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Chapter II - continued

Contents

Chapter II - continued

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But, in summary, General Hawley opened the all-day sessions and expressed the hope that agreement on the means to prevent and treat trenchfoot might come from the meeting. Col. John E. Gordon, MC, chief of the Preventive Medicine Division, Office of the Chief Surgeon, demonstrated some intriguing rates in relation to smaller units of battalion size and showed the prevalence of trenchfoot with respect to the command of such units. By field armies, Colonel Gordon showed, in order of severity, rates for the Third, First, Seventh, and Ninth U.S. Armies. He recommended the rotation of combat troops and better foot discipline. Lt. Col. Richard P. Mason, MC, of the Preventive Medicine Division, Office of the Chief Surgeon, emphasized the value of discipline and dry socks and the proper use of the shoepac.

Captain Leigh from the study group at the 108th General Hospital presented proposals for classifying patients for sorting and evacuation. He suggested that a circular letter now be published on the type of treatment which would be beneficial in the army areas and the criteria under which patients would be evacuated to the communications zone and to the Zone of Interior. Colonel Kneeland, medical consultant for the United Kingdom Base, explained the benefits of active exercise in the treatment of patients restorable to duty. Maj. Laurence B. Ellis, MC, studying trenchfoot at the 7th General Hospital, called attention to the remarkable rapidity of the disappearance of edema with the use of a thoracic respirator. He pointed out that this result was more rapid with the use of the respirator than with exercise or position of the patient, but that an explanation was wanting. It was observed, however, that femoral vein pressures were definitely diminished.

Colonel Crisler explained procedures used in the First U.S. Army in the management of trenchfoot cases (p. 290). He spoke of recurrent trenchfoot, asked for the criteria to differentiate trenchfoot and frostbite, and warned of the importance of associated injuries. Colonel Odom and Lt. Col. Guy H. Gowen, MC, presented the experience of the Third and Seventh U.S. Armies, respectively. Others spoke of the frequent superficiality of lesions studied and of the finding of an intact nervous system in most cases.

During the general discussion, there was agreement that amputations should rarely be done for uncomplicated trenchfoot and that pain was an insufficient symptom for removing a soldier from duty. Cases to be evacuated to the Zone of Interior, it was generally observed, should either show obvious tissue damage or have associated combat exhaustion. Those who at the end of 5 or 6 weeks of treatment still evidenced disturbed physiology, it was recommended, should also be evacuated to the Zone of Interior. The conferees were convinced that sympathectomy was undesirable, except for late manifestations of Raynaud's disease.

Colonel Cutler recorded his opinion, as follows: "The remarks made by Colonel [Sterling A.] Wood, [Regimental Commander,] 313th Infantry * * * in both afternoon and evening were more effective than any of the professional discussion." Colonel Wood was an Infantry regimental commander. While a patient in a general hospital for other reasons, he had become personally inter-


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ested in the tremendous wastage of manpower he had observed in the number of patients coming through with cold injury. He had personally acquainted himself with the facts then available and had studied the means by which a unit commander could curtail this great loss. Colonel Wood, before returning to duty, had spoken to Gen. Omar N. Bradley, the 12th Army Group commander, about what the line should do in preventing cold injury. At this trenchfoot meeting, he mentioned that directives to the line had to be brief and specific. He explained that new socks were now coming up at night with the rations and recommended that each soldier keep extra socks inside his shirt to keep them warm and dry. Colonel Wood emphasized the difficulty of keeping all company commanders apprised of the importance of preventive measures and of maintaining proper procedures in the prevention of cold injury because of heavy losses among his officers. Since D-day, he stated, the 313th Infantry had lost 200 officers and 4,800 men.

The occasion of this trenchfoot meeting also gave the Chief Consultant in Surgery the opportunity to speak with his surgical colleagues on many pressing matters of the moment. A dinner was given by General Hawley for all the participants at the meeting, and a period of lucid, informal discussions followed. Not a few of the visitors also attended the meeting of the Chief Surgeon's Consultants' Committee with General Hawley the following day. Further talks on items which were discussed in Paris at this time were taken up again after Colonel Cutler flew to the United Kingdom on Sunday, 28 January.

One of the factors which permitted Colonel Cutler to fly to England at this time was the return of Colonel Kimbrough from the United States one week previously.

United Kingdom revisited

Thoracic pulmotor - One of the things Colonel Cutler looked into on this visit to the United Kingdom was the functioning of the thoracic pulmotor at the 7th General Hospital, as used for the treatment of trenchfoot. The Chief Surgeon had classified all activities at this hospital in the possibility that, if the experiments being conducted there were going to provide something truly constructive, the enemy should not have the benefit of our discoveries.

Colonel Cutler learned that the machine induced a negative pressure of 10 or 12 mm. of mercury and was being used 1 hour daily for from 7 to 15 days per patient. Studies showed that trenchfoot patients submitted to this treatment late did less well than those submitted early. Moreover, patients originally apparently relieved of symptoms by this treatment were experiencing recurrence of symptoms. Little scientific information had been gathered on the physiological correlates to the machine's actions-decrease in femoral vein pressure, elevation of diaphragm with inspiration rather than depression, and unchanging pulse rate and blood pressure throughout the course of the machine's action.

Since little information had been gathered on the unusual action of the diaphragm, Colonel Cutler suggested that fluoroscopy be carried out. He


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pointed out that the apparatus was aluminum and that aluminum would not obstruct the roentgen rays.

Finally, Colonel Cutler noted in his journal: "I was not greatly impressed with this machine."

The Chief Consultant in Surgery spent the remainder of the day individually checking cold injury cases on the wards in this hospital. He was appalled to learn of the indiscriminate awarding of the Purple Heart decoration to frostbite cases of very minor severity. Such actions were making a farce of the decoration, he declared.

Meeting of United Kingdom Base surgical consultants - Colonel Morton had arranged for a meeting of all the surgical consultants in the United Kingdom Base Section. These consultants-coordinators in surgery at the hospital centers and specialist consultants strategically located at various hospital centers to act as regional consultants in their specialty-had assembled on Thursday, 1 February 1945, at the 7th General Hospital. Colonel Wright from the Air Forces and Col. Baxter Brown, MC, surgical consultant to CONAD, were also present. Colonel Brown had come to England with Colonel Cutler following the trenchfoot meetings in order to observe the organization for and care of patients in the United Kingdom Base Section. General Hawley, who had flown over to England, welcomed the group and pointed out the debt of the Army to the doctors. He asked them to try to assume fully the responsibility of the early restoration to duty of those who could be restored, pointing out the danger of trying to restore to duty those who could not be brought up to the standard. He mentioned that the alleged sending to replacement depots of those unfit for duty was currently a matter of joint investigation by the Chief Surgeon's Office and the theater Inspector General's Office.

Colonel Cutler then discussed with the group the overall system for the care of the wounded American soldier, beginning at the forward areas and ending up either with restoration to duty or evacuation to the Zone of Interior. He stressed particularly the importance of sorting and maintained that, if sorting was properly done all along the chain of evacuation, most of the problems to which those in the United Kingdom were heir would disappear.

"The next matter under discussion," Colonel Cutler later reported, "was early restoration to duty." He recorded:

I placed before the group the hope that within 2 weeks they could evacuate 5,000 beds in the United Kingdom of patients and bring some relief to our pressing need for beds. The matter of a more vigorous attack on the wounded soldier and a greater effort to make him exercise and move was brought forward as being the most important factor.

The rest of the morning was devoted to the improvement of current circular letters on the treatment of battle casualties. Particular stress was placed on the improvement of instructions concerning abdominal surgery, fractures, trenchfoot, hernia, and thoracic surgery.

The discussion on thoracic surgery was continued throughout the afternoon. First, it was brought out by the thoracic surgeons from the special treatment facilities that casualties were taking an extremely long time reach-


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ing them-an average of some 30 days after wounding. This fact, they stated, was completely nullifying the advantages of having special treatment facilities, since the patients reached them in bad condition and unsuitable for early primary treatment. Another difficulty, it was noted, was the reticence of individuals to accept thoracic cases as fit for duty even when they had been playing baseball and walking 4 or 5 miles a day. There seemed to be a prevailing psychological barrier that soldiers wounded in the thorax could not go back to duty. Facing this problem squarely, the Chief Consultant in Surgery was obliged to conclude: "I am afraid to do this whole thing properly we will have to re-educate all of the doctors in the FFRS (Field Force Replacement System)." Finally, Colonel Cutler received many sound ideas on specific items which would have to be included in a directive on thoracic surgery. Before returning to the Continent, Colonel Cutler was able to work up the data for the thoracic surgery directive in more or less final form with Colonel Morton and Colonel Miscall.

End of Long Winter Campaign

Another round of directives

Colonel Cutler crossed the Channel to France on 3 February 1945 with General Grow and Colonel Wright. In the afternoon, he spent his time preparing the new "professional circular" for publication. On 4 February, three new directives were ready to be submitted for publication in rapid fashion. One was the professional circular on the care of battle casualties, another dealt with changes to the list of conditions issued to disposition boards for guidance in selecting patients for return to the Zone of Interior, and the third was a paper on priorities for air evacuation to the Zone of Interior. Before going to the United Kingdom, in fact before the trenchfoot meeting, Colonel Cutler had submitted another directive, in draft, pertaining to information given to casualties. Immediately after, and as a result of, the trenchfoot meeting, the draft of a directive on trenchfoot had also been submitted.

Information to casualties - Colonel Cutler had originally intended to include the item pertaining to information being given casualties in the new directive on care of battle casualties. Colonel Bricker, however, convinced him that the matter was so important that it should be published separately. Consequently, it was issued by the Office of the Chief Surgeon on 31 January 1945 as Circular Letter No. 11. The reader will note that this directive pertained but little to professional matters outwardly; nevertheless, it had much to do with the successful rehabilitation of a casualty to duty and without his returning again to the medical chain of evacuation for the same injury. The directive, as published, was terse and quite self-explanatory. It stated:

1. Under no circumstances will medical officers in forward hospitals, whether Army units or general or station hospitals, tell casualties that their injury is such as to necessarily take them to the Zone of Interior. Frequently, what appears to be an injury necessitating evacuation to the Zone of Interior turns out to be recoverable, and, if the soldier has been told that he is to go to the Zone of Interior, the reverse of this decision


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leaves him disappointed and embittered, and lowers his usefulness to the Army in the future.

2. The practice of discussing the disposition of patients in hospital wards in the presence of the patient himself or of other patients must be stopped. All disposition board proceedings must be held confidential. Giving the patient strong implication that he may go to the Zone of Interior should be guarded against until final movement of patient commences.

Trenchfoot directive.-The trenchfoot directive was submitted on 28 January 1945 immediately following the meeting at the 108th General Hospital. It stated that TB MED (War Department Technical Bulletin) 81, which had been reproduced in the European theater, was the basic directive on the treatment of cold injury. However, the new directive, Circular Letter No. 18, Office of the Chief Surgeon, ETOUSA, dated 21 February 1945, gave additional advice on therapy based on current information gained in the theater. This guidance was in two parts-treatment in the forward area and treatment in fixed hospitals. The important part of the directive was a greatly simplified chart that attempted to show how to classify this type of casualty and to aid in the evaluation and disposition of these casualties. Dividing trenchfoot cases into mild (first degree), moderate (second degree), and severe (third degree), the directive showed under each of these categories what to expect in the way of history and physical findings and how the cases in the three categories were to be disposed of. The physical findings were further broken down into those observable during the hyperemic and posthyperemic stages and in the motor functions of the foot.

When Colonel Cutler was in England shortly after submitting this directive for publication, he discovered in no uncertain terms how necessary it was. During the meeting with the United Kingdom Base surgical consultants, Colonel Cutler was informed by the consultants that the routine care of cold injury was the responsibility of the medical service in the hospitals of that base as differentiated from the surgical service, and that the internists had not yet decided who could or could not be returned to duty.

Certain directives, however, by reason of the fact that they had been issued by higher headquarters, could not be changed or countermanded at the ETOUSA level. The directive pertaining to the awarding of the Purple Heart for frostbite was one of these. As it was seen, Colonel Cutler had found that the awarding of the Purple Heart decoration was being badly handled, but the basic directive permitting this had been issued by the War Department. Accordingly, the only action Colonel Cutler could take was to prepare for General Hawley's signature a letter to The Surgeon General requesting that he take action to correct the situation. The letter, as prepared in draft by Colonel Cutler, follows:

We are greatly troubled by War Department regulations stating that the Purple Heart is given for "Severe frostbite". We have qualified severe frostbite as follows:-

"The words 'severely frostbitten' will be interpreted to apply to only those cases of frostbite in which the lesion is so extensive and lasting that cells are killed and the result will show actual loss of substance; either loss of a digit or a slough which extends throughout the whole thickness of the corium."


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The fact is that with the temperature just at freezing, one day above and one below, and with "cold injury" the pathological agent, it is almost impossible to make a distinguishing diagnosis. Thus, some soldiers get a Purple Heart and others do not. As a result our wards contain many embittered Infantry men. This is emphasized when the "trenchfoot" victim has a greater injury than the "frostbite" casualty. It would appear that the Medical Department is asked to apply a policy which it did not establish or suggest and which it finds impossible to administer fairly. Forward units confer the Purple Heart and under pressure from Line Commanders, who demand liberality in order to keep troops reasonably mollified, are naturally not too strict. The Purple Heart is gradually becoming worse than a joke.

I think this is going to give us all a headache, but, still worse, it has greatly disturbed combat soldiers. Men with simple blisters from frostbite are getting the Purple Heart and men with incapacitating lesions from trench foot get nothing!

If you agree in this, perhaps you will take this up with the War Department and see if there can be any change in the present regulations.107

Care of battle casualties - Circular Letter No. 23, Care of Battle Casualties, 17 March 1945, issued by the Office of the Chief Surgeon, ETOUSA, was the last comprehensive directive on the surgical care of the wounded to be prepared under the direction of Colonel Cutler during the period of hostilities in the European theater. This directive, together with the Manual of Therapy, ETOUSA, Circular Letter No. 71, 15 May 1944, Circular Letter No. 101, 30 July 1944, and Circular Letter No. 131, 8 November 1944, all from the Office of the Chief Surgeon, ETOUSA, constituted the sum total of basic policies which prevailed during the period from D-day to V-E Day with reference to the surgical treatment of the wounded. The Manual of Therapy and the first circular letter, the reader will recall, were prepared before the invasion and stood in good stead-good enough to be still applicable in most respects at the war's end. The second letter published in July 1944 was a hurried affair to correct the mistakes which had been observed during the initial stages of the invasion. And, in November, with the difficult evacuation situation, Circular Letter No. 131 had been published, dealing extensively with the management of fractures, care of hand injuries, colostomies, and other items which were of immediate concern at the time and which required standardization.

