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serving the Soviet people and their ways were quite unique at this time-atime when the Soviet Union was allied with the free world against a commonenemy, when its people had undergone an untold amount of suffering, yet hadremained steadfast in their determination to resist the Nazi aggressor and hadactually begun to turn the tables on the Wehrmacht on the Eastern front. Underthe dateline of 7 August 1943, Colonel Cutler wrote the following to AmbassadorWinant:
The opportunity to enter Russia and contactpeople there inevitably led to certain impressions' being created in the mindof the visitor and since these thoughts may be of value to the State DepartmentI have tried to put them into writing.
We were shown every courtesy officially and wegathered the impression that those with whom we came into contact were delightedthat we had come. Intimate contacts and dinners up the line with the armyofficers of our own rank and responsibilities made us feel quite at home and atease. Every opportunity was given us to see the things we asked to see, both inMoscow and when forward with Army hospitals, but all the time one felt thatthere lay over the officials taking us about an iron hand, which made themcautious in their remarks and which often led to a change of conversation in anabrupt fashion. Thus, on several occasions when we asked questions and theconversation started to give us the answer, the Vice Commissar who accompaniedus would make a remark and the conversation on the question ceased and began onsome totally unrelated matter. It was as if only special people could speak onspecial problems and that no one was ever allowed to express an opinion beyondhis own special field where the problem had been set to him by someone "ontop."
This impression of a strong "fist"on top was strengthened by observation of the mission in Moscow itself. Thepeople were not cheerful. They kept their eyes fixed on the ground as a rule. Ofcourse no independent Russian could talk to us, because were a Russian seentalking to a foreigner he would immediately be taken aside and, if not punished,certainly have a difficult time. Up in the army there was a different feeling.It was as if they were away from that threatening something overhead. The peoplewere cheerful; they laughed; they had simple dances, and seemed entirely happy.
The power of this something overhead turned upin many ways. In intimate discussions with General Martel, the British militaryattache or observer in Moscow, who seemed to get on very well with the RussianArmy officers, it was quite clear that his dealings with the army were verysatisfactory, but that when something had to come out of the army and go to theGovernment in Moscow, then everything was different.
A further sense of the overhead power came tothe mission directly. We flew into Russia in a British plane, which was Ibelieve the second plane on this southern route, and which we were told had allbeen arranged for through the Ministries. Our plane was to return for us in 2?weeks. It reached Teheran but was never allowed to enter Russia and a greatdeal of diplomatic tangling went forward. Apparently the British had signed theagreement for this southern route but had not signed the agreement for thenorthern route. The Russians wanted certain things added to the northern routeagreement and when the British refused to sign this, then they refused to signthe southern route agreement.
* * * * * * *My own personal observations of the Russiancharacter were that he was really [a] pretty frank, open, very direct andentirely rational person. He had not forgotten the official attitudes of theU.S.A. and Britain toward his country a few years back. He was not going to befooled again, and he was going to stand on his own feet. Moreover, he hadsuffered horribly during this war, certainly more than 6 million casualties andperhaps 8 million. He confidently expected to win the war, and to win the waralone if necessary, but would like our help. Everyone spoke of our starting asecond front. They don't think
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the Mediterranean fights were much, and wereglad to quote to us the battle casualty figures as measurements of that effort.They refused to speak of the Japanese war, though they knew of its existence.However, it should be said in defense of the opinion of the ordinary Russianthat their newspapers and their radio announcements don't give very muchinformation concerning what was going on in the war except in Russia. Thepropaganda about Russia was tremendous and the personal propaganda for Stalinand Molotov was equally conspicuous. Each room in every hospital up the line,let alone the places in Moscow, contained a picture of very large size of bothStalin and Molotov.
I took the occasion to remind the Commissar,when he spoke as though we were doing nothing, of the efforts of ourselves andour allies, the British. I must say he took this smilingly, said he knew of allour efforts and thanked us. At the same time I am sure none of this would everget to the people.
My impression of Russian medicine was that itwas good, not excellent, but surprisingly good in view of what we had been ledto think of them. Their effort in medical education is enormous, and though 90percent of medical graduates are women, 40,000 were graduated from Governmentmedical schools last year, and these students go through a six year course.
Finally, I came back with a very strongimpression that Russia is a really good country with fine people in it, who arebound to take their rightful place as one of the great peoples in the comingcivilization. Anyone who fails to take this into consideration and who dealswith them with old fashioned diplomacy and not honesty and directly will failmiserably and to the discomfort of his country. We are fortunate in having inMoscow such a directly spoken man as Ambassador [William H.] Standley. He serveshis purpose well and is regarded with affection and esteem by the Russians. Theylike his honesty and frankness and even when he speaks to them contrary to theirdesires they take it well because of that honesty and frankness. Because of thishe stands out among the diplomats at Moscow. He has of course a tremendousadvantage in having in Moscow General Faymonville, who apparently is admitted bythe British as well as the American people there [to be] the one person personagrata with the Russian people, both the ordinary people and the government. Onecannot speak too highly of the eminent qualities of these two citizens who serveour country so well in Russia.
Late 1943-Early 1944
Thus wrote Colonel Cutler in his diary on 15 May 1944, a fewweeks before D-day in Europe: "Time flies with increasing agility. Thedeluge will be upon us soon and will we be ready? No, never fully satisfied, butto begin is something."
These few words truly characterize this period for the ChiefConsultant in Surgery. The pace was quickening upon his return from the SovietUnion. At the turn of the year, it had definitely accelerated. By May 1944, thesurge of activity was a headlong gallop to the day of destiny-D-day, Europe, 6June 1944.
During this period, American Forces in the United Kingdomwere built up from a few divisions to those making up the First U.S. Army withsupporting troops and the nucleus of the Third U.S. Army. In August 1943, uponhis return from the U.S.S.R., there were 6 general hospitals, 17 stationhospitals, and 2 evacuation hospitals in operation. A few months later, at thebeginning of 1944, these had been increased to 17 general hospitals and 34station hospitals actually in operation. The final SOS plan for mounting theassault on
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fortress Europe called for 79 fixed hospitals in the UnitedKingdom alone. This figure did not include those medical units staging to bemoved to the Continent at the first opportunity or the evacuation, field, andconvalescent hospitals assigned to the armies.48
This expansion of the theater troop basis requiredreorganization and decentralization. Hospital centers were created to operategroups of hospitals. Base section surgeons were given almost complete controlover medical facilities in their areas, except for the control of beds ingeneral hospitals. Colonel Cutler had to expand the consultant system to providefor consultants in these centers and base sections. The growth in numericalstrength of troops and units and the delegation of many functions to lowerechelons shifted the emphasis of activities in the Office of the Chief Surgeon,including those of the Chief Consultant in Surgery, from direct supervision tothat of liaison, coordination, and the development and enunciation of policies.
Conferences.-This change in emphasis meant thatColonel Cutler had to attend more routine staff conferences. Weekly meetings ofall the consultants in the Professional Services Division were held, preceded bypreliminary meetings of the surgical and medical consultants held separately. Oneach fourth Monday of the month the consultants and the Chief of ProfessionalServices met with the Chief Surgeon. There were also fortnightly meetings ofbase section surgeons, and the weekly staff meetings instigated by ColonelSpruit after he became Deputy Chief Surgeon at Cheltenham. Starting in January1944, General Hawley held weekly meetings with his division chiefs, whichColonel Cutler usually attended with Colonel Kimbrough.
In addition, there were the regular RAMC meetings whichColonel Cutler attempted to attend with regularity, especially as the day forthe invasion drew ever nearer. There was no consultant in surgery appointed bythe Americans at the Allied Supreme Headquarters level, and Colonel Cutler, bymutual understanding of all concerned, acted in that capacity: (1) Through hissuperior officers and staff at the theater level, (2) through Maj. Gen. AlbertW. Kenner, MC, USA, Chief Medical Officer, SHAEF (Supreme Headquarters, AlliedExpeditionary Force) (fig. 43) and (3) in meetings of the various committees ofthe British AMD and EMS.
Changes in senior consultants -Colonel Zollinger servedas Acting Chief Consultant in Surgery in the European theater during ColonelCutler's visits to the U.S.S.R. and, later, to NATOUSA (the North AfricanTheater of Operations, U.S. Army). After Major Storck's return to the UnitedStates, Colonel Zollinger was appointed Senior Consultant in General Surgery.Maj. (later Lt. Col.) John N. Robinson, MC, 2d General Hospital, was appointedSenior Consultant in Urology, in addition to his other duties, since thesupervision of urological activities in the theater had grown to be too great anactivity
48(1) Annual Report, Chief Consultant in Surgery, ETOUSA, 1943. (2) Annual Report, Professional Service Division, Office of the Chief Surgeon, ETOUSA, 1944. (3) SOS, ETOUSA Mounting Plan, Medical Corps, Annex No. 8: Medical Plan-Mounting the Operation.
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FIGURE 43.-Maj. Gen. Albert W. Kenner.
for Colonel Kimbrough to perform in addition to being Chief ofProfessional Services. Col. Roy A. Stout, DC, was appointed Senior Consultant inMaxillofacial Surgery on 8 November 1943, relieving Colonel Bricker of theseduties; Colonel Bricker remained Senior Consultant in Plastic Surgery and Burns.Maj. (later Lt. Col.) John E. Scarff, MC, 2d General Hospital, served for aconsiderable time as Acting Senior Consultant in Neurosurgery during ColonelDavis' trip to the U.S.S.R. and after his return to the United States.Finally, on 15 March 1944, Lt. Col. (later Col.) R. Glen Spurling, MC, arrivedin the theater and was appointed Senior Consultant in Neurosurgery. Lt. Col.(later Col.) Mather Cleveland, MC, arrived from a previous assignment as aservice command consultant in the Zone of Interior and in May 1944 was appointedSenior Consultant in Orthopedic Surgery replacing Colonel Diveley, who, in turn,became chief of the Rehabilitation Division.
Significant activities -Items of significance duringthis period, insofar as they involved Colonel Cutler, included various measuresto get ready for the invasion of the Continent-Operation OVERLORD, furtherdevelopments in the effort to provide whole blood for combat operations,extensive study of the efficiency of penicillin, a trip to the North Africantheater, discussions with The Surgeon General on the closure of wounds andamputations, and the expansion of the consultant system. These are discussedseparately, but the
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following items of no less importance, though perhaps morelimited in scope in some instances, were also his concern.
American Medical Society, ETOUSA -Following the Augustgeneral meeting of the American Medical Society, ETOUSA, General Hawley informedColonel Cutler that the general monthly meeting of the society could no longerbe held after the one for the current month. He suggested means of havingsmaller, decentralized meetings. As a result, the responsibility for forminglocal societies and holding meetings was eventually decentralized to the basesections. With decentralization, however, there was a lack of coordination withthe result that areas for local societies were overlapping, and so forth.Originally, Colonel Cutler had been told, the intent was to have a societycompletely independent of any control from the Chief Surgeon's Office, but acoordinating center had to be established. Actually, this coordination, ColonelCutler thought, benefited the local groups since it provided services such ashelping to formulate programs, obtaining guest speakers, and collecting papersfrom local meetings for forwarding to appropriate individuals and offices withinthe theater and, in some cases, to the Office of The Surgeon General. The lastgeneral meeting during this period was held in January 1944 at Widewing, EighthAir Force headquarters. At a business session of this general meeting, ColonelWright, Chief of Professional Services for the theater Army Air Forces, waselected president of the society.
Throughout this period, there were many stimulating meetingsheld locally in the various base sections (fig. 44). Colonel Cutler and hisconsultants were able to attend many of these local meetings and were gratifiedto find participation at the grass-roots level extremely healthy.
Education and training -The European theater MedicalField Service School at Shrivenham continued with its full curriculum, as didthe Air Force school at "Pinetree." The London tours course wasdiscontinued before the Americans "wore out their welcome" at the busyLondon hospitals. In spite of some initial reticence on the part of the ChiefSurgeon and his Education and Training Branch, a very extensive program in thetraining of anesthetists was begun under the direction of Colonel Tovell, SeniorConsultant in Anesthesia. Colonel Diveley, as Senior Consultant in OrthopedicSurgery, initiated a badly needed course of instruction in plaster work (fig.45). This instruction was carried out in 3-day periods, mostly for medicalofficers of the First U.S. Army.
Selected U.S. Army medical officers were sent to the variouscourses at the British Post-Graduate Medical School in continuation of a programwhich had been established in the very earliest days of the theater. The courseswhich were being offered during this time in successive weekly intervals were:Recent advances in war injuries, treatment of fractures, war surgery of thenervous system, war medicine, war surgery of the extremities, surgical care ofthe soldier in training, war surgery of the abdomen, and war surgery of the
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chest. Mr. Tudor Edwards' 2-week course in thoracic surgeryfor American medical officers was likewise continued at several British thoracicsurgery centers in and around London. The British Army Blood Supply Depotcontinued to accept a limited number of U.S. Army medical officers for trainingin the principles and techniques of bleeding, processing, storing,refrigerating, and shipping whole blood-together with the clinical aspects ofshock, whole blood transfusion, and resuscitation.
The previously stated policy of General Hawley thatspecialists would not be trained in the theater had to be modified, upon theinsistence of Colonel Cutler and the other consultants, to allow for the furthertraining of those who had had some preliminary training in a surgical specialty.The instruction was conducted at selected station and general hospitals forindividuals or small groups. The length of instruction was flexible, as was thescope of instruction, and was dependent upon the advice of the senior consultantconcerned.49
Monthly report of surgical service -In order tomaintain a closer touch on the pulse of surgical activities in the theater-somethingwhich was exceed-
49Circular Letter No. 174, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 28 Nov. 1943.
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FIGURE 45.-Training in the application of plaster at the 298th General Hospital, Bristol, England.
ingly necessary because of the decentralization of activitiesand the impossibility of the theater-level consultants personally supervisingall surgical activities-Colonel Cutler had Colonel Zollinger, SeniorConsultant in General Surgery, devise a monthly report of surgical services tobe submitted by all fixed hospitals in the theater. A daily operating room logwas also devised to be used as a standardized record in these hospitals, a logwhich would permit easy compilation of the monthly surgical report. Thereporting requirement was approved by the Chief Surgeon and promulgated on 12March 1944.50
From the outset, the report proved very satisfactory, andColonel Cutler was most pleased by the control it offered. He reported in themonthly Essential Technical Medical Data report for April 1944, as follows:
The report may from time to time beinaccurate, but it should prove informative and should provide us withinformation concerning the relative incidence of wound infections, battleinjuries and nonbattle injuries in the various specialties.
In a recent report * * * the number of wholeblood transfusions amounted to 172. Of these, 168 came from stored blood in ablood bank in a hospital. At the same time 637
50Administrative Memorandum No. 29, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 12 Mar. 1944 (Amended by Administrative Memorandum No. 134 and Administrative Memorandum No. 144, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 1944).
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units of dried plasma were given. In thisfirst monthly surgical report we computed the incidence of wound infections insix of the seven hospitals in East Anglia where airmen injured in missions overenemy territory are treated:
Battle injuries | 214 |
| Number infected | 15 |
| Incidence | 7 percent |
Nonbattle injuries | 388 |
| Number infected | 8 |
| Incidence | 2 percent |
Clean operations | 730 |
| Number infected | 3 |
| Incidence | 0.4 percent |
The above is a sample of the control such asimple report has on professional work.
This report was received from all hospitals in thecommunications zone for the entire period of the war-hospitals in which mostof the reparative surgery provided in the theater was conducted. The lastreport submitted by these hospitals was for the month of May 1945.
Activities in conjunction with Army Air Forces -One ofthe first things Colonel Cutler did upon his return from the U.S.S.R. was totour each of the hospitals which had been established primarily to serve the AirForce (fig. 46). These were at this time either in full operation or just aboutready to start operations, and the Air Force medical staff in the theater wasvery pleased with the results. For one thing, the surgical service at thesehospitals had to be first rate because they were treating air combat casualties,and Colonel Cutler had done everything in his power to make them so. However,the growth of the air arm, which paralleled the buildup in the theater of theother arms and services, soon outstripped the services these hospitals couldprovide. As more heretofore standby airfields were activated, their distance tohospitals became a serious problem in the eyes of the Air Forces, and, in spiteof other priorities, General Hawley gave first consideration to building andactivating additional hospitals to serve them. The duty of seeing that thesurgical service in these hospitals included the required high-gradeprofessional personnel befell to Colonel Cutler and his consultants. Theproviding of this personnel became a most difficult undertaking whenwell-qualified individuals were required to augment the staffs of newly arrivinghospitals with very little specialized talent and when surgical teams which hadbeen attached to the hospitals serving the Air Forces had to be withdrawn inpreparation for the land campaign on the Continent.
In addition, as the Air Forces in the theater grew, it becamenecessary for the theater Air Force medical staff to supervise activities on abroader, less personal scale. Consequently, the theater consultant staff wascalled upon from time to time to help formulate policy and write professionaldirectives which were issued by the theater Air Force commander, or by theSurgeon, General Grow. One of these, personally worked out by Colonel Cutler,was a basic directive on the reception and initial treatment of casualties atairbases.
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Maj. Gen. David N. W. Grant, the Air Surgeon, visitedthe theater in September 1943 and in March 1944. General Grant was an avowedadvocate of a separate medical service for the Air Forces, but he was forced toadmit-upon advice of the Eighth Air Force medical personnel-thatarrangements in the theater were as satisfactory as they could be under existingcircumstances and did not require any immediate major change. Colonel Cutlerwas pleased at this outcome and felt pride in having done much to cement thiscooperative close relationship-largely through his associations with ColonelWright and, also, through his intense interest in the combat casualties of theEighth Air Force (fig. 47).51
Study of casualties with respect to causes of death andcausative agent -Colonel Cutler had urged since his early days in thetheater that provision be made for the study of wounds and wounding, thedistribution of wounds, and the relationship of wounds to the causative agents.In his reports to the Chief Surgeon and The Surgeon General, he had always triedto indicate at least the distribution of wounds (regional frequency) wheneverthe data were amenable to such a tabulation. In his trip to the U.S.S.R., he hadmade it a point to obtain some data on the Soviet experience in the frequency bywhich various regions of the body were hit. Shortly after his return from theSoviet Union, he formally suggested that a group be established for the purposeof studying the wounds of war. The minutes of the Chief Surgeon's 23 August1943 meeting with his consultants show the following discussion on thisproposal:
The Surgical Subcommittee's proposal toestablish a pathological group for the study of fatality statistics in the armywas discussed. Colonel Cutler pointed out that the group might serve a doublepurpose; i.e., to find out what kind of wound causes death, and what kind ofmissile causes the wound. He felt that some valuable findings might result, andthat the group might work with the graves registration people. Colonel Spruitsaid that the responsibilities of the medical department were directed in oneline-to get men back to duty. He felt that there were two aspects of theproposal, (a) That this pathological group would have to be put in the frontline, and that the Division would have the burden of carrying them along, and(b) That if the scheme was practicable it might prove valuable, but that atpresent it was only possible to formulate ideas.
Finally, Maj. Gen. Norman T. Kirk, The Surgeon General,officially announced the need for obtaining such information in an articleprepared for the Bulletin of the U.S. Army Medical Department.52In January 1944, however, before publication, copies of the articlewere sent to all theaters of operations requesting that programs for thecollection of data on missile wounds be set up.
Colonel Cutler again recommended that teams consisting ofpathologists and enlisted men be set up to collect and make studies along theselines. But it was not until The Surgeon General visited the theater in March1944 that
51Minutes, Conference of the Deputy Chief Surgeon, 12 Sept. 1943.
52Office of The Surgeon General: Need for Data on the Distribution of Missile Wounds. Bull. U.S. Army M. Dept., No. 74, March 1944, pp. 19-22.
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sufficient impetus was given to the program to bring forthGeneral Hawley's approval for the establishment of a casualty survey team inthe theater. On 2 April, Colonel Cutler stated in a memorandum to ColonelKimbrough:
For about a year the Professional Servicesgroup have, at the approval of General Hawley, continued studies of how toimplement a group of people acquiring information as to what killed men inbattle, and where they were hit when injured. During the recent visit of TheSurgeon General and General Grant, a discussion of deaths in airplanes while onmissions over enemy territories led to the finding that personnel arriving deadwere not autopsied. I was then instructed by General Hawley to set up a groupfor such studies.
It so happened that Maj. Allan Palmer, MC, chief of thepathology service, 30th General Hospital, had accompanied Prof. S. (later SirSolly) Zuckerman of Oxford University on a special casualty survey mission toItaly and was well initiated in the procedures involved in conducting with rigidscientific precision the necessary studies to provide useful and meaningful dataon war wounds. Major Palmer was assigned to Colonel Cutler to undertake theorganization and establishment of a team to study casualties and the killed inaction. Since, at this time, the only fresh casualties being received in thetheater were the result of air combat, Major Palmer's unit-called theMedical Operational Research Section, Professional Services Division, Office ofthe Chief Surgeon-was established at the Cambridge American Military Cemeterywith full facilities for conducting autopsies of the Air Forces' dead, makingphotographic studies, and preserving specimens.
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One stumbling block in the building of the laboratory, it isinteresting to note, was the fact that there was a stately and ancient treegrowing exactly in the middle of the plot of ground which had been designatedfor the laboratory building. Apparently, Dr. Rosamond E. M. Harding, the ownerof Madingley Hall, Cambridgeshire-the estate within which the cemetery waslocated, had specified that the U.S. Army could use the grounds but that notrees would be cut down. The U.S. Army Engineers, accordingly, steadfastlyrefused to cut down this particular tree so that Major Palmer's laboratorycould be built. Finally, it was necessary for Colonel Cutler to call on Dr.Harding personally. This he did on 30 April 1944. The visit, which was mostpleasant, ended with talk over the possibility of Dr. Harding's coming toAmerica to see Colonel Cutler after the war in order to continue certain studiesshe was interested in. The tree was cut, but such were the duties of a ChiefConsultant in Surgery that they often carried him far afield from the hospitaloperating rooms.53
Free-French surgical teams -Late in this period, agroup of eminently qualified French surgeons, refugees in England,volunteered their services for the impending attack on the European mainland.They were welcomed by the Chief Consultant in Surgery who initiated thenecessary steps to organize, activate, and equip them as mobile surgicalteams. It was contemplated that they could most gainfully be employed insupport of the Free-French Forces which were scheduled for participation as apart of the Allied effort.54
"Vetting" newly arrived units -Especiallycharacteristicof this period was the necessity on the part of all the theater-levelconsultants to meet and evaluate the professional capabilities of the numerousmedical units newly arriving in the theater. This became known as"vetting." Of particular importance was the need to assesscarefully the merits of the professional personnel, since the supply ofwell-qualified physicians and surgeons was beginning to run low and many units werebeing sent overseas with the assumption that key professional personnel could be supplied fromunits already in the theaters.
There were many problems associated with the vetting andsubsequent need for exchanging personnel. First of all, ColonelCutler reiterated, it was imperative that unqualified officers arriving withthese new units be in the lower grades because the theater could not assimilate wellthose who were in higher grades. This was true because, in many cases, aprofessionally well-qualified individual being sent into these new units as the chief of a service or section washimself a relatively young, junior officer. Furthermore, most of the well-qualified talentwas in the affiliated units, and they believed they were being "robbed"of their better personnel, and, of course, resented it. Before long,
53Results of the studies conducted by the MedicalOperational Research Section at the Cambridge American Military Cemeteryas well as Major Palmer's casualty survey report on his Italian experiencesare published in full: in Medical Department, United States Army. Wound Ballistics.Washington: U.S. Government Printing Office, 1962, pp. 547-611.
54Memorandum, Col. E. C. Cutler, MC, to Chief, Professional Services Division, 3 June 1944, subject: FrenchSurgeons.
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these units recognized the overall needs of the theater andresponded well. Colonel Cutler was deeply gratified by this response and never ceased to commendthese units which were called upon again and again to give the personnel and yetcontinued to maintain their high standards. In a way, it was to the benefit ofthese units because such transfers permitted their junior officers to bepromoted, whereaspromotion possibilities were extremely limited if the junior officers continued tostay with the original units. Finally, there was thematter of command authority to effect transfers between units to spread thetalent more equally. On more than one occasion, a consultant had to reprimanded forgiving instructions which-in many cases unwittingly-were taken at the local level to becommands. The desired changes in personnel had to be offered as suggestions to the basesection surgeons, who were usually very cooperative in accepting andimplementing them. It was more difficult, Colonel Cutler noted, when two or morebase sections were involved in a series of transfers, aswas often the case.
General Hawley took a very firm position on this matterof exchanging personnel, realizing full well the necessity for it, whilealso recognizing the need to respect the authority of commanders at the lower levels.He made the following statement at his 25 October1943 conference with base section surgeons:
I do not need to tell you all, that we are neverbuildingup one Base Section at the expense of another and if these changes that we have areadvisable, while you may get a little shortchange on one changeyou are going to make it up on the next. We are trying to get a balanced setup.The thing which concerns us very largely is to getthoroughly competent Chiefs of Services in these hospitals.
Col. David E. Liston, MC, Chief, Personnel Division (laterDeputy Chief Surgeon) (fig. 48), was most helpful in undertaking thenecessary details to coordinate and effect the transfers which were desired bythe professional consultants. At a conference with base section surgeons on 2 August 1943,he made the following statement:
Sometimes we are told to move three men who have aspark of genius and it means we have to move three men who do not have this spark of genius.* * * Nobody wants these people [without thespark of genius] but we have to do something with them. If we are going to make a captain amajor, that is an easy decision. Thedifficult decision is where to put that man we kicked out where he can getproper training.
Eventually, the need to provide not only chiefs of service but nearly allthe specialists as well for the newly arriving unitsbecame a very serious problem. Colonel Cutler and Colonel Zollingercould meet this problem only by preparing lists in advance of those officers inthetheater who were qualified to become chiefs of surgical services in hospitalsand thosein the various specialties who could be used to bolster the incoming units. This foresighton the part of the Chief Consultant in Surgery and the Senior Consultant inGeneral Surgery proved particularly effective when, as D-day neared, many of the better, more experiencedmedical units of the theaterwere earmarked for movement to the Continent and their personnel werefrozen. Officers in these units
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FIGURE 48.-Col. David E. Liston, MC.
who had been selected to become chiefs of surgical serviceor specialists in other units were relieved from assignment to their unitsbefore the personnel freeze was effected and remained with their units afterthey were alerted on an attached unassigned basis until the need for aparticular individual arose.
As time went on, assaying and recommending the shiftingof personnel became one of the primary functions of consultants at the theaterheadquarters, in the base sections, and in the field armies.
Expansion of the consultant system
An attempt to establish a system of consultation at thelocal level was mentioned as having been initiated immediately before ColonelCutler's trip to the Soviet Union. This embryonic system of regionalconsultants and the "mother hospital" scheme was further expandedduring this period, which also saw the appointment of coordinators in medicineand surgery at hospital centers and surgical and medical consultants at thebase section level. The changes and innovations which were made during thisimmediate preinvasion period formed the framework for the duration of the warin the European theater, and it was not until well after V-E Day that that thisconsultant system required a complete overhaul, and then only to gearit to the needs of an army of occupation.
Regional consultants -At General Hawley's insistence,more than enough regional consultants in the various specialties had beenappointed. They were first announced by the Chief Surgeon's Circular LetterNo. 89, dated 21 May 1943. At that time, the directive listed eight regionalconsultants in general surgery, one in plastic surgery and burns, five inneurosurgery, two in orthopedic surgery, seven in otolaryngology, nine inurology, and four in
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anesthesiology. This directive required immediate amendment later in May and in earlyJune to provide for additionalconsultants in ophthalmology, roentgenology, orthopedic surgery, andplastic surgery. From the outset, this method of appointing and controllingregional consultants centrally from the Office of the Chief Surgeonwas doomed to be unwieldy. When, in June, the operation of medicalfacilities in the United Kingdom was delegated to base sections, the systembecame all the more cumbersome-a point which was consistently belabored by thenewly appointed base section surgeons. From time to time, Colonel Kimbroughreported that the surgical consultants were attempting to bring the original directive up todate,but changes were occurring so fast that revisions never passed the draftstage. Eventually, General Hawley directed that consultation at the locallevel be made a responsibility of the base section surgeon and that theOffice of the Chief Surgeon be informed of the actions taken.
Accordingly, Circular Letter No. 21, Office of the ChiefSurgeon, 7 February 1944, was published and set the policy for consultativeservices for the American Forces which remained in effectfor the duration of the war in Europe. It stated:
5. Regional Consultants. The personnel of generalhospitals and specially designated stations hospitals will be available forconsultation in the vicinity of their stations and will conduct their activitiesunder the direction of the base section surgeons. Base Section surgeons willinform each hospital where it will apply for consultant service in each ofthe several specialties.
In actual practice, the system of regional consultants didnot work out quite as simply as may be implied in the foregoingexcerpt. First of all, as Colonel Cutler explained on one occasion, there werenot enough good men to place in all the general hospitals so thatevery general hospital could be a mother hospital to station hospitals in itsvicinity for every specialty. Consequently, specific hospitals had to bedesignated for certain specialties as the mother hospital. In cases, thiscrossed boundaries of base sections so that, in some fields, surgeons oftwo or more base sections had to agree on the area to be covered by aparticular regional consultant. Finally, the hospitals which had designatedregional consultants were hard pressed for transportation andcould not afford to maintain a standby vehicle for the consultants-aproblem which had existed in World War I. On this occasion, however, an extra jeep waseventually authorized for each general and station hospital having regionalconsultants for the specific use of these consultants. The reader is also asked to notethat this system of administering regional consultants could not have beenestablished without creating base section consultants in general surgery andmedicine, a program which was carried out concurrently with thedevelopment of the regional consultant system.
