CHAPTER III
General Surgery
Robert M. Zollinger, M.D.
By the fall of 1943, Lt. Col. (later Col.) Robert M.Zollinger, MC, had been serving for approximately 15 months as chief of thesurgical service in the 5th General Hospital, ETOUSA (European Theater ofOperations, U.S. Army). This was a unit affiliated with Harvard University andwas the first general hospital to be shipped overseas. The 5th General Hospitalwas established in Northern Ireland early in the spring of 1942.
The incumbent Senior Consultant in General Surgery becameill, necessitating his return to the Zone of Interior (fig. 126). Thepossibility of Colonel Zollinger's replacing him was first broached to theauthor by Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant inSurgery in the European theater. At first, this new assignment seemed quiteacceptable, since the author had worked with Colonel Cutler for many yearsduring his surgical training and as a member of Dr. Cutler's immediate staffbefore the war. The author conferred with Col. Maxwell G. Keeler, MC, thecommanding officer of the 5th General Hospital, concerning this proposedreassignment (fig. 127). He was then sent to Cheltenham, England, to meet withCol. James C. Kimbrough, MC, Director of Professional Services in the Office ofthe Chief Surgeon, ETOUSA, in order that the actual appointment might besubmitted for formal consideration by the Chief Surgeon.
APPOINTMENT AS SENIOR CONSULTANT
There were both advantages and disadvantages inherent in anappointment as a senior consultant at the theater headquarters level at thatparticular time. These were graphically pointed out by Colonel Kimbrough, whowas both a Regular Army officer and a urologist enjoying national reputation. Hediscussed the advantages of taking care of patients as compared to those ofadministering their professional care. He pointed out, however, that theconsultant could be of utmost value in the long run by coordinating theutilization of personnel and standardizing therapy so as to provide optimumsurgical care. He also warned that a "desk job" incorporating thedifficulties of amalgamating the talents of various rugged individualists in thesurgical world could be particularly harassing.
Although, according to the letter of the protocol, the authorhad the privilege of refusing the appointment, it became obvious that it wasincumbent
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upon him to accept the appointment with good grace-much ashe was disinclined to leave the Harvard unit. Members of the unit had beenpromised, when it was organized, that it would be left intact; however, this wasnot the case. In addition, although living conditions at a higher headquarterswere usually exceptionally good, there was no particular sense of unit pride,and the junior officers were conscious of the presence of "brass." Themost imposing deterrent was the knowledge that 50 percent of the seniorconsultants had developed poor health as a result of their service and had beensent back to the Zone of Interior. Several of these men were nationally known intheir respective surgical fields. Any replacement, therefore, took a 50 percentchance on physical grounds alone.
One of the desirable features was that reportedly there was agood chance that senior consultants would be promoted from the rank oflieutenant colonel to that of colonel. The advantage of this became so strikingthat most medical officers, after a year or two overseas, would have led theCharge of the Light
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Brigade if the reward for survival had been promotion to afull colonel. A medical officer acting in an advisory capacity, rather thanparticipating purely in the professional care of patients, would need to havethis much rank, at least. Without it, he could not expect his recommendationsfor changes in procedure or personnel or his efforts to commandeertransportation to carry any weight, nor could he expect cooperation in otherendeavors.
The author accepted and was appointed to the position ofSenior Consultant in General Surgery in September 1943.
ORGANIZATION, FUNCTIONS, AND ACTIVITIES
The director of the group of consultants was the previously mentioned Colonel Kimbrough. The Chief Consultant in Medicine was Col. William S. Middleton, MC, of Madison, Wis., professor of medicine and dean of the University of Wisconsin Medical School. He headed the consultants who covered the various medical specialties. Colonel Cutler was the Chief Consultant in Surgery. The surgical group was larger than the medical group and included representatives of ophthalmology, otolaryngology, plastic surgery, neurosurgery, orthopedics, roentgenology, anesthesiology, maxillofacial surgery, and general surgery-the position to which this writer had been appointed.
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Colonel Kimbrough's office was one room about 12 feetsquare. The Chief Consultant in Surgery and the Chief Consultant in Medicine haddesks side by side in an adjacent room of similar size. Opposite them was a roomabout 12 by 20 feet, which was used for a common meeting place. Activities ofthe week were reviewed, and policies were formulated at meetings held eachSaturday morning in this room. Beyond this was a rather large room with desksaround the periphery. These desks were placed back to back. In other words,there were groups of two consultants sitting face to face around the sides ofthe room. At one end of the room and in the middle were British civiliansecretaries and several enlisted men who were used as messengers and fileclerks. As one might expect, the main room was quite noisy and inefficient forordinary working conditions. It was in many ways reminiscent of a boilerfactory.
The amount of work done, therefore, depended a great dealupon how many of the consultants were present in the room at the time, how manywere dictating, how many were holding conferences, how many were trying to makethemselves heard over the telephone, how many were arguing with the personnelofficer, the supply officer, or the motor pool or trying to interview newhospital personnel. These poor working conditions accounted in no small measurefor the high mortality which had existed among consultants up to this time. Inone room, gloom spreads rapidly. Certainly, these were working conditions quitedissimilar to any these surgeons had previously encountered. This does not implythat they needed more comfort than the surgeons in the field, but the nature oftheir work required a lot of planning and discussion, which was virtuallyimpossible in the peculiar offices assigned to them.
Responsibilities of Senior Consultant in General Surgery
Although the specialty consultant ordinarily handled only those problems in his field, the Senior Consultant in General Surgery served more or less as a coordinator of the surgical group. This difference in responsibility was in some respects due to the fact that the Chief Consultant in Surgery was a general surgeon who had a wide experience in practically all fields of surgery and one who did not hesitate to make decisions upon professional or administrative matters in these particular fields. At times, however, the specialty consultants felt that this was an infringement upon their province; thus, perhaps, the situation was responsible for the creation of discord.
The specialty consultants were in close liaison with theircounterparts in the British Army. In the field of general surgery, however, theentire group was represented by Colonel Cutler, who maintained living quartersin London. During the fall of 1943 and the winter of 1943-44, Colonel Cutlerdevoted considerable time to liaison work with the British and to the study ofthe care of wounded air force casualties who were being treated in the U.S.hospitals in East Anglia. The hospitals in East Anglia were, at that time, theonly hospitals taking care of fresh casualties, since they were responsible forthe reception and care of casualties from the U.S. Eighth Air Force.
