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This volume, the twenty-sixth to be published in the total series relating the history of the U.S. Army Medical Department in World War II, is the second of the two volumes dealing with the activities of surgical consultants. Volume I, published in 1962, describes the work of these consultants in the Office of the Surgeon General, the extension of the system to the service commands in the Zone of Interior, and its operation in U.S. field armies overseas. This second volume deals with the activities of the surgical consultants on the theater level overseas.

As is indicated in the first of these volumes, no formal provision for the consultant system existed in the Office of The Surgeon General before the outbreak of World War II, and this situation delayed its development and created many kinds of difficulties. A major problem was that consultants overseas were hampered in their activities, at least initially, by the inconvenience and actual inefficiency caused by the lack of direct channels of communication between themselves and the consultants in the Office of The Surgeon General. The situation led one consultant in the European theater to complain that the theater had had little from the Zone of Interior in the way of directives or other information on the treatment of casualties.

Just as in the Zone of Interior, so overseas the surgical consultants occupied themselves, with the full approval of those in authority, not only with clinical matters but with a variety of related administrative matters. They evaluated the qualifications of personnel and advised their assignment. They planned specialized treatment centers and helped to implement the planning. They supervised such professional training programs as were practical in an active theater of operations. They organized meetings and conferences on local and general levels and planned the agenda for them. They prepared circular letters and ETMD's (essential technical medical data). They planned such clinical studies and analyses as were practical in wartime. Finally, they held themselves on constant call to aid in the solution of problems on any level within their competence.

In short, consultants overseas followed the same pattern of endeavor as the consultants in the Zone of Interior, expanding their functions, and adapting them as necessary, in relation to the special conditions which they encountered. As I noted in the foreword to the first of these two volumes, it is a tribute to the tact of the consultants as well as to their competent performance that the original opposition to them gradually died away. It is an even greater tribute to them that, in the areas in which the consultant system did not operate, the desire for it was frequently expressed and that, when consultants were not formally appointed, acting consultants served in various specialties for longer or shorter periods of time.

There is a certain amount of overlapping of other volumes by this volume, but it is almost inevitable and warrants no apologies. To have avoided it would have meant the setting up of rigid and artificial distinctions. It would also have meant the loss of something of real value, the presentation of material on the same subject from different, but equally competent, points of view.

I am impressed in this volume, as I have been in all previous volumes, by the amount of factual material it contains and by the frankness with which the story is told. The consultant system did not always operate smoothly. There were many difficulties, some of them created by personalities, others by circumstances, and no purpose would be served by ignoring them. In fact, because these problems have been brought out into the open, it should be possible to cope better with similar situations in the future.

I am also impressed in this volume, as I have been in previously published volumes, by the wisdom of the basic editorial policy of utilizing the personal experiences of present and former medical officers who recorded, and often created, the data upon which this whole history is based. It is desirable, of course, to make a record of events as they occur, with an eye to the future use of these documents, but in wartime the ideal frequently gives way to the practical, and records, if they exist, are often no more than sketchy notes. If a formal record exists, that is good. If it does not, then we must rely upon the recollections of the medical officers who were there. There is scarcely a volume in this series in which there are not recorded one or more major events for which there is no formal documentation. In some instances there is no documentation at all for decisions that altered the whole course of therapy. I cannot share the pedantic view of the so-called historiographers who regard nothing as reliable unless it is corroborated by a bit of paper. To my mind, there are no more valid sources of data than the medical officers who served in World War II, who saw events happen, and who often played a part in their creation.

For that reason I applaud the unorthodox method used in this volume of telling the story of the surgical consultant service in the European Theater of Operations and in the Pacific by publishing the (edited) diaries of Brig. Gen. Elliott C. Cutler and Col. Ashley W. Oughterson, MC, who served as surgical consultants in those locations. Both officers died after the war ended, General Cutler before he had done any work at all on the history and Colonel Oughterson when his work on it was barely started.

The information which both of these officers possessed was essential for the history of the consultant system in both the European theater and the Pacific. It would have been unthinkable not to write this history. The solution was to use their official diaries, which, like most official diaries, often served as personal diaries as well. The material has been edited to eliminate irrelevant and extraneous material, perhaps not as drastically as it should have been, but the editorial work was done from the standpoint of deleting nothing that would alter the meaning or intent of the writers.

