Part II
THE PACIFIC AND ASIA
CHAPTER XI
Pacific Ocean Areas
John B. Flick, M.D., Forrester Raine, M.D., and RobertCrawford Robertson, M.D.
Prior to August 1944, the Pacific theater of war was dividedinto three parts: SWPA (the Southwest Pacific Area), SPA (the South PacificArea), and CPA (the Central Pacific Area). Each of these areas had its U.S. Armycomponent. In SWPA, there were USAFFE (the U.S. Army Forces in the Far East) andUSASOS (the U.S. Army Services of Supply). In CPA, the Army component was known asUSAFICPA (the U.S. Army Forces in the Central Pacific Area)and in the SPA, as USAFISPA (the U.S. Army Forces in the South Pacific Area).Overall command of the areas encompassed by CPA and SPA was placed upon Adm.Chester L. Nimitz, U.S. Navy, whose headquarters was known as CinCPOA (Commanderin Chief, Pacific Ocean Areas). This command corresponded to that of GeneralHeadquarters, SWPA, with its commander in chief, General of the Army DouglasMacArthur, U.S. Army.
SURGICAL CONSULTANTS
Col. Wm. Barclay Parsons, MC, was Consultant inSurgery, Office of the Chief Surgeon, USASOS, SWPA, and Col. Ashley W.Oughterson, MC, Consultant in Surgery, Surgery Section, USAFISPA. Both were on afull-time basis. Col. Forrester Raine, MC, was surgical consultant in USAFICPA,in addition to his duties as Chief, Surgical Service, 147th General Hospital, onthe outskirts of Honolulu. Also in the Central Pacific Area, functioning asconsultants in addition to other duties, were Col. Robert Crawford Robertson,MC, Consultant in Orthopedics, and Lt. Col. Leslie M. Garrett, MC, Consultant inRoentgenology. Colonel Robertson was Chief, Orthopedic Section, 219th GeneralHospital, Oahu, T.H., and Colonel Garrett, Chief, RoentgenologicalService, 218th General Hospital, Fort Shafter, Oahu.
USAFPOA (the U.S. Army Forces, Pacific Ocean Areas) was setup as an administrative overall command in approximately August 1944 to comparewith that of CinCPOA. At that time, USAFISPA and USAFICPA were reducedto the level of base commands under the jurisdiction of the USAFPOA. At the sametime, the area then known as the "forward area"-the Marianas group ofislands and, subsequently, Ulithi, Angaur, and Iwo Jima-became the WesternPacific Base Command. During the Ryukyu Islands campaign, Okinawa, Ie-jima, andadjacent smaller islands were under the jurisdiction of the USAFPOA. Later, inJune 1945, the USAFPOA became USAFMIDPAC
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(the U.S. Army Forces, Middle Pacific), a subordinate commandunder the overall Army command, AFPAC (Army Forces, Pacific).
When the USAFISPA became a base command, Colonel Oughtersonwas placed on temporary duty at the Surgeon's Office, Headquarters, USAFPOA,as full-time Consultant in Surgery. Colonel Oughterson served in this capacityfrom August 1944 to December 1944, when he went to the Philippines. In February1945, Colonel Oughterson returned from the Philippines, was assigned to theWestern Pacific Base Command, and became Consultant in Surgery there. Heremained until June 1945, when he was ordered to the Medical Section, GeneralHeadquarters, AFPAC, as Director of Research and Consultant in Surgery.
FIGURE 228.-Col. John B. Flick, MC.
The Tenth U.S. Army, whose headquarters and some of whose medical units had been staged on the island of Oahu, T.H., subsequently was sent to Okinawa. This army had the following consultants in the field of surgery: Col. George G. Finney, MC, Consultant in General Surgery, Lt. Col. (later Col.) Harold A. Sofield, MC, Consultant in Orthopedic Surgery, and, after arrival in Okinawa, Lt. Col. (later Col.) Douglas B. Kendrick, Jr., MC, Consultant on Whole Blood and Shock.
Col. John B. Flick, MC (fig. 228), became Consultant inSurgery, USAFPOA, on 1 April 1945. At this time, the surgical consultants wereColonel Oughterson for Western Pacific Base Command, Lt. Col. (later Col.) Willis J. Potts, MC, for South Pacific Base Command, bothon a full-timeduty basis, and Colonel Raine for Central Pacific Base Command, on a part-timeduty basis.
Colonel Robertson became full-time Consultant in Orthopedics,USAFPOA, on 31 May 1945.
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In May 1945, Lt. Col. (later Col.) Edward J. Ottenheimer, MC, replaced Colonel Oughterson as Consultant in Surgery, Western Pacific Base Command, in addition to his duties as Chief, Surgical Service, 148th General Hospital, Saipan. It was obvious, however, that it was impossible for Colonel Ottenheimer to function satisfactorily in either position in this dual capacity. In mid-July 1945, Colonel Ottenheimer was appointed Consultant in Surgery, Office of the Surgeon, Western Pacific Base Command, on a full-time basis despite the fact that he could ill be spared from the 148th General Hospital. Upon the cessation of hostilities, Colonel Ottenheimer was called to Headquarters, USAFPOA, to supervise the writing of the medical history of USAFPOA and USAFMIDPAC.
Prior to 1 April 1945, the surgical consultants to theSurgeon, USAFPOA, were on temporary duty from general hospitals with theexception of Colonel Oughterson, who was on temporary duty from Headquarters,South Pacific Base Command. It was not until 29 May 1945 that the allotment forofficers in the Surgeon's Office, USAFPOA, was increased from 17 to 47, whichenabled the assignment of the requisite number of professional consultants. Theprofessional consultants in the Surgeon's Office, Western Pacific Base Commandand Central Pacific Base Command, were on temporary duty from general hospitals.This policy made little difference in the Central Pacific Base Command (fig.229) which was so located that the professional consultants in the Surgeon'sOffice, USAFPOA, were available for advice, and the pressure
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FIGURE 230.-The 76th Field Hospital, Okinawa, Ryukyu Islands, June 1945.
of work was not so great as in the more forward areas. In the Western Pacific Base Command, however, the need for a full-time consultant in surgery was great and urgent during the fighting for Iwo Jima and Okinawa (fig. 230). The great distances to be covered in the Pacific and the need for close observation of the hospitals doing a large volume of surgical work made it imperative that a surgical consultant be appointed on a full-time basis there. Constant watchfulness of practices in caring for casualties and in their evacuation to areas further back was necessary. The surgical consultant at Headquarters, USAFPOA, acted in an advisory capacity and in liaison to the Surgeon, USAFPOA. It fell to the lot of the base command surgical consultant to follow recommendations made, and to see that policy was carried out.
The policy of using Medical Corps officers from generalhospitals for part-time or full-time service on temporary duty at variousheadquarters deprived the hospitals involved of the services of an officer,usually one of outstanding professional ability. Since there was a shortage ofspecialists throughout USAFPOA, these officers on temporary duty could not bereplaced in the hospitals to which they were assigned from a professionalstandpoint; neither could they be replaced numerically, because of the rigidityof the tables of organization. Furthermore, this practice interfered withpromotions.
DUTIES OF THE CONSULTANT
It was evident from the start that the duties of the consultant encompassed more than strictly professional work. The quality of surgery depended upon many factors, but the most important were the proficiency and distribution
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of personnel. Also of importance were the indoctrination ofmedical officers in the methods and policies of military surgery, the checkingof equipment, and the clinical supervision of work in the hospitals. Inaddition, the consultants acted as technical advisers to the theater surgeon.Not the least of the consultants' duties was to listen with a sympathetic earto the problems of their fellow medical officers serving in the Armed Forces.
Liaison between the Army, Navy, and Army Air Forces left much to be desired. This was evidenced inmany ways, but particularly in the evacuation of casualties. On one occasion, orders for the surgicalconsultant to visit the Marianas Islands forbade him to visit AdvanceHeadquarters, CinCPAC (Commander-in-Chief, Pacific), during the period oftemporary duty. This occurred at a time when several joint problems had become acute. Despite orders tothecontrary, conditions made possible a visit to CinCPAC advanceheadquarters, and in justice it must be said that the surgical consultantwas received and the joint problems were discussed.
Unless the consultant gained the confidence andreceived the wholehearted cooperation and support of the theater surgeon,his duties were futile.
PERSONNEL
Shortage of Medical Corps OfficersAlmost throughout the war, the strength of professionallyqualified Medical Corps officers in POA was inadequate to the needs for thehigh type of professional work which was the goal of all concerned. It wasonly by extending efforts almost to the breaking point of the individual duringcertain periods that the goal was attained. The tables oforganization of numbered general hospitals were inadequate for the type andvolume of work demanded for the care of casualties in the operations in POA. Forexample, it was necessary in the forward areas for all hospitals to maintain aperimeter guard against enemy infiltration of the hospital site with theorganically assigned personnel at hand. This was true in the Marianas until V-J Day. On those islands where Armypersonnel were admitted to Navyhospitals, the burden of preparing the payrolls, providing the clothing,recopying the admission and disposition forms, profiling, and so forth, ofthese patients fell to the lot of the nearby Army hospitals on whoserolls they were administratively carried. On 27 July 1945, the 204th GeneralHospital, Oahu, was responsible, from the administrative standpoint, for 934Army patients in Navy hospitals on Guam. At the same time, there were 1,908patients occupying beds in the 204th General Hospital. The burden was toogreat for the tired staff of the 204th General Hospital. The matter waspresented to the Chief of Staff, Western Pacific Base Command, and it wassuggested that a team be organized with qualified personnel taken from eachhospital in the Marianas and attached to Headquarters, Army GarrisonForces, Guam, to relieve the 204th General Hospital of this administrativeburden. This was done. Had similar personnel for
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guard, finance, refrigeration maintenance, and the like, beenfurnished, as planned, the problems would have been solved.
The number of Medical Corps officers authorized for numberedgeneral hospitals was particularly inadequate for the workloads imposed duringactive operations against the enemy. Ultimately, this was corrected in part byaugmenting these hospitals with special teams, but this did not take place untilthe Ryukyu Islands campaign was almost completed. Eleven special teams arrivedin the Marianas Islands and three in Oahu during the month of June 1945. In themeantime, the staffs of busy hospitals were reinforced with medical officersfrom the staffs of hospitals less busy. Medical Corps officers from Army AirForces medical treatment facilities, from Navy hospitals, and from ships inharbor were pressed into service. Teams were organized on the spot, sometimescomposed of Army, Navy, and Army Air Forces medical officers. Their serviceswere invaluable. In hospitals predominantly surgical, the internists becamemembers of shock teams and surgical ward officers.
The actual number of Medical Corps officers in POA was closeto the authorized allotment, but there was a shortage of specialists. This wasno doubt due chiefly to a shortage at the source of supply on the mainland, but,in part, the shortage was due to factors that crept in during the early days ofthe Pacific campaigns and that later were difficult to correct. The theory thata Medical Corps officer should be able to serve in any capacity had no smallpart to do with the shortage. This theory was definitely disproved to all as thewar progressed, but, in the meantime, position vacancies were filled withofficers not professionally qualified for the positions to which they wereassigned and were given job classifications instead of professional proficiencyclassifications. Such practices created a problem which was difficult to solve.The rigidity of tables of organizations, the problems of rank and precedence,and a confusing chain of command added to personal troubles. There were no pools of Medical Corps officers from which to draw. There was a shortage ofspecialists on the basis of authorized strength in every category. There was norapid method of requisitioning and securing personnel urgently needed.
A study of the rosters of all professional units in theUSAFPOA made in June 1945 showed shortages of specialists on the basis ofauthorized tables of organization as follows:
| Shortage |
3105 Gastroenterologist | 7 |
3107 Cardiologist | 12 |
3113 Allergist | 12 |
3303 Medical Laboratory Officer | 17 |
3306 Radiologist | 16 |
3151 Thoracic Surgeon | 2 |
3131Neurosurgeon | 12 |
3152 Plastic Surgeon | 3 |
3153 Orthopedic Surgeon | 13 |
3106 Opthalmologist & Otorhinolaryngologist | 28 |
3125 Ophthalmologist | 2 |
3115 Anesthetist | 28 |
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There appeared to be an overage of officers classified"3150, Medical Officer, General Surgery," but this was only apparentand not real. The explanation was obvious when this group was studied. Itincluded all Medical Corps officers who had had, or claimed to have had, anytraining in surgery whatsoever. Many of these were not qualified to fillvacancies to which they had been assigned.
