CHAPTER X
Anesthesia
Ralph M. Tovell, M.D.
When this writer (fig. 218) was requested, in November 1954,to prepare for publication a personal account of his experiences as SeniorConsultant in Anesthesia to the Chief Surgeon, ETOUSA (European Theater ofOperations, U.S. Army), he was hesitant about acceding to the request, for herealized that it would be difficult to recapture the spirit and anxieties of thenational effort during World War II. In addition, failures of memory werelikely to occur when one attempted to recall events after the lapse of almost 10years since the European campaigns had been successfully terminated. He wasaware of the fact that he had a copy of a factual account of anesthesiology inthe European theater that had been prepared at the end of the war as a part ofthe medical history of the theater in World War II. Little did he realizethe difficulties that would be encountered once he undertook to refer tosource material in the preparation of this chapter. When this was attempted,there immediately arose a conflict between the recorded data worthy ofpublication and the events that would be interesting to those who might readthis volume. It is in the shadow of this background that thewriter attempts to capture the reader's interest.
CALL TO ACTIVE DUTY
When the United States entered World War II on 7 December 1941, it was expected that the writer would be declared essential and that military service would fall to the lot of members of his staff at Hartford Hospital, Hartford, Conn., who were younger. It was, therefore, with some surprise that he received a call from Col. (later Brig. Gen.) Fred W. Rankin, MC, Chief Consultant in Surgery, Office of The Surgeon General, on 3 July 1942. Colonel Rankin's conversation was very much to the point. Colonel Rankin stated that there was a job he wanted this writer to do and that he would like him to come to Washington to discuss the program. In 1942, Independence Day fell on Saturday. The writer intimated that because of the holiday Colonel Rankin might not want to see him until Monday. Colonel Rankin's reply was specific. He stated that the Office of The Surgeon General was in full operation on Saturday and, as civilians might well realize, there was a war on. The writer reported to Colonel Rankin at 0900 hours on Saturday and was briefed regarding his prospective duties and responsibilities as a consultant in anesthesia in the European theater. The interview ended with the instruction that he return to Hart-
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ford and coordinate the program with the medical director andthe staff of Hartford Hospital. On Monday, 6 July, the writer called andinformed Colonel Rankin that he would be ready to report when orders wereissued.
FIGURE 218.-Col. Ralph M. Tovell, MC.
It had been anticipated that the writer would receive amajority. However, when he discussed this matter with Dr. Wilmar M. Allen,director of Hartford Hospital, Dr. Allen expressed the opinion that the rankoffered was not commensurate with the responsibilities to be undertaken. Itwas, therefore, with some satisfaction that the writer subsequently receivedorders specifying that he would report for duty in the grade of lieutenantcolonel. On 20 August he was sworn in as an officer of the Army of theUnited States, and on 26 August Lt. Col. (later Col.) Ralph M. Tovell, MC, reported for dutyin Washington. He was assigned to Walter Reed General Hospital, Washington,D.C., for the usual course of indoctrination which was hyphenated in order topermit him to spend considerable time in the Office of The Surgeon General.
ORIENTATION IN THE UNITED KINGDOM
The author proceeded from New York City to London by flying boat via Halifax, Nova Scotia, and Foynes in southern Ireland. His orders stipulated that the trip be made in civilian clothes. The trip was uneventful until the aircraft landed in the harbor at Foynes. There, the crew found that the tide was running in one direction and the wind was quartering from another. They taxied the flying boat over the choppy water for approximately 45 minutes, during which many of the passengers became seasick even though they had avoided airsickness during the trans-Atlantic trip. At Shannon the passengers
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were taken to the airport by bus, where they, as a combinedforce of civilians, Red Cross workers, and Army officers, were required to standinspection by customs and immigration officers. For this procedure, the authorwas fortunate enough to stand in line behind a Regular Army colonel. Becausethree planes had landed within a few minutes of one another, the congestion ofpassengers awaiting planes for England was considerable. As the travelers wereslowly making their way forward to the inspection points, it was announced overthe loudspeaker system that all military personnel were to come to thehead of the line. This was a rather startling announcement to Army officerssupposedly in disguise and particularly so to a lieutenant colonel who had beenin the Army less than a month. After a quick whispered conference with theRegular Army colonel preceding him, the two decided that this was no trickleading to internment in a neutral country. The two colonels promptly moved tothe head of the line where the necessary formalities were accomplished withdispatch. This incident made a vivid impression on the author, and he wasforced to alter his concept of neutrality, particularly of the southern Irishvariety. In subsequent conversation with military friends, he learned that therewere 150,000 southern Irish in the British Army. He was asked: "Underthose circumstances, what kind of neutrality could you expect?"
Soon, the passengers were winging their way to Bristol,England, in a British plane that was entirely blacked out. The trip from Bristolto London was made by train. The author arrived in London at approximately 2300hours on 25 September 1942 and suddenly was thrust into the utter darkness ofthe London blackout. It is difficult to describe this consultant'sdiscomfiture. He found himself in a strange land without adequate knowledge ofthe Army procedure to be followed in finding a billet. However, organization wasgood, and transportation was at hand for conveyance to the billeting office. Itwas surprising how well and how easily U.S. Army drivers were able to wend theirway through busy streets of a great metropolis pulsating with life in thedarkness.
On the morning of the next day, 26 September 1942, the authorreported at ETOUSA headquarters, 20 Grosvenor Square. He was informed that hewas to be reassigned immediately to Headquarters, SOS (Services of Supply), atCheltenham, England, a city approximately 90 miles west of London and some 30miles beyond Oxford. He proceeded to Cheltenham by train and once again wentthrough the prescribed procedure of getting bedded down, this time at the PloughHotel, a hostelry about 200 years old that, in days long gone by, had been usedas a terminal for stagecoaches plying their routes in the Cotswolds district.More recently, the hotel had been occupied by permanent residents includingelderly widows and spinsters and a smattering of British Army officers, retiredfrom the Indian Service. This hotel, along with many others in the town, hadbeen requisitioned by British authorities for U.S. Army personnel. In spite ofthe dislocation of the permanent residents, the reception of a growing horde ofAmericans arriving to staff a continually growing headquarters was remarkablyamiable.
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The next morning, the author reported for work, physicallyready for it but mentally in very much of a quandary regarding the future. Hemet his new superior, Col. James C. Kimbrough, MC, who had been assigned theunenviable job, for a Regular Army officer, of riding herd on a group of seniorconsultants representing the several specialties in medicine and surgery-individuals whomhe could not help but look upon as civilians in disguise andwho were reputed to be prima donnas in their civilian practice at home. ColonelKimbrough met the challenge of his assignment with fortitude and with adiplomacy that might be unexpected of a Regular Army officer who had been bornin the mountains of Tennessee. His advice and his encouragement were forthright.When all other attempts failed to orient civilians who could not have been otherthan stupid in their practices at home, he was able to quote volubly from theBible to illustrate his point. The personnel of the Professional ServicesDivision, Office of the Chief Surgeon, Headquarters, ETOUSA, were indeedfortunate to have as their chief "sheepherder" a urologist,professionally competent and renowned, who spoke in professional medical termsrather than in military jargon. In addition, he was capable of orienting them inmilitary thinking. He guided them through the maze of military procedure, theutilization of which was so necessary in order to accomplish their mission in agrowing Army that was preoccupied with tables of organization and equipment.They of the Professional Services Division are ever grateful for his leadership.
This consultant also met Col. (later Brig. Gen.) Elliott C.Cutler, MC, Chief Consultant in Surgery, and Lt. Col. (later Col.) William S.Middleton, MC, Chief Consultant in Medicine, Professional Services Division,Office of the Chief Surgeon, ETOUSA. Maj. (later Col.) James Barrett Brown, MC,Senior Consultant in Plastic Surgery, and Lt. Col. (later Col.) Loyal Davis, MC,Senior Consultant in Neurosurgery in the division, had been resident in thetheater for several weeks prior to the author's arrival. They were all veryhelpful in orienting him in problems they had faced and in problems they knew hewould face in the near future. Their help and advice were greatly appreciatedbecause this author, as the first Senior Consultant in Anesthesia appointed inthe U.S. Army, had no precedents to follow. Fortunately, great latitudesubsequently was allowed him in organizing a program.
EARLY ACTIVITIES AND RECOMMENDATIONS
During this period of groping for information upon which to build, this consultant decided that the best part of discretion was to meet his counterparts in the British Army, the Royal Navy, and the Royal Air Force and in the Canadian Army. He learned that Air Commodore R. R. (later Sir Robert) Macintosh, the Nuffield Professor of Anaesthetics at Oxford University, was senior adviser to the Royal Air Force and that Dr. I. W. Magill of London represented the EMS (Emergency Medical Service) and the Royal Navy. Col. (later Brigadier) Ashley S. Daly, RAMC, was his counterpart in the British
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Army. Dr. John Gillies, professor of anesthetics at theUniversity of Edinburgh, was the senior representative of anesthesia inScotland. Col. Beverly Leech, commanding officer of the 5th Canadian GeneralHospital and an old friend, was senior anesthetist with the Canadian Army. Thisconsultant immediately made plans for conferences with Colonel Leech andCommodore Macintosh, whom he had known previously.
Through Air Commodore Macintosh, arrangements were made forthis author to meet Colonel Daly, adviser in anesthetics to theBritish Army, whom he had not previously known except by reputation. But ColonelTovell first visited several of the U.S. Army hospitals and, subsequently,through the cooperation of his counterparts in the British Services, visitedBritish and Canadian hospitals. On 28 October 1942, he submitted Col. J. C.Kimbrough, MC, Director of Professional Services, a report covering impressionsgained during one month of duty in ETOUSA, with summary and recommendations.Inspection of several British hospitals, both military and EMS hospitals, hadrevealed that they were equipped to carry on all phases of anesthesia such aswould be conducted in British civilian hospitals, with the exception that, inmilitary hospitals, provision was not made for the use of cyclopropane andcarbon dioxide absorption (fig. 219). Endotracheal anesthesia was fully acceptedas an essential method. Equipment consisting of laryngoscopes, endotrachealtubes, and connecters were provided for all operating room units. Anestheticequipment was found to be standardized, and disposable deteriorating rubberparts were found to be interchangeable. Anesthetics were administered by medicalofficers only, and personnel were of a high order and included manyanesthesiologists of either national or international reputation.
Inspection of Canadian hospitals revealed that theiranesthetic equipment equaled that seen in civilian hospitals in either theUnited States or Canada. Anesthetic machines were of American origin, the modelswere standardized, and they provided for use of carbon dioxide absorption andcyclopropane. Personnel in anesthesia were found to be well trained andadequately able to make an intelligent choice of agent and method to be usedunder varying circumstances.
