CHAPTER IV
Neurological Surgery
Loyal Davis, M.D.
At the Arcadia Conference, held in Washington from 24December 1941 to 14 January 1942, a broad policy was decided upon for offensiveactions against Germany. It was decided that, during 1942, Germany'sresistance would be worn down by increasing air bombardment by British and U.S.Forces, giving assistance to the Soviet offensive, and gaining possession of theentire North African coast. This policy was examined many times, so that it isnot surprising that many changes were made in the program. For example, theJ.P.S. (U.S. Joint Staff Planners) believed that a considerable land attackcould be launched across the English Channel in 1942. This was to beaccomplished largely by British troops in the beginning, but participation ofU.S. Forces, it was believed, could be built up rapidly. In fact, the plannersoutlined a possible cross-Channel operation which would take place in the summerof 1942 with a D-day between 15 July and 1 August.
With this background, it is not difficult to understand whyThe Surgeon General of the U.S. Army hastened to implement his share of planningin this proposed operation and attempted to build up his medical forces rapidly.A part of this planning was to supply the Chief Surgeon, ETOUSA (EuropeanTheater of Operations, U.S. Army) with a staff of consultants in the fields ofmedicine, surgery, neurological surgery, plastic surgery, ophthalmology,radiology, anesthesiology, orthopedic surgery, and otolaryngology.
On 2 July 1942, Col. (later Brig. Gen.) Fred W. Rankin, MC,chief surgical consultant to The Surgeon General, telephoned the author andarranged for a conference in Washington on 5 July. Col. (later Brig. Gen.)Elliott C. Cutler, MC, professor of surgery at Harvard Medical School; Lt. Col.(later Col.) William S. Middleton, MC, professor of medicine and dean of theUniversity of Wisconsin Medical School; Maj. (later Col.) James B. Brown, MC,professor of plastic surgery at Washington University; Maj. (later Col.) Rex L.Diveley, MC, of Kansas City, Mo.; and Maj. (later Col.) Lloyd J. Thompson, MC,of Yale University School of Medicine, were either in England or on their way tojoin the Chief Surgeon's consultant group. To the specialties of surgery,medicine, plastic surgery, orthopedic surgery, and psychiatry, Colonel Rankinexplained, would be added neurological surgery. Though it was never at any timeduring the conference so stated, the impression was gained that there wereseveral general hospitals in the European theater (and this meant the Brit-
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ish Isles) and that several would be added very rapidly. Itis obvious that there was an immediate urgency to speed up Operation BOLERO, thebuildup operation for invasion of the Continent.
Col. (later Maj. Gen.) Paul R. Hawley, MC, had been named asChief Surgeon, ETOUSA, by Maj. Gen. (later Lt. Gen.) John C. H. Lee, who hadbeen sent to England as the commanding general of SOS (Services of Supply),ETOUSA. Colonel Hawley had been a member of the London Committee which had beenmade up of representatives of various British supply ministries andrepresentatives of the U.S. Army who had functioned in mufti in London duringthe entire year preceding the attack on Pearl Harbor. General Lee had arrived inEngland, however, with another medical officer designated as his Chief Surgeon,and it was a fortuitous circumstance which made him appoint Colonel Hawley onthe spot.
GETTING ACQUAINTED
Obviously, none of these circumstances were known to Lt. Col.(later Col.) Loyal Davis, MC, the newly appointed Senior Consultant inNeurological Surgery (fig. 138), when he arrived in England by air on 6September 1942, after having been commissioned on 20 August. Soon after hisarrival at Headquarters, SOS, in Cheltenham, Gloucestershire, the author wasformally introduced to the Chief Surgeon. Then the neurological surgicalconsultant joined the staff of Col. James C. Kimbrough, MC, Chief ofProfessional Services, a urologist, who had been on duty at Walter Reed GeneralHospital, and whose good humor and patience were exemplified in his statementand belief that the war spoiled the Army Medical Service.
It became evident immediately that for some reason, unknown,the speed of action had slowed considerably. There was one U.S. Army generalhospital in southern England, at Oxford, the 2d General Hospital, staffed bymedical officers from Columbia University College of Physicians and Surgeons,New York, and Presbyterian Hospital, New York. There was one in the Midlands, atMansfield, the 30th General Hospital, comprised of doctors from the Universityof California School of Medicine, San Francisco. Another, the 5th GeneralHospital, had been for some time in Northern Ireland; the staff of this hospitalwas composed of members of the Harvard Medical School faculty. There was oneneurological surgeon on the staff of the hospital at Oxford, Maj. (later Lt.Col.) John E. Scarff, MC, who needed no help from the Senior Consultant.
It had become the custom, and certainly it was logical, foreach consultant to make a tour of the theater and get acquainted with the U.S.hospital units as well as the English and Canadian groups. Mr. Hugh W. B.Cairns, Nuffield Professor of Surgery at Oxford, and an old friend who hadstudied at the Peter Bent Brigham Hospital, Boston, had become a brigadier andConsultant for
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Neurological Surgery to the RAMC (Royal Army Medical Corps).There was one important difference, however, in the respective posts of theBritish and U.S. consultants. Brigadier Cairns was responsible for advice inneurological surgery wherever the British Army was fighting, and his mobilityand responsibility created a unity which produced results in treatment andpolicies far surpassing anything which the U.S. Army attained.
On 17 September, this consultant submitted a memorandumdescribing his initial tour of inspection, and it was approved and returned bythe Chief Surgeon with a request that the recommendations be implemented.
Review of British Activities
A Military Hospital for Head Injuries was located in thebuildings of St. Hugh's College for Women in Oxford. This British hospitalreceived only patients who had received craniocerebral injuries of all degreesof severity, and, as a result of the careful and scientifically professionalservice which was given there, they demonstrated conclusively that a highpercentage of men so injured could be returned to their military units for duty.One of the most reliable symptoms upon which they prognosticated the ability ofthe soldier to return to military duty, particularly in blunt craniocerebralinjuries, was the length of the period of post-traumatic amnesia. BrigadierCairns instituted the policy of treating open craniocerebral injuries by shavingthe hair, cleansing the wound carefully with soap and water, applying a steriledressing, and transporting the wounded soldier as quickly as possible to ahospital where he could receive definitive treatment. The patients' records werecarefully made
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and kept so that they would provide a basis after the war fora study of the immediate and prophylactic treatment of craniocerebral injuries.
The Middleton Park Convalescent Hospital, near Bicester,Oxfordshire, was situated 10 miles from the head injury hospital in Oxford andto it patients were sent from the latter hospital for convalescent care andrehabilitation. The care at Middleton Park had been planned and was supervisedby Brigadier Cairns, and not by a student of physical medicine who knew nothingof the residuals of head injuries. Even Radcliffe Infirmary, a hospital ofOxford University, was utilized for the study of compound fractures of theextremities and severe burns.
Within the environs of Oxford was the Wingfield MorrisOrthopaedic Emergency Hospital under the direction of Herbert J. Seddon, anorthopedic surgeon who had received a considerable amount of surgical trainingat the University of Michigan Medical School, Ann Arbor. The RAMC found itpossible to make use of Professor Seddon without insisting that he be inuniform. To this hospital were sent all of the peripheral nerve injuries fromthe British military forces and the civilian population. It was immediatelyobvious that one of the most important contributions to peripheral nerve surgerywould one day come from this well-planned and well-organized hospital for studyand treatment.
In the aforementioned 17 September memorandum it wasemphasized that the U.S. Army records of examination, diagnosis, and treatmentof the peripheral nerve injuries in World War I were totally inadequate, wereincomplete, and were rarely available for study or for use in following up thefew patients who made their appearance from time to time in Veterans'Administration hospitals. It was emphasized repeatedly that this should notobtain during World War II and that the records at the Wingfield MorrisOrthopaedic Emergency Hospital could be used as models. Colonel Davis emphasizedthe point that neurosurgical records need not be so elaborate that they wouldobstruct the care of the wounded but that they should be complete so that futuremilitary surgery would benefit from their study. This required unified directionwhich was never obtained.1
Brigadier Cairns, through his friendship with Lord Nuffield,had initiated a project at the Morris Garage in Oxford for the construction ofmobile surgical units for the RCAMC (Royal Canadian Army Medical Corps). Theseunits were 3-ton motor vehicles with 4-wheel drives and contained an electricgenerator so that the unit could pull up beside a church or schoolhouse and goto work to help a forward hospital. Each unit carried two folding instrument andoperating tables, head rests, sterile drums of supplies, sterile basins, and awater tank but were not as elaborately equipped as were those originallydesigned by Brigadier Cairns, one of which was lost at Dunkirk.
1The recent five-center study of peripheral nerve injuries conducted by the Veterans' Administration with moneys made available through the National Research Council has pointed up this glaring error of organization repeated through two world wars.
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Other projects were underway at Oxford. Prof. S. (later SirSolly) Zuckerman was working upon the effects of blast as observed during theBattle of Britain. In his opinion, blast did not produce cerebral damage but forthe most part affected the lungs. He was given the opportunity by BrigadierCairns of doing actual fieldwork. Professor Zuckerman accurately plotted thescene of a bombing, the number and position of the individuals affected, theexact character of the agent, and whether the injured individual was stationaryor moving, in an effort to determine eventually what prophylactic measure mightbe worked out. By photographing and measuring the body in all conceivablepositions assumed during combat, Professor Zuckerman determined that the headand neck offered a target equal to about 12 percent of the entire body.Interestingly, a checkup on the actual location and nature of injuries which hehad investigated showed a remarkable percentage of correlation with ProfessorZuckerman's calculations on the projection of various body areas as targets.While he worked under the auspices of the British Medical Research Council,cooperation with the military was maintained through Brigadier Cairns.
In the laboratories of the Department of Anatomy at Oxford,Graham Weddell and Prof. John Z. Young were investigating thedegeneration and regeneration of nerve fibers to the skin and muscles followingperipheral nerve injuries. They found that any method of treatment whichincreased the blood supply to the involved muscles was very important in therehabilitation of these patients. By recording the degree of muscle fibrillationfollowing injury, Weddell believed he could determine whether or not a givenparalyzed muscle could regain its function.
Canadian Activities in United Kingdom
The Canadian Neurological (1st General) Hospital was situatedat Basingstoke, Southampton, and was built around Hackwood House in 1940. Fromthe beginning, it was designed and equipped as a neurological surgicalinstallation. It was superbly organized and administered. In addition to givingexcellent care to the wounded, it served as a training place for young generalsurgeons who could be taught the fundamentals of the immediate care ofneurosurgical injuries in forward hospitals. Personnel of this hospital hadcalled attention to the following important facts: (1) Small, apparentlytrivial, scalp wounds often hid serious underlying comminuted fractures of theskull with destruction of brain tissue; (2) injuries of the head had beentreated as long as 36 hours after receipt of the wound in the Dieppe raid andafter careful surgery, aided by the use of sulfanilamide; (3) no infections hadbeen observed when the craniocerebral injury had been cleaned carefully, thehead shaved, sulfanilamide placed in the wound, a sterile dressing applied, andthe wounded man sent back immediately to the Canadian Neurological Hospital fordefinitive treatment; and (4) in the presence of a defect in the skull, in apatient who has recovered function, repair of the defects by the use of aprosthesis could result
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in the return of the soldier to active military duty. Thisviewpoint upon the use of the sulfonamides was prior to the demonstration thattheir general administration with determination of the blood level was aseffective as, and less destructive to tissue than, their local administration.
Observed at this hospital were several patients who had beenoperated upon for herniated nucleus pulposus and returned to duty. Thisexperience resulted in a memorandum, which was adopted as U.S. Army policy inthe European theater, to the effect that these patients should be operated uponby neurological surgeons, but only when the clinical syndrome pathognomonic ofthis condition existed and when careful X-ray studies using the new myelographicmaterial, Pantopaque, corroborated the diagnosis. Finally, it was emphasizedthat intensive and supervised physical rehabilitation exercises should becarried out upon each patient.
Inadequate Facilities in U.S. Hospitals
This get-acquainted tour emphasized the complete lack ofinstruments and equipment on hand in the 2d General Hospital for neurologicalsurgery. In company with the Senior Consultant for Plastic Surgery, thisconsultant visited the British surgical instrument houses of Allen &Hanburys Ltd., and Down Bros., Ltd., and a representative of the BritishMinistry of Supply, in order to determine whether there were any instrumentsupon their shelves or in their stocks which could be supplied to U.S. Armygeneral hospitals. Thus was an unproductive day because those instrumentsavailable were completely outmoded; the field of neurological surgery and itsappliances and instruments had been developed in the United States. It was,however, a demonstration, many times repeated, of the facts that the Army couldput supplies into a depot but could not get them out; that, because an officerwas a doctor, it did not follow that he was capable of getting the rightsupplies where they belonged; that a good stock manager from a mail-order housewould have served far better; and, finally, that the principle of ordering astipulated supply of a particular item for a given number of men every 90 dayswould result in enough thermometers to roadblock an invading force and enoughhypertonic glucose solution to float the British Navy.
ANALYSIS OF THE SITUATION AND RECOMMENDATIONS
As a result of this tour, this consultant wrote a detailedmemorandum of the principles learned by the British for the care ofneurosurgical injuries and requested that it be sent to the Office of TheSurgeon General in Washington for dissemination among military and civilianneurological surgeons in the United States. He hoped that this might be starteda method of communication which would make it obvious that a unified method ofcare and handing was essential for obtaining results which later could bestudied to the advantage of the injured man. Whether this memorandum was eversent to Wash-
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ington, this consultant never knew; if it was, nothing camefrom it because, throughout the war, it seemed to the author that the Europeantheater remained a distinct, isolated entity instead of having a close liaisonwith the Office of The Surgeon General. It became evident, more and more, that aConsultant in Neurological Surgery should have been responsible, through theChief Consultant in Surgery to The Surgeon General, for the proper organizationof the care of neurosurgical injuries in whatever theater of war they occurred.Such a consultant could have been mobile enough to have spent the time necessaryin each theater to have provided methods and means of obtaining results whichcould later have been the basis for valuable contributions to this field ofsurgery. In the Mediterranean theater, there was no senior consultant inneurological surgery. In the European theater, during Colonel Davis' tour ofduty, there were never more than two qualified neurological surgeons with whomone could consult.
