CHAPTER XIV
India-Burma and China Theaters
A. Stephens Graham, M.D.
On 5 January 1945, Lt. Col. (later Col.) Herrman L. Blumgart,MC, and Lt. Col. (later Col.) A. Stephens Graham, MC (fig. 346), proceeded fromHeadquarters, Second Service Command, Governors Island, N.Y., to Miami. Therethey boarded a transport plane and flew by way of Bermuda, the Azores, NorthAfrica, and the Middle East to New Delhi, India, arriving at Headquarters,USFIBT (U.S. Forces, India-Burma Theater), on 28 January 1945.
Late in November 1944, they had been given the opportunity byMaj. Gen. Norman T. Kirk, The Surgeon General, U.S. Army, to become the firstprofessional consultants assigned to the India-Burma Theater. Since there was apressing need for these consultants, as had been indicated in the Kelser Missionreport1 submitted to The Surgeon Generalon 18 November 1944, General Kirk desired to send officers with prior experiencein this field. At the time, Colonel Blumgart and the author were serving asConsultant in Medicine and Consultant in Surgery, respectively, Second ServiceCommand, where they had pioneered as consultants somewhat more than a yearpreviously. Moreover, the author had served in an oversea combat area-theNorth African theater- as chief of surgical service of a 2,000-bed generalhospital. Therefore, he had had experience in the care and disposition of battlecasualties. As one of the organizers of the 45th General Hospital, an affiliatedunit of the Medical College of Virginia, Richmond, the author had, early in1942, served a tour of duty under Col. Norman T. Kirk, MC, then Chief ofSurgical Service, Walter Reed General Hospital, Washington, D.C. Under theguidance of Colonel Kirk and Col. Arden Freer, MC, Chief of Medical Service,Walter Reed General Hospital, the chiefs of medical and surgical services of theunits affiliated with Harvard, Yale, Maryland, and Johns Hopkins Universitiesand with the University of Maryland and the Medical College of Virginia hadcompleted the organization of their units and had received indoctrination in theoperation of a general hospital.
The author's assignment to USFIBT was contingent upon theaction of the disposition board of Fort Jay Regional Hospital, Governors Island,
1Report, Brig. Gen. Raymond A. Kelser, and Col. Robert H. Kennedy, MC, to The Surgeon General, 18 November 1944, subject: Report of Medical Department Mission to China-Burma-India.
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N.Y. This board, fortunately, changed his physical status togeneral duty from duty limited to the continental United States. In December1943, the disposition board of Walter Reed General Hospital had established thelimited duty status after Colonel Graham had been evacuated to the Zone ofInterior from the North African theater in November 1943.
There were other experienced service command consultants whohad not had a tour of duty overseas and who were most anxious for thisparticular assignment in the India-Burma Theater. This was particularly true ofCol. R. Arnold Griswold, MC, formerly Consultant in Surgery, Fourth ServiceCommand. At the time, Colonel Griswold was Chief of Surgical Service, WalterReed General Hospital. Unfortunately for these officers, Headquarters, USFIBT,refused to accept consultants in grades higher than lieutenant colonel. For thefirst time in their Army careers, Colonel Blumgart and the author were pleasedthat long-awaited promotions had not materialized. These came later.
FIGURE 346.-Col. A. Stephens Graham, MC
Two weeks prior to departure, Colonel Blumgart and the authorspent several days in Washington where they were intensively briefed on themedical situation in the India-Burma and China Theaters by officers in theOffice of The Surgeon General. The briefing included a careful study of thepreviously mentioned report of the Medical Department Mission toChina-Burma-India. The Mission was composed of Brig. Gen. Raymond A. Kelser,Chief, Army Veterinary Service (fig. 347); Col. Robert H. Kennedy, MC, eminentNew York surgeon, who had served as Chief of Surgical Service, Percy Jones
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General Hospital, Battle Creek, Mich., and was soon to becomethe author's successor as Consultant in Surgery, Second Service Command; andCol. Karl R. Lundeberg, MC, Chief, Epidemiology Division, Preventive MedicineService, Office of The Surgeon General. This highly illuminating report wasbased on a reasonably comprehensive survey of professional activities in most ofthe fixed hospitals of the China-Burma-India Theater.2Colonel Kennedy's discussion of deficiencies and irregularities most urgentlyin need of a consultant's attention materially shortened the period of theauthor's orientation at Headquarters, USFIBT, in New Delhi and also influencedthe sequence of hospitals visited in his initial tour of the theater.
The problems and activities of the surgical officer in theIndia-Burma and China Theaters can be more readily comprehended in relation tothe stated mission of the U.S. Forces in these theaters, the medical servicethat was developed to support this mission, and the environment in which thepersonnel operated.
2War Department orders divided the China-Burma-India Theater into the India-Burma and China Theaters in October 1944.
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FIGURE 348.-Lt. Gen. Joseph W. Stilwell at his headquarters with Brig. Gen. Frank D. Merrill.
HISTORICAL BACKGROUND
Mission of U.S. Army Forces in China-Burma-India3
Lt. Gen. (later General) Joseph W. Stilwell, USA, arrived in Chungking, China, on 4 March 1942 as head of a military mission charged with improving American assistance to the Chinese. At the suggestions of Generalissimo Chiang Kai-shek, General Stilwell was named chief of staff of the Generalissimo's joint staff, Commanding General of USAFCBI (U.S. Army Forces in China-Burma-India), and Commanding General of the Chinese Army in India (fig. 348). General Stilwell arrived at a most unfortunate period when Chinese, Burmese, and British-Indian Forces were being routed out of almost all of Burma in the fateful Burma Campaign. By the end of May 1942, the Japanese enemy was approaching the eastern border of India and had penetrated well into the Chinese province of Y?nnan through the Salween Valley. By their conquest of the heart of Burma, the Japanese were in possession of the southern terminus of the Burma Road and prohibited its use by the Allies.4
3Most of the material for this section was obtained from an official, unpublished historical report in two volumes by Maj. Robert G. Smith, MAC, titled: "History of the Attempt of the United States Army Medical Department to Improve the Efficiency of the Chinese Army Medical Service, 1941-1945."
4The Burma Road extended from Rangoon, Burma, to Chungking, China, approximately 1,445 miles. It was made up of a railroad from Rangoon to Lashio, Burma; a new motor road from Lashio to K'un-ming, China, which was constructed in 1937-39; and an old highway from K'un-ming to Chungking.
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In China, there was a desperate scarcity of everything butmanpower. It was on the basis of China's dearth of material but abundance ofpersonnel, therefore, that the United States was to attempt to fashion help forthe faltering Chinese Army. American efforts were to center upon the dualmission of providing supplies and molding Chinese manpower into an efficient warmachine. These missions were to be accomplished by taking remnants of theChinese Fifth Army, which had fallen back into India, and those of both theChinese Fifth and Sixth Armies, which had retreated into Y?nnan; regroup,equip, and train them; and assign them to a campaign to reconstitute the BurmaRoad as the vital overland artery between China and her allies.
From a sheer physical standpoint the undertaking-the secondBurma campaign-was prodigious.5 The plan,as it developed, involved three elements: (1) Chinese troops, trained andequipped by Americans but led by Chinese, were to strike westward from Y?nnanProvince to clear that section of the Burma Road which lay within the border ofChina; (2) simultaneously, Chinese troops, also trained and equipped byAmericans, and a few American troops (fig. 349), both under the command ofGeneral Stilwell, were to drive down the valleys of northern Burma and constructa new road, as they pro-
5This second Burma campaign was later officially designated as the India-Burma Campaign and extended from 2 April 1942 to 28 January 1945. It was followed by the Central Burma Campaign, 29 January 1945 through 15 July 1945.
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FIGURE 350.-Merrill's Marauders moving up along a newly constructed section of the Ledo Road.
gressed, from Ledo in Assam, India, to join with the Chinasection of the Burma Road at Mong Yu, Burma, just within the Burma-China border(fig. 350); and (3) the British, at the same time, were to operate from the ChinHills in northwestern Burma-between Burma and India, push eastward, anddisrupt Japanese lines of communications between north and south Burma.
The fighting for all three elements was of a most difficultnature, being conducted in mountains, jungles, and valleys. It involved, as onemedical officer assigned to the project described it, a kaleidoscope of mud,shortages, malaria, overtaxed equipment, rain, disappointment, heat, languagedifficulties, shifting priorities, jungle fighting, discarded plans, landslidesand homesickness.
A decision to extend their efforts to a large-scale programwas reached by the Americans in the fall of 1944 when it became apparent thatthe mission to reopen the Ledo-Burma Road (later Stilwell Road) probably wouldsucceed, but that the Japanese might be waiting at the China end of the road togreet the first convoy arriving there. As the Japanese pointed the prongs oftheir offensive toward Kuei-lin, the approaches to K'un-ming, key supplyterminal for shipment over the Himalayan "Hump" into China, and theapproaches to Chungking, provisional Chinese capital, appeared to be open andexposed to the enemy. The total collapse of the China war effort was not beyondthe realm of possibility.
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At this critical point, the War Department suddenly recalledGeneral Stilwell, Commander-in-Chief, USAFCBI, on 19 October 1944 and 5 dayslater, on 24 October, reconstituted the theater as two separate theaters, Chinaand India-Burma. Maj. Gen. (later Lt. Gen.) Albert C. Wedemeyer was appointedCommanding General, USFCT (U.S. Forces, China Theater), and Lt. Gen. Daniel I.Sultan, formerly Deputy Theater Commander, was named Commanding General, U.S.Forces, India-Burma Theater. China thereby became the operational arm of theAmerican Asiatic effort, and India-Burma became the supply and administrativebase for the operation. Only India possessed open ports, Karāchi and Calcutta,for receiving Allied materials. Both theaters continued as integral andsubordinate elements of the overall high command, the Southeast Asia Command,under the Supreme Allied Commander, Admiral Lord Louis Mountbatten (fig. 351).
FIGURE 351.-Admiral Lord Louis Montbatten.
In China, American ground troops were only used for advisory,logistic, and training purposes. In Burma, no more than two regiments ofAmerican troops with supporting arms and services, exclusive of air forces, werecommitted to battle. Service troops, including medical units, filled gaps in theChinese Army, which lacked specialists. The average strength of U.S. Forces inChina-Burma-India during 1944 was 168,700. They were spread thinly over theentire area. The various commands and units were engaged in the stupendous taskof transporting personnel, supplies, and equipment over long supply linesbetween the ports of India and the fronts in Burma and China (fig. 352),principally by means of air transport. They had to construct, maintain, andoperate the Stilwell Road, gasoline pipelines, and the communications systemwhich connected India, through Burma and across the Himalayas, with K'un-ming,China. Large numbers of troops carried out these service and constructionoperations under hazardous conditions instead of in
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relatively quiet rear areas, as is normally the case. There weremonsoons, almost impenetrable mountain jungles, mosquitoes6and myriads of other pests, and active interference by the Japanese troops.
Medical Activities of U.S. Army Forces in China-Burma-India
Theater surgeon's office - When General Stilwellassumed command he named as his theater surgeon, Col. Robert P. Williams, MC.During the period of the Burma Campaign, Headquarters, USAFCBI, was normally atChungking, but actually most of the time of the personnel was spent in the fieldor at Rear Echelon Headquarters, USAFCBI, at Lashio. Later, in the spring of1942, Rear Echelon Headquarters, USAFCBI, was established at New Delhi, Indiaafter General Stilwell's retreat from Burma. In April
6It has been estimated that in India, the population of which country in 1941 was 388 million, there were between 100 and 200 million cases of malaria and between 1 and 1? million deaths from this disease each year (Rehn, John W. H.: China-Burma-India. In Medical Department, United State Army. Preventive Medicine in World War II. Volume VI. Communicable Diseases: Malaria. Washington: U.S. Government Printing Office, 1963, pp. 347-398).
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1944, New Delhi was designated the main headquarters andForward Echelon Headquarters, USAFCBI, remained at Chungking. Colonel Williamsjustified his maintenance of the theater surgeon's office at Forward EchelonHeadquarters, USAFCBI, in these words:
In all other headquarters the Surgeon'sOffice is found in the Rear Echelon. That location was tried at the inception ofthis theater. It did not work, because all major decisions and long-rangeplanning were performed at Forward Echelon. * * * the Chinese Surgeon General,Red Cross, and National Health Administration simply would not do business withan assistant and it placed on the assistant the responsibility of formulation ofpolicy.
Deputy theater surgeon, Col. George E. Armstrong, MC,remained at Rear Echelon Headquarters, USAFCBI, in New Delhi. This arrangementcontinued until 14 May 1944 when, in accordance with a new theater policy, thetheater surgeon and his staff were ordered to reestablish their offices at themain headquarters in New Delhi. When the China Theater was established on 24October 1944, Colonel Armstrong, who had been moved to Forward EchelonHeadquarters, Chungking, was appointed Surgeon, USFCT. In view of the fact thatstaff officers and responsibilities had been transferred from forward echelonheadquarters at Chungking to the main headquarters at New Delhi, the creation oftwo separate theaters caught the China Theater short of personnel and many othernecessities. Colonel Armstrong's staff, inherited from forward echelonheadquarters of the China-Burma-India Theater, consisted of two officers and oneenlisted man. On 10 December 1944, a rear echelon of Headquarters, USFCT, wasestablished at K'un-ming, and the entire Medical Section, Headquarters, USFCT,moved to that location.