Inspection of American military hospitals revealed thatequipment for inhalation anesthesia was of British origin and was British owned(fig. 220). Admittedly, the 2d General Hospital, Headington, Oxford, did haveone McKesson and one Foregger machine, but they were British owned. Equipmentfor endotracheal anesthesia was lacking in many hospitals and incomplete inothers. Assigned anesthesiologists in units based in the theater were found tobe insufficiently trained, and they were, in addition, inexperienced. With thecivilian type of practice encountered at the time, they were relativelysatisfactory, but, in the opinion of the Senior Consultant, they wereinadequately equipped to cope with battle casualties in great numbers. Problems,as reported, were substantially as follows:
1. Medical officers assigned as anesthesiologists inhospitals need further training.
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2. Medical officers in hospitals and not assigned toanesthesia need training and experience in order to serve as alternateanesthesiologists to cover demands which would be placed on units upon thearrival of battle casualties.
3. There is need for training corpsmen of satisfactorypersonality and aptitude in the fundamentals of administering ether by theopen-drop method under supervision of an assigned anesthesiologist.
4. Many hospitals functioning in the theater are urgently inneed of equipment and supplies.
5. Hospitals moving out of this area for service in an activetheater of operations need their equipment checked. Essential items not includedin tables of equipment should be added. The need for checking is magnified whenit is realized that expendable parts for equipment produced by the severalsuppliers in the United States are not interchangeable. Equipment is useless ifaccessories and equipment are not manufactured by the same company.
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6. Because so much of the equipment in use in the American hospitals is ofBritish origin, there is need for descriptive literature to be made freelyavailable to anesthesiologists with each unit if they are to requisitionsupplies intelligently.
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This summary of problems was followed by a series of recommendations listedsubstantially as follows:
1. That facilities for training be established at the 30th General Hospital,Mansfield, and at the 2d General Hospital, Oxford, to provide courses inanesthesia for medical officers of the U.S. Army.
2. That two anesthesiologists of teaching caliber in the grade of captain orpreferably major be requistioned from the Zone of Interior to take charge ofanesthesia in the above-mentioned locations.
3. That, until such time as one or both of these facilities are functioning,the offer of Air Commodore Macintosh of Oxford to welcome observation ofpractice of anesthesiology at the Radcliffe Infirmary be accepted and that twomedical officers be assigned for periods of one month.
4. That anesthesiologists be advised to train medical officers of their ownunits in anesthesiology.
5. That anesthesiologists be advised to train suitable corpsmen in thefundamentals of the administration of ether.
6. That endotracheal tubes be approved in principle as essential and thatappropriate equipment for endotracheal anesthesia be provided as standard tooperating room units in general, evacuation, and surgical hospitals.
7. That the facilities for CO2 absorption be provided in equipmentsupplied to general and station hospitals.
8. That equipment contemplated for shipment with hospital units leaving thistheater be checked by a competent anesthesiologist.
9. That each hospital unit stationed in this theater be supplied with thefollowing British texts: "Essentials of General Anaesthesia" by R.R.Macintosh and Freda Pratt; and "Recent Advances in Anaesthesia andAnalgesia; Including Oxygen Therapy" by C. Langton Hewer.
10. That authorities in Washington be requested to prepare supply lists foranesthetic chests suitable for general, station, evacuation, surgical, andmobile operating units. Anesthetic equipment and supplies issued in units wouldeliminate the hazards of lack of standardization of equipment.
11. That training medical officers in anesthesia in the Zone of Interior,along the lines planned in civilian hospitals and in replacement pool centers,be facilitated to the fullest extent immediately.
It was further pointed out that these recommendations concerning the practiceof anesthesiology would in no way elevate this practice above the standardsalready established in British and Canadian hospitals in the theater.
On 2 December 1942, a report, entitled "Anesthesia," was preparedfor submission to The Surgeon General. Much of the data that had been recordedin the preceding report of 28 October was provided in the report to The SurgeonGeneral. The following points were made:
1. Tables of supply were inadequate to cover the requirements of modernanesthesiology.
2. Machines built by the several manufacturers in the United Stateswere not standardized, and expendable parts were not interchangeable.
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3. Descriptions in the tables of supply were inadequate to eliminate thepossibility of obtaining a machine built by one manufacturer and accessoriesbuilt by another. This chance of nonconformity was enhanced by the practice ofshipping a gas machine in one crate and equipment of a deteriorating nature(rubber parts) in another (fig. 221).
4. American machines were not equipped to use American and British gas tanksinterchangeably.
5. American equipment supplied to hospital units staging in the theater (forNorth Africa) was not checked by either the anesthesiologists involved or theSenior Consultant in Anesthesia for possible deficiencies due to losses.
The following impressions were stated. The problems involved in supplyingBritish equipment adequate for U.S. Army hospitals in the United Kingdom couldbe solved in cooperation with medical supply officers in this theater.Anesthesiologists could and would be trained in the fundamentals of thespecialty. Anesthesiologists, however, who arrived in the theater inadequatelytrained and who remained only for a short staging period could not be trained tomeet the demands that would be placed upon them in a field of active militaryoperations; that is, the North African theater where operations had opened on 8November 1942.
The report to The Surgeon General ended with a series of recommendations thatseemed important at the time. For instance, it was recommended that a competentconsultant in anesthesiology be obtained to function in the Office of TheSurgeon General in cooperation with the Personnel and Supply Divisions. It wasfurther recommended that tables of supply be amplified to meet modernrequirements; that standardization of suitable equipment for each type of unitbe achieved permitting interchangeability of rubber parts, endotrachealequipment, and masks; and that small pieces of equipment not connected with thegas machine (that is, ether masks, airways, tubes, needles, syringes, laryngoscopes, connecters, and drugs-particularly drugs usually supplied inampules) be listed and supplied as a unit in order to simplify problems insupply. It was requested that the work of the Committee on Standardization,initiated through the efforts of the American Anesthetists Society, ETOUSA, besupported and that, with the cooperation of the Army and Navy, its functions bepushed to their logical conclusion. It was pointed out that this committeeincluded representatives of manufacturers of gas machines and rubberaccessories, manufacturers of oxygen and anesthetic gases, and the NationalBureau of Standards, U.S. Department of Commerce. Representatives from the Armyand Navy, to this consultant's knowledge, had been assigned for each meetingthat he had attended before entering on active duty. It was further recommendedthat this effort be directed toward uniformity of threadings, tapers, openings,and valves and coordinated with projects in the Air Forces for standardizationof methods of supply, storage, and administration of oxygen to aircrews. Theurgency of augmenting the training programs pertaining to physicians inanesthesia in the Zone of Interior was emphasized, and in addition, it wasrecommended that the program be
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expanded. This request was a reflection of the fact thathospitals had arrived in the European theater without adequately trained medicalanesthesiologists before embarkation for foreign service. The report ended witha request that opportunity be afforded a consultant in anesthesia to observeoperation of hospital units in a theater of active military operations in orderto evaluate and to report needs in training of personnel, agents and methodsto be employed, and equipment to be supplied for future campaigns.
The 2 December report to The Surgeon General was supported bydata provided by Capt. Harry K. Shiffler, MC, of the 48th Surgical Hospital,T?bessa, Algeria, then engaged in the North African operations. On 24November 1942, he reported that his unit had taken over an ill-equipped localhospital and had started work immediately. The operating room was moderatelysized, and there were two tables on which the patient and litter were placed.Two patients, therefore, were always being operated on at the same time. It wasnecessary for him to put the heads of the tables together in a V-shape so thathe could give anesthesia to two patients at the same time. For 3 days, only two anesthetists were available, and each took12-hour shifts. For the first 2 days, only chloroform and ethyl chloride wereavailable. (There were a few cans of ether, but they lasted only a short time.)Since there was a limited supply of chloroform, he had to save it for thelonger operations and use the ethyl chloride for the minor procedures. He wrote asfollows:
Naturally, as you can readily understand, Lieutenant Marmerand myself were wishing for our own American supplies to come, as neither of uscoming from the States had ever had experience with chloroform. There was onlyone mask available, so I fashioned another out of a Planter'sPeanuts can-it worked quite well. Everything was done by the open-dropmethod, of necessity. * * * As soon as our own supplies arrived, includingPentothal Sodium and ether, we at least had a wider choice. * * * In my opinion,Pentothal Sodium is the most valuable single anesthetic agent for theanesthetist in the field during combat conditions. Unfortunately, we had no 20cc. syringes; and we had to do all our work with 10-cc. syringes. * * * Thelaryngoscopes you were kind enough to send me were used to great advantage. Ifeel that every hospital set up to do surgery should have, as part of its basicequipment, laryngoscopes and endotracheal tubes. * * * It should bestressed that any unit going into action should have plasma immediatelyavailable. There is no doubt in my mind that it was lifesaving to many of ourboys.
These reports have been cited in detail because they set thestage for future activity to be undertaken in preparation for the eventualinvasion of continental Europe. They outlined fundamental problems to beovercome in relation to organization for training of personnel, procurement ofstandardized equipment, alteration of tables of equipment to meet the needsof the several types of units, and the need for a competent observer to visit anactive theater of operations to evaluate the usefulness and possibledeficiencies of relatively recently and newly designed American equipment.Some of these problems entailed the establishment of long-term programs,particularly in reference to training of anesthesiologists in the Zoneof Interior and in the United Kingdom, and in standardization of equipmentinvolving new designs to permit employment of agents supplied from eitherAmerican or British sources.
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FIGURE 222.-Adaptable substitute expendable anesthetic equipment obtained from British sources.
The one immediate pressing problem was to rectifythe situation created by the shipment of gas machines in one crate and equipmentof deteriorating quality in another. This situation was due to practiceestablished in the United States on the principle that deteriorating rubberparts packed over a long period of time with nonexpendable equipment woulddeteriorate and be useless upon receipt in a theater of operations. Thisprinciple was well founded, but failure to "marry" deterioratingequipment with nonexpendable equipment at ports of embarkation created a serioussituation whereby nonexpendable equipment received in a theater of operationswas rendered useless so long as the corresponding expendable parts failed toarrive. This situation was particularly serious for hospital units unpackingtheir equipment for the first time upon their arrival in North Africa. Thesituation was less emergent, however, for those units arriving in the UnitedKingdom because there was an established industry to provide adaptablesubstitute expendable equipment (fig. 222). The supplies of expendable Britishequipment, however, were meager, and adaption and procurement were difficult.Another phase of the problem in Great Britain was the adaption of Americanmachines to make it feasible to utilize anesthetic gases supplied in Britishcylinders. The British Oxygen Co. was very helpful in designing adapterspermitting utilization of British deteriorating equipment and in designingadapters (fig. 223) per-
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mitting employment of British cylinders on American gasmachines. Due, however, to the necessity for time-consuming negotiationsthrough the Ministry of Supply, authorization for procurement of theseitems was slow. Production, due to shortage of materials and manpower, was alsotime-consuming. Ultimately, the principle of obtaining expendable suppliesthrough British sources raised the problem of identification of thesematerials by American anesthesiologists.
