History

Medical Science Publication No. 4, Volume II

EVACUATION AND SPECIALTY CENTERS*

LIEUTENANT COLONEL DOUGLASLINDSEY, MC

Besides the general scope implicit in the structure of this symposium,and the title "Evacuation and Specialty Centers," my invitationto make this presentation included three specific questions:

1. What was the experience in Korea, as to the requirements for, locationand distribution of, and physical facilities within the various specialtreatment centers?

2. Should these centers be used in any future operation comparable tothe Korean campaign?

3. What modifications in their facilities, organization and use wouldbe necessary in mobile, global war?

I can dispose of the second question with a categorical "Yes,"and then review the Korean experience, compare it to the past, and drawimplications from it for the future. Special treatment centers have beenconspicuous components of the United States Army Medical Service almostsince its inception. Witness Weir Mitchell's neurological center, at Turner'sLane Hospital in the Civil War. And further back we find that one of thefirst four hospitals in our Army, established shortly after the actionat Breed's Hill, was a hospital for epidemic disease, specifically smallpox.

Specialty centers are with us to stay. The prominence of such centersin Korea during 1950-53 was highlighted by the specific circumstances whichpertained then and there. This prominence is not attributable simply tothe static nature of the war over most of the period. I am inclined tosubmit other factors as of equal importance:

1. The steady trend toward specialization in medical education and practice.

2. The general shortage of professional medical personnel, in Koreaand Army-wide.

3. The development of transportation facilities permitting great flexibilityin the movement of patients.

All of these factors will carry over in the future. The trend to furtherspecialization is admittedly not reversible, but there are some hopefulsigns that it may taper off. I mention hope, because we in the Servicemust surely be interested in developing true general surgeons to care formassive wounds which forcibly violate anatomical

*Presented 26 April 1954, to the course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.

boundaries between traditional specialties. What with chest men stakingtheir claim on vagotomy, the vascular surgeons taking over the liver andspleen, and the proctologists reaching up to the ileocecal junction, itappears that the general surgeon may be restricted to the performance ofgastrectomy and herniorrhaphy.

We may as well realize that the shortage of medical professional personnelis chronic, though I cannot accept the starvation level we had in Korea,or the projected 3.0 per thousand, as necessary austerity. In alimited war, such as in Korea, personnel will be limited by a tight budget,and lack of popular support. In an all-out war the purse strings loosen,and popular and political enthusiasm rises, but then we begin to meet thefrank restrictions of the size of the national manpower pool.

And lastly, it hardly requires mention that the developments in transportationwill continue. Specialty centers will not only be utilized in operationscomparable to that in Korea, but, with little modification, will be essentialfeatures in any military campaign of the future.

Earlier presentations have outlined the basic evacuation system. Thescheme of evacuation and treatment as it was in Korea during most of thewar included the key features shown in figure 1. The

FIGURE1

surgical hospitals were spread evenly across the front. Helicopters,and other means of transportation, moved casualties to and between them.Patients were evacuated to the rear primarily by cargo aircraft and ambulancetrain.

Organizational Classification of Specialty Service

The salient specialty operations in Korea were the neurosurgicaldetachments, the psychiatric center, and the hemorrhagicfever center. The entire specialty service including these, as wellas the less publicized ones, can be considered as separable organizationallyinto the following classification:

1. Table of Organization professional service detachments.

2. Standard Table of Organization (or Table of Distribution) units,specially designated, organized and equipped for a certain function.

3. Research teams, with the concomitant attraction of special patientsto the host installation.

4. Individual specialists, assigned to standard units.

Of the T/O professional service detachments, the only ones that weremaintained in active status in Korea were the neurosurgical and phychiatric.The dental service detachments are not relevant to the discussion here.

The neurosurgical detachments were initially provisional units, expandedbeyond the T/O structure to formidable proportions. They were satellitedon active surgical hospitals, but were virtually autonomous, with separateoperating rooms, separate wards and separate nursing staffs. Later theyshrunk to or near T/O size, and were assigned directly to the hospitalcommander for all functions. The separate facilities were dissolved orconsolidated and the units then functioned essentially as integral elementsof the hospital.

