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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
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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.
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FIGURE 19.-Headquarters, V Corps, U.S. Army, at Clifton College, Bristol, England, 16 March 1943.
Colonel Kimbrough forwarded the letter to General Hawley 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
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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.
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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.
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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:
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FIGURE 21.-Lt. Col. William F. MacFee, MC.
The statistics show that the sulfonamides,even taken and given under the optimum conditions, do not keep infection 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
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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.
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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.
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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.
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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."
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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.
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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.
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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.
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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.
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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 Blood Transfusion unit isthe final product of months of experimentation with Major Emerson and MajorEbert of the 5th General Hospital.
2. In discussion with Colonel Perry we propose that if FieldMedical Chests are scarce the wooden boxes in which our U.S. Army plasma arriveswould act as suitable containers.
3. Two types of units may be dispensed.
a. The complete unit as listed for teams going into combat area.
b. A unit for hospital use consisting only of those items not available in static hospitals (chiefly bleeding and giving sets with citrate and large needles).
4. We believe the officers responsible for thisstandardization, 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 Zone of Interior
Blood collected in the Zone of Interior can be delivered tothe E.T.O. only by air transport. The collection, processing, and initialdelivery to a depot in the United Kingdom would be a function of an agency inthe Zone of Interior. Its reception, internal storage, and distribution to thebase unit and/or * * * transfusion teams would be the responsibility ofthe depot located in the United Kingdom * * *. The depot would necessarilybe located near an airport and would provide adequate refrigeration for theblood throughout its entire handling from the time of unloading the plane.
Collection of Blood in the U.K.
Blood can be obtained from two sources in the U.K.:
1. Base and SOS Troops.
2. Civilians (British).
The first * * * is somewhat problematical since thetroops * * * are scattered over a wide area and because thebleeding would take place during periods of activity when those troops will beleast available. The second source is probably the better. To put it intooperation would entail taking over an area in the U.K. where the civilians couldbe bled. This area must be outside of the British Army Area (roughly SouthernCommand) and * * * the London area where the EMS bleed heavily tosecure plasma for drying.
Organization of such an area would include enrolling ofdonors and procurement of bleeding centers. * * *
Bleeding Teams
These teams must be mobile and carry with them all of theequipment necessary to do one day's bleeding. Such a team when bleedingmilitary personnel can bleed 150 per day
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provided that a constant stream of donors is madeavailable. British teams bleeding civilians average 75 per day.
Depot
This unit serves as a base from which the mobile[bleeding] teams work. It supplies the teams with all the apparatus needed and maintains** * vehicles. Records are kept of the bleeding, apparatus [is] reconditionedand assembled, and blood [is] processed. This includes serologic tests,typing, addition of glucose, and bacteriologic control. Here also internalstorage of blood must be undertaken, which requires the provision of adequaterefrigeration.
Distribution to the Field
Behind any force there must be a base unit which drawsblood from the depot and distributes it to the shock teams. This unit may besmall and simply concerned with supply of blood or like the British unit becapable of producing crystalloid solutions as well as distributing blood andplasma. It must be equipped adequately to be able to recondition apparatus andcarry out sterilization. It must also have mobile refrigeration.
Refrigeration
Blood is ideally kept at +3? to +6?C. It must not be frozenand undergoes considerable deterioration if the temperature of storagefluctuates greatly. Two types of refrigeration may be used:
1. Ordinary refrigerator capable of maintaining the requiredtemperature. This type of refrigeration calls for fitting of airplanes andtrucks with refrigerators. It is the type of refrigeration used by the BritishArmy Transfusion Service and has worked well in practice.
2. Refrigeration by melting ice: Ice melts at+4?C whichis the ideal temperature for blood storage. By the utilization of compartment boxes intowhich ice and bottled blood can be placed inseparate chambers an adequate but simple type of refrigeration is obtained. Toutilize this to the fullest extent, lightweight well insulated containers couldbe built to hold 10 to 20 bottles of blood. Such containers under ordinarytemperature conditions will hold ice for 72 hours.
Advantages: Simple, accurate refrigeration, with nomachinery to break down. Dispersal of stores possible. Containers can becarried in any plane or vehicle without special installation.
Disadvantages: Procurability of ice. Ice making machineswould be necessary in the base unit and perhaps in the depot.37
In summary, Colonel Cutler had shown howtransfusions couldbe accomplished by "bleeding on the hoof," by obtaining whole bloodfrom the Zone of Interior, by bleeding British civilians, and by bleeding U.S.Army service troops. Each of these proposals posed an enormous logisticalundertaking to implement. It was certainly beyond the prerogatives of the ChiefConsultant in Surgery to decide which steps would be taken. Hence, his closingwords to the Chief Surgeon asked for "instruction to Professional Servicesconcerning the method selected for supplying a Continental Task Force withwhole blood that we may assist in implementing such decision * * *."
During Colonel Cutler's absence in the Soviet Union,General Hawley approved the construction and assembly of the field 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.
