|OFFICE OF MEDICAL HISTORY AMEDD REGIMENT AMEDD MUSEUM|
HISTORY OF THE OFFICE OF MEDICAL HISTORY
India-Burma and China Theaters
A. Stephens Graham, M.D.
On 5 January 1945, Lt. Col. (later Col.) Herrman L. Blumgart, MC, and Lt. Col. (later Col.) A. Stephens Graham, MC (fig. 346), proceeded from Headquarters, Second Service Command, Governors Island, N.Y., to Miami. There they boarded a transport plane and flew by way of Bermuda, the Azores, North Africa, and the Middle East to New Delhi, India, arriving at Headquarters, USFIBT (U.S. Forces, India-Burma Theater), on 28 January 1945.
Late in November 1944, they had been given the opportunity by Maj. Gen. Norman T. Kirk, The Surgeon General, U.S. Army, to become the first professional consultants assigned to the India-Burma Theater. Since there was a pressing need for these consultants, as had been indicated in the Kelser Mission report1 submitted to The Surgeon General on 18 November 1944, General Kirk desired to send officers with prior experience in this field. At the time, Colonel Blumgart and the author were serving as Consultant in Medicine and Consultant in Surgery, respectively, Second Service Command, where they had pioneered as consultants somewhat more than a year previously. Moreover, the author had served in an oversea combat area-the North African theater- as chief of surgical service of a 2,000-bed general hospital. Therefore, he had had experience in the care and disposition of battle casualties. As one of the organizers of the 45th General Hospital, an affiliated unit of the Medical College of Virginia, Richmond, the author had, early in 1942, served a tour of duty under Col. Norman T. Kirk, MC, then Chief of Surgical Service, Walter Reed General Hospital, Washington, D.C. Under the guidance of Colonel Kirk and Col. Arden Freer, MC, Chief of Medical Service, Walter Reed General Hospital, the chiefs of medical and surgical services of the units affiliated with Harvard, Yale, Maryland, and Johns Hopkins Universities and with the University of Maryland and the Medical College of Virginia had completed the organization of their units and had received indoctrination in the operation of a general hospital.
The author's assignment to USFIBT was contingent upon the action of the disposition board of Fort Jay Regional Hospital, Governors Island,
N.Y. This board, fortunately, changed his physical status to general duty from duty limited to the continental United States. In December 1943, the disposition board of Walter Reed General Hospital had established the limited duty status after Colonel Graham had been evacuated to the Zone of Interior from the North African theater in November 1943.
There were other experienced service command consultants who had not had a tour of duty overseas and who were most anxious for this particular assignment in the India-Burma Theater. This was particularly true of Col. R. Arnold Griswold, MC, formerly Consultant in Surgery, Fourth Service Command. At the time, Colonel Griswold was Chief of Surgical Service, Walter Reed General Hospital. Unfortunately for these officers, Headquarters, USFIBT, refused to accept consultants in grades higher than lieutenant colonel. For the first time in their Army careers, Colonel Blumgart and the author were pleased that long-awaited promotions had not materialized. These came later.
Two weeks prior to departure, Colonel Blumgart and the author spent several days in Washington where they were intensively briefed on the medical situation in the India-Burma and China Theaters by officers in the Office of The Surgeon General. The briefing included a careful study of the previously mentioned report of the Medical Department Mission to China-Burma-India. The Mission was composed of Brig. Gen. Raymond A. Kelser, Chief, Army Veterinary Service (fig. 347); Col. Robert H. Kennedy, MC, eminent New York surgeon, who had served as Chief of Surgical Service, Percy Jones
General Hospital, Battle Creek, Mich., and was soon to become the author's successor as Consultant in Surgery, Second Service Command; and Col. Karl R. Lundeberg, MC, Chief, Epidemiology Division, Preventive Medicine Service, Office of The Surgeon General. This highly illuminating report was based on a reasonably comprehensive survey of professional activities in most of the fixed hospitals of the China-Burma-India Theater.2 Colonel Kennedy's discussion of deficiencies and irregularities most urgently in need of a consultant's attention materially shortened the period of the author's orientation at Headquarters, USFIBT, in New Delhi and also influenced the sequence of hospitals visited in his initial tour of the theater.
The problems and activities of the surgical officer in the India-Burma and China Theaters can be more readily comprehended in relation to the stated mission of the U.S. Forces in these theaters, the medical service that was developed to support this mission, and the environment in which the personnel operated.
Mission of U.S. Army Forces in China-Burma-India3
Lt. Gen. (later General) Joseph W. Stilwell, USA, arrived in Chungking, China, on 4 March 1942 as head of a military mission charged with improving American assistance to the Chinese. At the suggestions of Generalissimo Chiang Kai-shek, General Stilwell was named chief of staff of the Generalissimo's joint staff, Commanding General of USAFCBI (U.S. Army Forces in China-Burma-India), and Commanding General of the Chinese Army in India (fig. 348). General Stilwell arrived at a most unfortunate period when Chinese, Burmese, and British-Indian Forces were being routed out of almost all of Burma in the fateful Burma Campaign. By the end of May 1942, the Japanese enemy was approaching the eastern border of India and had penetrated well into the Chinese province of Yünnan through the Salween Valley. By their conquest of the heart of Burma, the Japanese were in possession of the southern terminus of the Burma Road and prohibited its use by the Allies.4
In China, there was a desperate scarcity of everything but manpower. It was on the basis of China's dearth of material but abundance of personnel, therefore, that the United States was to attempt to fashion help for the faltering Chinese Army. American efforts were to center upon the dual mission of providing supplies and molding Chinese manpower into an efficient war machine. These missions were to be accomplished by taking remnants of the Chinese Fifth Army, which had fallen back into India, and those of both the Chinese Fifth and Sixth Armies, which had retreated into Yünnan; regroup, equip, and train them; and assign them to a campaign to reconstitute the Burma Road as the vital overland artery between China and her allies.
From a sheer physical standpoint the undertaking-the second Burma campaign-was prodigious.5 The plan, as it developed, involved three elements: (1) Chinese troops, trained and equipped by Americans but led by Chinese, were to strike westward from Yünnan Province to clear that section of the Burma Road which lay within the border of China; (2) simultaneously, Chinese troops, also trained and equipped by Americans, and a few American troops (fig. 349), both under the command of General Stilwell, were to drive down the valleys of northern Burma and construct a new road, as they pro-
gressed, from Ledo in Assam, India, to join with the China section of the Burma Road at Mong Yu, Burma, just within the Burma-China border (fig. 350); and (3) the British, at the same time, were to operate from the Chin Hills in northwestern Burma-between Burma and India, push eastward, and disrupt Japanese lines of communications between north and south Burma.
The fighting for all three elements was of a most difficult nature, being conducted in mountains, jungles, and valleys. It involved, as one medical officer assigned to the project described it, a kaleidoscope of mud, shortages, malaria, overtaxed equipment, rain, disappointment, heat, language difficulties, shifting priorities, jungle fighting, discarded plans, landslides and homesickness.
A decision to extend their efforts to a large-scale program was reached by the Americans in the fall of 1944 when it became apparent that the mission to reopen the Ledo-Burma Road (later Stilwell Road) probably would succeed, but that the Japanese might be waiting at the China end of the road to greet the first convoy arriving there. As the Japanese pointed the prongs of their offensive toward Kuei-lin, the approaches to K'un-ming, key supply terminal for shipment over the Himalayan "Hump" into China, and the approaches to Chungking, provisional Chinese capital, appeared to be open and exposed to the enemy. The total collapse of the China war effort was not beyond the realm of possibility.
At this critical point, the War Department suddenly recalled General Stilwell, Commander-in-Chief, USAFCBI, on 19 October 1944 and 5 days later, on 24 October, reconstituted the theater as two separate theaters, China and India-Burma. Maj. Gen. (later Lt. Gen.) Albert C. Wedemeyer was appointed Commanding General, USFCT (U.S. Forces, China Theater), and Lt. Gen. Daniel I. Sultan, formerly Deputy Theater Commander, was named Commanding General, U.S. Forces, India-Burma Theater. China thereby became the operational arm of the American Asiatic effort, and India-Burma became the supply and administrative base for the operation. Only India possessed open ports, Karāchi and Calcutta, for receiving Allied materials. Both theaters continued as integral and subordinate elements of the overall high command, the Southeast Asia Command, under the Supreme Allied Commander, Admiral Lord Louis Mountbatten (fig. 351).
In China, American ground troops were only used for advisory, logistic, and training purposes. In Burma, no more than two regiments of American troops with supporting arms and services, exclusive of air forces, were committed to battle. Service troops, including medical units, filled gaps in the Chinese Army, which lacked specialists. The average strength of U.S. Forces in China-Burma-India during 1944 was 168,700. They were spread thinly over the entire area. The various commands and units were engaged in the stupendous task of transporting personnel, supplies, and equipment over long supply lines between the ports of India and the fronts in Burma and China (fig. 352), principally by means of air transport. They had to construct, maintain, and operate the Stilwell Road, gasoline pipelines, and the communications system which connected India, through Burma and across the Himalayas, with K'un-ming, China. Large numbers of troops carried out these service and construction operations under hazardous conditions instead of in
relatively quiet rear areas, as is normally the case. There were monsoons, almost impenetrable mountain jungles, mosquitoes6 and myriads of other pests, and active interference by the Japanese troops.
Medical Activities of U.S. Army Forces in China-Burma-India
Theater surgeon's office - When General Stilwell assumed command he named as his theater surgeon, Col. Robert P. Williams, MC. During the period of the Burma Campaign, Headquarters, USAFCBI, was normally at Chungking, but actually most of the time of the personnel was spent in the field or at Rear Echelon Headquarters, USAFCBI, at Lashio. Later, in the spring of 1942, Rear Echelon Headquarters, USAFCBI, was established at New Delhi, India after General Stilwell's retreat from Burma. In April
1944, New Delhi was designated the main headquarters and Forward Echelon Headquarters, USAFCBI, remained at Chungking. Colonel Williams justified his maintenance of the theater surgeon's office at Forward Echelon Headquarters, USAFCBI, in these words:
In all other headquarters the Surgeon's Office is found in the Rear Echelon. That location was tried at the inception of this theater. It did not work, because all major decisions and long-range planning were performed at Forward Echelon. * * * the Chinese Surgeon General, Red Cross, and National Health Administration simply would not do business with an assistant and it placed on the assistant the responsibility of formulation of policy.
Deputy theater surgeon, Col. George E. Armstrong, MC, remained at Rear Echelon Headquarters, USAFCBI, in New Delhi. This arrangement continued until 14 May 1944 when, in accordance with a new theater policy, the theater surgeon and his staff were ordered to reestablish their offices at the main headquarters in New Delhi. When the China Theater was established on 24 October 1944, Colonel Armstrong, who had been moved to Forward Echelon Headquarters, Chungking, was appointed Surgeon, USFCT. In view of the fact that staff officers and responsibilities had been transferred from forward echelon headquarters at Chungking to the main headquarters at New Delhi, the creation of two separate theaters caught the China Theater short of personnel and many other necessities. Colonel Armstrong's staff, inherited from forward echelon headquarters of the China-Burma-India Theater, consisted of two officers and one enlisted man. On 10 December 1944, a rear echelon of Headquarters, USFCT, was established at K'un-ming, and the entire Medical Section, Headquarters, USFCT, moved to that location.
Relations with the Chinese - By the very nature of its function, the medical service of the U.S. Army Forces in the China-Burma-India Theater was drawn into very close association with both Chinese military and civilian personnel (fig. 353). First of all, the concept of a military medical service had not been firmly established in the Chinese Army. As a matter of fact, for all practical purposes, it was nonexistent. The Americans found it necessary to start at the bottom. An apparent disregard for human suffering and a depreciated concept, which prevailed in the everyday struggle for existence, of the value of human life had been carried over into the Chinese Army. To a Chinese accustomed to seeing Chinese civilians dying along the road with no one paying heed, the sight of Chinese wounded soldiers left to die on the battlefield seemed to cause little outward concern. The soldier was apparently considered expendable, and there was a resultant indifference to the wounded. It followed, therefore, that the medical service of the Chinese Army, whose function it was to conserve life, would be held in little repute.
The Chinese division surgeon was usually a major and a political appointee without adequate medical training. Properly trained and qualified personnel were notoriously scarce. There were few modern medical schools and only one Class-A school in China. Moreover, the available trained personnel were
not being used to the best advantage. Practically all qualified physicians had congregated in the treaty ports at Hong Kong and Shanghai. The hospitals available for military purposes were, in the main, hospitals by courtesy only. The Chinese physicians found no compulsion or inducement to join the military service.
