge this," Colonel Cutler later wrote, "as I am not sure this is a desirable situation, and I agreed with Colonel Shambora that he had a good commanding officer for his group, i.e. Colonel Gay, and a high grade consulting surgeon, and he might do well to continue as he was." Colonel Cutler thanked the Ninth U.S. Army surgeon for the interesting and instructive visit to his units.

Following this meeting and before leaving the Ninth U.S. Army area, Colonel Cutler visited the 41st Evacuation Hospital where he had a pleasant visit on the wards and found a general feeling in the hospital that sympathetic procedures for vascular damage were of little value and that the Tobruk splint was not good.


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Alleur, Belgium

En route to the First U.S. Army headquarters, Colonel Cutler and his party stopped by in Alleur, Belgium-several miles out of Liége-for visits to the 298th General Hospital and the 93d Medical Gas Treatment Battalion.

298th General Hospital - Colonel Cutler was overjoyed at seeing many old friends from the days in England still with the 298th General Hospital, the affiliated unit from the University of Michigan and one of the first general hospitals to be sent to the European theater. Col. Walter G. Maddock, MC, the commanding officer, was on hand to greet the visitors and provide them lunch. The hospital was under tentage and Colonel Cutler noted: "* * * a general feeling in this unit that a good unit like this should be in permanent construction. I heartily agreed with this, and the same comment about too frequent moving of hospitals as came up in this hospital also came up at the 30th General Hospital in Antwerp and later at the 25th General Hospital in Liége."

In other discussions, it was brought out that 420 beds of this 1,000-bed hospital were set aside in a separate unit to be used as a holding hospital for air evacuation. The prevailing differences in opinion concerning the Tobruk splint were again evident here. Colonel Maddock thought it was more comfortable and easier to transport, but the orthopedic surgeon at the hospital felt the Tobruk splint was uncomfortable and that the half ring often rested on the perineum, causing difficulty. It was also said that gas gangrene had been very rare and that delayed primary suture was being accomplished on cases which, for some reason, had to be held for more than 5 days.

93d Medical Gas Treatment Battalion - Colonel Cutler found the 93d Medical Gas Treatment Battalion a unique organization. It was located at a zinc mine about 2 miles from the 298th General Hospital. Detachment B of the 12th Field Hospital was attached to it. He described what he saw, thus:

Colonel Palmer, who was so efficient at the Southampton Hard, is commanding officer. He has 600 beds, 300 stretcher cases and 300 walking wounded. The patients come to him from the Liége general hospitals, and may be held for as long as 4 to 6 days, according to the air lift. The patients are all flown back to the United Kingdom. If any patient seems too ill and requires specific therapy, he is returned to the general hospital from which he came. In 3 weeks this hospital had returned 7,680 patients to the United Kingdom. Colonel Palmer made the comment that general hospitals are slow in sending patients to the holding hospitals. It was my impression that this holding group had done a bang-up job * * *.

First U.S. Army

Discussions with members of 3d Auxiliary Surgical Group.-Leaving Alleur, the party motored to Spa, Belgium, and the headquarters of the First U.S. Army. General Rogers, the army surgeon, was away for the day, but, while the visitors were speaking with members of the medical section, Colonel Crisler arrived. Colonel Crisler billeted the visitors with his 3d Auxiliary


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Group and then took them to the group's mess. After dinner, Colonel Cutler led a discussion on various professional matters-informally and openly, as was his fashion.

One of the subjects discussed was trenchfoot. Statistically, the First U.S. Army had no cases as of 27 September; by 8 October, there had been 140 cases; and on 12 October, 320 cases had occurred. By that time, it had seemed wise to organize to meet this problem, and the 91st Gas Treatment Battalion had been set up as a center for the study of trenchfoot. Apparently, an ordinary triage was being accomplished in evacuation hospitals, and 75 percent of the patients were being evacuated out of the army area. The other 25 percent were sent to the gas treatment battalion, where, the discussion revealed:

Treatment was rest, repeated sympathetic blocks and later exercises. A summary of the sympathetic block work showed that the feet were more comfortable, but, using the other foot as a control, sympathectomy proved to give no additional benefit. Pressure bandages were tried with no benefit. Finally, exercises were tried, and these seemed to bring some benefit. After 10 days in this specialized hospital, troops were sent to the convalescent hospital, but only those with no evidence of disease. There they were refitted with larger shoes, given exercises, and by 20 days 80 percent were returned to duty. In analyzing one thousand cases, the following occurs:-At the divisional level, 20 percent, i.e. 200 cases, returned to duty as having had a mistaken diagnosis, i.e., just cold feet. Of the 800 left, 75 percent go to a general hospital and 25 percent to the Gas Treatment Battalion for specialized care and treatment. Of those who go there, 25 percent are returned to general hospitals and 75 percent via the 4th Convalescent Hospital to duty. This makes a total of about 30 percent of the originally diagnosed trenchfoot cases to duty. I brought up the matter, for insertion in their trenchfoot circular, that tetanus toxoid should be given when the skin is broken, as also penicillin or sulfonamide for infection.

There then followed a long discussion of the benefits which had accrued in sending medical officers from combat units to hospitals in the base sections, either on the 60-day temporary duty exchange program or on the short-visit policy. Colonel Crisler pointed out that the greatest advantage had to do with records, for the men in the forward areas had found out how poor the records were which came down to the base areas and that it was not possible for surgeons in communications zone hospitals to do intelligent work without adequate records. It was also asserted that these tours of duty in the communications zone revealed to the medical officers, who were characteristically initiating reparative treatment of the battle casualty, the dangers involved when he failed to split his cast or when he plugged wounds too tightly.

