CHAPTER II
The Chief Consultant in Surgery
Elliott C. Cutler, M.D.
PROLOGUE
The war diary maintained by Brigadier General Elliott C.Cutler, MC (fig. 7) isan invaluable contribution to the overall history of the medical service in theEuropean Theater of Operations. As Chief Consultant in Surgery, General Cutleroccupied a position in which he could observe the many activities of themedical service in the theater, and this position, combined with an inquisitivemind, and limitless energy, enabled him to pursue the paths which hisobservations-including those not confined to his immediate field ofresponsibility-opened up.
Some of his observations were based upon incomplete orerroneous information. To have edited or deleted such entries would have marredthe reflection of his strong personality in his writing. Where an inaccuracy maypresent a distorted picture of an important event, an appropriate footnote hasbeen supplied.
Cutler`s diary portrays faithfully his dedication to histask, his resentment of everything which impeded its accomplishment, and hisintolerance of what he regarded as unjustifiable requirements of militaryadministration. Notwithstanding his occasional caustic criticisms, he was adevoted and loyal soldier who contributed more than his share to the success ofthe medical service of the European Theater of Operations.
PAUL R. HAWLEY
Major General, MC, USA (Ret.)
October 1958
1942: GETTING STARTED
The Beginning
Dr. Elliott Carr Cutler, Moseley Professor of Surgery at theHarvard University School of Medicine and Surgeon-in-Chief, Peter Bent BrighamHospital, Boston, was at Martha`s Vineyard, Mass., when, quite bycoincidence,
1Except where other sources arespecifically cited, this account has been compiled and edited from the officialdiaries maintained by Elliott C. Cutler, M.D., deceased, as well as from otherrecords, by Maj. James K. Arima, MSC, The Historical Unit, U.S. Army MedicalService.
20
FIGURE 7.-Brig. Gen. Elliott Carr Cutler.
he received on the Fourth of July 1942, orders to report foractive duty on 15 July 1942.
It was understood that he was to become Chief Consultant inSurgery in the European Theater of Operations, a position similar to that heldby Brig. Gen. John M. T. Finney, MC, with the AEF (American ExpeditionaryForces) in World War I. The reasons why Dr. Cutler was chosen for this positionwere inextricably rooted in that first great conflict.2 In 1915, hewas in Paris working with the French. He returned to the United States andreceived a commission in the Medical Corps Reserve as first lieutenant on 2 June 1916. He sailed for France on 11 May 1917 with BaseHospital No. 5, a unit affiliated with the Harvard Medical School. He served invarious capacities, one of which was as adjutant of an evacuation hospital. Dr.Cutler was associated closely with Dr. Harvey Cushing throughout World War I,but his most significant experiences probably were those gained while workingdirectly with Dr. Cushing on surgical teams, particularly in neurosurgery.3
Dr. Cutler was discharged as a major on 29 April 1919. He returned to the Medical Corps Reserve in1921 and, from then on, kept in constant close touch with Army MedicalDepartment affairs. One of The Surgeons General,
2Annual Report, Chief Consultantin Surgery, European Theater ofOperations, U.S. Army, 1942.
3Cushing, Harvey: From aSurgeon`s Journal, 1915-1918. Boston: Little, Brown & Co., 1936.
21
Maj. Gen. Robert U. Patterson, was Dr. Cutler`s commandingofficer while he was with Base Hospital No. 5. Subsequent Surgeons Generalwere well known to Dr. Cutler, and The Surgeon General at this time (1942),Maj. Gen. James C. Magee, was also a close acquaintance from World War Idays.
The immediate relation of Dr. Cutler to the present conflictcame in the fall of 1941 when he was asked by the dean of the Harvard UniversityMedical School to reactivate Base Hospital No. 5 as the 5th General Hospital.This was readily accomplished, but by the time the unit was pressed into activeservice in February 1942, The Surgeon General had requested that Dr. Cutler berelieved of his post as commanding officer and await further assignment. Shortlythereafter, Dr. Cutler was offered the position of Chief Consultant in Surgery,ETOUSA (European Theater of Operations, U.S. Army), a post which he eagerlyaccepted in spite of the objections by the president of Harvard University andthe trustees of Peter Bent Brigham Hospital.
Washington Orientation, 18 July to 5 August 1942
The first 10 days in Washington were crammed full ofinstruction, news, and renewing, and making new, acquaintances. Dr. Cutler`srank was the problem of immediate concern. While he had been a lieutenantcolonel since 1924 and had been offered a colonelcy for lesser assignments onthree prior occasions, there had been no choice but to come on active duty as alieutenant colonel. The situation was soon rectified, however, and Dr. Cutler`spromotion to colonel reached him on 22 July 1942.
While he was getting ready mentally and equipping himselfwith all the information he could gather, plans gradually emerged. At thistime, 29 July 1942, Colonel Cutler learned that the consultant group for theEuropean theater would probably consist of the following compartments andsubdivisions:
Medicine
William S. Middleton
Surgery
Elliott C. Cutler
Neuropsychiatry
Lloyd J. Thompson
Orthopedic Surgery
Rex L. Diveley
Neurosurgery
Loyal Davis
Otolaryngology
Lyman G. Richards
Ophthalmology
Derrick T. Vail
Anesthesia
Ralph M. Tovell
Blood and Plasma
Cornelius P. Rhoads
Venereal Disease
James C. Kimbrough
Laboratories
Ralph S. Muckenfuss
22
Colonel Kimbrough, he thought, might be changed and placedover the whole group, and perhaps Dr. A. Winternitz could be called for later toaugment the laboratory group.
He felt that the group should be a cabinet of advisers to theChief Surgeon and that its members should report as a group, and, therefore,have frequent common gatherings and meetings. He thought that the Chief Surgeonshould send them into the field for specific information and should ask them togive him specific advice. Success, he calculated, would depend on relationshipswith the Chief Surgeon and on the men in the field equally. He reasoned thatcontacts with professional colleagues in England would also be highly desirable.
The problem which bothered him most was that almost noprovision had been made for the professional care of the American soldier"up the line" or at "the front." He wrote in his diary:
It seems to me that the base area has had lots of thought.Base or general hospitals are well set up and well equipped. I have studied indetail lists of equipment until my eyes are sore-lists of drugs never to beused.
But what of the front where it seems to me men are saved ormarred for life? I cannot find any happy solution here. There is loose talk ofstation hospitals broken up, and of new but never assembled mobile evacuationhospitals, but the latter depend on 10-ton trailer trucks which will probablynever be delivered. And there is talk of a light field hospital of 400 beds.
Moreover, in a study of teams (surgical affiliated units) Ifind a tendency to make them rigid and to set them up here equipped in diverseways with a basic general equipment and then separate equipment for chests-neurosurgery,maxillofacial surgery, orthopedic teams, etc.
1. It is certain the old fixed American hospitals(evacuation, mobile, or surgical hospitals, U.S. Army; casualty clearingstations, British) have been of little use and dangerous in the present mobile,fluid conflict.
2. I believe the above is true and that early surgicaltherapy, if properly set up, may save many lives-perhaps the lives of mychildren.
3. If the above two are true, we must organize somethingnew for the U.S. Army Medical Department.
4. I believe the answer lies in putting surgical teams in theclearing station area.
a. Perhaps female nurses should not go.
b. Perhaps the new field hospital can go there.
c. The team personnel should be general surgery, notspecialists.
d. The team should be completely equipped; i.e., surgeonshould have instruments for head, chest, abdominal, and peripheral surgery. Theteam should also carry dry goods, supplies, anesthesia outfits, splints, etc.4
As a result of voicing his thoughts on this question, ColonelCutler was instructed to draw up an equipment list for teams serving thefrontlines. But where were the teams to come from? Affiliated groups beingorganized? Excess in general hospitals? There appeared to be no immediateanswer. At any rate, Colonel Cutler received his baptism into the complexitiesof supply procedures
4"This diary entry was made in Washington before GeneralCutler came to the E.T.O. He never had any such concern after arrival in theE.T.O. You may be sure that I had no thought of going into combat without thevery type of mobile medical units which we did have. The only new unit addedafter I left the U.S. was the field hospital-and I never thought very much of itas a front-line unit." (Letter, Paul R. Hawley, M.D., to Col. John BoydCoates, Jr., MC, 25 Aug. 1958.)
23
while working on the equipment for these teams, and thedifficulties of medical supply continued to challenge him on many occasionsthereafter.
As the long summer days of July turned into August andColonel Cutler found himself still in Washington, he became increasinglyrestless and anxious to leave. He recorded:
As a matter of fact, Washington is slow, let down, or, if notworse, full of inefficient people. No one quite at it hammer and tongs, unlessit is * * *. I cannot write more but it is awful slow when ourcountry is in danger-grave danger. How few seem to realize the seriousness ofthis! We are all too old, and yet the old men seem to have the right spirit.That`s what the country needs, a spiritual uplift! ** * If I had time, I should sit down and cast intoShakespearean English what stirs my "innards" and stimulates my days.As it is, I`m off for action. Perhaps that`s my cue. Now to serve mycountry.
London
While the last few days in Washington were long, the last was barely long enough. In something less than 12 hours from the time he received notification that travel priorities had been established for him, Colonel Cutler had to obtain his Government transportation requests and tickets, clear administratively for departure, finish packing, bid farewell to friends and family, run the last half mile to the Washington station, and be at La Guardia Airport in New York for a flight at 0100 hours on 6 August 1942. The Pan-American "Clipper" discharged its passengers at Limerick Airport, Foynes, Ireland, the next day. After two unsuccessful attempts to fly from Limerick to Bristol, owing to the fog, the third attempt resulted in the aircraft`s being grounded suddenly at an intermediate airport because "Jerry" was reported overhead. Colonel Cutler finally reached his destination, London, at 2350 hours, 8 August 1942, and was billeted at the Claridge Hotel.
Early the next morning, he was off to 20 Grosvenor Square(fig. 8), headquarters of ETOUSA, where he registered, turned in his passport,and filled out the numerous blank forms required upon arriving at a new command.
The next stop was 9 North Audley Street (fig. 9), the Londonoffice of the Chief Surgeon, Col. (later Maj. Gen.) Paul R. Hawley, MC. Therehe met another acquaintance, Col. Charles B. Spruit, MC, (fig. 10) who was nowDeputy Surgeon and represented the Chief Surgeon at Headquarters, ETOUSA.Colonel Hawley had moved to Cheltenham, headquarters of SOS (Services ofSupply), ETOUSA, when he was also designated Surgeon, SOS. All the medicalofficers Colonel Cutler met here, just as in Washington, were bitterly criticalof this new organization which ostensibly subordinated the Medical Department toan overall supply service. It seemed to leave no provision for integratingservices, such as medical, for the Services of Supply and the army in the field.The reorganization appeared to mean that there was no jobto correspond to that of Maj. Gen. Merritte W. Ireland with the AEF in World WarI. If anything, the squabble over this reorganization was worse in England thanin Washington. The immediate question confronting Colonel Cutler as a result ofthis situation was whether he was to stay in London or go to Cheltenham.
24
FIGURE 8.-Headquarters, ETOUSA, at 20 Grosvenor Square, London.
He soon learned the answer. The next day, Colonel Hawleyarrived in London, and Colonel Cutler was able to meet with him. Colonel Cutlerwas to be located with the Chief Surgeon at Cheltenham. He was given his missionin simple terms. As the chiefconsultant in surgery, he was to see that the American soldier received thebest medical care that the tactical situation and local circumstances wouldpermit. Colonel Hawley also expressed his policy of fostering the best ofrelations between the Americans and the British and working closely with them.Colonel Hawley also thought that the consultants should have and bring up theirown ideas as well as carry out orders from him.
"I think we will get on," Colonel Cutler wroteafter the meeting, "Indeed, we must."
The next few days were exceedingly busy as Colonel Cutler setout to make his contacts with other American agencies and the British officesin London.
Among the Americans he met again was Maj. (later Col.)Herbert B. Wright, MC, who was chief of the Professional Services for the Eighth Air Force surgeon and the latter`s liaison officer with the Office ofthe Chief Surgeon, ETOUSA. Colonel Cutler learned a great deal from MajorWright about medical organization, procedures, and functions in the Eighth U.S.Air Force.
Colonel Cutler also met Dr. Kenneth Turner, liaison officerof the American National Research Council with the British National ResearchCouncil. Dr. Turner was attached to and lived with the American Embassy staffin London.
25
FIGURE 9.-Office of the Chief Surgeon, ETOUSA, at 9 North Audley Street, London.
Among other things, Colonel Cutler discovered that Dr.Turner had a very complete file of National Research Council reports andpublications and received new items frequently and promptly. These papers wereobviously of critical importance to the maintenance of highest standards ofmedical practice among the American forces in the United Kingdom. Dr. Turner,however, informed Colonel Cutler that he was not permitted to release them tothe U.S. Army. They were strictly for his information to facilitate hisdealings with the British counterpart of the American National ResearchCouncil. This situation was disappointing, to say the least, and entirely atodds for the best conduct of the war effort. Colonel Cutler later made astrong appeal to have the unfortunate situation rectified. As a result, Dr.Turner was able to obtain State Department approval for receiving extra copies of theAmerican NationalResearch Council publications to be turned over to the Chief Surgeon, ETOUSA.In exchange therefor, Dr. Turner was later invited to attend all strictlyprofessional meetings and conferences held under auspices of the ChiefSurgeon.
In the next few days, ColonelCutler went about the most pleasant task of establishing himself with the staffof the AMD (British Army Medical Directorate) and the Canadian medical staffin England. Lunch on two occasions at the RAMC (Royal Army Medical Corps)School in one fell swoop placed Colonel Cutler in the midst of theiractivities. It was the custom of the DGMS (Director General, Medical Service) tohold a monthly meeting of his consul-
26
FIGURE 10.-Col. Charles B. Spruit, MC.
tants, advisers, and directors of medical services in areacommands. Consultants from the RCAMC(Royal Canadian Army Medical Corps) were already participating in thesemeetings. The chief surgical consultant, Brigadier J. M. Wedell, RAMC, and thechief medical consultant, Maj. Gen. Sir Alexander Biggam, RAMC, held meetings ofconsultants in their respective branches the day preceding the DirectorGeneral`s meeting. Colonel Cutler was askedto, and later became a regular participant in, themeetings of the surgical group andthose of the DGMS, Lt. Gen. Sir Alexander Hood, RAMC.
The subject of particular concern, on the occasion ofColonel Cutler`s first visit, was thatof rehabilitating men in convalescent camps rather than occupying beds inhospitals. The proposal was toprovide plenty of exercise and physical training, perhaps under the directionof line officers, and encourage men to fight their way back to health. TheBritish hoped to make extensive use ofphysiotherapists in this organization. The civilian-directed hospitals of theEMS (Emergency Medical Service), in which British soldiers were hospitalizedfor long-term definitivetreatment, had been much too lenient in the past.
On his last day in London,13 August 1942, Colonel Cutler, with an old-time acquaintance, Brigadier (laterMaj. Gen.) William Anderson, dined as guests of Surgeon Rear Admiral GordonGordon-Taylor (later knighted) (fig. 11), another good friend from pre-World WarII days. Brigadier Anderson was surgeonof the Scottish Command and Admiral Gordon-Taylor was Chief Consultant in Surgeryto the RoyalNavy. Brigadier Anderson later becameChief Surgical Consultant of the British Army.
27
FIGURE 11.-Surgeon Rear Admiral Gordon Gordon-Taylor, Royal Navy, with General Hawley.
In addition to these representatives of the British Army and the Royal Navy, Colonel Cutleralso met and spoke at length withTudor Gardiner of the Royal Air Force and Prof. J.Patterson Ross, neurosurgical consultantto the Emergency Medical Service.
Colonel Cutler felt that he had accomplished much in amere few days as he left London by train in the early afternoon of 14 August1942 and arrived at Cheltenham some 5 hours later. In a memorandum, a copy of which went tothe ChiefSurgeon, Colonel Cutler presented these impressions of his first few days inEngland:
Observations on military surgery atthis time-
a. The Combat Divisional Medical setup is O.K.,thoughwe need to get directives to the medical units as toproper professional handling (i.e., very simple, but to include use ofsulfonamides, splints and evacuation).
b. The Base Area Hospitals (Station and General) areadmirable and when brought up to the T.O. with American equipment cannot bebettered.
c. The area between the tail of the Division and the BaseArea is a so far uncharted area. It appears at first glance that the British maybe getting themselves too set on following up their Libyan experienceswhich practically leaves a plan that throws
28
out the C.C.S.`s {Casualty Clearing Stations] and other forward hospitalunits and relies almost entirely on the utilization ofsurgical teams in independent, self-contained,motor-transported small units.
I believe we must be prepared both for the above mobile, surgicalteam set-up,utilizing this close to a Clearing Company and possibly with part of our newfield hospital, as well as for putting in our evacuation hospitals, though theymust be stripped and cut down in weight for mobility. No one now can predictwhen and where, therefore, we must have alternate plans.
And when we come to contemplate a beach-head and medical care, thematter isfurther complicated * * *.
A final thought brings up the major problems of evacuation from the forwardarea. Try as one will there is no escaping the conviction which becomes evenfirmer that the optimum solution is in the air.5
Cheltenham, Headquarters, SOS
Cheltenham, Colonel Cutler found, was quite pleasant. He was given a tiny, but adequate, top-floor room at the Hotel Ellenborough. The officers were awakened at 0630, breakfast was at 0700, a bus transported them to the office at 0745, and working hours were from 0800 to 1700 daily. Saturdays, however, began an hour later, and on Sundays the officers were required to work only in the forenoon. The office facilities, unfortunately, were not the best, and later, when the full complement of consultants was on duty, the noise was said to be akin to a boiler factory (p. 362).
Col. James C. Kimbrough, MC, had been made Director of Professional Services, Office ofthe Chief Surgeon, Services of Supply, ETOUSA, asColonel Cutler had anticipated, and was thus placed over all the consultants. He wasalso acting as consultant inurology, his specialty, and was responsible forthe quality of treatment being given patients with venereal disease.
Lt. Col. (later Col.) William S. Middleton, MC, was Chief Consultant in Medicine. Theonlyother consultant present at the headquarters at this time was Lt. Col. (later Col.)James B. Brown, MC, Consultant in Plastic Surgery and Burns.Colonel Middleton, as he had explained to Colonel Cutler at their first meeting in London,did not expect to have a large full-time staff. He was operating under theprinciple that men of special abilities and qualifications in the generalhospitals could be designated theater and area consultants in addition to their regular duties in most ofthespecialties of medicine. He planned to have full-time consultants only in dermatologyand neuropsychiatry. Theconsultantswho were to make up the initial group of surgical consultants in the Europeantheater were expected (anddid arrive) in the next few weeks. They were Lt. Col. (later Col.) Rex L.Diveley, MC, Senior Consultant in OrthopedicSurgery; Lt. Col. (inter Col.) Loyal Davis, MC, Senior Consultant in Neurological Surgery; Lt. Col. (later Col.) Ralph M.Tovell, MC, Senior Consultant in Anesthesia; and Lt. Col. (later Col.) DerrickT. Vail, MC, Senior Consultant in Ophthalmology.
5Memorandum, Col. E. C. Cutler, MC,to Col. J. C. Kimbrough, MC, 16 Aug. 1942,subject: Report of Activities, Aug. 9-14, 1942.
29
Colonel Cutler had just arrived in Cheltenham late Friday,14 August; but Sunday, 16 August, found him off again to London. Innumerabletrips to London were to follow.
On Monday, he called on Air Marshal Sir Harold Whittingham,DGMS of the RAF (Royal Air Force), and Sir Francis Fraser, director of theEmergency Medical Service. He also dined and had conferences with Col. (laterMaj. Gen.) Malcolm C. Grow, MC, Surgeon, Eighth Air Force, and theaforementioned Major Wright. The conferences with Colonel Grow and othermembers of the Eighth Air Force concerned the curriculum of a proposed courseof instruction for medical officers with no previous training in aviationmedicine. The Eighth Air Force hoped to open a provisional medical school atHigh Wycombe by the end of August.