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States.38 He directed that the consultant group go ahead withplans for collection and distribution of blood and that the British beconsulted with reference to preservation and storage.
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 designed and hadbeen approved for clearing companies, evacuation hospitals, field hospitals, and auxiliary surgical groups.One hundred of these chests were being packedat Medical Depot G-35. Clearing companies and evacuation hospitals were toreceive 2 chests each, while field hospitals were to receive 3 chests, andauxiliary surgical groups, 10.
2. A smaller unit had also been designed which was builtaround a new quartermaster item known as the "man pack carrier." Twohundred of these man-pack-carrier, blood-transfusion sets were to be assembledas soon as the pilot model was approved and the quartermaster carriers becameavailable. Two of these kits were to be distributed to each collecting companyand regimental medical detachment.
3. The standard, approved transfusion bottles for both thechests and the man-pack-carrier units were being assembled at the 5th GeneralHospital.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 thatthe latter request Washington for the assignment of an auxiliary surgical groupto the European theater. By early 1943, he had gained considerable experiencein current Army ways and felt quite capable of coping with the problems involvedin coming forward with specific recommendations for the organization andequipment of 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 mobilesurgical team. On 16 February, he attended a session at the RAMC Collegeduring which Maj. Gen. David C. Monro, RAMC, newly appointed consulting surgeon tothe British Army, gave a brilliant discourse on hisexperiences of 2 years in
38There is strong implication in the early part [ofthe manuscript] that the Chief Surgeon's disapprovals of some of therecommendations of the consultants were purely arbitrary and capricious. Thetruth is that, throughout the war, the Chief Surgeon had top secret informationwhich he could not share even with his deputy; and many of these adversedecisions were based upon such information.
"One example of this is the account of the reluctanceof the Chief Surgeon early in the war to attempt to obtain wholeblood from the Zone of Interior. The reasons for this were (1) that the transatlanticairlift 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 theChief 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 ChiefSurgeon, ETOUSA, 10 July 1943. (2) Letter, Col. J. H. McNinch, MC, to ChiefSurgeon, ETOUSA, 26 July 1943, subject: Status of Development, Procurement andDistribution of Blood Transfusion Kit for Mobile Medical Units.-OperationalDir. #28.
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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,Colonel Cutler recommended that (1) mobility must be forced on all of themedical services, (2) this could probably be best achieved by mobile surgicalunits based on parent units which would continue to supply and administer them,and (3) a certain amount of segregation of casualties by anatomical groups wouldbe necessary in the rear areas for better surgical therapy. He concluded:"I believe that there are many lessons in this talk from which we shouldbenefit, and benefit now. * * * Perhaps this first-hand experience will bring theMedical Corps of our Army face to face with what I believe to be a major issue,which must be solved before we get into a real battle."40
At about that time, Lt. Col. Herbert Wright of the Eighth AirForce had submitted a special report to the Chief Surgeon in which he broughtGeneral Hawley's attention to the situation which confronted the AirForces in Cornwall. Many crippled aircraft returning from combat missions werelanding at RAF fields in this area with frequent serious casualties among theircrews. The nearest American hospital at Exeter (fig. 26) was some distance awayfrom
40Letter, Col. E. C. Cutler, MC, to Col. J. C.Kimbrough, MC, 16 Feb. 1943, subject: Summary of Talk by Maj. Gen. D. C.Monro, 11 Feb. 1943, at the RAMC College.
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this area, thus precluding the transfer of 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 medicalfacility to 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 whenit was not fully engaged in treating U.S. Army Air Forces casualties.
FIGURE 27.-Maj. Robert M. Zollinger, MC.
When this suggestion received General Hawley's approval,Colonel Cutler asked Maj. (later Col.) Robert M. Zollinger, MC (fig. 27), ofthe 5th 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 teamfrom an auxiliary surgical group, and (3) the team should take all thematerials necessary for lighting and for surgery to cover 50 to 100 majorsurgical casualties 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.
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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 operatingroom nurse, four ward nurses, and their necessary equipment was ready to go atthe 5th General Hospital. General Hawley and Colonel Cutler visited the 5thGeneral Hospital on 6 March and looked over the equipment for the team. On 14March, the director of the Royal Cornwall Infirmary telephoned Colonel Cutlerthat the institution was ready to receive the American contingent. The next day, Col. Maxwell G. Keeler, MC,commanding officer of the 5th General Hospital, and Major Zollinger went to Truro to makefinal arrangements. Ten days later, the surgical unit was well established andworking. Their work and attitude created a most favorable impression at theinfirmary (fig. 28). Within a month, as planned, this unit from the 5th GeneralHospital was relieved and returned to its parent unit, and a team of similarcomposition from the 3d Auxiliary Surgical Group took 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
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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 ofthe buttocks, and compoundfractures, especially in the joints. They were assignable on the basis of twoper 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 to those whichhave preceded it because the need for mobility in our forces is increasing, andbecause of recent attempts to reorganize the teams as they now appear in theAuxiliary Surgical Group.
