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Chapter XII - continued

Contents

Chapter XII

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FIGURE 282.-Headquarters, Philippine Base Section, Manila, Philippine Islands, 25 May 1945.

his own lack of knowledge reflected the general lack of knowledge of other medical officers concerning them. Once the ETMD reports were called to the attention of medical officers, they cooperated in producing material for them, and much valuable data were thus secured. It was the policy, as far as possible, to use the names of contributors, in fairness to them and also because of the stimulus thus provided to further production.

When the Consultant in Surgery finally learned of the existence of the ETMD reports, he suggested that whole articles, or abstracts of articles, of special value which appeared in them be reprinted in pamphlet form each month, either by the Office of The Surgeon General or in the area, and be distributed to officers performing surgery. The plan, which was suggested on a worldwide basis, proved impractical in the Southwest Pacific Area because of the rapid movement of Headquarters, USASOS, SWPA, to Hollandia in September 1944, to Leyte in January 1945, and to Manila in the following April.5

5There is an unfortunate lack of detailed data on various types of combat-incurred injuries from hospitals in the Southwest Pacific Area. This experience suggests that a standard form should have been provided for all of the theaters for the reporting of monthly battle casualties from each medical treatment facility. Such a form could have contained the information in more detail than was required in the official forms in use, without, at the same time, being so detailed as to impose an additional burden on medical officers already overwhelmed with work. There was no machine records unit in the Office of the Chief Surgeon, SWPA, at any time, and, even if it had been available, reports received from individual hospitals varied so widely that they could not have been fitted into a theater pattern.


726

Surgical Teams

As pointed out elsewhere (p. 756), the concept of surgical teams was not accepted in the Southwest Pacific Area until April 1944, shortly after General Denit had become Chief Surgeon, USAFFE (U.S. Army Forces in the Far East), and SOS, SWPA. The teams which were then formed on paper were offered to the Surgeon, Sixth U.S. Army, by General Denit in the summer of 1944, for the invasion of Leyte. The offer was declined, and no surgical teams were used to supplement the medical units scheduled to support the landings of 20 October. Shortly afterward, this decision was reversed, and four teams were placed on temporary duty with the Sixth U.S. Army, with the understanding that they would return to their original stations when the need for them had ceased. The value of the team concept was so evident that other teams were requested for support of the field and evacuation hospitals which landed in Lingayen Gulf in January 1945. In all, 23 teams were used in this invasion, and others landed elsewhere, with units of the Eighth U.S. Army. It was part of the author's duties as surgical consultant to provide the personnel for these teams.

The objections originally raised to the use of surgical teams when they were first proposed by Colonel Parsons in 1942 had been chiefly by medical personnel with limited clinical experience. The objections did not prove valid. Testimony from forward units was that the presence of these teams, far from being resented by organic personnel of field and evacuation hospitals, was welcomed. The second objection raised to the team system, that personnel constituting them would be lost permanently to the parent organization, also did not materialize; it was obviated by correctly written orders.

Although surgical teams filled an appreciable portion of the surgical breach in the last months of active fighting in the Southwest Pacific Area, auxiliary surgical groups would have been more satisfactory for a number of reasons. They were better organized. Their personnel had generally had better training and more experience, and were therefore of more even ability. Finally, the morale factor could not be ignored. The great weakness of surgical teams as they were constituted in the Southwest Pacific Area was that their makeup depended entirely upon the decisions of the commanding officers of the hospitals from which they were derived. Some of these commanding officers simply used the opportunities thus afforded to get rid of undesirable personnel. Many of the officers who served on the teams were well trained and highly competent, but commanding officers, quite naturally, did not willingly release their best surgeons. Therefore, the teams, like the staffs of portable surgical hospitals, though competent on the whole, represented a very uneven array of talent.

Specialized Hospitals

In both Australia and New Guinea, from 1943 on, a considerable amount of specialization was practiced in hospitals. Several bases were large enough to justify the establishment of hospital centers, one or more of the hospitals being devoted to particular specialties.


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When the idea of specialized hospitals in Hollandia was first proposed by this consultant, the chief of the Professional Services Division, Office of the Chief Surgeon, USASOS, did not regard the idea as practical because of the long distances between hospitals and the extremely poor roads. The idea was revived in Leyte but again was not regarded as practical in view of the bad weather, the poor roads, and the difficult terrain. In retrospect, it seems to have been an error not to have pressed the idea more vigorously at an earlier date in the Southwest Pacific Area, in view of the excellent results obtained by this method in the Mediterranean and European theaters.

The author's suggestion that casualties be moved from Leyte and Mindanao to Manila for specialized treatment was also not accepted because the officer in charge of the evacuation section in the Office of the Chief Surgeon, USASOS, SWPA, considered that evacuation from that city to the Zone of Interior would present undue transportation difficulties. Actually, these difficulties did not occur, and failure to accept the plan was unfortunate. Because of the delay in their utilization, hospitals in Manila played no part at all in the care of combat casualties, being utilized only for staging and for the care of station hospital type patients. The hospitals in Leyte, meantime, were seriously overcrowded, and their staffs were greatly overworked.

A limited form of specialization became effective in February 1945, when casualties with chest injuries were directed, as far as possible, from Luzon to the 118th General Hospital on Leyte, while surgeons from other units were brought over, as admissions required, to this hospital on temporary duty.

It should be emphasized that the idea of specialized hospitals to handle special types of wounds, including fresh wounds, like a number of other ideas which did not win acceptance, was proposed by the theater Consultant in Surgery on the basis of his own observations and his clinical experience. The idea was rejected in an office in which planning was largely by tables and charts, and usually by officers whose clinical experience was limited and who lacked firsthand knowledge of the surgical situation in forward areas.

Equipment

The theaters of operations in the Pacific were generally regarded as the stepchildren of the war, and in a sense they were, though the vast distances and the difficulties of communication between them and the mainland always had to be taken into account. In spite of the obstacles which had to be overcome, equipment was, on the whole, very satisfactory. Smaller hospitals frequently complained of the lack of certain items, but the explanation usually was that these items were not on their tables of equipment and were not needed for the mission of hospitals on this level.

Nonstandardized items could usually be procured when a real need for them could be shown, though there was often a considerable delay before they were received.


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Clinical Research and Investigation

No outstanding surgical research was accomplished in any of the Pacific areas, in contrast to the outstanding investigations in such medical fields as malaria, dengue fever, scrub (bush) typhus, and schistosomiasis.

Original plans for the Southwest Pacific Area did not include formal research studies. The need for an organization for the correlation and encouragement of both clinical and laboratory research was, however, promptly evident, and in 1943 Col. Maurice C. Pincoffs, MC, Consultant in Medicine, USASOS, SWPA, requested, through the Chief Surgeon, that a medical general laboratory be provided for this purpose. In March 1944, word was received from the Office of The Surgeon General that such a unit would be sent to the area. Because there were a number of medical officers in the theater with interest and training in investigative work, as evidenced by their previous accomplishments, it had been requested that the laboratory arrive with certain table of organization vacancies, to be filled by these officers. This request was complied with. Inability to secure necessary priorities and other factors delayed the arrival of the unit, and it was not until August 1944 that the 19th Medical General Laboratory debarked from the United States, designated to arrive in the Southwest Pacific in September.

From the surgical standpoint, it had always been considered highly desirable that the laboratory unit coming to the area should be operated in combination with hospital facilities. After considerable discussion among the consultants involved, it was decided to use for this purpose the 250-bed 12th Station Hospital, which was duly transferred from Australia to Hollandia.

With the assistance of USASOS engineers, plans were drawn up to house the laboratory and the hospital under one roof. Plans were also made for changes and additions required to make the portable hospital buildings, suitable for use in Australia, satisfactory for scientific investigative purposes in tropical New Guinea. A high priority was secured for the large amounts of material and extra equipment required for these new purposes. The necessary items were secured through the Office of the Chief Quartermaster, SWPA, then located in Sydney, Australia, and were placed aboard a liberty ship destined for Hollandia. During this period, steps were taken to locate personnel within the area who could contribute to the project.

In spite of these careful plans, nothing came of them. Not long after the arrival in Hollandia of the 12th Station Hospital, the 19th Medical General Laboratory, and the material and equipment just described, the tactical program for the invasion of the Philippines was so stepped up that the investigative project had to be curtailed. The 19th Medical General Laboratory was, however, established as planned at Hollandia (fig. 283).

Development of Body Armor for Infantrymen

Almost as soon as the author entered service, he became interested in the possibility of protecting particularly vulnerable areas of the body by the development of some sort of body armor for the chest and abdomen of infantrymen,


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FIGURE 283.-Col. Dwight M. Kuhns, MC, Commanding Officer, 19th Medical General Laboratory, Hollandia, New Guinea, March 1945.

just as helmets had been developed for the protection of the head. In September 1942, while still in Australia, he learned that the Japanese were testing an armored vest on their troops in New Guinea (fig. 284). Eventually, after a great deal of effort in various quarters, he was able to procure a specimen vest through the kindness of the commander of an Australian destroyer. In the meantime, Col. (later Brig. Gen.) Percy J. Carroll, MC, then Surgeon, USAFFE, had been informed of this consultant's project and had expressed great interest in it.

