Surgeon's Circular Letter. These Films Are Available Bff-5019 Let There Be Light (Neuropsy- in the Far East Command and May Be Procured Through Chiatry) 60 Min

/V. , HE SURGEONSv ireular

JAN - 1 952

V 0 L U M E - VII fetter NUMBER - 1

A FAR EAST PERIODICAL

ARMY HEDICAL SECTION-GHQ-FEC, SCAP AND UNC OF APO 500 MEDICAL SERVICES 6TH ARMY MEDICAL I®POT (EU3AK)

Some of the major activities of this medical depot include—

teohnioal or medioal maintenance— optioal repair and manufacture— whole blood receipts, shipments--

and storage including biologicals— storage of freesable items— and medicinal gasses. Volume VII - Mimber 1 THE SUR6E0N S JANUARY 1952

circular General Headquarters Far East Command Medical Section letter APO 500

ADMINISTRATIVE

Chicago Woman Key Figure in Japan's Public Health Rehabilitation / 1

Tuberculosis Control Program for Korean Children Now Under Way . 2

.... Aidmen Receive First Silver Stars Awarded in 45th Division . 2

Colonel Ginn Mew EUSAK Surgeon ..... 3

Administrative Officers Meet at Osaka . 3

Entomological Studies in the Far East Command ...... 3

Sanitation Battle to Avert Typhus Threat Under Way in Korea ...... 4

...... Casualties Among AMEDS Personnel ...... 4

Awards to Army Medical Service Personnel ...... 5 Narcotics Control 5 Requisitioning of Code 17 and Non-Standard Items 6 Recent Department of the Army and FEC Fubliaations 6 Clarification of Accounting Classifications 7 Training Films * 7 Blood Bank Research 7

CHICAGO WOMAN KEY FIGURE IN JAPAN'S PUBLIC HEALTH REHABILITATION

Modem medical education and the application of ap- though continuing medical education and practical proved public health methods have resulted in a assistance already had reduced the figure consider- marked reduction in the mortality rate of tubercu- ably. Coordination between Japanese medical groups, losis, Japan's leading killer, according to Dr. Anna such as private doctors, hospitals and sanatoria R. Manitoff, of Chicago, chief of medical services directors, and municipal health departments tradi- in the Public Health and Welfare Division of the GHii tionally was not encouraged. Medical Section in Tokyo. In her new assignment Dr. Manitoff worked closely A distinguished looking woman, with the air of calm with the Tokyo Health Bureau, to which she became efficiency associated with the medical profession, advisor and guide in all its undertakings. Here,as she recently described the manner in which modem in Germany, she was in charge of the control of epi- medical education, is slowly overcoming the didactic demics, hospitals, and the sanitation of streets and teachings of past decades. municipal buildings. The procurement of qualified personnel to carry out the multitude of public health "Tuberculosis, to the Japanese way of thinking," she programs presented a tremendous task. said, "used to be a disgrace. Patients went to the hospital only to die. How they go to get well." Dr. Manitoff recalls with pride the red letter day in March 1948 when she brought about the first com- Dr. Manitoff, a graduate of Boston University, and bined meeting of various medical groups in Tokyo, a resident of Chicago's North Side, has devoted her the initial conference of this kind in Japan. At- life to the advancement of medical education and pub- tended by more than 400 persons, including members lic health. After serving 20 years as an official of the Tokyo Medical Association, Tokyo Health Bu- of the Chicago Public Health Department, she has reau, sanitoria directors, and some Occupation per- spent the past six years in Germany and Japan,teach- sonnel, the meeting formulated plans for coordinat- ing the modem miracles of medical science and pub- ing the finding, reporting, hospitalization, contact- lic health. examination and follow-up of tuberculosis patients. Prom this meeting sprang a council in the city of In October 1947, when Dr. Manitoff arrived in Japan, Tokyo, under the jurisdiction of the governor, which Tokyo had a population of 5,000,000 and a disease has authority to make regulations and laws for the and death rate that reached alarming figures, al- control of tuberculosis.

1 Another important program under the jurisdiction of uals to serve their internship. She also helps in Dr. Manitoff was insect and rodent control. For cen- the selection and approval of Japanese doctors, turies, Japanese people believed that rats in their nurses and dentists for fellowships and scholarships homes were good omens, and it has taken considerable at American universities. effort to prove that the rat is a health hazard. Un- der her supervision, hundreds of teams of Japanese, Dr. Manitoff entered foreign service in 1945 whan trained by American sanitary engineers, have carried she went to Germany as a major in the United States out extermination and control programs against rats, Public Health Service. There she was detailed to mosquitoes, flies and other pests. These measures the United Nations Relief and Rehabilitation Agency have resulted in marked reduction in such diseases (UN££A) and given the post of chief medical officer, as typhus, Japanese B encephalitis and dysentery. Third and Fourth United States Districts, American Zone, which included two-thirds of Bavaria. These At the time of Dr. Manitoff'£ arrival, many Tokyo districts included 200 UMfiHA installations, serving streets were still impassable due to mountains of 130,000 displaced persons. debris and garbage accumulated since the end of the war. Under her vigorous leadership many of the un- The supervision, guidance and teaching of medical of- necessary, unsanitary canals which criss-crossed so ficers, nurses and meeting officers of the UHHHA or- much of the Tokyo metropolitan area, were filled in. ganization, composed of personnel from 51 nations, presented an interesting study to Dr. Manitoff. This resulted in the disposal of debris and the addition of passable streets and new business districts. "I well remember," she said, "the curious back- grounds encountered in my conferences with the pro- One of the best examples of this program's success fessional people of the different UNKRA teams. For is the street paralleling the Ginza, Tokyo's Broad- instance, one team might have a French doctor, a way. It was formerly the site of an old stagnant Danish nurse and a Belgian messing officer." canal. Now, lots are being sold for new business establishments with the revenue going to the city. Added to this, the variety of DP population, with the corresponding technical personnel, created a Dr. Manitoff*s present position, that of chief of “hodge-podge" of personalities, she explained. medical services, Public Health and Welfare Divi- sion, Medical Section, General Headquarters, SCAP, "We even had a variety of food tastes and habits. is a top-level, policy-making post. She is concern- We had to cater to national taste and, in some cas- ed with administrative supervision of Japanese hos- es, certain religious beliefs," Dr. Manitoff contin- pitals, medical education, dental affairs, nutri- ued. tion and nursing affairs. She travels throughout Japan, lecturing about hospital administration and Looking back on past experiences and reviewing pres- inspecting hospitals, pointing out the good and bad ent accomplishments, Dr. Manitoff believes that the qualities of each and suggesting improvements. medical profession in Japan still has a long way to go. Since most Japanese medical professors instruct She is currently busy changing and improving condi- from German texts of past years, and patient charts tions for Japanese internes both in their own hos- in Japanese hospitals are inscribed in German and pitals and in American hospitals in Japan, where Japanese, with a sprinkling of English, such a be- she is arranging opportunities for selected Individ- lief appears to be well founded.

TUBERCULOSIS CONTROL PROGRAM FOR KOREAN CHILDREN NOW UNDER WAX

A massive tuberculosis control program calling for The £0K Ministry of Health approved and sponsored vaccination of more than 250,000 Korean orphans and the program following a recent survey which report- primary sch'-ol children is under way in Korea. Head- ed more than 800,000 tuberculosis cases in Korea. quarters, United Nations Civil Assistance Command, Korea, announced today. This total is far higher than prewar estimates, ROK officials declared. They said much of the increase The preventive work will be conducted in Seoul, Pu- is due to extremely poor living conditions in war san, Choju, Taegu, Taejon and Inchon, South Korea's devastated areas. six largest cities, UNCACK officials stated. Dr. Elise Truelsen of Horning, Danmark, formerly in Vaccination teams now immunizing children in Seoul neurosurgical work at the Copenhagen Municipal Chil- are scheduled to complete the project in Inchon by dren' s Hospital, is general supervisor for UNCACK. mid-July. Dr. Truelsen came to Korea last spring as a staff BCG serum and other supplies are being provided by member of the hospital ship Jutlandia. She later the Civil Assistance Command. The project will be joined the UNCACK staff, working in the field of supervised by UNCACK medical personnel. children's medicine.

AIDMEN RECEIVE FIRST SILVER STARS AWARDED IN 45TH DIVISION

Two Army Medical Service aidmen serving with the ted to action in Korea. 45th Division have been awarded the Silver Star for gallantry in action. Both men also share the dis- Sergeants Ora V. Lawton and Henry Ford, both of Med- tinction of having been the first to receive Silver ical Company, 180th Infantry Regiment, received Stars awarded by the division since it was commit- their awards as a result of actions against the en-

2 emy during the latter part of December. tense fire to a sheltered position."

Sgt. Lawton was on a daylight patrol in the vicini- Sgt. Ford distinguished himself when, on 28 Decem- ty of Tapsang Dong, Korea, on 23 December, when his ber, the reinforced platoon he was accompanying on patrol was met by heavy enemy fire and one man was patrol, was subjected to intense mortar and sniper wounded in both legs. Without hesitation he left fire and three men were seriously wounded before his shelter and ran through a torrent of fire to the patrol could find cover. His citation read in reach the wounded man 200 yards away. "Disregard- part: "With complete disregard for the hostile fire ing the mortar, machine gun and small arms fire fall- to which he was again subjecting himself, Sergeant ing around him," his citation reads, "Sergeant Law- Ford ran back to his wounded comrades, dressed ton proceeded to dress his wounds in an efficient their wounds, and supervised their safe evacuation. manner. Then realizing the man needed further im- Only after the last of his fellow soldiers hod been mediate treatment, Sergeant Lawton calmly lifted moved to safety did Sergeant Ford leave his complete- him to his shoulder and carried him through the in- ly exposed position and return to his own lines."

COLONEL GINN NEW EUSAK SURGEON

announced Colonel Louis Holmes Ginn, Jr., MC, was lege of Virginia in 1927, and was subsequently ap- as the Surgeon, Eighth United States Army in Korea, pointed a first lieutenant, Regular Army Medical effective 27 January 1952. He replaces Col. Thomas Corps, in 1928* He attended the Army Medical N. Page, MC, who has been designated the Surgeon, School and the Medical Field Service School in 1929 Third Army, with headquarters in Atlanta, Georgia. and was a graduate of the Command and General Staff School in 1939. Prior to his EUSAK assignment, Col- Colonel Ginn reoeived his MD from the Medical Col- onel Ginn was the Surgeon, Third Army.

ADMINISTRATIVE OFFICERS MEET AT OSAKA

The fifth meeting of medical administrative offi- speaker and presented as his topic for discussion cers in the Osaka area was held 19 January in the "Medical Operations in GHQ." banquet room of the New Osaka Hotel, Osaka, Japan. Sixty-six members and guests, representing the 382d Inaugurated, in August 1951, at the suggestion of General Hospital, 279th General Hospital, US Arny Colonel .Robert L. Black, present Chief of the Medi- Hospital, 8163d Army Unit, US Army Hospital, 8164th cal Service Corps, the meetings have been held Army Unit, and the Far East Medical Service Special- monthly, except for last December. They are de- ists School at Camp Shinodayama, were present. signed to provide a means of acquiring a greater- Sponsored by the 382d General Hospital, the meet circle of friends and acquaintances among Army Med- was preceded by cocktails and dinner. The evening’s ical Service personnel as well as to keep abreast program was presided over by Lt Colonel Fred Vechnek, of the latest available administrative information Executive Officer, 382d General Hospital, ably as- and techniques. sisted by 1st Lieutenant James J. Norton* Major Donald H. Behrens, Plans and Operations Division, Sponsors for the February meeting will be the 279th Medical Section, General Headquarters, was the key General Hospital.