The Army utilized the neurosurgical facilities of the Navy hospitalships to the maximum practical degree. The ship at dockside in Pusan wasavailable for support of the communications zone until mid-1952. The shipoff-shore at Sokcho-ri, which moved to Inchon harbor after March 1952,primarily supported the Marines, but also received patients from nearbyArmy units, usually by helicopter, sometimes by surface means.

The Army neurosurgical detachments were located in such a manner asto serve the bulk of the Army forces (fig. 2). At the maximum practicalworking radius of the H-13 helicopter they adequately covered the front.The available helicopter lift likewise was usually sufficient to providefor movement of postoperative patients directly to pre-arranged Air Forceevacuation flights for transfer to the rear and to Japan.

FIGURE2.

The physical facilities of the neurosurgical detachments varied fromtime to time, but usually they were quite good in absolute terms, and relativelywere the best provided for our forward medical units. They operated onwood floors, sand floors and concrete floors, and were sheltered in somethingbetter than simple tentage-the Jamesway hut, or pre-fabricated buildings.The wards were in buildings, or under hospital tentage. During a portionof the war air-conditioning was provided by trailer-mounted units. Althoughthese units were burdened with a cubic air space load far beyond theirrated capacity, and the result by no means approached "air conditioning"as we commonly know it, the ventilation and cooling they offered made themhighly prized additions. What we can expect along these lines in the futurein a more demanding tactical situation I will mention later in this discussion.

The Eighth Army's psychiatric center was founded on a combinationof the standard psychiatric detachment and a slightly modified medicalholding company. By the time this installation was organized, about themid-point of the war, there was no great flow of common "combat fatigue"cases. Such of these that did occur were well taken care of at the divisionclearing stations. In the stable situation that existed these stationsoffered adequate facilities, and even in the

face of a brisk flow of battle wounded the great majority of those withcombat neuroses could be treated there and returned to duty. The patientload at the psychiatric center thus included a greater proportion of psychotics,personnel with character and behavior disorders, and candidates for administrativeboard actions, all requiring more extensive or intensive study and therapythan the traditionally oversimplified schedule of sympathy, sleep, showerand physical security.

The holding company, although attached to the psychiatric detachmentfor command and control, was in effect the host facility, doing the housekeepingand boarding the patients. The modification of the holding company wasa matter of replacing most of the unspecialized corpsmen with neuropsychiatrictechnicians.

This center monopolized all specialty psychiatry to the rear of divisions.The psychiatrists in the evacuation hospitals gradually and for good reasondropped from view. No psychiatric patient was to be evacuated from Koreaexcept through the center. And the center served as the base for all visitingpsychiatrists and psychiatric research teams, an orientation stop for newreplacement psychiatrists, and an academic center for psychiatric training.It was located at Seoul, the hub of our rail and air evacuation systems(fig. 2).

The center moved once, to another location still in the Seoul area.The physical facilities were analogous in the two locations, though qualitativelymuch better after the move. The wards were deliberately kept in tents (albeitfloored and with frames), although buildings could have been had. Thereis a presumptive psychiatric advantage in maintaining the patient undersemblance of field conditions, and along with the tents went a militaryregimen of training and drill. There was a good shower house, a movie theaterand private interview rooms-all in buildings.

The center was seldom pressed for beds. Psychiatric patients were evacuatedto Japan almost on an "appointment" basis, on such evacuationaircraft as were destined for the Tokyo area. Special attendants, whendesired, were included in Eighth Army's request to the Far East Air Forcefor the lift. Through a bit of administrative finagling at Army Headquartersthe psychiatric unit was given authority to issue the necessary traveland reassignment orders to return discharged patients to their units induty status, or to officially transfer them to replacement installationswith appropriate limitations on assignment.

I can say without hesitation that this was one of the most valuableorganizations we had in the medical service in Korea, and one of the mostefficient-both in the professional and administrative sense.

Of the second category of specialty services, and the last of the mostpublicized three, was the hemorrhagic fever center. One of

our surgical hospitals was specially staffed and equipped for this missionand thus became a surgical hospital in name only. It was originally establishedunder hospital tentage at a location just to the rear of the center ofdensity of incidence of the disease. With the opportunity for obtainingsemi-permanent construction at a location more toward the rear, the unitwas moved to Seoul, at a cost of well over a quarter of a million dollars.Even under tentage the unit was not "roughing it," and excellentand highly technical research could be, and was carried on. I recall, withembarrassment, one instance in which an Eighth Army Inspector General criticizedthe Medical Service because patients (then without slippers) were mussingup the sheets with their boots. In the Seoul location the unit had runningwater, flush toilets, concrete floors and insulated buildings.

