CHAPTER XII
Southwest Pacific Area
Wm. Barclay Parsons, M.D., I. Ridgeway Trimble, M.D., andGeorge O. Eaton, M.D.
JULY 1942 THROUGH AUGUST 1944
This portion dealing with theactivities of Col. Wm. Barclay Parsons, MC (fig. 262), asthe surgical consultant in USASOS (the U.S. Army Services of Supply),SWPA (the Southwest Pacific Area), covers a periodpreliminary to the engagement of large bodies of troops in combat; namely, fromJuly 1942 through August 1944, when the writer returned to the Zone ofInterior. At the beginning of this period, U.S. Army combat elements inAustralia consisted of two National Guard divisions, a few assorted antiaircraftand warning batteries, engineer regiments, and a small number of Army Air Forcespursuit and bombing squadrons. At the end of the period, the air forces hadgrown markedly, the Sixth U.S. Army had been organized, and the Eighth U.S.Army was being activated. In the beginning, an invasion of Australia by theenemy was assumed to be a realpossibility, which fortunately did not eventuate. Gradually, the Alliesestablished a foothold in New Guinea, and when the Japanese attacks on Milne Bayand over the Owen-Stanley Mountains toward PortMoresby had been repulsed late in 1942, the ground and air forces began the longtough road that led eventually to the Philippines.
General Characteristics of Operations in Southwest Pacific Area
It seems pertinent to review some of this history because the conduct of combat conditions in the Southwest Pacific Area was strikingly different from that in other theaters. The bases in Australia were far apart, as were those in New Guinea (map 2). For a long time, the number of troops engaged was comparatively small, and tropical disease of different types was for a time an important military problem.
The first combat with the enemy was the Buna, New Guinea,operations, lasting from October 1942 to early January 1943. This was foughtover almost unbelievably difficult terrain consisting of jungle swamps enjoying,if
1See Activities of Surgical Consultants,Vol.I, chapters XVII andXIX for information relating to the Sixth and Eighth U.S.Armies, both of which served in the SouthwestPacific Area during World War II. Seealso chapter XIII, From Aucklandto Tokyo, of this volume for the activities of Col. Ashley W. Oughterson,MC, who served as a surgical consultant in the Southwest PacificArea temporarily during the initial stages of the invasion of the Philippines and was laterassignedas surgical consultant at Headquarters, U.S. Army Forces, Pacific.-J.B. C., Jr.
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that is the word,an annual rainfall of about 12 feet,where, before Atabrine was available, malaria caused five casualties for eachman wounded in action. For most of the Buna operations, only two regimentalcombat teams were engaged. Their components, at times, fought as companies andsometimes as squads. Transportation was at a premium. There were two grassairstrips on the north side of the Owen-Stanley Range that would accept a C-47type of aircraft with difficulty. Flying was possible between Port Moresby andthe north coast at Dobodura (fig. 263) only during the morning hours because ofthe daily blanketing of the mountains by clouds and the coastal area by raineach day by noon or earlier. There were few roads or tracks, andusually the wounded had to be brought back from the front on native-typelitters, carried by four natives, after emergency treatment at a 25-bedportable surgical hospital (fig. 264). This litter carry frequently took as longas 8 hours through swamp and jungleto the nearest 50-bed station (fig. 265). The casualties had to be taken thenceby air to either a 750-bed evacuation or a 100-bed station hospital at PortMoresby to await transportation to Townsville, Australia, by air or freighter.From Townsville, they were taken by air or exceedingly slow train on a narrowgage railroad to one of the general hospitals in Brisbane, Gatton, Sydney, orMelbourne. Fortunately, battle casualties were few because of the limited scopeof combat activity, and the surgical caseload did not rise to really largeproportions until the invasion of the Philippine Islands. As a matter of fact,considerable hospitalization facilities were planned and construction had
FIGURE 262.-Col. Wm. Barclay Parsons, MC.
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MAP 2.-The Southwest Pacific Area.
started in eastern New Guinea, butthese were abandoned before completion because of the rapidity with which thestrategic situation changed.
The experience at Milne Bay was an excellent example ofpreparation for a need that could have been of major proportions but nevermaterialized. After the Buna area was secure, a base was established at thesmall harbor of Oro Bay (fig. 266) and a major base was begun at Milne Bay withits commodious deepwater harbor (fig. 267). Early in 1943, clearing of land,mosquito
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control, and pier and airfield construction were started. Two general and some 200- and 500-bed station hospitals were included in the plans. Before either general hospital was completed, however, the war had moved 1,500 miles away. The Allies then held Finschhafen, where construction was going on apace, and Milne Bay was abandoned, as it did not lie in a convenient line of supply or evacuation. These facts are mentioned to indicate the general mise en sc?ne composed as it was of great distances, a rapidly advancing combat area, and, fortunately, comparatively few battle casualties.
Interpersonal Relations
The Medical Department has often sensed an apparent reluctance on the part of line officers to encourage certain measures that the Medical Department strongly feels would contribute to the greater fighting efficiency of the troops. This seemed to hold true in the Southwest Pacific Area until a medical crisis arose that threatened the successful prosecution of the war. In December 1942 before the virtue of Atabrine had been established and the drug made available, the incidence of malaria in the small force stationed at Milne Bay was at the unbelievable rate of over 1,000 per 1,000 per annum. This occurrence, plus the fact that in the Buna operations there were over 8,000 casualties from malaria, made imperative some prompt action to institute medical measures against this new and threatening enemy. General Headquarters, SWPA,
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appointed a joint American and Australian medical commissionto deal with this problem. Theirmission was successfully accomplished. The important point from anadministrative standpoint was the fact that the carrying out of proper Atabrineadministration was made a command responsibility. It is certain that thiscircumstance improved beyond measure the relationship between the line and theMedical Department.
On the other hand, the relationship between the consultants(including the author) and the medical officers of the Regular Army was slowerto improve. At the time of this writing, and presumably for the future, therole of the consultant is well established, well understood, and appreciated.For some time, it was clear thatthe Surgeon, USASOS, SWPA, had no inkling of the role of the consultant and infact resented his presence, although, in fairness to him, it was doubtful thathe had ever received proper briefing. For some weeks, there was reluctance onhis part to allow this consultant to travel for the purpose of visiting varioushospitals in a professional capacity. He insisted,instead, upon strict Army-type inspections. Gradually, by emphasis and persuasion,theseinspection tours were officially changed to"instructional visits" and were so specified in travel orders. This changeresulted in an abrupt change in the reception accordedthe surgical consultant by area and base commanders and by the hospital commanders who, with few exceptions, wereRegular Army officers during the first year. All these men had quite naturallyresented another adjectival inspection but were glad to welcome someone whosesole, or at least major, interest was the care of patients.
As mentioned earlier,the situation in the Southwest Pacific Area during the first 2 years consistedof three elements: Great distances, limited combat activity, and aresultant relative excess of hospitals. The total numberof hospitals was not great, but the available space was useful until malariawas controlled. Later, hospital facilities were in excess of the surgical loaduntil the invasion of the Philippines. One of the problems that this factproduced for the surgical consultant was themaintenance of morale among many highly trained general andorthopedic surgeons in the various hospitals who complained, with considerable justice, that theyhad joined the Army to use their skills and experience for the benefit of the wounded soldier but wereidle, or nearly so, month after month. Many of thehospitals were at great distances from headquarters and other installations were in what seemed tothe personnelto be both God- and Headquarters-forsaken spots. The execrable climate, thelack of recreational outlets, inactivity, and a feeling of uselessness weremajor factors in the deterioration of morale. A visit of several days by theconsultant as often as possible to one ofthese "neglected" areas seemed to be refreshing and stimulating tothe local staff, even though no matters of much surgical importance might havebeen involved. A similar need for close liaison between the Office of TheSurgeon General and the theaters of operations is discussed later.
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Hospital Units
To understand the local geography in reference to the distances involved, it may be helpful to superimpose mentally the map of Australia and New Guinea on one of North America. If one places Melbourne at New Orleans, one would find Sydney in North Carolina, Brisbane in Delaware, Townsville in Maine, Port Darwin near Winnipeg, and New Guinea over Nova Scotia. From below Sydney northwards the railroad network was narrow gage, often only single track, on which trains ran at a leisurely pace. From Brisbane to Charleville, where there was a small station hospital near a magnificent airfield constructed in anticipation of a Japanese invasion of Australia, the distance was about 400 miles. The train required 22 hours to travel this distance as it sped along at not quite 20 miles per hour. Later, as air transport became available, travel by rail became unnecessary and the transportation of patients became more rapid and more comfortable.
With this brief geographical review it may be useful to notethe location of the hospitals before, as well as after, the development oflarge bases in New Guinea. During the first year, there were four affiliatedgeneral hospitals in Australia-the 4th from Western Reserve at Melbourne, the118th from Johns Hopkins at Sydney, the 142d from the University of Marylandat Brisbane, and the 105th Harvard unit at Gatton, some 40 miles west ofBrisbane (fig. 268).
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FIGURE 266.-The base area at Oro Bay, New Guinea, December 1943.695
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FIGURE 268.-The 118th General Hospital, Sydney, Australia, 8 July 1943.
Four other general hospitals, three affiliated, were assigned to the theater later on. The New York Hospital unit (the 9th General Hospital) arrived in mid-1943 and after a wait at Brisbane set up on Goodenough Island in the Trobriand Islands, near Milne Bay. In 1944, the University of Wisconsin's 44th General Hospital was assigned to a point near Townsville where it functioned in a mild way before moving onward, and the Presbyterian Hospital unit (13th General Hospital) was established at Finschhafen. One nonaffiliated general hospital and the 47th General Hospital from the College of Medical Evangelists were stationed temporarily at Milne Bay (fig. 269), but they arrived just as the Milne Bay base section began to close down, and later were moved forward.
The Southwest Pacific Area was fortunate in having two750-bed evacuation hospitals. The 10th Evacuation Hospital was moved to PortMoresby before the Buna operations and proved an important holding place forcasualties from the Buna area on their way to Australia (fig. 270). The 1stEvacuation Hospital functioned at Rockhampton in the Townsville area near adivisional training area before going to Oro Bay early in 1943.
Station hospitals were scattered about near cities such asBrisbane, Townsville, and Cairns, and near landing fields such as Cooktown,Charleville, and Port Darwin. In New Guinea, they wereat Moresby, Dobodura, Milne Bay, Oro Bay, Lae, and Finschhafen. When NewBritain was invaded and the attack up the coast was started, station hospitalswere at Cape Gloucester and Arawe on New Britain. The first leapfrogging northof Finschhafen brought units to Saidor and then to Hollandia before the attackat Leyte (fig. 271).
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FIGURE 269.-The 47th General Hospital, Milne Bay, New Guinea, 9 May 1944.
FIGURE 270.-The 10th Evacuation Hospital, Port Moresby, New Guinea, February 1943.698
FIGURE 271.-The 27th General Hospital, Hollandia, New Guinea, 1944.
Expansion of Consultant Staff
Until the spring of 1943, although the distances were great, it was possible for the surgical consultant, with the aid of Maj. (later Lt. Col.) George O. Eaton, MC, the orthopedic consultant, to visit all hospitals in the theater frequently enough and with sufficient time at each place to become well acquainted with the personnel and to influence the care of wounded by personal consultation at rounds, by staff conferences, and, from time to time, by communication from the Office of the Surgeon, USASOS, SWPA. An enlarged staff of consultants was purposely not established in the early period for two reasons. In the first place, the clinical load and the number of hospitals was not too heavy for the surgical and orthopedic consultants to cover adequately because, after a few months, it was possible to move the injured by air whenever desirable to all areas under the control of USASOS, SWPA. In the second place, it was considered wise to keep in units those men who later on might be needed to head surgical or orthopedic services, or to act as assistant consultants. Late in 1943, the bases in New Guinea began to increase in size with the activation of the Sixth U.S. Army, great increases in air force strength, and the arrival of new hospital units. It then became necessary to appoint two assistant consultants. Lt. Col. (later Col.) I. Ridgeway Trimble, MC (fig. 272), and Maj. (later Lt.
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Col.) George A. Marks, MC, were selected forthesepositions. They were placed on temporary duty from their affiliated units to differentareas in New Guinea with 2 or 3 bases under eachman. This arrangement furnished detailed consultative activity to the variousrapidly growing base sections and also afforded the senior consultantopportunity to cover the entire area and, whennecessary, to function within individual units.
FIGURE 272.-Col. I. Ridgeway Trimble, MC.
Teaching Functions of a Surgical Consultant
The two major functions of a surgical consultant in a theater of operations were, first, to insure the employment of accepted surgical principles and proper surgical techniques in the care of the wounded, and, second, to place available personnel in key positions in the most advantageous manner. Two methods of instruction were used; namely, direct contact and written directives. The directives were distributed to all units to correct errors that had occurred, or in anticipation of their occurrence. In the early period, it was comparatively simple to travel throughout the area, even though each trip covered three or four thousand miles, to visit all hospitals and to discuss in staff meetings problems of surgical therapy as the particular point in the chain of evacuation occupied by each unit affected such treatment. After about 12 months, new units began to arrive so frequently from the Zone of Interior and at such widely spaced points that assistant consultants were needed to assay their professional quality and to brief them promptly. This briefing immediately on arrival was most constructive. It impressed on the personnel the fact that there was a
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consultant interested in themand their professional performance, and it waseducational in that these newly arrived medical officers had but littleknowledge of war surgery in general. In particular, they had no appreciationof the influence transportation bore upon the repair process in a wound. Untilthe time arrived when the wounded soldier could be held for a considerableperiod at a relatively advanced unit where definitive treatment could be given,the emphasis in instruction had to be placed on the simplest basicprinciples of wound treatment, such as treatment of shock, thorough debridement without undue removal of bonefragments, approximation of divided nerves, loose packing, and effectiveimmobilization for transportation.
An example of how such instruction bore fruit follows. Thesurgical consultant met a small evacuation hospital at Milne Bay on its arrivalfrom the Zone of Interior and just before it embarked for the attack on Manus inthe Admiralty Islands. This unit was composed of fairly well trained surgeons but could notboast the presence of a single board diplomate on its staff, and none of themhad ever heard a shot fired in anger.A directive had been published covering the basic principles to be followed inthe care of wounds in a combat area such as that which faced this unit. At apersonal conference with the staff, the surgical consultant had an excellentopportunity to discuss the subject in detail,to indicate what was required ofthe incoming surgeons, and to review the operations that should not beundertaken and the reasons for the policy. Perhaps as a result of thisbriefing, the casualties returned by that unit were handled in a superiormanner. Shortly afterwards, the surgical consultant was invitedby the Sixth U.S. Army to visit units of that army. This was the first time that any consultant from USASOS, SWPA, had been invited to the army area, and,shortly thereafter, Maj. (later Lt. Col.) Frank Glenn, MC, was appointed as the Sixth U.S. Army surgical consultant.
