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Chapter IV

Contents

CHAPTER IV

Neurological Surgery

Loyal Davis, M.D.

At the Arcadia Conference, held in Washington from 24 December 1941 to 14 January 1942, a broad policy was decided upon for offensive actions against Germany. It was decided that, during 1942, Germany's resistance would be worn down by increasing air bombardment by British and U.S. Forces, giving assistance to the Soviet offensive, and gaining possession of the entire North African coast. This policy was examined many times, so that it is not surprising that many changes were made in the program. For example, the J.P.S. (U.S. Joint Staff Planners) believed that a considerable land attack could be launched across the English Channel in 1942. This was to be accomplished largely by British troops in the beginning, but participation of U.S. Forces, it was believed, could be built up rapidly. In fact, the planners outlined a possible cross-Channel operation which would take place in the summer of 1942 with a D-day between 15 July and 1 August.

With this background, it is not difficult to understand why The Surgeon General of the U.S. Army hastened to implement his share of planning in this proposed operation and attempted to build up his medical forces rapidly. A part of this planning was to supply the Chief Surgeon, ETOUSA (European Theater of Operations, U.S. Army) with a staff of consultants in the fields of medicine, 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 and arranged 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 the University 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 to join the Chief Surgeon's consultant group. To the specialties of surgery, medicine, plastic surgery, orthopedic surgery, and psychiatry, Colonel Rankin explained, would be added neurological surgery. Though it was never at any time during the conference so stated, the impression was gained that there were several 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. It is obvious that there was an immediate urgency to speed up Operation BOLERO, the buildup operation for invasion of the Continent.

Col. (later Maj. Gen.) Paul R. Hawley, MC, had been named as Chief Surgeon, ETOUSA, by Maj. Gen. (later Lt. Gen.) John C. H. Lee, who had been 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 been made up of representatives of various British supply ministries and representatives of the U.S. Army who had functioned in mufti in London during the entire year preceding the attack on Pearl Harbor. General Lee had arrived in England, however, with another medical officer designated as his Chief Surgeon, and it was a fortuitous circumstance which made him appoint Colonel Hawley on the spot.

GETTING ACQUAINTED

Obviously, none of these circumstances were known to Lt. Col. (later Col.) Loyal Davis, MC, the newly appointed Senior Consultant in Neurological Surgery (fig. 138), when he arrived in England by air on 6 September 1942, after having been commissioned on 20 August. Soon after his arrival at Headquarters, SOS, in Cheltenham, Gloucestershire, the author was formally introduced to the Chief Surgeon. Then the neurological surgical consultant joined the staff of Col. James C. Kimbrough, MC, Chief of Professional Services, a urologist, who had been on duty at Walter Reed General Hospital, and whose good humor and patience were exemplified in his statement and 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 general hospital in southern England, at Oxford, the 2d General Hospital, staffed by medical officers from Columbia University College of Physicians and Surgeons, New York, and Presbyterian Hospital, New York. There was one in the Midlands, at Mansfield, the 30th General Hospital, comprised of doctors from the University of California School of Medicine, San Francisco. Another, the 5th General Hospital, had been for some time in Northern Ireland; the staff of this hospital was composed of members of the Harvard Medical School faculty. There was one neurological 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, for each 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 had studied at the Peter Bent Brigham Hospital, Boston, had become a brigadier and Consultant 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 the British and U.S. consultants. Brigadier Cairns was responsible for advice in neurological surgery wherever the British Army was fighting, and his mobility and responsibility created a unity which produced results in treatment and policies far surpassing anything which the U.S. Army attained.

On 17 September, this consultant submitted a memorandum describing his initial tour of inspection, and it was approved and returned by the Chief Surgeon with a request that the recommendations be implemented.

FIGURE 138.-Lt. Col. Loyal Davis, MC, at his desk in the Office of the Chief Surgeon, ETOUSA, Cheltenham, England.

Review of British Activities

A Military Hospital for Head Injuries was located in the buildings of St. Hugh's College for Women in Oxford. This British hospital received only patients who had received craniocerebral injuries of all degrees of severity, and, as a result of the careful and scientifically professional service which was given there, they demonstrated conclusively that a high percentage 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 of the soldier to return to military duty, particularly in blunt craniocerebral injuries, was the length of the period of post-traumatic amnesia. Brigadier Cairns instituted the policy of treating open craniocerebral injuries by shaving the hair, cleansing the wound carefully with soap and water, applying a sterile dressing, and transporting the wounded soldier as quickly as possible to a hospital where he could receive definitive treatment. The patients' records were carefully made


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and kept so that they would provide a basis after the war for a 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 and to it patients were sent from the latter hospital for convalescent care and rehabilitation. The care at Middleton Park had been planned and was supervised by Brigadier Cairns, and not by a student of physical medicine who knew nothing of the residuals of head injuries. Even Radcliffe Infirmary, a hospital of Oxford University, was utilized for the study of compound fractures of the extremities and severe burns.

Within the environs of Oxford was the Wingfield Morris Orthopaedic Emergency Hospital under the direction of Herbert J. Seddon, an orthopedic surgeon who had received a considerable amount of surgical training at the University of Michigan Medical School, Ann Arbor. The RAMC found it possible to make use of Professor Seddon without insisting that he be in uniform. To this hospital were sent all of the peripheral nerve injuries from the British military forces and the civilian population. It was immediately obvious that one of the most important contributions to peripheral nerve surgery would one day come from this well-planned and well-organized hospital for study and treatment.

In the aforementioned 17 September memorandum it was emphasized that the U.S. Army records of examination, diagnosis, and treatment of the peripheral nerve injuries in World War I were totally inadequate, were incomplete, and were rarely available for study or for use in following up the few patients who made their appearance from time to time in Veterans' Administration hospitals. It was emphasized repeatedly that this should not obtain during World War II and that the records at the Wingfield Morris Orthopaedic Emergency Hospital could be used as models. Colonel Davis emphasized the point that neurosurgical records need not be so elaborate that they would obstruct the care of the wounded but that they should be complete so that future military surgery would benefit from their study. This required unified direction which 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 of mobile surgical units for the RCAMC (Royal Canadian Army Medical Corps). These units were 3-ton motor vehicles with 4-wheel drives and contained an electric generator so that the unit could pull up beside a church or schoolhouse and go to work to help a forward hospital. Each unit carried two folding instrument and operating tables, head rests, sterile drums of supplies, sterile basins, and a water tank but were not as elaborately equipped as were those originally designed 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 Sir Solly) Zuckerman was working upon the effects of blast as observed during the Battle of Britain. In his opinion, blast did not produce cerebral damage but for the most part affected the lungs. He was given the opportunity by Brigadier Cairns of doing actual fieldwork. Professor Zuckerman accurately plotted the scene of a bombing, the number and position of the individuals affected, the exact character of the agent, and whether the injured individual was stationary or moving, in an effort to determine eventually what prophylactic measure might be worked out. By photographing and measuring the body in all conceivable positions assumed during combat, Professor Zuckerman determined that the head and 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 he had investigated showed a remarkable percentage of correlation with Professor Zuckerman'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 the degeneration and regeneration of nerve fibers to the skin and muscles following peripheral nerve injuries. They found that any method of treatment which increased the blood supply to the involved muscles was very important in the rehabilitation of these patients. By recording the degree of muscle fibrillation following injury, Weddell believed he could determine whether or not a given paralyzed muscle could regain its function.

Canadian Activities in United Kingdom

The Canadian Neurological (1st General) Hospital was situated at Basingstoke, Southampton, and was built around Hackwood House in 1940. From the beginning, it was designed and equipped as a neurological surgical installation. It was superbly organized and administered. In addition to giving excellent care to the wounded, it served as a training place for young general surgeons who could be taught the fundamentals of the immediate care of neurosurgical injuries in forward hospitals. Personnel of this hospital had called attention to the following important facts: (1) Small, apparently trivial, scalp wounds often hid serious underlying comminuted fractures of the skull with destruction of brain tissue; (2) injuries of the head had been treated as long as 36 hours after receipt of the wound in the Dieppe raid and after careful surgery, aided by the use of sulfanilamide; (3) no infections had been observed when the craniocerebral injury had been cleaned carefully, the head shaved, sulfanilamide placed in the wound, a sterile dressing applied, and the wounded man sent back immediately to the Canadian Neurological Hospital for definitive treatment; and (4) in the presence of a defect in the skull, in a patient who has recovered function, repair of the defects by the use of a prosthesis could result


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in the return of the soldier to active military duty. This viewpoint upon the use of the sulfonamides was prior to the demonstration that their general administration with determination of the blood level was as effective as, and less destructive to tissue than, their local administration.

Observed at this hospital were several patients who had been operated upon for herniated nucleus pulposus and returned to duty. This experience resulted in a memorandum, which was adopted as U.S. Army policy in the European theater, to the effect that these patients should be operated upon by neurological surgeons, but only when the clinical syndrome pathognomonic of this condition existed and when careful X-ray studies using the new myelographic material, Pantopaque, corroborated the diagnosis. Finally, it was emphasized that intensive and supervised physical rehabilitation exercises should be carried out upon each patient.

Inadequate Facilities in U.S. Hospitals

This get-acquainted tour emphasized the complete lack of instruments and equipment on hand in the 2d General Hospital for neurological surgery. In company with the Senior Consultant for Plastic Surgery, this consultant visited the British surgical instrument houses of Allen & Hanburys Ltd., and Down Bros., Ltd., and a representative of the British Ministry of Supply, in order to determine whether there were any instruments upon their shelves or in their stocks which could be supplied to U.S. Army general hospitals. Thus was an unproductive day because those instruments available were completely outmoded; the field of neurological surgery and its appliances and instruments had been developed in the United States. It was, however, a demonstration, many times repeated, of the facts that the Army could put supplies into a depot but could not get them out; that, because an officer was a doctor, it did not follow that he was capable of getting the right supplies where they belonged; that a good stock manager from a mail-order house would have served far better; and, finally, that the principle of ordering a stipulated supply of a particular item for a given number of men every 90 days would result in enough thermometers to roadblock an invading force and enough hypertonic glucose solution to float the British Navy.

ANALYSIS OF THE SITUATION AND RECOMMENDATIONS

As a result of this tour, this consultant wrote a detailed memorandum of the principles learned by the British for the care of neurosurgical injuries and requested that it be sent to the Office of The Surgeon General in Washington for dissemination among military and civilian neurological surgeons in the United States. He hoped that this might be started a method of communication which would make it obvious that a unified method of care and handing was essential for obtaining results which later could be studied to the advantage of the injured man. Whether this memorandum was ever sent to Wash-


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ington, this consultant never knew; if it was, nothing came from it because, throughout the war, it seemed to the author that the European theater remained a distinct, isolated entity instead of having a close liaison with the Office of The Surgeon General. It became evident, more and more, that a Consultant in Neurological Surgery should have been responsible, through the Chief Consultant in Surgery to The Surgeon General, for the proper organization of 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 necessary in each theater to have provided methods and means of obtaining results which could later have been the basis for valuable contributions to this field of surgery. In the Mediterranean theater, there was no senior consultant in neurological surgery. In the European theater, during Colonel Davis' tour of duty, there were never more than two qualified neurological surgeons with whom one could consult.