The following day, Tuesday, 18 August, was a preview ofthings to come and the first trip in the field for the recently arrivedChief Consultant in Surgery. With Sir Harold Whittingham, Colonel Hawley,Colonel Grow, Colonel Spruit, Major Wright, and an engineer officer of theEighth Air Force, he visited Hendon Airport, London, to inspect the litterarrangements for transport aircraft. The demonstration showed only one thing of significance. It was very apparent that more work would have to bedone to make the conversion of transport aircraft into evacuation aircraft anefficient and simple operation. The aircrew required 10 minutes to positioneach of 18 litter racks. It took some 20 minutes for a British ambulance crewto load 10 litter cases. Much time was wasted because the litter racks weremade to take small-pole litters and not the American or British Army wooden litters. With properly modified litter racks and a trainedcrew,Colonel Cutler thought that the whole operation of setting up the litterracks and loading patients could beaccomplished in 30 minutes.6
After the demonstration, Colonel Cutler inspected adispensary located at Hendon Airport and then journeyed back to Cheltenham.There, he proceeded to write up reports of the trip to Londlon and toput down on paper the type of education and trainingthat would be necessary for medical officers in the immediate future. Heenvisaged three areas upon which emphasis in this training program could beplaced: (1) Early treatment at the front, (2) treatment during the evacuationphase, and (3) the type of treatment to be given in base hospitals. Hestressed particularly the following point:
Chief emphasis must be placed upon choice of soldier uponwhom surgery is to be carried out in the forward areas. A directive regardingthis can be written but will have to be modified bythe necessity. Precedence should be given to haemorrhage, shock, sucking chestwounds, major compound fratures. The military surgeon must learnthat the quickest way to win the war (and this in the end saves the mostsuffering) is to get back to duty as many men as possible. Abdominal cases andtime consuming major surgical procedures that offerlittle or no hope of return to duty can never have first call on theefforts of the good military surgeon.7
6Memorandum, Col. E. C. Cutler, MC, to Col. J. C.Kimbrough, MC, 19 Aug. 1942, subject: Report re Visit to LondonAugust 17 and 18, 1942.
7See footnote 6.
30
This bit of advice was something which many medical officers,including some of the specialist senior consultants in surgery, were going tofind most difficult to accept.
In this same paper on medical courses to be conducted in thetheater, Colonel Cutler also stated: "I consider an Auxiliary SurgicalGroup our chief necessity at this time!" Hewent on to report that the component teams were being carefully picked in theoffice of Brig. Gen. Charles C. Hillman, Chief, Professional Service Division,Office of The Surgeon General.
Having finished his London report and the suggestion forcourses in military medicine,Colonel Cutler found solace and cheer in the accomplishments of his first fewdays in the European theater. His diary entry read:
For the first time I feel orderly and as if something hadbeen done. Of course, I have only been here 10 days. Since I`vecemented myself with the RAMC, the RAF, and our own Air medical people, Imust have gotten something done. Also in touch with the Royal Navy throughGordon-Taylor and the EMS through Francis Fraser.
Solitary reflection on the general outlook, however, caused Colonel Cutler to philosophize:
The doctor at war is worth thought. He cools his heels inthis preparatory phase with those whose entire thoughts are directed toward implementing conditions he is already trying to oppose.True, the common fear binds them together. All must visualize the necessity ofthe undertaking lest a greater evil befall our people. But unmistakably, he isset aside-sometimes just as chaff, sometimes in undue respect as the necessity for hisministrationsseems more imminent, or as the limited imagination of his colleagues looks tothe future.
There was yet another reason for cheer on this day, ColonelCutler`s 10th day of duty in the Office of the Chief Surgeon, ETOUSA. TheBritish and Canadians, with a few attached Americans, had staged a major raidat Dieppe.
Dieppe and Its Aftermath
The raid at Dieppe sounded good to Colonel Cutler. It showed that a landing could be achieved. It proved that tanks could be landed. Was it worthwhile? Yes, for any offensive, no matter how small, would upset the Germans.
A Canadian from Saskatchewan who had just returned from the raid told Colonel Cutler that it was acinch. He had gone in 2 miles. Itwas easy. No one was frightened. This young man went on to say that theAllies might as well tellHitler when an attack was comingbecause nothing could stop it. He asserted that the Germans knew 5 daysbeforehand of the Dieppe attack.
But there were casualties, American casualties. The Chiefof Staff, ETOUSA, upon learning of the seriousness of their wounds, becameextremely concerned over the care the Americans were receiving in theCanadian Army hospitals to which they had been taken. Colonel Cutler, togetherwith Colonel Middleton, visited each of the three Canadian general hospitalsin which the American casualties were hospitalized and carefully reviewed eachcase. The
31
treatment and care being providedthem was excellent. To a man, each patient refused to be transferred to anAmerican hospital when the choice of remaining in theCanadian hospital or being transferred was proffered. They were happy where theywere and had utmost confidence in the Canadian medical officers into whose carethey had been entrusted.
There was one seriously illcase, a Colonel "H." Colonel "H." had been on the bridge of a destroyer when adirect hit blew off the bridge and amputated most of his left foot. He tied on a necktie as a tourniquet and hobbled to the gunwalesof the sinking ship. As he was preparing to go overboard, a gunboat hovealongside and Colonel "H." was handed over to it. "Goaft," he was ordered, but, seeing that the forward gunner was leadingenemy aircraft badly, he crawled forward and continued to direct the gunner`sfire. Some 30 hours elapsed before he was put ashore at Portsmouth, England.Another 24 hours passed before he reached the Canadian General Hospitalwhere he received his first surgical treatment.
At the hospital, Colonel "H." `s lower leftleg had been amputated 5 inches below the knee. Sulfonamide had been placed in thewound, whichwas left open. The wound was clean.He had been given doses of sulfanilamide for 24 hours, but this was stoppedbecause of nausea, mental confusion, and his general poor condition. In the 3postoperative days, he had been given 2,800 cc. of whole blood and 3,000 cc.of plasma. Repeated, continued transfusions were urged byboth Colonel Cutler and Colonel Middleton, and the professional staff at theCanadian hospital concurred.
Ten days after injury, the patient`s condition continued extremely grave.Colonel Cutler was directed to review the case personally. In a midnightvisit to the hospital on 30 August, he found Colonel "H." somewhatimproved but still apparently dying of apeculiar syndrome. His kidneys and heart werefailing, and the etiologyindicated multiple transfusions with reaction which had compounded theeffects of original blood loss. Colonel Cutler followed the case daily, thereafter, untilthe patientwas outof danger. This courageous officer made an excellent recovery, was returned toduty, and continued to serve in the European theater after having been fittedwith an artificial limb. His case became an object lesson formuch of the planning thatfollowed.
As the initial sensational aspects of the Dieppe raid woreoff, there were doubts in some circles as to its effectiveness or worthwhileness.The force hadsustained 55 percent casualties. The lessons for the Medical Department were clear. Ananalysis of the situation in England revealed the following facts:
If things could have been done better our Canadian colleagueswere the first to recognizeit. They pointed out to us * * * thatit would have been better if all of the wounded had been kept near thelanding areas [in England], even if additional teams had been focused there, orthe local hospitals enlarged to care forsuch an influx * * * . It was thought that therewould be a larger number of wounded than could be handled locally, andtherefore the first to arrive were sent by train to the Midlands, which wasperhaps a mistake for they went without surgery, evenafterarriving in England, for a considerable
32
period of time. The Canadians themselves were the first to be self-criticalabout this, but since * * * they handled individual cases so well, wecan have nothing but gratitude for their care.8
This analysis indicated that, with a Continental invasion, hospitalswould have to be set up near the points where casualties would be returnedto England in order to preclude undue delay in treatment as was experienced by Colonel "H." If generalhospitals were to function in this capacity of receiving evacuees from an over-wateroperation, they could only do so after provision had been made for some 10 ormore surgical teams to work at one time. The surgical teams,too, would have to be added to the normal surgical complement of a generalhospital.
On the far shore, it was clear that small medical units with attachedsurgical teams would haveto be deployed near allpossible handling sites. The Dieppe raid proved once again that confusion reigns supreme in war.Owing to many factors, significant among which was the destruction of smalllanding craft, landling serialsfound themselves at points completely foreign to their original intent,upsetting the most carefully prepared plans.
Finally, the important part which sorting or triage would play could notbe minimized. Sorting at the invasion beaches and the receiving areas in Englandhad to be done expertly and quickly so that the seriously wounded would receive immediate attention, as would alsothe lightly wounded inorder that they might be returned to duty as early as possible.9
British Army Blood Supply Depot at Bristol
One of the first items of official correspondence directed to Colonel Cutler for action was a report on the British Army Blood Supply Depot submitted by Capt. (later Lt. Col.) Robert C. Hardin, MC, who was the American liaison officer at the depot. Colonel Hawley, in turning over the report to Colonel Cutler, signified that the Chief Consultant in Surgery would be responsible for the technical aspects of providing blood, blood substitutes, crystalloids, and related substances to the U.S. Army medical units in the theater.10
Colonel Cutler, at the first opportunity, on 26 August 1942, made a trip toSouthmead Hospital, Bristol, where the depot was located. Colonel Kimbrough and Colonel Middletonaccompanied him. Brigadier L. E. H. Whitby, RAMC, the officer in charge of the depot and Director, Army BloodTransfusionService, was absent in London, but the visiting officers were received by MajorMaycock, RAMC, and Captain Hardin. They learned that the center preparedall plasma and arranged for the supply of blood transfusion kitsfor the British Army (fig. 12). The general setup was obviously geared forproduction. In the previous one year, the depot had supplied over110,000 pints of plasma.
8See footnote 2, p. 20.
9(1) See footnote 2, p. 20. (2) Memorandum, Col. E.C. Cutler, MC, and Lt. Col. W. S. Middleton, MC, toCol. J. C. Kimbrough, MC, 26 Aug. 1942,subject: Report of Survey of American and Canadian Casualties FromDieppe Operations, August 25, 1942, by Members ofProfessional Services Division.
10Medical Department, United States Army. Blood Program in World War II. Washington: U.S. Government PrintingOffice, 1964.
33
FIGURE 12.-Blood transfusion kits being packed at the British Army Blood Supply Depot.
Citrated whole blood was supplied only for limited use. A cream separator was usedin the preparation of a wet plasma, the red cells being thrown away. The plasmawas bottled and stored at room temperature and notsubsequently checked for sterility unless the solution became turbid (fig.13). It was obvious to the officers from Cheltenham that the onus ofapplying proper precautions in the use of British wet plasma rested with theuser. The visit to this center did not allay their fears of the propriety oftelling American medical installations to use British plasma liberally. Colonel Cutlerand Colonel Middleton recommended that, as soon as possible,all American medical installations be supplied with the Americanstandard dried plasma units.11
A short time later, on 7 October 1942, ColonelCutler met with Maj. Gen. L. T. Poole, RAMC, director of pathology, AMD, and Brigadier Whitby to work out for the interim an understanding between the American andBritish Forces in England with respect to the supply of blood andblood substitutes. At this conference, it was agreed that:
1. The AmericanForces would be glad to use British supplies of dry or wet plasma, but theamounts required would be no greater than for a British hospital in thesame circumstances.
2. Should the American Forces leave for operations outsideof England, they would take American plasma which was alreadystocked in quantity and would not require crated British stocks.
11Memorandum, Col. E. C.Cutler, MC, to Col. J. C. Kimbrough, MC, 27 Aug. 1942, subject: Visit to Central British Blood Procurement Center, Bristol, August 26, 1942.
34
35
Figure 13.-Continued. C. Plasma being packed for issue.
3. Individual American units would be prohibited fromrequesting blood or plasma directly from British centersbut would submit requisitions to American medical supply sources which wouldstock these items received in bulk from the British.
4. Far greater use would be made of Captain Hardin in thefuture as an assistant to the theater consultants and to help with the organization and training ofshock teams. Brigadier Whitby stated that Captain Hardin was essential both inrunning theplant and in the large teaching load which was carried there, and hadrequested that he continue in his present duties and assignment.
5. American hospitals would cooperate with the Britishblood bank program. That is, U.S. Army hospitals would bleed a few donors eachweek from a prepared panel of donors representing the community in which the hospital was located and turnthe blood over to the appropriate bank.
6. It would be inadvisable to use American troops as donorsfor this blood bank program because of the political implications. It wasbelieved that Americans at home might resent giving blood for the Americansoldier when he, in turn, was being bled for the citizens of another country.Moreover, there was the possibility that the combination of blood from Negroand white troops might complicate the situation.
36
7. Finally, Colonel Cutler promised to try to obtain additional Americanpersonnel to help staff theBritish Army Blood Supply Depot.12
This was indeed a humble beginning to a project whichwas to become, literally, the lifeblood of the theater`s medical efforts, and Colonel Cutler`sperspicacity with regard to the greater use to be madeof Captain Hardin was to be most amply vindicated.
First Supply Problem
On 24 August, just before he was called upon to inspect the Canadian hospitals harboring American casualties from the Dieppe raid, Colonel Hawley had summoned the Chief Consultant in Surgery. Colonel Cutler was directed to draw up a list of medical supplies necessary for the routine maintenance of a field force of 770,000 with 140,000 SOS troops. This was no small task. Colonel Cutler started Colonel Brown, Consultant in Plastic Surgery and Burns, on the list before embarking on the all-night trip to the Canadian hospitals.
A few days later, Colonel Cutler met with Lt. Col. (laterCol.) George W. Perkins, Jr., CWS, in London. Colonel Perkins worked withthe central procurement office of the ETOUSA staff and was concerned with theprocurementof medical supplies and equipment from British sources. This officer politelyinformed Colonel Cutler that the Medical Department was "all wet" onits figures. "I`ve no doubt," ColonelCutler noted in his diary, "andthis puts me in a difficultspot * * * [with respect toColonel Hawley`s request]."
Another aspect of the problem waswhat was needed now-at this time-as compared to what, ideally, might be required in ahypothetical operation.Phrased in another way, the problembecame a matter of what was available as compared to what was desired.Consultants visiting and inspecting hospitals had found critical shortages of necessaryequipment and the prevailing use of many unsatisfactory items. On the other hand,the U.S. Army medical supply depot at Thatcham was, fromall reports, quite well stocked. The fact remained that necessaryequipment for hospitals was, for reasons unknown to Colonel Cutler, not gettingout. Colonel Cutler wanted particularly to have the three general hospitals inthe theater brought upto their full authorized equipment, preferably their original Americanequipment. These general hospitals had professional talent of thehighest caliber, but they could notbe expected to provide services of a similar high caliber without the properequipment. Should U.S. Army sources in the theater not be able to provide this equipment, it was evident thatBritish sourceswould have to be tapped. And thus, Colonel Cutler had arranged the foregoingmeeting with Colonel Perkins.
On 3 September, Colonel Cutler and Colonel Brownvisited Ludgershall, the largest British Army medical supply depot, to pickout instruments suitable
12Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 9Oct. 1942, subject: Report on Meeting With British Officers Concerned With the Supply of Blood and Plasma for the Armed Forces
37
for interchange with American instruments. ColonelDiveley and Colonel Perkins had journeyed to the depot from London. In addition tothe RAMC officers concerned with the depot, representatives from three Britishinstrument manufacturers were present. The entire day was spent in going overitem byitem the instruments listed in American supply tables so that determination could be made as towhether a satisfactory substituteBritish item existed. On the whole, the British instruments were excellent,and, although somewhat heavier than American instruments, each itemaccepted was a satisfactory substitute. Therewas some question, however, as to whether some items could be produced insufficient quantity. There was a particular lack of production in England of all electrical apparatus,and only anegligible supply of heavy X-ray apparatus. Generally, instruments not being producedin England were not essential, and a good surgeon could do a satisfactory jobwithout them. Colonel Cutler was particularly impressed with the cleanliness andorderliness of this depot and the wonderful selection of materiel offered.13
Upon returning to Cheltenham, Captain Martin, in chargeof the American depot at Thatcham, was contacted. Arrangements were made forColonel Brownto visit the depot the next day to have a firsthand look at what was actuallyavailable and could be counted upon.
Before the Chief Surgeon`s firstproblem could be answered, another was posed. This time, it was not hypothetical, and it wasurgent.
Second Supply Problem
A persistent rumor had been that any attack on the Continent from England had been called off for the time being, and the basis of this rumor soon became clear. BOLERO, the buildup for invading the Continent was being subordinated to Operation TORCH, an attack in Africa which was to come off in the very near future. With this as a background, the following came about on 5 and 6 September, as chronicled by Colonel Cutler.
We work daily and seem to makeno progress, largely because, as will be clear below, we are caught in a mess! Ourarmy is still being trained broadly and absolutely lacks specialists. Takesupply as an example. Here is our chief, Major General Lee [Maj. Gen (later Lt.Gen.) John C. H.Lee, USA, Commanding General,SOS, ETOUSA], a very bright man and well equipped with native intelligence.Moreover, he is an engineer, but here his problem is supply. It is a professionaljob. His training in supply and logistics is more than mine, but not complete.His transport office has the job of the New York Central RR. Ofcourse he isn`t equipped. We must change this, and our army must havespecialists!
In the Medical Corps, it is just puerile.
Take the last 24 hours. At 9:00 last night,Colonel Hawley`s sergeant came here with a note from the Chief that the headsof his offices come to him at 9:00 AM. It was a supply problem. JCK, WSM, andECC [Cols. Kimbrough, Middleton, and Cutler] were given a list of medicalmaintenance units for 10,000 men per month. We were informed on Africa. We were warned aboutsecrecy, of course. Then we took the list and put 10 hour`s on it.
13Memorandum, Col. E. C. Cutler, MC, Lt. Col. J. B. Brown, MC, and Lt. Col. R. L. Diveley, MC, to Col. J. C. Kimbrough, MC, 4 Sept. 1942, subject: Report of Visit by Col. Cutler, Lt. Col. Brown and Lt. Col. Diveley to British Medical Supply Depot, Ludgershall.
38
We could make additions and increase the number ofitems, but there could be no deletions. It was a tough job. The list was a riot. It wassupposed tobe under battle conditions for 1 month. There were 3 litters, no tetanus toxoidor antitoxin, no instruments (were they supposed to last forever?), no oxygen tanks, but severalthousand rolls of toilet paper! One bedpan!
The next day, 7 September, Colonel Hawley asked ColonelCutler to drive to Oxford (2d General Hospital) with him. The Chief Surgeon seemed to havemuch on his mind. He explained what hospitals wouldbe going to Africa, a relatively small force from England. He said that theywould be sent well and fully equipped, but otherwise didn`t seem overlyinterested in them. The 2d and 5th General Hospitals, two of the best units,were to stay. Colonel Hawley implied that when the Operation TORCH forces hadgone he would settle down and clean up in England, and he realized there wasmuch to do. As to Colonel Cutler, the Chief Surgeon said that he would like tosee him make weekly visits to all hospitals, develop the instructionalprogram (schools), and stimulate high professional work.
It is elsewhere recorded that, as plans progressed furtherfor Operation TORCH, the European theater had to request that replenishmentsupplies to support the operation be sent directly from the Zone ofInterior. The basis for this request was therealization that it would be more feasible to furnish these supplies from thedistant Zone of Interior than to attempt to find them in the depots in England.14
Introduction to 1st Infantry Division
On 15 September 1942, a Captain Miller, MC, from the 1st Infantry Division visited Cheltenham to further activities for the professional education of the division`s medical personnel. He represented Lt. Col. (later Col.) James C. Van Valin, MC, division surgeon, who had previously written Col. Oramel H. Stanley, MC, the Chief Surgeon`s executive officer, on this matter.
Captain Miller was referred to Colonel Cutler. When CaptainMiller revealed the fact that the medical officers of the division would notbe permitted to attend the surgical courses being established in London,Colonel Stanley proposed that the consultants give a brief series of lecturesat the division. This suggestion was quickly accepted by Colonel Van Valin andthe II Corps surgeon, Col. Richard T. Arnest, MC.
The lectures were conducted at Tidworth Barracks during 16,17, and 18 September. On the first day, Colonel Cutler gave two exercises whichcovered first aid surgical measures in the first and second echelons of medicalservice within thedivision. There was no attempt to discuss definitive surgery as carried out inthe evacuation, surgical, or general hospitals. He stressed the fact that theprimary requisites for adequate initial surgical care of the wounded soldierwere the control of hemorrhage, relief of pain, adequate dressing of the woundand use of sulfonamides to prevent further contamination, booster dose
14Medical Department,U.S. Army. Medical Supply in World War II. [In preparation.]
39
of tetanus toxoid, proper splinting, closure of suckingchest wounds, and an adequate appreciation of shock, crush, and blast sothat proper therapy could be started as far forward as possible.
On the following days, Colonel Brown presented talks oninjuries to the face and jaw, care of burns, and care of injuries in AirForce personnel; Colonel Diveley spoke on care of fractures and theirtransport and evacuation; Colonel Davis discussed neurosurgery in war; and Lt. Col. (later Col.)Lloyd J. Thompson, MC,Senior Consultant in Neuropsychiatry, gave a talk on neuropsychiatricproblems in the field.