The first few months in Britain had been revealing.Making the rounds of hospitals scattered throughout southern England, by car,proved to be a frustrating experience. Roads were blocked with pitifully weaklog barriers, and directional signs were completely absent. The citizens werewell trained in their refusal to give out any information. It was commonexperience to inquire of an old "gaffer," who probably had never beenmore than 20 miles from home, the direction of a town that one knew waswithin a 3-mile radius. He characteristically replied that he "never heardof the place." If he was particularly well versed in civil defense, hewould refuse to tell you the direction to the nearest police station, whichwas usually your last resort for gaining information. A blanket of fog, which sofrequently covers Britain during the autumn months, added to the difficulty oftransportation. The English girls who were assigned as drivers from the motorpool were expert and very helpful.
Gradually, a bird's-eye view of problems was gained inrelation to anesthesia equipment, supplies, and personnel that would face ETOUSAduring
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the ensuing 2 years. It was indeed fortunate that a U.S. Armydestined to invade northern France was based in a country that was highlyindustrialized. Deficiencies in equipment that were a reflection of theunpreparedness for war at home, and the all too successful submarinecampaign against American convoys, could to a certain extent be alleviated byrequisitioning substitute items from British sources. Problems in personnelwere more difficult to solve, but it was noted that anesthesiologists in thetheater were gradually receiving equipment satisfactory to meet fully the needsof military practice. Relatively inexperienced anesthesiologists had improvedthe character of their work, particularly following temporary duty for thepurpose of observing and receiving instruction at British and Americanhospitals. The anesthesiologists who had arrived with the 3d Auxiliary SurgicalGroup constituted a pool from which anesthesiologists could be drawn to replaceless-experienced medical officers during their periods of absence for training. During this same period, severalwell-trained and experienced anesthesiologists arrived from the Zone of Interiorassigned to units whichwere to remain in the European theater. This made it possible to plan onusing these men as instructors in U.S. Army hospitals and led to the hope thatthe practice of assigning anesthesiologists to British units for trainingmight be augmented by training anesthetists in U.S. hospitals. It was inthis atmosphere that the year of preliminary planning, 1942, ended.
CONSULTANT DUTIES
The Senior Consultant in Anesthesia by this time realized the significance of his duties: To observe, to report, and to recommend to the Chief Surgeon, ETOUSA. The Division of Professional Services, of which he was a part, was without command function but was expected to formulate policies, obtain their authorization, and check on adherence to policies thus established in general, evacuation, station, and field hospitals and later in base sections and hospital centers. His problems were common to those of his associates, each consultant having a set of problems with which he had to deal that were peculiar to his specialty. The work of the Senior Consultant in Anesthesia included visits to hospitals, observation of work being done with criticism and suggestions regarding organization and practice, preparation of reports with recommendations, preparation of material covering policies for issue as directives by the Chief Surgeon, establishment of satisfactory report forms, collection and evaluation of statistical data, and establishment and maintenance of liaison with his counterparts among the Allies.
It was the responsibility of each senior consultant toevaluate the skill of members of his specialty in all types of units inrelation to the part which each unit was expected to play. This rolenecessitated the interviewing of personnel of incoming hospitals. A filesystem was established containing a summarized medical biography of eachofficer in the specialty. Notes were added recording observations madesubsequently regarding the skill of officers at work. This information was usedas a guide in establishing each officer's rating, and it was
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on the basis of this information that recommendations were made to the PersonnelDivision, Office of the ChiefSurgeon, Headquarters, ETOUSA, when it was necessary to reassign officers tofill vacancies. In the case of anesthesiology, it was also necessary totabulate the training, experience, and skill of anesthesia nurses attached to eachunit.
EXTENSION OF ACTIVITIES IN 1943
Supplies and Equipment for AnesthesiaIt was with some dismay that the work of the ensuing months wascontemplated, with the realization that the tempo of it would be intensified remarkably as thebuildup of the U.S. Army for invasionprogressed. During the month of January 1943, a survey of needs for anestheticand oxygen therapy equipment was completed. A report,entitled "A Consolidated Report Regarding Equipment for Anesthesia andOxygen Therapy in the ETO," was submitted on 31 January 1943. The salientpoints in the report concerned the requirements for gas machines and provision of adapters to permit use of supplies of gases from Britishsources. It was pointed out that British machines in American hospitalspermitted attachment of cylinders containing pure carbon dioxide, apractice which in itself was hazardous but which, under circumstances of military effort, was complicated bythe fact that Britishcylinders containing carbon dioxide were painted green in accordancewith the British Code of Identification. To an American physician, this colorindicated safety and the presence of oxygen. It was, therefore, recommended that supplies ofcarbon dioxide for anesthetic purposes be withdrawn. Subsequently, arrangements weremade with Mr. H. A. Chapman of the British Oxygen Co. that only mixtures of carbon dioxide in 7-percent concentrationwith oxygen in 93-percent concentration would be made available to Americanhospitals.
On 27 February 1943, a letter, entitled "Carbon DioxideFor Inhalation," was issued by the Office of the Chief Surgeon over thesignature of Col. Oramel H. Stanley, MC, Deputy Chief Surgeon, to base sectionsurgeons and commanding officers of all U.S. Army hospitals. This commandletter provided for the recall of all cylinders containing pure carbondioxide in exchange for cylinders containing a mixture of carbon dioxide andoxygen. Attachment to anesthetic machines of cylinders containing onlycarbon dioxide was to be discontinued as soon as the mixture was available, and it wasspecified that carbon dioxide in 7-percent concentration and oxygen could be used for stimulation ofrespiration when that was required.Hospitals possessing freezing microtomes could still obtain pure carbon dioxide,but under no circumstances was it to be stored with gases for inhalation.
It was necessary on 15 February 1943 to issue Circular LetterNo. 27, Office of the Chief Surgeon, Headquarters, ETOUSA, stating thatstandard U.S. and British color schemes differed and that, in order to identify gases in
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cylinders, the labels always must be read. Color markings oncylinders were to be considered only to corroborate labels. This was followedwith a description of British and American cylinders, including theircharacteristics, by which they might be differentiated. Information of generalinterest regarding cylinders and their gaseous contents was given broaddistribution.
This problem of identification of gases and cylinders wasrecognized by authorities outside the Medical Corps. On 20 February 1943,Circular No. 18 was issued by Headquarters, ETOUSA, under the title "Industrialand Breathing Gases and Cylinders." Means and methods of procurementof oxygen as well as acetylene, hydrogen, and nitrogen for industrial purposeswas stated. Confusion was subsequently occasioned in medical units by thisdirective because the color code for oxygen according to British specifications was stated as black. The directive failed to indicate thatnitrous oxide cylinders were also black but possessed a different type ofvalve. The directive also stated: "Where facilities for painting according to British standard specifications are not available, theRequisitioning Officer may request the British Oxygen Company to paint thecylinders. Correct shades and types of paint are available at Headquarters,SOS, ETOUSA, APO-871." This statement failed in the matter ofthoroughly assigning responsibility for painting according to the Britishstandard specifications, and at the same time introduced the hazard of errorwhere painting was undertaken by organizations other than the supplier.Another requirement of the directive was that, until all U.S. Army cylinderswere repainted to conform to British standard specifications, it was essentialthat a label clearly indicating the type of gas be securely pasted on thecylinder. To paste labels securely on cylinders stored in the open wasimpossible, and it was implied that identification of gases and cylinders bymeans of colored paint would subsequently be adequate. This policy introducedhazards where the American color code definitely conflicted with the British.This directive had originally been issued without the knowledge or concurrenceof the Office of the Chief Surgeon. It was unfortunate that distributionincluded units of the Medical Department.
At the time of the preparation of the "ConsolidatedReport Regarding Equipment for Anesthesia and Oxygen Therapy in E.T.O.,"which was submitted by this consultant to the Director of Professional Serviceson 31 January 1943, the hazards of a gas attack were very much in the minds ofall (fig. 224). The report, therefore, included the recommendation that eachhospital be provided with efficient quick-coupling oxygen sets of Britishorigin to provide a minimum coverage of 3 percent of bed capacity in eachhospital, additional equipment to be retained in supply depots to cover 2percent of the bed capacity. This level was set after consultation with Col.William D. Fleming, MC, Chief Gas Casualty Officer, Gas Casualty Division, andColonel Middleton, chief medical consultant to the European theater.Installation of quick-linkage pipelines was advocated to save shipping andutilize to the best advantage the limited supply of cylinders in time of realneed. It was noted that procurement of BLB (Boothby, Lovelace, Bulbulian) masksand regulators had been sat-
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isfactory, but, as a safeguard against gas attack, itwas recommended that 3,000 masks and regulators manufactured by the OxygenEquipment Manufacturing Co. of New York be procured from British sources wherethey were known to be surplus. Subsequently, 50 units of the oxygenquick-coupling sets (sufficient to supply 500 patients) were received ready fordistribution. Fortunately, gas attacks never materialized and the equipment wasnot used.
The use of oxygen tents was pointed out to be impractical inthe European theater because ice was not freely available in quantity andbecause the administration of oxygen in adequate concentration wasincompatible with good nursing care, in the presence of multiple woundsrequiring frequent treatment or observation. The logic of discontinuing theimport of oxygen tents requiring the utilization of ice was manifest in acountry where even chilled beer could not be obtained. Procurement of oxygentents from the Zone of Interior was discontinued.
During the early months of 1943, anesthetic machinescontinued to arrive in the European theater with deteriorating rubber equipment. This created a problem of major magnitude. Aftermuch difficulty,substitute equipment was obtained from British sources. Some delay wasoccasioned by lack of
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standardization between Heidbrink Co. and McKesson EquipmentCo. machines on the one hand, and between the machines produced by the BoyleCo. and the Medical and Industrial Equipment Co., both of London, on the other.This lack of standardization necessitated accumulation of four pools ofequipment for maintenance purposes and was responsible for no little confusion.Attempts to rectify this situation were without avail for many months, butprogress was made through a subsequently established committee, known as theService Consultants Committee on Anesthetics, which included representativesfrom the U.S. Army and the several sections of the British Forces as well as theMinistry of Health and the Department of Health for Scotland. In addition, the Canadian Armyhad direct representation.