And lastly, the new circular letter was the result of observations made by Colonel Cutler, the senior consultants in surgery, and the many consultants in subordinate commands-whether in field armies or base sections-throughout the course of this campaign in the Rhineland. This directive, together with its predecessors, tells a story which might well be entitled, "Surgery in the European Theater, World War II." The first of these circular letters has been reproduced as appendix B (p. 963), and, in like fashion, the last of the series, Circular Letter No. 23, Office of the Chief Surgeon, ETOUSA, of 1945, is reproduced as appendix D (p. 977).

107Memorandum, Professional Services Division (Col. E. C. Cutler, MC) to Chief Surgeon, ETOUSA, 4 Feb. 1945, subject: Letter to Surgeon General re Purple Heart Award for Frostbite and Trench Foot.


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FIGURE 111.-The 91st Medical Gas Treatment Battalion operating as an air evacuation holding unit at Giessen, Germany. Note the great numbers of aircraft available.

Hospitals for specialized treatment on Continent - Some time later, Colonel Cutler's directive, prepared in November 1944 and pertaining to hospitals for specialized treatment on the Continent, was approved for publication. Modified to bring it up to date, the directive eventually appeared as Circular Letter No. 32, Office of the Chief Surgeon, ETOUSA, dated 6 April 1945. Ironically, however, the field armies, by that time, had moved so rapidly that they had left the general hospitals in the forward sections of the communications zone far behind, and casualties were reaching hospitals in the Paris area by air more rapidly than they could be evacuated by land transportation to the intervening hospitals where some of the specialized treatment facilities had been established (fig. 111).

Visit to Third U.S. Army

After clearing the decks, as it were, of the staff work which was required after every period of visits to the field-including the submission of indicated directives for publication, Colonel Cutler next departed on a field trip to the Third U.S. Army where he had long conferences with Colonel Hurley, Surgeon, Third Army, and Colonel Odom. He was able to locate Captain Cutler, and on the evening of 6 February 1945 they dined with Lt. Gen. George S. Patton, Jr., Commanding General, Third U.S. Army, Maj. Gen. Hobart R. Gay, Chief of Staff, and others of the commanding general's staff (fig. 112)


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FIGURE 112.-Lt. Gen. George S. Patton, Jr., center, with some members of his staff, and other key officers in the Third U.S. Army.

The visit to the Third U.S. Army was most enlightening and encouraging in many respects. First, General Patton, himself, said that he would be delighted to have an operational research team work with the Third U.S. Army; next, Colonel Cutler discovered that a command letter had been issued to all units of the Third U.S. Army over the commanding general's personal signature forbidding the awarding of a Purple Heart for frostbite within the army area since the severity of this condition could only be determined late in the period of convalescence; and, finally, at the commanding general's briefing on the morning of 7 February 1945, Colonel Cutler was pleasantly surprised at the optimism which prevailed for an early crossing of the Rhine and the subjugation of Nazi Germany. But perhaps most satisfying to Colonel Cutler was the discovery that the mobile surgical teams-with tents and all-which he and Colonel Zollinger had so laboriously organized and established two years earlier were now finding great acceptance in the armored divisions of this field army. Colonel Cutler reported the following on his return:

Visits to Armies employing armored divisions in rapid tactical movements have revealed that PROCO units (the mobile surgical teams previously described in ETMD reports) have proved valuable with armored divisions. These PROCO units consist of a surgical team from an auxiliary group with organic transport and additional equipment. In this equipment is a tent used for the operating room and the supplies are adequate for approximately two hundred (200) surgical procedures. At first, divisions did not desire such assistance but after being employed one (1) or two (2) times, these units


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FIGURE 113.-Armored medical vehicles.

were attached to the armored train and have reached a point where the armored divisions are demanding that these units become an integral part of their medical support. In the field, the following use is made of this unit: when the collecto-clearing station of an armored division is set up, the mobile surgical team sets up next to it and is immediately available for definitive surgical care. If the armored division moves a day or even hours later, the team again moves with it. The use of such a unit should be further studied, and it may be discovered that a unit anticipated for general service and use, will find its most logical placement with armored or motorized infantry divisions (fig. 113).108

Colonel Kimbrough departs

At about that time, it became definitely known that Colonel Kimbrough was to return to the United States. After conferring with General Kenner on 10 February, as mentioned earlier, Colonel Cutler proceeded to a farewell dinner for Colonel Kimbrough, given by General Hawley on what, it turned out, was his eve of departure (fig. 114).

In addressing the dinner guests and toasting the departing chief of the Professional Services Division, Colonel Cutler said:

We meet to bid goodbye and to do honor to a colleague and a friend. It will be hard for Jim to listen to some of this because he is essentially a modest man, but he must bear with us and our encomiums, for we must be permitted this privilege.

In 2½ years that we in the Professional Services Division have been together, all have made friends with Colonel Kimbrough, not lightly, for in one's adult years friend­

108Essential Technical Medical Data, ETOUSA, for March 1945, 16 May 1945.


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FIGURE 114.-Left to right, Col. William S. Middleton, MC, Colonel Kimbrough, General Hawley, and Colonel Cutler at Colonel Kimbrough's farewell dinner. Colonel Kimbrough being presented with an autographed seating plan for the dinner, held at Hotel George V.

ship is a sacred matter not given easily to each unfledged comrade but given only to those whom time and trial have proven worthy. Love and friendship are the greatest gifts within the possession of individuals, and that our Division has so universally welcomed Jim Kimbrough to this grade is our greatest possible compliment. We have literally taken him to our hearts.

And now, let us examine what type of man we honor. First let us speak of his constructive, organizing ability. The plan under which Professional Services has operated in the European theater is the plan set by Colonel Kimbrough, to guide the Chief Surgeon, before any of us were in the theater. It has been tested by time and found satisfactory. It provides specialists in all the major fields of medical practice. It makes full use of professional skills for the soldier. It bespeaks a "canny" imagination.

Next, let us examine his professional attributes. He is a specialist in urological surgery and we his colleagues are happy to testify to his complete competence. But, soon we learned he was more than a surgeon, for we watched him as a teacher helping his junior colleagues. Thus, he is admitted to the company of "surgeons," who sit above the "operations" in a world where humanity loves to use its hands.

And, finally, we've travelled far with Colonel Kimbrough, sometimes actually in trains and cars, but often, in his stories, to the afterdecks of steamers in the China Seas, to many strange places. It is then that Jim often reaches his greatest heights. In the warm evening, with dusk shutting out the greater world, men (and women) are driven to a closer communion, life is freely discussed with individuals and, untrammelled by too much sunlight, takes on an added significance. Thus are friends born. They cannot be won by money. Life without them is an empty shell. And always, in his perception of the important, the


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amusing has cropped up, for he has an uncanny flair for rapidly judging the meat and truth of any matter. He has always said it was hillbilly common sense, but many of us who have played at the game of life and success for years know that such intuition is not confined to Tennessee, and we have learned that Jim's prognostications and judgments are usually confirmed by subsequent happenings.

Our feelings of Jim have fortunately already been inscribed in the annals for posterity by Sir Henry Tidy, President of the Royal Society of Medicine. In conferring an honorary fellowship on Colonel Kimbrough, he spoke of one who had a suitable and kindly disposition proven by the fact that he directed a diversified and motley group of independent scholars who peculiarly, from the British point of view, spoke of him as "Uncle Jim"-Thus was his fellowship conferred!

Jim Kimbrough, we who are your friends wish that happiness may dog your footsteps and "Lady Luck" always sit on your shoulder and kiss your cheek.

I give you "Uncle Jim!"

Colonel Kimbrough left for the Zone of Interior on 11 February 1945 via the United Kingdom. Before leaving, however, he addressed the following undated note to Colonel Cutler which, obviously, was intended for all the consultants in the theater headquarters:

My duties with the Professional Services Division are terminated. I take this opportunity to convey my deep appreciation to each of the Consultant Group for your hearty cooperation during these many months. A more proficient and splendid group of physicians has never been on duty in any echelon with the United States Army. It has been a great privilege and pleasure to have had the opportunity to be associated with you in a personal and professional capacity.

Your efforts have assured the American soldier the best medical care that has ever been given to any army at any time. Whatever recognition may be given you for your great work, I am sure the greatest reward each of you has is the consciousness of having given the best of your efforts and talents to the care of the U.S. Army personnel in this emergency.

Best wishes.

On the day of Colonel Kimbrough's leaving, Colonel Liston, Deputy Chief Surgeon, informed Colonel Cutler that he was to assume the position of Chief, Professional Services Division. Colonel Cutler's private feelings on the change were: "If I succeed, I'll be tied down; if I don't, we're stalled." To be sure that he would be neither completely tied down nor stalled, Colonel Cutler asked for and received the assignment of Lt. Col. Bernard J. Pisani, MC, as his executive officer. Colonel Pisani was the officer who had so successfully administered the Medical Field Service School, ETOUSA, while it existed at Shrivenham Barracks in England. Capt. Wayne H. Jonson, MAC, who had been administrative assistant to the chief of the Professional Services Division, remained. It is said that a new broom sweeps clean, and, without exception, Colonel Cutler obtained concessions from Col. John C. Rucker, MC, of the Personnel Division and from Colonel Doan concerning the Administrative Division so that he could effect "office changes leading to greater comfort and efficiency of personnel."

Rhine is breached

In early February, a series of coordinated onslaughts against German positions west of the Rhine had begun. The announcement from Supreme


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Headquarters, Allied Expeditionary Force, confidently stated that these attacks should mark the beginning of the destruction of German forces west of the Rhine. By the end of February, the First U.S. Army was besieging Cologne on the west bank. A few days later, this bastion city-a mass of ruins-had fallen to the First U.S. Army. On 7 February, a task force from the 9th Armored Division could hardly believe its eyes, for at Remagen a tremendous bridge across the swollen river barrier remained intact. It has often been told how, through many fortuitous circumstances-drunkenness of the German demolitions officer, faulty fuses, alertness of the U.S. reconnaissance party commander, and so forth-the bridge was secured minutes before its scheduled demolition. The First U.S. Army commander, quick to seize this favorable turn of the fortunes of war, exploited rapidly this breakthrough and jeopardized the carefully planned German defenses along the Rhine River line (fig. 115).

FIGURE 115.-First U.S. Army men and equipment pouring across the Remagen Bridge, 11 March 1945.

Colonel Cutler said to himself: "War going well. I believe it will be over in two months. Then how do we get out?"


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CAMPAIGN IN CENTRAL EUROPE

Collapse of Enemy

True to Colonel Cutler's private prognostication, the fight on German soil rapidly turned into a pursuit of demoralized German forces. To the extreme north the British 21 Army Group resorted to full-scale, amphibious operations to cross the Rhine, secure strongly held enemy islands in the Baltic, and advance across the Elbe River to occupy Wismar on the Baltic coast by the end of April. The First U.S. Army also neared the Elbe by the end of April and waited on the banks of the Fulda River for the Soviet Army, while the Soviets waited on the banks of the Elbe for the Americans. On 23 March, the Ninth U.S. Army crossed the Rhine in the vicinity of Düsseldorf and by the end of April, it too was on the Elbe-Mulde line to link up with the Soviet Army. The Third U.S. Army crossed the Rhine in March, drove rapidly through Bavaria and Hitler's "last redoubt" and was in Austria and Czechoslovakia by early May. The Seventh U.S. Army, in late March and early April, breached the upper Rhine defenses in the area of Worms and, by early May, a portion of the Army had made the complete circle and was back to its starting base, Italy. There, it linked up with the Fifth U.S. Army south of the Brenner Pass and received the surrender of all German forces in its area on 5 May 1945 (fig. 116). Fighting alongside the Seventh U.S. Army in the Sixth Army Group, were elements of the valiant First French Army.

Responsibilities of Chief, Professional Services Division

With this rapid collapse of the enemy's resistance, Colonel Cutler was extremely harried by the many responsibilities which befell him as the new chief of the Professional Services Division, Office of the Chief Surgeon. Some of these problems were inherited immediately upon Colonel Kimbrough's departure, and others came his way soon thereafter.

The first of these problems was the examining, evaluating, and profiling of the physical fitness of every enlisted man in the theater. The War Department had directed that a new PULHES system of physical profiling be accomplished rapidly so that the resulting profiles could be used in the redeployment of personnel in the European theater to other theaters of war when active hostilities in Europe ceased. Colonel Cutler could not help but recall with some dismay that he had participated in British talks on this system of profiling in January 1944 when it was devised by the Canadians. At that time, he had submitted complete notes on the Canadian system. He stated: "* * * for it is felt that perhaps some other division than The Professional Services Division would be interested in seeing this method of assessment." Even then, when ground hostilities had not yet begun in Europe, Colonel Cutler had stated:


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FIGURE 116.-Medical soldiers of the Fifth and Seventh U.S. Armies meeting at the Italian border at the Brenner Pass.

"It seemed to me that this is no time to establish such a system."109 Now, at this late date with an extremely fluid situation and the pursuit of the war at its peak, there was no choice but to take the matter in hand and fashion out plans which could be carried out with the minimum of disruption to the conduct of the war in Europe. Eventually, it was necessary to establish a physical standards branch under Colonel Middleton's direction to plan, supervise, and coordinate matters in this area.

Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General, had arrived and presented preliminary plans and ideas on the redeployment of medical personnel and units, and this was to be an ever-increasing problem as the end of hostilities neared.

The evacuation policy for hospitals in the communications zone on the Continent had been raised to 60 days, effective 1 March 1945, except for Delta Base Section which was permitted to keep patients for the 90- or 120-day theater policy. This necessitated changes in evacuation policies, for it meant that casualties who could be rehabilitated during that period now would be cared for in continental hospitals. This also required changes in rehabilitation procedures themselves, for it placed added responsibilities on general hospitals in this

109Letter, Col. E. C. Cutler to Chief, Professional Services Division, 16 Jan. 1944, subject: Meeting, British Consultants' Surgical Sub-Committee, 12 Jan. 1944.


