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Chapter II

Contents

CHAPTER II

The Chief Consultant in Surgery

Elliott C. Cutler, M.D.

PROLOGUE

The war diary maintained by Brigadier General Elliott C. Cutler, MC (fig. 7) is an invaluable contribution to the overall history of the medical service in the European Theater of Operations. As Chief Consultant in Surgery, General Cutler occupied a position in which he could observe the many activities of the medical service in the theater, and this position, combined with an inquisitive mind, and limitless energy, enabled him to pursue the paths which his observations-including those not confined to his immediate field of responsibility-opened up.

Some of his observations were based upon incomplete or erroneous information. To have edited or deleted such entries would have marred the reflection of his strong personality in his writing. Where an inaccuracy may present a distorted picture of an important event, an appropriate footnote has been supplied.

Cutler's diary portrays faithfully his dedication to his task, his resentment of everything which impeded its accomplishment, and his intolerance of what he regarded as unjustifiable requirements of military administration. Notwithstanding his occasional caustic criticisms, he was a devoted and loyal soldier who contributed more than his share to the success of the medical service of the European Theater of Operations.

PAUL R. HAWLEY
Major General, MC, USA (Ret.)
                             October 1958

1942: GETTING STARTED

The Beginning

Dr. Elliott Carr Cutler, Moseley Professor of Surgery at the Harvard University School of Medicine and Surgeon-in-Chief, Peter Bent Brigham Hospital, Boston, was at Martha's Vineyard, Mass., when, quite by coincidence,

1Except where other sources are specifically cited, this account has been compiled and edited from the official diaries maintained by Elliott C. Cutler, M.D., deceased, as well as from other records, by Maj. James K. Arima, MSC, The Historical Unit, U.S. Army Medical Service.


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FIGURE 7.-Brig. Gen. Elliott Carr Cutler.

he received on the Fourth of July 1942, orders to report for active duty on 15 July 1942.

It was understood that he was to become Chief Consultant in Surgery in the European Theater of Operations, a position similar to that held by Brig. Gen. John M. T. Finney, MC, with the AEF (American Expeditionary Forces) in World War I. The reasons why Dr. Cutler was chosen for this position were inextricably rooted in that first great conflict.2 In 1915, he was in Paris working with the French. He returned to the United States and received a commission in the Medical Corps Reserve as first lieutenant on 2 June 1916. He sailed for France on 11 May 1917 with Base Hospital No. 5, a unit affiliated with the Harvard Medical School. He served in various capacities, one of which was as adjutant of an evacuation hospital. Dr. Cutler was associated closely with Dr. Harvey Cushing throughout World War I, but his most significant experiences probably were those gained while working directly with Dr. Cushing on surgical teams, particularly in neurosurgery.3

Dr. Cutler was discharged as a major on 29 April 1919. He returned to the Medical Corps Reserve in 1921 and, from then on, kept in constant close touch with Army Medical Department affairs. One of The Surgeons General,

2Annual Report, Chief Consultant in Surgery, European Theater of Operations, U.S. Army, 1942. 
3Cushing, Harvey: From a Surgeon's Journal, 1915-1918. Boston: Little, Brown & Co., 1936.


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Maj. Gen. Robert U. Patterson, was Dr. Cutler's commanding officer while he was with Base Hospital No. 5. Subsequent Surgeons General were well known to Dr. Cutler, and The Surgeon General at this time (1942), Maj. Gen. James C. Magee, was also a close acquaintance from World War I days.

The immediate relation of Dr. Cutler to the present conflict came in the fall of 1941 when he was asked by the dean of the Harvard University Medical School to reactivate Base Hospital No. 5 as the 5th General Hospital. This was readily accomplished, but by the time the unit was pressed into active service in February 1942, The Surgeon General had requested that Dr. Cutler be relieved of his post as commanding officer and await further assignment. Shortly thereafter, Dr. Cutler was offered the position of Chief Consultant in Surgery, ETOUSA (European Theater of Operations, U.S. Army), a post which he eagerly accepted in spite of the objections by the president of Harvard University and the trustees of Peter Bent Brigham Hospital.

Washington Orientation, 18 July to 5 August 1942

The first 10 days in Washington were crammed full of instruction, news, and renewing, and making new, acquaintances. Dr. Cutler's rank was the problem of immediate concern. While he had been a lieutenant colonel since 1924 and had been offered a colonelcy for lesser assignments on three prior occasions, there had been no choice but to come on active duty as a lieutenant colonel. The situation was soon rectified, however, and Dr. Cutler's promotion to colonel reached him on 22 July 1942.

While he was getting ready mentally and equipping himself with all the information he could gather, plans gradually emerged. At this time, 29 July 1942, Colonel Cutler learned that the consultant group for the European theater would probably consist of the following compartments and subdivisions:

Medicine 
William S. Middleton 

Surgery 
Elliott C. Cutler 

Neuropsychiatry
Lloyd J. Thompson

Orthopedic Surgery
Rex L. Diveley

Neurosurgery
Loyal Davis

Otolaryngology
Lyman G. Richards

Ophthalmology
Derrick T. Vail

Anesthesia
Ralph M. Tovell

Blood and Plasma 
Cornelius P. Rhoads 

Venereal Disease
James C. Kimbrough   

Laboratories
Ralph S. Muckenfuss


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Colonel Kimbrough, he thought, might be changed and placed over the whole group, and perhaps Dr. A. Winternitz could be called for later to augment the laboratory group.

He felt that the group should be a cabinet of advisers to the Chief Surgeon and that its members should report as a group, and, therefore, have frequent common gatherings and meetings. He thought that the Chief Surgeon should send them into the field for specific information and should ask them to give him specific advice. Success, he calculated, would depend on relationships with the Chief Surgeon and on the men in the field equally. He reasoned that contacts with professional colleagues in England would also be highly desirable.

The problem which bothered him most was that almost no provision had been made for the professional care of the American soldier "up the line" or at "the front." He wrote in his diary:

It seems to me that the base area has had lots of thought. Base or general hospitals are well set up and well equipped. I have studied in detail lists of equipment until my eyes are sore-lists of drugs never to be used.

But what of the front where it seems to me men are saved or marred for life? I cannot find any happy solution here. There is loose talk of station hospitals broken up, and of new but never assembled mobile evacuation hospitals, but the latter depend on 10-ton trailer trucks which will probably never be delivered. And there is talk of a light field hospital of 400 beds.

Moreover, in a study of teams (surgical affiliated units) I find a tendency to make them rigid and to set them up here equipped in diverse ways with a basic general equipment and then separate equipment for chests-neurosurgery, maxillofacial surgery, orthopedic teams, etc.

1. It is certain the old fixed American hospitals (evacuation, mobile, or surgical hospitals, U.S. Army; casualty clearing stations, British) have been of little use and dangerous in the present mobile, fluid conflict.

2. I believe the above is true and that early surgical therapy, if properly set up, may save many lives-perhaps the lives of my children.

3. If the above two are true, we must organize something new for the U.S. Army Medical Department.

4. I believe the answer lies in putting surgical teams in the clearing station area.

a. Perhaps female nurses should not go.
b. Perhaps the new field hospital can go there.
c. The team personnel should be general surgery, not specialists.
d. The team should be completely equipped; i.e., surgeon should have instruments for head, chest, abdominal, and peripheral surgery. The team should also carry dry goods, supplies, anesthesia outfits, splints, etc.4

As a result of voicing his thoughts on this question, Colonel Cutler was instructed to draw up an equipment list for teams serving the frontlines. But where were the teams to come from? Affiliated groups being organized? Excess in general hospitals? There appeared to be no immediate answer. At any rate, Colonel Cutler received his baptism into the complexities of supply procedures

4"This diary entry was made in Washington before General Cutler came to the E.T.O. He never had any such concern after arrival in the E.T.O. You may be sure that I had no thought of going into combat without the very type of mobile medical units which we did have. The only new unit added after I left the U.S. was the field hospital-and I never thought very much of it as a front-line unit." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 25 Aug. 1958.)


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while working on the equipment for these teams, and the difficulties of medical supply continued to challenge him on many occasions thereafter.

As the long summer days of July turned into August and Colonel Cutler found himself still in Washington, he became increasingly restless and anxious to leave. He recorded:

As a matter of fact, Washington is slow, let down, or, if not worse, full of inefficient people. No one quite at it hammer and tongs, unless it is * * *. I cannot write more but it is awful slow when our country is in danger-grave danger. How few seem to realize the seriousness of this! We are all too old, and yet the old men seem to have the right spirit. That's what the country needs, a spiritual uplift! * * * If I had time, I should sit down and cast into Shakespearean English what stirs my "innards" and stimulates my days. As it is, I'm off for action. Perhaps that's my cue. Now to serve my country.

London

While the last few days in Washington were long, the last was barely long enough. In something less than 12 hours from the time he received notification that travel priorities had been established for him, Colonel Cutler had to obtain his Government transportation requests and tickets, clear administratively for departure, finish packing, bid farewell to friends and family, run the last half mile to the Washington station, and be at La Guardia Airport in New York for a flight at 0100 hours on 6 August 1942. The Pan-American "Clipper" discharged its passengers at Limerick Airport, Foynes, Ireland, the next day. After two unsuccessful attempts to fly from Limerick to Bristol, owing to the fog, the third attempt resulted in the aircraft's being grounded suddenly at an intermediate airport because "Jerry" was reported overhead. Colonel Cutler finally reached his destination, London, at 2350 hours, 8 August 1942, and was billeted at the Claridge Hotel.

Early the next morning, he was off to 20 Grosvenor Square (fig. 8), headquarters of ETOUSA, where he registered, turned in his passport, and filled out the numerous blank forms required upon arriving at a new command.

The next stop was 9 North Audley Street (fig. 9), the London office of the Chief Surgeon, Col. (later Maj. Gen.) Paul R. Hawley, MC. There he met another acquaintance, Col. Charles B. Spruit, MC, (fig. 10) who was now Deputy Surgeon and represented the Chief Surgeon at Headquarters, ETOUSA. Colonel Hawley had moved to Cheltenham, headquarters of SOS (Services of Supply), ETOUSA, when he was also designated Surgeon, SOS. All the medical officers Colonel Cutler met here, just as in Washington, were bitterly critical of this new organization which ostensibly subordinated the Medical Department to an overall supply service. It seemed to leave no provision for integrating services, such as medical, for the Services of Supply and the army in the field. The reorganization appeared to mean that there was no job to correspond to that of Maj. Gen. Merritte W. Ireland with the AEF in World War I. If anything, the squabble over this reorganization was worse in England than in Washington. The immediate question confronting Colonel Cutler as a result of this situation was whether he was to stay in London or go to Cheltenham.


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FIGURE 8.-Headquarters, ETOUSA, at 20 Grosvenor Square, London.

He soon learned the answer. The next day, Colonel Hawley arrived in London, and Colonel Cutler was able to meet with him. Colonel Cutler was to be located with the Chief Surgeon at Cheltenham. He was given his mission in simple terms. As the chief consultant in surgery, he was to see that the American soldier received the best medical care that the tactical situation and local circumstances would permit. Colonel Hawley also expressed his policy of fostering the best of relations between the Americans and the British and working closely with them. Colonel Hawley also thought that the consultants should have and bring up their own ideas as well as carry out orders from him.

"I think we will get on," Colonel Cutler wrote after the meeting, "Indeed, we must."

The next few days were exceedingly busy as Colonel Cutler set out to make his contacts with other American agencies and the British offices in London.

Among the Americans he met again was Maj. (later Col.) Herbert B. Wright, MC, who was chief of the Professional Services for the Eighth Air Force surgeon and the latter's liaison officer with the Office of the Chief Surgeon, ETOUSA. Colonel Cutler learned a great deal from Major Wright about medical organization, procedures, and functions in the Eighth U.S. Air Force.

Colonel Cutler also met Dr. Kenneth Turner, liaison officer of the American National Research Council with the British National Research Council. Dr. Turner was attached to and lived with the American Embassy staff in London.


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FIGURE 9.-Office of the Chief Surgeon, ETOUSA, at 9 North Audley Street, London.

Among other things, Colonel Cutler discovered that Dr. Turner had a very complete file of National Research Council reports and publications and received new items frequently and promptly. These papers were obviously of critical importance to the maintenance of highest standards of medical practice among the American forces in the United Kingdom. Dr. Turner, however, informed Colonel Cutler that he was not permitted to release them to the U.S. Army. They were strictly for his information to facilitate his dealings with the British counterpart of the American National Research Council. This situation was disappointing, to say the least, and entirely at odds for the best conduct of the war effort. Colonel Cutler later made a strong appeal to have the unfortunate situation rectified. As a result, Dr. Turner was able to obtain State Department approval for receiving extra copies of the American National Research Council publications to be turned over to the Chief Surgeon, ETOUSA. In exchange therefor, Dr. Turner was later invited to attend all strictly professional meetings and conferences held under auspices of the Chief Surgeon.

In the next few days, Colonel Cutler went about the most pleasant task of establishing himself with the staff of the AMD (British Army Medical Directorate) and the Canadian medical staff in England. Lunch on two occasions at the RAMC (Royal Army Medical Corps) School in one fell swoop placed Colonel Cutler in the midst of their activities. It was the custom of the DGMS (Director General, Medical Service) to hold a monthly meeting of his consul-


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FIGURE 10.-Col. Charles B. Spruit, MC.

tants, advisers, and directors of medical services in area commands. Consultants from the RCAMC (Royal Canadian Army Medical Corps) were already participating in these meetings. The chief surgical consultant, Brigadier J. M. Wedell, RAMC, and the chief medical consultant, Maj. Gen. Sir Alexander Biggam, RAMC, held meetings of consultants in their respective branches the day preceding the Director General's meeting. Colonel Cutler was asked to, and later became a regular participant in, the meetings of the surgical group and those of the DGMS, Lt. Gen. Sir Alexander Hood, RAMC.

The subject of particular concern, on the occasion of Colonel Cutler's first visit, was that of rehabilitating men in convalescent camps rather than occupying beds in hospitals. The proposal was to provide plenty of exercise and physical training, perhaps under the direction of line officers, and encourage men to fight their way back to health. The British hoped to make extensive use of physiotherapists in this organization. The civilian-directed hospitals of the EMS (Emergency Medical Service), in which British soldiers were hospitalized for long-term definitive treatment, had been much too lenient in the past.

On his last day in London, 13 August 1942, Colonel Cutler, with an old-time acquaintance, Brigadier (later Maj. Gen.) William Anderson, dined as guests of Surgeon Rear Admiral Gordon Gordon-Taylor (later knighted) (fig. 11), another good friend from pre-World War II days. Brigadier Anderson was surgeon of the Scottish Command and Admiral Gordon-Taylor was Chief Consultant in Surgery to the Royal Navy. Brigadier Anderson later became Chief Surgical Consultant of the British Army.


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FIGURE 11.-Surgeon Rear Admiral Gordon Gordon-Taylor, Royal Navy, with General Hawley.

In addition to these representatives of the British Army and the Royal Navy, Colonel Cutler also met and spoke at length with Tudor Gardiner of the Royal Air Force and Prof. J. Patterson Ross, neurosurgical consultant to the Emergency Medical Service.

Colonel Cutler felt that he had accomplished much in a mere few days as he left London by train in the early afternoon of 14 August 1942 and arrived at Cheltenham some 5 hours later. In a memorandum, a copy of which went to the Chief Surgeon, Colonel Cutler presented these impressions of his first few days in England:

Observations on military surgery at this time-

a. The Combat Divisional Medical setup is O.K., though we need to get directives to the medical units as to proper professional handling (i.e., very simple, but to include use of sulfonamides, splints and evacuation).

b. The Base Area Hospitals (Station and General) are admirable and when brought up to the T.O. with American equipment cannot be bettered.

c. The area between the tail of the Division and the Base Area is a so far uncharted area. It appears at first glance that the British may be getting themselves too set on following up their Libyan experiences which practically leaves a plan that throws


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out the C.C.S.'s {Casualty Clearing Stations] and other forward hospital units and relies almost entirely on the utilization of surgical teams in independent, self-contained, motor-transported small units.

I believe we must be prepared both for the above mobile, surgical team set-up, utilizing this close to a Clearing Company and possibly with part of our new field hospital, as well as for putting in our evacuation hospitals, though they must be stripped and cut down in weight for mobility. No one now can predict when and where, therefore, we must have alternate plans.

And when we come to contemplate a beach-head and medical care, the matter is further complicated * * *.

A final thought brings up the major problems of evacuation from the forward area. Try as one will there is no escaping the conviction which becomes even firmer that the optimum solution is in the air.5

Cheltenham, Headquarters, SOS

Cheltenham, Colonel Cutler found, was quite pleasant. He was given a tiny, but adequate, top-floor room at the Hotel Ellenborough. The officers were awakened at 0630, breakfast was at 0700, a bus transported them to the office at 0745, and working hours were from 0800 to 1700 daily. Saturdays, however, began an hour later, and on Sundays the officers were required to work only in the forenoon. The office facilities, unfortunately, were not the best, and later, when the full complement of consultants was on duty, the noise was said to be akin to a boiler factory (p. 362).

Col. James C. Kimbrough, MC, had been made Director of Professional Services, Office of the Chief Surgeon, Services of Supply, ETOUSA, as Colonel Cutler had anticipated, and was thus placed over all the consultants. He was also acting as consultant in urology, his specialty, and was responsible for the quality of treatment being given patients with venereal disease.

Lt. Col. (later Col.) William S. Middleton, MC, was Chief Consultant in Medicine. The only other consultant present at the headquarters at this time was Lt. Col. (later Col.) James B. Brown, MC, Consultant in Plastic Surgery and Burns. Colonel Middleton, as he had explained to Colonel Cutler at their first meeting in London, did not expect to have a large full-time staff. He was operating under the principle that men of special abilities and qualifications in the general hospitals could be designated theater and area consultants in addition to their regular duties in most of the specialties of medicine. He planned to have full-time consultants only in dermatology and neuropsychiatry. The consultants who were to make up the initial group of surgical consultants in the European theater were expected (and did arrive) in the next few weeks. They were Lt. Col. (later Col.) Rex L. Diveley, MC, Senior Consultant in Orthopedic Surgery; Lt. Col. (inter Col.) Loyal Davis, MC, Senior Consultant in Neurological Surgery; Lt. Col. (later Col.) Ralph M. Tovell, MC, Senior Consultant in Anesthesia; and Lt. Col. (later Col.) Derrick T. Vail, MC, Senior Consultant in Ophthalmology.

5Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 16 Aug. 1942, subject: Report of Activities, Aug. 9-14, 1942.


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Colonel Cutler had just arrived in Cheltenham late Friday, 14 August; but Sunday, 16 August, found him off again to London. Innumerable trips to London were to follow.

On Monday, he called on Air Marshal Sir Harold Whittingham, DGMS of the RAF (Royal Air Force), and Sir Francis Fraser, director of the Emergency Medical Service. He also dined and had conferences with Col. (later Maj. Gen.) Malcolm C. Grow, MC, Surgeon, Eighth Air Force, and the aforementioned Major Wright. The conferences with Colonel Grow and other members of the Eighth Air Force concerned the curriculum of a proposed course of instruction for medical officers with no previous training in aviation medicine. The Eighth Air Force hoped to open a provisional medical school at High Wycombe by the end of August.

The following day, Tuesday, 18 August, was a preview of things to come and the first trip in the field for the recently arrived Chief Consultant in Surgery. With Sir Harold Whittingham, Colonel Hawley, Colonel Grow, Colonel Spruit, Major Wright, and an engineer officer of the Eighth Air Force, he visited Hendon Airport, London, to inspect the litter arrangements for transport aircraft. The demonstration showed only one thing of significance. It was very apparent that more work would have to be done to make the conversion of transport aircraft into evacuation aircraft an efficient and simple operation. The aircrew required 10 minutes to position each of 18 litter racks. It took some 20 minutes for a British ambulance crew to load 10 litter cases. Much time was wasted because the litter racks were made to take small-pole litters and not the American or British Army wooden litters. With properly modified litter racks and a trained crew, Colonel Cutler thought that the whole operation of setting up the litter racks and loading patients could be accomplished in 30 minutes.6

After the demonstration, Colonel Cutler inspected a dispensary located at Hendon Airport and then journeyed back to Cheltenham. There, he proceeded to write up reports of the trip to Londlon and to put down on paper the type of education and training that would be necessary for medical officers in the immediate future. He envisaged three areas upon which emphasis in this training program could be placed: (1) Early treatment at the front, (2) treatment during the evacuation phase, and (3) the type of treatment to be given in base hospitals. He stressed particularly the following point:

Chief emphasis must be placed upon choice of soldier upon whom surgery is to be carried out in the forward areas. A directive regarding this can be written but will have to be modified by the necessity. Precedence should be given to haemorrhage, shock, sucking chest wounds, major compound fratures. The military surgeon must learn that the quickest way to win the war (and this in the end saves the most suffering) is to get back to duty as many men as possible. Abdominal cases and time consuming major surgical procedures that offer little or no hope of return to duty can never have first call on the efforts of the good military surgeon.7

6Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 19 Aug. 1942, subject: Report re Visit to London August 17 and 18,  1942.
7See footnote 6.


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This bit of advice was something which many medical officers, including some of the specialist senior consultants in surgery, were going to find most difficult to accept.