The study of the personnel situation that was made in June1945 by no means represented a true picture of shortages on the basis of actualneeds. A further consideration was the length of time many of the Medical Corpsofficers had served in the tropics or semitropics with consequent impairment oftheir efficiency. The needs were evident, but there was no way of meeting themat that time.
Requisitioning Medical Corps Officers
Requisitions for Medical Corps officers were made by theater units through channels. These were screened by Headquarters, Replacement Training Command, USAFPOA, and at regular intervals were sent by that headquarters to the War Department. Medical officers with a classification "3100, Medical Officer, General Duty," were being used to fill specialist vacancies, and additional officers with the "3100" classification were being requisitioned by units. Seldom were specialists in any other category requisitioned by units. The theater surgeon could only advise; he could not screen requisitions. Therefore, he could not correct deficiencies in the flow of personnel from the mainland.
It was not until the summer of 1945 that the professionalconsultants were able to screen requisitions for Medical Corps officers andadvise the Medical Section, Headquarters, Replacement Training Command,concerning them. At that time, 30 officers with the classification"3100" had been requisitioned by theater units. It was known thatthere existed an overage of officers classified "3100" and a shortageof officers classified as specialists. Thereupon, it was agreed to requisition30 specialists and, when they arrived, to assign them to hospitals wherespecialist shortages existed in exchange for officers who were classified"3100."
Classifying Medical Corps Officers
The classification coding of all Medical Corps officers in USAFPOA was begun toward the end of 1944 and was continued through the winter of 1945. Classification and coding were done principally by evaluation on the basis of questionnaires. Later, officers were reevaluated after personal contact and observation of their work. It was not uncommon to find that several classifications had been entered on the qualification record of an officer in accordance with the position that the officer held at the time of recording. Finally, revaluation on the basis of personal observation by the consultants led to many changes in classification and to the transfer of officers and brought to
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light the fact that the shortage of specialists was evengreater than that which appeared in the initial study of the situation.
In compliance with a letter directive, dated 1 July 1945,from Brig. Gen. B. M. Fitch, by command of General Douglas MacArthur, tocommanding generals in AFPAC, concerning Classification of Medical CorpsOfficers, a new classification survey was made. This consisted of thecompletion of a new WD AGO Form 178-2 and AFPAC MD Form No. 1 on eachmedical officer. The base command consultants and the USAFMIDPAC consultantsrecommended a classification by indorsement on each form. Finalclassification was determined by General Headquarters, AFPAC.
Surveys in Relation to Rotation
As early as the first week in July 1945, a survey of Medical Corps officers in the Middle Pacific from the standpoint of their service rating scores was completed. This was done in order to envision losses and prepare for reorganization when the announcement of a given "critical score" would permit many medical officers to rotate home. In August the survey was repeated, with consideration of three additional factors: age, length of service overseas, and length of total service-all of which had a bearing in determining "adjusted" service rating scores for rotation.
Personnel of Medical Units in Transit
The professional consultants of Central Pacific Base Command and USAFPOA (later USAFMidPac) inspected all medical units passing through Oahu from the standpoint of professional proficiency of the staff and adequacy of equipment. If necessary, replacements were made with Medical Corps officers taken from hospitals or other medical organizations within the Central Pacific Base Command or other base commands. This arrangement was far from satisfactory since it weakened base command units. But replacements could not be secured from the mainland without great delay, and it was imperative to send units forward with at least the minimum of specialists and as good a staff as could be assembled without wrecking the staffs of the fixed installations in the communications zone. After V-E Day, certain units originally destined for the European theater were sent to the Pacific. Frequently these were short of specialists, and it was impossible to supply them from personnel already in the Pacific.
Morale
Suitable assignment was perhaps the most important single factor in maintaining good morale. A medical officer would tolerate hardships if occupied by work in which he was interested and for which he had aptitude and training. Medical conferences, journal clubs, and attendance at medical meetings all bolstered morale, as did the establishment of library facilities (fig. 231) and the circulation of medical journals. Joint medical meetings
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FIGURE 231.-Medical Library, 39th General Hospital, Saipan, 1945.
of Army and Navy medical officers were held on most islands. The programs usually were well thought out and excellent. Consultants participated whenever possible. The oversea installations were adequately supplied with medical textbooks and journals. However, facilities for a library and conference room were not always created.
Living conditions and recreational facilities varied greatlyin each hospital and on each island (fig. 232). Housing, recreationalfacilities, and clubs were of prime importance on small islands inuncomfortable climates. It was evident that these things influenced the moraleof personnel. Military necessity-the construction of essential militaryprojects-was the reason given for not obtaining these facilities where theydid not exist.
On Guam at the 204th General Hospital, thequarters in which the officers lived were crowded; because of shortage ofpersonnel, there was no charge of quarters on duty; there were fewrecreational facilities; and there was no club. The comparison with Navyfacilities on the same island made these deficiencies stand out sharplyin contrast.
In some instances, notably on Saipan, medical officers werehoused in relatively primitive quarters and hospital constructionhad not been completed. These factors played an adverse role from the moralestandpoint of medical personnel.
In personal notes taken by the surgical consultant, herecorded that long periods overseas without any definite knowledge asto their prospects of being replaced was influencing the moraleof medical officers.
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FIGURE 232.-Continued. C. The library of the 129th Station Hospital, Hawaii, 1944.
Promotions and Rank
It was sometimes necessary to transfer officers who merited promotion because of their training and experience and for whom there were no position vacancies on the staffs of the hospitals to which they were assigned. This was particularly true of personnel in affiliated units. The assignment to hospitals of medical officers who had attained relatively high rank in line organizations but who had not had training or experience to equip them to head services or sections in hospitals remained a problem throughout the war. No satisfactory solution as to their use was found, and they continued to block the promotions of those more professionally proficient.
EDUCATION AND TRAINING
Indoctrination of Units in StagingThe medical units on the Hawaiian Islands, assigned orultimately to be assigned to the Tenth U.S. Army, were given instructions bythe consultants of USAFPOA as well as by the consultants of the TenthU.S. Army. This was accomplished by informal talks and demonstrations on surgeryin the combat zone (fig. 233). In addition, teams were organized from generalhospi-
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FIGURE 233.-An exhibit, for instruction purposes, of an operating room set up in the field, Hawaii.
tals staging at Oahu and went forward to augment the staffs of field hospitals designated for the assault phase of the Okinawa operation. At this time, no teams were available from the Zone of Interior.
School of Anesthesia
There was a shortage of medical officer anesthesiologists throughout USAFPOA. The shortage in this specialty was as great as, if not greater than, in any other. It was felt by this surgical consultant that every hospital at which surgery was being performed should have assigned a medical officer trained in anesthesia and put in charge of the operating room and anesthesia section. Toward this end, the first school of anesthesia was established at the 148th General Hospital on Saipan in June 1945. Instruction was carried out under the direction of the consultant in anesthesiology from the Surgeon's Office, USAFPOA. Students for the course were obtained from the 23d Replacement Depot, 8th Convalescent Hospital, and from surgical specialty teams whose officers assigned to anesthesia had had little or no formal training in this specialty.
It was felt by the surgical consultant that too littleemphasis had been placed on the importance of anesthesia for the managementof battle casualties
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in USAFPOA, especially in the forward areas. In most hospitals, nurses with some training in anesthesia were in charge of the anesthesia section (fig. 234). These, however, had had little or no training in endotracheal anesthesia, and did not have the necessary knowledge of physiology and pharmacology to direct difficult anesthesias such as in thoracic surgery and neurosurgery.
Because of the shortage of anesthesiologists, nurseanesthetists were obliged to administer spinal and intravenous anesthetics.
CENTERS FOR SPECIALIZED TREATMENT
On Oahu, the 147th General Hospital was designated as a center for thoracic surgery and the 218th General Hospital, for neurosurgery. The former had a thoracic surgeon and the latter a neurosurgeon on the staff. During the Okinawa operation attempts initially were made to admit all fractures of the femur to the 147th General Hospital. This plan was abandoned because the burden became too great for the staff of a single general hospital to handle.
In June 1945, preparation was made for fabrication ofartificial eyes at the 218th General Hospital. The necessary personnel hadalready been trained
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on the mainland. On 3 July, a directive was published concerning the artificial eye program directing that patients throughout USAFMIDPAC be transferred to the Central Pacific Base Command (218th General Hospital) for custom-made final prosthesis (fig. 235). Certain other hospitals in USAFMIDPAC were designated for ophthalmic surgery and were supplied with conformers for use following eye enucleations. These were the 148th General Hospital, Saipan; 204th General Hospital, Guam; 232d General Hospital, Iwo Jima, Volcano Islands; 233d General Hospital, Okinawa; and the 374th General Hospital, Tinian. The shortage of ophthalmic surgeons made it necessary to limit the number of hospitals designated for this type of work.
During the Okinawa operation, triage was accomplished at the ports of debarkation on SaipanIsland, Marianas Islands, and, as far aspossible, patients requiring specialized surgery were sent to those hospitalsdesignated for the purpose (fig. 236). The scarcity of specialists in certaincategories made this imperative. Thus, during the early part of the Okinawaoperation, the 148th General Hospital received all patients arriving in Saipanwith thoracic wounds (fig. 237) and wounds involving the brain and spinalcord. The cases of peripheral nerve injuries were too numerous to assign to asingle hospital which had only one neurosurgeon on the staff. Later, when the 39thGeneral Hospital, Saipan (fig. 238), was functioning, it wasdesignated as the island neurosurgical center and a center for burns, and the148th General Hospital remained the center for thoracic surgery. The 369thStation Hos-
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FIGURE 237.-Postoperative care of a patient after thoracic surgery, 148th General Hospital.
pital, Saipan, was utilized for battle casualties having soft-tissue wounds and for minor orthopedic conditions.
At Guam, the 204th General Hospital was designated a centerfor thoracic surgery. On this island, neurosurgical patients were sent to one ofthe Fleet hospitals until the arrival of a neurosurgical team on 15 June 1945, when they were cared for at the 204th General Hospital.
On Tinian, Army casualties were admitted to the Navy BaseHospital and to the 374th Station Hospital, there being no Army general hospitalon this island until the middle of May when the 374th Station Hospital wasdesignated a 1,000-bed general hospital. It was never possible, however,adequately to staff the 374th General Hospital from the professional standpointfor the care of battle casualties. Thoracic surgery patients arriving on Tinianwere cared for at the Navy hospital, where a thoracic surgeon was on the staff.Patients with lesions of the brain and spinal cord, if transportable, weretransferred to Saipan. This arrangement was not satisfactory, but all availablebeds were needed and had to be used. Fortunately, the number of casualtiesdebarked at Tinian was not great.
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DIRECTIVES CONCERNING PROFESSIONAL PRACTICE
Official medical publications (other than books or journals) and directives were universally scarce in USAFPOA. This was noted by The Surgeon General on his visit of inspection early in 1945. The matter was taken up in Washington, and improvement was effected. However, as late as August 1945, War Department Technical Bulletin (TB MED) 147, concerning management of battle casualties, which had been issued in March 1945, had not been distributed to Medical Corps officers in Guam and Tinian. Saipan had received an allotment of this publication and distributed it to that island only. None were left over for the other islands in the Western Pacific Base Command.
Apparently, medical publications were being sent promptly toUSAFPOA and Southwest Pacific Area, but there were deficiencies in distribution.In the case of the Southwest Pacific Area, for a number of months, initialdistribution involved mailing of publications to a number of points in thewidely dispersed area. Redistribution was, in turn, accomplished tosubsidiary facilities and units. At certain bases, such as Hollandia, Adjutant Generalpublication depots were established, but the lack ofmanpower continued to interfere with getting the publications out. This wastrue all along the lines of communications from depots to bases and to fieldarmy units.
In the case of USAFPOA prior to 1 March 1945, initialdistribution of publications was by mail from the Zone of Interior to a singleAdjutant General depot on Oahu. This depot, however, merely distributed thesepublications to the major technical services, with each service handling thedistribution of publications and forms pertaining to them. This decentralization was put intoeffect atthe request of the theater AdjutantGeneral because of lack of space, personnel, and experience by the AdjutantGeneral depot in this area. After 1 March 1945, initial distribution was bymail from the Zone of Interior to a number of bases, facilities, and units, asin SWPA. It was planned to establish a central Adjutant General depot on Oahuto take over the initial distribution within a specified area of all WarDepartment publications and forms, and the filling of requisitions from allactivities and units in the USAFPOA which had been handled on adecentralized basis. To the best knowledge of the authors, this was notaccomplished during the war. During the Okinawa operation, very fewmedical officers on Okinawa or in the Marianas had seen the aforementionedTB MED 147. A number of important directives, however, including "Surgeryin the Combat Zone," were written, reproduced, and widely distributed bythe Surgeon, USAFPOA.