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Evaluation of Surgical Service in New Hospitals
One of the chief assignments of every consultant was to visit the various hospitals as they came into the theater, in order to evaluate their professional personnel in his particular field. If at all possible, the incoming hospitals were visited in the staging area. In general surgery, each man on the surgical service was interviewed and a record of his professional background was maintained. Special attention was given to the evaluation of the chief and assistant chief of the surgical service, since the quality of professional care of any particular hospital was closely related to the training background of the chief of the surgical service.
The value of the intensive Halsted type of resident trainingwas never so clearly demonstrated as in those surgeons working in overseahospitals. Although they were far away from their ivory towers, they were neverfar away from the surgical principles they had been taught.
After each hospital service had been visited, the entiresurgical complement was reviewed and annotations were made with regard to thequalifications of each surgeon. The probable efficiency and competency of thesurgical service was discussed and assessed. In the fall of 1943, the quality ofthe surgical services in the theater's hospitals was quite good, andevaluation was not difficult. Eventually, however, as the theater began to beflooded with new hospitals, the quality of the surgical services became more ofa problem. Also, at that time, many medical officers were transferred from theArmy Air Forces to the Army Service Forces, and a number of officers of highrank but limited professional ability began to appear-distributed here andthere-in the roster of almost all of the new hospitals in the Europeantheater.
The visiting of hospitals by the consultant was important,since it gave each hospital's medical officers contact with men who wereinterested only in the professional care of patients. Frequently, the newmedical officers felt that the Army was interested only in a type of surgicaland medical care of which they disapproved. It was essential that the armydirectives and methods be explained to them by men who had been in the Europeantheater for some time-men who had some idea of their possible future problemsand of the reasons for differences between military and civilian practices. Themedical officers in the hospitals did not hesitate to talk freely with theconsultants on a "doctor to doctor" basis, and the consultants'visits were very beneficial in bolstering the morale of medical officers. On theother hand, the consultants occasionally might have been a little toosympathetic with a man desiring to make a change to further his own promotion.
Of greatest importance was the fact that at all times therewere consultants who had on record and also personally knew the professionalqualifications of all the medical officers of the hospitals in the Europeantheater. In case illness incapacitated a key surgeon, or if a particularhospital experienced an increased professional load, the consultants knewwhether or not the particular hospital
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involved was adequate and, if it was not adequate, where tofind men who had the qualifications to assume this additional load. In order tomake the most efficient use of this detailed knowledge of personnel, it wasimportant that the senior consultants be appointed for a long period of time.This knowledge was invaluable, since the consultants could very readily supplythe personnel officer with the names of additional, trained men to speed up theorganization of new surgical services when the need arose among the manyhospitals which eventually entered the theater without surgical personnel of therequisite high caliber.
The consultants, however, could only evaluate theprofessional personnel of the service as a whole and act as advisers to thepersonnel officer. Only the personnel officer at the appropriate headquarterscould initiate orders for the transfer of a surgeon from one place to another.The consultant could recommend such a transfer, but this did not make itautomatic. It was important, therefore, that the consultant be in close liaisonwith the personnel officer in the Office of the Chief Surgeon as well as withpersonnel officers in the base sections; and it was equally important that aspirit of complete confidence and cooperation exist between them.
Preparation of Manual of Therapy, ETOUSA
The Senior Consultant in General Surgery was also ultimately associated with the preparation of memorandums and directives. Information regarding the efficacy of treatment being given casualties in England, Ireland, and Wales was discussed as it was gained. Considerable time was taken to review previous directives and to prepare directives incorporating the new information. Every effort was made to promulgate directives that would be clearly understood by the surgeons and that would adhere to the best surgical standards yet be in accordance with the tradition of military directives and objectives.
This led to the realization of a need for developing astandard manual of therapy, including the medical and surgical aspects of careof the wounded soldier. Colonel Zollinger's predecessor had obviouslyencountered many obstacles in the preparation of such a manual, and practicallyno utilizable material had been compiled. After considerable discussion, it wasdecided that such a manual of therapy should (1) be small and compact so that itcould be easily carried by the medical officer far into the forward area, (2) beup to date and consistent with the directives of The Surgeon General and theChief Surgeon, ETOUSA, (3) contain the most recent information gained byexperiences of the Medical Corps during the Italian campaigns as well asinformation from the British and French Allies, and (4) serve medical officersin the forward area as well as those carrying out definitive treatment in thebase areas. It was finally decided, therefore, that each chapter should bedivided into two parts-the first to deal with emergency treatment, and thesecond to be concerned with definitive treatment.
In order to restrict the manual to pocket size, each chapterhad to be very concise and more or less in outline form. The medical consultantsapparently
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had very little disagreement in the preparation of theirchapters. The various surgical specialists, however, submitted long chapters andwere loath to endorse the requirements of emergency therapy so vital in the mostforward areas. It took considerable time and experience gained from their visitsto the North African theater to persuade them that evacuation must takeprecedence over definitive treatment. It was extremely difficult to convince themedical officer, newly commissioned from civilian practice, that only thesimplest things possible should be done in the forward areas; that is, cover thewound and then evacuate the patient to a place where definitive treatment couldbe carried out under more satisfactory conditions. The desire to do too much andtherefore delay evacuation was a constant problem.
Since there was no consultant in thoracic surgery, thisconsultant was responsible for the chapters on the treatment of abdominal woundsand thoracic wounds. The directives issued from the Office of The SurgeonGeneral were utilized, but, for the most part, the material was gleaned fromexperience gained in visits to various hospitals caring for Air Force casualtiesas well as for those casualties returning from Africa to the United Kingdom.Information was also gained from the North African theater and from talking withColonel Cutler and others who had visited the North African theater and theeastern front of the Soviet Army.
There was little disagreement regarding the generalcare of the wound. Some of the major problems at that time were the use ofchemotherapy and antibiotics-whether to use them locally or systemically, howmuch to use, and whether to use them simultaneously or separately. The use ofgas gangrene sera and tetanus antitoxin and toxoid was also thoroughlydiscussed, and decisions were made as to their use.
