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$Unique_ID{USH00820} $Pretitle{78} $Title{United States Army in the Korean War - The Medics' War Chapter 8 Medical Support Behind a Stable Front} $Subtitle{} $Author{Cowdrey, Albert E.} $Affiliation{US Army} $Subject{medical command korea hospitals army war service japan far korean} $Volume{} $Date{1987} $Log{Medics Using Plasma*0082001.scf Bug Dusting*0082002.scf Dentist at Work*0082003.scf Research Lab*0082004.scf Litterbearers*0082005.scf } Book: United States Army in the Korean War - The Medics' War Author: Cowdrey, Albert E. Affiliation: US Army Date: 1987 Chapter 8 Medical Support Behind a Stable Front Prime gainers from the new kind of warfare were the Korean rear areas. The stabilization of the front permitted rapid maturing of the medical support system. Command of the air allowed convoys to roll undisturbed, laden with all kinds of supplies. While the Chinese and North Koreans had to burrow underground, United Nations (U.N.) hospitals and depots could build in the open, free from attack. Under the Far East Air Forces' umbrella the medical system developed in near ideal conditions. Despite the ruin of war, the poverty and misery of many Koreans, and the sporadic fighting between South Korean troops and guerillas, the rear areas slowly began to assume a more normal aspect. Here, as at the front, rotation presented many difficulties for military commanders and administrators. Together with the doctor draft and the general draft it meant near 100-percent turnover in many medical units during 1951, and continuing turbulence thereafter. The problems involved in continuous retraining meant that military medicine, from its simplest to its most professional aspects, became an art that medics had not only to learn but also relearn as they worked with soldiers who themselves continuously came and went through the doorway marked "Big R." Rotation was one of the ways that America coped with the Korean conflict once it became apparent that the war would not be a short one, and in this sense it, too, represented a maturing of the system that supported the battle. Organization of the Rear Areas Within the Eighth United States Army, Korea (EUSAK), the 2nd Logistical Command organized and controlled the rear areas. It provided direct support to the Eighth Army, requisitioning supplies from the Japan Logistical Command (JLCOM) and overseeing storage and distribution. Its police duties included security in metropolitan Pusan, in Seoul-Inchon, and in other important military areas. The increasing burden of housekeeping chores led the Eighth Army surgeon to suggest making the command a JLCOM advance section. Instead, the Far East Command on 10 July 1952 established at Taegu a more weighty and complex structure - the Korean Communications Zone (KCOMZ). Under the new headquarters was a mixture of area commands and organizations having special functions. The major subordinate commands were the Korea Base Section, the United Nations Civil Assistance Command, Korea (UNCACK), and the Prisoner of War Command. Over the course of the year that followed, the 3rd Transportation Military Railway Service and the Taegu Military Post were added, the first to control the increasingly heavy rail traffic that supported the front and the second to provide services and security in and around the KCOMZ headquarters. UNCACK, on the other hand, was abolished on 1 July 1953 and replaced by the Korean Civil Assistance Command (KCAC), directly under the United Nations Command in Tokyo. The KCOMZ headquarters reported to the Far East Command (FEC). Its primary functions were and remained advisory, with operations in the hands of the many specialized subordinate commands. Of these, the Korea Base Section was simply the old 2nd Logistical Command under a new title, but with broader powers. Its subordinate elements were the 6th Army Medical Depot, the Swedish Red Cross Hospital, and three evacuation hospitals, which were reorganized as station hospitals in 1953. The field hospitals serving the vast prisoner population fell under the Prisoner of War Command, the medical trains under the 3rd Transportation Military Railway Service. Beyond this, the KCOMZ on 1 August 1951 assumed control of all major medical installations in Korea, except the MASHs and the 11th and 121st Evacuation Hospitals. Within its geographical area - mostly south of the 37th Parallel and about seven times the size of the region under EUSAK - it controlled all medical service units except those few installations, designated Class II, that remained under the Eighth Army. The KCOMZ furnished medical logistical support to the fighting forces; handled rail evacuation; provided medical, dental and veterinary care to all U.N. troops in its area, plus the prisoners of war (POWs); and, through UNCACK, directed U.N. medical services on behalf of the civilian population as well. A New Army Trying to staff the Army hospitals and to fill the medical units was a frustrating endeavor. The draft gave and rotation took away. The doctor draft, killed in 1948 by the American Medical Association's opposition, was revived with over whelming congressional support after the opening of the Korean War. Both the medical association and the reserve medical officers now backed it, motivated in part by a desire to satisfy the needs of the armed forces by placing in the first priority for the draft six thousand Army and Navy Specialized Training Program graduates (ASTPs and V-12s) who had not yet served. For their part the armed services turned to the draft for the usual reason: Efforts to persuade physicians to volunteer had no more success after the war began than before. As passed by the lawmakers in early September 1950, the draft legislation provided for induction first of ASTPs and V-12s with less than ninety days of service; second, those with ninety days but less than twenty-one months of service; third, other doctors, dentists, and veterinarians with no military service since 1940. When these categories were exhausted, professional men with recent military service were to be taken in inverse ratio to the length of their service. However, the inevitable delays in making the legislation work meant that no drafted medical officers reached Korea until January 1951. Meanwhile, amid complaints from men whose lives were being disrupted and reminders from the unsympathetic that reserve service was voluntary, the medical reservists - most of them veterans of World War II - continued to be called. Few men who were liable to the draft volunteered for reserve commissions, despite the Army's initial hopes. During 1951 regular draft calls summoned medical professionals into the service. By the end of August the standard five-week course at the Medical Field Service School at Fort Sam Houston, Texas, had given some twenty-five hundred medical, dental and Medical Service Corps officers their initial introduction to the Army and its ways. From that time forward the draft became increasingly important, and during 1952 over 90 percent of the medical officers required by the Army Medical Service in the Far East Command were procured through the doctor draft. In tandem with the general draft, the doctor draft brought a different kind of medical service into being in the Far East Command. The key to the rapidity of the change from an overwhelmingly volunteer to a largely conscript service was the rotation system. During 1950 the Medical Service had begun to rotate medical and dental officers to Japan for professional refreshment, as well as nurses on grounds of their supposed inability to sustain the stress of front-line service. In March 1951 the Far East Command announced a general rotation policy covering all who served in Korea. The basic principle was to return such men and women to the zone of interior, beginning with those who had the longest combat exposure. None, however, could leave the war zone until a qualified replacement had arrived to take his place. After some initial confusion the commander-in-chief came up with a plan dividing the command into three zones. Those who served with combat units in Korea received constructive credit of four months for each month served; those with noncombat units, two; those outside Korea, one. Troops were eligible for rotation after earning thirty six months of credit, which translated into nine months of actual service for those in forward areas. Clearly, such a system implied heavy demands for replacements, and when they initially failed to arrive on time much bitterness resulted among people on the line. By the end of September, however, an influx of replacements, most drafted, permitted rotation of almost all the eligible medical and dental officers. A mass arrival of Medical Service Corps and warrant officers during that month, producing a temporary surplus on the rolls, did not completely relieve the backlog of officers eligible for rotation, but by the end of October most had departed. The same period also saw the departure of other groups: residents who had come to the Far East on five months of temporary duty (TDY) just before the war broke out; Navy doctors, who returned to their own service; and other military and civilian residents, who went home to resume their interrupted studies. Adding normal losses for death and injury, illness or compassionate causes, a near revolution in staffing took place. Among those who departed was Colonel Dovell, the Eighth Army surgeon. In a month and a half - mid- August to 1 October - the chief of every division in the Eighth Army's Medical Section rotated, obliging Dovell's replacement, Col. Thomas N. Page, to build up an entirely new staff. During 1951 the Far East Command saw the departure of its chief surgeon, General