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Chapter XVII

Contents

CHAPTER XVII

Sixth U.S. Army

Frank Glenn, M.D.

    The military action in the Southwest Pacific Area was complex and unique in comparison with that in other theaters during World War II. It was complex because it involved amphibious landings, carrier-based and land-based air support, and infantry warfare with artillery support aided by tanks and flamethrowers in tropical jungle well defended by the enemy. It was unique in that there were numerous combat actions in various phases going on simultaneously over a wide geographic area. Thus, while one action was at its height, others were being initiated or completed. Planning was continuous and sometimes difficult to fulfill because of great distances between point of staging, embarkation, and invasion. These circumstances established the desirability for providing adequate surgical care that was not infrequently definitive in the most forward areas for the severely wounded.

DUTIES AND FUNCTIONS OF SURGICAL CONSULTANT

    Early in 1944, Maj. (later Lt. Col.) Frank Glenn, MC, was an assistant to Col. William B. Parsons, MC, Consultant in Surgery, SOS (Services of Supply), SWPA (Southwest Pacific Area). Concurrently, Major Glenn was in charge of special projects at the direction of Brig. Gen. (later Maj. Gen.) Guy B. Denit, Chief Surgeon, USAFFE (U.S. Army Forces in the Far East). In these capacities, Major Glenn visited the Sixth U.S. Army surgeon, Col. (later Brig. Gen.) William A. Hagins, MC. Although the specific purpose of this visit was to instruct forward medical units in the use of penicillin which had just been made available in limited quantities to the SWPA at the request of Colonel Hagins, two additional objectives were undertaken. The first of these was to evaluate the type of surgery performed in forward combat-area hospitals and the second was to brief and instruct personnel of hospitals assigned for the first time to the Sixth U.S. Army--hospitals that had had no experience under combat conditions.

    During the following months, until October 1944, in carrying out the duties of a surgical consultant, Major Glenn was able to visit both SOS and Sixth U.S. Army units. It therefore evolved that, after making a tour of the medical units in the forward area, the consultant would return to those in rear bases. Thus, an opportunity was presented to observe how the casualties of one campaign were cared for in the most forward combat areas and to follow


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them through the chain of medical evacuation to the fixed hospitals in the rear. It was the result of this overall picture that enabled a surgical consultant to make suggestions to the surgeon in the forward area.. Furthermore, such liaison relayed information to rear units that gave them a better understanding of the problems encountered by the forward medical units.

    There were certain differences between the problems of the theater consultant and an army consultant. Particularly was this true where the actions were relatively small and took place at intervals of great distance. Throughout the SWPA after the Buna operations, assault landings were of an amphibious nature, and the number of troops employed varied from a small task force of a few hundred men to a force of several divisions.. Each military objective presented different problems. The medical units accompanying such combat forces functioned for various periods and then were comparatively idle. The army consultant was confronted with the problem of having varying numbers of new medical units for only a short time before action and then for relatively brief intervals during the active phase of a campaign. He then moved on to a somewhat similar episode in the next step. It. was difficult for him to know the exact capacity and ability of the surgical personnel of these units. It was because of these circumstances that the army consultant, if he was to assist in giving the wounded the best. care, required that surgical personnel assigned to forward medical. units where surgery was to he performed--evacuation, field and portable surgical hospitals--be of the very best. In the type of warfare carried on in the SWPA, well-trained and mature surgeons were of greater critical and immediate importance in the forward medical units than in the rear bases. Surgical skill and judgment were urgent in the care of the wounded. If this service was available in the forward area, human life as well as limb could be conserved. The forward area was where the seriously wounded either died or lived, and the period required to determine this was relatively short.. On the other hand, if a wounded soldier reached a fixed medical installation in a rear base, whether he returned to duty or was evacuated to the Zone of Interior was largely a matter of the type of wound. Skill and mature judgment on the part of the surgeon in the base increased or decreased the time period required for the proper disposition of these wounded but rarely determined the life or death of the patient.

    The affiliated general hospital units in the SWPA had an abundance of surgical talent. The 400-bed evacuation hospital units frequently had only one well-trained surgeon, and in some field hospitals the best trained surgeon was of mediocre ability. The portable surgical hospitals, when they were first organized in the SWPA, had officer personnel of a superior type. Their surgeons were for the most part selected from affiliated units. It was the quality of the medical officer and his training, ability, and maturity that established the portable surgical hospitals in the eyes of the SWPA. More attention should have been paid to the allocation of professional personnel. There was reluctance on the part of SOS, SWPA, to release surgeons for duty in the forward


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FIGURE 80. - Lt. Col. Frank Glenn, MC, Consultant in Surgery, Sixth. U.S. Army.

area because they wished to keep them in the bases. This attitude led to the delay in sending surgical teams to the forward area.

    Major Glenn was assigned as surgical consultant to the Sixth U. S. Army on 1 October 1944 (fig.80). He was familiar with the organization of this army as a result of numerous visits to organizations assigned to it during his period of service with the Surgeon, SOS, SWPA.

    The Philippine campaigns then about to begin were the largest military operations yet to be undertaken in the SWPA. Throughout the Leyte campaign, which was a difficult one because of the weather and tactical situation, the surgical consultant was unable to cover each surgical service as frequently as he would have liked. Later, in the Luzon campaign, at the request of the Sixth U.S. Army surgeon, Lt. Col. George O. Eaton, MC, Consultant in Orthopedic Surgery, SOS, was placed on temporary duty with the Sixth U.S. Army. He and the surgical consultant together were able to maintain a closer relationship with a larger number of surgical services.

    The supervision of the surgical activities of an army was dependent upon many factors, one of the most important of which was an accurate knowledge of the personnel of the various surgical units. Insofar as it was feasible, surgical units were visited by the surgical consultant prior to their embarking upon a mission. It. was customary for the surgical consultant to visit the hospital and inform the commanding officer of the purpose of his visit. Thereafter,


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he would talk to the chief of the surgical service explaining the duties of the consultant and how these could best be accomplished for the benefit of the wounded. Time permitting, 2 or 3 days would be taken to gain an insight into the background, training, and personality of the individuals on the surgical service. During this period, meetings were also held to outline the general principles to be followed in the care of the wounded and to discuss any problems that might appear to be peculiar to the oncoming mission. In many instances where the unit had not formerly been in action under combat conditions, one encountered considerable enthusiasm and an equal amount of ignorance of forward area surgery. The surgical consultant found it difficult to understand how surgeons who had been in the military service for 1 or 2 years or longer and who presumably were trained for duty with combat troops could appear to have so little factual information concerning the task before them. The commanding officers of many of these hospitals had little information as to how their men performed in action.

    Some commanding officers had joined the units some time after their organization, even as late as the day of embarkation, and had had no Opportunity to see their personnel work together in a hospital. Information available to these hospital commanders was frequently limited to such data as appeared on the personnel record--Officer's and Warrant Officer's Qualification Card (WD AGO Form 66-1). By direct association, however, with the professional staff during the period of travel and staging, these hospital commanders were usually able to evaluate fairly well the adaptability of individuals. The information obtained by the surgical consultant from these initial visits concerned generally the training and qualifications of the professional members of the surgical staff. The outstanding surgeons were readily recognized, and likewise those who had very little in the way of training or experience. Many of the surgeons, however, could not be accurately evaluated from the contact of this one visit. It was true that gross misfits were sometimes found, and, when they were, their disposition was discussed with both the chief of the surgical service and the commanding officer and proper recommendations were made for a shift within the organization to resolve the problem. If, however, the transfer of the misfit to another organization was required, then, following discussion with the hospital commanding officer and his chief of surgical service, recommendations were made to the army surgeon to correct the malassignment. Generally speaking, commanding officers were cooperative; the chief of the surgical service was more directly concerned and was usually more aggressive in correcting an unfavorable situation. Failure to secure cooperation was encountered where there was a close personal relationship between the officer in command and a staff member. Under such circumstances, commanding officers were reluctant to accept the consultant's recommendations and offered excuses of various types for the individual.

    In an effort to secure uniformity of policy in handling cases, discussions of a common pattern were presented before all units, and at the same time


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directives that had been issued by the army surgeon on the recommendation of the surgical consultant were given to each medical officer. During these discussions, officers were given an opportunity to ask questions in order to clarify various types of treatment.. Although these meetings were well attended and enthusiasm and attention were excellent, later experience showed that many medical officers disregarded or forgot policies that had been clearly defined. This resulted in recurrence of mistakes that were common to many units operating in the forward area. Following these visits, the surgical consultant reported to the army surgeon his evaluation of a unit as a whole and made recommendations for strengthening the unit, and, if an excess of unusual talent was found, names of such officers were listed for use in other units. It was not possible to see all units before their arrival in the combat area because some of them came from other areas and, in some instances, although they were within the area., they were inaccessible. The Sixth U.S. Army surgeon was most interested and concerned in the evaluation of the personnel of the surgical services of the various medical units. Cooperation was complete and at no time were recommendations by the consultant regarding the change of personnel not accepted. It should be emphasized, however, that all deficiencies were not corrected because replacements were often not available.

    In evaluating the ability of operating surgeons assigned to medical units destined to function in combat areas it was evident that certain fundamental prerequisites were overlooked by those evaluating surgeons within the Zone of Interior. Surgeons for forward area units had to be particularly well balanced and mature if they were to carry out the duties of a chief of service or a section chief. Highly developed specialists with backgrounds suggesting unusual accomplishments were sometimes found ineffective in these units. In the selection of personnel for a field or evacuation hospital, it was necessary to take into consideration not only the type of surgery that was to be performed but also the conditions under which it would be accomplished. Highly emotional, easily excitable, and impatient individuals were a detriment to this type of medical installation.

    As an army moved forward into a combat area, the surgical consultant followed the medical units entrusted with the care of the wounded. Definitive surgery in the Sixth U.S. Army was done in portable surgical, field, and evacuation hospitals for the most part. After amphibious assault landings, the wounded were cared for by the Navy until one of the above organizations, or part of it, could be established ashore and set up for operation. As these installations were established and expanded, the surgical consultant attempted to maintain an overall picture of their actions. This was facilitated by the Medical Section, Headquarters, Sixth U.S. Army, for here information on the location and the patient load of each medical unit was at all times available. The general plan was to keep in close touch with those units that were carrying the heaviest patient loads. In Leyte, for instance, the evacuation hospitals did most of the definitive surgery during the early days of the fighting (fig.81).