The story of how the U.S. Army helped to form the medical service of the Chinese Forces, as an integral part of the overall plan known as "Operation plan Stepchild," has been recorded in highly revealing and interesting documents.7 The plan envisioned not only the provision of medical care for the malnourished and the sick-and-wounded Chinese soldier but also the establishment and conduct of technical-training schools in military medical subjects with students who for the most part were lacking in the necessary background or qualifications.
Any officer who might in future wars have to deal with oriental allies will profit from reading Capt. Kenneth M. Scott's "Some Suggestions for Medical Liaison Officers With Chinese Units," on file in The Historical Unit, U.S. Army Medical Service.
Morbidity - The U.S. Army medical officer in China-Burma-India was called upon to care for accidentally injured and diseased U.S. Army personnel to a far greater extent than he treated battle casualties. In 1943, when the average strength of U.S. Army personnel in the USAFCBI, was 39,600, there were 49,900 hospital admissions for all causes. Among the total admissions were 4,300 for nonbattle injury and only 200 for battle wounds and injuries. The remaining 45,400 were admitted for disease. During 1944 the average strength rose to 168,700, and during this year there were 173,900 hospital admissions: 157,600 because of disease, 14,500 for nonbattle injuries, and 1,800 battle wounds and injuries.8 In the same period, however, there were 12,739 Chinese battle casualties admitted to the hospitals of this theater in addition to strictly U.S. Army admissions.
Hospitals - Battle casualties from the Burma campaigns with a few exceptions received definitive treatment in what was known as the Advance Section, comprised of that territory in upper Assam, India, and northern Burma in the area of the Ledo Road. Hospitals were first established there in March 1943 in the vicinity of Margherita, Assam, India, about 8 miles from the town of Ledo in upper Assam and at the head of the Ledo Road. These were the 20th General Hospital and the 48th and 73d Evacuation Hospitals. By the end of 1943, hospital beds were provided for 3,705 patients by the following eight hospitals: The 20th General Hospital; the 14th (at the 19-mile mark, Ledo Road), 48th, and 73d Evacuation Hospitals, the 25th Field Hospital, Ledo; and the 40th, 42d, and 46th Portable Surgical Hospitals, Ledo, which for a short period functioned as fixed hospitals. This represented somewhat more than half the number of available beds at that time in India and Burma; in China, there were 1,465 additional beds.
The bed capacity of these hospitals in India had by March 1944 increased to 4,310, of which 2,963 were for Chinese soldiers. At the end of March, the 73d Evacuation Hospital moved to Shingbwiyang, Burma, at the 103-mile mark on the Ledo Road, where it was established as a fixed hospital on the sides of jungle hills, 5 miles from a newly constructed airstrip (fig. 354). It functioned as an evacuation and station hospital for American and Chinese troops and also as a general hospital for the Chinese.
During June 1944, the 69th General Hospital and the 28th, 32d, 34th, 35th, 50th, and 53d Portable Surgical Hospitals arrived in Ledo. The general hospital was established at Margherita, several miles from the 20th General Hospital, and the portable surgical hospitals were flown over the Himalayan "Hump" to support the Y-Force operating in the Salween River area.9
The entire fighting in Burma was jungle warfare (fig. 355). The usual doctrines of medical evacuation could not be utilized. The use of well-equipped, mobile evacuation hospitals situated relatively close to the fighting line, as was possible in the European theater, was totally out of the question here. The burden of early surgical care of battle casualties fell, in the early days, to the Seagrave Hospital Unit10 and the 151st Medical Battalion, and later to the portable surgical hospitals. These portable surgical hospitals were small units with 4 officers and 35 enlisted men. Many times these units were divided into two groups to operate in two different areas. Their men often had to march all day on a jungle trail, then set up at night, and immediately start operating upon the wounded. They were inadequately equipped owing to the fact that their entire equipment had to be carried on their backs or by a limited number of horses, except for the supplies dropped by parachute.
FIGURE 355.-Medical support of a jungle operation in Burma. A. Men of the Medical Detachment, 1st Battalion, Merrill's Marauders, barbecuing deer meat for the wounded, near Hsamshingyang, Burma, April 1944. B. An aid station along the Burma Road, February 1945.
Most of the work in the portable surgical hospitals was done at night since litter bearers usually brought in patients after dark. Except for occasional instances when portable units were relatively fixed, all operating had to be done with the aid of an ordinary flashlight. The fact that battle casualties of the Burma campaign had such excellent medical care and experienced such a low mortality is largely due to the men who worked in the portable surgical hospitals.11 It was obvious that hospitals working under such conditions could not hold patients. It was equally obvious that few patients would survive transportation over mountain jungle trails and the almost impassable roads from these forward hospitals to the field and evacuation hospitals well to the rear. It was for this reason that the system of air evacuation was perfected.
Air evacuation of the wounded12- At dawn on 15 October 1943, the Chinese Army in India initiated a drive which was to culminate in the reconquest of northern Burma. With the advance eastward into Burma, the Chinese troops were isolated from fixed hospitals in the base by difficulties of evacuation. The road, within any reasonable distance of the area of combat, existed only on engineering blueprints. The Seagrave Hospital Unit and Company D, 151st Medical Battalion, moved in on foot to provide medical service for the Chinese Army in India. With the capture of Shingbwiyang, the first forward airstrip was constructed. It was, however, still frequently necessary to transport patients by litter for several days before this airstrip could be reached. At this point in the campaign, the evacuation period was often as long as from 7 to 14 days from the time of injury to the time of admission at a fixed hospital in the base.
Gradually, as Chinese and American troops (committed in February 1944) advanced through the northern Burma jungle, 20 additional airstrips were constructed to keep pace with the troops. From 6 March to 14 April 1944, the interval between injury at the front and admission to fixed hospitals at the rear averaged 48 hours. Paddy fields were leveled by Chinese combat troops to receive the small liaison planes which were employed to evacuate the wounded, and occasionally sandbars were utilized. The remotest reaches of the densest jungle country in north Burma were penetrated by these planes which landed and took off with wounded soldiers from the most primitive and wholly inadequate strips (fig. 356). Both the planes and the strips were frequently within range of mortar, small arms, and machinegun fire.
The difficulties of evacuation were increased manifold with the onset of the monsoon rains in June. Motor ambulance evacuation came to a standstill. In the valleys, bullock carts with water buffalo "tractors" were employed. Yet, despite flooded airstrips and constant pouring rains, approximately 380 battle casualties reached the Ledo airstrip during June 1944. An additional 900
patients with disease or nonbattle injuries were evacuated from the combat area during this period. In the battle for Myitkyina, 25 percent of casualties arriving at the 20th General Hospital had been injured on the day of arrival (fig. 357).
Quality of surgical care in the India-Burma Campaign - It was the opinion of surgeons in fixed hospitals to the rear that the quality of surgery undertaken in forward units during the India-Burma Campaign was, on the whole, excellent. When viewed in the light of conditions under which the forward surgery was accomplished, the high percentage of good results represented a remarkable feat of courage, effort, improvisation, and sound, conservative surgical treatment.
In the initial stages of the northern Burma offensive, certain practices no doubt tended to increase both morbidity and mortality rates. But as the experience of surgeons both in the forward and rear areas accumulated, these difficulties were, to a considerable extent, overcome in several ways. On 4 April 1944, the chiefs of the surgical services13 of the 14th, 48th, and 73d Evacuation Hospitals and the 20th General Hospital were brought together for the purpose of discussing their observations of the care of battle casualties in forward medical units and to formulate recommendations for improvement in the surgical care of casualties by officers in these units. The meeting had been suggested
by Col. Vernon W. Petersen, MC, Surgeon, Northern Combat Area Command, and the officers had been assembled by Col. (later Brig. Gen.) I. S. Ravdin, MC, Commanding Officer, 20th General Hospital. The report and recommendations of this committee formed the basis for a document, "Epitome of Surgical Management," which was distributed by the theater surgeon to forward units.
There is little doubt that the "epitome" on wound management was responsible to some extent for the improvement subsequently noted at base hospitals in the initial treatment of wounds. Officers from these base hospitals observed, however, on visits to forward units that the "epitome" was not too well received. Not only was criticism implied (which was unavoidable), but surgical officers in the forward medical units considered that the proper orientation of SOS (Services of Supply) surgeons in working conditions at the front would have made for more sound, intelligent suggestions based on practical familiarity with the problems of portable surgical hospitals. Similar complaints were made to Colonel Graham when, some months later, he visited these forward units after their transfer to combat areas of China.
These criticisms of the "epitome" were well taken and resulted in an occasional exchange of officers between the rear and forward units. It was recommended that officers assigned to the forward units be relieved from duty at relatively frequent intervals and returned to rear installations for short periods of time. It was believed that, after a month of steady operation under the severe conditions of jungle operations, surgeons of the portable hospitals inevitably grew too fatigued to render the type of service of which they were normally capable. Return to a rear installation would, it was believed, restore the keenness of these officers' capabilities and in the long run result in greater efficiency of the portable surgical hospital. The disadvantage of medical officers working only in one type of unit was that the difficulties encountered by forward units were not appreciated by personnel in the rear, and that, on the other hand, officers at the front were unable to follow up their cases in order to determine the validity of their techniques or to correct errors. The benefits which could be obtained from increased medical liaison were considered to be significant, and efforts were made to achieve it by the exchange of officers as well as by other means.
MEDICAL SERVICES, U.S. FORCES, INDIA-BURMA THEATER
On 28 January 1945, when the consultants arrived in the India-Burma Theater, there were 27 hospitals in active operation: 6 general, 14 station, 4 field, and 3 evacuation hospitals. The total bed capacity of these hospitals was 19,772, and 512 Medical Department officers were assigned the care of 9,819 patients. From a one-man organization in 1942, the medical service had expanded to an organization of 13,780 officers and men.
The theater (map 6) extended west to east from Karāchi, India, to Lashio, Burma, a distance of 2,200 miles.14 Theater headquarters, at New Delhi, was
situated in north-central India, in the Punjab Desert, 650 miles from Karāchi. New Delhi was 1,300 miles from Ledo in the upper portion of the province of Assam, where a number of hospitals were located. The most southerly situated hospital was at Kandy, Ceylon, Headquarters of the Southeast Asia Command (of which the India-Burma Theater was a part), 1,600 miles from New Delhi. The most northerly situated hospital in Burma was at Tagap Ga on the Ledo Road at the 52-mile mark. If the shortest air route between this hospital and New Delhi were taken, one would fly over Bhutan, Tibet (just north of Mount Everest), and the Kingdom of Nepal.
Seventy percent of the hospitals-five general, eight station, the three field, and the three evacuation hospitals-were established in a rectangular area approximately 950 by 450 miles in the extreme eastern portion of India and entirely across northern Burma (map 7). This area was slightly larger than the combined square miles that comprise the 14 eastern coastal States, plus Vermont, Pennsylvania, and West Virginia. It was roughly of the same shape and dimensions. Moreover, it was comparable to the area included in the First, Second, Third, and Fourth Service Commands, as then constituted, or almost twice the size of Texas. The distance from theater headquarters in Delhi to the center of this rectangular area was about 1,200 miles, almost the same air distance from the Office of The Surgeon General in Washington to the center of Texas.
Except for the area of fighting in central and eastern Burma, this vast area encompassing the India-Burma Theater was subdivided into area commands known as the Base, Intermediate, and Advance Sections. The Northern Combat Area Command was comprised of the headquarters and troops conducting operations against the Japanese in the area of construction on the Ledo Road and, later, in central and eastern Burma.
MEDICAL SERVICE, U.S. FORCES, CHINA THEATER
The medical service of the U.S. Army in China had always been badly in need of almost everything: hospital units, qualified personnel (both officer and enlisted), and modern equipment (fig. 358). It was one of the lowest of low-priority theaters. For the most part, the theater had been entirely dependent for logistic support on air transportation over the Himalayan "Hump": Food, clothing, equipment, supplies, high-octane gas for both fighter and transport planes, ammunition, motor vehicles, and so forth. The overland "back door" supply route, the Ledo-Burma Road, and the gasoline pipeline had afforded some relief but conditions were still far from ideal. The first U.S. Army supply convoy entered China over the Ledo-Burma Road on 28 January 1945, the day the consultants arrived in India.