ENTOMOLOGICAL STUDIES IN THE FAR EAST COMMAND Entomology Seotion, 406th Medioal General Laboratory, APO 500

Probably that Oriental Sage, Confucius, never said ropod, all possibilities oust be investigated. half the things that have been attributed to him, If a rodent or rodents are known to be a disease and if he did actually say "one picture is worth reservoir, these investigations entail a detailed 10,000 words" he probably had in mind some fine study of the parasites of rodents, in order to example of Chinese Art. Nevertheless, the truth learn not only what arthopods are responsible for of that oliohe oannot be gainsaid, and in the teoh- transmitting the disease to man, but also those nioal field of biological soience the worth of ac- that transmit the disease from rodent to rodent. curate detailed illustrations in conveying ideas It may be necessary to determine at what time in as to shape, sixe, and relationships of component it8 life cycle a parasite is capable of transmit- parts probably exceeds the written word to an even ting the disease, and at what time it shows a greater extent than in that oft-quoted thought. predeliotion for assooiating with humans. Con- The use of soientifio illustrations as a means of sideration must be given to each aotive stage of complementing descriptive phrases and oircuanrent- each species of parasite, and in order to avoid ing language barriers and defioienoies is becom- confusion in these studies, it is necessary to ing increasingly oommon and attests to their val- distinguish these various forms, one from the ue in this respect. Probably nowhere in biology other, so that the important ones will not be are illustrations more important than in litera- confused with the innocuous, and vice versa. Med- ture concerned with the differentiation of close- ical Service personnel faced with the problem of ly related species of insects and other arthro- determing the veotors of suoh diseases as epidem- pods. ic hemorrhagic fever oust conduct such thorough and time consuming studies* Attempts to trace down the mode of transmission of diseases oommon to humans and other animals Unfortunately, our knowledge of mites (Acarina), frequently involve studies of parasitio arthro- ourrently considered the number one suspect group pods. Whenever a disease is thought to be trans- as a vector of epidemic hemorrhagic fever, is mitted to man from some lower animal by an arth- very fragmentary* We not only do not know what

3 species may live on rodents, but of those known ever information about the biology of these spe- to parasitize suoh hosts we know little about cies exists cannot be correlated with their stu- their biology, inoidenoe, and distribution* In- dies* The need for adequately illustrated liter- vestigation of the transmission of this disease ature for use of units in the field is recognized. mist include a study of its epidemiology, and at- At the request of the Medioal Service, the Depart- tempts to correlate the appearance of the disease ment of the Army has employed a specialist in in humans with the presence and abundance of po- mites to oome to Japan to assist in the prepara- tential arthropod vectors. This will entail care- tion of suoh aids* This specialist, with the ful surveys of parasites of rodents, with all the help of seven highly skilled Japanese scientific attendant difficulties of identification of mites illustrators, will have as a mission the prepara- and other parasites. tion of technical publications which it is believed will fill the existing need for literature The aocurate identification of mites, and the dif- for the use of personnel not specially trained in ferentiation of closely related species, almost the taxonomy of mites* Work on the illustrations invariably entails the examination of minute ana- which will constitute the basic and most valuable tomioal structures at magnifications of over 400 part of these publications is already under way diameters. But before a person can proceed intel- at Kyoto, Japan. ligently with this type of identification work it becomes neoessary to determine, through examina- The ultimate success of this projeot will depend tion of hundreds of specimens, just what struo- to a considerable extent upon how well it is sup- tures are of importance for distinguishing a giv- ported by field survey work* Obviously, a pub- en species from its close relatives. This means lication that treated but a small percentage of not only careful sorutiny, but also analysis of the oommon species encountered would be of little variation within a species, so that individual practical value; there would be too many blank differences will not be confused with species dif- spots remaining in the analysis of the mite fauna* ferences. Once the limits of variation of a spe- In order to take full advantage of the talents of oies are well understood it becomes possible to the artists now employed it is hoped and urged "define" a species so that other specimens of the that units in the field cooperate by making avail- same species may be identified. It is in connec- able for study and illustration representatives tion with this step that scientifio illustrations of whatever speoies of mites and fleas they en- become of particular value and are, literally, counter* Suoh material Bhould be forwarded to worth 10,000 words. the 406th Medioal General Laboratory, AFO 600, where it will be processed for further study. Field units of the Medical Service currently en- As soon as possible, an identification service gaged in surveys of rodent parasites are serious- will be established at that organization to assist ly handicapped by the lack of adequately illustra- units in the analysis of collected material* In ted publications which will enable them to identi- this way it is hoped that immediate progress can fy the specimens which they obtain. Until suoh be made in the matter of assembling definitive material is identified the results of their labors survey information, and that this procedure will in the field have little value. They do not know suffice during the interim until publications can what or how many speoies they encounter, and what- be prepared*

SANITATION BATTLE TO AVERT TYPHUS THREAT UNDER WAY IN KOREA

A sanitation battle to defeat the typhus threat in "HOK and UHCACK sanitation workers feel that through South Korea before it can get started during the Feb- a combination of the past year's mass typhus immuni- ruary, March, April danger period is being waged at zation program, dusting and general urban area clean- all levels with help from the United Nations Civil up, the disease can be kept far below the maximum in- Assistance Command, Korea. cidence of 14,000 cases among refugees early last year," Ribeiro stated. Efruin Ribeiro, of Lima, Peru, UNCACK'e Sanitation Division chief, said that nearly one million Koreans The cleanup drives have been hampered to some extent in congested areas already had been DDT dusted. by lack of municipal transportation to haul refuse out of the cities. However, the UHCACK official Cleanup campaigns now are conducted in major towns said, success has been achieved by assembling all and cities approximately every two months, he said. available hand and ox carts to remove debris. Dusting of refugee camps, prisons, jails, crowded orphanages and schools is scheduled for two or three times during winter months to destroy typhus-bearing lice, Ribeiro added. "Each family," Ribeiro added, "is responsible for cleanliness of streets, drains, and the general area UHCACK has a supply of more than two million pounds in which it resides. Disposal is by burning, bury- of 10 percent DDT powder for the program, the sani- ing or ocean dumping, according to the city's loca- tation chief said. tion."

CASUALTIES AMONG AMEDS PERSONNEL

The cry, "Hey, Medic," has resounded on all the bat- during the current conflict. Recent casualty statis- tlegrounds of the Korean peninsula. And the "medics" tics indicate that the attitude of "whither thou go- have responded in a mariner worthy of the finest tra- est, I will go" prevails among combat medical person- ditions of the service. nel in that where the shooting is the hottest, there, too, is the combat medic. Among enlisted personnel Commanders hold to the belief that few troops are serving on the Korean battlefront only the infantry- combat effective until they have b»en, so-called, man and the artilleryman have suffered greater cas- "blooded" — and medical personnel have been blooded ualties.

4 AWARDS TO ARMY MEDICAL SERVICE PERSONNEL

The following additional Army Medical Service personnel have been awarded the Distinguished Service Cross, Silver Star, Legion of Merit, Bronze Star Medal with ”V", Bronze Star Medal or Commendation Ribbon for exceptional bravery in face of the enemy and meritorious service during the Korean conflict:

iSTINGUISHED SERVICE CROSS| Hudson, Gilbert, Sgt Hiller, Moses, Sgt Logan, Gerald R., PFC Mount, James B., Sgt Wiseraore, Royal A., Sgt Morgan, Richard Y., 1st Lt, MSC Nelson, Carl A., Sgt Reichert, John C., Cpl Pennington, Hugh A., Capt, MSC SILVER STAR | Rivera-Carbana, Gui, PFC Ramos, Gregorio, Sgt Rubenstein, Max, PFC Regnier, Arthur V., Capt, MSC Allen, Theodore L., PFC Runyon, Benjamin F., PFC Roberts, Hoyt B., Cpl Blackburn, Claude T., Sgt Schrader, Rolf E., PFC Schane, Donald R., Cpl Cromer, Robert P., PFC Shibata, Chester T., 2d Lt, MSC Scott, Malcolm L., Cpl Davis, Howard, Sgt Southern, Lee G., Cpl SiIvey, James D., Maj, MSC Glasby, Thornes C., Sgt Street, Paul J., H/Sgt Simmons, Milton, Capt, MSC Graham, Gene G., Pvt Williamson, Warren, 1st Lt, MSC Sparks, Kenneth R.,Sgt Hall, Dale E., Sgt Youmans, Emory A., Cpl Swanson, Charles T., i$/Sgt Hermanski, Eugene, Sgt Szabo, Ferdinand, F., 1st Lt, MSC Johnson, Orville D., FFC Torres, Jose L., LaFrance, George A«, Cpl Trusko, Joseph P., Capt, MSC Maddox, Bill 3., Cpl Abby, Robert F., SFC Ventimigla, William, Lt Col, MSC Martin, Carl, 1st Lt, MSC Atencio, John R., PFC Walls, William H., SFC Martin, Carl, 2d Lt, MSC Babcock, Samuel A., Capt, MSC Ward, Charles E., Maj, MSC Osgood, Leroy G., PFC Baier, Floren J., ty/Sgt Wolf, Donald C., Sgt Patterson, James M., Sgt Bass, Lewis N., Capt, MSC Zimmerman, Lorenz E«, Lt Col, MSC Sayles, Curtis 0., Sgt Beeler, Thomas T., Jr., Lt Col, MSC Bernstein, Pobert, Lt Col, MSC COMMENDATION RIBBON | LEGION OF MERIT '• Bonilla-Matos, Jose, 2d Lt, MSC Bos, Gerald W., 1st Lt, MSC Anderson, Jerry J., Cpl Mahoney, Elizabeth, Lt Col, ANC Brooks, John R., 2d Lt, MSC Bender, James R«, Cpl Moursund, Walter N», Col, MC Bushouse, Arthur A., Maj, MSC Bookherst, Walter E., Cpl Wickliffe, Nell, Maj, WMSC Buzzelli, Frank D., Cpl Bradley, John P., Sgt Wunderlich, Frederick, Col, DC Chestnutwood, Jaok, 1st Lt, MSC Cates, Donald C., Capt, DC Coleman, Joseph R., SFC Cohen, Stanley, Capt, MSC | SOLDIER'S MEDAL 1 Collins, Edwin M., Capt, DC Daughtry, Jack L., Sgt Cox, James D., 1st Lt, MSC Edington, Roy D., Sgt Thomas, Everett W., Sgt Davis, Daniel E., Sgt Gelman, Leonard, PFC Diokey, Jack D., 1st Lt, MSC Hastings, James F., Sgt | BRONZE STAR. MEDAL with “V" 1 Eaton, Glennon W., PFC Holmes, James P., PFC Gilliland, Garland, Sgt Hubbard, John E., Cpl Arnold, William L., Cpl Hall, Robert M., Maj, MSC Balsa, Warren E., Cpl Bickerstaff, Glen R., Pvt Hanson, Godfried N., 1st Lt, MSC Kay, Marion, Sgt Bryan, William L., Cpl Hohl, James F., Maj, MC Kidwell, Eroel C., Sgt Chaney, Verne L., Capt, MSC Horrell, Irvin L., 1st Lt, MSC Kucharski, Edmund, PFC Coby, James L., PFCT Husband, Joseph L., SFC Lowe, Gordon W., Sgt Cole, George C., PFC Huth, Verlan, E., 1st Lt, MSC Meyer, Arnold W., Sgt Collins, William J«, Sgt Iannacone, Anthony, Maj, DC Middleton, Paul D., Sgt Cooley, Marvin M., Cpl Kershenblatt, Joseph, Capt, DC Mowry, Clair E., Jr., Sgt Cromer, Robert P., PFC Kidd, Wesley S., Lt Col, MSC Nash, Franklin W., SFC Davis, Gerald R., Pvt Lawson, Bige, SFC Pettigrew, Roy L., Sgt Dobson, David A., Jr., 2d Lt, MSC Lee, George W., Cpl Reed, Kenneth J., Sgt Esparza, Antonia A., Sgt Lehman, Robert H., Capt, MSC Saley, John, SFC Gervais, Francis R., PFC Lloyd, Thomas S., Jr. Capt, MSC Shelby, Preston E., SFC Higham, David M*, Cpl MoGrary, Warren A., Capt, MC Thompson, Walter L., Sgt Holly, A. B., Jr., Sgt MoXeithen, Daniel, Cpl Veth, Willie L., Cpl

NARCOTICS CONTROL

Section II, Department of the Army Circular No. 102, for daily usage and for use in dispensaries, out- dated 17 December 1951, is quoted for information patient clinics, or infirmaries where small quanti- and guidance of all concerned: ties of narcotics must be kept on hand to meet emergency treatment needs* Commanders of medical treat- NARCOTICS CONTROL AT MEDICAL TREATMENT FACILITIES. - ment facilities should utilize this item where nar- cotic control procedures for this purpose are nec- 1. Armed Services Medical Materiel, Item 7-029-240, essary. cabinet, medicine, combination type, CRM, has been designed with a small narcotics container spot- welded inside the cabinet. The purpose of this con- 2. Requisitions for this item, for the purposes tainer is to provide an adequate means to safeguard enumerated above, should be submitted through medi- those narcotics which are required on hospital wards cal supply channels.