It was apparent on 19 September 1942 that the 1st InfantryDivision was preparing to leave for a combat zone (Africa). The author gave themedical officers of this division an hour's talk on neurosurgery in war. Theyhad had no previous instruction on this subject during the 18 months to 2 yearsthey had been on active service. Perhaps it was just as well, considering thatthey lacked morphine Syrettes, blood pressure apparatus, anesthetic agents, andsulfonamides, to name a few glaring shortages. Medical officers were being usedas transportation officers and in other capacities; the division surgeon did notattend the meeting and had never attended a medical meeting of the division. Themorale of the division's medical officers was low.
St. Bartholomew's Hospital, which had been badly bombed,had its neurosurgical unit, under Mr. John E. A. O'Connell, at Hill EndEmergency Hospital, St. Albans, London, and was visited on 28 September, as wasthe Canadian 15th General Hospital. On the same tour, this consultant visitedthe 30th General Hospital. The Canadians presented a series of papers relatingtheir experiences in the treatment of casualties received following the Dieppefiasco. They emphasized the use of surgical teams consisting of two surgeons,two nurses, an anesthetist, and an orderly. The records of their examinationsand operations were dictated to, and kept in order by, ambulatory patients andenlisted men. Their data were uniform and provided excellent material for futurestudies.
A young captain with some training in general surgery andwith no aspirations to be a neurological surgeon had been assigned to care forneurosurgical injuries, when and if they occurred, at the 30th General Hospital.Colonel Davis recommended that a census of the number of neurosurgical injuriesin each of the U.S. hospitals in the theater be provided the ProfessionalServices Division because there was no way of knowing where such cases were orhow they were being treated. It became known that many American soldiers,injured severely in jeep accidents in the blackout, were scattered throughBritish EMS (Emergency Medical Service) hospitals and were receiving treatmentfor their craniocerebral injuries which was below American
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standards of treatment. On 1 October, an example of anAmerican soldier taken to an EMS hospital instead of to the 2d General Hospitalat Oxford was cited as a reason for seeking a method to transport such injuredAmerican soldiers to a U.S. hospital. As a corollary to this, and as a result ofa line officer's refusing to move one of his men from a British hospital evenafter the British doctor and an American medical officer directed his transfer,authority was also requested for the recognition of the American medical officer'sorders in such instances.
As a result of many conferences with Brigadier Cairns, Mr.Geoffrey Jefferson, and Dr. George Riddoch, as well as with various members ofCanadian hospital units, Colonel Davis recommended on 5 October 1942 that allgeneral hospitals have a qualified neurological surgeon assigned to their staff;that instruction in the primary surgical treatment of neurosurgical injuriesshould be given, in a teaching course, to battalion aid station, collectingstation, clearing station, and evacuation hospital medical officers, since thefinal results of the definitive treatment of those injuries depended upon theaccuracy and effectiveness of the early treatment. It was recommended that thisbe done without removing the officers from their units and before they reachedthe combat theater where such periods of instruction might interfere with moreimmediately urgent activities. Thus, another attempt was made to bring aboutsome sort of unity of effort in the care of neurosurgical injuries.
On 13 October, this consultant wrote the first of sevenmemorandums to govern the general principles of the treatment of craniocerebral,spinal cord, and peripheral nerve injuries. Six of these memorandums werecriticized on the grounds of poor English, and the seventh was accepted anddisposed of most effectively by one of the Chief Surgeon's staff officers whenhe filed it away among his effects.
On 15 October 1942, the author submitted a detailedmemorandum about the transfer of injured American soldiers from EMS hospitalsthroughout the British Isles to U.S. Army hospitals. With reference toneurosurgical patients (and it would have applied easily to other types ofinjuries), it was recommended that:
1. All EMS hospitals be requested through the director oftheir service to notify immediately the Division of Professional Services,Office of the Chief Surgeon, ETOUSA, of the admission of American soldiers withcraniocerebral, spinal cord, and peripheral nerve injuries.
2. The Director, EMS, be requested to supply to the Divisionof Professional Services, Office of the Chief Surgeon, a list of theneurological surgeons and the name and location of the EMS hospitals in whichthey are located.
3. In the absence at this time of an adequate number ofqualified and certified neurological surgeons in the American Forces, the SeniorConsultant in Neurological Surgery be given authority to contact the EMSneurological surgeon of the region nearest the EMS hospital to which the soldierhas been taken and request that he assume responsibility for removal of thesoldier to his
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own facility and there treat him, or direct his treatment ifin his judgment transportation is inadvisable.
4. An American soldier so injured be moved to a U.S. generalhospital where a qualified and certified neurological surgeon is available, justas quickly as the condition of the patient warrants, in the judgment of the EMSneurological surgeon.
5. The treatment of American injured by EMS neurologicalsurgeons be discontinued as soon as neurological surgeons in U.S. generalhospitals are available in sufficient numbers to render this service themselves.
6. Authority be granted to employ indigenous ambulanceservice to remove a patient to a U.S. hospital in the event that the employment ofAmerican ambulances is impossible or would involve unnecessary delay in thetreatment of the soldier in the judgment of the Senior Consultant in Neurological Surgery oran individual to whom he delegates the responsibility for such judgment.
On 19 October 1942, this consultant wrote directly toGeneral Rankin in Washington and asked that he assign neurological surgeons tothe 5th and 30th General Hospitals. Evidently, this gentleman quickly recognizedthe failure of this memorandum to stay within "channels" and by not answering it savedthe author momentarily from his ultimate difficulty.
On 22 October, a visit to the 30th General Hospital revealed thatno suction apparatus was available to the surgeons and that operations upon onepatient with a rupture of the spleen and upon another with a rupture of the kidneyhad nearly resulted in fatalities, although the surgeons had improvised with two bicyclepumps and the strength of an orderly. The first of a series of requests for such a suctionapparatus was written immediately and was followed by several others containingminute descriptions of a suction pump available from a supplycompany in Reading, England, for fifty dollars. The size of valves, theoverall size and weight, and minute specifications were given; in fact, a pump for each ofthe general hospitals in the European theater wasavailable and could have been delivered by hand by this consultant, ifnecessary. The requests ended up without action in the the Supply Division,Office of the Chief Surgeon, ETOUSA, which was at that time the most persistent ofGeneral Hawley's problems.
On 26 October, in answer to a query from the personnelofficer, Office of the Chief Surgeon, ETOUSA, this consultant emphasizedthe facts that (1) the neurological surgeons suggested for the 5th and 30thGerman Hospitals were already commissioned in the Medical Corps, AUS, and wouldnot, therefore, be taken from civil life, (2) there was only one neurologicalsurgeon in the European theater, and therefore the needcould not be supplied from the European theater, (3) the request was not forconsultants but for experienced neurological surgeons capable of assumingresponsibility for the treatment of craniocerebral, spinalcord, and peripheral nerve injuries and, finally, (4) dependence upon theBritish EMS head centers for the treatment and care of neurosurgical casesin the European theater should not be continued.
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Many memorandums later, it was evident that the ChiefSurgeon had never seen any of the many recommendations made by the SeniorConsultant in Neurological Surgery. They were passed back and forth orconveniently filed by a personally hostile medical officer who openly boasted thathe would put the new lieutenant colonel specialist consultants in their place.Soon, thereafter, a roster of officers was issued for allnightduty to answer the telephone to receive reports of deaths of soldiers in thetheater. The roster began with the lieutenant colonel consultants to theChief Surgeon, and the duty was served, at least by one consultant, until the roster andduty were canceled by General Hawley when it was called to his attention.
On 3 November 1942, accompanied by the Senior Consultantin Plastic Surgery, the author gave the first of a series of lectures at theEighth Air Force Provisional Medical Field Service School to young air forcemedical officers. At this time, it was not apparent that a schism existedbetween the Army Air Forces and the rest of the Army, based upon the Air Forces' attempts toestablish a medical service quite separate and distinct from that of theremainder of the Army. At this same time, the 92d Bomber Group Combat CrewReplacement Center at Bovingdonwas visited. This tour also included the East Grinstead Royal Victoria RAF Plastic Center, which wasunder the direction of Mr. A. H. McIndoe, ChiefConsultant in Plastic Surgery to the RAF. Mr. McIndoe made it possible tovisit Group Captain Atcherly of the RAF, who was in command of afighter group, and who personally conducted the two U.S. Army consultants over his station.Following these visits, comprehensive memorandums were written which recommendedthe placement of well-staffed, completely equipped, smaller types of hospitals, strategically locatedwithin rapid evacuation distance by ambulance from bomber and fighter airdromes, and theassignment of a liaison medical officer from the U.S. Army Air Forcesstationed in the United Kingdom to the Office of the Chief Surgeon to advisein the eventual disposition of injured air force personnel. It is now clear that, at the time of thewriting of these memorandums, the struggle for independence in medicalorganization was taking place, and these memorandums could not have beenmore timely, though they were completely ineffective.
On 9 November 1942, Colonel Davis wrote a detailedmemorandum to the Chief Surgeon, ETOUSA. The author was quite unaware of theorganization of the Army and the relationship of a theater ofoperations to the War Department in Washington as far as the MedicalDepartment was concerned. It was becoming more and more apparent that theMedical Department was completely subservient to the SOS command and that theChief Surgeon had access to the Commanding General, ETOUSA, only through theCommanding General, SOS, ETOUSA. This fact, learned bydiligent study of the volumes depicting the history of World War I, during which the same struggle for direct responsibility ofthe Medical Departmentto the commanding general occurred, made it obvious that the Air Forceseventually would have their separate medical
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service. If they were not to succeed immediately in such a division,at least it appeared they would conduct their affairs in such a manner. Thememorandum to the Chief Surgeon read:
1. The Consultant in Neurological Surgery in the European Theater ofOperations held the following views, which were expressed, when he accepted thepost offered by the Surgeon General's Office:
(a) Military neurological surgery differs in many ofits technical aspects from the neurological surgery of intracranialtumors and other common civilian neurosurgical conditions.
(b) There is no place for the trained, experienced neurologicalsurgeon in forward areas of combat.
(c) Only careful, well-directed immediate general surgical treatment shouldbe given to neurosurgical injuries in forward combat areas.
(d) Properly instructed and trained younger medical officers should have the responsibility ofgiving the type of immediate surgicaltreatment in forward areas necessary to obtain good definitive results.
(e) Meticulous, definitive surgical treatment should be given toneurosurgical injuries in general hospitals only, located withinreasonably rapid evacuation distance of a combat area.
(f) Experienced, well-trained and recognized neurological surgeons shoulddirect definitive treatment for neurosurgical injuries in a general hospital.
(g) Neurological surgery should be a service in a general hospital andspecial neurosurgical hospitals have no place in an Army.
2. With the statement contained in Paragraph 1b, the Chief Surgeon of theE.T.O. has expressed complete agreement.
(a ) This viewpoint is supported by the experience of theRoyal Army Medical Corps at Dunkirk and the Middle East and by the RoyalAustralian Medical Corps.
3. The Consultant in Neurological Surgery has (a) completed personalinvestigations and observations of facilities, equipment and personnel of theU.S. Army Medical Corps in the E.T.O., as they apply to neurological surgery and(b) has visited and observed the British andCanadian Army neurosurgical service in the U.K. and (c) theneurosurgical services in the E.M.S. and the Scottish E.M.S.
4. As a result of the statement contained in Paragraph 3, thefollowing facts are evident:
(a) Competent, experienced and self-reliant neurological surgeons arenowassigned to two of the four U.S. General Hospitals in this theater (#2 and#298).
(b) Ground and air force combat neurosurgical injuries in British hospitals inthe United Kingdom, both military and E.M.S., are comparatively small in number.The majority of such cases have been the result of blitz or ordinary civilianaccidents.
(c) Only one neurological surgeon in Great Britain and one fromCanada are in Army service.
(d) The overwhelming remainder of the neurologicalsurgeons in the United Kingdom are in the Emergency Medical Service.
(e) Very few, if any, peripheral nerve, spinal cord andcompounded craniocerebral injuries can be returned to militaryduty within the 180 day evacuation period established by the Chief Surgeon of theE.T.O. Only relatively minor closed cranio-cerebral injuries can meet therequirement of this evacuation period.
(f) Based upon neurosurgical casualty figures in World War I, onthe figures available from British services thus far, and upon the combat casualties which can be projected inthe immediate future in this theater, four neurological surgeons will meet all the needs forthe highesttype of surgical treatment for neurosurgical injuries.
(g) Equipment and supplies, for obtaining the best possibleresults for the soldier suffering from neurosurgical injuries, are lacking in completeness inU.S. General Hos-
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pitals in the E.T.O. This equipment cannot be obtained fromEnglish surgical instrument firms.
(h) Younger medical officers in the division who have beenobserved in this theater are poorly prepared by training and equipment togive proper immediate surgical treatment to neurosurgical injuries inforward combat areas.
5. The function of the Consultant in NeurologicalSurgery is to act in an advisory professional capacity to the ChiefSurgeon of the E.T.O. and to establish and correlate the highest type ofneurosurgical service in this theater to the end that eventually it willbe possible for the Medical Corps of the U.S. Army to make a significantand substantial contribution to the surgical care of the injured soldier.
6. As a contribution to this desired result, the Consultantin Neurological Surgery with the fullest sympathy of understanding on the partof the Chief Surgeon, has recommended:
(a) That experienced, competent and self-reliant neurologicalsurgeons be assigned to U.S. General Hospitals #5 and #30 in the E.T.O.
(b) That medical clinical records, supplemental to the F.M.R.,together with the necessary clerical aid, be made available to U.S. GeneralHospitals in E.T.O. The purpose of this recommendation was to afford theopportunity of compiling a record of the end results of neurological surgery inthis War which would surpass that of World War I.
(c) That a course of instruction to division medicalofficers be given in training camps on the principles of the immediate surgical treatment of neurosurgical injuries.
(d) That neurosurgical injuries be transferred as soon aspractical from station hospitals in the E.T.O., and be evacuated asrapidly as possible from forward combat areas, to general hospitals in theE.T.O. for definitive surgical treatment.