Colonel Armstrong's task of organizing the medical service of the China Theater had been rugged. On 2 November 1944, 5 days after he had been
advised of his appointment as theater surgeon, Colonel Armstrong wrote to Colonel Williams, Surgeon, USFIBT:
Returned to 879 [Chungking] yesterday morning and am now so thoroughly confused that I honestly do not know where to turn. Apparently there are so many big problems to iron out that no one has time to settle any of the little (mine) ones. I am unable to find out whether this office will duplicate all the things done in your office or whether your office will continue to perform many functions for us. Obviously Cavenaugh [Maj. (later Lt. Col.) Robert L. Cavenaugh, MC], Sergeant Copeland, and I cannot go far in running a medical section for a Theater.
A letter from Colonel Williams, which had crossed Colonel Armstrong's in transit had stated the former's views substantially as follows:
As Colonel Williams saw it, very few changes would be required for adequate medical service for both theaters. Practically the only change was that it would not be necessary for Colonel Armstrong to continue reporting to him. However, until circumstances altered things, Colonel Williams intended to send Colonel Armstrong carbons of everything that might interest him. He anticipated that Colonel Armstrong would reciprocate. Of necessity, the two theaters would be so closely booked together that constant interchange would be
required. Colonel Williams intended to make every effort to maintain the closest cooperation. Anything that he could do he would, just as though they were still one family.
It was mutually agreed that the Office of the Surgeon, USFIBT, would render for the China Theater all necessary medical reports and returns, pending the acquisition of additional personnel in the Medical Section, Headquarters, USFCT. By 10 December 1944, when the rear echelon of China Theater headquarters was established at K'un-ming in Hostel No. 1 and the entire Medical Section had moved to that location from Chungking, the personnel of the Medical Section, Headquarters, USFCT, had been increased sufficiently to relieve the India-Burma Theater of all medical functions pertaining directly to China with the following exceptions:
1. Personnel.-Because of a lack of port facilities in China, unit and individual requirements for personnel-both initial and replacements-were coordinated with those of the India-Burma Theater before their submission to Washington.
2. Medical supply.-For the same reason as cited above, medical supply requisitions were consolidated with those of the India-Burma Theater.
3. Hospitalization.-The India-Burma Theater served as a reservoir for cases from China requiring hospitalization exceeding the established 90-day evacuation policy of the China Theater. Patients en route to the Zone of Interior also had to rely on holding facilities in India-Burma, as no other route was available.
In all other respects, the Office of the Surgeon, USFCT, functioned as that of an independent theater. The theater surgeon's office continued to grow and the staff had increased considerably by the time this consultant arrived in India-Burma. Care had to be taken in accomplishing this not to draw keymen from medical units of the theater, since medical officers and enlisted men were at so high a premium in China that the loss of one man could interfere with the function of an installation. The possibility of replacing him in such a low-priority theater was remote.
The work of the Medical Department, of course, could not wait until all needs had been met. With his limited staff at K'un-ming, and in the early days at Chungking, and with only a skeletal medical organization throughout the new theater, Colonel Armstrong undertook the difficult task of lifting the Chinese medical service from the depths of demoralization and disorganization which attended the threatened collapse of China through the rout of the Chinese Army in southeastern China. At the same time, he had to implement plans for the medical care of U.S. troops who were coming into the theater in increasing numbers.
Inasmuch as the medical service of the USFCT remained throughout the war essentially that of a military mission aimed at improving the efficiency of the medical service of the Chinese Army, it became necessary for the theater surgeon to devote a large part of his time to work with the Chinese medical authorities. These were the Director (Surgeon General) of the Army Medical Administration, and representatives of the National Health Administration, and the National Red Cross Society of China. In addition to these were a considerable number of foreign philanthropic associations with whom the theater surgeon maintained liaison in an effort to coordinate the many diverse aspects of medical service in China bearing on the Allied military effort. In this atmosphere of confusion, division of responsibility and widespread disorganization, it is remarkable that the theater surgeon and his small, but intensely loyal and inspired, staff accomplished as much as they did.
Long before activation of the China Theater, the need for additional hospitalization in China was referred to in communications to the War Department as critical. When, finally, the 70th Field Hospital, designated for China, arrived in the India-Burma Theater in October 1944, it was retained for combat service in Burma until June 1945. In March 1945, two station and three field hospitals were assigned to the China Theater with a total of 1,800 beds. An additional five field hospitals and one general hospital (1,000-bed) were scheduled for transfer to the theater from the India-Burma Theater to make a total of 4,300 fixed beds for the China Theater.
In June 1945, however, when the author departed from the China Theater, there were still only one station and two field hospitals functioning, there were no provisions for establishing a general hospital, and none of the five field hospitals had arrived in China. The most pressing problem was what to do with Chinese casualties, since the War Department would not provide U.S. Army fixed beds for Chinese troops in China, as had been authorized in India-Burma. In China, hospitalization of Chinese troops was considered the responsibility of the Chinese Army Medical Administration. This administration and the Chinese Red Cross established a number of hospitals in the various categories, but practically all of them were woefully lacking in just about everything: Physical facilties, skilled personnel, supplies, and equipment. The Medical Department, U.S. Army, at the time of this consultant's visit to the China Theater, was committed to care for only casualties near the front who were brought into portable surgical hospitals manned by U.S. Army personnel. The manner in which the portable surgical hospitals functioned is described later in this chapter (pp. 942-945).
FUNCTIONS OF THE SURGICAL CONSULTANTGeneral Considerations
In addition to the medical and surgical consultants, Maj. John R. S. Mays, MC, Consultant in Neuropsychiatry, Maj. (later Lt. Col.) Richard W. Britt, MC, Reconditioning Officer, and four Medical Administrative Corps officers arrived on 28 January 1945 for assignment to the Office of the Surgeon, Headquarters, USFIBT. Brig. Gen. James E. Baylis, MC, the newly appointed Surgeon, SOS, USFIBT, arrived several days later. General Baylis' last previous assignment had been that of Commanding General, Medical Replacement Training Center, Camp Grant, Ill. Somehow during the period of briefing in Washington and as a result of conversations with officers returned from the theater, some of the newcomers had developed the feeling that their reception at Headquarters, USFIBT, and perhaps even in the field as well, would be somewhat less than cordial. Actually, they were welcomed with genuine warmth, not only at headquarters, but almost everywhere they went in the theater.
There was little doubt that this fine reception was, to a considerable extent, influenced by the character and personality of General Baylis, who was esteemed throughout the Army as an officer of superior ability as an organizer and administrator. He possessed a genius for inspiring subordinates, to whom he delegated great responsibility. He encouraged them to take the initiative in the development of their respective sections in the Office of the Surgeon. He never questioned professional opinions and recommendations of the consultants. The consultants were told to make corrections "on the spot" when they observed irregularities and deficiencies that required prompt action during visits to hospitals. At the same time, they were given to understand that their decisions
would be reversed if subsequently it was determined that they had erred. This arrangement in a theater spread out over the entire area of India and Burma, with many installations situated more than a thousand miles from theater headquarters, greatly facilitated and hastened the accomplishment of the consultants' mission. At the same time this implicit confidence in the professional judgment of the consultants had a sobering influence on them in curbing any tendency toward precipitate action of making recommendations without due deliberation.
The functions of the surgical consultant were concisely stated by Brig. Gen. Fred W. Rankin, MC, Chief Consultant in Surgery to The Surgeon General, in the annual report of the Surgery Division for fiscal year 1944, substantially as follows:
The surgical consultants exercise their functions by assisting and advising the service command or theater surgeons on all matters pertaining to surgical practice, including particularly the organization and program of surgical services in medical installations and the quality, distribution, and proper assignments of professional personnel, by providing advice on newer developments in diagnosis and treatment, by stimulating interest in professional problems and aiding in their investigation, and by encouraging educational programs such as conferences, ward rounds, and journal clubs. These consultants are concerned essentially with the maintenance of the highest standards of medical practice. It is their function to evaluate, promote, and improve further the quality of medical care by every possible means, to interpret the professional policies of The Surgeon General and to aid in their implementation.
The formulation of many policies and the making of decisions in regard to the solution of many problems required coordination of the medical, neuropsychiatric, and surgical consultants. Colonel Blumgart and the author were fortunate in that they had, during the preceding year, functioned as a team along with the service command neuropsychiatric consultant in the consideration of many common problems. Major Mays readily fitted into the team, as did the newly appointed chief of personnel in the Office of the Surgeon.
In August 1944, Col. Alexander O. Haff, MC, Surgeon, Services of Supply, USAFCBI, had also been designated deputy theater surgeon and Chief of Professional Services for both the theater headquarters and SOS medical sections. In February 1945, after arrival of the new consultants, these two sections were consolidated and Colonel Haff was evacuated to the United States without replacement. With the position of Chief of Professional Services discontinued, the consultants functioned directly under the theater surgeon rather than through an intermediary chief.
The aforementioned chief of the Personnel Section, Office of the Surgeon, SOS, USFIBT, was Lt. Col. Casey E. Patterson, MC, an officer of high professional attainments. Colonel Patterson cooperated in the consideration of routine professional matters as well as matters pertaining to personnel. In both instances, he screened material before referring it to the consultants.
When the consultants were absent from the office of the theater surgeon, he disposed of all matters except those which definitely required the attention of the consultants. When immediate action was required, he contacted them in the field by telephone, radio, or courier mail. Actually, this organization of the professional services officers with the personnel officer might be described as a committee on professional services and personnel, with the theater surgeon serving as chairman. Its successful operation was insured by the wholehearted cooperation of all members and their ability to discuss problems harmoniously, frankly, and critically. Decisions reached by this group were presented directly to the theater surgeon for consideration. Colonel Blumgart and the author were in a position to compare this simplified organization with the conventional one they had experienced in the Second Service Command, where the chief of professional services undertook activities of a technical and specialized nature with a minimum of consultation with the professional consultants. The simplified system was definitely more satisfactory, at least for the India-Burma Theater. Although no need occurred for the addition of administrative assistants to the professional services organization, such additions could have relieved the specialists of the burden of routine work which would have accumulated in a larger and more active theater.
Soon after the arrival of the consultants in the theater, General Baylis obtained permission of the theater commander to route the consultants' reports through technical medical channels. General Baylis also approved the consultants' recommendation that information copies of these reports be sent to commanding officers of hospitals which had been visited, a practice not hitherto carried out by the SOS or theater surgeons. Almost immediately upon return to theater headquarters from field trips and before formal reports had been compiled, the consultants submitted to the theater surgeon brief, confidential summaries of observations which would require prompt action. If on the tour there were noted deficiencies in physical plants, the need for air conditioning, or other similar nonprofessional matters that required corrective action, a memorandum to the effect was sent to the Chief of Staff, USFIBT.
Considerably less than half of the author's time was spent in the office of the theater surgeon. Here, as a member of the theater surgeon's staff, many activities claimed his time: Preparation of the section on surgery in ETMD (Essential Technical Medical Data) report; review of all publications on surgical subjects reaching the Office of the Surgeon; preparation of material on current surgical problems for the monthly Field Medical Bulletin, USFIBT; preparation of theater circulars, directives, and memorandums on professional surgical subjects; review of clinical records and post mortem findings in all deaths due to surgical causes; review of proceedings of boards of officers; conferences with the other consultants and with the personnel officer; and, finally, compilation of reports on hospitals which had been visited. Moreover, a rather large correspondence was conducted with the Surgeon, China Theater, with commanding officers of hospitals relative to problems of the surgical
services, with General Rankin, Chief Consultant in Surgery to The Surgeon General, and with Col. B. Noland Carter, MC, Assistant Chief, Surgical Consultants Division, Office of The Surgeon General. Practically all of these letters, or pertinent portions of them, were brought to the attention of the theater surgeon, or members of his staff, for information, guidance, or specific action.
The surgical consultant was responsible for the preparation of the section on surgery in the ETMD report submitted monthly to The Surgeon General. This consultant found that "feeder" reports submitted by hospitals had become routine and lacked material of clinical interest. The theater surgeon, therefore, advised all installations and the headquarters of the various base sections of the type of information desired.
During the visits of the consultants to the various hospitals, further effort was made to stimulate studies of unusual cases. Much valuable material was thereby accumulated and many excellent papers were submitted for publication in medical journals, particularly by officers of the 20th General Hospital (University of Pennsylvania affiliated unit).
