CHAPTER VII
Otolaryngology1
Norton Canfield, M.D.Otolaryngology in the Office of The Surgeon General at thebeginning of the war was a division of general surgery, and so it remained bothin the Office of The Surgeon General and in most military hospitals, except in afew where the administration wisely saw fit to make it a separate service. Wherethere was a separate otolaryngology service, the specialty made its greatestprogress because the service was usually under the direction of professionaltalent which was also responsible for separate services in the civilian teachinghospitals associated with large medical centers. In a rapidly expanding medicalservice, such as the Army was obliged to manage from 1941 to 1945, theadministrative wisdom of surgical specialties' being professionallyresponsible to the chief of general surgery was undeniable in many instances.But the inflexibility of this policy as interpreted by some commanding officersled to patient care which was often unfortunate. So rapid and frequent was theshifting of personnel in many medical units that a set professional "chainof command" was deemed of major importance. Indoctrination of newlycommissioned medical officers was, however, often insufficient to make Armypolicies for the administration of professional services completely acceptableto many civilian-trained specialists during their military service.
THE CHIEF SURGEON
In mid-1942 the European Theater of Operations, U.S. Army, was expanding, and the medical service was under the direction of the theater Chief Surgeon, Col. (later Maj. Gen.) Paul R. Hawley, MC, whose military career had been of long standing. His preliminary close association with the British which was so manifestly the result of his professional knowledge, human understanding, and military acumen, coupled with his absolute respect for professional integrity wherever it appeared, made him a superb "chief" in every respect. In addition to his excellent, but understandably not perfect, ability to select men for important posts and his willingness to replace officers who did not meet his expectations, General Hawley was so often correct in his decisions that even the professional consulting staff was hard put to it to substantiate recommendations when they ran counter to his ideas.
1For amplification of matters briefly reviewed in this chapter, see: Medical Department, United States Army. Surgery in World War II. Ophthalmology and Otolaryngology. Washington: U.S. Government Printing Office, 1957.
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Those consultants who were on duty in the Office of the ChiefSurgeon, ETOUSA (European Theater of Operations, U.S. Army), for the period1942-45 can never forget the "battle of the anesthetists" under theamazing leadership of Col. Ralph M. Tovell, MC. Colonel Tovell's strategy wasbased on solid professional polices and execution and was so keen that it tookGeneral Hawley by surprise, which he did not fancy. The general took specialpains to make his displeasure emphatically obvious. The outcome, however, underthe guidance of Colonel Tovell was so beneficial to the troops who neededprofessional medical care that the Chief Surgeon, in the presence of hisprofessional advisers and his administrative staff, accepted completely ColonelTovell's magnificent work, thereby demonstrating his stature (p. 300). GeneralHawley did this in a manner which was worthy of the finest of human character,and he let it be known that he was mistaken in his previous emphatic oppositionto policies which eventually made anesthesia one of the great services duringthe war. This was but an example of the many instances in which he acceded tothe high-grade professional advice from the men whom he preferred to haveassociated with him.
ACTIVITIES AND OBSERVATIONS
Appointment of Consultant in Otolaryngology ETOUSA.-In mid-1942, Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in Surgery, ETOUSA, initiated a request to The Surgeon General for an otolaryngologic consultant for the European theater. The Surgeon General responded by requesting Dr. Lyman Richards of Boston and, later, Dr. Albert C. Furstenberg of Ann Arbor, neither of whom, because of their important civilian posts, could accept the position. By the gracious recommendation of Dr. Furstenberg, the post was offered to Dr. Norton Canfield (fig. 179). At that time, Dr. Canfield was a full-time head of the Division of Otolaryngology, Yale University School of Medicine. Earlier, he had been designated as essential for medical school teaching, but, when this position became available, the dean of the Medical School, Dr. Francis G. Blake, agreed to remove his name from the essential list. Thus, on 28 November 1942, the author entered the Army as a lieutenant colonel and was placed on temporary duty in Washington in the Office of The Surgeon General to prepare for his duties in the European theater.
At that time Col. (later Brig. Gen.) Fred W. Rankin, MC, wasChief Consultant in Surgery to The Surgeon General. Colonel Rankin outlined thefunctions that the otolaryngologic consultant in the European theater might becalled upon to carry out. Arrangements were then made for the author's prompttransport to England. Within one week of landing in England in January 1943, hereported to the Chief Surgeon and was assigned as Senior Consultant inOtolaryngology, Office of the Chief Surgeon, ETOUSA. The author held thisposition from then until his return to the United States in 1945,
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after V-J Day. Before this consultant's arrival in theEuropean theater, duties of the otolaryngologic consultant were performed byMaj. (later Lt. Col.) Frank D. Lathrop, MC, formerly associated with the LaheyClinic in Boston, and by Capt. (later Maj.) Edmond P. Fowler, Jr., MC, Chief,Otolaryngological Section, 2d General Hospital, then at Oxford, England. Thepreliminary work of these two officers was of great assistance, especially inthe procurement of special surgical instruments from British sources during theearly part of 1943.