(e) That all equipment and supplies necessary to obtain thehighest type of neurosurgical end results be furnished U.S. General Hospitalswithout delay so that these hospitals would be able by their work to representthe highest type of American medicine and surgery.
(f) That a general directive governing the principles of thetreatment of neurosurgical injuries be issued to general hospitals in the E.T.O.
(g) That a fixed general hospital with a neurological surgeonassigned be strategically located within rapid evacuation distance of thepresent dispositions of the American Air Force installations in this theater.
7. The Consultant in Neurological Surgery has been able toeffect the following service to injured American soldiers:
(a) Through personal contact with the Chiefs of theneurosurgical service in E.M.S. and Scottish E.M.S., American soldiers withneurosurgical injuries taken to E.M.S. hospitals receive the immediate services ofthe regional neurological surgeons and are evacuated as rapidly as possible toU.S. General Hospitals.
8. The Consultant in Neurological Surgery finds himself indisagreement with the Table of Organization for U.S. General Hospitals, issuedin April 1942, which does not provide for a competent, experienced neurologicalsurgeon.
9. The Consultant in Neurological Surgery is in entireagreement as to his function as a professional advisor to the Chief Surgeon ofthe E.T.O. and if the theater of warfare was contained within the United States,it is reasonable to assume that he would act as liaison between the ChiefSurgeon of the forces and the Surgeon General's Office. The interveningdistance which exists under the present conditions, and can be rapidly bridged,should not be a deterrent to that function.
10. The Consultant in Neurological Surgery, therefore, isfirmly of the opinion that to accomplish his function to the best interests ofthe injured soldier, the Chief Surgeon and the Army Medical Corps and because ofthe significance of the facts cited above, he should be given the opportunitiesinherent in a liaison officer, representing the Chief Surgeon in neurosurgicalmatters only, between this theater and the United States, particularly duringthe present period of comparative combat inactivity.
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Recommendations:
1. The Consultant in Neurological Surgery should be giventhe opportunities of liaison between this theater and the UnitedStates, in matters pertaining solely to neurological surgery, to accomplish better the functions of hisappointment.2
On 17 November 1942, four circular letters were prepared byColonel Davis for the signature of the Chief Surgeon, ETOUSA, to be sent to thecommanding officers of U.S. general and station hospitals in theUnited Kingdom, covering the subjects of the treatment of: (1) Craniocerebralinjuries, (2) spinal cord injuries, (3) peripheral nerve injuries, and(4) ruptured intervertebral disks (herniated nucleus pulposus). On 21 November,these circulars were included in one, entitled "The Disposition andTreatment of Neurosurgical Injuries," which was included in CircularLetter No. 75, Office of the Chief Surgeon, ETOUSA, issued 4 December 1942.
On 18 November 1942, this consultant visited the 298thGeneral Hospital, the University of Michigan Medical School unit, at FrenchayPark. Arriving in England with the 26th and 29th General Hospitals, the unitsaffiliated with the Washington University School of Medicine, St. Louis, Mo.,and the University of Minnesota Medical School, Minneapolis, respectively, the298th General Hospital had been kept in England while the other two had beensent on to North Africa. The 298th General Hospital was sadly lacking inequipment and supplies, and much time elapsed before this hospital becameeffective. A quotation from the memorandum report of the visit written by theauthor will make evident these difficulties: "The professional staff isworking hard, and because of their own efforts they will rectify many of thedifficulties which now exist, but they need prompt and sympatheticunderstanding, and implementation of their needs, none of which areextravagant."
THE SURGEON GENERAL'S VISIT
About this time, Maj. Gen. James C. Magee, The Surgeon General of the U.S. Army, visited the European theater, and the consultants were asked by Colonel Kimbrough to prepare a list of questions which might be propounded to him. The naive assumption was expressed that they would be presented to The Surgeon General at the time of his visit and would be answered. Neither part of the assumption proved to be correct. However, the questions prepared and submitted by the Senior Consultant in Neurological Surgery show the difficulties which existed in connection with the attempt to establish a medical organization patterned on the Office of The Surgeon General but without any relation to it whatever. They were:
1. Is neurological surgery recognized by the Office of TheSurgeon General as a surgical specialty in the Medical Corps?
2. If so, why has a neurological surgeon been removed fromthe latest published table of organization of general hospitals?
2Memorandum, Lt. Col. Loyal Davis, MC, for Chief Surgeon, European Theater of Operations, U.S.Army, 9 Nov. 1942, subject: Consultant in Neurological Surgery, ETO.
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3. If it is not recognized, why should a consultant inneurological surgery be considered essential in this theater?
4. In view of the latest table of organization of generalhospitals, why have neurological surgeons been assigned to general hospitals inthe United States?
5. Does The Surgeon General agree that the standards ofprofessional work in general hospitals in the United Kingdom should representthe highest type of medical and surgical care that can be given Americansoldiers?
6. Should not the professional care given the soldiers ingeneral hospitals in the United Kingdom compare favorably with that of U.S. civilianpractice and with neurosurgical practice in British and Canadian militaryhospitals of a similar type?
7. If The Surgeon General's answers to questions 5 and 6are in the affirmative, would he agree that the supplemental list ofinstruments plus a portable Bovie electrical surgical apparatus, necessary to doneurological surgery properly, should be made available immediately to each ofthe general hospitals in the United Kingdom?
8. Is The Surgeon General aware that such a supplemental listof neurosurgical instruments plus a portable Bovie electrical surgicalapparatus was inspected in Washington at the Walter Reed Hospital by ColonelDavis on or about 1 September?
9. Does The Surgeon General agree that the greatestcompensation for the loss of life in any war is whatever contribution theMedical Corps can make from a humanitarian standpoint?
10. If he agrees, could not one contribution to militarysurgery and to the art and science of surgery in general come from thecompilation of the results of neurological surgery in this war?
11. Would The Surgeon General agree that this would be asignificant contribution from his office, and, also, could not the Consultant inNeurological Surgery be more effective in bringing this about if he hadliaison privileges between this theater and the Zone of Interior in order tocorrelate, to the highest degree, neurological surgery that is being done ingeneral hospitals in both places?
12. Would The Surgeon General agree that the Consultant inNeurological Surgery would be of more service to the effort if, in this periodof inactivity in the United Kingdom while the consultant has a total of 30patients upon which to consult, he was given this opportunity of liaison?
By 1 December 1942, the consultants were still attemptingto get proper records for the general hospitals, and the senior consultant inneurological surgery was still pursuing the suction apparatus for the 30thand 298th General Hospitals. The harassed supply division was still denying anunderstanding of Colonel Davis' requests for "all-day suckers," eventhough one had been purchased and installed in the 2d General Hospital and wasperforming efficiently.
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ATTEMPTS TO IMPROVE THE CONSULTANT GROUP
With the coming of the 3d Auxiliary Surgical Group to the European theater, the consultants were asked to evaluate and advise about the assignment of the group's personnel. The Chief Surgeon's Office had been told to expect the 2d Auxiliary Surgical Group, which was to be staged in England and reorganized, and the majority of whose members were to be reassigned to North Africa where fighting had begun. One of the consultants, Colonel Brown, volunteered to go to Glasgow to meet this contingent as a representative of the Chief Surgeon. He hurried there and waited 2 weeks to greet the commanding officer of the 2d Auxiliary Group by name, only to be told on the dock that he, the commanding officer, was Col. John F. Blatt, MC, and that the group was the 3d.
The mud around Oxford, where the group was eventuallybilleted, was ankle deep, and it was cold and rainy. They had no instrumentsand no other equipment worth discussing. Attempts were made to give themtemporary assignments according to their surgical interests to relieve thefrustrated sense of having been hurried from their surgical practices in manyinstances to meet an emergency which turned out to be a field of mud 2miles from Oxford. There was difficulty because the Personnel Division of theChief Surgeon's Office had no idea whatever of the character of the MilitaryHospital (Head Injuries), Oxford. So, without advice, two officers whohad no fundamental training or interest in neurological surgery were assignedto that fine head injury hospital. This brought a protest from BrigadierCairns and required placing the matter before General Hawley to effect asolution, which he accomplished swiftly.
On 4 December 1942, the Senior Consultant in NeurologicalSurgery called attention to the fact that the majority of craniocerebralinjuries among U.S. soldiers in the United Kingdom were due to accidentsthey met with while driving jeeps at night under circumstances which werenot strictly military missions. The author recommended that the activities ofenlisted men in jeeps be restricted to purely military missions. This resultedin an immediate lowering of the incidence of these compound head injuries and acommendation for the consultant, apparently for the complexsolution which had been suggested.
It was obvious to anyone who gave it thought that theconsultants were being thwarted at every turn by some of the Chief Surgeon'sstaff and without General Hawley's knowledge. He had instituted dinnermeetings with medical officers from other countries, principally from theRoyal Army Medical Corps, and the group of consultants properly acted at hisinvitation as his aides to entertain his guests. This was only one of the many incidentswhich, at this time, led some of the Regular Army medicalofficers to resent the consultant group. For a time even Colonel Kimbrough, underwhom the consultants served, appeared suspicious oftheir motives until he was assured that no one
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of them sought his post and that each consultant desiredonly to get the job done and to bring to him whatever credit was due.
This situation caused the Senior Consultant in NeurologicalSurgery to attempt to express a critical evaluation of the surgicalconsultant group in the Chief Surgeon's Office to The Surgeon General of the U.S. Army throughthe Chief Surgeon, ETOUSA.3 The followingthree reasons were assumed to have been the basis for the creation of theconsultant group: (1) The Chief Surgeon's need for a professional advisorybody in order to maintain the highest type of surgical service to the U.S.soldier in the European theater, (2) the need to perfect liaison inprofessional service between the U.S. Army, British, and Canadian medicalservices, and (3) the need to establish liaison between the Europeantheater and the surgical profession of the United States and the Office of The SurgeonGeneral. The author reiterated the point that the majorityof the consultants did not seek their appointments but were told they werechosen because of their professional attainments and standingin their particular surgical field and because of their potential ability toorganize and correlate the activities of their surgical specialty in theMedical Corps. General Hawley knew none of the consultants before hearrived in his command and had no voice in his choice. The Senior Consultant inNeurological Surgery was told that he alone would be responsible directly to the ChiefSurgeon for the policies governing theprofessional activities in neurological surgery. At the creation of thepost of Chief Consultant in Surgery, it became necessary to pass recommendationsthrough three channels before the Chief Surgeon could be reached by theconsultants in the surgical specialties.
It was pointed out that the Chief Consultant in Surgery,Colonel Cutler, was speaking for and establishing policies forsurgical specialties about which he had only a smattering of generalknowledge. The surgical consultant group had not been included in the plans for medical care ofthe casualties which would result from militaryoperations in North Africa and which at that time were a responsibility of the European theater. It appeared illogical thatthe majority of the surgicalspecialties represented by consultants were not recognized by the Office of The SurgeonGeneral officially in the tables of organization of general hospitals.
Suggestions to improve the effectiveness of the surgicalconsultants group included:
1. Implement the recommendations of the surgical consultantsthat are designed to raise the standards of professional servicein U.S. hospitals in the United Kingdom.
2. Make it possible for the surgical consultants to observe,correlate, and give advice concerning the surgical treatment being given U.S.soldiers in the North African operations.
3Letter, Lt. Col. Loyal Davis, MC, Consultant inNeurological Surgery, to The Surgeon General, U.S. Army, through the ChiefSurgeon, European Theater of Operations, U.S. Army, 9 Dec. 1942, subject: Critical Evaluation of the Surgical Consultant Group.
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3. Improve the operations of the several divisions in the Office ofthe Chief Surgeon by changing personnel if necessary.
4. Change the organizational plan of the surgical consultants groupand restrict the duties and responsibilities of the chief surgical consultant tothe field of surgery exclusive of the surgicalspecialties.
5. Remove restrictions from the surgical consultants that limit their activities tothe United Kingdom.
6. Make the surgical consultants more mobile by extending tothem controlled liaison privileges in their own field ofsurgery with the Zone of Interior, the United Kingdom, and the NorthAfrican theater.
7. Extend the functions of the consultant group to thegeneral hospitals situated in service commands in the Zone of Interior.
8. Allow surgical consultants to establish contactsbetween the Office of The Surgeon General and the civilian surgical profession to effect:
a. Better understanding of the problems of the Office of The SurgeonGeneral.
b. Support of the policies of The Surgeon General before the medical profession and the American public.
9. Establish immediately the principle of advisory function tothe Office of The Surgeon General so that in peacetime theconsultants' services as civilian advisers may be utilized.
Whether these suggestions were passed on to GeneralHawley is open to question; but, there is some reason to think that, withoutfanfare, the consultants began to reach his attention directly. Thisconsultant had written a long memorandum to the Chief Surgeon on 22 December after athorough study of the neurosurgical aspects of injuries totank crews. The investigation was made at Tidworth Barracks withCapt. Thomas M. Mar, MC, medical officer for the 751st Tank Battalion attached tothe 29th Infantry Division (fig. 139). The memorandum concerned recommendedchanges in the helmet worn for head protection, certain aspects of armored tankconstruction to minimize the occurrence of vertebral and other injuries, the evacuationhatch, first aid equipment, armored ambulances for tank battalions, and thecontents of the field chest for use by themedical officer of an armored tank battalion. Promptly, a reply came from the Chief Surgeon,signed by him and dated 26 December, stating that the report had been forwarded tothe Chief Ordnance Officer and expressing his interest in the comments andrecommendations made concerning the use of an armored halftrack personnel carrier asan ambulance since he had first proposed such an adaptation. A date was made to visitthebattalion together on 5 January, but unfortunately the joint trip nevermaterialized.
Had the above correspondence occurred sooner, it wouldundoubtedly have prevented the author from sending copies of the memorandums hehad written for 3 months, arranged in chronologicalorder and with the addressee's name removed, as separate letters, toBrig. Gen. Fred W. Rankin, Chief Consultant in Surgery to The SurgeonGeneral; Dr. Irving S. Cutter, dean of Northwestern University Medical School,Chicago; and Dr. Howard C. Naffziger, chairman
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FIGURE 139.-Tanks of the 29th Infantry Division on maneuvers in southern England on 5 December 1942.
of the Department of Neurological Surgery of the University ofCalifornia. An unwise attempt to bring to the attentionof men who, it was believed, might accomplish small changes whichwould make an organization more effective was stopped when censors opened thethree envelopes and charged this consultant with goingoutside channels of military communication and violating the rules that gave himthe right to censor his own mail. The information that he was to becourt-martialed was telephoned to him by a fellowconsultant on the day before Christmas 1942 when the author was visiting the 2dEvacuation Hospital, which had reached its destination in Huntingdonjust 12 hours earlier.