Relations with the Chinese - By the very nature of itsfunction, the medical service of the U.S. Army Forces in the China-Burma-IndiaTheater was drawn into very close association with both Chinese military andcivilian personnel (fig. 353). First of all, the concept of a military medicalservice had not been firmly established in the Chinese Army. As a matter offact, for all practical purposes, it was nonexistent. The Americans found itnecessary to start at the bottom. An apparent disregard for human suffering anda depreciated concept, which prevailed in the everyday struggle for existence,of the value of human life had been carried over into the Chinese Army. To aChinese accustomed to seeing Chinese civilians dying along the road with no onepaying heed, the sight of Chinese wounded soldiers left to die on thebattlefield seemed to cause little outward concern. The soldier was apparentlyconsidered expendable, and there was a resultant indifference to the wounded. Itfollowed, therefore, that the medical service of the Chinese Army, whosefunction it was to conserve life, would be held in little repute.
The Chinese division surgeon was usually a major and apolitical appointee without adequate medical training. Properly trained andqualified personnel were notoriously scarce. There were few modern medicalschools and only one Class-A school in China. Moreover, the available trainedpersonnel were
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not being used to the best advantage. Practically all qualifiedphysicians had congregated in the treaty ports at Hong Kong and Shanghai. Thehospitals available for military purposes were, in the main, hospitals bycourtesy only. The Chinese physicians found no compulsion or inducement to jointhe military service.
The story of how the U.S. Army helped to form the medicalservice of the Chinese Forces, as an integral part of the overall plan known as"Operation plan Stepchild," has been recorded in highly revealing andinteresting documents.7 The planenvisioned not only the provision of medical care for the malnourished and thesick-and-wounded Chinese soldier but also the establishment and conduct oftechnical-training schools in military medical subjects with students who forthe most part were lacking in the necessary background or qualifications.
Any officer who might in future wars have to deal withoriental allies will profit from reading Capt. Kenneth M. Scott's "SomeSuggestions for Medical Liaison Officers With Chinese Units," on file inThe Historical Unit, U.S. Army Medical Service.
7(1) Smith, Robert G.: History of the Attempt of the United States Army Medical Department to Improve the Efficiency of the Chinese Army Medical Service, 1941-1945, volumes I and II. [Official record.] (2) Medical Department, United States Army. Training in World War II, ch. IV. [In preparation.]
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Morbidity - The U.S. Army medical officer inChina-Burma-India was called upon to care for accidentally injured and diseasedU.S. Army personnel to a far greater extent than he treated battle casualties.In 1943, when the average strength of U.S. Army personnel in the USAFCBI, was39,600, there were 49,900 hospital admissions for all causes. Among the totaladmissions were 4,300 for nonbattle injury and only 200 for battle wounds andinjuries. The remaining 45,400 were admitted for disease. During 1944 theaverage strength rose to 168,700, and during this year there were 173,900hospital admissions: 157,600 because of disease, 14,500 for nonbattle injuries,and 1,800 battle wounds and injuries.8 Inthe same period, however, there were 12,739 Chinese battle casualties admittedto the hospitals of this theater in addition to strictly U.S. Army admissions.
Hospitals - Battle casualties from the Burma campaignswith a few exceptions received definitive treatment in what was known as theAdvance Section, comprised of that territory in upper Assam, India, and northernBurma in the area of the Ledo Road. Hospitals were first established there inMarch 1943 in the vicinity of Margherita, Assam, India, about 8 miles from thetown of Ledo in upper Assam and at the head of the Ledo Road. These were the20th General Hospital and the 48th and 73d Evacuation Hospitals. By the end of1943, hospital beds were provided for 3,705 patients by the following eighthospitals: The 20th General Hospital; the 14th (at the 19-mile mark, Ledo Road),48th, and 73d Evacuation Hospitals, the 25th Field Hospital, Ledo; and the 40th,42d, and 46th Portable Surgical Hospitals, Ledo, which for a short periodfunctioned as fixed hospitals. This represented somewhat more than half thenumber of available beds at that time in India and Burma; in China, there were1,465 additional beds.
The bed capacity of these hospitals in India had by March1944 increased to 4,310, of which 2,963 were for Chinese soldiers. At the end ofMarch, the 73d Evacuation Hospital moved to Shingbwiyang, Burma, at the 103-milemark on the Ledo Road, where it was established as a fixed hospital on the sidesof jungle hills, 5 miles from a newly constructed airstrip (fig. 354). Itfunctioned as an evacuation and station hospital for American and Chinese troopsand also as a general hospital for the Chinese.
During June 1944, the 69th General Hospital and the 28th,32d, 34th, 35th, 50th, and 53d Portable Surgical Hospitals arrived in Ledo. Thegeneral hospital was established at Margherita, several miles from the 20thGeneral Hospital, and the portable surgical hospitals were flown over theHimalayan "Hump" to support the Y-Force operating in the Salween Riverarea.9
8Provisional data based on sample tabulations of individual medical records, Medical Statistics Division, Office of The Surgeon General.
9The Y-Force consisted of Chinese Army units operating in Southern China and Along the French Indo-China border; the Infantry and Field Artillery Training Centers at K'un-ming; the Technical Service School at Ch'?-ching (K?tsing), China; the Medical and Veterinary School at Ta-li, China; traveling instructional group; and the Burma Road Engineers.
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FIGURE 354.-Continued. C. An operating room.
The entire fighting in Burma was jungle warfare (fig. 355). Theusual doctrines of medical evacuation could not be utilized. The use ofwell-equipped, mobile evacuation hospitals situated relatively close to thefighting line, as was possible in the European theater, was totally out of thequestion here. The burden of early surgical care of battle casualties fell, inthe early days, to the Seagrave Hospital Unit10and the 151st Medical Battalion, and later to the portable surgicalhospitals. These portable surgical hospitals were small units with 4 officersand 35 enlisted men. Many times these units were divided into two groups tooperate in two different areas. Their men often had to march all day on a jungletrail, then set up at night, and immediately start operating upon the wounded.They were inadequately equipped owing to the fact that their entire equipmenthad to be carried on their backs or by a limited number of horses, except forthe supplies dropped by parachute.
10The Seagrave Hospital Unit was created by Dr. Gordon S. Seagrave, an American missionary to Burma since 1922, from the personnel of the American Baptist Mission hospital at Namhkam, Burma. Consisting initially of Burmese doctors and nurses, it was later augmented as necessary for various missions by the attachment of U.S. Army personnel and units. Dr. Seagrave was at first given an honorary lieutenant colonelcy in the British Indian Army and was later commissioned as a major in the U.S. Army Medical Corps. Still later, he was promoted to lieutenant colonel, Medical Corps.
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Most of the work in the portable surgical hospitals was done at night sincelitter bearers usually brought in patients after dark. Except for occasionalinstances when portable units were relatively fixed, all operating had to bedone with the aid of an ordinary flashlight. The fact that battle casualties ofthe Burma campaign had such excellent medical care and experienced such a lowmortality is largely due to the men who worked in the portable surgicalhospitals.11 It was obvious that hospitalsworking under such conditions could not hold patients. It was equally obviousthat few patients would survive transportation over mountain jungle trails andthe almost impassable roads from these forward hospitals to the field andevacuation hospitals well to the rear. It was for this reason that the system ofair evacuation was perfected.
Air evacuation of the wounded12- At dawn on15 October 1943, the Chinese Army in India initiated a drive which was toculminate in the reconquest of northern Burma. With the advance eastward intoBurma, the Chinese troops were isolated from fixed hospitals in the base bydifficulties of evacuation. The road, within any reasonable distance of the areaof combat, existed only on engineering blueprints. The Seagrave Hospital Unitand Company D, 151st Medical Battalion, moved in on foot to provide medicalservice for the Chinese Army in India. With the capture of Shingbwiyang, thefirst forward airstrip was constructed. It was, however, still frequentlynecessary to transport patients by litter for several days before this airstripcould be reached. At this point in the campaign, the evacuation period was oftenas long as from 7 to 14 days from the time of injury to the time of admission ata fixed hospital in the base.
Gradually, as Chinese and American troops (committed inFebruary 1944) advanced through the northern Burma jungle, 20 additionalairstrips were constructed to keep pace with the troops. From 6 March to 14April 1944, the interval between injury at the front and admission to fixedhospitals at the rear averaged 48 hours. Paddy fields were leveled by Chinesecombat troops to receive the small liaison planes which were employed toevacuate the wounded, and occasionally sandbars were utilized. The remotestreaches of the densest jungle country in north Burma were penetrated by theseplanes which landed and took off with wounded soldiers from the most primitiveand wholly inadequate strips (fig. 356). Both the planes and the strips werefrequently within range of mortar, small arms, and machinegun fire.
The difficulties of evacuation were increased manifold withthe onset of the monsoon rains in June. Motor ambulance evacuation came to astandstill. In the valleys, bullock carts with water buffalo"tractors" were employed. Yet, despite flooded airstrips and constantpouring rains, approximately 380 battle casualties reached the Ledo airstripduring June 1944. An additional 900
11Report, 2d Lt. James H. Stone, MAC, Office of the Surgeon, U.S. Forces, India-Burma Theater, to The Surgeon General, U.S. Army, 30 June 1945, subject: The Portable Surgical Hospitals in Northern Burma.
12Official unpublished historical report, Office of the Surgeon, Northern Combat Area Command, U.S. Army Forces, India-Burma Theater, 28 July 1945, subject: A Report Summarizing the Activities of U.S. Army Medical Department Units Assigned to Northern Combat Area Command During the Northern and Central Burma Campaigns.
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patients with disease or nonbattle injuries were evacuatedfrom the combat area during this period. In the battle for Myitkyina, 25 percentof casualties arriving at the 20th General Hospital had been injured on the dayof arrival (fig. 357).
Quality of surgical care in the India-Burma Campaign - Itwas the opinion of surgeons in fixed hospitals to the rear that the quality ofsurgery undertaken in forward units during the India-Burma Campaign was, on thewhole, excellent. When viewed in the light of conditions under which the forwardsurgery was accomplished, the high percentage of good results represented aremarkable feat of courage, effort, improvisation, and sound, conservativesurgical treatment.
In the initial stages of the northern Burma offensive,certain practices no doubt tended to increase both morbidity and mortalityrates. But as the experience of surgeons both in the forward and rear areasaccumulated, these difficulties were, to a considerable extent, overcome inseveral ways. On 4 April 1944, the chiefs of the surgical services13 of the14th, 48th, and 73d Evacuation Hospitals and the 20th General Hospital werebrought together for the purpose of discussing their observations of the care ofbattle casualties in forward medical units and to formulate recommendations forimprovement in the surgical care of casualties by officers in these units. Themeeting had been suggested
13These chiefs of surgical services were: Lt. Col. Willis M. Weedon, MC, 14th Evacuation Hospital; Lt. Col. Kwan Heen Ho, MC, 48th Evacuation Hospital; Lt. Col. Clarence J. Berne, MC, 73d Evacuation Hospital; and Maj. John F. North, MC, 20th General Hospital.
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by Col. Vernon W. Petersen, MC, Surgeon, Northern Combat AreaCommand, and the officers had been assembled by Col. (later Brig. Gen.) I. S.Ravdin, MC, Commanding Officer, 20th General Hospital. The report andrecommendations of this committee formed the basis for a document, "Epitomeof Surgical Management," which was distributed by the theater surgeon toforward units.
There is little doubt that the "epitome" on woundmanagement was responsible to some extent for the improvement subsequently notedat base hospitals in the initial treatment of wounds. Officers from these basehospitals observed, however, on visits to forward units that the"epitome" was not too well received. Not only was criticism implied(which was unavoidable), but surgical officers in the forward medical unitsconsidered that the proper orientation of SOS (Services of Supply) surgeons inworking conditions at the front would have made for more sound, intelligentsuggestions based on practical familiarity with the problems of portablesurgical hospitals. Similar complaints were made to Colonel Graham when, somemonths later, he visited these forward units after their transfer to combatareas of China.
These criticisms of the "epitome" were well takenand resulted in an occasional exchange of officers between the rear and forwardunits. It was recommended that officers assigned to the forward units berelieved from duty at relatively frequent intervals and returned to rearinstallations for short periods of time. It was believed that, after a month ofsteady operation under the severe conditions of jungle operations, surgeons ofthe portable hospitals inevitably grew too fatigued to render the type ofservice of which they were normally capable. Return to a rear installationwould, it was believed, restore the keenness of these officers' capabilitiesand in the long run result in greater efficiency of the portable surgicalhospital. The disadvantage of medical officers working only in one type of unitwas that the difficulties encountered by forward units were not appreciated bypersonnel in the rear, and that, on the other hand, officers at the front wereunable to follow up their cases in order to determine the validity of theirtechniques or to correct errors. The benefits which could be obtained fromincreased medical liaison were considered to be significant, and efforts weremade to achieve it by the exchange of officers as well as by other means.
MEDICAL SERVICES, U.S. FORCES, INDIA-BURMA THEATER
On 28 January 1945, when the consultants arrived in the India-Burma Theater, there were 27 hospitals in active operation: 6 general, 14 station, 4 field, and 3 evacuation hospitals. The total bed capacity of these hospitals was 19,772, and 512 Medical Department officers were assigned the care of 9,819 patients. From a one-man organization in 1942, the medical service had expanded to an organization of 13,780 officers and men.
The theater (map 6) extended west to east from Karāchi,India, to Lashio, Burma, a distance of 2,200 miles.14Theater headquarters, at New Delhi, was
14All distances are expressed in terms of regular Air Transport Command routes between the points mentioned.
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MAP 6.-India-Burma Theater, approximately January 1945.