It was apparent on 19 September 1942 that the 1st Infantry Division was preparing to leave for a combat zone (Africa). The author gave the medical officers of this division an hour's talk on neurosurgery in war. They had had no previous instruction on this subject during the 18 months to 2 years they had been on active service. Perhaps it was just as well, considering that they lacked morphine Syrettes, blood pressure apparatus, anesthetic agents, and sulfonamides, to name a few glaring shortages. Medical officers were being used as transportation officers and in other capacities; the division surgeon did not attend the meeting and had never attended a medical meeting of the division. The morale 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 End Emergency Hospital, St. Albans, London, and was visited on 28 September, as was the Canadian 15th General Hospital. On the same tour, this consultant visited the 30th General Hospital. The Canadians presented a series of papers relating their experiences in the treatment of casualties received following the Dieppe fiasco. They emphasized the use of surgical teams consisting of two surgeons, two nurses, an anesthetist, and an orderly. The records of their examinations and operations were dictated to, and kept in order by, ambulatory patients and enlisted men. Their data were uniform and provided excellent material for future studies.

A young captain with some training in general surgery and with no aspirations to be a neurological surgeon had been assigned to care for neurosurgical injuries, when and if they occurred, at the 30th General Hospital. Colonel Davis recommended that a census of the number of neurosurgical injuries in each of the U.S. hospitals in the theater be provided the Professional Services Division because there was no way of knowing where such cases were or how they were being treated. It became known that many American soldiers, injured severely in jeep accidents in the blackout, were scattered through British EMS (Emergency Medical Service) hospitals and were receiving treatment for their craniocerebral injuries which was below American


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standards of treatment. On 1 October, an example of an American soldier taken to an EMS hospital instead of to the 2d General Hospital at Oxford was cited as a reason for seeking a method to transport such injured American soldiers to a U.S. hospital. As a corollary to this, and as a result of a line officer's refusing to move one of his men from a British hospital even after the British doctor and an American medical officer directed his transfer, authority was also requested for the recognition of the American medical officer's orders 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 of Canadian hospital units, Colonel Davis recommended on 5 October 1942 that all general hospitals have a qualified neurological surgeon assigned to their staff; that instruction in the primary surgical treatment of neurosurgical injuries should be given, in a teaching course, to battalion aid station, collecting station, clearing station, and evacuation hospital medical officers, since the final results of the definitive treatment of those injuries depended upon the accuracy and effectiveness of the early treatment. It was recommended that this be done without removing the officers from their units and before they reached the combat theater where such periods of instruction might interfere with more immediately urgent activities. Thus, another attempt was made to bring about some sort of unity of effort in the care of neurosurgical injuries.

On 13 October, this consultant wrote the first of seven memorandums to govern the general principles of the treatment of craniocerebral, spinal cord, and peripheral nerve injuries. Six of these memorandums were criticized on the grounds of poor English, and the seventh was accepted and disposed of most effectively by one of the Chief Surgeon's staff officers when he filed it away among his effects.

On 15 October 1942, the author submitted a detailed memorandum about the transfer of injured American soldiers from EMS hospitals throughout the British Isles to U.S. Army hospitals. With reference to neurosurgical patients (and it would have applied easily to other types of injuries), it was recommended that:

1. All EMS hospitals be requested through the director of their service to notify immediately the Division of Professional Services, Office of the Chief Surgeon, ETOUSA, of the admission of American soldiers with craniocerebral, spinal cord, and peripheral nerve injuries.

2. The Director, EMS, be requested to supply to the Division of Professional Services, Office of the Chief Surgeon, a list of the neurological surgeons and the name and location of the EMS hospitals in which they are located.

3. In the absence at this time of an adequate number of qualified and certified neurological surgeons in the American Forces, the Senior Consultant in Neurological Surgery be given authority to contact the EMS neurological surgeon of the region nearest the EMS hospital to which the soldier has been taken and request that he assume responsibility for removal of the soldier to his


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own facility and there treat him, or direct his treatment if in his judgment transportation is inadvisable.

4. An American soldier so injured be moved to a U.S. general hospital where a qualified and certified neurological surgeon is available, just as quickly as the condition of the patient warrants, in the judgment of the EMS neurological surgeon.

5. The treatment of American injured by EMS neurological surgeons be discontinued as soon as neurological surgeons in U.S. general hospitals are available in sufficient numbers to render this service themselves.

6. Authority be granted to employ indigenous ambulance service to remove a patient to a U.S. hospital in the event that the employment of American ambulances is impossible or would involve unnecessary delay in the treatment of the soldier in the judgment of the Senior Consultant in Neurological Surgery or an individual to whom he delegates the responsibility for such judgment.

On 19 October 1942, this consultant wrote directly to General Rankin in Washington and asked that he assign neurological surgeons to the 5th and 30th General Hospitals. Evidently, this gentleman quickly recognized the failure of this memorandum to stay within "channels" and by not answering it saved the author momentarily from his ultimate difficulty.

On 22 October, a visit to the 30th General Hospital revealed that no suction apparatus was available to the surgeons and that operations upon one patient with a rupture of the spleen and upon another with a rupture of the kidney had nearly resulted in fatalities, although the surgeons had improvised with two bicycle pumps and the strength of an orderly. The first of a series of requests for such a suction apparatus was written immediately and was followed by several others containing minute descriptions of a suction pump available from a supply company in Reading, England, for fifty dollars. The size of valves, the overall size and weight, and minute specifications were given; in fact, a pump for each of the general hospitals in the European theater was available and could have been delivered by hand by this consultant, if necessary. 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 of General Hawley's problems.

On 26 October, in answer to a query from the personnel officer, Office of the Chief Surgeon, ETOUSA, this consultant emphasized the facts that (1) the neurological surgeons suggested for the 5th and 30th German Hospitals were already commissioned in the Medical Corps, AUS, and would not, therefore, be taken from civil life, (2) there was only one neurological surgeon in the European theater, and therefore the need could not be supplied from the European theater, (3) the request was not for consultants but for experienced neurological surgeons capable of assuming responsibility for the treatment of craniocerebral, spinal cord, and peripheral nerve injuries and, finally, (4) dependence upon the British EMS head centers for the treatment and care of neurosurgical cases in the European theater should not be continued.


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Many memorandums later, it was evident that the Chief Surgeon had never seen any of the many recommendations made by the Senior Consultant in Neurological Surgery. They were passed back and forth or conveniently filed by a personally hostile medical officer who openly boasted that he would put the new lieutenant colonel specialist consultants in their place. Soon, thereafter, a roster of officers was issued for allnight duty to answer the telephone to receive reports of deaths of soldiers in the theater. The roster began with the lieutenant colonel consultants to the Chief Surgeon, and the duty was served, at least by one consultant, until the roster and duty were canceled by General Hawley when it was called to his attention.

On 3 November 1942, accompanied by the Senior Consultant in Plastic Surgery, the author gave the first of a series of lectures at the Eighth Air Force Provisional Medical Field Service School to young air force medical officers. At this time, it was not apparent that a schism existed between the Army Air Forces and the rest of the Army, based upon the Air Forces' attempts to establish a medical service quite separate and distinct from that of the remainder of the Army. At this same time, the 92d Bomber Group Combat Crew Replacement Center at Bovingdon was visited. This tour also included the East Grinstead Royal Victoria RAF Plastic Center, which was under the direction of Mr. A. H. McIndoe, Chief Consultant in Plastic Surgery to the RAF. Mr. McIndoe made it possible to visit Group Captain Atcherly of the RAF, who was in command of a fighter group, and who personally conducted the two U.S. Army consultants over his station. Following these visits, comprehensive memorandums were written which recommended the placement of well-staffed, completely equipped, smaller types of hospitals, strategically located within rapid evacuation distance by ambulance from bomber and fighter airdromes, and the assignment of a liaison medical officer from the U.S. Army Air Forces stationed in the United Kingdom to the Office of the Chief Surgeon to advise in the eventual disposition of injured air force personnel. It is now clear that, at the time of the writing of these memorandums, the struggle for independence in medical organization was taking place, and these memorandums could not have been more timely, though they were completely ineffective.

On 9 November 1942, Colonel Davis wrote a detailed memorandum to the Chief Surgeon, ETOUSA. The author was quite unaware of the organization of the Army and the relationship of a theater of operations to the War Department in Washington as far as the Medical Department was concerned. It was becoming more and more apparent that the Medical Department was completely subservient to the SOS command and that the Chief Surgeon had access to the Commanding General, ETOUSA, only through the Commanding General, SOS, ETOUSA. This fact, learned by diligent study of the volumes depicting the history of World War I, during which the same struggle for direct responsibility of the Medical Department to the commanding general occurred, made it obvious that the Air Forces eventually 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. The memorandum to the Chief Surgeon read:

1. The Consultant in Neurological Surgery in the European Theater of Operations held the following views, which were expressed, when he accepted the post offered by the Surgeon General's Office:

(a) Military neurological surgery differs in many of its technical aspects from the neurological surgery of intracranial tumors and other common civilian neurosurgical conditions.

(b) There is no place for the trained, experienced neurological surgeon in forward areas of combat.

(c) Only careful, well-directed immediate general surgical treatment should be given to neurosurgical injuries in forward combat areas.

(d) Properly instructed and trained younger medical officers should have the responsibility of giving the type of immediate surgical treatment in forward areas necessary to obtain good definitive results.

(e) Meticulous, definitive surgical treatment should be given to neurosurgical injuries in general hospitals only, located within reasonably rapid evacuation distance of a combat area.

(f) Experienced, well-trained and recognized neurological surgeons should direct definitive treatment for neurosurgical injuries in a general hospital.

(g) Neurological surgery should be a service in a general hospital and special neurosurgical hospitals have no place in an Army.

2. With the statement contained in Paragraph 1b, the Chief Surgeon of the E.T.O. has expressed complete agreement.

(a ) This viewpoint is supported by the experience of the Royal Army Medical Corps at Dunkirk and the Middle East and by the Royal Australian Medical Corps.

3. The Consultant in Neurological Surgery has (a) completed personal investigations and observations of facilities, equipment and personnel of the U.S. Army Medical Corps in the E.T.O., as they apply to neurological surgery and (b) has visited and observed the British and Canadian Army neurosurgical service in the U.K. and (c) the neurosurgical services in the E.M.S. and the Scottish E.M.S.

4. As a result of the statement contained in Paragraph 3, the following facts are evident:

(a) Competent, experienced and self-reliant neurological surgeons are now assigned 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 in the 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 civilian accidents.

(c) Only one neurological surgeon in Great Britain and one from Canada are in Army service.

(d) The overwhelming remainder of the neurological surgeons in the United Kingdom are in the Emergency Medical Service.

(e) Very few, if any, peripheral nerve, spinal cord and compounded craniocerebral injuries can be returned to military duty within the 180 day evacuation period established by the Chief Surgeon of the E.T.O. Only relatively minor closed cranio-cerebral injuries can meet the requirement of this evacuation period.