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FIGURE 81. - The 58th Evacuation Hospital at Tacloban, Leyte, 25 October 1944.

    Sometimes the surgical consultant would make one of these hospitals his headquarters, giving particular attention to the condition of the patients who arrived, watching in the operating room, correcting practices that were to be discouraged, and, not infrequently, taking a hand in an operation to demonstrate how the procedure might be improved. Rounds were made with surgical offices ranging from ward officers to the chief of services. There was no question in the mind of the surgical consultant that this was where a true evaluation of surgical personnel was to be made--by direct observation of the surgeons in action. The preoperative preparation of the wounded, a. decision as to when an operation should be performed, the judgment and dexterity exercised at the operating table, the postoperative care, and the interest accorded the patient made up the most important items that determined a surgeon's efficiency.

    The well-trained surgeon with years of clinical experience back of him, mature in judgment, and reasonable in reaction to adverse circumstances was the one individual in thus war who contributed most to the brilliant record of the Medical Corps as far as the professional care of the wounded in the forward area was concerned. It was not amiss to point out that it was there that the capable medical officers put forth superhuman effort, sleeping only a few hours a day, working continuously, and doing more than one individual was reasonably expected to accomplish. This effort was required not because there was a shortage of medical officers so far as table of organization strength


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was concerned, but because the abilities of all those who held authorized positions in the medical units were not comparable.

    The surgical consultant viewed his tasks as being concerned with maintaining as high a standard as possible for the surgical care of all the wounded in the army. In this, the army surgeon, General Hagins, concurred and provided all possible cooperation and support. In order to accomplish this, it was necessary for the consultant to see firsthand as many of the wounded as possible along the chain of medical evacuation from battalion aid stations to the rearmost hospitals. In the early phase of an action while the advancing perimeter was relatively small, this was easily done, but as the area increased there came a time when the consultant was able to see only a few of the medical units functioning each day. Their numbers increased as the days passed and the total area over which they were scattered became larger. For example, in Leyte, until the front extended into the Leyte Valley, operations were confirmed to within a few miles of the Leyte Gulf and all casualties were funneled into a relatively small area. Evacuation was from one airstrip and by water back to the rear bases. If the consultant was familiar with the units and kept their locations in mind, and if he knew the surgeons, he was able to be of invaluable aid to the army surgeon when new and unexpected problems arose. As a perimeter moved rapidly and extended its fingerlike projections several miles, as in the Leyte Valley, and medical units were for periods inaccessible, support was sent forward to bolster deficiencies that, might. have been anticipated. Evacuation points were excellent places to gain quickly an overall picture of what was being done in the surgical care of the wounded. Furthermore, other factors that had a bearing on the care of the wounded were much more apparent at evacuation points than in the individual units. Such factors included the tactical situation, its bearing on transportation, and the availability of beds, which in turn determined the evacuation policy to rear bases.

    The weather, roads, and transportation in turn influenced the number of beds that were available just as the same factors played a role in the transportation of patients from medical installations to evacuation points (fig. 82). The patients, as seen at these points, gave a fair cross section of what the hospitals from which they came were doing, for the quality and style of craftsmanship followed the pattern of the talent that produces it. One of the most effective methods for correcting improper practices was to list patients and what had been done and then to visit the hospitals involved and, through their commanding officers and chiefs of surgical service, present the findings to the responsible medical officer. When areas to be covered were small, the consultant could keep him direct contact with chiefs of surgical services by frequent visits.

    The surgical consultant going from one surgical service to another and with an overall view of the wounded was always able to indicate something of what the immediate future might hold. Preparation for a heavy casualty load always facilitated the actual caring for it. Innovations in one unit were suggested in others; likewise poor procedures in surgery were avoided.


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FIGURE 82. - Evacuation on Luzon was difficult after the Japanese retreated high into mountainous areas. A. The evacuation of casualties by collecting company jeep ambulances to a portable surgical hospital. Jungle terrain offered excellent cover for snipers. B. In mountainous areas, many hands were required to evacuate patients. Note that a portion of aid station is in defilade (lower right corner).


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FIGURE 82. - Continued. C. A team of 15 native Filipinos was required to evacuate one casualty down steep mountain slopes. Six were litter bearers the others formed a human chain to prevent litter bearers from sliding or falling from cliffs bordering the trail.

    Failures to follow policies previously set down by the surgeon in the surgical care of the wounded were best corrected on the spot. Direct explanation usually corrected the improper practices in the recalcitrant, but actual demonstration was the best means of telling another surgeon how a procedure should be done. No surgical consultant should have been inhibited in operating to demonstrate what he wanted done. He likewise should have been willing to assist any of the surgeons in his area when asked.

    When, as in the Lingayen Valley, long and irregular lines were formed and extended until a large number of medical units were distributed over several hundred miles, it became impractical to see all surgical services at frequent intervals. The general practice was to bypass those that were self-sufficient and to concentrate on those that required help. If indicated, such units were quickly reinforced by surgical teams with superior talent.

    Although the Luzon campaign extended over a larger area, transportation was seldom a problem because the weather was dry, there were hard-surfaced roads, and L-5 Cub planes were available. Thus, patients could for the first time in the SWPA be transported considerable distances quickly to field and evacuation hospitals. By and large, the portable surgical hospitals were no longer called upon to do so large a proportion of the primary definitive surgery. Because of overall circumstances referred to elsewhere, portable surgical hospitals, prior to the Luzon campaign, had to do more than it was ever intended they should. Working under trying combat conditions, the surgeons of these


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small units had for the most part functioned in a manner that stood out as a tribute to American surgery. It thus became a matter of pride and tradition for portable surgical hospitals to do more and greater surgery. Unfortunately, many of the oldest of these units by this time had lost their most capable surgeons by rotation, and replacements were too often surgeons of limited experience. The same was true for many of the new portable surgical hospitals. It required emphatic instructions to persuade them to do only what was indicated rather than what they were willing to attempt. It was fortunate that at this phase of the war the field and evacuation hospitals reinforced with surgical teams could be utilized as intended.

    The surgical consultant attempted to make himself available at all times for problems that were constantly occurring. Little time was spent in the army surgeon's office during active periods of combat, but the office kept in touch with him. Availability had to be stressed; critically ill wounded soldiers did not wait. If help was to be effectual, it was not to be postponed. If a surgeon in a forward unit asked for help or advice, the consultant could rest assured that his services would be appreciated.

    The consultant also concerned himself with seeking out hidden talent. No army the size of the Sixth U.S. Army in World War II could have been expected to have all persons, including medical officers, in the positions for which they were best fitted. Medical officers well trained in surgery were found in positions where no surgery could be done. Anesthesiologists, too, were found in line organizations doing a minimal amount of medical work. It should also be mentioned, however, that all medical officers who claimed to be misplaced and who desired a change could have readily misled a consultant who had a sympathetic ear.

    The problem of promotions became an item of great concern in the forward area after units and/or officers had been on foreign duty for a year or more. Many well-trained medical officers, some of whom were eligible for classification as specialists and some of whom had passed their respective boards, accepted lower rank than they should have on entrance into the service. In particular, this seemed to have been true for those doctors without previous military experience. At the same time, doctors in reserve military organizations too often were given rank that was not justified on a basis of professional qualifications. Many medical officers thus found themselves overseas with organizations under circumstances that fixed their rank or at least made promotion unlikely so long as they remained in the assignment they occupied at the time they arrived in the oversea theater. It was true that the policy of promoting lieutenants to captains enabled the lowest grades to be properly dealt with. But other medical officers in the SWPA who had worked efficiently and well for 2 years in the New Guinea jungle but who remained captains and majors--the grades they were given when they entered military service-had just cause for complaint.


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FIGURE 83. - Administration of plasma at an aid station, Leyte Island, Philippine Islands.

TRIAGE, TREATMENT, AND EVACUATION

    The treatment of the wounded soldier in the Southwest Pacific was a step-by-step procedure. Triage, so evident in the accounts of World War I, was always of the greatest importance in the forward area. Although no one medical unit could very often care for the seriously wounded from injury to recovery, all units were involved in triage and one or more steps in treatment. The handling of casualties was, in a sense, of an industrial pattern with certain stations for certain steps. These began with the emergency medical treatment given by aidmen and litter bearers as the first step-control of hemorrhage, administration of morphine, application of a dressing, or immobilization of a fracture. The second step often included a completion of the emergency medical measures of step one, the administration of plasma or even whole blood in a battalion aid station, and additional supportive measures for transportation to a clearing station and portable surgical hospital where definitive surgery might be undertaken (fig. 83). The seriously wounded were carefully reevaluated at the clearing station and portable surgical hospitals. The patient was viewed not only in the light of his specific wound or wounds but as a whole, and, at the same time, the distance and circumstances involved in transporting him farther to a field or evacuation hospital were considered.


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    If transportation was a simple matter, then the most important phase of triage occurred in field and evacuation hospitals. Thus, in the Southwest Pacific, the portable, field, and evacuation hospitals were the important stations for the seriously wounded. It was in these that the very important third step, definitive surgery, was accomplished.

    It was here then that mature judgment, straight thinking, and sound conclusions provided for the greatest good for the greatest number. Once the patient's status was established, preoperative treatment was begun and followed by the indicated surgical procedures. The procedures followed were based on the overall policy that provided first., for the saving of life; second, for the preservation of a part; and third, for the maintenance and restoration of function. Definitive surgery that failed to contribute to these was contraindicated. For the majority of wounds, the indicated procedures were simple. There were a limited number of injuries that required heroic procedures involving considerable technical detail. Head, intrathoracic, and intra-abdominal wounds were examples and required that the simplest procedure that accomplished the desired end was the one of choice. For instance, it was more important to deflect the fecal stream in injuries of the pelvis involving the rectum rather than to do extensive procedures that aimed at an end result such as might be undertaken in civilian practice under the most ideal surroundings. If procedures were not lifesaving or if they increased the hazard of treatment even though reconstructive, they were not considered justifiable. These procedures could be taken care of later when life would be more secure, either in rear area hospitals or in hospitals designated for reconstruction work in the United States.