The consultants were also responsible for articles or comments in the monthly Field Medical Bulletin, USFIBT. The surgical officers of the theater were encouraged to submit reports on their studies, and many of these were published. This bulletin also provided a valuable means of conveying information regarding recent advances in surgery. The policy recently instituted by the former deputy theater surgeon of reprinting in the theater advance copies of important War Department technical bulletins was continued. Distribution of these bulletins to the theater through normal publications channels was extremely slow, and many times essential bulletins never reached the hospitals. Thus, it was most fortunate that the consultants had brought with them the complete medical series of those that had been issued up to the time of their departure from the Zone of Interior. On the other hand, considerable numbers of bulletins consisting of 50 or more pages relating to the water supply of Germany and Czechoslovakia and sanitary data on the Aegean Islands and Finland were received with great promptness.
In some instances, where no suitable official guides or directives were available, appropriate circulars or memorandums were submitted to the theater surgeon and, following his approval, were reproduced and distributed. Restraint was practiced in the number issued. Moreover, the spirit of these publications was that of guidance rather than mandatory direction. Specific directions, however, had to be issued on the transfer of patients to general hospitals and on operations for deranged knee cartilages, chronically dislocated shoulders, and cases of herniated nucleus pulposus. These problems are discussed later.
Review of Clinical Records and Post Mortem Findings
Soon after arrival of the consultants, the theater surgeon approved their request that, in nonbattle casualties, the full clinical records and results of post mortem examinations be submitted to the theater headquarters for review. This practice proved of exceptional value. Theater headquarters was kept informed of some of the most interesting cases. A review of the medical care of the most seriously ill was thereby accomplished, and occasional suggestions were made or deficiencies were noted. Deficiencies were made the subject of correspondence or, more often, a conference with the staff concerned was held on the author's next visit to the installation. It was believed also that this procedure had anticipatory value in that it was generally understood that the clinical record of any seriously ill patient might eventually be scrutinized in the office of the theater surgeon.
SURGICAL PERSONNELPersonnel Problems
Basic to all other considerations in achieving a high standard of surgical care was the question of personnel. A combination of circumstances prompted the consultants on their arrival in the theater to give personnel matters priority over all other activities. First, Colonel Kennedy, of the Kelser Mission, had personally emphasized to Colonel Graham the need for the consultants to make a prompt survey of personnel. Second, Lt. Col. (later Col.) Durward G. Hall, MC, Director of Military Personnel and Chief of Personnel Services, Office of The Surgeon General, had set a deadline of 1 April 1944 for (1) the execution of the new WD AGO Form 178-2, Supplemental Data for Medical Officers, which had not been accomplished in this theater since its activation, and (2) assignment by the consultants of proper SSN (specification serial numbers) and ratings for all medical officers in the India-Burma and China Theaters. Third was the fact that the personnel officer in the Office of the Surgeon, USFIBT, was a young first lieutenant in the Medical Administrative Corps. The consultants' initial recommendation to the theater surgeon was the appointment of a highly qualified Medical Corps officer as Chief of Personnel. Colonel Patterson was immediately assigned to this position and proved to be an excellent choice. As has already been remarked, Colonel Patterson and the consultants functioned in a most satisfactory fashion as a committee on personnel and professional services.
Professional Classification of Surgical Officers
The information on the officer's qualification forms and the obsolete Medical Department questionnaire, prepared by the individual officer, was of little value since, in most instances, the information had been entered 2 or more years previously. It was most natural that the classification and proficiency ratings of these officers, based almost entirely on the interpretation of this meager infor-
mation by a nonmedical officer, should result in a number of incorrect classifications and malassignments.
As quickly as the new supplemental data forms were executed and returned to the Office of the Surgeon, USFIBT, the consultants reviewed them and appended their recommended classifications and proficiency ratings. Since a majority of the officers had been in the theater for 20 months or longer, it was not surprising that changes were made in almost every instance. In a moderate number of cases the officers had been incorrectly classified as to their appropriate specialty, owing to insufficient available data or invalid recommendations of their commanding officers. A far greater number had been given proficiency ratings which were either too high or too low. The most significant observation was the fact that many officers had been classified "general duty" who, through opportunities afforded them by chiefs of surgical services or by their own diligent application, had acquired proficiency in general surgery or one of the surgical specialties and because of demonstrated ability deserved a specialty classification.
Although by 31 March 1945 copies of the newly completed forms, with the revised classification and proficiency ratings, were ready to be forwarded to the Office of The Surgeon General, in only 60 percent of instances had the changes been made on the basis of personal interview and observation of the officer's professional activities. The theater surgeon, however, informed The Surgeon General and commanding officers of hospitals that the ratings made solely on the basis of the newly acquired personnel information were subject to revision after these officers had been observed by the consultants.
The individual statements of educational training and postgraduate surgical experience were not sure guides to individual surgical proficiency. Certain surgical officers, for instance, with a wide range of surgical knowledge-some qualified by an American Specialty Board-lacked conservative, sound, clinical judgment; others lacked necessary qualities of leadership. Conversely, other officers with little postgraduate training, who had taken advantage of their opportunities to acquire proficiency in assignments in the Army as surgical assistants, were found fully qualified to be chiefs of a surgical service at a 250-or 500-bed station hospital. The Chief Consultant in Surgery to The Surgeon General, himself one of the organizers of the American Board of Surgery, repeatedly insisted that absence of certification by the Specialty Boards did not prohibit inclusion of an officer in the higher proficiency classifications, as "Group A" and "Group B."
Appraisal of the intrinsic qualifications of the surgical officer could be made only on the basis of personal observation during actual ward rounds and in the operating room. This consultant spent at least one and usually many additional hours with each officer on his wards reviewing in detail physical findings, clinical records, treatment, and administrative dispositions of the patient. Informal discussions of related general subjects formed part of such visits. In some instances, personality clashes rendered an officer's services ineffective at a particular installation and could be obviated by assignment elsewhere. Oc-
casionally, the commanding officer of a hospital was encountered who failed to recognize the distinction between efficiency and proficiency classifications. He would question the propriety of the consultant's high proficiency rating in the case of an officer with superior training and demonstrated ability to whom he had given a relatively low efficiency rating. Others were mistaken in the belief that the proficiency rating was influenced by age, rank, length of service, and by the successful completion of advanced Army extension courses conducted for the Officers' Reserve Corps.
Actually, there was a superabundance of officers of field grade in both theaters who, although well versed in the details of Army medical administration, were nevertheless classified as general duty (MOS 3100) medical officers. In civilian life they had begun general medical practice after a 1-year internship. They were too old and possessed too much rank to be assigned as ward officers, yet lacked adequate surgical training and experience to warrant their assignment to positions of responsibility commensurate with their rank. Many, however, had requested such assignments, and a few had become chiefs of surgical services in small station hospitals.
Qualitative and Quantitative Studies
From an initial survey of records in the office of the theater surgeon, this consultant was inclined to believe, as was Colonel Kennedy, that there was an urgent need for many additional medical officers qualified as general surgeons and specialists. Actually, however, as the author was to determine later, there was no lack of capable surgical officers except for a few key specialists, notably experienced orthopedic surgeons. This discrepancy was quite easily explained. First, a large number of officers designated in personnel files as general-duty medical officers had, through earnest effort and careful supervision by highly competent surgeons, become eligible for classification as general surgeons or surgical specialists, "D" or "C." Second, a large excess of surgical talent was concentrated in three affiliated medical units in the Advance Base Section.
These affiliated units were a 2,000-bed general hospital and two 750-bed evacuation hospitals, the latter serving as station hospitals for U.S. Army personnel and as general hospitals for the Chinese. Sixty of the seventy-eight officers assigned to their surgical services were considered capable of undertaking operations without supervision. The census of surgical patients in these three hospitals seldom reached 2,000. This inequitable distribution of surgical personnel was not the fault of the theater surgeon. The trouble stemmed from a policy established in the Office of The Surgeon General around 1939. At that time, written agreements were negotiated with universities in which the university medical schools agreed to organize and staff the professional services of general and evacuation hospitals which were to be activated in the event of war; The Surgeon General, in turn, agreed not to dismember the units except with the consent of the school or the unit itself, or as an urgent military necessity. It is understood that in any future war such a situation as regards personnel in similar affiliated units will not recur.
In sharp contrast to the quantity and quality of surgical officers present in the three foregoing affiliated units in the India-Burma Theater was the situation at three general hospitals in the Second Service Command which the author had inspected during his last month as surgical consultant for the command. These three general hospitals-Tilton, at Fort Dix, Wrightstown, N.J., Rhoads, at Utica, N.Y., and England at Atlantic City, N.J.-had a combined authorized capacity of 6,000 beds. There were 3,889 surgical patients at the time of the survey. Of these, 2,395 were orthopedic cases, mostly battle casualties with multiple compound fractures. All patients were U.S. Army personnel, whereas some 75 percent of patients in the hospitals of the India-Burma Theater were Chinese. Only 37 of the total 62 surgical officers in the Zone of Interior hospitals were classified in categories which would ordinarily permit them to undertake operations without supervision. A quantitative and qualitative comparison of officers assigned to the three hospitals in India-Burma with those assigned to the three hospitals in the Second Service Command showed:
The disproportionately large surgical staff provided the evacuation hospitals (25 officers each) as compared with the number and quality of officers assigned to other fixed hospitals of comparable size was due to the fact that evacuation hospitals were originally organized to function as mobile field units situated close to and in support of actively engaged combat troops. Employment in this manner would have required a 24-hour operating schedule in which surgical teams would have alternated between surgical activities and periods of relaxation and sleep. The character of the warfare and terrain over which battles were fought in the Burma campaigns precluded the employment of evacuation hospitals in the conventional manner. It was not until near the close of the Central Burma Campaign that a number of these officers were transferred to other hospitals in order to insure balanced, efficient surgical staffs throughout the theater.
By May 1945, through the acquisition of qualified officers, including experienced orthopedic surgeons and other specialists from the United States, and reallocation of officers already in the theater, every surgical service in the hospitals of the India-Burma Theater was satisfactorily staffed. Moreover, the USFIBT was prepared by then to transfer to the USFCT a number of competent surgical officers to offset personnel deficiencies in the China Theater and to replace officers eligible for rotation.
In April and May, a large number of officers became eligible for rotation. Among these were 29 key surgical officers who were due for reassignment in the United States. A brief summary of this consultants' impression of their capabilities was sent to Col. B. Noland Carter, MC, Assistant Chief, Surgical Consultants Division, Office of The Surgeon General. Colonel Carter, in turn, conferred with Colonel Hall, Director of Personnel, in regard to these officers. As a result, by the time these returnees reached redistribution centers, reassignment orders awaited them. The initial success of this process prompted Colonel Carter to request that this information be forwarded in the case of every officer with a classification of "C" or higher.
EDUCATION AND TRAINING
The scarcity of surgical officers-except in affiliated units-sufficiently skilled and personally qualified for positions of responsibility and leadership made it imperative that hospitals be considered as training centers. Key personnel, lost through illness or rotation, could thereby be replaced. An additional incentive for high standards of performance possibly leading to promotion was provided. The accelerated wartime program of civilian medical education frequently resulted in producing young medical officers of considerable innate ability but with meager clinical knowledge or experience. Whenever possible, such officers were assigned to duties under the immediate supervision of mature, seasoned surgeons and, after varying periods of time, were qualified to be chiefs of surgical service in small station hospitals or heads of sections in the surgical services at general hospitals.
The policies governing treatment of various surgical conditions varied greatly from hospital to hospital and indeed from ward to ward. This was due to the fact that the medical officers largely represented a cross section of the American civilian medical profession with widely different types of training experience and personal views and had not received the fundamental directives and guides issued by the Office of The Surgeon General. Few if any TB MED's (War Department technical bulletins, medical) had been received, and but few overall professional policies had been established in the theater. To raise the quality of medical care to the highest possible level, each installation was directed to prepare a list of the TB MED's that had not been received, and adequate distribution was effected. It was further directed that a complete file of such bulletins as well as circulars and other directives issued by the theater surgeon be maintained by the commanding officer and in the offices of the chiefs of medical and surgical services at all fixed hospitals.
The consultants attempted to stimulate professional interest by recommending the establishment at hospitals of a suitable reading and conference room, even when a tent had to be erected for that purpose. Steps were undertaken to supply each installation with its authorized allowance of professional books and periodicals. Through the generosity of the Josiah Macy Jr. Foundation, New York, N.Y., reprints of outstanding articles appearing in current medical periodicals were distributed to the medical officers in the India-Burma Theater.
Medical officers were thereby encouraged to keep abreast of advancing medical knowledge.