Utilization of Surgical Manpower
Portable surgical hospitals - There were eventually several affiliated general hospitals in the Southwest Pacific Area. There has been considerable discussion as to the wisdom of forming such units, particularly in reference to the concentration of a large number of highly trained personnel in one unit. In the experience of the Southwest Pacific Area during this period, these units were of the greatest service. Not only was the care of the wounded in the affiliated units of superior caliber, but these units also furnished a pool of talent available for drafting into key positions. During the Buna fighting, where the movement and placement of even the smaller regularly constituted hospitals was impracticable, portable surgical hospitals were developed (fig. 273). They were formed from the personnel of the affiliated units. These small surgical hospitals did a magnificent job, and later others were formed for some of the larger station hospitals. Still later, when the consultant could influence
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the shifting of personnel, otherindividuals were drafted to fillcertain key positions. A striking example of how effective such a drafting could be and howuseful it was to have a pool available was indicatedby the experience with a station hospital at Port Moresby which had adistinctly inferior rating. The hospital commander was replacedby a medical officer of the Harvard unit, and the chief of surgery, by a surgeonfrom the New York Hospital unit. These two individuals inpositions of responsibility transformed this station hospital in afew months from perhaps the worst into one of the best in the theater.
Surgical teams - Another important use of availablepersonnel was accomplished afterthe arrival of Brig. Gen. (later Maj. Gen.) Guy B. Denit as Chief Surgeon,USASOS, SWPA. He brought with him a refreshing change of attitude, as any recommendations made tohim by the consultant receivedimmediate study, and those approved were putinto effect. For example, as it was certain that no auxiliary surgical group wasto be sent to the SouthwestPacific Area, this consultant had tried for a year to get approval of a plan toorganize surgical teams in thelarger hospitals for reinforcement of whatever small hospitals might becommitted in the area of combat. General Denit's predecessors had refused tosanction this plan. They had been unable to comprehendits usefulness and had been afraid of losing control of the personnel. GeneralDenit, however, at once foresaw the probability of the need for more manpower inthe forward hospitals and knew that orders could beworded to prevent the stealing of personnel. One or more teams, each consistingof medical officers, nurses and enlisted men, were thereupon organized in allgeneral, the two 750-bed evacuation, and certain larger station hospitals. Theseteams, with their own instruments, were to be on call for orders placing themon temporary duty wherever, and for as long as, the need for them existed, and untilthe parent organization might require their services. Thisarrangement had the virtue of flexibility in thatmany hospitals in the rear could readily spare one or more such teams for service in a forward unitduring the early stages of an operation, while a laterexchange could be effected as needed or desired. Exactly this same plan had beenused most advantageously by the American and BritishMedical Departments in World War I and was being usedsuccessfully by the Australians in the Southwest Pacific Area.
Which units might be committed to the combat area couldnot be foreseen at this time. There was only one field hospital in the theater,but the Southwest Pacific Area had one medical regiment, the various componentsof which had acquired experience in a station hospital at Port Moresby (which hospitaltheyhad built themselves) and had also operated small station and portable hospitalsin New Guinea and New Britain. It was expected that some of these units, as well as some smaller evacuationhospitals, might be the hosts, as it were, ofthese teams. The second section of this chapter contains a discussion by thisconsultant's successor of how they functioned.
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Equipment
In general, the equipment was satisfactory, but the smaller hospitals, particularly the portable surgical hospital, lacked an orthopedic table. The surgical consultant, therefore, designed and had constructed locally two types of aluminum tables. One was similar to the original Hawley table; the other was a light, collapsible model, packed in a box approximately 5 feet long by 18 inches in cross section.
Plasma and Whole Blood
Dry plasma was always in good supply, but early in 1943 whole blood became available from the first-class blood bank established in Sydney by the Royal Australian Army Medical Corps and the Australian Red Cross. The blood supplied was pooled O type, processed in accordance with the highest standards, packed in ice in a double-walled sheet metal box, and shipped by air. Because the casualties were limited in the early period, the supply of blood was adequate. The thermos bottle effect of the double-walled box served to keep the ice frozen until arrival at New Guinea, and the time taken in transit was reasonable until the combat area had moved far away. Before the attack on Hollandia (where casualties were minimal) an arrangement with the Seventh Fleet made blood available from the bank established on a converted LST (landing ship, tank). Well before the attack on the Philippines, plans had been made for the air shipment of blood from the Zone of Interior.2
Liaison With the Office of The Surgeon General
There was adistinct feeling at the time, which is confirmed in retrospect,that the liaison between the consultant in a theater and the Chief Consultant in Surgery toThe Surgeon General couldand should have been closer. This liaisoncould have been by frequent lettersand by less frequent personal visits by the Chief Consultant in Surgeryhimself or by one of his assistants. There was, unfortunately,an impenetrable barrier between the various theaters through whichinformation should have passed freely-information of a professional rather than a military nature-as to the problemsfaced and the measures devised to deal with them. It iscertain that the experience gained in any one of the theaters would have beenof benefit elsewhere. This communication, of course, should have been in bothdirections, and, if authorized by The Surgeon General, it could not havebeenobjected to by the theater surgeon. At least onevisit of reasonable length peryear by the Chief Consultant in Surgery or his representativewould have been most welcome, and, it is believed, constructive. Suchvisits would have given theopportunity to exchange muchinformation not suitable for transmission by correspondence.
The Chief Consultant in Medicine to The SurgeonGeneral did make one lengthy visit, passingseveral days at various hospitals and including several areas inNew Guinea. This visit was valued most highly by the medical
2Medical Department,United States Army. Blood Program in World War II.[In press.]
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services of these hospitals, and it is believed that theexperience was educational for the Chief Consultant in Medicine. Unfortunately,the Chief Consultant in Surgery was able to pay only one fleeting visit, so that he never became thoroughlyaware of the local situation in general orparticular, and there was no opportunity for quiet, leisurely discussion bywhich many lesser and certain major matters could have been clarified.
Military Rank of Consultants
One cannot be sure as to the importance of military rank for consultants, but it seemed reasonably certain that a more flexible table of organization for the staff of a theater surgeon would have been advantageous, that the surgeon in the theater should have had the rank of major general, and his chief consultants, the rank of brigadier general. In this respect, it was interesting to observe the ranks held by the senior medical officers in the Australian Army. Their surgeon general was a major general, even though there were but nine Australian divisions, and three of his consultants held the rank of brigadier. Also of interest was the fact that in the Australian Army there was no line drawn between the medical service and the combat forces such as that which existed in the U.S. Army between the SOS and field armies. This homogeneous arrangement led to smooth coordination, and one could not help but wonder as to a possible loss of effectiveness in the American organization under the existing system. Also, it was believed that the higher rank held by the Australian consultants was a large factor in their greater freedom and power.
Summary
In summary, one cannot be certain as to many of the problems that may appear in a future conflict, should one arise. Many unforeseeable conditions will of course have to be faced, although the peculiarities of the different areas of almost the entire globe as they may affect combat troops are now well-known and can therefore be taken into consideration in the plans for such a conflict. There are three points that the writer would, however, like to emphasize. First, a flexible table of organization for the professional services in the headquarters of any theater, liberal both as to numbers and as to ranks, would insure worthwhile freedom and prestige to the theater surgeon and his consultants. Second, it seems desirable to urge freer communication between the Office of The Surgeon General and the theater consultants and to emphasize the importance of personal contact at least once a year between the chief surgical consultant in the Office of The Surgeon General, or one of his associates, and the surgical consultant in a theater of operations. Finally, and of most importance, the consultant system at the end of World War II was well established and must not be allowed to lapse, as it was allowed to lapse between World Wars I and II. If the consultant system is continued with strength and enthusiasm, there will be in any future conflict immediate effectiveness of professional influence, hand in hand with the purely military development of the Medical Department.
WM. BARCLAY PARSONS, M.D.
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AUGUST 1944 THROUGH JANUARY 1946
In August 1944, Lt. Col. (later Col.) I. Ridgeway Trimble, MC, succeeded Col. Wm. Barclay Parsons, MC, as Consultant in Surgery, Office of the Chief Surgeon, USASOS, SWPA (fig. 274). This consultant continued to serve as surgical consultant to the Surgeon, AFWESPAC (the U.S. Army Forces, Western Pacific) after USASOS, SWPA, was absorbed into this organization in June 1945. In October 1945, he assumed the same position at General Headquarters, AFPAC (Army Forces Pacific), continuing in it until 27 January 1946, when he and the Consultant in Neuropsychiatry left Japan, the last of the wartime consultants to return to the Zone of Interior.
The Consultant System
In December 1943, when it had become apparent that a single surgical consultant could not cover the widely dispersed medical activities in the Southwest Pacific (map 2, p. 689), the author had been placed on temporary duty in the area surgeon's office, as assistant surgical consultant to Colonel Parsons. In this capacity, he visited the hospitals at Port Moresby and Milne Bay (Bases D and A) in New Guinea (maps 3 and 4).3
3Colonel Trimble's experiences beforehis assumption of his duties as assistant consultantand, later, as Consultant in Surgeryto the Surgeon, USASOS, SWPA, may be cited as typicalof the experiences of many medical officers. Since1940, he had held a commission as lieutenant colonel, Medical Corps Reserve, in the 18th General Hospital, theaffiliated unit of the Johns Hopkins Medical School where Colonel Trimble wasassistant professor of surgery. When the 18thGeneral hospital was divided into two units in April 1942, he became chief of the surgical service in the second unit, the 118th General Hospital. This hospital left Baltimore on 20 April 1942 and, after 10 days at Camp Edwards, Mass., was sent to the Port of Embarkation, San Francisco.
Up to that time, the Hopkins unit had been merely a paperorganization, with no military training other than occasional meetings and lectures. It had had no active duty and no sustained, practical, realistic military indoctrination. When it left Baltimore, it had no enlisted cadre, and its personnel consisted of only medical officers and nurses. When the unit sailed from San Francisco,it had its full complement of personnel, butthey were without training, and training could not be provided en route. Thecrowded conditions on shipboard (three other affiliated general hospitals, adozen station hospitals, and all their equipment werealso among the organizations transported on the U.S. Army Transport West Point), and the necessity for almost continuous messing and for frequent boat drills, as well as the prohibition against lights, made any instructional work of a major nature during the voyage entirely impossible.
The 118th General Hospital landed in Melbourne, Australia, on 4 June 1942. Ten days later it was moved to Sydney, where it wasset up at the Royal Prince Alfred Hospital, one of the teaching hospitals of the University of Sydney. For about a year, this unit was the only U.S Army hospital in New South Wales to care for Army, Navy, and Air Force patients. The work was chiefly of the station hospital type, though some combat-wounded casualties were received, among them a few Filipinos who had been brought out of the Philippines on the S.S. Mactan, the only hospital ship to leave the islands before their surrender. These patients had been cared for in Australian Army hospitals before the 118th General Hospital began to function.
The next battle casualties received came from Buna-Gona on New Guinea. When a permanent installation forthe 118th General Hospital was set up, as part of a hospital center constructed at Herne Bay, Australia, 25 miles south of Sydney, with Lend Lease funds, the surgery was derived chiefly from troops staging in the Sydney Base Area and was still chiefly of the station hospital type. The only battle casualties received were brought in by Australian hospital ships and were chiefly patients who required late orthopedic care.
Colonel Trimble's first real contact with battle casualties was therefore in December 1943, when he went on temporary duty for 4 months as assistant surgical consultant in the Office of the Surgeon, USASOS, SWPA. His experience duplicated that of many other medical officers who, when the need arose, were able to transfertheir fine training and broad experience in civilian surgery to the military situations they encountered.-J. B. C., Jr.
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MAP 3.-The Allied advance from Townsville, Australia.
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MAP 4.-The distances from mounting areas to Lingayen Gulf.
Although the original plans for the consultant system worked satisfactorily enough with this expedient and others, it would have been better if the table of organization for Headquarters, USASOS, SWPA, had been so set up that the consultant section could have been enlarged as needs increased. Originally, there had apparently been no real appreciation of the services which could be rendered by consultants. The situation changed when General Denit became Chief Surgeon in January 1944 and as his position and authority were widened in the successive reorganizations which occurred in the Pacific in 1945 (fig. 275). General Denit, who had served in the North African theater before his appointment to the Pacific, was thoroughly cognizant of the accomplishments of the consultant system in that theater and of the improvement in the care of battle casualties that had been effected through the system.
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However, it was not until after the organization of AFPAC, in June 1945, that a satisfactory table of organization for consultants in surgery was set up in the Pacific (chart 6). Even this plan, though in a sense it went from poverty to riches, was still a compromise because it provided for no consultants in the various specialties at the top level of AFPAC. The compromise could not be avoided. General Headquarters insisted upon such a small staff at this level that there were spaces for only three consultants, one in medicine, one in surgery, and one for special research projects. Initially, upon organization of General Headquarters, AFPAC, the late Col. Ashley W. Oughterson, MC, was assigned to fill the positions for both the consultant in surgery and special research projects. It was planned, therefore, to resort again to the expedient of temporary duty and to bring various surgical specialists assigned to AFWESPAC from that headquarters to General Headquarters, AFPAC, as they were needed for special periods.
Before it became necessary to put this plan into effect, theJapanese surrendered-on 14 August 1945 (fig. 276). A surgical and anorthopedic surgical consultant remained on dutyat Headquarters, AFWESPAC. Colonel Oughterson had a particularknowledge of, and interest in, wound ballistics.Almost as soon as he arrived at General Headquarters, AFPAC, the first atomic bomb
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CHART 6.-The table of organization for consultants in surgery, U.S. Army Forces, Pacific
was dropped, and he immediately assumed the responsibility for special studies of the casualties at Hiroshima and Nagasaki.
A consultant in anesthesiawas never appointed in the Southwest Pacific Area. Maj. (later Lt. Col.)Forrest E. Leffingwell, MC, was appointed in May 1945 to survey anesthesiapractices in hospitals in the Philippine Islands andto act as part-time consultant at Headquarters, AFWESPAC. While he performed these duties, untilNovember1945, Major Leffingwell also continued his duties in anesthesiain the 80th General Hospital in Manila.
Functions of the Consultant
When the author was appointed Assistant Consultant in Surgery, Office of the Chief Surgeon, USASOS, SWPA, his duties were to visit the hospitals in the bases in New Guinea (fig. 277), evaluate the surgical personnel in them, evaluate the professional care that casualties were receiving, and make recommendations to the Chief Surgeon based on these observations.
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When he assumed his duties as Consultant in Surgery, Office of the Chief Surgeon, USASOS, SWPA, in August 1944, in succession to Colonel Parsons, his functions were considerably broadened. The chief function of the surgical consultant in this office was to advise the Chief Surgeon on ways and means of giving the most expert professional care to wounded soldiers. The most efficient way of accomplishing this result was the correct evaluation and placement of surgical personnel (pp. 714-719).
Other duties of the Consultant in Surgery includedmaintenance of close liaison with all offices of the MedicalSection, Headquarters, USASOS, SWPA, especially those responsible for medical planning, evacuation, hospitalization, supply,and personnel; instruction of newly arrived personnel in the principles of the surgicalcare of battle casualties;correction of surgical errors by indoctrination and demonstration; disseminationof information secured from other theaters and the Zone of Interior;compilation of data for ETMD (Essential Technical Medical Data) reports;planning for medical support of future operations; andconstantly striving to formulate plans to prevent the occurrence ofcasualties and to improve the care of the wounded. Because of the vast distances andthe difficulties of communication in the Southwest Pacific (map 2, p. 689), the Consultant in Surgery, whenhe left the Office of the Surgeon, SWPA, hadto be prepared to function independently for long periods of time.
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FIGURE 277.-The 10th Evacuation Hospital, Oro Bay, New Guinea, December 1943.