In this same paper on medical courses to be conducted in the theater, Colonel Cutler also stated: "I consider an Auxiliary Surgical Group our chief necessity at this time!" He went on to report that the component teams were being carefully picked in the office of Brig. Gen. Charles C. Hillman, Chief, Professional Service Division, Office of The Surgeon General.

Having finished his London report and the suggestion for courses in military medicine, Colonel Cutler found solace and cheer in the accomplishments of his first few days in the European theater. His diary entry read:

For the first time I feel orderly and as if something had been done. Of course, I have only been here 10 days. Since I've cemented myself with the RAMC, the RAF, and our own Air medical people, I must have gotten something done. Also in touch with the Royal Navy through Gordon-Taylor and the EMS through Francis Fraser.

Solitary reflection on the general outlook, however, caused Colonel Cutler to philosophize:

The doctor at war is worth thought. He cools his heels in this preparatory phase with those whose entire thoughts are directed toward implementing conditions he is already trying to oppose. True, the common fear binds them together. All must visualize the necessity of the undertaking lest a greater evil befall our people. But unmistakably, he is set aside-sometimes just as chaff, sometimes in undue respect as the necessity for his ministrations seems more imminent, or as the limited imagination of his colleagues looks to the future.

There was yet another reason for cheer on this day, Colonel Cutler's 10th day of duty in the Office of the Chief Surgeon, ETOUSA. The British and Canadians, with a few attached Americans, had staged a major raid at Dieppe.

Dieppe and Its Aftermath

The raid at Dieppe sounded good to Colonel Cutler. It showed that a landing could be achieved. It proved that tanks could be landed. Was it worthwhile? Yes, for any offensive, no matter how small, would upset the Germans.

A Canadian from Saskatchewan who had just returned from the raid told Colonel Cutler that it was a cinch. He had gone in 2 miles. It was easy. No one was frightened. This young man went on to say that the Allies might as well tell Hitler when an attack was coming because nothing could stop it. He asserted that the Germans knew 5 days beforehand of the Dieppe attack.

But there were casualties, American casualties. The Chief of Staff, ETOUSA, upon learning of the seriousness of their wounds, became extremely concerned over the care the Americans were receiving in the Canadian Army hospitals to which they had been taken. Colonel Cutler, together with Colonel Middleton, visited each of the three Canadian general hospitals in which the American casualties were hospitalized and carefully reviewed each case. The


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treatment and care being provided them was excellent. To a man, each patient refused to be transferred to an American hospital when the choice of remaining in the Canadian hospital or being transferred was proffered. They were happy where they were and had utmost confidence in the Canadian medical officers into whose care they had been entrusted.

There was one seriously ill case, a Colonel "H." Colonel "H." had been on the bridge of a destroyer when a direct hit blew off the bridge and amputated most of his left foot. He tied on a necktie as a tourniquet and hobbled to the gunwales of the sinking ship. As he was preparing to go overboard, a gunboat hove alongside and Colonel "H." was handed over to it. "Go aft," he was ordered, but, seeing that the forward gunner was leading enemy aircraft badly, he crawled forward and continued to direct the gunner's fire. Some 30 hours elapsed before he was put ashore at Portsmouth, England. Another 24 hours passed before he reached the Canadian General Hospital where he received his first surgical treatment.

At the hospital, Colonel "H." 's lower left leg had been amputated 5 inches below the knee. Sulfonamide had been placed in the wound, which was left open. The wound was clean. He had been given doses of sulfanilamide for 24 hours, but this was stopped because of nausea, mental confusion, and his general poor condition. In the 3 postoperative days, he had been given 2,800 cc. of whole blood and 3,000 cc. of plasma. Repeated, continued transfusions were urged by both Colonel Cutler and Colonel Middleton, and the professional staff at the Canadian hospital concurred.

Ten days after injury, the patient's condition continued extremely grave. Colonel Cutler was directed to review the case personally. In a midnight visit to the hospital on 30 August, he found Colonel "H." somewhat improved but still apparently dying of a peculiar syndrome. His kidneys and heart were failing, and the etiology indicated multiple transfusions with reaction which had compounded the effects of original blood loss. Colonel Cutler followed the case daily, thereafter, until the patient was out of danger. This courageous officer made an excellent recovery, was returned to duty, and continued to serve in the European theater after having been fitted with an artificial limb. His case became an object lesson for much of the planning that followed.

As the initial sensational aspects of the Dieppe raid wore off, there were doubts in some circles as to its effectiveness or worthwhileness. The force had sustained 55 percent casualties. The lessons for the Medical Department were clear. An analysis of the situation in England revealed the following facts:

If things could have been done better our Canadian colleagues were the first to recognize it. They pointed out to us * * * that it would have been better if all of the wounded had been kept near the landing areas [in England], even if additional teams had been focused there, or the local hospitals enlarged to care for such an influx * * * . It was thought that there would be a larger number of wounded than could be handled locally, and therefore the first to arrive were sent by train to the Midlands, which was perhaps a mistake for they went without surgery, even after arriving in England, for a considerable


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period of time. The Canadians themselves were the first to be self-critical about this, but since * * * they handled individual cases so well, we can have nothing but gratitude for their care.8

This analysis indicated that, with a Continental invasion, hospitals would have to be set up near the points where casualties would be returned to England in order to preclude undue delay in treatment as was experienced by Colonel "H." If general hospitals were to function in this capacity of receiving evacuees from an over-water operation, they could only do so after provision had been made for some 10 or more surgical teams to work at one time. The surgical teams, too, would have to be added to the normal surgical complement of a general hospital.

On the far shore, it was clear that small medical units with attached surgical teams would have to be deployed near all possible handling sites. The Dieppe raid proved once again that confusion reigns supreme in war. Owing to many factors, significant among which was the destruction of small landing craft, landling serials found themselves at points completely foreign to their original intent, upsetting the most carefully prepared plans.

Finally, the important part which sorting or triage would play could not be minimized. Sorting at the invasion beaches and the receiving areas in England had to be done expertly and quickly so that the seriously wounded would receive immediate attention, as would also the lightly wounded in order that they might be returned to duty as early as possible.9

British Army Blood Supply Depot at Bristol

One of the first items of official correspondence directed to Colonel Cutler for action was a report on the British Army Blood Supply Depot submitted by Capt. (later Lt. Col.) Robert C. Hardin, MC, who was the American liaison officer at the depot. Colonel Hawley, in turning over the report to Colonel Cutler, signified that the Chief Consultant in Surgery would be responsible for the technical aspects of providing blood, blood substitutes, crystalloids, and related substances to the U.S. Army medical units in the theater.10

Colonel Cutler, at the first opportunity, on 26 August 1942, made a trip to Southmead Hospital, Bristol, where the depot was located. Colonel Kimbrough and Colonel Middleton accompanied him. Brigadier L. E. H. Whitby, RAMC, the officer in charge of the depot and Director, Army Blood Transfusion Service, was absent in London, but the visiting officers were received by Major Maycock, RAMC, and Captain Hardin. They learned that the center prepared all plasma and arranged for the supply of blood transfusion kits for the British Army (fig. 12). The general setup was obviously geared for production. In the previous one year, the depot had supplied over 110,000 pints of  plasma.

8See footnote 2, p. 20.
9(1) See footnote 2, p. 20. (2) Memorandum, Col. E. C. Cutler, MC, and Lt. Col. W. S. Middleton, MC, to Col. J. C. Kimbrough, MC, 26 Aug. 1942, subject: Report of Survey of American and Canadian Casualties From Dieppe Operations, August 25, 1942, by Members of Professional Services Division.
10Medical Department, United States Army. Blood Program in World War II. Washington: U.S. Government Printing Office, 1964.


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FIGURE 12.-Blood transfusion kits being packed at the British Army Blood Supply Depot.

Citrated whole blood was supplied only for limited use. A cream separator was used in the preparation of a wet plasma, the red cells being thrown away. The plasma was bottled and stored at room temperature and not subsequently checked for sterility unless the solution became turbid (fig. 13). It was obvious to the officers from Cheltenham that the onus of applying proper precautions in the use of British wet plasma rested with the user. The visit to this center did not allay their fears of the propriety of telling American medical installations to use British plasma liberally. Colonel Cutler and Colonel Middleton recommended that, as soon as possible, all American medical installations be supplied with the American standard dried plasma units.11

A short time later, on 7 October 1942, Colonel Cutler met with Maj. Gen. L. T. Poole, RAMC, director of pathology, AMD, and Brigadier Whitby to work out for the interim an understanding between the American and British Forces in England with respect to the supply of blood and blood substitutes. At this conference, it was agreed that:

1. The American Forces would be glad to use British supplies of dry or wet plasma, but the amounts required would be no greater than for a British hospital in the same circumstances.

2. Should the American Forces leave for operations outside of England, they would take American plasma which was already stocked in quantity and would not require crated British stocks.

11Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 27 Aug. 1942, subject: Visit to Central British Blood Procurement Center, Bristol, August 26, 1942.


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Figure 13.-Bottled wet plasma being prepared at the British Army Blood Supply Depot. A. A cream separator being used to separate blood cells and plasma. B. The filtering of plasma.


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Figure 13.-Continued. C. Plasma being packed for issue.

3. Individual American units would be prohibited from requesting blood or plasma directly from British centers but would submit requisitions to American medical supply sources which would stock these items received in bulk from the British.

4. Far greater use would be made of Captain Hardin in the future as an assistant to the theater consultants and to help with the organization and training of shock teams. Brigadier Whitby stated that Captain Hardin was essential both in running the plant and in the large teaching load which was carried there, and had requested that he continue in his present duties and assignment.

5. American hospitals would cooperate with the British blood bank program. That is, U.S. Army hospitals would bleed a few donors each week from a prepared panel of donors representing the community in which the hospital was located and turn the blood over to the appropriate bank.

6. It would be inadvisable to use American troops as donors for this blood bank program because of the political implications. It was believed that Americans at home might resent giving blood for the American soldier when he, in turn, was being bled for the citizens of another country. Moreover, there was the possibility that the combination of blood from Negro and white troops might complicate the situation.


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7. Finally, Colonel Cutler promised to try to obtain additional American personnel to help staff the British Army Blood Supply Depot.12

This was indeed a humble beginning to a project which was to become, literally, the lifeblood of the theater's medical efforts, and Colonel Cutler's perspicacity with regard to the greater use to be made of Captain Hardin was to be most amply vindicated.

First Supply Problem

On 24 August, just before he was called upon to inspect the Canadian hospitals harboring American casualties from the Dieppe raid, Colonel Hawley had summoned the Chief Consultant in Surgery. Colonel Cutler was directed to draw up a list of medical supplies necessary for the routine maintenance of a field force of 770,000 with 140,000 SOS troops. This was no small task. Colonel Cutler started Colonel Brown, Consultant in Plastic Surgery and Burns, on the list before embarking on the all-night trip to the Canadian hospitals.

A few days later, Colonel Cutler met with Lt. Col. (later Col.) George W. Perkins, Jr., CWS, in London. Colonel Perkins worked with the central procurement office of the ETOUSA staff and was concerned with the procurement of medical supplies and equipment from British sources. This officer politely informed Colonel Cutler that the Medical Department was "all wet" on its figures. "I've no doubt," Colonel Cutler noted in his diary, "and this puts me in a difficult spot * * * [with respect to Colonel Hawley's request]."

Another aspect of the problem was what was needed now-at this time-as compared to what, ideally, might be required in a hypothetical operation. Phrased in another way, the problem became a matter of what was available as compared to what was desired. Consultants visiting and inspecting hospitals had found critical shortages of necessary equipment and the prevailing use of many unsatisfactory items. On the other hand, the U.S. Army medical supply depot at Thatcham was, from all reports, quite well stocked. The fact remained that necessary equipment for hospitals was, for reasons unknown to Colonel Cutler, not getting out. Colonel Cutler wanted particularly to have the three general hospitals in the theater brought up to their full authorized equipment, preferably their original American equipment. These general hospitals had professional talent of the highest caliber, but they could not be expected to provide services of a similar high caliber without the proper equipment. Should U.S. Army sources in the theater not be able to provide this equipment, it was evident that British sources would have to be tapped. And thus, Colonel Cutler had arranged the foregoing meeting with Colonel Perkins.

On 3 September, Colonel Cutler and Colonel Brown visited Ludgershall, the largest British Army medical supply depot, to pick out instruments suitable

12Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 9 Oct. 1942, subject: Report on Meeting With British Officers Concerned With the Supply of Blood and Plasma for the Armed Forces


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for interchange with American instruments. Colonel Diveley and Colonel Perkins had journeyed to the depot from London. In addition to the RAMC officers concerned with the depot, representatives from three British instrument manufacturers were present. The entire day was spent in going over item by item the instruments listed in American supply tables so that determination could be made as to whether a satisfactory substitute British item existed. On the whole, the British instruments were excellent, and, although somewhat heavier than American instruments, each item accepted was a satisfactory substitute. There was some question, however, as to whether some items could be produced in sufficient quantity. There was a particular lack of production in England of all electrical apparatus, and only a negligible supply of heavy X-ray apparatus. Generally, instruments not being produced in England were not essential, and a good surgeon could do a satisfactory job without them. Colonel Cutler was particularly impressed with the cleanliness and orderliness of this depot and the wonderful selection of materiel offered.13

Upon returning to Cheltenham, Captain Martin, in charge of the American depot at Thatcham, was contacted. Arrangements were made for Colonel Brown to visit the depot the next day to have a firsthand look at what was actually available and could be counted upon.

Before the Chief Surgeon's first problem could be answered, another was posed. This time, it was not hypothetical, and it was urgent.

Second Supply Problem

A persistent rumor had been that any attack on the Continent from England had been called off for the time being, and the basis of this rumor soon became clear. BOLERO, the buildup for invading the Continent was being subordinated to Operation TORCH, an attack in Africa which was to come off in the very near future. With this as a background, the following came about on 5 and 6 September, as chronicled by Colonel Cutler.

We work daily and seem to make no progress, largely because, as will be clear below, we are caught in a mess! Our army is still being trained broadly and absolutely lacks specialists. Take supply as an example. Here is our chief, Major General Lee [Maj. Gen (later Lt. Gen.) John C. H. Lee, USA, Commanding General, SOS, ETOUSA], a very bright man and well equipped with native intelligence. Moreover, he is an engineer, but here his problem is supply. It is a professional job. His training in supply and logistics is more than mine, but not complete. His transport office has the job of the New York Central RR. Of course he isn't equipped. We must change this, and our army must have specialists!

In the Medical Corps, it is just puerile.

Take the last 24 hours. At 9:00 last night, Colonel Hawley's sergeant came here with a note from the Chief that the heads of his offices come to him at 9:00 AM. It was a supply problem. JCK, WSM, and ECC [Cols. Kimbrough, Middleton, and Cutler] were given a list of medical maintenance units for 10,000 men per month. We were informed on Africa. We were warned about secrecy, of course. Then we took the list and put 10 hour's on it.

13Memorandum, Col. E. C. Cutler, MC, Lt. Col. J. B. Brown, MC, and Lt. Col. R. L. Diveley, MC, to Col. J. C. Kimbrough, MC, 4 Sept. 1942, subject: Report of Visit by Col. Cutler, Lt. Col. Brown and Lt. Col. Diveley to British Medical Supply Depot, Ludgershall.


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We could make additions and increase the number of items, but there could be no deletions. It was a tough job. The list was a riot. It was supposed to be under battle conditions for 1 month. There were 3 litters, no tetanus toxoid or antitoxin, no instruments (were they supposed to last forever?), no oxygen tanks, but several thousand rolls of toilet paper! One bedpan!

The next day, 7 September, Colonel Hawley asked Colonel Cutler to drive to Oxford (2d General Hospital) with him. The Chief Surgeon seemed to have much on his mind. He explained what hospitals would be going to Africa, a relatively small force from England. He said that they would be sent well and fully equipped, but otherwise didn't seem overly interested in them. The 2d and 5th General Hospitals, two of the best units, were to stay. Colonel Hawley implied that when the Operation TORCH forces had gone he would settle down and clean up in England, and he realized there was much to do. As to Colonel Cutler, the Chief Surgeon said that he would like to see him make weekly visits to all hospitals, develop the instructional program (schools), and stimulate high professional work.

It is elsewhere recorded that, as plans progressed further for Operation TORCH, the European theater had to request that replenishment supplies to support the operation be sent directly from the Zone of Interior. The basis for this request was the realization that it would be more feasible to furnish these supplies from the distant Zone of Interior than to attempt to find them in the depots in England.14

Introduction to 1st Infantry Division

On 15 September 1942, a Captain Miller, MC, from the 1st Infantry Division visited Cheltenham to further activities for the professional education of the division's medical personnel. He represented Lt. Col. (later Col.) James C. Van Valin, MC, division surgeon, who had previously written Col. Oramel H. Stanley, MC, the Chief Surgeon's executive officer, on this matter.

Captain Miller was referred to Colonel Cutler. When Captain Miller revealed the fact that the medical officers of the division would not be permitted to attend the surgical courses being established in London, Colonel Stanley proposed that the consultants give a brief series of lectures at the division. This suggestion was quickly accepted by Colonel Van Valin and the II Corps surgeon, Col. Richard T. Arnest, MC.

The lectures were conducted at Tidworth Barracks during 16, 17, and 18 September. On the first day, Colonel Cutler gave two exercises which covered first aid surgical measures in the first and second echelons of medical service within the division. There was no attempt to discuss definitive surgery as carried out in the evacuation, surgical, or general hospitals. He stressed the fact that the primary requisites for adequate initial surgical care of the wounded soldier were the control of hemorrhage, relief of pain, adequate dressing of the wound and use of sulfonamides to prevent further contamination, booster dose

14Medical Department, U.S. Army. Medical Supply in World War II. [In preparation.]


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of tetanus toxoid, proper splinting, closure of sucking chest wounds, and an adequate appreciation of shock, crush, and blast so that proper therapy could be started as far forward as possible.

On the following days, Colonel Brown presented talks on injuries to the face and jaw, care of burns, and care of injuries in Air Force personnel; Colonel Diveley spoke on care of fractures and their transport and evacuation; Colonel Davis discussed neurosurgery in war; and Lt. Col. (later Col.) Lloyd J. Thompson, MC, Senior Consultant in Neuropsychiatry, gave a talk on neuropsychiatric problems in the field.

The talks were well received, but this course of instruction, which had begun as a one-way flow of information, provided a wealth of instruction to the consultants themselves. When Colonel Cutler had completed his portion of the program and a discussion of the basic first aid surgical measures had ensued, it became remarkably clear that the 1st Infantry Division was not equipped with instruments or drugs of the type to best facilitate and carry out these necessary measures. This alarmed Colonel Cutler. There were no morphine Syrettes for forward work, no sulfonamide powder for dusting wounds, and no local or intravenous anesthetics. There were only two blood pressure apparatuses within this division of 17,000 men. The instrument kits were inadequate, and the equipment on hand was, in many cases, nearly useless. A simple procedure which could be carried out by almost anyone and would save life was that of closing sucking chest wounds, but there was no supply of the necessary needles and silkworm gut sutures.

As a further check on the statements made by the medical officers, Colonel Cutler inspected the equipment and supplies on hand in the division's medical supply section. He also went over, item by item, the No. 2 medical chests which were being used in the division's dispensaries and which were also meant to be used under battle conditions for the care of casualties. Colonel Cutler was again struck by the lack of equipment and supplies which he now knew from personal experience were available and could be supplied from sources in England.

Upon returning to Cheltenham, he dictated a memorandum in which he detailed simple, but specific measures which could be accomplished to correct these deficiencies. He closed the memorandum with the following:

I consider these recommendations of vital importance. The material essential is all here. We have been instructed to see that the care of the American soldier is as adequate as it can be made under the conditions imposed by battle. The requests above are simple, but may be life saving, and if they are neglected we should be and will be severely criticised.15 

Once back in his room, he wrote:

Well, I have been told my job is to see that the Americans get the best professional care under circumstances presented by terrain, enemy resistance, etc. So I handed

15Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 18 Sept. 1942, subject: Teaching Exercises With the First Division at Tidworth Barracks, Sept. 16, 1942. (Copies to Colonel Hawley, Colonel Stanley, and Colonel Middleton.)


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in a memo today practically stating that, if an American newspaper knew 17,000 picked men were going into battle with simple things lacking which every American hospital had, then we all would be fixed.

This was the beginning of extensive medical supply operations in the European theater in which many individuals participated following the realization that elements of the U.S. Army were not adequately provided with modern medical equipment and supplies.

Inter-Allied Conferences on War Medicine

While Colonel Cutler and the consultants were planning the teaching exercises for the 1st Infantry Division, a secretary in another office of the headquarters was transcribing a telephone message from N. B. Parkinson, Director, Home Division of the British Council. Mr. Parkinson's message stated that the British Medical Association had recently been in touch with the British Council and had expressed their earnest desire that the Association do all it could to assist members of the medical professions of the allied nations now resident in England and to insure that British members of the profession benefit from the presence of so many medical persons from all over the world. To further this end, the British Medical Association was willing to provide certain facilities and privileges under its control. It had been suggested that an association or society be formed which would serve to bring together medical men of the allied nations and promote a sense of professional unity among them. Before any further steps were taken, Mr. Parkinson was suggesting that leading members of the various national groups meet to express their views at the offices of the British Council.

