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Chapter I

Battle Casualties in Korea, Studies of the Surgical Research Team, Volume I

Introduction-Historical Background and Development

Captain John M. Howard, MC, USAR
Director, Surgical Research Team in Korea

Research in the combat theater is as old as the inquiring mind. Throughout the history of military medicine, the occasional medical officer has seen his comrades die and dared to wonder that the death was not inevitable. Life and death were the only yardsticks. A wounded soldier either lived or died, his fate being only recorded as a respective statistic. Seldom was serious thought given as to why he lived or why he died so long as standard surgical care was employed. Gradually a changing attitude evolved and the occasional medical officer wondered if the medical services had not only the responsibility of providing standard treatment, but also the responsibility of finding better means of treatment. As this attitude evolved, it reached the stage in World War I where specific questions were asked and individual investigators in military and military-supported institutions sought specific answers. The Spanish Civil War marked a subsequent phase where a concept of wound surgery was developed by a responsible surgeon, given clinical trials and the results, in principle, recorded. During World War II, two developments of importance were recorded. One was the mass field testing and statistical study of tetanus and other toxoids. The second was the study in the combat theater of blood volume deficiency and the role of blood in the treatment of the severely injured. The latter investigations by the Board for the Study of the Severely Wounded were organized in, and supported by, the local forces of the Mediterranean Theater. It thus was not an individual effort but was an organized effort at clinical research in the combat theater. The initiative, however, arose with individuals at the local level; it did not represent a policy of the Department of the Army.

During the early phases of the Korean War, the Commandant of the Army Medical Service Graduate School of Walter Reed Army Medical Center, and the Chairman of his Board of Directors, envisioned a subsequent step-the development of clinical research in the combat theater on an organized, centrally directed and supported basis, and the incorporation of such a program as an integral part of the policy of the Department of Defense. This series of papers records the success of their idea. There were many mistakes, many failures by those who attempted to convert such an ideal into practical


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PICTURE 1
The forward surgical hospital after semi-mobile construction.


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contributions within the rigid disciplines of a combat theater; yet the history of military medicine will record the soundness of the basic concept and the combat casualty has profited, and will continue to profit thereby. By comparison, the personal sacrifices, if they actually existed, of the participants and the cost of such an operation are insignificant.

Because of his background in clinical investigation in the Mediterranean Theater, Dr. F. A. Simeone of Western Reserve University was chosen to head an observational team to visit the Korean Theater, to observe the outstanding problems confronting the military surgeons, and to consider the possibility of instituting a research program in the combat area. In addition to Dr. Simeone, the group included Major Curtis P. Artz, Captain George E. Schreiner and First Lieutenant Russell M. Nelson. Their report outlined the problems in Korea to include wound infections, dehydration, post-traumatic renal insufficiency and vascular injuries. Based on the report of this group, a meeting of civilian consultants of the Army Medical Service Graduate School was held in Washington in November 1951 to discuss the direction of the research. This report was of primary importance in planning and expediting the research effort.

The peace talks had begun between the United Nations and the Communist forces and, anticipating an early truce, the decision was made to organize a Surgical Research Team and to send it immediately to Korea so that should a truce be obtained at an early date, the members of the research unit would at least be sufficiently oriented in military conditions and problems to permit the initiation of a more realistic investigative program in the Zone of Interior.

Thus the first members of the Surgical Research Team left Andrews Air Force Base, Washington, D. C., 7 December 1951, headed for a Far East research assignment by Order of the Department of the Army.

When the Director of the Research Team presented his mission to the Surgeon of the Eighth Army on Christmas Eve, 1951, it appeared that the long trip had been in vain. The personnel of Eighth Army Headquarters were working almost 24 hours a day preparing a list of the prisoners of war. An armistice was expected momentarily . . . ; instead, almost 2 years were to elapse before a cease-fire was to be accomplished.

Dr. Frank Berry was currently touring the Korean Theater as Surgical Consultant to The Surgeon General. Upon his advice and at the generous offer of support of the Commanding Officer of the 11th Evacuation Hospital, the decision was made to base the Research Team at the 11th Evacuation Hospital on the relatively quiet Eastern


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PICTURE 2
The research wing of the hospital. The first year was spent in tents, the second here.
Note the mobile water supply.

Front rather than at one of the busier hospitals on the Western Front. The soundness of this decision, because of the tactical conditions and the loyalty of the Commanding Officers and personnel of the 11th Evacuation Hospital, was demonstrated in the subsequent development of the Research Team.