(f) Based upon neurosurgical casualty figures in World War I, on the figures available from British services thus far, and upon the combat casualties which can be projected in the immediate future in this theater, four neurological surgeons will meet all the needs for the highest type of surgical treatment for neurosurgical injuries.

(g) Equipment and supplies, for obtaining the best possible results for the soldier suffering from neurosurgical injuries, are lacking in completeness in U.S. General Hos-


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pitals in the E.T.O. This equipment cannot be obtained from English surgical instrument firms.

(h) Younger medical officers in the division who have been observed in this theater are poorly prepared by training and equipment to give proper immediate surgical treatment to neurosurgical injuries in forward combat areas.

5. The function of the Consultant in Neurological Surgery is to act in an advisory professional capacity to the Chief Surgeon of the E.T.O. and to establish and correlate the highest type of neurosurgical service in this theater to the end that eventually it will be possible for the Medical Corps of the U.S. Army to make a significant and substantial contribution to the surgical care of the injured soldier.

6. As a contribution to this desired result, the Consultant in Neurological Surgery with the fullest sympathy of understanding on the part of the Chief Surgeon, has recommended:

(a) That experienced, competent and self-reliant neurological surgeons 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. General Hospitals in E.T.O. The purpose of this recommendation was to afford the opportunity of compiling a record of the end results of neurological surgery in this War which would surpass that of World War I.

(c) That a course of instruction to division medical officers be given in training camps on the principles of the immediate surgical treatment of neurosurgical injuries.

(d) That neurosurgical injuries be transferred as soon as practical from station hospitals in the E.T.O., and be evacuated as rapidly as possible from forward combat areas, to general hospitals in the E.T.O. for definitive surgical treatment.

(e) That all equipment and supplies necessary to obtain the highest type of neurosurgical end results be furnished U.S. General Hospitals without delay so that these hospitals would be able by their work to represent the highest type of American medicine and surgery.

(f) That a general directive governing the principles of the treatment of neurosurgical injuries be issued to general hospitals in the E.T.O.

(g) That a fixed general hospital with a neurological surgeon assigned be strategically located within rapid evacuation distance of the present dispositions of the American Air Force installations in this theater.

7. The Consultant in Neurological Surgery has been able to effect the following service to injured American soldiers:

(a) Through personal contact with the Chiefs of the neurosurgical service in E.M.S. and Scottish E.M.S., American soldiers with neurosurgical injuries taken to E.M.S. hospitals receive the immediate services of the regional neurological surgeons and are evacuated as rapidly as possible to U.S. General Hospitals.

8. The Consultant in Neurological Surgery finds himself in disagreement with the Table of Organization for U.S. General Hospitals, issued in April 1942, which does not provide for a competent, experienced neurological surgeon.

9. The Consultant in Neurological Surgery is in entire agreement as to his function as a professional advisor to the Chief Surgeon of the 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 Chief Surgeon of the forces and the Surgeon General's Office. The intervening distance 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, is firmly of the opinion that to accomplish his function to the best interests of the injured soldier, the Chief Surgeon and the Army Medical Corps and because of the significance of the facts cited above, he should be given the opportunities inherent in a liaison officer, representing the Chief Surgeon in neurosurgical matters only, between this theater and the United States, particularly during the present period of comparative combat inactivity.


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Recommendations:

1. The Consultant in Neurological Surgery should be given the opportunities of liaison between this theater and the United States, in matters pertaining solely to neurological surgery, to accomplish better the functions of his appointment.2

On 17 November 1942, four circular letters were prepared by Colonel Davis for the signature of the Chief Surgeon, ETOUSA, to be sent to the commanding officers of U.S. general and station hospitals in the United Kingdom, covering the subjects of the treatment of: (1) Craniocerebral injuries, (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 and Treatment of Neurosurgical Injuries," which was included in Circular Letter No. 75, Office of the Chief Surgeon, ETOUSA, issued 4 December 1942.

On 18 November 1942, this consultant visited the 298th General Hospital, the University of Michigan Medical School unit, at Frenchay Park. Arriving in England with the 26th and 29th General Hospitals, the units affiliated with the Washington University School of Medicine, St. Louis, Mo., and the University of Minnesota Medical School, Minneapolis, respectively, the 298th General Hospital had been kept in England while the other two had been sent on to North Africa. The 298th General Hospital was sadly lacking in equipment and supplies, and much time elapsed before this hospital became effective. A quotation from the memorandum report of the visit written by the author will make evident these difficulties: "The professional staff is working hard, and because of their own efforts they will rectify many of the difficulties which now exist, but they need prompt and sympathetic understanding, and implementation of their needs, none of which are extravagant."

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 The Surgeon General as a surgical specialty in the Medical Corps?

2. If so, why has a neurological surgeon been removed from the 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 in neurological surgery be considered essential in this theater?

4. In view of the latest table of organization of general hospitals, why have neurological surgeons been assigned to general hospitals in the United States?

5. Does The Surgeon General agree that the standards of professional work in general hospitals in the United Kingdom should represent the highest type of medical and surgical care that can be given American soldiers?

6. Should not the professional care given the soldiers in general hospitals in the United Kingdom compare favorably with that of U.S. civilian practice and with neurosurgical practice in British and Canadian military hospitals of a similar type?

7. If The Surgeon General's answers to questions 5 and 6 are in the affirmative, would he agree that the supplemental list of instruments plus a portable Bovie electrical surgical apparatus, necessary to do neurological surgery properly, should be made available immediately to each of the general hospitals in the United Kingdom?

8. Is The Surgeon General aware that such a supplemental list of neurosurgical instruments plus a portable Bovie electrical surgical apparatus was inspected in Washington at the Walter Reed Hospital by Colonel Davis on or about 1 September?

9. Does The Surgeon General agree that the greatest compensation for the loss of life in any war is whatever contribution the Medical Corps can make from a humanitarian standpoint?

10. If he agrees, could not one contribution to military surgery and to the art and science of surgery in general come from the compilation of the results of neurological surgery in this war?

11. Would The Surgeon General agree that this would be a significant contribution from his office, and, also, could not the Consultant in Neurological Surgery be more effective in bringing this about if he had liaison privileges between this theater and the Zone of Interior in order to correlate, to the highest degree, neurological surgery that is being done in general hospitals in both places?

12. Would The Surgeon General agree that the Consultant in Neurological Surgery would be of more service to the effort if, in this period of inactivity in the United Kingdom while the consultant has a total of 30 patients upon which to consult, he was given this opportunity of liaison?

By 1 December 1942, the consultants were still attempting to get proper records for the general hospitals, and the senior consultant in neurological surgery was still pursuing the suction apparatus for the 30th and 298th General Hospitals. The harassed supply division was still denying an understanding of Colonel Davis' requests for "all-day suckers," even though one had been purchased and installed in the 2d General Hospital and was performing 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 eventually billeted, was ankle deep, and it was cold and rainy. They had no instruments and no other equipment worth discussing. Attempts were made to give them temporary assignments according to their surgical interests to relieve the frustrated sense of having been hurried from their surgical practices in many instances to meet an emergency which turned out to be a field of mud 2 miles from Oxford. There was difficulty because the Personnel Division of the Chief Surgeon's Office had no idea whatever of the character of the Military Hospital (Head Injuries), Oxford. So, without advice, two officers who had no fundamental training or interest in neurological surgery were assigned to that fine head injury hospital. This brought a protest from Brigadier Cairns and required placing the matter before General Hawley to effect a solution, which he accomplished swiftly.

On 4 December 1942, the Senior Consultant in Neurological Surgery called attention to the fact that the majority of craniocerebral injuries among U.S. soldiers in the United Kingdom were due to accidents they met with while driving jeeps at night under circumstances which were not strictly military missions. The author recommended that the activities of enlisted men in jeeps be restricted to purely military missions. This resulted in an immediate lowering of the incidence of these compound head injuries and a commendation for the consultant, apparently for the complex solution which had been suggested.

It was obvious to anyone who gave it thought that the consultants were being thwarted at every turn by some of the Chief Surgeon's staff and without General Hawley's knowledge. He had instituted dinner meetings with medical officers from other countries, principally from the Royal Army Medical Corps, and the group of consultants properly acted at his invitation as his aides to entertain his guests. This was only one of the many incidents which, at this time, led some of the Regular Army medical officers to resent the consultant group. For a time even Colonel Kimbrough, under whom the consultants served, appeared suspicious of their motives until he was assured that no one


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of them sought his post and that each consultant desired only to get the job done and to bring to him whatever credit was due.

This situation caused the Senior Consultant in Neurological Surgery to attempt to express a critical evaluation of the surgical consultant group in the Chief Surgeon's Office to The Surgeon General of the U.S. Army through the Chief Surgeon, ETOUSA.3 The following three reasons were assumed to have been the basis for the creation of the consultant group: (1) The Chief Surgeon's need for a professional advisory body 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 in professional service between the U.S. Army, British, and Canadian medical services, and (3) the need to establish liaison between the European theater and the surgical profession of the United States and the Office of The Surgeon General. The author reiterated the point that the majority of the consultants did not seek their appointments but were told they were chosen because of their professional attainments and standing in their particular surgical field and because of their potential ability to organize and correlate the activities of their surgical specialty in the Medical Corps. General Hawley knew none of the consultants before he arrived in his command and had no voice in his choice. The Senior Consultant in Neurological Surgery was told that he alone would be responsible directly to the Chief Surgeon for the policies governing the professional activities in neurological surgery. At the creation of the post of Chief Consultant in Surgery, it became necessary to pass recommendations through three channels before the Chief Surgeon could be reached by the consultants in the surgical specialties.

It was pointed out that the Chief Consultant in Surgery, Colonel Cutler, was speaking for and establishing policies for surgical specialties about which he had only a smattering of general knowledge. The surgical consultant group had not been included in the plans for medical care of the casualties which would result from military operations in North Africa and which at that time were a responsibility of the European theater. It appeared illogical that the majority of the surgical specialties represented by consultants were not recognized by the Office of The Surgeon General officially in the tables of organization of general hospitals.

Suggestions to improve the effectiveness of the surgical consultants group included:

1. Implement the recommendations of the surgical consultants that are designed to raise the standards of professional service in 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 in Neurological Surgery, to The Surgeon General, U.S. Army, through the Chief Surgeon, 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 of the Chief Surgeon by changing personnel if necessary.

4. Change the organizational plan of the surgical consultants group and restrict the duties and responsibilities of the chief surgical consultant to the field of surgery exclusive of the surgical specialties.

5. Remove restrictions from the surgical consultants that limit their activities to the United Kingdom.

6. Make the surgical consultants more mobile by extending to them controlled liaison privileges in their own field of surgery with the Zone of Interior, the United Kingdom, and the North African theater.

7. Extend the functions of the consultant group to the general hospitals situated in service commands in the Zone of Interior.

8. Allow surgical consultants to establish contacts between the Office of The Surgeon General and the civilian surgical profession to effect:

a. Better understanding of the problems of the Office of The Surgeon General.

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 to the Office of The Surgeon General so that in peacetime the consultants' services as civilian advisers may be utilized.