2. The regrouping of teams in the Auxiliary Surgical Groupwas submitted to the Chief Surgeon by Colonel Mason. In this regrouping it wasmade clear that practical experience in this war had but corroborated theexperience obtained in the last war, that the surgeon in the forward area mustbe a general surgeon. In the last war we had: a. General surgical teams, b. Shock teams,c. Splintteams. This resulted because experience showed that the general surgeonmust be the one to do the work in the forward area. Also it was found he neededas a colleague somebody to help put on the splints when compound fracturesexisted, just as he will today need such an expert colleague to put on theplaster for immobilization rather than the Thomas' splint used in the lastwar. Also, if the general surgeon is to be kept busy all the time at what he isbound to do, i.e. surgical operations, he should have as a further colleague aman trained in resuscitation and shock who can treat the cases before anoperation and then care for them afterwards, thus freeing the surgeon's timefor constant application to his handicraft in the operating theater. Thiscombination of experts needs highly trained personnel working at top speed intheir selected fields, and accomplishes the maximum overturn of labor in theshortest period of time. It would appear to me that the Auxiliary SurgicalGroup
42Dispatch, The War Office, London, 2 April1943,subject: Field Units (F.S.U.'s. M.E.F.W.E.).
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teams should be re-organized on a basis similar to thethinking above. In my mind, the best team would be one in which the surgeon wasa general surgeon, the assistant surgeon, however, an orthopedic individual orat least a surgeon properly trained in plaster technique. In addition, eachsurgical team would need a man trained in shock * * * though I believe thatwhere two surgical teams were out together to a single installation, one shockteam might care for the work of two surgical teams. The defect in the AuxiliaryGroup is that they only carry with them their instruments and would have to begiven all of the rest of the impedimenta of operating theaters by thehospital to which they were attached.
3. Mobile surgical teams.
The use of the term "mobile surgical team" iscoined to describe a setup somewhat different to that above, for in thissetup the team is to have its own transport and take with it everything itneeds 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 noticebecause it has its own transportation to any point desired by the corpsor army surgeon. To my way of thinking it might best be placed at theclearing company of a division, and the only matter which is not settled in ourminds is whether this mobile surgical group, with its team and shock men andsupplies should take its own tentage or not * * *.
As stated in previous memoranda, I am opposed to buildingin of the apparatus into the truck, feeling that something might happen tothe truck and thus immobilize the team. If the material can be easily put intoa truck and then taken out, then any truck will suffice, and complete freedomand mobility is assured. The TB/A of such a mobile surgical team as opposed tothe teams now organized in our Surgical Group is appended. It is largely thesystem set up by the group from the 5th General Hospital, with changes, bothdeletions and additions, as suggested in our Consultant Group and by our Britishcolleagues.
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 seemed to be the ideal unit for providing emergencylighting for the mobile surgical team in the event of power failure, and ColonelCutler on his return immediately ordered a sample unit for trial and study.Later that week, he was able, with the cooperation of Col. Charles E. Brenn,MC, the U.S. V Corps surgeon, to select and set up tenting for the proposedmobile surgical team. The feasibility of the tents for operating pavilionswas tested, particularly under blackout conditions.
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
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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 the enlisted men ofthe surgical and shock teams.
With reference to the shock team (fig. 31), Colonel Cutlerexplained:
We have called the second group a transfusion-laboratorygroup because as we visualize the work of a surgical team in the forward area itwill require a transfusion team to attend to the resuscitation of its patientsbefore the operation and to care for them afterwards. Moreover, this group willdo work such as blood counts, examination of the urine, determination ofhemoglobin for better treatment of shock, occasional microscopic examinationof smear preparations from joints, spinal canal, etc., and occasional microscopicexamination of the bacterial flora in the wound, where the finding of gasbacillus forms might strengthen one's hands 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 containerfor medical chest number 1 with a total packed weight of approximately 1,800pounds, and 2 used the container for medical chest number 2 with a total packedweight of approximately 250 pounds. The basic instrument set, stock number93212, 1942 model,
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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 5th General Hospital who assisted in the preparation ofthe list and had some further 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 amobile surgical 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 thetransfusion-laboratory team 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 AuxiliarySurgical Group to teach the rest of their teams this same matter and to teachin the Medical 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, toCol. J. C. Kimbrough, MC,22 May 1943, subject: Further Regarding Mobile Surgical Unit.
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FIGURE 32.-A chest containing orthopedic supplies and equipment for a mobile surgical unit.
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FIGURE 33.-A tray used by the anesthetist of a mobile surgical unit.
FIGURE 34.-A suction apparatus with an improvised holder, used by a mobile surgical unit.
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FIGURE 36.-Pitching an operating room tent of a mobile surgical unit.