Hume; of its consultant in preventive medicine, Col. Arthur P. Long; of its psychiatric consultant, Colonel Glass; of its medical consultant, Col. Francis W. Pruitt; and of many others, both of high rank and low. In the next year upheaval became institutionalized. In theory rotation should have distributed the burden of service in Korea, built up a pool of trained personnel, and avoided turbulence by integrating into units newcomers who could learn from veterans and then teach others in their turn. But in practice the ideal of regularly replacing a certain percent of the command each month was unattainable. Ruled by the tactical situation, the coincidence of rotation dates, and the availability of replacements, the system moved by jerks and starts. Because every failure to meet the announced criteria brought bitter complaints from men who had their thirty-six constructive months in hand, the Far East Command struggled to maintain morale, avoid congressional queries, and fend off adverse press reaction by meeting rotation dates even when replacements were not available. The result was that the command was soon understrength in every corps of the Medical Service, except the Dental. Late in 1952 the criterion for rotation was raised to thirty-eight months, but for the forward zone. During 1951 the massive turnover had ended in generally satisfactory staffing levels, for new people were available to replace the old. During 1952, however, nagging problems emerged as the draft and rotation interacted. Command experience was at a premium as veterans departed, yet - ironically - an oversupply of some medical specialists developed. Nurses were too few, Medical Service Corps officers were abundant but short on experience, and trained enlisted people were difficult to come by. Washington tended to justify shortfalls by the drop-off in military activity along the front. In 1952 the Office of the Surgeon General requested that the Far East Command accept "a small calculated risk" in regard to the supply of physicians. Doctors were said to be too few in civilian life, casualties in the command were at a low level, and the surgeon general feared "criticism from civilian medicine that [the] Armed Forces are wasteful in utilization of physicians"-a familiar theme. In the event that full-scale hostilities were renewed, the "staffing level could be restored by airlift of medical officers." In reply the Far East Command declined to agree to any decrease, pointing out that it was already taking a risk by operating with about 85 percent of its authorized strength under the tables of organization and equipment (T/O&Es) and tables of distribution. Combat divisions were functioning with thirty-two doctors each instead of forty-two, evacuation hospitals with twenty-four instead of twenty-nine, and MASHs with twelve instead of fourteen. In Japan itself the number of physicians at each of the four general hospitals was reduced from twenty-eight to eighteen, and "a proportionate decrease was effected in most of the other hospitals." In consequence, the rotation of doctors for the time being had almost come to a halt. By this time the stabilization of the front and the opening of negotiations had drastically changed the image of the war, from a crisis in the international conflict between the Communist and non-Communist powers to a purposeless struggle in which victory was no longer possible, or at any rate no longer pursued. Most Americans who could avoid the war did so; those who served submitted only as long as they must to a grim necessity. The declining activity in Korea reminded the Army of its obligations elsewhere in the world. A sign of the general tendency to minimize the importance of Korea as far as possible was the curtailment of battlefield promotions in August 1952. Time in grade began to count for more than it had during the period of heavy combat. First lieutenants in the Medical Corps and Dental Corps were promoted to captain upon completion of twenty months of active duty; 2nd lieutenants in the Medical Service Corps and Army Nurse Corps to 1st lieutenant after eighteen months. Promotions for enlisted men in medical units were cut back sharply, with the result that men of E-4 rank and below often filled slots tagged for E-5s to E-7s. At the top of the medical tree, command jobs existed with no one to fill them. At the end of 1952 the Eighth Army had 6 of its 11 authorized Medical Corps colonels, 14 of 37 lieutenant colonels, and 15 of 90 majors. It possessed in all 36 field-grade officers against a T/O&E requirement of 139. Only three of its eight hospital commanders and only two of its six divisional medical battalion commanders had had previous commands. Half the division surgeons lacked staff experience. During the first six months of 1952 a shortage of well-trained board-qualified general surgeons developed, and by the latter part of the year the Far East Command was obliged to assign specialists to such slots instead of the major hospitals. Spot shortages also occurred in those specialities - anesthesiology, orthopedics, urology, otolaryngology, neurosurgery - that had experienced problems intermittently since the war began. By and large, however, professional expertise was common, command rank and experience rare. Professionalization, the draft, and rotation were recreating in Korea the very situation that had typified many World War II theaters. Serious shortages developed as well among enlisted men and nurses. Theater personnel offices filled first the requirements of the line units, restricting the supply of aidmen and technicians, especially of those with prior training. Because women still could not be drafted, Army nurses went to Korea on a voluntary basis, and the continuing shortage could not be met by denying rotation to those who had served. A severe shortage of nurse anesthetists appeared in 1951 and, despite training in the hospitals, apparently continued during 1952. A gradual erosion of strength in the Army Nurse Corps - about 7 percent from mid-1951 to the end of 1952 - worsened the special problems of the Far East Command, and had to be met by a variety of expedients. Army nurses were relieved of much of the routine work in hospitals, both in patient care and administration, and enlisted personnel trained as practical nurses. In 1951 the Office of the Surgeon General discussed again the question of opening the Army Nurse Corps to male nurses, only to run into the baffling tangle of legislation and sentiment that declared nursing to be women's work. U.N. nurses helped to take up the slack; during the same year, 122 women - Danish, Swedish, Thai, Norwegian, Italian, Turkish, French, Dutch, Belgian and Greek - served in the Far East Command. Japanese nurses, graduates of Class A schools, worked in the hospitals in their homeland; Korean nurses from similar Korean schools in the prisoner-of-war hospitals. The stable tactical situation of 1952, the continued rapid evacuation, and the assignment of Army nurses to the hospitals with the heaviest work loads (rather than strictly by T/O&E) enabled the system to function, though shortages continued in both the KCOMZ and the Japan Logistical Command. Training High turnover implied training many newcomers. Skilled medical enlisted men remained the major problem. "Rotation was the big news in the Far East Command about 1 March [1951]," said a report, "and the 'Rotation Blues' was about to be adopted as a theme song by the Medical Section, GHQ, FEC, since it was found that adequately trained personnel were not available. . . ." With a backlog of almost five thousand eligibles waiting impatiently to go home it was "fairly obvious" that a training program would have to be instituted. At the behest of the FEC chief surgeon, that summer the Japan Logistical Command established the Far East Medical Service Specialist School at Camp Shinodayama, near Osaka. Early courses included four- to twelve-week sections for X-ray, pharmacy, laboratory, and operating room technicians and for field medical aidmen. Students sent by the command returned to their units after training; men taken from the pipeline were assigned throughout the command, with first priority to the Eighth Army, which apparently received 80-90 percent of the graduates. After a brief exchange with the adjutant general, the 250 spaces allotted to the school by the Japan Replacement Depot were filled automatically. Some question remained as to whether the Japan Logistical Command was selecting the students at random. Studies showed that only 4.5 percent had received medical basic, which corroborated the Medical Service's suspicion that the command was sending infantry, armor, and artillery-trained men (who made up 90 percent of the allotment) to become medics and medically trained men to line units. Various problems continued to be apparent, some as old as the Medical Service, some as new as the rotation system. The Medical Replacement Training Center at Fort Sam Houston, Texas, found that training divisions were sending their worst men to be medics, just as line units had done since the American Revolution. A second center was set up at Fort George G. Meade in March 1951, drawing its 220 men per month direct from the induction centers. A higher caliber of personnel was noted at once. During 1951 the highly specialized military occupational specialty (MOS) 1229 - Medical Equipment Maintenance Technician - remained critical. Inferior applicants in the zone of interior led to an excessive failure rate at the St. Louis Medical Depot, where 1229s were trained; in Japan brief instruction left many incompetent at the job for which they were supposedly qualified. Meanwhile, medical equipment became ever more complex, often with intricate electronic components. Complaints