It was this consultant's impression that the Europeantheater had very little in the way of directives or information from the Zone ofInterior regarding the treatment of casualties. However, it was frequentlyreemphasized through channels from the Office of The Surgeon General that allwounds were to be left open. Before the proofs for the Manual of Therapy,European Theater of Operations, were sent away, Colonel Kimbrough again calledthe author's attention to a recent cablegram stating that all amputations were tobe left open. These instructions were, of course, contrary to everydayexperience in civilian life, when wounds had been seen early and under idealconditions. Furthermore, Col. William F. MacFee, MC, had carried out primarydebridement and closure in a number of casualties in East Anglia which hadoccurred in the Army Forces, and he had apparently obtained excellent results.Men in the Army Air Forces, however, returned to their bases every day and hadbaths and clean clothing. The surroundings of an aircraft were not apt to be socontaminated as were those of the foot soldier who might be woundedon soil which had been tilled over a period of centuries.
A great deal of space was taken to describe the debridementof a wound. In order to demonstrate debridement with a simple sketch, a sergeantwho had been interested in drawing was transferred from the author's old unit,the 5th
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General Hospital, to Cheltenham. He made some very helpfulpen-and-ink sketches illustrating various principles of first aid treatment.
This consultant's experience in preparing the Manual ofTherapy convinced him that the most recent well-substantiated methods andprinciples of treatment of war casualties should be taught to all medicalstudents and become a part of the indoctrination of each medical officer. Itseemed a great waste of time and energy for surgeons to indoctrinate thousandsof medical officers scattered throughout the hospitals and bases in principleswhich could have been given better during medical school or at least duringtheir basic training.
In May 1944, Maj. Gen. Paul R. Hawley, the Chief Surgeon, andColonel Cutler presented the Manual of Therapy at a conference with Lt. Gen.John C. H. Lee, Commanding General, SOS (Services of Supply), in the BritishIsles. They were very proud of this booklet which could be carried in themedical officer's pocket. General Lee noted that it had not been dated andasked for which war the booklet had been prepared. This omission was remedied byhandstamping the date on the front of each booklet. It was the first U.S. Armymanual printed without having been officially dated.
Lectures at Medical Field Service School
One of the responsibilities of the consultants was to lecture at the Medical Field Service School. Each man was assigned to lecture in his particular field to a group of medical officers brought there from time to time for indoctrination (fig. 128). The Medical Field Service School was under the direction of Capt. (later Lt. Col.) Bernard J. Pisani, MC, an excellent director who cooperated extremely well with the consultants, making the trip a most enjoyable one.
This was one of the functions of the consultant group whichwas always pleasant, since it involved teaching younger men. Perhaps theteachers would not have been so enthusiastic had they realized that many oftheir students had been sent there for disciplinary indoctrination rather thanfor purely professional instruction. This consultant suspected that the mediocremedical officers from many of the units were given a better medical educationthereby than the men who adhered to the line. This was not altogether true,however, since many of the superior officers were originally sent to this school(fig. 129).
PREPARATIONS FOR NORMANDY INVASION
Planning LST OperationsIn the latter part of February 1944, Maj. Gen. Albert W. Kenner,Chief Medical Officer in General Eisenhower's Headquarters, SHAEF, held ameeting with General Hawley, Col. David E. Liston, MC (Deputy ChiefSurgeon), and representatives of the First U.S. Army, the British Army, theBritish Navy, and the U.S. Navy concerning the professional care to be providedon an LST (landing ship, tank). The Chief Surgeon's Office had maderecommendations concerning the policies to be carried out on these ships.
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Planning for the treatment of casualties to be evacuated onLST's during the initial invasion of Normandy became one of Colonel Zollinger'sresponsibilities. He thus became a liaison officer to the U.S. Navy for thispreinvasion planning. The number of LST's available, which was then, ofcourse, secret information, was 110.
Preparing these plans involved the following problems. First,what treatment could be carried out on the LST after it was loaded withcasualties on the far shore and directed back to the three unloading points insouthern England? Second, what medical personnel would be needed inaddition to the personnel of the LST? Third, what medical and surgical supplieswould be needed?
LST's converted to provide an operating-room platform werediscussed. Other proposed minor changes were to be made to assist the moving ofcasualties about the ship through the narrow passageways. It was planned thatthe casualties would be loaded on stretchers and placed on the floor of theinside deck after the tanks and trucks transported to France had been landed.This would provide a huge, readymade, one-room hospital ward.
The type and amount of surgery to be performed would dependupon how soon functioning hospitals could be set up on the far shore. It wasapparent that, in the initial stages of the invasion, many fresh casualtieswould have
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to be loaded on LST's and treated by the personnel aboard. It was thenagreed and promulgated in a directive that conservatism would be the policy withrespect to major surgery in the treatment of casualties being returned toEngland in the LST's.
Since the Navy had the primary responsibility, planning for supplies andpersonnel to be placed aboard LST's involved close coordination with the Navy.The author, acting as liaison officer to the Navy, required frequent conferencesto find out details concerning medical supplies already available on LST's andwhat was needed from the Army to complement them. A pharmacist's mate in navalheadquarters in London seemed to be the most thoroughly informed concerning themedical complement of every class of ship in the U.S. Navy. These supply listshad to be reviewed, and, so far as possible, necessary additions had to befurnished by the Navy. Any further supplies would have to be provided by theU.S. Army. A means of accomplishing this was the cause of considerable concern.
A problem which seemed almost insurmountable was how to provide sterile drygoods for the performance of any surgery on the LST. There was no room to storea large supply. Furthermore, since the LST was to return to the far shoreimmediately upon delivering the casualties to England, how were sterile drygoods to be laundered and replaced promptly at the end of each trip?Although there was some sterilizing equipment aboard an LST, the amount of drygoods was almost insignificant.
The previous year, while the author was assigned to the 5th General Hospital,he had been instrumental in developing a mobile surgical unit. At
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FIGURE 130.-Rubberized sheets replacing cloth drapes in a mobile surgical unit.
that time, it was learned that rubberized material supplied bythe British could be made available in place of the dry goods. The material camein bolts, and given lengths could be cut with a hole in the middle to be used aslaparotomy sheets. Similar sizes could be utilized for towels and drapes fortables and sterile instruments. The material, weighted down with clamps, couldbe boiled at the same time as the instruments. It could be boiled repeatedlywithout deterioration. It was decided that 25 yards of this material would bemade available to each LST (fig. 130).