Colonel Cutler had been aware of the fact that the Belgians had initially attempted to form such an inter-Allied medical organization. It was brought to his attention in Colonel Spruit's office when he had first arrived in London, but Colonel Cutler had since given it little thought. This time, he and Colonel Kimbrough were selected to attend the proposed meeting to represent the American point of view. The meeting was held as scheduled at the offices of the British Council on 23 September 1942. In attendance were representatives from Canada, Belgium, the Free French, Czechoslovakia, Norway, and The Netherlands in addition to the British and American delegates. The Poles could not come but telephoned expressing their interest.

Most of the participants at the meeting expressed a desire to have joint meetings, but there was little enthusiasm for a separate dues-paying association with a name, officer's, journal, and permanent fixtures. The Belgians reported that an organization had already been formed, under the honorary presidency of Mr. Biddle and the active presidency of General Hood, which was to hold its first open meeting in December. These deliberations were duly reported back to the British Medical Association by the British Council, but the matter again fell through. Apparently, the British thought a club and home were desired-the Belgians and Czechoslovaks had said so-and, in their usually astute way, questioned whether such an affair could be properly financed.


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Curiously enough, it was at a meeting of the editorial board of the British Journal of Surgery, on 12 October 1942, that the matter was again brought up. (Colonel Cutler had accepted the invitation to become a member of this board, a signal honor, since previously the journal was concerned only with publishing efforts from British surgeons.) The chairman of the board, Prof. George Gask, took keen interest in the proposed inter-Allied medical meetings. He arranged for Colonel Cutler to meet with Maj. Gen. H. L. (later Sir Henry) Tidy, President, Royal Society of Medicine, on Wednesday, 21 October. The Honorary Secretary, Mr. Broster, and Sir Geoffrey Edwards, Secretary, also attended the meeting. The officers of the Royal Society of Medicine were most willing and pleased to be able to sponsor such military medical meetings of the Allies.

Colonel Cutler was greatly encouraged by the outcome of this conference. Formerly, attempts to hold medical meetings of the Allies had been thwarted. These meetings now had a sponsor with the facilities and organization to see the desires through to fruition. "I think I kicked it on its way," he noted, "and I believe these meetings will serve not only to educate us now for the war, but will be a bridging force for all the Allies, helping us to organize the world and civilization which is to follow."

On Tuesday of the following week, 27 October 1942, a meeting was held at the Royal Society of Medicine attended by representatives of all His Majesty's services and representatives from each of the Allied countries. It was passed unanimously that monthly meetings should be held at the Royal Society of Medicine, under the sponsorship of this organization, to which members from all the Allied forces would go. The Directors General of His Majesty's medical services promised every assistance in the way of speakers and advice.

To carry the story a little further, the first meeting was held auspiciously enough on 7 December 1942, the first anniversary of the entry of the United States into the war. There was a large attendance, and comments were very favorable. Colonel Cutler thought the meeting was only fair and would have to be better in the future. Towards this end, he had already persuaded General Tidy to set up an executive committee to lend closer direction to program and coordinating activities. The meetings continued to improve and were held in series throughout the years of the war. Medical officers of the U.S. Army contributed in no small measure to the success of the meetings. Selected lectures from the entire series were published after the war under the honorary editorship of General Tidy.16

Operation TORCH: Hopes for an Early End

The attack on North Africa, to those in England, came off quietly and with some surprise insofar as the actual timing was concerned (fig. 14). True, the consultants had been called upon for advice on specific, limited aspects, but

16Tidy, Sir Henry (Ed.). Inter-Allied Conferences on War Medicine, 1942-1945, Convened by the Royal Society of Medicine. New York, Toronto, London: Staples Press, Ltd., 1947.


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FIGURE 14.-The Royal Navy cruiser Aurora, escorting a convoy to North Africa from the United Kingdom.

they had neither been taken into complete confidence on the plans nor asked to participate to the extent that they might have been able. Colonel Cutler, himself, asked on at least three separate occasions for permission to go with the force from England but was turned down. Unless he acquired experience in an actual combat area soon, he reasoned, then his words would eventually become empty and devoid of any worth, at least so far as this war was concerned.

As it was, Colonel Cutler realized that the attack was on only after some of the combat elements in England had pulled out of their stations for the staging areas. When news of the assault on 8 November 1942 arrived (fig. 15), it was through the public press, and it was good news. The news led to considerable optimism, which, as it eventually turned out, was rather premature. But, at the moment, Colonel Cutler was quite elated. Writing on 9 November, he said:

All the time the good news was waiting and tonight it is still better. It looks as if all Africa would shortly fall. This is the big thing we've been so secret about. Now it has really come off well. What next, Italy? Or an attack here by spring? It's the turn of the war. Victory and release all in the air. Home seems near us and smiles should grace our faces. I once said 5 years and thought of 3. But now, who can deny us hope that the ETO will be over within a year?

The Surgeon General Visits the European Theater

The first visit to the European theater from anybody in the Office of The Surgeon General which concerned the chief consultant in surgery was that of The Surgeon General, Maj. Gen. James C. Magee (fig. 16). General Magee


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FIGURE 15.-The beach at Saint-Leu, Algeria, North Africa, on D-day, 8 November 1942.

arrived at 9 North Audley Street on 20 November 1942, accompanied by General Hawley. Appointments were made by Colonel Spruit for General Magee to meet with the medical heads of the British services, and preliminary discussions were held with General Hawley and Colonel Spruit.

At 1500 hours, 21 November, a business meeting and dinner were held for The Surgeon General at Thurlestaine Hall, Hotel Cheltenham. Guests were the four base section surgeons, the V Corps surgeon, and from the Army Air Forces, Colonel Grow, Col. Harry G. Armstrong, MC, Col. Edward J. Tracy, MC, and Colonel Wright. As expected, The Surgeon General's chief interest in this trip was to iron out difficulties and to arbitrate differences in opinion for providing medical support to Air Force units. With no warning, Colonel Cutler was the first to be asked for an opinion. "I was pretty noncommittal," he later wrote, "except for saying Air Force was sustaining first casualties and, therefore, the men needed the first help." The problems were brought well into the open, however, and Colonel Cutler thought the meeting was very good. The aspects of the discussions which concerned Colonel Cutler were the desires by the Army Air Forces for recognition and support of the Air Force medical school, better equipment at Air Force stations, hospitals to care for casualties at the operational airfields, and consultants, or their equivalent, within the Air Force medical organization in England.

The following day, Sunday, 22 November, Colonel Cutler motored to "Pinetree," Eighth Air Force headquarters at High Wycombe, with Colonel


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FIGURE 16.-Maj. Gen. James C. Magee, The Surgeon General, visiting Stonehenge on the Salisbury Plain, Wiltshire, England, November 1942.

Grow, Colonel Armstrong, and Colonel Wright. "To my consternation," Colonel Cutler found, "Grow was very bitter. Said the Medical Corps wouldn't help him. He hereafter wouldn't help them. It may have been 'a show' for Daddy. I played it safe." Upon reaching "Pinetree," the party lunched with Maj. Gen. Ira C. Eaker, Commanding General, Eighth Air Force. After the luncheon, Colonel Cutler discussed possible means of satisfying Air Force desires but found Colonel Grow not easily convinced that a happy and cordial relation with the Ground Forces could be established.17

Colonel Cutler proposed that, if the Air Forces desired consultants, they would be most welcome to serve within the framework of the theater consultant plan and that the provisional school which was now being carried on could be integrated into a school for medical officers in general, as distinct from a school just for the Army Air Forces. The Eighth Air Force also desired that a separate treatment facility be established for the care of aircrews with flying fatigue or threatened with actual neurosis. Colonel Cutler suggested that Colonel Middleton and Colonel Thompson, him whose hands this responsibility lay, would be most willing to cooperate in this project.

"The answer to all this," Colonel Cutler reported, "depends upon whether the Air Force will accept the intimate relation to the Professional Services

17Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 27 Nov. 1942, subject: Relations of Your Office to Air Force.


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as outlined above, but until such time as we are instructed not to serve the Air Force it appears to me that we should lend every effort to keep together the entire medical service."

During the next 2 weeks of General Magee's visit, it was Colonel Cutler's privilege to accompany The Surgeon General on some of his visits to nearly all the major American medical installations in the United Kingdom and many of the British installations as well. In talks with General Magee, Colonel Cutler had the opportunity to approach him about the field dressing in the individual soldier's first aid packet. This was a matter to which Colonel Cutler had given considerable thought. Colonel Cutler had been able to obtain much information on the efficacy and requirements of field dressings as a result of an invitation to participate in the British First Field and Shell Dressing Committee. The British committee had decided that their dressing had to be larger and had recommended that it be put in a cellophane packet. Colonel Cutler believed that the U.S. Army field dressing, which was still packed in a metal container, could also profit by similar modifications and advised The Surgeon General so. He recommended that further studies be made under The Surgeon General's direction in the Zone of Interior to see whether a cellophane packaging could not replace the metal container and the bandage itself be made larger. The Surgeon General was given a sample of the new British packet to take back with him.18

Colonel Cutler was also able to ask General Magee for an assistant. He informed General Magee that such increasing needs for consultants as going into EMS and RAF hospitals at night as well as during the day made it impossible for Colonel Cutler to fulfill completely his obligations in such matters because of other and more weighty engagements which could not be broken. He asked that Maj. (later Lt. Col.) Ambrose H. Storck, MC, in Brig. Gen. Charles C. Hillman's office be selected for this position as assistant to the Chief Consultant in Surgery in the European theater. General Magee, in return, suggested that it would be nice if the European theater would invite Col. (later Brig. Gen.) Fred W. Rankin, MC, Chief Consultant in Surgery in the Office of The Surgeon General, to visit the theater.19

In a more formal vein, Colonel Middleton was given the project of collecting answers from the Professional Services Division to a list of questions which The Surgeon General had brought with him from members of his office. Questions which concerned the Chief Consultant in Surgery and his answers to Colonel Middleton on this occasion in effect provided a résumé of consultant activities to date. They were:

1. Education and training.

Many courses in medico-military subjects are being given to U.S. Medical Department officers to both those in the combat [units] and * * * those in the station, evacuation, and general hospitals, as well as to the Air Force.

18Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 27 Nov. 1942, subject: First Aid Packet for the American Soldier.
19Letter, Col. E. C. Cutler, MC, to Director of Professional Services, 30 Nov. 1942, subject: Additional Consultant in General Surgical Field.


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As a part of the above general courses, special attention has been paid to the proper treatment of the wounds in general, largely by Colonel Cutler, and wounds in special surgical fields by the senior consultants in orthopedic surgery, neurological surgery, maxillo-facial and plastic surgery and burns, ophthalmology, anesthesia, thoracic surgery, and transfusion and shock. These surgical courses have been given in turn at the Air Force school, to the medical officers of two American divisions, to groups of doctors in our base section areas, and to individual hospital assemblages.

2. Activities of surgical consultants.

All of the surgical consultants have the closest relationships with their opposite members in the British military set-up, including Army, Navy and Air Force, The Chief Consultant in Surgery attends the meeting of the British Surgical Consultant Group each month, and the meeting of the Director General of Medical Services, RAMC. He has a similar relationship with the EMS, RAF, and Royal Navy. Through this liaison we have been permitted to enter and study all of the organizations of the British Services, and have thereby profited greatly.

Another activity of the consultants has been to aid in establishing the high level of professional work in all of the American hospitals-station, evacuation or general, in ETOUSA. This has meant constant visits to institutions, the stimulation of ward rounds, clinical meetings, and assistance in acquiring the necessary material for proper professional endeavour. This activity goes on constantly, and I am sure that much benefit has accrued from this intimate contact of the Consultant Group with the hospital setup.

A special field might be said to be our relation with the American Air Force. We understand that we serve them as well as the Ground Forces, and we have been happy to teach in their schools and to look after their wounded as they enter our hospitals.

An unexpected labor to the Consultant Group has been the constant demands made upon them to assist in straightening out the medical supply situation in ETOUSA. A tremendous amount of labor and time have had to go into supplying proper lists for the medical requirements of both divisions and static hospitals, and a constant liaison has had to be established with those who purchased British medical material for the use of the American Forces.

3. Unit assemblages.

The answer to this is complicated, for the Consultant Group is not entirely familiar with unit assemblages. It should be said, however, that we have been instructed by General Hawley to go over the arrangements and material in medical chests Nos. 1 and 2 and delete certain items and add others that are necessary * * *. We believe that there should be another complete revision, by a group familiar with this matter, of material required in [an] active theater of war * * *. It appears that some of the material being sent, which was of value twenty years ago, is now out-moded.

4. Dried serum plasma.

The situation * * * is as follows. On hand Nov. 15-4,224 units. Issued in September-10,238 units. Issued in October-2,735 units. We need more plasma immediately, in view of the fact that combat forces are instructed to take such material with them.

5. Intravenous fluids.

The answer * * * is simple. If hospitals were supplied with adequate stills it would be unwise to send over bottled intravenous fluids. Stills, however, cannot be acquired in Great Britain, at this time, in sufficient number and of the type desired. They should therefore be sent with a high priority rating.

6. Physical standards for induction.

From visits to all of our hospitals, it is apparent to the Surgical Group that a considerable number of physically unfit enlisted men are arriving in ETOUSA. I have personally seen two individuals in a single hospital with large defects in their skulls produced by terrific accidents in youth, and I have seen large scrotal hernias in individuals taken into the Army; also two severe cases of Dupuytren's contracture of the hand. Another matter commented upon by Colonel Diveley is the failure, apparently, to examine the feet properly before induction.


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7. Weekly medical newsletter from the Office of The Surgeon General.

It is my impression that a weekly medical newsletter would be highly acceptable. Note that the Canadians do this, and do it very well. Undoubtedly a copy of their Newsletter is available from General Hillman.20

There were a few sidelights which appeared during General Magee's visit which Colonel Cutler found inviting to reflect upon but which were quite serious matters at the time of their occurrence, particularly to those involved. For example, he recorded:

But now this curious story: Yesterday was Thanksgiving. I had worked hard and hadn't paid any attention to an invitation by Lady Harding at St. James's Palace. Colonel Stanley saw me and asked why I was here [Cheltenham] when the King had sent for me. He said I couldn't refuse and had to go. So I worked all day, forewent lunch to get more done, and left by car at 2:00 PM for London. By then I had found out that Harding was the King's secretary. So I reported to C. Spruit and found General Hawley there just in from Buckingham Palace. He looked sick and promised to let Bill [Colonel Middleton] examine him tomorrow (i.e., today, which has been done, and he goes in hospital, 2d GH, tomorrow). Then C. S. [Charles Spruit] and I went to St. James's. Great crush of people, all tired, and I was hungry.

Unfortunately, the Royalty were unable to appear, and the two colonels later found it necessary to search elsewhere for food, but it was a unique honor to have been invited to the Palace and a privilege to have met the important personages of the era who were there. Concerning General Hawley, Colonel Cutler noted on a visit to the 2d General Hospital, 30 November 1942:

Came here [London] yesterday, stopping at the 2d General to see General Hawley and to get my X-rays. The former is better, but his laryngitis is bad and his temper is bad; the latter, beautiful and I have hardly coughed recently. Had long discussion re sitting of party for General Magee. There will be 13 with ECC, so I was out.

Avonmouth, Disembarkation of Hospital Ship No. 38, the Newfoundland

With the attack on North Africa, it was inevitable that casualties would sooner or later arrive in England. Colonel Kimbrough and Colonel Cutler journeyed to Avonmouth on the English south coast on 17 December 1942, to see one of the first shiploads disembark. Colonel Cutler's account follows:

Arrived in time to see her dock. It was the Newfoundland of Liverpool; all white with red crosses and a black "38" on her side (fig. 17). Could see American soldiers at the rail as she came in. Then we boarded. We were shown about by the RAMC major in charge. The men were in swivel beds that were set like tables in yachts so that when the boat rolled, the bed did not. They, about 400, were packed pretty close (fig. 18). Saw the sickest eight; just had morphine, so were comfortable. About one-half were Americans and one-half British. There were a few British marines and a handful of prisoners. Just through a stormy trip back. The unloading went on smoothly. There were plenty of ambulances; separate ones from the Royal Navy for the Marines! All other wounded went to the 298th GH (Michigan). The British were later sent to their own hospitals. We went to the 298th and had a nice chat with Colonel Kirksey and Walter Maddock. Am going to get them three teams from the 3d Auxiliary Surgical Group tomorrow. (Unit just in at Oxford.) Will set up a questionnaire to study effects of sulfonamides.

20Letter, Col. E. C. Cutler, MC, to Lt. Col. W. S. Middleton, MC, 20 Nov. 1942, subject: Memo for General Magee.


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FIGURE 17.-Hospital Ship No. 38, the Newfoundland of Liverpool.

FIGURE 18.-The interior of the Newfoundland.


49

Upon returning to Cheltenham, Colonel Cutler reported to the Director of Professional Services, as follows:

The most interesting phase was the visit to the ward containing seriously wounded or sick people. I talked to six seriously wounded Americans. My questions, other than their general condition to cheer them up, were objected solely as to whether they had taken the sulfonamides which each American soldier presumably carries on his person. Not one individual had either taken tablets by mouth or dusted the powder into his wounds. They seemed to know what these medicines were for but had not bothered to use them, partly because in each case the individual was apparently unconscious following the accident, or spitting up blood if injured in the chest, or was so near the first aid man or first aid post [aid station] that he preferred to have the latter give him the medicine. The individuals I talked to came from the 16th and 18th Infantry [Regiments] and 39th Engineers.

This lack of our men taking sulfonamides brings up the problem repeatedly put to the British, that it is not wise or intelligent to tie up such a vast amount of a precious drug in packets for soldiers when the drug can be better and more securely given by the first aid posts. The only criticism of this British attitude is that there may be a long interval between being wounded and reaching a first aid post.

The arrival of these American casualties in the United Kingdom gives us an opportunity to put out a questionnaire and study the matter of (a) whether sulfonamides were used [and] (b) the interval after being wounded and the use of sulfonamides [in order] to check on their value by study of the conditions of the wounds now, since many of of the wounds were sealed up in plaster almost from the beginning. Thus, the danger of secondary infection dismissed, we may be able to arrive at some fairly satisfactory scientific data.21

3d Auxiliary Surgical Group

On 18 December, the day following the visit to Avonmouth, Colonel Cutler, in the company of Colonel Kimbrough, hastened to visit the 3d Auxiliary Surgical Group, newly arrived at Cowley Barracks, Oxford, from a temporary station in Scotland. A pleasant meeting was held with the group's commanding officer, Lt. Col. (later Col.) John F. Blatt, MC. The problem was how to use the officers of the group in gainful pursuits in order to maintain their morale and spirits at as high a level as possible. The visitors explained how these officers could be used in hospitals, both British and American, and sent to American and British schools. Arrangements were made for the immediate dispatch of four teams to the 298th General Hospital and for Capt. (later Maj.) Benjamin R. Reiter, MC, to initiate the sulfonamide study. Colonel Cutler was particularly impressed by the high professional caliber of the group as a whole. He noted: "Some were among the best surgeons in the United States, and it is a great credit to those who assembled such a group that so many A-1 surgeons could be gotten together."22

It was just about Christmas Eve when General Hawley and Colonel Cutler conferred further on utilization of teams from the 3d Auxiliary Surgical Group. General Hawley decided to offer to the British up to 20 general surgical teams from the group for use with British Forces in North Africa. Both Gen-

21Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 18 Dec. 1942, subject: Visit to Hospital Ship Disembarkation, Avonmouth, Dec. 17, 1942.
22Memorandum, Col. E. C. Cutler, MC, 19 Dec. 1942, subject: Visit to No. 3 Auxilliary Surgical Group, Cowley Barracks, Oxford, 18 Dec.1942.


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eral Hawley and Colonel Cutler were aware of the acute shortage of doctors in the British Army and knew that, in characteristic fashion, the British had tightened their belts and had not asked the United States for additional medical personnel, even though this possibility had been suggested. They realized, too, that the experience which these teams might gain would be most valuable. It was Christmas Eve when Colonel Cutler approached Brigadier Anderson, chief surgical consultant, RAMC, on the loan of these 20 surgical teams to the British Army.

On 28 December, Brigadier Anderson telephoned Colonel Cutler and relayed General Hood's message accepting this offer. The Director General was very grateful and most complimentary. Colonel Blatt also happened to visit General Hawley's office on this day, and he was fully oriented on the forthcoming dispatch of these teams to Africa.

The following day, Colonel Cutler returned to Cowley Barracks and gave the group an hour's talk on professional matters-their job at the front, the importance of debridement, their equipment, history of medical activities in the theater to date, and so forth. At lunch with the group, Colonel Cutler was dismayed to find a strong anti-British sentiment among members of the group. "Made me mad," he later wrote, "* * * laid it down a bit, as gently as possible. Told them it's no way to begin a war by criticizing a generous ally."

The administrative difficulties in providing these teams for the British proved most formidable, and final arrangements had to be worked out personally by General Hawley and Colonel Spruit with higher echelons of command.

Summary of Miscellaneous Activities During 1942

In his annual report of activities for 1942, Colonel Cutler stated:

The multitudinous duties which confront a consultant group are hard to categorize, for, with our broad instructions to see that each individual soldier has the best medical or surgical therapy possible under the conditions imposed in this theater, we naturally cut across all the usual boundaries of Army organization.

Thus, while the highlights of Colonel Cutler's first year in the European theater, 1942, have been briefly described in the foregoing pages, a still briefer word in passing must be devoted to some of his other multifarious activities in order to provide a faithful account.