Adaption (fig. 223, p. 593) of American equipment toBritish cylinders likewise constituted a problem. The original estimate of thenumber of adapters required was predicated on the basis that the major supplyof anesthetic machines and apparatus for oxygen therapy would be procuredfrom British sources and would therefore not need adaptation to Britishcylinders. This calculation was based upon the fact that the outcome of thesubmarine campaign seemed grim; but, with subsequent marked Alliedsuccesses in dealing with submarines, delivery of equipment from the Zone ofInterior increased beyond original hopes and the procurement of adapterslagged behind needs thus created. The establishment of Depot M-400 atReading, England, on 1 February 1943, for maintenance and repair ofanesthetic and X-ray equipment, proved to be a real boon. Lt. Col. (later Col.)Kenneth D. A. Allen, MC, Senior Consultant in Radiology, was largely responsiblefor establishment of this facility. The original need was to staff this depotwith personnel skilled in servicing anesthetic and oxygen therapyequipment. Attempts to obtain skilled personnel from the Zone of Interior werewithout avail. As a result, technicians servicing such equipment were trained inEngland with the cooperation of the British Oxygen Co. Anesthetic and oxygentherapy equipment distributed to issuing depots throughout the theater wasscreened through Depot M-400 for completeness. American apparatus so screenedhad the proper adapters added in order to make possible utilizationof either British or American cylinders.
TrainingMedical officers trained in anesthesia continued to be in short supply. Training seemed to bethe only answer. Problems arising from the supply of unlike pieces of equipment from variousmanufacturers inAmerica and in Britain made training even more imperative. It was stressed thateach hospital should have a trained physician anesthesiologist and analternate physician to cover for him, and in addition, depending on the sizeand type of the hospital, should have a sufficient number of assistants to coverperiods of peakload. Training by apprenticeship to skilled anesthetists wascontinued and accelerated through the year. In case of need, arrangements weremade for trainees to go on temporary duty for a period of 30 days to hospitals
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possessing anesthesiologists of teaching caliber where theyhad sufficient clinical material for purposes of demonstration.
Early in the year, lack of clinical material in U.S. Armyhospitals necessitated making an arrangement with British military hospitals andthe EMS for augmenting the training and experience of U.S. Army officers. Inthis effort, Brigadier Daly, Air Commodore Macintosh, and Dr. F. Murchie of theMinistry of Health cooperated wholeheartedly. In all, 99 officers received oneor more months of training outside their own unit, and others receivedinstruction and gained experience within their own unit. As the year 1943 drewto a close, it was less frequently necessary to allocate trainees to Britishhospitals because U.S. Army hospitals contained more clinical material andanesthesiologists of teaching caliber. The program of arranging temporary dutyfor U.S. Army personnel at British hospitals led to its administrativedifficulties, sometimes with respect to rations, other times with respect to the jealousy of hospital commanders in reference to their prerogatives.Apparently, the Senior Consultant in Anesthesia had been less than efficient inlaying on the program through the highest international channels. Instead, thearrangements had been made at the operational level. Occasionally, thecommanding officer of a British hospital wanted to know why his unit had beeninvaded by one or two American officers who had arrived without the properfanfare of announcement. To the Senior Consultant in Anesthesia, it seemedthat, if the British had patients and were short of personnel and if the U.S.Army had physicians without patients, temporary duty for American officers toBritish hospitals was the logical procedure to remedy the situation and at thesame time provide for training.
Throughout the year, the Senior Consultant in Anesthesiaor his alternate, Maj. (later Lt. Col.) Fenimore E. Davis, MC, presented a2-hour lecture before each class attending the ETOUSA Medical Field ServiceSchool at Shrivenham. The presentation included a discussion and slidedemonstration of intravenous anesthesia, drugs for regional anesthesia, anduntoward reactions likely to be encountered in accomplishing blocks frequentlyemployed in military practice. Evidences of oxygen want and remedial measureswere outlined and stressed. In addition, lectures along similar lines werepresented before staff meetings at individual hospitals, on invitation.
Special Reports
In order to improve clinical anesthesia and to provide means for the accumulation of statistical data, two forms for reporting the course of each anesthetic administered were devised and circulated. The smaller form, known as the ETOUSA MD Form No. 55-0-1, was for general use and was designed to fit the EMT (Emergency Medical Tag) envelope. One side of the form provided space for recording the preoperative examination of the patient, and the opposite side was for recording progress of the anesthetic procedure. A larger form, identified as Form 15 E.T.O.-P.S., was similarly
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designed and was for use in general hospitals using thelarger-sized forms throughout their complete reporting system.
A monthly report covering activities of the anesthesia andoperating room section was required from each hospital in the European theaterby a command letter issued by the Office of the Chief Surgeon on 24 February1943. Through the cooperation of anesthesiologists in the theater, statisticalinformation was submitted to the Office of the Chief Surgeon for analysis. Thesedata were collected to establish experience factors in reference to agents andmethods used and thus provide the Supply Division, Office of the Chief Surgeon,data from which to estimate requirements for future supply. The data alsoindicated the direction in which emphasis should be placed in the training ofanesthetists.
Visit to North Africa
Revision of TM (War Department Technical Manual) 8-210, Guides to Therapy for Medical Officers, issued on 20 March 1942, was under consideration by the Professional Services Division throughout 1943. It became evident that, in order to intelligently prepare such an manual, a tour of observation in a theater of operations actually involved in combat was necessary. Therefore, on 11 September 1943, a request for orders to visit NATOUSA (North African Theater of Operations, U.S. Army) was submitted and eventually approved. The purpose of this trip was to collect data for completion of the portion of the manual on anesthesia and data relating to maintenance of a proper balance in the program for training anesthesiologists and oxygen therapists. Orders were issued on 12 October 1943 by Headquarters, SOS, ETOUSA, and the trip was accomplished between 20 October and 20 November 1943.
A tour of duty in NATOUSA, for observational purposes in anactive theater, proved to be interesting and instructive. This author observedhospitals in the vicinity of Algiers, Algeria, and Bizerte and Tunis, Tunisia,in North Africa; Palermo and Catania in Sicily; and Naples and Caserta in Italy.He also went as far forward as divisional clearing stations in Italy. Followinghis observations in the field, a report was submitted to the Chief Surgeon,ETOUSA, entitled "Impressions Gained During a Trip to NATOUSA and FifthArmy."
The author observed that there was a distinct shortage oftrained and experienced anesthesiologists to take care of peakloads ofcasualties. Some hospitals were without the services of a trained anesthetist.The greatest need for thoroughly qualified anesthesiologists existed in unitssituated in forward areas, where the severest injuries were seen and treated.It was in the forward areas that anesthetists attached to auxiliary surgicalgroups were rendering the most and best service.
There was a great need for portable gas machines in eachhospital platoon of field hospitals, where intermittent positive pressure wasessential for adequate care of nontransportables. A real need for the same typesof equip-
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ment existed in evacuation hospitals of either the 750- or 400-bed type. Aninequality of distribution of portable gas machines and anesthesia sets existed.In this regard, the situation was similar to that which existed in England,but, unlike the European theater, the North African theater could not procuremachines from British sources to cover the deficiencies. Distribution of sodalime for the machines was inadequate in quantity. When the need was extreme,Shell Natron was used as a substitute, thus diverting this specialized materialinto unintended channels. This practice was not without its hazard to bothpatients and anesthesiologists. Where continued, the use of Shell Natronproduced deterioration of already scarce anesthetic equipment. Because of these difficulties, thisconsultant reported that there was a real need for developing light, sturdy, and freely portable equipment to provideintermittent positive pressure for resuscitation with either air or oxygen, ifavailable. He further stated that this apparatus should be able to cleaninflowing air, if and when gas warfare was employed. He believed too, thatsuch equipment should incorporate facility for the administration of ethervapor when desired.
Portable suction apparatus also was scarce, while there was a real need forit in field and evacuation hospitals. Equipment designed in the United Statesand provided in tables of equipment was satisfactory when electricity wasavailable. Situations were encountered, however, in which portable apparatus,operated manually or by foot action, would have been of value. Such apparatus,aside from supplying the need in far-forward areas, could augment rather thandisplace existing portable equipment that was electrically operated. In hisreport, the author suggested that the reversal of the valve system infoot-operated tire pumps, currently in civilian use in England, would be easilypossible, and that, with the addition of a vacuum bottle, suitable tubing, and an aspirating tip,the apparatus would be satisfactory.
This consultant soon learned, upon his return, that in the Army one should nevermake a recommendation unless he is prepared to follow through with it. With the help of Major Davis, who was trained first as an engineer and subsequently as a physician, a sturdy and freely portable piece of equipment was designed (fig. 225) and produced at Depot M-400 to provideintermittent positive pressure for resuscitation with air or with oxygen, if available. This apparatus also provided a facility for the addition of ether vapor when desired. Through the cooperation of Down Bros. of London, medical equipment manufacturers, foot-operated tire pumps, designed to service heavy trucks in civilian use, were altered by reversal of their valve systems, and thus a foot-operated vacuum pump was produced andsupplied to augment suction pumps electrically operated in U.S. Army hospitals.
In NATOUSA, anesthesia practice was noted to be circumscribed by the lack of fully experienced anesthesiologists. This led to inexpert choice of agent and method for patients in critical condition. The same shortage tended toward the use of agents and methods beyond the boundaries of their known wisest employment. On the one hand, surgeons advocated and undertook the
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administration of spinal anesthetics in instances in which,with the services of an expert anesthesiologist, the same surgeons would haveelected inhalation anesthesia. On the other hand, there was a tendency to employPentothal sodium (thiopental sodium) in contravention of knowncontraindications because of its ease of employment in periods of peakload. Lackof skilled anesthesiologists, adequately equipped to undertake administrationof inhalation anesthetics employing carbon dioxide absorption and intermittentpositive pressure administered through an endotracheal tube, accentuatedthis tendency. The need for conservation of time also dictated the choice ofanesthesia. In some instances, erroneous judgment was responsible forsubsequent difficulties that would not have occurred had the patients been inas good condition as was first believed. Absorption of morphine administeredsubcutaneously to patients suffering from exposure and exhibiting peripheralvascular constriction resulted in delayed absorption, and the pain frequently was not relieved. A second dose underthese circumstances might be given with similar results; but, when the patient was treatedfor shock by warming or administration of fluids, or when given an anesthetic,absorption was rapidly hastened and morphine poisoning was exhibited.
An awareness of the hazards inherent in the use of Pentothal sodiumin the presence of shock, particularly following hemorrhage,was appreciated. It was recognized that Pentothal sodium was hazardous in thepresence of bleeding lesions within the mouth or in the presence of dyspneafrom any cause. The use of Pentothal sodium for surgical procedures within thethorax or abdomen was contraindicated. Ether was recognized as the agent ofchoice for production of muscular relaxation for the recently wounded.Anesthesiologists in the North African theater were of the opinion thatavailability of cyclopropane was highly desirable, particularly for patients in critical condition. In relation to problems of supply, the value ofcyclopropane seemed obvious because the space required to transportcyclopropane in quantity equivalently useful to nitrous oxide would be small in comparison.
