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Appendix A

APPENDIX A

OFFICE OF THE CHIEF SURGEON 
EUROPEAN THEATER OF OPERATIONS

3 August 1943

SUBJECT: Surgical Mission to Russia.

TO: Chief Surgeon, European Theater of Operations.

1. Through the British Ambassador to the U.S.S.R., a medical mission was established. The U.S. Army Medical Corps, E.T.O., was asked to participate. A Canadian member was added later. The British Medical Research Council and the British Council assisted in the preparations and organized the transportation.

2. Brig. General Paul R. Hawley appointed Colonel Elliott C. Cutler and Lt. Colonel Loyal Davis as the U.S. members of the mission.

3. Informal instructions to the U.S. members were given by the U.S. Ambassador to the Court of St. James's, Maj. Gen. John C. H. Lee, and Brig. General Hawley. Travel orders were issued by the A.G.O., E.T.O.

4. The purpose of the mission was (1) to learn as much about Soviet military medicine as possible in order that U.S. troops might benefit from the experience, and (2) to cultivate friendly relations with our Soviet allies.

5. The mission * * * arrived at Moscow at 5:45 p.m. July 2, 1943 * * *. It returned by airplane leaving Moscow July 23, and reached the United Kingdom, July 30 * * *.

6. The mission established highly friendly relations with the U.S.S.R. medical authorities, both military and civil. It was warmly welcomed at the Moscow airport by Soviet officials, including two Vice-Commissars of Public Health; was welcomed at a special sitting, by the People's Commissar of Public Health, and shown every courtesy while in Moscow. It was permitted to visit all of the important hospitals in that area. The mission met and had the most friendly relations with Lt. General Smirnov, Chief of the Red Army medical organization; [Vice Admiral] Dganaleidge, Chief of the Surgical Division of the Red Navy; [Rear Admiral] Andriev, head of the Red Navy medical service, and Lt. General Burdenko, Chief of the Surgical Division of the Red Army, as well as many other leading medical authorities.

7. General Medical Responsibility.

The care of the injured and sick is in two departments in Russia:

A: The responsibility for the care of injured soldiers in the forward areas is that of the Commissariat of Defence and the military medical organization of which Lt. General Smirnov is the Chief Officer, and Lt. General Burdenko the Chief [of surgery]. This included the care of the soldier in combat units, in Army hospitals and through evacuation to the base area.

B: The responsibility for the care of the wounded soldier in the Base Areas, as well as the care of all civilians, is that of the People's Commissariat of Public Health. Some, but not all, base hospitals have army officers as their administrators for purposes of discipline. Each province has an army as well as a civilian representative of the People's Commissar of Public Health in touch with all hospitals within that province. Many of the chief surgeons of the civilian or base hospitals, are officers in the Red Army Medical Service and are in uniform. Officers and men are treated alike in all hospitals and in some hospitals are bedded in common wards, whereas in others there are separate officers' wards.

8. Organization for Care of Wounded in Red Army.

A: Wounded are picked up on field by sanitary corps. (Some of these individuals are women who dress wounds and control hemorrhage).


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B: Battalion Aid Post-A nurse is here who adjusts bandages and gives first aid, administers morphine, sulfanilamide orally and applies splints.

C: Regimental Aid Post-First medical officer is here. Treatment for shock is begun (blood and plasma); better control of hemorrhage; bandages adjusted; novocainization of fractures if very painful; splints applied; tetanus toxoid and morphine given, and gas gangrene serum administered if large and badly lacerated wounds are present. Sulfanilamide placed in larger wounds.

D: Divisional Aid Post (6-8 kms. from front) Consists of a small hospital for emergency surgery only (some abdominal wounds, a few chest wounds and emergency amputations). Carries out the sorting of patients; redressing and adjusting of splints; further treatment of shock (blood and plasma). May add 200-bed mobile hospital at this point or send in additional surgical teams, as military situation demands and justifies.

