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Chapter XI

Contents

Part II

THE PACIFIC AND ASIA


CHAPTER XI

Pacific Ocean Areas

John B. Flick, M.D., Forrester Raine, M.D., and Robert Crawford Robertson, M.D.

Prior to August 1944, the Pacific theater of war was divided into three parts: SWPA (the Southwest Pacific Area), SPA (the South Pacific Area), and CPA (the Central Pacific Area). Each of these areas had its U.S. Army component. In SWPA, there were USAFFE (the U.S. Army Forces in the Far East) and USASOS (the U.S. Army Services of Supply). In CPA, the Army component was known as USAFICPA (the U.S. Army Forces in the Central Pacific Area) and in the SPA, as USAFISPA (the U.S. Army Forces in the South Pacific Area). Overall command of the areas encompassed by CPA and SPA was placed upon Adm. Chester L. Nimitz, U.S. Navy, whose headquarters was known as CinCPOA (Commander in Chief, Pacific Ocean Areas). This command corresponded to that of General Headquarters, SWPA, with its commander in chief, General of the Army Douglas MacArthur, U.S. Army.

SURGICAL CONSULTANTS

Col. Wm. Barclay Parsons, MC, was Consultant in Surgery, Office of the Chief Surgeon, USASOS, SWPA, and Col. Ashley W. Oughterson, MC, Consultant in Surgery, Surgery Section, USAFISPA. Both were on a full-time basis. Col. Forrester Raine, MC, was surgical consultant in USAFICPA, in addition to his duties as Chief, Surgical Service, 147th General Hospital, on the outskirts of Honolulu. Also in the Central Pacific Area, functioning as consultants in addition to other duties, were Col. Robert Crawford Robertson, MC, Consultant in Orthopedics, and Lt. Col. Leslie M. Garrett, MC, Consultant in Roentgenology. Colonel Robertson was Chief, Orthopedic Section, 219th General Hospital, Oahu, T.H., and Colonel Garrett, Chief, Roentgenological Service, 218th General Hospital, Fort Shafter, Oahu.

USAFPOA (the U.S. Army Forces, Pacific Ocean Areas) was set up as an administrative overall command in approximately August 1944 to compare with that of CinCPOA. At that time, USAFISPA and USAFICPA were reduced to the level of base commands under the jurisdiction of the USAFPOA. At the same time, the area then known as the "forward area"-the Marianas group of islands and, subsequently, Ulithi, Angaur, and Iwo Jima-became the Western Pacific Base Command. During the Ryukyu Islands campaign, Okinawa, Ie-jima, and adjacent smaller islands were under the jurisdiction of the USAFPOA. Later, in June 1945, the USAFPOA became USAFMIDPAC


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(the U.S. Army Forces, Middle Pacific), a subordinate command under the overall Army command, AFPAC (Army Forces, Pacific).

When the USAFISPA became a base command, Colonel Oughterson was placed on temporary duty at the Surgeon's Office, Headquarters, USAFPOA, as full-time Consultant in Surgery. Colonel Oughterson served in this capacity from August 1944 to December 1944, when he went to the Philippines. In February 1945, Colonel Oughterson returned from the Philippines, was assigned to the Western Pacific Base Command, and became Consultant in Surgery there. He remained until June 1945, when he was ordered to the Medical Section, General Headquarters, AFPAC, as Director of Research and Consultant in Surgery.

FIGURE 228.-Col. John B. Flick, MC.

The Tenth U.S. Army, whose headquarters and some of whose medical units had been staged on the island of Oahu, T.H., subsequently was sent to Okinawa. This army had the following consultants in the field of surgery: Col. George G. Finney, MC, Consultant in General Surgery, Lt. Col. (later Col.) Harold A. Sofield, MC, Consultant in Orthopedic Surgery, and, after arrival in Okinawa, Lt. Col. (later Col.) Douglas B. Kendrick, Jr., MC, Consultant on Whole Blood and Shock.

Col. John B. Flick, MC (fig. 228), became Consultant in Surgery, USAFPOA, on 1 April 1945. At this time, the surgical consultants were Colonel Oughterson for Western Pacific Base Command, Lt. Col. (later Col.) Willis J. Potts, MC, for South Pacific Base Command, both on a full-time duty basis, and Colonel Raine for Central Pacific Base Command, on a part-time duty basis.

Colonel Robertson became full-time Consultant in Orthopedics, USAFPOA, on 31 May 1945.


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FIGURE 229.-Col. Paul H. Streit, MC, Surgeon, Central Pacific Base Command (front row, center), and his staff, 1944.

In May 1945, Lt. Col. (later Col.) Edward J. Ottenheimer, MC, replaced Colonel Oughterson as Consultant in Surgery, Western Pacific Base Command, in addition to his duties as Chief, Surgical Service, 148th General Hospital, Saipan. It was obvious, however, that it was impossible for Colonel Ottenheimer to function satisfactorily in either position in this dual capacity. In mid-July 1945, Colonel Ottenheimer was appointed Consultant in Surgery, Office of the Surgeon, Western Pacific Base Command, on a full-time basis despite the fact that he could ill be spared from the 148th General Hospital. Upon the cessation of hostilities, Colonel Ottenheimer was called to Headquarters, USAFPOA, to supervise the writing of the medical history of USAFPOA and USAFMIDPAC.

Prior to 1 April 1945, the surgical consultants to the Surgeon, USAFPOA, were on temporary duty from general hospitals with the exception of Colonel Oughterson, who was on temporary duty from Headquarters, South Pacific Base Command. It was not until 29 May 1945 that the allotment for officers in the Surgeon's Office, USAFPOA, was increased from 17 to 47, which enabled the assignment of the requisite number of professional consultants. The professional consultants in the Surgeon's Office, Western Pacific Base Command and Central Pacific Base Command, were on temporary duty from general hospitals. This policy made little difference in the Central Pacific Base Command (fig. 229) which was so located that the professional consultants in the Surgeon's Office, USAFPOA, were available for advice, and the pressure


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FIGURE 230.-The 76th Field Hospital, Okinawa, Ryukyu Islands, June 1945.

of work was not so great as in the more forward areas. In the Western Pacific Base Command, however, the need for a full-time consultant in surgery was great and urgent during the fighting for Iwo Jima and Okinawa (fig. 230). The great distances to be covered in the Pacific and the need for close observation of the hospitals doing a large volume of surgical work made it imperative that a surgical consultant be appointed on a full-time basis there. Constant watchfulness of practices in caring for casualties and in their evacuation to areas further back was necessary. The surgical consultant at Headquarters, USAFPOA, acted in an advisory capacity and in liaison to the Surgeon, USAFPOA. It fell to the lot of the base command surgical consultant to follow recommendations made, and to see that policy was carried out.

The policy of using Medical Corps officers from general hospitals for part-time or full-time service on temporary duty at various headquarters deprived the hospitals involved of the services of an officer, usually one of outstanding professional ability. Since there was a shortage of specialists throughout USAFPOA, these officers on temporary duty could not be replaced in the hospitals to which they were assigned from a professional standpoint; neither could they be replaced numerically, because of the rigidity of the tables of organization. Furthermore, this practice interfered with promotions.

DUTIES OF THE CONSULTANT

It was evident from the start that the duties of the consultant encompassed more than strictly professional work. The quality of surgery depended upon many factors, but the most important were the proficiency and distribution


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of personnel. Also of importance were the indoctrination of medical officers in the methods and policies of military surgery, the checking of equipment, and the clinical supervision of work in the hospitals. In addition, the consultants acted as technical advisers to the theater surgeon. Not the least of the consultants' duties was to listen with a sympathetic ear to the problems of their fellow medical officers serving in the Armed Forces.

Liaison between the Army, Navy, and Army Air Forces left much to be desired. This was evidenced in many ways, but particularly in the evacuation of casualties. On one occasion, orders for the surgical consultant to visit the Marianas Islands forbade him to visit Advance Headquarters, CinCPAC (Commander-in-Chief, Pacific), during the period of temporary duty. This occurred at a time when several joint problems had become acute. Despite orders to the contrary, conditions made possible a visit to  CinCPAC advance headquarters, and in justice it must be said that the surgical consultant was received and the joint problems were discussed.

Unless the consultant gained the confidence and received the wholehearted cooperation and support of the theater surgeon, his duties were futile.

PERSONNEL

Shortage of Medical Corps Officers

Almost throughout the war, the strength of professionally qualified Medical Corps officers in POA was inadequate to the needs for the high type of professional work which was the goal of all concerned. It was only by extending efforts almost to the breaking point of the individual during certain periods that the goal was attained. The tables of organization of numbered general hospitals were inadequate for the type and volume of work demanded for the care of casualties in the operations in POA. For example, it was necessary in the forward areas for all hospitals to maintain a perimeter guard against enemy infiltration of the hospital site with the organically assigned personnel at hand. This was true in the Marianas until V-J Day. On those islands where Army personnel were admitted to Navy hospitals, the burden of preparing the payrolls, providing the clothing, recopying the admission and disposition forms, profiling, and so forth, of these patients fell to the lot of the nearby Army hospitals on whose rolls they were administratively carried. On 27 July 1945, the 204th General Hospital, Oahu, was responsible, from the administrative standpoint, for 934 Army patients in Navy hospitals on Guam. At the same time, there were 1,908 patients occupying beds in the 204th General Hospital. The burden was too great for the tired staff of the 204th General Hospital. The matter was presented to the Chief of Staff, Western Pacific Base Command, and it was suggested that a team be organized with qualified personnel taken from each hospital in the Marianas and attached to Headquarters, Army Garrison Forces, Guam, to relieve the 204th General Hospital of this administrative burden. This was done. Had similar personnel for


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guard, finance, refrigeration maintenance, and the like, been furnished, as planned, the problems would have been solved.

The number of Medical Corps officers authorized for numbered general hospitals was particularly inadequate for the workloads imposed during active operations against the enemy. Ultimately, this was corrected in part by augmenting these hospitals with special teams, but this did not take place until the Ryukyu Islands campaign was almost completed. Eleven special teams arrived in the Marianas Islands and three in Oahu during the month of June 1945. In the meantime, the staffs of busy hospitals were reinforced with medical officers from the staffs of hospitals less busy. Medical Corps officers from Army Air Forces medical treatment facilities, from Navy hospitals, and from ships in harbor were pressed into service. Teams were organized on the spot, sometimes composed of Army, Navy, and Army Air Forces medical officers. Their services were invaluable. In hospitals predominantly surgical, the internists became members of shock teams and surgical ward officers.

The actual number of Medical Corps officers in POA was close to the authorized allotment, but there was a shortage of specialists. This was no doubt due chiefly to a shortage at the source of supply on the mainland, but, in part, the shortage was due to factors that crept in during the early days of the Pacific campaigns and that later were difficult to correct. The theory that a Medical Corps officer should be able to serve in any capacity had no small part to do with the shortage. This theory was definitely disproved to all as the war progressed, but, in the meantime, position vacancies were filled with officers not professionally qualified for the positions to which they were assigned and were given job classifications instead of professional proficiency classifications. Such practices created a problem which was difficult to solve. The rigidity of tables of organizations, the problems of rank and precedence, and a confusing chain of command added to personal troubles. There were no pools of Medical Corps officers from which to draw. There was a shortage of specialists on the basis of authorized strength in every category. There was no rapid method of requisitioning and securing personnel urgently needed.

A study of the rosters of all professional units in the USAFPOA made in June 1945 showed shortages of specialists on the basis of authorized tables of organization as follows:


Military Occupational Specialty

Shortage

3105 Gastroenterologist

7

3107 Cardiologist

12

3113 Allergist

12

3303 Medical Laboratory Officer

17

3306 Radiologist

16

3151 Thoracic Surgeon

2

3131Neurosurgeon

12

3152 Plastic Surgeon

3

3153 Orthopedic Surgeon

13

3106 Opthalmologist & Otorhinolaryngologist

28

3125 Ophthalmologist

2

3115 Anesthetist

28

 


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There appeared to be an overage of officers classified "3150, Medical Officer, General Surgery," but this was only apparent and not real. The explanation was obvious when this group was studied. It included all Medical Corps officers who had had, or claimed to have had, any training in surgery whatsoever. Many of these were not qualified to fill vacancies to which they had been assigned.

The study of the personnel situation that was made in June 1945 by no means represented a true picture of shortages on the basis of actual needs. A further consideration was the length of time many of the Medical Corps officers had served in the tropics or semitropics with consequent impairment of their efficiency. The needs were evident, but there was no way of meeting them at that time.