5 REQUISITIONING OF CODE 17 AND NON-STANDARD ITEMS

Considerable confusion and misunderstanding exists It would appear that once the Army has agreed to regarding the availability of newly standardized "adopt” a non-standard item, that item becomes an (Code 17) items and the channels through which they "orphan" and cannot be requisitioned. This inter- may be obtained during the transition from "non- pretation is erroneous and must be dispelled. Any standard" to "standard" on the supply table. Quoted time that a commercial type "Code 17" item is re- below are the definitions of subject items taken quired for patient care, it may be requisitioned from a Medical Depot Supply Manual* in the same manner as prescribed for non-standard items. It may be obtained and issued provided de- "A non-standard item is any medical item that tailed information as to why the item is required is not provided through normal requisitioning and and an explanation of why another standard item issue channels; in other words, items that are not will not suffice is included on the requisition. yet officially listed as being available for issue Further, requisitions for "Code 17" items such as in the Catalog of Medical Materiel or any current the new 15 MA or the new 100 MA x-ray units having Spare Parts Catalog, Pamphlets or Lists provided military characteristics not found in commercial installations by Medical Depots." items must obviously be deferred until stock is available through central procurement. "Code 17 indicates that the item is newly standardized in the medical service and is in the This procedure is not intended to discourage the process of being procured centrally in the Zone of use of newly standardized items, but rather to in- the Interior for world-wide requirements. As soon sure that the limited supplies of these items are as stocks are received in Medical Depots, stations used where they are most needed and to obtain max- will be advised to include these items on the stan- imum use of non-standard funds allocated to this dard requisition submitted by the installation." command.

RECENT DEPARTMENT OF THE ARMY AND FEC PUBLICATIONS

AR 35-1350, 14 Deo 51* Finance and Fiscal - Pay of DA Cir 4, 8 Jan 52s Sec II - Completion of iff Form Retired Members of the Army 183A-1 (Excused From Duty Report) By Department AR 35-1355, 14 Deo 51* Finance and Fisoal - Pay of of the Army Medical Treatment Facilities; Members of Uniformed Services Retired for Physi- Sec IV - Physical Examinations of Second Lieuten- cal Disability ants, Regular Army - Required of Permanent Promo- AR 605-145, C-4, 2 Jan 52* Officers - Transfers, tions Made in 1949 Details, and Assignments AR 35-1705, C-3, 8 Jan 52* Finance and Fiscal - ATT-8-19, Training Test for General Hospitals, Com- Pay and Allowances, Members of the Organized munications Zone (t/O&E's 8-551, 8-552 and 8-553) Reserve Corps, and Officers, Army of the United States TB FMG-3, 3 Dec 51s Blood and Body Fluids AR 40-105, 9 Jan 52* Medical Service - Standards of Physical Examination for Commission or Warrant GO 104, 5 Dec 51j Meritorious Unit Commendation -

Officer in Regular Army, National Guard of the Para 11 - The 629th Medical Clearing Company United States, Amy of the United States, and Or- (Separate) ganized Reserve Corps AR 40-610, C—1, 9 Jan 52* Medical Service - General Administration of Medical Treatment Facilities AR 620-90, 15 Jan 52* Civilian Personnel - Employ- T/O&E 8-553, 29 Oct 51s General Hospital, 2,000- ment of Pregnant Women Bed, Communications Zone

SR 110-1-1, 26 Oct 51* Motion Picture and Photo- GHQ FEC Cir 5, 14 Jan 52s Central Hospital Rinds graphic Service - Index of Army Motion Pictures, and Hospital Funds Kinescope Recordings, and Film Strips GHQ FEC Cir 6, 23 Jan 52s Medical Attendance SR 795-200-45, C-2, 6 Dec 51* Supplies for Foreign

Aid Programs - Report of Status of Mutual Defense Assistance Program Operations SR 350-230-60, 8 Jan 52s Education and Training - SR 32-20-1, 7 Deo 51* Clothing and Equipage - Cloth- Tentative Courses at Civilian Educational In- ing Allowance System stitutions for Officers of the Army Medical Ser- SR 615-20-1, C-3, 10 Deo 51* Enlisted Personnel Ser- vice

vice Reoord SR 615-360-1, C-5, 8 Jan 52s Enlisted Personnel - SR 615-25-36, 10 Deo 51* Enlisted Personnel - WAC Discharge Procedures and Preparation of Separa- M0S Assignment tion Forms

- SR 35-1465-5, C-2, 17 Deo 51* Finance and Fiscal SR 600-145-40, 14 Jan 52s Personnel - Change of Basic Allowance for Subsistence for Service Mem- Station and Rotation of Duty Assignment of Cer- bers tain Veterinary Procurement Inspectors SR 600-60-1, C-l, 28 Deo 51* Personnel - Insignia

- SR 600-450-10, 4 Jan 52* Personnel Evaluation DA Cir 102, 17 Deo 51s Seo II - Narcotics Control and Separation for Physical Disability Whioh Ex- at Medical Treatment Facilities isted Prior to Entry on Active Service DA Cir 104, 19 Deo 51s Special Subject for Inspec- SR 140-180-15, C-l, 8 Jan 52* Organized Reserve tion - Misassignment of Physically Handicapped Corps - Administration of Benefits Provided by Rotation Combat Personnel Section 5 of Act of 3 April 1939, as Amended, as DA Cir 106, 28 Dec 51s Seo II - Nontaxable Compen- Further Amended by Act of 20 June 1949, For Mem- sation Shown on Forms W-2 bers Who Suffer Injury or Death in Line of Duty DA Cir 3, 3 Jan 52s Seo II - Income Exempt from While on Active Duty or in Reserve Duty Training. Withholding Tax

6 CLARIFICATION OF ACCOUNTING CLASSIFICATIONS

Section II of Department of the Army Circular No. the over-all rate for medical treatment that is to 96, dated 23 November 1951, is reprinted for the be deposited (or credited) to reimburse the appro- information of all concerned: priation for the cost of furnishing such supplies and services, and are based upon approved cost elem- 1. Information available to The Surgeon General -nts and factors of cost experience. Since such indicates that some misunderstanding exists at De- collections are not the result of direct issue or partment of the Army medical treatment facilities sale of supplies and equipment, as such, they are with respect to the correct appropriation and ac- not proper for deposit to a replacing account, but count code symbols to cite on vouchers when deposit- should be applied to the appropriation initially ing or crediting collections for medical treatment charged with the cost of furnishing such medical and also for sales of medical supplies and equip- service and/or supplies, i.e., for the fiscal year ment. 1952» 2122020 Maintenance and Operations, Army 1952. See breakdown of account codes and amounts 2. This misunderstanding is due apparently to the stated in DA Circular 67, 1951. fact that the rates of charge for medical treatment of pay patients (see DA Cir. 67, 1951) includes com- 3. For the fiscal y°ar 1952, collections for trans- ponent amounts creditable to standard medical sup- fer or sale of medical supplies and equipment as plies, nonstandard medical supplies, and/or personal 3uch, as differentiated from collections for medi- services, dependent upon the kind of medical treat- cal charges described above, will be deposited or ment furnished and the applicable rate. Such com- credited to 212/34820 Replacing Medical Supplies, ponent amounts reflect the proportionate share of 1952 and 1953, as outlined in SR 35-210-31. TRAINING FILMS

Training films (16mm) recommended by the Consultants cal Officer 44 min. Division, Medical Section, General Headquarters, Far FMF-5012 Combat Exhaustion (Neuropsy- East Command, will be periodically listed in The chiatry) 44 min. Surgeon's Circular Letter. These films are available Bff-5019 Let There Be Light (Neuropsy- in the Far East Command and may be procured through chiatry) 60 min. the nearest film equipment and exchange office (Sig- FMF-5047 Shades of Gray (Psychoneurosis nal Corps). in the Army - Causes and Treat- ment) 67 min. Release Recommended by the Running Humber Neuropsychiatric Consultant Time R1F-5116C Journey to Reality 40 min. FKF-5141 Feeling of Rejection 22 min. IMF-5011 Psychiatry For the General Medi- FMF-5142 Feeling of Hostility 30 min.

BLOOD BANK RESEARCH 406th Blood Bank, AP0 500

Two medical offioers, designated as a Blood Re- minima amount of loss and a paucity of reactions search Team, have been assigned from the Central and supply problems is of major Importance. It de- Blood Bank Depot to detormine factors pertinent to pends, to some extent, upon the using installation whole blood utilization and problems of supply, reporting any reactions, complications of transfu- both in the Japan Logistical Command and in Korea. sions, etc. to the Central Blood Bank in Tokyo. They have made surveys of the majority of medical Any such data, either of individual cases or of a installations using whole blood in the Japan Logis- series of cases, or any constructive comments on tical Command and in Korea. They have tried to de- the blood program should be directed to the Command termine approximate amounts of blood used in differ ing Officer, 406th Medical General laboratory, APO ent areas under varying conditions, the number and 500. types of reactions seen during administration of the blood, any delayed reactions or complications associated with blood transfusions, any problems During the period 1 January 1951 through 31 Novem- of supply, and also to evaluate the overall effi- ber 1951, a total of 113,056 pints of blood were ciency and distribution aspects of the whole blood supplied to medical installations in Korea and program. 28,213 pints were distributed in the Japan Logis- tical Command. To date, the using installations Any survey of the above factors is of necessity have reported an adequate supply at all times, rel- limited to a given period of time. The mainten- atively small numbers of reactions, and have expres ance of an adequate supply of whole blood with a sed a uniform approval of the whole blood program.

TECHNICAL

Of Surgery in the Orient 8 False Positive Darkfield Findings in the Presence of Condylomata Acuminata 16 OF SURGERY IN THE ORIENT Colonel Frank E. Hagman, MC, Consultant in Surgery, GHQ, FEC

aggressive armed forces of the North Korean Nations efforts. Nevertheless, much credit for the communists smashed across the 38th Parallel in excellent results obtained, must go to those who for- June 1950, without provocation, without warning mulated the fundamental concepts and principles upon THEand without opposition. These foroes were which the management of battle casualties is well based. equipped, well led, and well trained. They swept To a great degree, it is the young medical officer aside everything before them and it seemed certain who has carried the burden of responsibility for the the peninsula would be rapidly engulfed. care of the siok and the wounded. Ke has demonstrated magnificently, that he can readily adapt his train- The response of the United Nations forces to this ag- ing and experience to the peculiar requirement for gresion is common knowledge. Anxious days passed, managing battle casualties in a theater of operations. but the Pusan Perimeter held. Then the tide turned In the early stages of the conflict, surgical errors as the brilliantly planned and superbly executed In- occurred because of the lack of experience in mili- chon landing stunned the North Korean forces. The tary surgery. As rapidly as possible, the priceless campaign appeared to be nearing a successful conclu- lessons learned from the wars of the past were dis- sion for the United Nations forces as the Yalu River seminated to all responsible for the management of was reached. Then came the Chinese hordes from the casualties. These fundamental concepts and princi- North. The sickening and disheartening struggle was ples have made it unnecessary for each Dootor to renewed against a ruthless enemy. learn from his own experience what constitutes safe and effective surgical practice in the military The support given by the medical services to the arm- sphere. Technical Bulletins, Directives, Circular ed forces of the United Nations can never be depicted Letters, discussions and suggestions have increased completely. To paraphrase Churchill - "Never have so the frame of reference on which surgical judgment few done so much for so many." It is our purpose to has been based. Withal, it has been clear that review briefly seme of the surgical achievements and the judgment of the surgeon on the ground must pre- problems during eight months of bitter fighting on vail. It is impossible and unwise to spell out for the peninsula. him each detail in the management of the patient.