The Japanese vest was an ingenious article. It was made of metal plates, set in canvas, was buttoned on in three overlapping sections, and weighed a little over 5 pounds. Tests showed that this vest, which was designed to protect only the anterior chest, could resist missiles shot from machineguns and pistols at velocities of 800 f.p.s. Metal construction was obviously essential. Tests with vests of plastic material available at that time showed that they were easily pierced and fragmented by the .45-caliber automatic pistol and the Thompson submachinegun.

From the Japanese model, the author constructed a protective vest made of six large overlapping metal plates that had been molded on a man 5 feet 7 inches tall and weighing 150 pounds (fig. 285). The vest covered more of the region of the collar bones, upper breast bone, flanks, and lower abdomen than the Japanese vest.


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FIGURE 284.-A captured Japanese armored vest. A. The vest open. B. The vest closed.

On 25 March 1943, the author sent to Brig. Gen. Clyde C. Alexander, USASOS, SWPA, a summary of  his studies on protective body armor. In this communication, he recommended that a vest "constructed along the lines of the captured Japanese vest" be produced for U.S. Army infantrymen. In June, upon request, he sent his set of Japanese body armor to the Chief Ordnance Officer, USASOS, SWPA. In December, also upon request, he submitted the vest which he had designed to the Chief Ordnance Officer, USASOS, SWPA, to be sent to the Chief of Ordnance, War Department, Washington.

In February 1944, upon request of Maj. Gen. (later Gen.) Nathan F. Twining, Commanding General, Fifteenth U.S. Air Force, the vest was submitted through channels to the Surgeon, Fifteenth U.S. Air Force. General Twining had become interested in it while he was a patient in the 118th General Hospital.


731

FIGURE 285.-Metal plates designed by Colonel Trimble for a protective vest.

In April, a complete set of blueprints of this vest was made in the Office of the Surgeon, Fifteenth U.S. Air Force. Also in April, at the direction of the Chief Surgeon, USASOS, SWPA, a complete report on the body armor which he had devised was submitted by this consultant to the Office of Scientific Research and Development, Washington, with an indorsement by General Denit.

On 4 August 1945, in a memorandum to General Denit, Chief Surgeon, AFWESPAC, the author summarized conferences he had had in Washington with various officers in the Office of the Chief of Ordnance, Army Service Forces, and with Brig. Gen. Edward S. Greenbaum, USA, Executive Officer, Office of the Under Secretary of War. He learned during these conferences that 8,000 vests, 4,000 in a light and 4,000 in a heavier weight, were then on their way to AFPAC by ship and that an additional 100,000 of the heavier variety would become available about 1 September. A recommendation that 400,000 more be produced without further delay had not yet been acted upon.

The surrender of the Japanese on 14 August 1945 made unnecessary the use of the protective vests sent to the Pacific. It is not likely that these vests would have proved satisfactory. They were constructed as a sort of overhead apron, with a front and back, and were very awkward to put on and take off. More important, the basic idea of protective overlapping plates had been discarded entirely.6

6The story of the development of body armor in the Pacific, with illustrations, and its subsequent development and use in the Korean War, is told in greater detail in: Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962. It is unfortunate that the wearing of protective armor was not pushed as vigorously in World War II as it was in the Korean War. The use of protective armor would undoubtedly have saved many lives.-J. B. C., Jr.


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FIGURE 286.-Red Beach, Los Negros Island, Admiralty Group, 7 October 1944.

Amphibious Landings

When the author assumed his duties as surgical consultant, succeeding Colonel Parsons, in the Office of the Chief Surgeon, USASOS, SWPA, the next military move was to be the occupation of Morotai (Operation INTERLUDE), to be followed a month later by the first Philippine operation, then planned for the island of Mindanao (Operation KING I).

Planning for Morotai operation

The experiences gained in the medical support of amphibious landings in previous operations were immediately investigated by this consultant (fig. 286). His review included not only the reports of the landings in various portions of the Southwest Pacific Area but also the reports from the European theater in which Maj. Gen. Paul R. Hawley, Chief Surgeon, had summarized the medical experiences of the D-day landings in France.

In his report, General Hawley repeatedly emphasized the outstanding part played by LST's in the provision of medical service for the invading troops. These ships were used as both aid stations and hospital ships; each of them carried an experienced surgeon, 2 young Naval medical officers, and about 20 hospital corpsmen. Hundreds of casualties from the beaches received their


733

first medical care on them. Casualties with abdominal wounds were operated upon on them, with excellent results. Ships' personnel assisted in the care and feeding of the wounded during their off-watch periods. Returning LST's transported about 90 percent of the total casualties evacuated during the early days of the operation, sometimes carrying as many as 150 to 300 on a single trip.

On 6 September and 8 September 1944, in memorandums addressed to the Chief Surgeon, USASOS, SWPA, through the Chief of Professional Services, this consultant commented on the plans for the Morotai operation in the light of the D-day experience in Europe, and made the following recommendations:

1. Medical collecting and clearing company personnel should land with the assault waves during combined operations. This recommendation was based on General Hawley's criticism that during the landings in Normandy, only the 1st Division sent its medical troops in early; the clearing company that landed with it cared for the division casualties and for casualties of combat teams on either side of it for the first 24 hours.

2. Experienced surgeons should accompany the clearing company personnel. They could be selected from the list of surgical teams, each consisting of two surgeons and six enlisted men, submitted by the Chief Surgeon, USASOS, to the Sixth U.S. Army and the Seventh U.S. Fleet.

3. LST's to serve as hospital ships, especially staffed and equipped and clearly marked to indicate their mission, should go in to the beaches as soon as the task force commander deemed it suitable. These ships should not be used for cargo purposes; they should be ready to take on patients immediately and not have to wait until their cargoes were unloaded on the beaches.

4. An experienced surgeon and two assistant surgeons should be on each LST to be used for hospital purposes. Present plans of the Seventh U.S. Fleet called for an experienced surgeon on every fifth LST and a junior medical officer, with two Navy corpsmen, on each of the other LST's. The beachmaster was to direct casualties who in his opinion needed major surgery to the LST's carrying experienced surgeons. The author considered this plan practical only if the LST's not staffed with experienced surgeons were to be used only to transport casualties from the beaches to hospital ships lying a mile or two offshore for definitive surgery. If casualties were to be kept aboard LST's for any length of time, it was essential that they be staffed by experienced surgeons. The details of the plans were not clear in this respect.

5. Portable surgical hospitals with the best trained surgical staffs (the lst, 3d, 5th, 16th, and 23d) should go ashore about the sixth wave. Evacuation hospitals would go ashore later, the time of their landing depending upon the security of the position.

6. Army surgical teams could be used to supplement Navy medical personnel aboard the LST's. The professional training of the Navy medical officers was not clearly known, but reports suggested that they had had relatively little surgical experience.


734

7. Evacuation by air of casualties given definitive care in portable surgical hospitals and evacuation hospitals should begin as early as possible. In Normandy, although no air evacuation had been anticipated before D+7 and it was not expected to be significant before D+14, air evacuation began on D+3.

8. An ophthalmologist should be available promptly, as previous experiences had shown that there would be numerous eye injuries.

9. Regularly scheduled conferences should be held by representatives designated by the Chief Surgeon, USASOS, SWPA, and the Senior Medical Officer, Seventh U.S. Fleet.

Planning for invasion of Leyte

The Morotai operation, because of General MacArthur's strategy in outflanking the Japanese, was accomplished on 15 September 1944 without casualties. Operation KING I, the landings planned for the southern Philippines, was therefore canceled, and Operation KING II, the invasion of Leyte, was advanced to 20 October 1944.

The plan was that, during the assault phase of these landings, all casualties requiring immediate hospitalization would be evacuated by assault Naval craft, APA's (attack transports) and Geneva-protected hospital ships. To accommodate the casualties, certain changes were made in the structure of the LST's and the APA's. LST's, each staffed with a surgical team of three officers, were to care for 75 litter and 75 ambulatory wounded each. LST's without surgical teams were to transport 15 litter and 15 ambulatory wounded each. APA's with four medical officers were to transport 150 litter and 250 ambulatory wounded each. Naval medical personnel were to provide definitive surgical care to casualties en route from the target area to the New Guinea bases.

This consultant, with the approval of General Denit, visited the Senior Medical Officer, Seventh U.S. Fleet, several weeks before A-day, to review with him the plans for care of the wounded and the professional qualifications of the Army and Navy medical officers scheduled to provide definitive care. As already mentioned, the records indicated that most of them had little or no surgical training. The Senior Medical Officer had no detailed record of the professional qualifications of the Navy personnel assigned to this duty, but he stated that he was certain that they were competent. He added that some of them were lieutenant commanders. The offer made by the author, on behalf of General Denit, to supply experienced Army surgeons for duty on the LST's and APA's was declined.