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situated in north-central India, in the Punjab Desert, 650miles from Karāchi. New Delhi was 1,300miles from Ledo in the upper portion of the province of Assam, where a number ofhospitals were located. The most southerly situated hospital was at Kandy,Ceylon, Headquarters of the Southeast Asia Command (of which the India-BurmaTheater was a part), 1,600 miles from New Delhi. The most northerly situatedhospital in Burma was at Tagap Ga on the Ledo Road at the 52-mile mark. If theshortest air route between this hospital and New Delhi were taken, one would flyover Bhutan, Tibet (just north of Mount Everest), and the Kingdom of Nepal.
Seventy percent of the hospitals-five general, eightstation, the three field, and the three evacuation hospitals-were establishedin a rectangular area approximately 950 by 450 miles in the extreme easternportion of India and entirely across northern Burma (map 7). This area wasslightly larger than the combined square miles that comprise the 14 easterncoastal States, plus Vermont, Pennsylvania, and West Virginia. It was roughly ofthe same shape and dimensions. Moreover, it was comparable to the area includedin the First, Second, Third, and Fourth Service Commands, as then constituted,or almost twice the size of Texas. The distance from theater headquarters inDelhi to the center of this rectangular area was about 1,200 miles, almost thesame air distance from the Office of The Surgeon General in Washington to thecenter of Texas.
Except for the area of fighting in central and eastern Burma,this vast area encompassing the India-Burma Theater was subdivided into areacommands known as the Base, Intermediate, and Advance Sections. The NorthernCombat Area Command was comprised of the headquarters and troops conductingoperations against the Japanese in the area of construction on the Ledo Roadand, later, in central and eastern Burma.
MEDICAL SERVICE, U.S. FORCES, CHINA THEATER
The medical service of the U.S. Army in China had always been badly in need of almost everything: hospital units, qualified personnel (both officer and enlisted), and modern equipment (fig. 358). It was one of the lowest of low-priority theaters. For the most part, the theater had been entirely dependent for logistic support on air transportation over the Himalayan "Hump": Food, clothing, equipment, supplies, high-octane gas for both fighter and transport planes, ammunition, motor vehicles, and so forth. The overland "back door" supply route, the Ledo-Burma Road, and the gasoline pipeline had afforded some relief but conditions were still far from ideal. The first U.S. Army supply convoy entered China over the Ledo-Burma Road on 28 January 1945, the day the consultants arrived in India.
Colonel Armstrong's task of organizing the medical serviceof the China Theater had been rugged. On 2 November 1944, 5 days after he hadbeen
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advised of his appointment as theater surgeon, Colonel Armstrongwrote to Colonel Williams, Surgeon, USFIBT:
Returned to 879 [Chungking] yesterday morning andam now so thoroughly confused that I honestly do not know where to turn.Apparently there are so many big problems to iron out that no one has time tosettle any of the little (mine) ones. I am unable to find out whether thisoffice will duplicate all the things done in your office or whether your officewill continue to perform many functions for us. Obviously Cavenaugh [Maj. (laterLt. Col.) Robert L. Cavenaugh, MC], Sergeant Copeland, and I cannot go far inrunning a medical section for a Theater.
A letter from Colonel Williams, which had crossed ColonelArmstrong's in transit had stated the former's views substantially asfollows:
As Colonel Williams saw it, very few changes would berequired for adequate medical service for both theaters. Practically the onlychange was that it would not be necessary for Colonel Armstrong to continuereporting to him. However, until circumstances altered things, Colonel Williamsintended to send Colonel Armstrong carbons of everything that might interesthim. He anticipated that Colonel Armstrong would reciprocate. Of necessity, thetwo theaters would be so closely booked together that constant interchange wouldbe
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FIGURE 358.-Inadequate medical supplies being sorted at a Chinese medical collecting station.
required. Colonel Williams intended to make every effort tomaintain the closest cooperation. Anything that he could do he would, just asthough they were still one family.
It was mutually agreed that the Office of the Surgeon, USFIBT,would render for the China Theater all necessary medical reports and returns,pending the acquisition of additional personnel in the Medical Section,Headquarters, USFCT. By 10 December 1944, when the rear echelon of China Theaterheadquarters was established at K'un-ming in Hostel No. 1 and the entireMedical Section had moved to that location from Chungking, the personnel of theMedical Section, Headquarters, USFCT, had been increased sufficiently to relievethe India-Burma Theater of all medical functions pertaining directly to Chinawith the following exceptions:
1. Personnel.-Because of a lack of portfacilities in China, unit and individual requirements for personnel-bothinitial and replacements-were coordinated with those of the India-BurmaTheater before their submission to Washington.
2. Medical supply.-For the same reason as citedabove, medical supply requisitions were consolidated with those of theIndia-Burma Theater.
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3. Hospitalization.-The India-Burma Theater servedas a reservoir for cases from China requiring hospitalization exceeding theestablished 90-day evacuation policy of the China Theater. Patients en route tothe Zone of Interior also had to rely on holding facilities in India-Burma, asno other route was available.
In all other respects, the Office of the Surgeon, USFCT,functioned as that of an independent theater. The theater surgeon's officecontinued to grow and the staff had increased considerably by the time thisconsultant arrived in India-Burma. Care had to be taken in accomplishing thisnot to draw keymen from medical units of the theater, since medical officers andenlisted men were at so high a premium in China that the loss of one man couldinterfere with the function of an installation. The possibility of replacing himin such a low-priority theater was remote.
The work of the Medical Department, of course, could not waituntil all needs had been met. With his limited staff at K'un-ming, and in theearly days at Chungking, and with only a skeletal medical organizationthroughout the new theater, Colonel Armstrong undertook the difficult task oflifting the Chinese medical service from the depths of demoralization anddisorganization which attended the threatened collapse of China through the routof the Chinese Army in southeastern China. At the same time, he had to implementplans for the medical care of U.S. troops who were coming into the theater inincreasing numbers.
Inasmuch as the medical service of the USFCT remainedthroughout the war essentially that of a military mission aimed at improving theefficiency of the medical service of the Chinese Army, it became necessary forthe theater surgeon to devote a large part of his time to work with the Chinesemedical authorities. These were the Director (Surgeon General) of the ArmyMedical Administration, and representatives of the National HealthAdministration, and the National Red Cross Society of China. In addition tothese were a considerable number of foreign philanthropic associations with whomthe theater surgeon maintained liaison in an effort to coordinate the manydiverse aspects of medical service in China bearing on the Allied militaryeffort. In this atmosphere of confusion, division of responsibility andwidespread disorganization, it is remarkable that the theater surgeon and hissmall, but intensely loyal and inspired, staff accomplished as much as they did.
Long before activation of the China Theater, the need foradditional hospitalization in China was referred to in communications to the WarDepartment as critical. When, finally, the 70th Field Hospital, designated forChina, arrived in the India-Burma Theater in October 1944, it was retained forcombat service in Burma until June 1945. In March 1945, two station and threefield hospitals were assigned to the China Theater with a total of 1,800 beds.An additional five field hospitals and one general hospital (1,000-bed) werescheduled for transfer to the theater from the India-Burma Theater to make atotal of 4,300 fixed beds for the China Theater.
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In June 1945, however, when the author departed from theChina Theater, there were still only one station and two field hospitalsfunctioning, there were no provisions for establishing a general hospital, andnone of the five field hospitals had arrived in China. The most pressing problemwas what to do with Chinese casualties, since the War Department would notprovide U.S. Army fixed beds for Chinese troops in China, as had been authorizedin India-Burma. In China, hospitalization of Chinese troops was considered theresponsibility of the Chinese Army Medical Administration. This administrationand the Chinese Red Cross established a number of hospitals in the variouscategories, but practically all of them were woefully lacking in just abouteverything: Physical facilties, skilled personnel, supplies, and equipment. TheMedical Department, U.S. Army, at the time of this consultant's visit to theChina Theater, was committed to care for only casualties near the front who werebrought into portable surgical hospitals manned by U.S. Army personnel. Themanner in which the portable surgical hospitals functioned is described later inthis chapter (pp. 942-945).
FUNCTIONS OF THE SURGICAL CONSULTANT
General ConsiderationsIn addition to the medical and surgical consultants, Maj.John R. S. Mays, MC, Consultant in Neuropsychiatry, Maj. (later Lt. Col.)Richard W. Britt, MC, Reconditioning Officer, and four Medical AdministrativeCorps officers arrived on 28 January 1945 for assignment to the Office of theSurgeon, Headquarters, USFIBT. Brig. Gen. James E. Baylis, MC, the newlyappointed Surgeon, SOS, USFIBT, arrived several days later. General Baylis'last previous assignment had been that of Commanding General, MedicalReplacement Training Center, Camp Grant, Ill. Somehow during the period ofbriefing in Washington and as a result of conversations with officers returnedfrom the theater, some of the newcomers had developed the feeling that theirreception at Headquarters, USFIBT, and perhaps even in the field as well, wouldbe somewhat less than cordial. Actually, they were welcomed with genuine warmth,not only at headquarters, but almost everywhere they went in the theater.
There was little doubt that this fine reception was, to aconsiderable extent, influenced by the character and personality of GeneralBaylis, who was esteemed throughout the Army as an officer of superior abilityas an organizer and administrator. He possessed a genius for inspiringsubordinates, to whom he delegated great responsibility. He encouraged them totake the initiative in the development of their respective sections in theOffice of the Surgeon. He never questioned professional opinions andrecommendations of the consultants. The consultants were told to makecorrections "on the spot" when they observed irregularities anddeficiencies that required prompt action during visits to hospitals. At the sametime, they were given to understand that their decisions
913
would be reversed if subsequently it was determined that theyhad erred. This arrangement in a theater spread out over the entire area ofIndia and Burma, with many installations situated more than a thousand milesfrom theater headquarters, greatly facilitated and hastened the accomplishmentof the consultants' mission. At the same time this implicit confidence in theprofessional judgment of the consultants had a sobering influence on them incurbing any tendency toward precipitate action of making recommendations withoutdue deliberation.
The functions of the surgical consultant were conciselystated by Brig. Gen. Fred W. Rankin, MC, Chief Consultant in Surgery to TheSurgeon General, in the annual report of the Surgery Division for fiscal year1944, substantially as follows:
The surgical consultants exercise their functions byassisting and advising the service command or theater surgeons on all matterspertaining to surgical practice, including particularly the organization andprogram of surgical services in medical installations and the quality,distribution, and proper assignments of professional personnel, by providingadvice on newer developments in diagnosis and treatment, by stimulating interestin professional problems and aiding in their investigation, and by encouragingeducational programs such as conferences, ward rounds, and journal clubs. Theseconsultants are concerned essentially with the maintenance of the higheststandards of medical practice. It is their function to evaluate, promote, andimprove further the quality of medical care by every possible means, tointerpret the professional policies of The Surgeon General and to aid in theirimplementation.
The formulation of many policies and the making of decisionsin regard to the solution of many problems required coordination of the medical,neuropsychiatric, and surgical consultants. Colonel Blumgart and the author werefortunate in that they had, during the preceding year, functioned as a teamalong with the service command neuropsychiatric consultant in the considerationof many common problems. Major Mays readily fitted into the team, as did thenewly appointed chief of personnel in the Office of the Surgeon.
In August 1944, Col. Alexander O. Haff, MC, Surgeon, Servicesof Supply, USAFCBI, had also been designated deputy theater surgeon and Chief ofProfessional Services for both the theater headquarters and SOS medicalsections. In February 1945, after arrival of the new consultants, these twosections were consolidated and Colonel Haff was evacuated to the United Stateswithout replacement. With the position of Chief of Professional Servicesdiscontinued, the consultants functioned directly under the theater surgeonrather than through an intermediary chief.
The aforementioned chief of the Personnel Section, Office ofthe Surgeon, SOS, USFIBT, was Lt. Col. Casey E. Patterson, MC, an officer ofhigh professional attainments. Colonel Patterson cooperated in the considerationof routine professional matters as well as matters pertaining to personnel. Inboth instances, he screened material before referring it to the consultants.
914
When the consultants were absent from the office of thetheater surgeon, he disposed of all matters except those which definitelyrequired the attention of the consultants. When immediate action was required,he contacted them in the field by telephone, radio, or courier mail. Actually,this organization of the professional services officers with the personnelofficer might be described as a committee on professional services andpersonnel, with the theater surgeon serving as chairman. Its successfuloperation was insured by the wholehearted cooperation of all members and theirability to discuss problems harmoniously, frankly, and critically. Decisionsreached by this group were presented directly to the theater surgeon forconsideration. Colonel Blumgart and the author were in a position to comparethis simplified organization with the conventional one they had experienced inthe Second Service Command, where the chief of professional services undertookactivities of a technical and specialized nature with a minimum of consultationwith the professional consultants. The simplified system was definitely moresatisfactory, at least for the India-Burma Theater. Although no need occurredfor the addition of administrative assistants to the professional servicesorganization, such additions could have relieved the specialists of the burdenof routine work which would have accumulated in a larger and more activetheater.
Soon after the arrival of the consultants in the theater,General Baylis obtained permission of the theater commander to route theconsultants' reports through technical medical channels. General Baylis alsoapproved the consultants' recommendation that information copies of thesereports be sent to commanding officers of hospitals which had been visited, apractice not hitherto carried out by the SOS or theater surgeons. Almostimmediately upon return to theater headquarters from field trips and beforeformal reports had been compiled, the consultants submitted to the theatersurgeon brief, confidential summaries of observations which would require promptaction. If on the tour there were noted deficiencies in physical plants, theneed for air conditioning, or other similar nonprofessional matters thatrequired corrective action, a memorandum to the effect was sent to the Chief ofStaff, USFIBT.