Patients with known or suspected hemorrhagic fever were arbitrarilydeclared to be helicopter priority cases. They were usually still ambulatoryin the early stages, but they were lifted by helicopter to the nearestpoint of transfer to light aircraft for evacuation to the hemorrhagic fevercenter.

The installation had too many bosses, with at least five different officersproposing their own cardinal authority. In fairness to the other unitsin Korea I must state that this unit was organizationally disjointed, andadministratively confused, even though it turned out superior professionalwork.

This unit was, I believe, the greatest medical supply problem in Korea;certainly it was during the time I was the Medical Supply Officer of EighthArmy. The problem was not so much the quantity or the item requested, butthe apparent lack of regard for supply accounting and requisitioning procedures.

As specialty centers, the research teams we happen to have in Koreahad little specific effect in attracting particular types of cases. Anexception was the renal insufficiency team. The artificial kidney drewanuric patients from the whole front, and even from Japan. The vascularteam worked on whatever vascular cases were found among the normal admissionsto the hospital in which the team worked. Its function actually was todemonstrate technic to surgeons from all the hospitals, since vascularrepairs must be done when and where vascular damage is encountered.

The wound ballistics and body armor teams had representatives in manylocations. The stress research team was, in fact, operations research ratherthan medical research, but it contained many medical sciences personnel,and it was assigned to the Eighth Army Medical Service for support. Itattracted no special patients. It came into the theater quietly, accumulateddata, drew no conclusions, and quietly departed.

The physical setup of the surgical research team was excellent. Thelaboratory was well equipped and well housed, separate from the laboratoryof the hospital. There was no separate research ward; the clinical phasewas integrated with the regular surgical service of the hospital, whichtoo, was well equipped and well housed.

The renal insufficiency team maintained a separate ward, staffed bypersonnel assigned from the host hospital. Physical facilities were good;they included insulated buildings, an independent reserve power supplyand a tremendous diesel-fired thermocompression distillation apparatus.Moving the artificial kidney and its associated impedimenta to Seoul atthe end of the war was an operation comparable in complexity to relocatinga surgical hospital in semi-permanent postwar facilities.

The stress team was provided with a concrete-floored laboratory building,and new quarters for their WAVE officer technicians, and a secure basefrom which their teams could go forward (or to which combat soldiers couldbe brought back) for the collection of stress data.

The vascular, wound ballistics and body armor teams required no specialhospital facilities except for photography.

A specialty service less evident than these groups I have mentioned,but a service essential and invaluable, was that provided by individualprofessional specialists assigned to positions in standard medical units.Not all Table of Organization specialty positions could be filled, andoften we had a specialist not required by the tables. Specialists wereassigned where their talents appeared to be most needed. Mere knowledgeof their presence in an organization was sufficient to establish a patternfor evacuation of certain types of patients. They rapidly established aloyal clientele and developed significant in-patient, out-patient and consultingservices wherever they were. An outstanding example was the ophthalomologyservice at the evacuation hospital near Seoul.

A related factor in the development of specialty services, which I possiblyshould sub-classify under the category of specially designated and equippedunits, was the influence of availability and distribution of individualitems of diagnostic equipment. We transferred to the hospital ships certainpatients who needed physical therapy or electroencephalography. We shuttledpatients over Korea in various crisscrossing patterns, to get them to aplethysmograph or a flame photometer or a Drinker respirator.

It may surprise you to find that no unit of the Field Army Medical Service-noteven the 750-bed evacuation hospital-has an electrocardiograph on its authorizedequipment list. I well remember in World War II making a full day's journeyby jeep into the advance

section of the communications zone in order to arrange an EKG for abattalion staff officer. And for another officer, who needed an audiogram,a trip to England was necessary. By special dispensation of Far East Commandheadquarters we had both of these services freely available in Korea. Theywere daily necessities. The number of "complete work-ups" andfancy consultations that were performed was impressive. About 50 timesa month we received inquiries from members of Congress as to the physicalstatus of an individual soldier, and often an exhaustive clinical investigationwas required in order to settle without equivocation the questions thatwere raised. Annual physical examinations were accomplished for all thesenior officers of Eighth Army. And the hospitals and specialists conscientiouslyand painstakingly studied the problem cases and borderline cases that thephysicians in the forward area were unable to rule on with confidence.