Because of his interest in the condition of the battle casualties whom he had observed at Hollandia after they had been evacuated from Leyte early in that campaign, this consultant received permission from Headquarters, USASOS, SWPA, to go to Leyte on the hospital ship Comfort, to make first-hand observations there. The ship arrived on 14 November, "Bloody Sunday," the day of the first Japanese suicide (kamikaze) raids, and he operated all night with the Navy surgeons on the LST 464, assisting in the care of the casualties.
After a 10-day stay on Leyte, this consultant flew back toHeadquarters, USASOS, SWPA, in Hollandia,to organize the surgical teams which had been offered to Brig. Gen. William A.Hagins, Surgeon, Sixth U.S. Army, and had been accepted by him for the remainder ofthe operation on Leyte and for the invasion of Luzon (p. 726).
After he had landed on Leyte, the author learned thatarmy hospitals coming ashore were having considerable difficulty in setting up because, almost as fast asthey selectedappropriate sites, these sites were taken over by line orother troops (fig. 278). He was able to have this situation altered by the sortof fortunate personal contact that accomplished so much in this and othertheaters of operations. Instructions were promptly issued from General MacArthur'sheadquarters, which were then at Tacloban, Leyte, that medical units were tohave first priority on sites that they selected. To follow this up, thisconsultant wrote to General Denit, and had the letter hand-carried to him,suggesting that it would be well to send medical officers of high enough rankto Leyte at once, to prevent a repetition of this particular difficulty.
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FIGURE 278.-Hospital sites on Leyte, Philippine Islands, 8 December 1944.
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FIGURE 279.-The invasion fleet in the harbor, Leyte Gulf, Philippine Islands, 22 October 1944.
The author also, indirectly, achieved another change that was not a real medical responsibility by pointing out to Col. Roger O. Egeberg, MC, aide to Gen. Douglas MacArthur, an unnecessary tragedy which had occurred in the harbor at Leyte (fig. 279). A troopship, loaded with Air Force personnel, had lain at anchor for 13 days and then had incurred very heavy casualties from a Japanese suicide raid. The troops had not been landed before the raid because of lack of protection ashore from the heavy tropical rains. An order was at once issued from General MacArthur's headquarters that thereafter troops were to be landed as soon as their ships reached Leyte Gulf, whether or not they had to stay out in the rain when they went ashore.
Evaluation and Assignment of Personnel
Evaluation of personnel
The second surgical consultant in the Southwest PacificArea, like the first, had nomore important duty than the evaluation andassignment of surgical personnel. His task wasmore difficult, however, for, after the first hospitalswith outstanding surgical talent reached the theater in1942, there were no further increments of such caliber,and few, if any, replacements on any superior level of ability. Except forconsultants, no other fully trained ("A-
715
3150" or "B-3150") surgeons arrived in theSouthwest Pacific Area during the 3 years of active fighting there. Since notrained surgeons were made availableas casual replacements to the end of the war, it was necessary to reinforceweaker units by taking more experienced personnel from other more richlysupplied units.
Shortages of trained personnel could be partly explainedby a certain amount of wastage in newly arrived units. It was notpossible to remedy this situation throughout the war. Better planning forequipment, transportation, and otherdetails would have shortened staging periods and permitted surgical personnel to be putto workat once. This would have improved the morale of the medical officers, who,quite naturally, resented long periods ofenforced inaction.
The chief reason for shortages of personnel, however, wasthat in World War II, as in previous wars, too little attention was paid to theessential qualifications of medical personnel. Tables of organizationwere adequate, but the ability of the officers assigned to the various spaceswas often not correctly evaluated. As a rule, the assignmentwas on the basis of rank, without sufficient consideration of the adequacy ofprofessional abilities.
Emphasis on rank was not, of course, a fault confined to theMedical Department of the Army. Whensurgical help was offered to the Navy for the LST's which were to participatein the invasion of Leyte, it was refused as not needed, on the ground that theships were adequately staffed, some of them by officers with therank of lieutenant commander. It is true that all LST's had medicalofficers on them, but many of these officers were not surgeons, let aloneexperienced surgeons, and the casualties had to get along with such care asthese officers could provide them during the week'strip from Leyte to Hollandia. The classification of medical officers intospecialty groups came too late in the war to be helpful in the SouthwestPacific, and experienced personnel were in short supply until the fighting ended.
This consultant, like his predecessor, followed the planof studying all newly arrived hospitals in regardto qualifications of personnel and recommending such changes in assignmentas seemed necessary. As may be expected, the best surgeons were not always thosewith the best training on paper.
Selection of personnel for portable surgical hospitals(fig. 280) was a major responsibility of the surgical consultant, aresponsibility which increased in difficulty as the supply of experiencedsurgeons dwindled.
As of the middle of July 1945, a month before thesurrender of Japan, the 141 hospitals in AFWESPAC (including the Sixth andEighth U.S. Armies), with 67,000 beds, needed 314 surgical officers to bringthem up to authorized table of organization strength (table 3). The 32 surgeonsthen in the theater with a ratingof "B-3150," or higher (table 4), included the surgical consultants inthe Officeof the Surgeon, AFPAC, and the commanding officersof several hospitals. There were only 14 orthopedicsurgeons, 3 plasticsurgeons, and 2 neurosurgeons with the rating of "B" or higher.The single surgeon in the
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area with any training in thoracic surgery had a rating of only "D-3150." Because of these shortages, work beyond their abilities often had to be done by medical officers without specialty ratings.
Transfer and assignment of personnel
It was the policyof the Chief Surgeon that all changes of assignment of surgical personnel withinthe Southwest Pacific Area should be either initiated by the Consultant in Surgeryin his office or referred to the consultant for hisapproval. These instructions were usually carried out, though often afterconsiderable and usually unavoidable delays. When they were violated, they almost alwaysinvolved company grade officers, and the consequences oftheir disregard were seldom serious.
The Chief Surgeon's policy was entirely logical, sinceone of the functions of a surgical consultant was to evaluate the individualabilities of surgical officers, and changes in assignments should not have beenmade without his knowledge andconsent. After his visits to various hospitals, this consultant alwaysreported to the Chief Surgeon his evaluation of each unit as a whole, hisrecommendations for strengthening it if it was weak, or, if there was anexcess of surgical talent in it, for funneling some of it off to strengthen lessefficient and less well staffed units.
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|
| Number of hospitals | Number of beds | Number of surgical officers short of authorized strength | |||||||||
General | 29 | 37,500 | 103 | |||||||||
Station | 36 | 11,950 | 62 | |||||||||
Evacuation | 14 | 6,650 | 65 | |||||||||
Convalescent | 1 | 3,000 | 4 | |||||||||
Field | 17 | 6,800 | 42 | |||||||||
Portable surgical | 44 | 1,100 | 38 | |||||||||
| 141 | 67,000 | 314 | |||||||||
| Type of hospital |
| |||||||||||
3150 |
| 3106 | 3125 | 3126 | 3111 | 3131 | 3152 | 3151 | 3306 | 3115 | Total | |
General | 2 | 12 | 16 | 9 | 10 | 7 | 21 | 4 | 4 | 15 | 3 | 103 |
Station | 6 | 10 | 22 | 1 | --- | 9 | --- | --- | --- | 5 | 9 | 62 |
Evacuation | 2 | 6 | 6 | --- | --- | 6 | 8 | 12 | 13 | --- | 212 | 65 |
Convalescent | 2 | --- | 2 | --- | --- | --- | --- | --- | --- | --- | --- | 4 |
Field | 11 | --- | 9 | --- | --- | --- | --- | --- | --- | 8 | 14 | 42 |
Portable surgical | 31 | --- | --- | --- | --- | --- | --- | --- | --- | --- | 7 | 38 |
| 54 | 28 | 55 | 10 | 10 | 22 | 29 | 16 | 17 | 28 | 245 | 314 |
13150-general surgeon; 3152-orthopedicsurgeon; 3106-ophthalmologist and otorhinolaryngologist; 3125-ophthalmologist;3126-otorhinolaryngologist; 3111-urologist; 3131-neurosurgeon; 3152-plasticsurgeon; 3151-thoracic surgeon; 3306-radiologist; 3115-anesthesiologist.
2Corrected figure. The original document showed 14 in this block,which would have made the obviously erroneous shortage of anesthesiologists 47,the shortage of surgical officers in evacuation hospitals 67, and the grandtotal of shortages 316.
|
|
| ||||||||||
3150 | 3153 |
| 3125 | 3126 | 3111 | 3131 | 3152 | 3151 | 3115 | Total | |
B | 32 | 14 | 8 | 11 | 6 | 10 | 2 | 3 | 0 | 4 | 90 |
C | 180 | 31 | 15 | 15 | 26 | 23 | 10 | 1 | 0 | 13 | 314 |
D | 105 | 33 | 9 | 2 | 6 | 8 | 3 | 2 | 1 | 27 | 196 |
None | 70 | 0 | 2 | 1 | 1 | 3 | 2 | 0 | 0 | 6 | 85 |
| 387 | 78 | 34 | 29 | 39 | 44 | 17 | 6 | 1 | 50 | 685 |
13150-general surgeon; 3153-orthopedic surgeon;3106-ophthalmologist and otorhinolaryngologist; 3125-ophthalmologist; 3126-otorhinolaryngologist;3111-urologist; 3131-neurosurgeon; 3152-plastic surgeon; 3151-thoracicsurgeon; 3115-anesthesiologist.
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Recommendations for the transfer of surgical personnelsometimes were based on incompetence but more often were based on the lack ofexperienceof the particular officer in aposition in which surgical experience was not onlydesirable but essential. No matter how urgent the transfer might seem, however, itsaccomplishment was always tedious and was sometimes unsuccessful. The chief causes ofdelay were distances between units and headquarters and delays at headquarters.Even though written communications were dispatched by airmail, this method inwartime was often slower than ordinary mail in peacetime. For instance, when the author was acting asassistant surgical consultant in the winter of 1943-44, he might recommend, from abase hundreds of miles from headquarters, that a certain officer be transferred.The recommendationwould be made to the Chief Surgeon through Colonel Parsons, Consultant inSurgery in the Chief Surgeon's Office; communication took weeks, and, ifColonel Parsons was out of hisoffice, more weeks might elapse before the recommendation could be made and acted upon.
There were also other delays. Before an officer could betransferred, it was the policy to secure concurrence of(1) the base section commander, which in practice meant his surgeon, and(2) the commander of the hospital to which the medical officer to bemoved was assigned. The consultant had no authority to order the transferof personnel. He could only make recommendations, and the hospital commandercould think of many justifiable reasons why a transfer should not be made,particularly when it was proposed that a good officer be moved out of theunit.
This excess of military courtesy, which was a wartimedevelopment, really amounted to obstruction. Before the war, The SurgeonGeneral exercised a centralized control over all MedicalDepartment personnel and dictated their assignments. The concurrence of post commanderswas not necessarily secured in advance. During the war, army commanders had thisauthority within their armies, and, if the changes recommended werenot accepted, there was usually a sound reason, chiefly the shortage ofreplacements.
Proposal for temporary duty of medical personnel
At the end of December 1944, this consultant proposed tothe Chief Surgeon, USASOS, SWPA, a plan to augment the strength of themedical units in the Sixth U.S. Army on Leyte, in which casualties were thenbeing received in such numbers as to require augmentationof the table of organization strength. The plan was that hospitals that foundthemselvesin this situation should apply for additional personnel by requisition, specifyingthe military occupationalskill desired, and that these requisitions would be filled by personnel, on a temporaryduty status, from hospitalsin the rear that were less active or were building or staging. Hospitalsunder control of USASOS, SWPA, would make their requisitions to the ChiefSurgeon through the base, intermediate section, or basesection surgeons. Hospitals under the control of field armies would effectthe temporary exchange of personnel withinthe
719
army command at the discretion and direction of the army surgeon. When theemergency hadpassed, personnel on temporaryduty would be returned promptly to the parent organization.
The plan was approved informally by the Surgeon, Sixth U.S. Army, but wasdisapproved by the ChiefSurgeon, USASOS, SWPA, who feared that officers on temporary duty would beretained too long in an army area when they might be needed in theirown units or might be permanently lost to their own units and thuspass out of USASOS, SWPA, control.
When this plan was proposed, it was estimated that 40 percent of thehospitals in the area would be inactive for one or another of the reasonsmentioned. This estimate was much too high, but the proportion was stillconsiderable,because of the character of military operations in this area.Had the plan been approved, it would probably have addedsix or eight trained general surgeons andthe same number of trained orthopedic surgeons tothe hospitals in theSixth U.S. Army area. The number would have been no largerbecause so many surgeons had already been withdrawn from general andstation hospitals to serve on surgical teams, and, forthis and other reasons, these hospitals had already been stripped to the bare bonein professional personnel. Even this small number of competent surgeons could,however,have been assisted by less experienced surgeons, and the plan would have helped toovercome the acute shortages of trained personnel that frequently existed inarmy areas.
Training Policies and Problems
Long before World War II, the whole subject of the proper treatment of battle-incurred wounds had been well discussed in the official history of the U.S. Army Medical Department in World War I. Not many World War II surgeons were familiar with these volumes (although General Denit carried the surgical volumes ashore with him when he landed in North Africa). The information contained in these volumes, with the proper modifications for the advances in the management of shock, anesthesia, antimicrobial therapy, and similar subjects, could well have formed the basis of the directives concerning medical care promulgated in World War II. Few surgeons in the Southwest Pacific Area knew that this history existed.
Practical training
Didactic instruction was of great value in the indoctrination of newlyarrived units, butactual experience was necessary to convince most surgeons of the fundamentaldifferences between civilian and military practice. The misunderstandings wereuniversal. It was remarkable to note the sameness of the errors committed by surgeonsinexperienced inmilitary medicine, even though they wereexperienced and competent in civilian practice.
Primary suture of wounds, inadequate debridement-particularly ofinnocent-appearing perforating wounds of large muscles, tight packing of
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wounds, and undue reliance onbacteriostatic agents were among the cardinal errors. Itwas hard to make surgeons without combat experiencerealize that transportation of the combat casualty from one facility toanother was inevitable and that his care must be gearedto that fact. A procedure which would have beenreasonable and appropriate in civilian practice, when the patient couldremain in bed until his wounds were healed, was therefore not safe in militarypractice in forward hospitals from which the soldier must be transported to the rear. Transportation underthe happiest circumstances induced fatigueand further shock. The jolting caused shifting of fascial planes, withresulting hemorrhage or the collection of fluid in dead spaces, which was an invitation to infection. All ofthese possibilitieswere enhanced by the methods of evacuation necessary in the Pacific (fig.281).
Personal visits to hospitals by consultants were found toprovide the most effective form of teaching, and a large part of theconsultants' time was necessarily spent away from the Chief Surgeon'sOffice. In a theater in which hospitalunits were in isolated bases, thesevisits were especially appreciated by the hospital staffs. For one thing, theyindicated the official interest of the Chief Surgeon in the problems of allthe hospitals and their staffs. For another, they provided opportunities for discussion of professional problems. The liaison thusestablished between the consultants and the base surgeons proved mostuseful. The base surgeons came to rely upon the opinion of the consultantsconcerning the care and disposition of patients, as well as the placement ofpersonnel.
New units arriving in the theater were met at the staging areas by theconsultant. Meetings were held with the surgical staffs, and the surgicalpolicies of the theater were discussed. Whenever possible, surgical officerswere placed on temporary duty with active hospitals, so that they couldobtain instruction in special problems and could see for themselves how battlecasualties must be managed.