    The forward area hospitals concerned with triage in the SWPA attempted to direct the care of the wounded so that, first, life and limb would be preserved; second, the lightly wounded would be returned to duty as early as possible; and third, as a link in the chain of medical evacuation, their facilities would be kept available for new casualties. It followed that in order to accomplish this pattern, patients who could withstand transportation better before definitive surgery than after had to be operated upon, when possible, where the necessity for moving them after operation was reduced to a minimum.

    In the process of triage, treatment, and evacuation, all the exigencies of war were involved. So varied were these from operation to operation, from campaign to campaign, and from day to day in the Southwest Pacific forward areas that no rules could have been set that would have covered the various questions that arose. Only general policies could be set forth and the employment of these left to those who at the time and place were responsible. Only they could and did have the accurate picture of the various problems. The care of the wounded, triage, treatment, and evacuation in tropical jungle, on the one hand, and on the plains of Luzon, on the other, were different in detail but


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FIGURE 84. - Litter evacuation through rain-swollen streams on Leyte.

not in objective. All things considered, they were accomplished equally well in both types of terrain.

PHILIPPINE ISLANDS CAMPAIGNS

Leyte

    The invasion of the Philippines at Leyte, the largest operation yet to take place in the Southwest Pacific at that time, involved an entire field army. It began on 17 October 1944 and was declared ended on 1 July 1945. Sixth U.S. Army participation in the campaign was from 20 October 1944 to the end of the year. During the most active combat operations (until the end of December 144), almost 9,000 wounded were cared for in army medical installations. From the outset, acceleration of the assault date created a difficult medical situation.

    Adequate surgical care of patients was rendered difficult by the comparative isolation of certain forward units in the field, by the frequently long litter carries from place of wounding to the installation providing emergency surgery, and by the difficult weather and terrain (fig.84). Long and uncertain lines of evacuation, Japanese roadblocks, and other factors at times combined to force installations to perform surgery beyond their planned scope, to hold


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FIGURE 85. - Tent housing operating facilities of a portable surgical hospital at Consuegra, Leyte Island.

patients who should have been evacuated more promptly, and to evacuate patients who should have been held until fully transportable. A great deal of the surgery was performed in portable surgical hospitals attached to divisional clearing companies (fig.85). These hospitals saved many lives which would otherwise have been lost. These small units were, however, limited in personnel and equipment, and they lacked the facilities to give postoperative care. The early performance of operations upon patients with abdominal injuries was of great importance, but such patients could not be moved for some time afterward. Here, for example, it was not always possible to adhere to the policy of holding abdominal cases for 10 days after operation, and a mortality higher than had been anticipated resulted. Difficult evacuation from battalion aid stations to surgery, requiring days in certain extreme instances, made it impossible always to operate on critical cases within the 6 hours after wounding when the chance of success was greatest, and it was reported that the average interval between wounding and operation was longer than in previous campaigns. Additional surgical teams might have strengthened the forward surgery, but most of the surgical problems arose out of the tactical situation. Gas gangrene was more of a problem on Leyte than at any time previously in the Southwest Pacific. Penicillin was used more widely in Leyte than in any previous operation, as was whole blood that was made available by air shipments directly from the United States.

    Evacuation and field hospitals were broken down into sections and operated as independent units. The evacuation and other hospitals that were established early near the beaches and were functioning by D+2 or D+3


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gave excellent surgical care to the wounded because of adequate personnel, equipment, and proximity to the source of the patients. As the forces moved inland, the picture changed. A single road in the Leyte Valley with its lanes into the hills over which American troops could advance soon became impassable with continuous rain and truck traffic. It was not unusual for troops to be isolated on high ground by high water, Japanese roadblocks, or impassable roads. There was no continuous advancing line. Unlike the portable surgical hospitals and clearing stations, the evacuation and other larger hospitals which were first set up could not be moved forward under these circumstances. Small forward hospital units were on occasion shelled out of position, and the perimeters of some were penetrated by the enemy.

Luzon

    The invasion of Luzon by Sixth U.S. Army forces began on 9 January 1945. There had been ample time for planning with the result that provision for adequate medical support was accompanied by a policy of selecting highly qualified surgeons for field and evacuation hospitals. Furthermore, these units were supplemented with surgical teams. From January until the latter part of April, there occurred approximately 27,000 wounded. In contrast to the Leyte campaign, the overall tactical situation was ever favorable; there was a minimal display of hostile airpower so far as the ground troops were concerned. The weather was dry and pleasant. There were numerous hardsurfaced roads, and transportation for the wounded was adequate. Cub planes (L-5 type) were also available in fair numbers for the first time (fig.86).

    Each division had allocated to it one evacuation, one field, and two portable surgical hospitals. To each evacuation hospital one surgical team was attached, and, to each field hospital two surgical teams were attached. The teams had been selected from hospitals in the rear bases by the theater surgeon on the recommendation of his surgical consultant and for the most part were well known to the surgical consultant of the Sixth U.S. Army. It followed, therefore, that in the forward area the strongest teams were assigned to those hospitals that had the lesser amount of superior surgical talent or that promised to have the heaviest casualty loads.

    The surgical care accorded the wounded on Luzon was of a high degree of excellence and superior to that in any forward area in previous campaigns in the Southwest Pacific. Evacuation of the wounded was accomplished much more quickly and with greater ease. The proportion of patients that had to be operated upon in the portable surgical hospitals was greatly reduced. Not only were a greater proportion of the wounded operated upon in the field and evacuation hospitals, but certain of these hospitals were designated to care for special types of wounded for which they were particularly qualified. Head injuries, maxillofacial wounds, and others were thus given definitive treatment by specialty groups. These hospitals were located in permanent build-


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FIGURE 86. (See opposite page for legends.)


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ings, such as schoolhouses and churches, and could be expanded easily. Thus, the need for evacuation to the rear bases was rendered less acute than it had been on Leyte where tentage was at a premium.

    The reduction of the time lapse between wounding and definitive surgery diminished the incidence of severe wound infection. For example, gas gangrene was infrequent out Luzon as compared with the Leyte campaign in which almost 100 cases developed among approximately 9,000 casualties, whereas there were less than half that number in some 27,000 casualties on Luzon (p.494). That patients with abdominal wounds did not have to be evacuated to far-removed bases and could be left unmolested for from 10 days to 2 weeks after operation undoubtedly decreased the mortality for that group.

    The value of adequate whole blood from the United States in the treatment of the seriously wounded could not he overemphasized. In the seriously wounded and partially exsanguinated, to be able to replace large blood loss without stint and to be able to follow resuscitation with early superior surgery was gratifying. The daily distribution of blood to field and evacuation hospitals provided a source of whole blood for the more forward units even to time battalion aid stations where it could and should have been used. Approximately 20,000 units of blood were used on Luzon during the first quarter of 1945 by the Sixth U.S. Army.

SUPPORTIVE THERAPY

Plasma and Whole Blood

    During the first half of 1944, as one made rounds on surgical wards in the most forward medical units as well as in those of the hospitals in the rear bases, it was quite evident that more blood was needed for the wounded. Hemoglobin values and red blood cell counts were too low. In the forward areas, plasma was used in great quantities in the resuscitation of the wounded. It gave volume to the circulating medium, but it did not increase oxygen-carrying capacity. Blood was used too infrequently and in too small amounts. The source of fresh whole blood was limited to medical unit personnel and whatever troops might be nearby. Many of the men had had malaria so that this hazard was ever present. Facilities and equipment for processing blood for transfusions in the New Guinea jungle were more limited than in civilian hospitals back home, and the incidence of transfusion reactions was consequently higher. There were units whose professional personnel were limited in their experience with transfusions, and as a result they were easily discouraged and instead of seeking out the cause of the reactions took refuge in the erroneous conclusion that transfusion reactions were unavoidable in the tropics.

FIGURE 86. - Air evacuation on Luzon Island, Philippine Islands. A and B. Evacuation by L-5 aircraft. C. Catalina flying boat standing by for wounded D. Casualty on Stokes litter being loaded into Catalina flying boat for evacuation to Manila.


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    The patients evacuated from the forward area to the rear hospitals too often had a low serum protein level as well as reduced hemoglobin and red cell count.. It was the repeated experience of the consultant after making ward rounds in these hospitals to insist that more transfusions be given and then to hear the various reasons why they were not given. The answer rested in the fact that an adequate supply of satisfactory, preserved whole blood was not available. This was the state of affairs despite the fact that a highly efficient and scientifically controlled Australian blood bank in Sydney, a combined Australian Army Medical Corps and Australian Red Cross Society organization, furnished blood for American units in New Guinea. Citrated whole blood packed in insulated and iced boxes were sent from Sydney to New Guinea where it was re-iced or kept in refrigerators until used. This was not satisfactory because there were many instances of excessive hemolysis, fibrin clots, and reactions. These all contributed to a general lack of confidence in preserved whole blood and the tendency to further popularize plasma.

    When the SWPA was extended into Netherlands New Guinea and Hollandia became the main base, because of both the distance and unsatisfactory experience with time citrated refrigerated blood from Australia, it was decided to establish a blood bank. The U.S. Navy had had in operation for some time a blood bank on time LST (landing ship, tank) 464, and, in cooperation with Army units, blood was taken from troops, processed, and sent forward. With the same processing, a blood bank was established at the 27th General Hospital in Hollandia. Working in conjunction with the LST 464, this blood bank provided the greatest amount of citrated blood ever to accompany a task force up to that time in the SWPA; namely, the invasion of the Philippines at Leyte. This was a step forward to correct the inadequate supply and use of whole blood, in particular, in the care of the freshly wounded, but left considerable to be desired. There were still too many reactions. There was some breakage and also excessive hemolysis. Fibrin clots caused difficulty in administration.