The talks were well received, but this course of instruction,which had begun as a one-way flow of information, provided a wealth ofinstruction to the consultants themselves. When Colonel Cutler had completed his portion ofthe program and a discussion of the basic first aidsurgical measures had ensued, it became remarkably clear that the 1stInfantry Division was not equipped with instruments or drugs of the type to best facilitate and carry out thesenecessary measures. This alarmed Colonel Cutler. There were no morphine Syrettesfor forward work, no sulfonamide powder for dusting wounds, and no local orintravenous anesthetics. There were only two blood pressure apparatuses withinthis division of 17,000 men. The instrument kits were inadequate, and the equipment onhand was, in many cases, nearly useless. A simple procedure which could be carried out by almost anyone and would save life was that ofclosing sucking chest wounds, but there was no supply of the necessary needlesand silkworm gut sutures.
As a further check on the statements made by the medicalofficers, Colonel Cutler inspected the equipment and supplies on hand in the division`s medical supply section. He also went over, item by item, theNo. 2 medical chests which were being used in the division`s dispensariesand which were also meant to be used under battle conditions for the careof casualties. Colonel Cutler was again struck by the lack of equipment andsupplies which he now knew from personal experience were available and could besupplied from sources in England.
Upon returning to Cheltenham, he dictated a memorandum inwhich he detailed simple, but specific measures which could be accomplishedto correct these deficiencies. He closed the memorandum with the following:
I consider these recommendations of vital importance. Thematerial essential is all here. We have been instructed to see that the care ofthe American soldier is as adequate as it can be made under the conditionsimposed by battle. The requests above are simple, but may be life saving, and if they are neglected weshould be and will be severely criticised.15
Once back in his room, he wrote:
Well, I have been told my job is to see that the Americansget the best professional care under circumstances presented by terrain, enemyresistance, etc. So I handed
15Memorandum, Col. E. C. Cutler, MC,to Col. J. C. Kimbrough, MC, 18 Sept. 1942, subject:Teaching Exercises With the First Division at Tidworth Barracks, Sept. 16, 1942.(Copies to Colonel Hawley, Colonel Stanley, and Colonel Middleton.)
40
in a memo today practically stating that, ifan Americannewspaper knew 17,000 picked men were going intobattle with simple things lacking which every American hospital had, thenwe all would be fixed.
This was the beginning of extensive medical supply operations inthe European theater in which many individuals participated following the realizationthat elementsof the U.S. Army were not adequately provided with modern medical equipment and supplies.
Inter-Allied Conferences on War Medicine
While Colonel Cutler and the consultants were planning the teaching exercises for the 1st Infantry Division, a secretary in another office of the headquarters was transcribing a telephone message from N. B. Parkinson, Director, Home Division of the British Council. Mr. Parkinson`s message stated that the British Medical Association had recently been in touch with the British Council and had expressed their earnest desire that the Association do all it could to assist members of the medical professions of the allied nations now resident in England and to insure that British members of the profession benefit from the presence of so many medical persons from all over the world. To further this end, the British Medical Association was willing to provide certain facilities and privileges under its control. It had been suggested that an association or society be formed which would serve to bring together medical men of the allied nations and promote a sense of professional unity among them. Before any further steps were taken, Mr. Parkinson was suggesting that leading members of the various national groups meet to express their views at the offices of the British Council.
Colonel Cutler had been aware of the fact that the Belgianshad initially attempted to form such an inter-Allied medical organization. Itwas brought to his attention in Colonel Spruit`s office when he had firstarrived in London, but Colonel Cutler had since given it little thought. Thistime, he and Colonel Kimbrough were selected to attend the proposedmeeting to represent the American point of view. The meeting was held asscheduled at the offices of the British Council on 23 September 1942. Inattendance were representatives from Canada, Belgium, the Free French,Czechoslovakia, Norway, and The Netherlands in addition to the British andAmerican delegates. The Poles could not come but telephoned expressing their interest.
Most of the participants at the meeting expressed a desireto have joint meetings, but therewas little enthusiasm for a separate dues-paying association with a name, officer`s,journal, and permanentfixtures. The Belgians reported that an organization had already been formed,under the honorary presidency of Mr. Biddle and the active presidency of General Hood,whichwas to hold its first open meeting in December. These deliberations were duly reported back totheBritish Medical Association by theBritish Council, but the matter again fell through. Apparently, the Britishthought a club and home were desired-the Belgians and Czechoslovaks had said so-and,in their usually astute way, questioned whether such an affair could beproperly financed.
41
Curiously enough, it was at a meeting of the editorial board ofthe British Journal of Surgery, on 12 October 1942, that the matter wasagainbrought up. (Colonel Cutler had accepted the invitation to become a member of thisboard, a signal honor, since previously the journal was concernedonly with publishing efforts from British surgeons.) The chairman of the board, Prof. George Gask, tookkeen interest in theproposed inter-Allied medical meetings. He arranged for ColonelCutler to meet with Maj. Gen. H. L. (later Sir Henry) Tidy, President,Royal Society of Medicine, on Wednesday, 21 October. The HonorarySecretary, Mr. Broster, and Sir Geoffrey Edwards, Secretary, also attended themeeting. The officers of the Royal Society of Medicine were most willing and pleased to beable to sponsor such military medical meetings of the Allies.
Colonel Cutler was greatly encouraged by the outcome of this conference. Formerly,attempts to hold medical meetings of the Allies had been thwarted. Thesemeetings now had a sponsor with the facilities and organizationto see the desires through to fruition. "I think I kicked it on its way,"he noted, "and I believethese meetings will serve not only to educate us now for the war, but willbe a bridging force for all the Allies, helping us to organize the worldand civilization which is to follow."
On Tuesday of the following week, 27 October 1942, a meeting washeld at the Royal Society of Medicine attended by representatives of all His Majesty`s servicesand representatives fromeach of the Allied countries. It was passed unanimously that monthly meetingsshould be held at the Royal Society of Medicine, under the sponsorship of this organization, towhich members from all theAllied forces would go. The Directors General of His Majesty`s medicalservices promised every assistance in the way of speakers and advice.
To carry the story a little further, the first meeting washeld auspiciously enough on 7 December 1942, the first anniversary of the entry ofthe United States into the war. There was alarge attendance, and comments were very favorable. Colonel Cutler thought the meetingwas only fair and would have to bebetter in the future. Towards this end, he had already persuaded GeneralTidy to set up an executive committee to lend closer direction to program andcoordinating activities. The meetings continued to improve and were held in seriesthroughout the years of the war. Medical officers of the U.S.Army contributed in no small measure to the success of the meetings.Selected lectures from the entire series were published after the warunder the honorary editorship of General Tidy.16
Operation TORCH: Hopes for an Early End
The attack on North Africa, to those in England, came off quietly and with some surprise insofar as the actual timing was concerned (fig. 14). True, the consultants had been called upon for advice on specific, limited aspects, but
16Tidy, Sir Henry (Ed.). Inter-AlliedConferences on War Medicine, 1942-1945, Convened by the Royal Society ofMedicine. New York, Toronto, London: Staples Press, Ltd., 1947.
42
they had neither been taken into complete confidence on theplans nor asked to participate to the extent that they might have been able.Colonel Cutler, himself, asked on at least three separate occasions forpermission to go with the force from England but was turned down. Unless heacquired experience in an actual combat area soon, he reasoned, then his wordswould eventually become empty and devoid of any worth, at least so far as thiswar was concerned.
As it was, Colonel Cutler realized that the attack was ononly after some of the combat elements in England had pulled out of theirstations for the staging areas. When news of the assault on 8 November 1942arrived (fig. 15), it was through the public press, and it was good news. Thenews led to considerable optimism, which, as it eventually turned out,was rather premature. But, at the moment, Colonel Cutler was quite elated.Writing on 9 November, he said:
All the time the good news was waiting and tonight it isstill better. It looks as ifall Africa would shortly fall. This is the big thingwe`ve been so secret about. Now it has really come off well. What next,Italy? Or an attack here by spring? It`s the turn of the war. Victory andrelease all in the air. Home seems near us and smilesshould grace our faces. I once said 5 years andthought of 3. But now, who can deny us hope that the ETO will be over within ayear?
The Surgeon General Visits the European Theater
The first visit to the European theater from anybody in theOffice of The Surgeon General which concerned the chief consultant in surgerywas that of The Surgeon General, Maj. Gen. James C. Magee (fig. 16). GeneralMagee
43
FIGURE 15.-The beach at Saint-Leu, Algeria, North Africa, on D-day, 8 November 1942.
arrived at 9 North Audley Street on 20 November 1942,accompanied by General Hawley. Appointments were made by Colonel Spruit forGeneral Magee to meet with the medical heads of the British services, andpreliminary discussions were held with General Hawley and Colonel Spruit.
At 1500 hours, 21 November, a business meeting and dinnerwere held for The Surgeon General at Thurlestaine Hall, Hotel Cheltenham.Guests were the four base section surgeons, the V Corps surgeon, and from the Army Air Forces, Colonel Grow, Col. Harry G. Armstrong, MC, Col. Edward J.Tracy, MC, and Colonel Wright. As expected, The Surgeon General`s chiefinterest in this trip was to iron out difficulties and to arbitrate differences in opinion for providing medicalsupport to Air Force units. With no warning, Colonel Cutler was the firstto be asked for an opinion. "I was pretty noncommittal," he laterwrote, "except for saying Air Force was sustaining first casualtiesand, therefore, the men needed the first help." The problems were brought wellinto the open, however, and Colonel Cutler thought themeeting was very good. The aspects of the discussions which concerned Colonel Cutler werethe desires by the Army Air Forces for recognition and support of the Air Force medicalschool, better equipment at AirForce stations, hospitals to care for casualties at the operationalairfields, and consultants, or their equivalent, within the Air Forcemedical organization in England.
The following day, Sunday, 22 November, Colonel Cutlermotored to "Pinetree," Eighth Air Force headquarters at HighWycombe, with Colonel
44
Grow, Colonel Armstrong, and Colonel Wright. "To myconsternation," Colonel Cutler found, "Grow was very bitter. Said the Medical Corps wouldn`t helphim. He hereafter wouldn`t help them.It may have been `a show` for Daddy. I played it safe." Upon reaching"Pinetree," the party lunched with Maj. Gen. Ira C. Eaker, Commanding General,Eighth Air Force. After the luncheon, Colonel Cutlerdiscussed possible means of satisfying Air Force desires but found Colonel Grownot easily convinced that a happy and cordial relation with the GroundForces could be established.17
Colonel Cutler proposed that, if the Air Forces desiredconsultants, they would be most welcome to serve within the frameworkof the theater consultant plan and that the provisional school whichwas now being carried on could be integrated into a school for medicalofficers in general, as distinct froma school just for the Army Air Forces. The Eighth Air Force also desiredthat a separate treatment facility be established for the care of aircrews with flying fatigue orthreatened with actual neurosis. Colonel Cutler suggested that Colonel Middletonand Colonel Thompson, him whose hands this responsibility lay, would be most willing to cooperatein this project.
"The answer to all this," Colonel Cutlerreported, "depends upon whether the Air Force will accept the intimaterelation to the Professional Services
17Letter, Col. E. C. Cutler, MC, toCol. J. C. Kimbrough, MC, 27 Nov. 1942, subject: Relations of Your Officeto Air Force.
45
as outlined above, but until such time as we are instructednot to serve the Air Force it appearsto me that we should lend every effort to keep together the entire medicalservice."
During the next 2 weeks of GeneralMagee`s visit, it was Colonel Cutler`s privilege to accompany The SurgeonGeneral on some of his visits to nearly all the major American medicalinstallations in the United Kingdom and many of theBritish installations as well. In talks with General Magee, Colonel Cutler hadthe opportunity to approach him about thefield dressing in the individual soldier`s first aid packet. This was a matter towhich Colonel Cutler had given considerable thought. Colonel Cutler had beenable to obtain much information on the efficacy and requirements of fielddressingsas a result of an invitation to participate in the British First Field and Shell DressingCommittee. The British committee had decided that their dressing had to belarger and had recommended that it be put in a cellophane packet. Colonel Cutlerbelieved that the U.S. Army field dressing, which was still packed in a metalcontainer, could also profit by similar modifications and advised The SurgeonGeneral so. He recommended that further studies be made under The SurgeonGeneral`s direction in the Zone of Interior to see whether a cellophanepackaging could not replace the metal container and the bandageitself be made larger. The Surgeon General wasgiven a sample of the new British packet to take back with him.18
Colonel Cutler was also able to ask General Magee for anassistant. He informed General Magee that such increasing needs for consultants as going intoEMS and RAF hospitals at night as well as during the day made it impossible forColonel Cutler to fulfill completely his obligations in such matters because ofother and more weighty engagements which could not be broken. He asked that Maj. (laterLt. Col.) Ambrose H. Storck, MC,in Brig. Gen. Charles C. Hillman`s office be selected for this position asassistant to the Chief Consultant in Surgery in the European theater. GeneralMagee, in return, suggested that it would be nice if the European theater wouldinvite Col. (later Brig. Gen.) Fred W. Rankin, MC, Chief Consultant in Surgeryin the Office of The Surgeon General, to visit the theater.19
In a more formal vein, Colonel Middleton was given theproject of collecting answers from the Professional Services Division to a list of questionswhich The Surgeon General had brought with him from members of his office.Questions which concerned the Chief Consultant in Surgeryand his answers to Colonel Middleton on this occasion ineffect provided a r?sum? of consultant activities to date. They were:
1. Education and training.
Many courses in medico-military subjects arebeing given to U.S. Medical Department officers to both those in the combat [units] and * * * those in the station,evacuation, and general hospitals, as well as to the Air Force.
18Memorandum, Col. E. C.Cutler, MC, to Col. J. C. Kimbrough, MC, 27 Nov. 1942, subject: FirstAid Packet for the American Soldier.
19Letter, Col. E. C. Cutler, MC, to Director of Professional Services, 30 Nov.1942, subject: Additional Consultant in General Surgical Field.
46
As a part of the above general courses,special attention hasbeen paid to the proper treatment of the wounds in general, largely by ColonelCutler, and wounds in special surgical fields by the senior consultants inorthopedic surgery, neurological surgery, maxillo-facial and plasticsurgery and burns, ophthalmology, anesthesia, thoracicsurgery, and transfusion and shock. These surgicalcourses have been given in turn at the Air Forceschool, to the medical officers of two American divisions, to groups of doctorsin our base section areas, and to individual hospital assemblages.
2. Activities of surgical consultants.
All of the surgical consultants have the closestrelationships with their opposite members in the British military set-up,including Army, Navy and Air Force, The Chief Consultant in Surgery attends themeeting of the British Surgical Consultant Group each month, and the meeting ofthe Director General of Medical Services, RAMC. He has a similar relationship with the EMS, RAF, and Royal Navy. Through this liaisonwe havebeen permitted to enter and study all of the organizations of the BritishServices, and have thereby profited greatly.
Another activity of the consultants has been to aid inestablishing the high level of professional work in all of the Americanhospitals-station, evacuation or general, in ETOUSA. This has meant constantvisits to institutions, the stimulation of ward rounds, clinical meetings, andassistance in acquiring the necessary material for proper professional endeavour.This activity goes on constantly, and I am sure that much benefit has accrued fromthis intimate contact of the Consultant Group with thehospital setup.
A special field might be said to be ourrelation with the American Air Force. We understandthat we serve them as well as the Ground Forces, and we have been happy toteach in their schools and to look after their wounded as they enter ourhospitals.
An unexpected labor to the Consultant Group has been theconstant demands made upon them to assist in straightening out the medicalsupply situation in ETOUSA. A tremendous amount of labor and time have had to gointo supplying proper lists for the medical requirements of both divisions andstatic hospitals, and a constant liaison has had to be established with thosewho purchased British medical material for the use of the American Forces.
3. Unit assemblages.
The answer to this is complicated, for the Consultant Groupis not entirely familiar with unit assemblages. It should be said, however,that we have been instructed by General Hawley to go over the arrangementsand material in medical chests Nos. 1 and 2 and delete certain items and addothers that are necessary * * *. Webelieve that there should be anothercomplete revision, by a group familiar with this matter, of materialrequired in [an] active theater of war * * *. It appears that some of the material beingsent, which was of value twenty years ago, is now out-moded.
4. Dried serum plasma.
The situation * * * is as follows. On hand Nov. 15-4,224units. Issued in September-10,238 units. Issued in October-2,735 units. Weneed more plasma immediately, in view of the fact that combat forces areinstructed to take such material with them.
5. Intravenous fluids.
The answer * * * is simple. If hospitals were suppliedwithadequate stills it would be unwise to send overbottled intravenous fluids. Stills, however, cannot be acquired in GreatBritain, at this time, in sufficient number and of the type desired. They shouldtherefore be sent with a high priority rating.
6. Physical standards for induction.
From visits to all of our hospitals, it is apparent to theSurgical Group that a considerable number of physically unfit enlisted men arearriving in ETOUSA. I have personally seen two individuals in a single hospitalwith large defects in their skulls produced by terrificaccidents in youth, and I have seen large scrotal hernias in individuals takeninto the Army; also two severe cases of Dupuytren`s contracture of the hand.Another matter commented upon by Colonel Diveley is the failure, apparently, toexamine the feet properlybefore induction.
47
7. Weekly medical newsletter from the Office of The SurgeonGeneral.
It is my impression that a weekly medical newsletter would behighly acceptable. Note that the Canadians do this, and do it very well.Undoubtedly a copy of their Newsletter is available from General Hillman.20
There were a few sidelightswhich appeared during General Magee`s visit whichColonel Cutler found inviting to reflect upon but which were quite serious matters at the time oftheir occurrence, particularly to thoseinvolved. For example, he recorded:
But now this curious story: Yesterday was Thanksgiving. I hadworked hard and hadn`t paid any attention to aninvitation by Lady Harding at St. James`s Palace. Colonel Stanleysaw me and asked why I was here [Cheltenham] when the King had sentfor me. He said I couldn`t refuse and had to go. So I worked all day,forewent lunch to get more done, and left by car at 2:00 PM for London.By then I had found out that Harding was the King`s secretary. So I reportedto C. Spruit and found General Hawley there just in from Buckingham Palace. Helooked sick and promised to let Bill [Colonel Middleton] examine him tomorrow(i.e., today, which has been done, and he goes in hospital, 2d GH, tomorrow).Then C. S. [Charles Spruit] and I went to St. James`s. Great crush of people,all tired, and I was hungry.
Unfortunately, the Royalty were unable to appear, and the twocolonels later found it necessary to search elsewhere for food, but it was aunique honor to have been invited to the Palace and a privilege to have met theimportant personages of the era who were there. Concerning General Hawley,Colonel Cutler noted on a visit to the 2d General Hospital, 30 November 1942:
Came here [London] yesterday,stopping at the 2d Generalto see General Hawley and to get my X-rays. The former is better, but his laryngitis is bad and histemper is bad; the latter, beautiful and I have hardly coughed recently. Hadlong discussion re sitting of party for General Magee. There will be 13 withECC, so I was out.
Avonmouth, Disembarkation of Hospital Ship No. 38, the Newfoundland
With the attack on North Africa, it was inevitable that casualties would sooner or later arrive in England. Colonel Kimbrough and Colonel Cutler journeyed to Avonmouth on the English south coast on 17 December 1942, to see one of the first shiploads disembark. Colonel Cutler`s account follows:
Arrived in time to see her dock. Itwas the Newfoundland of Liverpool; all white with red crosses anda black "38" on her side (fig. 17). Could see American soldiers at therail as she came in. Then we boarded. We were shown about by the RAMC majorin charge. The men were in swivel beds that were set like tables in yachts sothat when the boat rolled, the bed did not. They, about 400, were packedpretty close (fig. 18). Saw the sickest eight; just had morphine, so werecomfortable. About one-half were Americans andone-half British. There were a few British marines and a handful of prisoners.Just through a stormy trip back. The unloading went on smoothly. There wereplenty of ambulances; separate ones from the Royal Navy for the Marines! Allother wounded went to the 298th GH (Michigan). The British were later sent totheir own hospitals. We went to the 298th and had a nice chat with ColonelKirksey and Walter Maddock. Am going to get them three teams from the 3dAuxiliary Surgical Group tomorrow. (Unit just in atOxford.) Will set up a questionnaire to study effects of sulfonamides.