Base section consultants -By far the most importantstep taken during this period in expanding the consultant system was theappointment of base section consultants. At first, base section surgeonsobjected to their appointment, for no positions had been established in theirtables of organization for
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consultants. There was also considerable question in theminds of the base section surgeons as to what such a consultant would do,or as to whether he would even have anything to do. On 20 December 1943, General Hawley, said, at his regular meeting of base section surgeons; "Thereis scarcely a base section whose job is not going to be bigger in a month thanthe whole theater was in the beginning of this month. I think yourconsultants for the time being should be limited to medicine and surgery,but I do feel that you need consultants for medicine and surgery. It maybe that, in Southern Base, you will need more than one."
The need for having base section consultants, when considered in thislight, was apparent. For the time being, there was noother course but to appoint them in addition to their other duties in hospitals towhich they were assigned. The policy concerning basesection consultants was announced in aforementioned Circular Letter No. 21,emanating from the Office of the Chief Surgeon. It stated:
4. Base Section Consultants
a. Upon recommendation of the Office of the ChiefSurgeon, base section surgeons will appoint consultants in generalmedicine and general surgery for their respective base sections. Theseconsultants will be available to all organizations of the American Forcesin their base sections. They may render service, on request of the commandingofficers, to Canadian and British Hospitals in which patients of the U.S. Forces areunder treatment. They may be obtained by request made to the office of the basesection surgeons. In urgentcases this request should be made by telephone.
b. Reports. The base sectionconsultants will render reports as required by the base section surgeons andwill send a copyto the Office of the Chief Surgeon.
At a somewhat later date, Colonel Cutler found itnecessary to state his policy with regard to the duties of base sectionconsultants. In a memorandum dated 2 April 1944, which was apparently issued toeach base section consultant personally, he wrote:
1. Keep familiar with level of professionalwork carriedout at all hospitals in your base section. This means constant personal visits. Written directionsand circulars can never take the part of the influence of a real surgeon at thebedside of the patient.
2. As a part of the above you must see all newunits whichenter your base section shortly after arrival, and evaluate the personnel. Youropinions should be turned into the Office of the Chief Surgeon, attention ofChief Consultant in Surgery, as soon as investigation has been completed.In addition to your evaluation of new units representatives of theconsultant group in the Division of Professional Services will also make theirown appraisal. Copies of these opinions will be forwarded to you.
3. Attend all meetings of the Professional ServicesDivision. This includes automatically: a. General Hawley's monthly meetingwith the Professional Services Division, b. Meeting of theProfessional Services Division each Saturday morning at 10 a.m., Headquarters,SOS. If you wish to bring up special subjects for discussion at either meeting sendnotice for agenda one week in advance. At the weekly Division meeting you will beexpected to make a brief report.
4. In your visits you should see that the professionaldirectives are lived up to, that station hospitals in a particular do not domajor elective surgery or undertake professional matters beyond theirprofessional capacity. You should also keep an eye on evacuation and see thathospitals are prompt in evacuating people either to the Zone of Interior, ifthey are of the type that should be returned to the Zone of Interior, or to therehabilitation
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hospitals, that their hardening process may begin aspromptly as possible. In particular you must keep an eye on inter-hospitalconsultations. Encourage this, and see that reports made by your regionalconsultants come to you promptly.
5. All of your hospital reports should be rendered totheBase Section surgeon, but copies should come to the Chief Consultant inSurgery.
Coordinators in hospital centers.-In the overalldecentralization program, it was necessary to establish hospital centers toadminister and operate groups of hospitals and to bring together underone administration the facilities and personnel required to treat any typeof injury. Hospital centers established in the United Kingdom during this period were at Malvern Wells, Worcestershire (12thHospital Center);Cirencester Park, Gloucestershire (15th Hospital Center); and Whitchurch,Flintshire (6810th Hospital Center, Provisional). There were, in each of thesecenters, hospitals provided with equipment and personnel for highly specializedtreatment in neurosurgery, thoracic surgery, plastic and maxillofacial surgery,urological surgery, and the surgical treatment of extensive burns.55Itis readily apparent that, with such extensive facilities in men and equipment,the center commander required an officer to manage the surgical care carriedout in the center. To differentiate this officer from the regional and basesection consultants, he was called a coordinator in surgery, and suchcoordinators were appointed at each hospital center at this time and inthose established later during the operations that followed.
Visit to North African Theater of Operations and Fifth U.S.Army
Perhaps one of the wisest moves made by the Chief Surgeon inpreparation for the eventual assault on continental Europe was to send keymedical personnel to the North African theater to observe firsthandthe combat and support activities in progress. Colonel Cutler's turn came inNovember 1943. He departed by air from Prestwick, Scotland, on 27 November andreturned to London on 24 December 1943.
During his visit, Colonel Cutler was able to observe ahospital train movement; general, station, and convalescent hospitals in thebase sections; and clearing stations (fig. 49), surgical teams, and field,evacuation, and convalescent hospitals in the Fifth U.S. Army area. He noted thegreat differences between the North African theater and the European theater,and, on his return, reported, as follows:56
In NATOUSA the distances are great, the transport problem anightmare (fig. 50), the hospitalization with the difficulties ofevacuation (fig. 51) seemed inadequate and the supply problem ismagnified by the above considerations. In spite of all this the medicaldepartment of NATOUSA must have our warm congratulations. Hospitals assumetremendous loads; for example General Hospital No. 21 (fig. 52) once hadas many as 2,600 patients and many 500 bed station hospitals went over 1,000patients! * * * In the Army area, even greater loads were necessary. Moreover, a large share ofthis load were battle casualties demanding on admissionimmediate attention and many requiring careful daily care.
55See footnote 48 (2), p. 107.
56Letter, Col. E. C. Cutler, MC, to Chief Surgeon, ETOUSA, 27 Dec. 1943, subject: Report on Visit to NATOUSA andFifth U.S. Army.
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FIGURE 49.-A clearing station of the 85th Infantry Division in Italy.
Colonel Cutler observed that, in the Fifth U.S. Army, aplatoon from a field hospital was usually established adjoining a divisionclearing station. Casualties who might be endangered by further transportationwere carried by litter from the clearing stations to these field hospitalplatoons, which were set up with from 40 to 100 beds (fig. 53). Four orfive surgical teams from the 2d Auxiliary Surgical Group were attached to thefield hospital platoons. Colonel Cutler was most favorably impressed by thissystem. He stated in his report:
I heartily approve the system for the care of the heavilydamaged nontransportables in Field Hospital platoons. I even would urge anextension of this forward surgery, believing that "surgery should bebrought to the soldier," not the soldier to the surgeon. In addition tochests and abdomens, perhaps all the femurs, all the lower leg wounds withvascular damage and some of the heads should be done here.
On the use of evacuation hospitals in Fifth U.S. Army (fig. 54),Colonel Cutler commented:
In Fifth Army, 400 to 750 bed Evacs were used interchangeably(* * * 750 Evac excellent and no one in this theater understands whyWashington (S.G.O.) thinks they are bad). As a matter of fact 400 and 750 Evacssoon overflowed even with low percentage casualties coming in. * * * EvacHospitals taking seriously wounded were unable to hold patients for sufficienttime to ensure safe evacuation. It seemed to me that the forward hospitals didnot keep a sufficient number of empty beds but this is not offered as a seriouscriticism since only those on top can gauge the necessity for free beds. Inrelation to my experience in forward hospitals in the last war where Evacsfrequently took 1,000 cases a day and were only able to dress and pass on thebulk of the wounded,
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I was favourably impressed with the far greaterpercentage of surgery now done in the forward area This is of course whereit should be done.
In conjunction with the evacuation hospitals, he alsonoted that they had too much paper work in the way of required reports. Therewere 8 daily, 7 weekly, 9 periodic, and 12 monthly reports required of them. Therewas also a bottleneck in the radiology service. The equipment wasadequate, but the personnel soon tired when overworked, indicating aneed for at least double the X-ray personnel in an evacuation hospital.Colonel Cutler's views reflected in the following observation in hisreport were to become the cause for vigorous action on his part upon hisreturn to the European theater:
I believe separate Evacs should be used forthe care of lightly wounded. These are the men we should restore to duty, these deserve ourbest surgeons, these can be evacuated direct to a convalescent hospital. Thismeans good sorting at the clearing station, but that is a function of clearingstations and if sorting is well done the multiple hospital transfers now going on will beminimized
Other aspects of the professional service in the NorthAfrican theater were reported by Colonel Cutler as follows:
The professional care of neurological cases is excellent.These can as a rule reach an Evac Hospital for definitive surgery. There arecriticisms in the forward areas of the tripod incision as practiced by HarveyCushing in the last war but I saw no adequate tripod wounds and am writing toremind the Surgeons of this war that the flap method
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FIGURE 51.-Air evacuation from the Fifth U.S. Army area by C-47 aircraft.
now in use was given an adequate try in the last warand found unsatisfactory. The secret of success in this field lies in careful,thorough and gentle debridement of the intercranial wound and especially in theremoval of indriven bone fragments, followed by closure of the wound. I am notconvinced the Bovie instrument isnecessary and its use adds to the injury and reaction. Also, I believe strong suction is a dangerrather than an advantage.
The care of thoracic and the combined thoraco-abdominalinjury is admirable and a chief advance. Emphasis on the chest wall rather than the lung as a chief source ofhemorrhage has been proven andleads to competent debridement of chest wall with hemostasis and minimalpulmonary surgery. Early repeated evacuation of blood beforeclotting and infection will avoid many empyemata. Emphasis onfrequency of the combined abdomino-thoracic injury is excellent andradiologic control needs continual emphasis.
Early abdominal surgery isthe only road to success inthis field. Resections of small bowel have been rarely necessary andexteriorization of large bowel injuries or closure rectosigmoid and colostomy above havegiven good results. I am not convinced that bowelsurgery through the thorax via an injured diaphragm is wise, but the numberof splenectomies via this route speaks for itself.
Extremity surgery -Hereadequate debridement,preservation of bone, holding cases with vascular damage for fear of clostridium infections and transportation in plasterseems well done. The low-waisted spica sometimes including sound thigh seemsbetter than the Tobruk plaster though Brigadier Weddell still votes for the latterexcept in upper femur cases.
Surgical Teams -These areessential and now that the Evacuation Hospitals have learned under pressure that with theirintrinsic personnel only they cannot do the job, they will be in greater demand.In fact I am willing to recommend that an active army of 3 active corps ormore needs two auxiliary surgical groups or an increasein the number of the teams as at present authorized.
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FIGURE 52.-A tented expansion area of the 21st General Hospital, Italy.
Colonel Cutler also saw the advantages of having specializedhospitals in each base area and recommended that a similar organization beestablished in the European theater, including a convalescent hospital in each base section. Professional work inthe base sections, he advised, hadbeen greatly clarified and improved by the setting up of special centers. Notonly were the individual cases better handled this way, he believed, butconcentrating material at special centers was certain to develop new methodsand policies.
Colonel Cutler closed his report to the Chief Surgeon, ETOUSA, with the following note of warning on the handling of fractures:
Fractures-This field needs furtherstudy. The tendency with femurs is to use skeletal traction at the base. Thisthrows out the work of the Spanish and Russian schools and greatly increasesprofessional labor. We had traction in the last war, we had some hope thatearly reduction and plaster might reduce work as well as give better results. Iam not myself convinced that we are yet masters of the plaster technique.When we are, I have a suspicion less skeletal traction will be practiced.
Sometime after his return from North Africa and Italy,Colonel Cutler was reminded of certain observations he had made there andhad, possibly, neglected to emphasize sufficiently. But, on 9 April 1944, hewrote the following memorandum, which was directed to the Chief Quartermaster,ETOUSA, through the Executive Officer, Office of the Chief Surgeon:
1. During December '43 I had the opportunity of visitingthe U.S. Fifth Army and made a particular point while there of studying with mycolleague, Colonel Churchill,
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Consultant in Surgery, NATOUSA, the many mencoming out of[the] line complaining of painful and swollen feet. The condition is notexactly similar to the "trench feet" of the last war, nor to the many cases of "immersion feet" so carefully studied by Navy medicalpersonnel. It is however a great and growing concern to the U.S. Army, for theloss of manpower from this source alone is disturbing.
2. Studies by medical personnel of the feet of suchcasualties up to this time have not brought forward any method of therapy likelyto restore the individual to combat duty in a short period of time. The generalmedical opinion is that prevention is the best method of treatment.
3. Colonel Holst, formerly Professor of Surgery at Oslo,Norway (now Chief Consultant in Surgery to the Norwegian Forces in the UnitedKingdom), has just returned from a two months' visit with the Fifth U.S.Army and the British VIIIth [Eighth] Army. He too made an exhaustive study ofthese "cold wet feet" and passed some remarks to me which should bein your possession. Note that Colonel Holst is a Norwegian, who participatedin the Finnish-Russian War, and has had as great an experience with cold wet feet as any competent medical officer living.
It is Colonel Holst's opinion that:-
a. The sock furnished the U.S. Army does not have asufficient content of wool.
b. That a rigid discipline must be enforced within combatcompanies insisting on the changing of socks daily, even if it only meanswringing out the wet sock and putting it on again.
c. That our soldiers are invariably fitted with shoes toosmall for them.
Later in the month, Colonel Cutler was asked to furnishsuggestions for line officers whose responsibility it was to insure that properdisciplinary measures were carried out in order to prevent cold injury.Accordingly, in a memorandum, dated 25 April 1944, he provided the followingsuggestions:
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FIGURE 54.-The 94th Evacuation Hospital, Fifth U.S. Army, Italy.
Care of the feet is the responsibility of the companycommander, but we are glad to furnish this draft for their use as they seefit.
1. The condition of trench or immersion footincapacitates the soldier for one or more months and we have no specifictherapy for this condition.
2. Prevention of the conditions giving rise totrenchfoot is largely possible if the following instructions are carefully adheredto.
a. Every attempt should be made to keep the feetwarm and dry, using overshoes where possible and encouraging mobility.
b. Shoes should not be tight, and when fitted are preferablyfitted over 2 pairs of heavy all-wool socks.
c. Canvas leggings, when worn, should not be tightly laced.
d. All-wool socks should be provided troops in areaswhere immersion or wetting is common.
e. Socks and shoes should be changed daily, even if atthechange the soldier does nothing more than wring out the wet pair of socks,rub his feet and put on the wet pair of socks again. This routine, if the socksare all-wool, will be a major factor in the prevention.
f. When wet shoes and socks are changed it is advisable torub in lanolin or Vaseline lightly after drying the skin.
It is not within the scope of this chapter to discuss furtherwhat actions were taken at this time on these recommendations by the ChiefConsultant in Surgery. This is done elsewhere, but it is significant to notethat the matter had been brought up and that simple remedial measures had beensuggested.57
57Medical Department, United States Army. Cold Injury,Ground Type. Washington: U.S. Government Printing Office, 1958, pp. 127-210.
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Closure of wounds
In a global war, such as World War II, it was indeeddifficult for those at the hub in Washington to establish policies which wouldbe applicable under most circumstances anywhere. Even if it was possible to doso, there remained the major problem of communicating the ideas in such amanner that all would receive them and interpret them identically. The incidentnext to be reported, in which Colonel Cutler was involved, brought out theseproblems well.
Colonel Cutler had attended a meeting of the surgicalconsultants subcommittee of the British Army consultants committee on 12January 1944. He was impressed by remarks made by Sir Harold Gillies. Hereported the following to Colonel Kimbrough by letter on 16 January1944:
Sir Harold Gillies, Hon. Consultant, RAMC, waspresent ata Consultants' Meeting for the first time in four years. He came toemphasize the value of early covering of surface wounds. He emphasized thatthere was great delay in the use of either plastic procedures or skin grafting,and urged that the Consultant Group promulgate through alltheaters the desirability of utilizing modern ideas of plastic surgery. I felthe made a good point and will some day try and write a note for the Bulletin of theChief Surgeon concerning covering of wounds, whether bydelayed primary suture, secondary sutures, skin grafting or flaps.
These observations by Sir Harold Gillies were mostapropos at this time since the early closure of wounds had only recently been amatter of concern to the Chief Consultant in Surgery. The causes for hisconcern resulted from two directives which had been issued by The SurgeonGeneral. The earlier of the two, Circular Letter No. 91, dated 26 April 1943,concerning amputations, stated: "Primary suture of all wounds of the extremities under war conditions is never to be done;it is permittedafter debridement in certain abdominal, chest, and maxillofacial injuriesonly." The directive further stated that the guillotine or open circularmethod of amputation was the procedure of choice in traumatic surgery underwar conditions and permitted the flap-type open operation to "be doneonly in cases in which early evacuation is not contemplated and subsequentclosure at the same station is deemed possible."
The later directive, Circular Letter No. 189, concerningsurgery of the extremities, was a followup of the earlier. Issued on 17November 1943, it noted that cases of gas gangrene infection were stilloccurring as a result of treatment of compound fractures and wounds of theextremities with closure of the wound and without thorough debridement. The directive made the following clear statements: "It is STRICTLYFORBIDDEN that any compound fracture or extensive wound of the extremitiesbe treated with closure of the wound. * * * It is STRICTLYFORBIDDEN that * * * amputation be done higher than necessary or that thestump be closed." The directive, in closing, warned: "Commandingofficers of all general and station hospitals will be held responsible for theabandonment of the improper pro-
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cedures described above and for the necessary instructionand compliance with these directives."
On 30 December 1943, Colonel Cutler, in a memorandum toColonel Kimbrough, called his attention to the fact that these circulars hadnot been reproduced in the theater as theater directives. Colonel Cutlerinformed Colonel Kimbrough that they had reached commanding officers ofhospitals, however, and that, if they were blindly followed, certain cases wouldbe forced to have two operations where one would suffice. He asked whether itwould not be proper to request The Surgeon General to reconsider thesedirectives as they might apply to casualties occurring in the Army Air Forcesand to nonbattle injuries. He suggested that perhaps TheSurgeon General had not given full consideration to the casualty of the ArmyAir Forces. In explanation of his stand, Colonel Cutler wrote:
In both of these categories previously healthy and oftenclean, vigorous young men reach a hospital within two hours of injury thussimulating civilian hospital practice. Several have had to haveimmediate amputation and in selected cases short flap amputation has permitted earlysecondary closure and even primary closure with highlysatisfactory results. It appears to us that there should be a difference intherapy according to terrain and environment. Thus, a sailor knocked into the seawater by a shell fragment and immediately picked up andtaken to a hospital ship and an aviator wounded in clean clothes, in a cleanairplane and reaching a hospital within three hours and a wounded infantry soldierwho has lived in a foxhole, covered with mud and clothesin filthy garments for one or two weeks and who reaches a hospital in 6-12 hoursneed entirely different treatment at the hand of the surgeon.
Colonel Kimbrough passed Colonel Cutler's memorandum toGeneral Hawley. The general's decision was to leave matters where theystood with respect to the directives and to take care of the exceptionsto The Surgeon General's policies by personal instruction within thetheater.
Colonel Cutler, however, did not believe that the ChiefSurgeon's decision went far enough. In a memorandum to the Chief Surgeon,dated 24 January 1944, concerning the amputation circular, he made thefollowing suggestion:
I believe it would be unwise to issueconfidential instructions which are in any way contrary to those recommendedby The Surgeon General. It was the intent of my memo of 30 December that youmight send a professional opinion to The Surgeon Generaloutlining the situation concerning amputations. I have tried to outline this for youin the attached letter. Would not this be thewisest policy?
General Hawley accepted Colonel Cutler's recommendations and sent the letter toThe Surgeon General asking the question of whether casualties of the Army Air Forces, for example, did notjustify a different type of therapy according to the environment in which they were wounded and the promptavailability of surgical care. The letter also inclosed a "short note"prepared by Colonel Cutler for publicationin the Medical Bulletin, ETO USA. Titled "The Importance ofWound Closure," this article read as follows:
"Do not suture" is accepted as amajor principle inthe surgery of battle casualties. It, however, must be applied intelligently.For example, it does not mean, never, at any time hereafter, suture thesewounds, nor does it mean keep this wound open forever. Yet the dictum has hadthe above unfortunate connotation. In fact, many surgeons, once
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a wound has been debrided, seem to relax theirinterest in the wound unless it becomes septic. This leads to longhospitalization and late return to duty. Moreover, to let a wound heal by cicatrizationoften leads to unnecessary stiffness in the part and even limitation of function.
We must all consider another principle when weleave a wound open, which is, the best way to sterilize a wound is toclose it. No antiseptic is equal to overlying complete epithelization, whether itbe achieved by delayed primary suture, early secondary suture, skin graft or flapprocedures. Indeed, we owe much to our plasticsurgical colleagues who constantly reiterate the importance of a closed wound.
With these two principles in mind let usreturn to a consideration of the battle casualty and the relation of his injury toterrain and environment. The man wounded in the battlefield where he has beenwearing the same suit of clothes for three weeks and who is covered with mud and dirt experiencesthe same wounds as an airman in his clean clothes, fresh from a bath, or thesailor blown off the deck of his ship by a bomb splinter. True, whensurgery is first applied it is wiser to follow the dictum ''do notsuture the wound''. But there analogy ceases; the foot soldier's woundis inevitably seriously contaminated, that of the airman or the sailor swimming insalt water has a minimum of infection. In the case of the foot soldier, delayedprimary suture or secondary suture can only be practiced infrequently; in the case of theairmanand the sailor it should be practiced almost as the rule.
A recent study in E.T.O. with early closureyields light upon this point. A study was made of the wounds of casualties whohad been given penicillin therapy, or sulfonamide therapy, or no chemotherapy.An outstanding observation was that those woundsclosed early, irrespective of chemotherapy or none, healed well. When there was delayin closure, infection resulted. And no great choicewas made which wounds to close early and which to leave open.
This matter is again brought forward because itappears that the inestimable advantages of an epithelial covering are not generallyrecognized. If early closure cannot be accomplished, thenearly grafting or even flap procedures should be carried out. The difficulties of these latter procedures are increased bycicatrization.
Not to suture a wound initially is good practice.To failto close it at the first safe moment is neglecting an opportunity toprotect the soldier against further infection and loss of function.
The reaction in Washington, upon receipt of General Hawley's letter andColonel Cutler's inclosure, was quick andsensational. First, there was a reply from General Rankin, Chief Consultant inSurgery, Office of The Surgeon General. The letter, dated 3 February 1944,stated:
General Kirk showed me your letter of January 24threlativeto amputations and, since there was an enclosure from Cutler on TheImportance of Wound Closure, he asked me to drop you a line relative tothis. I believe he intends to answer your letter, insofar as amputationsare concerned, himself.
In a word, we neither of us agree with themodification of the amputation program. I am sure that the wide experience of General Kirkand other men from the last war who dealt with amputations has resulted ingiving us a program which ispretty nearly as satisfactory as one can have, and when it comes to fashioning flaps, et cetera, I think thatwe will have to disagree withour colleagues. I just can't go along with the hypothetical case of the youngairman, either in the question of flaps for his amputation or in the proposedwound closure such as Elliott Cutler outlines. Ifthere is one thing that I thought we had learned from the past war and from ourexperiences in this war, it is do not closewounds primarily. I don't believe there is any evidence at all thatthis should be deviated from. I cannot agree with Cutler that infectionresults when there is delayed closure
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because of the delayed closure only. Infection resultsbecause infection is there. I am perfectly sure that any deviation fromthis principle will be followed by profound repercussions. There may be 1percent, or even 5 percent, of wounds which, when operated upon early, may be closedwith relative safety, but the 95 percent (and probably 99 percent) of warwounds, regardless of what service they are in, arebetter left open, in my judgment. One cannot visualize experienced surgeonsalways present when people are wounded under seeminglysatisfactory conditions for closure and the great difficulty, as I see it, isthat the example will be followed by inexperienced men in unfavorableconditions. We had the same thing to deal with here in the States in thetreatment of compound fractures occurring near camps produced by accidents inmotor vehicles. These fractures resembled in all details those of civil life and werefrequently gotteninto hospital within one to three hours. It was with the greatestdifficulty and only after numerous directives that the Surgeon General's Officewas able to compel the surgeons to leave these wounds open, more as an exampleand a lesson than anything else because many of them could be closed safely, butnot in war wounds. I have no hesitation in placing myself on record that we stilladhere to theprinciple of no closure. I think that I can buttress this with the experience ofthe surgeons in the Tunisian and Sicilian campaigns and I am sure that their recordsshow that a great many people developedserious complications both in the closure of wounds and in the packing ofwounds, which is equally undesirable.
On 4 February 1944, Maj. Gen. Norman T. Kirk wrote a letterto General Hawley containing the following:
Much bone length has been sacrificed by thesemethods. I am sure that the chances of infection are less in Air personnel andin the Navy with men aboard ships. However, I have seen many infections occur in operatingrooms under what were supposed to be ideal aseptic conditions and when electiverather than emergency surgery was being performed. I don't believe that awound has to be full of mud, manure or cinders to have streptococcus,staphylococcus or even gas bacillus present in it. Peterson, in a recenttour of our hospitals, found three amputations here at home where debridementand primary suture were carried out within the criticalperiod and gas gangrene occurred requiring amputation to save life. Ihave seen other cases so treated and the wound closed. The doctor said he tooka chance and got away with it. The patient took the chance, not thedoctor. Also, the patient didn't have a vote and wouldn't have known how to vote.
The Consultant in North Africa finds that many ofthese wounds, at the end of eight or ten days, with the assistanceof penicillin, sulfa drugs or none of these agents, may be safelyexcised and secondary suture performed. I am in accord withthis, particularly in superficial wounds, to get men back to dutyearlier. It may be applicable to compound fractures with destructionof large muscle masses. I am not too sure about this, however.
It is accepted that the flap type guillotine may initiallybe performed if that patient is not to be transported and can be held underobservation in a given hospital but the following must be weighedand when this is considered: traction is applied with difficulty and tractionmade by the use of sutures through flaps causes necrosis oftissue followed by infection. Bone length almost always has to besacrificed when this method is employed. We are getting back too many below-kneestumps from overseas that are too short to be fitted with prosthesis. We arealso getting many back with skin grafts. This is notat all necessary. The circular type guillotine of the thigh with proper tractionwill be healed in six weeks and will stay healed. If it is closed primarily, toomany cases of osteomyelitis will develop, too much shortening will be occasionedand the resulting stumps will frequently not be satisfactory from the prostheticstandpoint.
As you can see from the above, I am not at allinaccord with your policy of handling your Air casualties. I know everythingis going to speed these days and speed is a great thing but no matter how fast aplane can fly if the motor is cut out in flight it soonflops
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and it doesn't arrive at its destination. A lot more speed canbe obtained if sound principles of surgery are not at the same time observed. Inthe last war lives were lost, as well as extremities, from primary closureas well as too early secondary closures. No surgeon, no matter how expert, can always do acomplete debridement of a wound. If that were true we would not be having the increasein the incidence of gas gangrene inItaly. And I am very afraid of what that incidence is going to be when weget into the Continent. I am also afraid that a lot of it is going to developunder plaster, with disastrous results.
Under these circumstances, General Hawley's instructionsto the Chief, Professional Services Division, on 16 February 1944, were simply:"This policy will be followed in ETO. Implement."
The implementation was done by publishing The SurgeonGeneral's Circular Letter No. 91 as Circular Letter No. 28, Office of theChief Surgeon, ETOUSA, 1 March 1944, Section I of which was titled"Surgery of the Extremities." On 21 February 1944, Colonel Cutlerinformed General Rankin by letter that this was being done. He explainedas follows:
I fear you did not quite understand my little noteon''The importance of wound closure". It begins with the sentence: "'Do not suture' is accepted as the major principle in the surgery of battle casualties".What I was interested in was to have our surgeons remember that there also wassomethingto be desired in closing the wound eventually so that the man could be returned to duty. Everyone hasemphasized "do not suture a wound"so much that the young surgeon takes no interest in his wound after it isonce made, and wounds which could be closed in the second to fifth day bydelayed secondary suture or by skin grafts during the same period are left toslowly granulate, thus keeping a man in hospital sometimes a month ormore after he should have been discharged. I hope you and the Surgeon General donot for a moment think that we are practicing the primaryclosure of wounds.
The Surgeon General in his letter says: "Iam notat all in accordance with your policy of handling your air casualties".I cannot find we have done anything he would not approve of. There havebeen few amputations with the Air Force and only one in which very shortflaps were made. In this case the wound was closed by delayed secondary suturethe next day, and healed forthwith. It was an arm which had been blown off by rocket shellin the Schweinfurt raid, at about the junction of the middle and upper third. Everyattempt is made here to leave as much boneas possible and I feel certain that if you and the Surgeon General couldvisualize our work in those hospitals serving the Air Force you would bemost happy, as are General Grow and those responsible for the medical care ofthe Air Force itself.
Fortunately, only a few weeks later, General Kirk andGeneral Grant (fig. 55), the chief medical officers of the Army and the ArmyAir Forces, respectively, were sent to the European theater for the specificpurpose of reviewing hospitalization facilities for the Army Air Forces in theUnited Kingdom. It was Colonel Cutler's privilege to accompany andguide them through the many installations devoted to the care of aircasualties. In their tour of the hospitals, which began on 9 March 1944 andcontinued almost without a break through 17 March, there was completesatisfaction in the surgical care which was being provided.58
58Memorandum, Col. E. C. Cutler, MC, for Maj.Gen. N. T. Kirk,20 Mar. 1944, subject: Tour of Medical Units, E.T.O., March 8, 1944-March 17,1944.
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Penicillin
Spurred on by the war effort, knowledge concerningpenicillin increased by leaps and bounds. There grew an ever-hopefulattitude that here was a new medical implement which would have profoundeffects in improving the care which could be given the wounded. There wereindications that it might prove to be the greatest bacteriological agent yetproduced, although Colonel Cutler thought it needed furtherassay in the human body before final opinion could be hardened. There wereindications, also, that great strides were being made in devising methods forproducing penicillin, methods which, early in this period, were still laborious and time-consuming processes.Thus, for the Chief Consultant in Surgery, ETOUSA, it was imperative that he gain all the datahe couldin order to be able with some confidence to advocate a standardizedregimen of treatment using penicillin and to insure that adequate supplies ofthe antibiotic would be available to carry out the treatment recommended.Moreover, the opportunity to study the efficacy of penicillin in the Europeantheater was unparalleled, for here in the United Kingdom were someof the persons who were at the forefront in its development.