The timing of events is almost always more significant thanthe event itself. The author learned later that, in anticipation of the result ofpressing the charges against him, a successor hadalready been selected, put into uniform, and informed of his mission. However,General Hawleywas still to be reckoned with, and Colonel Davis' interview with him was calm,frank, and direct.
The method of procedure was admittedly an improper one,but this consultant pointed out the motivating reasons which could be foundclearly explained in the memorandums. They concerned the care of theU.S. soldier fundamentally and were not being made effective in manyfield. There was no desire to serve elsewhere, and all difficulties could besolved by a more direct access to the Chief Surgeon on matters that concernedthe treatment of injured
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men. The Chief Surgeon assured the author that therewould be no court-martial of one of his men, and he was sure organizationalchanges could be made which would accomplish results more smoothly. Thediscussion made it obvious to this consultant that the Chief Surgeon, on the onehand, and his consultants, on the other, wereseparated by the chief surgical consultant, the chief of the ProfessionalServices Division, and the remainder of the Chief Surgeon's staff.
This interview with General Hawley put at rest theworries over arrest, court-martial, and disgrace which had caused twosleepless nights. It also formed the basis for the beginning of a closefriendship and association which exists at the present. It made possiblecontributions to the care of the injured soldier which will be describedand which required the authority of the Chief Surgeon to effect.
YEAR'S END
By the end of December 1942, the 298th General Hospital, the University of Michigan Medical School unit, was functioning, and it was arranged to have all of the peripheral nerve injuries from the North African combat zone sent to that hospital where they could be cared for by Maj. (later Lt. Col.) Edgar A. Kahn, MC, a qualified neurological surgeon. Among the first group of patients, the majority of whom were German prisoners and injured British Army personnel, were four patients with extensive soft-tissue injuries of the upper extremity, comminuted fractures of the humerus at the junction of the lower third and upper two-thirds, and a paralysis of the radial nerve. The wounds had been packed open with petrolatum-impregnated gauze, and a plaster cast had been applied without support of the wrist. Attention was called to the desirability of better immediate care for these patients, the use of the sulfonamide drugs, and proper dressings. These recommendations were based upon the experiences observed in the Wingfield Morris Orthopaedic Emergency Hospital, which was devoted exclusively to the care of peripheral nerve injuries under the direction of Professor Seddon.
There was considerable discussion and certainly no unanimity ofopinion about the method of using the sulfonamides. Alarge number of observations upon experimentally produced peripheral nerve injuries had been madein the surgical laboratory at Northwestern University Medical School prior to 1942under a grant from the National Research Council. It had been shown thatsulfonamides used locally in potentially infected, severely lacerated soft-tissue woundswhich involved nerves did not affect the results of nerve repair. However, it wasbelieved that administration of the drugs by mouth, raising the blood level ofthe sulfonamides, would be equally or moreeffective. At this time, however, it was a moot question, and the coloredphotomicrographs which recorded the results of the controlled experimentsprovided some basis for opposing the prohibition of the sulfonamides locally inthe wounds. There were
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other psychological factors surrounding the use of the "wonder"drugs which affected the injured men and were not easily evaluated.
The Senior Consultant in Neurological Surgery attempted to establish the298th General Hospital as a peripheral nerve injury center, similar to thatexisting at Wingfield Morris, and recommended that this be accomplished. Itwas possible through Mr. Seddon's cooperation to have Major Kahn assignedfor temporary duty at that British hospital to assume Mr. Seddon's dutiesduring his absence in Malta to investigate an outbreak of poliomyelitis.However, this effort to establish special facilities at the 298th GeneralHospital did not come about because of the rule to hold the injured in generalhospitals in the United Kingdom not longer than 180 days after admission. They were then to be returned to the United States.Thus, one of the functions of a qualified neurological surgeon in the Europeantheater, that ofproperly treating a peripheral nerve injury definitely, was made impossible,and peripheral nerve centers in general hospitals in the United States assumed an importancewhich should have been planned for in the beginning.
The qualified neurological surgeon belongs in the place where definitivetreatment can be given and postoperative and rehabilitation care can beproperly supervised. This plan was effectively carried out by the British withthe assistance of Brigadier Hugh Cairns, the Consultant forNeurological Surgery to the DGMS (Director General of Medical Services) of theBritish Army. Well-trained and instructed young general surgeons can give thefinest immediate treatment for neurosurgical injuries, and their activities could be supervised by aConsultant in Neurological Surgerywho would also advise The Surgeon General about policies in this field ofsurgery in the combat zone and the Zone of Interior.
Another method of approach to the Chief Surgeon, ETOUSA, was initiatedby Colonel Cutler in the form of one memorandum which would include all of thesuggestions from each consultant. These "Reports of the SurgicalSub-committee" failed, in the opinion of the author, because the chiefsurgical consultant frequently vetoed suggestions and recommendations made bythe senior consultants in their specialty.
1943: FIRST HALF
By the first part of January 1943, a new supply officer in the Chief Surgeon's Officehad improved the flow of material and equipment to the hospitals, and goodclinical records were made available to the hospitals in the theater. A letter, dated 13 January 1943, from thisauthor to Colonel Kimbrough contained a report for the period 7 September 1942-15 January 1943, chronologically summarizing the author's opinions concerningthe functions and utilization of the consultants. At all times, General Hawley had the greatest sympathy with and understanding of the aims, desires, and ideals of the consultant group; this he proved by word and deed on many occasions.
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Head Protection for Aircrews
On 13 January 1943, this consultant wrote the first of several communications upon the subject of protection of the heads of airmen.The regular issue steel helmet worn by the U.S. soldier admittedly furnishedexcellent protection against craniocerebral injuries and (sometimes moreimportant to the soldier) had many other utilitarian advantages. However, it was not designed forthe use of the crews of aircraft or tanks and could not be used to advantage by them, mainly because of its size, shape, and weight. Nevertheless, the desire of a particular copilot for protection to his head from bursting 20-mm. Oerlikonshells led him to remove the liner of his helmet and pull on the outer steelshell over his regulation leather flying helmet. The effectiveness of this protection was emphasized when his pilot, wearing only aleather helmet, was struck in the head by the fragments of an Oerlikon shell which burst betweenthem. The pilot immediately lost consciousness, developed a left hemiplegia, and acomplete left homonymous hemianopsia. While the copilot's helmet was puncturedin several places by the high velocity fragments, it afforded complete protectionfrom even a scalp laceration.
It became obvious that members of an aircrew neededadequate protection from craniocerebral injuries. However, any helmet designedfor their use had to meet certain specifications. First, it had to be closefitting and comfortable so that it would simulate as closely as possible anordinary leather flying helmet and be considered a personal possession whichmight gather "good luck" like a favorite, battered felthat; second, it had to allow free and unrestricted movements of the head in alldirections and not interfere in any way with the field of vision; third, it had to be lightin weight and afford protection from the heat and cold; and fourth, it had to afford protection, at least equal to thatafforded by the regular issue steel helmet, against craniocerebral injuries produced byfragmenting Oerlikon shells, antiaircraft flak, or concussion due to direct,blunt trauma.
The percentage of wounds to the head, comparing thehead's surface area to that of the body, was found to be approximately 12percent. It was also found that the largest number of craniocerebral injuries inairmen resulted from the fragmentation of 20-mm. Oerlikon shells. Craniocerebralinjuries next most common were injuries from thelargest pieces of antiaircraft flak and concussion due to direct trauma, in that order.When an Oerlikon shell burst, it fragmented into thousandsof pieces which varied in weight from less than 1 mg. to 20 gm. (fig.140). However, the largest number of "effective" Oerlikon shellfragments bursting in an area 5 feet in diameter and capable of causingincapacitation to the person exposed was 260. The majority of those 260fragments weighed between 10 and 50 mg., and their velocity varied between400 and 600 m.p.s. (meters per second).
Many materials were subjected to accurate ballistic and other tests at the ballistics laboratory of Oxford University which was made available byBriga-
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dier Cairns. It was finally concluded that an acrylic resin,methyl methacrylate, properly manufactured, offered the largest number of advantages for the purpose and most closely met the specifications laid down. This material was obtained, through the friendship which existed between this consultant and a civilian in England, from a plastics firm which had begun to make artificial dentures. There are, of course, almost unending variations of the stages which can be reached in the manufacture of the products of an acrylic resin. The properties of the final product may vary within extremely wide limits so that one may think of it as a substitute for glass, a denture, a surgical suture, or a puttylikematerial. By modifying the amount or character of the plasticizer added, the flexibility, resiliency, hardness, water and weather resistance, flammability, and ballistic-protective properties of the material can be varied at will between wide limits.
The material tested was 4 mm. in thickness and had a velocity resistance, in relation to its weight per unit area, of 440 m.p.s. when tested with a 52-mg. steel
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ball fired and photographed electrically. The velocity resistance per unit weight area of the same material of 8-mm. thickness, similarly tested, was 700 m.p.s. Velocity resistance per unit weight area of 1-mm. thickness manganese steel, tested under identical circumstances, varied from 500 to 600 m.p.s.
The acrylic resin studied had a tensile strength of from 9,000 to 12,000 p.s.i. (pounds per square inch); a flexural strength of from 12,000 to 14,000 p.s.i.; an impact resistance of 0.1 to 0.3 ft.-lb., and a Brinell hardnessgreater than gold. It had a specific gravity of 1.10, so that it almost floated on water, and it absorbed less than 0.5 percent of water by weightupon immersion for 7 days. It was resistant to the rays of the sun and would not soften until a temperature of between 190? and 240? had been reached. It was a good nonconductor of heat and cold. It smoldered if a flame was applied to it, but it would not burn with an explosion; if it flamed, the slightest movementextinguished it. When the material was hit directly, the lines of shatter were at right angles to the force and notdirectly forward as in steel.
The consultant was able to mold pieces of the acrylic resin over a wooden hat mold sothat they would conform to the frontal, temporal, occipital, and vertex portions ofthe skull (fig. 141). These segments were hinged together snugly so that protection would not be lost and yet so that acertain pliability would be gained and a sense of a solid, bucketlike structure would be avoided. The helmet was then covered with the commonly used regulation leather flying helmet and lined with chamois skin or fleece. Portions of the protective material were brought down over the ears,and openingswere left into which the earphones could be fitted. This afforded furtherprotection and added the distinct advantage of the property of acrylic resinto exclude ambient noises.
Such a helmet allowed for complete movement of the head in all directions,provided complete protection over the skull, and in no way interfered withthe field of vision. As one molds a derby hat which may impinge slightly uponthe parietal eminences and be uncomfortable, so the individual flyercould mold this helmet by applying heat to the protective liner so that itbecame an integral and comfortable part of him. The pieces of molded plasticcould be fitted into pockets of the leather helmet and be removed when it wasnot being worn in combat. The completed helmet, made of 4-mm. methylmethacrylate covered and lined, weighed 18 ounces, and, if material 8 mm.thick was used, affording more protection per unit weight area, the totalweight was 27 ounces. The steel body of the regulation helmet weighed 35.84ounces.
It was also suggested that similar plastic panels could be inserted into theregular-issue flying suit for protection against chest, abdominal, and extremityinjuries.
Several flights were made in a B-17 bomber on practice missions with Maj.Daniel Wheeler, AC, and his crew, during which the model protective helmet wasadjusted and revised until it suited the entire crew.
At this time, Brig. Gen. (later Maj. Gen.) Malcolm C. Grow, Surgeon, EighthAir Force, had engaged the services of an armorer in England to devise
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a metal protective suit of armor for airmen. Ignoring theballistics test, he rejected the use of plastic material on the ground that he had shattered a piece of the plastic material with his own.45-caliber pistol. The obvious answer was, of course, that if one gotclose enough to a heavily armored battleship with a large enough shell, the battleship could be sunk. Under actual flying combat conditions, however,it was evident that the acrylic resin would afford real protection.
The difficulty with the metal armor was its weight and awkwardness, against which all of the bomber crews reacted unanimously. It wastheir consensus that General Grow should put it on himself, fly with them, and be asked to bail out overthe North Sea, an action which they were allowed 10 seconds to perform successfully. Moreover, the pilot, the last to leave the plane, was required to leavethrough a small window at his side through which he had to propel himself from a sitting position.
Actually, the Senior Consultant in Neurological Surgery could progress no further in spite of the support and enthusiasm ofhis Chief Surgeon. It was not until late in 1943 that the Quartermaster General's Office in Washington accepted all of the work performed and the suggestions made.Col. (later Brig. Gen.) Georges F. Doriot and his colleagues were working on a materialnamed Doron, similar in many respects to the material tested. Later, in the surgical laboratory atNorthwestern University, the author assisted General Doriot in making studies of tissue reaction to the implantation of Doron in subcutaneous tissue, muscle, and brain.
High-Altitude Frostbite
During the period when work was being done on the flyer's helmet, the Senior Consultant in Neurological Surgery had his attention called to the prob-
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lem of the results of cold injuries, in a lecture given by Maj. C. C. Ungley, RAMC, at the British Post-Graduate Medical School.
In a memorandum dated 13 January 1943, the subject matter of this lecture onimmersion foot was summarized and the symptoms of the prehyperemic, hyperemic, and posthyperemic stages were described in detail. However, the most important portion of the memorandum called attention to the advantage of sending these patients to one general hospital where they could be studied as a group and stated that severeinjuries from cold would produce similar symptoms. In other words, immersion foot wasonly one type of cold injury, and the cold injury received on the ground or in the air would differ only as to the time andtemperature of the exposure.