The Korean campaign began with a total of 197 medi- Equipment and facilities have been adequate, although cal officers assigned to the Far East Command, the simple and standardized. With these, the surgeon has lowest number since the beginning of the occupation. altered his technique and improvised as necessary in Cf the 197, 50 were residents from hospitals in the accordance with the circumstances of what needs to be United States, removed from the Army residency train- done. ing program for temporary duty to meet the medical needs of the occupation. Other branches of the The pressing demands of the Korean oampaign, as in medical services were scarcely any better situated, World War II, influenced the care of the wounded. Ac- nevertheless, from the limited personnel available, cordion-like moves of medical units up and down the one evacuation hospital and three mobile army surgi- peninsula occurred as the fortunes of war favored cal hospitals were organized, equipped and committed or militated against our forces. Danger of being to the medical support of the armed forces in Korea. cut off by enemy action, few and poor roads, and the The pressing emergency permitted no opportunity to limited number of hospitals available early in the indoctrinate the medical officers to the problems campaign were factors in keeping mobile surgical hos- encountered in war surgery. pitals farther to the rear than would have been ideal. These factors, together with unavoidable delays in Meanwhile medical installations in Japan continued the recovery of wounded in combat from remote and to execute their mission although severely handicap- difficult terrain under fire, increased the time lag ped by critical depletion of medical service person- between wounding and initial surgery. It also was nel. This deficiency was gradually relieved by the not unusual for patients to be moved to the rear, arrival of more medical officers and other medical after operation, much earlier than one would wish un- personnel assigned to the Far East on temporary du- der more stable and ideal circumstances. Beds had ty and others dispatched for permanent duty. Later, to be available for freshly wounded patients and hos- various new hospitals and medical units were organ- pitals were forced to move forward or rearward as ized and committed in Japan and Korea, thus strength- the tactical situation demanded. ening the medical support to the armed forces. The management of the patient, as in World War II, has been in phases and by many surgeons and hospitals along the chain of evacuation. Surgical pro- Even as fighting continued and progressed there was cedures have been placed in time and space relation- a large turnover of medical officers. Among US mil- ships altered by the tactical situation, the welfare itary medical officers alone, many hundreds have of the patient and the relationship between the sur- been sent to the command and large numbers have re- geon in one hospital with the surgeons in other hos- turned to the United States. Some returned to re- pitals, to the end that the military effort was not sume residencey training, others as rotatees and impeded or harm done to the patient by doing an oper- still others for compassionate reasons, illness or ation at the wrong time or in the wrong plaoe. injury. A very large turnover involved temporarily assigned medical officers of the United States Navy. As Dr Edward D. Churchill has pointed out, war sur- is the of trauma in These were loaned to the Army for periods of four gery management epidemic propor- to six months, following which they reverted to tions in young, vigorous men, with diagnosis rela- Navy control. tively simple and treatment immediate and direct. Complex diagnostic procedures are usually not necessary. By organization, teamwork and phased treatment, surgioal management of trauma in the Korean In contrast to World War II, very few physioians campaign has been accomplished within the bounds of and surgeons have donned the uniform to contribute accepted surgical standards and without undue con- their talents to the direct support of the United fusion and concessions to the need of haste.

8 WOUHD DEBRIDEMENT Usually, wound shock was not a difficult problem to manage with the means at hand. Many times, however, Because of the large number of casualties, wound de- patients in wound shock could not be resuscitated bridement has been a major problem. Antibiotics with satisfaction and were said to be in "irreversi- have been used freely and have been extremely valu- ble shock." The fundamental difficulty for failure able adjuncts to surgery. It has been amply demon- to resuscitate these patients usually was not deter- strated again, however, they are not substitutes for mined because necropsies were not done routinely. competent debridement. Wound shock which does not respond to the usual meas- Debridement of wounds without primary closure remains ures of resuscitation may be associated with compli- based on sound surgical principles. It cannot be pre- cations, the recognition and treatment of which may dicted with certainty which wounds, if sutured, will alter seeming "irreversibility" favorably. In addi- become dangerously infected. Recognition and removal tion to reduction in blood volume due to the loss of of all necrotic and devitalized tissue during debride- whole blood, plasma, and water, and other effects of ment cannot be done with absolute certainty unless bacterial contamination, cardio-respiratory embarrass- normal tissue is sacrificed unnecessarily. Further- ment may be present in sufficient degree to contribute more, it is frequently necessary to transport pa- to the continuation of the state of wound shock. The tients with debrided wounds early, thus interrupting recognition and treatment of tension pneumothorax, the professional supervision of the wound. massive hemothorax and atelectasis, cardiac tampon- ade, paradoxical respiration associated with flail At various times during the conflict, many wounds chest and laryngeal obstruction are extremely impor- were not debrided for one reason or another, particu- tant and may alter the course of events. In addition, larly in many instances during periods when there the recognition and treatment of concealed hemorrhage were large numbers of casualties. Many of these intra-abdominally and extraperitoneally, or into the were perforating soft tissue wounds which did not soft tissue of the thigh or buttocks may alter what develop untoward complications. At the same time, appears to be "irreversible" wound shock. however, a serious infection, including clostridial myositis, developed in some. Shock which fails to respond to therapy commonly is associated with thoraco-abdominal, retroperitoneal, Early in the conflict, attempts were made by inexper- and large extremity and buttocks wounds. The exact ienced personnel to close wounds primarily with con- role of infection and toxic factors in these cases siderable reliance placed on antibiotio therapy. De- is not completely understood. Suffice it to say that layed healing and risk of loss of life and limb are seeming "irreversibility" in wound shock appears to too high a price to pay for neglect of adequate wound be related to bacterial contamination in a signifi- surgery. It is axiomatic that wounds should be de- cant number of battle casualties. Antibiotio ther- brided when the danger from the infection is greater apy and surgical care of contaminated tissue there- than the risk of injuring important structures and fore must be considered as part of the plan for re- wounds should be left open without primary suture ex- suscitation. Antibiotic therapy should be institut- cept in certain specific instances. ed as soon as possible. Since patients in wound shock will not absorb substances injected subcutan- eously or intramuscularly satisfactorily, antibiotic therapy should be administered intravenously Experience in the Korean campaign has demonstrated whenever it is feasible so to do. Until it has been again that battle wounds should be debrided by em- demonstrated that other antibiotics are more valu- ploying bold incisions through skin and fascia, to able, intravenous administration of one or more mil- furnish free exposure of the tissues traversed by lion units of crystalline penicillin and 0.5 grams the missile. All devitalized tissue and foreign of streptomycin in isotonic fluid should be given to material which can be recognized, must be removed these patients. Massive doses of antibiotics should to prevent and eradicate infection. At the same be given intravenously subsequently as the circum- time, skin need not be sacrificed when viable and stances dictate. vital structures must be safeguarded during the procedure. Good lighting, adequate X-ray, satisfactory A Simple and reliable means of determining blood positioning of the part, anaesthesia as required by volume in forward hospitals would be of great value the exigencies of the wound and the alj-important to the medical officer. Unfortunately, thus far, and often neglected extra pair of hands for assist- such has not been developed. Lacking a direct meth- ing the operator, are minimal essentials for satis- od, the surgeon has been called upon to estimate the factory wound surgery. loss of blood volume clinically.

Debridement of large wounds is frequently necessary Clinical evidence indicates that reduction in blood as an integral part of the measures used in resusci- volume of 20$ or less requires either no specific tating the patient, Shock accompanying large wounds treatment or perhaps no more than replacement by at times cannot be completely controlled without sur- plasma, serum albumin, plasma substitute or electro- gical care of the tissue contaminated by bacteria. lytes and water. Reduction of blood volumes between 20-35$ can be compensated for, temporarily at least, WOUND SHOCK by blood plasma or other blood substitutes. Usually, however, whole blood must be administered after the Wound shock has occurred frequently in the Korean emergency is over. With reduction of blood volume campaign. Whole blood has been available in ample above 35$, whole blood is essential for resuscita- quantities at all times and has been used as the tion. fluid of choice for the restoration of blood volume. Plasma and serum albumin have been available for use Profound wound shock in previously healthy, young, in forward areas for emergency administration in the adults, may be considered for practical purposes to treatment of wound shock. Experience with other be the result of the loss of 3,000 to 3500 cc of blood substitutes has been limited to one hospital blood volume aggravated by the wound itself, by un- far to the rear and no conclusions as to their effi- splinted fractures, by pain from perforated viscus cacy can be drawn. by various complications discussed above, by dehy-

9 ♦EARLT FOST-IHJUHT THORACOTOMIES PERFORMED IH KOREA (JIJH-BOT 51)

(Tokyo Army Hospital, 11 Jan 52)

CASE SURGERY FINDINGS ON CONDI- DISPO- HO, WIA HOSPITAL OPERATION FINDINGS DONE ADMISSION TREATMENT TION SITION X 25 May 2nd MASH Intercostal Hemothorax Drainage 30 May Org. Hemothorax Thoracenteses Clear Duty tube Decortication 14 Sep 26 Jun 2 5 Jun 8076 MASH Intercostal Sucking Wd. Drainage 10 Jun Org. Hemothorax Thoracenteses Olearlng 6 Oct tube Decortication Slowly ZI 3 Jul 3 6 Jun 8063 MASH Intercostal Hemothorax Drainage 15 Jun Hemopneumo- Thoracenteses Clearing 20 Aug tube thorax Decortication Slowly ZI 12 Jul 4 11 Jun 8055 mash Intercostal Hemothorax Drainage 6 Sep Empyema Thoracenteses Clearing ZI for tube DecorticEtion Slowly nerve injury 5 L3 Jun 121a t Era: Intercostal Hemothorax Drainage 13 Jun Empyema Thoracenteses Clearing 6 Oct tube Decortication Slowly ZI 10 Jul 6 2 Jun 8055 MASH Intercostal Hemothorax Drainage 18 Jun Org. Hemothorax Thoracenteses Clearing 29 Sep tube Decortication Slowly ZI 24 Jul 7 18 Jun 8063 MASH Intercostal Hemothorax Drainage 24 Jun Org. Hemothorax Thoracenteses Clearing 12 Sep tube Decortication Slowly Duty 17 Jul 8 30 Jun 8055 MASH Intercostal Hemothorax Drainage Org. Hemothorax Thoracenteses Clear 13 Aug tube Zlfrarre iaiury ) 9 9 Jul 8055 MASH Intercostal Hemothorax Drainage 19 Jul Hemothorax Thoracenteses Clear 11 Aug tube ZI (MFB knees) 10 AX 8076 MASH Intercostal Pneumo- Drainage 20 Jul Lung Abscess RU Lobectomy Clear Duty 16 Jul tube thorax (Segmental) 21 Aug 11 SI 8076 MASH Thoracotomy laceration Repair 2 Aug lemopneumo- Thoracenteses Clear 361st 17 Jul RUL & in- thorax ternal mam- 17 Sep mary artery 12 17 Jul 6076 M&3H Intercostal Tension 17 Jul MFB in lung Thoracotomy Clear 5 Sep tube — pneumo- (LLL) removal Duty thorax 26 Jul 13 AI 161at SH Thoracotomy Perforation Repair 7 Aug Hydropenumo- Thoracenteses Clear 6 Sep 25 Jul Diaphragm thorax Duty 14 28 Jul 8225 MASH Intercostal Pneumo- Drainage 3 Aug Pneumothorax Conservative Clear 7 Sep tube .thOrax EKG: Pericardii 5 k Duty 15 3 Aug 8225 mash Thoraco- Laceration Repair 3 Aug Pneumonitis Conservative Clear 30 Aug abdominal of Duty exploration Diaohragm 16 6 Aug 8076 MASH Thoraco- Laceration Repair 31 Aug Residual hemo- Conservative Clear 8 Nov abdominal LLL,dia- thorax chest EKG ZI exploration phragm & MFB in heart pericard- 12J spleen itis 17 14 Aug 8225 MASH Intercostal Pneumo- Drainage tube thorax Osaka AH Open thora- Empyema Drainage 13 Oct Empyema (open In transit to ZI cotomy thor* 17 Oct 18 15 Aug 8055 MASH Intercostal Hemothorax Drainage 20 Aug LResidual hemo- Thoracenteses Clear 21 Sep tube thorax Duty 19 24 Aug OSS Bepoaa Intercostal Tension Repair 9 Oct Residual organ- Conservative Clearing 19 Nov tube pneumo- ized hemothorax Duty Thoracotomy thorax 20 1 Sep 121at Evac Thoraco- MFB RLL A Repair 5 Sep Residual hemo- Conservative Clear 25 Sep abdominal lirer lac- MFB liver thorax Duty exploration erated & lung removed 21 1 Sep 121at Erne Small thora- Hemothorax Drainage 12 Sep Hemothorax Thoracenteses Clearing 17 Oct cotomy Duty 22 6 Sep 8055 mash Thoracotomy Laceration Repair 25 Sep Pneumoherao- Thoracenteses Slow to 17 Oct of lung & thorax Clear ZI pericardium Pericarditis (EKG) 23 9 Sep 8055 MASH Small Laceration Repair 14 Sep Hemothorax Thoracenteses Clear 20 Oct Thoracotomy of Duty and liver 24 9 Sep 8063 mash Thoracotomy Laceration Repair 15 Sep Residual Conservative Clear 13 Oct LLL Hemothorax Duty 25 12 Sep 8076 MASH Thoracotomy Laceration Repair 25 Sep Residual Conservative Deformed 17 Nov HUL; multi- Hemothorax chest ZI ple rib Removed Che3t wall (Sthl- fragments Deformed ooia) 26 12 Sep 8225 MASH Intercostal Hemothorax Drainage 17 Sep Hemopneumo- Thoracenteses Clear 12 Oct tube thorax ZI for Rheumatic heart RHD disease 27 15 Sep 8209 MASH Intercostal Inexpend- Drainage 6 Oct Pneumohydro- Thoracenteses Chest Still tube able lung thorax Decortication Clear in TAH Pericarditis 31 Oct EKG still positive 28 1? Sep 121st Srac Intercostal Tension Drainage 22 Sep Pneumohydro- Thoracenteses Clear Trf for tube Pneumo- thorax. Mul- Sec. Closure Chest P.T. Closing of thorax tiple leg Sendai sucking wounds 16 Oct wound 29 21 Sep 8076 MASH Thoracotomy Laceration Repair 9 Oct Residual hemo- Thoracenteses Clear 28 Oct diaphragm Splenec- thorax Duty and spleen ‘W