The distribution of advance copies of directives to thevarious headquarters was satisfactory and kept the consultants informedconcerning the professional policies of The Surgeon General. Even thoughdirectives reached hospitals, there was no assurance that they would reach theindividual members of the staff or would be read by them. Thus, it became theresponsibility of the consultants to see that policy was carried out.
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VISITS TO HOSPITALS
The consultants made ward rounds much as a chief of service would make in a civilian hospital. Patients were examined, dressings removed, records perused, and cases discussed. Not infrequently, rounds, begun on the wards, ended in the library or laboratory. Rounds not only served to evaluate a medical officer's professional ability but to test his knowledge of policy. Every physician entering the Army needed indoctrination in Army policy concerning military surgery. Not infrequently, he would resist directives until the rationale of policy was made clear to him. He continued to be an individualist and wished to be convinced that certain procedures, which in his civilian experience were satisfactory, were not necessarily so in Army practice.
Inspection of the operating rooms, of operating-roomtechnique, of sterilizing equipment (fig. 239), of instruments, and ofoperating-room records were included in the visit. The X-raydepartments were inspected, not only in reference to equipment andquality of work but also with respect to protection of personnel from undueexposure to X-rays (fig. 240). In several hospitals, where lead sheet was notavailable, the substitution of sand-filled partitions was apractical improvisation which on test was found to be effective. Equipment forsurgery, including sterilizing apparatus, for the most part was good. This alsoapplied to anesthesia equipment. There was an ample supply of portable
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FIGURE 240.-Fluoroscopy facilities at the 148th General Hospital, Saipan, 1945.
operating-room lights. Ceiling lights for operating rooms had to be improvised and installed by hospital personnel in the majority of the facilities in the forward areas. Fluorescent tubes, usually eight in number, mounted in suitable ceiling fixtures was the most common type of ceiling light in use. Lamps removed from portable field surgical lights also were used as ceiling lights.
Air conditioning of operating rooms was an importantconsideration in the hospitals of the Marianas Islands. There, the heat was sointense in the operating rooms, usually quonset huts, that those working in themwere dehydrated and exhausted in a few hours-so much so that it was necessaryto put the operating-room personnel on a salt regimen. Air conditioning was notinstalled until toward the end of the Okinawa operation in the Army hospitals atSaipan. It had not yet been installed in the operating rooms of the hospitalson Guam and Tinian when the war ended. Air conditioning in the operating roomsof the 148th General Hospital (fig. 241) at Saipan brought the temperature downto 84? F.-cool in comparison to outside temperatures. It appeared that but fewof the engineers who were available understood the installation or maintenanceof air-conditioning units. Those installed on the outside of surgicalbuildings, exposed to the sun, stopped functioning frequently and had to beadjusted. When fresh air was brought in from the outside the heat of the airthrew too great a burden on the machines. It was necessary to recirculate theair in the building. A service team composed of members well trained in airconditioning was needed.
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THE OKINAWA OPERATION
The lack of evacuation hospitals and a shortage of well-qualified surgical specialists at Okinawa gave rise to serious difficulties in properly caring for casualties during the Okinawa operation. It was the consensus that each division should have been supported with field and evacuation hospitals and that "blown up" field hospitals did not functionally take the place of evacuation hospitals. The surgical teams did excellent work, but were too few in number. All hospital staffs were well indoctrinated in the use of blood (fig. 242). Shock was well managed by teams organized from among available internists and they did valuable work. Tents which were equipped to deal with shock and to prepare patients for operation were set up in close proximity to the surgical operating tents. Equipment included oxygen apparatus, materials for blood determinations by the copper sulphate specific-gravity method, and the Levin type of stomach tube as well as the usual materials for the emergency care of the wounded. A Levin tube was introduced in all patients with suspected penetrating wounds of the abdominal cavity. Priority for operation was established for casualties urgently in need of it by those in attendance in the "shock tent."
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Several patients with vascular wounds were seen whose amputations should have been performed earlier than they had been. The fault may have been due to failure to observe patients closely enough following ligation of vessels, to depending too much upon the efficacy of sympathectomy or parasympathetic nerve block, or to an effort to save a few additional inches of an extremity. One such patient was seen who went into profound shock on the sixth or seventh day, from which he died without amputation. He had had a ligation of the common femoral artery followed by lumbar sympathectomy, and the seriousness of his condition was not recognized until he was moribund.
There was considerable discussion concerning thedesirability of attempting repair of arterial injuries and the need forarterial suture material, Blakemore vitallium tubes, and heparin in thehospitals of the forward areas. It was believed by the surgical consultants,however, that more harm than good might come of it unless such work waslimited to certain hospitals staffed with surgeons trained in vascular surgeryand the work could be done on an investigative basis. Had the war continued, the establishment of centers for vascular surgery, staffed by qualifiedsurgeons, would no doubt have been recommended.
The field hospitals did not have a sufficient number oftrained anesthetists. They had an inadequate supply of anesthesia machines,suction apparatus, and oxygen therapy equipment. There was no shortage ofoxygen in large cylinders, but there was a shortage of reducing valves,flowmeters, and high-
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FIGURE 243.-Treatment at the 69th Field Hospital, Okinawa, in May 1945.
pressure tubing. It was the impression of the Consultant in Surgery, USAFPOA, that oxygen therapy should have been used more extensively in the management of shock. There were not enough reducing valves to use oxygen for many patients at the same time. The shortage was partially overcome by borrowing reducing valves from ships.
Shortages in medical equipment were due in part tolimitations imposed on the amount of shipping because of militarynecessity.
The specialized professional teams assigned for the Okinawaoperation included two general surgical, one neurosurgical, and two orthopedic teams. All of these teams were not up toauthorized strength.None of them had with them the equipment authorized for specialized teams.
A critique of the Okinawa operation stated with respect tofield hospitals (fig. 243):
Experience with field hospitals revealed incertaininstances notable deficiencies in selection of personnel and in the training ofthe unit. Insufficient attention had been paid to the professionalqualifications of officers designated for responsible positions on the medicaland surgical services. Organization and direction of the laboratory servicewas inadequate and the technical quality of the work poor. Training of thepersonnel in the operation of the unit as a hospital had been neglected. Thiswas particularly true of the organization and instruction of shockteams. Many of these deficiencies have been corrected by transfer andexchange of officers and by professional instruction on the ground.1
1The Report of Surgical, Medical, and Orthopedic Consultantsfor Operational Report of Okinawa Campaign, 30 June 1945.
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FIGURE 244.-Patients being prepared for air evacuation by converted C-54, Okinawa, July 1945.
The activity of the consultants of the Tenth U.S. Army did much to correct deficiencies. Despite criticisms herein contained, the quality of the medical service in the Okinawa operation in general was good.
During the Iwo Jima operation, casualties were evacuatedprincipally by ship to Saipan, overflowing the hospitals there and leaving bedsvacant on Guam and Tinian. During the Okinawa operation, air evacuation beganon D+8 and finally surpassed evacuation by ship (fig. 244). Planes debarked atGuam and almost none at Saipan or Tinian. At this time, the hospitals on Guamwere overwhelmed. All attempts to control evacuation of casualties in theMarianas Islands in accordance with the beds available on each island failed.This had a very definite influence on the care of the wounded and, throughfatigue, on the morale of personnel.
In a few instances consultants traveled as observers onships evacuating wounded from Okinawa to the Marianas Islands. In this way,valuable information was gained concerning treatment given casualties in theforward areas and their condition upon evacuation.
The routing of ships appeared to have been done without dueconsideration for facilities or vacant beds in the hospitals on Saipan, Guam, orTinian. Sufficient notification of the time of arrival of patients at a port wasnot given.
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In some instances, between five hundred and a thousandpatients arrived without previous notification, which led to confusion. Failurein properly "tagging" patients led to improper triage.
During the Okinawa operation, the 148th General Hospitalcared for the majority of the serious casualties brought to the island ofSaipan. The 39th General Hospital was not ready to receive patients until thecampaign was well underway. The 148th General Hospital was used exclusively asa surgical hospital and was so organized with the formation of shock,plaster, and traction teams. Surgical teams were formed with officers assignedto the staff of the 148th General Hospital, with Marine Corps and Air Forcemedical officers from local installations, and with Navy medical officers fromships in the harbor. Nine surgical operating teams worked around the clock inshifts.
As the Okinawa operation progressed and hospital beds in theMarianas became filled, the policy of retaining patients with fractures of thefemur temporarily was abandoned. Patients with compound fractures of the femurwere treated by debridement of the wounds if this had not been done, bysecondary debridement if this was indicated, by skeletal traction, and, insuitable cases, by secondary closure of the wounds 7 to 10 days after primaryor secondary debridement. Because of the need for beds, these patients, duringthe height of the campaign, were evacuated to the rearbefore the fractures were "frozen." Casts were applied, and Kirschner wires were removed beforethe patients were evacuated.
In the Marianas, circular casts were not split owing to the prevalent climatic conditionsand their instability when this was done.On the other hand, patients were not evacuated after the application ofcasts until the danger of interference with circulation was past.
The impression gained in the Marianas and at Oahu wasthat surgical patients who had arrived during the Okinawa operation had beenbetter treated and were in better condition than patients arriving during theIwo Jima operation.
In the Marianas, of necessity, battle casualties were sent tostation hospitals as well as to general hospitals. An effort was made to admitonly the less seriously wounded to station hospitals, but, on occasion, theseriousness of wounds was not recognized. This was particularly true of woundsof the buttock that had penetrated the rectum and of vascular wounds. Thelatter were not recognized until progressive extravasation of blood producednoticeable swelling in the region of the wound. The station hospitals werevisited frequently by consultants who advised on treatment and transfer ofseriously wounded patients to general hospitals. It was evident that theprofessional qualifications of staff members of station hospitals did not meetthe necessary requirements for the care of the seriously wounded. Directivesdealing with hospitalization of battle casualties were published by WesternPacific Base Command, and by the Surgeon's Office, USAFPOA, but could not befollowed always since at times the urgent need for beds demanded that thosevacant in station hospitals be utilized for battle casualties.
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During the height of the Okinawa operation, it becamenecessary to relieve medical officers in the hospitals on Saipan ofnonprofessional duties. This was accomplished by directive from the Office ofthe Surgeon, Headquarters, Island Command, Saipan. Medical officers, badlyneeded for surgical work in the operating rooms, were being given such dutiesas the censoring of mail. It was directed that officer patients convalescing inhospitals be used for this purpose; also, that property accountability andother nonprofessional duties be assigned to nonprofessional personnel.
During July and the early part of August, hospitals inthe Marianas Islands were visited by the Consultant in Surgery, USAFMIDPAC, andthe Consultant in Surgery, Western Pacific Base Command. All medicalofficers were revaluated from the standpoint of the positions to which they hadbeen assigned, and replacements, when indicated, were advised. Suggestionswere made regarding medical supplies and equipment from the standpoint of the heavyload anticipated in future operations. At this time, the hospital center at Tinian was inthe process of construction.
HOSPITAL CENTER AT TINIAN
The hospital center at Tinian comprised five 1,000-bed general hospitals. The facilities for surgery, the establishment of centers for specialized work in individual hospitals, the assignment of personnel, and the need for and requisitioning of specialists were discussed and planned in detail with the commanding officer of the hospital center. It was expected that 70 percent of the beds of the center would be devoted to surgery. The tentative plan for professional service in surgery envisioned a division of work in units as follows:
Unit 1. Neurosurgery, abdominal surgery, orthopedicsurgery, and urology.
Unit 2. Amputations, burns, general surgery, orthopedicsurgery, and urology.
Unit 3. Thoracic surgery, maxillofacial surgery, ophthalmic surgery, general surgery, orthopedic surgery, and urology.
Unit 4. Internal medicine and medical specialties, generalsurgery, orthopedic surgery, and urology.
Unit 5. Neuropsychiatry and neuropsychiatric patientsrequiring surgery.
Each hospital was designated as a center for specializedwork, and in addition-with the exception of Unit 5-would have caredfor general surgery, orthopedic surgery, and urology. The surgery performed inUnit 5 would have been limited to surgery which arose in neuropsychiatricpatients, most of which would have been in connection with self-inflicted wounds. Thisplan did not necessitate major changes in hospital staffs. Anacting director of surgery was selected. This officer was to have beenresponsible for the overall supervision of the surgical services throughout thehospitals comprising the center and in control of the surgical teams assigned to it.