Hospital units designated to accompany a task force werealways visited whenever possible by the surgical consultant before departure.
The training courses in various specialties provided by theMedical Department in the Zone ofInterior were excellent. However, judgment and skill cannotbe learned in a matter of weeks, andmost of the officers who had taken these courses were still inexperienced andrequired careful supervision. It was repeatedly observed that the selection ofofficers for these courses was not as wise as itmight have been. It would have been better, for instance, to train experiencedgeneral surgeons for neurosurgical duties rather than, as happened in a numberof instances, give the courses to officers who had had little surgicalexperience or none at all. It was later found that the consultants inneurosurgery in the Office of The Surgeon General had also arrived at this sameconclusion.
Except in anesthesia, no attempts were made at training inthe surgical specialties in the Southwest Pacific Area. This single attempt waslimited to the training courses in anesthesia given at the 118th GeneralHospital, at the
721
request of the Chief Surgeon. The 4-month period ofinstruction covered the physiology and pharmacology of anesthesia, care ofanesthetic equipment, and special techniques. There were 22 hours of lecture.The practical part of the course consistedof the administration of anesthetics, under supervision, to between 100 and120 cases for each graduate. The courses were discontinued in July 1944,because of shortages of surgical cases in the hospital. When the selection ofstudents for this assignment was judicious-as it sometimes was not-the graduates provedboth capable and useful.
It was recognized early in the fighting in theSouthwest Pacific Area that some means must be devised by which tours of activehospital duty could be provided for inexperienced medical officers servingin units in which no real clinical experience or training was possible. The basis ofplanning was that officers who were assigned as battalionsurgeons or to remote dispensaries or who were engaged in duties that werechiefly administrative should be transferred temporarily to hospitals in whichthey might receive the necessary training, while officers inthose hospitals would serve as their exchanges. The refresher courses in the designatedhospitals were to include anesthesia, ophthalmologyand otolaryngology, general surgery, orthopedic surgery, roentgenology, andgeneral medicine and allied specialties.
These plans were discussed vigorously at intervals, butthey were not implemented until Manila was taken and Luzon was secured, chiefly because ofthe long distances, shortages of transportation, anddifficulties in radio and postal communications in the Pacific. Early in August 1945,50 medical officers from the Sixth and Eighth U.S.Armies were finally placed on detached service in general hospitals on Luzon forthe purposes just described.4 Theyhad scarcely begun their workwhen both armies were alerted for occupation duty in Japan and they had to be recalled.
Dissemination of information
It would have been extremely profitable if exchangeof information concerning policies, techniques, and professional experiences had beenpermitted directly between the medical section of afield army headquarters and that of USASOS, SW PA, as well as between theSouthwest Pacific Area and other theaters. As it was, all of this informationwas transmitted by way of theOffice of The Surgeon General. It was slow in reaching the Pacific and evenslower in seeping down to the surgeons who needed it most. Much of thisinformation was also not asdetailed as it might have been.
Bases in New Guinea, including Port Moresby, Milne Bay, OroBay, Lae, Finschhafen, Hollandia, and Biak, all had their own medicalsocieties, as did the bases at Tacloban on Leyte and in Manila (fig. 282).Medical meetings were difficult to hold because of the conditions prevalent inthe area, but, in retrospect, they could have been morewidely utilized than they were. Ward rounds and seminars should also have been morewidely employed.
4Circular Letter No. 31, Office of the ChiefSurgeon, Headquarters, U.S. Army Forces, Pacific, 28 July 1945, subject: Training Program For Medical Officers.
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723
FIGURE 281.-Continued. C. Landing craft. D. A hospital ship.
724
FIGURE 281.-Continued. E. Light aircraft.
The professional training of inexperienced medical officers in the Southwest Pacific would have been greatly simplified if texts and journals had been provided in much larger quantities.
Directives - In the SouthwestPacific Area, as in other theaters, the varied training of medical officers andtheir range of surgical experience, ranging froma great deal to none at all, required that specific instructions beissued for methods of treatment of wounded casualties. Medical information wasissued in the form of technicalmemorandums, prepared in the Chief Surgeon's Office, USASOS, andpublished over his signature.
Before these official memorandums began to be issued,standing operating procedures were issued on various levels-by hospitalcommanders, division surgeons, corpssurgeons, and base surgeons. Theywere chiefly based on informationsecured from hospitals that had treated large numbers of casualties. Localizedstandardization of sorts was thus developed, and objectionable and questionablepractices were generally prevented, but therewas no true uniformity ofmanagement of casualties until the official directives just mentioned beganto be issued. These memorandums were based not onlyon the previous experience in thetheater but also on the experience of other theaters as relayed to theSouthwest Pacific Area in the form of ETMD reports.
The distribution of these reportsin the Southwest Pacific Area was not good. This consultant did not know oftheir existence until August 1944, and
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FIGURE 282.-Headquarters, Philippine Base Section, Manila, Philippine Islands, 25 May 1945.
his own lack of knowledge reflected the general lack of knowledge of other medical officers concerning them. Once the ETMD reports were called to the attention of medical officers, they cooperated in producing material for them, and much valuable data were thus secured. It was the policy, as far as possible, to use the names of contributors, in fairness to them and also because of the stimulus thus provided to further production.
When the Consultant in Surgery finally learned of theexistence of the ETMD reports, he suggested that whole articles, or abstracts ofarticles, of special value which appeared in them be reprinted in pamphlet formeach month, either by the Office of The Surgeon General or in the area, and bedistributed to officers performing surgery. The plan, which was suggested on aworldwide basis, proved impractical in the Southwest Pacific Area because of therapid movement of Headquarters, USASOS, SWPA, to Hollandia in September 1944, toLeyte in January 1945, and to Manila in the following April.5
5There is an unfortunate lack of detailed data on various types of combat-incurred injuries from hospitals in the Southwest Pacific Area. This experience suggests that a standard form should have been provided for all of the theaters for the reporting of monthly battle casualties from each medical treatment facility. Such a form could have contained the information in more detail than was required in the official forms in use, without, at the same time, being so detailed as to impose an additional burden on medical officers already overwhelmed with work. There was no machine records unit in the Office of the Chief Surgeon, SWPA, at any time, and, even if it had been available, reports received from individual hospitals varied so widely that they could not have been fitted into a theater pattern.
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Surgical Teams
As pointed out elsewhere (p. 756), the concept of surgical teams was not accepted in the Southwest Pacific Area until April 1944, shortly after General Denit had become Chief Surgeon, USAFFE (U.S. Army Forces in the Far East), and SOS, SWPA. The teams which were then formed on paper were offered to the Surgeon, Sixth U.S. Army, by General Denit in the summer of 1944, for the invasion of Leyte. The offer was declined, and no surgical teams were used to supplement the medical units scheduled to support the landings of 20 October. Shortly afterward, this decision was reversed, and four teams were placed on temporary duty with the Sixth U.S. Army, with the understanding that they would return to their original stations when the need for them had ceased. The value of the team concept was so evident that other teams were requested for support of the field and evacuation hospitals which landed in Lingayen Gulf in January 1945. In all, 23 teams were used in this invasion, and others landed elsewhere, with units of the Eighth U.S. Army. It was part of the author's duties as surgical consultant to provide the personnel for these teams.
The objections originally raised to the use of surgical teamswhen they were first proposed by Colonel Parsons in 1942 had been chiefly bymedical personnel with limited clinical experience. The objections did not provevalid. Testimony from forward units was that the presence of these teams, farfrom being resented by organic personnel of field and evacuation hospitals, waswelcomed. The second objection raised to the team system, that personnelconstituting them would be lost permanently to the parent organization, also didnot materialize; it was obviated by correctly written orders.
Although surgical teams filled an appreciable portion of thesurgical breach in the last months of active fighting in the Southwest PacificArea, auxiliary surgical groups would have been more satisfactory for a numberof reasons. They were better organized. Their personnel had generally had bettertraining and more experience, and were therefore of more even ability. Finally,the morale factor could not be ignored. The great weakness of surgical teams asthey were constituted in the Southwest Pacific Area was that their makeupdepended entirely upon the decisions of the commanding officers of the hospitalsfrom which they were derived. Some of these commanding officers simply used theopportunities thus afforded to get rid of undesirable personnel. Many of theofficers who served on the teams were well trained and highly competent, butcommanding officers, quite naturally, did not willingly release their bestsurgeons. Therefore, the teams, like the staffs of portable surgical hospitals,though competent on the whole, represented a very uneven array of talent.
Specialized Hospitals
In both Australia and New Guinea, from 1943 on, a considerable amount of specialization was practiced in hospitals. Several bases were large enough to justify the establishment of hospital centers, one or more of the hospitals being devoted to particular specialties.
727
When the idea of specialized hospitals in Hollandia was firstproposed by this consultant, the chief of the Professional Services Division,Office of the Chief Surgeon, USASOS, did not regard the idea as practicalbecause of the long distances between hospitals and the extremely poor roads.The idea was revived in Leyte but again was not regarded as practical in view ofthe bad weather, the poor roads, and the difficult terrain. In retrospect, itseems to have been an error not to have pressed the idea more vigorously at anearlier date in the Southwest Pacific Area, in view of the excellent resultsobtained by this method in the Mediterranean and European theaters.
The author's suggestion that casualties be moved from Leyteand Mindanao to Manila for specialized treatment was also not accepted becausethe officer in charge of the evacuation section in the Office of the ChiefSurgeon, USASOS, SWPA, considered that evacuation from that city to the Zone ofInterior would present undue transportation difficulties. Actually, thesedifficulties did not occur, and failure to accept the plan was unfortunate.Because of the delay in their utilization, hospitals in Manila played no part atall in the care of combat casualties, being utilized only for staging and forthe care of station hospital type patients. The hospitals in Leyte, meantime,were seriously overcrowded, and their staffs were greatly overworked.
A limited form of specialization became effective in February1945, when casualties with chest injuries were directed, as far as possible,from Luzon to the 118th General Hospital on Leyte, while surgeons from otherunits were brought over, as admissions required, to this hospital on temporaryduty.
It should be emphasized that the idea of specializedhospitals to handle special types of wounds, including fresh wounds, like anumber of other ideas which did not win acceptance, was proposed by the theaterConsultant in Surgery on the basis of his own observations and his clinicalexperience. The idea was rejected in an office in which planning was largely bytables and charts, and usually by officers whose clinical experience was limitedand who lacked firsthand knowledge of the surgical situation in forward areas.
Equipment
The theaters of operations in the Pacific were generally regarded as the stepchildren of the war, and in a sense they were, though the vast distances and the difficulties of communication between them and the mainland always had to be taken into account. In spite of the obstacles which had to be overcome, equipment was, on the whole, very satisfactory. Smaller hospitals frequently complained of the lack of certain items, but the explanation usually was that these items were not on their tables of equipment and were not needed for the mission of hospitals on this level.
Nonstandardized items could usually be procured when a realneed for them could be shown, though there was often a considerable delay beforethey were received.
728
Clinical Research and Investigation
No outstanding surgical research was accomplished in any of the Pacific areas, in contrast to the outstanding investigations in such medical fields as malaria, dengue fever, scrub (bush) typhus, and schistosomiasis.
Original plans for the Southwest Pacific Area did not includeformal research studies. The need for an organization for the correlation andencouragement of both clinical and laboratory research was, however, promptlyevident, and in 1943 Col. Maurice C. Pincoffs, MC, Consultant in Medicine,USASOS, SWPA, requested, through the Chief Surgeon, that a medical generallaboratory be provided for this purpose. In March 1944, word was received fromthe Office of The Surgeon General that such a unit would be sent to the area.Because there were a number of medical officers in the theater with interest andtraining in investigative work, as evidenced by their previous accomplishments,it had been requested that the laboratory arrive with certain table oforganization vacancies, to be filled by these officers. This request wascomplied with. Inability to secure necessary priorities and other factorsdelayed the arrival of the unit, and it was not until August 1944 that the 19thMedical General Laboratory debarked from the United States, designated to arrivein the Southwest Pacific in September.
From the surgical standpoint, it had always been consideredhighly desirable that the laboratory unit coming to the area should be operatedin combination with hospital facilities. After considerable discussion among theconsultants involved, it was decided to use for this purpose the 250-bed 12thStation Hospital, which was duly transferred from Australia to Hollandia.
With the assistance of USASOS engineers, plans were drawn upto house the laboratory and the hospital under one roof. Plans were also madefor changes and additions required to make the portable hospital buildings,suitable for use in Australia, satisfactory for scientific investigativepurposes in tropical New Guinea. A high priority was secured for the largeamounts of material and extra equipment required for these new purposes. Thenecessary items were secured through the Office of the Chief Quartermaster, SWPA,then located in Sydney, Australia, and were placed aboard a liberty shipdestined for Hollandia. During this period, steps were taken to locate personnelwithin the area who could contribute to the project.
In spite of these careful plans, nothing came of them. Notlong after the arrival in Hollandia of the 12th Station Hospital, the 19thMedical General Laboratory, and the material and equipment just described, thetactical program for the invasion of the Philippines was so stepped up that theinvestigative project had to be curtailed. The 19th Medical General Laboratorywas, however, established as planned at Hollandia (fig. 283).
Development of Body Armor for Infantrymen
Almost as soon as the author entered service, he became interested in the possibility of protecting particularly vulnerable areas of the body by the development of some sort of body armor for the chest and abdomen of infantrymen,
729
just as helmets had been developed for the protection of the head. In September 1942, while still in Australia, he learned that the Japanese were testing an armored vest on their troops in New Guinea (fig. 284). Eventually, after a great deal of effort in various quarters, he was able to procure a specimen vest through the kindness of the commander of an Australian destroyer. In the meantime, Col. (later Brig. Gen.) Percy J. Carroll, MC, then Surgeon, USAFFE, had been informed of this consultant's project and had expressed great interest in it.
The Japanese vest was an ingenious article. It was made ofmetal plates, set in canvas, was buttoned on in three overlapping sections, andweighed a little over 5 pounds. Tests showed that this vest, which was designedto protect only the anterior chest, could resist missiles shot from machinegunsand pistols at velocities of 800 f.p.s. Metal construction was obviouslyessential. Tests with vests of plastic material available at that time showedthat they were easily pierced and fragmented by the .45-caliber automatic pistoland the Thompson submachinegun.
From the Japanese model, the author constructed a protectivevest made of six large overlapping metal plates that had been molded on a man 5feet 7 inches tall and weighing 150 pounds (fig. 285). The vest covered more ofthe region of the collar bones, upper breast bone, flanks, and lower abdomenthan the Japanese vest.
730
FIGURE 284.-A captured Japanese armored vest. A. The vest open. B. The vest closed.
On 25 March 1943, the author sent to Brig. Gen. Clyde C. Alexander, USASOS, SWPA, a summary of his studies on protective body armor. In this communication, he recommended that a vest "constructed along the lines of the captured Japanese vest" be produced for U.S. Army infantrymen. In June, upon request, he sent his set of Japanese body armor to the Chief Ordnance Officer, USASOS, SWPA. In December, also upon request, he submitted the vest which he had designed to the Chief Ordnance Officer, USASOS, SWPA, to be sent to the Chief of Ordnance, War Department, Washington.