The greatest need for portable gas machines existed in fieldhospital platoons functioning independently and set up adjacent todivision clearing stations for the treatment of nontransportables. Thiscircumstance, the author reported, would necessitate supplying fieldhospitals in the European theater with nitrous oxide, oxygen, and sodalime. He further recommended that provision be made to supply each auxiliarysurgical group with 10 portable gas machines, 10 portable suctions, and the necessary gases forthem. He suggested that these machines be distributedto those teams assigned to hospital units operating under peakload, and thatfirst priority be given to thoracic, general surgical, and plastic surgicalteams. Supplies of these items in hospitals were inadequate to cover the needs ofthe teams.
Practice in hospitals in North Africa and Italy workingunder battle conditions demonstrated the sagacity of planning to supplycitrated blood from a blood bank established in a rear area. Such procurementmade thorough
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control possible in reference to syphilis, malaria, andjaundice and, at the same time, relieved units in forward areas of theresponsibility for setting up local blood banks. The consultant observed that,without the availability of sufficient blood, adequate care of the woundedwould be impossible. Upon the author's return to England, this matter wasthoroughly discussed within the Professional Services Division, Office of theChief Surgeon, and plans were laid to establish a centralized blood bank withMaj. (later Lt. Col.) Robert C. Hardin, MC, in charge of the operation. MajorHardin's organization ultimately provided blood for the initial stages of the invasion ofnorthern France. Procurement of blood from troops in England, and later on the Continent, wascontinued even after an adequateline of supply was established with the Zone of Interior. During the campaignsin northern Europe, Major Hardin's organization continued todistribute blood throughout the theater. If a patient died, his death wasattributed either to his having been given too much or too little blood ortoo faulty administration of the anesthetic. Seldom would surgeons admit deaths were due towounding, and never, it seemed, would they admit that the surgical procedure was contributory. Major Hardinand the author stoodshoulder to shoulder on the same chopping block.
The trip to North Africa was a geographic revelation. Thehandicaps under which an army in the field worked made a real impression. Thedisadvantage of a native population that on occasion was less than friendlywas observed. The native Arab was seen in his own habitat, with a discerningeye. It was adequately demonstrated that Africa is a cold continent with a hotsun. The trip back to England was more than interesting and a littlefrightening. When this consultant arrived in Marrakech, Morocco, via planefrom Algiers on the return trip, he both expected and desired to be forcedto remain there for 2 or 3 days until air transportation became available forthe trip to northern Scotland. After a very arduous trip across North Africato Bizerte, Tunisia, and then on through Sicily to Italy, he would havewelcomed time to bask in the sun. Much to his chagrin, upon inquiring abouttransportation to Scotland, the author was told that there would be a C-54plane on which he could leave within 1? hours. He decided to accept theaccommodation rather than wait 3 or 4 days or more for another vacancythat might be further delayed by high priorities given to ferry pilotsreturning to the United States to bring back still another plane.
The trip was uneventful during the first 13 hours.Subsequently, the passengers were told that the aircraft was bucking aheadwind and getting low on gasoline. The pilot was forced to break radiosilence and asked for permission to approach Scotland over the Irish Sea,rather than fly to the west of Ireland on a course that was usually followedto avoid German fighter bombers based in Brittany. His luck did not hold well.The plane was met over the Irish Sea by a JU-88 which attacked from therear. It was a physiologically stimulating experience to descend toapproximately 500 feet above sea level in the fashion of a falling leaf, notknowing whether the plane was in control or out of it. After the planelanded at Prestwick, Scotland, having been escorted in by two
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P-40's, it was discovered that one wing had beenpierced by a 20-millimeter shell. The shell had lodged between two wing tanks buthad failed to explode. Fortunately, no one aboard was injured. Itwas theorized that perhaps a Czech had sabotaged the German war effort. Thisconsultant realized that, although he was a noncombatant, he was not a neutral. Not many months were to pass before his status as anoncombatant would be brought into focus again. While he was accompanying a fullcomplement of wounded in a C-47 from France to England, a"trigger-happy" American shore battery, located on the south coastof England, fired at the plane. The flight engineer quickly shot off a coupleof identifying flares which were recognized by the gunners below. Thefiring ceased, and no damage was done. The pilot was exasperated. He saidthat he had approached the coast in the stipulated manner and was thereforetotally at a loss to account for the action of the guncrews.
PREINVASION ACTIVITIES
Many hoped that 1943 would be the year of action. This proved to be impossible; and, instead, the invasion of northern France was delayed until June 1944. The buildup for invasion started with the arrival of units of the First U.S. Army in the theater. It was immediately obvious that an accentuated program for training anesthesiologists was necessary. Three courses were held in 1944 at the 120th Station Hospital, Tortworth Court, the first from 17 to 22 January inclusive, the second from 21 to 26 February (fig. 226), and the third from 20 to 25 March inclusive. A fourth course was held at the 10th Station Hospital, Manchester, Lancashire, for Third U.S. Army personnel during the period 1 to 4 May inclusive. The average attendance was approximately 70, and at least half of the trainees were medical officers. The program was intensive; but, in retrospect, it seems to have been pitifully inadequate. Nevertheless, the writer is still confident that much was accomplished in the way of orientation. The many officers who participated as lecturers deserved commendation for their effort.
D-DAY AND ITS AFTERMATH
It is a well-known historical fact that D-day occurred on 6 June 1944. On 23 June, the author reported to the Chief Surgeon his impressions gained since D-day. It was with real satisfaction that this consultant was able to state that in all echelons anesthetic equipment had been adequate with only a few shortages of one or another article in isolated instances (fig. 227). Likewise, oxygen-therapy equipment had been adequate to meet the immediate need on the Continent. Once again, however, the problem of supply had raised its ugly head. Adapters for use on British cylinders were found to be lacking in some units equipped with complete hospital assemblies shipped directly from the Zone of Interior. Fortunately, adapters were available to cover these deficiencies. American cylinders were still being used in many fixed facilities in the United Kingdom. As a result, Col. Silas B. Hays, MC,
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chief of the Supply Division, Office of the Chief Surgeon,recalled both empty and filled cylinders from U.S. hospitals in the United Kingdom fortransportation to the Continent. The 130,000 bedsdistributed in over 100 hospitals in the United Kingdom were supplied with gasescontained in British cylinders. The most evident need for equipment during the first fortnight of theinvasion was for suctionapparatus. Tables of equipment were not adequate to cover needs. Americanequipment could not be used in Britain in wards wired with 230volts without utilization of transformers, and transformers were not freelyavailable. The need for foot-operated suction, first recognized inNorth Africa, was once again evident.
Pentothal sodium was the agent most frequently used in allechelons and with general satisfaction and safety. In certain isolatedinstances, anesthetists had been influenced to use this drug under unwarrantedcircumstances, such as the incision and drainage of a phlegmonof the neck. Spinal anesthesia was used in general hospitals providing definitive treatmentbut was seldom
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used for the treatment of those recently wounded. Thisconsultant received the impression that, although fluids had beenfreely administered, undertreatment rather than overtreatmentexisted. In one area at least, supplied from British sources, blood in relation toplasma was being used in the ratio of 10 unitsto 1. At the time, this was considered a nonjustifiable depletion ofsupplies of blood, but, as the campaign progressed, the need was more and more easily justified.
VISIT TO NORMANDY
During the first week of July, this consultant visited hospitals in Normandy, and a report of observations was prepared. He noted that some evacuation and field hospitals were in the process of packing in preparation for moving forward while other hospitals still remaining in operation were working beyond the limits of their capacity. One 400-bed evacuation hospital had 520 patients on its second day of operation, with a preoperative backlog of 250 to 300. This was due to a special circumstance: Its normal line of evacuation was over Utah Beach and the airstrip intended for evacuation of the wounded was needed for fighter squadrons. It was recognized that evacuation by hospital carrier might take as long as it would take to work down the backlog of preoperative patients. A problem in sorting, therefore, existed in regard to selection of patients to be transported by surface carrier to Great Britain and patients to remain with the unit for surgical treatment.
A platoon of the 13th Field Hospital was visited and found tobe not too busy. It was supported by two teams from the 3d Auxiliary Surgical Group. Equipment was adequate to meetneeds with the exception that Shell Natron canisters were lacking for closed-circuit oxygentherapyapparatus. These teams had had no deaths on the operating table. A neighboring unit,the 16th Field Hospital, Normandy, France, was attached to and working with the67th Evacuation Hospital, whileawaiting the arrival of equipment. This unit had been in active operation in Egypt.The 47th Field Hospital, Normandy, France, was likewise awaiting the arrival of its equipment,which its personnel knewlacked gas machines and equipment for oxygen therapy. This unit, originallybelonging to the Third U.S. Army, had arrived last and had been assigned to the First U.S. Army. Thiscircumstance accounted forfailure to obtain those supplementary items authorized for First U.S. Army units in theEuropean theater. A lack of coordination between the effortsof attached auxiliary surgical group teams and the personnel of a platoonof a field hospital was in evidence. Two units never do well under oneroof unless the commanding officer of the facility has full coordinatingcontrol. This matter was reported for policy decision in relation to fieldhospitals.
Pentothal sodium was being used in approximately 75 percent of the operations. Oxygen was frequentlygiven for support. For thelonger procedures, nitrous oxide and oxygen was given, and ether was employedto produce relaxation. The muscle relaxants of the curare series were notavailable at the time.
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It was also quite the usual practice for hospitals toprepare atropine-morphine and Pentothal sodium in bulk. This practiceresulted in the conservation of valuable time, facilitated preliminarymedication in the operating room, and eliminated haphazard premedicationin wards. In order to time properly the administration of preliminary medicationwith the beginning of an operation, it was necessary to give atropine andmorphine intravenously in the operating rooms.Because Pentothal sodium was being prepared in bulk, the prevailing practice ofprocuring Pentothal sodium in small l-gram ampules seemed extravagant in terms ofsupplies and also in the time required to make the preparation. This consultant suggestedthat Pentothal sodium might well be obtained in 10-gram ampules and that distilled water for itsdilution could better be supplied in bottles containing 500 or 1,000 cc. In oneinstance, faulty fillingof a cylinder constituted a problem. An officer of the 3d Auxiliary SurgicalGroup reported that a cylinder, marked "Oxygen" and painted blackwith white neck like its British standard, contained-in actual fact-carbondioxide. When the gas was employed, it produced cyanosis following a period ofhyperpnea. This was recognized, the contents of thecylinder were emptied, and the cylinder was returned for refill. No patients suffered.This circumstance was another facet of the overallproblem of identification of gases in cylinders.
Some deaths had occurred in which anesthesia was considered to becontributory. In these instances, inhalation anesthesiawas as frequently blamed as when Pentothal sodium was employed.Vomiting with aspiration during the induction of anesthesia was recognizedas a major hazard. It was noted that the critical interval in which anesthetistsshould be interested was the time between eating and wounding, rather thanwounding and operation, because digestion was inhibited immediately afterwounding. This author advised that accidents due to aspiration could, in someinstances, be prevented by initiating vomiting prior to induction of anesthesia.Attempts to wash a stomach with aLevin tube in place had given only partial protection.