E: Sorting-Evacuation Hospital (30-50 kms. from front * * * 1,000-4,000 beds) Careful sorting of patients into medical, lightly wounded and serious litter cases. Distributed to special wards in this hospital or to specialized attached mobile field hospitals of 200 beds each for abdominothoracic wounds, extremity injuries, neurological wounds; facio-maxillary wounds; medical diseases or walking wounded. These latter patients may be kept up the line or sent down the line as far as Moscow (200 kms.) but they remain in the Army hospitals and never come under the control of the Public Health Service. (This permits more rapid restoration to active duty.)

F: Evacuation from the above hospitals by train, motor cars or by air. The latter method is reserved for the critically ill patients, special cases (eye), guerrillas (this is a very large undertaking and a major part of the Russian Army), and in special circumstances, depending upon air control and the availability of planes.

G: Air Force and Ground Force personnel cared for in the same hospitals by the same staffs.

H: Organization within Army hospitals is well standardized, set up for a maximum flow of sick and wounded and reveals a high ability for organization. Example: 200 bed Mobile Field Hospital:

(a) Admitting Room: This is both for records and sorting. Personnel come in with simple field medical tag pinned on, simple record form filled out and put in envelope; special portion torn off and sent to medical headquarters; colored tag placed on patient (red=surgery, blue=urgent dressing, white=evacuate).

(b) Patient goes to barber if well enough for hair clipping and shaving.

(c) To washroom where clothes are removed and taken away for cleansing and mending. Patients thoroughly washed.Separate room for women. (This is one of the major contributions of the Red Army.)

(d) Dressing room-several tables and sterile supplies ready. Patient rebandaged and given fresh clean clothes.

(e) X-ray room.    

(f) Operating room for those selected. Up the line only serious cases done. Abdomen, chests and femurs held in hospital for 7-10 days preferably.

(g) A supply of blood (sent from base area refrigerated) is kept in a deep cellar with some ice which is cut in the winter and stored. Blood not used after 3 weeks.

(h) Stretchers are used for cots and two tiers are set upon wooden frames. Ambulatory patients use upper tier. In dressing room and sorting room have an excellent wooden horse which can be broken down by turning a wingnut and can be packed into a very small space.

(i) For each group of frontline hospitals (6-8) there is a laundry controlled by the medical department.

(j) Equipment of forward hospitals: Russian field tent is excellent; 15 feet wide and commonly 30 feet long with excellent windows in walls and often inner cloth lining. Autoclaves, sterilizers, X-ray apparatus, instruments of which a good many are American or British seemed to be sufficient.


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Distribution of Beds for Surgery

Front


Rear

General surgery

91.5

83.0

Neurosurgery

2.9

4.3

Facio-maxillary-plastic

1.6

3.1

Ophthalmology

1.3

2.0

Otolaryngology

0.9

1.3

Neuropsychiatry

0.2

0.1

Amputations

0.9

5.3

Gynecology

0.2

 

 

Distribution of Wounds


Levitt (In charge of hospital for chest, limbs and joints in base area):

Percent

Heads

10

Chests

6.7

Abdomen

2.4

Limbs

68-70


Vorshofsky (Chief Surgeon, Western Front):

Percent

Heads

1

Abdomens

2

Chest

4

Arms

40

Legs

35

9. Principles of Surgical Practice in care of wounded in Red Army.

A: Excision of wound (debridement) is practiced as far forward as possible, usually in sorting-evacuation hospitals, but, in instances where great numbers of wounded exist, this may be done in base hospitals. This is best practiced early, but Russian surgeons practice excision up to 10-15 days, including compound fractures; relying upon sulfonamides and immobilization to prevent generalized sepsis.

B: Immobilization of large soft part injuries as well as fractures by wooden splints (Deitrich) or Thomas type, for evacuation to place of first definitive surgical treatment, after which plaster of paris is applied. Plaster of paris is put on as early as possible and is used directly over the wound, "skin tight" and without padding. Not usually applied before 3 days after injury.