to the Office of the Surgeon General and much retraining resulted, but these measures apparently did not solve the problem. During 1952 the oddities of the rotation system also resulted in severe problems with the supply of field medical aidmen. In May, after the Camp Shinodayama school was abolished, aidmen trained at the Eta Jima Specialist School. Serving at the front in Korea, they earned the maximum constructive service time and consequently rotated in a fashion likely to cause vertigo in a personnel officer. Too few trained men were coming from the zone of interior, but the quota set for the pipeline by the school was not met - could not be met, according to the Far East Command's G-1 (personnel) section, because men with combat MOSs could not be diverted and those with noncombat MOSs were too few. As a final note, the dangerous nature of the job meant high losses by death, injury, and capture, further reducing the number of men on whom, when all was said and done, the whole medical superstructure rested. At the end of 1952 the command lacked twenty-four hundred of the more than eight thousand authorized aidmen. Though the shortage was nearing 30 percent, no solution had appeared. The Far East Command's decision to terminate the Shinodayama school apparently was based upon assurances that greater numbers of qualified replacements would be received through the pipeline. The Japan Logistical Command was suspicious from the first and recommended that the school be retained. When it was abolished, the logistical command set up its own courses for physical therapy technicians at the Kyoto Army Hospital and for medical equipment mechanics at the Japan Medical Depot. In Korea a chorus of complaints indicated that new technicians received from the zone of interior were not living up to their billing. According to the Eighth Army surgeon, the caliber of laboratory technicians now being sent to this organization is far below minimum standards. The graduates of the Laboratory Technicians School at Fort Sam Houston are universally unprepared to perform any of the routine procedures employed in the laboratory. They are not particularly interested in laboratory work, but rather seem to regard their MOS as insurance against more rigorous and dangerous assignments. Pointing out that the quality of medicine in any hospital depends in great measure on the quality of the laboratory work, the report concluded that the hospitals must rely upon the few technicians who were both willing and able and upon the universal Army cure for defective preparation, on-the-job training. Clinical training for doctors moved in familiar grooves, though greater maturity in the professionalization program was evident by comparison with the first year of the war. On arrival in Japan newly assigned physicians attended orientation courses at the JLCOM hospitals, set up to give them some familiarity with Army ways. Dating from the earliest days of the war, the program apparently underwent little change except for location. By 1951 instruction was carried out at installations in the Tokyo area to minimize transport and similar problems. For newcomer and veteran alike, conferences and symposia increased in number and sophistication. Radiologists, ophthalmologists, internists, and other specialists met at both regional and general conferences; dispensary physicians attended meetings on general medicine. In the Eighth Army - and in the KCOMZ after its establishment - postgraduate courses were designed to utilize the talents of visiting consultants who, while remaining inspectors, became instructors as well. Such "courses" might last only a few days, for the students were busy people and the consultants' visits to any given area usually short. Most were concerned with imparting the newest wrinkles in one or another specialty to professionals who already knew the basics, which they practiced every day. Refresher training was also provided for battalion surgeons and for the Medical Service Corps officers serving as assistant battalion surgeons. In Korea the field and evacuation hospitals were usually the sites chosen. After the 8228th MASH had become a hemorrhagic fever center, however, lectures there informed both newcomers and veterans about Korea's surprise contribution to American medical literature. A civilian consultant from Harvard spoke in Pusan on diseases of the chest; at some meetings, papers were presented, and physicians were encouraged to bring up interesting cases for discussion. Largely the work of General Ginn, who had succeeded Page as Eighth Army surgeon, the development of these brief courses indicated that medical men in Korea now had time to study as well as to work on patients. Both the rotation system and the ever-changing nature of modern medicine helped to make continuous professional training a feature of the Korean scene. The end of the war of movement enabled personnel from the general hospitals down to the battalion level to train and work simultaneously. Informal but effective were sessions at the medical and dental societies that sprang up in Korea - the 38th Parallel Medical Society, the X Corps Medical Society, the Military Preventive Medicine Society of Korea, and the Korean Communications Zone Medical and Dental Society. Despite all its faults the system accorded people with interest and ambition an unusual opportunity to learn, for a wide range of teaching was open to all. Classes were well attended, indicating that many used their chance to learn new skills and hone old ones in study as well as practice. Supply While personnel fluctuated, supply became more dependable. Over the course of 1951-52 a steady influx of zone-of-interior materiel supplanted the rapidly dwindling World War II stocks. In some areas - notably pharmaceuticals - the capacity of Japanese manufacturers increased. In time, Army units were able to utilize sturdier American products. This did not, however, imply a loss of business for all Japanese manufacturers, because the needs of Korean relief mounted as the reconstruction of the country began under U.N. supervision. Additionally, supplies from all over the world arrived in the warehouses of the Japan Medical Depot, bound for the war-battered nation across the Korea Strait. Another burden on medical stocks, both in the Far East and in the United States, resulted from the presence of increasing numbers of troops sent by other U.N. nations. Issues of medical supplies and equipment to U.N. forces increased in 1951 from about 3 percent of total issues in January to about 22 percent in October. As issues to the Republic of Korea (ROK) Army did not increase significantly, the diversion of supplies to other U.N. forces evidently caused the decrease in issues to U.S. troops from 94 to 75 percent during the same period. In 1951 medical supply operations divided into two phases, as the war did. Up to 10 July the war of movement, with continuous combat, meant high rates of usage. The opening of armistice talks at Kaesong, signaling the period of digging in and limited combat actions, meant lower consumption and, because materiel arrived from the zone of interior uninterruptedly, rising stocks in most goods. Until May the 6th Army Medical Depot at Yongdung-po remained the only supply organization in Korea itself; greatly overextended during the advance in late 1950, its scattered advance platoons benefited from the contraction of the front that followed the defeats of November and December. Subsequent advances underlined the need for a more elaborate system, and in May 1951 the 60th Medical Base Depot Company was activated at Pusan. In effect, the 6th and the 60th functioned as forward and rear support units, with the former serving the combat operations and the latter supplying the Pusan area, requisitioning from Japan, and operating as a transit depot. Located in small warehouses on the waterfront, the 60th by year's end was in process of acquiring newly constructed buildings for its work. Also in May 1951, the Japan Medical Depot moved from its old quarters in Yokohama, which the increasingly busy port authorities needed, to Camp Benda, 60 miles northwest of Tokyo. While stocks rose with shipments from the zone of interior, dependence on the Japanese economy continued, particularly for support of the ROK Army and for U.N. forces other than Americans. Textile deliveries for dressings were somewhat unsatisfactory, but Japan supplied many other items with success. Striking was the growth of Japanese sophistication in laboratory work and the production of biologics. Early in the Occupation the Army had established tight quality controls over manufacturers to ensure high-quality products needed for civilian relief. In 1946 the civil government created a laboratory control section in the Ministry of Health and Welfare to set and enforce standards for the production of biologics. By May 1951, when Japan entered the World Health Organization, other Asian nations already were turning to the Japanese for advice and assistance in plant design and construction and for general technical know-how. In vaccines, sera, antibiotics (except for some of the newest), and human blood products, Japan was by this time supplying itself and a substantial part of the Korean civil assistance program as well. The Far East Command called Japanese production of penicillin "one of the sagas of the occupation." From the little that was turned out in laboratories at the end of the war, production on the islands rose to compete with the leading nations of the world: By 1951 the Japanese were making 15 trillion units a year. One sign of the nation's remarkable growth in expertise was the fact that the command routinely submitted drug supplies from U.N. nations to Japanese government