Plasma and blood were being used in the ratio of 1 to1. In order to conserve blood, which was limited in supply, this consultant expressedthe hope that the ratio of plasma might be raised to2 units for 1 of blood. Along this line, he also noted that, during hot weatheror when patients were perspiring or vomiting, there was a veryreal need to replace chlorides by the administration of normalsaline. A common complaint was that the needles in plasma sets were too small in caliber to permit the administration of blood.The air vent in the blood bottle was too short to reach above the surface of the fluid.Filters became clogged with fibrim. Pressure was necessary to maintainflow of fluid. The valves of blood pressure bulbs, used to create pressure,became clogged. It was recommended that the Office of The Surgeon General beinformed of difficulties due to small-caliber needles and berequested to include larger, size-16 needles in plasma sets.
Arrangements for the treatment of shock seemed toentail some confusion. There was a general tendency toward failure toisolate patients requiring major effort in the treatment of shock. As a result,officers were confronted with
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patients in widely dispersed parts of preoperative tents andfailed to treat shock adequately. This consultant advised that it was desirableto segregate patients needing major effort in the treatment of shock in orderthat the medical officer in charge might be able to keep them under hisdirect supervision at all times. He further advised that an officer withmature experience be assigned to these duties. Surgeons found it impossible tomaintain continuity of observation between operations. It was with thesematters in mind that a senior consultant ended his first tour of duty to theNormandy beachhead on 8 July.
MOVE TO THE CONTINENT
On 28 August 1944, movement of the Professional Services Division, Office of the Chief Surgeon, to the Continent began. Travel was accomplished by train to the marshaling area near Southampton, thence by boat to Utah Beach, and lastly to Headquarters, Communications Zone, at Valognes, France, by truck. The group was delayed for 3 days en route at the marshaling area because the ship on which it was scheduled for transport to France had no accommodations for females. The party included two, the chief nurse and Capt. (later Maj.) Marion C. Loizeaux, MC. The party was subsequently assigned to a Victory Ship, carrying some 1,500 troops, packed like sardines in a can. The passage across the English Channel occupied 24 hours because of the circuitous route that the ship was forced to take in order to avoid minefields. Off Utah Beach, the travelers were transferred to a tender. This transfer necessitated climbing down a rope net to the deck of the tender which was in constant motion. For a landbound Army man, this was a new experience. Fortunately, the operation entailed no injuries to any of the group. From the tender, the members walked ashore over the hardstand, getting no more than their feet wet. The evidence of sunken ships and the litter of destruction on the beach were still present, reminding all of the contrast between the ease of their landing and the difficulties in the original invasion by shock troops.
As they proceeded inland, it was obvious that the Army hadaccomplished a great deal in clearing away the bits and pieces of glidersforced to land in fields that were too small because all the larger fieldshad been well planted with "Rommel's asparagus," postsapproximately 8 feet long imbedded upright in the ground at regular intervals.The purpose was to prevent the very landing thatoccurred in spite of this enemy action. It was amazing howthoroughly an Army in combat was able to clean up its new backyard in theless than 6 weeks that had elapsed between this consultant's first tripto the beachhead in early July and the permanent transfer of theOffice of the Chief Surgeon in August. Not only had the superficial evidenceof destruction occasioned by the invasion been removed, but the fields had been cleared of mines aswell. This total area had been cleared toprovide space for incoming troops and the buildup of a major supply base.
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The headquarters remained in Valognes only a few days. Atthis time, the advance of the Allied armies was extremely rapid. Orders werereceived to move to Paris. This city continued to be the location of Europeantheater headquarters throughout the remainder of the fighting in northernEurope. The first entry into Paris was memorable. Although the city had been secured afew days prior to the arrival of the headquarters group, theelation of the populace was very much in evidence. The author was intrigued tolearn that he had been assigned a billet in the Hotel California.Subsequently, after a tour of hospitals in the then existing forward area thatrequired approximately one week for its accomplishment, he returned to theHotel California to find that it was completely occupied by the Women's ArmyCorps. His gear had been moved out. He was temporarily dismayed with the idea thathe would never see it again. The personnel of the billeting office, however,were completely efficient. They informed him ofhis new assignment, and there were equipment and personnel belongings,completely intact with not one item of importance, collected during 2years' sojourn in England, missing.
ACTIVITIES DURING THE FINAL CAMPAIGNS
Thereafter, the work of the Senior Consultant in Anesthesia was divided between the Continent and installations in the United Kingdom Base. With the establishment of hospital centers in the United Kingdom Base, a consultant in anesthesia was nominated for each of the seven centers. The author expected that, during the remainder of 1944, and until the termination of the campaigns in northwestern Europe, his work in the main would be confined to facilities (60,000 beds) on the Continent with the hospital center consultants functioning in the United Kingdom. The medical officers to whom this responsibility was delegated were as follows:
| Officer | Hospital assignment |
I | Capt. Gilbert Clapperton, MC | 67th General Hospital, Musgrove Park, Taunton, Somerset |
II | Capt. Lawrence F. Schuhmacher, Jr., MC | 140th General Hospital, near Ringwood, Hampshire |
III | Capt. Arthur LeeRoy, MC | 154th General Hospital, near Wroughton, Wiltshire |
IV | Capt. Charles Burstein, MC | 160th General Hospital, Stowell Park, Gloucestershire |
V | Capt. Milton H. Adelman, MC | 155th General Hospital, near Hanley, Worcestershire |
VI | Capt. Jasper M. Hedges, MC | 137th General Hospital, Otley Deer Park, near Ellesmere, Shropshire |
VII | Capt. Phillip E. Schultz, MC | 7th General Hospital, North Mimms, Hertfordshire |
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As rounds of hospitals and auxiliary surgical groups weremade, it was apparent that accessory equipment beyond their authorizedallowances would facilitate their operations. The primary need was for amanually controlled apparatus for resuscitation which would supply intermittentpositive pressure without the necessity of having cylinders containing oxygen.The second need was for a suction apparatus that wasfoot operated rather than electrically driven. At the same time, it wasrealized that the allowance of gas machines to evacuation hospitals andfield hospitals was inadequate to meet their needs. During the lastquarter of 1944, it was agreed that the authorized allowance of theseitems should be increased so that each 400-bed evacuation hospital would have four gasmachines and each 400-bed field hospital would have six. In November, this authorwas notified by the Supply Division, Office of theChief Surgeon, that 1,000 units of foot-operated suctions had been received,500 from Down Bros., London, and 500 from the Zone of Interior. These units weredistributed, one unit to each general and station hospital, two units to eachevacuation hospital, and three units to each 400-bedfield hospital. The latter made available one unit to each of the three hospital platoons inthe field hospitals. Distribution at this stage of thecampaign was difficult on an automatic basis, and not until all unitslearned of the availability of these units for suction were requisitionsplaced for them.
Following practices established in the immediate preinvasion period, hospitalcommanders and their chiefs of surgicalservice were urged, throughout the year, to assign medical officers and nurses fortraining in anesthesia and oxygen therapy within their unitswhere trained anesthesiologists of teaching caliber were available.Admittedly, there was some reluctance to follow this advice withenthusiasm, but in many instances it was undertaken with ultimatebenefit accruing after the units were assigned their combat support missions. In September 1944, the lack ofanesthetists in forwardareas, particularly in evacuation hospitals, was creating a bottleneck in thetreatment of the wounded. Anesthetists to meet attrition were not available. Itwas therefore proposed to the Surgeon, United Kingdom Base, that 25 general and station hospitals possessing qualifiedanesthesiologistsof teaching caliber be ordered to undertake the training of one medicalofficer and one nurse in anesthesia. Col. (later Brig. Gen.) Charles B. Spruit, MC, Surgeon,United Kingdom Base, endorsed this program. Letters were written to the 25 selected hospitalsadvising each commandingofficer immediately to assign a medical officer and nurse from his unit tofull-time training in anesthesia with the understanding that when training was completed one orboth individuals would be subject to reassignment to units in greater need of their services.In November 1944, 10general hospitals arrived in the United Kingdom from the Zone of Interiorwithout coverage in anesthesia. Officers made available through the trainingprogram were assigned to these new units or to units already in operation requiring onlyminimal skills in anesthesia. In the latter instance, the more skilledanesthesiologist of the operating unit wasreassigned to the new general hospitals. The rate of attrition amonganesthetists throughout the theater
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was increasing due to illness, fatigue, and nonbattleinjury. The pool of anesthetists in training was being rapidly depleted.It was therefore recommended to the Surgeon, United Kingdom Base, that in eachinstance in which a trained anesthetist was moved his replacement was to be similarlytrained and oriented in anesthesia. Thus, the training program was perpetuated.
Because fatigue became evident among anesthesiologists ofauxiliary surgical groups and those assigned to evacuation hospitals, thepolicy was established in October 1944 that medical officers over 40years of age be permanently reassigned from forward units to fixedfacilities in the communications zone. A second phase of the programrotated younger anesthesiologists in forward areas to fixed facilities in thecommunications zone for a period of 60 days and sent anesthesiologists forward from fixedhospitals for a similar period of temporary duty in forward area hospitals. As a result of this exchangeprogram, the experience of anesthesiologists involved was broadened, and each hadan opportunity to observe at first hand the problems of the other.
Throughout the year until closure of the school, a lecture,illustrated by slides on anesthesia and oxygen therapy, was deliveredbefore each class for medical officers at the ETOUSA Medical Field ServiceSchool, Shrivenham. The practice, which had been initiated in 1943, of holding conferences foranesthesiologists immediately after each monthly meeting of the Section onAnesthetics of the Royal Society of Medicine in London was continued throughout 1944.Interesting clinical topics were presented by selected members, after which open discussion ofproblems was encouraged. By this means, use of agents and methodstended to become standardized for the benefit of the sick and wounded.Copies of three films, prepared by Dr. I. W. Magill and Dr. G. S. W. Organe ofLondon under the sponsorship ofImperial Chemical Industries, Ltd., were made available as training aidsthrough the Army Pictorial Service. These films dealt with ether anesthesia,endotracheal anesthesia, and intravenous anesthesia. Throughout the year, theywere shown to many groups. Attempt was made through the Officeof The Surgeon General to obtain copies of training films produced in theZone of Interior, but information was subsequently received thatshipment of these training aids overseas was not possible.
As the war progressed in Europe, lines of communicationlengthened tremendously and the battlefront becamefar flung, extending from The Netherlands through Belgium and Luxembourg and eventually tosouthern France. The problems of observation,supervision, and control of anesthetic practice grew tremendously as thebattleline was extended. Even changes in climatic conditions from the heat of summer tothe cold winter of 1944-45 created newproblems. The character of wounds and injuries changed. The incidenceof exposure was magnified. Frostbite and trenchfoot became prevalent. It wasnecessary to caution that doses of morphine given as preoperative medication for seriouslywounded patients should be small. It was further emphasized that morphine must beadministered with caution to the walking wounded, to patients to be evacuated byair, or in the presence of jaundice, craniocerebral
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injuries, pneumothorax, hematothorax, or pleural effusion.With the arrival of cold weather, the hazards of morphine poisoning wereaccentuated due to slower absorption in the presence of shock. The syndromebecame evident when patients were warmed and were given fluids toalleviate shock.