C: Tetanus-Active immunization with tetanus toxoid is practiced. The "booster" dose is given at the Regimental Aid Post.

D: Gas gangrene-A potent antiserum is used in all serious wounds, usually intravenously. A toxoid is in the experimental stage. Several surgeons told us that the antiserum was not effective.

E: Sulfonamides-sulfanilamide is used both in forward and in base hospitals by introduction  into the wounds, by mouth and intravenously. It is not carried on the person of the individual soldier. They also have a small supply of sulfapyridine. Observation of actual patients indicates that they use it more profusely in wounds than we do. A special form of sulfanilamide in which the preparation is broken down into very small particles by subjection to ultrasonic wave lengths is used as a cream applied to gauze and placed into the wound. It is thought to be very efficacious, but it is still in the experimental phase and is not in mass production.

F: Secondary suture is practiced wherever possible even after 7-12 days. Skin grafts are used when it seems advisable.

G: Inhalants uncommonly used, usually ether. Novocain commonly used and we saw many patients incompletely anesthetized writhing in pain. Spinal anesthesia used


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chiefly in base hospitals. Hexonal (like Pentothal) used but no gas oxygen machines seen and not told anywhere of its use.

10. Principles of Practice in Special Fields of Surgery.

A: Thoracic Surgery-Thoracic wounds treated conservatively. In forward areas sucking chest wounds are closed. Hemothorax treated by tapping; empyema by drainage for three weeks, then 2 or 3 rib fragments are removed and the wounds packed. Only large foreign bodies are removed. Prof. Levitt gave figure of 6.7 percent as proportion of chest wounds. Lt. General Burdenko said that the original mortality of chest wounds (65 percent) had now been reduced to 18 percent. In 1942, only 19 percent of chest wounds were of penetrating type, and of the 12 percent submitted to operation the mortality was 20.5 percent. A simple positive pressure machine was developed by Burdenko (bellows led air via a Wolff bottle (7 cms. of water) to ordinary gas mask).

B: Burns-Use some coagulants (tannic acid and silver nitrate) but prefer open method, in which they dust on a powder containing an anesthetic and an antiseptic (not sulfonamide). Said burns were very infrequent and mostly in air force personnel. Placental extract covering stimulates more rapid covering over with new skin. (??)

C: Fractures-We visited hospitals both in the forward and Base areas where fractures were concentrated. The care given these cases and their results made an excellent impression on us, and since plaster has been the procedure of choice in Russia ever since Pirogoff, in the Crimean War, wrote about its wonderful properties (book published in 1865) we found them masters of this technique. Professor Yudin had cared for over 2,000 fractures in the Finnish war before this war began. Their principles of fracture care are: (1) splint in the field with wooden or wire splints or Thomas' splints. They prefer the Dietrich wooden splint which has an axilla and groin crutch; (2) at sorting-evacuation hospital, or mobile hospital, or base hospital where first definitive treatment is given, all dead and devitalized tissue is widely excised, sulfanilamide is placed in the wound. They often suture the wound open (skin edges to deep fascia) and prefer no gauze packs; (3) "Skintight" plaster is applied without dressing on the wound. They do not transport the cases for a few days. They excise wounds 5-10 days old in the same way and are not afraid of spreading sepsis. Hospitals up the line had good fracture tables and one used a piece of rubber over the dorsum of the foot which was later removed after the cast had set. Casts are not split and never use windows. For best work up the line, a good fracture surgeon with 8 assistants must have three tables going; one for careful preparation, one for the actual operation and one for the application of the cast.

see table

Followup study of 500 cases of wounds of joints showed 58 percent incision and drainage and 42 percent resection. Of these 22 percent of the first group were unhealed at 6 months and 28 percent of the resections were unhealed at that time. Arthroplasties were done in 42 percent of the cases incised and drained and in 8 percent of the resections.