10 CASB SURGE HI ADMIS- FINDINGS ON CONDI- DISPO- NO, VIA HOSPITAL OPERATION FINDINGS DONE ADMISSION TREATMENT TION SITION 30 4 Oct 121st Emc Thoraco- Laceration Repair 9 Oct Pneumohydro- Border- 19 Nov abdominal HLL and thorax Thoracenteses line for ZI (for exploration diaphragm Decorti- nerve cation injury) 31 4 Oct 8063 MASH Thoracotomy Laceration Repair 8 Oct Hemothorax Thoracenteses Clear 5 Nov diaphragm Duty and liver 32 5 Oct Norwegian Thoracotomy Laceration Splen- 13 Oct Empyema Thoracenteses Clear 10 Dec MASH LUL and ectomy Decortication with MFB ZI 121st Evac Laoarotomy SDleen 25 Oct retained 33 6 Oct 8063 MASH Thoracotomy Laceration Repair 12 Oct Residual emp- Conservative Clear 27 Nov LLL & peri- yema peri- Limited cardium mvocarditis Duty 34 7 Oct Norwegian Thoracotomy Laceration Repair 13 Oct Bydropneumo- Thoracenteses Clearing 7 Dec MASH lung; thorax ZI(for Hemothorax nerve injury) 35 7 Oct Norwegian Thoracotomy laceration Repair 16 Oct Hydropneumo- Thoracenteses Clearing Still MASH LLL thorax in T.A.H. 36 7 Oct Norwegian Thoracotomy Laceration Repair 23 Oct Hydropneumo- Thoracenteses Clearing Still MASH right lung thorax Decortication in and liver Emoyema IT Nov T.A.H. 37 7 Oct Norwegian Thoracotomy Laceration Repair 12 Nov Hydropneumo- Conservative Residual 28 Nov MASH HLL thorax (Org. Hemothor- Zl(fer Hemothorax) ax nerve injury) 38 17 Oct Norwegian Thoracotomy Unknown Jnknown 3 Nov Org. Hemo- Thoracenteses Future Still MASH thorax decorti- in cation T.A.H. 39 8 Oct 8209 MASH Thoraco- laceration Repair 19 Oct Hydrothorax Thoracenteses Residual 8 Nov abdominal HML, dia- hemo- ZI exploration phragm and thorax liver 40 8 Oct 121st Srac Thoracotomy Perforation Repair 13 Oct Residual Conservative Clearing 8 Nov diaphragm Splenec- hemothorax Duty and soleen tomy (organized) 41 9 Oct 8076 MASH Thoracotomy Laceration Repair 17 Oct Organized Thoracenteses Future de- ZI HUL Hemothorax cortica- tion 42 9 Oct 8076 MASH Upper Laceration Repair 16 Oct Organized Conservative Clear 23 Nov Thoracotomy HUL & HLL Hemothorax Duty 43 10 Oct 121st Evac Small laceration Repair 16 Oct Hemothorax Thoracenteses Clearing 19 Nov Thoracotomy diaphragm & Duty ICC.10th rib 44 10 Cfct Norwegian Thoracotomy Laceration Repair 16 Oct Pneumohydro- Thoracenteses Clear 8 Nov HASH diaphragm thorax, rt; Duty and liver Hemothorax.lt 45 12 Oct 121st Evac Thoraco- Laceration Repair 17 Oct Bilateral Thoracenteses Clear 24 Nov abdominal diaphragm MFB hydrothorax Duty exoloration and bowel Removed 46 13 Oct Norwegian Thoracotomy Laceration Repair 19 Oct Pneumohydro- Thoracenteses Clearing Still MASH RUL & HLL thorax; Decortication in Emoyema 15 Nov T.A.H. 47 13 Oct Norwegian Thoracotomy laceration Repair 19 Oct Pneumohydro- Thoracenteses Clearing 10 Jan MASH HLL & dia- thorax ZI for phragm and combin- liver ed wainds 48 14 Oct 8076 MASH Thoracotomy Laceration Repair 7 Nov Organized Thoracenteses Slow to 12 Dec HUL hemothorax Clear ZI 49 17 Oct Norwegian Thoracotomy Laceration Repair 23 Oct Pneumohydro- Thoracenteses Slow to 8 Dec MASH rt lung thorax Clear ZI 50 17 Oct Norwegian Thoracotomy Laceration Repair 21 Oct Pneumohydro- Thoracenteses Candidate 10 Dec MASH rt lung thorax for decor- ZI tication 51 17 Oct 8063 MASH Thoracotomy Retained Removal 27 Oct Residual hemo- Conservative Clearing Duty MFB Hemo- drain- thorax treatment thorax ing 52 17 Oct 8076 MASH Thoraco- laceration Repair 19 Oct Residual hemo- Conservative Clearing 8 Nov abdominal rt lung,dia- nephrec- thorax treatment ZI for exploration phragm, hw=r tomy combined left Iddney wounds 53 19 Oct 8076 MASH Thoracotomy Laceration Repair 30 Oct Hemothorax Thoracenteses Candidate 19 Dec LUL, pneumo for decor- ZI hydrothorax tication 54 19 Oct 8225 MASH Intercostal Neck wound Drainage 23 Oct MFB subscapular Removal of Clear 10 Jan tube pneumo- region MFB ZI for thorax residual hemo- Conservative neck thorax treatment wound 55 23 Oct Norwegian Thoracotomy Laceration Repair 17 Oct Empyema Thoracenteses Improved 8 Deo MASH RLL, re- Open Thoraco- Further ZI tained MFB tomy. 27 Nov Trrnt rqd 56 24 Oct 8063 MASH Thoracotomy Laceration Repair 28 Oct Empyema Thoracenteses Clearing Still HLL, dia- Decortication Well at phragm 27 »ov T.A.H. liver 57 22 Nov 8055 mash Thoracotomy Laceration Repair 3 Dec Empyema Thoracentses Clearing Still ( small) lung, dia- Decortication Well at 4 Dec T.A.H. 58 10 Oct Norwegian Thoracotomy Laceration Repair 30 Nov Residual or- Conservative Clearing Still MASH lung ganized hemo- at thorax T.A.H.

•Early - within 24 hours.

11 dration, by apprehension, by cold and fatigue and Technical Eulletin Medical No. 9 was published by by morphine. Usually greater blood volume is lost the Department of the Army on 22 June 1951 and wide- from severe wounds of the extremities than fr.om ably distributed in the Far East Command. In the pre- dominal and chest wounds. paration of the Bulletin many authorities have been consulted and it therefore can be considered a re- As Beecher and others have pointed out, it is not nec- liable guide to present day antibiotic therapy. It essary to delay surgery until complete resuscitation seems worth while to emphasize a few of the thoughts has been attained. The aim is to obtain a systolic contained therein. blood pressure of 80-85 mm of mercury which is ris- The Bulletin establishes for medical personnel the ing, pulse rate that is dropping, color and tempera- principles governing the use of antibiotics. It ture that are improving and thirst which is slacken- should be correlated with its companion TB MED 172 ing. Surgical care of wounds should then be insti- concerning the use of sulfonamide compounds. The ex- tuted as part of the continuing plan of resuscitation. act mechanism of antibacterial action of antibiotics, is unknown. It is established that the activity of Intra-arterial transfusions have been utilized in pa- the drugs varies directly with the concentration and who have not responded to other methods of re- tients that they must reach the infection to be of suscitation. Clinical impressions have not been uni- value. Antibiotic drugs are bacteriostatic bacterio- form and its efficacy so far has not critically and/or been cidal. Aureomycin, chloramphenicol and Some officers have been terramycin evaluated. medical enthusi- are bacteriostatic only, while penicillin and strep- astic in their praise of the method, others have not tomycin are bacteriostatic in low and bacteriocidal been impressed that the method has offered more than in high concentration. Specific theraphy can be in- ephemeral improvements and benefits. stituted only when exact clinico-bacteriologic diag- LOYffiR NEPHRON NEPHROSIS nosis can be established. Since this is not always practicable, especially in the combat zone, the clin- Lower nephron nephrosis has frequently been encoun- ical diagnosis should be as rapid and exact as pos- tered during the Korean campaign. Most dishearten- sible. A valuable clinical aid is the direct smear ing to the staff of a forward hospital is oliguria and should not be overlooked. A he aid of a bacterio- or anuria developing in wounded patients after every- logist should be obtained when possible in severe in- thing considered possible has been done for him. Suc- fection, in staphloccal infection, in non-hemolytic cess has been attained in the resuscitation of the infection, in acute gram negative bacillary infect- patient and anaesthesia has been administered with tionj when there is poor response to treatment and skill and complete satisfaction to the anaesthesio- when there is an infection of questionable etiology. logist and Formidable operative procedure has been carried out to a successful conclusion. The Combined therapy with another antibiotic or with a tired staff has been stimulated by a glorious sense sulfonamide is of benefit when drug res! stant bacte- of achievement but, alas, post-operatively the pa- ria are encountered. Penicillin and chloramphenicol, tient appears to be doing well except for oliguria however, should not be combined because the effects or anuria. The water tolerance test to eliminate are antagonistic. Although treatment of peritonitis the possibility of dehydration as the cause of unsat- is dependent upon both early diagnosis and early cor- isfactory excretion of urine improves the out-put rective measures, the use of penicillin, one million none at all. Then all realize that medical knowledge units combined with streptomycin 0.5 gm intraven- contributes little except to sustain the patient as ously, twice daily, are usually the most effective best possible but above all, not to drown him by auxiliary and will be considered the drugs of choice pouring fluids into him in the vain hope that the until such time as further work establishes more ef- kidneys will be stimulated by more water. The staff fective substitutes. then hopes that restriction of fluid intake will prevent pulmonary edema and that the lower nephron will Cultural sensitivity determinations at regular inter- undergo spontaneous healing before the products of vals should be made in subacute and chronic infect- catabolism kill the patient. Unfortunately, the tions and may indicate the necessity for changing the wounds are often severe and complicated and the pa- antibiotics employed. It is again emphasized that tient succumbs from insults to his body economy long antibiotics are extremely valuable adjuncts to sur- before nature heals the lower nephron. gery but their use does not lessen or minimize the importance of basic surgical principles. A common factor in the etiology of lower nephron nephrosis appears to be a period of anoxia associ- CLOSTRIDIAL MYOSITIS ated with toxic substances. The roles of multiple transfusions, severe infection, vaso-constriction At this point it seems advisable to remind ourselves and the like, are not clearly understood. Surely of the ever present danger of clostridial myositis. what we call lower nephron nephrosis deserves in- As in other wars, many cases have been encountered vestigation by all the means available to the end during the Korean campaign. Of these, a large num- that more facts will be uncovered which will aid ber have been associated with arterial injuries but the medical profession in overcoming this serious others have followed single or multiple missile malady. wounds without apparent injury to the blood supply of the part. Clostridial myositis must be recognized and treated in the first few days after wounding. ANTIBIOTIC THERAPY The fate of an extremity and indeed the life of the patient are dependent upon prompt recognition and Development in the field of antibiotic therapy has treatment. The best treatment, of course, is preven- been rapid and promising. New drugs have become tion by early restoration of the general circulation, available end have found a place in the treatment of avoidance of constricting dressings and tight casts, wound infections. It became apparent to The Surgeon adequate wound debridement and measures such as fas- General that an intelligent discussion of the sub- ciotomy for tension within the muscle fascial envel- ject was necessary to give the medioal officer a ope. frame of reference from which to choose the antibiotic most likely to be successful. To this end Because of the ever present danger of clostridial