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Twenty-eight surgical operating rooms would have beenavailable in the four hospitals designated for surgical work. On the basisof the Okinawa operation, it was expected that approximately 140 surgicaloperations would be performed daily when the next military operation was under way. It wasestimated that each surgical team on a 12-hourshift would average eight operations per day. On this basis, 17 surgical teams wouldhave been needed. Nine of these teams were to have been requisitioned, and eight were to havebeen organized from the staffs of the five general hospitals composing the center.Teams were to have made up for the lack of certain specialists on the hospital staffs.
Plans included a request that an Air Transport Commandliaison officer be assigned to the center on a full-time basis to facilitateevacuation of patients by air.
It was planned also that the Consultant in Anesthesiology,USAFMIDPAC, would organize the anesthesia section and remain at the centerfor the early part of the next military operation.
Work on the hospital center was discontinued with thecessation of hostilities.
NOTES AND FORMAL REPORTS
The Consultant in Surgery, USAFPOA, made daily notes concerning visits to hospitals. These were too wide in scope and often too personal to submit as formal reports, but they were the basis for formal reports. Formal reports were sent through medical channels beginning with the commanding officer of the hospital visited and ultimately reaching the Surgeon, USAFPOA. Only those things were reported formally which could not be dealt with locally, or which were informative in a general way and upon which it was felt that the base command surgeon might wish to comment by indorsement. At the end of a visit to forward areas, the personal notes of the consultant were read by and discussed with the Surgeon, USAFPOA, often with other members of the headquarters staff in conference. Thus pertinent matters observed by the consultant came to the attention of the operations, personnel, and supply officers in the Surgeon's office. These matters were dealt with at once. Not infrequently, on visits to forward areas, notes were sent directly to the Surgeon by courier. In the last month of the war, formal reports were not made. Detailed notes, however, were kept and submitted to the Surgeon upon return of the consultant from the Marianas Islands.
JOHN B. FLICK, M.D.
CENTRAL PACIFIC AREA
Examination of the situation in the Central Pacific Area in the fall of 1942 revealed that the principal problem was a dearth of trained professional personnel. There was only one other diplomate of the American Board of Surgery in the area and, in addition, over the next 3 years, only three other
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Fellows of the American College of Surgeons in generalsurgery were in the area. With this personnel, five general hospitals and ninestation hospitals had to be manned.
Since additional trained surgeons could not be expected toarrive in the area, the first important task was an appraisal of all theexisting surgical talent followed by the training of these men in order toprovide adequate surgical care of patients. All medical officers in the area whohad had as much as one year's residency training in surgery were interviewed.The medical officers of divisions training in the area were interviewed and,where it seemed desirable for the good of the service, exchanges were made toaugment somewhat the percentage of at least partially trained surgeons. Whenit was felt advisable, officers were placed on temporary duty at the 147thGeneral Hospital for a 4- to 8-week period of observation so that their surgicalskills could be more accurately determined and, in addition, so that theythemselves could have a "brush-up" period in surgery. During 1943 some10 or 12 such temporary assignments were made, and during 1944 more than 30officers were rotated through the surgical service of the 147th GeneralHospital with a view to enhancing their previous surgical training (fig. 245).Since some of the station hospitals were more than 1,000 miles from theirnearest neighbor, it is obvious that consultations on individual problems wereimpossible and that the fate of the patient rested with those who wereimmediately available.
Besides the deficiencies in trained surgical personnel, there were very few corpsmen who had been trained for operating-room duty.Since some of the smaller station hospitals were going to forward areas whereno nurses would be available, it was felt that the training of corpsmen insurgical techniques was most important. Accordingly, a training school was setup at the 147th General Hospital for corpsmen in operating-room techniques.These men were put through an intensive two months' course, and it was verygratifying, as well as surprising, to see what excellent scrub nurses they madeat the end of that period. Actual figures were not available at the time of thiswriting, but there must have been at least 50 enlisted men so trained during thecourse of the war.
The war in the Central Pacific Area was under the command ofthe Navy and at no time was there an appreciable number of fixed Army hospitalsassigned to the care of frontline casualties. This meant that virtually all thecasualties received in the general hospitals in the Hawaiian Islands arrivedthere from 2 to 4 weeks after they were wounded. This naturally posed anentirely different problem from that encountered in the North African andEuropean theaters. It was fortunate that, during early operations on the coralislands, there had been no appreciable fertilization of the ground and gasbacillus infections were virtually unknown. Furthermore, it was found thatinitial debridement could be carried out 3 weeks after wounding withsurprisingly good results. The ideal time for secondary closure of those woundswhich had been debrided was, of course, lost during the period oftransportation. But again, it was found that secondary closure could besatisfactorily accomplished at the end of 3 weeks' time instead of at theend of from 6 to 10 days.
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The percentage of complicated chest wounds was, the writer fears, considerably higher in the Central Pacific Area because aspirations of hemothorax and even pneumothorax were, as a rule, delayed for 3 or 4 weeks. This necessarily increased the number of decortications that had to be done to achieve satisfactory respiratory function. These decortications were started in the Central Pacific Area at about the same time as in the North African theater and yielded excellent results.
The type of wounds received in the Central Pacific Areadiffered materially from those in other theaters. In at least the first 2 yearsof the war, attacks were all against small coral atolls and the littleartillery the enemy had was knocked out by Naval bombardment (fig. 246). Wounds,therefore, resulted predominantly from small-caliber bullets, small-calibermortars, or hand grenades. Japanese hand grenades were much lighter andsplintered into much finer particles than did the U.S. Army grenades, so thaton the whole wounds did not show the great destruction of tissue whichtypically occurred with high explosives. This may well account for part of thereasonable results attained in spite of delayed debridement.
The technical bulletins emanating from the Office of TheSurgeon General were of the greatest assistance. They permitted personnel in theCentral Pacific to profit by the experience earned from the management of atremendous
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number of casualties without having to go through an appreciable period of trial and error themselves.
The largest number of casualties handled over a short periodof time by the Central Pacific Area general hospitals occurred following theSaipan, Guam, and Tinian battles. These casualties were evacuated from theislands by hospital ship and landed at Kwajalein for care and transshipment tothe hospitals on Oahu. These casualties numbered 2,900 during June and Julyof 1944. The small station hospital at Kwajalein was enlarged to a 1,400-bedhospital with virtually no addition of medical personnel and did an excellentjob of screening, emergency treatment, and transfer. Among these casualtieswere approximately 60 with severe chest wounds who, it was believed, could notbe evacuated safely by air at the altitudes usually flown. With the marvelouscooperation of the Air Transport Command, two planeloads of these patientswere flown to Oahu at under 4,000 feet. Since this was below the usual cloudlevel, this air evacuation was carried out without utilization of refinednavigational aids. But, happily it can be said that planes and patients arrived in good shape,none the worse for their trip.
So far as the author is aware, no new developments oroutstanding contributions to surgical knowledge emanated from the CentralPacific Area. It was demonstrated many times, however, that, in spite of aninadequate number of fully trained personnel,satisfactory end results could be achieved in the
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management of casualties who were received long past theideal time for treatment. It was believed that this accomplishment resultedfrom foresight in anticipating the future and in attempts at training the many whoarrived with inadequate training before entering the service.
FORRESTER RAINE, M.D.
CONSULTATION IN ORTHOPEDIC SURGERY
The uncertainty of the United States' participation in World War II ended at Pearl Harbor on 7 December 1941. As an Infantry veteran of World War I, and a long-time Medical Reserve Officer of the Arms and Service Assignment Group, this author, Lt. Col. (later Col.) Robert Crawford Robertson, MC, received a telegram that day requesting his early active duty. On 26 December, a representative of The Surgeon General telephoned the author inquiring if he would like assignment to Hawaii as orthopedic consultant. Orders to Letterman General Hospital, San Francisco, which then contained many Hawaiian casualties, soon followed. The kind and considerate help of Lt. Col. (later Col.) Oral B. Bolibaugh, MC, Chief, Orthopedic Section, Letterman General Hospital, was invaluable in initiating the author into the professional and administrative problems of a large military hospital. Colonel Bolibaugh soon left to assume command of an evacuation hospital and later rendered outstanding service in the Mediterranean and European theaters.
On Friday, 13 March 1942, aboard the U.S.S. Republic, thisconsultant entered Pearl Harbor, a "graveyard of once proud ships"where intense repair activities were everywhere evident. At Fort Shafter, Oahu,T.H., he reported to Col. (later Brig. Gen.) Edgar King, MC, Surgeon, HawaiianDepartment, whose farsighted planning, combined with theoutstanding cooperation of the civilian doctors in Hawaii, had resulted in superior medical service duringand following the surprise attack of 7December. Colonel King was an officer with long service in the Regular Army.One of his basic convictions was: "He is a medical officer, he can doanything."
Hawaiian Department, 1942
The major Army hospitals on the island of Oahu were Tripler General Hospital (later the 218th General Hospital), where Maj. (later Col.) August W. Spittler, MC, was Chief of Surgical Service; and Schofield Station Hospital (later North Sector General Hospital, and eventually 219th General Hospital), where Maj. (later Col.) Leonard D. Heaton, MC, was Chief of Surgery. Major Spittler and Major Heaton were superior officers of the Regular Army who had rendered outstanding service during and following the raid. Their kind cooperation and help in the problems of medical supply, planning, personnel and patient evaluation, and the professional management of battle and garrison casualties were of the greatest aid in making the transition from an orthopedist in private practice to a staff orthopedist in an oversea theater.
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The Hawaiian Department at the time expected another attackby the Japanese and was serving as an oversea defense area. Numbered general andstation hospitals arrived and established on the islands of Oahu, Kauai, Maui,and Hawaii. Tables of organization did not meet local needs, and provisionalhospitals were established on these islands as well as on Molokai and Lanai.Throughout the early years of the war, many provisional units found it difficultto receive authorization for obtaining necessary personnel. As a result, manymedical officers were placed on temporary duty at various installations to meetneeds as they arose.
The year 1942 was spent chiefly in organizing to meetanticipated needs. A shortage of specialized personnel immediately becameapparent. This remained the major problem throughout the war. The shortage oforthopedic surgeons authorized by tables of organization in June 1945 totaled 13(26 percent). The assignment of Maj. (later Lt. Col.) John R. Vasko, MC, toTripler General Hospital, Honolulu, and the arrival of 1st Lt. Robert W. Ray,MC, with the 147th General Hospital early in 1942 established a firm foundationfor orthopedic care in the Department. Both of these officers demonstratedoutstanding professional ability and retained their assignments as chiefs ofthe orthopedic sections in these hospitals throughout the war. Staffing,equipping, and planning within the various hospitals of the islands was furthercomplicated by the various provisional hospitals considered necessary becauseof the terrain and anticipated attack. Plans had to include provision for thecare and evacuation of wounded on each island and by ship among the islands incase of attack.
In the summer of 1942, reports were received that there wasan unusual incidence of delayed union and nonunion in fractures treated in themilitary hospitals. Reports of all fracture cases showing delayed union ornonunion were obtained from the various hospital commanders and a personal checkwas made of all of these cases. No evidence was found to substantiate thesereports.
Among this consultant's early duties were the evaluationand assignment of personnel, the formulation of professional procedures inaccordance with the evacuation policy of 120 days, the providing of surgicalsupport for a regimental combat team in amphibious operations, the inspection ofthe proficiency of all numbered hospitals and all tactical medical units infirst aid procedures, the establishment of facilities for orthopedic alterationson shoes by a quartermaster shoe repair shop on each of the islands, thechanging of automatic medical supply items, the establishment of emergency andexpansion facilities within military and civilian hospitals and ships in all ofthe islands in anticipation of attack, and the marking of tourniquet cases inthe field. Employees of Hawaiian contractors who were performing constructionwork for Army expansion plans received Army medical care to includepreemployment physical examinations by teams composed of Army medical officersand subsequent medical care given in Army medical facilities.
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In June 1942, the Hawaiian Department received a few Army air and groundcasualties from the Battle of Midway. The Navy casualties, who were far morenumerous, were seen through the courtesy of the commanding officers of thevarious Navy hospitals. The shortage of specialized personnel experienced by theArmy was not then, and never became, apparent in the Navy hospitals in thePacific Ocean Areas. During the late 1930's, the splendid Navy medical servicehad commissioned into its Reserve Corps in advanced grades many doctors from thestaffs of medical schools and teaching hospitals. The outstanding men soobtained formed a magnificent pool at the outbreak of the war. In the author'sopinion, the Army would do well to consider similar methods in future Reserveplanning.