    On 23 November 1944, the first citrated blood provided by the American Red Cross was flown by C-54 to Leyte from the United States by way of Hawaii and Guam. Lieutenant Lake and Lieutenant Hendrick of the U.S. Navy, representing the Red Cross, accompanied the shipment of blood consisting of 64 bottles contained in 4 regular containers. These were used in medical units under control of the Sixth U.S. Army. This well-processed blood in containers equipped with adequate filters and individual sterile sets for administration immediately answered the common objections to giving transfusions. No longer was it necessary to call on troops staging for missions to give blood, processing setups were no longer needed, and the preparation of equipment for administration was obviated. Furthermore, the container for transporting the blood was well constructed and efficient. The unit containing 16 bottles was ideal for sending to the smallest units doing definitive surgery. The blood arrived on Leyte from San Francisco in from 5 to 7 days. This adequate supply of whole blood that was made available for the wounded soldier


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was one of the great accomplishments in the war. In due course a distribution system was established that provided a daily supply to field and evacuation hospitals. The ambulances and small planes evacuating patients from clearing companies and portable surgical hospitals transported blood forward. The use of large quantities of whole blood where severe hemorrhage had occurred did without doubt contribute to the saving of lives in the forward area that would otherwise have been host. As much as 4,000 cc. per wounded soldier were used within the first 24 hours of wounding. When such quantities were indicated, one transfusion alone was of little avail. With adequate blood available, exsanguinating hemorrhage and shock were much better treated immediately, and the general appearance of the more seriously wounded greatly improved. The proof that the product. and equipment supplied was excellent was demonstrated by the results. One evacuation hospital gave 720 units of blood in one month without a single serious reaction.

    Throughout the Luzon campaign, the blood supply from the States was well maintained and it was possible to set 4,000,000 RBC as a minimal level for all patients.

Chemotherapeutic Agents

    The use of sulfonamides locally as a first aid procedure in the treatment of the wounded was described in basic War Department Field Manual (FM) 21-11, First Aid for Soldiers.

    It was the observation of the surgical consultant that no other one procedure was followed so uniformly as the local application of sulfonamide powder to wounds in fresh battle casualties. It was applied by the aidman, and the soldier was well aware of the possible benefits of such chemotherapy. To that extent, it was a valuable moral therapeutic adjunct in his care. The use of sulfonamides locally during and following definitive treatment of wounds was likewise uniformly employed in the various surgical units of the forward area as late as the early part of 1943. Inadequate debridement was followed by the application of sulfonamide powder locally, and in many instances it was accompanied by the sense of false security on the part of the surgeon. On surgical rounds, one would occasionally see wounds that had been incised to various degrees and filled with sulfonamide powder that acted as a foreign body. It was common practice, following a well-done debridement, for the surgeon to sprinkle various amounts of sulfonamide powder into the depths of the wound. In exploration of the abdomen where no perforation of the viscera was encountered it was not unusual to see a surgeon sprinkle sulfonamide powder in a clean wound. Out direct questioning as to what was being accomplished by such use of sulfonamides, there were many replies indicating that they believed it was of great chemotherapeutic value, that it prevented infection if it was not already present, that its use in clean wounds was justified in the tropics on the basis of preventing infection, and that it accelerated wound healing.


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    Although there was considerable literature before 1942 which demonstrated the limited effective use of sulfonamides in infection, demonstrated that there was considerable foreign body reaction where sulfonamide was placed in the wound locally, and explained that the local use of sulfonamides inhibited wound healing and certainly did not accelerate it, these facts were not well known. Reports in publications by the Army and Navy, recording in glowing terms the prophylactic use of sulfonamides at the Pearl Harbor disaster, also gave a great number of medical officers a sense of false security. Medical officers not well trained in basic principles of surgery were inclined to do minimal surgery and then apply sulfonamide powder in or on the wound.

    When penicillin was made available to medical units in the forward area in March 1944, the assistant surgical consultant of the SWPA had an opportunity to discuss with a large number of medical officers their conception of wound infection and the mechanism of wound prophylaxis by means of chemotherapeutic agents. Too frequently, there was a lack of understanding that in the prevention of wound infection one of the most important requirements was the removal of devitalized tissue and the prevention of the extension of infection by providing adequate drainage. The impression did exist that sulfonamide placed on a wound superficially penetrated into its depths. That the pouring out of exudate from traumatized tissue mechanically moved the sulfonamide from where it would have been efficacious in inhibiting growth seemed to have been forgotten. The complications of the systemic use of the sulfonamides were not well appreciated, and serious complication occurred as a result of sulfonamide therapy plus dehydration. Directives were published by the army surgeon's office cautioning the use of these drugs systemically and outlining a course that provided for adequate fluid intake and alkalinization.

    An attempt was made to discourage the use of the sulfonamides locally following definitive surgery in the hope that there would be more attention given to complete and adequate surgery including the removal of devitalized tissue and providing for complete and free drainage.

    If, in the opinion of the surgeon, sulfonamide therapy was indicated, then it was recommended that surgeons watch the patient's fluid intake and check at frequent intervals the blood and urine in an effort to discover early any untoward complications of these groups of drugs. It was pointed out early in 1944 in a directive from the army surgeon's office that the use of sulfonamide was not obligatory. A few months later, it was recommended that the existing liberal local use of sulfonamide therapy be curtailed. Late in 1944, the surgical consultant of the Sixth U.S. Army recommended that local sulfonamide therapy be discontinued and that only systemic therapy be used on cases in which it was clearly indicated. In spite of the efforts of educational measures taken, a large number of medical officers continued to use sulfonamides locally in wounds. Those most convinced of its worth and most insistent on its merit were those who had recently arrived from the Zone of Interior. The publication of War Department Technical Bulletin (TB Med) 147, in March 1945,


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should have settled the problem which had been controversial since the reports, in January and February 1942, of the Pearl Harbor disaster.

SURGERY OF REGIONAL WOUNDS AND INJURIES

Neurological Injuries

    Casualties having head wounds with brain injury were evacuated, when possible, to designated field and evacuation hospitals for definitive treatment. During the various actions in New Guinea, there were many instances when this was impractical and definitive surgical treatment had to be done in portable surgical hospitals. For the most part, these patients withstood transportation well. Extensive, time-consuming procedures were sometimes required in massive injuries, and, thus, a small number of patients would keep a neurosurgeon busy. Too few trained neurosurgeons were in the forward area, and there were times when neurosurgical teams could have been well used. Large defects of the dura were closed with fascia and sliding scalp flaps. Damaged brain tissue and foreign bodies when accessible were removed. Fibrin foam was first available in early 1945 and proved to be of great value in the control of bleeding.

    The postoperative care of these patients during the early phases of an action and before Army Nurse Corps members arrived presented a real problem. Nurses trained in the care of postoperative neurosurgical patients were invaluable and second in importance only to the surgeon in the most seriously injured head cases. Both in New Guinea and on Leyte, lack of neurosurgeons and facilities for special nursing care limited the attention accorded these patients. On the other hand, on Luzon, both were available, and care given there was superior in every way.

    Spinal cord injuries due to intact missiles and shell fragments were occasionally subjected to laminectomy and exploration during the fighting in New Guinea. The results led to almost complete abandonment of this procedure. Following preliminary treatment including careful suprapubic drainage established by placing a well-fitting mushroom catheter in the dome of the bladder, these patients were given a high priority for evacuation to rear bases. They were transported in complete body spicas. Limited nursing facilities, cots, plaster spicas, and long distances from the rear area were factors that contributed to the large decubitus ulcers so common to those with cord injury.

    Peripheral nerve injuries were rarely repaired. The ends of divided nerves were frequently marked by placing a suture of black silk or a silver clip in time divided ends.

Thoracic Injuries

    The closure of open chest wounds in battalion aid stations and clearing stations was well done by strapping with adhesive tape and massive dressings. Large wounds and those associated with severe hemorrhage did poorly; lesser wounds did well. These patients likewise tolerated transportation if hemor-


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rhage was not great. Where circumstances required that these patients be cared for in a portable surgical hospital without intratracheal closed system anesthesia, operative procedures were limited. Local anesthesia and major chest surgery were not compatible; open anesthesia could be dangerous indeed. When possible, all major chest injuries were cared for in designated evacuation hospitals where those with both experience and equipment were available. Hemorrhaging wounds had to be controlled by the simplest procedure in the forward area. Sometimes, there was a tendency to do too much following the success of the control of blood loss.

    Perhaps in no other group was fresh whole blood more important than in massive chest wounds where there had been large blood loss. This with oxygen therapy was found to be lifesaving and was followed by successful resuscitation. It was found that preserved whole blood, such as that received from the States or rear blood banks, had a reduced oxygen-carrying capacity and, although better than plasma, could readily overload the circulation.

    The closed treatment of pneumothorax and hemothorax by early aspiration was in general followed. This practice, together with penicillin therapy, proved very satisfactory. While the later incidence of empyema in patients thus treated was not known, by far the great majority of these patients ran an afebrile course prior to evacuation or discharge.

Abdominal Injuries

    During the Leyte campaign, approximately one-half of those with abdominal wounds were operated upon in portable surgical hospitals, and the remainder were operated upon in surgical units of larger size, such as field and evacuation hospitals. Those operations that were done in the portable surgical hospitals were sometimes delayed for as long as 18 hours after wounding because these hospitals were most forward and isolated. During the first part of the campaign, plasma was used to bolster these patients on their way from the battalion aid stations to the hospital where definitive surgery was to be done. After the inauguration of the delivery of blood from the United States, it was possible to use more whole blood during this critical phase for those who were partially exsanguinated.

    Here again, whole blood was of great benefit to resuscitation. The period required for retrieving a patient from shock and reestablishing his vital processes so that he could withstand the added burden of operation was reduced. Experienced surgeons appreciated the importance of this preoperative phase, and for the most part the wounded were well prepared for operation.