In February 1944, upon request of Maj. Gen. (later Gen.)Nathan F. Twining, Commanding General, Fifteenth U.S. Air Force, the vest wassubmitted through channels to the Surgeon, Fifteenth U.S. Air Force. GeneralTwining had become interested in it while he was a patient in the 118th GeneralHospital.
731
FIGURE 285.-Metal plates designed by Colonel Trimble for a protective vest.
In April, a complete set of blueprints of this vest was made in the Office of the Surgeon, Fifteenth U.S. Air Force. Also in April, at the direction of the Chief Surgeon, USASOS, SWPA, a complete report on the body armor which he had devised was submitted by this consultant to the Office of Scientific Research and Development, Washington, with an indorsement by General Denit.
On 4 August 1945, in a memorandum to General Denit, ChiefSurgeon, AFWESPAC, the author summarized conferences he had had in Washingtonwith various officers in the Office of the Chief of Ordnance, Army ServiceForces, and with Brig. Gen. Edward S. Greenbaum, USA, Executive Officer, Officeof the Under Secretary of War. He learned during these conferences that 8,000vests, 4,000 in a light and 4,000 in a heavier weight, were then on their way toAFPAC by ship and that an additional 100,000 of the heavier variety would becomeavailable about 1 September. A recommendation that 400,000 more be producedwithout further delay had not yet been acted upon.
The surrender of the Japanese on 14 August 1945 madeunnecessary the use of the protective vests sent to the Pacific. It is notlikely that these vests would have proved satisfactory. They were constructed asa sort of overhead apron, with a front and back, and were very awkward to put onand take off. More important, the basic idea of protective overlapping plateshad been discarded entirely.6
6The story of the development of body armor in the Pacific, with illustrations, and its subsequent development and use in the Korean War, is told in greater detail in: Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962. It is unfortunate that the wearing of protective armor was not pushed as vigorously in World War II as it was in the Korean War. The use of protective armor would undoubtedly have saved many lives.-J. B. C., Jr.
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FIGURE 286.-Red Beach, Los Negros Island, Admiralty Group, 7 October 1944.
Amphibious LandingsWhen the author assumed his duties as surgical consultant,succeeding Colonel Parsons, in the Office of the Chief Surgeon, USASOS, SWPA,the next military move was to be the occupation of Morotai (OperationINTERLUDE), to be followed a month later by the first Philippine operation, thenplanned for the island of Mindanao (Operation KING I).
Planning for Morotai operation
The experiences gained in the medical support of amphibiouslandings in previous operations were immediately investigated by this consultant(fig. 286). His review included not only the reports of the landings in variousportions of the Southwest Pacific Area but also the reports from the Europeantheater in which Maj. Gen. Paul R. Hawley, Chief Surgeon, had summarized themedical experiences of the D-day landings in France.
In his report, General Hawley repeatedly emphasized theoutstanding part played by LST's in the provision of medical service for theinvading troops. These ships were used as both aid stations and hospital ships;each of them carried an experienced surgeon, 2 young Naval medical officers, andabout 20 hospital corpsmen. Hundreds of casualties from the beaches receivedtheir
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first medical care on them. Casualties with abdominal woundswere operated upon on them, with excellent results. Ships' personnel assistedin the care and feeding of the wounded during their off-watch periods. ReturningLST's transported about 90 percent of the total casualties evacuated duringthe early days of the operation, sometimes carrying as many as 150 to 300 on asingle trip.
On 6 September and 8 September 1944, in memorandums addressedto the Chief Surgeon, USASOS, SWPA, through the Chief of Professional Services,this consultant commented on the plans for the Morotai operation in the light ofthe D-day experience in Europe, and made the following recommendations:
1. Medical collecting and clearing company personnel shouldland with the assault waves during combined operations. This recommendation wasbased on General Hawley's criticism that during the landings in Normandy, onlythe 1st Division sent its medical troops in early; the clearing company thatlanded with it cared for the division casualties and for casualties of combatteams on either side of it for the first 24 hours.
2. Experienced surgeons should accompany the clearing companypersonnel. They could be selected from the list of surgical teams, eachconsisting of two surgeons and six enlisted men, submitted by the Chief Surgeon,USASOS, to the Sixth U.S. Army and the Seventh U.S. Fleet.
3. LST's to serve as hospital ships, especially staffed andequipped and clearly marked to indicate their mission, should go in to thebeaches as soon as the task force commander deemed it suitable. These shipsshould not be used for cargo purposes; they should be ready to take on patientsimmediately and not have to wait until their cargoes were unloaded on thebeaches.
4. An experienced surgeon and two assistant surgeons shouldbe on each LST to be used for hospital purposes. Present plans of the SeventhU.S. Fleet called for an experienced surgeon on every fifth LST and a juniormedical officer, with two Navy corpsmen, on each of the other LST's. Thebeachmaster was to direct casualties who in his opinion needed major surgery tothe LST's carrying experienced surgeons. The author considered this planpractical only if the LST's not staffed with experienced surgeons were to beused only to transport casualties from the beaches to hospital ships lying amile or two offshore for definitive surgery. If casualties were to be keptaboard LST's for any length of time, it was essential that they be staffed byexperienced surgeons. The details of the plans were not clear in this respect.
5. Portable surgical hospitals with the best trained surgicalstaffs (the lst, 3d, 5th, 16th, and 23d) should go ashore about the sixth wave.Evacuation hospitals would go ashore later, the time of their landing dependingupon the security of the position.
6. Army surgical teams could be used to supplement Navymedical personnel aboard the LST's. The professional training of the Navymedical officers was not clearly known, but reports suggested that they had hadrelatively little surgical experience.
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7. Evacuation by air of casualties given definitive care inportable surgical hospitals and evacuation hospitals should begin as early aspossible. In Normandy, although no air evacuation had been anticipated beforeD+7 and it was not expected to be significant before D+14, air evacuation beganon D+3.
8. An ophthalmologist should be available promptly, asprevious experiences had shown that there would be numerous eye injuries.
9. Regularly scheduled conferences should be held byrepresentatives designated by the Chief Surgeon, USASOS, SWPA, and the SeniorMedical Officer, Seventh U.S. Fleet.
Planning for invasion of Leyte
The Morotai operation, because of General MacArthur'sstrategy in outflanking the Japanese, was accomplished on 15 September 1944without casualties. Operation KING I, the landings planned for the southernPhilippines, was therefore canceled, and Operation KING II, the invasion ofLeyte, was advanced to 20 October 1944.
The plan was that, during the assault phase of theselandings, all casualties requiring immediate hospitalization would be evacuatedby assault Naval craft, APA's (attack transports) and Geneva-protectedhospital ships. To accommodate the casualties, certain changes were made in thestructure of the LST's and the APA's. LST's, each staffed with a surgicalteam of three officers, were to care for 75 litter and 75 ambulatory woundedeach. LST's without surgical teams were to transport 15 litter and 15ambulatory wounded each. APA's with four medical officers were to transport150 litter and 250 ambulatory wounded each. Naval medical personnel were toprovide definitive surgical care to casualties en route from the target area tothe New Guinea bases.
This consultant, with the approval of General Denit, visitedthe Senior Medical Officer, Seventh U.S. Fleet, several weeks before A-day, toreview with him the plans for care of the wounded and the professionalqualifications of the Army and Navy medical officers scheduled to providedefinitive care. As already mentioned, the records indicated that most of themhad little or no surgical training. The Senior Medical Officer had no detailedrecord of the professional qualifications of the Navy personnel assigned to thisduty, but he stated that he was certain that they were competent. He added thatsome of them were lieutenant commanders. The offer made by the author, on behalfof General Denit, to supply experienced Army surgeons for duty on the LST'sand APA's was declined.
The elaborate system planned for the Morotai operation by theNavy had been further expanded for this operation. The wounded would betransferred to the LST's with due regard for the nature of their wounds andthe specialized personnel aboard the ships, whose presence would be indicated bydifferent kinds of flags. The beachmaster was to decide where the individualcasualty belonged and was to start him on his way to the appropriate ship.
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The difficulties in this plan seemed obvious, and the authorpointed them out. They included the extent of the beaches; the confusion ofbattle, which would make identification of particular LST's difficult if notimpossible; the frequent multiplicity of wounds, which would make it difficultfor a lay person to decide which of the injuries was the most important; and thepossibility of hostile air attacks. It was thought that all of these conditionswould so complicate this specialized plan of triage as to make it impractical,as indeed it proved to be.
On 5 October 1944, in another memorandum to the ChiefSurgeon, USASOS, SWPA, the surgical consultant stated that the Navy planned touse LST's for hospital purposes only after the cargo was removed. Herecommended, as in an earlier memorandum, that these ships should be in thelanding force, ready to receive casualties immediately and not after the removalof their cargo, since a very large number of casualties might well occur duringthe assault on the beaches. He also recommended again that every LST,instead of every fifth ship, carry an experienced surgeon pointing out theefficiency of this plan in the Normandy landings. He recommended that severalportable surgical hospitals, staffed with experienced surgeons, be placed on theLST's which would act as hospitals during the invasion. He further recommended that the portable hospitals serve as hospitals throughout thelanding operation.
Report on Leyte invasion
ETMD reports from the Southwest Pacific Area for December1944 described the early surgical care during the Leyte invasion as follows:
In the first phase of the landings, casualties injured onlanding craft, after being given primary care, were transferred to LST's andattack transports staffed with surgical teams (fig. 287). Those injured on shorewere treated by battalion and regimental aid stations; they were given plasma asnecessary, and the usual first aid measures were carried out (fig. 288).
As the task force units moved inland, medical collecting andclearing companies began to function. Casualties received primary treatmentalmost immediately after wounding, and then, with little delay, were put aboardLST's, where blood was available and definitive surgery was undertaken.Although seven LST's were offshore on D-day with surgical teams aboard, onlytwo were primarily hospital ships. The others could not take over the care ofpatients until their cargoes were landed. Attack transport ships could beunloaded faster than LST's, and they were therefore the first ships to leaveLeyte with casualties.
The 7th Division Clearing Company was ashore by H+6 andperformed approximately 150 definitive operations within the next 48 hours. FromD-day until D+4, however, most definitive surgery was done on Navy craft
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FIGURE 287.-An American casualty being loaded aboard ship in Leyte Harbor, 20 October 1944.
offshore. When the wounded were near the beach, the timelag between wounding and first aid was a matter of minutes. The wounded were then carried almost immediately to LST's for definitive surgery, which sometimes was done within 1 or 2 hours after wounding.
In the second phase of the invasion, the distance ashorealong which the LST's were distributed was greatly increased, and theperimeter extended as much as 15 miles in depth. Mobile aid stations andclearing stations were kept well up near the line, and, at first, the woundedreceived both first aid and definitive care promptly. As the distance to thebeaches increased, 12 hours sometimes elapsed before definitive treatment on anLST followed primary care (fig. 289). Torrential rains, in addition to distance,played their part in the increased timelag.
The ships that had taken part in the original operation soonbecame crowded, and some were sent back to the bases well loaded. Not enoughthen remained to take care of casualties from the shore as well as theconsiderable number wounded in the harbor in the Japanese suicide raids. Later,it was possible to evacuate casualties to APH's (transports for wounded) andhospital ships.
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FIGURE 289.-A difficult litter carry on Leyte, inland from the beach.738
FIGURE 290.-The 58th Evacuation Hospital at Tacloban, Leyte, Philippine Islands, 26 October 1944.
In the third phase of the landings, field and evacuation hospitals were set up; the 58th Evacuation Hospital (fig. 290) was in full operation in a school in Tacloban on D+4 and had begun to function 48 hours earlier. Some hospitals were delayed in opening because the tactical situation did not permit unloading of their equipment.
After D+6, most definitive surgery was done in hospitals onshore (fig. 291). In order to keep beds clear for casualties, the hospitalscontinued to evacuate patients from rear areas to the LST's, where theyremained until hospital ships arrived; if a hospital ship was in the harbor,patients were taken directly to it. Air evacuation to New Guinea and Saipanbegan on D+6 and was in regular operation after D+16 and D+21, respectively.
The landings at Leyte presented a problem not encountered inany previous amphibious landings in the Southwest Pacific; for 38 days, largenumbers of casualties continued to occur in the harbor, from bombing andstrafing by enemy planes. Both first aid and definitive care for thesecasualties were supplied by LST's, APA's, and APH's. In the remaininglandings on the Philippines, the care of casualties during the assault phase wasrelatively simple because all enemy airfields within operating radius had beeneffectively destroyed by U.S. Navy and Army Air Force planes before thelandings.
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FIGURE 291.-Definitive surgery in a portable surgical hospital, Leyte, Philippine Islands.
LST 464, which had been converted for hospital purposes, and LST 1025, which had a surgical team aboard but had not been converted, carried heavy surgical loads from D-day on (fig. 292). These two ships, the Sixth U.S. Army surgeon stated, "saved their lives" before sufficient hospitalization was set up ashore to care for the casualties of the invasion.
This consultant, after his experience at Leyte (p. 712) , concludedthat the LST, properly altered, admirably fulfilled the needs created by the newtactical situation that had developed there. The great advantage was that, whenit was thus altered, it was primarily a hospital ship-not a cargo ship, usedsecondarily for hospital purposes. It could therefore remain on station in theharbor and be available for use at all times. A large hospital ship in theharbor would have served the same purposes, but the risk of its being hit, witha resulting heavy loss of life, made such an arrangement unwise.
Planning for invasion of Japan
Preliminary medical planning for the projected OLYMPIC andCORONET invasions of the Japanese islands were begun by General Denit'sdirections in May 1945. The first of these landings, on Kyushu, was scheduledfor 1 November.
On 8 May 1945, the author addressed a memorandum to GeneralDenit, a summary of which follows.
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An amphibious landing anywhere within range of undestroyedJapanese air bases would be attended by daily attacks of enemy planes uponallied troop and supply ships. Resulting casualties would be heavy. LST's andAPA's with surgical teams aboard would take care of casualties on D-daythrough D+2, but then after having discharged their cargoes, they would pullout, and their surgical teams would no longer be available. Large hospital shipsof the Geneva type would run too much risk by remaining in the harbor. Theestablishment of hospitals on shore would not solve the whole problem, fordistances would be great, landing on beaches often difficult, communicationspoor, and transportation scarce for some time.
This situation was first encountered on Leyte (p. 738). Immediatelyafter that operation, recommendations were made by the Office of the ChiefSurgeon, USASOS, SWPA, at this consultant's suggestion, to The Surgeon Generalby letter and to the senior medical officers of the Seventh U.S. Fleet and 7thAmphibious Force, by interview, that multiple small ships, of the stationhospital type, based on the LST 464 model, be maintained in the harbor at alltimes in all similar future operations. Lessons from the invasion of Leyte andfrom the Okinawa operation, then in progress, indicated that renewed andstronger representations should be made for greatly increased numbers of thistype of hospital ship to care for Army and Navy casualties in all futurecombined operations.
On 10 May 1945, this consultant sent to General Denit astatement from the Basic Concept of Operation OLYMPIC and pointed out that itwas not clear in it whether the 15 LST's planned as a minimum were to beequipped as hospital ships, like LST 464, and would be staffed to renderdefinitive care. The statement that they would "administer emergencytreatment and sort patients for further evacuation" implied the contrary.
The author recommended that these points be clarified. In hisopinion, repeatedly expressed, the value of these ships rested entirely upon (1)their availability in the harbor day and night, and (2) the provision on them ofadequate equipment and competent staffs to provide definitive major surgicalcare. On 14 May, the Medical Section, General Headquarters, concurred in theproposed use of the LST's; those ships whose primary function was to providedefinitive surgical care would be differentiated from those with minimalequipment and surgical teams.