It was necessary to issue an administrative memorandumthat the administration of spinal anesthetics would in all instances beundertaken by medical officers only, although care of the patient during theoperative procedure might be delegated as the situation warranted. The use ofspinal anesthesia was discouraged except for definitive late treatment of woundsinvolving the buttocks and lower extremities.
Material covering the subject of intravenousadministration of procaine hydrochloride had been prepared and distributed tothe Senior Consultants in Maxillofacial Surgery, Neurosurgery, Orthopedics, andDermatology with the request that the method be cautiously tried in suitableinstances. It was known that it was feasible to inject a dilute solution ofprocaine hydrochloride intravenously in order to obtain relief from pruritusassociated with jaundice. It was considered that patients with severe burns might be similarly helped withoutthe production of respiratorydepression. Sedation in the presence of involvement of the tracheobronchial tree due toinhalation of smoke and noxious vapor wasrecognized as a difficult problem. The incidence of burns proved to be muchlower in the European theater than had been contemplated. Opportunity wasafforded to give limited trial to the use of procaine hydrochloride administeredintravenously. Reasonably satisfactory sedation wasobtained in many instances. This experience led to the administration ofprocaine hydrochloride for sedation in the presence of conditions other thanburns. In patients with fractures recently confined within acast that included both the trunk and either a leg or arm, theadministration of procaine hydrochloride intravenously alleviated restlessness due tothe marked restriction of movement. It wassubsequently noted that reduction of swelling and edema occurred in surprisingly rapidfashion. Orthopedists found it necessary to change castsat shorter intervals in order to compensate for the rapid reduction in size ofa leg.
As the incidence of trenchfoot increased, utilization ofsympathetic block became more frequent. During the first 5 months after D-day,sympathetic block was reported employed in 1,300 instances for an overallincidence of 0.94 percent. Its employment in the presence of vascular injuries associatedwith marked edema was helpful. It was subsequently shown that utilization of sympathetic blockin the presenceof cold exposure of extremities or trenchfoot was essentially noncontributoryto improvement. Statistical data regarding the incidence of utilization ofother anesthetic agents and methods have been reported elsewhere.1
1(1) Tovell, Ralph M.: Problems in Supply of AnestheticGases in the European Theater of Operations, U.S. Army. Anesthesiology 8: 303-311,May 1947.(2) Tovell, Ralph M.: Problems of Training in and Practice of Anesthesiology intheEuropean Theater of Operations. Anesthesiology 8: 62-74, January 1947. (3)Tovell, Ralph M., and Barbour,Charles M.: Comparative Uses of Pentothal Sodium in Civilian and Military Practice.Lancet 67: 437-443, December 1947.
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The problem of promoting anesthesiologists became more acutethroughout the year, and no solution was found. A new table of organizationand equipment No. 8-550 for 1,000-bed general hospitals had been promulgatedby the War Department on 3 July 1944 stipulating that anesthesiologists be inthe rank of captain. In August 1944, this consultant commented to the ChiefSurgeon, ETOUSA, that there was a distinct correlation between the existingshortage of anesthesiologists and the lack of opportunity for advancement inrank. Medical officers had no incentive to qualify as anesthesiologists becauseof the existing limitations. He also pointed out that modern anesthesiademanded adequate training and experience if the lives of the sick and woundedwere to be adequately protected. He stressed the fact that anesthesiologistswere responsible for the safeguarding of equipment in operating rooms, the training and control of personnel, andthe supervision ofcentral supply and oxygen therapy as well as the administration ofanesthetics. The author therefore recommended that in order to provide anincentive for medical officers to qualify as anesthesiologists and in orderthat qualified anesthesiologists of long standing in the theater mightreceive the recognition they deserved, an urgent request for a change of thenew table of organization to provide for a majority for at least oneanesthesiologist in each 1,000-bed hospital be submitted to The SurgeonGeneral.
The problem of promotions was not limited to generalhospitals. The situation in auxiliary surgical groups became acute,particularly in those groups that had been overseas for 2 years or longer andhad served in Africa, Sicily, Italy, and France. In the 3d Auxiliary SurgicalGroup, there were 21 anesthesiologists with 2 years of service who had noopportunity under existing tables of organization to improve their rank, nomatter how long the war lasted. The situation was depressing to theirmorale in view of the fact that they had seen junior surgeons of lesstraining and experience become chiefs of surgical teams and gain the rank ofmajor. These anesthesiologists had been caring for nontransportables infield hospitals, their skills were recognized and appreciated by theirassociates, but this appreciation was not reflected in the tables oforganization. It was evident that a general overhaul of tables of organizationwas warranted.
Miscellaneous activities continued to occupy a great deal ofthe time of the Senior Consultant in Anesthesia. He attended meetings of theMedical Research Council in London, particularly those dealing with blood, bloodsubstitutes, and shock. Several meetings of the Service Consultants Committeeon Anesthetics held at 1 Wimpole Street, London, afforded an opportunity for the interchange ofinformation among consultants to the Ministry of Health,Scotland; the British Army, the Royal Navy, and the Royal Air Force; EMShospitals; and the Canadian Army. Liaison through these meetings wasparticularly valuable. Meetings of the Inter-Allied Conference on War Medicinewere also attended. The Senior Consultant in Anesthesia also attended twomeetings of British and American consultants, one held in Paris and the other in Brussels.
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From time to time throughout 1944, material wasprepared for submission to the Office of The Surgeon General regarding theadequacy of equipment and supplies for anesthesia and oxygen therapy. Thismaterial was forwarded in ETMD (Essential Technical Medical Data) reports that proved to bean important medium for the submission of informationto the Office of The Surgeon General. On 29 January 1945, a memorandum wassubmitted to Colonel Cutler regarding the preparation of sterile solutions of procainehydrochloride from bulk supplies of the drug. It waspointed out that two deaths had occurred, one following the subcutaneousinfiltration of procaine hydrochloride (presumed) for the investigationof a severed peroneal nerve and the other during the administration of asympathetic block. These deaths had occurred at different hospitals. At thehospital where the death occurred following subcutaneous injection in thepopliteal region, another patient exhibited convulsions of asevere nature but recovered under appropriate therapy. It was pointed out thatthe prevailing practice of supplying procaine hydrochloride in bulkled to difficulties in preparation and identification of solutions of properconcentration and sterility, particularly in field and evacuation hospitals.Sterilization was carried out either by boiling in a water bath or byautoclaving. Frequently, excessive heat tended to minimize the anestheticeffectiveness of the resulting solution. As a result, there was a tendencyto use a stronger solution than was justifiable for infiltration. Underthese circumstances, toxic doses were rapidly approached. It was recommendedthat serious consideration be given to a change in policy in supplying procainehydrochloride. It was believed that many of thesources of hazard would be eliminated if the drug were supplied in ampulescontaining 1.0 gm. in 5 cc. of solution. Such ampules could be sterilized byimmersion in any approved colored antiseptic solution. The proper dilutioncould be achieved using either sterile water or sterile normal saline inquantities of 95 cc. to produce a solution of 1.0 percent or 195 cc. to producea solution of 0.5 percent concentration. This was the type of material that was submitted inthe ETMD reports.
The ETMD reports moved on a "two-waystreet." Difficulties encountered in the use of piperocaine hydrochloride(Metycaine Hydrochloride) for spinal anesthesia were reported. In theETOUSA Manual of Therapy, issued 5 May 1944, a table of dosage for tetracainehydrochloride (Pontocaine Hydrochloride) and procaine hydrochloridecombined, procaine crystals dissolved in spinal fluid, and MetycaineHydrochloride in spinal fluid was outlined. The dose of MetycaineHydrochloride was limited to a maximum of 140 mg. Difficulties in the useof Metycaine Hydrochloride were experienced, and, as a result, the use ofMetycaine Hydrochloride was discouraged and supplies were allowed to dwindle. The Office of The Surgeon Generalwas acquainted with these problems because parallel difficulties had been experienced in the Zone ofInterior. On 16 June 1945, a memorandum from the Supply Division to theProfessional Services Division drew attention to Section VI of War DepartmentCircular No. 134, dated 4 May 1945, which stated that Metycaine Hydrochloridewould
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no longer be employed in Army hospitals in any form. Major Davis,acting for this author, replied to this memorandum on 18 June 1945 and advisedwithdrawal of Metycaine Hydrochloride from issue in the European theater.
Material submitted for the ETOUSA Essential TechnicalMedical Data Report for the month of April 1945 included a statistical summary ofanesthetics administered during the period 1 June-31 December1944. Comment regarding this summary was as follows:
Although field blocks including localinfiltrationswere employed less frequently during November and December 1944 thanthey had been in the previous five months, the incidence of employmentof specific regional blocks increased in all types of hospitals, the greatestincrease being in evidence in evacuation hospitals; and significantlyin evidence in Field Hospitals. The overall average of employment ofspecific regional blocks increased from 1.43 percent to 2.57 percent.This, too, is considered to be a development in a desirable direction becausewith proper organization of the section on anesthesia, the time lag between operationscan be decreased. Patients maintain full control of their own airway,dehydration through vomiting is not increased as it may beafter inhalation anesthesia, nursing care is kept at a minimum and patientsare immediately evacuable, if that is necessary.
Incidence of employment of sympathetic block increasedinall types of hospitals with the exception of field hospitals. This was in themain due to the increased incidence of "trench foot."Present opinion regarding the efficiency of sympathetic block for the treatment of trench foot is extremely guarded. It is felt that inno instancedid the accomplishment of a sympathetic block tend to increase the patient'sdebility insofar as his injury was concerned. In the vast majority ofinstances, however, it could not be thoroughly established that accomplishment ofsympathetic block improved the patient's rateof recovery. One death occurred during the accomplishment of stellateganglion block undertaken for relief of peripheral vascular inadequacy of theupper extremity. This death was probably due to inadvertent injection ofprocaine within the dural sheath where prolongation of the sheathexisted and protruded through the foramen.
* * * * * * *Pentothal supplemented by other anestheticagents was the method that was employed more frequently in November and December thanin the previous 5 months in all types of hospitals except fieldhospitals. Statistical data in relation to field hospitals has not beenbroken down on the basis of their working status, but it is known thatthroughout November and December a greater number of them were working asCommunications Zone units doing station hospital work. In many instances,these units so employed lacked the benefit of skilled anesthetists whereauxiliary surgical teams were not attached.