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respect, concurrently taking some of the load off the rehabilitation centers. Obviously, this lengthened evacuation policy for the continental hospitals changed the complexion of the extent of treatment to be given therein.

Colonel Cutler had to coordinate activities aimed at establishing a "recovery center" on the Continent. The original recovery center in England had been established by Col. Lloyd J. Thompson, Senior Consultant in Neuropsychiatry. The recovery center set up in a strictly nonhospital atmosphere, had been extremely successful in salvaging manpower from borderline cases of adjustment, such as the mentally deficient and those with character and personality disorders. The success of the center in England led line officers on the staff of the communications zone headquarters to desire strongly the establishment of a similar facility on continental Europe.

The care and treatment of RAMP (recovered Allied military personnel), liberated civilian prisoners, and displaced German nationals grew into problems of monumental proportions as the subjugation of the Nazi forces permeated ever deeper into the fatherland. Providing for the care of prisoners of war had been a problem since the Northern France Campaign and continued to mount in complexity as ever-larger numbers of the enemy surrendered (fig. 117). Colonel Cutler was the writer of the basic directive regarding their medical care and treatment.

There was also the program for establishing extensive educational opportunities throughout the theater following the cessation of hostilities. The overall theaterwide program was being coordinated by ETOUSA headquarters and theaterwide medical education and training by the education and training branch of the Operations Division, Office of the Chief Surgeon, ETOUSA. But it was the responsibility of Colonel Cutler to make plans and arrange for the professional education of medical officers during the posthostilities period in the renowed civilian medical centers of France and England and in U.S. Army general hospitals with qualified instructor personnel.

These, and many other problems of lesser scope, were to occupy much of the time and energies of Colonel Cutler in his new position. To compensate for the resulting loss of time and attention to his other position as Chief Consultant in Surgery, Colonel Cutler made more and more use of his specialist consultants on general surgical matters. This was particularly true of Colonel Bricker and Colonel Robinson who, perhaps, were in narrower fields of specialization than the others. There were many direct dealings with Lt. Col. Theodore L. Badger, MC, the medical consultant in Normandy Base Section, on whose able shoulders fell the brunt of the work in planning and supervising the professional aspects for the initial reception and care of RAMP. Colonel Zollinger, now commanding officer of the 5th General Hospital, helped Colonel Cutler in the preparation of directives on rehabilitation in general hospitals and, later, was to become a key figure in certain phases of the relocation and selection of personnel for redeployment. Colonel Pisani, as mentioned earlier, was of invaluable help on administrative matters pertaining to the entire divi-


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FIGURE 117-Delousing Soviet-recovered prisoners at Prisoner of War Exchange Camp No. 17, Lippstadt, Germany, 1945.

sion, and also in formulating plans and taking care of the liaison involved in the preparation of a posthostilities educational program. Through these various means, Colonel Cutler maintained close touch with the surgical picture in the theater and assured himself that he would not be completely tied down.Colonel Cutler Crosses Rhine

On 25 March, Colonel Cutler departed Paris by air for a visit to the First and Ninth U.S. Armies. Arriving at Euskirchen airport at 0915, he found that the 45th and 128th Evacuation Hospitals located near the airport were preparing to move across the Rhine (fig. 118).

Headquarters, First U.S. Army - At Headquarters, First U.S. Army, Colonel Cutler greeted General Rogers and obtained his concurrence for releasing Colonel MacFee to go to the Fifteenth U.S. Army as its surgical consultant. Then, with Colonel MacFee, he motored to Cologne to look over the St. Eliza-


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FIGURE 118.-The extensive holding and evacuation facilities of the 91st Medical Gas Treatment Battalion, Euskirchen airstrip, Euskirchen, Germany, 26 March 1945.

beth's Hospital. During the trip, Colonel Cutler was interested in the "delightfully complete" destruction of Cologne and the grimness of the people.

That evening, after messing with the 3d Auxiliary Surgical Group, Colonel Cutler engaged some of the surgical personnel of the First U.S. Army in his usual after-dinner free-for-all discussion. Later this same evening, Colonel Cutler discussed a proposed directive governing care of hand injuries with Colonel Crisler and Colonel MacFee. Colonel Cutler had already discussed this matter with Colonel MacFee, but one of the reasons for his having made this trip was further to discuss the topic with Colonel Crisler. Colonel Cutler was pleased to find, as expected, that the First U.S. Army surgical consultant had valuable ideas to offer.

Eventful Monday, 26 March - Colonel Cutler was up early the next morning, 26 March 1945. With Colonel Crisler, he made his first crossing of the Rhine during his participation for the second time in a war against Germany. The crossing was by motor vehicle over a pontoon bridge. Once across, he found the 45th Evacuation Hospital, under the command of Col. Abner Zehm, MC, already setting up in a disbanded schoolhouse. This was a unit Colonel Cutler had visited many times previously and always with pleasure. The hospital was well run, and the superior vascular surgery being performed under the direction of its chief of surgical service, Col. Bert Bradford, Jr., MC, always shed new light on developments in that field.


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FIGURE 119.-Gilder evacuation of wounded. The plane swooping low to hook up the gliders.

The present visit proved to be no exception, and a long discussion concerning vascular surgery ensued.

The next stop was the 42d Field Hospital, concerning which Colonel Cutler noted the following:

* * * The field hospital from which the gliders, loaded with patients, were jerked off the ground by a plane which did not stop. Reports from workers in this hospital indicated that the gliders worked well. Colonel Amspacher, who made a trip in one of them, thought they were very satisfactory, though it was frightening when the plane swooped low to hook up the gliders (fig. 119). Later, I heard that this type of evacuation had been called off.

A visit to the 13th Field Hospital completed Colonel Cutler's visit east of the Rhine. With Colonel Crisler, he recrossed the Rhine to the west bank over another pontoon bridge and visited the 102d Evacuation Hospital at Bad Neuenahr. Later that afternoon, Colonel Cutler drove to Headquarters, Ninth U.S. Army, with Major Hardin, who had accompanied him on this trip.

Ninth U.S. Army - The visit to the Ninth U.S. Army at this time was occasioned by an allegation prevailing in the Office of the Chief Surgeon that, owing to reactions, the 91st Evacuation Hospital had absolutely discontinued the use of blood supplied by the European theater blood bank. This was why Major Hardin had been brought along.

Colonel Cutler and Major Hardin arrived at Ninth U.S. Army headquarters at 1830 hours and reported immediately to Colonel Shambora, Surgeon, Ninth Army. The diary record of subsequent events follows:


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FIGURE 120.-First U.S. Army medical troops using a captured German launch to transport casualties across the Rhine, Unkel, Germany, March 1945.

After dimmer we spent two hours with Colonel Shambora, his consultant group, the chief of the medical laboratory, and members of the 91st Evacuation Hospital, discussing transfusion reactions. We had learned at headquarters (SOS, ETOUSA) that the 91st Evacuation Hospital would no longer use ETO blood bank blood. This is not true. They would merely like to continue their study of blood transfusion reactions with (1) ZI blood; (2) ETO blood, and (3) freshly drawn citrated blood from a panel in their vicinity. They expressed an interest in the overall study of blood and I believe we should encourage this, so we offered to send them either Major Emerson or Major Ebert of the 5th General Hospital, both of whom are experts in blood work, and have had long experience with blood banks. I feel that we reached an amicable settlement on what could have been a serious problem. The desire to have Major Emerson and Major Ebert sent here was immediately telephoned to Colonel Pisani.

Twenty-seven hundred yards away, the enemy.-During the next four days, Colonel Cutler alternated between the First and Ninth U.S. Armies and crossed and recrossed the Rhine, all this having started with a telephone conversation with Colonel Doan and Colonel Pisani on the morning of 27 March, at which time he was informed that General Hawley wanted to see him at the First U.S. Army for lunch (fig. 120). After missing him on two occasions, Colonel Cutler was finally able to meet General Hawley late on 28 March for dinner at First U.S. Army headquarters and a night at the 102d Evacuation Hospital. The next morning, 29 March, he left with General Hawley to go back


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to the Ninth U.S. Army and visited Headquarters, XIII Corps, where he discussed the job of a corps surgeon with Colonel Shambora. On the morning of Friday, 30 March, Colonel Cutler and General Hawley discussed with Colonel Shambora certain aspects of the professional services in the Ninth U.S. Army and the blood situation. As there was no aircraft available for a return to Paris, General Hawley and Colonel Cutler borrowed Colonel Shambora's staff car and proceeded to the banks of the Rhine on the approaches to Dorsten. There they borrowed a jeep and proceeded up to General Hawley's son's unit, the 399th Field Artillery Battalion of the 8th Armored Division. Colonel Cutler recorded: "They were firing at targets twenty-seven hundred yards away! It was a very interesting day. The Germans are apparently short of artillery as well as air."

Colonel Cutler and General Hawley were finally able to fly back to Paris later that day, arriving at 1900 hours. The one overall impression which prevailed was the relative inactivity of the evacuation hospitals of both armies, most of which were either on the move or preparing to move.

Eminent Visitors

On Monday, 2 April, after his return from visits to the First and Ninth U.S. Armies, Colonel Cutler first entertained Colonel Jurash, surgical consultant to the Polish Army in Exile. After a long conference with him, Colonel Cutler took the Polish officer for an audience with the Chief Surgeon and then escorted him to the G-5 Division, ETOUSA, for further conferences.

Later that day, Maj. Gen. Morrison C. Stayer, MC, Chief Surgeon, MTOUSA (Mediterranean Theater of Operations, U.S. Army), and his surgical consultant, Col. Edward D. Churchill, MC, arrived for a liaison visit to the European theater. Colonel Cutler dined with them and had a long evening with these colleagues whom he had not seen since November-December 1943. He continued talks with Colonel Churchill the next morning and also spoke with Lt. Col. Michael E. DeBakey, MC, Consultant in General Surgery to The Surgeon General.

Colonel DeBakey had arrived in the theater for a liaison visit following a similar visit to the Mediterranean theater. On 9 March, after conferring with him, Colonel Cutler had sent Colonel DeBakey off for a visit to the First U.S. Army in the company of Colonel MacFee, who was opportunely in Paris helping Colonel Cutler on certain personnel shifts and being interviewed concerning his contemplated reassignment to the Fifteenth U.S. Army. After the First U.S. Army visit, Colonel DeBakey had visited the Ninth, Third and Seventh U.S. Armies. His visits in the army areas had included conferences with the army surgeons and their surgical consultants and some corps surgeons. He had visited auxiliary surgical groups, evacuation hospitals, convalescent hospitals, field hospitals, and collecting and clearing stations, and, in the 75th Division area, he had visited a battalion aid station in action. He was at this time, 3 April, continuing visits to communications zone facilities in and around Paris.


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In the afternoon, 3 April, Colonel Cutler left with the visitors from the Mediterranean theater for the United Kingdom.

In the United Kingdom, they met with General Spruit and Colonel McNinch and planned an itinerary for the officers from MTOUSA. The tour included a visit, on the first day, to the showpiece of rehabilitation facilities, the 327th Station Hospital; hospitals of the Cirencester hospital center the second day, with special attention on the specialized treatment facilities of the center; and, on the third day, a trip to Oxford University to visit with Professor Florey and, later, visits to the 97th and 91st General Hospitals nearby. Colonel Spurling and Colonel Morton were sent out to escort the visitors while Colonel Cutler remained behind to arrange for their meeting with members of the staff of the DGMS, British Army, and for a continuation of their tour by visits to the First U.S. Army.

On Thursday, 5 April, however, Colonel Cutler learned during a telephone conversation with Colonel Pisani on the Continent that General Hawley wanted to see Colonel DeBakey soon. Colonel Cutler instructed Colonel Pisani to ask General Hawley to defer any meeting with Colonel DeBakey until he, Colonel Cutler, could get back, which would be the next day. Colonel Cutler returned to the Continent on 6 April. Before taking his hasty departure from England, Colonel Cutler had spoken by telephone with Colonel Spurling and Colonel Morton on the trip being taken by General Stayer and Colonel Churchill. He was pleased to note: "Reports were highly satisfactory."

Back in Paris, Colonel Cutler joined in conference with General Hawley and Colonel DeBakey on Saturday, 7 April. In the conference, Colonel Cutler emphasized the fact that the Army in the European theater, and the medical service in support of that Army, were extremely busy. He stressed the point that the professional care of patients must be planned and executed with the single thought in mind of the influence of tremendous numbers of casualties on professional activities.

On his return to the Zone of Interior, Colonel DeBakey reported to The Surgeon General in a letter, dated 17 April 1945, as follows:

The therapeutic adjuncts and basic surgical principles utilized in the program of wound management developed by the theater surgical consultant and his consultant staff and presented in various publications of the Office of the Chief Surgeon are being effectively applied by the surgeons in the Army hospitals. The Army surgical consultants have contributed immeasurably in the implementation of this program. In general, the policies established by this program of wound management conform closely with those presented in the recently published War Department Technical Bulletin (TB MED 147, March 1945). The development of this rational program of wound management and its successful application have been largely achieved through the profound influence of the theater surgical consultant and his staff. The attainment of such a high standard of surgical practice and the gratifying results achieved form a signal tribute to his broad vision, his untiring educational efforts, and his trenchant surgical judgment. The admirable manner in which he has performed his function is further reflected by the fine spirits of cooperation that exist between his staff and the Army surgical consultants and the respect and loyalty manifested by the surgeons in the hospitals toward him.


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That same evening, after the conference with Colonel DeBakey and General Hawley, a telephone call came in to the Chief Surgeon's Office from the Third U.S. Army-General Patton urgently requested Colonel Cutler's presence and was sending an airplane for him. Colonel Cutler was instructed to be ready to leave the first thing the next morning.

At 0800 hours on Sunday morning, 8 April 1945, Colonel Cutler left Paris by air, taking Colonel Pisani with him. Some 2 hours later, they arrived at Headquarters, Third U.S. Army, where General Gay, Chief of Staff, and Colonel Odom met them. From the headquarters, they went to the 34th Evacuation Hospital to look at the officer for whom consultation had been requested.