The elaborate system planned for the Morotai operation by the Navy had been further expanded for this operation. The wounded would be transferred to the LST's with due regard for the nature of their wounds and the specialized personnel aboard the ships, whose presence would be indicated by different kinds of flags. The beachmaster was to decide where the individual casualty belonged and was to start him on his way to the appropriate ship.


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The difficulties in this plan seemed obvious, and the author pointed them out. They included the extent of the beaches; the confusion of battle, which would make identification of particular LST's difficult if not impossible; the frequent multiplicity of wounds, which would make it difficult for a lay person to decide which of the injuries was the most important; and the possibility of hostile air attacks. It was thought that all of these conditions would so complicate this specialized plan of triage as to make it impractical, as indeed it proved to be.

On 5 October 1944, in another memorandum to the Chief Surgeon, USASOS, SWPA, the surgical consultant stated that the Navy planned to use LST's for hospital purposes only after the cargo was removed. He recommended, as in an earlier memorandum, that these ships should be in the landing force, ready to receive casualties immediately and not after the removal of their cargo, since a very large number of casualties might well occur during the assault on the beaches. He also recommended again that every LST, instead of every fifth ship, carry an experienced surgeon pointing out the efficiency of this plan in the Normandy landings. He recommended that several portable surgical hospitals, staffed with experienced surgeons, be placed on the LST's which would act as hospitals during the invasion. He further  recommended that the portable hospitals serve as hospitals throughout the landing operation.

Report on Leyte invasion

ETMD reports from the Southwest Pacific Area for December 1944 described the early surgical care during the Leyte invasion as follows:

In the first phase of the landings, casualties injured on landing craft, after being given primary care, were transferred to LST's and attack transports staffed with surgical teams (fig. 287). Those injured on shore were treated by battalion and regimental aid stations; they were given plasma as necessary, and the usual first aid measures were carried out (fig. 288).

As the task force units moved inland, medical collecting and clearing companies began to function. Casualties received primary treatment almost immediately after wounding, and then, with little delay, were put aboard LST's, where blood was available and definitive surgery was undertaken. Although seven LST's were offshore on D-day with surgical teams aboard, only two were primarily hospital ships. The others could not take over the care of patients until their cargoes were landed. Attack transport ships could be unloaded faster than LST's, and they were therefore the first ships to leave Leyte with casualties.

The 7th Division Clearing Company was ashore by H+6 and performed approximately 150 definitive operations within the next 48 hours. From D-day until D+4, however, most definitive surgery was done on Navy craft


736

FIGURE 287.-An American casualty being loaded aboard ship in Leyte Harbor, 20 October 1944.

offshore. When the wounded were near the beach, the timelag between wounding and first aid was a matter of minutes. The wounded were then carried almost immediately to LST's for definitive surgery, which sometimes was done within 1 or 2 hours after wounding.

In the second phase of the invasion, the distance ashore along which the LST's were distributed was greatly increased, and the perimeter extended as much as 15 miles in depth. Mobile aid stations and clearing stations were kept well up near the line, and, at first, the wounded received both first aid and definitive care promptly. As the distance to the beaches increased, 12 hours sometimes elapsed before definitive treatment on an LST followed primary care (fig. 289). Torrential rains, in addition to distance, played their part in the increased timelag.

The ships that had taken part in the original operation soon became crowded, and some were sent back to the bases well loaded. Not enough then remained to take care of casualties from the shore as well as the considerable number wounded in the harbor in the Japanese suicide raids. Later, it was possible to evacuate casualties to APH's (transports for wounded) and hospital ships.


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FIGURE 288.-First aid measures being carried out at an aid station on the beach at Leyte, 20 October 1944.

FIGURE 289.-A difficult litter carry on Leyte, inland from the beach.


738

FIGURE 290.-The 58th Evacuation Hospital at Tacloban, Leyte, Philippine Islands, 26 October 1944.

In the third phase of the landings, field and evacuation hospitals were set up; the 58th Evacuation Hospital (fig. 290) was in full operation in a school in Tacloban on D+4 and had begun to function 48 hours earlier. Some hospitals were delayed in opening because the tactical situation did not permit unloading of their equipment.

After D+6, most definitive surgery was done in hospitals on shore (fig. 291). In order to keep beds clear for casualties, the hospitals continued to evacuate patients from rear areas to the LST's, where they remained until hospital ships arrived; if a hospital ship was in the harbor, patients were taken directly to it. Air evacuation to New Guinea and Saipan began on D+6 and was in regular operation after D+16 and D+21, respectively.

The landings at Leyte presented a problem not encountered in any previous amphibious landings in the Southwest Pacific; for 38 days, large numbers of casualties continued to occur in the harbor, from bombing and strafing by enemy planes. Both first aid and definitive care for these casualties were supplied by LST's, APA's, and APH's. In the remaining landings on the Philippines, the care of casualties during the assault phase was relatively simple because all enemy airfields within operating radius had been effectively destroyed by U.S. Navy and Army Air Force planes before the landings.


739

FIGURE 291.-Definitive surgery in a portable surgical hospital, Leyte, Philippine Islands.

LST 464, which had been converted for hospital purposes, and LST 1025, which had a surgical team aboard but had not been converted, carried heavy surgical loads from D-day on (fig. 292). These two ships, the Sixth U.S. Army surgeon stated, "saved their lives" before sufficient hospitalization was set up ashore to care for the casualties of the invasion.

This consultant, after his experience at Leyte (p. 712) , concluded that the LST, properly altered, admirably fulfilled the needs created by the new tactical situation that had developed there. The great advantage was that, when it was thus altered, it was primarily a hospital ship-not a cargo ship, used secondarily for hospital purposes. It could therefore remain on station in the harbor and be available for use at all times. A large hospital ship in the harbor would have served the same purposes, but the risk of its being hit, with a resulting heavy loss of life, made such an arrangement unwise.

Planning for invasion of Japan

Preliminary medical planning for the projected OLYMPIC and CORONET invasions of the Japanese islands were begun by General Denit's directions in May 1945. The first of these landings, on Kyushu, was scheduled for 1 November.

On 8 May 1945, the author addressed a memorandum to General Denit, a summary of which follows.


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FIGURE 292.-An LST handling a surgical load during the Leyte invasion. A. An operating room set up in troop quarters on the middle deck. B. A treatment station on tank deck.


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FIGURE 292.-Continued. C. Casualty scuttle from tank deck to surgical teams in troop quarters. D. Litter arrangement in troop quarters.


742

An amphibious landing anywhere within range of undestroyed Japanese air bases would be attended by daily attacks of enemy planes upon allied troop and supply ships. Resulting casualties would be heavy. LST's and APA's with surgical teams aboard would take care of casualties on D-day through D+2, but then after having discharged their cargoes, they would pull out, and their surgical teams would no longer be available. Large hospital ships of the Geneva type would run too much risk by remaining in the harbor. The establishment of hospitals on shore would not solve the whole problem, for distances would be great, landing on beaches often difficult, communications poor, and transportation scarce for some time.

This situation was first encountered on Leyte (p. 738). Immediately after that operation, recommendations were made by the Office of the Chief Surgeon, USASOS, SWPA, at this consultant's suggestion, to The Surgeon General by letter and to the senior medical officers of the Seventh U.S. Fleet and 7th Amphibious Force, by interview, that multiple small ships, of the station hospital type, based on the LST 464 model, be maintained in the harbor at all times in all similar future operations. Lessons from the invasion of Leyte and from the Okinawa operation, then in progress, indicated that renewed and stronger representations should be made for greatly increased numbers of this type of hospital ship to care for Army and Navy casualties in all future combined operations.

On 10 May 1945, this consultant sent to General Denit a statement from the Basic Concept of Operation OLYMPIC and pointed out that it was not clear in it whether the 15 LST's planned as a minimum were to be equipped as hospital ships, like LST 464, and would be staffed to render definitive care. The statement that they would "administer emergency treatment and sort patients for further evacuation" implied the contrary.

The author recommended that these points be clarified. In his opinion, repeatedly expressed, the value of these ships rested entirely upon (1) their availability in the harbor day and night, and (2) the provision on them of adequate equipment and competent staffs to provide definitive major surgical care. On 14 May, the Medical Section, General Headquarters, concurred in the proposed use of the LST's; those ships whose primary function was to provide definitive surgical care would be differentiated from those with minimal equipment and surgical teams.

On 28 June 1945, in response to a request from the G-4 Section, General Headquarters, AFPAC, to General Denit, this consultant and Lt. Col. (later Col.) Harold A. Sofield, MC, orthopedic consultant in the Office of the Surgeon, AFWESPAC, submitted recommendations for General Denit's approval and transmission to the G-4 Section, General Headquarters, AFPAC. A summary of these recommendations follows.

1. The use of the LST as an auxiliary hospital ship is of the greatest importance in the care of casualties sustained in an assault landing; in the care


743

of casualties sustained on shore for the first 2 or 3 days, while hospitals are being established; in the care of casualties sustained on ships during the ensuing days or weeks as the result of enemy air attacks; in evacuation parallel to the beach when roads are obstructed; in triage of the wounded; and in the maintenance of a supply point for whole blood and medical supplies.