20Letter, Col. E. C. Cutler, MC, to Lt. Col. W.S.Middleton, MC, 20 Nov. 1942, subject: Memo forGeneral Magee.
48
FIGURE 17.-Hospital Ship No. 38, the Newfoundland of Liverpool.
FIGURE 18.-The interior of the Newfoundland.
49
Upon returning to Cheltenham, ColonelCutler reported to the Director of Professional Services, as follows:
The most interesting phase was the visit tothe ward containing seriously wounded or sick people. I talked to six seriouslywounded Americans. My questions, other than their general condition to cheer themup, wereobjected solely as to whether they had taken the sulfonamides which eachAmerican soldier presumably carries on his person. Not one individualhad either taken tablets by mouth or dusted the powder into his wounds. Theyseemed to know what these medicines were for but had not bothered touse them, partly because in each case theindividual was apparently unconscious following the accident, or spitting up bloodif injuredin the chest, or was so near the first aid man or first aid post [aidstation] that he preferred to have the lattergive him the medicine. The individuals I talked to came from the 16th and 18th Infantry[Regiments] and 39th Engineers.
This lack of our men taking sulfonamidesbrings upthe problem repeatedly put to the British, that it is not wise or intelligentto tie up such a vast amount of a precious drugin packets for soldiers when the drug can be better and more securely given bythe first aidposts. The only criticism of this British attitude is that there may be a longinterval between being wounded and reaching afirst aid post.
The arrival of these American casualties intheUnited Kingdom gives us an opportunity to putout a questionnaire and study thematter of (a) whether sulfonamides were used [and] (b) the interval after beingwounded and the use ofsulfonamides [in order] to check on their value by study of the conditions of thewounds now, since many of of the wounds were sealed up in plaster almost fromthe beginning. Thus, the danger of secondary infection dismissed, wemay be able to arrive at some fairly satisfactory scientific data.21
3d Auxiliary Surgical Group
On 18 December, the day following the visit to Avonmouth, Colonel Cutler, in the company of Colonel Kimbrough, hastened to visit the 3d Auxiliary Surgical Group, newly arrived at Cowley Barracks, Oxford, from a temporary station in Scotland. A pleasant meeting was held with the group`s commanding officer, Lt. Col. (later Col.) John F. Blatt, MC. The problem was how to use the officers of the group in gainful pursuits in order to maintain their morale and spirits at as high a level as possible. The visitors explained how these officers could be used in hospitals, both British and American, and sent to American and British schools. Arrangements were made for the immediate dispatch of four teams to the 298th General Hospital and for Capt. (later Maj.) Benjamin R. Reiter, MC, to initiate the sulfonamide study. Colonel Cutler was particularly impressed by the high professional caliber of the group as a whole. He noted: "Some were among the best surgeons in the United States, and it is a great credit to those who assembled such a group that so many A-1 surgeons could be gotten together."22
It was just about Christmas Eve when General Hawley andColonel Cutler conferred further on utilization of teams from the 3d AuxiliarySurgical Group. General Hawley decided to offer to the British up to 20 general surgicalteams from the group foruse with British Forces in North Africa. Both Gen-
21Letter, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough,MC, 18 Dec. 1942, subject: Visit to Hospital Ship Disembarkation, Avonmouth, Dec. 17, 1942.
22Memorandum, Col. E. C. Cutler, MC, 19 Dec. 1942, subject: Visit toNo. 3 Auxilliary Surgical Group, Cowley Barracks, Oxford, 18 Dec.1942.
50
eral Hawley and Colonel Cutler were aware of the acute shortage of doctors inthe British Army and knew that, in characteristic fashion, the British had tightened their belts and had notasked the United States for additional medical personnel, even though thispossibility had been suggested. They realized, too, that the experience whichthese teams might gain would be most valuable. It was Christmas Eve whenColonel Cutler approached Brigadier Anderson, chief surgical consultant, RAMC,on the loan of these 20 surgical teams to the British Army.
On 28 December, Brigadier Anderson telephoned Colonel Cutler and relayedGeneral Hood`s message accepting this offer. The Director General was verygrateful and most complimentary. Colonel Blatt also happened to visit GeneralHawley`s office on this day, and he was fully oriented on the forthcomingdispatch of these teams to Africa.
The following day, Colonel Cutler returned to Cowley Barracks and gave thegroup an hour`s talk on professional matters-their job at the front, theimportance of debridement, their equipment, history of medical activities in thetheater to date, and so forth. At lunch with the group, Colonel Cutler wasdismayed to find a strong anti-British sentiment among members of the group."Made me mad," he later wrote, "* * * laid it down a bit, as gentlyas possible. Told them it`sno way to begin a war by criticizing a generous ally."
The administrative difficulties in providing these teams for the Britishproved most formidable, and final arrangements had to be worked out personallyby General Hawley and Colonel Spruit with higher echelons of command.
Summary of Miscellaneous Activities During 1942
In his annual report of activities for 1942, Colonel Cutler stated:
The multitudinous duties which confront a consultant group are hard tocategorize, for, with our broad instructions to seethat each individual soldier has the best medical orsurgical therapy possible under the conditions imposed in this theater, wenaturally cut across all the usual boundaries of Army organization.
Thus, while the highlights of Colonel Cutler`s first year in the Europeantheater, 1942, have been briefly described in the foregoing pages, a stillbriefer word in passing must be devoted to some of his other multifariousactivities in order to provide a faithful account.
American women doctors in England.-For various administrative andpolitical reasons resulting from the war, General Hawley asked Colonel Cutler toinvestigate the status of women doctors in England of American citizenship andto look into the possibility of their employment as contract surgeons in theU.S. Army. In conferences with Sir Francis Fraser, director, EMS, and Dr.Murchie, the EMS personnel officer, Colonel Cutler was able to determine thatmost of these women doctors were advantageously employed by the British in theirEMS installations. One was a major in the RAMC, Maj. Barbara
51
Stimson, cousin of the U.S. Secretary of War. The women were happy where they were and did notwant to become contract surgeons,especially since, as they later learned, the pay was less than that beingreceived from the British. What was required was a mechanism for theircommissioning in the U.S. Army Medical Corps. Eventually, after many conferences andconsiderable give-and-take by all concerned, most of the women were made contract surgeonsand loaned to the British EMS to continue in their jobs. Major Stimson remained in the RAMCand was sentto an active British theater, the Middle East. Colonel Cutler`s final comment on this problemwas:
Barbara Stimson back from talk withher cousin HLS [Henry L. Stimson, Secretary of War] and Somervell [Lt. Gen.Brehon B. Somervell, Commanding General, SOS]. Guess women will get in MedicalCorps soon.I have long advised they be taken in gracefully before they are put inagainst wishes of the Medical Corps. They will get in forsure.
Acting senior consultants.-Senior consultants forthe theater in radiology and otolaryngology were expected momentarily, but,in the interim, individuals qualified and physically on duty in England had to be designated to act insuch capacities as the needs arose. Inaccordance with the policy of grouping all professional medical specialtiesunder the Chief Consultant in Medicine or the Chief Consultant in Surgery,radiology had been designated to come under the purview of Colonel Cutler. Accordingly, Lt. Col. Robert P.Ball, MC, and Capt. (later Maj.)Edmond P. Fowler, Jr., MC, both of the 2d General Hospital, wereappointed to act as senior consultants in radiology and otolaryngology,respectively, in addition to their regular duties.
British Medical Research Council.-Attendance atand membership on the various committees of the British Medical Research Council "** * have been extraordinarily enlightening * * *. Here onesees science applied to this devastating matter of war in an extraordinarilyintelligent manner. * * * The writer is satisfied that great progress has been made bythe intelligent few who sit with the British Medical Research Council."23
In particular, Colonel Cutler found attendance at meetings ofthe War Wounds Committee and its subcommittees most profitable.It was through this committee that he effected the promulgation of instructions tothe British Army Medical Service and the EMS to use tetanustoxoid prophylactic doses rather than antitoxin in the prevention of tetanus inwounded or injured American soldiers. The British habitually used antitoxinfor their wounded or injured soldiers in danger of tetanus infection. Whenantitoxin had been used on American soldiers, some serious reactions had occurred.Conversely,Colonel Cutler was able to have a circularletter published by the Chief Surgeon, ETOUSA, which instructed American medicalunits treating British soldiers on the proper prophylactic dose of antitoxin to begiven.
Return postcard (surgical).-From his World War I days,and from what he had seen so far in World War II, ColonelCutler realized that there
23See footnote 2, p. 20.
52
was very little interchange of information between the first echelons ofmedical service and those conducting definitive treatment in the rear. Yet, itwas important thatthere be a constant flow of information between those first treating apatient and those who saw him later.Colonel Cutler had mentioned this need to the Chief Surgeon at one of theirfirst conferences and had received his approval to design and have printed apostcard form for this purpose.
When the card was printed, the only casualties occurring in Englandwere among operational aircrews. Medical officers in the Eighth Air Force, whenasked, showed a keen desire to give the return postcard system a trial use.Accordingly, Circular Letter No. 79 was issued on 17 December 1942 by the Chief Surgeon. A portion of itfollows:
Follow-up cards (ETOUSAMD Form 303) are being distributed tounit surgeons of the 8th Air Force. These are pre-addressed cards designed forthe purpose of transmitting back to the medical officer who first treats aninjury or battle casualty information concerning the subsequent progress of the case.
The medical officer giving immediate treatment at thestation dispensary will print his name, grade, and A.P.O. number onthe address side of the card. * ** and the card * * * will accompany injured and wounded patients tohospital.
The medical officer treating such cases at the receivinghospital will complete the reverse side of the card as soon as immediate therapy hasbeen instituted, sign, and mail [it] * * *. A card will not be held athospitals until completion of the case.
When ground hostilities were later engaged in on the Continent, this directivewas modified to permit useof the card by all units initially treating casualties. This simple systemworked with considerable success.
Special studies.-In addition to the sulfonamide studyinitiated with the first receipt ofcasualties from North Africa, limited studies in other areas were alsobegun.
The problem of fatigue in long training marches was beinginvestigated by the 29th Infantry Division. Bloodpressure, pulse rate, and blood sugar levels before, during, and after thetraining efforts were being recorded in order to obtain reliable data upon which could be based proper decisions as tothe optimum amount of physicaleffort which could be expended without an inordinate increase infatigue and morbidity.
Maj. (later Lt. Col.) Rudolph N. Schullinger, MC, 2d GeneralHospital, at his own request, was permitted to procure penicillin in smallamounts from Prof. Howard E. Florey at Oxford and to experimenton its clinical application.
The consultants were asked to evaluate the efficacy of gasgangrene antitoxin and to make recommendations for its use in the theater.In this case, no actual experimentation could be initiated at the time,but expert opinion in the available literature and that obtained from interviewswith members of the Allied forces and the British Medical Research Councilindicated no conclusive results as to its efficacy. Since, however, there wereimplications in laboratory experiments that the antitoxin mightassist in preventing the development of infection,Colonel Cutler recommended that a small stock be kept in the medicalsupply depots where it would be available to surgeons who wished tomake use of it or who would like to make special studies on its efficacy and use. Herecom-
53
mended that gas gangrene antiserum not be included as a regularsupply item for all medical installations at this time.24
Journals, books, and headquarters` library - While theneed for books, journals, and libraries was universallyaccepted, there was no professional library at the Cheltenham headquarters, andthe sets of basic texts and journals for hospitals were lost in the depots.Colonel Cutler continually pressed the issueuntil the hospital sets were found and could be distributed, and one of the lastthings he did in 1942 was to appoint himself as librarianinorder to establish a professional medical library at the headquarters inCheltenham. A system wasinitiated whereby hospitals would get copies ofjournals routinely and reserve sets wouldbe maintained for the hospitals which were later to arrivein the theater.
On visiting the British libraries, particularly those ofthe Royal Society of Medicine and the Royal College of Surgeons, it wasmost disconcerting to Colonel Cutler to find that American medical journals werearriving in England badly mutilated by the American censors. He took it uponhimself to invite the attention of the War Department to this deplorablesituation. He stated:
* * * Copies of these journals come to theChief Surgeon`s Office uncensored, andthe Division of Professional Services * * * has never been ableto find any article in these journals in which censorship could in any way affectthe war * * * The extent to which such censorshipis carried out is out of reason as well as robbing American doctors in thiscountry of the abilityto keep abreast of modern medicine.
It is recommended that the War Department take steps tosee that American medical journals now going to the United Kingdom for use in publiclibraries * * * be uncensored. Thousands of these journals are freely distributedin America where their contents can easily be studied. It seems unnecessary tocensor these journals because they travel across the Atlantic to an alliednation with whom we should have the most cordial and friendly relations.25
Medical field service school.-Asindicated in the preceding narrative, there were many educational opportunities affordedthe medical officer in the United Kingdom. Most of the contacts with theteaching institutions had been established before Colonel Cutler`s arrival inEngland. After his arrival, hehad continued to supervise the input of surgical officers to the various coursesand had himself, or in cooperation with his senior consultants, created othertraining opportunities in British schools and hospitals and in certain of theU.S. Army hospitals. The instruction being received by officers attending thesecourses was of great value in keeping up and developing skills in certainaspects of medicine and surgery. There was needed, however, a centralized andcoordinated instruction of the civilian doctor in military uniform as to themany duties expected of him in which he had little or no prior experience. Itwas also necessary to indoctrinate him on the accepted, basic tenets of medical
24Memorandum, Col. E. C. Cutler, MC, to Col. J. C. Kimbrough, MC, 1 Sept 1942, subject: Gas Gangrene Anti-Toxin.
25Letter, Col. E. C. Cutler, MC,to the War Department, 26 Dec. 1942, subject: The Censoring of Medical Journals Now Being Forwarded to Libraries of MedicalInstallations in Great Britain.
54
and surgical practice in the theater inorder to standardize the treatment of the more commonconditions found as a result of military service or injuries incurred in combat.This obvious need was being met by plans to establish a medicalfield service school in conjunction with the SOSAmerican School Center at Shrivenham, Berkshire.
Colonel Cutler had started work on the curriculum andcourses of study for this school assoon as he had oriented himself in the theater. By earlySeptember, he had completed thecourses of study in the surgical topics to be covered. Hethen discussed them and arranged for their incorporation into the overallcurriculum with Lt. Col. George D. Newton, MC, who was initially in charge of establishingthe school at Shrivenham.
Observations at Year`s End
By the end of 1942, most of the positions for which senior consultants were contemplated had been filled. The many duties and responsibilities of a consultant had gradually evolved through his day-to-day commerce with fellow officers in the headquarters and in the field and through his concern in the medical matters of the theater. It was possible, at this time, to reflect on the activities of the year and to make recommendations which only the knowledge gained through experience could make possible.
Colonel Cutler had the following thoughts for The SurgeonGeneral:
The memorandum has been on my desk threemonths;it has been fully considered by mostof the present Consultant Group who give it their warm approval. It is presented withoutbias or criticism as a piece of constructive thinkingwhich has arisen during the day`s work. To myway of thinking, it is the most important contribution I can make in mypresent office.
* * * * * *
In this thinking, observation of and discussionwithour British and Canadian colleagues have beenhelpful for medical and surgical problems are universal and do not belong tonationalities. Always in these discussions the remark arises in those who arenot members of a Regular Army Medical Corps but who have left their civilianpositions to help as best they can at this time, "I wish we couldhave worked on these problems in peace time!"
And this desire to have played a role in peace time hasmany beginnings. It arises in part from the findings that the Regular Corps are not on a whole, though there be brilliant exceptions, as much abreast of modern medical and surgical practice as the civilian profession is. It arises because what to the military doctor is an essential apparatus or medication long since was dropped from use in medical practice. And it arises because the civilian doctor finds he thinks and talks even a little different medical philosophy from his regular colleague and wishes they had had more in common in the past.
I believe that were an arrangementset up with a permanent Advisor or Consultant Group established as a part of the Army MedicalDepartment there would result a steady flow of benefit to our Army Medical Corps. Such a Boardwouldbring an immediate close relationship between civilian doctors and theMedical Corps. Each would be led to the other`s domain. Each would attendthe medical meetings of the other group. The interest of the public as a wholewould be aroused and once again the Army medical man would be the real and actual colleague of his civilian prototype.
This would be especially true if amethod of appointment to this Board was utilized which [would] put the responsibility forappointment on the leading medical and surgical
55
societies in the USA * * *. This would putthese leading societies squarely behindthe Medical Department of the U.S. Army, for having assumed responsibility foran appointment the associations would inevitably follow through with anabiding interest. This alone would be a great step forward. * * *
Such a Board with the great clinical societies squarelybehind it would result in a new attitudeof civilian doctors to military doctors. The two would closely approach eachother, the civilian group would feed personnel into the Army group. Theadvantage from common meeting grounds in each other`s associations andsocieties would have incalculable benefits. And all the time the ConsultantGroup could be kept working on medical supplies and methods for militarymovements. It is not proper to wait until we go to war to prepare to bring proper medical and surgicalrelief to our soldiers. We must be prepared always with material and methods. Wemustpractice lest we fail in our responsibility. What amount oflabor by a doctor can equal the offering to his country of an infantry man,an aviator, or any member of the fighting forces? There can be no demands uponhis time and skill in peace time along these lines thatour profession would not gladly give.
The fact that the British Army and the British Army havehad for years civilian consultants in times of peace and the role they now playand all benefits to their service which have flowed fromthis arrangement strengthens my temerity inoffering this memorandum.
In closing, Colonel Cutler made the following specificrecommendations:
1. That an Advisory or Consultant Board in the fields ofMedicine and Surgery be set up as a Permanent Part of the U.S. Army MedicalDepartment. This is to function in times of Peace as well as War.
2. That the Senior Consultants in Medicine and Surgery benominated respectively by the American Association of Physicians and theAmerican Surgical Association. That the Senior Consultants in the Medical andSurgical Specialties be nominated by their respective Associations or Societiesin the USA.
3. That confirmation of these nominations rest in the handsof the Surgeon General.
4. That this Board be a continuously active part of themedical department and be consulted freely and continuously on all matterspertaining to the fields covered by its membership.26
1943 TO EARLY 1944: PLANNING, BUILDING UP, AND WAITING
The First Half, 1943
The new year began with quite anexperience for the Chief Consultant in Surgery. He left by auto from Cheltenhamfor London on 3 January in order to attend the secondsession of the Inter-Allied Conferences on WarMedicine. "The high point of 3 January," he later reported to ColonelKimbrough, "was the unfortunate fact that mycar rolled over on me while driving from Cheltenham to Swindon. Fortunately, noone was hurt, but I reported the accident immediately by telephone and dispatchrider to Headquarters and to the Inter-Allied Medical Meeting." The meeting,however, was very successful, and many favorable comments were made on GeneralHawley`s presentation and upon that by Colonel Diveley, Senior Consultant inOrthopedic Surgery.
26Letter, Col, E. C. Cutler, MC,to the Chief Surgeon, ETOUSA, and The Surgeon General, 13 Jan.1943, subject: A Plan for an Advisory or Consultant Board inMedicine and Surgery as a Part of the US Army MD in Peaceas well as in War.
56
Problems of interpersonal relationships
Perhaps the one thing which characterized the life andpursuits of the consultants during the greater partof 1943 was their attempt to acclimatize themselves tothe military, professional, and social milieu which prevailed in the ChiefSurgeon`s Office and among its members. This constant effort to adjust was stillan undertone to thebustle of activity which marked later, more active periods in the life of thetheater and remained a matter of deep concern to the consultants evenafter the fight was won. It was, however, during this period of relative calm-along, frustrating period of waiting for the big things tohappen-that these interpersonal relationships arose as manifestproblems to the welfare of the individuals involved and to the overalleffort of the medical headquarters in the European theater.
Had Colonel Cutler been able to take the time to write thisconsultant story, as he called it, he undoubtedly would have placedgreat emphasis on this aspect of the total picture. His diary containedfrequent reminders to himself that he would have to write the consultant story someday, reminders inevitablytied in with these problems of interpersonal relations. Unfortunately-or for that matter,fortunately-Colonel Cutler was, rather, a man whopreferred to do something about these things, and, thus, they were neverwritten.