Requisitioning Medical Corps Officers

Requisitions for Medical Corps officers were made by theater units through channels. These were screened by Headquarters, Replacement Training Command, USAFPOA, and at regular intervals were sent by that headquarters to the War Department. Medical officers with a classification "3100, Medical Officer, General Duty," were being used to fill specialist vacancies, and additional officers with the "3100" classification were being requisitioned by units. Seldom were specialists in any other category requisitioned by units. The theater surgeon could only advise; he could not screen requisitions. Therefore, he could not correct deficiencies in the flow of personnel from the mainland.

It was not until the summer of 1945 that the professional consultants were able to screen requisitions for Medical Corps officers and advise the Medical Section, Headquarters, Replacement Training Command, concerning them. At that time, 30 officers with the classification "3100" had been requisitioned by theater units. It was known that there existed an overage of officers classified "3100" and a shortage of officers classified as specialists. Thereupon, it was agreed to requisition 30 specialists and, when they arrived, to assign them to hospitals where specialist shortages existed in exchange for officers who were classified "3100."

Classifying Medical Corps Officers

The classification coding of all Medical Corps officers in USAFPOA was begun toward the end of 1944 and was continued through the winter of 1945. Classification and coding were done principally by evaluation on the basis of questionnaires. Later, officers were reevaluated after personal contact and observation of their work. It was not uncommon to find that several classifications had been entered on the qualification record of an officer in accordance with the position that the officer held at the time of recording. Finally, revaluation on the basis of personal observation by the consultants led to many changes in classification and to the transfer of officers and brought to


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light the fact that the shortage of specialists was even greater than that which appeared in the initial study of the situation.

In compliance with a letter directive, dated 1 July 1945, from Brig. Gen. B. M. Fitch, by command of General Douglas MacArthur, to commanding generals in AFPAC, concerning Classification of Medical Corps Officers, a new classification survey was made. This consisted of the completion of a new WD AGO Form 178-2 and AFPAC MD Form No. 1 on each medical officer. The base command consultants and the USAFMIDPAC consultants recommended a classification by indorsement on each form. Final classification was determined by General Headquarters, AFPAC.

Surveys in Relation to Rotation

As early as the first week in July 1945, a survey of Medical Corps officers in the Middle Pacific from the standpoint of their service rating scores was completed. This was done in order to envision losses and prepare for reorganization when the announcement of a given "critical score" would permit many medical officers to rotate home. In August the survey was repeated, with consideration of three additional factors: age, length of service overseas, and length of total service-all of which had a bearing in determining "adjusted" service rating scores for rotation.

Personnel of Medical Units in Transit

The professional consultants of Central Pacific Base Command and USAFPOA (later USAFMidPac) inspected all medical units passing through Oahu from the standpoint of professional proficiency of the staff and adequacy of equipment. If necessary, replacements were made with Medical Corps officers taken from hospitals or other medical organizations within the Central Pacific Base Command or other base commands. This arrangement was far from satisfactory since it weakened base command units. But replacements could not be secured from the mainland without great delay, and it was imperative to send units forward with at least the minimum of specialists and as good a staff as could be assembled without wrecking the staffs of the fixed installations in the communications zone. After V-E Day, certain units originally destined for the European theater were sent to the Pacific. Frequently these were short of specialists, and it was impossible to supply them from personnel already in the Pacific.

Morale

Suitable assignment was perhaps the most important single factor in maintaining good morale. A medical officer would tolerate hardships if occupied by work in which he was interested and for which he had aptitude and training. Medical conferences, journal clubs, and attendance at medical meetings all bolstered morale, as did the establishment of library facilities (fig. 231) and the circulation of medical journals. Joint medical meetings


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FIGURE 231.-Medical Library, 39th General Hospital, Saipan, 1945.

of Army and Navy medical officers were held on most islands. The programs usually were well thought out and excellent. Consultants participated whenever possible. The oversea installations were adequately supplied with medical textbooks and journals. However, facilities for a library and conference room were not always created.

Living conditions and recreational facilities varied greatly in each hospital and on each island (fig. 232). Housing, recreational facilities, and clubs were of prime importance on small islands in uncomfortable climates. It was evident that these things influenced the morale of personnel. Military necessity-the construction of essential military projects-was the reason given for not obtaining these facilities where they did not exist.

On Guam at the 204th General Hospital, the quarters in which the officers lived were crowded; because of shortage of personnel, there was no charge of quarters on duty; there were few recreational facilities; and there was no club. The comparison with Navy facilities on the same island made these deficiencies stand out sharply in contrast.

In some instances, notably on Saipan, medical officers were housed in relatively primitive quarters and hospital construction had not been completed. These factors played an adverse role from the morale standpoint of medical personnel.

In personal notes taken by the surgical consultant, he recorded that long periods overseas without any definite knowledge as to their prospects of being replaced was influencing the morale of medical officers.


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FIGURE 232.-Living conditions and recreational facilities. A. Officers' quarters on Okinawa, August 1945. B. The Officers Club, Fort Shafter, Hawaii. Brig. Gen. John M. Willis, Surgeon, USAFPOA, extreme left (behind palm fronds), and Col. Paul H. Streit, Surgeon, Central Pacific Base Command (second from right), 1944.


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FIGURE 232.-Continued. C. The library of the 129th Station Hospital, Hawaii, 1944.

Promotions and Rank

It was sometimes necessary to transfer officers who merited promotion because of their training and experience and for whom there were no position vacancies on the staffs of the hospitals to which they were assigned. This was particularly true of personnel in affiliated units. The assignment to hospitals of medical officers who had attained relatively high rank in line organizations but who had not had training or experience to equip them to head services or sections in hospitals remained a problem throughout the war. No satisfactory solution as to their use was found, and they continued to block the promotions of those more professionally proficient.

EDUCATION AND TRAINING

Indoctrination of Units in Staging

The medical units on the Hawaiian Islands, assigned or ultimately to be assigned to the Tenth U.S. Army, were given instructions by the consultants of USAFPOA as well as by the consultants of the Tenth U.S. Army. This was accomplished by informal talks and demonstrations on surgery in the combat zone (fig. 233). In addition, teams were organized from general hospi-


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FIGURE 233.-An exhibit, for instruction purposes, of an operating room set up in the field, Hawaii.

tals staging at Oahu and went forward to augment the staffs of field hospitals designated for the assault phase of the Okinawa operation. At this time, no teams were available from the Zone of Interior.

School of Anesthesia

There was a shortage of medical officer anesthesiologists throughout USAFPOA. The shortage in this specialty was as great as, if not greater than, in any other. It was felt by this surgical consultant that every hospital at which surgery was being performed should have assigned a medical officer trained in anesthesia and put in charge of the operating room and anesthesia section. Toward this end, the first school of anesthesia was established at the 148th General Hospital on Saipan in June 1945. Instruction was carried out under the direction of the consultant in anesthesiology from the Surgeon's Office, USAFPOA. Students for the course were obtained from the 23d Replacement Depot, 8th Convalescent Hospital, and from surgical specialty teams whose officers assigned to anesthesia had had little or no formal training in this specialty.

It was felt by the surgical consultant that too little emphasis had been placed on the importance of anesthesia for the management of battle casualties


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FIGURE 234.-A nurse administering ether anesthesia by the open-drop method, prior to the amputation of a gangrenous arm at the 69th Field Hospital, Okinawa, May 1945.

in USAFPOA, especially in the forward areas. In most hospitals, nurses with some training in anesthesia were in charge of the anesthesia section (fig. 234). These, however, had had little or no training in endotracheal anesthesia, and did not have the necessary knowledge of physiology and pharmacology to direct difficult anesthesias such as in thoracic surgery and neurosurgery.

Because of the shortage of anesthesiologists, nurse anesthetists were obliged to administer spinal and intravenous anesthetics.

CENTERS FOR SPECIALIZED TREATMENT

On Oahu, the 147th General Hospital was designated as a center for thoracic surgery and the 218th General Hospital, for neurosurgery. The former had a thoracic surgeon and the latter a neurosurgeon on the staff. During the Okinawa operation attempts initially were made to admit all fractures of the femur to the 147th General Hospital. This plan was abandoned because the burden became too great for the staff of a single general hospital to handle.

In June 1945, preparation was made for fabrication of artificial eyes at the 218th General Hospital. The necessary personnel had already been trained


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FIGURE 235.-Patients at the 218th General Hospital, Fort Shafter, T.H., after having been fitted with plastic eyes, August 1945.

on the mainland. On 3 July, a directive was published concerning the artificial eye program directing that patients throughout USAFMIDPAC be transferred to the Central Pacific Base Command (218th General Hospital) for custom-made final prosthesis (fig. 235). Certain other hospitals in USAFMIDPAC were designated for ophthalmic surgery and were supplied with conformers for use following eye enucleations. These were the 148th General Hospital, Saipan; 204th General Hospital, Guam; 232d General Hospital, Iwo Jima, Volcano Islands; 233d General Hospital, Okinawa; and the 374th General Hospital, Tinian. The shortage of ophthalmic surgeons made it necessary to limit the number of hospitals designated for this type of work.

During the Okinawa operation, triage was accomplished at the ports of debarkation on Saipan Island, Marianas Islands, and, as far as possible, patients requiring specialized surgery were sent to those hospitals designated for the purpose (fig. 236). The scarcity of specialists in certain categories made this imperative. Thus, during the early part of the Okinawa operation, the 148th General Hospital received all patients arriving in Saipan with thoracic wounds (fig. 237) and wounds involving the brain and spinal cord. The cases of peripheral nerve injuries were too numerous to assign to a single hospital which had only one neurosurgeon on the staff. Later, when the 39th General Hospital, Saipan (fig. 238), was functioning, it was designated as the island neurosurgical center and a center for burns, and the 148th General Hospital remained the center for thoracic surgery. The 369th Station Hos-


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FIGURE 236.-Debarkation activities at Tanapag Harbor, Saipan, in the spring of 1945. A. The U.S.S. Hope being unloaded. B. Patients boarding an ambulance of the 148th General Hospital, Saipan Island, Marianas Islands.


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FIGURE 237.-Postoperative care of a patient after thoracic surgery, 148th General Hospital.

pital, Saipan, was utilized for battle casualties having soft-tissue wounds and for minor orthopedic conditions.

At Guam, the 204th General Hospital was designated a center for thoracic surgery. On this island, neurosurgical patients were sent to one of the Fleet hospitals until the arrival of a neurosurgical team on 15 June 1945, when they were cared for at the 204th General Hospital.

On Tinian, Army casualties were admitted to the Navy Base Hospital and to the 374th Station Hospital, there being no Army general hospital on this island until the middle of May when the 374th Station Hospital was designated a 1,000-bed general hospital. It was never possible, however, adequately to staff the 374th General Hospital from the professional standpoint for the care of battle casualties. Thoracic surgery patients arriving on Tinian were cared for at the Navy hospital, where a thoracic surgeon was on the staff. Patients with lesions of the brain and spinal cord, if transportable, were transferred to Saipan. This arrangement was not satisfactory, but all available beds were needed and had to be used. Fortunately, the number of casualties debarked at Tinian was not great.


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FIGURE 238.-The 39th General Hospital, Saipan, 1945. A. The exterior, showing quonset construction. B. A corridor leading to operating rooms.


642

DIRECTIVES CONCERNING PROFESSIONAL PRACTICE

Official medical publications (other than books or journals) and directives were universally scarce in USAFPOA. This was noted by The Surgeon General on his visit of inspection early in 1945. The matter was taken up in Washington, and improvement was effected. However, as late as August 1945, War Department Technical Bulletin (TB MED) 147, concerning management of battle casualties, which had been issued in March 1945, had not been distributed to Medical Corps officers in Guam and Tinian. Saipan had received an allotment of this publication and distributed it to that island only. None were left over for the other islands in the Western Pacific Base Command.

Apparently, medical publications were being sent promptly to USAFPOA and Southwest Pacific Area, but there were deficiencies in distribution. In the case of the Southwest Pacific Area, for a number of months, initial distribution involved mailing of publications to a number of points in the widely dispersed area. Redistribution was, in turn, accomplished to subsidiary facilities and units. At certain bases, such as Hollandia, Adjutant General publication depots were established, but the lack of manpower continued to interfere with getting the publications out. This was true all along the lines of communications from depots to bases and to field army units.

