CHAPTER V
Ophthalmology
James N. Greear, Jr., M.D.The first Senior Consultant in Ophthalmology in ETOUSA(European Theater of Operations, U.S. Army) wasCol. Derrick T. Vail,MC, (fig. 151). Colonel Vail returned to the Zone of Interior on 26 December1944 for a period of temporary duty in the Office of The Surgeon General. Hispresence in the Zone of Interior at that time permitted a desirable andindicated exchange of certain key ophthalmologists. Colonel Vail was reassignedpermanently to the Office of The Surgeon General as consultant in ophthalmology,relieving the incumbent, Maj. (later Lt. Col.) M. Elliott Randolph, MC. MajorRandolph, in turn, relieved Lt. Col. James N. Greear, Jr., MC (fig. 152), asthe officer in charge of the rehabilitation program forthe blind at Valley Forge GeneralHospital, thus freeing the author for assignment to the European theater asSenior Consultant in Ophthalmology. Colonel Vail has recorded his experiencesand activities as the first Senior Consultant in Ophthalmology in the Europeantheater in the volume, "Ophthalmology and Otolaryngology," of thehistory of the Army Medical Department in World War II.1
During Colonel Vail's absence, Col. Norton Canfield, MC,the Senior Consultant in Otolaryngology in the European theater, took care ofproblems in ophthalmology that demanded attention at the theater headquarters.When Colonel Vail had not returned to the European theater by the end of January1945, Colonel Canfield recommended that Maj. Byron C.Smith, MC, of the 1st General Hospital be assigned temporarily as SeniorConsultant in Ophthalmology in addition to his other duties. The recommendation wasapproved. Major Smith was incharge of an active service in ophthalmology at his own hospital; therefore, he wasunable to make extensive visits to medical units in thetheater. He did keep in touch, however, with the activities concerning theSenior Consultant in Ophthalmology and gave valuable assistance and advicerelative to problems of a specific nature which were constantly arising.
Colonel Greear reported for duty at the Office of the Chief Surgeon, ETOUSA, on 29 March 1945 and began his tour as Senior Consultant in Oph-
1Medical Department, United States Army. Surgery in World War II. Ophthalmology and Otolaryngology. Washington: U.S. Government Printing Office,1957, Chapter V, "Administrative Aspects of Ophthalmology in the European Theater of Operations," and Chapter VI, "ClinicalPolicies in Ophthalmology, European Theater of Operations."
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thalmology in the European theater. He devoted the first fewdays after his arrival to searching the files of Colonel Vail in an effort todetermine the established policies of the theater and to familiarize himselfwith the many problems to be considered.
ORGANIZATION
The original plan for the organization of the Professional Services Division, Office of the Chief Surgeon, as set up early in 1942 by Col. James C. Kimbrough, MC, Director of Professional Services, was still in effect. In brief, the division consisted of a Chief Consultant in Medicine with subordinate senior consultants in neuropsychiatry, tuberculosis, dermatology, and infectious diseases and a Chief Consultant in Surgery with subordinate senior consultants in the specialties of orthopedic surgery, plastic surgery and burns, neurosurgery, anesthesia, transfusion and shock, ophthalmology, radiology, urology, otolaryngology, and maxillofacial surgery.
FIGURE 151.-Col. Derrick T. Vail, MC.
By January 1945, decentralization of all activities hadoccurred owing to the great number of wounded and the presence in the theater ofsome 200 hospitals. The larger base sections had consultants in medicine andsurgery, who reported on purely professional matters to the Chief, ProfessionalServices Division, Office of the Chief Surgeon, through either the ChiefConsultant in Medicine or the Chief Consultant in Surgery. This plan, alone, didnot provide adequate coverage of professional activity within the theater.Therefore, in order to maintain close contact with professional work,consultants in medicine and surgery were set up in the hospital centers. Theseofficers in turn re-
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FIGURE 152.-Lt. Col. James N. Greear, Jr., MC.
orted on professional matters through the base sectionsurgeons to the Chief Consultant in Medicine or the Chief Consultant in Surgery.Consultations in the medical and surgical specialties were also decentralized.In each hospital center, officers selected for their superior ability acted asregional or hospital center consultants while carrying on their regular duties.At a high level, and separate from this intimate organization for thesupervision of professional work in communications zone hospitals, there alwaysexisted a close liaison with the consultants of the various field armies and theair forces. This close liaison with the tactical elements was essential, for itwas believed that in any single theater there should be but one professionalpolicy if the soldier, whether sick or wounded, was to receive proper therapy.