American women doctors in England.-For various administrative and political reasons resulting from the war, General Hawley asked Colonel Cutler to investigate the status of women doctors in England of American citizenship and to look into the possibility of their employment as contract surgeons in the U.S. Army. In conferences with Sir Francis Fraser, director, EMS, and Dr. Murchie, the EMS personnel officer, Colonel Cutler was able to determine that most of these women doctors were advantageously employed by the British in their EMS installations. One was a major in the RAMC, Maj. Barbara


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Stimson, cousin of the U.S. Secretary of War. The women were happy where they were and did not want to become contract surgeons, especially since, as they later learned, the pay was less than that being received from the British. What was required was a mechanism for their commissioning in the U.S. Army Medical Corps. Eventually, after many conferences and considerable give-and-take by all concerned, most of the women were made contract surgeons and loaned to the British EMS to continue in their jobs. Major Stimson remained in the RAMC and was sent to an active British theater, the Middle East. Colonel Cutler's final comment on this problem was:

Barbara Stimson back from talk with her cousin HLS [Henry L. Stimson, Secretary of War] and Somervell [Lt. Gen. Brehon B. Somervell, Commanding General, SOS]. Guess women will get in Medical Corps soon. I have long advised they be taken in gracefully before they are put in against wishes of the Medical Corps. They will get in for sure.

Acting senior consultants.-Senior consultants for the theater in radiology and otolaryngology were expected momentarily, but, in the interim, individuals qualified and physically on duty in England had to be designated to act in such capacities as the needs arose. In accordance with the policy of grouping all professional medical specialties under the Chief Consultant in Medicine or the Chief Consultant in Surgery, radiology had been designated to come under the purview of Colonel Cutler. Accordingly, Lt. Col. Robert P. Ball, MC, and Capt. (later Maj.) Edmond P. Fowler, Jr., MC, both of the 2d General Hospital, were appointed to act as senior consultants in radiology and otolaryngology, respectively, in addition to their regular duties.

British Medical Research Council.-Attendance at and membership on the various committees of the British Medical Research Council "* * * have been extraordinarily enlightening * * *. Here one sees science applied to this devastating matter of war in an extraordinarily intelligent manner. * * * The writer is satisfied that great progress has been made by the intelligent few who sit with the British Medical Research Council."23

In particular, Colonel Cutler found attendance at meetings of the War Wounds Committee and its subcommittees most profitable. It was through this committee that he effected the promulgation of instructions to the British Army Medical Service and the EMS to use tetanus toxoid prophylactic doses rather than antitoxin in the prevention of tetanus in wounded or injured American soldiers. The British habitually used antitoxin for their wounded or injured soldiers in danger of tetanus infection. When antitoxin had been used on American soldiers, some serious reactions had occurred. Conversely, Colonel Cutler was able to have a circular letter published by the Chief Surgeon, ETOUSA, which instructed American medical units treating British soldiers on the proper prophylactic dose of antitoxin to be given.

Return postcard (surgical).-From his World War I days, and from what he had seen so far in World War II, Colonel Cutler realized that there

23See footnote 2, p. 20.


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was very little interchange of information between the first echelons of medical service and those conducting definitive treatment in the rear. Yet, it was important that there be a constant flow of information between those first treating a patient and those who saw him later. Colonel Cutler had mentioned this need to the Chief Surgeon at one of their first conferences and had received his approval to design and have printed a postcard form for this purpose.

When the card was printed, the only casualties occurring in England were among operational aircrews. Medical officers in the Eighth Air Force, when asked, showed a keen desire to give the return postcard system a trial use. Accordingly, Circular Letter No. 79 was issued on 17 December 1942 by the Chief Surgeon. A portion of it follows:

Follow-up cards (ETOUSAMD Form 303) are being distributed to unit surgeons of the 8th Air Force. These are pre-addressed cards designed for the purpose of transmitting back to the medical officer who first treats an injury or battle casualty information concerning the subsequent progress of the case.

The medical officer giving immediate treatment at the station dispensary will print his name, grade, and A.P.O. number on the address side of the card. * * * and the card * * * will accompany injured and wounded patients to hospital.

The medical officer treating such cases at the receiving hospital will complete the reverse side of the card as soon as immediate therapy has been instituted, sign, and mail [it] * * *. A card will not be held at hospitals until completion of the case.

When ground hostilities were later engaged in on the Continent, this directive was modified to permit use of the card by all units initially treating casualties. This simple system worked with considerable success.

Special studies.-In addition to the sulfonamide study initiated with the first receipt of casualties from North Africa, limited studies in other areas were also begun.

The problem of fatigue in long training marches was being investigated by the 29th Infantry Division. Blood pressure, pulse rate, and blood sugar levels before, during, and after the training efforts were being recorded in order to obtain reliable data upon which could be based proper decisions as to the optimum amount of physical effort which could be expended without an inordinate increase in fatigue and morbidity.

Maj. (later Lt. Col.) Rudolph N. Schullinger, MC, 2d General Hospital, at his own request, was permitted to procure penicillin in small amounts from Prof. Howard E. Florey at Oxford and to experiment on its clinical application.

The consultants were asked to evaluate the efficacy of gas gangrene antitoxin and to make recommendations for its use in the theater. In this case, no actual experimentation could be initiated at the time, but expert opinion in the available literature and that obtained from interviews with members of the Allied forces and the British Medical Research Council indicated no conclusive results as to its efficacy. Since, however, there were implications in laboratory experiments that the antitoxin might assist in preventing the development of infection, Colonel Cutler recommended that a small stock be kept in the medical supply depots where it would be available to surgeons who wished to make use of it or who would like to make special studies on its efficacy and use. He recom-


53

mended that gas gangrene antiserum not be included as a regular supply item for all medical installations at this time.24

Journals, books, and headquarters' library - While the need for books, journals, and libraries was universally accepted, there was no professional library at the Cheltenham headquarters, and the sets of basic texts and journals for hospitals were lost in the depots. Colonel Cutler continually pressed the issue until the hospital sets were found and could be distributed, and one of the last things he did in 1942 was to appoint himself as librarian in order to establish a professional medical library at the headquarters in Cheltenham. A system was initiated whereby hospitals would get copies of journals routinely and reserve sets would be maintained for the hospitals which were later to arrive in the theater.

On visiting the British  libraries, particularly those of the Royal Society of Medicine and the Royal College of Surgeons, it was most disconcerting to Colonel Cutler to find that American medical journals were arriving in England badly mutilated by the American censors. He took it upon himself to invite the attention of the War Department to this deplorable situation. He stated:

* * * Copies of these journals come to the Chief Surgeon's Office uncensored, and the Division of Professional Services * * * has never been able to find any article in these journals in which censorship could in any way affect the war * * * The extent to which such censorship is carried out is out of reason as well as robbing American doctors in this country of the ability to keep abreast of modern medicine.

It is recommended that the War Department take steps to see that American medical journals now going to the United Kingdom for use in public libraries * * * be uncensored. Thousands of these journals are freely distributed in America where their contents can easily be studied. It seems unnecessary to censor these journals because they travel across the Atlantic to an allied nation with whom we should have the most cordial and friendly relations.25

Medical field service school.-As indicated in the preceding narrative, there were many educational opportunities afforded the medical officer in the United Kingdom. Most of the contacts with the teaching institutions had been established before Colonel Cutler's arrival in England. After his arrival, he had continued to supervise the input of surgical officers to the various courses and had himself, or in cooperation with his senior consultants, created other training opportunities in British schools and hospitals and in certain of the U.S. Army hospitals. The instruction being received by officers attending these courses was of great value in keeping up and developing skills in certain aspects of medicine and surgery. There was needed, however, a centralized and coordinated instruction of the civilian doctor in military uniform as to the many duties expected of him in which he had little or no prior experience. It was also necessary to indoctrinate him on the accepted, basic tenets of medical

24Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 1 Sept 1942, subject: Gas Gangrene Anti-Toxin.
25Letter, Col. E. C. Cutler, MC, to the War Department, 26 Dec. 1942, subject: The Censoring of Medical Journals Now Being Forwarded to Libraries of Medical Installations in Great Britain.


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and surgical practice in the theater in order to standardize the treatment of the more common conditions found as a result of military service or injuries incurred in combat. This obvious need was being met by plans to establish a medical field service school in conjunction with the SOS American School Center at Shrivenham, Berkshire.

Colonel Cutler had started work on the curriculum and courses of study for this school as soon as he had oriented himself in the theater. By early September, he had completed the courses of study in the surgical topics to be covered. He then discussed them and arranged for their incorporation into the overall curriculum with Lt. Col. George D. Newton, MC, who was initially in charge of establishing the school at Shrivenham.

Observations at Year's End

By the end of 1942, most of the positions for which senior consultants were contemplated had been filled. The many duties and responsibilities of a consultant had gradually evolved through his day-to-day commerce with fellow officers in the headquarters and in the field and through his concern in the medical matters of the theater. It was possible, at this time, to reflect on the activities of the year and to make recommendations which only the knowledge gained through experience could make possible.

Colonel Cutler had the following thoughts for The Surgeon General:

The memorandum has been on my desk three months; it has been fully considered by most of the present Consultant Group who give it their warm approval. It is presented without bias or criticism as a piece of constructive thinking which has arisen during the day's work. To my way of thinking, it is the most important contribution I can make in my present office.

*   *   *   *   *   *

In this thinking, observation of and discussion with our British and Canadian colleagues have been helpful for medical and surgical problems are universal and do not belong to nationalities. Always in these discussions the remark arises in those who are not members of a Regular Army Medical Corps but who have left their civilian positions to help as best they can at this time, "I wish we could have worked on these problems in peace time!"

And this desire to have played a role in peace time has many beginnings. It arises in part from the findings that the Regular Corps are not on a whole, though there be brilliant exceptions, as much abreast of modern medical and surgical practice as the civilian profession is. It arises because what to the military doctor is an essential apparatus or medication long since was dropped from use in medical practice. And it arises because the civilian doctor finds he thinks and talks even a little different medical philosophy from his regular colleague and wishes they had had more in common in the past.

I believe that were an arrangement set up with a permanent Advisor or Consultant Group established as a part of the Army Medical Department there would result a steady flow of benefit to our Army Medical Corps. Such a Board would bring an immediate close relationship between civilian doctors and the Medical Corps. Each would be led to the other's domain. Each would attend the medical meetings of the other group. The interest of the public as a whole would be aroused and once again the Army medical man would be the real and actual colleague of his civilian prototype.

This would be especially true if a method of appointment to this Board was utilized which [would] put the responsibility for appointment on the leading medical and surgical


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societies in the USA * * *. This would put these leading societies squarely behind the Medical Department of the U.S. Army, for having assumed responsibility for an appointment the associations would inevitably follow through with an abiding interest. This alone would be a great step forward. * * *

Such a Board with the great clinical societies squarely behind it would result in a new attitude of civilian doctors to military doctors. The two would closely approach each other, the civilian group would feed personnel into the Army group. The advantage from common meeting grounds in each other's associations and societies would have incalculable benefits. And all the time the Consultant Group could be kept working on medical supplies and methods for military movements. It is not proper to wait until we go to war to prepare to bring proper medical and surgical relief to our soldiers. We must be prepared always with material and methods. We must practice lest we fail in our responsibility. What amount of labor by a doctor can equal the offering to his country of an infantry man, an aviator, or any member of the fighting forces? There can be no demands upon his time and skill in peace time along these lines that our profession would not gladly give.

The fact that the British Army and the British Army have had for years civilian consultants in times of peace and the role they now play and all benefits to their service which have flowed from this arrangement strengthens my temerity in offering this memorandum.

In closing, Colonel Cutler made the following specific recommendations:

1. That an Advisory or Consultant Board in the fields of Medicine and Surgery be set up as a Permanent Part of the U.S. Army Medical Department. This is to function in times of Peace as well as War.

2. That the Senior Consultants in Medicine and Surgery be nominated respectively by the American Association of Physicians and the American Surgical Association. That the Senior Consultants in the Medical and Surgical Specialties be nominated by their respective Associations or Societies in the USA.

3. That confirmation of these nominations rest in the hands of the Surgeon General.

4. That this Board be a continuously active part of the medical department and be consulted freely and continuously on all matters pertaining to the fields covered by its membership.26

1943 TO EARLY 1944: PLANNING, BUILDING UP, AND WAITING

The First Half, 1943

The new year began with quite an experience for the Chief Consultant in Surgery. He left by auto from Cheltenham for London on 3 January in order to attend the second session of the Inter-Allied Conferences on War Medicine. "The high point of 3 January," he later reported to Colonel Kimbrough, "was the unfortunate fact that my car rolled over on me while driving from Cheltenham to Swindon. Fortunately, no one was hurt, but I reported the accident immediately by telephone and dispatch rider to Headquarters and to the Inter-Allied Medical Meeting." The meeting, however, was very successful, and many favorable comments were made on General Hawley's presentation and upon that by Colonel Diveley, Senior Consultant in Orthopedic Surgery.

26Letter, Col, E. C. Cutler, MC, to the Chief Surgeon, ETOUSA, and The Surgeon General, 13 Jan.1943, subject: A Plan for an Advisory or Consultant Board in Medicine and Surgery as a Part of the US Army MD in Peace as well as in War.


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Problems of interpersonal relationships

Perhaps the one thing which characterized the life and pursuits of the consultants during the greater part of 1943 was their attempt to acclimatize themselves to the military, professional, and social milieu which prevailed in the Chief Surgeon's Office and among its members. This constant effort to adjust was still an undertone to the bustle of activity which marked later, more active periods in the life of the theater and remained a matter of deep concern to the consultants even after the fight was won. It was, however, during this period of relative calm-a long, frustrating period of waiting for the big things to happen-that these interpersonal relationships arose as manifest problems to the welfare of the individuals involved and to the overall effort of the medical headquarters in the European theater.

Had Colonel Cutler been able to take the time to write this consultant story, as he called it, he undoubtedly would have placed great emphasis on this aspect of the total picture. His diary contained frequent reminders to himself that he would have to write the consultant story some day, reminders inevitably tied in with these problems of interpersonal relations. Unfortunately-or for that matter, fortunately-Colonel Cutler was, rather, a man who preferred to do something about these things, and, thus, they were never written.

Briefly put, there were two problem areas. One problem was the relationship between the officers who had only recently come on active duty and the officers of the Regular Establishment. The other problem concerned the relationships of the consultants with one another. The officers in the Chief Surgeon's Office had come from many walks of life with greatly varying backgrounds and experiences. The consultants were men of outstanding ability and prominence who, to a great extent, owed their success to their unique individuality. It was to be expected that a great amount of give and take had to occur and that true communication was to be most difficult. In his annual report for 1942, Colonel Cutler gave the following indication of the rising problem:

It is fair to state that on the whole the consultants have been patient and forgiving. We who are used to the fast well-oiled machines of civilian life have often been irked at the slowness of action or certain hidebound regulations which do not seem to allow us to put the best man in the right place, or the right material where it is necessary. Curiously, those who went through the last war in this group seem more patient than those who did not. Perhaps we learnt something about the Army in the last war. I am sure that all the consultants see eye to eye in their main desire to render expert surgical and medical care to every American soldier. Our own Chief of the Professional Services, and, in particular, the Chief Surgeon, have been immensely patient with us, and we are happy to have this opportunity to give them our gratitude in return.

The weather, among other things, had been "rotten," rainy, cold and miserable, and Colonel Cutler, himself, had felt no better. He noticed that the morale of his consultants was particularly low. On Sunday, 25 October, he recorded: "In the afternoon, the boys * * * gave me hell; said we weren't


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getting anywhere and suggested it was partly my fault!" The following day, he wrote: "Staff meeting, 4:00 to 5:00, and this time the boys took it out on JCK [Colonel Kimbrough]. I think they are wrong, petulant, and a bit childish. Anything they can do will help our soldiers, but they seem to feel that, unless it is a great big job, they might demean themselves by doing it." A few days later, he commented: "I appreciate they have little to do that looks important, but why cannot they see that everyday they serve their country, it is a privilege. Why must all think: What are we doing? What do we get out of it? Perhaps I'm just a stupid little boy, but anyway, I'm happy to serve."

After these really uncalled for, but understandable, outbursts of temperament, Colonel Cutler tried, he believed successfully, to mend damaged feelings and arrive at a better understanding among the consultants. On occasions, however, things seemed to go from bad to worse.

The new year held no promise for improving the situation. On New Year's Day, Colonel Cutler entered this rather despondent statement: "I seem to feel that we are all stagnating and going to seed, though we work steadily at organization." And on 4 February he recorded: "All day I've felt bad, and now I feel just rotten. Discouraged with a system which isn't calculated to help a country at war, though that obviously is the reason for its existence.27

That this matter of interpersonal relationships was no trivial matter can well be attested by the attrition rate among the surgical consultants. During 1943, four of the senior consultants in surgery returned to the Zone of Interior for permanent change of assignment. Among reasons for their reassignment was that of failing health brought on by the environment and circumstances under which they worked. One of the consultants was seriously ill. Another had to be removed from the Professional Services Division and given a division of his own in order for the Service to obtain the maximum contribution that was expected and needed of him and that he was fully qualified to give. Apparently, from the written record, Colonel Cutler was able to contain himself remarkably well, considering the circumstances.

Another phase of this struggle, particularly as it might be applicable to the professional personnel who made up the group of surgical consultants, was the personality of Colonel Cutler, himself. These statements made by General Hawley, however, could have applied to each of the other consultants as well. Speaking in retrospect of Colonel Cutler, he wrote the following:

* * * An innate honesty often compelled his professional judgments to be severe; but, whenever possible, they were softened with praise of other qualities. His high ideals and his devotion to duty made him, in his younger and formative years, somewhat intolerant of mediocrity; and this occasionally brought him into conflict with others. But the years brought him the wisdom that recognizes the impossibility of universal perfection, and

27"Much of this was written in late 1942 and early 1943. At that time there was no firm war plan for the E.T.O., and none of us knew what the eventual plan would be. Plans were changed every week. The Air Force was still promising to 'bomb Germany to her knees'; and certainly no ground forces of the magnitude which were assembled in late 1943 and in 1944 were then planned." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 25 Aug. 1958.)


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a tolerance for human weakness that fell short only of abridging his high principles. He required a lot of knowing, did Elliott Cutler; and casual contact rarely revealed the true fineness of his character.28

It may be said with considerable certainty that Colonel Cutler's attitude on the position of general surgery vis-à-vis the specialized branches of surgery in war was an important factor in the conflict of ideas and aspirations among the surgical consultants (pp. 167-168). In a broader sense, this attitude could be related to Colonel Cutler's convictions on the surgery of trauma and the position of those in the fields of the more limited surgical specialties.

During the doldrums which gripped the consultants in late October 1942, Colonel Cutler found it necessary to comment on the place of surgical specialists in an oversea theater. His memorandum, presented to Colonel Kimbrough, read, in part, as follows:

1. This is a careful and thorough study deserving the most thorough consideration. It reveals careful consideration of the problem not only of this surgical specialty but of all surgical specialties.

2. The basic consideration that specialists are undesirable in the forward areas has my entire approval as does the corollary that the Surgeon General's Office, Washington, does not appreciate this since it is committed to a heavy training program, expensive and probably of no value.

3. * * * I have myself always been of the opinion that this is a small island and that if transportation is available (and safe) all who can no longer serve here should be evacuated to the Zone of Interior immediately.

4. The final suggestion that narrow specialists be sent home is not for my decision but this may be said:

a. Any good citizen now here can be of immense service to his country and replacement is difficult.

b. Lt. Col. - has been a major element in whatever value the Chief Surgeon may put upon his Surgical Consultants because he is loyal, faithful, a hard worker and a man of sound judgment.

c. Patience is a noble virtue and far transcends surgical specialization.29

The problem of traumatic surgery was not limited to the American forces in England. If anything, it was apparently a greater problem among the British medical profession. The 2 February meeting of EMS consultant advisers with the director, Sir Francis Fraser, brought out a heated argument on traumatic surgery and the orthopedists' claim to it. Colonel Cutler was asked to speak, and he did. As a result, he was asked to speak on the same subject at a forthcoming meeting of the British Surgical Association, particularly with reference to the educational system and the organization of a university teaching clinic. In his memorandum of 5 February 1943, reporting the meeting to Colonel Kimbrough, Colonel Cutler stated:

In furtherance of the discussions that took place, it seemed to me obvious that a psychological barrier has arisen between my general surgical colleagues and my orthopedic

28Hawley, Paul R.: Obituary-Brigadier General Elliott Carr Cutler, Med. Res. U.S. Army, Mil. Surgeon, 101: 351-352, October 1947.
29Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 30 Oct. 1942, subject: Comment on Contribution of Lt. Col. -.


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colleagues in Great Britain, in that the orthopedist has come to think he is the only one who can look after trauma. Of course, this is ridiculous. He cannot care for trauma of the head, nor care for the ruptured kidney or ruptured spleen, nor would he have any idea of what to do with nonperforating thoracic injury.

With the aforementioned memorandum of February 5, Colonel Cutler submitted also a memorandum which he had written, he stated, for his own thinking after the last meeting of "this Committee." The substance of this memorandum was as follows:

A disturbing finding in England is the professional thinking, which seems general, that only orthopedic surgeons can treat fractures and other forms of trauma. This seems to me to create a grave danger in the broad outlook of medical practice, both for the people we treat and for the profession.