In the case of USAFPOA prior to 1 March 1945, initial distribution of publications was by mail from the Zone of Interior to a single Adjutant General depot on Oahu. This depot, however, merely distributed these publications to the major technical services, with each service handling the distribution of publications and forms pertaining to them. This decentralization was put into effect at the request of the theater Adjutant General because of lack of space, personnel, and experience by the Adjutant General depot in this area. After 1 March 1945, initial distribution was by mail from the Zone of Interior to a number of bases, facilities, and units, as in SWPA. It was planned to establish a central Adjutant General depot on Oahu to take over the initial distribution within a specified area of all War Department publications and forms, and the filling of requisitions from all activities and units in the USAFPOA which had been handled on a decentralized basis. To the best knowledge of the authors, this was not accomplished during the war. During the Okinawa operation, very few medical officers on Okinawa or in the Marianas had seen the aforementioned TB MED 147. A number of important directives, however, including "Surgery in the Combat Zone," were written, reproduced, and widely distributed by the Surgeon, USAFPOA.

The distribution of advance copies of directives to the various headquarters was satisfactory and kept the consultants informed concerning the professional policies of The Surgeon General. Even though directives reached hospitals, there was no assurance that they would reach the individual members of the staff or would be read by them. Thus, it became the responsibility of the consultants to see that policy was carried out.


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FIGURE 239.-An exterior view of a sterilizer and steam boilers at the 148th General Hospital, Saipan, 1945.

VISITS TO HOSPITALS

The consultants made ward rounds much as a chief of service would make in a civilian hospital. Patients were examined, dressings removed, records perused, and cases discussed. Not infrequently, rounds, begun on the wards, ended in the library or laboratory. Rounds not only served to evaluate a medical officer's professional ability but to test his knowledge of policy. Every physician entering the Army needed indoctrination in Army policy concerning military surgery. Not infrequently, he would resist directives until the rationale of policy was made clear to him. He continued to be an individualist and wished to be convinced that certain procedures, which in his civilian experience were satisfactory, were not necessarily so in Army practice.

Inspection of the operating rooms, of operating-room technique, of sterilizing equipment (fig. 239), of instruments, and of operating-room records were included in the visit. The X-ray departments were inspected, not only in reference to equipment and quality of work but also with respect to protection of personnel from undue exposure to X-rays (fig. 240). In several hospitals, where lead sheet was not available, the substitution of sand-filled partitions was a practical improvisation which on test was found to be effective. Equipment for surgery, including sterilizing apparatus, for the most part was good. This also applied to anesthesia equipment. There was an ample supply of portable


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FIGURE 240.-Fluoroscopy facilities at the 148th General Hospital, Saipan, 1945.

operating-room lights. Ceiling lights for operating rooms had to be improvised and installed by hospital personnel in the majority of the facilities in the forward areas. Fluorescent tubes, usually eight in number, mounted in suitable ceiling fixtures was the most common type of ceiling light in use. Lamps removed from portable field surgical lights also were used as ceiling lights.

Air conditioning of operating rooms was an important consideration in the hospitals of the Marianas Islands. There, the heat was so intense in the operating rooms, usually quonset huts, that those working in them were dehydrated and exhausted in a few hours-so much so that it was necessary to put the operating-room personnel on a salt regimen. Air conditioning was not installed until toward the end of the Okinawa operation in the Army hospitals at Saipan. It had not yet been installed in the operating rooms of the hospitals on Guam and Tinian when the war ended. Air conditioning in the operating rooms of the 148th General Hospital (fig. 241) at Saipan brought the temperature down to 84 F.-cool in comparison to outside temperatures. It appeared that but few of the engineers who were available understood the installation or maintenance of air-conditioning units. Those installed on the outside of surgical buildings, exposed to the sun, stopped functioning frequently and had to be adjusted. When fresh air was brought in from the outside the heat of the air threw too great a burden on the machines. It was necessary to recirculate the air in the building. A service team composed of members well trained in air conditioning was needed.


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FIGURE 241.-Exterior installation of air-conditioning equipment at the 148th General Hospital, Saipan, 1945. Note the makeshift canopy to protect the equipment from strong sunlight.

THE OKINAWA OPERATION

The lack of evacuation hospitals and a shortage of well-qualified surgical specialists at Okinawa gave rise to serious difficulties in properly caring for casualties during the Okinawa operation. It was the consensus that each division should have been supported with field and evacuation hospitals and that "blown up" field hospitals did not functionally take the place of evacuation hospitals. The surgical teams did excellent work, but were too few in number. All hospital staffs were well indoctrinated in the use of blood (fig. 242). Shock was well managed by teams organized from among available internists and they did valuable work. Tents which were equipped to deal with shock and to prepare patients for operation were set up in close proximity to the surgical operating tents. Equipment included oxygen apparatus, materials for blood determinations by the copper sulphate specific-gravity method, and the Levin type of stomach tube as well as the usual materials for the emergency care of the wounded. A Levin tube was introduced in all patients with suspected penetrating wounds of the abdominal cavity. Priority for operation was established for casualties urgently in need of it by those in attendance in the "shock tent."


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FIGURE 242.-A nurse, one of the first group to land on Okinawa, checking the administration of whole blood to a casualty at a hospital in close support of the fighting, April 1945.

Several patients with vascular wounds were seen whose amputations should have been performed earlier than they had been. The fault may have been due to failure to observe patients closely enough following ligation of vessels, to depending too much upon the efficacy of sympathectomy or parasympathetic nerve block, or to an effort to save a few additional inches of an extremity. One such patient was seen who went into profound shock on the sixth or seventh day, from which he died without amputation. He had had a ligation of the common femoral artery followed by lumbar sympathectomy, and the seriousness of his condition was not recognized until he was moribund.

There was considerable discussion concerning the desirability of attempting repair of arterial injuries and the need for arterial suture material, Blakemore vitallium tubes, and heparin in the hospitals of the forward areas. It was believed by the surgical consultants, however, that more harm than good might come of it unless such work was limited to certain hospitals staffed with surgeons trained in vascular surgery and the work could be done on an investigative basis. Had the war continued, the establishment of centers for vascular surgery, staffed by qualified surgeons, would no doubt have been recommended.

The field hospitals did not have a sufficient number of trained anesthetists. They had an inadequate supply of anesthesia machines, suction apparatus, and oxygen therapy equipment. There was no shortage of oxygen in large cylinders, but there was a shortage of reducing valves, flowmeters, and high-


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FIGURE 243.-Treatment at the 69th Field Hospital, Okinawa, in May 1945.

pressure tubing. It was the impression of the Consultant in Surgery, USAFPOA, that oxygen therapy should have been used more extensively in the management of shock. There were not enough reducing valves to use oxygen for many patients at the same time. The shortage was partially overcome by borrowing reducing valves from ships.

Shortages in medical equipment were due in part to limitations imposed on the amount of shipping because of military necessity.

The specialized professional teams assigned for the Okinawa operation included two general surgical, one neurosurgical, and two orthopedic teams. All of these teams were not up to authorized strength. None of them had with them the equipment authorized for specialized teams.

A critique of the Okinawa operation stated with respect to field hospitals (fig. 243):

Experience with field hospitals revealed in certain instances notable deficiencies in selection of personnel and in the training of the unit. Insufficient attention had been paid to the professional qualifications of officers designated for responsible positions on the medical and surgical services. Organization and direction of the laboratory service was inadequate and the technical quality of the work poor. Training of the personnel in the operation of the unit as a hospital had been neglected. This was particularly true of the organization and instruction of shock teams. Many of these deficiencies have been corrected by transfer and exchange of officers and by professional instruction on the ground.1

1The Report of Surgical, Medical, and Orthopedic Consultants for Operational Report of Okinawa Campaign, 30 June 1945.


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FIGURE 244.-Patients being prepared for air evacuation by converted C-54, Okinawa, July 1945.

The activity of the consultants of the Tenth U.S. Army did much to correct deficiencies. Despite criticisms herein contained, the quality of the medical service in the Okinawa operation in general was good.

During the Iwo Jima operation, casualties were evacuated principally by ship to Saipan, overflowing the hospitals there and leaving beds vacant on Guam and Tinian. During the Okinawa operation, air evacuation began on D+8 and finally surpassed evacuation by ship (fig. 244). Planes debarked at Guam and almost none at Saipan or Tinian. At this time, the hospitals on Guam were overwhelmed. All attempts to control evacuation of casualties in the Marianas Islands in accordance with the beds available on each island failed. This had a very definite influence on the care of the wounded and, through fatigue, on the morale of personnel.

In a few instances consultants traveled as observers on ships evacuating wounded from Okinawa to the Marianas Islands. In this way, valuable information was gained concerning treatment given casualties in the forward areas and their condition upon evacuation.

The routing of ships appeared to have been done without due consideration for facilities or vacant beds in the hospitals on Saipan, Guam, or Tinian. Sufficient notification of the time of arrival of patients at a port was not given.


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In some instances, between five hundred and a thousand patients arrived without previous notification, which led to confusion. Failure in properly "tagging" patients led to improper triage.

During the Okinawa operation, the 148th General Hospital cared for the majority of the serious casualties brought to the island of Saipan. The 39th General Hospital was not ready to receive patients until the campaign was well underway. The 148th General Hospital was used exclusively as a surgical hospital and was so organized with the formation of shock, plaster, and traction teams. Surgical teams were formed with officers assigned to the staff of the 148th General Hospital, with Marine Corps and Air Force medical officers from local installations, and with Navy medical officers from ships in the harbor. Nine surgical operating teams worked around the clock in shifts.

As the Okinawa operation progressed and hospital beds in the Marianas became filled, the policy of retaining patients with fractures of the femur temporarily was abandoned. Patients with compound fractures of the femur were treated by debridement of the wounds if this had not been done, by secondary debridement if this was indicated, by skeletal traction, and, in suitable cases, by secondary closure of the wounds 7 to 10 days after primary or secondary debridement. Because of the need for beds, these patients, during the height of the campaign, were evacuated to the rear before the fractures were "frozen." Casts were applied, and Kirschner wires were removed before the patients were evacuated.

In the Marianas, circular casts were not split owing to the prevalent climatic conditions and their instability when this was done. On the other hand, patients were not evacuated after the application of casts until the danger of interference with circulation was past.

The impression gained in the Marianas and at Oahu was that surgical patients who had arrived during the Okinawa operation had been better treated and were in better condition than patients arriving during the Iwo Jima operation.

In the Marianas, of necessity, battle casualties were sent to station hospitals as well as to general hospitals. An effort was made to admit only the less seriously wounded to station hospitals, but, on occasion, the seriousness of wounds was not recognized. This was particularly true of wounds of the buttock that had penetrated the rectum and of vascular wounds. The latter were not recognized until progressive extravasation of blood produced noticeable swelling in the region of the wound. The station hospitals were visited frequently by consultants who advised on treatment and transfer of seriously wounded patients to general hospitals. It was evident that the professional qualifications of staff members of station hospitals did not meet the necessary requirements for the care of the seriously wounded. Directives dealing with hospitalization of battle casualties were published by Western Pacific Base Command, and by the Surgeon's Office, USAFPOA, but could not be followed always since at times the urgent need for beds demanded that those vacant in station hospitals be utilized for battle casualties.


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During the height of the Okinawa operation, it became necessary to relieve medical officers in the hospitals on Saipan of nonprofessional duties. This was accomplished by directive from the Office of the Surgeon, Headquarters, Island Command, Saipan. Medical officers, badly needed for surgical work in the operating rooms, were being given such duties as the censoring of mail. It was directed that officer patients convalescing in hospitals be used for this purpose; also, that property accountability and other nonprofessional duties be assigned to nonprofessional personnel.

During July and the early part of August, hospitals in the Marianas Islands were visited by the Consultant in Surgery, USAFMIDPAC, and the Consultant in Surgery, Western Pacific Base Command. All medical officers were revaluated from the standpoint of the positions to which they had been assigned, and replacements, when indicated, were advised. Suggestions were made regarding medical supplies and equipment from the standpoint of the heavy load anticipated in future operations. At this time, the hospital center at Tinian was in the process of construction.

HOSPITAL CENTER AT TINIAN

The hospital center at Tinian comprised five 1,000-bed general hospitals. The facilities for surgery, the establishment of centers for specialized work in individual hospitals, the assignment of personnel, and the need for and requisitioning of specialists were discussed and planned in detail with the commanding officer of the hospital center. It was expected that 70 percent of the beds of the center would be devoted to surgery. The tentative plan for professional service in surgery envisioned a division of work in units as follows:

Unit 1. Neurosurgery, abdominal surgery, orthopedic surgery, and urology.

Unit 2. Amputations, burns, general surgery, orthopedic surgery, and urology.

Unit 3. Thoracic surgery, maxillofacial surgery, ophthalmic surgery, general surgery, orthopedic surgery, and urology.

Unit 4. Internal medicine and medical specialties, general surgery, orthopedic surgery, and urology.