Each surgeon to serve aboard an LST was given a copy of theManual of Therapy, a dozen pairs of rubber gloves, and the 25 yards ofrubberized material to prepare for operating drapes and gowns. The army kit ofsurgical instruments was also given to each surgeon. Chemotherapy was madeavailable to each LST in a larger supply than its usual complement. All thesesupplies were delivered to the three collecting points where the personnelselected for LST duty were to be gathered for instructions.
The Navy was ready to supply, for each LST, one medicalofficer who had been brought into the Armed Forces immediately upon finishing a9-month internship. One surgeon and two surgical technicians were to besupplied by the Army for each LST.
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Discussions were held with the medical officer of the 1stMedical General Laboratory, who was in charge of meeting the demand for wholeblood on each LST, and adequate plans were made.
Toward the middle of May 1944, recommendations were made forthe actual selection and assignment of surgeons and surgical technicians for theLST's. One-third of the group was to come from theater SOS units, one-thirdfrom the Third U.S. Army which was staging at that time, and one-third from theArmy Air Forces. These men were ordered to various places in southern Englandfor indoctrination preliminary to being ordered to a particular LST.
It was part of this consultant's responsibility tocoordinate the indoctrination of these groups of men. They had not been aware,up to this time, that they were to comprise the medical complement of the LST's.When the medical personnel assigned to these LST's were apprised of theirmission, they were quite shocked. Most of them regarded it as being more or lessa suicide assignment. They believed that the shores of France were loaded withheavy artillery, mines, and multiple German divisions, and that poison gas wouldprobably be used. They had no way of knowing how poorly the coastline of Francewas defended, compared to their expectations. Most of the line officers hadalready been reassured.
Discussions as to procedure were started about 16 May 1944.On that day, this writer visited the 28th General Hospital, at Trowbridge, andreemphasized conservatism in the care of the wounded aboard LST's. At thislate date, only 16 of the 34 men ordered to report to this collecting point hadarrived, and some of these were without proper clothing. It was essential tosupply the physicians and their technicians with additional clothing, especiallyunderwear.
The group at the 316th Station Hospital at Newton Abbot wasalso interviewed and briefed, and the men seemed well qualified and confident oftheir capabilities to do major abdominal surgery, if necessary.
On 17 May 1944, a discussion was held with the groupassembled at the 115th Station Hospital, near Plymouth. The majority of thesemen had been taken from the Army Air Forces. One officer disclaimed his abilityto perform general surgery because he was a proctologist. Arrangements were madefor his replacement.
In discussions with the physicians assigned to these LST's,it was amazing to find that they invariably expressed concern over thequalifications of their so-called surgical technicians. Since the true nature ofthe technicians' assignments was not known, many of them were, in reality,anything or everything but surgical technicians. The officers evidenced realpanic and attempted in every way possible to contact their parent units toeffect a return of the untrained enlisted men and to have them replaced withwell-trained technicians. Necessary steps were taken to facilitate thesetransfers.
Considering the operation with the aid of hindsight, it wouldseem that the commanding officer of a hospital dispatching a medical officer toserve on an LST should have known the importance of the assignment. On the other
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hand, his consideration of the possible hazards involvedmight have made his decision more difficult.
Planning Special Studies
Lt. Col. (later Col.) Joseph A. Crisler, Jr., MC, surgical consultant to the First U.S. Army, visited Cheltenham rather regularly at the time of the surgical consultant's Saturday morning meetings. In addition, other conferences were held concerning his estimated requirements for penicillin, medical supplies, specially trained personnel, and so forth. Plans were also made for gathering data on abdominal wounds, thoracic wounds, and cases of gas gangrene, as they were treated on the far shore by the First U.S. Army.
Several forms were proposed in an attempt to gain somestatistical information regarding the treatment and outcome of these wounds. Itwas hoped that these reporting requirements could be printed and distributed tosurgical teams and that each unit in the hospital could be made responsible forcollecting such information. Actually, each form required too much informationto be practical, and, although such information would have been invaluable,there was no way that it could be secured easily. Certainly, it was regrettablethat there was no table of organization to provide for study groups which couldhave developed special studies for the cases carrying a high mortality.
Distinguished scientists were present and available in theEuropean theater, who could have constituted a research study group, had anappropriate table of organization been available. Such a group should have beenassigned not only to theater headquarters but also to each base section and eachhospital center.
It probably would have been most desirable to have had anofficer in every hospital, regardless of its size, designated as the responsibleindividual for collecting such professional data or for the maintenance of anappropriate and official diary concerning the treatment of patients-a diarywhich could have been submitted to the Office of the Chief Surgeon at regularintervals for study and appropriate action.
Provision of Whole Blood
Several months before the invasion, there was considerable discussion concerning the use of proportions of plasma and whole blood in the treatment of casualties. This aspect of planning has been thoroughly covered elsewhere. It should be mentioned, however, that Maj. (later Lt. Col.) Charles P. Emerson, MC, and Maj. (later Lt. Col.) Richard V. Ebert, MC, of the 5th General Hospital, devoted a great deal of time to the development of a mobile field transfusion kit. Their kit could be stored in a wooden box used in the shipment of 50-caliber ammunition. It consisted of material for typing and cross-matching and all other material necessary for collecting and giving blood. These very thoughtful, sincere individuals proved to their own satisfaction that it was possible to wash out transfusion bottles with distilled water and sterilize them with alcohol. Actually, they took blood from each other under these circumstances and readministered it to themselves without ill effects. This was, to be
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sure, a very crude arrangement, but it would have madeavailable whole blood transfusions in any area, should it have become necessaryas a lifesaving measure.
At that time, it was not clearly understood how sufficientamounts of whole blood could be delivered to the far shore, especially toforward areas. The Signal Corps, in cooperation with these two officers of the5th General Hospital, developed a teaching film on the use of the fieldtransfusion kit. It eventually became apparent that blood would be flown fromthe United States, and these kits would not be necessary; but it did show that,despite great handicaps of equipment and supply shortages, the ingenuity of theU.S. Army officer could provide the best possible care for the American soldier.