12 myositis developing in patients with vascular injur- above. To reiterate, these patients must be treated ies, these patients must be held in forward hospitals at the hospital performing the initial operation and where initial surgery is performed. Everything must not evacuated until improvement of oiroulation is be done here to improve the circulation and evacua- satisfactory; danger of clostridial myositis has pas- tion must be deferred until the extremity is no long- sed; or operative procedures, including amputation er threatened. If clostridial myositis supervenes, if necessary, have been performed. it must be promptly recognized and treated by surgical extirpation of the involved muscle, muscle groups Likewise, too rapid movement of maxillo-facial,cranio- or extremity. To place the patient with a threaten- cerebral and spinal cord injuries after operation may ed extremity in the chain of evacuation, except for eventuate in complications and perhaps death. A pe- pressing tactical reasons, invites a tragic outcome. riod of observation is mandatory until stabilization has been obtained permitting reasonably safe travel. VASCULAR INJURIES When possible tracheotomized patients should be held until they no longer are entirely dependent upon the Closely related to this subject is the management of tube as an air way. vascular injuries. Unfortunately, arterial injuries commonly are associated with severe soft tissue and The decision to transport surgical patients must not skeletal wounds. Attempts at repairing damaged ar- be undertaken lightly. Good judgment is of the es- teries in such cases have usually been fruitless and sence. It is the responsibility of mature medical unwise, because of the great risk of infection and officers with experience to decide the time for safe secondary hemorrhage. Furthermore, when the number transportation and it should never be undertaken in / of casualties requiring surgical care is large, it a cursory manner. is questionable whether the time expended in attempting to restore the continuity of the vessel is justi- THE RECORD fied. We must choose between a time consuming procedure of dubious value for one patient and attempt- There is need for a more uniform clinical record. Ob- ing to do the greatest good for the greatest number servations of the clinical course of patients common- who are awaiting surgical care in the preoperative ly are written on odd bits of paper which must be tent* Nevertheless there are cases and there are sorted out to obtain indispensable information for circumstances which justify every effort to restore the rational management of the case. These bits of the continuity of a major artery by operation. This paper flutter about as they are removed from the en- has been done with commendable frequency during the velope and are easily lost. present campaign. Indeed failure has occurred in many instances, especially in attempts to repair When many casualties inundate an organization, it the popliteal artery. Success, however, has been may be impossible to record observations in detail rewarding in a sufficient number of oases to en- because of time, fatigue, and other limiting condi- courage efforts in this direction. Let not the too tions. Essential information, however, in serioi's precipitous evacuation of such a patient vitiate cases and those likely to develop complications is these noble attempts. of paramount importance to medical officers who subsequently become responsible for their future intel- EVACUATION OF PATIENTS ligent management. In fairness to patients and professional colleagues, let the record show time, dates, Evacuation of certain types of patients too soon and therapy; let the record show what occurred at the after the operation is harmful and dangerous. De- operation; let the record shed a little light and terioration of the general condition of patients drop a few clues to alleviate the trials and tribu- with abdominal and thoraco-abdominal injuries has lations of the doctors to whom the patients are sent. occurred more often than is commonly realized. While the patient may appear to be doing well three or four days after operation, he has an entirely dif- AIERTKESS TO COMPLICATIONS ferent appearance upon arrival at his destination.

The trip from hospital to air field is often rough Complications are inevitable in surgical patients. and time consuming. Delay at the air field before Because of the nature of battle casualties, compli- loading and after boarding the plane frequently oo- cations are often encountered. A high degree of curs before take off. While the engines are being awareness to the•development of complications in warmed and the plane taxies about the field, the battle casualties must be engendered in medical of- cabin may become excessively hot, particularly in ficers responsible for their care. Complications summer months. Patients perspire profusely, there- must be sought for aggressively and treated early by losing much fluid. In flight some patients de- to give the patient the best chanoe for survival. velop abdominal cramps and distention. Some become air sick when the flight is made through rough weath- er. Technical Bulletin MED-147 on the management of After the flight, there is more loss of time and a battle casualties has been invaluable as a guide for long trip by ambulance must be endured before the pa- all medical officers during the conflict. It is per- tient arrives in the hospital. He may now require tinent to emphasize certain important details and treatment by nastro-gastric suction, intravenous certain unwise deviations from the concepts set forth fluids, operation for dehiscense of the abdominal in the bulletin. wound and other complications. It is strongly urged that patients with abdominal injuries following operation be held in the hospital performing the initial operation for seven to ten days and even longer MEDICAL MANAGEMENT IN DIVISIONAL AREAS should the clinical condition be unsatisfactory. Hemorrhage; The care of the wounded in the divi- Unwise early evacuation of patients with vascular in- sional area has been largely devoted to first aid juries and threatened extremities was discussed measures. Exsanguination does not occur in all in-

13 juries of major vessels of the extremities. Vaso- MEDICAL MANAGEMENT IN FORWARD HOSPITALS spasm produced by trauma may prevent lethal loss of blood volume and indeed severe ischemia followed by Neurosurgery; A pressing problem during the gangrene is possible. Control of bleeding by pres- early months of the conflict was the care of sure dressings or clamping and ligating blood ves- neurosurgical casualties. The principle of early sels is preferred to the application of a tourniquet. surgical care for these patients was well established from accumulated experience in previous The tourniquet is a ligature applied externally which wars. It was well known that neurosurgical wounds may be dangerous if applied unwisely and neglected, should be debrided; devitalized tissue and foreign or life saving if applied intelligently with proper material removed, particularly indriven bone frag- indications and handled with care. It is important ments; hemostasis assured; dura closed by fascial to distinguish between venous and arterial bleeding. graft, if necessary, and the scalp sutured. There Placing a tourniquet proximal to the source of ve- was never any doubt but that the management of nous bleeding increases hemorrhage unless sufficient neurosurgical casualties could best be done by sur- pressure is applied to prevent ingress of blood to geons with experience ih this field. Until, how- the extremity from arteries. A tourniquet should be ever, such surgeons were made available, it was applied only after bleeding is determined to be from necessary to do as well as possible under the cir- arteries which cannot be controlled otherwise. It cumstances. should be applied at conventional levels known to offer the greatest likelihood of positive control of The deficiency of neurosurgical personnel has been hemorrhage. When part of the extremity is hopeless- alleviated. Teams are now established in forward ly damaged and obviously requires amputation, a areas to which neurosurgical casualties are dis- tourniquet should be applied to the lowest level pos- patched for expert management. Neurosurgeons sible and left in place until the patient has been aboard U. S. Navy hospital ships and the Danish Hos- prepared for operation. pital Ship have given great support to the ground forces during oritical phases of the campaign prior Injudicious use of the tourniquet has resulted in to and since the establishment of neurosurgical teams the loss of extremities. The patient who has a tour- in Korea. niquet applied should be marked plainly by a large "T" on his forehead or by other means so that atten- Maxillo Facial Injuries; Maxillo facial injuries, in tion will be directed immediately to the fact that contrast to the general principle of delayed sutures a tourniquet is in place. If it is at all possible, of war wounds, should be closed primarily. Preserve a technician should accompany the patient during the all viable and excise only devitalized tissue. Buc- evacuation. cal mucosa should be sutured separately with absorbable material. Approximate muscles and skin accu- Splinting of Fractures; It is regrettable, but true, rately and make ample provision for adequate drain- that patients with fractures of the extremities have age; stab wound dependent drainage is very effective. been evacuated to surgical hospitals without splints. Moist pressure dressings applied post-operatively are This violates one of the fundamental principles of very helpful. first aid. Negleot of splinting fractures increases wound shock and danger of arterial and other injur- Tracheotomy should be performed without hesitancy ies during transportation. wi en obstruction of the air way exists or is likely When a Thomas splint and traction are used for frac- to develop. Hold these patients in forward hospi- tures of lower extremities, the shoe should not be tals until evacuation can be done safely. removed because traction applied to the bare foot has produced pressure necrosis. Neck Injuries; Exploration and debridement are necessary when it is likely that the esophagus, trachea, 'Circular Dressings; Circular dressings for wounds larynx, epiglottis, hypo-pharnyx, etc., are lacerated. of the extremity must be observed carefully during Defects in these structures should be carefully re- the transportation of the patient. What appears to paired and provision made for suitable drainage. Per- be a satisfactory dressing at the beginning of the form tracheotomy when laceration of the larnyx or journey may become too tight as the result of edema trechea is present or when obstruction of the air or bleeding into the tissues. Complete occlusion of way by existing or impending edema threatens. the blood supply may develop and the extremity may be irrevocably damaged. Thoracic Wounds; The indications for exploratory thoracotomy are delineated succinctly in TB MED-147. Morphine; Morphine overdosage has been noted from It is clear, therefore, that most penetrating and time to time. It must be realized that many wounded perforating wounds of the thorax are managed best patients require no drugs for the control of pain. by conservative measures including frequent aspira- Of those that do, usually a small dose is sufficient. tion of air and blood without air replacement using The morphine syrette contains l/2 grain of the drug needle and syringe. This method to be successful and to give more than half of this amount is usually must be done early in forward hospitals and at unwise. Morphine must be given judiciously in thor- least once daily until all air and blood have been acic injuries so that the cough reflex will not be removed and the lung expanded completely. obtunded. The drug is contraindicated in cranio- cerebral trauma. Patients who are in shock do not absorb morphine given intramuscularly satisfactorily. Because of this they may receive too large a Many cases of hemothorax have been treated by inter- dose or multiple doses for control of pain without costal tube underwater seal drainage. This method because it appeared to success. When the peripheral circulation is im- was preferred by some surgeons proved by resuscitation, the morphine deposited in- be simple and safe. When large numbers of casualties employed to the tissues will be absorbed and morphine poison- were treated in a hospital, the method was ing supervenes. For control of pain in patients to save time. Some surgeons were of the opinion that tube drainage good with wound shock,intravenous administration of a the result s of intercostal were as small dose is preferred. if not better than needle and syringe aspiration.