On 28 June 1945, in response to a request from the G-4Section, General Headquarters, AFPAC, to General Denit, this consultant and Lt.Col. (later Col.) Harold A. Sofield, MC, orthopedic consultant in the Office ofthe Surgeon, AFWESPAC, submitted recommendations for General Denit's approvaland transmission to the G-4 Section, General Headquarters, AFPAC. A summary ofthese recommendations follows.
1. The use of the LST as an auxiliary hospital ship is of thegreatest importance in the care of casualties sustained in an assault landing;in the care
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of casualties sustained on shore for the first 2 or 3 days,while hospitals are being established; in the care of casualties sustained onships during the ensuing days or weeks as the result of enemy air attacks; inevacuation parallel to the beach when roads are obstructed; in triage of thewounded; and in the maintenance of a supply point for whole blood and medicalsupplies.
2. The proposed role of the LST in the forthcoming operationshould be clarified. At this time, it is not known whether the LST's to beused will be of the hospital type, such as LST 464, or only secondarily forhospital use, such as LST 929. It is also not known whether the LST will act asa hospital ship primarily; will carry troops and cargo and, after unloading,accept patients for definitive major surgery while transporting them to a rearbase; or will act as a sorting station and evacuation point and be used fordefinitive surgery as an emergency measure only. If the plan is to use theGeneva type of hospital ship employed at Leyte, which retired from the combatarea as soon as casualties were received, a number of LST's of the 464 typeshould be provided, to function as station hospitals in the harbor and providespecialized care for harbor and beach casualties. If attack transports are to beemployed as hospital ships and remain with the assault shipping, they wouldprovide definitive care for these casualties, and the LST's could be of the929 type, functioning as sorting and evacuation points and doing only emergencydefinitive surgery.
Previous experience has shown that two LST's per assaultdivision are necessary to provide minimum coverage. If the APA's are to retirefrom the assault shipping, LST's of the 464 type should be provided in theratio of two ships to one of the 929 type. If the APA's are to remain in thearea, this ratio could be reversed. The number of LST's specified would be inaddition to those equipped and staffed to transport wounded from the target areaback to a base area.
3. A careful study should be made of the professionalqualifications of surgeons designated to do definitive surgery. Army personnelshould be freely offered to the Navy when additional experienced surgeons areneeded. The experience of the Normandy landings showed that one experiencedsurgeon and two assistants should be on each ship on which definitive surgery isto be performed. The surgical personnel of all Army APA's should be carefullyreinterviewed and strengthened by the Surgeon, Port of Embarkation, SanFrancisco. If, in the opinion of the surgical consultants, these staffs are notadequate, surgeons from AFWESPAC should be placed on board on recommendation ofthe Chief Surgeon.
On the recommendation of this consultant, Col. Douglas B.Kendrick, Jr., MC, who had inaugurated the blood program in the Office of TheSurgeon General and who was then serving as consultant in blood and transfusionwith the Tenth U.S. Army on Okinawa, was placed on temporary duty in GeneralDenit's office, to make plans for the supply of blood for the invasion ofJapan. Colonel Kendrick was also to organize auxiliary blood banks in Manila and
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on Okinawa to supplement the supply from the United Statesvia Guam in case difficulties of transportation reduced the supply. Lt. Col.Mark M. Bracken, MC, Chief of the Laboratory Service, 27th General Hospital, wasplaced on temporary duty to work with Colonel Kendrick on the implementation ofthese plans.
Colonel Bracken was also directed to form medical teams, eachconsisting of two medical officers and four enlisted men, from the generalhospitals in the theater, to serve as shock teams in field, portable surgical,and evacuation hospitals, and clearing companies. This was an entirely new ideain the Southwest Pacific Area, suggested by the surgical consultant to increasethe usefulness of the surgical teams by removing some burdens from them, so thatthey could pursue exclusively their work of operating on the wounded.
The planning for the invasion required a knowledge of troopstrengths, military objectives, the nature and amount of medical support, theairfields to be designated for evacuation, the naval plans, and other vitaldata. General Denit's office was given free access to all information, and themedical planning was based on full military knowledge.
The surrender of Japan in August 1945 made it unnecessary tocontinue the planning for Operation OLYMPIC. Planning for Operation CORONET hadnot yet begun. To show, however, the immense size of the projected medicalsupport, as well as the variegated duties and opportunities of a consultant tohelp in the whole theater planning, the following memorandum for General Denit,prepared by this consultant in Washington on 4 August 1945, is quoted:
My dear General:
1. In my notebook marked "Surgery",which I have left with Colonel Baker, is the latest information on such items asBlood Plan, Briefing of Hospitals, Body Armor, Hospital Personnel Equipment,Task Force Study, and Trench Foot.
a. In the Whole Blood Plan, Major McGraw of The Surgeon General's Office made certain suggestions, as are attached [not reproduced]. A letter from Colonel Robinson to you states that the Navy will cooperate in every way with Kendrick's plan.
b. I have talked with Colonel Studler of the Ordnance Dept. about Body Armor. A Major Shaw from his office, and a Captain of Infantry, are already in Manila with samples of armor. With Colonel Voorhees I interviewed General Greenbaum in the Office of the Secretary of War. After the conference General Greenbaum prepared a radio for General Somervell's signature addressed to General Styer of AFWESPAC, stressing the favorable opinion of the War Department about the armor and asking for early information as to the Theater's needs for it. The latest information on the subject is contained in my file.
c. Information on the Hospital Equipment problem which you asked me to take up is contained in this file also in a letter to you from General Bliss on the subject.
d. Personnel. Satisfactory arrangements have been reached about surgical consultant personnel, and Colonel Carter is having their orders cut. The 5th Surgical Auxiliary Group should be in the Theater at the present time. Hospitals arriving in the next few months are:
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Hospital |
| Expected Date of Arrival |
Evacuation | 5 (Five) | August |
Field | 10 (Ten) | August |
Station (250 Bed) | 3 (Three) | August |
Auxiliary Surgical Group | 1 (One) | August |
Evacuation | 6 (Six) | September |
Convalescent | 1 (One) | September |
Clearing Companies | 16 (Sixteen) | September |
Collecting | 5 (Five) | September |
Ambulance | 16 (Sixteen) | September |
General (1,000 Bed) | 41 (Forty-one) | September |
Station (750 Bed) | 5 (Five) | September |
Station (500 Bed) | 16 (Sixteen) | September |
Evacuation | 9 (Nine) | October |
General | 10 (Ten) | October |
Medical Professional Group | 1 (One) | October |
Station (500) | 4 (Four) | October |
Evacuation | 5 (Five) | November |
Station (500 Bed) | 1 (One) | November |
General (1,000 Bed) | 41 (Forty-one) | "Later" |
The importance of sending personnel in advance of T/O hospitals to which they are attached was emphasized to Dr. Ginsberg. He was likewise advised of the urgent need to send replacements for medical officers in the Pacific with three or more years' service overseas. Three hundred and fifty (350) medical officers from the European Theater have been discharged from the service, although they do not have so high a number of service points as do officers still left in the Pacific Theater. In spite of Congressional pressure, it would be fairer to keep men from the European Theater in the Army on duty in the Z.I. to release men from the Z.I. to go to the Pacific as replacements.
e. Task Force Study. One of the points which I asked Colonel Robinson and Colonel Kendrick to try to settle in our absence from Manila was the consent of the Navy to use Army surgical teams on ships carrying battle casualties not staffed with experienced surgeons. In a recent communication to you from Colonel Robinson it is stated that the Navy has agreed to this arrangement. The date of arrival of Geneva Convention hospital ships at the target has not yet definitely been established.
f. Trench Foot. Colonel Gordon and Major Shaw from The Surgeon General's Office are already in Manila. Colonel [Gordon] was Chief of Preventive Medicine in ETO.
Postsurrender Responsibilities
The Japanese surrender
Almost immediately after the first U.S. troops landed inJapan and assumed their occupation duties, General MacArthur issued an orderdirecting them to carry no firearms. Events proved the wisdom of this directive.The surrender of Japanese troops was so complete and so final that neither massnor isolated acts of violence occurred after it. As a result, there were no morebattle casualties, and occupancy of surgical wards consisted of patients injuredin traffic accidents and street fights. Burns from gasoline-driven equipmentwere also frequent.
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FIGURE 293.-The 49th General Hospital (formerly St. Luke's Hospital), Tokyo, Japan.
This consultant's chief problem after the surrender was to spread available surgical personnel, with adequate training and experience, over the larger Japanese islands of Honshu, Kyushu, and Hokkaido, as well as Formosa and Korea. This became his responsibility when he was transferred, late in October 1945, from the Office of the Surgeon, Headquarters, AFWESPAC, to the Office of the Surgeon, Headquarters, AFPAC. Early in December, he proceeded from Manila to Advance Echelon, AFPAC, in Tokyo, from which point he visited all the U.S. Army hospitals in Japan from the most northern at Sapporo on Hokkaido to the most southern at Sasebo on Kyushu (fig. 293).
At this time, the pressure for discharge of troops and othermilitary personnel had begun to be applied in the Zone of Interior, and theprocess which General Eisenhower was later to describe as "demobilizationby demoralization" had already begun. Specialists were in exceedingly shortsupply, and great care had to be exercised to utilize them wisely. The rapidtransportation of patients to centers in which specialists were available or themovement of specialists to isolated areas to meet major emergencies was notpractical because of poor roads, indifferent rail service, and closure of allair service during the winter. This made it necessary to staff more hospitalsthan would otherwise have been required with surgeons who were capable of givingdefinitive care
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in the event of major emergencies. It was a wasteful use ofpersonnel but was the only possible plan under the circumstances.
One of the principal emergencies after the occupation ofJapan was motor traffic accidents, which were frequent and serious on thenarrow, poorly lighted roads traversed by a population untrained in thealertness and rapid reflexes required by modern motor cars. In November 1945,admissions from this cause were at an all-time high. At one time, trafficaccidents accounted for 38 percent of all surgical admissions at the 165thStation Hospital, with compound fractures heading the list. It was not unusualto receive 5 or 10 patients at a time over the weekend, as the result of asingle accident. On one occasion, 38 Japanese prisoners of war were received enmasse when the vehicle in which they were being moved was overturned.7
Obligation in the Philippines
An unfortunate result of the rapid withdrawal of U.S.Army troops from the Philippines at the end of the fighting in the Pacific wasthe hardship it worked on the Philippine Army, including the Scouts. Medicalcare of these troops was very poor at this time, as was the medical care ofguerrillas and civilians, because of the almost total destruction of medicalservices during the Japanese occupation. Those who were aware of how manyAmerican lives had been saved by Filipino troops and civilians, often at greatcost to themselves, were much disturbed by the situation.
After observing these conditions, this consultant madecertain recommendations to the Surgeon, AFPAC, 7 December 1945, as follows: (1)Provision of additional technicians to supplement the single technician thenworking in the braceshop set up in the 313th General Hospital in Manila; (2)provision of additional technicians to instruct Philippine Army personnel in theoperation of the braceshop sent to the Philippine Army from the Zone of
7Colonel Trimble, as a result of these experiences, considered the whole question of traffic accidents so serious that, on his return to the Zone of Interior in the spring of 1946, he addressed a memorandum on the subject to The Surgeon General, through the Director, Surgical Consultants Division, Office of The Surgeon General. In it, he pointed out that at the time of writing traffic accidents were responsible for the great majority of deaths within the Army, for the largest proportion of seriously ill patients in hospitals, and for an incalculable amount of morbidity and permanent deformity. These accidents, he continued, were largely preventable, and, while accident prevention was a function of the Provost Marshal's Office, he believed that the Medical Department should assume a share of the responsibility, if only because of its responsibility for the management and end results of these injuries.
Colonel Trimble recommended that a special committee be appointed, under the jurisdiction of the Preventive Medicine Division, Office of The Surgeon General, to study the problem along epidemiologic lines and to formulate definite and vigorous directives based upon the findings of this study. The memorandum concluded with the statement that, since commercial transportation companies were able to hold their drivers to strict accountability in the matter of accidents, it was unrealistic to assume that the Army, with its far tighter control and discipline of personnel, could not achieve even better results. A similar program had been effective in the Southwest Pacific Area when it was set up in the fall of 1944.
No action was taken on these recommendations, on the ground that in the Zone of Interior safety committees were already in existence at each post and station and that a medical officer with advisory responsibility was usually assigned to them.-J. B. C., Jr.
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Interior; (3) transportation of the 20-odd Scouts then inneed of prosthetic appliances to amputation centers in the Zone of Interior, fornecessary plastic procedures and fitting of prostheses; and (4) provisionof a supply of prostheses, with a fully trained technician to take themeasurements for them, to provide for personnel in the Philippines in need ofsurgical care after amputation.
It was not considered possible to implement theserecommendations at this time, but later, in April 1946, a complete unit was sentby The Surgeon General to establish an amputation center for Filipino personnel.
Japanese Prisoners of War
Until the invasion of the Philippines, U.S. Army medical officers had no extended contacts with Japanese prisoners of war. This was partly because prisoners were not taken in large numbers and partly because they were chiefly the responsibility, from the medical standpoint, of the Australian Army Medical Department. As the number of prisoners increased, large camps to handle them were established on Leyte, Luzon, and the smaller islands of the Visayan group. American medical officers were then detailed to these camps.
Management of a typical camp
Since all prisoner-of-war camps were managed on the samegeneral plan, the experience of the 174th Station Hospital may be cited astypical. This hospital took over hospital facilities at New Bilibid Prison fromthe 21st Evacuation Hospital on 2 June 1945. The report from which most of thefollowing data are summarized was prepared at the request of this consultant byMaj. Joseph T. Kauer, MC, chief of the surgical service.8Other data have been obtained from the report of the official inspectionof the station hospital at the prison on 2 and 3 November 1945 by a committee ofmedical officers of which the author was a member.9
The experience at this camp may be accepted as typicalof the experiences of all similar camps.
During the peak of activities after V-J Day, additionalfacilities had to be provided at Luzon Prison Camp No. 1 at Canlubang, 5 milesaway from New Bilibid, and the personnel of the 174th Station Hospital had to beaugmented by personnel from the 136th General Hospital (fig. 294). When thefacilities were enlarged, the policy was set up of treating all surgicalpatients and all of the more seriously ill medical patients at New Bilibid.Other medical patients and convalescent patients were assigned to Canlubang.Medical, surgical, and neuropsychiatric patients were segregated.
8Essential Technical Medical Data, U.S. Army Forces, Pacific, for October 1945, appendix E, subject: Medical Experiences in Luzon P.O.W. Camp No. 1.
9Col. I. R. Trimble, MC, Surgical Consultant, for Army Forces, Pacific, through Surgeon, Base X, and Chief Surgeon, Army Forces, Western Pacific, 7 Nov. 1945, subject: Surgical Care Afforded Japanese Patients at the 174th Station Hospital, New Bilibid Prison, and at POW Camp No. 1 (Canlubang).
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FIGURE 295.-Japanese prisoner patients and ward attendants in New Bilibid Prison, Luzon.