All were in agreement that new circular letters should be written stressing the fact that abdominal retention sutures should not be removed until after evacuation, explaining the difference in right and left colostomies, and detailing the latest information on the surgery of major blood vessels. There was the inevitable discussion on shortages of certain personnel and requirements for changes in specialized personnel. Very satisfying to Colonel Cutler were remarks made by both Colonel Crisler and Colonel Smith that one of the greatest boons to surgeons in medical facilities of the field army were the anesthesiologists supplied by Colonel Tovell. In his official journal of the visit, Colonel


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Cutler remarked: "This may be taken as almost a personal triumph for Colonel Tovell, who has worked indefatigably in his special field and now is reaping a rich and well deserved harvest."

Hospital visits -The next morning, 15 December, the Chief Consultant in Surgery was up early and visiting hospitals of the First U.S. Army. At the 2d Evacuation Hospital, he was happy to see again old acquaintances from the early days in England and had a long visit with Colonel MacFee. Colonel Cutler and Colonel MacFee were in complete agreement on the following points:

1. Vascular surgery -Plastic tubes, over which suture could be done, might be better than the Blakemore tubes presently in use. If a vessel is ligated, it must be divided. All hospitals should make a definite assignment as to who should do the vascular surgery.

2. Abdominal surgery -For left side procedures involving the large bowel, complete diversion of the fecal stream is desired; for the right side, an exteriorized opening is preferable. If the small intestine is damaged, it should be closed and not left as a separate opening. For combined head and abdomen casualties, the abdomen should be done first and the head later, by the 5th day, and preferably under local anesthesia.

3. Delayed suture should be practiced in evacuation hospitals if the patient must remain for an appreciable period of time before being further evacuated.

Colonel Cutler also asked Colonel MacFee if he would like an appointment as surgical consultant for the Fifteenth U.S. Army, a new field army, the headquarters of which had recently arrived in England. Colonel MacFee was favorably inclined toward such an assignment.

Elsewhere during the day, Colonel Cutler visited the 45th, 128th, and 96th Evacuation Hospitals and the 13th Field Hospital. On the whole, he found excellent work being done in these facilities and thoroughly competent surgical services. He found that a team from the 3d Auxiliary Surgical Group attached to a field hospital platoon consisted of one surgeon, two assistant surgeons (one for shock work), one anesthetist, and four corpsmen. The nurses, he found, were attached separately-four at a time-to a field hospital platoon from the group. This permitted two for night duty in the operating room and two for day duty. It had proved better than having nurses assigned directly to teams. There were reports that plasma reactions had been mild, and blood transfusion reactions were mostly of the pyrogenic type. It was the consensus in these hospitals that the European theater blood from England had given chills; the European theater Paris blood was full of clots; and the Zone of Interior blood was better, in that fewer reactions occurred, but contained too few red cells in relation to fluid for casualties in severe shock.

Meeting with First U.S. Army surgeon and departure - On Saturday, 16 December, Colonel Cutler visited at length with General Rogers, the First U.S. Army surgeon, after earlier conferences with the chief of personnel in the Medical Section, Headquarters, First U.S. Army. General Rogers approved Colonel MacFee's transfer to the Fifteenth U.S. Army, if this were desired,


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and he favorably considered all of the personnel changes which had been conditionally agreed upon and coordinated with General Rogers' personnel officer. Finally, Colonel Cutler wrote: "I told General Rogers that such visits, particularly when two army consulting surgeons could be together with me, were of the most valuable and instructive type, and thanked him for the courtesies extended." Just as Colonel Cutler was concluding his meeting with General Rogers, reports arrived that Malmédy and Eupen in Belgium were being hard hit by what was supposedly a new weapon, and the decision was made to pull the 44th and 67th Evacuation Hospitals out of Malmédy.

On his return to Paris, Colonel Cutler visited the 25th General Hospital at Liége and Headquarters, Advance Section, Communications Zone, at Namur, Belgium. He reached Paris at 2300 hours that night.

Comments to Chief Surgeon on trip to Brussels  and to First and Ninth U.S. Armies

Upon returning to Paris, Colonel Cutler provided the Chief Surgeon a copy of his journal describing his recent trip to Brussels and the First and Ninth U.S. Armies. The Chief Consultant in Surgery, in a cover memorandum, dated 19 December 1944, forwarding the journal of the trip, called certain important aspects of his visits to General Hawley's attention. One of the items which pertained to the Seventh U.S. Army, follows:

*    *    *    *    *    *    *

b. From the Seventh Army Consultants, while in Brussels, I found a sincere regret that members of the Professional Services Division, ETO, had not paid them more visits. I am afraid that we were scared off by a quotation from a letter from Colonel Rudolph (Seventh U.S. Army Surgeon) to Colonel Liston which Colonel Kimbrough circulated in the Professional Services Division, the following being quoted:- 

"The commanding general issued instructions a long time ago to the effect that he expected potential visitors to be 'cleared' before their arrival in his area. On more than one occasion the chief of staff has personally questioned me as to the necessity and desirability of a proposed visit by some member of the medical section of a higher headquarters, and often inferring that the medical people were the worst offenders. In addition, the commanding general has severely pruned our headquarters throughout, and when he visits the section he always wants to know exactly who each one is and what they are doing."

Colonel Berry wanted to know whether we really were ETO consultants, which hurt a little bit. I had asked Colonel Kimbrough to run down the source of the quotation above, because no one from this office had visited the Seventh U.S. Army, except Colonel Middleton, and I am quite sure he gave no offence. This office took deep offence to the quotation from the letter, and therefore had not visited the Seventh Army. I expect to in the near future, unless Colonel Liston or you object to this.

Concerning Lt. Col. (later Col.) Gordon K. Smith of the Ninth U.S. Army, the Chief Consultant in Surgery advised the Chief Surgeon:

*    *    *    *    *    *    * 

c. I would like to commend Lt. Col. Gordon Smith, Consultant to the Ninth U.S. Army. It is my impression that he knows more about the personnel in his field and evacuation hospitals than any of our army consultants. I told this to Colonel Shambora, and am in the hope that he will take steps to eventually elevate his rank to that held by the other army consultants.