    Anesthesia employed on abdominal cases in the portable surgical hospitals was usually open-mask ether. Because the simple abdominal injury was associated frequently with injuries to the diaphragm or chest, one of the shortcomings of the portable surgical hospital was inadequate anesthesia. For abdominal injuries, open-mask ether was adequate, but it was not suitable for open chest operations. In field and evacuation hospitals, machines were


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available and intratracheal tubes were placed before operation was begun. Local and spinal anesthesia was discouraged and little used. The evacuation of gastric contents before beginning an anesthesia was routine practice.

    Abdominal wounds required a definite pattern or preoperative examination and preparation. The following procedure was followed: Complete physical examination in an attempt to determine site of entrance and exit of the missile, X-ray examination to determine the presence or absence of shell fragment on intra-abdominal air, neurological examination of the lower extremities to reveal absence of nerve or cord injury, and catheterization to establish integrity of the bladder wall. Carrying out these procedures preoperatively reduced the time consumed in determining them later during the operation.

    The exploration of the abdomen of the battle casualty required ingenuity. Large abdominal defects sometimes dictated the type of incision. The smaller wounds, and these might be associated with the most extensive abdominal injuries, were best explored by an adequate incision--midline, midrectus, or transverse. Observation of the difficulties that operating surgeons encountered showed that inadequate exposure accounted for many, as did also lack of a routine for exploring the abdominal contents. Occasional injuries of the large bowel, in particular in the distal portion, were overlooked. Then too, wounds of the pelvis involving the rectum required continual vigilance. The treatment of defects of the large bowel and rectum by those new to forward area surgery often demanded close supervision.

    The objective of saving life with the minimal risk and not attempting to determine what might be survived or tolerated had to be kept foremost in the surgeon's perspective. Post mortem examinations were all important for this purpose. Many surgeons found it extremely difficult to follow the instructions of exteriorization of the large bowel or complete deflection of the fecal stream by an adequate colostomy. Nevertheless, after a period of experience, surgeons accepted the policies which had been laid down in an attempt to guide them from these common pitfalls. In the reconstruction of the continuity of the intestinal tract, many surgeons insisted on using a side-to-side anastomosis, whereas an end-to-end, had they been familiar with it, could have been accomplished more quickly and would have given a better physiological result. Liver injuries combined with large bowel injuries had the highest mortality rate. Liver injuries alone likewise were dangerous. Drainage of these wounds to the exterior was accomplished with a more favorable result. Injuries of the stomach and small intestines unassociated with large bowel injuries had an incidence of recovery of upwards of 85 percent. The use of the Wangensteen tube or the Miller-Abbott tube postoperatively did a great deal to prevent abdominal distention and vomiting. The placing of these tubes postoperatively in all abdominal cases was routine.

    Wound disruption was a complication that could have been greatly diminished. Abdominal closures ordinarily were made with catgut, silk, or cotton. Catgut layer closure was probably most frequently used. Grossly contam-


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inated abdominal wounds were very prone to infection and dehiscence. Through-and-through suture material--silver wire, gage 12, without closure of the skin--proved most satisfactory, whereas through-and-through silk (number 14 or braided) and plastic suture material (such as Dermalon) or silkworm gut were very inefficient. Abdominal wounds in which the skin was left open with petrolatum-impregnated gauze placed in the subcutaneous tissue had an opportunity to drain if infected and were undoubtedly a means of reducing the incidence of wound disruption. It would be highly desirable to furnish all forward units in the future with adequate amounts of soft silver wire, 12 gage, with atraumatic needles to place these sutures.

    The greatest surgical heartbreak in World War II was the result of moving patients with intra-abdominal injuries too soon after operation. The experience of World War I had recorded this fact well. The various directives and instruction sheets dwelt upon it. Nevertheless, because of the nature of the fighting in New Guinea and on Leyte and, to a lesser extent, on Luzon, patients were brought into forward units where they could not be evacuated, sometimes for from 12 to 18 hours. The surgeons there viewing the situation as they saw it, and not without some justification, operated upon these patients whose postoperative course would be satisfactory. Then, for one of a number of reasons, the patient would be moved. The tactical situation might be the reason, or more space might be required. The reason was immaterial to the end result; the fact remained that abdominal patients moved within the first 10 days of operation developed a high incidence of complications and that many of them were fatal. This fact was more evident to the consultant than to anyone else, and at his insistence the Surgeon, Sixth U.S. Army, brought into action in the Luzon campaign ways and means that reduced to a minimum the moving of abdominal patients so soon after operation.

Injuries of the Extremities

    Approximately two-thirds of all injuries occurred in the extremities. For the purpose of discussing the experience of treating these injuries in the forward area, they may be divided into two groups, those involving soft tissue only and those involving soft tissue and bone. The goal in the care of these cases was to save life, save limb, and preserve function insofar as possible.

    All wounds occurring in the forward area, whether from the intact missiles or shell fragments, required adequate exposure of the missile track in order that devitalized tissue could be observed and that it might be ascertained that blood vessels supplying the structures in that area were intact. If adequate exposure was accomplished by long linear incisions, muscle groups separated to expose injured tissue, and injured tissue removed, and, at the same time, if the blood vessels were examined and, if injured, ligated, there were few later complications due to infection and hemorrhage. The term "debridement" was grossly misconstrued. The wounds of a bullet, entrance and exit,


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were sometimes said to be debrided when only a circular bit of skin was removed from the skin margin. The one procedure that, in the consultant's eyes, labeled a surgeon as being inadequate was to practice the circular incision of the skin about the bullet wound and sprinkle sulfonamide powder about it considering he had surgically treated the wound.

    Long linear decompressant incisions that exposed the missile track, followed by the removal of damaged tissue and the placing of a single sheet of petrolatum-impregnated gauze, established conditions that made anaerobic growth improbable and ordinary infection rare. The period of disability observed in the forward area from bold incisions was minimum. Wounds were approached from the wound of entrance or exit down to the depths. The exploration of blood vessels within a wound was continued stressed. Hematoma in the legion of the blood vessel invariably meant hemorrhage from one of the main vessels or a tributary. Patients in shock with lowered blood pressure would cease to hemorrhage, a clot would form, and, later, with a reestablished normal blood pressure or manipulation and, sometimes, infection, renewed hemorrhage would take place. Repair of blood vessels either by suture of a defect on by an anastomosis was unsatisfactory and not employed; rather, the blood vessel was ligated. Ligation of large vessels, such as the femoral or popliteal, which jeopardized the distal circulation were given the benefit of sympathetic block.

    The immobilization of soft-tissue wounds was insisted upon. Through-and-through bullet wounds that had been explored through adequate incision were immobilized in plaster just as routinely as were the massive soft-tissue wounds. In some of the evacuation and station hospitals that served as general hospitals in the forward area, early delayed closure was practiced as well as early skin graft. Both procedures were to be recommended and were not utilized as fully as they might have been. Soft-tissue wounds exhibiting considerable tissue damage were placed on penicillin therapy for from 8 to 10 days. Where the wounds were received late and the likelihood of anaerobic as well as aerobic bacterial growth was evident, sulfonamides were used systemically. Soft-tissue wounds of the thigh and buttocks, associated with injury to the pelvis and its contents, the bladder, the bowel, and the rectum, necessitated radical incision in an effort to prevent extension of infection, or to combat it, if already existing. Wounds of the upper thigh have been given inadequate attention chiefly because of the failure to recognize that many of these wounds involved intraperitoneal damage. Wounds involving all joints and, in particular, wounds of the elbow and knee required incision with decompression of fascia overlying adjacent muscle groups as well as exposure of blood vessels that may be the source of expanding hematoma. The optimum position of any soft-tissue wound is one that provides for the least restriction of circulation.

    In the battalion aid station, hemorrhage was controlled, dressings and splints were applied, sedation for the control of pain was administered, prophylactic chemotherapy was instituted, and patients were resuscitated from


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shock if time permitted. Definitive surgery for injuries involving bone began with the unit that could accomplish satisfactory treatment of the soft-tissue wound and completely immobilize bone fragments. The only satisfactory method of immobilization in forward area installations was the application of plaster cast. Immobilization rather than reduction of displaced fragments was adhered to when the patient was treated in portable, field, or evacuation hospitals. The transportation of compound fractures in plaster casts was associated with an extremely low- incidence of complications. If a wound had been well decompressed, and in the majority of compound fractures the injury had already established this, immobilization in plaster rarely if ever interfered with the circulation. In the field and evacuation hospitals where X-rays were available, alignment of fragments was satisfactorily done. There were times, it was true, when the ideal position was not obtained; however, it was expected that within 2 or 3 weeks from the time of wounding the patient could be transported to installations where additional procedures could be undertaken to accomplish this. Internal fixation and traction were not employed in forward area installations. Only occasionally was open reduction of a. fracture done to replace a fragment that jeopardized the circulation on nerve supply of an extremity. Too few surgeons arriving in the forward area had had adequate training in the use of plaster. The best quality of plaster of paris, adequate training in its use, and continual stimulation to develop better methods of securing strength with less bulk is to be encouraged in the future. The use of plaster was not the restricted domain of the orthopedic surgeon, and general surgeons should have been masters in its use. The supply of plaster frequently ran low during the early days of an action. Units accompanying combat groups should have carried large supplies of plaster and the necessary cotton batting to go with it.

    The principle of guillotine amputation at the lowest level of viable tissue was closely followed, but only by insistence and repeated admonition was skin traction maintained. The use of skin traction by stockinet and skin adherent was very effective in reducing the healing time of the stump, provided that elastic traction was maintained with proper adjustment.

    In the immobilization of fractures for transportation, there were certain tendencies that were common in all groups. The first was the hesitancy to use the plaster spica of insufficient extent to completely immobilize the part involved. In the transportation of patients by plane, in particular in plaster spica, exaggerated abduction made handling of the patient extremely difficult. Although ideal position could not be obtained always, the degree of abduction should be maintained at a minimum. Immobilization of a knee joint necessitates the immobilization of the joint above and below. This required repeated emphasis. The shoulder spica was of great importance in the evacuation of patients over long distances. Such casts required care in application in order that they fit well and that they be strong enough not to give way. A


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broken plaster shoulder spica was dangerous. Only rarely were hanging casts used on patients in the forward area who were to be evacuated.