Circular letters issued by the Office of The Surgeon General were extremelyhelpful during 1942, as were subsequent Essential Technical Medical Data reportsand War Department technical bulletins in standardizing new professionalmethods and in the management of garrison and battle casualties.
The organization stage was fairly complete by fall of 1942. On 5 November1942, this consultant was assigned as chief of a separate orthopedic service atNorth Sector General Hospital, Oahu, T.H., in addition to his duties asorthopedic consultant, Hawaiian Department. General King's instructions were: "You will keep me informed of the orthopedic situation from front torear at all times."
Replacements from the mainland arrived in large numbers. Many were in the40-year-plus group and presented various problems, chiefly those centering aboutunaccustomed physical activity. The majority were recruits of only 1 or 2 months'service, and outpatient services at the hospitals became extremely heavy. Onemuscular Texan who was inducted into the Army one month after injuring his legwas seen as an outpatient one month later in one of the Department'shospitals. X-rays showed a complete oblique fracture of the proximal end of thetibia and neck of the fibula, with slight displacement of fragments and withvery good callous formation. Upon his being questioned, he revealed that hehad received no medical care and had performed full duty, including hikes. Hestated: "They think I'm yellow, Doc, but I just can't take thoselong hikes very well." The "low backs" presented a major problemwhich continued throughout the war. Department policies were established asfollows:
1. In the absence of objective physical and X-ray findings, treatment will begiven on an outpatient basis.
2. Hospital cases will be disposed of on an individual basis, and as many aspossible will be returned to limited service within the Department if they areunable to perform full duty.
3. No case will be returned to the mainland in the absence of definitepathology.
These policies continued in effect throughout the war, and proved veryeffective.
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By the end of 1942, many senior regular medical officershad been rotated to the mainland for reassignment, chiefly in commandpositions. Several infantry divisions had arrived, the 25th Infantry Divisionhad departed for the South Pacific Area, the Department's numberedhospitals were well established, and they were set up for emergency andexpansion needs, including the treatment of gas casualties. The cooperation ofthe commanding officers, chiefs of surgery, and theorthopedic section chiefs in the various hospitals was excellent. Their problem cases were freelypresented, and "hideouts" were very infrequent. The Battles of the Coral Sea, Midway, andthe Solomon Islandshad disclosed that the Japanese were brave men, but not invincible. TheHawaiian Department's primary problem continued to be the procurementof specialized personnel.
Central Pacific Area, 1943
The new year, 1943, was ushered in by the following instructions from General King: "You keep a check on all the hospitals in this Department and transfer any case to the general hospitals as indicated without consulting me." General King believed that additional orthopedic surgeons should be developed within the Department instead of their being requested from the mainland. Search was made of personnel records and repeated many times throughout the war for officers suitable for such development. When available, they were transferred to a general hospital for training.
Largely because of the relatively low hospital workload andthe absence of combat casualties, there developed a marked tendency on thepart of several hospitals to attempt professional procedures beyond theirprofessional capacity. This was corrected by directives listing the type ofcases to be referred to general hospitals for definitive treatment.
The braceshop at North Sector General Hospital was developedand served the Department. Cases requiring braces were referred to thathospital for fitting and application of the brace.
Analysis of the outpatient clinics disclosed a very largenumber of foot cases. Because of this a spot check of eight companies or theequivalent was made by an orthopedic team. Findings indicated such poor footcare that a Department directive was issued emphasizing the duties of unitcommanders in preventing and correcting this problem.
First aid fracture procedures, including splinting, werechecked at the various hospitals on admission of each patient. Instructionswere issued requiring a report to the Department Surgeon of all casesevidencing unsatisfactory care. Only an occasional unsplinted case appearedthereafter. Standard and improvised splinting and first aid management offractures was checked in each tactical unit. These inspections werepersonally conducted, and many amusing incidents were encountered. One incident occurred in a battalion medical detachment of an antiaircraftartillery regiment. Improvised methods for treating a simulated compoundfracture of the femur were requested of two soldiers. When their job wascompleted, a small gauze bandage had been wrapped about
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the mid-thigh. A large wooden stake had been driven into theground in the region of each axilla, and each foot had been tied to asimilar stake for "traction" and for "still more traction."
Internal derangements of the knee, including manyunusual cases of osteochondritis dissecans, were seen in quite large numbers in all of thegeneral hospitals. Functional results permitting return to full duty weredisappointing following surgery. Fifty individualcases were personally followed up after surgery and formed the basis for acommand directive published 6 July 1944 restricting arthrotomy of the kneeto carefully selected cases.
Recurrent dislocation of the shoulder joint was also adifficult and fairly frequent problem. Surgery was considered only if the dislocation was seen by a medical officer.Initially the Nicola type of operation was favored, but followup disclosedrecurrences in an estimated40 percent following return to duty. Bankart's operation was first employed in 1943.The results of both types of operation were so generallydisappointing that surgery thereafter was restricted to carefully selectedpatients who were returned to limited service.
Fractures of the carpal scaphoid were very numerous. Freshcases responded well to conservative cast treatment and were returned to duty.Ununited fractures which were symptomatic and did not respond to conservative or to operativeprocedures (an entirelysatisfactory surgical procedure was not developed) were placed on limitedservice.
Following several requests for authority to visit theoutlying islands of the Department, Colonel Robertson went in June 1943 asrepresentative of the Department Surgeon with a general and special staffgroup from the headquarters staff of Maj. Gen. Robert C. Richardson, Jr.,Commanding General, Hawaiian Department. The group visited Canton, Christmas,Palmyra, and Fanning Islands. Small defense units held each of these islands.Medical personnel were adequate. Each island presented individual problems,but, in all, the medical plans both for garrison and for providing medicalsupport in the event of an enemy assault were considered sound. This trip wasmost informative and stimulating, as it introduced new thoughts regarding theproblems of medical reinforcement in case of enemy attack, and the managementand evacuation of casualties on an isolated island target.
On 14 August 1943, the Hawaiian Department became USAFICPA.During the same month, Brig. Gen. Hugh J. Morgan, Director, MedicalConsultants Division, Office of The Surgeon General, visited USAFICPA andpresented his observations in other theaters. He stated that penicillin was apromising drug and would be made available. And, in October, small amounts ofpenicillin did become available through the courtesy of good friends in theU.S. Navy. It was in January 1944 that the command obtained its firstsupply of penicillin through Army sources.
Because of troop concentrations on the island of Oahu,including the 7th Infantry Division which had arrived following itscapture of Attu, the orthopedic outpatient clinics became very large, eachclinic frequently handling in excess of 100 cases daily. This number ofoutpatients combined with the limited
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orthopedic staffs seriously interfered with hospital care. Atan informal meeting with the surgeons of the 6th, 7th, and 40th InfantryDivisions, it was agreed that the problem could best be solved by the followingmeasures: (1) Giving minor orthopedic care in the clearing company of eachdivision, and referring only more serious cases to a hospital; (2) restrictingto 50 the number of hospital outpatient clinic cases on each of the 3outpatient clinic days each week; and (3) formation of a reclassification boardwithin the area for disposition of division cases rather than boarding themthrough the hospitals. These measures proved effective.
On 7 November 1943, the Hawaii Chapter of the AmericanCollege of Surgeons gave a most delightful scientific and social program forFellows in the Armed Services. In the same month, General King directed thateach combat division be furnished an officer trained in the management offractures. He accepted the suggestion that each division provide one medicalofficer for training in fracture management during its stay in the islands andthat this officer accompany the division on its departure. This plan wasadopted, and subsequent personal observation of the professional skilldisplayed by many of these men during combat was gratifying.
Formally organized orthopedic training programs wereestablished in December 1943 to take place in designated general hospitals onthe island of Oahu for officers and enlisted personnel. The courses were madeavailable to selected medical personnel of divisions and other tactical units.This policy paid off handsomely in subsequent combat operations as well as inthe fixed hospitals. Largely because of the success of this program, a similartraining program was later established for all Army medical officers by order ofthe Commanding General, USAFPOA, dated 20 October 1944.
During the latter part of 1943, the 204th General Hospitalwas without an orthopedist because of the shortage of trained personnel, andorthopedic cases were directed to other hospitals. It was again recommended thatthe Surgeon, USAFICPA, requisition three orthopedists with professionalqualifications for section chiefs to be assigned to the area's large fixedhospitals, where the orthopedic census averaged about 25 percent of the totalhospital census. The surgeon of each incoming unit was contacted for an officerwith surgical background suitable for further orthopedic development, but rarelydid such a man become available.
A few battle casualties were received from the GilbertIslands operations. Analysis of 127 cases admitted to hospitals on Oahu showedwounds of the extremities, spine, and pelvis in 90, or 70.8 percent, of thecases. Practically all were wounds inflicted by small arms. The standard oftreatment in the forward area was good. No case of cast constriction, majoramputation, or gas gangrene was seen. Sulfonamides were given en route. Limitedair evacuation was used in this operation. Initial impressions were favorable.The author requested authority to participate in the coming invasion of theMarshall Islands but was refused.
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FIGURE 247.-The courtyard of the 147th General Hospital. A patient exercising on a walking board.
By January 1944, the orthopedic training program in the general hospitals was organized on a 13 weeks' basis, and several officers were attached to Tripler, North Sector, and the 147th General Hospitals (fig. 247).
The Marianas and Leyte, 1944
The first group of casualties from the Marshall Islands arrived on 12 February 1944. At North Sector General Hospital, 173 were received, of which 43 were orthopedic cases, chiefly patients with wounds inflicted by small arms. Many had received initial definitive treatment aboard ship. By Navy standing operating procedure, the medical officers of each ship decided prior to combat the principles and methods of treatment which would be followed during the action. This procedure was quite in contrast to the professional methods as prescribed by The Surgeon General of the Army and, in combined operations, resulted in confusion between the medical services. Colonel Raine, area surgical consultant, Col. Charles T. Young, MC, Consultant in Medicine, Office of the Surgeon, USAFICPA, and the author checked the 646 wounded in the various hospitals, and made the following observations:
1. Selected cases were given plasma or blood shortly afterwounding.
2. Sulfonamide therapy was well administered en route.
3. Clinical records and X-rays did not accompany thepatients to the rear area hospitals, but arrived several days later.
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4. Wound debridement was unsatisfactory in 13 percent.
5. Closed wounds were found in 13 percent. Of these, 60percent were infected.
6. Wounds treated by open methods rarely showedinfection.
7. Amputation stumps were not treated by traction. Fiftypercent were closed by flaps and were infected.
8. There was no gas gangrene or tetanus.
9. Splinting was good.
In the joint report, the three officers recommended that the area surgeonfurther emphasize directives that had been published on methods of treatment and thatagreement be obtained with the Navy on methods of wound management. This consultant wasconvinced thatconsultants should accompany each invasion and attempt to supervise themanagement of patients on the target. Lt. Col. (later Col.) Laurence A.Potter, MC, Surgeon, 7th Infantry Division, and an outstanding field medical officer, withexperience in Attu and the Marshall Islands, concurred, and so recommended toGeneral King.
A prominent visiting civilian consultant to the Navywas impressed by the Stader splint, which was used quite extensively inthat service. After checking this method of treatment with several Navyorthopedists and seeing their cases, this consultant recommended toGeneral King that the Army obtain the item for evaluation in each of thecommand's fixed general hospitals. The Surgeon General disapproved thisrequisition. Time proved him correct in so doing because of the numerous latecomplications which followed.
In the spring of 1944, Maj. John J. Cawley, Jr., MC, a"graduate" of the USAFICPA orthopedic training program, was assignedto the 204th General Hospital, which was for a time without an orthopedicsection. He reorganized the section, continued as chief throughout theremainder of the war, and rendered superior service.
In the hospitals, it was possible accurately to forecastcombat operations by the increased number of self-inflicted gunshot wounds ofthe extremities. When self-inflicted wounds became numerous, it was positiveevidence that an operation was pending. Unfortunately, nearly all of thesecases were reported by investigating boards as "Line-of-duty, yes."
On 15 May 1944, the author submitted a letter to GeneralKing requesting temporary duty on a combat mission "for the purpose ofsupervising and assisting in the care of orthopedic casualties." Fourdays later, he was unofficially advised that his request had been favorablyconsidered.
