This volume, the twenty-sixth to be published in the total series relating the history of the U.S. ArmyMedical Department in World War II, isthe second of the two volumes dealing with the activities of surgicalconsultants. Volume I, published in 1962, describes the work of these consultantsin the Office of the Surgeon General, the extension of the system to theservice commands in the Zone of Interior, and its operation in U.S. fieldarmies overseas. This second volume deals with the activities of the surgicalconsultants on the theater level overseas.
As is indicated in the first of these volumes, no formalprovision for the consultant system existed in the Office of The Surgeon Generalbefore the outbreak of World War II, and this situation delayed itsdevelopment and created many kinds of difficulties. A major problem was thatconsultants overseas were hampered in their activities, at least initially, bythe inconvenience and actualinefficiency caused by the lack of direct channels of communication betweenthemselves and the consultants in the Office of The Surgeon General. Thesituation led one consultant in theEuropean theater to complain that the theater had had little from the Zoneof Interior in the way of directivesor other information on the treatment of casualties.
Just as in theZone of Interior, so overseas the surgical consultants occupied themselves, withthe full approval of those in authority, not only with clinical matters but with a variety of related administrative matters.They evaluated the qualifications of personnel andadvised their assignment. They planned specialized treatment centers andhelped to implement the planning. They supervised such professional trainingprograms as were practical in an active theaterof operations. They organizedmeetings and conferences on localand general levels and planned the agenda for them. They prepared circular letters and ETMD's (essentialtechnical medical data). They planned such clinical studies andanalyses as were practical in wartime.Finally, they held themselves on constant call to aidin the solution of problems on any level within their competence.
In short, consultants overseas followed the same patternof endeavor as the consultants in the Zone of Interior, expanding their functions, and adaptingthem as necessary, in relation to the special conditions which theyencountered. As I noted in the foreword to the first of these two volumes, it is a tribute to the tact of theconsultants as well as to their competent performance that the originalopposition to them gradually died away. It is an evengreater tribute to them that, in the areas in which the consultant system did not operate, the desire for it was frequentlyexpressed and that, when consultants were not formally appointed, actingconsultants served in various specialties for longer orshorter periods of time.
There is a certain amount of overlapping of othervolumes by this volume, but it is almost inevitable and warrants no apologies.To have avoided it would have meantthe setting up of rigid and artificial distinctions. It would also have meantthe loss of something of real value, the presentation of material on the samesubject from different, but equally competent, points of view.
I am impressed in this volume, as I have been in all previous volumes, by theamount of factual material it contains and by the frankness with which the storyis told. The consultantsystem did not always operate smoothly. There were many difficulties,some of them created by personalities, others bycircumstances, and no purpose would be served by ignoring them. In fact, becausethese problems have been brought out into the open, it should be possible tocope better with similar situations in the future.
I am also impressed in this volume, as I have been in previously publishedvolumes, by the wisdom of the basic editorial policy of utilizing the personalexperiences of present and former medical officers who recorded, and oftencreated, the data upon which this whole history is based. It is desirable, ofcourse, to make a record of events as they occur, with an eye to the futureuse of these documents, but in wartime the ideal frequently gives way to thepractical, and records, if they exist, are often no more than sketchynotes. If a formal record exists, that is good. If itdoes not, then we must rely upon the recollections of the medical officers whowere there. There is scarcely a volume in this series in which there are notrecorded one or more major events for which there is no formal documentation. In some instances there isno documentation at all for decisions that alteredthe whole course of therapy. I cannot share the pedantic view of the so-calledhistoriographers who regard nothing asreliable unless it is corroboratedby a bit of paper. To my mind,there are no more valid sources of data than the medical officers whoserved in World War II,who saw events happen, and who often played apart in their creation.
For that reason I applaud the unorthodox method usedin this volume of telling the story of the surgical consultant service in the European Theater ofOperations and in the Pacific by publishing the (edited) diaries of Brig. Gen.Elliott C. Cutler and Col. Ashley W. Oughterson, MC, who served as surgicalconsultants in those locations. Bothofficers died after the war ended, General Cutlerbefore he had done any work at all on the history and Colonel Oughterson when his workon it was barely started.
The information which both ofthese officers possessed was essential for the history of the consultant system in both the European theater and the Pacific.Itwould have been unthinkablenot to write this history. The solution was to use their official diaries, which, like most officialdiaries, often served as personal diaries as well.The material has beenedited to eliminate irrelevant and extraneousmaterial, perhaps not as drastically as it should havebeen, but the editorial work was done from thestandpoint of deleting nothing that would alter the meaning or intent of thewriters.