It was not long after that the first airman was seen at the 2dGeneral Hospital with tremendous bullae upon the dorsum of his hands. Itwas believed at first that these were burns, since his aircraft had crashed onlanding and burned. Careful questioning elicited the fact that he had been at awaist gun position in a B-17 bomber, which at thattime was an open window (fig. 142). He had worn his electricallyheated flying suit at the time but had taken off his gloves tourinate. The parts of the suits, it was found, were wired in series, and thusthe entire suit was turned off completely if one portion was disconnected. The aircrafthad been at an altitude of considerably over 20,000 feet, and the temperature, -30?.Instances of cold injuries to the hands, occasionally to the feet, in isolatedinstances to the buttocks, and only once to the cheeks and ears, multipliedrapidly through April and May and early in June of 1943. Exposure to lowtemperatures and airblasts at high altitudes with failures of oxygen supply and,most important of all, failure of, or lack of, electrically heated clothing werethe important etiological factors.
Colored photographs were made of the striking lesions, which wereresulting in the complete disability of the airmen, and studies werebegun to devise the proper treatment and to prevent these injuries. Thisconsultant was ordered by General Hawley to present his data upon 25patients to General Grow, the surgeon of the Eighth Air Force. Anappointment was made, and the author was allowed to stand for 15 minutes while General Grow carried on adiscussion with Lt. Col. (later Col.) HerbertB. Wright, MC, of his office about his own experiences with frostbite when he wasin Russia following World War I. General Grow did not, at this time, take theproblem seriously. Hewas inclined to believe that cold injury in airmen was the result ofcarelessness.
The author placed on General Grow's desk copies of the patients' ownstories and color photographs of their lesions, which included complete casts ofthe skin of the fingers which had been shed, dry gangrene amputation stumps, andbullae of all degrees of severity.4 ColonelDavisstated that he had been instructed by General Hawley to deliver this materialand turned to leave. When he reached the door, he was calledback, asked to take off his
4For examples of these photographs and for additional discussion of high-altitude frostbite, see Medical Department, UnitedStates Army. Cold Injury, Group Type. Washington: U.S. Government Printing Office, 1958.
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overcoat and sit down. A lengthy discussion followed withan antagonistic attitude prevailing on the part of General Grow. He doubtedthat the electrically heated clothing was wired in series, and Col. HarryG. Armstrong, MC, director of the Eighth Air Force Central MedicalEstablishment, was called into the discussion. Colonel Armstrong said quitefrankly that he had no idea how they were wired (fig. 143).
Following this experience, permission was granted by General Hawley todesignate the 2d General Hospital as the center toreceive patients with cold injuries and to establish a laboratory and specialwards for their study. By 9 May 1943, capillary microscopic studies were underway, and mildly injured patients who had recovered without loss of digits werebeing studied at fixed low temperatures to see if they could be returned toflying duty with safety.
Requests were initiated for investigators to go tooperational Eighth Air Force fields to make capillary microscopic studies uponairmen immediately upon landing. Many methods were investigated in an effort toprevent the injuries, and it was recommended that the clothing be wireddifferently and that the open waist gun positions be protected. All requeststo visit airfields were denied by the Eighth Air Force, and finally, thesepatients became so numerous as the activities of the Eighth Air Forceincreased during May and June 1943 that the Chief Surgeon discussed thesituation directly with Lt.
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Gen. (later Gen.) Frank M. Andrews, Commanding General, ETOUSA. Unfortunately,General Andrews was killed in an airplane accident in Iceland soon after, and again it was necessary to brief his successor, Lt.Gen.Jacob L. Devers. Eventually, permission was obtained, and observations were made over a 2-week period by Major Scarff and thisconsultant at a bomber station of the Eighth Air Force. A part of the reporton these observations follows:5
* * * * * * *2. The observations and studies have included:
a. Skin temperature readings.
b. Microscopic capillary observations.
c. Black and white and colored photographs.
d. Complete physical examinations of the affected parts.
e. Personal observations of the Senior Consultant inNeurological Surgery upon the effects of cold at 13,000 feet on a practice raid mission.
3. The following types of patients have been studied:
a. Chronic cases (2) previously treated in the acute stages at U.S. General Hospital #2 and returned to duty at this Bomber Station.
b. Mild acute cases (12) which have not required hospitalization.
c. One severe acute case involving both hands removed to Evacuation Hospital #2 complicated by a severe intra-abdominal injury.
4. Certain facts should be noted from the result of these studies to date:
a. Mild acute cases continue to occur in spite of the risein ground temperature because, at this altitude of the operational missions, thetemperature has ranged at -30 degrees C.
b. The mild acute cases warm up rather promptly at room orfree air temperatures without serious damage to the digits; but, thesymptoms of tingling, stiffness and numbness continue for two or three days andrequire that the patients be grounded temporarily.
c. There is no demonstrable microscopic damage to, or changein,the capillaries in these mild acute cases.
d. Microscopic capillary studies of the severely frozen digits in the one patient show a complete obliteration of the capillaries and extravasation ofblood into the subcutaneous tissue within three hours of the trauma.
e. Capillary loops disappear with severe cold damage to the skinand inchronic cases, three months after injury, have not regenerated.
f. Defective clothing equipment and other technical defects pointedout in the first memorandum on this subject continue to play an importantrole in etiology.
g. The new type of "demand" oxygen mask provided is a distinctimprovement and answers the suggestions raised in the first memorandum writtenwhich would prevent the injurious effect of anoxia common to all the casesobserved early in the study.
h. Progress is being made to the end that an accurate, scientific method oftreatment can be outlined but this cannot be done at this time.
Cases continued to occur, and, during the 2-week period at the bomber station whereobservations were made, 30 patients had cold injuriesrequiring hospitalization for varying periods of time. One medical officer at abomber station denied that any of his personnel had received such injuries,until their names, ranks, and serial numbers were supplied to him during thediscussion.
5Letter, Lt. Col. Loyal Davis, MC, Senior Consultant in Neurological Surgery, to Brig. Gen. Paul R. Hawley, Chief Surgeon, European Theater of Operations, U.S. Army, 14 June 1943, subject: Cold Damage to Extremities.
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Proposal for Acrylic Helmet
In the meantime, a detailed report upon the number of craniocerebral injuries that had occurred in the European theater from 1 September to 1 May 1943 was reviewed for the Chief Surgeon. The number of patients returned to duty, the number returned to the Zone of Interior, and the average number of days in hospital were furnished to him. On 26 May 1943, another proposal of a helmet for the protection of aircraft and tank personnel was sent to the Chief Surgeon by the author, listing the following 16 advantages of the helmet.
* * * * * * *3. The proposed helmet consists of segments of an acrylic resin productmoulded to fit the head snugly, covered by soft leather and linedwith chamois skin.
The advantages of this helmet are:
(1) Compared with manganese steel per unit weight, acrylic resin affords onethird more protection against the penetration of metal fragments.
(2) Acrylic resin of 8 mm. thickness has a velocity resistance to a 52 mgm. steelball of between 700 and 800 meters per second (2,100 to2,400 ft./sec.).
(3) The model helmet made of 4 mm. thick acrylic resin weighs18ounces and has a velocity resistance to a 52 mgm. steel ball of 500 metersper second. If 8 mm. thick material is used, the weight of the helmet would be27 ounces.
(4) Acrylic resin is one of the best non-conductors of heat and coldknownto science.
(5) Acrylic resin can be moulded by heating so that this helmet will fitcomfortably and becomes an integral part of the soldier's head.
(6) The proposed helmet allows unrestricted movements of the head in everydirection and does not obstruct the field of vision of the wearer.
(7) Acrylic resin has a tensile strength of from 9,000 to 12,000 lbs. persquare inch; a flexual strength of 12,000 to 14,000 lbs. per square inch; an impactresistance of 0.1 to 0.3 ft. lbs., and a Brinell hardness greater than gold (500 kilograms on a 10mm. gold ball, 17-20).
(8) Acrylic resin has a specific gravity of 1.10, so that it almostfloats on water. It will absorb less than 0.5% of water by weight upon immersionfor 7 days. It is resistant to the rays of the sun and will not soften until atemperature of between 190 and 240 degrees F has been reached.
(9) If driven into or buried in the brain or soft tissues, acrylic resin isabsolutely inert and there is no tissue reaction.
(10) The lines of shatter of acrylic resin are at right angles to theforce, and not directly forward, as in steel.
(11) Acrylic resin smoulders if a flame is applied but will not burn with anexplosion, and if it flames the slightest movement extinguishes it.
(12) Shatter proof goggles can be made from the same material which can be soattached to the helmet that the present use of elastic bands to supportgoggles can be eliminated.
(13) Pieces of spring steel can be set into the acrylic resin whichwillcatch the elastic bands of the oxygen mask and will obviate the necessity for anairman to take off electrically heated gloves to fasten the small clips now usedto keep the elastic bands secure.
(14) This helmet can be worn constantly by tankmen and need not be removedwhen the head is thrust through the tank turret, or when using aperiscopic sight, as is true with the helmet for tankmen now in use.
(15) Acrylic resin can be used in making a solid complete helmetsimilar to the present steel helmet, if desired. It would afford one-thirdmore protection for the same unit weight against penetration and would notdent or cave in from rough usage. It could have an inner lining made of softeracrylic resin which can be moulded to the head by the soldier him-
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self. The inner softer acrylic resin will fuse inseparably with the hardermaterial. The proposed helmet would afford greater protection againstpenetration and impact resistance than the present steel helmet even if it wasdesired to have it weigh less.
(16) This material can be manufactured cheaply, easily and quickly intohelmets, and the use of high priority steel is eliminated. The number ofmanufacturers now necessary for the production of steel helmets can be reduced.
Immediately, General Hawley indicated that upon return from a surgicalmission to the U.S.S.R., Colonel Davis would be sent to the Zone of Interior topresent the proposed helmet and its advantages to The Surgeon General.
Professional Activities in June 1943
On 14 June 1943, a request was made for additional suction units for the 2dEvacuation Hospital to which injured airmen were being taken. A portable unithad become a part of the table of equipment of evacuation and general hospitals,but one was insufficient. On the same date, further data were submittedconcerning patients with cold damage to the extremities. On 21 June 1943,information obtained in experiments in the surgical laboratory of NorthwesternUniversity Medical School about the local use of the sulfonamides inexperimental gunshot injuries in animals was presented to the Chief Surgeon in amemorandum. Even at this date, it had not been completely established that thesystematic administration of the sulfonamides would offer the patient sufficientprotection from infection.
Policies for the surgical treatment of herniated nucleus pulposus wereestablished in a directive that required examination and consultation upon thesepatients by the Senior Consultant in Neurological Surgery, the performance of amyelogram, and performance of the operation by a qualified neurological surgeonin a general hospital. Pantopaque had just been prepared and was sent to thetheater for use before it had become available on the open market.
SURGICAL MISSION TO THE U.S.S.R.
In the latter part of April 1943, General Hawley asked the author if he would be interested in a trip to the U.S.S.R. Nothing further was added after an affirmative answer, and it was assumed that a well-laid plan undoubtedly had gone astray. However, on 6 May 1943, the Public Relations Division of G-2 (Intelligence), Headquarters, SOS, ETOUSA, requested of the author that an interview on a proposed trip to the U.S.S.R. be granted to Mr. Frederic Kuh, the London correspondent of the Chicago Daily Sun. After verifying the fact that all the proper channels had been cleared and permission had been granted, Mr. Kuh experienced a great disappointment. He was in complete possession of all the facts regarding a surgical mission to the U.S.S.R., upon which Col. Elliott Cutler was also to be included with four British surgeons, at least one of whom belonged to the RAMC. Mr. Kuh must have thought the interviewee was an excellent security risk; the fact was that this consultant was ignorant of all the information which Mr. Kuh gave him. He went on to say
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that this was the first mission of its kind ever to go to the Soviet Union, that Sir Archibald Clarke-Kerr (later Lord Inverchapel), British Ambassador to Russia, had arranged for it, and that the Soviet officials had insisted upon professors of surgery. This explained why Colonel Cutler and the author wereinvited to go because they were the only two professors of surgery in the U.S. Army Medical Corps then in the European theater. Thus, this consultant first learned that Mr. Reginald Watson-Jones (later knighted),Mr. Ernest Rock Carling, Surgeon Rear Admiral Gordon Gordon-Taylor, and Maj. Gen. D. C. Monro would be on the surgical missionrepresenting the British. Following this, there began a series of episodes confusing to the Chief Surgeon no doubt, as well as to hisneurosurgical consultant. It was the latter's first personal experience in a joint effortbetween one of the armed services and the State Department.
About the middle of May, the members of the mission had luncheon withProf. Semon Sarkisov,6 recently arrived fromthe U.S.S.R., and Sir HenryDale, representing the Medical Research Council of Great Britain. On the sameafternoon, the mission had tea with Ambassador Ivan M. Maisky atthe Soviet Embassy. Before going to tea, Colonel Cutler and this consultant hada 10-minute chat with John G. Winant, the U.S. Ambassador to the Court ofSt. James's, who told them that Wilder G. Penfield would represent Canadaon the mission. Ambassador Winant indicated at that time that the missionwould leave London on 12 June.
Later, Ambassador Winant requested the author to call upon him at theEmbassy. General Hawley was informed of the request and acquiesced. AmbassadorWinant asked this consultant to represent the National Research Council while onthe mission to the U.S.S.R. He also insisted that the author travel as acivilian throughout the trip, and not as one of the representatives of theU.S. Army Medical Corps. The reasons for making this unusual request were notexplained by the Ambassador. After consulting General Hawley, this consultantdecided to retain those advantages which could be obtained by being inuniform if by slight chance the aircraft was forced down over enemy territory.
Finally, the two members of the surgical mission to the U.S.S.R. from theUnited States were given informal instruction by Ambassador Winant, GeneralLee, and General Hawley, and travel orders were issued.
On 28 June 1943 the members of the mission were loaded into a bus at theSwindon railroad station and driven about the countryside until it became dark.They were given dinner at Marlborough and taken to the airfield which wasrecognized as the one at Lyneham. The four-engine British aircraft carriedthe members of the mission and two Soviet nationals, who remained grim anduncommunicative throughout the entire trip. The mission members were informedthat these two men were diplomatic-pouch couriers, but also members of the NKVD,the Soviet secret police. The takeoff was at midnight, and,
6The variation in the spelling of the names of Russian individuals in thisvolume is due to the fact that there are two systems of transliteration in use.