Considerably less than half of the author's time was spentin the office of the theater surgeon. Here, as a member of the theater surgeon'sstaff, many activities claimed his time: Preparation of the section on surgeryin ETMD (Essential Technical Medical Data) report; review of all publications onsurgical subjects reaching the Office of the Surgeon; preparation of material oncurrent surgical problems for the monthly Field Medical Bulletin, USFIBT; preparationof theater circulars, directives, and memorandums on professional surgicalsubjects; review of clinical records and post mortem findings in all deaths dueto surgical causes; review of proceedings of boards of officers; conferenceswith the other consultants and with the personnel officer; and, finally,compilation of reports on hospitals which had been visited. Moreover, a ratherlarge correspondence was conducted with the Surgeon, China Theater, withcommanding officers of hospitals relative to problems of the surgical
915
services, with General Rankin, Chief Consultant in Surgery toThe Surgeon General, and with Col. B. Noland Carter, MC, Assistant Chief,Surgical Consultants Division, Office of The Surgeon General. Practically all ofthese letters, or pertinent portions of them, were brought to the attention ofthe theater surgeon, or members of his staff, for information, guidance, orspecific action.
Editorial Duties
The surgical consultant was responsible for the preparation of the section on surgery in the ETMD report submitted monthly to The Surgeon General. This consultant found that "feeder" reports submitted by hospitals had become routine and lacked material of clinical interest. The theater surgeon, therefore, advised all installations and the headquarters of the various base sections of the type of information desired.
During the visits of the consultants to the varioushospitals, further effort was made to stimulate studies of unusual cases. Muchvaluable material was thereby accumulated and many excellent papers weresubmitted for publication in medical journals, particularly by officers of the20th General Hospital (University of Pennsylvania affiliated unit).
The consultants were also responsible for articles orcomments in the monthly Field Medical Bulletin, USFIBT. The surgicalofficers of the theater were encouraged to submit reports on their studies, andmany of these were published. This bulletin also provided a valuable means ofconveying information regarding recent advances in surgery. The policy recentlyinstituted by the former deputy theater surgeon of reprinting in the theateradvance copies of important War Department technical bulletins was continued.Distribution of these bulletins to the theater through normal publicationschannels was extremely slow, and many times essential bulletins never reachedthe hospitals. Thus, it was most fortunate that the consultants had brought withthem the complete medical series of those that had been issued up to the time oftheir departure from the Zone of Interior. On the other hand, considerablenumbers of bulletins consisting of 50 or more pages relating to the water supplyof Germany and Czechoslovakia and sanitary data on the Aegean Islands andFinland were received with great promptness.
In some instances, where no suitable official guides ordirectives were available, appropriate circulars or memorandums were submittedto the theater surgeon and, following his approval, were reproduced anddistributed. Restraint was practiced in the number issued. Moreover, the spiritof these publications was that of guidance rather than mandatory direction.Specific directions, however, had to be issued on the transfer of patients togeneral hospitals and on operations for deranged knee cartilages, chronicallydislocated shoulders, and cases of herniated nucleus pulposus. These problemsare discussed later.
916
Review of Clinical Records and Post Mortem Findings
Soon after arrival of the consultants, the theater surgeon approved their request that, in nonbattle casualties, the full clinical records and results of post mortem examinations be submitted to the theater headquarters for review. This practice proved of exceptional value. Theater headquarters was kept informed of some of the most interesting cases. A review of the medical care of the most seriously ill was thereby accomplished, and occasional suggestions were made or deficiencies were noted. Deficiencies were made the subject of correspondence or, more often, a conference with the staff concerned was held on the author's next visit to the installation. It was believed also that this procedure had anticipatory value in that it was generally understood that the clinical record of any seriously ill patient might eventually be scrutinized in the office of the theater surgeon.
SURGICAL PERSONNEL
Personnel ProblemsBasic to all other considerations in achieving a highstandard of surgical care was the question of personnel. A combination ofcircumstances prompted the consultants on their arrival in the theater to givepersonnel matters priority over all other activities. First, Colonel Kennedy, ofthe Kelser Mission, had personally emphasized to Colonel Graham the need for theconsultants to make a prompt survey of personnel. Second, Lt. Col. (later Col.)Durward G. Hall, MC, Director of Military Personnel and Chief of PersonnelServices, Office of The Surgeon General, had set a deadline of 1 April 1944 for(1) the execution of the new WD AGO Form 178-2, Supplemental Data for MedicalOfficers, which had not been accomplished in this theater since its activation,and (2) assignment by the consultants of proper SSN (specification serialnumbers) and ratings for all medical officers in the India-Burma and ChinaTheaters. Third was the fact that the personnel officer in the Office of theSurgeon, USFIBT, was a young first lieutenant in the Medical AdministrativeCorps. The consultants' initial recommendation to the theater surgeon was theappointment of a highly qualified Medical Corps officer as Chief of Personnel.Colonel Patterson was immediately assigned to this position and proved to be anexcellent choice. As has already been remarked, Colonel Patterson and theconsultants functioned in a most satisfactory fashion as a committee onpersonnel and professional services.
Professional Classification of Surgical Officers
The information on the officer's qualification forms and the obsolete Medical Department questionnaire, prepared by the individual officer, was of little value since, in most instances, the information had been entered 2 or more years previously. It was most natural that the classification and proficiency ratings of these officers, based almost entirely on the interpretation of this meager infor-
917
mation by a nonmedical officer, should result in a number ofincorrect classifications and malassignments.
As quickly as the new supplemental data forms were executedand returned to the Office of the Surgeon, USFIBT, the consultants reviewed themand appended their recommended classifications and proficiency ratings. Since amajority of the officers had been in the theater for 20 months or longer, it wasnot surprising that changes were made in almost every instance. In a moderatenumber of cases the officers had been incorrectly classified as to theirappropriate specialty, owing to insufficient available data or invalidrecommendations of their commanding officers. A far greater number had beengiven proficiency ratings which were either too high or too low. The mostsignificant observation was the fact that many officers had been classified"general duty" who, through opportunities afforded them by chiefs ofsurgical services or by their own diligent application, had acquired proficiencyin general surgery or one of the surgical specialties and because ofdemonstrated ability deserved a specialty classification.
Although by 31 March 1945 copies of the newly completedforms, with the revised classification and proficiency ratings, were ready to beforwarded to the Office of The Surgeon General, in only 60 percent of instanceshad the changes been made on the basis of personal interview and observation ofthe officer's professional activities. The theater surgeon, however, informedThe Surgeon General and commanding officers of hospitals that the ratings madesolely on the basis of the newly acquired personnel information were subject torevision after these officers had been observed by the consultants.
The individual statements of educational training andpostgraduate surgical experience were not sure guides to individual surgicalproficiency. Certain surgical officers, for instance, with a wide range ofsurgical knowledge-some qualified by an American Specialty Board-lackedconservative, sound, clinical judgment; others lacked necessary qualities ofleadership. Conversely, other officers with little postgraduate training, whohad taken advantage of their opportunities to acquire proficiency in assignmentsin the Army as surgical assistants, were found fully qualified to be chiefs of asurgical service at a 250-or 500-bed station hospital. The Chief Consultant inSurgery to The Surgeon General, himself one of the organizers of the AmericanBoard of Surgery, repeatedly insisted that absence of certification by theSpecialty Boards did not prohibit inclusion of an officer in the higherproficiency classifications, as "Group A" and "Group B."
Appraisal of the intrinsic qualifications of the surgicalofficer could be made only on the basis of personal observation during actualward rounds and in the operating room. This consultant spent at least one andusually many additional hours with each officer on his wards reviewing in detailphysical findings, clinical records, treatment, and administrative dispositionsof the patient. Informal discussions of related general subjects formed part ofsuch visits. In some instances, personality clashes rendered an officer'sservices ineffective at a particular installation and could be obviated byassignment elsewhere. Oc-
918
casionally, the commanding officer of a hospital wasencountered who failed to recognize the distinction between efficiency andproficiency classifications. He would question the propriety of the consultant'shigh proficiency rating in the case of an officer with superior training anddemonstrated ability to whom he had given a relatively low efficiency rating.Others were mistaken in the belief that the proficiency rating was influenced byage, rank, length of service, and by the successful completion of advanced Armyextension courses conducted for the Officers' Reserve Corps.
Actually, there was a superabundance of officers of fieldgrade in both theaters who, although well versed in the details of Army medicaladministration, were nevertheless classified as general duty (MOS 3100) medicalofficers. In civilian life they had begun general medical practice after a1-year internship. They were too old and possessed too much rank to be assignedas ward officers, yet lacked adequate surgical training and experience towarrant their assignment to positions of responsibility commensurate with theirrank. Many, however, had requested such assignments, and a few had become chiefsof surgical services in small station hospitals.
Qualitative and Quantitative Studies
From an initial survey of records in the office of the theater surgeon, this consultant was inclined to believe, as was Colonel Kennedy, that there was an urgent need for many additional medical officers qualified as general surgeons and specialists. Actually, however, as the author was to determine later, there was no lack of capable surgical officers except for a few key specialists, notably experienced orthopedic surgeons. This discrepancy was quite easily explained. First, a large number of officers designated in personnel files as general-duty medical officers had, through earnest effort and careful supervision by highly competent surgeons, become eligible for classification as general surgeons or surgical specialists, "D" or "C." Second, a large excess of surgical talent was concentrated in three affiliated medical units in the Advance Base Section.
These affiliated units were a 2,000-bed general hospital andtwo 750-bed evacuation hospitals, the latter serving as station hospitals forU.S. Army personnel and as general hospitals for the Chinese. Sixty of theseventy-eight officers assigned to their surgical services were consideredcapable of undertaking operations without supervision. The census of surgicalpatients in these three hospitals seldom reached 2,000. This inequitabledistribution of surgical personnel was not the fault of the theater surgeon. Thetrouble stemmed from a policy established in the Office of The Surgeon Generalaround 1939. At that time, written agreements were negotiated with universitiesin which the university medical schools agreed to organize and staff theprofessional services of general and evacuation hospitals which were to beactivated in the event of war; The Surgeon General, in turn, agreed notto dismember the units except with the consent of the school or the unit itself,or as an urgent military necessity. It is understood that in any future war sucha situation as regards personnel in similar affiliated units will not recur.
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In sharp contrast to the quantity and quality of surgicalofficers present in the three foregoing affiliated units in the India-BurmaTheater was the situation at three general hospitals in the Second ServiceCommand which the author had inspected during his last month as surgicalconsultant for the command. These three general hospitals-Tilton, at Fort Dix,Wrightstown, N.J., Rhoads, at Utica, N.Y., and England at Atlantic City, N.J.-hada combined authorized capacity of 6,000 beds. There were 3,889 surgical patientsat the time of the survey. Of these, 2,395 were orthopedic cases, mostly battlecasualties with multiple compound fractures. All patients were U.S. Armypersonnel, whereas some 75 percent of patients in the hospitals of the India-Burma Theater were Chinese. Only 37 of the total 62 surgical officers in theZone of Interior hospitals were classified in categories which would ordinarilypermit them to undertake operations without supervision. A quantitative andqualitative comparison of officers assigned to the three hospitals inIndia-Burma with those assigned to the three hospitals in the Second ServiceCommand showed:
| Number in India-Burma Theater | Number in 2d Service Command |
Certified by Specialty Boards | 26 | 16 |
Qualified for certification | 8 | 4 |
Classified by consultant, "A" or "B" | 32 | 20 |
Classified by consultant, "C" | 28 | 17 |
Classified by consultant, "D" | 15 | 13 |
Classified "General Duty" | 3 | 12 |
The disproportionately large surgical staff provided theevacuation hospitals (25 officers each) as compared with the number and qualityof officers assigned to other fixed hospitals of comparable size was due to thefact that evacuation hospitals were originally organized to function as mobilefield units situated close to and in support of actively engaged combat troops.Employment in this manner would have required a 24-hour operating schedule inwhich surgical teams would have alternated between surgical activities andperiods of relaxation and sleep. The character of the warfare and terrain overwhich battles were fought in the Burma campaigns precluded the employment ofevacuation hospitals in the conventional manner. It was not until near the closeof the Central Burma Campaign that a number of these officers were transferredto other hospitals in order to insure balanced, efficient surgical staffsthroughout the theater.
By May 1945, through the acquisition of qualified officers,including experienced orthopedic surgeons and other specialists from the UnitedStates, and reallocation of officers already in the theater, every surgicalservice in the hospitals of the India-Burma Theater was satisfactorily staffed.Moreover, the USFIBT was prepared by then to transfer to the USFCT a number ofcompetent surgical officers to offset personnel deficiencies in the ChinaTheater and to replace officers eligible for rotation.
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In April and May, a large number of officers became eligiblefor rotation. Among these were 29 key surgical officers who were due forreassignment in the United States. A brief summary of this consultants'impression of their capabilities was sent to Col. B. Noland Carter, MC,Assistant Chief, Surgical Consultants Division, Office of The Surgeon General.Colonel Carter, in turn, conferred with Colonel Hall, Director of Personnel, inregard to these officers. As a result, by the time these returnees reachedredistribution centers, reassignment orders awaited them. The initial success ofthis process prompted Colonel Carter to request that this information beforwarded in the case of every officer with a classification of "C" orhigher.