Briefly put, therewere two problem areas. One problem was the relationshipbetween the officers who had only recently come onactive duty and the officers of the Regular Establishment. The other problemconcerned the relationships of the consultants with one another. The officers inthe Chief Surgeon`s Office had come from manywalks of life with greatly varying backgrounds and experiences. The consultantswere men of outstanding ability and prominence who, to a great extent, owed their success to theirunique individuality. It was to be expected that a great amount of give andtake had to occur and that true communication was to be most difficult. In his annual report for 1942, ColonelCutler gave the following indication of the rising problem:
It is fairto state that on the whole the consultants have been patient and forgiving.We who are used to the fastwell-oiled machines of civilian life have often been irked at the slowness of action or certain hideboundregulations which do not seem to allow us to putthe best man in the right place,or the right material where it is necessary.Curiously, those who went through the last war in this group seem more patientthan those who did not. Perhaps we learnt somethingabout the Army in the last war. I am sure that all the consultants see eyeto eye in their main desire to render expert surgical and medical care toevery American soldier. Our own Chief of the Professional Services, and, inparticular, the Chief Surgeon, have been immensely patient with us, and weare happy to have this opportunity to give them our gratitude inreturn.
The weather, among other things, had been"rotten," rainy, cold and miserable, and Colonel Cutler, himself, hadfelt no better. He noticed that the morale of his consultants was particularlylow. On Sunday, 25 October, he recorded: "In the afternoon, the boys * * * gaveme hell; said we weren`t
57
getting anywhere and suggested it was partly myfault!" The following day, he wrote: "Staff meeting, 4:00 to5:00, and this time the boys took it out on JCK[Colonel Kimbrough]. I think they are wrong, petulant, and a bit childish.Anything they can do will help our soldiers, but they seem to feel that, unless it is a great big job,they might demeanthemselves by doing it." A few days later, he commented: "Iappreciate they have little to do that looks important, but why cannot they see thateveryday they serve their country, it is a privilege. Why mustall think: What are we doing? What do we get out ofit? Perhaps I`m just a stupid little boy, but anyway, I`m happy to serve."
After these really uncalled for, but understandable, outbursts oftemperament, Colonel Cutler tried, he believed successfully, to menddamaged feelings and arrive at a better understanding among the consultants. On occasions, however,things seemedto go from bad to worse.
The new year held no promise for improving the situation. On New Year`sDay, Colonel Cutler entered this rather despondent statement: "I seemto feel that we are all stagnating and going to seed, though we work steadily atorganization." And on 4 February he recorded:"All day I`ve felt bad, and now I feel just rotten. Discouraged with asystem which isn`t calculated to help a country at war,though that obviously is the reason for its existence.27
That this matter of interpersonal relationships was no trivial matter canwellbe attested by the attrition rate among the surgical consultants.During 1943, four of the senior consultants in surgeryreturned to the Zone of Interior for permanent change of assignment. Among reasons for theirreassignment was that of failing health brought on by theenvironment and circumstances under which they worked. One of the consultantswas seriously ill. Another had to be removed from the ProfessionalServices Division and given a division of his own in order for theService to obtain the maximum contribution that was expected and needed of himand that he was fully qualified to give. Apparently, from the written record, Colonel Cutlerwas able to contain himself remarkably well, considering the circumstances.
Another phase of this struggle, particularly as it might beapplicable to the professional personnel who made up the group of surgicalconsultants, was the personality of Colonel Cutler, himself.These statements made by General Hawley, however, could have applied to each ofthe other consultants as well. Speaking in retrospect ofColonel Cutler, he wrote the following:
* * * An innate honesty often compelled his professional judgments tobesevere; but, whenever possible, they were softened withpraise of other qualities. His high ideals and his devotion to duty made him, in his youngerand formative years, somewhat intolerant of mediocrity;and this occasionally brought him into conflict with others. But the years broughthim the wisdom that recognizes the impossibility of universal perfection, and
27"Much of this was written in late 1942and early 1943. At that time there was no firmwar plan for the E.T.O., and none of us knew what the eventual plan wouldbe. Plans were changed every week. The Air Force was still promising to`bomb Germany to her knees`; and certainly noground forces of the magnitude which wereassembled in late 1943 and in 1944 were then planned." (Letter, Paul R. Hawley, M.D., to Col. John Boyd Coates, Jr., MC, 25 Aug. 1958.)
58
a tolerance for human weakness that fell short only of abridging his highprinciples. He required a lot of knowing, did Elliott Cutler; and casualcontact rarely revealed the true fineness of his character.28
It may be said with considerable certainty thatColonel Cutler`s attitude on the position of generalsurgery vis-?-vis the specialized branches of surgery in war was an important factor in the conflict of ideas and aspirations among thesurgical consultants (pp. 167-168). In a broader sense,this attitude could be related to Colonel Cutler`s convictions on the surgeryof trauma and the position of those in the fields of the more limited surgicalspecialties.
During the doldrums which gripped the consultants in late October 1942,Colonel Cutler found it necessary to comment on the place of surgicalspecialists in an oversea theater. His memorandum, presented to Colonel Kimbrough,read, in part, as follows:
1. This is a careful and thorough study deserving the most thorough consideration. It reveals careful consideration of the problem not only of this surgicalspecialty but of all surgical specialties.
2. The basic consideration that specialists are undesirable in the forwardareas has my entire approval as does the corollary that the Surgeon General`sOffice, Washington, does not appreciate this since it iscommitted to a heavy training program, expensive andprobably of no value.
3. * * * I have myself always been of theopinion that this is a small island and that iftransportation is available (and safe) all who can no longer serve here shouldbe evacuated to the Zone of Interior immediately.
4. The final suggestion that narrow specialists be sent home is not formy decision but this may be said:
a. Any good citizen now here can be of immense service to his countryandreplacement is difficult.
b. Lt. Col. - hasbeen a major element in whatever value the Chief Surgeon may put upon hisSurgical Consultants because he is loyal, faithful, a hard worker and a man ofsound judgment.
c. Patience is a noble virtue and far transcends surgicalspecialization.29
The problem of traumatic surgery was not limited to the American forces in England. If anything, it was apparently a greater problemamong the British medical profession. The 2 February meeting ofEMS consultant advisers with the director, Sir Francis Fraser, brought outa heated argument on traumatic surgery and the orthopedists`claim to it. Colonel Cutler was asked to speak, and he did. As a result, he was asked to speak on the same subject at a forthcoming meeting oftheBritish Surgical Association, particularly with reference to the educationalsystem and the organization of a university teaching clinic. In his memorandumof 5 February 1943, reporting the meeting to Colonel Kimbrough, Colonel Cutlerstated:
In furtherance of the discussions that took place, it seemed to me obviousthat a psychological barrier has arisen between my general surgical colleaguesand my orthopedic
28Hawley, Paul R.: Obituary-Brigadier General Elliott Carr Cutler, Med. Res. U.S. Army, Mil. Surgeon,101: 351-352, October 1947.
29Memorandum, Col. E. C. Cutler, MC, to Col. J.C. Kimbrough, MC, 30 Oct. 1942, subject: Comment on Contribution of Lt.Col. -.
59
colleagues in Great Britain, in that the orthopedist has cometo think heis the only one who can look after trauma.Of course, this is ridiculous. He cannot care fortrauma of the head, nor carefor the ruptured kidney or ruptured spleen, nor wouldhe have any idea of what to do with nonperforating thoracic injury.
With the aforementioned memorandum of February 5, Colonel Cutlersubmitted also a memorandum which he had written, he stated, for his ownthinking after the last meeting of "this Committee." The substance ofthis memorandum was asfollows:
A disturbing finding in England is the professionalthinking, which seems general, that only orthopedic surgeons cantreat fractures and other forms of trauma. This seems to me to create a gravedanger in thebroad outlook of medicalpractice, both for the people we treat and for theprofession.
It creates immediatelya fundamental new specialty in that it carriesthe indication that every fracture incurred on thestreet must go to an orthopedic specialist. Such a fundamental breakdown ofmedical practice is just the sort of treatmentfor the people that is sure to give rise to new cults. * * * It is always our mistakes which giverise to new cults. Yetwe keep blaming the people for accepting them when we, the profession whichshould have the responsibilityof the people always atheart, have been responsible for the change.
A study of what happened in Britain reveals the following. With the great blitz,it was found that fractures were badly treated by the ordinary doctor. Therefore,those responsible ruled that only experts should treat fractures, and theythought that only orthopedic surgeons were experts in fractures.As a result, Britain now finds herself with onlya few people able to treat fractures, and the young man going out into the fieldwith the Army has no training in traumabecause at home such work has been not a part of his general surgical education but a specialty.What Britain should have done when the blow came was to have impressed upon the schools,the leaders, and the teachers that all doctors must learn adequately the care of trauma. Traumaconstitutes between 20 and 30 percent of every young doctor`s work, and theschools should drill the students completely in its handling and care. Had thisbeen done inEngland, she would now have thousands of people trained in trauma, and not just a pitiful handfulready. Itis the long run view which saves both people and the profession.
We can take a lesson from this-a lesson not taken in any schools from a criticalpoint of view-because we can benefit from the experience of our colleagues andour sister nation. We must now see thatevery young surgeon is taught trauma. If we do not do this, the foolishseparation already occurring in our country of a specialty for traumaticsurgeons, giving rise to even a society with this name, will jeopardize the care ofthe people, which is our complete responsibility.
Colonel Kimbrough forwarded both of the aforementioned memorandums to GeneralHawley who, in turn, had them copied andforwarded to General Hillman in the Office of The Surgeon General.
On 12 April, Colonel Cutler presented a talk to the British Consultants Club onorganization for sugical teaching clinics in the future. "Really an
60
attempt to hold specialization in place," he wrote. In a letter toColonel Kimbrough, dated 16 April 1943, he mentioned the following points madein his talk:
The real problem relates to the role to be played by specialists and thequestion is becoming more urgent whether there should be separate clinics orinstitutes for the specialties in medicine and surgery, or whether they shouldform part of a general clinic. The reasons for a general clinic seem to bemany, but in particular are included in the statement that a general clinic,especially where the patients are mixed in vast wards and not segregated in special wards, is best:
For the patient, since this permits simple cases which are recoverable to benext to more serious people whose outlook is hopeless.
For the students, and the Oath of Hippocrates states that every doctormust assist in educating students-since if the patients of all specialties, etc.mix in wards, the students` mental exercise in entering the ward is notsimplified as it is when he knows that all cases inthat ward are restricted to diseases in a certain domain.
For the doctor, for under these circumstances the specialists and thegeneral surgeons find themselves willy-nilly next to each other in an open warddiscussing their problems. If they run separate institutes then they are shut away from each other, andopen discussion and common problems [are] lost.
As for the Chief Surgeon,General Hawley announced on numerous occasions hispolicies on the use of specialists. Notes from aconference of 19 April 1943 show that General Hawleyemphasized the following points:
That it was not his policy to train specialists in the E.T.O.: that heconsidered a world war and a theatre of operations were neither the time nor theplace for medical education. He had found from experience in the last warthat General Practitioners, nervous of conditions when they returned home from the Army, had been anxiousto specialize. They had attended short courses in varied medical fields and hadthen considered themselves specialists. The outcome was that the men wereuseless in the theatre during the time of their so-called training; that thesoldier suffered and eventually the civilian population from"half-baked" specialists. General Hawley agreed * * * that somedifferentiation should be made concerning those men who were either in themidst of training or about to embark upon training as specialists when theyentered the Army.
Significant activities
The first half of 1943 found Colonel Cutler engaged in three primaryprojects. These were: (1) Preparations for participation in a British-Americansurgical mission to the U.S.S.R. (Union of SovietSocialist Republics), (2) providing a means for assuringthe supply of wholeblood in combat, and (3)creating mobile surgical units. These subjects will be discussed separately,but it should be noted here that they were interrelated in one respect. Asplans materialized for the trip to the U.S.S.R., it becameevident that the mission would leave sometime near midyear. There was a riskinvolved in making such an extended trip, particularlywhen plans called for visits to the combat zone. The risk, small as it may havebeen, could not be ignored. At the same time, it becameincreasingly evident to Colonel Cutler that there would have tobe a bountiful supply of whole blood in the combat zone and surgical units asfar forward as feasible in order to provide the optimum care for battlecasualties. The combination of these factors meant one thing to the Chief
61
Consultant in Surgery: He had to complete plans for theprovision 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 rigidlyadhered. Otherwise, the Chief Consultant in Surgery, in addition to carrying onwith the routines and programs already in effect, was directly involved in thefollowing noteworthy developments.
Change and expansion of consultant system - Colonel Diveley,Senior Consultant in Orthopedic Surgery, visited NATOUSA (the North AfricanTheater of Operations, U.S. Army), during the period 16 February to 19 March1943. Maj. (later Lt. Col.) William J. Stewart, MC, was appointed ActingConsultant in Orthopedic Surgery on 1 March 1943. Major Stewart remained on dutywith the theater consultant staff after Colonel Diveley`s return. His serviceswere most valuable because Colonel Diveley was required to give a great amountof 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 Brownwas 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 SeniorConsultant in Plastic and Maxillofacial Surgery and Burns in his stead. Lt. Col.Norton Canfield, MC, arrived from the Zone of Interior in January and wasappointed Senior Consultant in Otolaryngology on 1 July 1943.
During this period were initiated the beginnings of a systemof consultation at the local level. Colonel Cutler explained the basis of thesystem at a meeting of the Chief Surgeon`s Consultants` Committee on 30April 1943 as follows:
With the desire to be prepared for a maximumload in the near future, the surgical consultants are submitting * * * a list ofconsultants in general surgery and the surgical specialties which consist ofofficers now on the roster of our general hospitals but who are of suchprofessional 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 basesection; in some, less frequently; and in major fields for work for a consultantfrom each general hospital and evacuation hospital.
* * * The surgical Sub-Committee feels that bymaking this matter a permanent one now they may be protecting the patientssubsequently to come to this theater, ensuring them adequate surgical care.
General Hawley approved of the idea wholeheartedly and urgedthat more than the number presently necessary be appointed to plan for thefuture and to assure the availability of an alternate consultant in the eventthe regularly designated consultant could not answer a call.
Another change which occurred late in this period was areorganization of the theater command structure which involved the establishmentof base commands and a change in the internal organization and arrangement ofthe Chief Surgeon`s Office. The principal change in the latter was thereestablishment of General Hawley in London and the subsequent shifting of the
62
deputy surgeon, Colonel Spruit, to Cheltenham. The formerchange complicated matters greatly, but was an obvious necessity, just as it hadbeen in the First World War. It brought to the fore the question of who had theoperational responsibility for consultations at the local level, since the basecommander was to be supreme in his area, as Colonel Spruit informed theconsultants.
The change involving General Hawley and Colonel Spruit, itsoon became obvious, was the reorganization which had been required to improvethe management of the Chief Surgeon`s Office. General Hawley was one of thefirst to admit this, for he observed at a conference held by him on 28 June1943:
The only other thing that I want to say isthat it is very obvious to me that this office is working much better and thatColonel Spruit is doing [more] * * * to get [matters] working smoothly than Iwas ever able to do.
We are going to expand and decentralize, andmore and more responsibility is going to division chiefs. Obviously the time iscoming very, very soon when many things come up that cannot all be decidedcentrally. We are going to make mistakes. I have made several mistakes and youare going to make mistakes. I think we can all forgive mistakes that arehonestly made but I cannot forgive a mistake that is camouflaged. Many of themistakes 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 notthe result of that, and that is absolute and flagrant disobedience of a directorder. I can forgive almost anything else, but when I tell someone that I wantsomething done I expect that to be done and done promptly.
Expert surgical observation from battlefront to basehospital - A letter on this subject, dated 6 January 1943, was submitted byColonel Cutler to Colonel Kimbrough. The letter read as follows:
1. I have long been of the opinion that thenext step forward in military surgery will only come when experts can be placedin the forward elements of the Division, and can observe the wounded soldierfrom the time he is hit until he is convalescing. You will recall that it wasthe observations of a British R.A.M.C. Captain behind Ypres in the summer of1917 that gave us the complete evidence of a poisonous substance manufactured ina traumatized extremity on the way from front to rear.
2. I believe we should at this time have theprivilege 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 leastthrough to the hospital where the first definitive surgical treatment is given.These men should have the privilege of operating upon individuals if in theirjudgment that seems wise.
3. I am sure that observations made by realexperts even on 50 cases in each category would open up a new release for thewounded soldier.
4. I have been in long consultation withColonel Holtz, Chief Surgical Officer of the Norwegian Forces, who went throughthe Finnish campaigns as well as the present struggle. He is an expert chestsurgeon, and should such a group of American officers be allowed to go it wouldbe a great benefit to us as well as to him if he could accompany this group. Hisgovernment would be willing to give him two or three months leave for thispurpose.
63
FIGURE 19.-Headquarters, V Corps, U.S. Army, at Clifton College, Bristol, England, 16 March 1943.
Colonel Kimbrough forwarded the letter to General Hawley whocommented: "Noted with interest and will be applied when we startfighting." 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 Cutlerwas 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 tothe deputy surgeon on 20 February:
The officers of the American Board of Surgeryhave just corresponded with me and given permission for the examinations * * *,providing members of the Founders Group can give the examination. There aresufficient members of the Founders Group in the theater * * *.
Will you please study the requirementssubmitted with this, and then send in the names of any men who would like to becandidates and are suited to the requirements. At a later date we will settlethe examination time and place.
I am pleased at the action taken by the Boardat home, because at least it does not militate against the young surgeon, whenhe becomes a good patriot, and we should have a lift in surgical morale throughthis action.
Record forms were secured, and the matter was publicized inthe theater through notices in the Medical Bulletin, ETOUSA. Later,however, the Board in the United States felt that it was impossible to havethese examinations conducted away from the United States. "This is aregrettable decision," Colonel Cutler stated in his annual report for 1943,"for it might appear that the young
64
citizen who is willing to offer his services to his countryshould not thus be additionally penalized for patriotism. Our advice was to givethe examinations either here or neither here nor in the U.S.A. for the period ofthe war."
Elective surgery - As the troop and medical strength ofthe theater increased and more station hospitals came to England, theunqualified personnel performing surgery in these hospitals became a problem.The theater policy, established by General Hawley personally, was that no majorelective surgery would be permitted except at the 10th Station Hospital and ingeneral hospitals. Furthermore, there was a policy that patients who requiredmore than 30 days of hospitalization would not be held in station hospitals.There was, however, the large realm of cases which, conceivably, could havesurgery and be out of the hospital within this period. There were also stationhospitals assigned to bases of the Army Air Forces to which skilled personnelhad been assigned in order to provide definitive treatment for air casualtiesand the treatment of essential personnel which the Air Forces did not want tolose through ordinary replacement channels. In addition, there was the string ofstation hospitals which had been strategically placed in southern England withthe idea that they not only serve troops in that area but also take care ofevacuation from beaches upon the commencement of hostilities on the Continent.Colonel Vail, Senior Consultant in Ophthalmology, was of the opinion thatophthalmologists presently in the station hospitals were perfectly capable ofperforming the usual surgical procedures involving the eye. The real difficultylay in trying to define elective surgery accurately and so that the definitionwould be uniformly understood, particularly in such operations as the repair ofhernias. General Hawley`s opinion was that, when something could not bedefined accurately, it was impossible to enforce and control it rigidly. In thematter of station hospitals being permitted to perform special types of surgery,such as major ophthalmic procedures, the General stated that the surgeons in thetheater at this time (March 1943) might be competent but this would not holdalways.30
A policy was then agreed upon that no major elective surgerywould be allowed in station hospitals except when application was submitted bythe hospital for special permission to perform them, and the application wasapproved by the consultants concerned in the Professional Services Division.
The problem was not one of great magnitude, but it continuedto occupy the time of the consultants because so many specific incidentscontinued to arise in which differences of opinion resulted in an apparentbreach in theater policy and because the status of station hospitals had to beconstantly reviewed to ascertain whether they could be permitted to perform orcontinue to perform operations of election.
The Chief Surgeon, during this period, did not choose toaccept Colonel Cutler`s definition of elective surgery based on the criterionof time; that is, that surgery covering those conditions where delay intransport does not endanger
30Minutes, Chief Surgeon`s Consultants` Committee meeting, 5 Mar. 1943.
65
the patient`s welfare.31Neither did he permit the publication of a directive on certain types ofelective operations which could be performed in station hospitals.
American Medical Society, ETOUSA - At thesuggestion of the Chief Surgeon, Colonel Cutler was given the responsibility forcreating a medical society in which all American medical officers in theEuropean theater would have automatic membership. General Hawley specificallyprescribed that the management of the society should rest in the hands ofofficers outside the Office of the Chief Surgeon. Accordingly, Colonel Cutlerfurther delegated to Lt. Col. (later Col.) Robert M. Zollonger, MC, theresponsibility for forming the organization. An organizational meeting was heldon 14 May 1943 in conjunction with the meeting in Cheltenham of the chiefs ofmedical 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 medicalservices of the 30th and 2d General Hospitals, respectively, and ColonelZollinger were elected as a temporary executive committee. The 298th GeneralHospital offered to sponsor the first meeting of the proposed society.