The shortage of orthopedic personnel continued to be acute.General King advised this consultant that orthopedists were not availablefrom the mainland. Again the qualification card of each medical officer inUSAFICPA was reviewed in a search for prospects. Training programs in thegeneral hospitals were functioning well, but practically all of the officersin training were on temporary duty for only a few weeks and then moved on withtheir divisions. Nevertheless, two excellent men for development and permanent
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retention in orthopedic assignments were obtained. Theywere Capt. (later Maj.) Arthur M. Faris, MC, a diplomate of the AmericanBoard of Obstetrics and Gynecology, from a military police battalion; andCapt. (later Maj.) Lawrence L. Hick, MC, from the 7th Medical Battalion.
Brig. Gen. Earl Maxwell, formerly Surgeon, USAFISPA, andColonel Sofield, formerly Orthopedic Consultant, USASOS, SPA, reported toHeadquarters, USAFICPA, as the South Pacific Area was closing. ColonelSofield reported that USAFISPA had four general hospitals, three largestation hospitals, and a total of nine orthopedic board diplomates. Thisrelatively large number of certified orthopedists was present because USAFISPAhad affiliated units. In USAFICPA, there were no affiliated units, and,as a result, there were only two orthopedic board diplomates.
The Marianas operations
On 4 July 1944, the first battle casualties from Saipanarrived-six evacuated by air. By 14 July, the orthopedic census at NorthSector General Hospital totaled 336, of whom 78 were battle casualties. On 15July, General King directed this consultant to go to Kwajalein tosupervise the management of the cases arriving there from the Marianasoperations. On the author's arrival on Kwajalein, he met Lt. Col. ByronA. Nichol, MC, Island Surgeon; Brig. Gen. Clesen H. Tenney, IslandCommander; and Capt. Robert F. Sledge, MC, USN, Atoll Surgeon. The islandhospital-Provisional Station Hospital No. 2, commanded by Maj. (laterLt. Col.) Maximilian C. Kern, MC-was reinforced by personnel of the 51st and 52d Portable Surgical Hospitals, just arrivedfrom the South Pacific and without recent clinical experience. The instructions were to evacuatethe first 50 cases received each day to Guadalcanal station hospitalsbecause the Oahu hospitals were filling up.
There were 1,314 Army hospital beds on Kwajalein, obtained by usingthe newly erected Army Air Forces barracks for emergencyand expansion facilities. All hospital enlisted personnel were madeavailable for professional work when one officer and enlisted personnel weredetailed from tactical units to operate the hospital messes, run water details,and so on. The Navy operated all atollhospitals except Kwajalein. Penicillin and volunteer blood donors wereavailable. Colonel Nichol and the author agreed that white (14-day) casesbe retained on Kwajalein, blue (15- to 60-day) cases be evacuated toGuadalcanal, and red (60-plus day) cases be evacuated to Oahu, insofar aspractical. On 30 July, Kwajalein received 291 battle casualties from thehospital ship, U.S.S. Solace. Casualties remaining on board were taken tothe Navy hospital on Burton Island. On the same day, 50casualties came in by air. Cases arriving at the Army hospital were almostentirely Marines, who for the most part had been well treated, although many ofthe spica casts were broken and very few amputation stumps werein traction. A few instances of inadequate debridement, primarily closed wounds,tightly packed wounds, unnecessary excision of skin, unsplitcasts, anklet traction still in place, and several cases of anerobic
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cellulitis were encountered. Four aircraft were available forfurther evacuation out of Kwajalein each day-two for Oahu and two forGuadalcanal. These were C-54's, and each had two flight nurses and wasequipped to carry a total of 32 litter cases. The vast majority of patientswere evacuated from Kwajalein by air. On 3 August, General Tenney advised thatthe Kwajalein hospital beds would be limited to 450 upon arrival of additionalunits who would require the Army Air Forces barracks for housing. Atoll bedsafter arrival of these units were to be: Kwajalein 450, Roi 450, Burton 450,and Carlson 150. Reserve Army medical supplies were stored on Carlos Island,where it was possible to establish 300 additional beds, if necessary, buttransportation to that island was by boat only. On the same day, 50 casualtiesarrived from Tinian, many requiring blood transfusions.
On 6 August, this consultant sent a memorandum to Col.Eliot G. Colby, MC, Surgeon, Army Garrison Force, Island Command, Saipan,reporting the condition of cases received on Kwajalein. After one week, withpractically no battle casualties, a radio was sent to General King requestingtemporary duty in the Marianas. The author, meanwhile, visited Makin, one of the Gilbert Islands,where Maj. Robert D. McKee, MC, was Island Surgeon andcommanding officer of the 1st Station Hospital, which served the island andevacuated to Kwajalein. Personnel and supplies were adequate. On return toKwajalein, the author learned that hospital ships were expected on 20 August. On16 August, reports were received that the wounded were being well evacuated fromKwajalein. On 19 August, this consultant received radio orders from General Kingto proceed to the Marianas.
Colonel Colby was Island Surgeon, Saipan, where islandspraying with DDT was first done. The 369th Station Hospital was operating, andthe 148th General Hospital was just getting established. The evacuation policywas 30 days. This consultant immediately saw patients, checked supplies,reviewed surgical principles and methods, and discussed the effects of the30-day evacuation policy with the staffs of these two units and with ColonelColby. On 24 August, the author proceeded to Guam where Capt. John B. O'Neil,MC, USN, was surgeon of the V Amphibious Corps (fig. 248). The 77th InfantryDivision with the 36th Field Hospital, operating a forward and a rear section,and the 289th Station Hospital, which was just establishing facilities, formedthe Army contingents of this corps (fig. 249). Neither of these hospitals had anofficer trained in fracture management. Combat operations were practically at astandstill because of mud. DUKW's (amphibious trucks, 2?-ton cargo) wereuseful in the evacuation of wounded (fig. 250). Dengue fever was epidemic.Evacuation within the division was temporarily impossible because of the mud.The author reviewed cases and professional management at the 36th FieldHospital. It was impossible to visit the tactical units. Captain O'Neil, indiscussions, emphasized the need for qualified medical personnel in the combatzone and for a directive covering professional management in combat operations.On return to Saipan, minor recommendations regarding personnel and supplies weremade to Colonel Colby.
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FIGURE 248.-The landing on Guam, 23 July 1944.
Return to Hawaii
On reporting to General King, this consultant's major recommendationswere that:
1. Additional specialized medical officers be obtained to staff properly thelarge hospitals.
2. All training courses for Medical Department personnel emphasizeprinciples and methods to be employed in the combat zone.
3. Refresher courses in the large fixed hospitals be of at least 6 weeks'duration.
4. Consultants discuss anticipated problems of the combat zone with medicalofficers of tactical units shortly before their departure on combat missions.
5. Mobile surgical teams be made available for use in combat, forward, orrear area hospitals as required.
6. Officers of the Army Nurse Corps be made available to mobile hospitalssoon after their establishment.
7. Air evacuation from the combat zone be supervised by an air evacuationofficer.
8. The use of blood transfusions be increased in the combat zone.
9. An attempt be made to obtain skin traction methods in the management ofamputation stumps of Army personnel treated aboard ships.
10. Further use be made of consultants in the combat zone.
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General King then stated that the author was full-time orthopedic consultant for USAFPOA, the command's new designation, and relieved him of duty at North Sector General Hospital. General King ordered the author on temporary duty to the XXIV Corps as an observer for a coming operation and said that a request for leave on the mainland would be in order upon the author's return to Hawaii. Major Faris, another "graduate" of the orthopedic training program, was designated this consultant's replacement as Chief, Orthopedic Section, North Sector General Hospital. Colonel Oughterson (formerly surgical consultant in the South Pacific Area) was the new Consultant in Surgery, USAFPOA.
On 21 August, Brig. Gen. Raymond W. Bliss, Office of TheSurgeon General, and Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery toThe Surgeon General, visited Headquarters, USAFPOA. They had no specificrecommendations for the command's orthopedic problems.
On 2 September 1944, this consultant discussed the pendingoperation with Colonel Potter, Surgeon, XXIV Corps, and Lt. Col. (later Col.) Robert J.Kamish, MC, Surgeon, 7th Infantry Division. The authorwas to be a working observer, acting initially as orthopedic consultant to the7th Division and later as the Corps orthopedic consultant. On thefollowing day, he made
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FIGURE 250.-Casualties being loaded on DUKW's for evacuation.
final rounds at North Sector General Hospital with Major Faris and found that several of the knee cases that were closed with cotton had extruded sutures. The author also met with the staffs of all the available mobile surgical hospitals that would be attached for the operation and discussed orthopedic principles and case management.
On 12 September 1944, this consultant reported aboard theU.S.S. J. Franklin Bell in Pearl Harbor. On 14 September, a meeting washeld with the senior medical officers of all participating ships and the keymedical officers of the 7th Division. These officers, including the author,planned, discussed, and agreed upon the medical policies and the principlesand methods of treatment and evacuation to be followed in the operation.Particularly emphasized in professional care were early adequate initialsurgery, open treatment of wounds without tight packing, traction on amputationstumps, cast fixation of fractures and severe soft tissue injuries, and the use ofpenicillin.
The force departed Pearl Harbor on 15 September. On thefollowing day, the target was officially announced to be the island of Yap,Caroline Islands, and all were briefed on the operation. Three hourslater, it was announced that the target had been changed. The task forcearrived at Eniwetok, and 4 days later the new target was announced to be Leyte,Philippine Islands, and D-day, 20 October 1944. Now, the XXIV Corps would become part ofthe Sixth U.S. Army under Lt. Gen. (later Gen.) WalterKrueger.
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On 3 October, the force arrived on Manus, Admiralty Islands, where the new medical plans were discussed with Colonel Potter and Colonel Kamish. By his personal request, the author was to go ashore on D-day with a collecting company. The force left Manus on 14 October.
Leyte, Philippine Islands
On 20 October, the Pacific was calm as a millpond. The forceentered Leyte Gulf about dawn. The Japanese sent out an occasional welcomingcommittee of a Zero or a torpedo bomber flying low. All that this consultant sawwere shot down. By plan, the XXIV Corps assault wave which included one platoonof Company C, 7th Medical Battalion, was to go in at about J+4 or J+5 (hours)on call. Personnel were loaded into LCVP's (landing craft, vehicle andpersonnel), which circled briefly, then formed up on the line of departureabreast the bombarding ships. At J+25 (minutes), the LCVP in which the authorwas riding was on Beach Yellow 2 at Dulag (fig. 251). When the assault forcenewspapers appeared a few days later, the official version was: "Our troopsin their desire to close with the enemy, at times overran their line ofdeparture."
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The collecting company established in the remains of the church (which faced the square) and evacuated to the medical shore party,which in turn evacuated by LCVP to ship (fig. 252). At about 1500, thecollecting station was joined by Captain Minden and his surgical team from theClearing Company, 7th Medical Battalion. The team established itself inside thechurch and began definitive treatment for nontransportable military casualtiesand severely wounded civilians (fig. 253). Shore-to-ship evacuation stoppedbefore dusk, and, as the collecting company and surgical team were the onlymedical units behind the 184th Infantry, the group worked throughout the night.The Japanese attacked the 184th Infantry shortly before dawn withinfantry and tanks, as the regiment was warned they would. Both the U.S.Army and the U.S. Navy turned their full firepower onto the attackingJapanese, which made a deafening but magnificent display of coordinatedfireworks in the dark. On the following day, the clearing company arrived andestablished its station, and the collecting company moved forward. Twosurgical teams from the 76th Station Hospital, Leyte, soon joined the collectingcompany, which then established a station with a military section for emergency surgeryand a civilian section for definitive care.
While with the 7th Infantry Division or with the XXIV Corps,this consultant observed professional methods or assisted in patient care in abattalion aid station of the 184th Infantry, all companies of the 7th MedicalBattalion, 69th Field Hospital, Leyte, 76th Station Hospital, Leyte (fig. 254),165th Station Hospital, Leyte, and the 394th Clearing Company of the 71stMedical Battalion (Separate). Several of the mobile hospitals were not unitloaded, and their supplies were widely scattered on the various Corps beaches,causing much delay in getting them established. All medical units establishedtheir own perimeter of defense. Personnel of the 51st and 52d Portable SurgicalHospitals were used as surgical teams to reinforce clearing companies and fieldhospitals. Blood was obtained from patient and volunteer donors. Because ofnearby airfields, ammunition dumps, and artillery positions, several of themedical units received enemy fire of various types, which caused numerouscasualties among their personnel. On 24 October, this consultant was slightlywounded in the left thigh by a shell fragment, and a walking cast was appliedfrom ankle to groin.