Medical officers were urged to review series of cases at their own installations and prepare reports summarizing their experiences. In some instances, these reports were used solely as the basis for a talk at one of the medical conferences, at other times they were found suitable for publication in the Field Medical Bulletin or even in current leading periodicals in the United States. A schedule of at least one medical conference a week and one "grand ward round" for the discussion of the most interesting and perplexing cases was established at the various hospitals. The value of such an educational program in providing improved medical care, in heightening the professional interest of the medical officers, and, consequently, in raising the morale was gratifying.
The major portion of the time spent at each hospital by the surgical consultant was utilized in a careful review of medical practice on each of the wards. Each patient was examined, the clinical records were reviewed, and the clinical management was discussed.
PHYSICAL FACILITIES AND EQUIPMENT
Hospital construction.-Hospital construction of every type imaginable was observed: brick, cement (mostly sand and mud), basha, pinewood, teakwood, and tents (fig. 359). A few were excellent, most were highly satisfactory, and with only two or three exceptions, the remainder of the hospital plants were adequate. Some of the units occupied former missionary hospitals. Others moved into administrative buildings of tea plantations and added additional wards of basha construction for patients and erected pyramidal tents for personnel. The basha construction with thatched roof was satisfactory in the climate of India and Burma but it was difficult to maintain in a proper state of repair.
Supply liaison activities - Evidently there had been a marked improvement in the supply situation following the visit to the theater of the Voorhees Mission in 1944. Although in most installations there was found adequate equipment, in only the 20th General Hospital and a few of the most recently established units was most of the equipment and appliances of the more recent, standard models. Ingenius improvisations were satisfactory substitutes for the standard apparatus in most instances. The relatively few serious deficiencies in equipment which were observed by this consultant appeared in his reports to the theater surgeon with recommendations that the equipment be supplied. Invariably, Maj. Claud D. LaFors, PhC, the medical supply officer in the Office of the Surgeon, USFIBT, a most cooperative individual, handled these requests in a most expeditious manner. Officers in the field were grateful for this service, and unquestionably the professional consultants gained prestige as a result of this and also the manifestations of confidence in the consultants at theater headquarters.
Cooperative assistance of the same quality was rendered by the Office of The Surgeon General, particularly by Colonel Carter, through whom the author made all his requests for aid. One of these many requests was for an authoritative statement regarding the stability of penicillin at the high temperatures (110° to 140° F.) to which it was subjected in transit by plane from the United States to India, Burma, and China, when for hours or even days there was a delay at various airports. Clinical results following the administration of penicillin were not consistent. This had been observed by Colonel Kennedy on his visit to the theater and subsequently by the consultants. The question was resolved in 8 days. The consultant wrote to Colonel Carter, who referred the request to the Laboratories Division, Preventive Medicine Service, Office of The Surgeon General. The Laboratories Division, in turn, contacted the Food and Drug Administration, Federal Security Administration, and Charles Pfizer and Co. and then sent a report on the matter to Colonel Carter. When Colonel Carter made it the subject of discussion at the weekly staff meeting, the Supply Service, Office of The Surgeon General, was instructed to issue a directive on the subject and immediately advise the various oversea theater headquarters as to how to proceed in the matter. This is illustrative of the advantage of liaison between the consultant and the Office of The Surgeon General. Had the ques-
tion been processed through normal channels, this matter, which The Surgeon General considered of extreme importance, would not have received such expeditious handling.
Improvised equipment - This consultant observed, on his initial tour of the theater, remarkable improvisations of equipment. In many instances, the improvisations were almost exact replicas of standard equipment found in hospitals in the Zone of Interior. Particularly striking was the highly satisfactory reproduction of costly, critically scarce apparatus by enlisted personnel at the 69th General Hospital. At the author's request, the hospital forwarded to the theater surgeon detailed blueprints and photographs of these improvisations in order that a manual on their construction and use might be compiled and distributed throughout the India-Burma and China Theaters. Capt. Stanley C. Gillette, MAC, Reconditioning Consultant, Office of the Surgeon, USFIBT,15 extracted material from this report pertaining to physiotherapy equipment and sent it to all hospitals authorized physiotherapy departments with the recommendation that the apparatus designed to facilitate remedial exercises be reproduced locally and used in conjunction with the reconditioning program. The apparatus to be locally improvised included plans for a Kanavel table, quadriceps exercise table and chest weights, foot inversion board, chinning bar, shoulder wheel, stall bars, shoulder abduction ladder, Sayre head sling, exercise steps, therapeutic bicycle, rowing machine, and whirlpool bath (fig. 360).
On his second tour of the theater, Colonel Graham noted widespread acceptance of this advice to improvise equipment locally. One of the more useful pieces of equipment for the surgical services was an overhead, multibeam operating-room light constructed entirely of salvaged material. In fact most of the improvisations were constructed from salvage, most often from wrecked airplanes and motor vehicles. Perhaps even more practical was the improvised testing equipment used by the ophthalmologists. Equipment unavailable in the theater, and which was accurately reproduced, included Jackson crossed cylinders, illiterate charts, lens centering devices, perimeters, tangent screens, occluders, trial frame wall brackets, and adjustable stools for patients during perimetry and scotometry studies (fig. 361).
Equipment for evacuation hospitals - The evacuation hospitals perhaps experienced the greatest trouble acquiring adequate equipment. Whereas they gained a large surplus of surgical personnel through functioning as a fixed facility, they were handicapped in that their table of equipment was decidedly inadequate when serving as a station or general hospital. Although some of the deficiencies had been corrected, at the end of the campaigns in Burma they still had not received essential equipment (fig. 362). Requests for this
additional equipment, in accordance with the prevailing theater policy, had to be approved by the War Department. Finally, when the need for equipment in excess of tables of equipment no longer existed, the War Department informed the theater that changes in basic allowances should be accomplished by the theater on the basis of individual needs of the various units since "such a flexibility results in a more efficient medical service and is common practice in other theaters of operation."
SPECIAL PROBLEMSTransfer of Patients to General Hospitals
The most significant directive pertaining to the surgical service of the theater was issued on 2 April 1945. The directive was entitled "Transfer of Patients to Numbered General Hospitals" and was modeled on WD Circular No. 12, 10 January 1944, which applied to the transfer of patients to named general hospitals in the Zone of Interior. In the course of this consultant's initial tour of hospitals, he had noted that formidable or specialized surgical procedures of an elective nature were being undertaken at field and station hospitals by officers with inadequate formal training or practical experience. There was even less reason for this in the India-Burma Theater than in the Zone of Interior, since, with only two exceptions, these smaller hospitals were situated within several miles of major airfields from which patients could be transported by regularly scheduled evacuation aircraft to general hospitals located not more than 2-hours' flying distance away. Compliance with this directive was uniformly satisfactory, and, in most instances in which the condition of the patient precluded transfer, consultation was requested of a general hospital. In this manner, the quality of professional care afforded patients in the India-Burma Theater was materially enhanced; furthermore, a more equitable and economic distribution of key professional personnel was thus facilitated.
Treatment in Dispensaries
Along these lines there existed one problem for which a completely satisfactory solution was never reached. The same problem was encountered in the Second Service Command, but to a much less degree. Reference is made to the treatment of patients in dispensaries, which in the majority of instances were controlled by the Army Air Forces. Many patients, who should have been transferred to hospitals, were given definitive treatment in these dispensaries. Most dispensaries had established sickbays in which from 10 to 30 beds were maintained. These were, for the most part, operated by general-duty medical officers of recent graduation who had completed an accelerated medical course of 3 years, followed by an internship of 9 months.
Scores of patients were observed in hospitals who had been improperly retained in dispensaries, many with peritonitis from a ruptured appendix, others with malalinement of fractured bones which eventually required open reduction, others with severe second- and third-degree burns with infection and contractures, patients with severe local and systemic infections resulting from the late primary closure of lacerations, and patients with many other evidences of poor surgical judgment and treatment of an inferior quality.
This problem was made the subject of a memorandum to the theater surgeon, in which were listed the following recommendations: (1) Inactivate those dispensaries situated within several miles of hospitals or else place these dispensaries under the control of the hospitals which would provide personnel for conducting sick call, (2) prohibit the maintenance of beds in dispensaries except when specifically authorized by the theater surgeon, (3) require dispensaries to render a monthly report listing diagnosis, treatment, and disposition of each patient admitted to a sickbay, and (4) require hospital commanders to report to the office of the theater surgeon all instances of improper treatment in patients admitted from dispensaries.
The theater surgeon, in spite of his position, was limited in the actions he could take to correct this situation owing to the relative autonomy of the Army Air Forces in the theater, under whose jurisdiction were most of the dispensaries involved. All elements of the Army Air Forces in the theater, with the exception of the India-China Wing of the Air Transport Command but including the Tenth Air Force, were under the administrative and logistic control of the Army Air Forces, India-Burma Sector, whose headquarters were located at Hastings Mill, Calcutta. Through this headquarters, the Army Air Forces were operationally controlled by the Eastern Air Command of the Southeast Asia Command-a situation which further gave weight to the coequal and separate status of the Army Air Forces in relation to other elements of the Army in the theater. The Army Air Forces in the theater continued to operate their dispensaries on the contention that too many man-days were lost when Air Forces personnel had to be transferred to the fixed hospitals of the theater for the treatment of relatively minor medical and surgical conditions. Some improvement was noted on this consultant's second tour of the India-Burma Theater, but there was much to be desired in the correction of this pernicious situation. As it was earlier stated, no really satisfactory solution of the problem was ever reached.
Treatment of Appendicitis
Another problem which confronted this consultant shortly after his arrival was the relatively high mortality from appendicitis. Practically all of these deaths were in nonoperative cases or in patients who were not operated upon
until the appendix had ruptured. It was determined, after a careful study of clinical records and conference with some of the officers involved, that the following factors were influential: (1) The prevalence in Army personnel of diarrheal diseases which mimicked appendicitis, especially amebiasis; (2) retention in dispensary sickbays of patients with appendicitis, many of whom were administered purgatives, until abscess or generalized peritonitis developed (32 such cases were observed during the author's initial tour of hospitals); (3) undue caution of officers who had been criticized by the Surgeon, SOS, USFIBT, for removal of normal appendixes (hospitals had been instructed that all appendixes removed should be sent to the Central Laboratory for microscopic study). The latter no doubt served as a deterrent to the overzealous young surgeon, but at the same time, it tended to warp the judgment of the conscientious, timid individual who had been officially reprimanded or dreaded such an occurrence.
The combination of abdominal pain, vomiting, and right-lower-quadrant tenderness frequently resulted in the admission of patients with amebiasis to the surgical service. The amebiasis-minded surgeon was not readily deceived, for a history of diarrhea, abdominal tenderness also over other portions of the large bowel, and indurated, tender segments of the large intestines indicated the advisability of stool examination, proctoscopy, and other diagnostic tests. The presence of amebic colitis was, however, no guarantee that the patient did not also have acute appendicitis and require surgical intervention. It was therefore advised that, when any patient showed convincing signs of acute appendicitis, delay in surgery was not to be countenanced. The surgeons were given to understand that, if, after careful study and the use of available consultation, a normal appendix was removed, they would not be criticized or penalized by the theater surgeon. This attitude, it is believed, had a salutary effect on the officers and to some extent was responsible for a diminution in the number of deaths from appendicitis.
Effect of Climate
The consistently high temperatures prevailing in many parts of the India-Burma Theater, the meager recreational facilities, and the isolation of many of the posts had a profound effect on medical personnel. Even in the relatively brief experience of the consultants of somewhat less than a year, it was striking to witness alert, aggressive, enthusiastic medical officers gradually "flatten out" during the second monsoon of their stay. The same influences were apparent in many of the patients.
Heat exhaustion and heatstroke, surprisingly, were not prevalent and constituted a relatively minor problem. During the hot, humid months of the monsoon season, oral afternoon temperatures as high as 100° F. in apparently healthy males and as high as 100.4° F. in females were observed in nonhospitalized personnel engaged in routine activities. Similar elevations among patients were observed in the wards of hospitals in the absence of any other explanation.
The widespread use of sulfonamides, particularly sufadiazine, led to occasional renal complications during the hot season. Every effort was made to impress medical personnel with the necessity of maintaining an adequate urinary output rather than emphasizing fluid intake. Injection of even 3 or 4 liters of fluid a day led, under certain circumstances, to oliguria, hematuria, loin pain, and the like, even when only moderate doses of sulfonamides were administered. Owing to the occasional occurrence of anuria, a circular was distributed which related the advantages of spinal anesthesia in the relief of this state.