2. The proposed role of the LST in the forthcoming operation should be clarified. At this time, it is not known whether the LST's to be used will be of the hospital type, such as LST 464, or only secondarily for hospital use, such as LST 929. It is also not known whether the LST will act as a hospital ship primarily; will carry troops and cargo and, after unloading, accept patients for definitive major surgery while transporting them to a rear base; or will act as a sorting station and evacuation point and be used for definitive surgery as an emergency measure only. If the plan is to use the Geneva type of hospital ship employed at Leyte, which retired from the combat area as soon as casualties were received, a number of LST's of the 464 type should be provided, to function as station hospitals in the harbor and provide specialized care for harbor and beach casualties. If attack transports are to be employed as hospital ships and remain with the assault shipping, they would provide definitive care for these casualties, and the LST's could be of the 929 type, functioning as sorting and evacuation points and doing only emergency definitive surgery.

Previous experience has shown that two LST's per assault division are necessary to provide minimum coverage. If the APA's are to retire from the assault shipping, LST's of the 464 type should be provided in the ratio of two ships to one of the 929 type. If the APA's are to remain in the area, this ratio could be reversed. The number of LST's specified would be in addition to those equipped and staffed to transport wounded from the target area back to a base area.

3. A careful study should be made of the professional qualifications of surgeons designated to do definitive surgery. Army personnel should be freely offered to the Navy when additional experienced surgeons are needed. The experience of the Normandy landings showed that one experienced surgeon and two assistants should be on each ship on which definitive surgery is to be performed. The surgical personnel of all Army APA's should be carefully reinterviewed and strengthened by the Surgeon, Port of Embarkation, San Francisco. If, in the opinion of the surgical consultants, these staffs are not adequate, surgeons from AFWESPAC should be placed on board on recommendation of the Chief Surgeon.

On the recommendation of this consultant, Col. Douglas B. Kendrick, Jr., MC, who had inaugurated the blood program in the Office of The Surgeon General and who was then serving as consultant in blood and transfusion with the Tenth U.S. Army on Okinawa, was placed on temporary duty in General Denit's office, to make plans for the supply of blood for the invasion of Japan. Colonel Kendrick was also to organize auxiliary blood banks in Manila and


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on Okinawa to supplement the supply from the United States via Guam in case difficulties of transportation reduced the supply. Lt. Col. Mark M. Bracken, MC, Chief of the Laboratory Service, 27th General Hospital, was placed on temporary duty to work with Colonel Kendrick on the implementation of these plans.

Colonel Bracken was also directed to form medical teams, each consisting of two medical officers and four enlisted men, from the general hospitals in the theater, to serve as shock teams in field, portable surgical, and evacuation hospitals, and clearing companies. This was an entirely new idea in the Southwest Pacific Area, suggested by the surgical consultant to increase the usefulness of the surgical teams by removing some burdens from them, so that they could pursue exclusively their work of operating on the wounded.

The planning for the invasion required a knowledge of troop strengths, military objectives, the nature and amount of medical support, the airfields to be designated for evacuation, the naval plans, and other vital data. General Denit's office was given free access to all information, and the medical planning was based on full military knowledge.

The surrender of Japan in August 1945 made it unnecessary to continue the planning for Operation OLYMPIC. Planning for Operation CORONET had not yet begun. To show, however, the immense size of the projected medical support, as well as the variegated duties and opportunities of a consultant to help in the whole theater planning, the following memorandum for General Denit, prepared by this consultant in Washington on 4 August 1945, is quoted:

My dear General:

1. In my notebook marked "Surgery", which I have left with Colonel Baker, is the latest information on such items as Blood Plan, Briefing of Hospitals, Body Armor, Hospital Personnel Equipment, Task Force Study, and Trench Foot.

a. In the Whole Blood Plan, Major McGraw of The Surgeon General's Office made certain suggestions, as are attached [not reproduced]. A letter from Colonel Robinson to you states that the Navy will cooperate in every way with Kendrick's plan.

b. I have talked with Colonel Studler of the Ordnance Dept. about Body Armor. A Major Shaw from his office, and a Captain of Infantry, are already in Manila with samples of armor. With Colonel Voorhees I interviewed General Greenbaum in the Office of the Secretary of War. After the conference General Greenbaum prepared a radio for General Somervell's signature addressed to General Styer of AFWESPAC, stressing the favorable opinion of the War Department about the armor and asking for early information as to the Theater's needs for it. The latest information on the subject is contained in my file.

c. Information on the Hospital Equipment problem which you asked me to take up is contained in this file also in a letter to you from General Bliss on the subject.

d. Personnel. Satisfactory arrangements have been reached about surgical consultant personnel, and Colonel Carter is having their orders cut. The 5th Surgical Auxiliary Group should be in the Theater at the present time. Hospitals arriving in the next few months are:


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Hospital

 

Expected Date of Arrival

Evacuation

5 (Five)

August

Field

10 (Ten)

August

Station (250 Bed)

3 (Three)

August

Auxiliary Surgical Group

1 (One)

August

Evacuation

6 (Six)

September

Convalescent

1 (One)

September

Clearing Companies

16 (Sixteen)

September

Collecting

5 (Five)

September

Ambulance

16 (Sixteen)

September

General (1,000 Bed)

41 (Forty-one)

September

Station (750 Bed)

5 (Five)

September

Station (500 Bed)

16 (Sixteen)

September

Evacuation

9 (Nine)

October

General

10 (Ten)

October

Medical Professional  Group

1 (One)

October

Station (500)

4 (Four)

October

Evacuation

5 (Five)

November

Station (500 Bed)

1 (One)

November

General (1,000 Bed)

41 (Forty-one)

"Later"

The importance of sending personnel in advance of T/O hospitals to which they are attached was emphasized to Dr. Ginsberg. He was likewise advised of the urgent need to send replacements for medical officers in the Pacific with three or more years' service overseas. Three hundred and fifty (350) medical officers from the European Theater have been discharged from the service, although they do not have so high a number of service points as do officers still left in the Pacific Theater. In spite of Congressional pressure, it would be fairer to keep men from the European Theater in the Army on duty in the Z.I. to release men from the Z.I. to go to the Pacific as replacements.

e. Task Force Study. One of the points which I asked Colonel Robinson and Colonel Kendrick to try to settle in our absence from Manila was the consent of the Navy to use Army surgical teams on ships carrying battle casualties not staffed with experienced surgeons. In a recent communication to you from Colonel Robinson it is stated that the Navy has agreed to this arrangement. The date of arrival of Geneva Convention hospital ships at the target has not yet definitely been established.

f. Trench Foot. Colonel Gordon and Major Shaw from The Surgeon General's Office are already in Manila. Colonel [Gordon] was Chief of Preventive Medicine in ETO.

Postsurrender Responsibilities

The Japanese surrender

Almost immediately after the first U.S. troops landed in Japan and assumed their occupation duties, General MacArthur issued an order directing them to carry no firearms. Events proved the wisdom of this directive. The surrender of Japanese troops was so complete and so final that neither mass nor isolated acts of violence occurred after it. As a result, there were no more battle casualties, and occupancy of surgical wards consisted of patients injured in traffic accidents and street fights. Burns from gasoline-driven equipment were also frequent.


746

FIGURE 293.-The 49th General Hospital (formerly St. Luke's Hospital), Tokyo, Japan.

This consultant's chief problem after the surrender was to spread available surgical personnel, with adequate training and experience, over the larger Japanese islands of Honshu, Kyushu, and Hokkaido, as well as Formosa and Korea. This became his responsibility when he was transferred, late in October 1945, from the Office of the Surgeon, Headquarters, AFWESPAC, to the Office of the Surgeon, Headquarters, AFPAC. Early in December, he proceeded from Manila to Advance Echelon, AFPAC, in Tokyo, from which point he visited all the U.S. Army hospitals in Japan from the most northern at Sapporo on Hokkaido to the most southern at Sasebo on Kyushu (fig. 293).

At this time, the pressure for discharge of troops and other military personnel had begun to be applied in the Zone of Interior, and the process which General Eisenhower was later to describe as "demobilization by demoralization" had already begun. Specialists were in exceedingly short supply, and great care had to be exercised to utilize them wisely. The rapid transportation of patients to centers in which specialists were available or the movement of specialists to isolated areas to meet major emergencies was not practical because of poor roads, indifferent rail service, and closure of all air service during the winter. This made it necessary to staff more hospitals than would otherwise have been required with surgeons who were capable of giving definitive care


747

in the event of major emergencies. It was a wasteful use of personnel but was the only possible plan under the circumstances.