Upon leaving the XXIV Corps, the author reported toHeadquarters, Sixth U.S. Army. The surgeon, Col. (later Brig. Gen.) WiliamA. Hagins, MC, was a delightful gentleman with the wisdom of havingparticipated in the establishment of 14 previous beachheads. He felt thatclearing companies reinforced with surgical teams and evacuation hospitalsprovided the best medical support for divisions in amphibious operations. Withinthe X Corps, the 1st Field Hospital, Leyte, the 2d Field Hospital,Leyte, and the 3d Field Hospital, New Guinea, were establishing hospitalizationfacilities, while their surgeons were active with surgical teams reinforcingclearing stations and evacuation hospitals. The 36th and 58th EvacuationHospitals were established
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near Tacloban, Leyte. This consultant was greatly impressed with the evacuation hospitals. Both received patients on D-day, were fully established by D+3, were staffed with well-qualified specialists, and received whole blood daily by air. A few selected female nurses were with these two hospitals and were of great value, particularly in postoperative care and in raising the morale of the patient.
From Leyte, this consultant proceeded to Peleliu Island,Palau Islands, where combat operations were in progress. The 17th FieldHospital, Peleliu Island, in addition to serving the Marine assaultforce, was operating as a link in air evacuation between Leyte and Biak.
Major conclusions formed during these operations were:
1. Because of attacks on ships, blackout conditions,vagaries in the weather, and other unforeseen circumstances, medicalplans for operations in the future should include provision for completedefinitive surgery to be furnished ashore.
2. Four surgical teams should be attached to each divisionclearing company.
3. Each combat division should be supported by one evacuationhospital, semimobile.
4. Station hospitals, when employed as evacuationhospitals in combat, must be supplemented by surgical teams.
5. Personnel of portable surgical hospitals were bestemployed as surgical teams and for providing postoperative care.
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6. Well-trained surgical teams were of great value at all levels within the combat zone.
7. Medical personnel assigned to units entering combat should receivetraining in small arms to include the carbine.
8. Unit loading and unit control of supplies on the beaches was essential.
9. Civil affairs units should be established early to assume fullmedical care of civilians, thus freeing the medical service of tacticalunits of this additional burden (fig. 255).
10. Army Nurse Corps officers should be brought to the target on call ofthe surgeon of the combat forces.
11. Medical and dental officers of company grade and selected officers offield grade should be rotated between mobile and fixed medical units on a 12months' basis.
12. Use of the Thomas' arm splint should be discontinued in the combat zone.
13. New tents should be obtained that can be properly blacked out andyet permit work to continue within.
14. Morphine should be administered only by Medical Department personnel.
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15. Refresher courses given in large fixed hospitals resulted in improvedsurgical care on the target.
16. Refresher courses given in rear area hospitals for medical officers oftactical units should further emphasize procedures and techniques to be employedin the combat zone.
17. Training courses in the large rear area hospitals for selected enlistedmen should further emphasize training in the handling of trauma.
18. Consultants should be attached to each combat force.
In addition to these recommendations, the author brought back a renewed loveand admiration for the combat soldier, regardless of his color, flag, orreligion.
Hawaii again
On return to Headquarters, USAFPOA, in November, this consultant found thatGeneral King had been rotated to the mainland and Brig. Gen. John M. Willishad replaced him. Lt. Col. William B. McLaughlin, MC, a diplomate of theAmerican Board of Orthopaedic Surgery, from the South Pacific, was the newchief of the orthopedic section at North Sector General Hospital and doingsuperior work. Patients in all Oahu hospitals were receiving excellent care.Battle casualties found in a station hospital were transferred to a generalhospital.
General Willis recognized that the prevailing shortage of orthopedicpersonnel was acute and approved requisitioning the necessary personnel fromthe mainland. He also approved this consultant's writing directly to Col.Leonard T. Peterson, MC, Chief, Orthopedic Branch, Office of The SurgeonGeneral, and to Lt. Col. John J. Loutzenheiser, MC, Consultant, Orthopedics and Reconditioning, Ninth Service Command. Personal letters werewritten to each of them asking about the condition of patients on arrivalon the mainland. Mobile orthopedic teams were requested by General Willis.Personnel for the four that were to be formed were selected by the author.He continued to give talks on orthopedic management in the combat zone beforenumerous tactical, mobile, and fixed hospital units.
Back to the United States
Finally, this consultant submitted his request for temporary duty and leaveto the Zone of Interior. The request was approved. On 18 December 1944 he leftOahu, and on the following day at Letterman General Hospital, San Francisco,Calif., he checked the condition of patients evacuated from the Pacificwith the Commanding General, Brig. Gen. Charles C. Hillman, and his chief ofsurgery, Col. Russel H. Patterson, MC. Both reported that patients arrived ingood condition. Their chief criticism was the manner in which hands weresplinted.
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The author arrived at his home on 23 December, in time forChristmas and a happy reunion with his family. He gained 14 pounds during thefirst 2 weeks at home.
By invitation of Colonel Peterson, this consultant visitedBattey General Hospital, Rome, Ga., and made rounds with him and Maj. (later Lt.Col.) James J. Callahan, MC, Consultant in Orthopedic Surgery, Fourth ServiceCommand. The principles and methods of treatment seen were essentially thosethat had been followed in the Pacific. Hoping to find additional orthopedicpersonnel for USAFPOA, the author requested 10 days' temporary duty in theOffice of The Surgeon General. The request was approved, and he proceeded toWashington where much time was spent at Walter Reed GeneralHospital. Several of the Pacific wounded and other old friends were seen. WithColonel Peterson, he reviewed the qualification cards of all orthopedic surgeons available for assignmentand found no prospects for USAFPOA.
Okinawa, Victory, and Demobilization, 1945
In San Francisco, it developed that air transportation would mean a delay of at least 2 weeks. As this consultant had been alerted for the next operation, he returned to Pearl Harbor aboard the U.S.S. Okanagoan (APA 220) on her maiden voyage.
On Oahu, he found that General Willis was in the forwardareas with Maj. Gen. Norman T. Kirk, The Surgeon General of the Army. Theauthor saw all orthopedic cases in the general hospitals on Oahu, and receivedhis anticipated orders for temporary duty as observer with the Tenth U.S. Armyfor Operation ICEBERG (Okinawa). In the Tenth U.S. Army, Col. Frederic B.Westervelt, MC, was Surgeon; Colonel Finney, surgical consultant; Col. WalterB. Martin, MC, medical consultant; and Colonel Sofield, MC, orthopedicconsultant. Colonel Oughterson was to be surgical consultant and Col. BenjaminM. Baker, MC, medical consultant of the forward base area with headquarters onSaipan. General Maxwell was to accompany the invasion forces and becomeSurgeon, Army Garrison Force, following the operation. Lt. Col. (later Col.)Moses R. Kaufman, MC, theater psychiatric consultant, and the author were togo with the task force in addition to being assigned as Tenth U.S. Armyconsultants. There were no evacuation hospitals. Each division was to haveone field hospital, with two portable surgical hospitals and four surgicalteams attached, to act as an evacuation hospital. A directive, "Surgery inthe Combat Zone," was to be issued to all medical units of theTenth U.S. Army. When General Kirk and General Willis returned from the forward areas,the utilization of consultants in the various zones of the theater was discussed withthem (fig. 256).
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FIGURE 257.-An orthopedic ward at the 39th General Hospital, Saipan.
The Okinawa operation
On 5 March 1945, this consultant boarded the U.S.S. Montauk,assistant command ship, and arrived at Saipan on 13 March. At the 39th and148th General Hospitals and the 369th Station Hospital, he reviewed cases andmedical plans for Operation ICEBERG. Orthopedic cases were to be treated onlyat the 39th and 148th General Hospitals, where it was hoped that all fracturesof the long bones could be held until "frozen" (fig. 257). At Tinian,where Captain Mueller, USN, was Island Surgeon, the author discussedwith the combined Army and Navy medical officers the medical plans for care ofbattle casualties.
This consultant left Saipan in a convoy with the 2d MarineDivision. The target day was officially "Love Day," 1 April 1945(Easter Sunday), and H-hour was 0800. On "Love Day," the sea was calm,and the day, clear. The amphibious assault feint of the 2d Marine Division wasbeautifully executed. Then the convoy continued to the landing beaches on thewest side of the island. The power of American industry as evidenced by themany new types of ships engaged was amazing (fig. 258). The assault waves metlittle resistance. The author remained aboard ship, where occasional airattacks were received. On 4 April, he visited the hospital ships, U.S.S. Comfort(Army) and U.S.S. Solace (Navy) and reviewed professional methods. Healso visited Landing
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FIGURE 258.-The ships that carried men and supplies to Okinawa, 4 April 1945.
Ship, Tank, Hospital Ship 929, which was serving as the force blood bank until the blood bank could be established ashore and as the control ship for medical supplies and casualties.
On 5 April, this consultant went ashore where he saw Colonel Potter,Surgeon, XXIV Corps; Lt. Col. Byron B. Cochrane, MC, Surgeon, 7th InfantryDivision; Maj. Homer P. Struble, MC (who had excised the author'sshell-fragment wound on Leyte) and many other old friends(fig. 259). The 31st and 69th Field Hospitals were not fully operationalbecause of supply difficulties. The author was instructed to serve asconsultant with the XXIV Corps. Colonel Sofield was to serve in asimilar capacity with the III Amphibious Corps and with the Tenth U.S.Army. The XXIV Corps, moving south on Okinawa, had establishedcontact north of Naha. On 6 April, the author again went ashore. As heleft the beach to return to his ship, the first organized Japanese kamikaze(suicide) attack on the ships began and continued for about 5 hours. The LCVP,during the return to the ship, was a perfect ringside seat. Thekamikaze corps was not a suitable assignment for a coward.
On 8 April, the author reported to Headquarters, XXIVCorps, and served with the Corps through 6 May. He assisted in theorganization of shock wards; supervised and participated in the postoperativecare of patients and in their general management; held informal discussions on professional methods withthe various tactical and hospital units; corrected on the spot errors observed;and prepared indicated directives for the Corps surgeon.
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FIGURE 259.-An aid station on the beach at Okinawa, L-day, 1 April 1945.
Many of the wounds were caused by multiple shell fragments, and they were very severe and destructive. On 16 April, he submitted a report on the medical situation to General Willis.
This consultant served with and visited the following units: Allbattalion aid stations of the 105th and 106th Infantry, 27thInfantry Division; the aid station of the 3d Battalion, 165th Infantry,27th Infantry Division; regimental aid stations of the 17th, 32d, and 184thInfantry, 7th Infantry Division; Companies A, B, C, and D (52d and 66thPortable Surgical Hospitals attached) of the 7th Medical Battalion; CompaniesA, B, C, and D (96th and 98th Portable Surgical Hospitals attached) of the102d Medical Battalion (fig. 260); Companies A, B, C, and D (51st and 67thPortable Surgical Hospitals attached) of the 321st Medical Battalion; the31st and 68th Field Hospitals; the 394th Clearing Company of the 71stMedical Battalion (Separate), which was operating two holding platoons forevacuation from shore to ship; and the Evacuation Center, Tenth U.S. Army.
The experienced units for the most part establishedthemselves rapidly, functioned efficiently, and evacuated promptly. TheClearing Company (Company D), 7th Medical Battalion, was outstanding,largely as a result of the experience acquired in several previous campaigns andthe wise training of its personnel. It was the only divisionclearing company in the XXIV Corps that had early X-ray facilities,and it possessed the only barber, hot shower, and laundry seen during the author's stay on Okinawa.With this company, Captain Minden continued his superior surgery and was aconstant inspiration
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to all who witnessed his work. The field hospitals were slow in establishing adequate shock facilities and postoperative care for the large numbers of seriously wounded which they received, largely because of inexperience. Shore-to-ship evacuation was often long delayed because of darkness, air attacks on the ships, or weather conditions. The mobile orthopedic teams rendered professional care of superior quality. Medical supply difficulties were markedly reduced over previous operations. The medical control ship greatly simplified the evacuation of casualties from the shore to the proper ship and the movement of medical supplies from ships to the proper beach. The copper sulfate method of hematocrit determination was used in all clearing companies. Whole blood and oxygen were used in the 7th Infantry Division at the collecting station level and proved to be of great value.