This initial meeting was held on 23 June 1943. A businessmeeting was held preceding the meeting proper. A simple constitution and bylawswere drawn up which stated the purpose of the society to be as follows:
Upon authority of the Chief Surgeon, EuropeanTheater of Operations, this Society is formed for the purpose of disseminatingcurrent professional ideas and methods of military significance among officersof the Medical Corps of the United States Army in this theater.
This Society shall be known as The AmericanMedical Society, European Theater of Operations, United States Army.
The following officers were elected: President, ColonelZollinger, 5th General Hospital; Vice President, Lt. Col. (later Col.) WilliamF. 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 arotational basis at general hospitals were planned. Mornings were to be devotedto clinical ward rounds in the various sections followed by short presentationof topics related to the sections, and afternoon sessions were to be given overto topics of general interest. Provision was made for the submission of papersfrom individual medical officers for presentation and the invitation ofwell-known guest speakers. The chiefs of the medical and surgical services ofthe sponsoring hospital were designated the program committee for the meeting tobe held at any particular installation.
Honorary Fellowship in Royal College of Surgeons - Whiledining with Surgeon Rear Admiral Gordon Gordon-Taylor on the evening of 16 March1943, Colonel Cutler was informed by Admiral Gordon-Taylor that he was to bemade 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.
66
July at London. Colonel Cutler was very pleased, but he couldnot help but think: "It seems less important during a war, however."On 9 April, Admiral Gordon-Taylor informed Colonel Cutler that he had beenelected an Honorary Fellow of the Royal College of Surgeons. On this occasion,Colonel Cutler wrote: "I am and should be immensely proud-greatesthonor yet." The appointment was conferred on 26 May 1943, rather than inJuly, 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, atthe 298th General Hospital on returning wounded from North Africa proved quitedisappointing at first. After going over the results with Captain Reiter on 7January, Colonel Cutler had to conclude: "The information on sulfonamidesfrom Africa is a fizzle. There are too few figures and [they] provednothing."
The study was continued, however, and expanded to otherhospitals treating battle casualties from North Africa. Eventually, 259 caseswere studied in addition to Captain Reiter`s original 73 cases, making a totalof 332 cases-essentially all American wounded from North Africa evacuated tohospitals in the United Kingdom. With this number of cases, it was possible forColonel Cutler to say with some confidence in his letter of 24 May 1943 toColonel Kimbrough:
67
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 awayfrom wounds.
The presence of infection, however, does notmean that the wounds would not have been more highly infected had sulfonamidenot been used, and in fact we have every reason to believe that people who mighthave died of infection are now saved by the use of sulfonamide. * * *
Even transcending the above deductions ofimportance are the psychological effects upon the troops themselves. Almost to aman the soldiers have said, when questioned, that their lives were saved by theuse of sulfa drugs. Experienced clinicians will recognize the value of thismental attitude * * *, and whether recognized or not by the physical scientistsof this generation, [it] is something no good physician would be willing to setaside as a highly beneficial agent in the recovery from any physical ill.
Quite by coincidence, on the day Colonel Cutler submitted theforegoing conclusions, he was called upon to answer a question which had beenpresented in the British Parliament. A member of Parliament had asked from thefloor: "Can it be said that sulfonamides as used by the U.S. Armed Forceshave saved life?"
Colonel Cutler`s reply was: "The answer is difficultbut, put that way, must be `No`."
Other studies were encouraged and carried on by individualmedical officers. Notable among these was that by Lt. Col (later Col.) WilliamF. MacFee, MC (fig. 21), at the 2d Evacuation Hospital on fresh Air Forcecasualties at an American airbase in England. Of some 250 whose wounds had been
68
FIGURE 22.-Medical Field Service School, ETOUSA, at Shrivenham Barracks, England.
closed per primam after debridement and who had beenadministered sulfonamides, there were only four cases of infection, noneserious. "This," Colonel Cutler wrote in his annual report for theyear 1943 to the Chief Surgeon, "is an accomplishment that a good surgeonwith a fresh casualty might have without any chemotherapy * * *."
Penicillin.-Penicillin from the United States firstarrived in England only a short while before Colonel Cutler`s departure forthe U.S.S.R. First, there was a radio message from General Rankin in the Officeof The Surgeon General that a shipment was on its way. Then, on 5 May, uponnotification, Colonel Cutler hurried to Widewing, Air Force headquarters in thetheater. There he discovered a crate marked for his attention from Merck &Co., Rahway, N.J. The crate inclosed 180 boxes, each containing 10 ampules with10,000 Florey units of penicillin per ampule-a grand total of 18,000,000Florey units.
Colonel Cutler took, what was at this time, "a greatload of penicillin" to the 2d General Hospital. He immediately arrangedwith Professor Florey of Oxford to standardize the efficiency of this shipment.Three days later, with Professor Florey`s guidance, Colonel Cutler madearrangements for one laboratory officer in turn from each general hospital tocome to the 2d General Hospital and learn the laboratory procedures necessary touse and store penicillin and to recover it from the urine of patients treatedwith it. Other arrangements were made with the supply division for specialtubing and refrigeration equipment.
69
FIGURE 23.-Maj. Bernard J. Pisani, MC.
When, after correspondence with General Rankin, it wasapparent that considerable amounts of penicillin would continue to arrive inEngland, Colonel Cutler met with General Hawley on the morning of 19 May todetermine how the new drug would be used. General Hawley approved it forsituations where its use might be lifesaving. He did not approve its use, atthis time, for sulfonamide-resistant gonorrhea, as recommended. Some of the morespecific uses of penicillin agreed upon by General Hawley and Colonel Cutlerwere for:
1. All cases with gas gangrene.
2. Serious general infections, usually with osteomyelitis andpreferably infected with Staphylococcus aureus.
3. Eye infections (in a special ointment to be prepared byColonel Vail).
4. Septic hands.32
Serious investigation into the efficacy of penicillin insurgical conditions had to await Colonel Cutler`s return from the U.S.S.R. andlarger more frequent shipments from the Zone of Interior. As precious as it wasat this time, a generous amount of the drug was taken by the mission to Russiaas a gift to the Soviet peoples.
Schools and professional training.-A milestone inthe theater`s medical educational activities was the opening of the Europeantheater Medical Field Service School at the American School Center, ShrivenhamBarracks (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.
70
The first course convened on 8 March 1943 and continued for 3weeks.33 The purpose of the school,as announced, was to train medical officers, particularly those serving withfield units, in aspects of military medical practice not ordinarily familiar tocivilian physicians. Included in the curriculum were 22 hours of lectures andconferences on problems of combat as they affected surgery, acute medicalconditions, and neuropsychiatry.
Before the opening of the school, Colonel Cutler had workedmany hours on the surgical courses of study, but an item of immediate concern tohim shortly before the opening was the appointment of instructors onprofessional subjects. Some, apparently, had been appointed without knowledge ofthe Professional Services Division, and Colonel Cutler informed the ChiefSurgeon of his concern over this situation.
In reply, the Chief Surgeon stated at the February meeting ofhis Consultants` Committee the policy that all instruction in clinicalmedicine at the school, except chemical warfare, would be controlled by theProfessional Services Division and that no instructors on professional subjectswould be sent to Shrivenham without that division`s approval. General Hawleyfurther explained that he wanted the course at Shrivenham for the man in thefield, but also wanted it to include essential teaching on frontline treatmentto avoid the necessity of sending officers to two separate courses.
Partially as a result of this policy, professional trainingat the school retained a high level, and instruction could be varied ascircumstances indicated. Most of the teaching on strictly professional subjectswas given by the various theater consultants concerned.
Another course, initiated during this period, became known asthe London tours course. This program was created at Colonel Cutler`s requestby Surgeon Rear Admiral Gordon Gordon-Taylor, consulting surgeon to the RoyalNavy. A limited number of officers was accepted for a 1-week schedule of visitsto a different British hospital in the environs of London each day-to London,Guy`s, Middlesex, St. Mary`s, and St. Bartholomew`s Hospitals. Luncheonwas provided at each hospital, and, on certain afternoons, the American RedCross in London provided transportation and guides for tours to interestingpoints in the city. The professional interests of candidates selected wererelayed 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 inline units with those in hospitals. This program fulfilled the dual purpose ofproviding a more varied experience in clinical practice for medical officers ofline units and served to acquaint medical officers in hospitals with theproblems of providing medical service in line units. The plan was a goodprecursor for the system later adopted of rotating combat- and service-elementmedical officers when active hostilities ensued on the Continent.
33Circular No. 22, Headquarters, ETOUSA, 23 Feb. 1943.
71
Blood
Back in 1942, upon hearing a discussion on blood andplasma at a meeting of the Royal Canadian Medical Corps Pathological Club,Colonel Cutler had recorded: "Very interesting. It seemed to me that therise of plasma, etc., had let all forget the benefit of transfusion. Oursoldiers are all grouped. They should be the best vehicle for getting bloodforward. No bottles to carry!" But, comments he heard later and reflectionon the transfusion problems of World War I convinced him that the matter was notas simple as this. The problem lay in the area of a practical unit usable underthe conditions of combat to effect transfusions.
In a letter to the Chief Surgeon on 27 March 1943, concerningstandardization of the portable transfusion unit for combat areas, ColonelCutler wrote the following:
The information we have from the presentbattle fronts of all nations including our own in Africa and elsewhere, is thattransfusion as a method of resuscitation is steadily on the increase. ColonelDiveley brings us this information from our own troops in North Africa andBrigadier Whitby tells me that the use of wet plasma has practically been givenup, and transfusion used in its stead in the British Army.
He then proposed a simple transfusion kit to be used byAmerican units in the European theater (fig. 24). The kit was composed of itemsof 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, includedequipment for grouping donors rapidly and satisfactorily, for these officers haddiscovered that a 10-percent error existed on the blood types stamped onidentification tags of individuals.
Colonel Cutler recommended that a number of units of thistype be assembled, packed, and held for distribution in the medical depots.There was no immediate need for the item, since the British taking and givingsets currently in use were satisfactory for the type of medical service beingprovided.
Colonel Cutler, on 31 March 1943, was given a firsthandexplanation of a system used by the British in Africa. At the Post-GraduateMedical School, RAMC, in London, Col. A. E. Porritt, RAMC (later Brigadier andconsulting surgeon, 21 Army Group), gave a splendid discussion on how theBritish Forces in the Middle East drew blood in Cairo, flew it to a distributingpoint behind the lines, and then transported it in refrigerated vehicles toforward units, such as field ambulances and advanced surgical centers.
In a letter, dated 2 April 1943, concerning his 30 March-1April 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 sufficientblood at each medical installation from lightly wounded or hospitalpersonnel." He continued: "Both systems are open to the criticism thatadequate studies of the blood for syphilis, malaria and other diseases are notmade, and this needs critical thinking."
72
On 7 May, Colonel Cutler had a long session with BrigadierWhitby and others at the British Army Blood Supply Depot, Bristol. This meetingserved to review and consolidate all previous thinking which had been given tothe problem of supplying U.S. Army units with blood and protein fluids when theinvasion began. The core of the problem was expressed in the following threequestions and answers:
1. Are a common apparatus and a common sourceof blood and plasma essential for proper liaison between the British andAmerican Armies?
Answer: Should we invade the Continent, theanswer to this is that a common kit is not essential, for units using thematerials would never be so closely mixed. Also, the British would have greatdifficulty in supplying us with material in this field.
73
2. What is the optimum time for resuscitation?
Answer: The answer is early, rapidly andadequately. British figures show 10 percent of wounded require transfusion. TheRussian figure is 11 percent. Transfusion means blood or plasma, or both. Thesefigures may rise to greater heights. For example, in a private letter from theTunisian 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 toprocure blood for transfusion in the most forward elements and the value ofplasma is not fully appreciated by most medical officers. For example, word hascome back both from the American and British sources in North Africa that plasmawas no good and blood should be used. There can be no question but whatreplacement with plasma is highly efficacious and the opinions from frontlinesurgeons do not represent scientific evidence to the contrary but seem to bemostly hunches. It is as if these forward surgeons thought that certain seriouscasualties to whom plasma was given might have been saved if blood had beengiven. True, when massive hemorrhage has occurred blood is essential, but weshould have a directive concerning the use of blood and plasma and theconservation of these.34
The British system contemplated for a continental invasion,as described by Brigadier Whitby, was to follow closely the North Africanexperience. Freshly drawn refrigerated whole blood was to be delivered to theContinent by air. Thence, refrigerated trucks carrying 400 bottles each were tosupply forward transfusion teams which, in turn, were to be equipped with 3-tonrefrigerated trucks holding 80 bottles of blood and 200 units of plasma. TheBritish graciously offered to fly U.S. Army blood to the Continent, but fromthere on the responsibility would have to rest with U.S. Army elements.Moreover, it was impressed on the conferees that the British planned to drawonly 200 pints a day, which could be boosted with difficulty to 400. Thisabsolutely prohibited the U.S. Army from counting on the British for a supply offresh blood.
Considering the foregoing factors, the logical conclusionswere fourfold, and these Colonel Cutler expressed as his recommendations toColonel Kimbrough and the Chief Surgeon on 10 May 1943. First, there was theneed to publish a directive concerning the proper use of blood and plasma incombat. Secondly, he stated that plasma was now being supplied to divisionalmedical elements, mobile hospitals, and fixed hospitals and required no furtherelaboration except that ample stocks had to be made ready. The third and fourthrecommendations concerned the supply of whole blood and were divided into meansof providing whole blood (1) from donors in the field and (2) from sources inthe United Kingdom or the United States proper. They were as follows:
We recommend that a satisfactory bleeding andgiving set with the equipment for gross agglutination to determine compatibilityof blood be assembled and set up in the United Kingdom, this unit to go forwardwith our transfusion teams and be available for other medical use also. Theequipment is contained in the T/BA of the mobile surgical unit alreadysubmitted. We feel that the transfusion team "up the line" can bleedthe 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.
74
wounded in sufficient supply for most of theneeds for blood, provided plasma and blood are intelligently used.
It would seem desirable to have an additionalsupply of refrigerated fresh whole blood originating either in the U.S.A. or inthe SOS or the U.S. Army in the United Kingdom. This would require the settingup in the U.S.A. or in the United Kingdom of 1) Bleeding centers, 2) thetransport of such blood in a refrigerated aeroplane to the Continent, 3) the useof refrigerated automobiles to take the blood up the line to medicalinstallations who would have refrigeration in which to keep it. Blood, whenrefrigerated, has been used up to 2, 4 and even 6 weeks after withdrawal, but itis perhaps not wisely used after 2 weeks. (Calculating 72 hours from bleeding inU.S.A. to the Continent we would have plenty of time to follow the English andRussian system and have blood drawn in America reach this forward area beforeany deleterious changes had taken place. If the air transportation of freshlydrawn blood is too unreliable, blood could be secured from the U.S. Army SOSinstallations in the United Kingdom.)
The same day that the preceding recommendations wereprepared, 10 May 1943, Colonel Cutler briefly apprised the Chief Surgeon and hisstaff on the problems of providing blood to combat forces. He emphasizedparticularly, at this informal conference, the difficulties attendant on the airtransportation of blood from the United States and the fact that there was nomachine suitable for the use of U.S. Forces in the European theater for properlygiving and taking blood. The American equipment, Colonel Cutler told theconferees, was excellent, but when the slightest repairs became necessary, theequipment had to be returned to the Zone of Interior.
On 5 June 1943, Col. Walter L. Perry, MC, Major Storck, andCaptain Hardin met with Colonel Cutler in Cheltenham. Colonel Perry (fig. 25)was the theater medical supply officer, and Major Storck, the recently appointedSenior Consultant in General Surgery. The meeting was arranged to expand furtherthe proposals submitted by Colonel Cutler on 10 May 1943 and to recommend morespecific steps necessary for the implementation of Colonel Cutler`ssuggestions.
The matter of obtaining blood from the Zone of Interior wasleft in abeyance since it was obviously a separate problem from that ofobtaining, processing, storing, and distributing blood within the theater.Moreover, once blood from the United States had arrived in the theater, itpresented a problem no different from that for blood collected and processed inthe theater. Therefore, the conferees concentrated on facilities and programs tobe developed within the capabilities of the theater itself-the only basis onwhich absolutely reliable plans could be made. They made the followingdecisions:
1. A depot-type unit would be necessary in the United Kingdomto centralize and direct the many activities involved.
2. Bleeding of American troops and/or British civilians wouldbe necessary.
3. American bleeding teams and facilities would have to beused.
4. Provision had to be made for a unit to receive and furtherdistribute blood on the Continent, once a firm beachhead had been established.
5. Proper refrigeration equipment would be necessarythroughout all phases of the program.
75
FIGURE 25.-Col. Walter L. Perry, MC.
Also discussed was the progress which had been made inestablishing blood banks and donor panels at each active general hospital andthe work yet remaining to accomplish this objective.35
On 10 June, Colonel Cutler had a conference with GeneralHawley in London. The general, after first expressing his surprise at findingColonel Cutler still in London, directed him to finish by all means the plansfor 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; alldone."
"The purpose of this memo," he wrote GeneralHawley, "is to bring together all data concerning intravenous therapy forshock and allied conditions, and to conserve the use of these precious materials(blood, plasma and crystalloid solutions) which are often misused and wasted atthe present time."36
Colonel Cutler listed for General Hawley all the directiveswhich had been published to date on blood, plasma, and crystalloid solutions;presented an inventory of all plasma and crystalloids on hand, both American andBritish; and reviewed procurement demands still outstanding on the British forthese items. He provided General Hawley proposed directives on the making ofcrystalloids 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.
76
blood and plasma by units in the field. He stated that thegeneral medical laboratory, when established, should also have as one of itsduties the manufacture of crystalloid solutions.
On the matter of supplying whole blood, Colonel Cutler againreferred General Hawley to the basic tenets made in his letter of 10 May 1943;namely, that a simple field-transportable transfusion set was necessary forbleeding "on the hoof," and supplemental sources of blood wererequired within the theater or the Zone of Interior. He submitted copies of the10 May 1943 letter, a revised and final version of plans for the fieldtransfusion set, and letters prepared by Captain Hardin on the 5 June 1943meeting.
In submitting plans for the transfusion set, Colonel Cutlernoted:
1. The following TB/A for a Whole BloodTransfusion unit is the final product of months of experimentation with MajorEmerson and Major Ebert of the 5th General Hospital.
2. In discussion with Colonel Perry we proposethat if Field Medical Chests are scarce the wooden boxes in which our U.S. Armyplasma 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 forthis standardization, Majors Emerson and Ebert, would be happy to assist in theoriginal packaging.
Captain Hardin`s letter reviewed the following necessitiesfor any plan by which whole blood could be supplied to a continental force:
Blood from the Zoneof Interior
Blood collected in the Zone of Interior can bedelivered to the E.T.O. only by air transport. The collection, processing, andinitial delivery to a depot in the United Kingdom would be a function of anagency in the Zone of Interior. Its reception, internal storage, anddistribution to the base unit and/or * * * transfusion teams would be theresponsibility of the depot located in the United Kingdom * * *. The depot wouldnecessarily be located near an airport and would provide adequate refrigerationfor the blood throughout its entire handling from the time of unloading theplane.
Collection of Blood in the U.K.
Blood can be obtained from two sources in theU.K.:
1. Base and SOS Troops.
2. Civilians (British).
The first * * * is somewhat problematicalsince the troops * * * are scattered over a wide area and because the bleedingwould take place during periods of activity when those troops will be leastavailable. The second source is probably the better. To put it into operationwould 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 fordrying.
Organization of such an area would includeenrolling of donors and procurement of bleeding centers. * * *
Bleeding Teams
These teams must be mobile and carry withthem all of the equipment necessary to do one day`s bleeding. Such a team whenbleeding military personnel can bleed 150 per day
77
provided that a constant stream of donors ismade available. British teams bleeding civilians average 75 per day.
Depot
This unit serves as a base from which themobile [bleeding] teams work. It supplies the teams with all the apparatusneeded and maintains * * * vehicles. Records are kept of the bleeding, apparatus[is] reconditioned and assembled, and blood [is] processed. This includesserologic tests, typing, addition of glucose, and bacteriologic control. Herealso internal storage of blood must be undertaken, which requires the provisionof adequate refrigeration.