Burns

    With the invasion of Leyte, suicide bombings began to produce a large number of burned patients. Many ships were hit in the harbor, and, if a huge number of personnel were aboard, the resulting casualties were likewise great. The majority of these men suffered burns with or without other injuries. In some instances, the total number of wounded removed from a single liberty ship was 80. These patients were treated on LST's fitted out as hospital ships and operated by the Navy, and by shore medical units of the Army. The treatment of large numbers of burned patients became rather standardized during the 8 weeks that the Sixth U.S. Army was on Leyte. Patients were given morphine before they were removed from the ship and then transferred by litter to wherever they were to receive further treatment. Here, all clothing was cut away. Those with burns only were separated from those who had complicating injuries or other injuries or both. Debris and detached skin were removed, and the burned surfaces were covered with 12-inch squares of petrolatum-impregnated gauze. Over this was placed gauze waste or Dakin's padding reinforced with bandage. Over this was placed stockinet. This did not constitute a pressure dressing; rather, it was a petrolatum dressing on the burn surface so reinforced as to hold it in place. Patients received plasma while dressings were being applied. Patients with massive burns were followed closely with hematocrit, and the reading was used as the criteria for the amount of plasma to be given. When protein (serum) determinations could be made with the copper sulfate method, this was used. The local treatment of the burns consisted of using petrolatum-impregnated gauze and preventing, insofar as possible, further injury and contamination. Initial drug therapy for preventing infection was limited to penicillin--120,000 units per 24 hours. Original dressings, if expertly applied, could well be left unmolested for several days. The control of infection varied, and later sulfonamides were sometimes employed, in particular sulfadiazine, adequate attention being given to alkalization and water balance.

    The treatment of patients with severe burns and injuries from bomb fragments presented complicated problems that required every ingenuity. The mortality rate was high. For example, after a suicide plane hit one ship, 21 of time slap's personnel were killed, 26 were both wounded and burned, 12 were wounded only, and 8 died within 24 hours.

    Patients with wounds and extensive burns were difficult problems. The general plan was to treat shock with morphine, plasma, and transfusions. Thereafter the surgical procedure, as indicated, was followed. Burns were treated as early as possible, but there was of necessity considerable variation in therapy.


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TROPICAL JUNGLE FOOT

    Approximately 120 patients were admitted to two evacuation hospitals on the island of Leyte on 23 November 1944 because of swollen, painful feet, the skin of which showed various degrees of ulceration. These soldiers had all been through a similar experience. They had been under combat conditions on the frontline. Typhoons and rain had been almost continuous. They had been in foxholes and crawling through the jungle for a period of from 9 to 17 days. During this time, they had rarely removed their shoes. There were no dry socks or footwear to change to. A majority of the patients said that after being under this condition for from 4 to 7 days they began to have burning sensations, first on the dorsum of the feet and then on the toes and soles.

    At first, moving about gave them some relief. This was soon lost, however, and walking became increasingly painful. When they removed their shoes, their feet appeared swollen and quite pale. If the shoes were left off, the feet became flushed and warm, burned, and developed a tingling sensation that was quite painful. Elevating the feet gave some relief. If the shoes were left off for a half an hour or more the feet became so swollen that shoes could scarcely be replaced. In this early phase, the feet showed no areas of loss of skin or ulceration. As time went on under these conditions, the feet became more swollen and painful with ulcerations appearing first on the dorsum, then about the toes, and rarely on the soles, although cracks in the skin of the soles did appear. Because of pain, walking became impossible. Many of these patients had been in an isolated group. When relief came, they were carried by litter through swamp and over difficult terrain that they could not have traversed themselves. It was estimated by these troops that almost 50 percent of their group suffered similar foot disabilities. Two soldiers volunteered the information that their feet did fairly well as long as they could take their shoes off at night but that, when this was not possible, disabling symptoms developed rapidly.

    The findings on examination of these patients were remarkably similar and varied only in degree. They had been in the hospital less than 12 hours when examined by the army surgical consultant. All were fatigued, but only rarely did they seem to be resting. They assumed different positions; some lay with their feet elevated, others sat with their feet on the cots, still others clasped their ankles and lower legs, and some let their feet dangle. They tended to shift from one position to another. The most common complaint was a burning sensation of the dorsum and soles with a "deep ache." An attempt to stand on the feet was accompanied by a look of helplessness and distress as well as pain. On walking, they moved with hesitant deliberation, slowly increasing the body weight on the foot after putting it down. They reminded one of a cat walking on fly paper. Washing with cool water and a


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little soap gave momentary relief and then as the skin dried the discomfort returned. Socks and dressings were intolerable.

    There was considerable variation in the appearance of the feet of these patients; with rare exception, there was a marked to an intense erythema, while swelling made the soles bulge and the skin of the dorsum tense and shining. There were frequently blebs and ulcerations with weeping serum at the base of and between the toes. The distal portions of the toes were sometimes blue, white, mottled, and cold. In many, there was a swollen erythematous appearance of the remainder of the foot. After the feet had been washed with soap and water and the skin had been allowed to dry, the involved skin could be seen to be well demarcated at the shoe tops. There was edema below this level but rarely above it. There were scattered areas of ecchymosis in the patients showing greatest involvement. Pulses were not obliterated in any of the feet examined and the variation was within the normal range. Blushing on pressure was slow, likewise the return flush.

    The ulcerations of the skin likewise varied a great deal, being most numerous over the dorsum and toes. These were almost blotchy in appearance, giving the impression that they had been produced by abrasion and pressure, except for the fact that in some the superficial layers of skin had been lost and in others the destruction extended down to and through the true skin. Some of the ulcerations were well demarcated with a small zone of necrotic skin along the margin, giving the appearance of decubitus ulcer or gangrene. The skin between the ulcers, especially over the dorsum, was pale, cold, and inert. The erythematous areas did not readily blanch on pressure which caused pain.

    Systemic reactions were lacking, except fatigue from inability to sleep. Temperature, like pulse rates, was within normal range. There was a striking lack of secondary infection in the ulcerated areas. Only a few patients who had had previous troubles, such as epidermophytosis, exhibited any evidence of tubular lymphangitis. Approximately 15 percent admitted some discomfort in the groins on direct question; all of these had enlarged and sensitive lymph glands. There did not appear to be any parallelism between the swelling and pain of the feet and the lymphadenopathy.

    Sensory changes were indistinct. Areas of numbness and tingling could be demonstrated by light touch and pinprick, and yet pressure was painful. Elevation of the feet seemed to increase the areas of diminished sensation. In general, attempts to outline the areas of paresthesia and anesthesia were unsatisfactory because of the discomfort and fatigue of the patients.

    The treatment of these patients consisted first in general supportive measures. Shoes were removed, socks cut off, and the feet bathed in cool water with white soap. This gave considerable immediate relief but was of short duration. If the feet remained in the water longer than 10 or 15 minutes,


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the burning and tingling increased, as it did when they were removed from the water and allowed to dry. The absence of a dressing, or the application of a light dry dressing, seemed to give some slight relief. Mineral oil was not well tolerated, and lanolin was not used. Various sedatives were employed to give rest. The patients were kept off their feet insofar as this was possible in a crowded forward hospital. The majority of the patients were evacuated by ship within 36 hours.

    Contrary to the course of patients suffering with the usual trenchfoot or immersion foot, these patients recovered relatively rapidly from the local swelling, excoriation, and infection, and also from the vasomotor manifestations of discoloration and pain. They were greatly improved within 4 or 5 days after hospitalization.

    A follow-up study of these cases was made. Sympathetic block was done on a few of the patients with some improvement of symptoms, but few on no objective changes were observed. It was reported from a rear base, where these patients arrived some 10 days later, that they were almost symptom free and had evidently recovered rapidly.

GAS GANGRENE

    Before the Leyte campaign, reports made by medical units in the forward Sixth U.S. Army area showed 24 cases of gas gangrene during 1944. Forty-seven cases of clinically diagnosed gas gangrene occurred during the 65-day period that the Sixth U.S. Army was on Leyte. The 47 cases developed from 8,893 battle casualties and were of a fulminating type. Whereas the mortality rate for the group of 24 was less than 10 percent, in the 47 it was over 30 percent. The onsets of symptoms and signs were sudden and dramatic, the virulent infection sometimes appearing within 24 hours of wounding. A very probable explanation of the sudden increase was in the fact that most of the fighting on Leyte took place in the ricefields that were fertilized by the "night soil" in thickly populated areas, an ideal source of the clostridia. In addition, 45 cases developed in patients evacuated to rear bases. The total number of deaths following gas gangrene in the 92 patients was 29, a mortality rate of 31.4 percent.

    In contrast was the experience in the Luzon campaign where, in over twice the number of wounded, there were only 30 patients who developed gas gangrene during the months of January, February, March, and April. The mortality rate was 16.6 percent. The difference in these last two groups was caused by many factors, which can best be summed up as follows: On Luzon, conditions permitted the earlier and more satisfactory treatment of the wounded, and the weather and bacterial flora of the land where the fighting took place did not result in such a high degree of contamination of the wounds with Clostridium welchii or other anaerobes.


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TETANUS 1

    As Consultant in Surgery, Sixth U.S. Army, Colonel Glenn had an opportunity to observe many of the civilian wounded in Manila. The medical importance of the high incidence and severity of tetanus then appearing was evident early, and the collection of information and data about such patients was begun. The civilian hospitals, operating under combat and siege conditions which prevented the preparation and accumulation of detailed records, were aided by army personnel, and one civilian hospital--time San Lazaro Hospital-was operated directly by representatives of the Surgeon, Sixth U.S. Army, for a few weeks after American troops entered Manila. The account of the observations concerning the care of civilian battle casualties who developed tetanus represents information collected from all possible sources.