14 It has demonstrated beyond doubt that many more com- Following repair of lacerated liver,drain the ab- plications, including empyema and clotted hemothorax, domen to prevent accumulation of bile. When an as- developed in patients with hemothorax treated by in- sociated laceration of the diaphragm is present tercostal tube drainage than in those by simple mul- drain the subphrenio space to protect the suture tiple needle and syringe aspirations. line against stress and avoid thoraco-biliary fis- tula (Dr. Frank Berry). Drain through separate The thoracic surgical service at Tokyo Army Hospital stab wound rather than through the laparotomy inci- has prepared a chart of some patients who had thor- sion. Drain the lesser sac for wounds of the pan- acotomies within the first 24 hours after sustaining creas and the perirenal space for wounds of the thoracic injuries. We are indebted to Major Anibal kidney and after nephrectomy. R. Valle and Lt. Vlilfrid A. Cloutier for their kind- ness in providing this information. This chart is Exteriorize perforated colon and perform colostom- published to give the forward surgeons information ies after adequately mobilizing the bowel to avoid as to the subsequent course of patients with thoracic tension and subsequent retraction, and always through injuries. Review of these cases will be of assistance separate muscle splitting incision well away from to surgeons in the theater. the laparotomy incision. Avoid making colostomies in close proximity to suprapubic cystostomy. Use the transverse colon if a defunctioning colostomy Abdominal Wounds: X-ray films of the chest and ab- for injury to lower bowel segment and rectum must domen give the surgeon useful information that he can be done simultaneously with drainage of the bladder. ill afford to neglect. When missiles are retained some idea of the structures possibly injured as they Wounds of the rectum may be present when missiles traversed the abdomen may be obtained from consider- penetrate the abdomen, buttocks, and thighs and on ing the point of entrance and the location of the occasions have been overlooked completely until be- missile as depicted by the X-ray. Too much reliance lated complications have become manifest. Digital, cannot be placed on this, however, since missiles and if necessary proctoscopic, examination must be notoriously may take a bizarre course and may rico- done to establish the diagnosis. When the rectum chet after striking bone. has been injured, defunctioning colostomy and para- rectal drainage must be accomplished. Posterior The abdomen should be explored when a missile con- drainage to be effective requires a substantial in- ceivably could have perforated a hollow viscus. It cision on one or both sides of the sacrum and coc- is better to know than to take an unnecessary chance. cyx to enable free exposure of and dissection through the fascia propria. The best incisions for exploration of the abdomen are the right or the left pararectus or the mid-line. Genito-urinary wounds: Splint the severed urethra These incisions are readily made, readily extended at the tame of supra-pubic cystostomy by catheter upward or downward in accordance with what is found introduced from below through the urethral meatus and what needs to be done. Transverse incisions or from above through the bladder. Suture the take longerto make and to close. If wound infec- laceration over the catheter if this is possible. tion supervenes, they are more difficult to handle. Exteriorization of damaged colon may be technically Suprapubic cystostomy tube should be placed as compromised because it may have to oe done through high in the fundus as feasible to prevent pressure the incision and serious infection may result. It necrosis, infection of the symphysis publis and in- is always preferable to exteriorize injured colon jury to the trigone. through a separate muscle splitting incision well away from that made for exploratory laparotomy to It is fortunate if ureteral laceration can be dis- decrease the ohano© of subsequent serious infection. covered and repaired during initial surgery. Anas- Suoh may be impossible when a transverse incision tomosis over indwelling ureteral catheter and drain- has been made. age of the area may forestall serious complications. mis- Subcostal incisions are also unsatisfactory for Preserve all viable portions of the external geni- sile wounds of the abdomen unless the surgeon is ab- talia. The decision to emasculate patients should solutely certain that the injury is confined to the in most cases be made in a hospital to the rear.Cov- region exposed by it. If it is found necessary to er the exposed testicle with tissues available and explore other regions and repair damage to other provide suitable drainage. structures, the surgeon is embarrassed and it may be necessary to make another incision. Nephreotomy need not be undertaken except in hope- lessly damaged kidneys and renal pedicles. A con- Layer closure of the abdomen including the skin in servative policy, including drainage, when only a the presence of contamination from intestinal con- portion of the kidney is injured reflects wisdom. tents invites serious wound infeotion. It is safer Careful observation of the subsequent course of the to place non—absorbable sutures through the entire patient may or may not indicate the need for another abdominal wall and thus approximate the margins of operation for continuing hemorrhage or infection. the wound. Stainless steel when used should be of But many kidneys have been saved by conservative large caliber to decrease the risk of cutting through treatment. the layers of the abdominal wall. It should be twisted in such a manner that it can be unloosened Extremities: Circumcising skin about wounds of en- and retwisted should later inspection of the wound trance and exit is a futile gesture. Stuffing wounds indicate the suture is too tight. with gauze in the vain hope of promoting drainage is a snare end a delusion. Exploring wounds solely Explore the abdomen systematically, rapidly and com- by the finger is scarcely even a sop to the surgeon’s patient’s pletely, thus insuring that important injury be not conscience. Interest and sincerity in the overlooked. Control hemorrhage, tag injuries suit- welfare demand of the surgeon pride and craftsman- ably, and proceed with the operation in an orderly ship in the discharge of his responsibilities, al- to There manner. beit a missile wound may seem prosaic him.

15 is no substitute for competent v/ound surgery. Physical therapy must not be limited to a brief daily session in a well equipped and well staffed Fadding under casts must be abundant to forestall department. However important such treatment may pressure necrosis, nerve palsies and circulatory em- be, of much greater importance is what the patient barrassment of the extremities. Avoid circular dress himself contributes to his rehabilitation during ings under casts like the plague and split casts to the much larger part of the day. Restoration of the skin before transporting the patient. Bivalve function can be attained more rapidly and more com- and remove the upper half whenever casts are requir- pletely by insisting that the patient take positive ed for extremities with compromised circulation. action towards this goal during much of his other- Avoid window's in casts through which soft tissues wise idle moments. may herniate during transportation. CONCLUSION Reoognize, record and institute interim therapy for nerve injuries. A modicum of astuteness will readily discover the vast majority of traumatic inter- The writer has been privileged to witness the growth ruptions of nerve function. of the medical support of the United Nations effort in Korea during the past eighteen months. From a Splint hands in position of optimium function when babe in swaddling clothes, Medical Service has ma- necessary and evacuate at the earliest possible tured into a vast organization composed of many per- time. Do not sacrifice parts of the hand except sonnel of many nations. for massive infection, saving of life or limb, or ascending infection. Later reconstructive proce- It is hoped this brief review of some of the achieve- dures may utilize tissues of the hand judiciously ments of the Medical Service in this campaign thus preserved at initial surgery. Stress restoration far and some of the problems encountered in the man- of function rather than restitution of structural agement of battle casualties will, in a small meas- alignment to the end that the patient has useful ure, help to point the way to even greater progress prehensile mechanism. towards better surgical care of the wounded.

FALSE POSITIVE DARKFIELD FINDINGS IN THE PRESENCE OF OONDYLOMATA ACUMINATA 1st Lt. Joseph Asia, MC, 12th Medical Dispensary, APO 59 1st Lt. John F. Cox, MSC, 12th Medical Dispensary, APO 59 With the technical assistance of Sgt. Edward L. Corbin, AMQDS and Cpl. Gustav Hamann, AMEDS.

EDITORIAL NOTEi The following article is consider- positive serological test for sypnilis or has had ed appropriate and pertinent at this time as emph- clinical evidence of the disease. asis of the ever present problem of VD. The pit- falls into which the unwary or inexperienced may Seven cases of condylomata acuminata were treated fall are evident and the necessity for demonstra- with massive doses of penicillin. They have con- tion of characteristic morphology and motility of sistently shown these spirochetes after treatment Treponema pallidum are forcefully presented. The and have never presented serologio or clinical ev- prevalence of spirochetes other than those of syph- idence of the disease. Case No. 1 is ta«:en from ilis in venereal lesions is all too frequent and this group. only by careful examination of fresh, properly collected material can an adequate diagnosis of prim- CASS NO. 1, Cpl JMS was first seen on the 6th of ary syphilis be made. April l95l. He presented numerous oondylomata acuminata on the prepuce. N9 other penile lesion or In the past several months seven patients with inguinal adenopathy was present. The Darkfield ex- oondylomata acuminata (verruca acuminata, venereal amination revealed organisms with the morphological wart) were referred to the venereal disease section characteristics of Treponema pallidum. The cardio- of the 12th Medical Dispensary for treatment as lipin flocculation test syphilis was negative. primary syphilis. Diagnosis in these cases had During the following ten days he received six mil- been made on the finding of what appeared to be lion (6,000,000) units of penicillin in oil and Traponeiua pallidum on Darkfield examination made beeswax. The day following completion of therapy from the oondylomata. It should be noted in this Darkfield examination revealed what appeared to be paper that these cases are not clinical luetic in- Treponema pallidum. The patient received another fections and should not be treated as suoh. course of penicillin in oil and beeswax totaling six million (6,000,000) units. Upon completion of with There have been a total of thirty-one patients this course the same organisms as seen previously we oondylomata acuminata from the surface of which were still the Darkfield prepara- repeatedly or- demonstrable in have been able to demonstrate these tions from the oondylomata. ganisms that appear to be Treponema pallidum, and which we call "T.P.-like" organisms. In each in- Two months later it was still possible to demon- stance the patient was required to wash his penis strate these organisms. At this time a circumci- with water for fifteen (15) minutes and then for sion was done on the patient at the 21st Evacuation five (5) minutes with normal saline solution. The Hospital. Pathologic examination (silver stain) of organisms were demonstrated in the serous exudate the specimen failed to reveal the presence of spir- expressed from the oondylomata. Seven of these ochetes. The patient has been followed for a per- cases had previously received anti-luetic therapy. iod of two months since surgery. He has had no re- been followed All thirty-one of these cases have currence of the condylcmata, has shown no clinical serologically for periods varying from two to six signs of syphilis and the cardiolipin flocculation months. In no instance has a patient developed a test for syphilis has remained negative.

16 There have been seventeen cases of condylomata acu- Treponema pallidum. We are attempting at present minta and the described spirochete resembling Trep- to classify this organism. onema pallidum which have cleared completely with local treatment (salt soaks and/or podophyllum). SUMMARY. Three typical cases have been taken from They have received no anti-luetic treatment. No thirty-one cases that presented multiple condylamata clinical or serologic evidence of the disease has acuminata which showed, on Darkfield examination, developed in any patient. Case No. 9 is typical spirochetes morphologically resembling Treponema of'this group. pallidum. Seven of these cases had been referred to us for treatment as primary syphilis and seven- CASE NO. 9. PFC EWS was referred to this dispen- teen cases were initially seen in this dispensary. sary for Darkfield examination on the 16th day of None of the twenty-fcur cases have received anti- May 1951. He had numerous large condylomata acu- luetic therapy. An additional seven cases receiv- minata on the prepuce. No penile ulcer or inguin- ed anti-luetic therapy but persisted in showing the al adenopathy was present. Organisms morphologic- spirochete. None of these thirty-one cases have de- ally resembling Treponema pallidum were seen in veloped clinical or serologic evidence of syphilis. the condylomata on Darkfield preparation made from them. The cardiolipin flocculation tests for syphilis were negative. This patient received no anti- REFERENCES! luetic therapy. He was followed with weekly serologic tests until the 4th of October 1951 when he Marsh, 'William, Commander, MC, USN, Dermatology Sec- was referred to the 3d Station Hospital for circum- tion, USN Hospital Ship "HAVEN.” Personal communi- cision and excision of the condylomata. Pathologic cation. examination (silver stain) did not reveal the presence of spirochetes in the tissue. At no time has DeLamater, E. D., Newcomer, V., Haanes, M., and this patient shown clinical or serologic evidence Wiggall, R. H.i Studies on the Life Cycles of Spir- of syphilis. ochetes. An. J. Syph., Gonor. & Ven. Dis. 34:122, 1950. Seven cases were seen with condylomata acuminata which were thought to be Darkfield positive at the Grauer, Franklin H., Colonel, MC, Consultant in medical installations referring them for treatment. Dermatology, GHQ, FEC. Personal coramunication. These cases consistently showed the "T.P.-like" organisms but were clinically and serologically neg- Noguchi, H.t The Spirochetal Flora of the Normal ative. No anti-leutic treatment was administered. Male Genitalia. Journal of Experimental Medicine, Case No. 13 is taken from this group. 27 : 667, 1918.