Distribution to the Field
Behind any force there must be a base unitwhich draws blood from the depot and distributes it to the shock teams. Thisunit may be small and simply concerned with supply of blood or like the Britishunit be capable of producing crystalloid solutions as well as distributing bloodand plasma. It must be equipped adequately to be able to recondition apparatusand carry out sterilization. It must also have mobile refrigeration.
Refrigeration
Blood is ideally kept at +3? to +6?C. Itmust not be frozen and undergoes considerable deterioration if the temperatureof storage fluctuates greatly. Two types of refrigeration may be used:
1. Ordinary refrigerator capable ofmaintaining the required temperature. This type of refrigeration calls forfitting of airplanes and trucks with refrigerators. It is the type ofrefrigeration used by the British Army Transfusion Service and has worked wellin practice.
2. Refrigeration by melting ice: Ice melts at+4?C which is the ideal temperature for blood storage. By the utilization ofcompartment boxes into which ice and bottled blood can be placed in separatechambers an adequate but simple type of refrigeration is obtained. To utilizethis to the fullest extent, lightweight well insulated containers could be builtto hold 10 to 20 bottles of blood. Such containers under ordinary temperatureconditions will hold ice for 72 hours.
Advantages: Simple,accurate refrigeration, with no machinery to break down. Dispersal of storespossible. Containers can be carried in any plane or vehicle without specialinstallation.
Disadvantages: Procurabilityof ice. Ice making machines would be necessary in the base unit and perhaps inthe depot.37
In summary, Colonel Cutler had shown howtransfusions could be accomplished by "bleeding on the hoof," byobtaining whole blood from the Zone of Interior, by bleeding British civilians,and by bleeding U.S. Army service troops. Each of these proposals posed anenormous logistical undertaking to implement. It was certainly beyond theprerogatives of the Chief Consultant in Surgery to decide which steps would betaken. Hence, his closing words to the Chief Surgeon asked for "instructionto Professional Services concerning the method selected for supplying aContinental Task Force with whole blood that we may assist in implementing suchdecision * * *."
During Colonel Cutler`s absence in the Soviet Union,General Hawley approved the construction and assembly of the field transfusionunits. 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.
78
States.38 He directed thatthe consultant group go ahead with plans for collection and distribution ofblood and that the British be consulted with reference to preservation andstorage.
In reply to a question by General Hawley as to thedevelopment, procurement, and distribution of blood transfusion kits for mobilemedical units, his executive officer provided him with the following answers:
1. A blood transfusion chest had been designedand had been approved for clearing companies, evacuation hospitals, fieldhospitals, and auxiliary surgical groups. One hundred of these chests were beingpacked at Medical Depot G-35. Clearing companies and evacuation hospitals wereto receive 2 chests each, while field hospitals were to receive 3 chests, andauxiliary surgical groups, 10.
2. A smaller unit had also been designed whichwas built around a new quartermaster item known as the "man packcarrier." Two hundred of these man-pack-carrier, blood-transfusion setswere to be assembled as soon as the pilot model was approved and thequartermaster carriers became available. Two of these kits were to bedistributed to each collecting company and regimental medical detachment.
3. The standard, approved transfusion bottlesfor both the chests and the man-pack-carrier units were being assembled at the5th General Hospital.39
Mobile surgical units
From his first days in Washington, Colonel Cutler hadrealized that the key to providing optimum care for battle casualties lay intaking the surgeon to the wounded man instead of bringing him back to thesurgeon. This could only be accomplished, he believed, by a truly mobile,self-contained surgical team. At every opportunity, he had discussed thispossibility with the Chief Surgeon and his colleagues, both British andAmerican. One of the first things he had asked of General Hawley was that thelatter request Washington for the assignment of an auxiliary surgical group tothe European theater. By early 1943, he had gained considerable experience incurrent Army ways and felt quite capable of coping with the problems involved incoming forward with specific recommendations for the organization and equipmentof a surgical team such as he had in mind.
In early February 1943, two things happened which encouragedColonel Cutler to embark immediately upon the formation of a mobile surgicalteam. On 16 February, he attended a session at the RAMC College during whichMaj. Gen. David C. Monro, RAMC, newly appointed consulting surgeon to theBritish 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.
79
FIGURE 26.-The 36th Station Hospital, Exeter, England.
the Middle East. He traced the development of the fieldsurgical unit and its successor, the mobile surgical unit, as constituted inthat British theater of operations. General Monro emphasized the requirementsfor mobility, stated that team members had to be surgeons of outstanding abilityand mature judgment, and warned that teams with equipment fitted (built-in) tovehicles were undesirable. The latter, he suggested, could be disabled with asingle gunshot in the radiator.
Upon returning from this session at the RAMC College, ColonelCutler recommended that (1) mobility must be forced on all of the medicalservices, (2) this could probably be best achieved by mobile surgical unitsbased on parent units which would continue to supply and administer them, and(3) a certain amount of segregation of casualties by anatomical groups would benecessary in the rear areas for better surgical therapy. He concluded: "Ibelieve that there are many lessons in this talk from which we should benefit,and benefit now. * * * Perhaps this first-hand experience will bring the MedicalCorps of our Army face to face with what I believe to be a major issue, whichmust be solved before we get into a real battle."40
At about that time, Lt. Col. Herbert Wright of the Eighth AirForce had submitted a special report to the Chief Surgeon in which he broughtGeneral Hawley`s attention to the situation which confronted the Air Forces inCornwall. Many crippled aircraft returning from combat missions were landing atRAF fields in this area with frequent serious casualties among their crews. Thenearest 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.
80
this area, thus precluding the transfer of Americancasualties to it. Moreover, this was the only specialized hospital in thetheater, a neuropsychiatric facility with but a small surgical staff. ColonelWright recommended the procurement of certain buildings just outside of Truroand requested the assignment of surgical specialists to staff a medical facilityto be activated there.
Colonel Cutler found many objections to the plans submittedby Colonel Wright. He proposed, instead, that the U.S. Army obtain from 10 to 20beds 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 wasnot 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 the5th General Hospital to work on a mobile surgical unit with the followingguidance in mind: (1) The equipment should not be built in a truck, (2) theequipment and tentage should be for a mobile surgical team, such as a team froman auxiliary surgical group, and (3) the team should take all the materialsnecessary for lighting and for surgery to cover 50 to 100 major surgicalcasualties or 200 minor casualties.41
As things turned out, it was the obtaining of beds at theRoyal Cornwall Infirmary at Truro which proved to be the greatest obstacle tothis program. It was only through the intercession of Colonel Cutler`s closefriends, Prof. George Gask and Mr. Rock Carling, that an allocation of 12 bedswas obtained at the Royal Cornwall Infirmary for the hospitalization of U.S.Army Air Forces casualties. The trustees of the infirmary approved ColonelCutler`s plan on 25 February, but the space was not immediately availablebecause repair
41Annual Report, Chief Consultant in Surgery, ETOUSA, 1943.
81
of the buildings was underway following a bombing of theinfirmary. When reporting the approval received from the trustees, ColonelCutler added that a surgical unit consisting of two surgeons, one operating roomnurse, four ward nurses, and their necessary equipment was ready to go at the5th General Hospital. General Hawley and Colonel Cutler visited the 5th GeneralHospital on 6 March and looked over the equipment for the team. On 14 March, thedirector of the Royal Cornwall Infirmary telephoned Colonel Cutler that theinstitution was ready to receive the American contingent. The next day, Col.Maxwell G. Keeler, MC, commanding officer of the 5th General Hospital, and MajorZollinger went to Truro to make final arrangements. Ten days later, the surgicalunit was well established and working. Their work and attitude created a mostfavorable impression at the infirmary (fig. 28). Within a month, as planned,this unit from the 5th General Hospital was relieved and returned to its parentunit, and a team of similar composition from the 3d Auxiliary Surgical Grouptook over its functions.
In the meanwhile, suggestions to provide surgical teams toother areas in which the Air Forces were operating did not materialize sinceColonel Grow, after considerable thought on the matter, felt that the use ofthese teams might erroneously suggest to the British that their services wereinferior.
In London on 31 March, Colonel Cutler was privileged toattend 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
82
6 April 1943, Colonel Cutler received a communication fromthe British War Office, issued by the consulting surgeon, General Monro, whichquoted items of information from the Middle East theater on the outstandingsuccess the field surgical units had encountered. General Monro, in commentingon the reports, agreed that lighting was one of the main problems since, as oneunit reported, 80 percent of the work had been during hours of darkness. A mostimportant point, General Monro noted, was as follow: "If F.S.U.`s are togive of their best, they must train together not only in field exercises butin the operating theatre. Commands should be instructed to see to it, thatthe F.S.U.`s now mobilized in this country, relieve, as a team, one of theexisting 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 SouthernCommand the new organization of the RAMC field medical service which currentlyfeatured an advanced surgical center. This advanced surgical center, comprisedof a field dressing station, a field surgical unit, and a field transfusionunit, had 20 cots and many litters and was to perform only urgent surgery-abdominals,sucking chest wounds, wounds of the buttocks, and compound fractures, especiallyin the joints. They were assignable on the basis of two per combat division.
Armed with this wealth of recent information on the efficacyof mobile surgical units in combat plus detailed and complete reports on theworkings 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 onthe 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 tothose which have preceded it because the need for mobility in our forces isincreasing, and because of recent attempts to reorganize the teams as they nowappear in the Auxiliary Surgical Group.
2. The regrouping of teams in the AuxiliarySurgical Group was submitted to the Chief Surgeon by Colonel Mason. In thisregrouping it was made clear that practical experience in this war had butcorroborated the experience obtained in the last war, that the surgeon in theforward area must be a general surgeon. In the last war we had: a. Generalsurgical teams, b. Shock teams, c. Splint teams. This resultedbecause experience showed that the general surgeon must be the one to do thework in the forward area. Also it was found he needed as a colleague somebody tohelp put on the splints when compound fractures existed, just as he will todayneed such an expert colleague to put on the plaster for immobilization ratherthan the Thomas` splint used in the last war. Also, if the general surgeon isto be kept busy all the time at what he is bound to do, i.e. surgicaloperations, he should have as a further colleague a man trained in resuscitationand shock who can treat the cases before an operation and then care for themafterwards, thus freeing the surgeon`s time for constant application to hishandicraft in the operating theater. This combination of experts needs highlytrained personnel working at top speed in their selected fields, andaccomplishes the maximum overturn of labor in the shortest period of time. Itwould 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.).
83
teams should be re-organized on a basissimilar to the thinking above. In my mind, the best team would be one in whichthe surgeon was a general surgeon, the assistant surgeon, however, an orthopedicindividual or at least a surgeon properly trained in plaster technique. Inaddition, each surgical team would need a man trained in shock * * * thoughI believe that where two surgical teams were out together to a singleinstallation, one shock team might care for the work of two surgical teams. Thedefect in the Auxiliary Group is that they only carry with them theirinstruments and would have to be given all of the rest of the impedimenta ofoperating theaters by the hospital to which they were attached.
3. Mobile surgical teams.
The use of the term "mobile surgicalteam" is coined to describe a setup somewhat different to that above, forin this setup the team is to have its own transport and take with it everythingit needs in the way of professional supplies to cover the completion of 100major surgical operations. This is to include lights, bandages, a shock teamsetup, 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 ithas its own transportation to any point desired by the corps or army surgeon. Tomy way of thinking it might best be placed at the clearing company of adivision, and the only matter which is not settled in our minds is whether thismobile surgical group, with its team and shock men and supplies should take itsown tentage or not * * *.
As stated in previous memoranda, I am opposedto building in of the apparatus into the truck, feeling that something mighthappen to the truck and thus immobilize the team. If the material can be easilyput into a truck and then taken out, then any truck will suffice, and completefreedom and mobility is assured. The TB/A of such a mobile surgical team asopposed to the teams now organized in our Surgical Group is appended. It islargely the system set up by the group from the 5th General Hospital, withchanges, both deletions and additions, as suggested in our Consultant Group andby our British colleagues.
On 21 April 1943, Colonel Cutler conferred with General Monroand 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 surgicalunit, a part of the plans which had not been firmed. He was also shown a lanternwhich burned kerosene under pressure with a brilliance of some 400 cp. It seemedto be the ideal unit for providing emergency lighting for the mobile surgicalteam in the event of power failure, and Colonel Cutler on his return immediatelyordered a sample unit for trial and study. Later that week, he was able, withthe cooperation of Col. Charles E. Brenn, MC, the U.S. V Corps surgeon, toselect and set up tenting for the proposed mobile surgical team. The feasibilityof the tents for operating pavilions was tested, particularly under blackoutconditions.
In a letter, dated 6 May 1943, to General Hawley throughColonel Kimbrough, Colonel Cutler submitted complete proposed tables oforganization and equipment for a mobile surgical unit composed of a surgicalteam 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
84
For the shock team:
1 officer, preferably a physician
2 technicians, enlisted
The organization also called for two drivers to drive andmaintain the unit`s vehicles, one 2?-ton truck, and one ?-ton weaponscarrier (fig. 30). Assistant drivers, he stated, could be trained from among theenlisted men of the surgical and shock teams.
With reference to the shock team (fig. 31), Colonel Cutlerexplained:
We have called the second group atransfusion-laboratory group because as we visualize the work of a surgical teamin the forward area it will require a transfusion team to attend to theresuscitation of its patients before the operation and to care for themafterwards. Moreover, this group will do work such as blood counts, examinationof the urine, determination of hemoglobin for better treatment of shock,occasional microscopic examination of smear preparations from joints, spinalcanal, etc., and occasional microscopic examination of the bacterial flora inthe wound, where the finding of gas bacillus forms might strengthen one`shands before amputation.
All the medical supplies and equipment were packed into 18trunks with a total weight of approximately one ton, except for a few bulkyitems such as splints and litters. Of these 18 trunks, 16 used the container formedical 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 weightof approximately 250 pounds. The basic instrument set, stock number 93212, 1942model,
85
86
was used with a few extra instruments from special sets forneurosurgery, 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 asuction machine, complete, stock number 37750 (fig. 34). Expendables, such asdressings, bandages, adhesive tape, gauze, cotton, plaster, towels, sponges,suture material, anesthetics, medicinals, crystalloids, and the like, werepacked in quantities sufficient for 200 surgical operations (fig. 35).
The tent decided upon for the operating theater was thatknown as a tent, storage, camouflaged, with fly (fig. 36). All possibleequipment and supplies for emergency sources of lighting-battery-operatedlanterns and surgical lights and a 2.5 kw. gasoline-operated generator-wereincluded (fig. 37). The common oil-burning pot-bellied stoves were added forheating purposes. The final list of supplies and equipment, Colonel Cutleradvised the Chief Surgeon, was made in conjunction with the members of the 5thGeneral Hospital who assisted in the preparation of the list and had somefurther suggestions after returning from their temporary duty at Truro. Hesuggested that the responsibility for replenishing supplies of any particularteam 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 basedfor supply support on a field army.
On Tuesday, 18 May, General Hawley and Colonel Cutlerjourneyed to the 5th General Hospital and held a showdown inspection of themobile 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 along 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 mobilesurgical unit.
2. The 5th General Hospital should secure still and movingpictures of this unit in all phases, including putting up tents and operatingupon a patient.
3. Officers in the 5th General Hospital should write upseparately how the unit functions as a whole and how the transfusion-laboratoryteam is to function.
4. The equipment for a single mobile surgical unit shouldthen be transferred to the 3d Auxiliary Surgical Group after they have beentaught how it functions, including the putting up and taking down of the tents.
5. It will be the responsibility of the 3d Auxiliary SurgicalGroup to teach the rest of their teams this same matter and to teach in theMedical Field Service School at Shrivenham, if that was desired.
6. The headquarters of the auxiliary surgical group shouldacquire facilities for sterilizing dry goods so that, as the parentorganization, 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.
87
FIGURE 32.-A chest containing orthopedic supplies and equipment for a mobile surgical unit.
88
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.
89
90
FIGURE 36.-Pitching an operating room tent of a mobile surgical unit.
Finally, in a hectic rush to complete all aspects of the mobilesurgical unit plan prior to his trip to the U.S.S.R., Colonel Cutler was able toreport to the Chief Surgeon by letter, on 15 June 1943, the following:
Certain changes have been made in the TBAsubmitted [6 May 1943], and we now submit TBA in final form after repeatedexperimentation 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 thetent (fig. 38). These should arrive shortly. A film including the setting upoperation and taking down of the unit, has been made and is now being put inorder by the Signal Corps, and should also be in your hands shortly.
Lt. Col. Robert Zollinger who has beenexperimenting with this problem under our guidance since February 1943, iswriting up the complete functioning of the unit in the hope that you will sendthis 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 theexercises in the next classes.
While the principles of assembling the necessary equipmentfor the supply of a surgical team in the performance of at least a hundred majoroperations was followed by auxiliary surgical groups, it was rarely, if ever,necessary for a surgical team to function as an isolated unit during the combatperiod of operations on the Continent during 1944-45. Instead of utilizing theirown tentage, lighting, and other heavy equipment, surgical teams invariablyutilized the facilities of the unit to which they were attached; that is, fieldand evacuation
91
FIGURE 37.-Portable operating light, equipment of a mobile surgical unit.
FIGURE 38.-The arrangement of the operating tables of a mobile surgical unit.
92
hospitals. The teams carried with them and frequentlyutilized certain surgical instruments and other small medical supply itemsorganic to the auxiliary surgical group.
Surgical mission to Union of Soviet Socialist Republics
Background - Colonel Cutler, in a memorandum, dated 15January 1943, advised General Hawley as follows:
Some months ago when you were ill, I attendeda 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 RoyalSociety of Medicine of our colleagues for all that they have done for us. I thenpointed out what I thought might be the value of all the Allied people gettingto know something of each other. At that time I said I was greatly concernedthat I had been unable to meet a Russian, and I thought this was a pity, andwondered if there are any Russians in London. Sir Wilson Jameson and Sir AlfredWebb-Johnson and other people who knew all about the Russian difficulty, andthat a British hospital ship had even reached Murmansk and had been turned backagain, were much upset. They have talked to me repeatedly about this, andapparently had been to the Foreign Office again. I learned yesterday that arequest might shortly be made for three British medical officers, and threeAmerican medical officers, to visit Russia. I thought you should be apprised ofthis possibility early. It appears to me that a country who must have hadmillions of casualties should be able to teach us a good deal about militarysurgery and military medicine.
Colonel Cutler`s diary states, for 29 January: "I`mgetting worse at this [keeping up the diary], just when it is gettinginteresting. For example, Russia. I have long been worried I couldn`t find aRussia. I`ve spoken of it as a reason for the Inter-Allied Conferences. Ispoke of it at a dinner with Fraser, Sir Wilson Jameson, Sir AlfredWebb-Johnson, Dean * * * of the Graduate Schools, and Broster (hisdinner). As a result, I now have a commission of 3 British and 3 Americanmedical officers to be asked to go to Russia."
Colonel Cutler had just returned to Cheltenham from a trip toLondon, Basingstoke, and Chatham on the morning of Saturday, 10 April, whenGeneral Hawley called him to his office in the afternoon and instructed him tosee 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 lateafternoon. 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 jointmedical mission of British and American service personnel to Russia. He reportedprevious discussions re Russia and happenings in Russia that bore small relationto this problem. He reported the Typhus Commission was turned down. * * * Theurgency of the matter was again brought to his attention when I told him that onApril 16 Surgeon Rear Admiral Gordon-Taylor was lunching with M. Maisky, theRussian Ambassador, * * *, and that members of the British Commissionwere now instructed to get their passports. (British Commission headed bySurgeon Rear Admiral Gordon-Taylor, other members, Maj. Gen. Monro, Mr. RockCarling.) Finally he promised * * * to see M. Maisky, Mr. Eden, and Sir EdwardMellanby [on 15 April], and give you a final report.
93
Mission established.-On 19 April, Colonel Cutler wasgiven a message to call Admiral Gordon-Taylor. Mrs. Gordon-Taylor answered andinformed Colonel Cutler that he and Lt. Col. Loyal Davis, MC, were to go to theSoviet Union with the English mission (fig. 40). Colonel Cutler was elated. Herecorded: "This is something I have been working on for 4 weeks and indeedfeel partly responsible for. Now I am getting somewhere! We`re to go in about3 weeks; in May. Know nothing more. Of course it is a risk, but that is smallcompared to what others are doing. I`m happy for a moment."