Unfortunately, certain passages in these diaries require elucidation that cannot now be secured. In other passages, one wonders whether the diarists, had they had the opportunity, might have wished to modify certain of their statements, or perhaps to comment on them. For these and other reasons, the diaries were submitted to the theater (area) surgeons under whom the writers served. Maj. Gen. Paul R. Hawley, MC, USA (Ret.), Chief Surgeon, European theater, has read and commented on the Cutler diary, while Brig. Gen. Earl Maxwell, USAF (MC) (Ret.), Maj. Gen. John M. Willis, MC, USA (Ret.), now deceased, and Maj. Gen. Guy B. Denit, MC, USA (Ret.), under all of whom Colonel Oughterson served, have done the same for his diary.

After World War I ended, a board of medical officers, appointed to investigate and report upon the conduct of the Medical Department, Allied Expeditionary Forces, and to recommend improvements in it, stated that the chief consultant in surgery in an oversea theater should be a medical officer of the highest surgical attainments. Wittingly or unwittingly, that recommendation must have been borne in mind over the years. The consultant system in the European theater in World War II began with the appointment in June 1942 of Col. James C. Kimbrough, MC, as Chief of the Professional Services Division, Office of the Chief Surgeon, and the appointment the following month of Col. (later Brig. Gen.) Elliott C. Cutler, MC, as Senior Consultant in Surgery. It is hard to imagine more fortunate selections.

In February 1945, just before Colonel Kimbrough left the theater and General Cutler succeeded him as Chief of Professional Services, General Cutler paid tribute to him as a man possessed of  "a canny imagination." He gave no better proof of his canniness than in the imaginative use he made of his Senior Consultant in Surgery. General Cutler also paid tribute to the Theater Chief Surgeon who, while demanding the standardization of methods required in wartime, was always willing to allow changes, once a better way had been demonstrated.

In his comments on General Cutler's diary, General Hawley noted that, while some of the observations in it are based upon incomplete or erroneous information, they had been allowed to stand, with appropriate footnotes, because everything in the diary "* * * portrays faithfully his dedication to his task, his resentment of everything which impeded its accomplishment, and what he regarded as unjustifiable requirements of military administration. * * * he was a devoted and loyal soldier, who contributed more than his share to the success of the medical service of the European Theater of Operations."

Of all General Cutler's functions, perhaps the most important was his evaluation and assignment of professional personnel. It was an extremely difficult task, for needs far outran qualified personnel. It was doubly difficult for him, for, as General Hawley also pointed out, "an innate honesty often compelled his professional judgments to be severe," and he was "intolerant of mediocrity."

Immediately upon his appointment Colonel Cutler noted that while soldiers in base hospitals were well provided for, the care of the soldier "up the line" was entirely inadequate. For this lack he had a number of solutions including, first of all, mobility, which "must be forced on all medical services." As early as August 1942 he declared that the chief need was for auxiliary surgical groups. From the experience at Dieppe he concluded that if undue delay in treatment were to be avoided, hospitals must be set up near points at which casualties would be returned and that the successful operation of these hospitals would require the addition of surgical and shock teams to the normal hospital complement. The later establishment of transit hospitals can perhaps be traced to this concept. Colonel Cutler also stressed the importance of triage of casualties, and he thought that surgeons at the front must be general surgeons, not specialists in any particular field. He never lost sight of the fact that it was in forward areas that the end results of injuries were determined in terms of survival, morbidity, and permanent deformity versus complete restoration to normal.

In the courses of instruction that he planned and the circular letters that he prepared, in the lectures and talks that he gave, in fact, at every opportunity, General Cutler lost no chance of emphasizing the correct initial management of wounds in general and of regional wounds, with special reference to initial wound surgery. He found the almost universal ignorance of such surgery extremely depressing. Every young physician, he said, should be taught how to handle trauma, for it would constitute 20 to 30 percent of his peacetime practice. It would be better, in fact, if medical students were taught the principles of debridement in their undergraduate days. Certainly they should learn them as soon as they entered the Army. Traumatic surgery, he emphasized again and again, is not a separate specialty, and he could not see the logic-apparently he clearly saw the possible harm-of a special society devoted to it.