Finally, in a hectic rush to complete all aspects of themobile surgical unit plan prior to his trip to the U.S.S.R., Colonel Cutlerwas able to report to the Chief Surgeon by letter, on 15 June 1943, thefollowing:
Certain changes have been made in the TBA submitted [6May1943], and we now submit TBA in final form after repeated experimentation inpacking and unpacking and experimentation with tents.
Many photographs have been taken of the unit * * *duringprocesses of assembly and with patients being operated upon in the tent (fig.38). These should arrive shortly. A film including the setting up operation andtaking down of the unit, has been made and is now being put in order by theSignal Corps, and should also be in your hands shortly.
Lt. Col. Robert Zollinger who has beenexperimenting withthis problem under our guidance since February 1943, is writing up the completefunctioning of the unit in the hope that you will send this back to The SurgeonGeneral for his information and publication.
We have arranged with Major Pisani, E.T.O. Medical FieldService School, that this unit be demonstrated as a part of the exercises in the next classes.
While the principles of assembling the necessary equipment forthe supply of a surgical team in the performance of at least ahundred major operations was followed by auxiliary surgical groups, it wasrarely, if ever, necessary for a surgical team to function as an isolated unitduring the combat period of operations on the Continent during 1944-45.Instead of utilizing their own tentage, lighting, and other heavy equipment,surgical teams invariably utilized the facilities of the unit to which theywere attached; that is, field and evacuation
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FIGURE 37.-Portable operating light, equipment of a mobile surgical unit.
FIGURE 38.-The arrangement of the operating tables of a mobile surgical unit.
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hospitals. The teams carried with them and 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 attended a dinner givenby Mr. Broster, following his first Inter-Allied Medical Meeting. In responding for you I thanked President Tidyand the group in the RoyalSociety of Medicine of our colleagues for all that they have done for us. Ithen pointed out what I thought might be the value of all the Allied peoplegetting to know something of each other. At that time I said I was greatlyconcerned that I had been unable to meet a Russian, and I thought this was a pity,and wondered if there are any Russians in London. Sir Wilson Jameson and Sir AlfredWebb-Johnson and other people who knew all about theRussian difficulty, and that a British hospital ship had even reached Murmanskand had been turned back again, were much upset. They have talked to merepeatedly about this, and apparently had been to the Foreign Office again. Ilearned yesterday that a request might shortly be made for three Britishmedical officers, and three American medical officers, to visit Russia. Ithought you should be apprised of this possibility early. It appears to me that a country who must have hadmillions of casualties should be able to teachus a good deal about military surgery and military medicine.
Colonel Cutler's diary states, for 29 January: "I'mgetting worse at this [keeping up the diary], just when it is getting interesting.For example, Russia. I have long been worried I couldn't find a Russia.I've spoken of it as a reason for the Inter-Allied Conferences. I spoke of itat a dinner with Fraser, Sir Wilson Jameson, Sir Alfred Webb-Johnson, Dean * * *of the Graduate Schools, and Broster (his dinner). As aresult, I now have a commission of 3 British and 3 American medical officersto be asked to go to Russia."
Colonel Cutler had just returned to Cheltenham from a tripto London, Basingstoke, and Chatham on the morning of Saturday, 10 April,when General Hawley called him to his office in the afternoon andinstructed him to see the U.S. Ambassador in London about the trip to theSoviet Union. Dutifully, Colonel Cutler turned around, went back to London thenext day, and saw John G. Winant, U.S. Ambassador to the Court of St. James's(fig. 39), in the late afternoon. On 16 April, he reported on this meeting byletter to General Hawley (through Colonel Kimbrough). A portion of this letterfollows:
We discussed at great length the rumored joint medicalmission 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 thaton April 16 Surgeon Rear Admiral Gordon-Taylor was lunching with M. Maisky, theRussian Ambassador, * * *, and that members of the BritishCommission were now instructed to get their passports. (British Commissionheaded by Surgeon Rear Admiral Gordon-Taylor, other members, Maj. Gen. Monro,Mr. Rock Carling.) Finally he promised * * * to see M. Maisky, Mr. Eden,and Sir Edward Mellanby [on 15 April], and give you a final report.
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Mission established.-On 19 April, Colonel Cutler was givena message to call Admiral Gordon-Taylor. Mrs. Gordon-Taylor answered and informedColonel Cutler that he and Lt. Col. Loyal Davis, MC, were to go to the SovietUnion with the English mission (fig. 40). Colonel Cutlerwas elated. He recorded: "This is something I have been working onfor 4 weeks and indeed feel partly responsible for. Now I am getting somewhere! We'reto go in about 3 weeks; in May. Knownothing more. Of course it is a risk, but that is small compared to what othersare doing. I'm happy for a moment."