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Colonel Cutler reported the following concerning the general hospitals he visited:

*    *    *    *    *    *   *

3. Finally, and very important, I sensed in our general hospitals a deep sense of bitterness about the irrelative uselessness, as they put it. This turned up in the 30th, 298th, and 25th General Hospitals. Most of our good hospitals have the feeling that they have excellent personnel which has not been used. It is hard to counteract this, for they were stabled long before D-day, then acted as transit hospitals without a chance for real professional work, and are still acting as transit hospitals, or, as are the 25th, and 30th, stabling again. Apparently they are to act as transit hospitals again, and do not, therefore, have the opportunity to use their full professional talent. I have been consistently loyal in support of the movements dictated by this office. I find it extremely difficult to continuously support what from time to time seems to me not to be the best use of highly trained professional talent. Perhaps we can stabilize some of our good units soon and let them do high grade professional work for the good of the American soldier. I fully appreciate the flux and flow necessitated by the military situation, but I am equally sure that our good units could be put in places where they could carry on high grade professional work, and less good units could act as transit hospitals, under the present circumstances.

To Colonel Liston, Deputy Chief Surgeon, the Chief Consultant in Surgery addressed a terse and poignant note on 19 December, as follows:

In view of your interest in obtaining suitable transport for the consultants, you will be interested to know that the army consultants at Brussels arrived in nice big Packard Sedans, while the ETO consultants came in jeeps and command cars!104

New directives 

During these first few months on the Continent, the consultants had been able to observe more directly and frequently a variety of medical treatment facilities, practices, and conditions. There had been many opportunities to discuss these observations with their fellow American medical officers and the medical officers in the services of the Allies. The initial implementation of new ideas or changes in thought concerning past practices had been carried out to considerable extent by personal contact with consultants in the subordinate echelons or through corrective action on the scene. But changes in policies and procedures could only be thoroughly implemented by directive, and many directives on professional matters were published toward the year's end as a direct result of earlier experiences during this period on the Continent.

Additions to directive on care of battle casualties - One of the first directives to be published was Circular Letter No. 131, Office of the Chief Surgeon, ETOUSA, dated 8 November 1944, a supplement to Circular Letters No. 71 and 101, previously discussed, pertaining to the care of battle casualties. This was sorely needed, especially as it pertained to the care of fractures. Accordingly, the bulk of the directive concerned the treatment of wounds of bones and joints which was worked out by Colonel Cleveland working closely with the other senior consultants, the surgical consultant of the United

104Not all consultants arrived in Packard sedans. Col. Frank B. Berry, MC, Consultant in Surgery to the Seventh U.S. Army, arrived in an open command car. Consultants to the field armies routinely traveled in jeeps and command cars.-J. B. C., Jr.


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Kingdom Base, and the Chief Consultant in Surgery. The portions pertaining strictly to orthopedic surgery have been reproduced elsewhere in this history.105

Under the section dealing with the treatment of wounds of bones and joints was also a subsection detailing policies and procedures to be observed in the care of injured hands. Earlier reference was made to efforts by Colonel Cutler and his subordinate consultants to establish special facilities for the adequate treatment of injuries to the hand. In this directive, emphasis was placed on early closure of fractured hands by secondary suture or skin graft and the insistence of active motion as early as possible. "Amputations of hands or fingers," the directive cautioned, "should be performed only where there is no possibility of restoring some useful function or when circulatory loss has resulted in complete necrosis of the part." The directive emphasized: "* * * an upper extremity prosthesis is not in any sense to be considered as an adequate substitute for a hand." As a measure further to implement these policies, a list of hand centers which had been established in the United Kingdom was prepared by Colonel Cutler, Colonel Morton, Colonel Cleveland, and Colonel Bricker for promulgation within the United Kingdom Base.

Circular Letter No. 131 also directed special measures to be observed in handling neurosurgical problems, in the care of the bladder in patients with spinal cord injury, in the care of injured nasal mucosa, in the management of colostomies, and in whole blood transfusions. In addition, this circular letter contained notes on radiology, and precautionary measures with respect to the condition of patients evacuated to the Zone of Interior. With respect to colostomies, the circular letter warned against a too short, approximated septum in the formation of a double-barreled Mikulicz colostomy and a too large initial opening in the loop type of colostomy. The directive also encouraged the closing of colostomies as soon as the wound was free from infection and the local edema of the bowel had subsided and before the patient was evacuated to the Zone of Interior. The directive called attention to the fact that many cases could be returned to duty in the theater.

Whole blood and transfusion - Colonel Cutler, at the October meeting of the Chief Surgeon's Consultants' Committee, had mentioned that a new directive would be published defining transfusion reactions and stating what to do about them. This was accomplished by Administrative Memorandum No. 150, issued by the Office of the Chief Surgeon, under the dateline of 27 November 1944. The directive accepted the fact that reactions were bound to occur in the great number of transfusions being carried out. It dispelled major concern over allergic or pyrogenic reactions. For the relatively rare case in which bronchospasms occurred as an allergic reaction, the directive called for relief of the symptoms by subcutaneous injections of an Adrenalin (epinephrine) solution or intravenous administration of aminophylline. Hemolytic

105Medical Department, United States Army. Surgery in World War II. Orthopedic Surgery in the European Theater of Operations. Washington: U.S. Government Printing Office, 1956, Appendix A.


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reactions, the directive recognized, were not common but were to be feared because death could result from hemolytic shock or uremia following renal damage. The administrative memorandum directed:

Hemolytic reactions must be treated immediately and vigorously if survival of the patient is to be expected. Immediately upon the appearance of the symptoms of hemolytic shock the transfusion must be discontinued. Almost all patients will recover spontaneously when this is done. However, in patients with deep shock another transfusion of compatible blood should be started. All patients exhibiting hemolytic shock must be immediately alkalinized * * *.