He suffered many frustrations in his attempts to solve the early problems associated with medical supplies and equipment. There were critical shortages of both. Planning impressed him as totally unrealistic. Battle provisions for 10,000 men a month included three litters, several thousand rolls of toilet paper, and one bedpan, but no oxygen tanks and no tetanus toxoid or antitoxin. An infantry division of 17,000 men was authorized two sphygmomanometers. Closure of sucking wounds would save lives (and make casualties transportable), but the proper needles and silkworm gut required to close the wounds were not provided. General Cutler was perfectly aware that in wartime it is frequently necessary to accept what is available rather than what is desirable, but compromise with him went only so far, and his initial supply activities marked the beginning of the later superbly operated supply service in the European theater.

The provision of blood for forward casualties was one of General Cutler's major preoccupations, as it was of General Hawley, and it is interesting to note how his thoughts on this subject evolved. In 1942, after hearing a discussion on blood and plasma at a meeting of the Royal Canadian Medical Corps Pathological Club, he wrote in his diary that it seemed to him that "the rise of

plasma, etc., had let all forget the benefit of transfusion." "Our soldiers," he continued, "are all grouped. They should be the best vehicle for getting blood forward. No bottles to carry." He was soon to learn that it was not so simple, and it was only two years later that he was among the first to insist that local provision of whole blood was entirely inadequate and that the only satisfactory solution was an airlift of blood from the Zone of Interior.

His conversion to the perils of trenchfoot was similar. When he first observed it in Italy, in the fall of 1943, it seemed to him that the victims were "using their pain very hard to get out of fighting." Later, when the troops in the European theater were hard hit by cold injury, there was no more vigorous proponent of preventive measures than he was.

General Cutler approved of making casualties ambulatory as rapidly as possible after surgery, but he viewed early ambulation, which became popular in civilian circles in the course of the war, with considerable suspicion, terming it "a questionable acceleration of professional care."

He made plans for special studies on abdominal wounds, thoracic wounds, and other regional wounds, and for studies on gas gangrene, which fortunately proved unnecessary. He also planned special studies on penicillin therapy, again emphasizing that penicillin must be administered against a background of good surgery if it was to fulfill its usefulness. He concerned himself with securing texts and journals for hospital and other libraries. He directed the preparation of the "Manual of Therapy, European Theater of Operations," so successfully that during the war, and at the end, very few changes were required to bring it into conformity with current practices.

General Cutler was instrumental in forming the American Medical Society, ETOUSA, to which all U.S. medical officers in the theater automatically belonged. He also played a large part in founding the Inter-Allied Conferences on War Medicine, convened by the Royal Society of Medicine, and he lost no opportunity to stress the importance of liaison with our Allies, particularly the British. After his death, Sir Gordon Gordon-Taylor wrote: "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."

The special reports by consultants in the various specialties in the European theater all deserve careful reading. It is perhaps invidious to mention special chapters because space does not permit me to comment on them all, but attention must be called to:

1. The investigations by Col. Loyal Davis, MC, of high altitude frostbite; his development of protective helmets for Air Force crews; and his stabilization of policies concerning herniated nucleus pulposus.

2. The advances in rehabilitation, which permitted the return to duty, often to full duty, of greatly increased numbers of men.

3. The development of policies of rehabilitation for deafened and blinded casualties.

4. The miracles wrought by plastic surgery.

5. The enormous advances in surgical therapy made possible by the enormous advances in anesthesia under Col. Ralph M. Tovell, MC.

General Cutler and Colonel Oughterson were totally different persons and yet, oddly, much that has been said about General Cutler could well be said about Colonel Oughterson. Both were brilliant surgeons, whose technical dexterity was based on sound judgment. Both were born teachers. Both were men of ideas who were not satisfied until their ideas were translated into actions.

The comments of the surgeons under whom Colonel Oughterson served-and who did not always agree with his ideas-indicate the kind of medical officer he was. General Maxwell wrote that his diary represented the thoughts of a great organizer, "the thinking of a mature mind on a very difficult subject." It was written, he said, by a man who, if he had had the opportunity to edit it, would still think and write the same way.

General Denit was even more explicit. "I am not inclined," he wrote, "* * * to take exception to anything he has to say. After all he gives the picture as he sees it * * *. No one who hasn't experienced it [war in the jungle] can believe the difficulties encountered * * *. I had a great admiration for Colonel Oughterson and gave him the job of 'thinking' and advising me on how surgery and care of the wounded could be improved. I didn't want him to have any administrative authority. I wanted him to (1) see, (2) think and (3) advise. Often when one tries to correct he loses his value as an adviser."