CASE NO. 13. Sgt RDH was referred to this dispen- Noguchi, H.t Cultivation of Treponema Calligyrum sary from a nearby medical installation for treat- (New Species) from Condylanata of Man, Journal of ment of primary syphilis because of the finding of Experimental Medicine, xvii, 89, 1913. a positive Darkfield. The patient had multiple condylanata aouminata on the prepuce and the glans Noguchi, H. i Morphologioal and Pathogenic Varia- penis. There was no inguinal adenopathy or penile tions in Treponema Pallidum, Journal of Experiment- ulcer. Repeated Darkfield examinations revealed al Medioine, xiv, 90, 1913. organisms that morphologically appeared to be Trep- onema pallidum. The cardiolipin flocculation tests Newcomer, V.D., and Haanes, M.: Observation on tne for syphilis were negative and anti-luetic therapy Growth of the Nonpathogenic Nichols Strain of Trep- onema Pallidum the Chick was not given. Two months later the patient was in Embryonated Egg. Am. Syph., & 33s 318-322 (July) referred to the 21st Evacuation Hospital and the Jr. Gonor. Ven. Dis. condylanata were excised and the patient circumcis- 1949. ed. Pathologic examination of the tissues did not Rowe, and of th- demonstrate any spirochetes in them. The patient R. S., Curtis, A.C.s Studies Life and Motility of Treponema Pallidum in Fertile Hen’s remained asymptomatic and serologically negative. Eggs, Jr. Syph., Gonor. & Ven. Dis. 33: He is still under observation. Am. 303-307. Haanes, M. and Wiggall, R. H.,; Observation on the fte are not prepared to say whether or not the or- Growth of the Nonpathogenic Kazan Strain of Trepon- ganisms we have seen in these thirty-one cases are ema Pallidum. Am. Jr. Syph., Gonor. & V©n. Dis. 33: of the definite strain Treponema pallidum, and if 303-307, May 1950. so, that they are pathogenic. In the three oases described above we were unable to demonstrate any Beerman, H., Nicholas, L., Buerk, U.S., and Ford, invasion of the tissues by the spirochetes. An at- W.T.: Syphilis, A Review of the Recent Literature. tempt to produce a syphilitic lesion in a rabbit Arch, Int. Med. 85: 305-358 (Feb-May 1950). with inoculum from a condyloma was unsuccessful. We believe that the organism exists as a sapro- We wish to thank the following Medical Department phyte in the numerous depths and crevices of the Officers for their sincere cooperation: condyloma and is nurtured by the idoal environment of darkness, warmth and smegma, but bears no rela- Captain E. E. Tueller, MC, 1st Army Modical Field tion to the growth or development of the oondyloma. Laboratory, for the pathological examinations furnished. The normal flora beneath the prepuce contains many spirochetes readily distinguishable from Treponema Captain Newton F. McDonald, MC, 21st Evacuation pallidum. Noguchi has isolated fron a condyloma of Hospital, for the surgery performed. man an organism. Treponema calligyrum, which has many of the characteristics of Treponema pallidum. Captain C. W. Garrett, MSC, 1st Army Medical Field Noguchi and others (see references} have demonstrat Laboratory, for th« numerous serological tests for ed and described several non-pathogenic strains of syphilis.

17 HEALTH OF ARMY TROOPS, FEC

/per 1000 Admission Rate ('all causes) , U.S. Army Personnel, Far East Command \per yearj 1

1951 1950

Admission rates per 1,000 troops per annum, Army Personnel, for the four-week period ending 28 November 1951* were as follows: PHILCOM FEC JAPAN KOREA MARBO (AF) RYCOM

All Causes 552 458 607 272 266 437 Diseases 407 393 416 159 248 392 Injuries 92 64 108 113 18 45 Battle Casualties 54 .10 83 0 0 0 Psychiatric 27 15 34 0 0 4.2 Common Respiratory Diseases and Flu 67 102 50 34 46 70 Primary Atypical Pneumonia 1.4 1.6 1.4 0 9.2 0 Bacillary Dysentery .85 0 1.2 0 18 0 Amebiasis .82 .83 .86 0 0 0 Malaria, new 3.5 2.7 3.7 0 46 1.1 Infectious Hepatitis 7.9 7.5 8.0 0 0 13 Dermatophytosis 2.8 3.2 2.4 45 0 4.2 Rheumatic fever .23 .21 .25 0 0 0 Venereal Diseases 173 217 154 0 55 155

DAILY NON-EFFECTIVE RATE All Causes 30 70 11 11 36 11

ALL CAUSES ADMISSION RATE:

The admission rate of 552 for November is the lowest battle casualties. all causes rate for admission to medical treatment facilities in the Far East Command since the beginning of the Korean confliot. Medical treatment fac- The rate of admission due to disease decreased from ility "admissions” include all patients admitted to 427 in October to 407 in November. Japan and MARBO hospitals, infirmaries, dispensaries or on a sick-in- reported the most substantial decreases. The RYCCM quarters status and not returned to duty before mid- rate increased slightly. Throughout the Far East night of the day of first reporting for medical care. Command no noticeable changes occurred in the rates Except for RYCOM, where the rate remained the same, for common respiratory diseases, influenza and in- all other areas in the command reported decreases. fectious hepatitis, while decreases are noted in The greatest decline took place in Korea, from 874 to malaria and dysentery. The rate for pneumonia in- 607 for November, due to reduction in the number of creased .from 6.5 in October to 6.9 in November. Five

18 DISEASE, NON-BATTLE INJURY &• BATTLE CASUALTY admission rates (per IOOO per year) U.S. ARMY PERSONNEL, F.E.C

disease non battle inj. battle cas.

oases of encephalitis, 1 case of poliomyelitis s>d u ation policy and the intensity of combat. The 2 cases of meningitis were reported throughout the evacuation of patients from Korea to Japan and the command. No epidemic of scarlet fever, measles, United States tends to result in a low non-effective mumps or smallpox were reported during November. rate for Korea and a high rate in Japan. A compari- Diseases of the skin and cellular tissues, dental son of suoh rates among the major commands in FECOM diseases and conditions, diseases of the eye, ear, is not justified. The overall rate for FECCM was 30 nose and throat and various other chronic and un- per 1,000 for the month of November. This means diagnosed conditions continue to be principal con- that within the oommand, Z% of the strength was con- tributors to morbidity in Army troops. stantly absent from duty for medical reasons.

The nonbattle injury rate increased from 86 for the DISEASES: previous month to 92 for November. Only slight increases oocurred in Korea and Japan, while FHILCOM COMMON RESPIRATORY DISEASES AND INFLUENZA: (AF) and RYCCSd reported decreases. The rise in the rates for MARBO and an increase in cold injuries is The Far East Command rate of 67 remained the same as responsible for the higher rate in nonbattle injur- for the previous month. In 1950, the November rate ies. was 64 with sharp rises in both December and January. The Japan rate decreased from 114 to 102 for Novem- All conditions of ill-health caused by external ber while Korea reported an inorease from 45 to 50. agents, including aoute poisoning, food infections due to non-baoterial poisoning and results of ex- PSYCHIATRIC: posure to heat, cold or light are classified as nonbattle injuries. Injuries due to the elements A substantial deorease in the Far East Command psy- (frostbite, trench foot and immersion foot) are chiatric rate is noted for November. This deorease also considered to be nonbattle injuries. is a reflection of the lowered rate in Korea, which dropped from 55 in October to 34 in November. The There appears to be no consistent pattern for the Japan rate of 15 remained the same as for the pre- comparison in the rise and decline of nonbattle in- vious month. The RYCdi rate decreased from 7.5 to juries to battle casualties. The Korea battle cas- 4.2. FHILCOM (AF) and MARBO reported no cases of ualty rate for November dropped from 342 in October psychiatric conditions for November. to 83 in November* while the nonbattle injury rate rose from 103 to 108 for the same period. There MALARIA: has been a substantial deorease in the nonbattle injury rate throughout the year. During the month of November the incidence of new cases of malaria was 3.7 per 1,000 in Korea, and 2.7 DAILY NON-EFFECTIVE RATE: per 1,000 in Japan. Both rates are somewhat higher than for November 1950. The administration of chloro- The effect of the loss of time due to sickness, in- quine as a suppressive in Korea, originally sched- jury and wounds on the manpower of the Army is ex- uled for discontinuation on November 15,th, was con- pressed as the "daily non-effective rate," and is tinued throughout the month. given for a specified period such as a week, month or year. The rate as calculated indicates the average number of men out of each 1,000 strength who INFECTIOUS HEPATITIS: are constantly absent from duty for medical reasons. The rate has little significance in an active thea- Only slight increases oocurred in the incidence of ter of combat operations inasmuch as it is greatly infectious hepatitis throughout the Far East Com- influenced by evacuation of patients. Patients mand. 'The November rate is 7.9. The increase in evacuated from the combat zone are no longer charge- Korea offset the slight decrease in Japan. The Ko- able against the non-effective rate of the combat rea rate of 8.0 for November 1951 is low in contrast zone, but beoome chargeable against the non-effect- to the high rate of 17 for November 1950. The RYCCM ive rate of the communications zone or the zone of rate remains at 13. Again, PHLLCCM (AF) and MARBO the interior. It is obviously affected by the evac- report no cases. 19 VENEREAL DISEASES: EPIDEMIC HEMORRHAGIC FEVER;

The venereal disease rate in Korea reflected a great- The second rise in the incidence of this disease er decrease then any other area of the Far iiast Com- which began in the last week in September and continued throughout October, reached a second peak dur- mand. The 154 rate for November is the lowest since ing the first two weeks in November after which the last June. The rate shows a steady decrease since incidence began to fall. The greatest incidence was August. The Japan rate rose from 201 to 217 in No- in units located immediately north and northeast of Seoul.

vember. The RYCOM rate of 155 is .the lowest since DEATHS t June 1950 when the rate was 133. No cases of venereal disease were reported from MARBO. During the four-vreek period covered by this report, 78 deaths of TJ. S. Army personnel were reported by all medical treatment facilities in the Far East Com- mand. Of this total, 33 were battle casualties, 3 COLD INJURIES! of the deaths occurring after evacuation to Japan. Twenty-eight (28) deaths resulted from disease, and Cold injuries as reported include all cases of frost- 17 from nonbattle injuries. Of the 2’8 deaths from bite,*trench foot and immersion foot. Fifty-three disease, 12 were reported from Japan, 8 occurring (53) cases were reported from Northern Japan and 268 in cases having originated in Korea. RYCQM report- cases from Korea in November. For the same period ed 1 death from disease and Korea reported 15. All last year there were 267 cases reported, all of them of the 17 deaths due to nonbattle injuries were re- from Korea. ported from Korea.

HOSPITALIZATION: (These data cover all patients, Army, Air Force and others.) The percent of designated beds and operating beds in Army Hospitals occupied as of 28 November 1951 was as follows: Percent of Designated Beds Occupied Percent of Operating Beds Occupied

JAPAN 66 81 KOREA 53 45 MARBO 6.0 3.1 PHILCOM (AF) 54 47 RYCOM __50 _J*6

FEC 62 67

The bed status as of 28 November 1951 wa3 as follows:

Average Beds Occupied All Patients Army Patients Designated Beds Operating Beds Army Hospitals USAP Hospitals

JAPAN 13,300* 10,933 8,820 522 KOREA 4,500 5,282 2,384 6 MARBO 200 390 12 0 PHILCOM (AF) 100 116 54 4 RYCOM 400 200 0

FEC 18,500 17,077 11,470 532

beds of In Korea, there were 13,000 PsW operating , 9»204 which were occupied.

(♦Includes 2,000 TD Beds)

EVACUATION:

Tabulated below is the number of patients (all types of personnel) evacuated from the major commands to the ZI during the five report weeks in November and the number of patients awaiting evacuation as of 30 Novem- ber 1951: Patients Await- By Air By Water Total ing Evacuation

JAPAN 1,741 11 1,752** 127 HANBO 2 0 2 1 PHILCOM (AS*) 15 0 15 11 44 NYCOM JL — _£I FEC 1,802 12 1,814 162

(•■*1,420 patients originated, from Korea)

20 23446—FEC P&PC—2/52—2.7M EDGAR ERSKINE HUME Major General, USA

1889 - 1952

Born in Frankfort, Kentucky, 26 December 1889, died at Walter Reed Army Hospital, 24 January 1952.

Graduated from Centre College, Kentucky, BA, 1908, MA, 1909; Johns Hopkins University, Doc- tor of Medicine, 1913; University of Munich, 1914; University of Rome, 1915; Master of Pub- lic Health, Harvard University and Massachu- setts Institute of Technology, 1921; Harvard School of Tropical Medicine, 1922.

Appointed first lieutenant, Medical Corps, RA, January 1917. Promoted to Major General while serving as the Chief Surgeon,Far East Command, 30 May 1949.

A Fellow of the American Academy of Arts and Sciences,The American College of Surgeons, the American College of Physicians, the Royal Soc- iety of Edinburgh and other societies including the Academies of Medicine in Washington, Rome, Madrid, Mexico, Rio, Lima and Buenos Aires. Diplomate of the American Specialty Boards for Neurology, for Internal Medicine, and for Pre- ventive Medicine and Public Health. The Chief Surgeon extends an invitation to all Far East Command medical personnel of the U. S. Army, Navy and Air Force, or of the United Nations, to prepare and forward with view to publication, articles of professional or administrative nature. It is assumed that editorial privilege is granted unless author states otherwise.

Capt. Charles A. Copeland, MSC EDITOR