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FIGURE 144.-Mena House Hotel at Al Jizah, Egypt, at the foot of the Pyramids.
flying well out beyond the Bay of Biscay (where a planecarrying Leslie Howard, the famous British actor, had been shot down by theGermans 2 weeks before), the mission landed at Gibraltar at 0830 hours thefollowing morning, 29 June. After breakfast, the military hospital, a 200-bedunit built in a tunnel which had been drilled out of the rock, was visited.This hospital served also as a bomb shelter if the "Rock" wasbombed.
The mission was off again at noon and flew over theU.S. 12th General Hospital at Oran, Algeria, and on to Castel Benito, theairport at Tripoli, Libya. From the altitude of 8,000 feet, the countryappeared a solid brown color with only occasional green spots to break themonotony. The flight followed the route of the advance of the British EighthArmy, and damaged, abandoned material was visible along the road. TheBritish 48th General Hospital was visited in Tripoli, and it proved to be onewhich they had taken over from the Italians. After tea in a settingof desert sand, flies, bougainvillaea, and heat at an RAF (Royal Air Force)staging area, the flight was continued at midnight to arrive at Cairo at 0830hours on the morning of 30 June.
Barefooted Egyptians, with long wrappers and fezzes on theirheads, were working on the airfield and the roads. Arrangements had been made forthe mission to stay at Mena House, a clean, cool, well-staffed hotel on the outskirts of Cairo and atthe foot of the Pyramids (Al Jizah) (fig. 144). The military members of the mission (Gordon-Taylor, Monro, Cutler, and Davis) went to
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the British Embassy to register their presence. Thevarious headquarters were grouped around the Embassy buildings thathad been requisitioned, and the entire area in the center of Cairo was fenced off withbarbed wire.
A similar visit to Mr. Alexander C. Kirk, U.S. Ministerto Egypt, disclosed a tall, impressive, well-dressed man who complaineddiscouragingly and with a real nostalgia that diplomacy had died in 1918 andthat he would be glad when it was all over so he could go back home, sitdown, and not be bothered (fig. 145). A representative of the British Medical Research Council gave aluncheon, at which there were several representatives of the medical profession of Egypt, inthe famous andexclusive Mohammed Ali Club. Cold meats, watermelon, strawberries and cream,and an American beer constituted the luncheon in a private dining roomadjacent to a large, ornate gambling room.
Two British hospitals were visited; the one in a newlyconstructed modern hospital which the Egyptians had to close because theycould not make it support itself and the other in the building of a formerbeautiful hotel. The U.S. 38th General Hospital, staffedprincipally by the faculty of Jefferson Medical College of Philadelphia, waslocated at Heliopolis, but a visit there had to be postponed until the return trip.
On the morning of 1 July, after considerable delay whilethe plane's fuel and cargo were being redistributed at the insistence of theRAF pilot
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on a desert airfield which became hotter and hotter, the legof the trip from Cairo to Teheran, Iran, began. Without oxygen and at 13,000feet, one of the mission became cyanotic, another had periods of apnea, and athird developed scintillating scotoma, could not remember names, and had ahomonymous hemianopsia. All of these symptoms disappeared, and the missionpresented a unified front upon landing at Teheran late in the afternoon. Arepresentative of the British Embassy met the mission but had been notifiedof the arrival only 2 hours previously by the Soviet Embassy. There were noU.S. representatives.
It was hot and dusty on the airfield, which was surrounded byhigh mountains with snow on their peaks. There were many American soldiers tobe seen, and a station hospital was under construction. Water was running in asmall gutter along the side of the street, and people were washing theirbodies and clothes in it, watering horses in it, sweeping street cleaningsinto it, and putting it into pails which they were carrying away. The PalaceHotel provided two iron beds, a wooden washstand with a flowered china bowl, andone water faucet. The guests sprinkled insect powder on the mattress andpillow in liberal quantities.
A visit was paid by the Americans to Maj. Gen. Donald H.Connolly, Commanding General, Persian Gulf Command, an engineer who wasaccomplishing the project of supplying the Soviet Union through the PersianGulf and Basra, Iraq (fig. 146). General Connolly inquired about the purposeof the visit to the Soviet Union, since he knew nothing of the mission. When the purpose was explained, he expressed his doubts ofthe mission'slearning any more than what the Soviet hosts would specifically designate. Fromthis conversation, the author received the distinct impression that it wouldhave been more advantageous for the U.S. representatives to make this trip alonebecause of the Soviet distrust of the postwar intentions of the British.
Sandfly fever, characterized by a high fever for 2 or 3 daysand no fatalities, was a common disease amongst the natives. A form of malariawas described as occurring in places where the Anopheles mosquitocould not be found. Typhus had been prevalent during the previous winter, andtyphoid fever had caused an unheard of number of deaths in the spring andsummer months. Trachoma was abundant, as was syphilis.
The following morning there was another delay on the hot, dusty Teheran airfield while petrol was removed from the tanks so that the Liberator would be able to gain altitude quickly enough to clear the mountains surrounding the field. After a bumpy, rough trip, the mission landed in Moscow late on the afternoon of 2 July at a field about 30 miles from the city. They were met by Vice Commissar Vasillii Vassilievich Pairin, Vice-Commissariat of Public Health, and Leonid Aleksandrovich Koreisha, Secretary of the Medical Scientific Council, and a woman interpreter. Two U.S. Army Air Forces officers, who, Colonel Cutler believed, would be their aides while the two colonels were in the U.S.S.R., accompanied them to a cottage in a woods adjacent to the airfield where they were served tea, bread and butter, sausages,
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white caviar, and strawberries. On the trip to the NationalHotel where the mission was to be quartered, it was learned that the ArmyAir Forces officers were in Moscow with Capt. "Eddie" Rickenbackeron a mission which he was attempting to carry out for Secretary of War Stimson (fig. 147). CaptainRickenbacker's mission concerned the complaints which the Soviet Union wasmaking about the Airacobra (P-39) planes that the United States was furnishingthem on lend-lease agreement. The complaint was to the effect that they would not stand upin combat. It developed later that the Soviet military had no concept of ground crews to servicethe aircraft and keep the intricate mechanisms in good working order. It was their idea to flythem, discard them if theybroke down, and ask for new ones. The complaint was that the planes did notstand this type of treatment long enough, and they were put to considerabletrouble in asking for replacements.
After an assignment of rooms, the mission members found theyhad a large common sitting room which had a ceiling-to-floor mirror on one wall.The mirror was decorated with gold-painted birds and angels concealing a
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microphone. To the credit of the members of the mission,there was no one who lowered his voice or changed the frank expression ofhis opinions at any time. On one occasion when Prof. Serge Yudin visited themembers furtively at midnight, he kept up a constant tapping of the tablewith his pencil during the 2-hour visit to interfere with a clear pickup of his voice.
After a cold-water bath (and this did not vary at any time duringthe mission's stay), they had a breakfast of tea, cherry jam,cheese, caviar, and bread. Neither did this menu vary, except as they couldvary it with instant coffee and hot water heated over a Sterno can which theyhad brought along. The business office of the U.S. Embassy was only adoor or two from the National Hotel, and both faced Red Square, across whichthey could see the Kremlin and the new, gaudy, heavily built, yellow-stoneMoskva Hotel. The entire mission called upon Adm. William H. Standley, U.S.Ambassador to the U.S.S.R., who was charming and interested in learningeach man's name and his particular field of surgery. Leaving the Britishfor a moment, they called upon Brig. Gen. Philip R. Faymonville who hadbeen in the U.S.S.R., on four tours of duty, for 10 years. General Faymonvillewas the Lend-Lease Administrator and, in a frank talk with them, made hisposition perfectly clear. He was under direct instructions and orders fromPresident Roose-
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velt, delivered by Mr. Harry Hopkins, to supply everythingpossible to the U.S.S.R., regardless and without thought of getting something in return. He statedthat other branches of the U.S. Governmentwished to barter with the Soviet Union, using lend-lease material asleverage, on the grounds of protecting the United States. It became obviousquickly that the military attach? and embassy officials were in direct conflictwith General Faymonville and believed him personally responsiblefor a situation which was intolerable to them in dealing with the Sovietnationals, without accepting the fact that General Faymonville was carrying out specificorders from the President, and failing to consider that his own personal views might be entirelydifferent. General Faymonville's knowledge of the Russian language, his longresidence in the U.S.S.R., and his familiarity with the Soviets' music and customsmade themfriendly to him, and this was obvious at the social gatherings which were given forthe mission and at which he was present. However, this made him all the more suspect by his colleagues of favoritismwhen the war had finished and when the relationship between the United States and itsformer ally was changed.
British Ambassador Clarke-Kerr met the mission formallyand indicated that it had been made possible by his friendship withSerge Yudin who had suggested such a visit by U.S. and British surgeons.This version of the origin of the mission was at variance with the one which emanated fromthe U.S. Embassy in London-that it had beenarranged by the U.S. Ambassador to Great Britain as the result of discussionsbetween members of the National Research Council and the Medical ResearchCouncil of Great Britain. The truth probably is that all had a hand in the project andthat priority of ideas would be difficult to establish. Eachmember of the mission received 1,000 rubles from the British Embassy, but theycould use them only for gratuities to hotel employees, since therewere no shops or stores where one could purchase any kind of article without a ration card.
In the afternoon of 3 July, Monro, Cutler, Watson-Jones, Penfield, andthe author, with Brimelow, who was attachedto them from the British Embassy, visited VOKS-the Soviet society topromote cultural relations with foreign countries. Large posters of Churchill, Stalin,and Roosevelt hung side by side in the large museumlike room of the building towhich they were taken by Pairin and Koreisha. Oil paintings of Soviet soldiers in variousunits, cartoons, andlarge photographs of Charlie Chaplin and Paul Robeson completed the display. Onthe return to the hotel, a stop was made at a park where there were pictures ofthe party leaders lining the walk, a Ferris wheel andvarious airplane rides for the children, an area for dancing to the music coming fromthe loudspeakers distributed through the park, and a children's library. The orthopedistin the group remarked that it was much like saying: "Come into the park and we'll give you culture, damnyou."
At dinner, the mission members discussed when and howthey would get their visit underway, and Admiral Standley's admonition tobe patient was
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agreed upon to be the line to follow. After dinner, theywalked around Red Square, Lenin's tomb, the Kremlin, and the Church of St.Basil, a Byzantine structure, highly colored and resembling a gingerbread cake.This was their first unaccompanied trip of any distance on the streets, andthey noted that guards, walking along the top of the walls of the Kremlin,were either curious about them or were very alert to their duties. There were notaxicabs, and only the Intourist organization could supply transportation.
There were several discussions about drawing up their ownagenda for procedure and discussions with the People's Commissariat forHealth. The mission wished to see surgery of the war wounded in the forwardareas and at the bases and to see and discuss the Soviet research projects andways of exchanging information. These were pleasant periods of conversation witheach other but were like shadowboxing in a gymnasium.
During this interval while the mission waited for the dateof a meeting with Soviet authorities, a memorandum was written to be left withthe People's Commissar for Public Health, which would explain the desires ofthe mission (pp. 97-99).
So, July 4 was spent in viewing a large collection ofcaptured German war material-guns, planes, trucks, and medical supplies-gatheredtogether on the bank of the Moscow River and looking much like a World's Fair.Groups of soldiers were taken through and given lectures on the material displayed. Large crowds of civilians were atthe exhibition, andclothes and uniforms of the visitors from the Western World were the centerof close, unabashed, personal inspection. The afternoon was spent at SpassoHouse, the official home of Ambassador Standley, which had been occupied alsoby his predecessors, U.S. Ambassadors Bullitt, Davies, and Steinhardt. Capt."Eddie" Rickenbacker was present and brought up the question of thedamage airmen were receiving from high-altitude frostbite, interesting theAmbassador in the discussion.
The evening was spent watching the ballet "The SwanLake" with Dudinskya, the premi?re danseuse. The audience that eveningconsisted of workers from factories who had purchased tickets from allotmentsgiven to their factory. When the mission members went into the lobby betweenacts and returned, they had difficulty in regaining their seats from individuals who had moved into them from less desirable ones.
Eventually, at 1500 hours on 5 July, the mission was receivedin the office of the People's Commissar for Public Health, Georgii AndreevichMiterev. There were seven mission members and seven Russians; there were threeof the mission in uniform and three of them in mufti. The Soviet militaryincluded Lt. Gen. Efim Ivanovich Smirnov of the Soviet Army Medical Service, who was 38 years of age andcorresponded to The Surgeon General, and NicolaiNilovicin Burdenko, the chief surgical consultant to the Soviet Army, not aregular medical officer and with the added great distinction of being a member of the Academy of Sciences. The meeting got underway with a formalspeech by the Commissar, who described the existing organization for thetreatment
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of battle casualties and provided a typewritten programof activities for the week.
The care of the injured and sick in the army was directedfrom two departments, the People's Commissariat for Defense and the People'sCommissariat for Public Health. General Smirnov's medical organization was responsible forthe care of the soldier in combat units,in army hospitals, and through all evacuation steps to the base area. Thecare of the wounded soldier in the base area, as well as the careof all civilians, was the responsibility of the People's Commissariat for PublicHealth. It was stated that the methods of treatment were identicalin both organizations in order to insure continuity in the patients carewhen he was transferred from the combat zone to the rear. The line ofdemarcation between these two areas was never unchangeably fixed. When apatient received a certificate of fitness from the civilian doctors, he wastransferred back to the military authorities for reassignment. Patientsrequiring long convalescent care remained under the jurisdiction of the civilianauthorities in hospitals which were required to devote theirchief attention to the treatment of the war wounded. The People'sCommissar for Public Health stated that 70 percent of all wounded were returned to thecombat zone for duty, and he was obviously proud of the small incidence oftetanus and gas gangrene.
A detailed description was given of the organization forcare of the wounded on the field at battalion, regiment, and division aidstations and in the sorting-evacuation hospitals, placed 30 to 50 km. fromthe front, and from 1,000 to 4,000 beds in size. An explanation was providedof the methods of evacuation by train, automobile, and plane. Thepercentage distribution of beds was described, and it was emphasizedstrongly that 0.2 percent were devoted to neuropsychiatry at the front and0.1 percent, at the base area.