Preparing for Reception of Casualties
In addition to attending conferences with the First U.S. Army consultants, this consultant took part in several meetings in the Southern Base Section, at which time the surgical chiefs of the various hospitals were gathered together. At these meetings, emphasis was placed on the rehabilitation of patients and their early return to duty. It took constant surveillance by the consultants to make certain that patients were not held for definitive surgery which would prevent their being returned to duty within a period of 60 days. This became increasingly important, for, as the time of the Normandy invasion drew near, the necessity for providing empty beds in the transient hospitals, especially in the southern part of England, became more acute.
The surgical consultants visited hospitals in theSouthern Base Section rather frequently during May 1944, urging clearance of allpossible beds in preparation for the reception of casualties. In addition,plans were drawn up to provide surgical teams to the hospitals that wereconcentrated around the reception zones for casualties returning from the LST's.Detailed plans were made for the reception of these casualties and for the triaging of these cases in order that specialty care would be madeavailable as soon as possible, depending upon the type of wound.
Last-Minute Activities, May 1944
Late in May 1944, there were constant changes in the maxima of demands upon the consultants. The First U.S. Army had raised the requirements for whole blood, and new transfusion sets had arrived which were being made available for the Third U.S. Army. This occasioned changes in the supplies to be provided LST's.
There was also considerable discussion regarding theproper use of sulfanilamide, as well as penicillin. The feasibility ofproviding the First U.S. Army alone with sulfanilamide, to be taken by mouthas well as dusted on wounds, and providing the Third U.S. Army only withpenicillin was considered, in that it would afford a well-controlled experiment to determinewhich was the more effective in the control ofinfections in war wounds. It was the consensus, however, that theAmerican public would not approve such a study and that the U.S. soldier wasentitled to everything that was available for his care. The
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U.S. soldier seemed to feel psychologically secure when he hadsulfanilamide available for his own protection. The uniformedsoldier or technician had more confidence in these drugs as far as theirability to save life was concerned than had the experienced medical personnelresponsible for the details of administration of the drugs.
Some time was spent visiting the various hospitalcenters, which had now become organized for the mass reception ofcasualties. A consultant in surgery was to be assigned in each of thesehospital centers, or the best qualified chief of surgical service in one of the center's hospitals was to be nominated asa senior consultant for thecenter. Everywhere the hospitals were well organized for the reception ofcasualties. They had improved their central supply, and ample stores ofsterile dressings and so forth had been prepared in anticipation of a greatinflow of casualties (fig. 131).
This consultant was not apprised of the date of theinvasion, nor did he meet anyone who appeared to want to know the date.All were afraid that they might violate security in an accidental way. Asfar as could be ascertained, the hospitals were empty, the supplies wereadequate, the staffs were well balanced, and the hospitals weresupplemented by members of the 1st Auxiliary Surgical Group until such time as they wereneeded on the far shore.
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ACTIVITIES DURING NORMANDY INVASION
A conference was held with LST surgeons at Southampton on 8 June 1944 concerning observations on the unloading of casualties. This procedure was carried out quite smoothly, but the triaging officer was unable to carry out the plan to sort the patients at that point because of insufficient time. The LST's had to be reloaded quickly with fighting equipment.
Several LST surgeons were interviewed. One of these men stated that he hadbrought back 46 casualties on his LST. He had been able to debride somewounds and utilize his rubber sheeting, had given blood transfusions, and hadcarried out penicillin therapy. He seemed quite convinced that his supplieswere adequate and that he would be able to do the necessary surgery in asatisfactory manner. When the casualties were received, those who needed itwere given a large amount of plasma and some were given whole blood andprepared for early evacuation.
The surgeons who served on the LST's were required to submit a report oftheir experiences, One of these reports may be found in appendix E (p. 985).
Observations on Treatment of Casualties
One of the functions of the consultants was to observe and report on the treatment of casualties from the time they were received from the LST's to the time they were admitted to the various hospitals, including observations on the methods of transportation used (fig. 132). The consultants were the only ones who could provide any followup information and then report back to the surgeon responsible for the initial treatment regarding his successes or failures. The lack of adequate followup observations was one of the most disappointing experiences of the military surgeon.
Treatment by these physicians was quite good, and the few cases of gasgangrene seen during the everyday reception of casualties were usually inprisoners of war. Scanty records, failure to continue penicillin therapy,inadequate immobilization, improperly made colostomies, and failure to evacuatepatients when the patient load became excessive were some of the mistakes mostcommonly made.
Directives were quickly prepared by the consultant group in the Office of the Chief Surgeon to point out the common and more serious mistakes.Thesedirectives were disseminated to all hospitals and surgical tams. For example,some of the transient hospitals noted that abdominal cases were givenfruit juices quite early, and this, combined with early evacuation, resulted inconsiderable distention of the abdomen.
Study of Gas Gangrene and Wound Closure
There was hope that an extensive study of gas gangrene could be carried out and that facilities available at the 1st Medical General Laboratory could be used to develop a training film in gas gangrene. For example, it was ob-
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served that many patients with so-called cases of gas gangrene had receivedthe customary 18 ampules of gas gangrene serum but actually had never had thisdreaded infection. Some of these diagnoses were based on the smear taken ofthe wound, while others were based on inexperience-failure to appreciate thefact that most gunshot wounds contained air in the tissues and that crepitus was acommon finding. Several illustrative cases were found,and motion pictures were made of these particular patients, including theirtreatment.
Another function of the surgical consultant in the early days followingthe invasion was to urge the principle of early secondary closure of wounds. By18 June, some hospitals were already taking cultures of wounds, with the ideaof making intensive studies in the proper method of treating such wounds.Information gained regarding the proper debridement of woundsand proper principles to be followed in secondary closure was takento each hospital by frequent consultant visits. This was the only way thatsuch information could be rapidly disseminated. Any directive issued wouldhave lagged far behind in the promotion of better care for thousands ofpatients.
Practically every hospital center began its own study, trying to determinethe best principle of carrying out secondary closures. Some of the questions in theminds of the surgeon follow:
1. How extensively should the wound be debrided before secondary closure?
2. Could the wound including the skin be closed?
3. How soon after injury should the secondary closure be carried out?
4. Should local chemotherapy or antibiotics have any place in the management of thesecondary closure?
5. Did the administration of these drugs systemically before and followingthe procedure enhance the chance of success of the closures?