Preparations for departure.-The next fewweeks were kaleidoscopic for the Chief Consultant in Surgery. There wasso much to be done before leaving, and yet details concerning the mission tothe U.S.S.R. took time in 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 inOrthopedic Surgery to the Royal Air Force, and Mr. Ernest Rock Carling; andthat the U.S. representatives would be Colonel Cutler and Colonel Davis.Admiral Gordon-Taylor also confided to Colonel Cutler that he was learningRussian. Later that day, Colonel Cutler had a talk with General Hawley, afterwhich he recorded: "[General Hawley] informed me that the Ambassadorthought: (1) There should be separate missions, and (2) threeU.S. members. General Hawley and I agreed the joint mission was best. As to the third member, the
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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 who was to head the American representation, Colonel Cutler spoke again with General Hawley who confirmed the fact that Colonel Cutler would head the American representation. He then saw Admiral Gordon-Taylor again. The admiral approved the giving of fellowships to two famous Soviet surgeons, N. Burdenko and Serge Yudin,44 by the American College of Surgeons, and Colonel Cutler went back to General Hawley with this information.
By the middle of May, Colonel Cutler and Colonel Davis had written to the American College of Surgeons for permission to bestow the honorary fellowships. The ceremonial hoods had been borrowed from two Englishmen, Admiral Gordon-Taylor and Mr. Harry Platt, with the promise that these would later be replaced. The speech of investiture was then approved by General Hawley. There was also some confusion as to the diplomatic channels through which the names of the American representatives would be submitted to the Soviet Government, but the matter was eventually taken care of and
44The variation in the spelling of the names of Russian individuals in this volume is due to the fact that there are two systems of transliteration in use.
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passports were obtained on 11 May. On 13 May, Professor Sarkisov, an assistant to Academician Burdenko, arrived in England from Vladivostok and was introduced at a luncheon held at the Royal College of Surgeons. He gave the most comforting assurance that the mission would, in all probability, be warmly welcomed in the Soviet Union. And, finally, word was received that Prof. Wilder G. Penfield of McGill University, Montreal, Canada, would be added to the mission.
There was no further clarification, as of 15 May, as to when the mission would leave. But, with the arrival of Professor Penfield, the membership of the mission was complete, and amenities preparatory to departure continued at a high pace. As an example, on 24 May there was a luncheon given by the British Council for the mission at Claridge's in London. There was also a serious talk with the U.S. Ambassador on what to do and not to do while in the Soviet Union. Finally, there was tea at the Soviet Embassy, 13 Kensington Palace Gardens, given by Ambassador Maisky. With respect to the Soviet ambassador's tea, Colonel Cutler's comment was: "Tremendous." As to the meeting with Ambassador Winant, Colonel Cutler reported as follows in a letter to Colonel Kimbrough, dated 30 May 1943:
* * * He gave Colonel Davis and myself explicit verbal instructions, butsaid he did not wish to give us anything in writing, emphasizing that we shoulduse our own discretion, and hoping that we would get on well with our Russiancolleagues. The latter was emphasized as highly important, since if this missionis happily received others of great importance may be allowed to follow.Ambassador Winant made it very clear that the instructions to which weshould adhere closely were to discuss nothing except professional medicalmatters. He emphasized this point by stories of diplomacy wrecked on therocks of missions going beyond their protocol. He urged us to take anything withus that could enlighten the Russians on American surgical methods, and hoped wemight 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 rearand through 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 were picked up onthe battle field and given preliminary First Aid by a trained first aider. Theythen passed through battalion and divisional aid posts and to hospitalssimilar to our surgical hospitals, where definitive surgery was carried out.Certainly a great attempt was made to give as adequate care as possible, andevery effort was made to restore the soldier to active duty as soon as possible.
The most important observations of interest to me were:
The use of women in the forward area. Women were even in thedivisional aid posts of casualty clearing companies, and from the expressions onsoldiers' faces, even without the spoken word, one felt sure that theirpresence was of great moral value. * * *
Cleaning and bathing facilities. Here, the Russians, whom we have notthought of as a clean people, can give all of us a very good lesson. They hadexcellent bathing facilities
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in their most forward hospitals, and spoke of such facilities as equallyimportant to good surgery. * * *
Air transport. This was greatlyemphasized in the film, and is usedin the care of wounded amongst the guerillas, which is a part of the obligationof 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 seniormilitary members from the United States and the United Kingdom, there werestrong indications that Colonel Davis was being selected to represent theNational Research Council of the United States and that Mr. Ernest Rock Carlingwould represent 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 17June:
Conference with Ambassador, 2:30 PM, and then with General Hawley. GeneralHawley is to see the Ambassador at 4:30. No definite news, but PRH wroteour orders: "To help Gordon Gordon-Taylor, head of mission, and to carry outmission's protocol * * *." Also, I saw PRH's wire to The Surgeon General(written after phone call with me 2 or 3 days ago). Stated:
1. Mission arranged by British
2. American members invited by British
3. Professional protocol (not military)
4. Advises against further powers mixing into this.
The next day, Friday, 18 June, Colonel Cutler reviewed General Hawley's meeting with Ambassador Winant, as follows:
Saw General Hawley after he saw Ambassador Winant. As I thought, theAmbassador wants Loyal [Davis] to represent National Research Council inmufti. General Hawley told the Ambassador that was a mistake. TheAmbassador asked if he could go to Devers! Of course, General Hawley saidyes. General Hawley also saw a letter from Eden saying we leave in about aweek via Cairo. Good.