The administrative memorandum also called for a report from each fixed hospital showing the total amount of blood given during any one week and the number of reactions encountered broken down into six subordinate categories. Fearing that the reporting provisions might be eliminated, Colonel Cutler, in forwarding the draft for publication, justified the reporting requirement on the basis that transfusion reactions were a prevailing problem and that good data were necessary if anything sound and constructive were to be done about the situation.

Equally important to the issuance of a directive is the followup to ensure compliance with it. With respect to the matter covered in the directive under discussion, Colonel Cutler, before the end of the year, was able to call attention to significant progress in following up the problem. At the Twenty-Sixth Meeting of the Chief Surgeon's Consultants' Committee in Paris on 30 December, he announced: "We have been quite disturbed about reports of reactions in patients who had received blood. Major Hardin has been up forward, and has come back with information on that." Major Hardin then explained:

This report [the report called for by Admin. Memo. No. 150] that we have compiled has been very useful in making up our minds as to what is going on. Out of 3,741 transfusions that were given, 188 reactions of all types occurred. These were 3.7 percent pyrogenic and .48 percent hemolytic. That is high. It is four times as high as what we would like to see. I find that there is a lot of misinformation on how to distinguish between hemolytic and pyrogenic reaction. I pointed it out. It is very easy. All you do is draw 5 cc. of blood from the patient and spin it in the centrifuge. If the plasma is pink, you know the patient has had a hemolytic reaction. If not, you know he didn't. They were signing out a good many patients as hemoglobinuric nephrosis; patients who had died with anuria. When you go through their histories, you often find that anuria was present when they came to the hospital. Because the patient never put out any urine, they felt that the blood had killed the patient. The cause of this anuria has been discussed, and some think that in part it has been due to blast and in part to the shock and other people thought that there was something * * * due to alkalinization. The more we learn of patients not putting out urine, the more I am inclined to believe that it is not due to blood. There were some people who were giving patients 4,000 cc. of blood and then when they had a little febrile reaction, they read the directions and saw that they were supposed to have a 3,000 cc. intake, so they gave them 3,000 cc. of fluids more. This is particularly true in patients in whom anuria is found. Now, I am personally well satisfied with this reaction rate. I think it is pretty low, considering everything.

I found errors in hospitals in handling blood. In the attempt to lower this rate more, there has been started a program to raise our own requirements about the handling of blood and sets. We are ready to go over that now.


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FIGURE 109.-A delivery of whole blood under freezing conditions, 16th Field Hospital, Boulaide, Luxembourg, 29 January 1945.

The other thing which we have done: we have learned that blood coming from the States is not inspected before it leaves the States. We have set up an inspection system here. It is inspected before it is distributed.

We warned all of the advanced blood banks about taking full care of the storage of blood, because we were running into danger of freezing of blood, even in refrigerators (fig. 109). We have asked for some ambulance heaters, and we are actually going to have to heat some of it. We found at least one unit that was warming blood before transfusion.

General Hawley was greatly pleased with this summary of the situation by Major Hardin. "That is all very enlightening, and it is very comforting," the Chief Surgeon said, "because these people howl, and I am glad we have something to howl back with. I suspected that this anuria point was due not to the blood itself." The Chief Surgeon then attributed to Stonewall Jackson, who, he said, was a man of very few words, the following statement: "I can guard against everything but the stupidity of my assistants." Paraphrasing this quotation, the Chief Surgeon alerted the consultants, saying: "You are in the same situation. You can guard your blood and use all precautions, but you can't guard against the stupidity of the people who are sometimes using the blood."

Professional care on hospital trains - Supervision of professional care on hospital trains was effected by periodic checks at opportune moments. Since Major Robinson's trip on a hospital train movement, described earlier, there had been a notable incident wherein a general hospital had turned over to a hospital train a patient with dry gangrene of the hand because of a wound above the elbow. This was done with the expectation that it would be better professional


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care to let the line of demarcation be settled by time rather than to amputate early. To the consternation of everyone, the surgeon on the hospital train had proceeded immediately to amputate the extremity. On another occasion in mid-November, a hospital train had been loaded with serious casualties far up in the Third U.S. Army area. These casualties were to travel all the way to the port of Cherbourg through Paris for further evacuation to the United Kingdom. They were being sent by rail owing to the uncertain air evacuation situation. Colonel Cutler had sent Colonel Bricker and Colonel Canfield to "vet" the train when it arrived at Paris and had instructed them to use their judgment in supervising the removal of any casualties who could not reasonably continue through to Cherbourg. Colonel Cutler had gone to the 48th General Hospital the next day to inspect cases removed from the train, while Colonel Bricker had gone on with the train to Cherbourg.

Mindful of the dictum by the Chief Surgeon that professional care during transit was equally important with professional care of patients in hospitals, Colonel Cutler had conferred with members of the Evacuation Branch, Operations Division, Office of the Chief Surgeon, following Colonel Bricker's return from Cherbourg. As a result of this conference on care provided during hospital train movements, and in the light of observations that had been made from time to time, Colonel Cutler on 25 November submitted to the Office of the Chief Surgeon a memorandum containing a proposed circular letter concerning professional care on hospital trains. The proposed directive urged the continuous sorting on trains of the seriously ill from those who could travel further without detriment to their recovery. It described the types of casualties that would require special care and have to be removed at the first opportunity. It specified where certain categories of injuries would have to be detrained in order that they could obtain proper therapy. The proposed directive closed by giving suggestions on the care of immobilized patients in transit on hospital trains (fig. 110).

Since the scope of the directive pertained only to hospital train units, a limited portion of the theater's medical service, and since all hospital trains were directly under communications zone control, the directive was published, on 9 December 1944, as a command letter from the Office of the Surgeon, Headquarters, Communications Zone, ETOUSA, to commanding officers of all hospital trains on the Continent.