COMMENTS ON INDIVIDUAL HOSPITALS
It is difficult, after reading again the author's reports to the theater surgeon on hospitals visited, not to follow a strong inclination to write about each of them. The scope of this undertaking, however, will not permit this, although certain impressions obtained during field trips are reported in later sections of this chapter.
There were several outstanding hospitals in each category, a goodly number of highly satisfactory ones, and only a few definitely mediocre units. Some of the hospitals with the poorest physical facilities were rated by this consultant at the top of the list for performance. That is, esprit de corps was excellent, scarcity of equipment had been remedied by clever improvisations, and the quality of professional care was superior. In others with fine modern physical plants and the latest in equipment, the author found the morale poor and the quality of professional care below standard. The difference very often was owing to the character, qualifications and, or, state of health of the commanding officer and chiefs of services. In seven instances, the consultants and the chief nurse, Lt. Col. Agnes A. Maley, ANC, on their first field trip observed an urgent need for prompt repatriation of hospital commanders. For the most part, they had remained through one too many monsoon seasons and were physically and nervously exhausted. There was also a degree of doubt in some of these cases as to their initial qualifications to command. Replacement of these ill or derelict officers often would alone suffice to improve tremendously both the morale and quality of professional services.
Too frequently, this surgical consultant observed in India, Burma, China, North Africa, and, to a somewhat lesser extent in the Second Service Command, a tendency to assign to administrative posts, including that of hospital commander, officers of field grade rank for whom there was no available clinical assignment commensurate with their rank and military occupational specialty number (usually 3100, general duty). Often they were lacking in both efficiency and proficiency, in aptitude to command, and in administrative ability. Furthermore, it appeared to be somewhat more the rule than the exception in oversea hospitals for a relieved commander to be replaced by the ranking medical officer of the unit, who had acquired his relative position of rank solely by chance and who, consequently, more often than not lacked the qualities necessary to command such a complex organization as a modern army hospital.
FIELD TRIPS, INDIA-BURMA THEATER
Somewhat more than half of this consultant's 9 months in the India-Burma and China Theaters was occupied in field visits to the various installations. Travel was almost entirely by regularly scheduled transport aircraft, although occasionally, as a matter of expediency, bombers or L-5 liaison planes were used. Nearly 200 hours were required to travel approximately 30,000 miles, and probably half as many hours were spent in airports waiting on repairs to planes or, during the monsoons, waiting for what was said to be reasonably satisfactory flying weather.
The isolation arising from the wide dispersion of units and the poor lines of communication made it the more important for the consultants to be regarded as two-way ambassadors between the theater surgeon and the hospitals, interpreting locally the policies of headquarters and acquainting headquarters with the problems confronting officers in the field. For the most part, medical officers had had no opportunity to discuss professional matters with anyone other than their immediate associates and had but little information regarding experience with comparable problems at other hospitals or other theaters. The opportunity to display their own accomplishments was an important morale factor. At many hospitals, the experience and ingenuity of the medical officers provided constructive suggestions which could be transmitted to the officers at other hospitals. Colonel Blumgart said that this function of the surgical consultant as a "circuit rider of good ideas" was probably one of his chief contributions. Through a sincere endeavor to be as helpful as possible, the surgical consultant established confidence among hospital personnel, who accepted suggestions without resentment. In some instances, a surplus of medical talent was present; two or three highly competent surgeons would be found serving in a station hospital. In other instances, however, no surgeon with ability and sound, conservative surgical judgment had been assigned, and it would become necessary to prohibit further surgery in these hospitals until a qualified officer arrived. These instances were, however, relatively few and invariably were immediately rectified by the personnel officer in the office of the theater surgeon in response to a radiogram or telephone call from the consultant.
Advance Base Section No. 3
Soon after his arrival in the theater, this surgical consultant toured hospitals in the Advance Base Section comprised of upper Assam, India, and northern Burma (map 7, p. 908). Most of the battle casualties of the Burma campaigns were hospitalized in this area. Base Section headquarters was at Ledo, where the road of the same name began. The 69th General Hospital was located just outside of Ledo; several miles further along the Ledo Road was the 20th General Hospital (University of Pennsylvania-affiliated unit); at
the 19-mile mark of the road was the 14th Evacuation Hospital (New York City Hospital-affiliated unit); at the 52-mile mark, at Tagap Ga, Burma, was the 335th Station Hospital; and at the 103-mile mark of the road, at Shingbwiyang, Burma, was the 73d Evacuation Hospital (Los Angeles County General Hospital-affiliated unit). The Base Section surgeon, Lt. Col. John T. Smiley, MC, a relatively young career army officer, impressed the author as being an exceptionally able administrator.
The 69th General Hospital was an excellent example of what could be accomplished in the organization of a general hospital in a theater of operations when an officer possessing aptitude for command was assigned the task. Evidently, this unit had got off to an inauspicious start late in 1944, at about the time of Colonel Kennedy's visit. Colonel Kennedy was of the opinion that the unit was far from strong and urged the consultants to give it their initial consideration. Subsequent to his visit, Lt. Col. (later Col.) Edward M. DeYoung, MC, a young Regular Army officer, was designated commanding officer, and under his wise and effective direction the hospital became an efficient organization, with the prospects of becoming one of the outstanding general hospitals of the theater.
The 20th General Hospital was unequaled in the Southeast Asia Command. It is difficult to contemplate a discussion of this installation without becoming overwhelmed with superlatives. Suffice it to say that it was outstanding in every respect, and so it should have been, with a hospital commander of the caliber of General Ravdin-eminent surgeon, educator, and able administrator-and a staff that had remained nearly intact since its arrival in the theater 2½ years earlier, composed of officers practically all of whom possessed superior professional qualification. The physical plant, facilities, and equipment left little to be desired. Particularly impressive were the central supply service, the blood bank, operating rooms, and the unit ward system in which surgical wards were divided into administrative units, each consisting of one or more active and two or more convalescent wards. This hospital, together with the 14th, 48th, and 73d Evacuation Hospitals, performed a noteworthy service in the care of battle casualties during the Burma campaigns (fig. 363).
The 14th and 73d Evacuation Hospitals were also outstanding units, staffed (as has already been related) with an overabundance of highly talented surgeons. Their hospitals were of basha construction and were in a poor state of repair, owing to the monsoons and a predominance of Chinese patients. The 73d Evacuation Hospital was established on the sides of jungle mountains, and all personnel, including the nurses, lived in pyramidal tents. Despite the tremendous handicaps of more-or-less constant rain, mildew, and myriads of insects and pests, these units succeeded in maintaining asceptic conditions while undertaking formidable and highly technical surgical procedures with commendable low mortality and morbidity rates.
The 335th Station Hospital was unique in that the entire personnel of the unit consisted of Negroes. The hospital was situated on the most imposing, and almost the most isolated, site in the theater, with an elevation of about 3,000 feet on a hairpin curve of the Ledo Road and on the side of a hill in northern Burma from which could be viewed a vast expanse of territory including the mountain ranges of Tibet. While visiting the 73d Evacuation Hospital, this consultant was driven in a jeep by Lt. Col. Clarence J. Berne, MC, able chief of the surgical service of that hospital, through 20 miles of almost impenetrable mud to the 355th Station Hospital. Despite its isolation and relative inactivity (its main purpose was to provide medical service for the Negro troops working on the Ledo Road), the morale of this unit was not surpassed by that of any other organization in the theater. Moreover, from the author's observation and those of Colonel Berne, who visited there frequently, it was quite evident that they were rendering superior nursing and medical care.
Base Section No. 2
Base Section No. 2, with headquarters at Calcutta (map 8), contained one general hospital, nine station hospitals, and one field hospital. This base section served the Calcutta district through which port practically all the waterborne supplies for the theater arrived, the 20th Bomber Command, and Air Transport Command installations, a total personnel of about 60,000.
The 142d General Hospital, Calcutta, a unit affiliated with the University of Maryland, Baltimore, Md., took over an already established installation from the 263d General Hospital, which was inactivated in November 1944. There were 2,000 beds established in modern, well-equipped buildings in a 1-mile long area in a rather congested outlying section of Calcutta. Despite the fact that the personnel of this organization were under the impression they were being repatriated on leaving the South Pacific Area after a stay of 29 months, they undertook their new task in a remarkably fine spirit. It was necessary for them to reorganize their staff and expand from a 1,000- to a 2,000-bed hospital. This was accomplished in a highly commendable manner under the direction of the able hospital commander, Col. Murray M. Copeland, MC, himself a distinguished surgeon and formerly chief of the hospital's surgical service. The hospital was outstanding in almost every respect.
It was unfortunate that this unit and the 18th General Hospital, sponsored by The Johns Hopkins University, Baltimore, Md., were redeployed in the India-Burma Theater. Of the 33 Medical Corps officers at the 142d General Hospital, 22 had become eligible for rotation; 48 of this hospital's 83 nurses had become eligible for rotation. All of the personnel of the 18th General Hospital, which had been functioning for more than 30 months in the Fiji Islands, were eligible for rotation to the Zone of Interior. When it was learned that
FIGURE 363.-The 20th General Hospital, Ledo. A. Col. I. S. Ravdin, MC (right front), escorting Lady Mountbatten (center) and other visitors on an inspection of the hospital. B. A Chinese amputee, being measured for prosthesis.
these hospitals were to be sent to the India-Burma Theater, the theater commander requested the War Department to rotate all the personnel before redeployment was effected. This was not done.
The 18th General Hospital was doubly unfortunate. Its members had served longer in the South Pacific than had the 142d General Hospital. But, unlike the latter unit, which took over a splendid physical plant in the theater's port of debarkation, the 18th General Hospital was required to travel about 800 miles by a train that averaged 15 miles an hour to an abandoned installation on the Ledo Road whose dilapidated structures required almost complete rebuilding (fig. 364). Moreover, the hospital's equipment had not accompanied it from the last station. And, furthermore, the staff had been informed that admissions to their hospital were to be restricted to Chinese soldiers.
Colonel Kennedy of the Kelser Mission, after visiting this unit shortly after its arrival in upper Assam, urged in his report to the theater commander that the entire staff be rotated as rapidly as possible, both for their own good and for the good of the theater. He believed that to retain in the theater two such units would have an adverse effect on the morale of the remainder of the personnel in the theater who were anticipating rotation. Five months later, the author made the same recommendation when the deputy theater commander, Maj. Gen. Frank D. Merrill, solicited his aid in attempting to persuade these people to remain in order to establish a new 1,000-bed general hospital then being built in Myitkyina. The entire unit was rotated in March 1945.
FIELD TRIP, CHINA THEATER
The limited authorization of personnel for the Office of the Surgeon, USFCT, did not provide positions for consultants. Accordingly, on 5 May 1945, Colonel Armstrong, Surgeon, USFCT, requested of Colonel Baylis, Surgeon, USFIBT, the services of the India-Burma Theater consultants on temporary duty in the China Theater.
Ten days later, on the completion of his first tour of hospitals in the India-Burma Theater, this consultant proceeded by plane over the Himalayan "Hump" to K'un-ming, Rear Echelon Headquarters, China Theater, a distance of about 1,800 miles from Headquarters, USFIBT, in New Delhi. The author's reception in K'un-ming left nothing to be desired. Along with many other visitors to Rear Echelon Headquarters, he was impressed with the spirit of friendliness and cooperation that was more wholehearted than was usually encountered. In great part, it was believed, this spirit was influenced by the character and personality of the Commanding General, Rear Echelon, USFCT, Maj. Gen. Douglas L. Weart, and of the theater surgeon, Colonel Armstrong.16
The theater surgeon was optimistic that the consultants would be able, from their observations, to indicate in their reports the most serious deficiencies in personnel and equipment and thus assist in expediting the procurement of much needed relief. At the same time, as was strongly emphasized by Colonel Armstrong, he desired that all irregularities and all evidences of professional incompetence be recorded or brought to his personal attention. He earnestly desired criticism, advice, and help.
Visit to the Combat Area
It had been arranged for this consultant to remain at the Rear Echelon headquarters a few days for orientation, but the day after his arrival the opportunity was afforded him to accompany Col. Benjamin J. Birk, MC, Surgeon of the Chinese Combat Command (Provisional), on a tour of field units in the active combat area.17 Accordingly, on 17 May 1945, they flew to Chihchiang, the most forward fighter base after the fall of Kuei-lin, in a Combat Cargo Command plane filled with drums of aviation gasoline. From Chihchiang they went by jeep over mountains and a makeshift ferry across a river to An-chiang, headquarters of the Eastern Command, Chinese Combat Command.