laboratories for assay before including them in medical assemblies or shipping them to Korea for civilian relief. Despite improvements in its sources of supply, the Japan Medical Depot was not without problems. By December 1951 the low level of combat had ended one nagging difficulty - there was at last an adequate supply of litters in the Far East Command - but short supplies were noted at various times during 1951 in a number of basic items: nitrous oxide (for lack of containers), plasma, field dressings, and blankets, among others. The tendency of medical supplies to leak away into Korea's civilian economy was a factor, notably in the case of blankets and of items like antibiotics, which brought high prices on the black market. "The many and varied uses to which some medical items may be misapplied," noted the FEC surgeon, "are too numerous to mention, and are usually quite well known to all concerned." Exactly where pilferage occurred - on the ships, in warehouses, on trains - is difficult to determine. On the whole, however, supply personnel were inclined to congratulate themselves on their success during the year that had seen a transition from the high usage rates and catch-as-catch-can methods of 1950 to a more sedate, elaborate, and well-ordered system. Few shortages lasted to the year's end, and 1952 held out some promise of putting the depots both in Japan and in Korea at last ahead of the game. As the front stabilized, signs appeared of a typically American abundance verging on excess. In this the medical supply situation was one aspect of a more general trend. Partly the situation was geographic; supplies entered but rarely left the Korean cul-de-sac. More important was the changing character of the war. Not only was combat less steady, but the American people sought to compensate the few who bore the burden of the fight by attempting to reproduce for their benefit at least some of the comforts of home. Ice cream machines, snack bars, theaters, and PXs began to dot the landscape, often surprisingly far forward. (Every soldier and marine was supposed to receive at least one serving of ice cream a week.) American troops enthusiastically seconded this trend. Commanders and men alike gathered into bunkers, camps, and unit areas as much impedimenta as they could to improve the quality of life. Wherever municipal water supplies became available, flush toilets, sinks, and shower baths followed. The official logistical history somewhat dourly warned that "it is the exception rather than the rule [in war] to provide telephones, space heaters, and PX radios in every squad bunker, or thousands of rounds of artillery fire to repel local enemy attack." Encased in body armor, longing for his rest and recuperation (R&R) leave, and counting the days to his rotation date, the American soldier comforted himself with consumer goods - a habit learned at home - while enduring an assignment that was still bleak and dangerous enough. Transport reflected the new situation. The generally lower level of combat reduced the need for supplies, and its more predictable course meant that all medical supplies except whole blood, vaccines, biologics, and goods needed to meet sudden emergencies could be sent by sea. Transferred from the docks by truck to the medical depot in Pusan, materiel moved direct from the depot to U.N. troops in the area; to ROK Army medical depots; to the 25th Evacuation Hospital at Taegu, which supplied all U.N. units in that area; to the 171st Evacuation Hospital in Taejon, which filled the same role there; and to the 6th Army Medical Depot for distribution to troops in the Seoul area and to the advanced platoons at Uijongbu (I Corps), Chunchon (IX Corps), and Yanggu (X Corps). Supplies for UNCACK were turned over to the Korean Forwarding Company, a civilian concern, for shipment to another civilian establishment, the Korean Medical Company, a contractor with the South Korean government's Office of Supply. From the Japan Medical Depot to the forward platoons, integration and quality of service improved steadily during 1952. No critical shortages occurred. An agreement with the Air Force led to a mutually satisfactory allocation of medical supplies between the two services in Japan. Procurement for the Army's needs from civilian sources was in decline throughout the year as shipments from the zone of interior more closely approximated needs. In 1951 about 50 percent of expendable supplies needed for the ROK Army and for POWs had come from Japan; in 1952 the percentage was reduced to 15. But civilian aid procurements increased, not only because the relief program was expanding but also because they were cheaper and of constantly improving quality. The Japan Logistical Command boasted of a "very healthy relationship" between the Medical Service and Japanese suppliers. Clearly, it was healthy for the manufacturers. By the end of September they had sold $4.5 million of goods, including $2.8 million earmarked for Korean relief, to the Army for medical purposes alone. Of considerable importance from the medical angle was the improving quality of food delivered to the troops in Korea. During much of the early fighting field rations were in short supply, and to conserve canned rations against need, the quartermaster shipped in fresh foods. The soldiers' taste for such items did not dissipate with the stabilization of the front, particularly as supply became easier. Troops continued to demand two hot meals a day, battle permitting. In the spring of 1952 over half the dinners and suppers served on the line were said to include some fresh meat. Some 20,000 tons of steaks, eggs in the shell, fresh potatoes, lettuce, and fresh fruit each month went northward from Pusan. Not only the Japanese hydroponic gardens but also refrigerator ships from the zone of interior brought the food in. Supplies were transferred to cold storage barges in the Korean ports and sent to the front by "reefer" cars on the trains of the 3rd Transportation Military Railway Service. Technical improvements made even the dehydrated and canned foods, familiar from World War II, more palatable. Though 10 to 15 percent of the food shipments was lost to pilferage, American soldiers probably ate better in Korea than even their own well-nourished predecessors during most of the Second World War. Food supply was, of course, a Quartermaster responsibility, but members of the Veterinary Corps continued their accustomed work as food inspectors. (Their other duty, caring for Army animals, was minimal because the only ones in the command were 144 war dogs, of which 7 were in Korea at the end of 1951; furthermore, the health of the dogs was very good.) Food inspection work, by contrast, was heavy. In one month taken at random - January 1952 - nearly 793 million pounds of food had to be inspected; over 850,000 pounds were rejected. Besides the imports from the United States a variety of food - including fruit, swordfish, vegetables, recombined milk, and ice cream - was produced in Japan, though only the fruit and fish came from Japanese sources. To cab out inspections, by the end of 1951 thirteen veterinary units operated in Japan and six in Korea. The feeding of an international force presented unique challenges to all concerned. The ROK Army ate only one large meal a day - an Oriental ration of fish, kelp, rice, and beans - but snacked at other times, and exhibited a boundless appetite for hot peppers. Inspectors baffled by Korean labels on canned goods sometimes found their Korean assistants as helpless as themselves; educated under Japanese rule, they could read that tongue but not their own. Turks would eat pork in battle or in camp, but in hospitals often felt religious qualms and refused it. Greeks preferred their own food but would eat American rations, if pressed. (A request from a Greek Orthodox priest for virgin lambs for Easter was met with young male lambs, "which proved entirely satisfactory.") Because many supplies, especially for the Koreans, came from Japanese sources, veterinary officers had to learn the names of Japanese fish, of which there were altogether too many, and to accept the fact, difficult for American sensibilities, that the penicillin-like mold that grew on air-dried fish was harmless. Though surprised by such variations in military service where standardization was the rule, the Army tried to meet the tastes of its allies as far as possible, obtaining from Japanese producers a porkless ration for Moslems and a standard oriental ration that met ROK Army tastes. The chief questions remaining about the latter were its nutritional value, and, after it passed out of American hands, its distribution to the troops on the line. The depletion of World War II stocks, increased zone-of-interior shipments, and the shift of local goods to the relief program reshaped the supply picture during 1952. Reduced fighting, growing accumulations in the using units and the maturing of the transport system changed the character of the soldier's experience. The lot of the fighter in any war is by definition harsh, but by that low standard American soldiers in Korea had passed from the chaos of mid 1950 to relative prosperity. The static front, control of the air, and the nature of the war itself had brought them to a "pampered" state that critics deplored but did not offer to share. The medical system kept pace, delivering sophisticated equipment like electrocardiograph machines to forward hospitals and maintaining a steady flow of all necessities to the front in a war that now had become, and seemingly might long remain, part of the order of things. The Blood Program No single medical item was more important than blood, and its supply was a specialized program stretching from the zone of interior to