As reported previously (p. 52), a beginning in thisdirection had been made by the studies which Lt. Col. Rudolph N. Schullinger,MC, was con-
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ducting at the 2d General Hospital with the advice and helpof Prof. Howard E. Florey and Dr. Mildred Florey, his wife. By theopportune arrival of more penicillin in September 1943, Colonel Schullinger wasable to continue his work and bring it to a conclusion in March 1944. ColonelSchullinger gave the following account of these early experiences:59
Shortly after the Second General Hospital arrived atHeddington, Oxford, in July 1942, the University faculty as well as some of thehospital staff members held a reception for the"invaders" at Christ College. It was a most interesting andenjoyable occasion. Here it was my good fortune and privilege to meetProfessor Howard Florey, Director of the Sir William Dunn Research Laboratory,and his wife, Doctor Mildred Florey. In the course of our conversation, they spoke of their exciting studieswith penicillin and invited me to visit their laboratory. The invitation was eagerly accepted.The attractive and well built laboratory was situated on a quiet street notfar from Rhodes House. Once inside, the visitor could sense an atmosphere ofconsiderable activity. As one passed the various researchunits, it was apparent that doctors and technicians were busy and intent on theirwork. Professor Florey's study was a spacious oval room on the second floorflanked with bookshelves and files. In thecenter was a large table covered with papers and periodicals in "orderlydisorder" and, at the end, nearest the window, was Professor Florey'schair. No matter how busy he was with his studies, correspondence, and writings, the visitorwas always received with a welcome smile and an invitation to join his company.
It soon became apparent that here a great projectwas in full play. Professor Florey was at the helm, directing the technicalaspects in the production and refinement of penicillin, and consulting with hiswife, who carried out the clinical application of this new antibiotic. The process ofpreparing penicillin was so laborious in the early phases of this work that onlycarefully selected cases could be chosen for this therapy. In fact, the amount ofpenicillin was so limited that the urine of patients undergoing treatment wassaved and returned to the laboratory for extraction and repurification of thepenicillin for subsequent use. Sometimes the supply of penicillin gave outcompletely, thus necessitating temporary discontinuance in critically illpatients. These were trying and discouraging moments.
Thus, during the autumn and winter months of 1942-1943,the writer enjoyed the unusual privilege of witnessing the clinical application ofpenicillin to patients in some of the British military,civilian, and E.M.S. hospitals. Several trips were also made to the RAF Hospital atHolton. Wherever she went, Doctor Florey took careful notes and measured out the dosageswith precision (perhaps two to five thousand units per dose) for the next two or three days. The resultswere usually dramatic. Here was a boy with a fulminating hematogenousosteomyelitis who responded promptly to "large doses" (10,000units every four hours) of penicillin and required no operative interference. Inthe Radcliffe Infirmary a young army officer with cavernous sinus thrombosis and sepsis recoveredafter a fortnight of penicillin therapy.Infected wounds seemed to improve rapidly with local applications of penicillin. A penicillincream was used for certain types of burns.
Observing the clinical aspects with DoctorFlorey, anddiscussing the overall problem at various times with Professor Florey, it was obvious that herewas an agent that would be of enormous benefit both for military and civilian purposes.Colonel Elliott Cutler was consulted and it was decided to requisition a supply ofpenicillin "through channels" via the Chief Surgeon, E.T.O.Unfortunately, the supply in U.S.A. was quite limited and
59This account was obtained from Dr. Schullinger by WilliamS. Middleton, M.D., Chief Medical Director, Veterans' Administration. Dr. Middleton, who was formerly a colonel in the Medical Corps and Chief Consultant in Medicine in the European theater forwarded the paper to Col.J. B. Coates, Jr., MC, by letter, 26 August 1957.
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there was none available through British sources. After aconsiderable interval another attempt was madeto obtain the precious material by enlisting the British Research Council tomake a direct appeal to the O.S.R.D. Meanwhile, Professor Florey had flown tothe Eighth Army in North Africa to study theeffect of penicillin in its local application to septic war wounds.
Finally, on 8 May 1943 a consignment of one million units,valued at one thousand dollars, arrived at the Second General Hospital. It wasprepared in powder form, sealed in 10,000 unit vials. The consignment was lockedin the ice-box next to the main kitchen. A consultation was then held with ProfessorFlorey, Colonels Cutler, Kimbrough, and Storck, as well as Major Sloan and thewriter, in order to formulate certain policies on usage and dosage.
Although the penicillin was to be administered only tomembers of the U.S. Forces, it was difficult indeed to deny urgent requests fromneighboring British military and civilian hospitals. The first case to betreated was a young Air Force lieutenant with staphylococcus osteomyelitis ofthe left femur secondary to flak and shrapnel wounds of the thigh and pelvis.Othercases soon followed, chiefly infections secondary to injuries and wounds. Thiscontinued through the late spring and summer of l943.At the same time, instruction courses on the use and preservationof penicillin were given at the Second General Hospital to officers on detachedservice, and this was continued well into the springof 1944.
During the winter of 1943-1944 the writer presented resultsof penicillin therapy administered to patients in General Hospital Number Two atvarious U.S. Army Installations in England (Tavistock, Winchester, Leamington, etc.). Ofconsiderable interest was the reported recovery in January 1944 of a British soldier, at themilitary hospital in Shaftsbury, stricken with Staphylococcus aureuspyemia and endocarditis. He received a total dosage of five million units.Finally, on 11February 1944, through the kind offices of the late Sir Arthur Hurst, it was thewriter's privilege and honor to address the faculty and students at Guy'sHospital on penicillin therapy, based on clinical studies at the Second GeneralHospital.
During March 1944, sufficient penicillin had been received asto permit formulation of directives for its use at various U.S. militaryhospitals in the United Kingdom. Already plans were being drawn up forpenicillin therapy in advance combat areas.
On 29 March, the documented report on penicillintherapy at the Second General Hospital was submitted to Colonel Elliott Cutler.
Thus, in brief, the reader may appreciate the role played byone of the U. S. Army hospitals in Britain in the clinical application ofpenicillin therapy during the earlier years of its development (1943-1944). Itwould be impossible to give adequate expression of appreciation and gratitudeto Sir Howard and Lady Mildred Florey for their many kindnesses, gracioushospitality, and warm friendship, not to mention their unselfish expenditure oftime and interest in counseling and encouraging the writer during this stirring period of studyat the Second General Hospital in Oxford.
An abbreviated version of Colonel Schullinger's finalreport was forwarded by Colonel Cutler to The Surgeon General.60The summary portion of the report read, in part, as follows:
A somewhat varied group of forty cases,treated with penicillin in this theater between May 1943 and March 1944, hasbeen collected and presented. Twenty-six were improved or cured, seven haddoubtful or equivocal results and seven were failures. Five deaths occurred, inwhich three may have succumbed to other causesor, at best, to distantly related circumstances. * * * The forty cases comprisedtwo main categories, namely
60Essential Technical Medical Data, EuropeanTheater of Operations, U.S. Army, for May 1944, dated 14 June 1944.
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infections and prophylactically treatedwounds. Thisreport does not include sulfa-resistant gonococcal urethritis, lues, freshbattle wounds or medical infections, such as meningitis or pneumonia.* * *
An effort has been made to point out the necessity for strictadherence to the criteria governing proper penicillin therapy. The indicationsfor therapy should be carefully considered and evaluated, before resorting toactive treatment. Actual dosage should not be according to fixed or dogmaticrules, but should be governed by careful bacteriostatic control, because of thevariability in excretion rate. Inadequate dosage predisposes to thedevelopment of penicillin-fast strains. However, complete bacteriostasis,throughout the whole interval between doses, may not beessential. On the other hand, some strains have a natural resistanceeven though the family is ordinarily sensitive. Contrariwise, we haveencountered two sensitive strains of Streptococcus viridans. Theduration of treatment should be ample, particularly in the staphylococcalinfections. * * * Many of the patients, with successfully treated infections,followed a fairly typical pattern: the improvement was gradual, the temperature fell bylysis, they looked and feltbetter, the appetite increased, sometimes quite markedly; there wasless need for opiates, and the hemogram became normal. Inthose cases with infected wounds there was a marked diminution in pain, swellingand discharge, with rapidly appearing healthy granulations and acceleratedhealing. The route of penicillin administration was intramuscular, intravenous orlocal, sometimes in two, oreven all three combinations. * * * The locally treated infections illustrate theremarkable efficacy of relatively small amounts of penicillin. * * * The number ofequivocal results and failures in the present series suggests a lack of proper selection orinadequate therapy orpoor management.
* * * * * * *The prophylactic treatment of the group ofcompound fractures was most encouraging. This was due, in large part, to theshort duration between injury and operation, the relative cleanliness of thewounds in the successfully treated patients, the skillful management by theexperienced surgeons, and the local and parenteral administration of penicillin.The advantages of converting a compound fracture intoa simple one is obvious. * * * The treatment of these compound fractures unfoldsnew possibilities in war, as well as civil surgery. Nevertheless, with fewexceptions, primary closure of compound fractures must never be practicedin the forward areas.
Elsewhere in the report, Colonel Schullinger warned: "* * *the writer cannot too strongly emphasize the importance of adhering to soundsurgical principles in the treatment of patients with penicillin. To neglectsuch practice, with the expectation that penicillin can perform miracles, ispernicious, and may even jeopardizea patient's life. It demands too much of penicillin and nothing couldplace it more readily into disrepute."
The study by Colonel Schullinger was, actually, a clinical trial ofpenicillin and not an experiment in the classic sense.The question of the efficacy of penicillin when used prophylactically wasa paramount one because of its great implications for surgery in the field.True, Colonel Schullinger's studies had included eight compoundfractures in which penicillin had been administered prophylactically. Six of theeight had improved or been cured, one was a failure, and the otherresulted in death in which the result of the prophylactic use of penicillin was equivocal. Furthermore, except for a clinical appraisal,there was no wayto be absolutely certain that the improvement or cure of the six cases was dueas much to other extenuating circumstances and
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the expert surgery available as it was to the prophylacticuse of penicillin. Therefore, on 10 September 1943, Colonel Cutler conferredwith General Hawley and later the same day reported to Colonel Kimbrough bymemorandum, as follows:
The experience thus far in the use of this bactericidalagent has been largely in the treatment of chronically infected wounds.Our own experience as well as that of Mrs. Florey does not reveal that thisagent is as universally satisfactory as has been written. Recently,Professor Florey and Brigadier Hugh Cairns have returned from NorthAfrica and Sicily, where penicillin is now being placed infresh battle casualty wounds with a sulfonamide. Thus there is no proper control of the efficacy ofthe agent.
We have an opportunity with fresh battle casualties inour Eighth Air Force of testing out the value of implanting penicillin shortly afterwounding. I have proposed to General Hawley, and it has his approval, that weconduct proper controlled experimentswith casualties from the above source, treating every other battle casualty ineach of our 6 station hospitals with the 8th Air Force with penicillin.
The proposal was also approved by General Grow, Surgeon,Eighth Air Force. Initially, Lt. Col. (later Col.) William F. MacFee, 2dEvacuation Hospital, was placed on one month's temporary duty as a specialconsultant with the Eastern Base Section to supervise and control thestudy. Later, as the project continued with the advent of more penicillin,Lt. Col. (later Col.) Paul C. Morton, MC, and Capt. (later Maj.) William R. Sandusky, MC, wereassigned to the project. Colonel Morton eventually assumed primary responsibility forthe study after the relief of Colonel MacFee.
The first problem in getting the study started was penicillinitself. Where was the supply to come from? Of the original supply whichhad arrived in May 1943, there was little left. In the London depot, however, there were7,200,000 units remaining of a supply which had been sent to be used forsulfonamide-resistant gonorrhea. The only otherpurpose for which this could be used was in cases of overwhelming infection wherethe saving of life was involved. Colonel Cutler calculatedthat 5,100,000 units of the original penicillin had been used forlifesaving purposes or for the treatment of gonorrhea and was able to recoupthis amount, in exchange, from the stock in the depot.61 This supplyenabled the study to get underway. Shortly thereafter, General Hawley ruled thatany amount of the penicillin being received for the treatment ofsulfonamide-resistant gonorrhea could be used for the surgical penicillin work.62 This decision permittedthedistribution of 5,000,000 additionalunits to the study made on air force personnel and the 5,000,000 unitspreviously mentioned to the 2d General Hospital for Colonel Schullinger'sproject.
Meanwhile, to insure a continuing supply of penicillinfor the limited purposes for which it was then being used, over andbeyond that which had been requested for sulfonamide-resistant gonorrhea,Colonel Cutler had advised the Chief Surgeon to make a request for an increasein the proposed
61Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 14 Sept. 1943, subject: Re Withdrawal of 5,100,000 Units of Penicillin Now in London Medical Depot.
62Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 18 Sept. 1943, subject: Penicillin Supply.
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monthly allotment of penicillin for the theater. When theChief Surgeon accepted this advice, the following letter was prepared byColonel Cutler for General Hawley to send to General Kirk:
This communication relates to additional supplies ofpenicillin desired in the ETO. Our instructions from your office are that youwill send us a supply of penicillin for treatment of sulfa-resistant gonorrhea only. We have already submitted data on the number of units of penicillinnecessary to treat the expected incidence of this disorder according to thetroop basis. You have already shipped to the ETO for this purpose 20 millionunits. Preliminary reports suggest highly beneficial results.
In addition to the above supply for "sulfa-resistantgonorrhea only" there was donated to this theater, on 3 May 1943, 18million units. This has been used in close cooperation with Professor Florey and at presentwriting less than 2 million units remain on hand. Our Professional ServicesDivision are extremely anxious that additional supplies of penicillin beavailable for use in the ETO for the followingpurposes:
a. Treatment of cases with gas gangrene
b. Pyococcal septicemia and serious osteomyelitis cases
c. Treatment of certain of the meningitides
d. For a study of the value of penicillin when instilled into freshly acquiredbattle wounds.
We feel that we have an ideal set-up for properlycontrolled studies in the last category. Amongst casualties returning daily in our"bombers" the flow of patients is steady but not so pressing as todetract from the careful care and consideration. No other group of patients willpresent a better opportunity. We would like to treat every other patient without choice by placingpenicillin in the wound and using a certain amount parenterally. We will have the opportunity to conduct properbacteriological and other laboratory tests.
Heretofore in this theater the use ofpenicillin haslargely been carried out in chronically infected wounds where the multiplicityof organisms and the extent of infection mitigateagainst great success by any single remedy.
The British penicillin group, of which Professor Florey andBrigadier Hugh Cairns are the leaders, have just returned from the activetheater below us. There, penicillin is being instilled into fresh battlecasualties, but always in conjunction with a sulfonamide, which will give us no absolutely positive evidence.
Supply
For the above categories of penicillin therapy wewould like a monthly supply amounting to 50 million units a month for thepresent, in addition to that sent for the treatment of sulfa-resistantgonorrhea. We could easily use more and we are disturbed that our Canadiancolleagues have been promised large amounts when it appears to us that we havea great opportunity for a competent study. If this request is granted, coulda preliminary fraction be flown over shortly?
Because penicillin loses potency rapidly after being removedfrom the refrigerator and when in any other form than when dried andhermetically sealed, we would greatly prefer our units to come in the 10thousand unit ampoules, as in our first lot, than in the 100 thousand unit ampoules, as in the secondlot.63
The supply of penicillin seemingly assured, the controlledstudy on the efficacy of penicillin used prophylactically in combat-incurred wounds of air-crews was continued until March 1944, aswas the study being conducted by Colonel Schullinger. The March terminationof these studies was decided upon in order that final reports could beprepared for inclusion in a penicillin
63Letter, Brig. Gen. P. R. Hawley to Maj. Gen.N.T. Kirk, 17 Sept. 1943.
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fasciculus to the April issue of the British Journal ofSurgery. (The fasciculus was later postponed to the July issue.)
In the study made on air force personnel, there wereeventually 250 wounds occurring in 146 patients which were available forcomparison. In the penicillin treated group, there were 68 patients with 123wounds; in the control group, 78 patients with 127 wounds (table 1).
The final report of the studies mentioned some of thefollowing observations:
It should be clearly understood that the object of this study is not todetermine whether penicillin is effective in established wound infections, butrather to learn whether penicillin, used prophylactically, will prevent or lowerthe incidence of infection in the wounds of aerial combat in a theater of warwhere early definitive surgery and continued observation can be carried out.
The wounded patients were divided into two groups. Those inone group were given parenteral and local penicillin prophylactically * * *.Those in the other group received no chemotherapeutic agent and serve ascontrols.
Wound category and patient group | Wounds | Infections | Infection rate |
| Number | Number | Percent |
Compound fractures:1 |
|
|
|
| Penicillin-treated patients | 38 | 6 | 15.8 |
| Controls | 28 | 5 | 17.9 |
| 66 | 11 | 16.7 |
Soft-part wounds: |
|
|
|
| Penicillin-treated patients | 85 | 5 | 5.9 |
| Controls | 99 | 6 | 6.1 |
| 184 | 11 | 6.0 |
Total wounds:1 |
|
|
|
| Penicillin-treated patients | 123 | 11 | 8.9 |
| Controls | 127 | 11 | 8.7 |
| 250 | 22 | 8.8 |
1Excluding skull fractures.
Penetrating wounds of the abdomen or thorax orburns are not included in this study. The policy has been to administersulfonamides or penicillin or both to all such patients, therefore no group ofcontrol cases is available for comparison.
The local dosage for wounds involving onlysoft tissue varied from 5,000 to 20,000 units in accordance with thesize of the wound. Wounds associated with compound fractureand soft part wounds in the region of the anus or buttocks received from 10,000to 40,000 units. In a limited number ofinstances, doses as great as 100,000 units were administered.
The usual method of preparation for localapplication has been to dissolve the sodium salt of penicillin in sterilephysiological saline solution in amounts of 1,000 units ofpeni-
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cillin per cubic centimeter. This solution wassprayed on the wound by means of an atomizer. Another method only recentlydeveloped has been the insufflation of a mixture of penicillin powder anddehydrated human plasma on the wound surface. Ten thousand to 20,000 unitsof the sodium salt of penicillin to 0.1 to 0.2 gm of plasma has been found tobe a satisfactory combination.
The local use of penicillin was combined withparenteral administration. The practice was to give intramuscularly 10,000 units of thesodium salt dissolved in 1 cc of physiological saline solution. This dosage wasgiven immediately following operation and was repeated at three-hourintervals. Early in the study parenteral administration was continued forthree days, but subsequently this was reduced to 48 hours.
At the time of operation the debrided tissuefrom the majority of the wounds was placed in sterile wide mouthed bottles andsaved for culture. Following debridement and irrigation the wound was againsampled for bacteriologic examination. This was done by gently and thoroughlypassing, over all parts of the wound, a sterile cotton swab, which was latercultured. In the beginning of the study only aerobic cultures were done. Later, four ofthe hospitals hadfacilities for anaerobic, as well as aerobic cultural methods.
The results have been judged solely from thestandpoint of wound infection. The criteria for infection required the presence of one ormore clinical signs such as tenderness, swelling, redness, lymphangitis,lymphadenitis, the presence of purulent discharge or infected hematoma. Inwounds which wereleft open a distinction has been made between those having simple surfacecontamination and those showing clinical infection. The presense of organisms onthe surface of an otherwise healthy wound is not considered infection of thatwound.
The findings are presented in the tables[table 1]. Thedifferences in percentage between the infection rates in the penicillin groupand control group in each instance are not ofstatistical significance.
The results indicate that penicillin, used inconjunction with early definitive surgery did not lower the incidence ofinfection in such wounds. We cannot too strongly emphasize that our findings arenot to be compared nor confused with other studies inwhich penicillin has been used to treat established surgical infections.
It is obvious that penicillin usedprophylactically in the manner herein described did not prevent the development of gasgangrene in two patients. The role of this agent in modifying the infection,altering the toxicity, or in combatting secondary invaders cannot be evaluated atthe present time.
* * * there are several points of interestfrom the bacteriologic standpoint. One has been the finding of a high percentage ofcontaminated wounds in aerial casualties [85 percent.] * * *The predominant organism has been the staphylococcus. Another contaminant worthy of note isthe clostridium. The incidence of this organism in cultures of the debrided tissueincreased as improvements were made in the anaerobic methods in the differentlaboratories. In one of the laboratories, when anaerobic as well as aerobiccultures were done routinely the incidence of clostridia (anaerobic grampositive bacilli) in the debrided tissue was 24 percent. Equally noteworthy hasbeen the infrequent recovery of streptococci and enterobacilli. Anotherinteresting finding has been the persistence of contaminating organisms inalmost three-fourths [71 percent] of the woundsafter debridement and irrigation.64
Early in the course of these studies, three cases of gasgangrene developed, and ultimately, there were seven cases of gas gangreneoccurring in patients who had received therapeutic penicillin. Six of the seven were in wounds in-
64Essential Technical Medical Data,European Theater of Operations, U.S Army, for May 1944, dated 14 June 1944. Inclosure 9, subject: Observations on the Prophylactic Use of Penicillinin the Wounds of Aerial Warfare.
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curred as a result of air combat or air crashes, and five ofthe seven had also received penicillin prophylactically at thetime of initial definitive treatment.
The occurrence of these cases, Colonel Cutler knew, wasvery significant since, at this time, many had high hopes that penicillin could forestall orprevent the serious complications of gas gangrene in war wounds. Penicillin in vitrohad exhibited a bacteriostaticeffect upon the organisms frequently associated with gas gangrene. Certainclostridial infections, experimentally induced in laboratory amimals, had alsobeen treated as well as prevented by the inoculation of penicillin. On the other hand,there were very little data on its effects on clinical gas gangrene.
At the first opportunity, Colonel Cutler presented a reporton the findings in the three early cases. This was at a meeting of the Section ofExperimental Medicine, Royal Society of Medicine, on 9 November1943. A final report of all seven cases was prepared by Colonel Cutler andCaptain Sandusky to accompany the reports of the other two studies-thoseof Colonel Schullinger and Colonel Morton. The early report and the final reportemphatically brought out that the use of penicillin in these cases had notprevented the development of gas gangrene.
The final report observed:
While it is unwise to draw conclusions from sosmall a group of cases, we are so impressed with the fact that outof seven cases of gas gangrene, only one proved fatal and two recovered without loss oflimb. [The fatality occurred after amputation as a result of uremia.Microscopically the kidneys showed hemoglobinuric nephrosis. At time of death,the local clostridial infection appeared to have been controlled.]
Equally impressive is the fact that of therecovered cases in no instance was a fatality apprehended. Eachof the seven patients had the benefit of early diagnosis, prompt surgicalextirpation of the infected tissue, therapeutic penicillin, large amounts of gasgangrene antitoxin and frequent blood transfusions. With so many factors tendingto influence the outcome,it is difficult to estimate the value of any single one. * * *
For the group as a whole one conclusion isobvious and outstanding: Penicillin used prophylactically in the manner hereindescribed did not prevent the development of gas gangrene. * * *
There can be little doubt but that penicillin iseffective against many of the organisms which are found amongst the multiplecontaminants in the wounds of battle casualties. Also a reduction in thedevitalizing and even destructive effects of such other organisms tends toprevent a suitable medium for growth of the clostridia. At the same time thissmall experience does not fall in line with published and confidential reports tous that "penicillin is extremely effective in gas gangrene."65
In addition to these experiments, Colonel Cutler hadinformation from many other sources, chiefly from the British. Ofparticular importance, in this respect, were meetings of the PenicillinClinical Trials Committee and the War Wounds Committee of the Medical Research Council. As early asthe 12 October 1943 meeting of the PenicillinTrials Committee, there was already information available to Colonel Cutler onthe results of penicillin used prophy-
65Essential TechnicalMedical Data, European Theater of Operations, U.S. Army, for May 1944, dated 14 June 1944. Inclosure 10, subject: Treatment of Clostridial Infections With Penicillin.
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lactically and therapeutically in actual combat, for muchof this meeting was spent in discussion of the Florey-Cairns report.66In a memorandum, dated 16 October 1943, Colonel Cutler wrote to ColonelKimbrough:
Professor Florey gave us a summary of thereportof the Penicillin Commission which recently visited North Africa and Sicily. Hemade it clear that experience in that area had shown that placing some 50,000units of penicillin even in aseptic wound as late as 3 days allowed a great percentage of the wounds to closeimmediately and prevented the occurrence of osteomyelitisin compound fractures. This report will be of the utmost importance to us, for thematter of dosage now assumes a major problem. Professor Florey reported thatcalcium salt was as a rule used in conjunction with a sulfonamide in soft part injuries,but that where fractures were present larger amounts were used up to 750,000 units,and here sodium salt is used.
While these efforts were being made to gain as muchinformation as possible as penicillin, Colonel Cutler also had to define the purposes forwhich it could be used, who could use it, and how it was to be used as greater amounts becameavailable.
The first "penicillin circular," prepared indraft by Colonel Cutler, was Circular Letter No. 176, Office of the ChiefSurgeon, ETOUSA, issued on 7 December 1943. The circular letter stated thatpenicillin was being issued to all general hospitals and the 49th and 121stStation Hospitals. It limited therapy to: (1) Patients suffering fromoverwhelming infections whose lives might be saved by the use of penicillin, (2)patients suffering from sulfonamide-resistant gonorrhea, and (3) patientssuffering from infections which, althoughnot immediately endangering life, manifested symptoms which did notrespond to the usual treatment. The selection of patients at hospitals supplied with penicillinwas made a responsibility of the commandingofficer. In hospitals not supplied with penicillin, commanding officers wereinstructed to request base section surgeons for permission to use penicillinin any particular case. If the request was approved, penicillin could beobtained from the nearest hospital supplied with it. The circular letterfurther stated that instructions regarding local and systemic administrationof penicillin would be issued, as necessary.
The instruction to using hospitals was, of course, given toindividuals concerned at the 2d General Hospital, as previously mentioned. Obviously, too,this extended use of penicillin provided an opportunity to expand the clinical studies being conducted atthe 2dGeneral Hospital, and, accordingly, elaborate laboratory checks and recordswere required.
The minutes of the 17 January 1944 conference of base sectionsurgeons state that Colonel Kimbrough made the following announcement at theconference:
The supply of penicillin has increased so that it hasbecome available for more general treatment. The plan now, and the Circular No. 6 has just been issued, is that a supply
66Preliminary Report to the War Office and the Medical Research Council, H. W. Florey and Hugh Cairns, October1943, subject: Investigations Concerning the Use of Penicillin in War Wounds.
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will be kept in all hospitals-field,evacuation, convalescent, station and general. The only check this office keeps on itis that all requisitions will be referred to the Chief Surgeon's Office forapproval.67
The still wider use of penicillin within the theater made itnecessary for Colonel Cutler to have the original penicillin circularchanged. This was accomplished by Circular Letter No. 22, Office of theChief Surgeon, ETOUSA, 8 February 1944, concerning penicillin therapy. The new circular rescindedthe former and designated the following conditions for which penicillin therapy could begiven:
1. Patients with serious infection, which willinclude injury and battle casualty cases as well as pneumonias, septicaemias,meningitides, etc., proven to be sulfa-resistant.
2. Patients with gonorrhea proven to besulfa-resistant,and patients with gonorrhea untreated by sulfonamides, the importanceof whose duties make it desirable that they should be absent from duty for theshortest period of time.
3. Patients suffering from chronic infections,usually osteomyelitis or prolonged wound sepsis, where the condition though notendangering life greatly prolongs convalescence.
It was now necessary to train nearly all of the medicalofficers in hospitals in the use of penicillin. Procedures to be used incarrying this out were announced by Colonel Kimbrough at a conference of basesection surgeons on 31 January 1944, as follows:
Previously our plan was to have * * * a newhospitalthat was authorized to use penicillin send personnel to the nearest general hospital to beindoctrinated. It has gone so far now that all the personnel of the station hospitalsneed some training and it seemsadvisable to have an officer from the Medical Service, Surgical Service, andLaboratory Service visit their nearest general hospital for maybe a day or two'sindoctrination in the methods of penicillin therapy. As a rule, all thegeneral hospitals have officers that are trained. Rather than have one officerresponsible for all penicillin, it was thought better tohave medical, surgical, and laboratory officers. I was trying to avoid havingpenicillin put out to hospitals whose personnel were not familiar with its use and laboratory check.
Commenting on this statement, General Hawley warned:
The conditions for which penicillin can be usedin this theater are very definitely laid down. I am going to take very severeandvery summary action against any medical officer and any hospital commanderand the Chief of Service that wastes stocks of penicillin in personalexperimentation: I do not want any mistake about that. We need all thepenicillin we can get for the use for which we have authorized it.
Assured by Colonel Kimbrough that the selection of cases hadbeen definitely stipulated, the Chief Surgeon continued:
Professional policies are laid down by this officeand will be carried out. We have got the best professional advice in the worldand that is the way we are going to practice medicine in this theater.
With so many medical officers who would now be usingpenicillin receiving instruction from various sources, it was evident, thistime, that a statement of official policy on methods of therapy wasnecessary. In consideration of this
67Circular No. 6 pertained to the extension of penicillintreatment for sulfonamide-resistant gonorrhea.
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need, the Chief Consultant in Surgery submitted thefollowing instructions on the local and parenteral treatment of woundswhich were included in the aforementioned new directive Circular LetterNo. 22.
Methods of therapy
* * * * * * *(2) Local and general therapy * * *
(a) Make aerobic and anaerobic cultures of thewoundbefore and after debridement.
1. All debrided tissue will be placed in a sterile jarand sent to the laboratory for study * * *.
2. After debridement and irrigation, wound to be swabbed with cotton swab which should be sent to laboratory for making cultures * * *.