New Bilibid Prison, located 21 miles south of Manila was a Commonwealth of the Philippines institution, built in 1936. The long building in which professional activities were housed and which had formerly been used as a hospital contained 4 wards of 75 beds each; 3 general operating rooms; an operating room for orthopedic surgery; a supply room for sterile supplies; the X-ray department; the dental clinic; and the laboratory and pharmacy (fig. 295). Sewage facilities were modern and the water supply was adequate. This was generally true throughout the camp, even in the tented areas; improvisations were only occasionally necessary.
Between 2 June and 31 October 1945, 10,684 prisoners of war were admitted tothe hospital at New Bilibid. The peak census was 5,672 in October. Thesepatients were predominantly Japanese, with a small proportion of Formosans andKoreans. During this same period, 56,000 prisoners of war and internees wereconfined in 11 compounds at Canlubang. At the peak, the daily average sick callwas 12,500, chiefly for skin diseases, malaria, and beriberi.
Surgical equipment and instruments were those standard for a U.S. Armystation hospital. Medications were drawn from the standard Army suppliesprovided in medical depots. Routine laboratory examinations were performed atthe prison. Specimens for special or complicated tests were sent to the 19thMedical General Laboratory in Manila. All inmates of both camps received rationsequivalent to those given hospitalized American soldiers. Multivitamin powderwas included in all diets, and additional vitamin therapy was prescribed asindicated (fig. 296).
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FIGURE 296.-The serving of a meal at Prison Camp No. 1, Canlubang, Luzon.
Professional personnel
At a typical peak time during the operation of NewBilibid and Canlubang camps, the professional surgical personnel at New Bilibidconsisted of a chief of service with a rating of "B-3150," a surgicalward officer, a radiologist, an anesthetist, and two Dental Corps officers. Thehospital census rapidly outstripped the ability of U.S. Army personnel to carefor it. At one time, only two medical officers were caring for 1,900 patients,many of whom were critically ill.
To meet the shortages in personnel, Japanese medicalofficers, nurses, and corpsmen were pressed into service as rapidly as possible.Before V-J Day, there were only eight Japanese physicians at the prison; theyhad been taken prisoners when their hospital ship, which was functioning as atroop transport, had been captured in the East Indies. During the peak period,117 Japanese medical and dental officers were utilized in both camps. Of the 58officers assigned to New Bilibid, 28 ranked as surgeons, although only 8,including a well-trained otolaryngologist, an ophthalmologist, a gynecologist,and 2 dentists, had had any appreciable training according to Americanstandards.
Physicians - Japanese techniques differed widely fromthose employed in the United States, and the Japanese approach to all medicalproblems also differed widely. The physicians paid much less attention tohistory taking than American physicians. They were inclined to group allillnesses into
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broad general categories according to the presentingsymptoms. Physical examinations were cursory, and, until the Japanese medicalofficers were taught otherwise, they examined dirty surgical cases only at adistance, regarding any other course as beneath their professional dignity.Their approach to all surgical problems was stereotyped, and they wereinfluenced by their past general experience far more than by an independentconsideration of the physiological and pathological features of the special caseunder consideration.
Japanese physicians needed a great deal of education inoperating room techniques, beginning with the preservation of sterility. Theywere familiar with techniques of local and spinal analgesia, but only two orthree had ever seen intravenous anesthesia administered, and none of them hadhad any personal experience with it. They were also unfamiliar with modernanesthetic machines. They were ignorant of the indwelling nasal catheter,continuous intestinal decompression, and closed drainage in empyema.
Penicillin meant nothing to them either as a name or as atherapeutic agent. They used sulfonamides according to standard practices butdid not hesitate to place sulfathiazole powder into direct contact with nervetissue. The use of whole blood and plasma in malnutrition and the use of plasmafor burns and hypoproteinemia were outside of their experience. They relied onphysiologic salt solution for intravenous therapy and treated shock by theintravenous administration of camphor. Burns were treated by the tannic acidmethod.
All of these practices were obviously based on German medicalpractices in vogue 40 years earlier. When they were discussed with them, theJapanese officers repeatedly made the point that these practices were far moresuited to their economic status than the modern and elaborate system broughtback by the occasional physicians who had received their training in the UnitedStates. Their interest in these modern practices was, however, intense. Theyfully realized that Germany was no longer the fountainhead of medical knowledgeand that the pace of professional attainment in the immediate future would beset by the United States.
Nurses.-Nurses were in such short supply at NewBilibid that even when they were augmented by Japanese nurses, they could beassigned only to wards in which surgical patients and the most seriously illmedical patients were cared for. The work of these Japanese nurses was generallysatisfactory. The seven nurses who had been trained at St. Luke's Hospital inTokyo and who were used in the operating rooms compared favorably, in trainingand ability, with U.S.-trained nurses.
Clinical considerations
The prisoners of war received at New Bilibid Prison fell intotwo general groups, those received before the Japanese surrender and thosereceived later. Many of the patients admitted to the hospital wards before V-JDay came from U.S. Army hospitals, and their good condition was in markedcontrast to the status of the prisoners taken directly to the prisoner camps,most of whom were
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in poor nutritional condition by U.S. standards. Of the 2,395surgical patients, about 50 percent had sustained gunshot wounds of varioustypes without fractures; 14 percent had gunshot wounds with fractures associatedwith osteomyelitis.
After V-J Day, combat wounds became increasingly lessfrequent, and the chief patient load consisted of civilians, including women andchildren, some 300 or 400 of whom came out of the Luzon hills each day. All ofthem were placed on suppressive Atabrine (quinacrine hydrochloride) treatmentfor malaria as soon as they were admitted. Many of them were suffering fromirreversible nutritional and deficiency diseases. Their condition suggested thatof inmates of German concentration camps, and numbers of them died within a fewhours of admission.
Surgical conditions - None of the patients withcombat-incurred wounds had received adequate care by U.S. Army standards. Nowounds had been debrided, and all degrees of suppuration and gangrene wereobserved. Fractures, if they were splinted at all, were immobilized onlycrudely, with bamboo splints. Very few combat-incurred wounds could be managedby early secondary closure, regardless of the time at which they were seen,because of the patients' general status. Malnutrition and deficiency diseasespresented a most unfavorable background for the management of all surgicalconditions. The treatment of these diseases, in fact, had to take precedenceover all but the most dire surgical emergencies.
Anemia and hypoproteinemia, even after intensive therapy,retarded the response to ideal surgical management. Whole blood was usedliberally in these cases, donors being obtained from healthy prisoners of war onwork details. Women and children with severe hypoproteinemia were treated byplasma transfusions. There were no serious reactions to these methods.
A few late closures of combat-incurred soft-tissue woundswere done with good results, but most wounds of this kind were handled better byskin grafting than by excision and closure. Results of skin grafting were,surprisingly, about as good as among U.S. Army casualties.
A number of cases of tetanus developed, as was to be expectedunder the conditions. Two patients died from this cause a few hours after theyhad been admitted, and there were two other later deaths in the remainingthirteen cases. Therapy was by standard measures.
There were also four cases of gas gangrene, one of which wasfatal. One of the remaining patients required amputation of the leg, but theother two responded to wide incision, in one instance of the lower leg and inthe other of the upper arm. All of these patients received antitoxin.
As a matter of necessity, most surgery after V-J Day was doneby Japanese medical officers, U.S. Army surgeons limiting themselves to the mostserious procedures, such as intestinal surgery. During the June-October periodof the operation of the camp, there were 110 major and 706 minor operations, and245 casts were applied. The lack of surgical experience and judgment of Japanesemedical officers was reflected in the 33 appendectomies done by them
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in October for supposed acute disease. Only 11 of thesepatients really had acute appendicitis, and the elementary notion of aseptictechnique possessed by the Japanese surgeons was evident in the 12 percentincidence of infected wounds.
Beriberi abscess - An entirely new clinical entity (new,at least, to U.S. Army medical officers) was observed in many of these patients,so-called beriberi abscess. The infection, which occurred on the lowerextremity, usually in the anterior tibial area or on the dorsum of the foot,began as an extremely soft, fluctuant swelling. Neither rubor nor calor waspresent, and tenderness was not significant. When the swelling was incised,subcutaneous pus was released; only in longstanding cases was the fasciainvolved. The pus was thick, yellow, and of the typical Staphylococcus type,but the etiology was not established, for the circumstances were not favorablefor bacteriologic studies and none were made. The abscess cavity was lined withnecrotic subcutaneous tissue, and in no instance could a definite wall bedemonstrated.
As a rule, these abscesses appeared in extremities that wereor had been the site of serious nutritional edema; in two instances, the edemawas so intense that necrosis of the skin occurred. Their etiology was neverclarified. It was concluded that edema, although it was probably not anessential predisposing factor, apparently favored the growth of organisms whichhad entered the skin by way of the abrasions and scabietic lesions so prominentamong these patients.
Evaluation of medical care
Upon orders of the Chief Surgeon, AFPAC, the prison camps atNew Bilibid and Canlubang were visited on 2 and 3 November 1945, by a committeeof medical officers consisting of Col. Albert R. Dresibach, MC, chairman; Lt.Col. Clarke H. Barnacle, MC, recorder; and the author.10The objective of the inspection was to determine whether the medical care andgeneral treatment of sick and wounded Japanese prisoners of war and internees atthese installations accorded with the provisions of the Geneva Convention. Thecommittee report was entirely favorable; both medical care and generaltreatment, including the diet provided, fully conformed with these provisions.Not a fly was seen in either camp.
The findings of this committee were in agreement with thoseof Brig. Gen. Hugh J. Morgan, and Col. Francis R. Dieuaide, MC, who had visitedthe camps previously as representatives of The Surgeon General, U.S. Army.
These formal reports confirmed the information obtained oninformal attempts to gain some idea of the attitude of the patients in the campstoward U.S. Army personnel and of their reaction to the treatment which theywere receiving. Interpreters were directed to make inquiries along these linesat times when U.S. medical officers were not on the wards and were alsoinstructed to report on conversations among the patients.
10See footnote 9, p. 748.
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Without exception, the patients were very grateful. Some saidthat discipline in the U.S. Army must be very strict, since they had never seena commissioned or a noncommissioned officer strike a patient. Many expressedamazement that American medical officers themselves examined and dressed theirwounds; in the Japanese Army, this was the duty of the corpsmen. They alsoexpressed amazement that American medical officers answered night calls.
These and other instances of what Western physicians conceiveof as only normal medical care were to these prisoners signs of kindness andconsideration which were evidently unique in their experience. Their armytraining had led them to expect only brutality and neglect from their ownnationals, and propaganda had led them to expect the same kind of treatment fromtheir U.S. and other Western conquerors.
Lessons of the Pacific Fighting
Certain conclusions set down by the surgical consultant in the Southwest Pacific Area after his return to civilian life may be summarized as follows:
1. It is strange that such an obvious principle as that ofearly and expert definitive surgical care was not automatically adopted at thebeginning of World War II, when experts in the various surgical specialtiesjoined the Army in such great numbers. It was slow to be adopted in theSouthwest Pacific Area, chiefly because the value of the consultant system wasslow to be realized. Consultants were assigned to headquarters in the smallestpossible numbers. There were no consultants to the armies operating in theSouthwest Pacific until after the landings on Leyte, in October 1944. Thesurgical consultant in the Southwest Pacific Area was permitted to participatein the attack on Leyte but was refused permission to accompany the transports inthe attack on Luzon. More intimate contacts between theater and Army consultantsand surgeons would have enhanced the efficiency of medical care of casualties.
2. At the beginning of the war, there were only a handful ofexpertly trained clinical surgeons in the Regular U.S. Army. To the end of thewar, there was still a scattered lack of appreciation of the difference betweena medical officer designated to do surgery and a medical officer trainedto do surgery. In the Pacific, at least, there was only slow realization ofthe extreme importance of the wisdom of sending experienced surgeons of maturejudgment unto forward areas and assigning younger, less experienced surgeons tobase hospitals, where they could work under supervision.
3. The chief duty of the surgical consultant in the SouthwestPacific Area was the assignment of good surgeons to serve as chiefs of surgeryin the portable hospitals supporting the various landings. This was an extremelydifficult task because of the paucity of well-trained surgeons in the Pacific;practically all of them were sent to the Mediterranean and European theaters, orwere in the Zone of Interior.
4. The vast distances in the Pacific greatly complicatedmedical care of casualties. Sometimes 2,600 miles separated the target area andthe point from
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which an operation was mounted. In hops to small, isolatedislands, there was no such thing as a chain of evacuation. Definitive surgicalcare had to be given on the spot. Specialized hospitals were accepted as apractical possibility only after the Philippine invasions.
5. Distances in the Pacific also made communication extremelydifficult. Brig. Gen. Elliott C. Cutler, MC, Chief Consultant in Surgery, Officeof the Chief Surgeon, European Theater of Operations, U.S. Army, stated that hecould sit at his desk at headquarters in London and within a few minutes reachby telephone the commanding officer of any hospital in England or on theContinent. In the Pacific, even radio communication was not possible, and mostbusiness had to be conducted by mail. Attempts to transfer medical officersmight take a month or more. A visit by plane to hospitals in the various basesmight take a minimum of 2 weeks, partly because of waiting for priorities andthe vagaries of the weather; the visit itself was likely to consume the smallestpart of the time period.
6. Evacuation of casualties in the Pacific fighting wasalways a problem. Portable surgical hospitals were sometimes miles ahead of theartillery pieces going into the jungle. The hospitals would follow the infantryand set up a few hundred yards from the enemy. Evacuation was necessarily acomplicated process. It was first by litter, sometimes borne by natives but moreoften by Army litter bearers because the natives did not like to go forward.Then native litter bearers would take over later. Sometimes, evacuation was byox-drawn cart or by amphibious vehicle.
Air evacuation, which was an outstanding success and solvedmany of the problems of transportation in the Pacific, came late in the war.
7. Surgical teams were proposed very early in the Pacificfighting by Colonel Parsons, first Consultant in Surgery in the area, but theplan was not accepted until April 1944. Auxiliary surgical groups never servedin the Pacific; all of them were sent to the Mediterranean or European theaters.Portable surgical hospitals helped to solve the problems of forward care ofcasualties but did not prove an entirely acceptable solution. Specializedhospitals, as already mentioned, were not permitted until the Philippines wereinvaded and never really fulfilled their possibilities.
8. The difficulties of surgical care of casualties in theclimate, terrain, and vast distances of the Pacific areas were probably neverfully realized in the Office of The Surgeon General because there were no reallyintimate contacts between that office and the Pacific. The single visit, duringthe course of the hardest fighting, was by the Consultant in Surgery in thatoffice and was very brief. The only other visit, by The Surgeon General, wasalso brief and did not occur until after the Philippines had been almostsecured.
9. The difficulties under which medical care was accomplishedin the Pacific are unlikely to occur again. For one thing, the value of theconsultant system is now fully appreciated in the Medical Department of the Armyand is firmly established in it. For another, the Medical Department has set up
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residencies in its largest hospitals in the variousspecialties and is thus assured of a supply of fully trained medical officers inthe event of another emergency.
10. Far and away the most valuable surgical lesson learned bythe U.S. Army Medical Corps during World War II was not the use of penicillin,or of large quantities of whole blood, or of evacuation by air of the wounded-greatas these advances were. The most valuable lesson was the realization of thevalidity of the concept, well known to all trained surgeons, and also learnedand then forgotten by the Medical Corps after World War I, that the mortalityand morbidity of combat casualties can be reduced to a minimum only when mature,highly trained surgeons are available in forward areas of combat.