Unfortunately, certain passages in thesediaries require elucidation that cannot now be secured. In other passages,one wonders whether the diarists, had they had the opportunity, might have wished to modifycertain of their statements, or perhaps to comment on them.For these and other reasons, the diaries were submitted to the theater (area) surgeonsunder whom the writers served.Maj. Gen. Paul R. Hawley, MC, USA(Ret.), Chief Surgeon, Europeantheater, has read and commented on the Cutler diary, whileBrig. Gen. Earl Maxwell, USAF (MC) (Ret.), Maj. Gen. John M. Willis, MC,USA (Ret.), now deceased, andMaj. Gen. Guy B. Denit, MC, USA (Ret.),under all of whom Colonel Oughterson served, have done the same for his diary.
After World War I ended, a board ofmedical officers, appointed to investigate and report upon the conduct ofthe Medical Department, Allied Expeditionary Forces, andto recommend improvements in it,stated that the chief consultant in surgery in an oversea theater should be a medical officer of thehighest surgicalattainments. Wittingly or unwittingly, that recommendation must have been bornein mindover the years. The consultant systemin the European theater in World War II began with theappointment in June 1942 of Col. James C. Kimbrough, MC, as Chief of the Professional ServicesDivision,Office of the Chief Surgeon, and the appointment the following month of Col.(later Brig. Gen.) Elliott C. Cutler, MC, as Senior Consultant in Surgery.It is hard to imagine more fortunate selections.
In February 1945, just before Colonel Kimbrough left the theater andGeneral Cutler succeeded him as Chiefof Professional Services, General Cutler paid tribute to him as a man possessed of "a canny imagination."He gave no better proof of his canniness than in the imaginative use he made ofhis Senior Consultant in Surgery.General Cutler also paid tributeto the Theater ChiefSurgeon who, while demanding the standardization of methods required in wartime, wasalways willing to allow changes, once a better way had been demonstrated.
In his comments onGeneral Cutler's diary, General Hawley noted that, while some of the observationsin it are basedupon incomplete or erroneous information,they had been allowed to stand, with appropriate footnotes, because everything inthe diary "* * * portrays faithfully his dedication to his task, hisresentment of everything which impeded its accomplishment, and what heregarded as unjustifiable requirements of militaryadministration. * * * he was adevoted and loyal soldier, who contributed more than his share to the success ofthe medical service of the European Theater of Operations."
Of all General Cutler's functions, perhaps the most important was his evaluation andassignmentof professional personnel. It was an extremelydifficult task, for needs far outran qualified personnel. It was doublydifficult for him, for, as General Hawley also pointed out, "an innatehonesty often compelled his professional judgments to be severe," and he was"intolerant of mediocrity."
Immediately upon his appointment Colonel Cutler noted that whilesoldiers in base hospitals were well provided for, the care of the soldier"up the line" was entirely inadequate. For this lack he had a number of solutions including,first of all, mobility, which "must be forced on all medical services."As early as August 1942 he declared that the chief need was forauxiliary surgical groups. From the experience at Dieppe he concluded that ifundue delay in treatment were to be avoided, hospitals mustbe set up near points at whichcasualties would be returned and that the successful operation ofthese hospitals would require the additionof surgical and shock teams to the normal hospital complement. Thelater establishment of transit hospitals can perhaps be traced to this concept. Colonel Cutler also stressed the importanceof triage of casualties, and he thought that surgeons atthe front must be general surgeons, not specialists inany particular field. He never lost sight of the fact that it was in forwardareas that the end results of injuries were determined in terms of survival,morbidity, and permanent deformity versus complete restoration to normal.
In the courses of instruction that he planned and the circular letters that he prepared, in the lectures and talks that he gave, in fact, at every opportunity, General Cutler lost no chance of emphasizing the correct initial management of wounds in general and of regional wounds, with special reference to initial wound surgery. He foundthe almost universal ignorance of such surgery extremely depressing. Every young physician, he said, should be taught how to handle trauma, for it would constitute 20 to 30 percent of his peacetime practice. It would be better, in fact, if medical students were taught the principles of debridement in their undergraduate days. Certainly they should learn them as soon as they entered the Army. Traumatic surgery, he emphasized again and again, is not aseparate specialty, and he could not see the logic-apparently he clearly saw the possible harm-of a special society devoted to it.