* * * * * * *It is obvious from these statistical data that the bestqualified anesthetists should be assigned to auxiliary surgical groups andevacuation hospitals. * * *
Changes in T/O&E 8-580, 31 January 1945, for750-bed Evacuation Hospitals are also considered to reflect experienceencountered in this theater. However, inclusion of only one nurse anesthetist isinadequate to meet the needs for 24-hour operation of 10-12 operatingtables. Six nurse anesthetists for such a union represents the minimum numberrequired and then it would be necessary to orient three or four other nursesinto the intracacies of anesthesia or else depend upon augmentation by personnel from auxiliary surgical teams. Experience has been thatseldom isit necessary for 750-bed evacuation hospitals to be thus augmented. In the 2dEvacuation Hospital, 10 nurses have been oriented in the administration ofanesthetics.
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Comment in a similar direction was made with regard to400-bed evacuation hospitals. It was stated that four nurse anesthetists wererequired as a minimum to staff such a unit during active operations inspite of the fact that a 400-bed evacuation hospital was frequently augmented byauxiliary surgical teams.
Subsequently, statistical data covering the period from 1January through 31 May 1945 were submitted in the semiannual historical reportprepared by Major Davis in this consultant's absence on a trip to the Zone ofInterior, undertaken on 28 May 1945.
This sketchy account of activities during 32 months in Europewould be completely inadequate without comment upon a trip to the concentrationcamps in Weimar and Nordhausen, Germany, within a day or so of their capture byunits of the U.S. Army. Information had reached Headquarters, ETOUSA, in Paris,regarding the deplorable condition of the unfortunates incarcerated there. Asmall group of consultants, including this author, flew to Weimar to investigatethe situation. Upon arrival, the group first visited the pathologic museum,featuring tattooed skin taken from victims. The group learned that approximately51,000 individuals had died within the electrified wire enclosure after 1January 1945-many of them from starvation, others by hanging, andstill others in the furnaces that had been erected immediately above the gaschamber. A pile of human ashes, 6 feet high, was seen. The condition of theinmates of the several barracks defied description. Starvation, superimposedupon tuberculosis, was universal. These humans wore masks that were immobile andexpressionless; they appeared not to care whether they lived or died. Their dietof 600 calories per day was immediately increased, but any undue increaseproduced a dehydrating, fulminating diarrhea. Deaths continued to occur all toofrequently following liberation. In order to take care of the children, it wasnecessary for the U.S. Army to divert a 400-bed evacuation hospital for thispurpose alone.
The situation at Nordhausen was bad, but not as bad as atWeimar. In the Nordhausen internment camp, the internees had been forced to workin the underground factories producing V-1 and V-2 missiles. For thisreason, the caloric intake of the workers had been maintained at a higherlevel; nevertheless, the death rate had been high. Arrival of new and morehealthy individuals had been scheduled to meet the attrition. This was cheaperthan feeding the working force adequately. It was brought home to the group ofconsultants, once again, that the capacity of man's inhumanity to man wasinfinite.
VICTORY IN EUROPE
When V-E Day arrived, this author was in London. The joyexhibited by the British was real in a restrained way. Seeing the lights go on,even though they were turned on, of necessity, in haphazard fashion, was amemorable experience. The next day the author flew to Paris, and because of someconfusion in the announcement of V-E Day the French people were one
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day late in their celebration. Therefore, he had theopportunity to participate again in this gala event. He spent the eveningobserving the festivities. At 2300, he was walking down the Champs ?lys?es when he noticed that a group consisting of a man, awoman (apparentlyhis wife), a 14-year-old boy, and a woman who appeared to be the boy'sgrandmother were observing him specifically and with keen interest. Thisauthor, in turn, observed that after a hurried conversation among the four the younger woman was summoning courage to speak tohim, a complete stranger.This she did, in English.
She, Madame Cloup, stated that her family had noticed by hisinsignia that the author was a medical officer. Her husband was a surgeon,practicing urology. They would be honored, she continued, if the author wouldaccompany them to their home for an "after-the-theater" dinner tocelebrate the victory. Colonel Tovell was touched and pleased to be thussingled out for participation in their victory party. He accepted ratherhesitantly because he knew of the short rations that existed among theFrench population in Paris. He explained that he had just recently completeddinner but that he would be very happy to accompany them and join in theircelebration. Madame Cloup surmised his thoughts and explained that herfriend (the older woman in the group) had just arrived from Normandy, wherefood was more plentiful, and that she had brought a roast of beef which theywished to share with him. The author accompanied them to their flaton the Left Bank of the Seine where he was entertained royally. Afriendship was established that has been maintained by sporadic communicationthroughout the years.
AFTER V-E DAY
Victory in Europe brought with it, its problems. The war was not over; Japan still remained to be defeated. Problems of selection and redeployment had to be met. It was realized, ridiculous though it may seem, that, during the period of redeployment of medical officers to other theaters, a new training program in anesthesia and oxygen therapy should be set up. On 19 May 1945, this consultant submitted a memorandum to the Training Division, Office of the Chief Surgeon, outlining the proposed program. It was necessary geographically to divide the program into two sections, one for the Continent and another for the United Kingdom.
On the Continent, certain hospitals, designated as teaching units foranesthesia, were to have one medical officer trainee and one nurse trainee. Active training was for a period of not less than 3 months, the military situation permitting. Trainees were subject to reassignment in the hospital center in which they were trained on therecommendation of the hospital center's consultant in anesthesia. Names of trainees in excess of local requirements, who were declared ready for reassignment by the hospital center's consultant, were to be available for reassignment on recommendation by the base section consultant in surgery or the Senior Consultant in Anesthesia, Office of the Chief Surgeon,
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ETOUSA. It was the intent to continue this system at the specifiedhospitals as long as clinical material was available and teachinganesthesiologists remained assigned. It was further planned that monthlyconferences would be held at each hospital center at the discretion of thecenter consultant in anesthesia. Presentation of papers, exchange ofideas, and discussion of problems were thus to be made possible. In addition,the center consultant was to be authorized to make rounds of each hospital in his areain order to check on the organization,practice, and training within the section on anesthesia and operatingrooms of each unit. Furthermore, each hospital center was to receive fourmedical officer trainees and two nurse trainees on temporary duty fromcommunications zone and field army units for a period of 1 month's training inanesthesia and oxygen therapy. As a part of the trainingprogram, it was proposed that during operating periods trainees observe or work asapprentices under the supervision of the chief anesthesiologistof the particular facility. In order to support the senior assignedanesthesiologist in this training program, it was further proposed that onemedical officer of recognized teaching ability be ordered from fieldarmy units to each hospital on a temporary duty status. In this manner, a pool ofdemonstrators and lecturers could be established.
For the United Kingdom Base Section, a similar program was suggested andinitiated. The ETOUSA Society of Anesthetists was reactivated and held monthlymeetings in London at the Royal Society of Medicine headquarters.Major Burstein of the 160th General Hospital was chairman. Since there was a shortage ofanesthetists in the United Kingdom Base Section, and, since those available hadbeen closely tied to their work over aperiod of months, they needed relief. On the other hand, anesthetistsassigned to field army units needed to gain general hospital experience in theadministration of anesthetics and the organization of the section onanesthesia and operating room. It was, therefore, recommended that anesthetistsfrom auxiliary surgical groups and evacuation hospitals begiven a tour of temporary duty for 60 days in United Kingdom Base hospitals.The program in the United Kingdom was expandable beyond that possible on theContinent. The offer of anesthesiologists in British universitiesto participate in the retraining program of the U.S. Army was accepted with gratitude. Itwas therefore recommended that authorities of theUniversity of Edinburgh be contacted through Dr. John Gillies, Royal Infirmary,Edinburgh, to establish courses for anesthesiologists in C and D categories onthe basis of 30 days' temporary duty for classes not to exceed 20 medicalofficers. It was postulated that similar arrangements could be made at Glasgowthrough Dr. Andrew Tindal. Similar facilities, it was suggested,could be made available through Professor Macintosh, head of the Departmentof Anaesthetics, Oxford University.
Imperial Chemical Industries, Ltd., had undertaken to produce trainingfilms in anesthesia and resuscitation. Three films, entitled (1) "Open DropEther," (2) "Endotracheal Anaesthesia," and (3)"Intravenous Anaesthesia,"
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had been available to the U.S. Army in 1943. Arrangements had beenmade with Army Pictorial Service to copy thesefilms and to reduce them from 35 mm. to 16 mm. for distribution to hospitals. Inthe interval, Imperial Chemical Industries, Ltd., hadproduced five other films. Four of these were reviewed by the Senior Consultantin Anesthesia and were considered appropriate for the U.S.Army training program. As a result, it was recommended that the ArmyPictorial Service make three copies of each of these new films for distribution tohospitals on rotation. On 18 May 1945, the day before the proposals for thetraining program were submitted, this consultant had previewed a film producedin the United States, entitled "The Physiology of Anoxia, the Basis forInhalation Therapy." It was recommended that three copies of this film be obtainedfrom Washingtonat the earliest possible moment, one copy to be allocated to the United Kingdom Base, one copy to be made available forpurposes of training in the Paris hospitals, and the other copy to be madegenerally available through the film library.
In furtherance of the plans submitted, courses in anesthesiawere arranged at Radcliffe Infirmary, Oxford, and at theUniversity of Edinburgh. Various hospital centers on the Continent alsoconducted anesthesia courses. The Faculty of Medicine, University ofParis, cooperated in this work furnishing cadavers and a dissecting room wherethe technique of regional anesthesia could be demonstrated. Maj.Paul W. Searles, MC, 5th General Hospital, was in charge of this effort.
Duties associated with termination of the campaign,collection of statistical data, establishment of the new training program foranesthetists, and selection of personnel for reassignmentto another theater of operations occupied Colonel Tovell immediately after V-EDay. On his return to the Zone of Interior late in May he held conferences with interested chiefs of service inthe Office of TheSurgeon General, after which he attended a meeting of the American Boardof Anesthesiology in New York City and assisted in the conduct of the oralexaminations. On 17 July 1945, he received orders relieving him of duty asSenior Consultant in Anesthesia in the European theater. On this same day Maj.Lloyd H. Mousel, MC, was appointed Consultant in Anesthesia to The Surgeon General, butColonel Tovell continued to serve in an advisorycapacity until 15 October 1945, when he was relieved from active duty.Late in December of the same year he was invited to join the Veterans'Administration, of which Maj. Gen. Paul R. Hawley had just become ChiefMedical Director, as Chief Consultant in Anesthesiology. The passage ofPublic Law 293, on 3 January 1946, which established the Department ofMedicine and Surgery, Veterans' Administration, made it possible toformalize the invitation.
The story of anesthesiology in the European Theater ofOperations has been told fully and frankly, with the hope that if another war comes,the documentation of lessons learned during one major war will contribute to the effective use ofthis specialty in another.