    In order that the unusual background that provided such optimum conditions for the development of tetanus may be kept in mind, it is necessary to review some of the circumstances then existing. A city that is held and defended by one military force and attacked by another from the air and ground as well as by a not far off naval force soon becomes a place where the care of the wounded and sick is difficult indeed. Manila was such a place in February and March of 1945. The inhabitants could not flee the city; they were subjected to the action of Japanese military force as well as to the fire from the American elements besieging the city. The civilian population long had been on a limited diet, and this was markedly curtailed with the onset of active fighting. The wounded-victims of air bombing, artillery fire and small arms, hand grenades, and bayonets and swords of the Japanese-steadily accumulated. The casualties were taken by relatives, friends, or bystanders to the hospitals. These institutions were also casualties--some had sustained direct hits; personnel had been depleted in some instances by enemy action, in other instances by urgent demands to administer to those outside the hospitals; some in attempting to protect their families had been cut off from returning, others had been commandeered by the Japanese. The result was that only a token number of the hospital personnel were in these hospitals and, under the prevailing confusion, organization did not exist. The water supply was cut off early, the sewage systems became blocked, and the food supply was further limited as it had been for some time before, and very quickly became almost negligible. The civilian hospitals were overfilled with the wounded, the dying, and the dead.

    In the San Lazaro Hospital a few days after the beginning of the battle for Manila, there were approximately 1,300 civilian patients, and over 1,100 of these had been wounded. From this group, 156 cases of tetanus developed. The picture of this hospital was a most unhappy one--it was overcrowded, all beds and all floor space were filled with the wounded, many dying, many dead.

1 Glenn, Frank : Tetanus--A Preventable Disease. Ann. Surg. 6:124, December 1946


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    By and large, the dead had the most severe wounds of the head, thorax, and abdomen. However, among the living there were wounds of every part, approximately 70 percent involving one or more of the extremities. An occasional wound had been closed, but the majority had had no surgical care. Some wounds were covered with dressings of sorts consisting of parts of clothing. Bandages were few, and flies swarmed over the partially exposed wounds. Fractures of the extremities were splinted for the most part only by the pain that prevented patients from moving. The patients, children and adults, exhibited all phases of injury, exsanguination, shock, infection, and malnutrition.

    The location of wounds in the 156 patients who developed tetanus was as follows:

Location if wound  - Number of wounds

Head and face..............   20
Neck............................     1
Thorax.........................   12
Abdomen and back......   17
Buttocks......................    21
Pelvis...........................     4
Upper extremities.........   34
Lower extremities.........   76
Burns and miscellaneous. 21

    There were many instances of multiple wounds. The number of patients with wounds of the head and neck who developed tetanus was small in comparison to those with wounds in other regions of the body. Compound comminuted fractures of the long bones associated with massive soft-tissue damage and extensive infection, on the other hand, seemed to be the type of wound most frequently associated with tetanus. Dependable and accurate data were seldom available as to the exact time of wounding and the onset of the symptoms of tetanus. It can be said with certainty that there were instances of tetanus being evident as early as 3 days and as late as 20 days from the date of injury. It may be estimated that 60 percent of the patients who developed unmistakable evidence of tetanus did so within 7 days.

    The onset of symptoms was difficult to evaluate because of the general poor condition of these patients as described above. The vital processes were so depressed in the group and the clinical pictures so complicated by coexisting abnormal states and infections that they masked the classical early manifestations of the disease, such as the complaint of headache, stiffness of the neck muscles, and difficulty in chewing. Locked jaws were all too evident when fully developed, as were tetanic seizures and opisthotonos, and yet often these were the first manifestations of the disease to be observed. It should be stressed that the complaint of headache, stiffness of muscles, and pain in the region of the wounds could he elicited from the majority of the wounded.

    Local tetanus was observed in the legion of wounds and also in muscle groups proximal to the wound as well as in the muscle of the entire extremity.


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    Severe local tetanus associated with mild general tetanus was not uncommon, and muscle spasm, both tonic and clonic, was marked in the extremity where the wound was located. Usually, the wound was located in the distal portion, as on the forearm or hand of the upper extremity or on the leg or foot of the lower extremity. Local tetanus involving an extremity independent of the wound was not seen. However, one patient developed local tetanus in the stump of a mid-thigh amputation following removal of a gangrenous leg, the result of a compound fracture of the distal portion of the femur. Tetanus was not observed before the operation, and local tetanus was present on the following day. It persisted for almost 2 weeks and subsided. During this period, there was a slight trismus and almost no stiffness of the neck muscles.

    The most frequently observed clinical picture was as follows: A patient with a wound of considerable extent in an extremity would be unable to open his mouth by 5 or 7 days after injury. There would be marked trismus and stiffness of the neck muscles. Associated with these two findings there would exist, on soon follow, mild spasms which fixed the head, bodly, and extremities in a straight line--orthotonos. Within a matter of hours as the seizures became more pronounced and more frequent, opisthotonos developed with greater involvement of the back muscles, so that during a spasm the back became arched and the body was truly supported by the head and heels. Concomitantly, there would appear the classical risus sardonicus with elevation of the eyebrows and retraction of the corners of the mouth, producing a grimace that exposed the locked jaws (fig. 87). Orthotonos was observed to be followed not only by opistimotonos but emprosthotonos. Spasm and rigidity of the abdominal muscles was an early and common finding that preceded generalized seizures and persisted during and between them. As spasms became more intense over a period of hours or days, they rendered breathing difficult. With the muscles of the neck and diaphragm and the intercostals in spasm, the air exchange was so reduced that the lips and nail beds became very cyanotic. During the severe spasms, there was profuse perspiration, and pain was excruciating and unbearable. As the disease progressed and the spasms increased in severity and frequency, the patient became physically exhausted but remained mentally clear and terrified. An occasional patient died during a spasm, but the majority, following complete exhaustion, became listless, and the diminishing convulsive seizures were followed by death.

    Dysphagia was common and present in about 75 percent of all patients with tetanus, whereas trismus was more constant. A few (four) patients with a rapidly fulminating type of the disease did not exhibit trismus. The forearms and hands in the majority of tetanus patients were, in general, spared to a remarkable degree, so much so that even those with the most severe spasm could grasp the sides of the bed or cot during seizures.

    The deep reflexes were early exaggerated, and the Babinski reflex was positive in approximately 20 percent of new cases. Ptosis of the eyelids was observed in seven instances in the 156 patients. Facial paralysis was seen only


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FIGURE 87. - Patient, a Chinese, had been wounded in the hand by shell fragments and had active signs of tetanus upon admission to San Lazaro Hospital. Note the risus sardonicus.

once and no history could he obtained as to whether or not this was present before the onset of the disease. True cephalic tetanus as described in the literature was not observed. Extensor responses of the foot and leg on stimulation or during a convulsive seizure were common.

    Those patients with generalized tetanus exhibited various degrees of urinary retention and, without exception, had difficulty in urinating. During a spasm, urine would be expelled in small amounts. Although a spastic vesical sphincter has been the cause commonly ascribed to this, no difficulty was encountered in catheterizing men or women. Spasm of the rectal sphincter was readily demonstrated early in generalized tetanus. Fecal impactions were rarely seen because the food intake of most of the patients had for some time been negligible.

    The great variation of extent and severity of the wounds in such a group of civilian battle casualties with little or no previous primary surgical treatment offered some opportunity to evaluate late operative therapy. Those patients with well-established tetanus who could withstand operation, although improved by such therapy so far as sepsis and general condition were concerned, seemed to follow the common pattern of the disease and, with or without specific therapy, died. The incision and drainage of grossly infected wounds, the removal of foreign bodies and the accompanying manipulation, on the other hand, did not appear to increase the progress or severity of the disease. Furthermore, guillotine amputation for extensive injuries of the extremities


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sometimes associated with gangrene and Cl. welchii infection did not appear to alter the course. However, it was significant that, in the group of almost 40 patients in the San Lazaro Hospital upon whom amputations were performed and who had no evidence of tetanus at the the of operation and no other wounds, only 3 developed tetanus; 2 of these died and 1 ran a course of 2 weeks and eventually recovered. As previously stated, extensive wounds of the extremities involving deep structures accounted for the greater number of patients with tetanus, although there were also many examples of those who had superficial wounds. Burns in particular, with or without additional injuries, led to tetanus, although somewhat later. In a group of 37 patients with severe burns, 10 developed tetanus 10 days or longer after injury. The course of the disease in those patients was apparently just as fulminating as in those who developed the disease with a shorter incubation period, and all ten died.

    Penicillin was used in six patients with tetanus. Daily amounts of 200,000 units were given to five of these in 25,000-unit doses intramuscularly every 3 hours. There was no apparent effect upon the tetanus infection. The period of treatment was as follows: Two patients received penicillin for 6 days; one, for 5 days; one, for 2 days, and another for 36 hours. All of the six died. One child received a total of 1,200,000 units over a period of 48 hours, the initial dose being 25,000 units given intravenously and 50,000 units intramuscularly-- this was repeated every 3 hours. Again, the terminal course was unaltered. Penicillin was used locally in two patients who developed tetanus following burns. The wounds were grossly infected, and penicillin was applied in strengths of 500 units per cc. without evident improvement.

    In the last 3 weeks of February at the San Lazaro Hospital, 140 patients in the group of 156 with tetanus died, a mortality rate of almost 90 percent That death was due to tetanus alone cannot be said because of coexisting conditions and other infections. There was little tetanus antitoxin for specific treatment. The facilities for general supportive treatment were also limited, and sometimes even the most simple patient care was lacking. Many patients died within a few hours after the appearance of the symptoms of tetanus, but many more lived for from 3 to 10 days.

    The single most important item available was morphine. This drug in .008-gram doses reduced the duration and the severity of the spasms. It gave the patient rest and enabled those with dysphagia to swallow liquids that otherwise could not have been administered. Morphine given as indicated, sometimes as often as every 2 hours, did repress respirations, but it was the most useful of the drugs available and it is doubtful that pulmonary complications were increased by its use. Atropine, .0005 gram, given with morphine definitely improved respirations in severe spasms with marked opisthotonos.