The consultant's own experiences, both triumphs anddisappointments, and the similar experiences of others, bear out this concept.Any acceptable plans for surgical support of future operations must follow thesame principle. If any plans contain even the possibility of delay on theavailability of immediate, definitive surgical care by surgical experts, theyshould be discarded forthwith.
I. RIDGEWAY TRIMBLE, M.D.
ORTHOPEDIC SURGERY
Maj. (later Lt. Col.) George O. Eaton, MC, reported for active duty on 20 April 1942 as chief of the orthopedic section of the 118th General Hospital (fig. 297). Less than one month after activation, the unit proceeded to the west coast and embarked for oversea duty. After approximately one year of hospital duty at Sydney, Australia, Major Eaton received orders placing him on duty in the Office of the Surgeon, USASOS, SWPA, as the Consultant in Orthopedic Surgery. Headquarters at that time was at Sydney, Australia, but was almost immediately moved to Brisbane, Australia, approximately 500 miles closer to the combat zone in New Guinea with still some 1,700 miles intervening.
Functions and Activities
The orthopedic consultant served first under the direction of Col. Wm. Barclay Parsons, MC, Consultant in Surgery, USASOS, SWPA, and later under Colonel Parsons' successor, Col. I. Ridgeway Trimble, MC. He was charged with the responsibility of care of wounds of the extremities and spine, in addition to nonbattle injuries, which were at least 10 times as frequent. The nonbattle injuries closely resembled civilian practice as regards clinical management, except that transportation and evacuation policies had to be integrated with treatment of fractures and soft-tissue injuries.
At the beginning of the war in the Pacific, the reason forhaving consultants was little understood by those in command positions. Whenreporting into a base in the forward area, courtesy, convention, and ordersrequired his reporting to the commanding officer as well as the base surgeon. Itwas the exception rather than the rule that the mission of the consultant metwith the enthusiastic approval of those key officers. The fact that theconsultant's
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FIGURE 297.-Base 7, Sydney, Australia, and the 118th General Hospital, 1943.
report with its estimate of caliber of local efficiency was reported to the theater surgeon, but not back to the base, protected the consultant but at the same time tended to make him rate as a necessary nuisance, somewhat analogous to an uninvited guest. In forward areas, the consultant had to use various forms of hitchhiking and was usually dependent on the hospitality of the unit being visited. A visit from a consultant was often rated by the recipient as an inspection, and indeed at times the consultants were under orders to include an estimate of the quality and operation of utilities, mess, and other activities only remotely related to the surgical care of patients.
The fact that there was no provision in the tables oforganization for consultants further added to the difficulties under which theyworked. If a medical officer was assigned to a headquarters for duty as aconsultant, his chance of promotion was essentially nil. Administrativeofficers, rather than consultants, were given priority for any promotionalopportunities. Consultants of low field-grade or company-grade rank had lessinfluence with a full colonel commanding a hospital or serving as a basesurgeon.
There were several affiliated general hospital units in theSouthwest Pacific Area that were replete with very high-grade medical talentfrom a medical school. One such unit was left so far behind the center ofactivities that it had almost no patients. When the orthopedic consultant triedto persuade the
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commanding officer to permit the reassignment of two of histhree good orthopedic surgeons to units that had none, his answer was that hisunit represented their alma mater and was not to be molested no matter howurgent the need was elsewhere.
The Southwest Pacific Area included all Australia plus NewGuinea and the nearby islands. A consultant's travel was almost entirely byair. The usual procedure was to request approval to make a consultant trip whensuch a move was indicated, and orders were generally promptly approved andissued. Such a trip would include visiting all army hospitals in a given area,so long as they were operated under command of USASOS, SWPA. If the unit wereunder command of the Sixth U.S. Army or the Eighth U.S. Army, the USASOSconsultants were out of bounds unless especially invited by the army command. Avisit to a general hospital would consist of a 1-, 2-, or 3-day visit, seeingall cases, approving or criticizing management of cases, giving teaching wardwounds, spreading information as to newer development in the management ofspecific problems, and, sometimes, explaining the rationale of directives andtechnical memorandums. In smaller units such as station, evacuation, and fieldhospitals, the orthopedic consultant's obvious duty sometimes was to teach amedical officer who was not especially on adequately trained in orthopedics howto manage the usual orthopedic problems. It should be mentioned in passing thatthe station hospitals, field hospitals, and evacuation hospitals performedessentially identical missions in the Southwest Pacific Area. The smaller unitsseemed to value the visit of a consultant and made him feel very much needed.The opportunity for teaching by working several days with an incompletelytrained medical officer presented itself very frequently and was utilized to thegreat advantage of the patient (fig. 298).
Management of Patients With Low Back Complaints
The Southwest Pacific Area was a wide geographical area, and this fact led to the development of many minor changes in the treatment of the wounded and injured because of geographical factors and evacuation policies. It was necessary to develop a working rule for the management of patients with low back complaints. The incidence of such complaints seemed to increase whenever service became less attractive and sometimes when it became more hazardous. Some of the younger medical officers who were incompletely trained did not feel free to take on the responsibility of sending a patient back to duty if he was complaining of disabling, low back pain.
It became necessary to define by a technical memorandum therecognition of spondylolisthesis by X-ray examination and how to avoid making adiagnosis of spondylolisthesis when none was present. Spondyloschisis was alsofrequently discovered in the study of a patient. In the case ofspondylolisthesis, the recommendation was made that such patients be evacuatedto the Zone of Interior for disposition, with the application of a supportingplaster jacket and with the lumbar spine in mild flexion for transportation ifpain was severe
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or displacement very marked. A patient with preslipped spondylolisthesis, orspondyloschisis, if the condition was accompanied by moderate or severecomplaints, was also recommended to be returned to the Zone of Interior.
Congenital anomalies of the spine (such as spina bifidaocculta, sacralization of lumbar vertebrae unilateral or bilateral,lumbarization of sacral vertebrae, six lumbar vertebrae, ununited accessoryossification centers in the transverse or posterior spinous processes) werefound with approximately the same frequency in patients with or without low backcomplaints. The discovery of such anomalies was not sufficient reason tohospitalize or change the duty status of the complainer, and it was necessary tospread the word that the discovery of such anomalies was not to be given weightwhen deciding on the disposition of a patient. It was recommended that thedegree and reality of the disability in the function of the back, as determinedby positive physical findings, should in such cases be the basis for decision inregard to return to duty, reassignment, or evacuation to the Zone of Interior.The rule was gradually developed that the medical officer would use thediagnostic facilities at his command for the investigation of a low backcomplaint and, if insufficient positive objective findings developed, theofficer was to send that soldier back to duty rather than to send him to a rearand larger hospital for more exhaustive investigation of his complaint.
Evacuation Policy
In the early part of the war, the evacuation policy was determined by the relative frequency of opportunity to send patients back to the Zone of Interior by water. Air evacuation had not yet been developed. Consequently, the policy was that a patient who could not probably be returned to duty in 90 days should be tagged for evacuation to the Zone of Interior. It frequently happened that the patient would remain in a rear base hospital for 30 to 60 days awaiting transportation by ship to the Zone of Interior. As transportation facilities improved and as air evacuation became more prevalent, the evacuation policy was gradually reduced to 60 days, then to 30 days, and even less.
Transportation of Fractures
The following rules were laid down in the treatment of fractures admitted to any unit forward of the hospital that would give definitive treatment prior to evacuation to the Zone of Interior. Three essentials were named: (1) The treatment of shock, (2) care of the soft part wounds, and (3) immobilization for transportation. It was estimated that about 68 percent of battle wounds were of the extremities. About one-half of these were fractures, so that some 34 percent of battle wounds were compound fractures. Attention to length and alinement, although desirable, was not stressed if it jeopardized any of the three main essentials, prolonged the operative time, or involved manipulations which predisposed to infection. The main difference between military and civil practice was the necessity for transporting the soldier. Transporting
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involved jolting which caused shock, shifting of the tissueplanes, bleeding, the accumulation of fluid in dead spaces, and infection. Alapse of 2 or 3 weeks after infliction of the wound was not too long a delaybefore the successful restoration of length and alinement could be obtained inthe ordinary compound fracture encountered in combat. This statement is not tobe taken to mean that the bone wound was unimportant. The first stage of bonerepair depended on vascularized tissue from the surrounding soft parts. Thelater stages involved actual bone repair from the bone ends which therefore hadto be in contact. After transportation to a hospital where the patient could bekept for the required period, the bone wound assumed importance equal to that ofthe soft parts. Since all major fractures required prolonged hospitalization,they were to be evacuated to the rear as soon as their condition permitted.
The Thomas' splint was useful for the transportation ofcases of femoral fracture from the battalion aid station to the first hospitalfor definitive treatment. It was not recommended and in his not used for furthertransportation to rear echelon hospitals as it did not provide the essentialcomplete immobilization. Any of the methods of applying traction through theThomas' splint during extended transportation were unsatisfactory. The Tobruksplint, which was developed in the famous defense of Tobruk in the Middle East,was publicized for a while as an excellent method of management of compoundfractures of the femur but proved to be entirely unsatisfactory. Properlyapplied, a one-and-a-half spica cast was the method of choice for thetransportation of femoral fractures, and other long bone fractures weretransported in a solid plaster cast which was split the entire length of thelimb. In applying the cast the optimum position of the fragments was obtained ifeasily accomplished, but it was again emphasized that, for transportation,immobilization was relatively of far greater importance than the position of thefragments.
To avoid the needless and often harmful frequent changing ofcasts, a note was made on the field medical record as to any anticipated orfeared complications, or if, on the other hand, evacuation without changing thecast could be expected with confidence. Plating and operative fixation offractures in any of the forward units was discouraged because of the likelihoodof infection and the danger of damage in transportation. The journey to the basehospital was begun by the patient with a compound fracture after shock therapyhad been completed, the wound had been debrided, and the fracture immobilized.In the early days of the New Guinea campaign, the distance was about 1,500 airmiles, and evacuation might be by ship or plane with numerous stops andambulance rides en route. Stops would be made at military hospitals, and atendency developed to change the cast at each stop in order to observe andreport the condition of the wound. For this reason, the rule was made that apatient would not be subjected to change of cast if his temperature was normal,the injured limb comfortable, and the circulation in the toes or fingers normal.This rule proved to be satisfactory and practical.
All patients with compound fractures had a normal expectancyof not returning to duty within 4 months and were therefore destined to complete
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their convalescence in the United States. Treatment inskeletal traction of compound femoral fractures in forward units, such as fieldand evacuation hospitals, had to be discouraged and eliminated. There was toomuch risk of attack by air, in which case it would not have been possible to putthe patient into a protective slit trench. Thus, the only place in the overseatheater that a compound fracture of the femur could be safely treated inskeletal traction was at the rear base hospitals, out of reach of possible enemyair attack. In the later days when air evacuation became available, the patientwas returned to the Zone of Interior in his plaster spica cast by air evacuationand put up in traction after arrival and assignment to a hospital in the UnitedStates.
The experience in the Southwest Pacific Area with theimmediate open reduction of simple shaft fractures was not good, and the routineuse of open reduction and fixation as an elective method of treatment wasdiscouraged and frowned upon. In the forward areas, in field hospitals operatingunder tents, in the jungles, or around air strips, contamination and infectionplayed too big a role to justify the hazard of open reduction as contrasted withthe relative safety of closed reduction.
The transportation of compound fractures of the humerus intraction by means of hanging casts proved to be so unsatisfactory that the AirTransport Command announced that such patients would not be accepted forevacuation. The lack of immobilization led to swelling, bleeding, and pain andmarkedly increased the problems connected with the evacuation of such patients.The only exception to the rule of not transporting patients in traction was inthe case of guillotine amputations. The maintenance of continuous, even tractionof the skin during evacuation of amputees was considered to be of the highestimportance to the end result of such cases. The use of elastic traction provedto be more effective in maintaining a continuous, even traction duringevacuation. Accordingly, an elastic cord for traction was provided throughmedical supply sources, and this item became available on requisition for use inthe transportation of amputees. The cord was constructed of multiple rubberfibers and was supplied in a length of from 8 to 12 inches, which was sufficientlength for a single case.
Classification and Selection of Patients for Evacuation
In order to expedite the evacuation of major clinical problems to rear area general hospitals for further study and treatment, station, field, and evacuation hospitals were advised to classify selected cases for evacuation to a general hospital. The evacuation of such cases was ordered not to be interrupted at subsequent station hospitals en route except when the patient's condition was such as to require immediate interruption in the transportation journey. The fact that the general hospital type of treatment was indicated was shown by placing "GH" in red on the roster immediately preceding the name and number of the patient and on the face of the field medical jacket just above the patient's name. In general, major orthopedic conditions, including fractures
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requiring more than 60 days of hospitalization, were classed as "GH" cases (fig. 299). In cases of chronic low back complaints, chronic joint complaints, and chronic foot complaints, if no positive objective findings appeared after study (including X-ray, laboratory, and psychiatric investigation), and when complaints were disproportionate to the organic findings, it was recommended that the patient be returned to duty with reassurance. Only in the case of repeated admissions were such patients to be evacuated to a general hospital for further study, treatment, and disposition.
Summary and Recommendations
In the Southwest Pacific Area during World War II, any question of contact of the consultants with the Office of The Surgeon General was strictly informal and unofficial and, understandably, was frowned upon. The Office of The Surgeon General could perform a very useful function in a more or less global type of war by acting in the capacity of transmitter of information gained by experience in other theaters. Each theater will have its own peculiar problems, and it is difficult to see how the Office of The Surgeon General could appreciate or could advise in such problems unless it had firsthand experience with such specialized matters. Statistics of World War II will show a marked
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improvement over those of World War I in the rate of survivaland the escape from permanent crippling disabilities of individuals sufferingwounds of the extremities. This improvement will be primarily the result not ofadvances in chemotherapy but rather of advances in shock therapy and in woundmanagement. Further improvement will be possible.
The command and administrative branch of the Medical Corpsmust take a more active interest in the clinical welfare of the patient. Thevisit of The Surgeon General to the Pacific areas in the early months of 1945was a most powerful and pleasant stimulas to the average professional medicalofficer. Here was the highest ranking medical officer in the Army of the UnitedStates on a tour of inspection, making clinical bedside rounds, and givinghelpful instruction and criticism to the ward officer. The consultant system,begun in World War I and enlarged in World War II, is the key to improving thequality of medical service rendered to patients. Particularly in the moreforward areas, the average young surgeon is loaded with more responsibility thanhe has been trained to assume. He is notably conscientious and anxious that hispatients should receive the best possible treatment. He is unable to follow thepatient's progress after evacuation. Circulars and memorandums have a way ofnot reaching him. Only by the visits of consultants can he learn of his errorsand of new methods and procedures.
Military surgery has made great strides, but even moreprogress will be made if more emphasis is placed upon the quality ofprofessional accomplishment. Command and administrative officers in the MedicalCorps should look upon the consultant as a teacher rather than an inspector andshould not use the consultant to check on activities other than those directlyrelated to the welfare of the patient. Provision should be made in the tables oforganization for appropriate rank for consultants. Officers commanding medicalunits should be expected to place a high degree of importance on the quality ofthe medical care the patient in his unit receives instead of being nearlyentirely concerned with the impeccable management of utilities and visits ofInspectors General.
GEORGE O. EATON, M.D.