The mission of the Surgical Research Team was defined as follows:

To study in Korea and to report to the Army Medical Service Graduate School and to the Office of The Surgeon General, Department of the Army:

    1. The practicality of field research.

    2. The problems encountered in the care of combat casualties.

    3. Recommendations for improving the care of combat casualties.

    4. The problems encountered in the Combat Theater which require further research in the laboratories and clinics of the Zone of Interior.

The members of the Research Team were young men without previous combat experience. Their inexperience proved a disadvantage in the time required to gain orientation but it proved a distinct advantage in permitting the development of a new, broad perspective without the restraints of a firmly ingrained orthodoxy.

Several months elapsed during which the medical officers were largely observers, identifying the shortcomings of standard practice.


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During this time, members of the team were participating actively in the professional care of the battle casualties, working in the bunkers and foxholes, at the battalion aid stations, at the forward surgical hospitals, at the evacuation hospitals, and visiting the hospitals in Japan. Clinical records were begun to provide a better background for analysis of future direction. In order to conserve time, a simultaneous effort was made in the practical aspects of the development of laboratory and supply facilities. Captain Roy S. Mundy, MSC, established a base laboratory at the evacuation hospital level and began the organization of a laboratory at the forward surgical hospital. The latter laboratory was ultimately to be developed, within 8 miles of the front lines, with facilities seldom surpassed by any laboratory. Supply problems were solved by drawing standard supplies from the supporting medical installations. Non-standard items were obtained on the Japanese market through the 406th Medical General Laboratory in Tokyo or by air freight from the Army Medical Service Graduate School in Washington.

Gradually perspective was gained and as an armistice was not in sight, a recommendation entitled, "Recommendation for Continuation of the Activities of the Surgical Research Team in Korea" was forwarded to the Commandant of the Army Medical Service Graduate School:

"1. The experience of the Surgical Research Team indicates that extensive and varied clinical investigation on the problems of the care of the wounded is practical under the present tactical conditions in Korea."

"2. It is deemed advisable to continue the organization of the Surgical Research Team and its laboratory facilities as an outlet for the clinical investigation of problems originating in the Combat Zone and in military research institutions in the Zone of Interior."

A major hurdle had been achieved. The members of the team had identified the problems and felt that the combat area was the place to find the answers.

The organization was then developed on a broader scale. Medical officers and corpsmen were placed in several battalion aid stations and in the front lines to study the problems of stress, dehydration, plasma expanders, and resuscitation at the most forward areas. In addition, the collaboration of divisional medical officers was obtained in originating work at this forward level.

The team then established its major unit at the 46th Surgical Hospital (8209 Mobile Army Surgical Hospital) about 8 to 10 miles behind the front. A Renal Insufficiency Center was established 80 miles behind the forward hospital at the 11th Evacuation Hospital


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(semi-mobile). On the more active Western Front, a vascular surgical unit was established at the 43rd Surgical Hospital, another forward hospital in which casualties first received definitive treatment. The Departments of Chemistry, Bacteriology and Pathology of the 406th Medical General Laboratory in Tokyo made their personnel and facilities available to participate in certain major aspects of the program. Finally, the Department of Chemistry at the Army Medical Service Graduate School, the Mass Spectrometry Section of the National Bureau of Standards, and the Department of Surgery of Walter Reed Army Hospital agreed to participate in several of the analytical and clinical follow-up problems respectively.

Now with perspective as to the clinical problems, tactical and logistical conditions, and functional organization, an outline of the work in progress and the projects to be undertaken was more fully formulated.

    1. The Practicality of Field Research

    2. The Combat Soldier-Before Injury

      a. Dehydration survey
      b. Adrenal function

    3. The Battle Wound

      a. Experiences in clinical surgery
      b. Bacteriology of the war wound
      c. Dextran-gelatin extravasation
      d. Circulation in the injured limb
      e. Absorption of myoglobin
      f. Absorption of creatine
      g. Wound healing

    4. The Systemic Reaction to Wounding

      a. Blood volume studies
      b. The hematologic response to injury
      c. The clotting mechanism
      d. Pigment metabolism
      e. Red cell survival time after transfusion
      f. Renal function
      g. Hepatic function
      h. Adrenal function
      i. Gastrointestinal function
      j. Metabolic response

        (1) Carbohydrate
        (2) Protein
        (3) Creatine-creatinine

      k. Electrolytic response
      l. Pancreatic function


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        m. Cholecystic function
        n. The antibody response
        o. The response of the autonomic nervous system
        p. The bacterial flora of the blood stream after injury
        q. V. D. M. assays after injury and shock