It creates immediately a fundamental new specialty in that it carries the indication that every fracture incurred on the street must go to an orthopedic specialist. Such a fundamental breakdown of medical practice is just the sort of treatment for the people that is sure to give rise to new cults. * * * It is always our mistakes which give rise to new cults. Yet we keep blaming the people for accepting them when we, the profession which should have the responsibility of the people always at heart, have been responsible for the change.

A study of what happened in Britain reveals the following. With the great blitz, it was found that fractures were badly treated by the ordinary doctor. Therefore, those responsible ruled that only experts should treat fractures, and they thought that only orthopedic surgeons were experts in fractures. As a result, Britain now finds herself with only a few people able to treat fractures, and the young man going out into the field with the Army has no training in trauma because at home such work has been not a part of his general surgical education but a specialty. What Britain should have done when the blow came was to have impressed upon the schools, the leaders, and the teachers that all doctors must learn adequately the care of trauma. Trauma constitutes between 20 and 30 percent of every young doctor's work, and the schools should drill the students completely in its handling and care. Had this been done in England, she would now have thousands of people trained in trauma, and not just a pitiful handful ready. It is the long run view which saves both people and the profession.

We can take a lesson from this-a lesson not taken in any schools from a critical point of view-because we can benefit from the experience of our colleagues and our sister nation. We must now see that every young surgeon is taught trauma. If we do not do this, the foolish separation already occurring in our country of a specialty for traumatic surgeons, giving rise to even a society with this name, will jeopardize the care of the people, which is our complete responsibility.

Colonel Kimbrough forwarded both of the aforementioned memorandums to General Hawley who, in turn, had them copied and forwarded to General Hillman in the Office of The Surgeon General.

On 12 April, Colonel Cutler presented a talk to the British Consultants Club on organization for sugical teaching clinics in the future. "Really an


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attempt to hold specialization in place," he wrote. In a letter to Colonel Kimbrough, dated 16 April 1943, he mentioned the following points made in his talk:

The real problem relates to the role to be played by specialists and the question is becoming more urgent whether there should be separate clinics or institutes for the specialties in medicine and surgery, or whether they should form part of a general clinic. The reasons for a general clinic seem to be many, but in particular are included in the statement that a general clinic, especially where the patients are mixed in vast wards and not segregated in special wards, is best:

For the patient, since this permits simple cases which are recoverable to be next to more serious people whose outlook is hopeless.

For the students, and the Oath of Hippocrates states that every doctor must assist in educating students-since if the patients of all specialties, etc. mix in wards, the students' mental exercise in entering the ward is not simplified as it is when he knows that all cases in that ward are restricted to diseases in a certain domain.

For the doctor, for under these circumstances the specialists and the general surgeons find themselves willy-nilly next to each other in an open ward discussing their problems. If they run separate institutes then they are shut away from each other, and open discussion and common problems [are] lost.

As for the Chief Surgeon, General Hawley announced on numerous occasions his policies on the use of specialists. Notes from a conference of 19 April 1943 show that General Hawley emphasized the following points:

That it was not his policy to train specialists in the E.T.O.: that he considered a world war and a theatre of operations were neither the time nor the place for medical education. He had found from experience in the last war that General Practitioners, nervous of conditions when they returned home from the Army, had been anxious to specialize. They had attended short courses in varied medical fields and had then considered themselves specialists. The outcome was that the men were useless in the theatre during the time of their so-called training; that the soldier suffered and eventually the civilian population from "half-baked" specialists. General Hawley agreed * * * that some differentiation should be made concerning those men who were either in the midst of training or about to embark upon training as specialists when they entered the Army.

Significant activities

The first half of 1943 found Colonel Cutler engaged in three primary projects. These were: (1) Preparations for participation in a British-American surgical mission to the U.S.S.R. (Union of Soviet Socialist Republics), (2) providing a means for assuring the supply of whole blood in combat, and (3) creating mobile surgical units. These subjects will be discussed separately, but it should be noted here that they were interrelated in one respect. As plans materialized for the trip to the U.S.S.R., it became evident that the mission would leave some time near midyear. There was a risk involved in making such an extended trip, particularly when plans called for visits to the combat zone. The risk, small as it may have been, could not be ignored. At the same time, it became increasingly evident to Colonel Cutler that there would have to be a bountiful supply of whole blood in the combat zone and surgical units as far forward as feasible in order to provide the optimum care for battle casualties. The combination of these factors meant one thing to the Chief


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Consultant in Surgery: He had to complete plans for the provision of whole blood and surgical units before he departed for the U.S.S.R. This objective became an inescapable, moral obligation to which he rigidly adhered. Otherwise, the Chief Consultant in Surgery, in addition to carrying on with the routines and programs already in effect, was directly involved in the following noteworthy developments.

Change and expansion of consultant system - Colonel Diveley, Senior Consultant in Orthopedic Surgery, visited NATOUSA (the North African Theater of Operations, U.S. Army), during the period 16 February to 19 March 1943. Maj. (later Lt. Col.) William J. Stewart, MC, was appointed Acting Consultant in Orthopedic Surgery on 1 March 1943. Major Stewart remained on duty with the theater consultant staff after Colonel Diveley's return. His services were most valuable because Colonel Diveley was required to give a great amount of time to rehabilitation activities and the making of training films. Lt. Col. (later Col.) Kenneth D. A. Allen, MC, upon arrival from the Zone of Interior, was appointed Senior Consultant in Radiology on 9 February 1943. Colonel Brown was returned to the Zone of Interior on 29 March, and Maj. (later Lt. Col.) Eugene M. Bricker, MC, of the 298th General Hospital, was appointed Senior Consultant in Plastic and Maxillofacial Surgery and Burns in his stead. Lt. Col. Norton Canfield, MC, arrived from the Zone of Interior in January and was appointed Senior Consultant in Otolaryngology on 1 July 1943.

During this period were initiated the beginnings of a system of consultation at the local level. Colonel Cutler explained the basis of the system at a meeting of the Chief Surgeon's Consultants' Committee on 30 April 1943 as follows:

With the desire to be prepared for a maximum load in the near future, the surgical consultants are submitting * * * a list of consultants in general surgery and the surgical specialties which consist of officers now on the roster of our general hospitals but who are of such professional standing that they might well be used in a consultative capacity. Note that in some specialties they are spaced at the rate of one to each base section; in some, less frequently; and in major fields for work for a consultant from each general hospital and evacuation hospital.

* * * The surgical Sub-Committee feels that by making this matter a permanent one now they may be protecting the patients subsequently to come to this theater, ensuring them adequate surgical care.

General Hawley approved of the idea wholeheartedly and urged that more than the number presently necessary be appointed to plan for the future and to assure the availability of an alternate consultant in the event the regularly designated consultant could not answer a call.

Another change which occurred late in this period was a reorganization of the theater command structure which involved the establishment of base commands and a change in the internal organization and arrangement of the Chief Surgeon's Office. The principal change in the latter was the reestablishment of General Hawley in London and the subsequent shifting of the


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deputy surgeon, Colonel Spruit, to Cheltenham. The former change complicated matters greatly, but was an obvious necessity, just as it had been in the First World War. It brought to the fore the question of who had the operational responsibility for consultations at the local level, since the base commander was to be supreme in his area, as Colonel Spruit informed the consultants.

The change involving General Hawley and Colonel Spruit, it soon became obvious, was the reorganization which had been required to improve the management of the Chief Surgeon's Office. General Hawley was one of the first to admit this, for he observed at a conference held by him on 28 June 1943:

The only other thing that I want to say is that it is very obvious to me that this office is working much better and that Colonel Spruit is doing [more] * * * to get [matters] working smoothly than I was ever able to do.

We are going to expand and decentralize, and more and more responsibility is going to division chiefs. Obviously the time is coming very, very soon when many things come up that cannot all be decided centrally. We are going to make mistakes. I have made several mistakes and you are going to make mistakes. I think we can all forgive mistakes that are honestly made but I cannot forgive a mistake that is camouflaged. Many of the mistakes in this office, many of the failures in this office, I feel personally, result from poor leadership on my part. There are certain things that are not the result of that, and that is absolute and flagrant disobedience of a direct order. I can forgive almost anything else, but when I tell someone that I want something done I expect that to be done and done promptly.

Expert surgical observation from battlefront to base hospital - A letter on this subject, dated 6 January 1943, was submitted by Colonel Cutler to Colonel Kimbrough. The letter read as follows:

1. I have long been of the opinion that the next step forward in military surgery will only come when experts can be placed in the forward elements of the Division, and can observe the wounded soldier from the time he is hit until he is convalescing. You will recall that it was the observations of a British R.A.M.C. Captain behind Ypres in the summer of 1917 that gave us the complete evidence of a poisonous substance manufactured in a traumatized extremity on the way from front to rear.

2. I believe we should at this time have the privilege of sending into Division teams:

a. In general surgery,
b. In orthopedic surgery,
c. In thoracic surgery,
d. In neurological surgery,
e. In maxillo-facial surgery,

who should observe cases on the battlefield, certainly at the battalion aid station, and then travel down the line at least through to the hospital where the first definitive surgical treatment is given. These men should have the privilege of operating upon individuals if in their judgment that seems wise.

3. I am sure that observations made by real experts even on 50 cases in each category would open up a new release for the wounded soldier.

4. I have been in long consultation with Colonel Holtz, Chief Surgical Officer of the Norwegian Forces, who went through the Finnish campaigns as well as the present struggle. He is an expert chest surgeon, and should such a group of American officers be allowed to go it would be a great benefit to us as well as to him if he could accompany this group. His government would be willing to give him two or three months leave for this purpose.


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FIGURE 19.-Headquarters, V Corps, U.S. Army, at Clifton College, Bristol, England, 16 March 1943.

Colonel Kimbrough forwarded the letter to General Hawley who commented: "Noted with interest and will be applied when we start fighting." General Hawley also had his executive officer, Colonel Stanley, provide the Surgeon, V Corps (fig. 19), with a copy of the letter.

American Board of Surgery examinations - Colonel Cutler was most happy when the American Board of Surgery, in answer to his request, replied favorably in regard to examinations in the European theater. He wrote to the deputy surgeon on 20 February:

The officers of the American Board of Surgery have just corresponded with me and given permission for the examinations * * *, providing members of the Founders Group can give the examination. There are sufficient members of the Founders Group in the theater * * *.

Will you please study the requirements submitted with this, and then send in the names of any men who would like to be candidates and are suited to the requirements. At a later date we will settle the examination time and place.

I am pleased at the action taken by the Board at home, because at least it does not militate against the young surgeon, when he becomes a good patriot, and we should have a lift in surgical morale through this action.

Record forms were secured, and the matter was publicized in the theater through notices in the Medical Bulletin, ETOUSA. Later, however, the Board in the United States felt that it was impossible to have these examinations conducted away from the United States. "This is a regrettable decision," Colonel Cutler stated in his annual report for 1943, "for it might appear that the young


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citizen who is willing to offer his services to his country should not thus be additionally penalized for patriotism. Our advice was to give the examinations either here or neither here nor in the U.S.A. for the period of the war."

Elective surgery - As the troop and medical strength of the theater increased and more station hospitals came to England, the unqualified personnel performing surgery in these hospitals became a problem. The theater policy, established by General Hawley personally, was that no major elective surgery would be permitted except at the 10th Station Hospital and in general hospitals. Furthermore, there was a policy that patients who required more than 30 days of hospitalization would not be held in station hospitals. There was, however, the large realm of cases which, conceivably, could have surgery and be out of the hospital within this period. There were also station hospitals assigned to bases of the Army Air Forces to which skilled personnel had been assigned in order to provide definitive treatment for air casualties and the treatment of essential personnel which the Air Forces did not want to lose through ordinary replacement channels. In addition, there was the string of station hospitals which had been strategically placed in southern England with the idea that they not only serve troops in that area but also take care of evacuation from beaches upon the commencement of hostilities on the Continent. Colonel Vail, Senior Consultant in Ophthalmology, was of the opinion that ophthalmologists presently in the station hospitals were perfectly capable of performing the usual surgical procedures involving the eye. The real difficulty lay in trying to define elective surgery accurately and so that the definition would be uniformly understood, particularly in such operations as the repair of hernias. General Hawley's opinion was that, when something could not be defined accurately, it was impossible to enforce and control it rigidly. In the matter of station hospitals being permitted to perform special types of surgery, such as major ophthalmic procedures, the General stated that the surgeons in the theater at this time (March 1943) might be competent but this would not hold always.30

A policy was then agreed upon that no major elective surgery would be allowed in station hospitals except when application was submitted by the hospital for special permission to perform them, and the application was approved by the consultants concerned in the Professional Services Division.

The problem was not one of great magnitude, but it continued to occupy the time of the consultants because so many specific incidents continued to arise in which differences of opinion resulted in an apparent breach in theater policy and because the status of station hospitals had to be constantly reviewed to ascertain whether they could be permitted to perform or continue to perform operations of election.

The Chief Surgeon, during this period, did not choose to accept Colonel Cutler's definition of elective surgery based on the criterion of time; that is, that surgery covering those conditions where delay in transport does not endanger

30Minutes, Chief Surgeon's Consultants' Committee meeting, 5 Mar. 1943.


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the patient's welfare.31 Neither did he permit the publication of a directive on certain types of elective operations which could be performed in station hospitals.

American Medical Society, ETOUSA - At the suggestion of the Chief Surgeon, Colonel Cutler was given the responsibility for creating a medical society in which all American medical officers in the European theater would have automatic membership. General Hawley specifically prescribed that the management of the society should rest in the hands of officers outside the Office of the Chief Surgeon. Accordingly, Colonel Cutler further delegated to Lt. Col. (later Col.) Robert M. Zollonger, MC, the responsibility for forming the organization. An organizational meeting was held on 14 May 1943 in conjunction with the meeting in Cheltenham of the chiefs of medical and surgical service of all general hospitals. Lt Col. Gordon E. Hein, MC, and Lt. Col. (later Col.) Wale Kneeland, Jr., MC, chiefs of the medical services of the 30th and 2d General Hospitals, respectively, and Colonel Zollinger were elected as a temporary executive committee. The 298th General Hospital offered to sponsor the first meeting of the proposed society.

This initial meeting was held on 23 June 1943. A business meeting was held preceding the meeting proper. A simple constitution and bylaws were drawn up which stated the purpose of the society to be as follows:

Upon authority of the Chief Surgeon, European Theater of Operations, this Society is formed for the purpose of disseminating current professional ideas and methods of military significance among officers of the Medical Corps of the United States Army in this theater.

This Society shall be known as The American Medical Society, European Theater of Operations, United States Army.

The following officers were elected: President, Colonel Zollinger, 5th General Hospital; Vice President, Lt. Col. (later Col.) William F. MacFee, MC, 2d Evacuation Hospital; Secretary-Treasurer, Maj. Clifford L. Graves, MC, 3d Auxiliary Surgical Group; and Executive Committee at Large, Col. Edward J. Tracy, MC, Surgeon, Bomber Command, Eighth Air Force, and Lt. Col. Ralph S. Muckenfuss, MC, 1st Medical General Laboratory. Monthly meetings on a rotational basis at general hospitals were planned. Mornings were to be devoted to clinical ward rounds in the various sections followed by short presentation of topics related to the sections, and afternoon sessions were to be given over to topics of general interest. Provision was made for the submission of papers from individual medical officers for presentation and the invitation of well-known guest speakers. The chiefs of the medical and surgical services of the sponsoring hospital were designated the program committee for the meeting to be held at any particular installation.

Honorary Fellowship in Royal College of Surgeons - While dining with Surgeon Rear Admiral Gordon Gordon-Taylor on the evening of 16 March 1943, Colonel Cutler was informed by Admiral Gordon-Taylor that he was to be made an Honorary Fellow of the Royal College of Surgeons in

31Draft, by Col. E. C. Cutler, MC, of proposed circular letter, 5 Mar. 1943, subject: Policy Regarding Surgical Therapy in Station Hospitals.


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FIGURE 20.-Col. James C. Kimbrough, MC, congratulating Colonel Cutler upon his being made an Honorary Fellow of the Royal College of Surgeons.

July at London. Colonel Cutler was very pleased, but he could not help but think: "It seems less important during a war, however." On 9 April, Admiral Gordon-Taylor informed Colonel Cutler that he had been elected an Honorary Fellow of the Royal College of Surgeons. On this occasion, Colonel Cutler wrote: "I am and should be immensely proud-greatest honor yet." The appointment was conferred on 26 May 1943, rather than in July, because of the impending trip to the U.S.S.R. (fig. 20).

Sulfonamide studies -The sulfanomide study (pp. 49, 52) initiated by Colonel Cutler and carried out by Capt. Benjamin R. Reiter, MC, at the 298th General Hospital on returning wounded from North Africa proved quite disappointing at first. After going over the results with Captain Reiter on 7 January, Colonel Cutler had to conclude: "The information on sulfonamides from Africa is a fizzle. There are too few figures and [they] proved nothing."

The study was continued, however, and expanded to other hospitals treating battle casualties from North Africa. Eventually, 259 cases were studied in addition to Captain Reiter's original 73 cases, making a total of 332 cases-essentially all American wounded from North Africa evacuated to hospitals in the United Kingdom. With this number of cases, it was possible for Colonel Cutler to say with some confidence in his letter of 24 May 1943 to Colonel Kimbrough:


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FIGURE 21.-Lt. Col. William F. MacFee, MC.

The statistics show that the sulfonamides, even taken and given under the optimum conditions, do not keep infection away from wounds.

The presence of infection, however, does not mean that the wounds would not have been more highly infected had sulfonamide not been used, and in fact we have every reason to believe that people who might have died of infection are now saved by the use of sulfonamide. * * *

Even transcending the above deductions of importance are the psychological effects upon the troops themselves. Almost to a man the soldiers have said, when questioned, that their lives were saved by the use of sulfa drugs. Experienced clinicians will recognize the value of this mental attitude * * *, and whether recognized or not by the physical scientists of this generation, [it] is something no good physician would be willing to set aside as a highly beneficial agent in the recovery from any physical ill.

Quite by coincidence, on the day Colonel Cutler submitted the foregoing conclusions, he was called upon to answer a question which had been presented in the British Parliament. A member of Parliament had asked from the floor: "Can it be said that sulfonamides as used by the U.S. Armed Forces have saved life?"

Colonel Cutler's reply was: "The answer is difficult but, put that way, must be 'No'."

Other studies were encouraged and carried on by individual medical officers. Notable among these was that by Lt. Col (later Col.) William F. MacFee, MC (fig. 21), at the 2d Evacuation Hospital on fresh Air Force casualties at an American airbase in England. Of some 250 whose wounds had been


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FIGURE 22.-Medical Field Service School, ETOUSA, at Shrivenham Barracks, England.

closed per primam after debridement and who had been administered sulfonamides, there were only four cases of infection, none serious. "This," Colonel Cutler wrote in his annual report for the year 1943 to the Chief Surgeon, "is an accomplishment that a good surgeon with a fresh casualty might have without any chemotherapy * * *."

Penicillin.-Penicillin from the United States first arrived in England only a short while before Colonel Cutler's departure for the U.S.S.R. First, there was a radio message from General Rankin in the Office of The Surgeon General that a shipment was on its way. Then, on 5 May, upon notification, Colonel Cutler hurried to Widewing, Air Force headquarters in the theater. There he discovered a crate marked for his attention from Merck & Co., Rahway, N.J. The crate inclosed 180 boxes, each containing 10 ampules with 10,000 Florey units of penicillin per ampule-a grand total of 18,000,000 Florey units.

Colonel Cutler took, what was at this time, "a great load of penicillin" to the 2d General Hospital. He immediately arranged with Professor Florey of Oxford to standardize the efficiency of this shipment. Three days later, with Professor Florey's guidance, Colonel Cutler made arrangements for one laboratory officer in turn from each general hospital to come to the 2d General Hospital and learn the laboratory procedures necessary to use and store penicillin and to recover it from the urine of patients treated with it. Other arrangements were made with the supply division for special tubing and refrigeration equipment.


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FIGURE 23.-Maj. Bernard J. Pisani, MC.

When, after correspondence with General Rankin, it was apparent that considerable amounts of penicillin would continue to arrive in England, Colonel Cutler met with General Hawley on the morning of 19 May to determine how the new drug would be used. General Hawley approved it for situations where its use might be lifesaving. He did not approve its use, at this time, for sulfonamide-resistant gonorrhea, as recommended. Some of the more specific uses of penicillin agreed upon by General Hawley and Colonel Cutler were for:

1. All cases with gas gangrene.

2. Serious general infections, usually with osteomyelitis and preferably infected with Staphylococcus aureus.

3. Eye infections (in a special ointment to be prepared by Colonel Vail).

4. Septic hands.32

Serious investigation into the efficacy of penicillin in surgical conditions had to await Colonel Cutler's return from the U.S.S.R. and larger more frequent shipments from the Zone of Interior. As precious as it was at this time, a generous amount of the drug was taken by the mission to Russia as a gift to the Soviet peoples.

Schools and professional training.-A milestone in the theater's medical educational activities was the opening of the European theater Medical Field Service School at the American School Center, Shrivenham Barracks (fig. 22), under the direction of Capt. (later Lt. Col.) Bernard J. Pisani, MC (fig. 23).

32Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 22 May 1943, subject: Talk With General Hawley re Penicillin, Wednesday, 19 May.