One of the principal emergencies after the occupation of Japan was motor traffic accidents, which were frequent and serious on the narrow, poorly lighted roads traversed by a population untrained in the alertness and rapid reflexes required by modern motor cars. In November 1945, admissions from this cause were at an all-time high. At one time, traffic accidents accounted for 38 percent of all surgical admissions at the 165th Station Hospital, with compound fractures heading the list. It was not unusual to receive 5 or 10 patients at a time over the weekend, as the result of a single accident. On one occasion, 38 Japanese prisoners of war were received en masse when the vehicle in which they were being moved was overturned.7

Obligation in the Philippines

An unfortunate result of the rapid withdrawal of U.S. Army troops from the Philippines at the end of the fighting in the Pacific was the hardship it worked on the Philippine Army, including the Scouts. Medical care of these troops was very poor at this time, as was the medical care of guerrillas and civilians, because of the almost total destruction of medical services during the Japanese occupation. Those who were aware of how many American lives had been saved by Filipino troops and civilians, often at great cost to themselves, were much disturbed by the situation.

After observing these conditions, this consultant made certain recommendations to the Surgeon, AFPAC, 7 December 1945, as follows: (1) Provision of additional technicians to supplement the single technician then working in the braceshop set up in the 313th General Hospital in Manila; (2) provision of additional technicians to instruct Philippine Army personnel in the operation of the braceshop sent to the Philippine Army from the Zone of

7Colonel Trimble, as a result of these experiences, considered the whole question of traffic accidents so serious that, on his return to the Zone of Interior in the spring of 1946, he addressed a memorandum on the subject to The Surgeon General, through the Director, Surgical Consultants Division, Office of The Surgeon General. In it, he pointed out that at the time of writing traffic accidents were responsible for the great majority of deaths within the Army, for the largest proportion of seriously ill patients in hospitals, and for an incalculable amount of morbidity and permanent deformity. These accidents, he continued, were largely preventable, and, while accident prevention was a function of the Provost Marshal's Office, he believed that the Medical Department should assume a share of the responsibility, if only because of its responsibility for the management and end results of these injuries.

Colonel Trimble recommended that a special committee be appointed, under the jurisdiction of the Preventive Medicine Division, Office of The Surgeon General, to study the problem along epidemiologic lines and to formulate definite and vigorous directives based upon the findings of this study. The memorandum concluded with the statement that, since commercial transportation companies were able to hold their drivers to strict accountability in the matter of accidents, it was unrealistic to assume that the Army, with its far tighter control and discipline of personnel, could not achieve even better results. A similar program had been effective in the Southwest Pacific Area when it was set up in the fall of 1944.

No action was taken on these recommendations, on the ground that in the Zone of Interior safety committees were already in existence at each post and station and that a medical officer with advisory responsibility was usually assigned to them.-J. B. C., Jr.


748

Interior; (3) transportation of the 20-odd Scouts then in need of prosthetic appliances to amputation centers in the Zone of Interior, for necessary plastic procedures and fitting of prostheses; and (4) provision of a supply of prostheses, with a fully trained technician to take the measurements for them, to provide for personnel in the Philippines in need of surgical care after amputation.

It was not considered possible to implement these recommendations at this time, but later, in April 1946, a complete unit was sent by The Surgeon General to establish an amputation center for Filipino personnel.

Japanese Prisoners of War

Until the invasion of the Philippines, U.S. Army medical officers had no extended contacts with Japanese prisoners of war. This was partly because prisoners were not taken in large numbers and partly because they were chiefly the responsibility, from the medical standpoint, of the Australian Army Medical Department. As the number of prisoners increased, large camps to handle them were established on Leyte, Luzon, and the smaller islands of the Visayan group. American medical officers were then detailed to these camps.

Management of a typical camp

Since all prisoner-of-war camps were managed on the same general plan, the experience of the 174th Station Hospital may be cited as typical. This hospital took over hospital facilities at New Bilibid Prison from the 21st Evacuation Hospital on 2 June 1945. The report from which most of the following data are summarized was prepared at the request of this consultant by Maj. Joseph T. Kauer, MC, chief of the surgical service.8 Other data have been obtained from the report of the official inspection of the station hospital at the prison on 2 and 3 November 1945 by a committee of medical officers of which the author was a member.9

The experience at this camp may be accepted as typical of the experiences of all similar camps.

During the peak of activities after V-J Day, additional facilities had to be provided at Luzon Prison Camp No. 1 at Canlubang, 5 miles away from New Bilibid, and the personnel of the 174th Station Hospital had to be augmented by personnel from the 136th General Hospital (fig. 294). When the facilities were enlarged, the policy was set up of treating all surgical patients and all of the more seriously ill medical patients at New Bilibid. Other medical patients and convalescent patients were assigned to Canlubang. Medical, surgical, and neuropsychiatric patients were segregated.

8Essential Technical Medical Data, U.S. Army Forces, Pacific, for October 1945, appendix E, subject: Medical Experiences in Luzon P.O.W. Camp No. 1.
9Col. I. R. Trimble, MC, Surgical Consultant, for Army Forces, Pacific, through Surgeon, Base X, and Chief Surgeon, Army Forces, Western Pacific, 7 Nov. 1945, subject: Surgical Care Afforded Japanese Patients at the 174th Station Hospital, New Bilibid Prison, and at POW Camp No. 1 (Canlubang).


749

FIGURE 294.-Prison Camp No. 1 at Canlubang, Luzon. A. Colonel Trimble (second from right, standing), inspecting the condition of a patient. B. Medical supply.


750

FIGURE 295.-Japanese prisoner patients and ward attendants in New Bilibid Prison, Luzon.

New Bilibid Prison, located 21 miles south of Manila was a Commonwealth of the Philippines institution, built in 1936. The long building in which professional activities were housed and which had formerly been used as a hospital contained 4 wards of 75 beds each; 3 general operating rooms; an operating room for orthopedic surgery; a supply room for sterile supplies; the X-ray department; the dental clinic; and the laboratory and pharmacy (fig. 295). Sewage facilities were modern and the water supply was adequate. This was generally true throughout the camp, even in the tented areas; improvisations were only occasionally necessary.

Between 2 June and 31 October 1945, 10,684 prisoners of war were admitted to the hospital at New Bilibid. The peak census was 5,672 in October. These patients were predominantly Japanese, with a small proportion of Formosans and Koreans. During this same period, 56,000 prisoners of war and internees were confined in 11 compounds at Canlubang. At the peak, the daily average sick call was 12,500, chiefly for skin diseases, malaria, and beriberi.

Surgical equipment and instruments were those standard for a U.S. Army station hospital. Medications were drawn from the standard Army supplies provided in medical depots. Routine laboratory examinations were performed at the prison. Specimens for special or complicated tests were sent to the 19th Medical General Laboratory in Manila. All inmates of both camps received rations equivalent to those given hospitalized American soldiers. Multivitamin powder was included in all diets, and additional vitamin therapy was prescribed as indicated (fig. 296).


751

FIGURE 296.-The serving of a meal at Prison Camp No. 1, Canlubang, Luzon.

Professional personnel

At a typical peak time during the operation of New Bilibid and Canlubang camps, the professional surgical personnel at New Bilibid consisted of a chief of service with a rating of "B-3150," a surgical ward officer, a radiologist, an anesthetist, and two Dental Corps officers. The hospital census rapidly outstripped the ability of U.S. Army personnel to care for it. At one time, only two medical officers were caring for 1,900 patients, many of whom were critically ill.

To meet the shortages in personnel, Japanese medical officers, nurses, and corpsmen were pressed into service as rapidly as possible. Before V-J Day, there were only eight Japanese physicians at the prison; they had been taken prisoners when their hospital ship, which was functioning as a troop transport, had been captured in the East Indies. During the peak period, 117 Japanese medical and dental officers were utilized in both camps. Of the 58 officers assigned to New Bilibid, 28 ranked as surgeons, although only 8, including a well-trained otolaryngologist, an ophthalmologist, a gynecologist, and 2 dentists, had had any appreciable training according to American standards.

Physicians - Japanese techniques differed widely from those employed in the United States, and the Japanese approach to all medical problems also differed widely. The physicians paid much less attention to history taking than American physicians. They were inclined to group all illnesses into


752

broad general categories according to the presenting symptoms. Physical examinations were cursory, and, until the Japanese medical officers were taught otherwise, they examined dirty surgical cases only at a distance, regarding any other course as beneath their professional dignity. Their approach to all surgical problems was stereotyped, and they were influenced by their past general experience far more than by an independent consideration of the physiological and pathological features of the special case under consideration.

Japanese physicians needed a great deal of education in operating room techniques, beginning with the preservation of sterility. They were familiar with techniques of local and spinal analgesia, but only two or three had ever seen intravenous anesthesia administered, and none of them had had any personal experience with it. They were also unfamiliar with modern anesthetic machines. They were ignorant of the indwelling nasal catheter, continuous intestinal decompression, and closed drainage in empyema.

Penicillin meant nothing to them either as a name or as a therapeutic agent. They used sulfonamides according to standard practices but did not hesitate to place sulfathiazole powder into direct contact with nerve tissue. The use of whole blood and plasma in malnutrition and the use of plasma for burns and hypoproteinemia were outside of their experience. They relied on physiologic salt solution for intravenous therapy and treated shock by the intravenous administration of camphor. Burns were treated by the tannic acid method.