      5. Resuscitative Tools

        a. Review of the blood program
        b. Dextran in combat casualties
        c. Gelatin in combat casualties
        d. Vasoconstrictors
        e. Morphine absorption and metabolism
        f. Penicillin absorption and excretion
        g. Plastic bags for fluid administration
        h. Anesthetic agents
        i. Fluid administration to mass casualties

      6. Resuscitative Syndromes

        a. Response to wounds of various anatomical areas
        b. Circulatory patterns after injury

      7. Sequelae of Shock and Injury

        a. Resuscitation
        b. Post-traumatic renal insufficiency
        c. Vascular injuries
        d. Control of intra-abdominal hemorrhage
        e. Postoperative hypotension
        f. Refractory hypotension
        g. Gas gangrene
        h. Wound infections
        i. Fat embolism
        j. Paralytic ileus

    As demonstrated in the following reports, not all of the work was successful; some was never begun; some had to be dropped to permit expansion of more promising programs. The most important phases of the program were to be the study of resuscitation, the blood program, the plasma expanders, the systemic effects of and responses to injury (with emphasis on combat stress), arterial injuries and post-traumatic renal insufficiency.

    Conferences between the members of the Surgical Research Team, the Surgeon of Eighth Army, his Surgical Consultant and the Commanding Officer of the 11th Evacuation Hospital, regarding the extremely high case fatality rate following post-traumatic renal insufficiency, led to the decision to form a Renal Insufficiency Center at the 11th Evacuation Hospital, to selectively evacuate via air all United Nations troops with this complication to this Center, and to the joint


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    PICTURE 3
    The Forward Laboratory
    Upper. One of the finest research laboratories ever organized was assembled at the
    46th Surgical Hospital (Mobile Army) within 8 to 10 miles of the front lines.
    Lower. The stability of the battle lines permitted the assembly and practical use
    of delicate equipment previously seldom used in a combat theater.


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    staffing of this Center with physicians, nurses, clinical and laboratory corpsmen by the Research Team and the 11th Evacuation Hospital. The complete cooperation at the local level permitted this project to expand into a major program of investigation.

    Results of the management of arterial injuries had demonstrated a continuing, disastrously high, amputation rate. The following memorandum therefore had been forwarded by the Director of the Research Team to the Army Surgeon on 17 February 1952:

    "SUBJECT: Management of Acute Arterial Injuries.

    1. Ligation of the popliteal artery for acute injuries results in the loss of a limb. A corresponding loss may occur after ligation of other major arteries, such as the femoral or axillary.

    2. The application of a vein graft to an arterial defect has proved of value in elective surgery. Its application in this theater has met with at least an occasional success in spite of a very limited experience.

    3. In view of the very grave danger of the loss of limb, particularly after ligation of the popliteal artery, it would seem advisable that the chief of surgery of each hospital carefully consider the feasibility of applying vein grafts to acute arterial defects. Any patient treated by this means should then be kept under careful observation for a period of approximately two weeks.

    4. It is anticipated, at least on an investigational basis, that this program would result in the saving of a higher percentage of limbs."

    When an Army-wide program of arterial surgery did not appear feasible, the project was undertaken by the surgeons of the Research Team. The immediate results of primary arterial repairs and repairs with vein grafts were so successful that their usefulness throughout the theater was assured. The policy of submitting progress reports to the Army Surgeon began to pay dividends for now, while the war was still continuing, the lessons learned through the research program could be immediately applied across the front. Better vascular instruments were obtained and plans were made to develop short courses on the technics of arterial surgery. Obtaining dogs in the war-ravished country was not an easy task, but with the assistance of the Korean Army, this was accomplished. A series of operative clinics was then held, being participated in by at least two surgeons from each of the forward surgical hospitals. As a result, the caliber of arterial surgery improved throughout the theater. The amputation rate following arterial injuries fell sharply. This concept of clinical investigation, clinical instruction and clinical application appears so logical that the writing thereof does not nearly depict the misgivings experienced by responsible medical personnel.


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    Frequently the fighting subsided to the exchange of artillery fire. The number of casualties, at such times, was low but the occasional magnitude of injury to the individual soldier can only be visualized by those who have observed combat injuries. Helicopter evacuation permitted the immediate evacuation of such casualties to the forward hospital. Resuscitation was developed to a very high degree and many such casualties, previously considered hopelessly injured, were brought safely through the period of emergency surgery. Except for the occasional casualty with massive injury to the brain, the concept of hopelessly fatal injury did not exist.