Whether these suggestions were passed on to General Hawley is open to question; but, there is some reason to think that, without fanfare, the consultants began to reach his attention directly. This consultant had written a long memorandum to the Chief Surgeon on 22 December after a thorough study of the neurosurgical aspects of injuries to tank crews. The investigation was made at Tidworth Barracks with Capt. Thomas M. Mar, MC, medical officer for the 751st Tank Battalion attached to the 29th Infantry Division (fig. 139). The memorandum concerned recommended changes in the helmet worn for head protection, certain aspects of armored tank construction to minimize the occurrence of vertebral and other injuries, the evacuation hatch, first aid equipment, armored ambulances for tank battalions, and the contents of the field chest for use by the medical 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 to the Chief Ordnance Officer and expressing his interest in the comments and recommendations made concerning the use of an armored halftrack personnel carrier as an ambulance since he had first proposed such an adaptation. A date was made to visit the battalion together on 5 January, but unfortunately the joint trip never materialized.

Had the above correspondence occurred sooner, it would undoubtedly have prevented the author from sending copies of the memorandums he had written for 3 months, arranged in chronological order and with the addressee's name removed, as separate letters, to Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery to The Surgeon General; 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 of California. An unwise attempt to bring to the attention of men who, it was believed, might accomplish small changes which would make an organization more effective was stopped when censors opened the three envelopes and charged this consultant with going outside channels of military communication and violating the rules that gave him the right to censor his own mail. The information that he was to be court-martialed was telephoned to him by a fellow consultant on the day before Christmas 1942 when the author was visiting the 2d Evacuation Hospital, which had reached its destination in Huntingdon just 12 hours earlier.

The timing of events is almost always more significant than the event itself. The author learned later that, in anticipation of the result of pressing the charges against him, a successor had already been selected, put into uniform, and informed of his mission. However, General Hawley was 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 found clearly explained in the memorandums. They concerned the care of the U.S. soldier fundamentally and were not being made effective in many field. There was no desire to serve elsewhere, and all difficulties could be solved by a more direct access to the Chief Surgeon on matters that concerned the treatment of injured


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men. The Chief Surgeon assured the author that there would be no court-martial of one of his men, and he was sure organizational changes could be made which would accomplish results more smoothly. The discussion made it obvious to this consultant that the Chief Surgeon, on the one hand, and his consultants, on the other, were separated by the chief surgical consultant, the chief of the Professional Services Division, and the remainder of the Chief Surgeon's staff.

This interview with General Hawley put at rest the worries over arrest, court-martial, and disgrace which had caused two sleepless nights. It also formed the basis for the beginning of a close friendship and association which exists at the present. It made possible contributions to the care of the injured soldier which will be described and 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 of opinion about the method of using the sulfonamides. A large number of observations upon experimentally produced peripheral nerve injuries had been made in the surgical laboratory at Northwestern University Medical School prior to 1942 under a grant from the National Research Council. It had been shown that sulfonamides used locally in potentially infected, severely lacerated soft-tissue wounds which involved nerves did not affect the results of nerve repair. However, it was believed that administration of the drugs by mouth, raising the blood level of the sulfonamides, would be equally or more effective. At this time, however, it was a moot question, and the colored photomicrographs which recorded the results of the controlled experiments provided some basis for opposing the prohibition of the sulfonamides locally in the 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 the 298th General Hospital as a peripheral nerve injury center, similar to that existing at Wingfield Morris, and recommended that this be accomplished. It was possible through Mr. Seddon's cooperation to have Major Kahn assigned for temporary duty at that British hospital to assume Mr. Seddon's duties during his absence in Malta to investigate an outbreak of poliomyelitis. However, this effort to establish special facilities at the 298th General Hospital did not come about because of the rule to hold the injured in general hospitals 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 European theater, that of properly treating a peripheral nerve injury definitely, was made impossible, and peripheral nerve centers in general hospitals in the United States assumed an importance which should have been planned for in the beginning.

The qualified neurological surgeon belongs in the place where definitive treatment can be given and postoperative and rehabilitation care can be properly supervised. This plan was effectively carried out by the British with the assistance of Brigadier Hugh Cairns, the Consultant for Neurological Surgery to the DGMS (Director General of Medical Services) of the British Army. Well-trained and instructed young general surgeons can give the finest immediate treatment for neurosurgical injuries, and their activities could be supervised by a Consultant in Neurological Surgery who would also advise The Surgeon General about policies in this field of surgery in the combat zone and the Zone of Interior.

Another method of approach to the Chief Surgeon, ETOUSA, was initiated by Colonel Cutler in the form of one memorandum which would include all of the suggestions from each consultant. These "Reports of the Surgical Sub-committee" failed, in the opinion of the author, because the chief surgical consultant frequently vetoed suggestions and recommendations made by the senior consultants in their specialty.

1943: FIRST HALF

By the first part of January 1943, a new supply officer in the Chief Surgeon's Office had improved the flow of material and equipment to the hospitals, and good clinical records were made available to the hospitals in the theater. A letter, dated 13 January 1943, from this author to Colonel Kimbrough contained a report for the period 7 September 1942-15 January 1943, chronologically summarizing the author's opinions concerning the 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 furnished excellent protection against craniocerebral injuries and (sometimes more important to the soldier) had many other utilitarian advantages. However, it was not designed for the 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. Oerlikon shells led him to remove the liner of his helmet and pull on the outer steel shell over his regulation leather flying helmet. The effectiveness of this protection was emphasized when his pilot, wearing only a leather helmet, was struck in the head by the fragments of an Oerlikon shell which burst between them. The pilot immediately lost consciousness, developed a left hemiplegia, and a complete left homonymous hemianopsia. While the copilot's helmet was punctured in several places by the high velocity fragments, it afforded complete protection from even a scalp laceration.

It became obvious that members of an aircrew needed adequate protection from craniocerebral injuries. However, any helmet designed for their use had to meet certain specifications. First, it had to be close fitting and comfortable so that it would simulate as closely as possible an ordinary leather flying helmet and be considered a personal possession which might gather "good luck" like a favorite, battered felt hat; second, it had to allow free and unrestricted movements of the head in all directions and not interfere in any way with the field of vision; third, it had to be light in weight and afford protection from the heat and cold; and fourth, it had to afford protection, at least equal to that afforded by the regular issue steel helmet, against craniocerebral injuries produced by fragmenting Oerlikon shells, antiaircraft flak, or concussion due to direct, blunt trauma.

The percentage of wounds to the head, comparing the head's surface area to that of the body, was found to be approximately 12 percent. It was also found that the largest number of craniocerebral injuries in airmen resulted from the fragmentation of 20-mm. Oerlikon shells. Craniocerebral injuries next most common were injuries from the largest pieces of antiaircraft flak and concussion due to direct trauma, in that order. When an Oerlikon shell burst, it fragmented into thousands of pieces which varied in weight from less than 1 mg. to 20 gm. (fig. 140). However, the largest number of "effective" Oerlikon shell fragments bursting in an area 5 feet in diameter and capable of causing incapacitation to the person exposed was 260. The majority of those 260 fragments weighed between 10 and 50 mg., and their velocity varied between 400 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 by Briga-


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FIGURE 140.-A flash radiograph of a German 20-mm. HEI (high-explosive, incendiary) shell, Mk. 1, showing the fragmentation pattern. The broken line gives the reference position of the shell before static detonation.

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 puttylike material. 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 hardness greater 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 weight upon 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 movement extinguished it. When the material was hit directly, the lines of shatter were at right angles to the force and not directly forward as in steel.

The consultant was able to mold pieces of the acrylic resin over a wooden hat mold so that they would conform to the frontal, temporal, occipital, and vertex portions of the skull (fig. 141). These segments were hinged together snugly so that protection would not be lost and yet so that a certain 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 openings were left into which the earphones could be fitted. This afforded further protection and added the distinct advantage of the property of acrylic resin to 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 with the field of vision. As one molds a derby hat which may impinge slightly upon the parietal eminences and be uncomfortable, so the individual flyer could mold this helmet by applying heat to the protective liner so that it became an integral and comfortable part of him. The pieces of molded plastic could be fitted into pockets of the leather helmet and be removed when it was not being worn in combat. The completed helmet, made of 4-mm. methyl methacrylate covered and lined, weighed 18 ounces, and, if material 8 mm. thick was used, affording more protection per unit weight area, the total weight was 27 ounces. The steel body of the regulation helmet weighed 35.84 ounces.

It was also suggested that similar plastic panels could be inserted into the regular-issue flying suit for protection against chest, abdominal, and extremity injuries.

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 was adjusted and revised until it suited the entire crew.

At this time, Brig. Gen. (later Maj. Gen.) Malcolm C. Grow, Surgeon, Eighth Air Force, had engaged the services of an armorer in England to devise


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FIGURE 141.-A protective helmet for flyers. A. A fabricated and segmented acrylic resin protective liner. B. A protective liner within an ordinary leather flying helmet.

a metal protective suit of armor for airmen. Ignoring the ballistics 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 got close 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 was their consensus that General Grow should put it on himself, fly with them, and be asked to bail out over the 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 leave through 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 of his 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 material named Doron, similar in many respects to the material tested. Later, in the surgical laboratory at Northwestern 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 on immersion 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 severe injuries from cold would produce similar symptoms. In other words, immersion foot was only one type of cold injury, and the cold injury received on the ground or in the air would differ only as to the time and temperature of the exposure.

It was not long after that the first airman was seen at the 2d General Hospital with tremendous bullae upon the dorsum of his hands. It was believed at first that these were burns, since his aircraft had crashed on landing and burned. Careful questioning elicited the fact that he had been at a waist gun position in a B-17 bomber, which at that time was an open window (fig. 142). He had worn his electrically heated flying suit at the time but had taken off his gloves to urinate. The parts of the suits, it was found, were wired in series, and thus the entire suit was turned off completely if one portion was disconnected. The aircraft had 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 isolated instances to the buttocks, and only once to the cheeks and ears, multiplied rapidly through April and May and early in June of 1943. Exposure to low temperatures and airblasts at high altitudes with failures of oxygen supply and, most important of all, failure of, or lack of, electrically heated clothing were the important etiological factors.

Colored photographs were made of the striking lesions, which were resulting in the complete disability of the airmen, and studies were begun to devise the proper treatment and to prevent these injuries. This consultant was ordered by General Hawley to present his data upon 25 patients to General Grow, the surgeon of the Eighth Air Force. An appointment was made, and the author was allowed to stand for 15 minutes while General Grow carried on a discussion with Lt. Col. (later Col.) Herbert B. Wright, MC, of his office about his own experiences with frostbite when he was in Russia following World War I. General Grow did not, at this time, take the problem seriously. He was inclined to believe that cold injury in airmen was the result of carelessness.

The author placed on General Grow's desk copies of the patients' own stories and color photographs of their lesions, which included complete casts of the skin of the fingers which had been shed, dry gangrene amputation stumps, and bullae of all degrees of severity.4 Colonel Davis stated that he had been instructed by General Hawley to deliver this material and turned to leave. When he reached the door, he was called back, asked to take off his

4For examples of these photographs and for additional discussion of high-altitude frostbite, see Medical Department, United States Army. Cold Injury, Group Type. Washington: U.S. Government Printing Office, 1958.


