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Chapter IX

Contents

CHAPTER IX

Urology

John N. Robinson, M.D.

Maj. Gen. Paul R. Hawley, MC, Brig. Gen. Elliott C. Cutler, MC, and Col. James C. Kimbrough, MC, organized in ETOUSA (European Theater of Operations, U.S. Army) the finest surgical consultant system the U.S. Army has ever known. The system was initiated with the arrival of U.S. troops in Great Britain and was gradually curtailed after V-E Day. On 5 October 1943, Maj. (later Lt. Col.) John N. Robinson, MC (fig. 213), was appointed Senior Consultant in Urology, ETOUSA, in addition to being chief of urology at the 2d General Hospital.1 The small volume of troops and the small number of urological cases at this time made this part-time arrangement possible. Soon, however, the volume of work increased so much that it became necessary for the author to devote full time to this job. Thus, he became the only consultant in urology to be appointed at a theater headquarters level during World War II. The general duties of senior consultants in the European theater have been enumerated elsewhere. Briefly, they may be characterized as being "the eyes and ears of the Chief Surgeon."

JUSTIFICATION FOR A SENIOR CONSULTANT IN UROLOGY

How was a urological consultant justified when there were general surgeons available who might possibly cover this field?

First, it is necessary to recall that the development of Specialty Boards and certification had grown between the wars and that urology had become a specialty recognized by the leading societies and medical schools. In ETOUSA, as well as in the U.S. Army as a whole, the many civilian doctors who had volunteered for service were not qualified to do urology when compared with a certified urologist. Hence, with one or two urologists in each hospital and over 200 hospitals in operation, it was natural that there should be a urological consultant. Only one urologist had been certified by the board in the peacetime U.S. Army immediately prior to the period of limited emergency declared in 1939.

Second, in an oversea theater, it was not always possible to use civilian consultants as in the Zone of Interior, and the Army would have been open to criticism if the best specialty care had not been available.

1Office Order No. 40, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 5 Oct. 1943.


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Third, the general surgical consultants were so busy that they did not have time to attend to the details of urology, did not know the personnel, and, in some instances, were not familiar with certain new developments.

Fourth, the positive reasons for this appointment, from the writer's point of view, were that the urologist in a general hospital had no one to consult, no one with whom to discuss new developments, and no one with whom to air problems. Also, the consultant's visits were often a means of solving problems of a personal nature, especially in making some of the junior officers feel that they were needed and that someone above the hospital level was interested in their welfare. In other words, it helped the morale of these officers. There were also times when the consultant helped in ascertaining the capabilities of a hospital urologist as an aid to the chief of surgery and the commanding officer. The commanding officers of hospitals were always most helpful and cooperative.

FIGURE 213.-Maj. John N. Robinson, MC

Fifth, as the number of hospitals and urologists increased, a need for meetings developed for the purpose of discussing urological problems and new developments and formulating plans for the future. This author organized and held approximately nine of these meetings in Great Britain and on the Continent. Many of these meetings were held at the time of large Allied medical meetings so that urologists in the theater were able to attend both. From 15 to 45 urologists attended these sessions. Much of value came from these meetings; and, needless to say, they would not have been held had it not been for the fact that there was available someone with the ability to initiate and direct them.

Sixth, it is almost impossible to secure accurate and valid statistics after any war is finished. Regrettably, this collection of statistics did not start soon enough in the European theater; but, eventually, worthwhile information, based


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on reports received from the evacuation, station, and general hospitals in the theater, was compiled. One of the most important reasons for having special consultants was to direct the gathering of medical information. Also, a specialty such as urology needed representation in order not to be left out in planning for the future.

Finally, the writer was of the opinion that, had Colonel Kimbrough, Chief of Professional Services in the Office of the Chief Surgeon, not been a dedicated urologist, there might not have been a Senior Consultant in Urology in the European theater, in spite of all other cogent reasons for appointing such a consultant.

ACTIVITIES OF THE SENIOR CONSULTANT IN UROLOGY

Colonel Kimbrough was the acting urological consultant from 1942, when U.S. Army hospitals first arrived in the United Kingdom, until the appointment of the Senior Consultant in Urology in October 1943. In these early days, supply and administrative considerations were of the first order, with the result that, at the beginning, there was not much urology practiced other than some treatment of gonorrhea and a few operations. Often, the urologist learned to become one of the best foraging officers in the units (fig. 214). At times the British food and equipment were trying, but everyone soon became acclimatized. The first responsibility was to get back to duty every soldier, in preparation for the invasion. After the Senior Consultant in Urology was appointed, monthly visits to each hospital were made; but this soon became impossible due to the increasing number of hospitals.