POLICIES AND PROCEDURES
The policies of the Professional Services Division as established in 1942 were designed to implement measures whereby personnel of the U.S. Forces would receive promptly the highest standard of medical and surgical care. The condition of all patients reported seriously ill in U.S. Army hospitals as well as British hospitals could be easily and quickly determined. In order to stimulate and maintain professional morale and disseminate recent medical information, it was considered advisable that medical meetings be held regularly at general and station hospitals. The type and frequency of these meetings depended on local conditions at each hospital and on the general situation.
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The specialty senior consultants inmedicine and surgery submitted written dailyreports of their activities toColonel Kimbrough through their respective chief consultants, Col. WilliamS. Middleton, MC, in medicine,or Col. (later Brig. Gen.) Elliott C. Cutler, MC, in surgery. These reports wereconsolidated by Colonel Middleton, Colonel Cutler, andColonel Kimbrough for transmission to the Chief Surgeon. Itwas the policy of the Professional Services Division tohave consultation service immediately available at all times.Senior consultants for the various specialties in theOffice of the Chief Surgeon coordinated theactivities relating to their respective areas. They madesuch recommendations to the appropriate chief consultant as wereconsidered necessary for the instruction ofsubordinate consultants andspecialists in hospitals and otherunits. Under the guidance of the senior consultants, the consultants for fieldarmiesand base sections supervised and coordinated the work of specialists functioned under thedirection of the Chief, Professional Services Division, and its members were the responsible advisers to the Chief Surgeon onall professional and technical medical matters.
The specialist seniorconsultants visited all Medical Department unitsfor the purpose of giving their guidance and assistance with regard to technicaland professional matters falling within their fields of activity. They advised onthe selection and assignment of junior consultants and specialists and reported fromtime to time on the standard of professional efficiency maintained by suchofficers. They collaborated with members of the Operations Division, Office ofthe Chief Surgeon, in arrangingcourses of instruction, medical meetings, and trainingschools and in other measures designed to keep the officers of the MedicalDepartment in touch with the latest developments inmedical science. It was their duty toinitiate and carry out research and investigations with a view toconserving manpower in the field and restoringto health the sick and wounded. It was theirresponsibility also to maintain liaison with the consultants and specialists in all branches of medicine of the BritishArmed Forces and civilianpractice. They advised as tothe suitability of drugs, instruments, andequipment of a specific nature and made recommendations on other matters pertainingto thehealth of the U.S. Army in the European theater.
The most important function of theSenior Consultant in Ophthalmologywas to see that every U.S. soldier requiringeye care, in the European theater,received the highest possible standard of medical care (fig. 153). The best method of accomplishing this wastodetermine the capabilities of the ophthalmologistsassigned to the general and station hospitals. This information was obtained bypersonal contact and through the hospital center consultant inophthalmology. On several occasions, groups of ophthalmologists from both stationand general hospitals were invited to meet with the Senior Consultant inOphthalmology. The meetings were very satisfactory,and many important phases of the handling of patients were discussed.Following the general
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discussion, individual interviews were held with most of themen who had attended the meeting.
It was impossible for the Senior Consultant inOphthalmology to cover the entire area and to see the workthat was being done in each individual hospital.Nevertheless, he made every effortto visit hospitals where the larger numberof eye cases were being treated.These hospitals were primarily those treating large numbers of neurosurgicalpatients and maxillofacial injuries where, naturally, many eye cases would be located. On several occasions, groupsof hospital center consultants met at some centrally located hospital or at abase section headquarters, and informal discussions were carriedon among these consultants and the Senior Consultant in Ophthalmology. Thesediscussions proved of great benefit to all concerned insofar as the care ofpatients was concerned. Not infrequently, it was necessary for the centerconsultant in ophthalmology to have patients transferred from another hospitalto his own to assure adequate medical care, and this could be carried outwithout too much difficulty. The hospital center consultant had no authority toinitiate transfers of personnel from one hospital to another; however, it was his duty to report to the Senior Consultant inOphthalmology when he felt that such transfer was necessary, and the transfercould then be initiated from the Senior Consultant's level.