EDUCATION AND TRAINING
The scarcity of surgical officers-except in affiliated units-sufficiently skilled and personally qualified for positions of responsibility and leadership made it imperative that hospitals be considered as training centers. Key personnel, lost through illness or rotation, could thereby be replaced. An additional incentive for high standards of performance possibly leading to promotion was provided. The accelerated wartime program of civilian medical education frequently resulted in producing young medical officers of considerable innate ability but with meager clinical knowledge or experience. Whenever possible, such officers were assigned to duties under the immediate supervision of mature, seasoned surgeons and, after varying periods of time, were qualified to be chiefs of surgical service in small station hospitals or heads of sections in the surgical services at general hospitals.
The policies governing treatment of various surgicalconditions varied greatly from hospital to hospital and indeed from ward toward. This was due to the fact that the medical officers largely represented across section of the American civilian medical profession with widely differenttypes of training experience and personal views and had not received thefundamental directives and guides issued by the Office of The Surgeon General.Few if any TB MED's (War Department technical bulletins, medical) had beenreceived, and but few overall professional policies had been established in thetheater. To raise the quality of medical care to the highest possible level,each installation was directed to prepare a list of the TB MED's that had notbeen received, and adequate distribution was effected. It was further directedthat a complete file of such bulletins as well as circulars and other directivesissued by the theater surgeon be maintained by the commanding officer and in theoffices of the chiefs of medical and surgical services at all fixed hospitals.
The consultants attempted to stimulate professional interestby recommending the establishment at hospitals of a suitable reading andconference room, even when a tent had to be erected for that purpose. Steps wereundertaken to supply each installation with its authorized allowance ofprofessional books and periodicals. Through the generosity of the Josiah MacyJr. Foundation, New York, N.Y., reprints of outstanding articles appearing incurrent medical periodicals were distributed to the medical officers in theIndia-Burma Theater.
921
Medical officers were thereby encouraged to keep abreast ofadvancing medical knowledge.
Medical officers were urged to review series of cases attheir own installations and prepare reports summarizing their experiences. Insome instances, these reports were used solely as the basis for a talk at one ofthe medical conferences, at other times they were found suitable for publicationin the Field Medical Bulletin or even in current leading periodicals inthe United States. A schedule of at least one medical conference a week and one"grand ward round" for the discussion of the most interesting andperplexing cases was established at the various hospitals. The value of such aneducational program in providing improved medical care, in heightening theprofessional interest of the medical officers, and, consequently, in raising themorale was gratifying.
The major portion of the time spent at each hospital by thesurgical consultant was utilized in a careful review of medical practice on eachof the wards. Each patient was examined, the clinical records were reviewed, andthe clinical management was discussed.
PHYSICAL FACILITIES AND EQUIPMENT
Hospital construction.-Hospital construction of every type imaginable was observed: brick, cement (mostly sand and mud), basha, pinewood, teakwood, and tents (fig. 359). A few were excellent, most were highly satisfactory, and with only two or three exceptions, the remainder of the hospital plants were adequate. Some of the units occupied former missionary hospitals. Others moved into administrative buildings of tea plantations and added additional wards of basha construction for patients and erected pyramidal tents for personnel. The basha construction with thatched roof was satisfactory in the climate of India and Burma but it was difficult to maintain in a proper state of repair.
Supply liaison activities - Evidently there had been amarked improvement in the supply situation following the visit to thetheater of the Voorhees Mission in 1944. Although in most installations therewas found adequate equipment, in only the 20th General Hospital and a few ofthe most recently established units was most of the equipment and appliances ofthe more recent, standard models. Ingenius improvisations were satisfactorysubstitutes for the standard apparatus in most instances. The relatively fewserious deficiencies in equipment which were observed by this consultantappeared in his reports to the theater surgeon with recommendations that theequipment be supplied. Invariably, Maj. Claud D. LaFors, PhC, the medical supplyofficer in the Office of the Surgeon, USFIBT, a most cooperative individual,handled these requests in a most expeditious manner. Officers in the field weregrateful for this service, and unquestionably the professional consultantsgained prestige as a result of this and also the manifestations of confidence inthe consultants at theater headquarters.
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FIGURE 359.-Continued. C. A basha-constructed ward building.
Cooperative assistance of the same quality was rendered by the Office of The Surgeon General, particularly by Colonel Carter, through whom the author made all his requests for aid. One of these many requests was for an authoritative statement regarding the stability of penicillin at the high temperatures (110? to 140? F.) to which it was subjected in transit by plane from theUnited States to India, Burma, and China, when for hours or even days there was a delay at various airports. Clinical results following theadministration of penicillin were not consistent. This had been observed by Colonel Kennedy on his visit to the theater and subsequently by the consultants. The question was resolved in 8 days. The consultant wrote to Colonel Carter, who referred the request to the LaboratoriesDivision, Preventive Medicine Service, Office of The Surgeon General. The Laboratories Division,in turn, contacted the Food and Drug Administration, Federal SecurityAdministration, and Charles Pfizer and Co. and then sent a report on the matter to Colonel Carter. WhenColonel Carter made it the subject of discussion at the weekly staff meeting,the Supply Service, Office of The Surgeon General, was instructed to issue a directiveon the subject and immediately advise the various oversea theater headquarters as to how to proceed in thematter. This is illustrative of the advantage of liaison between the consultant and the Office of The Surgeon General. Had the ques-
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tion been processed through normal channels, thismatter, which The Surgeon General considered of extreme importance, would not have received such expeditioushandling.
Improvised equipment - This consultant observed, on hisinitial tour of the theater, remarkable improvisations of equipment. In manyinstances, the improvisations were almost exact replicas of standard equipmentfound in hospitals in the Zone of Interior. Particularly striking was thehighly satisfactory reproduction of costly, critically scarce apparatus byenlisted personnel at the 69th General Hospital. At the author's request, the hospital forwarded to the theater surgeon detailedblueprints and photographs of these improvisations in order that a manual on theirconstruction and use might be compiled and distributed throughout theIndia-Burma and China Theaters. Capt. Stanley C. Gillette, MAC, ReconditioningConsultant, Office of the Surgeon, USFIBT,15 extracted materialfrom this report pertaining to physiotherapy equipment and sent it to allhospitals authorized physiotherapy departments with the recommendation that the apparatusdesigned to facilitate remedial exercises be reproduced locallyand used in conjunction with the reconditioning program. The apparatus tobe locally improvised included plans for a Kanavel table, quadriceps exercisetable and chest weights, foot inversion board, chinning bar, shoulder wheel, stall bars,shoulder abduction ladder, Sayre head sling, exercisesteps, therapeutic bicycle, rowing machine, and whirlpool bath (fig. 360).
On his second tour of the theater, Colonel Graham notedwidespread acceptance of this advice to improvise equipment locally. One of themore useful pieces of equipment for the surgical services was an overhead,multibeam operating-room light constructed entirely of salvaged material. In fact most ofthe improvisations were constructed from salvage, most often from wreckedairplanes and motor vehicles. Perhaps even morepractical was the improvised testing equipment used by the ophthalmologists.Equipment unavailable in the theater, and which was accurately reproduced,included Jackson crossed cylinders, illiterate charts, lens centering devices,perimeters, tangent screens, occluders, trial frame wall brackets, andadjustable stools for patients during perimetry and scotometry studies (fig.361).
Equipment for evacuation hospitals - The evacuationhospitals perhaps experienced the greatest trouble acquiring adequateequipment. Whereas they gained a large surplus of surgical personnel throughfunctioning as a fixed facility, they were handicapped in that their table ofequipment was decidedly inadequate when serving as a station or generalhospital. Although some of the deficiencies had been corrected, at the end ofthe campaigns in Burma they still had not received essential equipment (fig.362). Requests for this
15Captain Gillette was one of the fourMedicalAdministrative Corps officers who arrived in the India-Burma Theater withColonel Graham (p. 912). He was first an assistant to Major Britt and then replaced Major Britt as the theater reconditioning consultant in May1945, when Major Britt was given command of the 30thStation Hospital.
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additional equipment, in accordance with the prevailingtheater policy, had to be approved by the War Department. Finally, when theneed for equipment in excess of tables of equipment no longer existed, theWar Department informed the theater that changes in basic allowances should be accomplished bythe theater on the basis of individual needsof the various units since "such a flexibility results in a more efficientmedical service and is common practice in other theaters of operation."
SPECIAL PROBLEMS
Transfer of Patients to General HospitalsThe most significant directive pertaining to the surgicalservice of the theater was issued on 2 April 1945. The directive was entitled "Transfer of Patients toNumbered General Hospitals" and was modeled on WD Circular No. 12, 10 January 1944, which applied tothe transfer of patients to named general hospitals in the Zone of Interior. Inthe course of this consultant's initial tour of hospitals, he had noted that formidable or specialized surgical procedures of an elective nature werebeing undertaken at field and station hospitals by officers with inadequate formal training or practicalexperience. There was even lessreason for this in the India-Burma Theater than in the Zone of Interior, since, withonly two exceptions, these smaller hospitals were situated within several miles of majorairfields from which patients could be transported by regularly scheduledevacuation aircraft to general hospitalslocated not more than 2-hours' flying distance away. Compliance with thisdirective was uniformly satisfactory, and, in most instances in which thecondition of the patient precluded transfer, consultation wasrequested of a general hospital. In this manner, the quality of professionalcare afforded patients in the India-Burma Theater was materially enhanced;furthermore, a more equitable and economic distribution of keyprofessional personnel was thus facilitated.
Treatment in Dispensaries
Along these lines there existed one problem for which a completely satisfactory solution was never reached. The same problem was encountered in the Second Service Command, but to a much less degree. Reference is made to the treatment of patients in dispensaries, which in the majority of instances were controlled by the Army Air Forces. Many patients, who should have been transferred to hospitals, were given definitive treatment in these dispensaries. Most dispensaries had established sickbays in which from 10 to 30 beds were maintained. These were, for the most part, operated by general-duty medical officers of recent graduation who had completed an accelerated medical course of 3 years, followed by an internship of 9 months.
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FIGURE 360.-Continued. C. A therapeutic bicycle. D. A rowing machine.
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FIGURE 361.-Continued. C. A trial frame wall bracket.
Scores of patients were observed in hospitals who had been improperly retainedin dispensaries, many with peritonitis from a ruptured appendix, others withmalalinement of fractured bones which eventually required open reduction, others withsevere second- and third-degree burns with infection and contractures, patientswithsevere local and systemic infections resulting from the late primary closureof lacerations, and patients with many other evidences of poor surgical judgment andtreatment of an inferior quality.
This problem was made the subject of a memorandum to thetheater surgeon, in which were listed the following recommendations: (1)Inactivate those dispensaries situated within several miles of hospitalsor else place these dispensaries under the control of the hospitals whichwould provide personnel for conducting sick call, (2) prohibit the maintenanceof beds in dispensaries except when specifically authorized by the theatersurgeon, (3) require dispensaries to render a monthly report listing diagnosis,treatment, and disposition of each patient admitted toa sickbay, and (4) require hospital commanders to report to the officeof the theater surgeon all instances of improper treatment in patients admittedfrom dispensaries.
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The theater surgeon, in spite of his position, was limited inthe actions he could take to correct this situation owing to the relative autonomy ofthe Army Air Forces in the theater, under whosejurisdiction were most of the dispensaries involved. All elements of the Army AirForces in the theater, with the exception of the India-China Wingof the Air Transport Command but including the Tenth Air Force, were under theadministrative and logistic control of the Army Air Forces, India-Burma Sector, whoseheadquarters were located at Hastings Mill,Calcutta. Through this headquarters, the Army Air Forces were operationallycontrolled by the Eastern Air Command of the Southeast Asia Command-asituation which further gave weight to the coequal and separatestatus of the Army Air Forces in relation to other elements of the Army in thetheater. The Army Air Forces in the theater continued to operate theirdispensaries on the contention that too many man-days were lost when Air Forcespersonnel had to be transferred to the fixed hospitalsof the theater for the treatment of relatively minor medical andsurgical conditions. Some improvement was noted on this consultant's second tour ofthe India-Burma Theater, but there was much to be desired in the correction of thispernicious situation. As it was earlier stated, no really satisfactory solution of theproblem was ever reached.
Treatment of Appendicitis
Another problem which confronted this consultant shortly after his arrival was the relatively high mortality from appendicitis. Practically all of these deaths were in nonoperative cases or in patients who were not operated upon
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until the appendix had ruptured. It was determined, after a careful study ofclinical records and conference with some of the officers involved, that thefollowing factors wereinfluential: (1) The prevalence in Army personnel of diarrhealdiseases which mimicked appendicitis, especially amebiasis; (2) retention in dispensary sickbays of patientswith appendicitis, many of whom were administered purgatives, until abscess or generalizedperitonitis developed (32 such cases were observed during the author's initial tourof hospitals); (3) undue caution of officers who had been criticized by theSurgeon, SOS, USFIBT, for removal of normal appendixes (hospitals had beeninstructed that all appendixes removed should be sent to theCentral Laboratory for microscopic study). The latter no doubt served as adeterrent to the overzealous young surgeon, but at the same time, it tended to warpthe judgment of the conscientious, timid individual who had been officiallyreprimanded or dreaded such anoccurrence.
The combination of abdominal pain, vomiting, andright-lower-quadrant tenderness frequently resulted in the admission of patientswith amebiasis to the surgical service. The amebiasis-minded surgeon was notreadily deceived, for a history of diarrhea,abdominal tenderness also over other portions of the large bowel, and indurated,tender segments of the large intestines indicated the advisability of stoolexamination, proctoscopy, and other diagnostictests. The presence of amebic colitis was, however, no guaranteethat the patient did not also have acute appendicitis and require surgicalintervention. It was therefore advised that, when any patient showedconvincing signs of acute appendicitis, delay in surgery was not to becountenanced. The surgeons were given to understand that, if, aftercareful study and the use of available consultation, a normal appendix wasremoved, they would not be criticized or penalized by the theater surgeon. This attitude, it is believed, had a salutary effecton theofficers and to some extent was responsible for a diminution in the number ofdeaths from appendicitis.