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The first course convened on 8 March 1943 and continued for 3 weeks.33 The purpose of the school, as announced, was to train medical officers, particularly those serving with field units, in aspects of military medical practice not ordinarily familiar to civilian physicians. Included in the curriculum were 22 hours of lectures and conferences on problems of combat as they affected surgery, acute medical conditions, and neuropsychiatry.

Before the opening of the school, Colonel Cutler had worked many hours on the surgical courses of study, but an item of immediate concern to him shortly before the opening was the appointment of instructors on professional subjects. Some, apparently, had been appointed without knowledge of the Professional Services Division, and Colonel Cutler informed the Chief Surgeon of his concern over this situation.

In reply, the Chief Surgeon stated at the February meeting of his Consultants' Committee the policy that all instruction in clinical medicine at the school, except chemical warfare, would be controlled by the Professional Services Division and that no instructors on professional subjects would be sent to Shrivenham without that division's approval. General Hawley further explained that he wanted the course at Shrivenham for the man in the field, but also wanted it to include essential teaching on frontline treatment to avoid the necessity of sending officers to two separate courses.

Partially as a result of this policy, professional training at the school retained a high level, and instruction could be varied as circumstances indicated. Most of the teaching on strictly professional subjects was given by the various theater consultants concerned.

Another course, initiated during this period, became known as the London tours course. This program was created at Colonel Cutler's request by Surgeon Rear Admiral Gordon Gordon-Taylor, consulting surgeon to the Royal Navy. A limited number of officers was accepted for a 1-week schedule of visits to a different British hospital in the environs of London each day-to London, Guy's, Middlesex, St. Mary's, and St. Bartholomew's Hospitals. Luncheon was provided at each hospital, and, on certain afternoons, the American Red Cross in London provided transportation and guides for tours to interesting points in the city. The professional interests of candidates selected were relayed to the hospital directors in advance.

Finally, an administratively difficult, but most worthwhile, program was begun of exchanging for short periods of time medical officers in line units with those in hospitals. This program fulfilled the dual purpose of providing a more varied experience in clinical practice for medical officers of line units and served to acquaint medical officers in hospitals with the problems of providing medical service in line units. The plan was a good precursor for the system later adopted of rotating combat- and service-element medical officers when active hostilities ensued on the Continent.

33Circular No. 22, Headquarters, ETOUSA, 23 Feb. 1943.


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Blood

Back in 1942, upon hearing a discussion on blood and plasma at a meeting of the Royal Canadian Medical Corps Pathological Club, Colonel Cutler had recorded: "Very interesting. It seemed to me that the rise of plasma, etc., had let all forget the benefit of transfusion. Our soldiers are all grouped. They should be the best vehicle for getting blood forward. No bottles to carry!" But, comments he heard later and reflection on the transfusion problems of World War I convinced him that the matter was not as simple as this. The problem lay in the area of a practical unit usable under the conditions of combat to effect transfusions.

In a letter to the Chief Surgeon on 27 March 1943, concerning standardization of the portable transfusion unit for combat areas, Colonel Cutler wrote the following:

The information we have from the present battle fronts of all nations including our own in Africa and elsewhere, is that transfusion as a method of resuscitation is steadily on the increase. Colonel Diveley brings us this information from our own troops in North Africa and Brigadier Whitby tells me that the use of wet plasma has practically been given up, and transfusion used in its stead in the British Army.

He then proposed a simple transfusion kit to be used by American units in the European theater (fig. 24). The kit was composed of items of standard equipment available in the theater, and, when packed in a chest, made it possible for a shock team to provide a large number of transfusions. This kit, developed by Capt. (later Lt. Col.) Richard V. Ebert, MC, and Capt. (later Lt. Col.) Charles P. Emerson, MC, 5th General Hospital, included equipment for grouping donors rapidly and satisfactorily, for these officers had discovered that a 10-percent error existed on the blood types stamped on identification tags of individuals.

Colonel Cutler recommended that a number of units of this type be assembled, packed, and held for distribution in the medical depots. There was no immediate need for the item, since the British taking and giving sets currently in use were satisfactory for the type of medical service being provided.

Colonel Cutler, on 31 March 1943, was given a firsthand explanation of a system used by the British in Africa. At the Post-Graduate Medical School, RAMC, in London, Col. A. E. Porritt, RAMC (later Brigadier and consulting surgeon, 21 Army Group), gave a splendid discussion on how the British Forces in the Middle East drew blood in Cairo, flew it to a distributing point behind the lines, and then transported it in refrigerated vehicles to forward units, such as field ambulances and advanced surgical centers.

In a letter, dated 2 April 1943, concerning his 30 March-1 April tour of duty, Colonel Cutler reported to Colonel Kimbrough: "With us, we had expected to send expert teams up the line who would then draw sufficient blood at each medical installation from lightly wounded or hospital personnel." He continued: "Both systems are open to the criticism that adequate studies of the blood for syphilis, malaria and other diseases are not made, and this needs critical thinking."


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FIGURE 24.-A transfusion set improvised by Capt. Richard V. Ebert, MC, and Capt. Charles P. Emerson, MC, of the 5th General Hospital.

On 7 May, Colonel Cutler had a long session with Brigadier Whitby and others at the British Army Blood Supply Depot, Bristol. This meeting served to review and consolidate all previous thinking which had been given to the problem of supplying U.S. Army units with blood and protein fluids when the invasion began. The core of the problem was expressed in the following three questions and answers:

1. Are a common apparatus and a common source of blood and plasma essential for proper liaison between the British and American Armies?

Answer: Should we invade the Continent, the answer to this is that a common kit is not essential, for units using the materials would never be so closely mixed. Also, the British would have great difficulty in supplying us with material in this field.


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2. What is the optimum time for resuscitation?

Answer: The answer is early, rapidly and adequately. British figures show 10 percent of wounded require transfusion. The Russian figure is 11 percent. Transfusion means blood or plasma, or both. These figures may rise to greater heights. For example, in a private letter from the Tunisian front to Brigadier Whitby 42 out of 180 serious casualties in an M.D.S. required transfusion, roughly 23 percent.

3. What is the problem in forward areas?

Answer: Everyone has agreed it is difficult to procure blood for transfusion in the most forward elements and the value of plasma is not fully appreciated by most medical officers. For example, word has come back both from the American and British sources in North Africa that plasma was no good and blood should be used. There can be no question but what replacement with plasma is highly efficacious and the opinions from frontline surgeons do not represent scientific evidence to the contrary but seem to be mostly hunches. It is as if these forward surgeons thought that certain serious casualties to whom plasma was given might have been saved if blood had been given. True, when massive hemorrhage has occurred blood is essential, but we should have a directive concerning the use of blood and plasma and the conservation of these.34

The British system contemplated for a continental invasion, as described by Brigadier Whitby, was to follow closely the North African experience. Freshly drawn refrigerated whole blood was to be delivered to the Continent by air. Thence, refrigerated trucks carrying 400 bottles each were to supply forward transfusion teams which, in turn, were to be equipped with 3-ton refrigerated trucks holding 80 bottles of blood and 200 units of plasma. The British graciously offered to fly U.S. Army blood to the Continent, but from there on the responsibility would have to rest with U.S. Army elements. Moreover, it was impressed on the conferees that the British planned to draw only 200 pints a day, which could be boosted with difficulty to 400. This absolutely prohibited the U.S. Army from counting on the British for a supply of fresh blood.

Considering the foregoing factors, the logical conclusions were fourfold, and these Colonel Cutler expressed as his recommendations to Colonel Kimbrough and the Chief Surgeon on 10 May 1943. First, there was the need to publish a directive concerning the proper use of blood and plasma in combat. Secondly, he stated that plasma was now being supplied to divisional medical elements, mobile hospitals, and fixed hospitals and required no further elaboration except that ample stocks had to be made ready. The third and fourth recommendations concerned the supply of whole blood and were divided into means of providing whole blood (1) from donors in the field and (2) from sources in the United Kingdom or the United States proper. They were as follows:

We recommend that a satisfactory bleeding and giving set with the equipment for gross agglutination to determine compatibility of blood be assembled and set up in the United Kingdom, this unit to go forward with our transfusion teams and be available for other medical use also. The equipment is contained in the T/BA of the mobile surgical unit already submitted. We feel that the transfusion team "up the line" can bleed the lightly

34Letter, Col. E. C. Cutler, MC, to Brig. Gen. P. R. Hawley (through Col. J. C. Kimbrough, MC), 10 May 1943, subject: The Use and Procurement of Blood and Plasma for the E.T.O.


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wounded in sufficient supply for most of the needs for blood, provided plasma and blood are intelligently used.

It would seem desirable to have an additional supply of refrigerated fresh whole blood originating either in the U.S.A. or in the SOS or the U.S. Army in the United Kingdom. This would require the setting up in the U.S.A. or in the United Kingdom of 1) Bleeding centers, 2) the transport of such blood in a refrigerated aeroplane to the Continent, 3) the use of refrigerated automobiles to take the blood up the line to medical installations who would have refrigeration in which to keep it. Blood, when refrigerated, has been used up to 2, 4 and even 6 weeks after withdrawal, but it is perhaps not wisely used after 2 weeks. (Calculating 72 hours from bleeding in U.S.A. to the Continent we would have plenty of time to follow the English and Russian system and have blood drawn in America reach this forward area before any deleterious changes had taken place. If the air transportation of freshly drawn blood is too unreliable, blood could be secured from the U.S. Army SOS installations in the United Kingdom.)

The same day that the preceding recommendations were prepared, 10 May 1943, Colonel Cutler briefly apprised the Chief Surgeon and his staff on the problems of providing blood to combat forces. He emphasized particularly, at this informal conference, the difficulties attendant on the air transportation of blood from the United States and the fact that there was no machine suitable for the use of U.S. Forces in the European theater for properly giving and taking blood. The American equipment, Colonel Cutler told the conferees, was excellent, but when the slightest repairs became necessary, the equipment had to be returned to the Zone of Interior.

On 5 June 1943, Col. Walter L. Perry, MC, Major Storck, and Captain Hardin met with Colonel Cutler in Cheltenham. Colonel Perry (fig. 25) was the theater medical supply officer, and Major Storck, the recently appointed Senior Consultant in General Surgery. The meeting was arranged to expand further the proposals submitted by Colonel Cutler on 10 May 1943 and to recommend more specific steps necessary for the implementation of Colonel Cutler's suggestions.

The matter of obtaining blood from the Zone of Interior was left in abeyance since it was obviously a separate problem from that of obtaining, processing, storing, and distributing blood within the theater. Moreover, once blood from the United States had arrived in the theater, it presented a problem no different from that for blood collected and processed in the theater. Therefore, the conferees concentrated on facilities and programs to be developed within the capabilities of the theater itself-the only basis on which absolutely reliable plans could be made. They made the following decisions:

1. A depot-type unit would be necessary in the United Kingdom to centralize and direct the many activities involved.

2. Bleeding of American troops and/or British civilians would be necessary.

3. American bleeding teams and facilities would have to be used.

4. Provision had to be made for a unit to receive and further distribute blood on the Continent, once a firm beachhead had been established.

5. Proper refrigeration equipment would be necessary throughout all phases of the program.


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FIGURE 25.-Col. Walter L. Perry, MC.

Also discussed was the progress which had been made in establishing blood banks and donor panels at each active general hospital and the work yet remaining to accomplish this objective.35

On 10 June, Colonel Cutler had a conference with General Hawley in London. The general, after first expressing his surprise at finding Colonel Cutler still in London, directed him to finish by all means the plans for providing blood and plasma before leaving for the Soviet Union.

June 11, Colonel Cutler's diary reveals, was spent "all day at work on memo re blood, plasma, and crystalloids; all done."

"The purpose of this memo," he wrote General Hawley, "is to bring together all data concerning intravenous therapy for shock and allied conditions, and to conserve the use of these precious materials (blood, plasma and crystalloid solutions) which are often misused and wasted at the present time."36

Colonel Cutler listed for General Hawley all the directives which had been published to date on blood, plasma, and crystalloid solutions; presented an inventory of all plasma and crystalloids on hand, both American and British; and reviewed procurement demands still outstanding on the British for these items. He provided General Hawley proposed directives on the making of crystalloids by general hospitals for their own use and on the economic use of

35(1) Letter, Capt. R. C. Hardin, MC, to Col. E. C. Cutler, MC, 5 June 1943, subject: A Plan for the Procurement and Delivery of Whole Blood for a Continental Task Force From the U.S.A. or U.K. (2) Letter, Capt. R. C. Hardin, MC, to Col. E. C. Cutler, MC, 5 June 1943, subject: Provision for Procurement of Whole Blood for Transfusion in General Hospitals in the E.T.O.
36Letter, Col. E. C. Cutler, MC, to Brig. Gen. P. R. Hawley (through channels), 11 June 1943, subject: The Procurement and Use of Blood, Plasma and Crystalloid Solutions (Saline and Sugar) for Intravenous Use in the E.T.O.


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blood and plasma by units in the field. He stated that the general medical laboratory, when established, should also have as one of its duties the manufacture of crystalloid solutions.

On the matter of supplying whole blood, Colonel Cutler again referred General Hawley to the basic tenets made in his letter of 10 May 1943; namely, that a simple field-transportable transfusion set was necessary for bleeding "on the hoof," and supplemental sources of blood were required within the theater or the Zone of Interior. He submitted copies of the 10 May 1943 letter, a revised and final version of plans for the field transfusion set, and letters prepared by Captain Hardin on the 5 June 1943 meeting.

In submitting plans for the transfusion set, Colonel Cutler noted:

1. The following TB/A for a Whole Blood Transfusion unit is the final product of months of experimentation with Major Emerson and Major Ebert of the 5th General Hospital.

2. In discussion with Colonel Perry we propose that if Field Medical Chests are scarce the wooden boxes in which our U.S. Army plasma arrives would act as suitable containers.

3. Two types of units may be dispensed.

a. The complete unit as listed for teams going into combat area.
b. A unit for hospital use consisting only of those items not available in static hospitals (chiefly bleeding and giving sets with citrate and large needles).

4. We believe the officers responsible for this standardization, Majors Emerson and Ebert, would be happy to assist in the original packaging.

Captain Hardin's letter reviewed the following necessities for any plan by which whole blood could be supplied to a continental force:

Blood from the Zone of Interior

Blood collected in the Zone of Interior can be delivered to the E.T.O. only by air transport. The collection, processing, and initial delivery to a depot in the United Kingdom would be a function of an agency in the Zone of Interior. Its reception, internal storage, and distribution to the base unit and/or * * * transfusion teams would be the responsibility of the depot located in the United Kingdom * * *. The depot would necessarily be located near an airport and would provide adequate refrigeration for the blood throughout its entire handling from the time of unloading the plane.

Collection of Blood in the U.K.

Blood can be obtained from two sources in the U.K.:

1. Base and SOS Troops.
2. Civilians (British).

The first * * * is somewhat problematical since the troops * * * are scattered over a wide area and because the bleeding would take place during periods of activity when those troops will be least available. The second source is probably the better. To put it into operation would entail taking over an area in the U.K. where the civilians could be bled. This area must be outside of the British Army Area (roughly Southern Command) and * * * the London area where the EMS bleed heavily to secure plasma for drying.

Organization of such an area would include enrolling of donors and procurement of bleeding centers. * * *

Bleeding Teams

These teams must be mobile and carry with them all of the equipment necessary to do one day's bleeding. Such a team when bleeding military personnel can bleed 150 per day


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provided that a constant stream of donors is made available. British teams bleeding civilians average 75 per day.

Depot

This unit serves as a base from which the mobile [bleeding] teams work. It supplies the teams with all the apparatus needed and maintains * * * vehicles. Records are kept of the bleeding, apparatus [is] reconditioned and assembled, and blood [is] processed. This includes serologic tests, typing, addition of glucose, and bacteriologic control. Here also internal storage of blood must be undertaken, which requires the provision of adequate refrigeration.

Distribution to the Field

Behind any force there must be a base unit which draws blood from the depot and distributes it to the shock teams. This unit may be small and simply concerned with supply of blood or like the British unit be capable of producing crystalloid solutions as well as distributing blood and plasma. It must be equipped adequately to be able to recondition apparatus and carry out sterilization. It must also have mobile refrigeration.

Refrigeration

Blood is ideally kept at +3º to +6°C. It must not be frozen and undergoes considerable deterioration if the temperature of storage fluctuates greatly. Two types of refrigeration may be used:

1. Ordinary refrigerator capable of maintaining the required temperature. This type of refrigeration calls for fitting of airplanes and trucks with refrigerators. It is the type of refrigeration used by the British Army Transfusion Service and has worked well in practice.

2. Refrigeration by melting ice: Ice melts at +4ºC which is the ideal temperature for blood storage. By the utilization of compartment boxes into which ice and bottled blood can be placed in separate chambers an adequate but simple type of refrigeration is obtained. To utilize this to the fullest extent, lightweight well insulated containers could be built to hold 10 to 20 bottles of blood. Such containers under ordinary temperature conditions will hold ice for 72 hours.

Advantages: Simple, accurate refrigeration, with no machinery to break down. Dispersal of stores possible. Containers can be carried in any plane or vehicle without special installation.

Disadvantages: Procurability of ice. Ice making machines would be necessary in the base unit and perhaps in the depot.37

 In summary, Colonel Cutler had shown how transfusions could be accomplished by "bleeding on the hoof," by obtaining whole blood from the Zone of Interior, by bleeding British civilians, and by bleeding U.S. Army service troops. Each of these proposals posed an enormous logistical undertaking to implement. It was certainly beyond the prerogatives of the Chief Consultant in Surgery to decide which steps would be taken. Hence, his closing words to the Chief Surgeon asked for "instruction to Professional Services concerning the method selected for supplying a Continental Task Force with whole blood that we may assist in implementing such decision * * *."

During Colonel Cutler's absence in the Soviet Union, General Hawley approved the construction and assembly of the field transfusion units. At his regular monthly conference with the consultants on 23 July 1943, General Hawley told them that blood should not be transported from the United

37See footnote 35(1), p. 75.


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States.38 He directed that the consultant group go ahead with plans for collection and distribution of blood and that the British be consulted with reference to preservation and storage.

In reply to a question by General Hawley as to the development, procurement, and distribution of blood transfusion kits for mobile medical units, his executive officer provided him with the following answers:

1. A blood transfusion chest had been designed and had been approved for clearing companies, evacuation hospitals, field hospitals, and auxiliary surgical groups. One hundred of these chests were being packed at Medical Depot G-35. Clearing companies and evacuation hospitals were to receive 2 chests each, while field hospitals were to receive 3 chests, and auxiliary surgical groups, 10.

2. A smaller unit had also been designed which was built around a new quartermaster item known as the "man pack carrier." Two hundred of these man-pack-carrier, blood-transfusion sets were to be assembled as soon as the pilot model was approved and the quartermaster carriers became available. Two of these kits were to be distributed to each collecting company and regimental medical detachment.

3. The standard, approved transfusion bottles for both the chests and the man-pack-carrier units were being assembled at the 5th General Hospital.39

Mobile surgical units

From his first days in Washington, Colonel Cutler had realized that the key to providing optimum care for battle casualties lay in taking the surgeon to the wounded man instead of bringing him back to the surgeon. This could only be accomplished, he believed, by a truly mobile, self-contained surgical team. At every opportunity, he had discussed this possibility with the Chief Surgeon and his colleagues, both British and American. One of the first things he had asked of General Hawley was that the latter request Washington for the assignment of an auxiliary surgical group to the European theater. By early 1943, he had gained considerable experience in current Army ways and felt quite capable of coping with the problems involved in coming forward with specific recommendations for the organization and equipment of a surgical team such as he had in mind.

In early February 1943, two things happened which encouraged Colonel Cutler to embark immediately upon the formation of a mobile surgical team. On 16 February, he attended a session at the RAMC College during which Maj. Gen. David C. Monro, RAMC, newly appointed consulting surgeon to the British Army, gave a brilliant discourse on his experiences of 2 years in

38There is strong implication in the early part [of the manuscript] that the Chief Surgeon's disapprovals of some of the recommendations of the consultants were purely arbitrary and capricious. The truth is that, throughout the war, the Chief Surgeon had top secret information which he could not share even with his deputy; and many of these adverse decisions were based upon such information.
"One example of this is the account of the reluctance of the Chief Surgeon early in the war to attempt to obtain whole blood from the Zone of Interior. The reasons for this were (1) that the transatlantic airlift at that time was so limited, and so restricted to other priorities, that it could not take on such a load; and (2) The Surgeon General had told the Chief Surgeon flatly that he would not approve." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 17 Sept. 1958.)
39(1) Operational Directive No. 28, Office of the Chief Surgeon, ETOUSA, 10 July 1943. (2) Letter, Col. J. H. McNinch, MC, to Chief Surgeon, ETOUSA, 26 July 1943, subject: Status of Development, Procurement and Distribution of Blood Transfusion Kit for Mobile Medical Units.-Operational Dir. #28.


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FIGURE 26.-The 36th Station Hospital, Exeter, England.

the Middle East. He traced the development of the field surgical unit and its successor, the mobile surgical unit, as constituted in that British theater of operations. General Monro emphasized the requirements for mobility, stated that team members had to be surgeons of outstanding ability and mature judgment, and warned that teams with equipment fitted (built-in) to vehicles were undesirable. The latter, he suggested, could be disabled with a single gunshot in the radiator.