So strong was this rumor about members of the mission going to the Soviet Union in mufti that Admiral Gordon-Taylor had gone to Surgeon Vice Admiral S. (Sir Sheldon) Dudley, DGMS, Royal Navy, and had asked him about it. Sir Sheldon had simply stated that Admiral Gordon-Taylor would go in uniform or else he would not go at all.45
45Letter, Sir Gordon Gordon-Taylor to Paul R. Hawley, M.D., 9 October 1958.
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Finally, on Sunday, 20 June, after receiving a message from Mr. Carling, Colonel Cutler felt constrained to admit that it was all "too bad-like politics at home."
Departure -The mission finally departed on 28 June 1943 with the military members in uniform. Admiral Gordon-Taylor, as one of the two ranking military members of the mission and representing the senior British service, the Royal Navy, had been officially recognized as the head of the mission. Colonel Davis had been confirmed as the representative of the Committee for Medical Research of the National Research Council, U.S.A.; Mr. Carling, as the representative for the Medical Research Council ofGreat Britain; and Professor Penfield, for the Medical Research Council ofCanada. Mr. Watson-Jones was going as a civilian consultant to the RoyalAir Force. General Hawley had approved the taking of 2,000,000 units of penicillin from the stockpile at the 2d General Hospital as a gift for theSoviet peoples. And, finally, all official papers which were to be taken by themission had been censored and sealed.46
Desires of mission expressed -The mission, upon arriving in Moscow,was delayed in getting about its business for reasons unknown. The members ofthe mission took the opportunity to compose a memorandum to theSoviet authorities on its intents and desires, as follows:
The Delegation of American, British and Canadian surgeons wishes to thank theSoviet authorities for having so kindly made possible their visit to theSoviet Union, and hopes during its stay to study the methods used by Sovietsurgeons in the treatment of battle casualties, reports on the success of whichhave made so deep an impression on the medical authorities in Canada, GreatBritain and the United States.
The study of the methods used by Soviet surgeons for the treatment offractures caused by weapons of war is the primary object of the Delegation.
The second object of the Delegation is to confer on Professors Burdenkoand Yudin, who are known abroad as two of the most distinguished surgeons ofthe Soviet Union, Honorary Fellowships of the Royal College of Surgeons ofEngland and Honorary Fellowships of the American College of Surgeons.
As regards the second of these objects, the Delegation is anxious to come toan agreement with the People's Commissariat regarding the date and place of the ceremony at which the Fellowships will beconferred. 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 itwould be appreciated if the ceremony could be photographed and prints madeavailable to the Delegation before its departure.
As regards the first object of the mission, the study of Soviet methods oftreating fractures caused by weapons of war, the Delegation trusts that itwill be given opportunities of seeing the work of Soviet surgeons at allstages in the treatment of battle casualties, and that each member of theDelegationwill be able to discuss with Soviet
46An account of the observations of Lt. Col. Loyal Davis, while he was enroute to the Soviet Union, his commentary on activities engaged in while hewas in that country, and his remarks concerning the return trip comprise pages420-439 of this volume. Any personal papers which Colonel Cutler may havemaintained during the trip to the U.S.S.R. were not available to the compilersof this chapter. The full official report prepared jointly by Colonel Cutlerand Colonel Davis is added to this volume as appendix A. It should be referredto as an integral part of Colonel Davis' chapter as well as of this chapter.-J. B. C., Jr.
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surgeons specializing in his field the problems in which heis particularly interested. The Delegation believes that this could best beaccomplished if facilities were granted for visiting forward medical units,inspecting methods for the evacuation of the wounded, and visiting hospitalunits, medical institutions and rehabilitation centres in the base area.
The Delegation, in addition to fulfilling the two basicobjects described above, would be glad to learn of any other surgical procedureswhich the Soviet authorities may consider of interest in the treatment of battlecasualties, and the members of the Delegation, if requested to do so, willgladly furnish any information which they may themselves possess.
The British members of the Delegation have been requested byvarious medical organizations in the United Kingdom to present to the Sovietauthorities a list of medical questions which it has not been possible to raisehitherto owing to the absence of any convenient channel of communication. TheDelegation would be most grateful if facilities could be offered to its membersto study these questions during their visit.
The Delegation has brought a number of publications andphotographs which may be of interest not merely to individual surgeons, but tothe Soviet medical authorities in general, who may already have been madeacquainted with them by their representatives abroad, such as ProfessorSarkisov in Great Britain and Professor Lebedenko in the United States. TheDelegation would be glad to learn whether books and journals of this nature areof assistance to the Soviet authorities and if so whether the Soviet authoritieswould like to be regularly supplied with similar publications.