All of these practices were obviously based on German medical practices in vogue 40 years earlier. When they were discussed with them, the Japanese officers repeatedly made the point that these practices were far more suited to their economic status than the modern and elaborate system brought back by the occasional physicians who had received their training in the United States. Their interest in these modern practices was, however, intense. They fully realized that Germany was no longer the fountainhead of medical knowledge and that the pace of professional attainment in the immediate future would be set by the United States.

Nurses.-Nurses were in such short supply at New Bilibid that even when they were augmented by Japanese nurses, they could be assigned only to wards in which surgical patients and the most seriously ill medical patients were cared for. The work of these Japanese nurses was generally satisfactory. The seven nurses who had been trained at St. Luke's Hospital in Tokyo and who were used in the operating rooms compared favorably, in training and ability, with U.S.-trained nurses.

Clinical considerations

The prisoners of war received at New Bilibid Prison fell into two general groups, those received before the Japanese surrender and those received later. Many of the patients admitted to the hospital wards before V-J Day came from U.S. Army hospitals, and their good condition was in marked contrast to the status of the prisoners taken directly to the prisoner camps, most of whom were


753

in poor nutritional condition by U.S. standards. Of the 2,395 surgical patients, about 50 percent had sustained gunshot wounds of various types without fractures; 14 percent had gunshot wounds with fractures associated with osteomyelitis.

After V-J Day, combat wounds became increasingly less frequent, and the chief patient load consisted of civilians, including women and children, some 300 or 400 of whom came out of the Luzon hills each day. All of them were placed on suppressive Atabrine (quinacrine hydrochloride) treatment for malaria as soon as they were admitted. Many of them were suffering from irreversible nutritional and deficiency diseases. Their condition suggested that of inmates of German concentration camps, and numbers of them died within a few hours of admission.

Surgical conditions - None of the patients with combat-incurred wounds had received adequate care by U.S. Army standards. No wounds had been debrided, and all degrees of suppuration and gangrene were observed. Fractures, if they were splinted at all, were immobilized only crudely, with bamboo splints. Very few combat-incurred wounds could be managed by early secondary closure, regardless of the time at which they were seen, because of the patients' general status. Malnutrition and deficiency diseases presented a most unfavorable background for the management of all surgical conditions. The treatment of these diseases, in fact, had to take precedence over all but the most dire surgical emergencies.

Anemia and hypoproteinemia, even after intensive therapy, retarded the response to ideal surgical management. Whole blood was used liberally in these cases, donors being obtained from healthy prisoners of war on work details. Women and children with severe hypoproteinemia were treated by plasma transfusions. There were no serious reactions to these methods.

A few late closures of combat-incurred soft-tissue wounds were done with good results, but most wounds of this kind were handled better by skin grafting than by excision and closure. Results of skin grafting were, surprisingly, about as good as among U.S. Army casualties.

A number of cases of tetanus developed, as was to be expected under the conditions. Two patients died from this cause a few hours after they had been admitted, and there were two other later deaths in the remaining thirteen cases. Therapy was by standard measures.

There were also four cases of gas gangrene, one of which was fatal. One of the remaining patients required amputation of the leg, but the other two responded to wide incision, in one instance of the lower leg and in the other of the upper arm. All of these patients received antitoxin.

As a matter of necessity, most surgery after V-J Day was done by Japanese medical officers, U.S. Army surgeons limiting themselves to the most serious procedures, such as intestinal surgery. During the June-October period of the operation of the camp, there were 110 major and 706 minor operations, and 245 casts were applied. The lack of surgical experience and judgment of Japanese medical officers was reflected in the 33 appendectomies done by them


754

in October for supposed acute disease. Only 11 of these patients really had acute appendicitis, and the elementary notion of aseptic technique possessed by the Japanese surgeons was evident in the 12 percent incidence of infected wounds.

Beriberi abscess - An entirely new clinical entity (new, at least, to U.S. Army medical officers) was observed in many of these patients, so-called beriberi abscess. The infection, which occurred on the lower extremity, usually in the anterior tibial area or on the dorsum of the foot, began as an extremely soft, fluctuant swelling. Neither rubor nor calor was present, and tenderness was not significant. When the swelling was incised, subcutaneous pus was released; only in longstanding cases was the fascia involved. The pus was thick, yellow, and of the typical Staphylococcus type, but the etiology was not established, for the circumstances were not favorable for bacteriologic studies and none were made. The abscess cavity was lined with necrotic subcutaneous tissue, and in no instance could a definite wall be demonstrated.

As a rule, these abscesses appeared in extremities that were or had been the site of serious nutritional edema; in two instances, the edema was so intense that necrosis of the skin occurred. Their etiology was never clarified. It was concluded that edema, although it was probably not an essential predisposing factor, apparently favored the growth of organisms which had entered the skin by way of the abrasions and scabietic lesions so prominent among these patients.

Evaluation of medical care

Upon orders of the Chief Surgeon, AFPAC, the prison camps at New Bilibid and Canlubang were visited on 2 and 3 November 1945, by a committee of medical officers consisting of Col. Albert R. Dresibach, MC, chairman; Lt. Col. Clarke H. Barnacle, MC, recorder; and the author.10 The objective of the inspection was to determine whether the medical care and general treatment of sick and wounded Japanese prisoners of war and internees at these installations accorded with the provisions of the Geneva Convention. The committee report was entirely favorable; both medical care and general treatment, including the diet provided, fully conformed with these provisions. Not a fly was seen in either camp.

The findings of this committee were in agreement with those of Brig. Gen. Hugh J. Morgan, and Col. Francis R. Dieuaide, MC, who had visited the camps previously as representatives of The Surgeon General, U.S. Army.

These formal reports confirmed the information obtained on informal attempts to gain some idea of the attitude of the patients in the camps toward U.S. Army personnel and of their reaction to the treatment which they were receiving. Interpreters were directed to make inquiries along these lines at times when U.S. medical officers were not on the wards and were also instructed to report on conversations among the patients.

10See footnote 9, p. 748.


755

Without exception, the patients were very grateful. Some said that discipline in the U.S. Army must be very strict, since they had never seen a commissioned or a noncommissioned officer strike a patient. Many expressed amazement that American medical officers themselves examined and dressed their wounds; in the Japanese Army, this was the duty of the corpsmen. They also expressed amazement that American medical officers answered night calls.

These and other instances of what Western physicians conceive of as only normal medical care were to these prisoners signs of kindness and consideration which were evidently unique in their experience. Their army training had led them to expect only brutality and neglect from their own nationals, and propaganda had led them to expect the same kind of treatment from their U.S. and other Western conquerors.

Lessons of the Pacific Fighting

Certain conclusions set down by the surgical consultant in the Southwest Pacific Area after his return to civilian life may be summarized as follows:

1. It is strange that such an obvious principle as that of early and expert definitive surgical care was not automatically adopted at the beginning of World War II, when experts in the various surgical specialties joined the Army in such great numbers. It was slow to be adopted in the Southwest Pacific Area, chiefly because the value of the consultant system was slow to be realized. Consultants were assigned to headquarters in the smallest possible numbers. There were no consultants to the armies operating in the Southwest Pacific until after the landings on Leyte, in October 1944. The surgical consultant in the Southwest Pacific Area was permitted to participate in the attack on Leyte but was refused permission to accompany the transports in the attack on Luzon. More intimate contacts between theater and Army consultants and surgeons would have enhanced the efficiency of medical care of casualties.

2. At the beginning of the war, there were only a handful of expertly trained clinical surgeons in the Regular U.S. Army. To the end of the war, there was still a scattered lack of appreciation of the difference between a medical officer designated to do surgery and a medical officer trained to do surgery. In the Pacific, at least, there was only slow realization of the extreme importance of the wisdom of sending experienced surgeons of mature judgment unto forward areas and assigning younger, less experienced surgeons to base hospitals, where they could work under supervision.

3. The chief duty of the surgical consultant in the Southwest Pacific Area was the assignment of good surgeons to serve as chiefs of surgery in the portable hospitals supporting the various landings. This was an extremely difficult task because of the paucity of well-trained surgeons in the Pacific; practically all of them were sent to the Mediterranean and European theaters, or were in the Zone of Interior.

4. The vast distances in the Pacific greatly complicated medical care of casualties. Sometimes 2,600 miles separated the target area and the point from


756

which an operation was mounted. In hops to small, isolated islands, there was no such thing as a chain of evacuation. Definitive surgical care had to be given on the spot. Specialized hospitals were accepted as a practical possibility only after the Philippine invasions.

5. Distances in the Pacific also made communication extremely difficult. Brig. Gen. Elliott C. Cutler, MC, Chief Consultant in Surgery, Office of the Chief Surgeon, European Theater of Operations, U.S. Army, stated that he could sit at his desk at headquarters in London and within a few minutes reach by telephone the commanding officer of any hospital in England or on the Continent. In the Pacific, even radio communication was not possible, and most business had to be conducted by mail. Attempts to transfer medical officers might take a month or more. A visit by plane to hospitals in the various bases might take a minimum of 2 weeks, partly because of waiting for priorities and the vagaries of the weather; the visit itself was likely to consume the smallest part of the time period.