This officer, a Colonel "W." of Armor, had been captured by the Germans in North Africa more than 2 years earlier at the battle of the Kasserine Pass, where he had distinguished himself by bravery and exemplary action. He had been shunted through various prison camps by the Germans and had recently arrived at the camp at Hammelburg, east of Kassel. General Patton, learning that there were American prisoners at the camp, in characteristic fashion sent a special armored task force knifing through the enemy defenses to liberate them. Colonel "W.," the ranking officer among the Americans in the camp, accompanied the German camp commander out of the compound under a flag of truce to surrender the camp to the oncoming Third U.S. Army task force. As he did so, a sniper shot Colonel "W." from very close range, and he was taken back to the camp for treatment. Meanwhile, the Germans surrendered the camp, and some of the liberated prisoners were loaded on the tanks for evacuation back to the Third U.S. Army lines. Strong and persistent pressure from a retreating German Division, however, forced the task force to withdraw under perilous circumstances. It was not until some 4 days later that Colonel Odom was able to fly to Kassel, join a combat patrol, and, skirting the fighting still going on around Hammelburg, enter the camp. During the night, he gave Colonel "W." what emergency treatment he could, including a transfusion of whole blood. The next morning, he called back to Third U.S. Army headquarters and requested that light aircraft be sent up. Two such aircraft were sent; Colonel "W." was evacuated to the 34th Evacuation Hospital in one, and Colonel Odom returned in the other.

Colonel Cutler found the officer's wound most unusual. The sniper's bullet had entered just below the right groin externally to the great vessels, must have passed under the neck of the femur, and emerged through the anus and buttock area, blowing out a considerable amount of tissue and the coccyx. A Serbian doctor in the prison camp had debrided the wound as well as he could with the limited facilities available to him and had sewed the sphincter, which was now intact. The wounded officer was having his second transfusion. He obviously required proctoscopy in order to determine the extent of damage to the rectum. Proctoscopy might reveal that a temporary colostomy was indicated until the rectum could heal. To Colonel Cutler, he looked well enough to transport.


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Back at Third U.S. Army headquarters, Colonel Cutler advised General Patton that the officer should be taken back to the 1st General Hospital in Paris to carry out the necessary examinations and operations. The General agreed to follow any advice the consultants gave him and expressed his gratitude.

After lunch, General Patton loaned the consultants his personal staff car so that they could go to Heidelberg to visit Dr. Richard Kuhn, the winner of the 1938 Nobel Prize in Chemistry. Dr. Kuhn, up to the time of the war, had been the director of the Max Planck Institute for Medical Research at the University of Heidelberg. He was one of the first to describe the constitution of riboflavin, vitamin B2. It was Dr. Kuhn who had first isolated 1 gram of riboflavin, vitamin B2, from 53,000 liters of skimmed milk. Dr. Kuhn had also isolated pyridoxine, vitamin B6.

Dr. Kuhn mentioned to the visitors, Colonel Cutler, Colonel Odom, and Colonel Pisani, that he had placed himself in considerable jeopardy by having spoken openly against the Nazi party. He said that an SS trooper lived in the institute and knew everything that went on. He informed the visitors that Dr. Martin Kirschner had passed away 3 years earlier (1942) and had been succeeded by Dr. K. H. Bauer, formerly of the University of Breslau.

Reviewing his wartime work, Dr. Kuhn first corrected a prevailing misconception that he had created a substance that acted as insulin and could be taken by mouth. He mentioned a complex unsaturated hydrocarbon that he had isolated which was similar to some of his other discoveries among the long-chain compounds containing conjugate double bonds. This deep-blue liquid had been found to be an effective bacteriostatic agent in experiments conducted in vitro against gram negative organisms. It had also been proved very useful against mustard gas injuries of the skin, although it had not been developed for general issue in the German Army. He also mentioned a product, "3065," that had been synthesized by a Professor Kahn. This product acted like penicillin and had been used extensively in experiments involving man and animals. It appeared especially efficacious against Staphylococcus aureus and gonococcus. With respect to the latter, it had proved particularly useful in genital infections of women proved to be sulfonamide resistant.

At dinner that night, at the Third U.S. Army headquarters mess, Colonel Cutler was pleased to meet John J. McCloy, Assistant Secretary of War, who was inspecting in the area. Among other items, the Assistant Secretary declared, during a discussion on the difficulties in paying troops in the European theater, that his chief difficulty with the Finance Department was having sufficient money printed! General Patton singled out, as one of his difficulties, getting decorations for acts of valor occurring in the Third U.S. Army. He stated that he had been able to obtain only two Congressional Medals of Honor for members of the Third U.S. Army, one of which had been given to a medical aidman.

The next morning, the consultants were up early to attend the departure of Assistant Secretary McCloy. Later, they went to the 34th Evacuation


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Hospital with General Patton where they dressed Colonel "W." They then put him in an ambulance, took him to the airplane, flew him to Paris, took him to the 1st General Hospital, and arranged details for the proctoscopy to be done the next day. Colonel "W." was eventually evacuated to the Zone of Interior where he recovered completely from his wounds and continued to serve on active duty, becoming a general officer in the U.S. Army.

Later that month, Colonel Cutler also met with a neuropsychiatric mission of distinguished civilian consultants headed by Dr. Karl Menninger to study the changes occurring in neuropsychiatric casualties during their evacuation from the front to the rear. There were conferences with Col. Esmond R. Long, MC, Consultant in Tuberculosis in the Office of The Surgeon General, concerning the care of recovered Allied military personnel. Colonel Cutler was also pleased to renew his friendship and talk with U.S. Senator Leverett Saltonstall, when he visited the theater late in the month.

"A Piece of Sadistic Thinking"

As more and more of German soil was conquered, the peoples of the Allied nations were shocked to learn of the horror which had been perpetrated by Nazi fanatics in their prison camps. In a way, too, they were humbled at the extremes to which man's inhumanity to man could be carried. The stories of these camps-Buchenwald, Pilsen, and many others-have oft been told by the soldier, statesman, and journalist. Each has contributed from his particular frame of observation in the telling of the complete story, and the doctor at war may tell his story, too, in a slightly different light from the others. Colonel Cutler visited Buchenwald on Saturday, 28 April 1945. The following account of his observations-unpolished and hastily written immediate recollections of his visit-were taken from his official journal:

We were given a 'plane and were lifted by air from Paris to a field near Weimar at 9 a.m. The party included Colonel Shook, Colonel Tovell, Colonel Long (from SGO), Maj. [Sarah] Bowditch, Major Loizeaux, Major [Malcolm E.] Beckham and Corporal Sansone. Rough ride under low clouds, just above trees, for 2¾ hours. At the airport near Weimar, I believe R-7, found an ambulance company, No. 429, who were working for the evacuation hospitals in that area; set up and had lunch; it was raining.

We were given two ambulances to take us to the camp, and took with us the crew of the aircraft, who were anxious to see the camp, and three correspondents who attached themselves to us. Found the 45th Evacuation Hospital set up next to the gate of the camp, but Colonel Zehm was away for the moment. Went to the gate and it was obvious that great restrictions had now been placed upon visiting this camp. Our orders were sufficient authority for us to enter but the newspaper correspondents were not allowed, though I did get permission to take in the crew of the aircraft, who were grateful for the opportunity.

We were shown around by two guides, one of whom was a doctor, a Slovak from Prague, captured in 1939. He told us that the original camp was built in 1937 for 7,000 people, and that in 1939 the first Czechs came in, the camp having been used for political prisoners, not war prisoners, preceedingly. We were shown the crematorium, with the beating room beneath it. Wards, rooms off wards, where so many patients a day-usually 30 or 40-were taken out for an injection, died and never returned to the ward. We were


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FIGURE 121.-Four-tiered compartments in a so-called hospital ward, Buchenwald Concentration Camp.

shown a ward, at the end of which operations were done, which housed children as well as men. In this ward there were four tiers of bunks, each compartment about 6 feet wide, and six lay in these compartments (fig. 121). The guide told us that 3,400 died in the hospital section alone, many of them with tuberculosis. We were told there were still 20,000 there, that only 2,000 French had been removed.

At a laboratory building, we saw tatooed sections of human skin, which apparently was a pet hobby of the former commanding officer, and we went through the tuberculosis ward and other wards in detail. In all, we were told, 51,000 people had died in this camp.

Comment: The fact that they used a crematorium to get rid of the hundreds that died daily is no criticism; it is the most intelligent and the best way to keep sanitation adequate.

The beating room beneath the crematorium, where there were hooks on the walls where men were strangled, and where they had a noise machine so that the cries of those dying could not be heard elsewhere, was unpleasant. Also, the rooms off wards where men were taken for injections, and subsequently died, was a piece of sadistic thinking in line with the German attitude. They might say in defense that this was euthanasia, that all these people were suffering and about to die. We were told, however, that sometimes young people died under similar circumstances, whether because their skins with tatoos were desirable, or whether because they were political agitators, no one will ever know.


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FIGURE 122.-Evidence of the starvation policy found at Buchenwald Concentration Camp.

The crowding, the placement of children on benches and in cubicles off an operating theater, the filthiness of the whole place, was something that cannot be denied.

The obvious starvation policy was pictured everywhere (fig. 122). I saw many men breathing with difficulty, sitting in bed and obviously soon to die, but whether with tuberculosis or other disorders, I did not determine. I talked to a young Pole, who said he was 17 and had been a prisoner three years; and I talked to many Russians, Jews and Poles, whose only release can be a kind and rapid death, for recovery appears impossible in such people.

The hospital section had really been well cleaned up. Floors had been scrubbed; it smelt and looked clean, but the bed linen was nasty and the whole thing looked hopeless. In the tuberculosis ward two men with tuberculosis were practically in bed together, coughing with each other. They all said they were much better and that the food was vastly improved, but such a mass of sick and starved humanity left a bad impression.

We were told that the Germans of the population nearby felt no responsibility; said they did not know it was going on, though on frequent occasions they were turned out to watch hangings of prisoners. Moreover, a renovated stables where some 7,000 Russian soldiers were shot in the neck when ostensibly backed naked against a wall for measuring, was just another part of the whole picture.

Colonel Cutler's journal entry for the same day, 28 April 1945, continues with details of conferences held with members of the Army surgeon's staff, Headquarters, First U.S. Army. The questions discussed were more-or-less


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characteristic of the entire front at this time-what to do about German military personnel and civilians requiring care; the problem of Soviet nationals, Poles, Czechoslovaks, Yugoslavs, and others liberated from the prison camps; idle specialists in the First U.S. Army's medical service; and so forth, as follows:

After leaving the camp, we had a talk with the commanding officer of the 45th Evacuation Hospital and then went to headquarters of the First Army in Weimar, where we discussed the care of these people with Colonel Snyder, Colonel Amspacher, Colonel Crone and Colonel Crisler. The First Army have adopted the following system:-they have a captured Major General of the German Army, Medical Corps, who has seen 33 years' service, and seemed to be able. They are giving him the responsibility of caring for all Germans, whether Army personnel, wounded in their hospitals or the civilian population. The First Army area has been broken up into districts under this German General and they have attached certain Medical Corps officers to him and in his district for overseeing the care of these people. The only difficulty that remains, since all the German Army casualties be kept where they are, is what to do with them when they are ready for discharge from hospital (this matter was discussed in detail with Colonel Fancher this morning and a paper submitted to him regarding it).

The care of RAMP is difficult and will be looked after by the teams of medical officers set up by the Army for this purpose. Insofar as possible, the RAMP will be kept where they are, their food improved and as much care as possible given to them. Every attempt will be made to utilize their own medical personnel. The only exceptions to be made will be that all tuberculous people be screened, removed from the RAMP hospitals and taken to Bad Berka a few miles out, for improved care.

Conference with Colonel Crone [medical consultant]. If he is not to return to the ZI he desires to take a course in tropical medicine to improve his usefulness in CBI. Colonel Middleton is implementing this.

Conference with Colonel Crisler. The First Auxiliary Surgical Group, attached to the First Army, are being returned to the headquarters. His own Auxiliary Surgical Group, the 3d, is being pulled in and he would like to send them to our Communications Zone hospitals soon. I approved this and hope he will send in recommendations so that we may use this valuable professional personnel in our busy Com Z hospitals.

Brought down a load of guns and swords for Colonel Doan.

Left by 'plane at 4:30, having picked up a full load of officers and newspaper men trying to get out of the First Army area, back to Paris. The trip back took three hours; it was by far the worst air trip I have ever taken, in spite of the fact that I have flown, since I have been in the Army, some 25,000 miles, including the great trip to Russia and back. It snowed hard while crossing the Rhine area, one could scarcely see the wing tips and, barely visible a feet below us, tree-tops, while mountains were about us on all sides. I shall send a note of commendation to the commanding officer of the unit to which the pilots who took us there belong, expressing our appreciation for their excellent services.

V-E DAY

Victory in Europe, V-E Day, came as no surprise to anyone. For days, its imminence had been the headline news. When it did come, there was some conjecture as to whether it was 7 or 8 May; it was 8 May. Colonel Cutler was in London at the time. Whether this was by coincidence or choice, his diaries do not say, but it is not difficult to conjecture that it was the latter.


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AFTER V-E DAY: GETTING OUT

The period after V-E Day settled down into a routine uninspired but still full of pressing items. All realized, with various feelings and motivations, that there was still a war on, but there was very little enthusiasm left.

Miscellaneous Activities

Physical standards and redeployment.-The projects of physically profiling all enlisted men and redeployment went hand in hand, for the second could not be accomplished without the first. Accordingly, the making out of the physical profile serials became a problem of extreme urgency in the post-hostilities period. Colonel Cutler, himself, was more personally involved, however, in the selection of professionally qualified surgical personnel for redeployment and the organization of professionally balanced and qualified units to be shipped to the Pacific and Asiatic areas. This eventually became a nightmarish activity. "What a life," the diary states, "Redeployment a terrific headache." Then, later: "It has all been a jumble. We're all exhausted and probably don't make sense, but I think there will be a Congressional investigation of redeployment-there should be. I've told Hawley so. Asked him to exonerate Professional Services Division as we have no authority, therefore no responsibility." Officially, in his semiannual report to the Chief Surgeon for the first half of 1945, Colonel Cutler stated:

Following V-E Day, redeployment began rapidly and pushed the Professional Services Division into greater activities, at a time when it was exhausted. While the theater was feverishly searching for a critical score system, and even before it was available, we had to assemble balanced professional units for immediate redeployment. During the phase of redeploying the first * * * units direct to the Pacific, urgent cables from Washington instructed us to send home about 1,000 doctors. Lists of certain critical specialists in fixed numbers were included. These were rapidly gathered and were ready for transshipment to the Zone of Interior by early July. This further depleted the supply of specialists to a critical point, since this theater never had a sufficient quota for adequate T/O coverage. Redeployment demanded the greatest co-operation between the Personnel and Professional Service Divisions. The Personnel Division drew up plans and, although every attempt was made to assist them, the result has not always been satisfactory. Redeployment of professional personnel has not been on a strictly professional basis, and only irregularly submitted to this Division. Although the point score may seem fairer than any other, it has definitely compromised the setup of these units. In disregarding longevity of service, it has worked hardship on a group of highly trained professional people. The Army has lost many of its best and critically needed officers, who are more tired and worn out than the general lack of battle stars, points and decorations might indicate.