On 6 July, the members of the mission began their tour ofthe facilities which the Soviet hosts wished them to see, and nothingbeyond that was possible. The Botkin Hospital, the Sklifossowsky Instituteheaded by Serge Yudin, the Central Institute for Traumatology and Orthopedy, the Institute ofNeurological Surgery (Burdenko's Hospital), aclearing hospital of the People's Commissariat for Public Health, twofrontline hospitals near Vyazma, a hospital for the "lightly wounded,"the first Medical Institute, the Pirogoff Clinic, the Balneological Institute,the Central Institute for Blood Transfusion, the Central Institute forMedical Research, and a final meeting with the People's Commissar for PublicHealth fulfilled the agenda provided by the hosts. At no time was any memberof the surgical mission asked to present his opinions about any surgical orresearch problem or to relate experiences of the British or U.S. Army MedicalCorps in treating the wounded.
In summary, the principles of Soviet surgical practice inthe care of the war wounded, as shown and explained to the mission, were:7
Wounds were debrided as far forward as possible, usually in the sorting-evacuation hospitals, although also in base hospitals. Excision,even in com-
7See also appendix A, p. 953.
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pound fractures, was carried out as late as 10 or 15 daysafter wounding, and the sulfonamides and immobilization were relied uponto prevent generalized sepsis.
Large soft-tissue injuries, as well as fractures, wereimmobilized by wooden splints of the Thomas type for evacuation to theplace of first definitive surgical treatment, after which plaster of pariswas applied. This was put directly over the wound, "skin tight"without padding.
Active immunization was obtained with tetanus toxoid. The booster dosewas given at the regimental aid station.
A potent antiserum was used in all serious wounds against thedevelopment of gas gangrene. It was usually given intravenously.Several surgeons admitted privately that the antiserum was noteffective.
Sulfanilamide was used in both forward and base hospitalslocally in the wounds, by mouth, and intravenously. A small supply ofsulfapyridine was in existence at that time. A special form of sulfanilamide inwhich the drug was broken down into small particles by subjecting it toultrasonic waves was used as a cream and applied to gauze dressings. Thelatter product was in an experimental stage, it was said, and was not in massproduction.
Secondary suture of wounds was practiced wheneverpossible, even more than 7 to 12 days after injury.
Inhalant anesthetics were commonly used, especially ether.Spinal anesthesia was used only in base hospitals, but no nitrous-oxideor oxygen machines were seen.
Sucking chest wounds were closed in forward areas; empyemawas treated by drainage for 3 weeks, following which two or three rib fragments were removed and the wound was packed. Only large foreign bodies wereremoved from the chest cavity.
Tannic acid and silver nitrate were used in the treatmentof burns, but the Soviets preferred an open method in which a powder containingan analgesic agent and an antiseptic was dusted on the burnedarea.
The best impressions of the Soviet methods of treatment wereobtained in their treatment of fractures. From the time of Pirogoff, in theCrimean War, they had become masters in the use of plaster of paris. They hada line of continuity in the treatment between surgeons at the front and in basehospitals which represented the same institution and methods. Yudin at the Sklifossowsky Institutehad cared for over 2,000 fractures during thewar with Finland. They preferred to splint the limb in the field with wooden,wire, or Thomas' splints at the place of the first definitive treatment. Thewound was widely excised and sulfanilamide was placed in it. Often the wound was suturedopen by uniting the skin edges to the deep fascia."Skin tight" plaster was then applied directly to the wound and skin. Casts were not splitand they never used windows.
An interesting sidelight resulted from the discussion which developed between Dr. Serge Yudin,who was not a member of theCommunist Party, and the mission, particularly Mr. Watson-Jones, about theresults of their meth-
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ods of treating fractures. It was a give-and-take friendlyexchange of opinions until Watson-Jones indicated that itwas difficult to believe the successes claimed. Yudin, whereupon, inquired ifWatson-Jones had ever treated 2,000 compounded fractures,and, when the reply was in the negative, Yudin stated again that he and his associateshad and these were the methods and results.
The Soviet Army Medical Service used large amounts ofcitrated whole blood and little or no plasma. An excellent technique wasemployed to collect the blood in the larger cities, but chiefly in Moscow, where 2,000pints a day were obtained. Donors were given a special food ration and a smallamount of money, but 85 percent of the latter was returned through gifts to theGovernment for airplanes and other military purposes. The name of each donor wasplaced on each container, and the name of the recipient was given to each donor.The blood was refrigerated at 6? C. and flown to a point near the front, fromwhich it was distributed in refrigerated vehicles to frontline hospitals. Theuse of plasma was confined to regimental aid stations. Much time was taken todescribe many other fluids used, but it wasobvious that this was done only to indicate the extent of theirknowledge.
Amputations, prostheses, and plastic surgery were well donein special hospital centers. One plastic surgeon, Frumkin, had received publicityin the Allied press for a series of patients upon whom he had operated to createa tubular graft which would simulate a penisthrough which the bladder could be emptied.
When the mission gave a dinner at theNational Hotel where they were billeted, the guestlist included Frumkin, agenial, intelligent, capable surgeon, who spoke English well. Frumkin's name was removed fromthe list, as well as several others, and other names were substituted, none ofwhom the mission had met. This was donewithout asking the mission's approval, and no reason was ever givenfor the action.
Lt. Gen. S. S. Guirgolave lectured to the mission at somelength about cold injuries received on the ground and in water but dismissedquestions about high-altitude cold injuries in flyers by denying theirexistence, an attitude which appeared to be common amongair force medical officers, Soviet or American, who were in positions ofresponsibility. It was their opinion that treatment should be guided byrapid heating of the individual and the injured part. Longitudinal incisions weremade in necrotic tissue within 5 or 6 days to promote the rapid development of drygangrene.
All of the neurological surgeons in the U.S.S.R. had beentrained under the supervision of General Burdenko, who also was a member of theAcademy of Sciences. The latter conferred far more distinction and privilegesthan any other classification with which wecame in contact. It was said that Academicians ranked in these respectsjust below the Politburo.
General Burdenko had established an Institute forNeurological Surgery, and it was claimed that 16 neurological surgeons at thefront had 3,200 beds at their disposal and that therewere 3,700 beds in the rear.
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In brief, the neurosurgical techniques shown were those which developed from World War I,without the subsequent refinements whichwere being practiced in the United States. In no area could Soviet surgery makeany contribution to this surgical specialty.
An incident occurred while the mission visited theInstitute for Neurological Surgery which revealed more of the Soviet mind thanwas being disclosed surgically. General Burdenko demonstrated a microscopicslide which purported to show the excellent regeneration which hadoccurred as the result of the experimental use of a formalin-fixed nerve graftin the repair of a peripheral nerve injury. The specimen was poorly stainedand showed nothing conclusive, and one of the mission turned away withoutcomment. Brudenko, through the interpretress, insisted upon a commentabout the demonstration, stating that he had a copy of the American's bookon peripheral nerve injuries. He indicated that an opinion would be highlyappreciated. The answer was, of course, that it had been proved during WorldWar I, and subsequently many times, that such formalin-fixed grafts werecompletely useless. General Burdenko was asked to indicate how many patientshad been operated on and to demonstrate one who showed a return of sensation or motion in any areain which overlap did not occur. GeneralBurdenko replied with a smile that 25 patients had been so operated on, thatall had recovered, and that they were unavailable for demonstration becausethey were at the front in combat.
The other members of the mission, and, in particular, theother member from the United States, were not hesitant in indicating thatsuch a doubting attitude might well impair the entire success of the missionand, if carried into other fields, might even destroy the alliance between theWestern nations and the Soviet Union and allow Germany to win the war. Thesequel to the incident occurred later at the dinner given by the mission inthe National Hotel. During the cocktail hour, General Burdenko was observedrearranging the placecards. It was protocol to have a lieutenant colonel sit atthe foot of the table and certainly not on the left of General Burdenko.However, this is what occurred-much to the embarrassment of the seniorranking officers on the mission who believed it must be due to the ignoranceof the lieutenant colonel or else his persistence in attempting to offend theSoviet officials. However, the placecard was authenticated by AmbassadorStandley who viewed the incident with amusement. During the dinner, GeneralBurdenko summoned the interpretress and asked again the neurosurgicalconsultant's opinion of the formalin-fixed nerve grafts and again wasinformed that they had been proved to be unsuccessful beyond any doubt.Whereupon, General Burdenko said he agreed completely but then inquired why theother members of the mission, particularly the British, had been socomplimentary in their praise of the experiment. He went on to say that this wasan example of how difficult it was to trust and negotiate with people who didnot always bluntly state their views and position. Ending by a firm, pumpinghandclasp, he stated that henceforth there would be no difficulty inunderstanding opinions expressed by the American neurological surgeon.
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Several clinical methods were under study which wereemphasized as being completely new and original ideas. These included theinjection of 70 percent alcohol with 2 percent Novocain (procaine hydrochloride) solution about fractures inthe early days following injury toincrease the blood supply and to stimulate callous formation; the use ofplacental extract to stimulate healing in chronic wounds or the growthof skin in severe burns; the use of a cytotoxin made by injecting mesenchymal tissue into a horse and usingthe antiserum to stimulate the healing of ulcers of the stomach, the healing of bone, and theloosening ofscars and stiffness in joints; the use of the smoke from burning pinewoodto stimulate healing; the use of naphthalene broken down by ultrasonic methods tostimulate healing; and the treatment of shock by thesuboccipital cistern injection of potassium phosphate solution to stimulate the vasomotorcenters in the medulla.
The mission visited Dr. Lena Stern's laboratory toobserve an experimental animal tested for shock by this method ofcisternal injection. Allowing for all of the difficulties which are inherent inthe demonstration of any experiment to a group, the basic technical methods employed were so crude and inaccurate as to throw completedoubt upon any conclusion which had been expressed. Dr. Stern was one of thefew women Academicians, and her apartment, automobile, food, and gasolinerations could not be compared with those of the average citizen.
One of the outstanding demonstrations to the missionwas that of the organization which had been effected, withoutrecourse to the more democratic method of employing committees, to hospitalizethe emergency injuries to the civilian population of Moscow. In fact, whenorganization alone was considered, the Soviet plans were efficient andsuperior.
It was apparent that women held equality with men in theU.S.S.R. as members of the street-repairing gangs and of otherconstruction groups on the country roads and as soldiers and officers in theArmy. In the line, the mission was informed that there was no woman with ahigher rank than colonel; several junior officers were seen with artilleryand infantry insignia. In the medical service, the Inspector General,Brigadier Surgeon Valentina Gorinovskaya, was a woman.
On 11 July 1943, the mission began a trip to the frontlinehospitals near Vyazma. It will be remembered that, during the following month,the Soviet Army opened an extensive and decisive campaign along theOrel-Kursk-Belgorod Line which extended directly south of Moscow. Vyazma wasabout 125 miles southwest of Moscow and represented a point to which the SovietArmy had driven the Germans back from their advance on Moscow.
The entourage consisted of several automobiles containing themembers of the mission and their hosts. But there were two additional carswhich served to transport the mission when the cars in which they were ridingbroke down, and this occurred four times going and coming. Extra cans ofgasoline were carried with the passengers, and the rugged, jolting ride wasonly a part of the rigors which it is said every doctor-soldier should betrained to expect. All
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of the traffic officers on the way to Vyazma were women,armed with rifles, whose demeanor and expression left no doubt as to theirability and willingness to use them.
At about 1700 hours, the mission arrived at a casualtyclearing station, well camouflaged in a thick forest. After the missionwas shown through the wards, vodka, strawberries, caviar, and smoked fish were servedin a fine example of a Mongolian tent. General Faymonville had briefed one ofthe U.S. delegates on the drinking oftoasts in vodka in the Russian fashion. It consisted of making up one'sown mind about how many vodka toasts could be tolerated and then going throughthe motions, substituting wine or water if possible, or otherwise simply raisingthe glass. It became obvious at this first stop that, if one accepted the Soviet rules,defeat was inevitable.
The mission arrived at a large evacuation hospital atabout 2200 hours that same night. It was raining and pitch dark, but the hospital too was obviously placed in a thick forest and seemed to beconstructed of logs. A sumptuous dinner had been prepared with an exactprotocol of seating arrangement along one side of an enormous table whichoccupied a large dining hall. The senior military member of the mission sat inthe center of the table, and on his left was a young,blonde, Amazon-like woman with the rank of major of infantry. Lower ranksand civilian representatives graduated downward to the ends of the table.Vodka, wine, champagne, and enormous quantities of all types of food wereserved while representatives of various Republics of the Soviet Union, dressedin their native costumes, entertained the guests with folk music and dances.
The toasts came thick and fast and, as was customary, by thetime it came to a lieutenant colonel, there was little left to toast. Theruling heads of governments, the Soviet Army, and the women of the Soviet Union had beenhonored, and a few well-delivered mumbled words with thecorrect emphasis and gestures now sufficed. It was evident that the youngwoman major had considerable capacity for vodka and a technique of eating largepieces of bread between toasts. It was also apparent that her table companionswere slowly but surely becoming unable to accept her challenges. It did not help for one ofthe mission to invite her to dance to the Ukrainian musicin the hope that the exercise might slow down her vodka-consumingabilities. As a matter of fact, her vigorous dancing probably burned up thealcohol more rapidly and only exhausted her partner. She was physicallysuperior to any one of the mission and probably was devoting herselfsingle-mindedly to carrying out an order.
The dinner was terminated abruptly, and the members of themission were guided to their billets by their Soviet hosts. They werebedded in one of the wards of the hospital which was cleaned and hadcomfortable beds. During the night, one of the mission had the first attack of severerenal colic and experienced the nursing technique ofSoviet nurses whose calloused and rough hands were nonetheless gentle andreassuring. The following morning the log and plankstructure could be admired. It had been erected by officers, nurses, andenlisted personnel, and the nurse who had been on night duty was observed
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using a hand ax as she, with others, worked on a window framein a recently added portion of the hospital.