6. How long should the wounds closed secondarily be immobilized?
7. How soon could rehabilitation exercises be started without danger ofdisruption of the secondary closure?
It soon became apparent that it was the thoroughness and careof the surgeon carrying out the debridement in secondary closure more than the type ofchemotherapy or antibiotic which was used that determined the result. If the surgical service of a hospital was in the chargeof a very well-trained surgeon-especially one who believed in attention tothe fine details in technique in care of patients-then the results in thehospital were good.
Regional Wounds
Eventually, thoracic wounds began to be concentrated in the various hospital centers, and the principles of early closed drainage and early decortication were followed. The principles had been developed in Italy, and it was the duty of all surgical consultants to impart this information wherever thoracic surgery was being performed.
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Although the treatment of abdominal wounds was good and themajority of these cases were kept on the far shore within a few days after theonset of the invasion, the problem of the management of high intestinal fistulaewas not satisfactorily solved. Small bowel fistulae were noted for their poorresponse to transportation. The surgeons were urged to avoid ileostomies orjejunostomies either by tube or exteriorization, if at all possible. They werefurther urged to administer sufficient fluids to bring these patients into fluidand electrolyte balance and to make every attempt at early surgical closure ofthe fistulae.
The management of vascular injuries of the extremities wasalso a problem. There was a tendency at times to incorporate the extremity in alot of padding and a plaster case, which resulted in overheatingas well as in covering the tissues and making it impossible to appraise theviability of the tissues during the hours of evacuation. The closenessof the cast to the heel enhanced the possibility of necrosis and infection. Itwas urged that these extremities be covered with sterile towels and that thepatients be evacuated from the transit hospital in traction.
Before the end of June, many casualties were being received by air, and the majority were in good condition.
ACTIVITIES ON THE CONTINENT
As Senior Consultant in General Surgery, the author was informed that he would be assigned to the advance section of the communications zone, under the overall command of Col. (later Brig. Gen.) Charles B. Spruit, MC, as soon as this headquarters was established on the far shore. After spending some time in the staging area, this consultant finally arrived on the far shore on 16 July 1944. Reporting to the surgeon of the communications zone, he was advised to report to Col. Charles H. Beasley, MC, surgeon of the advance section headquarters, to work in the Professional Services Division of that headquarters and on 19 July, he first contacted Colonel Crisler, surgical consultant to the First U.S. Army.
Surgical and Shock Teams From Base Hospitals
After 19 July, the author met almost daily with the consultants of the First and Third U.S. Armies. During these evening meetings, the needs for surgical teams and other needs were discussed.
As soon as general hospitals had been set up in the stagingarea in France, Colonel Zollinger contacted them and asked them to organizetheir professional personnel into surgical teams. These teams were to consist oftwo surgeons, one anesthesiologist, one surgical nurse, and two surgicaltechnicians. Each team was given the designation "A," and each was tobe ordered out by number.
The First U.S. Army was to keep by number and name the chiefof each team. It was planned that, insofar as possible, these teams would beassigned
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to evacuation hospitals to facilitate their relocation andeventual return to their parent units. In many instances, these men in generalhospitals had been in the staging area in England for a considerable time andwere more than eager to get into active work as members of a surgical team. They wereinstructed to report to a particular hospital, as designated by the army surgicalconsultant. No official orders were ever issued for theseteams, and probably no official record was ever made of the fact that between60 and 70 of these teams were used to supplement the surgical care of patientswithin the First U.S. Army during the middle of July 1944.
When the flow of casualties was quite heavy, it wasobvious that mortality, especially in field hospital platoons receivingnontransportable wounded, could be lowered if sufficient personnel wereavailable to administer whole blood to casualties awaiting operation.Accordingly, shock teams from the medical service of these same generalhospitals in staging were formed to consist of one officer, one nurse, andone enlisted mail. Two such shock teams were to be attached to each of thethree platoons of a field hospital. These teams were to take along with thema form to record the amount of whole blood and plasma given in a clearingstation both preoperatively and postoperatively. It was believed that in thisway valuable information could be obtained as to the actual needs for wholeblood and plasma in the forward areas. These data were to be gathered andcorrelated each week.
It was necessary for the author to visit the various fieldhospitals and explain the setup and function of the shock teams, since the newly formed teams werevery much overworked. It was estimated that one surgical team could do about 7 or8 abdominal operations or 12 chestcases within 12 hours (fig. 133). There were not enough personnel withthe surgical teams to provide preoperative and postoperative care, and forthat reason the shock team performed a valuable service. After these shockteams were assigned, they were so busy and engrossed in their work that records were inadequately kept. It was necessary, therefore, forthisconsultant to suggest that the nurse be made responsible for keeping theserecords. A report of the activities of these teams was submitted tocommunications zone headquarters for transmission to the ChiefSurgeon.
Approximately 104 surgical and shock teams were drawn fromthe various general hospitals in the staging areas. These teams were returned to their ownunits within a relatively short time after the breakthrough at Saint-Lo, France.The experience demonstrated that each hospital, regardless of its size, shouldbe subdivided and organized into surgical teams as well as shock teams. In this way, allprofessional personnel, including both surgeons and medical officers,could be assigned a useful function. Certainly, a shock team should beavailable to support each surgical team during the time of reception of heavy casualties.These shock teams, previously organized and set up,probably served as great a function in saving lives as did the surgicalteams.
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Evacuation and Sorting
This consultant visited various evacuation hospitals largely to maintain contact with the surgical and shock teams on temporary duty from the general hospitals and to make an effort to obtain data concerning the most efficient use of whole blood and plasma (fig. 134). On occasion, the consultants were also directed to visit holding units to assist in the triage of patients. For example, as many as 600 casualties awaiting air evacuation might be held by a medical battalion. Patients with large wounds, casts, or wounds of the abdomen and chest and those with complications were carefully checked before air evacuation. Chemotherapy was not attempted unless these casualties were to be held overnight. Surgical teams from the 1st Auxiliary Surgical Group were assigned to these units. Occasionally, surgery was necessary, especially when bad weather prevented evacuation by either air or sea. Hospitals did not find it difficult to supply auxiliary mobile surgical teams that had their own equipment. The parent hospitals were all in need of additional help, and a great spirit of cooperation existed among them.