Battle casualty survey team.-The Operational Research Section, Office of the Chief Surgeon, under Maj. Allan Palmer, MC, had been reconstituted as the 250th Medical Detachment, and, after 10 weeks of feverish activity, the necessary personnel and equipment had been assembled and authority had been obtained for independent action in the Third U.S. Army area. Colonel


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Cutler had great hopes for the collection of significant data by the team-an expectation which was the culmination of Colonel Cutler's efforts since his first days in the European theater. He had personally arranged with the Third U.S. Army commander, General Patton, and his chief of staff, General Gay, that every consideration would be given for the efficient employment of the team. But, even after the team was prepared to move into action, there were many administrative obstacles to be overcome before such an unusual unit could be moved from Cambridge Cemetery, England, to the Third U.S. Army front in Bavaria and Bohemia.

When the unit finally reached its destination, but 2 days of fighting remained before the surrender and the total number of casualties sustained during the period in the area in which the survey team was to operate turned out to be 21-12 killed in action and 9 wounded in action.

Colonel Cutler was disappointed that the casualty survey team could not have functioned sooner. It was small recompense for his work, but, in the period after V-E Day, the 250th Medical Detachment was singled out by Washington as a unit to be retained intact for possible redeployment to the Asiatic areas. At least, it seemed, someone else might obtain some use from his work.110

Transfusion reactions.-Maj. Charles P. Emerson, MC, who had been sent to the Ninth U.S. Army to study transfusion reactions, completed his studies and submitted a preliminary, but extensive, report on his findings. Other studies on the problem, notably that by the 43d General Hospital, were also consummated to contribute to the pool of overall knowledge on transfusion reactions. In a memorandum, dated 19 May 1945, bringing the Emerson report to the attention of General Hawley, who was personally greatly interested, Colonel Cutler stated:

2. * * *

a. Investigations point that there is a case against old or aged blood. Apparently a certain amount of blood becomes hemolyzed through the packing of red cells at the bottom away from the diluent. This is always more extensive when the diluent is a small quantity, such as the 160 cc. amount rather than the 500 cc. amount. The agent causing the reaction is stroma of the red cells, not of the free hemoglobin.

b. Transfused cells disappear slowly.

c. There is a definite danger from old ["O"] blood whether from the blood itself or O plasma. This is a relatively new contribution and points out that the universal donor is not without danger.

The renal failure cases seem to be largely due to anoxia, i.e., the period of low blood pressure preceding the transfusion. Thus, it is not the transfusion but primary injury of the cells through anoxia.

110(1) Palmer, A.: Report of a Ground Force Battle Casualty Survey Initiated Two Days Prior to V-E Day, With Appendix II, Diary of the 250th Medical Detachment. [Official record.] (2) Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962.


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Major Emerson, in his report, laid great emphasis on the point briefly mentioned by Colonel Cutler, the danger of the concept of the universal donor. The report stated:

The importance of these findings, from the practical point of view, lies in the following inferences:-

1) Repeated injection of group O blood into other than group O patients may be an ineffectual and uneconomic procedure, except in emergency replacement therapy.

2) The transfusion of very large amounts of group O blood, and even of pooled plasma, into recipients of other blood groups may result in serious hemolytic disease, as has been noted in certain cases with severe burns requiring massive plasma transfusions.

3) It is possible that irreversible organic changes involving the kidneys, liver, central nervous system, and other organs, could occur as a result of prolonged and diffuse intracapillary agglutination.

The implication is strong that, whenever feasible, strictly compatible blood, of the same group as the patient, should be used; and that, under conditions that render the exclusive use of group O blood advisable, only blood of low titer should be supplied. There are strong reasons to suspect that even pooled human plasma, with low agglutinin titer, when administered in very large amounts to individuals of blood groups other than group O, may have undesirable or even dangerous effects, and that the use of fractionated human albumin would be far preferable in such cases.111

Tobruk splint studies.-Studies on the efficacy of the Tobruk splint, so popular with the British, were completed under the direction of Colonel Manning, orthopedic consultant to the Ninth U.S. Army. The results of his studies were read at the last grand meeting of American and British consultants to be described below.

Rank and promotion.-As the years passed during the war, Colonel Cutler became more and more incensed at the inequalities of the promotion system in a theater of operations that was inexplicably tied to tables of organization and seemed to give the higher ranks to those in command and administrative positions at the expense of those in professional positions. For the last 2 years of the war, Colonel Cutler made the correction of these seeming inequalities a personal battle which he fought at every opportunity. The discussion at the meeting of the Chief Surgeon's Consultants' Committee on 30 December 1944 brought out well the facets which made the problem so difficult of solution. The following minutes show that Colonel Cutler brought up the matter by mentioning the inequality of the rank of otolaryngologists, previously referred to, and the discussion which ensued:

Col. Cutler: It has been brought up repeatedly that there are discrepancies in rank that we find difficulty in correcting. One in the new T/O, for instance, where the otolaryngologist is listed as captain. We happen to have some otolaryngologists who are lieutenant colonels and majors. It does present a problem. We also have many expert people who have served their country three years as captains, but it will be difficult for them to be promoted, unless we move them out into an administrative post. Then they will be promoted, but we don't want to lose them. What are we to say about the future of those cases?

111(1)Essential Technical Medical Data, European Theater of Operations, U.S. Army, for June 1945, dated 13 August 1945. Inclosure 9, subject: Investigation of Transfusion Therapy, Ninth U.S. Army. (2) Emerson, C. P., Jr., and Ebert, R. V.: Study of Shock in Battle Casualties; Measurements of Blood Volume Changes Occurring in Response to Therapy. Ann. Surg. 122: 745-772, November 1945.


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Gen. Hawley: verything you say is true. In so far as the specific case you mention as the otolaryngologist being a captain, I think that we can make strong presentations to the War Department to have things like that corrected. I don't know whether the War Department will do anything about it. It is a very difficult thing. Everything you can say that these people deserve rank can't be refuted. When you compare their ability, their training, their value to the government, when you compare them with officers of other branches, or even to other officers within the Medical Department, it is obviously unfair and unjust. There is no question about it. I agree with that wholeheartedly.

Col. Cutler: Would it be proper for us to write this up in the technical data report?

Gen. Hawley: Yes, it is really irrefutable argument.

Col. Cutler: It might be good for the next war.

Gen. Hawley: Yes, it might. You come into the question of a military organization. Now, there has got to be in every organization-it may be a necessary nuisance, but there has got to be a commander, and the wide experience-I am not talking about the Medical Department now; I am talking about the Army in general-many, many years of experience has shown that it is always essential that the commander be of at least one grade higher than anybody else in his organization. All right then, we come down, and nobody could defend in a one-thousand bed general hospital, I think, of rating the commander as a general officer. I think that colonel is all we can defend in a one-thousand bed hospital. Now, we come down to the chiefs of services. They are more or less specialized; their training may be, and usually is, much better, much more comprehensive than that of the hospital commander. Then when we come down to the chiefs of services, we have got to have section chiefs under them. When you analyze the ratings of our officers, and compare the other branches of service with the ratings in the Medical Department, you find that there is a much higher proportion of high rank than in any other branch of the service, with the exception, possibly, of The Judge Advocate General's Department.

I don't believe that we are ever going to solve this problem on the basis of military rank, because I think you run into that formidable thing of weakening the entire military structure when you get into it. Now, if there is any other approach to the problem, some other way-if we can discard rank from pay, for example, or any other way to give recognition to these people, we may be able to get them, but when we get right back into those things which were tried for 74 years in our army, and it worked awful. It didn't make for a very smooth staff, and particularly in the Medical Department, so they fought for years and years and finally they got general military rank instead of rank within their own branch, and I don't think that anybody who knows the history of those 75 years would want to go back to that system. I think that the thing that we have got to foster-this may sound silly to you; I realize that I am talking from a different point of view. I am trying to take into consideration your point of view. I know it is easy for me to talk and pat you on the back, because it was only through the channels of chance that I got much more than I deserved.

I was down in Nicaragua with Dan Sultan, who is now in the India Theater * * * That is separate from China-Burma now. He showed me several reports from some young Engineer officers. I knew about what the second lieutenants out of the academy were like, and these men were at the top of their class. Some of them were rated very, very low, and yet they were better officers than those in the same grade in any other service, and I said to him, "My God, man, what are you doing to these people? Compared to some other branches of the Service, these lads are superior plus. They have got everything." He said, "Yes, but that isn't the point. I am not rating them according to the other services; I am rating them with Engineer officers. They may be superior plus compared to the rest of the Army, but I am rating them within the Corps of Engineers."

That is one point of view. I think we are going to have to go back to that old­fashioned hillbilly religion, where they take the attitude that we are not going to set our rewards on earth, but in Heaven. I don't know of any way of recognizing by military


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rank the high professionally qualified experts and at the same time preserving the military structure. If anybody can work out a more feasible plan, that will fit both of those requirements, I will go along with it. On the other hand, I think it is quite correct to put that in a report, and I will send it to The Surgeon General.

Col. Cutler: In the last war, it was felt that this terrible matter of rank consciousness which is doing so much injury now is due to the fact that there has been too much rank given. I was up in the Ninth U.S. Army, and I saw four evacuation hospitals with young colonels commanding. I don't see why the commanding officer of a 400-bed evacuation hospital should be a full colonel. If they had left it down to a lower grade, there wouldn't be this problem. There is certainly a lot more trouble in this war than in the last war.

Gen. Hawley: I think that it is a good point to take up with The Surgeon General. I think they are overrated. Well, all I can do is to say that I am terribly sympathetic, and I will support any program that will solve this problem.

The first result of this discussion, and the General's promise to do anything he could about it, was that, whenever necessary, hospitals were exhorted to carry specially qualified professional personnel as overstrength to be absorbed by the total number in various grades regardless of the position for which these grades were specified. This permitted the placing of well-qualified specialists wherever they were needed, regardless of vacancies, but it certainly did not enhance their popularity. Moreover, this procedure had merely permitted the unrestricted placement of "over in rank" professional medical officers, but did not, per se, clear a path for their promotion.

The alternative, within the existing system to provide positions calling for higher rank was to obtain tables of organization for larger hospitals. Quite fortuitously, at about that time, the War Department informed the European theater that no more hospital units could be provided from the Zone of Interior, and, if more beds were needed, some of the 1,000-bed units presently in the European theater would have to be expanded.

When General Hawley received this information, he called Colonel Cutler and Colonel Middleton into his office and instructed each to give him the names of the twelve best chiefs of surgery and of medicine in the European theater. He told them that the hospitals to be expanded had to be selected on the basis of the adaptability of present plants and facilities to expansion, and that it was unfair to afford the opportunity for increased rank upon any such basis. Therefore, he said, before announcing the hospitals to be expanded, he would transfer the best chiefs of surgery and medicine into them so that these men would get the promotions.112

Colonel Cutler selected the surgical individuals personally with the advice and recommendations of the other consultants. He interviewed each individual selected as to whether he would leave close friends and working associates for the dubious reward of recognition by an advance in rank at a strange hospital. It so happened that most of those deserving promotion to the rank of colonel were in hospitals in the United Kingdom, while the hospitals with

112Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 17 Sept. 1958.


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expanded tables of organization were on the Continent. Now, these individuals singled out for the new promotion positions were superior officers, and everyone knew it. Hospital commanders and General Spruit, the United Kingdom Base surgeon, were not inclined to release them. Again, through the persuasive efforts of Colonel Cutler, and eventually, by the positive actions of General Hawley, these objections were overcome. Meanwhile, individuals in these hospitals with expanded tables of organization who thought they were deserving of the promotion had to be pacified, and the hospital commanders, from whose hands the requests for promotion had to emanate, required close scrutiny so that they would not give the rank called for by the professional position to some other officer.

After these herculean efforts, recommendations for promotion had finally been submitted for the selected few. Periodically, Colonel Cutler was obliged to ask what was happening to the promotion requests and to exhort their rapid promulgation. For instance, on 19 May 1945, he wrote, in a memorandum to the Chief Surgeon, the following:

1. At your request we brought over to the Continent the seven best surgeons we could find. This was done after considerable difficulty with General Spruit and all the Hospital Commanders who were affected.

2. It was my understanding that these officers would be promoted to the T/O vacancies of Colonel.

3. None of them have been promoted, and I have serious misgivings about their being promoted, for at the 203rd I understand the Commanding Officer has put in the Executive Officer for one of the colonelcy vacancies.

4. I believe failure to promote these men will be highly destructive of morale and broaden the chasm between the Regular Army Medical Corps and civilian doctors which it will be extremely difficult to heal.

5. Perhaps you feel this is important enough to take action personally.

The ultimate result was that, by theater policy, all promotions in a wide category of units were suddenly frozen before these selected officers could be promoted, although the necessary requests had been submitted a long time previously. The Chief Consultant in Surgery, on this untoward turn of events, asked whether exceptions could not be made in the case of those whose promotion recommendations had been submitted prior to the restriction. He was asked to cite specific examples as basis for pressing the case. Citing the case of three officers on 22 July 1945 in a memorandum addressed to the Deputy Chief Surgeon, General Cutler wrote:

1. * * *

Note that the original promotion request went in in February 1945 and was just kicked around by the worst kind of red tape.

2. General Hawley asked me to submit individual instances of this kind and said that some relief could be had. It would, in my opinion, be a far better solution to have G-1 draw up a general recommendation, stating that officers whose request for promotion was submitted in good faith and approved at all levels preceding V-E Day, but whose promotion did not go through because of red tape, should now be permitted the channels for promotion. If this cannot be done, something should be done to wipe out the most regrettable situation which has occurred because of Army red tape and favoritism.


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FIGURE 123.-Colonel Shook, General Hawley, and newly promoted Brig. Gen. Elliot C. Cutler.