(b) The debridement should be conservativewith respect to living tissues particularly skin and bone fragments.
(c) Irrigate the wound thoroughly withphysiological salt solution at body temperature during and at the endof debridement; penicillin works best in a slightly alkaline medium.
(d) Penicillin will be provided as a powder in ampulesof 10,000 units or 100,000 units each.
(e) Local use of penicillin: For localuse in wounds10,000 units are dissolved in 10 cc. of sterile physiological salt solution, (strength 1,000units per cc.).
1. For small wounds of the soft parts 5,000 units aresprayed into the wound.
2. For wounds of medium size 10,000 units should be used in the same manner.
3. For wounds of large size 20,000 units are similarly employed.
4. For compound fractures of the large bones the dose should be from 30,000 to 60,000 units * * *.
(f) After debridement and treatment withpenicillin, the wound may be closed by primary suture, by secondary suture, orleft open as circumstances warrant.
(g) Parenteral use of penicillin: Forparenteral use,10,000 units of penicillin are dissolved in one (1) cc. of physiologicalsalt solution immediately before injection * * *.
1. For small wounds of the soft parts and medium sized wounds with little contamination, no parenteral use ofpenicillin is necessary.
2. In large wounds, incompound fractures, and inbadly contaminated wounds of any size, the patient should receive 20,000units intramuscularly every three (3) hours for two (2) days.
(h) If the wound has been left open followingdebridement,as in a compound fracture, the initial treatment of the wound withpenicillin is followed by further penicillin sprayed into the wound as wellas by intramuscular injection * * *. The wound dosage in such cases is 5,000units sprayed twice a day.
(i) For wounds in the vicinity of the anus, buttocks,perineum, upper inner side of thigh and lower back, the standard dosageshould be doubled.
(j) The initial dressing of the wound should be ample insize and well secured. Frequent changes of dressing are undesirable because ofthe risk of secondary contamination.
(k) In solution, penicillin deteriorates rapidly. It shouldbe freshly prepared before each use. It is unfavorably affected by heat inboth powder and liquid form and should be kept in the refrigerator or in thecoolest place available. The solution will remain potent however, for 5 or 6 days, if prepared under aseptic conditions and kept in the refrigerator.
(l) Penicillin is a bacteriostatic agent and not abactericide. It is excreted rapidly in the urine; fluids, therefore, should bemoderately restricted unless other considerations preclude this measure.
(m) Penicillin affects particularly staphylococci,streptococci, gonococci, meningococci, pneumonococci and the clostridii. Itis most effective in unmixed infections. It does not affect the colon group ofgram negative organisms, the diphtheroids nor pyocyanus.
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(n) Sensitivity and bacteriostatic tests must be carriedout in every case.
(o) Records. All observations of woundstreated with penicillin will be recorded on the forms provided, in order todetermine applicability of this drug in the treatment of war wounds.* * * All three forms will become part of the Clinical Record of the patient.
(p) All clostridii isolated in bacteriologicallaboratories at station or general hospitals * * * will be sent to the 1stGeneral Medical Laboratory for final identification.
(q) Laboratory instructions, wound treatment. Theseinstructions may be obtained from the Office of the Chief Surgeon * * *.
As the second long English winter ended for the ChiefConsultant in Surgery, there was no doubt that the new spring wouldfinally see an invasion of the Continent by the Allies. The production ofpenicillin at home had been stepped up tremendously.The shipment to the European theater for the month of March was500,000,000 units. There were indications that this would be increased soon to 3,000,000,000units. Other sources had said that the supply was now unlimited. Col. Silas B.Hays, MC, the new theater medical supplyofficer, said at the conference of base section surgeons on 13 March 1944: "In fact Iwould not be at all surprised if by the summer time we don't get too muchpenicillin."
In spite of the great amount of data on penicillin nowavailable, much of it was tentative and some of it, contradictory. Current instructionson the use of penicillin were obviously neither intended for, nor applicable to, a combatsituation. But what were the instructions to be? This question was of constantconcern to ColonelCutler, and there was not much time left. In a memorandum, dated 3April 1944, he wrote the following to Colonel Kimbrough:
On 29 March 1944, I held a meeting in the Office of theChief Surgeon of a group consisting of Colonel Schullinger, Colonel Morton andmyself in order to discuss the present situation of penicillin in this theater.
In particular we met to discuss the materialbeing assembled for publication in the British Journal of Surgery.
* * * * * * *The Committee took up further the matter ofrevisingour penicillin circular. This is much too bulky and demands too muchfor actual battle conditions, and by the time we have the next meeting we musthave a simple circular telling the surgeon just how much penicillin to put in the wound, andwe must rid ourselves ofelaborate laboratory tests. Such a circular is now being drawn up.
And, on 10 April 1944, he wrote to Colonel Morton:
I have sent you a copy of the Florey & Cairns report.There is no one here much to help you with gas gangrene, though if we canarrange some kind of a meeting with MacLennan, who is back from the Mediterraneannow, I will see you are implicated.
* * * * * * *We will call another meeting about the end of themonth, but before then harden your mind as to exactly what you wishto put in a circular covering the use of penicillin in Army hospitals. My own ideas are crystallized asfollows:
a. It will not be used in small wounds.
b. In large wounds of soft parts 20,000 unitswill be givenin some suitable vehicle, and I presume this will have to be sulphanilamide.
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c. In all fractures we will lift the dose to 40,000units.
d. I am dubious about additional dosage byintramuscular injection, but perhaps we should attempt it, and you must specify overhow many doses this is to be used.
The meeting alluded to was convened on 18 April. In hisdiary, Colonel Cutler noted that he worked with Colonel Schullinger on thepenicillin directive and with Colonel Morton on the gas gangrene directive. Buthe informed Colonel Kimbrough by memorandum on 22 April 1944:
18 and 19 April was put in mostly working onpenicillin, the greater part of the time with Lieutenant ColonelsSchullinger and Morton.
* * * * * * *Attached to this is a fairly final draft ofthe use ofpenicillin for battle casualties as it will be incorporated in theprofessional directive now being drawn up for our combat forces. In general Iwould like to state that we have presented in this document the optimum method;that is, we begin the parenteraluse of penicillin as far forward as it seems possible to get the drug and wecontinue it for as long a period as we think ideally necessary. In addition, we placepenicillin in the wound. I have heard that theU.S. Army in Italy is not using penicillin in the wound and I believe we have reachedthat point in our knowledge of this agent where we can say it is best used as arethe sulfonamides; that is, by maintaining an adequate blood level which can bedone withoutplacing penicillin in the wound. However, if we do not limit our thinking to terms ofthe supply of the agent, then the method cited inour draft is optimum. Note that if we utilize penicillin as outlined the amount of drug requiredruns in to astronomical figures.
a. Each soft part injury requires 420,000units.
b. Each compound fracture, 580,000 units, andboth ofthese amounts are doubled when the wound is about the perineum orbuttocks.
c. If we take 6,000 injuries per day, which onemight say is 1,000 casualties a day from each of 6 divisions, onecorps of a 3 corps army in fighting, then the requirements would be,for 4,000 soft part injuries 1,680,000,000 units, and for 2,000 fractures1,160,000,000 units, or a total of 2,840,000,000 units, and if 10 percent of the caseswere wounds of the buttock, upper thigh or perineum,i.e. 600 cases, in which the dose would be double, then these 600cases would need roughly 300,000,000 units or a total daily demand of3,140,000,000 units. This for one month would mean 94,200,000,000 units which wouldmean 940,000 vials. Recommend that you transmit a demand for at least 75,000,000,000units per month, once operations commence.
We believe there is no contradiction to, andindeeddesire that sulfonamide therapy continue at the same time as penicillin therapy.
In addition to the recommendations made on theattached draft concerning penicillin in the Army, we are now revamping the circular forthe use of penicillin in S.O.S.installations.
On the same day, recommendations for the treatment of gasgangrene were also submitted in final form. Both the penicillin and gas gangrenestatements were included in Circular Letter No. 71, Office of the ChiefSurgeon, ETOUSA, dealing with the treatment of battle casualties in the combatzone (appendix B, paragraphs 7 and 10). These instructions were publishedon 15 May 1944, not any too soon, and only 3 weeks before D-day. The importantfact, however, is that the necessary decisions had been made and the command hadbeen informed. Moreover, the decision had been independently made. The British,at this time, had not yet hardened their minds as to what their policies wouldbe for the use of penicillin in the continental invasion.
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Status of the blood bank
A question asked on more than one occasion by the ChiefSurgeon during this period was: "What is the status of the blood bank?"
And therein lies the clue to activities at this time in thefield of transfusion and resuscitation for the Chief Consultant in Surgery,ETOUSA. Unlike penicillin, facts in the case had been assembled, and he hadmade his recommendations. He had determined that probably 1 out of every 10casualties would require parenteral fluids for resuscitation and that theproportion of plasma to whole blood used would be about two to one. Instructionshad been issued to begin making some 350 field transfusion kits of theEbert-Emerson type, and their assembly had begun. The Chief Surgeon had decidedthat whole blood would not be procured from the Zone of Interior,which left only one alternative-to provide for supplemental sources ofwhole blood within the theater itself.
The problem at this stage was to present the overallobjectives to the theater commander for his approval, since the planinvolved all elements of the command. Following approval of the plan, ifgranted, there would be an enormous amount of staff work to set up and establishthe desired organization for the whole blood service, obtain the personnel and equipment, andgain further approval for specific operationsinvolving elements other than the medical. In other words, the problem was no longer primarily professional. It was now a matter ofoperations andsupply. Accordingly, the guiding force in establishing a whole blood servicedevolved upon Lt. Col. (later Col.) James B. Mason, MC, of the Operations andTraining Division, Office of the Chief Surgeon (fig. 56). Later, Lt. Col.(later Col.) Angvald Vickoren, MC (fig. 57) , replaced ColonelMason in this responsibility. Initially, the supply aspects of the problemfell upon Col. Walter L. Perry, MC, then the theater medical supply officer.
Actually, much of the work on this project was done incommittee fashion with Colonel Cutler representing the professional services;Colonel Perry, medical supply; Colonel Mason, operations; Lt. Col. Ralph S.Muckenfuss, MC, the 1st Medical General Laboratory; and Captain Hardin,transfusion and resuscitation. Obviously, efforts of the operations and supplyofficers would have been limited without the "ammunition" andadvice provided by the professional members of this committee.
The first meeting of this group was on 19 August 1943. Inaddition to those mentioned above, Lt. Col. Ambrose H. Storck, MC, thenSenior Consultant in General Surgery, also attended. The purpose of themeeting was to consider the matter of implementing the supply of whole blood and the entireproblem of blood transfusion for the Europeantheater. Colonel Cutler's report of the meeting mentioned certain points, substantially asfollows:
1. After full discussion of the present transfusion fieldkit set originally laid down by Majors Ebert and Emerson, of the 5thGeneral Hospital, it was
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decided to place with each kit issued a printed list ofinstructions of its use. In this instruction sheet it will appear that 50 cc.of 2.5 percent sodium citrate should be added to 400 cc. of whole blood,giving a final concentration of sodium citrate of 0.27 percent. Colonel Perrybelieves he can now implement the securing of a sufficient number of thesesets for our requirements.
2. The securing of whole blood in the SOS and its transportto combat forces on the Continent.
a. Source of blood. The source is to be SOS troops andlightly wounded and the ground personnel of the Air Force (about 40 percentof American troops are in Group O and are therefore satisfactory donors).The source above should be ample for our requirements.
FIGURE 56.-Col. James B. Mason, MC.
b. The giving of blood by the above troops should be compulsory(General Lee).
c. Collection of blood. This requires mobile units with arefrigeration plant for 120 pints. It is suggested we use 1?-tontrucks. Personnel and T/BA of these mobile bleeding units already laid down andin the hands of Colonel Mason, and copies to be given to Colonel Muckenfuss.
d. Storage. This should be at 1st Medical GeneralLaboratory. The refrigerator plant should be the large Navy refrigeratorsalready acquired by Medical Supply. We should need 2,000 pints in storage and should be prepared to supply 200 pints per day tothe Army. The GeneralMedical Laboratory will need: (1) Storage space, (2) cleaning space, and (3)personnel for cleaning. They will require 2,000 bleeding sets, 5,000bottles, and 5,000 giving sets.
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e. Delivery to the Army. Delivery from the laboratory to theArmy should be by air in iced or Thermos containers. Colonel Perry isto look into the supply of these and Colonel Mason should make contact with the Air Force forthe privilege of using such planes.
f. During delivery from the Army Medical Depot to the Armyhospitals the blood will be kept in iced or Thermos containers. Theresponsibility for the returning of giving sets, bottles, and containers will bethat of the Army surgeon.
g. None of this program should be implemented unlessfirst priorities can be secured for the handling of such a precious and vital material aswhole blood. This includes items of collection, storage,transportation, and return of vitally important apparatus to thelaboratory for cleaning and reuse.
FIGURE 57.-Col. Angvald Vickoren, MC.
On 24 August, Colonel Cutler and Colonel Mason visitedWidewing, Eighth Air Force headquarters, for exploratory talks on the flying ofblood to the Continent. At a conference on 20 September, Colonel Mason was requested bythe Chief Surgeon to prepare with the least delay for submission to the Chief of Operations, SOS,details of plans for the whole blood service. After informing the medical supply officer ofthis requirement, Colonel Perry informed Colonel Mason that all necessary supplieswere available in the theater except vehicles to be converted into refrigerated trucks.These, after Captain Hardin had checked over all types of vehicles foradaptability, were 2?-ton,6 x 6, short-wheel-based cargo trucks. Colonel Perry initiated requests throughthe theater Chief of Ordnance to the Zone of Interior for 30of these trucks. (Later, four additional trucks of this type were requested.)Provision of these trucks became known, in supply parlance, as Project GS22 and GS 22 Supplemental.
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In addition, Colonel Muckenfuss and Captain Hardin wereasked to prepare a paper which would show the entire project in detail. This they didwith their paper broken down into the following sections:Operating procedures, volunteer blood panel, estimate of requirements,operating agencies, the blood collection section of the base blood depot, the laboratorysection of the base blood depot, distribution during theassault phase, personnel requirements, and necessary organic equipment.
Their report showed that 200 pints of blood per day would be requiredduring the period from D-day to D+90 and that the whole blood service could collect 600 pints per day as a maximum.Beginning at about D-7, they estimated that 3,000 pints of blood could becollected by D-day. Following that, they contemplated maintaining a levelof 1,000 pints at the base blood depot and 200 pints in advanced blooddepots.
It was proposed that each SOS unit would maintain currentlists of volunteer donors. Each SOS unit would report monthly the number ofdonors available to their base section commanders who, inturn, would consolidate these reports and notify the Chief Surgeon of thetotal number of donors available in their areas. The sum total of thesevolunteers would be known as the ETO Volunteer Blood Panel.
The operating agencies of the whole blood service wereto consist of a headquarters section located at the 1st Medical GeneralLaboratory, a base blood depot, and advanced blood depots. The headquarterswould include the director of the whole blood service; aMedical Administrative Corps or Sanitary Corps officer in charge ofadministration, records, and supply; and clerks, orderlies, drivers, andautomotive and refrigeration mechanics.
Under the headquarters, there would be a base blooddepot with four bleeding teams and a laboratory section. The base blooddepot was to be located at the 1st Medical General Laboratory with additional refrigerators at the5th General Hospital for emergency storage and dispersion. The blood collectingsection was to be composed of fourbleeding teams, each having one Medical Corps officer and seven enlisted menwith a refrigerated truck and other equipment necessary to operate mobilebleeding stations. The laboratory section was to recondition, clean, assemble,and sterilize equipment; process and store the blood; and prepare blood for shipment. One officer,an expert in transfusion and resuscitation, was to head the laboratory serviceand the base blood depot. He was to have 33 enlisted men to operate the washing room;the assembly room; thesupply, still, and sterilizer facilities; the glassblowing and needle-sharpening facilities;the blood-processing facilities; and therefrigerators.
Contemplated for the other side of the channel were advanced blood depots to be attached toarmies and those to be attached tocommunications zones. The functions of advance blood depots were solelyto store and distribute blood under the supervision of the army orcommunications zone medical supply depot to which they would be attached.The primary difference between an army type of unit and a communications zone type ofunit was that, in the former, there
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were to be eight refrigerated trucks and, in the latter, only four. In addition to the refrigerated trucks, eachunit was to have an unmounted storage refrigerator.
The operation of each of these agencies was described inminute detail, as well as proposals for operating the service during the initial phase of the attack on theContinent.
Needless to say, preparation of a document of this sort,accompanied by charts and figures, required time. An equally lengthyperiod was required by the Operations Division, Office of the Chief Surgeon, toreview, revise, and dress it up for formal presentation insufficient copies.
In order to submit the proposed plan, Colonel Masonrequired a succinct statement as to why it was so essential, and heasked Colonel Cutler for this "ammunition." On 15 November 1943Colonel Cutler provided Colonel Mason the following statement concerning thewhole blood service in the European theater:
2. The evidence that whole blood is valuable incaringfor battle casualties seems completely established.
a. We have the analysis of 30,000 givings ofblood fromthe British North African campaigns. In these campaigns blood was drawn in Cairo,flown to forward areas and delivered byrefrigerated trucks to forward medical units.
b. We have evidence that certain casessuffering from severe blood loss can only be saved by restoration of the volume throughwhole blood. Plasma alone may prove insufficient, and has been provenso by physiological experimentation was well as by clinical trial.
c. The Russian and British armies have a setup similar tothat proposed.
d. Correspondence with our own medical units in theNorth African campaign shows that the forward medical units greatly desireblood in addition to plasma and some observers felt lives could have been savedhad blood been supplied in sufficient quantity.
e. Direct communications from British officers follow:
From General Ogilvie,Consulting Surgeon, BritishM.E.F.: "Blood is being used more frequently, earlier and further forward. Bloodtransfusions save more useful lives than ever before."
From Colonel Porritt: "The best thing in the Britishmedical services in North Africa was the Blood Transfusion Service."
On the same day that he submitted the foregoing information, Colonel Cutler alsowrote to the chief of the OperationsDivision, Office of the Chief Surgeon, substantially as follows:
1. I am worried what might happen in this theater ifa big attack started and great quantities of wounded people were brought tothis island and our blood bank was not working.
2. Should we set up blood banks in station hospitals aswell as in general hospitals now, or can we count upon our blood bank'ssupplying station hospitals with blood, should the necessity arise?
Colonel Mason assured Colonel Cutler that the distributionplan for whole blood provided for the emergency supply to station and general hospitals in theUnited Kingdom.
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He also indicated that it was probable that each hospital could provideenough blood for transfusion from donorsavailable in and about the hospital. Authorization of the Blood Panel, ETOUSA,and command arrangements for shipping, Colonel Mason stated,were being handled in the London office. As of that date, Col. ThomasJ. Hartford, MC, had not sent out the letters to the Commanding General,SOS, although he had indicated this would be done in the very nearfuture. Colonel Mason added that he would like to discuss with ColonelCutler the matter of the supply of blood to SOS units in the United Kingdom atColonel Cutler's earliest convenience.
The matter of supplying blood to SOS units in the UnitedKingdom was settled most opportunely at a later date. Meanwhile, General Hawleyhad submitted his recommendations (based on information submitted by the whole blood committee) for awhole bloodservice for the theater, as follows:
1. The problem To furnish fresh, whole bloodfor transfusion of battle casualties as far forward as division clearingstations.
2. Facts bearing upon the problem a The experienceof the British and Russian Armies, as well as the experience of U.S.forces on all fighting fronts, is that dried plasma meets the requirements ofonly about two-thirds of all cases requiring replacement of blood volume.
b One-third of all battle casualties requiring replacementof blood volume must have whole blood as well as plasma.
c Early transfusion with whole blood in manycases greatly reduces the time spent in hospital and hastens the restoration ofthe casualty to full duty.
d A small amount of whole blood is available"on the hoof" in all medical installations; but this cannot meet therequirements for the following reasons:
(1) It must be typed under field conditions which favor inaccuracy, and death may result from giving unmatched blood.
(2) No tests can be made for syphilis and other communicable diseases; and the battle casualty may be given a disease by such transfusions.
(3) The efficiency of duty personnel is greatly reduced when they must donate blood.
e Fresh blood can be collected in the SOS, processed,stored and delivered to frontline divisions in small trucks carryingrefrigerators.
f A total of 1 officer and 22 enlisted men,and 8 2?-ton trucks, 2 motorcycles and one ?-ton car will be required foreach field army. All necessary personnel and equipment is already on hand in theTheater and the troop basis will not be increased.
3. Recommendations a That the policy offurnishing refrigerated whole blood to medical units as far forward as divisionclearing stations, inclusive, be established in this Theater.
b That each army commander be informed that the necessary personnel and equipment * * * will be attached to the medical depot assigned to his army * * *.
c That all agencies transporting supplies be directedthat refrigerated whole blood will be shipped on thehighest priority.68
Following approval of the plan by the Commanding General, SOS,and the theater commander, the basis for the whole bloodservice was firmly established with instructions to the Commanding General, FirstU.S. Army Group, and
68Memorandum, Brig. Gen. P. R. Hawley to Commanding General, SOS, ETOUSA, 26 Nov. 1943, subject: Provision of WholeBlood for Battle Casualties.
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instructions from the Commanding General, SOS, toset up the ETOUSA blood panel.
The command letter, dated 2 January 1944, from Lt. Gen. (laterGen.) Jacob L. Devers, Commanding General, ETOUSA, to the Commanding General, First U.S. Army Group,contained the following statement:
1. The provision of whole blood for thetreatmentof casualties in this theater, throughout all echelons down to and includingdivision clearing stations, is approved.
2. Whole blood will be an item of medicalsupply and will be distributed through medical supply channels. It will be giventhe highest priority in transportation.
3. * * * personnel and special equipment will befurnished to each Army without requisition from sources available to theCommanding General, SOS, ETOUSA, * * *.
The ETOUSA blood panel was established by a command letterfrom Maj. Gen. John C. H. Lee's SOS headquarters, on 6 January 1944. Thesubstance of the letter was as follows:
1. The establishment of a blood panel for thetheater, to furnish whole blood in the treatment of casualties, has beenapproved by the theater commander.
2. It is desired that:
a. In each unit of the SOS, a nominal list ofvolunteer donors of TYPE O be prepared and retained in the unit headquarters.
b. A record of the number of TYPE Ovolunteers, by unit, in your command be maintained in your headquarters.
c. The records required by subparagraphs a andb be corrected as of the 15th of each month; and, immediately following eachsuch correction, a report of the number of TYPE O donors in each unit ofthe SOS in your command be sent to the Commanding Officer, Blood Bank,ETOUSA, 1st General Medical Laboratory.
d. Upon call of the Commanding Officer, BloodBank, ETOUSA, the volunteer TYPE O donors of the unit specified beassembled at a designated bleeding station (ordinarily the unit dispensary) atan hour, to be determined by you, which will not seriously interfere with thenormal duties of the unit and which will be reasonably convenient for thebleeding team.
e. Only light duty be requiredof donors from the time of bleeding until reveille the following morning.
3. The general rule will be that four-fifths ofa pint of blood will be taken at each bleeding, and that donors will not be bledoftener than once in each 3 months. This amount of bleeding will have no ill effectupon any donor and will neither reduce his physical capacity for work norpredispose him to illness.
4. Your active interest in obtaining as manyvolunteersas possible is enjoined.
As slow and ponderous as progress on the project might haveseemed, there was no doubt that it was being carefullyand thoroughly established. Colonel Cutler was pleased with the workbeing done and must have felt considerable pride in seeing whathad been but a year before an idea of his maturing into a full-fledgedtheaterwide operation. After one apparently most satisfactory conference withGeneral Hawley on the whole blood service, he wrote in his diary: "Blood projectOK. Hope I got Jim Mason promoted."
The groundwork having been laid, there was still much to beaccomplished before the whole blood service could be areality. There was the question of how to provide the manpower for the service,and opinion varied between merely augmenting the 1stMedical General Laboratory or using a separate
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unit. The decision was made on the latter and a specialtable of distribution was made up for the 152d Station Hospital, whichbecame the Blood Bank, ETOUSA. In December, both Colonel Mason and ColonelCutler urged that it was high time to appoint an officer to be in charge of thewhole blood service and command the 152d Station Hospital. Some names weresuggested, but none proved acceptable for various reasons. The only positionon which there was complete agreement was that Captain Hardin should bein charge of the base blood depot and the laboratory and bleeding sections underit. Eventually, Colonel Muckenfuss was placed in charge of the whole blood serviceand in command of the 152d Station Hospital. This was in addition to his duties asthe commanding officer of the 1st Medical General Laboratory and as the theaterconsultant on laboratories. Since the headquarters and base blood depot of thewhole blood service wereto be located physically within the premises of the 1st Medical GeneralLaboratory, and, since there would be no need to move either the wholeblood service headquarters or the 1st Medical General Laboratory soon after theinvasion, the choice was reasonable. Moreover, Colonel Muckenfuss had been acting, forall intents and purposes, as the head of the whole blood service up until this time. Thesearrangements solved the personnel aspects of establishing the blood project.
In late December 1943, not long after initiating the requestfor trucks, Colonel Perry had been notified by a message from PEMBARK, the NewYork oversea supply depot, that the trucks, as requested, had beenapproved and that 12 trucks were at the port awaiting shipment and the otherssoon would follow.
On 31 January 1944, General Hawley asked at the meeting ofbase section surgeons: "What is the status of the blood bank?"
Colonel Kimbrough, replying to the questions, said:"The last report they were 10 days from having the construction done-thatwas a week ago. The equipment is almost in. Refrigeratorsare frozen, allocated but not delivered. The people are there under thedirection of Colonel Muckenfuss on the administration side, and CaptainHardin is carrying out the professional side. They have not called on usfor any more personnel."
Two weeks later, at the 14 February 1944 conference of base section surgeons, GeneralHawley again asked: "What is thestatus of the blood bank?" This time, he added: "When are theygoing to be ready to start some bleeding?"
Colonel Kimbrough said that the physical plant waspractically complete and that they should be able to begin bleeding at anearly date (fig. 58). Lt. Col. (later Col.) Raymond E. Duke, MC, OperationsDivision, Office of the Chief Surgeon, said that, according to ColonelMuckenfuss, they should be ready to go within 2 weeks.
The bottleneck was in trucks and refrigerators. Anincoming message from PEMBARK, 16 March 1944, said that the 30 trucksrequested on project GS 22 were in port and were expected to go forward soonand that the four trucks requested in project GS 22 Supplemental were also inport and were
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expected to be shipped soon. It was disheartening to learn at this latedate that the vehicles were still awaiting shipping. But Colonel Vickoren, with keen foresight, hadanticipatedsuch an outcome. PEMBARK had said in December 1943 that 12 trucks wereready to be shipped. As these had not arrived by the end of February1944, Colonel Vickoren arranged to "borrow" 12 similar trucks fromOrdnance maintenance stocks in the theater which were to be repaid by the 12 atNew York when they arrived. These 12 were received from the theater Ordnance stocks latein March. When surveillance of the manifests revealed that none of the trucksfrom New York were onboard any ships due to arrive soon, Colonel Vickoren requested that theremaining 22 trucks be supplied from Ordnance maintenance stocks. In therequest, he stated: "These trucks are urgently needed, asapproximately three (3) weeks' time is required to install refrigerators in these trucks afterdelivery is effected. The European theater blood bank cannot function withoutthis vehicular equipment, yet each unitmust be completely equipped prior to start of operations."69
69Memorandum, Chief Surgeon, European Theater ofOperations, U.S. Army (by Lt. Col. A. Vickoren, MC), to G-4, G-3,Chief of Ordnance, Services of Supply, European Theater of Operations, U.S.Army, 18 Apr. 1944, subject: Vehicles for E.T.O. Blood Bank.
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The story was the same with the refrigerators. They wereapproved and available on paper but could not be gotten physically. It was notuntil mid-February that the first refrigerators were received, but a relativelysteady trickle continued to be received thereafter. Even at three per week,however, this represented four-fifths of the output of the British supplier. Theremainder was being used by the British for maintenance of existing equipment.The delay in obtaining the original shipment was due to demands fromactive theaters.
At this time, when it appeared that the barest needs forestablishing a whole blood service to support one army in the field seemedassured, Col. Thomas J. Hartford, MC, Executive Officer in the Office ofthe Chief Surgeon, London, returned from North Africa and Italy with somestartling details. Certain of these bothered General Hawley and, in a memorandumto his Professional Services Division, on 28 March 1944, he wrotethe following:
1. * * *
b. This not to be discussed outside the Division. Lessand less reliance is being placed upon plasma. Plasma seems to be quiteeffective if nothing is done to the patient afterwards, includingtransportation. But, if the patient is operated [on,] or if he is placed in anambulance and moved, if he has had only plasma he relapses rapidly into shock.
In the early days of the campaign, one pint of whole bloodwas used for each eight casualties. Now, one pint of whole blood is usedfor each 2.2 casualties (fig. 59).
* * * * * * *2. The increasing use of whole blood makes me concerned aboutthe capacity of our own blood bank.
We cannot count upon an average useful life of more than 10days for whole blood. I am informed that, under the best conditions, we cannotdeliver whole blood to the front in less than 4 days after procurement. Thismeans that an average life of usable whole blood is not more than 6 days;and, to be safe, we should not count on more than 5 days.
This, in turn, means that the blood bank must be able toreplace the total demands for blood at the front every 5 days.
Can it do it?
Colonel Kimbrough optimistically replied that plans werebeing made to furnish whole blood in the ratio mentioned and that the bloodbank would be able to replace whole blood in the time and amount required.Colonel Liston, acting for General Hawley while the latter was in the UnitedStates, insisted, however, that a firm figure for planning purposes be providedof the ratio of whole blood required to the number of casualties.