It was felt that informal meetings with the medicalofficers of all units and on-the-spot correction of errors were particularlyvaluable functions for consultants during combat. Meetings within the divisionswere normally held at the clearing company and were attended by practically allofficers of the division medical battalion and the regimental medicaldetachments. The consultant received many invaluable viewpoints and suggestionsduring these meetings
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and will always be grateful for the opportunity he had to learn from theseindispensable men. The chief difficulties encountered stemmed largely from the fact that there wasan insufficient number of trained personnel on the target. In correcting thisdeficiency, the attachment to armyhospitals of excellent specialized teams obtained from the Navy hospitals that didnot operate as units was of the greatest value.
On 8 May, this consultant was released from temporary duty with the XXIVCorps and Tenth U.S. Army and reported aboard the U.S.S. Relief. Afterseeing cases and discussion with the surgical staff, he sent a memorandum to the Surgeon,Tenth U.S. Army, concerning thecondition of patients as received and seen aboard ship. Surgical principlesaboard ship did not vary appreciably from those followed in Army facilitieson land, except that traction was rarely applied to amputation stumps. At Guam, all patients were unloaded and taken to thehospitals of theirrespective services.
The author then visited all fixed army hospitals on Saipan, Tinian, and Guamduring the period 15-27 May, and each orthopediccase was seen and discussed. Because of a shortage of hospital beds andpersonnel, it appeared these hospitals could not long continue to holdpatients with fractures of the long bones in traction until "frozen."The author made the trip from the Marianas Islands to Oahu by evacuationaircraft. Excellent patient selection and care was observed.
Experience in this campaign resulted in the following major recommendations:
1. Medical officers with high professional qualifications should beassigned as far forward as possible, normally at clearing company level.
2. Refresher training in fixed hospitals should be given on every possibleoccasion to officers assigned to mobile medical units.
3. In the training of mobile hospitals preceding combat, additional emphasisshould be placed on living in the field under combat conditions, rapid establishment of facilities forthe reception of large numbers of patients, the treatment of shock, postoperative care, rapidevacuation, and the provision of professional care on a 24-hour basis.
4. Company grade and selected field grade Medical Department officers shouldbe rotated between fixed and mobile units, preferably after 12 months'service.
5. Air evacuation is particularly desirable for major fracture andamputation cases.
6. Halftracks serve well as ambulances in exposed areas because of theirprotection against near misses and small arms fire. The chief limitation istheir capacity of only one litter case.
7. Female nurses should be brought to the target as soon as the danger oftheir being captured by the enemy has passed.
8. Theater consultants should continue to accompany each invasion force.
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Following his return to Oahu on 28 May 1945, this consultantvisited the various hospitals where he checked and found the care being givenpatients to be excellent. Great improvement in patient care was apparent in allechelons during the Okinawa operation. This improvement was the result of theincreased number of trained personnel on the target, the availability of wholeblood, improved methods in the management of wounds and shock, and the increaseduse of air evacuation. Because of the shortage of hospital beds in the theater,it was not possible to hold the numerous casualties with fractures of the longbones until the fragments were frozen in traction, as had been planned. Thesecasualties had to be evacuated in casts by air to the mainland.
General Willis was very critical of this consultant's longabsence in the combat zone. Even after he explained the situation on the targetand pointed out that it was on the target, rather than in the rear areas, thatmortality and morbidity were reduced, he remained in obvious disfavor until aletter of commendation arrived from Colonel Westervelt, Surgeon, Tenth U.S.Army. General Willis added a nice indorsement, brought it to the author inperson, and then asked if he would like to go on the next operation. Thisconsultant was restored to favor.
Preparations for invasion of Japan
Major activities now centered about medical plans for theinvasion of Japan. The author met with all medical officers of the 98thInfantry Division; with the staffs of the 317th General Hospital, the 97th and98th Station Hospitals, and many of the island's fixed hospitals. Usingprepared talks and informal discussions, he stressed the space and otherrequirements for the treatment of shock and hemorrhage, the importance ofmaking hematocrit determinations, the required standards of resuscitation priorto and following surgery, the necessity for adequate initial surgery and thesplinting of fractures and soft-tissue wounds, the need for adequatepostoperative care, and the value of air evacuation. Field conditions in combatwere also emphasized before the mobile hospitals. Motion pictures of surgeryduring the Okinawa operation were shown and discussed at a meeting of the AirTransport Command surgeons at Hickam Field and before the staffs of severalother tactical and fixed units. This consultant made several visits to the 8thStation Hospital, which operated the reconditioning center on Oahu (fig. 261).
On 1 July 1945, USAFPOA was redesignated USAFMIDPAC, andplaced under General Headquarters, AFPAC, with General MacArthur in overallcommand. During July, Colonel Potter arrived from Okinawa en route to themainland for temporary duty and leave. He concurred in Colonel Robertson'sformal report on Operation ICEBERG and brought news of mutual friends, some ofwhom had been killed in action, and many of whom had been wounded.
On 25 July, this consultant observed a dry run by therecently arrived 86th Evacuation Hospital, which was attached to the 98thInfantry Division. An informal discussion was then held with the staff regardingcombat zone surgery.
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Thereafter, the author had frequent informal discussions jointly with the Surgeon, 98th Division, and the Commanding Officer, 86th Evacuation Hospital, regarding their particular problems in the approaching operation. The orthopedic surgery detachments were busy on temporary duty at the 218th and 219th General Hospitals. A hospital center was being organized in the Marianas.
In addition to plans for the invasion of Japan andconsultations in the various hospitals of the Central Pacific Base Command,this author was occupied with various other staff duties. There were reportsto General Maxwell listing the orthopedic qualifications of the officers ofthe general and station hospitals assigned to him on Okinawa. He made personnelstudies of the orthopedic surgeons, Central Pacific Base Command, which showedthat there were present only 37 of the 50 authorized by tables of organization.He served as a member of a reclassification board on the militaryoccupational specialty classification (professional and administrative) ofall Central Pacific Base Command medical officers. In addition, he was a firingmember of the Surgeon's Office pistol team, which finished 10th in the fieldof 15 entries from the general and special staff sections in theheadquarters pistol tournament.
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Victory and demobilization
The atomic bomb on Hiroshima caused much excitement. On 14 August came the big news that the war was over! During the next few weeks, this consultant received several letters from medical officers with long and outstanding combat experience stating that they were being retained in division medical units doing no professional work while newly arrived officers with only 9 months' internship were being assigned to hospitals. General Willis, while sympathetic, felt that men with combat experience should be retained in tactical units as there might yet be need for them in this capacity.
On 1 September, the author presented a paper entitled"Management of Orthopedic Battle Casualties in the Pacific" withslides showing the care of wounded from battalion aid stations to rear areageneral hospitals. This presentation was before the Hawaii Chapter, AmericanCollege of Surgeons. The slides were made from motion pictures taken for theofficial medical history, most of which were taken by Capt. Ted Bloodhart, SnC,and were very complete.
Plans were rapidly developed to reduce medical installationsand personnel. Colonel Ottenheimer was assigned to the office to edit thetheater medical history. On 17 September, the 40-hour week became effective.Aside from working on the orthopedic section of the history, duties were verypleasant with much golf and swimming. Colonel Potter, en route back from themainland, visited before returning to the XXIV Corps, destination Korea.Col. Elbert DeCoursey, MC, Consultant in Pathology, AFMIDPAC, and Col. VerneR. Mason, MC, Medical Consultant, AFMIDPAC, left for Japan to join ColonelOughterson in the study of the medical effects of the atomic bombs. The author'sorders for release from active duty appeared on 17 September. He completedthe orthopedic portion of the medical history and turned it over to ColonelOttenheimer.
On 24 September 1945, the author boarded the U.S.S. AzaleaCity destined for San Francisco. On 1 October, the returnees changed fromkhaki to olive drab uniform. All hands were on deck, silent and thankful as the coastneared. The underside of Golden Gate Bridge was lovely. Inside the harbor, a "Welcome Home" ship with flags flying and bands playingcircled the U.S.S. Azalea City several times, an unexpected and joyouswelcome. Never before had "The States" appeared so beautiful.
Summary
The Pacific Ocean Areas, commanded by Adm. Chester W. Nimitz, U.S.N., consisted of numerous widely separated small islands. The duties of USAFPOA, commanded by General Richardson, were those of a defense force operating a training and staging area and maintaining a base for, and conducting, amphibious operations. Cooperation among medical officers of tactical and fixed medical units, line officers, and medical officers of the Navy was excellent. As a consultant assigned to Headquarters, USAFPOA, the author
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received authority to move and act within the theater inkeeping with his assigned duties.
The major problem throughout the war was theprocurement of adequately trained personnel. The deficiency in trained personnel was met in part bytraining courses for selected individuals whosubsequently served in tactical units and in the mobile and fixed hospitals. The shortage, particularly noticeable in the earlyinvasions, wascorrected in part by the assignment of qualified individuals and orthopedicteams to task forces. In attempting to correct the overall theater shortage, theSurgeon, USAFPOA, was most cooperative in approving recommendedtransfers and assignments for the more optimum distribution of availablesurgical talent.
Another difficulty arose from the fact that combatoperations in the POA were joint operations involving both the Army and theNavy. The Surgeon General of the Army directed principles and methods oftreatment which would result in high standards of professional care anduniformity of methods throughout the Army. In the Navy, principles and methodsof treatment were established at the local level. The differences inprofessional management between the two services did not occasion friction atunit levels during combat or garrison duty, but the differences were quiteapparent to the other service when large numbers of casualties were handled byone service. Such differences can only be corrected centrally, either inWashington or at the theater level by issue of similar directives to allservices. Casualties were as a rule evacuated to fixed hospitals, operated bytheir respective services, rather than to the hospitals, regardless of theservice, best suited for the management of their particular pathology. Whenseparate hospitals are maintained in the same area by the several services, the formation of interservice hospital groups andthe assignment ofcasualties, irrespective of service, to hospitals staffed for their variousspecialized needs should result in improved case management and in economy ofmedical personnel.
The third major difficulty was in establishing facilitiesduring combat with sufficient trained personnel and beds to provide complete24-hour care on the target. The need for 24-hour service was indicated in manyinstances because of the unavoidable delay in evacuating from shore to ship,and was most marked in the early phases of an invasion. During combat, the needfor trained personnel was greatest on the target. When combat ceased, the needwas greatest in the forward and rear area fixed hospitals. These varying needswere best met by the use of mobile specialized teams transported by air.
Medical officers who were assigned to tactical units lostmuch of their specialized professional skill during their long periods ofinactivity, while officers assigned to rear area fixed hospitals often possessedskills which were in greatest demand in the combat zone. The first mentioneddeficiency was met in part by the establishment of refresher courses in reararea hospitals to which officers assigned to tactical units were attached forvarying periods of time prior to their entry into combat. The second deficiencywas overcome by the limited transfer of personnel from fixed to mobilehospitals. The initial
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definitive surgery received by a severely wounded man wasusually the most important single factor in determining his survival oreventual disability. This treatment should be given as soon as possible afterwounding. For these reasons all physically able company grade medical officersand selected field grade officers should be rotated between tactical and fixedinstallations after a period of one year. Mobile hospital commanders shouldbe carefully briefed on and envision situations which their units arelikely to encounter in combat, and, during training, these units shouldprepare for such conditions. Areas particularly to be stressed were: Unitloading and care of supplies in the combat zone; rapid establishment offacilities for the treatment of large numbers of wounded; establishment ofadequate shock, X-ray, surgical, and postoperative facilities; and rapiddefinitive treatment and evacuation. There was no substitute for combatexperience. The best alternative was wise briefing by experienced officers with combatexperience.
Pertinent technical and professional information should bedisseminated to all units and individuals and carefully studied prior tocombat. This goal was never fully attained, largely because invasions conductedin the Pacific Ocean Areas were combined operations, participating units oftenmounting from widely scattered areas of departure. This difficulty was in partcorrected by the activities of consultants on the target.
Members of the Army Nurse Corps proved invaluable in mobilehospitals, from both a professional and a morale viewpoint. They should bebrought to the target on call of the surgeon of the task force.
Air evacuation was extremely valuable because of the greatdistances covered by lines of evacuation in the Pacific Ocean Areas. Orthopediccases were particularly suitable for evacuation by air. When personnel orhospital facilities are limited in an oversea theater, major fractures andamputees should be evacuated by air to the United States soon after initialdefinitive treatment.
Consultants, as special staff officers, must be free to moveabout and act both in advisory and professional capacities throughout theentire command.
ROBERT CRAWFORD ROBERTSON, M.D.