the battlefield. Basic both to its value and to many of the problems encountered in handling it was the fact that whole blood is a living tissue, obtainable only from human subjects. To be usable, blood had to be treated to prevent clotting, stored at 38-42 degrees F, and used within twenty-one days. During transport it had to be handled carefully to prevent the oxygen-carrying red cells from being destroyed. A part of the body of the donor, and consequently reflecting his state of health, both whole blood and plasma (the fluid part of the blood) had to be carefully controlled to prevent the spread of disease. Because the results of new tests revealed that the danger of transmitting serum hepatitis was much greater than previously realized, the use of plasma during the Korean War tended to give way to serum albumin and synthetic plasma expanders. The lifesaving qualities of whole blood, however, were so remarkable that its use grew steadily, though no means of sterilizing it were known. The year 1951 saw the blood program established during the first months of the war grow and matured. In September the secretary of defense set up the Armed Forces Blood Donor Program, with centers at thirty-one major military installations across the country. The Red Cross rapidly increased its own capacity to obtain and process blood. Plasma-processing plants were operating at full capacity. Blood collections continued high well into 1952, but fell off in May. In October, responding to the fierce fighting of that month, they rose again, only to fall thereafter in response to the general national disillusionment with the war. Throughout, the Red Cross supplied about three-fourths of the blood, the armed services the rest. Besides obtaining blood the laboratories typed and otherwise classified it, and processors salvaged serum albumin from blood unsuitable for plasma, from overage blood, and from contaminated plasma. From the zone of interior, Type O blood, especially the low titer universal donor variety - so called because it caused fewer problems than other nonmatched types when administered to Type A and Type B recipients - was shipped to the Far East, most of it being sent on from the 406th Medical General Laboratory to Korea. Once in Korea blood moved through the supply system much like any other critical item, though medical officers often called for special treatment of a most unusual and fragile substance. In medical depots blood was stockpiled and the oldest that was usable issued to the hospitals - a reasonable arrangement but one that tended to increase the age of the blood by the time it got into the recipients' veins. With nine or ten usable days left for most when it reached Korea, the blood actually transfused was from nine to twenty days old. [See Medics Using Plasma: Medics administering blood plasma.] Air transport was the key to the successful forward use of whole blood. Blood was flown by the Military Air Transport Service (MATS) to Travis Air Force Base in Oakland, California. Here the Armed Forces Blood Processing Laboratory examined and repacked it. MATS planes then carried it via Hawaii and Wake Island to Tokyo. Again traveling by air to the depots at Pusan and Seoul, and by fixed-wing aircraft or helicopter to the forward depot platoons in the corps areas, containers of blood completed the journey to the MASHs on medevac helicopters, strapped into the pods like casualties. As with casualties, the two great advantages of air travel were speed and smoothness. Blood came in time and in condition to be used, which was not always true after spending hours or days in transit over the cocktail-shaker Korean roads. Though wastage occurred, in considerable part because of the widely fluctuating needs of the front once the static phase of the war began, the Far East Command judged the blood supply system on the whole an "extreme success" and a continuing key to the remarkable survival rates in the hospitals of both Korea and Japan. The problem of hepatitis in plasma proved, however, insoluble during the Korean War. Armed with new tests for detecting subclinical hepatitis, hospitals in Korea found rates that reached 23 percent among men who received multiple transfusions of plasma and whole blood. Investigations by the Armed Forces Epidemiological Board and the National Research Council showed that ultraviolet radiation did not destroy the virus in plasma. Unlike whole blood, plasma had no oxygen-carrying ability and functioned in hemorrhaging patients merely as a filler for the vascular system, preventing a disastrous fall in blood pressure. The problems with plasma turned the attention of investigators to other blood substitutes that might accomplish the same goal with less risk. Serum albumin, a natural protein prepared from blood or plasma, proved to have marked advantages. It was not infectious and could be stored easily and used by medics in the field to stabilize the wounded for their journey to a MASH, where whole blood was available. Another substitute was Dextran, a commercial product made from sugars that increased the fluid within the vascular system by drawing it from the surrounding tissues. Despite its dehydrating effect it too proved useful, especially to unit aidmen and in battalion aid stations. By such means the Medical Service attempted to minimize the problem of secondary infection until a conclusive answer was found. Preventive Medicine Apart from the baffling mystery of serum hepatitis, spread by the very transfusions that saved life, the record of the medics was generally one of improving control over the sources of disease, even hemorrhagic fever. The other form of hepatitis - the infectious variety that was endemic in Korea - reached near epidemic proportions during 1951. But change was on the way. The Army had developed an iodine water purification tablet shortly after World War II but had hesitated to employ it because of fears that it might prove toxic. Tests showed, however, that ingestion of the amount needed was not harmful, and as a result Halazone tablets, long proved unsatisfactory after storage, were withdrawn and iodine tablets issued. Chlorine also continued to have value in water purification. Troops located near municipalities increasingly drew their water from civilian supply systems and adding chlorine provided a margin of safety. In the Eighth Army, the standard field requirement rose from 1 to 5 parts per million. In response to this change, and to the slackening of combat that enabled troops to drink treated water, the infectious hepatitis rate fell from 33 to 12 cases per 1,000 per annum. With canteen water disinfected, engineer water supply points multiplying, and municipal supplies hyperchlorinated, hepatitis and many enteric diseases as well were brought under better control during late 1951 and 1952 than at any time since the outbreak of fighting. Control of pests and disease vectors generally improved, though with one or two exceptions of note. Insect and rodent control in Korea was carried out by one preventive medicine company and a number of smaller units. The larger unit - designated the 37th Preventive Medicine Company after reaching the Far East - was a new type of organization that quickly demonstrated its value. Serving with the IX Corps, the company provided one control section for each division; its members conducted training sessions for the troops, mixed and provided poisons, carried out field work, made sanitary inspections, and collected water samples and insect specimens for testing. The company's officers were entomologists or sanitary engineers, and its enlisted men had received training in one or more phases of preventive medicine. The company proved so useful an innovation that the Medical Service began to train a second in the zone of interior. [See Bug Dusting: Dusting for mosquitoes with an improvised device.] In cooperation with the Air Force, planes were used in what the Far East Command called the "largest military spray program ever conducted." Under Maj. William M. Wilson, four aircraft began to fly missions in June 1951, spraying a 20-percent DDT emulsion over some 370,000 acres. Repeated flights were necessary to suppress insect (especially fly) populations, which tended to rise quickly after each treatment. Major cities and all fields were the favored targets, with special missions to the Munsan peace conference area. As usual, it was difficult to separate the various factors influencing disease rates. Malaria, for example, peaked in early summer at a rate of only 18 cases per 1,000 troops per annum, markedly lower that its maximum of 31 the year before. Possible causes included the fact that prophylaxis was more rigorously enforced, that weather was unfavorable to mosquitoes, that ground sprayers were at work as well, and that the new face of the war separated combatants from civilians more completely than before. Whatever the reason, diseases borne by insects and other arthropods were markedly less important than in the past. One serious disease, Japanese B encephalitis, almost disappeared. Unfortunately, malaria became a problem in Japan as it ceased to be one in Korea, for returning personnel infected the local anophelines, which in turn attacked a population with little natural resistance. Troops returning to the zone of interior also had frequent relapses on shipboard, a sharp reminder of the fact that chloroquine suppressed the symptoms of malaria but did not kill the parasites. In December the new antimalarial primaquine came into use, a promising innovation because tests indicated that it killed the Plasmodia in the tissues of victims. The environmental dangers of using broad-spectrum insecticides were little appreciated at the time. Soon, however, it became apparent that