Preparations for departure.-The next few weeks werekaleidoscopic for the Chief Consultant in Surgery. There was so much to be donebefore leaving, and yet details concerning the mission to the U.S.S.R. took timein themselves.
On Wednesday, 21 April, he had tea with Admiral Gordon-Taylorwho 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 tothe Royal Air Force, and Mr. Ernest Rock Carling; and that the U.S.representatives would be Colonel Cutler and Colonel Davis. Admiral Gordon-Tayloralso 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 shouldbe separate missions, and (2) three U.S. members. General Hawley and I agreedthe joint mission was best. As to the third member, the
94
Russians would like men of high academic standing in surgery[professors of surgery]. The General thought Loyal Davis and I were the onlyones here who filled the bill."
The next day, because there was some uncertainty as to whowas to head the American representation, Colonel Cutler spoke again with GeneralHawley who confirmed the fact that Colonel Cutler would head the Americanrepresentation. He then saw Admiral Gordon-Taylor again. The admiral approvedthe giving of fellowships to two famous Soviet surgeons, N. Burdenko and SergeYudin,44 by the American College ofSurgeons, and Colonel Cutler went back to General Hawley with this information.
By the middle of May, Colonel Cutler and Colonel Davis hadwritten to the American College of Surgeons for permission to bestow thehonorary fellowships. The ceremonial hoods had been borrowed from twoEnglishmen, Admiral Gordon-Taylor and Mr. Harry Platt, with the promise thatthese would later be replaced. The speech of investiture was then approved byGeneral Hawley. There was also some confusion as to the diplomatic channelsthrough which the names of the American representatives would be submitted tothe 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.
95
passports were obtained on 11 May. On 13 May, Professor Sarkisov, anassistant to Academician Burdenko, arrived in England from Vladivostok and wasintroduced at a luncheon held at the Royal College of Surgeons. He gave the mostcomforting assurance that the mission would, in all probability, be warmlywelcomed in the Soviet Union. And, finally, word was received that Prof. WilderG. Penfield of McGill University, Montreal, Canada, would be added to themission.
There was no further clarification, as of 15 May, as to when the missionwould leave. But, with the arrival of Professor Penfield, the membership of themission was complete, and amenities preparatory to departure continued at a highpace. As an example, on 24 May there was a luncheon given by the British Councilfor the mission at Claridge`s in London. There was also a serious talk withthe 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 withAmbassador Winant, Colonel Cutler reported as follows in a letter to ColonelKimbrough, dated 30 May 1943:
* * * He gave Colonel Davis and myself explicit verbalinstructions, 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 geton well with our Russian colleagues. The latter was emphasized as highlyimportant, since if this mission is happily received others of great importancemay be allowed to follow. Ambassador Winant made it very clear that theinstructions to which we should adhere closely were to discuss nothing exceptprofessional medical matters. He emphasized this point by stories of diplomacywrecked on the rocks of missions going beyond their protocol. He urged us totake anything with us that could enlighten the Russians on American surgicalmethods, and hoped we might bring back matters of importance to our people.
The Ambassador also promised Colonel Cutler a list of American diplomaticofficials in the countries through which the mission would travel en route toand from the Soviet Union.
Soviet motion picture - On 31 May 1943, Colonel Cutler was privileged tosee, at the Soviet Embassy, a motion picture depicting the care given thewounded Soviet Army soldier during his evacuation from the front to the rear andthrough his rehabilitation. His account of the film showing in a letter toColonel Kimbrough, dated 5 June 1943, follows:
This was a battle picture and most interesting. Soldiers werepicked up on the battle field and given preliminary First Aid by a trained firstaider. They then passed through battalion and divisional aid posts and tohospitals similar to our surgical hospitals, where definitive surgery wascarried out. Certainly a great attempt was made to give as adequate care aspossible, and every effort was made to restore the soldier to active duty assoon as possible.
The most important observations of interest to me were:
The use of women in theforward area. Women were even in the divisional aid posts of casualtyclearing companies, and from the expressions on soldiers` faces, even withoutthe 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 usa very good lesson. They had excellent bathing facilities
96
in their most forward hospitals, and spoke of such facilitiesas equally important to good surgery. * * *
Air transport. This was greatlyemphasized in the film, and is used in the care of wounded amongst theguerillas, which is a part of the obligation of the Russian Medical Corps.
"Like politics at home"-The motion picture served toincrease the desires of the mission members to see the Soviet medical servicefirst hand, but the actual departure was not to be for quite some time.Partially, perhaps, as a result of this interminable waiting, the solidarityamong the members became strained. By the time 13 June arrived and the missionwas still awaiting travel instructions, Colonel Cutler was quite concerned. So,apparently, was General Hawley, for he called Colonel Cutler by telephone andasked him about the situation. There were varying claims as to how the missionhad originated and who was responsible for its establishment. There was aquestion as to who was going to head the mission. Instead of the senior militarymembers from the United States and the United Kingdom, there were strongindications that Colonel Davis was being selected to represent the NationalResearch Council of the United States and that Mr. Ernest Rock Carling wouldrepresent the British Medical Research Council.
"Real trouble is my worry over the Russian mission," the diaryentry for 13 June reads, "Have warned General Hawley and C. Spruit-thewhole 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 GeneralHawley. General Hawley is to see the Ambassador at 4:30. No definite news, butPRH wrote our orders: "To help Gordon Gordon-Taylor, head of mission, andto carry out mission`s protocol * * *." Also, I saw PRH`s wire to TheSurgeon 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`smeeting with Ambassador Winant, as follows:
Saw General Hawley after he saw Ambassador Winant. As Ithought, the Ambassador wants Loyal [Davis] to represent National ResearchCouncil in mufti. General Hawley told the Ambassador that was a mistake. TheAmbassador 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 viaCairo. Good.
So strong was this rumor about members of the mission going to the SovietUnion 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 Sheldonhad simply stated that Admiral Gordon-Taylor would go in uniform or else hewould not go at all.45
45Letter, Sir Gordon Gordon-Taylor to Paul R. Hawley, M.D., 9 October 1958.
97
Finally, on Sunday, 20 June, after receiving a message from Mr. Carling,Colonel Cutler felt constrained to admit that it was all "too bad-likepolitics at home."
Departure -The mission finally departed on 28 June 1943 with themilitary members in uniform. Admiral Gordon-Taylor, as one of the two rankingmilitary members of the mission and representing the senior British service, theRoyal Navy, had been officially recognized as the head of the mission. ColonelDavis had been confirmed as the representative of the Committee for MedicalResearch of the National Research Council, U.S.A.; Mr. Carling, as therepresentative for the Medical Research Council of Great Britain; and ProfessorPenfield, for the Medical Research Council of Canada. Mr. Watson-Jones was goingas a civilian consultant to the Royal Air Force. General Hawley had approved thetaking of 2,000,000 units of penicillin from the stockpile at the 2d GeneralHospital as a gift for the Soviet peoples. And, finally, all official paperswhich were to be taken by the mission had been censored and sealed.46
Desires of mission expressed -The mission, upon arriving in Moscow, wasdelayed in getting about its business for reasons unknown. The members of themission took the opportunity to compose a memorandum to the Soviet authoritieson its intents and desires, as follows:
The Delegation of American, British and Canadian surgeonswishes to thank the Soviet authorities for having so kindly made possible theirvisit to the Soviet Union, and hopes during its stay to study the methods usedby Soviet surgeons in the treatment of battle casualties, reports on the successof 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 thetreatment of fractures caused by weapons of war is the primary object of theDelegation.
The second object of the Delegation is to confer on ProfessorsBurdenko and Yudin, who are known abroad as two of the most distinguishedsurgeons of the Soviet Union, Honorary Fellowships of the Royal College ofSurgeons of England and Honorary Fellowships of the American College ofSurgeons.
As regards the second of these objects, the Delegation isanxious to come to an agreement with the People`s Commissariat regarding thedate and place of the ceremony at which the Fellowships will be conferred. TheDelegation trusts that the ceremony will be conducted with due dignity andpublicity and that the People`s Commissariat will agree that the diplomaticrepresentatives of Great Britain and the United States should be invited toattend. For purposes of record in Great Britain and the United States it wouldbe appreciated if the ceremony could be photographed and prints made availableto the Delegation before its departure.
As regards the first object of the mission, the study ofSoviet methods of treating fractures caused by weapons of war, the Delegationtrusts that it will be given opportunities of seeing the work of Soviet surgeonsat all stages in the treatment of battle casualties, and that each member of theDelegation 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.
98
surgeons specializing in his field theproblems in which he is particularly interested. The Delegation believes thatthis could best be accomplished if facilities were granted for visiting forwardmedical units, inspecting methods for the evacuation of the wounded, andvisiting hospital units, medical institutions and rehabilitation centres in thebase area.
The Delegation, in addition to fulfilling thetwo basic objects described above, would be glad to learn of any other surgicalprocedures which the Soviet authorities may consider of interest in thetreatment of battle casualties, and the members of the Delegation, if requestedto do so, will gladly furnish any information which they may themselves possess.
The British members of the Delegation havebeen requested by various medical organizations in the United Kingdom to presentto the Soviet authorities a list of medical questions which it has not beenpossible to raise hitherto owing to the absence of any convenient channel ofcommunication. The Delegation would be most grateful if facilities could beoffered to its members to study these questions during their visit.
The Delegation has brought a number ofpublications and photographs which may be of interest not merely to individualsurgeons, but to the Soviet medical authorities in general, who may already havebeen made acquainted with them by their representatives abroad, such asProfessor Sarkisov in Great Britain and Professor Lebedenko in the UnitedStates. The Delegation would be glad to learn whether books and journals of thisnature are of assistance to the Soviet authorities and if so whether the Sovietauthorities would like to be regularly supplied with similar publications.
The Delegation has brought 2,000,000 units ofPenicillin which the United States Medical Corps wish to present to the Sovietmedical authorities.
Certain members of the Delegation have alsobrought a number of new surgical instruments for presentation to the appropriatemedical authorities at the discretion of the People`s Commissariat.
Several members of the Delegation carry withthem letters of introduction and greeting addressed to prominent Sovietsurgeons. They would be grateful for advice as to the correct procedure fortransmitting these letters to the addressees.
A number of members of the Delegation havealso brought in their individual capacities certain publications on surgerywhich they would like to present to individual Soviet surgeons interested in thevarious fields of surgery which the publications cover. In some instances themembers of the Delegation have in mind the individual Soviet surgeons to whomthey wish to present these publications. In others they would welcome the adviceof the People`s Commissariat regarding the most suitable candidate forpresentation. In both cases the advice of the People`s Commissariat is soughtregarding the procedure to be followed.
The Ministry of Supply have requested theSoviet Trade Delegation in London to clear up certain questions connected withmedical supplies ordered by the Soviet authorities. While not wishing toduplicate their request for elucidation of certain items which they have notproperly understood, the Ministry have informed Mr. Rock Carling of the pointson which they require further information, and Mr. Rock Carling would be glad todiscuss these points with the competent Soviet authorities if the latter shouldconsider it desirable. There are in addition one or two other questions ofdetail regarding medical supplies to the Soviet Union which the Delegation isanxious to raise.
General Monro has brought with him certainmemoranda regarding the work of the Directorate of Army Psychiatry. If theSoviet military authorities are interested in this branch of medicine he wouldbe glad to make available to them the material which he has brought with him.
Lastly, if the Soviet authorities should wishto discuss questions of medical research or explore the possibility ofestablishing closer medical liaison between the Union of Soviet SocialistRepublics and the countries represented by the Delegation, the Delegation wouldbe glad to discuss these questions with them. The surgeons who represent the
99
Surgical Committee of (1) The Medical Research Council ofGreat Britain (Mr. Rock Carling); (2) The Committee for Medical Research and theNational Research Council, U.S.A. (Lt. Col. Loyal Davis); (3) The NationalResearch Council of Canada (Prof. Wilder Penfield) will also gladly discuss thework of these Committees and the methods by which surgical information is nowbeing exchanged between these three countries for the use of the variouscombatant services.
Investiture of Burdenko and Yudin into Royal College of Surgeons and AmericanCollege of Surgeons- One of the highpoints of the delegation`s visit tothe Soviet Union was the conferring of honorary fellowships to Academician Lt.Gen. Nicolai Nilovich Burdenko and Prof. Serge S. Yudin in the Royal College ofSurgeons and the American College of Surgeons. Academician Burdenko occupied aposition in the Soviet Army Medical Service equivalent to that of chiefconsultant in surgery. Professor Yudin had been outstanding for his surgicalaccomplishments at the Sklifossowsky Institute. The investiture of these twoeminent Soviet surgeons into the American College of Surgeons was accomplishedby Colonel Cutler and Colonel Davis. The formalities were preceded by thefollowing address presented by Colonel Cutler:
This gathering is momentous. We doctors now signify to thesolidarity and common purpose of a majority of living peoples. The occasionjustifies the hope that this junction of our races is but the beginning of afriendly and cooperative liaison for all time. As a token of this spiritualunion Colonel Davis and I are empowered to grant Honorary Fellowships in theAmerican College of Surgeons to two distinguished Russian surgeons, a functionwhich heretofore has never occurred beyond the confines of our own country.
* * * * * *
We congratulate ourselves that in this tumultuous world men ofsuch eminence have found in service to the State a way of life that bringssatisfaction to all.
Academician General Burdenko`s acknowledgment (fig. 41) of thisunprecedented and unique honor of being made a member of both these greatorganizations simultaneously and on soil foreign to the sponsoring organizationsfollows:
I am deeply moved by the honor of electing me member of theAmerican College of Surgeons.
I understand this honor as a generous approval of my papersand my work in the past and present. It makes me think about my work in thefuture, particularly now when the fight against Fascists has reached a decisivestage.
I recognize this election to be of deep and wide meaning.
The last decade has shown that the United States is now thecenter of medical science, and scientific problems are to be solved from thepoint of view of American science.
During this year I have received very many proofs of attentionfrom the United States.
My contributions to world science and field surgery are butmodest. 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 uponhim follows:
You will easily understand my animation when immediately afterone high honor the surgeons of a second great Allied country-the U.S.A.-bestowon me another.
100
101
I know little of your beautiful country. I amproud of my personal acquaintanceship-and even friendship-with George Crile,Howard Kelly, the late Mayo brothers, and some other American surgeons of worldfame.
But could I dream 15 years ago that the time would come when Ishould 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 greatHarvey Cushing`s successor.
By the way, it is an astonishing fact that the day of mydecoration by the Allies completely coincides with the day I was severelywounded by a German shell on the eve of July 15, 1915.
For the second time in the same quarter of a century ournations are united in their hard efforts to save their countries and the world`scivilization. Now, just as it was the first time, we are fighting with the sameeternal dangerous enemy-Germany. But as it was on the first occasion, ourBritish Allies are fighting again on our side.
Victory will be ours. Nobody has any doubts about it, even ourenemies. Let our scientific relations which have begun in a time of suchstrained military needs get stronger and flourish more and more after thisvictory and the won peace.
In the time of struggle, surgery is as necessary for victoryas arms, transport, and all kinds of supplies. But when the last gun of theenemy ceases and released humanity turns with hope to the restoration of greatdestruction caused by the war, we surgeons will have to heal the wounds andinjuries of hundreds of thousands of people, who have won for us this victory.
Your high election of me as honorary fellow of the AmericanCollege of Surgeons will serve as a new additional stimulus for furtherdevelopment of my scientific work in surgery, which has already received fromyou such high estimation.
I once more deeply and sincerely thank you.
The official acknowledgment of this auspicious event on behalf of the SovietGovernment 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 RoyalCollege of Surgeons of England presents itself to us, witnesses of this act, asan occasion of great cultural and political meaning.
The Royal College of Surgeons of England since long ago hasbeen famed as an organization, responsible in no small way for the developmentof surgery both in England and outside her boundaries. Amongst the fellows ofthis College have been, and are now some of the outstanding representatives ofEnglish surgical thought. The greatest exponents of surgery of othercountries have earned the honor of being honorary fellows of this College sinceits creation, in accordance with its established and glorious traditions. Onevery occasion the selection of honorary fellows amongst foreign scientists hasbeen an unbiased and just appreciation of their really great technicalcontributions. Therefore, selection to an honorary fellowship of the RoyalCollege of Surgeons of England has always been a distinction in the eyes of theworld`s scholars. Similarly, the glory of the American College of Surgeons iswell known.
We are glad in the knowledge that, today, the choice of theRoyal College of Surgeons and the American College of Surgeons should havefallen on the two best representatives of our native surgery. Both the newhonorary fellows of the Colleges, Academician Burdenko and Professor Yudin, aredeservedly famed in our country, and outside her boundaries, as leading expertsin the realm of their specialties. Not for nothing are they both worthy of thehighest scientific decoration of our country-the Stalin Prize; whilstAcademician Burdenko with honor holds the title of Hero of Socialist Work.
102
103
The outstanding contributions of AcademicianBurdenko 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 certainthat he will be a worthy member of the glorious family of the finestrepresentatives of contemporary surgery that is combined in the Royal College ofSurgeons and the American College of Surgeons. Professor Yudin will bear thetitle of Fellow of the Colleges with equal honor and worthiness. His name istied with great successes in abdominal surgery, in plastic operations on thealimentary tract, in blood transfusion, and in the prophylaxis and treatment ofinfected wounds, etc.
We, the representatives of the family of Soviet medicalworkers, are today justifiably proud of the great honor bestowed on AcademicianBurdenko and Professor Yudin. At the same time we express our sincerestappreciation to the Royal College of Surgeons of England and to the AmericanCollege for this mark of distinction. In the name of the People`s Commissarand in our name I ask you, Mr. Vice-President and Colonel Cutler, to convey ourthanks to your organizations. In the name of the People`s Commissar and in ourname I congratulate Academician Burdenko and Professor Yudin on their selectionfor the honorary fellowship of the Colleges.
104
Today`s occasion takes place in days ofbitter warfare against the cruel enemy of progressiveness-Hitler`s Fascism!In this war, our medical teaching has extensively become the teaching of warmedicine, and it helps our armies in their struggle against this cruel foe. Theadmission of the most famous Soviet scientists to the honorary fellowship of theColleges marks in itself a strengthening of the scientific ties between theallied nations. I am certain that those ties will strengthen further in thecontinuation of this struggle to complete victory over our common enemy.
Summary of observations on military medicine and surgery inU.S.S.R.-On their return to the United Kingdom, Colonel Cutler and ColonelDavis prepared jointly a concise summary of their full report. (appendix A, p.953) for General Hawley. They asked that special consideration be given thefollowing topics because they appeared to be of chief value to the MedicalDepartment of the U.S. Army.
Care of the lightly wounded.
These are early segregated into specialhospitals and are preferably kept in these hospitals in the forward area, notsent to the base. Secondary suture of all wounds is practiced early.Rehabilitation and reconditioning exercises begin at once and the men arerestored often within a month to active duty.
Cleansing facilities, i.e., bath andbarbers in all hospitals.
This is a great contribution to militarysurgery * * * every soldier, unless he be urgently required in the operatingroom, goes first to the barber and a room where he can be washed. This issincerely appreciated by the troops and is something we should emulate in ouropinion.
Facilities for Blood Transfusion.
The [full] report emphasizes the great amountof blood used in the Russian Army and its easy availability. Though thisdoubtless wasted some blood it made it certain that every wounded man could getblood if that was desirable. We should establish a system making blood as wellas plasma available to our forward hospitals.
Laundry facilities.
In the Russian Army the medical departmentcontrols laundries serving the hospitals. In the Russian Army laundries are setup and serve a group of adjacent hospitals. We suggest that a similar set up beprovided for the medical department U.S. Army. This might be in the ratio of onelaundry to a Corps surgeon.
Surgical specialization.
The Russians begin major specialization at theforward hospital level. This provides that in the more important fields ofsurgery soldiers are given what the specialist thinks is wisest from the verybeginning of his treatment.
Sorting and triaging.
This is carried out beautifully at the forwardhospitals and emphasizes the organization of forward hospitals found necessaryin the last Great War. If large numbers of wounded people are to be competentlycared for, some systematic sorting must occur. In the Russian Army thispermitted the segregation of slightly wounded in hospitals in the forward areaand their rapid restoration to duty; it facilitated the care by specialists ofthose needing special care and it greatly facilitated the major problem ofevacuation.47
Soviet Union and its people.-Colonel Cutler couldnot help but be impressed with the Soviet scene in general, and, patriot that hewas, he felt it his duty to make these impressions known to those who might beable to take advantage of them in their official duties. He realized that hisopportunities 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.