With respect to special items and luxury equipment our position in Koreawas fortunate. The theater medical depot also supplied and equipped thepermanent hospitals in Japan, and thus normally stocked items which mightotherwise be difficult to obtain for an overseas theater of operations.

This covers briefly what our experience was in Korea specialty centers,insofar as location, distribution, and facilities are concerned.I have purposely omitted any mention of what our requirements werein this field. I know rather well what the requirements were, but the questionis almost an idle one. We had everything that our painfully restrictivetroop ceiling would allow, or that military resources of professional manpowercould staff. It is impossible to make sense out of a discussion of minimumrequirements or optimum allocations of specialty personnel and professionalservice detachments without bringing up for background the matter of themedical troop basis as a whole. Troop ceilings are heartlessly inflexible.If we deem it essential to have another hospital, or several more specialtydetachments, we must decide at the same time who is not essential-whichindividual positions will be declared vacant or which units will be inactivatedto create the personnel spaces for the units we propose to add.

Recommended Future Allocation of Combat Support Medical Units

In order to facilitate the comparison of what we actually had in Koreawith what we considered to be the requirements for the war there, and inorder to bring the recommendations for future allocation in line with thenormal military service school pattern, I have projected the troop basisfigures of Eighth Army to a purely theoretical figure representing whatwe would have had if Eighth Army had been

Table 1. Medical Troop Basis

Unit	Type field army	Comparative projection Eighth Army-Korea	Recommended practical figure
Group Hq.	3	1	3
Battalion Hq.	9	4	6
Ambulance Co.	15	9	12
Clearing Co.	9	4	5
Holding Co.	3	2	4
Litter Co.	3	1	3
Surg. Hosp.	12	12	12
Evac. Hosp. (400-bed)	12	4	6
Evac. Hosp. (750-bed)	3	----	2
Conv. Hosp.	3	----	1
Hcptr. Amb. Co.	(?)	1	4
Army Med. Comd.	(?)	----	1
Laboratory	1	1	1
Depot	1	1	1
Prev. Med. Co.	3	3	3
Gen. Disp.	8	4	6
Med. Det.	20	16	16
Dent. Svc. Det.	8	4	6
Psych. Det.	4	2	3
Prof. Svc. Hq.	1	----	----
Surg. Det.	24	----	(?)
Neurosurg. Det.	3	3	4
Orth. Det.	6	----	----
Thor. Surg. Det.	6	----	----
Max-Fac. Det.	3	----	----
Shock Det.	12	----	----

a type field army, fighting the war at that that time in Korea.The type field army, you may recall, consists of three corps, of four divisionseach, with certain non-divisional combat and service troops. Eighth Armydid have three U. S. corps, but only six U. S. divisions, plus a numberof United Nations units, and the corps and divisions of the Republic ofKorea Army. In making my projection I have attempted to allow forboth the unfavorable and the favorable factors in our situation in Korea:the dispersion of the six United States divisions across the front, theready availability of air and sea transportation to a fixed base in Japan,planned operations, and the practical limitations on personnel that wouldstill be applicable even if Eighth Army had been brought to full 12-divisionstrength. Since my methods of making these allowances are purely personal(meaning both subjective and private), the projected figure (table 1) servesan added purpose of preserving the security of the military informationpertaining to the details of the Eighth Army medical troop basis, beyondthat which can be readily extracted from press releases.

In making my recommendations for the allocation of combat support medicalunits in the future I propose a medical troop basis noticeably slimmerthan that of the present type field army, but well above what we had inKorea. On my troop basis (table 1) I have called this a recommended practicalfigure. It is definitely not the optimum; I am not optimisticas to what cut we can get out of the national manpower pool, and what proportionthe service troops can get under the bulk troop ceiling given to a theatercommander. It is not a liberal estimate; it approaches austerity and appliesthe economies which appear attainable through applications in advancesin the field of transportation. It is well above what Eighth Army had,but I have no hesitation in saying that Eighth Army did not have enoughmedical units to support a drive (as distinguished from a race)to the Yalu.