Unit 5. Neuropsychiatry and neuropsychiatric patients requiring surgery.

Each hospital was designated as a center for specialized work, and in addition-with the exception of Unit 5-would have cared for general surgery, orthopedic surgery, and urology. The surgery performed in Unit 5 would have been limited to surgery which arose in neuropsychiatric patients, most of which would have been in connection with self-inflicted wounds. This plan did not necessitate major changes in hospital staffs. An acting director of surgery was selected. This officer was to have been responsible for the overall supervision of the surgical services throughout the hospitals comprising the center and in control of the surgical teams assigned to it.


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Twenty-eight surgical operating rooms would have been available in the four hospitals designated for surgical work. On the basis of the Okinawa operation, it was expected that approximately 140 surgical operations would be performed daily when the next military operation was under way. It was estimated that each surgical team on a 12-hour shift would average eight operations per day. On this basis, 17 surgical teams would have been needed. Nine of these teams were to have been requisitioned, and eight were to have been organized from the staffs of the five general hospitals composing the center. Teams were to have made up for the lack of certain specialists on the hospital staffs.

Plans included a request that an Air Transport Command liaison officer be assigned to the center on a full-time basis to facilitate evacuation of patients by air.

It was planned also that the Consultant in Anesthesiology, USAFMIDPAC, would organize the anesthesia section and remain at the center for the early part of the next military operation.

Work on the hospital center was discontinued with the cessation of hostilities.

NOTES AND FORMAL REPORTS

The Consultant in Surgery, USAFPOA, made daily notes concerning visits to hospitals. These were too wide in scope and often too personal to submit as formal reports, but they were the basis for formal reports. Formal reports were sent through medical channels beginning with the commanding officer of the hospital visited and ultimately reaching the Surgeon, USAFPOA. Only those things were reported formally which could not be dealt with locally, or which were informative in a general way and upon which it was felt that the base command surgeon might wish to comment by indorsement. At the end of a visit to forward areas, the personal notes of the consultant were read by and discussed with the Surgeon, USAFPOA, often with other members of the headquarters staff in conference. Thus pertinent matters observed by the consultant came to the attention of the operations, personnel, and supply officers in the Surgeon's office. These matters were dealt with at once. Not infrequently, on visits to forward areas, notes were sent directly to the Surgeon by courier. In the last month of the war, formal reports were not made. Detailed notes, however, were kept and submitted to the Surgeon upon return of the consultant from the Marianas Islands.

JOHN B. FLICK, M.D.

CENTRAL PACIFIC AREA

Examination of the situation in the Central Pacific Area in the fall of 1942 revealed that the principal problem was a dearth of trained professional personnel. There was only one other diplomate of the American Board of Surgery in the area and, in addition, over the next 3 years, only three other


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Fellows of the American College of Surgeons in general surgery were in the area. With this personnel, five general hospitals and nine station hospitals had to be manned.

Since additional trained surgeons could not be expected to arrive in the area, the first important task was an appraisal of all the existing surgical talent followed by the training of these men in order to provide adequate surgical care of patients. All medical officers in the area who had had as much as one year's residency training in surgery were interviewed. The medical officers of divisions training in the area were interviewed and, where it seemed desirable for the good of the service, exchanges were made to augment somewhat the percentage of at least partially trained surgeons. When it was felt advisable, officers were placed on temporary duty at the 147th General Hospital for a 4- to 8-week period of observation so that their surgical skills could be more accurately determined and, in addition, so that they themselves could have a "brush-up" period in surgery. During 1943 some 10 or 12 such temporary assignments were made, and during 1944 more than 30 officers were rotated through the surgical service of the 147th General Hospital with a view to enhancing their previous surgical training (fig. 245). Since some of the station hospitals were more than 1,000 miles from their nearest neighbor, it is obvious that consultations on individual problems were impossible and that the fate of the patient rested with those who were immediately available.

Besides the deficiencies in trained surgical personnel, there were very few corpsmen who had been trained for operating-room duty. Since some of the smaller station hospitals were going to forward areas where no nurses would be available, it was felt that the training of corpsmen in surgical techniques was most important. Accordingly, a training school was set up at the 147th General Hospital for corpsmen in operating-room techniques. These men were put through an intensive two months' course, and it was very gratifying, as well as surprising, to see what excellent scrub nurses they made at the end of that period. Actual figures were not available at the time of this writing, but there must have been at least 50 enlisted men so trained during the course of the war.

The war in the Central Pacific Area was under the command of the Navy and at no time was there an appreciable number of fixed Army hospitals assigned to the care of frontline casualties. This meant that virtually all the casualties received in the general hospitals in the Hawaiian Islands arrived there from 2 to 4 weeks after they were wounded. This naturally posed an entirely different problem from that encountered in the North African and European theaters. It was fortunate that, during early operations on the coral islands, there had been no appreciable fertilization of the ground and gas bacillus infections were virtually unknown. Furthermore, it was found that initial debridement could be carried out 3 weeks after wounding with surprisingly good results. The ideal time for secondary closure of those wounds which had been debrided was, of course, lost during the period of transportation. But again, it was found that secondary closure could be satisfactorily accomplished at the end of 3 weeks' time instead of at the end of from 6 to 10 days.


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FIGURE 245.-Maj. Gen. Norman T. Kirk, The Surgeon General, making ward rounds in the 147th General Hospital, accompanied by Gen. John M. Willis (right), Colonel Streit (center, behind patient), and Col. Forrester Raine, MC (left).

The percentage of complicated chest wounds was, the writer fears, considerably higher in the Central Pacific Area because aspirations of hemothorax and even pneumothorax were, as a rule, delayed for 3 or 4 weeks. This necessarily increased the number of decortications that had to be done to achieve satisfactory respiratory function. These decortications were started in the Central Pacific Area at about the same time as in the North African theater and yielded excellent results.

The type of wounds received in the Central Pacific Area differed materially from those in other theaters. In at least the first 2 years of the war, attacks were all against small coral atolls and the little artillery the enemy had was knocked out by Naval bombardment (fig. 246). Wounds, therefore, resulted predominantly from small-caliber bullets, small-caliber mortars, or hand grenades. Japanese hand grenades were much lighter and splintered into much finer particles than did the U.S. Army grenades, so that on the whole wounds did not show the great destruction of tissue which typically occurred with high explosives. This may well account for part of the reasonable results attained in spite of delayed debridement.

The technical bulletins emanating from the Office of The Surgeon General were of the greatest assistance. They permitted personnel in the Central Pacific to profit by the experience earned from the management of a tremendous


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FIGURE 246.-Litter bearers of the 7th Infantry Division, bringing in a wounded soldier, Kwajalein, February 1944. Note the great destruction of vegetation.

number of casualties without having to go through an appreciable period of trial and error themselves.

The largest number of casualties handled over a short period of time by the Central Pacific Area general hospitals occurred following the Saipan, Guam, and Tinian battles. These casualties were evacuated from the islands by hospital ship and landed at Kwajalein for care and transshipment to the hospitals on Oahu. These casualties numbered 2,900 during June and July of 1944. The small station hospital at Kwajalein was enlarged to a 1,400-bed hospital with virtually no addition of medical personnel and did an excellent job of screening, emergency treatment, and transfer. Among these casualties were approximately 60 with severe chest wounds who, it was believed, could not be evacuated safely by air at the altitudes usually flown. With the marvelous cooperation of the Air Transport Command, two planeloads of these patients were flown to Oahu at under 4,000 feet. Since this was below the usual cloud level, this air evacuation was carried out without utilization of refined navigational aids. But, happily it can be said that planes and patients arrived in good shape, none the worse for their trip.

So far as the author is aware, no new developments or outstanding contributions to surgical knowledge emanated from the Central Pacific Area. It was demonstrated many times, however, that, in spite of an inadequate number of fully trained personnel, satisfactory end results could be achieved in the


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management of casualties who were received long past the ideal time for treatment. It was believed that this accomplishment resulted from foresight in anticipating the future and in attempts at training the many who arrived with inadequate training before entering the service.

FORRESTER RAINE, M.D.

CONSULTATION IN ORTHOPEDIC SURGERY

The uncertainty of the United States' participation in World War II ended at Pearl Harbor on 7 December 1941. As an Infantry veteran of World War I, and a long-time Medical Reserve Officer of the Arms and Service Assignment Group, this author, Lt. Col. (later Col.) Robert Crawford Robertson, MC, received a telegram that day requesting his early active duty. On 26 December, a representative of The Surgeon General telephoned the author inquiring if he would like assignment to Hawaii as orthopedic consultant. Orders to Letterman General Hospital, San Francisco, which then contained many Hawaiian casualties, soon followed. The kind and considerate help of Lt. Col. (later Col.) Oral B. Bolibaugh, MC, Chief, Orthopedic Section, Letterman General Hospital, was invaluable in initiating the author into the professional and administrative problems of a large military hospital. Colonel Bolibaugh soon left to assume command of an evacuation hospital and later rendered outstanding service in the Mediterranean and European theaters.

On Friday, 13 March 1942, aboard the U.S.S. Republic, this consultant entered Pearl Harbor, a "graveyard of once proud ships" where intense repair activities were everywhere evident. At Fort Shafter, Oahu, T.H., he reported to Col. (later Brig. Gen.) Edgar King, MC, Surgeon, Hawaiian Department, whose farsighted planning, combined with the outstanding cooperation of the civilian doctors in Hawaii, had resulted in superior medical service during and following the surprise attack of 7 December. Colonel King was an officer with long service in the Regular Army. One of his basic convictions was: "He is a medical officer, he can do anything."

Hawaiian Department, 1942

The major Army hospitals on the island of Oahu were Tripler General Hospital (later the 218th General Hospital), where Maj. (later Col.) August W. Spittler, MC, was Chief of Surgical Service; and Schofield Station Hospital (later North Sector General Hospital, and eventually 219th General Hospital), where Maj. (later Col.) Leonard D. Heaton, MC, was Chief of Surgery. Major Spittler and Major Heaton were superior officers of the Regular Army who had rendered outstanding service during and following the raid. Their kind cooperation and help in the problems of medical supply, planning, personnel and patient evaluation, and the professional management of battle and garrison casualties were of the greatest aid in making the transition from an orthopedist in private practice to a staff orthopedist in an oversea theater.


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The Hawaiian Department at the time expected another attack by the Japanese and was serving as an oversea defense area. Numbered general and station hospitals arrived and established on the islands of Oahu, Kauai, Maui, and Hawaii. Tables of organization did not meet local needs, and provisional hospitals were established on these islands as well as on Molokai and Lanai. Throughout the early years of the war, many provisional units found it difficult to receive authorization for obtaining necessary personnel. As a result, many medical officers were placed on temporary duty at various installations to meet needs as they arose.

The year 1942 was spent chiefly in organizing to meet anticipated needs. A shortage of specialized personnel immediately became apparent. This remained the major problem throughout the war. The shortage of orthopedic surgeons authorized by tables of organization in June 1945 totaled 13 (26 percent). The assignment of Maj. (later Lt. Col.) John R. Vasko, MC, to Tripler General Hospital, Honolulu, and the arrival of 1st Lt. Robert W. Ray, MC, with the 147th General Hospital early in 1942 established a firm foundation for orthopedic care in the Department. Both of these officers demonstrated outstanding professional ability and retained their assignments as chiefs of the orthopedic sections in these hospitals throughout the war. Staffing, equipping, and planning within the various hospitals of the islands was further complicated by the various provisional hospitals considered necessary because of the terrain and anticipated attack. Plans had to include provision for the care and evacuation of wounded on each island and by ship among the islands in case of attack.

In the summer of 1942, reports were received that there was an unusual incidence of delayed union and nonunion in fractures treated in the military hospitals. Reports of all fracture cases showing delayed union or nonunion were obtained from the various hospital commanders and a personal check was made of all of these cases. No evidence was found to substantiate these reports.

Among this consultant's early duties were the evaluation and assignment of personnel, the formulation of professional procedures in accordance with the evacuation policy of 120 days, the providing of surgical support for a regimental combat team in amphibious operations, the inspection of the proficiency of all numbered hospitals and all tactical medical units in first aid procedures, the establishment of facilities for orthopedic alterations on shoes by a quartermaster shoe repair shop on each of the islands, the changing of automatic medical supply items, the establishment of emergency and expansion facilities within military and civilian hospitals and ships in all of the islands in anticipation of attack, and the marking of tourniquet cases in the field. Employees of Hawaiian contractors who were performing construction work for Army expansion plans received Army medical care to include preemployment physical examinations by teams composed of Army medical officers and subsequent medical care given in Army medical facilities.