Although the local military commanders showed little concern over a pincer movement that the Japanese were attempting in this area, they were nevertheless bothered about the considerable number of Japanese disguised as Chinese civilians reported by Chinese military intelligence and the Office of Strategic Services to be in Chih-chiang and An-chiang and the intervening territory. As a consequence, contrary to practices in most other theaters, Colonel Birk and Colonel Graham were issued carbines and pistols and told to display them prominently. All tactical medical units in the combat zone were not only well armed but were also given a special course in the function,
stripping, assembling, and firing of the various small arms, including the Thompson submachinegun. Moreover, it was theater policy that the Geneva Cross brassard not be worn, "it having been used as a target by the enemy, often at extreme ranges of automatic fire."
At An-chiang, this consultant reported to Col. Woods King, Commanding Officer, and to Col. Paul G. Hansen, MC, Surgeon, Eastern Command. During the next 2 days, Colonel Birk, Colonel Hansen, and the author visited all Chinese and U.S. Army hospitals between An-chiang and Tu-chou, along a road to which Chinese casualties were evacuated through narrow mountain files. They saw many Chinese wounded limping along the road with the aid of a stick or rifle, or being supported by, or carried on the backs of, other soldiers. Still others, unable to walk, were on the ground beside the road. Their pleas for assistance were ignored by the Chinese soldiers who passed them. The incongruity of these actions were explained to the author by the Chinese interpreter, who said that the lightly wounded soldier who carried for many miles a more seriously wounded comrade did so because the latter was either related to him or was a member of his squad or platoon. He might even offer some measure of aid to a member of his company who was in another platoon, but beyond that he would volunteer assistance to no one, regardless of the urgency of the need.
At the most likely points of entry to the road were stationed U.S. Army medical corpsmen to guide or litter-carry casualties to nearby portable surgical hospitals established in tents or Chinese temples or combinations of these two.
The Portable Surgical Hospital
At this time there were only four portable surgical hospitals in the area, and only one section (2 officers and 18 enlisted men) of the 34th Portable Surgical Hospital was then functioning. They had been treating casualties more or less constantly for 36 hours. Scores of wounded, both Chinese and Japanese, were stretched out on the ground surrounding the ancient and quite dilapidated building in which the unit had set up a temporary operating room. Since the two officers were operating on an "assembly line" basis, it was necessary that enlisted men conduct the triage of patients, determining the order in which the casualties would undergo operation. Corpsmen would undress the patients, clean the injured area, accomplish a superficial debridment of wounds, and, when necessary, administer intravenous Pentothal sodium (thiopental sodium) anesthesia. The surgeons progressed along the line of tables as quickly as possible, performing a simple suture of a superficial wound in one, enucleating an eye in another, or amputating a leg or an arm.
The quality of the surgery performed under considerable pressure was, for the most part, highly satisfactory. Working under such trying conditions and in the face of many handicaps, these officers and enlisted men rendered outstanding service (fig. 365). Many lives were saved in instances of the severely wounded and injured, and a considerable number of the lightly wounded were enabled to return to the front after a short period of time.
Certainly this was not the time or place for criticism of surgical judgment or of techniques. From this consultant's observations of officers in action in these small units and from his conversations with them during periods of inactivity, it became clear that most of their surgical training had been acquired, in many instances, in the field by the trial and error method. Even where competent, well-trained surgeons were on duty with the units, they seldom had time to supervise the operating of inexperienced members when there was the great pressure of a large backlog of patients awaiting operation. The author's inclination, soon after arrival in the India-Burma Theater, was to be critical of the assignment to the portable surgical hospitals of so many officers with little or no surgical training and an overabundance of pediatricians, obstetricians, and general practitioners. A study of personnel records of 19 of these units, however, revealed that in well over 80 percent of instances the assignments had been made by the Office of The Surgeon General before they were sent to China-Burma-India. The theater surgeon's error had been to assume that the Office of The Surgeon General had selected qualified personnel for the portable surgical hospitals. Certainly, in any future war only highly skilled young men, preferably under 35 years of age, should be employed in such units.
There was much to discourage the personnel of the portable surgical units. For each Chinese soldier they saved, many others died. Some died in transit to their hospital or shortly after arrival because of the long delay in reaching them (many casualties observed by this consultant had been wounded 4 or 5 days previously). Others died after receiving treatment when they failed to survive the trip to fixed installations of the Chinese Army further to the rear. Lt. Col. John H. Sharp, QMC, whose trucks transported these casualties, told the author that on one occasion approximately 200 out of 600 Chinese died in the trucks during their evacuation from U.S. Army hospitals. This was readily understandable since the patients were transported in trucks over rough mountain roads on which there were innumerable hairpin curves. The trucks were driven at high rates of speed by irresponsible Chinese drivers. Moreover, the wounded Chinese soldier, so everyone with whom this consultant conferred agreed, received practically no nourishment throughout the course of his evacuation from the front, except for the short period he remained in the portable surgical hospital. This deplorable situation existed despite the fact that ample supplies of food had been furnished by the U.S. Army to Chinese responsible for feeding patients in transit. Furthermore, it was believed that the total battle casualties and injuries of an entire Chinese Army (somewhat larger than the full comple-
ment of a U.S. infantry division) could not be properly cared for by the personnel of one half of a standard portable surgical hospital.
A most discouraging observation was the handling of fracture cases, particularly those that had been compounded by shell fragments or bullets. They could not be properly treated in these small units. Those fractures in which union occurred usually presented marked deformity (as observed in Chinese and American field hospitals to the rear) for two reasons: First, there were no X-ray machines available for the portable surgical units; and second, even if alinement was perfect when the plaster cast was applied, the Chinese soldier invariably removed the cast within a few days.
On the basis of the experience of the portable surgical hospital with the Y-Force in the Salween Valley operations,18 the theater surgeon proposed a revision in the table of organization and equipment for such units to be employed in China. The medical plan had provided for the use of 18 American portable surgical hospital units for the Y-Force. Actually, however, only 10 arrived in time to participate, as 8 were diverted for service in India-Burma. Colonel Armstrong's supporting arguments for the proposed changes were substantially as follows:
The portable surgical hospitals, as originally organized in Table of Organization and Equipment 8-572, were planned for a specific purpose; namely, giving frontline surgical treatment in support of American units in combat. Under this plan, there were always larger hospital units to the rear, which could take care of any medical problems that might arise. In the China Theater, however, the use of the portable surgical hospitals was entirely different. The patients were almost exclusively Chinese soldiers and usually there were no longer American hospitals to the rear which could handle complicated problems. Therefore, it was necessary that portable surgical hospitals also function as field, station, evacuation, and general hospitals (for the Chinese); in other words, they had to be equipped to handle all types of surgical and medical cases and at the same time remain relatively mobile in order to be able to maintain close support of the Chinese units in combat. As mentioned previously, many of these units were split into two sections in order to provide surgical and medical care to the greatest number of Chinese patients, and therefore it was necessary that each section be adequately equipped to operate separately.
Colonel Armstrong indicated changes that should be effected. Four officers, he noted, would be assigned as in the original organization, but, since the units would be split, emphasis should be placed on the assignment of more qualified surgeons. Eleven enlisted men were to be dropped, leaving twenty-two.
At the time of this consultant's visit, there was no indication that the war would end in such a short time, and it was considered an urgent necessity to increase the efficiency of the portable surgical hospitals to the fullest extent,
since the War Department had disapproved the further utilization of fixed beds in U.S. Army hospitals for Chinese casualties. The commanding general of Chinese troops in the Eastern Combat Command expressed to the author his deep concern over the change in policy. His comments paralleled those of the division commander of the l30th Chinese Division, who, according to the American Surgeon for the Y-Force, stated, in effect, that his soldiers were much braver in this campaign than in previous ones because they knew that a portable surgical hospital was close by. The Chinese division commander, it was held, stated also that in previous campaigns the Japanese bullets were not so much of a hazard as the infection resulting from them and that the techniques used by the portable units rendered this danger and fear less important both in actuality and psychologically.
The officers of the portable surgical hospitals that this consultant visited apparently appreciated his visit and the discussions of new concepts in surgical treatment. They expressed the desire, however, to have a surgical consultant assigned to their command who would visit each unit every week or so. The theater surgeon, on the author's recommendation, selected an excellent officer for this post, but before he could start on a tour of duty at the front the war ended. In conferences with the Chinese Surgeon General, Gen. Robert K. S. Lim, a distinguished physician and physiologist who was well known and esteemed in the United States and Great Britain, it was suggested that he arrange for the repatriation of two Chinese surgeons, friends of his and the author's, both highly skilled and possessed of superior surgical judgment, to serve as counterparts of the U.S. Army theater surgical consultant and the contemplated combat area consultant. The suggestion was favorably received, and it is believed that an effort was made to acquire the services of these outstanding countrymen of General Lim, but the plan was never consummated. Practically none of the highly trained Chinese physicians and surgeons, sent to the United States before the war for medical education or for postgraduate training, returned to China during the war.
The Field Hospital
Both the Chinese so-called field hospitals and the U.S. Army field hospitals were visited during this consultant's tour in China.
Chinese field hospitals - The Chinese field hospitals were primitive. A typical Chinese field hospital was described by the commanding officer of the U.S. 47th Portable Surgical Hospital, I-liang, as follows:
This hospital consisted of several British 'four-man' tents, which are approximately 12x15 feet, plus a fairly large adjacent temple, the court sides of which were open. * * * Eight patients were placed in each of the tents, four on each side lying head to head with about a foot of space between each patient. The patient's bed consisted of boards elevated about a foot above the ground on mud bricks. On the boards was placed a thin straw mat. The more fortunate patients had a thin cotton blanket to put over the straw beneath them * * *.
The patients housed in the temple were similarly arranged in the rooms of this building except that in some of the smaller rooms there were large common beds, extending the length of the room, in which several patients were placed.* * * * * * *
The food allowance of the patients in the hospital was the same as that allotted for other Chinese soldiers; namely, 25 ounces of rice per man per day. In addition to this, the hospital was allowed 20 Chinese dollars [approximately 25 cents, U.S. currency] per man per day to buy products available on the local market. This was later increased to 120 dollars, but even this didn't buy very much with the marked inflation as illustrated by the fact that an egg cost about 90 dollars and the prices of other products were in proportion* * * * * * *
Nutritional and deficiency diseases comprised a goodly number of the patients in the hospital, and, as can be realized by the above diet which they received, their recovery was not very much enhanced in the hospital.
The nursing care which the sick received was essentially nil. The soldiers assigned to the hospital were technically called nursing soldiers but they had never received any training in these duties. No charts or records were kept on the patients. There was no routine for the giving of medications and other than the bringing of rice into the center of the tent area twice a day for feeding of the patients, no other care was attempted. If the patient had to visit the latrine, which was only a few feet away from the temple and was open, he had to make it under his own power or with the assistance of a fellow patient. The sicker ones being unable to make this journey resorted to the area just outside the tent * * * [or] to the ground in the tent. No water was provided for the patients to wash * * *.* * * * * * *
* * * No effort was made to segregate the infectious or contagious diseases. There was no preliminary examination or delousing.
The interest of the Chinese medical officers in the patient was * * * only slightly better than that of the nursing soldiers. They made irregular and indifferent rounds * * * somewhere between ten o'clock in the morning and noon, following which the patients were given drugs which they prescribed. No drug was given without the prescription of the medical officer for each individual dose. As a result of this, regular medication was never given.
There were better Chinese hospitals than this, the author was informed, but in too many instances were many of these conditions reproduced. The Chinese hospitals this consultant visited were about the same as that described. Not once on visits to these places did he see anyone who even claimed to be a doctor, and the nursing soldiers were extremely scarce.
U.S. field hospitals.-On leaving An-chiang, Colonel Birk and the author returned to Chih-chiang, where they visited an Air Force dispensary and two sections of the 21st Field Hospital, only one of which was functioning. The third platoon, situated about 600 miles away, was visited as this consultant returned to the India-Burma Theater. There were among the officers a number of Chinese-American doctors and old China hands, who were former missionaries or sons of missionaries to China. Among these were a number of competent general surgeons, but there was an urgent need for surgical specialists, especially orthopedic surgeons. Moreover, most of the experienced officers were due for rotation, as was the case in the other field hospitals and a number of the portable surgical hospitals.