Regular monthly reports were received by the SeniorConsultant in Ophthalmology from most of the ophthalmologists in station andgeneral hospitals in the theater. These reports were informal, but theycontained information pertinent to both the type and the number of ophthalmiclesions being dealt with in each particular hospital. This information wasvaluable to the author in that it kept him acquainted with the needs forpersonnel and equipment in various units as conditions changed. A monthly reportwas not received from some of the newer units.
Early policy in the European theater had dictated that newlyblinded casualties be sent to St. Dunstan's Institute for the Blind nearShrewsbury, Shropshire, England, for a period of training before evacuation tothe Zone of Interior (fig. 154). Since September 1944, however, the establishedpolicy in the European theater was to evacuate all blinded patients to the Zoneof Interior, at the earliest possible moment after they were transportable. Beforehis transfer tothe European theater, this consultant had learned thatpatients who had been sent to St. Dunstan's in England for initialrehabilitation before returning to the Zone of Interior were usually critical ofthe training they received at special rehabilitation centers in the Zone ofInterior. They constantly compared procedures carried out in the two places.Therefore, personnel dealing with blinded casualties in thetheater were instructed as to the proper psychological approach. The necessityfor these blinded patients to become independent as quickly as possible in orderto regain confidence in themselves was emphasized.
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FIGURE 153.-Continued. C. Optometry. D. An eye operation in progress.
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HOSPITAL CENTERS
During November and December of 1944 and the early months of 1945, thirty 1,000-bed general hospitals had arrived in the European theater. In addition, there were 10 new 400-bed evacuation hospitals and 1 new 750-bed evacuation hospital (fig. 155). In some of these hospitals there was no ophthalmologist, and in others the ophthalmologist had received meager training in his specialty. The rapid movement of the armies had necessitated an increased dispersion of hospitals and had thus made the author's personal contacts with the ophthalmologists in the theater much more difficult. This greatly increased the importance of competent and active subordinate consultants.
Hospital centers were well established in theUnited Kingdom Base and were well organized. In eachcenter, there was a very competent consultant in ophthalmology who made regular visits to hospitals inthecenter and who worked, in most instances, in close cooperation with the commanding officer of thecenter. Thus, the commanding officer was kept advised concerning the care ofophthalmological patients in his center. Shifts in personnel were recommended throughthe center consultant in ophthalmology wherever it was deemed necessary. The more serious eye problems wereconcentratedin hospitals where more capableophthalmological officers were assigned.
On the Continent, hospital centers generally wereless well organized, and, while consultants in ophthalmology had been assigned ina few instances, they had not hadtheir functions well defined and were of the opinion that they should not visit hospitals until they were invited. Aneffort wasmade to clarify thissituation in order that this consultant might be kept informed as to
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the ophthalmic care of patients inwidely scatteredhospitals. Additional consultants were appointed to newcenters which had been organized on the Continent andevery effort was made to acquaint them with their duties and responsibilities.An able center or regional consultant was of inestimable value in coordinating the functions of his specialtyinhis area.
FIGURE 155.-An eye clinic in an evacuation hospital.
The majority of the hospital center consultants in the Europeantheater were captains. This wasa great handicap to them in carrying out their duties, sincea great many of the eye,ear, nose, and throat men assignedto general and station hospitals were majors and resented an officer of alower grade inspecting their services and making recommendations as to the care of patients.This situation was commonthroughout the entire theater. The hospital center consultanthad important responsibilities. It was hisduty to visit the hospitals in the center at least monthly andoftener if necessary; he certainly had to visit themoften enough to ascertain that the patients in the hospitals of his center werereceiving the best possible eye care. Itwas important that he gain the confidence and respect of the ophthalmologists assigned tothe hospitals inhis center in order that they would freely seek the center consultant'sadvice on problem patients. A higher rank would have made it easier for him tocarry out his responsibilities.