The Delegation has brought 2,000,000 units of Penicillinwhich the United States Medical Corps wish to present to the Soviet medicalauthorities.
Certain members of the Delegation have also brought a numberof new surgical instruments for presentation to the appropriate medicalauthorities at the discretion of the People's Commissariat.
Several members of the Delegation carry with them letters ofintroduction and greeting addressed to prominent Soviet surgeons. They would begrateful for advice as to the correct procedure for transmitting these lettersto the addressees.
A number of members of the Delegation have also brought intheir individual capacities certain publications on surgery which they wouldlike to present to individual Soviet surgeons interested in the various fieldsof surgery which the publications cover. In some instances the members of theDelegation have in mind the individual Soviet surgeons to whom they wish topresent these publications. In others they would welcome the advice of thePeople's Commissariat regarding the most suitable candidate for presentation.In both cases the advice of the People's Commissariat is sought regarding theprocedure to be followed.
The Ministry of Supply have requested the Soviet TradeDelegation in London to clear up certain questions connected with medicalsupplies ordered by the Soviet authorities. While not wishing to duplicate theirrequest for elucidation of certain items which they have not properlyunderstood, the Ministry have informed Mr. Rock Carling of the points on whichthey require further information, and Mr. Rock Carling would be glad to discussthese 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 certain memorandaregarding the work of the Directorate of Army Psychiatry. If the Soviet militaryauthorities are interested in this branch of medicine he would be glad to makeavailable to them the material which he has brought with him.
Lastly, if the Soviet authorities should wish to discussquestions of medical research or explore the possibility of establishing closermedical liaison between the Union of Soviet Socialist Republics and thecountries represented by the Delegation, the Delegation would be glad to discussthese questions with them. The surgeons who represent the
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Surgical Committee of (1) The Medical Research Council of Great Britain (Mr.Rock Carling); (2) The Committee for Medical Research and the NationalResearch Council, U.S.A. (Lt. Col. Loyal Davis); (3) The National ResearchCouncil of Canada (Prof. Wilder Penfield) will also gladly discuss the work ofthese Committees and the methods by which surgical information is now beingexchanged between these three countries for the use of the various combatantservices.
Investiture of Burdenko and Yudin into Royal College of Surgeons and AmericanCollege of Surgeons - One of the highpoints of the delegation'svisit to the Soviet Union was the conferring of honorary fellowships toAcademician Lt. Gen. Nicolai Nilovich Burdenko and Prof. Serge S. Yudin in theRoyal College of Surgeons and the American College of Surgeons. AcademicianBurdenko occupied a position in the Soviet Army Medical Service equivalent tothat of chief consultant in surgery. Professor Yudin had been outstanding forhis surgical accomplishments at the Sklifossowsky Institute. The investitureof these two eminent Soviet surgeons into the American College of Surgeons wasaccomplished by Colonel Cutler and Colonel Davis. The formalitieswere preceded by the following address presented by Colonel Cutler:
This gathering is momentous. We doctors now signify to the solidarityand common purpose of a majority of living peoples. The occasion justifies the hopethat this junction of our races is but the beginning of a friendly and cooperative liaison for all time. As a token of this spiritual union Colonel Davis and I are empowered to grant Honorary Fellowships in the American College of Surgeons to two distinguished Russian surgeons, a function which heretofore has never occurred beyond the confines of our owncountry.
* * * * * *We congratulate ourselves that in this tumultuous world men of such eminencehave found in service to the State a way of life that brings satisfaction toall.
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 the American Collegeof Surgeons.
I understand this honor as a generous approval of my papers and my work inthe past and present. It makes me think about my work in the future,particularly now when the fight against Fascists has reached a decisive stage.
I recognize this election to be of deep and wide meaning.
The last decade has shown that the United States is now the center of medicalscience, and scientific problems are to be solved from the point of view ofAmerican science.
During this year I have received very many proofs of attention fromtheUnited States.
My contributions to world science and field surgery are but modest. Itpleases 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 after one high honorthe surgeons of a second great Allied country-the U.S.A.-bestow on meanother.
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I know little of your beautiful country. I am proud ofmy personal acquaintanceship-and even friendship-with George Crile, HowardKelly, 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 great HarveyCushing's successor.
By the way, it is an astonishing fact that the day of my decoration bythe Allies completely coincides with the day I was severely wounded by aGerman 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 theircountries and the world's civilization. Now, just as it was thefirst time, we are fighting with the same eternal dangerous enemy-Germany. Butas it was on the first occasion, our British Allies are fighting again on ourside.