    Tremendous quantities of blood were sometimes needed in the care of the individual casualty but when the flow of casualties was low, blood sometimes accumulated in the blood bank. As a result of this transient accumulation, blood sometimes remained to be used well past the accepted 21-day age limit. This resulted from the natural desire to use the old blood first lest it be wasted. Because of the possible hazard of such a practice, Dr. Francis Moore, Consultant to the Research Team, recommended to the Surgeon of the Far East Command that additional efforts be made to supply the forward hospitals with fresher blood. This recommendation resulted in definite improvements in the supply of whole blood. Occasionally, patients, after receiving large quantities of Type O bank blood, were given fresh, type-specific blood. Typing and crossmatching of such patients became difficult and transfusion reactions sometimes resulted. Subsequent studies demonstrated that the policy of using Type O blood, without crossmatch, was an excellent military expedient but that large infusions of Type O blood transiently changed the blood type of recipients of other types. As a result, the policy was established that if a casualty received large quantities of Type O blood, any subsequent transfusions at the forward level should also be of Type O blood.

    Information from the military hospitals in Japan and the United States indicated a distressingly high incidence of serum hepatitis among those casualties who had received plasma during resuscitation. Blood bank facilities were seldom practical forward of the hospital so that pooled plasma and albumin were often used. Because of the high incidence of hepatitis, the expense and relative scarcity of concentrated albumin, and in order to gain information applicable to any future treatment of mass casualties, dextran and modified fluid gelatin were introduced as resuscitative agents for use at the most forward levels. Under the existing condition of a short evacuation time, these agents appeared so satisfactory that in the spring of 1953 The Surgeon General directed that pooled plasma be withdrawn from


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    the military installations in Korea and that, where whole blood was not available, dextran and albumin should be used.

    Studies as to the basic nature of battle injuries, the response to injury, the resuscitative tools and methods, are described in the following volumes. Their ultimate basic contribution will be more fully appreciated in the future but already appreciated is one fact: a planned program of clinical investigation in a combat theater can result in the better care of the injured soldier. Improvement in care, like the provision of standard care, is a national responsibility resting on military as well as civilian medicine. The medical authorities of the Department of Defense will not have met their responsibility if, in looking to the future, they fail to formulate their plans accordingly.

    Acknowledgments

    Little credit is due the participants in these studies. They and their families, like millions of Americans in the past, had a job to be done. Many soldiers and civilians whose names are not listed on the individual reports participated in this program. Foremost among this group are the staffs of the 46th and 43rd Surgical Hospitals and the 11th Evacuation Hospital in Korea. Lieutenant Colonel George Hayes, and Captains Frank Inui and Alvin Bronwell of the 46th Surgical Hospital, Colonels Harold Glascook and Fred Seymour of the 11th Evacuation Hospital, and Major J. H. Holleman of the 43rd Surgical Hospital were largely responsible for the close cooperation between the Research Team and the respective hospitals which permitted the research units to function as part of the clinical service. The complete cooperation of Brigadier General P. D. Ginder, Commanding General of the 45th Infantry Division, and Colonel Byron Steger, Surgeon of X Corps, permitted the research program to be extended into the divisional and corps areas. The Engineers, Supply, and Transportation Corps were unstinting in their assistance.

    Lieutenant Colonels H. H. Ziperman, James Broun, Jack Rush, and Colonel John K. Davis, as Surgical Consultants to Eighth Army, assisted in orienting the work in the direction of solving the clinical problems. Brigadier General Holmes Ginn, Surgeon of Eighth Army, Major General William E. Shambora, Surgeon of the Far East Command, and Colonel Oral B. Bolibaugh, Chief of Professional Personnel, Far East Command, by their real assistance in logistical support, their tolerance and practical criticisms in molding a functional unit, and their many personal kindnesses, added perspective as well as pleasure to the work. Colonel Richard P. Mason, Commanding Officer of the 406th Medical General Laboratory and of the


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    Far East Medical Research Unit, and his staff functioned almost as part of the Research Team. Brigadier General Sam F. Seeley, Lieutenant Colonels William D. Tigertt and Edwin J. Pulaski, Captain Jacob Pokras, and Doctors David Rioch, Arnold V. Wolf and Stanley Levenson of the Army Medical Service Graduate School, by their administrative, professional and technical support, added vital assistance at the Washington base of supply and personnel. As Consultants to the Research Team, Dr. Francis D. Moore provided additional perspective in the early organizational phase, and Doctors Robert D. Dripps, A. C. Corcoran and William A. Altemeier, by their professional status in their respective fields, their tolerance and loyalty, greatly extended the value of the research program.

    During the closing weeks of the war, a photographic team under the leadership of Lieutenant Stephen P. Dittman, MSC, joined the Research Team to record by movies the salient features of emergency care of the injured soldiers, a contribution which will be of continuing value in the orientation of new medical officers and in the teaching of medical students.