Chief Consultant in Surgery - Under the wise counsel andable advice of Elliott Cutler, the otolaryngologic consultant during his entiretour of duty was given full professional authority. As he looks back upon theexperience, it would be hard for this consultant to believe that any superiorcould have been more thoughtful and helpful in the execution of his duties.General Cutler's experience in World War I as a medical officer with combatforces admirably fitted him for the much more important post which he held asChief Consultant in Surgery for the European theater in World War II. Hismilitary knowledge, high professional integrity, consummate geniality, anduntiring efforts were largely responsible for the success in the handling ofsurgical problems in the European theater.
FIGURE 179.-Col. Norton Canfield, MC.
Associations with British - Immediately upon theassumption of his position in England, the author was placed in touch with theBritish authorities in his specialty. His association throughout the rest of thetime in Europe with Brigadier Myles L. Formby, RAMC, was entirely satisfactory.Not only were many professional ideas exchanged, but the actual surgical care ofmembers of both armies was at all times a matter of closest cooperation. One ofthe most pleasant and beneficial associations of the specialty officers inEurope during the period 1943-45 was the association with both British militaryand civilian
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specialists. The meetings of the Royal Society of Medicine in London were open to all medical officers of the U.S. Army, and it was the pleasant duty of the Senior Consultant in Otolaryngology to arrange for specialists in the theater to attend these meetings. On their own initiative, U.S. Army otolaryngologists attended meetings, both Army and civilian, at British installations near their own stations.
Administrative considerations - It was the policy in the European theater not to train otolarygologists, although there were available men capable of conducting such training in several of the large general hospitals. As the theater expanded, no one consultant could cover all of the hospitals; consequently, a system of regional consultants was initiated by General Hawley. The outstanding men in any one locality were assigned as regional consultants with orders to travel, if necessary, to nearby hospitals for consultation on individual difficult cases. The transfer of patients from one hospital to another was permitted under certain circumstances, always with the idea that the injured or sick soldier would receive the best possible professional care. It was the express policy of General Hawley that the administrative side of military medicine justified itself only when it could make the best possible professional care available to the sick and wounded (p. 349). Military considerations sometimes seemed to make this policy ineffective, but it never assumed this flavor by any design of the Chief Surgeon whose professional qualifications were of an exceedingly high order.
Relations with Army Air Forces - The Army Air Forces in Europe had theirown unit medical service to which no otolaryngologic consultant was assignedduring the war. At the operational airfields, much of the medical support foundto be necessary for the pilots and aircrews was in the field of otolaryngology,and a number of qualified otolaryngologists were assigned to the variousairbases. The U.S. Army hospitals in the area of East Anglia, where Army AirForces activities were the greatest, provided most of the medical service forthe Army Air Forces, and capable otolaryngologists were always assigned to thesehospitals. Before D-day, battle casualties were confined largely to bomber crewsflying between East Anglia and the European mainland. These casualties weregiven preliminary medical attention at airfields and were then quicklytransferred to Services of Supply hospitals for definitive care. Much credit isdue Captain Fowler for his initiation in the theater of special attention toaero-otitis and for his direction of the subsequent care given to aircrews byotolaryngologists assigned to those medical units which directly supported theAir Forces. The Senior Consultant in Otolaryngology and other highly qualifiedspecialists were active in medical training courses given at Eighth Air Forceheadquarters for flight surgeons assigned to individual airfields.
Manual of Therapy - The training of otolaryngologists before their Armyservice had been largely directed toward providing definitive care to anindividual needing medical attention. In a theater of operations, however,
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FIGURE 180.-An otolaryngologic clinic in a general hospital.
it was not always possible for the original specialist togive final care. Therefore, practices which at times seemed contradictory to thecivilian training of medical officers were necessary because of troop movementson the one hand and the need to concentrate special surgical ability on theother. It was one of the duties of the senior consultant group to formulatepolicies to comply with such exigencies, and the Manual of Therapy, ETOUSA,setting forth these policies, was written and distributed in 1944.