Guidance to disposition boards - On 5 December 1944, Colonel Cutler submitted two directives for publication. One pertained to changes in a previous directive giving guidance to disposition boards and the other delineated hospitals established on the Continent for specialized treatment. Shortly before the invasion, Colonel Cutler had convinced the Chief Surgeon that some sort of a yardstick was necessary to serve as a guide to hospital disposition boards for the early determination and selection of patients to be evacuated to the Zone of Interior (p. 190). The previous directive had been published when the 180-day evacuation policy was in effect. But the evacuation policy had been dropped to 120 days in October 1944, and instructions had been given that a


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FIGURE 110.-Caring for immobilized casualties in a hospital train.

90-day policy would be in effect whenever crowding of facilities dictated it or when the available lift to the Zone of Interior could not be filled with cases selected under the 120-day policy.

Moreover, the many new general hospitals which had arrived since publication of the earlier directive were in a quandry over the disposition problem. In addition, certain station hospitals had from time to time been permitted to establish disposition boards and act as general hospitals in the selection of patients to be evacuated to the Zone of Interior. The situation was particularly acute in the United Kingdom where casualties destined for longer-term hospitalization had been evacuated from the Continent. On each occasion of his visits to the United Kingdom, Colonel Cutler had been advised by both Colonel Spruit and Colonel Morton that a revision of the outmoded directive was urgently required.

In view of these conditions, Colonel Cutler had obtained recommendations for changes and additions to the original directive from the senior consultants in surgery. He consolidated their recommendations and forwarded them to Colonel Kimbrough, on 5 December 1944, for any changes he desired to make with respect to genitourinary conditions. In forwarding the proposed modifications, Colonel Cutler noted that the situation made it clear that it was necessary to revise the conditions which automatically returned people to the Zone of Interior under the new hospitalization program.

By the time Colonel Cutler returned from his trip to Belgium and the First and Ninth U.S. Armies, the new directive (Circular Letter No. 142) had


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been promulgated. Portions of Circular Letter No. 142, issued by the Office of the Chief Surgeon, ETOUSA, on 8 December 1944, which pertained to surgical conditions making it advisable to evacuate a patient to the Zone of Interior under a 120- or 90-day evacuation policy, are contained in appendix C (p. 973). The list should become of increasing historic significance with the passage of years in view of the difficulty which always seems present when a decision must be made as to whether a soldier or officer remains in a theater of operations or goes home.

Hospitals for specialized treatment on the Continent - Colonel Cutler's proposed directive for the establishment of hospitals for specialized treatment on the Continent had been worked out after careful and long planning. As of the time he had completed his draft (4 December) the hospitals designated to provide the specialized treatment were equipped and in a position to carry out their specialized mission, and the specialists necessary to provide the surgery were present. Colonel Cutler submitted his draft of the proposed directive on 5 December advising Colonel Kimbrough as follows:

1. Attached is a draft for a circular letter on specialized treatment, which has incorporated in it

a. All the suggestions made by Operations Division, and
b. Redesignation of certain hospitals after a more careful selection.

2. Recommend immediate publication of this circular.

3. When the matter of these specialized treatment centers was proposed, both the Hospitalization and the Operations Divisions proposed moving hospitals selected for such work into permanent buildings, if they are now in tented construction areas. Perhaps final approval of this letter should therefore pass through Hospitalization as well as Operations.

Colonel Cutler's proposed directive designated the following hospitals for the treatment of patients requiring specialized treatment:

Hospital

Area

Neurosurgery units:

 

    

48th General Hospital

Paris

    

298th General Hospital

Liége

    

100th General Hospital

Toul

Thoracic surgery units:

 

    

48th General Hospital

Paris

    

15th General Hospital

Liége

    

5th General Hospital

Toul

Urological surgery units:

 

    

48th General Hospital

Paris

    

298th General Hospital

Liége

    

100th General Hospital

Toul

Units for plastic and maxillofacial surgery and surgical treatment of extensive burns:

 

    

108th General Hospital

Paris

    

15th General Hospital

Liége

    

5th General Hospital

Toul

The directive, in draft, specified: "Patients requiring treatment in neurosurgery, thoracic surgery, plastic and maxillofacial surgery, surgical treatment


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of extensive burns and urological surgery, when transfer to the United Kingdom is impracticable or inadvisable, will be sent without delay to the appropriate hospital designated * * *."

When Colonel Cutler returned from his extended trip in the field, he found that the directive had not been published. Investigating further, he learned that the heavy bombardment experienced just before leaving the First U.S. Army area had been in earnest and that the Germans had launched a large counteroffensive. He conferred with members of the Evacuation Branch and Operations Division of the Chief Surgeon's Office, who informed Colonel Cutler that the directive had to be held up in view of the fluid situation. They decided, however, that there would be no objection to the Seine Base Section surgeon's issuing a directive pertaining to the special facilities in the Paris area. General Hawley, later in the month, decided that the designation of the specialized facilities should be made but that there could not be the rigid enforcement of the distribution of patients as was exercised in the United Kingdom.

Christmas and year's end

Even during war in an active combat theater, a few days of idyllic peace may suddenly appear. Colonel Cutler's third Christmas in the European theater was one of these, a day far-removed from the routines of war. He was able to meet his son, Capt. Elliott C. Cutler, Jr., Inf., who had recently arrived in England with an infantry division. Colonel Cutler, doting parent for the day, toured London leisurely with his young West Point son. Later, the two joined Admiral and Mrs. Gordon-Taylor for Christmas dinner.