Geographic dispersion of hospitals in each hospital centerrarely offered any real problem since most of the hospitals in the centers weresituated within
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a relatively small radius and in most instances could easilybe reached within less than an hour. The question of transportation was never aserious problem. Most hospital center consultants could obtain transportationfrom their own units; if not,transportation was available from the hospital center headquarters.
SUPPLIES AND EQUIPMENT
The standard equipment supplied to general and station hospitals in the European theater was extremely deficient in certain items which were essential to accurate diagnosis of many eye disorders. Because of the inability of the medical officer to make early and accurate diagnoses as a result of a lack of diagnostic instruments or because of inadequate equipment, alleviative measures were not instituted until the patient reached another hospital where such equipment was available.
The slit lamp and corneal microscope are indispensable to theaccurate diagnosis and treatment of injuries or diseases of the anterior segmentof the globe. A good many of theseinstruments were distributed to hospitals in the UnitedKingdom Base, but very few ever reached the hospitals on the Continent. In onehospital center, there was not one single such item, and, inanother center, there was only one such item-and that was in a rather isolatedhospital.
Abnormal fields of vision could be accurately determined onlyby plotting such changes with the use of a perimeter or tangent screen. Neitherof these items was on the standard table of equipment for general or stationhospitals. In some instances, throughthe ingenuity of some medical officers or their technical assistants, bothtangent screen and perimeters were constructed. These proved to be verysatisfactory and most useful.
It was the opinion of all concerned that every generalhospital should have been supplied with a giant magnet as standard equipment sincethe hand magnetwas found to be not sufficientlypowerful to remove many of the smallerintraocular magnetic foreign bodies.
OPTICAL SUPPLY
Full credit was given to Colonel Vail for establishing the optical program in the European theater. This program had worked and was thoroughly organized at the time the author arrived in the theater. Late in 1944, one section of the issue branch of the ETOUSA Base Optical Shop was moved from Blackpool, England, to Paris. Col. Silas B. Hays, MC, Chief of the Supply Division, Office of the Chief Surgeon, ETOUSA, was most cooperative in instituting this transfer to the Continent. This unit was designed as the Base Optical Shop and located at the 7th General Dispensary to service the optical requirements of the U.S. Army on the Continent. This facility not only filled prescriptions for glasses arising from the immediate area but also provided all optical supplies to mobile units, both Services of Supply
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FIGURE 156.-A technician in a mobile optical repair unit checking a lens for accuracy of grinding.
and field army, on the Continent. Initially,requisitions were drawn on the Blackpool Base Optical Shop in England to maintainstock levels. Special jobscould be expedited with the use of air courier service to the UnitedKingdom.
By 1945, there were 2 base optical shops, 27 mobile opticalrepair units (fig. 156), and 54 portable optical repair units employed on theContinent. In the first 6 months of 1945, 186,000 spectacle requisitions wereprocessed by these units, of whichmore than 99 percent were processed immediately from available materials.Mobile units processed 102,000 prescriptions, portableunits processed 66,000 prescriptions, and 82,000 of thetotal number of prescriptions were processed by opticalunits operating in the army areas. Without these units, approximately 10,000troops each month would have been evacuated because they were visually unfitfor duty. Capt. Chester E. Rorie, SnC, commanding officerof the Base Optical Shop, also had the responsibility for compilinginformation and requisitioning, receiving, storing, and issuing all opticalsupplies and equipment for all echelons. His work in thisfield was outstanding.
Soon after plans for redeployment had been announced, aletter was received from Colonel Vail, then Consultant in Ophthalmology to TheSurgeon General, outlining the necessity for equippingtroops being redeployed with
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spectacles and gas mask inserts. On 18 May 1945,the author was in conference with Colonel Cutler; Colonel Hays; Col. AngvaldVickoren, MC, Chief, Troops and Training Branch, Operations Division; Col. John E. Gordon, MC, Chief,Preventive Medicine Division; Lt.Col. Bernard J. Pisani, MC, ExecutiveOfficer, Professional Services Division; and Captain Rorie. Thequestion of supply of eyeglass gas mask inserts and spectacles was thechief topic under discussion. It was proposed that an ETOUSA directive be sent to all unitcommandersconcerned with the medical processing of troops for redeployment. The following day, a proposeddirective dealing withspectacles and gas mask inserts was transmitted to the Deputy Chief Surgeon. The directivewas never published on the basis that items covered by the proposed directivewere already adequately covered in published ETOUSA command directives onredeployment. On 29 June 1945, this consultant submitteda letter to the Chief Surgeon pointing out the necessityfor more specific instructions relative tothis phase of redeployment because there was so much misunderstanding.