Otolaryngologic service prior to D-day - During thetime of the troop buildup before D-day, otolaryngologic service in the varioushospitals was largely similar to that rendered to any fairly healthy civiliangroup (fig. 180). Outpatient clinics were, in general, very busy with routinerespiratory infections, tonsillitis, otitis media, and sinusitis. The problem ofhearing loss was not great, but many soldiers were sent to the European theaterwith hearing defects which required their assignment to special duties in ordernot to endanger them and their comrades unduly in combat (fig. 181). As the warprogressed, a system for issuing hearing aids was instituted with considerablesuccess.
Otolaryngologic service after D-day - After D-day, the nature of professional service from otolaryngologists necessarily changed, although as a group these specialists were rather busy before D-day. Thereafter, however, their activities were directed toward the wounded in their specialty, and, in general, they were well prepared for the onslaught of casualties as they
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FIGURE 181.-Audiometric testing for hearing acuity.
poured into the hospitals. Let it be known that many medical officers were onduty before D-day without much professional activity. These included the plasticsurgeons and the oral surgeons who immediately assumed much more importance whenthe wounded began to appear. This naturally led to some conflict of ideasconcerning the responsibility for certain types of cases, and expectedcontroversies were encountered. Wounds of the head and neck were frequent, andprofessional policies of treatment had been carefully enumerated by medicalofficers of World War I, whose writings were well documented but notwidely distributed for use in World War II. Again, the Manual of Therapyreferred to earlier was extremely useful. As the fighting proceeded, hospitalswere quickly transferred to the European mainland, and specialty services wereestablished along the chain of evacuation of the wounded. Medical records notedprevious treatments in sequence, but of course they were in many cases toobriefly or incompletely prepared because of the tactical situation.
Relations with French - After the liberation of Paris by theAllies, large hospitals in the vicinity were used by the U.S. Army. Again,association with French surgical specialists and attendance at their meetingswere sources of professional interest which continued during the years followingthe final victory.
Redeployment - After V-E Day, the selection of medical officers for redeployment to thePacific was a difficult and unpleasant task for the professional consultants.Although most of the men in Europe had had more
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than 2 years of duty, it was necessary to assign many of themto duty in the Pacific. V-J Day, however, came so soon after V-E Day thatmuch of this work was fortunately found to be unnecessary, and most of thespecialists from the European theater were returned directly to the UnitedStates.
REASSIGNMENT IN THE UNITED STATES
Following the duty in Europe, this author was assigned asConsultant in Otolaryngology to The Surgeon General at his offices inWashington, D.C. Upon his return, he found Maj. (later Lt. Col.) Leslie E.Morrissett, MC, who had so ably directed the program for hearing rehabilitationcenters in the Zone of Interior. After the war, prompt demobilization was asource of satisfaction to many of the specialists, but there was much more workto be done in the Office of The Surgeon General. The author remained on activeduty until May 1946 attending to administrative matters and collecting data forthe history of the Medical Department of the U.S. Army in World War II. His recommendations for the initiation of severalclinical research projects which might have been carried out by officersremaining on duty were not acted upon by The Surgeon General, although it wouldhave been possible to arrange for a very excellent facial nerve surgery serviceunder the direction of Colonel Lathrop at Cushing General Hospital, Framingham,Mass. In addition, this consultant inspected the three aural rehabilitationcenters and found them to be of the highest possible order. These centers weregradually closed, but The Surgeon General saw the wisdom of this extraordinarilyfine program and established a permanent aural rehabilitation center at theForest Glen Section of Walter Reed General Hospital, Forest Glen, Md. Thisinvolved a construction program in an old building, but a permanent hearing andspeech center with a highly qualified staff was established. So effective wasthe program for aural rehabilitation that later the Veterans' Administration,also under the leadership of General Hawley, established a program for thoseservicemen who were discharged and were found to have service-connected hearingimpairment. That story is still being written and will constitute one of thebrightest spots in the annals of military and Veterans' Administrationmedicine.
SUMMARY
In looking back on his experiences as Senior Consultant in Otolaryngology in the European theater during World War II, this author is convinced that, if knowledge and experience in any way can be carried forward into future years, much grief will be prevented.
One of the civilian medical profession's main objections tomilitary medicine is the fact that professional ability does not necessarilylead to a commensurate advance in military rank. The history of this problem inthe U.S. Army was reviewed on several occasions by General Hawley, and he, atvarious times, admitted that a solution was difficult to find (pp. 336-338).
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It is the belief of this writer, whose experience can be saidto have been extremely gratifying from his standpoint, that a small corps ofwell-trained otolaryngologists with every opportunity for professionaladvancement as well as advancement in military rank should be the solidpolicy of The Surgeon General during peacetime.
The consultants' program fully justified the highimportance placed upon it during World War II, and the civilianorganization which existed following the war, namely the Association of MedicalConsultants of World War II (later The Society of Medical Consultants toThe Armed Forces), attested to this fact.