On 11 August 1945, the day before his departure home and, possibly in the last paragraph of the last piece of official action correspondence to be prepared by Brigadier General Cutler, he bitterly and plaintively wrote:

5. I should inform you also that General Hawley and I submitted to General Lee the names of those surgeons who were brought to hospitals with increased T/O's in March, for promotion to full colonelcy. General Lee promised he would see these things through, and I hope the matter will not be forgotten. These men were brought here in good faith, they have filled a T/O vacancy for the required time, and Army red tape should not jeopardize their greatly deserved promotion.113

The U.S. Senate, when asked to consent to his promotion to temporary brigadier general rank, among others, was quick to comply (fig. 123). But General Cutler could not budge what he called the "red tape" in the theater with respect to the promotion of a mere handful of deserving, outstanding surgeons-lieutenant colonels-to full colonels.

Professional services for the occupation army - From time to time during the posthostilities period, General Cutler, by request, made recommendations for the organization of professional services in the occupation army. It was planned to have a system of hospital centers to administer the farflung network of hospitals which would be required for the occupation forces. The

113Memorandum, Professional Services Division (Brig. Gen. E. C. Cutler) to Deputy Chief Surgeon, 11 Aug. 1945, subject: Status of Professional Service Division, 11 Aug. 45.


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prevailing system of appointing qualified specialists in hospitals of a particular center as consultants in their specialties for the hospitals of the center and the surrounding area was quite applicable for the contemplated centers of the occupation force. Likewise, the system of surgical coordinators to coordinate the surgical activities within a hospital center was quite appropriate. Thus, new directives outlining the functions and operations of hospital centers included these plans just as they had been operating for some time.

In a memorandum, dated 6 July 1945, General Cutler advised the Deputy Chief Surgeon concerning the plan for the constitution of the Professional Services Division as it was to serve USFET (the U.S. Forces in the European Theater), the posthostilities command. General Kenner, who had relieved General Hawley as Chief Surgeon, accepted in principle the concept expressed in the following excerpt from this memorandum:

2. I spent five hours on 5 July with General Kenner, discussing matters relating to Professional Services Division, ETO, and redeployment. This conference resulted in the following plan for the Division of Professional Services, ETO, being approved by General Kenner:-

a. There are to remain in Professional Services Division the following officers:-

One Colonel, Chief of Division.
One Colonel, Chief Consultant in Surgery.
One Colonel, Chief Consultant in Medicine.
One Field grade officer, Psychiatry.
One Field grade officer, Orthopedic surgery.
One Field grade officer, Consultant to WAC.
One Executive officer.

b. In addition to these officers permanently assigned to the Office of the Surgeon, ETO-Com Z at this time, and later to move to U.S. Forces Headquarters, Frankfurt, there must be in the Paris hospitals thoroughly competent specialists in the following fields: Radiology; Otolaryngology; Neurosurgery; Maxillofacial surgery; Anesthesiology; Ophthalmology; Urology; and Burns. These officers should be of high caliber, competent to act as consultants, and holding the respect of their fellow officers for their professional abilities. They in turn, or substitutes for them to be provided later, must be moved to hospitals near Frankfurt when Professional Services Division moves to Frankfurt from Paris-Versailles.

3. The group of consultants in Paris will be the only consultant group in ETO, other than Army consultants, and they will continue to function to set proper professional standards and policies for the optimum care of the American soldier. In particular, during the period of redeployment, when confusion exists, visits to hospitals must continue in order that there be no relaxation in the care rendered by the Medical Department.

4. In order that this program be implemented immediately, it is now requested that orders be issued moving Lt. Col. Hall G. Holder, Lt. Col. Wm. Field and Lt. Col. Currier McEwen on D/S into the Office of the Chief Surgeon, so that they may become acquainted with the duties that they must shortly assume in their entirety.

In the interim before General Cutler was ready to leave the European theater, there were several minor changes to the original recommendations, and General Kenner decided that a director of professional services was not required. Lt. Col. Hall G. Holder, MC, had, however, been ordered to Headquarters, ETOUSA, to understudy the position of Chief, Professional Services


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Division, and was still filling the job on 11 August 1945 when General Cutler advised:

1. I hope to be flying from the Continent on 12 August.

2. Arrangements have been made for Colonel Pisani and Major Loizeaux to leave the theater within a month.

3. By the end of this month, Professional Services Division will consist of the following officers:

Chief of the Division-Lt. Col. Hall G. Holder
Chief Consultant in Medicine-Lt. Col. O. C. McEwen
Chief Consultant in Surgery-Lt. Col. L. Miscall
Senior Consultant in Orthopedic Surgery-Maj. G. T. Aitken
Consultant to the WAC-Capt. Martha Howe

And, for a period of a few weeks, 1st Lt. Jean L. Beatty, PTO [Physical Therapy Officer].

4. The enlisted personnel remaining will consist of 3 EM and 3 WAC, together with 3 or 4 British secretaries.114

Third Anglo-American Consultants' Conference

The long-drawn-out period after V-E Day had its bright moments, too. One of these was the continuation of the conferences between British and American consultants. The first had been held under American auspices in Paris, the second was in Brussels under sponsorship of the British 21 Army Group, and the third reverted to Paris again. The site was the same, the 108th General Hospital; the dates, 25 and 26 May 1945. On each successive occasion of these conferences, consultants who should have been invited to previous meetings, and were not, had been added to the list and, by the time of this third and final conference, there were American consultants from the field armies, base sections, and theater headquarters plus Dr. Karl A. Meninger, Dr. Romano, and Dr. Kubie from the visiting commission of civilian neuropsychiatric consultants to The Surgeon General. From the British side, there were consultants from the headquarters of the British Army, the Royal Navy, and the Royal Air Force and from the 21 Army Group. There were representatives from the Canadian Forces. In addition, as observers, there were Colonel Osipov representing the Soviet Armed Forces and guests from the French Army (fig. 124).

The discussions were lively and the points made were vigorously indorsed or opposed. Coming as they did so shortly after the cessation of hostilities, the meetings were very much a review of thinking on the professional highlights of the war-the failures, the successes, and the unresolved problems. It is most unfortunate that space does not permit the reproduction of the complete transcript of the meetings, for, together, the thoughts expressed represent the combined and individual thinking of the officers who were the leaders in professional medical matters throughout the war in Europe and elsewhere in their respective services and commands.

114See footnote 113, p. 340.


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FIGURE 124.-Participants at the Inter-Allied Consultants' Conference on 25 and 26 May 1945 at the 108th General Hospital, Paris, France.

Medical manpower.-The topic for the general session on 25 May 1945 was medical manpower. General Hawley was chairman of the session and opened the proceedings with the following remarks:

Gentlemen. I have a very happy memory of the last meeting of this group in this room. One of the happiest is that the discussion was full, fluid and often forceful. I hold that up to you as an example and I hope that this meeting repeats. I want to remind you of the famous remark made by Duke-Elder when the inclusion of other people in the membership of this club was the topic under discussion at a dinner meeting. Duke settled the discussion by saying to us Americans: "I can tell you that you don't know what you are talking about, but we can't tell that to some of the other nationalities.'' So I ask, if anyone disagrees with anything that is said here, that he take exception to it. I assure you I shall be a qualified and unprejudiced referee of all bouts here. The subject for this morning's discussion was selected by Colonel Cutler who talked to me about it at length before the program was made. It is a subject which has been very close to his heart for a long time. It is a subject which didn't concern the Americans very much at the outset of the war but has been of increasing concern to us as the war has gone on. Never has it been more critical than it is now with the necessity of redeployment to the Pacific. This is especially true in the field of specialties. It is a subject which has concerned the British from the outset of the war. When I first came to Britain in 1941, I remember meeting with your Medical Manpower Board. They wanted information on our use of medical manpower, and told me at that time of the critical shortage. For these reasons we think that this is a very vital subject. We have


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all had experience in the campaign here. Now do we need more medical manpower or can we do without some that we have? The subject has been divided into echelons of service because obviously the problem varies with the different echelons of the fighting forces.

Accepting General Hawley's suggestion that the meeting pick up the full, fluid, and forceful discussions of previous meetings, the conference proceeded at a lively pace on the discussion of medical manpower as it affected the division medical service, medical service in the field army, and finally the communications zone. Fortunately, the transcript of the meeting contains a summarization written by Colonel Cutler at a later date. His synthesis of the opinions expressed was as follows:

1. The major matter brought up by all speakers, and approved by all, was that highly-trained professional personnel must be kept mobile. This principle referred to the personnel not only in "Army" installations but also in Com Z institutions.

2. The division personnel. It would appear that no cut could be had in the medical battalion personnel attached to the division per se, which numbers about twenty-six (26), but some further cut might be made in the attached personnel which brings the total medical officers in [U.S.] divisions to around forty-four (44), as compared with the British number of thirty (30).

3. Army. All but Colonel MacFee thought the surgical teams should be kept mobile and there was even a suggestion that evacuation hospitals, as well as field hospitals, be largely housekeeping units, though the evacuation hospital should have a medical and surgical chief and a few officers to enable it to give competent assistance when acting as a station hospital.

4. A suggestion was made that the surgical teams should be cut down to one (1) surgeon, one (1) anesthetist, and two (2) enlisted men.

5. The final suggestion was that difficulties of mobility, and thus saving manpower, were more wrapped up in:-

a. Transportation, or
b. Red tape,

which prevented easy interchange between the Army and the Com Z units.

Few of the comments made can here be quoted; however, using Colonel Cutler's summary as a jumping off point, the following excerpts from the transcript were typical of the thoughts expressed.

Colonel Berry, Consultant in Surgery, Seventh U.S. Army, and with experience in North Africa, Italy, and the campaigns in the European theater, said of medical manpower in the field army:

General Hawley and guests. The [types of] Army medical installations of the second echelon, as you know, in our army consist of the field hospital with the auxiliary teams and two evacuation hospitals; a semimobile one of four hundred (400) beds and one of seven hundred and fifty (750) beds. We also have a neuropsychiatric center, a venereal disease center, a convalescent hospital of three thousand (3,000) beds, a mobile army laboratory, an optical unit, and a blood bank detachment. It seems to me our function in the army is twofold: First aid medical care to the patient and retention of the maximum number of ill or wounded soldiers within the army area. The field hospital has been a godsend to us. It was first used in the Sicilian campaign in its present type. It was easy to adapt and carry over and it has been used essentially in the same manner by the various armies conforming to a standard that was finally developed by the Fifth Army where it was perfected. It has operated largely as a housekeeping unit. It has a small head-


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quarters detachment and it has three (3) platoons each commanded by a major with three (3) medical officers. All of the professional work, all of the casualties, have been handled by the auxiliary surgical teams. The three (3) officers have been used to help out in resuscitation, assisting in the operating room and postoperative care. Immediately behind that was the four hundred (400) bed semimobile hospital on the basis of one (1) per division. Now discussion has centered particularly on this unit and the seven hundred and fifty (750) bed evacuation hospital, which we have used on the basis of one (1) per two (2) divisions or one (1) per three (3) divisions. The personnel of the four hundred (400) bed evacuation hospital has twenty-seven (27) medical officers. The seven hundred and fifty (750) bed evacuation hospital has thirty-five (35) medical officers, including two chiefs of services. Now, if you ration patient beds, you will find that the medical officers in the seven hundred and fifty (750) bed unit have about five (5) or six (6) more patients per officer. The seven hundred and fifty (750) bed unit is so styled that it is capable of expansion up to double the number with the same number of doctors and enlisted men. It creaks and groans when it gets over twelve hundred (1,200) beds, but it will go over. The four hundred (400) bed is so streamlined in personnel that it is incapable of going over fifty (50) or one hundred (100) beds more than its table of organization and equipment. The four hundred (400) bed has been made more mobile than the seven hundred and fifty (750) bed. One argument that has been advanced for the four hundred (400) bed evacuation hospital is that it is mobile. Well, the difference is not in the size of the hospital but in the fact that the four hundred (400) bed evacuation hospital is equipped with twenty (20) trucks and eighteen (18) trailers and the seven hundred and fifty (750) bed evacuation hospital until recently has been equipped with two (2) trucks and no trailers. It wasn't the size that made the difference in mobility. That has been overcome by arranging headquarters transportation. Now, the question of saving manpower comes on various stages and it seems to me first from the professional standpoint that these large staffs in the evacuation hospitals could be cut down somewhat. How much I am not prepared to say and the auxiliary teams could be greatly expanded to include groups of other specialists. Let's take the neurosurgical team. That is a highly skilled group. They are needed badly. Having them permanently assigned as the staff of an evacuation hospital ties them up because it is very difficult to move them from one evacuation hospital to another. It is far less difficult to call up or send a message to the commanding officer of an auxiliary group and say that the neurosurgical team is needed and as soon as it is finished it could return to group headquarters. One evacuation hospital has had the same neurosurgical team since August. It became part of the staff. Two others have had theirs for two (2) or three (3) months; one throughout the winter. It seems to me that the same type of team could be greatly expanded. On the latest T/O of the seven hundred and fifty (750) bed evacuation hospital there are at least eighteen (18) on the surgical side and thirteen (13) on the medical side and included in that number are specialists-neurologists, thoracic surgeons, to say nothing of plastic, oral, eye, ear, nose and throat, and other surgeons. It has been very difficult to get all the specialists and yet an army should have that within the army area. All of them should be used where necessary. It is a waste of manpower to send a soldier back to the communications zone for those specialist services * * *.

Col. J. P. Ross of the RAMC, Consultant in Neurosurgery, to the EMS, spoke also, as follows, of the problem of moving medical officers to where they are needed when they are needed:

* * * The difficulty with medical manpower is this. It is exemplified in this chart very well. You have three (3) divisions [echelons] perhaps four (4) and you have communications zone, and these, medically speaking, are all water tight compartments. You give to each of those regiments, divisions, corps, armies, etc., a number of medical men and they think that they own them. They hesitate to allow them to shift, because they


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fear they will not get them back again. In any army or in any campaign a battle lasts only so long and that must always be so. There may be a great many casualties or there may be a few casualties, but the battle can only last a certain length of time because of other factors. If you have an organization which will allow you to move medical men from the front and back again without too much red tape, you can save medical manpower. When you set up forward medical installations with certain skeletal staffs, then you require a pool or a series of pools with medical officers who can be attached. The difficulty we have had in our army, and I think it is the same in other armies, is that of movement of officers. We decide there may be a fair number of casualties in this area and we want to get some medical personnel from the back area. We have had the battle, we have had the casualties, they have been evacuated, and the medical officers are needed in the rear. The necessity is to have skeleton staffs on hospitals, on CCS [Casualty Clearing Stations], and on teams and add to them. You see, what happens is that when a commanding officer of twelve hundred (1,200) bed hospital thinks that he has thirty (30) or forty (40) medical officers and he is quite convinced that he owns them and that if they get away he will never get them back, he will not release them.