body lice in Korea - probably because of immunity developed during earlier spray campaigns - were becoming DDT-resistant. At first medical personnel thought that the DDT in use must be old, and they obtained freshly made supplies. When the new DDT also proved ineffective, search for another insecticide began, with the specter of possible typhus epidemics to encourage speed. Experiments in Korea during the summer of 1951 included new reliance on an old standby, pyrethrum, and trials of 1-percent lindane (benzene hexachloride), then in agricultural use in the United States. Lindane proved effective, and by the end of the year the 38th Preventive Medicine Control Detachment reported that two applications reduced the lice problem among some POWs - the worst afflicted group in Korea because of initial infestation, crowding, and restricted movement - from 92 to 0.9 percent. Meanwhile, studies in Japan showed again a highly specific resistance in lice to DDT, further evidence that the substance, for almost a decade the nuclear weapon of the war on noxious insects, was losing its punch. Other diseases demanded quite different methods of control. In December 1950 the surgeon general had warned of a possible influenza epidemic in Korea, and by January 1951 the case rate had risen in the Far East Command to 203 per 1,000 troops. On 22 January the command ordered all U.N. troops immunized against influenza. Thereafter the disease fell off, though rates throughout the command remained higher than in 1950. Venereal disease (VD), as usual, showed an inverse relationship to the level of combat, rising in Korea as the front stabilized and the intensity of fighting fell. Narcotic addiction was reported a problem in some parts of Korea, reflecting the ready availability of both marijuana and heroin. Poliomyelitis was relatively more common, the bulbar form in particular exhibiting a high mortality rate, and tuberculosis began to rise among Americans in both Korea and Japan. Probably for genetic reasons, blacks were especially susceptible. No disease, however, was of major military importance. Overall, the changes that appeared in the disease picture during 1951 reflected, not medical innovations, but political and military events. The signing of the Japanese peace treaty meant more contacts between Americans and Japanese and consequent dangers to both. In Korea the stabilization of the front drastically altered the possibilities of preventive medicine and, as the rise in VD rates showed, increased the prevalence of some ills while enabling medics to suppress others more effectively. The rotation system, R&R leave, and the introduction of dependent travel to Japan all produced movements of people that implied the spread of disease. When all was said and done, however, the positive signs far outweighed the negative. The following year saw many of these trends continue and intensify. The activation of the KCOMZ brought into being a headquarters where preventive medicine throughout the rear areas was a matter of major concern. At the end of 1952 the command reported that the health of the troops was, all things considered, amazingly good. Systematic immunization, begun in 1950 and carried on through 1951 and 1952, was basic to the soldiers' ability to resist the local disease environment. Increasing numbers now were housed in permanent or semipermanent quarters. Messing facilities were good, and the men themselves were said to be showing considerable self-discipline in avoiding contaminated water and food, in great measure because their own rations were palatable and commissary liquor was abundant and cheap. Another key to success was the fact that the KCOMZ by this time had four preventive medicine units operating within its boundaries: the 38th, 152nd, and 154th Preventive Medicine Control Detachments, and the 219th Preventive Medicine Survey Detachment. The 38th was assigned to the Prisoner of War Command and the 152nd to the Korea Base Section. The 154th, headquartered in Pusan, supplied groups of one to five technicians for special assignment to meet local problems, and the 219th served the entire KCOMZ. Upon these units fell the responsibility of controlling what the command surgeon called the "entomological theater" of Korea, performing work similar to that of the preventive medicine company in the forward areas. The two great medical problems of the forward areas - hemorrhagic fever and cold injury - were nonexistent in the communications zone. The main exceptions to the generally happy picture were infectious hepatitis - much reduced by chlorination but still too high - and that traditional problem of the zone, venereal disease. The command surgeon traced the continued incidence of hepatitis to three factors. Most, he noted, occurred in the Pusan area, a center of the drug traffic and drug addiction, and he raised the question of whether the two might not be connected. Occasional slips in personal discipline, primarily from drinking nonpotable water or eating seafood or fruit displayed in the street stalls and markets, might also be a source. Finally, and seemingly most important in his eyes, he cited the large and increasing use of Korean food-handlers in messes, clubs, snack bars, and railroad diners. Many surveys had shown that Koreans of the laboring class were all parasitized in some degree; it seemed reasonable that such people might be a source of hepatitis as well. As for venereal disease, rates were high and climbing, in 1952 jumping between September and November from 176.8 cases per 1,000 troops per annum to 202. The KCOMZ began to construct prophylactic stations in Korean cities, sought wider cooperation from South Korean authorities in treating the civilian population, set up a Public Health Advisory Council composed of medical officers from its major commands, and began trials of oral penicillin therapy in hard-hit Taegu. The usual calls for "wholesome entertainment" for GIs were heard again. The zone surgeon found fundamental problems, however, in the extraordinary number of prostitutes, both registered and unregistered. Korean authorities followed traditional practice by informally licensing brothels and inspecting their inmates; the U.S. Army's policy of either breaking up houses of prostitution or putting them off limits, Koreans pointed out, merely drove women into the streets and put a premium on uncontrolled streetwalking. The Americans countered that actual Korean practice was extremely haphazard, with insufficient treatment of diseased women and poor contact tracing. Because both accusations were probably true, and because the military and civil authorities were at loggerheads over policy, the prospects for improvement in VD rates did not, at year's end, appear to be very good. It was also true that infection on the average of one man out of five once a year did not, with antibiotic therapy, represent a very serious drain on job performance. Psychiatry in the Korean rear areas showed trends which fitted in well with the patterns of physical disease. Neuropsychiatric disorders in the KCOMZ were higher than in the American Army as a whole, though "not excessive" in the judgment of the zone surgeon. Among causes he cited the "boredom of service in Korea," which certainly had not been a difficulty during 1950. TDY to Japan came too seldom; places for sightseeing, given the continuing presence of guerillas, were few. He noted, however, that the shortage of "hobby shops, day rooms, special service activities and equipment, service clubs and the like" was rapidly being corrected. The nature of the war was probably the root problem in that a sense of futility underlay many apparently superficial complaints. American soldiers simply did not feel any longer that they were part of a significant endeavor. Against this background the erratic supply of replacements and lack of promotions caused serious morale problems, for every revision in the point score for rotation had "a shattering effect." Such changes were, of course, particularly noticeable in the rear areas, because the Far East Command, if faced with a shortage of replacements, would lengthen the time of service troops rather than that of men on the line. What the headquarters found to be - and in fact was - reasonable and just often appeared to those affected as a heartless "manipulation" of rotation dates. Meanwhile, the well-nourished monotony of military life was surrounded by the "squalor, poverty, wretchedness, malnutrition and disease" of a wrecked and ravaged land - a comfortless prospect. Narcotic addiction raised minor furors in the press every few months, though the Far East Command judged the rate to be "not . . . anything alarming." However, heroin was cheap in Korea - between eighty and ninety cents for about 65 milligrams - and was the most commonly used hard drug. A fair percentage of users did not appear to be addicts but rather exhibited a social pattern of indulgence, similar to the ordinary use of alcohol, which the command found surprising. Use in Korea was spotty, "two or three persons in some companies with four or five hanger-ons [sic]". Aside from suggesting that a field for research might exist, the neuropsychiatric consultant apparently found no cause for concern in the phenomenon. Dental Care The dental service reflected the tendency toward improved care. The armed forces had 2,358 dentists on 1 July 1950 and 5,729 one year later. In the Far East Command the number of dentists, with few exceptions, was adequate; but for a very few months, Eighth Army figures hovered within 5 percent of the authorized strength. Replacements were sufficient in numbers, though sometimes spasmodic in their arrivals. Normally, new men requested and received forward duty, often at division level, in