95th Station Hospital
On his return from the combat area, the author visited the only station hospital in the theater, the 95th Station Hospital, which actually functioned as a general hospital and had been granted the privilege of conducting disposition boards. This hospital was situated on the outskirts of K'un-ming. It was one of the most unimpressive hospitals visited in either theater, from the standpoint of both structure and physical facilities. Most of the station hospitals in the India-Burma Theater were superior to the 95th Station Hospital in almost every respect.
Facilities - In January 1944, the table of organization had been increased to accommodate 250 patients. On 1 October 1944, the hospital had again been reorganized and designated a 750-bed station hospital. Actually, however, the bed capacity had not exceeded 522 until 10 days prior to this consultant's visit, when it had reached 643. The normal bed capacity had always been lower than the actual census. For instance, on 1 October 1944 there had been 81 patients in excess of normal beds, and on 1 May 1945 there had been in excess of 38 patients. In order to hospitalize these extra patients, it had been necessary to resort to the expedient of installing double-decker beds and cots, which had materially reduced the normal cubic feet of space per patient below the minimum permitted in army hospitals.
Without exception, all of the physical facilities were inadequate as to space and essential equipment. In most instances, they did not meet the normal requirements of a 100-bed station hospital. These included the physical therapy and X-ray departments; the orthopedic, and ear, nose and throat, and eye clinics; the library; wards; and, from the standpoint of essential equipment, the operating rooms as well. Yet, paralleling the increase in patient census, the workload of the clinics and laboratories had steadily increased, although the facilities, which had been inadequate from the first, had not been expanded.
Clinical laboratory - The clinical laboratory was perhaps greatest in need of expansion. It functioned as a central laboratory for the China Theater, yet the existing facilities were below the minimum requirements for a 200-bed station hospital. Since space for equipment and personnel necessary to accomplish blood chemistry analyses was not available, it had been necessary to send specimens for such determinations to the 234th General Hospital, at Chābua, or the 142d General Hospital, in Calcutta, both in the India-Burma Theater. The pressing need for additional laboratory space, which this consultant, in his report, urged be given priority in the new construction, was emphasized by the high incidence of amebiasis and other diarrheal diseases, typhus, plague, hepatitis, venereal diseases, and other conditions in which diagnosis and guide to therapy were almost entirely dependent on laboratory studies.
X-ray Department - Although possessing nearly adequate space, the X-ray Department had not been provided adequate protective measures against the radiation hazard for either the X-ray personnel or the patients waiting for examination. Since it was highly problematic when this department would
be relocated, Headquarters, SOS, USFCT, was urged to provide as promptly as possible auxiliary protective measures such as lead screens and brick partitions, and, in the new construction, to comply with TB MED 62, 1 July 1944, which prescribed the necessary protective measures. Evidently, this important bulletin had not been received in the theater or SOS headquarters.
A dangerous practice was observed in the X-ray department of this hospital-a practice which had also been noted in a number of station hospitals in the India-Burma Theater. There was a tendency among the less well trained radiologists to employ X-ray therapy to a much greater extent than did the Board-certified, highly competent radiologists in general hospitals. As a matter of fact, in only two hospitals in the Southeast Asia Command, the 20th and 142d General Hospitals, did there exist the two prerequisites to undertaking radiotherapy in a U.S. Army hospital; namely, a radiotherapist certified by the American Board of Radiology and an accurately calibrated X-ray machine (and an apparatus with which calibration could be undertaken at frequent intervals).
Personnel - The medical officers assigned to the surgical service appeared adequate in number and sufficiently proficient. The acting chief of surgical service was on temporary duty from the 172d General Hospital, which anticipated eventually being established in K'un-ming. It was believed, however, that, in a hospital that possessed the privileges and functions of a general hospital, the chief of the X-ray Department should have had formal radiologic training and extensive experience, if not Board certification. At this hospital, however, the radiologist's sole training had been received in the course of a rotating internship and while conducting a general practice, during which time he had read films with experienced radiologists on an entirely informal basis.
The quality of professional service rendered surgical patients in this hospital, judging from observations made on complete ward rounds, from discussions with members of the surgical service, and from review of many clinical records, was on the whole very satisfactory. There was ample evidence of sound, conservative surgical judgment and competence in surgical undertakings.
Reconditioning.-Physical reconditioning for hospitalized patients had not been instituted at this hospital. At a nearby convalescent facility, however, under the able direction of 2d Lt. Ben Rubin, MAC, who was eminently qualified for the undertaking, a comprehesive reconditioning program for Class-2 and Class-3 patients was being developed and was found to be superior in every respect. It was believed that this program could be of inestimable value in hastening the recovery and return to duty of army personnel. The success of the program was to a considerable extent dependent on the establishment of an effective physical reconditioning program for patients in the hospital. Accordingly, an effort was made to convince the commanding officer and members of the surgical staff of the tremendous importance of their cooperation in this undertaking. In both the China Theater and the India-Burma Theater, this consultant had occasionally met with resistance in attempting to "sell" reconditioning, and it was particularly difficult if the commanding officer did not
favor the program. However, units that had finally become aware of the therapeutic value of remedial and conditioning exercises in speeding recovery were enthusiastic converts. Pre-emptory orders from the theater headquarters that such a program be established were not sufficient; it was essential that wholehearted cooperation be obtained from the entire professional staff, the nurses, and the corpsmen of a hospital and that they become thoroughly conversant with TB MED 137, published in January 1945, and the coordination of physical and surgical therapy of orthopedic cases, as described in TB MED 10, published in February 1944.
Failure of Headquarters, SOS, USFCT, to proceed more energetically with new construction that would expand the theater's sole fixed installation capable of undertaking major elective surgery on U.S. Army personnel made the likelihood of a physical plant's being constructed for the 172d General Hospital, committed to the China Theater for June 1945, extremely doubtful. Scarce materials allocated for use in such construction had, apparently, been diverted for other purposes.
The 21st and 22d Field Hospitals were also visited. The former, situated at Pao-shan, southern China, was in the foothills of the Himalayan Mountains and was visited on this consultants' return flight to India. The 22d Field Hospital at Chan-i, 100 miles east of K'un-ming, was reached by jeep in the company of Lt. Col. Robert L. Cavenaugh, MC, able executive officer to the theater surgeon and assistant theater surgeon.
In both units there was observed a deficiency in qualified personnel competent to perform major surgical operations. Owing, however, to the excellent character of the officers conducting the surgical services, there had been, in most instances, proper transfer to the 95th Station Hospital of patients requiring the more formidable surgical procedures.
On the morning of 3 June 1945, this consultant departed from K'un-ming, following a festive evening during which for 5 hours he was honored with a fabulous Chinese dinner of innumerable courses, interspersed with many toasts. The dinner was given by Colonel Armstrong and Gen. Robert K. S. Lim, Chinese Surgeon General, and section chiefs of their respective headquarters.
Return to Headquarters, India-Burma Theater
On completion of his tour of temporary duty in China, the author was discouraged and not at all satisfied that he had materially assisted the Medical Section, China Theater, despite the more than generous expressions of appreciation by the Commanding General and the Surgeon, China Theater, to him personally, and later, in a communication to the Commander and the Surgeon, India-Burma Theater. The U.S. Medical Department in China was woefully
lacking in almost everything. There was not a single hospital of modern construction, standard equipment was scarce, and there were too few qualified professional personnel. The whole setup was more in keeping with a mental image of conditions that existed in the frontier days of the Far West or in the South during the Civil War. Mud and filth prevailed everywhere, including K'un-ming.
One was hesitant about criticizing officers who were conscientiously doing their best under most unfavorable circumstances. Although their best was frequently not good enough, it was not their fault that, in many instances, they had been assigned to undertakings for which they did not possess adequate proficiency. On the other hand, the SOS and theater surgeons in the China Theater had no alternative to the employment of personnel sent to them by the India-Burma Theater. And, actually, the latter theater had little superior talent to spare, outside the university-affiliated units that they were disinclined to dismember. It was only natural therefore that, in fulfilling requisitions from China, the Surgeon, USFIBT, did not relinquish his most capable surgeons. In the final analysis, then, it would appear that the shortage of officers in China qualified to perform major operations was due to the War Department's failure in the first instance to assign a sufficient number of officers in this category to the China-Burma-India Theater.
Several weeks after this consultant's return to India, he received a communication from Colonel Armstrong, the substance of which follows:
He was still woefully short of medicos and was trying to persuade the India-Burma Theater's replacement center to facilitate the China Theater's requisitions. Unfortunately, the China Theater at the time had 7 medical officers who had been over there for 30 months, approximately 20 who had "point scores" above 100, and about 8 who were patients in hospitals at the time of writing. Among the medical officers in the China Theater, there were three or four who were over 50 years of age whom Colonel Armstrong was attempting to have sent home under special "WD radio," and the picture was really gloomy.
Two weeks later, the author wrote to Colonel Armstrong as follows:
A great effort has been made by Patterson, Chief of Personnel, Theater Surgeon's Office, and myself to secure for you qualified surgeons classified C- or B-3150, in order to meet your request for eleven so rated, and at the same time assign a sufficient number of officers of same qualification to the 70th and 71st Field Hospitals (prior to transfer to China). In order to accomplish this we have depleted the hospitals of this theater of all but key men and a few qualified limited-duty officers.
A concentrated effort was continued by the consultants and Colonel Patterson, not only to replace promptly officers who were rotated from the China Theater, but to replace them with officers of the highest qualifications available. The war ended too soon to judge the effectiveness of these intercessions, but it was believed that, had the war continued, these efforts would have resulted in a material improvement in the medical personnel picture in the China Theater.
SUMMARY AND CONCLUSIONS
A comprehensive review has been made by this consultant of the activities of the surgical consultant in the Southeast Asia Command, which comprised the India-Burma and China Theaters. Also, the stated mission and activities of U.S. Forces in these theaters has been narrated in order that the problems and activities of surgical officers can be more readily comprehended.
Certain observations and experiences of the consultants would seem to indicate lessons which could be profitably studied by medical officers who might be involved in any future war. Some of the practices of which the consultants were critical were common to all theaters and the Zone of Interior and stemmed from policies formulated in the War Department; others represented policies established in an individual command. Some of the policies which were considered objectionable have been appropriately corrected, others which pose serious problems have not. A brief outline of the more significant lessons learned is here recorded:
1. Improvement in the effectiveness of the consultant system was observed when the position of chief of professional services was discontinued.
2. Similar benefits resulted when the reports of consultants were routed through technical rather than command channels of communications to theater headquarters.
3. Benefits accrued from close relationship between the consultants and the chief of personnel in the medical section at theater headquarters.
4. Supply liaison activities of the consultants between the hospital medical supply agencies were considered decidedly worthwhile by all concerned.
5. Direct communication between the consultants in the theater and the directors of their respective divisions in the Office of The Surgeon General, prohibited in some other commands, proved equally helpful to The Surgeon General and in promoting the success of the consultants' activities.
6. Disadvantages were noted in the theater practice of referring all the way to the War Department, for approval, requests for changes in basic equipment allowances of units functioning in capacities other than originally intended-such as evacuation hospitals employed as station or general hospitals.
7. Failure to send to hospital commanders copies of the consultants' reports with the theater surgeon's indorsement tended to lessen the effectiveness of the consultants' visits.
8. The advantage of making all military units, including the air force, subordinate on medical policies to the theater surgeon was conclusively demonstrated to the consultants of the India-Burma Theater.
9. The unfortunate policy was formulated in the Office of The Surgeon General, prior to the entrance of the United States into the war, that prohibited the transfer of officers out of affiliated hospital units. This policy resulted in the excessive concentration of talented specialized personnel in a few hospitals, while most of the hospitals of the theater woefully lacked competent general surgeons and specialists capable of independent surgery without supervision.
10. Perhaps the most unfortunate practice noted by the consultants in all the theaters in which they served (to a lesser extent in the Zone of Interior) was a tendency to assign to administrative positions, particularly that of hospital commander, officers of field grade rank for whom there was no available clinical assignment commensurate with their rank and military occupational specialty (MOS 3100, general duty). These officers were too often lacking in both efficiency and proficiency, in aptitude to command, and in administrative ability. The solution to this problem, it would seem, is the formulation of a long-range plan during peacetime in which carefully screened reserve officers with aptitude for command are afforded the opportunity to attend special courses supplemented by yearly periods of training directly under highly competent commanders of various types of Army medical installations.