The problem of triaging patients from holdingunits to advance section hospitals consumed increasing amounts of time. Atfirst, those cases were selected that had a reasonable chance of returning toduty within 10 days after admission to hospitals in the advance section area. Allegedly,the first time abdominal cases were kept 10 days instead of 7, the patient load in the fieldhospitals wasincreased. The rapid forward advance of friendly armies after 1 August,however, resulted in a marked decrease in the number of casualties.
On 4 August, members of the Advance Section, Communications Zone,visited the holding unit at Omaha Beach. There were1,100 patients in the particular unit, and 300 were selected for transportation onthe first ambulance train from Lison Junction toCherbourg. The visitors attempted to select cases that might have areasonable chance of getting back to duty within 10 days or 2 weeks. Therefore, soft-tissue wounds, acute sprains, medicalcomplaints, and similar cases, for the most part, were chosen. No fractures, nerve,tendon, or major blood vessel injuries, or wounds of the palm of the hand, the sole ofthe feet, the scrotum, the peritoneum, or thebuttock were selected unless they were quite small.
Officers were instructed as a group and as individuals in triagingthese cases. Two hundred and twenty-one weresent by the first train. The author accompanied this group to observe how wellpatients could tolerate transportation in the 40 hommes et 8 chevauxboxcars, which had been converted into an ambulance train (fig. 135).
There were three tiers of litters, with the wounds of the patientspositioned toward the aisle in order that they could beinspected frequently by the medical officer. Several No. 2 medicalchests were on the train, as were plasma and tourniquets. Fruitjuice, K-rations, urinals, water, and so forth, were available ineach car. The train ride was extremely slow, the train fairly crept to Cherbourg,and the entire trip took about 5 hours. The patients, however, withstood itquite well and were delivered to the 298th General Hospital.
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Evaluation of patients with hernias, varicose veins, andsimilar disorders determined whether they should be operated upon at that timeor should be transferred to another type of unit. The entire policy of necessitychanged rather rapidly, depending upon the bed space available in the advancesection hospitals.
On 5 August, the author visited the 5th GeneralHospital, which was functioning in Carenton, France, at the base of the peninsula.The hospital staff estimated that no more than10 or 20 percent of its cases could be returned to dutywithin 10 days. The period of rehabilitation then had to be extended, and it wassuggested that triage be more rigid in order to make more beds available forminor casualties that had a good chance of returning to duty within 2weeks. These types of cases usually included soft-tissue wounds under 3 inches in length without associated damage to nerves, tendons, and majorblood vessels.
From time to time, the consultants returned to England orother parts of the United Kingdom to visit the various hospitals andhospital centers. On these visits, they made rounds with the chiefs of surgeryin order to discover any mistakes made on the far shore. It was worthwhileto point out to these men the difficulties under which the surgeons on the farshore labored. It was also necessary to check upon how well the patients werewithstanding transportation by air, because there was some question as to howwell thoracic and abdominal patients would tolerate the airlift. When theconsultants returned again to France, they could report to the surgeons in theforward area concerning the good work that they had done as well as noteerrors which might be rectified with benefit to the patients.
In addition to visiting hospitals, consultants reviewedarticles for inclusion in the monthly medical bulletin which was prepared forthe information of all officers. Several meetings were held with the variousthoracic surgeons in order to develop general principles of thoracic surgery tobe included in the medical bulletin. Similar notations were made concerning thetreatment of arterio-venous aneurysms.
The consultants shuttled back and forth between the UnitedKingdom and France as the occasion demanded. Toward the latter part of August1944, a fair amount of the consultants' time was concerned with changes inpolicy. More and more patients were being held in the general hospitals, whichbecame more completely established in France as the army moved eastward.
As patients were evacuated, it became necessary to mark onthe outside jacket or record whether or not they were to go to communicationszone facilities on the Continent or to the United Kingdom. As a general policy,it was suggested that all patients with fractures of the long bones and thosewith hernias be sent to the United Kingdom. On the other hand, patients withsoft-tissue wounds were to be held for as long as 30 days and then be sent toconvalescent hospitals located in areas near the general hospitals in Normandy.It was also planned that any patient whose condition would permit transfer
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to the Zone of the Interior at the end of 1 month would be treated in a general hospitalon the Continent. The samerule was to apply to prisoners of war.
It was necessary to arrange for the indoctrination oftriaging officers at the various field hospitals near airstrips. Thesetriaging officers were selected from general hospital personnel because theyplayed a very important role in the conservation of manpower and in keepingpatients in France who might be quickly rehabilitated and returned to duty.
Miscellaneous Activities and Observations
During the latter part of August, a circular instructed all general hospitals to compile lists of various types of surgical shock teams, according to the new table of organization that had been sent over from the Zone of Interior, for assignment to the 12th Army Group, which in turn would determine their distribution.
Arrangements were made to assign Major Ebert and MajorEmerson of the 5th General Hospital to a forward field hospital to studyshock. They carried their own laboratory equipment. These men ultimatelygathered very significant data which were later publishedin Annals of Surgery. One of their most significant findings was thefact that, by actual measurement, many of the compound fractures of the femur hadlost as much as 40 percent of their total blood volume.These medical officers were impressed by the great need for whole bloodreplacement and emphasized that plasma was not an adequate substitute forwhole blood in a severely wounded soldier.
As the armies began to move forward farther and fartherinto Europe, distances became so great that the role of the consultantbecame less effective. Furthermore, the consultants in the United Kingdom had been wellorganized and were quite capable of functioning independently. More and more attention could be devoted to the development ofprinciples regarding definitive treatment of casualties. For example, somehospitals began to segregate all their hand cases into a separate ward.
A number of surgical principles seemed to be violatedfrom time to time. Such errors as the inadequate exteriorization of the colonfor a temporary colostomy were studied, and corrective measures were thenwritten up as an editorial in the European theater Medical Bulletin. Somedifficulty was encountered in the evaluation of casualties in holdingunits before they were finally sent back to the Zone of Interior. The holding unitsapparently were too busy and did not assume the responsibility of continuedtreatment before the patients were evacuated. It was obvious that moreexperienced surgeons were needed toevaluate these cases and screen them before the patients were evacuated, whether by sea or air.