The problem was put to Colonel Cutler, who advised asfollows:
British plans (from talk with Colonel Benstead in officeof Major General Poole, British War Office, 6 April 1944)
1. Original British planning after North Africancampaign was that 1 in every 10 casualties would require fluidreplacement including blood. When this is necessary, give 1 pint bloodand 2 pints plasma-repeat S.O.S.
2. Recent planning calls for greater use of blood. ColonelBoyd who was in charge of British Medical Blood Banks, favors 1.5 pints forevery 10 casualties.
U.S. Army plans
1. Originally we planned as in paragraph 1 [Under Britishplans], 1 pint for every 10 casualties, supplemented with plasma.
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2. Colonel Hartford, recently returned from Italy and NorthAfrica, brings back use of blood after establishment of blood bank at Naples inArmy Med. Lab.
Recent 5th Army beachhead statistics show: U.S. Forces used 1pint blood to each 1.85 casualties, British used 1 pint blood to each 2.79casualties. Total 5th Army statistics equal 15,000 casualties, show use of 1pint of blood to each 2.2 casualties (this is field hospital andevacuation hospitals).
Comment: (1) Note Colonel Hartford's figures are forpintsused, not blood per casualty. Thus, if 2 pints per casualty, it would be atfollowing rate: blood would be required by each 4.4 casualty.
(2) In Italy donors are paid $10 per bleeding.
Recommend: U.S. Army E.T.O. Blood Bank be equipped to supplycombat force with whole blood at rate 1 pint for every 5th casualty.70
While this recommendation and the logic by which it wasattained might appear to be not entirely satisfactory, the fact of thematter was that the demand for a new planning ratio was merely anacademic question at this time. It was obvious enough that the originalobjective of one pint of blood for every 10 casualties was going to be difficultto realize. Moreover, it had been necessary for the Commanding General, SOS,ETOUSA, to issue another command letter, on 6 April 1944, notifying SOSsubordinate commanders that the number of donors had fallen far short ofexpectations and requirements and that action would be taken to increase thenumber of whole blood donors.
On the brighter side of the picture, however, were thesefactors. When Colonel Cutler had visited the blood bank on 31 March 1944 todiscuss the possible extension of blood production, he had learned that six ofthe large walk-in type of storage refrigerators had been installed at the 1stMedical General Laboratory and were ready for use. Eleven trucks had been fittedwith refrigerators and were also ready for use. And, with these facilitiesavailable, the blood bank was ready to engage in trial distributions of blood tothe East Anglia area as an experiment-to ascertain how the service wasactually going to function. Colonel Cutler noted, too, with pleasure, thatCaptain Hardin had finally been promoted to major.
Arrangements for the air delivery of blood to the Continenthad long since been completed by Colonel Mason. In conferene with Col. Edward J.Kendricks, MC, Surgeon, Ninth U.S. Air Force, Colonel Masonhad obtained complete agreement on the following procedures: (1) Troop carrieraircraft from the Ninth Air Force would deliver blood from the vicinity of thebase blood depot to the vicinity of the army medical supply depot on theContinent, (2) an enlisted man from the base blood depot could accompany ashipment of blood to insure proper handling and delivery, and (3) aircraft wouldreturn empty containers and equipment from the far shore and bring back the
70(1) Memorandum, Col. E. C. Cutler, MC, to Col. J. C.Kimbrough, MC, 7 Apr. 1944, subject: Demands for Whole Blood. (2) "If the full truth be told,it was not until fighting was well under way that the consultants discoveredthat their estimates on the amount of blood needed were far too low. Until thattime, they had thought that the capacity of the ETO blood bank would besufficient." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr.,MC, 17 Sept. 1958.)
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FIGURE 60.-Bottled whole blood from the Blood Bank, ETOUSA, ready for delivery or storage.
enlisted men who had accompanied the blood shipments.Colonel Kendricks also revealed the encouraging note that the Troop CarrierCommand of the Ninth Air Force was quite familiar with the transportation of blood, since they had transported blood forthe British Eighth Army during the North African campaign.
As D-day approached, there was no longer any doubt that thewhole blood service was ready and able to conduct its initial missionof supplying whole blood in support of the invasion of the Continent (fig.60).
While the whole blood service was being developed in thismanner, there were also significant development in the matter oftransfusion sets for "bleeding on the hoof."
Individuals in the Office of The Surgeon General saw certain difficulties and undesirable characteristicsin the Emerson-Ebert transfusion unit, when they received details of the set. They realizedthatit had been devised with consideration for material available in the theaterand for use, possibly, in areas forward of hospitals where autoclavingfacilities would not be available. But they did not believe that directionsgiven for cleansing and sterilizing the set would eliminate pyrogens andcontaminants. The special representative to The Surgeon General ontransfusions and intravenous solutions, Lt. Col. (later Col.) Douglas B.Kendrick, Jr., MC, suggested that it might be better
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to follow the system using empty plasma containers asdescribed in Circular Letter No. 108, Office of The Surgeon General, 1943.The ideal solution to the problem, he suggested, was the expendable vacuumbottles and expendable recipient sets with filters, which were beingproposed as regular medical supply items. Unfortunately, however, theserecommendations could not be applied until the necessary equipment could beobtained.71
There were disadvantages, too, to the method recommended byThe Surgeon General in Circular Letter No. 108, 27 May 1943, utilizing thedried plasma apparatus. Major Emerson brought these to Colonel Cutler'sattention. The objections were pointed out in a memorandum, dated 27 Sept. 1943,to Maj. (later Lt. Col.) Michael E. DeBakey, MC, in the Surgeon General'sOffice, and included the following: (1) Cross-matching, as recommended, wasnot feasible with equipment available in the field, (2) the open technique wasliable, in the field, to introduce appreciable amounts of foreign matter intothe blood, (3) the type of airway in the apparatus would cause air pressurein the bottle to be below atmospheric pressure, and this, plus a layer of glassbeads, two needles, and filter, would materially limit the rate at whichblood could be administered, and (4) the material and equipment required for thecleaning and sterilization procedures recommended would not always be availablein the field. The primary objection, however, was to the fact that only300-cc. flasks of dried plasma were available in the European theater and whenthese were used for collecting sets with the requisite introduction of 50cc. of citrate solution, the amount of blood collected would scarcely make theeffort worthwhile.
In view of this situation, Major Emerson was detached tothe medical supply depot at Thatcham, England, with enlisted men to helphim, and continued to assemble the transfusion units devised by him and MajorEbert. Some 800 sets of instruction were printed to go into the unit packing,which eventually was done in used .50 caliber ammunition cases repainted tomedical standards with the Geneva Cross. A 25-minute training film in color wasalso made to show how the transfusion kit was to be used. With only minorproblems of obtaining the necessary items at the right time, the production ofthese transfusion units proceeded well.
In the meanwhile, Major Ebert was sent to the Officeof The Surgeon General to present the European theater plans for providing wholeblood in the field. Upon his return, he prepared a report of his visit forColonel Cutler. The report was substantially as follows:
A brief interview with The Surgeon General and a longdiscussion with Colonel Kendrick, Special Representative in Transfusions andIntravenous Solutions in the Surgeon General's Office, were held on 6December 1943 and subsequent days.
The Surgeon General was of the opinion that whole bloodwas not necessary in the most forward areas and that plasma should be usedfor the treatment of
71Memorandum, Lt. Col. B. N. Carter, MC, for General Hillman, 28 Oct. 1943, subject: Essential Technical Data, ETOUSA, and inclosurethereto.
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shock under these conditions. In general, he did notbelieve whole blood should be used forward of the evacuation or field hospital.
A complete discussion was held with Colonel Kendrickconcerning the nature and relative advantages of the equipment used at presentin the European theater and the equipment recommended by the Surgeon General'sOffice. Colonel Kendrick described the equipment for blood transfusions now inproduction but not available at the present time. This consists of 750-cc.vacuum bottles containing 200 cc. of sterile McGill solution (an anticoagulantcontaining sodium citrate and glucose which is suitable for storage and blood).These bottles are manufactured by the Baxter Co., are expendable, and are usedonce and then discarded. In addition, donor sets and expendable recipient setsare provided. The recipient sets are made of viscose (cellophane) tubing, arepackaged under sterile conditions, and are ready for immediate use. A simplewiremesh filter is included in each recipient set. This transfusion equipment issuitable for fresh blood transfusion or for the storage of whole blood.
In the discussion with Colonel Kendrick, the advantage ofhaving all the equipment necessary for performing a blood transfusionincluded in a single container was pointed out. As a consequence it wasdecided to package the equipment in a fiber box which will contain 11 vacuumtransfusion bottles, 11 recipient sets (sterile expendable), 1 donor set, and abox each of anti-A and anti-B typing serum. This equipment will not be readyfor distribution until approximately February 1944. The equipment should,however,be requisitioned immediately. The equipment has not yet been given an ordernumber. It can be requisitioned as follows:
Complete transfusion set containing the following: 11vacuum transfusion bottles with McGill solution, 11 recipient sets (sterileexpendable), 1 donor set, 1 box of typing serum anti-A, 1 box of typing serumanti-B.
In view of the fact that the exact date of delivery couldnot be guaranteed, it was recommended that the present plans for transfusionequipment in the European theater should be continued until such a time as thenew equipment should be substituted.
A 4-cubic-foot electric refrigerator designed for storage ofwhole blood is available. This has sufficient capacity to hold approximately50 bottles of blood. The refrigerator can be operated from the usual powerline supply aswell as by a small 500-watt generator which issupplied with it. It is recommended that these refrigerators be placed inall general, evacuation, and field hospitals. The refrigerators can berequisitioned as follows:
Refrigerator for storage of whole blood.
Generator for above.
It was strongly felt by all concerned in thediscussion that transfusion services should be established in all hospitalsunder the supervision of a transfusion officer. This service would beresponsible for the formation of a donor panel, typing of blood, withdrawal and administration of blood and storage of blood. Itwas felt that provision should be made for training men in modern transfusiontechnique.
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Through the courtesy of Capt. John Elliott, SnC, ArmyMedical School, and Dr. Louis K. Diamond, of Harvard Medical School, 20cc. of anti-Rh serum (in dried form) was obtained for use in this theater.
In accordance with Major Ebert's suggestions, ColonelZollinger, acting for Colonel Cutler, took the necessary steps through theOperations Division and the Supply Division, Office of the Chief Surgeon, toprocure 4,000 complete transfusion sets of the expendable type and some 200refrigerators and generators for storing whole blood. Sufficientrefrigerators, over and beyond those already available in the theater'shospitals, were requisitioned so that not only the general, evacuation, and fieldhospitals-as recommended by Major Ebert-but station andconvalescent hospitals and general dispensaries as well could be equipped withblood-storage facilities.
By mid-March, the Emerson-Ebert transfusion units were ready for distributionand were issued to units of the First U.S. Army on the following basis:
First U.S. Army Unit | Transfusion sets |
| Evacuation Hospital (750-bed) | 2 |
| Evacuation Hospital (400-bed) | 2 |
Field Hospital (2 each platoon) | 6 |
Convalescent Hospital | 1 |
Auxiliary Surgical Group | 20 |
Clearing Company, Medical Battalion | 2 |
Colonel Zollinger explained that these units varied from the original inthat sufficient serum for typing only 25 donors was includedinstead of enough for the original 50. In addition, the number of transfusionspossible from each kit was 10 or 11 instead of 18, as originally planned.These changes were necessitated because it was necessary to use Britishsodium citrate solution, which was more bulky in its packing thanAmerican supplies of the solution.72
On the basis of issue determined by the OperationsDivision, the First U.S. Army required some 175 of the transfusion units. Whenthe decision was made that the Third U.S. Army would be equipped with thenew expendable type of unit being developed by the Surgeon General's Office,the excess transfusion units developed in the European theater were provided Army Air Forces medical units at operational airbases in theUnitedKingdom for emergency use. It was further contemplated that replacement of theEmerson-Ebert transfusion sets would be accomplished by using the newexpendable type.
The equipment and facilities for transfusion andrestoration of blood having been completed, the entire program was finallytied together with intensive courses conducted throughout the medicalunits in the theater on the reconstitution of blood plasma for administration,attendance of First U.S. Army medical officers at the course on transfusion andresuscitation at the British Army Blood Supply Depot, and instruction on theuse of the European theater transfusion unit utilizing the motion picture which had been prepared.
72Memorandum, Lt. Col. R. M. Zollinger, MC, to Lt. Col.A. Vickoren, MC, 13 Mar. 1944, subject: Concerning Field Transfusion Units.
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Finally, permission was obtained to classify therefrigerator trucks, which would be distributing blood, as surgical trucks sothat they could be painted with the Geneva cross and receive protectedstatus-and also, so that they would be given priority on the roads incarrying out their lifesaving mission of mercy (fig. 61).
Incidental preparations for invasion-Operation OVERLORD
General Hawley continually insisted that all planningshould be done with combat operations in mind. For instance, at the 30August 1943 meeting of base section surgeons, he stressed the point that noprocedures should be established which could not be followed when combat started.Thus, all planning was, or should have been, directlyrelated to contemplated combat operations. But some things were done specifically forthe firstphase of combat in the European theater, the assault upon the Continent-OperationOVERLORD. Other activities, while the intent was for their continuance during and after Operation OVERLORD, neverthelesshad to be completed forOVERLORD or were conducted with OVERLORD specifically in mind. Among thelatter, incidental preparations which concerned the Chief Consultant in Surgerywere such programs as: (1) Rehabilitation, (2) care of the lightly wounded, (3)realinement of teams within auxiliary surgical groups, and(4) preparation of documents which would be readily available and wouldcontain all basic policies on surgical care and management of casualties.
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Rehabilitation.-The preliminary meeting of the surgicalsubcommittee preceding the meeting of the Chief Surgeon with hisconsultants on Monday, 22 November 1943, was lengthy and concerned chiefly thematters of rehabilitation and care of the lightly wounded. While Colonel Diveley, under General Hawley's direction, had initiated a huge,comprehensive rehabilitation program, there was yet a notable lack ofagreement on many points (fig. 62). The program set up by Colonel Diveley, andat times looked upon with considerable alarm by Colonel Cutler, was basedon large rehabilitation centers which were to bear the brunt of therehabilitation program. There was also a requirement that hospital commanders,using their initiative, establish rehabilitation programs for theirin-patients. Questions in this area now involved such items as (1) how muchand what rehabilitation was to be conducted in hospitals, (2) who were togo to these rehabilitation centers and during what phase of theirconvalescence they were to go, (3) what the distinction was between hardening(reconditioning) and rehabilitation, (4) what the functions were of areplacement center as compared to those of the rehabilitation center, and (5)when a soldier was to be considered as rehabilitated? While the rehabilitationproblem was of considerable concern to all the consultants during this periodand had been a responsibility of the Chief Consultant in Surgery at one time, aseparate portion of this chapter deals with the subject and this report on the
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activities of the Chief Consultant in Surgery will notbelabor the subject. Let it be said, however, that Colonel Cutler and theother consultants all saw eye to eye in the needs for a sound rehabilitation program regardless oftheir individual differences as to how the program should be carried out. AndColonel Cutler, with characteristic energy, strove to develop the rehabilitation programwhilekeeping it in bounds. Although the object of the rehabilitation program wasto return as many patients as possible as early as possible to some usefulform of duty in the theater, it is mentioned here because there was also the contingent need tomake the most efficient use of hospital beds bytransferring elsewhere those who were ambulant and could convalesce withlittle professional medical care.
Care of lightly wounded - The care of the lightlywounded was a topic near to the heart of the Chief Consultant in Surgery,for it was in the optimum management of these cases that surgery could makeits major contribution for returning the greatest number of wounded to thebattlefronts. This matter had been frequently discussed within theProfessional Services Division, but at the aforementioned meeting of 22November 1943, there was enough agreement of opinion to permit Colonel Cutlerto recommend that some 10 miles behind the 400-bed evacuation hospitalssupporting divisions on the line, there should be a 750-bed evacuationhospital. "This," Colonel Cutler stated, "should be ahospital for the care of the lightly wounded and the nonseriously illmedical [patients]. At a moderate distance from this evacuation hospital should bethe convalescent hospital, centered for the army, and the lightly wounded and nonseriously ill medical [patients]should be ableto stream through this 750-bed evacuation hospital for initial treatment, andthen recover in the convalescent hospital, from which they could be restoredto active duty without traveling further down the line. Indeed, somepersonnel could go directly from this 750-bed evacuation hospital to activeduty."
The overall system using platoons of field hospitals closeto division clearing stations, 400-bed evacuation hospitals farther to therear, a 750-bed evacuation hospital well in the corps rear area, and aconvalescent hospital in the army service area would allow for the care ofthe nontransportable seriously injured individuals either in the fieldhospitals or small evacuation hospitals close to the line, and the care of thelightly wounded and others restorable to active duty in a 750-bed hospital anda convalescent hospital.73
At the 22 November afternoon meeting of all the consultantswith the Chief Surgeon, the subject was again presented. Col. (later Brig.Gen.) John A. Rogers, MC, First U.S. Army surgeon, wanted to know whatsize army Colonel Cutler was referring to for his suggested use of 750-bedevacuation hospitals, and Colonel Spruit offered the thought that perhaps anevacuation hospital was not the correct type of unit to provide care of thissort. Colonel Cutler replied that he was thinking of one 750-bed evacuationhospital for an
73Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC,22 Nov. 1943, subject: Minutes of Surgical Sub-Committee Meeting, 22 Nov. 1943.
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army corps. To Colonel Spruit's assertion that theequipment of an evacuation hospital was too extensive to be used in thissituation, Colonel Cutler submitted the opinion that, if these wounded wereto fight again, they needed good care.
Colonel Rogers directed the attention of the conferees to the fact thatthere were not enough 750-bed evacuation hospitals in thetheater to be used at the rate of one per corps and that the First U.S. Army wasgoing to have only one. Colonel Cutler insisted that two would be necessary, but addedthat perhaps two field hospitals could replace oneof them. Colonel Cutler mentioned that there were many of the largerevacuation hospitals in North Africa. Colonel Tovell confirmed this statementby reporting that there were 14 in the North African theater. Colonel Cutlerclosed the discussion by explaining that he was not so interested in the typeof unit as in the care of the lightly wounded in hospitals.
"We could save a lot of personnel for theArmy," he maintained, "and it would make a big step forward."
The implementation of such a program rested squarely with the army surgeon,within the limits of facilities available to him. AndColonel Cutler was very gratified to learn that Colonel Rogers saw theproblem and its solution in much the same light as he.
Auxiliary surgical groups - On 30 September 1943,Colonel Cutler visited the newly arrived 1st Auxiliary Surgical Group whichhad recently arrived in England and was quartered at the 68th Station Hospital.He had an excellent talk with the group's commander, Col. Clinton S.Lyter, MC, who, he discovered, had some excellent ideas about the employment of mobile surgical teams. Colonel Cutler also learned, inhislengthy visit with the unit, that some of the medical officers were"pure" specialists in the sense that they were specialized insuch a narrow field that they could not be employed on more general typesof surgery. For instance, there were two neurological surgeons who couldnot be counted on to carry out surgical procedures elsewhere than on thebrain. They, obviously, would have to be removed from the group since they would be of no great useunder combat conditions. Colonel Lyter also informedColonel Cutler that there was a new table of organization whichgreatly reduced the strength of the group and more or less limited teams togeneral surgery, a change which Colonel Cutler approved heartily and had beenrecommending since his first days in the Army in this war.
Later, Colonel Cutler and Colonel Lyter met with MajorGraves of the 3d Auxiliary Surgical Group and planned to replace teams from the 3d Auxiliary Surgical Group on temporary duty at various installations inand about the United Kingdom by teams from the 1st Auxiliary Surgical Group.However, on 2 October, word was received that the members of the 3dAuxiliary Surgical Group who had been loaned to the North African theater were returning. Thisnews necessitated cancellation of plans to exchangeteams in the United Kingdom until more definite information was available asto the return of the 3d Auxiliary Surgical Group's long-absent members.
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One specific measure was initiated as a result of thesemeetings. Under instructions from Colonel Mason, Colonel Cutler asked MajorGraves to turn over the property in the hands of the 3d Auxiliary SurgicalGroup relating to mobile surgical teams to the 1st Auxiliary Surgical Group.74
At the conference of the Deputy Chief Surgeon on 3 October1943, Colonel Cutler mentioned the arrival of the 1st Auxiliary SurgicalGroup and the expected return of that part of the 3d Auxiliary Surgical Groupthat had been in Africa and Italy. The immediate problem, he explained, waswhat to do with 300 doctors with nothing to do and nowhere to go.
Colonel Cutler met with General Hawley on 5 October 1943and, among other things, there was a long discussion about auxiliarysurgical groups. General Hawley asked Colonel Cutler to have the consultantsdraw up a comprehensive plan for the use of these groups, differentiatingfunctions and personnel, as seemed wise, for a group with an army and fora group when employed within the SOS. Colonel Cutler advised General Hawley thathe should ask the North African theater to return immediatelyan officer from the 3d Auxilliary Surgical Group for the purpose of trainingmembers of the newly arrived 1st Auxiliary Surgical Group. In a letter, dated7 October 1943, written after his return to Cheltenham, Colonel Cutler informed ColonelKimbrough of the conference with General Hawley andreported that he had drawn up a plan for the employment of auxiliarysurgical groups under the dichotomous situations stipulated by the ChiefSurgeon.
Colonel Cutler's recommendations entailed the following:
Regarding the use of auxiliary surgical groups with afield army, he thought that their function should be to carry outdefinitive surgical procedures in the forward areas by being attached toevacuation hospitals, field hospitals, and, possibly, even division clearingstations. The professional requirements for team members working in anarmy area and the need for specialists, he stated, were as follows:
The professional requirements of chiefs of surgical teamsshould be those of well trained general surgeons. The chiefs of teams shouldbe competent to deal with injuries of any part. Strict specialists in the sensethat they are competent to deal only with injuries to the brain, to thechest, to the extremities, the abdomen, the face and jaw are ideallyundesirable. However, surgeons specializing in certain fields and at the sametime competent to work in other fields would be desirable. And finally, theprosthetic teams, providing they were scattered and never concentrated in oneplace, should prove of great value to those surgeons dealing with injury tothe jaws. Similarly, the orthopedic teams, as sent over with the 1stAuxiliary Surgical Group, could be of continuous value to all teams dealing withcompound fractures. This was the arrangement in the last war when such teamswere called splint teams.
As for the distribution of teams in any army area, hecalculated that general surgical teams should be used in the ratio of twoor three to one orthopedic team and that a prosthetic team was only needed forfrom four to six general teams. Further, he thought that the prostheticteams would be needed only
74Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough,MC, 3 Oct. 1943, subject: Visit to 1st Auxiliary Surgical Group.
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at very hard-pressed and active units. Neurological, chest,and maxillofacial teams would be required, according to his plans, only as the needs for them arose. This distribution of teams,Colonel Cutlerstipulated, was based on the assumption that teams would be needed for 24-hourduty in the hospitals to which they would be attached, thus necessitatingthe assignment of two teams to every one team which would be working at anyspecific time and place.
Turning to the use of auxiliary surgical groups incommunications zone facilities, Colonel Cutler stated that their mission wouldbe to strengthen the professional capacity of hospitals and should be employedonly in station and general hospitals. Special teams, he pointed out, couldalways be used to greater advantage in communications zone facilities thanin those of a field army. This would be especially true if parts of severalgeneral hospitals were set aside as centers for thoracic, neurosurgical, ormaxillofacial work.
After the usual Sunday meeting of the Professional ServicesDivision on 10 October 1943, the surgical consultants, with Colonel Cutler,decided upon the temporary assignment of the various teams of the 1st AuxiliarySurgical Group to hospitals then active in the theater and turned over theplan to the Operations Division for implementation.
Later, certain specialists were gradually removed from thetwo groups, and, as revised tables of organization were received from theWar Department, the component teams were reconstituted. The latter procedureswere, primarily, a function of the Operations and Personnel Divisions and the commanders of the groups. They concerned Colonel Cutler little as theprofessional qualifications of those being realined within the groups was of thenecessary high standard. Those qualified specialists who were dropped from the groups werereassigned most advantageously to hospital centers where their special talents were in greatneed. By thetime D-day drew near, in addition to an auxiliary surgical group assigned tothe communications zone, there was an auxiliary surgical group to be assignedto each of the two U.S. field armies-one of them to be used in the UnitedKingdom to augment medical facilities during the initial receipt of casualtiesfrom the far shore, as the Third U.S. Army was not scheduled for immediateparticipation in Operation OVERLORD, and the other to accompany the First U.S. Army duringthe assault on Normandy (fig. 63).
Publications and directives - Shortly after returningfrom the Soviet Union, Colonel Cutler reported that the project of revising WarDepartment TM (Technical Manual) 8-210, Guides to Therapy for MedicalOfficers, to make it more applicable to the European theater had been continuing for almost a year. He statedthat, actually, it had beennecessary to rewrite rather than revise and that there was stillconfusion in the revision concerning frontline care and the type of care to begiven in fixed hospitals. The final revision, Colonel Cutler considered,entailed cutting down the manual still more and deleting some of thephilosophical dissertations.75
75Minutes, 10th Meeting of the Chief Surgeon's Consultants'Committee, 23 Aug. 1943.
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At the 14th meeting of the Chief Surgeon's Consultants'Committee on 28 December 1943, Colonel Cutler reported that much additional workhad been done on the manual after discussions with medical officers who had had experience inthe Sicilian and Italian campaigns. The original revision had been recast in simpleform with short, directive, staccato statements. He suggested that it was just about ready forthe printer. Inaddition to this manual of therapy, which was to be printed in pocket-sizeeditions, Colonel Cutler asked the Chief Surgeon whether it would bepossible to issue a circular covering the care of battle casualties in generaland applicable to the whole European theater. He said that thecircular might be similar to Circular Letter No. 178, published by The SurgeonGeneral, and NATOUSA Circular Letter No. 13 on forward surgery.76 GeneralHawley approved the publication of such a circular and said that it was high time special policieswere set up for the European theater.
A month later, Colonel Cutler reported that the manual wasready for the printer. He submitted, for General Hawley's consideration,remarks, from
76(1) Circular Letter No. 178, Office of The SurgeonGeneral, 23 Oct. 1943. (2) Circular Letter No. 13, Office of the ChiefSurgeon, Headquarters, NATOUSA, 15 May 1943.
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which he asked the Chief Surgeon to prepare an introductorynote. Colonel Cutler stated that the manual contained the principles underlyingprofessional care of medical and surgical emergencies which may beencountered in the European theater-well-established principles whichhad been correlated with recent experience gained by the Americans and theAllies in the present war. Colonel Cutler further explained that the materialwas divided into three parts: (1) Primary surgical treatment of the soldierintended primarily for medical officers in division areas, (2) definitivesurgical treatment as may be applied to hospitals regardless of type, and (3)treatment of medical emergencies. (The last part had been composed by thetheater medical consultants under Colonel Middleton, the Chief Consultant in Medicine.) Lastly, itwas explained, medical officers would be expectedto adhere to the policies contained in the manual insofar as possible.77
By early May, the booklet had been received from theprinter. Distribution had started. An appointment was made with GeneralLee for General Hawley and Colonel Cutler to present and explain the handbookto the SOS commander in the European theater. What happened at the meeting with General Lee iswell explained in Chapter III of this volume (p.366).
The same dual purpose of War Department TM 8-210 promptedthe compilation of the circular for establishing policies with regard tosurgical treatment and management. That is, one portion of the circular waswritten primarily for emergency surgical treatment and another portion wasaimed at fixed facilities which would be providing definitive reparative care.
Colonel Cutler took upon himself the onus of compiling the firstpart on emergency surgical care. He was given help by all thesurgical consultants, but particularly by Colonel Zollinger, Captain Hardin,and, as previously shown, by Colonel Morton and Colonel Schullinger on the gasgangrene and penicillin portions. Colonel Bricker, the Senior Consultant inPlastic Surgery and Burns, was given the responsibility of compiling thesecond portion of the proposed circular dealing with definitive care in fixedhospitals. Colonel Bricker experienced more difficulty than Colonel Cutler sincehis portion was of a more detailed and specific nature involving each of thespecialist consultants. As a result, that portion dealing with the emergencymanagement of battle casualties was finished first, and it became veryapparent that the two parts were quite separate and distinct from each other.So, as time grew short, Colonel Cutler advised the chief of the ProfessionalServices Division in a memorandum, dated 6 May 1944, as follows:
After a great amount of work we have decided that it isnecessary to have two circular letters concerning surgical professional care.One is the major circular largely covering SOS fixed units, upon which ColonelBricker has put so much work, and which he has
77Letter, Col. E. C. Cutler, MC, to Chief, ProfessionalServices Division, subject: Minutes of Surgical Sub-Committee, 24 Jan. 1944.
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about finished. The other is a circular dealing largelywith battle casualties; that is, Army surgical therapy. It is attached, andI believe will be implemented immediately, as the Army needs this now.
Circular Letter No. 71, Office of the Chief Surgeon, ETOUSA,was published on 15 May 1944 and was titled "Principles of SurgicalManagement in the Care of Battle Casualties." It was as succinct astatement as could be made at the time on the emergency care and initialtreatment of battle casualties in the combat zone. It included: (1) A definitionof the functions and responsibilities of the various echelons of surgical service in the combat zone, (2)administration of morphine with particular emphasis on contraindications, aswellas the causes of morphine poisoning, (3) blood transfusion, (4) definitionof certain nontransportable cases, (5) dressings, debridement, andamputation, (6) sulfonamide therapy, (7) penicillin therapy, (8) closure ofwounds, particularly early secondary closure, (9) general principles to befollowed in the use of plaster casts, (10) treatment of anaerobicinfections, (11) radiology in forward areas, and (12) identification of gases in cylinders,with particular reference to the difficulty caused by different British andAmerican markings. The complete circularletter appears in this volume as appendix B (p. 963), and, in subsequentdiscussions, it may bereferred to merely as Circular Letter 71.