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FIGURE 142.-The waist gun position in the B-17 bomber. A. A B-17 on a tactical mission over The Netherlands, showing the open waist gun position with protruding muzzle of a flexible machinegun, September 1944. B. Waist gunners of the Invader II model of the B-17 bomber, March 1943.


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FIGURE 143.-Flyers' clothing. A. An electrically heated suit. Note the sockets for plugging in gloves. B. Flying clothing worn over an electrically heated suit.

overcoat and sit down. A lengthy discussion followed with an antagonistic attitude prevailing on the part of General Grow. He doubted that the electrically heated clothing was wired in series, and Col. Harry G. Armstrong, MC, director of the Eighth Air Force Central Medical Establishment, was called into the discussion. Colonel Armstrong said quite frankly that he had no idea how they were wired (fig. 143).

Following this experience, permission was granted by General Hawley to designate the 2d General Hospital as the center to receive patients with cold injuries and to establish a laboratory and special wards for their study. By 9 May 1943, capillary microscopic studies were under way, and mildly injured patients who had recovered without loss of digits were being studied at fixed low temperatures to see if they could be returned to flying duty with safety.

Requests were initiated for investigators to go to operational Eighth Air Force fields to make capillary microscopic studies upon airmen immediately upon landing. Many methods were investigated in an effort to prevent the injuries, and it was recommended that the clothing be wired differently and that the open waist gun positions be protected. All requests to visit airfields were denied by the Eighth Air Force, and finally, these patients became so numerous as the activities of the Eighth Air Force increased during May and June 1943 that the Chief Surgeon discussed the situation 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 this consultant at a bomber station of the Eighth Air Force. A part of the report on 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 in Neurological 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 rise in ground temperature because, at this altitude of the operational missions, the temperature has ranged at -30 degrees C.

b. The mild acute cases warm up rather promptly at room or free air temperatures without serious damage to the digits; but, the symptoms of tingling, stiffness and numbness continue for two or three days and require that the patients be grounded temporarily.

c. There is no demonstrable microscopic damage to, or change in, 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 of blood into the subcutaneous tissue within three hours of the trauma.

e. Capillary loops disappear with severe cold damage to the skin and in chronic cases, three months after injury, have not regenerated.

f. Defective clothing equipment and other technical defects pointed out in the first memorandum on this subject continue to play an important role in etiology.

g. The new type of "demand" oxygen mask provided is a distinct improvement and answers the suggestions raised in the first memorandum written which would prevent the injurious effect of anoxia common to all the cases observed early in the study.

h. Progress is being made to the end that an accurate, scientific method of treatment 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 where observations were made, 30 patients had cold injuries requiring hospitalization for varying periods of time. One medical officer at a bomber station denied that any of his personnel had received such injuries, until their names, ranks, and serial numbers were supplied to him during the discussion.

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 product moulded to fit the head snugly, covered by soft leather and lined with chamois skin.

The advantages of this helmet are:

(1) Compared with manganese steel per unit weight, acrylic resin affords one third more protection against the penetration of metal fragments.

(2) Acrylic resin of 8 mm. thickness has a velocity resistance to a 52 mgm. steel ball of between 700 and 800 meters per second (2,100 to 2,400 ft./sec.).

(3) The model helmet made of 4 mm. thick acrylic resin weighs 18 ounces and has a velocity resistance to a 52 mgm. steel ball of 500 meters per second. If 8 mm. thick material is used, the weight of the helmet would be 27 ounces.

(4) Acrylic resin is one of the best non-conductors of heat and cold known to science.

(5) Acrylic resin can be moulded by heating so that this helmet will fit comfortably and becomes an integral part of the soldier's head.

(6) The proposed helmet allows unrestricted movements of the head in every direction 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. per square inch; a flexual strength of 12,000 to 14,000 lbs. per square inch; an impact resistance of 0.1 to 0.3 ft. lbs., and a Brinell hardness greater than gold (500 kilograms on a 10 mm. gold ball, 17-20).

(8) Acrylic resin has a specific gravity of 1.10, so that it almost floats on water. It will absorb less than 0.5% of water by weight upon immersion for 7 days. It is resistant to the rays of the sun and will not soften until a temperature of between 190 and 240 degrees F has been reached.

(9) If driven into or buried in the brain or soft tissues, acrylic resin is absolutely inert and there is no tissue reaction.

(10) The lines of shatter of acrylic resin are at right angles to the force, and not directly forward, as in steel.

(11) Acrylic resin smoulders if a flame is applied but will not burn with an explosion, and if it flames the slightest movement extinguishes it.

(12) Shatter proof goggles can be made from the same material which can be so attached to the helmet that the present use of elastic bands to support goggles can be eliminated.

(13) Pieces of spring steel can be set into the acrylic resin which will catch the elastic bands of the oxygen mask and will obviate the necessity for an airman to take off electrically heated gloves to fasten the small clips now used to keep the elastic bands secure.

(14) This helmet can be worn constantly by tankmen and need not be removed when the head is thrust through the tank turret, or when using a periscopic sight, as is true with the helmet for tankmen now in use.

(15) Acrylic resin can be used in making a solid complete helmet similar to the present steel helmet, if desired. It would afford one-third more protection for the same unit weight against penetration and would not dent or cave in from rough usage. It could have an inner lining made of softer acrylic 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 harder material. The proposed helmet would afford greater protection against penetration and impact resistance than the present steel helmet even if it was desired to have it weigh less.

(16) This material can be manufactured cheaply, easily and quickly into helmets, and the use of high priority steel is eliminated. The number of manufacturers now necessary for the production of steel helmets can be reduced.

Immediately, General Hawley indicated that upon return from a surgical mission to the U.S.S.R., Colonel Davis would be sent to the Zone of Interior to present 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 2d Evacuation Hospital to which injured airmen were being taken. A portable unit had become a part of the table of equipment of evacuation and general hospitals, but one was insufficient. On the same date, further data were submitted concerning patients with cold damage to the extremities. On 21 June 1943, information obtained in experiments in the surgical laboratory of Northwestern University Medical School about the local use of the sulfonamides in experimental gunshot injuries in animals was presented to the Chief Surgeon in a memorandum. Even at this date, it had not been completely established that the systematic administration of the sulfonamides would offer the patient sufficient protection from infection.

Policies for the surgical treatment of herniated nucleus pulposus were established in a directive that required examination and consultation upon these patients by the Senior Consultant in Neurological Surgery, the performance of a myelogram, and performance of the operation by a qualified neurological surgeon in a general hospital. Pantopaque had just been prepared and was sent to the theater 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 were invited 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 mission representing the British. Following this, there began a series of episodes confusing to the Chief Surgeon no doubt, as well as to his neurosurgical consultant. It was the latter's first personal experience in a joint effort between one of the armed services and the State Department.

About the middle of May, the members of the mission had luncheon with Prof. Semon Sarkisov,6 recently arrived from the U.S.S.R., and Sir Henry Dale, representing the Medical Research Council of Great Britain. On the same afternoon, the mission had tea with Ambassador Ivan M. Maisky at the Soviet Embassy. Before going to tea, Colonel Cutler and this consultant had a 10-minute chat with John G. Winant, the U.S. Ambassador to the Court of St. James's, who told them that Wilder G. Penfield would represent Canada on the mission. Ambassador Winant indicated at that time that the mission would leave London on 12 June.

Later, Ambassador Winant requested the author to call upon him at the Embassy. General Hawley was informed of the request and acquiesced. Ambassador Winant asked this consultant to represent the National Research Council while on the mission to the U.S.S.R. He also insisted that the author travel as a civilian throughout the trip, and not as one of the representatives of the U.S. Army Medical Corps. The reasons for making this unusual request were not explained by the Ambassador. After consulting General Hawley, this consultant decided to retain those advantages which could be obtained by being in uniform 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 the United States were given informal instruction by Ambassador Winant, General Lee, and General Hawley, and travel orders were issued.

On 28 June 1943 the members of the mission were loaded into a bus at the Swindon railroad station and driven about the countryside until it became dark. They were given dinner at Marlborough and taken to the airfield which was recognized as the one at Lyneham. The four-engine British aircraft carried the members of the mission and two Soviet nationals, who remained grim and uncommunicative throughout the entire trip. The mission members were informed that 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 this volume 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 plane carrying Leslie Howard, the famous British actor, had been shot down by the Germans 2 weeks before), the mission landed at Gibraltar at 0830 hours the following morning, 29 June. After breakfast, the military hospital, a 200-bed unit 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" was bombed.

The mission was off again at noon and flew over the U.S. 12th General Hospital at Oran, Algeria, and on to Castel Benito, the airport at Tripoli, Libya. From the altitude of 8,000 feet, the country appeared a solid brown color with only occasional green spots to break the monotony. The flight followed the route of the advance of the British Eighth Army, and damaged, abandoned material was visible along the road. The British 48th General Hospital was visited in Tripoli, and it proved to be one which they had taken over from the Italians. After tea in a setting of 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 0830 hours on the morning of 30 June.

Barefooted Egyptians, with long wrappers and fezzes on their heads, were working on the airfield and the roads. Arrangements had been made for the mission to stay at Mena House, a clean, cool, well-staffed hotel on the outskirts of Cairo and at the 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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FIGURE 145.-Hon. Alexander C. Kirk, U.S. Minister to Egypt, on the occasion of a visit to the 38th General Hospital, Heliopolis, Egypt, with Maj. Gen. Russell L. Maxwell, Commanding General, Services of Supply, U.S. Army Forces in the Middle East.

the British Embassy to register their presence. The various headquarters were grouped around the Embassy buildings that had been requisitioned, and the entire area in the center of Cairo was fenced off with barbed wire.

A similar visit to Mr. Alexander C. Kirk, U.S. Minister to Egypt, disclosed a tall, impressive, well-dressed man who complained discouragingly and with a real nostalgia that diplomacy had died in 1918 and that he would be glad when it was all over so he could go back home, sit down, and not be bothered (fig. 145). A representative of the British Medical Research Council gave a luncheon, at which there were several representatives of the medical profession of Egypt, in the famous and exclusive Mohammed Ali Club. Cold meats, watermelon, strawberries and cream, and an American beer constituted the luncheon in a private dining room adjacent to a large, ornate gambling room.

Two British hospitals were visited; the one in a newly constructed modern hospital which the Egyptians had to close because they could not make it support itself and the other in the building of a former beautiful hotel. The U.S. 38th General Hospital, staffed principally by the faculty of Jefferson Medical College of Philadelphia, was located at Heliopolis, but a visit there had to be postponed until the return trip.

On the morning of 1 July, after considerable delay while the plane's fuel and cargo were being redistributed at the insistence of the RAF pilot


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on a desert airfield which became hotter and hotter, the leg of the trip from Cairo to Teheran, Iran, began. Without oxygen and at 13,000 feet, one of the mission became cyanotic, another had periods of apnea, and a third developed scintillating scotoma, could not remember names, and had a homonymous hemianopsia. All of these symptoms disappeared, and the mission presented a unified front upon landing at Teheran late in the afternoon. A representative of the British Embassy met the mission but had been notified of the arrival only 2 hours previously by the Soviet Embassy. There were no U.S. representatives.

