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Chapter II - continued

Contents

Chapter II

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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 +3 to +6C. 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 +4C 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 2-ton truck, and one -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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