order to earn rotation points as quickly as possible and to finish their military tours in more agreeable locations than Korea. Customary problems remained in the lack of adequately trained enlisted men, especially well-qualified dental laboratory technicians. Replacements often arrived at their assignments with long-neglected mouths that required lengthy work in the dental chair and prostheses. A survey in late 1952 on replacements in a field artillery battalion showed that 6.5 percent needed emergency treatment, 15 percent prostheses, 43 percent immediate treatment of advanced dental conditions, 33 percent preventive or corrective action, and only 16 percent no dental work at all. Such conditions, the result of personal reluctance to face the dentist as long as possible plus the Army's failure to survey and treat men adequately before shipping them overseas, needlessly burdened the Far East Command. They were, however, quite in line with the experience of earlier years. [See Dentist at Work: Forward Dentistry.] With the stabilization of the front, dentists began to do a great deal more dentistry and less emergency filling in for surgeons. The general tendency was to increase dental staffing forward. During 1952 one oral surgeon was attached to each of five MASHs to give added support to front- line units. Each of the Eighth Army's two evacuation hospitals had one dentist and one oral surgeon. Evacuation hospitals provided some outpatient services, and the MASHs made their X-ray facilities available for unit dental officers in their areas. In the divisions of the Eighth Army all eighteen Dental Corps officers were assigned to the medical battalion but were attached to various units as the situation might require. Usually, one dental officer was needed in each regimental collecting station, in the replacement company, and in the division headquarters. Battalions serving in difficult or remote locations often received their own dentist, principally field artillery and antiaircraft units and combat engineers. The division dental clinic was an innovation that was proving itself in practice. Additionally, the Eighth Army had in the 163rd Medical Battalion an organization that provided, among other functions, a dental service throughout the Army area. The battalion controlled several dispensaries, eleven dental operating detachments, and a dental prosthetic detachment. The battalion took up any slack by sending help to needy units. In the field the lot of the itinerant dentist was often difficult, strapped for shelter and for electric power to run his lights and drill. Dentists permanently attached to units showed considerable skill at digging in. Their tents were framed and floored and usually set into the south slope of a hill, or against the defilade of an east- and west-running ridge. Where possible, dental officers used bunkers solidly constructed of logs, railroad ties, or bridge timbers. The framed semicylindrical Jamesway tent (usually called "Janeway") was, however, a dark place when several sections were joined together, for the only windows were on the ends. Except for the mobile prosthetic units that carried their own power source, dentists were dependent on an outside source for electricity, or on small portable generators that often worked poorly. With a chair, his dental field operating chest, and electricity, the Dental Corps officer was ready for work, of which there was seldom any lack. Dentists assigned to rear areas had little to report after 1950, except the familiar problems among replacements and dependents and ongoing improvement of facilities. In Japan, clinics and dispensaries tended to remain in one place for lengthy periods, adding to the increased sense of regularity and order among those who worked in them. The number of dentists was adequate, and the rapidity of air evacuation from Korea enabled the dental consultant to recommend primary closure of maxillofacial wounds after temporary debridement - an important matter from a cosmetic standpoint because early wound closure resulted in less scarring. Oral surgeons usually found wounds fresh and uninfected, and their own numbers were adequate to the lessened casualty load. Of Professional Interest The work of the FEC consultants continued along familiar lines, interviewing newcomers, recommending assignments in their own specialties, and carrying out tours of inspection. Instruction remained a basic duty, the consultant's lectures deriving much of their influence from his professional reputation, experience, and expertise, rather than from his position in the military hierarchy. The consultant's manner toward more junior physicians and surgeons was clearly derived from the tradition of ward rounds in teaching hospitals. The surgical consultant wrote in 1951 that during visits to hospitals, professional ward rounds were made with members of the surgical staffs. At all times the Consultant assumed the attitude of a friend and counselor who was willing and desirous of being of help professionally. Suggestions were made in difficult or complicated cases. Mistakes were brought to the attention of those responsible, in a spirit of friendliness to the end that the Consultant (at least, so we sincerely hope) was looked upon, not as an inspector or fault finder, but as a colleague having a paramount interest in the welfare of the patient and in the service." Youth and inexperience in military surgery characterized most of the huge number of new men who arrived during 1951, obliging the consultant to distribute the "sprinkling of Board eligible and Board certified officers as well as possible throughout the Command." Whenever possible, new surgeons were assigned to hospitals in the Japan Logistical Command before being sent to Korea. Here they could learn from both veteran soldiers and men returned from the battlefront and could observe at firsthand the consequences of proper and improper procedure in forward hospitals. No consultants as such were assigned to the KCOMZ; specialists working there doubled as consultants. Frequent visits from those in Japan provided an attraction for the monthly meetings of the Korean Communications Zone Medical and Dental Society, held at Pusan, Taegu, and Taejon. Deficiencies in the supply of critical specialists continued, mitigated by the reduced work load. Rising numbers of orthopedic surgeons during 1951 combined with lessening combat activity to make a continuing shortage less acute. General surgeons were trained in orthopedic procedures and, reassigned to the MASHs, in many instances did outstanding work. Changes on the battlefield and the rotation policy directly affected the nature and quality of surgical work. The advent of body armor noticeably reduced injuries to the trunk and increased proportionally the number of wounds to the extremities. Artillery duels across the entrenched lines meant increased injuries from shell fragments, also mostly to the extremities, for even when fragments penetrated the armored vests, the wounds were usually quite superficial. Chest injuries tended now to be the result of crushing forces, such as the blast effect of nearby explosions, or the result of direct impacts from high-velocity missiles. In October and November 1952 a large number of men with infected wounds reached the hospitals in Japan. The reason was not only the increased combat during October but also the amval in the Eighth Army and the KCOMZ of a large number of surgical replacements with hardly any experience in the treatment of massive traumas in a septic environment. The patients were inadequately debrided, and at least two required lower extremity amputations that should not have been necessary. Energetic activity by the FEC orthopedic consultant and the Eighth Army surgical consultant - with frequent lectures and demonstrations - apparently ended the problem by mid-November. The general lessening of combat allowed patients to be held longer in the theater and more elaborate procedures to be undertaken. Generally speaking, the duties of forward hospitals in handling wounds were to perform adequate debridement, leaving most wounds open; to stop bleeding; to treat shock; and to prevent infection. In the KCOMZ every effort was made to close wounds as soon as possible after the fifth day. Physical therapists worked closely with orthopedists to restore function to injured limbs. Fracture victims could now be held long enough for callus - a flexible tissue formed by the body as the first stage in healing a break - to form, avoiding complications caused by attempts to move the patient prematurely. Nailing, or pinning, of broken long bones was routine. Though no attempt at elaborate reconstructive surgery was made in the theater, treatment of chest wounds had become so effective that only occasional evacuations to the zone of interior were necessary. For all wounded who reached medical installations, the mortality rate declined from World War II's 4.5 percent to 2.1 percent in 1951 and again to 1.8 percent in 1952. Research teams continued to visit Korea, bringing and seeking new ideas, methods, and data. In 1951 the Office of the Surgeon General's Research and Development Board listed nine: in surgery, anesthesia, wound ballistics, cold injury, field investigation, malaria, DDT-resistant lice, dysentery, and hepatitis. The malaria team's primary function was to study primaquine; that of the hepatitis team was to study the hospital management of the patient. Studies by the wound ballistics team led to more rigorous enforcement of the rule that steel helmets were to be worn by combat troops at all times. Methadone as a morphine substitute was still undergoing trials, which generated favorable reports. The field investigation team aimed to pinpoint important