A breakfast of tea, smoked meats, and bread was followed bya visit to Colonel Davis from the previous night's table companion, aSoviet medical officer of the same rank. The Soviet officer apologized forattempting to embarrass a member of the mission by publicly calling attention tothe fact that he had not drunk each toast in vodka. He conceded as quite correctthis consultant's direct, frank answer thatif he (the Soviet colonel) was a guest in the United States he wouldbe permitted to drink as often and as he pleased, and on that basis the American guest tothe Soviet Union would conduct himself. The Sovietofficer went on to say that there was no real necessity for accepting theRussian rules about drinking toasts, but, if they were accepted, then the Soviet peoplewent all out to drink their guests under thetable. A Russian salutation on both creeks ended the apology and appeared to cement afriendship between at least two of the Allies.
The return to Moscow was completed late that night and the nextday was spent in rest and at a symphony concert. The following day the missionvisited a hospital for lightly wounded who were able to be quickly rehabilitatedand returned to the combat zone. On 15 July, the British and Americans conferredhonorary Fellowships upon Burdenko and Yudin in the officeof the People's Commissar for Public Health with as many Sovietofficials as members of the mission present and no other guests. The British and U.S.Ambassadors were not present, and both Sovietrecipients prominently displayed their stars of the Order of Stalin. Itwas a ceremony completely unworthy, in its setting, of the Fellowships from thedistinguished Colleges of Surgeons of England and America, both of which hadbroken a precedent in conferring their Fellowship away from the home of the College.
The following activities occupied the remainder of themission's stay in Russia: A return visit to the Sklifossowsky Institute;visits to the Pirogoff Clinic and to the Balneological Institute, whereit was claimed that a pine-oil water and Odessa mud were miraculous curingagents; a visit to the Central Institute for Blood Transfusion where,accidentally, it was learned that the mission's constant Soviet companion,physiologist Pairin, understood English perfectly, though he had never utteredone audible word of English; attendance at a performance of the ballet from Otto Nicolai's opera, "The MerryWives of Windsor," and at a performance of Tschaikovsky's opera,"The Queen of Spades;" a meeting at the Central Institute forMedical Research, at which Mr. Carling, Professor Penfield, and this consultant recited that GreatBritain, Canada, and the United Statesfreely exchanged research information, without eliciting the slightestsign of encouragement that the Soviet Union would join in.
On 23 July, the mission finally took off on their returnflight. The last week had been difficult for the hosts as well asthe members of the mission and it had been hard to keep occupied. Thetime allotted to the mission had been overstayed. It had been impossibleto walk about alone, because the ever-present NKVD representatives had beennearby; there were no shops in which
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to purchase mementos of the trip, and the members of themission had become slightly weary of one another's frailties.
The obstacle, however, was the fact that no airplane wasavailable to take the mission back to their starting place. The British andSoviet authorities had been negotiating an agreement whereby, in the summermonths, one route would be flown by way of the Mediterranean, Cairo, andTeheran, as the mission had come, and another directly across Europe from Londonto Moscow. One aircraft by each route each week was the schedule. In the wintermonths, two planes would fly the southern route. The British believed theagreement to be firm, but flew two planes in one week in July via the southernroute, instead of one directly across Europe, because of operationaldifficulties, which would quickly straighten out. The Soviet authoritiesconsidered this a violation of the agreement and refused to allow any planeto enter Soviet territory by any route.
The week passed with the British Ambassador franklyadmitting that he could get nowhere with the Soviet Foreign Office. The U.S.Ambassador finally demanded passage out of the U.S.S.R. for the two U.S.citizens and, on 23 July, all of the members of the mission arose at0300 hours and arrived at an airfield near Moscow at 0545 hours. Theycould see the two-motored U.S.-built plane sitting on the field. A large redstar decorated its side. After waiting 2 hours for Walter Citrine, a Britishlabor leader and his companions who had also been in the U.S.S.R. studyingSoviet labor relations, they boarded the plane whose motors were still idle. Themotors were started, and, without preliminary revving of themotors, the plane taxied to the end of the field and took off. The flightwas never above 1,000 feet because, recently, an order had been issued to theantiaircraft crews to shoot at any plane above that height, withoutattempting to identify it. Stalingrad was circled at 500 feet and all thatcould be seen standing was one stone chimney. At 1730 that evening, thepilot dove the field at Teheran, and, with the smell of scorched rubber tiresin their nostrils, the members of the mission were unceremoniously depositedon the airstrip. They were out of the U.S.S.R..
The unceremonious delivery of the members of the mission inTeheran left the Americans stranded at the airport, while the British left byan automobile provided by Sir Reader W. Bullard, British Minister to Iran. A carwas commandeered, and, after a great deal of shouting and gesticulating, thebillet of General Connolly was reached. Hot, dirty, and tired, Colonel Cutler andthe author burst in upon the general and his staff who were having a cocktail before dinner. The general quickly grasped their predicamentand sent an orderly outside to silence the Persian driver who was honking theautomobile horn and screaming Iranian curses on his passengers.
After hearing their story and realizing that they had nomeans of transportation from Teheran to Cairo, General Connolly arranged forhotel accommodations overnight, removed two passengers from a U.S.freight-passenger plane that was leaving in the morning for Cairo via Basra,and said he would send a car to pick them up early in the morning and put themon the airfield. With
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FIGURE 148.-The headquarters of the U.S. Army Forces in the Middle East.
many sighs of relief, they arrived at the hotel withthe general's aide, cleaned up, and answered a telephone call from theBritish Minister to come to dinner at his home. There was some tension afterdinner when methods of transportation to Cairo were compared. The British were beingflown directly to Cairo in the commanding general's comfortable plane.
The U.S. plane had two motors, and its aisle was filled with engines, crated to be returned to Cairo. Its bucket seats were filled withofficers and enlisted men, all of whom had one goal in common-tobe able successfully to crawl on their hands and knees across the enginecrates to and from the toilet, since all were suffering from diarrhea. Basra'stemperature was 120? that morning at about 1000 hours, andgriddlecakes and thick molasses was not an appetizing menu. It was not long,however, before the plane took off again and landed in Cairo at about1730 hours that evening, 24 July.
Colonel Cutler and the author were unsuccessful in obtaining aroom at Shepheard's Hotel and eventually got to MenaHouse where they found the other members of the mission. The next 3 dayswere spent in talking with Mr. Kirk, U.S. Minister to Egypt, the members of the U.S. Typhus Commission, and Col. Crawford F. Sams, Surgeon, U.S.Army Forces in the Middle East (fig. 148); visiting the U.S. 38th GeneralHospital; sightseeing among the Pyramids and the Sphinx at Al Jizah; lunching withAli Pasha Ibrahim, Dean, Faculty of Medicine, EgyptianUniversity (Cairo); and listening in on a critique of the British-Americanlandings in Sicily.
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FIGURE 149.-A parting look at the airfield at Heliopolis, Egypt, July 1943.
The DMS of the British Eighth Army in Cairo at that time wasMaj. Gen. William H. (later Sir Heneage) Ogilvie. ColonelCutler and the author were warned by him that thecritique would be highly critical of the American air forces andparatroopers. After they had sat down and after Gen. Henry Maitland Wilson had arrived,the Americans were given the opportunity to leaveif they chose. The critique lost all of its objectiveness and value, evento the British Armed Forces, when the colonel who conducted the critiquebecame highly emotional and delivered a sarcastic diatribe about the favorable publicity that the U.S. ArmedForces had received and their popularity with the female population of the British Isles.
At midnight on 28 July, the mission was driven to theairfield at Heliopolis (fig. 149). It was stifling hot on the desert, and thesand was blowing as they sat in a small brightly lighted roomwithout ventilation. The young RAF wing commander who had beendelegated to fly the mission back to England had been one of the heroes of theBattle of Britain. It was as if he had been an engineer on the Twentieth Century Limited andnow was hauling an express milk train. Eachof the members of the mission was asked to demonstrate his proficiencies ingetting into a life preserver and a parachute and in adjusting an oxygen mask.
Again, they landed at Gibraltar and the Americans found asmall room in a barracks. One iron bed without a mattress was hardly a place for two men to sleep or rest,and so the daywas spent sightseeing and having dinner in the hotel. At midnight, offthey went, but it was with great difficulty that their
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wing commander managed to get the plane off the short runway. Early thenext morning, 30 July, the plane sat down on the airfieldat Swindon. As they were getting their bags off, the pilot discovered that theflight had been particularly difficult for him because a cargo, placedbeneath the floorboards of the passenger cabin and sent from London toCairo, had never been unloaded. He had carried it all the way back toEngland again. This explained the difficulty with which his plane becameairborne.
The mission had learned little about new advances insurgery, but each member had formed his own opinion of Soviet practicesfrom observation of the individuals with whom he had come in contact. The Soviet people appeared to belike 10-year-old American boys who brag about the size of their houses andchimneys and recklessly claim that their fathers can lick anyone. They wereunsure of themselves and suspicious and could understand only directness,frankness, and the show of confidence which comes from strength, both physical andintellectual.
It was learned that medical education, formerly under thecontrol of the universities, was put under the Commissariat forPublic Health in 1930. There were, then, 72 institutes (schools) ofmedicine with 107,000 medical students. Students were admitted after 10 years insecondary schools, and the medical course was 5 years. The first 2years were spent in scientific studies, and the last 3 years were clinical.During a part of the clinical years, the students were farmed out tovillage and town clinics for practical experience. There was specialization withtraining for industrial surgery, military surgery, hygiene, andbacteriology. Upon their passing a required state examination, a diplomawas issued which conferred the right to practice medicine. Higher degrees,those of bachelor or doctor of medicine, were given after 2 or 3 additionalyears of postgraduate work, which could be clinical practice or continued workin the institute. A thesis was required which determined whether or notadditional examinations were to be given. The percentage of students who becomebachelors or doctors of medicine was small. From 1935 to 1940, there were 140doctor's degrees given at theFirst Medical Institute and 284 bachelor's degrees. From this group came the professorsand teachers. When a chair was vacant, anyonecould apply, but a commission chose and appointed the individual. It was saidthat they had a Research Council, also under the Commissariat forPublic Health, and that into that organization flowed problems from thearmy, navy, industry, and the faculties of the medical institutes. This councilthen assigned special problems to certain faculties or individuals.
WASHINGTON AND RELEASE FROM SERVICE
Colonel Davis spent the month of August 1943 preparingreports8 and accompanying General Hawley to the wards ofthe 2d GeneralHospital where Major Scarff and his associates had been caring for thehigh-altitude frostbite
8See pp. 92-106, and appendix A for additional chroniclingof the mission to the Soviet Union and appendix A fora report on the mission prepared jointly by Colonel Cutler and Colonel Davis.
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cases. Gen. Henry H. Arnold, Commanding General of the ArmyAir Forces, Maj. Gen. David N. W. Grant, the Air Surgeon, and General Grow werealso present on that Sunday morning when General Arnold visited the men at their beds andheard their stories of failure of clothing and equipment.
General Grow accompanied General Grant and General Arnoldback to Washington. Colonel Davis received orders the following week to go toWashington and present the colored photographs of high-altitude frostbiteinjuries, the clinical histories, and all other data which had been developedduring the study of these patients. He was also instructed to present thedata on the protective helmet.
FIGURE 150.-Col. R. Glen Spurling, MC.
Maj. Gen. Norman T. Kirk, The Surgeon General, and hisstaff were greatly interested in the high-altitude cold injuries. General Kirktook the author to the Pentagon and arranged a presentation of the material tothe Air Surgeon's executive officer, Col. Walter S. Jensen, MC, and a group ofother Army Air Forces medical officers. General Grow appeared during thepresentation. He objected strenuously to any implications that he and his staffhad missed the injuries in the first place, had continued to disregard them, andhad failed at any time to study them. The facts, not the implications, neededno defense.
Mr. Henry Field, a friend from Chicago, was in Washingtonengaged in governmental work which made use of his great knowledge of theMiddle East and his abilities to bring important matters to the attention ofthose in high places, who otherwise had to rely upon the complex lines ofcommunication between bureaus and departments. He was greatly interested in thestory of the high-altitude cold injuries and in the possibilities of theprotective helmet.
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Thus it was that contacts were made with Colonel Doriot and Mr. BradfordWashburn9 of the Quartermaster Corps. These menhadbeen working energetically to develop clothing for airmen which wouldprotect them against extreme cold. Mr. Washburn had had considerable experiencein mountain climbing and exposure to severecold. Unfortunately, this research group had been ordered to stop working further on protectiveclothing for airmen. Colonel Doriot'sgroup was also working on a new protective material-Doron-namedfor Colonel Doriot, and it was possible for the author to help at length on themedical aspects of its development (p. 414).
After a tour as a patient through three general hospitals ended on30 March 1944, Colonel Davis was released from active duty andreturned to his duties as chairman of the Department of Surgery, NorthwesternUniversity.
On 12 March 1944, Lt. Col. (later Col.) R. Glen Spurling, MC (fig. 150),was appointed Senior Consultant in Neurosurgery in the Office of theChief Surgeon, ETOUSA.10
The Army Air Forces eventually requested the author's colored photographs ofhigh-altitude frostbite and made educational posters designed to instruct theairman on proper protective measures. Properly wired clothing was issued, andthe sidegun apertures onaircraft were closed in.
The plastic material for protective armor was field tested by the Marine Corpsand the Navy, and finally, on 15 September 1951, Maj. Gen. Edgar E. Hume of the Army Medical Corpsannounced that a plastic-protectedvest would stop a .45-caliber bullet fired from a distance of 3 feet. In an article publishedin 1944, this consultant had suggested that theplastic material designed for use in aviators' helmets could also be adapted for protectiveclothing.11 Such armored protectiveclothing was finally used in the field during the Korean War withgreat success. At the time of this writing, the plastic material forms the basicprinciple of protection for the jet pilot's acrosonic helmet.
9Director, Boston Science Museum, Boston, Mass., in 1959.
10For accounts of Dr. Spurling's activities, see: (1) Medical Department, United States Army.
Surgery in World War II. Neurosurgery. Volume I. Washington: U.S. Government Printing
Office, 1958, chapters III and VII; (2) Medical Department, United States Army. Surgery in World War II. Neurosurgery. Volume II. Washington: U.S. Government Printing Office, 1959, chapters IV, VIII, and XII.
11Davis, L.: Helmet for Protection Against Craniocerebral Injuries. Surg., Gynec. & Obst., 79: 89-91, July 1944.