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In June 1942, the Hawaiian Department received a few Army air and ground casualties from the Battle of Midway. The Navy casualties, who were far more numerous, were seen through the courtesy of the commanding officers of the various Navy hospitals. The shortage of specialized personnel experienced by the Army was not then, and never became, apparent in the Navy hospitals in the Pacific Ocean Areas. During the late 1930's, the splendid Navy medical service had commissioned into its Reserve Corps in advanced grades many doctors from the staffs of medical schools and teaching hospitals. The outstanding men so obtained formed a magnificent pool at the outbreak of the war. In the author's opinion, the Army would do well to consider similar methods in future Reserve planning.

Circular letters issued by the Office of The Surgeon General were extremely helpful during 1942, as were subsequent Essential Technical Medical Data reports and War Department technical bulletins in standardizing new professional methods and in the management of garrison and battle casualties.

The organization stage was fairly complete by fall of 1942. On 5 November 1942, this consultant was assigned as chief of a separate orthopedic service at North Sector General Hospital, Oahu, T.H., in addition to his duties as orthopedic consultant, Hawaiian Department. General King's instructions were: "You will keep me informed of the orthopedic situation from front to rear at all times."

Replacements from the mainland arrived in large numbers. Many were in the 40-year-plus group and presented various problems, chiefly those centering about unaccustomed physical activity. The majority were recruits of only 1 or 2 months' service, and outpatient services at the hospitals became extremely heavy. One muscular Texan who was inducted into the Army one month after injuring his leg was seen as an outpatient one month later in one of the Department's hospitals. X-rays showed a complete oblique fracture of the proximal end of the tibia and neck of the fibula, with slight displacement of fragments and with very good callous formation. Upon his being questioned, he revealed that he had received no medical care and had performed full duty, including hikes. He stated: "They think I'm yellow, Doc, but I just can't take those long hikes very well." The "low backs" presented a major problem which continued throughout the war. Department policies were established as follows:

1. In the absence of objective physical and X-ray findings, treatment will be given on an outpatient basis.

2. Hospital cases will be disposed of on an individual basis, and as many as possible will be returned to limited service within the Department if they are unable to perform full duty.

3. No case will be returned to the mainland in the absence of definite pathology.

These policies continued in effect throughout the war, and proved very effective.


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By the end of 1942, many senior regular medical officers had been rotated to the mainland for reassignment, chiefly in command positions. Several infantry divisions had arrived, the 25th Infantry Division had departed for the South Pacific Area, the Department's numbered hospitals were well established, and they were set up for emergency and expansion needs, including the treatment of gas casualties. The cooperation of the commanding officers, chiefs of surgery, and the orthopedic section chiefs in the various hospitals was excellent. Their problem cases were freely presented, and "hideouts" were very infrequent. The Battles of the Coral Sea, Midway, and the Solomon Islands had disclosed that the Japanese were brave men, but not invincible. The Hawaiian Department's primary problem continued to be the procurement of specialized personnel.

Central Pacific Area, 1943

The new year, 1943, was ushered in by the following instructions from General King: "You keep a check on all the hospitals in this Department and transfer any case to the general hospitals as indicated without consulting me." General King believed that additional orthopedic surgeons should be developed within the Department instead of their being requested from the mainland. Search was made of personnel records and repeated many times throughout the war for officers suitable for such development. When available, they were transferred to a general hospital for training.

Largely because of the relatively low hospital workload and the absence of combat casualties, there developed a marked tendency on the part of several hospitals to attempt professional procedures beyond their professional capacity. This was corrected by directives listing the type of cases to be referred to general hospitals for definitive treatment.

The braceshop at North Sector General Hospital was developed and served the Department. Cases requiring braces were referred to that hospital for fitting and application of the brace.

Analysis of the outpatient clinics disclosed a very large number of foot cases. Because of this a spot check of eight companies or the equivalent was made by an orthopedic team. Findings indicated such poor foot care that a Department directive was issued emphasizing the duties of unit commanders in preventing and correcting this problem.

First aid fracture procedures, including splinting, were checked at the various hospitals on admission of each patient. Instructions were issued requiring a report to the Department Surgeon of all cases evidencing unsatisfactory care. Only an occasional unsplinted case appeared thereafter. Standard and improvised splinting and first aid management of fractures was checked in each tactical unit. These inspections were personally conducted, and many amusing incidents were encountered. One incident occurred in a battalion medical detachment of an antiaircraft artillery regiment. Improvised methods for treating a simulated compound fracture of the femur were requested of two soldiers. When their job was completed, a small gauze bandage had been wrapped about


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the mid-thigh. A large wooden stake had been driven into the ground in the region of each axilla, and each foot had been tied to a similar stake for "traction" and for "still more traction."

Internal derangements of the knee, including many unusual cases of osteochondritis dissecans, were seen in quite large numbers in all of the general hospitals. Functional results permitting return to full duty were disappointing following surgery. Fifty individual cases were personally followed up after surgery and formed the basis for a command directive published 6 July 1944 restricting arthrotomy of the knee to carefully selected cases.

Recurrent dislocation of the shoulder joint was also a difficult and fairly frequent problem. Surgery was considered only if the dislocation was seen by a medical officer. Initially the Nicola type of operation was favored, but followup disclosed recurrences in an estimated 40 percent following return to duty. Bankart's operation was first employed in 1943. The results of both types of operation were so generally disappointing that surgery thereafter was restricted to carefully selected patients who were returned to limited service.

Fractures of the carpal scaphoid were very numerous. Fresh cases responded well to conservative cast treatment and were returned to duty. Ununited fractures which were symptomatic and did not respond to conservative or to operative procedures (an entirely satisfactory surgical procedure was not developed) were placed on limited service.

Following several requests for authority to visit the outlying islands of the Department, Colonel Robertson went in June 1943 as representative of the Department Surgeon with a general and special staff group from the headquarters staff of Maj. Gen. Robert C. Richardson, Jr., Commanding General, Hawaiian Department. The group visited Canton, Christmas, Palmyra, and Fanning Islands. Small defense units held each of these islands. Medical personnel were adequate. Each island presented individual problems, but, in all, the medical plans both for garrison and for providing medical support in the event of an enemy assault were considered sound. This trip was most informative and stimulating, as it introduced new thoughts regarding the problems of medical reinforcement in case of enemy attack, and the management and evacuation of casualties on an isolated island target.

On 14 August 1943, the Hawaiian Department became USAFICPA. During the same month, Brig. Gen. Hugh J. Morgan, Director, Medical Consultants Division, Office of The Surgeon General, visited USAFICPA and presented his observations in other theaters. He stated that penicillin was a promising drug and would be made available. And, in October, small amounts of penicillin did become available through the courtesy of good friends in the U.S. Navy. It was in January 1944 that the command obtained its first supply of penicillin through Army sources.

Because of troop concentrations on the island of Oahu, including the 7th Infantry Division which had arrived following its capture of Attu, the orthopedic outpatient clinics became very large, each clinic frequently handling in excess of 100 cases daily. This number of outpatients combined with the limited


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orthopedic staffs seriously interfered with hospital care. At an informal meeting with the surgeons of the 6th, 7th, and 40th Infantry Divisions, it was agreed that the problem could best be solved by the following measures: (1) Giving minor orthopedic care in the clearing company of each division, and referring only more serious cases to a hospital; (2) restricting to 50 the number of hospital outpatient clinic cases on each of the 3 outpatient clinic days each week; and (3) formation of a reclassification board within the area for disposition of division cases rather than boarding them through the hospitals. These measures proved effective.

On 7 November 1943, the Hawaii Chapter of the American College of Surgeons gave a most delightful scientific and social program for Fellows in the Armed Services. In the same month, General King directed that each combat division be furnished an officer trained in the management of fractures. He accepted the suggestion that each division provide one medical officer for training in fracture management during its stay in the islands and that this officer accompany the division on its departure. This plan was adopted, and subsequent personal observation of the professional skill displayed by many of these men during combat was gratifying.

Formally organized orthopedic training programs were established in December 1943 to take place in designated general hospitals on the island of Oahu for officers and enlisted personnel. The courses were made available to selected medical personnel of divisions and other tactical units. This policy paid off handsomely in subsequent combat operations as well as in the fixed hospitals. Largely because of the success of this program, a similar training program was later established for all Army medical officers by order of the Commanding General, USAFPOA, dated 20 October 1944.

During the latter part of 1943, the 204th General Hospital was without an orthopedist because of the shortage of trained personnel, and orthopedic cases were directed to other hospitals. It was again recommended that the Surgeon, USAFICPA, requisition three orthopedists with professional qualifications for section chiefs to be assigned to the area's large fixed hospitals, where the orthopedic census averaged about 25 percent of the total hospital census. The surgeon of each incoming unit was contacted for an officer with surgical background suitable for further orthopedic development, but rarely did such a man become available.

A few battle casualties were received from the Gilbert Islands operations. Analysis of 127 cases admitted to hospitals on Oahu showed wounds of the extremities, spine, and pelvis in 90, or 70.8 percent, of the cases. Practically all were wounds inflicted by small arms. The standard of treatment in the forward area was good. No case of cast constriction, major amputation, or gas gangrene was seen. Sulfonamides were given en route. Limited air evacuation was used in this operation. Initial impressions were favorable. The author requested authority to participate in the coming invasion of the Marshall Islands but was refused.


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FIGURE 247.-The courtyard of the 147th General Hospital. A patient exercising on a walking board.

By January 1944, the orthopedic training program in the general hospitals was organized on a 13 weeks' basis, and several officers were attached to Tripler, North Sector, and the 147th General Hospitals (fig. 247).

The Marianas and Leyte, 1944

The first group of casualties from the Marshall Islands arrived on 12 February 1944. At North Sector General Hospital, 173 were received, of which 43 were orthopedic cases, chiefly patients with wounds inflicted by small arms. Many had received initial definitive treatment aboard ship. By Navy standing operating procedure, the medical officers of each ship decided prior to combat the principles and methods of treatment which would be followed during the action. This procedure was quite in contrast to the professional methods as prescribed by The Surgeon General of the Army and, in combined operations, resulted in confusion between the medical services. Colonel Raine, area surgical consultant, Col. Charles T. Young, MC, Consultant in Medicine, Office of the Surgeon, USAFICPA, and the author checked the 646 wounded in the various hospitals, and made the following observations:

1. Selected cases were given plasma or blood shortly after wounding.

2. Sulfonamide therapy was well administered en route.

3. Clinical records and X-rays did not accompany the patients to the rear area hospitals, but arrived several days later.


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4. Wound debridement was unsatisfactory in 13 percent.

5. Closed wounds were found in 13 percent. Of these, 60 percent were infected.

6. Wounds treated by open methods rarely showed infection.

7. Amputation stumps were not treated by traction. Fifty percent were closed by flaps and were infected.

8. There was no gas gangrene or tetanus.

9. Splinting was good.

In the joint report, the three officers recommended that the area surgeon further emphasize directives that had been published on methods of treatment and that agreement be obtained with the Navy on methods of wound management. This consultant was convinced that consultants should accompany each invasion and attempt to supervise the management of patients on the target. Lt. Col. (later Col.) Laurence A. Potter, MC, Surgeon, 7th Infantry Division, and an outstanding field medical officer, with experience in Attu and the Marshall Islands, concurred, and so recommended to General King.

A prominent visiting civilian consultant to the Navy was impressed by the Stader splint, which was used quite extensively in that service. After checking this method of treatment with several Navy orthopedists and seeing their cases, this consultant recommended to General King that the Army obtain the item for evaluation in each of the command's fixed general hospitals. The Surgeon General disapproved this requisition. Time proved him correct in so doing because of the numerous late complications which followed.

In the spring of 1944, Maj. John J. Cawley, Jr., MC, a "graduate" of the USAFICPA orthopedic training program, was assigned to the 204th General Hospital, which was for a time without an orthopedic section. He reorganized the section, continued as chief throughout the remainder of the war, and rendered superior service.

In the hospitals, it was possible accurately to forecast combat operations by the increased number of self-inflicted gunshot wounds of the extremities. When self-inflicted wounds became numerous, it was positive evidence that an operation was pending. Unfortunately, nearly all of these cases were reported by investigating boards as "Line-of-duty, yes."

On 15 May 1944, the author submitted a letter to General King requesting temporary duty on a combat mission "for the purpose of supervising and assisting in the care of orthopedic casualties." Four days later, he was unofficially advised that his request had been favorably considered.