D: Supply of Blood and Transfusion Service: The Red Army medical service uses great amounts of citrated whole fresh blood and little plasma. The blood is collected in the larger cities, chiefly Moscow (about 2,000 pints a day and in one hospital bleed 600 people daily). Use excellent technique, physical examination of donors including Wassermann reaction; grouping is done twice; bleed into 250 cc. ampoules with open ends which have rubber tube attachments which are bent over and sealed with paraffin. Blood is refrigerated at 6 degrees C and flown to fronts where it is distributed in refrigerated cars and in frontline hospitals is kept in deep cellars iced at 6-10 degrees C. It is not used after three weeks.

Cadaver blood is still being used at the Sklifossowsky Institute by Professor Yudin. From 1935 to 1943, 2964 cadavers have been bled yielding 5,092 liters of blood. Of this quantity 1,332 liters were discarded (240 for positive Wassermann reaction; 54 for acute bacterial endocarditis; 80 generalized tuberculosis). Bled from jugular vein in Trendelenburg position under aseptic precautions. If yield is small they wash out by injecting Ringer's solution in the arterial side. Sulfanilamide .06 percent is added for preservation. Other medical men do not approve of this method.

At the Central Institute for Blood and Transfusions in Moscow (Director, Professor A. A. Bagdasarov) daily bleeding of donors averages 600 in number. 250 ccs. is taken by gravity method into 2 ampoules (500 ccs. per donor); bleed into citrate solution (using 5 percent sodium citrates). Donors are given a special food ration and some money, but 85 percent of this is given back for airplane construction and other military purposes. Name of donor goes on each ampoule and often is the source of many romances. The donors are largely women. The Central Institute has 79 allied institutions and all plasma and serum is sent to the Central Institute for bacteriological testing before it goes to the army. Transportation to the army and civilian hospitals is by air and motor. The blood is good for 30 days under refrigeration if it is not moved; if transported, 15 to 17 days. Small insulated boxes with ice container hold 4 pints of blood.


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Types of fluids used: (a) Whole blood (5 percent citrate and glucose to isotonicity); (b) Salt solution; (c) Special preservative fluid for use with whole blood which renders it useful twice as long as simple citrated blood but it must be added in proportion of 50 percent special fluid (C.I.B.T.) and 50 percent blood. (This C.I.B.T. fluid contains sodium chloride 7.5 grams, potassium chloride 0.4 gms., magnesium chloride 0.1 gms., sodium potassium phosphate 0.208 gms., sodium acid phosphate 0.119 gms., and glucose 10.0 gms. with distilled water to make 1,000 ccs.); (d) Alcohol-sugar solution (Silsovsky's Solution); sodium chloride 7.0 gms., potassium chloride 0.2 gms., magnesium sulphate .04 gms., Vobel's solution 3.3 ccs., glucose 54 gms. distilled water up to 1,000 ccs. (To this is added 80 ccs. of 96 percent alcohol); (e) Dried plasma-add sugar to isotonicity before drying. (Send forward with sterile distilled water, needle and connections. Plasma is kept labelled by groups-if over 750 ccs., it must be used in a compatible group); (f) Federov's solution-80 percent saline and 20 percent serum (not used much); (g) Blood serum-allow this to be made in other institutions but not plasma; (h) Colloid solution from casein-treat casein to detoxify of antigenic and anaphylactic properties, use as 2 or 4 percent solution; (i) Anesthetic and antishock solution-ephedrine, salt solution and codeins (amount not given).

In the army, they use plasma at regimental aid posts and transfusions of whole citrated blood at front hospitals. Believe blood is best treatment for traumatic shock and believe Academician Lena Stern's suboccipital injection of potassium phosphate solution purely experimental.

E: Amputations-practiced as little as possible and rarely in the upper extremities. When done short flap technique and early use of bucket and stick to keep muscles in training. Of amputations done in forward hospitals, 50 percent are reamputed in special centers in base area where prosthetic appliances are specialized in. In such base centers they practice some kineplastic amputations such as forearm with ulna and radius separated for useful stump. They continuously improve prostheses by the utilization of new ideas of the patients who work out individual problems according to the type of future work and the length of the stump. Points of election for amputation are roughly our own. Use button of preserved bone in medullary cavity end of stump.