The other circular letter entered the publication millduring the very height of activities for D-day, 6 June 1944, and did notappear until 10 June 1944. It was published as Circular Letter No. 80, Officeof the Chief Surgeon, ETOUSA. It concerned policies and procedures governingcare of patients in the European theater.
The new circular letter rescinded 33 prior directives whichhad been issued by the Office of the Chief Surgeon over a period of nearly 2 years. To place all pertinent items inthese many directives into one was an accomplishment in itself which certainly helped to ensurecompliance with these policies and procedures which had been built upover such a length of time-policies and procedures which many hadforgotten or, as in the case of those newly arrived, had not known of theirexistence.
Circular Letter No. 80, calling attention to the Manual ofTherapy, ETOUSA, stated:
The Manual of Therapy, ETOUSA, sets forth principles oftreatment which have been tested in active operations by both our own forcesand those of our Allies. In it are incorporated many of the professionalpolicies of the medical service of ETO. These policies will be followedhabitually. Any one of them may, and should, be disregarded in an individualcase where there is sound reason for departing from policy. Personal preferencefor other methods of treatment as a routine is not "sound reason."Departures from policies will be made only because of specialcircumstances associated with individual cases.
There was a lengthy and detailed explanation of allpractices to be followed with respect to the procurement of blood andtransfusions in general
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and station hospitals. It required all hospitals: (1) Todevelop a "casualty organization" to facilitate the reception,resuscitation, triage, and treatment of multiple casualties, (2) to utilizeofficers from the surgical, medical, and laboratory services, and (3) to makespecific preparations in advance to meet great numbers of such conditions asburns, hemorrhage, profound shock, exhaustion, and chemical warfare casualties.
One of the items which had held up this directive was thatof hospitals for special treatment. From the outset, General Hawley hadinsisted that there would be no specialized hospitals, except for treatment ofthe psychoneurotic and psychotic. At the 6 December 1943 meeting of basesection surgeons, the only concession General Hawley would make was that in thefollowing statement:
Unless it can be thoroughly justified, we are not going tospecialize hospitals. There may be a time, after we get trains running andbattle casualties, we may specify certain hospitals for certain cases, but atthe moment it is just complicating our evacuation system.
The Chief Surgeon never permitted any hospital to become"specialized," but, when the need became apparent, he eventuallypermitted the location of personnel and equipment at certain hospitals orhospital centers to provide special treatment. Circular Letter No. 80, compiledby Colonel Bricker, described these hospitals with facilities for specialtreatment as follows:
Certain hospitals where special types of treatment areavailable will be designated from time to time in separate directives from thisoffice. The policies enumerated below will govern the treatment of patientsrequiring therapy in which a high degree of specialization is necessary.
a. Surgery: Selected patients requiring special surgicaltreatment will be transferred at the earliest practical time to thosedesignated hospitals where additional facilities for their care have beenprovided. Such hospitals will include those for-Neurosurgery, ThoracicSurgery, Urological Surgery, Plastic and Maxillofacial Surgery, Treatment ofBurn Cases, and other surgical specialties as may be found necessary.
(1) In those hospitals designated for the treatment of casesrequiring * * * [special surgical facilities], it is recommended that separatesections of the Surgical Service be formed for each specialty. Administratively, these sectionswould function as all other sections of thesurgical service.
(2) The surgical specialists in charge of these sections maybe used by the Base Section Surgeons as Regional Consultants in their respective fields.
Another circular letter issued under the same date, 10 June1944, designated the three hospital centers with special treatment facilitiesfor neurosurgery, thoracic surgery, plastic and maxillofacial surgery, surgicaltreatment of extensive burns, and urological surgery. This additional directive,Circular Letter No. 81, Office of the Chief Surgeon, ETOUSA, designated otherhospitals in which special facilities had been established for neurosurgery(with special urological facilities to care for the paraplegic) and for plasticand
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maxillofacial surgery (with special facilities for thesurgical treatment of extensive burns).
Circular Letter No. 80 also specified administrative policiesand procedures for X-ray therapy, hospitalization and disposition ofneuropsychiatric patients, rehabilitation of the blind at St. Dunstan'sInstitute, the holding of regular medical meetings in hospitals as a part of the educational program,and care of members of the WAC (Women's ArmyCorps). There were also specific professional policies pertaining tocertain conditions which were listed under the headings of general surgery,neurosurgery, orthopedic surgery, plastic surgery, and X-ray diagnosis in fixedhospitals.
In closing this section on publications and directives, acase must be noted wherein the Chief Consultant in Surgery thought he hadnothing to do with a directive which to him was nearly allprofessional. As will be seen soon, the subjects discussed in this directivewere the very items on which he and Colonel Zollinger were devotingtheir utmost energies at the time. And he was startled to see the directivefor the first time a month after it had been written and promulgated. It waspublished not as a circular letter but as Administrative Memorandum No. 62,Office of the Chief Surgeon, ETOUSA, to Base Section Surgeons and TransitHospitals. Dated 3 May 1944, it stated:
1. General
a. Patients will be evacuated from the Continent to theUnited Kingdom in vessels manned by the Navy and in aircraft of the TroopCarrier Command. Patients returned by water will be disembarked at hards orports having been classified into evacuable and nonevacuable patients prior todisembarkation. Evacuable patients are those who can withstand furtherevacuation by ambulance to "transit" hospitals (15 to 30miles). Patients who are nonevacuable will be given emergency treatment in"holding units" in order to prepare them for further evacuation to"transit" hospitals. Patients arriving at "transit"hospitals will again be classified into evacuable and nonevacuable patients;evacuable patients being those who can travel 12 hours by train withreasonable safety. Nonevacuable patients will be prepared for furtherevacuation as soon as possible.
b. Patients evacuated by air will be removed to a"holding unit" at the airfield or a nearby fixed hospital, from whenceevacuable patients will be evacuated to a general hospital for definitivetreatment.
c. Designated general and station hospitals functioning as"transit" hospitals, will streamline their administrative procedures,and will function similarly to evacuation hospitals. "Transit"hospitals will be called upon to admit large numbers of patientsexpeditiously, and to evacuate them in trainload groups.
* * * * * * *3. Professional Care in "Transit"Hospitals
a. The scope of professional care in transit hospitalswill be the same as that in evacuation hospitals, bearing in mind that thosewounded who may travel safely for another 12 hours will be immediately evacuatedwithout definitive surgery. [Italics are the editor's.] As a rule, allcasualties will have their wounds debrided; no wounds will be closed;immobilization apparatus, splinting, or plaster of paris will be applied forall fractures; and patients will be given the necessary supportive treatment.Post-operative abdominal cases are usually not transportable for 7 days.Ambulatory and lightly wounded
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MAP 1.-Medical support in the United Kingdom for the Normandy invasion, 1 July 1944.
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casualties will be evacuated through transit hospitals asrapidly as possible. This type of casualty represents a primary responsibilityof the Medical Department because these patients, with good treatment, can berestored to active duty in the combat forces at an early date.
When Colonel Cutler first saw the directive on 2 June 1944,invasion fever was running high, and it was very obviously too late to doanything about it. At the same time, he was having a most difficult timetrying to obtain approval for stationing his consultants in key areas during the invasion phase. Itwas, in a way, the last straw. He wrote mostbitterly in his diary: "SOP's get written, and I never see them.God, how they have opened themselves to criticism. It is a colossal blunder.Only today I [saw] Administrative Memorandum No. 62, 3 May 1944. None of it isour responsibility [doing] and yet it is all the professional system." On secondthought, he added: "Well, maybe it will be OK." And well might he add thatthought,for the words in the directive were very much those of Colonel Cutler as he, from time to time, reported on the progress being madefor the careof patients in transit through the evacuation chain on the southern shoresof England.
However, he had advised: "* * * Bearingin mind that if the pressure for evacuation is great, those wounded who maytravel safely for another 24 hours will then be immediately evacuated withoutdefinitive surgery at the 'transit' hospitals." He had furtherqualified this statement with his definition: "An evacuablepatient varies with the pressure of work and the demands forbeds." Colonel Cutler was greatly exercised and chagrined to learn thatbase section surgeons and transit hospital commanders had been directed toevacuate all patients who could travel for 12 hours without definitivesurgery. The clear intent of Colonel Cutler's recommended policy was thatall patients in need of definitive surgery would receive such in transithospitals except when (1) the pressure for evacuation was great at thesehospitals and (2) the patient could travel safely for an additional 24 hours.
But now, more about these preparations to which thediscussion of this directive has brought us.
Specific preparations for Operation OVERLORD
General Hawley explains.-Colonel Cutler attended aconference held by the Chief Surgeon at 9 North Audley Street, London, on 10January 1944. The Deputy Chief Surgeon and executive officer, chiefs ofdivisions in the Chief Surgeon's Office, Col. Alvin L. Gorby, MC, from theOffice of The Surgeon General, and Maj. Gen. Robert H. Mills, DC, director ofthe Dental Division, Office of The Surgeon General, were there. The minutesof the meeting show that General Hawley outlined plans formulated by hisoffice for the reception, hospitalization, and evacuation of casualties inconnection with the projected operations (map 1).
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The plans for the medical support for the Normandy invasion included the following hospitals anddepots:
General Hospitals | Location |
22d & 522d (composite unit) | Anson & Craddock Barracks, Pimperne, Dorset |
22d (detachment) | Benbow Barracks, Pimperne, Dorset |
28th | Kingston Lacey, Wimborne Minster, Dorset |
40th | Daglingworth, Gloucester |
48th | Stockbridge, West Hampshire |
62d | Ullenwood, Cheltenham, Gloucester |
62d (detachment) | Prince Maurice Barracks, Devizes, Wiltshire |
67th | Musgrove Park, near Taunton, Somerset |
91st | Churchill, Headington, Oxford |
91st (detachment), augmented with a detachment of the 127th. | Norton Manor Barracks, near Taunton, Somerset |
94th | Tortworth Court, near Falfield, Gloucester |
97th | Holton Park, near Wheatley, Oxford |
97th (detachment), augmented with a detachment of the 25th. | Waller Barracks, Devizes, Wiltshire |
98th | Hermitage, near Newbury, Berkshire |
98th (detachment) | Busigny & Fowler Barracks, Perham Downs, Wiltshire |
106th | Kingston Lacey, Wimborne Minster, Dorset |
141st | Erlestoke Park, near Erlestoke, Wiltshire |
154th | Chisledon Camp, Chisledon, Wiltshire |
158th | Odstock, near Salisbury, Wiltshire |
159th | Houndstone Barracks, near Yeovil, South Somerset |
159th (detachment) | Lufton Barracks, near Yeovil, South Somerset |
160th | Stowell Park, near Stowell, Gloucester |
185th and 685th (composite unit). | Sandhill Park, Bishop's Lydeard, Somerset |
186th and 686th (composite unit). | Fairford Park, near Fairford, Gloucester |
187th and 687th (composite unit). | Everleigh Manor, near Everleigh, Wiltshire |
187th (detachment), augmented with a detachment of the 32d. | Rawlinson Barracks, near Newton Abbot, Devon |
188th | Cirencester No. 1, Gloucester |
192d | Cirencester No. 2, Gloucester |
203d | Broadwell Grove, Burford, West Oxford |
216th | Longleat Park, near Warminster, Wiltshire |
216th (detachment), augmented with a detachment of the 127th. | Drake Barracks, East, Pimperne, Dorset |
217th | Burderop Park, near Wroughton, Wiltshire |
217th (detachment), augmented with a detachment of the 32d. | Drake Barracks, West, Pimperne, Dorset |
Station Hospitals | Location |
| 3d | Tidworth, Wiltshire |
36th | Exeter, Devon |
38th | St. Swithins School, Winchester, Hampshire |
68th | Ramsden Heath, Ramsden, Oxford |
77th | Erlestoke Park, Erlestoke, Wiltshire |
110th | Royal Victoria, "E" Block, Netley, Hampshire |
115th | Plasterdown, Tavistock, Devon |
120th | Charlton Park, Charlton, Wiltshire |
127th | Odstock, Salisbury, Wiltshire |
130th | Chisledon, Wiltshire |
152d | Odstock, Salisbury, Wiltshire |
160th | Bath, Somerset |
228th | Sherborne Park, Haydon, Dorset |
250th | Grimsditch, Coombe Bissett, Dorset |
302d | Lydiard Park, Swindon, Wiltshire |
304th | Kingwood Common, Rotherfield Peppard, Oxford |
306th | Checkendon, Oxford |
313th | Fremington, Devon |
314th | Polwhele, Truro, Cornwall |
315th | Axminster, Devon |
316th | Stover Golf Club, Teigngrace, Devon |
318th | Middleton Stoney, near Middleton, Oxford |
327th | Northwick Park, Blockley, Gloucester |
347th | Marlborough Common, Marlborough, Wiltshire |
365th | Ramsden Heath, Ramsden, Oxford |
Field Hospitals |
|
6th | Tunbridge Wells, Kent |
DEPOTS: Taunton, Bristol, Witney, Thatcham, Reading, Romsey, London
The minutes of the 10 January conference state:
He [General Hawley] gave first a broad picture of the overallplan for the reception of casualties. * * * All the hospitals, including thegeneral hospital at Stockbridge, but excluding other general hospitals in adesignated area along the south coast of England had been made available to theSouthern Base Section for the purpose of receiving casualties. Casualties wouldbe unloaded and given immediate attention on beaches and hards and thenevacuated to the hospitals in this area [later called "transit"hospitals]. Evacuation of patients from these hospitals by hospital train tohospitals elsewhere in the United Kingdom would ensure that beds were constantlyavailable in the designated area. Certain beaches and hards were to bedesignated as medical and the Navy would deliver casualties here as much aspossible. A fixed holding unit of at least 50 beds would be placed at a maximumdistance of 500 yds. from each medical beach and hard; situated preferably inwhatever buildings were available. Here casualties which could not betransported by ambulance without immediate treatment would be transported byhand. These units, being so close to the beach or hard, would be exposed tobombing, but in order to deal with patients who could not be transported byambulance without treatment, this was unavoidable. Ambulances and buses, forwalking wounded, would be used to transport all other types of casualties to thenearby hospitals.
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Owing to the many difficulties attendant upon bringing thecasualties back-the diversion of LST's due to sudden emergencies, thepossibilities of damage to the craft, the fact that trips were made at night andthe crews were young and inexperienced- there would be frequent occasions onwhich casualties were brought to beaches and hards other than those designatedas medical. There were large numbers of such beaches and hards which would allhave to be "covered." For this purpose, with close liaison establishedbetween the Navy and [the] Southern Base Section, a large reserve of ambulances and personnel for unloading LST's would have to be kept availableto move to any point on call. It was essential that any congestion shouldbe avoided and a considerable number, possibly as many as twenty-five,ambulances would have to be available to unload each LST, in order that all thecasualties on board should be evacuated immediately. In addition there wouldhave to be under a central control (not that of the SBS [Southern Base Section])two big reserve pools of ambulance and bus transportation to reinforce that forboth medical and nonmedical beaches and hards and meet any sudden emergenciesthat might arise.
Colonel Cutler asked the general about provision for triageat the beaches and holding units. General Hawley replied that no sorting wouldbe done at the beaches and hards or in the "holding" units and thatall those casualties that could possibly be transported would be movedimmediately to hospitals.
The minutes state:
General Hawley then went on to explain, in slightly moredetail, the methods for dealing with the casualties received. All hospitals inthe area would be reinforced with surgical teams and resuscitation and shockteams would be present on the beaches or hards. To meet requirements in theinitial stages of the operation, and until "the route of evacuation wascanalized," teams and ambulance companies would have to be borrowed fromareas north of the Southern Base Section.
* * * * * * *General Hawley explained how it was the responsibility of theEvacuation Division to keep the beds in the reception area "fluid." Itwas essential that patients should not be immobilized in these hospitalsand beds thus "frozen." Therefore only essential surgical treatment,such as that given in Evacuation Hospitals, must be given therein. The bulk ofthe patients should be evacuated within 24 hours.
The Chief Surgeon then explained what measures would have tobe implemented to care for the great influx of troops into the staging areas.
In the discussions that followed, Colonel Cutler againbrought up the desire for sorting at the beaches and suggested that hospitaltrains evacuate less seriously wounded and neuropsychiatric patients from thereceiving areas. General Hawley said that evacuation by hospital train of suchpatients could not be considered since there were no facilities for parking thetrains in the vicinity of the beaches and hards. He insisted that sorting ofpatients could not be done at the beaches. He stressed that it was essential forall to be moved away immediately, and he added the conjecture that the run ofneuropsychiatric cases would not be high. He also said that very littletreatment would be given by the Navy on LST's, although the Naval medicalofficer in charge of LST operations was most cooperative. Colonel Spruit saidthat naval medical personnel might need reinforcing by Army personnel. GeneralHawley agreed and directed that this question be looked into.
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To a question on air evacuation by Colonel Gorby, General Hawley replied:
* * * the possibilities of Air Evacuation of casualties hadbeen considered, but it was not estimated that it would start until D+10 orD+15. In the early stages, aircraft would have to return to specified troopcarrier command airfields. Since there were no fixed hospital facilities in thevicinity of these airfields, tented hospitals would have to be used. Later it mightbe possible for aircraft to "touch down" near fixed hospitals.General Hawley pointed out that the demands on the air forces would be sogreat that it was extremely unlikely that aircraft would be available forevacuation of patients from hospitals in the reception area in the event of adislocation of rail traffic, at any rate initially.
General Hawley concluded his explanation with comments on the supplysituation and the need for decentralization.He said that supplies which would have to be furnished would belargely maintenance, but that a reserve must be kept to replace equipmentlost by sinking or from other causes. For an example, he mentioned thefact that a whole evacuation hospital might be needed, and that arrangements must be made in advance to providereplacement for immediate and speedy loading on LST's. Provision must be made,he added, forthe transport of blood and its storage at ports.
So this was it, pondered Colonel Cutler. The bigeffort was finally going to be made soon-but when? He recalled with someapprehension that, just before Christmas, General Hawley had warned the base section surgeonsthat in a month there would bescarcely a base section whose job would not be bigger than the theater was atthe beginning of the month (December 1943). He could not help but conjure upmemories of those southern shores of Devon, the European theater AssaultTraining Center, which he had visited not long ago.
Visit to Assault Training Center, ETOUSA - On 5 November1943, Colonel Cutler departed Cheltenham to visit the Assault TrainingCenter, ETOUSA, near Braunton, Devon. On the way, he had stopped by atFirst U.S. Army headquarters and learned the happy news from ColonelRogers that General Hawley had suggested Maj. William J. Stewart, MC,as orthopedic consultant for the First U.S. Army. He knew that Major Stewartwould be an excellent consulting surgeon for the First U.S. Army and ofgreat assistance to Colonel Rogers and to Maj. (later Col.) J. Augustus Crisler,Jr., MC, its surgical consultant, but this suggested appointment did notmaterialize.78
At the Europeaun theater Assault Training Center, ColonelCutler was pleasantly surprised at the realism and practicality of thedemonstration he observed on the employment of the medical services uponassaulting a hostile beach (fig. 64). However, he stated in a memorandum toColonel Kimbrough, dated 7 November 1943, that, while the role of the Navalbeach control officer had not been made entirely clear, the Chief Consultantin Surgery had been somewhat taken aback by the impression he had receivedthat the Navy controlled entirely evacuation from the beach. Colonel Cutleralso had a ride in a "duck" [DUKW (amphibious truck, 2? ton cargo)]and found it quite a task for a healthy man unencumbered by theparaphernalia of war to mount
78Memorandum, Col. E. C. Cutler, MC, to Col. J. C.Kimbrough, MC, 6 Nov. 1943, subject: Orthopedic Consultant for the FirstArmy.
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into one. From this experience, he could not help butconclude that the means for getting walking wounded and even litter cases into a"duck" are inadequate. As a substitute, he suggested that everythingshould be done to land jeeps for use as light ambulances at the earliestpossible time. Jeep ambulances, he said, would save much time for the woundedand perhaps make it unnecessary to set up what was called, in the demonstration,a reinforced regimental aid post.
British EMS plans - And recently, just a few days beforeGeneral Hawley's talk, Colonel Cutler had participated in a similar discussionon the British side. Mr. Willinck, the new Minister of Health, was present atthe meeting of consultant advisers to the EMS held at the ministry offices,Whitehall, London, on Tuesday, 4 January 1944. The Director General, EMS, newlyknighted, was chairman as usual. Sir Francis Fraser led the discussion on thecare of battle casualties by the EMS when the Continent was invaded. The Britishwere going to use three selected ports for the receipt of their wounded. Thewounded, upon their return to England, would be taken to "transit"hospitals in the general locality of these ports. After surgical therapy, orimmediately in medical cases, the wounded were to be sent to base hospitals inthe north and west of England. They did not plan to use the great Londonhospitals as base hospitals, since heavy retaliation on London by the Germanswas expected. Following treatment at the base hospitals, selected cases were tobe sent as necessary to special hospitals for maxillofacial surgery,neurosurgery, and so forth. The need for basic surgical directives and mobileteams was cited, although it was stressed that their professional men would besent to transit hospitals as well as the many base and special hospitals towhich they were already assigned. Colonel Cutler offered to send the EMS copiesof the NATOUSA circular letters on surgical therapy which he had recentlybrought back with him from Italy, and the EMS consultants implied that theywould like to model theirs after the NATOUSA directives-just as ColonelCutler, himself, was to do later.
After returning to Cheltenham, Colonel Cutler submitted toColonel Kimbrough on 8 January a brief memorandum summarizing the highlights ofthis meeting with the EMS. He concluded his memorandum with: "I believethis meeting makes it clear that we should keep in close liaison with theBritish setup for the care of casualties returning from possible continentalinvasion."
Elsewhere, he wrote this enigmatic afterthought of themeeting: "The EMS is to look after all returned battle casualties, and,after 4 years, are still surprised over it!"
The buildup begins - As General Hawley had foretold, theremainder of January 1944 set the pace for the busy months that were to follow.Taking a quick respite on Sunday, 23 January, Colonel Cutler noted in his diary:"Catching up; things moving. Hospitals arriving daily. Hard to keep up withwork. Robert Zollinger is a great help."
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Problems in Allied coordination - Colonel Cutler hadsaid that the American should keep close liaison with the British in the workingout of procedures for the reception of casualties. It soon became apparent thatthe British thinking was very similar. Sir Francis Fraser asked Colonel Cutlerto meet with British representatives for the joint working out of certainproblems which had appeared. On 28 January, Colonel Cutler journeyed to Oxfordand met with Prof. Geoffrey Jefferson, adviser in neurosurgery to the EMS, andBrigadier Hugh Cairns, Consultant in Neurosurgery to the British Army.
Professor Jefferson stated that the EMS had a very meagersupply of specialists to meet the tremendous demands which were expected. Whilethe British Army could help to a limited extent, it was particularly inneurosurgery where they feared the greatest shortage of qualified professionalhelp. Professor Jefferson asked if the American Army would be willing to haveBritish neurosurgical casualties sent to their hospitals for care. It wasapparent to Colonel Cutler that similar decisions were desired for other typesof cases as well. Significant, and most obvious, was the fact that the EMS hadnot been informed on these matters, and Colonel Cutler did not have the answerseither. He could but say that there was an overall planning group which hadprobably settled these problems and that, certainly, representatives of theCanadian, British, and U.S. Army medical services had to meet, settle, andintegrate plans for the care of all casualties arriving in the reception areas.
In a memorandum, written on 29 January, after his return toCheltenham, Colonel Cutler advised the Deputy Chief Surgeon, through the chiefof the Professional Services Division, that the following specific questionsshould be put to the Allied planning group:
1. Will U.S. Army hospitals, Canadian Army hospitals, and EMShospitals in the reception areas take in and care for Allied casualties justlike their own?
2. Can the EMS count upon U.S. Army hospitals taking in andcaring for specialty injuries over and above the general run of casualties?
3. Should the answer to question 2, above, be favorable, cana list of U.S. Army hospitals in the reception areas with information as towhere what specialists are assigned be submitted to the EMS so that the EMS mayroute patients to such hospitals?
And here, the reader should note, was the first instancewhere Colonel Cutler was acting as the American surgical representative forAllied planning of the invasion-a function which was to grow and become moreinvolved as time passed and which devolved upon him naturally in the course ofevents without any specific orders.
At the monthly meeting of advisers and consultants to the EMSheld on 8 February, it was still obvious to Colonel Cutler that the EMS was inignorance about overall plans, and the professional board of the EMS felt thatits planning could not be reasonable until they had further information. ColonelCutler noted, too, that the specialists desired early triage so that casualtiesrequiring
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special treatment could receive that care within a reasonableperiod of time. As it was, if the general plan were followed, 3 to 5 days wouldbe consumed before this special care would be available to casualties needingit, and mortality and morbidity would be increased by such delay. The DirectorGeneral, EMS, spoke of the need for gradually vacating beds in the betterhospitals, the possibility of triage at transit hospitals, the necessity forrapid passing of cases through transit hospitals where long holdovers would beundesirable, and securing additional special instruments for work in specialfields for use in transit hospitals.79 Theseproblems, with which the EMS was contending, were to Colonel Cutler the veryproblems that the U.S. Army had yet to face, and matters of serious concern.
Following this last meeting, Colonel Cutler visited the ChiefSurgeon's London office and spoke with Colonel Liston, the Deputy ChiefSurgeon, on the various matters which had been brought up by the EMS. ColonelCutler told Colonel Liston that planning was not his problem and that he hadasked the EMS to put in writing to him any specific desires they had so that he,Colonel Cutler, could pass them on to the Chief Surgeon, ETOUSA.
Critical shortage of qualified officers in ETOUSA - OnThursday, 10 February, a teleprinter conference was in progress between theChief Surgeon and the Office of The Surgeon General in Washington. PerhapsColonel Cutler was unaware of the conference, itself, but, as has been shown, hewas certainly aware of the problem which was its subject (pp. 37-38). Theconference concerned personnel, particularly supply personnel. The tenor of theconference also indicated how critical activities were in this immediatepreparatory period prior to launching Operation OVERLORD. An excerpt from theteleprinter conference of 10 February 1944 follows:
This is Hawley speaking: Colonel Voorhees andhis group have done a splendid job in diagnosing the troubles and pointing outthe cure. I am implementing their suggestions at once, but I must have help toimplement them properly. Until recently this theater was of minor importance inthe large picture. Realizing this, I have refrained from asking for the ablestofficers available, with the result that, with a few notable exceptions, theofficer personnel furnished me was not of high quality. We have tried to carryon during this period of relative inactivity and we have barely succeeded. Thissituation has now changed. This is the most important of all theaters and wehave fully demonstrated that the quality of personnel furnished us in the pastis totally inadequate for the task that lies ahead of us. We must not fail. Yetwe cannot succeed unless we are given the tools to work with. The best officersto be had are none too good for the jobs to be done here.
The most critical time of all is now. Afterplans are made and operations are proceeding smoothly, some key personnel can bereleased and their places taken by subordinates who they have trained. I realizefully the many positions that have to be filled and the few really qualifiedpeople there are to fill them; and I shall be unselfish when the time comes thatthe need for able people is greater elsewhere than it is here. But now, for thefirst time in more than two years, I am really begging for assistance.
"Rotten ships for care of wounded Americanboys."-Colonel Cutler's impression of LST's, after his first twoencounters with them, was that they
79Memorandum, Col. E. C. Cutler, MC, to Chief, Professional Services Division, 11 Feb. 1944, subject: E.M.S. Preparations.
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were "rotten ships for care of wounded Americanboys." These initial impressions, however, were but a challenge to ColonelCutler to make them the best possible vehicles for evacuation by sea under thecircumstances. To this end, Colonel Zollinger, his consultant in generalsurgery, was of inestimable help.80
Already, on 4 February 1944, Colonel Zollinger had met withColonel Liston, the Deputy Chief Surgeon, and Capt. George B. Dowling, MC, U.S.Navy, who was the Naval medical officer in charge of LST operations for theevacuation of casualties. On 8 February, he had met again with Captain Dowlingand a Lt. William A. DuCharme, HC, U.S. Navy, to go over and evaluate medicalsupplies and equipment which the Navy planned to load on LST's for the care of200 casualties. And, on 14 February, he had gone to the Southern Base Sectionand discussed with the base section surgeon the placing of surgical teams on LST'sand the scope of treatment to be given. They had also discussed the advisabilityof placing general surgical and shock teams at the field hospitals to be locatedright at the hards for the care of nontransportable casualties. They alsobelieved that it would be necessary to break up one or two general surgicalteams to obtain experienced medical officers to supervise triage at the hards.There was talk, too, of the placement of general surgical and orthopedic teamsat the transit hospitals and the use of the specialty teams in hospitals for thedefinitive treatment of casualties.
With this as a background, Colonel Cutler, Colonel Kimbrough,and Colonel Liston joined Colonel Zollinger on Tuesday, 15 February 1944, atPlymouth, Devonshire, to look over an LST. Colonel Muckenfuss and Captain Hardinfrom the Blood Bank, ETOUSA, also joined the party. The inspection of the LST,which had been arranged through Captain Dowling, was conducted by Comdr. LutherG. Bell, USN (MC). Colonel Zollinger informed the group that the ship had beenused at the Salerno landings but that it was not of the type which had beenconverted to carrying casualties.
"We were able to inspect the entire LST," ColonelCutler wrote of the expedition in a 15 February memorandum to the chief of theOperations Division, through Colonel Kimbrough, "including the main deck,on which was the upper battle dressing station in ward room, the middle deck,where a second battle dressing station was contemplated in the crew's messingcompartment, and the lower or tank deck."
Colonel Cutler noted that the usual difficulties of movementon a ship were present. There were narrow doorways, sharp right-angled turns,and steep ladders or stairways between decks-difficulties which could not bechanged but had to be recognized in the proper planning and loading ofcasualties on such a ship. A primary consideration underlying all planning forthe care of casualties and returning sick personnel on such ships, ColonelCutler mentioned, was the fact that "loading of casualties and patientsmust proceed simultaneously with the unloading of the ship." With this inmind, he believed the following sequence of care should prevail:
80See also Colonel Zollinger's personal narrative of his activities in Chapter III.