He suffered many frustrations in his attempts to solve the early problems associated with medical supplies and equipment. There were critical shortages of both. Planning impressed him as totally unrealistic. Battle provisions for 10,000 men a month included three litters, several thousand rolls of toilet paper, and one bedpan, but no oxygen tanks and no tetanus toxoid or antitoxin. An infantry division of 17,000 men was authorized two sphygmomanometers. Closure of sucking wounds would save lives (and make casualties transportable), but the proper needles and silkworm gut required to close the wounds were not provided. General Cutler was perfectly aware that in wartime it is frequently necessary to accept what is available rather than what is desirable, but compromise with him went only so far, and his initial supply activities marked the beginning of the later superbly operated supply service in the European theater.
The provision of blood for forward casualties was one of General Cutler's major preoccupations, as it was of General Hawley, and it is interesting to note how his thoughts on this subject evolved. In 1942, after hearing a discussion on blood and plasma at a meeting of the Royal Canadian Medical Corps Pathological Club, he wrote in his diary that it seemed to him that "the rise of
plasma, etc., had let all forget the benefit of transfusion." "Oursoldiers," he continued, "are all grouped. They should be the bestvehicle for getting blood forward. No bottles to carry." He was soon tolearn that it was not so simple, and it was only two years later that he wasamong the first to insistthat local provision of whole blood was entirelyinadequate and that the only satisfactory solution was an airlift of blood from the Zone of Interior.
His conversion to the perils of trenchfoot was similar. When hefirst observed it in Italy, in the fall of 1943, it seemed to him that the victims were"usingtheir pain very hard to get out of fighting." Later, when the troops inthe European theater were hard hit by cold injury, there was no more vigorousproponent of preventive measures than he was.
General Cutler approved of making casualties ambulatory as rapidly aspossible after surgery, but he viewed early ambulation, which became popular incivilian circles in the course of the war,with considerable suspicion, terming it "a questionable acceleration of professional care."
He made plans for special studies onabdominal wounds, thoracic wounds, and other regionalwounds, and for studies on gas gangrene, which fortunately provedunnecessary. He also planned special studies on penicillin therapy, againemphasizing that penicillin must be administered against a background ofgood surgery if it was to fulfill its usefulness. He concerned himself withsecuring texts and journals for hospital and other libraries.He directed the preparation of the "Manual of Therapy, European Theaterof Operations," so successfully that during the war, and at the end, veryfew changes were required to bring it into conformity with current practices.
General Cutler was instrumental in forming theAmerican Medical Society, ETOUSA, to which all U.S. medical officers in the theater automaticallybelonged.He also played a large part in founding the Inter-Allied Conferences on WarMedicine, convened by the Royal Society of Medicine, and he lost noopportunity to stress the importance of liaison with our Allies, particularlythe British. After his death, Sir Gordon Gordon-Taylor wrote: "Thedeath of Elliott Cutler * * * will occasion deep sorrow in the hearts of his many friends in theUnitedKingdom. Perhaps no surgeon of the United States ever yearned or strove moreearnestly to forge lasting bonds of friendship, not only between the surgeons,but between the peoples of the great English-speaking countries on either side of the NorthAtlantic, and to this end he directed bothwritten and spoken word."
The special reports by consultants in the various specialties in the European theater all deserve careful reading. It isperhapsinvidious to mention special chapters because space does not permit me to comment onthem all, but attention must be called to:
1. The investigations by Col. Loyal Davis, MC, ofhigh altitude frostbite; his development of protective helmets for Air Forcecrews; and his stabilization of policies concerning herniated nucleus pulposus.
2. The advances in rehabilitation,which permitted the return to duty, often to full duty, of greatly increasednumbers of men.
3. The development of policies of rehabilitation for deafened and blindedcasualties.
4. The miracles wrought by plastic surgery.
5. The enormous advances in surgical therapy made possible by the enormous advances inanesthesia under Col. Ralph M. Tovell, MC.
General Cutler and Colonel Oughterson were totally different persons and yet,oddly, much that has been said about General Cutler could well be said aboutColonel Oughterson. Both were brilliant surgeons, whose technicaldexterity was based on sound judgment. Both were born teachers. Both were men ofideas who were not satisfied until their ideas were translated into actions.
The comments of the surgeons under whom Colonel Oughtersonserved-and who did not always agree with his ideas-indicatethe kind of medical officer he was. General Maxwell wrotethat his diary represented the thoughts of a great organizer, "the thinking of a maturemind on a very difficult subject." It was written, he said, by a man who, ifhe had had the opportunity to edit it, would still think and write the same way.
General Denit was even more explicit. "I am not inclined," hewrote, "* * * totake exception to anything he has to say. After all he gives the pictureas he sees it * * *. Noone who hasn't experienced it [war in the jungle] can believe the difficultiesencountered ** *. I had a great admiration for Colonel Oughterson andgave him the job of 'thinking' and advising me on how surgery and care ofthe wounded could be improved. Ididn't want him to have any administrative authority. I wanted him to (1)see, (2) think and (3) advise. Often when one tries to correct he loses hisvalue as an adviser."