The shortage of orthopedic personnel continued to be acute. General King advised this consultant that orthopedists were not available from the mainland. Again the qualification card of each medical officer in USAFICPA was reviewed in a search for prospects. Training programs in the general hospitals were functioning well, but practically all of the officers in training were on temporary duty for only a few weeks and then moved on with their divisions. Nevertheless, two excellent men for development and permanent


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retention in orthopedic assignments were obtained. They were Capt. (later Maj.) Arthur M. Faris, MC, a diplomate of the American Board of Obstetrics and Gynecology, from a military police battalion; and Capt. (later Maj.) Lawrence L. Hick, MC, from the 7th Medical Battalion.

Brig. Gen. Earl Maxwell, formerly Surgeon, USAFISPA, and Colonel Sofield, formerly Orthopedic Consultant, USASOS, SPA, reported to Headquarters, USAFICPA, as the South Pacific Area was closing. Colonel Sofield reported that USAFISPA had four general hospitals, three large station hospitals, and a total of nine orthopedic board diplomates. This relatively large number of certified orthopedists was present because USAFISPA had affiliated units. In USAFICPA, there were no affiliated units, and, as a result, there were only two orthopedic board diplomates.

The Marianas operations

On 4 July 1944, the first battle casualties from Saipan arrived-six evacuated by air. By 14 July, the orthopedic census at North Sector General Hospital totaled 336, of whom 78 were battle casualties. On 15 July, General King directed this consultant to go to Kwajalein to supervise the management of the cases arriving there from the Marianas operations. On the author's arrival on Kwajalein, he met Lt. Col. Byron A. Nichol, MC, Island Surgeon; Brig. Gen. Clesen H. Tenney, Island Commander; and Capt. Robert F. Sledge, MC, USN, Atoll Surgeon. The island hospital-Provisional Station Hospital No. 2, commanded by Maj. (later Lt. Col.) Maximilian C. Kern, MC-was reinforced by personnel of the 51st and 52d Portable Surgical Hospitals, just arrived from the South Pacific and without recent clinical experience. The instructions were to evacuate the first 50 cases received each day to Guadalcanal station hospitals because the Oahu hospitals were filling up.

There were 1,314 Army hospital beds on Kwajalein, obtained by using the newly erected Army Air Forces barracks for emergency and expansion facilities. All hospital enlisted personnel were made available for professional work when one officer and enlisted personnel were detailed from tactical units to operate the hospital messes, run water details, and so on. The Navy operated all atoll hospitals except Kwajalein. Penicillin and volunteer blood donors were available. Colonel Nichol and the author agreed that white (14-day) cases be retained on Kwajalein, blue (15- to 60-day) cases be evacuated to Guadalcanal, and red (60-plus day) cases be evacuated to Oahu, insofar as practical. On 30 July, Kwajalein received 291 battle casualties from the hospital ship, U.S.S. Solace. Casualties remaining on board were taken to the Navy hospital on Burton Island. On the same day, 50 casualties came in by air. Cases arriving at the Army hospital were almost entirely Marines, who for the most part had been well treated, although many of the spica casts were broken and very few amputation stumps were in traction. A few instances of inadequate debridement, primarily closed wounds, tightly packed wounds, unnecessary excision of skin, unsplit casts, anklet traction still in place, and several cases of anerobic


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cellulitis were encountered. Four aircraft were available for further evacuation out of Kwajalein each day-two for Oahu and two for Guadalcanal. These were C-54's, and each had two flight nurses and was equipped to carry a total of 32 litter cases. The vast majority of patients were evacuated from Kwajalein by air. On 3 August, General Tenney advised that the Kwajalein hospital beds would be limited to 450 upon arrival of additional units who would require the Army Air Forces barracks for housing. Atoll beds after arrival of these units were to be: Kwajalein 450, Roi 450, Burton 450, and Carlson 150. Reserve Army medical supplies were stored on Carlos Island, where it was possible to establish 300 additional beds, if necessary, but transportation to that island was by boat only. On the same day, 50 casualties arrived from Tinian, many requiring blood transfusions.

On 6 August, this consultant sent a memorandum to Col. Eliot G. Colby, MC, Surgeon, Army Garrison Force, Island Command, Saipan, reporting the condition of cases received on Kwajalein. After one week, with practically no battle casualties, a radio was sent to General King requesting temporary duty in the Marianas. The author, meanwhile, visited Makin, one of the Gilbert Islands, where Maj. Robert D. McKee, MC, was Island Surgeon and commanding officer of the 1st Station Hospital, which served the island and evacuated to Kwajalein. Personnel and supplies were adequate. On return to Kwajalein, the author learned that hospital ships were expected on 20 August. On 16 August, reports were received that the wounded were being well evacuated from Kwajalein. On 19 August, this consultant received radio orders from General King to proceed to the Marianas.

Colonel Colby was Island Surgeon, Saipan, where island spraying with DDT was first done. The 369th Station Hospital was operating, and the 148th General Hospital was just getting established. The evacuation policy was 30 days. This consultant immediately saw patients, checked supplies, reviewed surgical principles and methods, and discussed the effects of the 30-day evacuation policy with the staffs of these two units and with Colonel Colby. On 24 August, the author proceeded to Guam where Capt. John B. O'Neil, MC, USN, was surgeon of the V Amphibious Corps (fig. 248). The 77th Infantry Division with the 36th Field Hospital, operating a forward and a rear section, and the 289th Station Hospital, which was just establishing facilities, formed the Army contingents of this corps (fig. 249). Neither of these hospitals had an officer trained in fracture management. Combat operations were practically at a standstill because of mud. DUKW's (amphibious trucks, 2-ton cargo) were useful in the evacuation of wounded (fig. 250). Dengue fever was epidemic. Evacuation within the division was temporarily impossible because of the mud. The author reviewed cases and professional management at the 36th Field Hospital. It was impossible to visit the tactical units. Captain O'Neil, in discussions, emphasized the need for qualified medical personnel in the combat zone and for a directive covering professional management in combat operations. On return to Saipan, minor recommendations regarding personnel and supplies were made to Colonel Colby.


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FIGURE 248.-The landing on Guam, 23 July 1944.

Return to Hawaii

On reporting to General King, this consultant's major recommendations were that:

1. Additional specialized medical officers be obtained to staff properly the large hospitals.

2. All training courses for Medical Department personnel emphasize principles and methods to be employed in the combat zone.

3. Refresher courses in the large fixed hospitals be of at least 6 weeks' duration.

4. Consultants discuss anticipated problems of the combat zone with medical officers of tactical units shortly before their departure on combat missions.

5. Mobile surgical teams be made available for use in combat, forward, or rear area hospitals as required.

6. Officers of the Army Nurse Corps be made available to mobile hospitals soon after their establishment.

7. Air evacuation from the combat zone be supervised by an air evacuation officer.

8. The use of blood transfusions be increased in the combat zone.

9. An attempt be made to obtain skin traction methods in the management of amputation stumps of Army personnel treated aboard ships.

10. Further use be made of consultants in the combat zone.


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FIGURE 249.-An operating room, established in a building that had been recaptured from the Japanese, Guam, July 1944.

General King then stated that the author was full-time orthopedic consultant for USAFPOA, the command's new designation, and relieved him of duty at North Sector General Hospital. General King ordered the author on temporary duty to the XXIV Corps as an observer for a coming operation and said that a request for leave on the mainland would be in order upon the author's return to Hawaii. Major Faris, another "graduate" of the orthopedic training program, was designated this consultant's replacement as Chief, Orthopedic Section, North Sector General Hospital. Colonel Oughterson (formerly surgical consultant in the South Pacific Area) was the new Consultant in Surgery, USAFPOA.

On 21 August, Brig. Gen. Raymond W. Bliss, Office of The Surgeon General, and Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery to The Surgeon General, visited Headquarters, USAFPOA. They had no specific recommendations for the command's orthopedic problems.

On 2 September 1944, this consultant discussed the pending operation with Colonel Potter, Surgeon, XXIV Corps, and Lt. Col. (later Col.) Robert J. Kamish, MC, Surgeon, 7th Infantry Division. The author was to be a working observer, acting initially as orthopedic consultant to the 7th Division and later as the Corps orthopedic consultant. On the following day, he made


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FIGURE 250.-Casualties being loaded on DUKW's for evacuation.

final rounds at North Sector General Hospital with Major Faris and found that several of the knee cases that were closed with cotton had extruded sutures. The author also met with the staffs of all the available mobile surgical hospitals that would be attached for the operation and discussed orthopedic principles and case management.

On 12 September 1944, this consultant reported aboard the U.S.S. J. Franklin Bell in Pearl Harbor. On 14 September, a meeting was held with the senior medical officers of all participating ships and the key medical officers of the 7th Division. These officers, including the author, planned, discussed, and agreed upon the medical policies and the principles and methods of treatment and evacuation to be followed in the operation. Particularly emphasized in professional care were early adequate initial surgery, open treatment of wounds without tight packing, traction on amputation stumps, cast fixation of fractures and severe soft tissue injuries, and the use of penicillin.

The force departed Pearl Harbor on 15 September. On the following day, the target was officially announced to be the island of Yap, Caroline Islands, and all were briefed on the operation. Three hours later, it was announced that the target had been changed. The task force arrived at Eniwetok, and 4 days later the new target was announced to be Leyte, Philippine Islands, and D-day, 20 October 1944. Now, the XXIV Corps would become part of the Sixth U.S. Army under Lt. Gen. (later Gen.) Walter Krueger.


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FIGURE 251.-The shoreline of Leyte Island at the invasion point, as seen from an incoming LCVP, 20 October 1944. The smoke is from the naval bombardment.

On 3 October, the force arrived on Manus, Admiralty Islands, where the new medical plans were discussed with Colonel Potter and Colonel Kamish. By his personal request, the author was to go ashore on D-day with a collecting company. The force left Manus on 14 October.

Leyte, Philippine Islands

On 20 October, the Pacific was calm as a millpond. The force entered Leyte Gulf about dawn. The Japanese sent out an occasional welcoming committee of a Zero or a torpedo bomber flying low. All that this consultant saw were shot down. By plan, the XXIV Corps assault wave which included one platoon of Company C, 7th Medical Battalion, was to go in at about J+4 or J+5 (hours) on call. Personnel were loaded into LCVP's (landing craft, vehicle and personnel), which circled briefly, then formed up on the line of departure abreast the bombarding ships. At J+25 (minutes), the LCVP in which the author was riding was on Beach Yellow 2 at Dulag (fig. 251). When the assault force newspapers appeared a few days later, the official version was: "Our troops in their desire to close with the enemy, at times overran their line of departure."


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The collecting company established in the remains of the church (which faced the square) and evacuated to the medical shore party, which in turn evacuated by LCVP to ship (fig. 252). At about 1500, the collecting station was joined by Captain Minden and his surgical team from the Clearing Company, 7th Medical Battalion. The team established itself inside the church and began definitive treatment for nontransportable military casualties and severely wounded civilians (fig. 253). Shore-to-ship evacuation stopped before dusk, and, as the collecting company and surgical team were the only medical units behind the 184th Infantry, the group worked throughout the night. The Japanese attacked the 184th Infantry shortly before dawn with infantry and tanks, as the regiment was warned they would. Both the U.S. Army and the U.S. Navy turned their full firepower onto the attacking Japanese, which made a deafening but magnificent display of coordinated fireworks in the dark. On the following day, the clearing company arrived and established its station, and the collecting company moved forward. Two surgical teams from the 76th Station Hospital, Leyte, soon joined the collecting company, which then established a station with a military section for emergency surgery and a civilian section for definitive care.

While with the 7th Infantry Division or with the XXIV Corps, this consultant observed professional methods or assisted in patient care in a battalion aid station of the 184th Infantry, all companies of the 7th Medical Battalion, 69th Field Hospital, Leyte, 76th Station Hospital, Leyte (fig. 254), 165th Station Hospital, Leyte, and the 394th Clearing Company of the 71st Medical Battalion (Separate). Several of the mobile hospitals were not unit loaded, and their supplies were widely scattered on the various Corps beaches, causing much delay in getting them established. All medical units established their own perimeter of defense. Personnel of the 51st and 52d Portable Surgical Hospitals were used as surgical teams to reinforce clearing companies and field hospitals. Blood was obtained from patient and volunteer donors. Because of nearby airfields, ammunition dumps, and artillery positions, several of the medical units received enemy fire of various types, which caused numerous casualties among their personnel. On 24 October, this consultant was slightly wounded in the left thigh by a shell fragment, and a walking cast was applied from ankle to groin.