Effect of Climate
The consistently high temperatures prevailing in many parts of the India-Burma Theater, the meager recreational facilities, and the isolation of many of the posts had a profound effect on medical personnel. Even in the relatively brief experience of the consultants of somewhat less than a year, it was striking to witness alert, aggressive, enthusiastic medical officers gradually "flatten out" during the second monsoon of their stay. The same influences were apparent in many of the patients.
Heat exhaustion and heatstroke, surprisingly, were notprevalent and constituted a relatively minor problem. During the hot, humid months ofthe monsoon season, oral afternoon temperatures as highas 100? F. in apparently healthy males and as high as 100.4? F. in femaleswere observed in nonhospitalized personnel engaged in routineactivities. Similar elevations among patients were observed in the wards of hospitals inthe absence of any other explanation.
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The widespread use of sulfonamides, particularly sufadiazine, led tooccasional renal complications during the hot season.Every effort was made to impress medical personnel with the necessity ofmaintaining an adequate urinary output rather than emphasizing fluid intake.Injection of even 3 or 4 liters of fluid a dayled, under certain circumstances, to oliguria, hematuria, loin pain, and thelike, even when only moderate doses of sulfonamides were administered. Owing tothe occasional occurrence of anuria, a circular was distributed which relatedthe advantages of spinal anesthesia in therelief of this state.
COMMENTS ON INDIVIDUAL HOSPITALS
It is difficult, after reading again the author's reports to the theater surgeon on hospitals visited, not to follow a strong inclination to write about each of them. The scope of this undertaking, however, will not permit this, although certain impressions obtained during field trips are reported in later sections of this chapter.
There were several outstanding hospitals ineach category, a goodly number of highly satisfactory ones, and only a fewdefinitely mediocre units. Some of the hospitals with the poorest physical facilitieswere rated by this consultant at the top of the listfor performance. That is, esprit de corps was excellent, scarcity ofequipment had been remedied by clever improvisations, and the quality ofprofessional care was superior. In others with fine modern physical plants andthe latest in equipment, the author found the morale poor and the quality of professional carebelow standard. The difference very often was owing to the character, qualificationsand, or, state of health of the commanding officer and chiefs of services. In seven instances,theconsultants and the chief nurse, Lt. Col. Agnes A. Maley, ANC, on their firstfield trip observed an urgent need for prompt repatriation of hospitalcommanders. For the most part, they had remained through one too many monsoonseasons and were physically and nervously exhausted. There was also adegree of doubt in some of these cases as to their initial qualifications tocommand. Replacement of these ill or derelict officers often would alone suffice to improve tremendously both the morale and quality of professional services.
Too frequently, this surgical consultant observed in India,Burma, China, North Africa, and, to a somewhat lesser extent in the Second ServiceCommand, a tendency to assign to administrative posts, including that of hospitalcommander, officers of field grade rank for whom there was no available clinicalassignment commensurate with theirrank and military occupational specialty number (usually 3100, general duty).Often they were lacking in both efficiency and proficiency, in aptitudeto command, and in administrative ability. Furthermore, it appeared to besomewhat more the rule than the exception in oversea hospitals for arelieved commander to be replaced by the ranking medical officer of the unit,who had acquired his relative position of rank solely by chance and who, consequently, more oftenthan not lacked the qualities necessary to command such a complex organization as amodern army hospital.
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FIELD TRIPS, INDIA-BURMA THEATER
Somewhat more than half of this consultant's 9 months in the India-Burma and China Theaters was occupied in field visits to the various installations. Travel was almost entirely by regularly scheduled transport aircraft, although occasionally, as a matter of expediency, bombers or L-5 liaison planes were used. Nearly 200 hours were required to travel approximately 30,000 miles, and probably half as many hours were spent in airports waiting on repairs to planes or, during the monsoons, waiting for what was said to be reasonably satisfactory flying weather.
The isolation arising from the wide dispersion of units andthe poor lines of communication made it the more important for theconsultants to be regarded as two-way ambassadors between the theater surgeonand the hospitals, interpreting locally the policies of headquarters andacquainting headquarters with the problems confrontingofficers in the field. For the most part, medical officers had had noopportunity to discuss professional matters with anyone other than theirimmediate associates and had but little information regardingexperience with comparable problems at other hospitals or other theaters.The opportunity to display their own accomplishments was an important morale factor. Atmany hospitals, the experience andingenuity of the medical officers provided constructive suggestions which couldbe transmitted to the officers at other hospitals. Colonel Blumgart said thatthis function of the surgical consultant as a "circuit riderof good ideas" was probably one of his chief contributions. Througha sincere endeavor to be as helpful as possible, the surgical consultantestablished confidence among hospital personnel, who accepted suggestionswithout resentment. In some instances, a surplus of medical talent was present; two or three highlycompetent surgeons would be found serving in a station hospital. In otherinstances, however, no surgeon with ability and sound, conservative surgical judgment hadbeen assigned, and it would become necessary to prohibit furthersurgery in these hospitals until a qualified officer arrived. These instanceswere, however, relatively few and invariably were immediately rectified by the personnel officer in the office ofthe theater surgeon in response to a radiogram or telephone call from theconsultant.
Advance Base Section No. 3
Soon after his arrival in the theater, this surgical consultant toured hospitals in the Advance Base Section comprised of upper Assam, India, and northern Burma (map 7, p. 908). Most of the battle casualties of the Burma campaigns were hospitalized in this area. Base Section headquarters was at Ledo, where the road of the same name began. The 69th General Hospital was located just outside of Ledo; several miles further along the Ledo Road was the 20th General Hospital (University of Pennsylvania-affiliated unit); at
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the 19-mile mark of the road was the 14th Evacuation Hospital(New York City Hospital-affiliated unit); at the 52-mile mark, at Tagap Ga,Burma, was the335th Station Hospital; and at the 103-mile mark of the road, at Shingbwiyang, Burma,was the 73d Evacuation Hospital (Los Angeles County General Hospital-affiliatedunit). The Base Section surgeon, Lt. Col. JohnT. Smiley, MC, a relatively young career army officer, impressed theauthor as being an exceptionally able administrator.
The 69th General Hospital was an excellentexample of what could be accomplished in the organization of a general hospitalin a theater of operations when an officer possessing aptitudefor command was assigned the task. Evidently, this unit had got offto an inauspicious start late in 1944, at about the time of Colonel Kennedy'svisit. Colonel Kennedy was of the opinion that the unit was far fromstrong and urged the consultants to give it their initial consideration.Subsequent to his visit, Lt. Col. (later Col.) Edward M. DeYoung, MC, a youngRegular Army officer, was designated commandingofficer, and under his wise and effective direction the hospital became anefficient organization, with the prospects of becoming one of the outstandinggeneral hospitals of the theater.
The 20th General Hospital was unequaled in theSoutheast Asia Command. It is difficult to contemplate adiscussion of this installation without becoming overwhelmed with superlatives. Suffice it to say thatit was outstanding in every respect, and so it should have been, with a hospitalcommander of the caliber of General Ravdin-eminent surgeon, educator, and ableadministrator-and a staff that had remained nearly intact sinceits arrival in the theater 2? years earlier, composed of officerspractically all of whom possessed superior professional qualification. The physicalplant, facilities, and equipment left little to be desired.Particularly impressive were the central supply service, the blood bank,operating rooms, and the unit ward system in which surgical wards were divided intoadministrative units, each consisting of one or more active and two or moreconvalescent wards. This hospital, together with the14th, 48th, and 73d Evacuation Hospitals, performed a noteworthy servicein the care of battle casualties during the Burma campaigns (fig. 363).
The 14th and 73d Evacuation Hospitals were also outstandingunits, staffed (as has already been related) with an overabundance of highly talentedsurgeons. Their hospitals were of basha construction and were in a poor state of repair,owing to themonsoons and a predominance of Chinese patients. The 73d Evacuation Hospital wasestablished on the sides of jungle mountains, and all personnel, including thenurses, lived in pyramidal tents. Despite the tremendous handicaps of more-or-lessconstant rain, mildew, and myriads of insects and pests, these units succeededin maintaining asceptic conditions while undertaking formidable and highlytechnical surgical procedures with commendable low mortality and morbidity rates.
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The 335th Station Hospital was unique in that the entirepersonnel of the unit consisted of Negroes. The hospital wassituated on the most imposing, and almost the most isolated, site in thetheater, with an elevation of about 3,000 feet on a hairpin curveof the Ledo Road and on the side of a hill in northern Burma from which could beviewed a vast expanse of territory including the mountain ranges of Tibet. Whilevisiting the 73d EvacuationHospital, this consultant was driven in a jeep by Lt. Col. Clarence J. Berne, MC, ablechief of the surgical service of that hospital, through20 miles of almost impenetrable mud to the 355th Station Hospital. Despiteits isolation and relative inactivity (its main purpose was to providemedical service for the Negro troops working on the Ledo Road), the moraleof this unit was not surpassed by that of any other organization in thetheater. Moreover, from the author's observation and those of Colonel Berne,who visited there frequently, it was quite evident that they were rendering superior nursing andmedical care.
Base Section No. 2
Base Section No. 2, with headquarters at Calcutta (map 8), contained one general hospital, nine station hospitals, and one field hospital. This base section served the Calcutta district through which port practically all the waterborne supplies for the theater arrived, the 20th Bomber Command, and Air Transport Command installations, a total personnel of about 60,000.
The 142d General Hospital, Calcutta, a unit affiliated withthe University of Maryland, Baltimore, Md., took over an already establishedinstallation from the 263d General Hospital, which was inactivated inNovember 1944. There were 2,000 beds established in modern, well-equippedbuildings in a 1-mile long area in a rather congested outlying section ofCalcutta. Despite the fact that the personnel of this organization were underthe impression they were being repatriated on leaving the SouthPacific Area after a stay of 29 months, they undertook their new task ina remarkably fine spirit. It was necessary for them to reorganize theirstaff and expand from a 1,000- to a 2,000-bed hospital. This was accomplished in ahighly commendable manner under the direction of the able hospital commander, Col.Murray M. Copeland, MC, himself a distinguished surgeon and formerly chief ofthe hospital's surgicalservice. The hospital was outstanding in almost every respect.
It was unfortunate that this unit and the 18th General Hospital,sponsored by The Johns Hopkins University, Baltimore, Md., were redeployed inthe India-Burma Theater. Of the 33 MedicalCorps officers at the 142d General Hospital, 22 had become eligible forrotation; 48 of this hospital's 83 nurses had become eligible for rotation. All ofthe personnel of the 18th General Hospital, which had been functioning for more than 30months in the Fiji Islands,were eligible for rotation to the Zone of Interior. When it was learnedthat
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FIGURE 363.-Continued. C. A ward for Japanese prisoners of war.
these hospitals were to be sent to the India-Burma Theater,the theater commander requested the War Department to rotate all the personnel beforeredeployment waseffected. This was not done.
The 18th General Hospital was doubly unfortunate. Its membershad served longer in the South Pacific than had the 142dGeneral Hospital. But, unlike the latter unit, which took over a splendidphysical plant in the theater's port of debarkation, the 18th General Hospitalwas required to travel about 800 miles by a trainthat averaged 15 miles an hour to an abandoned installation on theLedo Road whose dilapidated structures required almost complete rebuilding (fig.364). Moreover, the hospital's equipment had not accompanied it from the last station.And, furthermore, the staff had been informed that admissions to their hospitalwere to berestricted to Chinese soldiers.
Colonel Kennedy of the Kelser Mission, after visitingthis unit shortly after its arrival in upper Assam, urged in his reportto the theater commander that the entire staff be rotated as rapidlyas possible, both for their own good and for the good of the theater. Hebelieved that to retain in the theater two such units would have an adverse effecton the morale of the remainder of the personnel in the theater who wereanticipating rotation. Five months later, the author made the samerecommendation when the deputy theater commander, Maj. Gen. Frank D. Merrill, solicitedhis aid in attempting to persuade these people to remain in order to establish anew 1,000-bed general hospital then being built in Myitkyina. The entire unitwas rotated inMarch 1945.
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FIELD TRIP, CHINA THEATER
The limited authorization of personnel for the Office of the Surgeon, USFCT, did not provide positions for consultants. Accordingly, on 5 May 1945, Colonel Armstrong, Surgeon, USFCT, requested of Colonel Baylis, Surgeon, USFIBT, the services of the India-Burma Theater consultants on temporary duty in the China Theater.
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Ten days later, on the completion of his first tour ofhospitals in the India-Burma Theater, this consultant proceeded by planeover the Himalayan "Hump" to K'un-ming, Rear EchelonHeadquarters, China Theater, a distance of about 1,800 miles fromHeadquarters, USFIBT, in New Delhi. The author's reception in K'un-mingleft nothing to be desired. Along with many other visitors to Rear EchelonHeadquarters, he was impressed with the spirit of friendliness and cooperationthat was more wholehearted than wasusually encountered. In great part, it was believed, this spirit was influenced bythe character and personality of the Commanding General, RearEchelon, USFCT, Maj. Gen. Douglas L. Weart, and of the theatersurgeon, Colonel Armstrong.16
The theater surgeon was optimistic that the consultants would be able, fromtheir observations, to indicate in theirreports the most serious deficiencies in personnel and equipment and thusassist in expediting the procurement of much needed relief. At the same time,as was strongly emphasized by Colonel Armstrong, he desired that allirregularities and all evidences of professional incompetence be recorded orbrought to his personal attention. He earnestly desired criticism, advice,and help.
