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Chapter 1, Part 4

Medical Science Publication No. 4, Volume II

EVACUATION AND SPECIALTY CENTERS*

LIEUTENANT COLONEL DOUGLAS LINDSEY, MC

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

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

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

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

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

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

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

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

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

All of these factors will carry over in the future. The trend to further specialization is admittedly not reversible, but there are some hopeful signs that it may taper off. I mention hope, because we in the Service must surely be interested in developing true general surgeons to care for massive wounds which forcibly violate anatomical


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


26

boundaries between traditional specialties. What with chest men staking their claim on vagotomy, the vascular surgeons taking over the liver and spleen, and the proctologists reaching up to the ileocecal junction, it appears that the general surgeon may be restricted to the performance of gastrectomy and herniorrhaphy.

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

And lastly, it hardly requires mention that the developments in transportation will continue. Specialty centers will not only be utilized in operations comparable to that in Korea, but, with little modification, will be essential features in any military campaign of the future.

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

FIGURE 1


27

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

Organizational Classification of Specialty Service

The salient specialty operations in Korea were the neurosurgical detachments, the psychiatric center, and the hemorrhagic fever center. The entire specialty service including these, as well as the less publicized ones, can be considered as separable organizationally into the following classification:

1. Table of Organization professional service detachments.

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

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

4. Individual specialists, assigned to standard units.

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

The neurosurgical detachments were initially provisional units, expanded beyond the T/O structure to formidable proportions. They were satellited on active surgical hospitals, but were virtually autonomous, with separate operating rooms, separate wards and separate nursing staffs. Later they shrunk to or near T/O size, and were assigned directly to the hospital commander for all functions. The separate facilities were dissolved or consolidated and the units then functioned essentially as integral elements of the hospital.

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

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


28

FIGURE 2.

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

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


29

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

The holding company, although attached to the psychiatric detachment for command and control, was in effect the host facility, doing the housekeeping and boarding the patients. The modification of the holding company was a matter of replacing most of the unspecialized corpsmen with neuropsychiatric technicians.

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

The center moved once, to another location still in the Seoul area. The physical facilities were analogous in the two locations, though qualitatively much better after the move. The wards were deliberately kept in tents (albeit floored and with frames), although buildings could have been had. There is a presumptive psychiatric advantage in maintaining the patient under semblance of field conditions, and along with the tents went a military regimen of training and drill. There was a good shower house, a movie theater and private interview rooms-all in buildings.

The center was seldom pressed for beds. Psychiatric patients were evacuated to Japan almost on an "appointment" basis, on such evacuation aircraft as were destined for the Tokyo area. Special attendants, when desired, were included in Eighth Army's request to the Far East Air Force for the lift. Through a bit of administrative finagling at Army Headquarters the psychiatric unit was given authority to issue the necessary travel and reassignment orders to return discharged patients to their units in duty status, or to officially transfer them to replacement installations with appropriate limitations on assignment.

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

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


30

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

Patients with known or suspected hemorrhagic fever were arbitrarily declared to be helicopter priority cases. They were usually still ambulatory in the early stages, but they were lifted by helicopter to the nearest point of transfer to light aircraft for evacuation to the hemorrhagic fever center.

The installation had too many bosses, with at least five different officers proposing their own cardinal authority. In fairness to the other units in Korea I must state that this unit was organizationally disjointed, and administratively confused, even though it turned out superior professional work.

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

As specialty centers, the research teams we happen to have in Korea had little specific effect in attracting particular types of cases. An exception was the renal insufficiency team. The artificial kidney drew anuric patients from the whole front, and even from Japan. The vascular team worked on whatever vascular cases were found among the normal admissions to the hospital in which the team worked. Its function actually was to demonstrate technic to surgeons from all the hospitals, since vascular repairs must be done when and where vascular damage is encountered.

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


31

The physical setup of the surgical research team was excellent. The laboratory was well equipped and well housed, separate from the laboratory of the hospital. There was no separate research ward; the clinical phase was integrated with the regular surgical service of the hospital, which too, was well equipped and well housed.