In units to administer, control and support the various elements ofthe Eighth Army Medical Service we were woefully lacking. It took 6 daysof hard driving, 16 to 18 hours a day, for the commander of the singlemedical group to visit his unit commanders and spend only a few minuteswith each of them, personally looking into their needs and problems. Thisobviously did not contribute to the rendering of the most prompt and mostefficient support; there is no substitute for continuous first-hand informationand direct contact.

We needed several more group and battalion headquarters. And I believewe proved the need for a new addition to medical Tables of Organization:an Army Medical Command, headed by the Army Surgeon himself, and operatingall of the units of the Field Army Medical Service-hospitals, service units,professional detachments and evacuation elements. The present arrangement-aninfinite multitude of individual units directly under the Army Commander,with "operational control" released to the Army Surgeon-weakensboth command and control.

Many of the ambulance units we had in Korea sat idle (except for training)much of the time in 1952 and 1953. However, they were idle only at thesame time that combat troops were sitting idle in their bunkers or in reservepositions. The several flare-ups of tactical activity repeatedly and clearlydemonstrated that our ambulance lift was actually marginal for the supportof any widespread tactical activity even on our geographically stable front.Planning analyses made it plain that in the event of an advance againstsustained resistance we would outrun our ambulance support before we hadgone 40 miles. I emphasize the question of sustained resistance; a dramaticsweep after breakthrough is not particularly productive of casualties requiringthe long haul back.

We did have a sufficient number of surgical hospitals in Korea. We maintaineda sufficient number of holding units for the existing situa-

tion, but we had almost no flexibility or reserve with which to supportan advancing front. We were able to maintain our number of holding unitsby utilizing platoons of separate clearing companies, cut down in professionalpersonnel actually to the status of holding sections. This increased theload on the evacuation hospitals, since the holding installations couldnot efficiently carry out the normal function of a separate clearing company-thatof providing clearing station support to non-divisional troops. An activeenemy air force, guided missiles and nuclear weapons may subject corpsand army troops to a much higher proportion of casualties than sustainedin the past, but I still feel that we can do all right with half the numberof clearing companies now allocated to the type field army.

The extent to which we channeled aur evacuation through Seoul in thelatter part of the war is undesirable in pripciple. It was due to the specialconditions that pertained at the time, both permissive and restrictive.It represented both a calculated risk and the best we could do under thecircumstances.

Evacuation centers are not recognized by a specific Table of Organization,but they will inevitably develop as essential features of both the combatzone and the communications zone. Because of its capacity and relativeimmobility, the 750-bed evacuation hospital is ideal for this role in thecombat zone. With the need for dispersion of logistic facilities for protectionagainst enemy air and atomic attack, with the flexibility of air evacuation,and with a figure of only two of the 750-bed hospitals in the field army,the smaller, semi-mobile (400-bed) evacuation hospital may well be utilizedfrom time to time as the nucleus of an evacuation center.

The larger hospital is by far the more economical of the two in theuse of professional personnel, and for this reason, along with the largerbed capacity, it can be just as appropriately considered for use as a treatmentcenter as in evacuation. A vast number of short-term patients of varioustypes were lost from Eighth Army for periods of time far disproportionateto the severity of their disease or injury. It was a common lament of unitcommanders that: "I sent my first sergeant down to the clearing stationwith a touch of flu. Instead of getting him back in a few days I got apostcard from him in Japan, saying he would be back in a couple of weeks."And that did happen. A sudden influx of casualties, and we had to clearout everything to make room. In the mind of the unit commander, the MedicalService gets all the credit for inefficiency and all the blame for timespent in the replacement system. The consultations and work-ups, the simplemedical illnesses and the minor wounds-all could have been taken care ofin the army area if bed space had been available. A single 750-bed evacuationhospital, possibly operating in conjunction with

a convalescent center, could have retained in Eighth Army a vast portionof the patients we sent out to the Korean communications zone and to Japanin 1952 and 1953. With joint planning and close coordination between theArmy Surgeon and the Army G-1, patients of this type returning to dutycan be shipped directly from the hospital to their combat organizationand be back on the line in 1 to 3 days after discharge.