Toward the end of August, this consultant visited various army areas andcontinued a close relationship with the verycooperative consultants in the armies. Toward the end of September, theconsultants were directed to visit the 16th Field Hospital which had received anumber of wounded French
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from the 2d Armored Division. The question arose whythis hospital should encounter such a high mortality. Upon visiting it, theconsultants learned that these patients were severely wounded because, like many braveFrenchmen, they had left their tanks and walked directly into the line of enemy fire. Theirdistaste for takingcover, as practiced by other types of troops, accounted for the very extensivewounds.
As a matter of fact, a platoon of this hospital received60 severely wounded during this specific period, 34 of whom came from the 2dArmored Division. Four of the thirty-four patients hadbeen operated upon in the clearing station of the French division. Allfour died within 2 days.
The average delay from admission to operation was 10 or12 hours. This was due to the fact that, during the first 24 hours, the platoon had but onesurgical team. This time interval was consistent with the delay observed in manyother field hospitals during the study on shock. Actually, when receiving casualties,the field hospitals needed both surgical and shock teams.
About the first of October 1944, it became a policy thataffiliated units which had been overseas for a long time should be commanded bymembers of their own units. Accordingly, Lt. Col. (laterCol.) Louis M. Rousselot, MC, of Columbia University, was assigned as commandingofficer of the 2d General Hospital, and, on 9 October 1944, the authorreplaced Col. Maxwell G. Keeler, MC, as commanding officer of the 5th General Hospital (figs. 136and 137). Such a change was welcome, since the great distances involved made the role ofthe consultant increasingly difficult. Furthermore, the various armies were wellorganized with their own consultant staffs, and the principles of treatment were by then well understood by all. Professional care inthe armyareas was excellent, and the theater was filled with highly skilled men.Base sections had been set up in France as well as in the United Kingdom. Atthis time, it would have been invaluable had research teams been
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FIGURE 137.-The entrance to the 5th General Hospital.
organized to gather and record data regarding theprofessional care of these patients, returning such data to the Zone ofInterior.
The author was in command of the 5th GeneralHospital until it returned to the United States in October 1945. The unit wasdisbanded at Fort Dix, N.J., that same month.
CONCLUSIONS
The position of a consultant in a theater of operations is hard to define, since there was no tangible table of organization and no precedent as to authority and responsibility. It might be said that the consultant had the same relationship to the regular medical officers as the regular medical officers had to the line officers. In other words, under ordinary circumstances they were a necessary nuisance, especially when they justifiably sought promotion to the rank of colonel; but they were absolutely essential when casualties were high, when morale of the soldier was low, and when morbidity and mortality were unsatisfactory.
Provision should be made to insure sufficient rank up to andincluding brigadier general for nationally known men who serve in overseatheaters as consultants. Highrank is most essential in order to command the same authority as consultants of similarcapacity in Allied armies and to add weight to the consultant'srecommendations to hospital commanders.
Since the professional care of patients is not limited toany particular army or base section, and since casualties must invariablybe evacuated from
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the field army back through the communications zone and finally to the Zone of Interior,the nomad consultant should be welcomein any area. He is, after all, concerned with the professional care of patientsand functions primarily as a doctor.
There was too great a barrier between the consultants in the headquarters ofthe Office of the Chief Surgeon and those in the various field armies. There was no friction betweenthe consultants themselves, but limitations did exist, since each army wasindependentlyresponsible for its own internal administration and resented any outsideinterference.
The consultants in the European theater were concernedespecially with their inability to requisition transportation. Perhaps it wouldhave been better, however, had they moved more as a group. Whenseveral consultants, each in a special car, arrived simultaneously at ahospital, it was disturbing to the officers of the hospital and tended to create afriction which persisted throughout the war.
Because the duty of the consultant was to "observe andrecommend," he often lacked the authority to achieve hisgoal. It may have been due partially to the fact that he was not thoroughlyinformed as to the overall program of the theater. Consultants should have beenbetter briefed by administrative officers concerning their problems of supplies,men, and equipment.
Both the regular and the reserve medical officers whoserved as consultants point to the fact that the morbidity and mortalityrates were lower than those of any previous war, despite the great mass ofcasualties. These low rates are attributed to many factors, among which areplanning, training, evacuation, and indoctrination in the professionalcare of patients. Each group, therefore, played a vital role and shouldhave made every attempt to understand the goals and problems of theother group. By the end of the war, a much clearer understanding had developedamong them.
RECOMMENDATIONS
Under the system which prevailed in the European theater during World War II, consultants could only recommend the transfer of individual medical officers. The rapport attained with the personnel officer, therefore, became a matter of utmost importance. It should have been incumbent upon the personnel officer to accept without reservation the consultant's recommendations for the transfer of professional personnel.
The tables of organization of headquarters of all levelsshould include authorized positions for the entire group of consultants andprovide for their ranks. Sufficient authority should be given consultants to carryout their recommendations. This, of necessity, includes the granting ofsufficiently high rank, commensurate with the authority desired. Furthermore,promotion or appointment of one of the consultants in a table of organizationheadquarters should not preclude the promotion of another because there is only onevacancy
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in that particular rank. This situation could be alleviated by the creation of a separate tablethat provides for thepositions and ranks of consultants.
In order to assure the most efficient application of theirtime and energies, consultants should have permanently assigned transportation on call, asdoes a physician in civil practice. To enable consultants to visit various facilities at willand coordinate professional activities by personal conferences would greatly aid thestandardization of procedures, bolster the morale of surgeons, and improve the professional care of patients. Theconsultant should not have to wastetime trying to wrangle transportation from the motor pool.
The theater surgeon, the army surgeon, the base sectionsurgeon, and even the commanding officer of a hospital center should have a table oforganization and manpower allocations for research and observation teams. Such teamsshould be accepted, in principle, as being just as essential for good surgical care as arelogistics, evacuation, and the like. These teams could then observe and record the type ofprofessional care casualties receive as they pass fromfirst echelon medical services all the way to the installations for definitivetreatment and rehabilitation.