    Much of the work of collecting and preparing the material for publication has been done by Mr. F. Y. Halsey and his staff of the Publications Department of the Army Medical Service Graduate School, and by Miss Edith M. Royce, medical editor of the Surgical Research Unit, Brooke Army Medical Center.

    Finally, the editors and participants wish to acknowledge by dedication:


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    The Injured and Dead of the Military Forces
    of the United Nations in Korea

    and

    Colonel William S. Stone, MC

    For Vision, Integrity and Loyalty
    in
    Support of Military Casualties


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    Participants

    Surgical Research Team in Korea

    Curtis P. Artz, Major, MC
    Henry Balch, Major, MC
    William H. Crosby, Lt. Col., MC
    John H. Davis, Jr., Capt., MC
    Robert Donato, 1st Lt., MC
    John P. Frawley, 1st Lt., MSC
    John M. Howard, Capt., MC
    Carl W. Hughes, Lt. Col., MC
    Edwin Jahnke, Major, MC
    Michael E. Ladd, 1st Lt., MC
    William H. Meroney, Major, MC
    Roy L. Mundy, Capt., MSC
    Arthur Newton, Major, MSC
    John M. Olney, 1st Lt., MC
    Fred Parrott, 1st Lt., MSC
    Robert S. Post, 1st Lt., MC
    Theodore Prentice, Capt., MC
    Yoshio Sako, Capt., MC
    Russell Scott, Jr., 1st Lt., MC
    Lloyd H. Smith, Jr., Capt., MC
    Robert R. Stahl, 1st Lt., MC
    Joseph G. Strawitz, 1st Lt., MC
    Paul E. Teschan, Capt., MC

    * * * *

    Charles Adams, Cpl.
    Roger C. Anderson, Cpl.
    James Beggin, Pfc.
    William Bohley, Cpl.
    William H. Cox, Pvt.
    George L. Deaver, Pfc.
    R. M. Deering, Cpl.
    Norman Dial, Pfc.
    William H. Dibrell, Cpl.
    William Evans, Cpl.
    Donald Feeney, Pfc.
    Henry J. Gagnon, Cpl.
    Herbert Gochman, Cpl.
    John. J. Harrison, Sfc.
    Meyers Henry, Sgt.
    Edward Hess, Pfc.
    Albert F. Lingle, Jr., Sfc.
    John T. Mackemull, Cpl.
    Horace M. Mazzoni, Pvt.
    Clarence Meier, M/Sgt.
    Joseph Miller, Sgt.
    Burton F. Pease, Cpl.
    Frank Ponterio, Pfc.
    Elmer R. Sheaves, Sfc.
    Carl J. Steinmetz, Cpl.
    G. A. Szarama, Pvt.
    Joel R. Wolfe, Cpl.
    John H. Wynn, Jr., Cpl.

    Collaborators

    Renal Insufficiency Center

    Eighth Army Personnel

    Robert S. Abernathy, 1st Lt., MC
    W. A. Anderson, Capt., MC
    W. D. Blake, Capt., MC
    G. C. Branche, 1st Lt., MC
    Robert P. Gibb, 1st Lt., MC
    Dell M. Gray, Major, MC
    R. F. Herndon, 1st Lt., MC
    Kenneth E. Johnson, Capt., MC
    Edward Klopp, Capt., MC
    Maurice P. O'Meara, 1st Lt., MC
    W. G. Rice, 1st Lt., MC


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    Ben F. Rush, 1st Lt., MC
    J. B. Selby, Capt., MC
    Alice Service, Capt., ANC
    Anna Smyth, 1st Lt., ANC
    W. G. Stalter, Pvt.
    B. T. Uyeno, 1st Lt., MC
    Mary Wilborne, Capt., ANC

    406th Medical General Laboratory

    Tokyo, Japan

    Robert Anderson, Major, MC
    George R. Haynes, 1st Lt., MSC
    Edward C. Knoblock, Major, MSC,
    Koibong Li, Ph.D.
    Robert B. Lindberg, Lt. Col., MSC
    John D. Marshall, Capt., MSC
    Henry R. Philhorn, 1st Lt., MSC
    Robert E. Scully, Capt., MC
    Arthur Steer, Lt. Col., MC
    Austin L. Vickery, Jr., Capt., MC
    Theodore F. Wetzler, B.S.

    United States Navy

    (Personnel on temporary duty)

    C. E. Catlow, Lt., MC, USN
    D. R. Fitch, Lt., MC, USN