F: Plastic surgery-Orders are issued in the front areas not to remove bone and skin in jaw and face wounds and not to suture but to leave for experts in base area centers. In facio-maxillary and plastic centers, excellent work is being done, using tubular waltzing grafts well. By the use of early secondary sutures they reduce the plastic work. One specialist, Professor Frumkin, had made 12 new penises out of tubular grafts containing some cartilage from thoracic cage which he waltzed down.

G: Frostbite-The Russian soldier wears woolen wrappings about his feet and thick felt moccasin boots in the winter time. It is in the season of thawing that the large number of frostbite cases occur. Lt. Gen. S. S. Guirgolave, who is accepted as the authority on frostbite in the Red Army, emphasizes the following points:

Damage produced by cold may be divided into the local and general effects. Congelation (formation of ice in the tissues) never follows the local effects even with the descent of the tissue temperature to zero degrees. The pathological processes, and in particular necrosis, are secondary and are a consequence of changes in the viability and metabolism of the tissues and are not an immediate primary effect of refrigeration. The local effects are the result of meteorological and other factors which lower the local and general resistance of the organism, so that the lesions produced are equivalent to those caused by long exposure to intense cold. In the development of the local effects, there is a "prereactive" period during which, by proper treatment, many of the serious lesions can be prevented.

At a body temperature of plus 26 to plus 28 degrees C, the thermoregulatory mechanism of a homeothermic animal ceases to function and it becomes isothermic. An animal, under such conditions, cannot re-establish a normal temperature by normal means and must be actively heated. By a special technique (electro-thermometrie) in which the central nervous system plays a specific and preponderant role, the damaging effects of cold can


959

be reversed. Carbohydrate metabolism, the adrenal glands and the sympathetic nervous system play important roles in this treatment. Intensive and active heating of the frozen parts and of the body must be carried out in line with these pathogenic conceptions in order to treat rationally and prevent the lesions produced by cold. Rapid heating for 20 or 30 minutes causes no damage to the affected parts or to the body. An animal rapidly heated loses less tissue than one slowly heated. Rapid heating has a beneficial effect upon the functions of the cardiovascular and respiratory systems.

Longitudinal incisions should be made in necrotic tissue within 5-6 days and should extend as far as there is no pain or bleeding. In the presence of subcutaneous edematous fluid such an operation (necrotomy) causes a dry gangrene of the part to develop rapidly. If bones are involved amputation of the necrotic portion should be done 6-10 days after injury. These procedures reduce by two to three times the length of time necessary to treat tissue damaged by cold.

H: Neurological Surgery-There are 16 neurological surgeons at the front who have at their disposal 3,200 beds and there are three large hospitals in the rear with clinics which provide 3,700 beds. In other words there are 6,900 beds in the Soviet Union devoted to the care of neurosurgical injuries and diseases. At the front, 2.9% of all surgical beds are for neurosurgical patients, and in the rear hospitals the percentage is 4.3.

Neurosurgical surgeons in the U.S.S.R. have all been trained under the supervision of Lt. Gen. (Academician) Burdenko who dictates and directs all policies and the expression thereof.

The sorting and evacuation of neurosurgical injuries to special hospitals is practiced as far forward as possible in the combat zone and the one neurosurgical group inspected by the mission was on the Vyazma sector in Sorting-Evacuation Hospital No. 290 located about 70 kilometers from the frontline. The maximum distance for evacuation to such a hospital should not exceed 48-72 hours from the receipt of injury. The most seriously wounded are not moved and not operated upon, and it is concluded that they are expected to be mortally wounded cases. Those injured in whom an operation is possible but who are in shock are kept until shock is treated and then evacuated. Hemorrhages and a rise in intracranial pressure are indications for operation on the spot. Neurosurgical definitive care must be located, according to their dictates, at a maximum distance of 2-3 days from the frontline with trained neurosurgeons, neurologist, neuropathologist, ophthalmologist and otolaryngologist in attendance. Evacuation must be rapid, smooth and preferably by air at altitudes not exceeding 5,000 meters. It is agreed that craniocerebral wounds stand evacuation better before than after operation. Postponed operations in well-equipped and staffed hospitals are preferred to immediate operations under poor conditions.