field medical and surgical problems. A practical result of its efforts was the introduction in 1951 of a new field dressing for wounds and burns. [See Research Lab: Men at work in a surgical research team laboratory.] The surgical research team was especially prolific in its studies of the clinical management of war casualties. Though research in combat theaters dated from World War I, it was further systematized in Korea as a policy of the Medical Service and the Department of Defense. Under Dr. Fiorindo A. Simeone of Western Reserve University and later under Capt. John M. Howard, the team found a home at the 11th Evacuation Hospital on the relatively quiet eastern sector of the front. Here and at the MASHs team members practiced and taught arterial repair and also studied kidney and liver damage, bum treatment, and other types of wounds. Emphasizing the dynamic and pervasive effects of wounding, Howard and his colleagues helped to make the Korean War a landmark in battlefield medicine. The Flow of the Wounded All these varied activities had meaning, of course, only in the flow and treatment of the wounded. Though increasing numbers stayed in Korea, many continued to be earned by air or sea to Japan and the zone of interior. During 1951-52 the railways remained the most important means of evacuation within Korea, while movement out of the country became more dependent on air transport than ever before. [See Litterbearers: Litterbearers carrying casualties to a hospital train.] Rail evacuation might begin as far forward as the clearing station, if tracks were nearby and the tactical situation permitted. When a line was available, ambulance buses were attached to the medical battalion. Fitted with additional flanged wheels for travel on the rails, the buses also could move on the roads to and from the rail line in case of need. With the stabilization of the front, tracks were extended northward in the I Corps zone to within 8,000 yards of the front line. By late 1951 sixty-two hospital ward cars were reported to be working in Korea. The standard train now consisted of thirteen cars - eight ward cars, a kitchen, dining room, and pharmacy car, an officer personnel car, two orderly cars, and one utility car. Maintained and operated by Transportation Corps personnel and staffed by the Medical Service, the trains evidently had come a long way from the rough early days of medical railroading in Korea. With the organization of the KCOMZ, control of the railroads passed to the new headquarters, but the Eighth Army reported at the end of 1952 that the "evacuation system has changed very little during the year." In terms of function and relative dependence upon the different modes of transport, the estimate seems fair. Evacuation from the Army area into the KCOMZ was by train or plane. Ambulance convoys brought the wounded to railheads, where they passed into the hands of the communications zone, or to airfields for flights to the zone or Japan. Assigning the wounded to the proper hospital continued to be the function of the medical regulating officer at Pusan. In mid-1951 Lt. Col. Vincent J. Amato of the 52nd Medical Battalion explained the medical regulating officer's duties: He must be thoroughly familiar with the regulations, with the facilities, and with the specialties of the various hospitals; he must keep a list showing the location of special equipment (eye magnets for removing metal fragments, iron lungs, EKGs, to name a few); and he must know what languages were spoken in the various hospitals so that, if possible, a U.N. soldier might find himself in a unit with nurses or at least an interpreter from his own country. Armed with this information, the medical regulating officer confronted the inflow by train and plane. While the most serious cases were being unloaded first, the officer, using advance data on the makeup of a particular group of wounded, conferred with accompanying doctors and nurses and began to make hospital assignments on the basis of available bed strength and specialty. Rear area hospitals underwent considerable change in response to the lower level of fighting. At the end of October 1951 the 21st and 22nd Evacuation Hospitals, Semimobile, replaced the 3rd and 10th Station Hospitals, respectively, and the 25th Evacuation Hospital replaced the 4th Field Hospital. Ironically, during 1952 the rear area hospitals changed unmistakably into settled installations providing area care. Though their titles suggested semimobile organizations, part of a system of emergency medicine geared to quick evacuation, their functions approximated more and more closely those of conventional station hospitals. As the MASHs had evolved into general-purpose forward hospitals, the evacuation hospitals in their turn grew as omnicompetent backup facilities. Lack of a medical field laboratory in EUSAK compelled hospitals to perform more elaborate tests than their T/O&Es contemplated and led to recommendations for expanded laboratory facilities. Evacuation policy shifted frequently, but the long-range tendency was for the time limit to rise, and studies showed that when it passed fourteen days a marked increase occurred in the demand for tests. But the basic factor in the elaboration of equipment and service was the stabilization of the rear areas during 1952. Here troops mainly were located in a few major concentrations around the urban areas and the ports. Disease and nonbattle injuries dominated the admission rolls, especially during quiet periods on the front. The evacuation hospitals also provided outpatient clinics and diagnostic and consultant services. When battle casualties seemed likely to increase, medical authorities attempted to "clean out" the lightly injured, only to find that few qualified for the term. Though complex equipment, such as electrocardiographs and audiometers, had to be obtained by special authorization from Japan or the zone of interior, the hospitals were caring for substantial numbers of patients with fairly serious nonbattle conditions. As support troops grew in number, and the fighting along the line remained sporadic, the proportion of such patients held by the evacuation hospitals could only grow. With the creation of the KCOMZ, the 21st, 25th, and 171St Evacuation Hospitals plus the Swedish Red Cross Hospital were transferred to the new command. The remaining step was evident, and in early 1953 the KCOMZ evacuation hospitals again were reorganized and redesignated as station hospitals, with the added personnel, equipment, and bed strength of such installations. The history of the evacuation hospitals in many ways symbolized the transformation of the rear areas and, indeed, of the war itself. From the earliest days of the Korean fighting, hospital ships of the British and American navies - later supplemented by another from Denmark - served first as seaborne ambulances and later as mobile hospitals. The original mission of such ships was to transport patients, giving care en route. However, Korean conditions made them far more valuable as floating hospitals. Ships loaded patients either by winching up litters directly from the docks, by lifting them from lighters at sea, or from helicopters landing on their decks. The first and third methods were by far the best, and the advent of the medevac helicopter meant that a hospital ship anchored off a port could receive patients with as little difficulty as one tied up to a pier. In evacuating to Japan, on the other hand, movement by air was preferable because of the delay, possible danger, and need for several transfers that a sea voyage imposed on the wounded. Evacuation by ship was rare after mid-1951. As a British surgeon had noted in the early days of the war, "One movement only is the ideal [for a wounded man]: direct from the field to a base hospital where he is able to remain for several weeks without interruption and the sooner this movement from the time of injury takes place the better." The result was what Rear Adm. Lamont Pugh called the "unique decision to leave the hospital ships in the Korean ports for considerable lengths of time." The ships became a new Kind of mobile hospital in Korea, for all moved from place to place: sometimes supporting the Inchon invasion (as the USS Consolation did), or doing service in Japan for a while, or aiding the Hungnam evacuation, or simply shifting about the Korean coast as needed. Up to the end of September 1952 admissions to the three U.S. Navy hospital ships totaled some 40,662, about 35 percent battle casualties and the rest nonbattle injuries. Additionally, a large number of outpatients were treated, possibly equal to the total cared for aboard ship, for a ship at its pier could conduct a clinic just as capably as a conventional hospital could. With the early service of the HMHS Maine and the later arrival of the Danish Jutlandia, five such ships in all provided an unusual and successful addition to rear area medical resources, and another example of military hospitals whose function Korean conditions had transformed. Such were a few of the salient points in the evolution of the Korean rear areas as the war shifted from one of movement to one of static confrontation. The improvisations of 1950 yielded to a stable, complex system designed to support a war of low casualties in which victory was not sought and for which no end could be foreseen. The KCOMZ assumed the form and many of the functions of the advance section of a World War II communications zone, while Japan continued to serve in a manner reminiscent of the British Isles during the campaigns of the European theater. In Japan lay the largest, most complex hospitals, and from the Japanese airports Air Force planes carried the most severely injured to definitive care at home.