It was hot and dusty on the airfield, which was surrounded by high mountains with snow on their peaks. There were many American soldiers to be seen, and a station hospital was under construction. Water was running in a small gutter along the side of the street, and people were washing their bodies and clothes in it, watering horses in it, sweeping street cleanings into it, and putting it into pails which they were carrying away. The Palace Hotel provided two iron beds, a wooden washstand with a flowered china bowl, and one water faucet. The guests sprinkled insect powder on the mattress and pillow in liberal quantities.

A visit was paid by the Americans to Maj. Gen. Donald H. Connolly, Commanding General, Persian Gulf Command, an engineer who was accomplishing the project of supplying the Soviet Union through the Persian Gulf and Basra, Iraq (fig. 146). General Connolly inquired about the purpose of the visit to the Soviet Union, since he knew nothing of the mission. When the purpose was explained, he expressed his doubts of the mission's learning any more than what the Soviet hosts would specifically designate. From this conversation, the author received the distinct impression that it would have been more advantageous for the U.S. representatives to make this trip alone because of the Soviet distrust of the postwar intentions of the British.

Sandfly fever, characterized by a high fever for 2 or 3 days and no fatalities, was a common disease amongst the natives. A form of malaria was described as occurring in places where the Anopheles mosquito could not be found. Typhus had been prevalent during the previous winter, and typhoid fever had caused an unheard of number of deaths in the spring and summer 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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FIGURE 146.-Maj. Gen. Donald H. Connolly and Soviet officers meeting, at the Soviet acceptance point, the first all-American supply train from the Persian Gulf, in March 1943.

white caviar, and strawberries. On the trip to the National Hotel where the mission was to be quartered, it was learned that the Army Air Forces officers were in Moscow with Capt. "Eddie" Rickenbacker on a mission which he was attempting to carry out for Secretary of War Stimson (fig. 147). Captain Rickenbacker's mission concerned the complaints which the Soviet Union was making about the Airacobra (P-39) planes that the United States was furnishing them on lend-lease agreement. The complaint was to the effect that they would not stand up in combat. It developed later that the Soviet military had no concept of ground crews to service the aircraft and keep the intricate mechanisms in good working order. It was their idea to fly them, discard them if they broke down, and ask for new ones. The complaint was that the planes did not stand this type of treatment long enough, and they were put to considerable trouble in asking for replacements.

After an assignment of rooms, the mission members found they had 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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FIGURE 147.-Capt. "Eddie" Rickenbacker, in Teheran, Iran, in July 1943, proudly pointing to the inscription, "Mission Rickenbacker," painted on his Liberator bomber by Soviet pilots in Moscow. Maj. Jacob Popov, U.S.S.R. air officer, is on the right.

microphone. To the credit of the members of the mission, there was no one who lowered his voice or changed the frank expression of his opinions at any time. On one occasion when Prof. Serge Yudin visited the members furtively at midnight, he kept up a constant tapping of the table with 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 during the mission's stay), they had a breakfast of tea, cherry jam, cheese, caviar, and bread. Neither did this menu vary, except as they could vary it with instant coffee and hot water heated over a Sterno can which they had brought along. The business office of the U.S. Embassy was only a door or two from the National Hotel, and both faced Red Square, across which they could see the Kremlin and the new, gaudy, heavily built, yellow-stone Moskva 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 learning each man's name and his particular field of surgery. Leaving the British for a moment, they called upon Brig. Gen. Philip R. Faymonville who had been in the U.S.S.R., on four tours of duty, for 10 years. General Faymonville was the Lend-Lease Administrator and, in a frank talk with them, made his position perfectly clear. He was under direct instructions and orders from President Roose-


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velt, delivered by Mr. Harry Hopkins, to supply everything possible to the U.S.S.R., regardless and without thought of getting something in return. He stated that other branches of the U.S. Government wished to barter with the Soviet Union, using lend-lease material as leverage, on the grounds of protecting the United States. It became obvious quickly that the military attaché and embassy officials were in direct conflict with General Faymonville and believed him personally responsible for a situation which was intolerable to them in dealing with the Soviet nationals, without accepting the fact that General Faymonville was carrying out specific orders from the President, and failing to consider that his own personal views might be entirely different. General Faymonville's knowledge of the Russian language, his long residence in the U.S.S.R., and his familiarity with the Soviets' music and customs made them friendly to him, and this was obvious at the social gatherings which were given for the mission and at which he was present. However, this made him all the more suspect by his colleagues of favoritism when the war had finished and when the relationship between the United States and its former ally was changed.

British Ambassador Clarke-Kerr met the mission formally and indicated that it had been made possible by his friendship with Serge 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 from the U.S. Embassy in London-that it had been arranged by the U.S. Ambassador to Great Britain as the result of discussions between members of the National Research Council and the Medical Research Council of Great Britain. The truth probably is that all had a hand in the project and that priority of ideas would be difficult to establish. Each member of the mission received 1,000 rubles from the British Embassy, but they could use them only for gratuities to hotel employees, since there were 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, and the author, with Brimelow, who was attached to them from the British Embassy, visited VOKS-the Soviet society to promote cultural relations with foreign countries. Large posters of Churchill, Stalin, and Roosevelt hung side by side in the large museumlike room of the building to which they were taken by Pairin and Koreisha. Oil paintings of Soviet soldiers in various units, cartoons, and large photographs of Charlie Chaplin and Paul Robeson completed the display. On the return to the hotel, a stop was made at a park where there were pictures of the party leaders lining the walk, a Ferris wheel and various airplane rides for the children, an area for dancing to the music coming from the loudspeakers distributed through the park, and a children's library. The orthopedist in the group remarked that it was much like saying: "Come into the park and we'll give you culture, damn you."

At dinner, the mission members discussed when and how they would get their visit underway, and Admiral Standley's admonition to be patient was


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agreed upon to be the line to follow. After dinner, they walked 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, and they 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 no taxicabs, and only the Intourist organization could supply transportation.

There were several discussions about drawing up their own agenda for procedure and discussions with the People's Commissariat for Health. The mission wished to see surgery of the war wounded in the forward areas and at the bases and to see and discuss the Soviet research projects and ways of exchanging information. These were pleasant periods of conversation with each other but were like shadowboxing in a gymnasium.

During this interval while the mission waited for the date of a meeting with Soviet authorities, a memorandum was written to be left with the People's Commissar for Public Health, which would explain the desires of the mission (pp. 97-99).

So, July 4 was spent in viewing a large collection of captured German war material-guns, planes, trucks, and medical supplies-gathered together 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 at the exhibition, and clothes and uniforms of the visitors from the Western World were the center of close, unabashed, personal inspection. The afternoon was spent at Spasso House, the official home of Ambassador Standley, which had been occupied also by his predecessors, U.S. Ambassadors Bullitt, Davies, and Steinhardt. Capt. "Eddie" Rickenbacker was present and brought up the question of the damage airmen were receiving from high-altitude frostbite, interesting the Ambassador in the discussion.

The evening was spent watching the ballet "The Swan Lake" with Dudinskya, the première danseuse. The audience that evening consisted of workers from factories who had purchased tickets from allotments given to their factory. When the mission members went into the lobby between acts 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 received in the office of the People's Commissar for Public Health, Georgii Andreevich Miterev. There were seven mission members and seven Russians; there were three of the mission in uniform and three of them in mufti. The Soviet military included Lt. Gen. Efim Ivanovich Smirnov of the Soviet Army Medical Service, who was 38 years of age and corresponded to The Surgeon General, and Nicolai Nilovicin Burdenko, the chief surgical consultant to the Soviet Army, not a regular medical officer and with the added great distinction of being a member of the Academy of Sciences. The meeting got underway with a formal speech by the Commissar, who described the existing organization for the treatment


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of battle casualties and provided a typewritten program of activities for the week.

The care of the injured and sick in the army was directed from two departments, the People's Commissariat for Defense and the People's Commissariat for Public Health. General Smirnov's medical organization was responsible for the care of the soldier in combat units, in army hospitals, and through all evacuation steps to the base area. The care of the wounded soldier in the base area, as well as the care of all civilians, was the responsibility of the People's Commissariat for Public Health. It was stated that the methods of treatment were identical in both organizations in order to insure continuity in the patients care when he was transferred from the combat zone to the rear. The line of demarcation between these two areas was never unchangeably fixed. When a patient received a certificate of fitness from the civilian doctors, he was transferred back to the military authorities for reassignment. Patients requiring long convalescent care remained under the jurisdiction of the civilian authorities in hospitals which were required to devote their chief attention to the treatment of the war wounded. The People's Commissar for Public Health stated that 70 percent of all wounded were returned to the combat zone for duty, and he was obviously proud of the small incidence of tetanus and gas gangrene.

A detailed description was given of the organization for care of the wounded on the field at battalion, regiment, and division aid stations and in the sorting-evacuation hospitals, placed 30 to 50 km. from the front, and from 1,000 to 4,000 beds in size. An explanation was provided of the methods of evacuation by train, automobile, and plane. The percentage distribution of beds was described, and it was emphasized strongly that 0.2 percent were devoted to neuropsychiatry at the front and 0.1 percent, at the base area.

On 6 July, the members of the mission began their tour of the facilities which the Soviet hosts wished them to see, and nothing beyond that was possible. The Botkin Hospital, the Sklifossowsky Institute headed by Serge Yudin, the Central Institute for Traumatology and Orthopedy, the Institute of Neurological Surgery (Burdenko's Hospital), a clearing hospital of the People's Commissariat for Public Health, two frontline 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 for Medical Research, and a final meeting with the People's Commissar for Public Health fulfilled the agenda provided by the hosts. At no time was any member of the surgical mission asked to present his opinions about any surgical or research problem or to relate experiences of the British or U.S. Army Medical Corps in treating the wounded.

In summary, the principles of Soviet surgical practice in the 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 days after wounding, and the sulfonamides and immobilization were relied upon to prevent generalized sepsis.

Large soft-tissue injuries, as well as fractures, were immobilized by wooden splints of the Thomas type for evacuation to the place of first definitive surgical treatment, after which plaster of paris was applied. This was put directly over the wound, "skin tight" without padding.

Active immunization was obtained with tetanus toxoid. The booster dose was given at the regimental aid station.

A potent antiserum was used in all serious wounds against the development of gas gangrene. It was usually given intravenously. Several surgeons admitted privately that the antiserum was not effective.

Sulfanilamide was used in both forward and base hospitals locally in the wounds, by mouth, and intravenously. A small supply of sulfapyridine was in existence at that time. A special form of sulfanilamide in which the drug was broken down into small particles by subjecting it to ultrasonic waves was used as a cream and applied to gauze dressings. The latter product was in an experimental stage, it was said, and was not in mass production.

Secondary suture of wounds was practiced whenever possible, 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-oxide or oxygen machines were seen.