The year ended with the lengthy but most worthwhile meeting of the Chief Surgeon's Consultants' Committee on Saturday, 30 December. This time, Colonel Cutler was in the chair since Colonel Kimbrough had been returned to the Zone of Interior for a period of indefinite temporary duty. Among other things, Colonel Cutler arranged for Colonel Tovell to present to the Chief Surgeon a very comprehensive analysis of various anesthetics and procedures being used in the theater according to the type of medical facility. It had been mentioned by the other consultants, too, but it was after this report that General Hawley made the statement which perhaps more than ever impressed the consultants with the Chief Surgeon's true, fine mettle. General Hawley said:

This is a very splendid study here. It is very illuminating. It only to me emphasizes the splendid work that has been done in anesthesia in this theater. It is a reflection of the energy, the ability, and the aggressive, and I might say religious, application that Colonel Tovell has shown, and I would like to take this opportunity to say that, however much in the early days I might not have absorbed as much of his enthusiasm as he thought I should have absorbed, I have been converted, and I am quite convinced that the fine surgical results that have been gained in this theater are in no small way attributable to Colonel Tovell and the fine * * * service that he has brought here. I say that very sincerely.


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The New Year

Need for a united theater

One of Colonel Cutler's utterances as the new year began was to the effect that the political implications of SOLOC were almost insurmountable, but a united theater was essential. The reader may recall that Colonel Cutler, following his return from Brussels, had given the Chief Surgeon due warning that he fully intended to visit the Seventh U.S. Army in spite of apparent reluctance by that Army to have visitors from theater headquarters. The Surgeon, SOLOC, had also requested that consultants from European theater headquarters refrain from visiting the SOLOC area until it could be established on firmer footing.

Meanwhile, the situation in the Ardennes and Alsace areas had tied down personnel of the Chief Surgeon's Office pretty much to the headquarters in Paris. While the theater surgical consultants were awaiting an opportunity to visit the units to the south and to observe the type of work being done, a letter from The Surgeon General questioned the Chief Surgeon, ETOUSA, on the numbers of orthopedic casualties with internal fixation who were arriving in the Zone of Interior from the European theater. It was quite obvious that most of these cases had been evacuated from Marseilles, and there was an urgent need for visits to the areas of southern France so that responsible persons at theater headquarters could speak intelligently on all aspects of the theater's medical responsibilities.

At the aforementioned 30 December meeting of the Chief Surgeon's Consultants' Committee, Colonel Cutler pointedly asked:

Some of the members of this group are going to visit SOLOC hospitals. There is one thing that has been brought up that we need clarification on. Hospitals there have been doing internal fixation of fractures. We wish to go with a clear mind as to what position we take. Shall we ask them to live up to ETO directives?

General Hawley replied:

Yes. I would like to stop at this point. I had to send that thing to the Surgeon General; I couldn't postpone it any more. I stated frankly that in that type of case where proper reduction could not be obtained by traction, which applied to only a very small amount of the cases that a certain amount of internal fixation of fractures has been done, but it is true that the number of that is from the Southern Line of Communications.

Further explaining General Hawley's answer, Colonel Cleveland commented:

It must be, General Hawley. After I wrote a little memo for that letter of yours in answer to General Kirk, I went over the disposition proceedings and I looked over fairly carefully those of the 21st and the 26th, but these hospitals are in SOLOC. The 21st had a very high percent of the internal fixation. It is often hard to get the information, but you know they are doing it, and I think it is only by going down there to find out what they are doing.


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"Yes," General Hawley confirmed, "they have got to stop it." He continued: "Where proper reduction cannot be effected, then it is all right. I think even General Kirk agrees that we have got to do that." Then, in reply to Colonel Cutler's original question, the Chief Surgeon stated emphatically: "They are going to adhere to the policies of this office, or else."

On 31 December, the day after the meeting, Colonel Cutler hastened to write the following in a letter to Colonel Shook:

I am frightfully sorry but I have been unable to get over to see you, and, now that I am holding down Colonel Kimbrough's desk as well as my own, it is impossible. Several of the officers on our staff will be over to see you shortly and I am giving this note to Colonel Spurling, the consultant in neurosurgery, who is traveling with Colonel Canfield, the consultant in otolaryngology and ophthalmology. These officers will see all your hospitals and, after a discussion with you, will also visit your southern area and study newly arrived hospitals. I am sure we all have the keenest desire to be of service to you, and please ask these officers to do anything you wish.

Since I can not come myself, and since you and I have discussed the matter of your consultant in surgery, and after a long discussion with Colonel Berry, Consultant in Surgery, Seventh Army, who turned up at a meeting in Brussels, I am happy to recommend to you that Colonel Ira Ferguson become your consultant in general surgery. If this is in accordance with your desires, will you please take steps to implement this and move him to your headquarters. Perhaps by the time this is done I will be over to see you. Meanwhile, I hate to hold up anything important for better service in your area.

Colonel Canfield and Colonel Spurling returned from their visit to SOLOC and the Seventh U.S. Army and conferred with Colonel Cutler on 7 January 1945. Their visit had been most rewarding in respect to information gathered. General Hawley, himself, also planned to tour the SOLOC and Seventh U.S. Army areas, and asked Colonel Cutler to accompany him. After meeting with the Chief Surgeon on 9 January and obtaining a firm date for the proposed trip, Colonel Cutler telephoned Colonel Shook on 10 January and informed the SOLOC surgeon that General Hawley and Colonel Cutler would be visiting him on 14 January.

Visit to SOLOC and CONAD - On Sunday, 14 January 1945, General Hawley and Colonel Cutler departed Paris at 0900 and arrived at Dijon at 1630. The Chief Surgeon contacted Colonel Shook by telephone and joined him, while Colonel Cutler proceeded to confer with Col. Ira Ferguson. The two quickly reviewed the professional status of all hospitals in CONAD (Continental Advance Section) and the Delta Base Section, the two base sections subordinate to SOLOC. They spoke especially of the problem of bringing up newly arrived general hospitals to a respectable professional standard, and it seemed to Colonel Cutler that the older established hospitals "had plenty of export material * * * for helping new institutions." Colonel Ferguson also informed Colonel Cutler that he would not particularly care for a full-time job as surgical consultant at SOLOC headquarters. He hoped that another officer could be found for the position, or that, with consultants at each of the two bases, a third at SOLOC headquarters would be unnecessary.