Brigadier H. C. Edwards spoke of the tremendous potential usefulness of the British FSU (Field Surgical Unit).

General Hawley, the moderator, asked Colonel Bricker to say a few words as Consultant in Plastic Surgery because most of the discussion had been monopolized by the general surgeons. An earlier speaker had said that specialists were not needed up front and that the more specialized a doctor became, the further to the rear was his place of business. At any rate, Colonel Bricker confined his comments to the specialist in the communications zone, without arguing the point made earlier, as follows:

What I have to say * * * [concerns] * * * the efficient use of specialists in communications zone hospitals. We have a large number of one thousand (1,000) bed general hospitals in the communications zone. It has obviously been impossible to make them self-sufficient. The solution has been the obvious one of putting the specialty in the designated hospitals and placing them in a strategical location and seeing that the patients get to them. This has had serious difficulties because of our T/O in certain hospitals. We need thoracic surgeons, neurosurgeons and plastic surgeons. They have filled the jobs of the assistant chief of the surgical and chief of septic surgery and ward officer. We have had to use them. This means that once they are in the hospital they are assigned. If the situation changes as it can change, we have to change the personnel, that means making the [trade] between hospital center, commanding officer and finding replacement and it takes time and in some cases it has taken weeks. In an emergency we can make a trade quickly. Routine changes have taken a tremendous amount of time * * *. In England we had time to get our plan set up. It has worked very well. On the Continent, it hasn't worked so well because the hospitals were coming in rapidly. The solution, I am quite convinced, is the one mentioned by Colonel Seeley. It is putting specialist personnel in cellular units * * *.

Surgical meeting.-The surgical meeting took place the following morning, Saturday, 26 May 1945. Colonel Cutler was the chairman and moderator. The initial topic was the management of combined bone and nerve injury, procedures which had seen considerable improvement during World War II with the realization and acceptance of the fact that a flail limb was a useless one, regardless of the condition of bone, and that repair of the nerve in these cases had to take precedence over the fracture. It was mentioned that asepsis of the


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wounds seen in World War II was a great factor in permitting the early repair of nerve injuries. Colonel Spurling and Colonel Cleveland were very much in evidence throughout the discussion, which was opened by the reading of a report by Colonel Spurling on the experience of the U.S. Army in the European theater in the management of combined bone and nerve injury. From the British side, Mr. Geoffrey Jefferson, EMS Consultant in Neurosurgery; Brigadier Rowley W. Bristow, British Army Consultant in Orthopedics; and Air Commodore Osmond Clark, RAF Consultant in Orthopedics, carried the discussion. Brigadier Porritt, surgical consultant to the 21 Army Group also spoke at length.

The second subject for discussion was the Tobruk splint. Colonel Manning, orthopedic consultant to the Ninth U.S. Army, opened the topic by reading his paper on the studies conducted in that Army. He explained:

During the months of November and December 1944 five evacuation hospitals assigned to Ninth U.S. Army applied the Tobruk splint to every fracture of the femur treated, with the exception of those cases in which the ring of the splint would cause pressure on a wound of the upper thigh or buttock and those in which skin traction could not be applied because of wounds or fractures of the leg.

Every effort possible was made to obtain a supply of full ring leg splints so that the British technique of application could be followed. However, this was found to be impossible. A technique of application was standardized * * *.

After giving detailed data on the results of the study, Colonel Manning, in his summary, said that 19 percent of the total number of 63 splints were considered to be superior to the spica cast as a transportation splint, 78 percent were inferior, and 2 percent were not recorded on the questionnaires returned. He also mentioned that the comfort of the splint and the opinion as to its superiority did not coincide because 32 percent of the splints were considered to have been comfortable, but only 19 percent were recorded as being superior to the spica cast. His conclusions follow:

The Tobruk type splint requires less plaster, time and work to apply than does the spica cast, but it cannot be applied universally to all fractures of the femur, and does not provide adequate splinting or comfort. The results of the study are conclusive that the Tobruk splint is inferior to the spica cast as a transportation splint for fractures of the femur.

The barrage of opinion from the British side, following this report was pretty much one sided. The minutes describe Brigadier Bristow's comments on the British experience as follows:

He would like it to be clearly understood that he was not going to try to sell the Americans anything, he was not competing with Colonel Cleveland! He was just trying to tell the experience they had had with this splint. The name "Tobruk" was perhaps almost unfortunate because it appeared as if this was something tremendously new and some great invention. It was simply Hugh Owen Thomas' splint, designed in the year 1870, reinforced with a bit of plaster of paris around the outside to keep it snug on the limb while the patient was on his journey. It was a transport appliance and nothing else. The British experience had been that this splint, properly applied, helped patients on the whole to travel back extremely well. The experience now was fairly large; they had seen them return


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from long distances from the Western desert, had seen many in Italy and Africa, and had had over 2,000 femurs back to the United Kingdom out of this theater. We were speaking of a considerably large section, and the experience was not that of any individual man. * * *

As regarded ease of application, he noted that the Americans were now in agreement with the British that this method of splintage did save time and material. He had had a report only a week or two ago from one of the hospital ships, from the surgical specialist, who remarked that he wished people would not send the patients with spicas because he very often had to change them en route and it was difficult to change spicas on a hospital ship. The meeting could take it that it was a considered opinion in Britain, by all types of surgeons who had seen these patients return, that they were satisfied that they do travel home pretty well, and they all thought this a good and useful appliance.

Colonel Eyre-Brook, orthopedic consultant, 21 Army Group, mentioned that the result of finding 19 percent who were of the opinion that the Tobruk plaster had been superior to the spica was very good as a start, considering the difficulties involved in training people to put on the Tobruk as it should be put on, and allowing for various technical difficulties which must have been weighty. Colonel Eyre-Brook had come to the European theater from the Mediterranean completely uninfluenced and stated that he had been quite convinced that the Tobruk splint, properly applied, effectively immobilized the limb and gave comfort.

There were other opinions from the British which generally coincided with these. Colonel Cleveland said that this splint of the Americans was not the Tobruk splint. They had not the same material and had not been able to put it on as well. He stated that this was the Maastricht splint, and it had not been as satisfactory as the spica. General Hawley said that this topic was the "piece de resistance" which had brought him to that particular session. Colonel Cutler closed this subject with the remark that this slight difference over the Tobruk splint served to put in very considerable relief the fact that this was about the only thing concerning which they had had any controversy in the past 3 years.

The meeting then continued on to similarly detailed discussions on anesthesia in war and thoracic surgery with active participation in the discussions on the part of both the British and the Americans. Colonel Cutler, at the close of the meeting, made the following speech:

I wish to take a moment before we part to speak about consultants in general and this group in particular. The life of a consultant is difficult; more difficult in the American Army than in the British Army because consultants are not on a regular T/O and are not a part of our Army in peace time. I know also, as a background to these remarks, that the United States Army Consultant Group in the last war did not have a very happy relation with the officers of the Regular Army. As a result, officers of the Medical Corps were in fact warned of the difficulties that might arise if consultants were used. Thus, officers now acting as consultants started under a certain cloud. Those who had been through the last war and knew of this were able to discount some of their difficulties. The life of a consultant is difficult for many reasons. It is difficult physically and difficult intellectually. It is difficult physically because to be a good consultant one should be steadily moving; it is a peripatetic existence. It is the Hippo-


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cratic method of teaching. It necessitates continual visits to hospitals, ward rounds, conferences with medical officers, all of whom have a differing point of view. And in each place and with each officer advice must be given so that treatment is of a high order and standardized. It is difficult intellectually because you are always meeting new people, always having to convince others by persuasion rather than force, which is a very real strain. In addition, as deficiencies show up new standards must be set; and where personnel are inadequate transfers must be brought about. To move continuously, with inadequate transport, shift your bed each night, eat field rations-to do this day after day and talk to new people day after day is difficult and it is a life of strain. I congratulate the United States Army officers here for having lived through it so well. I know you have done a good job and I know that your Chief feels that way. I wish to add my own deep conviction of satisfaction that you have done your job well; that is all that any man should ask for. You have served your country well and you will be satisfied in that service.

To our British and Russian colleagues I have a different message. We are under a very deep debt of gratitude to each of you individually, and to the group as a whole. You have offered us every facility, and you have offered us the kindest and most generous personal hospitality. It is something we will probably never be able to repay. You all cannot come to our homes, and we cannot thank you individually, and we cannot entertain you in the way we should like. But I know I can speak for all the United States Army officers in this room when I say that if there are any of you who ever do come to the United States of America, each officer here in this room will be happy to entertain you, he will be grateful to see you again, and he will be privileged that you came.

General Hawley then addressed the meeting in the following words:

I think that from my point of view I realize that everything Colonel Cutler has said is true. I was very young and unimportant in the last war, but I have heard handed down to me by the older men who were in responsible positions that the situation in our services in France was not always completely happy with the consultants. Well, I think that the consultants perhaps may have exaggerated that feeling here. Certainly, no group around me has been more essential and more welcome at all times. It takes a lot of adjustment on both sides, and I separate the sides into administrative and professional. It takes most of the adjustment on the administrative side. It takes some little adjustment for the professional men too realize not that things cannot be done, but too realize that we are treating hundreds of thousands of patients instead of one patient, and that all methods and all procedures must be adjusted to that point of view. The policy in our office has been that the only reason for the existence of the medical service has been the care of patients, and there are no administrative reasons why a thing cannot be done professionally for 100,000 patients.

The American soldier, in my considered opinion, has received better care than he has ever received in his life, in former wars or in civilian life. There is only one reason for this, because this Consultant Group of mine have completely directed and administered the care of the soldier, and to them all credit for this is due. Wherever this, in a few cases, has not been achieved, the reason usually is an administrative one, where we have not been able to get that patient and that doctor together at the proper time, and so I say, without any effort at flattery, but most sincerely, that all the good in the care of patients in this theater has come from this group of consultants, and all the bad has come from the administrative side.

I am awfully happy to have had all of you here and, while I shall probably not be having the privilege of meeting with this group again, these meetings we have had will always stand out in all my life as very high spots. Thank you all.


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FIGURE 125.-General Cutler being decorated with the Distinguished Service Medal by Robert P. Patterson, Secretary of War, at Boston, Mass., in 1947.

Military Surgery, ETOUSA, 1944-45

Perhaps, to General Cutler, the greatest honor which was bestowed on him as a result of his wartime activities in the United Kingdom and on the Continent was the invitation from the Royal College of Surgeons of England to give the Hunterian Lecture for 1945. He humbly accepted the invitation, and at a time when he was close to exhaustion, placed all his faculties into an effort to make a worthy contribution to the first resumption of this traditional lecture following the peace in Europe. No more fitting ending could be given to this account of a great chapter in General Cutler's life, which except for 2 short years that followed was his final chapter (fig. 125), than to quote from his Hunterian Lecture.

The topic was "Military Surgery-United States Army-European Theater of Operations, 1944-45." The date was 14 June 1945. General Cutler began his lecture by saying that the mission of the Medical Department, U.S. Army (as far as military surgery was concerned), was threefold: (1) Evacuation of the wounded from the battlefield where their presence jeopardizes morale, and from army hospitals where their care infringes upon the mobility and supply of combat forces, (2) provision of professional medical care wherein


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the battle casualty, medical officer, and proper facilities must all be brought together, and (3) restoration of the injured man to combat. He then proceeded:

To accomplish this threefold mission, there must be a carefully integrated organization, and some understanding of this is desirable if one is to appreciate the results which it has achieved. A primary consideration is the complete interdependence of administration and professional care, on which depends its effectiveness. The civilian doctor is prepared to expend every ounce of energy and all of his time on a single patient, knowing that others can be found to care for additional injured or sick people who might present themselves at the same time. This policy, when one is confronted with thousands and not individuals, must be forgotten in the greater good for the larger number. This change of outlook from the individual to the mass is the chief difficulty confronting the civilian doctor when he enters military service. Moreover, if the three functions of the Medical Department are to be fulfilled-evacuation, medical and surgical care, and restoration to combat fighting-attention must be focused more and more on those who can be returned to duty. By so doing, eventually a greater good for humanity will be achieved, for, if large numbers of men can be restored to the fighting forces, war will end sooner and thus humanity suffer less. This need not result in neglect of the severely damaged soldiers.

After explaining in detail the complete accepted organization of the medical service of a theater of operations, he continued:

* * * only the perfect interdigitation of administrative and professional personnel can lead to a happy solution when thousands of wounded men are handled daily. Professional personnel must be informed where the load is to be borne, how long casualties can remain in one hospital, and what methods of evacuations are to be used if proper care is to be given. And personalities must be forgotten. In spite of difficulties, the professional group always attempted to carry out the policies set by the Chief Surgeon, both those which placed a time limit on professional care and that which demanded of us that the American soldier be given the best care possible under the conditions imposed by the military situation. Administration must set evacuation and hospitalization policies, but these policies and the burden they impose are borne by others. Good results will accrue only when both are completely informed of the labor and responsibility of the other. Directives are no substitute for good briefing, whether the goal be tactical or medical.

Next, General Cutler presented statistical data showing the load carried in the European theater and comparing it with the other theaters of war with respect to total numbers of casualties and the types of wounds received. He began his discussion of professional care provided in the European theater by referring to the Manual of Therapy and the various circular letters on professional policies and procedures. He said:

* * * the Medical Corps, scattered throughout the entire theater, have been willing to assimilate these standardized methods and have greatly improved the original directives by suggestions and additions as experience hardened our opinion or showed flaws and defects in the original methods outlined.

This willingness to accept standardization, the thirst for education in military surgery, and the ability to improve on original standards has characterized our professional colleagues from the very beginning.

Further, on professional care, the general pointed out:

The one item in professional care which distinguishes care from this war from care in World War I, as well as the single factor most directly contributing to the improvement of


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morbidity and mortality statistics, is the resuscitation of the wounded man. This transcends in importance any single method of therapy, such as our ability to procure and deliver blood and plasma to casualties, for it betokens that the American surgeon has at last appreciated the importance of the complete evaluation of his patients before therapy. He has learned to care for the whole of man and not for any fragment or any particular wound. * * *

* * * It is this overall appreciation of diminution in the amount of circulating blood, and this overall desire to look at the whole man, and not the wound alone, that has led to our greatest advance in this war.