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

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

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

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

A related factor in the development of specialty services, which I possibly should sub-classify under the category of specially designated and equipped units, was the influence of availability and distribution of individual items of diagnostic equipment. We transferred to the hospital ships certain patients who needed physical therapy or electroencephalography. We shuttled patients over Korea in various crisscrossing patterns, to get them to a plethysmograph or a flame photometer or a Drinker respirator.

It may surprise you to find that no unit of the Field Army Medical Service-not even the 750-bed evacuation hospital-has an electrocardiograph on its authorized equipment list. I well remember in World War II making a full day's journey by jeep into the advance


32

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

With respect to special items and luxury equipment our position in Korea was fortunate. The theater medical depot also supplied and equipped the permanent hospitals in Japan, and thus normally stocked items which might otherwise be difficult to obtain for an overseas theater of operations.

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

Recommended Future Allocation of Combat Support Medical Units

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


33

Table 1. Medical Troop Basis

Unit

Type field army

Comparative projection
Eighth Army-Korea

Recommended practical figure

Group Hq.

3

1

3

Battalion Hq.

9

4

6

Ambulance Co.

15

9

12

Clearing Co.

9

4

5

Holding Co.

3

2

4

Litter Co.

3

1

3

Surg. Hosp.

12

12

12

Evac. Hosp. (400-bed)

12

4

6

Evac. Hosp. (750-bed)

3

----

2

Conv. Hosp.

3

----

1

Hcptr. Amb. Co.

(?)

1

4

Army Med. Comd.

(?)

----

1

Laboratory

1

1

1

Depot

1

1

1

Prev. Med. Co.

3

3

3

Gen. Disp.

8

4

6

Med. Det.

20

16

16

Dent. Svc. Det.

8

4

6

Psych. Det.

4

2

3

Prof. Svc. Hq.

1

----

----

Surg. Det.

24

----

(?)

Neurosurg. Det.

3

3

4

Orth. Det.

6

----

----

Thor. Surg. Det.

6

----

----

Max-Fac. Det.

3

----

----

Shock Det.

12

----

----

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


34

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

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

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

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

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


35

tion, but we had almost no flexibility or reserve with which to support an advancing front. We were able to maintain our number of holding units by utilizing platoons of separate clearing companies, cut down in professional personnel actually to the status of holding sections. This increased the load on the evacuation hospitals, since the holding installations could not efficiently carry out the normal function of a separate clearing company-that of providing clearing station support to non-divisional troops. An active enemy air force, guided missiles and nuclear weapons may subject corps and army troops to a much higher proportion of casualties than sustained in the past, but I still feel that we can do all right with half the number of clearing companies now allocated to the type field army.

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

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

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


36

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

Such use of the evacuation hospital is appropriate under conditions of reasonable geographic stability, either with or without heavy casualty incidence along the battle line. When casualties are heavy it will be even more important to see that the minor wounded and sick are not siphoned out of the army area by the rush of casualties to the rear.

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

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

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

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

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


37

FIGURE 3.

It is more economical in personnel and transportation. Theater special authorizations will have to provide some extra facilities for the specialized detachment in the rear. A few Jamesway huts will probably be the mobile equivalent of the semi-permanent construction we provided for the unit in Seoul.

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

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


38

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

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

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

I cannot be so dogmatic about the maxillofacial detachment. Perhaps one or two might be used within the army area, depending on the helicopter to bring in, still alive, the patients who need true specialist care in this field. I think as good an answer is that of concerted liaison, coordination and study on the part of the surgical hospital surgeon and selected dental officers of the supported division.

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


39

The internal organization and equipment of the neurosurgical detachment I leave to Colonel Hayes. He worked both as a neurosurgical detachment commander, attached to a hospital, and as commander of a hospital, with an attached neurosurgical team.

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

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

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

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


40

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

I would like to summarize in closing:

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

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

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

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

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