Victory will be ours. Nobody has any doubts about it, even ourenemies. Let our scientific relations which have begun in a time ofsuch strained 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 victory asarms, transport, and all kinds of supplies. But when the last gun of the enemy ceasesand released humanity turns with hope to the restoration of great destruction caused by thewar, we surgeons will have to heal the wounds and injuries of hundreds ofthousands 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 theSoviet Government was made by Vice Commissar Kolesnikov, who said:
The admission today of two outstanding Russian surgeons, Academician Burdenkoand Professor Yudin to the honorary fellowship of the Royal College of Surgeonsof England presents itself to us, witnesses of this act, as an occasion ofgreat cultural and political meaning.
The Royal College of Surgeons of England since long ago has been famedas an organization, responsible in no small way for the development of surgery both in England and outside herboundaries. Amongst the fellowsof this College have been, and are now some of the outstanding representativesof English surgical thought. The greatest exponents of surgeryof other countries have earned the honor of being honorary fellows of thisCollege since its creation, in accordance with its established and glorioustraditions. On every occasion the selection of honorary fellows amongstforeign scientists has been an unbiased and just appreciation of their reallygreat technical contributions. Therefore, selection to an honoraryfellowship of the Royal College of Surgeons of England has always been adistinction in the eyes of the world's scholars. Similarly, the glory ofthe American College of Surgeons is well known.
We are glad in the knowledge that, today, the choice of the Royal Collegeof Surgeons and the American College of Surgeons should have fallen on thetwo best representatives of our native surgery. Both the new honorary fellowsof the Colleges, Academician Burdenko and Professor Yudin, are deservedly famed in our country, and outside herboundaries, as leading experts in the realm of their specialties. Not for nothingare 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.
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The outstanding contributions of Academician Burdenko in thedevelopment of neurosurgery, his brilliant experimental work, and hiselaboration of the basic principles of a new type of field surgery, whichhave 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 the title of Fellow of the Colleges with equalhonor and worthiness. His name is tied with great successes in abdominal surgery, in plastic operations on the alimentary tract, in bloodtransfusion, and in the prophylaxis and treatment of infected wounds, etc.
We, the representatives of the family of Soviet medicalworkers, are today justifiably proud of the great honor bestowed on Academician Burdenko and Professor Yudin. At thesame time we express our sincerest appreciation to the Royal College of Surgeons ofEngland and to the American College for this mark of distinction. In the name ofthePeople's Commissar and in our name I ask you, Mr. Vice-President and ColonelCutler, to convey our thanks to your organizations. In the name of the People'sCommissar and in our name I congratulate Academician Burdenko and Professor Yudin on their selection forthe honorary fellowship of theColleges.
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Today's occasion takes place in days of bitterwarfare against the cruel enemy of progressiveness-Hitler's Fascism! In this war,our medical teaching has extensively become the teaching of war medicine, and ithelps our armies in their struggle against this cruel foe. The admission of the most famous Soviet scientists to the honorary fellowship ofthe Colleges marks in itself a strengthening of the scientific ties between the allied nations. I am certain that those ties willstrengthen further in the continuation of this struggle to complete victory over our common enemy.
Summary of observations on military medicine and surgery inU.S.S.R. - Ontheir return to the United Kingdom, Colonel Cutler and Colonel Davis preparedjointly a concise summary of their full report. (appendix A, p. 953) for GeneralHawley. They asked that specialconsideration be given the following topics because they appearedto be of chief value to the Medical Department of the U.S. Army.
Care of the lightly wounded.
These are early segregated into special hospitalsand are preferably kept in these hospitals in the forward area, not sent tothe base. Secondary suture of all wounds is practiced early. Rehabilitation and reconditioning exercisesbegin at once and the menare restored often within a month to active duty.
Cleansing facilities, i.e., bath and barbers in all hospitals.
This is a great contribution to military surgery* * * every soldier, unless he be urgently required in the operating room, goes first tothe barber and a room where he can be washed. This is sincerely appreciated bythe troops and is something we shouldemulate in our opinion.
Facilities for Blood Transfusion
The [full] report emphasizes the great amount ofblood used in the Russian Army and its easy availability. Though thisdoubtless wasted some blood it made it certain that every wounded mancould get blood if that was desirable. We should establish a system makingblood as well as plasma available to our forward hospitals.
Laundry facilities.
In the Russian Army the medical department controlslaundries serving the hospitals. In the Russian Army laundries are set up andserve 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 ratioof one laundry to a Corps surgeon.
Surgical specialization.
The Russians begin major specialization at theforwardhospital level. This provides that in the more important fields of surgerysoldiers are given what the specialist thinks is wisest from the verybeginning of his treatment.
Sorting and triaging.
This is carried out beautifully at the forward hospitals andemphasizes the organization of forward hospitals found necessary in thelast Great War. If large numbers of wounded people are tobe competently cared for, some systematic sorting must occur. In the RussianArmy this permitted the segregation of slightly wounded in hospitals in theforward area and their rapid restoration to duty; it facilitated the care byspecialists of those needing special care and it greatly facilitated the majorproblem of evacuation.47
Soviet Union and its people.-Colonel Cutler could nothelp 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.