The wars in which General Cutler and Colonel Oughterson served were utterlydifferent in many respects. In the European theater, for instance, evacuation of casualties was often a matter of hours. In the Pacific areas, it was usually a matter of days and sometimes a matter of weeks. The Pacific War was a war of incredible distances, which had to be taken into account in every aspect of medical care. In the European theater, coincidental disease seldom complicated the management of wounds. In the Pacific, malaria was a possible concomitant of every wound until the war was more than half over, and other tropical diseases were a possibility all through the war. Gas gangrene, which proved no problem in the European theater, was sometimes a serious problem in the Pacific. And so it went.
Nevertheless, in spite of the differences in the warsthat were fought in Europe and the Pacific, it is surprising how squarely the views of thesetwo eminent surgeons corresponded with each other in basicprinciples if not always in details.
Colonel Oughterson's constant plea was for the placing of qualifiedsurgeons well forward in combatareas, where their talents were required because
of the inevitable delays in evacuation. The shortage of qualified surgeons,however, in a theater in which each island was a unit in itself was always extreme and wasenhanced by the concentration of talent in affiliated units, from which it was often detachedwith great difficulty. Shortages of anesthesiologists with proper training andqualifications further complicated shortages of surgeons. At one time,when Colonel Oughterson surveyed six portablehospitals, he found three of them competently staffed and three otherscompletely unusable because of lack of qualified personnel. The portablehospital, he noted, was excellent in jungle warfare but ill adapted andwasteful when communications were good. When it was not properlystaffed, he said, "It gives the dangerousillusion that a surgical hospital is available."
His comments were always to the point. The incidence of gas gangrene, henoted, was an index of the kind of surgery being performed at the front, but theomission of plaster becausegas gangrene might occur was simply the correction ofone surgical mistake by making another. His comments on "moderatedebridement" were caustic. He had never seen a surgeon who didgood surgery at home do bad surgery in the Army. Almostas soon as he arrived in thePacific, in November 1942, he began to comment that the principal cause of warneurosis was weak leadership, that men who were not happy were men who were not keptbusy, and that the way to correct poor morale and poor surgery in a hospitalwas to provide it(1) with a strong commanding officer and (2) with a good surgeon. Whether ColonelOughterson was evaluating surgical qualifications, correcting surgical errors, or trying toprovide washing machines for hospital linens,screens for operating rooms, or hobnailedshoes for litter carriers, he was both practical and perceptive, and many of hiscomments might wellbecome aphorisms.
The brilliant study of casualties in the Bougainville Campaign, which heinitiated and directed, is alasting addition to the science of wound ballistics. The conclusions he derived,and the lessons he drew, from medical care in each campaign in the Pacificdeserve the most careful reading and reflection. Like the Cutler diary, theOughterson diary is a real contribution to military medicine.
The consultant system was introduced late in the China-Burma-India theater, butthe chapter describing it, the final chapter in this volume, is another experiencewell worth recording of medical care in inhospitableterrain, with constant shortages of personnel and supplies, in which not the least ofthe problems was theattempt to improve the efficiency of the Chinese Army Medical Service.
Again and again General Cutlermentions in his diary how desirableit would have been to have worked in peacetimeon the problems he encountered during the war. He reminded himself frequentlythat one of his responsibilities as surgical consultant in the European theaterwould be to write the storyof the consultant service. The chief problems of this service, as he saw it,were the relations of the consultants with each other and therelations be-
tween Regular Army medical officers and the officers who had just comeinto service from what he called "the well-oiled machinery of civilianpractice." He found more patient those who, like himself, had served inWorld War I-thought it might come as a surprise to some of his associates to hearthe word patienceattached to any activity of General Cutler's. At any rate, it was his urgent wishthat a permanent consultant system beestablished as an integral part of the Army Medical Department. He would havebeen happy, had he lived, to know that this ardent desire of his has beentranslated into reality.
As in all volumes in this series for which it is my privilegeto write the foreword, it is a pleasure to express my gratitude to theeditors and authors who wrote and directed this volume, particularly thespecial editor for the two volumes dealing with the activities of surgicalconsultants, the former Col. B. Noland Carter, MC; to the Advisory EditorialBoard for Surgery; and to the personnel in myoffice who are helping me to carry out what Iregard as one of my truly important missions, the preparation and publication ofthe history of the U.S. Army Medical Department inWorld War II.
LEONARD D. HEATON,
The Surgeon General.