Later that evening, Colonel Cutler joined General Hawley, Colonel Shook, Col. Harry A. Bishop, MC, and Col. Crawford F. Sams, MC, for dinner at the


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CONAD mess and conferences in Colonel Shook's quarters. They decided to defer the matter of appointing consultants until Colonel Cutler had completed his visit. Colonel Cutler promised to help obtain personnel from the field armies to "shore up" vacancies in the new SOLOC hospitals. Colonel Shook, in return, promised to distribute pertinent circular letters of the Office of the Chief Surgeon, ETOUSA, so that all medical treatment facilities in SOLOC could be apprised of European theater policy. While the visitors from Headquarters, ETOUSA, were most pleasantly entertained, General Hawley and Colonel Cutler could see that the SOLOC staff was not going to acquiesce to theater policies and procedures without some difficulty.

The next day, Colonel Cutler visited the 46th General Hospital at Besançon and was not impressed, although the orthopedic work and anesthesia were good. He thought the hospital was not closing wounds as early as should be done. After lunch at this hospital, Colonel Cutler returned to Dijon where he inspected the 36th General Hospital. The hospital and surgical service were excellent. The 36th General Hospital, with 2,000 beds available, had had a census of as many as 3,000 patients on occasion and had 2,873 patients on the day visited. After completing his hospital visit, Colonel Cutler took the night train to Marseilles with General Hawley and Colonel Ferguson.

Visit to Delta Base Section.-At Marseilles, the headquarters of Delta Base Section, the party was met by Col. Vinnie H. Jeffress, MC, base section surgeon. After breakfast at the headquarters mess, Colonel Cutler visited the 70th and 80th Station Hospitals which were acting as holding hospitals for evacuation to the Zone of Interior and were also providing local station hospital service. As expected, there were a good many cases with internal fixation. Soldiers with enucleations had been provided poorly fitted glass eyeballs not nearly as good as the acrylic eyes which were being made in the dental laboratories in the rest of the European theater. There were many patients earmarked for evacuation to the Zone of Interior who should have been retained in the theater. There then followed a visit to the 235th General Hospital. Here again, Colonel Cutler was not satisfied with the work being done, there was no clear idea of proper disposition procedures, and there was confusion because the hospital was operating partly under MTOUSA and partly under ETOUSA directives. Lunch at a hostel for nurses provided the opportunity to meet the commanding officers of the 69th and 78th Station Hospitals who had traveled from Cannes and Nice.

The afternoon visits were a revelation of another sort. Colonel Cutler found the 43d General Hospital affiliated with Emory University, Atlanta, Ga., and the 3d General Hospital, affiliated with Mount Sinai Hospital, New York, N.Y., excellent in their professional work. Colonel Ferguson was the chief of surgical service at the former, and there Colonel Cutler found the orthopedic work particularly good, although many cases were being bone plated. At the 3d General Hospital, Colonel Cutler was shown a ward for abdominal surgery run by Maj. (later Lt. Col.) Leon Ginzberg, MC. Colonel


304

Cutler considered this the most interesting and beautifully run ward seen on the whole trip.

Back to SOLOC headquarters and CONAD - On the night train back to Dijon, Colonel Cutler was able to have a long discussion with Colonel Ferguson on the overall hospitalization plans for SOLOC. Colonel Cutler recorded that they were in general agreement on the following: "* * * The forward general hospitals at CONAD should absorb all the people who could go back to duty within 30 days, and have a high-powered reconditioning center. The rear hospitals, that is those in Delta Base, should take up the cases requiring long hospitalization, whether going to the Zone of Interior or not." In such a scheme, the station hospitals in and around the Marseilles area could act as holding hospitals for water evacuation to the Zone of Interior. Too, there would be a need for hospitals to provide specialized care. These should be in the Delta Base Section, and Colonel Cutler suggested that the 43d General Hospital could well take care of thoracic surgery and neurosurgery and the 3d General Hospital, of maxillofacial, abdominal, and hand surgery.

Back again in the Dijon area, Colonel Cutler visited the 23d General Hospital, the affiliated unit from Buffalo at Vittel, France. Here, he met Lt. Col. Baxter Brown, MC, chief of surgery, whom he described as "an excellent man." Colonel Brown was a urologist, but his services had been requested by the CONAD surgeon as surgical consultant for the command. Colonel Cutler also visited the Sixth Army Group headquarters where the surgeon, Col. Oscar L. Reeder, MC, explained the French medical service of the First French Army, a component of the Sixth Army Group.

In the afternoon, Colonel Cutler proceeded to the 21st General Hospital at Mirecourt, France, which he described as follows: "* * * an enormous new insane institution spread out over a mile, but well adapted." Commanding officers and chiefs of surgery from nearby hospitals assembled at the 21st General Hospital for meetings and dinner with the guests from up north. The hospitals represented included the 236th, 237th, and 238th General Hospitals, and the 23d, 35th, and 51st Station Hospitals. Colonel Berry from the Seventh U.S. Army, Colonel Ferguson, and Colonel Brown were also present. Colonel Cutler had the wonderful opportunity to have a long discussion with these chiefs of surgery and the surgical consultants-it was becoming quite obvious, now, that Colonel Ferguson would be the consultant for Delta Base and Colonel Brown, for CONAD. Colonel Cutler, as a result of his visits to the various facilities in SOLOC, urged the early restoration to duty of all patients and less use of internal fixation.