    Paraldehyde and chloral hydrate by rectum were well tolerated and effectual in a limited degree. The various barbiturates available were of minimal value. Severe and devastating generalized seizures were sometimes controlled


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by using chloroform or ether or both as a general anesthesia for short periods in order to give the patient some respite. Ether in oil, administered rectally, likewise reduced convulsive seizures and was perhaps the best drug for the purpose under the prevailing conditions. Very little tribomoethanol (Avertin) was available, but, in the few patients who were fortunate enough to receive it, the relief was gratifying. The Filipino physicians were unanimous in advocating the use of a 25-percent solution of magnesium sulfate, injecting it intramuscularly in 2-cc, doses, and employed it almost routinely. It depresses respiration to an alarming degree. Sedatives of all kinds were of some value in controlling seizures and spasms, and, by conserving the patient's strength, life was frequently prolonged.

    During February, March, and April of 1945, almost 500 patients were reported to have had tetanus in various civilian hospitals in Manila. It was estimated that there were, during this period, approximately 12,000 civilians wounded, and an incidence of almost 40 per thousand developed tetanus. The mortality rate for the 473 reported cases was 82.1 percent. These patients for the most part had little or no primary or early surgical care. As far as is known, none had had tetanus toxoid before being injured.

    The incidence of tetanus in Manila under peacetime conditions would indicate that it would be high in combat. The American soldier was fighting under conditions quite similar as to climate and soil. His physical condition was, of course, superior to that of the average citizen of Manila. Furthermore, when wounded, he received early and adequate surgical care and, in addition, he had been immunized with tetanus toxoid. That thus immunization was completely successful is borne out by the complete absence of tetanus among the U.S. Army forces on Luzon.

SPECIAL CONSIDERATIONS

Portable Surgical Hospitals

    The portable surgical hospital consisting of 4 medical officers and 25 enlisted men became popular soon after it was introduced in 1942. It was a small compact mobile unit and could be attached to some elements of a combat team. In comparison to any other existing unit providing definitive surgical treatment of the wounded, it was easy to move and easy to supply. The deserved popularity of this unit and its accomplishments were, however, due to the personnel. The officers who volunteered for this type of service were exceptionally well trained. They in turn selected the best in the way of noncommissioned officers and enlisted men they could find. During the early days of the New Guinea campaign, the demand for this type of unit was great, and, had it not been available, many wounded would not have received the excellent care that they did. The portable surgical hospitals were used throughout the New Guinea campaign, through Leyte, and to a lesser degree in Luzon.


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    Sometimes, the same general conditions existed as prevailed in the early part of the New Guinea campaign, but, as the campaign progressed and greater numbers of troops were employed, the portable surgical hospital was still used. It had at best certain shortcomings. First, equipment--particularly for anesthesia--was limited; second, facilities for postoperative care were limited; and third, these units might result in a great waste of surgical personnel. Yet, if they did not contain excellent surgical talent, they were worse than useless-- they were dangerous.

    For small task forces fighting in the jungle, the portable surgical hospital, well staffed with a minimal amount of equipment, functioned to an unusual degree of efficiency. When this unit, however, was used where larger combat units were employed and where transportation was available, it was not the unit of choice in which to do definitive surgery. Because replacements in some of the earlier formed portable surgical hospitals were not of the same caliber as the personnel of the original groups and because in the formation of newer hospitals superior personnel was not placed in them, the quality of work under comparable circumstances became distinctly inferior. Small groups not well trained, out on their own, and confronted with problems far beyond them were apt to repeat unnecessary mistakes. The combination of portable surgical hospitals and clearing companies was permissible when other organizations were not available, but they did not constitute the proper unit for definitive war surgery. Portable surgical hospital units were too small for doing definitive surgery and they lacked personnel and equipment. Most importantly, they were unable to provide proper postoperative care and from a practical standpoint tended to evacuate postoperative patients too early. This was particularly applicable to patients operated upon for abdominal injuries. Far better were the 400-bed evacuation hospitals.

Surgical Teams

    Surgical teams consisting of 2 officers and 4 enlisted men equipped with basic operating instruments were requested by the surgeon of the Sixth U.S. Army and provided by the Surgeon, SOS, SWPA. Orders provided for their assignment to the Sixth U.S. Army on temporary duty and their return to their original station when the duty was completed. In the army, these teams were assigned to those medical units where they could be employed most profitably. On Leyte 4 teams were used, and on Luzon 23 teams.

    In the Sixth U.S. Army, it was the general policy to have one team attached to an evacuation hospital and two to each field hospital. Without exception these teams were well received by the forward units, and, from the time of their arrival, cooperation was excellent. The teams worked under the direction of the chief of the surgical service of the hospital to which they were attached. They were given the same responsibility as the regular staff members. One team functioned as a unit in the operating room when feasible. Teams


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participated in the care of patients from shock ward to evacuation, caring for their own postoperative patients. When hospitals were carrying peakloads, the teams would often be split, and each surgeon was paired with a less experienced medical officer of the hospital staff to make up a team. Thus, very early, the teams were absorbed by the surgical service so that they functioned as an integral part of it. The great volume of work that the forward units were called upon to do taxed them all. The commanding officers and surgical chiefs of these hospitals stated that they could not have rendered the treatment that they were able to give the wounded had their staffs not been supplemented by these teams. For the most part, the hospitals that sent these teams deserved commendation for the careful selection of both the professional and technical personnel. The officers and men of the teams were well pleased with their experience, and their value was well demonstrated. Some of the teams were shifted from their original assignments when work became slack and help was needed elsewhere.

    Two parachute surgical teams commanded by Capt. Robert S. McCleary, MC, under Lt. Col. Francis W. Regnier, MC, Surgeon, 11th Airborne Division, were first used near Ormoc on Leyte. Each team was composed of 2 medical officers and 12 enlisted men and was equipped with materials and instruments to enable them to do major surgery in the field. The first team to embark on a mission jumped in southern Leyte and in the ensuing 20 days cared for 160 patients, 42 being litter cases. There were 3 head, 4 chest, and 2 abdominal wounds; 18 compound fractures; and 1 appendectomy. Two patients died before operation could be undertaken. This experience demonstrated that this type of unit had a place with airborne troops who may for some time be isolated. The teams were used in other missions on Leyte and on southern Luzon.

Nurses in the Forward Area

    In spite of the provision for nurses in field and evacuation hospitals, members of the Army Nurse Corps were not in the forward areas early when the patient loads were at their peak in these medical units. This was observed in the Admiralty Islands, in Netherlands New Guinea, Leyte, and Luzon. The immediate postoperative care of the wounded was without exception superior when nurses with years of training were in charge, in comparison to the Medical Department enlisted men-willing and enthusiastic as these enlisted men were. The care of the wounded would have been improved by placing nurses in all field and evacuation hospitals as soon as they were secure. Indeed, the small risk to which the nurses would have been subjected would have been greatly overshadowed by the service they could have performed. That this was not realized was attested to by the attitude of commanding officers, task force surgeons, and some members of the professional staff of various hospitals who held that "female" nurses were an added burden and required additional quarters and facilities, and that additional personnel for guards was


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required. They frankly stated that they did not want them because they were too much trouble, and yet they had never had them forward in the early phases of an action. Some medical officers were naive enough to believe that the corpsmen were just as expert in postoperative care as the nurses. The standards for postoperative care were low among surgeons who professed to this belief. Another objection offered was that to bring nurses in after the men had put up the hospital and place them in charge in the care of the patients would be a blow to the corpsmen's morale.

    There were many reasons, arguments, and opinions as to why nurses should have been in the forward areas much earlier than they were. No one could doubt that members of the Army Nurse Corps were capable of rendering nursing care far superior to that provided by the less well trained corpsmen. Furthermore, it would have been the rare experienced surgeon who did not consider that good nursing was of major importance in, and an inseparable part of, postoperative care. The contrast was evident when, in the later phases of the action, nurses arrived and assumed their role.

Clinical Research and Investigation

    The need for an organization for the correlation and encouragement of clinical and laboratory research had prompted Col. Maurice C. Pincoffs, MC, Chief Consultant in Medicine, USAFFE, and Col. Henry M. Thomas, Senior Consultant in Medicine, SOS, SWPA, to request through the theater chief surgeon and the Office of the Surgeon General a medical general laboratory. From a surgeon's standpoint, it was highly desirable that hospital facilities and laboratory be combined. After considerable discussion among the consultants, it was decided to combine a 250-bed station hospital with the general medical laboratory to form a research unit. Because there were several medical officers in the theater who were interested in and capable of investigative work, as evidenced by previous accomplishments, it was requested that the general medical laboratory be sent to the theater with certain of its positions vacant. In March of 1944, requisitions having passed proper channels, word was received from the chief surgeon's office that a general medical laboratory with certain specified vacancies would arrive in the theater. Inability to secure proper priorities and other delays resulted, and the 19th Medical General Laboratory at Hollandia, New Guinea, did not disembark from the United States until August 1944, to arrive in September.

    In the meantime, steps were taken to locate personnel within the theater who would contribute to such an organization. The 12th Station Hospital was selected to be combined with the medical general laboratory, and it was transferred from Australia to Hollandia. Plans were drawn up with the assistance of SOS, SWPA, engineers to house together the two organizations. Likewise, plans were made for such changes and additions required to render the Australian portable buildings suitable for scientific investigation in tropical New Guinea. The amount of material and extra equipment required was great.


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    However, with a high priority obtained in higher headquarters, the material was secured from quartermaster sources, then located in Sydney, Australia, and was placed aboard a liberty ship destined for Hollandia. Not long after the arrival of the l2th Station Hospital, the 19th Medical General Laboratory, and the extra equipment in Hollandia, the tactical program was stepped up for the invasion of the Philippine Islands and the project was curtailed, although the laboratory was later completed.

    Clinical and laboratory investigation should have been considered an integral part and function of the Medical Department during service in a foreign theater. Knowledge of tropical surgery as well as tropical medicine could have been increased with profit much earlier, had the proper organization been available. Because there was no official organization of this type provided for, the construction and securing of one was met by a great deal of resistance. One ranking medical officer in the theater chief surgeon's office bitterly opposed "research in the jungle." A base surgeon of equal rank was insistent that such an organization would deprive the wounded of proper care. Such attitudes were relics of the dark ages, and they delayed progress.

    A table of organization and equipment for a combined laboratory and hospital capable of doing clinical and laboratory investigation and including the facilities of a medical general laboratory should be set up for use in any future war.