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HISTORY OF THE OFFICE OF MEDICAL HISTORY
Chapter II - continued
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
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.
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.
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
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
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:
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-
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."
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-
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
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.
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).
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.
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.
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
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
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
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."
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.
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
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:-
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
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.
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.
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-
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.
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
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
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,
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.
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
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
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
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.
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
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
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
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
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:
The directive, in draft, specified: "Patients requiring treatment in neurosurgery, thoracic surgery, plastic and maxillofacial surgery, surgical treatment
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.
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.
"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
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
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,
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.
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.
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.
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