In this period before the invasion, everyone was busy with the planning and improvisation necessary to take care of expected casualties (fig. 215). Most of this work was routine, but the use of penicillin in the treatment of gonorrhea was of great interest. Its first use took place at the 2d General Hospital, which was located near Oxford, where Dr. Howard E. Florey was developing penicillin for clinical use. At first, small doses of 10,000 units every hour or 2 for 10 doses were given, and then larger doses, until finally a large single dose was accepted as the standard method of treatment. The first war casualties from air raids over the Continent were also received in this period. Data gathered from the operational research unit of the Office of the Chief Surgeon, ETOUSA, showed that, of 147 airmen killed in action, 9.5 percent had injuries to the genitourinary tract in addition to their fatal injuries.2

Another important service performed by the urological consultant was the writing and editing in collaboration with Colonel Kimbrough and Maj. Howard I. Suby, MC, of the urological section of the "Manual of Therapy, European Theater of Operations," a guide to the handling of all severe genitourinary injuries.3

2(1) Kimbrough, J. C.: War Wounds of the Urogenital Tract. J. Urol. 55: 179-189. February 1946. (2) Medical Department, United States Army. Surgery in World War II. General Surgery. Volume I. [In preparation.]
3Manual of Therapy, European Theater of Operations, Surgical Emergencies, Section B, VIII. Wounds of the Genito-Urinary System.


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During the early days of the invasion, before hospitals could be established on the Continent, Colonel Robinson's duties consisted of visiting hospitals set up along the south shore of England to assure that urology was well taken care of and, as did all surgical consultants, to carry out orders of the Chief Surgeon concerning general surgical matters. As the hospitals began to function on the Continent, hospital centers began working fully, and, in some of these, special treatment facilities were set up to take care of special problems. With the exception of neurogenic bladders associated with paraplegics, there was no need for genitourinary special treatment facilities because there were a sufficient number of well-trained urologists. Thus, all problems could be taken care of in any of the general hospitals (fig. 216). There was a urologist for all but one general hospital. All but a few station hospitals had a urologist, and those that did not had consultation available at a short distance. The evacuation hospitals had at least one capable urologist per field army available for consultation.

FIGURE 214.-A drawing of a portable tidal drainage-cystometer set designed and built in the European theater.


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FIGURE 215.-Improvisation at the 38th Station Hospital, Winchester, England, to permit the performance of complete cystoscopy with retrograde pyelography. The 38th Station Hospital was established to act as a transit (evacuation) hospital during the continental invasion. A. Improvised stirrups for ordinary Bucky X-ray table. B. A patient in position, fully draped.


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FIGURE 216.-The genitourinary clinic at the 45th General Hospital. A. Cystopyelographic facilities. B. A ward.


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FIGURE 217.-A hospital train being loaded at Liége, Belgium.

During full-scale operations on the European Continent, consultation, inspection, and personnel placing were the primary functions of the writer, as Senior Consultant in Urology. Clinical meetings were held when possible at places where most officers could attend. In between these duties, one of this consultant's interesting assignments was to report on the efficiency of an ambulance train plying between Liége, Belgium, and Paris (fig. 217). Interestingly enough, this ambulance train was commanded by a urologist who liked his work. Getting the soldiers back to duty as soon as possible was still the most important responsibility, and, in this connection, the writer helped to set up urological rehabilitation facilities at the chief rehabilitation center in England. The result was a saving of time in returning a soldier to duty.4 Much time was devoted to checking on all cases that did not do well and endeavoring to find out how to correct bad results.

During the closing days of the war in Europe, the author gathered some of the theater's top urologists in Paris for the purpose of assembling data and writing about wounds of the genitourinary tract, using as sources their personal experiences and material collected from the hospitals.5 A final remark about urologic personnel is that more than 200 urologists were working in urology on V-E Day. Twenty-five urologists were not. Many of the latter had been averse to remaining in urology because, by doing so, they would have lost any chances for promotion.

4(1) Urological rehabilitation was organized by Capt. Marius Russo, MC, at the rehabilitation center at the 307th Station Hospital, Stoneleigh Park, Warwickshire, under command of Col. Frank E. Stinchfield, MC. (2) See footnote 2 (2), p. 575.
5See footnote 2 (2), p. 575.

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