That evening, there were two meetings of great consequence for the fostering of close and cooperative relationships between those at Headquarters, ETOUSA, and the personnel of SOLOC. Of pertinence to the Chief Consultant in Surgery were the following, as recorded in his official diary:

Later in the evening we had a long meeting, attended by General Hawley, Colonels Bishop, Berry, Ferguson and Brown, regarding functions and duties of consultants. We agreed it was unnecessary for the moment to have free [full-time] consultants for SOLOC,


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but accepted the consultants chosen for CONAD and DELTA. These consultants will remain in their hospital posts, will feel free to go out and examine institutions when they desire, will not speak to Commanding Officers or members of units regarding any changes they may deem wise and will not make promises to Commanding Officers or people concerning new equipment, but when they have examined their unit will go back and give a complete report to the Surgeon, SOLOC. Further, all consultants will feel free to correspond directly with their consultant colleagues in any base section or at ETO headquarters without such letters going through the base surgeon. This facility of professional correspondence is fundamentally to better the professional care, and General Hawley urged this strongly as the very basis of the consultant group. Colonel Bishop is to distribute ETO circulars shortly. Colonel Shook will be given a report of all this, and then will establish any other policies which he deems wisest for SOLOC. At this discussion, the matter was brought up as to whether men fresh from hospital who might later be general assignment could go on limited duty for 3 months and then be reevaluated.

Still later in the evening there was a meeting of professional people at which there was a long discussion * * * [concerning] the reasons * * * [for] internal fixation. These would seem to be as follows:

1. Fractures into joints.
2. Multiple fractures, long bones.
3. Where fragments of fracture may possibly injure blood vessel, if reduction is not perfect.

Visit to Seventh U.S. Army - The following day, Thursday, 18 January, General Hawley, Colonel Cutler, and Colonel Berry motored to Headquarters, Seventh U.S. Army, Lunéville, France, after making rounds at the 21st General Hospital. At Seventh U.S. Army headquarters, they were met by Maj. Gen. Arthur A. White, USA, Chief of Staff, and Col. Myron P. Rudolph, MC, army surgeon. General Hawley impressed on Colonel Rudolph the importance which was being placed on the rotation of medical officers between the field armies and communications zone facilities. The Chief Surgeon made it clear that requests for rotation had to be initiated within the field armies. He specifically instructed Colonel Rudolph that correspondence pertaining to such interchanges was to be made directly to his office and not with the base sections.

Privately with Colonel Berry, Colonel Cutler discussed the administration of the 2d Auxiliary Surgical Group and the availability of qualified surgeons. The Seventh U.S. Army had one-half of the 2d Auxiliary Surgical Group. The group's executive officer, Maj. (later Lt. Col.) James M. Sullivan, MC, customarily remained forward of army headquarters and, from this forward location, disposed and supervised the teams. He habitually maintained close liaison with Colonel Berry, who remained with the surgeon, Colonel Rudolph, at Seventh U.S. Army headquarters. This had worked well, and Colonel Berry told Colonel Cutler that it would be a mistake for the consulting surgeon of a field army to try to operate directly the auxiliary surgical group, as Colonel Crisler was doing in the First U.S. Army, in addition to his duties as the surgical consultant. Colonel Berry also confirmed his advice earlier offered that there were many surgeons in the evacuation hospitals and the auxiliary surgical group to the Seventh U.S. Army who could go to the new hospitals in SOLOC to strengthen their surgical services.


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Return to Paris - Before leaving the Seventh U.S. Army area, General Hawley and Colonel Cutler visited the 9th and 95th Evacuation Hospitals. After this, they proceeded to the 2d General Hospital which was just setting up at Nancy and spent the night of 18 January there. The next day, they went to Headquarters, 8th Armored Division, at Pont-à-Mousson, and were given a guide by the assistant division commander to take them to Raucourt, where General Hawley's son was located. After a pleasant reunion with the son of the Chief Surgeon, General Hawley and Colonel Cutler visited the 58th General Hospital in Commercy and, finally, arrived back in Paris at 1730 on 19 January.

Back in Paris, Colonel Cutler provided the Chief Surgeon with a summary of items which had been discussed, a draft of a letter to Colonel Shook confirming agreements made, and a draft of a letter for the Chief Surgeon to send to The Surgeon General explaining the three general circumstances when the internal fixation of fractures should be permitted. Colonel Cutler initiated necessary procedures in coordination with the Dental Division in the Chief Surgeon's Office to train dental personnel in SOLOC to fabricate acrylic artificial eyes. He also made the necessary arrangements to have shipped to the Seventh U.S. Army some units of the mobile surgical team assembly for use by attached French surgical teams which had been trained by the U.S. Army Medical Department.

It is interesting to note, in the letter on use of internal fixation under special conditions, Colonel Cutler wrote: "We have not utilized these procedures in ETOUSA, but we are always willing and eager to improve our service to the soldier, and I think we are convinced that under special circumstances these procedures are desirable." Certainly, these thoughts clearly indicate that, however strong Colonel Cutler personally felt about any matter, he always maintained an open mind to the suggestions and feelings of others. On this occasion, he had gone to SOLOC with a strong obligation to curtail the widespread use of internal fixation in the hospitals of that command, but, nevertheless, he had returned to vindicate their practices, where warranted.

Trenchfoot meeting

But a few days after Colonel Cutler's return from southern France, medical and surgical consultants from throughout the European theater began to assemble in Paris for a combined meeting and a coordinated assault on a major problem which the winter fighting in the Rhineland had fostered for the Medical Department-the problem of trenchfoot. Present also were representatives of the theater's preventive medicine activities and members of the trenchfoot study group (surgical) at the 108th General Hospital, Paris, and the medical group in England at the 7th General Hospital.

The proceedings of this meeting held at the 108th General Hospital on 24 January 1945 are more thoroughly covered in another volume of this history.106

106Medical Department, United States Army Cold Injury, Ground Type. Washington: U.S. Government Printing Office, 1958, pp. 179-184.


CHAPTER II CONTINUED

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