Following the discussion of professional care, General Cutler then described the various surgical specialties and their contribution to the war effort. He made a particular point of the importance of delayed wound closure in the restoration of the fighting man to early duty, emphasizing that delayed closure had to be attempted at the first safe moment, that delayed closure did not mean a secondarily closed wound because it had never been closed before, and that delayed closure was not delayed primary closure because there had been no primary closure. General Cutler then attempted to outline the reasons for improved statistics in World War II in the following words:

It would be impossible, at this time, to evaluate and put in proper perspective the reasons why the mortality rates in the United States Army in World War II are one-half as great as those in World War I, but there is every reason to believe that the following have each played a role:

1. Resuscitation. The proper treatment of the patient in shock, chiefly by the use of plasma and blood.

2. Better first aid by the Company Aid man on the battlefield.

3. Penicillin and sulfonamides, which have vastly reduced the horror of infection.

4. Improved methods of transport and evacuation, which allow earlier meeting of surgeon and casualty, and more comfortable travel.

5. Good general physical condition of the soldier. This may be partly diet, or it may relate to the physical training to which he has been subjected before battle.

6. Standardization of therapy and the great medical and surgical educational programs emanating from the Office of the Chief Surgeon, European Theater of Operations. This did not exist in World War I.

7. Better surgery, through better anesthesia, better development of specialists and better training of the young surgeon in the Army.

The surgical technique has been put last to give full credit to obvious new advances that did not exist in World War I, and because no amount of good surgery could play such a major role in freeing the wounded from terrible infection. However, the great debt of every wounded soldier to his surgeon remains a hard fact.

And, finally, General Cutler paid his respects to the civilian doctor in uniform without whose efforts the fine results in the European theater could never have been achieved:

In conclusion, it is fitting to pay a tribute to the civilian doctors of the United States. Of the 16,055 Medical Corps officers in the European Theater of Operations, over 97 percent are civilian doctors who have been but recently commissioned. These civilian doctors have shown a willingness to conform to a standardized method of therapy that does them great credit. At the same time, they have revealed an immense capacity too learn from experience, and it is suggestions from the workers in the field, in all installations, both in the forward and in the rear areas, which have permitted us to improve consistently the methods of


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therapy originally outlined. Their ability to withstand great physical hardship, to subordinate themselves for the good of the Army, their ability to learn in the face of the conditions which have been imposed upon them in the forward areas, all show how very real are the personal attributes of these doctors.115

EPILOGUE I

Elliott Carr Cutler's contribution toward the physical care of the men in the European Theater of Operations is difficult to overestimate. The preceding medical history documents this fact only too well. It seems fitting to enlarge upon some of the personal attributes of this man who bore the principal responsibility of setting the level of professional surgical care in the European theater which he believed, by the end of the war, surpassed that in other theaters.

General Cutler was an individualist, a forceful man tempered by experience and endowed with great charm. He was not readily adaptable to the standardization required by a great war, but he made it his primary mission to cooperate, obey, and implement orders which served the medical betterment of the soldier. Cutler could become volubly indignant over what appeared to him stupidity, negligence, or lack of foresight; on the other hand, he was relentless in his efforts to gain promotion or reward for the men he considered deserving. The observations he had made during World War I had given him a good concept of military procedures which often enabled him to accomplish worthwhile objectives that might otherwise have been missed.

It is difficult to write an estimate of the person who was Elliott Cutler because he had so many facets to his personality. In retrospect, those qualities that stand foremost are dedication, intelligence, and practicality. He had a great sense of and feeling for history. He was in fact a man of parts, with a background in no way confined to medical and surgical knowledge. Extremely well read, and with more than a nodding acquaintance with art, he was a fine sportsman, and, in everything he did, his curiosity, competence, and enthusiasm were boundless. He could, and would, discuss at length anything from cattle raising to sailing to vintage wines. Cutler was not a visionary by any means, but neither were his thoughts confined to present or personal problems. In 1942, he was already considering the eventual victory over Germany, which to him was inevitable, and remarkable that he thought the Allies should take over all teaching after the war. In other words, the man whom all knew as an outstanding surgeon was also one of the most interesting and rewarding friends a man could hope to have.

Whether on philosophic matters or with the more practical concern of supplying the front with blood and plasma, Cutler's mind was always active, inquiring, and inventive. No task was too small; no mission, unimportant. His efforts were unending, and, in view of what we now know about his increas­

115Cutler, E. C.: Military Surgery-United States Army-European Theater of Operations, 1944-1945. Surg. Gynec. & Obst. 28: 261-274, March 1946.


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ingly poor health, it is the more amazing to realize what he accomplished. He never spoke of himself but confided in his diary about sleepless nights, persistent cough, headache, and loss of weight. He fought this personal battle alone, although it was in all probability the prelude to the disease that finally killed him. In the presence of others he was all energy, and wherever he went, which was everywhere, he left the inspiration and heightened morale of his own great spirit.

One thing the war availed him was the opportunity to teach, which he loved to do and which no one could do better. His schedule was crowded with conferences at the Air Force School, at the American School Center, and with the staffs of hospitals or field units. So high a priority did he place on teaching and so great was his power of persuasion that he had little difficulty in prevailing on his British colleagues to help. He arranged for men like Grey Turner, Gordon Gordon-Taylor, Lionel Whitby, Willie Anderson, Tudor Edwards, and many others to address groups of U.S. Army medical officers.

Cutler undoubtedly made enemies, just as every purposeful man does; but, he would never compromise with his own high standards, and most of the quarrels involved the maintenance of these standards for everyone. Of far greater importance are the friends he made for all of us. Some of these friends he had met 25 years earlier during service abroad in the First World War, and others knew of him through his own professional attainments. No man tried so hard and so successfully to unite the efforts of the Allied medical forces. The following eulogy written by Sir Gordon Gordon-Taylor in 1947 after Cutler's death gives eloquent expression to this:

"The death of Elliott Cutler * * * will occasion deep sorrow in the hearts of his many friends in the United Kingdom. Perhaps no surgeon of the United States ever yearned or strove more earnestly to forge lasting bonds of friendship, not only between the surgeons, but between the peoples of the great English-speaking countries on either side of the North Atlantic, and to this end he directed both written and spoken word."

Despite his sophistication, Cutler was delighted at being made an Honorary Fellow of the Royal College of Surgeons of England and the Royal Society of Medicine. He was similarly honored by the Royal College of Surgeons of Edinburgh, and, as a final, unique award, he was placed on the Editorial Committee of the British Journal of Surgery. No other "outsider" had ever attained such a position. Small wonder that, after the end of the war in 1945 when he had been roundly applauded for his Hunterian Lecture, he recorded: "Certainly the British make me feel they appreciate my services more than my own people. It's rather sad when one has worked one's heart out. But I am satisfied we have done a good job."

But Cutler probably took greatest pride in the Inter-Allied Conferences on War Medicine, held within the precincts of the Royal Society of Medicine. He had been a main figure in the accomplishment of these meetings. As Sir Gordon Gordon-Taylor wrote: "Elliott's wonderful tact and diplomacy at these


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Inter-Allied Conferences will long be remembered by those privileged to attend." Cutler was never happier than when the evidence submitted at these conferences bore out his belief and pride in American primacy and efficiency. At the same time, he held in great respect the British medical tradition, and he admired the individual ability of many of the men in surgery who, like himself, were devoting their skill to the war effort.

It was to Cutler's great advantage that he had on his side Maj. Gen. Paul R. Hawley, Chief Surgeon, ETOUSA, an exceptional soldier-physician, who dared to make operative a division of his office that in the past had been mostly consultive and advisory. Cutler speaks of Hawley thus: "* * * Though demanding standardization, you have always been willing to allow changes in our form for practice, once a better way has been demonstrated. This openmindedness and the backing of new ventures * * * are evidence of an unusual perspective and critical appreciation in science. We believe in you, we acknowledge you as a stimulating and exemplary leader and we are happy that we have been privileged to serve with you."

Cutler, for his part, ably fulfilled his own description of the task of the consultant, and this fact was recognized by his chief, General Hawley, in the following encomium:

"Obviously, the complexity of the functions of a Professional Services Division, the peculiarity of its organization which makes necessary both action as a whole and much individual action on the part of its members-these characteristics require the very highest type of leadership at its head. Its leader must be a man of force; otherwise, individual differences among its members may create serious dissentions. He must be a man of courage because he risks his personal standing among his colleagues in the profession when he admonishes them or rules against them. And he must be a man of kindness and understanding because he must keep discord out of his division and all of his men happy and contented.

"These qualifications are not often found in one man. But it meant more to the sick and injured soldier in the European theater than he, or any of the rest of us, can tell-that my Chief of Professional Services had all those qualifications."

Because he did consider the future and all its implications so thoughtfully, forgetting his own increasing fatigue and ill health in his enthusiasm, he became interested in General Hawley's urgent plea to help with a reorganization of the Department of Medicine and Surgery within the Veterans' Administration. He helped formulate some of the basic criteria by which the medical service of the Veterans' Administration is being run today.

This was Elliott Carr Cutler, who died before he could realize all of his objectives but had accomplished far more than most of us even dream of. In conclusion, let us be generous enough to quote again from the British who said of him : "* * * Perhaps the finest ambassador in surgery the world has known."


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And, for ourselves, we might reflect on this man of extraordinary caliber and stature. Many of us have our own personal feelings of bereavement, but far more important is our sure knowledge of what his vision and statesmanship could have accomplished today.

BERNARD J. PISANI, M.D.
February 1959

EPILOGUE II

The rugged individualism of the American physician was never more apparent than after his indoctrination into the Armed Services. His antagonism to what he believed was the unnecessary regimentation of the military tended all too frequently to interfere with his peace of mind and at times his professional efficiency. While the consultants were usually older and more seasoned in administrative, professional, and military experience, they too were not immune to the same human emotions, especially during the early part of World War II. They tended to be discouraged by the interest of the administrative planners in supply and evacuation during the early years of the war. This, in the opinion of the consultants, did not provide adequate consideration for the professional care of patients. Furthermore, they were frustrated by their prolonged absence from heavy professional responsibilities, irked by the lack of suitable transportation, aggravated by the discipline of military red tape, and depressed by slow promotions which rarely approximated their counterpart in the Allied armies.

On the other hand, the administrative planners were impatient with the consultants' "impossible" demands, their intentional ignorance on occasion of military channels, the difficulties arising from a sympathetic ear lent to a disgruntled medical officer who could think of nothing but a promotion, memorandums prepared without due regard for the problems of evacuation and theater policies, and, finally, the problem of pacifying commanding officers who on occasion angrily objected to the consultants' raids on their personnel.

History must record these problems, although it is doubtful if the Chief Consultant in Surgery, European Theater of Operations, Brig. Gen. Elliott Carr Cutler, would have mentioned them had he lived personally to record his own activities. There was, however, no doubt that he was very disturbed in the early days when he encountered some of the same problems he had known as a medical officer in World War I. Yet, his intense patriotism and keen desire to prepare young medical officers for things to come maintained his spirit. Like his chief, Maj. Gen. Paul R. Hawley, to whom he was devoted, he was dedicated to the ideal that American medicine must and would provide the best surgical care in the quickest possible time, starting in the forward areas, which was ever offered a soldier in time of war.

The lack of medical challenge to the consultant group by the Army in the European theater during the early planning days was compensated for by the medical problems presented by the Eighth Air Force, the problems


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of medical supply, lectures at the Medical Field Service School, ETOUSA, and the organization of medical meetings for the exchange of ideas with the consultants and medical officers of the British and other Allied armies. Later on, they eagerly welcomed a trip to the Mediterranean theater to gain firsthand information of the problems to come on a much larger scale to their theater. By this time, it was "their theater" in thinking and loyalty. As the time of the invasion grew nearer, the consultants became more indoctrinated into the Army and the Army in turn became more convinced of the value of the consultants. It was very soul-satisfying to General Cutler to observe the ever-increasing usefulness of the consultant group. He was freed to give his energies to projects more suitable to his background and capabilities. Few experiences made as great an impression on him as his membership in the medical mission to the Soviet Union. He was tremendously impressed, and some believed so much enthusiasm was not warranted. Subsequent events attest to his astuteness in predicting the Russian people were a major force to be reckoned with in the future.

The consultants came to their own with the invasion of Normandy. These "nomads" of the Chief Surgeon were familiar with the professional background and location of thousands of medical officers who could be used to meet the constantly shifting needs of combat. Their mobility tended to overcome one of the great weaknesses of military medicine by providing a followup system on the effectiveness of treatment from clearing station to general hospital. Despite failing health, General Cutler continued an aggressive interest in all of the problems associated with the care of the wounded soldier. His spirits were maintained in part by the active participation of two sons who were on active duty in the European theater and the thousands of medical officers who looked to him as their chief link with civilian surgery. This Master Surgeon, Inspiring Teacher, Peppery Patriot, and Intense Anglophile, who had few equals in personal charm and natural ability, assumed this responsibility with enthusiasm and determination. His natural talents toward the dramatic and idealistic invariably lifted the morale of the individual medical officer, not only during but in the hectic days after the war. His dream and active participation in the Veterans' Administration to insure better care for the wounded veteran and opportunities for the returning veteran medical officer were typical of his complete devotion to his country and profession. Perhaps, his greatest contribution was to plant the seeds for the active participation of civilian medicine in military medicine long after the war ended. The loyalty and continued interest of the consultants to the Army Medical Corps since their return to busy civilian life is ample proof of the fine esprit de corps that has continued, thanks to leaders like General Cutler.

It was his hope and dream that military medicine would make adequate provisions for the active participation of civilian consultants during peacetime as well as in wartime. To some, this may be hard to justify, since the role of the consultant was so frequently of such an individual effort without docu­


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mented evidence that history may find it difficult to evaluate the consultant's true worth. Testimonials of thousands of individual medical officers would be required to ferret out their greatest contribution to the war effort. None will be remembered longer or with more warmth and affection by American and Allied physicians than the late Elliott Carr Cutler, Brigadier General, MC; Chief Consultant in Surgery, European Theater of Operations; Moseley Professor of Surgery of the Harvard Medical School; and Surgeon-in-Chief of the Peter Bent Brigham Hospital.

ROBERT M. ZOLLINGER, M.D.
February 1959

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