Such use of the evacuation hospital is appropriate under conditionsof reasonable geographic stability, either with or without heavy casualtyincidence along the battle line. When casualties are heavy it will be evenmore important to see that the minor wounded and sick are not siphonedout of the army area by the rush of casualties to the rear.

I have explained that the "recommended practical figure" onthe table is not an optimum or a liberal estimate. You will not that thefigure I propose for evacuation hospitals gives only half the number presentlyconsidered proper for the type field army. The normal allocation is onesemi-mobile (400-bed) hospital per division, and one 750-bed hospital percorps. This would mean that on a moving front a single hospital is frequentlyin close support of two divisions-every time its neighbor is in the processof moving. With half this number of hospitals, one 400-bed hospital willoften be required to render the close support to all four divisions ofthe corps. This is just about as thin as we can cut it. The 750-bed hospitalwill have to be placed well forward before an attack, and kept well forwardin an advance. It will then have little opportunity to hold patients forany considerable period of time.

Using the map of Korea and the battle line of 1952, figure 3 shows howwe might use these eight evacuation hospitals. Here we have two field armiesabreast, planning the drive to the Yalu, but uncertain whether a stillangry, still active and still powerful enemy will beat them to the punch.

I have no question or comment on the allocation or capabilities of laboratory,supply and preventive medicine units in Korea, or for the type field army.

Our area medical service in Eighth Army is adequate, using theadjective in the sense of reserved approbation. The whole area medicalservice concept needs revision, but if we must have it in accordance withpresent doctrine, the one we had in Korea was good.

In active combat, three or four psychiatric detachments shouldbe sufficient. One can do the highly specialized work in a center in thearmy rear area; the others will work well forward in the corps zone, caringfor the common battle anxiety cases. The medical holding company a betterbase for the detachment than is the clearing company.

FIGURE3.

It is more economical in personnel and transportation. Theater specialauthorizations will have to provide some extra facilities for the specializeddetachment in the rear. A few Jamesway huts will probably be the mobileequivalent of the semi-permanent construction we provided for the unitin Seoul.

The rather long list of surgical professional service detachments waspoorly represented in Korea, and is not prominent in my recommendationsfor the future. We did not use the orthopedic, thoracic,maxillofacial or shock detachments in Korea for reasons thatwill continue to be valid in the future. And that means reasons besideslimited authorized personnel spaces and actual available professional manpower.If we had desired them, we would have whittled out the relatively few spacessuch units require, and we could have designated from our personnel rostersthe qualified specialists to fill most of them.

But, professionally speaking, where in the field army are we going touse an orthopedic detachment? The initial treatment of fractures,particularly under field conditions, is not classical or specialty orthopedics.The fact that a battle wound involves osseous tissue does not make it anorthopedic case until the time comes for reparative or reconstructive surgery.How would we dispose these detachments? If we have only a few across thefront, what will be the criteria for

selection of patients to be shuttled to them? If we are to have oneteam per surgical hospital, why not add the orthopedist to the Table ofOrganization? Why not? Because he is not needed there as an orthopedicsurgeon. The surgical hospitals can readily use men well qualified in primaryMOS 3153, and so we did in Korea. They are good military surgeons, andcan débride and cast a major extremity wound just as well if itis without fracture as they can if it includes a shattered joint.

Thoracic surgical detachments? Again-why? Relatively few chestwounds require thoracotomy. Must we transfer the patient to a chest teamwhen he begins to deteriorate under appropriate conservative management?If we do we will lose more patients than we save. And it does not requirea specialist in thoracic surgery to open the chest, to clamp and tie, orto débride or resect a destroyed lobe. The answer lies in the trainingof the military general surgeon. A thoracic surgical detachment may wellbe used in selected hospitals of the communications zone (it does takea specialist to do a good decortication); but it has no place in the fieldarmy.

The shock detachment is an anachronism. The treatment of shockis a basic function of all medical officers in field medical units. Whena hospital is swamped with shock cases it needs another hospital, not ashock team.

I cannot be so dogmatic about the maxillofacial detachment. Perhapsone or two might be used within the army area, depending on the helicopterto bring in, still alive, the patients who need true specialist care inthis field. I think as good an answer is that of concerted liaison, coordinationand study on the part of the surgical hospital surgeon and selected dentalofficers of the supported division.