Accompanied by Major Smith and Captain Rorie, the authorvisited Twelfth Army Group headquarters and then the headquarters of theThird, Seventh, and Fifteenth U.S. Armiesand discussed with the army surgeons the eyeglass andspectacle requirements for troops being redeployed. This information was wellreceived and the army surgeons were quite willing tocooperate.
Despite early planning, after V-E Day (8 May 1945),some critical problems developed which demandedimmediate action. Some 2 million troops were to be redeployed either directlyor indirectly just as quickly as transportation facilities would permit. Alltroops having visual error were tobe redeployed with their maximumspectacle requirements of two pairs of issue spectaclesand, if visual acuity was lessthan 20/70, one pair of gas mask inserts. Service troops were tobe redeployed first, and this was the category that mostoptical units came under. In practically no time at all, 65 percent ofoptical facilities had ceased operations in preparationfor redeployment. The personnel on temporary duty in theBase Optical Shop haddwindled down to four.
The Commanding General, AssemblyArea Command, had demanded six mobile units to serve theassembly area alone. The commanding general of theLe Havre area had requestedan extra unit, the Marseilles Port had requested an additional unit there, the armies weredemanding additional units to replace those that had ceased operations forredeployment, the BremenPort had requested a unit, and a unit was requested for Berlin. In short, therequirements hadincreased to about 20 percent more than they ever had beenat any time during the war, and about 65 percent of the optical supply units had ceasedoperations. This, ofcourse, created temporarily a serious condition and"Immediate Action" was stamped on practicallyevery requisition placed on the operatingoptical supply units.
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This problem was solved in the following manner. A teletype message was sent toall prisoner-of-war stockades directing that prisoners be screened immediatelyfor experienced opticians. Between 50 and 75 opticians were located and allocatedto various units. A 24-hour shift wasput in operation in the assemblyarea, and additional equipment was set up. The stocks of supplies were doubled in all unitshaving a large demand. Nine Belgian civilians were employed in Li?ge.Twenty-seven French civilians were employedin Paris. A unit was sent to Bremen Port. Two portable units were sent to Berlin.In the last month of operationsprior to V-J Day (14 August), 37,000 pairs of glasses were processed. Again,Captain Rorie cannot be too highly commended for the splendidjob he did in supplying the entire Army in Europe with instant service on optical supplies under themost difficult circumstances.
TRAINING
Early in May 1945, the Medical Field Service School, ETOUSA, was reestablished near Paris. The Senior Consultant in Ophthalmology, assisted by Maj. Kenneth Fairfax, MC, and Maj. Byron C. Smith, MC, gave lectures on war ophthalmology to the medical officers attending the school. These lectures and demonstrations were designed to impress upon the general medical officers the need to handle patients with injured eyes carefully, particularly patients with perforating wounds of the globe. Lectures were also given to nurses attending the school (fig. 157). These talks emphasized the necessity for nursing care in patients with severe eye injuries. Procedures pertaining to the nursing of newly blinded soldiers were discussed.
During 1944, it was anticipatedthat there would be a period following hostilities in which some type oftraining program or refreshercourses in the various medicalspecialties would be of tremendous value to the men in variousfields of medicine, either in continued service activities or in civilian practice.Before reporting for duty in theOffice of the Chief Surgeon, ETOUSA, the author had conferred with ColonelVail relative to posthostilities training for the ophthalmologists in theEuropean theater. Colonel Vail had given the subject considerable thought, butno definite action had beentaken. Prior to the cessation of hostilities, thissubject was discussed with center consultants and with individual ophthalmologiststhroughout the theater. It was decidedthat a didactic program in ophthalomology would beinaugurated at Oxford University under the direction of Prof. Ida Caroline Mann, Head ofthe Department ofOphthalmology at the university.