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4. * * *:
a. Casualties will come up over the side inspecial stretcher slings developed by the Navy * * *. These deliver patients toupper deck (fig. 65).
b. From the deck the casualty may go eitherto: (1) The battle dressing station in the ward room, or (2) the battle dressingstation in the crew's messing compartment on the middle deck. There, adequatedressing facilities for all types of wounds must be present with additionalsplints. There, proper notation should be made on the EMT as to some sort ofcategorization concerning the ability of the individual to withstand transporton reaching the near shore. If surgical procedures are necessary to save life orlimb, such as ligation of a vessel or the amputation of an extremity hanging onby a few parts, then the FMR must be begun and proper notation made on it.
c. After primary first aid care has beengiven, as above, the casualties will then go either to the area known as thecrew's quarters, which is adjacent to their messing compartment, or to thetank deck, if they are on stretchers. As there is space for some 78 stretchersin the crew's quarters it would be advisable for all stretcher cases to beheld in this area if possible. Those who are ambulatory, both sick and wounded,can go down to the middle deck and be held in the space allotted as "troopquarters," which can provide for 175 men. The number of stretchers or othercasualties which can be placed on the tank deck will depend upon whether we areutilizing a converted ship with wall brackets for stretchers or not (fig. 66).
5. Comment on battle dressing stations orfirst aid posts: Of the two areas provided for this service, i.e., thewardroom on the upper deck and the crew's messing compartment upon the middledeck, the latter would seem more reasonable, for if there be only one surgeon hewould have near him in the adjacent crew's room (sleeping quarters)practically all of his stretcher or seriously injured people. Both stations,however, are suitably lighted and supplies could be assembled there. Moreover,both stations have tables which could serve as operating tables. The crew'squarters stations are near the kitchen, so that sterilization by boiling wouldbe more simple, unless an electrical hotplate is added to the wardroom, wherethere is a plug for such a receptacle on a table.
The visitors, particularly the two from the blood bank,observed that there were two types of cold rooms on the ship. One was for meatswhere the temperature was kept at 20? F. This room was obviously unsuitable forstoring blood. But there was another space for storing vegetables and fruitswhere the temperature was held at 48? F. Fortunately, they discovered, thetemperature could be adjusted to 40? F. which would be appropriate for storingblood and still not hurt the fruits or vegetables.
On his return from Plymouth, Colonel Cutler reported:"No intelligent regulation can be drawn up concerning the care ofcasualties on such ships until knowledge is available as to timelimitations." Time, he showed, would affect considerations in professionalcare on LST's in the following manner:
If casualties will be on such ships up to andbeyond 20 hours after being wounded, then one would have to advise and providefor abdominal surgery, since the percentage of recovery in the cases ofabdominal injury becomes almost nil after 24 hours. A similar attitude ondefinitive surgery of all types must be dictated according to the time interval.If instructions are to be given to medical officer personnel on LST's as towhat they are to do, that would depend entirely upon this time interval, and ifindoctrination courses are to be given to the medical officer personnel who areto be on LST's, some rough estimate of this time interval should be known tothe instructor before speaking, else his advice will be inappropriate andpossibly damaging to the American soldier.
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FIGURE 66.-Litter patients in an LST that had been converted with wall brackets to hold litters.
It is my hope that the interval will be so shortthat the professional work on an LST will be largely first aid, i.e.:
1. Control of hemorrhage.
2. Treatment of shock (for which blood and plasma will be provided).
3. Proper dressing of wounds.
4. Proper splinting of fractures.
5. The elimination of pain through medication.
6. The giving of tetanus toxoid.
If, however, the time is to be over 24 hours,or even if there is danger that it is to be over 24 hours, then an entirelydifferent set of circumstances will prevail and different instructions must begiven the medical officers in charge. We would be committing a wrong against theAmerican soldier in this event if we did not provide for definitive surgery inthe care of cases on the LST's.
On the Monday following, 21 February, Colonel Cutler joined amost illustrious group in the inspection of an LST at the chief British navalbase, Portsmouth. The American representation, in addition to Colonel Cutler,included Maj. Gen. Albert W. Kenner, Chief Medical Officer, SHAEF, and Col.Alvin L. Gorby, MC, who was now assigned to the First U.S. Army Group, theoverall planning organization on the American side for Operation OVERLORD. Thedirectors general of the Royal Navy and the British Army medical services headedthe British delegation, with their respective surgical
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consultants, Admiral Gordon-Taylor and Maj. Gen. David C.Monro. There were also Surgeon Rear Admiral Cecil P. G. Wakeley, a consultingsurgeon to the Royal Navy; Brigadier Arthur E. Porritt, RAMC, then consultingsurgeon with the British 21 Army Group, the British counterpart of the FirstU.S. Army Group; and other officers from the British 21 Army Group.
Colonel Cutler was quite disconcerted with the Britishattitude toward the handling and care of casualties on LST's, since, if theiropinions were to prevail, much of the planning and work so far accomplished byColonel Zollinger would have been for nought. Yet, there was on evading the factthat this particular inspection of LST's was conducted primarily from theviewpoint of the British Army and the Royal Navy medical services. ColonelCutler's 28 February report of the trip to the Chief of the OperationsDivision in General Hawley's office contained the following statement:
1. The British seemed to have hardened theiropinion even before visiting the ship that:
a. The ship must load casualties via the ramp through the bows.
b. They prefer not to use the ship's company's quarters, as these people will be working very hard and should not be disturbed.
c. They wish to keep all casualties on the tank deck and have plans to construct a small first-aid post, screened off, at the rear end of the tank deck.
d. The medical personnel for an LST will consist of two general duty medical officers, one qualified surgeon, one anesthetist and 32 men of noncommissioned ranks, about 20 of whom would be trained Navy medical personnel. Others would be largely used to clean the tank deck after tanks have left and before the casualties are brought in.
2. The British group felt certain that itwould be impossible to take casualties up over the side in units or by any othermethod. They believe it will be necessary to beach the vessel, leave her on thebeach throughout the fall and flow of one tide and take her off afterwards. Thisopinion is contrary to that of American Naval officers when inspecting.
3. On travelling back with Lt. Gen. Hood [DGMS,British Army], he expressed the opinion that the LST was an unsuitable vesselfor carrying back wounded people, that it was outrageous that better provisioncould not be made, and that he might take this to the Prime Minister and GeneralEisenhower. He expressed the opinion that an LST was a "cold, dirtytrap."
4. Out of the above objections, many of theprofessional people present, notably General Monro and Brigadier Porritt, aswell as myself, felt it might be better to try and hold certainly all littercases on the far shore, rather than accept the risks of transport back on thesevessels. Certainly the "Collecto-clearing company" or the platoon ofthe field hospital could be landed with the second wave and give the necessarysurgical care.
Much of the meeting of the Chief Surgeon's Consultants'Committee on 25 February 1944 was taken up with the subject of care ofcasualties on LST's. Colonel Zollinger gave a summary of the existing problemsand plans which, so far, had been worked out with the Navy. One of the remainingproblems was the treatment of abdominal wounds, he reported. The Navy wasestimating a 16-hour journey on LST's, once they were loaded, but risk ofmortality in abdominal cases rose precipitously after 6 hours. There was ageneral desire to do abdomens, if necessary, on the LST's, but there were noprovisions for the equipment or personnel. Furthermore, planning to operate onabdomens on the far shore had its disadvantages in the initial stages becausethere would not be facilities to perform such operations and, because it was
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the general policy not to move for about a week eitherabdominal or chest cases which had been operated upon. Of the situation at thetime, Colonel Zollinger said: "If a man happens to be qualified to operateon [board] LST's, good; if not, he will have to depend upon morphine."
General Hawley was quite taken aback by the prospect, andsaid: "These are young chaps-recent graduates. They will not have doneany kind of residency. To operate on a belly on an LST!! The question is whetherit is better to operate on the far shore and put him immediately on an LST; isthat worse than operating on an LST?"
In answer to his own question, General Hawley said that itwould be better to operate anyway rather than go so long as 16 hours and that itwould probably be better to operate on the far shore and then have the patienttaken aboard, with special care available on the ship. The reason, he said, wasthat there would be a better concentration of talent on the far shore and"we have to think of the most good for the largest number and establish aruling for it."
Colonel Kimbrough, however, insisted: "I would like tostick to the recommendation that there be facilities to operate on any case thatmight arise on an LST."
"I agree," General Hawley replied.
The discussion on LST's was closed with strong exhortationfrom the Chief Surgeon that the consultants crystallize their opinions on whathad to be done and how and to "get it down into an operating procedure thatthe Navy thoroughly understands."81
The reader may recall that shortly after this, in March 1944,The Surgeon General and the Air Surgeon arrived in the theater for an extendedtour of medical facilities serving the Army Air Forces and that Colonel Cutlerwas required to accompany the visiting officers. The inspection tour and itsaftermath required the services of the Chief Consultant in Surgery for the bestpart of a month at this critical time. The bulk of the work to develop thenecessary operative procedures with the Navy fell on Colonel Zollinger.
Physical standards and disposition boards - At theaforementioned meeting of the Chief Surgeon's Consultants' Committee on 25February, General Hawley said, "Now I have a problem. What can we do to getthese disposition boards to realize more fully their responsibilities in theconservation of manpower. I think it is getting better, but I think we are stillevacuating too many people. What can we do about that?"
The disposition boards had been established at most generalhospitals and certain station hospitals in August 1943.82Each board consisted of the
81"The emergency operating rooms on the LST's were built in the center of the tank deck along the after bulkhead. Each such room took up the space of one vehicle, but the combat troops were not advised by general headquarters of this alteration. The loading tables had been prepared for each unit; so, when the troops embarked, each unit had one truck, or other vehicle, which could not be loaded and had to be left behind. There was a lot of hell raised about this, but nobody ever criticized the Chief Surgeon. These changes had been made through command channels." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 17 Sept. 1958, and personal conferences, Dr. Hawley and Colonel Coates, during October 1958.)
82Circular Letter No. 122, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 17 Aug. 1943.
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chief of medical service, the chief of surgical service, andthe ward officer of the particular patient. If a chief of service wasunavailable, the appropriate assistant chief was directed to act for his chief.The directive further required a review by a disposition board of all cases inwhich it was believed a patient should be returned to the United States forfurther observation, treatment, and disposition. The recommendations of theboards required final approval by the hospital commander.
The action of these boards had been notably inconsistent and,in many cases, unduly delayed. To General Hawley's question, Colonel Kimbroughreplied that the appropriate consultants had been reviewing reports and spotchecking final recommendations. He said that a great many cases which theconsultants felt could be retained for duty in the theater were still being sentto the Zone of Interior. In such cases, Colonel Kimbrough continued, telephonecalls were being made to hospitals involved to check on the validity of thedecisions.
General Hawley then instructed the professional services tocontinue just that action and to submit recommendations for improving theprocedures.
The emphasis at this time was on the conservation ofmanpower, and General Hawley's feelings were well expressed at this meeting asfollows:
* * * The point is this. We all want toprotect ourselves. We have to conserve manpower. We have to stop getting peopleout of the Army who can do any kind of a job at all. Can we be in a position tosay there is nothing wrong with this man? He might walk right out and drop dead.That is just too bad. We have done everything we can, but it is going to savehundreds of other people for duty if we establish a policy and stick to it. Iwant you to think it over. We have, all of us, to get out of the family doctor'spsychology here and we have to know that we are going to make some mistakes. Canwe keep those mistakes down within reason and can we assure our preventing a lotof mistakes being made on the other side? If we can almost break 50/50 on it Ithink it will be worth trying because we have to preserve manpower.
Colonel Cutler, in his visits to hospitals, had found thatone source of the problem lay in the lack of guidance to disposition boards. Forexample, he had found that many officers would have liked a list of conditionswhich would be appropriate for returning a soldier to the Zone of Interior. Withhis senior consultants, the Chief of Consultant in Surgery worked out such alist, as did the medical consultants. The list was submitted, but General Hawleywas reluctant about publishing a list of this type because he thought that eachindividual case had to be judged on its own merits, especially with regard tothe duty which the patient would be expected to perform should he be retained inthe theater. Yielding to the advice of his consultants, however, the ChiefSurgeon permitted the list to be published on 24 March 1944, as Circular LetterNo. 45, with the following qualification: "It is to be remembered that thislist is to be used only as a guide, each case to be decided on its individualmerits."
Aftermath of Operation CRACKSHOT - When the general planfor medical operations in England to support the invasion had been more or lessfirmly established, General Hawley had called for trial evacuations from transithospitals to the southern belt of general hospitals which were being designated
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for the primary definitive treatment of patients. These wereactual movements of real patients using ambulance and hospital train units whichhad been earmarked for the evacuation mission in England (fig. 67). One of thesetrials was Operation CRACKSHOT. The Chief Surgeon was quite pleased withCRACKSHOT because it showed where weaknesses in the plan were and because theobservers of the trials had made such a thorough and careful analysis of theseweaknesses. The Chief Surgeon called a meeting of his key staff officers on 24March 1944 at which he opened proceedings by saying:
We have to button up some things here beforeoperations.
There will be a stenographic report made ofthis but * * * anything decided here ought to be put out as a directive and bythe time I get back [from the Zone of Interior] I would like to see most of iteither accomplished or well on the way. We have not much longer now. All ourmistakes have to be behind us.
The first thing is this report in detail onthe Operation CRACKSHOT. I understand that we have had, in a few days, somethingwhich has pointed out the weakness of things in general.
From this beginning, the conference proceeded in rapid-firefashion, most of the decisions being made by the Chief Surgeon followed by hisspecific directions as to the actions to be taken. The following topicsconcerned the Chief Consultant in Surgery.
"Here is a very important thing," said GeneralHawley reading from the Operation CRACKSHOT report, "Recommend that thescope of treatment given at these transit hospitals be definitely outlined andthat Professional Services be consulted as to the necessity for augmentingpersonnel with surgical teams." The Chief Surgeon continued: "Now,these are evacuation hospitals and they have definitely to limit the amount ofwork that is done. You cannot immobilize patients there any more than in anyother evacuation hospital."
"That has been considered," Colonel Kimbroughanswered, "and that is a general policy."
General Hawley then directed, "Will you give ussomething that can be published that we can hold them to?"
And then a little while later, "Question ofprocedure," said General Hawley, "slightly wounded ambulatory patientsto be separated from serious cases."
Colonel Kimbrough explained, "That triaging is plannedto start on LST's."
General Hawley's comment: "It will work on LST's,but it won't be complete and final. Every hospital has to triage its ownpatients. Hospitals cannot depend upon triaging on LST's; every unit has to doits own."
Colonel Kimbrough then made a recommendation which hadcontinually been made by his division. He stated: "It is recommended that aresponsible medical officer, not just a junior officer, be at the hard to dotriaging."
Thinking aloud, General Hawley said:
When these patients get to a general hospitalthey have to be triaged again. We have to keep those beds for seriously wounded.If a patient does not get definitive treatment in transit hospital he has to getcompletely definitive treatment in some station hospital some place else toclear that bed for a seriously wounded man who cannot he moved.
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Our first run of patients will be from transit hospitals tothe southern belt of general hospitals. We cannot let that southern belt ofgeneral hospitals get full of minor casualties. We have to keep those beds forpeople who cannot be moved any farther than that.
We have a lot of beds in East Anglia not going to be full,perfectly competent for taking care of arms and things after first definitivetreatment. The point is, you have to keep those southern belt general hospitalsfor serious cases that cannot be moved after definitive surgery.
And then, after a very brief discussion, General Hawley madea decision and issued to the Operations Division the following instructions:"Incorporate in the plan the further evacuation to station hospitals ofslightly wounded whose initial definitive treatment has been completed, in orderto keep the beds in the first row of general hospitals fluid for serious casesthat cannot be moved."
FIGURE 68.-Lt. Col. Fred H. Mowrey, MC.
This discussion brought to General Hawley a thought on the spur of themoment. "A second thing on that," he added, "it is to keep thesegeneral hospitals indoctrinated that as soon as the patient can safely be movedto the Zone of Interior he is out and on his way home. I cannot impress that toomuch."
"I would like to emphasize that they do that now," explained Lt.Col. (later Col.) Fred H. Mowrey, MC, the hospitalization and evacuation officer(fig. 68). "However, some of them have been keeping patients more than 180days. I would like to have all of those boarded so that we get rid of themwithin the next 6 weeks."
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"I approve of that," agreed the Chief Surgeon,"In every case right now, let's start unloading beds-every case thatwill not be fit for duty in 180 days to be boarded and reported forevacuation." Then, addressing Colonel Kimbrough, he stated:"Responsibility of Professional Services. The hospitals are keeping uptheir bed strength unnecessarily. Professional Services, you have to stopthat."
"We have been working on that both with hospitalcommanders and at base section meetings," Colonel Kimbrough assured thegeneral, "We checked up to see about it. When we find they are not doing itwe tell them to get this man or that man out."
General Hawley warned with portent, "We have to gettough with somebody here-or else."
Colonel Kimbrough took these and other discussions at thismeeting to mean that this division would have to work out an SOP for the care ofpatients in near-shore installations and transit hospitals. He also emphasizedthe necessity for checking on and instructing hospital disposition boards, notonly in their responsibilities for conserving manpower, but for acting quicklyand early on all cases to keep their hospital beds free.
General Hawley went one step further. He issued a directiveapplicable to each consultant in the Chief Surgeon's Office which made it hispersonal responsibility to check on disposition board procedures at eachhospital visited, regardless of the original purpose of the visit, and to seethat hospitals were not keeping patients who should have been transferredelsewhere.
SOP (standing operating procedure) for professional care ofcasualties - Three days after the Operation CRACKSHOT meeting, ColonelZollinger had prepared and submitted to Colonel Kimbrough, with Colonel Cutler'sapproval, a statement of the professional care to be provided casualties in thevarious echelons in England during the attack on the Continent. ColonelZollinger also prepared the necessary correspondence for obtaining the personnelrequired to provide the care stipulated.
With respect to surgical treatment on board LST's, thesubstance of the SOP was as follows:
Surgical treatment on board LST's will be similar to thatof a divisional clearing station. Definitive surgery is not contemplated exceptin those instances in which it is necessary to receive patients with abdominalwounds, or similar casualties, occurring on board ship as a result of directenemy action. The decision to perform major definitive surgery on board LST'swill be governed by the type of wound, the estimated time interval from woundinguntil near shore definitive treatment is available, the professionalqualifications of medical personnel, and, finally, the volume of casualties.
The casualties will be triaged on board ship into two majorclasses, ambulatory and stretcher cases. The stretcher cases will be furthertriaged into "transportable" and "nontransportable" * * *.The nontransportable casualty will be defined as a casualty requiringimmediate resuscitation or surgical intervention after unloading from the LST.
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FIGURE 69.-The 46th Field Hospital at Chandler's Ford, Hampshire, England, June 1944.
At the hard, the plan called for two or three experiencedsurgeons for triage. These officers with mature surgical judgment were toreevaluate casualties into transportable and nontransportable cases. The planalso noted that ambulance evacuation was now going to be necessary from ships tothe nearest medical facility, of which there were to be two types-fieldhospital platoons augmented by surgical teams and full field hospitals alsoaugmented by surgical teams. The scope of treatment at these facilities was tobe substantially as follows:
Field hospital platoons of 100-bed capacity will be located nearthree of the major hards. These units will receive the nontransportablecasualties and other casualties which might occur about the hard. Such casesshould be of the type requiring resuscitation as well as definitive surgery. Ithas been suggested that two general surgical teams and two shock teams beassigned to each of these units.
A tented field hospital with a capacity of 400 beds, will belocated 5 or 7 miles from each of the three major hards (fig. 69). Because ofthe urgency of unloading LST's rapidly, it is anticipated that it will benecessary for the ambulance companies to unload the majority of the casualtiesat these stations. Major definitive surgery of all types, chiefly on thosecasualties labeled nontransportable, except neurosurgery, maxillofacial surgery,and the less urgent chest surgery, will be performed in these units. It will benecessary, therefore,
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that these units be heavily reinforced with surgical teams.It has been suggested that three surgical teams and one splint team be assigned.
For the general and station hospitals designated to act astransit hospitals, the plan called for procedures substantially as follows:
If time permits and the condition of the patient warrants,the ambulance companies will deliver casualties directly to these hospitals.Furthermore, they will evacuate the casualties from the field hospitals to theseunits as soon as possible. Casualties will be subsequently transported inlandfrom the transit hospitals by hospital train.
It is essential that the professional qualifications of themedical personnel of these designated transit hospitals be evaluated by theProfessional Services Division. Furthermore, it has been suggested that threesurgical teams be assigned to each of the nine transit hospitals to insureadequate personnel to cover the 24-hour period. The surgical chief of one of thethree teams assigned to each unit should be an orthopedic surgeon.
The plan was forwarded by Colonel Kimbrough to the OperationsDivision, Office of the Chief Surgeon, on 3 April 1944 for guidance andinformation in the formulation of operational plans and directives.
On 27 March 1944, when the SOP was prepared, ColonelZollinger addressed a memorandum to Colonel Kimbrough through Colonel Cutlerrequesting the augmentation of transit hospital staffs so that the care calledfor in the plan could be carried out. In this communication, Colonel Zollingermentioned that personnel of the 1st Auxiliary Surgical Group could not beconsidered for these augmentations, since most of the teams would be assigned tothe field hospitals and field hospital platoons working independently. Asurgical team for transit hospitals, Colonel Zollinger recommended, shouldconsist of two surgeons, one anesthetist, one nurse, and two surgicaltechnicians. He reiterated the portion of the SOP which called for three teamsto be assigned to each transit hospital, the chief of one of the teams to be anorthopedic surgeon. He asked also for two or three experienced surgeons fortriage of casualties at each of the hards. Finally, the recommendation was madethat these teams be organized sufficiently in advance of their actual employmentto permit individual members to learn to function as a unit.
The request was forwarded to the Personnel Division, Officeof the Chief Surgeon, which assessed quotas to each of the four base sectionsfor 18 surgical teams and 9 orthopedic teams. The requirement for providingtriage officers at the hards was placed on the Southern Base Section.
When Colonel Cutler finally had more time to devote to theseplans, he submitted additional items for the SOP on the care of casualties inthe forthcoming operations.
With respect to transit hospitals, he offered the followingin a memorandum to Colonel Kimbrough, dated 10 April 1944:
In the event that the transit hospitals arecrowded with casualties needing definitive surgery then the ambulatory andlightly wounded personnel should immediately be evacu-
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ated to the General Hospitals in the base areain order that there should be no great delay in their surgical treatment. Thiscategory of casualty represents a primary responsibility of the MedicalDepartment, for these men with good surgery at an early date can be restored toactive duty in the combat forces.
In the same memorandum, he submitted the following item, withrespect to general hospitals in the base area:
The general hospitals in the base area willcarry out primary definitive surgical treatment on all casualties reaching themin whom such care has not already been given. This may largely consist of thelightly wounded ambulatory cases who are expected to stream through the transithospitals without opportunity for definitive surgery at that level. These areextremely valuable personnel and deserve optimum surgical care since theyrepresent returnable manpower to the combat forces.
Cases also will reach the general hospitalsafter definitive surgery has been carried out at the transit hospitals. Many ofthese with the assistance of chemotherapy, either the sulfonamides orpenicillin, or both, will be found suitable for secondary suture of the woundand thus have the period of disability limited.
Another function at the general hospital levelwill be the transfer of Allied forces casualties, chiefly British, to their ownhospitals. This function will be implemented through the Office of the BaseSection Surgeon. Transfer of the British casualties to British hospitals mustnot occur until the base area has been reached.
Personnel requirements confirmed.-At about the sametime that Colonel Cutler was dictating these additions to the standing operatingprocedure for professional care during the invasion, Colonel Zollinger notifiedthe Chief Consultant in Surgery, in a memorandum, dated 8 April 1944, that therewas some question as to the number of surgical teams required or desirable inthe transit hospitals. Colonel Zollinger said that there might be changes, also,in the final number of transit hospitals. Colonel Cutler informed the chief ofthe Professional Services Division that there was no reason to change theoriginal professional opinion for two general surgical teams and one orthopedicteam to augment each of the transit hospitals.
Exercise SPLINT - A few days later, Colonel Cutler wasable to catch up with the most recent planning on the contemplated LSToperations. With Colonel Liston, he journeyed to the southern port of Newquay on12 April 1944. There, the entire morning was spent in observing an exerciseinvolving beach operations and the loading of casualties into LST's (fig. 70).In the afternoon, General Kenner, Chief Medical Officer, SHAEF, presided over acritique of the exercise, following which General Lee flew Colonel Liston andColonel Cutler back to London in his private aircraft.
Among other matters, there was a good discussion on the timerequired to load an LST with casualties. The Navy pointed out that it took 3hours to unload an LST, and perhaps more. With the proposed single-sling loadingof casualties over the sides of LST's from small boats, one casualty could beloaded each minute, thus making a good load of 180 casualties in 3 hours.Furthermore, the Navy pointed out, there was no reason to load the LST anyfaster because there was no room for casualties until the material on the shipwas moved out.
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With respect to the weather hampering operations, the Navystated that, if LST's could be unloaded, they could be loaded. That is, if theoperation was on, casualties could be returned. But, perturbing, at thiscritique, was the estimate now entertained by some that casualties would be onLST's for 48 and even 72 hours!
"The above expectation of the time a man awaitssurgery," warned Colonel Cutler, "demands the presence of a goodsurgeon on each LST." "Moreover," he added, "we mustremember that the first casualties, irrespective of the condition, will beshovelled into the nearest boat and, also, serious casualties may occur on anyship."
Colonel Cutler was pleased to learn, however, that the Navywould provide 2 general medical officers for each LST and would accept acomplement of 100 Army surgeons, with assistants, for assignment to these ships.Col. (later Brig. Gen.) Thomas D. Hurley, MC, Surgeon, Third U.S. Army, saidthat he was providing 45 good surgeons for this purpose. The others were to comefrom Air Force and Service units in the United Kingdom. Captain Dowling of theNavy stated that a course of instruction would be given these surgeons, whowould be doing the major work on the LST's, some 4 or 5 days before theoperation.83
However, on 24 April, at the conference of base sectionsurgeons, it was necessary for Colonel Cutler to make this rather dismalannouncement:
With reference to furnishing the Navy fullyqualified surgeons for LST's, a directive was sent out asking for nominations,and we have been checking on those we have received. We promised the Navywell-qualified surgeons. I think the Base Section Surgeons may not have fullyappreciated this as we have received nominations of very young and inexperiencedmen.
"I think everybody understood thoroughly,"commented General Hawley pointedly. And then to Colonel Cutler, he said: "Ithink you are going to have to get those people by looking over their * * *cards in this office, deciding whether they can be spared from that unit or notand ordering them."
Early ambulatory management - General Hawley-everconcerned with having a sufficient number of available beds before and duringthe continental invasion-directed the Professional Services Division to lookinto the matter of accelerating professional care by early ambulatory managementof postoperative patients. He referred to precedents' having been establishedin the United States in this direction and suggested that it might even bebetter for the patient, himself. The matter was brought to the attention ofColonel Cutler, who stated in a memorandum to the chief of the ProfessionalServices Division, dated 24 April 1944, that the Professional Services Divisionexerted constant pressure to assure that personnel hospitalized for surgicalreasons were out of bed at the earliest possible moment. He continued:
The tendency in the U.S.A. to get people up onthe first or second day is now widespread. * * * In the Peter Bent BrighamHospital, Boston, Mass., I have heard recently
83Memorandum, Chief Consultant in Surgery to Chief, Professional Services Division, 16 Apr. 1944, subject: Comment on Exercise SPLINT.
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with joyous comments from my junior associatesthat the average patient is out of bed the day after his surgical ordeal. This Iconsider to be unfortunate and an undesirable practice for the advance ofsurgery. We must remember that the art of medicine and surgery has attached toit just as many fads and fancies as other walks in life, and we must recall thatit take time for wounds to heal. We know many ways by which wound healing isprevented, but we have as yet discovered no agent and no method for hasteningNature's process. Certainly to keep people in bed unnecessarily long merelyweakens their general condition and probably therefore somewhat delays healing,but to force Nature beyond her powers is even more foolish.
The U.S. Navy has stated that they get peopleout of bed earlier than we do in the Army. Maybe they do. That does not make thewound heal faster, and moreover we must recollect the people in the Navy and inthe Air Force do not have to walk with 50 odd pounds on their back over greatdistances. Rehabilitation for the soldier is rehabilitation for the maximumeffort, and that is not true with other branches.
Colonel Cutler then called attention in the memorandum to thefact that a manual for bed exercises was being prepared and that the period ofbed rest could probably be considerably shortened with specific setting-upexercises. He also made the following recommendations:
That the Division of Professional Servicescontinue their influence to reduce the period of bed rest to the shortest periodof time compatible with solid healing of the wound, and this of course varieswith the position of the wound, for all those except those with wounds of theabdomen and lower extremity may be out of bed within a few days of theirsurgical ordeal.
While these recommendations were no doubt acceptable, therewas apparently a decision that a directive was also necessary to make a programof accelerated care mandatory upon hospitals in the theater. Accordingly, underdateline of 14 May 1944, Colonel Cutler submitted in draft a directive entitled"Early Ambulatory Management Following Surgical Procedure." Insubmitting the proposed directive, Colonel Cutler advised Colonel Kimbrough:"When the document is presented to General Hawley I believe it shouldcontain a statement that 'Professional Services Division believes that agreater contribution to the saving of time in hospitals will result fromacceleration of the administrative program than from this questionableacceleration of professional care.'"