Sulfonamides locally placed in craniocerebral wounds is advocated, but General Burdenko complained that they were not used immediately as systematically at the front as they should be. Sulfonamides are also given to the patients orally and intravenously.

In the first 24 hours after injury 21% were treated in the "First Line"; 20% in the "Second Line"; and 14% in the "Third Line." In the second 24 hours the percentages respectively were 59, 62, and 65 and in the third 24 hours the percentages were respectively 19, 19, and 11. The mortality of craniocerebral wounds in the rear hospitals is 8% and for spinal cord injuries 56%.

Indications for operation in spinal cord injuries are not clear, but they are stated as (a) prophylaxis against infection; (b) symptomatic, and (c) morphological. The clinical conditions for which operation is advised include progressive paralysis, traumatic edema, subarachnoid space block, pain, and meningitis.

The surgical technique employed in the treatment of craniocerebral wounds consists of irrigation of the wound tract with a bulb syringe and suction removal of the blood and injured brain tissue. Treatment of the dural wound is not considered necessary and the lacerated dura is never sutured. Rubber ring pressure dressings are employed to treat cerebral fungi or herniations. Well-encapsulated brain abscesses are removed in toto by


960

electrocoagulation, and drainage is seldom employed. Contrast media for the diagnosis of abscesses and the location of fragments around the abscess are used.

Formalin fixed nerve and spinal cord grafts are used for the repair of large continuity defects in peripheral nerve injuries. The grafts are fixed successively in alcohol, alcoholic ether, alcoholic glycerin, magnesium chloride, and glucose. Twenty-seven patients have been so operated upon, but none of these were presented for demonstration or examination of the results obtained. The microscopic evidence of the experimental studies was not conclusive.

At the Institute of Experimental Medicine, Prof. Propper Graschenko has 150 neurosurgical beds and is conducting problems of clinical research both in the frontline area and at this Institute so that he has continuous control over patients selected for study. He is studying (1) the character of head injuries, their course, and the influence of infection upon the healing of the wounds; (2) the clinical and bacteriological application of sulfonamides to craniocerebral injuries; (3) the diagnosis of early and late traumatic encephalitis and cerebral abscess and (4) the rehabilitation therapy of craniocerebral and peripheral nerve injuries. He has at his disposal an auxiliary microbiological laboratory staff, half of which is at the front and the remainder in the rear zone.

In the short time at his disposal he presented his work upon gas gangrene infections and other anaerobic infections of the brain. Under field conditions, 100 cases of craniocerebral injuries were studied bacteriologically and in 20.3% pathogenic organisms were present; in 24% aerobic organisms were cultured; in 12.4% sporogenic (putrid anaerobes) organisms were present; in 26.8% coccal infections were present; in 16.5% miscellaneous organisms were found. These cultures were made from 48 to 72 hours after receipt of the injury. In 620 cases examined bacteriologically, only 2 were found to be sterile.

After 3 to 4 weeks wounds showed a flora of pathogenic anaerobes in 12%; aerobes in 20%; cocci in 70% and 8 to 10% were infected with putrid anerobes. Of the 20.3% in which pathogenic anaerobes were found, 1.4% died in 6-7 days of severe gas gangrene infections. Subacute anaerobic infection of the brain is found in all large brain fungi, and of 12 such cases, 9 died. Thirty-two cases of chronic anaerobic infection of the brain were studied, and of these 10 died. The course was long 3-4 months, and often encapsulated abscesses formed which often opened on to the surface or into the ventricles with the production of a severe meningitis. In 34 cases of mild anaerobic infection of the brain, there were no deaths.