6. Evacuation of casualties in the Pacific fighting was always a problem. Portable surgical hospitals were sometimes miles ahead of the artillery pieces going into the jungle. The hospitals would follow the infantry and set up a few hundred yards from the enemy. Evacuation was necessarily a complicated process. It was first by litter, sometimes borne by natives but more often by Army litter bearers because the natives did not like to go forward. Then native litter bearers would take over later. Sometimes, evacuation was by ox-drawn cart or by amphibious vehicle.

Air evacuation, which was an outstanding success and solved many of the problems of transportation in the Pacific, came late in the war.

7. Surgical teams were proposed very early in the Pacific fighting by Colonel Parsons, first Consultant in Surgery in the area, but the plan was not accepted until April 1944. Auxiliary surgical groups never served in the Pacific; all of them were sent to the Mediterranean or European theaters. Portable surgical hospitals helped to solve the problems of forward care of casualties but did not prove an entirely acceptable solution. Specialized hospitals, as already mentioned, were not permitted until the Philippines were invaded and never really fulfilled their possibilities.

8. The difficulties of surgical care of casualties in the climate, terrain, and vast distances of the Pacific areas were probably never fully realized in the Office of The Surgeon General because there were no really intimate contacts between that office and the Pacific. The single visit, during the course of the hardest fighting, was by the Consultant in Surgery in that office and was very brief. The only other visit, by The Surgeon General, was also brief and did not occur until after the Philippines had been almost secured.

9. The difficulties under which medical care was accomplished in the Pacific are unlikely to occur again. For one thing, the value of the consultant system is now fully appreciated in the Medical Department of the Army and is firmly established in it. For another, the Medical Department has set up


757

residencies in its largest hospitals in the various specialties and is thus assured of a supply of fully trained medical officers in the event of another emergency.

10. Far and away the most valuable surgical lesson learned by the U.S. Army Medical Corps during World War II was not the use of penicillin, or of large quantities of whole blood, or of evacuation by air of the wounded-great as these advances were. The most valuable lesson was the realization of the validity of the concept, well known to all trained surgeons, and also learned and then forgotten by the Medical Corps after World War I, that the mortality and morbidity of combat casualties can be reduced to a minimum only when mature, highly trained surgeons are available in forward areas of combat.

The consultant's own experiences, both triumphs and disappointments, and the similar experiences of others, bear out this concept. Any acceptable plans for surgical support of future operations must follow the same principle. If any plans contain even the possibility of delay on the availability of immediate, definitive surgical care by surgical experts, they should be discarded forthwith.

I. RIDGEWAY TRIMBLE, M.D.

ORTHOPEDIC SURGERY

Maj. (later Lt. Col.) George O. Eaton, MC, reported for active duty on 20 April 1942 as chief of the orthopedic section of the 118th General Hospital (fig. 297). Less than one month after activation, the unit proceeded to the west coast and embarked for oversea duty. After approximately one year of hospital duty at Sydney, Australia, Major Eaton received orders placing him on duty in the Office of the Surgeon, USASOS, SWPA, as the Consultant in Orthopedic Surgery. Headquarters at that time was at Sydney, Australia, but was almost immediately moved to Brisbane, Australia, approximately 500 miles closer to the combat zone in New Guinea with still some 1,700 miles intervening.

Functions and Activities

The orthopedic consultant served first under the direction of Col. Wm. Barclay Parsons, MC, Consultant in Surgery, USASOS, SWPA, and later under Colonel Parsons' successor, Col. I. Ridgeway Trimble, MC. He was charged with the responsibility of care of wounds of the extremities and spine, in addition to nonbattle injuries, which were at least 10 times as frequent. The nonbattle injuries closely resembled civilian practice as regards clinical management, except that transportation and evacuation policies had to be integrated with treatment of fractures and soft-tissue injuries.

At the beginning of the war in the Pacific, the reason for having consultants was little understood by those in command positions. When reporting into a base in the forward area, courtesy, convention, and orders required his reporting to the commanding officer as well as the base surgeon. It was the exception rather than the rule that the mission of the consultant met with the enthusiastic approval of those key officers. The fact that the consultant's


758

FIGURE 297.-Base 7, Sydney, Australia, and the 118th General Hospital, 1943.

report with its estimate of caliber of local efficiency was reported to the theater surgeon, but not back to the base, protected the consultant but at the same time tended to make him rate as a necessary nuisance, somewhat analogous to an uninvited guest. In forward areas, the consultant had to use various forms of hitchhiking and was usually dependent on the hospitality of the unit being visited. A visit from a consultant was often rated by the recipient as an inspection, and indeed at times the consultants were under orders to include an estimate of the quality and operation of utilities, mess, and other activities only remotely related to the surgical care of patients.

The fact that there was no provision in the tables of organization for consultants further added to the difficulties under which they worked. If a medical officer was assigned to a headquarters for duty as a consultant, his chance of promotion was essentially nil. Administrative officers, rather than consultants, were given priority for any promotional opportunities. Consultants of low field-grade or company-grade rank had less influence with a full colonel commanding a hospital or serving as a base surgeon.

There were several affiliated general hospital units in the Southwest Pacific Area that were replete with very high-grade medical talent from a medical school. One such unit was left so far behind the center of activities that it had almost no patients. When the orthopedic consultant tried to persuade the


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commanding officer to permit the reassignment of two of his three good orthopedic surgeons to units that had none, his answer was that his unit represented their alma mater and was not to be molested no matter how urgent the need was elsewhere.

The Southwest Pacific Area included all Australia plus New Guinea and the nearby islands. A consultant's travel was almost entirely by air. The usual procedure was to request approval to make a consultant trip when such a move was indicated, and orders were generally promptly approved and issued. Such a trip would include visiting all army hospitals in a given area, so long as they were operated under command of USASOS, SWPA. If the unit were under command of the Sixth U.S. Army or the Eighth U.S. Army, the USASOS consultants were out of bounds unless especially invited by the army command. A visit to a general hospital would consist of a 1-, 2-, or 3-day visit, seeing all cases, approving or criticizing management of cases, giving teaching ward wounds, spreading information as to newer development in the management of specific problems, and, sometimes, explaining the rationale of directives and technical memorandums. In smaller units such as station, evacuation, and field hospitals, the orthopedic consultant's obvious duty sometimes was to teach a medical officer who was not especially on adequately trained in orthopedics how to manage the usual orthopedic problems. It should be mentioned in passing that the station hospitals, field hospitals, and evacuation hospitals performed essentially identical missions in the Southwest Pacific Area. The smaller units seemed to value the visit of a consultant and made him feel very much needed. The opportunity for teaching by working several days with an incompletely trained medical officer presented itself very frequently and was utilized to the great advantage of the patient (fig. 298).

Management of Patients With Low Back Complaints

The Southwest Pacific Area was a wide geographical area, and this fact led to the development of many minor changes in the treatment of the wounded and injured because of geographical factors and evacuation policies. It was necessary to develop a working rule for the management of patients with low back complaints. The incidence of such complaints seemed to increase whenever service became less attractive and sometimes when it became more hazardous. Some of the younger medical officers who were incompletely trained did not feel free to take on the responsibility of sending a patient back to duty if he was complaining of disabling, low back pain.

It became necessary to define by a technical memorandum the recognition of spondylolisthesis by X-ray examination and how to avoid making a diagnosis of spondylolisthesis when none was present. Spondyloschisis was also frequently discovered in the study of a patient. In the case of spondylolisthesis, the recommendation was made that such patients be evacuated to the Zone of Interior for disposition, with the application of a supporting plaster jacket and with the lumbar spine in mild flexion for transportation if pain was severe


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FIGURE 298.-Station hospitals in the Southwest Pacific Area. A. The operating pavilion of the 13th Station Hospital, Mindoro, Philippine Islands, February 1945. B. The 155th Station Hospital, Morotai, 2 June 1945.


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or displacement very marked. A patient with preslipped spondylolisthesis, or spondyloschisis, if the condition was accompanied by moderate or severe complaints, was also recommended to be returned to the Zone of Interior.

Congenital anomalies of the spine (such as spina bifida occulta, sacralization of lumbar vertebrae unilateral or bilateral, lumbarization of sacral vertebrae, six lumbar vertebrae, ununited accessory ossification centers in the transverse or posterior spinous processes) were found with approximately the same frequency in patients with or without low back complaints. The discovery of such anomalies was not sufficient reason to hospitalize or change the duty status of the complainer, and it was necessary to spread the word that the discovery of such anomalies was not to be given weight when deciding on the disposition of a patient. It was recommended that the degree and reality of the disability in the function of the back, as determined by positive physical findings, should in such cases be the basis for decision in regard to return to duty, reassignment, or evacuation to the Zone of Interior. The rule was gradually developed that the medical officer would use the diagnostic facilities at his command for the investigation of a low back complaint and, if insufficient positive objective findings developed, the officer was to send that soldier back to duty rather than to send him to a rear and larger hospital for more exhaustive investigation of his complaint.