Upon leaving the XXIV Corps, the author reported to Headquarters, Sixth U.S. Army. The surgeon, Col. (later Brig. Gen.) Wiliam A. Hagins, MC, was a delightful gentleman with the wisdom of having participated in the establishment of 14 previous beachheads. He felt that clearing companies reinforced with surgical teams and evacuation hospitals provided the best medical support for divisions in amphibious operations. Within the X Corps, the 1st Field Hospital, Leyte, the 2d Field Hospital, Leyte, and the 3d Field Hospital, New Guinea, were establishing hospitalization facilities, while their surgeons were active with surgical teams reinforcing clearing stations and evacuation hospitals. The 36th and 58th Evacuation Hospitals were established


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FIGURE 252.-Casualties aboard the U.S.S. J. Franklin Bell, Leyte Island, Philippine Islands, 20 October 1944. A. The officers' wardroom. B. The operating room.


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FIGURE 253.-A church used by the 7th Medical Battalion as a collecting and clearing station with an attached surgical team, Leyte Island, 24 October 1944.

near Tacloban, Leyte. This consultant was greatly impressed with the evacuation hospitals. Both received patients on D-day, were fully established by D+3, were staffed with well-qualified specialists, and received whole blood daily by air. A few selected female nurses were with these two hospitals and were of great value, particularly in postoperative care and in raising the morale of the patient.

From Leyte, this consultant proceeded to Peleliu Island, Palau Islands, where combat operations were in progress. The 17th Field Hospital, Peleliu Island, in addition to serving the Marine assault force, was operating as a link in air evacuation between Leyte and Biak.

Major conclusions formed during these operations were:

1. Because of attacks on ships, blackout conditions, vagaries in the weather, and other unforeseen circumstances, medical plans for operations in the future should include provision for complete definitive surgery to be furnished ashore.

2. Four surgical teams should be attached to each division clearing company.

3. Each combat division should be supported by one evacuation hospital, semimobile.

4. Station hospitals, when employed as evacuation hospitals in combat, must be supplemented by surgical teams.

5. Personnel of portable surgical hospitals were best employed as surgical teams and for providing postoperative care.


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FIGURE 254.-Some 7th Infantry Division and XXIV Corps medical installations on Leyte visited by Colonel Robertson. A. Command Post, 7th Medical Battalion. B. Tents of the 76th Station Hospital, Leyte.


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FIGURE 255.-Surgical ward of the 165th Station Hospital, Leyte Island, showing numbers of civilian patients, November 1944.

6. Well-trained surgical teams were of great value at all levels within the combat zone.

7. Medical personnel assigned to units entering combat should receive training in small arms to include the carbine.

8. Unit loading and unit control of supplies on the beaches was essential.

9. Civil affairs units should be established early to assume full medical care of civilians, thus freeing the medical service of tactical units of this additional burden (fig. 255).

10. Army Nurse Corps officers should be brought to the target on call of the surgeon of the combat forces.

11. Medical and dental officers of company grade and selected officers of field grade should be rotated between mobile and fixed medical units on a 12 months' basis.

12. Use of the Thomas' arm splint should be discontinued in the combat zone.

13. New tents should be obtained that can be properly blacked out and yet permit work to continue within.

14. Morphine should be administered only by Medical Department personnel.


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15. Refresher courses given in large fixed hospitals resulted in improved surgical care on the target.

16. Refresher courses given in rear area hospitals for medical officers of tactical units should further emphasize procedures and techniques to be employed in the combat zone.

17. Training courses in the large rear area hospitals for selected enlisted men should further emphasize training in the handling of trauma.

18. Consultants should be attached to each combat force.

In addition to these recommendations, the author brought back a renewed love and admiration for the combat soldier, regardless of his color, flag, or religion.

Hawaii again

On return to Headquarters, USAFPOA, in November, this consultant found that General King had been rotated to the mainland and Brig. Gen. John M. Willis had replaced him. Lt. Col. William B. McLaughlin, MC, a diplomate of the American Board of Orthopaedic Surgery, from the South Pacific, was the new chief of the orthopedic section at North Sector General Hospital and doing superior work. Patients in all Oahu hospitals were receiving excellent care. Battle casualties found in a station hospital were transferred to a general hospital.

General Willis recognized that the prevailing shortage of orthopedic personnel was acute and approved requisitioning the necessary personnel from the mainland. He also approved this consultant's writing directly to Col. Leonard T. Peterson, MC, Chief, Orthopedic Branch, Office of The Surgeon General, and to Lt. Col. John J. Loutzenheiser, MC, Consultant, Orthopedics and Reconditioning, Ninth Service Command. Personal letters were written to each of them asking about the condition of patients on arrival on the mainland. Mobile orthopedic teams were requested by General Willis. Personnel for the four that were to be formed were selected by the author. He continued to give talks on orthopedic management in the combat zone before numerous tactical, mobile, and fixed hospital units.

Back to the United States

Finally, this consultant submitted his request for temporary duty and leave to the Zone of Interior. The request was approved. On 18 December 1944 he left Oahu, and on the following day at Letterman General Hospital, San Francisco, Calif., he checked the condition of patients evacuated from the Pacific with the Commanding General, Brig. Gen. Charles C. Hillman, and his chief of surgery, Col. Russel H. Patterson, MC. Both reported that patients arrived in good condition. Their chief criticism was the manner in which hands were splinted.


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The author arrived at his home on 23 December, in time for Christmas and a happy reunion with his family. He gained 14 pounds during the first 2 weeks at home.

By invitation of Colonel Peterson, this consultant visited Battey General Hospital, Rome, Ga., and made rounds with him and Maj. (later Lt. Col.) James J. Callahan, MC, Consultant in Orthopedic Surgery, Fourth Service Command. The principles and methods of treatment seen were essentially those that had been followed in the Pacific. Hoping to find additional orthopedic personnel for USAFPOA, the author requested 10 days' temporary duty in the Office of The Surgeon General. The request was approved, and he proceeded to Washington where much time was spent at Walter Reed General Hospital. Several of the Pacific wounded and other old friends were seen. With Colonel Peterson, he reviewed the qualification cards of all orthopedic surgeons available for assignment and found no prospects for USAFPOA.

Okinawa, Victory, and Demobilization, 1945

In San Francisco, it developed that air transportation would mean a delay of at least 2 weeks. As this consultant had been alerted for the next operation, he returned to Pearl Harbor aboard the U.S.S. Okanagoan (APA 220) on her maiden voyage.

On Oahu, he found that General Willis was in the forward areas with Maj. Gen. Norman T. Kirk, The Surgeon General of the Army. The author saw all orthopedic cases in the general hospitals on Oahu, and received his anticipated orders for temporary duty as observer with the Tenth U.S. Army for Operation ICEBERG (Okinawa). In the Tenth U.S. Army, Col. Frederic B. Westervelt, MC, was Surgeon; Colonel Finney, surgical consultant; Col. Walter B. Martin, MC, medical consultant; and Colonel Sofield, MC, orthopedic consultant. Colonel Oughterson was to be surgical consultant and Col. Benjamin M. Baker, MC, medical consultant of the forward base area with headquarters on Saipan. General Maxwell was to accompany the invasion forces and become Surgeon, Army Garrison Force, following the operation. Lt. Col. (later Col.) Moses R. Kaufman, MC, theater psychiatric consultant, and the author were to go with the task force in addition to being assigned as Tenth U.S. Army consultants. There were no evacuation hospitals. Each division was to have one field hospital, with two portable surgical hospitals and four surgical teams attached, to act as an evacuation hospital. A directive, "Surgery in the Combat Zone," was to be issued to all medical units of the Tenth U.S. Army. When General Kirk and General Willis returned from the forward areas, the utilization of consultants in the various zones of the theater was discussed with them (fig. 256).


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FIGURE 256.-Maj. Gen. Norman T. Kirk, touring the Middle Pacific. A. An occupational therapy shop of the 129th Station Hospital convalescent center. General Kirk (with hand on patient), Colonel Streit (second from right, standing), and General Willis (extreme right). B. An orthopedic ward of the 22d Station Hospital, Oahu, T.H.


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FIGURE 257.-An orthopedic ward at the 39th General Hospital, Saipan.

The Okinawa operation

On 5 March 1945, this consultant boarded the U.S.S. Montauk, assistant command ship, and arrived at Saipan on 13 March. At the 39th and 148th General Hospitals and the 369th Station Hospital, he reviewed cases and medical plans for Operation ICEBERG. Orthopedic cases were to be treated only at the 39th and 148th General Hospitals, where it was hoped that all fractures of the long bones could be held until "frozen" (fig. 257). At Tinian, where Captain Mueller, USN, was Island Surgeon, the author discussed with the combined Army and Navy medical officers the medical plans for care of battle casualties.

This consultant left Saipan in a convoy with the 2d Marine Division. The target day was officially "Love Day," 1 April 1945 (Easter Sunday), and H-hour was 0800. On "Love Day," the sea was calm, and the day, clear. The amphibious assault feint of the 2d Marine Division was beautifully executed. Then the convoy continued to the landing beaches on the west side of the island. The power of American industry as evidenced by the many new types of ships engaged was amazing (fig. 258). The assault waves met little resistance. The author remained aboard ship, where occasional air attacks were received. On 4 April, he visited the hospital ships, U.S.S. Comfort (Army) and U.S.S. Solace (Navy) and reviewed professional methods. He also visited Landing


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FIGURE 258.-The ships that carried men and supplies to Okinawa, 4 April 1945.

Ship, Tank, Hospital Ship 929, which was serving as the force blood bank until the blood bank could be established ashore and as the control ship for medical supplies and casualties.

On 5 April, this consultant went ashore where he saw Colonel Potter, Surgeon, XXIV Corps; Lt. Col. Byron B. Cochrane, MC, Surgeon, 7th Infantry Division; Maj. Homer P. Struble, MC (who had excised the author's shell-fragment wound on Leyte) and many other old friends (fig. 259). The 31st and 69th Field Hospitals were not fully operational because of supply difficulties. The author was instructed to serve as consultant with the XXIV Corps. Colonel Sofield was to serve in a similar capacity with the III Amphibious Corps and with the Tenth U.S. Army. The XXIV Corps, moving south on Okinawa, had established contact north of Naha. On 6 April, the author again went ashore. As he left the beach to return to his ship, the first organized Japanese kamikaze (suicide) attack on the ships began and continued for about 5 hours. The LCVP, during the return to the ship, was a perfect ringside seat. The kamikaze corps was not a suitable assignment for a coward.

On 8 April, the author reported to Headquarters, XXIV Corps, and served with the Corps through 6 May. He assisted in the organization of shock wards; supervised and participated in the postoperative care of patients and in their general management; held informal discussions on professional methods with the various tactical and hospital units; corrected on the spot errors observed; and prepared indicated directives for the Corps surgeon.


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FIGURE 259.-An aid station on the beach at Okinawa, L-day, 1 April 1945.

Many of the wounds were caused by multiple shell fragments, and they were very severe and destructive. On 16 April, he submitted a report on the medical situation to General Willis.

This consultant served with and visited the following units: All battalion aid stations of the 105th and 106th Infantry, 27th Infantry Division; the aid station of the 3d Battalion, 165th Infantry, 27th Infantry Division; regimental aid stations of the 17th, 32d, and 184th Infantry, 7th Infantry Division; Companies A, B, C, and D (52d and 66th Portable Surgical Hospitals attached) of the 7th Medical Battalion; Companies A, B, C, and D (96th and 98th Portable Surgical Hospitals attached) of the 102d Medical Battalion (fig. 260); Companies A, B, C, and D (51st and 67th Portable Surgical Hospitals attached) of the 321st Medical Battalion; the 31st and 68th Field Hospitals; the 394th Clearing Company of the 71st Medical Battalion (Separate), which was operating two holding platoons for evacuation from shore to ship; and the Evacuation Center, Tenth U.S. Army.

The experienced units for the most part established themselves rapidly, functioned efficiently, and evacuated promptly. The Clearing Company (Company D), 7th Medical Battalion, was outstanding, largely as a result of the experience acquired in several previous campaigns and the wise training of its personnel. It was the only division clearing company in the XXIV Corps that had early X-ray facilities, and it possessed the only barber, hot shower, and laundry seen during the author's stay on Okinawa. With this company, Captain Minden continued his superior surgery and was a constant inspiration


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FIGURE 260.-Whole blood being administered to a casualty at a clearing station of the 102d Medical Battalion, Okinawa, 21 April 1945.

to all who witnessed his work. The field hospitals were slow in establishing adequate shock facilities and postoperative care for the large numbers of seriously wounded which they received, largely because of inexperience. Shore-to-ship evacuation was often long delayed because of darkness, air attacks on the ships, or weather conditions. The mobile orthopedic teams rendered professional care of superior quality. Medical supply difficulties were markedly reduced over previous operations. The medical control ship greatly simplified the evacuation of casualties from the shore to the proper ship and the movement of medical supplies from ships to the proper beach. The copper sulfate method of hematocrit determination was used in all clearing companies. Whole blood and oxygen were used in the 7th Infantry Division at the collecting station level and proved to be of great value.