The types of anaerobic infection of the brain found included Clostridium perfringens (Cl. welchii), Cl. sordellii, Cl. fallax, Cl. oedematiens, Cl. oedematiens maligni and Streptococcus anaerobius. A serum is used against gas gangrene infection which is polyvalent and contains Cl. histolyticum, Cl. perfringens, Cl. oedematiens and Cl. oedematiens maligni. A prophylactic dose of 10,000 international units is given intramuscularly and therapeutic doses of 3-40,000 units are used intravenously and intramuscularly.

I: New Clinical Methods under Study-

(a) The injection of 70 percent alcohol with 2 percent Novocain solution about fractures in the early days following injury to increase blood supply and to stimulate callus formation. (The mission was not convinced of the usefulness of this procedure.)

(b) The use of placental extract to stimulate healing in chronic wounds or the growth of skin in severe burns.

(c) The use of a cytotoxin made by injecting mesenchymal tissue into a horse and using his antiserum to stimulate the healing of ulcers of the stomach, healing of bone, loosening of scars and stiffness in joints. (The mission was not convinced of the usefulness of this procedure.)

(d) The use of smoke from burning pine wood to stimulate healing (??).

(e) The use of naphthalen (a heavy oil) broken down by ultrasonic method to stimulate healing (??).


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(f) Treatment of shock by the suboccipital cistern injection of potassium phosphate solution to stimulate the [vasomotor] centers in medulla. (See article by Lena S. Stern in Lancet Nov. 14, 1942, page 572.)

J: City Accident and Medical Service: Here we saw an excellent demonstration of the Russian ability at organization which surprised us. The Sklifossowsky Institute is the center of this work for Moscow but has 6 or 7 "district" hospitals. All telephone calls come into a central telephone room at this Institute where there are many switch boards and an elaborate system of intercommunication and directing officials. Apparently patients, doctors, police or friends may call in and state facts. Ambulances go out immediately either from the Central Institute or from the nearest hospital to patient after the information is relayed to that hospital. If a doctor is not necessary he does not go on ambulance, but if there has been an accident or if the case is questionable the ambulance contains a doctor, nurse, and driver. As the message leaves the telephone central room in writing, a time clock is started and officials in the room know when the ambulance leaves, for the doctor, nurse, and driver all press separate buttons [which flash lights on in the central telephone room] as they leave. A check list is also kept by director of the time consumed by each operator per case and number of cases per day. Also, the director in a separate room can plug into any line and listen to incoming and outgoing calls. The system, in part, was like that of an Air Raid Warden's set up in some American cities.

K: Gifts to U.S.S.R.-At our original meeting with the People's Commissar for Public Health we spoke of our gifts, letters, etc. Letters cannot be delivered directly to the individual, and conversation with a Russian is safe for him only when some other Russian is present. Two days later Professor Koreisha came to the hotel and took away the penicillin, our letters, and other gifts. General Smirnov, and General Burdenko came to us personally to ask that their thanks be transmitted to General Hawley for his letter. Both stated they would write him in length. General Smirnov toasted a meeting to General Hawley in Berlin as suggested in the latter's letter. No more information regarding the gifts has been forthcoming.

L: Women in Russia: One of the most impressive things is the obvious equality of men and women, and the latter do everything that men do. They are in the Army as soldiers and officers. In the line, we were told there was no woman with a higher rank than colonel. We saw several junior officers with artillery and infantry insignia. In the Medical Service the Inspector General (Brigadier Surgeon Valentina Gorinovskaya) is a woman. Most of the traffic officers all the way from Moscow to Vyazma were women carrying rifles. Trolley cars are run by women. Women help lay car tracks in the city. The nurses not on duty at the 290 Evacuation Sorting Hospital were doing the major share in the construction of the new log houses for future wards.

Elliott C. Cutler
ELLIOTT C. CUTLER 
Colonel, Medical Corps, 
Chief Consultant in Surgery

Loyal Davis
LOYAL DAVIS
Lieutenant Colonel, Medical Corps, 
Senior Consultant in Neurological Surgery

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