Visit to the Combat Area
It had been arranged for this consultant to remainat the Rear Echelon headquarters a few days for orientation, but the dayafter his arrival the opportunity was afforded him to accompany Col.Benjamin J. Birk, MC, Surgeon of the Chinese Combat Command (Provisional), ona tour of field units in the active combat area.17 Accordingly,on17 May 1945, they flew to Chihchiang, the most forward fighter baseafter the fall of Kuei-lin, in a Combat Cargo Command plane filled withdrums of aviation gasoline. From Chihchiang they went by jeep over mountainsand a makeshift ferry across a river to An-chiang, headquarters of theEastern Command, Chinese Combat Command.
Although the local military commanders showed littleconcern over a pincer movement that the Japanese were attempting in this area,they were nevertheless bothered about the considerable number of Japanesedisguised as Chinese civilians reported by Chinese military intelligenceand the Office of Strategic Services to be in Chih-chiang and An-chiangand the intervening territory. As a consequence, contrary to practices inmost other theaters, Colonel Birk and Colonel Graham were issued carbinesand pistols and told to display them prominently. All tactical medical unitsin the combat zone were not only well armed but were also given aspecial course in the function,
16Later The Surgeon General, U.S. Army.
17The Chinese Combat Command (Provisional) along withthe Chinese Training Command (Provisional) comprised the Chinese Trainingand Combat Command, which was formed as a result of the consolidation inNovember 1944 of the predecessor Y-Force and Z-Force operations staffs andactivities. The new command continued the training and logistic programs insupport of Chinese Forces in Central and southern China which had beenthe missions of the Y-Force and Z-Force.
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FIGURE 364.-Continued. C. The interior of an occupational therapy shop.
stripping, assembling, and firing of the various smallarms, including the Thompson submachinegun. Moreover, it was theaterpolicy that the Geneva Cross brassard not be worn, "it having beenused as a target by the enemy, often at extreme ranges of automaticfire."
At An-chiang, this consultant reported to Col. Woods King,Commanding Officer, and to Col. Paul G. Hansen, MC,Surgeon, Eastern Command. During the next 2 days, Colonel Birk, Colonel Hansen,and the author visited all Chinese and U.S. Army hospitals between An-chiang andTu-chou, along a road to which Chinesecasualties were evacuated through narrow mountain files. They saw many Chinesewounded limping along the road with the aid of a stickor rifle, or being supported by, or carried on the backs of, other soldiers.Still others, unable to walk, were on the ground beside the road. Theirpleas for assistance were ignored by the Chinese soldiers who passed them. The incongruity ofthese actions were explained to the author by the Chinese interpreter, who saidthat the lightly wounded soldier whocarried for many miles a more seriously wounded comrade did so because thelatter was either related to him or was a member of his squad or platoon. Hemight even offer some measure of aid to a member of his company who was inanother platoon, but beyond that he would volunteer assistance to no one, regardless ofthe urgency of the need.
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At the most likely points of entry to the road werestationed U.S. Army medical corpsmen to guide or litter-carrycasualties to nearby portable surgical hospitals established in tents orChinese temples or combinations of these two.
The Portable Surgical Hospital
At this time there were only four portable surgical hospitals in the area, and only one section (2 officers and 18 enlisted men) of the 34th Portable Surgical Hospital was then functioning. They had been treating casualties more or less constantly for 36 hours. Scores of wounded, both Chinese and Japanese, were stretched out on the ground surrounding the ancient and quite dilapidated building in which the unit had set up a temporary operating room. Since the two officers were operating on an "assembly line" basis, it was necessary that enlisted men conduct the triage of patients, determining the order in which the casualties would undergo operation. Corpsmen would undress the patients, clean the injured area, accomplish a superficial debridment of wounds, and, when necessary, administer intravenous Pentothal sodium (thiopental sodium) anesthesia. The surgeons progressed along the line of tables as quickly as possible, performing a simple suture of a superficial wound in one, enucleating an eye in another, or amputating a leg or an arm.
The quality of the surgery performed under considerablepressure was, for the most part, highly satisfactory. Working under suchtrying conditions and in the face of many handicaps, these officers andenlisted men rendered outstanding service (fig. 365). Many lives were savedin instances of the severely wounded and injured, and a considerable number ofthe lightly wounded were enabled to return to the front after a shortperiod of time.
Certainly this was not the time or place for criticism ofsurgical judgment or of techniques. From this consultant's observationsof officers in action in these small units and from his conversations withthem during periods of inactivity, it became clear that most of their surgicaltraining had been acquired, in many instances, in the field by the trial anderror method. Even where competent, well-trained surgeons were on duty with the units, theyseldom had time to supervise the operating of inexperienced members when therewas the great pressure of a largebacklog of patients awaiting operation. The author's inclination, soonafter arrival in the India-Burma Theater, was to be critical of theassignment to the portable surgical hospitals of so many officers withlittle or no surgical training and an overabundance of pediatricians,obstetricians, and general practitioners. A study of personnel recordsof 19 of these units, however, revealed that in well over 80 percent ofinstances the assignments had been made by the Office of The Surgeon General beforethey were sent to China-Burma-India. The theater surgeon'serror had been to assume that the Office of The Surgeon General hadselected qualified personnel for the portable surgical hospitals. Certainly, inany future war only highly skilled young men,preferably under 35 years of age, should be employed in such units.
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There was much to discourage the personnel of the portablesurgical units. For each Chinese soldier they saved, many others died. Some diedin transit to their hospital or shortly after arrival because of the long delayin reaching them (many casualties observed by this consultant had been wounded 4 or 5 dayspreviously). Others died after receiving treatment when they failed to survivethe trip to fixed installations of the Chinese Army further to the rear. Lt. Col.John H. Sharp, QMC, whosetrucks transported these casualties, told the author that on one occasionapproximately 200 out of 600 Chinese died in the trucks duringtheir evacuation from U.S. Army hospitals. This was readily understandable sincethe patients were transported in trucks over rough mountain roads on which therewere innumerable hairpin curves. The trucks were driven at high rates of speed byirresponsible Chinese drivers. Moreover, the wounded Chinese soldier, so everyonewith whom this consultant conferred agreed, received practically no nourishmentthroughout the course of his evacuation from the front, except for the shortperiod he remained in the portablesurgical hospital. This deplorable situation existed despite the fact that ample supplies of foodhad been furnished by the U.S. Army to Chinese responsible for feeding patientsin transit. Furthermore, it was believed that the total battle casualties andinjuries of an entire Chinese Army (somewhat larger than the full comple-
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ment of a U.S. infantry division) could not beproperly cared for by the personnel of one half of a standard portablesurgical hospital.
A most discouraging observation was the handling offracture cases, particularly those that had been compounded by shell fragmentsor bullets. They could not be properly treated in these small units. Thosefractures in which union occurred usually presented marked deformity (asobserved in Chinese and American field hospitals to the rear) for tworeasons: First, there were no X-ray machines available for the portablesurgical units; and second, even if alinement was perfect when theplaster cast was applied, the Chinese soldier invariably removed thecast within a few days.
On the basis of the experience of the portable surgicalhospital with the Y-Force in the Salween Valley operations,18the theater surgeon proposed a revision in the table of organization andequipment for such units to be employed in China. The medical plan hadprovided for the use of 18 American portable surgical hospital units for theY-Force. Actually, however, only 10 arrived in time to participate, as 8 werediverted for service in India-Burma. Colonel Armstrong's supporting arguments forthe proposed changes were substantially asfollows:
The portable surgical hospitals, as originally organized inTable of Organization and Equipment 8-572, were planned for a specificpurpose; namely, giving frontline surgical treatment in support of Americanunits in combat. Under this plan, there were always larger hospital units to the rear,which could take care of any medical problems that might arise. In the China Theater,however, the use of the portablesurgical hospitals was entirely different. The patients were almostexclusively Chinese soldiers and usually there were no longer American hospitals tothe rear which could handle complicated problems.Therefore, it was necessary that portable surgical hospitals also functionas field, station, evacuation, and general hospitals (for the Chinese); inother words, they had to be equipped to handle all types of surgical and medical casesand at the same time remain relatively mobile in order to be able to maintain close support of theChinese units in combat. As mentioned previously, many of these units were splitinto two sections in order to provide surgical and medical care to the greatestnumber of Chinese patients, and therefore it was necessary that each section beadequately equipped to operate separately.
Colonel Armstrong indicated changes that should be effected.Four officers, he noted, would be assigned as in the original organization, but, sincethe units would be split, emphasis should beplaced on the assignment of more qualified surgeons. Eleven enlisted men were to be dropped, leavingtwenty-two.
At the time of this consultant's visit, there was no indicationthat the war would end in such a short time, and it wasconsidered an urgent necessity to increase the efficiency of the portablesurgical hospitals to the fullest extent,
18See footnote 9, p. 899.
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since the War Department had disapproved the furtherutilization of fixed beds in U.S. Army hospitals for Chinesecasualties. The commanding general of Chinese troops in the Eastern CombatCommand expressed to the author his deep concern over the change in policy. Hiscomments paralleled those of the division commander of the l30th Chinese Division,who, according to the American Surgeon for the Y-Force, stated, in effect, thathis soldiers were much braver in this campaign than in previous ones becausethey knew that a portable surgical hospital was close by. The Chinesedivision commander, it was held, stated also that in previous campaignsthe Japanese bullets were not so much of a hazard as the infection resulting from themand that the techniques used by the portable units rendered this danger and fear lessimportant both inactuality and psychologically.
The officers of the portable surgical hospitals that thisconsultant visited apparently appreciated his visit and the discussionsof new concepts in surgical treatment. They expressed the desire, however, to have a surgicalconsultant assigned to their command who would visit each unit every week or so.The theater surgeon, on the author's recommendation, selected an excellent officer for thispost, but before he could start on a tour of duty at the front the warended. In conferences with the Chinese Surgeon General, Gen. Robert K. S. Lim, adistinguished physician and physiologist who was well known and esteemed in theUnited States and Great Britain, it was suggested that he arrange for therepatriation of two Chinese surgeons, friends of his and the author's, both highly skilledand possessed of superior surgical judgment, to serve as counterparts of theU.S. Army theater surgical consultant and the contemplated combat areaconsultant. The suggestion was favorably received, and it is believed that an effort was made to acquire the services of these outstanding countrymen ofGeneral Lim, but the plan was never consummated.Practically none of the highly trained Chinese physicians and surgeons, sent tothe United States before the war for medical education or for postgraduate training,returned to China during the war.
The Field Hospital
Both the Chinese so-called field hospitals and the U.S. Army field hospitals were visited during this consultant's tour in China.
Chinese field hospitals - The Chinese field hospitalswere primitive. A typical Chinese field hospital was described by the commanding officer of the U.S. 47th Portable SurgicalHospital, I-liang, as follows:
This hospital consisted of several British 'four-man'tents, which are approximately 12x15 feet, plus a fairly large adjacent temple, the court sides of whichwere open. * * * Eight patients were placedin each of the tents, four on each side lying head to head with about a foot ofspace between each patient. The patient's bed consisted of boards elevatedabout a foot above the ground on mud bricks. On the boards was placed athin straw mat. The more fortunate patients had a thin cotton blanket to putover the straw beneath them * * *.
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The patients housed in the temple were similarlyarranged in the rooms of this building except that in some of thesmaller rooms there were large common beds, extending the length of the room, inwhich several patients were placed.
* * * * * * *The food allowance of the patients in the hospitalwas the same as that allotted for other Chinese soldiers; namely, 25ounces of rice per man per day. In addition to this, the hospital wasallowed 20 Chinese dollars [approximately 25 cents, U.S. currency] per man perday to buy products available on the local market. This was later increased to 120 dollars, buteven this didn't buyvery much with the marked inflation as illustrated by the fact that an egg cost about 90dollars and the prices of other products were in proportion
* * * * * * *Nutritional and deficiency diseases comprised a goodlynumber of the patients in the hospital, and, as can be realized bythe above diet which they received, their recovery was not very muchenhanced in the hospital.
The nursing care which the sick received wasessentially nil. The soldiers assigned to the hospital were technicallycalled nursing soldiers but they had never received any training inthese duties. No charts or records were kept on the patients. There was noroutine for the giving of medications and other than thebringing of rice into the center of the tent area twice a day forfeeding of the patients, no other care was attempted. If the patient had tovisit the latrine, which was only a few feet away from the temple and was open,he had to make it under his own power or with the assistanceof a fellow patient. The sicker ones being unable to make this journeyresorted to the area just outside the tent * * * [or] to the ground in the tent. No waterwas provided for the patients to wash * * *.
* * * * * * ** * * No effort was made to segregate the infectious orcontagious diseases. There was no preliminary examination or delousing.
The interest of the Chinese medical officers inthepatient was * * * only slightly better than that of the nursingsoldiers. They made irregular and indifferent rounds * * * somewhere between ten o'clock inthe morning and noon, following which the patients were given drugs which they prescribed. No drugwas givenwithout the prescription of the medical officer for each individual dose. Asa result of this, regular medication was never given.
There were better Chinese hospitals than this, the author wasinformed, but in too many instances were many of these conditions reproduced.The Chinese hospitals this consultant visited were about the same as thatdescribed. Not once on visits to theseplaces did he see anyone who even claimed to be a doctor, and the nursing soldierswere extremely scarce.