The wars in which General Cutler and Colonel Oughterson served were utterly different in many respects. In the European theater, for instance, evacuation of casualties was often a matter of hours. In the Pacific areas, it was usually a matter of days and sometimes a matter of weeks. The Pacific War was a war of incredible distances, which had to be taken into account in every aspect of medical care. In the European theater, coincidental disease seldom complicated the management of wounds. In the Pacific, malaria was a possible concomitant of every wound until the war was more than half over, and other tropical diseases were a possibility all through the war. Gas gangrene, which proved no problem in the European theater, was sometimes a serious problem in the Pacific. And so it went.

Nevertheless, in spite of the differences in the wars that were fought in Europe and the Pacific, it is surprising how squarely the views of these two eminent surgeons corresponded with each other in basic principles if not always in details.

Colonel Oughterson's constant plea was for the placing of qualified surgeons well forward in combat areas, where their talents were required because

of the inevitable delays in evacuation. The shortage of qualified surgeons, however, in a theater in which each island was a unit in itself was always extreme and was enhanced by the concentration of talent in affiliated units, from which it was often detached with great difficulty. Shortages of anesthesiologists with proper training and qualifications further complicated shortages of surgeons. At one time, when Colonel Oughterson surveyed six portable hospitals, he found three of them competently staffed and three others completely unusable because of lack of qualified personnel. The portable hospital, he noted, was excellent in jungle warfare but ill adapted and wasteful when communications were good. When it was not properly staffed, he said, "It gives the dangerous illusion that a surgical hospital is available."

His comments were always to the point. The incidence of gas gangrene, he noted, was an index of the kind of surgery being performed at the front, but the omission of plaster because gas gangrene might occur was simply the correction of one surgical mistake by making another. His comments on "moderate debridement" were caustic. He had never seen a surgeon who did good surgery at home do bad surgery in the Army. Almost as soon as he arrived in the Pacific, in November 1942, he began to comment that the principal cause of war neurosis was weak leadership, that men who were not happy were men who were not kept busy, and that the way to correct poor morale and poor surgery in a hospital was to provide it (1) with a strong commanding officer and (2) with a good surgeon. Whether Colonel Oughterson was evaluating surgical qualifications, correcting surgical errors, or trying to provide washing machines for hospital linens, screens for operating rooms, or hobnailed shoes for litter carriers, he was both practical and perceptive, and many of his comments might well become aphorisms.

The brilliant study of casualties in the Bougainville Campaign, which he initiated and directed, is a lasting addition to the science of wound ballistics. The conclusions he derived, and the lessons he drew, from medical care in each campaign in the Pacific deserve the most careful reading and reflection. Like the Cutler diary, the Oughterson diary is a real contribution to military medicine.

The consultant system was introduced late in the China-Burma-India theater, but the chapter describing it, the final chapter in this volume, is another experience well worth recording of medical care in inhospitable terrain, with constant shortages of personnel and supplies, in which not the least of the problems was the attempt to improve the efficiency of the Chinese Army Medical Service.

Again and again General Cutler mentions in his diary how desirable it would have been to have worked in peacetime on the problems he encountered during the war. He reminded himself frequently that one of his responsibilities as surgical consultant in the European theater would be to write the story of the consultant service. The chief problems of this service, as he saw it, were the relations of the consultants with each other and the relations be-

tween Regular Army medical officers and the officers who had just come into service from what he called "the well-oiled machinery of civilian practice." He found more patient those who, like himself, had served in World War I-thought it might come as a surprise to some of his associates to hear the word patience attached to any activity of General Cutler's. At any rate, it was his urgent wish that a permanent consultant system be established as an integral part of the Army Medical Department. He would have been happy, had he lived, to know that this ardent desire of his has been translated into reality.

As in all volumes in this series for which it is my privilege to write the foreword, it is a pleasure to express my gratitude to the editors and authors who wrote and directed this volume, particularly the special editor for the two volumes dealing with the activities of surgical consultants, the former Col. B. Noland Carter, MC; to the Advisory Editorial Board for Surgery; and to the personnel in my office who are helping me to carry out what I regard as one of my truly important missions, the preparation and publication of the history of the U.S. Army Medical Department in World War II.

Lieutenant General, 
The Surgeon General.