With minor modifications, Colonel Cutler's document waspublished as Administrative Memorandum No. 74, Office of the Chief Surgeon,ETOUSA, 22 May 1944, and directed that all patients be made ambulatory as soonas possible following surgical procedures. Certain obvious exceptions to thepolicy were specified, and the directive warned that abdominal incisions, exceptfor the McBurney type, now had to be supported by "through andthrough" or retention sutures. Colonel Cutler was able, however, to haveinserted in the directive instructions requiring the number of days of total bedrest to be noted on each patient's record. General and station hospitals werealso required to make an evaluation of the results of this regimen in theirmonthly surgical reports. To Colonel Cutler, it was a matter of waiting andseeing if the results bore out the contention of this directive, which openedwith the statement: "Recent observations have suggested that thetraditional duration of bed rest following surgical procedures can be shortenedmaterially with
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benefit to the patient. This leads to a reduction in thepatient's recovery period, a conservation in manpower, and a saving ofhospital beds."
Curiously, the same proposition was brought up in a meetingof the British Army's consultant committee meeting, but Lt. Gen. Sir AlexanderHood and his consultant accepted Colonel Cutler's recommendation that theBritish Army await results of the American experience before committingthemselves to such a program.
Recapitulation - At the Chief Surgeon's meeting withhis division chiefs on 2 June 1944, Colonel Cutler heard General Hawley closethe meeting with these words:
I don't know when D-day is, and if I did Icouldn't tell you anyhow. But it is logical to assume that it is not too faroff now; if we have left anything undone, the time is falling short. We must beready to go. I think in the transit areas they are ready to go.
What had the Chief Consultant in Surgery done to be ready togo? In summing up, the following things stand out:
1. Everything possible from the professional side had beendone to clear beds in anticipation of the expected casualties. Dispositionboards had been trained, checked, and exhorted to carry out their functionsrapidly and properly. A program of early ambulatory management had beeninstituted to get the patient on his feet more quickly. When it was discoveredthat administrative proceedings, rather than professional, were holding up thedisposition of patients, the consultants had adamantly brought this to theattention of those in the position to do something about it. The rehabilitationprogram had been put in full force to clear hospital beds and return men to dutyearlier and in better physical condition.
2. The blood bank was ready to go, and bleeding sets had beenconstructed and distributed to augment the distribution of whole blood. Lastminute procedures had been completed to supply LST's with 10 pints of bloodeach. Marmite (Thermos) cans had been procured so that whole blood could bepacked in them and taken along by the leading assault elements (fig. 71). Toolate, possibly, it had been realized that the supply of whole blood availablefrom local sources might be insufficient. It would be sufficient for the initialphases, however, and plans had been made for increasing blood-collectingfacilities.
3. Penicillin for the initial assault had been assembled orwas on its way. Quantities required to sustain subsequent operations had beencalculated and requisitioned. Decisions had been made on how penicillin was tobe used, and the command instructed accordingly.
4. LST's had been carefully studied and the lifesavingprocedures necessary on shipboard had been agreed upon and were well understoodby all concerned. Surgical instruments, scarce as they were, had been assembledinto kits and placed on these ships. Linen was obtained and rolls of disposablerubberized sheeting had been supplied to be used for surgical drapes. Finally, ahandpicked complement of 100 qualified surgeons was ready to board
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the ships-one to an LST. They had been briefed by ColonelCutler and his assistant, Colonel Zollinger. They were also being briefed by theNavy.
5. Principles of triage on LST's had been formulated, andcards for tagging the casualties had been prepared. Surgeons of mature and soundjudgment had been selected to act as triage officers at the hards and ports. Thesupervision of these triage officers and the control of surgical teams in thetransit areas were in the able hands of Lt. Col. George K. Rhodes, MC, surgicalconsultant to Southern Base Section. He had also personally inspected thepersonnel and facilities at all the hospitals in his area to be sure that thework to be done at each facility was being supervised by a topnotch surgeon andthat all understood just what was to be done and what was to be left undone.
6. Surgical teams had been picked, organized, briefed, andstationed at holding and transit hospitals to augment their regularly assignedstaffs. Policies for the assignment and use of surgical teams in the field armyand in other areas of the communications zone had been elaborated and announced.
7. Policies and procedures for the professionaladministration and management of battle casualties from the frontline areas tohospitals in the rear had been established and promulgated. A pocket-sizededition of the Manual of Therapy had been printed and distributed so that eachmedical officer caring for patients in the combat zone or in the communicationszone would have a ready reference as to how injuries and diseases were to becared for in the European theater.
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8. A close and sympathetic understanding had been establishedbetween the British and the Americans as to the surgical plans each wasfollowing. They were ready to accept each other's casualties and care for themuntil they reached the base areas.
These were the preparations. Was there anything yet undone?There was.
Use of consultants during assault phase - On Thursday, 1June, the day before the 2 June meeting with the Chief Surgeon, Colonel Cutlerhad approached Colonel Mowrey and Colonel Liston as to what the professional menmight do during the assault on the Continent. He had proposed that certain ofthe consultants might help out at the holding hospitals for thenontransportables, the orthopedic men could help out at the transit hospitals,and the remainder of the specialist consultants might work out of Cheltenham andbe used wherever their services were required. Now some had been opposed tothese thoughts, but on this occasion, both Colonel Mowrey and Colonel Listonwere agreeable to the idea.
Earlier during the Chief Surgeon's meeting on Friday, 2June, Colonel Cutler had managed to mention, in passing, his hopes for the useof consultants during the attack. "They may be used in transit hospitalsbest by pushing patients through," he said. And then, dwelling on GeneralHawley's favorite theme during this period, Colonel Cutler added:"Hospitals tend to keep patients too long."
"I agree with you," the general replied, "butthose people down there have a responsibility, and if these consultants are usedin that capacity only, that is fine, but none of us, short of an extremeemergency where the system will fall down, none of us can step in down there tooperate the system. That is the function of SBS [Southern Base Section]."
To Colonel Cutler, this reply was noncommittal anddiscouraging. He took it to mean that General Hawley was against the proposal.So, he remained after the meeting and, in the afternoon, was able to see GeneralHawley with Colonel Liston. Both General Hawley and Colonel Liston were entirelyin favor of the proposed use of consultants. Moreover, General Hawley askedColonel Cutler to be with him, personally, during the early phases of theattack. To Colonel Cutler these reactions were wonderful. He was elated, but atthe same time he was cautious. "So I laid it on in a memo," he wrotein his diary. The 4 June 1944 memorandum, the subject of which was theutilization of surgical consultants during operations, was addressed to theChief Surgeon through the Chief of the Professional Services Division. Itstated:
1. During periods of great activity, thefunction of evacuation must be the prime concern of the MedicalDepartment.
2. The surgical consultants are seniorofficers with a long experience in this theater, and are fully cognizant of theimportance of evacuation. They realize that to choke a hospital with morecasualties than the surgical teams assigned there can handle in a 24-hour periodmeans undesirable delay in the period before definitive surgery can be
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carried out. If evacuation is prompt andefficient, casualties passing through transit hospitals without definitivesurgery will actually have surgical care at an earlier period in some generalhospital behind the transit hospital area.
3. There are two points at which evacuationmay be unnecessarily delayed.-
a. By holding "transportable" casualties as "nontransportable" in field hospitals.
b. By attempting to hold too many casualties for elaborate surgical care at the "transit" hospitals.
4. To assist in facilitating evacuation andequally to hold in field and transit hospitals those who should be held there Irecommend that the following officers be assigned as designated below during thefirst phase of the operation until a proper procedure is established.
a. To the field hospitals for "nontransportables" at each area as follows:
Hard A-S [Southampton area] (FH 46, FH 28, SH110)-Lt. Col R. M. Zollinger.
Hard B-P [Portland-Weymouth area] (FH 12, FH 50, EH 109, EH 12)-Lt. Col. G. K.Rhodes.
Hard C-B [Torquay-Brixham area] (FH 7, FH 49)-Lt. Col. E. M. Bricker.
b. To the transit hospitals above A-S (GH 95, GH 48, SH 38)-Lt. Col. M. Cleveland.
To the transit hospitals above B-P (GH 28, SH228, SH 315)-Lt. Col. W. Stewart.
To the transit hospitals above C-B (SH 316, SH 115)-Special assignmentunnecessary.
5. The remaining senior consultants in thesurgical specialties, Colonels Stout, Vail; Colonels Spurling, Allen, Canfield,and Tovell will remain at Headquarters, SOS, prepared to go where their servicesare required. Since definitive surgery will largely be done in the generalhospitals behind the level of the transit hospital, their activities will belargely in that area.
The memorandum was returned quickly to Colonel Cutler withone word on it in General Hawley's bold scrawl, "Approved," followedby his initials. This document facilitated the procurement of necessary passesfor the consultants to permit their entry into and egress from the staging area.It was difficult enough to enter the critical areas, but it was more difficultto get out, once a person was in. The actual date for the invasion was stillobscure, but the surgical consultants were now ready.
NORMANDY
D-Day WeekOn Tuesday, 6 June, Colonel Cutler was off on a trip withColonel Kimbrough and Colonel Zollinger in the direction of the A-S hard tocheck on preparations made by holding and transit hospitals in the area. Theyfirst visited the 38th Station Hospital at Winchester, Hampshire, and foundeverything satisfactory. Next was the 110th Station Hospital at Netley,Hampshire. The Southern Base Section surgeon, Col. Robert E. Thomas, was there.He appeared surprised when three officers from headquarters appeared on arelatively routine visit. The invasion was on, he told them (fig. 72). ColonelCutler could scarcely believe him. The radio was turned on, and, sure enough,the same story appeared. With renewed purpose, the three officers continuedtheir tour. At the Royal Victoria Hospital, which had recently been turned
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over to the Americans by the British, quantities ofammunition crates littered the beach where they had drifted in after beingthrown overboard from combat ships of the Navy on their way out (fig. 73). Thethree officers completed their tour with visits to the 46th Field Hospital, aholding unit, and to the 48th General Hospital, one of the transit hospitalssupporting the A-S hard, and returned to London.
Arriving at 9 North Audley Street the next morning, ColonelCutler learned that General Hawley had packed and motored to Cheltenham. ColonelCutler hastened to the 1st Medical General Laboratory at Salisbury, Wiltshire,which had been designated the command post for the Chief Surgeon during theassault phase. There, he learned that penicillin was a problem and that thefifty billion units ordered for June had not arrived. "Ordered 50billion," he wrote in his diary, "only 600 million now here. Half onbeaches 'far shore,' half on LST's and for distribution here. But it is amess. All write lots of penicillin! We order and none comes." At midnight,he was still preparing a letter to Col. (later Brig. Gen.) John A. Rogers, MC,First U.S. Army surgeon, for General Hawley, saying there was no penicillin.Nevertheless, he did have time to note: "The continental invasion is on atlast. All are excited; too much so. Here I am with General Hawley sleeping innext room to me. I wouldn't have believed it possible 2 weeks ago."
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Thursday, 8 June, Colonel Cutler wrote, was a "wonderfulday with PRH [General Hawley], all day." He was up at 0630, had breakfastat 0700, and embarked on the following:
1. Off with PRH at 8 :00 a.m. * * *.
2. Southern Base Section and reports onwounded arriving and evacuated on.
3. 12th and 109th Evacuation Hospitals. Intents, pretty good-not too good-interesting femur and buttock at 109th. Badjaw and chest at 12th. Sent jaw, chest, femur, and 1 other by ambulance to 67thGeneral Hospital.
4. Lunch at 50th Field Hospital in Weymouth(two platoons) (fig. 74). George Rhodes there. Bad eye case; sent for D. Vail.Many cases were treated. GKR [Rhodes] had seen 3 abdominal cases all operated onLST's. Good work * * *.
5. To Bristol, hard. Other platoon of 50thField Hospital close by. Did not visit and did not go to 12th Field Hospital.Roads full of LCP's; went on one. U.S.S. Quincy in harbor; 1 majorgeneral and 1 brigadier general [aboard]. Skipper told of tough time on beach.Many dead * * * underwater stuff.
6. To 305th. Interesting cases. Spleen, 36hours. Eye and brain case.
7. To Sherborne to see train unload; late(fig. 75).
8. Visits to 3d Armored Division to MeetGeneral Hawley's son-in-law, Captain Towsey. All in pup tents.
9. To Southern Base Section headquarters.
10. Here Salisbury. Thomas came to call. Hesaid (a) Orders not to do surgery but evacuate means no evacuation 'tillhospital fills; negative number of cases, therefore nothing doing. (b) No recordif in hospitals under 48 hours-wrong. Field Medical Record (FMR) should startwith first definitive procedure. (c) Thomas reported cases at various hospitals,including 60 PW's, largely at 110th Station Hospital.
11. Call in from First Army re penicillin. Isaid General Hawley had written letter to Colonel Rogers.
12. Now I must write something for ColonelThomas.
At the end of the day, Colonel Cutler had these thoughts inmind:
The war is on here. Have been about, as onecan see. * * * But is it going OK? Where are the LST's? They are not comingback and wounded are coming in on APA's; no good staff, poorly cared for. Onefemur with no splint. Stories from wounded: Left on beach between 6:00 and 8:00a.m., lay on beach, no assistance * * * got wet as tide came up, crawled torocks (one with fractured femur), help to one at 4:00 p.m.
The next day, 9 June, was D+3. Colonel Cutler arrived atSouthern Base Section headquarters at 0830 for a long talk with Colonel Thomas.They discussed further the problem of hospitals erroneously assuming that theywere to do no surgery and just wait until enough patients accumulated to beevacuated by train. They also spoke of means to rectify the situation withrespect to initiating field medical records at the time of first definitivetreatment. Later, Colonel Cutler visited Maj. Gen. Eric Barnsley, RAMC, thesurgeon of the British Southern Command. General Barnsley said that the Britishhad had 400 wounded on D+1 and 1,200 on D+2. Next, Colonel Cutler went on to the109th Evacuation Hospital, where he had lunch and spent the remainder of the dayat the beach at Portland (fig. 76). It was a great day and experience. Some 19to 22 LST's came in with about 2,000 wounded (fig. 77). Care on the LST'shad been good, but Colonel Cutler noticed considerable crowding anddisorganization on some of them. Ships with casualties were
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waiting an inordinately long time in the harbor in order tocome in and unload their precious cargo.
The next day, Saturday, 10 June, was spent in catching upwith the events of the past week and reflection upon what he had observed. Inthe morning Colonel Kimbrough held a meeting of the Professional ServicesDivision, and the remainder of the day was spent by Colonel Cutler in writingletters, preparing reports, and putting some order into the data beingassembled. The following recommendations were submitted to Colonel Kimbrough ina memorandum, dated 11 June 1944, as a result of the observations made duringthe first week:
1. Medical record. In all hospitalsvisited found F.M.R. was not started following surgical therapy for fear ofstaff that this was not allowed (see SOP). Because of this feeling, and with thedesire for some record, most hospitals had mimeographed a form of their own witha clinical chart, so that some record could be kept of surgical cases.
Recommendation: TheF.M.R. shall begin at the time any definitive medical or surgical care starts.
2. Surgical care. At all hospitalsvisited I found that the staff and the commanding officer had interpreted theSOP to mean that only the first aid care could be given in transit hospitals.This had led to men being given first aid care and then, since there were fewadmissions, the staff sitting around waiting for the patients to be evacuated,but, as only a trainload could dictate when a hospital was to be evacuated,casualties were not being evacuated and were sitting around with nothing butfirst aid care, when a surgical procedure might have greatly increased theiropportunity for rapid restoration to duty and survival with better function.
Recommendation: a.Surgical procedures shall be carried out in transit hospitals as indicated bythe nature of the casualties and in relation to the pressure exerted by thenumber of casualties admitted. Thus, when there are only a few casualties, mostof them could have definitive surgery in a transit hospital. When there arelarge numbers of admissions, only those urgently requiring surgical care shouldhave it at the transit hospital level.
b. In special instances where ambulances areavailable and the condition of the patient justifies travel and the treatment ofthe condition can best be done at a neighboring hospital, then that patientshall be transferred by ambulance to the appropriate hospital where the facilityis available.
3. In observing the unloading of LST's atPortland, it is clear that only 5 LST's can unload at one time, 2 on the hardand 3 at the pier. It did not appear to us that more than 6 LST's would beunloaded and loaded in a 24-hour period, for the loading of an LST after thewounded are evacuated takes 6 to 8 hours. This delay is injurious to thecondition of casualties, and another method must be found for unloadingcritically ill people.
Recommendation: Whenthe hards and the pier are filled with LST's and more are waiting in the roadsthan can be unloaded in the next 12 hours, smaller crafts, such as LCT's (fig.78) shall go out to the LST's, take off the casualties and land at the manybeach areas where such smaller craft can unload.
The "SOP" Colonel Cutler was referring to in hisrecommendations was, as the reader may have realized, Administrative MemorandumNo. 62, which is discussed on pp. 173, 175. To Colonel Cutler, his fears hadbeen realized. The arbitrary changes which had been made on his recommendationshad resulted in a situation where patients who could and should have receiveddefinitive care were being neglected, and proper records were not beingprepared.
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FIGURE 74.-Continued. C. An operating pavilion. D. A surgical truck with attached operating tent.
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FIGURE 76.-A view of the Portland area and Weymouth, South Dorset, England.
Second Week, D+5 to D+11
The second week after D-day was pretty much a resumption ofthe first few days. On Monday, 12 June, Colonel Cutler accompanied GeneralHawley, Col. Howard W. Doan, MC, Colonel Humphrey, and Mr. Littell, warcorrespondent for The Reader's Digest, on a field trip to the Portlandarea. Concerning a visit to the 109th Evacuation Hospital during this trip,Colonel Cutler recorded: "* * * saw bad case blown up on ship; leftfoot gone, open fracture on right leg into knee joint. Very ill; not yetdressed; 6 days. Bad Rx, but not yet infectious. Suggested blood and then dressunder ether." In connection with the visit to the 50th Field Hospital, herecorded: "* * * have had five or six cases of gas gangrene; not allamputations, yet 6 days old! Why no more infection? Sulfonamide and penicillin?Saw German with right lower-quarter abdominal wound. Prisoner said: 'WeGermans have no chance-replacements not allowed.'" At the Portlandhard, Colonel Cutler was shocked to see many prisoners of war with wounded handsbeing taken off LCT's as litter patients.
Colonel Cutler was most pleased to see that LCT's weregoing out to the LST's to unload patients as he had suggested the week before(fig. 79). The entourage went out on a Higgins boat to watch the procedure. AtLST 59, they found: "Bob White aboard as triage [officer]. Captain Stewardof 85th
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FIGURE 77.-Ambulances on a dock at Weymouth awaiting the unloading of casualties.
General Hospital in charge. 85-plus Germans (fig. 80); 266casualties picked up wounded on D+2, 3, 4 but convoy [was] slow inreturning." And then: "To LST No. 501. (Should have seen GeneralHawley go over side!) Captain Keleher, 16th General Hospital, in charge. He haddone one abdominal wound on LST; OK; and one tracheotomy-died from multiplewounds [of the] chest. Needs blood and more penicillin; needs Atabrine formalaria and Levin tubes. Major Wilcox, 2d General Hospital, aboard as triageofficer. Saw women snipers in civilian clothes as wounded PW's. Americanboys had thought they had come to help French, yet French women had shotthem."
It was a busy day at Portland. By 1400, 715 casualties hadbeen taken off LST's, and by 1500, the total had risen to 1,052. The joy ofseeing LCT's unloading LST's was short-lived, for, as the party returned tothe 50th Field Hospital, they were informed that LCT's could no longer be usedfor this purpose. Back at the 1st General Medical Laboratory that night, therewas more talk about women snipers and, Colonel Cutler wrote, "PRH said you(ECC) and I go [to] France next week-goody!"
But, before going to France, Colonel Cutler was able toobserve the reception of casualties evacuated by air. Air evacuation had startedearly in the campaign, perhaps as early as D+4. A platoon of the 6th FieldHospital was at Ramsbury, East Wiltshire, and a platoon of the 28th FieldHospital, at Membury to receive air-evacuated casualties (fig. 81). ColonelCutler visited these facilities on 14 June. He saw three planes unloaded in 20minutes, and thought: "A-1. This is the secret for future good care, butcases must be se-
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FIGURE 78.-U.S.S. LCT 217, beached at Weymouth, England.
lected: no post-operative abdominal cases. Almost killed Lt.Col. [William D.] McKinley."
On Friday, 16 June, Colonel Cutler worked in the morning atthe Cheltenham office. He was back at the Salisbury "CP" by noon,where General Hawley had said he would meet Colonel Cutler.
The Prague and NormandyThe period from 17 through 22 June was spent on the hospitalcarrier, Prague. The Prague was one of four hospital carriersloaned by the British to the Americans during last-minute preparations forOperation OVERLORD. It was a 4,100-ton vessel with British crew and a complementof U.S. Army medical personnel. These hospital carriers were protected by theGeneva Convention, and were painted white with prominent markings using theGeneva Cross. The Prague was the largest of the four vessels loaned tothe Americans and could carry 194 litter and 228 ambulatory patients at onetime. Its complement of medical personnel included female nurses and attachedAmerican Red Cross workers. The record is notable for the absence of anyinformation concerning this period on the Prague. But, in thanking theship's captain on behalf of General Hawley and himself, Colonel Cutler wrote:"It was pleasant and the enforced rest did us much good." It also gaveColonel Cutler the opportunity to observe the evacuation of a group ofcasualties from the time they were loaded on the continental shores until theydisembarked in England.
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General Hawley and Colonel Cutler returned to Salisbury forthe night of 23 June (fig. 82) but left early the next morning by air for theNormandy beachhead, arriving at the Utah air strip at 0845 on 24 June. Theydeparted from Omaha airstrip at 2000 the next day, but in the interim ColonelCutler was able to visit the three platoons of the 45th Field Hospital, the 3dPlatoon of the 13th Field Hospital, the 621st Clearing Company at the Utahairstrip, and the 5th, 24th, 41st, 44th, 45th, 67th, and 97th EvacuationHospitals. In addition, he had the opportunity for lengthy conferences with theFirst U.S. Army surgical consultant, Colonel Crisler, and also Colonel MacFee.Upon returning, the Chief Consultant in Surgery reported to General Hawley in amemorandum, dated 28 June 1944, as follows:
* * * * * * *4. It is unnecessary here to take upindividual professional comments which were made directly to Colonel Crisler andmany of which were embodied in the memo for the First U.S. Army Medical Bulletinwhich he was preparing at the time we were there for Colonel Rogers' study andsignature, but the following comments may be of value:-
a. Blood
A large quantity of blood is being used by theFirst U.S. Army (fig. 83). I saw no instances, however, where I felt it was nothelpful and indeed desirable for the treatment of casualties. Should pressuredecrease, perhaps more plasma can be used in proportion to blood. I could notjudge from statistical data the exact relation between
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blood and plasma but I had the impression it was being usedalmost as frequently as plasma; that is, in the ratio of 1:1, whereas one hassome justification for the hope that a smaller amount of blood, backed up byplasma might yield almost as beneficial results, i.e. in the proportion of 1 ofblood to 3 of plasma. * * *
There were numerous complaints about the "set" notworking well. Some thought it was the filter, some the size of the giving needlein the vein, which was a part of the plasma set, and some thought it was theneedle which let air into the bottle as the blood ran out. * * * I am of theopinion that a chief difficulty lies in the method by which air enters thebottle, * * * or if the blood is not shaken and carefully mixed it becomesclogged by the buffy coat and coagulum which always settles out on top. Thismatter was discussed in detail with Major Hardin on my return, and he hopes tomake a trip immediately to the First U.S. Army and see if the difficultiescannot be smoothed out. Not all officers made complaints, so that the difficultycertainly is not insurmountable.
b. Penicillin
I believe the theater stocks will be able to keep up to thedemand for 500 million units of penicillin daily. * * * 500 million units willtreat only a little better than 2,000 casualties a day. * * * if the casualtiesare of a less serious type, the dose is halved and therefore 500 million unitswould suffice for 4,000 casualties a day. I am of the opinion that as pressuredecreases and the hospitals become well stocked, 500 million units of penicillinwill be ample for the present. Also, during my visit I found one surgeon who wasgiving 100,000 units per injection instead of the 40,000 prescribed. This isneither proper nor scientific and * * * I warned him it was unwise forindividual surgeons to experiment with doses at this time.
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FIGURE 82.-Omaha Beach, 23 June 1944.
c. Wound debridement
This, on the whole, was being well carriedout, but Colonel Crisler and I did see some assistant team surgeons operatingwhile their chiefs were resting who were not sufficiently well trained for thispurpose, and it would be wiser for the assistant to go off duty while his chiefis resting, and the casualty shipped by air to the United Kingdom, where thereare hundreds of capable surgeons waiting, than to do inadequate debridementunder the circumstances imposed. In commenting on surgery as a whole, I thoughtit was a little better in the field hospital platoons than in the evacuationhospitals, but my visit was very short and perhaps some brilliant surgeon'swork in one of the platoons of the 45th Field Hospital and one platoon of the13th Field Hospital overweights my judgment, or it may be that Colonel Crislerhas wisely placed his best surgeons with the field hospitals, where thenontransportables are being cared for.
d. Plaster of paris
I thought the general level of plaster workexcellent but I did notice a tendency for all femurs to be put in double spicaswith a good deal of abduction. It must be recalled that plaster is used toimmobilize the fracture in the period between the evacuation and generalhospital and that this period should be short. In the general hospitals, plasterwould invariably be removed and replaced by skeletal-suspension traction. Thismerely requires temporary immobilization and low-waisted single spicas should besufficient for transport. If double spicas are to be applied, the abduction mustnot exceed litter-width, else transport becomes difficult.
e. Abdominal surgery
I found four eviscerations in two days. Thiswas due to failure to use retention sutures. Colonel Crisler has calledattention to this in his professional memo for Colonel
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Rogers. I also saw two cases in which the surgeon did notexteriorize large bowel wounds but closed them without a colostomy. I believethis to be an unfortunate mistake and if frequently occurring would surely bringdisaster.
f. Thoracic and thoraco-abdominalwounds
The wounds I saw done at field hospitals bring forth my mostsincere appreciation. I still recollect a very difficult case of this type beingdone by Partington at a 45th [Field Hospital] platoon which had every element ofperfect surgical performance.
g. P.O.W.'s
At one hospital, where some 300 preoperative cases hadaccumulated, I found three prisoners being operated upon ahead of our ownsoldiers.
h. General comment
It is my overall opinion that the level of professional careis very high, certainly better than in the last war. The fact that members ofthe 3rd Auxiliary Surgical Group, who are well trained and thoroughly instructedin battle casualty care are doing much better work than the 4th Group as awhole, who had little in the way of orientation and instruction, emphasizesagain the importance of Army instruction even in professional work. The lowincidence of serious infection was striking and must be related to thebacteriostatic agents, penicillin and the sulfonamides, now employed in militarysurgery. The incidence of amputations seemed happily low, the incidence of gasgangrene also much lower than was expected or was present in the European War,1914-18.
In closing his report, Colonel Cutler recommended that medical elements ofthe First U.S. Army, at this time, should direct their energies to providingfirst aid care for the wounded and surgery only for those in which it would
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save life or limb. These priorities should be adopted, heexplained, for the following reasons:
Casualties given expert first aid care arrivedin the United Kingdom even two or three days later in excellent condition, but agood many did not have this. Many wounds had lost their dressings because theywere improperly applied, many were improperly splinted, and some, even compoundfemurs (personally observed), reached the United Kingdom totally unsplinted. Ifevery medical officer in the first week devoted himself to the control ofhemorrhage, adequate dressing, adequate treatment of shock with plasma andblood, and perfect immobilization, a perfect task would have been performed.When surgery is permitted early, many hands treat but a few, and many othersmust go carelessly dressed or improperly splinted.
Even at the present time I would suggest lessemphasis on immediate surgery for all and more emphasis on properly evacuatingthose who can travel safely. This must be a large number, and it seems mostunwise to allow any evacuation hospital to carry a backlog of unoperated casesof much over fifty cases.
Major Hardin Visits Normandy
On 28 June 1944, when Colonel Cutler submitted his report,Major Hardin was already on his way to Normandy to determine whether whole bloodwas being used in excess and what difficulties were being encountered in itsadministration. In the 3 days that he was there, he contacted members of theMedical Section, Headquarters, First U.S. Army; 1st Medical Depot; AdvancedBlood Bank, ETOUSA, Detachment A, 152d Station Hospital; and the 45th, 67th, and128th Evacuation Hospitals (fig. 84).
He informed Colonel Cutler, on his return, as follows:
* * * * * * *3. The problems encountered in the use ofstored blood were first discussed with Colonel Crisler, Consultant in Surgery,First U.S. Army. The difficulties were mainly in administration of the blood inthat the speed of flow was inadequate. The general opinion seemed to be that thefilter was at fault.
* * * * * * *Other errors in the use of the equipment whichwhen corrected will help increase the speed of flow were failure to thoroughlymix the blood by shaking and improper use of the filter. * * *
In the three hospitals visited the ratio ofblood to casualties was one (1) pint to four and seven tenths (4.7) casualties.The ratio of plasma to casualties was one (1) unit to three and two tenths (3.2)casualties.
The ratio of blood to plasma was one (1) pintto one and four tenths (1.4) units plasma. Many casualties receive plasma beforeadmission to hospitals, so that these figures do not present a wholly accuratepicture of the ratio of plasma to blood.
Reactions to blood as reported are extremelylow. It is not believed that this paucity of reactions is possible. Undoubtedly,minor febrile reactions are being overlooked in the rush of caring for numerouscasualties. No serious hemolytic reactions were encountered and consequently nodeaths from transfusion have been reported. A few instances of jaundice havebeen encountered in patients who have received large amounts of blood(3,500-5,000 cc's). In each case complicating factors were present such ashepatic injury, sulphonamide therapy, and collections of blood in body cavitiesor muscles. There was no case in which the jaundice could be attributed solelyto blood transfusion. However, * * * all stored blood, regardless of age,contains some free hemoglobin and * * * with massive