U.S. field hospitals.-On leaving An-chiang,Colonel Birk and the author returned to Chih-chiang, where they visited an Air Forcedispensary and two sections of the 21st FieldHospital, only one of which was functioning. The third platoon,situated about 600 miles away, was visited as this consultant returned to the India-BurmaTheater. There were among the officers a number of Chinese-American doctors and old Chinahands, who were former missionaries or sons of missionaries to China. Amongthese were a numberof competent general surgeons, but there was an urgent need for surgicalspecialists, especially orthopedic surgeons. Moreover, most of the experienced officerswere due for rotation, as was the case in the other field hospitals and a number ofthe portable surgical hospitals.
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95th Station Hospital
On his return from the combat area, the author visited the only station hospital in the theater, the 95th Station Hospital, which actually functioned as a general hospital and had been granted the privilege of conducting disposition boards. This hospital was situated on the outskirts of K'un-ming. It was one of the most unimpressive hospitals visited in either theater, from the standpoint of both structure and physical facilities. Most of the station hospitals in the India-Burma Theater were superior to the 95th Station Hospital in almost every respect.
Facilities - In January 1944, the table oforganization had been increased to accommodate 250 patients. On 1 October1944, the hospital had again been reorganized and designated a 750-bed stationhospital.Actually, however, the bed capacity had not exceeded 522 until 10 days prior tothis consultant's visit, when it had reached 643. The normal bed capacity hadalways been lower than the actual census.For instance, on 1 October 1944 there had been 81 patients in excess of normal beds,and on 1 May 1945 there had been in excess of 38 patients. In order tohospitalize these extra patients, it had been necessary to resort to theexpedient of installingdouble-decker beds and cots, which had materially reduced the normalcubic feet of space per patient below the minimum permitted in army hospitals.
Without exception, all of the physical facilities wereinadequate as to space and essential equipment. In most instances, they did notmeet the normal requirements of a 100-bed station hospital. These included the physicaltherapy and X-ray departments; theorthopedic, and ear, nose and throat, and eye clinics; the library; wards;and, from the standpoint of essential equipment, the operating rooms as well. Yet, paralleling theincrease in patient census, theworkload of the clinics and laboratories had steadily increased,although the facilities, which had been inadequate from thefirst, had not been expanded.
Clinical laboratory - The clinical laboratory wasperhaps greatest in need of expansion. It functioned as a centrallaboratory for the China Theater, yet the existing facilities were below theminimum requirements for a 200-bed station hospital. Since space for equipmentand personnel necessary to accomplish blood chemistryanalyses was not available, it had been necessary to send specimensfor such determinations to the 234th General Hospital, at Chābua, orthe 142d General Hospital, in Calcutta, both in the India-Burma Theater. Thepressing need for additional laboratory space, which this consultant, in his report,urged be given priority in the new construction, was emphasized by the highincidence of amebiasis and other diarrheal diseases, typhus, plague, hepatitis,venerealdiseases, and other conditions in which diagnosis and guide totherapy were almost entirely dependent on laboratory studies.
X-ray Department - Although possessing nearly adequate space, the X-ray Department had not beenprovidedadequate protective measures against the radiation hazard for either theX-ray personnel or the patients waiting for examination. Sinceit was highly problematic when this department would
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be relocated, Headquarters, SOS, USFCT, was urged toprovide as promptly as possible auxiliary protective measures such as leadscreens and brick partitions, and, in the new construction, to comply with TB MED 62,1 July 1944, which prescribed the necessaryprotective measures. Evidently, this important bulletin had not beenreceived in the theater or SOS headquarters.
A dangerous practice was observed in the X-ray department ofthis hospital-a practice which had also been noted in a number of station hospitalsin the India-Burma Theater. There was a tendency among the less well trainedradiologists to employ X-ray therapy to a much greater extent than did the Board-certified,highly competent radiologists in general hospitals. As a matter of fact, in onlytwo hospitals in the Southeast Asia Command, the 20th and 142d GeneralHospitals, did there exist the two prerequisites to undertaking radiotherapy in a U.S.Army hospital; namely, a radiotherapist certifiedby the American Board of Radiology and an accurately calibrated X-ray machine (andan apparatus with which calibration could be undertaken at frequent intervals).
Personnel - The medical officers assigned to thesurgical service appeared adequate in number and sufficiently proficient. Theacting chief of surgical service was on temporary duty from the 172d General Hospital,which anticipated eventually being established in K'un-ming.It was believed, however, that, in a hospital that possessed theprivileges and functions of a general hospital, the chief of the X-rayDepartment should have had formal radiologic training and extensiveexperience, if not Board certification. At this hospital, however, theradiologist's sole training had been received in the course of a rotatinginternship and while conducting a general practice, during which time he had readfilms with experienced radiologists on an entirely informalbasis.
The quality of professional service rendered surgicalpatients in this hospital, judging from observations made on complete wardrounds, from discussions with members of the surgical service, and from review of many clinical records,was on the whole verysatisfactory. There was ample evidence of sound, conservative surgicaljudgment and competence in surgical undertakings.
Reconditioning.-Physical reconditioning forhospitalized patients had not been instituted at this hospital. At a nearbyconvalescent facility, however, under the able direction of 2d Lt. Ben Rubin, MAC,who was eminently qualified for the undertaking, a comprehesive reconditioningprogram for Class-2 and Class-3 patients was being developed and was found to be superior in every respect.It was believed that this program could be of inestimable value in hasteningthe recovery and return to duty of army personnel. The success of theprogram was to a considerable extent dependent on the establishment of aneffective physical reconditioning program for patients in the hospital.Accordingly, an effort was made to convince the commanding officer and members of the surgical staff ofthe tremendous importance of their cooperation in this undertaking. In both theChina Theater and the India-Burma Theater, this consultant had occasionally metwith resistance in attempting to "sell" reconditioning, and it was particularlydifficult if the commanding officer did not
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favor the program. However, units that had finally becomeaware of the therapeutic value of remedial and conditioningexercises in speeding recovery were enthusiastic converts. Pre-emptory ordersfrom the theater headquarters that such a program be established were notsufficient; it was essential that wholehearted cooperation be obtainedfrom the entire professional staff, the nurses, and the corpsmen of a hospital and that theybecome thoroughly conversant with TB MED 137,published in January 1945, and the coordination of physical and surgical therapy oforthopedic cases, as described in TB MED 10, published in February 1944.
Failure of Headquarters, SOS, USFCT, to proceed moreenergetically with new construction that would expand the theater'ssole fixed installation capable of undertaking major elective surgery on U.S.Army personnel made the likelihood of a physical plant's being constructed forthe 172d General Hospital, committed to the China Theater for June 1945,extremely doubtful. Scarce materials allocated for usein such construction had, apparently, been diverted for other purposes.
Other Hospitals
The 21st and 22d Field Hospitals were also visited. The former, situated at Pao-shan, southern China, was in the foothills of the Himalayan Mountains and was visited on this consultants' return flight to India. The 22d Field Hospital at Chan-i, 100 miles east of K'un-ming, was reached by jeep in the company of Lt. Col. Robert L. Cavenaugh, MC, able executive officer to the theater surgeon and assistant theater surgeon.
In both units there was observed a deficiency in qualifiedpersonnel competent to perform major surgical operations. Owing, however, to the excellentcharacter of the officers conducting the surgical services, there had been, inmost instances, proper transfer to the 95th Station Hospital of patientsrequiring the more formidable surgical procedures.
Departure
On the morning of 3 June 1945, this consultant departed from K'un-ming,following a festive evening during whichfor 5 hours he was honored with a fabulous Chinese dinner of innumerable courses,interspersed with many toasts. The dinner was given by Colonel Armstrong and Gen. Robert K. S.Lim, Chinese Surgeon General, and section chiefs of their respectiveheadquarters.
Return to Headquarters, India-Burma Theater
On completion of his tour of temporary duty in China, the author was discouraged and not at all satisfied that he had materially assisted the Medical Section, China Theater, despite the more than generous expressions of appreciation by the Commanding General and the Surgeon, China Theater, to him personally, and later, in a communication to the Commander and the Surgeon, India-Burma Theater. The U.S. Medical Department in China was woefully
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lacking in almost everything. There was not asingle hospital of modern construction, standard equipment wasscarce, and there were too few qualified professional personnel. The whole setupwas more in keeping with a mental image of conditions that existed in thefrontier days of the Far West or in the South during the Civil War. Mud and filthprevailed everywhere, including K'un-ming.
One was hesitant about criticizing officers who wereconscientiously doing their best under most unfavorable circumstances. Although their bestwas frequently not good enough, it was not their fault that, in many instances,they had been assigned to undertakings for which they did not possess adequateproficiency. On the other hand, the SOS and theater surgeons in the ChinaTheater had no alternative to the employment of personnel sent to them by theIndia-Burma Theater. And, actually, the latter theater had little superiortalentto spare, outside the university-affiliated units that they were disinclined todismember. It was only natural therefore that, in fulfilling requisitions fromChina, the Surgeon, USFIBT, did not relinquish his most capable surgeons. In the finalanalysis, then,it would appear that the shortage of officers in China qualified to performmajor operations was due to the War Department's failure in the first instance toassign a sufficient number of officers in this category to the China-Burma-IndiaTheater.
Several weeks after this consultant's return to India, hereceived a communication from Colonel Armstrong, the substance of which follows:
He was still woefully short of medicos and was trying topersuade the India-Burma Theater's replacement center to facilitate the ChinaTheater's requisitions. Unfortunately, the China Theater at the time had 7 medical officerswho had been over there for 30 months, approximately 20 who had "pointscores" above 100, and about 8 who were patients in hospitalsat the time of writing. Among the medical officers in the China Theater, therewere three or four who were over 50 years of age whom Colonel Armstrong wasattempting to have sent home under special "WD radio," and the picturewas really gloomy.
Two weeks later, the author wrote to Colonel Armstrong asfollows:
A great effort has been made by Patterson,Chief of Personnel, Theater Surgeon's Office, and myself to secure for youqualified surgeons classified C- or B-3150, in order to meet your request for eleven so rated,and at the same time assign a sufficientnumber of officers of same qualification to the 70th and 71st Field Hospitals(prior to transfer to China). In order to accomplish this we have depleted thehospitals of this theater of all but key men anda few qualified limited-duty officers.
A concentrated effort was continued by the consultants and ColonelPatterson, not only to replace promptly officers who were rotated from the ChinaTheater, but to replace them with officersof the highest qualifications available. The war ended too soon to judge theeffectiveness of these intercessions, but it wasbelieved that, had the war continued, these efforts would have resulted in amaterial improvement in the medical personnel picture in the China Theater.
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SUMMARY AND CONCLUSIONS
A comprehensive review has been made by this consultant of the activities of the surgical consultant in the Southeast Asia Command, which comprised the India-Burma and China Theaters. Also, the stated mission and activities of U.S. Forces in these theaters has been narrated in order that the problems and activities of surgical officers can be more readily comprehended.
Certain observations and experiences of the consultants would seem toindicate lessons which could be profitably studied bymedical officers who might be involved in any future war. Someof the practices of which the consultants were critical were common to alltheaters and the Zone of Interior and stemmed from policies formulated in theWar Department; others represented policies established in an individualcommand. Some of the policies which were considered objectionable have beenappropriately corrected, others which pose serious problems have not.A brief outline of the more significant lessons learned is here recorded:
1. Improvement in the effectiveness of the consultantsystem was observed when the position of chief of professional services wasdiscontinued.
2. Similar benefits resulted when the reports of consultantswere routed through technical rather than command channels of communications to theaterheadquarters.
3. Benefits accrued from close relationship between theconsultants and the chief of personnel in the medical section at theaterheadquarters.
4. Supply liaison activities of the consultants between thehospital medical supply agencies were considered decidedly worthwhile by allconcerned.
5. Direct communication between the consultants in thetheater and the directors of their respective divisions in the Office of TheSurgeon General, prohibited in some other commands,proved equally helpful to The Surgeon General and in promoting the success ofthe consultants' activities.
6. Disadvantages were noted in the theater practiceof referring all the way to the War Department, for approval, requestsfor changes in basic equipment allowances of units functioning in capacitiesother than originally intended-such as evacuationhospitals employed as station or general hospitals.
7. Failure to send to hospital commanders copies of theconsultants' reports with the theater surgeon's indorsement tended to lessenthe effectiveness of the consultants' visits.
8. The advantage of making all military units, including the air force,subordinate on medical policies to the theater surgeon was conclusivelydemonstrated to the consultants of the India-Burma Theater.
9. The unfortunate policy was formulated in theOffice of The Surgeon General, prior to the entrance of the United Statesinto the war, that prohibited the transfer of officers out of affiliatedhospital units. This policy resulted in the excessive concentration oftalented specialized personnel in a few hospitals, while most of thehospitals of the theater woefully lacked competent general surgeons andspecialists capable of independent surgery without supervision.
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10. Perhaps the most unfortunate practice noted by theconsultants in all the theaters in which they served (to alesser extent in the Zone of Interior) was a tendency to assign toadministrative positions, particularly that of hospital commander, officersof field grade rank for whom there was no available clinical assignmentcommensurate with their rank and military occupationalspecialty (MOS 3100, general duty). These officers were too often lacking inboth efficiency and proficiency, in aptitude to command, and inadministrative ability. The solution to this problem, it would seem, is theformulation of a long-range plan during peacetime in which carefullyscreened reserve officers with aptitude for command are afforded theopportunity to attend special courses supplemented by yearly periods of training directlyunder highly competent commanders of varioustypes of Army medical installations.