Upon returning from this session at the RAMC College, Colonel Cutler recommended that (1) mobility must be forced on all of the medical services, (2) this could probably be best achieved by mobile surgical units based on parent units which would continue to supply and administer them, and (3) a certain amount of segregation of casualties by anatomical groups would be necessary in the rear areas for better surgical therapy. He concluded: "I believe that there are many lessons in this talk from which we should benefit, and benefit now. * * * Perhaps this first-hand experience will bring the Medical Corps of our Army face to face with what I believe to be a major issue, which must be solved before we get into a real battle."40

At about that time, Lt. Col. Herbert Wright of the Eighth Air Force had submitted a special report to the Chief Surgeon in which he brought General Hawley's attention to the situation which confronted the Air Forces in Cornwall. Many crippled aircraft returning from combat missions were landing at RAF fields in this area with frequent serious casualties among their crews. The nearest American hospital at Exeter (fig. 26) was some distance away from

40Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 16 Feb. 1943, subject: Summary of Talk by Maj. Gen. D. C. Monro, 11 Feb. 1943, at the RAMC College.


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this area, thus precluding the transfer of American casualties to it. Moreover, this was the only specialized hospital in the theater, a neuropsychiatric facility with but a small surgical staff. Colonel Wright recommended the procurement of certain buildings just outside of Truro and requested the assignment of surgical specialists to staff a medical facility to be activated there.

Colonel Cutler found many objections to the plans submitted by Colonel Wright. He proposed, instead, that the U.S. Army obtain from 10 to 20 beds at the EMS Royal Cornwall Infirmary at Truro, send a surgical team there, and, in recompense, offer the service of the team to the infirmary when it was not fully engaged in treating U.S. Army Air Forces casualties.

FIGURE 27.-Maj. Robert M. Zollinger, MC.

When this suggestion received General Hawley's approval, Colonel Cutler asked Maj. (later Col.) Robert M. Zollinger, MC (fig. 27), of the 5th General Hospital to work on a mobile surgical unit with the following guidance in mind: (1) The equipment should not be built in a truck, (2) the equipment and tentage should be for a mobile surgical team, such as a team from an auxiliary surgical group, and (3) the team should take all the materials necessary for lighting and for surgery to cover 50 to 100 major surgical casualties or 200 minor casualties.41

As things turned out, it was the obtaining of beds at the Royal Cornwall Infirmary at Truro which proved to be the greatest obstacle to this program. It was only through the intercession of Colonel Cutler's close friends, Prof. George Gask and Mr. Rock Carling, that an allocation of 12 beds was obtained at the Royal Cornwall Infirmary for the hospitalization of U.S. Army Air Forces casualties. The trustees of the infirmary approved Colonel Cutler's plan on 25 February, but the space was not immediately available because repair

41Annual Report, Chief Consultant in Surgery, ETOUSA, 1943.


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FIGURE 28.-A U.S. Army Air Forces patient being attended by one of the nursing sisters at Royal Cornwall Infirmary, Truro, Cornwall, England.

of the buildings was underway following a bombing of the infirmary. When reporting the approval received from the trustees, Colonel Cutler added that a surgical unit consisting of two surgeons, one operating room nurse, four ward nurses, and their necessary equipment was ready to go at the 5th General Hospital. General Hawley and Colonel Cutler visited the 5th General Hospital on 6 March and looked over the equipment for the team. On 14 March, the director of the Royal Cornwall Infirmary telephoned Colonel Cutler that the institution was ready to receive the American contingent. The next day, Col. Maxwell G. Keeler, MC, commanding officer of the 5th General Hospital, and Major Zollinger went to Truro to make final arrangements. Ten days later, the surgical unit was well established and working. Their work and attitude created a most favorable impression at the infirmary (fig. 28). Within a month, as planned, this unit from the 5th General Hospital was relieved and returned to its parent unit, and a team of similar composition from the 3d Auxiliary Surgical Group took over its functions.

In the meanwhile, suggestions to provide surgical teams to other areas in which the Air Forces were operating did not materialize since Colonel Grow, after considerable thought on the matter, felt that the use of these teams might erroneously suggest to the British that their services were inferior.

In London on 31 March, Colonel Cutler was privileged to attend another brilliant discussion on mobile surgical units, given, this time, by Col. Arthur E. Porritt, RAMC, at the RAMC Post-Graduate Medical School (p. 71). On


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6 April 1943, Colonel Cutler received a communication from the British War Office, issued by the consulting surgeon, General Monro, which quoted items of information from the Middle East theater on the outstanding success the field surgical units had encountered. General Monro, in commenting on the reports, agreed that lighting was one of the main problems since, as one unit reported, 80 percent of the work had been during hours of darkness. A most important point, General Monro noted, was as follow: "If F.S.U.'s are to give of their best, they must train together not only in field exercises but in the operating theatre. Commands should be instructed to see to it, that the F.S.U.'s now mobilized in this country, relieve, as a team, one of the existing surgical teams in a static unit, for a period of 3 to 4 weeks."42

Finally, on 12 April, Colonel Cutler heard General Hood, DGMS, British Army, explain to a group of medical officers in the British Southern Command the new organization of the RAMC field medical service which currently featured an advanced surgical center. This advanced surgical center, comprised of a field dressing station, a field surgical unit, and a field transfusion unit, had 20 cots and many litters and was to perform only urgent surgery-abdominals, sucking chest wounds, wounds of the buttocks, and compound fractures, especially in the joints. They were assignable on the basis of two per combat division.

Armed with this wealth of recent information on the efficacy of mobile surgical units in combat plus detailed and complete reports on the workings of the team at Truro, submitted by Colonel Keeler and Major Zollinger, Colonel Cutler dictated a memorandum, dated 18 April 1943, to the Chief Surgeon (through Colonel Kimbrough) which brought up to date his complete thinking on the matter of mobile surgical teams for the U.S. Army in the European theater. The body of the memorandum follows:

1. Introductory.

This memorandum on surgical teams is added to those which have preceded it because the need for mobility in our forces is increasing, and because of recent attempts to reorganize the teams as they now appear in the Auxiliary Surgical Group.

2. The regrouping of teams in the Auxiliary Surgical Group was submitted to the Chief Surgeon by Colonel Mason. In this regrouping it was made clear that practical experience in this war had but corroborated the experience obtained in the last war, that the surgeon in the forward area must be a general surgeon. In the last war we had: a. General surgical teams, b. Shock teams, c. Splint teams. This resulted because experience showed that the general surgeon must be the one to do the work in the forward area. Also it was found he needed as a colleague somebody to help put on the splints when compound fractures existed, just as he will today need such an expert colleague to put on the plaster for immobilization rather than the Thomas' splint used in the last war. Also, if the general surgeon is to be kept busy all the time at what he is bound to do, i.e. surgical operations, he should have as a further colleague a man trained in resuscitation and shock who can treat the cases before an operation and then care for them afterwards, thus freeing the surgeon's time for constant application to his handicraft in the operating theater. This combination of experts needs highly trained personnel working at top speed in their selected fields, and accomplishes the maximum overturn of labor in the shortest period of time. It would appear to me that the Auxiliary Surgical Group

42Dispatch, The War Office, London, 2 April 1943, subject: Field Units (F.S.U.'s. M.E.F.W.E.).


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teams should be re-organized on a basis similar to the thinking above. In my mind, the best team would be one in which the surgeon was a general surgeon, the assistant surgeon, however, an orthopedic individual or at least a surgeon properly trained in plaster technique. In addition, each surgical team would need a man trained in shock * * * though I believe that where two surgical teams were out together to a single installation, one shock team might care for the work of two surgical teams. The defect in the Auxiliary Group is that they only carry with them their instruments and would have to be given all of the rest of the impedimenta of operating theaters by the hospital to which they were attached.

3. Mobile surgical teams.

The use of the term "mobile surgical team" is coined to describe a setup somewhat different to that above, for in this setup the team is to have its own transport and take with it everything it needs in the way of professional supplies to cover the completion of 100 major surgical operations. This is to include lights, bandages, a shock team setup, plasma, saline, basins to scrub up their hands in, soap, drugs, anesthetics, etc. Such a team could be sent at a moment's notice because it has its own transportation to any point desired by the corps or army surgeon. To my way of thinking it might best be placed at the clearing company of a division, and the only matter which is not settled in our minds is whether this mobile surgical group, with its team and shock men and supplies should take its own tentage or not * * *.

As stated in previous memoranda, I am opposed to building in of the apparatus into the truck, feeling that something might happen to the truck and thus immobilize the team. If the material can be easily put into a truck and then taken out, then any truck will suffice, and complete freedom and mobility is assured. The TB/A of such a mobile surgical team as opposed to the teams now organized in our Surgical Group is appended. It is largely the system set up by the group from the 5th General Hospital, with changes, both deletions and additions, as suggested in our Consultant Group and by our British colleagues.

On 21 April 1943, Colonel Cutler conferred with General Monro and Maj. Gen. Max Page, RAMC, at the British AMD, 39 Hyde Park Gate, London (fig. 29). He discussed with them the matter of tents for a mobile surgical unit, a part of the plans which had not been firmed. He was also shown a lantern which burned kerosene under pressure with a brilliance of some 400 cp. It seemed to be the ideal unit for providing emergency lighting for the mobile surgical team in the event of power failure, and Colonel Cutler on his return immediately ordered a sample unit for trial and study. Later that week, he was able, with the cooperation of Col. Charles E. Brenn, MC, the U.S. V Corps surgeon, to select and set up tenting for the proposed mobile surgical team. The feasibility of the tents for operating pavilions was tested, particularly under blackout conditions.

In a letter, dated 6 May 1943, to General Hawley through Colonel Kimbrough, Colonel Cutler submitted complete proposed tables of organization and equipment for a mobile surgical unit composed of a surgical team and a transfusion-laboratory team. The proposed organization included:

For the surgical team:

1 general surgeon, chief
1 assistant surgeon, preferably trained in plaster technique
1 anesthetist, officer or enlisted
3 operating room technicians, enlisted


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FIGURE 29.-Maj. Gen. Max Page, RAMC (left), and Air Commodore Geoffrey Keynes, consulting surgeon to RAF (right), with Col. Oramel H. Stanley, MC, at the reception and dinner given in their honor by General Hawley and his consultant group.

For the shock team:

1 officer, preferably a physician
2 technicians, enlisted

The organization also called for two drivers to drive and maintain the unit's vehicles, one 2½-ton truck, and one ¾-ton weapons carrier (fig. 30). Assistant drivers, he stated, could be trained from among the enlisted men of the surgical and shock teams.

With reference to the shock team (fig. 31), Colonel Cutler explained:

We have called the second group a transfusion-laboratory group because as we visualize the work of a surgical team in the forward area it will require a transfusion team to attend to the resuscitation of its patients before the operation and to care for them afterwards. Moreover, this group will do work such as blood counts, examination of the urine, determination of hemoglobin for better treatment of shock, occasional microscopic examination of smear preparations from joints, spinal canal, etc., and occasional microscopic examination of the bacterial flora in the wound, where the finding of gas bacillus forms might strengthen one's hands before amputation.

All the medical supplies and equipment were packed into 18 trunks with a total weight of approximately one ton, except for a few bulky items such as splints and litters. Of these 18 trunks, 16 used the container for medical chest number 1 with a total packed weight of approximately 1,800 pounds, and 2 used the container for medical chest number 2 with a total packed weight of approximately 250 pounds. The basic instrument set, stock number 93212, 1942 model,


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FIGURE 30.-Transport for a mobile surgical unit. A. A truck loaded with the complete equipment and supplies for a unit. B. A weapons carrier used for the transport of personnel.


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was used with a few extra instruments from special sets for neurosurgery, orthopedic surgery (fig. 32), abdominal surgery, et cetera. Included also was a complete anesthesia set, stock number 93512, endotracheal, inhalation, intravenous, regional, and spinal, 1942 model (fig. 33), and a suction machine, complete, stock number 37750 (fig. 34). Expendables, such as dressings, bandages, adhesive tape, gauze, cotton, plaster, towels, sponges, suture material, anesthetics, medicinals, crystalloids, and the like, were packed in quantities sufficient for 200 surgical operations (fig. 35).

The tent decided upon for the operating theater was that known as a tent, storage, camouflaged, with fly (fig. 36). All possible equipment and supplies for emergency sources of lighting-battery-operated lanterns and surgical lights and a 2.5 kw. gasoline-operated generator-were included (fig. 37). The common oil-burning pot-bellied stoves were added for heating purposes. The final list of supplies and equipment, Colonel Cutler advised the Chief Surgeon, was made in conjunction with the members of the 5th General Hospital who assisted in the preparation of the list and had some further suggestions after returning from their temporary duty at Truro. He suggested that the responsibility for replenishing supplies of any particular team would rest with the parent unit from which the team personnel were derived (for example, an auxiliary surgical group), and the parent unit would be based for supply support on a field army.

On Tuesday, 18 May, General Hawley and Colonel Cutler journeyed to the 5th General Hospital and held a showdown inspection of the mobile surgical unit as constituted in the 6 May letter to the Chief Surgeon. After their return from the hospital, General Hawley and Colonel Cutler had a long talk on the proposed unit. General Hawley's opinions follow:

1. The 5th General Hospital should assemble in Salisbury (where the hospital was located) all the equipment finally selected for a mobile surgical unit.

2. The 5th General Hospital should secure still and moving pictures of this unit in all phases, including putting up tents and operating upon a patient.

3. Officers in the 5th General Hospital should write up separately how the unit functions as a whole and how the transfusion-laboratory team is to function.

4. The equipment for a single mobile surgical unit should then be transferred to the 3d Auxiliary Surgical Group after they have been taught how it functions, including the putting up and taking down of the tents.

5. It will be the responsibility of the 3d Auxiliary Surgical Group to teach the rest of their teams this same matter and to teach in the Medical Field Service School at Shrivenham, if that was desired.

6. The headquarters of the auxiliary surgical group should acquire facilities for sterilizing dry goods so that, as the parent organization, it could keep the dispersed units supplied with materials.43

43Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 22 May 1943, subject: Further Regarding Mobile Surgical Unit.


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FIGURE 31.-The equipment and supplies for a shock team, mobile surgical unit, set up for use. The boxes on which the cots rest are plasma cartons.

FIGURE 32.-A chest containing orthopedic supplies and equipment for a mobile surgical unit.


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FIGURE 33.-A tray used by the anesthetist of a mobile surgical unit.

FIGURE 34.-A suction apparatus with an improvised holder, used by a mobile surgical unit.


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FIGURE 35.-Expendables and a sterilizing drum of a mobile surgical unit. A. A sterilizing drum, packed in a Medical Department chest and containing surgical sponges. B. Gauze bandages and dressings sufficient for 200 surgical operations.


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FIGURE 36.-Pitching an operating room tent of a mobile surgical unit.

Finally, in a hectic rush to complete all aspects of the mobile surgical unit plan prior to his trip to the U.S.S.R., Colonel Cutler was able to report to the Chief Surgeon by letter, on 15 June 1943, the following:

Certain changes have been made in the TBA submitted [6 May 1943], and we now submit TBA in final form after repeated experimentation in packing and unpacking and experimentation with tents.

Many photographs have been taken of the unit * * * during processes of assembly and with patients being operated upon in the tent (fig. 38). These should arrive shortly. A film including the setting up operation and taking down of the unit, has been made and is now being put in order by the Signal Corps, and should also be in your hands shortly.

Lt. Col. Robert Zollinger who has been experimenting with this problem under our guidance since February 1943, is writing up the complete functioning of the unit in the hope that you will send this back to The Surgeon General for his information and publication.

We have arranged with Major Pisani, E.T.O. Medical Field Service School, that this unit be demonstrated as a part of the exercises in the next classes.

While the principles of assembling the necessary equipment for the supply of a surgical team in the performance of at least a hundred major operations was followed by auxiliary surgical groups, it was rarely, if ever, necessary for a surgical team to function as an isolated unit during the combat period of operations on the Continent during 1944-45. Instead of utilizing their own tentage, lighting, and other heavy equipment, surgical teams invariably utilized the facilities of the unit to which they were attached; that is, field and evacuation


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FIGURE 37.-Portable operating light, equipment of a mobile surgical unit.

FIGURE 38.-The arrangement of the operating tables of a mobile surgical unit.


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hospitals. The teams carried with them and frequently utilized certain surgical instruments and other small medical supply items organic to the auxiliary surgical group.

Surgical mission to Union of Soviet Socialist Republics

Background - Colonel Cutler, in a memorandum, dated 15 January 1943, advised General Hawley as follows:

Some months ago when you were ill, I attended a dinner given by Mr. Broster, following his first Inter-Allied Medical Meeting. In responding for you I thanked President Tidy and the group in the Royal Society of Medicine of our colleagues for all that they have done for us. I then pointed out what I thought might be the value of all the Allied people getting to know something of each other. At that time I said I was greatly concerned that I had been unable to meet a Russian, and I thought this was a pity, and wondered if there are any Russians in London. Sir Wilson Jameson and Sir Alfred Webb-Johnson and other people who knew all about the Russian difficulty, and that a British hospital ship had even reached Murmansk and had been turned back again, were much upset. They have talked to me repeatedly about this, and apparently had been to the Foreign Office again. I learned yesterday that a request might shortly be made for three British medical officers, and three American medical officers, to visit Russia. I thought you should be apprised of this possibility early. It appears to me that a country who must have had millions of casualties should be able to teach us a good deal about military surgery and military medicine.

Colonel Cutler's diary states, for 29 January: "I'm getting worse at this [keeping up the diary], just when it is getting interesting. For example, Russia. I have long been worried I couldn't find a Russia. I've spoken of it as a reason for the Inter-Allied Conferences. I spoke of it at a dinner with Fraser, Sir Wilson Jameson, Sir Alfred Webb-Johnson, Dean * * * of the Graduate Schools, and Broster (his dinner). As a result, I now have a commission of 3 British and 3 American medical officers to be asked to go to Russia."

Colonel Cutler had just returned to Cheltenham from a trip to London, Basingstoke, and Chatham on the morning of Saturday, 10 April, when General Hawley called him to his office in the afternoon and instructed him to see the U.S. Ambassador in London about the trip to the Soviet Union. Dutifully, Colonel Cutler turned around, went back to London the next day, and saw John G. Winant, U.S. Ambassador to the Court of St. James's (fig. 39), in the late afternoon. On 16 April, he reported on this meeting by letter to General Hawley (through Colonel Kimbrough). A portion of this letter follows:

We discussed at great length the rumored joint medical mission of British and American service personnel to Russia. He reported previous discussions re Russia and happenings in Russia that bore small relation to this problem. He reported the Typhus Commission was turned down. * * * The urgency of the matter was again brought to his attention when I told him that on April 16 Surgeon Rear Admiral Gordon-Taylor was lunching with M. Maisky, the Russian Ambassador, * * *, and that members of the British Commission were now instructed to get their passports. (British Commission headed by Surgeon Rear Admiral Gordon-Taylor, other members, Maj. Gen. Monro, Mr. Rock Carling.) Finally he promised * * * to see M. Maisky, Mr. Eden, and Sir Edward Mellanby [on 15 April], and give you a final report.


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FIGURE 39.-John G. Winant, U.S. Ambassador to the Court of St. James's, and Mrs. Winant with Gen. Dwight D. Eisenhower.

Mission established.-On 19 April, Colonel Cutler was given a message to call Admiral Gordon-Taylor. Mrs. Gordon-Taylor answered and informed Colonel Cutler that he and Lt. Col. Loyal Davis, MC, were to go to the Soviet Union with the English mission (fig. 40). Colonel Cutler was elated. He recorded: "This is something I have been working on for 4 weeks and indeed feel partly responsible for. Now I am getting somewhere! We're to go in about 3 weeks; in May. Know nothing more. Of course it is a risk, but that is small compared to what others are doing. I'm happy for a moment."

Preparations for departure.-The next few weeks were kaleidoscopic for the Chief Consultant in Surgery. There was so much to be done before leaving, and yet details concerning the mission to the U.S.S.R. took time in themselves.

On Wednesday, 21 April, he had tea with Admiral Gordon-Taylor who informed Colonel Cutler that the mission would depart on or about 15 May; that the English members would be Admiral Gordon-Taylor, General Monro,. Mr. R. (later Sir Reginald) Watson-Jones, Civilian Consultant in Orthopedic Surgery to the Royal Air Force, and Mr. Ernest Rock Carling; and that the U.S. representatives would be Colonel Cutler and Colonel Davis. Admiral Gordon-Taylor also confided to Colonel Cutler that he was learning Russian. Later that day, Colonel Cutler had a talk with General Hawley, after which he recorded: "[General Hawley] informed me that the Ambassador thought: (1) There should be separate missions, and (2) three U.S. members. General Hawley and I agreed the joint mission was best. As to the third member, the


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FIGURE 40.-American members of the surgical mission to the U.S.S.R., Lt. Col. Loyal Davis, MC (center), and Colonel Cutler, with Surgeon Rear Admiral Gordon Gordon-Taylor, RN, head of the mission.

Russians would like men of high academic standing in surgery [professors of surgery]. The General thought Loyal Davis and I were the only ones here who filled the bill."

The next day, because there was some uncertainty as to who was to head the American representation, Colonel Cutler spoke again with General Hawley who confirmed the fact that Colonel Cutler would head the American representation. He then saw Admiral Gordon-Taylor again. The admiral approved the giving of fellowships to two famous Soviet surgeons, N. Burdenko and Serge Yudin,44 by the American College of Surgeons, and Colonel Cutler went back to General Hawley with this information.