Sucking chest wounds were closed in forward areas; empyema was treated by drainage for 3 weeks, following which two or three rib fragments were removed and the wound was packed. Only large foreign bodies were removed from the chest cavity.

Tannic acid and silver nitrate were used in the treatment of burns, but the Soviets preferred an open method in which a powder containing an analgesic agent and an antiseptic was dusted on the burned area.

The best impressions of the Soviet methods of treatment were obtained in their treatment of fractures. From the time of Pirogoff, in the Crimean War, they had become masters in the use of plaster of paris. They had a line of continuity in the treatment between surgeons at the front and in base hospitals which represented the same institution and methods. Yudin at the Sklifossowsky Institute had cared for over 2,000 fractures during the war 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. The wound was widely excised and sulfanilamide was placed in it. Often the wound was sutured open by uniting the skin edges to the deep fascia. "Skin tight" plaster was then applied directly to the wound and skin. Casts were not split and they never used windows.

An interesting sidelight resulted from the discussion which developed between Dr. Serge Yudin, who was not a member of the Communist Party, and the mission, particularly Mr. Watson-Jones, about the results of their meth-


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ods of treating fractures. It was a give-and-take friendly exchange of opinions until Watson-Jones indicated that it was difficult to believe the successes claimed. Yudin, whereupon, inquired if Watson-Jones had ever treated 2,000 compounded fractures, and, when the reply was in the negative, Yudin stated again that he and his associates had and these were the methods and results.

The Soviet Army Medical Service used large amounts of citrated whole blood and little or no plasma. An excellent technique was employed to collect the blood in the larger cities, but chiefly in Moscow, where 2,000 pints a day were obtained. Donors were given a special food ration and a small amount of money, but 85 percent of the latter was returned through gifts to the Government for airplanes and other military purposes. The name of each donor was placed 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, from which it was distributed in refrigerated vehicles to frontline hospitals. The use of plasma was confined to regimental aid stations. Much time was taken to describe many other fluids used, but it was obvious that this was done only to indicate the extent of their knowledge.

Amputations, prostheses, and plastic surgery were well done in special hospital centers. One plastic surgeon, Frumkin, had received publicity in the Allied press for a series of patients upon whom he had operated to create a tubular graft which would simulate a penis through which the bladder could be emptied.

When the mission gave a dinner at the National Hotel where they were billeted, the guestlist included Frumkin, a genial, intelligent, capable surgeon, who spoke English well. Frumkin's name was removed from the list, as well as several others, and other names were substituted, none of whom the mission had met. This was done without asking the mission's approval, and no reason was ever given for the action.

Lt. Gen. S. S. Guirgolave lectured to the mission at some length about cold injuries received on the ground and in water but dismissed questions about high-altitude cold injuries in flyers by denying their existence, an attitude which appeared to be common among air force medical officers, Soviet or American, who were in positions of responsibility. It was their opinion that treatment should be guided by rapid heating of the individual and the injured part. Longitudinal incisions were made in necrotic tissue within 5 or 6 days to promote the rapid development of dry gangrene.

All of the neurological surgeons in the U.S.S.R. had been trained under the supervision of General Burdenko, who also was a member of the Academy of Sciences. The latter conferred far more distinction and privileges than any other classification with which we came in contact. It was said that Academicians ranked in these respects just below the Politburo.

General Burdenko had established an Institute for Neurological Surgery, and it was claimed that 16 neurological surgeons at the front had 3,200 beds at their disposal and that there were 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 which were being practiced in the United States. In no area could Soviet surgery make any contribution to this surgical specialty.

An incident occurred while the mission visited the Institute for Neurological Surgery which revealed more of the Soviet mind than was being disclosed surgically. General Burdenko demonstrated a microscopic slide which purported to show the excellent regeneration which had occurred as the result of the experimental use of a formalin-fixed nerve graft in the repair of a peripheral nerve injury. The specimen was poorly stained and showed nothing conclusive, and one of the mission turned away without comment. Brudenko, through the interpretress, insisted upon a comment about the demonstration, stating that he had a copy of the American's book on peripheral nerve injuries. He indicated that an opinion would be highly appreciated. The answer was, of course, that it had been proved during World War I, and subsequently many times, that such formalin-fixed grafts were completely useless. General Burdenko was asked to indicate how many patients had been operated on and to demonstrate one who showed a return of sensation or motion in any area in which overlap did not occur. General Burdenko replied with a smile that 25 patients had been so operated on, that all had recovered, and that they were unavailable for demonstration because they were at the front in combat.

The other members of the mission, and, in particular, the other member from the United States, were not hesitant in indicating that such a doubting attitude might well impair the entire success of the mission and, if carried into other fields, might even destroy the alliance between the Western nations and the Soviet Union and allow Germany to win the war. The sequel to the incident occurred later at the dinner given by the mission in the National Hotel. During the cocktail hour, General Burdenko was observed rearranging the placecards. It was protocol to have a lieutenant colonel sit at the foot of the table and certainly not on the left of General Burdenko. However, this is what occurred-much to the embarrassment of the senior ranking officers on the mission who believed it must be due to the ignorance of the lieutenant colonel or else his persistence in attempting to offend the Soviet officials. However, the placecard was authenticated by Ambassador Standley who viewed the incident with amusement. During the dinner, General Burdenko summoned the interpretress and asked again the neurosurgical consultant's opinion of the formalin-fixed nerve grafts and again was informed that they had been proved to be unsuccessful beyond any doubt. Whereupon, General Burdenko said he agreed completely but then inquired why the other members of the mission, particularly the British, had been so complimentary in their praise of the experiment. He went on to say that this was an example of how difficult it was to trust and negotiate with people who did not always bluntly state their views and position. Ending by a firm, pumping handclasp, he stated that henceforth there would be no difficulty in understanding opinions expressed by the American neurological surgeon.


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Several clinical methods were under study which were emphasized as being completely new and original ideas. These included the injection of 70 percent alcohol with 2 percent Novocain (procaine hydrochloride) solution about fractures in the early days following injury to increase the blood supply and to stimulate callous formation; the use of placental extract to stimulate healing in chronic wounds or the growth of skin in severe burns; the use of a cytotoxin made by injecting mesenchymal tissue into a horse and using the antiserum to stimulate the healing of ulcers of the stomach, the healing of bone, and the loosening of scars and stiffness in joints; the use of the smoke from burning pinewood to stimulate healing; the use of naphthalene broken down by ultrasonic methods to stimulate healing; and the treatment of shock by the suboccipital cistern injection of potassium phosphate solution to stimulate the vasomotor centers in the medulla.

The mission visited Dr. Lena Stern's laboratory to observe an experimental animal tested for shock by this method of cisternal injection. Allowing for all of the difficulties which are inherent in the demonstration of any experiment to a group, the basic technical methods employed were so crude and inaccurate as to throw complete doubt upon any conclusion which had been expressed. Dr. Stern was one of the few women Academicians, and her apartment, automobile, food, and gasoline rations could not be compared with those of the average citizen.

One of the outstanding demonstrations to the mission was that of the organization which had been effected, without recourse to the more democratic method of employing committees, to hospitalize the emergency injuries to the civilian population of Moscow. In fact, when organization alone was considered, the Soviet plans were efficient and superior.

It was apparent that women held equality with men in the U.S.S.R. as members of the street-repairing gangs and of other construction groups on the country roads and as soldiers and officers in the Army. In the line, the mission was informed that there was no woman with a higher rank than colonel; several junior officers were seen with artillery and 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 frontline hospitals near Vyazma. It will be remembered that, during the following month, the Soviet Army opened an extensive and decisive campaign along the Orel-Kursk-Belgorod Line which extended directly south of Moscow. Vyazma was about 125 miles southwest of Moscow and represented a point to which the Soviet Army had driven the Germans back from their advance on Moscow.

The entourage consisted of several automobiles containing the members of the mission and their hosts. But there were two additional cars which served to transport the mission when the cars in which they were riding broke down, and this occurred four times going and coming. Extra cans of gasoline were carried with the passengers, and the rugged, jolting ride was only a part of the rigors which it is said every doctor-soldier should be trained 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 their ability and willingness to use them.

At about 1700 hours, the mission arrived at a casualty clearing station, well camouflaged in a thick forest. After the mission was shown through the wards, vodka, strawberries, caviar, and smoked fish were served in a fine example of a Mongolian tent. General Faymonville had briefed one of the U.S. delegates on the drinking of toasts in vodka in the Russian fashion. It consisted of making up one's own mind about how many vodka toasts could be tolerated and then going through the motions, substituting wine or water if possible, or otherwise simply raising the 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 at about 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 be constructed of logs. A sumptuous dinner had been prepared with an exact protocol of seating arrangement along one side of an enormous table which occupied a large dining hall. The senior military member of the mission sat in the center of the table, and on his left was a young, blonde, Amazon-like woman with the rank of major of infantry. Lower ranks and civilian representatives graduated downward to the ends of the table. Vodka, wine, champagne, and enormous quantities of all types of food were served while representatives of various Republics of the Soviet Union, dressed in their native costumes, entertained the guests with folk music and dances.

The toasts came thick and fast and, as was customary, by the time it came to a lieutenant colonel, there was little left to toast. The ruling heads of governments, the Soviet Army, and the women of the Soviet Union had been honored, and a few well-delivered mumbled words with the correct emphasis and gestures now sufficed. It was evident that the young woman major had considerable capacity for vodka and a technique of eating large pieces of bread between toasts. It was also apparent that her table companions were slowly but surely becoming unable to accept her challenges. It did not help for one of the mission to invite her to dance to the Ukrainian music in the hope that the exercise might slow down her vodka-consuming abilities. As a matter of fact, her vigorous dancing probably burned up the alcohol more rapidly and only exhausted her partner. She was physically superior to any one of the mission and probably was devoting herself single-mindedly to carrying out an order.

The dinner was terminated abruptly, and the members of the mission were guided to their billets by their Soviet hosts. They were bedded in one of the wards of the hospital which was cleaned and had comfortable beds. During the night, one of the mission had the first attack of severe renal colic and experienced the nursing technique of Soviet nurses whose calloused and rough hands were nonetheless gentle and reassuring. The following morning the log and plank structure could be admired. It had been erected by officers, nurses, and enlisted 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 frame in a recently added portion of the hospital.

A breakfast of tea, smoked meats, and bread was followed by a visit to Colonel Davis from the previous night's table companion, a Soviet medical officer of the same rank. The Soviet officer apologized for attempting to embarrass a member of the mission by publicly calling attention to the fact that he had not drunk each toast in vodka. He conceded as quite correct this consultant's direct, frank answer that if he (the Soviet colonel) was a guest in the United States he would be permitted to drink as often and as he pleased, and on that basis the American guest to the Soviet Union would conduct himself. The Soviet officer went on to say that there was no real necessity for accepting the Russian rules about drinking toasts, but, if they were accepted, then the Soviet people went all out to drink their guests under the table. A Russian salutation on both creeks ended the apology and appeared to cement a friendship between at least two of the Allies.