A conference was held with Professor Mann, and plans werecompleted for such a program to begin on 17 July and extend through 14 August1945. This course was to consist of lectures and demonstrations by ProfessorMann and her staff, supplemented by a number of invited lecturers from the UnitedKingdom.Following this lecture course, ophthalmologists who were available wereto be assigned to various civilian ophthalmological services in the United Kingdomfor a period of 2 weeks. This consultant visited several of these
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hospitals, and, in each instance, they were willing to have U.S.Army officers attend clinics and observe the activities of the hospitalgenerally. Lt. Col. (later Col.)Einar C. Andreassen, MC, Chief ofthe Operations Division, Medical Section, Headquarters, United Kingdom Base,assured the author that the 91st General Hospital would be available forbilleting and messing the officers attending the course at Oxford University.All financial arrangements for the course were completed with the authorities ofOxford University, utilizing theater information and education funds. Maj.Ferdinand P. Calhoun, MC, of the 2d General Hospital was appointed coordinatorof the course and, from 13 June to 30 June, was attached to the Office of theSurgeon, United Kingdom Base. With the cooperation of Professor Mann, eminentBritish ophthalmologists throughout the United Kingdom were interviewed andworked into a lecture timetable. The coordinator found that the lecturers, allprominent in ophthalmology, were most eager and willing to do all they could,despite the inconvenience of preparing a lecture and of traveling to Oxfordfrom their homes throughout England. Except for Sir Stewart Duke-Elder,who was prevented by his important military duties, every Britishophthalmologist who was asked to participate accepted the invitation. Thisspirit was a great tribute to the friendly and cooperative relationship betweenthe U.S. and British ophthalmologists, established during the war by ColonelVail.
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The course waseminently successful in providing a taste of academic ophthalmology to men whohad been doing military ophthalmology for varying periods of time. Themen were unusually and uniformly appreciative and eager to take advantage of the opportunity afforded them and were repeatedly impressed by theeducation,poise, and affability of the British lecturers, many of whom wereinternationally known. The scope and duration of the course did not in any way qualify an officer for acertificate,diploma, or degree. The intention of the course wasmerely to give the officer who hadbeen doing military ophthalmology a review of academic ophthalmology, to refreshand broaden him, and to stimulate his future serious study of opthalmology.Owing to unavoidable redeployment requirements at this particular time, onlyabout half the number of students originally scheduled to attend could attend.
SUMMARY AND CONCLUSIONS
The consultant system made possible the high type of medical and surgical care that was available to the U.S. soldier in the European theater in World War II. A consultant in ophthalmology was always available in the hospital center, and, if it was his belief that the Senior Consultant in Ophthalmology should be called to see any individual patient, the latter could be reached through the base section headquarters. The consultant system was essential for the best surgical care of the Army in the European theater. It did not work perfectly; however, in the event of any future conflict it should work far more smoothly than it did in World War II.
No general or station hospital should have been sent toan oversea theater without adequate equipment to renderall the specialized services for which the hospitalwas formed. Certainly, they should have had the essential equipment forspecialties such as ophthalmology. The equipment should have includeda perimeter, a giant magnet, slit lamp and cornealmicroscope, a first-rate ophthalmoscope, and a tangent screen. These items are mentioned becausethey were notincluded in the standard equipment of ophthalmological departments in thehospitals of World War II.
In a theater of war, hospital centers should be organizedand hospital center consultants should be given very explicit instructions as totheir duties and responsibilities. One of the chief responsibilities of thehospital center consultant should be to apprise his senior consultant inophthalmology of any hospital in which a low grade of ophthalmology is beingpracticed.
The sole purpose of any system is to provide the U.S. soldierwith the very best medical and surgical care, and this purpose certainly wasaccomplished in World War II. It isbelieved that the system could be improved in any future conflict with onlyminor changes. Perhaps the most important advance would be to commissionophthalmologists in ranks in keeping with their professional attainments andprevious training. This applies particularly to men who have been selected asregional or hospital center consultants.