The neurosurgical detachment? Yes. We can train the general surgeonto render an effective professional performance on any type of battle wound,but he will still prefer to unload the major head cases and paraplegicson a neurosurgeon. These patients can be picked from the casualty streamwith ease-the diagnosis is usually evident. They carry a dramatic appealthat almost always assures them a helicopter ride, no matter who else getsleft behind. The number of locations for neurosurgical teams can, in fact,be decided on the basis of practical helicopter radius of the machinesavailable. I would choose to allocate one detachment per corps, plus onefor some evacuation center in the army rear. This latter is not essential.There is nothing really wrong about evacuating a patient forward toa neurosurgeon, though it was interesting in Korea to see a patient flownall the way up to a gravel strip a few miles from the front-after he felldown the hatch of a ship in Pusan.

The internal organization and equipment of the neurosurgical detachmentI leave to Colonel Hayes. He worked both as a neurosurgical detachmentcommander, attached to a hospital, and as commander of a hospital, withan attached neurosurgical team.

As to the development of the neurosurgical teams, I feel that the evacuationhospital may be a more appropriate place in the future than the surgicalhospital. In Korea our evacuation hospitals were necessarily too far tothe rear to make this feasible during active operations, though I notethat it has been done in Korea since the armistice. With any reasonableallocation of evacuation hospitals, and a helicopter system as good orbetter than we had in Korea, the evacuation hospital would offer the neurosurgicalteam and its patients more stability and better facilities, and the evacuationtime to the team would not be increased to any noticeably detrimental degree.

The question of the general surgical detachment I wouldlike to leave open. I have not indicated a recommended figure for futureuse, but I mean differently by that than I did in the deliberate deletionof the other surgical detachments. We did not use these teams in Korea.We organized, but seldom used, provisional teams from one hospital to goover and help another. I find it much simpler, and professionally better,to move the excess patients over to an available hospital than to movea team into a hospital that is overworked. The preoperative, operativeand postoperative elements of the surgical hospital are balanced. The wardscan take care of what surgery puts out, and not much more. Diversion ofpatients or relocation of another hospital appears preferable to addinga team. But I do not wish to be adamant on this point. The surgical teamoffers a prospect of flexibility, reinforcement and rest to an overworkedunit that is appealing. Total war with heavy damage to the civil populaceand civil institutions will certainly increase the need for them.

Certain of the specialty centers we had in Korea, notably the renalinsufficiency center and the hemorrhagic fever center, do not appear onthe troop list, either as standard or recommended Tables of Organization.I doubt if we could, or should attempt to standardize the renal insufficiencyunit. We did work up, ready for publication, a proposed Table of Distributionand Table of Allowances for the team in Korea, but I feel that a unit ofthis type demands greater flexibility, and will show faster evolution,than even continuous revision of fixed tables can provide.

We will not always have hemorrhagic fever, but it is fair to state thatthe field army will always have a need for something we may call an "Epidemic(or Seasonal) Disease Center," whether the epidemic be self-inflictedwounds, venereal disease, cold injury, or something more exotic. This centerwill be founded on one of the standard

organizations, with individual items of equipment, blocks of personnel,and physical facilities provided as indicated.

I would like to summarize in closing:

1. Evacuation centers are just as important in combat zone medical serviceas are base depots in the supply system. The necessity for dispersion,or other special requirements of the combat at hand, may alter their number,facilities and disposition. They can be readily tailored out of the standardelements of the field army medical troop list.

2. Doctrine pertaining to the mission, allocation and use of psychiatricdetatchments needs little, if any, change at this time.

3. Medical and surgical specialty centers will continue to be essentialand prominent features of field medical service. Personnel restrictions-relativein a limited campaign, absolute in all-out war-demand their use. Considerationsof quality of professional work would demand their use even if personnelshortage did not.

4. Very few of the specialty centers should be established in Tablesof Organization. They should be developed to fit the situation. This canbe done if we continue present policy in the United States Army of givingthe theater commander a free hand.

5. The requirements by type and number of professional personnel andprofessional service detachments, and the disposition and utilization ofspecialty centers, are related to the pattern of field evacuation, whichin turn depends on the tactics and strategy, the terrain and the enemy,and the logistics and administration of the war we may fight.