Evacuation Policy

In the early part of the war, the evacuation policy was determined by the relative frequency of opportunity to send patients back to the Zone of Interior by water. Air evacuation had not yet been developed. Consequently, the policy was that a patient who could not probably be returned to duty in 90 days should be tagged for evacuation to the Zone of Interior. It frequently happened that the patient would remain in a rear base hospital for 30 to 60 days awaiting transportation by ship to the Zone of Interior. As transportation facilities improved and as air evacuation became more prevalent, the evacuation policy was gradually reduced to 60 days, then to 30 days, and even less.

Transportation of Fractures

The following rules were laid down in the treatment of fractures admitted to any unit forward of the hospital that would give definitive treatment prior to evacuation to the Zone of Interior. Three essentials were named: (1) The treatment of shock, (2) care of the soft part wounds, and (3) immobilization for transportation. It was estimated that about 68 percent of battle wounds were of the extremities. About one-half of these were fractures, so that some 34 percent of battle wounds were compound fractures. Attention to length and alinement, although desirable, was not stressed if it jeopardized any of the three main essentials, prolonged the operative time, or involved manipulations which predisposed to infection. The main difference between military and civil practice was the necessity for transporting the soldier. Transporting


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involved jolting which caused shock, shifting of the tissue planes, bleeding, the accumulation of fluid in dead spaces, and infection. A lapse of 2 or 3 weeks after infliction of the wound was not too long a delay before the successful restoration of length and alinement could be obtained in the ordinary compound fracture encountered in combat. This statement is not to be taken to mean that the bone wound was unimportant. The first stage of bone repair depended on vascularized tissue from the surrounding soft parts. The later stages involved actual bone repair from the bone ends which therefore had to be in contact. After transportation to a hospital where the patient could be kept for the required period, the bone wound assumed importance equal to that of the soft parts. Since all major fractures required prolonged hospitalization, they were to be evacuated to the rear as soon as their condition permitted.

The Thomas' splint was useful for the transportation of cases of femoral fracture from the battalion aid station to the first hospital for definitive treatment. It was not recommended and in his not used for further transportation to rear echelon hospitals as it did not provide the essential complete immobilization. Any of the methods of applying traction through the Thomas' splint during extended transportation were unsatisfactory. The Tobruk splint, which was developed in the famous defense of Tobruk in the Middle East, was publicized for a while as an excellent method of management of compound fractures of the femur but proved to be entirely unsatisfactory. Properly applied, a one-and-a-half spica cast was the method of choice for the transportation of femoral fractures, and other long bone fractures were transported in a solid plaster cast which was split the entire length of the limb. In applying the cast the optimum position of the fragments was obtained if easily accomplished, but it was again emphasized that, for transportation, immobilization was relatively of far greater importance than the position of the fragments.

To avoid the needless and often harmful frequent changing of casts, a note was made on the field medical record as to any anticipated or feared complications, or if, on the other hand, evacuation without changing the cast could be expected with confidence. Plating and operative fixation of fractures in any of the forward units was discouraged because of the likelihood of infection and the danger of damage in transportation. The journey to the base hospital was begun by the patient with a compound fracture after shock therapy had been completed, the wound had been debrided, and the fracture immobilized. In the early days of the New Guinea campaign, the distance was about 1,500 air miles, and evacuation might be by ship or plane with numerous stops and ambulance rides en route. Stops would be made at military hospitals, and a tendency developed to change the cast at each stop in order to observe and report the condition of the wound. For this reason, the rule was made that a patient would not be subjected to change of cast if his temperature was normal, the injured limb comfortable, and the circulation in the toes or fingers normal. This rule proved to be satisfactory and practical.

All patients with compound fractures had a normal expectancy of not returning to duty within 4 months and were therefore destined to complete


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their convalescence in the United States. Treatment in skeletal traction of compound femoral fractures in forward units, such as field and evacuation hospitals, had to be discouraged and eliminated. There was too much risk of attack by air, in which case it would not have been possible to put the patient into a protective slit trench. Thus, the only place in the oversea theater that a compound fracture of the femur could be safely treated in skeletal traction was at the rear base hospitals, out of reach of possible enemy air attack. In the later days when air evacuation became available, the patient was returned to the Zone of Interior in his plaster spica cast by air evacuation and put up in traction after arrival and assignment to a hospital in the United States.

The experience in the Southwest Pacific Area with the immediate open reduction of simple shaft fractures was not good, and the routine use of open reduction and fixation as an elective method of treatment was discouraged and frowned upon. In the forward areas, in field hospitals operating under tents, in the jungles, or around air strips, contamination and infection played too big a role to justify the hazard of open reduction as contrasted with the relative safety of closed reduction.

The transportation of compound fractures of the humerus in traction by means of hanging casts proved to be so unsatisfactory that the Air Transport Command announced that such patients would not be accepted for evacuation. The lack of immobilization led to swelling, bleeding, and pain and markedly increased the problems connected with the evacuation of such patients. The only exception to the rule of not transporting patients in traction was in the case of guillotine amputations. The maintenance of continuous, even traction of the skin during evacuation of amputees was considered to be of the highest importance to the end result of such cases. The use of elastic traction proved to be more effective in maintaining a continuous, even traction during evacuation. Accordingly, an elastic cord for traction was provided through medical supply sources, and this item became available on requisition for use in the transportation of amputees. The cord was constructed of multiple rubber fibers and was supplied in a length of from 8 to 12 inches, which was sufficient length for a single case.

Classification and Selection of Patients for Evacuation

In order to expedite the evacuation of major clinical problems to rear area general hospitals for further study and treatment, station, field, and evacuation hospitals were advised to classify selected cases for evacuation to a general hospital. The evacuation of such cases was ordered not to be interrupted at subsequent station hospitals en route except when the patient's condition was such as to require immediate interruption in the transportation journey. The fact that the general hospital type of treatment was indicated was shown by placing "GH" in red on the roster immediately preceding the name and number of the patient and on the face of the field medical jacket just above the patient's name. In general, major orthopedic conditions, including fractures


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FIGURE 299.-An orthopedic casualty in the 54th General Hospital, Hollandia, New Guinea, after evacuation from Leyte, January 1945.

requiring more than 60 days of hospitalization, were classed as "GH" cases (fig. 299). In cases of chronic low back complaints, chronic joint complaints, and chronic foot complaints, if no positive objective findings appeared after study (including X-ray, laboratory, and psychiatric investigation), and when complaints were disproportionate to the organic findings, it was recommended that the patient be returned to duty with reassurance. Only in the case of repeated admissions were such patients to be evacuated to a general hospital for further study, treatment, and disposition.

Summary and Recommendations

In the Southwest Pacific Area during World War II, any question of contact of the consultants with the Office of The Surgeon General was strictly informal and unofficial and, understandably, was frowned upon. The Office of The Surgeon General could perform a very useful function in a more or less global type of war by acting in the capacity of transmitter of information gained by experience in other theaters. Each theater will have its own peculiar problems, and it is difficult to see how the Office of The Surgeon General could appreciate or could advise in such problems unless it had firsthand experience with such specialized matters. Statistics of World War II will show a marked


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improvement over those of World War I in the rate of survival and the escape from permanent crippling disabilities of individuals suffering wounds of the extremities. This improvement will be primarily the result not of advances in chemotherapy but rather of advances in shock therapy and in wound management. Further improvement will be possible.

The command and administrative branch of the Medical Corps must take a more active interest in the clinical welfare of the patient. The visit of The Surgeon General to the Pacific areas in the early months of 1945 was a most powerful and pleasant stimulas to the average professional medical officer. Here was the highest ranking medical officer in the Army of the United States on a tour of inspection, making clinical bedside rounds, and giving helpful instruction and criticism to the ward officer. The consultant system, begun in World War I and enlarged in World War II, is the key to improving the quality of medical service rendered to patients. Particularly in the more forward areas, the average young surgeon is loaded with more responsibility than he has been trained to assume. He is notably conscientious and anxious that his patients should receive the best possible treatment. He is unable to follow the patient's progress after evacuation. Circulars and memorandums have a way of not reaching him. Only by the visits of consultants can he learn of his errors and of new methods and procedures.

Military surgery has made great strides, but even more progress will be made if more emphasis is placed upon the quality of professional accomplishment. Command and administrative officers in the Medical Corps should look upon the consultant as a teacher rather than an inspector and should not use the consultant to check on activities other than those directly related to the welfare of the patient. Provision should be made in the tables of organization for appropriate rank for consultants. Officers commanding medical units should be expected to place a high degree of importance on the quality of the medical care the patient in his unit receives instead of being nearly entirely concerned with the impeccable management of utilities and visits of Inspectors General.

GEORGE O. EATON, M.D.

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