It was felt that informal meetings with the medical officers of all units and on-the-spot correction of errors were particularly valuable functions for consultants during combat. Meetings within the divisions were normally held at the clearing company and were attended by practically all officers of the division medical battalion and the regimental medical detachments. The consultant received many invaluable viewpoints and suggestions during these meetings


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and will always be grateful for the opportunity he had to learn from these indispensable men. The chief difficulties encountered stemmed largely from the fact that there was an insufficient number of trained personnel on the target. In correcting this deficiency, the attachment to army hospitals of excellent specialized teams obtained from the Navy hospitals that did not operate as units was of the greatest value.

On 8 May, this consultant was released from temporary duty with the XXIV Corps and Tenth U.S. Army and reported aboard the U.S.S. Relief. After seeing cases and discussion with the surgical staff, he sent a memorandum to the Surgeon, Tenth U.S. Army, concerning the condition of patients as received and seen aboard ship. Surgical principles aboard ship did not vary appreciably from those followed in Army facilities on land, except that traction was rarely applied to amputation stumps. At Guam, all patients were unloaded and taken to the hospitals of their respective services.

The author then visited all fixed army hospitals on Saipan, Tinian, and Guam during the period 15-27 May, and each orthopedic case was seen and discussed. Because of a shortage of hospital beds and personnel, it appeared these hospitals could not long continue to hold patients with fractures of the long bones in traction until "frozen." The author made the trip from the Marianas Islands to Oahu by evacuation aircraft. Excellent patient selection and care was observed.

Experience in this campaign resulted in the following major recommendations:

1. Medical officers with high professional qualifications should be assigned as far forward as possible, normally at clearing company level.

2. Refresher training in fixed hospitals should be given on every possible occasion to officers assigned to mobile medical units.

3. In the training of mobile hospitals preceding combat, additional emphasis should be placed on living in the field under combat conditions, rapid establishment of facilities for the reception of large numbers of patients, the treatment of shock, postoperative care, rapid evacuation, and the provision of professional care on a 24-hour basis.

4. Company grade and selected field grade Medical Department officers should be rotated between fixed and mobile units, preferably after 12 months' service.

5. Air evacuation is particularly desirable for major fracture and amputation cases.

6. Halftracks serve well as ambulances in exposed areas because of their protection against near misses and small arms fire. The chief limitation is their capacity of only one litter case.

7. Female nurses should be brought to the target as soon as the danger of their being captured by the enemy has passed.

8. Theater consultants should continue to accompany each invasion force.


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Following his return to Oahu on 28 May 1945, this consultant visited the various hospitals where he checked and found the care being given patients to be excellent. Great improvement in patient care was apparent in all echelons during the Okinawa operation. This improvement was the result of the increased number of trained personnel on the target, the availability of whole blood, improved methods in the management of wounds and shock, and the increased use of air evacuation. Because of the shortage of hospital beds in the theater, it was not possible to hold the numerous casualties with fractures of the long bones until the fragments were frozen in traction, as had been planned. These casualties had to be evacuated in casts by air to the mainland.

General Willis was very critical of this consultant's long absence in the combat zone. Even after he explained the situation on the target and pointed out that it was on the target, rather than in the rear areas, that mortality and morbidity were reduced, he remained in obvious disfavor until a letter of commendation arrived from Colonel Westervelt, Surgeon, Tenth U.S. Army. General Willis added a nice indorsement, brought it to the author in person, and then asked if he would like to go on the next operation. This consultant was restored to favor.

Preparations for invasion of Japan

Major activities now centered about medical plans for the invasion of Japan. The author met with all medical officers of the 98th Infantry Division; with the staffs of the 317th General Hospital, the 97th and 98th Station Hospitals, and many of the island's fixed hospitals. Using prepared talks and informal discussions, he stressed the space and other requirements for the treatment of shock and hemorrhage, the importance of making hematocrit determinations, the required standards of resuscitation prior to and following surgery, the necessity for adequate initial surgery and the splinting of fractures and soft-tissue wounds, the need for adequate postoperative care, and the value of air evacuation. Field conditions in combat were also emphasized before the mobile hospitals. Motion pictures of surgery during the Okinawa operation were shown and discussed at a meeting of the Air Transport Command surgeons at Hickam Field and before the staffs of several other tactical and fixed units. This consultant made several visits to the 8th Station Hospital, which operated the reconditioning center on Oahu (fig. 261).

On 1 July 1945, USAFPOA was redesignated USAFMIDPAC, and placed under General Headquarters, AFPAC, with General MacArthur in overall command. During July, Colonel Potter arrived from Okinawa en route to the mainland for temporary duty and leave. He concurred in Colonel Robertson's formal report on Operation ICEBERG and brought news of mutual friends, some of whom had been killed in action, and many of whom had been wounded.

On 25 July, this consultant observed a dry run by the recently arrived 86th Evacuation Hospital, which was attached to the 98th Infantry Division. An informal discussion was then held with the staff regarding combat zone surgery.


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FIGURE 261.-The 8th Station Hospital, Hawaii. Formation, to mourn the death of the Commander in Chief, President Franklin D. Roosevelt.

Thereafter, the author had frequent informal discussions jointly with the Surgeon, 98th Division, and the Commanding Officer, 86th Evacuation Hospital, regarding their particular problems in the approaching operation. The orthopedic surgery detachments were busy on temporary duty at the 218th and 219th General Hospitals. A hospital center was being organized in the Marianas.

In addition to plans for the invasion of Japan and consultations in the various hospitals of the Central Pacific Base Command, this author was occupied with various other staff duties. There were reports to General Maxwell listing the orthopedic qualifications of the officers of the general and station hospitals assigned to him on Okinawa. He made personnel studies of the orthopedic surgeons, Central Pacific Base Command, which showed that there were present only 37 of the 50 authorized by tables of organization. He served as a member of a reclassification board on the military occupational specialty classification (professional and administrative) of all Central Pacific Base Command medical officers. In addition, he was a firing member of the Surgeon's Office pistol team, which finished 10th in the field of 15 entries from the general and special staff sections in the headquarters pistol tournament.


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Victory and demobilization

The atomic bomb on Hiroshima caused much excitement. On 14 August came the big news that the war was over! During the next few weeks, this consultant received several letters from medical officers with long and outstanding combat experience stating that they were being retained in division medical units doing no professional work while newly arrived officers with only 9 months' internship were being assigned to hospitals. General Willis, while sympathetic, felt that men with combat experience should be retained in tactical units as there might yet be need for them in this capacity.

On 1 September, the author presented a paper entitled "Management of Orthopedic Battle Casualties in the Pacific" with slides showing the care of wounded from battalion aid stations to rear area general hospitals. This presentation was before the Hawaii Chapter, American College of Surgeons. The slides were made from motion pictures taken for the official medical history, most of which were taken by Capt. Ted Bloodhart, SnC, and were very complete.

Plans were rapidly developed to reduce medical installations and personnel. Colonel Ottenheimer was assigned to the office to edit the theater medical history. On 17 September, the 40-hour week became effective. Aside from working on the orthopedic section of the history, duties were very pleasant with much golf and swimming. Colonel Potter, en route back from the mainland, visited before returning to the XXIV Corps, destination Korea. Col. Elbert DeCoursey, MC, Consultant in Pathology, AFMIDPAC, and Col. Verne R. Mason, MC, Medical Consultant, AFMIDPAC, left for Japan to join Colonel Oughterson in the study of the medical effects of the atomic bombs. The author's orders for release from active duty appeared on 17 September. He completed the orthopedic portion of the medical history and turned it over to Colonel Ottenheimer.

On 24 September 1945, the author boarded the U.S.S. Azalea City destined for San Francisco. On 1 October, the returnees changed from khaki to olive drab uniform. All hands were on deck, silent and thankful as the coast neared. The underside of Golden Gate Bridge was lovely. Inside the harbor, a "Welcome Home" ship with flags flying and bands playing circled the U.S.S. Azalea City several times, an unexpected and joyous welcome. Never before had "The States" appeared so beautiful.

Summary

The Pacific Ocean Areas, commanded by Adm. Chester W. Nimitz, U.S.N., consisted of numerous widely separated small islands. The duties of USAFPOA, commanded by General Richardson, were those of a defense force operating a training and staging area and maintaining a base for, and conducting, amphibious operations. Cooperation among medical officers of tactical and fixed medical units, line officers, and medical officers of the Navy was excellent. As a consultant assigned to Headquarters, USAFPOA, the author


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received authority to move and act within the theater in keeping with his assigned duties.

The major problem throughout the war was the procurement of adequately trained personnel. The deficiency in trained personnel was met in part by training courses for selected individuals who subsequently served in tactical units and in the mobile and fixed hospitals. The shortage, particularly noticeable in the early invasions, was corrected in part by the assignment of qualified individuals and orthopedic teams to task forces. In attempting to correct the overall theater shortage, the Surgeon, USAFPOA, was most cooperative in approving recommended transfers and assignments for the more optimum distribution of available surgical talent.

Another difficulty arose from the fact that combat operations in the POA were joint operations involving both the Army and the Navy. The Surgeon General of the Army directed principles and methods of treatment which would result in high standards of professional care and uniformity of methods throughout the Army. In the Navy, principles and methods of treatment were established at the local level. The differences in professional management between the two services did not occasion friction at unit levels during combat or garrison duty, but the differences were quite apparent to the other service when large numbers of casualties were handled by one service. Such differences can only be corrected centrally, either in Washington or at the theater level by issue of similar directives to all services. Casualties were as a rule evacuated to fixed hospitals, operated by their respective services, rather than to the hospitals, regardless of the service, best suited for the management of their particular pathology. When separate hospitals are maintained in the same area by the several services, the formation of interservice hospital groups and the assignment of casualties, irrespective of service, to hospitals staffed for their various specialized needs should result in improved case management and in economy of medical personnel.

The third major difficulty was in establishing facilities during combat with sufficient trained personnel and beds to provide complete 24-hour care on the target. The need for 24-hour service was indicated in many instances because of the unavoidable delay in evacuating from shore to ship, and was most marked in the early phases of an invasion. During combat, the need for trained personnel was greatest on the target. When combat ceased, the need was greatest in the forward and rear area fixed hospitals. These varying needs were best met by the use of mobile specialized teams transported by air.

Medical officers who were assigned to tactical units lost much of their specialized professional skill during their long periods of inactivity, while officers assigned to rear area fixed hospitals often possessed skills which were in greatest demand in the combat zone. The first mentioned deficiency was met in part by the establishment of refresher courses in rear area hospitals to which officers assigned to tactical units were attached for varying periods of time prior to their entry into combat. The second deficiency was overcome by the limited transfer of personnel from fixed to mobile hospitals. The initial


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definitive surgery received by a severely wounded man was usually the most important single factor in determining his survival or eventual disability. This treatment should be given as soon as possible after wounding. For these reasons all physically able company grade medical officers and selected field grade officers should be rotated between tactical and fixed installations after a period of one year. Mobile hospital commanders should be carefully briefed on and envision situations which their units are likely to encounter in combat, and, during training, these units should prepare for such conditions. Areas particularly to be stressed were: Unit loading and care of supplies in the combat zone; rapid establishment of facilities for the treatment of large numbers of wounded; establishment of adequate shock, X-ray, surgical, and postoperative facilities; and rapid definitive treatment and evacuation. There was no substitute for combat experience. The best alternative was wise briefing by experienced officers with combat experience.

Pertinent technical and professional information should be disseminated to all units and individuals and carefully studied prior to combat. This goal was never fully attained, largely because invasions conducted in the Pacific Ocean Areas were combined operations, participating units often mounting from widely scattered areas of departure. This difficulty was in part corrected by the activities of consultants on the target.

Members of the Army Nurse Corps proved invaluable in mobile hospitals, from both a professional and a morale viewpoint. They should be brought to the target on call of the surgeon of the task force.

Air evacuation was extremely valuable because of the great distances covered by lines of evacuation in the Pacific Ocean Areas. Orthopedic cases were particularly suitable for evacuation by air. When personnel or hospital facilities are limited in an oversea theater, major fractures and amputees should be evacuated by air to the United States soon after initial definitive treatment.

Consultants, as special staff officers, must be free to move about and act both in advisory and professional capacities throughout the entire command.

ROBERT CRAWFORD ROBERTSON, M.D.

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