The return to Moscow was completed late that night and the next day was spent in rest and at a symphony concert. The following day the mission visited a hospital for lightly wounded who were able to be quickly rehabilitated and returned to the combat zone. On 15 July, the British and Americans conferred honorary Fellowships upon Burdenko and Yudin in the office of the People's Commissar for Public Health with as many Soviet officials as members of the mission present and no other guests. The British and U.S. Ambassadors were not present, and both Soviet recipients prominently displayed their stars of the Order of Stalin. It was a ceremony completely unworthy, in its setting, of the Fellowships from the distinguished Colleges of Surgeons of England and America, both of which had broken a precedent in conferring their Fellowship away from the home of the College.

The following activities occupied the remainder of the mission's stay in Russia: A return visit to the Sklifossowsky Institute; visits to the Pirogoff Clinic and to the Balneological Institute, where it was claimed that a pine-oil water and Odessa mud were miraculous curing agents; 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 uttered one audible word of English; attendance at a performance of the ballet from Otto Nicolai's opera, "The Merry Wives of Windsor," and at a performance of Tschaikovsky's opera, "The Queen of Spades;" a meeting at the Central Institute for Medical Research, at which Mr. Carling, Professor Penfield, and this consultant recited that Great Britain, Canada, and the United States freely exchanged research information, without eliciting the slightest sign of encouragement that the Soviet Union would join in.

On 23 July, the mission finally took off on their return flight. The last week had been difficult for the hosts as well as the members of the mission and it had been hard to keep occupied. The time allotted to the mission had been overstayed. It had been impossible to walk about alone, because the ever-present NKVD representatives had been nearby; there were no shops in which


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to purchase mementos of the trip, and the members of the mission had become slightly weary of one another's frailties.

The obstacle, however, was the fact that no airplane was available to take the mission back to their starting place. The British and Soviet authorities had been negotiating an agreement whereby, in the summer months, one route would be flown by way of the Mediterranean, Cairo, and Teheran, as the mission had come, and another directly across Europe from London to Moscow. One aircraft by each route each week was the schedule. In the winter months, two planes would fly the southern route. The British believed the agreement to be firm, but flew two planes in one week in July via the southern route, instead of one directly across Europe, because of operational difficulties, which would quickly straighten out. The Soviet authorities considered this a violation of the agreement and refused to allow any plane to enter Soviet territory by any route.

The week passed with the British Ambassador frankly admitting 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 at 0300 hours and arrived at an airfield near Moscow at 0545 hours. They could see the two-motored U.S.-built plane sitting on the field. A large red star decorated its side. After waiting 2 hours for Walter Citrine, a British labor leader and his companions who had also been in the U.S.S.R. studying Soviet labor relations, they boarded the plane whose motors were still idle. The motors were started, and, without preliminary revving of the motors, the plane taxied to the end of the field and took off. The flight was never above 1,000 feet because, recently, an order had been issued to the antiaircraft crews to shoot at any plane above that height, without attempting to identify it. Stalingrad was circled at 500 feet and all that could be seen standing was one stone chimney. At 1730 that evening, the pilot dove the field at Teheran, and, with the smell of scorched rubber tires in their nostrils, the members of the mission were unceremoniously deposited on the airstrip. They were out of the U.S.S.R..

The unceremonious delivery of the members of the mission in Teheran left the Americans stranded at the airport, while the British left by an automobile provided by Sir Reader W. Bullard, British Minister to Iran. A car was commandeered, and, after a great deal of shouting and gesticulating, the billet of General Connolly was reached. Hot, dirty, and tired, Colonel Cutler and the author burst in upon the general and his staff who were having a cocktail before dinner. The general quickly grasped their predicament and sent an orderly outside to silence the Persian driver who was honking the automobile horn and screaming Iranian curses on his passengers.

After hearing their story and realizing that they had no means of transportation from Teheran to Cairo, General Connolly arranged for hotel 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 them on 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 with the general's aide, cleaned up, and answered a telephone call from the British Minister to come to dinner at his home. There was some tension after dinner when methods of transportation to Cairo were compared. The British were being flown 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 with officers and enlisted men, all of whom had one goal in common-to be able successfully to crawl on their hands and knees across the engine crates to and from the toilet, since all were suffering from diarrhea. Basra's temperature was 120° that morning at about 1000 hours, and griddlecakes and thick molasses was not an appetizing menu. It was not long, however, before the plane took off again and landed in Cairo at about 1730 hours that evening, 24 July.

Colonel Cutler and the author were unsuccessful in obtaining a room at Shepheard's Hotel and eventually got to Mena House where they found the other members of the mission. The next 3 days were 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 General Hospital; sightseeing among the Pyramids and the Sphinx at Al Jizah; lunching with Ali Pasha Ibrahim, Dean, Faculty of Medicine, Egyptian University (Cairo); and listening in on a critique of the British-American landings 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 was Maj. Gen. William H. (later Sir Heneage) Ogilvie. Colonel Cutler and the author were warned by him that the critique would be highly critical of the American air forces and paratroopers. After they had sat down and after Gen. Henry Maitland Wilson had arrived, the Americans were given the opportunity to leave if they chose. The critique lost all of its objectiveness and value, even to the British Armed Forces, when the colonel who conducted the critique became highly emotional and delivered a sarcastic diatribe about the favorable publicity that the U.S. Armed Forces had received and their popularity with the female population of the British Isles.

At midnight on 28 July, the mission was driven to the airfield at Heliopolis (fig. 149). It was stifling hot on the desert, and the sand was blowing as they sat in a small brightly lighted room without ventilation. The young RAF wing commander who had been delegated to fly the mission back to England had been one of the heroes of the Battle of Britain. It was as if he had been an engineer on the Twentieth Century Limited and now was hauling an express milk train. Each of the members of the mission was asked to demonstrate his proficiencies in getting into a life preserver and a parachute and in adjusting an oxygen mask.

Again, they landed at Gibraltar and the Americans found a small room in a barracks. One iron bed without a mattress was hardly a place for two men to sleep or rest, and so the day was spent sightseeing and having dinner in the hotel. At midnight, off they 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 the next morning, 30 July, the plane sat down on the airfield at Swindon. As they were getting their bags off, the pilot discovered that the flight had been particularly difficult for him because a cargo, placed beneath the floorboards of the passenger cabin and sent from London to Cairo, had never been unloaded. He had carried it all the way back to England again. This explained the difficulty with which his plane became airborne.

The mission had learned little about new advances in surgery, but each member had formed his own opinion of Soviet practices from observation of the individuals with whom he had come in contact. The Soviet people appeared to be like 10-year-old American boys who brag about the size of their houses and chimneys and recklessly claim that their fathers can lick anyone. They were unsure of themselves and suspicious and could understand only directness, frankness, and the show of confidence which comes from strength, both physical and intellectual.

It was learned that medical education, formerly under the control of the universities, was put under the Commissariat for Public Health in 1930. There were, then, 72 institutes (schools) of medicine with 107,000 medical students. Students were admitted after 10 years in secondary schools, and the medical course was 5 years. The first 2 years were spent in scientific studies, and the last 3 years were clinical. During a part of the clinical years, the students were farmed out to village and town clinics for practical experience. There was specialization with training for industrial surgery, military surgery, hygiene, and bacteriology. Upon their passing a required state examination, a diploma was issued which conferred the right to practice medicine. Higher degrees, those of bachelor or doctor of medicine, were given after 2 or 3 additional years of postgraduate work, which could be clinical practice or continued work in the institute. A thesis was required which determined whether or not additional examinations were to be given. The percentage of students who become bachelors or doctors of medicine was small. From 1935 to 1940, there were 140 doctor's degrees given at the First Medical Institute and 284 bachelor's degrees. From this group came the professors and teachers. When a chair was vacant, anyone could apply, but a commission chose and appointed the individual. It was said that they had a Research Council, also under the Commissariat for Public Health, and that into that organization flowed problems from the army, navy, industry, and the faculties of the medical institutes. This council then assigned special problems to certain faculties or individuals.

WASHINGTON AND RELEASE FROM SERVICE

Colonel Davis spent the month of August 1943 preparing reports8 and accompanying General Hawley to the wards of the 2d General Hospital where Major Scarff and his associates had been caring for the high-altitude frostbite

8See pp. 92-106, and appendix A for additional chronicling of the mission to the Soviet Union and appendix A for a 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 Army Air Forces, Maj. Gen. David N. W. Grant, the Air Surgeon, and General Grow were also present on that Sunday morning when General Arnold visited the men at their beds and heard their stories of failure of clothing and equipment.

General Grow accompanied General Grant and General Arnold back to Washington. Colonel Davis received orders the following week to go to Washington and present the colored photographs of high-altitude frostbite injuries, the clinical histories, and all other data which had been developed during the study of these patients. He was also instructed to present the data on the protective helmet.

FIGURE 150.-Col. R. Glen Spurling, MC.

Maj. Gen. Norman T. Kirk, The Surgeon General, and his staff were greatly interested in the high-altitude cold injuries. General Kirk took the author to the Pentagon and arranged a presentation of the material to the Air Surgeon's executive officer, Col. Walter S. Jensen, MC, and a group of other Army Air Forces medical officers. General Grow appeared during the presentation. He objected strenuously to any implications that he and his staff had missed the injuries in the first place, had continued to disregard them, and had failed at any time to study them. The facts, not the implications, needed no defense.

Mr. Henry Field, a friend from Chicago, was in Washington engaged in governmental work which made use of his great knowledge of the Middle East and his abilities to bring important matters to the attention of those in high places, who otherwise had to rely upon the complex lines of communication between bureaus and departments. He was greatly interested in the story of the high-altitude cold injuries and in the possibilities of the protective helmet.


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Thus it was that contacts were made with Colonel Doriot and Mr. Bradford Washburn9 of the Quartermaster Corps. These men had been working energetically to develop clothing for airmen which would protect them against extreme cold. Mr. Washburn had had considerable experience in mountain climbing and exposure to severe cold. Unfortunately, this research group had been ordered to stop working further on protective clothing for airmen. Colonel Doriot's group was also working on a new protective material-Doron-named for Colonel Doriot, and it was possible for the author to help at length on the medical aspects of its development (p. 414).

After a tour as a patient through three general hospitals ended on 30 March 1944, Colonel Davis was released from active duty and returned to his duties as chairman of the Department of Surgery, Northwestern University.

On 12 March 1944, Lt. Col. (later Col.) R. Glen Spurling, MC (fig. 150), was appointed Senior Consultant in Neurosurgery in the Office of the Chief Surgeon, ETOUSA.10

The Army Air Forces eventually requested the author's colored photographs of high-altitude frostbite and made educational posters designed to instruct the airman on proper protective measures. Properly wired clothing was issued, and the sidegun apertures on aircraft were closed in.

The plastic material for protective armor was field tested by the Marine Corps and the Navy, and finally, on 15 September 1951, Maj. Gen. Edgar E. Hume of the Army Medical Corps announced that a plastic-protected vest would stop a .45-caliber bullet fired from a distance of 3 feet. In an article published in 1944, this consultant had suggested that the plastic material designed for use in aviators' helmets could also be adapted for protective clothing.11 Such armored protective clothing was finally used in the field during the Korean War with great success. At the time of this writing, the plastic material forms the basic principle 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.

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