By the middle of May, Colonel Cutler and Colonel Davis had written to the American College of Surgeons for permission to bestow the honorary fellowships. The ceremonial hoods had been borrowed from two Englishmen, Admiral Gordon-Taylor and Mr. Harry Platt, with the promise that these would later be replaced. The speech of investiture was then approved by General Hawley. There was also some confusion as to the diplomatic channels through which the names of the American representatives would be submitted to the Soviet Government, but the matter was eventually taken care of and

44The variation in the spelling of the names of Russian individuals in this volume is due to the fact that there are two systems of transliteration in use.


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passports were obtained on 11 May. On 13 May, Professor Sarkisov, an assistant to Academician Burdenko, arrived in England from Vladivostok and was introduced at a luncheon held at the Royal College of Surgeons. He gave the most comforting assurance that the mission would, in all probability, be warmly welcomed in the Soviet Union. And, finally, word was received that Prof. Wilder G. Penfield of McGill University, Montreal, Canada, would be added to the mission.

There was no further clarification, as of 15 May, as to when the mission would leave. But, with the arrival of Professor Penfield, the membership of the mission was complete, and amenities preparatory to departure continued at a high pace. As an example, on 24 May there was a luncheon given by the British Council for the mission at Claridge's in London. There was also a serious talk with the U.S. Ambassador on what to do and not to do while in the Soviet Union. Finally, there was tea at the Soviet Embassy, 13 Kensington Palace Gardens, given by Ambassador Maisky. With respect to the Soviet ambassador's tea, Colonel Cutler's comment was: "Tremendous." As to the meeting with Ambassador Winant, Colonel Cutler reported as follows in a letter to Colonel Kimbrough, dated 30 May 1943:

* * * He gave Colonel Davis and myself explicit verbal instructions, but said he did not wish to give us anything in writing, emphasizing that we should use our own discretion, and hoping that we would get on well with our Russian colleagues. The latter was emphasized as highly important, since if this mission is happily received others of great importance may be allowed to follow. Ambassador Winant made it very clear that the instructions to which we should adhere closely were to discuss nothing except professional medical matters. He emphasized this point by stories of diplomacy wrecked on the rocks of missions going beyond their protocol. He urged us to take anything with us that could enlighten the Russians on American surgical methods, and hoped we might bring back matters of importance to our people.

The Ambassador also promised Colonel Cutler a list of American diplomatic officials in the countries through which the mission would travel en route to and from the Soviet Union.

Soviet motion picture - On 31 May 1943, Colonel Cutler was privileged to see, at the Soviet Embassy, a motion picture depicting the care given the wounded Soviet Army soldier during his evacuation from the front to the rear and through his rehabilitation. His account of the film showing in a letter to Colonel Kimbrough, dated 5 June 1943, follows:

This was a battle picture and most interesting. Soldiers were picked up on the battle field and given preliminary First Aid by a trained first aider. They then passed through battalion and divisional aid posts and to hospitals similar to our surgical hospitals, where definitive surgery was carried out. Certainly a great attempt was made to give as adequate care as possible, and every effort was made to restore the soldier to active duty as soon as possible.

The most important observations of interest to me were:

The use of women in the forward area. Women were even in the divisional aid posts of casualty clearing companies, and from the expressions on soldiers' faces, even without the spoken word, one felt sure that their presence was of great moral value. * * *

Cleaning and bathing facilities. Here, the Russians, whom we have not thought of as a clean people, can give all of us a very good lesson. They had excellent bathing facilities


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in their most forward hospitals, and spoke of such facilities as equally important to good surgery. * * *

Air transport. This was greatly emphasized in the film, and is used in the care of wounded amongst the guerillas, which is a part of the obligation of the Russian Medical Corps.

"Like politics at home"-The motion picture served to increase the desires of the mission members to see the Soviet medical service first hand, but the actual departure was not to be for quite some time. Partially, perhaps, as a result of this interminable waiting, the solidarity among the members became strained. By the time 13 June arrived and the mission was still awaiting travel instructions, Colonel Cutler was quite concerned. So, apparently, was General Hawley, for he called Colonel Cutler by telephone and asked him about the situation. There were varying claims as to how the mission had originated and who was responsible for its establishment. There was a question as to who was going to head the mission. Instead of the senior military members from the United States and the United Kingdom, there were strong indications that Colonel Davis was being selected to represent the National Research Council of the United States and that Mr. Ernest Rock Carling would represent the British Medical Research Council.

"Real trouble is my worry over the Russian mission," the diary entry for 13 June reads, "Have warned General Hawley and C. Spruit-the whole thing is loaded with dynamite."

The following inkling of this warning is mentioned in the diary on 17 June:

Conference with Ambassador, 2:30 PM, and then with General Hawley. General Hawley is to see the Ambassador at 4:30. No definite news, but PRH wrote our orders: "To help Gordon Gordon-Taylor, head of mission, and to carry out mission's protocol * * *." Also, I saw PRH's wire to The Surgeon General (written after phone call with me 2 or 3 days ago). Stated:

1. Mission arranged by British
2. American members invited by British
3. Professional protocol (not military)
4. Advises against further powers mixing into this.

The next day, Friday, 18 June, Colonel Cutler reviewed General Hawley's meeting with Ambassador Winant, as follows:

Saw General Hawley after he saw Ambassador Winant. As I thought, the Ambassador wants Loyal [Davis] to represent National Research Council in mufti. General Hawley told the Ambassador that was a mistake. The Ambassador asked if he could go to Devers! Of course, General Hawley said yes. General Hawley also saw a letter from Eden saying we leave in about a week via Cairo. Good.

So strong was this rumor about members of the mission going to the Soviet Union in mufti that Admiral Gordon-Taylor had gone to Surgeon Vice Admiral S. (Sir Sheldon) Dudley, DGMS, Royal Navy, and had asked him about it. Sir Sheldon had simply stated that Admiral Gordon-Taylor would go in uniform or else he would not go at all.45

45Letter, Sir Gordon Gordon-Taylor to Paul R. Hawley, M.D., 9 October 1958.


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Finally, on Sunday, 20 June, after receiving a message from Mr. Carling, Colonel Cutler felt constrained to admit that it was all "too bad-like politics at home."

Departure -The mission finally departed on 28 June 1943 with the military members in uniform. Admiral Gordon-Taylor, as one of the two ranking military members of the mission and representing the senior British service, the Royal Navy, had been officially recognized as the head of the mission. Colonel Davis had been confirmed as the representative of the Committee for Medical Research of the National Research Council, U.S.A.; Mr. Carling, as the representative for the Medical Research Council of Great Britain; and Professor Penfield, for the Medical Research Council of Canada. Mr. Watson-Jones was going as a civilian consultant to the Royal Air Force. General Hawley had approved the taking of 2,000,000 units of penicillin from the stockpile at the 2d General Hospital as a gift for the Soviet peoples. And, finally, all official papers which were to be taken by the mission had been censored and sealed.46

Desires of mission expressed -The mission, upon arriving in Moscow, was delayed in getting about its business for reasons unknown. The members of the mission took the opportunity to compose a memorandum to the Soviet authorities on its intents and desires, as follows:

The Delegation of American, British and Canadian surgeons wishes to thank the Soviet authorities for having so kindly made possible their visit to the Soviet Union, and hopes during its stay to study the methods used by Soviet surgeons in the treatment of battle casualties, reports on the success of which have made so deep an impression on the medical authorities in Canada, Great Britain and the United States.

The study of the methods used by Soviet surgeons for the treatment of fractures caused by weapons of war is the primary object of the Delegation.

The second object of the Delegation is to confer on Professors Burdenko and Yudin, who are known abroad as two of the most distinguished surgeons of the Soviet Union, Honorary Fellowships of the Royal College of Surgeons of England and Honorary Fellowships of the American College of Surgeons.

As regards the second of these objects, the Delegation is anxious to come to an agreement with the People's Commissariat regarding the date and place of the ceremony at which the Fellowships will be conferred. The Delegation trusts that the ceremony will be conducted with due dignity and publicity and that the People's Commissariat will agree that the diplomatic representatives of Great Britain and the United States should be invited to attend. For purposes of record in Great Britain and the United States it would be appreciated if the ceremony could be photographed and prints made available to the Delegation before its departure.

As regards the first object of the mission, the study of Soviet methods of treating fractures caused by weapons of war, the Delegation trusts that it will be given opportunities of seeing the work of Soviet surgeons at all stages in the treatment of battle casualties, and that each member of the Delegation will be able to discuss with Soviet

46An account of the observations of Lt. Col. Loyal Davis, while he was en route to the Soviet Union, his commentary on activities engaged in while he was in that country, and his remarks concerning the return trip comprise pages 420-439 of this volume. Any personal papers which Colonel Cutler may have maintained during the trip to the U.S.S.R. were not available to the compilers of this chapter. The full official report prepared jointly by Colonel Cutler and Colonel Davis is added to this volume as appendix A. It should be referred to as an integral part of Colonel Davis' chapter as well as of this chapter.-J. B. C., Jr.


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surgeons specializing in his field the problems in which he is particularly interested. The Delegation believes that this could best be accomplished if facilities were granted for visiting forward medical units, inspecting methods for the evacuation of the wounded, and visiting hospital units, medical institutions and rehabilitation centres in the base area.

The Delegation, in addition to fulfilling the two basic objects described above, would be glad to learn of any other surgical procedures which the Soviet authorities may consider of interest in the treatment of battle casualties, and the members of the Delegation, if requested to do so, will gladly furnish any information which they may themselves possess.

The British members of the Delegation have been requested by various medical organizations in the United Kingdom to present to the Soviet authorities a list of medical questions which it has not been possible to raise hitherto owing to the absence of any convenient channel of communication. The Delegation would be most grateful if facilities could be offered to its members to study these questions during their visit.

The Delegation has brought a number of publications and photographs which may be of interest not merely to individual surgeons, but to the Soviet medical authorities in general, who may already have been made acquainted with them by their representatives abroad, such as Professor Sarkisov in Great Britain and Professor Lebedenko in the United States. The Delegation would be glad to learn whether books and journals of this nature are of assistance to the Soviet authorities and if so whether the Soviet authorities would like to be regularly supplied with similar publications.

The Delegation has brought 2,000,000 units of Penicillin which the United States Medical Corps wish to present to the Soviet medical authorities.

Certain members of the Delegation have also brought a number of new surgical instruments for presentation to the appropriate medical authorities at the discretion of the People's Commissariat.

Several members of the Delegation carry with them letters of introduction and greeting addressed to prominent Soviet surgeons. They would be grateful for advice as to the correct procedure for transmitting these letters to the addressees.

A number of members of the Delegation have also brought in their individual capacities certain publications on surgery which they would like to present to individual Soviet surgeons interested in the various fields of surgery which the publications cover. In some instances the members of the Delegation have in mind the individual Soviet surgeons to whom they wish to present these publications. In others they would welcome the advice of the People's Commissariat regarding the most suitable candidate for presentation. In both cases the advice of the People's Commissariat is sought regarding the procedure to be followed.

The Ministry of Supply have requested the Soviet Trade Delegation in London to clear up certain questions connected with medical supplies ordered by the Soviet authorities. While not wishing to duplicate their request for elucidation of certain items which they have not properly understood, the Ministry have informed Mr. Rock Carling of the points on which they require further information, and Mr. Rock Carling would be glad to discuss these points with the competent Soviet authorities if the latter should consider it desirable. There are in addition one or two other questions of detail regarding medical supplies to the Soviet Union which the Delegation is anxious to raise.

General Monro has brought with him certain memoranda regarding the work of the Directorate of Army Psychiatry. If the Soviet military authorities are interested in this branch of medicine he would be glad to make available to them the material which he has brought with him.

Lastly, if the Soviet authorities should wish to discuss questions of medical research or explore the possibility of establishing closer medical liaison between the Union of Soviet Socialist Republics and the countries represented by the Delegation, the Delegation would be glad to discuss these questions with them. The surgeons who represent the


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Surgical Committee of (1) The Medical Research Council of Great Britain (Mr. Rock Carling); (2) The Committee for Medical Research and the National Research Council, U.S.A. (Lt. Col. Loyal Davis); (3) The National Research Council of Canada (Prof. Wilder Penfield) will also gladly discuss the work of these Committees and the methods by which surgical information is now being exchanged between these three countries for the use of the various combatant services.

Investiture of Burdenko and Yudin into Royal College of Surgeons and American College of Surgeons- One of the highpoints of the delegation's visit to the Soviet Union was the conferring of honorary fellowships to Academician Lt. Gen. Nicolai Nilovich Burdenko and Prof. Serge S. Yudin in the Royal College of Surgeons and the American College of Surgeons. Academician Burdenko occupied a position in the Soviet Army Medical Service equivalent to that of chief consultant in surgery. Professor Yudin had been outstanding for his surgical accomplishments at the Sklifossowsky Institute. The investiture of these two eminent Soviet surgeons into the American College of Surgeons was accomplished by Colonel Cutler and Colonel Davis. The formalities were preceded by the following address presented by Colonel Cutler:

This gathering is momentous. We doctors now signify to the solidarity and common purpose of a majority of living peoples. The occasion justifies the hope that this junction of our races is but the beginning of a friendly and cooperative liaison for all time. As a token of this spiritual union Colonel Davis and I are empowered to grant Honorary Fellowships in the American College of Surgeons to two distinguished Russian surgeons, a function which heretofore has never occurred beyond the confines of our own country.

*   *   *   *   *   *

We congratulate ourselves that in this tumultuous world men of such eminence have found in service to the State a way of life that brings satisfaction to all.

Academician General Burdenko's acknowledgment (fig. 41) of this unprecedented and unique honor of being made a member of both these great organizations simultaneously and on soil foreign to the sponsoring organizations follows:

I am deeply moved by the honor of electing me member of the American College of Surgeons.

I understand this honor as a generous approval of my papers and my work in the past and present. It makes me think about my work in the future, particularly now when the fight against Fascists has reached a decisive stage.

I recognize this election to be of deep and wide meaning.

The last decade has shown that the United States is now the center of medical science, and scientific problems are to be solved from the point of view of American science.

During this year I have received very many proofs of attention from the United States.

My contributions to world science and field surgery are but modest. It pleases me to share this great honor with all surgeons of my country.

The acknowledgment by Professor Yudin (fig. 42) of the honor bestowed upon him follows:

You will easily understand my animation when immediately after one high honor the surgeons of a second great Allied country-the U.S.A.-bestow on me another.


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FIGURE 41.-A copy of Academician Lt. Gen. Nicolai N. Burdenko's speech upon his being made an Honorary Fellow of the American College of Surgeons.


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I know little of your beautiful country. I am proud of my personal acquaintanceship-and even friendship-with George Crile, Howard Kelly, the late Mayo brothers, and some other American surgeons of world fame.

But could I dream 15 years ago that the time would come when I should not only become an honorary fellow of the American College of Surgeons, but should also receive my degree and this diploma from the hands of the great Harvey Cushing's successor.

By the way, it is an astonishing fact that the day of my decoration by the Allies completely coincides with the day I was severely wounded by a German shell on the eve of July 15, 1915.

For the second time in the same quarter of a century our nations are united in their hard efforts to save their countries and the world's civilization. Now, just as it was the first time, we are fighting with the same eternal dangerous enemy-Germany. But as it was on the first occasion, our British Allies are fighting again on our side.

Victory will be ours. Nobody has any doubts about it, even our enemies. Let our scientific relations which have begun in a time of such strained military needs get stronger and flourish more and more after this victory and the won peace.

In the time of struggle, surgery is as necessary for victory as arms, transport, and all kinds of supplies. But when the last gun of the enemy ceases and released humanity turns with hope to the restoration of great destruction caused by the war, we surgeons will have to heal the wounds and injuries of hundreds of thousands of people, who have won for us this victory.

Your high election of me as honorary fellow of the American College of Surgeons will serve as a new additional stimulus for further development of my scientific work in surgery, which has already received from you such high estimation.

I once more deeply and sincerely thank you.

The official acknowledgment of this auspicious event on behalf of the Soviet Government was made by Vice Commissar Kolesnikov, who said:

The admission today of two outstanding Russian surgeons, Academician Burdenko and Professor Yudin to the honorary fellowship of the Royal College of Surgeons of England presents itself to us, witnesses of this act, as an occasion of great cultural and political meaning.

The Royal College of Surgeons of England since long ago has been famed as an organization, responsible in no small way for the development of surgery both in England and outside her boundaries. Amongst the fellows of this College have been, and are now some of the outstanding representatives of English surgical  thought. The greatest exponents of surgery of other countries have earned the honor of being honorary fellows of this College since its creation, in accordance with its established and glorious traditions. On every occasion the selection of honorary fellows amongst foreign scientists has been an unbiased and just appreciation of their really great technical contributions. Therefore, selection to an honorary fellowship of the Royal College of Surgeons of England has always been a distinction in the eyes of the world's scholars. Similarly, the glory of the American College of Surgeons is well known.

We are glad in the knowledge that, today, the choice of the Royal College of Surgeons and the American College of Surgeons should have fallen on the two best representatives of our native surgery. Both the new honorary fellows of the Colleges, Academician Burdenko and Professor Yudin, are deservedly famed in our country, and outside her boundaries, as leading experts in the realm of their specialties. Not for nothing are they both worthy of the highest scientific decoration of our country-the Stalin Prize; whilst Academician Burdenko with honor holds the title of Hero of Socialist Work.


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FIGURE 42.-A copy of Prof. Serge Yudin's speech upon his being made an Honorary Fellow of the American College of Surgeons. The letterhead is of the Sklifossowsky Institute.


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FIGURE 42.-Continued.

The outstanding contributions of Academician Burdenko in the development of neurosurgery, his brilliant experimental work, and his elaboration of the basic principles of a new type of field surgery, which have proved so brilliantly successful in the present war, make us certain that he will be a worthy member of the glorious family of the finest representatives of contemporary surgery that is combined in the Royal College of Surgeons and the American College of Surgeons. Professor Yudin will bear the title of Fellow of the Colleges with equal honor and worthiness. His name is tied with great successes in abdominal surgery, in plastic operations on the alimentary tract, in blood transfusion, and in the prophylaxis and treatment of infected wounds, etc.

We, the representatives of the family of Soviet medical workers, are today justifiably proud of the great honor bestowed on Academician Burdenko and Professor Yudin. At the same time we express our sincerest appreciation to the Royal College of Surgeons of England and to the American College for this mark of distinction. In the name of the People's Commissar and in our name I ask you, Mr. Vice-President and Colonel Cutler, to convey our thanks to your organizations. In the name of the People's Commissar and in our name I congratulate Academician Burdenko and Professor Yudin on their selection for the honorary fellowship of the Colleges.


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Today's occasion takes place in days of bitter warfare against the cruel enemy of progressiveness-Hitler's Fascism! In this war, our medical teaching has extensively become the teaching of war medicine, and it helps our armies in their struggle against this cruel foe. The admission of the most famous Soviet scientists to the honorary fellowship of the Colleges marks in itself a strengthening of the scientific ties between the allied nations. I am certain that those ties will strengthen further in the continuation of this struggle to complete victory over our common enemy.

Summary of observations on military medicine and surgery in U.S.S.R.-On their return to the United Kingdom, Colonel Cutler and Colonel Davis prepared jointly a concise summary of their full report. (appendix A, p. 953) for General Hawley. They asked that special consideration be given the following topics because they appeared to be of chief value to the Medical Department of the U.S. Army.

Care of the lightly wounded.

These are early segregated into special hospitals and are preferably kept in these hospitals in the forward area, not sent to the base. Secondary suture of all wounds is practiced early. Rehabilitation and reconditioning exercises begin at once and the men are restored often within a month to active duty.

Cleansing facilities, i.e., bath and barbers in all hospitals.

This is a great contribution to military surgery * * * every soldier, unless he be urgently required in the operating room, goes first to the barber and a room where he can be washed. This is sincerely appreciated by the troops and is something we should emulate in our opinion.

Facilities for Blood Transfusion.

The [full] report emphasizes the great amount of blood used in the Russian Army and its easy availability. Though this doubtless wasted some blood it made it certain that every wounded man could get blood if that was desirable. We should establish a system making blood as well as plasma available to our forward hospitals.

Laundry facilities.

In the Russian Army the medical department controls laundries serving the hospitals. In the Russian Army laundries are set up and serve a group of adjacent hospitals. We suggest that a similar set up be provided for the medical department U.S. Army. This might be in the ratio of one laundry to a Corps surgeon.

Surgical specialization.

The Russians begin major specialization at the forward hospital level. This provides that in the more important fields of surgery soldiers are given what the specialist thinks is wisest from the very beginning of his treatment.

Sorting and triaging.

This is carried out beautifully at the forward hospitals and emphasizes the organization of forward hospitals found necessary in the last Great War. If large numbers of wounded people are to be competently cared for, some systematic sorting must occur. In the Russian Army this permitted the segregation of slightly wounded in hospitals in the forward area and their rapid restoration to duty; it facilitated the care by specialists of those needing special care and it greatly facilitated the major problem of evacuation.47

Soviet Union and its people.-Colonel Cutler could not help but be impressed with the Soviet scene in general, and, patriot that he was, he felt it his duty to make these impressions known to those who might be able to take advantage of them in their official duties. He realized that his opportunities for ob-

47Letter, Col. E. C. Cutler, MC, and Col. L. Davis, MC, to Chief Surgeon, ETOUSA, 7 Aug. 1943, subject: Surgical Mission to Russia.


Chapter II continued

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